European Surgery-Acta Chirurgica Austriaca最新文献

AIM OF STUDY: The aim of this study is to compare demographic and clinical data as well as applied treatment methods in patients with rare benign and malignant tumours of the oesophagus. METHODS: Eight hundred and thirty patients with oesophageal cancer were treated in the Department of Surgical Oncology in 1960-2005. In 15 cases (1.8 %), rare benign (n = 11) or malignant (n = 4) types of tumours were diagnosed. Patients with rare oesophageal tumours were included in the study, excluding those with squamous cell carcinoma or adenocarcinoma of the oesophagus. Demographic and clinical data were analysed from each patient qualified for the study. Oesophageal X-rays with contrast medium, gastroscopies and, as of 1991, computed tomographies (CTs) were performed as preoperative diagnostic procedures. RESULTS: In the postoperative histopathological examinations, all benign tumours proved to be oesophageal leiomyomas. Four different malignant tumours-a sarcoma, a neuroendocrine carcinoma, a lymphoma, and a squamous cell carcinoma in a patient with Crohn's disease, were diagnosed in the other four patients. In a group of 15 patients with rare oesophageal tumours there were ten (66.7 %) males and five (33.3 %) females. In patients with benign and malignant tumours, the mean age for the benign group reached 44 years (range: 26-75 years old) and 54.7 years (range: 47-59 years old) for the malignant group. In the preoperative period, symptoms such as swallowing disturbances, retrosternal pains, and epigastric pains were observed. Dysphagia was the leading symptom in patients with benign and malignant oesophageal tumours. Out of 15 patients, surgical procedure was carried out in 13 cases with rare oesophageal tumours. In the group of 11 patients, with benign tumours, ten (90.2 %) warranted surgical treatment. Three patients (75 %) with malignant oesophageal tumours underwent an extensive Akiyama procedure of oesophageal resection. Chemo- and radiotherapy alone were performed on one (25 %) patient with oesophageal lymphoma. Postoperative complications were observed in only four (26.6 %) patients; pneumonia in the postoperative period was diagnosed in two patients who underwent surgery; infections of the postoperative wounds were diagnosed in the other two patients. CONCLUSIONS: Benign oesophageal tumours are characterised by similar clinical symptoms to malignant tumours of this organ. It is more complicated to obtain biopsy specimens for a histopathological examination in cases of benign tumours in comparison to malignant tumours. Treatment methods should be adjusted individually for each patient with a rare oesophageal tumour. For rare benign oesophageal tumours, the results of treatment are very good; however, for malignant tumours the prognosis depends on their histopathological type.

Summary: Background: By developing a standard clinical pathway, we tried to assess the cost of a coronary bypass procedure at our in institution in order to find possibilities for cost containment and financial decision-making.

Methods: A standard clinical pathway was designed for an aortocoronary bypass procedure. Using this pathway, we assessed the procedural costs in a stepwise manner for each individual patient to obtain the average cost for a bypass operation at our institution.

Results: Overall costs for a standard coronary bypass operation at our institution were 7,411 EUR. Costs for the surgical procedure, intensive care unit, intermediate care unit and 9 days on the ward were 3,722 EUR, 1,171 EUR, 271 EUR and 558 EUR, respectively. Expenses for personnel amounted to 3,194 EUR; for drugs, 78 EUR; for disposables, 2,919 EUR; for diagnostics, 274 EUR; and indirect costs, 609 EUR.

Conclusions: Standard clinical pathways are a valid means for assessing procedural costs. Making costs transparent is the basis for cost containment, benchmarking and financial decision-making in cardiac surgery.

Summary: Background: Recently, it has become widely accepted that prosthetic material is needed for the repair of incisional hernias. Therefore, the laparoscopic approach with an intraperitoneal onlay mesh technique seems to be promising. No dissection of the abdominal wall is necessary, implying reduced surgical trauma. The laparoscopic technique is based on the intraperitoneal coverage of the whole scar with a mesh that provides ingrowth of tissue on one side and prevents adhesions on the other side. Methods: Based on published and own experiences we compare the results of the laparoscopic and the conventional technique. Furthermore, we can clearly define the indication and pitfalls of the laparoscopic repair and present recommendations concerning the prevention of complications. Results: Since 1993, some series have been published that clearly demonstrate excellent results in terms of very low infection and recurrence rates. Most recurrences are explained by technical mistakes. No mesh-related intestinal complications such as fistula formation or ileus due to adhesions between mesh and bowel have been described so far. Conclusions: The laparoscopic repair of incisional hernias represents a worthwhile extension of the surgical armamentarium and has almost completely replaced conventional repair in our department.

Summary: Background: It is generally assumed that groin hernia is caused by ‘intra-abdominal pressure’ that is contained by transversalis fascia. The intra-abdominal compartment consists of two components: the intraperitoneal and the extraperitoneal compartment. The respective contribution of each of these two components to groin hernia aetiology has never been differentiated.Methods: Morphological and physiological correlates were sought to explain striking inconsistencies in the above-mentioned theory: The processus vaginalis obliterates only after birth, when crying and straining first raises intraperitoneal pressure. Epidemiologically, groin hernia incidence is lowest in the 15 –  45-years age group, in which pressure strains from physical work, sports, pregnancy and delivery are highest. Maximal intra-abdominal pressure increase in pregnancy and labour never causes a groin hernia in women. In patients treated with chronic pneumoperitoneum at a pressure of 10 mm Hg, stretching of the abdominal wall and a large increase of the intraperitoneal space occurs without concomitant hernia development. Intraperitoneal pressure of 20 mm Hg causes a lethal compartment syndrome.Results: The internal inguinal ring is formed by the separation of two portions of transversalis fascia: Laterally, transversalis fascia is attached to the posterior edge of the inguinal ligament. Medial to the inferior epigastric vessels, transversalis fascia inserts into the Cooper ligament, at some distance from the inguinal ligament, and extends over the pubis into the cavity of the pelvis. The course of an indirect hernia corresponds to a tangentially acting aetiology. Intraperitoneal pressure acts at a right angle upon the oblique course of the processus vaginalis, causing compression and obliteration of the processus. Radially acting intraperitoneal pressure would have to be deviated at a right angle to cause de novo formation of an indirect hernia.Conclusions: The word and the historical notion of traumatic ‘rupture’ are misleading conceptions for groin hernia aetiology. In childhood, indirect hernia is a process of foetal development; at old age, a process of involution of the extraperitoneal fatty-fascial compartment. This involution is characterized by the formation of lipomas and, histologically, by fatty degeneration of connective tissue components. The extraperitoneal fatty-fascial compartment is contained by external oblique aponeurosis, not by transversalis fascia. This is the reason why a small prosthesis sublayed to external oblique aponeurosis is more effective than a much larger prosthesis sublayed to transversalis fascia. This concept is helpful in the strategy of using as little prosthetic material as possible.

Summary: Background: Pancreatic cancer is characterized by early local and systemic spread and low complete resection rates. Patients are highly symptomatic and the sensitivity of the tumour cells towards irradiation and most of the currently available chemotherapeutic agents is low. These factors account for the dismal prognosis.Methods: A critical analysis of adjuvant and neoadjuvant treatment results for resectable pancreatic cancer is presented. Management issues for unresectable pancreatic cancer and novel therapeutic approaches are discussed.Results: Recently, a gradual improvement in results from surgery and in chemotherapeutic efficacy has been observed. The local disease extension and the rapid dissemination call for a multimodality treatment consisting of surgery, if possible, radiotherapy, and efficient systemic chemotherapy both in the (neo)adjuvant setting as well as in locally advanced unresectable tumours. In resectable cancers, neoadjuvant treatment seems preferable, but should be followed within clinical trials. Local chemotherapies or chemoimmunotherapies have provided promising results but must be considered experimental. New cytotoxic agents are used for improved radiosensitization and for better systemic disease control. Their optimal dosage, sequence, and combination with surgery and/or radiotherapy still have to be established.Conclusions: Improvement may be expected from a better understanding of tumour biology, the developing armoury of drugs targeting angiogenesis, oncogene signalling, and metastatic potential as well as from vaccination strategies incorporated into multimodality treatments. Finally, genetic analyses will allow better risk stratification and individualization of treatment options.

Summary: Background: Systemic chemotherapy significantly prolongs survival and helps to maintain or improve quality of life in a substantial proportion of patients with colorectal cancer. 5-fluorouracil (5-FU) has been the most important chemotherapeutic agent for more than 30 years. Higher response rates together with better tolerability favour 5-FU continuous infusion (CI) regimens +/– modulation by folinic acid. During recent years the two new drugs irinotecan and oxaliplatin have dramatically expanded the treatment options in colon cancer. Both drugs have shown activity in patients resistant to 5-FU.Methods: A review of recent developments in chemotherapy for colon cancer is presented.Results: Four large randomized studies, which compared 5-FU/LV either with the combination of irinotecan + 5-FU/LV or oxaliplatin + 5-FU/LV as first-line treatment, demonstrated significant increases in response rate and time to progression for the combination therapy. In addition, the two irinotecan studies showed a significant gain in survival. In patients with stage III tumours, 5-FU/LV given for 6 months is able to reduce the recurrence rate by 40 % and the death rate by 30 %. In stage II tumours, although there is at least evidence for the efficacy of chemotherapy, its role is currently not definitively established.Conclusions: In stage III colon cancer, 5-FU/LV for 6 months is currently standard treatment; CI 5-FU regimens seem to be at least equivalent to the well-established bolus schedules. There is evidence for the efficacy of chemotherapy also in stage II colon cancer, but its role is currently not definitively established. Future perspectives include combinations of 5-FU with irinotecan or oxaliplatin in the adjuvant setting and inhibitors of signal transduction such as farnesyl transferase inhibitors or inhibitors of epidermal growth factor receptor.