[Short version of the updated S3 (level 3) guidelines for diagnosis and treatment of gallstones of the German Society for Digestive and Metabolic Diseases and the German Society for the Surgery of the Alimentary Tract]

This short version of the guidelines summarizes the evidence-based key recommendations for the diagnosis and treatment of gallstones. The guidelines were developed by an interdisciplinary team of gastroenterologists, surgeons, radiologists, geneticists, and patient support groups, under the auspice of the German Society for Gastroenterology and Metabolic Diseases and the German Society for General Surgery and Surgery of the Alimentary Tract. It used structural level 3 consensus-based methodology and includes statements on clinical practice, prevention, quality assurance, outcome analysis, and integration of outpatient and inpatient care for patients with gallstone disease.

[S3-guidelines for diagnosis and treatment of gallstones. German Society for Digestive and Metabolic Diseases and German Society for Surgery of the Alimentary Tract]

This guideline provides evidence-based key recommendations for diagnosis and therapy of gallstones and upgrades version 2000. It was developed by an interdisciplinary team of gastroenterologists, surgeons, radiologists, geneticists, external comparative quality assurance and patient support groups under the auspices of the German Society for Digestive and Metabolic Diseases and the German Society for Surgery of the Alimentary Tract. The guideline used structural S3 consensus-based methodology and includes statements on clinical practice, prevention, outcome analysis, and integration of outpatient and inpatient care for patients with gallstone diseases.

[Tumors of the foot skeleton]

About 3-4% of all tumors and tumor-like lesions of the skeleton are located in the foot. Many of these lesions have a predilection for certain locations, so that the spectrum of entities occurring in the foot differs from the rest of the skeleton. Despite the fact that practically any entity can occur in the foot in rare cases, taken together the ten most frequent lesions make up for the vast majority of tumors and tumor-like lesions of the foot. The differential diagnosis of these lesions follows the general principles that apply in the rest of the skeleton. It is based on the analysis of the lesion's X-ray morphology and location, the patient's age, and in certain entities, the MR morphology. This article describes the most important tumors and tumor-like lesions of the foot, their differential diagnosis, and the principles of local staging.

Rectourethral fistula after combination radiotherapy for prostate cancer

OBJECTIVES

To describe 6 cases of rectourethral fistula in patients treated with brachytherapy plus external beam radiotherapy for localized prostate cancer and subsequent rectal biopsies or rectal surgery.

METHODS

A retrospective chart review was undertaken of patients with prostate cancer treated with brachytherapy who presented to our institution with the diagnosis of rectourethral fistula from February 1999 to June 2002. Potential contributing factors, including patient age, cancer grade and stage, cancer treatment, rectal procedure, and time to the complication, were evaluated. Potential approaches to rectourethral fistula treatment and their outcomes are reported.

RESULTS

The mean patient age was 63.8 years. All 6 men underwent combination prostate brachytherapy and external beam radiotherapy with subsequent rectal biopsy/hemorrhoidectomy. All 6 patients developed a rectourethral fistula, with an average time between the end of radiotherapy and fistula development of 22.6 months. Four patients underwent hyperbaric oxygen therapy, which failed. Three patients underwent fecal diversion with gracilis interposition flaps, and two underwent pelvic exenteration.

CONCLUSIONS

The results of our study have shown that rectourethral fistula development is a serious complication of combination radiotherapy, with definitive repair requiring major intraabdominal surgery. Biopsy of rectal ulcers in the clinical setting of combined radiotherapy should not be performed. In addition, elective rectal surgery should not be performed on irradiated tissue. In our series, hyperbaric oxygen therapy and conservative treatment did not obviate the need for definitive surgical management of the rectourethral fistula.

Optimised surgery (so-called TME surgery) and high-resolution MRI in the planning of treatment of rectal carcinoma

BACKGROUND

Since November 1998, we have applied the concept of total mesorectal excision (TME) to rectal carcinoma together with a standardised pathological quality assessment. Participation in the European MERCURY study [The MERCURY Study Group Radiology (in press), 2006] required us to establish the indication for neoadjuvant radiochemotherapy on the basis of an magnetic resonance imaging (MRI) scan. The aim of the present retrospective study is to evaluate the quality of the surgery, the efficacy of the MRI and the oncological outcomes achieved.

MATERIALS AND METHODS

Between November 2001 and October 2005, 68 out of 109 patients with carcinoma of the rectum were submitted to radical surgery in curative intent and 23/68 (34%) were given neoadjuvant therapy. In an interdisciplinary study group, each patient was evaluated pre-operatively and post-operatively using standardised MRI and histopathological methods.

RESULTS

The quality of surgery was established on the basis of the pathological examination of the surgical specimen. The rates of incomplete mesorectal excision, intra-operative tumour cell dissemination and positive circumferential margins were all low at 4%, 7% and 3%, respectively. The effectiveness of MRI proved to be greatest in predicting the tumour status at the circumferential resection margin: in the admittedly limited number of patients it proved possible to correctly predict the tumour status for every patient. The assessment of the anatomic extent of the primary tumour and of the regional lymph node metastasis according to the TNM system, in contrast, was considerably less successful at 73% and 75%, and 37% and 57%, respectively.

CONCLUSION

By applying the TME concept and MRI-based therapy planning, excellent results can be achieved and, at the same time, the number of patients requiring neoadjuvant treatment is considerably reduced.

[Management of pancreatic metastases from renal cell carcinoma report of five cases]

Pancreatic metastases from renal cell carcinoma are rare. In most cases metastases occur many years after nephrectomy. Solitary pancreatic metastases of renal cell cancer can be the only manifestation of tumor dissemination. Between 1995 and 2005 five patients after nephrectomy due to renal cell cancer were suspected of having malignant pancreatic tumor and underwent an operation. The histology revealed metastases of renal cancer. The intervals from primary renal tumor resection to recognition of metastases in the pancreas varied from 6-17 years. The prognosis of metastatic invasion to the pancreas is better than that of primary pancreatic carcinoma. Radical resection of the tumor is the treatment of choice for isolated solitary late metastases of renal cell cancer in the pancreas.

Magnetresonanztomographie des Sprunggelenkes

The ankle represents an anatomically complex region with a broad spectrum of pathologies. Magnetic resonance imaging (MRI) of the ankle offers detailed, high-resolution imaging of the bones, the ligaments and the surrounding soft tissue structures and therefore has a major role in the diagnostic evaluation of traumatic sequelae, infectious diseases or ankle pain of unknown origin. MRI is especially valuable in the detection of radiographically occult stress reactions or osteomyelitis because it can visualize bone marrow edema earlier than any other imaging method. MRI is superior to any other imaging method for visualizing the tendons and ligaments of the foot and is an important basis for further treatment planning.

The Kraske procedure: a critical analysis of a surgical approach for mid-rectal lesions

BACKGROUND AND OBJECTIVES

To analyze the Kraske procedure as an approach to mid-rectal disease.

METHODS

Twenty-two patients underwent a Kraske procedure at either Duke University Medical Center, the Durham Veterans Administration Medical Center, or the Durham Regional Hospital between 1992 and 1997. The clinical and pathologic characteristics of these patients were retrospectively analyzed and compared with previous published series.

RESULTS

Of the 22 patients, 13 underwent resection of an adenocarcinoma and 9 underwent resection of a villous adenoma. Post-operative complications included four fecal fistulas (two of which required a temporary diverting colostomy), two wound infections, two cases of urinary retention, and one case of transient fecal incontinence.

CONCLUSIONS

The Kraske procedure minimizes exposure of mid-rectal lesions without the morbidity of a major laparotomy. However, it does carry a moderate complication rate and thus should be utilized selectively in managing patients with mid-rectal tumors not amenable to other treatment options.

Toxicity and efficacy of four schedules of intensified neoadjuvant chemoradiotherapy (RCT) with irinotecan and 5-Fu or Capecitabine in patients with locally advanced rectal cancer (LARC)

13550

Background: After neoadjuvant RCT in patients with LARC the rate of complete response (pCR), nearly complete response (nCR)and also the ypN0 category influences survival. So four different schedules of neoadjuvant RCT with irinotecan and 5-Fu or Capecitabine were compared in efficacy (pCR, nCR, ypN0) but also in the main toxicity (diarrea III/IV CTC). Methods: Conventional radiation was given at daily fractions of 1.8Gy to a total dose of 50.4Gy and 5.4Gy boost in all schedules. In our first schedule 5-Fu (250mg/m2, d1–43) and irinotecan (40mg/m2, d1,8,15,22,29,36) (group A), in our next schedule capecitabine (1500mg/m2, d1–43) and irinotecan (40mg/m2, d1,8,15,22,29,36) (group B), and then next capecitabine (1500mg/m2, d1–14, 22–35) and irinotecan (50mg/m2, d1,8,22,29) (group C) and now capecitabine (1500mg/m2, d1–14, 22–35) and irinotecan (60mg/m2, d1,8,22,29) (group D) was applicated concurrently. Surgery was performed 4–6 weeks after RCT. Results: Group A-B-C-D: number of patients: 37 - 28 - 20 - up to now 11; clinical state UICC II/III: 6/31 - 2/28 - 5/15 - 1/10; diarrhea (III+IV): 12/37(32%) - 11/28(39%) - 2/20(10%) - 1/11(9%); pCR: 9/37(24%) - 4/26(15%) - 0/20(0%) -3 /9(33%); nCR: 10/37(27%) - 3/26(12%) - 5/20(25%) - 1/9(11%); ypNo: 25/37(68%) - 15/26(58%) - 12/20(60%) - 6/9(67%). Conclusions: Neoadjuvant RCT with 5-Fu or capecitabine in combination with irinotecan is high effective. The splitting of capecitabine with a break in the third week of radiation reduces toxicity but not efficacy. In our trials during RCT a total dose of 240mg/m2 irinotecan in combination with 5-Fu/capecitabine must be applicated to receive a high rate of pCR.

No significant financial relationships to disclose.

[Computed tomography of the musculoskeletal system]

Computed tomography (CT) is an important diagnostic modality in the work-up of musculoskeletal diseases. Just as projection radiography and magnetic resonance imaging, it has specific possible uses. As a tool to guide interventional and surgical procedures, it is a significant imaging technique. The technical development of multislice spiral CT in recent years has contributed considerably to increasing the diagnostic quality of CT. In particular, the possibilities for depicting the findings with methods for secondary image reconstruction have been decidedly improved.

Concurrent chemoradiation with capecitabine and weekly irinotecan as preoperative treatment for rectal cancer: results from a phase I/II study

The aim of this study was to investigate the efficacy and safety of chemoradiation using capecitabine and irinotecan as neoadjuvant therapy for patients with rectal cancer. Conventional radiation was given at daily fractions of 1.8 Gy on 5 days a week for a total dose of 55.8 (50.4+5.4) Gy. Concurrently, irinotecan 40 mg m⁻² once weekly and capecitabine continuously at dose levels of 500, 650, 750 and 825 mg m⁻² twice daily were administered. Surgery was performed 4–6 weeks following completion of chemoradiation. A total of 28 patients (3 UICC II, 25 UICC III) were enrolled and all received treatment. Dose-limiting toxicity was diarrhoea grade IV and hand–foot syndrome at the 825 mg m⁻² dose level. The maximum tolerated dose of capecitabine was 750 mg m⁻². Diarrhoea was the most common toxicity: grade III in nine patients. Two patients died, one due to pneumonia and one due to sudden cardiac death. A complete response and only microfocal residual tumour disease was achieved in four and three patients (27%). In all, 25 of 28 patients undergoing surgery, 24 (96%) had R0 resection. Preoperative chemoradiation based on continuous daily capecitabine and weekly irinotecan appears to tolerated and effective in patients with rectal cancer.

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.