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.
After cholecystectomy a certain number of patients continue to suffer from abdominal symptoms or develop such symptoms postoperatively. The aim of this study was to compare the prevalence of postcholecystectomy symptoms with open cholecystectomy during the prelaparoscopic era and those with laparoscopic cholecystectomy 4 years after introduction of the laparoscopic technique. Between July 1988 and June 1989 a total of 163 consecutive patients with elective open cholecystectomy and between September 1994 and August 1995 a total of 234 consecutive patients with elective laparoscopic cholecystectomy were prospectively evaluated using a standard questionnaire about preoperative symptoms, diagnostic modalities, and intraoperative findings. After a minimum of 12 months the patients were interviewed by telephone. Since the introduction of the minimal invasive technique the number of cholecystectomies performed at our institution increased. There was no significant difference in the prevalence of postcholecystectomy symptoms found after the open procedure compared with laparoscopic cholecystectomy: 90% of patients after open and 94% after laparoscopic cholecystectomy had no or only minor symptoms.
As the modern treatment for anal carcinoma is either radiotherapy alone or combined radiochemotherapy, an exact histological staging is impossible. Therefore we have to depend on an accurate preoperative staging method. Endoanal ultrasonography enables imaging of the normal anal canal and its pathologies. In a prospective investigation we were able to confirm the histological proven diagnosis of an anal epidermoid carcinoma in 12 patients with a 10-MHz transducer covered with a sonolucent plastic cone. The depth of infiltration can be determined in relation to the normal layers of the anal canal. Six patients treated with radiotherapy alone or combined radiochemotherapy were followed and the success or failure of the treatment was documented. Endosonography of the anal canal allows an exact staging of a primary anal carcinoma and the follow-up in irradiated carcinomas. Besides digital palpation and proctoscopy with biopsy, endosonography complements the preoperative staging of anal carcinomas.
In a national prospective multicenter study 3,722 laparoscopic cholecystectomies (LC) performed by 179 surgeons in 50 institutions were analyzed with special regard to technique and complications. Conversion to open cholecystectomy was necessary in 259 patients (7.0%), either without intraoperative complications (4.5%) or due to intraoperative complications (2.5%). Three patients (0.08%) died within 30 days after operation and a total of 39 patients (1.0%) had to be reoperated; 22 (0.6%) bile duct injuries were registered. Common bile duct (CBD) stones were treated mainly by ERCP. In eight cases laparoscopic removal of common bile duct stones was attempted, and it was performed successfully in six patients. Postoperatively patients were discharged home after a mean of 4.4 days and returned to work after 14.0 days (range: 2-28). Laparoscopic cholecystectomy became the golden standard to remove the gallbladder, but further development is needed to establish laparoscopic treatment of biliary tract stones in the near future.
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