Activities

Standard procedures which are performed routinely in the Department of Surgery of Martha-Maria Hospital are used to treat diseases of the

Oesophagus     

Cervical oesophageal diverticula, so-called Zenker`s diverticula, almost always require surgical therapy since they cause a variety of symptoms such as obstructed passage during swallowing (dysphagia), reflux of undigested chyme into the mouth (regurgitation), a feeling of pressure and tightness in the cervical region, or impulse coughing because of the transfer of chyme into the trachea (aspiration).  Depending on the size of the diverticle, on age and on accompanying diseases we offer different surgical procedures:

Diverticles in the lower portion of the oesophagus are much rarer. They may, if they bother the patient at all, be resected via endoscopy of the thorax (thorcoscopy). This is a minimally invasive procedure which does not require large incisions or an opening of the thoracic cavity. The same procedure is used to treat other rare and benign tumors of the oesophageal wall musculature (leiomyoma) if they have narrowed the oesophagus or exceeded a certain size (danger of malignant degeneration).

Diaphragm     

The most common diaphragmatic hernias (axial hernias) are harmless and will only require surgical therapy if they cause complaints. These hernias are mostly sliding hiatal hernias. In such cases the entrance of the stomach may slide axially up above into the chest and along the enlarged passage through the diaphragm (hiatus). Sliding commonly depends on the position of the body. Surgery is indicated in symptomatic patients If there is a simultaneous malfunction of the stomach entrance (cardia insufficiency), if this insufficiency causes heartburn (reflux of gastric juice into the oesophagus), and if drug treatment did not succeed in treating this reflux disease.  During surgery for reflux disease one will also repair the axial diaphragmatic hernia.

Certain types of diaphragmatic hernias such as paraoesophageal hernias will always require surgery. Surgery is mandatory if parts of the stomach or almost the complete stomach slide up above into the chest next to the entrance of the oesophagus into the abdominal cavity (upside-down stomach or thoracic stomach). Such cases are at risk of partial incarceration of the stomach (emergency case) or may develop ulcers and chronic bleeding. Often these hernias cause complaints such as chest pain, regurgitation or cardiac pain which are initially and falsely attributed to other reasons. To treat paraoesophageal hernias we  perform minimally invasive procedures via laparoscopy if there are no contra-indications. To do so we relocate again the stomach completely into the abdominal cavity and we attach the stomach to the diaphragm via sutures. Simultaneously, we are narrowing the site of passage (hiatus) at the diaphragm with a few sutures. The endoscopic procedure corresponds to the open surgical procedure (using an abdominal incision).

Stomach     

Fortunately, the frequency of surgical procedures at the stomach was declining significantly over the last 20 years in all hospitals across the world and also in our institution. This decline mostly results from progress in drug treatment of gastric ulcers and in identification of bacteria causing these ulcers.

Today, we regularly perform gastric surgery only for ulcers resistant to therapy, thus in benign tumors which do not respond to any type of non-surgical therapy, and obviously for malignant tumors of the stomach. It completely depends on the disease whether we have to remove a small portion of the stomach, four quarters of the stomach, the whole stomach, or the whole stomach with a small portion of the lower oesophagus.

Certain types of gastric cancer (gastric carcinoma) require a preoperative chemotherapy (neoadjuvant chemotherapy being part of a multimodal therapeutic concept).  Such carcinoma are those which have already invaded the whole gastric wall and neighbouring lymph nodes, but not distant organs (no remote metastases). 

Treatment of malignant gastric carcinoma always requires removal of neighbouring lymph nodes to proof or to exclude tumor affection. Advanced gastric carcinoma metastasising into other organs are exclusively treated by chemotherapy. However, removal of the tumor may still be indicated if it obstructs the passage of food (stenosis) or causes life-threatening bleeding. This type of removal will no longer be curative (intended to heal the patient), but will be palliative (to improve the quality of life). The so-called bypass procedures answer the same purpose. They change the passage by bypassing the affected bowel segment in those situations where stomach or parts of the intestines are tumor-affected but can no longer by removed surgically. Thereby, the patient may eat or drink again (or at least, permanent vomiting due to intestinal obstruction is prevented). 

Also, we place feeding tubes into the stomach or the small bowel either from the inside (an endoscopic procedure named percutaneous endoscopic gastrostomy = PEG) or via abdominal endoscopy (laparoscopic procedure) or via open surgery (using an abdominal incision).

If a patient requires frequent infusions to support nutrient supply or to allow a chemotherapy, he will have a so-called port implantation. A closed chamber which one may puncture without pain with a needle, is implanted subcutaneously. From this chamber a catheter leads to a large vessel (vein), and this catheter will allow  feeding or drug administration without problems. This small procedure can usually be done using local anaesthesia (also in out-patients). Obviously, this device can be removed again under local anaesthesia if no longer needed.

Small bowel     

Planned surgical procedures at the small bowel are comparably rare and are mostly performed for inflammatory diseases. Complaints resembling those of an appendicitis may be caused by Meckel`s diverticle which is a protuberance of the small bowel wall with a length of two to 15 centimeters and which is located 40 to 120 centimeters upstream to the junction of the small and large bowel. Meckel`s diverticle should be always removed, even if it is discovered only by chance. 

Benign and malignant tumors of the small bowel are very rare and are treated by resection of the tumor-bearing bowel segment. Resection of an appropriate, unaffected portion (safety margin) is mandatory.

After open abdominal surgery (laparotomy) but also after minimally invasive endoscopy (laparoscopy) adhesions may be formed in the abdomen. These adhesions may cause recurrent pain, vomiting and finally bowel obstruction (ileus). A so-called adhesiolysis (removal of adhesions) will only be performed, if all other potential reasons for the complaints have been excluded, and if the patient is suffering significantly. Adhesiolysis should alleviate the complaints as much as possible, but even after such a procedure new adhesions may arise and cause the same complaints as before.

Large bowel     

Surgery for large bowel diseases is part of standard patient care also in our hospital. In benign diseases such as sigma diverticulitis (inflammation of  protuberances in the distant large bowel wall) and large bowel polyps (benign tumors) we offer minimally invasive surgical techniques. They include laparoscopic sigma resection (using endoscopy) and a combination of laparoscopy and simultaneous endoscopy (in the inside of the bowel) to remove benign polyps (adenoma). This combination is necessary, if one cannot remove polyps from the inside of the bowel via colonoscopy because of their size and/or location, and if a large open surgical procedure (using an abdominal incision) is to be avoided. 

To remove large polyps of the rectum we use general anaesthesia and we employ special instruments (ultracision) to remove the affected mucosa  through a transanal access (mucosectomy). 

To treat hemorrhoid diseases we offer the complete array of classic surgical techniques. Stapler-assisted hemorrhoidectomy according to Longo (circular removal of rectal mucosa with a special device for bracket sutures) will be only applied if convincing long-term results support the success of this procedure. 

Unfortunately, the frequency of malignant large bowel tumors is rising. Fortunately, examinations for early diagnosis help the patients more frequently to be diagnosed with less advanced stages of their disease. Thereby, the chances for cure are improved when these patients undergo surgery. Also awareness from molecular genetics in family accumulated colorectal carcinoma allows a definition of risk groups (patients who are highly likely to develop a malignant tumor of the large bowel). These patients can be assigned to corresponding programs for early diagnosis.

Minimally invasive surgical techniques are not established yet for treatment of malignant large bowel tumors. Because of the high frequency of these tumors surgical methods are very standardized and can be performed with a corresponding degree of routine. Certain parts of the colorectum are removed together with the tumor and adjacent lymph nodes. The extent of bowel removal does not only depend on the tumor itself but to a high degree also from the vascular supply of the bowel. The majority of malignant tumors are located closely to the anus in the rectum and sigma. In such case an artificial anus is usually not necessary. Only if the tumor affects the anal sphincter, one has to remove the complete rectum and to construct a new artificial anus (anus praeter). Today, the maintenance possibilities of an artificial anus are so fully developed that nobody will notice it at you. Also bathing in swimming pools is possible.

Inflammatory bowel disease (Crohn`s disease, ulcerating colitis)     

Crohn`s disease is a disease of the adolescent and of the juvenile adult, and is related to ulcerating colitis. A primary symptom of both diseases is diffuse diarrhea, but further problems and complications may appear.

Crohn`s disease may principally affect the whole gastrointestinal tract. Surgery is always indicated if complications such as fistulas, abscesses or bowel constrictions (with or without bowel obstruction) develop, and if these complications can no longer be treated conservatively (by medication or drugs).

Ulcerating colitis is an exclusive disease of the large bowel and can usually be treated conservatively without surgery. Surgery is indicated if the disease exists over a prolonged period of time and if there are problems and difficulties with medical therapy. If the disease is associated with recurrent episodes and if symptoms persist over several years, a surgical therapy should be considered. Surgery usually includes removal of the whole large bowel thereby eliminating symptoms in almost all patients.

Pancreatic disease     

In our institution we regularly perform surgical procedures also for pancreatic diseases. Usually, these diseases result from pancreatic tumors.  Among those, endocrine tumors of the pancreatic gland prevail. These tumors produce certain hormones and have to be removed for that reason. The type of surgery varies with the location of the tumor which may frequently be removed by comparably small surgical procedures.

In contrast, malignant tumors of the pancreas represent a big problem which often requires comparably large surgical procedures. If the tumor is located in the head of the pancreas, one has to remove this portion of the pancreas together with the duodenum, a portion of the stomach, parts of the bile duct, and the gall bladder (Whipple`s procedure).

If the tumor is located in the tail of the pancreas, on has to do a so-called left-sided, distal resection of the pancreas, usually combined with a removal of the spleen.

Also inflammations of the pancreas may require surgery. The type of surgery also depends on the nature and localisation of the inflammatory process. Usually, there is an inflammatory enlargement of the pancreatic head. This affection is associated with a dilated pancreatic duct which, in addition, often contains stones. Patients commonly present with very strong pain which may frequently not be controlled by appropriate pain therapy. In such case, several different surgical procedures are available, ranging from a partial removal of the pancreatic gland to so-called drainage procedures.

A frequent consequence of acute pancreatitis are so-called pancreatic pseudo-cysts. These are cysts of variable size which contain fluid and originate from the pancreatic gland. These cysts may cause chronic complaints per themselves, but may also increase their size. With the latter, separate symptoms may arise from pressure on neighbouring organs. In such cases one should drain these cysts into the bowel or the stomach using special surgical procedures. Subsequently, relief of complaints will mostly be complete.

Gastrointestinal endoscopy     

The Department of Surgery of Martha-Maria Hospital regularly performs procedures for diseases of the oesophagus, stomach, small bowel, large bowel, and rectum. Our institution disposes of a surgical endoscopy unit which not only allows a surgically relevant, goal-oriented diagnosis before surgery, but also provides for a corresponding experience in treating problems (complications) conservatively (non-operatively) after surgery. Furthermore, we may perform simultaneous endoscopy during surgery for gastrointestinal diseases. Thereby, we may e.g. identify the source of gastric or intestinal bleeding, or localize small tumors of the mucosa (adenoma, polyps) for minimally invasive, laparoscopic removal which is then possible.

Contact

	0049-(0)89-7276-224
	0049-(0)89-7276-233
	chirurgie.muenchen@martha-maria.de
	Krankenhaus Martha-Maria München Chirurgische Klinik Wolfratshauser Straße 109 D-81479 München Germany