[Evidence-based surgery of rectal cancer]. / Evidenzbasierte Chirurgie des Rektumkarzinoms.

Over the past four decades, the treatment algorithms for rectal cancer have fundamentally changed, which resulted in a considerable improvement of oncological outcomes. In this context, the surgical concept of total mesorectal excision and the implementation of multimodal treatment strategies represent key milestones. These improvements were complemented by a standardized histopathological work-up of the surgical specimen and the introduction of high-resolution magnetic resonance imaging (MRI) diagnostics. In addition, novel surgical techniques have been introduced, such as laparoscopic and robotic rectal resection. Other technological innovations include intraoperative pelvic neuromonitoring and fluorescence imaging. This review highlights the current evidence for selected, sometimes controversially discussed principles of surgical treatment strategies in rectal cancer.

[Is acute appendicitis a surgical emergency?] / Ist die akute Appendizitis ein chirurgischer Notfall?

Acute appendicitis is one of the most common causes of acute abdomen. Whereas patients with a complicated form of appendicitis need prompt surgery, short preoperative delays are tolerable for patients with uncomplicated appendicitis. Delays of up to 8 h between hospital admission and beginning of surgery are not associated with increased rates of perforation or postoperative complications.

Relevance of surgery in patients with non-variceal upper gastrointestinal bleeding.

INTRODUCTION: Upper GI bleeding remains one of the most common emergencies with a substantial overall mortality rate of up to 30%. In severe ill patients, death does not occur due to failure of hemostasis, either medical or surgical, but mainly from comorbidities, treatment complications, and decreased tolerated blood loss. Management strategies have changed dramatically over the last two decades and include primarily endoscopic intervention in combination with acid-suppressive therapy and decrease in surgical intervention. Herein, we present one of the largest patient-based analysis assessing clinical parameters and outcome in patients undergoing endoscopy with an upper GI bleeding. Data were further analyzed to identify potential new risk factors and to investigate the role of surgery. PATIENTS AND METHODS: In this retrospective study, we aimed to analyze outcome of patients with an UGIB and data were analyzed to identify potential new risk factors and the role of surgery. Data collection included demographic data, laboratory results, endoscopy reports, and details of management including blood administration, and surgery was carried out. Patient events were grouped and defined as "overall" events and "operated," "non-operated," and "operated and death" as well as "non-operated and death" where appropriate. Blatchford, clinical as well as complete Rockall-score analysis, risk stratification, and disease-related mortality rate were calculated for each group for comparison. RESULTS: Overall, 253 patients were eligible for analysis: endoscopy was carried out in 96% of all patients, 17% needed surgical intervention after endoscopic failure of bleeding control due to persistent bleeding, and the remaining 4% of patients were subjected directly to surgery. The median length of stay to discharge was 26 days. Overall mortality was 22%; out of them, almost 5% were operated and died. Anticoagulation was associated with a high in-hospital mortality risk (23%) and was increased once patients were taken to surgery (43%). Patients taking steroids presented with a risk of death of 26%, once taken to surgery the risk increased to 80%. Patients with liver cirrhosis had a risk of death of 42%; we observed a better outcome for these patients once taken to theater. Clinically, once scored with Blatchford score, statistical correlation was found for initial need for blood transfusion and surgical intervention. Clinical as well as complete Rockall score revealed a correlation between need for blood transfusion as well as surgical intervention in addition with a decreased outcome with increasing Rockall scores. Risk factor analysis including comorbidity, drug administration, and anticoagulation therapy introduced the combination of tumor and non-steroidal antirheumatic medication as independent risk factors for increased disease-related mortality. CONCLUSION: UGIB remains challenging and endoscopy is the first choice of intervention. Care must be taken once a patient is taking antirheumatic non-steroidal pain medication and suffers from cancer. In patients with presence of liver cirrhosis, an earlier surgical intervention may be considered, in particular for patients with recurrent bleeding. Embolization is not widely available and carries the risk of necrosis of the affected organ and should be restricted to a subgroup of patients not primarily eligible for surgery once endoscopy has failed. Taken together, an interdisciplinary approach including gastroenterologists as well as surgeons should be used once the patient is admitted to the hospital to define the best treatment option.

[Intraoperative multidimensional visualization]. / Intraoperative mehrdimensionale Visualisierung.

Modern intraoperative techniques of visualization are increasingly being applied in general and visceral surgery. The combination of diverse techniques provides the possibility of multidimensional intraoperative visualization of specific anatomical structures. Thus, it is possible to differentiate between normal tissue and tumor tissue and therefore exactly define tumor margins. The aim of intraoperative visualization of tissue that is to be resected and tissue that should be spared is to lead to a rational balance between oncological and functional results. Moreover, these techniques help to analyze the physiology and integrity of tissues. Using these methods surgeons are able to analyze tissue perfusion and oxygenation. However, to date it is not clear to what extent these imaging techniques are relevant in the clinical routine. The present manuscript reviews the relevant modern visualization techniques focusing on intraoperative computed tomography and magnetic resonance imaging as well as augmented reality, fluorescence imaging and optoacoustic imaging.

[Robotic Rectal Cancer Surgery]. / Roboterassistierte Rektumkarzinomchirurgie.

BACKGROUND: The oncological outcome of patients with rectal cancer has improved considerably over the past few decades. This is mainly due to the introduction of the surgical concept of total mesorectal excision (TME) and the implementation of multimodal treatment strategies. Additionally, it has recently been demonstrated that the oncological results of open and laparoscopic TME are comparable. For some time there has been an ongoing debate on the potential relevance of robotic assistance systems in visceral surgery. The aim of this study was to evaluate the operative and perioperative outcomes of patients with rectal or rectosigmoid cancer, who were operated on using the Da Vinci Surgical System. PATIENTS AND RESULTS: We retrospectively analysed the outcomes of 202 consecutive patients, who were operated between September 2010 and November 2015 in three Surgical Centers. The cohort consisted of 136 men and 66 women with a mean BMI of 28. We performed the following procedures: 49 anterior rectal resections, 119 low anterior rectal resections, and 34 abdominoperineal excisions. Conversion to an open procedure was required in 13 patients. Non-surgical complications (n = 27) occurred in 24 patients (12%) and surgical complications (n = 67) in 62 patients (31%). Most complications were due to abdominal or sacral wound infections (n = 25) and anastomotic leaks (n = 18). The mortality rate within 30 days was 2%. The rate of R0 resections was 95%, with circumferential resection margins being negative in 98% of the patients. The quality of the mesorectal resection was scored as good in 91% of the patients. CONCLUSIONS: The Da Vinci Surgical System can be used safely and with a low complication rate for surgical treatment of rectal cancer. While primary evidence suggests that the outcome of robotic-assisted surgery is comparable with open and laparoscopic surgery, its definitive value has to be determined upon publication of the prospective randomized ROLARR trial. The main advantages of the Da Vinci system are its endowristed instruments with multiple degrees of freedom and its optimised visualisation (3D, stable camera platform controlled by the surgeon). Another positive feature is the significant ergonomic advantage for the surgeon.

[Management of delayed complications after esophagectomy]. / Management von Spätkomplikationen nach Ösophagusresektion.

Esophagectomy and subsequent reconstruction represent major physiological insults to the upper gastrointestinal (GI) tract, which as a consequence can lead to malnutrition, dysphagia and reflux. From a technical perspective, operative reconstruction involving gastric pull-up with a 2-3 cm wide tube and an anastomosis cranial to the azygos vein may minimize the symptoms. Overall, the problems tend to improve approximately 6 months after the operation. Newly occurring delayed physical functional impairments with previously known underlying malignant disease may be indicative of cancer relapse. Interventional techniques, such as stent placement or brachytherapy may be better suited for treatment of recurrent disease.

Increased growth of colorectal liver metastasis following partial hepatectomy.

Nearly 50 % of colorectal cancer (CRC) patients develop liver metastases with liver resection being the only option to cure patients. Residual micrometastases or circulating tumor cells are considered a cause of tumor relapse. This work investigates the influence of partial hepatectomy (PH) on the growth and molecular composition of CRC liver metastasis in a syngeneic rat model. One million CC531 colorectal tumor cells were implanted via the portal vein in WAG/Rij rats followed by a 30 % PH a day later. Control groups either received tumor cells followed by a sham-operation or were injected with a buffer solution followed by PH. Animals were examined with magnetic resonance imaging (MRI) and liver tissues were processed for immunolabeling and PCR analysis. One-third PH was associated with an almost threefold increase in relative tumor mass (MRI volumetry: 2.8-fold and transcript levels of CD44: 2.3-fold). Expression of molecular markers for invasiveness and aggressiveness (CD49f, CXCR4, Axin2 and c-met) was increased following PH, however with no significant differences when referring to the relative expression levels (relating to tumor mass). Liver metastases demonstrated a significantly higher proliferation rate (Ki67) 2 weeks following PH and cell divisions also increased in the surrounding liver tissue. Following PH, the stimulated growth of metastases clearly exceeded the compensation in liver volume with long-lasting proliferative effects. However, the distinct tumor composition was not influenced by liver regeneration. Future investigations should focus on the inhibition of cell cycle (i.e. systemic therapy strategies, irradiation) to hinder liver regeneration and therefore restrain tumor growth.

Metastatic recurrence after complete resection of colorectal liver metastases: impact of surgery and chemotherapy on survival.

PURPOSE: Surgery is the standard of care for resectable colorectal liver metastases (CRC-LM). Unfortunately, 60% of patients develop secondary metastatic recurrence (SMR) after R0-resection of CRC-LM. We investigated the impact of surgical re-intervention and chemotherapy (Ctx) on survival in a consecutive series of patients with SMR. METHODS: From 01/2001 to 11/2011, 104 out of 178 consecutive patients with R0-resection of CRC-LM developed SMR and were evaluated. The impact of surgical and Ctx re-interventions on recurrence free (RFS) and cancer-specific survival (CSS) was analyzed. Median follow-up was 28.0 (95%CI: 19.4-37.4) months. RESULTS: SMR occurred in 81 patients at a single site (49× liver, 18× lung, 14× other) and in 23 patients at multiple sites. Forty-two patients were scheduled for primary surgery. Fifty-three patients were classified as non-resectable and treated with median 5.0 [IQR, 3.0-10.0] cycles of Ctx, combined with an EGFR/VEGF-antibody in 27 patients. Nine patients received best supportive care only. R0/R1 resection could be achieved in 35 patients primarily and even in 8 patients secondarily after Ctx. Surgical morbidity and mortality were 16 and 0%, respectively. The 5-year RFS rates for patients with R0 versus R1-resection were 22 and 24% (p = 0.948). The 5-year CSS rate for R0/R1-resected patients was 38% versus 10% for those patients treated by Ctx alone (p < 0.001). CONCLUSION: In SMR, surgical re-intervention is feasible and safe in a remarkable number of patients and offers significantly longer CSS compared to patients without resection.

Bilobar spreading of colorectal liver metastases does not significantly affect survival after R0 resection in the era of interdisciplinary multimodal treatment.

PURPOSE: Bilobar colorectal liver metastases (CRLM) are often considered incurable or associated with poor prognosis even after R0 resection. In this single-center study, we evaluate the impact of CRLM spreading on recurrence-free survival (RFS) and cancer-specific overall survival (CSS) after R0 resection of CRLM with respect to multimodal treatment strategies including perioperative chemotherapy and multistep resections. METHODS: Between January 2001 and December 2010, R0 resection could be achieved in 70 patients with bilobar and 100 with unilobar CRLM. Extent of disease, perioperative chemotherapy, surgical procedures, adjuvant treatment, histopathological workup, RFS, and CSS were compared between both cohorts. RESULTS: Forty-six (66 %) patients with bilobar and 26 (26 %) patients with unilobar CRLM received preoperative chemotherapy (p < 0.001). For bilobar CRLM, more extended and multistep resection including portal vein occlusion were performed (29 % versus 3 %; p < 0.001). Morbidity (39 % versus 28 %, p = 0.183) and mortality (1 % versus 3 %, p = 0.644) rates were comparable in both patients' cohorts. Postoperative therapy was applied in adjuvant intent to 42 (60 %) versus 51 (51 %) patients (p = 0.275). The 5-year RFS and CSS rates were 24 % versus 31 % (p = 0.169) and 42 % versus 55 % (p = 0.131), respectively. CONCLUSIONS: To our single-center experience, there is no significant effect of CRLM spreading (bilobar versus unilobar) on RFS and CSS rates. Bilobar CRLM are more likely to require extended multimodal efforts to achieve R0 resection.

[Rectal cancer: current status of multimodal therapy--when and how?]. / Rektumkarzinom: Aktueller Stand der multimodalen Therapie--wann und wie?

Preoperative 5-fluorouracil-based radiochemotherapy (RCT) followed by quality assessed total mesorectal excision (TME surgery) are the two most important elements of multimodal treatment for patients with locally advanced rectal cancer (UICC stages II and III). The optimum sequence of these neoadjuvant modalities complemented by adjuvant (postoperative) chemotherapy, has been addressed in several randomised trials. Especially within the trials of the German Rectal Cancer Study Group (GRCSG), preoperative RCT has been shown to be superior to postoperative treatment for a variety of endpoints (pathologically confirmed complete tumour remission (pCR), RCT-induced tumour regression, R0 resection rates (including circumferential resection margins) and long-term locoregional control). This neoadjuvant multimodal strategy has decreased the 5-year and 10-year local recurrence rates below 10%, and the development of distant metastases (e.g., 35% to 45% liver metastases) remains the predominant reason for failure. Furthermore, approximately 25% of patients do not receive adjuvant chemotherapy, mainly due to surgical complications, patients' refusal or the investigator's discretion. Thus, today, integrating more effective systemic therapy into (preoperative) multimodal regimens is the most accepted challenge! But from the clinical point of view this demand is also a dilemma. The question to be addressed is how and when to apply intensified systemic therapy with adequate dosage and intensity as well as acceptable treatment-associated toxicity. The increase of therapeutic options requires valid predictive biomarkers that may help to stratify patients into regimens associated with low toxicity (5-FU monotherapy alone) or into more intensified treatment for better long-term outcome. In summary, the use of biomarkers for individualised risk-adapted treatment is one of the most promising areas of clinical investigations, not only in rectal cancer. The assessment of individual tumour response, toxicity, and prognosis during multimodal treatment of rectal cancer as a model of a very common solid tumour offers radiooncologists, surgeons, pathologists, gastroenterologists as well as oncologists immense insights into the under-standing of tumour biology.

[Extramural Gastral GIST Manifested by Spontaneous Perforation with Acute Intraabdominal Bleeding and Haemoperitoneum]. / Extramuraler GIST des Magens mit Manifestation durch Spontanruptur und akuter intraabdomineller Blutung mit Hämatoperitoneum.

We report on the case of a 38-year-old male patient with a huge extramural gastrointestinal stromal tumour (GIST) of the stomach, located in the left upper and middle abdominal cavity that was diagnosed on the basis of a spontaneous -rupture and consecutive haemoperitoneum. The lesion was resected completely in an emergency operation. The tumour was classified as a high-risk lesion for aggressive biological behaviour and with regard to tumour rupture with perforation of the serosa, an adjuvant systemic therapy was indicated.

The mesopancreas is the primary site for R1 resection in pancreatic head cancer: relevance for clinical trials.

PURPOSE: The prognosis of patients with pancreatic cancer remains poor, even after potentially curative R0 resection. This discrepancy may be due to the histopathological misclassification of R1 cases as curative resections (R0) in the past. MATERIALS AND METHODS: To test this hypothesis, color coding of all resection margins and organ surfaces as part of a standardized histopathological workup was implemented and prospectively tested on 100 pancreatic head specimens. RESULTS: Thirty-five patients were excluded from the analysis owing to the pathohistological diagnosis; only pancreatic ductal adenocarcinoma, distal bile duct adenocarcinoma, and periampullary adenocarcinoma were included. Applying the International Union Against Cancer criteria, 32 cancer resections were classified R0 (49.2%), while 33 cases turned out to be R1 resections (50.8%). The mesopancreas was infiltrated in 22 of the 33 R1 resection specimens (66.6%). It proved to be the only site of tumor infiltration in 17 specimens (51.5%). Applying the Royal College of Pathologists' criteria, 46 resections were classified R1 (70.8%). As expected, the mesopancreas again was the most frequent site of noncurative resection (n = 27; 58.7%). CONCLUSION: Using the intensified histopathological workup for pancreatic head cancer specimens resulted in an increased rate of R1 resections and the mesopancreas represents the primary site for positive resection margins. Such results are of relevance for patients' stratification in clinical trials.

Papular exanthem discloses acute myeloid leukaemia: interphase fluorescence in situ hybridization revealed deletion of p53 and gain at 8q22/8q24/Tel8q without trisomy 8.

We describe a 79-year-old patient who presented with fatigue, weight loss, pancytopenia and a papular exanthem. Previous attempts to taking bone-marrow biopsies had resulted in a 'dry tap', with no material collected, suggesting idiopathic myelofibrosis. Histological examination of skin biopsies showed dermal infiltration of monocytoid cells, resulting in a diagnosis of acute myeloid leukaemia (French-American-British M5 morphology) with leukaemia cutis (LC). Numerous abnormalities of chromosome 8 (trisomy or tetrasomy) have been identified in association with LC. We performed fluorescent in situ analysis on cutaneous tissue using directly labelled probes for various gene loci often involved in patients with AML; these tests showed deletion of p53 and excluded trisomy 8. However, application of probes for AML/ETO, MYC and telomere 8q revealed a gain at 8q22/8q24/8q telomere in a significant number of infiltrating cells. We hypothesize that a partial gain at 8q rather than trisomy of the whole chromosome 8 exhibits an association with LC in AML.

[Individualizing treatment for locally advanced rectal cancer]. / Therapie beim lokal fortgeschrittenen Rektumkarzinom. Ansätze zur Individualisierung.

Based on results of the German Rectal Cancer Study Group CAO/ARO/AIO-94 trial, long-term chemoradiotherapy (RT/CTx) is recommended as standard treatment for locally advanced rectal cancer (UICC stages II/III) in the lower two thirds of the rectum (0-12 cm from the anocutaneous verge). Tumor response to neoadjuvant therapy is very heterogeneous, ranging from complete remission to total resistance to RT/CTx. To fulfill the clinical requirement of individual and risk-adapted multimodal treatment, distinct progress in translational research has been achieved (e.g. gene profiling). However, in clinical reality "individualization" of the therapy of rectal cancer patients has not actually been realized. This can be achieved only on the basis of successful randomized clinical trials (e.g. the CAO/ARO/AIO-04 and GAST-05 trials) translationally combined with basic scientific approaches. One simple first step toward individualizing rectal cancer therapy is being made with the ongoing GAST-05 trial. This investigator initiated phase II trial funded by the German Research Foundation (Deutsche Forschungsgemeinschaft) excludes preoperative RT/CTx for patients with rectal cancer localized in the upper third of the rectum, using only quality controlled principles of radical surgery (partial vs total mesorectal excision) followed by adjuvant chemotherapy.

Two-stage hepatectomy (R0) with portal vein ligation--towards curing patients with extended bilobular colorectal liver metastases.

BACKGROUND AND AIMS: Patients with bilobular colorectal liver metastases (CRLM) experience poor prognosis, especially when curative resection cannot be achieved. However, resectability in these patients is often limited by low future remnant liver volume (FRLV). The latter can be enhanced by a two-stage liver resection, using portal vein ligation to induce liver hypertrophy. The aim of this prospective pilot study was to evaluate safety, secondary resectability, and time to recurrence of two-stage hepatectomy with portal vein ligation (PVL) and complete surgical clearance of the FRLV in patients with bilobular CRLM. MATERIALS AND METHODS: Out of 24 patients (63+/-8.26 years) with extended bilobular CRLM (metachronous n=10, synchronous n=14), 18 received preoperative 5-FU-based chemotherapy combined with oxaliplatin or irinotecan. Staging included thoracoabdominal computed tomography and (18)F-fluorodeoxyglucose-positron emission tomography scans. First-stage procedure consisted of PVL, resection of all CRLM in the FRLV, and radiofrequency ablation (RFA) of CRLM situated near the future resection plane. RESULTS: During first-stage procedure, 7x RFA, 4x non-anatomical resections, and 4x bisegmentectomies were performed additionally to PVL. FRLV/body-weight ratio increased from 0.4% to 0.6% within 55 days (median) after PVL. Second-stage hepatectomy was performed in 19 patients without tumor progression. R0 resection was possible in 14 patients. During a median follow-up of 17 months, intrahepatic recurrence occurred in two, and extrahepatic recurrence in nine out of 14 patients. CONCLUSION: Two-stage hepatectomy with PVL and complete surgical clearance of FRLV is safe even after intensified systemic chemotherapy resulting in a curative resection rate of 58.3% (73.7% of re-explored cases).

[Present treatment strategies for rectal carcinoma]. / Aktuelle Behandlungsstrategien beim Rektumkarzinom.

In the last ten years, considerable progress has been achieved in the treatment of rectal cancer. According to improved interdisciplinary staging, rectal carcinomas can be treated based on a stage-dependent concept: "low-risk" pT1 (G1/G2) carcinomas can be cured by local full wall excision, while "high-risk" pT1 (G3/G4) and pT2 carcinomas require transabdominal resection. In contrast, locally advanced rectal cancers in cUICC-II/-III stages (T3/T4 or N(+)) should receive long-term, 5-FU-based, neoadjuvant chemoradiotherapy according to the excellent results of the CAO/AIO/ARO-94 trial of the German Rectal Cancer Study Group. High-quality resection must be based on radical oncologic principles such as "no-touch" technique, radicular dissection of vessels, and total mesorectal excision. Multimodal treatment is completed with adjuvant 5-FU-based chemotherapy. This therapeutic approach led to a reduction in the 5-year local recurrence rate to 6% and disease-free survival of approximately 68% in advanced rectal cancer (overall survival: 76%).

Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection.

BACKGROUND AND AIMS: The minimally invasive technique of transanal endoscopic microsurgery (TEM) combines the benefits of local resections, a low complication rate and high patient comfort, with low recurrence rate and excellent survival rate after radical surgery (RS). The use of an ultrasonically activated scalpel rather than electrosurgery further improves the results of TEM. PATIENTS AND METHODS: A retrospective study was performed of 182 operations on 162 patients with early rectal carcinoma (pT1, G1/2) or adenoma to compare the outcome following four different kinds of surgical resection techniques: RS (anterior or abdominoperineal resection; n=27), conventional transanal resection using Park's retractor (TP; n=76), transanal endoscopic microsurgery (TEM) with electrosurgery (TEM-ES; n=45), and TEM with UltraCision (TEM-UC; n=34). One-third of the patients with RS (33%) received either a colostomy or a protective loop-ileostomy. RESULTS: Operation time with TEM-UC was significantly shorter than with TEM-ES or RS. Hospitalization was significantly longer with RS than for TEM or TP. Complication rate with TEM was significantly lower than with RS. Recurrence rate with RS and TEM was significantly lower than with TP, with a trend to TEM-UC being better than TEM-ES. Mortality rate was 3.7% with RS and 0 with TP and TEM. The 2-year survival rate was 96.3% with RS and 100% each with TP and TEM. CONCLUSION: TEM using UC seems to be the technique of choice. TP leads to an unacceptable recurrence rate, and RS results in a higher incidence of complication and impairment of life quality.

[Preoperative diagnostic procedures in locally advanced rectal carcinoma (> or =T3 or N+). What does endoluminal ultrasound achieve at staging and restaging (after neoadjuvant radiochemotherapy) in contrast to computed tomography?]. / Präoperative Diagnostik beim lokal fortgeschrittenen Rektumkarzinom (> or =T3 oder N+). Was leistet die Endosonographie gegenüber der Computertomographie im Staging und Restaging (nach neoadjuvanter Radio-/Chemotherapie)?

INTRODUCTION: Neoadjuvant radiochemotherapy (neoRT/CT) in locally advanced rectal cancer requires an exact initial determination of the depth of the cancerous infiltration (T-status) and of locoregional lymph node metastasis (N-status). For staging and restaging, contrast-enhanced computed tomography (CT) is usually used. In specialised centers, the endorectal ultrasound (rES) may be preferred. METHODS: Between January 1998 and May 2001, the T- and N-status of 102 patients with adenocarcinoma of the rectum (> or =T3 or N+) was determined prospectively by rES and CT (group I: n=61 without neo-RT/CT, examined once; group II: n=41 examined before and after neoRT/CT). All diagnostic findings were compared using the (y)pTNM-classification. RESULTS: In the patients from group I, the depth of infiltration (uT) was predicted correctly by rES in 75% and by CT in 48% of cases; the carcinomas were understaged in 10% and 41% of cases and overstaged in 15% and 11%, respectively. According to the histopathological findings, the N-status was determined correctly by rES and CT in 75% and 57% of cases, understaging occurred in 8% and 30% and overstaging in 17% and 13%, respectively. In cases in which both methods resulted in identical T- (uT+ctT) or N-staging (uN+ctN), the accuracy increased to 82% and 80%, respectively. In patients from group II, after neoRT/CT rES and CT allowed the exact prediction of the yuT-stage in 66% and 51%, respectively. Only 2% were understaged by rES (understaging by CT: 22%). Overstaging occurred in 32% and 27% by rES and CT, respectively. The N-status determined by rES and CT was in accordance with the histopathological findings in 68% and 76%of cases, respectively. Understaging occurred in 20% and 17%,overstaging in 12% and 7%, respectively. Again identical staging results in both rES and CT increased the accuracy of the T- (yuT+yctT) or N- (yuN+yctN) classification to 90% and 83%, respectively. In group II, downsizing of the tumor by more than one T-stage was correctly assessed by rES results in 15/20 cases (75%). A complete remission of initial uT3-carcinoma was diagnosed correctly in only two of eight ypT0-cases. In contrast, CT demonstrated a remission of disease in all cases but was unable to predict the extent of tumour reduction. A remission of lymph node metastasis was accurately shown by rES in 17/19 cases (90%) and by CT in 10/12 cases (83%). CONCLUSION: The staging of pretherapeutic, locoregional T- and N-status by rES is superior to that by CT (T-status: P=0.0164, N-status: P=0.0035). At restaging, rES offers higher accuracy in the detection of residual tumour infiltration (but not significantly to CT, yT-status: P=0.0833, yN-status: P=0.7962) and assessment of local remission. Therefore rES should be the method of choice in staging to avoid overtreatment in neoadjuvant settings.After neoRT/CT, the predictive efficacy of the rES for the downsizing/-staging of rectal cancer must be evaluated on greater numbers of patients receiving standardised diagnostic procedures and therapy.

[The carcinogenic potential of biomaterials in hernia surgery]. / Zum kanzerogenen Potenzial von Biomaterialien in der Hernienchirurgie.

The implantation of meshes to correct inguinal as well as incisional hernias is widely used in the U.S.A. and Western Europe. The short and long term results of meshes are convincing concerning complications, recurrence rate and patient's comfort. On the other hand side some scientific groups discuss the possibility of malignant tumor development due to implanted meshes. In fact, experimental models exist which demonstrate that soft tissue sarcomas can be induced in mice and rats by implanting artificial materials such as synthetics or metal. Beside millions of hernia repairs using meshes worldwide no patient has been reported with a soft tissue tumor until today. The analyses of molecular markers of proliferation, of apoptosis as well as the modulation of heat shock proteins seem not to prove the carcinogenic potential of meshes. In conclusion, there are no data so far indicating a real risk for humans to develop malignant tumors due to implanted meshes. Therefore we further propagate the implantation of meshes in hernia repair in adult patients.

Delay of diagnosis in pancreatic cancer due to suspected symptomatic cholelithiasis.

BACKGROUND: A single centre study was conducted to examine the frequency of cholecystectomies, both open and laparoscopic, up to 2 years prior to the diagnosis of pancreatic cancer. In particular, it was of interest to investigate whether there is a diagnostic delay in a significant number of pancreatic cancer patients and if these patients already have symptoms or findings at the time of cholecystectomy that might have been indicative of the underlying malignant disease. METHODS: It is demonstrated that 17 out of 186 pancreatic cancer patients (9%) underwent a cholecystectomy within the 2 years prior to cancer diagnosis. RESULTS: A significant number of these patients showed a considerable weight loss at the time of the cholecystectomy. It is hypothesized that symptoms which led to cholecystectomies in these patients were most likely related to the pancreatic cancer. Owing to the resulting delay of pancreatic cancer diagnosis the resection rate with curative intent decreases to 35% from 44% in the whole series. CONCLUSION: Patients suffering from cholecystolithiasis and showing atypical symptoms or other notable findings such as considerable weight loss might be assessed in more detail pre- as well as postoperatively in order to minimize the diagnostic delay in pancreatic cancer and to avoid unnecessary operations.