Christoph Gebhardt

Multivisceral resection of advanced colorectal carcinoma.

Background and aims: In about 10% of patients with carcinoma of the colorectum, the tumour has already invaded contiguous organs or else inflammatory tumorous adhesions involving neighbouring structures are found. In such a situation, the question arises whether one should perform a multivisceral resection, the usefulness of which in terms of surgical risk and late oncological results have been investigated in the present study. Patients and methods: A total of 173 patients with colorectal carcinoma who underwent a multivisceral resection during the period between 1984 and 1995 are reported. Excluded from the study were patients with recurrent tumour or distant metastases. Results: In the majority of cases (63%), the primary tumour originated in the sigmoid colon or rectum. In 102 patients, only a single neighbouring organ was additionally involved, while the remaining patients had involvement of two or more contiguous organs. In 140 patients, the resection was curative, while in the remaining patients an R1/2 situation presented. In the curative group, tumour infiltration was confirmed histologically in 55% of the cases, while in the remaining patients a peritumourous adhesion had mimicked tumour invasion. Postoperative surgical complications occurred in only 1.4% of the interventions, a figure identical to the incidence of complications seen with conventional limited operations. The same applied to the postoperative 30-day mortality rate of 3.6%. The 5-year survival rate of the overall group of patients undergoing multivisceral resection was 42%, that of the subgroup undergoing curative surgery was 51%, and that of the subgroup receiving only palliative resection was 0%. Calculation of the stage-related 5-year survival rates for Union Internationale Contra la Cancrum stage-II and stage-III tumours revealed figures of 58% and 43%, respectively. After non-extended resection, the respective survival rates were identical (60% and 41%). Conclusion: An identical surgical risk and survival rates for curative resection, equally as good as those seen with conventional, non-extended procedures, justify the liberal use of multivisceral resection in the surgical treatment of colorectal carcinomas directly invading neighbouring organs.

Prognostic factors in the operative treatment of ductal pancreatic carcinoma.

Abstract  Background and aims: The average 5-year survival rate following resection of a ductal adenocarcinoma of the pancreas is 10%, worldwide. Despite increasing resection rates, only about 20% can be operated on with curative intent. A differential histopathological analysis of the resected tumors may help to justify expanding the surgical procedure by extended lymph-node dissection. Patients/methods: Between January 1986 and December 1995, a total of 113 patients underwent resection with curative intent for a ductal pancreatic carcinoma with regional lymph-node dissection. All histological findings were reviewed and reclassified in accordance with the 1997 Union Internationale Contra la Cancrum (UICC) classification. Survival data for all of these patients were obtained from family doctors and registration offices. Independent prognostic factors were statistically analyzed. Results: Of the 113 patients, 93 received an R0 resection. The postoperative mortality rate was 2.2% (2 of 93). More than one-half of the tumors had a diameter of between 2.1 cm and 4 cm. Among the 22 tumors measuring up to 2 cm in diameter, 41% already had lymph-node metastasis and 86% invasion of the lymphatic vessels. Carcinomas measuring between 4.1 cm and 6 cm were all associated with lymph-vessel invasion. Perineural invasion was present in 50% of the tumors. A noteworthy finding was the fact that 64% of the 25 tumors with negative lymph nodes had lymph-vessel invasion, and 48% perineural invasion. The cumulative 5-year survival rate of the R0-resected patients was 10.5%. Patients with lymph-node-negative stages survived significantly longer (26.5%) than patients with lymph-node-positive stages (5%). Furthermore, a significant difference was seen between pN1a and pN1b (16.7% vs 2.2%). Multivariate analysis identified tumor grading, tumor size and lymph vessel invasion as independent prognostic factors. Conclusions: Apart from the factors tumor size and tumor grading, lymph-vessel invasion appears to be of special significance for the long-term prognosis. Already in the pN0 stage, the latter was present in 64% of the cases and must be considered a precursor of lymphogenic metastasization. Since lymph-vessel invasion was demonstrated in 86% of tumors measuring less than 2 cm, the therapeutic consequence for all ductal pancreatic tumors is an extended lymphatic and soft tissue dissection that goes beyond the regional lymph-node stations.

Pathomorphological and Histological Prognostic Factors in Curatively Resected Ductal Adenocarcinoma of the Pancreas

The fate of patients with potentially resectable carcinomas is not only determined by the pTNM tumor stage, but also possibly by tumor-biological factors. The aim of this study was to identify these prognostic factors in patients undergoing primary curative (R0) resection. The study retrospectively analyzed 113 patients with ductal adenocarcinoma who were operated on between 1986 and 1995. R0 resection was able to be performed in 93 patients. Lymph node metastases were found in 73%. The rates of lymph vessel and perineural invasion were 83.5% and 45%, respectively. Among the 25 carcinomas without lymph node metastases, 64% already had lymph vessel invasion and 48% had perineural invasion. The cumulative 5-year survival rate of the 91 surviving patients analyzed was 10.5%. Depending on the tumor stage we found a significant difference in 5-year survival rates between patients without lymph node metastases (26.5%) and those with lymph node involvement (5%) (P 5 0.008). A multivariate analysis only identified lymph vessel invasion (L0/1), tumor size (≦/≦2 cm), and tumor grading (G) to have significant and independent prognostic value. Lymph vessel invasion, tumor size, and tumor grading proved to be independent factors determining long-term prognosis.

Multiviszerale Resektion des fortgeschrittenen kolorektalen Karzinoms Multivisceral resection in advanced colorectal carcinoma

From 1 September to 1 January 1990, a total of 1232 patients underwent surgery for colorectal cancer. Resection was performed on 1112 (90.3%) patients. It was curative in 917 cases and palliative in 195. Multivisceral resection was necessary 82 times because of tumour infiltration of adjacent organs (curative: 69 cases; palliative: 13 cases). The complication rate (26.7% vs 27.5%) and mortality rate (3.4% vs 2.9%) were similar to those for curative resections without multivisceral extension. The 5-year survival rate was also similar in the two groups (58% vs 55%). These results show that curative multivisceral resections can lead to the same long-term results as conventional curative resections. These data are encouraging, and tumour infiltration of neighbouring organs should not be taken to demonstrate inoperability.ZusammenfassungBerichtet wird über die operative Behandlung von 1232 Patienten mit einem kolorektalen Karzinom aus dem Zeitraum 1.09.1984 bis 1.01.1990. Entsprechend einer Resektionsquote von 90,3 % wurden 1112 Patienten (kurativ: n = 917, palliativ: n = 195) reseziert. Bei 82 Patienten war wegen Organüberschreitung des Tumors eine multiviszerale Resektion von einem oder mehreren benachbarten Organen (69mal kurativ, 13mal palliativ) notwendig. Komplikationsraten (26,7% zu 27,5 %) und die 30-Tageletalität (3,4% zu 2,9 %) waren in beiden Gruppen der kurativ and kurativ erweitert resezierten Patienten gleich. Die Berechnung der Fünfjahresüberlebensrate ergab für die kurativ resezierten Patienten ohne Erweiterung einen Wert von 58% gegenüber 55 mit Erweiterung. Auch die Subgruppenanalyse ergab keinen Unterschied in den einzelnen Stadien. Die Ergebnisse lassen den Schlulβ zu, daβ bei gleicher Komplikations-und Letalitätsrate die kurativ erweiterte Resektion von pT3- and pT4-Tumoren gleiche Spdtergebnisse wie die entsprechende Behandlung von nicht erweitert resezierten pT3-Tumoren erwarten läβt. Die Daten zeigen, daβ eine Infiltration von Nachbarorganen durch ein kolorektales Karzinom nicht als Inoperabilitätskriterium gelten darf.

Prognostic importance of isolated peritumoral lymphangiosis carcinomatosa in lymph-node-negative colorectal carcinoma

Abstract. Background: The prognostic value of microinvasion of lymph vessels and lymph nodes has become increasingly important; there is a wide range in prognosis of patients with nodal-negative tumor stages after curative resection for colorectal cancer. Aim: Detection of the prognostic importance of isolated lymph-vessel invasion as a possible precursor of lymph-node metastasis in patients with nodal-negative tumor stages. Patients/methods: Retrospective analysis of 894 patients with R0-resected colorectal cancer, uni- and multivariate analysis of tumorbiologic prognostic factors, immunohistochemical proof of tumor cells in negative lymph nodes (pN0) using the epithelial marker HEA-125 (human epithelial antigen). Results: The incidence of lymph-vessel invasion (L) was 37.7% in total. A pN0,L1 status was found in 144 patients (16.1% of all analyzed patients). Comparing patients with pN0,L1 status to those with pN+,L0 status showed that both groups have similar rates of overall survival and tumor relapse. Lymph-node status, lymph-vessel invasion, depth of tumor infiltration (pT) stage, and age were detected as independent prognostic factors by multivariate analysis. After reanalysis of 54 cases primarily classified as 18.5% pN0,L1, microinvasion in lymph nodes was detected by immunohistochemistry. We found a higher rate of tumor relapse (~20%) for those patients. In regard to the overall survival rate, however, there was no difference when compared to patients without immunohistochemical proof of microinvasion. Conclusion: Isolated lymph-vessel invasion in nodal-negative tumor stages and a lymph-node-positive tumor status have equivalent prognostic importance in colorectal cancer.

Behandlungsstrategien bei der akuten komplizierten Divertikulitis

ZusammenfassungDie möglichst einzeitige, elektive Resektion ist der Trend in der chirurgischen Behandlung der akuten komplizierten Divertikulitis. Lokalisierte Komplikationen werden nach Abklingen der akuten Entzündung zunehmend minimalinvasiv reseziert. Auch bei der vital bedrohlichen Perforationsperitonitis ist eine Tendenz zur primär einzeitigen Resektion erkennbar. Im Stadium der fortgeschrittenen Peritonitis hat bei multimorbiden Patienten in schlechtem Allgemeinzustand die Diskontinuitätsresektion weiterhin ihre Berechtigung. Die Hartmann-Wiederanschlussoperation kann heute risikoarm und zunehmend laparoskopisch assistiert durchgeführt werden.AbstractInterval single stage resection with primary anastomosis is the new strategy in management of acute complicated colonic diverticulitis. With increasing tendency localized complications are treated with minimally invasive techniques. Life threatening peritonitis with evidence of free perforation in old, multimorbid, bad conditioned patients should be further an indication for 2-stage resection. Laparoscopic assisted Hartmann reversal can be done with minimally invasive risk in experienced hands.

Das Ulcuscarcinom des Magens

Summary46 patients were operated upon for an ulcerocancer of the stomach. In detail the differential diagnosis and the possibilities for preoperatively establishing an exact diagnosis are described. The good results after resection of the tumor (5-year-survival rates are for early cancer 100% and for the other tumors 67.7%) demonstrate, that usually for the ulcerocancer a total gastrectomy is unnecessary. Depending on the localisation of the tumor a proximal or distal resection of the stomach is sufficient. The results indicate that tumors, in which the ulcer floor shows a partial infiltration of carcinomatous cells, are not to be called as ulcerocancer. It is suggested to speak in these cases of “primary” carcinoma of the stomach.ZusammenfassungEs wird über ein Kollektiv von 46 Patienten berichtet, die unter der Diagnose eines Ulcuscarcinoms des Magens operiert wurden. Ausführlich wird auf die Differntialdiagnose und die Möglichkeiten der präoperativen Diagnosesicherung eingegangen. Die guten Ergebnisse nach Resektion (5 Jahres-Heilung beim Frühcarcinom 100% und bei den übrigen Tumoren 67,7%) zeigen, daß - von Ausnahmen abgesehen - eine Gastrektomie beim Ulcuscarcinom nicht erforderlich ist. Je nach Tumorlokalisation ist eine proximale oder distale Magenresektion als ausreichend anzusehen. Die Untersuchung zeigt, daß solche Tumoren, bei denen der Geschwürsgrund partiell von Tumorkomplexen durchsetzt ist, nicht als Ulcuscârcinom, sondern auf Grund ihrer anderen biologischen Wertigkeit als genuine Carcinome zu bezeichnen sind. In diesen Fällen sind die prognostischen Aussichten gleichzusetzen mit den Erfahrungen beim primären Magenkrebs.

Frequency and Late Results of Local Recurrence and Metachronous Distant Metastases in Rectal Cancer

Over a 5-year period (1990 to 1995) 425 patients were operated on for rectal cancer. There were 48 local recurrences, 15 with additional distant metastases, 61 patients only had distant metastases. In our patients we found as a well known fact an increasing number of local recurrences and distant metastases with an increasing T- or N stage, no metastases in cases of low tumor grading (28/425 G1), but a high increase comparing patients with or without blood vessel invasion (V 12.3%, V1 42.9%). Lymphatic vessel invasion also shows a higher rate of local recurrences and distant metastases, even in nodal and blood vessel negative patients (L0, N0, V0, L1, N0, V0 60%).L- and V-positive patients should be included in a postoperative adjuvant therapy regime as well (together with all cases Stage II and III UICC), even in nodal negative cases.ZusammenfassungIn einem Zeitraum von fünf Jahren (1990 bis 1995) wurden 425 Patienten wegen eines Rektumkarzinoms operiert. 48 Patienten entwickelten ein lokales Tumorrezidiv, 15 hatten zusätzlich Fernmetastasen und 61 Patienten nur Fernmetastasen. Wir fanden bei unseren Patienten die bekannten Einflussfaktoren bestauml;tigt, nämlich steigende Rate an Lokalrezidiven und Metastasen mit höherem T- und N-Stadium, keine Metastasen bei Tumoren niedriger Malignität (28/425 G1), aber eine deutliche Zunahme bei den Fällen mit Blutgefäßeinbruch (V0 12,3%, V1 42,9%). Lymphgefäßeinbruch des Tumors führte ebenfalls zu einer deutlich höheren Rate an Lokalrezidiven oder Fernmetastasen (L0, N0, V0 6,7%, L1, N0, V0 60%).L- und V-positive Patienten sollten wie die Fälle des UICC-Stadiums II und III in ein adjivantes postoperatives Therapieregime mit einbezogen werden.

Die multiviszerale Resektion zur Behandlung fortgeschrittener kolorektaler Karzinome

ZusammenfassungZur Einhaltung strenger onkologischer Kriterien ist bei etwa 10% der Patienten mit einem lokal fortgeschrittenen kolorektalen Karzinom eine multiviszerale En-bloc-Resektion notwendig. Wir haben retrospektiv aus einem Kollektiv von 2 462 Patienten, die in den Jahren 1984 bis 1995 wegen eines kolorektalen Karzinoms operiert wurden, insgesamt 173 (7%) nach multiviszeraler Resektion analysiert. Das Durchschnittsalter lag bei 71 Jahren. Das Karzinom war mit 63% am häufigsten im Sigma und Rektum lokalisiert. In 102 Fällen wurden ein zusätzliches Nachbarorgan, bei den restlichen 71 Operationen zwei und mehr multiviszeral entfernt. In Vordergrund standen Organe des inneren weiblichen Genitales, gefolgt von Dünndarm- und Harnblasenteilresektionen. Eine tatsächliche histologische Tumorinfiltration lag in 55% vor. Chirurgische postoperative Komplikationen traten in 11,4% der Eingriffe auf, die 30-Tage-Letalität betrug 3,6%.Die Fünf-Jahres-Überlebensrate aller multiviszeral resezierten Patienten betrug 42%, die der kurativ operierten 51% gegenüber 0% der palliativ resezierten Patienten. Bei der Ermittlung der stadienbezogenen Fünf-Jahres-Überlebensrate fanden sich für das UICC-Stadium II bzw. III Werte von 58% bzw. 43%, nahezu identische Ergebnisse wie bei konventionellen, nicht erweiterten Resektionen.AbstractAbout 10% of patients with colorectal cancer have locally advanced tumors, so only a multivisceral en bloc resection offers the chance to radically remove the local disease and effect a cure. Between 1984 and 1995, 173 (7%) out of a total of 2,462 patients undergoing resection for colorectal carcinoma underwent a multivisceral resection. The mean patient age was 71 years. In the majority of cases (63%), the primary tumor originated in the sigmoid colon or rectum. In 102 patients, only a single neighboring organ was additionally removed, while the remaining patients had involvement of 2 or more contiguous organs. Topping the list were the internal female genital organs, with small bowel and urinary bladder in second place. A true, histologic proven tumor invasion of 1 or more contiguous organs was found in 55% of the patients. Postoperative surgical complications were observed in 11.4% of the patients, the 30-day mortality rate was 3.6%.The 5-year survival rate of the overall group of patients was 42%; the corresponding figure for those patients undergoing curative resection was 51%, compared with 0% for patients receiving only palliative surgery. Stage-related survivals revealed a 5-year survival rate of 58% for UICC Stage II and 43% for Stage III with no noteworthy differences to conventional non multivisceral resections.