The Influence of Intraoperative Factors and Histopathological Staging on the Performance of Sentinel Node Biopsy in Colon Cancer.

BACKGROUND: The aim of this study was to assess sentinel node biopsy (SNB) results in colon cancer (CC) regarding intraoperative staging of the disease and pathological cancer features. MATERIAL AND METHODS: The study was conducted on the basis of 132 SNBs in CC. The elements of intraoperative staging of the disease and pathological cancer features were compared with accuracy, sensitivity and false negative results of SNB in CC by means of ROC curves and the tests for population proportions. RESULTS: ROC curve analysis did not reveal any statistical significance for tumour measurements (all p > 0.05). Statistically significantly worse results in sensitivity (not in accuracy) were achieved for T3 tumours in comparison with T2 tumours (83% vs 89%, p = 0.0066). Statistically significantly worse results in accuracy (not in sensitivity) of the method were obtained in the cases of involved lymph nodes (78% vs 100%, p < 0.0001), infiltration of the lymph node capsule (80% vs 97%, p = 0.0023) and infiltration of the perinodal tissue (73% vs 97%, p = 0.0002). The analyses of SNB sensitivity and accuracy in combination with other features showed no statistical significance (all p > 0.05). CONCLUSIONS: The sensitivity of the method is significantly worse for tumours with deeper infiltration of intestinal wall. The presence of nodal metastases, lymph node capsule and perinodal invasion significantly affects the accuracy results of SNB in CC. The problem of qualifying patients for the procedure in regard to the other analysed features, however, remains open and requires further analysis.

Indocyanine green angiography for evaluation of gastric conduit perfusion during esophagectomy--first experience.

BACKGROUND: A complication of esophageal surgery is leakage at the anastomosis site and one of the factors involved in this complication is poor blood flow in the distal portion of the tube. The aim of this study was to evaluate the feasibility of indocyanine green fluorescence imaging as a method of determining the perfusion of the gastric conduit after esophagectomy. METHODS: We analysed 15 consecutive patients who underwent transhiatal esophagectomy (THE) due to cancer. All of the patients had reconstruction of the gastrointestinal tract using the gastric conduit. Before performing the anastomosis, the blood flow in the area of the tube was evaluated using intravenous indocyanine green and observing its vascular flow with a camera equipped with an infrared laser. RESULTS: In all cases it was possible to visualize the vascular flow of indocyanine green within the region of the gastric tube. The fluorescence imaging system showed vascular insufficiency of the distal gastric conduit in 4 patients--in all of these patients the anastomosis was performed end-to-side and there was no subsequent leak. Leakage at the anastomosis site was observed in 1 patient (6.66%). The leak was observed in the 9th postoperative day, despite visualization of a good vascular supply of the tube. CONCLUSIONS: Indocyanine green fluorescence imaging of gastric tube allows for intraoperative modifications, but it must be noted that the patient's comorbidities and general health may also increase the risk of anastomosis leakage.

The effect of biofeedback pelvic floor training with ACTICORE1 on fecal incontinence A prospective multicentric cohort pilot study.

INTRODUCTION: Fecal incontinence refers to the inability to pass stool in a localized and timely manner resulting in the involuntary loss of intestinal contents such as air, intestinal mucus or stool. The prevalence of fecal incontinence in the general population is approximately 2-21%. Women are more frequently affected than men. Physiotherapeutically guided pelvic floor training, otherwise known as Kegel exercise, is the mainstay of treatment for fecal incontinence. The objective of this study was to evaluate the feasibility and potential benefits of a new biofeedback training, which uses a non-insertable pelvic floor sensor with digital interface, called ACTICORE1. METHODS: From January 2020 to April 2021, we conducted a prospective non-randomized multicentric clinical pilot study at the Alexianer St. Hedwig Hospital Berlin (Germany), private clinic Strack (Germany) and the University Hospital Magdeburg (Germany). Patients with fecal incontinence, defined as a Wexner score >2, were recruited and asked to either perform biofeedback training with ACTICORE1 (6 min daily for 16 weeks) or daily Kegel exercise (Physiotherapeutic guidance weekly for the first 6 weeks; biweekly for the remaining 10 weeks). The primary outcome was severity of fecal incontinence after 16 weeks of training assessed using the Wexner score. Secondary outcomes were severity of fecal incontinence after 12 weeks and patients' quality of life assessed using the EQ-5D-3L questionnaire after 16 weeks of training. The two-one-sided t-tests (TOST) procedure was used to determine if training with ACTICORE1 has equivalent or noninferior efficacies compared to Kegel exercise. RESULTS: A total of 40 individuals were included. Dropout occurred in 4 cases. The final sample included 19 patients who performed the ACTICORE1 training (ACTICORE-group) and 17 patients who performed guideline-based physiotherapy (PHYSIO-group). Univariate analysis of biometric parameters showed no statistically significant differences. Individuals in the ACTICORE-group were younger (M=46,6 (SD=18,9) years vs. M=57,1 (SD=17,3) years, p=0.093). In terms of endpoint evaluation, a non-inferiority of ACTICORE1 compared to the therapy standard (Kegel exercise) was detected. Both groups showed a statistically significant intraindividual improvement in fecal incontinence as measured by Wexner scoring after 16 weeks. The TOST detected a non-inferiority of ACTICORE1 training (98% confidence interval with equivalence bounds 5 for low and high; Results: 1.36, upper 6.75). CONCLUSION: Pelvic floor training with ACTICORE1 may enable sufficient pelvic floor training as a digital health application. The study at hand revealed a non-inferiority of ACTICORE1 training compared to Kegel exercise.

Feasibility of delayed hyperthermic intraperitoneal chemotherapy in case of unforeseen complications.

BACKGROUND: Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) can improve the prognosis of selected patients with peritoneal surface malignancy (PSM). Usually, treatment is performed as an extensive one-step approach. We investigated the feasibility of delayed HIPEC, if the one-step procedure was interrupted precociously. METHODS: 42 patients with PSM who underwent CRS and delayed HIPEC from 2006-2008 were studied. HIPEC was performed 5 days after treatment with mitomycin, cisplatin and hyperthermia. Perioperative complications and toxicity were analyzed. RESULTS: Delayed HIPEC was successfully completed in 40 of the 42 patients. In 2 cases, HIPEC was omitted because of complications during chemotherapy (anastomotic leakage and retroperitoneal edema). Minor and major surgical complications occurred in 18 and 9 of the 40 patients treated with HIPEC (45 vs. 22.5%), respectively. Toxicity grade II-IV (WHO criteria) was observed in 4 of them (10%). Median stay in the intensive care unit was 9 days (range 2-31) while the mean hospitalization time was 24 days (range 14-59). In this series, there was no mortality. CONCLUSION: Postponement of HIPEC after CRS (two-step approach) is feasible. Analysis of morbidity and mortality showed no significant difference to the one-step approach reported in the literature and no disadvantages for the patient. The two-step approach is an alternative option for patients who had to discontinue the one-step approach due to unpredictable intraoperative complications.

Breast duct endoscopy: ductoscopy from a diagnostic to an interventional procedure and its future perspective.

OBJECTIVE: Breast duct endoscopy is increasingly used for evaluation of intraductal disease. We present a new rigid instrument for ductoscopy that allows intraductal biopsy and the removal of small lesions. METHODS: Overall, 102 women with breast cancer or pathologic nipple discharge were included in the analysis. All ductoscopies were performed with a rigid gradient index micro-endoscope (phi 0.7 mm) in combination with a special device for intraductal vacuum assisted biopsy. Ductoscopy, ductal lavage and intraductal biopsy were correlated with ductal cytology and histopathology of the resection specimen. RESULTS: Gradient index ductoscopy provided high resolution images of the breast ducts and identified additional intraductal lesions in 45% of the patients with breast cancer. The accuracy of ductal lavage, ductoscopy and mammography in the detection of an extensive intraductal component was 14%, 65% and 50%, respectively. Intraductal vacuum assisted biopsy yielded diagnostic material in 92% of 38 patients with nipple discharge and papillomatous lesions. Histology of the resection specimen confirmed the diagnosis in all cases including 2 in situ carcinoma and 2 invasive ductal carcinoma. CONCLUSIONS: Ductoscopy is a useful supplement for the standard radiological workup of breast cancer especially in patients with extensive intraductal carcinoma. Ductoscopic vacuum assisted biopsy is an effective technique for intraductal tissue sampling and allows ablation of small lesions. This technique provides new perspectives for interventional therapy of intraductal tumours.

Repeated cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy in patients with peritoneal carcinomatosis: A retrospective cohort study.

INTRODUCTION: The prognosis of abdominal cancer with peritoneal carcinomatosis (PC) is poor. In literature, some authors described a repeated Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in patients with recurrent PC as feasible for overall survival improvement. Hence, we implemented this approach at our hospital and analyzed our cases. METHODS: A unicentric retrospective observational study took place at the Helios hospital Berlin-Buch in 2020. The data of individuals who received a HIPEC in the time of 2007-2019 were extracted. The data were entered in the HIPEC database of the German Society of General and Visceral Surgery (StuDoQ|HIPEC, German society for general and visceral surgery). The primary objective was the overall survival after first HIPEC procedure. RESULTS: A total of 292 data files from were extracted and 14 patients were identified as eligible for further analysis (7× colorectal, 3x gastric, 1× appendix cancer, 1× cancer of unknown primary, 1× Mesothelioma, 1× Pseudomyxoma peritonei). The mean age was 57 (8) years. The BMI was on average 23.5 (3.5) kg/m2. A total of 8 individuals were female and 6 male (6xASA-Score I, 8xASA-Score II). The initial Peritoneal Cancer Index (PCI) was on average 11.5 (9.1). The average overall survival after 1. HIPEC for colonic cancer was 74 months (n = 3; 43, 70 and 90 month), for gastric cancer 29 months (n = 2; 19 and 39 month) and for mesothelioma 44 months (n = 1). CONCLUSIONS: Based on our findings Repeated Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy may improve overall survival of selected patients suffering from peritoneal carcinomatosis.

The negative pressure wound therapy may salvage the infected mesh following open incisional hernia repair.

BACKGROUND: s: Incisional hernias may occur in 10-25% of patients undergoing laparotomy. In cases of a surgical site infection (SSI) after incisional hernia repair (IHR) secondary operative intervention with mesh removal are often needed. There is only minimal data available in the literature regarding the treatment of a wound infection with negative pressure wound therapy (NPWT). Conducting the study at hand, we aimed to provide more evidence on this topic. METHODS: From April to June 2020 a monocentric retrospective study has been performed. Patients who underwent NPWT due to a SSI with mesh involvement following open IHR from 2007 to 2020 were included. The primary endpoint was the mesh removal rate in the end of NPWT. Main secondary endpoints were the duration of NPWT and the amount of NPWT procedures. RESULTS: The data of 30 patients were extracted. The average age was 65.9 years (9.9). A total of 13 individuals were male and 17 females. The BMI was on average 31.1 kg/m2 (4.9). All patients received a polypropylene mesh. The average duration of NPWT was 31.3 days (22.1). The first wound revision with initiation of a NPWT was conducted on average 31.1 days (34.0) after IHR. The average amount of NPWT procedures was 8.3 (7.2). In 5 of 30 patients (16.6%) the mesh was removed (Open sublay group n = 4 (36.34%) vs. open onlay group n = 1 (5.26%), p = 0.047). CONCLUSION: In cases of SSI following IHR the NPWT may facilitate mesh selvage. Further trials with a larger sample size are mandatory to confirm our hypothesis.

Sentinel node biopsy by indocyanine green retention fluorescence detection for inguinal lymph node staging of anal cancer: preliminary experience.

BACKGROUND: There is some evidence that sentinel lymph node (SLN) biopsy guided by dye injection and/or radioisotopes can improve staging of inguinal lymph nodes (LNs) in anal cancer. This study was performed to investigate the feasibility of fluorescence detection of SLN and lymphatic mapping in anal cancer. METHODS: Twelve patients with anal cancer without evidence for inguinal LN involvement were included in the study. Intraoperatively, all patients received a peritumorous injection of 25 mg indocyanine green (ICG) for fluorescence imaging of the SLN with a near-infrared camera. For comparison, conventional SLN detection by technetium-(99)m-sulfur radiocolloid injection in combination with blue dye was also performed in all patients. The results of both techniques and the effect on the therapeutic regimen were analyzed. RESULTS: Overall, ICG fluorescence imaging identified at least one SLN in 10 of 12 patients (detection rate, 83%). With the combination of radionuclide and blue dye, SLN were detected in 9 of 12 patients (detection rate, 75%). Metastatic involvement of the SLN was found in 2 of 10 patients versus 2 of 9 patients. Patients with metastatic involvement of the SLN received extended radiation field with inguinal boost. CONCLUSIONS: ICG fluorescence imaging allows intraoperative lymphatic mapping and transcutaneous SLN detection for selective biopsy of inguinal SLN in anal cancer. This technique should be further evaluated in comparative studies with larger patient numbers.

The role of nodal staging in breast cancer. Past, present and future.

The axillary nodal status is accepted as the most powerful prognostic tool available for early stage breast cancer. In the past radical removal of level I and level II lymph nodes at axillary node dissection (ALND) has been the most accurate method to assess nodal status, and it is the universal standard; however, it is associated with several adverse long-term sequelae. New diagnostic technologies have helped to individualize diagnostic evaluation and therapy of breast cancer thus improving efficacy and minimizing morbidity of treatment. Lymphatic mapping with sentinel lymph node biopsy has emerged as an effective and safe alternative to the ALND for detecting axillary metastases. Many issues such as indications or technique of performing sentinel node biopsy have been evaluated. Multiple studies now confirm that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection. Blue dye, radiocolloid, or both can be used to identify the sentinel node, and several injection techniques may be used successfully. Sentinel node biopsy is now minimally invasive, highly accurate method of axillary staging, and has replaced routine axillary lymph node dissection as the new standard of care in breast cancer. New technologies for axillary nodal staging include innovative imaging techniques such as single photon emission computerized tomography (SPECT) and modern histopathologic evaluation of sentinel nodes using molecular biologic approaches.

Ultrasound-versus visual-guided transversus abdominis plane block prior to transabdominal preperitoneal ingunial hernia repair. A retrospective cohort study.

BACKGROUND: The transversus abdominis plane block is a regional anesthesia technique. Recently, its impact on early chronic pain and the cumulative need of analgesic medication following inguinal hernia repair is being monitored. In terms of effectiveness and patient safety, it remains unclear whether the approach should be conducted preoperatively through ultrasound guidance, or through intraoperative visual guidance.The study at hand aims to provide more evidence on this topic. METHODS: A monocentric retrospective matched pair analysis was performed. The intraoperative visual guided and ultrasound guided -transversus abdominis plane block prior to inguinal hernia repair in transabdominal preperitoneal technique were consecutively compared in regard to analgesic effectiveness and complication rate. The data of individuals who were operated on from June 2007 to February 2019 were analyzed. The matching criteria were ASA-Score, Gender, Age ( ±6 years), and hernia size (<1,5 cm, 1,5-3 cm, >1,5 cm). RESULTS: A total of 116 patients were enrolled. Both groups were homogenous in terms of age, gender contribution, body mass index, ASA-Score, hernia type, and size. The pain score at the postoperative anesthesia care unit was lower in the ultrasound-guided-transversus abdominis plane group without being statistically significant (VAS-Score: 0.67 vs.0.84). Patients of the ultrasound-guided-transversus abdominis plane group received significantly less metamizole on the day of operation (1.29 g (0.96) vs. 1.68 g (0.70), p = 0.015). CONCLUSION: Due to our findings, we assume that the ultrasound-guided-transversus abdominis plane -Block may reduce postoperative pain and analgesic consumption more effectively than the visual-guided-transversus abdominis plane lock. Further prospective clinical trials are mandatory.

Sentinel lymph node biopsy in breast cancer guided by indocyanine green fluorescence.

BACKGROUND: Sentinel lymph node (SLN) biopsy with radioisotope and blue dye has been used successfully for axillary staging in breast cancer. This study evaluated the feasibility of fluorescence detection of SLNs with indocyanine green (ICG) for lymphatic mapping and SLN biopsy. METHODS: Thirty women with breast cancer had a periareolar injection of ICG for fluorescence detection of SLN using a near-infrared camera. Twenty also received (99m)Tc-labelled sulphur radiocolloid for SLN scintigraphy. All patients underwent axillary lymph node dissection. Detection rate and sensitivity of both methods were the study endpoints. RESULTS: Visualization of lymphatic vessels by fluorescence detection depended on the dose of ICG. ICG imaging identified SLNs in 29 of 30 women (detection rate 97 per cent). Nineteen of 21 patients had metastatic SLN involvement (sensitivity 90 per cent) with false-negative results in two. Among the 20 patients who had both methods, ICG fluorescence and radiocolloid identified SLNs in 20 and 17 patients respectively. Metastatic lymph nodes were diagnosed in 12 and ten of 13 patients (sensitivity 92 and 77 per cent). False-negative rates were 8 and 23 per cent respectively. CONCLUSION: ICG fluorescence allowed transcutaneous imaging of lymphatic vessels and SLN detection, thus combining the advantages of radioisotope and blue dye methods.

Treatment of oesophageal anastomotic leaks by temporary stenting with self-expanding plastic stents.

BACKGROUND: Oesophageal anastomotic leakage is associated with considerable morbidity and mortality. The aim of the present study was to assess the feasibility of using temporary self-expanding plastic stents to treat postoperative oesophageal leaks. METHODS: Patients with anastomotic leakage after abdominothoracic oesophagectomy treated by endoscopic insertion of self-expanding plastic stents between 2001 and 2007 were studied. Clinical outcomes were analysed, including healing of the leak, morbidity and mortality. RESULTS: Stents were inserted successfully in all 22 patients without procedure-related complications. Ten patients also required computed tomography-guided drainage because surgical drains had been removed. Non-ventilated patients received oral nutrition a mean of 4 days after stent placement. Combined treatment with stenting and drainage resulted in resolution of the leak in 21 of 22 patients. The mean healing time (time to stent removal) was 23 days. Stent migration occurred in five of 22 patients, but endoscopic reintervention with placement of a new stent was successful in all patients. Repeat thoracotomy with intraoperative stent placement was necessary in one patient with an oesophagocolonic anastomosis. One patient died in hospital. CONCLUSION: In combination with effective drainage, self-expanding plastic stents are an option for the treatment of oesophageal anastomotic leaks, and may reduce leak-related morbidity and mortality.

[Diagnosis of and therapy for gastric cancer--work-flow]. / Diagnostik und Therapie des Magenkarzinoms--Workflow.

AIM: This review comments on the diagnosis and treatment of gastric cancer in the classical meaning--excluding adenocarcinoma of the -oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are presented. PREOPERATIVE DIAGNOSIS: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recommended for preoperative evaluation of tumours > T1, laparoscopy has become an effective stag-ing tool in T3 and T4 tumours avoiding unnecessary laparotomies and improving the detection of small -liver and peritoneal metastases. TREATMENT: Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a / no ulcer / G1, 2 / Laurén intestinal / L0 / V0 / tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2 LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in -patients with favourable prognosis, this also -applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50 % of patients with liver metastases show concomitant peritoneal dissemination of the disease. DISCUSSION AND CONCLUSIONS: Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4 tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoperative chemoradiotherapy may be debated.

Impact of endoscopic ultrasonography (EUS) on surgical decision-making in upper gastrointestinal tract cancer: an international multicenter study.

BACKGROUND: Endoscopic ultrasonography (EUS) is an integrated part of the pretherapeutic evaluation program for patients with upper gastrointestinal (GI) tract cancer. Whether the clinical impact of EUS differs between surgeons from different countries is unknown. The same applies to the potential clinical influence of EUS misinterpretations. The aim of this study was to evaluate the interobserver agreement on predefined treatment strategies between surgeons from four different countries, with and without EUS, and to evaluate the clinical consequences of EUS misinterpretations. METHODS: One hundred patients with upper GI tract cancer were randomly selected from all upper GI tract cancer patients treated at Odense University Hospital between 1997 and 2000. Based on patient records and EUS database results, a case story was created with and without the EUS result for each patient. Four surgeons were asked to select the relevant treatment strategy in each case, at first without knowledge of the EUS and thereafter with the EUS result available. Interobserver agreement and impact of EUS misinterpretations were evaluated using the actual final treatment of each patient as reference. RESULTS: Three of four or all four surgeons agreed on the same treatment strategy for nearly 60% of the patients with and without the EUS results. Treatment decisions were changed in 34% based on the EUS results, and the majority of these changes were toward nonsurgical and palliative treatments (85%). Interobserver agreement was relatively low, but overall EUS increased kappa values from 0.16 ("poor") to 0.33 ("fair"), thus indicating increased overall agreement after the EUS results were available. EUS conclusion regarding stage or resectability was wrong in 17% of the cases, but only one serious event would have been the clinical result of EUS misinterpretations. CONCLUSION: Despite being used in different ways by different surgeons, EUS did change patient management in one third of the cases. The impact of EUS misinterpretations seemed very low, and this study confirmed one of the strongest clinical possibilities of EUS, i.e., the ability to detect nonresectable cases. EUS is an important imaging modality for oncosurgeons from different countries.

[R1 resection in the region of the lower gastrointestinal tract: relevance and therapeutic consequences]. / R1-Resektion im Bereich des unteren Gastrointestinaltrakts: Bedeutung und therapeutische Konsequenzen.

Incomplete resection (R1) and local recurrence of colorectal cancer continue to be a significant surgical problem. Radical resection of bowel and lymph node bassin are clearly necessary after incomplete endoscopic resection or local surgical excision. However, the situation is more difficult after previous conventional surgery. Anastomotic recurrence following resection and lymph nodal recurrence can often precede curative reresection. Locoregional lymph node metastases due to incomplete surgical clearance of the lymphatic drainage of colonic cancer may also be cured by radical reresection. Despite application of neoadjuvant therapy, integration of modern surgical concepts such as the circumferential resection margin and advances in surgical technique, R1 resection of rectal cancer remains a major problem. Although primary surgical therapy may be considered in selected cases, this situation will require multimodal therapy in most instances.

[Transcutaneous ultrasound]. / Transkutane Sonographie.

Preoperative transcutaneous ultrasound allows surgeons to assess the pathology directly, thus supplementing clinical examination of the patient. Technical advances including power doppler, three-dimensional ultrasound, and the advent of ultrasound contrast agents have increased the quality and broadened the diagnostic spectrum of ultrasound. This article reviews relevant new aspects of transcutaneous ultrasound in the surgical setting.

Prediction of gastric cancer lymph node status by sentinel lymph node biopsy and the Maruyama computer model.

AIMS: The extent of lymph node dissection in gastric cancer remains controversial. The Maruyama computer model and the sentinel lymph node biopsy (SLNB) are compared for their value to predict the nodal status and lead to stage-adapted surgery. METHODS: Thirty four patients with stage I-IV gastric cancer underwent both staging procedures. For SLNB, 15 patients underwent endoscopic, peri-tumoural injection of (99m)Tc-colloid, and 19 patients were injected of Patent blue V. All 'hot' or blue sentinel lymph nodes (SLNs) were separately excised and histopathologically assessed. If the SLN was negative after routine staining by H&E, it was processed completely and reanalysed after immunohistochemistry. RESULTS: At least, one SLN was detected by means of SLNB in 33/34 of the patients. The sensitivity to identify a positive nodal status was 22/33 and the specificity/positive predictive value was 10/10 and 22/22. Additional micrometastases or isolated tumour cells in the SLN led to 'upstaging' of 5/15, initially classified as nodal negative by H&E-staining. Using the Maruyama computer model, a sensitivity of 22/23 for the correct prediction of the lymph node involvement was associated with a specificity of 2/10 and a positive predictive value of 22/30. CONCLUSIONS: The clinical impact of the Maruyama computer model is limited due to low specificity and a low positive predictive value, rendering the method less useful as an indicator for individualised surgery.

[CT-guided resection of pulmonary metastases]. / CT-gesteuerte Resektion pulmonaler Metastasen.

PURPOSE: To evaluate the feasibility and potential use of intraoperative computed tomography (IOP CT) as guidance for video-assisted thoracic surgery (VATS). MATERIAL AND METHODS: Fifteen consecutive patients with peripheral intrapulmonary nodules underwent a thoracoscopy with IOP CT. Solitary lesions were known in 6/15 patients (40 %, group II) whereas 9/15 (60 %, group I) patients had multiple lesions (n >/= 2). IOP CT was performed with the mobile CT scanner Philips Tomoscan M. Radiologists intraoperatively placed percutaneous marks of lung lesions after unsuccessful VATS by use of a lung marker set (Somatex, Teltow, Germany). VATS was performed under general anaesthesia and with double lumen endotracheal intubation for single lung ventilation. Imaging quality and imaging of pulmonary nodules were rated. RESULTS: IOP CT was evaluated as feasible combined with VATS. Thoracotomy was avoided in 5/15 patients where lesions could not be detected by VATS. A CT-guided biopsy was performed in two patients after an unsuccessful attempt of thoracoscopy. There were no documented side effects. CONCLUSION: First clinical results suggest that a combination of VATS and IOP CT is feasible. Thus, the number of open thoracoscopies might be decreased. Intrapulmonary lesions not detectable with VATS could be marked under CT -- guidance intraoperatively and then resected by thoracoscopy.

Palliative endoscopic therapy of rectal carcinoma.

Curative surgery is not feasible in a considerable proportion of patients with rectal cancer because of extensive local spread or metastatic disease. However, most of these patients require palliative treatment to improve the symptoms of the disease, e.g. obstruction, pain and haemorrhage. Palliative surgery may be associated with a morbidity of 20-40% and a mortality of more than 10%. Endoscopic procedures can provide effective palliation with less complications. Before the development of lasers, endoscopic electrocoagulation and cryosurgery were used with some success. Currently, endoscopic Nd:YAG photocoagulation must be considered the treatment of choice in non-resectable rectal cancer. Laser therapy allows effective palliation in 85-95% of the patients, and generally, treatment-related complications occur in less than 10% of the patients and mortality is negligible. Transanal endoscopic resection may be effective in selected patients. New approaches to endoscopic palliation include photodynamic therapy (PDT) and implantation of self-expanding metal stents.

Transesophageal biopsy of mediastinal and pulmonary tumors by means of endoscopic ultrasound guidance.

OBJECTIVE: The aim of this study was to investigate the value of endoscopic ultrasound-guided biopsy for the diagnosis of thoracic lesions. METHODS: Transesophageal ultrasound-guided biopsy was performed in 29 patients with mediastinal (n = 25) or pulmonary tumors (n = 4). A flexible echoendoscope with a 7.5 MHz curved array transducer (Pentax FG 32 UA, Hamburg, Germany) and a biopsy device with a fine needle (diameter 0.8 mm) were used for all examinations. Three patients were excluded from the analysis of the data because a definite diagnosis based on surgery or follow-up was not available. RESULTS: Real-time visualization of the biopsy procedure with endoscopic ultrasound enabled accurate tissue sampling even of small mediastinal lesions with a diameter of less than 1 cm. Diagnostic material was obtained in 23 of the 26 patients (88%). In 3 cases (12%) non-representative biopsy material was found in the specimen. The sensitivity and specificity of transesophageal biopsy in the diagnosis of malignancy were 89% and 83%, respectively. Histologic analysis of the biopsy specimens established malignancy in 17 of 23 patients, whereas benign lesions were diagnosed in 6 patients. Endoscopic ultrasound-guided biopsy confirmed the diagnosis suggested by conventional diagnostic methods in 15 of 23 patients (65%), whereas an unsuspected diagnosis was disclosed in 8 patients (35%). The results of the biopsy had considerable impact on the therapeutic strategy. None of the patients had complications related to the procedure. CONCLUSIONS: Endoscopic ultrasound-guided biopsy provides a new minimally invasive approach to the biopsy of lesions in the posterior mediastinum and may complement surgical staging procedures.