Damage control strategy for the treatment of perforated diverticulitis with generalized peritonitis.

BACKGROUND: The best surgical strategy for the management of perforated diverticulitis with generalized peritonitis of the sigmoid colon is not clearly defined. The aim of this retrospective cohort study was to evaluate the value of a damage control strategy. METHODS: All patients who underwent emergency laparotomy for perforated diverticular disease of the sigmoid colon with generalized peritonitis between 2010 and 2015 were included. The damage control strategy (study group), included a two- stage procedure: limited resection of the diseased colonic segment, closure of proximal colon and distal stump, and application of an abdominal vacuum at the initial surgery followed by second-look laparotomy 24-48 h later At this point a choice was made between anastomosis and Hartmann's procedure. The control group consisted of patients receiving definitive reconstruction (anastomosis or Hartmann's procedure) at the initial operation. RESULTS: Thirty-seven patients were included in the study. Damage control strategy was applied in 19 patients and the control group consisted of 18 patients. Both groups were comparable in terms of demographics, severity of peritonitis, and comorbidities. The overall postoperative mortality was 11 % (n = 4). There were no statistically significant differences between both groups regarding postoperative morbidity and mortality; however, a significantly higher proportion of patients in the control group had a stoma after the initial hospital stay (83 vs. 47 %, p = 0.038). This difference was still significant after adjustment for sex, age, Mannheim Peritonitis Index, American Society of Anesthesiologists class and presence of septic shock at presentation. At the end of the follow-up period, 15 of 17 survivors in the study group and 13 of 16 survivors in the control group had their intestinal continuity restored (p = 0.66). CONCLUSIONS: Damage control strategy in patients with generalized peritonitis due to perforated diverticulitis leads to a significantly reduced stoma rate after the initial hospital stay without an increased risk of postoperative morbidity.

[Fistulas and fissures. Part II: fissures]. / Fisteln und Fissuren. Teil II: Fissuren.

Fissures in ano are linear ulcers situated in the anal canal and extending from the dentate line to the margin of the anus. They cause pain and spasms. Diagnosis is made by the history alone. Local medical treatment might consist of topical 0.4% glycerol trinitrate or 2% calcium blocker. In case of therapy resistance, botulinum toxin injection into the internal sphincter is an effective but expensive alternative with encouraging results. If medical treatment fails, then operation has to be recommended. As lateral internal sphincterotomy represents poses a clear danger to continence, fissurectomy combined with the excision of skin tags and any anal papilla is now the operative treatment of choice.

[Fistulas and fissures. Part I: perianal fistulas]. / Fisteln und Fissuren. Teil I: Perianale Fisteln.

Perianal abscesses are caused by cryptoglandular infections at the dentate line between the anal sphincters. Acute therapy will relieve the pain but not the development of perianal fistulas. The challenge in therapy of perianal fistulas balances between the best possible cure and the preservation of continence. Local treatment with fibrin glue is a first step whenever continence might be endangered by operative procedures. First results with fistula "plugs" are promising but need further critical observation. Lower, intersphincteric fistulas can be treated by fistulotomy without risking a substantial loss in continence, but higher, suprasphincteric or complex fistula systems might be treated as a first step with a seton--followed by surgery as a second step. Excision of the external fistula tract, closure of the internal opening, and a local advancement flap are now competing with fistulotomy, curettage, and immediate reconstruction.

[Diagnosis and therapy for anal carcinoma]. / Diagnostik und Therapie des Analkarzinoms.

Of all carcinomas in the anal canal, 75-80% are squamous cell carcinomas-the remaining 25% being adenocarcinomas. Carcinomas of the anal margin are to be differentiated from basal cell carcinomas and Paget's and Bowen's diseases. More than 80% of anal carcinomas show high-risk HP viruses. Every suspicious lesion in the anal canal and margins must be examined histologically. Primary radiochemotherapy is the first treatment option for epidermoid carcinomas of the anal canal and anal margin. Overall 5-year survival is reported at up to 90%. Surgery is reserved for the primary biopsy or excision of small tumors and for salvage abdominoperineal resection in patients with tumor persistence or local recurrence after radiochemotherapy. Systematic inguinal lymphadenectomy is not indicated. The first follow-up examination should be done 6 weeks after the end of radiochemotherapy. A biopsy is necessary after 3 months.

Influence of hospital volume on local recurrence and survival in a population sample of rectal cancer patients.

AIMS: To investigate the role of hospital volume and individual hospitals on long term outcomes (local recurrence and survival) of rectal cancer patients. METHODS: One thousand thirty-eight patients with rectal cancer were diagnosed between 1996 and 1998. From these, we analysed 884 patients with a resected invasive primary rectal cancer. Median follow-up was 5.7 years. The impact of hospital volume (<10, 10-30 and >30 rectal cancer patients annually) on local recurrence and survival was examined in a Cox model. Differences between the four largest clinics in the high volume group were also investigated. RESULTS: In the multivariate model predicting survival the following variables were significant: UICC stage, grade, age, local recurrence, and (neo-) adjuvant therapy treatment. In the multivariate model predicting local recurrence UICC stage, tumour localisation, and neoadjuvant therapy treatment were significant variables. Hospital volume was not a significant factor for survival or local recurrence. Within the high volume category one hospital showed significantly worse local recurrence rates than all other hospitals, but no survival difference could be seen between the four largest hospitals of the high volume group. CONCLUSIONS: This analysis of a rectal cancer population found that hospital volume did not determine survival or local recurrence. Detailed clinical data with long term follow-up from cancer registries are vital to demonstrate the quality of routine care.

[Rectal prolapse in adults]. / Der Rektumprolaps des Erwachsenen.

The etiology of rectal prolapse is unclear. Diagnosis is easy by local inspection. The ideal surgery would repair the prolapse, correct any functional problems such as incontinence or constipation, be minimally invasive and cost-effective, and result in minimal morbidity and recurrence. The best surgical repair remains controversial-whether by the transanal/perineal or abdominal approach-with or without resection and rectopexy. There are no prospective-randomized studies that convincingly answer the numerous questions. The best possible option today seems to be the abdominal/laparoscopic method with a resection rectopexy according to Frykman and Goldberg.

[Are there differences in prodromal illnesses, symptoms and prognosis for various forms of mesenteric infarct?]. / Existieren Unterschiede bei Vorerkrankungen, Symptomatik, und Prognose für die verschiedenen Formen des Mesenterialinfarktes?

Comparing 105 patients with mesenteric infarction, the typical attributes of the underlying diseases, arterial embolization (aE) (n = 26), arterial thrombosis (aT) (n = 40), venous thrombosis (vT) (n = 32) and combined arterio-venous occlusion (n = 7) could be demonstrated. Present heart disease, diabetes and arterial hypertonia, rapid onset of symptoms, severe abdominal pain and signs of peritonitis, extended gangrene of bowel and a high mortality of about 90% is the typical combination for aE. Over 70 years old patients with higher incidence of arteriosclerosis, more digitalis intake, longer duration of symptoms and with bowel problems in the past have a higher incidence of aT and a slightly better prognosis. Risk of thrombosis, long-standing symptoms and a clearly better prognosis are typical for the vT.

[Long-term intubation following tracheotomy]. / Beobachtungen bei Langzeitintubation nach Tracheotomie.

Between 1981 and 1983 tracheotomy was performed on 61 patients in the Surgical University Clinic of Tübingen. The dominant factors in indication of tracheotomy was for 49% of patients the persistingly necessary artificial respiration, for 26% a better bronchial toilet and other reasons for 25%. With 40.5% of all cases pneumonia was the most frequent complication encountered with our patients. The most frequent bacteria was Pseudomonas aeruginosa. Because of the decisive advantage constituted by the possibility of unproved bronchial toilet an earlier realisation of tracheotomy is to be recommended.

[Anal and perianal tumors]. / Anale und perianale Tumoren.

The anal canal extends from the anorectal ring to the anal verge. Different kinds of epithelium are existing. Below the dentate line is squamous epithelium, above columnar. In between is a gradual transition area, the so called transitional zone. According to the World Health Organization the anal margin is outside the anal verge and the anal canal reaches up to the superior border of the levator muscle. The lymphatic drainage of the anal margin is to the inguinal lymph nodes, from the anal canal to the inferior mesenteric nodes. Tumors of interest in the perianal location are Paget's disease and Bowen's disease as an intraepithelial adenocarcinoma or a squamous cell carcinoma in situ. Wide local excision is the treatment of choice. The true epidermoid carcinoma can be found at the anal margin and the anal canal. The symptoms are mild and unspecific. Many tumors are diagnosed late. The standard treatment has changed in the last 20 years. Local excision and abdominoperineal resections were followed by a high rate of local recurrence. The 5 year survival rate was 50% overall. The treatment of choice today is a combined chemoradiation therapy following Nigro's recommendation. The 5 year survival rate is approximately 85%.

[Perianal fistula and anal fissure]. / Perianale Fistel und Analfissur.

CRYPTOGLANDULAR ANAL FISTULA: Perianal abscesses are caused by cryptoglandular infections. Not every abscess will end in a fistula. The formation of a fistula is determined by the anatomy of the anal sphincter and perianal fistulas will not heal on their own. The therapy of a fistula is oriented between a more aggressive approach (operation) and a conservative treatment with fibrin glue or a plug. Definitive healing and the development of incontinence are the most important key points. ANAL FISSURES: Acute anal fissures should be treated conservatively by topical ointments, consisting of nitrates, calcium channel blockers and if all else fails by botulinum toxin. Treatment of chronic fissures will start conservatively but operative options are necessary in many cases. Operation of first choice is fissurectomy, including excision of fibrotic margins, curettage of the base and excision of the sentinel pile and anal polyps. Lateral internal sphincterotomy is associated with a certain degree of incontinence and needs critical long-term observation.

[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.

[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.

[A 67-year-old patient with diarrhoea and constipation without any pathological findings in virtual colonoscopy]. / 67-jähriger Patient mit paradoxer Diarrhoe und unauffälliger virtueller Koloskopie.

Virtual colonoscopy provides a computer-simulated endoluminal perspective of the air-filled, distended colon using modern CT scanning (spiral CT). According to recent studies the sensitivity and specificity of this technique are high for adenomatous polyps > or = 10 mm. A 67-year-old patient was admitted to our hospital because of diarrhoea and constipation, associated with abdominal pain in the lower right abdomen. Prior to admission the patient had undergone virtual colonoscopy in a specialised radiological practice which had detected no abnormalities apart from colonic diverticulosis. However, conventional video-colonoscopy revealed a subtotal circular malignant stenosis in the region of the right colonic flexure. A poorly differentiated adenocarcinoma was diagnosed histologically. Staging showed peritoneal carcinosis with infiltration of the right ureter and lymphangiosis carcinomatosa of the pectoral lobe of the left lung. After right hemicolectomy because of metastasised carcinoma of the ascending colon (pT4pN1pM1) we started palliative chemotherapy with oxaliplatin, 5-fluorouracil and leucovorin. The risk of misdiagnosis by virtual colonoscopy is clearly increased in patients with subtotal tumour stenosis of the ascending colon. Conventional video-colonoscopy remains the gold standard for the diagnosis of colorectal carcinoma.

[When is a breast-preserving operation permitted?]. / Wann ist eine brusterhaltende Operation erlaubt?

Breast preserving operations in cases of breast cancer are permitted only under following conditions: Tumor extension should not exceed stage pT1. Axillary lymph nodes have to be removed completely. Histological examination requires a competent pathologist. Carefully planned and consequently applied radiotherapy with a dosage of at least 60 Gy (6000 rad) is mandatory.