Surgery for early gastric cancer: a European one-center experience.

Between 1972 and 1995 a total of 251 patients with early gastric cancer underwent resection in our department of surgery. At the time of the operation 10.8% of the patients were proved to have lymph node involvement, and two already had distant metastases. A subtotal gastric resection was performed in 59.8% of cases (n = 150), a total gastrectomy in 33.8% (n = 85), and either a proximal or an atypical resection in 6.4% (n = 16). Since 1985 subtotal distal resection and total gastrectomy were accompanied by a systematic lymphadenectomy of compartments I and II. The overall postoperative morbidity was 18.3%, and the hospital mortality, 4.9%; it was only 1.6% within the last decade. Concerning these short-term results there were no statistically significant differences between the different surgical procedures. The cumulative overall 5-year-survival rate was 82.6%. There was no statistically significant influence of either the different surgical procedures or the histologic types according to the Japanese classification of early gastric cancer.

Trocar incision and closure: daily problems in laparoscopic procedures--a new technical aspect.

A mini-laparotomy as described by Hasson was used in a modified way in 1,500 laparoscopic procedures. In comparison with the insertion of a Veress needle, we find the open approach to be a safer and quicker technique to obtain the pneumoperitoneum. A new technique for closure of the trocar incision is described. The technique is recommended due to its easy and safe approach requiring no additional special equipment.

Quality-of-life after curative surgery for gastric cancer: a comparison between total gastrectomy and subtotal gastric resection.

BACKGROUND/AIMS: Quality-of-Life has become an increasingly important factor for long term survivors after surgery for gastric cancer. Quality-of Life also includes social and psychological aspects. Many gastric carcinomas are located in the distal two thirds of the stomach. In these cases, a subtotal gastric resection may be adequate if a proximal safety margin of 5 cm in intestinal type tumors according to Laurén and 10 cm in diffuse type cancers respectively can be achieved. On the other hand total gastrectomy "de principe" has been advocated for all gastric malignancies because of high local recurrence rates after subtotal resection. The aim of the present study was to assess the Quality-of-Life in long term survivors after resection for gastric cancer comparing subtotal gastric resection with total gastrectomy. METHODOLOGY: One hundred ninety-five patients were examined with the Gastrointestinal Quality-of-Life-Index (GLQI). Hard clinical data such as postoperative weight loss, frequency of daily meals and bowel emptying were evaluated. One hundred five patients were submitted for total gastrectomy and in 90 patients a subtotal gastric resection was performed. None of the patients had clinical, radiological or endoscopic evidence of recurrence. RESULTS: After subtotal gastric resection, patients achieved statistically significant better scores concerning disease/therapy-related symptoms, physical functions resulting in a better overall score (p < 0.02). Following subtotal resection, patients had a significantly lower weight loss compared to patients after total gastrectomy (p < 0.02), a smaller number of daily meals (p < 0.001) and a lower frequency of bowel emptying/day (p = 0.031). There was no statistically significant difference in emotional status or social activities showing a similar acceptance of disease and therapy in both groups. CONCLUSIONS: In those cases where an adequate proximal safety margin can be achieved by a subtotal gastric resection, this procedure is preferable to a total gastrectomy. However preservation of the gastric stump should never be allowed to compromise oncological radicality.

[Hormone inactive neuroendocrine tumors of the pancreas]. / Hormoninaktive neuroendokrine Tumoren des Pankreas.

During the past 10 years (1987-1996), 842 laparotomies were performed for pancreatic or periampullary neoplasms; in 25 patients (2.9%) a neuroendocrine tumor was diagnosed. In 19 of these 25 patients (76%) a non-functioning endocrine tumor and in 6 patients (24%) a hormone-active tumor (four insulinoma, one gastrinoma, one VIPoma) was found. Of 19 non-functioning neuroendocrine tumors, 14 were malignant. The resection rate of these malignant tumors was 78.6% (11 of 14; 3 resections were palliative); in comparison, the resection rate of ductal pancreatic carcinoma in our hospital was 28.1%. The probability of 5-year survival amounts to 73% after surgical resection in malignant endocrine tumors and to 19% in ductal pancreatic carcinoma (including palliative resections). As it is not always clear whether non-functioning endocrine tumors are benign or malignant, oncological resection is recommended. Adjuvant chemotherapy seems not to be necessary.

[Results of surgical therapy of stomach carcinoma in the elderly]. / Ergebnisse der chirurgischen Therapie des Magencarcinoms beim älteren Menschen.

In our hospital 35% of the patients undergoing resection for gastric carcinoma are over 70 years old. This group was divided into three age groups; clinico-pathological features, operative morbidity and mortality as well as long-term prognosis were compared with findings taken from a control group of subjects under 70 years old. No differences were noted in the distribution of the UICC stages and the incidence of early gastric cancer. The number of subtotal gastric resections was significantly higher in older patients. During the past 10 years the perioperative morbidity and mortality rates have decreased markedly and only minor differences in comparison with the control group have been recorded. However, the 5-year survival rate was significantly lower in the age group above 80 years old (13.7%) than in the control group (48.7%). Univariate analysis of prognostic factors showed the UICC stage, lymph node metastases, resection line involvement and the patient's age to be of significance. In contrast, in the multivariate analysis age was not of prognostic value.

[Open laparoscopic approach--an alterative to the Veress needle. Experiences after 1,000 laparoscopies]. / Der offene laparoskopische Zugang--Alternative zu der Veress-Nadel. Erfahrungen nach 1000 Laparoskopien.

A mini-laparotomy as described by Hasson was used in a modified way in 1000 laparoscopic procedures. In comparison with the insertion of a Veress needle we find the open approach to be a safer and quicker way of obtaining pneumoperitoneum.

[Hepatic encephalopathy after portosystemic shunt]. / Hepatische Enzephalopathie nach porto-systemischem Shunt.

A total of 28 cirrhotic patients with porto-systemic anastomosis were compared with 38 cirrhotic patients without porto-systemic shunts concerning their mental state and biochemical parameters of importance for hepatic encephalopathy. A group of 37 metabolically healthy individuals provided the reference values for the psychometric test results and the EEG power spectra. Laboratory values for both groups showed marginal elevation of bilirubin, while the ammonia levels were significantly increased in the operated group. A significant difference was found concerning both the tyrosine level and that of the branched-chain amino acids. None of the patients who had surgical treatment showed clinical evidence of hepatic encephalopathy. Regarding the results in the flicker photometry, the non-shunted cirrhotic patients differed significantly from the healthy control subjects. For both the shunted and non-shunted cirrhotic patients, the results of the Viennese determination test and the number connection test indicated subclinical encephalopathy. We conclude that the elevated ammonia level in patients with porto-systemic anastomosis does not cause a significant mental disturbance. In well-selected patients, the porto-systemic end-side shunt is an appropriate procedure in the treatment of esophageal varices.

[Comparative study of the quality of life after stomach resection]. / Vergleichende Untersuchung zur Lebensqualität nach Magenresektion.

In the present study, 195 patients, following total gastrectomy (n = 105) or subtotal gastric resection (n = 90) for carcinoma without evidence of recurrence, were examined with regard to their quality of life using the Gastrointestinal Quality-of-Life Index (GLQI). After subtotal gastric resection patients achieved statistically significant better scores concerning disease-therapy-related symptoms and physical functions, resulting in a better overall score (p < 0.02). However, it seems to be questionable whether these statistically significant differences are of clinical relevance in the patient's daily life. Preservation of the gastric stump with the aim of improving postoperative quality of life should never be allowed to compromise oncological radicality.

[Results of surgical therapy of early stomach cancer]. / Ergebnisse der chirurgischen Therapie beim Magenfrühkarzinom.

Between 1972 and 1993 232 patients with early gastric cancer have been resected at the Surgical University Hospital of Mannheim. At the time of surgery 9.9% of the patients had lymph node involvement, 2 of them had distant metastases. In 59.9% of the cases (n = 138) a subtotal distal gastric resection, in 34.1% (n = 79) a total gastrectomy and in 6.4% (n = 15) a proximal or an atypical resection were performed. Following distal resection and total gastrectomy a radical lymphadenectomy of the compartments I and II was performed. The hospital lethality was 5.2%, the morbidity 18.1%. There were no statistical significant differences between the different surgical methods. The cumulative-5-year-survival rate was 80% without any statistically significant differences between the surgical methods and the histological types according to the Japanese classification of early gastric cancer.

Complications in endoscopy of the lower gastrointestinal tract. Therapy and prognosis.

This is a report on 126 prospectively registered and controlled complications in 29,695 consecutive endoscopic procedures of the lower gastrointestinal tract. The overall complication rate is 0.4%. All endoscopic procedures were performed in our institution; no referrals "from other hospitals" are included. The therapy and prognosis of occurring complications are described. Especially after therapeutic endoscopy--above all, after polypectomy--the complication rate of 0.83% is not negligible. A serious aspect is the average interval of 30 h from endoscopically caused complication to the onset of symptoms. Bleeding could be managed conservatively in 76% of cases. Nevertheless perforation and transmural burn injuries required surgical intervention in 78% of cases. The authors conclude that in the case of transmural burn an attempt at "active conservative treatment" is justified if the patient is under close surgical control, if the symptoms improve, and if there is a possibility of immediate surgery.

[Becoming a surgeon--at the university clinic]. / Der Weg zum Chirurgen--an der Universitätsklinik.

The "surgeon's road" in an university department is marked by the demands of research, clinical work and teaching. The demands made by all 3 can hardly be met in the prescribed 6 years of training when adhering to the statutory 38.5 hours week. At present there are 1227 surgeons "on the road" at West German surgical departments (12% are women). Of these some 24% will reach a consultant post and less than 2% will become chairmen of a university department.

[Recurrent meningitis in familial deficiency of the 8th component of the complement system]. / Rezidivierende Meningitis bei familiärem Mangel der achten Komponente des Komplementsystems.

An 18-year-old man suffered from recurrent bacterial meningitis. Investigation of the complement system revealed deficiency of the 8th complement component (C8) in the patient and his sister. Genetic defects of the terminal complement components C5 to C8 predispose to Neisseria infections, probably due to a lack in bacteriolytic activity. It is to be noted that 1 year ago the patient had been hospitalized for a culture-proved pneumococcal meningitis.