Dieter Bussen

Influence of tumor position on accuracy of endorectal ultrasound staging.

Endorectal ultrasound is a well-established method of preoperative staging of rectal neoplastic lesions. PURPOSE: This study was undertaken to evaluate whether tumor site (in terms of height) and position (with respect to the rectal circumference) have an influence on the reliability of endoluminal ultrasound staging. METHODS: From January 1991 to May 1996, 154 consecutive patients with a total of 162 rectal tumors were examined preoperatively using endorectal ultrasound. Apart from staging all tumors using the uT/uN classification, tumor level and tumor position were recorded prospectively. Neoplasms were subdivided into low rectal (0–6 cm from the anal verge), mid rectal (7–12 cm), and higher lesions (>12 cm). Furthermore, the lumen was divided into an anterior, left lateral, posterior, and right lateral position, and all tumors, apart from circular lesions (n=9), were subclassified accordingly. RESULTS: Overall, we found 40 (25 percent) adenomas, 15 (9 percent) T1, 29 (18 percent) T2, 67 (41 percent) T3, and 11 (7 percent) T4 lesions. Overall accuracy was 78 percent. Staging accuracy for low rectal tumors (n=41) was 68 percent, whereas 76 and 88 percent of mid (n=96) and high (n=25) neoplasms were staged correctly, respectively. The difference was not statistically significant. With regard to position, 47 tumors were situated anteriorly (77 percent accuracy), 42 in the left lateral position (69 percent accuracy), 33 posteriorly (73 percent accuracy), and 31 in the right lateral position (81 percent accuracy). Differences did not reach statistical significance. CONCLUSION: Endorectal ultrasound is currently the best method for preoperative assessment of the depth of infiltration of rectal tumors. However, rectal anatomy seems to affect staging accuracy in the lower rectum because the structure of the ampulla recti renders endosonographic examination more difficult. In addition, endosonographic layers are less well defined at this level. Both factors contribute to a lower reliability and predictive value of endorectal ultrasound staging in the lower rectum, although statistical significance was not reached in this study. On the other hand, tumor position with respect to rectal circumference does not influence the predictive value of endorectal ultrasound.

Endoscopic Ultrasound–Guided Transrectal Biopsies of Pelvic Tumors

The aim of this study was to evaluate the feasibility, safety, and diagnostic accuracy of endorectal ultrasound-guided biopsies in patients with extrarectal lesions. Data from all patients with suspicious pelvic pathology who underwent endorectal ultrasound-guided biopsies were collected prospectively. To evaluate the accuracy of the diagnosis, all patients with benign histology but primary suspicion of a malignant lesion were followed up for at least 12 months. A total of 48 patients whose median age was 66 years were evaluated. Apart from one postbiopsy hemorrhage, which was managed conservatively, no other complications were encountered. Sufficient tissue was removed to allow histologic examination in all cases. A large variety of diagnoses including primary and secondary malignancies (n = 25) as well as benign pathologies (n = 23) could be established. There were no false positive but three false negative histologies in patients with proven local recurrence of a malignant tumor during the follow-up period. This results in a sensitivity of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 89%. It is concluded that endoscopic ultrasound-guided transrectal biopsy is a safe method with a high diagnostic accuracy in the assessment of pelvic tumors.

DeloRes trial: study protocol for a randomized trial comparing two standardized surgical approaches in rectal prolapse - Delorme’s procedure versus resection rectopexy

BackgroundMore than 100 surgical approaches to treat rectal prolapse have been described. These can be done through the perineum or transabdominally. Delorme’s procedure is the most frequently used perineal, resection rectopexy the most commonly used abdominal procedure. Recurrences seem more common after perineal compared to abdominal techniques, but the latter may carry a higher risk of peri- and postoperative morbidity and mortality.Methods/DesignDeloRes is a randomized, controlled, observer-blinded multicenter trial with two parallel groups. Patients with a full-thickness rectal prolapse (third degree prolapse), considered eligible for both operative methods are included. The primary outcome is time to recurrence of full-thickness rectal prolapse during the 24 months following primary surgery. Secondary endpoints are time to and incidence of recurrence of full-thickness rectal prolapse during the 5-year follow-up, duration of surgery, morbidity, hospital stay, quality of life, constipation, and fecal incontinence. A meta-analysis was done on the basis of the available data on recurrence rates from 17 publications comprising 1,140 patients. Based on the results of a meta-analysis it is assumed that the recurrence rate after 2 years is 20% for Delorme’s procedure and 5% for resection rectopexy. Considering a rate of lost to follow-up without recurrence of 30% a total of 130 patients (2 x 65 patients) was calculated as an adequate sample size to assure a power of 80% for the confirmatory analysis.DiscussionThe DeloRes Trial will clarify which procedure results in a smaller recurrence rate but also give information on how morbidity and functional results compare.Trial registrationGerman Clinical Trial Number DRKS00000482

Severe pyomyositis caused by Panton–Valentine leucocidin-positive methicillin-sensitive Staphylococcus aureus complicating a pilonidal cyst

BackgroundTo our best knowledge, Panton–Valentine leucocidin (PVL)-positive methicillin-sensitive Staphylococcus aureus (MSSA) has not been described yet as cause for severe pyomyositis.Case reportWe present a 23-year-old apparently healthy male patient without any typical predisposing findings who developed severe pyomyositis secondary to an operated pilonidal cyst. In the follow-up, the patient showed signs of immunocompromisation. The causative agent for purulent infection of multiple muscles was a MSSA strain harbouring PVL toxin.ResultsIn the reported case, aggressive antibiotic and surgical treatment with additional application of immunoglobulins has lead to recovery from the disease without relapse.ConclusionsPVL-positive S. aureus are associated with skin diseases, multiple abscesses and often complicated by severe sepsis and necrotising pneumonia. Under such circumstances, the mortality rate can reach up to 75%. In addition, the PVL toxin can cause immunocompromisation and might be therefore involved in the aetiology of pyomyositis. Aggressive antibiotic and surgical treatment with additional application of immunoglobulins is recommended for treatment.

Die Endosonographie des Analkarzinoms

ZusammenfassungZur exakten Therapieplanung des Analkarzinoms ist das prätherapeutische Staging von großer Bedeutung. Während früher hie operative Entfernung maligner Analkarzinome als Standardbehandlung galt, werden heutzutage die meisten Tumoren durch eine kombinierte Radiochemotherapie therapiert. Mit Hilfe der analen Endosonographie verfügen wir erstmals über ein bildgebendes Verfahren, das eine präzise Erfassung der Tiefeninfiltration des Karzinoms erlaubt. Außerdem kann eine etwaige Beteiligung des Schließmuskelapparats beurteilt werden. Von Januar 1993 bis Oktober 1996 wurden an der Chirurgischen Universitätsklinik Würzburg 19 Patienten (Alter 43 bis 90 Jahre; 13 weiblich, sechs männlich) mit einem histologisch gesicherten Plattenepithelkarzinom des Analrands (n=11) bzw.-kanals (n=8) endosonographisch untersucht. Bis auf einen Patienten mit einem hochgradig stenosierenden Tumor konnten alle Befunde exakt dokumentiert werden. Es fanden sich fünf uTI-Karzinome, acht uT2-, drei uT3- und zwei uT4-Karzinome. Das Ansprechen auf die Primärtherapie kann durch den Nachweis der Tumorregression dargestellt werden. Im Rahmen der regelmäßigen Tumornachsorge empfehlen wir die Endosonographie zur Erfassung von subanodermalen Rezidiven, die gegebenenfalls endosonographisch gezielt biopsiert werden können.SummaryA precise pretherapeutic staging of anal carcinomas is important for their correct treatment. While surgical excision used to be the standard method in the treatment of anal malignancies, most tumors are nowadays dealt with using combined radiochemotherapy. With the aid of anal endosonography the depth of tumor infiltration can be precisely assessed. Furthermore anal sphincter involvement can be visualised. From January 1993 to October 1996 at the Department of Surgery of the University Hospital Würzburg, Germany we examined 19 patients (age: 43 to 90 years; 13 female, 6 male) with histologically proven squamous cell carcinomas of the anal margin (n=11) or anal canal (n=8). Apart from one patient with a highly stenosing cancer all other tumors could be exactly classified. We found 5 uT1, 8 uT2, 3 uT3, and 2 uT4 cancers. Treatment response could be assessed by reduction of tumor size. We recommed regular anal endosonography in the follow-up of treated patients. Subanodermal recurrences can thus be detected and biopsied under ultrasound guidance.

Bundesweite Umfrage zum therapeutischen Vorgehen bei Hämorrhoidalleiden und Analfissur

Summary. A survey among coloproctologists was performed to assess current therapeutic concepts for the treatment of hemorrhoidal disease and anal fissure. A total of 261 clinical and non-clinical proctologists participated, representing the entire range of therapies in hospital and practise. A wealth of widely differing, in some aspects contradictory concepts were recorded, leaving almost no subject entirely undisputed. There are controversies regarding the different therapeutic alternatives as well as indications for surgery and choice of operative procedure. Future research has to address the existing controversies in order to reach a higher degree of standardization in the therapy of these common proctological disorders.Zusammenfassung. Mit einer bundesweit unter coloproktologisch tätigen Ärzten durchgeführten Umfrage wurden Konzepte und Kontroversen in der Behandlung von Hämorrhoidalleiden und Analfissuren erhoben. Unter den 261 Umfrageteilnehmern befinden sich sowohl klinisch tätige als auch niedergelassene Proktologen, wodurch der aktuelle Stand und das gesamte Spektrum der Behandlungsformen vertreten sind. Neben einer üppigen Therapievielfalt bestehen auch deutlich unterschiedliche und z. T. widersprüchliche Behandlungskonzepte. Kontroversen zeigen sich sowohl in der Beurteilung der diversen konservativen Therapieformen als auch in der Indikationsstellung und Verfahrenswahl der operativen Therapie. Eine wissenschaftliche Klärung bestehender Kontroversen und damit eine größere Einheitlichkeit in Diagnostik und Therapie sind anzustreben.

[Operations for hemorrhoids: indications and techniques].

ZusammenfassungDas Hämorrhoidalleiden ist eine der häufigsten Erkrankungen überhaupt, ohne Therapie ist meist mit einer Progredienz des Leidens zu rechnen. Therapeutisch sind konservative Maßnahmen und in den fortgeschrittenen Stadien operative Verfahren Mittel der Wahl. In Deutschland werden 40.000 bis 50.000 Operationen pro Jahr durchgeführt. Mit den heute zur Verfügung stehenden unterschiedlichen Operationstechniken ist das Ziel eine individualisierte Therapie und Indikationsstellung. Damit ist eine hohe Heilungsrate, niedrige Komplikationsrate und hohe Patientenzufriedenheit erreichbar.AbstractHaemorrhoidal disease is one of the most common diseases in general and will in most cases progress without therapy. In the therapeutic context the means of choice are conservative therapies and in the advanced stage of the disease operative measures are necessary. In Germany 40,000–50,000 operations are performed each year. Our aim with the currently available various operation techniques is individualized therapy and indications. Thus a high healing rate, low complication rate and high patient satisfaction can be achieved.Haemorrhoidal disease is one of the most common diseases in general and will in most cases progress without therapy. In the therapeutic context the means of choice are conservative therapies and in the advanced stage of the disease operative measures are necessary. In Germany 40,000-50,000 operations are performed each year. Our aim with the currently available various operation techniques is individualized therapy and indications. Thus a high healing rate, low complication rate and high patient satisfaction can be achieved.

Vergleich der dynamischen MR-Defäkographie und konventionellen Röntgendefäkographie in der Diagnostik der Beckenbodeninsuffizienz

ZusammenfassungHintergrund:Ziel dieser Arbeit war, die Magnetresonanz-(MR)-Defäkographie mit der konventionellen Röntgendefäkographie in der Diagnostik der Beckenbodeninsuffizienz zu vergleichen.Patienten und Methoden:Von Juli 1998 bis Oktober 1999 wurden bei 30 Patientinnen, die sich wegen Beschwerden einer Beckenbodeninsuffizienz vorstellten, sowohl eine konventionelle Röntgendefäkographie als auch eine dynamische MR-Defäkographie durchgeführt. Durch zwei unabhängige Untersucher wurden mittels beider Techniken während der Defäkation die Veränderung des anorektalen Winkels, die Absenkung des anorektalen Übergangs und die Größe der vorderen Rektozele ermittelt.Ergebnisse:Bezüglich des anorektalen Winkels unter Defäkation und der Ausdehnung der vorderen Rektozele bestand zwischen beiden Methoden eine signifikante Korrelation (r = 0,60; p < 0,001; r = 0,81; p < 0,0001). Weder für die Absenkung des anorektalen Übergangs (r = 0,29; p = 0,12) noch für die Veränderung des anorektalen Winkels unter Defäkation (r = 0,16; p = 0,40) ließ sich eine Übereinstimmung der Untersuchungsergebnisse nachweisen.Schlussfolgerung:Aufgrund der hohen diagnostischen Aussagekraft der Magnetresonanztomographie (MRT) im Vergleich zu konventionellen Röntgenverfahren erscheint die dynamische MR-Defäkographie als interessante Alternative zur konventionellen Defäkographie.AbstractBackground:The aim of this study was to evaluate the diagnostic accuracy of dynamic magnetic resonance tomography (MR) in comparison with x-ray defaecography in the diagnosis of defaecation disorders.Patients and Methods:Between July 1998 and October 1999 30 consecutive patients seeking counselling for pelvic floor dysfunction were studied with dynamic MR and underwent an evacuation defaecography. Changes of the anorectal angle, the anorectal junction descent and the size of anterior rectoceles during defaecation were determined by two independent examiners for both techniques.Results:Significant correlation existed for anorectal angle under straining (r = 0,60; p < 0,001) and rectocele size as measured using the two techniques (r = 0,81; p < 0,0001). No significant correlation was found between dynamic MR and evacuation defaecography comparing either changes of anorectal angle (r = 0,16; p = 0,40) or anorectal junction descent (r = 0,29; p = 0,12).Conclusion:Although standard measurements of anorectal parameters using evacuation defaecography as well as dynamic MR imaging showed only partial correlation, MR-defecography seems to be an attractive alternative for evaluation of pelvic floor disorders.

Korrelation von Symptomen und objektiven Befunden bei Patienten mit Beckenbodendysfunktionen

ZusammenfassungFragestellung:Ziel dieser Arbeit war es zu ermitteln, welcher Zusammenhang zwischen der Symptomatik von Patienten mit Darmentleerungsstörungen und nachweisbaren morphologischen Veränderungen besteht.Patienten und Methodik:In dieser Studie wurden retrospektiv die Befunde von 116 Patienten analysiert, die sich zur Abklärung einer Darmentleerungsstörung vorstellten. Bei allen Patienten wurden folgende Untersuchungen durchgeführt: klinisch-proktologische Untersuchung, Prokto- und Rektoskopie, Defäkographie, anorektale Endosonographie, Sphinktermanometrie, Röntgendoppelkontrastuntersuchung des Kolons und Kolontransitzeitmessung.Ergebnisse:Durch eine klinisch-proktologische Untersuchung wurde bei 96% der Patienten ein pathologischer Befund wie Marisken, Narben, Rektozelen, Rektumprolaps oder Descensus perinei diagnostiziert. Mittels Defäkographie konnte gezeigt werden, dass 74% der untersuchten Patienten mit einer Beckenbodendysfunktion Rektozelen aufwiesen. Der anorektale Winkel lag bei 35% der untersuchten Patienten außerhalb des Normbereichs. Die endosonographisch darstellbaren anatomischen Strukturen zeigten bei 57% Auffälligkeiten. Bei 29% des Studienkollektivs ergab sich ein auffälliger manometrischer Befund. Mit Hilfe der Röntgendoppelkontrastuntersuchung des Kolons wurde bei 70% der untersuchten Patienten ein Colon elongatum oder ein Sigma elongatum nachgewiesen. Bei 58% des Studienkollektivs war eine pathologische Kolontransitzeit darstellbar.Schlussfolgerung:Bei der überwiegenden Anzahl untersuchter Patienten mit Symptomen einer Darmentleerungsstörung ermöglichen eine sorgfältige Anamneseerhebung und eine routinierte klinisch-proktologische Untersuchung die zuverlässige Detektion pathologischer Befunde. Durch weitergehende apparative Diagnostik lässt sich nur vereinzelt ein zusätzlicher Erkenntnisgewinn erzielen.AbstractPurpose:The aim of this study was to evaluate the correlation between the complaints of patients suffering from defecatory difficulties and the morphological findings obtained by different diagnostic tools.Patients and Methods:In this study, data of 116 patients presenting with obstruction defecation syndrome were analyzed retrospectively. The applied diagnostic procedures included clinical examination, proctorectoscopy, defecography, anorectal endosonography, anorectal manometry, barium enema, and colonic transit evaluation.Results:In 96% of the patients, the clinical examination including rectoproctoscopy showed pathologic findings. Defecography revealed a rectocele in 74% and an abnormal anorectal angle in 35% of the study collective. In 57% of the patients, morphological changes of the sphincter were detectable by anorectal sonography. Abnormal results regarding barium enema investigation and colonic transit evaluation were obtained in 70% and 58% of the study patients, respectively.Conclusion:Carefully performed clinical assessment was confirmed to be the most reliable tool for the detection of pathologic findings in patients presenting with obstruction defecation syndrome in a specialized coloproctologic outpatient unit.

Operationen beim Hämorrhoidalleiden

ZusammenfassungDas Hämorrhoidalleiden ist eine der häufigsten Erkrankungen überhaupt, ohne Therapie ist meist mit einer Progredienz des Leidens zu rechnen. Therapeutisch sind konservative Maßnahmen und in den fortgeschrittenen Stadien operative Verfahren Mittel der Wahl. In Deutschland werden 40.000 bis 50.000 Operationen pro Jahr durchgeführt. Mit den heute zur Verfügung stehenden unterschiedlichen Operationstechniken ist das Ziel eine individualisierte Therapie und Indikationsstellung. Damit ist eine hohe Heilungsrate, niedrige Komplikationsrate und hohe Patientenzufriedenheit erreichbar.AbstractHaemorrhoidal disease is one of the most common diseases in general and will in most cases progress without therapy. In the therapeutic context the means of choice are conservative therapies and in the advanced stage of the disease operative measures are necessary. In Germany 40,000–50,000 operations are performed each year. Our aim with the currently available various operation techniques is individualized therapy and indications. Thus a high healing rate, low complication rate and high patient satisfaction can be achieved.Haemorrhoidal disease is one of the most common diseases in general and will in most cases progress without therapy. In the therapeutic context the means of choice are conservative therapies and in the advanced stage of the disease operative measures are necessary. In Germany 40,000-50,000 operations are performed each year. Our aim with the currently available various operation techniques is individualized therapy and indications. Thus a high healing rate, low complication rate and high patient satisfaction can be achieved.