[Value of surgery in the palliative therapy for rectal cancer]. / Stellenwert der Chirurgie in der palliativen Behandlung des Rektumkarzinoms.

The treatment of advanced rectal cancer is a complicated task that can only poorly be reduced to the simple question "to operate or not to operate?" Instead the following factors must be taken into consideration: symptomatic versus non-symptomatic patients, emergency surgery versus elective surgery, proximal versus distal rectal cancer, local advanced versus metastatic disease, primary tumour versus recurrence, unresectable versus potentially resectable metastases, resection versus diversionary surgical procedures, etc. Also within the conservative group one must decide between interventional therapy (combined chemotherapy, stent placement, radiotherapy, etc.) and purely palliative therapy. Results from studies are not sufficient for the formulation of general recommendations. However, there are only few arguments against a surgical procedure in a symptomatic situation when the primary tumour dominates. In cases of metastasizing colorectal cancer modern chemotherapeutic procedures and new antibody therapies can markedly prolong survival. These results cannot be achieved by surgery alone. In this situation, it should be considered whether the longer life expectancy will be accompanied by the later occurrence of symptoms, which again justifies a surgical indication within the framework of multimodality therapy. The widely differing starting situations lead to different therapeutic approaches so that an individual indication can be made in the course of a tumour board discussion.

Formaldehyde application for haemorrhagic radiation-induced proctitis: a clinical and histological study.

OBJECTIVES: Haemorrhagic radiation-induced proctitis is a serious complication of radiotherapy of pelvic organs. In severe cases, massive haemorrhage may necessitate hospitalization and repeated transfusions. Application of formaldehyde under direct vision is one of the most efficient treatments. The aim of this study was to evaluate the results of this treatment as well as the histological changes induced by formaldehyde on the rectal mucosa. MATERIAL AND METHODS: From January 1991 to September 2001, 13 patients who presented a haemorrhagic radiation-induced proctitis have been treated in our outpatient clinic with 4% formaldehyde cotton soaked applications. They were followed up to one year after the treatment. Endoscopic biopsies were performed before, immediately after the application, 1 month later, as well as at the one-year follow-up. RESULTS: In eight cases bleeding stopped after the first application. In two patients a second application was necessary to control the haemorrhage and in two other patients bleeding ceased definitively after the fourth application. Follow-up evaluation at 12 months showed no sign of acute proctitis or rebleeding. One asymptomatic patient had a mild stenosis of the rectum. Baseline biopsies showed signs of acute inflammation. Those performed after the application of formaldehyde showed fresh thromboses of the vessels of the mucosa. Biopsies at 1 month and 1 year showed only chronic changes secondary to the radiotherapy. CONCLUSION: Local application of 4% formaldehyde for the treatment of haemorrhagic radiation-induced proctitis gives good results, is well tolerated and easy to perform. Formaldehyde applied selectively causes thromboses of the bleeding vessels, without deep lesions or extended necrosis.

Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases.

SUMMARY: Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

Successful treatment of a pseudoaneurysm of the cystic artery with microcoil embolization.

Pseudoaneurysms of visceral arteries are uncommon but well-characterized vascular abnormalities, usually provoked by intraabdominal inflammatory processes such as pancreatitis or cholecystitis, or by surgical trauma. However, pseudoaneurysms of the cystic artery are rare. They complicate cholecystitis or cholecystectomy, and manifest as hemobilia as they rupture into the biliary tree. The advent of transcatheter embolization techniques has begun to allow minimally invasive treatment of these life-threatening complications. Transcatheter embolization can be performed using several types of material, such as synthetic occlusive emulsions, gelatin sponges or other particles, or metallic microcoils. Microcoils are small metallic helical particles, made of stainless-steel, platinum, or tungsten. Super-selective catheterization of an artery and release of microcoils causes the vessel to thrombose and allows control of bleeding.

Management of bleeding pseudoaneurysms in patients with pancreatitis.

BACKGROUND: Bleeding pseudoaneurysm is a rare but frequently fatal complication in patients with pancreatitis. METHOD: The medical records of ten patients who presented to this institution with a bleeding pseudoaneurysm between 1978 and 1997 were reviewed retrospectively. Six patients had chronic pancreatitis and four had acute pancreatitis. The splenic artery was involved in six cases, a pancreaticoduodenal artery in two, the gastroduodenal artery in one and the cystic artery in one. RESULTS: Computed tomography (CT) revealed the bleeding pseudoaneurysm in all patients (n = 6) with chronic pancreatitis but in only one of three with acute pancreatitis. Arteriography always gave the correct diagnosis. Seven patients underwent pancreatic resection as an emergency (n = 3) or within 48 h (n = 4), and survived. Three patients presenting with acute pancreatitis and massive bleeding underwent transcatheter arterial embolization. Two of them had a favourable outcome and one died from a recurrent haemorrhage 7 days later. Overall, two patients suffered significant perioperative complications and one died. CONCLUSION: CT is accurate in the diagnosis of pseudoaneurysms complicating pseudocysts. Primary resection of the pseudoaneurysm, which frequently requires pancreatic resection, is the treatment of choice. Angiography followed by transcatheter embolization is effective, but should be rapidly followed by operation.

Arteriomesenteric syndrome as a cause of duodenal obstruction in children with cerebral palsy.

Two cases of gastroduodenal outlet obstruction caused by arteriomesenteric compression in children who have cerebral palsy are reported. Clinical symptoms of gastrointestinal obstruction include recurrent postprandial nausea and vomiting, upper abdominal distension, and pain. In such patients, multiple predisposing factors can contribute to the development of arteriomesenteric compression, including marked weight loss, supine position, and severe scoliosis. Upper gastrointestinal x-rays using barium contrast allow diagnostic confirmation. In our experience, this cause of acute gastroduodenal outlet obstruction may usually resolve after conservative treatment using a jejunal feeding tube passed beyond the compression, left lateral positioning, and renutrition.