European Surgery-Acta Chirurgica Austriaca最新文献

Summary: Background: First-line treatment in early stages of oesophageal carcinoma is surgery. Radiotherapy is well accepted as palliative treatment of choice in advanced stages. As survival rates are poor for single modality approaches, a number of phase II and phase III studies have been performed to evaluate combined modality treatment protocols.Methods: Results from our institutions and the current literature are presented.Results: There is no statistically significant benefit in adjuvant therapy schemes. Preoperative combined chemoradiotherapy can lead to a complete remission rate between 16 % and 37 %, may decrease the rate of local recurrence and lead to an overall survival benefit especially when a microscopic tumour-free resection has been reached.Conclusions: New agents in combined modality treatment schedules are showing encouraging results. With regard to the still remaining poor prognosis for patients with oesophageal carcinoma, further trials are needed to evaluate the ideal operative technique and combined modality treatment.

Summary: Background: Unlike a solid organ allograft, the rejection of a solid organ porcine xenograft involves almost all branches of the immune system, and prevention or treatment of rejection appears a complicated task.Methods: Part of experience gathered in the transplantation programs at BioTransplant-USA and Novartis-Imutran-UK (founders of Immerge BioTherapeutics) will be presented, as well as potential complications in the nonhuman primate model with respect to potential extrapolation of experimental animal data to the clinical situation.Results: The major barriers in xenograft rejection are hyperacute rejection mediated by natural antibodies, followed by acute humoral and acute cellular rejection, which can require sensitization. Various aspects of the xenogeneic rejection response can be studied in vitro or ex vivo, but a final proof-of-concept in preclinical work is to come from experimental transplantation. Since natural anti-porcine carbohydrate antibodies, which form the major part of the hyperacute rejection reaction, only occur in Old-World nonhuman primates and humans, large-animal transplantation models often involve cynomolgus monkeys and baboons.Conclusions: In addition to conventional immunosuppression, animal genetic engineering and tolerance induction are presently actively pursued to obtain long-term xenograft survival in this model.

Summary: Background: Adjuvant therapy is an integral component in the management of rectal cancer. Two broad approaches have been used: preoperative and postoperative. Although there are relative advantages and disadvantages of each approach, investigators from Scandinavia, Great Britain, the Netherlands, and other selected European countries advocate preoperative radiation therapy, most commonly delivered with an intensive short course (25 Gy in 5 treatments followed by surgery one week later), without chemotherapy. In contrast, most investigators in North America have advocated the postoperative approach with conventional radiation and 5-FU-based chemotherapy.Methods: Our own results and the relevant literature regarding adjuvant and neoadjuvant radiochemotherapy for rectal cancer are reviewed with an emphasis on clinical management and future directions.Results: More recently, in North America as well as in an increasing number of European and South American countries, there has been a shift toward preoperative combined modality therapy. This shift is based on data that suggest less acute toxicity and an increase in sphincter preservation with preoperative compared with postoperative combined modality therapy.Conclusions: There is still much controversy regarding the ideal sequencing (preoperative vs. postoperative), techniques (intensive short course vs. conventional course), and the use of concurrent chemotherapy in rectal cancer. Randomized trials should provide a definitive answer to these questions within the next few years. Phase I/II trials examining the use of new chemotherapeutic agents in combination with pelvic radiation therapy are in progress.

Summary: Background: The aim of this study was to verify the accuracy of a guided drilling tool in conjunction with a three-dimensional infrared navigation system (SMN, Zeiss, Oberkochen, Germany) in oromaxillofacial surgery.Methods: One hundred and twenty directed target drillings in 6 standardized Plexiglas blocks were carried out with an angulated drilling tool. The target object was the surface of wooden spheres enclosed in the block. The information basis for the directed drilling were CT scans with 1-mm layer distance. Referencing was carried out with 9 fiducials attached to the Plexiglas block. Following drilling the drilled canal was exposed by milling machine and depth of drilling and distance between the deepest point reached and the surface of the wooden sphere were measured.Results: A mean distance of 0.16 mm was found. In 17 % of drillings the target structure was damaged.Conclusions: Directed drilling achieves high precision and precise targeting using an individual drilling tool was demonstrated.

Summary: Background: Liver resection represents the only cure for patients with hepatic metastases from colorectal cancers.Methods: The discussion will address which patients should be considered for hepatic resection, what are the appropriate diagnostic modalities to employ, and what are the hallmarks of surgical therapy. The biologic determinants of recurrence as the basis for rational patient selection for hepatectomy will be addressed. This review will then concentrate on recent data guiding adjuvant therapy, and emerging developments for staging.Results: Median survival of patients after liver resection for hepatic metastases is on the order of 40 months (45, 93, 105), five-year survival is 30 % – 40 %, and ten-year survival approximately 20 %. Operative mortality at most major centers is uniformly less than 5 %.Conclusions: These comparative results have made any random-assignment trial of resection versus nonresectional approach unethical and resection the standard of care.

Summary: Background: In 2002 colorectal carcinoma (CRC) will affect more than 700,000 patients. Approximately 60 % of patients with colorectal cancer will go on to develop hepatic metastases and in one third, it will be the only site of involvement. The management of 1 – 3 liver metastases from CRC is surgical resection; however, 75 % of patients who undergo hepatic resection will recur within 2 years. Systemic chemotherapy and hepatic arterial infusion therapy (HAI) are used in the adjuvant setting following hepatic resection and in nonresectable patients.Methods: The results of chemotherapy trials from our institution and from the literature in patients with liver metastases of colorectal cancer are reported.Results: Ninety percent of patients will be ineligible for resection and usually receive systemic chemotherapy. Although combination of new agents such as CPT-11 or oxaliplatin with 5-fluorouracil has produced response rates of approximately 40 % and increased median survival to 14 – 15 months, generally less than 25 % of patients are alive at 2 years. In the treatment of nonresectable hepatic metastases from colorectal cancer, several trials demonstrated a significant increase in response rate and progression-free survival with HAI compared to systemic therapy. In a randomized trial of combination therapy of HAI and systemic therapy (HAI + SYS) versus systemic therapy (SYS) alone in patients undergoing resection of hepatic metastases at Memorial Sloan-Kettering Cancer Center, survival was significantly increased with HAI + SYS (86 %) vs. SYS alone (72 %) at 2 years (P = 0.03).Conclusion: Hepatic arterial infusion therapy allows the administration of high doses of chemotherapy locally. Response rates with HAI therapy have been shown in multiple studies to be higher than those attainable with systemic chemotherapy. Additional work is needed to investigate the role of other systemic chemotherapeutic agents with HAI.

Summary: Background: The incidence of gastric cancer has fallen dramatically from 35/100 000 in 1930 to 3/100 000 in 1970. The clinical forms of presentation of gastric cancer vary and oscillate between two forms, one including intestinal metaplasia, achlorhydrosis, and infection with Helicobacter pylori, whereas the other includes gastric metaplasia of the oesophagus resulting from gastro-oesophageal (GO) reflux. These two forms are mutually exclusive. With this being said, the question turns to the best available treatment, which has consisted in surgery until today and has been defined to necessitate gastrectomy of various extension with en bloc N2 resection (D2). Adjuvant radiochemotherapy has recently been shown to improve survival.Methods: The results of adjuvant chemotherapy and multimodality regimens in patients with gastric cancer are discussed.Results: Although patients do not benefit from D2 resection as compared to D1 resection concerning survival, D2 resection results in a significantly better staging of the disease. This resulted in the universally accepted recommendation of D2 resection as surgical state of the art in gastric tumours. Better staging itself should not detract, however, from the detrimental prognosis of gastric cancer, which is mirrored in a 30 % overall survival of patients with N1 disease.Due to all of these aspects, a series of polychemotherapy regimens have been applied for advanced gastric cancer. All of these regimens have yielded a maximum rate of 15 % complete remissions, which were of short duration only.Recently it was shown that a multimodality approach combining surgery and chemoradiation was significantly superior over surgery alone concerning both disease-free (49 % and 32 %, respectively; P = 0.001) and overall survival (52 % and 41 %, respectively; P = 0.03) at 3 years.Conclusions: Despite limited efficacy of cytotoxic therapy in advanced gastric cancer, adjuvant chemotherapy has no beneficial effect upon survival. In contrast, multimodality treatment including chemotherapy, radiotherapy, and surgery is the treatment of choice for resectable disease. Multimodality treatment including surgery, chemo- and radiotherapy has to be considered as state of the art treatment of adenocarcinoma of the stomach and the GO junction.

Summary: Background: Pancreatic cancer is a common malignancy in the United States with approximately 28,000 cases per year. Two-thirds of these patients will have adenocarcinoma of the pancreas, and for the majority of patients it is a lethal disease.Methods: Current diagnosis and results of surgical and adjuvant treatment options for pancreatic cancer are discussed.Results: Operative mortality has been reduced to < 5 % in all major centers, and direct correlation of volume with outcome has become established. Preoperative biopsy is not mandatory in our hands. Preoperative biliary drainage has not been shown to be beneficial. Prospective randomized trials of nutritional support following pancreatic resection have shown routine nutritional support to be of no value. Adjuvant treatment trials have shown limited if any benefit following resection for adenocarcinoma of the pancreas.Conclusion: Surgical resection offers the only hope for cure or significant palliation and ensures that patients with more favorable histopathologies are not neglected. Recent advances involve improvement in noninvasive diagnosis and the accurate prediction of resectability so that patients do not undergo unnecessary procedures. Current approaches focus on innovative investigative treatment regimes.