F. Stelzner

Unteres, kloakogenes Rektumviertel

ZusammenfassungDas distale Rektumviertel ist ein Kloakenanteil. Nur die proximalen drei Viertel gehören zum Darm. Nur sie haben ein Mesorektum. Zehn Besonderheiten kennzeichnen das kloakogene Rektumviertel: 1. die Blut- und Lymphgefäßversorgung, 2. die embryologischen und vergleichend anatomischen Befunde, 3. das zentrale Haltesystem der Denonvilliers-Faszie, 4. die besondere Innervation, 5. die Missbildung des Kontinenzorgans, 6. die MR-Bilder und die histologischen Großschnitte, 7. die PET-CT-Befunde, 8. die Muskelwandarchitektur, 9. die Kontinenzregulation, 10. der Sitz der meisten postoperativen Lokalrezidive des Rektumkarzinoms trotz automatischer Entfernung des Mesorektums, seit 100 Jahren.AbstractThe distal quarter of the rectum is derived from the cloaca and can be viewed as a specialized “sensory organ”. Only the proximal three quarters of the rectum stem phylogenetically from intestinal tissues. Therefore, only this upper portion has an associated mesorectum. A significant amount of data support the notion that profound differences exist between the enterogenic, upper segments and the cloacogenic, lower segment of the rectum: 1. differing supply with blood and Iymph vessels, 2. embryologic and comparative anatomic findings, 3. the central support system provided by Denonvilliers’ fascia, 4. specialized innervation, 5. malformations of the continence organ, 6. findings on magnetic resonance images and histologic macro sections, 7. findings on PET-CT images, 8. the muscular wall architecture of different portions of the rectum, 9. differences in basic function (storage vs continence), 10. location of most postoperative local recurrences of rectal carcinomas, even when complete mesorectal resection was performed, since hundred jears.

PET-CT-Untersuchungen der Halterung und Kontinenz der Beckenorgane

ZusammenfassungAn allen Beckenorganen sind, wie an allen Organen in den Körperhöhlen, keine Haltebänder nachweisbar, wie wir sie am Skelett erkennen. Die Beckenorgane werden trotzdem, sogar wenn sie ihren Inhalt entleeren, festgehalten. Die schon lange bekannte, unauffällige glatte Muskulatur, verstreut im Fettfüllgewebe des Beckens und an den Beckenfaszien, ganz besonders an der Denonvilliers-Faszie, ist ihr Haltesystem. Mit dem PET-CT kann das statistisch signifikant als natürliche Spontanaktivität nachgewiesen werden. Sie ist am stärksten an der Denonvilliers-Faszie. Auch die Kontinenz, Anfüllung und Entleerung hängen mit dieser Spontanaktivität und der damit verbundenen Aufsteifung in den Beckenhohlorganen zusammen. Bei der chirurgischen Therapie aller Störungen, die fließend zu Normalbefunden übergehen und oft falsch gedeutet werden, muss ihr Versagen berücksichtigt werden.AbstractLike all other organs in the chest or abdominal cavities, pelvic organs are not suspended by specialized ligaments such as those in the skeletomuscular system. In spite of this, the organs of the pelvis remain well suspended within their cavity even during evacuation. This support system for these organs consists of inconspicuous smooth muscle elements scattered throughout pelvic structural fat tissue and fascial structures, in particular Denonvilliers’ fascia. We used PET-CT studies to identify spontaneous muscle activity in the pelvis, which is strongest at Denonvilliers’ fascia. We were able to correlate continence function, filling, and evacuation of pelvic organs with this spontaneous muscle activity that leads to stiffening and relaxation of the muscular walls of these organs. During the course of different disease processes such as visceral prolapse, these pelvic support structures are prone to fail gradually. Surgical interventions should take the pelvic support system into account to avoid therapeutic errors.

Nachweis der natürlichen Spontanaktivität der kranioösophagealen und der Kehlkopfmuskulatur durch das PET-CT

ZusammenfassungWie am anorektalen Kontinenzorgan, hat auch die Muskulatur des kranialen Abschlusssystems eine andauernde, natürliche Spontanaktivität. Sie ist durch signifikant höhere Radionuklidspeicherung im PET-CT und durch einen eindeutigen Farbumschlag nachweisbar. Die Statistik der 23 Untersuchten (9 Männer, 14 Frauen) weist hochsignifikante Werte der natürlichen Spontanaktivität gegenüber inaktiver Muskulatur nach. Im Gegensatz zu der horizontal entwickelten einfachen Funktionskette der analen Sphinkteren ist das obere Abschlusssystem als lange, vertikal ineinandergreifende, röhrenförmige Muskulatur angelegt. 5 Hirnnervenpaare und 3 Nervenpaare der Sinnesorgane befeuern eine Funktionskette, die mit dem Musculus orbicularis oris beginnt und über Pharynx und Ösophagus mit dessen unterem Verschlusssegment endet. Dazwischen liegt der Eingang des Luftweges, dessen singulärer Öffnungsmuskel im Kehlkopf diesen zumeist dauernd offen hält. Der untere Ösophagusabschluss kann in dieser vertikal angelegten Funktionskette als vertikal arbeitender Dehnverschluss im PET-CT nachgewiesen werden. Sein Aktionsprinzip bildet sich als asymmetrische Muskelaktivität schon in der wendelförmigen Anordnung der Muskelmaxima und -minima im Ösophagus ab. Dieses alternierend arbeitende, komplizierte obere Abschlusssystem wird in sehr großer Variabilität auch bei vielen Tieren gefunden. SummaryThe muscles of the cranioesophageal sphincter system feature continuous natural spontaneous resting activity. Thus, they resemble the anorectal sphincter system. We studied metabolic activity and morphology of the proximal sphincter system at rest in 23 individuals (14 females, nine males) using PET-CT scanning. We found that metabolic activity was significantly higher than in other muscle groups of the body at rest (P=0.001). In contrast to the horizontally oriented anal sphincters, the proximal sphincter system is developed as a vertical assembly of long, interlocking muscular tubes. These are innervated by five cranial nerves and three sensory organ nerves and form a functional unit that extends from the orbicularis oris muscle via the pharynx and larynx to the lower esophageal sphincter. The larynx shows only one active muscle, i.e., the posterior cricoarytaenoid muscle, that maintains airway patency. The lower esophageal sphincter can be visualized by PET-CT as a vertically oriented stretching sphincter. It features a spiral-shaped design made up of muscle maxima and minima which correlates well with its asymmetric muscle activity. This complex proximal sphincter system shows great developmental variability among different animal species. However, the general functional principle is similar in all.

PET-CT-Untersuchungen zur Stammzellkarzinogenese im Kolorektalbereich

Formation of cancer stem cells which are both rare and variably therapy-resistant marks the beginning of a new disease without precursors. Based on molecular changes, these cells are derived from normal cells and exhibit pre-programmed malignant behaviour. In vitro studies have shown that hybrid cancers which behave in a similar way to Dukes A, B or C cancers in vivo can be produce by horizontal gene transfer. The level of aggressiveness follows a Galton curve in the probability distribution. In the current paper we analyzed colorectal cancers by PET-CT in follow-up studies which extended over several years. We conclude that the primary tumors behave differently from distant metastases. Radical exstirpation of the primary tumor is able to cure the malignant process if the homing area is resected. The primary tumor acts as the supplier of cancer stem cells for metastases which appear in different organs. When chemotherapy is administered the distribution of metastases in different organs appears dependent of the response or non-response of cancer stem cells to this therapy. Large numbers of colorectal carcinomas existed for the same time duration before death (15 years) independent of the malignancy grade. The tumor metastasizes immediately after formation. The primary tumor and the metastases appear variably quickly depending on the malignancy grade and are autonomic processes.

Dehnverschluss der Speiseröhre

The investigations described in this article clearly show that the lower esophageal sphincter (LES) represents a variation of circular muscular occlusive mechanisms found elsewhere in the gastrointestinal tract. The LES is a double layer stretch sphincter that operates in an apparently paradoxical manner: it closes when under stretch but opens when the muscle fibers contract. Impedance manometry studies demonstrate that the entire esophagus is involved in the normal functioning of the esophagus as well as in esophageal disorders. The pronounced elasticity of esophageal tissue is a functional feature that has its basis in the singular architecture of elastic fibers located between the muscle layers. All traditional forms of operative treatment of gastroesophageal reflux disease (GERD) impede the natural functioning of the stretch sphincter to a greater or lesser degree by locking it up. The cause of GERD is mainly by contraction of the esophagus brought about by the cephalad transposition of the stretch sphincter segment into the chest. In a sense this is an incipient axial hernia that frequently remains undiagnosed in the early stages. The operative repositioning of the stretch sphincter segment into the abdominal cavity provides sufficient restoration of the natural topographic relationships to achieve a cure of GERD. Whether this straightforward repair restores the function of the entire esophagus remains to be elucidated. The concept of the stretch provides a good explanation of the pathophysiology of achalasia, a condition in which a paralyzed paradoxical ring sphincter remains occluded. Successful myotomy approaches only split the muscularis propria layer of the stretch sphincter while leaving subepithelial muscle fibers intact that remain paralyzed. This limited intervention provides a good relief of symptoms.ZusammenfassungDie im vorliegenden Beitrag beschriebenen Untersuchungen machen deutlich, dass der Ringsphinkter, ein Urelement viszeraler Muskulatur, an der Speiseröhre zu einem doppelten Dehnverschluss, einem paradoxen Sphinkter, variiert ist. Er verschließt gedehnt und öffnet sich kontrahiert. Die Impedanzmanometrie weist nach, dass in allen Funktionen und ihren Entgleisungen immer die ganze Speiseröhre beteiligt ist. Ihre starke Elastizität ist ein Funktionselement, das in einer singulären Architektur elastischer Fasern zwischen den Muskeln nachgewiesen werden kann. Alle bisherigen Operationen für die häufige Refluxkrankheit („gastroesophageal reflux disease“, GERD) behindern mehr oder weniger den natürlichen Dehnverschluss; sie sperren ihn ein. Die Ursache der GERD ist eine Kontraktion des Ösophagus durch Verlagerung des dann versagenden Dehnverschlusses in einer bisher übersehenen, lange unsichtbaren Hernienanlage, in der Bursa infracardiaca. Die Nachspannung mit Verlagerung der Abschlusssegmente zurück in die Bauchhöhle stellt den normalen Situs wieder her. Dieses Vorgehen hat sich bewährt. Wie sich dann die Dysfunktion der ganzen Speiseröhre verhält, wissen wir nicht. Sie könnte sich beruhigen? Nur der Dehnverschluss erklärt die seltene Chalasie (nicht Achalasie); nur ein gelähmter paradoxer Sphinkter ist verschlossen. Die erfolgreiche Therapie durchtrennt nur den halben, versackten Dehnverschluss, der subepithelial liegende weiter paretische, hindert jetzt nicht mehr.AbstractThe investigations described in this article clearly show that the lower esophageal sphincter (LES) represents a variation of circular muscular occlusive mechanisms found elsewhere in the gastrointestinal tract. The LES is a double layer stretch sphincter that operates in an apparently paradoxical manner: it closes when under stretch but opens when the muscle fibers contract. Impedance manometry studies demonstrate that the entire esophagus is involved in the normal functioning of the esophagus as well as in esophageal disorders. The pronounced elasticity of esophageal tissue is a functional feature that has its basis in the singular architecture of elastic fibers located between the muscle layers. All traditional forms of operative treatment of gastroesophageal reflux disease (GERD) impede the natural functioning of the stretch sphincter to a greater or lesser degree by locking it up. The cause of GERD is mainly by contraction of the esophagus brought about by the cephalad transposition of the stretch sphincter segment into the chest. In a sense this is an incipient axial hernia that frequently remains undiagnosed in the early stages. The operative repositioning of the stretch sphincter segment into the abdominal cavity provides sufficient restoration of the natural topographic relationships to achieve a cure of GERD. Whether this straightforward repair restores the function of the entire esophagus remains to be elucidated. The concept of the stretch provides a good explanation of the pathophysiology of achalasia, a condition in which a paralyzed paradoxical ring sphincter remains occluded. Successful myotomy approaches only split the muscularis propria layer of the stretch sphincter while leaving subepithelial muscle fibers intact that remain paralyzed. This limited intervention provides a good relief of symptoms.

Voraussage der Prognose des Pankreaskarzinoms in seinem Homing-Areal

ZusammenfassungDas Homing-Areal ist ein genetisch geprägter Ort, an dem ein Primärmalignom und sein Lokalrezidiv entstehen. Eine erfolgreiche radikale Operation muss das Homing-Areal gründlich entfernen. Im Kolonbereich ist das oft möglich. Die Homing-Grenzen sind weit vom Tumor entfernt und die wenigen, sehr langen Metastasenstraßen ebenso. Beim Pankreas ist, wie bei allen Drüsen, das Homing-Areal auf die Drüse selbst beschränkt. Seinen Homing-Charakter beweist ein Pankreaskarzinom dadurch, dass die in der Drüse verteilten Inselzellgebiete gemieden werden. Bei ihrer Entwicklung im Duodenum-descendens-Drüsenareal hat das Pankreas dessen embryologisch angelegtes ventrales und dorsales Mesenterium bis auf Reste verbraucht. Seine kurzen Lymphstraßen, zahlreich zentrifugal die Drüse verlassend, münden in Lymphknoten, die das Pankreas zu allermeist mit den Nachbarorganen gemeinsam hat. Die Lymphknoten sind in Stockwerken und nicht in flachen Mesenterien angelegt. Der Plan einer Radikaloperation ist sehr schwer durchführbar.AbstractThe homing area is a genetically defined location where primary malignancy originates and local recurrences occur. In order to be completely successful, curative resections of malignant tumors have to eradicate the homing area. This is possible in colon resection where the borders of the homing area are distant from the tumor and the lymph nodes can easily be resected to remove possible node metastases. In contrast, the homing area of the pancreas comprises only the gland itself, similar to all other glandular organs. The high specificity of the homing area is demonstrated by the finding that even pancreatic islets are spared by the malignant disease. During fetal development the pancreas loses most of the original dorsal and ventral mesentery. Via short lymphatic pathways, metastatic cells leave the gland in a centrifugal manner and find their way to regional lymph nodes that often share drainage with other neighboring organs. The lymph nodes are arranged in multiple layers and not in flat mesentery-like structures. Radical resections are therefore difficult to achieve.The homing area is a genetically defined location where primary malignancy originates and local recurrences occur. In order to be completely successful, curative resections of malignant tumors have to eradicate the homing area. This is possible in colon resection where the borders of the homing area are distant from the tumor and the lymph nodes can easily be resected to remove possible node metastases. In contrast, the homing area of the pancreas comprises only the gland itself, similar to all other glandular organs. The high specificity of the homing area is demonstrated by the finding that even pancreatic islets are spared by the malignant disease. During fetal development the pancreas loses most of the original dorsal and ventral mesentery. Via short lymphatic pathways, metastatic cells leave the gland in a centrifugal manner and find their way to regional lymph nodes that often share drainage with other neighboring organs. The lymph nodes are arranged in multiple layers and not in flat mesentery-like structures. Radical resections are therefore difficult to achieve.

Chirurgie ohne Anatomie

ZusammenfassungDie Anatomie ist die Grundlage jeder operativen Medizin. Sie wird in den Veröffentlichungen nicht mehr erwähnt, weil sie jeder gelernt hatte und meint, sie sei eine abgeschlossene Wissenschaft. In unserem Zeitalter des Bildes, ja des bewegten Bildes, des Films erscheinen Operationen in natura, aber ohne ein erklärendes, gezeichnetes Bild mit der Nomenklatur oder Autorennamen.Das gilt auch für die vielen Farbbilder wissenschaftlicher Veröffentlichungen, die wie Trophäen aneinandergereiht erscheinen, mit therapeutischen Andeutungen. In den umfangreichen Anatomiebüchern heute ist ein großes Wissen auch mit Bildern und Zeichnungen zu finden, über das sich ein Student oder Praktiker nur schwer für seine Belange unterrichten kann.In der sehr großen Anzahl wissenschaftlicher Veröffentlichungen ist die sich oft wiederholende Information mit vielen Autoren die Regel, oft ohne ein Bild. Informationen werden viel häufiger zitiert als die seltenen kreativen Neuschöpfungen. Es werden Beispiele gebracht, dass man aus ihnen, selbst wenn sie sehr lange zurückliegen, einen Fortschritt für die Gegenwart gewinnen kann. Die archaischen NO-Signalmoleküle werden genannt. Wir haben diesen 1775 entdeckten, bis heute in der Chirurgie unbekannten Neurotransmitter für den paradoxen Sphinkter des Menschen 2012 und 2015 beschrieben. Die vielen stummen Mitarbeiter einer Publikation könnten sich mit Grundlagen zum Hauptthema zu Worte melden (Malignogramm, Lymphgewebe usw.).AbstractAnatomy is the basis of all operative medicine. While this branch of scientific medicine is frequently not explicitly mentioned in surgical publications, it is nonetheless quintessential to medical education. In the era of video sequences and digitized images, surgical methods are frequently communicated in the form of cinematic documentation of surgical procedures; however, this occurs without the help of explanatory drawings or subtexts that would illustrate the underlying anatomical nomenclature, comment on fine functionally important details or even without making any mention of the surgeon. In scientific manuscripts color illustrations frequently appear in such overwhelming quantities that they resemble long arrays of trophies but fail to give detailed explanations that would aid the therapeutic translation of the novel datasets. In a similar fashion, many anatomy textbooks prefer to place emphasis on illustrations and photographs while supplying only a paucity of explanations that would foster the understanding of functional contexts and thus confuse students and practitioners alike. There is great temptation to repeat existing data and facts over and over again, while it is proportionally rare to make reference to truly original scientific discoveries. A number of examples are given in this article to illustrate how discoveries that were made even a long time ago can still contribute to scientific progress in current times. This includes the NO signaling molecules, which were first described in 1775 but were only discovered to have a pivotal role as neurotransmitters in the function of human paradoxical sphincter muscles in 2012 and 2015. Readers of scientific manuscripts often long for explanations by the numerous silent coauthors of a publication who could contribute to the main topic by adding in-depth illustrations (e. g. malignograms, evolution and involution of lymph node structures).Anatomy is the basis of all operative medicine. While this branch of scientific medicine is frequently not explicitly mentioned in surgical publications, it is nonetheless quintessential to medical education. In the era of video sequences and digitized images, surgical methods are frequently communicated in the form of cinematic documentation of surgical procedures; however, this occurs without the help of explanatory drawings or subtexts that would illustrate the underlying anatomical nomenclature, comment on fine functionally important details or even without making any mention of the surgeon. In scientific manuscripts color illustrations frequently appear in such overwhelming quantities that they resemble long arrays of trophies but fail to give detailed explanations that would aid the therapeutic translation of the novel datasets. In a similar fashion, many anatomy textbooks prefer to place emphasis on illustrations and photographs while supplying only a paucity of explanations that would foster the understanding of functional contexts and thus confuse students and practitioners alike. There is great temptation to repeat existing data and facts over and over again, while it is proportionally rare to make reference to truly original scientific discoveries. A number of examples are given in this article to illustrate how discoveries that were made even a long time ago can still contribute to scientific progress in current times. This includes the NO signaling molecules, which were first described in 1775 but were only discovered to have a pivotal role as neurotransmitters in the function of human paradoxical sphincter muscles in 2012 and 2015. Readers of scientific manuscripts often long for explanations by the numerous silent coauthors of a publication who could contribute to the main topic by adding in-depth illustrations (e. g. malignograms, evolution and involution of lymph node structures).

PET-CT-Untersuchungen zur Stammzellkarzinogenese im Kolorektalbereich@@@PET-CT studies of metastasizing cancer of the colon and rectum: Malignitätsvariabilität als mikroevolutionärer Prozess mit festgelegter Prognose@@@Variability of tumor aggressiveness as a micro-evolutionary process of cancer stem cells with predetermined prognosis

Formation of cancer stem cells which are both rare and variably therapy-resistant marks the beginning of a new disease without precursors. Based on molecular changes, these cells are derived from normal cells and exhibit pre-programmed malignant behaviour. In vitro studies have shown that hybrid cancers which behave in a similar way to Dukes A, B or C cancers in vivo can be produce by horizontal gene transfer. The level of aggressiveness follows a Galton curve in the probability distribution. In the current paper we analyzed colorectal cancers by PET-CT in follow-up studies which extended over several years. We conclude that the primary tumors behave differently from distant metastases. Radical exstirpation of the primary tumor is able to cure the malignant process if the homing area is resected. The primary tumor acts as the supplier of cancer stem cells for metastases which appear in different organs. When chemotherapy is administered the distribution of metastases in different organs appears dependent of the response or non-response of cancer stem cells to this therapy. Large numbers of colorectal carcinomas existed for the same time duration before death (15 years) independent of the malignancy grade. The tumor metastasizes immediately after formation. The primary tumor and the metastases appear variably quickly depending on the malignancy grade and are autonomic processes.