The oesophagus has a length of approx. 25 cm and is used to transport food from the oral cavity into the stomach. There are three parts: the neck part, the thoracic part and the abdominal part. An upper and a lower closure mechanism (sphincter) act like a valve to prevent the chyme from flowing back. If the function of the lower oesophageal sphincter is impaired, the clinical picture of heartburn (reflux disease) develops. There is an anatomical proximity to the trachea and the aorta in the chest area.
Malignant oesophageal tumours (oesophageal carcinoma)
These are caused either by excessive alcohol consumption, smoking, long-standing reflux disease, chemical burns or previously unknown causes. The tumours do not show any early symptoms. Difficulty swallowing only occurs when the narrowing of the oesophagus exceeds 50 %. Appropriate environmental examinations (staging) are used to determine the stage of the disease. If the patient is in a good general condition and there are no metastases, surgery will be sought. This may be preceded by pre-treatment with radiotherapy and/or chemotherapy.
During the operation, the oesophagus is removed via an abdominal and a thoracic incision together with the tumour-bearing part and the lymph vessels. The food passage is restored by forming a stomach tube. As this operation is usually performed as a so-called two-cavity procedure, it is a major operation. An exact risk assessment must be carried out beforehand. The stay is approx. 3 weeks.
If major surgery is not appropriate, a number of alternative procedures are available, such as the endoscopic insertion of a feeding tube (PEG), the insertion of a prosthesis (stent) and the insertion of a port access system to initiate combined chemo-radiotherapy.
Stomach
The stomach mixes the chyme arriving from the oesophagus, stores it and releases it via the pylorus into the duodenum, where pancreatic juice and bile are supplied. The stomach produces gastric juice containing hydrochloric acid (gastric acid), which pre-digests the food. It also produces gastric mucus to protect its own mucous membrane. The stomach is located in the upper abdomen below the diaphragm. Symptoms of stomach diseases include food intolerance, loss of appetite, weight loss, a feeling of pressure and fullness as well as belching, vomiting and the passing of black-coloured stools (tarry stools). Diseases of the stomach are diagnosed by gastroscopy and duodenoscopy. This allows samples to be taken. If an endoscopy is not possible and only the inner lining of the stomach needs to be visualised, this can be done using X-ray contrast medium.
If an image of the entire stomach wall and the other abdominal organs is also required, this can be done using computer tomography. The most important gastric diseases are gastric ulcers, gastric haemorrhage and malignant gastric tumours (gastric carcinoma).
Malignant stomach tumour
The stomach is located in the middle and left upper abdomen. Due to the central location of the organ, both the blood supply and the drainage of lymph are very complex. There are close connections to the spleen, pancreas, oesophagus, duodenum and large intestine, as well as to the main artery and the inferior vena cava. When operating on the stomach due to a malignant tumour, this fact must be taken into account and a very complex lymph node removal must be performed.
Pancreas (inflammation and malignant tumours)
One focus of the clinic is the treatment of pancreatic diseases, in particular pancreatitis and pancreatic tumours.
The pancreas is located in the upper abdomen in a central position with a close anatomical connection to the liver, the duodenum, the main artery, the spleen and the blood vessel supply to the intestine. It has two main functions: the production of digestive juice (exocrine function), which is released into the duodenum via a delicate duct, and the production of the hormone insulin, which regulates blood sugar levels (endocrine function). The common course of the bile duct and pancreatic duct with a common opening in the duodenum (papilla) is of significant anatomical importance. This explains why a gallstone that blocks the pancreatic duct and the bile duct can cause severe pancreatitis. This also explains why, for example, a tumorous narrowing of the bile duct can cause bile stasis with jaundice (icterus).
The pancreatic juice can already be activated in the pancreas during an inflammatory disease process and thus cause the severe clinical picture of pancreatitis with tissue dissolution (necrotising pancreatitis). A second major trigger of pancreatitis is the consumption of alcohol, which has a direct damaging effect on the organ.
Sometimes the distinction between an inflammatory and a malignant enlargement of the pancreatic head can only be clarified by surgery. The treatment procedures for pancreatitis range from infusion treatment and inpatient observation in the mild (oedematous) form to intensive therapy with removal of dissolved pancreatic parts and flushing of the abdomen in the severe necrotising form (self-digestion of the organ).
Depending on the clinical picture, various surgical procedures can be used for late effects of pancreatic disease: If there is an inflammatory thickening of the pancreatic head, which leads to pain and restricted food intake, surgical removal similar to tumour surgery (Kausch-Whipple surgery, see below) can be performed. If the focus is on the formation of fluid accumulations (pseudocysts), it is possible to surgically drain the cyst contents into the small intestine (cystojejunostomy).
If a malignant growth in the area of the pancreas (pancreatic carcinoma) is suspected, the feasibility of an operation must be clarified after the imaging examination procedures have been carried out. If the tumour can be removed, either a "pylorus-preserving partial duodenopancreatectomy" or Whipple surgery is performed. In this procedure, the head and body of the pancreas and the duodenum are removed. The corresponding lymph node sections are also removed.
Three suture connections are made with the small intestine, one with the pancreas, one with the bile duct and one with the stomach. Hospital discharge is possible after approx. 14 days if there are no complications. In rare cases, a leaky suture in the tail of the pancreas (pancreatic fistula) or delayed gastric emptying may occur after this surgical procedure. This can prolong hospitalisation.
The benefits of additional (adjuvant) chemotherapy and/or radiotherapy following surgical removal of pancreatic cancer have not been conclusively clarified and are currently being investigated in studies. It can be initiated by our clinic on request and after detailed counselling(follow-up treatment). The aftercare we offer also includes the treatment of functional consequences of the surgical procedure (digestive disorders, diabetes).
Liver
The surgical treatment of liver diseases is one of the clinic's specialities. Organ-sparing and blood-saving surgical techniques are used as well as local treatment procedures, which are carried out in close cooperation with the Radiology Clinic (sclerotherapy procedures, especially thermal ablation and chemoembolisation, see below).
With a weight of 1500 g, the liver is the largest solid organ in the human body and has a central function as a metabolic organ. It is organised into 8 segments distributed over 2 lobes. Numerous metabolic products are "detoxified" in the liver via the blood and bile is produced, which is excreted into the intestinal tract via the main bile duct. Due to its segmental structure, it is possible to surgically remove large parts of the liver if it is functioning normally.
Signs of liver disease can include abdominal fluid formation (ascites), jaundice (icterus), pain and fever. The diagnostic measures used include laboratory and functional tests, an ultrasound examination, computerised tomography, magnetic resonance imaging and a puncture.
Liver metastases
The most common cause of malignant tumours in the liver is liver metastases (metastases). This refers to metastases from tumours into the liver. However, there are also so-called primary liver tumours that arise in the liver itself (hepatocellular carcinoma, cholangiocellular carcinoma, see below). Liver tumours can be surgically removed with an appropriate safety margin. Recently, liver tumours can be sclerosed by thermal ablation using high-frequency probes, either openly (by surgery) or guided by computer tomography in the radiology department. Other procedures include regional chemotherapy or chemoembolisation.
Hepatocellular carcinoma
Hepatocellular carcinoma can develop either in a liver with altered connective tissue or in normal liver tissue. For tumours that have developed in normal liver tissue, surgical removal of the tumour is the treatment of choice. The illustration shows a large liver tumour in the right lobe of the liver that could be surgically removed.
In the case of hepatocellular carcinomas, which often develop as a result of liver cirrhosis, surgery is often not possible due to impaired liver function. In these cases, sclerotherapy (chemoembolisation) can be used or smaller foci can be treated by thermal ablation (among other things).
Benign liver tumours
Benign liver tumours include haemangiomas (blood sponges), which can be surgically removed or embolised, liver adenomas, which should be surgically removed once they reach a certain size due to the risk of bleeding, and liver cysts, which can be relieved by open or laparoscopic surgery.
If cystic liver tumours caused by parasites (dog tapeworm, fox tapeworm) grow in a displacing manner, surgical cyst removal, cyst disinfection or liver resection may be necessary in addition to drug treatment. The treatment plan is determined in close consultation with the supra-regional specialised outpatient clinic of the Department of Internal Medicine at Oberer Eselsberg.
Spleen
The spleen weighs 150 to 200 grams. It is protected under the left costal arch, in the immediate vicinity of the diaphragm, stomach, tail of the pancreas and left kidney. Its function is to dispose of old red and white blood cells. It also stores platelets and plays an important role in the body's defence against infection. For this reason, a vaccination (HIB, pneumococci) is carried out approximately two weeks before a planned splenectomy.
The spleen can be injured in accidents. As a rule, the spleen is preserved by means of special surgical procedures. Enlargement of the spleen (splenomegaly) occurs in a variety of different diseases. Diseases of the blood or lymphatic system may necessitate the surgical removal of the altered spleen.
Small intestine and peritoneum
The small intestine varies in length between 3 and 7 metres. Several litres of digestive juices flow through it into the large intestine every day. The passage time is 6 - 10 hours. The enormous absorption capacity of the small intestine is achieved by its large surface area. The alkaline content of the duodenum neutralises the acidic gastric juice. In the small intestine, the food components are broken down further so that they can finally be absorbed through the intestinal wall and reach the liver via the portal vein.
The small intestine is divided into the duodenum (25 cm) and the remaining sections, the jejunum (2/5) and ileum (3/5).
The small intestine is suspended from the mesentery and is otherwise freely movable in the abdomen. Only one blood vessel (superior mesenteric artery) supplies the small intestine with oxygen-rich blood.
If, for various reasons, a section of active small intestine remains less than 60 cm after removal of the small intestine, this is referred to as short bowel syndrome. In this case, nutrition via infusions is necessary. In special cases, the clinical picture can be treated with a small bowel transplant, which is carried out in specialised centres.
Adhesions:
Adhesions of the small intestine (but also of the large intestine and other intestines) with the peritoneum or with each other can be pathological. In extreme situations, this is referred to as an "adhesion abdomen", which can result in an obstruction to the passage of food. After careful clinical examination and visualisation of the obstruction using imaging techniques (computer tomography, magnetic resonance imaging), surgical removal of the adhesions may be indicated. Depending on the severity of the condition, it may be necessary to remove part of the bowel or even create an artificial outlet.
If adhesions lead to an intestinal obstruction, this is known as an ileus. This is usually accompanied by pain and vomiting. Initially, treatment is attempted with conservative (laxative) measures and infusion treatment. If this is unsuccessful and there is a clear, insurmountable obstruction, an operation is indicated. As adhesions or adhesions between intestines are very often found after surgical interventions, but can also be present at birth, surgical measures to loosen adhesions are only carried out after careful preliminary examination and with great caution.
Adhesions of the small intestine to the abdominal cavity can also be caused by tumour seeding. This clinical picture is known as peritoneal carcinomatosis. In this case, an attempt can be made to restore the passage by means of an internal bypass.
Diverticulitis
Diverticulitis occurs when protrusions in the wall of the large intestine, which are more common with increasing age (diverticulosis), become inflamed. This typically leads to pain in the left lower abdomen with signs of inflammation and peritoneal irritation, especially if a defect has formed in the intestinal wall (intestinal wall rupture or perforation). These changes are typically found in the S-shaped part of the colon (sigmoid colon), but can also affect the entire left part of the colon.
The disease is suspected on the basis of the patient's medical history and clinical examination, including a blood test. The diagnosis is confirmed either by colonoscopy (not in the acute inflammatory phase), computer tomography or an X-ray contrast enema of the colon. Depending on the severity of the findings, we discuss with our patients whether immediate surgery is necessary (e.g. in the case of perforation) or whether inpatient treatment without surgery can be carried out first. After the acute phase of a diverticulitis episode has subsided (with infusion treatment and administration of antibiotics), it may be necessary to remove the affected section of bowel in the so-called symptom-free interval, especially if the inflammation has healed with a scarred narrowing (stenosis). In particularly severe cases of sigmoid diverticulitis with intestinal wall perforation and abdominal cavity infection, it may be necessary to insert an artificial anus - usually temporarily. In addition, detailed nutritional counselling is offered in our clinic for this clinical picture.
Crohn's disease, ulcerative colitis
These proper names are used to summarise chronic inflammatory bowel diseases, which are usually initially treated by our colleagues in the Medical Clinic. If the effects of the disease cannot be controlled by internal measures, surgery may be necessary. This includes the treatment of inflammatory fistulas (duct formation) at the anus or between neighbouring sections of the bowel, constrictions or abscesses (accumulations of pus). A basic principle of treatment is organ-sparing surgery and the close involvement of patients in an interdisciplinary treatment concept.
Tumours of the large intestine (colon)
The colon is located over a length of approx. 1.5 metres in an arc from the right lower abdomen (appendix region) via the upper abdomen (transverse colon) down to the rectum. Its function is to recover water from the low-viscosity stool in the small intestine and thus solidify the stool. Functional disorders in the colon can therefore manifest themselves as diarrhoea or constipation. The development of malignant colon tumours is a process that is influenced by various factors (genetic changes, eating behaviour, inflammation), but the details are not yet fully understood.
As benign growths (polyps) can initially form in the area of the colon mucosa, which can develop into malignant tumours (colon cancer) over the course of several months or years, early detection examinations (so-called haemoccult test as an examination for blood in the stool and colonoscopy) are of particular importance here. In particular, colon polyps can be painlessly removed and examined using a colonoscopy procedure before surgery becomes necessary.
Surgical procedures using minimally invasive access methods are currently being trialled(keyhole surgery). In the case of colon tumours, it is generally not necessary to create an artificial anus. Depending on the stage of the tumour, additional chemotherapy (adjuvant chemotherapy) may be recommended. This can usually be carried out on an outpatient basis(follow-up treatment).
Our patients continue to be cared for via a standardised aftercare programme in close consultation with the attending physician. If a permanent change in diet is required after the operation, the patient will receive detailed nutritional counselling during their inpatient stay.
Tumours of the rectum - rectal carcinoma
In contrast to the colon, the rectum is significantly shorter than the colon, measuring 12 to 15 cm in length. Its special significance lies in the control of defecation, which is essentially coordinated by a complex sphincter apparatus. Rectal tumours in the lower part of the rectum can be detected by a simple physical examination. The symptoms correspond to those mentioned above(colon). A loss of the stool retention function is very stressful for patients (faecal incontinence). Modern surgical procedures are therefore designed to preserve the faecal retention function.
Among other things, our clinic performs the particularly gentle and function-preserving surgical procedure of TME according to HEALD (total mesorectal excision). The question of whether an artificial outlet needs to be created, either permanently or temporarily (as a "protective stoma"), depends on defined surgical rules, e.g. how advanced the tumour is and how close it is to the sphincter muscle. If an artificial bowel outlet cannot be avoided, we offer systematic counselling in advance(stoma therapy), which is continued after the operation. Treatment procedures that precede surgery and aim to improve the results of rectal surgery (neoadjuvant radiochemotherapy) are currently being trialled. Depending on the extent of the rectal cancer, additional chemotherapy or radiotherapy may be necessary in accordance with the recommendations of the German Cancer Society, the specifics of which are discussed in detail with our patients(follow-up treatment).
Sarcomas
The clinic specialises in the treatment of soft tissue sarcomas of the abdominal cavity, the abdominal wall and the retroperitoneum (i.e. the region of the body behind the intestine towards the kidneys).
Sarcomas are malignant tumours that can occur anywhere in the body. They develop from mesenchymal tissue, such as bone and muscle tissue, but also fat and nerve tissue.
Basically, sarcomas can be divided into two main groups - bone sarcomas on the one hand and soft tissue sarcomas on the other. These are rare tumours. Only about 1% of all malignant tumours are sarcomas. Approximately 1-3 new sarcomas occur per 100,000 inhabitants every year. Sarcomas in the retroperitoneal space belong to the soft tissue sarcomas. They are even rarer and account for approx. 15% of all sarcomas. Important tumour types are, for example, liposarcoma (arises from fatty tissue), fibrosarcoma (arises from connective tissue) or leiomyosarcoma (arises from smooth muscle tissue). Soft tissue sarcoma can develop at any age, but occurs more frequently between the ages of 45 and 55 or under the age of 15. Men are affected slightly more frequently than women.
Due to its rare occurrence, it is crucial for the course of the disease that patients are treated by experienced sarcoma doctors, preferably in a centre with many years of experience.
At our clinic, patients with soft tissue sarcomas have been treated in an interdisciplinary manner for over 20 years. In 2006, the Sarcoma Centre for Bone and Soft Tissue Sarcomas was integrated into the Comprehensive Cancer Centre Ulm (CCCU), which is evaluated and certified annually as a Certified Oncology Centre according to the criteria of the German Cancer Society (DKG).
All patients with a sarcoma are therefore discussed in a special tumour conference (sarcoma board) when the tumour is first diagnosed and also when changes to the treatment concept are necessary during the course of the disease.
Doctors from all necessary disciplines take part in this weekly tumour conference. All necessary examinations and treatment steps are jointly determined in this committee.
Investigations
Diagnosis generally requires an anamnesis (structured patient interview), physical examination, ultrasound examination, computer tomography (CT), magnetic resonance imaging (MRI) and biopsy (taking a tissue sample). Additional examinations such as X-ray examination, FDG-PET or PET/CT or skeletal scintigraphy or angiography to visualise tumour vessels may also be required.
Treatment
Once the diagnosis has been confirmed by taking a sample from the tumour, an interdisciplinary treatment plan is drawn up. In addition to surgery, pre-treatment with chemotherapy and/or radiotherapy may be necessary. The aim of treatment is to stop tumour growth and prevent metastases before surgery.
The latest findings in sarcoma treatment are taken into account, and patients can also take part in studies on promising new drugs.
Surgery
Removal of the soft tissue sarcoma is the most important treatment procedure. Patients with a small to medium-sized tumour can often be cured by removing the sarcoma alone.
The success of an operation depends largely on the size and position of the tumour in relation to its neighbouring structures.
Soft tissue sarcomas often form tumour cell nests in the immediate vicinity of the original tumour, which cannot be seen on CT or MRI. For this reason, either a compartment resection (removal of the tumour and adjacent organs, e.g. colon, spleen or kidney) or a simple resection with a sufficient safety margin is performed. The aim is a wide resection with a sufficient safety margin to the healthy tissue (>= 1 cm on all sides).
Relapse and metastases
In principle, surgery is the treatment of choice here too. Complete removal of the tumour recurrence (return of the tumour) and/or metastases after complete successful removal of the primary tumour offers the best chance of remaining tumour-free for a long time.
In most cases, additional systemic therapy will be necessary (chemotherapy or targeted therapy, possibly participation in a clinical trial)
Aftercare and rehabilitation
All patients with treated soft tissue sarcomas are offered follow-up care in the clinic's special outpatient clinic with scheduled checks of medical history, physical examination, laboratory tests and the use of imaging procedures. The examination intervals are individualised, usually at intervals of 2-3 months. Follow-up treatment is initiated by qualified social service staff during the inpatient stay.
Visceral surgery sarcoma consultation hours
Central appointment allocation under 0731-500 53555
Operations on the thyroid, parathyroid and adrenal glands
Operations on the thyroid, parathyroid and adrenal glands are performed at our clinic around 200 times a year using modern surgical techniques. The various treatment options - conservative or surgical - are examined for each individual and an individual recommendation is made in close cooperation with the endocrinologists and nuclear medicine specialists in the clinic. By carrying out our own scientific investigations and actively participating in national (Surgical Working Group for Endocrine Surgery), we are able to continuously implement the latest scientific findings.
Operations on the thyroid and parathyroid glands require particularly gentle surgical techniques, especially with regard to the vocal cord nerves and the parathyroid glands. Neuromonitoring is therefore used during every operation to examine the function of the vocal cord nerves. For operations on the parathyroid glands, the success of the operation is monitored during the operation by determining the parathyroid hormone. Furthermore, the intraoperative histopathological examination is carried out by an experienced pathologist so that the correct diagnosis can usually be made during the operation. If a malignant thyroid tumour (carcinoma) is detected, the operation can then be extended if necessary. Repeated operations due to thyroid carcinomas are therefore rarely necessary.