[Primary gastric lymphoma]. / Primäre Magenlymphome.

Primary gastric lymphoma derives from a secondary MALT system developing after a reaction of the immune system, e.g. following chronic gastritis induced by Helicobacter pylori. Morphologically, follicular hyperplasia is found in the gastric mucosa. The pathoetiologic model confirms the transformation of a malignant lymphoma from low grade to high grade by demonstrating increasing autonomous proliferation and, finally, uncontrolled dissemination. Modern diagnostic tools are essential for staging and planning an adequate therapeutic strategy. At present, the therapeutic strategies regarding primary lymphoma are under discussion. Nevertheless, the consensus of international medical and surgical associations still recommends surgical therapy with curative intention for low-grade malignant lymphomas staged I 2-II 2. In cases of high-grade malignant lymphoma, conservative therapy is supposed to be similarly successful. The recent success of noninvasive therapeutic concepts seems to justify the application of triple eradication medication in case of Hp infection as well as radio- and chemotherapy in low- and high-grade malignant lymphomas. However, in cases of nonremission or therapy-associated complications such as uncontrollable bleeding or tumor perforation, surgery is the only therapeutic option. Regarding the oncological aspects of lymphoma growth, surgery should then be performed in order to achieve R0 resection.

Laser-induced interstitial thermotherapy of liver metastases in an interventional 0.5 Tesla MRI system: technique and first clinical experiences.

Laser-induced interstitial thermotherapy (LITT) surveyed by magnetic resonance imaging (MRI) has been shown to be effective in various applications. The laser treatment of colorectal liver metastases usually requires a separate device (e.g., ultrasound or CT) to position the laser applicator. In this study, we used an interventional 0.5 T MRI system, allowing both the navigation to the target tissue and on-line thermometry. Laser irradiation was performed using a near-infrared laser source combined with a cooled laser light guide. We treated 20 patients exhibiting a total of 58 colorectal liver metastases. Clinically relevant complications did not occur. No residual tumor was observed after laser irradiation in all metastases with a diameter below 2 cm. Metastases with a mean diameter between 2 and 3 cm demonstrated total necrosis in 71%, while in larger tumors this proportion decreased to 46% (diameter, 3-4 cm) and 30% (diameter, >4 cm), respectively. We conclude that LITT, guided by the employed interventional MRI system, is feasible and safe. The results suggest a more aggressive treatment, especially for larger metastases. J. Magn. Reson. Imaging 2001;13:729-737.

Helicobacter pylori in the upper gastrointestinal tract: medical or surgical treatment of gastric lymphoma?

The treatment of primary gastric lymphoma is controversial. The role of surgery has come to be questioned with increasing knowledge about the pathogenesis of gastric lymphoma and with new therapeutic approaches such as eradication of Helicobacter pylori. We review published clinical trials of primary gastric lymphoma, including preliminary results of our own prospective multicenter trial. The results of 7 trials of H. pylori eradication and 12 prospective therapeutic trials trial are discussed. On basis of these data it is concluded that surgery with intention of R0 resection is the treatment of choice in stages EI2 and EII1 of low-grade lymphoma. In high-grade lymphomas it is still unclear whether surgery or its primary combination with radio- or chemotherapy should be preferred. The eradication of H. pylori is a promising therapeutic approach for localized low-grade mucosa-associated lymphoid tissue lymphoma. A randomized trial is needed to clarify whether medical or surgical management of localized gastric lymphoma or a combination of two is the best treatment modality.

[Principles of surgical management of stromal tumor]. / Prinzipien des chirurgischen Vorgehens beim Stromatumor.

Gastrointestinal stromal tumors (GIST) have been regarded as rare tumor manifestations of the mesenchymal tissue fraction of the intestinal building principle; however, this tumor is now established as an independent tumor entity owing to independent immunohistochemical and ultrastructural characteristics. In spite of increasing awareness of their biological behavior and their molecular-biological basis, evaluating the grade of many of these tumors remains open, not only on a preoperative but also on a postoperative basis. Thus, how radical the surgical procedure must be is not standardized, as it is in carcinoma surgery. The literature available today is not sufficient to make a valid analytical assumption possible because of small numbers of cases and the heterogeneity of clinical and pathological variables. Therefore, recommendations concerning oncological-surgical radicality have at this time an empirical character. Owing to the rarity of the tumor, this will probably not change in the near future. Adjuvant therapeutical treatment of relevant effectiveness does not exist. Therefore, the radicalness of the operation is organ-specific, tumor-specific and based on tumor-biological criteria.

Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain.

OBJECTIVE: To assess the value of plain abdominal radiographs and of data from the medical history and physical examination in the diagnosis of acute abdominal pain in general and of bowel obstruction in particular. DESIGN: Prospective study. SETTING: 4 university and 2 community hospitals, Germany. SUBJECTS: 1254 patients with acute abdominal pain lasting less than 7 days, and with no history of abdominal injury including surgery. INTERVENTIONS: Standardised and structured medical history and physical examination, study of results of plain abdominal radiographs. MAIN OUTCOME MEASURES: Positive predictive value and sensitivity of clinical variables and abdominal film with respect to the diagnosis at discharge. RESULTS: 48 patients (3.8%) had bowel obstruction. 704 patients (56.1%) had plain abdominal films taken at the time of initial presentation. 111 studies (15.8%) showed important findings leading to diagnosis or immediate treatment, 455 (64.7%) showed unimportant or no findings. In 138 (19.6%) results of films were not reported. 16 of 45 single variables were of help in diagnosing bowel obstruction. The six with the highest sensitivity were distended abdomen, increased bowel sounds, history of constipation, previous abdominal surgery, age over 50, and vomiting. If only patients presenting with any two of these symptoms had had radiographs taken, 300 (42.6%) could have been avoided without loss in diagnostic accuracy. CONCLUSION: A considerable number of plain abdominal films taken for patients with acute abdominal pain could be avoided by focusing on clinical variables relevant to the diagnosis of bowel obstruction.

[Stage-adapted radical principles in gastric carcinoma]. / Stadienadaptierte Radikalitätsprinzipien beim Magenkarzinom.

The aim of any surgical approach to gastric carcinoma should be a complete resection with no residual tumor left behind, that is, a R0-resection according to UICC. Complete tumor resection in this respect refers to the primary tumor as well as to the lymphatic drainage and requires an adequate safety margin. The indications for surgical therapy of gastric cancer and the choice of procedure should consequently be guided by the tumor stage. This requires accurate preoperative staging, which can today be achieved with endoscopic ultrasonography and surgical laparoscopy. Gastric carcinoma stage IA (mucosa carcinoma) can be cured by local excision. In patients with tumor Stages IB (submucosa carcinoma), II, and IIIA, lymph node metastases are common. Based on the available data, this group of patients benefits from radical resection and D2 lymph node dissection. The overall 5-year survival rate of 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of extended lymphadenectomy. In patients with advanced gastric carcinoma, that is, tumor stages IIIB and IV, a complete tumor removal usually can not be achieved by surgical dissection. Neoadjuvant therapeutic modalities should consequently be assessed in these patients. Based on tumor location and growth pattern, a total gastrectomy is the procedure of choice in patients with middle and proximal third gastric cancer. A subtotal gastrectomy may be performed in patients with tumors of the distal third and "Laurens intestinal type" growth pattern. The distal site of the main lesion must be investigated carefully to ensure that incidental concomitant lesions are not overlooked. Depending on the individual tumor situation, the gastrectomy can be extended toward varying portions of the distal esophagus or the pancreas, preserving splenectomy and resection of the retroperitoneal lymph nodes. The high incidence of locoregional recurrences and distant metastases after curative surgery for gastric cancer calls for improved locoregional control and systemic adjuvant treatment.

[Early stomach carcinoma--pathologic-anatomic findings and prognosis]. / Das Magenfrühcarcinom--Pathologisch-anatomische Befunde und Prognose.

BACKGROUND: The therapy for early gastric cancer (endoscopy, gastric resection, D1/2 dissection) is controversial. MATERIALS AND METHODS: In a retrospective study (4/86-12/95) we analyzed the prognosis of 57 early gastric cancer patients with respect to pathological findings and surgical therapy. RESULTS: The R0 resection rate was 100%. In 7% multifocal tumor growth was seen. The 5-year survival rate was 70%. LN-metastases were found in 12% of all cases, more often in pT1b than in pT1 a tumors (17 vs 9%) and more often in large carcinomas than in small carcinomas (> 1000 mm2: 27%; < 300 mm2: 0%). Long-term survival was significantly better in pN0 patients than in patients with LN metastasis (P = 0.020). CONCLUSION: Prognosis of early gastric cancer after curative resection is good.

[Current therapeutic strategy in primary intestinal non-Hodgkin's lymphoma]. / Aktuelle therapeutische Strategie des primären Intestinalen Non-Hodgkin-Lymphoms.

Of all surgical interventions of intestinal non-Hodgkin's lymphomas 58% (15 or 26 patients) are performed in an emergency situation. In 42% of cases, examination by ultrasonography, endosonography, intestinoscopy. Sellink's enema, thoracic, abdominal/pelvic CT and bone marrow puncture could determine the stage preoperatively. This could also be done by examining the regional and juxtaregional lymph nodes or performing a liver biopsy intraoperatively. Crucial for the therapy is in all cases the adequate staging even in emergency situations. Only special knowledge of the intestinal non-Hodgkin's lymphoma can lead to the necessary stage-adapted multimodal therapy--operation/irradiation/chemotherapy.

[Perspectives of virtual control of visceral surgery interventions in open MRI]. / Perspektiven der virtuellen Kontrolle viszeralchirurgischer Eingriffe im offenen MRT.

Since July 1997 we have operated on 23 patients with different visceral surgical diagnoses in an open-configured Magnetic Resonance System (MRI). Among them we found 7 patients with benign soft tissue tumors, 5 patients with anal fistulas, 1 patient with an abscess on the pelvic wall, 1 patient with a rectocele, 1 patient with an inoperable, restrictive oesophageal carcinoma, and 8 patients with metastatic lesions in the liver. In the last 8 patients we performed MRI-guided laser-induced interstitial thermotherapy, in one patient in an open development. We did not face any postoperative complications. The median duration of the intervention was 2 hours, pre- and postscans included. Our experiences show that it is possible to carry out visceral surgical interventions in the open-configured MRI. The main indications we see now are anal fistulas, soft tissue tumors and MRI-guided laser-induced interstitial thermotherapy of liver metastases.

[Therapy planning and surgical indications for Crohn-associated anal fistulas]. / Therapieplanung und Operationsindikation Crohn-assoziierter Analfisteln.

A prospective study conducted from April 1988 to April 1998 in 83 patients with anal fistulas associated Crohn's diseases registers and evaluates data regarding the type of fistula, the planned therapy, the operative procedure, and the therapy itself. The choice of the operation time with special regard to the type of fistula and the presence of proctitis as well as the interdisciplinary management in cooperation with the gastroenterologist and the strict observance of the operative procedure for the different types of fistulas enable individually defined surgical treatment of anal fistulas associated with Crohn's disease. It is important that the primary intervention be performed by a surgeon who is experienced in classifying the different types of fistulas because of the recurrence rate of 23% and the required interval between the first and final surgical intervention and so that patients are well informed.

[Perioperative therapy of HIV infections]. / Perioperative Therapie bei HIV-Infektionen.

A meta-analysis of the literature demonstrates high operation complication rates in HIV-positive patients. Own experience connected with a general hospital in San Francisco, University of California, indicates that such an analysis provides the surgeon with the possibility of optimizing the treatment of HIV-positive patients in the perioperative phase.

[Roentgen imaging in acute abdominal pain is dispensable]. / Röntgennativaufnahmen bei akuten Bauchschmerzen sind vermeidbar.

Plain abdominal X-ray films are overused in patients with acute abdominal pain. Focusing on medical history and physical examination helps to reduce the number of plain films used and saves costs.

[MALT-lymphoma--surgical therapy]. / MALT-Lymphome--chirurgische Therapie.

To perform laparotomy in each histological sub-type of a primary gastric lymphoma with the intention of a total resection seems to be rather aggressive and should be seen with respect to other effective treatment modalities. But for curative treatment total gastrectomy with systematic lymphadenectomy or sampling respectively seem to be necessary. Classification is changing and there is an uncertainty about nature and dissemination of the tumor and even an uncertainty with respect to diagnosis. Basic informations become available only by standardized operative procedures. Multi-modal therapy planning is based on this knowledge but it has to hold up to clinical investigation such as the German multi-center trial. Preliminary data show an overall total resection rate of 88%.

[Intra-disciplinary therapy strategy in esophageal carcinoma from a surgical viewpoint]. / Interdisziplinäre Therapiestrategie beim osophaguskarzinom aus operativer Sicht.

Extensive long segment resection for carcinoma of the esophagus including also consequent mediastinal and celiac lymph node dissection is able to achieve satisfactory radicality only in early tumor stages while there is little influence on long term prognosis for advanced tumor stages. Only better risk analyses and improved surgical outcome with reduced operative mortality has improved the overall outcome. In locally limited primary tumors and even more in locally advanced stages generalisation or dissemination of tumor disease is to be expected. Therefore it is generally agreed upon that only multimodal therapy including systemic chemotherapy and local radiotherapy is able to improve therapeutic results in this disease with otherwise very poor prognosis. We report our own experience on 200 esophageal resections including modification of our strategy and protocol presently in use for tumor stages IIB to IV.

[Standard intervention in primary lymphoma of the stomach--initial results of a prospective multicenter study]. / Standardeingriff beim primären Magenlymphom--Erste Ergebnisse einer prospektiven Multizenterstudie.

An R0 resection seems to be a rather aggressive treatment, but can be achieved in 80% of localized gastric lymphomas and should be seen in contrast to other effective treatment modalities. For curative treatment at stage EI1-EII1, total gastrectomy with systematic lymphadenectomy (D2) seems to be necessary. Basic information about the clear diagnosis, tumor dissemination and the individual prognosis only becomes available by a standardized operation as part of multimodal therapeutic concepts.

[Primary non-Hodgkin lymphoma of the stomach--surgical aspects]. / Primäres Non-Hodgkin-Lymphom des Magens--chirurgische Aspekte.

In each histological subtype of a primary gastric non-Hodgkin lymphoma laparotomy is performed with the intention of an R0 resection. This concept appears to be rather aggressive if you take into account the possibilities of the other treatment modalities; however, because of the diagnostic uncertainty and of the changing histologic classifications there is an uncertainty about the character and the dissemination of the tumor. Consequently total gastrectomy with systematic lymphadenectomy provides enough basic informations to plan multimodal therapeutic concepts and their clinical evaluations.

Transhiatal oesophagectomy compared with transthoracic resection and systematic lymphadenectomy for the treatment of oesophageal cancer.

OBJECTIVE: To compare the results of transhiatal oesophagectomy with those of transthoracic resection with systematic two field en bloc lymphadenectomy in the treatment of carcinoma of the oesophagus. DESIGN: Prospective open (non-random) study. SETTING: University hospital, Germany. SUBJECTS: 87 patients with carcinoma of the oesophagus of whom 46 underwent transhiatal, and 41 transthoracic resection. MAIN OUTCOME MEASURES: Morbidity and short and long term mortality. RESULTS: The type of operation was chosen on clinical grounds, and the groups were comparable except for site and type of tumour, and nodal stage. The hospital mortality was 7/46 (15%) in the transhiatal group and 4/41 (10%) in the transthoracic group. The most common complication was anastomotic leak (23/46, 50%, compared with 10/41, 24%, p = 0.014), followed by major pulmonary complications (16/46, 35%, compared with 12/41, 29%), and cardiac complications (12/46, 26% compared with 11/41, 27%). Median survival was 350 days in the transhiatal group and 378 days in the transthoracic group. The percentage survival after one, two, and three years in the two groups was 48 and 55, 26 and 18, and 21 and 17, respectively. There were no significant differences in short or long term mortality. CONCLUSION: We have been unable to show that the oncologically more radical procedure (transthoracic resection with systematic two field en bloc lymphadenectomy) results in longer survival, but we have shown that it can be done with similar morbidity and short term mortality. Because it is possible to stage the disease exactly with a transthoracic resection, and because published reports from other centres have hinted at improved prognosis after it, we shall continue to do the operation for suitable patients.

[Surgical therapy of uncomplicated ulcer: results of a prospective epidemiologic study. DUSUK Study Group]. / Operative Therapie beim unkomplizierten Ulcus: Ergebnisse einer prospektiven epidemiologischen Studie. DUSUK-Studiengruppe.

In a prospective, multicenter and interdisciplinary study (DUSUK I) the present position of elective surgery in uncomplicated peptic duodenal and gastric ulcers was evaluated. Ten Düsseldorf hospitals (surgery and internal medicine) participated in the study. The investigation focussed on the proportion of operated patients related to hospitals and clinical disciplines, the operative procedure and results and possible selection criteria for the indication of operation. In the study period a total of 1030 patients with uncomplicated peptic ulcer was documented, an incidence of indoor patients with uncomplicated peptic ulcers of 180/100,000 inhabitants/year and an incidence of elective ulcer surgery of 7.5/100,000 inhabitants/year was calculated. Patients primarily admitted to surgical units were operated in 27% of cases (39/146) in contrast to 0.5% (4/884) of patients primarily admitted to internal units. The majority of hospitals perform rare or no elective peptic ulcer surgery at all. There is a considerable difference between the hospitals and clinical disciplines. The collective of operated patients concentrated on young patients with positive ulcer history. In the long run a negative effect on surgical training and results is apprehended.

[Prognostic factors in curative resection of stomach carcinoma. A uni- and multivariate analysis]. / Prognostische Faktoren beim kurativ resezierten Magenkarzinom. Eine uni- und multivariate Analyse.

The TNM system, including tumor infiltration (T category), lymph node infiltration (N category) and metastasis (M category), is a well-established system of prognostic factors. To evaluate the prognostic importance of patient characteristics and tumor parameters 5 clinical and 13 pathological factors were analyzed. Data on 200 consecutive patients with histologically verified stomach cancer were prospectively recorded using a standardized form. In the subgroup with curative resection (R0, n = 108) a uni- and multivariate analysis was performed with respect to 5-year survival. In the univariate analysis statistical significance was demonstrated for the following factors: tumor size, tumor localization, T category, N category, number of infiltrated lymph nodes infiltrated, lymph node compartments, tumor stage, lymph node ratio: infiltrated/inspected. Multivariate analysis, taking into consideration the interaction between prognostic factors, revealed only two factors as statistically significant: number of infiltrated lymph nodes and tumor size. Our results and those in the literature indicate that the infiltration of lymph nodes is the most relevant prognostic factor. In addition to the TNM system the number of infiltrated lymph nodes seems to be of prognostic importance.

Multivisceral surgery in advanced gastric carcinoma.

From April 1986 to June 1994 a total of 284 patients with gastric carcinoma were admitted to the authors' department. Mainly advanced tumour stages were seen: stage I = = 23%, II = 13%, III = 22% and IV = 42%. In 256 tumour resections (resection rate = 90%) multivisceral surgery (mvs) was necessary in 146 patients (mvs = 57%). Long-term survival of stage IV gastric cancer patients cannot be prolonged by mvs, and RD-resection can be achieved in few patients (9/120 = 7.5% in stage IV). Perioperative morbidity, postoperative complications and the mean postoperative hospital stay were increased after extensive surgery. Major complications were anastomotic leakage, local infections and pulmonary diseases. Even when resection seems to be an acceptable palliation for stage IV gastric cancer patients, mvs in only justified where RD-resection seems achievable.