Pressurized intraperitoneal aerosol chemotherapy with oxaliplatin in colorectal peritoneal metastasis

AIM

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is an experimental drug delivery method that applies chemotherapy into the abdominal cavity as an aerosol under pressure. We present the first results obtained with PIPAC in colorectal peritoneal metastasis (CPM).

METHOD

This is a retrospective analysis. PIPAC was applied in 17 consecutive patients with pretreated CPM. All patients had previously undergone surgery, and 16 had undergone previous lines of systemic chemotherapy (median, two lines). The mean peritoneal metastasis index (peritoneal cancer index) was 16 ± 10. Forty-eight applications of PIPAC with oxaliplatin (92 mg/m2 ) were given every 6 weeks at 37 °C and 12 mmHg for 30 min. The outcome criteria were microscopic pathological response, survival and adverse events according to Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.

RESULTS

Forty-eight PIPAC administrations were performed with no intra-operative complications. The mean number of PIPAC administrations per patient was 2.8 (minimum one, maximum six). Postoperative adverse events (CTCAE level 3) were observed in four patients (23%), no CTCAE level-4 adverse events were reported. The hospital mortality was zero. Objective tumour responses were observed in 12/17 patients (71%), and the overall responses were as follows: complete pathological response (seven patients), major response (four patients), partial response (one patient), no response (two patients) and not eligible (three patients). The mean survival after first PIPAC was 15.7 months.

CONCLUSION

Repeated PIPAC with oxaliplatin can induce the regression of pretreated CPM. The toxicity appears to be low. These preliminary results are encouraging and justify prospective clinical studies.

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) with Low-Dose Cisplatin and Doxorubicin in Gastric Peritoneal Metastasis

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel technique of intraperitoneal chemotherapy. First results obtained with PIPAC in patients with advanced peritoneal metastasis (PM) from gastric cancer (GC) are presented.

METHODS

Retrospective analysis: Sixty PIPAC were applied in 24 consecutive patients with PM from GC. 67 % patients had previous surgery, and 79 % previous platinum-based systemic chemotherapy. Mean Peritoneal Carcinomatosis Index (PCI) of 16 ± 10 and 18/24 patients had signet-ring GC. Cisplatin 7.5 mg/m(2) and doxorubicin 1.5 mg/m(2) were given for 30 min at 37 °C and 12 mmHg at 6 week intervals. Outcome criteria were survival, adverse events, and histological tumor response.

RESULTS

Median follow-up was 248 days (range 105-748), and median survival time was 15.4 months. Seventeen patients had repeated PIPAC, and objective tumor response was observed in 12 (12/24 = 50 %): no vital tumor cells = 6, major pathological response = 6, minor response = 3. Postoperative adverse events > CTCAE 2 were observed in 9 patients (9/24, 37.5 %). In 3/17 patients, a later PIPAC could not be performed due to non-access. Two patients (ECOG 3 and 4) died in the hospital due to disease progression.

CONCLUSION

PIPAC with low-dose cisplatin and doxorubicin was safe and induced objective tumor regression in selected patients with PM from recurrent, platinum-resistant GC. First survival data are encouraging and justify further clinical studies in this indication.

Quality of life of patients with end-stage peritoneal metastasis treated with Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC)

BACKGROUND

Quality of Life (QoL) plays an important role in patients with peritoneal metastasis and is deteriorating continuously until death. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is an innovative palliative treatment of peritoneal metastasis. We present the first QoL results under PIPAC therapy.

METHODS

Retrospective analysis of QLQ30 questionnaire results during repeated courses of PIPAC applications in palliative patients with pretreated peritoneal metastasis.

RESULTS

91 patients (M:F = 40:51, median age 64 (34-77) years) with 158 PIPAC applications were analyzed. 86% patients had previously received systemic chemotherapy. Peritoneal metastasis was advanced (Peritoneal Carcinomatosis Index I = 16 ± 10). At admission, only moderate impairment of functioning (62-83%) and symptom scores (17-47%) was observed. 48 patients received at least 2 PIPAC every 6 weeks. After PIPAC # 1, the global physical score deteriorated slightly (from 82% to 75%), but improved after PIPAC # 2 (up to 89%). Gastrointestinal symptoms (nausea/vomiting, constipation, diarrhoea, anorexia) remained stable under PIPAC therapy.

CONCLUSIONS

Quality of life was relatively high in this group of patients with advanced, pretreated peritoneal metastasis, explaining their wish for further therapy. Functioning scores and disease-related symptoms were not altered for at least 3 months in the patients able to receive repeated PIPAC. Except for a transient moderate increase of pain scores, PIPAC did not cause therapy-related QoL deterioration, especially no gastrointestinal symptoms.

Activity of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) with cisplatin and doxorubicin in women with recurrent, platinum-resistant ovarian cancer: preliminary clinical experience

OBJECTIVE

To assess the activity of laparoscopic Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) in women with recurrent, platinum-resistant ovarian cancer.

METHODS

Prospective case series using repeated courses q 28-42 days of PIPAC containing cisplatin 7.5 mg/m(2) and doxorubicin 1.5 mg/m(2) at 12 mmHg and 37°C for 30 min. Objective tumor response was defined as tumor regression on histology and peritoneal carcinomatosis index (PCI) improvement on repeated video-laparoscopy.

RESULTS

34 PIPAC procedures were performed in 18 women, in 8 instances combined with cytoreductive surgery (CRS). Eight women had repeated PIPAC and objective tumor response was observed in 6 (complete remission: 1; partial remission: 2; stable disease: 3). Five adverse events WHO grade ≥ 2 were noted, 3 of them after combined CRS. No perioperative mortality occurred. Median follow-up was 192 days (min. 13-max. 639). Cumulative survival after 400 days was 62% and mean actuarial survival time was 442 days. In a multivariable regression analysis with objective tumor response (yes vs. no) as the dependent variable and PIPAC (1 vs.>1), patient age (<75 vs.≥75 years), serum CA-125 (<1000 vs.>1000 U/mL), and the presence of ascites (yes vs. no) as independent variables, PIPAC independently predicted objective tumor response.

CONCLUSION

PIPAC has activity in women with recurrent, platinum-resistant ovarian cancer and should be investigated in prospective clinical trials.

[Pre-endoscopic assessment to predict outcome of acute upper gastrointestinal bleeding--a retrospective study in patients subject to emergency endoscopy outside regular working hours]

BACKGROUND AND OBJECTIVES

To evaluate the predictive value of pre-endoscopic risk scores in patients with upper gastrointestinal bleeding (UGI-B).

PATIENTS AND METHODS

The medical records of patients evaluated by emergency esophago-gastro-duodenoscopy (E-EGD) for suspected UGI-B outside regular working hours were retrospectively analysed.

RESULTS

During the 75 months of the study period 112 E-EGDs met the inclusion criteria. Mean age was 65.5 ± 14.7 years. 38.4 % of patients were female. Endoscopy revealed 41 gastro-duodenal ulcers, 16 Mallory-Weiss, 13 varices, 4 neoplasia. 72 patients received transfusions, 39 had endoscopic interventions. 2 patients were surgically treated, 16 had recurrent bleeding. 16 of the 110 patients died during hospitalisation. The following sensitivities were found for the Blatchford score (cut-off > 1), the clinical Rockall score (cut-off > 0) and the Adamopoulos score (cut-off > 2) in predicting need for clinical intervention (endoscopic or surgical intervention or transfusion): 100/97.7/93%, recurrent bleeding: 100/100/93.8%, in-hospital mortality: 100/93.8/93.8%, respectively.

CONCLUSIONS

The Blatchford score is a suitable tool in determining the need for clinical intervention and the risk of recurrent bleeding and death in patients with UGI-B. The clinical Rockall score and the Adamopoulos score (the latter had originally been developed to predict active UGI-B at endoscopy and was used with a lower cut-off in our study) are inferior alternatives.

[Demands for endoscopy service outside of regular hours: a retrospective study and literature analysis]

BACKGROUND AND OBJECTIVE

Many acute care hospitals provide round-the-clock emergency endoscopy to guarantee immediate diagnosis and treatment of acute conditions of the gastrointestinal tract. This study is the first one to assess the demand for emergency endoscopy outside usual working hours.

PATIENTS AND METHODS

This study evaluated retrospectively 315 consecutive emergency endoscopies done at an acute care hospital (575 beds; catchment population 100,000, in the Ruhr area of Germany) between 26.7.2003 and 01.11.2009 (6 years and 3 months) outside usual working hours (i.e. during the weekend and from 6 pm to 8 am during weekdays). This represents 50 emergency endoscopies outside working hours per 100,000 people per year.

RESULTS

56.8 % of the examinations took place during the weekend (Saturday or Sunday), 26.7 % during the night (10 pm - 8 am). The distribution of the different endoscopic modalities was: 228 EGD (72.4 %), 42 incomplete colonoscopies or recto-sigmoidoscopies (13.3 %), 28 retrograde cholangio- or cholangiopancreatographies (8.9 %), 16 complete colonoscopies (5.2 %) and one oral enteroscopy. 208 (66%) of endoscopic procedures were purely diagnostic without any therapeutic intervention. The indication for endoscopy was documented in 243 of the 315 procedures. In 76.5 % of those cases the suspicion of a gastrointestinal bleeding was the indication for endoscopy.

CONCLUSION

In an acute care hospital in Germany 50 emergency endoscopies outside working hours were performed per 100,000 population per year. This rate exceeds that reported in other European countries (Great Britain: 26.7, Norway: 24). Further studies are needed to evaluate the impact of different emergency endoscopic strategies on patient outcome and treatment costs.

Impact of ilio-inguinal nerve excision on sexual function in open inguinal hernia mesh repair: a prospective follow-up study

The aim of this study was to prospectively compare sexual function in patients undergoing inguinal hernia surgical repair with or without excision of the ilio-inguinal nerve. Eighty-four patients (76 males and 8 females) with a unilateral inguinal hernia were enrolled in the study. They underwent an open tension free repair with mesh implantation ("plug and patch" technique). The ilio-inguinal nerve was identified and was either preserved (Preservation group, n = 42) or divided (Excision group, n = 42). Patients were asked to answer an anonymous standardised questionnaire about their sexual function pre-operatively, 3 months postoperatively and every 6 months afterwards during the followup. Thirty-two patients (excision group: n = 17 ; preservation group: n = 15 ; p > 0.05) reported pre-operative sexual dysfunction related to the groin hernia. Three months after surgery 19 patients referred a clear improvement of their preoperative complaints. Eleven patients reported new functional problems. About 20% of the patients in both groups reported an improvement of their pre-operative sexual disorders. New sexual functional symptoms were reported significantly more in the preservation group compared to the excision group (21% vs. 7%, p < 0.05). Twenty-four months after surgery the number of patients with functional sexual symptoms was lower in both groups but yet significantly higher in the preservation group. In conclusion, neurectomy of the ilio-inguinal nerve during surgical repair of inguinal hernia could have a favourable influence on sexual function without relevant complications. It causes significantly less sexual problems compared to preservation of the nerve and it is recommended especially for patients with pre-operative sexual dysfunction due to the groin hernia.

Transanal endoscopic microsurgery (TEM) vs. radical surgery (RS) in the treatment of rectal cancer: indications, limitations, prospectives. A review

BACKGROUND AND STUDY AIMS

Principal goal in the management of any patient with rectal cancer is to provide an optimal chance for cure while maintaining their quality of life. Transanal endoscopic microsurgery (TEM) is a minimal invasive procedure that allows full thickness local excision or rectal tumors. The role or TEM in the treatment of rectal cancer remains controversial. The aim of this study was to review the evidence related to the role of TEM compared to radical surgery in the treatment of rectal cancer.

PATIENTS AND METHODS

We reviewed 5 studies (two controlled randomized and three non-randomized) comparing outcome after TEM vs. radical surgery (RS), either open or laparoscopic, in patients with rectal cancer. We evaluated the results in terms of safety of the procedure as well as its efficacy.

RESULTS

Hospital stay, complication rate and overall morbidity and mortality were lower in the TEM groups in all studies. With the exception of one study, recurrence was slightly (but non-significantly) increased in the TEM groups. No difference for T2 tumors with TEM vs. laparoscopic resection was seen though. Overall survival was not statistically different.

CONCLUSIONS

TEM is a safe, effective minimal invasive method for treatment of T1 rectal carcinomas and possibly T2 carcinomas in selected patients after neoadjuvant chemoradiation. Its role in advanced tumor stages should be further defined.

Medical effectiveness and safety of conventional compared to laparoscopic incisional hernia repair: a systematic review

BACKGROUND

Incisional hernias are a common complication following abdominal surgery and represent about 80% of all ventral hernia. In uncomplicated postoperative follow-up they develop in about 11% of cases and in up to 23% of cases with wound infections or other forms of wound complications. While conventional mesh repair has been the standard of care in the past, the use of laparoscopic surgery is increasing. It therefore remains uncertain which technique should be recommended as the standard of care.

OBJECTIVES

To compare the medical effectiveness and safety of conventional mesh and laparoscopic incisional hernia repair.

METHODS

A structured literature search of databases accessed through the German Institute of Medical Documentation and Information (DIMDI) was conducted. English and German literature published until August 2005 was included and their methodological quality assessed.

RESULTS

The search identified 17 relevant publications and included 15 studies for final assessment. Among those were one meta-analysis, one randomized clinical trial (RCT) ,and 13 cohort studies. All studies suffered from significant methodological limitations, such as differences in baseline characteristics between treatment groups, small case numbers, and the lack of adjustment for relevant confounders. Overall, medical effectiveness and safety were similar for both surgical approaches. However, there was a trend towards lower recurrence rates, length of hospital stay, and postoperative pain as well as decreased complication rates for the laparoscopic repair in the majority of studies. The impact of the technique of mesh implantation and mesh fixation as well as the impact of certain patient-related factors was not systematically assessed in any of the studies.

CONCLUSION

No conclusive differences could be identified between the operative techniques. There was, however, some evidence for a trend towards similar or slightly improved outcomes associated with the laparoscopic procedure. There remains an urgent need for high-quality prospective studies to evaluate this question conclusively.

Does an informative video before inguinal hernia surgical repair influence postoperative quality of life? Results of a prospective randomized study

PURPOSE

Patients undergoing surgery can be impaired in several health-related quality of life areas. As a result, a modern and effective presentation of medical information before elective surgery is of great importance. Thorough preoperative education of the patient could possibly lead to an improvement of postoperative quality of life.

MATERIALS AND METHODS

In a prospective randomized study we examined the influence of a preoperative informative video on the postoperative quality of life of patients undergoing elective surgery for inguinal hernia. Quality of life was assessed with a short form questionnaire (SF-36) preoperatively, on the first postoperative day and 3, 6, and 12 months after surgery.

RESULTS

From January 2004 until January 2005, 100 patients were included in the study (video group n = 50 patients, control group n = 50 patients). Quality of life was measured higher in the video group soon after surgery and until 3 months afterwards. In the same group other aspects evaluated such as "global health" and "social role" showed higher values postoperatively and resumption of preoperative activities took place earlier. No difference was detectable 6 months after surgery.

CONCLUSION

Informative video presents a modern and cost-effective method for the justified and detailed education of the patient about the several pre-, intra-, and postoperative steps of an elective groin hernia operation. The higher information level and the better conditions of surgical care, as the patients perceive these, lead to a better postoperative quality of life.

Submandibular Ectopic Thyroid Gland

Ectopic thyroid glands are generally a rare entity appearing mostly in the cervical midline (90% of the cases) and even more rarely in other anatomical sites (10%). We present the case of an ectopic submandibular thyroid gland. An 81-year-old woman was referred to our department with a history of right-sided submandibular swelling. Preoperative FNA revealed benign ectopic thyroid tissue. The patient was submitted to resection of the mass. Histological examination of the specimen confirmed the diagnosis. A substitution treatment with thyroxin was initiated postoperatively, as this was the only functional thyroid tissue. Review of the literature revealed 18 similar cases. Physicians should be aware of the possibility that a submandibular swelling could be an ectopic thyroid gland. This entity poses specific diagnostic and therapeutic difficulties. Thorough preoperative diagnostics and resection of the ectopic tissue guarantee a good outcome.

Videoinformationsfilm vor Leistenhernienoperationen

BACKGROUND

Although it is a significant part of surgical treatment, informing patients beforehand seems to be more and more neglected, mainly due to the enormous amount of work and time pressure on surgical personnel.

MATERIAL AND METHODS

A video clip explaining groin hernia surgical repair was produced as additional information for patients. In it, visual material from actual practice describes the disease, the operation itself, all the perioperative aspects, and patients' own experiences. In a prospective comparison study, the length of patient education, its quality, patient satisfaction, and the duration of hospitalization and time off work were compared between patients who saw the video clip (n=50) and those who did not (n=50).

RESULTS AND CONCLUSION

In summary, the time spent informing the video group was shorter (P<0.05) and their total satisfaction and evaluation of the information material were both higher (P>0.05) for comparable duration of treatment and time off work. This informative video was adopted without problems in our daily clinical life and, besides reducing the time needed to inform patients, it has significantly improved patient understanding of the operative procedure and their satisfaction with treatment.

[Trevira: a new polyester implant for the treatment of incisional hernia. Results of an experimental study]

OBJECTIVE

The synthetic implant meshes in clinical use for the treatment of abdominal hernias are generally made of polyester in France and of polypropylene in Germany. Serving as an implant material for the replacement of the cruciate ligament, the Trevira is another polymer of polyester in clinical use with excellent results. This animal trial was performed to ascertain whether it offers any advantages over polypropylene for abdominal incisional hernia repair.

MATERIAL AND METHODS

[corrected] In 12 pigs 10 x 10 cm of the abdominal wall preserving the peritoneum was resected and subsequently implanted a 15 x 15 cm synthetic mesh of polyethylene terephthalate (Trevira) in half of them and of polypropylene (Prolene) in the other half using a sublay technique. After two and six month the implant size was measured and the extend of the foreign body reaction determined by the microscopically presence of foreign body giant cells.

RESULTS

No significant differences concerning the implant size were shown between the two groups at any of the time periods. The acute inflammatory reaction observed was significantly higher at the polypropylene than at the polyethylene terephthalate implant (number of giant cells after 2 month: Prolene 2.2 +/-0.4, Trevira: 0.8 +/-0.2, after six month: Prolene: 4.6 +/-1.3, Trevira: 1.1 +/-0.5). In contrast to the polyethylene terephthalate all polypropylene samples showed calcification areas after six month.

CONCLUSION

In this animal trial Trevira mesh showed a high biocompatibility with a low foreign body reaction. It appears to be a promising new implant for the treatment of hernia.

Pylorus preservation after complete gastrectomy and jejunal interposition: experimental study investigating motility and alkaline reflux

BACKGROUND

Pylorus preservation has been proposed to reduce the disturbance in gastric emptying following gastrectomy but little is known about the role of the pylorus regarding motility patterns and alkaline reflux.

AIMS

To assess the motility patterns and alkaline reflux following pylorus preservation after complete gastrectomy and jejunal interposition in the pig.

METHODS

Motility patterns and alkaline reflux were studied in 12 conscious pigs before and after gastrectomy and jejunal interposition with preservation of the pylorus and a 1 cm antral ring (PYL+) or excised pylorus (PYL-) 6 and 14 weeks postoperatively. Gastroduodenal motility was investigated by manometry after fasting and fed, respectively and alkaline reflux by a fiberoptic system for detecting bilirubin.

RESULTS

The number of propagated phase-III activities of the jejunal interponat to the duodenum and propagating velocity were lower in the PYL+ group after 6 weeks (p < 0.05) but higher after 14 weeks (p < 0.05) compared to the PYL- group. In the PYL+ the number of intrapyloric pressure waves (IPPWs) was lower after 6 weeks (p < 0.05) but higher after 14 weeks (p < 0.05) in comparison to preoperative controls. Alkaline reflux was significantly higher in the PYL- group than in the PYL+ group throughout the time observed.

CONCLUSIONS

Pyloric function shows a delay after 6 weeks but restores within 14 weeks postoperatively. Pylorus preservation was associated with a significant decrease of alkaline reflux compared to PYL- in this setting.

[What is the value of the internet as a source of information for patients with inguinal hernias? First results of an observational study]

INTRODUCTION

The increasing use of the internet has led to a variety of medical web pages and an increasing amount of information about hospitals. Little is known about the extent to which this new medium is already used by patients as a source of information. For patients with inguinal hernia, for example, a frequent surgical symptom with large method variety, the value of the internet as a source of information should be examined.

METHODS

One hundred patients facing an elective inguinal hernia repair at the Surgical Department Charité Berlin took part in a prospective observation study (a questionnaire with 10 questions) between July 1999 and March 2001. The questions referred to the possibility of PC/internet access, other sources of information (e.g., general practitioner, friends, internet) as well as the criteria by which the clinic was chosen. Patients were asked to answer basic questions about the development and treatment of inguinal hernia and to give a self-assessment of their knowledge of inguinal hernia (0 = no knowledge; 10 = maximum knowledge).

RESULTS

The questionnaire revealed that 39% of the patients (average age 47 +/- 16 years) had a PC in their homes, 24% of those with internet access; 11% had internet access at other places. It also showed that 53% of the patients sought medical information from their general practitioner, 29% from friends, and 18% from the internet. Young patients (median age 29 years), employees and patients with private internet access use the internet with significantly more frequency. Their medical knowledge as well as their self-assessment of medical knowledge was significantly higher (median 19 versus 7 points and median 8.6 versus 5.7, respectively) and they chose the clinic because of the information from their research on the internet.

CONCLUSION

At present, the internet still plays a subordinate role as a source of information for patients with an inguinal hernia. The increasing presence of this medium as well as the higher internet acceptance of future patients indicates that it has a promising future as a source of medical information.

Quality of life after gastrectomy: Longmire's reconstruction alone compared with additional pouch reconstruction

The optimal reconstruction protocol after total gastrectomy is still a matter of debate. Pouch reconstructions are developed to create a larger reservoir for food, to provide a barrier against intestinoesophageal reflux, and to lengthen the food transit time. Preservation of the duodenal passage should result in better physiologic regulation of the ingested food. Controlled randomized clinical studies must be conducted to assess the quality of life after gastrectomy and various types of reconstruction. In the present trial, which compared Longmire's reconstruction without a pouch and Longmire's reconstruction with a pouch of varying sizes, we evaluated the quality of life for 41 patients during the first postoperative year. The quality of life was examined by an EORTC questionnaire and an organ-specific module. There were no statistically proven benefits for pouch reconstruction in comparison with Longmire's reconstruction alone. Some benefits are shown for the large pouch but it was only a trend. This is especially so with regard to diarrhea and food consumption. A definitive answer to the question about the value of a pouch reconstruction after gastrectomy has not yet been attained. It is possible that there will be significant differences between reconstruction groups during the long-term follow-up.

Sexual function and testicular perfusion after inguinal hernia repair with mesh

BACKGROUND

Open tension-free techniques of hernia repair using synthetic meshes revealed an excellent patient comfort with low recurrence rates. The influence of the resulting fibrosis on testicular perfusion and sexual function is still unclear.

METHODS

In a prospective observation study testicular volume, perfusion, and sexual function was investigated before plug and patch repair, after 3 months, and every 6 months thereafter. Testicular volume and perfusion was examined by a standardized scrotal ultrasound and duplex sonography. Sexual function was assessed by a validated anonymized questionnaire.

RESULTS

Seventy-three patients were included and follow-up examinations by questionnaire and sonography, respectively, were completed in 73 and 68 patients after 3 months, 51 and 43 after 6, and 24 and 14 after 12 months. Preoperative testicular volume and flow volume was comparable between the side of hernia and the contralateral side (average 10.2 +/- 4.8 cm3 versus 9.8 +/- 5.3, respectively) and showed no significant differences during follow-up. In 11 (15%) patients with preexisting disorders sexual function was normalized postoperatively. Ten (14%) other patients (3 of them with neuralgia pain) described limitations of sexual activity due to inguinal pain (n = 4; 6%) or a loss of sensitivity in the inguinal area (n = 6; 8%) after the procedure. Among these, sexual function recovered spontaneously within 12 months postoperatively in 6 patients (2 with inguinal pain, 4 with loss of sensitivity). In all other patients sexual function showed no changes after inguinal hernia repair.

CONCLUSIONS

So far there is no evidence for a significant impairment of the cord structures and the sexual function after inguinal hernia repair in the plug and patch technique.

Isolated dislocation of the hamate bone. Case report and review of the literature

A case of isolated dislocation of the hamate bone is reported. Mechanism of the injury and treatment are described including a review of the literature.

Inguinal hernia repair in the new millennium: plug and patch repair with local anesthesia

Plug and patch repair is a safe, economic method for repairing inguinal hernias, with patient comfort comparable to that with laparoscopic hernia repair. The technique is simple to perform under local anesthesia and easily learned without a learning curve. Complications are rare, and recovery and return to work are rapid. After performing plug and patch repair on 400 patients with a follow-up examination rate of 93% and a median postoperative observation time of 42 months, we have recorded a recurrence rate of only 0.25%.

Prognosis factors in carcinoma of the head of the pancreas

BACKGROUND

Due to a low survival rate even after a R0 resection of cancer of the head of the pancreas, a strict indication for a pancreaticoduodenectomy seems to be sensible. We have therefore analyzed our patients for possible prognosis factors.

METHODS

In a retrospective trial the courses of disease of all patients (1981-1996) with resected histologically proven carcinoma of the head of the pancreas were analyzed. The following patient-specific parameters were evaluated and examined in a single or multivariate analysis of prognosis factors: age, gender, tumor size (T status), lymph node involvement (N status), dimension of resection, operation method, time of operation, morbidity, clinic lethality and survival rate.

RESULTS

Between 1981 and 1996, 500 patients with ductal adenocarcinoma of the head of the pancreas were treated surgically. The rate of resection increased from 32.1% (1981-1986) to 37.8% (1991-1996) whereas the mortality rate decreased from 13.3 to 7.3%. The 5-year survival rate after resection was 11.8% with a median survival time of 13.8 months. In a multivariate analysis, only small tumors (T1, p < 0.016), the R0 status (p < 0.017) and the resection had a significant influence on the survival rate.

CONCLUSION

Prognosis factors in the treatment of pancreatic cancer were tumor size (T1), tumor resection and R0 status.

[Repair of inguinal hernia in the elderly. Results of the plug-and-patch repair with special reference to quality of life]

In a prospective study the perioperative results of plug-and-patch repair were investigated in patients > or = 65 years, and quality of life was assessed using the SF36 preoperatively and 3 months after the procedure in 34 consecutive patients. From August 1994 to February 1999 147 patients with a mean age of 73 +/- 5 years (65-92 years) were operated on using the plug-and-patch technique, mostly under local anesthesia (LA: n = 124, 84%, ITN: n = 23, 16%). Preoperative risk factors were alcohol consumption, hypertonus, diabetes mellitus, ischemic heart disease, smoking, cerebrovascular disease, hyperlipidaemia and pulmonary disease. Most of the patients were ASA II (ASA I: n = 14, 9%, ASA II: n = 82, 56%, ASA III: n = 51, 35%). No intraoperative complications occurred, postoperative complications consisted of superficial wound hematoma (n = 6, 3.7%) and infection (n = 1, 0.6%), seroma (n = 7, 3.8%), urinary retention (n = 3, 1.8%) and ilioguinal pain syndrome (n = 3, 3.8%). The total amount of postoperative analgesic consumption was 4.9 +/- 1.8 g Novalgin for about 4 +/- 3 days. The duration of postoperative hospitalization was 2 +/- 1 days and limitation of daily activities 6 +/- 3 days. Clinical examinations after 3 months revealed no recurrence or late complications. Investigation of quality of life showed a significant improvement in the SF36 domains of physical activity, pain, vitality, and social functioning after the operation. No significant change was observed for physical, emotional, and global health.

Disaster with a new type of band for gastric banding

BACKGROUND

Laparoscopic gastric banding has become an established therapy for morbid obesity. Typical complications are band dislocation, pouch dilatation and stomach slippage. A new type of adjustable silicone band with eyes for suture fixation was proposed to avoid these complications. The experience with this new kind of band is reported.

METHODS

Between April 1998 and August 1998, 15 morbidly obese patients were treated by laparoscopic adjustable gastric banding using a new band type (manufactured by MEDING, Heinsberg, Germany). The band was fixed by single sutures using the eyes at each side of the buckle. There were 13 women and 2 men, with mean age 34 (range 21-54) years and mean body-weight 138.6 (range 113-213) kg.

RESULTS

Intraoperative complications did not occur. Postoperatively 8 patients (53%) had increasing capacity for food intake and 2 (13%) had uncharacteristic abdominal pain. Radiographs revealed band rupture in 13 of 15 patients 3-11 months postoperatively. These patients were operated laparoscopically using a new technique for band change. Now, a Lap-band (BioEnterics, Carpinteria, CA, USA) was inserted and fixed to the ventral stomach with three sutures similar to a ventral fundoplication. Radiographic and clinical follow-up have been uneventful in all patients until now.

CONCLUSION

This series demonstrated: 1) the importance of clinical follow-up; 2) a material defect of a new band type; and 3) development of a new laparoscopic technique for band change.

Fundoplication: a model for immunologic aspects of laparoscopic and conventional surgery

BACKGROUND AND PURPOSE

Immunologic investigations of laparoscopic and conventional procedures have recently been performed during cholecystectomy or colon resection, but the results might have been influenced by the amount of dissection or the presence of malignant tumor. Because fundoplication is characterized by moderate dissection and no resection, we supposed it to be an appropriate procedure for comparing immunologic changes during laparoscopic and conventional surgery.

PATIENTS AND METHODS

Immunologic analysis (interleukin [IL]-6, IL-10, leukocytes, HLA-DR monocytes) was carried out on the peripheral blood of 34 patients who underwent elective Nissen fundoplication by the laparoscopic (LAP; N = 26) or conventional (OPEN; N = 8) technique for gastroesophageal reflux disease. Blood samples were obtained before and 1 and 4 hours after the beginning of the operation and on days 1, 2, 4, 7 after the procedure.

RESULTS

A very fast and significant (P < 0.01) increase of the proinflammatory cytokines (IL-6, IL-10) and leukocytes and a decrease of cell-mediated functions (HLR-DR monocytes) were detected. Most of the analyzed measures had returned to preoperative values by 2 days after the procedure. All of the changes were similar in the two groups with the exception of IL-6. Throughout the post-operative study period, IL-6 concentrations were higher in the OPEN group, being significant 4 hours, 1 day, 2 days, and 4 days after the operation.

CONCLUSION

The investigation measures do not give evidence that laparoscopic fundoplication is superior to conventional fundoplication in its immunologic effects.

Tumor size and lymph-node status in pancreatic carcinoma - is there a correlation to the preoperative immune function?

BACKGROUND AND AIMS

It has not been clarified whether there is a correlation between the tumor size and the preoperative immune function in pancreatic carcinoma.

PATIENTS/METHODS

In a prospective trial, the influence of tumor size and lymph-node status on different immune system factors [interleukins (IL)-6 and -10, tumor necrosis factor (TNF)-alpha, CD3-, CD4-, and CD8-lymphocytes, and human leukocyte antigen (HLA)-DR-monocytes] was analyzed in 28 patients with pancreatic carcinoma and compared with a control group (n=20). There were 3 pancreatic carcinomas of the T1-tumor type, 20 T2- and 5 T3-tumors; 14 patients were in stage N1.

RESULTS

In comparison with the control group, tumor patients preoperatively showed a significant increase of leukocytes (P=0.02), monocytes (P=0. 04), and granulocytes (P=0.03). The total count of lymphocytes, the number of CD3-, CD4- and CD8-lymphocytes, and the expression of HLA-DR on monocytes were significantly decreased as a sign of immunosuppression in tumor patients. A multivariate analysis proved that only tumor size (T-stage) but not lymph-node status correlates with the deficiency of immune competence. Progressive tumor size correlated with decreasing expression of HLA-DR on monocytes, CD3- (P=0.04) and CD8- (P=0.02) lymphocytes. In contrast IL-6, IL-10 (P=0. 04) and TNF-alpha (P=0.02) increased with progressive tumor size.

CONCLUSION

Regarding the negative prognosis after resection, the preoperative immune status could be an additional help for decision between a resection or a preoperative immune stimulation in pancreatic carcinoma.

Does dietary alpha-linolenic acid promote liver metastases in pancreatic carcinoma initiated by BOP in Syrian hamster?

BACKGROUND

alpha-Linolenic acid (ALA) has been shown to have a promoting effect on pancreatic carcinogenesis. The purpose of this study was to evaluate the influence of ALA on liver metastases in a model of BOP-induced pancreatic ductular carcinoma in the Syrian golden hamster.

METHODS

While the control group (group V) received a standard diet low in fat (soya oil, 3 w/v) without ALA, groups I-IV were fed a diet high in fat (soya oil 25 w/v) with increasing percentages of ALA (2.5, 5, 7.5 and 10%) for 16 weeks.

RESULTS

No significant differences in mean body weight and pancreas weight were found between the groups. But significant differences (p = 0.0001) were observed in the mean weight of the resected liver. Treatment with BOP alone resulted in the induction of well-differentiated ductal pancreatic adenocarcinoma in 91%, while all groups treated with different amounts of ALA had induction of 100%. The incidence of liver metastases differed significantly between the groups. The incidence of liver metastases in group I (2.5% ALA) was 18%, in group II (5% ALA) 27%, in group III (7.5% ALA) 50%, and in group IV (10% ALA) 91%. Moreover, the diameter of liver metastases increased significantly according to ALA supplementation (p = 0.001).

CONCLUSION

The results indicate that dietary ALA increases liver metastases in BOP-initiated pancreatic cancer.

Effects of fibrin glue and growth factors released from platelets on abdominal hernia repair with a resorbable PGA mesh: experimental study

INTRODUCTION

The purpose of this study was to investigate if the strength and quality of an abdominal wall repair with a resorbable PGA (polyglycolic acid) mesh can be improved by fibrin glue or releasates from platelets.

MATERIALS AND METHODS

An abdominal wall defect in the rat was repaired using a PGA mesh in a sublay technique (CG) alone and either with additional fibrin glue (FG) or with platelet releasates (REL). Endpoints were clinical herniation pressure and hydroxyproline concentration (HP) as well as number of fibroblasts and collagen fibers at 7, 14, and 90 days after implantation.

RESULTS

In both experimental groups (REL and FG) higher herniation pressures, hydroxyproline contents, and number of fibroblasts/collagen fibers were found at all times of measurement compared to the CG. The PGA mesh alone showed a significant lack of stability after 14 days which can be compensated for by the investigated components. Significant differences (P < 0.05) were observed regarding the herniation pressure (REL vs CG at 7 and 14 days; FG vs CG at 14 days) and the number of collagen fibers (REL vs CG at 14 days).

CONCLUSIONS

These results suggest that the quality of a PGA mesh repair can be improved by application of fibrin glue or platelet releasates in the described experimental setting.

Tube thoracostomy complicates unrecognized diaphragmatic rupture

A case of traumatic diaphragmatic rupture is reported in which herniated stomach mimicked a tension pneumothorax. Tube thoracostomy by trocar caused insertion of the pleural drain into the intrathoracic stomach. CT scan of the thorax after oral administration of contrast material revealed the correct diagnosis. After removal of the drain and retraction of the stomach into the abdomen the gastric perforation and diaphragmatic defect could be closed by suture. The further course of the patient was uneventful. This case report underlines the importance of differential diagnosis of symptoms in a case with a history of blunt chest trauma and shows the risks of unnecessary use of a trocar.

[Hormone therapy of postoperative recurrent pancreatic carcinoma with octreotide and tamoxifen]

BACKGROUND

In a prospective trial (October 1996-April 1998) the effect of octreotide and tamoxifen on the recurrence of pancreatic carcinoma after R0 resection was evaluated.

METHODS

Patients with a local recurrence after curative resection of ductal adenocarcinoma of the pancreas were treated with 100 micrograms of octreotide three times a day and tamoxifen 20 mg once daily. The median survival time, quality of life (EO-RTC-QLQ-30) and side effects of the octreotide-tamoxifen group were compared with a historic cohort (n = 14) of patients treated in our department (9/95-9/96) according to the "best supportive care" concept.

RESULTS

Recurrences were diagnosed after R0 resection in a mean time of 13 +/- 6.8 months. Patients treated with octreotide and tamoxifen had a significantly (P < 0.05) longer median survival time (7 months; range: 3-12) vs 3.5 months; range: 1.5-5). The octreotide-tamoxifen group suffered less from lack of appetite, nausea, fatigue, and pain and needed fewer analgesics. The only side effect of the octreotide-tamoxifen therapy was moderate diarrhea in 2 patients at the beginning of the therapy.

CONCLUSION

Since combined therapy with octreotide and tamoxifen can be administered comfortably for outpatient treatment, this seems to represent progress in the palliative therapy of pancreatic cancer.

Repeated boluses of local anaesthetic for pain relief after inguinal hernia repair

OBJECTIVE

To compare the effect of repeated boluses of local anaesthetics with an oral analgesic for pain management after tension-free inguinal hernia repair.

DESIGN

Prospective randomised study.

SETTING

University hospital, Germany.

SUBJECTS

104 patients undergoing elective hernia repair.

INTERVENTIONS

52 patients were given boluses of 0.5% bupivacaine 10 ml through a subcutaneous catheter and 52 dipyrone 500 mg orally 6, 12 and 24 hours after operation.

MAIN OUTCOME MEASURES

Postoperative pain measured on a visual analogue scale, complications, systemic side effects, supplementary analgesics, costs, and time taken to give the analgesics.

RESULTS

There were no significant differences between the groups in absolute pain scores, course of pain, and the effects of analgesics. Thirteen patients [5 in the bupivacaine group and 8 in the dipyrone group] required additional dipyrone [mean (range) 2000 mg (500-5000) and 2500 mg (500-4000) respectively]. There were no systemic side effects of either treatment. There were 5 wound haematomas in the bupivacaine group (10%), and 2 wound haematomas and 1 superficial wound infection in the dipyrone group (6%). Mean costs of material and time taken to give the analgesics were pound sterling 104.70 and 47 minutes in the bupivacaine group compared with pound sterling 3.40 and 6 minutes in the dipyrone group. The median (range) hospital stay was 2 (1-3) days in both groups.

CONCLUSIONS

Repeated boluses of local anaesthetic did not result in better or cheaper pain control than oral analgesics after tension-free inguinal hernia repair.

K-ras mutations in tissue and stool samples from patients with pancreatic cancer and chronic pancreatitis

BACKGROUND AND AIM

K-ras oncogene is the most promising molecular marker of pancreatic cancer. However, the incidence of single and combined K-ras mutations in stool and pancreatic tissue is unknown, and it is not clear whether detection of the K-ras oncogene in stool could be employed in screening tests.

PATIENTS/METHODS

Stool and pancreatic tissue of patients with ductal adenocarcinoma (n = 36), cystadenocarcinoma (n = 1), periampullary carcinoma (n = 7), endocrine tumour (n = 2) and chronic pancreatitis (CP, n = 5) were analysed for mutated K-ras sequences prospectively. DNA of stool and pancreatic tissue was amplified by polymerase chain reaction and K-ras status was analysed by hybridisation.

RESULTS

K-ras mutations were detected in the pancreatic tissue of 28 patients with ductal adenocarcinoma (78%), in 1 patient with cystadenocarcinoma, in 1 patient with periampullary carcinoma (14%) and in 1 patient with CP (20%). In 1 patient with an endocrine tumour, no K-ras mutations were diagnosed. K-ras mutations were detected in stool in 7 patients with ductal adenocarcinoma (20%), in 1 patient with cystadenocarcinoma and in 2 patients with CP (40%). Sensitivity of K-ras mutations for pancreatic cancer was 78% in tissue and 20% in stool.

CONCLUSION

K-ras mutations lack specificity to discriminate malignant pancreatic disease from chronic inflammation in tissue and stool.

Is mesh fixation necessary in abdominal hernia repair? Results of an experimental study in the rat

BACKGROUND

Abdominal hernia repair with implantation of synthetic meshes using the sublay technique has resulted in low recurrence rates and high patient satisfaction.

AIM

The purpose of this experimental animal study was to investigate whether mesh fixation is necessary in abdominal hernia repair using a polypropylene mesh in the sublay technique.

METHODS

Forty-five rats were divided into three groups after creating an abdominal wall defect (CG control group, no mesh implantation; NoFixG mesh implantation without fixation group; SG mesh with suture fixation group) with 15 animals in each group. End-points were clinical herniation pressure, hydroxyproline (HP) concentration, mesh shape and number of fibroblasts/collagen fibres of the anchor zone 7, 14 and 90 days after implantation.

RESULTS

Herniation pressure, HP content and number of fibroblasts were similar between NoFixG and SG, although significantly higher in these groups than in the CG (P<0.05). Both mesh groups had significantly higher counts of fibroblasts and collagen fibres than the CG. Mesh shrinking occurred in both groups but was less in the SG.

CONCLUSION

Mesh fixation was not mandatory in abdominal hernia repair using this animal model.

[Adjustable "banding" of the hepatic artery in treatment of shunt-induced heart failure in Osler-Rendu-Weber disease]

Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is rare. Among local pathologic alterations like fibrosis and cirrhosis, arteriovenous shunts lead to hypercirculatory heart failure and require efficient therapy. Present therapeutic strategies consist of percutaneous selective embolization or complete ligation of the hepatic artery. We describe a 53-year-old woman with HHT in whom percutaneous selective embolization of the left hepatic artery failed because of unfavorable anatomy. Instead of ligation a new method of adjustable banding of the hepatic artery was tested. After small-incision laparotomy an expander prosthesis was put on the proper hepatic artery. By filling the prosthesis via the implanted port system the hepatic perfusion could be reduced under control. This method led to effective reduction of the liver perfusion and heart time volume and to successful treatment of heart failure. The method described is an alternative treatment to ligation of the hepatic artery in cases in which percutaneous embolization failed or is not possible.

Intravascular disruption of central venous ports

Intravasal catheter disruption is a rare complication of central venous ports. Main causes are chronic trauma due to compression of the catheter between clavicle and first rib, or primary damage by sharp instruments during insertion. Utilizing the subclavian route, a more lateral insertion can minimize the risk of catheter compression. Regular postoperative X-ray controls can help to recognize progressive catheter compression. In the case of significant compression, early replacement is advisable to avoid disruption. Percutaneous transvenous snare technique is the therapy of choice to retrieve dislocated fragments.

Prospective randomized study comparing laparoscopic and open tension-free inguinal hernia repair with Shouldice's operation

BACKGROUND

Although tension-free techniques of hernia repair using synthetic meshes revealed encouraging results, the best method of inguinal hernia repair is still unclear.

METHODS

In a prospective randomized phase-II-B study, early postoperative results of laparoscopic transabdominal preperitoneal repair (n = 80), open plug and patch repair (n = 80), and Shouldice's operation (n = 80) were compared. Postoperative pain and patient's comfort were defined as main endpoints.

RESULTS

The laparoscopic approach had significantly longer operation time and was more expensive (61 +/- 12 minutes; $1,211) than plug and patch repair (36 +/- 14 minutes; $124) and Shouldice's operation (47 +/- 17 minutes; $69). Main postoperative complications were wound hematomas, seromas, and superficial wound infection, without significant difference between the groups. Postoperative pain, analgesia requirements, limitation of daily activities, and return to work did not differ between laparoscopic and open tension-free repair but were significantly lower in both groups compared with Shouldice's operation. So far, no recurrence was observed after a mean follow-up of 25 months.

CONCLUSION

Open plug and patch repair is a promising technique of hernia repair in adults, because it offers the same excellent patient comfort as the laparoscopic repair but is less expensive and can be performed under local anesthesia.

Is tissue oxygen tension during esophagectomy a predictor of esophagogastric anastomotic healing?

PURPOSE

The genesis of anastomotic leakage and late stenosis of esophagogastrostomy is still unknown, although minimal blood flow and tissue hypoxia of the gastric tube are discussed as main reasons. However, the changes in tissue oxygen tension (PtO2) on esophagogastric anastomoses have not yet been evaluated in the perioperative course.

METHODS

Submucosal tissue oxygen tension (PtO2) was measured in 33 patients with cervical esophagogastrostomy during resection of esophageal carcinoma and reconstruction by a gastric tube. Measurements were taken close to the projected resection line and latter anastomosis using a Clark-type oxygen electrode.

RESULTS

Mean baseline PtO2 was 55.1 +/- 10.4 mmHg. Following the ligature of the vasa gastricae brevis and the left gastroepiploic artery (46.1 +/- 9.7 mmHg), the left gastric artery (34.8 +/- 9.8 mmHg), and the pull up of the gastric tube, PtO2 decreased to 25.8 +/- 9.4 mmHg. Anastomotic leakage occurred in 6 patients and late stenosis in 10 patients. During the operation there was no significant evidence of decreased PtO2 levels in these two groups. Postoperative PtO2 levels showed a significant increase in patients with anastomotic leakage.

CONCLUSION

A disorder in oxygen consumption may cause a significant increase of PtO2 in anastomotic tissue, which is associated with anastomotic leakage.

Quality of life after surgical treatment of gastric carcinoma

OBJECTIVE

To see if there was a correlation between self-assessment and external evaluation of quality of life (QL) after resection of gastric carcinoma, a correlation between overall QL and different components, and the impact of social and medical factors on QL.

DESIGN

Prospective study.

SETTING

University hospital, Germany.

SUBJECTS

71 patients assessed once 12 months after R0-resection of gastric carcinoma and 35 patients assessed regularly, starting postoperatively.

INTERVENTIONS

QL was assessed by the patients using the European Organisation for Research and Treatment of Cancer (EORTC) core QL questionnaire (QLQ-C36) and by a psychologist using the Spitzer Index.

MAIN OUTCOME MEASURES

Correlations between self-assessment and external assessment, between overall scores and single items of QL, and between social and medical factors and QL, as well as changes in QL-scores during postoperative follow-up.

RESULTS

Self-assessment and external evaluation of global QL showed a significant but not particularly close correlation (r = 0.40) and QL was evaluated as better by the external observer using the Spitzer Index. All physical, emotional, and social components of the QLQ-C36 correlated significantly with patients overall evaluation of QL. Postoperative QL was affected mainly by somatic complaints and physical limitations. Of several factors analysed, tumour recurrence was the decisive factor in deciding patients' QL. Compared with the preoperative assessment, QL had deteriorated on discharge from hospital but was restored during the following six months in patients who remained disease-free.

CONCLUSION

Compared with the Spitzer Index the QLQ-C36 differentiates the QL of patients with gastric cancer better and disease-specific complaints are included.

[The plug and patch repair for managing the inguinal hernia of the adult]

The basic principles of the Plug and Patch Repair of inguinal hernia are positioning of a prolene plug behind the internal ring in combination with a prolene onlay patch on the fascia transversalis. From July 1994 until December 1996 243 inguinal hernias were operated in this technique in a consecutive series of 221 patients. There were 211 primary and 32 recurrent hernias. 187 operations were performed in local anesthesia and 34 patients wished general anesthesia. No intraoperative complications were noted. The average operation time was 36 +/- 14 minutes. Postoperative complications were 8 subcutaneous hematomas and 1 superficial wound infection, which healed spontaneously. The average stay in hospital was 2 +/- 2 days and the patients returned to work after 17 +/- 11 days. Patients' self assessment of postoperative pain and limitations of daily activities revealed an excellent comfort. The follow-up rate is 97% and no late complications were observed after a median follow-up time of 21 months. The Plug and Patch technique is a very promising procedure for inguinal hernia repair in adults.

Quality of life following resection of oesophageal carcinoma

Quality of life following resection of oesophageal carcinoma was assessed by patients using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and by a psychologist using the Spitzer Index. Quality of life was evaluated in 119 patients on one occasion 12 months after operation and in 30 patients regularly, starting with a preoperative assessment. Self and external evaluation showed a significant correlation (r = 0.61), but quality of life was assessed as being higher by the external observer. Limited physical performance status and somatic complaints were the most important postoperative dysfunctions, whereas emotional, social and economic disorders were found to be less frequent and less severe. Of several factors analysed only tumour recurrence (P < 0.01) and anastomotic stricture (P < 0.05) lowered quality of life significantly. Compared with the preoperative assessment, quality of life had decreased on discharge from hospital but was restored within 6 months of operation in disease-free patients. Further studies are required to determine the impact of adjuvant therapy for quality of life in patients undergoing surgery for oesophageal cancer.

[Assessment of quality of life after resection of colorectal carcinoma]

Quality of life (QL) following resection of carcinoma of the colon (n = 68) and rectum (n = 58) was studied in 126 patients 12 months postoperatively and in 34 patients at regularly intervals, starting with a preoperative assessment. QL was assessed by the patients themselves using the EORTC QL questionnaire (QLQ-30) and by a psychologist using the Spitzer index. Between self-assessment and evaluation by the independent observer, a significant but not very strong correlation (r = 0.48) was determined and QL was evaluated as being better by the observer. Although somatic and emotional problems were significantly more common in patients with rectal cancer following abdominoperineal resection and the Spitzer index was significantly lower in these patients, the subjectively perceived global QL did not differ from that after sphincter-preserving resection. Of several factors analysed, tumour recurrence was the decisive factor determining postoperative QL. In disease-free patients QL had deteriorated on discharge from hospital but was restored within 3-6 months postoperatively.

[Laparoscopic or conventional repair of inguinal hernia with synthetic mesh?]

Laparoscopic inguinal hernia repair by means of the transabdominal preperitoneal technique (TAPP) was compared with open plug-and-patch-repair (PP) in a prospective study. From September 1992 until July 1994, 86 patients were operated using the TAPP technique; after introduction of PP in August 1994, 105 patients were operated using this technique. From August 1994 until April 1995, 24 more patients wanted the laparoscopic procedure. The two groups were comparable with regard to age, sex and the distribution of hernia types. Eighty-eight (84%) of the PP patients were operated under local anesthesia, while the others chose general anesthesia. The only intraoperative complication was a bleeding from the epigastric vessel in the laparoscopic group. Postoperative complications were three wound hematomas after TAPP (2.2%) and two wound hematomas and one superficial wound infection after PP (2.4%). All complications healed spontaneously. No detectable statistical difference was noted between the two groups with respect to postoperative pain, the consumption of analgetics, duration of hospitalization and reconvalescence. After a median follow-up of 34 months, two recurrences after TAPP (1.4%) and no recurrences after PP has been detected. Based on our experience we prefer PP for inguinal hernia repair in adults because it affords the same patient comfort as TAPP but is less expensive and can be performed under local anesthesia.

Diagnosis, treatment and prognosis of the leiomyosarcoma of the inferior vena cava. Three cases and summary of published reports

OBJECTIVE

To describe our experience with three cases of leiomyosarcoma of the inferior vena cava, and summarise current methods of diagnosis and treatment.

DESIGN

Descriptive study.

SETTING

University hospital, Germany.

SUBJECTS

3 Patients with histologically confirmed leiomyosarcoma of the inferior vena cava.

INTERVENTIONS

Resection, with or without vascular reconstruction.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

Case 1 was diagnosed on magnetic resonance imaging, the tumour was resected, and the vena cava replaced with a polytetrafluoroethylene (PTFE) graft. She made an uncomplicated recovery and was well and free of symptoms 10 months later. Case 2 was diagnosed at operation (the differential diagnosis on computed tomography was a retroperitoneal tumour), the tumour was resected, and the defect oversewn. She made an uneventful recovery and was well and free of symptoms 14 months later. Case 3 was diagnosed at operation (a diagnosis of pancreatic cancer had been made preoperatively), the tumour was resected, and the defect oversewn. She was well and free of symptoms 10 months after operation.

CONCLUSIONS

Magnetic resonance imaging is superior to computed tomography in the diagnosis of leiomyosarcoma of the inferior vena cava. The treatment of choice is resection; small defects can be closed by suture or PTFE patch, and large defects by PTFE prostheses. Reported resectability is 40% to 60%, but the prognosis is poor; the local recurrence rate is about 36%, most patients are dead within 2.5 years, and the 5-year survival is 30%. Chemotherapy and radiotherapy will give some degree of palliation, but do not affect the outcome.