Neoadjuvant concurrent chemoradiotherapy with and without hyperthermia in retroperitoneal sarcomas: feasibility, efficacy, toxicity, and long-term outcome.

PURPOSE: Retroperitoneal (RPS) sarcomas are associated with poor local and abdominal tumor control. However, the benefit of preoperative radio- or chemotherapy alone for these entities is currently unclear. Moreover, as intermediate- and high-grade sarcomas have a tendency toward early metastasis, exploration of neoadjuvant strategies is of high importance. This analysis reports the results of our 20-year single-institution experience with preoperative neoadjuvant concurrent chemoradiation. METHODS: From 2000-2019, 27 patients with intermediate- or high-grade RPS (12 dedifferentiated liposarcoma, 10 leiomyosarcoma, 5 others) were treated with radiotherapy (median dose: 50.4 Gy; range 45-75 Gy) and two cycles of chemotherapy (doxorubicin 50 mg/m2 BSA/d3 q28 and ifosfamide 1.5 g/m2 BSA/d1­5 q28) in neoadjuvant intent. Chemotherapy consisted of doxorubicin alone in two cases and ifosfamide alone in one case. Fifteen patients (56%) additionally received deep regional hyperthermia. RESULTS: The median follow-up time was 53 months (±56.7 months). 92% of patients received two cycles of chemotherapy as planned and 92% underwent surgery. At 5 and 10 years, abdominal-recurrence-free survival was 74.6% (±10.1%) and 66.3% (±11.9%), distant metastasis-free survival was 67.2% (±9.7%) and 59.7% (±11.1%), and overall survival was 60.3% (±10.5%) and 60.3% (±10.5%), respectively. CTC grade III and IV toxicities were leukocytopenia (85%), thrombocytopenia (33%), and anemia (11%). There were no treatment-related deaths. CONCLUSION: Neoadjuvant chemoradiotherapy with and without hyperthermia for retroperitoneal sarcomas is feasible and provided high local control of intermediate- and high-grade sarcoma.

Operative results, sexual function and quality of life after gracilis muscle transposition in complex rectovaginal fistulas.

AIM: Successful treatment of complex rectovaginal fistulas (RVFs) continues to be a surgical challenge. Interposition of well-perfused tissue, such as gracilis muscle, is one treatment option. The aim of this study was to investigate the operative results, sexual function and quality of life after gracilis muscle transposition (GMT) in the authors' own group of patients. METHOD: The study included 19 women with RVF (mean age 48 years). The postoperative outcome was evaluated by a questionnaire and clinical examination. RESULTS: The postoperative follow-up period was 7 months to 3.5 years (mean 23 months). GMT led to primary healing of RVF in 10 (53%) patients. Recurrences were observed in nine (47%) patients with RVF, in four (44%) of whom healing was achieved as a result of further interventions. Following GMT, two complications (abscess formation) requiring revision occurred. Although 42% of the patients reported certain limitations following muscle removal, GMT is a procedure that has a positive influence on the healing rate (74%), quality of life, continence and patient satisfaction. CONCLUSION: GMT is a procedure that allows healing in the majority of patients with RVFs, and it should be considered especially in patients with recurrent fistulas, in whom a correlation between decreasing healing rates and the number of previous operations has been demonstrated.

[Practical Implementation of the "Four-column Concept" in the Situation-Adjusted Therapy for Haemorrhoidal Disease in the Daily Routine of a Proctology Department]. / Praktische Anwendung des "4-Säulen-Konzepts" der situationsadaptierten Therapie des Hämorrhoidalleidens im alltäglichen Arbeitsfeld einer proktologischen Abteilung.

INTRODUCTION: In addition to the stage, several factors influence the treatment of haemorrhoids. The aim of this study was the elaboration of an individual therapy concept which is situation-adjusted. In this context, our own experience and approaches are presented. MATERIALS AND METHODS: In the Department of Coloproctology of the Prosper-Hospital Recklinghausen, from January 2009 to August 2012, 903 haemorrhoidectomies (2nd to 4th degree) have been performed. We report our results on the practical implementation of a situation-adjusted treatment of haemorrhoidal disease. In this context we present an overview of effective modifications of surgical techniques. Retrospectively the perioperative course and postoperative outcome were evaluated. RESULTS: Even in a collective with a large number of high-risk patients (26 %) respecting the "four columns" that constitute the fundament of a situation-adjusted treatment of haemorrhoids, high patient satisfaction and good outcome with low complication (7 %) and recurrence (0 %) rates could be attained. CONCLUSION: The "four columns" (findings of examination, therapeutic options, physician and patient) form the fundament of an effective treatment of haemorrhoidal disease without many complications and guarantee an individually tailored therapy for each patient.

[Situation-adjusted Treatment of Haemorrhoidal Disease]. / Situationsadaptierte Therapie des Hämorrhoidenleidens.

In addition to the stage several factors influence the treatment of haemorrhoids. The adequate treatment of haemorrhoids is not solely dependent on the stage, thus a situation-adapted therapy should be preferred. Advantages, disadvantages and specific characteristics of different therapy strategies in addition to potential complication risks have to be evaluated in order to obtain an effective and low-risk course. Also requests and personal living conditions of the patient as well as the expertise and experience of the physician have to be considered. A review of the current literature has been performed and a "four columns concept" has been developed that constitutes the fundament of a situation-adjusted treatment of haemorrhoids. The "four columns" that should be considered when therapy strategies are determined are composed of the following key factors: diagnostic findings, treatment alternatives, physician, and patient.

[Arterial reconstruction in pancreatic carcinoma ­demonstration of surgical techniques]. / Arterielle Rekonstruktion beim duktalen Pankreaskarzinom­ Darstellung chirurgischer Techniken.

INTRODUCTION: For a highly selected group of patients, a complete resection (R0) of a pancreatic carcinoma including arterial resection and reconstruction can represent an advantage in survival. The expertise of the surgeon in vascular and pancreatic surgery as well as the proficiency of the entire surgical and anaesthesiological team and the appropriate infrastructure of the hospital are prerequisites for the success of such complex operations. Proximal and distal of the tumour, sufficient lengths of the vessels are needed for the vascular anastomoses. In this video, the principles of arterial resection and reconstruction are shown in two patients with advanced pancreatic carcinoma. INDICATION: This procedure is indicated for locally advanced pancreatic carcinoma with arterial infiltration without distant metastasis after neoadjuvant therapy. PROCEDURE: The procedure involves 2 steps: 1. pancreatic head resection with resection of the common hepatic artery and end-to-end anastomosis of the hepatic artery and portal vein resection; 2. left pancreatic resection including splenectomy; resection of the celiac trunk, the superior mesenteric artery; reinsertion of the superior mesenteric artery into the aorta; end-to-end anastomosis of the common hepatic artery with the stump of the celiac trunk. CONCLUSION: Given the appropriate experience, technically demanding arterial resections and reconstructions in pancreatic carcinoma are feasible and can provide superior survival for the patient compared to palliative therapy.

[Recurrent colorectal liver metastases: who benefits from a second hepatic resection?]. / Rezidivlebermetastasen kolorektaler Karzinome: Wer profitiert von einer zweiten Leberresektion?

BACKGROUND: Hepatic recurrence is seen in approximately 40 % of patients undergoing hepatectomy for colorectal metastases. The authors assessed the benefit and the main prognostic factors for a second liver resection of recurrent colorectal metastases. METHODS: This study reports the experience with second liver resections for recurrent liver metastases at a German University Hospital. A total of 39 parameters from 60 patients were identified from a prospective database and analysed as to their influence on recurrence-free survival and overall survival. RESULTS: At a median follow-up of 26 months (range: 2-173 months) after second hepatic resection, recurrence-free survival at 3 and 5 years were 50 % and 37 %, respectively. The overall survival at three and five years were 61 % and 52 %, respectively. Recurrence was identified in 58.3 % of the patients. Recurrences involved exclusively the liver in 19 patients (31.6 %). By multivariate analysis (Cox proportional hazard model), a time interval between diagnosis of the liver metastases of less than 24 months after operation for colorectal primary carcinoma (HR: 6.47, p = 0.002), a CEA level of 4.0 ng/mL or more (HR: 3.48, p = 0.004) at the time of first liver metastases and a size of second liver metastases of 80 mm or more (HR: 4.73, p = 0.007) were independent prognostic factors for a reduced recurrence-free survival. A repeat recurrence of liver metastases without the option of curative resection was the only risk factor for overall survival after second hepatic resection (p = 0.009). In these cases, mortality risk was 4.51-fold, however, when the second liver recurrence was resectable, the mortality risk increased only 1.4-fold. CONCLUSIONS: Technically resectable recurrent colorectal hepatic metastases should be resected the same as the first metastases. Characteristics of the primary metastasis as well as parameters of the hepatic recurrence are shown to influence the prognosis of patients after resection of recurrent liver metastases. Repeat resection of colorectal liver metastases allows for improved survival in patients even after two previous liver operations.

Effects of immunosuppression on alpha and beta cell renewal in transplanted mouse islets.

AIMS/HYPOTHESIS: Immunosuppressive drugs used in human islet transplantation interfere with the balance between beta cell renewal and death, and thus may contribute to progressive graft dysfunction. We analysed the influence of immunosuppressants on the proliferation of transplanted alpha and beta cells after syngeneic islet transplantation in streptozotocin-induced diabetic mice. METHODS: C57BL/6 diabetic mice were transplanted with syngeneic islets in the liver and simultaneously abdominally implanted with a mini-osmotic pump delivering BrdU alone or together with an immunosuppressant (tacrolimus, sirolimus, everolimus or mycophenolate mofetil [MMF]). Glycaemic control was assessed for 4 weeks. The area and proliferation of transplanted alpha and beta cells were subsequently quantified. RESULTS: After 4 weeks, glycaemia was significantly higher in treated mice than in controls. Insulinaemia was significantly lower in mice treated with everolimus, tacrolimus and sirolimus. MMF was the only immunosuppressant that did not significantly reduce beta cell area or proliferation, albeit its levels were in a lower range than those used in clinical settings. CONCLUSIONS/INTERPRETATION: After transplantation in diabetic mice, syngeneic beta cells have a strong capacity for self-renewal. In contrast to other immunosuppressants, MMF neither impaired beta cell proliferation nor adversely affected the fractional beta cell area. Although human beta cells are less prone to proliferate compared with rodent beta cells, the use of MMF may improve the long-term outcome of islet transplantation.

[Surgical technique for pancreas transplantation]. / Die chirurgische Technik der Pankreastransplantation.

OBJECTIVE: The transplantation of a cadaveric donor pancreas represents a therapeutic option for the type 1 diabetic. A precondition is the proof of negative serum C-peptide after glucagon stimulation (< 0.02 ng/ml) as it is found in the typical patient with type 1 or a pancreoprive diabetes. The pancreas can be transplanted alone (PTA) or after a kidney (PAK), either following a preceding living related or cadaveric kidney transplantation. The majority of pancreata worldwide are transplanted simultaneously with a kidney (SPK) in stage 4 and 5 (eGFR < 29 ml/min) of chronic kidney disease. The beneficial effect of physiological glucose regulation on mortality, kidney failure and diabetic complications (cardiovascular, neuropathy, retinopathy) is well established. Patient survival rate at 1 year after transplantation is above 90 %, pancreas graft survival overall after 1 year is about 80 %. INDICATIONS: Type 1 diabetic patients with recurrent hypoglycemic episodes or major complications due to dysregulated glucose metabolism qualify for pancreas transplantation alone in case of a stable kidney function. Patients with chronic kidney disease stage 4 and 5 are candidates for SPK. PROCEDURE: Pancreatic transplantation into the right iliac fossa. CONCLUSION: Although technically demanding, pancreas transplantation is safely performable with a low periprocedural morbidity and mortality. Potential perioperative complications include inflammation, rejection or graft thrombosis. After a successful transplantation, long-term physiological glucose regulation can be achieved which results in a prolonged life expectancy and quality of life in type 1 diabetic patients.

Can the new RCP R0/R1 classification predict the clinical outcome in ductal adenocarcinoma of the pancreatic head?

PURPOSE: According to the International Union Against Cancer (UICC), R1 is defined as the microscopic presence of tumor cells at the surface of the resection margin (RM). In contrast, the Royal College of Pathologists (RCP) suggested to declare R1 already when tumor cells are found within 1 mm of the RM. The aim of this study was to determine the significance of the RM concerning the prognosis of pancreatic ductal adenocarcinoma (PDAC). METHODS: From 2007 to 2009, 62 patients underwent a curative operation for PDAC of the pancreatic head. The relevance of R status on cumulative overall survival (OS) was assessed on univariate and multivariate analysis for both the classic R classification (UICC) and the suggestion of the RCP. RESULTS: Following the UICC criteria, a positive RM was detected in 8 %. Along with grading and lymph node ratio, R status revealed a significant impact on OS on univariate and multivariate analysis. Applying the suggestion of the RCP, R1 rate rose to 26 % resulting in no significant impact on OS in univariate analysis. CONCLUSIONS: Our study has shown that the RCP suggestion for R status has no impact on the prognosis of PDAC. In contrast, our data confirmed the UICC R classification of RM as well as N category, grading, and lymph node ratio as significant prognostic factors.

[Anal sphincter repair in the treatment of anal incontinence - when and how to do it?]. / Anal Sphincter Repair zur Therapie der Stuhlinkontinenz - Wann und wie?

Anal incontinence is a disease of high prevalence. For many patients the disease causes severe stress and often results in social isolation. Whenever a sphincter lesion has been diagnosed by digital rectal examination and endosonographic access, anal sphincter reconstruction can be performed with the same results either in overlapping or in end-to-end suture technique. sing these procedures, in more than 60 % of patients the continence can be initially improved. However, benefit decreases after 5 years down to 40-50 %. The prognosis gets worse with increasing age and supplementary descending pelvic floor. Anal repair with reconstruction of internal and external sphincters is performed in neurogenic incontinence. This can be achieved by posterior or anterior anal repair (total pelvic floor repair). Nowadays these procedures are not common, due to unsuccessfulness. Instead, sacral nerve stimulation as a more expensive but less invasive method has displaced the anal repair on this indication. Interpretation of the published results remains delicate because of heterogenous evaluation criteria of postoperative outcome: subjective amelioration, postoperative satisfaction and quality of life, improvement of incontinence score or achievement of complete anal continence. However, it is proven that after immediate reconstruction of traumatic sphincter lesions the postoperative outcome is better than a two-step operation with primary ostomy.

Synchronous lymph node and liver metastasis in a well differentiated gastric endocrine tumour type I.

Gastric endocrine tumours constitute less than 1% of all (neuro-)endocrine tumours and less than 2% of all gastrointestinal malignancies. They are classified into three groups: well-differentiated endocrine tumours, well-differentiated endocrine carcinoma, poorly-differentiated endocrine carcinoma. We report the rare case of a patient with a metastasising gastric endocrine tumour that histologically revealed all signs of a well-differentiated endocrine tumour.

[Amyloidosis of the small intestine following whipple operation is a rare cause of chronic ileus and has to be considered as differential diagnosis]. / Die Amyloidose des Dünndarms als seltene Differenzialdiagnose eines chronischen Ileus nach Whipple-Operation.

INTRODUCTION: When patients who underwent a Whipple operation because of a tumour of the pancreas develop symptoms of chronic ileus several months after surgery, the most common cause is a relapse of tumour growth or a peritoneal carcinomatosis. In this paper we report that secondary amyloidosis of the small intestine can produce similar symptoms and has to be evaluated as a rare differential diagnosis in chronic ileus. CASE REPORTS: Three patients (2 men: 82, 70 years old and 1 woman 70 years old) were admitted to our hospital with symptoms of chronic ileus. All of them had undergone a Whipple operation several months (4, 5, 13 months) before. In two patients surgery was performed due to carcinoma in situ and in one patient due to benign cystadenoma of the pancreas. Chronic ileus resulted in relaparotomy in all patients. Surprisingly, the intraoperative situs did not show any tumour growth. Instead severe adhesions of the small intestine were detected. The entire small intestine was covered with a substance that had a similar aspect to sugar icing. Thereby the motility of the small intestine was constricted. An extensive adhaesiolysis and a decompression of the bowel was carried out. By histopathology, amyloidosis was diagnosed using congo red staining. Diffuse amyloid deposits were found on the small intestine. In the postoperative course two patients could be discharged free of complaints after 7 to 9 days in the hospital. One man died four months later, after transfer to a geriatric hospital, because of intestinal atony and a serious senile depression. CONCLUSION: Secondary amyloidosis following the Whipple operation is a rare reason for the symptoms of chronic ileus. Surgeons have to keep in mind that amyloidosis is a possible differential diagnosis in addition to relapse of tumour growth and peritoneal carcinomatosis in these patients. Thus, in our opinion, relaparotomy should be undertaken as early as possible because this is the only chance to detect the cause of chronic ileus.

Contrast-enhanced ultrasonography in patients with colorectal liver metastases after chemotherapy.

PURPOSE: A systematic single-center analysis was performed to evaluate the efficacy of contrast-enhanced ultrasonography (CEUS) in the detection of colorectal liver metastases in patients with systemic chemotherapy in their medical history. MATERIALS AND METHODS: Between May 2005 and December 2007, 48 patients were referred to our institution for further evaluation after chemotherapeutic pretreatment for colorectal liver metastases. In all cases, the liver was screened by both unenhanced and contrast-enhanced ultrasonography with SonoVue to detect focal liver lesions. The results of sonographic explorations were prospectively collected and compared with intraoperative findings including histopathological results as reference. RESULTS: A total of 40 patients underwent laparotomy and were included in the analysis. The rate of correct ultrasound findings (rate of detection) increased from 24 patients (60%) with 35 metastases (57.4%) to 31 patients (77.5%) with 50 metastases (82.0%) after administration of SonoVue. Thus CEUS showed a significantly improved sensitivity compared to unenhanced US in both patient-by-patient analysis (79.5 versus 63.2%, p = 0.041) and lesion-by-lesion analysis (82.0 vs. 60.3%, p = 0.0008). On the basis of the ultrasound results, the surgical strategy had to be changed in 16 (40.0%) cases examined by unenhanced US compared to only nine cases (22.5%) examined by CEUS (p = 0.002). In CEUS a higher number of lesions were identified with an increasing metastasis size. CONCLUSION: After chemotherapeutic pretreatment, unenhanced US should be replaced by CEUS for the detection of liver metastases from colorectal carcinoma.

Isolated aneurysm of the internal jugular vein.

True venous aneurysms are rare. We report the case of a 70-year-old male with the extremely uncommon finding of an aneurysm of the internal jugular vein. Due to their rarity, no general guidelines for the treatment of these aneurysms have been established. Upon surgical exclusion of the aneurysm, a progressive swelling of the right side of the face was noted in this patient leading to the decision to interpose a thin-walled ePTFE prosthesis for want of a suitable vein graft. Upon follow-up three years later, the patient is completely asymptomatic and the prosthesis is patent in Doppler sonography.

Acute renal failure after allogeneic myeloablative stem cell transplantation: retrospective analysis of incidence, risk factors and survival.

Acute renal failure (ARF) is an important complication after stem cell transplantation (SCT). We retrospectively analysed ARF in 363 recipients of allogeneic myeloablative SCT to identify incidence, risk factors, associated post-transplantation complications and mortality of ARF. ARF was graded as grade 0 (no ARF) to grade 3 (need for dialysis) according to creatinine, estimated glomerular filtration rate and need for dialysis. The incidence of severe renal failure (grades 2 and 3 combined) was 49.6% (180 of 363 patients). Hypertension present at SCT was identified as a risk factor for ARF (P=0.003). Despite this, survival of these patients was not different compared to patients without hypertension. Admission to the intensive care unit (ICU) was a post-transplantation complication significantly associated with ARF (P<0.001). Survival rate was highest in patients with ARF grade 0-1 and lowest in patients with grade 3 (P<0.001). However, after correction for complications associated with high mortality (admission to the ICU, thrombotic thrombocytopenic purpura, sinusoidal occlusion syndrome (SOS) and acute graft-versus-host disease) the significant difference in survival disappeared, showing that ARF without co-morbid conditions has a good prognosis, and ARF with co-morbid conditions has a poor prognosis. This poor prognosis is due to the presence of co-morbid conditions rather than development of ARF itself.

The role of contrast-enhanced ultrasound for focal liver lesion detection: an overview.

The development of new ultrasound (US) contrast agents and sonographic techniques has considerably improved the possibilities of ultrasound in the assessment of liver tumors. An overview is given on diagnostic potential of contrast-enhanced US (CEUS) and real-time low mechanical index technique in the detection of various focal liver lesions compared with computed tomography, magnetic resonance imaging or intraoperative US. In two of our own studies that included 100 patients each we showed an increase of correct findings in CEUS compared with B-mode US from 64% to 87% and from 67% to 84% as confirmed by intraoperative evaluation of the liver. Especially after chemotherapy and in the case of small metastases, significantly more metastases were correctly detected by CEUS compared with B-mode US. These results and clinical study results in the literature show that CEUS allows tumor detection and direct visualization of the tumor vascularity and put contrast-enhanced sonography among recommended noninvasive imaging methods for focal liver lesions with improvements in diagnostic strategy.

[Alloplastic material in prolapse surgery : Indications and postoperative outcome of ventral rectopexy]. / Alloplastisches Material in der Prolapschirurgie : Indikation und postoperatives Outcome der ventralen Rektopexie.

BACKGROUND: In rectopexy the use of meshes provides stability by mechanical support as well as by the induction of scar formation; however, one of the problems of conventional methods of mesh rectopexy is that many patients postoperatively suffer from functional disorders, such as fecal incontinence and stool evacuation disorders. One reason is the damage of vegetative nerves following dorsal and lateral mobilization of the rectum, which is required for positioning of the mesh. In 2004 D'Hoore and Penninckx first described the method of ventral rectopexy, a new technique of mesh rectopexy which allows preservation of the autonomic nerves. OBJECTIVE: Does ventral rectopexy provide advantages regarding functional outcome, complications and recurrence rates? MATERIAL AND METHODS: A search was carried out in the databases PubMed and Medline for studies on ventral rectoplexy. Presentation and analysis of the current state of relevant studies relating to ventral rectopexy. RESULTS: Ventral rectopexy is characterized by a low complication rate and good functional results in terms of improvement of incontinence, constipation and stool evacuation disorders. The indications for ventral rectopexy are considered in patients with external prolapse of the rectum. Also in a well-selected patient population internal prolapse, rectocele as well as enterocele accompanied by obstructive defecation syndrome represent relative indications for ventral rectopexy. CONCLUSION: In order to obtain a valid assessment of the value of this procedure it is crucial to improve the current lack of evidence (level 3) by prospective randomized studies that compare ventral rectopexy with other surgical techniques and nonsurgical treatment options.