Biomedical subjects
Publications and source records attributed to F Stelzner.
Radical surgical removal of colorectal carcinomas with removal of adherent related viscera and abdominal patients is today the only way for ultimate survival. Radiotherapy, excision of liver metastases and local or general chemotherapy have only an auxiliary palliative effect.
At the mouth of the oesophagus there is an aganglionic zone similar to that in the anorectal organ of continence. This is part of the system of permanent closure. Since the musculature at the oesophageal entrance is arranged in a screw-like fashion the aganglionic zone lies obliquely to the longitudinal axis of the oesophagus. Closure at the oesophageal entrance is further supported by a kind of corpus cavernosum similar to that in the rectum. In this pharyngeal corpus cavernosum blood is drained between the muscular fibres and their contraction prevents its drainage, thus facilitating the closure of the musculature. The constrictor pharyngeus muscle takes a similar course as does the puborectalis which leads to a bend in the anal canal. Thus also at the entrance to the gastrointestinal tract an arterial angiomuscular system of closure exists in the center of which an aganglionic segment is conspicuous.
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The closure systems of the gastro-intestinal canal are based on three major forms, constrictive sphincter, dilatory closure, and kinking closure. A constrictive sphincter is attached to the oesophageal inlet and a dilatory closure to the cardiac orifice. Reflux oesophagitis may result from failure of dilatory closure. Helical fibres in crosswise arrangement rather than isolated sphincters are recordable from the pyloric region. Their function is identical with that of dilatory closure. The principle of kinking closure applies to the Papilla Vateri and the ileocecal valve. Conclusions are suggested for therapeutic approach problems of the closure systems.
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Painful glomus tumors near the coccyx have not yet been described before. Three patients with coccygodynia were treated by excision of the glomus coccygeum. All of them were free of pain afterwards. Two glomus tumors were found. The tumors of the glomus coccygeum are compared with the well-known glomus tumors "Masson".
Pilonidal sinus is of the same origin as the Pyodermia fistulans sinifica . Both diseases are retention dermatopathies . These sinuses are not of congenital origin. Our observations have made an acquired origin seem more likely. Deep skin folds in the rima ani, the stiffness of the body hairs, the rolling movement of naturally separated hairs push the hair through the skin like a pin. If a hair is rubbed, it moves in the direction of its root with the peripherally directed hair scales. Excision of the sinus area and transplantation of an epithelial flap is the best therapy.
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The special anatomy of the "Rectum-Grenzlamellen" is the reason for justification to carry out a curative sphincter-preserving resection in carefully selected cases. In a small segment just above the pelvic floor muscles there are not any lymphnodes, when the lateral ligaments are divided and the rectum is thoroughly mobilized from the sacral concavity and stretched. The length of rectum below the tumor measured on fixed pinned-out pathologic specimens was about 2 cm. The local recurrences were 6% of 196 cases. The 5-year survival rate of this low restorative resection at St. Marks Hospital was excellent. These results suggest that a margin about 2 cm below a rectal carcinoma does not affect survival or local recurrence adversely.
The special and highly complicated anatomy of the continence organ is the basis for surgery in the perineal region and in the region of anus and rectum. The rectal cavernous body, the sphincter ani internus, which is aganglionic, as well as the asymmetry of the female external sphincter muscle, are new facts which must be given attention in respect of pathogenesis and therapy of many diseases occurring in this region. The article discusses piles, anorectal abscesses and fistulas, prolapse of the rectum and rectal cancer under these special aspects.
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Between 1965 and 1981 a series of 30 esophageal strictures and one severe refluxoesophagitis have been treated. Till 1977 we used fundoplication, resection of stenosis and gastropexy. Since 1977 we treated 12 strictures by 2/3-gastrectomy with a 45 cm long Y-anastomosis only. Nearly all patients have been completely relieved of the stenosis and all have a dramatic improvement in their dysphagia (follow-up period up to 4 years).
The gastric pylorus is not a constricting sphincter but a valve closing on distension, resembling the situation in the lower esophageal sphincter. Both contiguous segments (stomach and duodenum) are able to regulate its function physiologically allowing also some degree of reflux.
Esophagectomy without thoracotomy is performed by an abdomino-cervical blunt dissection. A cancer-free margin after resection is only possible after total esophagectomy. The proximal stomach including the lymph nodes at the right and left paracardia and the whole of the lesser curvature are removed with the esophagus. The food canal is restored by splitting the stomach longitudinally and forming a stomach tube from the greater curvature. This stomach tube is pulled up to the neck through the now empty mediastinum and anastomosed. This movement is easy because the blood supply of the esophagus flows craniocaudally and not segmentally. This technique has a low mortality: in 20 cases only 3 patients died (15%).
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Radical operative treatment of ulcerative colitis and regional granulomatous enteritis leads to satisfactory short-term results. The high mortality of one-stage proctocolectomy in the acute case can be markedly reduced by a staged operation. The same applies for surgery in toxic megacolon. Preservation of continence in ulcerative colitis is rarely possible without endangering long-term results. Chances of evading life-long ileostoma in granulomatous enteritis are very much better. The prominent ileostoma represents a great step forwards. Conservatively treated patients with ulcerative colitis are by no means free from the risk of dangerous complications. 10% had to undergo surgery in the end and only 36% were symptom-free according to their own evaluation. Out of patients with ulcerative colitis treated with procto-colectomy and ileostoma 75% were completely symptom-free. Patients with symptoms had not obtained a prominent ileostoma or it was unsuccessful. Acute ileitis should not be treated operatively. Surgical treatment of chronic granulomatous enteritis need seldom be urgently performed and should be carefully evaluated. Late mortality in operated patients occurs only in the young, in a small percentage due to relapse.
On the preoperative day before colorectal operations (n = 36), 3 g neomycine and 3 g erythromycine were administered as oral prophylactic antibiotics. No antibiotics were administered to the controls (n = 24). The number of postoperative septic complications was reduced after preoperative prophylactic antibiotics. There were two abscesses of the abdominal wound, one fecal fistula, and two anastomotic disruptions in the control group but only two abscesses of the abdominal wound in the antibiotic group. No toxic effects were observed during this trial.
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