Aims: The results of surgical treatment of locally advanced rectal cancer with special regard to multivisceral resections and preoperative radiotherapy should be analyzed. Methods: From 10/86 until 12/95, 40 patients with preoperatively assessed T4 stage rectal cancer were treated in our department whose data were evaluated retrospectively. Results: Apart from 10 nonresecting procedures we performed 30 resections in which the mortality rate was 7%. In 50% of these patients a multivisceral resection was conducted. A R0 situation could be achieved in 70%. But only in 53% the operation was carried out with curative approach due to distant metastasis. After extended resections more frequent urological complications resulted in prolonged hospitalization. Survival time was markedly longer in patients without tumor residuals or metastasis. Following preoperative radiotherapy a higher number in tumor free patients and better prognosis was noticed. Conclusions: In accordance to the literature it is suggested to submit patients with T4-stage rectal cancer to preoperative radiation to improve the overall outcome.

From 1988 to 1996 we performed 18 total pelvic exenterations in patients with an average age of 59.8 years who could be followed up for a mean 29.8 months. In 10 cases a recurrent tumor of the pelvic viscera and 7 times a primary carcinoma of the rectum, bladder or prostate were treated. In 1 patient a radiogenic fistula led to this operation. Intestinal continuity could be reconstructed in 7 cases. Following cystectomy, urinary diversion was accomplished in half of the cases by an ileal conduit. Due to septic multiorgan failure 2 patients died postoperatively (hospital mortality rate 11%). In 82% a complete resection (R0) was possible. Subsequently 5 patients (29%) developed tumor recurrence. Distant metastases were observed in 3 patients, 8-9 months after surgery. So far 10 further patients have died. Their mean survival time was 28.9 months (range 5-99 months). The remaining 6 patients are still alive between 22 and 36 months postoperatively. Despite the extent of this kind of major surgery, which also requires multidisciplinary cooperation, and the psychosocial problems resulting from two permanent stomas, total pelvic exenteration should be regarded as an adequate alternative in the treatment plan in selected patients with locally advanced or recurrent pelvic disease.

From January 1977 to July 1997, 16 patients with aorto/iliac-enteric fistulas underwent repair. The fistula became apparent at a mean of 51 months. Gastrointestinal bleeding was the main symptom in 11 cases, 4 patients had a cutaneous fistula, and 1 developed retroperitoneal bleeding. The preoperative diagnosis was established in one-half of the cases. Three patients had to be treated surgically on an emergency basis without a preoperative diagnosis because of bleeding, 7 patients were semi-urgent and 6 had elective surgery. In 3 cases treatment consisted only of local repair. In 6 patients we performed extra-anatomic revascularization and in 7 patients we achieved restoration by in situ replacement after removal of all infected prosthetic material. Eight of 16 patients survived the perioperative period. Local repair alone cannot be recommended. All 3 patients died. The mortality rates between extra-anatomic revascularization and in situ reconstruction are comparable.

The project shows that such a program can be systematically developed and pilot studies can be carried out. The central problems in implementation involve the traditional informal further education culture, which as a rule does not implement a systematic elicitation of the state of learning continuously distributed over the whole period of further education and the practical testing of competence development.

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