[Paradoxical sphincters and cardinal continence function of the gastric fundus]. / Die paradoxen Sphinkteren und die kardinale Kontinenzfunktion des Magenfundus.

Gastroesophageal reflux disease is a common disorder in humans and has been treated for the last 67 years using fundoplication. However, treatment results have generally not been satisfactory. Physiological and anatomic findings must be taken into account to improve the therapy technique. In this article, these are described using the example of paradoxical sphincters and the effect of NO signal molecules in the gastrointestinal tract.

[Surgery without anatomy?]. / Chirurgie ohne Anatomie?

Anatomy is the basis of all operative medicine. While this branch of scientific medicine is frequently not explicitly mentioned in surgical publications, it is nonetheless quintessential to medical education. In the era of video sequences and digitized images, surgical methods are frequently communicated in the form of cinematic documentation of surgical procedures; however, this occurs without the help of explanatory drawings or subtexts that would illustrate the underlying anatomical nomenclature, comment on fine functionally important details or even without making any mention of the surgeon. In scientific manuscripts color illustrations frequently appear in such overwhelming quantities that they resemble long arrays of trophies but fail to give detailed explanations that would aid the therapeutic translation of the novel datasets. In a similar fashion, many anatomy textbooks prefer to place emphasis on illustrations and photographs while supplying only a paucity of explanations that would foster the understanding of functional contexts and thus confuse students and practitioners alike. There is great temptation to repeat existing data and facts over and over again, while it is proportionally rare to make reference to truly original scientific discoveries. A number of examples are given in this article to illustrate how discoveries that were made even a long time ago can still contribute to scientific progress in current times. This includes the NO signaling molecules, which were first described in 1775 but were only discovered to have a pivotal role as neurotransmitters in the function of human paradoxical sphincter muscles in 2012 and 2015. Readers of scientific manuscripts often long for explanations by the numerous silent coauthors of a publication who could contribute to the main topic by adding in-depth illustrations (e. g. malignograms, evolution and involution of lymph node structures).

Discovery of rhenium and masurium (technetium) by Ida Noddack-Tacke and Walter Noddack. Forgotten heroes of nuclear medicine.

The history of the early identification of elements and their designation to the Mendeleev Table of the Elements was an important chapter in German science in which Ida (1896-1978) and Walter (1893-1960) Noddack played an important role in the first identification of rhenium (element 75, 1925) and technetium (element 43, 1933). In 1934 Ida Noddack was also the first to predict fission of uranium into smaller atoms. Although the Noddacks did not for some time later receive the recognition for the first identification of technetium-99m, their efforts have appropriately more recently been recognized. The discoveries of these early pioneers are even more astounding in light of the limited technologies and resources which were available during this period. The Noddack discoveries of elements 43 and 75 are related to the subsequent use of rhenium-188 (beta/gamma emitter) and technetium-99m (gamma emitter) in nuclear medicine. In particular, the theranostic relationship between these two generator-derived radioisotopes has been demonstrated and offers new opportunities in the current era of personalized medicine.

[Paradoxical sphincters in the abdomen]. / Paradoxe Sphinkteren im Abdomen.

Nitric oxide molecules serve as neurotransmitters to relax smooth muscle tension in many parts of the body. In humans and other mammals they play an important role for correct smooth muscle function in unusual locations. We previously described this mechanism (Stelzner, Chirurg. doi:10.1007/s00104-014-2777-z, 2014) using the occlusive mechanism of the upper and lower esophageal sphincters as an example. Cells producing nitric oxide can be found in the gastric fundus, the anorectal continence organ, vesicourethraltract and also in the uterine cervix in the final trimester of pregnancy. In all these locations they serve as elements of anatomical sphincter structures that have a paradoxical function. These observations confirm the points made in the introduction of this article on the stretch sphincter mechanism of the lower esophageal sphincter and the treatment of gastroesophageal reflux disease by retensioning of the esophagus in the diaphragmatic hiatus. In particular, high-resolution esophageal manometry of the lower esophageal sphincter can easily detect every functional disturbance caused by gastric plication and such changes were to be expected based on what we described in articles I and II.

[Stretch sphincter of the esophagus : Paradoxical sphincter with angiomyoelastic architecture]. / Dehnverschluss der Speiseröhre : Paradoxer Sphinkter mit angiomyoelastischer Architektur.

The investigations described in this article clearly show that the lower esophageal sphincter (LES) represents a variation of circular muscular occlusive mechanisms found elsewhere in the gastrointestinal tract. The LES is a double layer stretch sphincter that operates in an apparently paradoxical manner: it closes when under stretch but opens when the muscle fibers contract. Impedance manometry studies demonstrate that the entire esophagus is involved in the normal functioning of the esophagus as well as in esophageal disorders. The pronounced elasticity of esophageal tissue is a functional feature that has its basis in the singular architecture of elastic fibers located between the muscle layers. All traditional forms of operative treatment of gastroesophageal reflux disease (GERD) impede the natural functioning of the stretch sphincter to a greater or lesser degree by locking it up. The cause of GERD is mainly by contraction of the esophagus brought about by the cephalad transposition of the stretch sphincter segment into the chest. In a sense this is an incipient axial hernia that frequently remains undiagnosed in the early stages. The operative repositioning of the stretch sphincter segment into the abdominal cavity provides sufficient restoration of the natural topographic relationships to achieve a cure of GERD. Whether this straightforward repair restores the function of the entire esophagus remains to be elucidated. The concept of the stretch provides a good explanation of the pathophysiology of achalasia, a condition in which a paralyzed paradoxical ring sphincter remains occluded. Successful myotomy approaches only split the muscularis propria layer of the stretch sphincter while leaving subepithelial muscle fibers intact that remain paralyzed. This limited intervention provides a good relief of symptoms.

[Pathways of regional lymph node metastases originating from soft tissue sarcomas]. / Der Weg regionärer Lymphbahnmetastasen bei Weichgewebssarkomen.

Lymph node metastases originating from soft tissue sarcomas are very rare and the reason for this is unclear. While this observation was less important in former times when ultraradical excision and amputation were the norm, modern reconstructive surgical treatment options have to take the possibility of lymphatic metastases into account.We attempted to identify parameters that may be predictive of lymphatic metastases in a cohort of 1,597 patients with soft tissue sarcomas of whom 26 patients (1.6  %) had regional lymph node (RLN) metastases. We studied these RLN metastases with recently described techniques that enabled us to histologically visualize lymphatic vessels.We conclude that sarcomas should not be evaluated from a histogenetic perspective but more on the basis of regional topography of the lymphatic vasculature. As we described previously, two different lymphatic systems should be differentiated: lymphatic vessel system I (LGS I) contains RLN and lymph vessels are mostly superficial; however, there are also vessels near large blood vessels of the extremities. System LGS II is more delicate and its vessels run into the musculature, a metastatic homing area of many sarcomas. Lymph vessels of system LGS II drain directly into veins without intervening lymph nodes. Sarcomas with LGS I drainage will form RLN metastases. In contrast, sarcomas with LGS II drainage will do so only after surgical resection if system LGS I has been opened.

[Prediction of prognosis of pancreatic cancer based on the homing area]. / Voraussage der Prognose des Pankreaskarzinoms in seinem Homing-Areal.

The homing area is a genetically defined location where primary malignancy originates and local recurrences occur. In order to be completely successful, curative resections of malignant tumors have to eradicate the homing area. This is possible in colon resection where the borders of the homing area are distant from the tumor and the lymph nodes can easily be resected to remove possible node metastases. In contrast, the homing area of the pancreas comprises only the gland itself, similar to all other glandular organs. The high specificity of the homing area is demonstrated by the finding that even pancreatic islets are spared by the malignant disease. During fetal development the pancreas loses most of the original dorsal and ventral mesentery. Via short lymphatic pathways, metastatic cells leave the gland in a centrifugal manner and find their way to regional lymph nodes that often share drainage with other neighboring organs. The lymph nodes are arranged in multiple layers and not in flat mesentery-like structures. Radical resections are therefore difficult to achieve.

[The crural diaphragm belongs to the pharyngeo-cardial continence organ (PET-CT and impedance measurements on the stretch sphincter and its fixation in the hiatus oesophageus of the diaphragm)]. / Das krurale Zwerchfell gehört zum ösophagokardialen Kontinenzorgan (PET-CT und Impedanzmessung am Dehnverschluss und seine Verankerung im Hiatus oesophageus des Zwerchfells).

This paper provides evidence that pharyngeo-cardial propulsion in the oesophagus follows similar principles as translocation of luminal contents in other locations in the body. In brief, the following statements are discussed in the paper: 1. Only animals with a lung-based respiratory system have an oesophagus. 2. Its bulky muscular wall is made up of the elastic fibres which ensure that the oesophagus stays elastic during an entire lifetime. 3. While short-segment ring sphincter systems exist in several locations in the body, the lower oesophageal sphincter is maximally elongated. This configuration helps with the propulsion of luminal contents in addition to this sphincter's opening and occlusive functions. 4. The musculature of the diaphragm is genetically related to the cervical muscles. The crural portion of the diaphragm works in coordination with the lower oesophageal stretch sphincter. 5. Gastro-oesophageal reflux disease is fairly common. In patients with this disorder, the oesophagus is too short and the stretch sphincter remains patent for abnormal periods of time. 6. When the stretch sphincter is surgically retightened by transposition of the oesophageal cardia into the abdomen, a proper function of the regulatory lower oesophageal stretch sphincter can be restored. 7.-9. All fundoplication procedures place the lower oesophageal sphincter under stretch, squeeze and create an oesophageal wrap out of gastric fundus tissue. X-ray images confirm in many patients undergoing fundoplication that the anatomic stretch sphincter already starts above and proximally to the plicated cuff.

[Spontaneous change of malignancy of solid malignant tumors : statistical investigations of colorectal and pancreatic carcinoma]. / Spontane Malignitätsänderung bei soliden Malignomen : Statistische Erhebungen beim kolorektalen und beim Pankreaskarzinom.

The distribution curves of grades of malignancy for colorectal carcinomas and pancreatic carcinomas have not been stable over the years and investigations have shown a clear variability in the temporal distribution. Colon carcinomas were found to diminish considerably in aggressiveness in different time periods and colorectal carcinomas were found to increase in aggressiveness in some years. However, the distribution curve of grades of malignancy varies in both carcinomas over time and this variation follows a random distribution. In contrast to colorectal carcinomas, pancreatic carcinomas have not been followed up for very long time periods. While the distribution curve of malignancy was unchanged in most countries an increase in malignancy was observed in two countries. For colorectal and pancreatic carcinomas increases in malignancy are linked to a highly significant decrease in the number of cancers with lowest grades of malignancy. Even though the exact nature of variations in these malignancy distribution curves is incompletely understood, these variations appear important for comparative outcome statistics in cancer therapy as the aggressiveness of these malignancies has a direct bearing on the overall prognosis.

Deutsche Zeitschrift für Chirurgie (1872-1947) and Bruns Beiträge (1885-1974) and their connections to Langenbeck's Archive.

INTRODUCTION: At the end of the nineteenth century, three prominent German surgical journals (i.e., "Deutsche Zeitschrift für Chirurgie," "Bruns' Beiträge," and "Langenbeck's Archiv für Klinische Chirurgie") dominated the surgical academic scene in Germany. While written exclusively in German, these publications were widely read in Germany as well as abroad. Today, only the oldest of these journals, Langenbeck's Archiv, remains. In 1913, the "Zentralorgan für die gesamte Chirurgie" was instituted in Germany as a separate publication specifically dedicated to improve the communication of foreign scientific contributions. However, on a number of occasions, landmark papers from outside the country were not fully appreciated by the German readership, just as nowadays, key surgical papers published in German are only infrequently acknowledged in the Anglo-American scientific literature. At all times, innovative scientific works had a difficult time finding open ears and minds if they challenged long-held academic preconceptions. It appeared hard to question dogmas that readers had believed to be true for so long. After 1945, German surgery found itself eclipsed in many areas by new developments in the anglophone surgical communities since the academic exchange of ideas had been largely curtailed for more than a decade. English-speaking surgeons were more numerous, and the flow of communication became easier and more and more rapid. CONCLUSION: Over time, the entire field of surgery in Germany began to emulate what had proven so effective in the English-speaking world. Langenbeck's Archiv is now published in English.

[PET-CT studies of metastasizing cancer of the colon and rectum. Variability of tumor aggressiveness as a micro-evolutionary process of cancer stem cells with predetermined prognosis]. / PET-CT-Untersuchungen zur Stammzellkarzinogenese im Kolorektalbereich. Malignitätsvariabilität als mikroevolutionärer Prozess mit festgelegter Prognose.

Formation of cancer stem cells which are both rare and variably therapy-resistant marks the beginning of a new disease without precursors. Based on molecular changes, these cells are derived from normal cells and exhibit pre-programmed malignant behaviour. In vitro studies have shown that hybrid cancers which behave in a similar way to Dukes A, B or C cancers in vivo can be produce by horizontal gene transfer. The level of aggressiveness follows a Galton curve in the probability distribution. In the current paper we analyzed colorectal cancers by PET-CT in follow-up studies which extended over several years. We conclude that the primary tumors behave differently from distant metastases. Radical exstirpation of the primary tumor is able to cure the malignant process if the homing area is resected. The primary tumor acts as the supplier of cancer stem cells for metastases which appear in different organs. When chemotherapy is administered the distribution of metastases in different organs appears dependent of the response or non-response of cancer stem cells to this therapy. Large numbers of colorectal carcinomas existed for the same time duration before death (15 years) independent of the malignancy grade. The tumor metastasizes immediately after formation. The primary tumor and the metastases appear variably quickly depending on the malignancy grade and are autonomic processes.

[Regional growth preferences in hereditary, synchronous, and metachronous colorectal carcinomas. Basics of tumor surgery Part II]. / Homingareale bei erblichen, synchronen und metachronen Rektokolonkrebsen. Grundlage schonender Tumorchirurgie Teil II.

This article discusses the therapeutic importance of the loss of self-regulation of cell division in polypoid adenomas and in the cloacogenic, cancerophilic rectal segment. Regional growth preferences can observed in familial adenomatous polyposis (FAP) and ulcerative colitis, as in other diseases featuring a cancerous disposition on the mucosa. For example, rectal carcinomas are more common than colon carcinomas if one considers the total mucosal surface area at risk. Malignant changes do not occur randomly in existing adenomas of FAP patients, and the adenomas' cell division--as in other adenomas--is governed by some degree of self-regulation. In FAP patients undergoing proctocolectomy, preferred new growth areas for carcinomas include the duodenum and ileum. In patients with synchronous colorectal cancers, the rectum is more commonly affected than other colon segments. If the rectum is resected, metachronous carcinomas are exceedingly rare in the remaining colon segments. Clinical decisions about rectal resection must be informed by understanding of the importance of this organ for anorectal continence as well as the described growth of colorectal malignancies.

[Autoregulatory growth control of adenomatous polyps and carcinogenesis in the colorectal region. Basics of tumor surgery Part I]. / Zellvermehrungsselbstkontrolle der polypösen Adenome und Karzinogenese in der Kolorektalregion. Grundlage schonender Tumorchirurgie Teil I.

Autoregulatory growth control of adenomatous polyps in the colon and rectum is an important factor in the success of sphincter-sparing surgical resections. It is the basis for the coexistence of billions of somatic cells in multicellular organisms. Similar to normal mucosa, adenomatous polyps in the colorectum show autoregulatory growth control in their tissues. This applies whether they are differentiated or undifferentiated. In most cases, their growth and expansion is controlled throughout life. While colorectal adenomas have malignant potential, their transformation to cancerous lesions is exceedingly rare (e.g., in familial polyposis, or FAP, with a prevalence of only one in 10,000). It has been hypothesized that "fully developed adenomas" frequently are a prestage of colorectal cancer. However, convincing evidence on a molecular level that this so-called adenoma-carcinoma sequence indeed occurs in vivo is lacking. In contrast, there is good evidence that colorectal carcinogenesis is a microevolutionary process and that the irrevocable loss of autoregulatory growth control is one of its features. The most prominent homing area for colorectal cancer is the rectum. If the rectum is resected, metachronous cancer occurs only very rarely. The most distal quarter of the rectum is cloacal in origin and a pivotal structure for anorectal continence. It should be preserved whenever a more proximal location of the tumor makes this possible. These conclusions are based on our extensive case series and observations extending over several decades.

[Imaging, anatomic, and surgical considerations for rectal organs and function following radical resection of a rectal carcinoma]. / Unteres, kloakogenes Rektumviertel. Anatomie und chirurgische Bedeutung für Mastdarmvorfall, Inkontinenz, Rektozele und Radikaloperation beim Rektumkarzinom.

The distal quarter of the rectum is derived from the cloaca and can be viewed as a specialized "sensory organ". Only the proximal three quarters of the rectum stem phylogenetically from intestinal tissues. Therefore, only this upper portion has an associated mesorectum. A significant amount of data support the notion that profound differences exist between the enterogenic, upper segments and the cloacogenic, lower segment of the rectum: 1. differing supply with blood and lymph vessels, 2. embryologic and comparative anatomic findings, 3. the central support system provided by Denonvilliers' fascia, 4. specialized innervation, 5. malformations of the continence organ, 6. findings on magnetic resonance images and histologic macro sections, 7. findings on PET-CT images, 8. the muscular wall architecture of different portions of the rectum, 9. differences in basic function (storage vs continence), 10. location of most postoperative local recurrences of rectal carcinomas, even when complete mesorectal resection was performed, since hundred years.