[Indications and results of sacral nerve stimulation in faecal incontinence]. / Indikationen und ergebnisse der sakralnervenstimulation bei stuhlinkontinenz.

BACKGROUND: Sacral nerve stimulation (SNS) is an effective and less invasive treatment of faecal incontinence (FI). Patient selection has evolved from strict criteria to a more liberal approach, since temporary testing reliably predicts the efficacy of permanent stimulation in FI of various aetiologies. PATIENTS AND METHODS: From November 2005 until June 2007, we evaluated 20 consecutive patients (17 females, 3 males) with FI by percutaneous nerve evaluation (PNE), i. e., temporary stimulation. 13 patients proceeded to a permanent implantation of a pulse generator (3 bilateral generators). 11 patients with permanent stimulation were eligible for a minimum follow-up of 3 months. Median follow-up for this group was 10 (range 3-19) months. All patients provided bowel diaries, the disease-specific quality of life questionnaire of the American Society of Colon and Rectal Surgeons (ASCRS), and the Standard Short Form Health Survey Questionnaire (SF-36) at baseline, screening and at the follow-up. RESULTS: The aetiologies of the FI were pelvic floor insufficiency (n = 12), history of anterior resection (n = 3), history of surgery for disk prolaps (n = 2), sphincter disruption (n = 1), history of surgery for recto-vaginal fistula (n = 1), and idiopathic (n = 1). The mean number of incontinence episodes dropped from 9.9 to 1.3 during temporary testing (p = 0.02) and to 4.5 at last follow-up (p = 0.043). The quality of life assessment showed a significant improvement in the subscale embarrassment of the ASCRS (p = 0.043). There were 2 minor postoperative complications, and 1 medium-term failure of SNS treatment. CONCLUSION: SNS is a minimally invasive and effective treatment of FI. A pragmatic approach is justified due to the possibility of temporary testing and the low rate of complications.

Short-term results of Karydakis flap for pilonidal sinus disease.

BACKGROUND: Because of the higher quality of life that the Karydakis flap provides compared to excision-only treatment, it became a recommended closure technique for pilonidal sinus disease. This study aimed to evaluate whether Karydakis flap technique can be performed in potentially infected tissue if the surrounding cellulitis allows wound closure. METHODS: 188 patients with pilonidal sinus who underwent excision only (n=91, 48%) or the Karydakis-flap technique (n=97, 52%) were evaluated. The results were reviewed according to the degree of wound contamination, and the effects of closure technique were studied in terms of early wound complications and the duration of hospital stay. RESULTS: In the excision-only group, one patient developed a hematoma (1%) and one patient had cellulitis of the surrounding tissue (1%), which resulted in a 2% complication rate this group. In the Karydakis flap group, wound abscesses were observed in 12 patients (12%). Additionally, four patients (4%) had hematomas, two patients had seromas (2%) and three had other complications. For the Karydakis group, the overall complication rate was 21%, significantly higher than that for the excision-only group (p<0.01). In the Karydakis group, no association was found between complications and the degree of contamination (p=0.36). CONCLUSIONS: These data provide evidence that the Karydakis flap technique might be performed even in potentially infected tissue. Although a considerable number of wound-related complications was observed in the Karydakis flap group, the majority of patients had primary healing. Thus, from our viewpoint, the Karydakis flap seems to be a potential alternative to simple excision in infected pilonidal sinus disease.

Stapled transanal rectal resection under laparoscopic surveillance for rectocele and concomitant enterocele.

PURPOSE: Stapled transanal rectal resection recently became a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential threat to structures located in front of the anterior rectal wall. We decided to perform a combined procedure of transanal rectal resection with a simultaneous laparoscopy for patients with obstructed defecation syndrome and an enterocele. METHODS: Between November 2002 and May 2005 a total of 41 patients were treated surgically for obstructed defecation syndrome. Four patients with concomitant enterocele underwent stapled transanal rectal resection under laparoscopic surveillance. Before surgery all patients underwent preoperative assessment, including clinical examination, colonoscopy, conventional video defecography, dynamic magnetic resonance imaging defecography, gynecology examinations, and psychologic evaluation. RESULTS: The mean operative time was 50 (+/-16.5) minutes for the conventional stapled transanal rectal resection and 67 (+/-14.1) minutes for combined laparoscopy and stapled transanal rectal resection (P < 0.01). Three major complications were observed: two had bleeding in the staple line (one from each group) and one had a late abscess in the staple line. CONCLUSIONS: The combination of the stapled transanal rectal resection procedure and laparoscopy provides the opportunity to perform transanal rectal resection without the threat of intra-abdominal lesions caused by enterocele.

Severe intra-abdominal bleeding following stapled mucosectomy due to enterocele: report of a case.

Stapled rectal mucosectomy (SRM) became a widely accepted surgical procedure for haemorrhoids. One of the rare complications is severe bleeding. We report the case of a patient who underwent SRM for thirddegree haemorrhoids. In addition, he suffered symptoms of outlet obstruction, although defecography showed no serious disease. One day after SRM, the patient complained of abdominal pain and peritonitis. Computed tomography revealed blood in the abdomen. The patient underwent laparotomy, which revealed a deep enterocele that reached down to the level of the sphincteric muscle. The ventral part of the stapled ring was placed intraperitoneally, and a longitudinal defect of the rectal serosa was observed. The serosa defect was sutured and a diverting sigmoid stoma was carried out. The patient left the hospital 10 days later. We emphasize vigilance for undetected enteroceles in mucosal prolapse syndrome combined with defecation problems.

[Perioperative risk assessment in surgery - an analysis in 10 395 patients]. / Perioperative Risikoeinschätzung in der Chirurgie - eine Analyse bei 10 395 Patienten.

UNLABELLED: The aim of this study was to perform a risk analysis on the basis of routinely documented variables (age, sex, ASA-classification, priority of operation, malignant disease, intraperitoneal or intrathoracic operation and duration of operation) to identify surgical patients who benefit from a more complex risk assessment. PATIENTS AND METHODS: In a prospective observational trial we analysed a consecutive series of 10 395 patients who were operated on in our General Surgical Department from January 1996 until December 2000 in respect to in-hospital mortality. The variables were examined in univariate tests. Factors with significant impact were subsequently included in a multiple logistic regression analysis. This was done for all variables and afterwards for each ASA-class separately. Predictive accuracy of the prediction model was calculated by the area under a receiver operating characteristic curve (AUC (ROC)). RESULTS: The overall mortality was 3.9 %. For ASA-classes 2 to 4 we were able to establish a prediction model by means of multiple logistic regression that identified ASA-classification (Odds Ratio [OR ] ASA-class 3 = 3.7; OR ASA-class 4 = 22.4), age (OR 1.019 per year), duration of operation (OR for duration > or = 240 min = 2.25), intraperitoneal/intrathoracic operation (OR = 4.6), emergency operation (OR = 3.1), and malignant disease (OR = 1.5) as independent predictive factors. Both risk group 1 and risk group 5 were excluded from the analysis because there was no mortality in risk group 1 and too few patients in risk group 5. We found an AUC (ROC) of 91.6 % for the considered ASA-classes. CONCLUSION: The ASA-classification is a good instrument for the assessment of perioperative mortality. Its predictive power can substantially be improved in the classes 2 to 4 by the variables age, duration of operation, intraperitoneal or intrathoracic operation, priority of operation, and malignant disease.

[Experiences with reconstruction of large abdominal wall cicatricial hernias using Stoppa-Rives pre-peritoneal mesh-plasty]. / Erfahrungen mit der Rekonstruktion grosser Bauchwandnarbenhernien mittels präperitonealer Netzplastik nach Stoppa-Rives.

BACKGROUND: The observed recurrence-rate up to 20-50% of conventional incisional-hernia repair might be improved by alloplastic hernia repair in "sublay-technique" described by Stoppa and Rives. METHODS: From 12/94 to 12/97 122 pt. underwent surgery of incisional hernia of whom 50 had a very large abdominal wall defect so that hernia repair by alloplastic technique was necessary. All 50 pt. had mesh-implantation in subfascial plane, 28 pt. by ePTFE-patch (Gore-Tex) and 22 pt. by polypropylen-mesh (Prolene). RESULTS: The implantation-procedure required a mean time of 165 min. (range 55-345 min.). There were pulmonary complications in 2 patients (4%) of whom one had to be ventilated over 34 days, prosthesis-infection occurred in 3 pt. (6%). Follow-up on average 19 months (range 5-44 months) postoperatively revealed 5 hernia-recurrences (10.4%) in 48 patients. CONCLUSION: Mesh-implantation for hernia repair in sublay-technique requires intensive preparation of preperitoneal plane. Thus it took approximately 3 hours for mesh-implantation in this study. From our data Stoppa-Rives-procedure seems to be effective for 4-repair of large incisional hernias and allows immediate abdominal wall stress.

[Sugerbaker technique in para-colostomy hernia. An analysis of personal experiences]. / Die Versorgung der Parakolostomiehernie nach Sugarbaker. Eine Analyse eigener Erfahrungen.

Paracolostomy hernias represent the most common complication after colostomy surgery occurring in approximately 30% of all patients. The need for operation, however, emerges in only 20% of the hernias becoming symptomatic with pain, difficulties in stoma care, bowel obstruction and cosmetic problems. Due to their often huge size the repair is technically difficult and frequently accompanied by complications and recurrence. The method of intraperitoneal mesh repair and lateralisation of the colon presented by Sugarbaker 1980 offers not only the advantages of sufficient strengthening of the ventral abdominal wall even in big hernias and of an aseptic technique but also the chance of simultaneous treatment of other hernias. We present 9 patients with large paracolostomy hernias operated on according to Sugarbaker. In three patients we delt with a recurrence of a paracolostomy hernia. Three patients suffered additionally from an incisional hernia, one from an umbilical hernia and another one from an inguinal hernia. The hernial orifice was usually closed with a 30 x 20 cm Gore patch. All patients (6 males, 3 females, median age 63 years) tolerated the operation well which lasted as a mean 240 min. In the follow-up we saw two recurrences one of them being small, asymptomatic and without tendency to enlargement. In conclusion we can say that a considerable improvement was achieved in 89% of our patients after surgery performed in the herein presented way. We esteem this method a good option in a situation with otherwise poor alternatives.

[Delayed toxicity of brief preoperative irradiation and risk-adjusted postoperative radiotherapy of operative rectal carcinoma. Results of a randomized prospective study]. / Spättoxizität nach präoperativer Kurzzeitvorbestrahlung und risikoadaptierter postoperativer Nachbestrahlung bei operablem Rektumkarzinom. Resultate einer randomisierten prospektiven Studie.

AIM: Analysis of a randomized study of preoperative radiation therapy for operable carcinoma of the rectum with regard to late sequelae. Results of tumor control and survival, which have already been published in detail are summarized for comparison and for confirmation of the conclusions. PATIENTS AND METHODS: Between January 1988 and October 1993 94 patients with operable carcinoma of the rectum were included in a randomized trial. Fourty-seven patients were treated with 5 x 3.3 Gy (field size 16 x 16 cm, 9 MeV photons) 24 to 48 hours prior to surgery; 46 patients did not receive preoperative irradiation. If risk factors (T4-stage, R1/R2 resection, intraoperative tumor perforation) were present, postoperative irradiation was performed after CT-planning. Total postoperative doses of 41.4 Gy (preoperative irradiation) or 59.8 Gy (surgery only) were applied with doses per fraction of 1.8 to 2.0 Gy. Local control, survival, and pattern of side effects were analyzed at 5 years after conclusion of the trial. RESULTS: The frequency of local recurrence was markedly reduced by preoperative irradiation of R0-resected patients (24% vs 13%, p = 0.08). The time to recurrence was delayed (1.9 vs 3 years). The 5-year actuarial survival rate was significantly higher in the preoperatively irradiated group compared to the not pre-irradiated group (40% vs 28%, p = 0.027). Multivariate analysis revealed UICC-grading as the only independent parameter for local control (p = 0.0003), while preoperative irradiation (p = 0.07) and T-stage (p = 0.08) only displayed a trend. For patient survival, age (p = 0.0003). R-status (p = 0.01) and UICC-score (p = 0.001) were significant prognostic factors. Preoperative irradiation had a non-significant effect only (p = 0.078). Radiation-induced side effects with a LENT-SOMA score > 2 were observed neither during frequent follow-up nor at an additional examination of those patients still alive in 1998 (n = 25). Of 4 pre- and postoperatively irradiated patients with risk factors, 3 had side effects grade 1 or 2, predominantly rectal changes, at 5 to 11 years after treatment. CONCLUSIONS: A positive effect on tumor control and survival is achieved with preoperative irradiation with the doses used in this study, with moderate side effects.

Anastomotic leakage: impact on local recurrence and survival in surgery of colorectal cancer.

Anastomotic leakage is a serious complication in colorectal surgery, especially in the treatment of adenocarcinoma located in the left-sided colon and rectum. It is controversial whether anastomotic leakage is a prognostic factor for local recurrence and/or survival in this disease. To evaluate the impact of anastomotic dehiscence on the outcome of surgery we reviewed data on 467 consecutive patients with adenocarcinoma of the left colon and rectum treated between 1985 and 1995 in our Department. Of these, 41 (8.8%) developed anastomotic leakage. The overall-survival differed nonsignificantly (P = 0.57) between leakage and nonleakage groups. Of 331 patients with curative resection 29 showed an anastomotic leakage. There were 46 R0-resected patients who died under disease-related conditions: 7 patients in the leakage group (24.1%) and 39 in the nonleakage group (12.9%; P = 0.045). In the curatively resected group 5 of 29 patients developed local recurrence in the leakage group (17.2%) but only 26 of 302 patients in the nonleakage group (8.6%; P = 0.0357). Multivariate analysis showed only the factors of age, stage of resection, staging of lymph nodes, and tumor staging as independent prognostic factors for overall survival. For local recurrence the multivariate analysis revealed tumor staging and anastomotic leakage as independently significant. Anastomotic leakage thus appears to be a prognostic factor for local tumor recurrence of colorectal cancer. In addition, disease-related survival is considerably decreased under leakage conditions. Anastomotic leakage was not shown in this study to be an independent prognostic factor for overall survival due to the lack of statistical significance.

[Brief preoperative radiotherapy in surgical therapy of rectal carcinoma. Long-term results of a prospective randomized study]. / Präoperative Kurzzeitstrahlentherapie in der chirurgischen Therapie des Rectumcarcinoms. Langzeitergebnisse einer prospektiv-randomisierten Studie.

To ascertain whether preoperative short-term radiotherapy can improve local tumor control and the long-term survival of patients with operable rectal cancer, a prospective randomised trial was performed from 1988 to 1993. Ninety-three patients with rectal cancer were either directly treated with surgery (n = 46) or underwent preoperative radiotherapy with 5 x 3.3 Gy irradiation and operation within 48 h (n = 47). If indicated (T4, UICC stage III) patients also received postoperative irradiation. Comparison of the methods of operation (abdominoperineal amputation versus anterior resection) revealed no significant difference in 5-year survival rate (P = 0.393). Local control of R0-resected tumors was improved after preoperative irradiation (P = 0.08). The 5-year survival rate was significantly higher after preoperative short-term radiotherapy (P = 0.027). Preoperative radiotherapy is not an independent factor according to overall survival (P = 0.078) and local recurrence (P = 0.07). In agreement with the results of other authors the present study indicates improved local tumor control of rectal cancer after preoperative radiation therapy. The 5-year survival rate was significantly better after preoperative radiotherapy than after surgery alone.

[Gallbladder carcinoma--an unexpected finding after laparoscopic cholecystectomy]. / Das Gallenblasenkarzinom--ein unerwarteter Befund nach laparoskopischer Cholezystektomie.

The carcinoma of the gallbladder can be found mostly in a late stage. We have to expect a incidental carcinoma of the gallbladder in 1-2% after conventional cholecystectomy. We report 9 cases of unexpected carcinoma of the gallbladder after 1700 laparoscopic cholecystectomies. The time of survival were--dependent on tumor stage--2 to 36 month. We outline special items of this disease within the context of minimal-invasiv surgery.

[Incidental gallbladder carcinoma--a report of experiences after 1,200 laparoscopic cholecystectomies]. / Das unerwartete Gallenblasenkarzinom--ein Erfahrungsbericht nach 1200 laparoskopischen Cholezystektomien.

Incidental carcinoma of the gallbladder can be found histologically in 1-2% of specimens after surgery of benign diseases of the hepatobiliary tract. We present our results of 7 cases of incidental gallbladder carcinoma in 1200 laparoscopic cholecystectomies. Surgical treatment and clinical outcome are reported. We tried to outline special items of this disease within the context of minimal-invasive surgery.