[Transanal total mesorectal excision-a critical appraisal]. / Transanale totale mesorektale Exzision ­ eine kritische Standortbestimmung.

INTRODUCTION: Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence. METHOD: The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken. RESULTS: A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME. CONCLUSION: Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.

[Quality indicators for surgery of rectal cancer : Evidence-based development of a set of indicators for quality]. / Qualitätsindikatoren für die Chirurgie des Rektumkarzinoms : Evidenzbasierte Entwicklung eines Indikatorensets für die Ergebnisqualität.

The definition of valid quality indicators is an essential task of medical self-administration and quality assurance. Based on the literature and the results of the Study, Documentation, and Quality Center (StuDoQ) Rectal Cancer Registry, we suggest the following QIs: rate of circumferential resection margin (CRM) positive resected material, rate of anastomotic leak in patients with anastomoses, rate of abdominal wound healing disorders and rate of patients with newly established permanent urinary diversion. Additionally, a new marker, the MTL30, which subsumes patient death within 30 days after the index operation, patient transfer to another acute hospital within 30 days after the index operation or a length of inpatient hospital stay of more than 30 days.

Results of the Gore Bio-A fistula plug implantation in the treatment of anal fistula: a multicentre study.

BACKGROUND: The aim of this prospective study was to determine the efficiency of the Gore Bio-A synthetic plug in the treatment of anal fistulas. METHODS: A synthetic bioabsorbable anal fistula plug was implanted in 60 patients. All fistulas were transsphincteric and cryptoglandular in origin. RESULTS: The healing rate after 1 year of follow-up was 52 % (31 out of 60 patients). No patient was lost to follow-up. The treatment had no effect on the incontinence score. The plug dislodgement rate was 10 % (6 out of 60 patients). Thirty-four per cent of the patients (16 out of 47) required reoperation. The average operating time was 32 ± 10.2 min, and the average length of hospital stay was 3.3 ± 1.8 days. CONCLUSIONS: Synthetic plugs may be an alternative to bioprosthetic fistula plugs in the treatment of transsphincteric anal fistulas. This method might have better success rates than treatment with bioprosthetic fistula plugs.

[Complications after rectal prolapse surgery]. / Komplikationen nach Rektumprolapsoperationen.

Major complications only rarely occur after rectal prolapse surgery. Generally, the spectrum of possible complications should always be considered depending on the selected surgical procedure. Minor complications in all techniques have been described in up to 36 %. The commonest complication is bleeding with 2-5 %, urinary tract infections and wound infections. Finally, the risk of recurrence must be considered, which shows substantial differences (4-40 %); therefore, no operation technique can be given preference based solely on the risk of recurrence. Therapy decisions are always more individualized and must take the personal environment of the patient as well as the experience of the surgeon into consideration.

[Pelvic floor disorders from the surgeon's viewpoint]. / Beckenbodendysfunktion aus chirurgischer Sicht.

Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon.

Clinical value of sentinel node mapping in carcinoma of the colon.

AIM: Sentinel lymph node mapping has been used in colon cancer to improve prognosis. This study aimed to determine the accuracy of in vivo SLNM in patients with colon carcinoma undergoing surgery with curative intent. METHOD: Thirty-one patients operated for colon carcinoma underwent in vivo sentinel lymph node mapping using patent blue dye. Each sentinel lymph node (SLN) was marked intraoperatively, and histological examination was performed after en bloc resection. If no metastasis was found, step sectioning with immunohistochemistry was performed. RESULTS: The SLN was successfully identified in 28 (90%) of 31 patients. The false-negative rate to identify stage III disease was 66% (eight of 12), the negative predictive value was 46% (19 of 27) and the accuracy was 14% (four of 28). One patient negative on routine histopathology had micrometastasis on step sectioning of the SLN. CONCLUSION: Sentinel lymph node mapping in colon carcinoma cannot accurately predict nodal status.

[Quality criteria for treatment of colorectal cancer. From a surgeon's viewpoint]. / Qualitätsanforderungen zur Behandlung des Kolon- und Rektumkarzinoms. Aus chirurgischer Sicht.

The surgeon is the key "prognosis factor" for colorectal cancer. For this reason quality criteria were recently established (including minimum numbers) in order to treat patients who are entitled to the best quality of care and to improve the prognosis. The aim of this study was to critically discuss the existing demands on the surgeon based on the current literature and our own results and to formulate evidence-based quality criteria for surgical clinics. After reviewing the current literature criteria were compiled, discussed and finally presented in a summarized form. These are based on current developments on the diagnostic and therapy of large intestine and colorectal carcinoma. New developments of the German Cancer Society for planning of organ centers are incorporated. The quintessence of our study is that the number of cases alone is not decisive for the success of therapy. Important are the application of the correct surgical-oncology operation procedure, adherence to standards and the training of surgeons. Following the S3 guidelines stage-oriented therapy should additionally be carried out in a structured sequence. This includes an interdisciplinary decision making on the diagnostic and therapy strategy (tumor board). The organization structure of the hospital (teams, tumor board, emergency care with intensive care unit, emergency diagnostic and options for interventional measures) can be more important than the hospital case numbers alone. These demands which have been evaluated from published data and own results are designed to raise the therapy of colorectal cancer to the best possible level of quality and to effect a further improvement in the prognosis.

[Diagnosis and therapy of stool incontinence]. / Diagnostik und Therapie der Stuhlinkontinenz.

Incontinence may have different causes. First it is necessary to diagnose any underlying muscular defects. Neurologic lesions and coordinative disturbances should also be excluded. A great variety of methods are available for treatment. In fact conservative therapy alone will very often be successful. In all traumatic lesions of the sphincter muscle, surgical reconstruction is the method of choice if the defect is not too large. In cases of extensive sphincter destruction, an artificial anorectal sphincter implant or dynamic graciloplasty may be options. In all cases with no or only small muscular defects, sacral nerve stimulation should be offered to the patient. Plicating techniques such as pre- or postanal repair have lost their therapeutic attractiveness at present. Therefore in any case of incontinence, the correctly structured stoma still has a place. To date it is not possible to confirm how much new methods such as bulking agents may contribute to the treatment of incontinence.

[Anorectal manometry]. / Empfehlungen zur Anorektalen Manometrie im Erwachsenenalter.

This document contains the guidelines of the German Societies of Neurogastroenterology and Motility, Gastroenterology (committee for proctology), Abdominal Surgery (coloproctology working group), and Coloproctology for anorectal manometry in adults. Recommendations are given about technical notes, study preparation (equipment; patient), technique for performing manometry and data analysis, reproducibility, and indications. Minimum standards for anorectal manometry are measurement of resting and squeeze pressure, testing of rectoanal inhibitory reflex, determination of rectal sensation (first perception and urge), and calculation of rectal compliance. Anorectal manometry is indicated in patients with fecal incontinence and constipation in the context of a structured programme.

[Functional results after transvaginal, transperineal and transrectal correction of a symptomatic rectocele]. / Funktionelle Ergebnisse nach transvaginaler, transperinealer und transrektaler Korrektur einer symptomatischen Rektozele.

INTRODUCTION: The aim of this study was to compare functional outcome after transvaginal, transperineal and transrectal repair of a symptomatic rectocele and to develop the ideal surgical approach. PATIENTS AND METHOD: 28 patients (27 female, 1 male) who had undergone rectocele repair from 1996 to 2003 were analysed. Mean age was 59 years (range 30-79 years), follow-up was 24 months (range 3 to 70 months) and mean appearance of symptoms was 4 years prior to the operation (6 months-32 years). Transvaginal repair was performed in 13 cases, transperineal repair in 8 cases and transrectal repair in 7 cases. RESULTS: 24 of 28 patients (85.7 %) are satisfied with the operation-result (transvaginal 12 of 13 patients [92.3 %], transperineal 7 of 8 patients [87.5 %] and transrectal 5 of 7 patients [71.4 %]). 25 patients (89.3 %) are free of complaints or describe an evident improvement of symptoms (transvaginal 12 of 13 patients [92.3 %], transperineal 7 of 8 patients [87.5 %] und transrectal 6 of 7 patients [85.7 %]). There is one postoperative dyspareunia. DISCUSSION: Best treatment of a rectocele starts with patients selection. Considering pelvic floor as functional unity, concomitant urologic-gynaecologic lesions and proximal intraabdominal disturbances the appropriate surgical procedure is selected. CONCLUSION: Surgical approach to correct a symptomatic rectocele depends on the concomitant lesion.

Laparoscopic TME: better vision, better results?

One of the most controversial discussions on laparoscopic surgery deals with the question of whether to apply this technique to malignant disease and specifically to rectal cancer. The four major issues are the adequacy of oncologic resection, recurrence rates and patterns, long-term survival and quality of life. There is evidence, from nonrandomized studies, suggesting that margins of excision and lymph node harvest achieved laparoscopically reached comparable results to those known from conventional open resection. Our own experience of laparoscopic surgery on rectal cancer is based on 52 patients treated with curative intent. Focusing on the postoperative long-term run, we gained the following results: The median age of patients was 66.7 years and ranged from 42-88. Anastomotic leakage was seen in 6.1% of cases. In a median follow-up of 48 months (36-136), we reached an overall 3-year survival rate of 93% and a 5-year survival rate of 62%. Local recurrence was 1.9%, distant metastasis occurred in 11.5% of cases. We saw no port-site metastasis. To evaluate functional results following laparoscopic surgery a matched pair analysis was carried out. Matching of patients after laparoscopic and conventional open surgery was performed according to sex, age, type of resection, time period of surgery, and stage of disease classified by UICC. Regarding bladder and sexual dysfunction, using the EORTC QLQ CR38 score we found no statistical significant difference between the examined groups. As far as can be seen, laparoscopic surgery in rectal carcinoma may achieve the same or, in selected patients, even better results than open surgery. However, at present no published study has shown much evidence. Many more studies are necessary to define the place of laparoscopic technique in rectal cancer surgery, regarding appropriate selection of patients and evaluating adjuvant or neoadjuvant treatment in combination with the laparoscopic approach.

Rectal prolapse: which surgical option is appropriate?

Numerous surgical procedures have been suggested to treat rectal prolapse. In elderly and high-risk patients, perineal approaches such as Delorme's procedure and perineal rectosigmoidectomy (Altemeier's procedure) have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Functional results of transabdominal procedures, including mesh or suture rectopexy and resection-rectopexy, are thought to be associated with low recurrence rates and improved continence. Transabdominal procedures, however, usually imply rectal mobilization and fixation, colonic resection, or both, and some concern is voiced that morbidity, in terms of infection or leakage, and mortality could be increased. If we focus on surgical outcome, our own experience of laparoscopic resection-rectopexy for rectal prolapse shows that the laparoscopic approach is safe and effective, and functional results with respect to recurrence are favorable. However, the controversy "which operation is appropriate?" cannot be answered definitely, as a clear definition of rectal prolapse, the extent of a standardized diagnostic assessment, and the type of surgical procedure have not been identified in published series. Randomized trials are needed to improve the evidence with which the optimal surgical treatment of rectal prolapse can be defined.

[Obstructed defecation]. / Defäkationsobstruktion.

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.

[Early results of laparoscopic surgical procedures in Crohn's disease]. / Frühergebnisse nach laparoskopischer Operation bei Morbus Crohn.

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 Crohns 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.

Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients.

BACKGROUND: It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease. METHODS: All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience. RESULTS: A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% ( n=27), so that laparoscopic completion rate was 93.2% ( n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection ( n=279), followed by anterior resection ( n=36) and left colectomy ( n=29). Total complication rate was 18.4% ( n=68). Major complication rate was 7.6% ( n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% ( n=12). Anastomotic leakage occurred in 1.6% ( n=6). Minor complications were noted in 10.7% ( n=40), late-onset complications occurred in 2.7% ( n=10). Mortality was 0.5% ( n=2). Mean duration of surgery was 193 (range 75-400) min, return to normal diet was completed after 6.8 (range 3-19) days. Mean hospital stay was 11.8 (range 4-71) days. No recurrence of diverticulitis occurred. CONCLUSION: Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.

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.

Uretero-iliac artery fistula--a rare cause of massive hematuria.

Uretero-arterial fistulae are rare. Immediate diagnosis and treatment are crucial in this life-threatening disorder and thus a uretero-arterial fistula in a patient with persistent hematuria should be taken into consideration. The authors report a case of a fistula between the right ureter and right common iliac artery.

Laparoscopic colorectal surgery in obese and nonobese patients: do differences in body mass indices lead to different outcomes?

BACKGROUND: The aim of this prospective study was to compare the outcome of laparoscopic colorectal surgery in obese and nonobese patients. METHODS: All patients who underwent laparoscopic surgery for both benign and malignant disease within the past 5 years were entered into the prospective database registry. Body mass index (BMI; kg/m(2)) was used as the objective measure to indicate morbid obesity. Patients with a BMI >30 were defined as obese, and patients with a BMI <30 were defined as nonobese. The parameters analyzed included age, gender, comorbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion rate, overall morbidity rate including major complications (requiring reoperation), minor complications (conservative treatment) and late-onset complications (postdischarge), stay on intensive case unit, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t test and chi-square analysis. Statistical significance was assessed at the 5% level (p < 0. 05 statistically significant). RESULTS: A total of 589 patients were evaluated, including 95 patients in the obese group and 494 patients in the nonobese group. There was no significant difference in conversion rate (7.3% in the obese group vs 9.5% in the nonobese group, p > 0.05) so that the laparoscopic completion rate was 90.5% (n = 86) in the obese and 92.7% (n = 458) in the nonobese group. The rate of females was significantly lower among obese patients (55.8% in the obese group vs 74.2% in the nonobese group, p = 0.001). No significant differences were observed with respect to age, diagnosis, procedure, duration of surgery, and transfusion requirements (p > 0.05). In terms of morbidity, there were no significant differences related to overall complication rates with respect to BMI (23.3% in the obese group vs 24.5% in the nonobese group, p > 0.05). Major complications were more common in the obese group without showing statistical significance (12.8% in the obese group vs 6.6% in the nonobese group, p = 0.078). Conversely, minor complications were more frequently documented in the nonobese group (8.1% in the obese group vs 15.5% in the nonobese group, p = 0.080). In the postoperative course, no differences were documented in terms of return of bowel function, duration of analgesics required, oral feeding, and length of hospitalization (p > 0.05). CONCLUSION: These data indicate that laparoscopic colorectal surgery is feasible and effective in both obese and nonobese patients. Obese patients who are thought to be at increased risk of postoperative morbidity have the similar benefit of laparoscopic surgery as nonobese patients with colorectal disease.