Biomedical subjects
Publications and source records attributed to K Manncke.
Preventive hemostasis is extremely important in endoscopic surgery. Ultrasonic dissectors are used very often. We tested the occlusion safety of bipolar forceps and ultrasonic dissector for porcine vessels. Thermographic videos showed maximum temperature up to 200 degrees C when using one ultrasonic dissector. The lateral damage zone in vivo and in vitro measured between 2 and 6 mm.
67 patients with achalasia were treated either medically, endoscopically or surgically from 1987 to 1997 in the Department of Surgery of the University of Tübingen. 27/67 (40%) of the patients, who were pneumatically dilatated, had a very successful therapy within the first year after dilatations. 12/67 (17%) of the patients had good results with a dysphagia score less than 1 after dilatations within the first year. The perforation rate of interventionally treated patients was 1.4% without any surgical procedure. Open myotomy according to Heller was performed in 28 of 67 patients (41%); after 1993 a laparoscopic procedure was performed in all patients. The average hospitalization for MIC was 5.4 days. The manometric control investigations showed a decrease of the basal LES pressure from preoperative values. When evaluated manometrically 87% showed good results in the follow up time of at least 24 months. 14% of those who underwent surgery had to be endoscopically dilatated after surgery.
The early relief of esophageal outflow obstruction in patient with achalasia diminishes complaints and avoids deterioration as a result of this disease. The pneumatic myotomy of the lower esophageal sphincter is the initial therapeutic concept. After two unsuccessful dilations, the laparoscopic myotomy with semifundoplication shows the best long-term results in the treatment of achalasia with fewer complications.
BACKGROUND: Local therapy of early rectal carcinoma has become an alternative to the classical radical operation which has a higher morbidity and mortality rate. METHODS: Rectal carcinoma was treated by transanal endoscopic microsurgery (TEM) in 113 patients. The indications for the procedure were pT1 low-risk tumour, advanced tumour in high-risk patients, and patients who refused more radical surgery based on oncological guidelines. RESULTS: Sixty-four patients had pT1, 33 pT2 and 16 pT3 tumours. No patient died as a result of TEM. The rate of complications which needed operative intervention was 7 per cent. So far, two of the patients treated by local resection of pT1 low-risk tumours have had a recurrence. In both cases, a secondary procedure was possible with curative intent. CONCLUSION: Patients with pT1 rectal tumours represent a suitable group for local treatment because of the acceptability of the procedure and the low recurrence rate.
PURPOSE: The aim of the study is to outline the rising importance of local treatment of rectal tumors and a changing strategy in therapy of early rectal cancer. METHODS: As the surgical procedure, transanal endoscopic microsurgery was used. Indications for the local procedure were pT1 low-risk tumors and tumors of higher stages in patients with severe risk factors and of those who refused the operation according to oncologic guidelines. RESULTS: A total of 236 rectal adenomas and 98 carcinomas were locally excised using the transanal endoscopic microsurgery technique. Mortality rate was 0.3 percent, and rate of complications requiring surgical reintervention was 5.5 percent in adenomas and 8 percent in carcinomas. Final histology of removed carcinomas revealed 56 pT1, 27 pT2, and 15 pT3 stages. After an average follow-up time of 24 months, two recurrences were observed in the group of patients with pT1 low-risk carcinomas who only underwent local therapy. In both cases, a second intervention for cure was undertaken but for tumors in a late stage. CONCLUSIONS: In selected cases, local therapy of rectal carcinoma avoids high morbidity and mortality of the classical operation. Quality of life will be improved, especially if an artificial anus can be avoided. In case of recurrence, the chance of a secondary procedure for cure is not to be underestimated.
PURPOSE: Compared with traditional operations, superior results after transanal endoscopic microsurgery (TEM) for rectal tumors have been demonstrated in terms of morbidity and mortality. However, no data were available on functional outcome after TEM. We, therefore, studied 42 patients who were undergoing TEM. METHODS: Patients were examined by anorectal manometry and participated in a standardized interview preoperatively and three months and one year after surgery. RESULTS: Anorectal function as assessed by manometry was impaired three months after surgery but improved again during the first postoperative year. In parallel, some patients complained of impaired continence or defecation disorders in the interview three months postoperatively. These functions improved during the first year after surgery, too. CONCLUSIONS: Correct comparison of our results with functional outcome after anterior rectal resection is impossible. We feel, however, that functional results after TEM are likely to be superior to those after anterior resection for rectal tumors.
Local therapy of rectal carcinoma with the method of TEM was performed in 98 patients during the period from August 1, 1989 to January 31, 1994. 56 of the patients had pT1, 27 pT2, and 15 pT3 tumours. There was no lethality. The rate of complications, which required operative intervention, was 8%. No lymph node metastases were found in the specimens of the patients with pT1 tumours, who were re-resected, because the margin of the primary specimen were judged to be not free of tumour. In the specimens of the re-resected patients with pT2 carcinomas, lymph node involvement was more common than remnants of the primary tumour. Two of the patients with local therapy of pT1 low-risk carcinomas developed a recurrence so far. A secondary procedure for cure according to oncologic criteria could be performed in both cases. In selected cases the local therapy of rectal carcinoma avoids the high morbidity and mortality of the classical operation. Live quality will be improved, especially if an artificial anus can be avoided. In case of a recurrence the chance of a secondary procedure for cure is not to be underestimated.
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Following a laparoscopic cholecystectomy 400 patients have been interviewed with a questionnaire on the late results of the surgery (15 to 40 months postop.). The cholecystectomies had been performed within the time from March 7, 1990 to April 30, 1992 in Tübingen. After a mean of 16.8 days the patients returned to work, while they themselves felt reduced for an average of 10.6 days. 11.9% of the patients complained of slight wound healing problems and in 3.1% wound infections have been registered. Although 97% of the patients were satisfied with the results of surgery, 8.7% still complained of upper abdominal trouble. Slight persistent problems like light pain or flatulence have been reported by 19%.
Transanal Endoscopic Microsurgery (TEM) was introduced into clinical practice by the Buess group in 1983. Since then vast experience has been gained in removing tumours of the rectum by the operative rectoscope. Though the indication in benign lesions for TEM as a local resection therapy is undisputed, the indication for resection of T1 or advanced carcinomas has to be evaluated. By using a 40 mm operating rectoscope sealed with a gastight working insert to prevent pressure loss after creation of a pneumorectum and a stereoscopic optic with sixfold magnification, exact visualisation of a rectal tumour can be achieved. The insertion of endoscopic surgical instruments like the high frequency knife, forceps, scissors, and suction device allows precise excision of the lesion as well as suture closure of the wound. Recently a bipolar multifunctional combination instrument has been developed for more precise dissection, less blood loss and shorter operation times.
From August 1st 1989 to May 1st 1993, 190 rectal adenomas and 75 carcinomas were locally excised with the TEM technique. The mortality was 0.4%, the rate of complications which required surgical re-intervention was 3% in adenomas and 8% in carcinomas. The final histology of the removed carcinomas revealed 44 pT1, 23 pT2 and eight pT3 stages. In two of the eight re-resected patients with pT1 low-risk tumours, residual primary tumour but no lymph node metastases were found. In contrast to this, three of the eleven re-resected patients with pT2 low-risk tumours had already developed lymph node metastases. After an average follow-up time of 14 months, two recurrences were observed in the group of the only locally treated patients with pT1 low-risk carcinomas. Both underwent a secondary procedure for cure but in late tumour stages. No recurrence was diagnosed so far among the re-resected patients.
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Conventional transhiatal dissection of the oesophagus is usually performed without visual control. The attendant danger of this is that complications such as bleeding and tracheal lesions may be overlooked. This problem can be avoided by the use of an endoscopic operation system. This report describes a new technique of endoscopic microsurgical dissection of the oesophagus (EMDOE) and the results of the first 35 cases. Under visual control with a specially designed mediastinoscope the soft tissue surrounding the oesophagus is carefully dissected, and the oesophageal blood vessels can be safely exposed, coagulated and divided. The dissection begins cervically and proceeds along the oesophagus down to the oesophagocardiac junction. A simultaneously working abdominal team helps remove the oesophagus, which is then replaced by a stomach tube. Although the method is still under evaluation, results to date have been especially good for small distal tumors, especially adenocarcinomas.
Subtotal oesophagectomy and stapled oesophagogastric anastomosis is a favoured option for cure or palliation of oesophageal carcinoma. This approach currently involves a thoracotomy and laparotomy exposing the patient to the attendant pulmonary and intrathoracic complications. Alternative approaches to oesophagectomy without thoracotomy have failed to diminish the complication rate and may compromise the chance of cure. An endoscopic approach to the oesophagus is considered to be an evolving solution because it removes the need for thoracotomy and laparotomy but adheres to established oncologic principles. In order to assess the feasibility of complete endosurgical oesophagectomy and immediate reconstruction a non-survival study using 10 pigs was undertaken. Under general anaesthesia a 3-step operation was performed consisting of thoracoscopic oesophageal dissection, laparoscopic gastric mobilisation and thoracoscopic oesophagogastric anastomosis using a circular endoluminal stapler (Stealth-Ethicon). Conversion to open surgery was required only once during a gastric dissection, and all anastomoses were safely constructed thoracoscopically. In three animals small anastomotic tears were repaired with endoscopically-placed sutures. Three animals died intraoperatively, two from an anaesthetic complication prior to the introduction of intra-operative monitoring, and the other following haemorrhage from an hepatic vein traumatised by a liver retractor. This study has shown that endosurgical oesophagectomy is technically feasible and stapled oesophagogastric anastomosis can be performed in a comparable manner to the conventional procedure.
Techniques for intrathoracal stapler anastomosis under thoracoscopic control were studied and developed in an experimental program. Since this procedure is possible from two directions, both directions were evaluated. Two different techniques, a transoral and a transhiatal, resulted. For the transoral technique the stapler is inserted from above. The anvil, which is connected to a wire, is drawn into the abdomen together with the distal oesophagus. Retracting the wire pulls both the anvil and the stomach tube up into the thorax after the insertion of the anvil. The second technique requires a special attachment to introduce the anvil transhiatally into the thorax and into the oesophageal stump. The gastric tube is pushed into the thorax by the stapler gun, which is inserted into the stomach through an antrostomy. The insertion of the anvil into the oesophageal stump can also be achieved with the support of a flexible endoscope including a polyp snare.
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In order to save time for changing instruments and minimize thermal damage in underlying tissue caused by monopolar high frequency in transanal endoscopic microsurgery (TEM), we have developed a new electrosurgical instrument, in which four functions are integrated: bipolar cutting, monopolar coagulation, suction and irrigation. The new device and the conventional monopolar knife were tested during both in vitro and in vivo experiments to compare the thermal alterations and effects on operating time. In vitro experiments demonstrated that the extent of thermal alterations created by bipolar cutting was less than in the case of monopolar cutting in the fresh porcine liver and bovine rectum. The mean severity scores for carbonization, coagulation and vacuolization in the resected mucosae obtained during in vivo animal operations by the bipolar procedure were 2.09, 2.27 and 1.36, respectively, whereas those obtained using the monopolar technique were 2.64, 2.82 and 2.36, respectively. The new device required an average operation time of 673.5 seconds, whereas the conventional setup required 701.9 seconds to resect the same diameter of rectal mucosa. Reduced operation time with the new device was mainly attributable to the reduced time needed for changing the instruments for hemostasis. The decreased thermal damage to the underlying bowel wall produced by the bipolar procedure should reduce the incidence of such operative complications in TEM (Transanal Endoscopic Microsurgery, developed in 1983 by Buess, Theis and Hutterer) as perforation, dehiscence in the suture line or post-polypectomy coagulation syndrome. By quickly switching between the multiple functions of this new device a clear operative field can always be achieved, thus decreasing operation time and bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)
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