Biomedical subjects
Publications and source records attributed to F Köckerling.
Ectopic mammary tissue in the inguinal region giving rise to a hamartoma is reported. This localization of ectopic breast is infrequent and hamartomas of the breast at this site have not been described previously. The unusual size of the lesion caused pre-operative diagnostic difficulties.
At present, a differentiated surgical treatment approach allows a curative resection (R0) for carcinoma of the rectum to be obtained in up to 80% of cases. Through the introduction of organ-preserving therapeutic procedures (polypectomy and transanal full-thickness excision), as well as the consequent extension of sphincter-preserving procedures (deep anterior rectum resection with stapler anastomosis and abdomino-peranal rectum resection with colo-anal anastomosis), the rate of sphincter-preserving operations has been increased to 80-85%. A detailed knowledge of the mode of spread of carcinoma of the rectum forms the basis for all differential diagnostic considerations as well as the operative technique. Observance of an adequate margin of clearance as dependent on tumour stage as well as the performance of an anatomically--and oncologically--correct pelvic dissection are requisites for a radical treatment of carcinoma of the rectum. Only a strict compliance of the indications criteria which have been worked out permit the use of limited therapeutic procedures.
There is no disagreement over the advantages of minimal-invasive surgical procedures even in the older patient. However the criteria for indication and patient selection concerning cardiopulmonary contraindications for CO2-pneumoperitoneum must be strictly considered. Using cholecystectomy and colorectal surgery as an example the problems and limits of the laparoscopic method are described.
Before 1978, where cystic tumors of the pancreas were concerned, pathologists only differentiated between cystic adenomas and cystadenocarcinomas. Recently, however, further tumor entities have been introduced. We now differentiate between the generally benign serous cystic adenoma, the potentially malignant mucinous cystadenoma, the possibly malignant papillary cystic tumor, and the always malignant mucinous cystadenocarcinoma. Other rare tumors include the solid cystic acinous-cell tumor, the cystic islet tumor, and mucinous ductal hyperplasia. Because of their slow growth and primary displacement nature, all of these tumors can usually be detected only after they have attained considerable size. Computed tomography (CT), sonography and endoscopic retrograde cholangiopancreatography (ERCP) have an established role in diagnosis. With these methods, as a rule, it is possible to identify pseudocysts; however, differentiation between the individual tumor types is almost impossible. In our study from 1979 to 1990, we observed ten cases of serous cystic adenomas, nine cystadenocarcinomas, and four malignant papillary-cystic tumors. Of these, nine of the ten serous cystic adenomas, four of the five mucinous cystadenomas, all four papillary-cystic tumors, and five of the nine cystadenocarcinomas were curatively resected. All patients with curatively resected adenomas and one patient with an R1-resected cystic adenoma remained free of recurrence throughout the follow-up period. One 86-year-old female patient in whom a serous cystic adenoma was histologically determined still has no symptoms 8 years after diagnosis despite slow tumor progression. Two of the five patients in whom a cystadenocarcinoma was curatively resected died postoperatively; a third patient died of tumor recurrence 4 months following resection.(ABSTRACT TRUNCATED AT 250 WORDS)
Extended lymph node dissection, creation of a safe anastomosis and specimen retrieval pose the greatest problems in laparoscopic colorectal surgery. A safe technique for the performance of extended lymph node dissection with high vessel ligation has been developed on the basis of experimental studies. Abdominoperineal excision of the rectum is ideal for laparoscopic colorectal surgery because this procedure requires no anastomosing, and the specimen is retrieved perianally. From January to August 1992, we performed a laparoscopic excision of the rectum with high ligation of the inferior mesenteric artery in ten patients with low carcinomas. This paper presents clinical and technical data.
BASIC REMARKS: Concomitant cardiovascular and pulmonary diseases in particular represent a considerable risk to the postoperative course in the geriatric patient. MAIN DISCUSSION POINTS: The main aim of intensive care consists in the avoidance and treatment of systemic complications. In contrast, local surgical complications as the reason for intensive care are of secondary importance in the geriatric patient. In the postoperative phase, the main problems encountered by the geriatric patient affect the cardiovascular system and pulmonary function. Age-specific pathophysiological changes affecting the lungs and heart require prophylactic measures aimed at preventing atelectasis, bronchial pneumonia and edema. As a rule, patients of advanced age require such intensive care for one to three days. CONCLUSIONS: The perioperative care of the elderly patient comprises, where possible, preoperative preparation and, postoperatively, a specific prophylactic intensive care regimen.
Between 1985 and 1992, 46 patients with epidermoid carcinoma of the anal canal were treated prospectively by a protocol of combined radiation and chemotherapy with 5-Fluorouracil and Mitomycin C. The survival rate, NED-survival rate and local tumour control rate were 84%, 71% and 83% at 5 years. Anorectal function was retained in 33 of 41 patients (80%). We observed severe acute toxicity including three deaths, but very little late morbidity. The only marginally significant prognostic factor (P = 0.06) for local tumour control was T-stage. NED-survival was significantly affected (P = 0.02) by reduction of chemotherapy during the second course.
Multivisceral resection in combination with extended lymph node dissection is used in the surgical treatment of locally advanced colon carcinoma without distant metastases. This also applies to tumours with marked peritumorous inflammation in contact with neighbouring organs where an intraoperative diagnostic attempt could result in tumour seeding. The low mortality and complication rate following multivisceral resection justifies this concept. The 5-year survival rate following multivisceral resection in advanced colon carcinoma is over 80%.
As our experimental studies demonstrate save laparoscopic tubular resection of colon and rectum is possible using linear staplers for resection and circular staplers for the anastomosis. As soon as linear endostaplers are available this technique can be applied in clinical work. Open colon resection and subsequent purse-string suture or endoloops to fixate the bowel ends on PCEEA-staplers turned out to be insufficient.
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During nine years (1979-1988) there was carried out cholecystectomy in 21 patients for gallbladder polyps of unknown histology. The sex ratio female to male was 9 to 12, median age 51 (29-76) years. Most of the polyps were smaller than 5 mm, all proved to be cholesterol polyps, showing multiple localisations. Two benign adenomas had a size of 6 resp. 9 mm. Among the polyps with a diameter of more than 10 mm we found only two cholesterol polyps, but one heterotopia, one adenoma and one adenocarcinoma. Cholecystectomy is indicated for polyps with a diameter of more than 10 mm or suspicious sonographic criteria, especially sessile lesions or concomittant thickening of the gallbladder wall.
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Between 1. 1. 1970 and 31. 12. 1986/31. 12. 1987, 90 patients with primary malignancies of the small bowel were treated at the Department of Surgery of the University Erlangen-Nürnberg. Only 21% (19 of 90) of the patients had no regional or distant metastases at the time of the operation. The 5-year-survival rate of the 90 patients was 41% +/- 14%. Twenty-one of 34 patients suffering from adeno-carcinoma were treated by curative surgery. The 5-year-survival rate of these 21 patients was 44% +/- 23%. The prognosis of patients with primary malignant tumors of the small bowel depends on early diagnosis and curative surgery.
Because of the normally far advanced tumor stages of carcinomas of the gallbladder, the resection rate in the literature varies from 10 to 30 percent. Our own curative resection rate was 19% in a series of 89 patients between 1969 and 1985 first treated in our hospital. The palliative resection rate was 29%, in 10% we performed a palliative operation and in 36% an explorative laparotomy. The curative resected gallbladder carcinomas were mainly stage I and II tumors, incidentally found at operation or histopathological examination. Has the gallbladder carcinoma invaded perimuscular connective tissue, an extended operation with resection of the segments IVb and V of the liver and lymphnode dissection must be recommended. Stage III and IV carcinomas of the gallbladder with infiltration of the liver can be curatively operated organ-saving in using en-bloc resection of the gallbladder with the adjacent segments IVb and V, or IVb and VI and with lymphnode dissection of the hepatoduodenal ligament. The observed five-year-survival rate (Cutler and Ederer) including lethality of the curative resected carcinoma of the gallbladder is 56.3 +/- 25.2%.
In a retrospective study 51 patients who underwent chest wall resection for malignant chest wall tumors were reviewed. There were 28 male and 23 female patients with ages ranging from 6 to 76 years (average 50). 34 patients had primary malignant neoplasms (including breast and lung) 17 had metastatic tumors. The tumor was located in the ribs in 45 patients and in the sternum in 6. Reconstruction was with prosthetic material in 16 patients and further plastic reconstruction in 10. Aggressive resection for malignant chest wall tumors and reliable reconstruction can be performed safely, and early wide resection proved to be a potentially curative treatment for primary neoplasms.
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