Reduced neorectal capacitance is a more important factor for impaired defecatory function after rectal resection than the anal sphincter pressure.

OBJECTIVE: The role of the diverse anorectal diagnostic tools like manometry and determination of the preception threshold and the maximal tolerable volume is still a matter of debate. Currently, there is a scarcity of physiological data in the long-term follow-up of patients who underwent sphincter-preserving rectal resection. The aim of this study was therefore to perform these anorectal physiological measurements and to correlate the determined parameters with a faecal incontinence score. METHOD: In 45 patients, anorectal manometry, electromyography (EMG) and neorectal volume measurements were performed 21.6 +/- 1.4 months after rectal resection. Additionally, patients answered questions to help in the determination of a modified faecal incontinence score. RESULTS: More than half of the patients had more than four bowel movements per day and suffered from defecatory urgency, evacuation and discrimination problems. Manometric data were not related to any functional deficits. In contrast, perception threshold and maximal tolerable volume were correlated with the faecal incontinence score. CONCLUSION: Defecatory problems especially after radiochemotherapy are still common after rectal resection and the satisfactory functionality post resection should not be oversimplified to just the number of bowel movements. A precondition of an adequate defecation is not only the integrity of the sphincter muscles, but also the recovery of the rectal reservoir function.

[Intraarterial thrombolysis in acute limb ischaemia: alternative treatment and basic principles of further interventions]. / Lokale Lyse bei akuter peripherer Extremitätenischämie: Therapiealternative und Grundlage weiterer Interventionen.

INTRODUCTION: Intraarterial thrombolysis of acute arterial occlusions in the lower limbs is an established therapeutic procedure. However, its value as a primary treatment is discussed controversially and it is mostly seen as a competing procedure to primary vascular surgical interventions. METHODS: From January 2001 to December 2004, we performed a total of 132 intraarterial thrombolysis procedures in 112 patients with acute or subacute ischaemia of the lower limbs. In the majority of the cases, there was an ischaemia of stage I or II a according to Rutherford, a few further cases were in stage II b at the start of treatment. The patients' ages at the time of thrombolysis was 64.7+/-11.3 years (mean value+/-standard deviation, range: 27-91 years). There were 46 female and 86 male patients. RESULTS: The average duration of thrombolysis was 35.2+/-20.8 hours (mean+/-standard deviation, range: 6-142 hours). As median 2 (range: 0-8) angiographic controls were performed. In 100 cases (75.8%), an operation could be avoided by thrombolysis alone or in combination with an supplementary intervention. On the other hand, in 32 cases (24.2%) a subsequent operative therapy including 10 major amputations (7.6%) was necessary. Because of hemorrhagic complications, 15 thrombolysis procedures (11.4%) had to be terminated prematurely but only 2 patients required an inguinal revision. Therapy-related mortality was 0.8% (1 patient). CONCLUSION: In the majority of our patients, primary intraarterial thrombolysis was successful and often led to the discovery of the underlying vascular lesion. It can serve both as a therapeutic alternative to a primary vascular surgical intervention and as the foundation further interventional or vascular surgical therapies although this cannot always be predicted for individual cases.

Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms.

PURPOSE: Transanal endoscopic microsurgery (TEM) is a technique that has found its place in routine practice due to its minimal invasive character and associated low morbidity. The purpose of this study was to assess the influence of anatomical variables of rectal neoplasms as well as surgeon experience on postoperative complications in patients undergoing TEM at a tertiary care center. METHODS: Data from 288 patients undergoing TEM over a 16 year period were entered in a prospective data base. Anatomical data of rectal neoplasms, operative data, and early postoperative outcome were analyzed retrospectively. RESULTS: Overall surgical complications [OR 7.0 (1.5-45,5); p < 0.01] and bleeding [OR 222 (82 - 14316); p < 0.01] correlated with the localization of the neoplasm on the lateral wall of the rectum. Furthermore there was a trend for more surgical overall complications as well as bleeding in neoplasms with a diameter of >2 cm and neoplasms located >8 cm from the anal verge. Complications did not correlate with the number of TEM procedures performed. CONCLUSION: TEM resection of neoplasms located on the lateral rectal wall have a higher risk of bleeding. The learning curve for transanal endoscopic microsurgery appears to be negligible in surgeons with experience in minimal invasive surgery.

[Surgery of complicated gastroduodenal ulcers: outcome at the millennium]. / Chirurgie des komplizierten gastroduodenalen Ulkus: Eine Standortbestimmung zur Jahrtausendwende.

INTRODUCTION: Complications of gastroduodenal ulcers such as bleeding and perforation have been afflicted with a mortality of up to 40 % in the past. Altered ulcer manifestation by improvement of medical treatment as well as advances in surgical techniques and intensive care medicine might currently have improved the outcome of these severely ill patients. PATIENTS AND METHODS: A retrospective analysis of 73 patients with emergency operation for bleeding or perforated gastric (n = 50) and duodenal ulcer (n = 23) between 10/1994 and 7/2001 was performed. RESULTS: The median age was 58 years (17-90 years) with 30 % of patients exceeding the age of 70 years. Eighty-one percent of patients had perforation, 19 % had bleeding. Factors predisposing for gastroduodenal ulcers were present in 88 %. Five percent of gastric perforations were due to gastric malignancies. Diagnosis of perforation was made in 88 % by conventional X-rays, in 12 % of perforations no free abdominal gas was detectable. A local surgical procedure (excision of ulcer and sutures/pyloroplasty) was performed in 64/73 patients (88 %), partial gastroduodenal resection was necessary in 9 patients (12 %). Histologic examination for helicobacter pylori was positive in 30/39 specimens (77 %). In-hospital mortality was 14 %, both for patients with bleeding and perforated ulcers. Surgical complications were 12 %. DISCUSSION: Altered ulcer manifestation, minimized surgical therapy and improved intensive care medicine led to a recent reduction in postoperative mortality of patients suffering from perforated or bleeding gastroduodenal ulcer. A further reduction of this still high mortality might be expected by improvement of surgical training and/or restriction of therapy to a limited number of surgeons.

[Laparoscopy-assisted colorectal resections: morbidity, conversions, outcomes of a decade]. / Laparoskopisch assistierte kolorektale Resektionen. Morbidität, Konversionen, Komplikationen--Ergebnisse eines Jahrzehnts.

BACKGROUND: After one decade of laparoscopic resections of the colon and rectum the parameters morbidity, conversion and complications were analyzed. The analysis of the literature comprises the results of operations performed for benign and malignant indications. METHODS: The analysis is based on the medline research of the past ten years. Publications in German language not listed were added. Results of multicenter studies were included if differentiation by indication and dignity could be achieved. Surveys of different operations of the colon and rectum not differentiated by the parameters to be analyzed were excluded. Publications of the early beginning of laparoscopic surgery were included even if not more than 10 cases were presented but the parameters described in detail. RESULTS: ADENOMAS OF THE COLON: The morbidity ranges from 0-17.4%, the conversion rate is 17.4 and 18.4% in 23 respectively 38 patients. SIGMOID DIVERTICULITIS: Mortality 0-1.8%. The morbidity was 16% in the early series and was later below 10% (8.7 and 7.3%). In the beginning the conversion rate was over 10% (12.0-38.9%) with one exception (0%). It dropped below 10% (4.6-9.2%) and was 0% in a recent study of 64 patients. The reasons for conversion are: inflammatory mass, fistula; perforation and obesity. Intraoperative complications are rare. The rate of postoperative complications did not change within 10 years (9.7 to 25.0% against 7.3 to 17.0%). CROHN'S DISEASE: The morbidity is around 10% (10.6-14.0%) and is lower in series with exclusively ileocoecal resections. The conversion rate is low or zero in ileocoecal resections and raises with the degree of inflammation and the spectrum of procedures. COLON CANCER: Mortality: 0-1.9%. The morbidity ranges from 6.8 to 30% and is especially high after conversions (up to 50%). The conversion rate reflects with the range of 4.2 to 21.0% in the beginning and 1.6 to 23.5% later the experience of the individual surgeon. RECTAL CANCER: Even in large series (n = 157) the mortality of laparoscopic rectal resections is zero. The conversion rate is 0-7.6%; the morbidity 11.5 to 26.4%. REVERSAL OF HARTMANN PROCEDURE: The number of cases is low, the conversion rate is around 20%. The morbidity ranges from 14.3-41.1% with one exception (0%). RECTOPEXY: Four different techniques are applied laparoscopically. The morbidity ranges from 0 to 16%. The conversion rate is 0-2.6%, except one (16.0%). CONCLUSION: After one decade of laparoscopic colorectal surgery there are advantages for benign indications (adenomas, Crohn's disease, rectopexy) when compared with open surgery. Disadvantages arise from conversions. Experience of the surgeon is a strong parameter for a successful outcome. Results of ongoing studies are awaited for malignant indications.

Reoperations at the ileostomy in Crohn's disease reflect inflammatory activity rather than surgical stoma complications alone.

After ileostomy construction for Crohn's disease reoperations due to ileal recurrences are thought to be unusually rare, whereas reconstructions of the ileostomy due to stoma complications are considered to be unusually frequent. It remains unclear why the natural course of a disease as well as outstanding results of a standardized surgical procedure should be perverted. Therefore reconstructions of the ileostomy in 92 patients colectomized during a 12.5-year period and followed up for 5.4 years were analyzed concerning preoperative indication and postoperative histology. In 28 patients (30.4%) a total of 42 reoperations were necessary. The clinical indication was prestomal recurrence in 5 reoperations (11.9%) and stoma complications in 37 (88.1%). In contrast, ileal recurrence was demonstrated histologically in 28 specimens (66.7%) and healthy ileum in the rest. There was a statistically significant association between fibrotic recurrence and stoma stenosis/retraction and a trend for association between penetrating recurrence and peristomal ulceration. The cumulative risk for a first reoperation due to clinical recurrence was calculated at 3.3% and 14.0% at 5 and 10 years postoperatively, whereas the corresponding figures for stoma complications were 25.7% and 40.0%. In contrast, the cumulative risk that a recurrence was found histologically on the occasion of the reoperation was 23.0% and 35.0%, while the probability that the ileum was healthy in the case of a stoma complication remained low. In conclusion, most reoperations after ileostomy-construction in Crohn's disease are associated histologically with recurrent inflammation. The accentuation of the inflammatory recrudescence at the stoma itself or the prestomal ileum is decisive for the clinical presentation as stoma complication or intestinal complication. These findings reinforce both well known characteristics of the inflammatory disease and of established surgery.

[Laparoscopically assisted surgery in Crohn disease]. / Laparoskopisch assistierte Chirurgie bei M. Crohn.

UNLABELLED: From Jan. 1993 to Apr. 1997 intestinal resections in Crohn's disease have been performed in 275 patients. 89 patients have been operated on laparoscopic assisted. The following parameters were analyzed: previous laparotomies, extent of resection, steroid medication, conversionrate, complications, operative time and postoperative stay. Endpoints were: conversionrate, complications, reconvalescence and overall satisfaction with the laparoscopic technique. RESULTS: The duration of the disease ranged from 1 to 16 years (x = 6). 47 patients were under steroid medication at the time of surgery. 30 patients had undergone previous laparotomies. In 10 patients the operation had to be converted into open surgery. The following procedures have been performed: ileocaecal resections (45), anastomotic resections (14), small bowel resections (4), hemicolectomies (12), colectomies (9), loopileostomies (4), adhesiolysis (1). Minor complications occurred in 6.7% of patients, major complications in 5.6%. Operative time ranged from 70 to 420 minutes (x = 173.7). The postoperative hospital stay was 13.3 days in the average. CONCLUSION: The morbidity of 12.3% is not higher than in open surgery. When complications do not occur the patients benefit from early convalescence, better cosmetics and shorter hospital stay.

[Changes in colitis surgery. I: Is there a standard in primary surgical treatment?]. / Wandel der Colitis-Chirurgie. Teil I: Gibt es einen Standard in der operativen Primärbehandlung?

In a 15 years period surgery of ulcerative colitis expanded from ileostomy (IS) via Kock's pouch (KP) and ileoanal pouch (IAP) to ileorectal anastomosis (IRA). Interactions between availability of methods and frequency of operations are investigated retrospectively in order to establish an optimal primary procedure. With an overall amount of 80 operations the yearly operative frequency raised in correlation to the introduction of continence reconstructive procedures. As a consequence of this fact history of disease was shortened to less than 8 year and global colitis-associated morbidity markedly decreased. For patients readiness to undergo operation Kock's pouch was only important at the beginning (n = 9/11.3%). Most decisive was IAP (n = 49/61.3%) which could be realized last even in an one-stage-procedure with better early results due to improved patients conditions and simplified technical modifications. IRA (n = 7/8.8%) played only a limited role in the last years for selected patients, whereas IS (n = 15/18.8%) kept reserved for contraindications to reconstructive surgery. For all procedures operative complications decreased from 46.1% (12/26) to 11.0% (6/54) and lethality to 0%. Late complications were related to proctectomy (nerve damage) and construction of IAP (pouchitis in 34.8% and defunctioning of the pouch in 10.4%), whereas IRA was free of specific morbidity so far. Surgery of ulcerative colitis is characterized today by restoration of anal continence. The advantage of the changed surgical concept lies within the ability to perform colectomy at an earlier stage of the disease. Safe construction of IAP is the most important technical progress. Early operation of colitis and late morbidity of pouch justify (preliminary) IRA. Thus, surgical standard in colitis-surgery is defined more individually.

[Laparoscopically-assisted proctocolectomy with ileoanal pouch in ulcerative colitis]. / Die laparoskopisch assistierte Proktokolektomie mit ileoanalem Pouch bei Colitis ulcerosa.

Laparoscopic assisted proctocolectomy with ileoanal pouch is a technical alternative to the conventional open procedure. The aim of this technique are better cosmetics. Mobilisation of the colon is achieved laparoscopically. Rectal resection, J-pouch creation, and pouchanal anastomosis are performed via a Pfannenstiel incision. Laparoscopic assisted proctocolectomy has been performed in five selected patients, three female and two male aged 17 to 36 years. Operative time ranged from 305 to 420 minutes. Intra- and postoperative complications were not encountered. Postoperative hospital stay ranged from 13 to 16 days. On a scale from 1 to 10 the average quality of life was graded 9 and the overall satisfaction level with the results of surgery scored 10. Function was identical to open surgery in not selected patients.

[Changes in colitis surgery. II: Corrective interventions and conversion operations]. / Wandel der Colitis-Chirurgie. Teil II: Korrektureingriffe und Konversionsoperationen.

Over a period of 9 years in 48 patients already operated on for ulcerative colitis secondary surgical interventions had to be planned. 25 patients had an ileostomy (IS), 10 a Kock-pouch (KP), 11 an ileoanal pouch (IAP) and 2 an ileorectal anastomosis (IRA). Whereas in 4 patients only the subjective wish for another procedure with better quality of life predominated, in 44 patients (91.7%) also objective, sometimes multiple indications for reoperation existed. In 37 patients main indications were complications or dysfunctions of the preexisting procedures, combined with the need for further resection of the colitis in 6 of them. Resection of the residual colitis was the main indication in the remaining 7 patients. The aim of the reoperation in all patients was both complete elimination of the eventually persisting colitis and restoration of quality of life in the best way wished or possible. Our of 25 IS 3 remained, 3 were reconstructed, 17 were converted to KP and 2 to IAP. Out of 10 KP one remained and in 9 corrective surgery of the nipple valve was performed. Out of 11 IAP 2 had to be resected with construction of IS, 5 were converted to KP and 4 were corrected. Two IRA were converted to IAP. The rate of early complications was 8.3% (n = 4), lethality was zero. Late complications occurred in 13 cases (27.1%) and were associated ten times with KP. Complications of KP decreased with time to zero due to technical modifications. They could always be corrected restoring function. Since only one KP had to be resected due to severe pouchitis, KP was an important secondary procedure for 31 out of 48 patients also in the long-term course ensuring both complete elimination of colitis and good quality of life owing to voluntary fecal control.

[Diagnosis of non-palpable testis: value of a new miniaturized laparoscope]. / Diagnostik des nicht tastbaren Hodens: Stellenwert eines neues, miniaturisierten Laparoskops.

Laparoscopy and magnetic resonance imaging (MRI) are competitive tools in the diagnosis of nonpalpable testis. We investigated 29 boys for this indication with MRI. If MRI failed to locate the testis, laparoscopy was performed with a new, miniaturized set of pediatric instruments (1.9-mm optic). MRI revealed 10 inguinal and 7 abdominal testes. There was no false-positive finding. In 12 boys MRI showed no testis. Four cases were true negative, 8 false negative (32%). In these 8 MRI-negative patients, laparoscopy revealed 7 inguinal and 1 abdominal testis. The optical quality of the mini-telescope was sufficient for a 100% correct diagnosis. Laparoscopy-related complications did not occur. In summary, laparoscopic evaluation is the preferred method in pediatric cases of nonpalpable testes.

[Laparoscopic resections in colon carcinoma]. / Laparoskopische Resektionen beim Kolonkarzinom.

Since 1992 laparoscopic-assisted resections have been performed in 43 patients with tumors of the right or left colon. Excluding one patient with anastomotic leak there were no harvest complications. After a mean follow-up of 25 months 26/39 patients are living without tumor progress or recurrence, none of the 39 patients have abdominal wall metastases as yet; nine patients died due to tumor progress.

[Endosonography of the esophagus and mediastinum]. / Endosonographie von Speiseröhre und Mediastinum.

It was only the endoscopic ultrasonography that allowed the esophagus and posterior mediastinum to be accessible to ultrasonography. The esophageal wall may be presented in its different anatomic layers to a degree of precision unattained by any other imaging procedure. Being important in the esophagus, both the upper rim of the tumor and the infiltration depth can this way be prognosed correctly to about 85%. In consequence, this allows proceedings appropriate to the tumor stage within the bounds of a multimodal therapeutic concept of esophagus carcinomas. Impressions of the esophagus caused by mediastinal tumors are safely distinguished from intramural tumors. Multiple biopsies to get an examination specimen from a deeper layer should be performed under no other conditions than after endoscopic ultrasonographic examination and just for special questions. In the differential diagnosis of achalasia and peptic stenosis of the esophagus, endoscopic ultrasonography proved to be less efficient. As for bronchial carcinomas, conclusive hints may be drawn from transesophageal and intratracheal ultrasonography. However, due to limited possibilities of judgment caused by air-containing structures these methods are not firmly established in the preoperative staging.

[Laparoscopic resections in Crohn disease]. / Laparoskopische Resektionen bei Morbus Crohn.

39 patients with Crohn's disease underwent laparoscopic bowel resections during January 1993 to May 1995 (16 female, 23 male, with an average age of 33 years). The duration of the disease ranged from one to 18 years. 21 of the 39 patients were under steroid therapy at the time of operation. Seven patients have had ileocaecal resection for Crohn's disease. The operative technique is laparoscopically assisted. We performed: small bowel resections (8), ileocaecal resections (16), hemicolectomies (11), subtotal colectomies (2), colectomies (2). Operative time ranged from 90 to 280 min for ileocaecal resections and from 330 to 420 min for colectomies. Intraoperative complications were not encountered. Postoperatively one patient developed a subhepatic abscess which was drained under sonographic guidance on day 6. One patient was reoperated for a different disease on postoperative day 2. Two patients had fever till day 9 and 13 without clinical relevance. Two patients had delayed incision site healing. Postoperative clinical stay was 11 days. The main benefit for the patients was early mobilisation due to reduced pain. Patients experienced the small abdominal incision as a ray of hope in their chronic disease.

[Intersphincteric rectum resection with colosphincter pouch]. / Die intersphinctere Rectumresektion mit colosphincterem Pouch.

In rectal cancer the emphasis has moved towards sphincter saving resection. Tumor site and penetration depth decide the operative technique in low rectal cancer. 1) Resection at the upper confinement of the anal canal. 2) Intersphincteric resection at the level of the dentate line. Reconstruction is achieved by a colonic J-pouch. From 1991 to 1994 we operated on 35 patients with an average age of 58.1 years. An intersphincteric resection was performed in 11 patients whose tumor was situated between 0 and 2 cm upwards the dentate line. 24 cancers were situated between 2 and 6 cm of the dentate line and were resected at the upper confinement of the anal canal with a linear stapler. Tumor penetration depth was determined endosonographically (ES). Four patients had tumor stage ES T1, 13 ES T2 and 18 ES T3. A J-pouch of 7-9 cm size was sutured (11) or stapled (24) to the anal canal. In 10 patients who underwent intersphincteric resection the pre- and post-operative anal pressures were determined. We did not encounter major complications. In three patients a leakage at the colonal anastomosis postponed closure of the diverting colostomy. We had no anastomotic recurrence but one pelvic side recurrence. Four patients developed liver metastases; in one case resectable. Postoperative anal sphincter pressure was reduced in all cases but clinically relevant only in one. This patient has frequent major soiling, three patients have occasional minor leak. Two patients are incontinent of gas, 26 are perfect continent. One patient has bowel movements every two days, 15 one per day, 12 two per day and 3 three per day.(ABSTRACT TRUNCATED AT 250 WORDS)