[Quality of life and sexuality after surgery for rectal cancer--a follow-up study]. / Sexualität und Lebensqualität bei Patienten mit Rektumkarzinomen.

BACKGROUND: Previous studies have suggested that sexuality following surgery for rectal cancer is better in women than in men and differs with type of surgery in terms of impact on Quality of Life. However, the findings were inconsistent. The aim of the presented study was to address these issues. METHODS: 570 patients that had undergone surgery for rectal cancer in our department from 1992 to 1999 were included. After determination of survival status questionnaires on Quality of Life were sent to 370 patients one to two years post surgery. We analysed data from 215 patients of which 103 were female and 112 male. 248 patients died during the time observed. Statistical analysis was done with descriptive methods, Kaplan-Meier analysis (log rank test), T-test and analysis of variance using SPSS 11.0 for Windows. RESULTS: Significant differences were seen in symptom scales between men and women. Women scored higher for distress through medical treatment and had higher values for insomnia, fatigue and constipation. Both sexes had impaired sexual life but men had significantly higher values and felt more distressed by the impairment of sexuality than women. For patients receiving abdominoperineal resection sexuality was most impaired. Anterior resection with pouch had a detrimental effect on diarrhoea and treatment strain. CONCLUSION: The study showed that sexuality is influenced by gender and type of surgery and impacts Quality of Life after surgery for rectal cancer. Assessing quality of life with generic and specific instruments is helpful to determine differences between surgical procedures, age, gender, and adjuvant therapy where standard parameters such as survival have their limitations.

[Endoscopic removal of large colorectal polyps]. / Ist die endoskopische Polypektomie grosser kolorektaler Polypen gerechtfertigt?

BACKGROUND: Due to the potential risk of malignancy and technical difficulties in achieving complete removal, large colorectal polyps represent a special problem for the endoscopist. The aim of this study was to evaluate the capabilities and risks of endoscopy in complete removal of large colorectal polyps. METHODS: Endoscopic polypectomy of 189 colorectal polyps (141 sessile, 48 pedunculated) larger than 3 cm in diameter (range 3-13 cm) was carried out. Sessile polyps were removed using the piecemeal technique. RESULTS: Histology showed an adenoma in 173 cases, and invasive carcinoma was present in the adenoma in 16 patients. Complete endoscopic removal was achieved in one session in 129 sessile polyps and all pedunculated polyps; the other patients required two to ten sessions. Bleeding occurred in 20 patients during polypectomy, and after polypectomy in four. Except for two cases, definitive hemostasis was immediately achieved by endoscopic treatment. Perforation occurred in four patients. 3 were treated conservatively, in one patient who showed an invasive carcinoma of the cecum, resection was performed. There was no mortality due to polypectomy. During a median follow-up period of 77 months (6-107 months), six patients presented with recurrence of a benign adenoma, which was treated endoscopically, and one patient presented with a recurrent invasive carcinoma, which was treated surgically. CONCLUSIONS: Endoscopic polypectomy is a safe and effective method of treating large colorectal polyps, associated with a low complication rate, reduced hospital stay and lower costs in comparison to surgical procedure.

[Current status of diagnosis and nonoperative therapy of small bowel ileus]. / Aktueller Stand zur Diagnostik und nichtoperativen Therapie des Dünndarmileus.

In obstructed small bowel the number of stercoral bacteria increases due to stasis, inducing a liberation of mediators that are leading to ileus disease with facultative sepsis and breakdown of the circulatory system. The therapeutic procedures have to cure the stasis. In the case of mechanical obstruction cure is achieved by operation, while functional ileus may be healed by conservative treatment. Implantation of a gastric tube or Dennis' tube can evacuate the small intestine. Several peristalsis-inducing drugs are in use, although their clinical relevance remaines to be demonstrated. Clinical examination and anamnesis offer initial information; X-ray of the abdomen confirms the diagnosis of ileus and is the baseline examination. Addition of oral contrast medium, ultrasonography, CT and endoscopy may help to evaluate the underlying cause of small-bowel paralysis.

Effectiveness of endoluminal sonography in the identification of occult local rectal cancer recurrences.

PURPOSE: Local recurrence of rectal cancer after curative surgery appears in 5 to 30 percent of all cases. It is necessary to detect local recurrence in a resectable stage to have an opportunity for curative reintervention or palliative prevention of those symptoms. Because most local recurrences occur extraluminally, conventional follow-up fails to detect them at an early stage. Therefore, a prospective study was performed to assess the diagnostic potential of endorectal and endovaginal ultrasound to detect asymptomatic resectable local recurrence. METHODS: In 338 patients 721 endoluminal ultrasound examinations were added to routine follow-up of rectal and left colonic cancer, with a mean of 2.1 (range, 1-10) endoluminal ultrasound examinations for each patient. RESULTS: A total of 116 patients (34.3 percent) were shown to have local recurrence, which was suggested by endoluminal ultrasound and proven by endoluminal ultrasound-guided needle biopsy in all cases of unclear pararectal structures that could not be verified by endoscopic biopsy. Digital examination failed to detect local recurrence in 91 patients, endoscopy failed to detect local recurrence in 80 patients, and the levels of tumor markers were normal in 25 patients with confirmed local recurrence. In 33 cases of local recurrence, both digital examination and endoscopy results were normal. Twenty-five patients, in whom carcinoembryonic antigen levels, digital examination, and endoscopy results were normal, underwent potential curative reoperation, with total resection of the local recurrence. All 25 patients were still alive at the end of the study period, and 21 were free from disease. On the other hand, only 6 of 67 patients with local recurrence detectable by conventional follow-up could be operated on with curative intention. CONCLUSION: Postoperative endoluminal ultrasound is able to detect local recurrence at an earlier and asymptomatic stage and can be verified by endosonography-guided needle biopsy. Routine use in follow-up may raise the ratio of curative retreatment by early detection of extramural local recurrence.

[Diagnosis-oriented diagnosis, therapy and fee schedules in oncology. A model trial]. / Diagnose-orientierte Diagnostik, Therapie und Kostenerstattung in der operativen Onkologie. Ein Modellversuch.

In 1996 the project "operative oncology" was initiated by the Department of Surgery University of Kiel in order to guarantee a solid and longterm financing of surgical oncological interventions with a high quality standard. First step was to determine the detailed costs of the diagnostic and different surgical procedures in order to calculate flat rates per case. Covered by these comprehensive prices per case are also the psychooncological support, prospective evaluation of quality of life and molecular-oncological diagnostics (determination of micrometastasis). The development of project was primarily financed by the AOK health insurance company of Schleswig-Holstein. It was calculated by the GSbG and is supported since April, 1st, 1998 by all health insurance companies of the region.

New method of radiotherapy for anal cancer with three-dimensional tumor reconstruction based on endoanal ultrasound and ultrasound-guided afterloading therapy.

PURPOSE: Standard treatment of anal cancer is a protocol of combined chemotherapy and percutaneous radiotherapy. We developed a new endosonography-based radiation target simulation method, because endoanal sonography gives the best opportunity to stage the tumor accurately. Based on this method, an afterloading needle application procedure could be performed to optimize the radiation target geometry and to control the application of afterloading needles. In a prospective study, this new method was evaluated, with special regard for complications and tumor recurrence. METHODS: Anal cancer was restaged endosonographically six weeks after external beam radiation with 45 Gy. A computer-generated three-dimensional reconstruction of the tumor and radiation target simulation was performed based on endoanal sonographic imaging. By using a new type of applicator, which is permeable to ultrasound waves, the transperineal implantation procedure of afterloading needles could be controlled. Application needles were inserted into the target area according to the endoanal sonography-based dosimetry planing. The dose of the (high-dose rate) brachytherapy boost was started with two 6-Gy fractions, each within eight days. The fraction dose was reduced to 4 Gy to minimize side effects. Lymph node-positive tumors got additional chemotherapy (5-fluorouracil and mitomycin C). RESULTS: From January 1992 until August 1996, we performed 42 endosonography-guided afterloading procedures in 18 patients. One patient underwent percutaneous radiation two years before and was treated only by afterloading radiation. In every patient, we found complete tumor remission at the end of radiotherapy. Three patients with a high-dose rate of 2 x 6 Gy developed radiogenic proctitis, and two patients developed ulceration, which lead to reduction of the dose. After reduction to 4 Gy per fraction, no more side effects could be seen. In follow-up (median, 24 (range, 1-56) months), we detected two anal cancer recurrences (2/18 patients). CONCLUSION: The radiation target field can be optimized by individual endosonography-based three-dimensional tumor reconstruction and radiotherapy simulation. Endosonography-guided transperineal implantation of afterloading needles can be performed according to the computer-generated simulation by using a new type of applicator. We could achieve total primary tumor remission in every patient. After reduction of the afterloading dose to 2 x 4 Gy, no brachytherapy-related side effects could be seen.

[Fractionated, interstitial postoperative HDR-/PDR-brachytherapy with intraoperatively placed probes--initial experiences with a new radiotherapy modality in treatment of recurrent or non-resectable colorectal carcinomas]. / Die fraktionierte, interstitielle postoperative HDR-/PDR-Brachytherapie über intraoperativ plazierte Sonden--erste Erfahrungen mit einer neuen Strahlentherapiemodalität in der Behandlung rezidivierter oder nicht curativ resezierbarer colorektaler Karzinome.

Twenty-eight patients with recurrent (82.1%) and/or noncuratively resected (71.4%) colorectal cancer underwent fractionated interstitial BT (20.1 Gy) by using median 5.6 (3-11) afterloading tubes placed directly on the tumor bed intraoperatively. HDR/PDR BT started 2-3 weeks after multivisceral resection (50%) and was combined with external beam radiation therapy in 96% and with chemotherapy (5-FU/Leucoverin) in 86% of the patients. Though the R0-resection rate before BT was only 28.6% multimodality treatment resulted in a local tumor control rate of 64.3%, a survival rate of 53.6%, and a tumor-free survival rate of 42.9%, in an average of 19.8 months (2-43 months) after BT.

Endoluminal ultrasound diagnosis and operative management of rectal endometriosis.

PURPOSE: Endorectal ultrasound was performed in patients with endometriosis to evaluate the role of this technique for rectal wall involvement and to evaluate the position of preoperative diagnosis in the operative management of rectal endometriosis. METHODS: Sixteen patients with suspected fixation of endometriomas to the rectal wall during bimanual examination were included in the study. Endorectal ultrasound was performed using a real time unit with a 7.5 MHz endorectal transducer. The probe was introduced via a rectoscope into the rectum up to the rectosigmoid. RESULTS: Endometriosis was confirmed histopathologically in all patients. In six patients rectal wall involvement was diagnosed, in two patients endometriomas were adjacent to the rectal wall, and in eight patients rectal wall involvement could be excluded. Preoperative diagnosis was confirmed in all patients during operation. Laparotomy was performed in those patients with preoperatively diagnosed rectal wall involvement, whereas the remaining patients were treated laparoscopically. Endometriomas with rectal wall involvement were treated in five of six patients with resection of the affected bowel predominantly by low anterior resection. CONCLUSIONS: Preoperative endorectal ultrasound is a reliable technique to visualize perirectal endometriomas and to assess rectal wall involvement. Based on preoperative endosonographic diagnosis, an operative management was established with laparotomy and resection of the affected bowel in cases of rectal wall involvement.

[Value of endorectal sonography in the follow-up of patients treated surgically for rectum carcinoma]. / Die Wertigkeit der endorektalen Sonographie in der Tumornachsorge bei operiertem Rektumkarzinom.

This prospective study included 80 patients in routine follow-up examinations after rectal cancer treatment. We performed anamnesis, clinical examination, total colonoscopy and endorectal sonography and tested the level of tumour markers CEA and CA 19-9. In 10 cases we detected local cancer recurrence of the rectal tumour. In 8 cases tumour markers were pathologically raised. Endoscopy detected the local recurrence in 4 patients only. Endorectal US was able to detect all of the recurrence cases. A histological confirmation was possible by EUS-guided needle biopsy in all cases. We were able to perform R 0-re-resection with the hope of curing in 4 patients out of 10 recurrence cases. Only endorectal US was able to detect two of those 4 recurrent tumours. In the follow-up of rectal cancer endorectal US seems to be a highly sensitive examination that may raise the number of re-resection with the hope of curing after rectal cancer treatment.

[Functional pathomechanisms of anal fissure]. / Funktionelle Pathomechanismen der Analfissur.

In a prospective consecutive study of 40 patients with anal fissure we analysed the anal sphincter function at rest and rectal distension. Healthy persons with comparable age and sex distribution were controls. The anal pressures were registered with thin water perfused catheters (2 ml/min). Our patients with anal fissure showed significant elevation of anal pressures at rest along the whole length of anal canal. During rectal distension only the distal part of anal sphincter (up to a level of 2 cm from the anocutaneous line) showed a spasm with reduced relaxation. Our results are useful for operative therapy, since lateral internal sphincterotomy corresponds very well to functional pathomechanism of anal fissure.