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Zusammenfassung Hintergrund In den vergangenen Jahren gab es einen deutlichen Wandel in den Therapieempfehlungen der akuten Divertikulitis. Die stadiengerechte Therapie orientiert sich an der neuen Klassifikation der Divertikelkrankheit aus der aktuellen Leitlinie. Patienten und Methode Erfasst wurden alle Patienten, die in den Jahren 2010 bis 2014 wegen einer akuten Divertikulitis im Universitätsklinikum Würzburg behandelt wurden. Einschlusskriterium für die Auswertung war das Vorhandensein einer Computertomografie zur Stadieneinteilung. Ergebnisse Gut die Hälfte der untersuchten Patienten (n = 135, 52,9%) hatte bei Aufnahme eine akute unkomplizierte Divertikulitis, 112 (43,2%) wiesen eine gedeckte Perforation (Mikroabszess n = 63, 24,3%; bzw. Makroabszess n = 49, 18,9%), 12 Patienten (4,6%) eine freie Perforation auf. Bei insgesamt 150 (57,9%) Patienten war es der 1. Schub einer Divertikulitis, eine gedeckte (66,1%) oder eine freie Perforation (75,0%) trat dabei überdurchschnittlich häufig als Erstmanifestation auf. Knapp zwei Drittel (66,4%, n = 168) der Patienten wurden im Verlauf sigmareseziert. Diskussion und Schlussfolgerung Trotz des Trends hin zu einer konservativen Therapie der akuten Divertikulitis bleibt die (elektive) Sigmaresektion nach wie vor ein zentraler Bestandteil in der Therapie über alle Stadien hinweg. Die Indikationsstellung ist jedoch heutzutage deutlich differenzierter und erfordert neben der individuellen Klassifikation der Entzündungssituation auch Kenntnisse über die individuelle krankheitsspezifische Prognose in Bezug auf Rezidivwahrscheinlichkeit und Lebensqualität.

The treatment of peritoneal surface malignancies ranges from palliative care to full cytoreductive surgery (CRS) and Heated Intraperitoneal Chemotherapy HIPEC. Ongoing monitoring of patient recruitment and volume is usually carried out through dedicated registries. With multiple registries available worldwide, we sought to investigate the nature, extent and value of existing worldwide CRS and HIPEC registries.METHODS: A questionnaire was sent out to all known major treatment centres. The questionnaire covers: general purpose of the registry; inclusion criteria in the registry; the date the registry was first established; volume of patients in the registry and description of the data fields in the registries. Finally, the population size of the catchment area of the registry was collected.RESULTS: 27 questionnaires where returned. National databases are established in northwest European countries. There are five international general databases. Most database collect data on patients who have undergone an attempt to CRS and HIPEC. Two registries collect data on all patients with peritoneal carcinomatosis regardless the treatment. Most registries are primarily used for tracking outcomes and complications. When correlating the number of cases of CRS and HIPEC that are performed to the catchment area of the various registry, a large variation in the number of performed procedures related to the overall population was noted, ranging from 1.3 to 57 patients/million year with an average of 15 patients/1 million year.CONCLUSION: CRS and HIPEC is a well-established treatment for peritoneal surface malignancies worldwide. However, the coverage as well as the registration of treatment procedures differs widely. The most striking difference is the proportion of HIPEC procedures per capita which ranges from 1.3 to 57 patients per million. This suggests either a difference in patient selection, lack of access to HIPEC centres or lack of appropriate data collection.

Patients with peritoneal metastases of gastric cancer have a poor prognosis with a median survival of 7 months. A benefit of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) could be shown in several selected patient cohorts but remains controversial. The aim of this study was, to reflect the results of a national German HIPEC registry initiated by the German Society of General and Visceral Surgery (DGAV). The DGAV HIPEC registry StuDoQ|Peritoneum documents patients with peritoneal malignancy contributed from 52 hospitals. All consecutive documented patients from 2011 until 2016 (n = 3078) were treated with CRS and HIPEC and were analysed. A total of 315 (10%) suffered from gastric cancer and were analysed. A complete data set of 235 patients was available for this study, including 113 male (48.1%) and 122 female (51.9%) patients with a median age of 53.4 years (SD ± 11.9). The median PCI was 8.0 (range 1–30). A complete cytoreduction was achieved in 121 patients (71.6%). Postoperative complications (Clavien–Dindo grades 3–4) occurred in 40 patients (17%). The median overall survival (OS) time was 13 months. The 5-year survival rate was 6%. According to the PCI from 0–6 (n = 74); 7–15 (n = 70) and 16–39 (n = 24) the median OS differs significantly (18 months vs. 12 months vs. 5 months; p = 0.002). CRS and HIPEC in selected patients with gastric cancer and peritoneal spread can improve survival when they are treated in centers. An accurate staging and patient selection are of major importance to achieve long-term survival.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are performed for well-selected patients with peritoneal surface malignancies. This combined treatment is potentially associated with an increased rate of complications. The aim of this paper was to analyze the morbidity and mortality of CRS and HIPEC in the German national registry. We present a retrospective analysis of 2149 consecutive patients from 52 hospitals. The data were prospectively documented in the DGAV StuDoQ Registry between February 2011 and December 2016. Almost two-thirds of all patients had a colorectal malignancy; therefore, the most frequently performed resections were colectomies (54%) and rectal resections (30%). Only 36.2% of all patients had no anastomosis, and fewer than 20% of all patients were older than 70 years of age (16.4%). Enteric fistula and anastomotic leaks occurred in 10.5% of all cases. The reoperation rate was 14.6% (95% confidence interval [CI] 11.51–18.1). Major grade 3 and 4 complications (Clavien–Dindo classification) occurred in 19.3% of all patients, half of which were due to surgical complications. The overall 30-day postoperative hospital mortality was 2.3% (95% CI 1.02–3.85). Multivariate analysis showed an increased risk for morbidity associated with pancreatic resections (odds ratio [OR] 2.4), rectal resection (OR 1.5), or at least one anastomosis (OR 1.35), and mortality with reoperation (OR 8.7) or age > 70 years (OR 3.35). CRS and HIPEC are associated with acceptable morbidity and low mortality. These results show that CRS and HIPEC can be safely performed nationwide when close mentoring by experienced centers is provided.

Background: At present, there are only few objective quality criteria for the treatment of peritoneal carcinomatosis using cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (HIPEC). Method and Results: However, because this therapy is associated with significant morbidity and mortality, such quality criteria are quite important. Accreditation of peritoneal carcinomatosis centers by the German Society for General and Visceral Surgery was a first step towards establishing these clinics. Conclusion: One key requirement for accreditation is membership in the German Peritoneal Carcinomatosis Registry. This prospective database provides a collation and evaluation of the epidemiological and therapeutic factors relating to this disease.

Tumor involvement of the peritoneum-peritoneal carcinomatosis-is a heterogeneous form of cancer that had been generally regarded as a sign of systemic tumor disease and as a terminal condition. The multimodal treatment approach for patients with peritoneal carcinomatosis, which had been conceived and developed, consists of what is known as cytoreductive surgery, followed by hyperthermic intraperitoneal chemotherapy (HIPEC). Depending on the tumor mass as assessed intraoperatively and the histopathological differentiation, patients who undergo cytoreductive surgery and HIPEC have a significant survival benefit. Mean increases in the survival period ranging from six months to up to four years have now been reported. In view of the substantial logistic effort and the extent of the surgery involved, this treatment approach represents a major challenge both for patients and for surgical oncologists, as well as for the members of the overall interdisciplinary structure required, which includes oncology, anesthesiology and intensive care, psycho-oncology, and patient management. The surgical procedures alone may take 8-14 hr. The present paper provides an overview of the basis for the approach and the use of specialized classifications and quantitative prognostic indicators.

There is controversy about the effect of the influence of hyperthermia and chemotherapeutic agents on the healing of intestinal anastomosis. The effects of hyperthermic intraperitoneal chemoperfusion (HIPEC) of wound healing after colonic anastomosis were investigated in a rat model.Thirty-six Wag/Rija rats were randomized into three groups of 12 animals each: group I: control (only colonic anastomosis was performed) (n = 12); group II: HIPEC (mitomycin C in a concentration of 20 mg/m(2) (n = 12) colonic anastomosis was performed before HIPEC; group III: HIPEC (mitomycin C in a concentration of 20 mg/m(2) (n = 12) colonic anastomosis was performed after HIPEC. Bursting pressure and bursting sites were recorded 4 and 10 days after intervention. Collagen deposits, inflammation and foreign body reactions were evaluated.Lower bursting pressure and lost of collagen were found in both HIPEC groups and compared with the control group. There was almost no difference between both HIPEC groups. They were noted overwhelmingly at the anastomosis in the HIPEC group. The degree of collagen accumulation was well-correlated with bursting pressure.These results have shown that hyperthermic intraperitoneal chemoperfusion (HIPEC) impairs wound healing in colonic anastomosis in rats.

Background The learning curves for cytoreductive surgery with intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei (PMP) were explored between international centres/surgeons to identify institutional or other factors that might affect performance. Methods Data from patients with PMP treated with the combined procedure across 33 international centres between 1993 and 2012 were analysed retrospectively. A risk-adjusted sequential probability ratio test was conducted after defining the target outcome as early oncological failure (disease progression within 2 years of treatment), an acceptable risk for the target outcome (odds ratio) of 2, and type I/II error rates of 5 per cent. The risk prediction model was elaborated and patients were evaluated sequentially for each centre/surgeon. The learning curve was considered to be overcome and proficiency achieved when the odds ratio for early oncological failure became smaller than 2. Results Rates of optimal cytoreduction, severe postoperative morbidity and early oncological failure were 84·4, 25·7 and 29·0 per cent respectively. The median annual centre volume was 17 (range 6–66) peritoneal malignancies. Only eight of the 33 centres and six of 47 surgeons achieved proficiency after a median of 100 (range 78–284) and 96 (86–284) procedures respectively. The most important institutional factor affecting surgical performance was centre volume. Conclusion The learning curve is extremely long, so centralization and/or networking of centres is necessary to assure quality of services. One centre for every 10–15 million inhabitants would be ideal.

Objective: To determine if hyperthermic intraperitoneal chemoperfusion (HIPEC) of colonic anastomoses is detrimental to subsequent anastomotic healing. Methods: 24 Wag/Rija rats were randomized into four groups of six animals each: group 1: control (n = 6), group 2: HIP (n = 6), group 3: HIPEC with mitomycin C in a concentration of 30 mg/m2 (n = 6), group 4: mitomycin i.p. in a concentration of 20 mg/m2 (n = 6). In all animals colon anastomosis approximataly 3 cm proximal to the peritoneal reflection was performed. After 10 days, the anastomic breaking strength and the number of anastomic complications were observed. Results: No postoperative deaths were reported. The postoperative morbidity rate was 18,7%. No severe locoregional or systemic toxity was observed. In HIPEC treated animals bursting pressure of anastomoses was lower than in group I. No significant difference in bursting pressure were found in groups I, II and IV. In group III one animal had a covered perforation and one animal showed extensive adhesions. Conclusion: The healing of colonie anastomoses did not differ between group I, II and IV. In contrast, anastomotic complications were significantly more common in HIPEC animals.

Laser-induced thermotherapy (LITT) or interstitial laser thermotherapy is an in situ ablation technique for the treatment of malignant tumors of the liver. 1,2 The potential of LITT is that laser light is directly transmitted through flexible bare fibers into the tumor tissue with high precision. The biologic effect of the laser light is based on the transformation of laser photon energy into heat by the absorption of tissue-specific chromophores. The aim is to induce uniform coagulation necrosis of the treatment volume. 3 Of great importance to the method’s success is the size of the induced coagulation necrosis, which must contain the whole volume of the tumor tissue. This lesion size largely depends on the temperature distribution in the target volume, which is determined partly by the blood perfusion in the target organ. 4,5 In organs with a high blood perfusion, such as the liver, a cooling effect results because of the temperature difference between the hyperthermic area and blood. 6,7 Temporary interruption of hepatic blood flow by occlusion of hepatic inflow vessels (Pringle maneuver) during LITT has been proven to increase its efficacy. 8–11 The Pringle maneuver usually requires laparotomy 10,11 or at least laparoscopy 12 and may therefore be difficult to repeat in cases of insufficient therapy. LITT, however, can be applied percutaneously without laparotomy or laparoscopy and can thus be easily repeated. 1,2 An alternative to the temporary interruption of hepatic arterial blood flow to liver tumors is the application of degradable starch microspheres (DSM), as used for chemoembolization. 13,14 The purpose of this study was to assess the effect of combined LITT and DSM on intrahepatic temperature distribution and tumor response in rats with liver tumors.