J. Göhl

Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection.

IntroductionAlthough Seprafilm® has been demonstrated to reduce adhesion formation, it is not known whether its usage would translate into a reduction in adhesive small-bowel obstruction.MethodsThis was a prospective, randomized, multicenter, multinational, single-blind, controlled study. This report focuses on those patients who underwent intestinal resection (n = 1,701). Before closure of the abdomen, patients were randomized to receive Seprafilm® or no treatment. Seprafilm® was applied to adhesiogenic tissues throughout the abdomen. The incidence and type of bowel obstruction was compared between the two groups. Time to first adhesive small-bowel obstruction was compared during the course of the study by using survival analysis methods. The mean follow-up time for the occurrence of adhesive small-bowel obstruction was 3.5 years.ResultsThere was no difference between the treatment and control group in overall rate of bowel obstruction. The incidence of adhesive small-bowel obstruction requiring reoperation was significantly lower for Seprafilm® patients compared with no-treatment patients: 1.8 vs. 3.4 percent (P < 0.05). This finding represents an absolute reduction in adhesive small-bowel obstruction requiring reoperation of 1.6 percent and a relative reduction of 47 percent. In addition, a stepwise multivariate analysis indicated that the use of Seprafilm® was the only predictive factor for reducing adhesive small-bowel obstruction requiring reoperation. In both groups, 50 percent of first adhesive small-bowel obstruction episodes occurred within 6 months after the initial surgery with nearly 30 percent occurring within the first 30 days. Additionally no first adhesive small-bowel obstruction events were reported in Years 4 and 5 of follow-up.ConclusionsThe overall bowel obstruction rate was unchanged; however, adhesive small-bowel obstruction requiring reoperation was significantly reduced by the use of Seprafilm®, which was the only factor that predicted this outcome.

Surgical Management of Pulmonary Metastases from Colorectal Cancer in 153 Patients

BackgroundSurgery has become a recognized therapeutic means in selected patients with pulmonary metastases from colorectal origin. We reviewed our experience in the surgical treatment of 153 patients with pulmonary colorectal metastases and investigated factors affecting survival.MethodsA retrospective analysis of the records of all patients (n = 153) with pulmonary metastases from colorectal cancer who underwent thoracotomy between 1978 and 2003 at a single surgical center was performed.ResultsOne hundred fifty-three patients with pulmonary metastases from colon (n = 61) or rectal (n = 92) cancer underwent 180 thoracotomies. The 2- and 5-year probabilities of survival after the first thoracotomy were 64% and 37%, respectively. Sex, age, site, International Union Against Cancer stage of the primary tumor, prethoracotomy carcinoembryonic antigen level, size of metastases, and previous resection of hepatic metastases were not found to be statistically significant prognostic factors. Number of metastases (solitary vs. multiple), mode of operation (wedge vs. anatomical resection), disease-free interval (DFI; >36 months), negative hilar or mediastinal lymph node status, resection margin >10 mm, and administration of intraoperative blood substitution were predictors of a longer survival duration by univariate analysis, but only number of metastases (P = .019), mode of operation (P = .004), DFI (P = .027), and intraoperative blood substitution (P = .002) were identified as independent prognostic factors by multivariate analysis.ConclusionsPulmonary resection for metastases from colorectal cancer is safe and results in long-term survival in selected patients. Single metastases, anatomical resection, intraoperative blood substitution, and DFI >36 months seem to be the most reliable predictors of survival.

Changes in indication and results after resection of hepatic metastases from noncolorectal primary tumors: a single-institutional review.

BackgroundThe isolated occurrence of noncolorectal liver metastases is rare. The available data are inconsistent in terms of indication for surgery, treatment, and outcome, so a generally applicable therapeutic algorithm is currently lacking.MethodsA total of 162 patients underwent resection for noncolorectal liver metastases between 1978 and 2001. The patients were divided into two groups from different time periods (group 1, 1978–1989; group 2, 1990–2001) that were similar in terms of number of patients, operating surgeons, and surgical techniques used. The groups were compared, and the data were retrospectively analyzed with regard to indication, survival, and factors predictive for survival.ResultsResection was performed to remove liver metastases from noncolorectal gastrointestinal carcinoma (n = 50), neuroendocrine tumors (n = 12), genitourinary primary tumors (n = 11), breast carcinoma (n = 24), leiomyosarcoma (n = 15), and metastases from other primary cancers (n = 50). Extrahepatic tumor involvement was seen in 38 (23%) of the 162 cases. Sixty-two (38%) major hepatectomies and 100 (62%) minor resections were performed. In 100 (62%) of 162 patients, a curative resection (R0) could be achieved. Overall 2- and 5-year survival rates of 49% and 26%, respectively, were observed, and the median survival was 23 months. Survival was significantly longer in patients who underwent an R0 resection.ConclusionsIn selected patients, resection of noncolorectal liver metastases is associated with a 5-year survival rate of up to 50%. Resection of liver metastases from gastrointestinal adenocarcinomas correlates with a poor prognosis. Extrahepatic metastases may be considered a relative contraindication for liver resection.

Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision.

The implementation of complete mesocolic excision (CME) for colonic cancer was accompanied by other important changes, including more patients with early diagnosis by screening and the introduction of adjuvant chemotherapy in patients with stage III disease. The contribution of CME remains unclear.

Quality management in rectal carcinoma: what is feasible?

PurposeA cohort study was carried out to analyse quality indicators in the diagnosis and treatment of rectal carcinoma.MethodsA total of 2,470 patients with rectal carcinoma treated between 1985 and 2007 at the Department of Surgery, University of Erlangen, were analysed and compared within four time intervals.ResultsMost of the indicators analysed from 2004 to 2007 fulfilled the defined target values. The indicators for process quality of surgical treatment and the surrogate indicators of outcome quality in surgery showed excellent results. Comparing this to previous data, it displays the new developments such as introduction of multimodal treatment for high-risk patients. While the rate of locoregional recurrences decreased, no significant improvement in survival was found.ConclusionsCareful analysis of quality indicators is important for both quality management and comparison of treatment results. The progress in diagnosis and treatment requires a continuous update of definitions and target values.

Perineal and vaginal wall reconstruction using a combined inferior gluteal and pudendal artery perforator flap: A case report

Reliable perineal and posterior vaginal wall restoration following extensive abdominoperineal excision or pelvic exenteration is a reconstructive challenge, especially if the rectus abdominis is unavailable or insufficient for transpelvic transposition. In this short report, we present a novel combined perforator-based technique, in which an inferior gluteal perforator flap is used for perineal reconstruction whereas vaginal reconstruction is performed simultaneously by means of a pudendal artery perforator flap. This procedure circumvents functional muscle loss, permits a tension-free closure of difficult three-dimensional defects and offers a high degree of reconstructive flexibility, which allows a straightforward and independent reconstruction of two different anatomical units.

Lymphknotendissektionen beim malignen Melanom

Summary. Elective lymph node dissection and its potential as a staging procedure, the prognosis of established lymph node metastases and the sentinel lymph node identification procedure are the most important aspects of lymph node dissection in malignant melanoma. It is widely accepted that subgroups of patients benefit from elective lymph node dissection. The question of which parameters identify the relevant patients properly is still under discussion. pT-categories are the most important prognostic factor; however, localisation and type of tumour and the sex of the patients are additional parameters influencing patient selection. Recently, the first studies have identified subgroups of nodal positive patients who would profit from adjuvant chemo-/immunotherapy. Therefore, lymph node dissection as a staging procedure has to be discussed in the future. Identification of the sentinel lymph node is receiving increasing attention because of its potential influence on the reassessment of elective lymph node dissection. However, this method needs further evaluation. If lymph node metastases have occurred, the prognosis of malignant melanoma decreases by 20 %–50 %, depending on the extent of metastasis in the individual case. The relevant topics and results are discussed on the basis of data of the Surgical Department of the University Hospital of Erlangen-Nuremberg.Zusammenfassung. Die Indikation zur elektiven Lymphknotendissektion, ihre evtl. zukünftige Bedeutung als Stagingmaßnahme vor adjuvanten Therapieverfahren, die Prognose der therapeutischen Dissektion sowie die Identifizierung des Pförtner-Lymphknotens und die daraus sich ergebenden therapeutischen Konsequenzen sind die wichtigsten Aspekte der Lymphknotendissektion beim malignen Melanom. Die Indikation zur elektiven Dissektion orientiert sich nicht nur an der pT-Kategorie, sondern auch an der Tumorlokalisation, dem Tumortyp und dem Geschlecht des Patienten. Ein allgemein akzeptierter Konsens zur Auswahl der in Frage kommenden Patienten besteht noch nicht. Da die ersten Studien mit Chemo-/Immuntherapie bei nodal positiven Patienten eine Prognoseverbesserung zeigen, muß zukünftig auch die Lymphknotendissektion als Stagingmaßnahme diskutiert werden. Neue Anregungen wurden in den letzten Jahren durch die Identifikation des Pförtner(„sentinel“)-Lymphknotens eingebracht. Diese Methodik bedarf noch der weiteren Evaluierung, dürfte aber zukünftig einen wesentlichen Einfluß auf die Indikation zur elektiven Lymphknotendissektion nehmen. Mit eingetretener Lymphknotenmetastasierung verschlechtert sich die Prognose des malignen Melanoms global um 20–50 %, abhängig vom Ausmaß der Metastasierung. Die Thematik wird anhand der eigenen Ergebnisse diskutiert.

Anti-TNF-refractory colitis after checkpoint inhibitor therapy: Possible role of CMV-mediated immunopathogenesis

ABSTRACT Immune-related adverse events (irAEs) induced by checkpoint inhibitors are well known. Since fatal outcomes have been reported early detection and adequate management are crucial. In particular, colitis is frequently observed and can result in intestinal perforation. This is the first report of an autoimmune colitis that was treated according to algorithms but became resistant due to a CMV reactivation. The 32-y-old male patient with metastatic melanoma treated within an anti-PD-1/ipilimumab combination study developed severe immune-mediated colitis (CTCAE grade 3) with up to 18 watery stools per day starting 2 weeks after treatment initiation. After improving upon therapy with immunosuppressive treatment (high dose steroids and infliximab) combined with parenteral nutrition diarrhea again exacerbated. Additionally, the patient had asymptomatic grade 3 CTCAE amylase and lipase elevation. Colitis was monitored by weekly endoscopies and colon biopsies were analyzed histologically with CMV staining, multi-epitope ligand cartography (MELC) and qRT-PCR for inflammatory genes. In the course, CMV reactivation was detected in the colon and treated with antiviral medication in parallel to a reduction of corticosteroids. Subsequently, symptoms improved. The patient showed a complete response for 2 y now including regression of bone metastases. CMV reactivation under checkpoint inhibitor therapy in combination with immunosuppressive treatment for autoimmune side effects has to be considered in these patients and if present treated. Potentially, CMV reactivation is underdiagnosed. Treatment algorithms should include CMV diagnostics.

Prognostic subdivision of ypT3 rectal tumours according to extension beyond the muscularis propria

The subdivision of T3 in rectal carcinoma according to the depth of invasion into perirectal fat has been recommended in the TNM Supplement since 1993. This study assessed the prognostic impact of this pathological staging in tumours removed after neoadjuvant chemoradiotherapy (ypT3).

Hyperthermic Isolated Limb Perfusion – 23 Years’ Experience and Improvement of Results by Modification of Technique

Background: Locoregional tumor relapse of malignant melanomas of the extremities, particularly multiple intransit metastases, is frequent, but sometimes difficult to treat. In this situation hyperthermic isolated limb perfusion (HILP) may offer a therapeutic option. We reviewed our 23 years’ experience with this technique in order to evaluate indication and to investigate if there has been improvement of remission rates over the years. Material and Methods: From 1973 to 1994, 163 patients (group I) were treated with HILP for manifest locoregional metastases of melanoma localized at the extremities. The cytostatic drug used was melphalan, dactinomycin (1 mg) was applied in addition. Simultaneously, regional lymph node dissection was performed. Since 1992, a further group of 20 patients (group II) with intransit metastases was treated with a modified perfusion technique (90 min, drug continuously infused over 20 min into the arterial line) and followed up prospectively. Survival, remission and complication rates were analyzed. Results: Postoperative mortality was 2.5% in group I (n = 4) and 5% in group II (n =1). One patient (group II) had to be amputated postoperatively (coexisting arterial occlusive disease). 10-year survival rate (sr) of group I patients amounted to 37%. Patients with intransit metastases (n = 51) or lymph node metastases exclusively (n = 79) had the best prognosis with a 10-year sr of 41% and 40% (stage IIIA and IIIB, respectively, according to M.D. Anderson classification). In case of simultaneous intransit and regional lymph node metastases (n = 33, stage IIIAB), prognosis significantly deteriorated (10-year sr 26%). Concerning remission rates, results in group II patients showed an increase of complete remissions from 49% (group I) to over 80%. Conclusions: With appropriate patient selection, HILP is an effective procedure to control locoregional tumor relapse of malignant melanomas of the extremities, above all multiple intransit metastases, with acceptable morbidity and low mortality. An improvement of results seems possible by modification of technique using standard drugs. Schlüsselwörter Melanom · Isolierte Extremitätenperfusion · Intransitmetastasen · Melphalan