Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence.

Functional deficits of the striated anal sphincteric muscles without any apparent gross defect often result in a lack of ability to postpone defaecation by intention or in faecal incontinence in response to increased intra-abdominal or intra-rectal pressure. We applied electrostimulation to the sacral spinal nerves to increase function of the striated muscles of the anal sphincter. Of three patients followed for 6 months, two gained full continence and one improved from gross incontinence to minor soiling. Closure pressure of the anal canal increased in all. Preliminary data indicate that anal closure pressure increases with the duration of stimulation. Continuous stimulation of sacral spinal nerves can help some patients with faecal incontinence. It may be possible to promote continence with intermittent stimulation.

[Permanent electrostimulation of sacral spinal nerves with an implantable neurostimulator in treatment of fecal incontinence]. / Permanente Elektrostimulation der sacralen Spinalnerven mit einem implantierbaren Neurostimulator zur Behandlung von Stuhlinkontinenz.

Functional deficits of the striated muscular anal sphincter frequently result in faecal incontinence. The therapeutic options for patients without a defined muscular defect are limited. Our patient without defined lesion, but with a clinically relevant reduction of the voluntary force of the anal sphincter resulting in daily loss of stool, underwent an electrostimulation procedure of the sacral spinal nerves. The procedure was divided in three steps: acute percutaneous testing, temporary percutaneous nerve evaluation and permanent electrostimulation phase with an implantable neurostimulation device. In all three phases electrostimulation of the third sacral spinal nerve resulted in a positive clinical effect and an increase of the anal canal closure pressure. By application of permanent electrostimulation of the third sacral spinal nerve the patient became completely continent.

Extended gastrectomy: who benefits?

In the area of radical surgical treatment of gastric carcinoma, extended or multiorgan resection is--as is systematically extended lymph node dissection--becoming increasingly important. One indication for extended gastrectomy is intramural or transmural infiltration of neighboring organs or the gross presence of metastatic involvement of the lymph nodes associated with the celiac trunk, splenic artery, or splenic hilum. Because the mortality rate associated with extended gastrectomy is hardly any higher than that for nonextended gastrectomy, the indication for the former may be generously applied. The prognostically most unfavorable case is histologic evidence of transmural infiltration of neighboring organs (pT4). Multiorgan resection with improved systematic extension of lymph node dissection is of greatest benefit to patients with inflammatory adhesion of the stomach to neighboring organs or pN2 lymph node metastases. Intramural infiltration of the esophagus can be treated by including the thoracic part of the esophagus in the gastric resection done via an abdominothoracic approach, ensuring an appropriate margin of clearance, with no significant worsening of the prognosis.

[Direct electrostimulation of sacral spinal nerves within the scope of the diagnosis of anorectal function]. / Direkte Elektrostimulation der sakralen Spinalnerven im Rahmen der anorektalen Funktionsdiagnostik.

A technique is demonstrated to evaluate the functional relevance of the sacral spinal nerves regarding anal sphincter function. Sacral spinal nerves S2, S3, S4 can be reached selectively for electrical stimulation by a dorsal approach through the sacral foramina. Electrical stimulation of S3 and S4 results in visible contraction of the different striated muscular anal sphincter components and in an increase of anal canal closure pressure. These effects differ among individuals. Thus, the functional relevance of each single sacral spinal nerve on the striated muscular anal sphincter can be tested specifically.

[Surgical standards in rectal cancer]. / Chirurgische Standards beim Rectumcarcinom.

At present, a differentiated surgical treatment approach allows a curative resection (R0) for carcinoma of the rectum to be obtained in up to 80% of cases. Through the introduction of organ-preserving therapeutic procedures (polypectomy and transanal full-thickness excision), as well as the consequent extension of sphincter-preserving procedures (deep anterior rectum resection with stapler anastomosis and abdomino-peranal rectum resection with colo-anal anastomosis), the rate of sphincter-preserving operations has been increased to 80-85%. A detailed knowledge of the mode of spread of carcinoma of the rectum forms the basis for all differential diagnostic considerations as well as the operative technique. Observance of an adequate margin of clearance as dependent on tumour stage as well as the performance of an anatomically--and oncologically--correct pelvic dissection are requisites for a radical treatment of carcinoma of the rectum. Only a strict compliance of the indications criteria which have been worked out permit the use of limited therapeutic procedures.

[Systematic extended lymph node dissection in curative therapy of stomach cancer]. / Die systematische erweiterte Lymphknotendissektion in der kurativen Therapie des Magencarcinoms.

On 545 patients with gastric carcinoma treated surgically for cure during June, 1, 1982 and December, 31, 1989 the value of the systematic extended lymph node dissection (SELD) was studied prospectively. In SELD neither surgical mortality nor postoperative complications were observed with increasing frequency. In stage II survival was significantly improved in patients with SELD, in stages IA, IB and IIIA an analogous trend was seen. Patients in stage IIIB and IV showed with and without SELD identical survival.

Epidermoid carcinoma of the anal canal: treatment by combined radiation and chemotherapy.

From June 1985 to September 1991, 44 patients with epidermoid carcinoma of the anal canal were treated prospectively by a protocol of combined radiation and chemotherapy (RCT) with 5-fluorouracil (5-FU) and mitomycin C (MTC). External radiation was delivered with 10 MV photons and single daily fractions between 1.8 and 2 Gy in an uninterrupted course up to a median total dose of 50 Gy. 5-FU was given by a continuous intravenous infusion (1 g/m2/day) for 96 h on days 1-4 and 29-32, MTC by a single bolus intravenous injection of 10 mg/m2 on days 1 and 29. The actuarial survival rate, no evidence of disease (NED) survival rate and local tumour control rate were 84%, 71% and 83% at 5 years. Anorectal function was retained in 33 of 41 patients (80%). Severe acute toxicity including three fatal outcomes was observed and there was an acceptable late morbidity. The only marginally significant prognostic factor (p = 0.06) for local tumour control was T-stage. RCT can provide good local control and preserve anal function with acceptable morbidity.

Osteoclastic giant cell tumor of the pancreas. An immunohistological study and review of the literature.

A case of an osteoclastic giant cell tumor of the pancreas is presented. The different surgical specimens during the forty months of observation suggest that the histological feature of the tumor has changed. Although immunohistological studies were performed, the histogenesis remains obscure. Additional 19 cases of the literature were briefly reviewed.

Laparoscopic abdominoperineal excision of the rectum with high ligation of the inferior mesenteric artery in the management of rectal carcinoma.

Extended lymph node dissection, creation of a safe anastomosis and specimen retrieval pose the greatest problems in laparoscopic colorectal surgery. A safe technique for the performance of extended lymph node dissection with high vessel ligation has been developed on the basis of experimental studies. Abdominoperineal excision of the rectum is ideal for laparoscopic colorectal surgery because this procedure requires no anastomosing, and the specimen is retrieved perianally. From January to August 1992, we performed a laparoscopic excision of the rectum with high ligation of the inferior mesenteric artery in ten patients with low carcinomas. This paper presents clinical and technical data.

[Cystic pancreatic tumors]. / Zystische Pankreastumoren.

Before 1978, where cystic tumors of the pancreas were concerned, pathologists only differentiated between cystic adenomas and cystadenocarcinomas. Recently, however, further tumor entities have been introduced. We now differentiate between the generally benign serous cystic adenoma, the potentially malignant mucinous cystadenoma, the possibly malignant papillary cystic tumor, and the always malignant mucinous cystadenocarcinoma. Other rare tumors include the solid cystic acinous-cell tumor, the cystic islet tumor, and mucinous ductal hyperplasia. Because of their slow growth and primary displacement nature, all of these tumors can usually be detected only after they have attained considerable size. Computed tomography (CT), sonography and endoscopic retrograde cholangiopancreatography (ERCP) have an established role in diagnosis. With these methods, as a rule, it is possible to identify pseudocysts; however, differentiation between the individual tumor types is almost impossible. In our study from 1979 to 1990, we observed ten cases of serous cystic adenomas, nine cystadenocarcinomas, and four malignant papillary-cystic tumors. Of these, nine of the ten serous cystic adenomas, four of the five mucinous cystadenomas, all four papillary-cystic tumors, and five of the nine cystadenocarcinomas were curatively resected. All patients with curatively resected adenomas and one patient with an R1-resected cystic adenoma remained free of recurrence throughout the follow-up period. One 86-year-old female patient in whom a serous cystic adenoma was histologically determined still has no symptoms 8 years after diagnosis despite slow tumor progression. Two of the five patients in whom a cystadenocarcinoma was curatively resected died postoperatively; a third patient died of tumor recurrence 4 months following resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined radiation and chemotherapy for epidermoid carcinoma of the anal canal.

Between 1985 and 1992, 46 patients with epidermoid carcinoma of the anal canal were treated prospectively by a protocol of combined radiation and chemotherapy with 5-Fluorouracil and Mitomycin C. The survival rate, NED-survival rate and local tumour control rate were 84%, 71% and 83% at 5 years. Anorectal function was retained in 33 of 41 patients (80%). We observed severe acute toxicity including three deaths, but very little late morbidity. The only marginally significant prognostic factor (P = 0.06) for local tumour control was T-stage. NED-survival was significantly affected (P = 0.02) by reduction of chemotherapy during the second course.

[Polypoid lesions of the gallbladder--preventive cholecystectomy?]. / Polypoide Läsionen der Gallenblase--prophylaktische Cholecystektomie?

During nine years (1979-1988) there was carried out cholecystectomy in 21 patients for gallbladder polyps of unknown histology. The sex ratio female to male was 9 to 12, median age 51 (29-76) years. Most of the polyps were smaller than 5 mm, all proved to be cholesterol polyps, showing multiple localisations. Two benign adenomas had a size of 6 resp. 9 mm. Among the polyps with a diameter of more than 10 mm we found only two cholesterol polyps, but one heterotopia, one adenoma and one adenocarcinoma. Cholecystectomy is indicated for polyps with a diameter of more than 10 mm or suspicious sonographic criteria, especially sessile lesions or concomittant thickening of the gallbladder wall.

[Intensive care of geriatric patients in surgery]. / Intensivmedizin geriatrischer Patienten in der Chirurgie.

BASIC REMARKS: Concomitant cardiovascular and pulmonary diseases in particular represent a considerable risk to the postoperative course in the geriatric patient. MAIN DISCUSSION POINTS: The main aim of intensive care consists in the avoidance and treatment of systemic complications. In contrast, local surgical complications as the reason for intensive care are of secondary importance in the geriatric patient. In the postoperative phase, the main problems encountered by the geriatric patient affect the cardiovascular system and pulmonary function. Age-specific pathophysiological changes affecting the lungs and heart require prophylactic measures aimed at preventing atelectasis, bronchial pneumonia and edema. As a rule, patients of advanced age require such intensive care for one to three days. CONCLUSIONS: The perioperative care of the elderly patient comprises, where possible, preoperative preparation and, postoperatively, a specific prophylactic intensive care regimen.

[Abdominal multivisceral resection of colonic cancer]. / Abdominale multiviszerale Resektion beim Kolonkarzinom.

Multivisceral resection in combination with extended lymph node dissection is used in the surgical treatment of locally advanced colon carcinoma without distant metastases. This also applies to tumours with marked peritumorous inflammation in contact with neighbouring organs where an intraoperative diagnostic attempt could result in tumour seeding. The low mortality and complication rate following multivisceral resection justifies this concept. The 5-year survival rate following multivisceral resection in advanced colon carcinoma is over 80%.

[Pelvic multivisceral resection from the viewpoint of surgery]. / Pelvine multiviszerale Resektion aus der Sicht der Chirurgie.

Even rectal carcinomas, carcinomas of the female genital tract, and retroperitoneal sarcomas of the pelvis with invasion of adjacent organs are potentially curable by extending the operation to the relevant structures. In the Surgical Department of the University of Erlangen, 1535 patients with a first diagnosis of rectal carcinoma were treated from 1978 to 1988. Among these patients, 97 multivisceral pelvic resections (patients with distant metastases excluded) were performed. True tumor invasion had occurred in 48%, the others were operated on for inflammatory adhesion. In 54 patients, the anal sphincter was preserved. Postoperative mortality was 7%. The 5-year survival of those patients with tumor invasion of adjacent organs and R0-resection (n = 26) was 32%. Excluding the five patients with a tear or incision of the tumor (n = 5), the 5-year survival of the remaining patients was 44%. One patient who was operated on for a leiomyosarcoma of the rectum with a multivisceral resection of the rectum, prostate, and urine bladder is still alive 9 years after the operation without recurrence. The history of this patient argues for pelvic exenteration also in males, if a R0 resection can be performed.

[Laparoscopic tubular rectum and colon resection. An animal experiment study]. / Die laparoskopische tubuläre Rektum- und Kolonresektion. Eine tierexperimentelle Untersuchung.

As our experimental studies demonstrate save laparoscopic tubular resection of colon and rectum is possible using linear staplers for resection and circular staplers for the anastomosis. As soon as linear endostaplers are available this technique can be applied in clinical work. Open colon resection and subsequent purse-string suture or endoloops to fixate the bowel ends on PCEEA-staplers turned out to be insufficient.