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Background: The oncological outcome of patients with rectal cancer has improved considerably over the past few decades. This is mainly due to the introduction of the surgical concept of total mesorectal excision (TME) and the implementation of multimodal treatment strategies. Additionally, it has recently been demonstrated that the oncological results of open and laparoscopic TME are comparable. For some time there has been an ongoing debate on the potential relevance of robotic assistance systems in visceral surgery. The aim of this study was to evaluate the operative and perioperative outcomes of patients with rectal or rectosigmoid cancer, who were operated on using the Da Vinci Surgical System., Patients and Results: We retrospectively analysed the outcomes of 202 consecutive patients, who were operated between September 2010 and November 2015 in three Surgical Centers. The cohort consisted of 136 men and 66 women with a mean BMI of 28. We performed the following procedures: 49 anterior rectal resections, 119 low anterior rectal resections, and 34 abdominoperineal excisions. Conversion to an open procedure was required in 13 patients. Non-surgical complications (n = 27) occurred in 24 patients (12%) and surgical complications (n = 67) in 62 patients (31%). Most complications were due to abdominal or sacral wound infections (n = 25) and anastomotic leaks (n = 18). The mortality rate within 30 days was 2%. The rate of R0 resections was 95%, with circumferential resection margins being negative in 98% of the patients. The quality of the mesorectal resection was scored as good in 91% of the patients., Conclusions: The Da Vinci Surgical System can be used safely and with a low complication rate for surgical treatment of rectal cancer. While primary evidence suggests that the outcome of robotic-assisted surgery is comparable with open and laparoscopic surgery, its definitive value has to be determined upon publication of the prospective randomized ROLARR trial. The main advantages of the Da Vinci system are its endowristed instruments with multiple degrees of freedom and its optimised visualisation (3D, stable camera platform controlled by the surgeon). Another positive feature is the significant ergonomic advantage for the surgeon., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Adenocarcinomas of the oesophagogastric junction are increasingly being considered as a separated tumour entity. The prognosis is rather poorer compared with that for distal gastric cancer. Data from a multicentre study as part of research on clinical care aim to reflect the current situation in surgical treatment after inauguration of neoadjuvant modalities., Patients and Method: As part of the ongoing prospective multicentre observational study QCGC 2 (German Gastric Cancer Study 2), 544 adenocarcinomas of the oesophagogastric junction (AEG 1-3) were registered from 01/01/2007 to 12/31/2009., Results: Patients underwent surgical intervention in 108 (76.6 %) of the 141 surgical departments which provided data to the study. In 391 patients (82.5 %), R0 resection was achieved. Almost 60 % of the carcinomas of the oesophagogastric junction were approached in departments with no more than 10 of these tumour lesions through the whole study period (3 years). Endoscopic ultrasonography was performed in 283 cases (53 %); the rate of neoadjuvant treatment was 34.4 % (n = 187). Intraoperative fresh frozen section was only included in intraoperative decision-making in 242 patients (60.8 %). In the revealed heterogeneous spectrum of surgical interventions, a limited number of transthoracic approaches (20 %) and a mediastinal lymphadenectomy rate of only 47 % were found. Hospital lethality was 6.6 %. In the adenocarcinomas of the oesophagogastric junction, a significantly lower median survival (25 months) compared with distal gastric cancer (38 months) was observed depending on the tumour stage. In addition, 5-year survival rate of AEG patients (33.1 %) was distinctly lower than for patients with distal gastric cancer (41.4 %). There was no significantly better survival by neoadjuvant treatment in the group of investigated patients., Conclusion: The results in the treatment of carcinomas of the oesophagogastric junction in the multicentre setting including surgical departments of each profile and region even after introduction of multimodal therapeutic concepts are not satisfying. In particular, modern diagnostic and surgical strategies need to be widely used or their percentage has to be increased. In this context, centralisation of the surgical care of this specific tumour entity appears reasonable., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Resection is currently the only established reasonable therapeutic option with curative potential in pancreatic and ampullary carcinoma. The aim of the study was i) to analyze value and results of surgical therapy and ii) to detect the prognostic parameters, which determine significantly higher survival rates., Methods: Two-hundred-twenty patients with pancreatic and ampullary carcinoma (mean age, 61.4 years; 104 females/116 males) underwent surgery. Histologic investigation revealed 19 carcinomas of the papilla of Vater and 201 ductal pancreatic carcinomas. In 126 patients, stage IV a or b tumors were found, in addition, stage I (n =26), II (n = 17) and III (n = 51). Survival-rate was determined according to the method by Kaplan/Meier. Survival was compared using log-rank test. Association of several or multiple parameters with survival was tested using Cox model., Results: Hundred-ten patients underwent tumor resection with primary curative intention (50 %): 96 resections of the pancreatic head, 2 total pancreatectomies and 12 left resections of the pancreas. R0-resection was achieved in 94 patients (42.7 %), whereas intervention was classified R1 in 10 and R2 in 6 cases. In addition, 60 palliative interventions (28 gastroenterostomies, 17 biliodigestive anastomoses, 15 anastomoses at both sites) and 50 explorative laparotomies were performed. In 42.3 % of patients, postoperative complications were found, but only 12/220 individuals died (overall letality, 5.4 %). Postoperative letality of curative pancreatic resections was 3.6 % (palliative intervention, 6.7 %; explorative laparotomy, 8.8 %). Five-year survival-rate of carcinoma of the papilla of Vater and pancreatic carcinoma was 73.3 % and 16.2 %, respectively (median survival time was 66.0 and 14.0 months, respectively). Taken together all other interventions, median survival time ranged between 4.0 (palliative intervention) to 10.0 months (R1-resection). No patient survived 5 years. Therefore, the most relevant prognostic factor was R0-resection. In addition, prognosis after successful R0-resection is determined significantly by tumor site, stage of the tumor (according to UICC), T- and N-category., Conclusion: Resection of pancreatic and ampullary carcinoma according to oncological criteria with tumor-free margins can be considered a treatment option with curative intention and potential. Despite relative high postoperative morbidity, only a low mortality rate was observed. The 5-year survival-rate of 16.2 % in ductal pancreatic carcinoma underlines the demand for the development of effective multimodal therapeutic concepts. Interventions with primary palliative intention or resections with microscopically or macroscopically detectable tumor residual in situ lead to no significant or only marginal prolongation of survival time. Such interventions in patients with pancreatic carcinoma are no reasonable treatment alternative. They are of value only for treatment of tumor-associated complications and problems.

High local recurrence rates within the previous tumor bed or at the peritoneum remain an unsolved problem after surgical resection of malignant gastrointestinal tumors such as gastric, colorectal or pancreatic carcinoma. Currently, there are no standardized treatment protocols available for the prevention or treatment of peritoneal carcinomatosis. In a basic experimental trial, mitomycin, cisplatin, 5-FU, oxaliplatin and CPT-11 were used to prevent or treat peritoneal carcinomatosis induced in rats. Experiments were performed in three groups (n = 8 each) of animals plus two control groups. In the first group, Mitomycin, Cisplatin, 5-FU, Oxaliplatin and CPT-11 (n = 24 each) were applied directly following tumor cell implantation into the peritoneal cavity. In the second group, early postoperative intraperitoneal (i. p.) chemotherapy (day [d] 5, 10, 15 following surgical intervention for tumor cell transfer) was administered, whereas in the third group, late i. p. chemotherapy (d 15, 20, 25 following surgery) was given via a port-a-cath aiming for significant reduction of a visible, already established peritoneal carcinomatosis. Mitomycin and cisplatin were highly effective to prevent peritoneal carcinomatosis (direct application immediately after tumor cell transfer - 1 (st) treatment group). Using early postoperative i. p. chemotherapy (2 (nd) group), 5-FU and CPT-11 were shown to be significantly effective to reduce the intraperitoneal tumor spread. None of the cytostatic agents was able to decrease significantly an already generated peritoneal carcinomatosis (3 (rd) treatment group). The results suggest that novel chemotherapeutic drugs should be proven for their potential to alter peritoneal metastases of GI tumors i) in comparison with established drugs and ii) depending on the application time and mode.

Purpose: Since there are currently no data available from a prospective trial, the primary objective of this prospective study was to investigate whether the rate of R0-liver resections without morbidity would be at least 50 % in patients with neoadjuvant chemotherapy for colorectal liver metastases., Patients and Methods: 42 patients were treated with a biweekly FOLFOX regimen. Chemotherapy consisted of a 2-hour infusion of folinic acid (FOL) 500 mg/m2, followed by a 24-hour infusion of 5- fluorouracil (F) 2000 mg/m2 daily for two days. Oxaliplatin (OX) 85 mg/m 2 was given simultaneously with FOL. Treatment allocation was randomized with either 3 or 6 cycles for the final 30 patients. A liver resection was performed 2 to 5 weeks after the final infusion., Results: An objective response was observed in 20 of 42 patients (response rate was 27 % higher after 6 cycles). Liver resection (R0) could be performed in 34 patients. Postoperative complications were reported in 14 patients (13 occurring within 30 days after resection) and severe complications in 5 cases (including two deaths after extended resection). Liver failure and persistent biliary fistula were the most frequently documented complications. There was no relevant difference in safety criteria between 3 and 6 applications., Conclusion: The use of neoadjuvant chemotherapy in resectable liver metastases induced significant remissions without increasing morbidity. The rate of severe complications and cases of no R0-resection in this study was 31 % and was with that significantly lower than 50 % (95 % CI 17.6 %-47.1 %). The risk to the patient is therefore acceptable when undergoing neoadjuvant treatment in a prospective intergroup trial.

Introduction: We report our results of laparoscopic anterior transperitoneal adrenalectomy., Patients: Between 4/1996 to 05/2001, a laparoscopic adrenalectomy was performed in 34 patients (median age 48 years). The adrenalectomy was performed transperitoneally (31 unilateral; 3 bilateral). The adrenaline level was measured in 7 patients with a pheochromocytoma., Results: All tumors (mean size 3.5 cm; 0.4 to 8.0 cm) could be extirpated by laparoscopy. 9 pheochromocytomas; 9 cortisol producing tumors (one patient with a Carney's syndrome); 7 Conn's adenomas and 9 incidentalomas constituted these tumors. In the first third of the observation period, the surgery lasted 176 (95-270) minutes, in the last third 82 (50-130) minutes (p < 0,01). We postoperatively observed the following complications: one abdominal wall hematoma at a port-site and one edematous pancreatitis after alteration of the pancreatic tail. The adrenaline level continually rose from the beginning of surgery to the ligature of the suprarenal vein., Conclusion: Transperitoneal adrenalectomy in benign tumors (< 8 cm) is our method of choice. The resulting learning curve allowed the performance of adrenalectomy within an acceptable operative time and without significant blood loss. The transperitoneal technique is safe and well reproducible. The cosmetical results are convincing. We recommend an early ligature of the suprarenal vein in a pheochromocytoma.

We report a case of a 56-year-old patient with an acute upper gastrointestinal bleeding following penetration of an aneurysm of the gastroduodenal artery in the duodenal bulb. The patient received an i.a. portsystem five month before the reported acute gastrointestinal bleeding. The portsystem was implanted for treatment of multiple liver metastases of an neuroendocrine tumor. This life-threatening situation could not controlled endoscopically. Also an embolisation was impossible so we carried out a laparotomy with ligation of the proper hepatic artery. The postoperative course was uneventful. Due to her tumor disease the patient died 13 month after surgery.

Patients with gastric cancer have a poor prognosis. Only in early tumorstadium a tumor-free-resection is possible. Because curative surgery is often impossible or extremely difficult and the majority of patients undergoing curative resection relapse. To improve this situation adjuvant and neoadjuvant concepts necessary to check. Current adjuvant therapy regimes have a marginal importance. Only nodal positive patients (T3N2M0) may profit from an adjuvant therapy. Neoadjuvant concepts seem to be very effective. The activity is proving in two current studies. Several combination chemotherapy regimens have been developed with activity in locally advanced and metastatic disease. But only an overall survival in median of about 11 month could be reached and a standard protocol not exists. Therefore many studies are initiated. In the follow article three study concepts with new substances especially with Taxanes and with CPT-11 having a great potential to improve the prognosis of patients with advanced gastric cancer are explained.

Recommendations for adjuvant treatment of patients with breast cancer are given based on the International Consensus panel of adjuvant Therapy of Breast Cancer in St. Gallen in 1998. Possible therapeutical options (antihormonal therapy, chemotherapy with CMF or EC/AC) are discussed in dependence on the risc of recurrence. Problems of individual therapeutical strategies are discussed additionally.

The obstruction of the hepatic venous outflow tract with or without involvement of the inferior vena cava results in the Budd-Chiari syndrome (BCS). With its very heterogenous etiology and variable epidemiology the rare disease either takes a chronic or an acute foudroyant clinical course. In general the prognosis is poor. Together with the clinical signs the diagnosis is based on radiological measures and the histology of the hepatic parenchyma. The exact etiological investigation of the BCS is of great significance. Typical findings are discussed and a diagnostic scheme is developed. Between 1979 and 1991, altogether 16 operations were carried out in 13 patients with a BCS. Predominantly there were undertaken a porto-systemic shunt procedure or an orthotopic liver transplantation, respectively, in 6 cases each. The need for an always individually tailored therapeutic strategy of the BCS is underlined by a case history. An overview analyzes the different therapeutic modalities of the BCS and their differential indications.

31 patients with congenital ectasias of extra- and intrahepatic bile ducts have been diagnosed and treated between 1980 and 1991 at the Charité. 7 ectasias belonged to type I, two to type II, three to type III, four to type IV and fifteen to type V of classification by Alonso-Lej/Todani. The age of affection was between 8 and 80 years. Symptoms are not specified and directed to affection of liver or bile ducts. Main symptoms of type I--III were complaints in the upper abdomen and jaundice, of type IV--especially after previous surgery--fever and also jaundice. Complaints in the upper abdomen and fever dominated in type V. The right diagnosis succeeds at 27 out of 31 patients with direct cholangiography. Sonography and computerized tomography were not always in a position to attach the clinical picture to congenital ectasias. In extrahepatic ectasias is the resection of bile duct cysts--carried out in 2/3 of all cases--the therapy of choice. Once was found a carcinoma in a resected bile duct cyst 23 years after a choledochocysto-jejunostomy. By Caroli syndrome the therapy must be fixed individually. 6 patients were supplied operative (liver resection, choledochotomy, papillotomy, extraction of lithiasis). Instrumentally were carried out 9 endoscopic papillotomies with extraction of concrements and 6 lay ins of internal drainage catheters were done.

The etiology of choledochal cysts isn't yet clarified unequivocably. Numerous theories have been worked out. One of them is the 1969 by Babbitt postulated "common-channel"-theory, which is based on an anomaly of the pancreaticobiliary connection. In case of a fusion of ductus choledochus and ductus pancreaticus widely before the papilla of Vater and the formation of a common channel with a minimum length of 15 mm the reflux of pancreatic secretion into the off-leading biliary ducts may occur and choledochal cysts may develop. In order to check up this hypothesis we evaluated retrospectively pictures of a direct cholangiography (ERCP, PTC and/or intraoperative cholangiography) of 26 patients suffering from type I, IV and V ectasias of the biliary ducts according to Todani. We found a common channel with an abnormal length in 8 of 12 patients suffering from extrahepatic ectasias of the biliary duct type I and IV (66%), but we didn't find it in patients with type V intrahepatic ectasias of the biliary duct. This analysis may be recognized as a reference to the truth of the Babbitt-theory.

Seventy-nine patients with extrahepatic malignant cholangiocarcinomas were treated at the Surgical Clinic of the Charité from 1981 to 1989. Thirty-two of these patients suffered from Klatskin tumour. Exact preoperative staging includes sonography, CT scan, cholangiography (PTC or ERCP). Angiography can help to clear the diagnoses. Sixteen patients were considered inoperable. The therapy was surgical bypass, surgically or percutaneously placed catheters and endoscopically placed endoprostheses, a median survival time was 2 to 6 months. The other 16 patients underwent 12 resections and four liver transplantations. Two of these transplanted patients are still tumour-free, their survival times ranging from 2 to 6 years. The median survival time of the patients undergoing resection amounts to 22 months and operation mortality, 12%. Optimal treatment strategies by the Klatskin tumours is the radical resection.

Locoregional chemotherapy was applied to 30 patients for isolated, surgically not removable liver tumours (13 colorectal carcinomas, 17 carcinomas on different sites). Ten patients were in Stage I, 16 in Stage II, and four in Stage III. Cytostatics were administered through totally implantable catheter systems. The following therapeutic protocol was mainly used: 5-flourouracil 800-1,000 mg/m2/3hr/die X 5 in 22 days, adriamycin 30 mg/m2/3 hr/die X 2 in 22 days. The average time of treatment amounted to ten months. Cytotoxis side effects were of minor importance. Hepatic side effects, such as chemical hepatitis or sclerosing cholangitis, were not recordable. Reduction of tumour size by 50 percent or more was recorded by computed tomography from 14 cases (46.6 percent). The objectivated rate of responsiveness in patients with colorectal carcinoma was 61.5 percent. The average period up to progression amounted to 12.1 months. Premortal spreading of the disease beyond the liver was recorded from six patients.