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Patients with rectovaginal fistulas have a significantly reduced quality of life. Therefore, surgical therapy is often needed even in palliative cases. The aim of the present study was to perform an analysis of the results of the different treatment options available today. We performed a retrospective analysis of patients who underwent treatment for rectovaginal fistulas at the Department of Surgery, University of Schleswig–Holstein, Campus Luebeck and the Department of Surgery, WKK Heide, between January 2000 and September 2016. Complication and recurrence rate were retrospectively evaluated. The median follow-up period was 13 months (range 3–36 months). During the observation period, 58 patients underwent surgery (53 curative, 5 palliative) for rectovaginal fistulas. All patients who underwent curative surgery had an omentoplasty, and 39 of 53 (73.6%) patients underwent a resection. Thirty of 39 (77.0%) resections were low anterior resection, while non-continence-preserving resection included subtotal colectomy (n = 5), pelvic exenteration (n = 2), and proctectomy (n = 2). The fistulas were mainly secondary to inflammatory bowel disease (n = 18) or diverticulitis (n = 13), while 19 fistulas were a complication of different cancers or precancerous lesions. The median follow-up time was 13 months (range 6–36). Four patients (6.9%) had fistula recurrence (3 recurrences after low anterior resection, 1 after primary fistula closure). The mortality rate was 6.9% (n = 4). Non-resecting methods should be used only in uncomplicated fistulas. Rectovaginal fistulas secondary to inflammatory or malignant disease mostly require extensive therapy. Omentoplasty is effective for the treatment of both high and low rectovaginal fistulas.

Laparoscopy for colorectal cancer resection bares early post-operative advantages and results in equal oncologic long-term outcome. However, data on laparoscopic right hemi-colectomy is scarce. Aim of the present study was to analyze a well selected collective of patients with right-sided colon cancer treated open and laparoscopically with regard to peri-operative and long-term outcome. We analyzed all patients who underwent right-sided hemi-colectomy for colon cancer between January 1996 and March 2013. Data was extracted from our prospective database. Inclusion criteria were tumor localization in the ascending colon, oncologic resection, histology of an adenocarcinoma, tumors UICC I–III, and R0 resection. Exclusion criteria were multiple malignancies including colon, emergency operation, adenoma or pT0 status, and UICC IV. For the matched pairs approach between patients undergoing laparoscopic (LAP) or open (OPEN) surgery, the parameters age, UICC stage, tumor grading, and sex were applied. A total of 188 patients was included in the analysis with n = 94 in both the LAP and the OPEN group. Some peri-operative results demonstrated advantages for laparoscopy including median return to liquid (p

Die Bewertung der Qualitat arztlichen Handelns ist eine legitime gesellschaftliche Forderung. Dabei wird weltweit nach verlasslichen Methoden der Qualitatsmessung gesucht. Haufig wird dabei die Qualitat aus Abrechnungsdaten (sog. Routinedaten) ermittelt. In Deutschland hat die AOK dieses Verfahren umgesetzt. 1) Wie wird das AOK-Qualitatssystem von chirurgischen Chefarzten eingeschatzt? 2) Wie ist die Validitat von Qualitatsaussagen, die aus Abrechnungsdaten hergeleitet werden? Die vorliegende Arbeit wird in Anlehnung an das PRISMA-Statement fur eine qualitative systematische Ubersichtsarbeit erstellt. Zur Beantwortung der 1) Fragestellung fuhrte der Berufsverband der Deutschen Chirurgen zwei Umfragen durch. Zur Beantwortung der 2) Frage erfolgte eine strukturierte Literaturrecherche in Anlehnung an das PICO-Format. Zusatzlich wurden zahlreiche Webseiten kontaktiert. Insgesamt 95 % der antwortenden chirurgischen Chefarzte sind der Meinung, dass die AOK-Methodik, aus Abrechnungsdaten Qualitatsaussagen zu treffen, nicht objektiv ist. Ein Drittel wurde konkret falsch beurteilt. Aus der Literaturrecherche geht hervor, dass fur AOK-Indikatoren inklusive des Elixhauser-Risikoscores, keine Validierung vorliegt. Insgesamt ist die Sensitivitat von Indikatoren in der Literatur schlecht, wenn man eine gute Sensitivitat als ≥ 80

Hintergrund: Neuroendokrine Neoplasien (NEN) sind seltene und heterogene Tumoren. Die mit unklarem Primarius (N-CUP) stellen eine Untergruppe mit schlechter Prognose dar. Die Resektion des Primarius ist die Voraussetzung fur einen kurativen Ansatz, sodass sich die Frage nach dem sinnvollsten diagnostischen und therapeutischen Vorgehen bei N-CUP stellt. Patienten/Methoden: Die Datenbankauswertung von 03/1990 bis 03/2011 ergab 35 N-CUP aus 261 Fallen mit NEN. Es wurde unterteilt in Patienten, bei denen nach operativer Exploration ein Primarius gesichert wurde (Kollektiv 1 = K1, n = 10), durch operative Exploration kein Primarius gesichert wurde (K2, n = 10) und in Patienten, die nicht operativ exploriert wurden (K3, n = 13). Ergebnisse: Die N-CUP-Rate betragt bei Erstvorstellung 13,4 % (35/261), nach erneuter Diagnostik im Zentrum 12,7 % (33/261) und nach operativer Exploration 8,8 % (23/261). Das Geschlechterverhaltnis ist ausgeglichen, das mittlere Alter ist mit 63,8 Jahren (J) in der CUP-Gruppe signifikant hoher als in der Gesamtgruppe (55,9 J, p = 0,004). Das 5-Jahres-Uberleben (JUL) ist 58 % (Gesamtgruppe: 72 %, n. s.). Operativ exploriert wurden 60,6 % (20/33), von denen 30 % (6/20) inoperabel waren. Bei 20 % (4/20) erfolgte die R0-Resektion von solitaren Metastasen ohne Primariusdarstellung und bei 50 % (10/20) konnte der Primarius intraoperativ lokalisiert werden (8 × Dunndarm, 2 × Pankreas). Hier erfolgte in 70 % (7/10) eine R0-Resektion und in 30 % eine Primariusresektion mit Debulking von Lebermetastasen. In der nicht operierten Gruppe (39,4 %, 13/33) erhielten 69,2 % (9/13) eine Chemotherapie. Das mittlere Alter ist signifikant niedriger in K1 mit 54,9 J, im Vergleich zu K3 mit 68,3 J (p = 0,028), eine mannliche Dominanz ist in K3 mit 3,3 : 1 (m : w, n. s.) zu sehen. Der mittlere Ki-67-Index betragt 4,3, 23,8 und 53 % in K1, K2 und K3 und ist hochsignifikant zwischen (zw.) K1 und K3 (p

Laparoskopische Kolon- und Rektumoperationen stellen durch die extremen Lagerungen zur Erzielung des Gravity-Displacements eine Gefahrdung peripherer Nerven dar. Die Haufigkeit lagerungsbedingter Nervenlasionen ist nur unzureichend bekannt und wird in der Literatur bei allgemeinen Operationen mit ungefahr 0,5 % angegeben. Bezuglich laparoskopischer Operationen fehlen aktuelle Daten. Ziel dieser Untersuchung ist die Erhebung der Haufigkeit und der Prognose von postoperativen Nervenlasionen im Rahmen von laparoskopischen kolorektalen Eingriffen. In unserer prospektiven kolorektalen Datenbank wurden von 1992–2010 alle Patienten mit lagerungsbedingten Nervenlasionen nach laparoskopischen kolorektalen Eingriffen ausgewertet und ihre Prognose analysiert. Hierbei wurden Patienten mit postoperativen Nervenlasionen bezuglich des Body-Mass-Indexes (BMI), der Operationsdauer sowie in Hinblick auf die Lagerung mit ausgelagertem bzw. angelagertem Arm untersucht. Im Zeitraum zwischen 1992 und 2010 traten bei 2698 Kolon- und Rektumoperationen 19 (0,7 %) Falle mit neurologischen Symptomen im Sinne einer lagerungsbedingten Nervenlasion auf. Bei rektalen Eingriffen lag die Inzidenz bei 1,08 %; bei Kolonoperationen bei 0,54 %. In der Patientengruppe mit postoperativen neurologischen Symptomen waren die mittlere Operationsdauer langer (267 ± 119 vs. 185 ± 77 Minuten; p = 0,01) und der mittlere BMI groser (27,93 ± 4,93 vs. 25,79 ± 4,45 kg/m2; p = 0,033) als bei den symptomfreien Patienten. Durch die Anlagerung des linken Armes ab 2007 konnte der Anteil der Nervenlasionen der oberen Extremitat, bezogen auf die durchgefuhrten laparoskopischen kolorektalen Operationen, von 0,23 % auf 0,1 % reduziert werden. In 89,47 % der Falle waren die neurologischen Beschwerden vollstandig rucklaufig. Lagerungsbedingte Nervenlasionen treten trotz extremer Lagerungsart wahrend Kolon- und Rektumoperationen nur in einem geringen Mase auf und heilen meist ad restitutionem ad integrum wieder ab. Grunde fur die Nervenlasionen konnen neben der Lagerung selbst durch die Operationsdauer und den Patienten-BMI bedingt sein. Durch die Optimierung der Lagerung mit Anlagerung beider Arme kann eine Reduktion der Nervenlasionen an den oberen Extremitaten erzielt werden.

Einleitung: Die Magen- und Duodenalperforation stellt eine lebensbedrohliche Komplikation der Ulkuskrankheit mit der sofortigen Indikation zur operativen Versorgung dar. Inwieweit die Laparoskopie in dieser Akutsituation ein geeignetes Verfahren darstellt, soll die vorliegende Untersuchung zeigen. Material und Methoden: Die Daten aller Patienten, die innerhalb eines Zeitraums von 15 Jahren (01/1996–12/2010) wegen eines perforierten Magen- oder Duodenalulkus laparoskopisch operiert worden waren, wurden prospektiv erfasst und hinsichtlich Alter, Geschlecht, Perforationslokalisation, Diagnostik, Klinik, Operationsverfahren, intra- und postoperativen Komplikationen sowie postoperativem Verlauf retrospektiv analysiert. Ergebnisse: Im Beobachtungszeitraum wurden 45 Patienten mit einer Magen- oder Duodenalperforation laparoskopisch operiert. Das mediane Lebensalter bei Operation betrug 58 (18–91) Jahre. Eine NSAR-Medikation bestand bei 11 (24,4 %) Patienten. Die Perforation lag bei 12 (26,7 %) Patienten prapylorisch, bei 10 (22,2 %) postpylorisch, bei je 1 (2,2 %) Patienten an der kleinen und an der grosen Kurvatur, bei 18 (40,0 %) an der Vorder- und 3 (6,7 %) an der Hinterwand. In 2 Fallen bestand eine vorangegangene operative Versorgung im Oberbauch. Nach primarer diagnostischer Laparoskopie wurde bei 20 (44,4 %) Patienten die Indikation zur Konversion gestellt. Im Verlauf der laparoskopisch beendeten Operationen wurden bei 18/25 (72,0 %) Patienten eine Ubernahung und bei 7/25 (37,8 %) Patienten eine Ulkusexzision durchgefuhrt. Nach Konversionen wurde bei 7/20 (35,0 %) Patienten eine Ubernahung, bei 10/20 (50,0 %) Patienten eine Ulkusexzision und bei 3/20 (15,0 %) Patienten ein resezierender Eingriff durchgefuhrt. Die mediane Operationszeit betrug 105 (40–306) Minuten und die mittlere Verweildauer 11 (4–66) Tage. Der Intensivaufenthalt lag im Median bei 2 (0–37) Tagen. Majorkomplikationen bestanden bei 11 (24,4 %) Patienten. Hierbei sind im Wesentlichen Relaparotomien (n = 7; 15,6 %) und Nachblutungen (n = 4; 8,9 %) zu nennen. Minorkomplikationen waren in 8 (17,8 %) Fallen zu beobachten. Die Letalitat betrug 11,1 % (n = 5). Schlussfolgerung: Die laparoskopische Versorgung von Magen- und Duodenalperforationen stellt eine minimalinvasive therapeutische Option fur die definitive Versorgung dieser lebensbedrohlichen Erkrankung dar. Die Indikation fur ein laparoskopisches Vorgehen ist jedoch individuell zu stellen und wird in entscheidendem Mas von der laparoskopischen Erfahrung des Operateurs bestimmt.

The purpose of the present study was to investigate on the acceptance and frequency of laparoscopic surgery for the management of acute and chronic bowel obstruction in a general patient population in German hospitals. To receive an authoritative opinion on laparoscopic treatment of bowel obstruction in Germany, a cross-sectional online study was conducted. We designed an online-based survey, supported by the German College of Surgeons (Berufsverband der Deutschen Chirurgen, BDC) to get multi-institutional-based data from various level providers of patient care. Between January and February 2014, we received completed questionnaires from 235 individuals (16.7 %). The participating surgeons were a representative sample of German hospitals with regard to hospital size, level of center size, and localization. A total of 74.9 % (n = 176) of all responders stated to use laparoscopy as the initial step of exploration in expected bowel obstruction. This procedure was highly statistically associated with the frequency of overall laparoscopic interventions and laparoscopic experience. The overall conversion rate was reported to be 29.4 %. This survey, investigating on the use of laparoscopic exploration or interventions in bowel obstruction, was able to show that by now, a majority of the responding surgeons accept laparoscopy as an initial step for exploration of the abdomen in the case of bowel obstruction. Laparoscopy was considered to be at least comparable to open surgery in an emergency setting. Furthermore, data analysis demonstrated generally accepted advantages and disadvantages of the laparoscopic approach. Indications for or against laparoscopy are made after careful consideration in each individual case.

Hypoxia in malignant tissues is associated with poor prognosis and treatment options. It is obvious that the grade of malignancy is associated with dedifferentiation of a given tissue. Our aim was to assess the expression of proteins that act as cellular oxygen sensors, which directly regulate the hypoxia-inducible factor 1 (HIF-1) pathway, i.e., prolyl hydroxylase domain proteins (PHD) PHD-1, PHD-2, PHD-3, and its target gene vascular endothelial growth factor (VEGF) in colorectal cancer (CRC). In this study, we cultured a human colon cancer cell line (SW480) and its correspondent lymph-node metastasis cell line (SW620) under normoxic or hypoxic conditions for different time periods. We then measured the HIF-1a expression using Western-Blot, the messenger RNA (mRNA)-expression of the PHDs with real-time polymerase chain reaction (PCR) and the amount of one of the target-genes using an VEGF-ELISA. SW620 shows a clearly elevated HIF-1a expression under normoxic and hypoxic states compared with SW480. Under hypoxic conditions, the amount of VEGF is elevated in both primary and secondary tumor-cell line, but the metastasis-cell line has a significant higher increase. PHD-1 shows no higher expression under hypoxic condition, PHD-2 expression is elevated but only in SW480. PHD-3 levels raised in both of the cell lines, with significant higher rates in SW480. HIF-regulating proteins are highly expressed in CRCs and their metastases. These molecules play an important role in the control of hypoxia-induced genes and may also have a function in the regulation of cellular proliferation and differentiation during tumorigenesis and dedifferentiation of CRCs. Our results emphasize the important role of PHDs not only as an oxygen-sensor, but also as a control-unit for tumor growth, apoptosis, and angiogenesis through HIF-1 pathway.

Hintergrund Wahrend einer Spinalanasthesie verursacht die dabei entstehende sympathische Blockade eine Gefaserweiterung der Kapillaren mit einem hoheren Blutfluss, der zu einem Anstieg der lokalen Hauttemperatur fuhrt.

Die Outlet Obstruction ist eine Unterform der chronischen Obstipation. Fast immer sind Kombinationen von morphologischen Veranderungen des Beckens, des Beckenbodens und des Kolorektums nachzuweisen. Im Rahmen der Diagnostik gilt es, diejenigen Patienten zu identifizieren, die von einer operativen Therapie profitieren. Die Resektionsrektopexie versucht, die physiologische Anatomie und damit das funktionelle Zusammenspiel der beteiligten Strukturen wiederherzustellen, wobei die laparoskopische Technik die Vorteile der minimalinvasiven Chirurgie mit sich bringt. Neben der Erlauterung des eigenen operativen Vorgehens und des Algorithmus zur Indikationsstellung werden die Ergebnisse nach 19 Jahren eigener Erfahrung dargestellt. Innerhalb dieses Zeitraums wurden 264 Resektionsrektopexien in laparoskopischer Technik aufgrund einer Outlet Obstruction durchgefuhrt. Bei einer mittleren Dauer der Nachbeobachtung von 58,2 Monaten betrug die Rate der Besserung der Obstruktionsbeschwerden 79,5 % (n = 128 von n = 161 Nachbeobachtungen). Die vorliegenden Studien deuten darauf hin, dass die (laparoskopische) Resektionsrektopexie gegenuber nicht resezierenden Verfahren und Verfahren mit Implantation allogenen Materials zu besseren Ergebnissen fuhrt. Voraussetzung ist hierbei eine korrekte Selektionierung der Patienten und die laparoskopische Expertise. Sowohl die perioperativen als auch die funktionellen Ergebnisse des eigenen Kollektivs untermauern die Vorteile der laparoskopischen Resektionsrektopexie bei Patienten mit einer Outlet Obstruction.

Einleitung: Die rektovaginale Fistel ist eine seltene Erkrankung mit uneinheitlicher Genese. Die Genese scheint den Umfang der operativen Versorgung und deren prognostischen Verlauf zu bestimmen. Ziel der Untersuchung ist die Darstellung unterschiedlicher chirurgischer Techniken in der Versorgung rektovaginaler Fisteln und deren Ergebnisse in Abhangigkeit ihrer Genese. Material: Im Zeitraum von 1 / 2000 bis 1 / 2010 wurden die Daten der Patientinnen mit rektovaginaler Fistel erfasst. Die retrospektive Auswertung der Daten erfolgte zur Erfassung biografischer und anamnestischer Daten, klinischer Charakteristika, Analyse von allgemeinen und spezifischen Komplikationen sowie postoperativem Verlauf. Ergebnisse: Im Zeitraum von 1 / 2000 bis 1 / 2010 wurden 36 Patienten mit rektovaginaler Fistel versorgt. Inflammatorische Grunderkrankungen (n = 21) und vorhergehende chirurgische Masnahmen (n = 6) waren die haufigsten Ursachen. Daneben wurden tumorassoziierte – (n = 5) und Fisteln ungeklarter Genese (n = 4) beobachtet. Als chirurgische Therapieverfahren wurden die anteriore Rektumresektion (n = 23), transrektale Verschiebelappchenplastik (n = 7), subtotale Kolektomie (n = 3), pelvine Exenteratio (n = 2) und Rektumexstirpation (n = 1) angewendet. Der Verschluss des vaginalen Defektes erfolgte durch Einzelknopfnaht (n = 25), Verschiebelappchenenplastik (n = 6), transvaginale Omentumplastik (n = 2) und posteriore Scheidenplastik (n = 1). Alle Patienten erhielten eine simultane linksgestielte Omentumplastik zur sicheren Trennung betroffener Areale. Patientinnen mit einer Fistelhohe Schlussfolgerung: Die Genese der rektovaginalen Fisteln ist entscheidend fur das Ausmas der Resektion und kann von einer einfachen Exzision bis hin zur pelvinen Exenteratio reichen. Zur Gewahrleistung eines optimalen Therapieergebnisses ist die chirurgische- und die Behandlung der zugrunde liegenden Erkrankung zu kombinieren. Die zusatzliche linksgestielte transperineale Omentumplastik bietet eine weitere Therapieoption zur Trennung betroffener Areale.

BACKGROUND Radiofrequency ablation (RFA) and electrochemical treatment (ECT) are competing methods of intrahepatic ablation. We compared RFA and ECT in a perfusion model and in vivo in pigs. MATERIAL AND METHODS Twenty-seven fresh porcine livers were obtained from a slaughterhouse and placed ex vivo into a perfusion model. RFA or ECT electrodes were inserted under ultrasound guidance in perivascular locations at a distance of 10 mm from a portal vessel. A total of 83 areas of ablation were created. In vivo ablations were performed at perivascular sites in 10 laparotomised pigs. Four areas of ablation were created per liver using RFA or ECL. Inflammatory parameters, liver values and cytokine levels were determined before and after surgery and on days 1, 3 and 7 after surgery. On day 7, the livers were harvested and specimens were analysed histo-logically by independent experts. RESULTS In 29% of 59 ex vivo RFA ablations, the target temperature was not reached and the procedure was discontinued. Intact hepatocytes were detected in close proximity to 70 % of the vessels within necrotic areas. In 24 ECT applications, treatment time depended on the charge delivered and ranged between 50 min at 150 coulombs (C) and 200 min at 600 C. The pH level was 0.9 at the anode and 12.2 at the cathode. ECT always led to complete perivascular necrosis and vessel wall destruction. The animals had an in vivo -median weight of 39.5 kg. Neither RFA nor ECT caused major complications such as bleeding, bile leaks or abscesses. Treatment time was 67 min (200 C) for ECT and 12.4 min for RFA. In 73% of the cases, RFA led to incomplete perivascular areas of necrosis. ECT induced complete perivascular necrosis and vessel wall destruction. On day 1 after surgery, both ECT and RFA were associated with a significant increase in monocyte, C-reactive protein and aspartate aminotransferase levels. Leukocyte counts were elevated only after ECT, bilirubin levels only after RFA. There were no significant differences in interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α) and IL-1β. CONCLUSION Both RFA and ECL are safe methods of intrahepatic ablation. As a result of a heat sink effect of blood flow in nearby vessels, RFA leads to incomplete necrosis in perivascular sites both ex vivo and in vivo. ECT has the disadvantage of long treatment times but the advantage of lower costs since the platinum electrodes are reusable. Without a reduction in liver perfusion, the central application of RFA in close proximity to vessels should be considered problematic.

Hintergrund: Medizinprodukte mussen funktionieren und sicher sein, so der Gesetzgeber. Ein Wirksamkeitsnachweis von Medizinprodukten (MP), die zur Therapie eingesetzt werden, wird nicht gefordert. Wir untersuchen, welche besonderen Anforderungen und Probleme sich daraus ergeben. Methoden: Die Situation der Hersteller von MP wird mit der der Arzneimittelindustrie verglichen. Anhand der relevanten Gesetze werden die besonderen Anforderungen an klinische Prufungen mit MP diskutiert. Publizierte klinische Prufungen aus dem Bereich der analen Inkontinenz (AI) werden unter Anwendung der Richtlinien auf ihre Qualitat hin untersucht. Ergebnisse: Therapiestudien zu MP bei AI haben erhebliche methodische Mangel, die eine Nutzenbewertung nicht gestatten. Schlussfolgerung: Qualitativ hochwertige und ausreichend grose klinische Prufungen von MP zum Nachweis der Wirksamkeit von Therapien sind zwingend erforderlich. Ohne diese sind keine Nutzenbewertungen moglich, die die Basis fur Kostenerstattungen sind.

Background The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline. Methods An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. Results Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery. Conclusions Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

Background: Anesthesia per se and pneumoperitoneum during laparoscopic surgery lead to atelectasis and impairment of oxygenation. We hypothesized that a ventilation with positive end-expiratory pressure (PEEP) during general anesthesia and laparoscopic surgery leads to a more homogeneous ventilation distribution as determined by electrical impedance tomography (EIT). Furthermore, we supposed that PEEP ventilation in lung-healthy patients would improve the parameters of oxygenation and respiratory compliance. Methods: Thirty-two patients scheduled to undergo laparoscopic cholecystectomy were randomly assigned to be ventilated with ZEEP (0 cmH2O) or with PEEP (10 cmH2O) and a subsequent recruitment maneuver. Differences in regional ventilation were analyzed by the EIT-based center-of-ventilation index (COV), which quantifies the distribution of ventilation and indicates ventilation shifts. Results: Higher amount of ventilation was examined in the dorsal parts of the lungs in the PEEP group. Throughout the application of PEEP, a lower shift of ventilation was found, whereas after the induction of anesthesia, a remarkable ventral shift of ventilation in ZEEP-ventilated patients (COV: ZEEP, 40.6 ± 2.4%; PEEP, 46.5 ± 3.5%; P

BACKGROUND Iatrogenic colon perforation is a rare but life-threatening complication of colonscopy. As in other diseases, laparoscopic treatment has increasingly been propagated for the treatment of colonic disorders in the last years. The aim of this comparative study was to answer the question of whether laparoscopic surgical treatment may serve as a suitable treatment for the acute colon perforation comparable to open surgery. PATIENTS AND METHODS The data of all patients who underwent surgery for iatrogenic colon perforation within a 13-year time period (1997-2009) were recorded prospectively and analysed retrospectively with regard to different perioperative parameters. In the following analysis the laparoscopically and open surgically treated patients were compared. RESULTS In the observation period 24 patients with iatrogenic colon perforation were treated laparoscopically and 12 patients with open surgery. There were no significant differences concerning age in both groups. In both groups resection of the affected region was preferred [open surgically: 58 % (n = 7), laparoscopically: 80 % (n = 19)]. The median operation time was 105 min (range: 35 - 180) for the open surgically treated patients and 165 min (90 - 420) for laparoscopic procedures (p = 0.006). In 4 cases of the laparoscopic group a conversion via laparotomy was -necessary. There was no significant difference concerning the hospital stay between both groups with 14.5 days (7-40) for the open surgical and 11 days (7-25) for the laparoscopic group. Concerning the postoperative morbidity a significantly higher incidence could be seen in the open surgical group (p < 0.0001). CONCLUSION An iatrogenic colon perforation mostly leeds to the immediate indication for a surgical treatment. The morbidity and mortality is -primarily determined through the appearance of postoperative complications due to delays in diagnostics and treatment. In this study the feasibility of a laparoscopic treatment could be shown. The laparoscopy with its minimal access trauma offers an enlargement of the diagnostics as well as a safe treatment of the perforation in most patients. However, the laparoscopic treatment especially in emergancy situations requires -advanced experience of the surgeon and always needs a critical benefit-risk consideration in the individual situation.

BACKGROUND: Colorectal cancer is one of the most common malignant diseases in the industrialized nations. Despite advances in research on tumor development and biology, improved therapeutical concepts, and an increasing motivation to undergo screening examinations and surveillance programs the overall mortality remains high. METHODS: PubMed database was used to screen the current literature for the topics of epidemiology, colorectal cancer development, histopathologic features, and diagnosis in colorectal cancer. RESULTS: A general overview of epidemiologic data in terms of incidence, geographic differences in occurrence and risk factors is given. Molecular mechanisms for the formation of colorectal cancer within the adenoma-carcinoma sequence are explained and additional aspects such as ploidy-status of colorectal tumors and microsatellite instability put into perspective. Various variables of routine histopathologic evaluation are summarized, more advanced analyses explained and prognostically relevant features listed. Diagnostic workup and staging of patients with colorectal cancer are based on several different techniques which are discussed for their effectivity, sensibility and sensitivity. CONCLUSIONS: Early detection of colorectal cancer together with a more detailed understanding of tumor heterogeneity and the prospect of tailoring individualized therapeutical concepts constitute essential factors in order to further ameliorate the outcome of colorectal cancer patients.

BACKGROUND: Laparoscopic colorectal procedures for the treatment of benign disorders are increasingly appreciated and have become the standard procedure for e.g. surgical treatment for recurrent diverticulitis. METHODS: Data show that even laparoscopic surgery for left sided colon cancer is seen as oncologically equal to the classic open resection. Laparoscopic resections offer several benefits e.g. minimal impairment of gastrointestinal and pulmonary functions, lower immunosuppression, shorter hospital stay, and faster reconvalescence. RESULTS: However, laparoscopic resections for rectal cancer are still discussed controversially as concerns are raised in terms of oncologic radicality, port-site metastases, autonomic nerve preservation, and completeness of total mesorectal excision especially in obese male patients with a tight pelvis. CONCLUSIONS: The clinical reality and several studies demonstrate that laparoscopic rectal surgery for cancer is oncologically feasible, lymph node dissection is equivalent to open surgery, and the incidence of port-site recurrence is not increased compared to wound recurrence in conventional laparotomy.

Hintergrund Bis dato ist die Technik der laparoskopischen Leberchirurgie lediglich in einzelnen Zentren bei einem hoch selektierten Patientenkreis etabliert. In einer Umfrage wurde der Stand der laparoskopischen Leberchirurgie in Deutschland im Jahr 2008 ermittelt.

Hintergrund Eine konservativ interventionell nicht beherrschbare gastrointestinale Blutung (GIB) ist bis heute vital bedrohlich. Wir analysieren die Ergebnisse nach chirurgischer Intervention in dieser Situation und stellen unsere diagnostische und therapeutische Strategie vor.

Der gastrointestinale Notfall in der Onkologie besitzt eine enorme Bandbreite an Manifestation, Ursache und Schwere sowie u.U. Dramatik. Die Therapie sollte somit immer im interdisziplinaren Konsens zwischen Chirurgen, Onkologen, Gastroenterologen und Intensivmediziner erfolgen. Hierbei ist insbesondere der individuelle Zustand des Patienten (Alter, Vorerkrankungen, bisher durchgefuhrte Therapie, Organfunktionen, Prognose etc.) in der Therapieentscheidung zu berucksichtigen. Grundsatzlich sollte das Primum movens jeglichen therapeutischen Handelns die Sanierung der Komplikationsursache sein und daruber hinaus den Prinzipien der onkologischen Radikalitat Rechnung tragen. Die klinische Manifestation der Perforation und Blutung wird in Abhangigkeit ihrer Ursache und der entsprechenden Organlokalisation diskutiert. Die sich hieraus ableitenden diagnostischen und therapeutischen Masnahmen erlauben im interdisziplinaren Konsens die notwendige Individualisierung der Therapie.

Background Postoperative surveillance after curative resection for colorectal cancer has been demostrated to improve survival. It remains unknown however, whether intensified surveillance provides a significant benefit regarding outcome and survival. This study was aimed at comparing different surveillance strategies regarding their effect on long-term outcome. Methods Between 1990 and 2006, all curative resections for colorectal cancer were selected from our prospective colorectal cancer database. All patients were offered to follow our institution's surveillance programm according to the ASCO guidelines. We defined surveillance as "intensive" in cases where > 70% appointments were attended and the program was completed. As "minimal" we defined surveillance with < 70% of the appointments attended and an incomplete program. As "none" we defined the group which did not take part in any surveillance. Results Out of 1469 patients 858 patients underwent "intensive", 297 "minimal" and 314 "none" surveillance. The three groups were well balanced regarding biographical data and tumor characteristics. The 5-year survival rates were 79% (intensive), 76% (minimal) and 54% (none) (OR 1.480, (95% CI 1.135-1.929); p < 0.0001), respectively. The 10-year survival rates were 65% (intensive), 50% (minimal) and 31% (none) (p < 0.0001), respectively. With a median follow-up of 70 months the median time of survival was 191 months (intensive), 116 months (minimal) and 66 months (none) (p < 0.0001). After recurrence, the 5-year survival rates were 32% (intensive, p = 0.034), 13% (minimal, p = 0.001) and 19% (none, p = 0.614). The median time of survival after recurrence was 31 months (intensive, p < 0.0001), 21 months (minimal, p < 0.0001) and 16 month (none, p < 0.0001) respectively. Conclusion Intensive surveillance after curative resection of colorectal cancer improves survival. In cases of recurrent disease, intensive surveillance has a positive impact on patients' prognosis. Large randomized, multicenter trials are needed to substantiate these results.

Background Mucoceles of the appendix are rare. After appendectomy, mucoceles are detected with a frequency of 0.2 to 0.3 %. Both stenosing / obliterating processes and alterations of the epithelium (hyperplasia, mucinous cystadenoma, cystadenoma with uncertain malignant potential (UMP), mucinous cystadenocarcinoma lead to the occurrence of mucoceles. The perforation of a mucocele with possible spread of mucus and cells into the abdominal cavity constitutes a severe complication (pseudomyxoma peritonei). Surgical resection is the curative approach for mucoceles of the appendix. Materials and methods Data of patients who were treated for an appendiceal mucocele between 1995 and 2009 were analysed retrospectively with regard to clinical presentation, diagnostic measures, surgical procedure and histopathological result. Follow-up was evaluated in telephone interviews. Results We extracted 5 cases from our database. Clinical symptoms varied greatly among the individual patients, ranging from peracute abdominal pain in the right lower quadrant to chronic obstipation. Results from abdominal ultrasound and / or abdominal CT scans contributed to the indication for surgical intervention in all cases. In 2 patients surgery was stated as urgent whereas in 3 the operation was scheduled electively. In one patient the diagnosis of an appendiceal mucocele was stated preoperatively and in another intraoperatively. In 3 patients only the histopathological result revealed the underlying mucocele. We performed 1 open and 1 laparoscopic appendectomy, 1 open appendectomy with a partial resection of the coecum and 2 laparoscopic ileocoecal resections. One of the patients had a pseudomyxoma peritonei. The histopathological diagnoses ranged from mere epithelial hyperplasia to an adenoma with uncertain malignant potential and a mucinous cystadenocarcinoma. One patient's long-term follow-up could not be evaluated. All other patients had neither recurrence nor any complications after discharge. Conclusions Mucoceles of the appendix present with a wide spectrum of clinical symptoms and histopathological alterations. Only an accurate histological analysis reveals the underlying pathological lesion correctly. This study emphasises that a mucocele of the appendix constitutes an important differential diagnosis in patients presenting with pathologies in their right lower abdominal quadrant.

Als Standardverfahren zur praoperativen bildmorphologischen Diagnostik bei Patienten mit zentralen malignen Lungentumoren ist das axiale 2-D-Computertomogramm des Thorax akzeptiert und etabliert. Tumorausdehnung, Infiltration von zentralen Strukturen oder segmentaler Bezug sind entscheidende Parameter zur Abklarung der technischen Operabilitat und des Resektionsausmases. Durch computergestutzte Methoden der Segmentierung anatomischer Strukturen in CT-Daten (Fraunhofer MeVis, Bremen) ist erstmals eine selektive dreidimensionale Visualisierung moglich. Im Zeitraum zwischen 08/07 und 06/09 wurden 22 Patienten mit zentralem Lungentumor in der Thoraxchirurgischen Abteilung der Universitat Schleswig-Holstein, Campus Lubeck, behandelt. 15 Manner, 7 Frauen, mittleres Alter bei Diagnosestellung 60,2 Jahre (Spannweite 41–74 Jahre). Lediglich 4 von 22 Patienten waren Nichtraucher gewesen, die ubrigen 18 Patienten hatten eine zum Teil erhebliche Raucheranamnese. 20 Patienten hatten ein primares Bronchialkarzinom, je ein Patient hatte ein Lokalrezidiv nach Tumorlobektomie bzw. eine zentrale Lungenmetastase eines extrapulmonalen Primarius. In allen Fallen wurde praoperativ ein Dunnschicht-MSDCT (Multi-slice detector computer tomogramm) angefertigt. Die Daten wurden mittels computerassistierter Software dreidimensional rekonstruiert und visualisiert. Lungenfunktionstests, geschatzte postoperative Lungenrestfunktion, Bronchoskopiebefund, Allgemeinzustand des Patienten sowie die 3-D-rekonstruierten CT-Datensatze wurden zur individuellen praoperativen Risikoanalyse und Auswahl der Operationstaktik verwendet. Vierzehn der 22 Patienten wurden aufgrund der durchgefuhrten Risikoanalyse operiert, 7 Patienten wurden als funktionell inoperabel eingestuft, ein Patient war technisch inoperabel. Insgesamt wurden 5 Pneumonektomien, 4 Bi-/Lobektomien, 3 erweiterte Lobektomien und jeweils eine atypische Resektion und eine Manschettenresektion durchgefuhrt. 2 Patienten wurden im Stadium I operiert, 7 Patienten im Stadium II und 3 Patienten im Stadium IIIa. Der mediane stationare Aufenthalt betrug 8,5±33,0 Tage. Die Hospitalletalitat betrug bei 0%. Die 3-D-Visualisierung des Tumors sowie der anatomische Bezug zu Nachbarstrukturen waren in allen Fallen exakt moglich. Intraoperativ konnte die 3-D-Rekonstruktion zu 100% validiert werden. Die computerassistierte 3-D-Rekonstruktion eines Thorax-CT ist eine neuartige und vielversprechende Methode zur praoperativen Darstellung und Risikoanalyse von zentralen Lungentumoren. Die 3-D-Visualisierung des Tumors in Kombination mit farbkodierter Lappenzugehorigkeit, beweglich in allen Ebenen, ermoglicht dem Chirurgen eine differenzierte Strategieplanung bei zentralen Lungentumoren.

BACKGROUND: In laparoscopic colon surgery, endostaplers generate 2 parallel rows of staples. The aim of this paper is to analyse whether the introduction of a new endostapler generating a third row of staples influences the rate of anastomotic leakage and bleedings. METHOD: 362 patients of the Department of Surgery, University Clinic of Schleswig-Holstein, Campus Lubeck, were included in this study. All patients underwent colon resection with performance of double-stapling anastomosis. In Group I (n = 148; 7 / 2004 to 12 / 2005), the Endopath® TSB 45 endostapler (2 rows of staples) was used, whereas in Group II (n = 214; 7 / 2006 to 12 / 2007), the Echelon™60 EC60 stapler (3 rows of staples) was used. All further operational steps were identical for both groups. Target parameters were the postoperative anastomotic leakage and anastomotic bleeding rates. RESULTS: Between July 2004 and December 2005, the number of anastomotic leaks (Stapler Endopath®, TSB 45) was n = 4 (2.7 %), for the second period (Stapler Echelon™60 EC60), it was n = 9 (3.7 %) (not significant). Using the Endopath® TSB 45 stapler, the number of anastomotic bleedings was n = 12 (8.1 %), and for the Echelon™60 EC60 stapler, it was n = 8 (3.7 %) (p = 0.074; not significant). Within the 18-month period between July 2006 and December 2007, the number of endoscopic colon operations (n = 214) rose by 44.6 % compared to the 18-month period between July 2004 and December 2005 (n = 148). CONCLUSION: The application of the advanced Echelon endostapler has no impact on the number of anastomotic leaks, and reduces the number of anastomotic bleedings slightly but not significantly. The increased number of endoscopic procedures in the second period results both from the growing number of indications for the application of endoscopic techniques and the positive findings of recent studies carried out by our own and other working groups.

Diagnostics and therapy of anorectal disorders remain a surgical question. In close cooperation between different departments (radiology and gastroenterology, urology and gynecology, dermatology and psychology), the role of radiologic imaging is of growing importance. Exact knowledge of functional anatomy and precise clinical examination constitute the basis of the according therapeutic strategies. In this context radiology has contributed decisively. Developments in imaging techniques, e.g. dynamic MRI, highly contributed to better understanding of complex functional pelvic floor disorders. The combination of nanotechnology and high-resolution imaging allows precise staging, especially in rectal cancer. Furthermore, advances in virtual colonoscopy could lead to widely acceptable and patient-friendly screening for colorectal malignancies.

Background In spite of the important role of conservative treatment, up to 90 % of all patients with Crohn's disease will undergo an operation during the course of their illness. Up to 50 % even need a second operation or further surgical procedures - with an increasing risk for perioperative complications. This study was designed to identify the risk factors for recurrence in patients with Crohn's disease and the influence of the primary operation. Methods Between 1986 and 2004, 412 patients with Crohn's disease required operative treatment. 218 underwent a primary procedure and 194 needed a reoperation. In particular, the indications for surgical treatment, the surgical procedures and the perioperative complications were registered and evaluated in the context of a possible recurrence of Crohn's disease. In this study, "recurrence" is defined as a reoperation because of Crohn's disease after a primary operation. Results The most common indications for a surgical treatment were stenosis (58.4 %) and fistulas (38.5 %). As the most frequent procedures, the ileocoecal resection and the partial resection of the small bowel were performed. Altogether, the complication rate was 11.5 %. The primary procedures (6.52 %) had less complications than the operations for a recurrence of Crohn's disease (17.70 %). The rate for the recurrence of Crohn's disease was 17.4 % after 5 years, 36.7 % after 10 years and 52.8 % after 15 years. Patients with fistulas as the indication for primary operation had the highest rate of recurrence (45 %). Patients with an isolated Crohn's lesion of the small intestine had a significantly higher risk for recurrence (59.5 %) than patients with lesions in the ileocoecal region or the colon. The anastomosis region (73 %) was the most common localisation for recurrence. Conclusion On the basis of defined risk factors, patients with a high risk for recurrence can be identified. This is very important because of the higher risk for complications caused by reoperations compared to primary procedures. That is why interdisciplinary cooperation including postoperative care and optimal conservative treatment are absolutely essential.

A 17-year-old girl from Turkey had for 6 years been suffering from right-sided upper abdominal symptoms not usually related to food intake. Treatment of suspected gastritis remained ineffective. Laboratory tests were unremarkable, except for an accelerated erythrocyte sedimentation rate (12/30 mm), eosinophilia (6.4%) and albumin concentration of 52.6 g/l. Upper abdominal sonography revealed a cyst, about 10 cm in diameter, in the right liver lobe. Computed tomography showed the 8 x 8.5 cm cyst which was septated at its caudal portion and compressed the vena cava for 5.6 cm. The antibody titre against echinococcus antigen was 1:3200. At laparotomy the echinococcal cyst was found to have extended to the left adrenal gland, renal fat capsule and left part of the diaphragm. There was a pressure necrosis on the right lateral aspect of the vena cava. The affected parts were resected and the patient quickly recovered. Postoperative treatment consisted of the administration of mebendazole (1.5 g daily) for 18 months. The patient had come from an area where echinococcal infection is endemic. The disease could have been quickly and easily diagnosed and cured if sonography had been undertaken early, sparing the patient major surgery.

Background and aims Despite improved techniques, the determination of tumor origin in poorly differentiated adenocarcinomas still remains a challenge for the pathologist. Here we report the use of protein profiling combined with principal component analysis to improve diagnostic decision-making in tumor samples, in which standard pathologic investigations cannot present reliable results. Materials and methods A poorly differentiated adenocarcinoma of unknown origin located in the pelvis, infiltrating the sigmoid colon as well as the ovary, served as a model to evaluate our proteomic approach. Firstly, we characterized the protein expression profiles from eight advanced colon and seven ovarian adenocarcinomas using two-dimensional gel electrophoresis (2-DE). Qualitative and quantitative patterns were recorded and compared to the tumor of unknown origin. Based on these protein profiles, match sets from the different tumors were created. Finally, a multivariate principal component analysis was applied to the entire 2-DE data to disclose differences in protein patterns between the different tumors. Results Over 89% of the unknown tumor sample spots could be matched with the colon standard gel, whereas only 63% of the spots could be matched with the ovarian standard. In addition, principal component analysis impressively displayed the clustering of the unknown case within the colon cancer samples, whereas this case did not cluster at all within the group of ovarian adenocarcinomas. Conclusion These results show that 2-DE protein expression profiling combined with principal component analysis is a sensitive method for diagnosing undifferentiated adenocarcinomas of unknown origin. The described approach can contribute greatly to diagnostic decision-making and, with further technical improvements and a higher throughput, become a powerful tool in the armentarium of the pathologist.

Folgt man dem Zitat „Ubung macht den Meister“ wurde dies auf den Medizinsektor ubertragen bedeuten, dass Arzte und Krankenhauser mit groseren Behandlungsvolumina an bestimmten Eingriffen auch bessere Ergebnisse in diesem Bereich erzielen als „Low-volume“-Institutionen. In den letzten drei Jahrzehnten wurde eine Vielzahl von Studien, vor allem im onkologisch-chirurgischen Bereich und der Gefaschirurgie sowie fur kardiologische Interventionen, zur moglichen Assoziation von Behandlungsmenge und Behandlungsqualitat publiziert. Auch fur kolorektale Karzinome konnte gezeigt werden, dass der „case-load“ pro Chirurg ein wichtiger, aber bei weitem nicht der einzige therapieassoziierte Prognosefaktor ist.

The treatment of severe diffuse peritonitis is still associated with a mortality of up to 50 %. Particularly the postoperative peritonitis shows high mortality rates due to septic organ failures. The aim of surgical treatment is the definitive source control followed by removal of fibrin and abdominal lavage of contaminants and infectious fluids. Dependent on the severity of the peritoneal reaction, further treatment consists of primary abdominal closure and relaparotomy on demand, programmed lavage or laparostomy respectively. Septic complications have to be treated by intensive care medicine.

Ein wesentliches Anliegen der modernen Chirurgie ist die Reduktion des Zugangstraumas, um die operative Behandlung fur den Patienten weniger belastend zu gestalten. Ohne Zweifel hat die minimal-invasive Chirurgie in den letzten 10 Jahren entscheidend zur Verbesserung der operativen Therapieergebnisse in der Viszeralchirurgie beigetragen und gilt daher als die dritte patientenfreundliche Revolution in der Chirurgie nach Einfuhrung der Asepsis und der Anasthesie. Operationen, die vor einigen Jahren noch grose Belastungen fur den Patienten bedeuteten und der Gesellschaft erhebliche Kosten durch Arbeitsunfahigkeit und umfassende Rehabilitationsmasnahmen verursachten, haben durch den minimal-invasiven Zugang viel von ihrem Schrecken verloren. Die korperliche Belastung ist ungleich niedriger, der kosmetische Effekt positiv und durch die wesentlich kurzere Rekonvaleszenz konnten die Kosten fur die Gesellschaft deutlich reduziert werden.

Dysphagia is a severe symptom that has to be clarified. A rare cause of dysphagia is the perforation of the esophagus. We report about two cases of perforations of the esophagus from osteosynthesis material: in an 88-year-old patient 7 years after ventral cervical spondylodesis of C 5-7 and in a 66-year-old female one year after corporectomy and replacement of cervical spine corps of C 2-Th 2 by a titanium basket. Arrosion with perforation of the esophagus is a (rare but) well known complication in surgical therapy of degenerative, traumatic or neoplasmatic cervical spine diseases. Surgery should be first line therapy. In exceptional cases for example with a high surgical risk it may be treated conservatively.

UNLABELLED DIAGNOSTIC FINDINGS: We report about a 83 years old female with persisting abdominal pain for 3 days. Abdominal x-ray, as well as abdominal ultrasound examination were unsuccessful. CT scan revealed a 7 cm tumor, suspicious for abscess. OPERATION: Diagnostic laparotomy showed a 6 cm inflammatory tumor with covered perforation of a jejunal diverticula at the 4th intestinal loop distal the ligament of Treitz. We performed a segmental resection. FOLLOW UP Clinical follow-up was uneventful, the patient was without any symptoms within the first 6 months. Pre- and intraoperative pathology will be explained and discussed referring to the literature.

Das akute Abdomen reprasentiert kein eigenstandiges Krankheitsbild, sondern eine Zustandsbeschreibung, die mit der Entwicklung starker abdomineller Schmerzen innerhalb weniger Stunden verbunden ist. Das Behandlungskonzept des akuten Abdomens fordert in der Regel eine interdisziplinare Strategie mit dem Ziel der raschen Diagnosestellung und Therapieeinleitung. Dies setzt den zielfuhrenden Einsatz effizienter Diagnostik voraus. Einen besonderen Stellenwert nimmt hierbei die diagnostische Laparoskopie ein. Durch diese Technik ergeben sich nicht nur diagnostische, sondern auch gleichzeitig therapeutische Optionen. Insbesondere die Rate der „negativen“ Laparotomien kann gesenkt werden.

Zur invasiven Therapie der arteriellen Verschlusskrankheit (AVK) stehen verschiedene operative und interventionelle Behandlungsformen zur Verfugung. Die Auswahl der geeigneten Methode richtet sich nach dem Allgemeinzustand des Patienten, der Morphologie des arteriellen Verschlusses, dem Komplikationsrisiko und der Erfolgswahrscheinlichkeit der jeweiligen Behandlung im Langzeitverlauf. Hierbei konkurrieren die verschiedenen Verfahren nur oberflachlich betrachtet miteinander, sie erganzen sich in ihren jeweiligen technischen Moglichkeiten und dem Risikoprofil. Die Kombination chirurgischer und interventioneller Methoden bietet neue Behandlungsoptionen. Im Rahmen dieses Artikels werden die verschiedenen Operationsverfahren und deren Ergebnisse dargestellt.

In contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis. The aim of this study was to analyze surgical challenge in right-sided diverticulitis. All patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996–2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry. From a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens. As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.

The aim of this study was to determine the prognostic role of matrix metalloproteinases in rectal cancer.Formalin-fixed and paraffin-embedded tissue sections of 94 rectal carcinomas were used for the immunohistochemical analysis of matrix metalloproteinases (MMP)-2, MMP-7, MT1-MMP, and tissue inhibitor of metalloproteinases (TIMP)-2. Inclusion criteria were sporadic rectal adenocarcinoma resected curatively (including total mesorectal excision), adjuvant radiochemotherapy in UICC stages II and III, and complete intra-institutional follow-up. Results of immunohistochemistry were correlated with clinical and histopathologic data from the prospective rectal cancer registry and prognosis. End points of the prognostic analysis were tumor progression caused by local and/or distant recurrence and 5-year survival (disease-free and overall). To assess prognostic significance, statistics included univariate and multivariate analysis (p0.05 statistically significant).Of the 94 rectal carcinomas, 35% (33/94) showed an epithelial MMP-2 expression, 77% (72/94) were MMP-2 positive in the stroma. Fifty-four percent (51/94) were MMP-7 positive, and 47% (46/94) were positive for both MT1-MMP and TIMP-2. The stromal MMP-2 staining pattern was correlated with the depth of invasion (pT status, p=0.006) with MMP-7 (p=0.016) and TIMP-2 expression (p=0.036). Positive expression of MMP-2 in tumor epithelium was correlated with MMP-7 (p=0.027), MT1-MMP (p=0.036), and TIMP-2 expression (p0.0001). A positive staining pattern of MMP-7 was significantly correlated with depth of invasion and TIMP-2 (p0.01). The positive staining pattern of MT1-MMP was correlated with epithelial MMP-2 (p=0.036), MMP-7 (p=0.004), and TIMP-2 expression (p=0.002). TIMP-2 immunoreactivity correlated with depth of invasion (p=0.013), epithelial MMP-2 (p0.001), stromal MMP-2 (p=0.036), MMP-7 (p0.001), and MT1-MMP (p=0.002). Neither pattern correlated with age, gender, tumor stage (UICC), grading, preoperative serum carcinoembryonic antigen (CEA) level, or nodal status (p0.05). Within a mean follow-up of 46 months, tumor progression, caused by either local recurrence or distant metastasis, occurred in 14 patients (15.4%). There was no significant association between the MMP expression and the incidence of local and/or distant recurrence. In terms of survival, preoperative CEA level (disease-free 5-year survival 46% with increased CEA vs 70% with normal CEA, p=0.01; overall 5-year survival 43 vs 74%, p0.01) and UICC stage were the only factors to be significantly related to 5-year survival by univariate analysis, whereas the metalloproteinases failed to show a significant association. In multivariate analysis, CEA and UICC stage were not identified as independent factors predictive of survival.MMP-2, MMP-7, MT1-MMP, and TIMP-2 do not appear to be significant predictors of prognosis in a homogenous collective of curatively resected rectal adenocarcinomas.

BACKGROUND: Up to 80% of all patients with Crohn's disease undergo one or more operations during the course of their illness, despite the fact that conservative treatment plays the major role in Crohn's disease. Efficiency and safety of Crohn-surgery are well proven, but the characteristics of this incurable disease cause reoperations in up to half of all patients. So the objective in today's Crohn-surgery has to be: reduction of operative trauma while retaining a well established treatment regime. Minimal invasive surgery (MIS) appears useful for meeting these requirements. METHODS: From 8/94 to 12/03 60 patients with Crohn's disease underwent minimal-invasive operative treatment. Average age in these 38 females and 22 males was 33.1 years (16–63 ys.). Indications for laparoscopically assisted ileoceocal-resection (ICR) (n = 33), right-hemicolectomy (n = 3), left-hemicolectomy (n = 3), resection of sigmoid (n = 4), colectomy (n = 1), colostomy (n = 2) or ileostomy (n = 14) were non-responding to medical therapy or symptomatic stenosis. Exclusion criteria for laparoscopic treatment were large intraabdominal abscesses or fistulae, acute obstruction or perforation and toxic colitis. RESULTS: In 57 patients the operation could be finished laparoscopically. In 3 cases multiple adhesions required conversion to laparotomy. There were no intraoperative complications. Mean operation time was 145 min (35–360 min). In 3 cases postoperative complications (small bowel obstruction, diffuse hemorrhage, peritonitis) required surgical treatment. There was one parastomal hernia 6 months postoperatively. CONCLUSIONS: Our results show – as in the collected literature covering a total of 885 interventions – that laparoscopically assisted bowel resection or fecal diversion can be undertaken with good outcome in well-selected patients with Crohn's disease. Because of individual variation in Crohn surgery, small patient numbers and the lack of controlled randomized studies, no definite evaluation of this therapeutical option can be made at this point in time. Our positive assessment of MIS in Crohn's disease is based on well-known advantages such as increased patient-comfort.

Because of the creation of a pneumoperitoneum, impairment of ventilation is a common side-effect during laparoscopic surgery. Electrical impedance tomography (EIT) is a method with the potential for becoming a tool to quantify these alterations during surgery. We have studied the change of regional ventilation during and after laparoscopic surgery with EIT and compared the diagnostic findings with computed tomography (CT) scans in a porcine study. After approval by the local animal ethics committee, six pigs were included in the study. Two laparoscopic operations were performed [colon resection (n=3) and fundoplicatio (n=3)]. The EIT measurements (6th parasternal intercostal space) were continuously recorded by an EIT prototype (EIT Evaluation Kit, Drager Medical, Lubeck, Germany). To verify ventilatory alterations detected by EIT, a CT scan was performed postoperatively. Ventilation with defined tidal volumes was significantly correlated to EIT measurements (r 2=0.99). After creation of the pneumoperitoneum, lung compliance typically decreased, which agreed well with an alteration of the distribution of pulmonary ventilation measured by EIT. Elevation of positive end-inspiratory pressure reopened non-aerated lung areas and showed a recovery of the regional ventilation measured by EIT. Additionally, we could detect pulmonary complications by EIT monitoring as verified by CT scans postoperatively. EIT monitoring can be used as a continuous non-invasive intraoperative monitor of ventilation to detect regional changes of ventilation and pulmonary complications during laparoscopic surgery. These EIT findings indicate that surgeons and anesthetists may eventually be able to optimize ventilation directly in the operating theatre.

The aim of this study was to assess the results of laparoscopic stoma creation for fecal diversion, specifically focussing on feasibility, safety, and efficacy, as well as indications and techniques. Within a 10-year-period, all patients requiring laparoscopic stoma creation were evaluated prospectively. Patients’ profiles and indications, procedures and results of operation, conversion, morbidity, mortality and short-term complications (stoma-related, laparoscopy-associated) were analyzed. A total of 80 patients (39 males, 41 females) with a mean age of 55.5 years (range, 17–91) underwent laparoscopic stoma creation. Most common indications were unresectable advanced colorectal cancer (n=20), pelvic malignant cancer (e. g. ovarian, cervix and prostate cancer, n=16), and perianal Crohn’s disease with complex fistulas (n=16). Only in one female patient with pelvic malignant disease was the procedure converted to laparotomy due to obesity (conversion rate, 1.3%). 79 patients underwent laparoscopic stoma creation (completion rate, 98.7%) including loop ileostomy (n=30), loop sigmoid colostomy (n=40) and end sigmoid colostomy (n=9). Postoperative complications were documented in 9 patients (overall morbidity rate, 11.4%), including 4 minor complications treated conservatively (2 cases of prolonged atonia and 1 case each of pneumonia and urinary tract infection) and 5 major complications requiring reoperation (reoperation rate, 6.3%): one parastomal abscess (drainage), one stoma retraction following rod dislocation (laparoscopic stoma recreation), small bowel obstruction in two patients (small bowel resection), one port-site hernia (fascial closure), and hemorrhage (managed by re-laparoscopy). Mean operation time was 74 min (range, 30–245 min). Mean blood loss volume was 80 ml (range, 30–400 ml). Patients were discharged from hospital after a mean of 10.3 days (range, 3–47). Within a 1-year follow-up, no further stoma complications were documented. The advantages of laparoscopic stoma creation are low morbidity and reoperation rates, and no procedure-related mortality; our results suggest that laparoscopic stoma creation for fecal diversion is safe, feasible and effective. Therefore, at our institution, laparoscopic stoma creation is the method of choice for fecal diversion.

Patients suffering from type I diabetes mellitus have a descending expectancy of life, after developing diabetic nephropathy and undergoing haemodialysis. After 3 years of haemodialysis, approximately only 40% of the patients are still alive. The only remedy of this incurable metabolic disease is the simultaneous pancreas-kidney transplantation. After transplantation, fungal colonization and fungal infection is a serious threat for the patient's life. In this context, it is necessary to distinguish between colonization and invasive mycosis. In the case of unsuccessful antimycotic treatment, the removal of the transplanted organ, depending on the patient's condition, may be necessary to save the patient's life.

Systemic mycoses, especially pulmonary diseases and septicemia are observed increasingly at intensive care units. Essential risk factors for development of candidosis are the expanded use of antibiotics and immunocompromised patients, caused either as a result of a severe underlying disease or iatrogenically induced after organ transplantation. Candida albicans is the most frequent pathogen in microbiological findings. Blood cultures are only positive in massive fungemia. We report a 50-year-old patient with recurrent Candida-septicemia: rupture of the distal esophagus after dilatation because of cardiac achalasia with mediastinal emphysema and mediastinitis. Severe acute respiratory distress syndrome after aspiration with septic shock and acute renal failure at the beginning. Long-term mechanical ventilation, continuous renal replacement therapy and multifarious antibiotic therapy. Early microbiological samples of several positive blood cultures and bronchoalveolar lavages revealed the presence of Candida albicans. In the further clinical course, detection of Pseudomonas species in bronchoalveolar lavages and Staphylococci as well as Enterococci in a number of positive blood cultures. Later on development of a severe liver dysfunction with test results that showed an intrahepatic cholestasis. Because of coagulation failure commencement of artificial liver support with the MARS-system (molecule adsorbent recirculating system). Decrease of high bilirubin levels was accompanied by improvement of clinical condition of the patient. In the following course, repeated severe systemic infections with phases of septicemia or rather septic shock and detection of Candida in several positive blood cultures and bronchoalveolar lavages. In each case increasing bilirubin levels with signs of intrahepatic cholestasis and each time improvement with antimycotic therapy (voriconazol, caspofungin and fluconazol). The patient showed more and more signs of immunodeficiency in the sequel. The clinical appearance of candidosis is manifold. Systemic Candida infections are frequent in patients with immunodeficiency. A recurrent Candida septicemia with prolonged respiratory failure and severe liver dysfunction in form of cholestatic hepatosis, that improved several times with antimycotic therapy in combination with evidence based intensive care measures and artificial organ support is a comparatively rare event.

Introduction Left-sided diverticulitis is a common disease in Western countries, whereas right-sided diverticultitis is rare and symptoms are often similar to the clinical signs of an acute appendicitis. It was the aim of this study to analyse surgical experience in right-sided diverticulitis. Methods All patients who underwent resectional surgery for both right-sided and sigmoid diverticular disease were entered prospectively in a registry database (8-year observation period, 1996-2003). For the current study, a retrospective analysis of all patients who underwent ileocolic resection or right colectomy for right-sided colonic diverticulitis was performed, specifically focussing on incidence, clinical symptoms, indication for surgery, type of procedure, and histopathological parameters including immunohistochemistry, and outcome in right-sided diverticulitis. Results Within eight years, 481 patients were treated surgically for chronically recurrent or acute complicated diverticular disease: 468 patients with sigmoid diverticulitis, 12 patients with right-sided diverticulitis, and 1 patient with combined right-sided and sigmoid diverticular disease. This corresponds to an incidence of right-sided diverticulitis of 2.5 % related to the total number of resections for diverticulitis, and an incidence of 1.3 % in relation to the appendectomies in our patients. In 4 patients, acute appendicitis was presumed preoperatively. Most common diagnostic tool was ultrasonography. Right colectomy was performed in 9 patients with complicated cecal diverticulitis, whereas ileocolic resection was performed in 2 patients and simultaneous ileocolic and sigmoid resection was carried out in one patient. Postoperatively, no morbidity occurred. Histopathological assessment showed local perforation in 75 % (9/12). Hypoganglionosis or aganglionosis was detected in 5 of 12 resected specimen. Discussion As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis can be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis, and surgery is only indicated in complicated right-sided diverticulitis. Resection of the inflamed colon with primary anastomosis is safe and can be performed by laparoscopy in experienced centers. At present, it can only be speculated whether hypoganglionosis or aganglionosis are causative factors in the etiology of right-sided diverticulitis.

INTRODUCTION The aim of this study was to compare functional outcome after transvaginal, transperineal and transrectal repair of a symptomatic rectocele and to develop the ideal surgical approach. PATIENTS AND METHOD 28 patients (27 female, 1 male) who had undergone rectocele repair from 1996 to 2003 were analysed. Mean age was 59 years (range 30-79 years), follow-up was 24 months (range 3 to 70 months) and mean appearance of symptoms was 4 years prior to the operation (6 months-32 years). Transvaginal repair was performed in 13 cases, transperineal repair in 8 cases and transrectal repair in 7 cases. RESULTS 24 of 28 patients (85.7 %) are satisfied with the operation-result (transvaginal 12 of 13 patients [92.3 %], transperineal 7 of 8 patients [87.5 %] and transrectal 5 of 7 patients [71.4 %]). 25 patients (89.3 %) are free of complaints or describe an evident improvement of symptoms (transvaginal 12 of 13 patients [92.3 %], transperineal 7 of 8 patients [87.5 %] und transrectal 6 of 7 patients [85.7 %]). There is one postoperative dyspareunia. DISCUSSION Best treatment of a rectocele starts with patients selection. Considering pelvic floor as functional unity, concomitant urologic-gynaecologic lesions and proximal intraabdominal disturbances the appropriate surgical procedure is selected. CONCLUSION Surgical approach to correct a symptomatic rectocele depends on the concomitant lesion.

It was the aim of this prospective study to compare the outcome of laparoscopic sigmoid and anterior resection for diverticulitis and non-diverticular disease.All patients who underwent laparoscopic colectomy for benign and malignant disease within a 10-year period were entered into the prospective PC database registry. For outcome analysis, patients who underwent laparoscopic sigmoid and anterior resection for diverticular disease were compared with patients who underwent the same operation for non-inflammatory (non-diverticular) disease. The parameters analyzed included age, gender, co-morbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion, morbidity including major (requiring reoperation), minor (conservative treatment) and late-onset (postdischarge) complications, stay in the ICU, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t-test and chi-square analysis (p0.05 was considered statistically significant).A total of 676 patients were evaluated including 363 with diverticular disease and 313 with non-inflammatory disease. There were no significant differences in conversion rates (6.6 vs. 7.3%, p0.05), so that the laparoscopic completion rate was 93.4% (n=339) in the diverticulitis group and 92.7% (n=290) in the non-diverticulitis group. The two groups did not differ significantly in age or presence of co-morbid conditions (p0.05). In the diverticulitis group, recurrent diverticulitis (58.4%), and complicated diverticulitis (27.7%) were the most common indications, whereas in the non-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%) were the main indications. The most common procedure was laparoscopic sigmoid resection, followed by sigmoid resection with rectopexy and anterior resection. No significant differences were documented for major complications (7.4 vs. 7.9%), minor complications (11.5 vs. 14.5%), late-onset complications (3.0 vs. 3.5), reoperation (8.6 vs. 9.3%) or mortality (0.6 vs. 0.7%) between the two groups (p0.05). In the postoperative course, no differences were noted in terms of stay in the ICU, postoperative ileus, parenteral analgesics, oral feeding, and length of hospitalization (p0.05).These data indicate that laparoscopic sigmoid and anterior resection can be performed with acceptable morbidity and mortality for both diverticular disease and non-diverticular disease. The results show in particular that laparoscopic resection for inflammation is not associated with increased morbidity.

Die klinischen Auspragungsformen der Beckenbodeninsuffizienz sind vielschichtig und reichen von der Defakationsobstruktion uber verschiedene Prolapszustande bis hin zur kombinierten Stuhl- und Harninkontinenz. Die Differenzialdiagnostik muss dieser Komplexitat entsprechen. Haufige Erkrankungen des Beckenbodens sind Descensus perinei, Rektozele, Rektumprolaps und Enterozele bzw. Sigmoidozele. Neben Anamnese und proktologischer Basisuntersuchung sind die Endosonographie und anorektale Manometrie, die Defakographie und die dynamische Beckenboden-MRT wichtige diagnostische Verfahren, um die haufig kombinierten Storungen bei der Beckenbodeninsuffizienz darzustellen. Sowohl Diagnostik als auch Therapie mussen in ein interdisziplinares Konzept eingebunden sein.