In rectal cancer, depth of infiltration and metastatic involvement of lymph nodes are important prognostic factors. The correct choice of operative treatment depends on the extent of the disease. In a prospective study, the value of endorectal ultrasound in staging rectal cancer was evaluated, and factors affecting the method's accuracy are discussed. The overall accuracy in staging depth of infiltration was 89 percent. Overstaging occurred in 10.2 percent, understaging in 0.8 percent. Tumors of the lower rectum are incorrectly staged in 16.7 percent, whereas tumors of the middle and upper rectum had an incorrect staging in 6.3 percent (P < 0.001). Compared with computed tomography, endorectal sonography is the more accurate staging method (74.7 vs. 90.8 percent). In staging lymph nodes, the overall accuracy was 80.2 percent, sensitivity was 89.4 percent, specificity was 73.4 percent, positive predictive value (PPV) was 71.2 percent, and negative predictive value (NPV) was 90.4 percent. The staging accuracy depends on the size of the node. Endorectal ultrasound is a safe, inexpensive, and accurate staging method, in the assessment of both depth of infiltration and nodal status. The results are strongly related to the experience of the investigator.
Intestinal nonrotation has been recognized as a cause of obstruction in neonates and children and may be complicated by volvulus and intestinal necrosis. It is very rarely seen in the adult and may present acutely as a bowel obstruction and intestinal ischemia associated with midgut or ileocecal volvulus, or chronically as vague intermittent abdominal pain. The purpose of this communication is to reveal the pathogenesis and the surgical significance of intestinal nonrotation in adults and to review the English and German language literature since 1923 to establish the optimal therapeutic management. Between 1983 and 1992, we have managed and observed prospectively 10 adults with intestinal nonrotation. In four patients the nonrotation has been detected at emergency laparotomy owing to midgut or ileocecal volvulus. Four patients suffered from chronic symptoms of intermittent volvulus or small bowel obstruction and in two patients the nonrotation has been noted as an incidental finding at laparotomy for another condition. A survey of the literature from 1923 to 1992 revealed 40 adults with symptomatic intestinal nonrotation to which we contribute nine patients. We establish that in the acute symptomatic pattern, only emergency laparotomy can provide the correct diagnosis and decrease the risk of bowel disturbance. In the chronic situation, barium studies of the upper and lower gastrointestinal tract reveal varying degrees of midgut malrotation and confirm the nonrotation in each case. Also, in these forms the explorative laparotomy with a consequent staging of the abdominal situs is to be recommended. All reported cases at our institutions are without complaints after surgery. Adult patients with intestinal nonrotation and acute or chronic obstructive symptoms or those detected incidentally at laparotomy for other conditions should undergo a Ladd procedure because of the risk of midgut volvulus. In this operation, the nonrotation is left in place and the ascending colon is sutured at the colon descendens and sigmoideum. After this procedure the mesenteric pedicle is fixed and the risk of midgut torsion remains minimal.
With moderate weight loss following LAGB, co-morbidities were cured in 50-80% or improved in 10-40% of all patients.
We describe a young female patient suffering from a PEComa (perivascular epithelioid cell tumor) of the cecum, incidentally found at an examination made by her family physician. The perivascular epithelioid cell tumor is a very rare tumor, until today reported in a few cases in falciform ligament, uterus, jejunum, terminal ileum, rectum, liver, kidney, lung, pancreas, prostate, and soft tissue of the thigh. This tumor is part of a new group of tumors, comprised of angiomyolipoma, lymphangiomyolipoma, and clear-cell myomelanocytic "sugar" tumor. Defined by coexpression of melanocytic (HMB-45) and muscle markers (smooth muscle actin and desmin) the perivascular epithelioid cell tumor does not have predictable histopathologic behavior. Some cases of metastasis are described, comorbidities such as tuberous sclerosis of the brain "Bourneville" and lymphangioleiomyomatosis have to be excluded. The therapy consists of the radical resection. An adjuvant therapy is not known. Recommended is a close and long-term follow-up clinically and by CT scan.
Radiologic and endoscopic examinations before LASGB revealed pathology needing therapy in 42% of the patients and provided important additional information influencing the operative procedure. At an average follow-up of 17 months, 24% of the 148 patients needed unplanned additional upper GI series.
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