Internal anal sphincter nerves - a macroanatomical and microscopic description of the extrinsic autonomic nerve supply of the internal anal sphincter.

AIM: The internal anal sphincter (IAS) contributes substantially to anorectal functions. While its autonomic nerve supply has been studied at the microscopic level, little information is available concerning the macroscopic topography of extrinsic nerve fibres. This study was designed to identify neural connections between the pelvic plexus and the IAS, provide a detailed topographical description, and give histological proof of autonomic nerve tissue. METHODS: Macroscopic dissection of pelvic autonomic nerves was performed under magnification in seven (five male, two female) hemipelvises obtained from body donors (67-92 years). Candidate structures were investigated by histological and immunohistochemical staining protocols to visualize nerve tissue. RESULTS: Nerve fibres could be traced from the anteroinferior edge of the pelvic plexus to the anorectal junction running along the neurovascular bundle anterolaterally to the rectum and posterolaterally to the prostate/vagina. Nerve fibres penetrated the longitudinal rectal muscle layer just above the fusion with the levator ani muscle (conjoint longitudinal muscle) and entered the intersphincteric space to reach the IAS. Histological and immunohistochemical findings confirmed the presence of nerve tissue. CONCLUSIONS: Autonomic nerve fibres supplying the IAS emerge from the pelvic plexus and are distinct to nerves entering the rectum via the lateral pedicles. Thus, they should be classified as IAS nerves. The identification and precise topographical location described provides a basis for nerve-sparing rectal resection procedures and helps to prevent postoperative functional anorectal disorders.

[Criteria for the resectability of malignant extrahepatic bile duct tumours]. / Kriterien der Resektabilität von malignen extrahepatischen Gallengangstumoren.

BACKGROUND: Most cholangiocarcinomas of the extrahepatic bile duct are diagnosed at an advanced stage. Surgery represents the only potentially curative treatment. An assessment as to whether a curative resection is possible is based on the experience of the treating physicians. METHODS: The present guidelines are based on comprehensive literature surveys in PubMed, including results from randomised controlled trials, systematic reviews and meta-analyses, and cohort studies. RESULTS: The experience of the surgeon is determining for defining criteria for resection. The surgical standards for treating Klatskin tumours are extended liver resections. Liver transplantation after neoadjuvante chemo / radiation therapy offers good results. N1 regional lymph node metastases are not a contraindication for resection. R1 resection is justified as a very efficient palliative procedure. The surgical standard for treating distal cholangiocarcinoma is the partial pancreatoduodenectomy. Infiltration of the mesenterico-portal veins or regional lymph nodes is not a contraindication for resection. However, resection has not been shown to provide survival benefit if the coeliac trunk or the superior mesenteric artery is infiltrated. There is no evidence for or against a palliative R1/R2 resection. CONCLUSIONS: For anatomic reasons, the resection rates for distal cholangiocarcinoma are higher than those for Klatkin tumours. The decision as to whether or not a curative resection is possible, especially for Klatskin tumour, requires detailed preoperatzive diagnostics and a conditioning of the patient.

Quality of care and emotional support from the inpatient cancer patient's perspective.

BACKGROUND: Patient satisfaction and emotional support are crucial elements of cancer care. Little is known, however, about which areas of care are important from the patient's perspective and the roles emotional distress and support play in this context. METHODS: Multicenter prospective study was conducted (n = 396 cancer patients; t1 = after admission to hospital, t2 = before discharge). Quality of care was measured with the quality of care from the patient's perspective questionnaire, and emotional distress was measured with the hospital anxiety and depression scale. Additional questions regarding emotional support wished (at t1) and provided (at t2) were administered. RESULTS: The patients reported that the domains of care most important to them were as follows: respect and commitment of the physicians, information before procedures, care equipment, and medical care. The areas where improvements are most obviously needed were nutrition, participation, clarity about who is responsible for personal care, and having the possibility of speaking in private with nurses and psycho-oncologists. Fifty-six percent of the patients were highly emotionally distressed, 84% wanted support from physicians, 76% from nurses, 33% from psychologists, and 7% from a pastor. CONCLUSION: Emotional support is a crucial part of patient satisfaction and should be provided by several members of the oncological team, especially the patients' physicians. In turn, it is crucial that medical professionals be equipped with good communication skills.

[Quality indicators for pancreatic surgery : Scientific derivation and clinical relevance]. / Qualitätsindikatoren für die Pankreaschirurgie : Wissenschaftliche Herleitung und klinische Relevanz.

Quality indicators are by definition indirect measures of quality. The selection for the field of pancreatic surgery was based on the clinical relevance and controllability, scientific evidence and the practicability of data acquisition. In terms of outcome quality, hospital mortality, the composite endpoint MTL30 (mortality-transfer-length of stay), and major complications (Clavien-Dindo classification grades 3b and 4) were chosen as being essential. With respect to structural quality, the presence of interventional radiology with constant availability was considered essential. To evaluate target values two strategies were used: a systematic literature search and evaluation of the current numbers from the German Society for General and Visceral Surgery (DGAV) StuDoQ|Pancreas registry for the years 2014-2016. The results are presented in the following consensus statement.

Evaluation of VEGF A expression and microvascular density as prognostic factors in extrahepatic cholangiocarcinoma.

OBJECTIVES: Angiogenesis is essential for tumor growth and metastasis. An association between microvessel density, a measure of tumor angiogenesis, and conventional prognostic variables has been shown for many different tumor entities. In extrahepatic cholangiocarcinoma, the VEGF expression and microvessel density have rarely been investigated. METHODS: Paraffin-embedded specimens from 51 resected adenocarcinomas of the extrahepatic bile duct were immunostained for vascular endothelial growth factor A (VEGF A) and CD 34 to evaluate the microvessel density (MVD). VEGF A staining was evaluated by combining intensity and percentage of positive tumor cells, as low (expression equal or below the median), or high (above the median). Microvessel density was assessed using a method published by Weidner et al. RESULTS: Median disease free survival (DFS) of the study group was 12.5 months (range, 1-66.3 months). DFS was calculated in the 39 patients with complete resection. It was significantly better in patients with low microvessel density than DFS in patients with high microvessel density (33 months (range, 3-66.3 months) vs. 21.8 months (range, 1.6-31.6 months); p=0.022). In contrast, VEGF A expression did not correlate with survival. There was a trend toward a higher VEGF A expression in highly vascularized tumors (p=0.08), but failed to reach statistic significance. CONCLUSIONS: The present study indicates, that vascularisation has an important impact on survival of extrahepatic cholangiocarcinoma patients. Other molecules than VEGF A are probably involved in neovascularization in extrahepatic cholangiocarcinoma.

Severe hypoglycemia due to insulin autoimmune syndrome with insulin autoantibodies crossreactive to proinsulin.

We report the case of a 69-year-old woman with insulin autoimmune syndrome first misdiagnosed as insulinoma. The case demonstrates the difficulties to correctly diagnose this rare disorder as both insulin and proinsulin levels were increased by crossreactive autoantibodies. No known triggering agent could be identified. We suggest that this diagnosis should be considered more often also in caucasian patients to avoid useless operations for such patients.

Pharmacological regulation of postischemic sinusoidal diameters in rats--a new approach for reducing hepatic ischemia/reperfusion injury.

UNLABELLED: Ischemia leads to profound endothelin-related constriction of the hepatic microcirculation with resulting disturbances in blood and oxygen supply. The aim of the study was to modulate hepatic microvascular diameters by blocking endothelin receptors with bosentan, and also to find the best possible vessel width (as produced by bosentan) for minimizing ischemia/reperfusion injury. METHODS: In an in vivo rat model hepatic ischemia was induced for 30 minutes by crossclamping the hepatoduodenal ligament. The endothelin receptor antagonist (ERA) bosentan was administered before ischemia in stepwise dosages of 0.1, 1.0 and 10 mg/kg bw i.v. and 10 mg/kg bw intraportally (i.p.). Vasoactive effect was assessed by in vivo microscopy. The influence on hepatic oxygen supply and hepatocellular function was evaluated by measuring local tissue pO(2) and AST levels. RESULTS: Because of ischemia sinusoidal diameters were reduced to 76.3 +/- 7.4% compared with values found in sham-operated animals. After administration of 0.1 mg/kg ERA (bosentan) the sinusoids remained constricted (89.7 +/- 9.9%). Blocking endothelin receptors with 1 mg/kg bosentan avoided sinusoidal constriction (99.0 +/- 8.8%, p<0.05) and led to the most effective reduction of AST level peak after 6 h of reperfusion (244.0 +/- 34.2 U/l vs 422.9 +/- 163.3 U/l in untreated ischemia). 10 mg/kg i.v. caused an increase in sinusoidal diameter to 109.1 +/- 6.4% and 10 mg/kg intraportally to 136.8 +/- 19.3% and even an increase in AST levels (618.9 +/- 209.3 U/l). Hepatic ischemia led to a significant decrease of local tissue pO(2) after reperfusion (9.4 +/- 1.2 mm Hg; p<0.05 vs sham: 16.8 +/- 1.8 mm Hg). The greatest improvement in postischemic oxygen supply was found in the 1.0 mg/kg group (12.9 +/- 1.0 mm Hg; p< 0.05 vs ischemia). Venular diameter changed almost to the same extent as sinusoidal diameter. Perfusion rate was significantly increased and sticking of leukocytes in sinusoids and venules was reduced after doses of 1 and 10 mg/kg bw bosentan i.v. (p<0.05). IMPLICATIONS: In this model we were able to regulate the diameters of sinusoids and postsinusoidal venules incrementally. We conclude that the avoidance of constriction, without excessive vasodilatation gives increased perfusion rates with improved hepatic oxygen supply and hepatocellular function.

[The ultrasound scalpel in laparoscopic surgery]. / Ultraschallskalpell in der laparoskopischen Chirurgie.

The ultrasonically activated scalpel works by means of the longitudinally vibrating sharp blade. The most important advantages- compared with electrosurgery-are the lack of current flow through the patient and limited local heat generation. It can be used as an instrument for coagulation, dissection and preparation. There is no generation of smoke. It is easy to use. Disadvantages are the slow speed of cutting and the high costs. In the future it could be an alternative to preparation on with dissector, scissors, and electrosurgery.

[Intra-abdominal abscess]. / Intraabdominelle Abscesse.

In more than 80% of cases, intra-abdominal abscesses derive from an intra-abdominal organ, and in most cases they develop after operative procedures. Regarding anatomy, intra-abdominal abscesses can be divided into intra-peritoneal and visceral abscesses and those located in the anterior retroperitoneal space. Despite improvements in ultrasonography, CT is still the most effective method in diagnosis and therapy. Percutaneous ultrasound or CT-guided drainage is a therapy characterized by low procedural morbidity and is successful in 80% of cases if strict criteria are met. Complicated abscesses and those cases in which the underlying disease has to be treated require surgical intervention. Most liver abscesses are treated interventionally; in abscesses of the pancreas or spleen and in Crohn's disease, surgery is necessary. The combination with sufficient antibiotic drug therapy is very important. Specific infectious diseases appearing as intra-abdominal conglomerates (tuberculosis, actinomycosis, amebiasis) lead to a delay in diagnostics because of their scarcity and are characterized by special patho-anatomical, diagnostic and therapeutic features. The crucial thing is to take a specific infection into consideration.

[Therapy of anal cancer]. / Therapie des Analcarcinoms.

The primary non-invasive treatment of anal-carcinoma by radiochemotherapy (RCT) is generally accepted although prospective randomised trials have not been finished yet. Finally the complex interaction of the radiotherapy and the commonly used cytotoxic agents 5-FU and Mitomycin-C are unknown, besides the radiosensitization. In the radiotherapy quality assurance is warranted in different radiotherapy-techniques and the total and single doses are well established for primary tumor (50-55 Gy) and lymphatic pathways (40-50 Gy) with 1,8 Gy single dose per fraction. According to the slow tumor regression restaging is made three months after completion of RCT. Residual tumor needs abdomino-perineal-resection.

[Lactic acidosis--recognition and treatment of an important complication of perioperative parenteral nutrition]. / Lactatacidose--Erkennung und Behandlung einer wichtigen Komplikation unter perioperativer parenteraler Ernährung.

We report 5 cases of acute vitamin B-1 induced lactic acidosis in surgical patients receiving parenteral nutrition. In all patients treatment with vitamin B-1 induced a dramatical improvement of clinical findings. 4 patients recovered completely, 1 patient died from already developed irreversible cardiocirculatory failure. These cases underline the need for regular vitamin B-1 substitution in patients with parenteral nutrition and preoperatively in alcoholics and in patients, in whom a sufficient food intake can not be assured.

[Treatment concept of adenomas of Vater's ampulla]. / Behandlungskonzept von Adenomen der Papilla Vateri.

INTRODUCTION: The most common benign ampullary tumors are adenomas (80%). They are considered as premalignant lesions with a transformation rate to carcinoma of up to 30%. METHODS: From 1 January 1997 to 28 February 1999 we treated 11 patients with adenoma of the ampulla of Vater. An ampullectomy was performed in 10 cases. One poor-risk patient could not be operated on. RESULTS: No operative mortality occurred. In two patients a pT1 adenocarcinoma was diagnosed postoperatively. One of the two patients with a high-risk carcinoma underwent a second operation, a Whipple pancreatoduodenectomy. Nine of 10 patients had no recurrence with a median follow-up of 12 months. CONCLUSION: One patient died of glioblastoma. We would therefore recommend ampullectomy as the first-line treatment for benign tumors of the ampulla of Vater. In low-risk pT1 carcinoma (G1/G2, L0) and R0 resection, local excision is acceptable. In high-risk pT1 carcinoma (G3 and/or L1) Whipple pancreatoduodenectomy is mandatory.

[Vulvar involvement as a rare extra-intestinal manifestation of Crohn disease]. / Vulvabeteiligung als seltene extraintestinale Manifestation bei Morbus Crohn.

BACKGROUND: Crohn's disease may involve all parts of the gastrointestinal tract. Extraintestinal manifestations with and without continuity to the intestine are described. The most common complications are the involvement of bone (articulations), liver and eyes. Crohn's disease of the vulva is rare and only a few cases have been reported in the literature. CASE REPORT: The 45-year-old woman has a 15-year history of a marked chronic-inflammatory bowel disease. The diagnosis of Crohn's disease was never confirmed histologically. In 1984, she developed a painful vulvar swelling and erythema. A fungal infection was suspected and she was treated with topical antimycotic medication, but there wasn't any improvement. In July 1995, biopsies of the vulva showed a granulomatous inflammation consistent with Crohn's disease. Oral metronidazol therapy (20 mg/kg/day) was started. After 2 months, the erythema had healed completely but the vulvar swelling remained. CONCLUSIONS: The treatment of this extraintestinal manifestation is very difficult. Systemic or topical application of steroids is without response in most cases. Surgical excision showed good results in a few cases. A long-term treatment with oral metronidazol 20 mg/kg/day could be a chance for healing without adverse effects.

[Uncommon solid abdominal tumor]. / Seltener solider abdominaler Tumor.

HISTORY AND ADMISSION FINDINGS: A 67-year-old female patient got ill during holidays in USA with acute abdominal pain. She was discharged after symptomatic treatment and presented afterwards in Germany for further clarification and treatment. INVESTIGATIONS, TREATMENT AND COURSE: Following abdominal sonography, gastroscopy and CT scan with contrast medium, a gastrointestinal stromal tumor (GIST) was assumed. Thereupon a tumor extirpation with cholecystectomy and liver resection was performed. After laparotomy a solid fibrous abdominal tumor could be diagnosed histologically. There was no indication for an adjuvant treatment. CONCLUSION: In the international literature reports about these tumors are rare. A complete resection is essential; there is no data for an adjuvant treatment.

[Anorectal diagnostics for proctological diseases]. / Anorektale Diagnostik bei proktologischen Erkrankungen.

The majority of proctological diseases can be defined by a structured evaluation of the symptoms and a physical examination. Magnetic resonance imaging (MRI) and anal endosonography can detect complex anal fistulas with a high accuracy but MRI should be preferred because of its objective visualization. Functional anorectal disorders are multifactorial and show morphological and functional irregularities in different compartments of the pelvic floor which is why MR defecography is now one of the most important methods in diagnostic algorithms. Interpreting the results of anal endosonography, anal manometry and neurophysiological testing is highly demanding because of large interindividual variability. Scores are used for objective measurement of symptom severity and quality of life. In clinical practice, well validated scores evaluated in large patient groups with predetermined circumstances are needed. Bringing together morphological results with scores based on subjective perception is required to optimize diagnostics and therapy evaluation in proctology.