Oesophageal squamous cell neoplasia in head and neck cancer patients: upregulation of COX-2 during carcinogenesis.

Patients with (previous) head and neck cancer (HNC) are at high risk for developing second squamous cell cancer of the oesophagus. The role of cyclooxygenase-2 (COX-2) in oesophageal squamous carcinogenesis has not yet been investigated in this high-risk group. Therefore, this study examined COX-2 mRNA and protein expression in oesophageal biopsies and resected tissues of 44 HNC patients. The evaluation covered 55 oesophageal tissue samples (18 invasive oesophageal squamous cell cancers, four high- and eight low-grade dysplasias, 25 normal squamous epithelia) from the 44 patients. mRNA levels of COX-2 were measured by real-time PCR using a LightCycler. COX-2 protein expression was studied immunohistochemically and graded by a staining score. COX-2 mRNA was detected in all samples, and its levels correlated positively with the immunohistochemical staining score (P<0.05). COX-2 expression was upregulated during oesophageal squamous carcinogenesis in HNC patients, that is COX-2 expression increased significantly from normal oesophageal squamous epithelium to low- and high-grade dysplasia and finally to invasive squamous cell cancer (P<0.001). Our findings suggest that COX-2 upregulation contributes to oesophageal squamous carcinogenesis in HNC patients. Prospective studies are needed to evaluate the chemopreventive potential of COX-2 inhibitors in this high-risk group.

[Current epidemiology of carcinoma of the esophagus and cardia in Germany]. / Aktuelle Epidemiologie des Osophaguskarzinoms und des Kardiakarzinoms in Deutschland.

BACKGROUND AND OBJECTIVE: In the past 20-30 years the incidence of adenocarcinoma (AC) of the esophagus and the cardia has risen in western countries, while that of squamous cell carcinoma (SC) of the esophagus has largely stayed constant. Current data in the epidemiology of these cancers in Germany were analysed. METHODS AND MATERIAL: The data of the epidemiological cancer register of the Saarland (Old State of former West Germany) and the combined registers of the New States of Germany (former East Germany) and Berlin were collected. Because of the excellent registration procedures, data from the Saarland and the New States, Mecklenburg-Pommern, Brandenburg and Saxony were selected for this study. The incidence was calculated and corrected for age in relation to the world population. RESULTS: The incidence of esophageal AC among males in the Saarland rose from 0.22 per 100 000 population to 1.17 between 1986 to 1997, an increase of 432%, while in Brandenburg, Mecklenburg-Vorpommern and Saxomy it rose, between 1977 and 1998, from 0.23 to 0.8 i.e. by 248%. Esophageal SC incidence remained largely constant in both cancer registers since 1986. In 1998 it was 3.31 in the three New States of Germany and 5.05 in the Saarland. In females the incidence was markedly lower. In 1996-1998 fewer than 10% of cases of esophageal cancer were in UICC stage 1 (T 1 N 0 M 0, early carcinoma). Correspondingly the 5-year survival of all patients with esophageal carcinoma in the Saarland was less than 10% in 1971-1995. AC of the cardia also increased. In the three New States of Germany the incidence among males rose from 1.27 in 1977 to 2.18 in 1998, in females from 0.4 to 0.58. During the same period malignant tumors of the entire stomach, including the cardia, decreased in males from 29.5 to 17.1, in females from 14.3 to 9.2. CONCLUSION: In Germany, during the past 15-20 years, the incidence of esophageal AC and presumably also of AC of the cardia has increased. But the incidence of squamous cell carcinoma of the esophagus has remained largely constant. The proportion of early carcinoma and the 5-year survival with esophageal carcinoma remains under 10%.

Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1336 consecutive cases at a single center.

BACKGROUND: We compare the use of unilateral and simultaneous bilateral laparoscopic hernioplasty [transabdominal preperitoneal patch (TAPP)] METHOD: We employed a prospective consecutive single-center trial lasting from April 1993 to December 2000. RESULTS: In our study, 5524 consecutive patients underwent 6860 laparoscopic hernia repairs. The median age in group A (unilateral repair, n = 4188) was 58 years (16-94 years), and that in group B (simultaneous bilateral repair, n = 1336) was 60 years (19-97 years) in (simultaneous bilateral repair, n = 1336). Morbidity in group A was 3.2% (135/4188) with a 0.6% reoperation rate (24/4188); in group B morbidity was 5.0% (67/1336) with a 1.4% reoperation rate. (19/1336). Morbidity and reoperation rates showed no statistically significant difference between the two groups in relation to number of repairs in group B. After a median 24-month clinical follow-up period (1-84 months) (follow-up rate 93.1%) 38 recurrences were observed in group A (0.9%) and 17 in group B (0.6%; 17/2672) (p = 0.2668). Median time off work was 14 days after unilateral (2-63 days) and 17 days after bilateral repair (3-100 days) (p = 0.1359). Pain levels (numerical analogue scale) and incidence of persistent inguinal and scrotal pain are not higher after bilateral repair. CONCLUSION: Compared to unilateral repair, bilateral simultaneous laparoscopic hernia repair (TAPP) is safe, comfortable for patients, and cost-effective, without increased morbidity or recurrence risk. Bilateral inguinal hernia is an ideal indication for endoscopic transabdominal repair.

Screening for oesophageal neoplasia in patients with head and neck cancer.

Due to advanced disease at the time of diagnosis the prognosis of oesophageal cancer is generally poor. As mass screening for oesophageal cancer is neither feasible nor reasonable, high-risk groups should be identified and surveilled. The aim of this study was to define the risk of oesophageal cancer in patients with (previous) head and neck cancer. A total of 148 patients with (previous) head and neck cancer were prospectively screened for oesophageal cancer by video-oesophagoscopy and random oesophageal biopsies. Even in a macroscopically normal looking oesophagus, four biopsy specimens were taken every 3 cm throughout the entire length of the squamous oesophagus. Low- or high-grade squamous cell dysplasia was detected histologically in 10 of the 148 patients (6.8%). All but one dysplasias were diagnosed synchronously with the head and neck cancers. In addition, oesophageal squamous cell carcinoma was diagnosed in 11 of the 148 patients (7.4%). Most invasive cancers (63.6%) occurred metachronously. The risk of squamous cell neoplasia of the oesophagus is high in patients with (previous) head and neck cancer. Surveillance is recommended in this high-risk group.

Long-term results of a randomized clinical trial between laparoscopic hernioplasty and shouldice repair.

BACKGROUND: At present only short-term follow-up data are available to compare endoscopic and conventional hernia surgery. This paper presents data from a randomized study 6 years after initial recruitment. METHODS: In 1993 a randomized comparative study of transabdominal preperitoneal (TAPP) and Shouldice repair was commenced. Endpoints were rate of recurrence, late complications, complaints and patient satisfaction. RESULTS: The rate of recurrence in the TAPP group was one (2 per cent) of 48 patients and in the Shouldice group two (5 per cent) of 43. Only five patients in the Shouldice and three in the TAPP group reported slight discomfort in the inguinal region at 6-year follow-up. In neither group was chronic pain syndrome observed. Altogether, 46 (96 per cent) of 48 patients in the TAPP group and 35 (81 per cent) of 43 of those having the Shouldice procedure stated complete satisfaction with the hernia repair. CONCLUSION: Long-term evaluation demonstrated greater satisfaction with the result of the repair in the endoscopic group. The difference between the groups in the recurrence rate was not significant, because of the small numbers. The TAPP method appears to be an effective surgical alternative in patients with inguinal hernia.

A single institution's experience with transperitoneal laparoscopic hernia repair.

BACKGROUND: Previous evaluations of endoscopic hernia surgery mostly are based on small prospectively documented series or on a few randomized comparative studies. In the following, results of a large single-institution experience concerning the transabdominal preperitoneal patch (TAPP) technique with regard to the development of methods and the routine use are described. METHODS: From April 1993 to March 1997, 2,700 TAPP procedures were performed at the Department of General and Visceral Surgery, Marien-hospital, Stuttgart, Germany. The follow-up was documented prospectively in all cases by use of computed data base. RESULTS: The majority of patients (83.8%) were operated because of primary hernias. In 17.2% a first or multiple recurrence of an inguinal hernia was indicated. At a median postoperative observation period of presently 20 months and a follow-up rate of 86.5%, 28 recurrences have been determined so far (total recurrence rate 1.03%), 6 of which occurred after a recurrent hernia reparation (1.33%) and 22 after primary hernia repair (0.97%). The most common cause for recurrence was in 39.3% a mesh (12 x 8 cm) being too small. The total complication rate was 4.6%; as an expression of the learning curve it was reduced from 7.8% (operations 1 to 500) to 2.8% (operations 2,200 to 2,700). CONCLUSIONS: According to our experience, the TAPP technique is sufficiently applicable as a standard method for an unselected group of patients in a routine setting. It is especially suited to the repair of recurrent and bilateral hernias as well as for patients with a high risk for recurrence that can profit from a tension-free endoscopic procedure, particularly in case of obesity.

[Endoscopic hernia surgery (TAPP)--gold standard in management of recurrent hernias?]. / Endoskopische Hernienchirurgie (TAPP)--Goldstandard in der Versorgung von Rezidivhernien?

From April 1993 to December 1995 210 TAPP procedures were performed because of recurrent hernia. With the TAPP method there is no difference between primary and recurrent repair. All procedures in this study were done with general anaesthesia by senior surgeons. The learning curve shows a reduction of operation time (60 to 55 min) with increasing experience and a reduction in complications as well (total 4.3%). Recurrence was observed in two cases. The reasons for these recurrences were technical failures during the previous repair. In both cases a second TAPP repair was carried out successfully. The main advantage of TAPP in recurrent hernia is that this method gives possibilities to avoid anterior scar tissue. Secondly tension-free repair can be combined with the benefit of the minimal access technique. For this reason, the TAPP procedure must be considered the method of choice in recurrent hernia repair.

[Laparoscopic hernioplasty (TAPP)--complications and recurrences in 900 operations]. / Die laparoskopische Hernioplastik (TAPP)--Komplikationen und Rezidive bei 900 Operationen.

A prospective study of 900 patients with inguinal hernia who underwent transabdominal preperitoneal laparoscopic hernia repair (TAPP) was performed. The median operation time was 50 minutes (range 20-155); overall 44 complications (4.8%) were recorded. 8 patients (0.9%) required reoperation, in 6 cases because of postoperative bleeding or haematoma formation respectively, in one case because of testicular tenderness and in one case because of a mesh infection. Now, with the maximum follow-up of 26 months, 12 recurrences have been noted, giving a 1.33% recurrence rate. Return to work was 21 days (range 4-47 days). One year postoperatively about 83% of patients were without any complaints. A strict correlation between the complication and recurrence rate and the learning curve was found. It is concluded, that laparoscopic hernia repair (TAPP) is a safe and effective procedure. Complications and hernia recurrences diminish with experience.

[Standardized laparoscopic hernioplasty vs. Shouldice repair. Results of a randomized comparative study]. / Standardisierte laparoskopische Hernioplastik vs. Shouldice-Reparation. Ergebnisse einer randomisierten Vergleichsstudie.

From 5/93 up to 12/93 a prospective randomized trial was performed. 102 patients with unilateral primary inguinal hernias were included. In 48 patients a Shouldice repair and in 54 patients a laparoscopic TAPP procedure was performed. The laparoscopic method is described. There were significantly less pain and quicker mobility in the laparoscopic group. In addition a shorter period of disability of work was seen (21 vs. 38 days) in the same group. The morbidity of the procedures was as low in the Shouldice as in the laparoscopic group. There was a regular control of all patients. The current follow-up period is 16 months (13-21) in median. In both groups there were no recurrences up to now. The efficiency of laparoscopic hernia repair is discussed.