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Introduction: Aim of this study was to investigate the influence of diabetes mellitus (DM) onto the early postoperative and long-term oncosurgical outcome after surgery for rectal cancer using data prospectively obtained in a representative number of patients., Methods: Data (using a registration form of 68 items) from the ongoing multicenter observational study "rectal cancer (primary tumor) - elective surgery" on Quality Assurance was used including years 2008 to 2011. A voluntary and frequent follow-up was done to gain long-term data. Patients were grouped as non-diabetic and not-/insulin-dependent DM (NIDDM/IDDM)., Results: In total, 10 442 patients were enrolled; 11.0 % had NIDDM and 7.2 % IDDM. Average age of patients without DM was 67.3 [95 %-CI: 67,07; 67,55] years (yr) and was lower than in IDDM- (71.7 [95 %-CI: 71,01; 72,35] yr) and NIDDM-patients (70.9 [95 %-CI: 70.41; 71.45] yr) (p < 0.001). Tumor stages according to classification by UICC were comparable (p = 0.547). Patients with DM were more likely to be obese and to have cardiovascular and renal risk factors as well as a more critical ASA-classification (p < 0.001 each). Postoperative morbidity (in the group 65 - 74 yr; p = 0.006) and in-hospital mortality (< 65 yr; p = 0.011) was higher in patients with DM. The 5-year overall survival (OS) was 60.6 % in patients without DM. IDDM (46.4 %) and NIDDM (53.3 %) decreased the OS (p < 0.001 each). The 5-year disease-free survival (DFS) was also worsened by IDDM (p < 0.001) and NIDDM (p = 0.004). No difference was observed concerning 5-year local recurrence rate, neither for IDDM (p = 0.524) nor NIDDM (P = 0.058)., Discussion: The metabolic disorder DM has a significant impact onto the outcome after surgery for rectal cancer most likely due to its own risk potential and associated comorbidities. Postoperative morbidity and mortality were increased and the oncological survival was worsened., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Iatrogenic lesions of the spleen during surgery of colorectal carcinoma is considered a significant risk factor for a worse early postoperative outcome. With regard to the impact of iatrogenic splenic lesions particularly associated with splenectomy on the oncological long-term outcome, only limited valid data are available., Methods: Data obtained in a prospective multicenter observational study were analyzed. The study enrolled 45,265 patients with surgery for colorectal carcinoma in curative and palliative intentions during the study period from 01 January 2000 to 31 December 2004, with regard to the impact of iatrogenic splenic lesions on survival rates., Results and Conclusion: Follow-up data with corresponding informed consent were obtained from 564 patients with iatrogenic splenic lesions, resulting in a follow-up rate of 99.8 %. The median follow-up period was 50.2 months. The median 5-year overall survival was 4.8 years in group I (splenic lesion with splenectomy) and in group II (splenic lesion with organ preservation) 8.0 years (p = 0.009). Between group II (splenic lesion with organ preservation) and group III (control group with no splenic lesion) there were no significant differences with regard to long-term survival. Using multivariate Cox regression analysis, iatrogenic splenic lesions with splenectomy were identified as an independent risk factor for a worse oncological long-term outcome.

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.)

Introduction: Unlike gastric carcinomas, the consequences of spleen damage during operative treatment of colorectal carcinoma have barely been investigated, as splenectomy is not performed on these tumor patients to extend the radicality. In this context, the only interest is in the iatrogenic intraoperative spleen lesions, which make a splenectomy necessary or require reconstructive spleen preservation., Methodology: During the study period from January 2000 to the end of December 2004 the perioperative data of a prospective multicenter observational study of 46,682 Patients whose tumor had been removed with a curative or palliative intent were analyzed with respect to the early postoperative consequences of an iatrogenic spleen lesion., Results: Of these 46,682 Patients, 640 (1.4%) suffered an iatrogenic spleen injury during the operative therapy. The spleens of 127 Patients (0.3%) were removed and the spleens of 513 Patients (1.1%) could be left in situ following repair. In more than 80% of the cases with an iatrogenic spleen injury, the tumor was localized in the left colon and in the rectum. Logistic regression analysis showed that the decisive risk factor for this organ lesion was the mobilization of the left colonic flexure with tumor localization in the left colon and rectum. Following spleen lesion a significantly higher morbidity rate was registered (47.2% following splenectomy, 48.5% following spleen repair) compared to patients without spleen injury (36.5%). Anastomotic leaks requiring surgery were most frequently observed following splenectomy (7.9%) but this was significantly lower following spleen preservation (3.3%, p = 0.003). The total hospital mortality was 3.1%. In patients with splenectomy the hospital mortality was 11.8% and subsequent repair with organ preservation was 4.7% (p < 0.0001)., Conclusions: Iatrogenic spleen lesions during colorectal carcinoma surgery represent a significant risk factor for a poor early postoperative result. In particular, this concerns the high rate of anastomotic leaks and infectious septic complications. This also leads to a higher rate of total morbidity and hospital mortality. By comparison significantly worse postoperative results were found in the group of splenectomised patients compared to the group with organ preservation through repair of the injured spleen.

Background: Multi-center observational studies in surgery can yield important findings, as long as they are appropriately designed and monitored and employ modern methods of statistical analysis., Methods: In a multi-center quality assurance study carried out in 346 German hospitals from 2000 to 2004, data were collected from a total of 31 055 patients who underwent surgery for colon carcinoma. The current, overall state of medical care for this disease was analyzed, with particular attention to aspects of quality assurance., Results: 46.7% of the patients were in the advanced, prognostically unfavorable stages UICC III and IV and had an overall 5-year survival of 53.8% in stage III and 9.8% in stage IV. Laparoscopic intention-to-treat procedures were performed on 1401 patients (4.7%), of whom 20.6% required conversion to laparotomy. The patients who required conversion to laparotomy had a worse overall outcome. 28 271 patients were treated with tumor resection and primary anastomosis; in this group, 3% (n = 844) developed an anastomotic leak. Logistic regression analysis identified the following risk factors for anastomotic leakage: duration of surgery, ileus, tumor localization in the left colon, and single-layer suturing., Conclusion: This multi-center observational study yields valid findings about the epidemiology and overall quality of medical care for colon carcinoma in Germany.

Introduction: Randomized trials have demonstrated a reduction in local recurrence rate in rectal cancer patients treated with preoperative chemoradiotherapy and total mesorectal excision (TME) compared to patients undergoing TME alone. Accordingly, preoperative chemoradiotherapy in all UICC stages II and III rectal cancers has been recommended in the German treatment guidelines as of 2004. However, this policy has been questioned in recent years, partly due to concern regarding an increase in postoperative complications through preoperative therapy. Studies on this issue are sparse; most have been conducted in specialized centers, included relatively few patients, and yielded partly contradicting results. It was the aim of our analysis to investigate the influence of preoperative chemoradiotherapy on anastomotic leak rate and postoperative bladder dysfunction in rectal cancer patients using a representative data set from the Quality Assurance in Rectal Cancer Surgery multicenter observational trial., Method: This is a retrospective analysis of data from the Quality Assurance in Rectal Cancer Surgery prospective multicenter observational trial. Data of all patients undergoing curatively intended sphincter-preserving resection for UICC stage I through III rectal carcinoma between 01 Jan 2005 and 31 Dec 2007 with or without preoperative chemoradiotherapy (groups A and B, respectively) were included. Multivariate statistical analysis using propensity score analysis was carried out regarding outcome parameters total anastomotic leak rate, rate of anastomotic leaks requiring reoperation, and postoperative bladder dysfunction., Results: A total of 2,085 patients were included (group A, n = 676, group B, n = 1,409). Significant differences were present between groups regarding age, sex, distance of the tumor from the anal verge, pT-stage, UICC stage, hepatic risk factors, and use of protective enterostomy by univariate analysis. Multivariate logistic regression including these parameters was used to calculate the propensity score (likelihood to be assigned to group A or B as a consequence of the individual profile of these factors) for each patient. When outcome parameters were compared between groups A and B after stratification for propensity score, no significant differences regarding postoperative bladder dysfunction (p = 0.12), total anastomotic leak rate (p = 0.56), and anastomotic leaks requiring reoperation (p = 0.56) could be demonstrated., Conclusion: Neoadjuvant chemoradiotherapy for rectal carcinoma does not increase the risk for anastomotic leakage or postoperative bladder dysfunction after curatively intended sphincter-preserving rectal resection.

Aim: The objective of this study was to find out the effects of anastomotic leakage (AL) following resection of colon cancer upon perioperative outcome and long-term oncological result., Patients and Methods: Using the database of a country-wide quality assurance study "Quality Assurance in Primary Colorectal Carcinoma" we analysed the data from the complete sub-population of 844 patients who had AL after resection of colon cancer. These were compared with corresponding data from 27 427 similar patients without AL. Hospital mortality, AL-associated post-operative morbidity and long-term outcome were investigated., Results: Hospital mortality after AL was 18.6%, compared with 2.6% for patients without AI. AL-related secondary complications occurred in 62.7% cases, while patients without AL had a corresponding rate of 19.9%. Those with AL had a poorer long-term oncological result, with a five-year survival rate of 51.0% (p<0.001) and a five-year tumour-free survival rate of 63.0% (compare 74.6% without AL; p<0.001)., Conclusions: Post-operative AL after resection of colon cancer is associated with significant morbidity and hospital mortality rates and with a greater risk of a poor oncological outcome., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to evaluate the incidence and risk factors associated with anastomotic leakage after colon cancer surgery using data compiled in the nationwide German qualitative multi-center study "Colon/Rectum Cancer" (WGCRC)., Methods: From 01/01/2000 to 12/31/2004 data recorded from patients with anastomotic leakages were evaluated to determine independent predictors of leakage using logistic regression analysis., Results: A total of 28,271 patients underwent colon resection with anastomoses and anastomotic leaks occurred in 3.0% (n=844). Multivariate analysis identified long duration of surgery, a high ASA score, male gender, obstruction, left-sided tumor, cardiovascular hepatic comorbidity, single-layer hand suture, anastomoses using the biofragmentable Valtrac ring, intraoperative complications and BMI>30 kg/m(2) as risk factors for postoperative occurrence of anastomotic leakage., Conclusions: Even though the rate of anastomotic leaks in patients with anastomoses after resection for colon cancer is low, it remains a significant complication, associated with significant morbidity and mortality. The knowledge of risk factors should be considered in perioperative decision-making regarding anastomotic technique and indications for Hartmann's procedure.

Background: The creation of a stoma is an established therapeutic concept for the palliation of non-resectable rectal carcinomas and advanced tumours infiltrating the pelvis., Materials and Methods: In two prospective country-wide multicentre studies, each conducted over a similar period of time, the peri-operative course and postoperative short-term outcomes of laparoscopic vs laparotomy-based stoma construction were compared., Results: A total of 90 patients underwent palliative laparoscopic construction; 550 patients received a stoma via a laparotomy. The intra-operative complication rate was lower after open surgery than after laparoscopic surgery (2.7 vs 5.6%; p = 0.15), although the difference was not significant. With regard to general (30.9 vs 15.6%; p = 0.003) and also specific postoperative complications (13.8 vs 5.6%; p = 0.029), however, a significant advantage of the laparoscopic approach was seen. Furthermore, mortality in the laparoscopic group was also significantly lower (4.4 vs 14.0%; p = 0.011)., Conclusion: Palliative stoma done via laparoscopy had significantly better outcomes in terms of postoperative morbidity and mortality in comparison with the open surgical procedure.

Background: To investigate recent developments in therapeutic approaches, we examine the quality of and discuss current trends in the routine treatment of colorectal cancer in Germany., Material and Methods: We conducted a prospective, multicentre, country-wide observational study in Germany at a representative number of hospitals providing care at all levels., Results: The perioperative morbidity and mortality rates were found not to have changed for a given risk profile of patient and tumour characteristics. The resection rates and long-term oncological results achieved in clinical routine are comparable with those reported in the current literature for colorectal cancer. The quality of care of rectal carcinoma patients has improved significantly, as measured by perioperative oncosurgical criteria (abdominoperineal resection rate, total mesorectal excision rate and quality, and proportion of neoadjuvant procedures)., Conclusion: At present, it remains to be seen whether these factors will lead to a further improvement in long-term results (e.g. rates of local recurrence), and this will require further critical analysis., (Copyright (c) 2009 S. Karger AG, Basel.)

Background: Anastomotic leak is a serious complication of resection for low rectal carcinoma., Methods: Data from a prospective multicentre study conducted between January 2000 and December 2001 were analysed to determine the early outcome after low anterior resection in patients with and without a protective stoma. The morbidity and mortality rates associated with ileostomy and colostomy closure were compared., Results: Eight hundred and eighty-one (32.3 per cent) of 2729 patients received a protective stoma after low anterior resection. Overall anastomotic leak rates were similar in patients with or without a stoma (14.5 versus 14.2 per cent respectively). The incidence of leaks that required surgical intervention was significantly lower in those with a protective stoma (3.6 versus 10.1 per cent; P < 0.001), as was the mortality rate (0.9 versus 2.0 per cent; P = 0.037). Logistic regression analysis showed that provision of a protective stoma was the most powerful independent variable for avoiding an anastomotic leak that required surgical correction. Seven hundred and twenty-four of the 881 patients who received a stoma were followed up. The overall postoperative morbidity associated with stoma closure was significantly lower for colostomy than for ileostomy (15.3 versus 22.4 per cent; P = 0.031)., Conclusion: A protective stoma reduced the rate of anastomotic leakage that required surgical intervention, and mitigated the sequelae of such leakage. Colostomy closure was associated with less morbidity than closure of an ileostomy., (Copyright 2005 British Journal of Surgery Society Ltd.)

The risks and benefits of surgery for colorectal cancer in old patients have not been unequivocally defined. The present investigation was carried out in 309 hospitals as a prospective multicenter study. In the period between 1 January 2000 and 31 December 2001, a total of 19,080 patients were recruited for the study; 16,142 (84.6%) patients were younger than 80 years (<80) and 2932 (15.4%) were 80 years and older (> or =80). Significant differences between the age groups were observed for general postoperative complications (22.3% for <80 years; 33.9% for > or =80). Specific postoperative complications were identical in both groups. Overall, significantly elevated morbidity and mortality rates were found with increasing age (morbidity: 33.9% vs. 43.5%; mortality: 2.6% vs. 8.0%). The distribution of tumor stages revealed a significantly higher percentage of locally advanced tumors in the older age group (stage II: 28.0% vs. 34.4%). In contrast, no increase in metastasizing tumors was found in the older age group (stage IV: 17.4% vs. 14.1%). Logistic regression showed that, in concert with a number of other parameters, age is a significant influencing factor on postoperative morbidity and mortality. The increase in postoperative morbidity and mortality rates associated with aging is a result of the increase in general postoperative complications, in particular, pneumonia and cardiovascular complications. Age as such does not represent a contraindication for surgical treatment. The short-term outcome and quality of life are of overriding importance for the geriatric patient.

Background: Colonic resection according to the procedure by Hartmann is considered a fast and safe surgical intervention, which has been used for years, in particular, in emergency situations., Methods: Using data of a prospective multicentre study on the operative treatment of colorectal carcinoma over the time period from 1 January 2000 to 31 December 2002, the value of Hartmann's procedure was investigated in carcinoma of the left colon (n=8825) compared with alternative surgical options under emergency circumstances. The significant impact of independent variables on the type of the selected approach was determined by means of logistic regression., Results: While in total 422 primary Hartmann's procedures (4.8%) were executed under curative intention, 213 (50.5%) of those were carried out in emergency situations. Hartmann's procedure was beneficial in cases with tumour-associated obstruction and perforation of the left colon as it resulted in the lowest mortality (7.5%) of the radical operations. Even under palliative intention, Hartmann's procedure was preferred at the left colon but led to a postoperative mortality (32.7%) very similar to that in creation of a colostoma (33.3%) or segmental colonic resection (38.9%)., Conclusions: Hartmann's procedure has been widely accepted as a curative intervention in emergency cases (oncosurgically adequate R0 resection) for the carcinoma of the left colon. Because of the high postoperative morbidity and mortality in emergency situations with only palliative options (R0 resection not possible), alternative endoscopic treatment should be considered more frequently.

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.

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: Anastomotic leakage is a major problem in colorectal surgery and in particular in operations for low rectal cancer. The present study investigates the question whether a protective stoma can reduce the (clinical and radiologic) anastomotic leakage rate and/or the rate of leakage requiring surgery., Methods: The investigation took the form of a prospective multicenter study involving 75 German hospitals and was performed between January 1, 1999, and December 31, 1999. A comparison was made of the postoperative results of procedures performed with and those performed without a protective stoma in patients undergoing low anterior rectal resection. In addition, logistic regression using the target criteria, overall anastomotic leakage and anastomotic leakage requiring surgery, was applied., Results: Among the 3,695 operations performed for carcinoma of the rectum or colon, 482 were low anterior resections. In 334 patients (69.3 percent) no protective stoma was constructed, whereas 148 (30.7 percent) received such protection. Age, American Society of Anesthesiologists physical status, and body mass index were identical in both groups. In the group receiving a protective stoma, however, neoadjuvant radiochemotherapy was more common, the tumors were lower-and thus the total mesorectal excision rate higher, the intraoperative complication rate was higher, and the duration of the operation was longer. The differences were all significant. The major criterion (overall anastomotic leakage rate) was identical in the two groups, but the rate of leakage requiring surgery was significantly lower in patients receiving a protective stoma (p = 0.028). The logistic regression revealed that use of a protective stoma is a predictor of protection against anastomotic leakage requiring surgery. The distance of the tumor from the anal verge and the duration of the operation are further predictors., Conclusion: The particular benefit of a covering stoma is reduction in the rate of leaks requiring surgery and thus in the severe consequences of an anastomotic leakage.

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.

Background: Patient age has a decisive impact on the short-term postoperative results in surgery for carcinoma., Patients and Methods: This prospective multicenter study involved 75 German hospitals and 3756 patients undergoing treatment in 1999: 1447 aged under 65 years, 1847 aged 65-79 years, and 458 aged over 80 years., Results: In the oldest patient group, there was a significantly higher proportion of extensive, localized tumors (UICC stage II: 25.9%, 28.4%, and 36.1%, respectively) and significant differences were found among the three groups in operation rates (98.8%, 98.6%, and 96.5%), resection rate (94.2%, 93.2%, and 83.9%), general postoperative complications (21.5%, 28.6%, and 41.2%), morbidity (36.5%, 42.6%, and 50.0%) and mortality (2.7%, 6.6%, and 11.8%)., Conclusion: In the elderly, locally advanced tumors, but not metastasizing tumors, are to be expected. The increase in postoperative morbidity and mortality rates with increasing age was due to the increase in general postoperative complications. Surgery for colorectal carcinoma in patients of advanced age is not associated with any increase in intraoperative or specific postoperative complications.

This prospective multicenter study investigated the effect of hospital caseload on early postoperative outcome of surgery for carcinoma of the colon in 75 German hospitals and included 2293 patients. The hospitals were divided into those with a caseload of 1-30 (group A), 31-60 (group B), and more than 60 (group C) operations. Increasing caseload was associated only with fewer general postoperative complications. It was also associated with significantly greater use of antibiotic prophylaxis. No significant differences between the groups were found in resection rates, intraoperative complications, specific postoperative complications, overall postoperative morbidity, hospital mortality, or 30-day mortality. The significance of hospital caseload for the short-term postoperative outcome following surgery on the colon should not be overestimated. Basing conclusions about the results to be expected simply on the case volume is impermissible. On the basis of the available data it is not possible to establish a threshold value, that is, a minimum number of required operations.

Background: The aim of the study was to investigate the impact of hospital caseload on the short-term postoperative outcome of patients with rectal carcinoma., Methods: A multicentre study involving 75 German hospitals was carried out between January and December 1999. Some 1463 patients with rectal carcinoma were studied., Results: The hospitals were divided into three groups by annual caseload as follows: less than 20 (group 1), 20-40 (group 2) and more than 40 (group 3). The groups were identical in terms of age, gender, height, weight, tumour stage, risk factors and American Society of Anesthesiologists classification. Postoperative morbidity was less in hospitals with a case volume of more than 20 patients per year (41.7 per cent in group 2 versus 49.9 per cent in group 1). The proportion of patients undergoing abdominoperineal resection with a permanent stoma was less in hospitals with a case volume of more than 40 patients per year (26.4 per cent in group 3 versus 34.0 per cent in group 2)., Conclusion: A large caseload in rectal surgery results in a significant reduction in permanent stoma formation and postoperative morbidity.

Risk factors for postoperative complications of benign goiter surgery have not been investigated systematically. To this end, a prospective multicenter study (January 1 through December 31, 1998) was conducted involving 7266 patients with surgery for benign goiter from 45 East German hospitals. High-volume providers (>150 operations per year) performed 69% (5042/7266), intermediate-volume providers 27% (50-150), and low-volume providers 4% (258/7266) of operations. Among the hospital groups, the pattern of thyroid disease did not vary significantly, but there was a trend that small-volume providers tended to perform more operations for uninodular goiter and high-volume providers treated more patients with Graves' disease and recurrent goiter. Extent of resection (p < 0.0001) and remnant size (multinodular goiter and recurrent goiter, p < 0.001), differed significantly, with total thyroidectomy being performed more often in hospitals with more than 150 operations compared to hospitals with an operative volume of less than 150 procedures per year. Despite the larger extent of resection and smaller remnant size, rates of recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism were not increased. When the logistic regression analyses were fitted to evaluate the impact of risk factors on transient and permanent RLN palsy and hypoparathyroidism, larger extent of resection [relative risk (RR) 1.5-2.1] and recurrent goiter (RR 1.8-3.4) consistently evolved as independent risk factors. With hypoparathyroidism, additional significant factors included patient gender (RR 2.1-2.4), hospital operative volume (RR 0.8-1.5), and Graves' disease (RR 2.8). Unlike parathyroid gland identification during hypoparathyroidism, RLN identification (RR 1.6) significantly (p = 0.01) reduced permanent RLN palsy rates. The multivariate analyses clearly confirmed the pivotal role of routine RLN identification, independent of the extent of the thyroid resection. These findings might help hospitals with lower operative volumes to identify patients at increased risk whom they might consider for specialist care.

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.

In the period of time between September 1, 1991 and August 31, 1993 a total of 1927 patients at 22 East German hospitals were operated for colorectal carcinoma. In anticipation of quality assuring aspects these surgeries were registered and interpreted. An application of a constant classification (pTNM, R-classification) at this was essential. The resection rates of 87.3% on the colon (R0-resections 74.4%) and of 83.1% on the rectum (R0-resection 70.8%) were established in total patient group. Preoperative measures and technique of surgery were also registered. The rate of the colonic anastomosis insufficiencies was about 3.2%, resp. of the rectum 8.2%. Wound suppurations occurred after surgery of the colon in 6.5% of the cases, resp. the rectum in 9.9%. The postoperative mortality was 7.1% in the overall patient group. The practical realization and the efficiency of studies for quality assurance is pointed out.

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.

Between 1.7. 1988-31. 12. 1989 in 18 surgical departments of the former GDR 6, 266 patients suffering from "appendicitis" were registered and qualitatively evaluated. The perforation rate was 8.3%. 30% of these patients had no typical diagnosis. Postoperative lethality was 0.32%.

Thoracic trauma was treated in 159 hospitalised patients within a five-year period, with polytrauma being recorded from 40 per cent of the patients. Application of thorax suction drainage proved to be the most effective first treatment for 50 per cent of all cases. Emergency thoracotomy was necessary in 7.6 per cent. The lethality rate recorded from these cases of thorax injury amounted to twelve per cent.