Technique and clinical results of endorectal surgery

At the Surgical Department of the University of Cologne, a new system has been developed for transanal endoscopic surgery that allows all the conventional surgical techniques within the entire rectal cavity. The method has been in clinical use since 1983. The main indication is the removal of sessile adenomas. Early rectal carcinomas with favorable histologic grading (grades 1 and 2) and staging (Mason I and II) are also suitable for the method. Advanced cancers can also be removed endoscopically in one session, but we perform local excisions of advanced cancers only in cases in which the patient is unwilling to undergo extensive surgery. During the period from July 1983 to December 1990, this method has been employed on 233 patients in 251 cases. The intraoperative and postoperative course of 236 (94%) operations out of 251 was free from any complications. Early postoperative complications consisted of intraperitoneal perforations (five cases), rectovaginal fistulas (four cases), hemorrhages (four cases), and death as a result of cardiopulmonary failure (two cases). The recurrence rate of adenomas is 4.9%. Endorectal surgery allows endoscopic local transanal excision of large adenomas and early cancers with minimal morbidity and excellent presentation of specimens for complete histologic analysis.

[Resection of esophageal cancer without thoracotomy by manual dissection and eversion stripping]

At the department of surgery of the university of Cologne-Lindenthal, 184 patients (142 with squamous cell carcinoma of the esophagus, 42 with adenocarcinoma of the gastroesophageal junction) underwent blunt dissection of esophageal cancer between 1983 and 1991. Tumor expansion classified by the pathologist was stage I in 13.6%, stage II in 31.0%, stage III in 41.8%, and stage IV in 13.6% of all cases. Histological tumor differentiation was graded well in 4.3%, moderate in 71.7%, and poor in 19.6%. Principally a gastric tube was used for esophageal replacement (96.3%), while interposition of the large bowel was performed in 5 cases. All the patients were prospectively monitored for perioperative complications. 64.7% fared without any complications intraoperatively. The most frequent intraoperative complications were damage of the pleura parietalis (16.3%), rupture of the tumor during dissection (13.0%), and lesion of the spleen (11.4%). 29.9% of the patients had a postoperative course without any complications. Pleural effusion (38.6%) and insufficiency of the cervical anastomosis (22.8%) were the most frequent complications seen postoperatively. Hospital mortality amounted to 6.0%. Six months after the operation most patients deemed their quality of life satisfying or excellent, respectively. The cumulative survival rate (without hospital mortality) was 78.3% after the first year, 24.7% after the third year and 20.6% after the fifth year.

[Penetrating thoracic injuries]

In a period of peace in Germany and other westeuropean countries, penetrating trauma of the thorax (PTT) is much more rarer than blunt trauma. An analysis of 103 patients with PTT, treated in the Surgical Department of the University of Cologne from 1980 to 1990, showed, that these are usually isolated injuries in young patients. These occur usually following violence as stab wounds and less commonly gunshot wounds. Two thirds of the patients could be treated adequately with intensive care therapy and the use of thoracic drains. One third of the patients underwent thoracotomy, which was carried out in two thirds within one hour after hospital admission and in the remaining one third within the first 24 hours. The mortality for all PTT was 13%, being 10% for isolated thoracic injuries and 19% for patients with multiple trauma.

[Transanal endoscopic microsurgery: technique and clinical results]

A new system has been developed for transanal endoscopic microsurgery (TEM), which allows all the conventional surgical techniques within the rectal cavity. The main indication is the removal of sessile adenomas. "Early rectal carcinomas" are also suitable for local excision. We perform local excision of advanced cancer only in cases where a contraindication exists to perform radical surgery or when the patients is unwilling to undergo demolitive surgery. The system has been employed at our Surgical Department on 206 patients in 223 cases. In 192 cases (87.7%) only one local excision was carried out due to sufficient excision as confirmed by histology (including patients with early "low risk" cancer). the postoperative course of 208 cases (93.3%) was free from any complications. The recurrence rate of adenomas amounted to 5.2%. This technique is particularly applicable for elderly, high risk patients and those with broad based adenomas so that anterior resection, abdominoperineal resection or other invasive operations can be avoided.

The risk of infection following OKT3 and antilymphocyte globulin treatment for renal transplant rejection: results of a single center prospectively randomized trial

Some 43 of 60 (72%) renal allograft recipients who were prospectively randomized to receive either OKT3 monoclonal antibody (n = 30) or ALG (antilymphocyte globulin) polyclonal antibody (n = 30) for steroid-resistant rejection suffered from infection, 25 (83%) following OKT3 and 18 (60%) following ALG treatment (P < 0.05). Clinically evident herpes infection was most frequently seen (9 and 7, respectively), followed by pneumonia (6 and 1, respectively P < 0.05), urinary tract infection and wound infection (2 of each in both groups) fungal (Candida) and multibacterial infections. One patient died in each group due to cytomegalovirus (CMV) pneumonia, giving a mortality of 4.3% in each group. Actuarial 1-year graft and patient survival rates were 80% and 97% in both groups, respectively. It is concluded that ALG and OKT3 are equally effective in renal allograft rejection resistant to steroid treatment, however, the risk of infection appears to be higher with OKT3.

[Thoracotomies in thoracic injuries--indications and results]

Most thoracic injuries can be treated adequately with intensive care, pleural drainage and judicious physiotherapy. From the total of 571 patients with severe thoracic injuries treated in the Surgical Department of the University of Cologne over the last 10 years, 14% of those with blunt trauma (BT) and 33% with penetrating trauma (PT) underwent thoracotomy. Thoracotomy for PT was usually performed earlier and gave better results than thoracotomy for BT. With one exception, all PT underwent thoracotomy in the first 24 h after admission. For thoracotomy carried out for BT however, 38% took place after 24 h and 21% after 5 days. Postoperative mortality for BT was 3 times higher than for PT (56% vs. 18%). Reasons for this are to be found in the severe thoracic and general injuries associated with BT. The surgical procedure will depend on the type and extent of the thoracic and general injuries and on the general condition of the patient.

[Treatment of advanced non-small cell bronchial cancer--a review of the literature of the last 5 years]

In the course of a metaanalysis concerning adjuvant therapy and the therapy of inoperable non-small-cell carcinoma of the lung, undertaken from 1.1. 1985 to 1.5. 1990, 376 publications were evaluated on a point system based on a decision tree. Out of a maximum of 71 obtainable points only 5.4% of the publications on adjuvant therapy and only 7.3% of publications on palliative therapy obtained more than 45 points. Regarding inoperable cases X-ray therapy with a median survival of 11 months and satisfactory life quality demonstrated the best results. Significant increases in survival are also possible with chemotherapy (7.4 months) in standard-dose pair combinations which, however, are associated with negative side effects on the treated patients. Immune and radio-chemotherapy cannot be recommended on account of treatment toxicity without a gain in life quality. Adjuvant therapy shows no life-prolonging effect. Consequently surgical treatment remains the first choice of therapy.

[Palliative surgical treatment of cancer of the esophagus]

Palliative surgery, including cleaning resection, colon or stomach bypass, intubation or fistula is all one can offer to the majority of patients suffering from oesophageal carcinoma due to an usually advanced tumor stage at the time of diagnosis. The primary goal is to prevent or resolve dysphagia. A prolongation of survival time can - with the exception of cleaning resection - not be expected by these procedures. The average survival time was 9.4 months after cleaning resection and 4.7 months after other palliative procedures in our series. If a cleaning resection is not possible, the endoscopic implantation of an endotube is the treatment of choice because of its low mortality and morbidity.

[Effect of accidental splenectomy on long-term outcome in colorectal tumor surgery]

In the period from 1967 till 1988 an accidental splenectomy was carried out at 1318 colon resections because of a malignant tumor in 34 cases (2.5%). The preoperative risk of this patient group was increased clearly in opposite to the whole patient clientele. So every fifth suffering from ileus or subileus was operated as in emergency. The complication rate, time of rest and clinic lethality were increased. The five-years survival rate did not change significantly in stage T1 and T2 in comparison with the whole patient clientele. In the stage T3, however, a significant prolonged survival rate was found out in the target group. Therefore the oncological aspect does not supply any reason to preserve the spleen in colorectal tumor surgery.

Surgical therapy of oesophageal carcinoma

During the past 10 years, postoperative mortality associated with surgical treatment of oesophageal carcinoma has been reduced by one-half. However, it appears that all efforts to improve long-term survival with extensive excisional procedures and adjuvant chemotherapy and radiotherapy have failed. Fifty-six of 100 patients presenting to the surgeon with an oesophageal carcinoma have resectable disease. Recent studies suggest that seven of them will die from postoperative complications and 49 patients will be discharged from the hospital after an average of 3 weeks. Of these patients, 27 will survive the first, 12 the second, and ten the fifth year. Although it may be possible to further reduce postoperative complications and mortality, the chances of improving the long-term prognosis of patients with oesophageal carcinoma seem small.

[Neopterin as a marker of aspecific immunostimulation with Propionibacterium avidum KP-40 in patients with gastrointestinal tumors. A prospective randomized study]

This prospective randomized study demonstrated that a preoperative intravenous infusion of 10 mg of the bacterial preparation Propionibacterium avidum KP-40 to patients with gastrointestinal tumors significantly (P less than 0.001) enhanced the secretion of neopterin, measurable as long-lasting (greater than 16 days) elevated urine excretion. Postoperative re-infusion of P. avidum KP-40 caused (statistically significant (p less than 0.001] re-enhancement of neopterin urine levels.

[Splenic cysts: indications for surgery and surgical procedures]

Based on a late physical examination of 18 patients with splenic cysts, we discuss symptoms, diagnostics and indication to operate and the procedure of operation. We found no specific symptoms. The ultrasound is the most important diagnostic method and may be supplemented by computerized axial tomography. The indication depends on the symptoms, the diameter within the organ and, most important, the dignity of the cyst. For pseudocysts we prefer resection of the cyst wall, because it is a simple and safe procedure. Splenectomy is the treatment of choice for cysts with unknown dignity.

[Percutaneous transluminal angioplasty of the infrarenal abdominal aorta]

The results of percutaneous transluminal angioplasty (PTA) (n = 13) of the lower abdominal aorta are reported in 12 patients. The mean patient age was relatively low (46 years). In 7 cases there were isolated aortic obstructions (6 stenoses, 1 occlusion). In the remaining 6 aortic stenoses, there were also major atherosclerotic lesions distally. The mean diameter of the aortic section in which PTA was performed, measured 8.2 mm. The total diameter of the PTA balloon(s) averaged 19.1 mm. The arterial gradient dropped significantly from 41.4 mm Hg (mean) to 2 mm Hg after PTA. The arm-ankle index increased significantly from 0.64 to 0.97. The follow-up included 9 patients; 1 showed restenosis 38 month after PTA. There were no clinically relevant complications. The data published on abdominal PTA in atherosclerotic lesions are summarized.

Results of esophagectomy and gastric bypass for cancer of the esophagus

Improvements in operative technique and perioperative management have lowered hospital mortality of esophageal resection at our department from 31% to 8% during the past decade. Cumulative 5-year-survival rate depending on the tumor stage only remained unchanged at 21%. Neither extended resection nor perioperative chemo- or radio-therapy show any advantage compared to conventional resection or blunt dissection regarding long-term survival.

[Stapler and manual bronchial anastomosis--results of a consecutive trial series]

After lobectomy and pneumonectomy in experimental evaluations stapled bronchial closures showed the lowest incidence of inflammatory reaction and the highest strength determined by leakage pressure compared with other suture material. A total of 233 lung resections-performed at Surgical University Clinic Köln-Lindenthal and the Clinic for General and Abdominal Surgery of the Johannes-Gutenberg-Universität Mainz--were reviewed. Mechanical stapling reduced the rate of bronchopleural fistulas to 2.0% compared with 7.1% after manual suturing. In parallel, mortality related to bronchial stump leakage decreased to 0.7%. Main advantages of bronchial closure with staplers are the simplicity of their use, the speed and the uniformity of the closure. Thereby stapling devices are valuable completions in pulmonary surgery.

Long-term results of highly selective vagotomy for the treatment of duodenal ulcer

Between 1971 and 1987, highly selective vagotomy (HSV) was carried out in 984 patients suffering from duodenal ulcer disease. In 97.3% of these cases, the surgical intervention was uncomplicated, the related mortality being 0.3%. During the follow-up period the postoperative condition of the patients was checked once a year wherever possible; in 92.3%, follow-up was continued until december 1987, the maximum period of postoperative follow-up being 16 years. No prognostically reliable indication of the risk of ulcer recurrence was obtained from an analysis of gastric juice. In 79.1% of the cases who underwent surgery, the result was good to satisfactory, while 11.7% had functional complaints such as dumping or diarrhea. The probability of developing a recurrent ulcer within 16 years after the initial operation was 29.7%. This rate of recurrence is determined among other things, by the discovery of clinically quiescent ulcers during the yearly follow-up examinations, when these are performed carefully, and over a sufficiently long period.

[Surgical treatment of early stomach cancer]

At the department of surgery at the university hospital in Cologne 94 patients suffering from early gastric cancer of the stomach were operated in the years between 1968 and 1983. From 1972 till 1987 the department of surgery at the university hospital Mainz has had 74 patients. Survival rates and times without recurrence were calculated dependent on the surgical treatment carried out. In both collectives the prognosis for the patients with mucosal carcinoma was good no matter which operation was carried out. In the case of submucosal infiltration the frequency of recurrence was smaller and the survival rates significantly higher in those patients who subjected to a cancer operation than in those on whom only a resection of two third of the stomach was performed. The results indicate a radical approach in the treatment of early gastric cancer. At least in the case of submucosal carcinoma a dissection of the N2 lymph nodes is advisable.

[Lung injuries]

Even though lungs can be injured solitarily, most of pulmonary lesions occur within the scope of multiple trauma. Because of various patho-physiological processes resulting from the multiple trauma, the valuation of extent, course and prognosis of pulmonary injuries is difficult. Depending on examined cases, mortality of thoracic injuries as stated in various references amounts to between 6 and 55%. Concerning thoracic injuries we dealt with severe traumas of the thorax. This explains the relatively high rate of thoracotomy of 17% as well as the high mortality of 34% we confirmed. Because of described variety of injuries, it is necessary for better comparison of clinical investigations to specify the lesions in accordance with general and specific thoracic severity of injury--as described in the multiple trauma score of the Medical University of Hannover--. Especially pulmonary contusions with associated conspicuous injuries are often primarily underestimated concerning their dimensions and consequences. Therefore the importance of subtle inquiry of pulmonary findings must be strictly underlined.