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Background: The treatment of rectal cancer has undergone pronounced changes during the last two decades. There has been a significant improvement in local tumour control due to consequent use of neo-adjuvant therapy and total mesorectal excision in cases of distal rectal cancer. The presented analysis examines the realisation of the multimodal therapy for rectal cancer under the conditions of routine patient-centred care over a period of ten years., Method: The data acquired in the prospective multicentre observational study "Quality Assurance - Rectal Cancer" from the years 2000 to 2010 were analysed. N = 33,724 patients were documented. The resection rate was 95.2 %. The rate of curative resection was 84.2 %., Results: No change was detected in perioperative total morbidity and lethality during the course of the study. The percentage of patients with neo-adjuvant treatment and curative resection rose from 5.6 % (2000) to 40.5 % (2012). The rate of performed TME in distal rectal cancer rose from 75.2 % (2000) to 95.3 % (2012). For patients who underwent curative resection in the years 2000/2001 the 5-year local recurrence rate was 11.7 %, while it was found to be 4.6 % for patients who were thus treated in the years 2005/2006 (p < 0.001). There was no improvement of total survival., Conclusion: While an increase in the use of neo-adjuvant treatment for rectal cancer and the establishment of TME in routine patient-centred care have led to a significant improvement in local tumour control with a constant total morbidity and lethality, there is no detectable influence on the patients' total survival., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Adenocarcinomas of the oesophagogastric junction are increasingly being considered as a separated tumour entity. The prognosis is rather poorer compared with that for distal gastric cancer. Data from a multicentre study as part of research on clinical care aim to reflect the current situation in surgical treatment after inauguration of neoadjuvant modalities., Patients and Method: As part of the ongoing prospective multicentre observational study QCGC 2 (German Gastric Cancer Study 2), 544 adenocarcinomas of the oesophagogastric junction (AEG 1-3) were registered from 01/01/2007 to 12/31/2009., Results: Patients underwent surgical intervention in 108 (76.6 %) of the 141 surgical departments which provided data to the study. In 391 patients (82.5 %), R0 resection was achieved. Almost 60 % of the carcinomas of the oesophagogastric junction were approached in departments with no more than 10 of these tumour lesions through the whole study period (3 years). Endoscopic ultrasonography was performed in 283 cases (53 %); the rate of neoadjuvant treatment was 34.4 % (n = 187). Intraoperative fresh frozen section was only included in intraoperative decision-making in 242 patients (60.8 %). In the revealed heterogeneous spectrum of surgical interventions, a limited number of transthoracic approaches (20 %) and a mediastinal lymphadenectomy rate of only 47 % were found. Hospital lethality was 6.6 %. In the adenocarcinomas of the oesophagogastric junction, a significantly lower median survival (25 months) compared with distal gastric cancer (38 months) was observed depending on the tumour stage. In addition, 5-year survival rate of AEG patients (33.1 %) was distinctly lower than for patients with distal gastric cancer (41.4 %). There was no significantly better survival by neoadjuvant treatment in the group of investigated patients., Conclusion: The results in the treatment of carcinomas of the oesophagogastric junction in the multicentre setting including surgical departments of each profile and region even after introduction of multimodal therapeutic concepts are not satisfying. In particular, modern diagnostic and surgical strategies need to be widely used or their percentage has to be increased. In this context, centralisation of the surgical care of this specific tumour entity appears reasonable., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: With about 135,000 operations every year appendectomy is one of the most frequent surgical operations in Germany. Acute appendicitis has shown changes in diagnosis and therapy with time. The status of the laparoscopic appendectomy has had to be redefined recently. The aim of this study was to make an analysis of the current surgical therapy for appendicitis and the individual procedures., Patients and Methods: Three prospective multi-centre quality assurance studies (1988 / 89, 1996 / 97; 2008 / 09) of the "An-Institut" acquired 17,732 treatments from all supply levels of Germany., Results: The average age of patients increased within of the three studies from 25.7 to 34.6 years. Within the studies in 1996 / 97 and in 2008 / 09 the share of laparoscopic appendectomy advanced from 33.1 to 85.8 percent. In the study from 2008 / 09 the laparoscopic appendectomy showed a significant advantage over the conventional technique in terms of wound-healing disturbances (p < 0.001) and a clinical duration of stay (p < 0.001). At no stage of the appendix inflammation did the laparoscopic appendectomy lead to a significant increase of intraabdominal abscesses. Compared with the conventional technique the operating time was shorter (46.6 min vs. 53.5 min). Currently the use of a stapler is the mostly frequently applied method of appendiceal stump closure (83.6 percent)., Conclusion: The laparoscopic appendectomy is the most common method of current operative therapy. In comparison to former publications, there is no proof of any disadvantages of laparoscopic appendectomy., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: In the present study, different variables focusing on quality of colorectal surgery were investigated with respect to hospital categories: university hospital - U; hospital with maximum care responsibility (with a full spectrum of medical disciplines) - M; secondary care hospital with central regional responsibility (6-9 departments) - S; primary care hospital with local responsibility (2-5 departments) - G; The primary goal of this study was to analyse the current standard of care in patients with colorectal carcinoma in Germany., Methods: From 2000-2004, data of 47 435 patients with colorectal cancer were evaluated, using data compiled in the German multi-centred observational study "Colon/Rectal Carcinoma". Analysis was performed for all variables with respect to hospital categories. Due to the remarkable number of patients, differences between the groups were to be regarded as significant if p<0.01., Results: Preoperative colonoscopy (U: 70.1% M: 70.4% S: 67.9% G: 67.2) and preoperative determination of serum tumour markers (U: 83.8% M: 80.1% S: 81.9% G: 77.1) mainly indicate the quality of gastroenterological work-up before surgical intervention. In general, standards established by the "German Cancer Association" were not met and showed significantly lower rates for primary and secondary care hospitals. In contrast, variables indicating quality of perioperative course and outcome: rate of anastomotic leak (U: 2.1% M: 2.8% S: 2.1% G: 3.1%), rate of surgical intervention (U: 4.3% M: 3.1% S: 3.5% G: 3.1%) and mortality rate (U: 4.4% M: 2.2% S: 3.5% G: 4.1%) were in accordance with the requirements and did not differ significantly between all groups. However, an analysis of surgical and histopathological process quality (complete histology: U: 96.3% M: 93.6% S: 91.9% G: 90.9%) revealed significant differences with results being significantly lower for primary care hospitals., Conclusion: There is in principle no necessity to centre colorectal surgery in tertiary care hospitals as quality parameters focusing on results and outcome are comparable. However, in primary care hospitals, there are deficits with regards to process quality. Therefore, all measures aiming to enhance in particular process quality, i. e., hospital certification or participation with quality assurance studies, are highly desirable to further improve patient care., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Colorectal cancer is one of the most common malignancies in the Western world. In the past two decades, a growing amount of data has been reported suggesting that carcinomas of the right and left colon should be considered as different tumour entities. The aim of this review is to present a detailed analysis of the current knowledge regarding differences between right- and left-sided colon cancer and potential consequences for daily practice., Methods: For this report all articles with relevant information on differences between right- and left-sided colon carcinoma found via Pubmed searches were analysed. Furthermore, findings of a previous study performed by our group were included., Results: Patients with right-sided colon cancer are significantly older, predominantly women, with a higher rate of comorbidities. Most of the large epidemiological studies reported a continued rightward shift of colorectal cancer. Histopathologically, carcinoma of the right colon show a higher percentage of poorly differentiated, locally advanced tumours with a higher rate of mucinous carcinoma and different pattern of metastatic spread. Survival is significantly worse in patients with right-sided carcinomas. There are numerous genetic differences which account for the distinct carcinogenesis and biological behaviour., Conclusions: The numerous findings regarding differences between right- and left-sided colon cancers should have an impact on colon cancer screening and therapy. Firstly, there are defined risk groups which should receive complete colonoscopy, particularly if they present with symptoms suspicious for colon carcinoma. Furthermore, location of the colon cancer should be considered before group stratification into genetic, clinical and especially chemotherapy trials. A more tailored approach to colon cancer treatment would be highly desirable if future trials further support the hypothesis of two distinct tumour entities., (Georg Thieme Verlag Stuttgart ˙ New York.)

Aim: This review comments on the diagnosis and treatment of gastric cancer in the classical meaning--excluding adenocarcinoma of the -oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are presented. PREOPERATIVE DIAGNOSIS: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recommended for preoperative evaluation of tumours > T1, laparoscopy has become an effective stag-ing tool in T3 and T4 tumours avoiding unnecessary laparotomies and improving the detection of small -liver and peritoneal metastases., Treatment: Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a / no ulcer / G1, 2 / Laurén intestinal / L0 / V0 / tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2 LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in -patients with favourable prognosis, this also -applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50 % of patients with liver metastases show concomitant peritoneal dissemination of the disease., Discussion and Conclusions: Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4 tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoperative chemoradiotherapy may be debated., (Georg Thieme Verlag Stuttgart.New York.)

Actinomycosis is a rare disease. Clinical symptoms and diagnostic imaging results need to be differentiated from those of malignancies and abscesses. We report the case of a 51-year-old woman who presented with nocturnal sweating, weight loss, fever, and abdominal pains. Ultrasound and MRI showed a mass in the liver that was diagnosed as actinomycosis by fine needle -biopsy. Antibiotic therapy led to an initial de-crease of both the complaints and the size of the mass, but was followed by progressing inflammation and deterioration of the patient's general condition. Surgical intervention and resection of the liver lesion led to a near full recovery. Aetiology, symptoms, diagnostic measures and therapy are discussed in the context of the presented clinical case.

Introduction: Laparoscopic cholecystectomy (LCE) is the standard treatment for symptomatic non-complicated cholecystolithiasis. However, there is still an ongoing debate about the appropriate surgical approach in cases with complicated cholecystolithiasis. As a result, an initial decision whether to use the open or laparoscopic approach must be primarily based on patient safety. Additional indications favouring the use of LCE must not lead to an increase in the rate of serious complications., Methods: All patients who underwent operations for cholecystolithiasis performed in a single surgical centre, from 1 / 1 / 1994 to 12 / 31 / 2007, were considered in this analysis. Parameters for the characterisation of the results were intervention-associated hospital mortality and iatrogenic transsection of the common bile duct., Results: 5 084 cholecystectomies were performed during the study period, 84 % (n = 4 272) intended as laparoscopic and 16 % (n = 812) as open procedures. The LCE operations were done by 36 surgeons. The conversion rate to open surgery was 6.2 % (n = 265), in cases of acute cholecystitis, however, it was 26.3 % (n = 86). One LCE procedure involved an iatrogenic bile duct transsection (0.02 %). The in-hospital mortality rate for LCE was 0.05 % (n = 2)., Conclusions: In the hands of experienced surgeons LCE is a safe procedure for the treatment of symptomatic, non-complicated cholecystolithiasis. Associated with complicated cholecystolithiasis however are an increase in conversion rate and thus the risk of severe complications.

By means of a prospective multi centre study, 13 419 cases of surgically treated patients with rectum carcinomas were registered between 1.1.2000 and 31.12.2003 and assessed in regard to possible problems concerning indications and operative procedures. Beside a high rate of non-local resective procedures in T1-low risk carcinomas, unnecessary extirpations in cases of tumour localisation over 8 cm from the anal verge were found. Tumours of the lower two-thirds of the rectum were treated by incomplete TME in 20 % of the patients. In addition, there seems to be too low a rate of neo-adjuvant therapy procedures. Protective stomata were frequently foregone after low anterior resection. Endoscopic interventional methods were still used reluctantly in inoperable situations.

By the mean of a prospective multicenter observational study (East German Gastric Cancer Study - EGGCS), 1 139 consecutive patients with gastric cancer were enrolled in 80 East German surgical departments from January 1 to December 31, 2002. Out of them, 1,031 (90.5%) underwent surgical intervention. The resection rate was 86.4% (n = 891); the R0 resection rate (n = 726) was 81.5%. Gastrectomy was performed in 79.8 % (n = 649) of subjects with radical resections (n = 813). In approximately 70 % of the interventions with curative intention, lymph node resection of the D2 compartment was carried out. The postoperative hospital mortality was 8.3%. The results were compared with the data obtained in the German Gastric Cancer Study (GGCS 1992); relevant differences and aspects were discussed.

Objectives: To investigate the intraluminal and extraluminal healing behaviour of a new metallic silver coated, gelatine impregnated vascular graft., Design: Comparative animal experimental investigation with randomisation of the animals to control and experimental groups., Material and Methods: 24 pigs were assigned to two control and two experimental groups. The prostheses were interposed in the pigs' infrarenal aorta. For the evaluation, macroscopic, histological and immunohistochemical criteria were applied., Results: The macroscopic evaluation after explantation of the prosthesis revealed similar healing characteristics in the control and experimental groups. The microscopic determination of neo-intimal thickness showed no significant differences between the groups; nor did the immunohistochemical investigations show any significant difference between the control group and the silver-coated prosthesis group., Conclusions: No disadvantage of the silver coating in terms of healing and graft patency was found. A possible advantage in terms of the antibacterial effect of the silver coating must be investigated in the clinical setting.

Introduction: The quality of treatment of cancer of the female breast is reflected not only in such parameters as local recurrence rate and survival times, but also in the development of surgical complications. Within the framework of a study investigating the performance and quality assurance in surgical treatment of breast cancer, therefore, the wound infection rate (WIR) and factors influencing it were analysed in a large patient population., Methods: In the period between 1.1.2000 and 31.12.2000, 84 surgical departments participated in a prospective multicenter study to investigate primary surgery for breast cancer. A total of 1 416 patients were recruited to the study, the organization and conduction of which was in the hands of the former surgical department 1 of the University of Leipzig under the patronage of the East German Working Group for Performance and Quality Control in Surgery in cooperation with the An Institute for Quality Control in Operative Medicine of the Otto-von-Guericke University in Magdeburg. In addition to parameters characterizing patients, tumors and diagnostic work-up, we also analysed the surgical treatment and its possible complications with the aid of a questionnaire. The definition of wound infection was based on the criteria of the "Hospital Infection Control Practice Advisory Committee"., Results: The overall WIR was 4.5 % (n = 65). 21 (32 %) of the wound infections (WI) were diagnosed exclusively on a clinical basis without establishing the responsible pathogens. In 44 (68 %) of the WI, a search for the pathogen was undertaken which in 3 cases (7 %) was negative, and in 41 cases (93 %) positive. 118 (8.3 %) of the patients received perioperative antibiotic cover. The following parameters were found to have a significant influence on WIR: local drainage, blood transfusion, the time lapse between biopsy and definitive surgery, and the size of the primary tumor., Discussion: Some of the above factors (transfusion, time lapse, drainage) can be influenced by the therapist. The wound infection rate is a marker for treatment quality.

Background: Operative treatment of high-grade carotid stenosis is an established procedure. The question whether a temporary - either selective or routine - shunt is needed, is a matter of controversy, and the decision is based on a number of available monitoring procedures. Within the framework of quality assurance based on the regular collection of our own patient data, carotid thromboendarterectomy (TEA) with recording of somatosensory evoked potentials (SEP) was analysed for its effectiveness., Patients and Methods: Two non-randomised groups of patients were analysed retrospectively: Group I: 99 carotid TEAs with no recording of SEP (1.1.99-31.12.99); Group II: 139 carotid TEAs with SEP recording (1.1.01-31.12.01). These two groups were unselected in terms of procedure, as also with regard to age, sex, stage or degree of carotid stenosis or surgeon, and were homogeneously distributed. A comparison was made of anaesthesia and operating times, shunt rate and the outcome of the two groups. Additionally, the two subgroups surgery with no shunt, and surgery with shunt, and the subgroups thromboendarterectomy with patchplasty (TEA) and eversion endarterectomy (EEA), were analysed., Results: A temporary shunt was employed in 41 (41.4 %) of the patients in Group I (no SEP recording) and in 16 (11.5 %) of those in Group II (SEP recording). The average operating time in Group II was 11.4 min shorter (p < 0.001) than in Group I. The average carotid clamping time in Group II was significantly reduced (by 4.2 min; p < 0.001), while the duration of anaesthesia prior to skin incision was increased by an average of 18.3 min (p < 0.001), and the overall duration of anaesthesia by an average of 15.8 min (p < 0.001). A comparison of the subgroups surgery with no shunt and surgery with shunt revealed - both in Group I and Group II - a significant prolongation of the anaesthesia time and operating time (p < 0.001). In both Groups I and II, the subgroup TEA revealed a significant prolongation of both the anaesthesia and operating times vis-à-vis EEA. The major stroke rate was 2.0 % in Group I and 1.4 % in Group II, and the minor stroke rate 3.0 in Group I and 3.6 % in Group II; no deaths were observed., Conclusions: A reduction in the shunt rate to 11 % (by means of SEP) significantly decreased the average operating time (incision - suture) and the clamping time, with identical outcome in Groups I and II. Despite a reduction in the average incision-suture time in Group II (with SEP recording), the average overall operating time (anaesthesia time) was significantly increased due to the greater technical effort required. Carotid TEA with a selective shunt as determined by SEP is a high-cost procedure with no demonstrable benefit. At a stroke rate < 5 % and a need for stratification into several groups in accordance with the AHA classification, it is not possible to achieve adequate patient recruitment for a randomised analysis of outcome of the individual monitoring procedures. Alternative procedures are the routine use of a shunt and operation under regional anaesthesia.

This report is the first description of an additional major complication seen with the Nuss repair. In addition to the conventional Rehbein and Ravitch operations for funnel chest, the minimally invasive procedure developed by Nuss has recently been added to the therapeutic options. The present report describes the case of a 21-year-old man who underwent a Nuss repair with implantation of 2 pectus bars 4 months previously. During the primary operation the central tendon of the left diaphragm was unnoticed injured. We performed an emergency operation on the patient to repair an incarcerated diaphragmatic hernia. The thorax was found to contain not only the entire, twisted stomach, but also the transverse colon and the spleen. During induction of anaesthesia the patient suffered a cardiovascular collapse. After successful resuscitation, thoraco-abdominal surgery was performed and the diaphragm closed from the thoracic side. Other authors have also reported major life-threatening complications of the Nuss-procedure, such as perforation of the heart. A careful evaluation of this procedure and the establishment of clear indications taking the age of the patient, the thoracic deformity and connective tissue disease into account, are mandatory to avoid discredit of this method.

Over the last 10 years a dramatic decrease became apparent in primary treatment of breast cancer in general surgical departments. A prospective 1-year observational study involving 84 surgical departments was carried out to describe the current therapeutic situation. A total of 1,416 patients undergoing primary surgical treatment for mammary carcinoma were recorded, and their data evaluated. 68.9% of the carcinomas were treated in departments with an annual case load for this disease of more than 20 operations, with 50% of them being operated on in 8 departments with a case load of 40-100 procedures per year. 94.4% of the carcinomas were confirmed histologically, and in 91% of the patients surgery was performed in curative intention. The rate of breast-preserving procedures was 40%, and breast amputations accounted for 60%. An analysis of the data allowed an evaluation of this specific patient group in the surgical departments. Deficits in terms of management quality are identified.

The data obtained from 926 patients who, between 01.01.1998 and 31.12.2000, underwent thyroid gland surgery involving the use of neuromonitoring (NM) were recorded prospectively. Every patient was submitted to a preoperative and postoperative laryngoscopic examination by an ENT specialist unrelated to the department. Immediately following surgery, 58 patients were diagnosed as having unilateral or bilateral laryngeal nerve palsy. All of these patients were subsequently followed up by an ENT specialist on an outpatient basis, and 68.3 % (n = 41) of the laryngeal nerve palsies detected immediately after surgery were seen to have resolved. For first operations for benign goitre, a side-related nerve palsy rate ("nerve at risk") of 0.51 % was found. For recurrence surgery, this rate increased to 6.6 %, and for surgery of malignant lesions it was 4.8 %. The conclusion is drawn that in first operations for benign goitre, NM can be employed when and as dictated by the intraoperative findings. In the case of surgery for recurrences or malignant disease, however, intraoperative NM should be applied on a routine basis.

Introduction: The postoperative decease is the most severe complication in surgery., Patients and Method: Within the framework of a multicentre study between January 1 (st) and December 31, 1999, 3,756 patients, 1,463 of them suffering from rectal cancer and 2 293 from colon carcinoma, from 75 clinics were documented with the help of a standardized questionnaire. We compared data of 211 patients who died postoperatively with data of 3,484 patients who survived after surgical treatment of colorectal cancer. Logistical regressions, under inclusion and exclusion of intra- and postoperative complications, show independent influence factors on the postoperative decease and provide models for the prediction of the postoperative death., Results: Compared to the patients who survived, the postoperative deceased patients were significantly older. They had a poorer risk profile and therefore a higher ASA-score (p < 0.001). 20.4 % of the patients underwent an emergency operation. General and specific postoperative complications occurred significantly more frequently. The model of a logistical regression allowed the prediction of postoperative decease with a sensitivity and specificity of 91 %. General postoperative complications such as pulmonary embolism (relative risk: 30.3), cardiac (relative risk: 24.1), renal (relative risk: 22.1), and pulmonary complications (relative risk: 12.0) are crucial for lethality., Discussion: The postoperative decease is influenced by several factors. It is impossible to reduce the number of influence factors for the prediction of outcome. The general postoperative complications, however, represent a crucial problem. It is important to avoid these problems in order to reduce postoperative lethality.

The importance of laparoscopy in the management of blunt abdominal trauma should be evaluated. Therefore we retrospectively analysed all patients with blunt abdominal trauma treated in the Department of Surgery at the Carl-Thiem-Hospital Cottbus between 1998 and 2000. Within this period a total number of 53 patients with blunt abdominal trauma underwent operative treatment, 20 (37.7 %) of them had primary laparoscopy. Of the 11 cases where laparoscopic operation could be completed without conversion to exploratory laparotomy, 8 patients had intra-abdominal injuries and underwent sufficient laparoscopic treatment. The percentage of so called "negative" exploratory laparotomies within this study was 13.2 %. Our analysis suggests that laparoscopy should become firmly established in the diagnostic management and, if indicated, in the treatment of blunt abdominal trauma as well.

Iatrogenic perforations of the colon are serious complications that have been observed in association with both diagnostic and therapeutic colonoscopies, and are not always avoidable, even in the hands of an experienced investigator. Patients suffering from a perforation during elective colonoscopy are starving, and have a clean bowel. If the perforation is quickly diagnosed with only local mild peritonitis, laparoscopic treatment is often possible. The therapeutic options available are: oversewing, wedge resection and, in the individual case, tubular resection, as well as laparoscopic-assisted reconstruction, if indicated including a protective stoma. The decision to perform a laparoscopic procedure should depend on the time of detection of the lesion, and on the skills of the existing surgical team; otherwise, a laparotomy is indicated. We describe four cases that reflect the relevance of the laparoscopic approach.

Aims of the Study: The authors present an accurate and comprehensive snapshot of appendicitis in the last decade of the 20 (th) century. The present study also aims to determine the influence of introduction of laparoscopic techniques on the quality of appendicitis therapy., Patients and Methods: All consecutive patients admitted for suspected appendicitis were recruited into this prospective multicenter study. Two different periods of time were considered: from 1. 7. 1988 to 31. 12. 1989, 6 266 patients from 18 hospitals were included, and from 1. 6. 1996 to 31. 5. 1997, 7 398 patients from 34 institutions., Results: In the first period (1988/89), 1 869 patients were treated conservatively (29.8 %), 4 397 (70.2 %) were operated. Histopathological analysis of the appendix documented no acute inflammation in 28.8 %, the perforation rate was 8.3 % and the wound infection rate 9.6 %. In the second period (1996/97), 2 430 patients were treated conservatively (32.8 %), in 24.9 % of all operated cases, the histopathological examination shows no acute inflammation of the appendix, the perforation rate was 5.9 % and the rate of wound infections 2.5 %. During this second period, 33.2 % of all appendectomies were performed using the laparoscope, the conversion rate was 7.2 %., Conclusions: The introduction of laparoscopic techniques did not modify the operative indications for treatment of appendicitis. An increase in the number of normal appendices removed was not observed. The number of perforations and the incidence of wound infections was significantly reduced in the second period.

Introduction: Surgical quality control in the form of multicentre studies make it possible to analyse the treatment status of a given surgical illness under quality assurance aspects., Material/methods: On 1. 1. 2000, under the patronage of the Convent of Hospital Chief Surgeons a project (ongoing) - organised and conducted by the Institute for Quality Management in Operative Medicine at the Otto-von-Guericke University of Magdeburg - was initiated to document and collect the data of patients with colorectal cancer throughout the whole of Germany. This work is supported by the German Society of Surgery, and the Surgical Working Group, Quality Assurance within the German Society of Surgery. Currently, some 282 hospitals throughout the country are involved in establishing a prospective documentation of colorectal carcinoma. Participation in this study is on a voluntary basis. The anonymity of both patients and hospitals is guaranteed, and no hospitals wishing to participate are excluded. Both operatively and conservatively treated patients are being documented, and no randomization takes place., Results: In the year 2000, the participating hospitals documented a total of 9 477 patients with a colorectal carcinoma, including 6 975 patients with a carcinoma of the colon, and 3 402 with a rectal carcinoma. The average age of the patients was 68.5 years, and there were 5 010 men and 4 467 women. The operation rate was 99.2 %, the resection rate 95.6 %. The abdominoperineal resection rate was 27.4 %. The indicators for diagnostic quality as set out by Hermanek were largely complied with, but some deviations were noted., Discussion: On the basis of the data collected, structures were established for a uniform Germany-wide quality management for a clinical condition with a major health policy impact. This information make it possible for the hospitals to identify and eliminate deficits in the structural and process quality in the diagnosis and treatment of colorectal cancer, and in this way to improve outcome quality. This means that the results of medical care research have an immediate impact on the individual treatment received by a given patient.

We report on a 69-year-old man presenting with a giant scrotal hernia, who failed to tolerate a pre-operative pneumoperitoneum applied with the intention to increase his intra-abdominal capacity. After enlarging the hernial orifice, the hernia contents - comprising the entire small bowel, the right colon and the greater omentum - were replaced into the abdominal cavity. Closure of the abdominal wound with mesh support was possible only after extensive resection of the small bowel, together with the voluminous mesentery and greater omentum. In a second operation performed later on revision of the scrotum and penis was undertaken. It is not always possible to achieve the required increase in intra-abdominal capacity through the use of a pneumoperitoneum. In such cases, extensive bowel resections and the use of biomaterials for tension-free abdominal wall repair must form an integral part of the treatment concept. Surgical management of such giant hernias has to be adapted to the individual situation of the patient using all therapeutic options.

We present the rare case of a solitary pancreatic metastasis of renal cell cancer being the only manifestation of tumordissemination. In 1993 the patient underwent a transperitoneal nephrectomy for removal of a clear cell renal cancer. In 1998 during follow up we detected a pancreatic tumor which was treated by pancreas resection, splenectomy and resection of the colon transversum. The histology revealed a metastasis of the previously resected renal cancer. The postoperative recovery was impaired by the development of an abcess in the former pancreatic region. During the first year of follow up we did not find any signs for local or distant tumor recurrence. Pancreas resection adapted to the location of the tumor is the treatment of choice for isolated solitary late metastases of renal cell cancer.

Only a few therapeutic approaches in colon cancer therapy are based on controlled study results. Via an internet search using different search strategies 965 abstracts written about colon cancer therapy between 1980-2000 were analysed. Studies focussing on adjuvant therapy were not included. We found 446 retrospective, 150 prospective randomized, 151 prospective non-randomized studies and 218 review articles. Controlled study results as a scientific base are available for perioperative antibiotic prophylaxis (127 prospective randomized studies), mechanical intestinal cleansing (n = 5), a similar efficacy of stapler and hand-made anastomosis (n = 15), and the early onset of a stage-adjusted nutrition (n = 3). Our internet search shows that only a minor fraction (approximately 10%) of colon surgery is evidence based. The most important prerequisites for an appropriate surgical resection are the pathology results reflecting the degree of tumor spreading. Besides the data from controlled studies we have to take the results from prospective multi-center studies in consideration.

Despite all the efforts made in the areas of intensive care and surgery, severe peritonitis remains a feared condition that is associated with a high mortality rate. Severe abdominal infections are accompanied by a high level of endotoxin production, resulting in the so-called systemic inflammatory response syndrome (SIRS), which is often complicated by multiple organ failure. In addition to the surgical elimination of the source of the infection, the removal of the endotoxin is of prime importance. The aim of surgical treatment of peritonitis is, in the first instance, the elimination of the bacterial contamination and prevention or reduction--if possible--of fibrin formation. Attempts to block the cascade of mediators by pharmacological means have so far proved ineffective. For more than 10 years, therefor, various forms of abdominal lavage have been of vital importance in reducing bacterial contamination and aiding the healing process after successful surgical elimination of the focus of infection. A watertight temporary closure for the abdominal wall (TAC) was developed, which makes possible the continuous irrigation of the abdominal cavity. At the same time, it also gives the oedematous abdominal organs room to expand without the constraints otherwise imposed by the abdominal wall. This concept has extended the spectrum of surgical options, and we believe that, as a result, a reduction in the mortality rate associated with severe peritonitis with sepsis (MPI > 26) can be achieved. To investigate this hypothesis, a multi-centre study is presently being conducted. In a prospective parallel-group study, patients are randomized to either programmed etappenlavage with the Ethizip or to open dorsoventral interval therapy using the TAC. The patients are stratified on the basis of APACHE II and MPI, and the post-operative course is documented in a standardized manner. As secondary objectives, the study also aims to clarify the question as to whether the new therapeutic concept is also capable of reducing the number of revisions necessary, the duration of intensive care treatment, and the lenght of hospitalization, as also of abbreviating antibiotic treatment. Since it is being done under controlled conditions, and a uniform documentation is being used, the study represents a major contribution to quality control in the field of surgical treatment of peritonitis.

With the introduction of laparoscopic cholecystectomy (LCE) the method became very fast successful in clinical practice. To describe the actual situation we initiated in 1994/95 a clinical multicenter study with the name CESAQ. 29 hospitals participated in the study. 4,675 cholecystectomies were performed, a total number of 2,960 patients were operated upon with the laparoscopic and 1,468 with the conventional technique. Furthermore, conversion to open cholecystectomy was necessary in 247 cases. One part of the study focused on the results achieved for patients with acute cholecystitis. 9.4% of the laparoscopic but 37.3% of the conventional cholecystectomies were performed due to acute cholecystitis. We differentiated a simple (adhesions to gallbladder, hydrops) and complicated form (empyema, gangrenous gallbladder) of acute cholecystitis. Treating acute cases the incidence of intraoperative (simple 8.3%, complicated 12.1%) and specific postoperative complications (simple 9.2%, complicated 6.9%) was higher compared to elective procedures (intraoperative 4.6%, specific postoperative 3.7%). This is well known from the experience of open surgery. Nevertheless there were lower general complication rates (simple 5.5%, complicated 5.2%) and no mortality in acute cholecystitis when LCE was performed. Considering an early conversion to open cholecystectomy in cases of severe acute cholecystitis the indication for LCE can be made generously. Great surgical experience in LCE is a requirement for the laparoscopic management of acute cholecystitis.

Quality management of physicians' performance is supposed to guarantee optimal diagnostic and therapeutic procedures for patients. Quality control in the scope of prospective multicenter quality securing programs are based on the overall analysis of cases with selected tracer diagnoses. It serves as voluntary self-regulation for surgeons who perform an evaluation of their results in a team-based setting. Using colorectal cancer as an example, the quality management of diagnostic issues and surgical treatment are used to outline a treatment protocol for a surgical condition under quality securing aspects. We present the treatment protocol of colorectal cancer on the basis of three studies from 1985/1986, 1991/1993 and 1999. We emphasize our opinion that quality management should be addressed as an concern of the surgical profession, and not as an administrative problem.

The safety of laparoscopic liver resections compared to open procedure was to be evaluated in an animal study. Besides it had to be examined, whether onco-surgical principles could be kept sufficiently. Therefore 8 one-year-old pigs underwent laparoscopic liver resections; in 2 pigs left-lateral segmental resections were performed, in 5 left-sided hemi-hepatectomies and in one right-sided hemihepatectomy. It became obvious that a control of the vessels around the v. cava inf., of the left branch of the portal vein and of the suprahepatic veins was not possible with sufficient safety. Extraction of the preparations was a further problem. According to these results laparoscopic hemihepatectomy cannot be recommended for clinical routine. Further indications for a laparoscopic operation like deroofing of liver cysts, wedge-resections or treatment of superficial liver injuries are to be accepted.

301 patients underwent thyroid surgery in 1998 by using the intraoperative neuromonitoring. The documentation was done prospectively. The system of intraoperative neuromonitoring consists of a stimulation circuit and an electromyographic record. We placed the deriving electrode transligamentally through the cricothyroid membrane. By relaxometry we investigated the influence of the relaxation level on the electromyographic record of the vocal muscle. Using a standardized operative technique we found a side-related rate of primary palsy of 2.3% (n = 13), from which 61.5% (n = 8) showed to be only temporary during a postoperative follow-up period. The intraoperative neuromonitoring with the purpose of identification of the recurrent laryngeal nerve is a safe and reliable method.

The vast majority of surgical tasks can be managed by using basic, special and experts' knowledge gained during many years of clinical training and by applying solid surgical skills. This refers to elective cases as well as to emergency surgery and to general surgeons as well as to subspecialists. Consensus statements and standards of care derived from objective study results are aimed to be helpful as practice guidelines and in the decision making process. Only rare, non-foreseeable, unexpected and suddenly occurring exceptional situations require actions based on intuition, which results from a quick, sharp and brilliant decision founded on huge knowledge and experience. But in the scope of surgical work an overstatement or a mystic glorification of intuition should always be avoided.

Based on animal trials the presented study describes two versions of thoracoscopic oesophageal anastomosis within the scope of abdomino-thoracoscopic oesophagectomy. This experimental approach is considered to provide a solution for the oncological problem to salvage the tumor bearing oesophagus. We describe the procedure of intrathoracic stapler anastomosis under thoracoscopic vision. By using a laparoscopic purse string suture clamp we were enabled to prepare the proximal oesophageal stump for anastomosis. A circular stapling instrument turned out to be very suitable for the thoracoscopic use. The final evaluation of the importance of minimally invasive surgery for the resection of oesophageal carcinomas should not be given until multicenter studies are performed.

Between 1992 and 1997, 424 female patients were treated for primary breast cancer at the Department of Surgery of the Carl-Thiem-Klinikum in Cottbus. The percentage of breast conserving surgical methods hat increased from 10% (1992)-30% (1997). The rate of local recurrence after breast conserving surgery was 8% in 1997. We found a ratio of breast cancer surgery to diagnostic biopsies of 1:1, 1 in 1992 and of 1:2,1 in 1997. After the introduction of reconstructive breast surgery in 1997 we carried out 3 immediate reconstructions with endoprosthesis and 7 cases with myocutaneous flapping. Our own concept of plastic surgery as well as indications for breast conserving therapy will be demonstrated and discussed.

The changes of surgical treatment of gallstone disease to the laparoscopic procedure was performed just at the same time in East Germany was destroyed the socialism. That's why the new operative technique was possible in many hospitals in 1992/93 first. To describe the actually situation and the trend we started a prospective multi-institutional study included 29 East German surgical departments of all kinds. The most interesting things were perioperative antibiotic prophylaxis, laparoscopically procedures in elderly or high risc patients, the management of common bile duct stones and the minor and major complications. We discuss the results and the comparison with the results of externe quality assurance.

Based on the East German quality assessment study our investigation was aimed to evaluate if sonography has a diagnostic value for the indication to appendectomy or if it is only relevant for the differential diagnosis of acute abdominal pain. In a prospective trial we recorded and analysed all sonograms which were obtained in a period of one year at 34 East German hospitals. 3924 patients were examined by ultrasonography. The sex distributions was 1:1.8 on behalf of the female patients. The correlation of sonogram and intraoperative macroscopic findings showed a high rate (68.2%) of acute inflamed appendices in cases with negative ultrasound results. A positive sonogram with an inflamed appendix was confirmed in 90% of the cases intraoperatively. In our study the routine use of ultrasonography for the diagnosis of acute appendicitis shows a sensitivity of 21.5% an a specificity of 80.1%. The positive predictive value is 95.6% and the predictive value for negative results is 9.8%. In conclusion, if clinical examination shows the presumptive diagnosis of acute appendicitis, a negative sonogram should not withhold the surgeon to perform an operative intervention.

4675 patients which underwent a cholecystectomy because of gallstone disease were included in a prospective multi-institutional study from 01/09/1994 to 31/08/1995 at 29 east-german hospitals. 3,207 (68.6%) patients had done a laparoscopic cholecystectomy (LCE). 1,468 (31.4%) patients received a primary open cholecystectomy (KCE). A conversion rate of 7.7% (n = 247) was seen. In 32.8% of LCE and in 39.5% of KCE diagnostic procedures of the common bile duct were not performed at all. The rate of open revision of the common bile duct was 4.5% (n = 211). The highest postoperative morbidity and operative mortality were found in KCE with revision of the common bile dutct.

In a period of 10 years we carried out two prospective multicentric trials to evaluate the state of the art in treatment of appendicitis. One study was performed before introduction of laparoscopy. Important criteria like new diagnostic methods (sonography, laparoscopy), frequency of operation, perforation rate, frequency of appendectomies in case of non acute inflammation and postoperative complications were compared.

Based on animal trials the presented study results describe a method of abdomino-thoracoscopic oesophagectomy for the treatment of oesophageal carcinoma of the middle and lower third. Technical details and the advantages of the surgical procedure, including the avoidance of thoracotomy and the practicability of the thoracoscopic dissection of the oesophagus are shown. Problems exist in the salvage of the specimen, especially in the transcervical passage of the tumorbearing oesophageal part. A final evaluation of the importance of the minimally invasive techniques in oesophageal surgery should not be given until the results of clinical studies are available.

Between January 1st, 1979 and December 31st 1993, 2501 operations for benign diseases of the thyroid gland were performed. The documentation was done prospectively. The operation technique remained the same during these years. The recurrent laryngeal nerve wasn't routinely identified. All together we saw 0.6% permanent vocal cord palsies. The incidence of nerve paralysis was correlated to the size (weight), to the expansion of the goiter, to the performed operative procedure and to patients' age and gender.

The resection of lung metastases as a component of a multistep therapeutic concept is an established treatment approach. 5-year survival rates of 30% are attainable in combination with a low postoperative lethality. We performed 99 operations on 89 patients with lung metastases between 1977 and 1997 in the Department of Thoracic Surgery on the Carl-Thiem-Klinikum Cottbus. No postoperative lethality was observed.

Based on animal trials the presented study results describe a laparoscopic assisted removal of an extra-long free jejunal graft to reconstruct voice and swallowing after a total laryngo-pharyngectomy in cases with advanced malignancies of the larynx including invasion in the upper oesophagus. With a microvascular anastomosed small bowel segment, we have been able to reconstruct parts of the pharynx and to create a speaking syphon as devised by Ehrenberger in an one-stage procedure. The concept of avoidance of an extensive laparotomy may result in an decreased morbidity of this surgical procedure. Therefore it represents a challenging single indication of minimally invasive surgery of the oesophagus. A well established interdisciplinary teamwork is the key for success in this extensive procedure.

For certain indications, anterior fusion of the lumbar spine is a standard operation. The surgeon specializing in operations on the vertebral column needs to learn to utilize the advantages of laparoscopic surgery. However, an absolute must before employing the technique in patients is adequate training in its use in living animals. For this purpose, the pig is a highly suitable model. The surgical team comprises a surgeon experienced in spinal procedures, an abdominal surgeon with skills in laparoscopic surgery and an experienced camera assistant. In the animal model and in clinical trials, a change in position-organ preparation from the cranial direction, a suprasym-physial approach to the vertebrae-has proved expedient. The use of a special instrumentarium for maintaining the pneumo-peritoneum, for protecting the spinal cord and for exact centering, including the application of a special dowel (ESKA-spacer and instruments) is essential. The greater technical effort may be expected to result in shorter hospitalization (2-3 days) in the future.

Surgery of colorectal cancer is suited for assurance of surgical quality. The R0-resection rate in 1927 operations for colorectal cancer was 74.4%. The postoperative mortality was 7.1%. Wound suppuration occurred after surgery of the colon in 6.5%, after surgery of rectal cancer in 9.9% of the cases. In 68.6% of pT4-tumors we found lymphoid metastasis, in 19.3% around the trunk of the inferior mesenteric artery. For compilation of comparative data the quality assurance in colorectal surgery should be realised every 3 to 5 years.

There is no disagreement over the advantages of minimal-invasive surgical procedures even in the older patient. However the criteria for indication and patient selection concerning cardiopulmonary contraindications for CO2-pneumoperitoneum must be strictly considered. Using cholecystectomy and colorectal surgery as an example the problems and limits of the laparoscopic method are described.