[Comment on the Schmiegel et al. contribution--Z Gastroenterol 2004: 1129-1177].
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Colorectal Neoplasms↗
Biomedical subjects
T Junginger
Publications and source records attributed to T Junginger.
[Rectal prolapse in adults--causes, diagnostic, treatment].
Despite progress in modern surgery, the choice of the surgical procedure of rectal prolapse is regarded with controversy. Selection criteria between the abdominal or perineal approach or between rectopexy and resection rectopexy are not yet proven. This article gives a review of the literature about rectal prolapse and an analysis of the outcome of posterior rectopexy and resection rectopexy--partly conventionally and partly laparoscopically--in 25 patients with rectal prolapse III degrees and IV degrees. All except for one patient were examined during a mean follow-up of 5.5 (3.1) years for the rectopexy group and 2.1 (0.7) years for the resection rectopexy group. Recurrence occurred in one patient in each group respectively. There was no significant difference concerning the continence function (p = 0.32) and constipation (p = 0.36) between both groups. No mesh-related complications such as infection, fistula or rectum stenosis were observed. According to the review of the literature and our data, we believe that the choice of the operative procedure for rectal prolapse should be based on individual criteria. Fit patients should be offered laparoscopic procedures such as resection rectopexy and rectopexy without colonic resection.
Adult↗
Influence of splenectomy on perioperative morbidity and long-term survival after esophagectomy in patients with esophageal carcinoma.
The aim of this study was to determine the influence of splenectomy on perioperative morbidity and mortality, as well as on the long-term survival after esophageal resection for carcinoma of the esophagus. From September 1985 to July 2003, 404 patients underwent surgery for esophageal carcinoma in our institution. Splenectomy was performed in 34 (8.4%) patients. Perioperative morbidity and long-term survival were compared in patients with and without concomitant splenectomy. Splenectomy was associated with an increase in intraoperative blood loss and the need for transfusions of blood preserves (P < 0.0001). However, there were no significant differences in pulmonary, general, or surgical complications between patients with and without (P > 0.05) splenectomy. While the survival rate of 13.9 months recorded in patients without splenectomy was longer compared with a survival rate of 8.9 months for patients after splenectomy, it did not reach statistical significance (P = 0.315). The analysis of survival time (log-rank) did not yield any differences between squamous cell and adenocarcinoma, distal tumor location and adenocarcinoma in combination with distal location for patients with and without concomitant splenectomy (P > 0.05). Incidental splenectomy in esophageal resection for esophageal carcinoma is not associated with an increase in perioperative morbidity. Both effective intraoperative management and postoperative intensive care therapy are essential measures in the avoidance of fatal complications after splenectomy. Although it is not yet proven, that splenectomy may have an adverse effect on long-term prognosis, operative procedure should avoid removing the spleen.
Adenocarcinoma↗
[Puncture of every mass lesion in the pancreas? Point of view of surgery].
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Biopsy, Needle↗
Inguinal hernia: measurement of the biomechanics of the lower abdominal wall and the inguinal canal.
BACKGROUND: The stability of the lower abdominal wall may play a considerable role in the development of inguinal hernia. Therefore, the strength of the individual wall layers needs to be quantified. Despite numerous advances in hernia repair, comparatively few systematic biomechanic and morphometric analyses have been performed. Our aim was to establish and apply a standardised procedure for testing the abdominal wall layers' stability. METHODS: After dissecting the abdominal walls of 16 cadavers into separate layers, we used a spherical punch and a force transducer to investigate the forces necessary to foraminate the layer. In addition, maximum tensile-strength and suction tests and histologic morphometry were performed. RESULTS: The transversalis fascia was torn up on an average of 10.5 N, the peritoneum including pre- and subperitoneal tissue on 46.6 N, the aponeurosis of obliquus internus abdominis muscle on 51.7 N, and the aponeurosis of obliquus externus abdominis muscle on 92.6 N. Tensile tests of tissue strips obtained from defined areas showed comparable results. In contrast, surgical mesh revealed values between 60 and 150 N in punching tests. Left-right comparisons, as well as comparisons of the individual areas, revealed considerable intra- and inter-individual differences. CONCLUSIONS: Biological hernia repair should focus on a reinforcement of the tissue layers with the highest biomechanic stability. Reinforcement of the transversal fascia must be questioned according to our results of poor mechanical resistance.
Abdominal Wall↗
[Concerning the article "Extirpation of the rectum in deep-seated rectal carcinoma" by F. Marusch et al, Chirurg (2003) 74:341-352].
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Colostomy↗
[Selection of patients with rectal tumors for local excision based on preoperative diagnosis. Results of a consecutive evaluation study of 552 patients].
INTRODUCTION: The aim of our study was to evaluate the accuracy of clinical staging (CS), biopsies, and endoluminal ultrasonic examination (EUS) in preoperative staging of rectal tumors treated with transanal local excision. This local excision is an adequate procedure for benign rectal polyps and low-risk T1 carcinoma. PATIENTS AND METHODS: The study included 552 patients with rectal adenocarcinoma, villous adenoma, or tumors with other histologic characteristics who underwent a transanal excision (transanal endoscopic microsurgery n=513 or transanal excision n=39). We compared the results of CS, biopsies, and EUS with postoperative pathology findings. RESULTS: Preoperative histological diagnosis of the rectal carcinoma depended on tumor size (52% in cancers <3 cm, 25% in cancers >3 cm; p=0.001) and was correct in 56% of cases. Transanal ultrasonography (uT0/1) had superior sensitivity (95% vs 78%) and a higher positive predictive value (93% vs 85%) than clinical staging (CS I) in detecting adenoma or T1 rectal carcinoma, whereas specificity was similar in both (62% vs 58%). In patients in whom preoperative histological analysis revealed adenomas, transanal ultrasonography was accurate (uT0/1) for the postoperatively assessed adenoma pT1 in 97%, whereas diagnosis (uT0/1) was correct in only 71% of cases in which preoperative histological analyses showed rectal carcinomas. CONCLUSIONS: In patients with rectal tumors, preoperative staging with transanal ultrasonography and biopsy is essential for the indication and allows selection of patients for transanal local excision.
Adenocarcinoma↗
[Identification of pelvic autonomic nerves during partial and total mesorectal excision--influence parameters and significance for neurogenic bladder].
INTRODUCTION: The objective of the present prospective study was to determine the frequency of pelvic autonomic nerve preservation (PANP) during total mesorectal excision (TME) for rectal carcinoma, and to identify a possible link between PANP and postoperative micturition disturbances. METHODS: Between March 1997 and February 2003, 229 patients with adenocarcinoma of the rectum were operated on with sphincter preservation in 178 (78%) cases. In 101 (48%) patients, the tumor did not invade the muscularis propria. To determine influence parameters on the achievement of complete PANP, a multivariate analysis was performed. The number of complete-partial-or nonidentification of the nerves (superior hypogastric plexus up to the neurovascular bundles) was documented and correlated with micturition disturbances. RESULTS: The pelvic autonomic nerves were identified completely in 169 (74%), partially in 25 (11%), and could not be demonstrated in 35 (15%) patients. Multivariate analysis showed multivisceral resection ( p<0.001), gender ( p<0.001), surgeon (<25 operations >, p<0.001), and tumor site (middle/upper third vs lower third of rectum, p= 0.011) to exert an independent influence on the achievement of complete PANP. Twenty (8.8%) patients needed a long-term urinary catheter. Preservation of the parasympathetic nerves was associated with low bladder dysfunction rates (4.1 vs 22.4%, p<0.001). CONCLUSIONS: To minimize the risk of postoperative micturition disturbances due to neurogenic bladder, pelvic autonomic nerves should be identified during TME. Neurogenic bladder after TME is a useful parameter to assess the quality of surgical treatment for rectal carcinoma.
Adult↗
[Surgical interdisciplinarity-abdomen excluding the pelvis].
Cooperation between different surgical disciplines arises from the employment of nonoperative procedures as a supplement to operative treatment (sequential multidisciplinary operations) and synchronized multidisciplinary or simultaneous operations. The objective is to ensure optimized treatment results. Complementary preoperative measures are the endoscopic removal of bile duct stones, interventional portal vein embolization, percutaneous abscess drainage, and so-called stenting in case of mechanical bowel obstruction. Intraoperative cooperation is advised in case of abdominal surgical diseases, especially with vascular surgery. Visceral surgeons should have a good command of vascular surgical techniques when performing corresponding operations. The aim of operative cooperation between different disciplines is to safeguard optimal treatment results. From this follows a right to and, for physicians, the duty of interdisciplinary cooperation. A prerequisite is the knowledge of the potentialities of the different disciplines as well as mutual respect for their limits. Intensive communication is an important aspect during the whole process of diagnostics, therapy, and postoperative care.
Abdominal Neoplasms↗
[The choice between transperitoneal and retroperitoneal adrenalectomy. A prospective study].
INTRODUCTION: The aim of this prospective study was to evaluate the optimal surgical approach to endoscopic adrenalectomy. PATIENTS AND METHODS: Between March 1997 and February 2003, we performed 221 endoscopic adrenalectomies in 202 patients (right side 83, left side 100, bilateral 19), with an conversion rate of 2,5%. In 197 patients endoscopic adrenalectomy was carried out via retropertioneal approach 128 times and via transperitoneal approach 88 times. RESULTS: Endoscopic adrenalectomy was performed in 98% of the total number patients. No statistically significant influence ( P=0.05) was found for the parameters intraoperative blood loss, rate of postoperative complications, or duration of hospitalization in regard to the procedure. The operative time and learning curve were significantly longer with the retroperitoneal approach. Multivariate analysis identified surgical approach, tumor size (5 cm), and body mass index (25) as independent factors for operative time. CONCLUSION: The lateral transperitoneal approach is the optimal procedure for endoscopic adrenalectomy.
Adrenal Gland Neoplasms↗
[S3-Guidelines Conference "Colorectal Carcinoma" 2004].
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Colorectal Neoplasms↗
[Long-term results for Heller-myotomy with anterior semifundoplication in achalasia].
INTRODUCTION: The positive success rate of cardiomyotomy in the treatment of achalasia has recently - especially in young patients - resulted in a primary operative treatment concept. Few studies of long-term effects of myotomy concerning the removal of dysphagia and the development of gastroesophageal reflux have been submitted. PATIENTS AND METHODS: In the period between September 1985 and March 2003, an open, transabdominal Heller-myotomy combined with a Dor-semifundoplication was carried out in 93 patients with achalasia. 77 patients were followed for more than 6 months postoperatively (median follow-up: 70 months). The procedure was prospectively observed, and patients were questioned concerning their clinical symptoms by means of structured interviews. X-ray examinations of the esophagus were pre- and postoperatively available of 47 patients, manometrical findings before and after myotomy of 26 patients. RESULTS: The pre-operatively existing symptoms dysphagia, regurgitation, retrosternal pain and weight-loss could be improved by myotomy in 97 % of the patients with good to excellent long-term results. Post-operatively, a significant reduction of the median maximum diameter of the esophagus of 50 mm to 30 mm was evident (p < 0.001), whereas the diameter of the cardia increased from 3 mm to 10 mm (p < 0.001). The pre-operative resting pressure of the lower esophageal sphincter (LES) of 29.3 mmHg was reduced to 7.9 mmHg (p < 0.001). Patients suffering from reflux esophagitis showed a significant lower resting pressure of the LES (4 mmHg) in comparison with patients without reflux esophagitis (8.5 mmHg) after myotomy (p=0.045). The clinical long-term results of patients with preceding pneumatic dilation did not differ significantly from those with primary myotomy. CONCLUSION: Conventional Heller-myotomy with anterior semifundoplication can in the long run remove the symptoms existent in achalasia with high efficiency. If the decrease of the post-operative resting pressure of the LES is too intense (< 5 mmHg), a possible gastroesophageal reflux has to be taken into account. The results of open cardiomyotomy have to be regarded as standard for assessing the minimal-invasive procedure.
Adolescent↗
Residual urine volume after total mesorectal excision: an indicator of pelvic autonomic nerve preservation? Results of a case-control study.
OBJECTIVE: The rate of bladder dysfunctions after total mesorectal excision (TME) for rectal cancer can be decreased by bilateral pelvic autonomic nerve preservation (PANP). However, it is not clear yet, how often partial nerve impairment may lead to bladder dysfunction. It was the aim of a case-control study, to examine the residual urine volume in patients before and after TME with and without complete PANP, in order to clarify, whether this parameter allows conclusions on the quality of PANP. PATIENTS AND METHODS: Regarding bladder function, a case group (n = 26) without complete PANP was compared with a control group (n = 26) with complete identification and nerve preservation according to standadized intra-operative documentation. Twenty-six match pairs were established, identical regarding gender, wall infiltration depth, tumour site, operation procedure and operation extent. Rates of neoadjuvant therapy, R0-classification, anastomotic leakage, wound and urinary tract infection were equally distributed for both the case- and control group (P > 0.05). Residual urine volume was pre- and post-operatively determined by sonography. RESULTS: Pre-operatively, residual urine volumes differed neither between the pairs nor between both groups with and without nerve preservation. In the case group with incomplete PANP there was a difference between pre- and post-operative residual urine volume (median; quartil: 2.5 ml; 0.0-32.5 ml vs 130 ml; 0.0-317 ml; P = 0.001). In the control group there was no difference (median; quartile: 0.0 ml; 0.0-20 ml vs 15.5 ml; 0.0-62.0 ml; P = 0.07). The difference between the postoperatively measured volumes of the case and control group were significant (P = 0.001). With residual urine volume = 100 ml, the risk of incomplete PANP was 14 times higher (odds ratio). CONCLUSIONS: Residual urine volume is an indicator of the completeness of PANP during TME. It should be determined pre- and post-operatively, and besides the recording of the neurogenic bladder, serve as a quality control.
Adult↗
Cryotherapy for liver tumors: current status, perspectives, clinical results, and review of literature.
Cryotherapy has gained importance as a locally ablative treatment option for patients with non-resectable liver tumors, especially metastases from colorectal cancer. We have used this technique since 1996 for the treatment of 77 patients with malignant liver tumors. Patient data was prospectively recorded and follow-up was until September 2002 or death. Fifty-five patients had colorectal cancer liver metastases, 16 metastases from other primaries and 6 had hepatoma. Forty patients had cryotherapy only and 37 had an additional liver resection. Morbidity and mortality were 22% and 1.3%, respectively. In 68% of patients with colorectal liver metastases and an elevated serum carcinoembryonic antigen-level preoperatively, it returned to the normal range following cryosurgery. For all 77 patients, median survival was 28 months with a 3- and 5-year-survival rate of 39% and 26%, respectively, and median survival was 29 months with a 3- and 5-year-survival rate of 44% and 26%, respectively, for the 55 patients with colorectal liver metastases. Local recurrence at the cryosite was observed in 13 of 65 patients (20%) with initially complete treatment. For cryotherapy to further establish as a treatment for malignant liver tumors in a time where many new local ablative techniques are developing, different goals need to be achieved. The trauma of the procedure and local treatment failure need to be minimized and survival results need to be optimized. Published studies and new possible fields of research regarding these goals are discussed.
Adult↗
Synchronous bilateral endoscopic adrenalectomy: experiences after 18 operations.
BACKGROUND: Patients who undergo unilateral adrenalectomy are known to benefit from the endoscopic procedure. Only a few reports on bilateral endoscopic adrenalectomy exist. The optimal approach and the value of this operation were assessed in this study. METHODS: For 18 patients, synchronous bilateral lateral adrenalectomy with intraoperative repositioning was performed for different indications. The transperitoneal and retroperitoneal approaches were varied on both sides. RESULTS: With the reported procedure, the operative time diminished considerably. Blood loss was low, and no blood transfusions were required. No conversion to an open procedure was necessary. There were no intraoperative or postoperative complications, except for one death from pulmonary embolism. The mean postoperative hospital stay was 7 days, and the follow-up evaluation showed overall improvement. CONCLUSION: The risk associated with endoscopic bilateral adrenalectomy is low. Transperitoneal and retroperitoneal lateral adrenalectomy are recommended as approaches of choice. The authors advocate early bilateral adrenalectomy for Cushing's disease after unsuccessful transsphenoidal operation and ectopic adrenocorticotropic hormone production from an inaccessible tumour.
ACTH Syndrome, Ectopic↗
Anterior partial fundoplication for gastroesophageal reflux disease.
BACKGROUND: This study examined the effect of anterior partial fundoplication on reflux symptoms and dysphagia in gastroesophageal reflux disease. PATIENTS AND METHODS: Perioperative results in 249 patients were evaluated retrospectively for 93 conventional and prospectively for 156 laparoscopic procedures. The patients were followed up by standardized questionnaire. Median clinical follow-up period was 9 months (range 6-44) after laparoscopic and 88 months (range 15-194) following partial open fundoplication. RESULTS: The median operating time was 58 and 115 min for laparoscopic and open partial fundoplication. Intraoperative complications were rare (1%) for both approaches. After introduction of the laparoscopic procedure the morbidity rate was reduced (mean 3.2% vs. 1.3%) at a shorter postoperative hospital stay (10 vs. 5 days). No reflux symptoms were found in 71.4% patients after conventional and in 69% after laparoscopic partial fundoplication, dysphagia did not develop in 86% and 85%, respectively, and 66% and 82% received no medications. Among the patients with reflux symptoms 6.5% and 0.9% underwent revision surgery. Satisfaction with the surgical outcome was expressed by 78% and 85% of patients, respectively. CONCLUSIONS: Anterior partial fundoplication achieves effective medium- and long-term control of reflux symptoms. Technically easy to perform and associated with few complications, the procedure is superior to fundoplication with respect to the development of postoperative dysphagia and therefore represents a viable alternative to fundoplication.
Deglutition Disorders↗
[Total excision of the mesorectum in cancer of the lower and middle rectum. Oncological and functional results].
INTRODUCTION: The introduction of total mesorectal excision (TME) in the treatment of rectal cancer has improved survival rates and decreased recurrence. Our objective was to analyse perioperative data as well as the results of the follow-up examination. Risk-factors for local recurrence should be identified since the indication for adjuvant therapy in "optimal surgery" has to be redefined. PATIENTS AND METHODS: Between March 1997 and December 2001, 108 patients with adenocarcinoma of the lower and middle rectum were operated on by three surgeons according to the concept of total mesorectal excision. In 75 (69.4%) patients,a lower anterior resection and in 32 (29.2%) cases an abdominoperineal resection was performed. One patient received a Hartmann's resection. There were 15 cases of stage IV (UICC) present and in 53 patients the tumor extension was restricted to the wall. Demographic and perioperative data as well as the results of the follow-up examination were registered prospectively. The median follow-up period amounted to 24 months (2-56). RESULTS: A total of 87 patients underwent a curative resection. Fourteen lymph nodes were dissected (median). Pelvic autonomic nerve preservation was possible in 90 patients. The median intraoperative blood loss was 500 ml. As surgical complications, anastomotic leakage occurred in 18% of cases, perineal wound infection in 33%, and bladder dysfunction (requiring catheterisation) in 5.6%. The overall rate of recurrence was 17.5%. The rate of local recurrence was 4.9% and the survival rate was 91% over 3 years. Risk factors for local recurrence are N2-disease, transmural growth and tumor localisation in the lower third of the rectum. CONCLUSIONS: TME offers good oncological and functional results with low complication rates for the treatment of cancer in the middle and upper third of the rectum. Interdisciplinary multicenter studies are still necessary to redefine the place of adjuvant radiation and chemotherapy in cases of cancer in the lower two thirds of the rectum and stage III disease.
Adenocarcinoma↗
[Indicators of quality in surgical treatment of rectal carcinoma].
INTRODUCTION: For the assessment of surgical therapy for rectal cancer, perioperative and oncological as well as aspects of quality of life have to be taken into consideration. The objective of the present analysis was to identify indicators allowing assessment of the quality of the surgical intervention. PATIENTS AND METHODS: Between March 1997 and August 1998,50 patients with adenocarcinoma of the rectum were operated on by five surgeons according to the concept of total or partial mesorectal excision. In 4 patients an anterior, in 35 a low anterior resection, and in 11 an abdominoperineal resection was performed. There was a stage IV (UICC) present in 9 cases, and in 18 patients the tumor extension was restricted to the wall. The demographic and perioperative data as well as the results of the follow-up examination were registered prospectively. The median follow-up period amounted to 44 months (5-57). RESULTS: Intraoperative parameters showed no differences concerning the individual operating surgeons. General complications arose in 9 (50%) and surgical complications in 34 (68%) patients. Anastomotic leakage (5/39), perineal wound infection, and bladder dysfunction (requiring catheterization for bladder emptying) occurred as frequent complications and there were differences with regard to the surgeon. The rate of local recurrence was different and was between 0% and 75% for the individual surgeons. CONCLUSIONS: For the assessment of surgery for rectal carcinoma, only a few parameters are necessary. As indicators of quality after rectal resection, the rate of anastomotic leakage should be registered; after abdominoperineal resection, the rate of perineal wound infection, the ratio of postoperative bladder dysfunction, and the locoregional rate of recurrence should be registered.
Adenocarcinoma↗