[Laparoscopic esophagotomy without diverticular resection for treating epiphrenic diverticulum in hypertonic lower esophageal sphincter]. / Therapie des epiphrenischen Divertikels bei hypertonem unterem Osophagussphinkter. Laparoskopische Osophagomyotomie ohne Divertikelresektion.

INTRODUCTION: As a rule, epiphrenic diverticulum occurs in combination with most diverse forms of dysfunction in the lower esophageal sphincter (LES) and/or in the esophagus itself. The main symptoms are dysphagia, pain, and regurgitation. The operation consists in myotomy, diverticulum resection, and partial fundoplication via abdominal or thoracic approach using conventional or minimally invasive technique. The main risk is postoperative suture dehiscence after diverticular resection. The present study was therefore undertaken to establish whether the operation succeeds in risk patients even without resection of the diverticulum. PATIENTS AND METHODS: In the period from 1998 to 2001, six patients were investigated preoperatively by means of esophageal manometry, endoscopy, and radiological barium swallow. The four risk patients underwent only myotomy of the LES, if appropriate, in combination with laparoscopic partial fundoplication. Resection of the diverticulum by thoracoscopy or with conventional thoracic technique was also performed in the two patients with normal risk. RESULTS: Three of the four risk patients showed normal postoperative courses after laparoscopic myotomy and rapidly became free of symptoms and were able to eat normally. One patient died perioperatively of pulmonary complications. After thoracic diverticulum resection, both patients developed postoperative suture dehiscence with a complicated course. Altogether, freedom from symptoms with regard to dysphagia and regurgitation could be attained in five out of six patients over a follow-up period of 6 to 25 months. CONCLUSION: In patients with epiphrenic diverticulum and disorder of LES function, myotomy alone without resection of the diverticulum may be sufficient to relieve or eliminate symptoms. Laparoscopy and the combination with partial fundoplication are the preferred techniques. In our opinion, this method must be considered in order to reduce the surgical risk in multimorbid and elderly patients.

[Importance of rectal extirpation for the therapy concept of low rectal cancers]. / Stellenwert der Rektumexstirpation im Therapiekonzept des tief sitzenden Rektumkarzinoms.

INTRODUCTION: The main objective of surgery of rectal carcinomas is to avoid a permanent colostomy by sphincter-sparing surgical procedures. A variety of different abdominoperineal resection rates is described in the literature. MATERIAL/METHOD: The study was performed in 2000 within the framework of a multicentric study including 282 hospitals. The purpose of the study was to document the quality of diagnosis and therapy for colorectal carcinomas.A total of 9477 patients were included in this study: 3402 suffering from a rectal carcinoma and 6075 suffering from a colon carcinoma. RESULTS: A total of 866 abdominoperineal resections was performed. This corresponds to an abdominoperineal resection rate of 27.4%. In 30.4% of all men and in 23.0% of all women an abdominoperineal resection was performed. Of all tumor patients who underwent abdominoperineal resection, 8.3% had a pT4 carcinoma and 57.5% a pT3 carcinoma. Adapted to the localization of the tumor in the rectum, i.e., the distance of the aboral tumor margin to the anal verge, the following abdominoperineal resection rates were found: <4 cm from the anal verge 84.6%, 4-7.9 cm 43.9%, 8-11.9 cm 5.8%, and 12-16 cm 0.5%.Intraoperative complications occurred in 11.8%, specific postoperative complications in 33.1%, and general postoperative complications in 27.4% of the patients. The postoperative lethality was 2.8%. The mean postoperative hospital stay was 21.7 days. Logistic regression identified the body mass index, gender, the distance of the carcinoma from the anal verge, and the T category as independent factors influencing the abdominoperineal resection rate. DISCUSSION: Despite an overall decrease in use, abdominoperineal resection will continue to play an important role for the surgical treatment of low rectal cancers in routine clinical practice in Germany. It will remain an individual decision for each patient whether the tumor and the patient allow sphincter preservation or whether abdominoperineal resection seems to be necessary. According to the results of the present study,a general definition of an abdominoperineal resection rate in an unselected group of patients should be viewed critically.

[Local recurrence and survival rate after rectal cancer operations and multimodal therapy]. / Lokalrezidiv- und Uberlebensraten nach Rektumkarzinomoperationen und multimodaler Therapie.

INTRODUCTION: In the guidelines of the German specialist medical societies, postoperative chemoradiotherapy is recommended for rectal carcinomas in stages II and III. In the meantime, there are important study findings favoring preoperative radiotherapy as against postoperative irradiation. In the present unicentric study, the clinical results after preoperative irradiation and postoperative chemotherapy are to be determined. In period I, sandwich radiation without total mesorectal excision was applied. In period II, the treatment was developed further with exclusive preoperative radiation and total mesorectal excision. Since from 1994 the therapy regimen has changed with the introduction of total mesorectal excision and improved radiotherapy, the present study was carried out to check whether this has led to better results of therapy. PATIENTS AND METHODS: Over a period of 7 years, data from 607 patients with rectal carcinoma were recorded and stored in an Excel file. The carcinomas were grouped into lower, middle and upper segment levels and classified endosconographically. Multimodal treatment was administered in stage uT3. In period I, sandwich radiation was carried out with 24 Gy preoperatively and 24 Gy postoperatively, followed by adjuvant chemotherapy. Total mesorectal excision was not performed. In period II, 50.4 Gy were applied preoperatively, followed by adjuvant chemotherapy. The operation comprised total mesorectal excision of the lower two thirds of the rectum. Calcium folinate and 5-fluoroucil were administered in six chemotherapy cycles. Primarily inoperable patients received preoperative irradiation with up to 50.4 Gy in both periods to attain down-staging. The following surgical procedures were applied: abdominal perineal extirpations, deep anterior resections, coloanal anastomoses, colon pouch anal anastomoses and transanal microsurgical resections. RESULTS: In 469 curatively operated patients, including primarily inoperable patients after down-staging radiotherapy, the rates of local recurrence were 5.8% with a mean follow-up observation of 4.29 years, and the carcinoma-specific 4-year actuarial survival was 84%. The rate of recurrence was highest in the lowest segment level of the rectum (7.6 as compared to 2.4%, P = 0.042). The rates of local recurrence were 7.4% in period I and 4.3% in period II (P = 0.44). The carcinoma-specific 4-year actuarial survivals were 81% in period I and 87% in period II (P = 0.202). Investigation of the subgroups of irradiated patients showed complete freedom from recurrence after a mean follow-up observation time of 3.58 years for patients in stage uT3 with total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy (n = 51). The difference from patients without postoperative chemotherapy was significant (P = 0.018). After radiotherapy, the complication observed was a raised rate of sacral cavity infections after total resection of the rectum (p = 0.039). CONCLUSION: Total mesorectal excision, preoperative radiotherapy and postoperative chemotherapy can effectively influence the rate of local recurrences after rectal carcinoma operations (0-4.3% after a mean period of follow-up observation of 3.58 years). No appraisal can be made with regard to the benefit resulting from the individual measures.

[Spontaneous bleeding of focal nodular hyperplasia as a rare cause of acute abdomen]. / Eine spontan blutende focal noduläre Hyperplasie als seltene Ursache eines akuten Abdomens.

Focal nodular hyperplasia (FNH) is a benign tumor of the liver. It is most frequently found in women of reproductive age. An association with oral contraceptives and sexual hormones is therefore possible. FNH lesions are frequently discovered incidentally. Spontaneous complications are rare. When the diagnosis is known with reasonable accuracy, a nonoperative approach is in common use. We report here the rare case of spontaneous intraabdominal bleeding from FNH.

[The "short esophagus problem" in laparoscopic anti-reflux surgery]. / Zur Problematik des "short esophagus" in der laparoskopischen Antirefluxchirurgie.

INTRODUCTION: Esophageal shortening as a complication of advanced gastroesophageal reflux disease is seen in 2-4% of patients with GERD. For such patients undergoing laparoscopic antireflux surgery, the procedure is doomed to failure because of excessive tension. As a consequence, recurrent hiatal hernia or thoracic placement of the fundoplication with unfavorable functional results can occur. METHODS: The Collis gastroplasty as an esophageal lengthening procedure was first described by Collis in 1957. Collis gastroplasty combined with Nissen fundoplication produces an intraabdominal neoesophagus with a fundic wrap. RESULTS: We performed 255 laparoscopic antireflux procedures between March 1994 and February 2000. We report on five patients (2.0%) with a shortened esophagus treated with Collis gastroplasty and Nissen fundoplication. On follow-up, all patients showed symptomatic relief from reflux symptoms, especially from dysphagia. CONCLUSION: The Collis gastroplasty combined with Nissen fundoplication is an effective procedure in patients with shortened esophagus diagnosed intraoperatively during laparoscopic antireflux surgery. Because of neoesophageal acid production proximal to an intact fundoplication coupled with poor esophageal clearance, there was no complete restitution.

[Laparoscopic antireflux surgery for gastroesophageal reflux disease: report on a 4-year experience]. / Laparoskopische Antirefluxchirurgie bei gastrooesophagealer Refluxkrankheit. Ein 4-Jahres-Erfahrungsbericht.

In a period of 4 years between March 1994 and March 1998, 143 patients with gastroesophageal reflux disease (GERD) underwent laparoscopic antireflux surgery. According to manometric studies 76 patients had a short-floppy Nissen fundoplication, patients with impaired motility or paraesophageal hernias received a hemifundoplication (Toupet = 42, Dor/Thal = 25). Recurrent reflux symptoms appeared in 6.3% after mean 16.7 months follow-up (Nissen = 2.6%, Toupet = 2.3%, Dor/Thal = 24%, P < 0.01). Persistent dysphagia with reoperation occurred in 2.1% (Nissen = 2.6%, Toupet = 2.3%, Dor/Thal = 0%, n.s.). The assessment of Visick's score at the latest control showed the following: Visick I = 63.6%, Visick II = 30.1%, Visick III = 6.3%, Visick IV = 0%. The outcome of the operation was rated "excellent" or "good" by 91.6% of the patients.

[Temporary closure of interposed intestine in treatment of anastomotic dehiscence in esophageal surgery]. / Passagerer Interponatverschluss zur Behandlung von Anastomoseninsuffizienzen in der Oesophaguschirurgie.

INTRODUCTION: Though resections of the esophagus are performed today with a mortality of below 10% anastomotic leakages still represent a serious threat especially when located intrathoracically. METHODS: In cases with intrathoracic leakage and severe septic disease the interposed intestinum was interrupted by staples within the abdomen in order to inhibit bile and intestinal reflux to the anastomosis. Care was taken not to hurt the mesentery. RESULTS: Of 102 patients with adenocarcinoma of the gastroesophageal junction and the distal esophagus 48 were treated with cervical anastomosis and stomach or colon interposition. Anastomotic leakages occurred in 12.5% of cases and were cured without special measures. In 54 patients an intrathoracic anastomosis was done using small intestine or colon for interposition. Four cases (7.4%) with anastomotic leakage and severe septic disease were recorded. In these patients the interposed intestine was interrupted. The anastomotic leakage healed. With small intestine interposition a spontaneous reopening of the staples was observed after 6 weeks. Total mortality up to the time of discharge in 102 patients was 2%. No patient died because of anastomotic leakage. CONCLUSIONS: With the method of interruption of the interposed intestine anastomotic leakages in esophageal surgery can be cured. The effect is based on the prevention of intestinal reflux to the anastomosis. With small intestine interposition a spontaneous reopening of the interruption can be expected after 6 weeks.

[Laparoscopic anti-reflux surgery in gastroesophageal reflux. Diagnosis, surgical technique and outcome in 143 patients]. / Laparoskopische Antirefluxchirurgie bei gastroösophagealer Refluxkrankheit. Diagnostik, Operationstechnik und Ergebnisse bei 143 Patienten.

Within the period March 1994 to March 1998, 143 patients with gastroesophageal reflux disease (GERD) underwent laparoscopic antireflux surgery. According to manometric studies, 76 patients underwent short-floppy laparoscopic Nissen fundoplication, 42 patients with impaired motility had a Toupet hemifundoplication, and 25 patients had an anterior Dor hemifundoplication. Recurrent reflux symptoms appeared in 6.3% after 16.7 +/- 12 months of follow-up (Nissen 2.6%, Toupet 2.3%, Dor 24%, p < 0.01). Persistent dysphagia with reoperation occurred in 2.1% (Nissen 2.6%, Toupet 2.3%, Dor = 0%, n.s.). Follow-up included assessment of the Visick score and patient satisfaction with operation results. Excellent or good results were found in 92% of the patients.

[How safe is short-term inpatient treatment after laparoscopic cholecystectomy]. / Wie sicher ist die stationäre Kurzzeitbehandlung nach laparoskopischer Cholecystektomie?

In 534 patients after laparoscopic cholecystectomy an earliest discharge was intended. The median day of discharge was day 3 postoperatively. The limitations to discharge were; normal physical findings, temperature back to normal and sonographic findings, which did not exceed the usual fluid accumulation in the gallbladder bed. Under strict application of these limitations no postoperative complication was missed. Due to outpatient pre-examination and operation on the day of admission the total length of stay could be limited to 2 days median. Also in this subgroup of 178 patients the chosen procedure was save.

Immunoscintigraphy using different methods of applying a 99mTc labeled monoclonal anti-CEA-antibody in the staging of patients with liver metastases before partial hepatectomy.

It was the aim of this study to determine the value of portal-venous (p.v.), intra-arterial (i.a.) or intravenous (i.v.) IS in the detection of liver metastases. Immediately after angiography and i.a. CT (20 patients) or p.v. CT (6 patients), 0.7-1.2 GBq of the 99mTc labeled anti-CEA MoAb were injected via the i.a. catheter, and in 10 patients i.v. Planar scanning was performed. Using IS in the detection of liver metastases a total sensitivity of 61% was established. However, IS was still found to be the decisive method of excluding extrahepatic tumor deposits.

Mesocaval and distal splenorenal shunts: effect on hepatic function, hepatic hemodynamics, and portal systemic encephalopathy.

The effect of the mesocaval interposition shunt (n = 12) and the distal splenorenal shunt (n = 9) on the wedged hepatic venous pressure, the estimated hepatic blood flow, quantitative hepatic function, and the rate of portal systemic encephalopathy was evaluated in 21 patients who had bled from esophageal varices. After mesocaval shunt the wedged hepatic venous pressure was significantly reduced by 42% (from 26 +/- 3 mm Hg to 15 +/- 5 mm Hg, P less than 0.001) compared to 16% only (from 25 +/- 3 mm Hg to 21 +/- 2 mm Hg, P less than 0.005) after distal splenorenal shunt. The estimated hepatic blood flow also decreased significantly after mesocaval shunt by 61% (from 1.45 +/- 0.46 l/min to 0.56 +/- 0.25 l/min, P less than 0.001) compared to 29% (from 1.29 +/- 0.32 l/min to 0.91 +/- 0.39 l/min, P less than 0.05) after distal splenorenal shunt. Despite significantly different influences of both types of shunt operations on wedged hepatic venous pressure and estimated hepatic blood flow (P less than 0.001), postoperative changes of hepatic function were comparable in both groups of patients. The galactose elimination capacity, the initial plasma disappearance rate of Bromsulphalein, and the plasma ratio of valine, leucine, and isoleucine to phenylalanine and tyrosine were reduced by 13%, 26%, and 29%, respectively, after mesocaval shunt, compared to 12%, 25%, and 17% after distal splenorenal shunt. Only two patients of the mesocaval shunt group with the largest decrease in estimated hepatic blood flow developed portal systemic encephalopathy postoperatively, and the distal splenorenal shunt patients with their minor hemodynamic sequelae remained free of portal systemic encephalopathy.

[Treatment of renal artery stenosis following kidney transplantation]. / Therapie der Nierenarterienstenose nach Nierentransplantation.

Stenoses of the renal artery occurred in 4.6% of 415 transplanted kidneys between 1969 and 1983. Most of them were caused by traumatic intima-lesions and were localised postanastomotically. The best therapeutic procedure seems to be the transperitoneal approach with widening venous patch plasty or venous bypass. The percutaneous transluminal catheter dilatation may be successful in suitable cases.

[Late results of mesocaval and distal splenorenal shunts]. / Spätergebnisse nach mesocavalen und distalen splenorenalen Shunts.

Shunt operations were carried out in 63 patients. Child A and B patients received alternatingly a distal splenorenal or mesocaval shunt, Child C and emergency patients exclusively mesocaval shunts. The postoperative mortality in the emergency group was 29%, in the elective group with mesocaval shunts 13% and with distal splenorenal shunts 17%. After 3 years the cumulative survival rates were similar in all patient groups and amounted to 54-64%. Episodes of acute encephalopathy in the late phase were observed only after mesocaval shunts (7%).

[Results of continuous permanent irrigation in diffuse purulent peritonitis]. / Ergebnisse der kontinuierlichen Dauerspülung bei diffus-eitriger Peritonitis.

In a prospective study continuous peritoneal lavage was carried out in 30 patients with diffuse purulent or fecal peritonitis using a volume of 20-50 1/24 h during 5-7 days. Bacteria were recognised in the effusate until day 5. Protein losses per 24 hours amounted to 4,1-46 g. A mean value of 14,5 +/- 14 g was determined. The fractional protein clearance of IgG had increased compared to other proteins. A mortality of 26,7% was obtained. Death causes were the consequences of septic shock. In none of the investigated cases remaining empyemas in the peritoneal cavity could be shown. There was no support for the establishment of lavage tracks.

[The blunt abdominal trauma (author's transl)]. / Das stumpfe Bauchtrauma.

Up to 1970 the number of patients suffering from blunt abdominal trauma showed a substantial increase. In more than 50% of all cases there are additional injuries. The most important factor influencing the prognosis of these patients is the early and correct indication for operation and the avoidance of unnecessary laparotomies. As a primary aim in diagnosis one should consider the recognition of an intraperitoneal bleeding without risk for the patient. Peritoneal lavage as an invasive method with low complication rates has proved good. First reports also show good results using the sonography of the abdomen. The recognition of the injured organ allows a carefully directed operation. Concerning the prognosis it is of minor importance. The diagnosis in patients with blunt abdominal trauma at the university clinic of Freiburg consists of: sonography, followed in positive cases by laparotomy or angiography and laparotomy. In cases with questionable results a lavage is done.

[Ultrasonic diagnosis of blunt abdominal injuries]. / Ultraschall-diagnostik des stumpfen Bauchtraumas.

In 190 patients with blunt abdominal trauma a sonogramm was made after admission. In 25 cases blood and fluid had accumulated in the abdominal cavity. In 24 cases diagnosis was correct. In patients who had organ lesions without fluid in the abdominal cavity the injured organ could be determined in 22 out of 25 cases. The danger of late liver and spleen ruptures existed in patients with organ hematomas. False positive results regarding fluid accumulation in the peritoneal cavity were found in 3 out of 165 patients.