Sven Petersen

Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches.

AbstractPURPOSE: Pilonidal sinus is a common disease and surgical removal and subsequent wound closure is crucial for lasting cure. To evaluate the outcome of different primary closure techniques we performed a pooled analysis of data published in the past 35 years. nMETHODS: We identified reports on wound infection, early failure, and late recurrence status in relation to treatment modality. Surgical techniques were classified into five groups: simple closure technique in the midline, asymmetric or oblique closure techniques, and full-thickness flap techniques like rhomboid flaps, vy-plasty, and z-plasty. Estimations of the incidences resulted from the quotient of number of responses and the number of patients for each study, and these quotients were summarized over all studies. nRESULTS: The MEDLINE search identified 74 publications including 10,090 patients. Pooled data analysis revealed an inhomogeneous effect of the surgical techniques on the infection rate. In contrast, there was a significantly lower early failure rate and late recurrence rate of both the asymmetric-oblique closure techniques and the full-thickness flap techniques when compared with the midline repair technique. No difference was found between the asymmetric repairs and the full-thickness flap techniques. nCONCLUSION: Beside the various statistical considerations when using a pooled data analysis combining results from the literature, this overview suggests a significant benefit of asymmetric-oblique closure techniques or flap techniques in comparison with simple closure in the midline. Thus, we recommend an asymmetric closure technique for primary closure of a chronic pilonidal sinus. These asymmetric procedures provide better results than the simple closure in the natal midline. Furthermore, they are not as sophisticated as the full-thickness plasty techniques.

Deep prosthesis infection in incisional hernia repair: predictive factors and clinical outcome.

OBJECTIVEnTo evaluate the incidence of prosthetic infection in incisional hernia repairs, to determine whether there are any factors associated with prosthetic infection and to describe the clinical outcome.nnnDESIGNnRetrospective clinical study.nnnSETTINGnTeaching hospital, Germany.nnnSUBJECTSn121 consecutive patients who underwent incisional hernia repair in our department from December 1994 to December 1999.nnnINTERVENTIONnHernia repair by implantation of an alloplastic prosthesis by the Stoppa-Rives technique.nnnMAIN OUTCOME MEASURESnPostoperative deep prosthetic infection and associated factors.nnnRESULTSnAll 121 patients had the mesh implanted in the subfascial plane, 77 had a polypropylene mesh (Prolene) (64%), 7 had a polyester mesh (Mersilene) (6%), and 37 patients had a expanded polytetrafluoroethylene patch (ePTFE, Gore-Tex) (31%). Postoperatively the mesh became infected in 8 patients (7%), a mean of 4.5 months (range 0.5-16) after hernia repair. All three infected ePTFE patches had to be removed whereas drainage was sufficient treatment for the infected polypropylene and polyester meshes.nnnCONCLUSIONnOnce a mesh infection is verified adequate drainage seems to be sufficient for polypropylene and polyester meshes but ePTFE patches should be removed.

Stapled transanal rectal resection under laparoscopic surveillance for rectocele and concomitant enterocele.

PurposeStapled transanal rectal resection recently became a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential threat to structures located in front of the anterior rectal wall. We decided to perform a combined procedure of transanal rectal resection with a simultaneous laparoscopy for patients with obstructed defecation syndrome and an enterocele.MethodsBetween November 2002 and May 2005 a total of 41 patients were treated surgically for obstructed defecation syndrome. Four patients with concomitant enterocele underwent stapled transanal rectal resection under laparoscopic surveillance. Before surgery all patients underwent preoperative assessment, including clinical examination, colonoscopy, conventional video defecography, dynamic magnetic resonance imaging defecography, gynecology examinations, and psychologic evaluation.ResultsThe mean operative time was 50 (±16.5) minutes for the conventional stapled transanal rectal resection and 67 (±14.1) minutes for combined laparoscopy and stapled transanal rectal resection (P < 0.01). Three major complications were observed: two had bleeding in the staple line (one from each group) and one had a late abscess in the staple line.ConclusionsThe combination of the stapled transanal rectal resection procedure and laparoscopy provides the opportunity to perform transanal rectal resection without the threat of intra-abdominal lesions caused by enterocele.

Severe intra-abdominal bleeding following stapled mucosectomy due to enterocele: report of a case.

Abstract.Stapled rectal mucosectomy (SRM) became a widely acceptednsurgical procedure for haemorrhoids. One of the rarencomplications is severe bleeding. We report the case of anpatient who underwent SRM for thirddegree haemorrhoids. Innaddition, he suffered symptoms of outlet obstruction, althoughndefecography showed no serious disease. One day after SRM, thenpatient complained of abdominal pain and peritonitis. Computedntomography revealed blood in the abdomen. The patient underwentnlaparotomy, which revealed a deep enterocele that reached downnto the level of the sphincteric muscle. The ventral part of thenstapled ring was placed intraperitoneally, and a longitudinalndefect of the rectal serosa was observed. The serosa defect wasnsutured and a diverting sigmoid stoma was carried out. Thenpatient left the hospital 10 days later. We emphasize vigilancenfor undetected enteroceles in mucosal prolapse syndrome combinednwith defecation problems.

Immunohistochemically detected p53 mutations in epithelial tumors and results of treatment with chemotherapy and radiotherapy. A treatment-specific overview of the clinical data.

Background: The aim was to ascertain whether many hundreds of clinical reports over the last decade are consistent with the prediction of a poorer outcome in cancer patients wit p53 abnormalities treated with cytotoxic drugs and radiation.nn Material and Methods: There are 301 studies on the influence of p53 overexpression published through summer 2000, in which chemotherapy or radiotherapy was used alone or in combination with surgery. From 45 reports meeting stringent selection rules, comparison groups are identified in whom the same measure of outcome was reported for the same treatment applied to the same tumor, with results corrected for important prognostic factors. Metaanalysis techniques are then applied to the comparison groups. Attention was limited to reports using immunohistochemical techniques, to form comparison groups of sufficient size.nn Results: Four comparison groups were identified by treatment and endpoint: 1) Stage I–III breast cancer (surgery and chemotherapy, disease-free survival, seven studies); 2) stage I–III breast cancer (surgery and chemotherapy, overall survival, six studies); 3) stage II–IV head and neck cancer (radiotherapy and chemotherapy, overall survival, five studies); 4) FIGO I–IV ovarian cancer (surgery and chemotherapy, overall survival, six studies). In the breast (disease-free survival) and ovarian (overall survival) comparison groups, the hazard ratio for a deleterious effect of p53 overexpression was significant or marginally significant, depending on assumed ranges for unreported hazard ratios in non-significant studies.nn Conclusions: Despite the many caveats related to metaanalysis applied to retrospective data, high variability of immunohistochemical technique, etc., a nearly significant negative effect of p53 overexpression on outcome of treatment with cytotoxic drugs and radiation emerges in the few studies where heterogeneity can be sufficiently reduced or accounted for.Hintergrund: Es sollte überprüft werden, ob die im letzten Jahrzehnt zahlreich publizierten klinischen Untersuchungen die Aussage zulassen, dass eine Chemo- und Strahlentherapie mit einem schlechteren Ergebnis bei der Therapie von Tumorpatienten einhergeht bei Vorliegen einer p53-Mutation.nn Material und Methode: Bis Sommer 2000 wurden 301 Studien zum Einfluss einer p53-Überexpression publiziert, bei denen eine Chemo- bzw. Strahlentherapie allein oder in Kombination mit einer Operation eingesetzt wurde. Von 45 Studien, die definierte Selektionskriterien enthielten, wurden Untergruppen gebildet, bei denen der gleiche klinische Endpunkt bei Vergleichbarkeit von Behandlung und Tumorstadium unter Berücksichtigung wichtiger prognostischer Parameter auf das Behandlungsergebnis erfasst wurde. Diese Untergruppen wurden einer Metaanalyse unterzogen. Um dabei eine ausreichende Gruppengröße zu gewährleisten, wurde die Auswahl der Studien auf solche mit immunhistochemischer Untersuchung des p53-Status begrenzt.nn Ergebnisse: Vier Untergruppen konnten gemäß Behandlung und Endpunkt identifiziert werden: 1. Stadium-I-III-Mammakarzinome (Operation und Chemotherapie, krankheitsfreies Überleben, sieben Studien), 2. Stadium-I-III-Mammakarzinome (Operation und Chemotherapie, Gesamtüberleben, sechs Studien), 3. Stadium-II-IV-Kopf-Hals-Tumoren (Radiotherapie und Chemotherapie, Gesamtüberleben, fünf Studien) und 4. FIGO-Stadien-I-IV-Ovarialkarzinome (Operation und Chemotherapie, Gesamtüberleben, sechs Studien). Für die Gruppen Mamma- (krankheitsfreies Überleben) und Ovarialkarzinome (Gesamtüberleben) fand sich eine signifikante bzw. marginal signifikante Hazard Ratio für einen negativen Einfluss einer p53-Überexpression auf das Behandlungsergebnis, wobei Spannweiten für nicht publizierte Hazard Ratios in den nicht signifikanten Studien geschätzt wurden.nn Schlussfolgerung: Ungeachtet der vielen Einschränkungen, die bei der Metaanalyse der retrospektiven Daten bei ausgeprägter Variabilität der immunhistochemisch eingesetzten Techniken u.a. zu berücksichtigen sind, lässt sich ein nahezu signifikant negativer Effekt einer p53-Überexpression auf das Behandlungsergebnis nachweisen, wenn die Heterogenität ausreichend reduziert bzw. berücksichtigt wird.

Sublay Prosthetic Repair for Incisional Hernia of the Flank

PURPOSEnA large hernia after flank incision for nephrectomy is a challenging problem in hernia surgery. In recent decades preperitoneal prosthetic herniorrhaphy became a widely accepted procedure for hernias of the abdominal wall. To evaluate the outcome of mesh hernia repair of the flank we reviewed our data on all patients who underwent preperitoneal mesh repair.nnnMATERIALS AND METHODSnWe identified 4 patients who underwent prosthesis repair after incisional hernia of the flank within the last 6 years. The primary reason for surgery was nephrectomy in 2 cases, pyeloplasty in 1 and complicated kidney cyst resection in 1. Mean followup time was 33 months.nnnRESULTSnIn a mean operative time +/- SD of 208 +/- 55 minutes the patients underwent incisional hernia repair with prosthesis implantation in the sublay position. In 3 patients an expanded polytetrafluoroethylene patch was used and in 1 polypropylene mesh was implanted. Mean prosthesis size was 25 x 38 cm. (950 +/- 300 cm. ). There were no postoperative complications. Patients were discharged from the hospital after a mean of 15 +/- 2 days. Followup revealed that none of the 4 patients with flank incision had recurrent hernia. Pain persisted in 3 patients after flank incision. However, no regular analgesic drug prescription was necessary.nnnCONCLUSIONSnMesh repair for incisional flank hernia provides reinforcement of the hernia. However, the flank remains paralyzed with a muscle bulge and some patients have persistent discomfort.

Spättoxizität nach präoperativer Kurzzeitvorbestrahlung und risikoadaptierter postoperativer Nachbestrahlung bei operablem Rektumkarzinom : Resultate einer randomisierten prospektiven Studie

Ziel: Auswertung einer randomisierten Studie zur präoperativen Strahlentherapie bei operablem Rektumkarzinom im Hinblick auf Spätnebenwirkungen. Die bereits ausführlich publizierten Ergebnisse zur Tumorkontrolle und zum Überleben werden zum Vergleich und zur Absicherung der Schlußfolgerungen dargestellt.nPatienten und Methoden: Zwischen Januar 1988 und Oktober 1993 wurden in eine randomisierte Studie 94 Patienten mit operablem Rektumkarzinom einbezogen. 47 Patienten wurden mit 5mal 3,3 Gy (16 × 16 cm Feldgröße, 9-MeV-Photonenbestrahlung) präoperativ bestrahlt und 24 bis 48 Stunden danach operiert; 46 Patienten erhielten keine präoperative Strahlentherpie. Bei Vorliegen von Risikofaktoren (T4-Stadium, R1/R2-Resektion, intraoperative Tumorperforation) erfolgte eine CT-gestützt geplante postoperative Bestrahlung mit Einzeldosen von 1,8 bis 2,0 Gy und Gesamtdosen im Mittel von 41,4 Gy (präoperative Bestrahlung) und 59,8 Gy (nur postoperativ Bestrahlte). Es wurden lokale Kontrollen, Überleben und Nebenwirkungsmuster fünf Jahre nach Abschluß der Studie ausgewertet.nErgebnisse: Die Zahl der Lokalrezidive in der R0-resezierten Gruppe konnte durch die Vorbestrahlung deutlich gesenkt werden (24 versus 17%, p = 0,08) und auf einen späteren Zeitpunkt (1,9 versus drei Jahre) verschoben werden. Das aktuarische Fünf-Jahres-Überleben war mit 49% in der vorbestrahlten gegenüber 28% in der nichtvorbestrahlten Gruppe signifikant (p = 0,027) günstiger. Eine multivariate Analyse erbrachte für die lokale Kontrolle als signifikant unabhängigen Parameter lediglich das UICC-Stadium (p = 0,0003). Die Vorbestrahlung (p = 0,07) und das T-Stadium (p = 0,08) zeigten einen statistischen Trend. Für das Überleben war das Alter der Patienten (p = 0,0003), das R-Kriterium (p = 0,01) und das UICC-Stadium (p = 0,001) prognostisch signifikant. Die Vorbestrahlung (p = 0,078) hatte auch hier einen noch nicht signifikanten Einfluß. Radiogene Nebenwirkungen > Grad 2 (LENT-SOMA) konnten weder bei der engmaschigen Nachsorge aller Patienten noch in einer 1998 durchgeführten zusätzlichen Untersuchung der zu diesem Zeitpunkt noch lebenden bestrahlten Patienten (n = 25) beobachtet werden. Von vier prä- und postoperativ bestrahlten Patienten mit Risikofaktoren, die fünf bis elf Jahre nach der Behandlung nachuntersucht wurden, hatten drei Nebenwirkungen Grad 1 oder 2, wobei besonders die Enddarmstörungen klinisch bedeutsam waren.nSchlußfolgerung: Die präoperative Bestrahlung in der genannten Dosierung zeigt einen positiven Effekt auf lokale Tumorkontrolle und Überleben bei moderaten Nebenwirkungen.Aim: Analysis of a randomized study of preoperative radiation therapy for operable carcinoma of the rectum with regard to late sequelae. Results of tumor control and survival, which have already been published in detail are summarized for comparison and for confirmation of the conclusions.nPatients and Methods: Between January 1988 and October 1993 94 patients with operable carcinoma of the rectum were included in a randomized trial. Fourty-seven patients were treated with 5 × 3.3 Gy (field size 16 × 16 cm, 9 MeV photons) 24 to 48 hours prior to surgery; 46 patients did not receive preoperative irradiation. If risk factors (T4-stage, R1/R2 resection, intraoperative tumor perforation) were present, postoperative irradiation was performed after CT-planning. Total postoperative doses of 41.4 Gy (preoperative irradiation) or 59.8 Gy (surgery only) were applied with doses per fraction of 1.8 to 2.0 Gy. Local control, survival, and pattern of side effects were analyzed at 5 years after conclusion of the trial.nResults: The frequency of local recurrence was markedly reduced by preoperative irradiation in R0-resected patients (24% vs 13%, p = 0.08). The time to recurrence was delayed (1.9 vs 3 years). The 5-year actuarial survival rate was significantly higher in the preoperatively irradiated group compared to the not pre-irradiated group (40% vs 28%, p = 0.027). Multivariate analysis revealed UICC-grading as the only independent parameter for local control (p = 0.0003), while preoperative irradiation (p = 0.07) and T-stage (p = 0.08) only displayed a trend. For patient survival, age (p = 0.0003), R.-status (p = 0.01) and UICC-score (p = 0.001) were significant prognostic factors. Preoperative irradiation had a non-significant effect only (p = 0.078). Radiation-induced side effects with a LENT-SOMA score > 2 were observed neither during frequent follow-up nor at an additional examination of those patients still alive in 1998 (n = 25). Of 4 pre- and postoperatively irradiated patients with risk factors, 3 had side effects grade 1 or 2, predominantly rectal changes, at 5 to 11 years after treatment.nConclusions: A positive effect on tumor control and survival is achieved with preoperative irradiation with the doses used in this study, with moderate side effects.

Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids

BackgroundWithin the last years, stapled rectal mucosectomy (SRM) has become a widely accepted procedure for second and third degree hemorrhoids. One of the delayed complications is a stenosis of the lower rectum. In order to evaluate the specific problem of rectal stenosis following SRM we reviewed our data with special respect to potential predictive factors or stenotic events.MethodsA retrospective analysis of 419 consecutive patients, which underwent SRM from December 1998 to August 2003 was performed. Only patients with at least one follow-up check were evaluated, thus the analysis includes 289 patients with a mean follow-up of 281 days (±18 days).For statistic analysis the groups with and without stenosis were evaluated using the Chi-Square Test, using the Kaplan-Meier statistic the actuarial incidence for rectal stenosis was plotted.ResultsRectal stenosis was observed in 9 patients (3.1%), eight of these stenoses were detected within the first 100 days after surgery; the median time to stenosis was 95 days. Only one patient had a rectal stenosis after more than one year. 8 of the 9 patients had no obstructive symptoms, however the remaining patients complained of obstructive defecation and underwent surgery for transanal strictureplasty with electrocautery. A statistical analysis revealed that patients with stenosis had significantly more often prior treatment for hemorrhoids (p < 0.01). According to the SRM only severe postoperative pain was significantly associated with stenoses (p < 0.01). Other factors, such as gender (p = 0.11), surgical technique (p = 0.25), revision (p = 0.79) or histological evidence of squamous skin (p = 0.69) showed no significance.ConclusionRectal stenosis is an uncommon event after SRM. Early stenosis will occur within the first three months after surgery. The majority of the stenoses are without clinical relevance. Only one of nine patients had to undergo surgery for a relevant stenosis. The predictive factor for stenosis in the patient-characteristics is previous interventions for hemorrhoids, severe postoperative pain might also predict rectal stenosis.

Iatrogenic colon perforation from the viewpoint of the surgeon. Experiences with 11 patients

Abstract. Iatrogenic colonic perforation is a rare but very dangerous complication of colonoscopy. We report on eleven prospectivly recorded patients treated between 1994 and 1998. In seven cases the colonoscopy had been done for diagnostic and in four cases for therapeutic reason. Nine women and two men (age range 56 to 92 years) were affected. In 77 % the perforation was found in the sigmoid colon. All patients were operated on and five sutures, five resections and one colostomy were performed. No significant differences could be shown in six patients with classical perforation compared with five patients presenting with prolonged abdominal pain. Only duration of symptoms was significantly different in the two groups. Three patients (85, 90 and 92 years) died from late complications.Zusammenfassung. Die iatrogene Colonperforation ist eine seltene und gefürchtete Komplikation der Coloskopie. Vorgestellt werden 11 prospektiv erfasste eigene Patienten aus einem Zeitraum von 1994–1998. Sieben diagnostische und 4 therapeutische Prozeduren verursachten bei 9 Frauen und 2 Männern (56–92 Jahre) den iatrogenen Notfall. Die Perforation fand sich in 77 % im Colon sigmoideum. Alle Patienten wurden operiert (5 Übernähungen, 5 resezierende Eingriffe, eine Anus-praeter-Anlage). Bis auf die Anamnesedauer zeigten 6 Patienten mit klassischer Perforation keine signifikanten Unterschiede im Vergleich zu 5 Patienten mit protrahierter Bauchsymptomatik. Drei letale Verläufe (85, 90 und 92 Jahre) waren durch Spätkomplikationen gekennzeichnet.

New Targets for the Modulation of Radiation Response - Selective Inhibition of the Enzyme Cyclooxygenase 2

The development of new chemotherapeutic agents and concepts of radiation therapy has led to new perspectives in cancer therapy. Recently developed novel agents interfere with molecular mechanisms that are altered in cancer cells. Cyclooxygenase-2 (COX-2) is an enzyme induced by a variety of factors including tumor promoters, cytokines, growth factors and hypoxia. It is involved in the metabolic conversion of arachidonic acid to prostanoids, primarily in inflammatory states and tumors. In normal tissues, prostanoids are synthesized by COX-1, and they exert numerous homeostatic physiological functions. COX-2 overexpression is linked to carcinogenesis, maintenance of progressive tumor growth and metastatic spread. COX-2 and its products may act as protectors against cell damage by ionizing radiation. In this context, the treatment with selective COX-2 inhibitors became of interest for radiation oncology within the last years. In this review we focus on the effects of COX-2 in the modulation of the radiation response and the potential clinical application as cancer preventive drug or as novel agents in adjuvant clinical settings. The experimental data available suggest that COX-2 inhibitors can enhance the radiation response in tumors without serious side effects to the normal tissue. In conclusion COX-2 might be a useful tool for cancer prevention and represents a potential molecular target for improving cancer treatment in combination with radiotherapy.