Th. Junginger

Heller Myotomy for Failed Pneumatic Dilation in Achalasia: How Effective Is It?

Objectives:This long-term prospective study describes the effect of myotomy in patients who fail to respond to repeated pneumatic dilations and compares their clinical course with that of patients responding to dilation therapy. Methods:Nineteen consecutive patients who had never reached a clinical remission after repeated pneumatic dilation underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n = 34) or multiple (n = 14) pneumatic dilation(s). Symptoms were graded with a previously described symptom score ranging from 0 to 12. Remission was defined as a score of 3 or less persisting for at least 6 months. Duration of remission was summarized using Kaplan Meier survival curves. Association between baseline factors and the need for surgery was evaluated using logistic regression. Results:Complete follow-up was obtained for 98.5% of the patients. The median duration of follow-up was similar in patients treated by myotomy (10.0 years), in patients reaching a clinical remission after a single dilation (10.6 years), but differed in patients undergoing repeated dilations (6.9 years). The 10-year remission rate was 77% (95% CI 53–100%) in patients undergoing myotomy, 72% (95% CI: 56–87%) in patients “successfully” treated with a single pneumatic dilation and 45% (95% CI: 16–73%) in patients undergoing several dilations. Among all baseline factors investigated, young age was associated with an increased need of surgery. Conclusions:Myotomy is an effective treatment modality in patients with achalasia who have failed to respond to pneumatic dilation. Young patients may benefit from primary surgical therapy.

The examiner's learning effect and its influence on the quality of endoscopic ultrasonography in carcinoma of the esophagus and gastric cardia

AbstractBackground: The preoperative diagnosis of tumors of the esophagus and the gastric cardia is an important element in their stage-oriented therapy. The goal of the present study was to evaluate the accuracy of endosonographic ultrasound (EUS) and to test its usefulness in tumor staging and the assessment of operability. Methods: A total of 139 tumors were scanned via EUS by one examiner ≤14 days prior to resection (TNM staging per UICC, 1987). Results: The accuracy for completely traversable tumors was 60.8% for T1, 82.1% for T2, 77.5% for T3, and 33% for T4 stages. This accuracy was somewhat reduced in cases of nontraversable tumor stenosis (51.9%). In T staging, a significant case-dependent improvement in accuracy to 89.5% was found; this was regarded as a learning effect. In N staging, we considered only those tumors that were resected by the transthoracic approach with systematic node dissection and complete EUS (n= 80). N-stage accuracy (T1–T4) was 71.3%, and no improvement could be shown. To assess operability, discrimination between T1/T2 and T3/T4 tumors is crucial. Accuracy, sensitivity, and specifity can thus be improved significantly. Conclusions: The quality of EUS depends on the experience of the examiner. Reliable results can be obtained after >75 examinations have been done. EUS is a valuable tool in tumor staging when it is performed by an experienced examiner or under the direct supervision of such a person.

Three different types of surgeon-specific stress reactions identified by laparoscopic simulation in a virtual scenario

BackgroundMinimally invasive surgery causes higher mental strain for surgeons than conventional surgery and is significantly more stressful in consecutive cases. This study aimed to investigate whether individual stress responses are associated with intraoperative alterations of manual surgical skills and technical errors of the laparoscopic surgeon.MethodsThe LapSim virtual reality simulator was used. Stress measurement was carried out for 18 surgeons performing a virtual cholecystectomy using the LapSim simulator in the context of the patient simulator provided by the METI Corporation. In the course of the study, the surgeons were exposed to different external stressors (S1–S4) in defined intervals. The activity of the sympathetic nervous system was evaluated by skin resistance with the help of a sympathicograph.ResultsThree different surgeon-specific stress reactions (SSR) could be identified. The first, SSR-1, with significant stress reactions during the study without recovery, showed larger laparoscopic extensions of movement but fewer intraoperative complications than SSR-2 (recovery after the stress reactions) or SSR-3 (without significant stress reactions).ConclusionsThe mental load of the laparoscopic surgeon might be highly optimized by continuous activity of the sympathetic nervous system. The question of what extent or quality of stress produces adverse effects remains unclear.

Long‐term survivors of esophageal cancer: Disease‐specific quality of life, general health and complications

The aim of our study was to assess the quality of life as well as secondary cancers/diseases and esophagectomy‐related or unrelated interventions in the long‐term course of surgery.

Resistance factors in colon cancer tissue and the adjacent normal colon tissue: glutathione S-transferases α and π, glutathione and aldehyde dehydrogenase

Glutathione S-transferases (GST) alpha and pi, glutathione (GSH) and aldehyde dehydrogenase (ADH) were determined in colorectal cancer tissue specimens and in the adjacent normal colon tissue. The median contents in normal and cancer tissue were 8.1 (2.3-30.3) (5-95% quantiles) and 15.1 (5.3-50.3) microg/mg protein for GST pi (P = 0.035), 0.0 (0.0-1.4) and 0.4 (0.0-3.5) microg/mg protein for GST alpha (P = 0.019), 7.3 (1.3-22.7) and 5.6 (2.3-26.0) microg/mg protein for GSH (P = 0.171) and 30.8 (13.0-42.0) and 23.2 (9.0-32.9) microg/mg protein for ADH (P = 0.0017), respectively. Thus, the mean GST alpha and pi both significantly increased in colon cancer compared to the adjacent normal tissue, which underlines their importance as possible resistance factors. A highly significant correlation was obtained between the GSH content in colon cancer and normal tissue (P = 0.0017). Thus, the constitutive GSH expression seems to be maintained during tumor development. A similar correlation was obtained for ADH (P = 0.0075), but the median ADH was lower in cancer tissue compared to the adjacent normal tissue (P = 0.0017). Contrary to GSH and ADH, GST pi did not correlate between normal and colon cancer tissue. Whereas GSH and ADH correlated in normal colon tissue (P = 0.014), no significant correlation for GSH and ADH was observed in colon cancer tissue (P = 0.109). In conclusion, significant correlations between colon cancer and normal tissue were obtained, suggesting that the expression levels of these resistance factors are maintained during carcinogenesis in most patients.

Prediction model of lymph node metastasis in superficial esophageal adenocarcinoma and squamous cell cancer including D2-40 immunostaining†

It was the aim of our study to establish a model for prediction of lymph node metastases in superficial esophageal cancer.

Changes in the extracellular matrix of the vein wall : The cause of primary varicosis?

BACKGROUND Conflicting theories on the development of primary varicosis have led to the molecular biological investigation of the vein wall or, more accurately, of the extracellular matrix. It was the aim of this study to quantify matrix expression and to compare pathological changes in the vein wall with valve-orientated staging of varicosis, in order to determine indicators of the primary cause of varicosis. MATERIALS AND METHODS Three hundred seventy-two tissue specimens of greater saphenous veins were obtained from 17 patients with varicosities and categorised according to Hach stage and procurement site. The specimens were compared with 36 specimens collected from six patients without varicosities, incubated with fluorescence-stained antibodies for collagen 4, laminin, fibronectin and tenascin prior to being assessed with confocal laser scan microscopy. In addition, 22 vein specimens (16 varicose, 6 normal veins) serving as negative controls were investigated. RESULTS Image analysis and statistical evaluation showed that compared with normal veins, varicose veins are associated with a significant increase in matrix protein expression for collagen 4, laminin and tenascin. A trend towards an increase in matrix expression was further observed for fibronectin. There was, however, no difference between varicose veins and clinically healthy vein segments inferior to a varicose segment. CONCLUSION If the findings of the present investigation can be confirmed by other studies, alterations in the vein wall may be regarded as the primary cause of varicosis and valvular insufficiency as the result of these changes.

Carcinoma of the hypopharynx and the cervical oesophagus: a surgical challenge.

OBJECTIVE To report our results after reconstruction of the upper digestive tract for locally advanced carcinoma of the hypopharynx and cervical oesophagus. DESIGN Open study. SETTING Teaching University hospital, Germany. SUBJECTS Of the 517 patients who presented with carcinoma of the oesophagus between September 1985 and March 1997, 16 had a locally advanced tumour of the hypopharynx and 25 of the cervical oesophagus. INTERVENTIONS Free jejunal grafts were used after circular resection in all patients with carcinoma of the hypopharynx, and for the 3 with oesophageal carcinoma in whom we obtained adequate resection margins. In the remainder stomach was used in 21 and colon in 1. MAIN OUTCOME MEASURES Morbidity and mortality. RESULTS After jejunal grafting 1 patient died within 30 days and 2 died in hospital. After gastric or colonic reconstruction 2 patients died within 30 days and 4 in hospital. There was 1 anastomotic leak, 1 transplant became necrotic and had to be replaced, in 2 patients the recurrent nerve was damaged, 1 patient developed a wound infection and 1 a cardiac infarction. After gastric or colonic replacement 7 patients had paralysed recurrent laryngeal nerves, there was 6 anastomotic leaks, 1 chylous leak, 1 haemorrhage, and in 1 the transplant necrosed. CONCLUSION Despite the fact that we compared tumours in different sites, these results suggest that the jejunal graft is safer for upper oesophageal and hypopharyngeal reconstruction.

Developments in esophageal surgery for adenocarcinoma: a comparison of two decades

BackgroundThe objective of this study was to examine outcomes in patients undergoing esophageal resection for adenocarcinoma at our institution during a 20-year period and, in particular, to address temporal trends in long-term survival.MethodsOut of 470 patients who underwent esophagectomy for malignancy between September 1985 and September 2005, a total number of 175 patients presented with esophageal adenocarcinoma. Patients enrolled in this study included AEG (adenocarcinoma of the esophagogastric junction) type I tumors only. Time trends were studied comparing two decades, 9/1985 to 9/1995 (DI) and 10/1995 to 9/2005 (DII).ResultsThe overall survival was significantly more favourable in patients undergoing esophageal resection for adenocarcinoma in the recent time period (DII, 10/1995 to 9/2005) as compared to the early time period (DI, 9/1985 to 9/1995) (log rank test: p = 0.0329). Significant differences in the recent decade were seen based on lower ASA-classifications, earlier tumor stages, and the operative procedure with a higher frequency of transhiatal resections (p < 0.05). 30-day mortality improved from 8.3% to 3.1% during the 20-year time-interval, thus without statistical significance.ConclusionBased on our experience, overall survival is improving over time for adenocarcinoma of the esophagus. Factors that may play an important role in this trend include early diagnosis and improved patient selection through better preoperative staging, improved surgical technique with a tailored approach carefully evaluated by physiologic patient status, comorbidity and tumor extent.

Therapeutische Strategien bei malignen Weichteiltumoren

Abstract.Introduction: This study, carried out by the Surgical Oncology Working Group (CAO) of the German Society for Surgery, was performed to analyse the strategies in the treatment of soft tissue sarcomas in adults. Methods: In a period of 19 months the data on 292 patients suffering from soft tissue sarcomas, treated in 99 surgical departments in Germany, were analysed prospectively. A special questionnaire was developed including pretherapeutic biopsy, previous treatment, definitive surgical treatment, combined modality approach and histopathological results. Results: Thirty-nine per cent of the tumours were treated in university hospitals, 36 % in medical centres, 24 % in regional hospitals. During the observation period two patients were treated on average (median) by each hospital. Limb-sparing treatment was performed in 96 % of the extremity tumours. There was no significant difference in the frequency of R0 resections between the different hospitals. At the university hospitals local extended operations and additive measures were used more often. The indication for adjuvant radiotherapy differed: after compartmental resection, adjuvant radiotherapy was performed in 39 % of cases (19/49); after wide-excision of high-grade tumours, in 45 % of cases (20/44) no adjuvant radiotherapy was necessary. In spite of less radical treatment in tumours of the trunk, additional radiotherapy was not more frequently performed. Conclusion: To improve the quality in the treatment of soft tissue sarcomas it seems to be of great importance to avoid inadequate initial treatment (18 %), to respect the rules of oncological surgery (tumour rupture in 7 % of cases), to improve the histopathological examination (no R classification in 5–12 %) and to develop guidelines for multimodality treatment.Zusammenfassung.Einleitung: Ziel einer Weichteiltumor-Registerstudie der Chirurgischen Arbeitsgemeinschaft Onkologie (CAO) der Deutschen Gesellschaft für Chirurgie war die Erfassung der Behandlungsstrategien bei malignen Weichteiltumoren des Erwachsenen. Methodik: In 19 Monaten wurden Daten von 292 Patienten von 99 chirurgischen Kliniken Deutschlands nach einem speziell entwickelten Dokumentationsbogen prospektiv zur prätherapeutischen Biopsie, Vorbehandlung, definitiven chirurgischen Therapie, zu multimodalen Maßnahmen und zum pathohistologischen Befund erhoben. Ergebnisse: 39 % der Tumoren wurden in Universitätskliniken, 36 % in Schwerpunktkrankenhäusern und 24 % in Krankenhäusern der Grundversorgung behandelt. Im Median behandelten die Kliniken 2 Patienten im Beobachtungszeitraum. Bei Extremitätentumoren kam in 96 % ein extremitätenerhaltendes Vorgehen zur Anwendung. Die Häufigkeit einer R0-Resektion unterschied sich in den einzelnen Kliniken nicht signifikant. An Universitätskliniken kamen lokal ausgedehntere Verfahren und additive Maßnahmen häufiger zur Anwendung. Die Indikation zur adjuvanten Radiotherapie wurde unterschiedlich gestellt. Nach Kompartmentresektion kam sie in 39 % (19/49) zur Anwendung, nach weiter Excision bei high grade-Tumoren wurde auf sie in 45 % (20/44) verzichtet. Obwohl bei Tumoren des Körperstamms die Radikalität des operativen Eingriffs geringer war, kam eine ergänzende Strahlentherapie nicht häufiger zum Einsatz. Schlussfolgerung: Ansatzpunkte für eine Verbesserung der Behandlungsqualität bei Weichteiltumoren sind die Vermeidung einer inadäquaten Vorbehandlung (18 %), die Einhaltung der Regeln der onkologischen Chirurgie (Tumoreinriss in 7 %), die Verbesserung der pathohistologischen Aufarbeitung (fehlende R-Klassifikation in 5–12 %) und die Entwicklung von Leitlinien zur interdisziplinären Therapie.