Futility: ein Begriff im chirurgischen Alltag?

Zusammenfassung: Ethisch anspruchsvolle Indikationsstellungen bei Patienten, die ihren Willen nicht selbst äußern können, wie beispielsweise schwer demenzkranke Patienten, konfrontieren uns häufig. Es stellt sich hierbei die Frage, ob wir mit operativen Eingriffen eine Übertherapie vollziehen. Der Begriff "futility" der Medizinethik beschreibt Übertherapie, ist allerdings für eine konkrete Anwendung problematisch, da eine exakte Definition fehlt. In der klinischen Situation von schwer demenzkranken, hochbetagten Patienten muss in chirurgischen Abteilungen eine Aufarbeitung von medizinischem Hintergrund, Lebensumständen des Patienten und belegtem oder mutmaßlichem Patientenwillen erfolgen mit dem Ziel, Indikationen individualisiert zu stellen. Nur so können diese Patienten optimal versorgt werden, eine klare Kommunikation über Behandlungsziele mit Angehörigen stattfinden sowie eine Vermeidung eines "burn out" bei den Behandelnden erreicht werden. Von großem Nutzen ist hierbei eine enge Zusammenarbeit mit Medizinethiker

Keine gewöhnliche perianale Fistel

Zusammenfassung: Wir präsentieren den Fall eines 63-jährigen Schweizer Staatsbürgers mit chronischer Diarrhö, Schleimabgang ab ano, analer Fistel und chronischem Analulkus bei anamnestisch bekannter Lungentuberkulose vor 56Jahren. Nach Bildgebung wurde klinisch und endoskopisch initial der Verdacht auf eine chronisch entzündliche Darmerkrankung geäußert. Erst eine gezielte Probenentnahme und Untersuchung mittels PCR konnte die Diagnose einer abdominalen Tuberkulose mit perianaler Manifestation sichern. Die differenzialdiagnostische Berücksichtigung der extrapulmonalen Tuberkulose ist wichtig bei der Abklärung chronisch abdomineller Symptome. Eine immunsuppressive Therapie bei ursprünglich vermuteter chronisch entzündlicher Darmerkrankung hätte zu einer Progression mit Gefahr der miliaren Tuberkulose führen könne

Molecular lymph node staging with one-step nucleic acid amplification and its prognostic value for patients with colon cancer: the first follow-up study

Background Molecular lymph node workup with one-step nucleic acid amplification (OSNA) is a validated diagnostic adjunct in breast cancer and also appealing for colon cancer (CC) staging. This study, for the first time, evaluates the prognostic value of OSNA in CC. Patients and methods The retrospective study includes patients with stage I-III CC from three centres. Lymph nodes were investigated with haematoxylin and eosin (H&E) and with OSNA, applying a 250 copies/mu L threshold of CK19 mRNA. Diagnostic value of H&E and OSNA was assessed by survival analysis, sensitivity, specificity and time-dependent receiver operating characteristic curves. Results Eighty-seven patients were included [mean follow-up 53.4 months (+/- 24.9)]. Disease recurrence occurred in 16.1% after 19.8 months (+/- 12.3). Staging with H&E independently predicted worse cancer-specific survival in multivariate analysis (HR = 10.77, 95% CI 1.07-108.7, p = 0.019) but not OSNA (HR = 3.08, 95% CI 0.26-36.07, p = 0.197). With cancer-specific death or recurrence as gold standard, H&E sensitivity was 46.7% (95% CI 21.3-73.4%) and specificity 84.7% (95% CI 74.3-92.1%). OSNA sensitivity and specificity were 60.0% (95% CI 32.3-83.7%) and 75.0% (95% CI 63.4-84.5%), respectively. Conclusions In patients with CC, OSNA does not add relevant prognostic value to conventional H&E contrasting findings in other cancers. Further studies should assess lower thresholds for OSNA (< 250 copies/mu L).Surgical oncolog

Molecular investigation of lymph nodes in colon cancer patients using one-step nucleic acid amplification (OSNA): a new road to better staging?

BACKGROUND: A new diagnostic system, called one-step nucleic acid amplification (OSNA), has recently been designed to detect cytokeratin 19 mRNA as a surrogate for lymph node metastases. The objective of this prospective investigation was to compare the performance of OSNA with both standard hematoxylin and eosin (H&amp;E) analysis and intensive histopathology in the detection of colon cancer lymph node metastases. METHODS: In total, 313 lymph nodes from 22 consecutive patients with stage I, II, and III colon cancer were assessed. Half of each lymph node was analyzed initially by H&amp;E followed by an intensive histologic workup (5 levels of H&amp;E and immunohistochemistry analyses, the gold standard for the assessment of sensitivity/specificity of OSNA), and the other half was analyzed using OSNA. RESULTS: OSNA was more sensitive in detecting small lymph node tumor infiltrates compared with H&amp;E (11 results were OSNA positive/H&amp;E negative). Compared with intensive histopathology, OSNA had 94.5% sensitivity, 97.6% specificity, and a concordance rate of 97.1%. OSNA resulted in an upstaging of 2 of 13 patients (15.3%) with lymph node-negative colon cancer after standard H&amp;E examination. CONCLUSIONS: OSNA appeared to be a powerful and promising molecular tool for the detection of lymph node metastases in patients with colon cancer. OSNA had similar performance in the detection of lymph node metastases compared with intensive histopathologic investigations and appeared to be superior to standard histology with H&amp;E. Most important, the authors concluded that OSNA may lead to a potential upstaging of &gt;15% of patients with colon cancer

Molecular Lymph Node Staging with One-Step Nucleic Acid Amplification and its Prognostic Value for Patients with Colon Cancer: The First Follow-up Study.

Molecular lymph node workup with one-step nucleic acid amplification (OSNA) is a validated diagnostic adjunct in breast cancer and also appealing for colon cancer (CC) staging. This study, for the first time, evaluates the prognostic value of OSNA in CC. The retrospective study includes patients with stage I-III CC from three centres. Lymph nodes were investigated with haematoxylin and eosin (H&amp;E) and with OSNA, applying a 250 copies/μL threshold of CK19 mRNA. Diagnostic value of H&amp;E and OSNA was assessed by survival analysis, sensitivity, specificity and time-dependent receiver operating characteristic curves. Eighty-seven patients were included [mean follow-up 53.4 months (± 24.9)]. Disease recurrence occurred in 16.1% after 19.8 months (± 12.3). Staging with H&amp;E independently predicted worse cancer-specific survival in multivariate analysis (HR = 10.77, 95% CI 1.07-108.7, p = 0.019) but not OSNA (HR = 3.08, 95% CI 0.26-36.07, p = 0.197). With cancer-specific death or recurrence as gold standard, H&amp;E sensitivity was 46.7% (95% CI 21.3-73.4%) and specificity 84.7% (95% CI 74.3-92.1%). OSNA sensitivity and specificity were 60.0% (95% CI 32.3-83.7%) and 75.0% (95% CI 63.4-84.5%), respectively. In patients with CC, OSNA does not add relevant prognostic value to conventional H&amp;E contrasting findings in other cancers. Further studies should assess lower thresholds for OSNA (&lt; 250 copies/μL)

[No ordinary anal fistula...]

We present the case of a 63 year-old male Swiss patient with chronic diarrhea, mucous anal discharge, anal fistula, chronic anal ulceration and history of tuberculosis 56 years ago. Imaging and endoscopy was highly suspicious for Crohn's Disease, but histology and culture for M. tuberculosis proved tuberculous proctitis with perianal involvement and fistulation. The consideration of extrapulmonal tuberculosis with its various manifestations is crucial for the investigation of chronic abdominal complaints in order to avoid serious consequences of tuberculosis treated with immunosuppressive therapy