Brigitte Holzer

Technique and Long-Term Results of Intersphincteric Resection for Low Rectal Cancer

PURPOSEIntersphincteric resection of low rectal tumors is a surgical technique extending rectal resection into the intersphincteric space. This procedure is performed by a synchronous abdominoperineal approach with mesorectal excision and excision of the entire or part of the internal sphincter. This study was designed to evaluate the long-term results of this method focused on continence function and oncologic results.METHODSFrom 1984 to 2000, a total of 121 patients were operated on. The patients were evaluated prospectively according to a detailed preoperative and postoperative program.RESULTSOne hundred seventeen patients had rectal cancers, two had dysplastic villous adenomas, and two had carcinoid tumors. Cancers were staged according to the Dukes classification (Stage A in 41 percent, Stage B in 28 percent, and Stage C in 31 percent; median distance from the anal margin, 3 (range, 1–5) cm). Postoperative complications were: one death because of pulmonary embolism, 5.1 percent developed an anastomotic fistula, one patient had a fistula to the bladder requiring reoperation, one patient with ileus needed relaparotomy as well as one for intra-abdominal hemorrhage and a small-bowel fistula. One patient developed a fistula after closing the protective colostomy. Five patients developed late strictures of the coloanal anastomosis. After a median follow-up of 72.86 months, 5.3 percent of patients developed local recurrence. The continence status was satisfactory with 16 patients (13.7 percent) showing continence for solid stool only, and 1 patient (0.8 percent) showing episodes of incontinence. A transient problem was a high stool frequency after closure of the protective stoma.CONCLUSIONSIntersphincteric resection is a valuable procedure for sphincter-saving rectal surgery. We showed that this technique has satisfactory long-term results in functional and oncologic respects. An important prerequisite is a careful preoperative evaluation of local tumor spread with rectal magnetic resonance imaging excluding infiltration of the external sphincter.

Do Geographic and Educational Factors Influence the Quality of Life in Rectal Cancer Patients With a Permanent Colostomy

PURPOSEThis study was designed to evaluate possible social and geographic factors that could have an impact on quality of life in patients after abdominoperineal excision of the rectum. Although the number of patients with rectal cancer who need to be treated with abdominoperineal excision of the rectum and construction of permanent colostomy has greatly decreased in the past, there is still controversy about the influence on quality of life caused by this procedure.METHODSIn a prospective trial, patients operated on for low rectal cancer by abdominoperineal excision of the rectum were evaluated by a quality of life questionnaire, modified from The American Society of Colon and Rectal Surgeons questionnaire, to assess fecal incontinence. The results for the four domains of quality of life (lifestyle, coping behavior, embarrassment, depression), as well as for subjective general health, were evaluated with regard to age, gender, education, and geographic origin in univariate and multivariate analyses.RESULTSThirteen institutions in 11 countries included data from 257 patients. Although the analysis of general health did not reveal any significant differences, the analysis of the four quality of life domains showed the significant influence of geographic origin. The presence of a permanent colostomy showed a consistently negative impact on patients in southern Europe as well as for patients of Arabic (Islamic) origin. On the other hand, age, gender, and educational status did not reveal a statistically significant influence.CONCLUSIONSThis is the first study to show the influence of geographic origin on quality of life of patients with a permanent colostomy. Possible factors that may influence the outcome of patients after surgical treatment of rectal cancer, such as weather, religion, or culture, should be taken into account when quality of life evaluations are considered.

Phyllodes tumours of the breast

SummaryBACKGROUND: Phyllodes tumour is a very rare fibroepithelial neoplasia of the female breast. As a consequence of its low worldwide incidence of 0.3–1% of female breast tumours, the diagnosis, treatment, and prognosis of this disease are largely speculative and unresolved. A nationwide multicentre analysis was carried out with the objective of describing the diagnostic and therapeutic methods currently used and assessing the prognosis of this rare disease. METHODS: From April 2000 to June 2001 a computer-assisted survey was carried out in 24 surgical and gynaecological departments in Austria. Using a data sheet, the departments collected information on phyllodes tumours treated until present, as well as the follow-up care, treatment, and the long-term results. RESULTS: Across Austria 85 cases of women with phyllodes tumour covering the period from January 1985 to December 2000 were included in this study. In 40 (47%) cases the tumour was localised in the left breast, in 37 (44%) cases it was in the right breast. The histological review of the surgical specimens found that 28 (33%) patients had a malignant phyllodes tumour. Eight (9%) cases were borderline and 46 (54%) benign. The mean follow-up time was 39 (11–85) months. Seven patients died during the study. CONCLUSIONS: Patients with borderline and benign lesions should also undergo regular follow-up. A breast-conserving operation with adequate excision margins should be the primary objective, since even malignant tumours seldomly metastasise.ZusammenfassungGRUNDLAGEN: Der Phyllodestumor ist eine äußerst seltene fibroepitheliale Neoplasie der weiblichen Brust. Aufgrund der niedrigen weltweiten Inzidenz von 0,3–1 % der Tumore der weiblichen Brust sind Diagnose, Behandlung und Prognose dieser Erkrankung weitestgehend spekulativer Natur und ungelöst. Eine landesweite Multizenterstudie mit dem Ziel der Beschreibung der momentan angewandten diagnostischen und therapeutischen Methoden als auch der Erfassung der Prognose dieser seltenen Erkrankung wurde durchgeführt. METHODIK: In der Zeit von April 2000 bis Juni 2001 wurde eine EDV-gestützte Erhebung in 24 chirurgischen und gynäkologischen Abteilungen in Österreich durchgeführt. Die Abteilungen erhielten ein Informationsblatt über den Phyllodestumor mit den Anweisungen zur Dokumentation der bisher behandelten Fälle, der weiteren Therapie und Pflegeverläufe und der Langzeitergebnisse. ERGEBNISSE: In Österreich wurden 85 Fälle von Patientinnen mit Phyllodestumoren in der Zeit zwischen Jänner 1985 und Dezember 2000 für diese Studie erfasst. Bei 40 (47 %) der Fälle war der Tumor in der linken Brust, bei 37 (44 %) in der rechten Brust lokalisiert. Die histologische Aufarbeitung der chirurgischen Präparate zeigte bei 28 (33 %) Patientinnen das Vorliegen eines malignen Phyllodestumors. Bei 8 (9 %) Patientinnen zeigte sich ein Borderlinetumor und bei 46 (54 %) Patientinnen ein benigner Phyllodestumor. Die mittlere Beobachtungsdauer war 39 (11–85) Monate. Sieben Patientinnen verstarben im Erhebungszeitraum. SCHLUSSFOLGERUNGEN: Patientinnen mit Borderlinetumoren und benignen Tumoren sollten ebenfalls ein regelmäßiges Kontrollintervall einhalten. Eine brusterhaltende Operation mit entsprechenden Exzisionsrändern sollte das primäre Therapieziel darstellen, da auch maligne Phyllodestumore selten metastasieren.

Efficacy of Diagnosis of Mechanical Cholestasis by MagneticResonance Cholangiography

The aims of this study were to evaluatethe effectiveness of magnetic resonance cholangiography (MRC) indiagnosing patients with cholestasis and to compare these results tothose obtained with endoscopic retrograde cholangiopancreaticography(ERCP). From January 1996 to December 1998 a total of 85consecutive patients who were candidates for ERCP because of asuspected diagnosis of mechanical cholestasis were included in thisstudy. All patients underwent MRC and consecutive ERCP 24 to 48 hourslater. The sensitivity for detecting common bile duct stones was 93%,specificity 74%, positive predictive value 89%, and negativepredictive value 82%. For the determination of tumorous bile ductstenosis the sensitivity and specificity were both 100%. MRC might bean ideal method for evaluating patients with unclear laboratory orultrasonography findings before laparoscopic cholecystectomy, therebyavoiding unnecessary invasive diagnostic tests with possible harmfulcomplications.

Quality of Life with a Permanent Colostomy

31.4 Individual Factors Influencing QoL in Patients with a Stoma . . . . . . . . . . . . . . . . . . . . . . . . . 433 31.4.1 Age and Gender . . . . . . . . . . . . . . . . . . . . . . . . 433 31.4.2 Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . 434 31.4.3 Time of QoL Evaluation . . . . . . . . . . . . . . . . . . . 434 31.4.4 Social Factors (Education, Religion) . . . . . . . . . . . . 435