Surgical options for locally recurrent rectal cancer--review and update.

Locally recurrent rectal tumours in the pelvis are found in about 6% following treatment for rectal cancer. This type of tumour can cause serious local complications and symptoms. The aim of modern surgical oncology is to offer a curative treatment option embedded in an interdisciplinary network of specialities to the patient. Due to advancements in surgical techniques and procedures, especially regarding surgical reconstruction, the possibilities of a curative treatment regarding recurrent cancers have been expanded and established. To aim for a curative treatment one must introduce a multimodal therapy including radio- and chemotherapy, and a radical oncological surgery with en bloc resection of the tumour and affected surrounding organs to achieve a R0-resection.

[Plastic surgery of extended defects after exenteration of the pelvis]. / Plastische Deckung ausgedehnter Defekte nach exenterativen Eingriffen im Becken.

Extended resections of pelvic malignancies, especially in cases of recurrent malignancies, result in the formation of large tissue defects in the region of the pelvic floor and perineum, which are difficult to deal with. Both after extra levator rectal excision and pelvic exenteration, wound healing deficiencies and local infections of the perineal wound are frequent. Primary closure is often impossible due to a lack of tissue substance after resection and an additional previous radiotherapy in most cases. This can result in poor or non-healing wounds, a consecutive need of complex care and an increased risk of secondary problems including tumour recurrences. A permanent wound closure of good quality can therefore only be achieved by plastic surgery. This can be done by local or distant muscle flaps with or without skin, for example, the gluteus maximus flap, the vertical rectus abdominis muscle flap (VRAM) or free flaps such as the latissimus dorsi flap.

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery--the APAP trial (ISRCTN45810007).

PURPOSE: Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery. METHODS: Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5 days before until 5 days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30 days after surgery. RESULTS: A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints. CONCLUSIONS: Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

Leucocyte-depleted blood transfusion is an independent predictor of surgical morbidity in patients undergoing elective colon cancer surgery-a single-center analysis of 531 patients.

BACKGROUND: Leukocyte-depleted packed red blood cells (PRBC) were introduced to reduce potential immunomodulatory effects and transfusion-associated morbidity. It has, however, remained unclear, if leucocyte depletion prevents negative side effects of blood transfusion. The aim of this analysis was to examine the effects of leukocyte-depleted PRBC on surgical morbidity after elective colon cancer surgery. METHODS: Data were prospectively collected from 531 consecutive patients undergoing elective colon cancer surgery at a single high-volume center (University Hospital) from 2002 to 2008. Potentially predictive factors for surgical morbidity were tested on univariate and multivariate analysis. RESULTS: A total of 531 patients with colon cancer were included. A curative (R0) resection was performed in 497 patients (94%). The mortality rate, overall morbidity rate, and surgical morbidity rate were 1.1, 33, and 21%, respectively. Some 135 patients (25%) received perioperative transfusion of PRBCs. On multivariate analysis age (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02-1.06; P = 0.001), BMI (OR 1.08, 95% CI 1.03-1.13; P = 0.003), and PRBC transfusion (2.4, 1.41-4.11; P = 0.001) were revealed as independent predictors of surgical morbidity. The risk of surgical complications increased continuously with the amount of transfused PRBCs. The adverse impact of PRBC transfusion was neither restricted to the timepoint of transfusion (intraoperative or postoperative), nor to the kind of complication (infectious vs noninfectious complication). CONCLUSION: Perioperative transfusion of leukocyte-depleted PRBCs has a significantly negative effect on surgical morbidity of patients undergoing elective colon cancer surgery. The use of perioperative blood transfusions in these patients should be avoided, whenever possible.

Surgical treatment of sigmoid diverticulitis--analysis of predictive risk factors for postoperative infections, surgical complications, and mortality.

BACKGROUND AND AIMS: Sigmoid diverticular disease has great clinical importance due to its increasing incidence in the Western world and a broad spectrum of clinical features with potential fatal complications after surgery. The definition of risk factors associated with postoperative infections, surgical complications and mortality could be helpful in clinical decision-making and optimizing perioperative treatment. MATERIALS AND METHODS: Based on a prospective database, 168 consecutive patients undergoing surgery for sigmoid diverticulitis were included in this study. The association of different potential risk factors such as age, Hinchey classification, type and duration of operation, surgeons' experience, blood loss, comorbidities, and hospital course with perioperative complications and mortality were tested by univariate and multivariate analysis. RESULTS: Of the 168 patients enrolled in this study, there were 84 male and 84 female. A third of patients were operated as emergency cases (within 24 h after surgical evaluation); 62% underwent open surgery, 35% were treated laparoscopically with a conversion rate of 3%. A blood transfusion received 14% of patients, a surgical infection occurred in 20%, surgical complications appeared in 24% with a necessity for re-exploration in 9.5%. Leakage of the primary anastomosis was seen in 3.3%, whereas a leakage of the Hartmann's stump occurred in 4.3%. Overall in-hospital mortality was 4.1%. Multivariate analysis demonstrated Hinchey classification and intraoperative blood transfusion to be independently associated with postoperative infections, complications and mortality. CONCLUSION: Hinchey classification and intraoperative blood transfusion are independently associated with a worse perioperative outcome in patients undergoing surgery for sigmoid diverticular disease. While Hinchey classification cannot be influenced per se by the surgeon, outcome might be influenced by reducing the need for intraoperative blood transfusion.

Influence of two different resection techniques (conventional liver resection versus anterior approach) of liver metastases from colorectal cancer on hematogenous tumor cell dissemination - prospective randomized multicenter trial.

BACKGROUND: Surgical hepatic resection remains the treatment of choice for patients with liver metastases from colorectal cancer despite the use of alternative therapeutic strategies. Although this procedure provides long-term survival in a significant number of patients, 50-75% of the patients develop intra- and/or extrahepatic recurrence. One possible reason for tumor recurrence may be intraoperative hematogenous tumor cell dissemination due to mechanical manipulation of the tumor during hepatic resection. Surgical technique may have an influence on hematogenous tumor cell spread. We hypothesize that hematogenous tumor cell dissemination may be reduced by using the anterior approach technique compared to conventional liver resection. METHODS/DESIGN: This is a multi-centre prospective randomized controlled, superiority trial to compare two liver resection techniques of liver metastases from colorectal cancer. 150 patients will be included and randomized intraoperatively after surgical exploration just prior to resection. The primary objective is to compare the anterior approach with the conventional liver resection technique with regard to intraoperative haematogenous tumor cell dissemination. As secondary objectives we examine five year survival rates (OS and DFS), blood loss, duration of operation, requirement of blood transfusions, morbidity rate, prognostic relevance of tumor cell detection in blood and bone marrow and the comparison of tumor cell detection by different detection methods. CONCLUSION: This trial will answer the question whether there is an advantage for the anterior approach technique compared to the conventional resection group with regard to tumor cell dissemination. It will also add further information about prognostic differences, safety, advantages and disadvantages of each technique. TRIAL REGISTRATION: Current controlled trials - ISRCTN45066244.

Specific immune recognition of pancreatic carcinoma by patient-derived CD4 and CD8 T cells and its improvement by interferon-gamma.

Pancreatic carcinoma is a very aggressive disease and little is known about its immunobiology. We here describe the presence in pancreatic cancer patients of spontaneously induced functional CD4 and CD8 memory/effector T cells reactive to autologous tumor cells or to the pancreatic cancer associated antigen, MUC-1. Such specific cells were present in the bone marrow or peripheral blood of most of the 23 tested patients. Low dose stimulation of primary cultures of pancreatic cancer cells with 500 IU/ml IFN-gamma for 72 h enhanced HLA-I expression and induced the de novo expression of HLA-II molecules. This led to a much better immune recognition by autologous HLA-I restricted and purified CD8 T cells and allowed tumor cell recognition by HLA-II restricted purified CD4 T-helper cells. Thus, interferon-gamma appears to be a useful adjuvant cytokine to enhance the immunogenicity of a patients' tumor cells and their recognition by tumor reactive immune cells.

Treatment of Esophageal Perforation: A Single-Center Expertise.

BACKGROUND AND AIMS: Esophageal perforation is a rare diagnosis, which is associated with a high morbidity and mortality. There is only small scientific background regarding the best choice of treatment. Parameters indicating a good clinical outcome seem to be localization, depth of the defect, pre-existing risk factors, and time interval between the event and start of treatment. MATERIAL AND METHODS: We evaluate retrospective data from 39 patients who were treated with a esophageal perforation in our hospital between 2004 and 2012. RESULTS AND CONCLUSIONS: Our collected data agree with the available published literature. Endoscopic treatment seems to be favorable in early diagnosis.

[The intra-arterial calcium stimulation test in site diagnosis for surgical therapy of insulinoma]. / Der intraarterielle Calciumstimulationstest (ASVS) in der Lokalisationsdiagnostik zur chirurgischen Therapie des Insulinoms.

BACKGROUND: Approximately 10% of all insulinomas--the most common neuroendocrine pancreatic tumor--occur in multiple sites of the pancreas (e.g., multiple endocrine neoplasia type I) and rarely as islet cell hyperplasia. Malignant insulinomas appear in 10% to 15% of cases. For these special groups and for patients with a reoperation preoperative localization of the tumour is advisable. With current imaging technology, including computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography, and somatostatin receptor scintigraphy (SRS), localization of insulinomas is often inadequate. METHODS: In this study we report our results using intra-arterial calcium-stimulated venous blood sampling (ASVS) to localize and guide the management of insulinomas for patients with a reoperation because of recurrent insulinomas or persistent hyperinsulinism, for patients with malignant neoplasm and for patients with a previous abdominal operation. RESULTS: For all three cases the insulinomas were correctly localized by the ASVS in contrast to the preoperative imaging studies. CONCLUSIONS: Our experience and a review of the current literature demonstrate that ASVS is a highly accurate (sensitivity > 90%) and a safe method for preoperative localization of insulinomas. For patients with a reoperation ASVS is recommended and the extensive use of other costly preoperative methods should be avoided.

[Limitations of surgery for rectal cancer]. / Grenzen der Chirurgie beim Rektumkarzinom.

This article presents and summarizes different treatment options for rectal cancer. The aim of this article is an historical review of treating primary and recurrent rectal cancer, highlighting the development and advancement in surgical and multimodal therapy. Limitations, specifically regarding recurrent rectal cancer are discussed and reviewed. A R0 resection can almost always be achieved in primary rectal cancer. In recurrent rectal cancer a R0 resection with extended surgical resection can be achieved in up to 70 % of the cases. In addition, surgical therapy plays a crucial role in the case of metastatic disease but should be incorporated into a multimodal network. The analysis of tumor genetics and predictive parameters will lead to the emergence of new treatment concepts shifting the limits of the current gold standard. Oncological long-term survival and improving the quality of life are the main focal points.

[Preoperative management for malnourished patients in abdominal surgery. Practical treatment regimen for reduction of perioperative morbidity]. / Präoperatives Management bei Mangelernährten in der Viszeralchirurgie : Praktischer Behandlungspfad zur Reduktion perioperativer Morbidität.

The incidence of malnutrition in oncological and visceral surgical units can be high. The screening of malnourished patients is very important, especially in the preoperative setting. The available published literature provides crucial knowledge about the risks inherent to malnutrition and subsequent perioperative morbidity and mortality. The preoperative screening of malnourished patients followed by a subsequent renutrition is the key to decreasing rates of postoperative morbidity and mortality. The data and guidelines given by the European Society of Parenteral and Enteral Nutrition (ESPEN) in 2006 for the preoperative nutritional conditioning are clear and give no doubt regarding the necessity of preparation of malnourished patients for elective abdominal surgery. Despite this fact, the observance and application of these guidelines among German surgical units remain low. To fill this void a model of systematic screening and treatment of malnutrition in the preoperative setting for elective abdominal surgery was created and implemented at the university hospital of Oldenburg. A practical treatment regimen was designed to prepare malnourished patients within 2-3 weeks before elective surgery. Initial results regarding the feasibility of preoperative home renutrition therapy were moderate but encouraging. The success of such a conditioning process depends on cooperation between the surgical unit, the general practitioner (GP) and the homecare environment. In the German healthcare system the prescription of home nutrition (i.e. enteral feeding) can lead to the prescription limits of a GP being exceeded and has to be justified to the medical insurance company in each case. This article presents a simple yet applicable way of screening and preparing malnourished patients a few weeks prior to elective surgery. Therefore, simple tools which can be promptly used in daily clinical life, especially in the outpatient surgical consultations prior to elective visceral surgery are proposed.

Treatment of recurrent rectovaginal/pouch-vaginal fistulas by gracilis muscle transposition - a single center experience.

PURPOSE: Rectovaginal fistulas constitute a serious burden for the affected patient and a major challenge for the attending surgeon. Definitive surgical treatment of the fistula depends on the size and location of the fistula, the underlying disease, and any previous therapies. In regards to complicated recurrent rectovaginal fistulas, transposition of the gracilis muscle is one of the well-established therapeutic options with a success rate of up to 70%. MATERIAL AND METHODS: Between 01/2004 and 06/2010, ten patients diagnosed with a recurrent rectovaginal fistula were treated in the surgical department of Klinikum Oldenburg by gracilis muscle transposition; their data were collected and analyzed. Post-operative evaluation was performed using a standardized telephone interview. All patients had a protective stoma. The primary endpoint of assessment was the long-term healing of the fistula following stoma reversal, and the comparison between those who were treated successfully versus those who were not. RESULTS: Over a time span of 6years, ten women with a complicated rectovaginal fistula underwent fistula repair with the gracilis muscle transposition. Patient age ranged from 29 and 64years. There were five rectovaginal fistulas, four pouch-vaginal fistulas, and one anovaginal fistula. The underlying disease was rectal cancer in seven patients, Crohn's disease in one patient, previous complicated gynecologic surgery in one patient, and idiopathic anal fistula in one patient. All seven patients with rectal cancer underwent radiochemotherapy with 50.4Gy (n=6 neo-adjuvant, n=1 adjuvant). All ten patients had previously undergone repair by a different surgical approach while five presented with a second or third recurrence. Post-operative complications were noted in two patients (perineal wound defect, thigh hematoma). Follow-up of the patients ranged from 8 to 60months. Recurrent rectovaginal fistula occurred in four patients. Evaluation of the data failed to identify statistically significant criteria for treatment failure of rectovaginal fistula repair. CONCLUSION: Our results are similar to previous studies in this area. For the majority of the patients, the gracilis muscle transposition was a long-term effective treatment of recurrent rectovaginal fistulas, however recurrences were noted in 40% of cases. Predictive criteria for treatment failure could not be established.