Local excision and endoscopic posterior mesorectal resection versus low anterior resection in T1 rectal cancer.

BACKGROUND: Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer. METHODS: Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups. RESULTS: Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0.402 for major and P = 0.691 for minor complications). Median number of lymph nodes removed was 7 (range 1-22) for EPMR and 11 (range 2-36) for LAR (P = 0.132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence. CONCLUSION: EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.

[Medial mobilisation of the left hemicolon]. / Die Mobilisation des linken Hemikolons von medial.

INTRODUCTION: Laparoscopic surgery of the colon is becoming more and more popular. However, regarding sigmoid resection, controversy remains concerning the extent of mobilisation, particularly regarding the splenic flexure. We developed a technique for anterior resection that meets all surgical standards: the anterior approach. MATERIALS AND METHODS: From October 1999 to March 2001, 50 patients with benign diseases of the colon underwent laparoscopically assisted sigmoid resection. A completely anterior approach for mobilisation of the left hemicolon was used in all cases. Positioning the patients in Trendelenburg position on the extreme right side enabled primary ligation of the inferior mesenteric vein and artery as well as complete mobilisation of the splenic flexure from the middle. A transanal circular stapling device was used to reanastomose the colon 10-12 cm from the anus. RESULTS: There were conversion and complication rates of 10% each, and three patients needed to be reoperated. The median operating time was 180 min. Patients could be dismissed on the 14th postoperative day. CONCLUSION: To establish an operative standard, this technique has so far been used only for benign colon diseases. According to our experience, we think that it meets all oncological standards. Use of this technique in the treatment of malignant diseases seems therefore justified.

[Status and outcome of laparoscopic appendectomy--results of a prospective study of 600 consecutive appendectomies]. / Stellenwert und Ergebnisse der laparoskopischen Appendektomie--Resultate einer prospektiven Studie von 600 konsekutiven Appendektomien.

In a prospective study 600 consecutive appendectomies were held. In 51 cases the surgery was conventionally ended after laparoscopic beginning. The laparoscopic proceeding was set independently of the dimension of the inflammation. Also the perforation did not exhibit any contraindication. The rate of complications of 8.7% was in the range of the conventional appendectomy. We, however, could show that with increased experience and save technique the morbidity, especially the septic complications could have been sinked to 2%. The duration of hospitalisation amounted on an average of 5.0 days, the surgery time 53.6 minutes. The main advantage of the laparoscopic proceeding is the outstanding overview with the possibility of a diagnostics of the abdominal cavity. Besides an acute appendicitis of which in 14.6% a perforation was present, relevant side findings were elevated in 11.3% which in 7.7% were endoscopic surgically treated at the same time.

Anastomotic leakage as a risk factor for the long-term outcome after curative resection of colon cancer.

AIMS: Long-term outcome for curative colon cancer surgery may be impaired by anastomotic leakage, but most studies regard colon and rectal cancer patients as one group. The aim of this study was to determine whether anastomotic leakage following potentially curative resection for colon cancer is a risk factor for postoperative mortality and for long-term survival. PATIENTS AND METHODS: Medical records of a cohort of 440 consecutive patients undergoing 445 curative resections for explicit colon cancer with primary anastomosis above the peritoneal reflection were reviewed. Therefore patients with rectal cancer were not included. Diagnosis of leakage was made by clinical features or abdominal CT-scans. RESULTS: The study population consisted of 266 men and the mean age was 68.6 years. Median follow-up time was 66.5 months. Anastomotic leakage occurred in 12 patients. Four of these died within 30 days after surgery compared to 15 of the remaining 428 patients without leakage (p<0.001). The 5-year overall survival rate was 25% in patients with anastomotic leakage compared to 61.2% in those without leakage (p<0.001). Excluding 30-day mortality, respective values were 33.3 and 63.7% (p=0.02). CONCLUSION: Although anastomotic failure after colon cancer surgery is rare, it is a very severe complication that not only impairs the perioperative morbidity and mortality but also significantly influences the long-term outcome negatively.

[Laparoscopic diagnosis in suspected acute appendicitis]. / Laparoskopische Diagnostik bei Verdacht auf akute Appendizitis.

Since introduction of laparoscopic appendectomy we have the possibility to examine the whole abdominal cavity and not only the ileocaecal region and right adnex. The aim of the study is to find out if there is an advantage in laparoscopic diagnostics compared to conventional laparotomy for suspected acute appendicities. We compared prospectively all patients who underwent laparoscopy for acute right lower abdominal pain between August 1991 and March 1993 with a comparable group retrospectively analyzed who underwent conventional appendectomy in 1989. In both groups 20% of patients had a normal appendix. In 1% of the laparoscopically operated patients we couldn't find any pathological findings, in 12% of the conventionally operated group we couldn't find an accurate diagnosis. The average operation time of laparoscopically operated patients without acute appendicities was 20 minutes shorter compared to conventionally operated patients. We found identically results for the duration of hospital stay. The median hospital stay for conventionally operated patients was 6.6 days, for laparoscopically operated patients 4.7 days. The complications were in both groups 1-2%. We conclude that in laparoscopy the diagnostics are more reliable, and with a diagnostic accuracy of almost 100% the unnecessary appendectomy with a higher morbidity would not be necessary in 12% of patients.