Samuel A. Käser

Mucinous and Signet-Ring Cell Colorectal Cancers Differ from Classical Adenocarcinomas in Tumor Biology and Prognosis

Objectives:To define the prognostic value of different histological subtypes of colorectal cancer. Background:Most colorectal cancers are classical adenocarcinomas (AC). Less frequent subtypes include mucinous adenocarcinomas (MAC) and signet-ring cell carcinomas (SC). In contrast to established prognostic factors such as TNM and grading, the histological subtype has no therapeutical consequences so far, although it may reflect different biological behavior. Methods:Between 1982 and 2012, a total of 3479 consecutive patients underwent surgery for primary colorectal cancer (AC, MAC, or SC). Clinical, histopathological, and survival data were analyzed. Results:Of all 3479 patients, histological subtype was AC in 3074 cases (88%), MAC in 375 cases (11%), and SC in 30 cases (0.9%). MAC (51%, P < 0.001) and SC (50%, P = 0.029) occurred more frequently in right-sided tumors than AC (28%). Compared with AC, tumor stages and histological grading were higher in MAC and SC (P < 0.001 for each). Rates of angioinvasion were lower in MAC than in AC (5% vs 9%, P = 0.011). Rates of lymphatic invasion were higher in SC than in AC (67% vs 25%, P < 0.001). Five-year cause-specific survival was 67 ± 1% for AC, 61 ± 3% for MAC, and 21 ± 8% for SC (P < 0.001 for difference between the groups). In multivariable analysis, survival did not differ significantly between AC and MAC after correction for tumor stage. However, SC remained an independent prognostic factor associated with worse survival (hazard ratio = 2.5, 95% confidence interval = 1.6–3.8, P < 0.001). Conclusions:MAC and SC are histological subtypes of colorectal cancer with different characteristics than classical AC. Both are diagnosed in more advanced tumor stages, but the dismal prognosis of SC seems to be caused by its intrinsic tumor biology.

C-reactive protein is superior to bilirubin for anticipation of perforation in acute appendicitis

Abstract Objective. Very recently it has been shown that hyperbilirubinemia is a specific predictor of perforation in acute appendicitis. We compared the diagnostic importance of bilirubin, C-reactive protein (CRP), leukocyte count and age as markers of perforation in acute appendicitis. Material and methods. A two-center retrospective cohort study was completed. Patients with acute appendicitis (n = 725) were divided into two groups, group A with perforation (n = 155) and group B without (n = 570). Results. In group A an elevated CRP (> 5 mg/l) was measured in 98% of cases versus 72.5% in group B. Hyperbilirubinemia (> 20 μmol/l) was measured in 38% of cases in group A versus 22.3% in group B. Leukocytosis (> 10 × 109/l) was measured in 85% of cases in group A versus 79.3% in group B. Analysis of qualitative and quantitative data showed every marker to be significantly correlated with perforation except elevated white cell blood count. However CRP showed the strongest correlation. The logistic regression model showed CRP to be by far the most significant marker of perforation. Conclusions. Our results confirm hyperbilirubinemia to be a statistically significant marker of perforation in acute appendicitis. However, CRP is superior to bilirubin for anticipation of perforation in acute appendicitis.

Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Kolon - Pro-Position

Hintergrund: Laparoskopische Resektionen von Kolonkarzinomen werden in Deutschland immer häufiger durchgeführt. Dabei müssen sich die minimalinvasiven Verfahren an den onkologischen Ergebnissen der offenen Chirurgie messen, die bisher den Goldstandard darstellen. Die vorliegende Arbeit soll anhand der evidenzbasierten Literatur einen kritischen Überblick über die Kurz- und Langzeitergebnisse der laparoskopischen Kolonchirurgie geben und sie in Bezug zu den Ergebnissen der offenen Chirurgie setzen. Methoden: Die Grundlage dieser Übersichtsarbeit bilden die fünf größten prospektiv randomisierten Studien zum Vergleich laparoskopischer und offener Chirurgie beim Kolonkarzinom (ALCCaS, Barcelona Trial, CLASICC Trial, COLOR Study und COST Study) sowie die bisher größte und aktuellste Metaanalyse. Im Folgenden sollen die erwähnten Studien hinsichtlich der Kurzzeit- und Langzeitergebnisse kritisch zusammengefasst sowie die wichtigsten Endpunkte beleuchtet werden. Ergebnisse: Die laparoskopische Chirurgie des Kolonkarzinoms ist hinsichtlich der onkologischen Langzeitergebnisse der offenen Resektion zumindest gleichwertig. Vorteile bestehen in der frühen postoperativen Phase sowie im perioperativen Outcome. Die höheren direkten Kosten werden durch kürzere Liegezeiten, niedrigere Morbidität und weniger Re-Interventionen bezüglich Adhäsionen und Narbenhernien ausgeglichen. Schlussfolgerungen: Eine kritische und individuelle Indikationsstellung vorausgesetzt, sollte bei entsprechender Expertise und Erfahrung den laparoskopischen Verfahren zur Therapie des Kolonkarzinoms der Vorzug gegeben werden, um den Patienten bei gleichwertigen onkologischen Langzeitergebnissen die Vorteile der minimalinvasiven Chirurgie nicht vorzuenthalten.

Prevalence and clinical implications of diverticulosis of the vermiform appendix

Objective The epidemiology and the aetiology of inflammatory diseases of the vermiform appendix remain poorly understood. The prevalence of appendiceal diverticulosis and diverticulitis in patients undergoing appendectomy for suspected acute appendicitis was investigated. Methods A retrospective study was completed on patients who underwent appendectomy for suspected acute appendicitis. Pathology reports of all patients were screened for diverticula of the vermiform appendix. Patients with either diverticulitis of the vermiform appendix or normal appendicitis were compared. Results Out of two sets of consecutive patients (n = 1073), nine (0.8%) were identified with diverticulosis of the vermiform appendix. Two of these patients had diverticulitis of the vermiform appendix without appendicitis, three had diverticulitis with consecutive localized appendicitis, and four had proper acute appendicitis with a noninflamed diverticulum of the vermiform appendix. One patient had perforated appendicitis. Two patients had an obstructing neuroendocrine carcinoid which may have caused diverticular formation. Conclusions Diverticula of the vermiform appendix are rare. If inflamed, they mimic acute appendicitis and are treated by appendectomy. If not inflamed, and diagnosed intraoperatively, incidental appendectomy is recommended.

Liver resections can be performed safely without Pringle maneuver: A prospective study

AIM To evaluate liver resections without Pringle maneuver, i.e., clamping of the portal triad. METHODS Between 9/2002 and 7/2013, 175 consecutive liver resections (n = 101 major anatomical and n = 74 large atypical > 5 cm) without Pringle maneuver were performed in 127 patients (143 surgeries). Accompanying, 37 wedge resections (specimens < 5 cm) and 43 radiofrequency ablations were performed. Preoperative volumetric calculation of the liver remnant preceeded all anatomical resections. The liver parenchyma was dissected by water-jet. The median central venous pressure was 4 mmHg (range: 5-14). Data was collected prospectively. RESULTS The median age of patients was 60 years (range: 16-85). Preoperative chemotherapy was used in 70 cases (49.0%). Liver cirrhosis was present in 6.3%, and liver steatosis of ≥ 10% in 28.0%. Blood loss was median 400 mL (range 50-5000 mL). Perioperative blood transfusions were given in 22/143 procedures (15%). The median weight of anatomically resected liver specimens was 525 g (range: 51-1850 g). One patient died postoperatively. Biliary leakages (n = 5) were treated conservatively. Temporary liver failure occurred in two patients. CONCLUSION Major liver resections without Pringle maneuver are feasible and safe. The avoidance of liver inflow clamping might reduce liver damage and failure, and shorten the hospital stay.

Enlargement of umbilical incision in standard laparoscopic cholecystectomy is frequently necessary: An argument for the single incision approach?

Abstract Objective: Cosmetic result after cholecystectomy is up for debate. The aim of this study was to investigate the incidence and extent of enlargement of initial skin and fascia incision in standard laparoscopic cholecystectomy and to detect predictive factors for such an enlargement. Material and methods: The size of the umbilical incision was measured before and after standard laparoscopic gallbladder removal in 391 patients from August 2009 to October 2012. Predisposing factors for the need of enlargement of the umbilical incision were analysed. Results: Additional enlargement of the umbilical incision for gallbladder removal was required in 35.8% of the patients at skin level, and in 40.4% at fascia level. The median enlargement of the umbilical skin incision was 11 mm, from 25 mm to 36 mm. Gallbladder weight, total stone weight, maximum diameter of largest stone and shorter initial length of incision were independent predisposing factors for enlargement of the incision. Conclusions: In standard laparoscopic cholecystectomy the umbilical incision frequently requires secondary enlargement, especially if a large stone mass is involved. Therefore, the cosmetic result after laparoscopic cholecystectomy depends on more than only the technique used for access and the surgical technique for cholecystectomy should be chosen individually for each patient according to the stone mass.

Insurance status does not affect short-term outcomes after oncological colorectal surgery in Europe, but influences the use of minimally invasive techniques: a propensity score-matched analysis

Background and PurposeControversy exists whether surgical treatment is influenced by insurance status. American studies suggest higher morbidity and decreased survival in uninsured patients with colorectal cancer (CRC). It remains elusive, however, whether these findings apply to European countries with mandatory, government-driven insurance systems. We aimed to analyze whether operative techniques, quality of surgery, and complication rates differ among patients covered by statutory (SI) versus private (PI) healthcare insurance.MethodsBased on a prospective national surgical quality database, patients undergoing elective resection for CRC during 2007–2015 were identified. A propensity score match of eligible patients with SI and PI yielded 765 patients per group.ResultsHierarchical status of the operating surgeon differed substantially (p = 0.001): junior surgeons operated on > 50% of patients with SI, whereas over 80% of patients with PI were operated by senior surgeons. Minimally invasive techniques were used more frequently in patients with PI (p = 0.001) and patients with SI undergoing colonic resection showed an increased conversion rate (OR 2.44). Median duration of surgery (p = 0.001) and blood loss (p = 0.002) were higher in patients with SI; however, length of hospital stay was equal. Neither the rate of positive resection margins nor the number of resected lymph nodes differed among groups. Complications and mortality occurred with similar frequencies for patients undergoing colon (p = 0.140) and rectal (p = 0.335) resection.ConclusionThe use of minimally invasive techniques was favored in patients with PI; however, the quality of oncological resection was not affected by insurance status and only minor differences in perioperative complications observed.