Die Prognose des Transversumkarzinoms inklusive der Flexurenkarzinome wurde in der Vergangenheit als inferior zu den Karzinomen der restlichen Kolonabschnitte bewertet.

1 Universitätsklinikum Essen, Klinik für Allgemein-, Viszeralund Transplantationschirurgie, Sektion Endokrine Chirurgie, Medizinisches Zentrum, Essen, Deutschland 2 Schlichtungsstelle für Arzthaftpflichtfragen der norddeutschen Ärztekammern, Hannover, Deutschland 3 Klinik für Allgemein-, Viszeralund Thoraxchirurgie, Städtisches KlinikumDresden, Dresden, Deutschland 4 Chirurgische Klinik, UniversitätsklinikumKnappschaftskrankenhaus, Ruhr-Universität Bochum, Bochum, Deutschland

AIM:The internal anal sphincter (IAS) contributes substantially to anorectal functions. While its autonomic nerve supply has been studied at the microscopic level, little information is available concerning the macroscopic topography of extrinsic nerve fibres. This study was designed to identify neural connections between the pelvic plexus and the IAS, provide a detailed topographical description, and give histological proof of autonomic nerve tissue. METHODS:Macroscopic dissection of pelvic autonomic nerves was performed under magnification in seven (five male, two female) hemipelvises obtained from body donors (67-92 years). Candidate structures were investigated by histological and immunohistochemical staining protocols to visualize nerve tissue. RESULTS:Nerve fibres could be traced from the anteroinferior edge of the pelvic plexus to the anorectal junction running along the neurovascular bundle anterolaterally to the rectum and posterolaterally to the prostate/vagina. Nerve fibres penetrated the longitudinal rectal muscle layer just above the fusion with the levator ani muscle (conjoint longitudinal muscle) and entered the intersphincteric space to reach the IAS. Histological and immunohistochemical findings confirmed the presence of nerve tissue. CONCLUSIONS:Autonomic nerve fibres supplying the IAS emerge from the pelvic plexus and are distinct to nerves entering the rectum via the lateral pedicles. Thus, they should be classified as IAS nerves. The identification and precise topographical location described provides a basis for nerve-sparing rectal resection procedures and helps to prevent postoperative functional anorectal disorders.

Das humane Pankreasekret enthält zwei wesentliche Trypsinogen-Isoformen: das kationische und das anionische Trypsinogen. Bis jetzt wurden 18 genetische Varianten des kationischen Trypsinogen-Gens bei Patienten mit hereditärer oder sporadischer chronischen Pankreatitis nachgewiesen. Wichtigstes Merkmal der meisten bisher untersuchten Mutationen des kationischen Trypsinogens ist deren gegenüber dem Wildtyp erleichterte Autoaktivierbarkeit. Dieses Phänomen könnte durch eine erleichterte intrapankreatische Aktivierung von Verdauungsenzymen zur Organschädigung führen.

Einleitung: Nur 20–30% der hilären Gallengangskarzinome lassen sich potenziell kurativ resezieren mit Rezidivraten bis zu 76%. Es war das Ziel dieser prospektiven Phase II Studie herauszufinden, ob sich die neoadjuvante PDT für eine selektive Tumordestruktion eignet.

PURPOSE:Preoperative chemoradiotherapy (CRT) has been established as standard treatment for locally advanced rectal cancer after first results of the CAO/ARO/AIO-94 [Working Group of Surgical Oncology/Working Group of Radiation Oncology/Working Group of Medical Oncology of the Germany Cancer Society] trial, published in 2004, showed an improved local control rate. However, after a median follow-up of 46 months, no survival benefit could be shown. Here, we report long-term results with a median follow-up of 134 months.PATIENTS AND METHODS:A total of 823 patients with stage II to III rectal cancer were randomly assigned to preoperative CRT with fluorouracil (FU), total mesorectal excision surgery, and adjuvant FU chemotherapy, or the same schedule of CRT used postoperatively. The study was designed to have 80% power to detect a difference of 10% in 5-year overall survival as the primary end point. Secondary end points included the cumulative incidence of local and distant relapses and disease-free survival.RESULTS:Of 799 eligible patients, 404 were randomly assigned to preoperative and 395 to postoperative CRT. According to intention-to-treat analysis, overall survival at 10 years was 59.6% in the preoperative arm and 59.9% in the postoperative arm (P = .85). The 10-year cumulative incidence of local relapse was 7.1% and 10.1% in the pre- and postoperative arms, respectively (P = .048). No significant differences were detected for 10-year cumulative incidence of distant metastases (29.8% and 29.6%; P = .9) and disease-free survival.CONCLUSION:There is a persisting significant improvement of pre- versus postoperative CRT on local control; however, there was no effect on overall survival. Integrating more effective systemic treatment into the multimodal therapy has been adopted in the CAO/ARO/AIO-04 trial to possibly reduce distant metastases and improve survival.

BACKGROUND:Most cholangiocarcinomas of the extrahepatic bile duct are diagnosed at an advanced stage. Surgery represents the only potentially curative treatment. An assessment as to whether a curative resection is possible is based on the experience of the treating physicians.METHODS:The present guidelines are based on comprehensive literature surveys in PubMed, including results from randomised controlled trials, systematic reviews and meta-analyses, and cohort studies.RESULTS:The experience of the surgeon is determining for defining criteria for resection. The surgical standards for treating Klatskin tumours are extended liver resections. Liver transplantation after neoadjuvante chemo / radiation therapy offers good results. N1 regional lymph node metastases are not a contraindication for resection. R1 resection is justified as a very efficient palliative procedure. The surgical standard for treating distal cholangiocarcinoma is the partial pancreatoduodenectomy. Infiltration of the mesenterico-portal veins or regional lymph nodes is not a contraindication for resection. However, resection has not been shown to provide survival benefit if the coeliac trunk or the superior mesenteric artery is infiltrated. There is no evidence for or against a palliative R1/R2 resection.CONCLUSIONS:For anatomic reasons, the resection rates for distal cholangiocarcinoma are higher than those for Klatkin tumours. The decision as to whether or not a curative resection is possible, especially for Klatskin tumour, requires detailed preoperatzive diagnostics and a conditioning of the patient.

The majority of proctological diseases can be defined by a structured evaluation of the symptoms and a physical examination. Magnetic resonance imaging (MRI) and anal endosonography can detect complex anal fistulas with a high accuracy but MRI should be preferred because of its objective visualization. Functional anorectal disorders are multifactorial and show morphological and functional irregularities in different compartments of the pelvic floor which is why MR defecography is now one of the most important methods in diagnostic algorithms. Interpreting the results of anal endosonography, anal manometry and neurophysiological testing is highly demanding because of large interindividual variability. Scores are used for objective measurement of symptom severity and quality of life. In clinical practice, well validated scores evaluated in large patient groups with predetermined circumstances are needed. Bringing together morphological results with scores based on subjective perception is required to optimize diagnostics and therapy evaluation in proctology.

Durch eine strukturierte Anamnese, die Erfassung von Konsensuskriterien und die klinische Untersuchung lässt sich die überwiegende Zahl proktologischer Erkrankungen diagnostizieren. Zur weiterführenden Diagnostik von Analfisteln sind Endosonographie und Magnetresonanztomographie (MRT) gleichwertige Verfahren. Die MRT bietet Vorteile bei der Darstellung von komplexen Fisteln und Rezidivfisteln. Anorektale Funktionsstörungen sind multifaktoriell und mit Veränderungen im Bereich der Beckenbodenkompartimente vergesellschaftet. Bei der Beckenbodendiagnostik nimmt die MR-Defäkographie eine zentrale Stellung ein. Andere funktionelle diagnostische Methoden und neurophysiologische Untersuchungen treten wegen fehlender Standards und hoher physiologischer Variabilität in den Hintergrund. Zur Objektivierung der vielschichtigen Symptomenkomplexe und der Lebensqualität ist die subjektive Einschätzung des Patienten anhand von Scores notwendig. Problematisch sind die Vielzahl, die unterschiedliche Güte und fehlende Standards bei der Anwendung von Scores. Die Zusammenführung der bildmorphologischen Untersuchungsbefunde mit der in Scores erfassten subjektiven Wahrnehmung ist Voraussetzung für eine Optimierung der Diagnostik und Therapiebewertung in der Proktologie.

Einleitung: Seit Mitte 2008 existiert am Universitätsklinikum Dresden ein Pankreas/Nieren- und Inseltransplantationsprogramm. Als Kooperationsprojekt der Kliniken für Chirurgie, Urologie, Diabetologie und Diabetes-orientierter Forschungslabors bietet das Zentrum damit ein umfassendes therapeutisches Spektrum für die Behandlung von Patienten mit Diabetes mellitus Typ 1 (T1DM) und ermöglicht die direkte Translation wissenschaftlicher Arbeit in die klinische Anwendung.