[Transanal Tumor Resection: Indication, Surgical Technique and Management of Complications]. / Transanale Tumorresektion: Indikation, Operationstechniken und Komplikationsmanagement.

Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.

[Slow transit constipation]. / Chronische Obstipation.

Slow transit constipation (STC) is a rare condition almost exclusively encountered in middle-aged women. Pathophysiology and aetiology are poorly understood but a multi-factorial pathogenesis seems likely. With regard to differential diagnoses mechanical, drug induced, degenerative, metabolic, endocrinologic, neurologic, and psychiatric causes of constipation must be excluded by an interdisciplinary approach. Gastrointestinal physiologic investigations including colonic transit studies are mandatory. Furthermore, pangastrointestinal delay, pelvic floor dysfunction, and irritable bowel syndrome should be excluded. Initial treatment is strictly conservative. In cases of progression or persistence of symptoms surgical therapy should be discussed. Subtotal colectomy with ileorectal anastomosis is regarded as the standard operation for STC. Using strict selection criteria, overall success rates are reported in excess of 80%.

[Transanal resection procedures-current status]. / Transanale Resektionsverfahren ­ heutiger Stellenwert.

Transanal resection procedures are special surgical methods for the minimally invasive treatment of rectal tumors. Apart from benign tumors, this operative procedure is suitable for the excision of so-called low-risk T1 rectal carcinomas, if these can be completely removed up to healthy tissue (R0 resection) due to the size and localization. With stringent patient selection very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient when there is complete or near complete remission after neoadjuvant radiotherapy/chemotherapy. Numerous studies have confirmed that in particular the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low rectal resection or abdominoperineal extirpation.

[Slow Transit Constipation]. / Management der schweren idiopathischen Darmträgheit.

Slow transit constipation is a rare condition that is almost exclusively encountered in middle-aged women. The pathophysiology and aetiology are poorly understood, but a multi-factorial pathogenesis seems likely. In the course of the differential diagnosis, mechanical, drug-induced, degenerative, metabolic, endocrinological, neurological and psychiatric causes of constipation must be excluded by an interdisciplinary approach. Gastrointestinal physiological investigations are mandatory, including measurement of colonic transit. Furthermore, pangastrointestinal transit delay, pelvic floor dysfunction and irritable bowel syndrome should be excluded. The initial mode of treatment is strictly conservative. In cases of progression or persistence of symptoms, surgical therapy should be discussed. Subtotal colectomy with ileorectal anastomosis can be regarded as the standard operation for slow transit constipation. Postoperative complications include small bowel obstruction, incontinence and persistence or recurrence of constipation and/or abdominal pain. Using strict criteria for patient selection, overall success rates are reported in excess of 80%.

Groin hernia diagnostics: dynamic inguinal ultrasound (DIUS).

PURPOSE: Although clinical examination is the gold standard for the diagnosis of groin hernia, imaging procedures can improve the detection of femoral hernias, incipient hernias, and less-common types of hernias (e.g., an obturator hernia). The aim of this study is to evaluate the sensitivity and specificity of dynamic inguinal ultrasound (DIUS). MATERIALS AND METHODS: Between July 2010 and June 2015, 4951 clinical and ultrasound examinations of the groin area were conducted at the Hanse-Hernienzentrum in Hamburg, Germany. The ultrasonographic findings were prospectively evaluated to determine the number of inguinal and femoral hernia diagnoses that were ultrasonically confirmed and also to consider cases in which clinical examination overlooked these diagnoses. The results were compared with the intraoperative findings. RESULTS: The results show that standardized ultrasound examination of the groin area with high-frequency, small-part linear transducers also serves to accurately display femoral and small or occult groin hernias. The high-level specificity (0.9980) and sensitivity (0.9758) are proof of the procedure's quality. CONCLUSIONS: To ensure high-quality hernia treatment, regular use of standardized ultrasound examinations is recommended.

TST36 stapling for rectocele and hemorrhoidal prolapse - early results of the prospective German multicenter study.

Introduction: The aim of the study was to evaluate the safety and feasibility of stapled transanal procedures performed by a 36 mm stapling device, the so-called TST36 stapler. Methods: From September 2013 to June 2014 a prospective observational study was carried out by 8 proctology centers in Germany. The Cleveland Clinic Incontinence Score (CCIS) for incontinence and the Altomare ODS score were determined preoperatively. Follow-up examinations were performed after 14 days, one month and 6 months, at this time both scores were reevaluated. Results: 110 consecutive patients (71 women, 39 men) with a mean age of 59.7 years (±13.8 years) were included in the study. The eight participating institutes entered 3 to 31 patients each into the study. The indication for surgery was an advanced hemorrhoidal disease in 55 patients and ODS with rectal intussusception or rectocele in 55 patients. Mechanical problems with stapler introduction occurred in 22 cases (20%) and a partial stapleline dehiscence in 4 cases (3.6%). Additional stitches for bleeding from stapleline were necessary in 86 patients (78.2%). Reintervention was necessary for bleeding 7 times (6.3%). Severe complications during follow-up were stapleline dehiscence in one case and recurrent hemorrhoidal prolapse in 5 cases (4.5%). Altomare ODS score and CCIS improved significantly after surgery. Conclusions: Despite a notable complication rate during surgery and the postoperative period, the TST36 can be considered as an effective tool for low rectal stapling for anorectal prolapse causing hemorrhoids or obstructed defecation.

German S3-Guideline: rectovaginal fistula.

BACKGROUND: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. METHODS: A systematic review of the literature was undertaken. RESULTS: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient. CONCLUSION: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.

German S3 guideline: anal abscess.

BACKGROUND: The incidence of anal abscess is relatively high, and the condition is most common in young men. METHODS: A systematic review of the literature was undertaken. RESULTS: This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. CONCLUSION: In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.

Cryptoglandular anal fistulas.

BACKGROUND: Cryptoglandular anal fistula arises in 2 per 10 000 persons per year and is most common in young men. Improper treatment can result in fecal incontinence and thus in impaired quality of life. METHOD: This S3 guideline is based on a systematic review of the pertinent literature. RESULTS: The level of evidence for treatment is low, because relevant randomized trials are scarce. Anal fistulae are classified according to the relation of the fistula channel to the sphincter. The indication for treatment is established by the clinical history and physical examination. During surgery, the fistula should be probed and/or dyed. Endo-anal ultrasonography and magnetic resonance imaging are of roughly the same diagnostic value and may be useful as additional studies for complex fistulae. Surgical treatment is with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter, and occlusion with biomaterials. Only superficial fistulae should be laid open. The risk of postoperative incontinence is directly related to the thickness of sphincter muscle that is divided. All high anal fistulae should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterials yields a lower cure rate. CONCLUSION: This is the first German S3 guideline for the treatment of cryptoglandular anal fistula. It includes recommendations for the diagnostic evaluation and treatment of this clinical entity.

The concurrence of histologically positive resection margins and sessile morphology is an important risk factor for lymph node metastasis after complete endoscopic removal of malignant colorectal polyps.

INTRODUCTION: The optimal procedure to be followed after colonoscopic polypectomy of malignant colorectal polyps with nontumour-free resection margins at histology is a matter of controversy. While some authors recommend merely local or segmental follow-up resection, others favour an oncological resection. PATIENTS AND METHODS: One hundred five patients, each with a single malignant polyp, were investigated. Patients with a macroscopically evident malignant polyp and those in whom the endoscopist reported incomplete polypectomy were excluded from the study. RESULTS: Postpolypectomy morbidity was 4%, and postoperative was 14%. In only 39 cases were the resection margins adjudged to be tumour-free. Histology following subsequent surgery or the follow-up examinations revealed a local recurrence or residual carcinoma at the polypectomy site in only three (2.8%) cases and lymph node metastasis in eight (7.6%) cases. Five patients had remnant adenoma at the polypectomy site. Of the high-risk factors, histological incomplete removal (n = 66, p = 0.04, odds ratio (OR) 10.2) and lymph vessel infiltration (n = 7, p = 0.02, OR 9.2) revealed a significant correlation with lymph node metastasis, but not with remnant tumour. In the case of sessile polyp, the assessment of histological incomplete removal was highly significantly correlated with lymph node metastasis (n = 55, p = 0.007, OR 18.1). CONCLUSIONS: Polypectomy artefacts appear to be responsible for the discrepancy between histology and the tumour remnants actually present. On the other hand, histologically incompletely removed sessile malignant polyps represent an appreciably higher risk for lymph node metastasis. Such cases should, therefore, be submitted to further oncological resection.

Prospective phase II study of preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy--long-term results.

BACKGROUND: To evaluate clinical outcome after preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy and adjuvant chemotherapy for pathological stage UICC >or= II. METHODS: 118 patients (median age 64 years; male : female ratio 2.5 : 1) with pathological proven rectal cancer (clinical stage II 50%, III 41.5%, IV 8.5%) were treated preoperatively with twice daily radiotherapy of 2.9 Gy single fraction dose to a total dose of 29 Gy; surgery was performed immediately in the following week with total mesorectal excision (TME). Adjuvant 5-FU based chemotherapy was planned for pathological stage UICC >or= II. RESULTS: After low anterior resection (70%) and abdominoperineal resection (30%), pathology showed stage UICC I (27.1%), II (25.4%), III (37.3%) and IV (9.3%). Perioperative mortality was 3.4% and perioperative complications were observed in 22.8% of the patients. Adjuvant chemotherapy was given in 75.3% of patients with pathological stage UICC >or= II. After median follow-up of 46 months, five-year overall survival was 67%, cancer-specific survival 76%, local control 92% and freedom from systemic progression 75%. Late toxicity > grade II was observed in 11% of the patients. CONCLUSIONS: Preoperative short-course radiotherapy, total mesorectal excision and adjuvant chemotherapy for pathological stage UICC >or= II achieved excellent local control and favorable survival.

Impact of biopsy on the accuracy of endorectal ultrasound staging of rectal tumors.

PURPOSE: Endorectal ultrasound is a well-established method for the preoperative staging of rectal tumors. This prospective study was performed to establish whether obtaining a biopsy before endorectal ultrasound has an influence on staging accuracy. METHODS: Between 1990 and 2003, a total of 333 rectal tumors were examined preoperatively by using endorectal ultrasound. All patients underwent rectal resection, and the specimens were sent for histologic evaluation. Thirty-three were not biopsied, the remaining at various times before endorectal ultrasound. The chi-squared test or Fisher's exact test were used for statistical analysis to compare the accuracies. RESULTS: The overall staging accuracy was 71 percent but differed significantly (P = 0.004) between the groups as a function of time elapsed since biopsy. The best results were seen in tumors that were not biopsied before endorectal ultrasound, which were correctly staged in 85 percent of the cases. The least accurate staging (53 percent) was noted when endorectal ultrasound was performed in the third week after biopsy, mostly as a result of overstaging. Biopsy did not have a significant effect on nodal staging. CONCLUSIONS: Biopsy before endorectal ultrasound significantly affects its accuracy. To achieve the most accurate staging, biopsy should be performed after endorectal ultrasound. Endorectal ultrasound staging performed in the first week after biopsy is the second best option but should be interpreted with caution in the second or third week.

Effect of cholecystectomy on gastric and esophageal bile reflux in patients with upper gastrointestinal symptoms.

Epidemiologic data have shown that cholecystectomy is associated with a moderately increased risk of esophageal adenocarcinoma. The study objective was to evaluate the role of refluxed bile. A total of 696 patients with upper gastrointestinal symptoms were included in the study, of whom 55 had a history of cholecystectomy (CHE). Bilirubin exposure was measured in percent time above absorbance 0.25 in the stomach and above 0.14 in the esophagus. Total gastric and esophageal bilirubin exposure was similar in both groups. Supine gastric bile reflux was slightly increased after cholecystectomy (30.6 +/- 30.2 vs. CHE: 37.1 +/- 29.5, P < 0.05). In patients with erosive esophagitis or Barrett's esophagus, there were differences in total gastric exposure (24.3 +/- 22.6 vs. CHE: 36.7 +/- 26.8, P < 0.05) but not in esophageal exposure. Cholecystectomy slightly augments bile reflux into the stomach without detectable differences in the esophagus. Therefore, increased esophageal bile reflux following cholecystectomy as a potential cause for the associated cancer risk could not be substantiated.

Radiation-induced sequelae affecting the continence organ: incidence, pathogenesis, and treatment.

INTRODUCTION: Incontinence is a late complication that causes symptoms years after radiation treatment and is difficult to deal with; it poses a particular challenge for care-providing physicians. REVIEW: This review looks at our current knowledge of the incidence, symptoms, and treatment of fecal incontinence induced by radiation treatment. An approximate estimation based on retrospective data suggests an incidence of fecal incontinence of up to one-third of patients. The mechanism that causes incontinence are changes in anal resting tone, squeeze pressure, and rectal volume or rectal compliance. The other associated aspects of incontinence include such further disorders as proctitis, colitis, and other disturbances involving the lower digestive tract. The therapeutic options mainly comprise the treatment of associated aspects, such as proctitis or diarrhea. CONCLUSION: Surgical treatment should be the absolute exception. If the creation of a stoma is being considered, a resective procedure offering freedom from symptoms seems to be the more advantageous option.

Association of anorectal dose-volume histograms and impaired fecal continence after 3D conformal radiotherapy for carcinoma of the prostate.

PURPOSE: The late toxicity of fecal incontinence after pelvic radiotherapy is now frequently recognized but the etiology poorly understood. We therefore investigated associations between dose-volume histogram (DVH) parameters of the rectum and the anal canal with fecal continence as measured by an established 10-item questionnaire. METHODS AND MATERIALS: Forty-four patients treated for carcinoma of the prostate with 58-72 Gy of 3D conformal radiotherapy between 1995 and 1999 who completed the questionnaire formed the study population. Total continence scores of treated patients obtained 1.5 years (median) after radiotherapy were compared to a control group of 30 patients before radiotherapy. Median, mean, minimum and maximum doses as well as the volume (% and ml) treated to 40, 50, 60 and 70 Gy were determined separately for anal canal and rectum. DVH parameters were correlated with total continence score (Spearman rank test) and patients grouped according to observed continence were compared regarding DVH values (Mann-Whitney U-test). RESULTS: Median fecal continence scores were significantly worse in the irradiated than in the control group (31 vs. 35 of a maximum 36 points). In treated patients, 59%/27%/14% were classified as fully continent, slightly incontinent and severely incontinent. Continence was similar in the 58-to-62-Gy, 66-Gy and 68-to-72-Gy dose groups. No DVH parameter was significantly correlated with total continence score, but severely incontinent patients had a significantly higher minimum dose to the anal canal than fully continent/slightly incontinent, accompanied by portals extending significantly further inferiorly with respect to the ischial tuberosities. CONCLUSIONS: Excluding the inferior part of the anal canal from the treated volume in 3D conformal therapy for carcinoma of the prostate appears to be a promising strategy to prevent radiation-induced fecal incontinence.

Measuring quality of life in rectal cancer patients.

Quality of life assessment in rectal cancer patients is necessary to provide a more comprehensive understanding of the outcome of surgery and other forms of treatment. Quality of life aspects must be placed in broader concept and should provide complementary information to healthcare professionals, together with classical outcomes, such as mortality, morbidity and long-term survival. There is a general lack of well-designed quality of life trials in rectal cancer patients. Ideally, individual patients could benefit from the data analysis, insofar as deficits should be disclosed and appropriately addressed. Finally, quality of life studies may also be used to monitor and evaluate the quality of care which patient receive, potentially leading to improved management.

Gastric bilirubin monitoring to assess duodenogastric reflux.

Duodenogastric reflux (DGR) was assessed with 24-hour gastric bilirubin monitoring in 345 patients (219 men; 49 +/- 13 years) with foregut symptoms and 41 healthy subjects (24 men, 28 +/- 5 years). Bilirubin exposure was measured as percent time above absorbance level 0.25 and excessive DGR was defined above the 95th percentile of normal values (>24.8%). DGR was highest following Billroth II gastric resection (60 +/- 24%, N = 15). Patients after cholecystectomy (28 +/- 25%, N = 25), patients with gastroesophageal reflux disease (24 +/- 24%, N = 199), and patients with nonulcer dyspepsia (23 +/- 21%, N = 61) had a significantly higher exposure to DGR than healthy subjects (7 +/- 8%, P < 0.0001). In conclusion, gastric bilirubin monitoring is useful for the assessment of DGR specifically in symptomatic patients following gastric resection. Increased amounts of DGR may further be of clinical importance in patients with reflux disease or nonulcer dyspepsia and following cholecystectomy.

Chronic fatigue after radiotherapy for carcinoma of the prostate: correlation with anorectal and genitourinary function.

In an investigation of chronic fatigue in patients treated with radical or post-operative radiotherapy for carcinoma of the prostate, the Brief Fatigue Inventory, urinary and anorectal function questionnaires were completed by 103 patients 2.1 years (median) after treatment. The mean fatigue score (2.8+/-2.3) and the rate of severe fatigue (18.7%) were higher than published data for healthy controls (2.2+/-1.8 and 5%, respectively). Fatigue was significantly correlated with fecal incontinence and urinary symptoms, suggesting an association of chronic fatigue and late radiation toxicity in carcinoma of the prostate.

Endoscopic ultrasound-guided transrectal biopsies of pelvic tumors.

The aim of this study was to evaluate the feasibility, safety, and diagnostic accuracy of endorectal ultrasound-guided biopsies in patients with extrarectal lesions. Data from all patients with suspicious pelvic pathology who underwent endorectal ultrasound-guided biopsies were collected prospectively. To evaluate the accuracy of the diagnosis, all patients with benign histology but primary suspicion of a malignant lesion were followed up for at least 12 months. A total of 48 patients whose median age was 66 years were evaluated. Apart from one postbiopsy hemorrhage, which was managed conservatively, no other complications were encountered. Sufficient tissue was removed to allow histologic examination in all cases. A large variety of diagnoses including primary and secondary malignancies (n = 25) as well as benign pathologies (n = 23) could be established. There were no false positive but three false negative histologies in patients with proven local recurrence of a malignant tumor during the follow-up period. This results in a sensitivity of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 89%. It is concluded that endoscopic ultrasound-guided transrectal biopsy is a safe method with a high diagnostic accuracy in the assessment of pelvic tumors.