Franz Paul Gall

Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence

Functional deficits of the striated anal sphincteric muscles without any apparent gross defect often result in a lack of ability to postpone defaecation by intention or in faecal incontinence in response to increased intra-abdominal or intra-rectal pressure. We applied electrostimulation to the sacral spinal nerves to increase function of the striated muscles of the anal sphincter. Of three patients followed for 6 months, two gained full continence and one improved from gross incontinence to minor soiling. Closure pressure of the anal canal increased in all. Preliminary data indicate that anal closure pressure increases with the duration of stimulation. Continuous stimulation of sacral spinal nerves can help some patients with faecal incontinence. It may be possible to promote continence with intermittent stimulation.

Local excision of cancer of the rectum.

Local excision of rectal cancer can be a part of treatment of this tumor. The authors do not feel that this procedure is only palliative. Clinical staging I and II, tumor diameter less than 3 cm, malignancy grade 1 or 2, invasion no deeper than the submucosa, and no signet-cell carcinoma are all requisites for limited, local excision of rectal carcinoma. Patients operated upon under these criteria have a five-year survival rate of 89.6±21.7 per cent for those with invasion into the submucosa and 78±49.9 per cent for those with invasion into the muscularis propria. But to get such good results, strict self control must be exercised in selecting patients.

Pulmonary resection for metastatic colon and upper rectum cancer

The predictive value of the route of venous drainage on prognosis was investigated in a consecutive series of 44 patients who underwent curative resection of pulmonary metastases from colorectal carcinoma. The primary tumor was located in the colon in 14 patients and in the upper third of the rectum in 11 patients, thus indicating blood drainage directed toward the portal vein (Group I). In 10 and 9 cases, respectively, the initial growth was in the middle and lower thirds of the rectum with the venous outflow at least partially directed into the vena cava (Group II). There was no obvious difference between the two groups regarding the initial site of cancer relapse. The liver was involved in 4 of 15 patients failing in Group I as opposed to 4 of 13 patients with hematogenous relapse in Group II. Median survival and tumor-free survival times were significantly longer in patients in Group I (58.4 and 50.2 months) than in patients in Group II (30.9 and 16.8 months), and, even more pronounced, in colon cancer patients (75.4 and 60.2 months) when compared with rectal cancer patients (31.0 and 17.9 months). In contrast, survival curves did not differ significantly if either the two groups with different routes of drainage (5-year survival 53 percentvs. 38 percent, 5-year tumor-free survival 43 percentvs.37 percent), or tumors of the colon and rectum (5-year survival 67 percentvs.38 percent, 5-year tumor-free survival 60 percentvs.32 percent) were compared using the log-rank test. Similar trends were obtained for the subgroup of 34 patients without previous or simultaneous extrapulmonary recurrent disease at the time of lung resection. The primary tumor site does therefore not become a major criterion in selecting patients for surgical resection.

Whipple's procedure plus intraoperative pancreatic duct occlusion for severe chronic pancreatitis: clinical, exocrine, and endocrine consequences during a 3-year follow-up.

The present investigation provides follow-up data (up to 36 months) of exocrine and endocrine pancreatic function, inflammatory activity, pain, and body weight in 23 chronic pancreatitis patients submitted to Whipples procedure plus intraoperative Ethibloc occlusion of the remaining pancreatic duct system between January 1983 and February 1984. Clinically, Whipples procedure plus intraoperative pancreatic duct occlusion resulted in almost complete and continuous cessation of pain as well as significant (p <0.05) increase in body weight. With regard to exocrine pancreatic function (Secretin-Pancreozymin test, plasma amino acid consumption test, Pankreolauryl test, fecal chymotrypsin determination), intraoperative pancreatic duct occlusion was shown to induce high-grade insufficiency and thus exocrine parenchymal atrophy in all patients. Simultaneously, the inflammatory process (represented by serum levels of trypsin, lipase, and pancreatic isoamylase) was terminated in all 23 patients. Endocrine pancreatic function, evaluated by serum levels of insulin and C-peptide measured under fasting conditions and subsequent maximal combined β-cell stimulation as well as corresponding integrated hormone releases, was reduced by partial pancreas resection by about 50%, while there was no further impairment during the 36-month follow-up period in consequence of additional intraoperative pancreatic duct occlusion. Altogether, Whipples procedure plus intraoperative Ethibloc occlusion of the residual pancreatic duct system seems suitable for termination of the inflammatory process and thus preservation of residual endocrine pancreatic function in chronic pancreatitis.

Decision-making in Curative Rectum Carcinoma Surgery

Rectal carcinomas are increasingly treated by more and more differentiated regimens. Until the 1970s, the rectal excision was standard, whereas in 58% sphincter-saving procedures were performed during the last years. Locoregional recurrences are the main problem of surgical treatment for rectum carcinomas. They are of decisive importance for the patients. Without locoregional recurrence during the first two years, the overall five-year survival is 85% which decreases tremendously to 23% in case of a locoregional recurrence. Overall, this rate depends primarily on patho-histological parameters of the primary, as well as on therapeutic modalities and quality, too. For this reason, the arguments for routine neo- or adjuvant radio-(chemo-)therapy, increasingly arising during the last two years, is debatable. Global recommendations do not realize that low rates of locoregional recurrences may be achieved by surgery alone, e.g., 13% in the surgical Department of the University of Erlangen. However, these patients do include some groups with increased risk, for example, those who have positive lymph nodes along the course of a named vascular trunk (18%). These patients at increased risk may profit from adjuvant-radio-(chemo-)therapy. This is not yet, however, proven by any prospective study.

Significance of Serum Phosphohexose Isomerase in Gastrointestinal Cancer at Different Stages

The purpose of this study was to reevaluate the significance of serum PHI in gastrointestinal cancer at histopathologically defined stages prior to primary treatment. A total of 248 patients with malignant tumors of the gastrointestinal tract and a collective of 42 patients with noncancerous diseases were studied. The results are compared with those obtained with the established markers tissue polypeptide antigen (TPA) and carcinoembryonic antigen (CEA). Phosphohexose isomerase (PHI) revealed an overall diagnostic sensitivity of 69%, combined with a specificity of 74%. The corresponding data for TPA were found to be 73 and 47% while for CEA 26 and 95% respectively were determined. Even in the early stages of colorectal and esophageal carcinoma, PHI showed a sensitivity of about 60%. A continuous rise of PHI serum levels, correlating well with the extent of the tumor disease, could be detected. In contrast to TPA and CEA, PHI assay can be carried out with a minimum of laboratory efforts, in a short time and at low costs. These findings suggest that serum PHI assay is a useful aid for screening of gastrointestinal cancer, especially esophageal and gastric carcinoma, and a reliable marker for treatment control and follow-up.

Fibrin sealing in liver surgery

Intraoperative bleedings, postoperative hepatic insufficiency and local complications such as postoperative bleeding, biliary fistulas, liver necrosis and subphrenic absecess increase the risk of liver resection. The decisive prophylaxis of bleeding is the precise resection technique according to intrahepatic vascular structures. Fibrin sealing is suited to stop oozings and residual bleedings on the resection surface and to avoid postoperative bleedings and/or biliary fistulas from the resection surface.ZusammenfassungDas Risiko einer Leberresektion steigt mit dem Auftreten einer intraoperativen Blutung, einer postoperativen Leberinsuffizienz und lokalen Komplikationen, wie Nachblutung, Gallefistel. Lebernekrose und subphrenischem Abszeß. Die entscheidende blutungsprophylaktische Maßnahme stellt die präzise, an intrahepatischen Gefäßstrukturen orientierte Resektion-stechnik dar. Die Fibrinklebung ist zur Stillung von Sicker- und Restblutungen an der Resektionsfläche und zur Prophylaxe einer Nachblutung und/oder einer Gallefistel aus der Resektionsfläche geignet. *** DIRECT SUPPORT *** A22P1115 00002

Hat die Berechnung der Geschwindigkeit des Geschwulstwachstums klinische Bedeutung

Bei 142 Lungenrundherden von 78 Patienten bestimmten wir die Tu∼ morverdoppelungszeiten (13 Bronchialkarzinome, 7 benigne Lungen-tumoren und 122 Lungenmetastasen). Sie bewegten sich zwischen + 12 und

Zystische Pankreastumoren@@@Cystic tumors of the pancreas

Before 1978, where cystic tumors of the pancreas were concerned, pathologists only differentiated between cystic adenomas and cystadenocarcinomas. Recently, however, further tumor entities have been introduced. We now differentiate between the generally benign serous cystic adenoma, the potentially malignant mucinous cystadenoma, the possibly malignant papillary cystic tumor, and the always malignant mucinous cystadenocarcinoma. Other rare tumors include the solid cystic acinous-cell tumor, the cystic islet tumor, and mucinous ductal hyperplasia. Because of their slow growth and primary displacement nature, all of these tumors can usually be detected only after they have attained considerable size. Computed tomography (CT), sonography and endoscopic retrograde cholangiopancreatography (ERCP) have an established role in diagnosis. With these methods, as a rule, it is possible to identify pseudocysts; however, differentiation between the individual tumor types is almost impossible. In our study from 1979 to 1990, we observed ten cases of serous cystic adenomas, nine cystadenocarcinomas, and four malignant papillary-cystic tumors. Of these, nine of the ten serous cystic adenomas, four of the five mucinous cystadenomas, all four papillary-cystic tumors, and five of the nine cystadeno-carcinomas were curatively resected. All patients with curatively resected adenomas and one patient with an R1-resected cystic adenoma remained free of recurrence throughout the follow-up period. One 86-year-old female patient in whom a serous cystic adenoma was histologically determined still has no symptoms 8 years after diagnosis despite slow tumor progression. Two of the five patients in whom a cystadenocarcinoma was curatively resected died postoperatively; a third patient died of tumor recurrence 4 months following resection. The two remaining patients are alive and tumor-free at 16 and 28 months postoperatively. All four patients with mucinous cystadenocarcinomas who underwent palliative operations died of their tumor 8 to 28 months later. Two of the four patients with a malignant papillary cystic tumor were alive and recurrence-free 73 and 30 months postoperatively. One patient died free of tumor 45 months postoperatively, and the fourth patient is presently at the preterminal stage following development of a synchronous metastasizing second tumor. Diagnostic techniques cannot be used to differentiate between the individual tumor types; however, because cystic tumors of the pancreas have a good prognosis following curative resection, complete removal of the tumor and a complete histological workup of the entire cyst is required. The resection should be performed in accordance with the oncological rules radical operations.ZusammenfassungVor 1978 unterschied man bei den zystischen Tumoren des Pankreas nur zwischen Zystadenom und Zystadenokarzinom [2]. Inzwischen wurden von den Pathologen eine Reihe weiterer Tumorentitäten klassifiziert. Man differenziert heutzutage zwischen dem generell gutartigen serösen Zystadenom, dem potentiell maligne entartenden muzinösen Zystadenom, dem fakultativ malignen papillär-zystischen Tumor und dem muzinösen Zystadenokarzinom als obligat malignen Tumor. Weitere seltenere Tumortypen sind der solid-zystische Acinuszelltumor, der zystische Inselzelltumor sowie die muzinöse duktale Hyperplasie. Aufgrund des langsamen Wachstums mit in erster Linie verdrängendem Charakter werden alle diese Tumoren häufig erst bet schon beachtlicher Tumorgröße diagnostiziert. Bei der Diagnostik haben das CT, die Ultraschalluntersuchung sowie die ERCP einen festen Stellenwert. Dabei ist es in der Regel zwar möglich, eine Unterscheidung zur Pseudozyste zu führen, eine Differenzierung der einzelnen Tumortypen ist mit Mitteln der Diagnostik nahezu unmöglich. In unserem Krankengut sahen wir in den Jahren 1979 his 1990 10 Fälle von serösen Zystadenomen, weiterhin 5 muzinöse Zystadenome, 9 Zystadenokarzinome sowie 4 maligne papillär-zystische Tumoren. Von diesen konnten 9 der 10 serösen Zystadenomen, 4 von 5 muzindsen Zystadenomen, alle 4 papillär-zystischen Tumoren Bowie 5 von 9 Zystadenokarzinomen kurativ reseziert werden. Alle Patienten mit kurativ resezierten Adenomen blieben wie auch ein Patient mit einem RI -resezierten Zystadenom in der Nachbeobachtungszeit tumorfrei. Eine Patientin, bei der ein seröses Zystadenom nur histologisch gesichert worden war, lebt inzwischen 8 Jahre nach Diagnosestellung mit nunmehr 86 Jahren unter langsamer Progression weiterhin beschwerdenfrei. Von den 5 Patienten, bei denen ein Zystadenokarzinom kurativ reseziert worden war, verstarben 2 Patienten postoperativ. Ein dritter verstarb 4 Monate nach dem Eingriff an einem ausgedehnten Tumorrezidiv. Die beiden restlichen Patienten leben nach 16 und 28 Monaten tumorfrei. Alle 4 palliativ operierten Patienten mit muzindsen Zystadenokarzinomen verstarben nach 8 bis 28 Monaten an ihrer Tumorerkrankung. Von den 4 Patienten mit einem malignen papillär-zystischen Tumor leben 2 73 und 30 Monate nach der Operation erscheinungsfrei. Ein Patient verstarb tumorfrei 45 Monate nach dem Eingriff und der vierte ist 39 Monate nach dem Eingriff wegen eines synchronen metastasierenden Zweittumors inzwischen in einem präfinalen Zustand. Eine Unterscheidung zwischen den einzelnen Tumortypen ist durch diagnostische Maßnahmen nicht möglich. Da aber nach kurativer Resektion zystische Pankreastumoren eine sehr gute Prognose aufweisen, ist grundsätzlich eine komplette Entfernung des Tumors sowie anschließend eine vollständige histologische Aufarbeitung der gesamten Zyste zu fordern. Diese Resektion sollte nach den Grundsätzen der onkologischen Radikalität durchgeführt werden.Before 1978, where cystic tumors of the pancreas were concerned, pathologists only differentiated between cystic adenomas and cystadenocarcinomas. Recently, however, further tumor entities have been introduced. We now differentiate between the generally benign serous cystic adenoma, the potentially malignant mucinous cystadenoma, the possibly malignant papillary cystic tumor, and the always malignant mucinous cystadenocarcinoma. Other rare tumors include the solid cystic acinous-cell tumor, the cystic islet tumor, and mucinous ductal hyperplasia. Because of their slow growth and primary displacement nature, all of these tumors can usually be detected only after they have attained considerable size. Computed tomography (CT), sonography and endoscopic retrograde cholangiopancreatography (ERCP) have an established role in diagnosis. With these methods, as a rule, it is possible to identify pseudocysts; however, differentiation between the individual tumor types is almost impossible. In our study from 1979 to 1990, we observed ten cases of serous cystic adenomas, nine cystadenocarcinomas, and four malignant papillary-cystic tumors. Of these, nine of the ten serous cystic adenomas, four of the five mucinous cystadenomas, all four papillary-cystic tumors, and five of the nine cystadenocarcinomas were curatively resected. All patients with curatively resected adenomas and one patient with an R1-resected cystic adenoma remained free of recurrence throughout the follow-up period. One 86-year-old female patient in whom a serous cystic adenoma was histologically determined still has no symptoms 8 years after diagnosis despite slow tumor progression. Two of the five patients in whom a cystadenocarcinoma was curatively resected died postoperatively; a third patient died of tumor recurrence 4 months following resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Die Resektion von Lebermetastasen

Die Ergebnisse der Metastasenresektion in der Leber sind zu messen am naturlichen Verlauf ohne Therapie, wobei die 5-Jahres-Uberlebensraten je nach Anzahl der Metastasen zwischen 0 und 3 % betragen [5