Transanal endoscopic microsurgery (TEM) presents a minimally invasive procedure for local removal of large rectal adenomas (>/= 2 cm) and early, so called "low-risk" carcinomas (uT1, G1 - 2) in curative as well as of advanced tumors in palliative intent. Over a 6-year period 92 TEM excisions of rectal tumors were carried out including 91 patients with 56 adenomas, 35 carcinomas (9 pTis, 17 pT1, 5 pT2, 3 pT3, 1 Ca after snare diathermy) and one neurinoma. Two patients of the carcinoma group had to be reoperated by means of anterior resection due to false preoperative rectal ultrasound examination (2 x uT1--> pT2). 4 patients required palliative therapy on account of age or high morbidity. After a mean follow-up time of 23 months (adenomas 23 months, pT1 carcinoma 26 months and advanced tumors 38 months) we encountered a total of 7 complications, of which in 5 cases surgical reintervention was necessary (5,4 %). One 86-year-old patient with a pT2-carcinoma, who was unsuitable for low anterior resection due to a high morbidity risk, died from myocardial infarction after emergency reintervention caused by postoperative bleeding. To date, overall 9 recurrences occurred (9,8 %). In the specific target group of TEM (adenomas and pT1, G1-2 carcinomas) consisting of n = 83 cases, the overall recurrence rate was 7,2 %, of which 5,3 % were due to adenomas and 11,5 % due to carcinomas. After palliative excision 2 recurrences occurred. These results of transanal endoscopic microsurgery (TEM) indicate that this technique has a useful place in curative, as well as in palliative management of rectal tumors.

Adenoma↗

PubMed2001

Outcome of patients with a performance status of 2 in Eastern Cooperative Oncology Group Study E1594: a Phase II trial in patients with metastatic nonsmall cell lung carcinoma .

BACKGROUND: Eastern Cooperative Oncology Group (ECOG) Study E1594 compared paclitaxel and cisplatin with three newer chemotherapy doublets in the treatment of patients with advanced nonsmall cell lung carcinoma (NSCLC). The accrual of patients with an ECOG performance status (PS) of 2 was discontinued due to a perceived rate of unacceptable toxicity. METHODS: Patients were stratified by PS and randomized to one of the following treatments: 1) paclitaxel (135 mg/m2) over 24 hours with cisplatin (75 mg/m2) on a 21-day cycle; 2) cisplatin (100 mg/m2) with gemcitabine (1 g/m2) on Days 1, 8, and 15 on a 28-day cycle; 3) cisplatin (75 mg/m2) with docetaxel (75 mg/m2) on a 21-day cycle; and 4) paclitaxel (225 mg/m2) over 3 hours with carboplatin (area under the curve, 6). All tests of statistical significance were two-sided. RESULTS: Sixty-eight patients with an ECOG PS of 2 were enrolled, and 64 patients were evaluable for toxicity and response. Fifty-six percent of 64 evaluable patients were male, and 81% had Stage IV disease. Grade 3-4 hematologic toxicities occurred in > 50% of the patients in each treatment group. Nonhematologic Grade 3-4 toxicities occurred significantly less often in the paclitaxel and carboplatin arm (P = 0.0032). The overall rate of toxicity did not differ significantly from the rate of toxicity in the PS-0 or PS-1 cohorts. There were 5 deaths (7.35%) among 68 patients with a PS of 2 during therapy; however, only 2 of those deaths were attributed to therapy. The overall response rate for the 64 evaluable patients was 14%. The overall median survival of all 68 patients with a PS of 2, as determined by an intent-to-treat analysis, was 4.1 months. CONCLUSIONS: Patients with advanced NSCLC and a PS of 2 experienced a large number of adverse reactions and overall poor survival. A comparison with patients with a PS of 0-1 suggests that these events and the shorter survival were related to disease process rather than treatment. Alternative strategies need to be explored with therapy specifically tailored for this group of patients.

Aged↗

PubMed2001

Cell-derived apolipoprotein E (ApoE) particles inhibit vascular cell adhesion molecule-1 (VCAM-1) expression in human endothelial cells.

Sub-endothelial infiltration of monocytes occurs early in atherogenesis and is facilitated by cell adhesion molecules that are up-regulated on activated endothelium. Apolipoprotein E (apoE) helps protect against atherosclerosis, in part, because apoE particles secreted by macrophages have local beneficial effects at lesion sites. Here, we hypothesize that such protection includes anti-inflammatory actions and investigate whether cell-derived apoE can inhibit tumor necrosis factor-alpha-mediated up-regulation of vascular cell adhesion molecule-1 (VCAM-1) in human umbilical vein endothelial cells (HUVECs). Two models were used to mimic endothelial exposure to macrophage-derived apoE. In the first, HUVECs were transiently transfected to secrete apoE; VCAM-1 induction inversely correlated with secretion of apoE into the media (r = -0.76, p < 0.001). In the second, incubation of HUVECs with media from recombinant Chinese hamster ovary (CHO) cells expressing apoE (CHO(apoE)) also reduced VCAM-1 in a dose-dependent manner (r = -0.70, p < 0.001). Characterization of CHO(apoE) cell-derived apoE revealed several similarities to apoE particles secreted by human blood monocyte-derived macrophages. The suppression of endothelial activation by apoE most likely occurs via stimulation of endothelial nitric oxide synthase; apoE increased levels of intracellular nitric oxide and its surrogate marker, cyclic guanosine monophosphate, while the nitric oxide synthase inhibitor, ethyl-isothiourea, blocked its effect. We propose that apoE secreted locally at lesion sites by macrophages may be anti-inflammatory by stimulating endothelium to release NO and suppress VCAM-1 expression.

Animals↗

PubMed2001

UltraCision or high-frequency knife in transanal endoscopic microsurgery (TEM)? Advantages of a new procedure.

The potential advantages of ultrasound dissection using UltraCision (UC) an ultrasonically activated scalpel, rather than conventional electrosurgery (ES) were investigated retrospectively in 63 patients following transanal endoscopic microsurgery (TEM) in 22 cases of rectal carcinoma (16 pT1, four pT2, two pT3), 40 cases of rectal adenoma >2 cm, and one neurinoma. In all, 21 patients (13 adenomas, seven carcinomas, and one neurinoma) were operated with UltraCision (Ethicon, Norderstedt, Germany), whereas 42 patients (27 adenomas, 15 carcinomas) were treated with conventional electrocautery. All tumors were completely excised (R0) in both groups. We encountered a total of nine complications, seven after ES and two after UC use. Surgical reintervention was necessary in three cases (4.7%), exclusively following resection by ES. There were five cases of tumor recurrence (7.9%), once again only in the ES group. The advantages of ultrasound dissection are magnified under the particular conditions of minimally invasive endoscopic rectum surgery by means of TEM. In principle, all the known risks associated with the application of electric current can be avoided by using ultrasound technology.

Adenoma↗

PubMed2001

[Endosonography in epithelial rectal tumors. Value of a differentiated therapy concept].

INTRODUCTION: Endorectal ultrasound (EU) is the most important examination for pretherapeutic stratification of primary rectal tumors. Preoperative histology and endosonography determine the therapeutic strategy by using the criteria of depth of infiltration (uT) and lymph node status (uN). METHODS: The effectiveness of endoluminal ultrasound in the preoperative differentiation between locally restricted tumors (adenomas and "low-risk" carcinomas, uT0/1, G1-2) and advanced rectal carcinomas (uT3) was assessed in a retrospective study of 284 patients. In the examination period (UZ) from 3/94 to 12/97 (UZ I) 104 patients (group 1) were examined with a 7-MHz endoprobe, and from 1/98 to 12/99 (UZ II), 116 (group 2) with a 10-MHz endoprobe. Additionally, in 64 patients (group 3) with an advanced uT3/4 or uN + tumor we compared the accuracy of ultrasound with computed tomography (CT). In this group 32 patients were restaged by EU and CT after preoperative chemoradiation. The results of präoperative endorectal ultrasound were correlated with the postoperative histological data. RESULTS: Concerning the whole period (UZ I and II) we achieved a total hit rate of 83.6% for adenomas and "low-risk" carcinomas (uT0/1, G1/2) by EU (79.8% in UZ I, 87.1% in UZ II). For advanced rectal carcinoma (> or = uT3) we found a total accuracy of 87.3% (82.7% in UZ I, 91.4% in UZ II). In 62 cases endosonographic lymph node status was correlated with postoperative histology during UZ II, with a hit rate of 64.5%. In group 3 (n = 64), in 32 patients without preoperative chemoradiation we found an accuracy for depth infiltration of 93% (EU) and 82% (CT). Concerning lymph node status there was a correlation of 57% (EU) and 64% (CT). After preoperative chemoradiation (n = 32) we found an accuracy of 91% (EU) and 73% (CT) for depth infiltration--for lymph node status 70% (EU) and 82% (CT). CONCLUSIONS: High accuracy in endoluminal ultrasound leads to a secure and differentiated stratification of therapy in primary rectal tumors. The hit rate concerning depth of infiltration is higher for EU than for CT both before and after chemoradiation, but not regarding lymph node status.

Adenoma↗

PubMed2001

[Problem of recurrent incisional hernia after mesh repair of the abdominal wall].

INTRODUCTION: Depending on the surgical technique, mesh material and follow-up, the figures for recurrences of incisional hernia vary from 0 to 31%. What are the reasons for recurrences, and which options exist for more successful therapy? METHODS: Fourteen operations for recurrences after mesh repair of incisional hernias were analyzed retrospectively and correlated with a literature review of the years 1990-2000. RESULTS: An inadequate surgical technique is the main reason for recurrences after the use of polypropylene or polyester, but with PTFE, it is instead the properties of the material. In our patients we found central mesh recurrences. The first results with laparoscopic technique are very promising. CONCLUSIONS: Open incisional hernia mesh repair should be performed with the sublay technique, preferably with polypropylene; the use of polyester can be recommended only with reservations and the use of PTFE ought to be limited to very few indications. The entire incision should always be prepared with safe fixation of the mesh and wide overlap of the hernia. Recurrences after polypropylene implantation can be treated with additional mesh; concerning PTFE, a different material is recommended. A final evaluation of laparoscopic mesh repair cannot be assessed yet.

Adult↗

PubMed2001

[Standardized sublay technique in polypropylene mesh repair of incisional hernia. A prospective clinical study].

INTRODUCTION: With the introduction of meshes to support hernia repairs the recurrence rates were reduced from 50% to less than 10%. Special complications such as scar plates with restriction of the mobility of the abdominal wall, pain and fistula formation are described. METHODS: In a prospective study trial 38 patients with incisional hernia were treated with Marlex mesh repair in the standard sublay technique. RESULTS: Within a mean follow-up period of 3 years most of the patients were free from pain and very satisfied. Two recurrences (5.2%) occurred and 2 hematomas (5.2%) had to be removed surgically. CONCLUSIONS: Using a standard operation technique with the mesh in sublay position, even with heavy-weight Marlex mesh, good clinical results can be achieved compared to published findings. To our surprise we found two central recurrences through the mesh.

Adult↗

PubMed2001

Central mesh recurrence after incisional hernia repair with Marlex--are the meshes strong enough?

The use of biomaterial meshes in the repair of incisional abdominal wall hernias is now widely accepted internationally. The introduction of synthetic meshes to achieve tension-free repair has led to a satisfactory reduction in the recurrence rate to less than 10%. However, the use of such biomaterials can result in the occurrence of undesirable complications such as increased risk of infection, seromas, restriction of the abdominal wall and failure caused by mesh shrinkage. Additionally, at the time of writing there is much discussion concerning the potential risk of a persistent foreign body reaction directly associated with the meshes with regard to possible malignant transformation. As such, the trend seems to be toward the use of lighter meshes utilizing less non-absorbable material. One particular novel mesh theoretically capable of guaranteeing the necessary mechanical stability uses 70% less biomaterial. Against this background, we report a central mesh recurrence through the mesh following incisional hernia repair with a Marlex mesh. To our knowledge, this is the first description of a central mesh recurrence, and we discuss a possible mechanism with particular emphasis on the required abdominal wall forces both physiologically and after incisional hernia repair.

Elasticity↗