Spontaneous changes in tumour cell dissemination to bone marrow in colorectal cancer.

AIM: The study aimed to evaluate the incidence of disseminated tumour cells (DTCs) in bone marrow (BM) preoperatively and during follow up and to correlate these with established risk factors in patients with colorectal cancer. METHOD: We prospectively studied BM in 57 patients using the anti-cytokeratin antibody A45-B/B3. RESULTS: The overall detection rate of DTCs was 23% with a similar detection rate through all stages of the disease. No significant association was found between the presence of DTCs and clinicopathological parameters. After a median follow up of 35.4 months, no differences were found in relapse and overall survival between patients with and without DTC preoperatively. In 31 of 45 patients with local disease, we performed a follow-up BM examination after 1 year. In 26% of the patients, the BM status had changed as compared with the preoperative finding. CONCLUSION: This is the first study to report the follow up of DTC in BM in colorectal cancer using the A45-B/B3 antibody. The presence of tumour cells in the preoperative BM had no impact on outcome. The BM status had changed after 12 months in a quarter of patients.

Caspase-cleaved cytokeratin 18 fragment (M30) as marker of postoperative residual tumor load in colon cancer patients.

BACKGROUND: Soluble cytokeratin 18 (CK18; M65) and a caspase-cleaved fragment of CK18 (M30) have been used as biomarkers, corresponding to tumor cell death and apoptosis, respectively. METHODS: In the present study, M30 was quantified for the first time in serum samples of colon cancer patients pre- and postoperatively as well as during chemotherapy. Minimal residual disease (MRD) was assessed preoperatively by detection of pan-cytokeratin antibody A45-B/B3-positive cells in bone marrow aspirates. RESULTS: Out of 46 patients, those with colon tumors of stages I and IV had significantly elevated M30 serum concentrations compared to controls (n = 23). In 31 colon cancer patients, M30 determinations were performed prior to and seven days after tumor surgery. A group of 24 patients exhibited a significant decrease of M30 in response to tumor removal, in contrast to seven patients who revealed either persistent or higher M30 levels postoperatively. The frequency of MRD was not significantly different for patients with decreasing (4/24) and persisting (3/7) M30. However, M30 correlated significantly with the increased number of recurrences within 36 months in the group with persisting M30 (4/7 versus 2/24, p = 0.032; hazard ratio 8.3, p = 0.016). In a group of patients (n = 10) receiving capecitabine/oxaliplatin chemotherapy (CapOx), transient increases in M30 did not correlate with responses. CONCLUSION: The data obtained within the present limited pilot study in colon cancer patients demonstrate that perioperative changes of M30 may indicate systemic residual tumor load and increased risk of recurrence warranting further evaluation of this marker of apoptosis in a larger prospective clinical trial.

Sacral nerve stimulation in patients with severe constipation.

PURPOSE: Constipation is frequently a multifactorial disease. This study was designed to evaluate the potential effects of sacral nerve stimulation for patients suffering from severe chronic constipation. METHODS: Nineteen patients suffering from pathologic colonic transit time or rectal outlet obstruction were included. Only patients with severe rectal outlet obstruction who needed digital manipulation for defecation or patients suffering from pathologic colonic transit constipation with less than two bowel movements per week were regarded as candidates. A temporary stimulation lead was implanted into the sacral foramen that showed the best muscular response. After an evaluation period, the stimulation electrode was removed. An improvement in constipation (more than 2 bowel movements per week or defecation without digital manipulation, respectively) during the test stimulation, as well as a recurrence of prestimulation constipation symptoms during the following surveillance period of three weeks were prerequisites for implanting the permanent sacral nerve stimulating system. RESULTS: All of the patients showed a positive motor response to acute needle stimulation. After the evaluation period, eight patients (42 percent) reported an improvement of constipation, and permanent systems were implanted successfully. During the median follow-up of 11 (range, 2-20) months, a significant improvement in the Wexner constipation score was observed compared with the preoperative baseline level (baseline: median: 23, range, 18-27; 12 months after implantation: median, 8, range, 4-13). After successful sacral nerve stimulation, patients also showed a significant improvement in their quality of life. CONCLUSIONS: Patients suffering from severe constipation are a new challenge for sacral nerve stimulation but further research on pelvic floor function is needed.

Sacral nerve stimulation for neurogenic faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) has emerged as a promising technique for the treatment of faecal incontinence. This study assessed the outcome of SNS in a cohort of patients with incontinence of neurological aetiology. METHODS: Thirty-six patients were included in a trial of SNS. Twenty-nine subsequently had a permanent implant. Evaluation consisted of a continence diary, anal manometry, saline retention testing and quality of life assessment. RESULTS: After a median follow-up of 35 (range 3-71) months, 28 patients showed a marked improvement in or complete recovery of continence. Incontinence to solid or liquid stool decreased from a median of 7 (range 4-15) to 2 (range 0-5) episodes in 21 days (P = 0.002). Saline retention time increased from a median of 2 (range 0-5) to 7 (range 2-15) min (P = 0.002). Maximum resting and squeeze anal canal pressures increased compared with preoperative values. Quality of life on all scales among patients who received a permanent implant increased at 12 and 24 months after operation. CONCLUSION: SNS is of value in selected patients with neurogenic faecal incontinence.

Patients' expectations of colorectal surgery for cancer.

OBJECTIVE: The primary objectives of surgery for colorectal cancer are to achieve radical resection of the tumour and to ensure a satisfactory quality of life for the patient. But what is satisfactory quality of life for the patients? What do patients desire? The goal of our exploratory investigation was to evaluate prospectively the patient pre-operative expectations as objectively as possible and to analyse results in relation to age, gender and socio-economic status. METHODS: In the period from 1998 to 2001, 167 patients were given a questionnaire consisting of 15 questions prior to surgery. The questionnaire included various aspects that were thought to influence the patient's quality of life. Moreover the patients were given the opportunity to rate the questions they considered most important. RESULTS: The following five points were considered most important by the total group of patients: Complete cure of the disease was rated most important (95%); it was the prime expectation of the patients. This was followed by the avoidance of a stoma (81%), a reliable control of defaecation (52%), normal digestion (44%) and little pain (26%). CONCLUSION: Age, gender and education influence the pre-operative expectations of patients undergoing surgery for colorectal cancer. In addition to the surgical standard, the care of the individual patient must be given due consideration in the treatment strategy.

Aetiology and surgical management of toxic megacolon.

OBJECTIVE: The purpose of this article is to review the surgical management and outcome of toxic megacolon and to update the aetiology of toxic megacolon. PATIENTS AND METHOD: A retrospective chart review of three academic colorectal surgery units was undertaken. Over a period of 20 years, 70 patients with surgically managed toxic megacolon were identified: 32 men and 38 women, median age 63 years (range, 23-87 years). RESULTS: In 33 (48%) patients the main cause of toxic megacolon was inflammatory bowel disease. Thirty-seven (52%) patients had toxic megacolon of different aetiology. Sixty-three patients underwent colonic resection: 49 (70%) subtotal colectomies and 14 (20%) total colectomies, including 4 (6%) proctocolectomies. Seven (10%) patients had decompression (n=3) or faecal diversion (n=4) only. Forty-four of the resected patients underwent a Hartmann's procedure and an ileostomy; 13 (19%) patients had primary anastomoses, 11 (16%) ileorectal anastomoses (IRA) and 2 (3%) patients had ileal pouch-anal anastomosis (IPAA). Twenty-six (37%) patients subsequently had continuity restored. Total surgical complication rate was 19% (n=13), 8% (n=4) in patients treated with subtotal colectomy, 21% (n=3) in patients treated with total proctocolectomy and 86% (n=6) in patients treated with either decompression or diversion. The total mortality rate was 16% (n=11). CONCLUSIONS: Toxic colitis complicated by toxic megacolon can occur after various diseases of the colon and remains a life-threatening disorder associated with a significant risk of postoperative complications. Subtotal colectomy with ileostomy remains the procedure of choice. Surgical colonic decompression with faecal diversion alone is associated with a high rate of complications.

Improving the safety of laparoscopic cholecystectomy: the routine use of preoperative magnetic resonance cholangiography.

BACKGROUND: The aim of this study was to determine the value of routinely performed preoperative magnetic resonance cholangiography (MRC) in detecting common bile duct (CBD) stones in patients stated to undergo elective laparoscopic cholecystectomy. In addition, we used MRC to investigate possible variants of the cystic duct. METHODS: Magnetic resonance cholangiography was performed preoperatively in 773 patients (311 male and 462 female; median age 55 years, range 16-91) who had no clinical signs of cholestasis prior to undergoing elective laparoscopic cholecystectomy. In cases where the MRC was positive for CBD stones, endoscopic retrograde cholangiopancreatiography (ERCP) was then performed. A total of 532 patients were available for continuous postoperatively follow-up (median 54 months, range 36-85). In 462 patients (247 female, and 215 male), MR images were also reviewed for variants of the cystic duct. RESULTS: In 705 patients (91%), MRC was negative for CBD stones. In 64 patients (9%) MRC was positive. Of these patients, 47 (6%) had CBD stones on ERCP. In 12 patients (2%), MRC was false positive. In five cases (0.6%), ERCP had an inconclusive result postoperative follow-up (532 patients, or 69%) revealed evidence of CBD stones in three patients (10.4%) despite a preoperative negative MRC result. Anatomical variants in the course of the cystic duct and its confluence with the common bile duct were found in 27 of 462 patients (6%). CONCLUSIONS: Magnetic resonance cholangiography proved to be a reliable screening technique in the preoperative evaluation of patients with silent CBD stones. Imaging of the course of the cystic duct is possible in a high percentage of cases. Therefore, MRC can be recommended as a screening technique before laparoscopic cholecystectomy.

[Collateral circulation of the left colon: historic considerations and actual clinical significance]. / Die kollaterale Gefässversorgung des linken Hemikolons. Historische Beobachtungen und aktuelle klinische Bedeutung.

INTRODUCTION: The arterial communication between the superior and inferior mesenteric arteries is important in surgery of the colon and aorta. METHODS: The anastomosis between the median colic artery (ACM) and the superior colic artery (AMS) was studied on 52 cadavers (32 female, 20 male). The length of the artery was measured using a flexible scale, and its diameter was determined at three different locations (origin, middle, end). RESULTS: The median lengths of the arteries were: 6.8 cm (range 3.9-9.7) for ACM, 12.2 cm (range 7-17.4) for ACS, and 23 cm (range 13.6-34.2) for margin artery. The median diameters were: 3.4 mm (range 2.7-4.1) for ACM, 3.1 mm (range 2.1-4.1) for ACS, and 2.7 mm (range 2-3.4) for margin artery. In 9.6% of the cadavers ( n=5), additional anastomoses between the AMS and inferior mesenteric arteries were proven. In 90.4% ( n=47), only margin arteries were found. SUMMARY: The low incidence of an additional communication (Riolan's arch) and possible additional impairment of the blood supply should be taken into account during operation.

[Immunocytochemical and molecular detection of minimal residual disease in blood and bone marrow in colorectal cancer]. / Immunzytochemischer und molekularer Nachweis der minimalen Resterkrankung in Blut und Knochenmark bei kolorektalem Karzinom.

Immunocytochemical and molecular biological methods to analyze minimal residual disease (MRD) in colorectal cancer in blood and bone marrow were compared. The concept of a study in the Donauspital will be presented which will permit a comparative judgement of minimal residual disease in blood and bone marrow in patients with colorectal cancer.

Long-term results of modified graciloplasty for sphincter replacement after rectal excision.

OBJECTIVE: Restoration of the anal sphincter by means of electrically stimulated (dynamic) graciloplasty is a new therapeutic option for patients with severe faecal incontinence or those having abdomino-perineal resection (APR) of the anorectum. The present study reviews the outcome of total anorectal reconstruction (TAR) after APR for low rectal cancer or recurrent anal cancer. METHODS: From 1992 to 2000, 35 of 64 patients treated with dynamic graciloplasty had a TAR performed either synchronously (n=26) or as a secondary procedure one to five years after rectal excision (n = 9). RESULTS: The most frequent complication was injury or erosion of the neorectum (n = 9) which, was avoided with increasing surgical experience. Defaecation disorders and consequent incontinence were the most common functional problem and had to be treated with periodical enemas. CONCLUSION: Although sphincter replacement by means of TAR after APR led to poorer functional results than those achieved in patients treated with dynamic graciloplasty for faecal incontinence, TAR remains a valid treatment option for patients who do not tolerate a permanent stoma.

[Determination of therapy management in rectal carcinoma by staging with 18-FDG-PET]. / Bestimmung des Therapiemanagements beim Rectumcarcinom durch Staging mittels 18-FDG-PET.

The curative treatment of carcinoma of the rectum in the early stage of the disease is radical local surgery. If there is a solitary liver metastasis, resection is also a curative treatment. This report describes a female patient with rectal carcinoma, in whom a solitary liver metastasis in the left lobe was diagnosed only by FDG-PET and verified at surgery. This case report demonstrates the potential role of FDG-PET even for primary staging in detecting occult hepatic and extrahepatic metastases, thus significantly influencing the therapeutic management and prognosis of these patients.

[Single and multiple interventions in ileus of the large intestine due to carcioma]. / Ein- und mehrzeitige Eingriffe beim Dickdarmileus wegen Carcinom.

Ileus due to a colorectal carcinoma is still an illness with high mortality currently between 15 and 20%. Advanced tumor stages are found in the majority of the patients. Today one-staged procedures are preferred, although a clear advantage in postoperative mortality was not proven so far. We recommend a concept, depending on localization, general condition and tumor stage. For patients in very bad general condition a primary colostomy is still a good option today. In case of a damaged intestine we recommend either a two-staged procedure with primary resection and colostomy and secondary closure of the stoma or a subtotal colectomy in patients who are in a good general condition. For patients in very good condition an one-staged procedure should be performed, whereby we prefer the resection with on table lavage.

Sacral nerve stimulation as a treatment for fecal incontinence.

BACKGROUND & AIMS: Sacral nerve stimulation is a proven therapeutic option for the treatment of some forms of urinary incontinence. Very recently, preliminary reports have given evidence for its efficacy in fecal incontinence (FI) too. METHODS: Since November 1998, 20 patients have been treated for severe FI. The cause of FI was mainly neurologic (n = 15), and was idiopathic in 5 patients. After temporary (subchronic) external stimulation over a period of 10-14 days, patients whose continence status improved underwent implantation of a permanent quadripolar lead and a subcutaneously implanted pulse generator. RESULTS: Acute (needle) testing revealed a positive pelvic floor response in 16 patients who underwent subsequent permanent implantation. The median number of incontinence episodes decreased from 6 episodes (3-15/21 days) to 2 (0-5/21 days). The time period of retention of a volume of saline causing an urge until definitive defecation was 2 minutes (range, 0-5 minutes) preoperatively and increased to 7.5 minutes (2-15 minutes) postoperatively. Results of preoperative and postoperative (3 months) anal manometry showed a statistically significant increase in maximal resting and squeeze pressures. CONCLUSIONS: Sacral nerve stimulation seems to be a new and promising modality for patients with certain types of FI in whom conventional treatment options have failed to achieve an improvement.

[Acute and perforated sigmoid diverticulitis. Surgical indication: single stage versus multiple-stage operation]. / Die akute und perforierte Sigmadivertikulitis. Chir. Indikation: Einzeitige versus mehrzeitige Operation.

The indication and the optimal surgical procedure of complicated diverticulitis are still under discussion. The choice of the surgical therapy has its highest priority in the cure of the infection by sigmoid resection. Resection with primary anastomosis can be done in cases of covered perforation (Hinchey 1 + 2) with a low mortality. Diffuse peritonitis should be treated depending on the individual local situation.

Needle perforation of the appendix.

BACKGROUND/AIMS: Needles are among the most frequently swallowed foreign bodies. In most cases they are excreted per vias naturales, but in some cases needles can lead to perforation of the stomach or duodenum in adults. METHODS: We report a case of acute appendicitis after perforation of the appendix by a swallowed needle. An appendectomy was performed without any knowledge of the reason for perforation. RESULTS: Inspection of the resected appendix demonstrated a needle of 1.5 cm length inside the lumen of the appendix, which had caused a perforation of the distal end of the appendix. CONCLUSION: As seen in this case a longer-lasting nondiagnosed perforation can lead to extensive local inflammation which could have been avoided by early surgical treatment which should also be considered if the patient has very few symptoms, as in this case.

Preservation and restoration of sphincter function in patients with rectal cancer.

Radical resection of rectal cancer is the standard treatment for curing this disease. Half of these tumours are located in the rectosigmoid region or the upper third of the rectum and are, therefore, easily resectable with preservation of the sphincter muscles, thus guaranteeing acceptable continence in most patients. However, tumours that originate in the lower parts of the rectum have been accompanied with the need for an abdominoperineal resection and the threat of a permanent colostomy. In the past 20 years, sphincter-saving surgery has become increasingly common in the treatment of tumours of the middle and low rectum due to the knowledge of tumour growth, the use of stapling devices, and the knowledge of the physiology of the pelvic floor and the sphincter muscles, respectively. Recent surgical techniques of resection of the 'ultralow' rectum (intersphincteric resection) and the reconstruction by coloanal anastomosis are reviewed. Functional problems following ultralow resections are emphasized, as well as the possibility of sphincter restoration after abdominoperineal resection by use of dynamic graciloplasty. Taking all surgical options into account, a permanent colostomy for rectal cancer can be avoided in most curatively and electively operated patients.

MR imaging for the preoperative planning of sphincter-saving surgery for tumors of the lower third of the rectum: use of intravenous and endorectal contrast materials.

PURPOSE: To evaluate the value of magnetic resonance (MR) imaging with a flexible surface coil in predicting the resectability of tumors in the lower rectum and the feasibility of sphincteral salvage. MATERIALS AND METHODS: In a prospective study, 61 patients with histologically proved primary adenocarcinoma of the lower or middle third of the rectum (<12 cm from the pectinate line) were examined at double-contrast-material-enhanced MR imaging with a circular polarized flexible surface coil. RESULTS: Assessment of anal sphincteral infiltration at MR imaging was excellent, with a specificity of 98% and a sensitivity of 100%. In the determination of tumor infiltration into adjacent organs (T4), the specificity was 100%, and the sensitivity was 90%, with surgical and histologic findings as the standards. While MR imaging showed negative nodes in 40 patients (stage N0 at MR imaging), histologic examination showed negative nodes in 27 patients and positive nodes in 34. At MR imaging, sensitivity was 68%, and specificity was 24%. CONCLUSION: While preoperative staging at MR imaging according to the TNM system still has limited value and accuracy, MR imaging provides the surgeon with valuable information regarding the presence of sphincteral invasion and the surrounding structures in patients with cancers in the lower third of the rectum.

Magnetic resonance imaging of perianal fistulas: predictive value for Parks classification and identification of the internal opening.

OBJECTIVE: MRI has been reported to be valuable in the investigation of patients with fistula in ano. The aim of this study was to evaluate the results of preoperative magnetic resonance imaging (MRI) in such patients using a surface coil and to compare it with surgical findings. PATIENTS AND METHODS: In a prospective study, 28 patients (19 males, nine females, median age 39 years) with perianal fistula underwent preoperative MRI. Parks classification as well as the identification of an internal opening into the anal canal and/or rectum were compared with the surgical findings. RESULTS: Classification during surgery revealed five extrasphincteric, eight transsphincteric, seven suprasphincteric and eight intersphincteric fistulas. All patients with intersphincteric, suprasphincteric and transsphincteric fistulas were correctly classified by MRI. The comparison of MRI and surgical results revealed a concordance in 27 of 28 (96%) patients in terms of classification (κ 0.95, P < 0.01) and in 21 (75%) patients regarding the identification of the internal opening (sensitivity 63%, specificity 92%). CONCLUSION: Our results indicate that MRI of perianal fistulas with the use of extra-anal surface coils can accurately assess the surgical anatomy. It is a rapid, well-tolerated technique which might play an important role in the management of perianal fistula.

Quality of life after surgery for rectal cancer: do we still need a permanent colostomy?

INTRODUCTION: A permanent colostomy is a serious limitation of the quality of life. Besides cure of cancer, preservation of sphincter function is an important goal of surgery for rectal cancer. METHODS: In a prospective study a concept offering every patient with rectal cancer either sphincter salvage or a "neosphincter" was investigated, and the impact of this strategy on oncologic results, sphincter function, and quality of life was analyzed. RESULTS: From 1992 to 1997, 276 patients were accepted for the study. Two hundred sixty-one patients had elective surgery, and 15 patients had emergency surgery for their rectal tumors. The postoperative mortality rate was 4 percent. A radical resection (R0) was possible in 197 patients (75 percent). Anterior resection was the most common procedure (n = 87), and intersphincteric resection with coloanal anastomosis was the preferred method for low tumors (n = 65). Abdominoperineal resection was necessary in 15 cases. Thirteen patients had an immediate restoration of sphincter function by means of a dynamic graciloplasty, and 2 patients needed emergency abdominoperineal resection for bleeding. The follow-up was relatively short (median, 36.4 months) at the time of data analysis and showed a local recurrence rate of 8 percent. Although postoperative continence according to the Williams score revealed satisfactory results, subjective quality of life and the scale for specific symptoms showed a significantly worse outcome in patients with ultralow (coloanal) anastomoses compared with those with anterior resection. CONCLUSIONS: We conclude that for elective curative surgery of rectal cancer, a permanent colostomy is not necessary provided all presently available techniques of sphincter salvage and restoration are applied. However, the patient has to be informed about possible side effects associated with surgical procedures such as coloanal anastomosis or neosphincter reconstruction, to avoid severe psychological difficulties.

Abdominosacral resection of recurrent rectal cancer in the sacrum.

PURPOSE: Resection of the sacrum is the only curative therapy of isolated sacral recurrence after primarily resected rectal cancer. The aim of the study was to assess whether there is a benefit in terms of overall survival, morbidity, and mortality when sacrum resection is performed more radically and in cooperation between colorectal and orthopedic surgeons. Possible prognostic factors were also assessed. METHODS: Twelve consecutive patients who underwent interdisciplinary partial sacral resection were included in a retrospective cohort study. Furthermore, overall survival rate and survival time were calculated. RESULTS: Histologic examination showed tumor-free resection margins in all cases. Extended resection was necessary in seven patients, including total pelvic exenteration in two. No perioperative death occurred and no patient required early reoperation. Complications were observed in 42 percent of patients, mainly caused by poor wound healing. All patients experienced relief from pain. One-year and three-year overall survival rates were 50 and 17 percent, respectively. The overall mean survival time was 21.7 months. Patients who died of recurrent disease within one year either underwent former resection for locoregional recurrence, had extensive local recurrent tumors affecting pelvic visceral structures, or retrospectively suffered from metastatic sacral tumor manifestation. CONCLUSION: The mortality and morbidity rates observed in the present study seem to justify partial sacral resection as a means to achieve palliation of perineosacral pain in spite of rare overall long-term survival.