Improved Access to Organo-Soluble Di- and Tetrafluoridochlorate(I)/(III) Salts.

A facile one-pot gram-scale synthesis of tetraalkylammonium tetrafluoridochlorate(III) [cat][ClF4 ] ([cat]=[NEt3 Me]+ , [NEt4 ]+ ) is described. An acetonitrile solution of the corresponding alkylammonium chloride salt is fluorinated with diluted fluorine at low temperatures. The reaction proceeds via the [ClF2 ]- anion which is structurally characterized for the first time. The potential application of [ClF4 ]- salts as fluorinating agents is evaluated by the reaction with diphenyl disulfide, Ph2 S2 , to pentafluorosulfanyl benzene, PhSF5 . The CN moieties in acetonitrile and [B(CN)4 ]- are transferred in CF3 groups. Exposure of carbon monoxide, CO, leads to the formation of carbonyl fluoride, COF2 , and elemental gold is dissolved under the formation of tetrafluoridoaurate [AuF4 ]- .

[Transanal staplermucosectomy for symptomatic rectocele with outlet obstruction]. / Die transanale Stapler-Mukosektomie zur Therapie der symptomatischen Rektozele mit Outlet Obstruction.

Between 1.1.2001 and 30.6.2002 n = 52 female patients with symptomatic isolated anterior rectocele underwent transanal staplermucosectomy. All of them were suffering from outlet obstruction. In addition 9 patients complained incontinence grade I and n = 1 incontinence grade III. Complete colonoscopy, defecography and combined anal manometry with needle EMG were carried out preoperativly for exclusion of synchronous pathological findings. Sphinctermanometry showed a significant lower preoperative resting pressure (p < 0.01, t-test ) of 77.0 +/- 21.0 cm H (2)O in comparison to a normal collective. Surgical procedure consisted in a modified staplerresection of the rectocele area with tightening of the anterior rectal wall. No intraoperative complications occurred and outlet obstruction disappeared in all patients. Further investigations have to be performed to show long-term effects of this procedure.

[Rectal prolapse--laparoscopic resection and results]. / Rektumprolaps--laparoskopische Resektion und Ergebnisse.

postoperatively Seventeen females presenting rectal intussusception with a combined outlet obstruction underwent laparoscopic resection of the rectum (n = 4) or rectum and sigma (n = 13). Mean age was 61.5 +/- 9.7 years, mean duration of surgery took 117 +/- 30.4 minutes, realimentation started 3.5 +/- 1.3 days postoperatively and the mean stay in hospital lasted 11.8 +/- 2.9 days. In all patients an ano-rectal pressure-measurement and EMG were carried out. There was a significant lower resting-pressure of the anal sphincter in comparison to a normal collective of healthy patients with 67.8 +/- 21.6 cm H2O (p < 0.006). Postoperatively one severe complication with a generalized peritonitis and a resulting ARDS occurred. No perioperative mortality had to be remarked. Our results show that laparoscopic resection in patients with a rectal intussusception and outlet obstruction is safe. Wether rectal intussusception apart of rectal prolapse is an entity of its own, has to been shown in further investigations.

[The amelanotic melanoma of the rectum]. / Das amelanotische Melanom des Rektums.

The amelanotic melanoma of the rectal mucosa is a very rare, difficult to discover tumor. We report on a 65-year-old female patient with an amelanotic melanoma of the rectum who underwent several transanal resections and finally, after an exact histological diagnosis,was treated by abdominoperineal excision. The present case emphasizes the necessity for an obligate histological examination of all suspicious alterations of the anorectum. Even with a very unfavourable prognosis, the amelanotic melanoma of the anorectum should be treated by radical surgical procedures to achieve a significant prolongation of life.

Laparoscopic-assisted coloscopic polypectomy.

PURPOSE: Patients with colorectal polyps often display a large kink or distinct mucosal fold in the area where the polypectomy is to take place. As a result, there is a higher risk of perforation or partial ablation during an endoscopic polypectomy. Is it safer to perform an endoscopic polypectomy using the control and assistance of a laparoscope? Can a segment resection of the colon that would otherwise be necessary be avoided? METHODS: An endoscopic polypectomy using a laparoscope was conducted on six patients whose colorectal polyps were in an anatomically unfavorable location. The need for an open or laparoscopic segment resection or colotomy was indicated in all cases. The growth was located in the rectosigmoidal transition in five patients and in the region of the left flexure in one patient. We decided that an endoscopic polypectomy using the assistance of a laparoscope would be the most comfortable and technically elegant method, as well as easy. Except the well-known risks of laparoscopy and endoscopic polypectomy, no other risks have been seen in our patients. The affected area of the colon, the sigma, and the left flexure were mobilized and stretched as much as possible to enable a simultaneous and low-risk endoscopic polypectomy. In one case, we had to conduct a fractionated ablation because of a very wide-based finding. RESULTS: The operation averaged 57 minutes, and no operation-specific complications were observed. Postoperative recovery in the hospital was very short and averaged 2.5 days. The histopathologic findings were benign in all cases, but a serious dysplasia was diagnosed in one patient. CONCLUSIONS: The laparoscopic-assisted polypectomy is a safe method to remove even complicated polyps in anatomically unfavorable locations.

[Fournier gangrene as a rare complication after stapler hemorrhoidectomy. Case report and review of the literature]. / Fournier-Gangrän als seltene Komplikation nach Staplerhämorrhoidektomie. Kasuistik und Literaturübersicht.

Fournier's gangrene is a well known often fatal fasziitis of the pelvic floor following ano-rectal, urologic and gynecologic infections. Although rarely it is described as a complication of operative anal procedures and predisposing factors such as diabetes, alcoholism, immune-defects and consumptive diseases. To our knowledge the described case of a lethal outcome after staplerhemorrhoidectomy is the first one reported in literature.

[Stapler hemorrhoidectomy. A new alternative to conventional methods]. / Die Stapler-Hämorrhoidektomie. Eine neue Alternative zu den konventionellen Methoden.

Conventional, generally accepted methods of hemorrhoidectomy as the methods of choice in the therapy of IIIrd and IVth degree hemorrhoids often involve problems of attaining sufficient mucosa preservation or are technically highly complex. A new surgical procedure, stapler hemorrhoidectomy, is less risky, permits the preservation of more mucosa, and takes significantly less time (only 5 to 15 minutes) than conventional procedures. Especially important is the high degree of acceptance on the part of patients and operators. The operation is based on the principle of a mucosectomy at least 2 cm above the dentate line. A purse-string suture placed 3-4 cm above the dentate line is tied around the stapler shaft (Ethicon Endosurgery SDH 33). Then the resection and stapling of the mucosa are carried out. This procedure effectively reduces mucosa and blocks the end branches of the upper rectal artery, thus stopping venous and arterial blood flow of the hemorrhoidal plexus. During the period April-September 1998 we treated 42 patients with an average age of 55.5 years using stapler hemorrhoidectomy. We treated IIIrd-IVth degree hemorrhoids (in 29% of cases), partial (in 22% of cases) and circular mucosa prolapse (in 49% of cases). The complication rate was 14%; we observed one case of bleeding, two submucosal hematomas, one partially interrupted suture, one short incontinence (I degree after Parks), and one partial recurrence. All complications occurred at the start of application of the new method and could be brought under control with no difficulties; after a short time the patients were without any discomforts whatsoever. In particular, post-operative pain was generally slight, measuring by means of the visual analog scale (VAS) ranging from 0-100. From the day of the operation until the 21st postoperative day the pain score ranged from 0 to 35. The use of analgetics was significantly less, with 50% of the patients not using analgetics on and following the 1st postoperative day. First experiences with stapler hemorrhoidectomy have shown that patients with distinct hemorrhoids and/or mucosa prolapse benefit greatly by this procedure, when indications and operative techniques are correctly used.

[Malignant lymphomatous polyposis--a rare disease entity of malignant centrocytic lymphoma with characteristic endoscopic appearance]. / Die maligne lymphomatöse Polypose--eine seltene Krankheitsentität des malignen zentrozytischen Lymphoms mit charakteristischem endoskopischen Aspekt.

It is considered as special gastrointestinal manifestation on the nodal centrocytic lymphoma of intermediate malignancy. We demonstrate a 77 years old male patient, who underwent colonoscopy because of rectal bleeding. We found the colonic mucosa dotted with small, flat, lentiform polyps. In the terminal ileum these polyps were much larger. No changes were seen in the esophagus. In the antrum we found flat elevations and in the duodenum again lentiform nodules. Presenting in stage IV of non-Hodgkin's lymphoma the patient was treated with five cycles of combined chemotherapy with prednimustin and mitroxanthrone without side effects. Restaging showed distinct remission of the disease with significant reduction of the mucosal alterations.

Is manometry essential for surgery of chronic fissure-in-ano?

PURPOSE: Although many studies reported the association between high anal sphincter pressures and anal fissures, one question is open to date: is manometry really necessary for surgical management/does manometry influence the outcome? METHODS: Between October 1, 1990 and December 31, 1991, lateral sphincterotomy was performed in 177 patients with chronic anal fissure. In all patients the operation was performed as an outpatient procedure under local anesthetic. Electromanometry of the anal canal was carried out preoperatively to demonstrate the raised resting pressure profile within the anal canal. At the same time the maximum squeezing pressure was determined by electromanometry, and electromyography was performed to detect dysfunction of the external sphincter or the levators. The control group consisted of 14 proctologically healthy patients with a resting pressure of 74.4 +/- 8.9 and a maximum squeezing pressure of 130.2 +/- 15 (cm H2O). On the basis of resting pressures determined in healthy patients, an upper limit of 90 was defined as normal, taking into account the standard deviation and standard error rate. For statistical comparison patients were divided into two groups, retrospectively. All patients in Group A had a resting pressure of < or = 90, and all patients in Group B had a resting pressure of > 90. Six weeks after operation electromanometry was again performed to determine the resting pressure profile and maximum squeezing pressure of the sphincter system, and patients were examined to determine whether the fissure had healed. RESULTS: As a result of the lateral sphincterotomy, the resting pressure was lowered in all patients from 106.6 +/- 21.5 to 80.9 +/- 10.4 and maximum squeezing pressure from 149.3 +/- 27.6 to 135.3 +/- 27.2. Both results were highly significant (P < 0.001, chi-squared). Regarding either reduction in postoperative resting pressure or continence, Groups A and B did not differ statistically. In Group A soiling occurred in 3.2 percent and Grade 1 incontinence in 3.2 percent (1 patient each), and in Group B only one patient (0.7 percent) complained of soiling. Recurrences occurred in 9.7 percent of patients in Group A and in 2.1 percent of patients in Group B (3 patients in each case). CONCLUSION: Electromanometric examinations showed that internal sphincterotomy significantly reduces pressure within the anal canal, thus permitting the anal fissure to heal. No significant continence problems were observed. Although manometric selection of patients leads to different results regarding both postoperative continence and recurrence, these differences are not statistically significant. Therefore, it follows that, in experienced hands and using a standardized technique, manometry before surgical management of anal fissure by lateral sphincterotomy is probably superfluous.

[Stomach neurinoma]. / Das Magenneurinom.

Between 10 and 15% of all benign nonepithelial tumors of the stomach are neurinoma. The majority of these tumors originating from the plexus myentericus do not cause clinical symptoms. They become clinically important because of complications like hemorrhage, perforation or displacement of neighbouring organs. Typical clinical symptoms, laboratory data, radiological or endoscopic findings do not exist. The diagnosis neurinoma can only be established by histological examination; differentiation of myogenic tumors is often difficult. The surgical procedure has to take into account extension, localisation, and relation of the tumor to the stomach wall. If multiple neurinoma extending from the cardia to the pylorus are present total gastrectomy may be necessary.

[Sonographically guided and intraoperative alcohol block of the celiac ganglia in conservatively uncontrollable cancer-induced epigastric pain]. / Sonographisch gezielte und intraoperative Alkoholblockade der Zöliakalganglien bei konservativ nicht beherrschbaren malignombedingten Oberbauchschmerzen.

Preliminary results of sonographically controlled alcohol injection into the region of the coeliacal ganglion for treatment of medically intractable pain in inoperable pancreas carcinoma (6 patients) are compared with results of a similar treatment using a surgical approach (10 patients). Both procedures resulted in up to total pain relief and marked reduction of consumption of analgetics. Neurolysis of the coeliacal ganglion by means of sonographically guided alcohol injection seems to be a useful treatment to reduce pain in inoperable pancreas carcinoma.

Pancreatico-pleural fistula with chronic pleural effusion--endoscopic-retrograde visualization and therapy by ultrasonically--guided drainage.

In a patient with alcohol-induced chronic pancreatitis, a large chronic left-sided pleural effusion persisted after partial pancreatectomy (resection of the pancreatic tail). ERCP outlined a transdiaphragmatic fistula between the duct of the remaining pancreas and the pleural cavity. The effusion was removed by ultrasound-assisted thoracocentesis, and the fistulous canal was obliterated permanently.

Pulmonary hamartoma.

From 1973 to 1980, 9 pulmonary chondromatous hamartomas of the lung were resected at our Clinic. One of these hamartomas was a rare endobronchial chondroma. To our knowledge, 91 cases of endobronchial hamartomas have been described in the previous literature. Although a similar origin of intrapulmonary and endobronchial hamartomas is postulated, there is a difference in their clinical features. The endobronchial type of hamartoma often causes respiratory symptoms of obstructing the bronchus with consequent destruction of the distal lung, whereas patients with intra-pulmonary hamartomas are symptom-free.

Liposarcoma of the mediastinum. Case report and review of the literature.

A case of liposarcoma of the mediastinum in reported and a review of the literature is given. To our knowledge 53 cases have been described in the literature. The most common symptoms are dyspnea, chest-pain, a cough and loss of weight. There is no relation between operability, the duration of clinical symptoms and the size of the tumor. The final diagnosis was made by histological examination in all cases. A clinical classification of the tumor is not possible, because there are no characteristic clinical findings. The prognosis in general depends on the histological type of the malignant. Although recurrence of the tumor appears in more than 40% of cases, radical surgical resection is the only method of successful treatment. The significance of the five-year survival rate is doubtful, because recurrent tumors were reported up to 14 years after the initial surgical procedure.