Postoperative versus definitive chemoradiation in early-stage anal cancer. Results of a matched-pair analysis.

BACKGROUND AND PURPOSE: The goal of the present study was to comparatively assess the results of definitive chemoradiation (CRT) with or without previous macroscopically complete resection in patients with early-stage node-negative (T1-2 N0) anal carcinoma. PATIENTS AND METHODS: A total of 20 patients with T1-2 N0 anal carcinoma who received radiotherapy (RT) with or without chemotherapy following incidental R0/1 tumor resection (S/CRT group) were selected. These were matched to 20 comparable patients who underwent definitive chemoradiation without previous surgery (CRT group). Major objectives of this analysis were treatment outcomes in terms of locoregional tumor control (LRC), overall survival (OS), colostomy-free survival, and toxicity. RESULTS: Patients treated postoperatively received significantly lower RT doses (median 54.0 Gy vs. 59.7 Gy; p < 0.001) and less frequently concomitant chemotherapy than those treated definitely. The 5-year LRC and 5-year OS rates were 97.5% and 90.0%, respectively, without significant differences between the S/CRT and the CRT groups. The distribution of acute and late toxicities was comparable, and the 5-year colostomy-free survival was 95% in both groups. CONCLUSION: This matched-pair comparison of incidental R0/1 resection plus dose-reduced CRT with standard definitive CRT of early-stage anal cancer shows similar treatment results. Thus, dose-reduced RT with or without chemotherapy may be considered in R0/1 resected patients with T1-2 N0 anal carcinoma.

Squamous cell carcinoma of the gastric stump. A case report and review of the literature.

Adenosquamous and pure squamous cell carcinomas of the stomach are very rare. This report is apparently the first published case of pure squamous cell carcinoma of the gastric stump. It occurred in a 67-year-old patient 37 years after Billroth II resection. This case satisfied the criteria established in the literature for the diagnosis of gastric squamous cell carcinoma. A diagnosis of adenosquamous carcinoma was excluded by extensive histologic investigation of a large number of tissue samples--a total 122 sections from 25 blocks--that revealed neither glandular structures nor mucin. The tumor stroma contained an unusually large number of eosinophils. Immunohistochemically, the tumor cells reacted with a monoclonal antibody against keratin (KL1), but not with antibodies against neuroendocrine or endothelial markers, or alpha 1-antichymotrypsin. The tumor may possibly originate from ectopic squamous epithelium, squamous metaplasia of the gastric mucosa, or an undifferentiated mucosal stem cell. However, we excluded an endothelial origin (which has been proposed by other authors) on the basis of immunohistochemical findings.

[Significance of computer tomography for operative tactics in esophageal cancer]. / Die Bedeutung der Computertomographie für die Operationstaktik beim Oesophaguscarcinom.

In patients with tumor stage T1-CT is useful in the detection of enlarged lymph nodes. In 93% of the cases with tumor stage T2-CT gives exact information about tumor extension and infiltration. In addition 70% of the patients with positive lymph nodes can be evaluated. In T3 tumor infiltration in nearby organs can be demonstrated in 94% and lymph node metastases in 79% of the cases. The therapeutic consequences are: In tumor stage T2 and T3 subtotal esophagectomy with retrosternal stomach replacement by cervical anastomosis should be aspired for reasons of postoperative irradation of the esophageal bed.

[Surgical management of gastroduodenal ulcer in the aged]. / Chirurgische Behandlung des gastroduodenalen Ulkus beim alten Menschen.

Very high mortality rates are encountered in emergency gastric operations in the aged. In contrast, elective surgery is associated with a low mortality rate. The outcome is strongly influenced by concomitant diseases. Timing of operation is crucial in aged patients with gastrointestinal ulcer.

[Results of thoracic vagotomy for stomal ulceration following Billroth I gastric resection (author's transl)]. / Ergebnisse der thorakalen Vagotomie bei Billroth I-Anastomosenulcus.

Thoracic vagotomy is rarely considered today. This procedure is justified only in stomal ulcerations following partial gastrectomy. Since 1974, we have been using this operative method at the Chirurgische Universitätsklinik in Tübingen, Germany, routinely for all cases of stomal ulcerations following Billroth I gastric resection. In contrast to this in stomal ulcerations following Billroth II gastric resection, we perform a converting resection into Billroth I as the standard operation, since in this case control of the duodenal stump for retained antrum is mandatory. To date we have performed thoracic vagotomy in 24 patients. This approach compares well with the abdominal approach. There is a short operating time (average 70 min), a short hospital stay (average 15 days), a low complication rate, and nonexistent mortality. All ulcers, even giant ones penetrating into the pancreas, healed within 6 weeks postoperatively. None of the patients developed postvagotomy diarrhea. On follow-up examination 1.5--6.5 (mean = 4) years after surgery only three patients had a recurrent ulcer. All patients were examined pre- and postoperatively by roentgenography, endoscopy, gastric acid analysis, and serum gastrin evaluation. The Zollinger-Ellison syndrome was excluded in all cases. Because of our excellent results, we consider thoracic vagotomy a safe and successful operative method, which can be recommended as a routine procedure for stomal ulceration following Billroth I gastric resection.

[Is the jejunoileal bypass still justified? (author's transl)]. / Hat der jejunoileale Bypass noch eine Daseinsberechtigung?

The jejunoileal bypass for the treatment of extreme obesity is being increasingly criticized because of its severe metabolic complications. With the gastric bypass, developed by Mason in 1967, there now exists an operative alternative that is equivalent concerning weight reduction, but does not create such non-physiologic conditions of absorption, and therefore is not burdened with the severe metabolic disturbances of the jejunoileal bypass. Therefore the jejunoileal bypass should not be used any longer for the treatment of obesity.

[Comparative study on single layer and two layer anastomoses of small intestine (author's transl)]. / Vergleichende Untersuchungen ein- und zweireihiger Anastomosen am Schweinedünndarm.

The one layer anastomosis after Gambee is compared with the two layer anastomosis after Dick at the small bowel of 20 minipigs. The end-to-end anastomosis after Gambee consists of an interrupted, inverting suturing of the bowel wall. Dick suggested a closed method, applying bronchial clamps before resecting the bowel. Seromuscular sutures and inner all layer sutures are inserted interrupted. Experimental studies have been done after 4, 7, 14 and 21 days. In Histology two layer anastomoses caused delayed wound healing after 4 days. Twenty-one days after the operation histological findings in both groups were equal. Microangiographic studies showed, that in single layer anastomoses revascularization began 3 days earlier than in two layer anastomoses. Measuring of the bursting strength showed no significant differences. All parameters suggest equal value of both techniques. In our opinion the two layer anastomosis after Dick combines the advantages of a closed method with a simple, easy performable technique. We therfore apply it all over the gastrointestinal tract with exception of esophagel and rectal anastomoses.

[Animal studies on the construction of continent ileostomies and colostomies with the use of BioCarbon implants]. / Tierexperimentelle Untersuchungen zur Konstruktion kontinenter Ileo- und Colostomien unter Verwendung von BioCarbon-Implantaten.

Ring-shaped implants of BioCarbon, a recently developed vitreous carbon polymer, were used for construction of continent ileostomies and colostomies in dogs. The stoma was fashioned by suture fixation of the intestine inside the ring, which was then placed subfascially in the abdominal wall. The exterior of the implant could be hermetically sealed with a screw cap. Implantation in 19 dogs performed so far showed a high rate of incorporation of BioCarbon devices.

[Reversal of small bowel segments to delay intestinal passage after total colectomy (author's transl)]. / Segmentgegenschaltung am Dünndarm zur Passageverlangsamung nach Kolektomie. Tierexperimentelle Untersuchungen und klinische Anwendung

Five female mini-pigs underwent total colectomy including resection of the ileocecal valve. Sparing the terminal rectum, we reformed an end-to-end anastomosis between terminal ileum and remaining rectal cuff. In a second series 8 female mini-pigs have been colectomized using the same model. To delay intestinal passage, in addition a 10-12 cm long reversed segment of terminal ileum has been inserted between small bowel and rectal stump. Both groups were compared with a group of normal unoperated mini-pigs in a study up to 1 year, observing intestinal transit time, blood chemistry and general development of the animals. It could be proved that the reversal of a small bowel segment in colectomized animals leads to a prolongation of the intestinal transit time, to normalization of electrolytes and general appearance. Colectomy was only survived by animals with a reversed segment. The clinical application of a reversed small bowel segment following total colectomy in 1 patient was successful.

[Separation and immunological characterization of lymphocytes isolated from human appendix (author's transl)]. / Isolierung und immunologische Charakterisierung von Lymphocyten aus humanen Appendices

The isolation of viable lymphocytes from fresh human appendices is described. Under standardized experimental conditions of cell preparation no selective enrichment of either T- or B-lymphocytes was observed. The mean percentage of T-lymphocytes as judged by spontaneous rosette formation found in 34 appendices examined was 50.0%. After overnight incubation surface-Ig was detected by immunoradioautography on 46.8% of the recovered lymphocytes from 10 appendices. For the detection of surface-Ig specifically purified antibodies to heavy chains mu, gamma and alpha were used. Of the 46.8% surface-Ig positive lymphocytes the class distribution was as follows: IgM 17.7%, IgG 24.4% and IgA 4.7%. The isolated lymphocytes showed a variable mitotic response to PHA (stimulation index ranging from 3.3 to 200.9) as well as to allogeneic lymphocytes in a one-way mixed lymphocyte culture. So far, a distinct correlation could not be found between the histological degree of inflammation and the class or mitotic response of appendix lymphocytes.