[Recurrent micro-satellite stable colonic cancer: prolonged survival of 16 years without adjuvant therapy]. / Rezidivierendes, Mikrosatelliten-stabiles Kolonkarzinom: Verlauf über 16 Jahre ohne adjuvante Therapie.

Long-term survival in malignant disease is often linked to intensified therapeutic interventions. We report the case of a colonic cancer in a 78 years old female patient, who underwent her first operation in 1987 for a symptomatic T4 carcinoma. Since then, the patient has always denied any form of follow-up examination and adjuvant therapy. Recently, she has undergone her fourth operation, which for the first time demonstrated peritoneal carcinosis, and is still in very good health.Clinical experience shows that in some cases standard therapies may unexpectedly produce extremely long survival times. This has to be kept in mind when the value of prognostic markers is discussed and limits the validity of survival data in the context of small scale studies dealing with especially extended therapeutic protocols.

[Sigmoid diverticulitis. Extent of resection and choice of procedure]. / Sigmadivertikulitis. Resektionsausmass und Verfahrenswahl.

Diverticular disease of the colon ranks in prevalence equal to diabetes or coronary heart disease. Surgical treatment of colonic diverticulitis is in general very successful. Therapeutic options have broadened in recent years: while improved diagnostic modalities allow a pre-surgical containment of the disease process by percutaneous techniques, minimally-invasive surgical procedures can replace conventional surgery in many cases without a change in the risk of complications. However, there is no proof of a general superiority of the laparoscopic approach. Surgical morbidity and mortality mainly derives from perforations with diffuse peritonitis. As a rule, these cases should be treated by a Hartmann procedure. In selected cases it is also possible to perform a primary anastomosis. This decision should be guided by well-known scoring systems.

[Update on incisional hernia. Parastomal hernia]. / Update Narbenhernie Parastomale Hernie.

Parastomal herniation is a frequent complication when an artificial anus is constructed. As a tunnel through the abdominal wall is nonphysiological, there is an inherent trend to enlargement of the aperture with any artificial stoma. However, none of the technical modifications tried has proved reliable in reducing the incidence of parastomal herniation. The only clear-cut indications for repair are ileus and incarceration or serious problems with the colostomy bags. There are three basic methods of repair: fascial closure, stoma relocation and augmentation of the abdominal wall by nonabsorbable meshes, and any of the three can be combined in many ways. The first two techniques each have a recurrence rate of 40%-80%, and neither can therefore any longer be recommended for use in isolation. Only with the last technique of abdominal wall reinforcement it is possible to achieve a recurrence rate of under 20%. The best type of mesh and the optimal implantation technique are still under discussion.

[Outcome quality in oncological surgery]. / Ergebnisqualität in der onkologischen Chirurgie.

The term "quality" is a new buzzword used in connection with diagnostic and therapeutic activities. In the context of surgery, the term is usually restricted to the subdivision "quality of results." The specific circumstances surrounding a patient threatened by a malignant tumor justify separate consideration of oncologic surgery. Upon scrutiny, the frequency with which the term quality of results is used is in stark contrast to the lack of distinct clarification of the parameters it covers and grave uncertainty in data collection. Since medical action is not identical to technical action, attention must be called to the limitations of this popular terminology, especially with regard to oncology.

Childbirth and incontinence: a prospective study on anal sphincter morphology and function before and early after vaginal delivery.

PURPOSE: Disturbance of anal continence is a well-known problem after vaginal delivery. However, only few and incongruent data on the incidence and pathogenesis of postpartum incontinence are available. This study examined the effects of vaginal delivery on anal continence prospectively. METHODS: In 42 unselected women anal vector manometry and endoanal ultrasonography were performed, and pudendal nerve terminal motor latency (PNTML) and rectal sensibility were measured in the 32th week of pregnancy and 6 weeks after delivery. Continence was evaluated according to the Kelly-Holschneider score. Patients with occult sphincter defects were additionally followed-up 12 weeks after vaginal delivery. To exclude any effect of pregnancy alone ten patients with elective cesarian section served as controls. RESULTS: Overall continence after vaginal delivery did not differ significantly from that before delivery, there was a significant reduction in postpartum anal squeeze and resting pressures in all patients. Obstetric tears of grade III or IV occurred in 9% of the patients. Endosonography revealed occult lesions of the internal and external anal sphincter in an additional 19% of women who clinically seemed to have an intact sphincter. Manometric results and continence in these women did not differ significantly from those with intact sphincter and remained unchanged after 12 weeks. PNTML and rectal sensibility were not affected by vaginal delivery. After cesarian section there were no changes in continence, anal pressures, rectal sensibility, or PNTML. CONCLUSIONS: Vaginal delivery leads to direct mechanical trauma to the anal sphincters, while stretch and distension of the pudendal nerve seem to be of minor importance. Only endoanal ultrasonography is suitable for detection of occult sphincter lesions.

[Role of surgical biliary bypass for palliation of pancreatic cancer - a retrospective study of 107 cases]. / Stellenwert der biliodigestiven Anastomose in der palliativen Therapie des Pankreaskopfkarzinoms - Eine retrospektive Analyse an 107 Patienten.

UNLABELLED: BACKGROUNDS AND STUDY AIMS: At the time of diagnosis most patients with pancreatic cancer are still irresectable for cure. The aim of this study was to evaluate surgical palliation, in particular against the background of endoscopic stent placement. PATIENTS AND METHODS: This retrospective study analyses the therapeutic results in 107 patients with an irresectable pancreatic carcinoma operated on between 1990 and 1998. RESULTS: 104 patients showed primary therapeutic success with adequate bile drainage. In 97 % a simultaneous gastrojejunostomy was performed. The overall complication rate was 24 % and the hospital mortality 3.7 %. Median survival after surgical treatment was 201 days. CONCLUSIONS: Because of a decrease in perioperative morbidity and mortality, surgical palliation of irresectable pancreatic carcinoma still remains an effective therapy, especially for patients expected to survive 6 months or more. The surgical procedure offers the better chance for long-term palliation of obstructive jaundice and duodenal obstruction compared to the endoscopic approach. However, to consider both, the surgical and the endoscopic treatment, complementing each other, seems to be important to guarantee optimal palliation for the individual patient.

Increased distribution of collagen type III and reduced expression of matrix metalloproteinase 1 in patients with diverticular disease.

Diverticular disease is an increasingly common clinical problem especially in Western industrialized countries, but the mechanism by which the disease develops remains unclear. Based on studies showing a structural change in the colonic wall in these patients, we examined whether there are any disorders concerning the collagen metabolism in patients with diverticular disease. Samples of colonic tissue from 13 patients with diverticulitis were compared to 14 controls. We performed a Sirius red test for the overall collagen content and immunohistochemical studies facing differentiation between collagen type I and type III and the expression of matrix metalloproteinases 1 and 13. In the bowel sections of patients with diverticulitis there were decreased levels of mature collagen type I (1.37+/- 0.32 vs. 1.59 +/- 0.31) and increased levels of collagen type III (1.61+/- 0.32 vs. 1.42 +/- 0.42), with a resulting lower collagen ratio I/III. The expression of MMP-I was reduced significantly in the diverticulitis group (4.83 +/- 0.92 vs. 6.02 +/- 1.98) while expression of MMP-13 did not differ significantly between the two groups (1.03 +/- 0.11 vs. 1.04 +/- 0.12). Our findings support the theory of structural changes in the colonic wall as one of the major pathogenic factors in the development of diverticular disease. Further studies must focus on the complex interactions of several extracellular matrix components.

Limited value of positron emission tomography in treatment of pancreatic cancer: surgeon's view.

We aimed to assess, from a surgical point of view, the value of positron emission tomography (PET) in the routine preoperative diagnostic evaluation of a pancreatic mass. In particular, we were interested in PET's ability to distinguish a malignancy from a nonmalignant process and its impact on surgical decision making. We documented prospectively the results of preoperative ultrasonography, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and PET in terms of a correct diagnosis of malignancy in 103 patients. All patients underwent surgery at our department and had a complete histologic workup. We then related the preoperative findings to the intraoperative and histologic findings and analyzed the advantages and limitations of PET in comparison with conventional diagnostic techniques. Both CT and PET showed high sensitivities (82% and 84%, respectively) but rather low specificities (61%). ERCP showed good specificity at 83% but weak sensitivity at 46%. The positive predictive value was higher than 80% for all methods, whereas the negative predictive value was around 60% at best. Both the CT and the PET diagnoses were wrong in 15% of the cases. In all cases with a false CT diagnosis, the results of the other conventional examinations provided sufficient evidence to indicate the need for surgical intervention. In all cases where PET gave misleading results, CT findings indicated the need for surgery. PET overlooked pT1 cancers in three of the patients. PET does not reliably prove or exclude malignancy in situations where conventional diagnostic procedures leave doubt as to the nature of a pancreatic mass. PET does introduce a new procedure-related spectrum of misinterpretations to the diagnostic process.

Comparison of colonic J-pouch reconstruction and straight coloanal anastomosis after intersphincteric rectal resection.

The tendency towards sphincter-preserving resection for distal rectal cancers has led to the technique of straight coloanal anastomosis (CAA) and colonic J-pouch anal anastomosis (CPA) after low anterior resection. The aim of the present study was to compare complication rate, anorectal physiology and functional results after both types of reconstruction after ultra-low intersphincteric resection. A total of 31 patients who had undergone CPA were followed up prospectively using anorectal manometry and a standardised questionnaire and were compared with 63 patients who had undergone CAA and were followed up in the same way. The complication rate after CPA did not differ significantly from that after CAA. One year postoperatively, the median stool frequency and urgency were reduced after CPA (1.7+/-2.2/day; 7% vs. 2.4+/-3.6/day; 14%; P<0.05). Three months after colostomy/ileostomy closure, the maximum tolerable volume, threshold volume and compliance were decreased after CAA when compared with CPA (55+/-12, 34+/-12, and 3.9+/-0.3 ml/mmHg vs. 85+/-21, 53+/-11 and 6.2 ml/mmHg, respectively; P<0.05). Anal manometry revealed no significant differences in the anal resting and squeeze pressure. One year postoperatively, continence also did not differ significantly between CPA and CAA. Colonic J-pouch reconstruction seems to be superior to the straight coloanal anastomosis, especially during the first postoperative year. In view of the often poor prognosis of the patients, it is the reconstruction of choice after ultra-low resections of the rectum.

[Evidence-based surgery of rectal carcinoma]. / Evidence-based Chirurgie des Rektumkarzinoms.

The surgery of rectal cancer has seen significant development in recent years. When there is a multitude of therapeutic options available, it is essential to identify what can be considered a proven standard or, at least, what has to be included in planning a surgical treatment. Therefore, at this point of time a distal resection margin of 2 cm, total mesorectal excision, en-bloc resection of adherent structures, colonic pouch reconstruction after very deep resections and limitation of local excision to T1/G1 tumors have to be regarded as standards of the surgical strategy.

Pancreatoblastoma: ultrastructural and image DNA cytometric analysis.

BACKGROUND: Since the first description of a pancreatoblastoma as a malignant pancreatic tumour of childhood in 1957, approximately 60 cases have been reported. We present the symptoms, pathology, and therapy of this rare tumour in a 17-year-old girl. CASE REPORT: The patient initially presented with upper gastro-intestinal bleeding. During laparotomy a 16-cm (diameter) tumour was recognized in the pancreatic tail. Open biopsy and radical resection, followed by histological and immunohistochemical examinations, confirmed the diagnosis of a pancreatoblastoma. The results of single-cell DNA cytometry underlined the low DNA grade of malignancy of the primary tumour. In spite of adjuvant chemotherapy with cisplatin and adriamycin, the patient returned 22 months later with many hepatic and peritoneal metastases measuring up to 5 cm in diameter. Peritoneal tumour debulking and an extended hemihepatectomy were performed as a palliative treatment. Unfortunately, the patient died 18 months later from further tumour progression. CONCLUSIONS: A review of the literature reveals that a pancreatoblastoma in childhood has to be considered malignant, but usually shows a favourable prognosis in contrast to pancreatic neoplasms in adult patients. The treatment of choice is radical resection. Adjuvant chemotherapy or radiotherapy should be considered because of the metastatic potential of the tumour.

Functional impairment and complaints following incisional hernia repair with different polypropylene meshes.

The influence of mesh material on the clinical outcome of hernia repair has often been neglected, although recent studies have clearly demonstrated the importance of mesh properties for integration in the abdominal wall. Of particular significance are the amount of mesh material and the pore size. In the following study, patients received different mesh types with distinct amounts of polypropylene and of various pore sizes for incisional hernia repair. We investigated whether the type of material influenced the clinical and functional outcomes. Between 1991 and 1999, 235 patients received polypropylene meshes in a sublay position for incisional hernia repair: 115 patients were implanted with a Marlex heavy-weight mesh (Mhw mesh), 37 patients with an Atrium heavy-weight mesh (Ahw mesh) and 83 with a Vypro low-weight mesh (Vlw mesh). The study protocol included ultrasound examination and 3D-stereography in all patients, with a total follow-up of 24 +/- 13 months (Mhw-mesh), 11 +/- 8 months (Ahw-mesh) and 8 +/- 7 months (Vlw-mesh). Our findings demonstrate that the side effects of mesh implantation, comprising paraesthesia and restriction of abdominal wall mobility, were significantly affected by the type of material implanted. Three-dimensional stereographic examinations were well in accordance with our clinical findings. Our data support the hypothesis that the use of low-weight large-pore meshes is advantageous for abdominal wall function.

[Tumor surgery and quality of life--reconstructive rectal surgery]. / Tumorchirurgie und Lebensqualität--Rekonstruktive Rektumchirurgie.

Numerous innovations in recent years have allowed a variable therapeutic approach for rectal cancer with a concomitant drastic reduction in extirpations. This development was paralleled by an increasing research into postoperative quality of life in colorectal cancer. This showed that a very ambitious preservation of the sphincter does not automatically lead to good quality of life. On the other hand is the expectation of healing a generally important factor in a good quality of life. Whether routine evaluation of quality of life data does in fact improve medical care is an open question.

Vascular organization in the mesorectum: angiography of rectal resection specimens.

The technical advances in rectal cancer surgery are known as the total mesorectal excision. The resection in an anatomically defined plane under direct vision and with sharp dissection distinguishes it conventional rectal surgery. The result must be a complete mesorectum without deep gouges. We performed specimen angiography to confirm completeness of the removed mesorectum. Thirteen total mesorectal excision specimens were examined by angiography after continence-preserving resection of rectal carcinoma. In 11 of the 13 cases the vascular supply was exclusively via the superior rectal artery. In two cases with hypoplastic left terminating branches of the superior rectal artery there was additional perfusion via a caudally ascending vessel or via smaller vessels connected laterally. In all specimens both arterial supply and venous outflow were located within the mesorectal fascial sheath. There was no radio-opaque substance leaking from the mesorectal surface in the case of a complete mesorectal specimen. Tiny vascular branches running laterally occurred in 7 of the 13 cases. We found no larger vascular connections branching off in the lateral direction. The rectal blood supply comes almost exclusively through the superior rectal vessels. Thus the fascia covering the mesorectum forms, as far as rectal vascularization is concerned, a closed compartment. The mesorectal vessels are enclosed in the fibrous avascular mesorectal fascia. They run close above the fascia. In the case of an incomplete mesorectal excision the specimen angiography shows a stain leaking from the mesorectal fascia. Our method can be used to confirm the completeness of the removed mesorectum.

[Primary liposarcoma of the stomach wall--a rare mesenchymal tumor]. / Primäres Liposarkom der Magenwand--ein seltener mesenchymaler Tumor.

INTRODUCTION: Primary liposarcoma of the stomach wall is rare. Only eight cases have been described so far. MATERIAL AND METHOD: Here we report the ninth case, occurring in a 74-year-old woman who presented with weight loss and a therapy-resistant ulcer of the stomach wall. RESULTS: Pre- and perioperative findings suggested a benign lipoma of the stomach wall. The patient was treated with subtotal gastrectomy. On microscopic examination the tumor showed features of a benign lipoma but for a distinctive capillary net. Immunohistochemically the S-100 reaction was positive. Less than 1% of Ki67-positive cells could be found, thus suggesting a highly differentiated primary liposarcoma of the stomach wall. CONCLUSION: In situations where the benign or malignant nature of a submucosal lesion cannot be diagnosed with certainty a mesenchymal tumor of the stomach wall has to be included in the differential diagnosis. Here the indication for complete surgical excision and histological workup has to be set widely.

The repair of large parastomal hernias using a midline approach and a prosthetic mesh in the sublay position.

Parastomal herniation is a very frequent complication in enterostomy. The therapeutic strategy consists of three approaches: local fascial repair, relocation of the stoma, and a variety of more elaborate procedures, many of which also involve the use of nonabsorbable meshes. Despite this multitude of available techniques, recurrence rates are high, and long-term complications, especially after mesh implantation, are frequent. In order to improve operative results, we would suggest that a parastomal hernia be treated like a subtype of incisional herniation and that methods be employed that have proved to be effective in this situation. A midline approach allows the operation to be performed under practically sterile conditions. The reinforcing mesh is placed in a sublay position, using a combined intraperitoneal and epifascial preparation. Any direct contact between mesh and intestines is thus avoided. A new type of mesh with substantially reduced polypropylene content decreases the occurrence of both early and late complications.

[Value of positron emission tomography (18F-FDG-PET) in the diagnosis of recurrent rectal cancer]. / Die Wertigkeit der Positronen-Emissionstomographie (18F-FDG-PET) in der Diagnostik von Rectum-Rezidivcarcinomen.

INTRODUCTION: Diagnosis of extraluminal recurrent rectal cancer may be difficult. Currently the diagnosis is based on routine imaging procedures. Diagnosis often remains unverified until histological proof can be acquired by transcutaneous biopsy or operative exploration. The diagnostic value of positron emission tomography (PET) in recurrent rectal cancer was evaluated in a prospective study at the Department of Surgery of the RWTH Aachen University Hospital. The aim of the study was to assess the sensitivity of PET in the detection of recurrent rectal cancer in comparison with conventional procedures. Furthermore, the valency of PET in the diagnosis of the local expansion and metastasis was evaluated. METHODS: Since June 1997, PET has been performed in all patients with suspected recurrent rectal cancer. The examined area reaches from the neck to the symphysis. Visual assessment follows transversal, frontal and sagittal sector scans. Enhanced focal FDG uptake over the physiological enrichment of the environment (e.g., urinary tract) was defined as a criterion of malignancy. The findings were compared with the results of routine diagnosis and histological examinations. RESULTS: Up to now, 23 patients have been subjected to a PET examination. In 17 cases, a local recurrence could be proved. An intrahepatic metastasis was found in 11 patients, pulmonary metastasis in 3 patients, lymph-node metastasis in 5 patients, and a peritoneal carcinomatosis was found in 4 patients. All these findings were confirmed by histological examinations after biopsy and operation or by other imaging procedures and the clinical follow-up. CONCLUSIONS: The controlled results show that PET can detect recurrent rectal cancer and its metastasis with great precision. PET seems to be a useful additional examination in the diagnosis of extraluminal recurrent rectal cancer.

[Risk factors for anastomosis dehiscence after very deep colorectal and coloanal anastomosis]. / Risikofaktoren der Anastomoseninsuffizienz nach sehr tiefer colorectaler und coloanaler Anastomose.

INTRODUCTION: Very low colorectal anastomoses are considered to be more prone to complications than other anastomoses. We aimed to analyze possible risk factors for the surgically most relevant complication, anastomotic leakage. METHODS: Uni- and multivariate analysis of the relation between leakage and 18 patient- and procedure-dependent variables were performed in 98 patients after very low colorectal or coloanal anastomosis. RESULTS: In all, 18 patients developed a dehiscence. Two patients, both without a protective stoma, died because of the leakage (overall mortality 2%). From all analyzed variables, only smoking remained as an independent risk factor for anastomotic dehiscence. For all other parameters, such as protective stoma, experience of the surgeon, stage of tumor, radiation therapy, or the need for blood transfusions there was no significant correlation. CONCLUSIONS: From our study, a typical risk pattern for anastomotic dehiscence, with the exception of being a smoker, cannot be defined. Presumably, anastomotic leakage is being caused by a multitude of factors, such as a preexisting or intra-/postoperatively developing reduction of microperfusion, which have a strong influence but cannot be as readily evaluated as other parameters. Until this situation improves, protective stomata, which do not prevent leakage but attenuate the consequences, should be used regularly.