T. T. Trinh

Permanent stoma after low anterior resection for rectal cancer.

BACKGROUND AND OBJECTIVES: A low anterior resection procedure for removing a rectal tumor aims to preserve the sphincter and avoid a permanent stoma. Permanent stomas are primarily necessary in cases of poor anorectal function and local recurrence. The aim of this study was to clarify whether anastomosis-related complications and local recurrence influenced the rate of permanent stomas in a long-term follow-up. METHODS: Of 1032 consecutive patients with rectal cancer, 397 were treated by low anterior resection (R0 and R1 resections) between 1985 and 2007 at the Department of General and Abdominal Surgery of the University Hospital, Mainz (Germany). All patient data were collected prospectively. A retrospective, multivariate analysis was conducted to determine factors that influenced the occurrence of delayed and nonreversal of defunctioning stoma, the rate of repeat stoma after closure, and the need for a permanent stoma in patients whose stomas were not initially defunctioning. RESULTS: A defunctioning stoma was created in 292 of 397 patients (74%); 12% of stomas were not reversible (33/279 that survived the operation >90 d); 11% (28/246) required a repeat stoma after stoma closure; 10% (10/105) of patients whose stomas were not initially defunctioning received a late permanent stoma. The overall rate of a permanent stoma was 18%. The main reasons for a permanent stoma were anastomosis-related complications and local recurrence. Risk factors for anastomosis-related complication were male gender, low tumor site, and tumor stage. Despite a significant reduction in local recurrence rates from 1997 to 2007, the rate of creating a permanent stoma did not change. CONCLUSIONS: The possibility of a permanent stoma should be considered when planning surgery for treating rectal cancer. It might be preferable in older patients, in poor condition and with more advanced rectal cancers, to consider an abdominoperineal resection or Hartmann procedure instead of a low anterior resection.

Long-term Oncologic Outcome After Transanal Endoscopic Microsurgery for Rectal Carcinoma.

BACKGROUND: Transanal endoscopic microsurgery is superior to other methods of local excision of rectal cancer, but few studies report long-term follow-up data. OBJECTIVE: This study investigated the use of transanal endoscopic microsurgery alone as curative and compromise therapy based on long-term disease recurrence and mortality. DESIGN: This was a retrospective review of prospectively collected data. SETTINGS: The study was conducted at a tertiary care university medical center. PATIENTS: The study included 133 patients treated between 1985 and 2007. There were 3 groups, including transanal endoscopic microsurgery in curative intent (low-risk rectal carcinoma, including pT1, G1/2, L0, and LX with clear margins and a minimal distance between tumor and resection margin of >1 mm (N = 64) or clear margins only (N = 18 ))) and as compromise therapy (high-risk or incompletely resected rectal carcinoma; N = 51). MAIN OUTCOME MEASURES: Log-rank tests were used to compare overall and cancer-specific survival. RESULTS: The median follow-up time was 8.6 years (range, 0.2–25.1 years), and a total of 131 of 133 patients (98.5%) were followed >5 years or until death. The preoperative diagnosis of carcinoma was not associated with belonging into 1 of the 3 categories. In patients with low-risk completely (>1 mm) resected carcinoma, the 5- and 10-year local recurrence rates were 6.6% and 11.6%. In patients with high-risk or incompletely resected carcinoma, the rates were 32.5% and 35.0% (p = 0.006). The 5- and 10-year cancer-specific survival rates for low-risk patients were 98.0% and 91.0% and 84.3% and 74.3% for high-risk patients (p = 0.05). LIMITATIONS: The study was limited by its retrospective design and small subgroups. CONCLUSIONS: The high cancer-specific survival justifies transanal endoscopic microsurgery alone as curative treatment in low-risk rectal carcinoma. Complete resection is essential to lower the risk of local recurrence. The high local recurrence rate in patients with high-risk rectal carcinoma restricts the use of TEM alone as compromise therapy.

[Anterior semifundoplication in the treatment of gastroesophageal reflux disease: long-term results following conventional surgery].

AbstractIntroduction. According to randomized studies, semifundoplication in the treatment of gastroesophageal reflux disease (GERD) is related to lower postoperative dysphagia rates than with fundoplication in comparable reflux controls. However there is a lack of long-term results. The object of this study was therefore to determine the influence of partial anterior fundoplication on the long-term clinical outcome (>1 year) in patients with GERD. Method. From December 1986 until May 2000, 100 patients suffering from GERD were operated on. Seven of them were not evaluated, four because of revisional surgery, two because of preceding multiple abdominal operations (MEN, colitis ulcerosa), and one because of Nissen fundoplication. In all, the perioperative results of 93 patients (51 men and 42 women aged 21 to 86 years) were evaluated. Fourteen patients died during the follow-up period and two were lost because of changes in address. Thus, 77 patients with a median follow-up of 88 months (range 15–94) were interviewed with a list of standardized questions concerning reflux control and dysphagia. Results. The median operation time was 110 m (range 55–270). In one patient, an esophageal mucosal tear was detected intraoperatively and promptly repaired. Postoperatively, 71.4% (55/77) had no reflux complaints, 85.7% (66/77) had dysphagia, 66.2% took no further medication, and 31.2% (24/77) continued taking medication. The median interval free of symptoms was 25.5 months, and in 40.9% of the patients, symptoms recurred within the first year after operation. Five patients were in need of reoperation. A total of 77.9% of the patients were satisfied with the results of the operation. Conclusions. With regard to reflux control, long-term results of anterior semifundoplication are comparable to those of fundoplication. However, considering postoperative dysphagia, the technically easier anterior semifundoplication is less eventful and therefore a good alternative which in the long run shows good results after laparoscopic intervention. ZusammenfassungHintergrund. Bei der Behandlung der Refluxkrankheit ist die Semifundoplicatio nach randomisierten Studien mit einer geringeren Dysphagierate im Vergleich zur Fundoplicatio bei vergleichbarer Refluxkontrolle verbunden. Allerdings fehlen hierzu Langzeitergebnisse. Ziel der Studie war daher, den Einfluss der konventionell durchgeführten Semifundoplicatio bei gastroösophagealer Refluxerkrankung (GERD) auf die Refluxsymptomatik im Langzeitverlauf (>1 Jahre) zu ermitteln. Methode. Zwischen Dezember 1986 und Mai 2001 wurden 100 Patienten wegen GERD operiert. Nicht bewertet wurden Patienten, die wegen eines Rezidivs erneut operiert wurden (n=4), 2 Patienten mit multiplen abdominellen Voroperationen (MEN, Colitis ulcerosa) und ein Patient, der nach Nissen mit einer Fundoplicatio versorgt wurde, so dass die perioperativen Ergebnisse von 93 Patienten, 51 Männer und 42 Frauen im Alter von 21–86 Jahren (Median 56 Jahre), ausgewertet wurden. 14 Patienten waren im Beobachtungszeitraum verstorben, 2 unbekannt verzogen. 77 Patienten mit einer medianen Nachbeobachtungszeit von 88 Monaten (15–194) wurden mittels standardisiertem Fragebogen hinsichtlich postoperativer Refluxbeschwerden und Dysphagie befragt. Ergebnisse. Die mediane Operationsdauer betrug 110 min (55–270 min). Bei einem Patienten wurde der Ösophagus wegen Perforation übernäht. Postoperativ hatten 71,4% (55/77) der Patienten keine Refluxbeschwerden. 85,7% (66/77) der Patienten hatten keine Dysphagie. 66,2% der Patienten nahmen keine, 31,2% weiterhin Medikamente ein (58,3%<40 mg PPI; 33,3% ≥ 40 mg PPI; 8,4% sonstige). Das rezidivfreie Intervall betrug 25,5 Monate (Median), wobei 40,9% (9/22) der Patienten ihre Beschwerden im ersten postoperativen Jahr angaben. Bei Refluxbeschwerden wurden 5 (6,5%) Patienten erneut operiert. Insgesamt waren 77,9% der Patienten mit dem Ergebnis der Operation zufrieden. Schlussfolgerung. Die Langzeitergebnisse der anterioren Semifundoplicatio sind hinsichtlich der Refluxkontrolle mit denen der Fundoplicatio vergleichbar. Bezüglich der postoperativen Dysphagie ist die technisch einfachere anteriore Semifundoplicatio komplikationsärmer, und stellt damit eine gute Alternative dar, die auch im Langzeitverlauf nach laparoskopischem Vorgehen guten Resultate erwarten lässt.

Die anteriore Semifundoplicatio zur Behandlung der gastroösophagealen Refluxkrankheit

AbstractIntroduction. According to randomized studies, semifundoplication in the treatment of gastroesophageal reflux disease (GERD) is related to lower postoperative dysphagia rates than with fundoplication in comparable reflux controls. However there is a lack of long-term results. The object of this study was therefore to determine the influence of partial anterior fundoplication on the long-term clinical outcome (>1 year) in patients with GERD. Method. From December 1986 until May 2000, 100 patients suffering from GERD were operated on. Seven of them were not evaluated, four because of revisional surgery, two because of preceding multiple abdominal operations (MEN, colitis ulcerosa), and one because of Nissen fundoplication. In all, the perioperative results of 93 patients (51 men and 42 women aged 21 to 86 years) were evaluated. Fourteen patients died during the follow-up period and two were lost because of changes in address. Thus, 77 patients with a median follow-up of 88 months (range 15–94) were interviewed with a list of standardized questions concerning reflux control and dysphagia. Results. The median operation time was 110 m (range 55–270). In one patient, an esophageal mucosal tear was detected intraoperatively and promptly repaired. Postoperatively, 71.4% (55/77) had no reflux complaints, 85.7% (66/77) had dysphagia, 66.2% took no further medication, and 31.2% (24/77) continued taking medication. The median interval free of symptoms was 25.5 months, and in 40.9% of the patients, symptoms recurred within the first year after operation. Five patients were in need of reoperation. A total of 77.9% of the patients were satisfied with the results of the operation. Conclusions. With regard to reflux control, long-term results of anterior semifundoplication are comparable to those of fundoplication. However, considering postoperative dysphagia, the technically easier anterior semifundoplication is less eventful and therefore a good alternative which in the long run shows good results after laparoscopic intervention. ZusammenfassungHintergrund. Bei der Behandlung der Refluxkrankheit ist die Semifundoplicatio nach randomisierten Studien mit einer geringeren Dysphagierate im Vergleich zur Fundoplicatio bei vergleichbarer Refluxkontrolle verbunden. Allerdings fehlen hierzu Langzeitergebnisse. Ziel der Studie war daher, den Einfluss der konventionell durchgeführten Semifundoplicatio bei gastroösophagealer Refluxerkrankung (GERD) auf die Refluxsymptomatik im Langzeitverlauf (>1 Jahre) zu ermitteln. Methode. Zwischen Dezember 1986 und Mai 2001 wurden 100 Patienten wegen GERD operiert. Nicht bewertet wurden Patienten, die wegen eines Rezidivs erneut operiert wurden (n=4), 2 Patienten mit multiplen abdominellen Voroperationen (MEN, Colitis ulcerosa) und ein Patient, der nach Nissen mit einer Fundoplicatio versorgt wurde, so dass die perioperativen Ergebnisse von 93 Patienten, 51 Männer und 42 Frauen im Alter von 21–86 Jahren (Median 56 Jahre), ausgewertet wurden. 14 Patienten waren im Beobachtungszeitraum verstorben, 2 unbekannt verzogen. 77 Patienten mit einer medianen Nachbeobachtungszeit von 88 Monaten (15–194) wurden mittels standardisiertem Fragebogen hinsichtlich postoperativer Refluxbeschwerden und Dysphagie befragt. Ergebnisse. Die mediane Operationsdauer betrug 110 min (55–270 min). Bei einem Patienten wurde der Ösophagus wegen Perforation übernäht. Postoperativ hatten 71,4% (55/77) der Patienten keine Refluxbeschwerden. 85,7% (66/77) der Patienten hatten keine Dysphagie. 66,2% der Patienten nahmen keine, 31,2% weiterhin Medikamente ein (58,3%<40 mg PPI; 33,3% ≥ 40 mg PPI; 8,4% sonstige). Das rezidivfreie Intervall betrug 25,5 Monate (Median), wobei 40,9% (9/22) der Patienten ihre Beschwerden im ersten postoperativen Jahr angaben. Bei Refluxbeschwerden wurden 5 (6,5%) Patienten erneut operiert. Insgesamt waren 77,9% der Patienten mit dem Ergebnis der Operation zufrieden. Schlussfolgerung. Die Langzeitergebnisse der anterioren Semifundoplicatio sind hinsichtlich der Refluxkontrolle mit denen der Fundoplicatio vergleichbar. Bezüglich der postoperativen Dysphagie ist die technisch einfachere anteriore Semifundoplicatio komplikationsärmer, und stellt damit eine gute Alternative dar, die auch im Langzeitverlauf nach laparoskopischem Vorgehen guten Resultate erwarten lässt.

Begrenzung und Reduktion der Intensivtherapie — Allgemeinund Viszeralchirurgie

Wahrend das Problem der Begrenzung der Intensivtherapie in den USA und vielen anderen Landern seit langem diskutiert wird und umfangreiche Daten hierzu vorliegen, wird das Problem in Deutschland zwar angesprochen [10, 11], konkrete Angaben zur Indikation und Haufigkeit eines Therapieverzichts liegen allerdings bislang nicht vor. Daher war es das Ziel einer retrospektiven Untersuchung bei auf der Intensivstation der Klinik fur Allgemein- und Abdominalchirurgie der Johannes-Gutenberg-Universitat Mainz gestorbenen Patienten, die Inzidenz und Art einer Therapiebegrenzung, die Bedeutung einer Patientenverfugung sowie die Grunde fur einen Therapieverzicht zu erfassen, mit dem Ziel, hiermit zur Diskussion dieses Themas und zur Offenlegung der Erfahrungen beizutragen.