Michael J. Starlinger

Technique and results of transanal endoscopic microsurgery in early rectal cancer

The anatomy of the pelvis makes it difficult to perform local excisions in the rectum when the tumor is some distance from the anal verge. We have, therefore, developed a new minimally invasive technique for tumor resection. A rectoscope with a 40-mm diameter permits tumor resection under stereoscopic control in the gas-dilated rectal cavity. Excisions in full-thickness technique up to segmental resections with end-to-end anastomosis can be performed. In selected cases, local excision of a small rectal cancer can be regarded as appropriate treatment. However, most local resections of carcinomas are performed when removal of an adenoma is planned, and the postoperative histology shows a carcinoma. Since 1983, we have operated on 326 patients, 274 who have been enrolled in a prospective clinical trial. Definitive histologic examination proved that 74 of these tumors were carcinomas. The rate of severe complications in patients with carcinomas was 9%, and the mortality rate was 0%. The advantages of this new technique are: The stereoscopic magnified view in the gas-dilated rectum allows precise surgery in an operative field that is otherwise difficult to reach. During the postoperative period, minimal discomfort and pain result in a short hospitalization.

High prevalence of bone disorders after gastrectomy

BACKGROUND Studies indicate that gastrectomy might alter calcium and bone metabolism, resulting in bone disorders. No data are currently available on the prevalence of bone disorders after gastrectomy. METHODS Sixty gastrectomy patients were investigated for serum parameters of calcium and bone metabolism 5 to 20 years postoperatively and compared to an age- and sex-matched healthy control population. Forty patients agreed to a radiological investigation of the spine by anterior-posterior and lateral radiographs of the thoracic and lumbar spine and by computed tomography (CT) osteodensitometry. RESULTS Serum calcium and 25-(OH)-vitamin D were decreased in gastrectomized patients, while parathyroid hormone and 1,25-(OH)2-vitamin D were increased. Serum parameters of calcium metabolism were altered in as many as 68% of patients. We found 31 vertebral fractures in 13 patients, 30 grade 2 vertebral deformities in 18 patients, and osteopenia in 15 patients, corresponding to a prevalence of 33%, 45%, and 37% in gastrectomized patients, respectively. The overall rate of gastrectomy patients having vertebral fractures and/or osteopenia was 55%. The risk of having a vertebral deformity was increased by more than sixfold after gastrectomy. Our study is the first report evaluating vertebral deformities in gastrectomized patients, and the largest series of gastrectomized patients investigated by CT osteodensitometry. CONCLUSION We found a high prevalence of bone disorders in gastrectomized patients, possibly resulting from disorders in calcium metabolism. Postgastrectomy bone disease might derive from a calcium deficit, which increases calcium release from bone and impairs calcification of newly build bone matrix.

Perianal abscess in Crohn's disease.

PURPOSE: Perianal disease is frequent in patients with Crohns disease, and many of these patients will eventually have abscess formation. In a prospective follow-up study, we evaluated factors influencing the occurrence and recurrence of perianal abscesses. METHODS: Of 126 consecutive patients with perianal Crohns disease seen regularly in an outpatient clinic, 61 (48.4 percent) had at least one perianal abscess (mean follow-up, 32±17 months). In all, 110 episodes of an abscess with 145 anatomically distinct abscesses were documented. RESULTS: The occurrence of first abscesses was dependent on the type of anal fistula (ischiorectal, 73 percent; transsphincteric, 50 percent; superficial, 25 percent;P< 0.02). Surgical therapy consisted of seton drainage (34 percent), mushroom catheter drainage (49 percent), or incision and drainage (29 percent) and led to inactivation in all patients. Cumulative two-year recurrence rates after the first and second abscess were 54 and 62 percent, respectively. Abscess recurrence was less frequent in patients with a stoma (13vs.60 percent in patients without stoma after two years) and in patients with superficial anal fistulas (0vs.55 percent/56 percent in patients with transsphincteric/ischiorectal fistulas). Only two abscesses recurred within one year after removal of seton drainage, whereas 13 abscesses recurred with the seton still in place. Neither intestinal nor rectal activity of Crohns disease significantly influenced the occurrence of an abscess. During the study period, only two patients developed partial stool incontinence. CONCLUSION: Development of perianal abscesses in Crohns disease depends on the fecal stream and the anatomic type of anal fistula. Seton and catheter drainage are safe and highly effective in treatment. Long-term use of setons to prevent recurrent abscesses is not supported by our data.

C-fos protein expression in the nucleus of the solitary tract correlates with cholecystokinin dose injected and food intake in rats

C-fos protein expression was investigated in the nucleus of the solitary tract (NTS) in response to increasing cholecystokinin (CCK) doses and food intake in rats by counting the number of c-fos protein positive cells in the NTS. C-fos protein expression in the NTS dose-dependently increased in response to CCK, the lowest effective dose being 0.1 microg/kg. The ED(50) for c-fos protein expression in the NTS in response to CCK was calculated to be 0.5 to 1.8 microg/kg, depending on the anatomical level of the NTS investigated. Food intake increased c-fos protein expression in the NTS, the maximum number of c-fos protein positive cells being reached at 90 min after the start of food intake. Regression analysis identified a positive correlation between c-fos protein expression and the amount of food intake. Our data indicate that subpopulations of the NTS that are activated by CCK or food intake are involved into the short-term regulation of food intake and the neural control of feeding by the caudal brainstem.

Level of the anastomosis does not influence functional outcome after anterior rectal resection for rectal cancer

Anorectal function was studied in 55 patients undergoing low anterior resection for rectal adenocarcinoma. Patients were examined preoperatively and 3 months postoperatively by anorectal manometry and standardized interview. Postoperatively, the patients showed, in general, an impairment of anorectal functions. After 3 months, continence for flatus was defective, the ability to discriminate flatus from feces, and the ability to defer defecation were compromised. Stool frequency was elevated, and anal resting pressure, squeeze pressure, and rectal compliance were decreased. The rectoanal inhibitory reflex was abolished in all patients. However, the two groups with the level of the anastomosis less than or equal to 6 cm (n = 27, range 3 to 6) and more than 6 cm (n = 28, range 7 to 10) above the anal verge showed no differences in manometric values, stool frequency, or fecal continence assessed by the interview. No correlation was found between the level of the anastomosis and manometric values and between the level of the anastomosis and stool frequency (regression analysis = not significant). We concluded that anorectal function after anterior resection and low colorectal anastomosis are not influenced by the remaining length of the rectum but by the surgical trauma to the sphincter and its innervation.

Functional results after transanal endoscopic microsurgery

PURPOSE: Compared with traditional operations, superior results after transanal endoscopic microsurgery (TEM) for rectal tumors have been demonstrated in terms of morbidity and mortality. However, no data were available on functional outcome after TEM. We, therefore, studied 42 patients who were undergoing TEM. METHODS: Patients were examined by anorectal manometry and participated in a standardized interview preoperatively and three months and one year after surgery. RESULTS: Anorectal function as assessed by manometry was impaired three months after surgery but improved again during the first postoperative year. In parallel, some patients complained of impaired continence or defecation disorders in the interview three months postoperatively. These functions improved during the first year after surgery, too. CONCLUSIONS: Correct comparison of our results with functional outcome after anterior rectal resection is impossible. We feel, however, that functional results after TEM are likely to be superior to those after anterior resection for rectal tumors.

Postoperative colonic motility and tone in patients after colorectal surgery.

PURPOSE: Colonic motility is crucial for the resolution of postoperative ileus. However, few data are available on postoperative colonic motility and no data on postoperative colonic tone. We aimed to characterize postoperative colonic tone and motility in patients. METHODS: Nineteen patients were investigated with combined barostat and manometry recordings after left colonic surgery. During surgery a combined recording catheter was placed in the colon with two barostat bags and four manometry channels cephalad to the anastomosis. Recordings were performed twice daily from Day 1 to Day 3 after surgery. RESULTS: Manometry showed an increasing colonic motility index, which was a mean (± standard error of the mean) of 37±5 mmHg/minute on Day 1, 87±19 mmHg/minute on Day 2, and 102±13 mmHg/minute on Day 3 (P<0.05 for Day 1vs. Day 2 and Day 2vs. Day 3). Low barostat bag volumes indicating a high colonic tone were observed on Day 1 after surgery and increased subsequently (barostat bag I was 19±4, 32±6, and 32±6 ml; barostat bag II was 13±1, 19±3, and 22±5 ml on Days 1, 2, and 3, respectively; for both barostat bagsP<0.05 for Day 1vs. Day 2 but not Day 2vs. Day 3). CONCLUSIONS: Colonic motility increased during the postoperative course. The low barostat bag volumes indicated a high colonic tone postoperatively which would correspond to a contracted rather than to a distended colon. High colonic tone postoperatively may be relevant for pharmacologic treatment of postoperative ileus.

Prognose des Morbus Crohn—Vorhersage der Operationswahrscheinlichkeit und des postoperativen Verlaufs

ZusammenfassungGrundlagenDie meisten Patienten mit Morbus Crohn (MC) müssen sich mindestens 1 Operation unterziehen. In vorliegender Arbeit wurden prognostische Faktoren zu Operationswahrscheinlichkeit und postoperativem Verlauf untersucht.MethodikDer Krankheitsverlauf von 492 Patienten (mittlere Beobachtungszeit 5,23 Jahre) wurde ausgewertet. Operations- und Rezidivraten wurden mittels Lifetable-Analyse, die Krankheitsaktivität anhand klinischer und laborchemischer Parameter beschrieben.ErgebnissePatienten mit ileokolischem Befall haben eine hohe Wahrscheinlichkeit für eine Erstoperation und für das Auftreten eines therapiepflichtigen postoperativen Rezidivs. Patienten mit alleinigem Dünndarmbefall haben zwar eine hohe Wahrscheinlichkeit einer Erstoperation, die therapiepflichtige post-operative Rezidivrate ist jedoch gering. Bei isoliertem Kolonbefall sind Erst- und Reoperationsrate niedrig. Das frühzeitige Vorliegen ungünstiger laborchemischer Entzündungsparameter kennzeichnet Patienten mit einem aggressiveren Krankheitsverlauf, unabhängig von der intestinalen Ausbreitung. Die Krankheitsaktivität war postoperativ im Mittel über Jahre deutlich niedriger als in den Jahren vor Operation. Patienten mit perforierender oder nichtperforierender Komplikation wiesen keinen Unterschied im postoperativen Verlauf auf. Ein endoskopisches Rezidiv zeigt sich bei fast allen Patienten innerhalb weniger Jahre nach Operation und erlaubt deshalb allein keine weiteren prognostischen Aussagen.SchlußfolgerungenDie Operation führte zu einer nachhaltigen Verbesserung der Krankheitsaktivität. Aufgrund dieser ausgeprägten Verbesserung des Gesundheitszustandes und der niedrigen Reoperationsrate vor allem bei Patienten mit alleinigem Ileum- oder Kolonbefall erscheint es ratsam, bei Vorliegen einer medikamentös nicht oder nur schlecht beherrschbaren Symptomatik und Befall nur eines Darmabschnitts eine frühzeitige Operation durchzuführen.SummaryBackgroundMost patients with Crohns disease have to undergo surgery during the course of the disease. The aim of our study was the evaluation of factors predicting surgery and the postoperative course.MethodsThe charts of 492 patients with Crohns disease (mean follow up 5.23 years) were reviewed. The probabilities for surgery and postoperative recurrence were analyzed by actuarial methods. Disease activity was assessed by clinical and biochemical parameters.ResultsPatients with ileocolitis had a risk of surgery and reoperation. Patients with small bowel disease only had a high risk for surgery but recurrence rate (symptomatic or reoperation) was low. In Crohns disease confined to the colon both, risk for surgery and reoperation were low. Patients presenting with unfavourable laboratory values early during the disease have a more aggressive course, independent on disease location. Mean disease activity in the postoperative years was significantly lower than in the years before surgery. An endoscopic recurrence developed in almost all patients early following surgery, therefore lacking prognostic relevance. Indication for first surgery (perforating or non-perforating type) did not influence postoperative recurrence rate.ConclusionsSurgery was followed by a longstanding improvement of disease activity. Due to this marked improvement of health state and a low reoperation rate especially in patients with single site involvement of the bowel, an early operation might be recommended in those cases with symptomatic disease and no or only unsatisfactory response to medical therapy.

Intestinale Fisteln bei Morbus Crohn—Ein chirurgisches Therapiekonzept

ZusammenfassungGrundlagenIntestinale Fisteln sind eine Spielart der perforierenden Form des Morbus Crohn (MC). Mit einer Inzidenz von 35% stellen sie ein häufiges therapeutisches Problem in der chirurgischen MC-Therapie dar.MethodikEine Analyse der Literatur und eine eigene retrospektive Studie über 621 Operationen bei 441 MC-Patienten führen zu einem präzisen Konzept der chirurgischen Therapie von intestinalen MC-Fisteln.ErgebnisseNicht eine nachgewiesene Fistel per se, sondern nur die Wirksamkeit einer Fistel (Durchfälle, Mangelernährung oder hohes Fistelvolumen) stellt eine Operationsindikation dar. Basis des hier vorgestellten Therapiekonzeptes ist eine sorgfältige endoskopische und radiologische Ausbreitungsdiagnostik des MC-Befalls. Nachgewiesene Abszesse sollten vor einer Fisteloperation drainiert werden, am besten CT-gesteuert, um den Patienten in einem guten Allgemeinzustand zu einem elektiven Zeitpunkt und mit primärer Anastomosierung operieren zu können. Prinzipiell sollte der entzündete Darmabschnitt, von dem die Fistel ausgeht, reseziert, der die Fistel aufnehmende Darmabschnitt jedoch nur mit Fistelexzision und Übernähung versorgt werden.SchlußfolgerungenDurch dieses Therapiekonzept lassen sich unnötig ausgedehnte Operationen vermeiden, das Operationsrisiko deutlich reduzieren und früher häufig zu beobachtende Spätzustände wie das Kurzdarmsyndrom verhindern.SummaryIntroductionWith an incidence of 35% intestinal fistulae represent the most common type of perforating Crohns disease. For many surgeons there is still an uncertainty when to operate and how to operate for intestinal Crohns fistulae.MethodsThe analysis of data in literature and an own retrospective study of 621 operations performed in 441 patients with Crohns disease is condensed to a precise concept for the treatment of intestinal Crohns fistulae.ResultsIntestinal fistulae per se are not an indication for surgery. The severity of the symptoms caused by the fistula (e. g. diarrhea, malnutrition, high fistula output) dictates surgical intervention. The treatment policy of intestinal Crohns fistulae is based on a minute endoscopical and radiological assessment of Crohns disease activity and extent. Abdominal abscesses should be preliminarily treated by CT-guided drainage. Thus, a resection with a primary anastomosis can be safely performed after an interval of time. The fistula-bearing inflamed segment of the intestine must be resected, while the fistula opening in the fistula-receiving non-inflamed segment should only be excised and closed by suture.ConclusionsWith this concept for the management of intestinal Crohns fistulae the extent of resection and the risk of the operation can be minimized.