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Background: Despite multimodal treatment strategies, locoregional recurrence rates are still significant in colorectal carcinoma (CRC). Methods: Clinical, pathological, perioperative, and survival data of 203 patients with recurrent CRC enlisted in a prospective database from 1990 to 2011 were analyzed. Results: Median disease-free survival in our cohort of 203 patients was 23 months after resection of the primary tumor. In total, 113 of these patients had surgical therapy with resection of the recurrent tumor. The primary tumor was localized in the rectum in 63 (56%) patients and in the colon in 50 (44%) patients. A complete resection of the recurrent tumor (R0) was achieved in 69 (61%) patients. Postoperative complications occurred in 42 (37%) patients. Postoperative mortality was 2.7%. The median overall survival for R0-resected patients without distant metastasis was 91 months. Those patients had better overall survival compared to patients in whom no complete resection of the recurrent tumor was possible (p < 0.001). There was no statistically significant difference (overall survival) between patients that had R0-resection with systemic metastasis and R1 (p = 0.794) or R2 (p = 0.422) resection. Conclusion: Surgical resection of a locally recurrent CRC leads to a substantial long-term survival rate for R0-resected patients. [ABSTRACT FROM AUTHOR]

A biography of Professor Rainier E. J. Arbogast, physician and the president of the German Society of Surgery, is presented. He was born on June 18, 1944 in Poland, and attended primary and grammar school in Speyer, Germany. He served in the military, but stopped and enrolled in human medicine at the Universities of Heidelberg and Freiburg. Professor Arbogast is married to Ingrid Halling, a pharmacist, and they have a daughter who is studying pathology and a son who has a legal career.

Purpose: Large randomized controlled trials have investigated the oncological value of the laparoscopic approach to colorectal cancer. Mainly, non-inferiority for the laparoscopic approach regarding long-term survival could be shown. Nevertheless, some recent trials revealed inferiority especially due to histopathological quality of specimen or location of the tumor in the rectum. The main objective of this study was to compare two historical patient collectives of specialized centers for either the laparoscopic or the open resection approach, regarding long-term survival and disease progression of rectal cancer according to tumor localization in a retrospective propensity score–matched analysis. Methods: A retrospective analysis, based on two prospectively maintained institutional colorectal cancer databases, was performed. The database of the reference center in Erlangen maintained almost exclusively open operations whereas the database in Lübeck maintained to a vast majority laparoscopic operations. To adjust risk profiles, a 1:1 propensity score matching was performed. Results: Seven hundred fifty-five patients of both centers (Erlangen, n = 507, Lübeck n = 248) were included. Propensity score matching resulted in two equalized groups with 248 patients. Regarding the postoperative complications, advantages for the open approach were seen. Analyzing the survival data, no differences in disease-free as well as overall survival were shown. Also, no differences in the overall loco-regional recurrence and distant metastasis rate were detected. Conclusion: In centers with adequate expertise, open and laparoscopic procedures result in equivalent oncologic long-term outcomes. Advantages for the open resected group concerning short-term results and complications were detected, due to remarkably low rates of anastomotic leakage. [ABSTRACT FROM AUTHOR]

In the PubMed citation records, the author's name shows. [ABSTRACT FROM AUTHOR]

Purpose: Difficulties at the beginning of the learning curve in minimally invasive surgery (MIS) can well be overcome by simulation outside the operating room. Despite a great number of available devices, standardized, structured, and validated training curricula for video simulators are scarce.Methods: The Lübeck Toolbox (LTB) video trainer provides six training modules and online video tutorials. Proficiency levels for the tasks were defined by performance analysis of MIS experts (n = 15). Mean values of the best performed repetitions were set as benchmarks for a validation study with n = 30 MIS novices and the learning curves calculated. The novices performed a cholecystectomy on a pig organ model before and after the curriculum which were analyzed using the GOALS score.Results: Benchmarks defined by expert performance for the task Nos. 1 to 6 were 72 s (± 8) (Pack Your Luggage), 49 s (± 9) (Weaving), 66 s (± 10) (Chinese Jump Rope), 89 s (± 28) (Triangle Cut), 138 s (± 44) (Hammer Cut), and 98 (± 22) (Suturing). The median numbers of required repetitions by the novices to reach the proficiency level were n = 42 (7-80), n = 26 (9-55), n = 32 (14-77), n = 44 (15-59), n = 19 (6-68), and n = 26 (15-60). These values were all located at the beginning of the plateau phase of the learning curves. GOALS score improved significantly after completion of the curriculum (18.0 (± 2.6) vs. 10.9 (± 1.6), p < 0.0001).Conclusion: The LTB curriculum constitutes a new highly standardized and proficiency level-based training program for basic skills in MIS. Transferability of the task content to a (sub)-realistic environment could be demonstrated. Still, future trials will have to further validate the effectiveness of the LTB curriculum. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) is one of the most frequent malignancies in the Western world. Early tumor detection and intervention are important determinants on CRC patient survival. During early tumor proliferation, dissemination and angiogenesis, platelets store and segregate proteins actively and selectively. Hence, the platelet proteome is a potential source of biomarkers denoting early malignancy. By comparing protein profiles of platelets between healthy volunteers ( n = 12) and patients with early- ( n = 7) and late-stage ( n = 5) CRCs using multiplex fluorescence two-dimensional gel electrophoresis (2D-DIGE), we aimed at identifying differentially regulated proteins within platelets. By inter-group comparisons, 94 differentially expressed protein spots were detected ( p < 0.05) between healthy controls and patients with early- and late-stage CRCs and revealed distinct separations between all three groups in principal component analyses. 54 proteins of interest were identified by mass spectrometry and resulted in high-ranked Ingenuity Pathway Analysis networks associated with Cellular function and maintenance, Cellular assembly and organization, Developmental disorder and Organismal injury and abnormalities ( p < 0.0001 to p = 0.0495). Target proteins were validated by multiplex fluorescence-based Western blot analyses using an additional, independent cohort of platelet protein samples [healthy controls ( n = 15), early-stage CRCs ( n = 15), late-stage CRCs ( n = 15)]. Two proteins-clusterin and glutathione synthetase (GSH-S)-featured high impact and were subsequently validated in this independent clinical cohort distinguishing healthy controls from patients with early- and late-stage CRCs. Thus, the potential of clusterin and GSH-S as platelet biomarkers for early detection of CRC could improve existing screening modalities in clinical application and should be confirmed in a prospective multicenter trial. [ABSTRACT FROM AUTHOR]

Purpose: A perforated peptic ulcer can be managed laparoscopically in selected patients. The purpose of this study was to evaluate whether conversion of emergency laparoscopy is inferior to primary median laparotomy in terms of postoperative morbidity and mortality. Methods: We analyzed patients who underwent laparoscopic or open surgery for a perforated peptic ulcer at the Department of Surgery, University of Schleswig-Holstein, Campus Luebeck between January, 1996 and December, 2010. Perforations were graded according to the Boey classification, a preoperative risk-scoring system. Results: Conversion to laparotomy was necessary in 20 of the 45 patients who underwent laparoscopic surgery (CG); therefore, laparoscopic operations were completed in 25 patients (LG). The third patient cohort comprised 139 patients who underwent primary laparotomy (OG). Overall minor morbidity was significantly lower ( p = 0.048) in the LG patients than in the OG patients, whereas no significant differences were found in major morbidity and mortality, particularly between the OG and CG. Conclusion: Patients' suitability for laparoscopic management should be decided on according to Boey's clinical scoring system. Our findings demonstrated that conversion from laparoscopy to laparotomy was not associated with elevated postoperative morbidity or mortality versus initial laparotomy. Therefore, emergency operations may be commenced laparoscopically in selected patients, especially considering the postoperative advantages of this approach. [ABSTRACT FROM AUTHOR]

Background: Biobanks are becoming increasingly important for assessment of disease risk as well as identification and validation of new diagnostic biomarkers and druggable targets. The validity of data obtained from biobanks is critically limited by the biomaterial quality of the biological samples. External quality assessment (EQA) programs suitable to comprehensively measure the biomaterial quality in archived materials are currently lacking. We report on quantitative assay designs for the analysis of both structural and functional integrity of DNAs that were applied in a first pilot EQA within the priority program on tumor tissue biobanking funded by the German Cancer Aid. Methods: Participating biobanks isolated DNAs from a standardized set of 10 samples comprising sections of four different formalin-fixed paraffin-embedded tissues using their standard operating procedures. Isolated DNAs and analytical results were returned and analyzed centrally for nucleic acids yield, purity, fragmentation and amplificability at a quantitative level using dedicated assay designs. Results: The amount of extracted DNA varied in isolates ranging between 1.5 µg and 25.8 µg. Quantification of DNA fragmentation and amplificability allowed to highlight considerable discrepancies in DNA quality. Amplicons yielded from the isolates of these identical EQA samples ranged from 105 to 411 bp suggesting differences between residual inhibitors of downstream enzymatic reactions. Conclusions: The quality of extraction of bioanalytes from biomaterial archives is heterogeneous even for stable biomolecules like DNA isolated with highly standardized methods. EQAs are appropriate tools to uncover strengths and weaknesses in biobanks in a systematic fashion. Biomaterial integrity is insufficiently reflected by standard methods, but needs to be assessed to improve biobank interoperability. Finally, our results also point towards the problem of measuring the quality of more delicate biomolecules like proteins or metabolites. [ABSTRACT FROM AUTHOR]

Purpose: The risk, prevention, and treatment of colorectal neoplasia in inflammatory bowel disease (IBD) are still a matter of debate. The aim of this study was to analyze the occurrence of colorectal neoplasia in IBD patients who underwent proctocolectomy. Methods: The study population comprised of 123 IBD patients who underwent proctocolectomy because of neoplasia, therapy refractivity, or complications between January 2000 and July 2011. Results: One hundred fourteen (92.7 %) patients were pre-operatively diagnosed with ulcerative colitis, 5 (4.1 %) with colitis indeterminata, and 4 (3.3 %) with colonic Crohn's disease. Colectomy was indicated in 39 (31.7 %) patients because of a neoplasia, in 68 (55.3 %) because of a refractory course of the disease, and in 16 (13.0 %) because of complications. Neoplasia was found in 36 patients on a histopathologic evaluation of the colectomy specimens. Ten (8.1 %) patients post-operatively showed a pre-operatively not described advanced neoplasia. In three (2.4 %) of these patients, the detection of advanced neoplasia (two high-grade intraepithelial neoplasias (IENs), one carcinoma) was a complete de novo finding. Carcinoma had not been diagnosed pre-operatively in six (4.9 %) patients. A multifocal distribution of neoplasia was seen in 66.7 % of patients with neoplasia. The median duration of disease was 15.5 years in case of neoplasia opposed to 6.0 years in those without neoplasia detection. Conclusion: Our data demonstrate a high rate of pre-operatively undetected high-grade IENs and carcinoma and a frequent multifocal occurrence in IBD patients with long-standing inflammation of the colon. This should be kept in mind for treatment decisions particularly in patients with a chronic refractory course of the disease. [ABSTRACT FROM AUTHOR]

Purpose: Re-anastomosis after a Hartmann procedure is associated with a higher morbidity and mortality than other elective colorectal operations. The goal of this comparative study was to evaluate whether laparoscopic reversal is a justified operative approach, although the initial operation is most often an emergency laparotomy. Methods: A retrospective analysis was conducted on data collected on all 70 patients who underwent laparoscopic and open reversal of a Hartmann procedure at the Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, between January 1999 and December 2011. Together with general demographic data, the analysis included the indication for the initial Hartmann procedure, time to reversal, intraoperative findings, the choice of operative method, operating time, postoperative pain control, return of normal bowel function, length of hospital stay, and peri- and postoperative morbidity and mortality. Results: In most patients, the Hartmann procedure was performed after a perforated sigmoid diverticulitis. We were not able to find any statistically significant differences with respect to gender, body mass index (BMI) and American Society of Anesthesiologists classification between the laparoscopic group (LG) ( N = 24 patients) and the open group (OG) ( N = 46). In the LG, patients were significantly younger ( p = 0.019). The median operating time was 210 min (75-245) in the LG, which was significantly longer than in the OG (166 min; 66-230). The statistical analysis of the duration of postoperative analgesic therapy (LG 7 days [-]; OG 12 days [-] ), return to normal diet (LG 3 days [-]; OG 4 days [-] ), return of normal bowel function (LG 3 days [-]; OG 4 days [-] ) and length of hospital stay (LOS) (LG 10 days [-]; OG 15 days [8-163]) detected significant differences in advantage for the LG. Unplanned return to theatre during index admission was only necessary in the OG ( N = 7, 15.2 %). With a median follow-up of 8 months (range 1-20), we observed a comparable number of minor complications in both groups but a significantly higher number of major complications in the OG ( N = 27, 58.7 %) ( p = 0.001). Conversion occurred in three cases (12.5 %). There was no mortality in either of the two groups. Conclusions: This study was able to demonstrate the feasibility of the laparoscopic approach. In terms of postoperative results it should be seen as equivalent to the open procedure. However, the laparoscopic approach requires profound surgical expertise. The indication should be made after a careful risk/benefit analysis for each individual patient. [ABSTRACT FROM AUTHOR]

BACKGROUND: Chromosomal aneuploidy has been identified as a prognostic factor in the majority of sporadic carcinomas. However, it is not known how chromosomal aneuploidy affects chromosome-specific protein expression in particular, and the cellular proteome equilibrium in general. OBJECTIVE: The aim was to detect chromosomal aneuploidy-associated expression changes in cell clones carrying trisomies found in colorectal cancer. METHODS: We used microcell-mediated chromosomal transfer to generate three artificial trisomic cell clones of the karyotypically stable, diploid, yet mismatch-deficient, colorectal cancer cell line DLD1 - each of them harboring one extra copy of either chromosome 3, 7 or 13. Protein expression differences were assessed by two-dimensional gel electrophoresis and mass spectrometry, compared to whole-genome gene expression data, and evaluated by PANTHER classification system and Ingenuity Pathway Analysis (IPA). RESULTS: In total, 79 differentially expressed proteins were identified between the trisomic clones and the parental cell line. Up-regulation of PCNA and HMGB1 as well as down-regulation of IDH3A and PSMB3 were revealed as trisomy-associated alterations involved in regulating genome stability. CONCLUSIONS: These results show that trisomies affect the expression of genes and proteins that are not necessarily located on the trisomic chromosome, but reflect a pathway-related alteration of the cellular equilibrium. [ABSTRACT FROM AUTHOR]

Purpose: Presently, no markers exist to predict metachronous metastasis at the time a primary colorectal cancer is diagnosed. While aneuploidy indicates poor survival prognosis and elevated carcinoembryonic antigen (CEA) levels the presence of recurrent disease, the predictive value of both markers regarding imminent metachronous metastases is unclear. Methods: Sixty patients with distant recurrence throughout a 5-year follow-up (TM+) were randomly chosen and 60 patients without metastasis matched to this cohort (TM−). In addition, an enlarged collective ( n = 217; n = 85, n = 132) with median follow-up of 79.2 months was assessed by logistic regression regarding metachronous metastases. Univariate and stepwise regression analyses included clinicopathological characteristics, preoperative CEA levels and aneuploidy assessed by DNA image cytometry. Results: The matched-pair collective showed aneuploidy in 71.1 % (TM−) and 85.0 % (TM+; p = 0.076), and elevated CEA in 24.5 % (TM−) and 52.2 % [TM+; odds ratio (OR), 3.414; p = 0.007]. The enlarged collective presented aneuploidy in 71.2 % (TM−) and 83.5 % (TM+; OR 2.050, p = 0.038), and elevated CEA in 28.6 % (TM−) and 48.9 % (TM+; OR 2.391, p = 0.020). Elevated CEA and aneuploidy did not show any association ( p = 0.919). In contrast, logistic regression analyses demonstrated that besides increased T category (OR 1.745, p = 0.019), both elevated CEA level (OR 2.633, p = 0.015) and aneuploidy (OR 1.929, p = 0.058) were independent predictive markers for metachronous metastasis. Conclusions: Our data show that aneuploidy and elevated CEA levels besides increased T category could serve for individual risk assessment to predict metachronous metastases. The fact that still aneuploidy missed the significance level by a small margin emphasizes the need for larger validation studies. [ABSTRACT FROM AUTHOR]

Introduction. Aneuploidy has been suggested as independent prognostic marker in ulcerative colitis (UC) patients for developing UC-associated colorectal carcinomas (UCCs). UCCs are associated with a poorer prognosis and more frequently present with synchronous carcinomas when compared with sporadic colorectal carcinomas (SCCs). The authors therefore investigated if the adjacent non-malignant mucosa of aneuploid UCCs and aneuploid SCCs shows differences regarding the frequency of aneuploidy and if this aneuploidy is associated with histomorphological alterations. Methods. Primary tumors of 25 UCCs and 20 SCCs were selected showing exclusively aneuploid DNA patterns and matching DNA stemlines. The UCCs' ( n = 82) and SCCs' ( n = 40) adjacent non-malignant mucosa were evaluated for histopathology and assessed for DNA ploidy status by image cytometry. Results. UCCs' non-malignant mucosa showed dysplasia in 31.7% and aneuploidy in 89%. In contrast, SCCs' non-malignant mucosa revealed no dysplasia and aneuploidy in only 5%. Irrespective of dysplastic lesions, aneuploidy was observed more frequently in adjacent non-malignant mucosa of UCCs than of SCCs ( p < 0.001). Neither a correlation between aneuploidy and inflammation ( p = 0.916) nor between aneuploidy and dysplastic lesions ( p = 0.159) could be observed. Conclusion. Aneuploidy is more frequent in adjacent non-malignant mucosa of aneuploid UCCs than in adjacent non-malignant mucosa of aneuploid SCCs. Furthermore, aneuploidy seems to be irrespective of inflammation or dysplasia. The results therefore emphasize the importance of aneuploidy for UC-associated carcinogenesis and its potential as new diagnostic target. [ABSTRACT FROM AUTHOR]

Background: Recurrent Crohn's disease activity at the site of anastomosis after ileocecal resection is of great surgical importance. This prospective randomized multi-center trial with an estimated case number of 224 patients was initially planned to investigate whether stapled side-to-side anastomosis, compared to hand-sewn end-to-end anastomosis, results in a decreased recurrence of Crohn's disease following ileocolic resection (primary endpoint). The secondary endpoint was to focus on the early postoperative results comparing both surgical methods. The study was terminated early due to insufficient patient recruitment and because another large study investigated the same question, while our trial was ongoing. Methods and study design: Patients with stenosing ileitis terminalis in Crohn's disease who underwent an ileocolic resection were randomized to side-to-side or end-to-end anastomosis. Due to its early discontinuation, our study only investigated the secondary endpoints, the early postoperative results (complications: bleeding, wound infection, anastomotic leakage, first postoperative stool, duration of hospital stay). Results: From February 2006 until June 2010, 67 patients were enrolled in nine participating centers. The two treatment groups were comparable to their demographic and pre-operative data. BMI and Crohn's Disease Activity Index were 22.2 (±4.47) and 200.5 (±73.66), respectively, in the side-to-side group compared with 23.3 (±4.99) and 219.6 (±89.03) in the end-to-end group. The duration of surgery was 126.7 (±42.8) min in the side-to-side anastomosis group and 137.4 (±51.9) min in the end-to-end anastomosis group. Two patients in the end-to-end anastomosis group developed an anastomotic leakage (6.5%). Impaired wound healing was found in 13.9% of the side-to-side anastomosis group, while 6.5% of the end-to-end anastomosis group developed this complication. The duration of hospital stay was comparable in both groups with 9.9 (±3.93) and 10.4 (±3.26) days, respectively. Conclusions: Because of the early discontinuation of the study, it is not possible to provide a statement about the perianastomotic recurrence rates regarding the primary endpoint. With regard to the early postoperative outcome, we observed no difference between the two types of anastomosis. [ABSTRACT FROM AUTHOR]

The regular colonisation of the oesophagus with a Candida species can, after oesophageal perforation, result in a contamination of the mediastinum and the pleura with a Candida species. A patient cohort of 80 patients with oesophageal perforation between 1986 and 2010 was analysed retrospectively. The most common sources with positive results for Candida were mediastinal biopsies and broncho-alveolar secretions. Candida species were detected in 30% of the patients. The mortality rate was 41% in patients with positive microbiology results for Candida, whereas it was 23% in the remaining patient cohort. This difference did not reach statistical significance ( P = 0.124). Mortality associated with oesophageal perforation was attributed mainly to septic complications, such as mediastinitis and severe pneumonia. During the study period we observed a shift towards non-albicans species that were less susceptible or resistant to fluconazole. In selected patients with risk factors as immunosuppression, granulocytopenia and long-term intensive-care treatment together with the finding of Candida, an antimycotic therapy should be started. A surgical approach offers the possibility to obtain deep tissue biopsies. The antimycotic therapy should start with an echinocandin, as the resistance to fluconazole is growing and to cover non-albicans Candida species, too. [ABSTRACT FROM AUTHOR]

Aim The increasing experience within the area of laparoscopic procedures has paved the way for technically-complex procedures, such as distal pancreatectomy. In order to avoid complications associated with concomitant splenectomy, these procedures are increasingly performed with spleen preservation. A drawback is the low number of cases, which does not allow for an evidence-based comparison between laparoscopic and open procedures, and spleen-preserving and concomitant splenectomy procedures. Patients and Methods Between 2006 and 2010, all data for patients who underwent a laparoscopic distal pancreatectomy (LDP) at the Department of Surgery, University of Schleswig- Holstein, Luebeck, Germany, were collected are stored in a prospectively-maintained database. Patients with tumours in the pancreatic tail and body that did not exceed the level of the portal vein were included in this database. Results A total of 22 patients who underwent LDP could be included in the evaluation. Ten of those patients underwent a laparoscopic spleen-preserving distal pancreatectomy ( LSPDP), while the remaining 12 received an LDP with splenectomy ( LDPwS). The median operation time was 155 min (range: 98-253) for the LSPDP group, and 201 min (range: 60-310) for the LDPwS group ( P = 0.06). The median hospital stay was 8.5 days (range: 5-23) in the LSPDP group compared to 11 days (range: 4-41) in the LDPwS group ( P = 0.06). Pancreatic fistula occurred in two patients from each group. It caused an intraabdominal haemorrhage in one patient of the LSPDP group, which required re-laparoscopy. Two patients experienced subphrenic abscesses in the LDPwS group and were treated interventionally. Histological examination revealed six cystadenomas and five pseudocysts (maximum diameter: 7 cm) in the LDPwS group, and six neuroendocrine tumours (maximum diameter: 2 cm) in the LSPDP group. Conclusion LDP can be performed safely. The optic magnification provided by laparoscopy facilitates LSPDP, as dissection of the splenic vessels can be avoided. Although not significant, there was a trend towards reduced hospital stay and operating time for LSPDP. Oncologic outcomes and morbidity seem to not be inferior to open procedures. The size of the tumours and the peripancreatic, as well as paraneoplastic, tissue alterations determine the indication for splenectomy. [ABSTRACT FROM AUTHOR]

Purpose: For treatment of rectal prolapse, abdominal approaches are generally offered to younger patients, whereas perineal, less invasive procedures are considered more beneficial in the elderly. The aim of this study was to analyze whether laparoscopic resection rectopexy (LRR) is suitable for older patients. Patients/Methods: Patients who received LRR for rectal prolapse were selected from a prospective laparoscopic colorectal surgery database. Perioperative and long-term outcome were compared between patients <75 years old (group A) and ≥75 years old (group B). Results: Of 154 patients, 111 were in group A and 43 in group B. There was one conversion that occurred in group B. Overall mortality rate was 1.3% ( n = 2). Both patients were in group B (group B, 4.7%; p = 0.079). Differences in major and minor complications between the groups were not significant. Rates of improvement for incontinence were 62.7% (group A) and 66.7% (group B; p = 0.716); for constipation, the rates were 78.9% (group A) and 73.3% (group B; p = 0.832). All recurrences occurred in group A ( n = 10; overall, 10.3%; group A, 13%). After exclusion of patients who had previously received perineal prolapse surgery, recurrence rate was 3.3% overall (group A, 4.3%). Conclusions: This study supports the benefits of LRR for rectal prolapse in elderly patients. Age per se is not a contraindication for LRR. Elderly patients encounter complications slightly more frequently (although not statistically significant) than younger patients. Therefore, a very careful patient selection in the elderly is of paramount importance. However, the long-term outcome does not seem to differ between younger and elderly patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: Radiofrequency ablation (RFA) and electrochemical treatment (ECT) are two methods of local liver tumour ablation. The objective of this study was to compare these methods when applied in proximity to vessels in vivo. Methods: In a total of ten laparotomised pigs, we used ECT (Group A, four animals) and RFA (Group B, four animals) to create four areas of ablation per animal under ultrasound guidance within 10 mm of a vessel. Group C consisted of two control animals. Chemical laboratory tests were performed immediately before and after each procedure and on days 1, 3 and 7 after surgery. Following the last tests, the livers were harvested for morphological evaluation. Results: The mean duration of surgery was 5 h 40 min in Group A (ECT), 2 h 47 min in Group B (RFA), and 2 h 30 min in Group C (control animals). After ECT, the harvested livers showed a mean volume of necrosis of 1.84 cm3 ± 0.88 at the anode and 2.59 cm3 ± 1.06 at the cathode. The presence of vessels did not influence the formation of necrotic zones. Ablation time was 67 min when a charge of 200 coulombs was delivered. We measured pH values of 1.2 (range: 0.9–1.7) at the anode and 11.7 (range: 11.0–12.1) at the cathode. In one of the 16 RFA ablations (6%), the target temperature was not reached and the procedure was discontinued. After 14 of 16 RFA procedures (88%), morphological analysis showed incomplete ablation in perivascular sites. Both ECT and RFA were associated with a reversible increase in monocyte, C-reactive protein (CRP) and aspartate aminotransferase (AST) levels. There was no significant increase in interleukin-1β (IL-1β), tumour necrosis factor-α (TNF-α) and IL-6. Conclusion: In the majority of cases, intrahepatic RFA in vivo leads to incomplete necrosis in proximity to vessels and the presence of histologically intact perivascular cells. Without a reduction in liver perfusion, the central application of RFA should be considered problematic. ECT is a safe alternative. It is not associated with a heat sink effect but has the disadvantage of long treatment times. [Copyright &y& Elsevier]

Background: Radiofrequency ablation (RFA) and electrochemical treatment (ECT) are two methods of local liver tumor ablation. A reproducible perfusion model allowed us to compare these methods when applied in proximity to vascular structures. Material and Methods: In a porcine liver perfusion model, we used RFA (group A) and ECT (group B) to perform ablations under ultrasound guidance within 10 mm of a vessel and examined the induced necrosis macroscopically and histologically. Results: We created 83 lesions (RFA: 59, ECT: 24) in 27 livers. In group A (mean liver weight: 2046 g), perfusion was macroscopically found to limit necrosis in 52.5% of the procedures. Histology demonstrated the destruction of only 30.4% of the vessel walls within the ablation areas. In group B (mean liver weight: 1885 g), we detected reproducible and sharply demarcated ablation areas both macroscopically and histologically. Necrosis was unaffected by nearby vessels. No viable cells were found perivascularly. Histology showed destruction of the vascular endothelium without any discontinuities. We measured pH values of 0.9 (range: 0.6–1.8) at the anode and 12.2 (range: 11.4–12.6) at the cathode. Treatment time was 100 min when a charge of 300 coulombs was delivered. Conclusions: Electrochemical treatment is a method of ablation that creates reproducible and predictable volumes of necrosis. It produces sharply demarcated areas of complete necrosis also in perivascular sites. ECT, however, requires much longer treatment times than RFA. In our model, the effects of RFA were considerably limited by perfusion, which caused incomplete areas of necrosis in proximity to vessels. [ABSTRACT FROM AUTHOR]

Background/Aim: In contrast to diverticulosis of the colon, jejunal diverticulosis is a rare entity that often becomes clinically relevant only after exacerbations occur. The variety of symptoms and low incidence make this disease a difficult differential diagnosis. Patients and Methods: Data from all patients who were treated in our surgical department for complicated jejunal diverticulitis, that is, gastrointestinal hemorrhage or a diverticula perforation were collected prospectively over a 6-year period (January 2004 to January 2010) and analyzed retrospectively. Results: The median age among the 9 patients was 82 years (range: 54-87). Except for 2 cases (elective operation for a status postjejunal peridiverticulitis and a re-perforation of a diverticula in a patient s/p segment resection with free perforation), the diagnosis could only be confirmed with an exploratory laparotomy. Perforation was observed in 5 patients, one of which was a retroperitoneal perforation. The retroperitoneal perforation was associated with transanal hemorrhage. Hemodynamically relevant transanal hemorrhage requiring transfusion were the reason for an exploratory laparotomy in 2 further cases. In one patient, the hemorrhage was the result of a systemic vasculitis with resultant gastrointestinal involvement. A singular jejunal diverticulum caused an adhesive ileus in one patient. The extent of jejunal diverticulosis varied between a singular diverticulum to complete jejunal involvement. A tangential, transverse excision of the diverticulum was carried out in 3 patients. The indication for segment resection was made in the case of a perforation with associated peritonitis (n=4) as well as the presence of 5 or more diverticula (n=2). Histological analysis revealed chronic pandiverticulitis in all patients. Median operating time amounted to 142 minutes (range: 65-210) and the median in-hospital stay was 12 days (range: 5-45). Lethality was 0%. Major complications included secondary wound closure after s/p repeated lavage and bilateral pleural effusions in one case. Signs of malabsorption as the result of a short bowel syndrome were not observed. Minor complications included protracted intestinal atony in 2 cases and pneumonia in one case. Median follow-up was 6 months (range: 1-18). Conclusion: Complicated jejunal diverticulitis often remains elusive preoperatively due to its unspecific clinical presentation. A definitive diagnosis can often only be made intraoperatively. The resection of all diverticula and/or the complete diverticula-laden segment is the goal in chronic cases. The operative approach chosen (tangential, transverse excision vs segment resection) should be based on the extent of the jejunal diverticulosis as well as the intraoperative findings. [ABSTRACT FROM AUTHOR]

DNA aneuploidy has been identified as a prognostic factor in the majority of epithelial malignancies. We aimed at identifying ploidy-associated protein expression in endometrial cancer of different prognostic subgroups. Comparison of gel electrophoresis-based protein expression patterns between normal endometrium ( n = 5), diploid ( n = 7), and aneuploid ( n = 7) endometrial carcinoma detected 121 ploidy-associated protein forms, 42 differentially expressed between normal endometrium and diploid endometrioid carcinomas, 37 between diploid and aneuploid endometrioid carcinomas, and 41 between diploid endometrioid and aneuploid uterine papillary serous cancer. Proteins were identified by mass spectrometry and evaluated by Ingenuity Pathway Analysis. Targets were confirmed by liquid chromatography/mass spectrometry. Mass spectrometry identified 41 distinct polypeptides and pathway analysis resulted in high-ranked networks with vimentin and Nf-κB as central nodes. These results identify ploidy-associated protein expression differences that overrule histopathology-associated expression differences and emphasize particular protein networks in genomic stability of endometrial cancer. [ABSTRACT FROM AUTHOR]

Purpose: The current study was designed to identify prognostic factors for long-term survival in patients with advanced colorectal cancer in a consecutive cohort. Methods: A total of 123 patients were operated because of T4 colorectal cancer between 1 January 2002 and 31 December 2008 in the Clinic of Surgery, UK-SH Campus Luebeck. Results: A total of 78 patients underwent a multivisceral resection. The postoperative morbidity was elevated in the patient group with multivisceral resections (34.6% vs. 26.7%). Nevertheless, we detected no significant differences concerning 30 days mortality (7.7% vs. 8.9%; p = 0.815). The main prognostic factor that reached significance in the multivariate analysis was the possibility to obtain a R0 resection ( p < 0.0001) resulting in a 5-year survival rate of 55% for patients with curative resection. There were no statistically significant differences in 5-year survival between multivisceral and non-multivisceral resections ( p = 0.608). Also we were not able to detect any significant differences for cancer of colonic or rectal origin ( p = 0.839), for laparoscopic vs. open procedures ( p = 0.610), and for emergency vs. planned operations ( p = 0.674). Moreover, the existence of lymph node metastases was not a predictive factor concerning survival as there was no difference between patients with and without lymph node metastases ( p = 0.658). Conclusions: Multivisceral resections are associated with the same 5-year survival as standard resections. Therefore, the aim to perform a R0 resection should always be the main goal in surgery for colorectal cancer. In planned operations, a laparoscopic approach is justified in selected patients. [ABSTRACT FROM AUTHOR]

Laparoscopic liver resection has been performed mostly in centers with an extended expertise in both hepatobiliary and laparoscopic surgery and only in highly selected patients. In order to overcome the obstacles of this technique through improved intraoperative visualization we developed a laparoscopic navigation system (LapAssistent) to register pre-operatively reconstructed three-dimensional CT or MRI scans within the intra-operative field. After experimental development of the navigation system, we commenced with the clinical use of navigation-assisted laparoscopic liver surgery in January 2010. In this paper we report the technical aspects of the navigation system and the clinical use in one patient with a large benign adenoma. Preoperative planning data were calculated by Fraunhofer Me Vis Bremen, Germany. After calibration of the system including camera, laparoscopic instruments, and the intraoperative ultrasound scanner we registered the surface of the liver. Applying the navigated ultrasound the preoperatively planned resection plane was then overlain with the patient's liver. The laparoscopic navigation system could be used under sterile conditions and it was possible to register and visualize the preoperatively planned resection plane. These first results now have to be validated and certified in a larger patient collective. A nationwide prospective multicenter study (ProNavic I) has been conducted and launched. [ABSTRACT FROM AUTHOR]

Background: More than 1.2 million new cases of colorectal cancer are reported each year worldwide. Despite actual screening programs, about 50% of the patients are diagnosed at advanced tumor stages presenting poor prognosis. Innovative screening tools could aid the detection at early stages and allow curative treatment interventions. Methods: A nine target multiplex serum protein biochip was generated and evaluated using a training- and validation-set of 317 highly standardized, liquid nitrogen preserved serum samples comprising controls, adenomas, and colon cancers. Results: Serum levels of CEA, IL-8, VEGF, S100A11, MCSF, C3adesArg, CD26, and CRP showed significant differences between cases and controls. The largest areas under the receiver operating characteristics curve were observed for CEA, IL-8, and CRP. At threshold levels yielding 90% specificity, sensitivities for CEA, IL-8 and CRP were 26%, 22%, and 17%, respectively. The most promising marker combinations were CEA + IL-8 reaching 37% sensitivity at 83% specificity and CEA + CRP with 35% sensitivity at 81% specificity. In an independent validation set CEA + IL-8 reached 47% sensitivity at 86% specificity while CEA + CRP obtained 39% sensitivity at 86% specificity. Early carcinomas were detected with 33% sensitivity for CEA + IL-8 and 28% for CEA + CRP. Conclusions: Apart from CEA, IL-8, and CRP, the screening value of additional blood markers and the potential advantage of combining serum biochip testing with fecal occult blood testing needs to be studied. Multiplex biochip array technology utilizing serum samples offers an innovative approach to colorectal cancer screening. [ABSTRACT FROM AUTHOR]

Purpose: For a long time, laparoscopic pancreatic surgery was simply a matter of extended diagnostics without a simultaneous resection. Methods: The increase of experience in complex laparoscopic procedures combined with a substantial improvement in technical equipment has led to the possibility of performing pancreatic resections laparoscopically. Results: In contrast to the experimental laparoscopic pancreaticoduodenectomy, laparoscopic distal pancreatectomy has proved its safety and efficacy. Conclusion: In order to avoid splenectomy-associated complications, such as the OPSI-syndrome or formation of abscesses in the splenic area, the spleen-preserving technique is more favorable. Due to ischemia caused by the resection of the splenic vessels, as well as portal hypertension in the long-term follow-up, those vessels should remain untouched. The following article and video describe our approach for laparoscopic spleen-preserving distal pancreatectomy with sparing of the splenic vessels. [ABSTRACT FROM AUTHOR]

DNA aneuploidy has been identified as a prognostic factor for epithelial malignancies. Further understanding of the translation of DNA aneuploidy into protein expression will help to define novel biomarkers to improve therapies and prognosis. DNA ploidy was assessed by image cytometry. Comparison of gel-electrophoresis-based protein expression patterns of three diploid and four aneuploid colorectal cancer cell lines detected 64 ploidy-associated proteins. Proteins were identified by mass spectrometry and subjected to Ingenuity Pathway Analysis resulting in two overlapping high-ranked networks maintaining Cellular Assembly and Organization, Cell Cycle, and Cellular Growth and Proliferation. CAPZA1, TXNL1, and HDAC2 were significantly validated by Western blotting in cell lines and the latter two showed expression differences also in clinical samples using a tissue microarray of normal mucosa ( n = 19), diploid ( n = 31), and aneuploid ( n = 47) carcinomas. The results suggest that distinct protein expression patterns, affecting TXNL1 and HDAC2, distinguish aneuploid with poor prognosis from diploid colorectal cancers. [ABSTRACT FROM AUTHOR]

Background/Aim: Ablative techniques such as radiofrequency ablation or non-thermal electrochemical treatment (ECT) are used to manage unresectable liver metastases. Although ECT is not affected by the cooling effect from adjacent vessels, there is a paucity of data available on ECT. Materials and Methods: We used porcine livers to establish an organ model with portal venous and hepatic arterial blood flow for a standardized analysis of the relationship between dose (electric charge) and response (volume of necrosis). Results: This model allowed us to study pressure-controlled perfusion of portal venous and hepatic arterial circulation in the absence of a capillary leak. A specially designed guiding template helped us place platinum electrodes at reproducible locations. With two electrodes, there was a linear relationship between charges of no more than 200 C and necrosis. The relationship was logarithmic at charges of 400-600 C. Larger electrode spacing led to a significant increase in necrosis. We measured pH values of 0.9 (range: 0.6-1.3) at the anode and 12.6 (range: 11.6-13.4) at the cathode. Conclusions: Using a perfusion model, we established an experimental design that allowed us to study ECT in the liver of large animals without experiments on living animals. An electrode template helped us improve the standardized analysis of dose-response relationships. ECT created reproducible and sharply demarcated areas of necrosis, the size of which depended on the charge delivered as well as on the number and spacing of electrodes. Doses higher than 600 C require longer treatment times but do not increase the area of necrosis (logarithmic dose-response relationship). [ABSTRACT FROM AUTHOR]

Introduction: A variety of surgical strategies have been suggested and many surgical techniques, both abdominal and perineal, have been introduced for treatment of rectal prolapse. All these techniques and approaches are based on the attempt to restore the normal anatomy and physiologic function. Methods: In 1992, Berman et al. published the first laparoscopically performed rectopexy. Meanwhile, many different minimally invasive procedures have been described. Throughout the past century, more than 100 different surgical techniques have been introduced to treat patients with rectal prolapse. Unfortunately, there is still lack of one generally accepted standard technique for the surgical treatment of rectal prolapse. Results and discussion: Our current data strongly supports laparoscopic resection rectopexy to be a safe, fast, and very effective procedure to improve function in patients with rectal prolapse. More evaluations of long-term outcome are needed that focus on each particular laparoscopic procedure to adequately compare different techniques. The indication to perform a laparoscopic resection rectopexy in patients with a previous perineal procedure and a recurrent prolapse should be stated critically because these patients seem to have a high risk to develop yet another recurrence. [ABSTRACT FROM AUTHOR]

Purpose: Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. Materials and methods: The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). Results: Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. Conclusion: The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies. [ABSTRACT FROM AUTHOR]

Background: Resection of isolated hepatic or pulmonary metastases from colorectal cancer is widely accepted and associated with a 5-year survival rate of 25-40%. The value of aggressive surgical management in patients with both hepatic and pulmonary metastases still remains a controversial area. Materials and methods: A retrospective review of 1,497 patients with colorectal carcinoma (CRC) was analysed. Of 73 patients identified with resection of CRC and, at some point in time, both liver and lung metastases, 17 patients underwent metastasectomy (resection group). The remaining 56 patients comprised the non-resection group. Primary tumour, hepatic and pulmonary metastases of all patients were surgically treated in our department of surgery, and the results are that of a single institution. Results: The resection group had a 3-year survival of 77%, a 5-year survival of 55% and a 10-year survival of 18%; median survival was 98 months. The longest overall survival was 136 months; six patients are still alive. In the resection group, overall survival was significantly higher than in the non-resection group ( p < 0.01). Independent from the chronology of metastasectomy, 5-year survival was 55% with respect to the primary resection, 28% with respect to the first metastasectomy and 14% with respect to the second metastasectomy. A disease-free interval (>18 months), stage III (UICC) and age (<70 years) were found to be significant prognostic factors for overall survival. Conclusion: Our report strongly supports aggressive surgical therapy in patients with both hepatic and pulmonary metastases from CRC. Overall survival for surgically treated selected patients with both hepatic and pulmonary metastases from CRC is comparable to hepatic or pulmonary metastasectomy. Simultaneous metastases tend to have a poorer outcome than metachronous metastases. [ABSTRACT FROM AUTHOR]

Fournier’s gangrene is a necrotizing fasciitis that affects the perineal, genital, or perianal regions. The objective of this study was to highlight this uncommon condition with a particular focus on the disease course in females. From 1996 to 2008, we prospectively collected data from 38 patients with Fournier’s gangrene (12 women, 26 men) and retrospectively analyzed relevant parameters. The mean age was 60.9 ± 11.3 years for females (group I) and 56.2 ± 11.7 years for males (group II). In both groups, the main predisposing factors were diabetes mellitus and obesity (body mass index of 30 or higher). Twelve men (46.2%), but no women, had chronic alcoholism. The most commonly isolated agents were Escherichia coli ( n = 22), streptococcal species ( n = 18), Pseudomonas aeruginosa ( n = 9), and Staphylococcus aureus ( n = 7). Mortality was significantly higher among females (50%) than males (7.7%; p = 0.011). Peritonitis was present in seven group I patients (58.3%) and in two group II patients (7.7%). The retroperitoneum was involved in seven female patients (58.3%) and four male patients (15.4%). The female gender is a risk factor for mortality in patients with Fournier’s gangrene and is associated with a higher incidence of inflammation of the retroperitoneal space and abdominal cavity. Differences in male and female genital anatomy may be the reason for the rapid spread of infection to the retroperitoneum and the fatal outcome in women. Fournier’s gangrene as a high-risk disease in females should attract exceeding attention. [ABSTRACT FROM AUTHOR]

To examine the treatment outcome for patients with acute bleeding from the lower gastrointestinal tract requiring transfusion and acute surgical care as a function of various risk factors Between 1999 and 2007, we collected data on 59 patients (39 male and 20 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion at our university clinic. Treatment complications and mortality were analyzed retrospectively. The average age of the patients in this study is 70.0 ± 12.2 years (range, 39 to 97 years) with an overall mortality of 15.3%. Blood transfusions >10 U ( p = 0.031), postoperative need for ventilation ( p = 0.004), necessary reoperations ( p = 0.016), and an initial hemoglobin level <80 g/L ( p = 0.043) proved to be significant risk factors for death. Blood transfusions >10 U ( p = 0.028), necessary reoperations ( p = 0.001), and an initial hemoglobin level <80 g/L ( p = 0.033) were found to be significant risk factors for postoperative complications. All other parameters have no significant impact. The decisive factors for the outcome of lower gastrointestinal hemorrhage requiring surgery are the severity of bleeding, beginning of treatment (initial hemoglobin level, need for packed red blood cells), and treatment efficiency (necessary reoperation). [ABSTRACT FROM AUTHOR]

In the past, women with Crohn’s disease (CD) as a risk factor in pregnancy were discouraged from becoming pregnant. Today, by contrast, gestation is medically acceptable in these patients despite several severe complications. We present the course of five female patients with CD requiring surgery during pregnancy and giving birth at our institution between 1998 and 2008. These cases as well as our treatment recommendations for patients wishing to have children and our approaches to the management of complications during pregnancy are discussed in the light of the literature. Three of five women had a preterm delivery (26 to 31 weeks’ gestation) with a decreased neonatal weight. Generally, the diagnosis of CD is often delayed and diagnostic errors (four of five women) are not uncommon. The symptoms vary widely and include those typical of pregnancy. Three patients had to have a cesarean and only two patients were able to deliver vaginally. Especially in pregnant patients, the course of the disease is highly variable and difficult to predict. Our experience suggests that patients should be advised to conceive during remission. Indications for surgery in pregnant patients are the same as for nonpregnant women and include perforation, obstruction, hemorrhage, and abscess. The advantages of endoscopic surgery also apply to pregnant patients with acute manifestations. A stoma is not a contraindication to vaginal delivery. [ABSTRACT FROM AUTHOR]

Endoscopic polypectomy still remains the cornerstone of therapy for colorectal polyps and adenomas. However, if colorectal polyps are too large or not accessible for endoscopic ablation or cannot be removed without an increased risk for perforation, operative procedures are required. In such circumstances, laparoscopic resection represents a minimally invasive alternative. Between January 1993 and December 2004, more than 2,500 endoscopic polypectomies were performed at the Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, Germany. In patients which could not be treated by endoscopic polypectomy due to size, location, and/or risk of complications, a laparoscopic colorectal resection was performed. All data were prospectively assessed in our “colorectal resection” database. The database analysis revealed 58 patients with endoscopically not resectable colorectal polyps who underwent a laparoscopic colorectal resection (intend to treat). In 54 patients, the operative procedure could be finished by the laparoscopic approach (study population). The conversion rate was 6.9% (four of 58). An ileocolic resection was performed in 20 patients (37.0%), and 14 patients (25.9%) underwent an anterior rectal resection. A right colectomy was necessary in 12 patients (22.2%), and six patients (11.1%) underwent a sigmoid resection. In the remaining two patients, a left colectomy and a resection of the transverse colon were performed. Intra- and postoperative complications occurred in five patients (9.3%). Perioperative mortality was not registered. The histopathological work-up revealed benign disease in all cases. Laparoscopic resection of colorectal polyps is a safe and minimally invasive technique for the management of benign colorectal tumors. Thus, the laparoscopic approach to endoscopically not resectable polyps enriches the therapeutic spectrum. [ABSTRACT FROM AUTHOR]

Abstract: Background: Fournier''s gangrene is a fulminant and destructive inflammation of the scrotum, penis, and perineum. The objective of this study was to compare 2 different approaches to wound management after aggressive surgical debridement. Methods: Data from 35 patients with Fournier''s gangrene were prospectively collected (1996–2007). Once the patients were stabilized following surgery, they were treated with either daily antiseptic (polyhexanide) dressings (group I, n = 16) or vacuum-assisted closure (VAC) therapy (group II, n = 19). Results: The mean age of the patients was 58.2 years in group I and 57.2 years in group II. In both groups, the most common predisposing conditions were diabetes mellitus, chronic alcoholism, and obesity. Escherichia coli, streptococcal species, Pseudomonas aeruginosa, and Staphylococcus aureus were the most frequently isolated organisms. Length of hospital stay was 27.8 days ± 27.6 days (mortality: 37.5%) in group I and 96.8 days ± 77.2 days (mortality: 5.3%) in group II. Enterostomies were performed in 43.8% of group I patients and in 89.5% of group II patients. Conclusions: VAC was associated with significantly longer hospitalization and lower mortality. A partial explanation is that some patients with severe sepsis died within the first 3 days after admission and thus could not undergo vacuum therapy. Since our clinical experience has shown that vacuum dressings are particularly effective in the management of large wounds, we use VAC primarily for this indication despite the considerable material requirements involved. [Copyright &y& Elsevier]

Background and Purpose: To this day, the diagnostic and therapeutic strategy for acute lower gastrointestinal hemorrhage requiring transfusion varies among different hospitals. The purpose of this paper was to evaluate our own data on the group of patients presented and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years.Methods: Following prospective data collection on 63 patients of a university hospital (40 male, 23 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion, we retrospectively analyzed the data. After a medical history had been taken, all patients underwent clinical examination, including digital palpation; 62 patients underwent procto-rectoscopy, 38 gastroscopy and colonoscopy, 52 patients colonoscopy only, and 45 patients gastroscopy only. Angiography was applied in 14 cases and scintigraphy in 20 cases.Results: Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%.Conclusions: Examination and stabilization of the patient is directly followed by diagnostic localization. Today, we primarily rely on nonsurgical control of hemorrhage by endoscopy or angiography; the indication for surgery is mainly limited to peracute, uncontrollable, and recurrent forms. In the case of surgery, intestinal segmental resection is recommended after identification of the lesion; if the localization of colonic hemorrhage is uncertain, subtotal resection is the method of choice. For stable patients with unverifiable small-bowel hemorrhage we recommend regular re-evaluation. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is the second leading cause of cancer deaths despite the fact that detection of this cancer in early stages results in over 90% survival rate. Currently less than 45% of at-risk individuals in the US are screened regularly, exposing a need for better screening tests. We performed two case-control studies to validate a blood-based test that identifies methylated DNA in plasma from all stages of CRC. Methodology/Principal Findings: Using a PCR assay for analysis of Septin 9 (SEPT9) hypermethylation in DNA extracted from plasma, clinical performance was optimized on 354 samples (252 CRC, 102 controls) and validated in a blinded, independent study of 309 samples (126 CRC, 183 controls). 168 polyps and 411 additional disease controls were also evaluated. Based on the training study SEPT9-based classification detected 120/252 CRCs (48%) and 7/102 controls (7%). In the test study 73/126 CRCs (58%) and 18/183 control samples (10%) were positive for SEPT9 validating the training set results. Inclusion of an additional measurement replicate increased the sensitivity of the assay in the testing set to 72% (90/ 125 CRCs detected) while maintaining 90% specificity (19/183 for controls). Positive rates for plasmas from the other cancers (11/96) and non-cancerous conditions (41/315) were low. The rate of polyp detection (>1 cm) was ∼20%. Conclusions/Significance: Analysis of SEPT9 DNA methylation in plasma represents a straightforward, minimally invasive method to detect all stages of CRC with potential to satisfy unmet needs for increased compliance in the screening population. Further clinical testing is warranted. [ABSTRACT FROM AUTHOR]

Because of their low morbidity and mortality, limited resection or local excision are accepted therapeutical approaches in early colorectal cancer treatment. Even though, recent publications report recurrence rates after local excision of rectal cancer in up to 30%. This prompted us to evaluate our data for T1N0 colorectal cancer treated by radical surgery regarding recurrence, morbidity, mortality, and survival rates. Clinical, histopathological, and surveillance data from our prospective “colorectal cancer database” from 1979 to 2005 were analyzed to evaluate outcome and prognosis of T1N0 colorectal cancer treated by radical surgery. Only curative resections were included in this study. All patients were followed in an internal surveillance program, which enabled us to prospectively assess morbidity, mortality, and survival. A total of 105 T1N0 colon and 69 rectal carcinomas were included in the study. Overall morbidity was 25% (colon) and 34% (rectum). Thirty-day mortality was 1.9% (colon) and 4.3% (rectum). After a median follow-up of 92 and 87 month, no isolated local recurrence occurred. One patient developed both local recurrence and liver metastases. Distant metastases were seen in 4.9% (colon) and 7.5% (rectum). The 5- and 10-year overall survival was 86 and 71% (colon) and 82 and 68% (rectum), respectively. Even if radical surgical approaches are associated with a higher rate of morbidity and mortality, our data show that radical surgery for T1N0 colorectal cancer results in excellent tumor control which is of paramount importance for the patients’ prognosis and survival. Combining the data presented with those of the current literature suggests that local approaches to rectal cancer can be recommended for highly selected T1N0 tumors, in palliative situations, or if the patient is unfit for general surgery. [ABSTRACT FROM AUTHOR]

Colorectal cancer is the second leading cause of cancer-related death. Current clinical practice in colorectal cancer screening (fecal occult blood test, FOBT; colonoscopy) has contributed to a reduction of mortality. However, despite these screening programs, about 70% of carcinomas are detected at advanced tumor stages (UICC III/IV) presenting poor patient prognosis. Thus, innovative tools and methodologies for early cancer detection can directly result in improving patient survival rates. Biomedical research has advanced rapidly in recent years with the availability of technologies such as global gene and protein expression profiling. Comprehensive tumor profiling has become a field of intensive research aiming at identifying biomarkers relevant for improved diagnostics and therapeutics. In this paper, we report a comprehensive review of genomic, transcriptomic, and proteomic approaches for biomarker identification in tissue and blood with a main emphasis on two-dimensional gel-electrophoresis (2-DE) and mass spectrometry analyses. Proteomics-based technologies enable to distinguish the healthy patient from the tumor patient with high sensitivity and specificity and could greatly improve common classification systems and diagnostics. However, this progress has not yet been transferred from bench to bedside but could open the door to a more accurate and target specific personalized medicine with improved patient survival. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic radiofrequency ablation (RFA) is a safe and effective method for tumor destruction in patients with unresectable liver tumors. However, accurate probe placement using laparoscopic ultrasound guidance is required to achieve complete tumor ablation. This study aimed to develop a perfusable ex vivo tumor-mimic model for laparoscopic radiofrequency ablation training.Methods: After rinsing the prepared liver vessels with anticoagulants, porcine livers were perfused. Tumor-mimics were created by injecting a mixture consisting of 3% agarose, 3% cellulose, 7% glycerol, and 0.05% methylene blue, creating hyperechoic lesions in ultrasound. Heparinized porcine blood was used as perfusion medium. Continuous perfusion of the porcine liver was provided by connection of a pump system to the portal vein and the vena cava inferior. Laparoscopic RFA techniques were taught using a laparoscopic pelvi-trainer.Results: A total of 30 laparoscopic ablations were performed in four porcine livers. The simulated "tumors" were clearly visible on laparoscopic ultrasound and not felt during placement of the RFA probe. In addition, color duplex ultrasound showed clear signals indicating for a sufficient liver perfusion.Conclusion: Laparoscopic RFA requires advanced laparoscopic ultrasound skills for an accurate placement of the RFA probe. The perfused tumor-mimic model presented is a safe, easy, effective, and economic method to improve and train laparoscopic RFA skills on porcine liver tissue. [ABSTRACT FROM AUTHOR]

Background. Laparoscopic radiofrequency ablation (RFA) is a safe and effective method for tumor destruction in patients with unresectable liver tumors. However, accurate probe placement using laparoscopic ultrasound guidance is required to achieve complete tumor ablation. After evaluation of an ultrasound navigation system for transcutaneous and open RFA, we now intend to tranfer this technique to laparoscopic liver surgery. This study aimed to evaluate an electromagnetic navigation system for laparoscopic interventions using a perfusable ex vivo artificial tumor model. Materials and methods. First a special adapter was developed to attach the ultrasound and electromagnetic tracking-based navigation system to a laparoscopic ultrasound probe. The laparoscopic online navigation system was studied in a laparoscopic artificial tumor model using perfused porcine livers. Artificial tumors were created by injection of a mixture of 3% agarose, 3% cellulose, and 7% glycerol, creating hyperechoic lesions in ultrasound. Results. This study showed that laparoscopic ultrasound-guided navigation is technically feasible. Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Artificial tumors were clearly visible on laparoscopic ultrasound and not felt during placement of the RFA probe. Anatomic landmarks and simulated 'tumors' in the liver could be reached safely. Discussion. Laparoscopic RFA requires advanced laparoscopic ultrasound skills for accurate placement of the RFA probe. The use of an ultrasound-based, laparoscopic online navigation system offers the possibility of out-of-plane needle placement and could increase the safety and accuracy of punctures. The perfused artificial tumor model presented a realistic model for the evaluation of this new technique. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopic radiofrequency ablation is safe, practicable, and combines minimally invasive surgery with the advantages of laparotomy. However, application of the laparoscopic freehand puncture is restricted because of capnoperitoneum and the consequent fixation of the needle on two different points. The use of a laparoscopic ultrasound probe with a canal for puncture can solve this problem and improve precision. However, a stiff needle limits the necessary angulation that is needed to reach right-lateral and cranial liver metastases. Therefore we present a new navigation tool for laparoscopic interventions. Materials and Methods: The US Guide 2000 (Ultra Guide, Tirat Hacarmel, Israel) is an independent navigation system compatible with all ultrasound machines and has six degrees of freedom. After proper evaluation of this system under operating room conditions during transcutaneous radiofrequency ablation, we used this technique in laparoscopic radiofrequency ablation. A special adapter was developed to attach the ultrasound-based navigation system to a laparoscopic ultrasound probe. After calibrating the system with an ultrasound phantom, laparoscopic navigation in a liver organ model was studied. Results: Even in cases of angulation of the ultrasound probe no disturbances of the navigation system could be detected. Anatomic landmarks in the liver could be safely reached. No interaction between the navigation system and the laparoscopic ultrasound probe or operating instruments was observed. Conclusion: Our preliminary results show the feasibility of this technique in laparoscopic radiofrequency ablation. The use of an ultrasound-based laparoscopic inline navigation system offers the possibility of out-of-plane needle placement and could combine the flexibility of freehand puncture with the accuracy of a canal for puncture. This could increase the safety and accuracy of punctures. [ABSTRACT FROM AUTHOR]

Background and aims: Radiofrequency-ablation (RFA) is increasingly used for destruction of unresectable primary and secondary liver tumors. We report our experience in the use of RFA for the management of unresectable hepatic malignancies. Patients and methods: Between February 2000 and December 2004 we have undertaken 120 RFA procedures to ablate 426 unresectable primary or metastatic liver tumors in 88 patients. RFA was performed via laparotomy (n=68), laparoscopy (n=9) or a percutaneous approach (n=43). Primary liver cancer was treated in seven patients (8%) and metastatic liver tumors were treated in 81 patients (92%). All patients were followed to assess complications, treatment response and recurrence of malignant disease. Results: Procedure-related complication rate was low (3.4%). During a mean follow-up of 21.2 months, 15 patients had local tumor progression (17%), 21 patients (23,9%) had new malignant disease and 27 patients (30.7%) died from intervention-unrelated complications of their malignant disease. Additional liver lesions were identified in 27 (35%) of 77 cases by intraoperative ultrasound. Thirty-six patients received simultaneous resection and RFA. Conclusion: RFA is a safe, well-tolerated and effective treatment for patients with unresectable primary and secondary liver malignancies. [ABSTRACT FROM AUTHOR]

Presents information on a study which evaluated the baseline preoperative voiding and sexual function in a cohort of patients undergoing deep rectal resection with mesorectal excision. Information on the total mesorectal excision technique; Relationship between postoperative urological dysfunction and the patient's age.

Purpose: The present study retrospectively examines the expression of pKi-67 mRNA and protein in colorectal carcinoma and their correlation to the outcome of patients. Methods: Immunohistochemistry and quantitative RT-PCR were used to analyze the expression of pKi-67 in 43 archival specimens of patients with curatively resected primary colorectal carcinoma, who were not treated with neo-adjuvant therapy. Results: We determined a median pKi-67 (MIB-1) labeling index of 31.3% (range 10.3-66.4%), and a mean mRNA level of 0.1769 (ΔCT: range 0.01-0.69); indices and levels did not correlate. High pKi-67 mRNA ΔCT values were associated with a significantly favorable prognosis, while pKi-67 labeling indices were not correlated to prognostic outcome. A multivariate analysis of clinical and biological factors indicated that tumor stage (UICC) and pKi-67 mRNA expression level were independent prognostic factors. Conclusion: Quantitatively determined pKi-67 mRNA can be a good and new prognostic indicator for primary resected colorectal carcinoma. [ABSTRACT FROM AUTHOR]

Patients with ulcerative colitis have a significantly increased lifetime risk for the development of colorectal carcinomas. While genetic and genomic changes during carcinogenesis have been thoroughly studied in sporadic colorectal cancers, less is known about ulcerative colitis–associated colorectal carcinomas. The aim of this study was to extend the identification of specific genomic imbalances to ulcerative colitis–associated colorectal carcinomas and to establish a comprehensive map of DNA gains and losses by investigating 23 tumor specimens from 23 patients. The molecular cytogenetic characterization was performed using comparative genomic hybridization; immunohistochemistry was used to measure proliferative activity and laminin-5 expression as a marker for invasiveness. The results indicate that these tumors are invariably aneuploid, with a high proliferative activity and increased invasive potential. The average number of copy alterations correlates with increased cyclin A levels (P = 0.044), which is an independent predictor of risk of carcinoma development in ulcerative colitis. Despite severe genetic instability, the general pattern of specific chromosomal aberrations that defines sporadic colorectal carcinomas is maintained in ulcerative colitis–associated malignancies. High-level copy number increases (amplifications) are dispersed throughout the genome. Strikingly, these amplifications are much more frequent than in sporadic carcinomas and map to chromosomal regions that have not been described before. [Copyright &y& Elsevier]

Background and Objectives: Hydro-jet technology has long been used to cut various materials, such as metal and wood, in the industrial field. In the medical field, this technology has been applied successfully in selective cutting of the parenchyma of the liver. However, to our knowledge, no data are available on the use of the hydro-jet technique for pneumonectomy. The purpose of this study was to evaluate a new dissection technique in which a high-pressure water stream (hydro-jet) and a new dissection probe for pulmonary resection are used. Methods: Thirty pigs underwent right pneumonectomy. Pigs were randomized to either the conventional or hydro-jet-assisted dissection technique. The feasibility of this technique and the features of surgical dissection were evaluated and compared between the two groups. Results: Pneumonectomy was successful in all animals. The mean operative times were 55 and 65 minutes and the mean volumes of blood loss were 37 and 65 mL for the hydro-jet and conventional dissection techniques, respectively. Complications included vascular injury in 6% and 20% of cases with the hydro-jet and conventional techniques, respectively. The use of hydro-jet for pneumonectomy had clear technical advantages over the conventional dissection. Hydro-jet resulted in a selective dissection of fibrous and connective tissue, preserving blood vessels for later ligation. Therefore, the dissection was performed in a relatively bloodless field. The ease of dissection with the bent-tip dissector represents another advantage. The continuous water flow allows a clear view for the operator. Conclusions: This study shows that hydro-jet dissection represents an excellent alternative to the conventional technique for pulmonary resection. The improved anatomic dissection combined with an almost bloodless operating field secondary to continuous water flow may decrease dissection-related complications. [ABSTRACT FROM AUTHOR]

Muhl E, Siemens H-J, Kujath P, Bruch H-P. Therapy and monitoring of heparin-induced thrombocytopenia type II in critically ill patients during continuous venovenous hemodiafiltration: comparison of aPTT and ecarin clotting time for monitoring of r-hirudin therapy. J Intensive Care Med 2002; 17:34–40. We conducted a survey of therapy, complications, and monitoring of heparin-induced thrombocytopenia (HIT) type II in critically ill patients during continuous venovenous hemodiafiltration (CVVHDF). We also compared activated partial thromboplastin time (aPTT) and ecarin clotting time (ECT) for monitoring recombinant (r)-hirudin therapy. Six patients with HIT type II were treated with r-hirudin and were on CVVHDF due to acute renal failure (blood flow rate 90 ml/hr, dialysate flow rate 1 L/hr, substitution 1 L/hr predilution, acrylonitrile membrane 0.9 m2 ). The mean duration of CVVHDF was 6.2 ± 3.6 days (range 3–17 days). Diagnosis of HIT was established 5.0 ± 1.5 days (range 3–8 days) after a decrease in the platelet count. Three of six patients had other possible reasons for thrombocytopenia apart from HIT, such as massive transfusion, sepsis, or liver cirrhosis. Three thromboembolic events occurred before the diagnosis of HIT was established, none of them during treatment of HIT with r-hirudin. In all patients the platelet count doubled or increased up to 100/nl within 2.5 ± 0.5 days. The dose-response relationship of r-hirudin and aPTT was not satisfactory (r = 0.371). In patients receiving CVVHDF with one of two different doses of r-hirudin (1 mg/hr versus 2 mg/hr), there was no difference in aPTT (p < 0.77) but a significant difference in ECT (p < 0.001). The correlation between r-hirudin dose and ECT was r = 0.654 (p < 0.0001). r-Hirudin was safe and effective in the treatment of HIT type II in critically ill patients during CVVHDF. ECT seems to be superior to aPTT for monitoring r-hirudin therapy because it... [ABSTRACT FROM AUTHOR]

Postoperative lymphoceles after renal transplantation appear in up to 18% of patients, followed by individual indisposition, pain or impaired graft function. Therapeutic options are percutaneous drainage, needle aspiration with sclerosing therapy, or internal surgical drainage by conventional or laparoscopic approach. The laparoscopic procedure offers short hospitalisation time and quick postoperative recovery. From 1993 to 1997, 16 patients underwent laparoscopic fenestration of a post-renal transplant lymphocele, and were presented in a retrospective analysis. Three patients have had previous abdominal surgery. Following preoperative ultrasound and CT scan, 16 patients underwent laparoscopic drainage after drainage and staining of the lymphocele with methylene blue. No conversion was necessary. Mean operation time was 42 min, no intraoperative complications were seen. Oral nutrition and immunosuppression were continued on the day of surgery, and patients were discharged between the 2nd and 5th (median hospital stay 3.3 d) day after surgery. No recurrence was evident in a follow-up time of 15–54 months (median 31.4 months). Renal function remained unchanged in all patients postoperatively. [ABSTRACT FROM AUTHOR]