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In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.

Introduction: The objective of a multicentric observational study, that was performed in Germany between 1(st) September 1996 and 30(th) September 1997, was to assess postoperative infections as a function of risk factors and antibiotic prophylaxis under everyday clinical conditions. 2 481 patients from 114 centres who received infection prophylaxis prior to elective colonic resection were included. In the descriptive analysis of the study it was noted that 36.1 % of the patients had received no prophylaxis with metronidazole despite the fact that the study protocol recommended the use of this drug in preoperative antibiotic combinations. The present analysis therefore considers the influence of metronidazole on the postoperative infection rate., Methods: In order to exclude any bias due to intergroup differences in risk profile, the groups with and without metronidazole were subjected to a matched-pair analysis. Matching parameters were: duration of operation, blood loss, age, diabetes mellitus, hepatic, renal, or chronic airways disease, immunosuppressive therapy, and rectal resection. This led to the formation of 800 pairs that were matched with respect to these parameters. The 800 pairs were then stratified into the following treatment groups: Group 1 a and b: long-acting cephalosporine (ceftriaxone) with or without metronidazole (n = 2 x 491); Group 2 a and b: short-acting cephalosporines with or without metronidazole (n = 2 x 133); Group 3 a and b: broad-spectrum penicillines with or without metronidazole (n = 2 x 176)., Results: In all three treatment groups combination therapy with metronidazole was found to be significantly superior. Postoperative infection rates were 9.4 % and 18.7 % (p = 0.000) respectively in Group 1 a and b, 12.0 % and 25.6 % (p = 0.008) respectively in Group 2 a and b, and 19.9 % and 29.0 % (p = 0.009) respectively in Group 3 a and b., Conclusion: Preoperative administration of metronidazole in addition to an effective beta-lactam antibiotic is strongly advised in elective colonic surgery, as absence of antibiotic cover against anaerobic colonic flora leads to a significantly higher postoperative infection rate.

Aim of the Study: For all resection-techniques of liver tissue intra- and post-operative blood-loss remains an important problem. Two novel resection-techniques the ultrasound-aspirator (CUSA) and the water-jet dissector (Jet-Cutter) appear to offer significant advantages regarding this problem. Aim of the present prospective clinical study was the comparison of these dissection techniques., Material and Methods: Prospective randomized study with the end points blood-loss, length of surgery, tissue trauma and long-term survival., Findings: Significant differences between both procedures with Jet-Cutter (n = 31) versus ultrasonic surgical aspirator CUSA (n = 30) were observed regarding length of resection and complete liver ischemia time (Pringle-time). Here significant advantages of the jet-cutter-technique were observed with 28 +/- 11 minutes length of resection versus 46 +/- 19 minutes and 29 +/- 12 minutes Pringle-time versus 39 +/- 16 minutes. Furthermore, significant fewer blood transfusions were required following jet-cutter-resection with a mean of 1.5 blood units vs. 2.5 blood units using the CUSA. No differences were observed regarding postoperative long-term survival., Conclusions: The jet-cutter-technique is a fast and safe surgical procedure for liver resections and offers an attractive therapeutic alternative for various indications in liver surgery.

It was the aim of this report to evaluate the laparoscopic transabdominal preperitoneal hernia repair (TAPP) which has been standardized at our department. Along with the demographic characterisation of 795 patients with 1000 inguinal hernia repairs we report about complications and early recurrences. The patient data were collected prospectively. The rate of follow-up amounted to 79.9% with an average follow-up of 1 year. The complications were divided into intraoperative, minor, major, as well as severe ones. In 30 repairs minor complications (3%) were detected. Major (n = 28) and severe (n = 9) complications were detected in 3.7% of the cases. There were two deaths, 3 patients with an intestinal obstruction due to adhesions (2 segmental small bowel resections), two patients with testicular atrophy, two mesh infections, two trocar hernias, 6 surgical revisions for removal of hematomas, one exploration of a testicle, 4 diagnostic laparoscopies for suspected recurrences with a negative result, and 15 patients with a nerve irritation syndrome. The early rate of recurrence was 0.7%. In 6 cases primary hernias had been repaired and in one case a recurrent hernia. The recurrent hernias became apparent in an average of 2 years (minimum 2.5 months, maximum 36 months) after surgery. The results of the clinical study demonstrate an acceptable rate of complications and a low rate of early recurrences. Based on these data we recommend the laparoscopic transabdominal preperitoneal technique and see an ideal indication in the case of bilateral, recurrent and femoral hernias.

For the creation of a gastrostomy percutaneous endoscopic technique should be the method of first choice. If impossible a laparoscopic procedure should be preferred to a conventional one. Laparoscopic Janeway-gastrostomy might have some advantages compared to Kader-Stamm-Fistulas. We present the results with this method which we have used since 1993 in 12 patients. The postoperative course of these patients with mainly malignant diseases of ENT (n = 4), esophagus (n = 3) and thyroid gland (n = 3) as well as two non-malignant underlying diseases is presented and discussed in the light of recent publications. The Janeway-gastrostomy is an effective, easily feasable and safe procedure that ensures a good palliation also due to easy handling and care.