[Hemorroids Therapy: a Tailored Approch]. / Tailored Approach in der Therapie der Hämorrhoidalleiden.

One of the most common reasons to consult a coloproctologist is symptomatic haemorrhoids. Typical signs and symptoms as well as a specialised examination, including proctoscopy, are essential for the correct diagnosis. The vast majority of patients can be treated conservatively with excellent results in terms of quality of life. Sclerotherapy provides good control of symptoms at any stage of haemorrhoidal disease. If conservative treatment fails, there are various surgical options. A tailored approach is mandatory. Besides well-known procedures such as Fergusson, Milligan-Morgan procedure or haemorrhoidopexy (Longo) there are less invasive options such as HAL-RAR, IRT, LT and RFA. Postoperative bleeding, pain and faecal incontinence are rare complications after surgery.

Intensified Histopathological Work-Up after Pancreatic Head Resection Reveals Relevant Prognostic Markers.

INTRODUCTION: Local recurrence remains a major problem after pancreatic head resection. Intensified histopathological work-up of surgical specimens after pancreatic head resection has revealed an increased number of incomplete resections (R1) depending on tumor infiltration front at the resection margins (RMs). It remains unclear to which extent the increased R1 resection rate has a clinical relevance for the patients' prognosis. MATERIALS AND METHODS: Pancreatic head resections between 2006 and 2012 were histologically intensively worked-up by a previously described protocol. The distance between the tumor infiltration front and the resection planes or organ surfaces was documented. The impact of the size of the tumor and an additional portal vein resection was analyzed. The effect of a R1 resection status on development and type of recurrence was evaluated. RESULTS: A total of 203 pancreatic head resections were evaluated. Different definitions of R1 resection were applied. These led to significantly different prognosis for patients. A greater distance between the tumor infiltration front and the resection plane or organ surface was associated with a better outcome for the patients. For the ventral surface, the mesopancreas and the pancreatic body these differences were statistically significant comparing the different R1 definitions. For the dorsal surface, a significant difference in prognosis was found if the tumor was >2 mm away from the resection surface. A tumor size of 3 cm was identified to play a relevant role for the prognosis. Patients who had a portal vein resection without a histologically proven infiltration showed a statistically significant higher overall survival. Patients with R1 resection were at highest risk for developing local recurrence as well as distant metastasis. CONCLUSION: Intensified histopathological work-up with an increased number of R1 resections has a clinical relevance for patients' prognosis. Tumors with a smaller size or with a greater distance to the organ surface or RM have a better outcome.

Risk-adapted anastomosis for partial pancreaticoduodenectomy reduces the risk of pancreatic fistula: a pilot study.

BACKGROUND: Pancreatic fistula (PF) is the main cause of postoperative morbidity and mortality after pancreatectomy. Two reasons for PF are a "soft" pancreatic texture and a narrow pancreatic duct (high-risk gland). Pancreaticojejunostomy (PJ) may lead to a higher fistula rate in such glands. In the literature there are no data available on risk-adapted assignment of pancreatogastrostomy (PG) in a high-risk gland. Therefore, an observational pilot study was conducted to address this issue. METHODS: Since January 2007 the concept of a "risk-adapted pancreatic anastomosis" (RAP) was introduced (PG for high-risk glands). The PF rate, morbidity, and mortality during this period (January 2007 to December 2008, n = 74) were compared to those between January 2004 and December 2006 (n = 119, only PJ). PF was defined according to the International Study Group on Pancreatic Surgery. RESULTS: Through RAP the PF rate was reduced from 22 to 11% (P = 0.0503). Grade C PF rate was reduced from 6.7 to 1.4% (P = 0.1569) and grade A PF from 6 to 1.4% (P = 0.2537). The PF-associated mortality was reduced from 3.4 to 1.4%. PG revealed a PF rate of 7% and PJ accounted for 19% of PFs (P = 0.1765). There was no incidence of grade C PF following PG. The incidence of intraluminal hemorrhage (P = 0.0422) and delayed gastric emptying (P = 0.0572) was higher following PG. CONCLUSIONS: The rate of PF could be significantly reduced with the use of RAP. One should be cautious about the indication for PG, since it is associated with a higher rate of intraluminal hemorrhage and delayed gastric emptying. There are no long-term results on PG with respect to its durability and function. A general recommendation for its use cannot currently be made.

Factors predicting long-term survival following pancreatic resection for ductal adenocarcinoma of the pancreas: 40 years of experience.

BACKGROUND: Long-term survival after resection for pancreas carcinoma has rarely been reported. Factors influencing long-term survival are still under debate. The aim of this study was to define predictors for long-term survival. METHODS: Between 1972 and 2004, a total of 415 patients underwent resection. Data were collected in a prospective data base. Data of 360 patients were available for further analysis in 2011. All specimens of long-term survivors were histologically reviewed. RESULTS: Long-term survivors (n = 69) had a median survival of 91 months. Pathological re-evaluation of all specimens re-confirmed the diagnosis. Predictive factors for long-term survival in univariate analysis were no preoperative biliary stent, low CA 19-9 level, lack of blood transfusion, R0 resection, tumour diameter, and -grading, absence of lymph node or distant metastases, lymphangiosis, and perineural infiltration. Adjuvant chemotherapy showed a significant influence on overall survival but not on long-term survival. In multivariate analysis, lymph node ratio and volume of blood transfusion were predictors of long-term survival. CONCLUSION: Nearly 20% of patients with pancreas carcinoma who undergo surgical resection have a chance of long-term survival. Survival beyond 5 years is predicted by clinical and tumour-specific factors. Adjuvant chemotherapy might prolong overall survival but is, according to these results, unable to contribute to long-term survival. There is still a risk of recurrence after a 5- or even a 12-year mark. Survival beyond 5 or even 12 years, therefore, does not assure cure.