Middle and lower third rectum carcinoma: sphincter saving or abdominoperineal resection?

Sphincter saving resections (SSR) are performed with increasing frequency in carcinoma of the lower and middle third of the rectum. In this retrospective study local and distant recurrence and survival were compared to abdominoperineal resection (APR). In 71 women and 71 men (mean age: 64 years) with a primary adenocarcinoma between 5 and 10 cm from the anal verge 89 SSR, and 53 APR, were performed (Dukes stages--SSR--A 19%; B 30.3%; C 50.7% vs APR--A 15%; B 45.3%; C 39.6%). Patients have been followed up for a minimum of 24 months (mean time 62 months). There were no differences in intraluminal diameters of the tumours in each operative procedure. The distal tumour-free distance was more than 6 cm in 52% after APR (SSR: 10%) and less than 3 cm in 43% after SSR. Survival was not different between procedures in Dukes stages A and B. A survival advantage for patients with Dukes C carcinoma after APR did not reach statistical significance. No differences in distant spread were found for SSR (Dukes stage A 0%; B 7%; C 18%) and APR (Dukes stage A 0%; B 8%; C 14%) for local recurrence in Dukes stages A and B after SSR (A and B 0%) and APR (A 0%; B 8%) whereas a significant increase in local recurrence rate was seen in Dukes stage C after SSR (24% vs, APR 5%). Although a further resection could be performed in almost all of these patients a negative effect of local recurrence on survival occurred (25.4 months with and 80 months without local recurrence). While SSR seems to be favourable in Dukes stages A and B, APR should be considered in carcinoma of the lower and middle third of the rectum with lymphatic spread. Effective preoperative staging determines selection of the appropriate operation.

[Congenital duodenal obstruction in combination with heterotopic gastric mucosa in the gallbladder. Case report and etiology]

A hitherto unique case of ectopic gastric mucosa of the gallbladder in combination with a congenital duodenal stenosis in an young male adult is presented and the etiology of both anomalies is elucidated. While the intestinal obstruction was confirmed prior to the operation, the diagnosis of the gastric heterotopia in the gallbladder has been established, as usually, first by histopathologic examination. Both anomalies required surgical treatment. The long-standing indistinct abdominal complaints of the patient vanished after cholecystectomy and duodenojejunostomy.

Intramedullary reduction and stabilisation of adult radial neck fractures

We report the treatment of six adult patients with displaced fractures of the radial neck by intramedullary reduction and stabilisation. Nine months after operation all the patients had good joint function, little or no pain, complete healing and no significant periarticular calcification. This simple semi-closed procedure may help to avoid resection of the radial head in some cases.

Intramedullary reduction and stabilisation of adult radial neck fractures

We report the treatment of six adult patients with displaced fractures of the radial neck by intramedullary reduction and stabilisation. Nine months after operation all the patients had good joint function, little or no pain, complete healing and no significant periarticular calcification. This simple semi-closed procedure may help to avoid resection of the radial head in some cases.

Prospective randomized study of preoperative bowel cleansing for patients undergoing colorectal surgery

Three different methods of preoperative bowel preparation were tested in a prospective randomized trial examining efficacy and morbidity. In all, 163 patients were treated by gut irrigation with Ringer's lactate, Prepacol or polyethylene glycol (PEG). Fluid retention, cleansing effect, postoperative complications and subjective acceptance were documented. Relevant weight gain and decrease in haematocrit indicating fluid retention were seen only after the use of Ringer's lactate. There were no significant differences in bowel cleansing. In the Prepacol group the postoperative complication rate was significantly increased. Prepacol was tolerated best, with few side-effects. PEG was better tolerated than Ringer's lactate, but vomiting occurred in 2 and 21 per cent of patients respectively. PEG is most suitable for bowel preparation in patients undergoing colorectal surgery.

Influence of various fatty acids on tumour growth in total parenteral nutrition

The aim of parenteral nutrition in tumour patients is to offer an alternative nutritional support to the patient without accelerating the growth of the tumour. For this purpose we fed a total of 100 rats, divided into five groups of 20 animals each (10 with and 10 without tumours), for a total period of 15 days with various nutritional regimes. Group 1 received glucose, group 2 long-chain triglycerides, group 3 medium-chain triglycerides (MCT), group 4 omega-3 fatty acids, and group 5 an oral diet. On the 10th day the Yoshida sarcoma in its ascites form was implanted into the tumour-bearing rats. In animals receiving MCT or omega-3 fatty acids tumour growth was considerably smaller than in the other groups (group 1 vs. groups 3 and 4; p < 0.05). Unfavourable effects of the administration of these fatty acids on the general condition of the animals were not observed [muscle nitrogen content (mg/kg body weight): MCT = 82.3, omega-3 fatty acids = 65.25]. The impulse cytophotometric measurements did not demonstrate any influence on the pattern of cell division (p > 0.05). We think that modulation of the immune system by feeding with MCT or omega-3 fatty acids was responsible for the reduced tumour growth in relation to the other groups. The extrapolation of these results to the clinical situation, however, may not be possible.

[Intramedullary nailing of fractures during the growth period with a new implant]

Intramedullary nailing with flexible titan pins is a simple and safe method for the treatment of fractures in children. Avoiding the epiphysis two pins are introduced into the medullary space in a double-crossing way to stabilise diaphysial fractures of bigger bones such as femur, tibia or humerus. Forearm fractures are splinted with a single pin each to radius and ulna. The method is also practicable in proximal fractures of the radius, reduction and stabilisation can be achieved with an intramedullary pin in one step avoiding arthrotomy.

[Surgical treatment of dislocated 3 and 4-segment fractures of the proximal humerus]

Twenty-eight three- and four-segment fractures of the proximal humerus were treated by plate fixation (n = 22), screw or Kirschner wire stabilization (n = 5), and primary endoprothesis (n = 1). There were no early postoperative complications. Fourteen months after the operation, 80% of the patients examined showed good results; 4 cases had poor results. In comparison to other reports our results are positive and support plate fixation as the method of choice in these situations.

[The management of complete shoulder joint dislocation without metallic implants]

In 14 patients reduction of the acromioclavicular joint was reinforced by completely absorbable polydioxanon cord. In 3 cases parts of the cord were rejected and a fistula formed through the scar without further impairment following as a result of healing local treatment. Altogether we had 12 good and 2 poor results with respect to function, X-ray appearance and pain. The complication rate and general outcome of the method described do not differ substantially from those of other commonly used procedures. However, no second operation for removal of the metal implants is necessary.

[The effectiveness of hypercaloric and hypocaloric postoperative parenteral nutrition in large abdominal surgery. A prospective randomized study]

By means of a prospective randomised trial protein turnover and general energy expenditure were measured after stomach or bowel resections in patients receiving either hypercaloric or hypocaloric parenteral nutrition. The results were correlated with the availability of various blood proteins and amino acids as well as the concentration of different substrates of the intermediary metabolism. The results show that there is no need for a hypercaloric parenteral nutrition even after major abdominal surgery. Apart of a slightly better nitrogenbalance, which is, however, connected with an increased nitrogen impact on the organism there was no advantage over hypocaloric intravenous nutrition at least until the fifth day after the operation.

[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.

[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.