Colonic pouch vs. side-to-end anastomosis in low anterior resection.

PURPOSE: Colonic pouches have gained increasing popularity in reconstruction after low anterior resection. In this prospective, randomized trial colonic pouch reconstruction is compared with side-to-end anastomosis for functional outcome. METHODS: From October 1995 to October 1996, 29 patients had colonic pouch and 30 patients had side-to-end anastomosis reconstruction after low anterior resection. Patients were matched for age, gender, and tumor stage and localization. All patients underwent functional evaluation preoperatively and at three and six months postoperatively. RESULTS: There was no difference in preoperative anorectal function. The operating time was higher in the colonic pouch group (167 vs. 149 minutes). Twenty-three patients (79.3 percent) with colonic pouch had a protective stoma compared with 21 patients (70 percent) with side-to-end anastomosis. Postoperative complications were 10.3 and 13.3 percent, respectively. There was no difference in manometric pressure of the anus, in anorectal angle, and in continence status after three and six months. Stool frequency was higher in the side-to-end anastomosis group, with 2.2 vs. 5.4 per day at three months and 2.3 vs. 3.1 per day at six months. Constipation was noted in two patients with colonic pouch (7 percent) and none in the side-to-end anastomosis group at three months and two vs. none at six months. Maximum tolerated volume and threshold volume was higher in the colonic pouch group at three and at six months. CONCLUSION: Both forms of reconstruction have similar satisfactory long-term functional results. The major advantage of colonic pouch was seen in the immediate postoperative phase.

Locally advanced rectal cancer: resection and intraoperative radiotherapy using the flab method combined with preoperative or postoperative radiochemotherapy.

PURPOSE: Surgery often fails to achieve local control in advanced rectal cancer. Additional measures are necessary to prevent local recurrence. The aim of this study was to evaluate intraoperative radiation therapy (IORT) (flab technique) combined with preoperative or postoperative radiochemotherapy. PATIENTS/METHODS: IORT is performed using a flexible flab containing hollow plastic tubes that are connected to a multichannel afterloading device with a 370 Gbq-192-Ir source. Patients receive an intraoperative dose of 15 Gy. Target volumes were measured in a cadaver experiment. From 1989 to 1993, 38 patients were included in this study. Nineteen patients were staged as T3 tumors by preoperative endosonography (Group I) and 19 as T4 tumors (Group II). Patients in Group I underwent resection (abdominoperineal resection (APR), 16; anterior resection, 3) and IORT, followed by postoperative radiochemotherapy (50 Gy/5-fluorouracil), whereas patients in Group II received preoperative radiochemotherapy (40 Gy/5-fluorouracil) followed by resection (APR, 18; anterior resection, 1) and IORT. Mean follow-up was 25.5 months. RESULTS: Operative radicality in Group I was RO (13), R1 (3), and R2 (3), and in Group II it was RO (14), R1 (3), R2 (2). R2 resections were attributable to preoperative undetected distant metastases. Perioperative mortality was 0 percent in Group I and 10.5 percent (n = 2) in Group II. Postoperative morbidity was 53 percent (n = 10) in Group I and 84 percent (n = 16) in Group II with delayed sacral wound healing being the predominant problem. Stenosis of the ureter occurred in two patients (Group II). Late or persistent therapy-related complications were seen in two patients in Group I and in six patients in Group II. Local recurrence developed in three patients in Group I (15.8 percent) and in two patients in Group II (10.5 percent). Survival data do not reach statistical significance between the two groups because of small numbers but show a favorable trend for the preoperative radiochemotherapy group. When compared with a matched historical control group of patients receiving resection only, adjuvant/neoadjuvant radiotherapy with resection/IORT improves survival significantly. CONCLUSION: The flab method is a simple but especially practical technique for IORT in the pelvis. Adjuvant/neoadjuvant therapy combined with resection/IORT is associated with high morbidity but acceptable mortality. Preliminary survival data are encouraging and call for a controlled prospective randomized trial.

[Early elective surgery of acute diverticulitis of the colon]. / Frühelektive Chirurgie der akuten Diverticulitis des Colons.

The aim of surgery for acute diverticulitis is the removal of the inflammatory focus, i.e. resection of the diseased bowel segment. With the aid of modern surgical technique, intensive care medicine, and interventional radiology surgery for acute diverticulitis is increasingly performed under elective conditions. This has led to a decrease in two- or three-staged resections in favor of primary resection and anastomosis even in advanced stages of diverticulitis.

[Abdominal recurrence after interventions on the intestines]. / Abdominelle Rezidive nach Eingriffen am Intestinum.

Local recurrences (LR) of intestinal tumors have to be divided into intra- and extraluminal LR since operative reintervention is more frequently possible in intraluminal tumor recurrences. Esophageal cancer most frequently recurs in the posterior mediastine and in the neck. In our own patients we found 16% LR following curative esophagectomy. Curative reresection is normally not possible. Palliative treatment aims to maintain the passage of food. In gastric cancer LR is most frequently seen following resection of a diffuse type carcinoma. The incidence of 7,8% in our series is low. Curative reresection was possible in 19% of extraluminal LR and in 75% of intraluminal LR. Colon carcinoma usually recurs in the abdomen. 12% of left sided primary tumors recur in the pelvis. Quite frequently extended multivisceral resections are necessary to deal with the LR. In 69% reresection was possible and in 41.5% R0-resection was achieved. As in gastric cancer intraluminal LR tend to have a better prognosis. The decision for operative reintervention has to take individual risk factors into consideration.

Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection.

Constipation and incontinence are frequent complications of rectal prolapse. Surgery should not only aim to correct prolapse but also improve bowel and sphincter function. From 1986-1991 42 patients with procidentia were treated by rectopexy and sigmoid resection. The mean age was 61.1 years. Thirty-nine patients were available for follow-up examination. Mean follow-up was 54 months. Functional data were collected prospectively before the operation and at follow-up and included clinical parameters, a constipation score, an incontinence score, anal manometry [mean resting pressure (MRP), mean maximum pressure (MMP)], proctography [anorectal angle (ARA)] and colonic transit studies [mean transit time (MTT), rectosigmoid transit time (RSTT)]. The postoperative complication rate was 7.1% (n = 3), mortality was 0%. No recurrence was seen. Constipation complaints improved from 43.6% to 25.6% (p < 0.001) and incontinence from 66.6% to 23.1% (p < 0.001). MRP increased from 36.5 mmHg to 46.0 mmHg and MMP from 90.5 mmHg to 103.0 mmHg (p < 0.001). ARA changed from 102 to 98 degrees (p < 0.001) and correlated with sphincter tone and continence. MTT decreased from 47.8 to 38.5 hours, segmental transit (RSTT) from 21.1 to 12.7 hours (p < 0.001). Our results indicate that rectopexy with sigmoid resection is a safe and effective procedure for rectal prolapse and improves functional disorders of bowel and sphincter.

[Is surgical therapy of locoregional recurrence of resected colorectal cancer effective?]. / Lohnt die chirurgische Therapie des lokoregionalen Rezidivs nach reseziertem kolorektalem Karzinom?

The role of surgery in the treatment of local recurrence of colorectal carcinoma is controversial. This study aims to analyse the value of surgical reintervention. From July 1982 to June 1991 157 patients were treated for local recurrence after "curative resection" of primary colorectal carcinoma in our institution. The mean age was 60.3 years. In 67 patients tumor recurred in the pelvis (45% distant metastases) and in 90 patients in the abdomen (39% distant metastases). Intraluminal recurrence was found in 55 patients (35%), extraluminal recurrence in 102 patients (65%). The mean interval between primary tumor resection and recurrence was 24 months. The resection rate was 73.9% (n = 116). R0-resection was achieved in 38% (n = 44). There was no significant difference in the R0-resection rate between pelvic and abdominal recurrences (33% vs. 41%). In contrast to that intraluminal tumors showed a significant difference in R0-resections when compared with extraluminal tumor recurrences (57% vs. 23%). In 34 patients (22%) only palliative surgery was performed, while in 7 patients (45%) no surgical intervention was possible at all. Multivisceral resections were necessary in 36% of pelvic and in 81% of abdominal recurrences. The postoperative complication rate was 58% (19% major complications), mortality was 3.4%. For R0-resection mean survival was 44.1 months, for R1-resection 16.5 months and for R2-resection 10.9 months. Survival in intraluminal recurrences was 42 months compared with 13.8 months in extraluminal tumors. Tumor location (abdominal/pelvic) had no influence on survival.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of postoperative alcohol withdrawal syndrome after esophageal resection]. / Behandlung des postoperativen Alkoholentzugsyndroms nach Oesophagusresektion.

Prophylaxis and treatment of alcohol withdrawal syndrome following esophagectomy consists of substitution with alcohol (1-2 g/kg/d), monotherapy with Midazolam (0.2-0.4 mg/kg/h) und Clonidin (1-2 mg/d). Out of 218 patients undergoing esophagectomy from X/86 till III/90 52 were classified as alcoholics and divided in 3 comparable groups. The Midazolamgroup showed the best results as far as withdrawal symptoms, time at the ICU, ventilation time, respiratory complications, delirium tremens and mortality are concerned. Patients in the Clonidin-group needed extensive supplimentary sedation.