F. Marusch

Protective defunctioning stoma in low anterior resection for rectal carcinoma

Anastomotic leak is a serious complication of resection for low rectal carcinoma.

Value of a Protective Stoma in Low Anterior Resections for Rectal Cancer

AbstractINTRODUCTION: Anastomotic leakage is a major problem in colorectal surgery and in particular in operations for low rectal cancer. The present study investigates the question whether a protective stoma can reduce the (clinical and radiologic) anastomotic leakage rate and/or the rate of leakage requiring surgery. METHODS: The investigation took the form of a prospective multicenter study involving 75 German hospitals and was performed between January 1, 1999, and December 31, 1999. A comparison was made of the postoperative results of procedures performed with and those performed without a protective stoma in patients undergoing low anterior rectal resection. In addition, logistic regression using the target criteria, overall anastomotic leakage and anastomotic leakage requiring surgery, was applied. RESULTS: Among the 3,695 operations performed for carcinoma of the rectum or colon, 482 were low anterior resections. In 334 patients (69.3 percent) no protective stoma was constructed, whereas 148 (30.7 percent) received such protection. Age, American Society of Anesthesiologists physical status, and body mass index were identical in both groups. In the group receiving a protective stoma, however, neoadjuvant radiochemotherapy was more common, the tumors were lower—and thus the total mesorectal excision rate higher, the intraoperative complication rate was higher, and the duration of the operation was longer. The differences were all significant. The major criterion (overall anastomotic leakage rate) was identical in the two groups, but the rate of leakage requiring surgery was significantly lower in patients receiving a protective stoma (P = 0.028). The logistic regression revealed that use of a protective stoma is a predictor of protection against anastomotic leakage requiring surgery. The distance of the tumor from the anal verge and the duration of the operation are further predictors. CONCLUSION: The particular benefit of a covering stoma is reduction in the rate of leaks requiring surgery and thus in the severe consequences of an anastomotic leakage.

Impact of anastomotic leakage on oncological outcome after rectal cancer resection

Anastomotic leakage has a major impact on morbidity and mortality in rectal cancer surgery. Its relevance to oncological outcome is controversial. This observational study investigated the influence of anastomotic leakage on oncological outcome.

The Impact of the Risk Factor “Age” on the Early Postoperative Results of Surgery for Colorectal Carcinoma and Its Significance for Perioperative Management

The risks and benefits of surgery for colorectal cancer in old patients have not been unequivocally defined. The present investigation was carried out in 309 hospitals as a prospective multicenter study. In the period between 1 January 2000 and 31 December 2001, a total of 19,080 patients were recruited for the study; 16,142 (84.6%) patients were younger than 80 years (<80) and 2932 (15.4%) were 80 years and older (≥ 80). Significant differences between the age groups were observed for general postoperative complications (22.3% for <80 years; 33.9% for ≥ 80). Specific postoperative complications were identical in both groups. Overall, significantly elevated morbidity and mortality rates were found with increasing age (morbidity: 33.9% vs. 43.5%; mortality: 2.6% vs. 8.0%). The distribution of tumor stages revealed a significantly higher percentage of locally advanced tumors in the older age group (stage II: 28.0% vs. 34.4%). In contrast, no increase in metastasizing tumors was found in the older age group (stage IV: 17.4% vs. 14.1%). Logistic regression showed that, in concert with a number of other parameters, age is a significant influencing factor on postoperative morbidity and mortality. The increase in postoperative morbidity and mortality rates associated with aging is a result of the increase in general postoperative complications, in particular, pneumonia and cardiovascular complications. Age as such does not represent a contraindication for surgical treatment. The short-term outcome and quality of life are of overriding importance for the geriatric patient.

Prospektive Multizenterstudien “Kolon-/Rektumkarzinome” als flächendeckende chirurgische Qualitätssicherung

AbstractIntroduction. Currently, only a small percentage of the diagnostic and therapeutic data on colonic carcinomas has been confirmed by data obtained in randomized controlled studies. For this reason, the results of prospective multicentre observational studies are extremely important. Method. Within a multicentre observational study involving 75 surgical departments carried out between 01.01. and 31.12.1999, 3,756 patients with a colorectal carcinoma (2,293 carcinoma of the colon; 1,463 carcinomas or the rectum) were investigated prospectively using a standardised questionnaire. Results. The OP rate was 98.4%, the resection rate 92.5% (colon 94.1%, rectum 89.9%). The rate of rectal extirpations was relatively high at 30.3%. General postoperative morbidity was 27.4% (colon 27.0%, rectum 27.9%); the specific postoperative morbidity was 24.6% (colon 21.8%, rectum 29.1%). The anastomotic insufficiency rate was 5.2% (colon 3.7%, rectum 9.5%). The 30-day mortality rate was 4.7%, and the postoperative mortality rate 5.7%. Conclusions. Surgical quality control in the form of prospective multicentre observational studies make possible the analysis of the therapeutic situation of a surgical disease under quality assurance aspects. At the same time, the comprehensive data material available will serve the specific planning of prospective randomized studies. With the aid of the present study, a basis for a thorough and complete evaluation of colorectal carcinoma has been created.ZusammenfassungHintergrund. Nur ein geringer Teil der Diagnostik und Therapie des kolorektalen Karzinoms ist derzeit durch prospektiv randomisierte Studiendaten abgesichert. Aus diesem Grund kommt den Ergebnissen prospektiver multizentrischer Beobachtungsstudien ein hoher Stellenwert zu. Methode. Innerhalb einer multizentrischen Beobachtungsstudie wurden vom 01.01.–31.12.1999 an 75 Kliniken 3.756 Patienten mit einem kolorektalen Karzinom (2.293 Kolonkarzinome, 1.463 Rektumkarzinome) mittels eines standardisierten Fragebogens prospektiv erfasst. Ergebnisse. Die Operationsrate betrug 98,4%. Die Resektionsquote lag bei 92,5% (Kolon 94,1%, Rektum 89,9%). Die Rektumexstirpationsquote war mit 30,3% relativ hoch. Die allgemeine postoperative Morbidität betrug 27,4% (Kolon 27,0%, Rektum 27,9%), die spezifische postoperative Morbidität 24,6% (Kolon 21,8%, Rektum 29,1%). Die Anastomoseninsuffizienzrate lag bei 5,2% (Kolon 3,7%, Rektum 9,5%). Es war eine 30-Tage-Letalität von 4,7% und eine postoperative Letalität von 5,7% zu verzeichnen. Schlussfolgerung. Chirurgische Qualitätssicherung in Form von prospektiven multizentrischen Beobachtungsstudien ermöglicht die Analyse der Behandlungssituation eines chirurgischen Krankheitsbildes unter qualitätssichernden Aspekten. Gleichzeitig wird mit dem vorliegenden umfangreichen Datenmaterial die gezielte Planung von prospektiv randomisierten Studien unterstützt. Mit dieser Studie wurden die Grundlagen für eine bundesweite Erfassung der kolorektalen Karzinome geschaffen.

Effect of caseload on the short-term outcome of colon surgery: results of a multicenter study

Abstract This prospective multicenter study investigated the effect of hospital caseload on early postoperative outcome of surgery for carcinoma of the colon in 75 German hospitals and included 2293 patients. The hospitals were divided into those with a caseload of 1–30 (group A), 31–60 (group B), and more than 60 (group C) operations. Increasing caseload was associated only with fewer general postoperative complications. It was also associated with significantly greater use of antibiotic prophylaxis. No significant differences between the groups were found in resection rates, intraoperative complications, specific postoperative complications, overall postoperative morbidity, hospital mortality, or 30-day mortality. The significance of hospital caseload for the short-term postoperative outcome following surgery on the colon should not be overestimated. Basing conclusions about the results to be expected simply on the case volume is impermissible. On the basis of the available data it is not possible to establish a threshold value, that is, a minimum number of required operations.

Emergency operation in carcinomas of the left colon: value of Hartmann’s procedure

BackgroundColonic resection according to the procedure by Hartmann is considered a fast and safe surgical intervention, which has been used for years, in particular, in emergency situations.MethodsUsing data of a prospective multicentre study on the operative treatment of colorectal carcinoma over the time period from 1 January 2000 to 31 December 2002, the value of Hartmann’s procedure was investigated in carcinoma of the left colon (n=8825) compared with alternative surgical options under emergency circumstances. The significant impact of independent variables on the type of the selected approach was determined by means of logistic regression.ResultsWhile in total 422 primary Hartmann’s procedures (4.8%) were executed under curative intention, 213 (50.5%) of those were carried out in emergency situations. Hartmann’s procedure was beneficial in cases with tumour-associated obstruction and perforation of the left colon as it resulted in the lowest mortality (7.5%) of the radical operations. Even under palliative intention, Hartmann’s procedure was preferred at the left colon but led to a postoperative mortality (32.7%) very similar to that in creation of a colostoma (33.3%) or segmental colonic resection (38.9%).ConclusionsHartmann’s procedure has been widely accepted as a curative intervention in emergency cases (oncosurgically adequate R0 resection) for the carcinoma of the left colon. Because of the high postoperative morbidity and mortality in emergency situations with only palliative options (R0 resection not possible), alternative endoscopic treatment should be considered more frequently.

Stellenwert der Rektumexstirpation im Therapiekonzept des tief sitzenden Rektumkarzinoms

AbstractIntroduction. The main objective of surgery of rectal carcinomas is to avoid a permanent colostomy by sphincter-sparing surgical procedures. A variety of different abdominoperineal resection rates is described in the literature. Material/method. The study was performed in 2000 within the framework of a multicentric study including 282 hospitals.The purpose of the study was to document the quality of diagnosis and therapy for colorectal carcinomas.A total of 9477 patients were included in this study: 3402 suffering from a rectal carcinoma and 6075 suffering from a colon carcinoma. Results. A total of 866 abdominoperineal resections was performed. This corresponds to an abdominoperineal resection rate of 27.4%. In 30.4% of all men and in 23.0% of all women an abdominoperineal resection was performed.Of all tumor patients who underwent abdominoperineal resection, 8.3% had a pT4 carcinoma and 57.5% a pT3 carcinoma.Adapted to the localization of the tumor in the rectum, i.e., the distance of the aboral tumor margin to the anal verge, the following abdominoperineal resection rates were found: <4 cm from the anal verge 84.6%, 4–7.9 cm 43.9%, 8–11.9 cm 5.8%, and 12–16 cm 0.5%.Intraoperative complications occurred in 11.8%, specific postoperative complications in 33.1%, and general postoperative complications in 27.4% of the patients.The postoperative lethality was 2.8%. The mean postoperative hospital stay was 21.7 days.Logistic regression identified the body mass index, gender, the distance of the carcinoma from the anal verge, and the T category as independent factors influencing the abdominoperineal resection rate. Discussion. Despite an overall decrease in use, abdominoperineal resection will continue to play an important role for the surgical treatment of low rectal cancers in routine clinical practice in Germany.It will remain an individual decision for each patient whether the tumor and the patient allow sphincter preservation or whether abdominoperineal resection seems to be necessary.According to the results of the present study,a general definition of an abdominoperineal resection rate in an unselected group of patients should be viewed critically.ZusammenfassungEinleitung. Die Vermeidung einer permanenten Kolostomie durch sphinktererhaltende Operationsverfahren ist ein Hauptziel der Rektumkarzinomchirurgie. In der Literatur werden sehr unterschiedliche Rektumexstirpationsraten angegeben. Material/Methode. Die Untersuchung wurde innerhalb einer prospektiven Multicenterstudie zur Erfassung der Qualität der Diagnostik und Therapie des kolorektalen Karzinoms an 282 Kliniken innerhalb des Jahres 2000 durchgeführt. In dieser Untersuchung wurden 9.477 Patienten erfasst, 3.402 mit einem Rektumkarzinom und 6.075 mit einem Kolonkarzinom. Ergebnisse. Es wurden 866 Rektumexstirpationen durchgeführt.Dies entspricht einer Rektumexstirpationsrate von 27,4%; 30,4% aller Männer mit einem Rektumkarzinom und 23,0% aller Frauen wurden einer Rektumexstirpation unterzogen; 8,3% aller Tumore, die einer Rektumexstirpation zugeführt wurden,hatten eine pT4-Kategorie und 57,5% eine pT3-Kategorie.Die Rektumexstirpationsraten, adaptiert an die Höhenlokalisation des Tumors,d.h.Abstand des aboralen Tumorrandes von der Anokutanlinie, betrugen: <4 cm ab ACL – 84,6%, 4–7,9 cm – 43,9%,8–11,9 cm – 5,8% und 12–16 – – 0,5%.Intraoperative Komplikationen traten in 11,8%, spezifische postoperative Komplikationen in 33,1% und allgemeine postoperative Komplikationen in 27,4% auf.Die postoperative Letalität betrug 2,8%.Die postoperative Verweildauer lag bei 21,7 Tagen.Die logistische Regression zeigte den BMI,das Geschlecht, die Höhe des Karzinoms und die T-Kategorie als unabhängige Einflussfaktoren auf die Rektumexstirpationsrate. Diskussion. Trotz insgesamt rückläufiger Häufigkeit spielt die abdominoperineale Rektumexstirpation in Deutschland auch weiterhin eine bedeutende Rolle bei der operativen Therapie tief sitzender Rektumkarzinome im klinischen Alltag. Es bleibt eine individuelle Entscheidung bei jedem einzelnen Patienten, ob eine Sphinktererhaltung von Seiten des Tumors und des Patienten machbar ist oder ob eine Exstirpation erforderlich erscheint. Die generelle Vorgabe einer Rektumexstirpationsrate bei einem unselektionierten Krankengut sollte nach den Ergebnissen der vorliegenden Untersuchung sehr kritisch gesehen werden.

Importance of rectal extirpation for the therapy concept of low rectal cancers

AbstractIntroduction. The main objective of surgery of rectal carcinomas is to avoid a permanent colostomy by sphincter-sparing surgical procedures. A variety of different abdominoperineal resection rates is described in the literature. Material/method. The study was performed in 2000 within the framework of a multicentric study including 282 hospitals.The purpose of the study was to document the quality of diagnosis and therapy for colorectal carcinomas.A total of 9477 patients were included in this study: 3402 suffering from a rectal carcinoma and 6075 suffering from a colon carcinoma. Results. A total of 866 abdominoperineal resections was performed. This corresponds to an abdominoperineal resection rate of 27.4%. In 30.4% of all men and in 23.0% of all women an abdominoperineal resection was performed.Of all tumor patients who underwent abdominoperineal resection, 8.3% had a pT4 carcinoma and 57.5% a pT3 carcinoma.Adapted to the localization of the tumor in the rectum, i.e., the distance of the aboral tumor margin to the anal verge, the following abdominoperineal resection rates were found: <4 cm from the anal verge 84.6%, 4–7.9 cm 43.9%, 8–11.9 cm 5.8%, and 12–16 cm 0.5%.Intraoperative complications occurred in 11.8%, specific postoperative complications in 33.1%, and general postoperative complications in 27.4% of the patients.The postoperative lethality was 2.8%. The mean postoperative hospital stay was 21.7 days.Logistic regression identified the body mass index, gender, the distance of the carcinoma from the anal verge, and the T category as independent factors influencing the abdominoperineal resection rate. Discussion. Despite an overall decrease in use, abdominoperineal resection will continue to play an important role for the surgical treatment of low rectal cancers in routine clinical practice in Germany.It will remain an individual decision for each patient whether the tumor and the patient allow sphincter preservation or whether abdominoperineal resection seems to be necessary.According to the results of the present study,a general definition of an abdominoperineal resection rate in an unselected group of patients should be viewed critically.ZusammenfassungEinleitung. Die Vermeidung einer permanenten Kolostomie durch sphinktererhaltende Operationsverfahren ist ein Hauptziel der Rektumkarzinomchirurgie. In der Literatur werden sehr unterschiedliche Rektumexstirpationsraten angegeben. Material/Methode. Die Untersuchung wurde innerhalb einer prospektiven Multicenterstudie zur Erfassung der Qualität der Diagnostik und Therapie des kolorektalen Karzinoms an 282 Kliniken innerhalb des Jahres 2000 durchgeführt. In dieser Untersuchung wurden 9.477 Patienten erfasst, 3.402 mit einem Rektumkarzinom und 6.075 mit einem Kolonkarzinom. Ergebnisse. Es wurden 866 Rektumexstirpationen durchgeführt.Dies entspricht einer Rektumexstirpationsrate von 27,4%; 30,4% aller Männer mit einem Rektumkarzinom und 23,0% aller Frauen wurden einer Rektumexstirpation unterzogen; 8,3% aller Tumore, die einer Rektumexstirpation zugeführt wurden,hatten eine pT4-Kategorie und 57,5% eine pT3-Kategorie.Die Rektumexstirpationsraten, adaptiert an die Höhenlokalisation des Tumors,d.h.Abstand des aboralen Tumorrandes von der Anokutanlinie, betrugen: <4 cm ab ACL – 84,6%, 4–7,9 cm – 43,9%,8–11,9 cm – 5,8% und 12–16 – – 0,5%.Intraoperative Komplikationen traten in 11,8%, spezifische postoperative Komplikationen in 33,1% und allgemeine postoperative Komplikationen in 27,4% auf.Die postoperative Letalität betrug 2,8%.Die postoperative Verweildauer lag bei 21,7 Tagen.Die logistische Regression zeigte den BMI,das Geschlecht, die Höhe des Karzinoms und die T-Kategorie als unabhängige Einflussfaktoren auf die Rektumexstirpationsrate. Diskussion. Trotz insgesamt rückläufiger Häufigkeit spielt die abdominoperineale Rektumexstirpation in Deutschland auch weiterhin eine bedeutende Rolle bei der operativen Therapie tief sitzender Rektumkarzinome im klinischen Alltag. Es bleibt eine individuelle Entscheidung bei jedem einzelnen Patienten, ob eine Sphinktererhaltung von Seiten des Tumors und des Patienten machbar ist oder ob eine Exstirpation erforderlich erscheint. Die generelle Vorgabe einer Rektumexstirpationsrate bei einem unselektionierten Krankengut sollte nach den Ergebnissen der vorliegenden Untersuchung sehr kritisch gesehen werden.

Offene vs. laparoskopische Appendektomie

ZusammenfassungAnhand der Daten randomisierter Studien, der Analyse von Metaanalysen und der Darstellung von Daten einer eigenen nicht randomisierten Multicenterstudie zur Evaluierung der Appendizitisbehandlung in der klinischen Routine wird der derzeitige Wissensstand zu der Fragestellung, ob eine Appendektomie laparoskopisch oder offen erfolgen sollte, diskutiert. Die offene Appendektomie (OA) bietet in der Analyse der Daten einen Vorteil insbesondere hinsichtlich einer signifikant kürzeren Operationszeit und geringerer stationärer Kosten. Die laparoskopische Appendektomie (LA) zeichnet sich durch eine signifikant verringerte Rate septischer Wundheilungsstörungen und schnellere Rekonvaleszenz aus. Bei der akuten Appendizitis können beide Verfahren mit der gleichen Sicherheit und einem vergleichbaren “out come” angewandt werden. Vorteile für die laparoskopische Appendektomie werden insbesondere in der diagnostischen Abklärung von Unterbauchbeschwerden bei Frauen im geburtsfähigen Alter und bei übergewichtigen Patienten gesehen. In der Behandlung der Appendicitis perforata kann nach der derzeitigen Datenlage keine eindeutige Antwort gegeben werden. Auffällig sind jedoch tendenzielle Hinweise für eine erhöhte postoperative intraabdominelle Abszessrate nach laparoskopischer Appendektomie, sodass bei fortgeschrittener Appendizitis das laparoskopische Vorgehen derzeit nicht als Standardverfahren angesehen werden kann.AbstractThis article discusses the question of whether open or laparoscopic appendectomy is preferable in todays clinical routine. The article is based on data from randomized studies, evaluation of meta-analyses, and data from nonrandomized, multicentric studies evaluating the treatment of appendicitis in routine clinical practice. According to the data analysis, open appendectomy (OA) offers advantages with regard to a significantly shorter operative time and lower hospital costs. Laparoscopic appendectomy (LA) is characterized by a significantly decreased rate of failed septic wound healing and faster recovery. Both procedures can be performed with the same degree of safety and comparable outcome for acute appendicitis. Laparoscopic appendectomy offers significant advantages for establishing a precise diagnosis in young fertile women and overweight patients suffering from lower abdominal pain. The currently available data do not provide precise guidelines for the treatment of perforating appendicitis. However, we found significant evidence indicating an increased rate of postoperative intra-abdominal abscess after laparoscopic appendectomy. Thus, a laparoscopic approach cannot be regarded as a standard technique in advanced appendicitis.