Hamed Esnaashari

Metachronous metastasis- and survival-analysis show prognostic importance of lymphadenectomy for colon carcinomas

BackgroundLymphadenectomy is performed to assess patient prognosis and to prevent metastasizing. Recently, it was questioned whether lymph node metastases were capable of metastasizing and therefore, if lymphadenectomy was still adequate. We evaluated whether the nodal status impacts on the occurrence of distant metastases by analyzing a highly selected cohort of colon cancer patients.Methods1,395 patients underwent surgery exclusively for colon cancer at the University of Lübeck between 01/1993 and 12/2008. The following exclusion criteria were applied: synchronous metastasis, R1-resection, prior/synchronous second carcinoma, age < 50 years, positive family history, inflammatory bowel disease, FAP, HNPCC, and follow-up < 5 years. The remaining 421 patients were divided into groups with (TM+, n = 75) or without (TM-, n = 346) the occurrence of metastasis throughout a 5-year follow-up.ResultsFive-year survival rates for TM + and TM- were 21% and 73%, respectively (p < 0.0001). Survival rates differed significantly for N0 vs. N2, grading 2 vs. 3, UICC-I vs. -II and UICC-I vs. -III (p < 0.05). Regression analysis revealed higher age upon diagnosis, increasing N- and increasing T-category to significantly impact on recurrence free survival while increasing N-and T-category were significant parameters for the risk to develop metastases within 5-years after surgery (HR 1.97 and 1.78; p < 0.0001).ConclusionsBesides a higher T-category, a positive N-stage independently implies a higher probability to develop distant metastases and correlates with poor survival. Our data thus show a prognostic relevance of lymphadenectomy which should therefore be retained until conclusive studies suggest the unimportance of lmyphadenectomy.

Laparoscopic Navigated Liver Resection: Technical Aspects and Clinical Practice in Benign Liver Tumors

Laparoscopic liver resection has been performed mostly in centers with an extended expertise in both hepatobiliary and laparoscopic surgery and only in highly selected patients. In order to overcome the obstacles of this technique through improved intraoperative visualization we developed a laparoscopic navigation system (LapAssistent) to register pre-operatively reconstructed three-dimensional CT or MRI scans within the intra-operative field. After experimental development of the navigation system, we commenced with the clinical use of navigation-assisted laparoscopic liver surgery in January 2010. In this paper we report the technical aspects of the navigation system and the clinical use in one patient with a large benign adenoma. Preoperative planning data were calculated by Fraunhofer MeVis Bremen, Germany. After calibration of the system including camera, laparoscopic instruments, and the intraoperative ultrasound scanner we registered the surface of the liver. Applying the navigated ultrasound the preoperatively planned resection plane was then overlain with the patients liver. The laparoscopic navigation system could be used under sterile conditions and it was possible to register and visualize the preoperatively planned resection plane. These first results now have to be validated and certified in a larger patient collective. A nationwide prospective multicenter study (ProNavic I) has been conducted and launched.

Epidemiology, molecular changes, histopathology and diagnosis of colorectal cancer

ZusammenfassungHINTERGRUND: Das kolorektale Karzinom ist eine der häufigsten malignen Erkrankungen in den Industrienationen. Ungeachtet der zunehmenden Erkenntnisse über die Entstehung und das biologische Verhalten der Tumoren, verbesserter therapeutischer Konzepte und der steigenden Bereitschaft sowohl Vor- als auch Nachsorgeprogramme wahrzunehmen, bleibt es eine Erkrankung mit hoher Mortalität. METHODEN: Die PubMed-Datenbank wurde in Hinblick auf aktuelle Literatur in den Bereichen Epidemiologie, Entstehung, histopathologische Beurteilung und Diagnostik des kolorektalen Karzinoms gesichtet. ERGEBNISSE: Es wird ein Überblick über die epidemiologischen Daten bezüglich der Inzidenz, der geographischen Unterschiede und der Risikofaktoren gegeben. Die molekularen Mechanismen für die Entstehung kolorektaler Karzinome entlang der Adenom-Karzinom-Sequenz werden erläutert und zusätzliche Aspekte der Tumorbiologie wie Ploidestatus und Mikrosatelliteninstabilität diskutiert. Die standardmäßig in der histopathologischen Beurteilung untersuchten Parameter werden zusammengefasst, neue Kriterien vorgestellt und weitere prognostisch relevante Tumoreigenschaften aufgeführt. Die Diagnose sowie das Staging von Patienten mit einem kolorektalen Karzinom basieren auf diversen Untersuchungsmodalitäten, deren Effektivität, Sensitivität und Spezifität dargestellt werden. SCHLUSSFOLGERUNGEN: Die frühe Detektion kolorektaler Karzinome, das Verständnis von der Tumorheterogenität und die daraus resultierende Konzeption individualisierter Therapieansätze stellen essentielle Zielvorgaben dar, um das outcome von Patienten mit einem kolorektalen Karzinom weiter verbessern zu können.SummaryBACKGROUND: Colorectal cancer is one of the most common malignant diseases in the industrialized nations. Despite advances in research on tumor development and biology, improved therapeutical concepts, and an increasing motivation to undergo screening examinations and surveillance programs the overall mortality remains high. METHODS: PubMed database was used to screen the current literature for the topics of epidemiology, colorectal cancer development, histopathologic features, and diagnosis in colorectal cancer. RESULTS: A general overview of epidemiologic data in terms of incidence, geographic differences in occurrence and risk factors is given. Molecular mechanisms for the formation of colorectal cancer within the adenoma-carcinoma sequence are explained and additional aspects such as ploidy-status of colorectal tumors and microsatellite instability put into perspective. Various variables of routine histopathologic evaluation are summarized, more advanced analyses explained and prognostically relevant features listed. Diagnostic workup and staging of patients with colorectal cancer are based on several different techniques which are discussed for their effectivity, sensibility and sensitivity. CONCLUSIONS: Early detection of colorectal cancer together with a more detailed understanding of tumor heterogeneity and the prospect of tailoring individualized therapeutical concepts constitute essential factors in order to further ameliorate the outcome of colorectal cancer patients.

Video Tutorials Increase Precision in Minimally Invasive Surgery Training – a Prospective Randomised Trial and Follow-up Study

BACKGROUND Simulation-based practice has become increasingly important in minimally invasive surgery (MIS) training. Nevertheless, personnel resources for demonstration and mentoring simulation-based practice are limited. Video tutorials could be a useful tool to overcome this dilemma. However, the effect of video tutorials on MIS training and improvement of MIS skills is unclear. METHODS A prospective randomised trial (n = 24 MIS novices) was conducted. A video-trainer with three different tasks (#1 - 3) was used for standardised goal-directed MIS training. The subjects were randomised to two groups with standard instructional videos (group A, n = 12) versus comprehensive video tutorials for each training task watched at specific times of repetition (group B, n = 12). Performance was analysed using the MISTELS score. At the beginning and following the curriculum, an MIS cholecystectomy (CHE) was performed on a porcine organ model and analysed using the GOALS score. After 18 weeks, participants performed 10 repetitions of tasks #1 - 3 for follow-up analysis. RESULTS More participants completed tasks #1 and #2 in group B (83.3 and 75%) than in group A (66.7 and 50%, ns). For task #2, there was a significant improvement in precision in group B (p < 0.001). For the entire cohort, the GOALS-Scores were 12.9 before and 18.9 after the curriculum (p < 0.001), with no significant difference between groups. Upon follow-up, 84.2% (task#1), 26.3% (task#2) and 100% (task#3) of MIS novices were able to reach the defined goals (A vs. B ns). There was a trend for a better MISTELS score in group B upon follow-up. CONCLUSIONS Standardised comprehensive video tutorials watched frequently throughout practice can significantly improve precision in MIC training. This aspect should be incorporated in MIS training.

Hinweise für Autoren

A rare case of hibernoma about the nipple in a 9-year-old boy is presented: the tumour was peculiar not only for the age and region, but also for its superficial, subepidermal site.

Patientenvorbereitung sowie intra- und postoperatives Managementkonzept für die Ösophagusresektion

Trotz der Reduzierung der Mortalität nach Ösophagusresektion an Zentren auf unter 5% ist die Chirurgie des Ösophagus nach wie vor durch hohe perioperative Morbidität gekennzeichnet. Die chirurgischen Komplikationen, wie z.B. die Anastomoseninsuffizienz, sind mittlerweile konservativ gut beherrschbar. Demgegenüber steht die hohe Rate an postoperativen Pneumonien – insbesondere bei neoadjuvant vorbestrahlten Patienten –, die für etwa 50% der Gesamtmortalität verantwortlich sind. Dies macht die Notwendigkeit einer kritischen Patientenselektion und ausgedehnten präoperativen Befunderhebung deutlich. Nur in enger interdisziplinärer Zusammenarbeit von Internisten und Intensivmedizinern sowie von Anästhesisten und Chirurgen wird es möglich sein, Patienten bereits präoperativ nach entsprechender Risikoklassifizierung so vorzubereiten, dass sie einem ausgedehnten thorakoabdominalen Eingriff mit vertretbarer Morbidität und Mortalität gewachsen sind. Nur so kann eine weitere Reduzierung von Morbidität und Mortalität erreicht werden.

Laparoskopische Chirurgie bei chronisch-entzündlichen Darmerkrankungen

ZusammenfassungHintergrund:Die technische Machbarkeit laparoskopisch assistierter Verfahren bei Morbus Crohn und Colitis ulcerosa ist mehrfach beschrieben. Sie erfordert einen in chronisch-entzündlichen Darmerkrankungen (CED) und laparoskopischen Techniken erfahrenen Operateur.Eigene Daten:Wir untersuchten prospektiv dokumentierte laparoskopische Eingriffe bei Morbus Crohn und Colitis ulcerosa. Seit 1994 erfolgte bei 64 Patienten mit Morbus Crohn und seit 1996 bei 22 Patienten mit Colitis ulcerosa ein minimalinvasiver Eingriff.Schlussfolgerung:Laparoskopische Chirurgie bei CED ist mit hoher Sicherheit durchführbar. Die Vorteile der laparoskopischen Chirurgie sind auch für dieses Patientenspektrum gegeben.AbstractBackground:The technical feasibility of laparoscopically assisted procedures in patients with inflammatory bowel disease (IBD) has been reported repeatedly. These minimally invasive techniques need an experienced surgeon in IBD and laparoscopic techniques.Own Results:Prospective documented laparoscopic procedures in IBD were analyzed. Since 1994 laparoscopy has been performed in 64 patients with Crohn’s disease and since 1996 laparoscopically assisted procedures have been performed in 22 patients with ulcerative colitis.Conclusion:Laparoscopic surgery in patients with IBD is a safe procedure with low morbidity. The advantages of minimally invasive surgery are proven for these patients as well.