A. Heintz

Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum

Abstract.Background: We compared the results of transanal endoscopic microsurgery and radical surgery in patients with T1 carcinomas of the rectum. Methods: We performed a retrospective study (1985–96) to compare the results obtained in 103 patients with T1 rectal carcinomas (low-risk T1, n= 80; high-risk T1; n= 23) undergoing transanal endoscopic microsurgery and radical surgical therapy. Results: The complication rate in patients undergoing local excision was 3.4% (two of 58); it was 18% (eight of 45) in the group treated with radical surgery. Two of 45 patients (3.8%) died after radical resection; there were no deaths after local excision. With regard to the actuarial 5-year survival rate, no difference was observed in the group with low-risk T1 carcinoma between patients treated with local excision (79%) and those who had radical resection (81%) (p= 0.72). In patients with high-risk T1 carcinoma, lymph node metastases were identified in four of 11 patients undergoing radical resection (36%). Four of 12 patients with high-risk T1 carcinoma treated by local excision developed recurrences, whereas none of the patients undergoing primary radical surgery had a recurrence. Conclusions: Transanal endoscopic microsurgery for the treatment of low-risk T1 carcinomas is associated with a significantly lower complication rate than radical surgical therapy. There is no difference in 5-year survival between local and radical surgical therapy in patients with low-risk T1 carcinoma.

The examiner's learning effect and its influence on the quality of endoscopic ultrasonography in carcinoma of the esophagus and gastric cardia

AbstractBackground: The preoperative diagnosis of tumors of the esophagus and the gastric cardia is an important element in their stage-oriented therapy. The goal of the present study was to evaluate the accuracy of endosonographic ultrasound (EUS) and to test its usefulness in tumor staging and the assessment of operability. Methods: A total of 139 tumors were scanned via EUS by one examiner ≤14 days prior to resection (TNM staging per UICC, 1987). Results: The accuracy for completely traversable tumors was 60.8% for T1, 82.1% for T2, 77.5% for T3, and 33% for T4 stages. This accuracy was somewhat reduced in cases of nontraversable tumor stenosis (51.9%). In T staging, a significant case-dependent improvement in accuracy to 89.5% was found; this was regarded as a learning effect. In N staging, we considered only those tumors that were resected by the transthoracic approach with systematic node dissection and complete EUS (n= 80). N-stage accuracy (T1–T4) was 71.3%, and no improvement could be shown. To assess operability, discrimination between T1/T2 and T3/T4 tumors is crucial. Accuracy, sensitivity, and specifity can thus be improved significantly. Conclusions: The quality of EUS depends on the experience of the examiner. Reliable results can be obtained after >75 examinations have been done. EUS is a valuable tool in tumor staging when it is performed by an experienced examiner or under the direct supervision of such a person.

Major urinary dysfunction after mesorectal excision for rectal carcinoma

Urinary dysfunction may occur after mesorectal excision and pelvic autonomic nerve preservation (PANP) in patients with rectal carcinoma. The aim of this prospective study was to identify factors predictive of long‐term urinary catheterization.

Follow-up after transanal endoscopic microsurgery or transanal excision of large benign rectal polyps

Methods: Between January 1986 and December 1995, 238 patients with benign rectal polyps under-went either transanal endoscopic microsurgery (n = 226) or transanal excision (n = 12) at the Clinic of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz. Results: Mean polyp size was 4.2 cm; 89.1% of polyps measured more than 2 cm in diameter. In 89.1% of cases, histological analysis revealed polyps containing tubulovillous or villous adenomas. Synchronous colonic polyps were detected in 12.5% of patients. Follow-up data are available on 222 patients (94%). At follow-up examination, 169 of the 193 surviving patients (87.6%) were recurrence free. Seven of 193 patients (3.6%) had developed neoplastic colonic polyps and, in 17 patients (8.8%), metachronous polyps were detected. Conclusions: Transanal endoscopic microsurgical polypectomy was furthermore demonstrated to be a low-risk procedure with a low recurrence rate for the complete resection of large rectal polyps. At a follow-up rate of 61.1%, the incidence of metachronous carcinoma ranged at 3.1%, which is markedly below the rate of 8–18% for tubulovillous or villous adenomas larger than 1 cm in diameter cited in the literature.

Endoscopic adrenalectomy: an analysis of the transperitoneal and retroperitoneal approaches and results of a prospective follow-up study

BackgroundEndoscopic adrenalectomy is currently performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to determine which of these is the optimal surgical technique in a prospectively designed analysis of a large series of patients operated on by a single team over a 10-year period.MethodsFrom February 1994 to March 2004, 267 endoscopic adrenalectomies (retroperitoneal in 132 patients and transperitoneal in 135 patients) were performed in 245 consecutive patients. There were 102 right lateral and 121 left lateral procedures (22 patients had a bilateral procedure). The most prevalent indication was incidentaloma (35.9%), followed by pheochromocytoma and Conn’s adenoma.ResultsThe endoscopic procedure was performed in 238 of 245 patients (97.1%). The conversion rate was 1.5% for the transperitoneal approach and 3.8% for the retroperitoneal approach. No statistically significant influence was noted for the parameters of intraoperative blood loss, rate of postoperative complications, and duration of hospital stay with regard to the surgical technique. The operative time and the learning curve proved to be significantly longer for the retroperitoneal adrenalectomy. In addition, a variance analysis identified tumor size (>5 cm) as a significant factor influencing the operative time, whereas body mass index and localization (right/left lateral) did not prove significant.ConclusionIndependent of the underlying pathology, endoscopic adrenalectomy using either the trans- or retroperitoneal approach can be performed in 96-98% of all patients. Differences between the two techniques in operative time and learning curves clearly favor the transperitoneal adrenalectomy.

Totale Mesorektumexzision bei Karzinom des mittleren und unteren Rektumdrittels

AbstractIntroduction. The introduction of total mesorectal excision (TME) in the treatment of rectal cancer has improved survival rates and decreased recurrence. Our objective was to analyse perioperative data as well as the results of the follow-up examination.Risk-factors for local recurrence should be identified since the indication for adjuvant therapy in “optimal surgery” has to be redefined. Patients and methods. Between March 1997 and December 2001, 108 patients with adenocarcinoma of the lower and middle rectum were operated on by three surgeons according to the concept of total mesorectal excision.In 75 (69.4%) patients,a lower anterior resection and in 32 (29.2%) cases an abdominoperineal resection was performed. One patient received a Hartmanns resection.There were 15 cases of stage IV (UICC) present and in 53 patients the tumor extension was restricted to the wall.Demographic and perioperative data as well as the results of the follow-up examination were registered prospectively. The median follow-up period amounted to 24 months (2–56). Results. A total of 87 patients underwent a curative resection.Fourteen lymph nodes were dissected (median).Pelvic autonomic nerve preservation was possible in 90 patients.The median intraoperative blood loss was 500 ml. As surgical complications, anastomotic leakage occurred in 18% of cases, perineal wound infection in 33%, and bladder dysfunction (requiring catheterisation) in 5.6%.The overall rate of recurrence was 17.5%.The rate of local recurrence was 4.9% and the survival rate was 91% over 3 years.Riskfactors for local recurrence are N2-disease, transmural growth and tumor localisation in the lower third of the rectum. Conclusions. TME offers good oncological and functional results with low complication rates for the treatment of cancer in the middle and upper third of the rectum.Interdisciplinary multicenter studies are still necessary to redefine the place of adjuvant radiation and chemotherapy in cases of cancer in the lower two thirds of the rectum and stage III disease.ZusammenfassungHintergrund. Onkologische Ergebnisse wurden nach Einführung der totalen Mesorektumexzision (TME) zur Behandlung des Rektumkarzinoms verbessert. Ziel vorliegender Analyse war es, perioperative, funktionelle und onkologische Ergebnisse chirurgischer Behandlung zu analysieren und Situationen mit erhöhtem Risiko eines lokoregionären Rezidivs zu identifizieren, da der Stellenwert multimodaler Therapie bei optimierter chirurgischer Therapie neu zu definieren ist. Patientengut und Methodik. Zwischen März 1997 und Dezember 2001 wurden 108 Patienten mit Adenokarzinom im unteren und mittleren Rektum nach dem Konzept der TME durch 3 Fachärzte für Chirurgie operiert.Bei 75 (69,4%) Patienten erfolgte eine tiefe anteriore Resektion, bei 32 (29,2%) eine abdominoperineale Rektumexstirpation und bei einer Patientin die Operation nach Hartmann.Ein Stadium IV lag bei 15 Erkrankten vor, und bei 53 war das Tumorwachstum wandbegrenzt.Demographische und perioperative Daten sowie Ergebnisse der Nachuntersuchungen wurden prospektiv erfasst.Die mediane Nachbeobachtungszeit betrug 24 Monate (2–56). Ergebnis. R0-Resektionen wurden bei 87 Patienten durchgeführt und im Median 14 Lymphknoten entfernt.Autonome Beckennerven wurden bei 90 Patienten komplett dargestellt und geschont.Der intraoperative Blutverlust lag bei 500 ml im Median.Anastomoseninsuffizienz (8%), perineale Wundheilungsstörung (33%) und behandlungsbedürftige Blasenentleerungsstörung waren chirurgische Komplikationen.In 17,3% kam es zum Tumorrezidiv.Lokalrezidive traten bei 4,9% auf.Die 3-Jahres-Überlebensrate betrug 91%.N2-Situation,T3/T4-Tumor und Sitz im unteren Rektumdrittel sind Risikofaktoren des Lokalrezidivs. Schlussfolgerung. Bei Rektumkarzinom im mittleren und unteren Drittel sind gute onkologische und funktionelle Ergebnisse der TME bei niedrigen Komplikationsraten nachvollziehbar. Interdisziplinäre, multizentrische Studien sind notwendig,um Wert und Notwendigkeit multimodaler Therapiekonzepte bei Tumoren der unteren 2 Rektumdrittel und im Stadium III zu klären.

Endoscopic adrenalectomy for pheochromocytoma: difference between the transperitoneal and retroperitoneal approaches in terms of the operative course

BackgroundDue to the intraoperative catecholamine secretion with hemodynamic changes, a larger tumor size and marked neovascularization, as compared with other adrenal pathologies, endoscopic adrenalectomy for pheochromocytoma represents a particular challenge involving a more difficult and morbid procedure. The aim of this study was to identify the optimal surgical approach for endoscopic adrenalectomy in patients with pheochromocytoma.MethodsOver a period of 10 years (February 1994 to June 2004), 38 consecutive patients underwent endoscopic adrenalectomy for pheochromocytoma. As three patients underwent a bilateral procedure, a total of 41 adrenalectomies were performed. The transperitoneal approach was carried out in 23 patients, whereas 18 patients underwent a retroperitoneal adrenalectomy by a single operative team. Perioperative parameters were prospectively followed.ResultsThere was no conversion to the open procedure. Intraoperative hypertensive episodes occurred in 21 patients (55.3%) and were controlled by antihypertensive agents. In 11 patients (28.9%), blood pressure values rose to above 200 mmHg (>1 min). A comparison between the retroperitoneal and transperitoneal procedures did not show a significant difference between the maximum intraoperative systolic (p = 0.730) and diastolic (p = 0.663) blood pressure values although intraoperative blood pressure peaks were seen more frequently during retroperitoneal adrenalectomy. The operative time was shorter for the patients who had transperitoneal adrenalectomy than compared to for those who had retroperitoneal adrenalectomy, although the difference was not significant. The intraoperative blood loss, perioperative morbidity, and length of postoperative hospital stay did not differ significantly between the surgical techniques (p > 0.05).ConclusionAfter adequate preparation, endoscopic adrenalectomy may be performed in patients with pheochromocytoma via both the retroperitoneal and the transperitoneal approaches. The shorter operating time, less frequent intraoperative blood pressure peaks, and the better overview of the operating field recommend the transperitoneal approach with the patient placed in a lateral position as the preferred operative procedure.

Total excision of the mesorectum in cancer of the lower and middle rectum. Oncological and functional results

AbstractIntroduction. The introduction of total mesorectal excision (TME) in the treatment of rectal cancer has improved survival rates and decreased recurrence. Our objective was to analyse perioperative data as well as the results of the follow-up examination.Risk-factors for local recurrence should be identified since the indication for adjuvant therapy in “optimal surgery” has to be redefined. Patients and methods. Between March 1997 and December 2001, 108 patients with adenocarcinoma of the lower and middle rectum were operated on by three surgeons according to the concept of total mesorectal excision.In 75 (69.4%) patients,a lower anterior resection and in 32 (29.2%) cases an abdominoperineal resection was performed. One patient received a Hartmanns resection.There were 15 cases of stage IV (UICC) present and in 53 patients the tumor extension was restricted to the wall.Demographic and perioperative data as well as the results of the follow-up examination were registered prospectively. The median follow-up period amounted to 24 months (2–56). Results. A total of 87 patients underwent a curative resection.Fourteen lymph nodes were dissected (median).Pelvic autonomic nerve preservation was possible in 90 patients.The median intraoperative blood loss was 500 ml. As surgical complications, anastomotic leakage occurred in 18% of cases, perineal wound infection in 33%, and bladder dysfunction (requiring catheterisation) in 5.6%.The overall rate of recurrence was 17.5%.The rate of local recurrence was 4.9% and the survival rate was 91% over 3 years.Riskfactors for local recurrence are N2-disease, transmural growth and tumor localisation in the lower third of the rectum. Conclusions. TME offers good oncological and functional results with low complication rates for the treatment of cancer in the middle and upper third of the rectum.Interdisciplinary multicenter studies are still necessary to redefine the place of adjuvant radiation and chemotherapy in cases of cancer in the lower two thirds of the rectum and stage III disease.ZusammenfassungHintergrund. Onkologische Ergebnisse wurden nach Einführung der totalen Mesorektumexzision (TME) zur Behandlung des Rektumkarzinoms verbessert. Ziel vorliegender Analyse war es, perioperative, funktionelle und onkologische Ergebnisse chirurgischer Behandlung zu analysieren und Situationen mit erhöhtem Risiko eines lokoregionären Rezidivs zu identifizieren, da der Stellenwert multimodaler Therapie bei optimierter chirurgischer Therapie neu zu definieren ist. Patientengut und Methodik. Zwischen März 1997 und Dezember 2001 wurden 108 Patienten mit Adenokarzinom im unteren und mittleren Rektum nach dem Konzept der TME durch 3 Fachärzte für Chirurgie operiert.Bei 75 (69,4%) Patienten erfolgte eine tiefe anteriore Resektion, bei 32 (29,2%) eine abdominoperineale Rektumexstirpation und bei einer Patientin die Operation nach Hartmann.Ein Stadium IV lag bei 15 Erkrankten vor, und bei 53 war das Tumorwachstum wandbegrenzt.Demographische und perioperative Daten sowie Ergebnisse der Nachuntersuchungen wurden prospektiv erfasst.Die mediane Nachbeobachtungszeit betrug 24 Monate (2–56). Ergebnis. R0-Resektionen wurden bei 87 Patienten durchgeführt und im Median 14 Lymphknoten entfernt.Autonome Beckennerven wurden bei 90 Patienten komplett dargestellt und geschont.Der intraoperative Blutverlust lag bei 500 ml im Median.Anastomoseninsuffizienz (8%), perineale Wundheilungsstörung (33%) und behandlungsbedürftige Blasenentleerungsstörung waren chirurgische Komplikationen.In 17,3% kam es zum Tumorrezidiv.Lokalrezidive traten bei 4,9% auf.Die 3-Jahres-Überlebensrate betrug 91%.N2-Situation,T3/T4-Tumor und Sitz im unteren Rektumdrittel sind Risikofaktoren des Lokalrezidivs. Schlussfolgerung. Bei Rektumkarzinom im mittleren und unteren Drittel sind gute onkologische und funktionelle Ergebnisse der TME bei niedrigen Komplikationsraten nachvollziehbar. Interdisziplinäre, multizentrische Studien sind notwendig,um Wert und Notwendigkeit multimodaler Therapiekonzepte bei Tumoren der unteren 2 Rektumdrittel und im Stadium III zu klären.

Changing pattern of the intraoperative blood pressure during endoscopic adrenalectomy in patients with Conn’s syndrome

BackgroundPrimary hyperaldosteronism caused by an aldosterone-producing adenoma of the adrenal gland is regarded as the most common type of endocrine hypertension. The aim of this study was to analyze the changing pattern of the intraoperative blood pressure during endoscopic adrenalectomy recorded in patients with Conn’s syndrome compared to patients with hormone-inactive incidentaloma and its possible influence by the surgical approach.MethodsFrom February 1994 to March 2004, 40 patients underwent endoscopic adrenalectomy for Conn’s syndrome. All patients had arterial hypertension over a median period of 84 (5–240) months and were pretreated with an aldosterone antagonist in 76.3% and with specific antihypertensive medication in 85%. Over the same period of time, endoscopic adrenalectomy was carried out in 80 patients with incidentaloma. Of these, 41 (53.2%) displayed arterial hypertension requiring drug therapy.ResultsThe adrenal gland was resected using the retroperitoneal in 25 and the transperitoneal approach in 15 patients with Conn’s syndrome. Conversion to an open procedure was required in two patients. Intraoperative increases in blood pressure necessitating antihypertensive therapy were observed in 17 of 40 patients (44.7%), in 11 of 40 patients (28.9%) blood pressure peaks of >200 mmHg (> 1 min) were noted. Differences between the preoperative and maximum intraoperative blood pressure were significant for the retroperitoneal approach only (systolic: p = 0.0001; diastolic: p = 0.0005), but not for the transperitoneal technique. The increase in intraoperative blood pressure in patients with Conn’s syndrome was significantly higher, for both systolic (p < 0.0001) and diastolic (p = 0.0037) readings, compared to that in patients with incidentaloma undergoing endoscopic adrenalectomy during the same period of time.ConclusionOur results demonstrate that relevant intraoperative increases in blood pressure occur in patients with Conn’s syndrome despite prior therapy with an aldosterone antagonist, necessitating specific precautionary measures during anesthesia. Intraoperative blood pressure was significantly higher for the retroperitoneal than for the transperitoneal procedure, which leads us to advocate the latter approach for endoscopic adrenalectomy.

Technique and results of the retroperitoneoscopic adrenalectomy via a lumbar approach.

Introduction: Since 1992, endoscopic techniques have been used increasingly in adrenal-gland surgery. In the present paper, the technique of the retroperitoneoscopic adrenalectomy via a lumbar approach is described. Methods: The patient is placed in a lateral decubitus position. In the first step, a dilatation trocar is introduced in the retroperitoneal space to create an artificial cavity. The dilatation trocar is replaced by a blocking trocar to close off the operating field. After insufflation of CO2, two additional trocars are introduced in the area of the conventional flank incision. Adrenalectomy is performed via these ports. Once the adrenal gland is completely mobilized, it is inserted into a sterile plastic bag and removed through the 1.5-cm incision. Conclusion: The retroperitoneoscopic approach to the adrenal gland appears to be suitable for benign adrenal-gland tumors up to a size of 6 cm.