[Navicular bone fractures in horses: Prognosis after conservative and surgical treatment]. / Strahlbein-Frakturen beim Pferd: Prognose nach konservativer und chirurgischer Therapie.

INTRODUCTION: The aim of this retrospective study is to describe and compare conservative and surgical treatment of navicular fractures in horses. An attempt is made to identify critical points that can favorably influence the prognosis of this orthopedic disease. All horses treated for a navicular fracture at the Equine Clinic, Vetsuisse Faculty, University of Zurich between 2005 and 2017 were included in this study. The severity of lameness at initial examination, radiographic assessment, hoof conformation, treatment (conservative or surgical), complications and outcome were determined from the medical records. Conservative and surgical treatment consisted of stable rest, a controlled exercise program and therapeutic orthopedic shoeing. During surgical treatment, fracture reduction was also carried out with a cortical screw. Computer assisted surgery were used in five horses and computer tomography in three horses. Follow-up examinations included clinical and radiographic examinations. The outcome was divided into three categories: 1 = very good; 2 = good; 3 = poor. Twelve horses met the inclusion criteria; Four horses were treated conservatively and eight were treated surgically. After conservative treatment, two horses (50 %) had a very good outcome and two (50 %) had a good outcome. After surgical treatment, four horses (50 %) had a very good outcome and four (50 %) had a poor outcome. Overall, 67 % of horses had a very good or good outcome, although radiographic signs of bone healing was not present in any of these cases. Various complications were identified, such as the fracture of a screw, the fragmentation of the small navicular bone fragment, the development of osteoarthrosis in the coffin joint and progressive podotrochosis. This study shows that the prognosis of navicular fractures is generally cautious and that degenerative changes to the navicular apparatus worsen the prognosis. In the present study, surgical treatment did not improve the prognosis of navicular fractures despite the intrasurgical use of three-dimensional imaging. However, technical advances could reduce the complication rate in the future.

INTRODUCTION: Le but de cette étude rétrospective était de décrire et de comparer le traitement conservateur et chirurgical des fractures de l'os naviculaires chez le cheval. Une tentative est faite pour identifier les points critiques qui peuvent influencer favorablement le pronostic de cette maladie orthopédique. Tous les chevaux traités pour une fracture de l'os naviculaire à la Clinique équine de la Faculté Vetsuisse de l'Université de Zurich entre 2005 et 2017 ont été inclus dans cette étude. La gravité de la boiterie lors de l'examen initial, l'évaluation radiographique, la conformation du sabot, le traitement (conservateur ou chirurgical), les complications et le résultat ont été déterminés à partir des dossiers médicaux. Le traitement conservateur et chirurgical consistait en un repos au box, un programme d'exercice contrôlé et un ferrage orthopédique thérapeutique. Au cours du traitement chirurgical, une réduction de la fracture a également été effectuée à l'aide d'une vis corticale. La chirurgie assistée par ordinateur a été utilisée sur cinq chevaux et la tomographie assistée par ordinateur sur trois chevaux. Les examens de suivi comprenaient des examens cliniques et radiographiques. Les résultats ont été divisés en trois catégories: 1 = très bon; 2 = bon; 3 = mauvais. Douze chevaux répondaient aux critères d'inclusion ; quatre chevaux ont été traités de manière conservatrice et huit ont été traités chirurgicalement. Après un traitement conservateur, deux chevaux (50 %) ont eu un très bon résultat et deux (50 %) un bon résultat. Après le traitement chirurgical, quatre chevaux (50 %) ont eu un très bon résultat et quatre (50 %) un mauvais résultat. Dans l'ensemble, 67 % des chevaux ont eu un très bon ou un bon résultat, bien que les signes radiographiques de guérison osseuse n'aient été présents dans aucun de ces cas. Diverses complications ont été identifiées, telles que la fracture d'une vis, la fragmentation du petit fragment de l'os naviculaire, le développement d'une arthrose dans l'articulation interphalangienne distale et une podotrochlose progressive. Cette étude montre que le pronostic des fractures de l'os naviculaire est généralement réservé et que les modifications dégénératives de l'appareil naviculaire aggravent le pronostic. Dans la présente étude, le traitement chirurgical n'a pas amélioré le pronostic des fractures du naviculaire malgré l'utilisation intra-chirurgicale de l'imagerie tridimensionnelle. Cependant, les progrès techniques pourraient réduire le taux de complications dans le futur.

Impact of laparoscopic versus open surgery on humoral immunity in patients with colorectal cancer: a systematic review and meta-analysis.

BACKGROUND: Laparoscopic surgery (LS) is hypothesized to result in milder proinflammatory reactions due to less severe operative trauma, which may contribute to the observed clinical benefits after LS. However, previous systematic reviews and meta-analyses on the impact of LS on immunocompetence are outdated, limited and heterogeneous. Therefore, the humoral response after laparoscopic and open colorectal cancer (CRC) resections was evaluated in a comprehensive systematic review and meta-analysis. METHODS: Included were randomized controlled trials (RCTs) measuring parameters of humoral immunity after LS compared to open surgery (OS) in adult patients with CRC of any stage. MEDLINE, Embase, Web of Science (SCI-EXPANDED), Cochrane Library, Google Scholar, ClinicalTrials.gov and ICTRP (World Health Organization) were systematically searched. Risk of bias (RoB) was assessed using the Cochrane RoB2 tool. Weighted inverse variance meta-analysis of mean differences was performed for C-reactive protein (CRP), interleukin (IL)-6, IL-8, tumour necrosis factor (TNF)α and vascular endothelial growth factor (VEGF) using the random-effects method. Methods were prospectively registered in PROSPERO (CRD42021264324). RESULTS: Twenty RCTs with 1131 participants were included. Narrative synthesis and meta-analysis up to 8 days after surgery was performed. Quantitative synthesis found concentrations to be significantly lower after LS at 0-2 h after surgery (IL-8), at 3-9 h (CRP, IL-6, IL-8, TNFα) and at postoperative day 1 (CRP, IL-6, IL-8, VEGF). At 3-9 h, IL-6 was notably lower in the LS group by 86.71 pg/ml (mean difference [MD] - 86.71 pg/ml [- 125.05, - 48.37], p < 0.00001). Combined narratively, 13 studies reported significantly lower concentrations of considered parameters in LS patients, whereas only one study reported lower inflammatory markers (for CRP and IL-6) after OS. CONCLUSION: The increase in postoperative concentrations of several proinflammatory parameters was significantly less pronounced after LS than after OS in this meta-analysis. Overall, the summarized evidence reinforces the view of a lower induction of inflammation due to LS.

"Prophylactic" transanal irrigation (TAI) to prevent symptoms of low anterior resection syndrome (LARS) after rectal resection: results at 12-month follow-up of a controlled randomized multicenter trial.

BACKGROUND: Low anterior resection syndrome (LARS) is associated with a severe negative impact on patients' quality of life (QOL). In a recent prospective randomized controlled trial (RCT) by our group, early ("prophylactic") use of transanal irrigation (TAI) following rectal resection for rectal cancer was shown to improve symptoms associated with LARS significantly compared with a group under supportive therapy (ST) within 1 and 3 months following closure of the protective ileostomy. The aim of the present study was to evaluate the outcome after 12 months when patients had the option to choose between the two therapeutic options and/or modify the regimen of TAI (volume and time). METHODS: In the RCT, 18 patients had been allocated to start with TAI following ileostomy closure, while 19 patients remained on ST only. Once the 3-month follow-up had been completed patients could choose between TAI or ST, respectively, and were invited for follow-up after 12 months. The maximum number of bowel movements during the day and the Wexner and LARS score as well as physical (PC) and mental (MC) component of the SF-36 questionnaire were evaluated. Furthermore, in patients who had changed their treatment arm, reasons for this decision were reported. RESULTS: Six patients were lost to follow-up (all in the ST group). One patient from the ST group started with TAI due to problems associated with LARS, bringing the total number of TAI patients to 19. Nine patients from the previous TAI arm changed to ST due to the long duration of the emptying process (n: 8) or pain during TAI (n: 1), respectively. After 12 months, the median volume of water used for irrigation was 600 ml (range 200-1000 ml). The ten patients who continued with TAI patients showed a lower number of defecation episodes per daytime (TAI median 3; 1-6, ST median 5; 2-10, p: 0.018) and per night (TAI median 0; 0-1, ST median 1; 0-5, p: 0.004) compared to the ST group. Although the LARS score was lower in patients who used TAI after 12 months (TAI median 18; 9-32, ST median 30; 3-39), this failed to reach the level of significance (p: 0.063). Evaluation of the Wexner score and the 36-item Short Form Health Survey as well as comparison of patients who remained on TAI (n: 9) versus those who had stopped TAI after 3 months (n: 9) failed to find any statistically significant difference between TAI and ST. CONCLUSIONS: This follow-up study revealed that a considerable number of patients decided to stop TAI within 12 months. However, the number of bowel movements during the day were still lower when TAI was used than when patients had ST only. CATEGORY: Randomized trial. REGISTRATION NUMBER: DRKS00011752, https://apps.who.int/trialsearch/ .

[Quality in coloproctology training : How is coloproctology training qualitatively integrated into the national training catalogue?] / Qualität in der koloproktologischen Ausbildung : Wie lässt sich koloproktologische Ausbildung in den nationalen Ausbildungskatalogen qualitativ integrieren?

The incorporation of coloproctology as a part of the surgical training and further education of assistant and specialist physicians shows great differences between Germany, Austria and Switzerland. In this article the international and national possibilities before and after specialist medical training are described in detail. In Austria, an optional coloproctology module can already be chosen in the third year of surgical training. Coloproctology is a compulsory component during the complete surgical training in Germany but a lower number of operations are required. In the basic module in Switzerland coloproctology is compulsory but contained in the operation catalogue to a lesser extent, although it has to be explicitly chosen in the further specialist training. The mandatory training in coloproctology in Germany enables all surgical assistants to undergo training, even if it is less intensive. As a result of partially compulsory and partially optional modules in Switzerland, a lower proportion of trainees receive specific training but it is more detailed. The number of trainees who are trained in coloproctology is even smaller in Austria due to the coloproctological training being optional. In the German-speaking regions a variety of specialized courses and further education are available for assistants and surgeons to further deepen their knowledge, no matter which form of training they had. At the international level the European Board of Surgical Qualification (EBSQ) for coloproctology has been available since 1998 and for many European specialists is the only possibility for formal specialization. The quality of a coloproctology training and further education curriculum may vary with national and international factors; however, it is a parameter for high standards in coloproctology in routine daily work, for the numbers of young coloproctology surgeons and is associated with a sufficient research performance in this discipline.

[Treatment strategy for early stage rectal cancer (T1 carcinoma)]. / Therapeutische Strategie bei Frühkarzinomen im Rektum (T1­Karzinom).

BACKROUND: A common consensus for the definition for early rectal cancer does not exist. This item is used in cases of histological findings including pTis, pT1 or pT2 tumors. The term early rectal cancer is not mentioned in the German S3 guidelines on colorectal cancer. The pTis tumors are located at the mucosa level of the intestinal wall and they have nearly no tendency to develop metastases but pT2 tumors have a high risk of local metastases; therefore, the term early rectal cancer is not adequate for pT2 tumors. OBJECTIVE: This focus of this article is exclusively on pT1 rectal cancer. Following the histological definition, pT1 tumors of the rectum are located at the level of the mucosa and submucosa of the intestinal wall. CONCLUSION: With respect to the nature of the tumor (e.g. size, grading, invasion of lymphatic and/or blood vessels, Kikuchi classification) local methods (endoscopic procedure, surgical techniques) or radical resections are recommended. Tumor budding is of increasing interest and importance. Depending on the severity of the tumor budding classification (bd1-bd3) there is an association with a more frequent occurrence of lymph node metastases and should therefore be taken into consideration in treatment decisions in the future.

[Quality indicators for surgery of rectal cancer : Evidence-based development of a set of indicators for quality]. / Qualitätsindikatoren für die Chirurgie des Rektumkarzinoms : Evidenzbasierte Entwicklung eines Indikatorensets für die Ergebnisqualität.

The definition of valid quality indicators is an essential task of medical self-administration and quality assurance. Based on the literature and the results of the Study, Documentation, and Quality Center (StuDoQ) Rectal Cancer Registry, we suggest the following QIs: rate of circumferential resection margin (CRM) positive resected material, rate of anastomotic leak in patients with anastomoses, rate of abdominal wound healing disorders and rate of patients with newly established permanent urinary diversion. Additionally, a new marker, the MTL30, which subsumes patient death within 30 days after the index operation, patient transfer to another acute hospital within 30 days after the index operation or a length of inpatient hospital stay of more than 30 days.

[Differential indications for ileoanal pouch anastomosis : Ulcerative colitis, familial adenomatous polyposis, synchronous colorectal cancer - Crohn's disease, constipation]. / Differenzialindikation zur ileoanalen Pouchanlage : Colitis ulcerosa, FAP, multilokuläres kolorektales Karzinom ­ M. Crohn, Obstipation.

Ileoanal pouch anastomosis is the procedure of choice for patients with drug refractory ulcerative colitis, indeterminate colitis and familial adenomatous polyposis (FAP). In selected patient groups this procedure is a treatment option for patients with Crohn's disease, hereditary nonpolyposis colorectal cancer (HNPCC), synchronous colorectal cancer and for severe colorectal constipation refractory to conservative drug treatment. The pouch procedure provides the opportunity to avoid a permanent ileostomy. The majority of surgeons prefer the ileal J­pouch as the construction is the easiest to perform and complications and dysfunction rates are low. Due to functional reasons most pouch surgeons favor a circular stapled ileoanal pouch anastomosis. The more radical proctocolectomy can produce sensory defects in the anal canal with subsequent soiling and incontinence. Studies have shown that even after proctocolectomy residual rectal mucosa was found in the anal canal. Therefore, the functionally important anorectal transitional zone should be preserved if possible. Ulcerative colitis can be "healed" with proctocolectomy; however, pouchitis can still occur in one third of the patients. Patients must be informed about the risk of pouchitis and a multidisciplinary monitoring and treatment strategy must be available. In Crohn's disease the ileoanal pouch survival rate of 80% in the long-term follow-up is surprisingly good despite an increased postoperative complication rate. The anal pouch anastomosis is the standard operation in patients with drug refractory ulcerative colitis, indeterminate colitis and FAP. Synchronous colorectal cancer, HNPCC and severe therapy refractive constipation represent rare indications for proctocolectomy where decisions must be made on an individual basis.

[Training course transanal total mesorectal excision (TaTME) : Concept and establishment of a training course for safe application]. / Trainingskurs transanale totale mesorektale Exzision (TaTME) : Konzept und Realisation eines Trainingskurses zur sicheren Anwendung.

BACKGROUND: In recent years the video endoscopy-assisted transanal approach to total mesorectal excision (TME) combined with the conventional laparoscopic technique was developed as an alternative indication for treatment of low rectal cancer (TaTME). OBJECTIVE: The concept and results of the first German TaTME hands-on cadaver course with subsequent live surgery are presented. MATERIAL AND METHODS: The 2­day training course was structured into an anatomical and a clinical surgery part. The participants could learn from basics to live surgery and shared their experiences during presentations about currently available data, rationale and technique of TaTME with special emphasis on technical failures and pitfalls. The supervised simulator training and TaTME exercises at three cadaver work stations were proctored by experienced surgeons. On day 2 the participants observed two cases of TaTME at the moderated live surgery session. RESULTS: The step-up learning curve for the transanal approach could be clearly observed in each team from warm-up to hands-on training sessions. In the practical session the participants could train the milestones of the transanal approach on cadavers, including the pitfalls. Finally, the participants observed live surgery on two patients with low rectal tumors on day 2 of the course. CONCLUSION: A step-up training course on cadavers is indispensable regarding implementation of techniques, such as TaTME into clinical practice. Coordinated clinical guest demonstrations provide translation of theoretical basic principles and practical skills from the cadaver course to real patient treatment. Participants should be encouraged to report their cases to registered trials or registries.

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.

[Gender-specific aspects of Lynch syndrome--an update]. / Genderspezifische Aspekte des Lynch-Syndroms--Ein Update.

Approximately 3-5% of all colorectal cancers are based on a hereditary predisposition, of which Lynch syndrome is by far the most frequent hereditary cancer syndrome. Beside colorectal cancer Lynch-Syndrome is the most frequent predisposing hereditary cause of endometrial cancer and is also associated with gastric cancer, ovarian cancer, cancer of the urinary tract as well as several other cancers. Genetically Lynch syndrome is caused by a germline mutation in one of the so-called mismatch-repair-genes. Based on several epidemiological studies, increasingly differences in the penetrance of the different cancers occurring are associated with the affected gene and also gender of the patient have been reported. The lifetime risk of colorectal cancer for males with Lynch syndrome generally is significantly higher and the age of first manifestation significantly earlier compared to females. The difference is especially notable in men with a MSH6-mutation. Moreover, the lifetime risk for gastric, bladder, and urothelial cancer is much higher in males. Women with an MSH6 mutation have a much higher risk for endometrial (and ovarian) cancer than for colorectal cancer. In patients with Muir Torre syndrome again males are predominantly affected and almost all affected have a mutation in MSH2 rather than in any other MMR gene. This review is an update of the literature analyzing gen and gender specific aspects of Lynch syndrome. To date these associations are based on retrospective studies, that require confirmation in a prospective setting with large patient numbers in order to identify validated, individualized gene and gender screening recommendations in the future. Especially in a syndrome with multiple potential cancer targets, an intense yearly program comprising several invasive procedures has a negative effect on patient compliance.

Management of rectourinary fistula after urological interventions using biodesigned mesh: first experiences of an innovative technique.

PURPOSE: Rectourinary fistula (RUF) is an uncommon but devastating condition that usually occurs as a complication of surgical treatment or radiotherapy of prostate cancer. Although operative fistula repair remains the most successful treatment, there still is no consensus concerning the management of RUF. We present first experiences and transanal surgical technique using biological mesh for fistula repair after urological intervention. MATERIAL AND METHODS: From January 2009 to December 2013, four cases of RUF were reported at our university hospital. Fistula occurred after extraperitoneal laparoscopic radical prostatectomy, open radical prostatectomy, and high-intensity focused ultrasound, respectively. All patients were initially treated with transanal Cook Biodesign™ mesh, whereas two patients received reoperation with rectal mucosa advancement flap and gracilis muscle flap interposition, respectively. Mean follow-up was 36 months (range 9-62). RESULTS: Fistula diameters ranged from 0.6 to 3.0 cm and were located 5 to 6 cm of anocutaneous line. The time from diagnosis to fistula repair was 3 to 7 weeks. The median operative time for Cook Biodesing™ mesh procedure was 79 min (IQR 60, 98). The initial success rate for biological mesh was 50 % (2/4 patients). Larger fistulae were minimalized successfully and finally closed with reoperation mentioned above. No deterioration of continence was documented. CONCLUSIONS: Management of rectourinary fistula is still challenging. Using biomaterials for fistula closure seems to be a promising and minimally invasive transanal technique in future. Further analysis including more patients is needed to clarify its exact role in comparison to traditional surgical techniques.

[Colorectal Carcinoma with Suspected Lynch Syndrome: A Multidisciplinary Algorithm]. / Kolorektales Karzinom bei V. a. Lynch-Syndrom: ein interdisziplinärer Algorithmus.

Lynch syndrome is the most frequent hereditary cancer syndrome, accounting for approximately 3-5 % of all colorectal cancers. In addition, it is the most frequent predisposing hereditary cause of endometrial cancer and is also associated with gastric cancer, ovarian cancer, cancer of the urinary tract as well as several other cancers. In clinical practise Lynch syndrome is frequently not detected and many clinicians admit uncertainties regarding diagnostic procedures. Also, counselling of patients is considered difficult regarding therapeutic - especially prophylactic surgical and chemopreventive options and recommendations. Based on a review of available literature we discuss optimized strategies for improved detection of suspected Lynch syndrome patients. The aim of this review is to establish a clinical algorithm of how to proceed on a diagnostic level and to discuss surgical options at the time of a colorectal cancer. In order to identify patients with Lynch syndrome, family history should be ascertained and evaluated in regards to fulfilment of the Amsterdam-II- and/or the revised Bethesda criteria. Subsequently immunohistochemical staining for the mismatch-repair-genes, BRAF testing for MLH1 loss of expression, as well as testing for microsatellite instability in some, followed by genetic counselling and mutation analysis when indicated, is recommended. Pathological identification of suspected Lynch syndrome is readily feasible and straightforward. However, the need of performing these analyses in the tumor biopsy at the time of (gastroenterological) diagnosis of CRC neoplasia is essential, in order to offer patients the option of a prophylactically extended surgery and - as recommended in the German S3 guidelines - to discuss the option of a merely prophylactical hysterectomy and oophorectomy (if postmenopausal) in women. Close cooperation between gastroenterologists, pathologists and surgeons is warranted, so that patients may benefit from options of extended or prophylactically extended surgery at the time of diagnosis of a colorectal primary. Patients nowadays must be involved in informed decision-making regarding prophylactic or extended prophylactic surgery at the time of a colorectal primary. To date, however, limitations in daily clinical practise, the failure to assess family history and the lack of awareness of this important hereditary syndrome is the major asset leading to severe underdiagnosis and putting to risk the indexpatients themselves and their families to (metachronous) CRC and the associated extracolonic cancers. If at all tumors of patients fulfilling Bethesda criteria will be analysed for MSI in the surgical specimen and therefore Lynch syndrome patients are not given the opportunity to opt for extended surgery. In clinical experience the postoperative MSI-analysis is inconsistently performed - even if the Bethesda criteria are fulfilled - and in case of suspected Lynch syndrome genetically counselling is not consistently recommended. Therefore affected cancer patients are left unaware of their increased genetic risk and in average 3 high-risk gene carriers per family miss the opportunity to actively engage in the recommended screening program.

[Scientific evidence for laparoscopic rectal cancer surgery]. / Evidenzlage der laparoskopischen Chirurgie beim Rektumkarzinom.

BACKGROUND: Innovative surgical techniques in colorectal surgery aim to provide diminished surgical injury and at least equivalent or even improved quality of treatment and oncological results. High level clinical studies are mandatory to examine the feasibility and advantages (or disadvantages) of new operative techniques. OBJECTIVES: Laparoscopic colonic resection for cancer has been investigated with respect to safety and oncological quality in various prospective randomized studies (COST study, COLOR-I and CLASICC). The minimally invasive procedure is feasible and safe which was demonstrated in many studies but can these results be extrapolated to laparoscopic rectal cancer surgery? RESULTS: The short term outcomes of the COLOR-II trial were published recently and laparoscopic resection for rectal cancer was not found to be inferior compared to open resection. Recovery after laparoscopic surgery was better than after open surgery. Laparoscopic surgery was found to have significant advantages with respect to blood loss, operating time, use of pain medication, early restoration of bowel function and reduction of hospital stay as well as the lateral safety margins in the distal third of the rectum. The long-term results focussing on local recurrence showed a positive trend in favor of laparoscopic rectal surgery and will be published shortly. CONCLUSION: Laparoscopic total mesorectal excision (TME) appears to have clinically measurable short-term advantages in patients with primary rectal cancer based on the evidence of randomized studies. Laparoscopic rectal cancer resection may become the gold standard in the future.

Health-related quality of life after laparoscopic and open surgery for rectal cancer in a randomized trial.

BACKGROUND: Previous studies comparing laparoscopic and open surgical techniques have reported improved health-related quality of life (HRQL). This analysis compared HRQL 12 months after laparoscopic versus open surgery for rectal cancer in a subset of a randomized trial. METHODS: The setting was a multicentre randomized trial (COLOR II) comparing laparoscopic and open surgery for rectal cancer. Involvement in the HRQL study of COLOR II was optional. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR38, and EuroQol - 5D (EQ-5D™) before surgery, and 4 weeks, 6, 12 and 24 months after operation. Analysis was done according to the manual for each instrument. RESULTS: Of 617 patients in hospitals participating in the HRQL study of COLOR II, 385 were included. The HRQL deteriorated to moderate/severe degrees after surgery, gradually returning to preoperative values over time. Changes in EORTC QLQ-C30 and QLQ-CR38, and EQ-5D™ were not significantly different between the groups regarding global health score or any of the dimensions or symptoms at 4 weeks, 6 or 12 months after surgery. CONCLUSION: In contrast to previous studies in patients with colonic cancer, HRQL after rectal cancer surgery was not affected by surgical approach. REGISTRATION NUMBER: NCT00297791 (http://www.clinicaltrials.gov).

[Prophylaxis of thromboembolic events in surgery. DVT prophylaxis: a comparison of out-patient and hospitalized patients]. / Prophylaxe thromboembolischer Ereignisse in der Chirurgie. TVT-Prophylaxe: Vergleich ambulant vs. stationär.

BACKGROUND: The aim of this study was to compare the efficacy and tolerability of enoxaparin for preventing thromboembolism after surgery in the out-patient and in-hospital settings. MATERIALS AND METHODS: A total of 2,005 out-patient and 1,360 hospitalized patients were included in the study. Prophylaxis was carried out with 20 or 40 mg enoxaparin and follow-up examination after 4-6 weeks. RESULTS: Out-patients were younger (mean 48.4 vs. 58.5 years, p<0.01), had less cardiovascular comorbid diseases (7.1 vs. 20.8%, p<0.01) and underwent less complex interventions (arthroscopy 33.6 vs. 7.5%, p<0.01). Out-patients also received 20 instead of 40 mg enoxaparin more frequently (60.7 vs. 38.3%, p<0.01). The mean duration of thromboprophylaxis was reduced (12.6 vs. 15.3 days). For patients treated with 20 and 40 mg minor bleeding was observed in 1.8 and 3.4%, respectively (4.7 with 20 mg and 4.5% with 40 mg in hospital), major bleeding was 0.1% for both doses in out-patients and 0.0% with 20 mg and 0.3% with 40 mg in-hospital. Deep vein thrombosis (DVT) occurred in 0.4% of out-patients receiving 20 mg enoxaparin and 0.6% with 40 mg (0.0% with 20 mg and 0.9% with 40 mg in-hospital). There were no cases of pulmonary embolism (PE) in out-patients but PE was observed in 0.2% and 0.5% with 20 mg and 40 mg in-hospital patients, respectively. CONCLUSIONS: Thromboprophylaxis with enoxaparin is well tolerated under clinical conditions as well as under out-patient treatment and severe bleeding complications are rare.

[Lynch syndrome--epidemiology, clinical features, molecular genetics, screening, therapy]. / Das Lynch-Syndrom - Epidemiologie, Klinik, Genetik, Screening, Therapie.

Lynch syndrome is characterised by a familial predisposition of colorectal and endometrial carcinomas in association with a variety of other cancers. The underlying autosomal dominant inheritance has a penetrance of 85-90%. The molecular genetic underlying mechanism is a mutation in one of the mismatch-repair genes. The identification of the molecular genetic basis of Lynch syndrome enabled the implementation of predictive testing in families with a proven mutation. A prerequisite to detect patients with Lynch syndrome is a knowledge of the clinical and histopathological features of this disease. Typical for Lynch syndrome associated carcinomas is the early age of onset of about 45 years as well as the characteristic localisation within the right hemicolon. However, in order to increase the rate of identification of this underestimated syndrome, the awareness of the clinician must extend beyond this classical phenotype. For this purpose close interdisciplinary cooperation is warranted! The cancers are mostly low-differentiated with solid areas without a tubular structure. Crohn's-like lesions as well as peritumoural and tumour-infiltrating lymphocytes may frequently be found in the periphery of the malignant formation. Within the framework of the clinical evaluation of any index patient, an extended family history must be ascertained and matched with the Amsterdam-I and -II criteria as well as with the revised Bethesda criteria. If a patient fulfills these criteria, testing for microsatellite instability and if positive after genetic counselling mutation analysis should be recommended. Patients with a proven mutation and high risk individuals from families with an unidentified underlying mutation are encouraged to participate in an intensified screening programme. Due to the incomplete penetrance there is no recommendation towards prophylactic surgery in high-risk individuals without tumour manifestation. Nevertheless, the effect on quality of life of prophylactic, extended surgery in addition to the obligatory oncologic resection with or without prophylactic hysterectomy needs to be established in prospective controlled trials.

[Surgical removing of an ectopic tooth in an Iceland mare]. / Chirurgische Entfernung einer ektopischen Zahnanlage bei einer Isländerstute.

Ectopic teeth occur because of failure of the first branchial cleft to close during development and are found mostly in young horses. Such dentigerous cysts are often located at the base of the ear, forming a notable swelling with a fistula, as it was the case with the two year old Iceland mare «Runa¼. In order to confirm the diagnosis, x-ray images were taken, which is also necessary to locate the ectopic tooth correctly. While operating, the whole cystic membrane should be removed and it is important to prevent adjacent nerves and blood vessels from damage. Prognosis for complete healing after removing an ectopic tooth is excellent.