Is radiochemotherapy necessary in the treatment of rectal cancer?
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Combined Modality Therapy↗
Biomedical subjects
W Hohenberger
Publications and source records attributed to W Hohenberger.
Gastrectomy osteopenia in the rat: the role of vitamin B12 deficiency and the type of reconstruction of the digestive tract.
1. The mechanisms underlying gastrectomy osteopenia are not yet clear. The gastrectomy-associated cobalamin (vitamin B12) deficiency may favour osteopenia and skeletal fractures. Also, the exclusion of the duodenum from the food passage may contribute to gastrectomy osteopenia. To investigate this, rats were gastrectomized and the passage of nutrients restored either with the duodenum excluded (Roux Y) or included (Longmire). Sham-operated rats served as controls. In half of the rats in each gastrectomy group the serum B12 levels were normalized by parenteral administration of B12.2. Four months post operation, both gastrectomy groups showed a similar degree of osteopenia. There was normal bone mineralization; serum levels of parathyroid hormone were normal, but decreased for 25-hydroxyvitamin D, and elevated for 1,25-dihydroxyvitamin D; in urine there was decreased pH and excessive hyperphosphaturia.3.B12 therapy had no influence on any of the essential bone and mineral metabolic parameters.4. We conclude that osteopenia in the gastrectomized rat (i) is not due to B12 or folic acid deficiency, calcium deficiency or secondary hyperparathyroidism; (ii) is independent of the type of anatomic reconstruction of the digestive tract; (iii) appears to be related to disturbed vitamin D, phosphorus and acid-base metabolism.
Acid-Base Imbalance↗
Monocyte function before and after surgical trauma.
The monocyte/macrophage plays a key role in the network of immune reactions. Dependent on activation, it is able to produce various cytokines which act on other cells of the immune system in the sense of upregulation or downregulation. In addition, it presents antigens by the HLA-DR molecule as an initial trigger of an antigen-specific T-cell response. Monocyte function is affected by surgical disease and further affected by surgical trauma. We found the monocyte to be activated in a subgroup of patients before the operation, related to an increased rate of postoperative septic complications. After the operation, plasma concentrations of IL-6 and IL-10 were increased indicating the activation of an immune response. After surgery HLA-DR expression decreased as well as LPS-stimulated TNFalpha and IL-6 production, the latter indicating a hyporesponsiveness of peripheral blood cells (presumably monocytes) to further stimulation. On the other hand, continuously high plasma concentrations of activation markers like neopterin and IL-6 in the postoperative course were associated with complications and poor outcome. In postoperative septic shock monocytes may be almost areactive towards natural stimuli like bacteria and endotoxin, since IL-6 and TNFalpha production decreased to very low amounts. Adequate pre- and postoperative monocyte function is related to an uneventful postoperative course after major surgical operations. Surgical trauma affects monocyte function rendering it less reactive, which is a potential risk factor for postoperative septic complications.
Humans↗
The pneumoperitoneum and its role in tumor seeding.
Port site recurrences (PSR) are abdominal wall recurrences that occur within a trocar site after cancer laparoscopy and that are not associated with peritoneal carcinosis. The short clinical delay of occurrence of PSR (median 190 days in colorectal cancer) suggests a massive cell seeding into the abdominal wall (over 10(6) cells) during the operation. In human and animal studies, CO2 was not able to aerosolize large numbers of tumor cells using pressures of 8-15 mm Hg, even though isolated mesothelial cells have been found in the aerosol. Such large numbers of tumor cells have only been demonstrated on instruments and trocars. PSR occur not only after CO2 laparoscopy, but also after thoracoscopy, where no CO2 is used. Gaseless laparoscopy was able to reduce, but not to eliminate port site contamination in animal models. Tumor growth was enhanced in numerous animal models using CO2, suggesting an adjuvant effect on tumor growth in the trocar wound. Nevertheless, reported clinical incidences between 0 and 21% suggest that PSR might be a surgeon-related variable dependent mainly on experience and technical expertise. Technical measures have been proposed that might reduce the incidence of PSR.
Abdominal Muscles↗
Influence of surgery on metachronous distant metastases and survival in rectal cancer.
PURPOSE: Total mesorectal excision (TME) and other technical surgical factors reduce local recurrence rate in rectal cancer. Scientific evidence of the positive effect of optimal surgery on survival is locking. Whether a reduction in the incidence of distant metastases can be achieved with optimal surgery is uncertain. We examine the effects of the quality of surgery, as reflected by local recurrence rate, on survival and the incidence of initial distant metastases. PATIENTS AND METHODS: Between 1974 and 1991, 1,581 consecutive patients who underwent curative resection (RO) for rectal carcinoma were monitored for recurrence and survival. TME was introduced in 1985. No patient received adjuvant radiotherapy or chemotherapy. The median follow-up time was greater than 13 years. RESULTS: The local recurrence rate decreased from 39.4% to 9.8% during the study period (P < .0001). The observed 5-year survival rate improved from 50% to 71% (P < .0001). Three hundred six patients with local recurrence had a significantly lower observed 5-year survival rate (P < .0001). A total of 1,285 patients had no local recurrence, but 275 of them developed distant metastases (International Union Against Cancer [UICC] stage I, 8%; stage II, 16%; stage III, 40%). Better-quality surgery had no effect on the incidence of initial distant metastases, which remained constant (P = .44). CONCLUSION: Quality of surgery is an independent prognostic factor for survival in rectal cancer, but has no influence on initial occurrence of distant metastases. Local recurrence cannot be considered an outcome criterion of adjuvant treatment without consideration of the surgeon as a risk factor.
Adult↗
[Surgical therapy of liver metastases in breast carcinoma].
The literature contains little information on the surgical treatment of metastases from carcinoma of the breast. Advanced stages of mammary cancer with generalised metastatic spread are considered to be the therapeutic domain of systemic chemotherapy. Patients with isolated liver metastases may, under certain circumstances, be considered candidates for partial resection of the liver. Another therapeutic option in this group of patients is intraarterial chemotherapy via a port catheter system implanted in the hepatic artery. A number of institutions employ a combination of both treatment modalities. Overall 5-year survival rates are low for both the regional and the systemic form of treatment. A carefully selected group of patients may be expected to benefit from partial resection of the liver, intraarterial chemotherapy or a combination of the two by having their survival time prolonged--provided that due consideration is given to all contraindications, and there are no extrahepatic manifestations. Wherever possible, resections should be carried out in curative intent. However, palliative resection may be justified in individual cases where alleviation of symptoms and an improvement in the patient's quality of life is to be expected. The present paper discusses the results achieved in 21 women who underwent liver resection at the surgical department of the University of Erlangen between 1980 and 1997, and compares these results with those reported in the literature. The average age of the patients was 54 years, and 9 had a solitary metastasis. As was to be expected, the R classification had a decisive influence on survival. The 2-year survival rate was 60% for R0 resections as compared with 16.7% for R1 or R2 resections.
Adult↗
[Focal nodular hyperplasia and liver cell adenoma: operation or observation?].
PATIENTS: In a 15-year period a total of 146 patients underwent surgery for benign hepatic tumors, including 54 focal nodular hyperplasias (FNH) and 23 hepatic cell adenomas (65 hemangioma and 4 cholangioma). METHODS: The medical records of these patients were retrospectively analyzed with respect to tumor-related symptoms, surgical procedures and postoperative complications. RESULTS: Regardless of the type of the tumor, 70% of the patients had no or only non-specific symptoms. Most frequently, surgery was indicated due to questionable dignity of the lesion (adenoma 70%, FNH 41%). In hepatic cell adenomas (HCA) also perforation or bleeding of the tumor (17%) and severe symptoms (13%) required urgent operation. In two of three cases local excision of the lesion or segmental hepatic resection were performed, whereas extended resection procedures became necessary only in 20 (FNH) to 34% (HCA). The mean duration of postoperative intensive care treatment was significantly shorter in FNH and HCA than in other benign hepatic tumors (1.0 vs. 2.0 days, p < 0.01). After resection of FNH no fatalities or significant complications were observed. In HCA morbidity was 13% without related mortality (hemangioma: 3% mortality; 11% morbidity). CONCLUSION: The elective resection of benign hepatic tumors can be achieved with very low mortality and morbidity, and usually provides longterm relief of annoying symptoms. Whenever HCA is suspected surgery should be performed, since severe symptoms and spontaneous hemorrhage (30%) are common in this tumor. Also hepatocellular carcinoma can be excluded only by histologic work-up of the operative specimen. In focal nodular hyperplasia (FNH), complications are rare and malignant transformation does not occur even when observation is employed only. Resection should be restricted to symptomatic or growing tumors with subsequent cholestasis or to cases with uncertain diagnosis.
Adenoma, Liver Cell↗
[Laparoscopic splenectomy].
To date more than 400 laparoscopic splenectomies have been reported in the literature. The main indications for the procedure are benign haematological diseases, in particular idiopathic thrombocytopenic purpura. Laparoscopic splenectomy to treat malignant illnesses is rare and is usually restricted to small or only moderately enlarged spleens. Technically, the lateral abdominal approach with the patient in a right decubitus position has the advantage over the anterior approach in the supine patient of permitting better access to the organ. Under the force of gravity the stomach and intestines drop out of the operating field, and the splenic ligaments are placed under tension. This facilitates dissection with the harmonic scalpel and safe divisioning of the hilar vessels using the linear stapler. The individual steps of the procedure are described in detail.
Humans↗
[Surgical therapy of choledocholithiasis].
Following the introduction of endoscopic papillotomy and stone extraction, surgical bile duct revision has decreased considerably in importance during the past two decades. Surgical bile duct revision is associated with an appreciably higher rate of complications than endoscopic stone extraction. The result has been that most working groups now favour a "therapeutic splitting" approach. This means that, wherever possible, endoscopic revision of the bile duct is first attempted. If, during laparoscopic cholecystectomy, intraoperative cholangiography reveals the presence of bile duct stones, they may, after consultation with the endoscopist, be left in place for removal by endoscopic papillotomy at some later date. Only in the case of very young patients and exceptionally, a highly experienced laparoscopic surgeon may attempt a transcystic extraction of such stones. Continuing indications for conventional surgical treatment of choledocholithiasis are local factors obstructing access to the papilla (gastrectomy, stenosis of the pylorus) and other bile duct changes requiring correction (choledochocele, strictures, stenoses, Mirizzi's syndrome, over-looked impacted stone obstructing an over-long cystic duct stump, intrahepatic lithiasis).
Adult↗
[Thoracoscopic resection of epiphrenic esophageal diverticula by an intracavitary/endoluminal combined intervention].
Epiphrenic oesophageal diverticula are of the pulsation type, the underlying cause is a motility disorder. Resection is indicated by severe symptoms like dysphagia, regurgitation or aspiration and should be performed after endoscopic dilatative treatment of the neuromotor disturbance. Thoracoscopic resection under endoluminal endoscopic surveillance is considered to be a reliable procedure with low morbidity for the patient.
Dilatation↗
Quality criteria of surgical treatment of rectal carcinoma: preservation of continence, and local recurrence.
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Algorithms↗
[Rectal cancer: influence of the surgeon and the quality of surgery on long-term carcinologic results].
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Follow-Up Studies↗
[Treatment of insufficiency of the anal sphincter by sacral spinal nerve stimulation with implantable neurostimulators].
The feasibility of permanent electrostimulation of the sacral spinal nerves was studied in patients with fecal incontinence and no detectable morphological lesions and thus not amenable to conventional surgical management. Applying acute percutaneous stimulation with needle electrodes, the most relevant sacral spinal nerve for striated sphincter muscle function was identified (sacral spinal nerve S3 or S4). The therapeutic potential of stimulation was tested by subchronic stimulation with temporary wire electrodes and, if effective, permanent electrodes were implanted in four patients. Long-term sacral spinal nerve stimulation persistently improved anal continence and increased the function of the striated muscular anal sphincter.
Adult↗
[Reconstruction of incisional hernias with defined tensiometrically controlled tension--a possibility for anatomically correct reconstruction of the abdominal wall].
The repair of incisional hernias of the abdominal wall is characterized by high rates of recurrence if arbitrary tension is applied. A rationale for selecting the appropriate reconstruction technique as defined by intraoperative tension measurements has proven effective and successful. Here, the inlay/onlay technique tolerates up to 3.5 kilopounds (kp). Our results show that using this technique, complete reconstruction is possible in 65% of cases with a recurrence rate of 2.3%.
Cicatrix↗
[Does sentinel node biopsy (SNB) solve the problem of elective lymph node excision in malignant melanoma?].
Elective lymph node dissection in high-risk melanoma has been hotly debated for years. The technique of sentinel node (SN) biopsy may be a solution to the problem. Consequently, radical lymph node dissection is restricted to patients with an actual metastatic involvement of the SN (20-25%). The use of a hand-held gamma probe increases accuracy of SN detection.
Biopsy↗
[Beta-catenin expression and its significance for metastasis in curatively operated rectum carcinoma].
Two selected groups of 77 patients each (matched for age, sex, UICC stage and year of surgery) were compared. All patients were curatively operated on for rectal cancer by surgery alone. All remained locally disease-free, differing only in distant metachronous metastatic spread. beta-Catenin expression was investigated using immunohistochemical methods. Overexpression of nuclear beta-catenin was not correlated with disease-free survival or distant metachronous metastasis. Thus, this potential oncogen cannot be used as a prognostic marker in rectal cancer. Additionally, in four cases of intense nuclear staining, after DNA isolation and sequencing of exon 3, which encodes for the GSK-3 beta phosphorylation site, no mutations could be detected.
Biomarkers, Tumor↗
[Prognostic factors in combined radiochemotherapy of the anal canal carcinoma].
Combined radiation and chemotherapy is an effective treatment for all stages of carcinoma of the anal canal. Abdominoperineal resection is reserved for patients with incomplete regression of tumor or recurrent carcinoma.
Antineoplastic Combined Chemotherapy Protocols↗
[Malignant melanoma of the skin: is there a curative surgical approach in locoregional metastasis?].
Between 1969 and 1993 at the Surgical University Hospital of Erlangen, 273 patients with synchronous or metachronous locoregional metastases were operated on with curative intent; patients with distant metastases at the time of primary operation or first recurrency were excluded. In 216 patients (79.1%) a curative operation was performed and we achieved a statistically significant improvement of the 5-year-survival rate compared with those patients treated only palliatively (39.3% vs. 21.1%, p < 0.01). If regional lymph node metastases occur, the prognosis becomes significantly worse (5-year survival rate 45.2% vs. 25.2%, p < 0.01); hyperthermic isolated limb perfusion shows a high importance in the treatment of locoregional metastases and the 5-year survival rate of patients treated with hyperthermic limb perfusion is significantly higher (39.0 vs. 64.2%, p < 0.05).
Adolescent↗