[Prevention and early detection of colorectal cancer]. / Kolonkarzinom--Prävention.

With 60000 new cases and approximately 31000 deaths annually the colorectal carcinoma is the second most frequent cause of death due to a tumour in Germany. In over 90% of all colorectal carcinomas the precursors (adenomas) are well known. Moreover the early carcinoma of the colorectum (pT1-carcinoma) has an exceptional benign prognosis. To detect those precursors and early stages effective methods of primary, secondary and tertiary prevention are available.

[Gastroenterology in the G-DRG-System 2004]. / Gastroenterologie im G-DRG-System 2004.

After a year of preliminary voluntarily introduction of casemix funding in hospitals in 2003 nearly every German hospital will be confronted with lump sump payments on the basis of the G-DRG system for their inpatient care starting from January 2004. To analyse weaknesses referring to gastroenterology services within the G-DRG version 1.0 the German Association for Disorders of the Digestive System and Metabolism (DGVS) and the DRG-Research-Group from the University of Muenster conducted a DRG evaluation project. In the analysis patient data from 16 hospitals were included. As a result of the project recommendations for G-DRG adjustments were generated. Those recommendations were implemented in the advancement to G-DRG version 2004. Also the International Classification of Diseases (ICD-10) was modified to ICD-10 German Modification. The classification of procedures OPS-301 was revised. The main adjustments to the G-DRG system and both classifications will be presented in this paper.

[Endoscopic Therapy of Early Colorectal Cancer (pT1) - A Prospective Study]. / Prospektive Studie zur endoskopischen Therapie des kolorektalen pT1-Karzinoms.

INTRODUCTION: In a prospective study initiated in 1982, we have been investigating the question as to whether - and if so, which - pT1 carcinomas of the colorectum can be treated exclusively via the endoscope. METHOD: In the period between February 1, 1982 and April 30, 2001, a total of 5,470 polyps were removed endoscopically at the Medical Department I of the Klinikum Ludwigsburg. Among these lesions, a total of 144 (2.6 %) pT1 carcinomas were found in 141 patients. We were able to follow 120 patients with 123 pT1 carcinomas over a mean follow-up period of 46 months (range: 1-60). In low-risk situations (definitive removal in healthy tissue, G1-G2, no lymphatic involvement), endoscopic treatment alone usually represented sufficient treatment. In high-risk cases (removal in healthy tissue uncertain or negative, and/or lymphatic vessel involvement, and/or G3/G4), subsequent surgical resection was carried out. RESULTS: 64 cases were classified as high-risk, 59 as low-risk. Nevertheless, 9 patients with 10 low-risk carcinomas were submitted to surgery (young age, patient's own request). In none of these 10 cases was residual tumour or lymph node metastasis detected in the surgical specimen. 47 patients with 49 low-risk carcinomas were treated solely by endoscopic polypectomy using the diathermy snare, and 45 patients with 47 carcinomas remained recurrence-free during the follow-up period. In a single case, a local recurrence was detected 2 months after polypectomy and underwent curative resection. In another case, peritoneal carcinosis with tumour infiltrating into the colon developed 8 months after initial treatment; this, however, was most probably a recurrence of a previously operated carcinoma of the uterus. Among the high-risk cases, 10 were not submitted to surgery on account of advanced age and/or rejection of an operation by the patient; all remained recurrence-free. Among the surgically treated high-risk carcinomas, 3 surgical specimens contained residual tumour, while 2 revealed a lymph node metastasis. In our group of patients, no tumour-related mortality was seen among endoscopically treated patients. DISCUSSION: In the light of the fact that the reported mortality rate associated with open surgery for colorectal carcinoma is 3 % as compared with about 1 % risk of lymph node metastasis and 0,1 % mortality rate for the endoscopic modality, endoscopic removal of a pT1 tumour in a low-risk situation followed by appropriate surveillance can be considered as adequate treatment.

[Congenital cystic dilatation of the cystic duct associated with an anomalous pancreaticobiliary ductal junction]. / Kongenitale zystische Dilatation des Ductus cysticus in Kombination mit einer Anomalie der pankreatikobiliären duktalen Junktion.

We report a case of congenital cystic dilatation of the cystic duct detected in a 40-year-old woman. She had intermittent pain in the right upper quadrant of the abdomen independent of the intake of meals for the last two years. In the ultrasound we found a cystic formation in the vicinity of the enlarged gallbladder, the common hepatic duct/common bile duct and the portal vein. The endoscopic retrograde cholangiography confirmed a cystic duct malformation, which was associated with an anomalous pancreaticobiliary ductal junction (APBDJ). A cholecystectomy with excision of the whole cystic duct and common bile duct and Roux-en-Y hepaticojejunostomy is indicated because there is an increased risk of the development of bile duct cancer and gallbladder cancer in the presence of biliary cystic duct anomalies and APBDJ.

Evaluation of a new three-dimensional magnetic imaging system for use during colonoscopy.

BACKGROUND AND STUDY AIMS: A prototype magnetic imaging system (Scope Guide, Olympus Optical Co., Ltd.) provides a new facility for continuous viewing on a monitor of the position of the colonoscope during examination, without exposing patients or medical staff to radiation. The aim of this prospective study was to compare this magnetic imaging system with routine colonoscopy, including fluoroscopy. The study parameters were the detection of loops, the location of the endoscope tip at defined positions, the insertion time, and the premedication rate. MATERIALS AND METHODS: In the first part of the study, 133 consecutive patients were examined - 64 using an integrated three-dimensional colonoscope and 69 with the three-dimensional probe inserted into the biopsy channel of a routine video colonoscope. Fluoroscopy was used in all investigations for comparison at defined anatomical points and loops, and pathological findings and defined anatomic structures were documented using a laser printer both for three-dimensional colonoscopy and fluoroscopy. In the second part of the study, 25 further patients underwent colonoscopy with a modified prototype, now exclusively using the integrated three-dimensional colonoscope. RESULTS: The total time for insertion and the premedication rate did not differ from those of routine colonoscopies with fluoroscopy available. Precise detection of loops was observed in the first study in 79 - 100 % of cases in comparison with fluoroscopy. Precise localization of the endoscopic tip improved from 30 % in the first part of the study to 80 % in part 2. CONCLUSION: Using magnetic three-dimensional imaging systems, the position of the colonoscope, the detection and observation of loops during straightening, and localization of pathological findings can be accurately achieved. Modification of the prototype led to satisfactory improvement in all parameters tested.

[Budesonide foam as a new therapeutic principle in distal ulcerative colitis in comparison with mesalazine enema. An open, controlled, randomized and prospective multicenter pilot study]. / Budesonid-Schaum als neues Therapieprinzip bei der distalen Colitis ulcerosa im Vergleich mit Mesalazin-Klysmen. Eine offene, kontrollierte, randomisierte und prospektive multizentrische Pilotstudie.

Budesonide is a locally acting steroid with a high first-pass metabolism in the liver and low systemic effects. We performed the first pilot study comparing budesonide foam (1 mg/50 ml b.i.d.) with mesalazine enemas (4 g/60 ml o.d.). 33 patients from 3 centres were enrolled in this open randomized clinical trial. 16 patients got budesonide foam and 17 got mesalazine enemas. The drugs were administered for 4 weeks. Histological index (HI) and endoscopic index (EI) were assessed at day 1 and day 28, clinical activity index (CAI) at day 1, 14 and 28. For patients with left-sided colitis and proctosigmoiditis improvement was defined as decrease in CAI of > or = 2 points. For patients with proctitis improvement was defined as decrease in HI of > or = 1 point. The primary efficacy evaluation was performed with the intention to treat population (n = 32). Improvement was found in 67% of the patients in the budesonide group compared to 71% in the mesalazine group. There was no statistically significant difference between the groups. Adverse events were mild and rare in both groups. Both treatments had no significant influence on plasma cortisol. In this pilot study for distal ulcerative colitis budesonide foam is as safe and effective as mesalazine enema.

[Removing adenomas reduces colon carcinoma risk up to 90%. Effective cancer prevention with the endoscope]. / Adenomentfernung reduziert Kolonkarzinom--Risiko um bis zu 90%. Effektive Krebsprävention mit dem Endoskop.

Endoscopic polypectomy is considered the method of choice for the diagnosis and treatment of colorectal polyps. 70-80% of all colorectal polyps are adenomas, which are precursors of colorectal carcinoma. The endoscopic detection and rigorous removal of colorectal polyps is an effective means of preventing colorectal carcinoma, since the incidence of the latter can be reduced by 90%. If technically possible, a snare should be used to remove all polyps larger than 5 mm in diameter. Tiny polyps may be removed with forceps. The removed polyp must be send for histological work-up and the results obtained used to plan the further steps or post-polypectomy surveillance. In defined cases (removal with adequate clearance, well-differentiated carcinoma, low risk situation), endoscopic polypectomy of adenomas with invasive carcinoma (pT1 carcinoma) is now the only treatment needed. Further surgical resection is not necessary. Surveillance is as for surgically removed colorectal carcinoma.

[Paranasal sinus mycetoma with orbital involvement in a patient with AIDS]. / Nasennebenhöhlenmyzetom mit Einbruch in die Orbita bei einem Patienten mit AIDS.

A patient with AIDS was hospitalized with a left-sided face swelling and protrusion of the bulbus. After cranial computed tomography and fine-needle aspiration biopsy of the fossa temporalis we diagnosed a mycetoma; localisation and histology made an aspergilloma most probable. Antimycotic therapy led to complete remission of the symptoms. Post mortem we only could culture Candida albicans out of the abscess cavity.