[What is evidence based in the therapy of pelvic floor insufficiency?].
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Chronic Disease↗
Biomedical subjects
H-P Bruch
Publications and source records attributed to H-P Bruch.
[Obstructed defecation].
Adequate therapy of obstructed defecation (pelvic outlet obstruction) is often challenging, as the etiology and clinical symptoms include a wide range of disorders. Standardized diagnostic assessment has to differentiate between obstructed defecation caused by either pelvic outlet obstruction or slow transit constipation. Additionally, morphologic changes of colon, rectum, or the pelvic floor have to be separated from functional disorders. Providing defecography or dynamic MR of the pelvic floor, common causes of outlet obstruction such as sigmoidoceles, in which surgery is indicated, and rectal prolapse can be diagnosed with high accuracy. However, the diagnosis and therapeutic options in symptomatic rectocele and intussusception are controversial. Patients with functional disorders such as rectoanal dyssynergia are candidates for conservative treatment (biofeedback). To identify patients who will benefit from surgery for obstructed defecation, careful patient selection remains the crucial issue in diagnostic assessment.
Adolescent↗
[Differential diagnosis in descending perineum syndrome].
Clinical symptoms in descending perineum syndrome show considerable variations, ranging from obstructed defecation to combined fecal and urinary incontinence and including different types of prolapse. Differential diagnosis has to compete with this complexity. Common pelvic floor disorders associated with descending perineum are rectocele, rectal prolapse, enterocele, and sigmoidocele. Standardized diagnostic tools include detailed history and clinical examination with proctorectoscopy as well as anorectal manometry, endoanal ultrasound, defecography, and dynamic MR of the pelvic floor. The diagnosis and proposed therapy have to be developed within an interdisciplinary concept.
Chronic Disease↗
[Ulcerative colitis. Fulminant disease].
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Administration, Oral↗
[Early results of laparoscopic surgical procedures in Crohn's disease].
INTRODUCTION: During the last years laparoscopic surgical procedures are used more frequently in benign bowel diseases like Crohn's disease. We are reporting early results of laparoscopic procedures in Crohn's disease at our hospital. PATIENTS AND METHOD: From 1994 to 2003 54 patients (20 male and 34 female) underwent laparoscopic colonic and small bowel surgery in Crohn's disease. The mean age was 32 years (range: 16 to 55 years). RESULTS: Complications occurred in 6 patients (11.1 %). 3 patients needed a laparotomy. One computed tomography puncture was performed due to a hematoma. The remaining patients are treated successfully non-operatively. No patient died during the perioperative period. The mean operating time was 152 minutes (range 35 to 360 minutes) and the mean postoperative stay in hospital was 10 days (range 6-35 days). 0.2 blood cell concentrates were needed per operation (range 0 to 6), on average. The patients needed no analgesics after the 5 (th) day (range 1 to 13 days), got liquid diet on the 2 (nd) (range 0 to 6 days) and solid diet on the 3 (rd) day after surgery (range 1 to 14 days). DISCUSSION: Laparoscopic surgery in Crohńs disease is safe when performed by an experienced surgeon. The laparoscopic procedure results in a better cosmetic result, while the longer operating time is the mean disadvantage. There are low complication rates during the early postoperative period.
Adolescent↗
Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach.
BACKGROUND AND AIMS: This study analyzed the results of a standardized approach in anastomotic leakage following low anterior resection for rectal cancer without performance of a protective ileostomy during the primary operation. PATIENTS AND METHODS: The study included all 306 patients with rectal cancer electively undergoing low anterior resection with retroperitonealization of the anastomosis over 9 years. The diagnostic procedure for anastomotic leakage included serum laboratory investigations and abdominal CT together with contrast enema. Minor leakages, i.e., small leakages and pelvic abscess, were treated with rectoscopic lavage and/or CT-guided drainage of the abscess, respectively. Major leakage was defined as broad insufficiency with or without septicemia. Nonseptic patients were treated by ileostomy and rectoscopic treatment. In septic patients a revision of the anastomosis with loop ileostomy was performed. RESULTS: Anastomotic leakage was diagnosed in 30 patients (overall 9.8%; 12 major, 18 minor leakages). Common clinical signs were pelvic pain and fever. No patient developed a peritonitis. The most accurate diagnostic instrument was CT (96.7%). CONCLUSION: Retroperitonealization appears to prevent peritonitis in patients with anastomotic leakage following low anterior resection. A differential treatment leads to good results in terms of mortality and anorectal function.
Adenocarcinoma↗
Pouch reconstruction in the pelvis.
ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.
Adenomatous Polyposis Coli↗
[Limitations of laparoscopic visceral surgery in oncology].
Controversial discussion focuses on the application of laparoscopic curative resection for cancer due to oncologic radicality,tumor cell dissemination, and port site metastases. Considering the limitations of laparoscopic surgery, it is necessary to objectively evaluate whether laparoscopic surgery is associated with an improved quality of curative treatment. Therefore, controlled studies comparing the results of laparoscopic vs conventional cancer surgery are mandatory. To date, comparable findings on short-term outcome of laparoscopy with open resection can only be shown for colorectal cancer. However, long-term data including recurrence and survival are still missing as randomized studies (phase IIIb) are still to be completed. Consequently, laparoscopic curative resection should only be performed within controlled trials. In terms of the upper GI tract, minimally invasive surgery has proven to be technically feasible in expert centers including limited resections for early gastric cancer, left pancreatectomies, or hepatic resections for malignancy. Finally, laparoscopy has gained acceptance in the field of diagnosis (e.g., staging laparoscopy, laparoscopic ultrasound) and palliative treatment (e.g. gastroenterostomy, thermoablation) without the need for controlled studies.
Colorectal Neoplasms↗
[Surgical therapy of rectal carcinoma].
Total mesorectal excision (TME) has gained a revolutionary impact on the surgical therapy of rectal cancer within the last 2 decades, providing superior local tumor control in comparison to conventional resection. Consequently, 85% of rectal carcinomas can be resected by sphincter-preserving surgery without compromising either oncologic radicality or continence. With the introduction of TME, local recurrence rates have been reliably decreased below 10% after curative resection. Surgical dissection along the connective tissue space between rectal and parietal pelvic fascia with complete mesorectal excision results in reliable excision of all relevant lymphatic pathways with preservation of continence and sexual function. Complete removal of a TME specimen is mandatory in carcinomas of the middle and lower third of the rectum. Both removal of the complete TME specimen and careful pathologic examination of the circumferential resection margin have decisive significance. An additional pelvic lymphadenectomy with the potential risk of increased morbidity does not improve prognosis. As a spread of tumor distally along the bowel wall rarely exceeds a few centimeters, a distal resection margin of 1-2 cm is oncologically sufficient in sphincter-saving procedures without compromising prognosis. Taken together, the convincing results of TME provide a rationale for using TME as the dissection policy of choice to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from prospective randomized trials. The question whether laparoscopic curative resection for rectal cancer is oncologically adequate cannot be definitely answered to date, as results of randomized studies are currently missing. However, the preliminary results of laparoscopic resection for rectal cancer provided by centers are promising.
Anal Canal↗
[Manipulation of the step borer as cause of too shallow boring depth in the femoral neck with the gamma nail system].
The gamma nail step drill has been sold over 500,000 times worldwide. Depending on the construction used and the way it is handled, it can lead to a drill depth in the femoral head that is too shallow if the anatomic dimension of the femoral neck is rather long. Whenever the relationship between rotational speed and drive force is unfavorable, as it is by hand reaming, the triple-bladed drill only produces a triangular hole in the lateral cortical bone. Subsequently, it draws itself through this hole like a screw, without forming the hole into a complete circle. The drill shaft expands conically along its length preventing it from passing through the hole in the cortical bone at a depth of 90 mm. Until now, this phenomenon has been traced back to blunt drills or perhaps curved guide wires. Since the lag screws that have been used could not be screwed into undrilled cancellus bone, screws have sometimes been implanted at a sub-optimal length. The problem was noticed, however, and documented in experiments, and potential solutions were proposed.
Bone Nails↗
Colorectal carcinomas with high MIB-1 labelling indices but low pKi67 mRNA levels correlate with better prognostic outcome.
AIMS: Antibodies specific to the proliferation-associated protein pKi67 (e.g. Ki67, MIB-1) are routinely used in oncology to assess the proliferation index of tumour cells. In untransformed cells the amount of pKi67 present at any time of the cell cycle is strictly regulated. To achieve a better understanding of expression and regulation of this protein in tumour cells, we investigated both pKi67 mRNA and protein expression in routinely fixed and embedded tissue of colorectal carcinoma. METHODS AND RESULTS: We determined a median pKi67 specific in-situ hybridization labelling index of 42% (9-79%) and a median Ki67 index (MIB-1 labelling index) of 59% (26-94%) in 47 resected colorectal adenocarcinomas of different stages and grades. In 32 cases expression of pKi67 mRNA and protein correlated well but we observed a significant difference between both values in 15 tumours. In these cases more than 30% of the cells expressed the protein but not the mRNA of pKi67, possibly due to cell cycle arrest. Patients belonging to this group had a significantly (P < 0.012) better prognosis. CONCLUSIONS: Tumours with a high pKi67 protein level but low mRNA expression are likely to proliferate more slowly than calculated on the basis of their Ki67 staining index, which possibly explains the patients' improved outcome.
Adenocarcinoma↗
[Laparoscopic therapy of colorectal cancer--wishful thinking or realism?].
The laparoscopic resection of the colon and rectum is established for surgery of benign diseases. The main advantages compared to the open-conventional operation technique are reduced postoperative pain, reduced negative influences on pulmonary and gastrointestinal functions as well as a shorter reconvalescence. Minimally invasive curative resections of colorectal carcinomas are still controversially discussed concerning sufficient radicality and the spread of tumor cells. The given oncological standards of the conventional approach can be kept without restriction when resections of the colon and rectum are performed laparoscopically. Newer comparative studies do not describe raised recurrence or lower survival rates following the minimal-invasive procedure. In the coming years prospective randomized multicenter studies must give proof whether or not the long-term survival is comparable with the conventional approach.
Aged↗
Morbidity and mortality of perforated peptic gastroduodenal ulcer following emergency surgery.
BACKGROUND: This study assessed the surgical concept and prognosis of perforated gastroduodenal ulcers. PATIENTS AND METHODS: Data from 102 patients who underwent emergency surgery for peptic ulcer perforation were recorded prospectively. To evaluate morbidity and mortality ulcer perforation was classified into three types: type A, solitary peripyloric ulcer located anteriorly in which laparoscopic closure by suture with omentoplasty was treatment of choice and postoperative endoscopic biopsy was mandatory; type B, perforated ulcer with large defect in which excision and suture was necessary; type C, complicated perforated ulcer with destruction of proximal duodenum and penetration into adjacent organs in which resectional surgery was indicated. RESULTS: Morbidity and mortality were significantly lower in type A (9%, 4%, respectively) than types B (22%, 20%) and C (34%, 17%). Closure of type A perforation was managed laparoscopically in all cases. Billroth II resection was performed in 75% of type C cases. Age, ASA status, and time of surgery were independent prognostic factors by multivariate analysis, with increased mortality in patients older than 65 years, ASA III and IV, and surgery after 24 h following onset of symptoms. CONCLUSIONS: Prognosis of perforated ulcer disease is highly correlated with age, comorbid conditions (ASA status), and time of surgery. The proposed classification system helps to determine patients at risk of mortality.
Adult↗
Oligoneuronal hypoganglionosis in patients with idiopathic slow-transit constipation.
PURPOSE: Several alterations of the enteric nervous system have been described as an underlying neuropathologic correlate in patients with idiopathic slow-transit constipation. To obtain comprehensive data on the structural components of the intramural nerve plexus, the colonic enteric nervous system was investigated in patients with slow-transit constipation and compared with controls by means of a quantitative morphometric analysis. METHODS: Resected specimens were obtained from ten patients with slow-transit constipation and ten controls (nonobstructive neoplasias) and processed for immunohistochemistry with the neuronal marker Protein Gene Product 9.5. The morphometric analysis was performed separately for the myenteric plexus and submucous plexus compartments and included the quantification of ganglia, neurons, glial cells, and nerve fibers. RESULTS: In patients with slow-transit constipation, the total ganglionic area and neuronal number per intestinal length as well as the mean neuron count per ganglion were significantly decreased within the myenteric plexus and external submucous plexus. The ratio of glial cells to neurons was significantly increased in myenteric ganglia but not in submucous ganglia. On statistical analysis, the histopathologic criteria (submucous giant ganglia and hypertrophic nerve fibers) of intestinal neuronal dysplasia previously described in patients with slow-transit constipation were not completely fulfilled. CONCLUSION: The colonic motor dysfunction in slow-transit constipation is associated with quantitative alterations of the enteric nervous system. The underlying defect is characterized morphologically by oligoneuronal hypoganglionosis. Because the neuropathologic alterations primarily affect the myenteric plexus and external submucous plexus, superficial submucous biopsies are not suitable to detect these innervational disorders.
Adult↗
Expression of vascular endothelial growth factor mRNA and protein in human chronic renal allograft rejection.
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Chronic Disease↗
[Quality of life assessment after surgery for diverticulitis - a follow-up study].
BACKGROUND: Laparoscopic sigmoid resection is a well established procedure for surgical treatment of benign colorectal diseases. The aim of the present study was to assess the longterm quality of life of patients who underwent laparoscopic sigmoid resection for sigmoid diverticulitis. Differences in health related life quality to the open-conventional approach were evaluated in a matched pair analysis (age, gender, Hinchey-Stage, Type of Surgery) using a validated quality of life instrument. METHODS: A total of 45 matched pairs (laparoscopic/open) operated for diverticulitis at stage I-IIa (Hinchey classification) were included in this study. The quality of life was measured with the Short-Form-36-Health Survey (SF-36), a standardized questionnaire with 8 scales and 36 items. The follow-up period was at least 2 years (mean 62.2 months). RESULTS: Pair members (n = 45) operated via laparoscopic or open approach for Hinchey I-IIa diverticulitis were of the same sex (21 female/24 male pairs) and age at time of surgery (range: lap.: 53.5-66 years; open: 53.5-67 years). Mean follow-up periods for patients operated laparoscopically and with open procedure were 2 (range: 1-3) and 7 (range: 5-9) years, respectively. The SF-36 scale scores for both groups appeared high and only slightly below a validated norm population. This represents a high quality of life after open as well as laparoscopic surgery for sigmadiverticulitis. No significant differences were apparent between the 45 matched-pairs. Pairs 65 years old or older presented no significantly different score values compared to those younger than 65 years. CONCLUSIONS: The long-term follow-up data in this age and sex matched pair analysis showed favorable results after open as well as laparoscopic surgery for sigmadiverticulitis. No statistically significant differences were observed between the two surgical techniques. Self-reports by the patient concerning his or her health condition, recovery and quality of life following any surgical procedure are needed to assess valid outcome data of new surgical treatments including a critical evaluation of all its benefits and burdens.
Aged↗
Acceleration of cutaneous wound healing by transient p53 inhibition.
The increase of cell proliferation during early wound healing is thought to be regulated by a decrease of apoptosis. In contrast, the reduction of cellularity during final wound maturation may be controlled by an increase of apoptotic cell death. Herein we studied whether p53 is involved in wound healing-associated apoptosis and whether transient inhibition of p53 is effective to improve the early healing process of cutaneous wounds. Using intravital microscopic and immunohistochemical techniques in hairless mice, we demonstrated that in vivo inhibition of p53 by pifithrin-alpha (PFT-alpha; 2.2 mg/kg ip) accelerates early epithelialization and neovascularization of cutaneous wounds by (i) promoting leukocyte recruitment, (ii) increasing cell proliferation, and (iii) reducing apoptotic cell death. We further show that final wound closure with down-regulation of cell proliferation is not inhibited by PFT-alpha treatment, indicating that transient blockade of p53 function does not affect the process of wound maturation. Western blot analysis revealed that PFT-alpha lowered nuclear but not cytoplasmic p53, implying that cytoplasmic retention of p53 mediates the antiapoptotic effects of PFT-alpha. Furthermore, PFT-alpha significantly increased expression of proliferating cell nuclear antigen protein in whole extracts of cutaneous tissue and caused a rise in proliferation of wild-type, but not mutant, p53-expressing keratinocytes. From our study we conclude that transient inhibition of p53 supports the early cell proliferation required for rapid tissue repair and that this may represent an attractive approach in the treatment of delayed wound healing.
Animals↗
Prognostic significance of p21 and p27 protein, apoptosis, clinical and histologic factors in rectal cancer without lymph node metastases.
The aim of this study was to evaluate the prognostic role of clinical and histopathologic factors, cell-cycle regulator proteins (p21(Waf1/Cip1), p27(Kip1)), and apoptotic index in lymph node-negative rectal cancer. Formalin-fixed, paraffin-embedded tissue samples of 97 rectal carcinomas (UICC stages I and II) resected curatively within five years were used. Immunohistochemical analysis of protein expression was performed by monoclonal antibodies: p21 (clone SX118), p27 (clone SX53G8). Apoptosis was assessed by the TUNEL method. Clinical, surgical, histopathologic, and follow-up data were prospectively recorded in a computerized registry. To assess prognostic significance (end points: metachronous distant metastases, 5-year disease-free and overall survival), statistics included univariate and multivariate analysis (p < 0.05 statistically significant). Of the 97 rectal carcinomas without lymph node metastases, 46.4% (45/97) were p21-positive, 49.5% were p27-positive (48/97), whereas 27.8% (27/97) showed a high apoptotic index. Within a median follow-up of 54 months, 4 patients developed local recurrence (4.1%). Distant metastases occurred in 12 patients (12.4%). Univariate analysis showed that gender, UICC stage, p21 and p27 were significantly associated with the incidence of distant metastases (p < 0.05). UICC stage and p21 were the only factors to be significantly related to 5-year disease-free survival by univariate analysis (p < 0.05). Only UICC stage was significantly related to 5-year overall survival (p < 0.05). The apoptotic index was correlated neither to recurrence nor to survival (p > 0.05). Multivariate analysis demonstrated that gender, UICC stage and p21 were independently related to the incidence of distant metastases; however, UICC stage was the only independent factor predictive of 5-year disease-free survival and overall survival (p < 0.05).
Apoptosis↗