German National Guideline on the management of pilonidal disease: update 2020.

BACKGROUND: The present German National Guideline is an updated version of previous Guideline published in 2014. It aims to compare various treatment methods and to assist physicians with evidence-based recommendations. METHODS: Systemic literature review. RESULTS: Three types of disease manifestation could be differentiated: asymptomatic disease, an acute abscess, and the chronic pilonidal disease. At present, there is no treatment method fulfilling all desired criteria: simple, painless procedure associated with rapid wound healing, and low recurrence rate. Thus, treatment modality should be tailored to disease manifestation and extent. CONCLUSION: Asymptomatic pilonidal disease should not be treated. A pilonidal abscess should be unroofed. After resolution of the acute inflammation, the disease should be treated definitely. As for today, sinus excision is the standard treatment of the chronic pilonidal disease. Wide excision and open treatment of chronic disease is a safe procedure which, however, leads to prolonged secondary healing and time off-work, as well as to considerable recurrence rate. The extent of excision should be as limited as possible. Excision and midline wound closure is associated with impaired outcomes. Today, it has become obsolete. Minimally invasive procedures (e.g., pit picking surgery) represent a treatment option for chronic pilonidal disease. However, the recurrence rate is higher compared to excision procedures. Nevertheless, they may be used for small primary disease. Off-midline procedures should be used for disease not suitable for minimally invasive treatments. The Limberg flap and the Karydakis procedure are two best described methods which are associated with similar short- and long-term results.

German national guideline on the management of pilonidal disease.

PURPOSE: The present national guideline aims to provide recommendations for physicians involved in the treatment of patients with pilonidal disease. It has been published previously as an extended version in German language. METHODS: This is a systemic literature review. The present guideline was reviewed and accepted by an expert panel in a consensus conference. RESULTS: Some of the present guideline conclusions were based on low- to moderate-quality trials. Therefore, an agreement was necessary in those cases to provide recommendations. However, recommendations regarding the most frequently used surgical procedures were based on numerous prospective randomized trials. CONCLUSIONS: An asymptomatic pilonidal disease does not require treatment. A pilonidal abscess should be incised. After regression of the acute inflammation, a definitive treatment method should be applied. An excision is the standard treatment method for the chronic pilonidal disease. Open wound healing is associated with a low postoperative morbidity rate; however, it is complicated by a long healing time. The minimally invasive procedures (e.g., pit picking surgery) represent a potential treatment option for a limited chronic pilonidal disease. However, the recurrence rate is higher compared to open healing. Excision followed by a midline wound closure is associated with a considerable recurrence rate and increased incidence of wound complications and should therefore be abandoned. Off-midline procedures can be adopted as a primary treatment option in chronic pilonidal disease. At present, there is no evidence of any outcome differences between various off-midline procedures. The Limberg flap and the Karydakis flap are most thoroughly analyzed off-midline procedures.

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.

Long-term results after stapled hemorrhoidopexy: a prospective study with a 6-year follow-up.

BACKGROUND: Stapled hemorrhoidopexy was introduced in 1998 as a new technique for treating advanced hemorrhoidal disease. Despite a clear perioperative advantage regarding pain and patient comfort, literature reviews indicate a higher recurrence rate for stapled hemorrhoidopexy than for conventional techniques. OBJECTIVE: Our aim was to present long-term on the use of this technique. DESIGN: Observational study. SETTING AND PATIENTS: Consecutive patients with hemorrhoid prolapse treated at a regional surgical center from May 27, 1999, through December 31, 2003. INTERVENTION: Stapled hemorrhoidopexy with accompanying resection of residual hemorrhoidal nodules if necessary. MAIN OUTCOME MEASURES: Standardized patient questionnaire regarding satisfaction, resolution of symptoms, and performance of further interventions. RESULTS: Of 257 patients (82 female, 175 male, mean age 53 ± 13 years) undergoing stapled hemorrhoidopexy, follow-up data were available for 224 patients (87.2%) with a mean duration of 6.3 ± 1.2 years. Of these, 195 patients (87.1%) were satisfied or very satisfied with the operation outcome; 19 patients (8.5%) were moderately satisfied; and 10 (4.5%) were not satisfied. Regarding preoperative anal symptoms, complete relief was observed in 179 patients (80.6%) for prolapse, 172 (77.5%) for bleeding, 139 (85.3%) for mucus discharge, 139 (78.5%) for burning sensation, and 115 (75.5%) for itching. Considering all recorded symptoms, 194 patients (86.6%) reported absence and or an improvement at follow-up. Twelve patients (5.4%) reported newly developed incontinence in the sense of urge symptoms; 42 patients out of 51 patients (82.4%) with preexisting incontinence reported an improvement. Local or topical retreatment (ointment, suppositories, sclerotherapy) was performed in 48 patients (21.4%). Reoperation for residual or newly developed hemorrhoidal nodules was needed in 8 patients (3.6%). LIMITATIONS: Lack of a comparative group. CONCLUSION: Our long-term results show that this strategy for stapled hemorrhoidopexy can achieve a high level of patient satisfaction and symptom control, with a low rate of reoperation for recurrent hemorrhoidal symptoms.

Matrix metalloproteinase inhibitor RO 28-2653 decreases liver metastasis by reduction of MMP-2 and MMP-9 concentration in BOP-induced ductal pancreatic cancer in Syrian Hamsters: inhibition of matrix metalloproteinases in pancreatic cancer.

BACKGROUND: Matrix metalloproteinases (MMP) are proteolytic enzymes which degrade the extracellular matrix and therefore play an important role in metastasis. However, the impact of MMP inhibitors (MMPI) on pancreatic cancer is still unclear. Thus we evaluated the influence of selective MMPI Ro 28-2653 on the incidence of liver metastases and the concentration of MMP-2 and MMP-9 in ductal pancreatic adenocarcinoma in Syrian hamster. MATERIAL AND METHODS: One hundred and thirty male Syrian hamsters were randomised into 8 groups (Gr.1-3: n=15, Gr.4-8: n=17). Pancreatic cancer was induced by weekly subcutaneous injection of 10mg N-nitrosobis-2-oxopropylamin (BOP)/kg body weight (Gr.4-8) while healthy control Gr. 1-3 received 0.5 ml sodium chloride 0.9%. Gr.1 and 4 had free access to a standard diet, Gr. 2, 3 and 5-8 received a diet rich in polyunsaturated fatty acids, which increases liver metastasis in this model. In week 17 oral therapy started: Gr.3 and 6: 60 mg Eudragit/kg body weight/d (vehicle of MMPI), Gr.7 and 8: 40 mg, respectively, 120 mg RO 28-2653/kg body weight/d; Gr.1, 2, 4, 5: no therapy. After 30 weeks all hamsters were sacrificed and histopathologically examined. Additionally concentrations of MMP-2 and MMP-9 were measured in non-metastatic liver and liver metastases. RESULTS: Concentrations of MMP-2 and MMP-9 in liver metastases were decreased by high- and low-dose therapy with MMPI. Furthermore, the incidence of liver metastases was significantly reduced by low-dose therapy with Ro 28-2653. CONCLUSION: Low-dose therapy with Ro 28-2653 decreased liver metastasis due to an inhibition of MMP-2 and MMP-9 concentration in ductal pancreatic cancer.

[Evacuation defecography and defecoflometry in diagnosis of chronic constipation. A prospective comparative study of 49 patients]. / Die Entleerungsdefäkographie und die Defäkoflowmetrie in der Diagnostik der chronischen Obstipation. Eine prospektiv vergleichende Studie bei 49 Patienten.

Chronic constipation can be divided in two large groups: slow-transit constipation, caused by pathological intestinal transit, and obstructive defecation disorder, caused by pelvic and rectal wall abnormalities. Videodefecography and defecoflowmetry are methods used to study dynamic evacuation of the rectum. Videodefecography also enables visual estimation of rectal evacuation. Defecoflowmetry allows analysis of anal and rectal pressures. Within this prospective study we utilized and compared these methods in 19 patients with slow transit and 30 patients with obstructive disease. In patients with slow transit, both investigations demonstrated a significantly higher defecation rate than in obstructive defecation disorder (slow transit: defecoflowmetry 65%, videodefecography 80%; obstructive defecation disorder: 50% and 58%). The evacuation time was pathologically prolonged in both types of constipation, with a range of 43-55 s. Rectoceles are demonstrated in 94% of cases with slow transit and in 72% with obstructive defecation disorder. Also, we often found obstructive components in slow-transit constipation patients. Normal defecography or defecoflowmetry can rule out obstructive defecation disorder. We conclude that videodefecography and defecoflowmetry are important items in the complex diagnostic regimen needed in evaluation of chronic constipation.

[Results of transperineal levator-plasty in treatment of symptomatic rectocele]. / Ergebnisse der transperinealen Levatorplastik bei der Behandlung der symptomatischen Rectocele.

A rectocele is a herniation of the anterior rectal wall through the rectovaginal septum into the vagina. The most important risk factors are a previous hysterectomy, obstetic injuries and the descending perineum syndrome. In some patients the rectocele becomes symptomatical because of defecation disorders. The patients have to give manual vaginal or perineal help during defecation. Radiological parameters like the size of the rectocele or retention of barium only have limited value for the clinical evaluation. In a high percentage we find simultaneous symptoms of fecal incontinence. Transperineal anterior levatorplasty makes it possible to close the rectocele. This procedure has a positive influence on defecation and continence. In a prospective study we performed anterior levatorplasty in 35 female patients having a rectocele in combination with rectal outlet obstruction. Subjective improvement of the defecation disorder was found in 74%. Only 1 patient complained of deterioration. No patient needed manual vaginal help postoperatively. Patients who needed perineal help preoperatively had worse results. Patients who did not need any manual help preoperatively nevertheless reported an improvement postoperatively. Fifteen of 20 patients, who suffered from fecal incontinence preoperatively, reported a better continence postoperatively (75%). Even in patients with incontinence the anterior levatorplasty is a good method for rectocele repair, as it improves rectal emptying and simultaneously provides therapy for fecal incontinence.

[Management of primary non-classifiable anal fistulas]. / Vorgehen bei primär nicht klassifizierbaren Analfisteln.

UNLABELLED: In the surgery of anal fistulae, very demanding problems warranting special consideration are caused by the non-classifiable fistulae in ano. RESULTS: Of 823 patients who underwent surgery for anal fistulae between 1993 and 1996, 38 (4.5%) were, according to Parks' classification, non-classifiable; the anal canal was intact. There was no internal opening. All patients had already undergone operations, some of them multiple. In 53%, complete healing of the fistula was achieved by using a single excision. In 47% a recurrence developed. During a second revision we explored the intersphincteric space and were able to reclassify the fistulae in 50% of the cases. A continent fistulectomy led to complete healing in these patients. CONCLUSION: Non-classifiable fistulae in ano, in which an internal opening of the fistula cannot be found, can primarily be treated by a single excision of the fistula. If recurrence does occur, the patient should undergo exploration of the intersphincteric space in the region, where the cryptoglandular infection is suspected.

[Surgical reconstruction of high grade carotid stenosis: a safe procedure?]. / Die operative Rekonstruktion der hochgradigen Karotisstenose: ein sicheres Verfahren? Ergebnisse aus 2.162 Eingriffen.

Carotid surgery is still controversial. Some large randomized trials have demonstrated the benefit of surgery in correlation to conservative treatment alone, but these positive results depend on how specific the diagnosis is and a low complication rate. This study presents the results of 2162 patients (male n = 1596 (74%), female n = 566 (26%), mean age 65 +/- 9 years), who underwent carotid surgery between 1990 and 1999. Forth-three percent of these patients had no ipsilateral neurological symptoms with high-grade carotid artery stenosis (Stage I). Thirty-eight percent appeared with prior ipsilateral TIA or PRIND--symptomatology (Stage II) and 19% suffered from stroke with persisting deficits (Stage IV). The operative technique of choice was thromboendarterectomy of the carotid bifurcation with vein-patch closure in 1967 patients (91%). In 1324 patients segmental resection of the internal carotid artery was performed. Carotid endarterectomies and other reconstructions for coronary artery disease including abdominal aortic aneurysm were combined during the same operation in 11% of the patients. The rate of postoperative ipsilateral neurological events was 4.1%. On the ontralateral side neurological symptoms appeared among 0.8%, and 0.4% of the patients had bilateral symptoms. Twenty patients (0.9%) died as a result of postoperative stroke. In relation to preoperative staging of the cerebrovascular occlusive disease in stage I, postoperative neurological symptoms appeared in 2.8% (mortality 0.6%), stage II in 5.7% (mortality 1.0%) and stage IV in 7.8% (mortality 1.2%) of the patients. These results confirm the importance of carotid reconstruction as a measure in the prevention of cerebral infarction in patients with asymptomatic or symptomatic high-grade carotid artery stenosis. The complication rate was lower than the data reported in the literature and the results were clearly better than under conservative treatment alone. In our opinion, the indication for carotid artery reconstruction should be made by a team of vascular surgeons, neurologists and neuroradiologists taking all patient-specific factors into consideration. Only by optimal patient selection and minimal complication rates will a significant benefit for the patient be achieved.

Gore BioA Fistula Plug in the treatment of high anal fistulas--initial results from a German multicenter-study.

BACKGROUND: Treatment of high anal fistulas may be associated with a high risk of continence disorders. Beside traditional procedure of flap-reconstruction the occlusion of the fistula tract using fistula-plugs offers a new sphincter-saving treatment option. In this study for the first time results from Germany are described. PATIENTS AND METHOD: 40 patients (30 male, 10 female, age 51 ± 12 years) underwent closure of a high trans-sphincteric (n = 28) or supra-sphincteric (n = 12) fistula with Gore BioA Fistula Plug(®) in three surgical departments. The surgical procedures had been performed by five colorectal surgeons. Four patients had Crohn's disease. Preoperatively 33 patients were completely continent; seven patients complained of minor continence disorders. Treatment of the patients was performed on a intent-to-treat basis and evaluation of the results was retrospective using pooled data from each center. RESULTS: Postoperatively one patient developed an abscess, which had to be managed surgically. In two patients the plug had fallen out within the first two weeks postoperatively. Six months after surgery the fistula has been healed in 20 patients (50.0%). Three additional fistulas healed after 7, 9 rsp. 12 months. The overall healing-rate was 57.5% (23/40). The healing rate differs considerably between the surgeons from 0 to 75% and depends on the number of previous interventions. In patients having only drainage of the abscess success occurred in 63.6% (14/22) whereas in patients after one or more flap fistula reconstruction the healing rate decreased slightly to 50% (9/18). No patient complained about any impairment of his preoperative continence status. CONCLUSION: By occlusion of high anal fistulas with a plug technique definitive healing could be achieved in nearly every second patients. Previous surgery seems to have a negative impact on success rate. We have not observed any negative impact on anal continence. From that point of view anal fistula plugs might be discussed as a treatment option for high anal fistulas, but further studies are needed to gain conclusive evidence.

[Gastrointestinal stromal tumor (GIST) of the anterior rectal wall. R0 resection with simultaneous radical retropubic prostatectomy]. / Gastrointestinaler Stromatumor (GIST) der vorderen Rektumwand. R0-reseziert bei simultaner radikaler retropubischer Prostatektomie.

This case report deals with a 79-year-old patient with a gastrointestinal stromal tumor (GIST) of the anterior rectal wall which was unusually located between the rectum and the prostate gland. In addition, this patient suffered from subvesical obstruction accompanied by an elevated PSA level. These circumstances led to our decision to operate on the tumor via simultaneous radical retropubic prostatectomy. In our opinion this resection technique was easier and less traumatic for the patient compared to procedures performed via the abdomen and perineum. This case report demonstrates that in the case of tumors located between the rectum and the prostate gland the differential diagnosis should include not only prostate carcinoma but also rare tumor entities such as GIST.

Continence disorders after anal surgery--a relevant problem?

SUBJECT: Anal incontinence is a well-known and feared complication following surgery involving the anal sphincter, particularly if partial transection of the sphincter is part of the surgical procedure. METHODS: The literature was reviewed to evaluate the risk of postoperative incontinence following anal dilatation, lateral sphincterotomy, surgery for haemorrhoidal disease and anal fistula. RESULTS: Various degrees of anal incontinence are reported with frequencies as follows: anal dilatation 0-50%, lateral sphincterotomy 0-45%, haemorrhoidal surgery 0-28%, lay open technique of anal fistula 0-64% and plastic repair of fistula 0-43%. Results vary considerably depending on what definition of "incontinence" was applied. The most important risk factors for postoperative incontinence are female sex, advanced age, previous anorectal interventions, childbirth and type of anal surgery (sphincter division). Sphincter lesions have been reported following procedures as minimal as exploration of the anal canal via speculum. CONCLUSIONS: Continence disorders after anal surgery are not uncommon and the result of the additive effect of various factors. Certain risk factors should be considered before choosing the operative procedure. Since options for surgical repair of postoperative incontinence disorders are limited, careful indications and minimal trauma to the anal sphincter are mandatory in anal surgery.

Stapled transanal rectal resection (STARR): a new option in the treatment of obstructive defecation syndrome.

BACKGROUND: Rectocele and distal intussusception are organic causes of outlet obstruction. A new surgical option called the stapled transanal rectal resection (STARR) is described within a prospective study. PATIENTS AND METHODS: Fourteen patients with symptomatic rectocele (four females), rectocele with coexistent intussusception (eight females), and intussusception (two males) underwent STARR procedure. The symptoms were measured by means of a defecation score (0-20 points). RESULTS: Complications included local bleeding postoperatively in two cases, and temporary ischuria in four cases. The subjective sense of pain was low; from day 1 postoperatively five patients did not need any analgetics. Only one female patient had prolonged pelvic pain, without any organic reason. All patients showed improvement in rectal evacuation. The mean score of defecation (0-20 points) decreased from 13+/-3 to 4+/-3 after 1 month (p<0.05) and remained low. The overall follow-up was 19+/-9 months. Only one male patient with intussusception had defecation disorder again 6 months after surgery. Three patients had temporary urge incontinence. CONCLUSION: STARR is an effective therapy for obstructive defecation disorder due to a symptomatic rectocele and/or a distal intussusception.

[How good is the prognosis in differentiated thyroid gland carcinoma]. / Wie gut ist die Prognose beim differenzierten Schilddrüsenkarzinom.

Between 1980 and 1995, 4233 thyroid operations were carried out in our hospital and in 152 patients a thyroid carcinoma was treated. The choice of therapy concerning differentiated thyroid carcinoma, excluding the papillary microcarcinoma, is the thyroidectomy with resection of the central lymph node compartment. Since the introduction of routine, recurrent nerve representation, the rate of permanent nerve injury could be reduced from 7.2% to 1.3%. The permanent therapy of hypoparathyroidism was necessary for 9.9% of the patients. The well-known good prognosis of the differentiated and especially papillary thyroid cancer could be confirmed in our study.

[Dynamic gracilis-plasty as final therapeutic possibility in anorectal incontinence]. / Die dynamische Gracilisplastik als letzte therapeutische Möglichkeit bei anorektaler Inkontinenz.

UNLABELLED: Six patients (five women, one man with an average age of 63 years) underwent a dynamic graciloplasty. Three patients had a three- or two-stage procedure; the past three patients were treated by a one-stage procedure without any negative consequences. None of the patients received a protective stoma. COMPLICATIONS: COMPLICATIONS, needing surgical intervention occurred in two patients. In one of these patients a positive final result may still fail. RESULTS: Five patients are subjectively continent and satisfied. Four are able to retain a clysma without any problem. As a result of stimulation, three patients developed optimal anal pressures. In two patients the pressure values are satisfactory. Three patients developed evacuation problems, which up to now have been managed by laxatives. CONCLUSION: The dynamic graciloplasty is a new hope for carefully chosen patients, in whom other methods have failed.

Reconstructive surgery for carotid artery occlusive disease in the elderly--a high risk operation?

Patients over 80 yr of age may require carotid surgery for symptomatic or critical asymptomatic carotid artery occlusive disease.A total of 2262 operations were performed between 1990 and 1999; 76 (3.4%) were carotid reconstructions in 70 patients over 80 yr of age. Twenty patients (26%) presented with asymptomatic critical stenosis. Transient ischemic symptoms were the reason for presentation in 35 patients (46%). Progressive stroke was documented in two patients (3%) and a stroke with persisting neurological deficit was demonstrated in 19 cases (25%). Coronary artery disease was present in 47 patients (38%) and arterial hypertension in 55 (72%). Fifty-nine patients (84%) were classified as ASA group 3. Seventy-one thromboendarterectomies of the carotid bifurcation with vein-patch closure were performed. Five patients had other types of reconstruction. Simultaneous operations (aorto-coronary vein-bypass, aortic interposition graft etc.) were performed in nine patients. Postoperative complications occurred in three patients. One had a transient neurological deficit and another a lethal stroke; the third patient died from myocardial infarction. The in-hospital mortality was 2.9%, which was not significantly higher than the results of the other 2186 reconstructions (1.5%). Surgery for carotid artery occlusive disease can be safely performed in selected patients of more than 80 yr of age.

Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum: analysis of 31 patients.

INTRODUCTION: Between 1985 and 1996, 190 patients underwent a low anterior rectal resection with coloanal anastomosis for adenocarcinoma of the lower one-third of the rectum. METHODS: This article reports on 31 (17 males) of these patients with a very low localization of the tumor (distal tumor margin 1.3 +/- 0.9 cm above the dentate line). If the function of the sphincter was acceptable and we could exclude tumor infiltration into the sphincter through endosonography, we relocated the resection plane distally into the intersphincteric region to attain an acceptable margin of safety. In all of these cases, it was impossible for us to perform the usual surgical procedure of a mechanical anastomosis by means of a circular stapler. After intersphincteric rectal resection, the anastomosis was handsewn, using interrupted sutures from the perineal approach, 2.5 to 3 cm above the anal verge, implementing Parks' retractor. A protective stoma was performed in all cases. All data were documented prospectively. COMPLICATIONS: Postoperative mortality was 0 percent. Postoperatively, none of the patients showed an indication for relaparotomy. The leakage rate was 48 percent. Only 16 percent later needed additional surgery for anastomotic strictures or for rectovaginal fistulas. Long-term observations showed that the anastomosis healed well in 27 patients (87.1 percent). Four patients (12.9 percent) decided to have a terminal colostomy performed (anastomotic stricture, 3 patients; anorectal incontinence, 1 patient). FOLLOW-UP: During the follow-up period of 6.8 +/- 3.7 years, six patients (19.4 percent) developed a tumor progression (9.7 percent local recurrences and 12.9 percent distant spread). The five-year survival rate was 79 percent (Dukes A, 100 percent (n = 18); Dukes B, 67 percent (n = 4); and Dukes C, 44 percent (n = 9)). Continence: One-third of patients developed anorectal incontinence for liquid (29.6 percent) or solid stool (3.7 percent). Average stool frequency was 3.3 times per day. Resting pressure decreased significantly by 29 percent (preoperative, 105 +/- 37 cm H2O and postoperative, 75 +/- 19 cm H2O; P < 0.05), whereas squeeze pressure did not change. CONCLUSION: In selected patients with tumors close to the dentate line, an intersphincteric resection of the rectum may help to avoid an abdominoperineal excision of the rectum with a terminal stoma, without any curtailment of oncologic standards. A protective stoma for three months is advantageous.

[Transrectal ultrasound-assisted gun-biopsy in the diagnostic of presacral recurrent rectal carcinoma]. / Die transrektale ultraschallassistierte Stanzbiopsie in der Diagnostik des präsakralen Rektumkarzinomrezidivs.

Suspected extraluminal recurrence of rectal carcinoma after surgical treatment represents a frequent diagnostic challenge. Clinical history and examination as well as tomographic imaging often do not equivocally settle this tissue. Glucose-PET is an expensive, not universally available test. Early diagnosis is required for both successful operative reintervention aiming at cure and indication to palliative therapy. We performed gun-biopsy of presacral space-occupying lesions in three patients, choosing the ultrasound-guided transrectal approach in three of them. Extraluminal recurrence was proven in one patient. In another patient, anastomotic recurrence was proven by endoscopic biopsy and presacral recurrence ruled out before reoperation. In the third patient, no tumour tissue was found in the samples, as confirmed by his clinical course and by another biopsy after one year. By providing a sufficient amount of tissue for histological examination, ultrasound-guided gun-biopsy allows definite diagnosis in presacral space-occupying lesions and hence represents an important expansion of the diagnostic repertoire in the follow-up of rectal cancer.

[Simultaneous surgical intervention for occlusion of the internal carotid artery and coronary disease--reasonable or high-risk combination?]. / Simultane operative Behandlung von A. carotis interna-Stenosen und koronarer Herzerkrankung. Sinnvolle oder zu risikoreiche Kombination?

BACKGROUND AND OBJECTIVE: Carotid artery stenosis as risk factor for postoperative stroke after cardiac surgery is confirmed in recent publications. Nevertheless indications for combined procedures in carotid occlusive disease and coronary artery disease are discussed controversely in the literature. Based on our own experiences since 1992 the risk factors are reviewed. PATIENTS AND METHODS: The data of 104 patients (80 male, 24 female, age 67 +/- 7 years), with 106 combined operations performed between 1992 and 1999, were evaluated retrospectively. 36% of the patients had symptomatic and 64% had asymptomatic carotid artery stenosis. RESULTS: Seven patients (6.6%) developed postoperative neurological deficits. One patient (1.0%) died as result of a stroke. In three patients a stroke occurred in the ipsilateral hemisphere, whereas two of three patients with cerebral infarction in the contralateral hemisphere had no significant carotid artery stenosis on this side. One patient had multiple bilateral embolism. Cardiac complications occurred in seven patients (6.6%). The inhospital mortality for non-stroke related complications was 3.8%, the total mortality 4.8%. CONCLUSION: From our experiences the combined approach for carotid artery occlusive disease and coronary artery disease can be recommended in selected patients. The rate of complications seems to be lower than in staged procedures. The spontaneous course of the disease can be improved and the patient is spared a second operation.