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BACKGROUND: Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery. OBJECTIVE: Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty. METHODS: 14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained. RESULTS: Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients. CONCLUSION: The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.

Lay Summary Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.Management of obstructed defaecation is challenging and remains controversial. No international guidelines have been published.

Die total anale Rekonstruktion (TAR) wird im dargestellten Ansatz zweizeitig durchgefuhrt. In einem ersten Schritt erfolgt die abdominoperineale Rektumexstirpation (APE) mit perinealer Rekonstruktion durch ein VRAM-Perineostoma (vertikale myokutane M.-rectus-abdominus-Plastik), gefolgt von einer neurostimulierten Levatorenaugmentation (NLA) mittels U‑geformter intrapelviner dynamischer Grazilisplastik. Es werden operative Zugangswege sowie eine Schritt-fur-Schritt-Beschreibung der Operationsablaufe dargestellt. Die initialen Ergebnisse zu Morbiditat und Funktion werden unter Berucksichtigung fruherer Publikationen angegeben. Wichtige Informationen zur praoperativen Aufklarung sind dabei ohne Gewahr.

Technisch gesehen ist ein Stoma eine unnaturliche Verlagerung eines Darmabschnitts durch die Bauchwand hindurch vor die Bauchdecke. Zu unterscheiden ist sowohl welcher Darmabschnitt verlagert wird (Dunndarm, Dickdarm) als auch die Art der Darmausleitung (endstandig/doppellaufig). Grundsatzlich wird ein Stoma den individuellen Bedurfnissen des Patienten angepasst. Dabei kann es offen-chirurgisch wie auch minimal-invasiv angelegt werden. Der Artikel beschaftigt sich mit technischen Aspekten der Stomaanlage (Ileostoma/Kolostoma) in Bezug auf die Anatomie der Bauchdecke. Es werden spezielle Situationen, wie beispielsweise die protektive Stomaanlage im Rahmen einer tiefen anterioren Rektumresektion, die prophylaktische Mesh-Augmentation zur Verhinderung einer parastomalen Hernie, die Bedeutung der Stomaanlage bei adiposen Patienten und die Anlage eines Split- und Chimney-Stomas beschrieben und diskutiert. Das Fazit ist, dass die Kenntnis der Anatomie der Bauchdecke, das Bewusstsein um die spatere Versorgung des Stomas und die individuelle Berucksichtigung der personlichen Situation des Patienten grundlegende Voraussetzungen fur die Verfahrenswahl und die technische Umsetzung einer suffizienten Stomaanlage sind.

Die Geschichte der chirurgischen Therapie des externen Vollwandprolapses reicht bis in das 17. Jahrhundert zuruck. Dabei war jahrzehntelang das transanale und/oder perineale Verfahren die bevorzugte Technik. Im Folgenden sollen die heute gebrauchlichen Verfahren in Bezug auf Indikation, Technik und Ergebnisse vorgestellt werden. Die Operationstechnik nach Rehn-Delorme eignet sich fur betagte und hochbetagte Patienten, die mit minimalem Risiko behandelt werden sollen. Technisch wird dabei lediglich eine Mukosektomie mit anschliesender Raffung der Rektumwand durchgefuhrt. Die transperineale Rektosigmoidresektion nach Altemeier dagegen beinhaltet eine Vollwandresektion mit entweder End-zu-End- oder Seit-zu-End-Anastomose, wobei zusatzliche eine Levatorenplastik erfolgen kann. Das Morbiditatsrisiko erscheint dabei hoher, die Effektivitat im Langzeitverlauf dagegen verbessert zu sein. In jungster Zeit wurde das operative Spektrum durch die sog. perineale staplergestutzte Prolapsresektion (PSP) erganzt, die auf Radikalitat und Levatorenplastik verzichtet. Aufgrund der nicht unerheblichen Rezidivrate im Langzeitverlauf eignet sie sich am ehesten fur hochbetagte und multimorbide Patienten mit eingeschrankter Lebenserwartung.

Die Contour®-Transtar™-Operation ist eine methodische Weitentwicklung der konventionellen transanalen Stapler-Resektion des Rektums (STARR) zur Behandlung eines obstruktiven Defakationssyndroms (ODS) und/oder eines externen Rektumprolapses. Im Gegensatz zum konventionellen STARR wird dabei ein einzelner offen-gebogener Stapler verwendet, mit dem die Rektumwand zirkular durchtrennt und anastomosiert wird. Hierdurch wird eine Monoblockresektion mit uneingeschranktem Resektionsausmas moglich. Die Datenlage muss hinsichtlich der Indikationen ODS und externer Rektumprolaps unterschiedlich betrachtet werden. Generell erweist sich das Verfahren sowohl in monozentrischen als auch in multizentrischen Studien als effektiv zur Behandlung des ODS bei Intussuszeption und Rektozele. Im Vergleich zum konventionellen STARR sind die Resektate dabei groser und die funktionelle Wirksamkeit vergleichbar. Im prospektiv-randomisierten Vergleich ist daruber hinaus eine hohere Effektivitat im Langzeitverlauf dokumentiert. Bezuglich des externen Prolapses bestehen Machbarkeitsstudien mit geringer Morbiditat, allerdings deuten erste Langzeitstudien auf eine hohe Rezidivhaufigkeit von >40 % hin.

Die Behandlung des externen Rektumprolapses ist eine Domane der kolorektalen Chirurgie und stellt nach wie vor aufgrund der engen Lagebeziehung zu den urogenitalen Kompartimenten des Beckenbodens und deren simultaner funktioneller Storungen eine besondere interdisziplinare Herausforderung dar. Es stehen abdominelle und perineale chirurgische Verfahren mit entsprechenden Modifikationen zur Verfugung. Beim Vergleich der verschiedenen Techniken und Zugangswege unterscheiden sich die primaren Endpunkte Rezidivrate sowie Verbesserung der Stuhlinkontinenz und Obstipation in den zahlreichen Studien nicht signifikant. Aufgrund der heterogenen Studienlage ist auch in diesem Update keine objektive therapeutische Empfehlung oder Aussage zur Praferenz einer Technik moglich. Minimal-invasive und weiterentwickelte Fixationstechniken scheinen jedoch einen kurzeren Krankenhausaufenthalt, geringere postoperative Schmerzen und eine raschere Wiederaufnahme der Alltagsaktivitaten zu ermoglichen.

Although various strategies exist for chronic constipation therapy, the pathogenesis of chronic constipation is still not completely understood. The aim of this exploratory experimental study is to elucidate alterations of the autonomous enteric nervous system at the molecular level in patients with obstructed defecation, who represent one of the most predominant groups of constipated patients. Full-thickness rectal wall samples of patients with obstructed defecation were analyzed and compared with controls. Differential gene expression analyses by RNA-Seq transcriptome profiling were performed and gene expression profiles were assigned to gene ontology pathways by application of different biological libraries. Analysis of the transcriptome showed that genes associated with the enteric nervous system functions were significantly downregulated in patients with obstructed defecation. These affected functions included developmental processes and synaptic transmission. Our results therefore indicate that obstructed defecation may represent an enteric neuropathy, comparable to Hirschsprung disease and slow-transit constipation.

Aim Reported recurrence rates after perineal rectosigmoidectomy (Altemeier's procedure) in patients with full-thickness rectal prolapse vary from 0% to 60%. The object of this study was to analyse risk factors for recurrence after this procedure. Method From May 2004 to December 2012, 63 consecutive patients suffering from full-thickness rectal prolapse undergoing perineal rectosigmoidectomy were included. Of these 46 were female and the median age of the whole group was 79 (30–90) years. The median follow-up was 53 (3–99) months. Patient characteristics and operative parameters were compared between patients with and without recurrence. Results One patient died and another patient needed re-operation. Eight full-thickness recurrences occurred in eight patients after a median of 18 (6–48) months. Stapled compared with handsewn anastomosis (hazard ratio 7.96, 95% confidence interval 1.90–33.47; P = 0.001) and shorter specimen length (hazard ratio 4.06, 95% confidence interval 0.97–16.99; P = 0.03) increased the risk of recurrence in Cox regression analysis. Conclusion The operative technique including stapled anastomosis and length of the resected specimen seems to be associated with a high recurrence rate after perineal rectosigmoidectomy.

Die operative Therapie chronisch-entzundlicher Darmerkrankungen (CED) hat vornehmlich einen sekundaren Stellenwert und kommt insbesondere bei konservativ-refraktarem Verlauf sowie bei Komplikationen zum Einsatz. Daruber hinaus besteht aber auch ein prophylaktischer Therapieansatz, wie die elektive Ileozakalresektion beim M. Crohn oder die prophylaktische restaurative Koloproktektomie bei der Colitis-ulcerosa-assoziierten intraepithelialen Neoplasie. Die vorliegende Ubersicht diskutiert den Stellenwert der chirurgischen Therapie bei M. Crohn sowie Colitis ulcerosa und evaluiert die Ergebnisse der operativen Verfahren kritisch. Dargestellt werden selektive Ergebnisse aus der Literatur und eine retrospektive Analyse von Patientendaten der eigenen Klinik. Morbus Crohn manifestiert sich am haufigsten ileozakal, kolorektal, enterisch und anorektal. Abhangig von der Lokalisation, vom Ausmas der Entzundung und vom klinischen Verlauf werden die Indikation und Verfahrenswahl chirurgischer Optionen diskutiert. Insbesondere die langjahrige Proktitis bei M. Crohn mit Stenose und Fisteln stellt ein therapeutisches Dilemma dar. Eigene Ergebnisse belegen, dass die intersphinktare Rektumresektion mit peranalem Rektumdurchzug und Handnahtanastomose in ausgewahlten Fallen eine effektive Behandlung der Stenose mit Abheilung der Fisteln ermoglicht. Hierbei kann in 67 % der Falle ein definitives Stoma verhindert werden. Die Ergebnisse der Pouch-Operation bei der Colitis ulcerosa aus spezialisierten Zentren ergeben neben einer akzeptablen Komplikationsrate exzellente funktionelle Daten im Langzeitverlauf und eine gute postoperative Lebensqualitat der behandelten Patienten. Prophylaktische Aspekte der chirurgischen Therapie von CED sollten insbesondere im Zeitalter neuer medikamentoser Therapieansatze zunehmend interdisziplinar diskutiert werden.

Die Koloproktektomie ist ein viszeralchirurgischer Eingriff, bei dem das komplette Kolon und Rektum bis in Hohe des Beckenbodens bzw. der Linea dentata und des Analkanals entfernt werden. Dabei bleiben in der Regel der Analkanal und die Beckenbodenmuskulatur inklusive analer Schliesmuskel erhalten. Zur Rekonstruktion des Dunndarms hat sich die ileoanale J-Pouch-Anlage durchgesetzt hat. In dem folgenden Beitrag stellen wir anhand eines Operationsvideos, welches online zur Verfugung steht, die Vorgehensweise bei einer offenen Koloproktektomie mit ileoanaler J-Pouch-Rekonstruktion vor.

The Contour® Transtar™ operation represents a further methodological development of conventional transanal stapled rectal resection (STARR) for the treatment of obstructed defecation syndrome (ODS) and/or full thickness rectal prolapse. In contrast to the conventional STARR technique a specially designed single curved stapler is used with which the rectal wall is incised in a circular fashion and anastomosed. This results in a monoblock resection with almost unlimited extent of resection. In multicenter studies the procedure has generally been shown to be effective for treatment of ODS with intussusception and rectocele. In comparison to conventional STARR the resected tissue samples are larger and the functional effectiveness is comparable. Furthermore, data from prospective randomized trials revealed higher effectiveness in long-term follow-up. With reference to full thickness rectal prolapse, feasibility studies have been performed which showed low morbidity but long-term follow-up studies suggest a high recurrence rate of40 %.

Die chronische Obstipation ist mit einer Pravalenz von 5–15 % eine haufige Erkrankung in den westlichen Industrienationen. Generell muss die globale Transportstorung (»slow-transit-constipation«) von der Stuhlentleerungsstorung differenziert werden, wobei kombinierte Storungen haufig sind. Daruber hinaus ist die Differenzierung der chronischen Obstipation vom »Reizdarm-Syndrom« nicht selten eine Herausforderung. Die Einordnung der chronischen Obstipation umfasst subjektive (z. B. unvollstandige Entleerung, heftiges Pressen zur Defakation) und objektive (z. B. Stuhlfrequenz, Stuhlkonsistenz) Kriterien. Fokussiert man auf die Stuhlentleerungsstorung, so sind sowohl morphologische als auch funktionelle Ursachen moglich, wobei kombinierte Storungen haufig sind. Die Diagnostik hat zum Ziel, die chronische Obstipation (slow-transit) von der Stuhlentleerungsstorung zu differenzieren, wobei die gastroenterologisch- proktologische Diagnostik hier den hochsten Stellenwert besitzt. In der Differenzialdiagnose der Stuhlentleerungsstorung erlauben die Anamnese und die proktologische Basisuntersuchung in den meisten Fallen eine orientierende Differenzierung.

Eine endoskopische Diagnostik (Proktoskopie, Rektoskopie) ist bei allen proktologischen Patienten durchzufuhren, bei denen der Verdacht auf eine organische oder funktionelle Erkrankung des Rektums oder des Analkanals besteht. Somit kann sich die Indikation zur Endoskopie aus der Anamnese des Patienten ergeben (z. B. Blutung, Schmerzen, Entleerungsstorung, etc.) oder aus Auffalligkeiten der vorangegangenen digital-rektalen Untersuchung (z. B. Palpation eines Tumors). Die anale oder rektale Endosonografie ist Bestandteil der erweiterterten proktologischen Diagnostik. Hauptindikationen stellen neben dem Staging (Rektumkarzinom) die Abszess- und Fisteldiagnostik sowie der Ausschluss bzw. Nachweis eines Sphinkterdefekts bei der Abklarung einer Stuhlinkontinenz dar.

Die chirurgische Therapie der Beckenbodeninsuffizienz fokussiert sich im Wesentlichen auf zwei funktionelle Storungen, die Darmobstruktion und die Stuhlinkontinenz. Der Stellenwert der chirurgischen Therapie ist hier insbesondere nach Nichtansprechen der konservativen Moglichkeiten zu sehen. Die Differenzialindikation der operativen Verfahren basiert auf einer prazisen praoperativen Evaluation. Das Ausmas der funktionellen Beeintrachtigung wird anhand einer ausfuhrlichen Anamnese unter Verwendung krankheitsspezifischer Fragebogen bestimmt, gefolgt von einer klinisch-proktologischen Untersuchung mit digital-rektaler Untersuchung und starrer Prokto-/Rektoskopie. Bildgebende Verfahren (anorektale Endosonographie, dynamische Defakographie) erfolgen erganzend zur Visualisierung morphologischer, funktionell wirksamer Pathologien. Die Schwere der Beeintrachtigung und Auspragung der morphologischen Pathologie bilden die Grundlage eines therapeutischen Algorithmus bei zunehmend differenzierten Operationsverfahren. Ziel dieser Ubersicht ist die Darstellung der differenzierten Diagnostik bei Obstruktion und Stuhlinkontinenz fur eine exakte Patientenselektion zur zielgerichteten Therapie.

Die transanalen Operationsverfahren werden sekundar nach Ineffektivitat oder Versagen der konservativen Therapie bei funktionellen Darmerkrankungen wie dem obstruktiven Defakationssyndrom (ODS) eingesetzt. Als etablierte transanale Verfahren kommen zum Einsatz die transanale Rektozelenresektion (RR), die transanale Mukosaresektion beim inneren Rektumprolaps nach Rehn-Delorme (MR) und die transanale Staplerresektion des Rektums (STARR). Die Datenlage ist sowohl fur die RR als auch die MR sparlich und von geringer Evidenz. Generell erweisen sich die Verfahren als wirksam in Bezug auf obstruktive Beschwerden wie die unvollstandige und erschwerte Stuhlentleerung und die Digitation. Die STARR-Operation dagegen ist durch zahlreiche z. T. prospektiv-randomisierte Studien in ihrer Wirksamkeit zur Behandlung des ODS belegt. Die funktionellen Resultate in Bezug auf eine Verbesserung der Konstipation nach einem Jahr und im Langzeitverlauf (bis 68 Monate) zeigen ein Ansprechen von bis zu 90% bei einer Rezidivrate von 5–18%. Zusammenfassend stellt die STARR-Operation ein gut evaluiertes operatives Verfahren zur Behandlung eines konservativ refraktaren ODS dar mit einer hohen primaren Ansprechrate, einer akzeptablen Morbiditat und nach ersten Analysen offenbar mit einem stabilen Langzeiteffekt.

There is limited evidence on the natural course of ventral and incisional hernias and the results of hernia repair, what might partially be explained by the lack of an accepted classification system. The aim of the present study is to investigate the association of the criteria included in the Wuerzburg classification system of ventral and incisional hernias with postoperative complications and long-term recurrence. In a retrospective cohort study, the data on 330 consecutive patients who underwent surgery to repair ventral and incisional hernias were analyzed. The following four classification criteria were applied: (a) recurrence rating (ventral, incisional or incisional recurrent); (b) morphology (location); (c) size of the hernial gap; and (d) risk factors. The primary endpoint was the occurrence of a recurrence during follow-up. Secondary endpoints were incidence of postoperative complications. Independent association between classification criteria, type of surgical procedures and postoperative complications was calculated by multivariate logistic regression analysis and between classification criteria, type of surgical procedures and risk of long-term recurrence by Cox regression analysis. Follow-up lasted a mean 47.7 ± 23.53 months (median 45 months) or 3.9 ± 1.96 years. The criterion “recurrence rating” was found as predictive factor for postoperative complications in the multivariate analysis (OR 2.04; 95 % CI 1.09–3.84; incisional vs. ventral hernia). The criterion “morphology” had influence neither on the incidence of the critical event “recurrence during follow-up” nor on the incidence of postoperative complications. Hernial gap “width” predicted postoperative complications in the multivariate analysis (OR 1.98; 95 % CI 1.19–3.29; ≤5 vs. >5 cm). Length of the hernial gap was found to be an independent prognostic factor for the critical event “recurrence during follow-up” (HR 2.05; 95 % CI 1.25–3.37; ≤5 vs. >5 cm). The presence of 3 or more risk factors was a consistent predictor for “recurrence during follow-up” (HR 2.25; 95 % CI 1.28–9.92). Mesh repair was an independent protective factor for “recurrence during follow-up” compared to suture (HR 0.53; 95 % CI 0.32–0.86). The ventral and incisional hernia classification of Dietz et al. employs a clinically proven terminology and has an open classification structure. Hernial gap size and the number of risk factors are independent predictors for “recurrence during follow-up”, whereas recurrence rating and hernial gap size correlated significantly with the incidence of postoperative complications. We propose the application of these criteria for future clinical research, as larger patient numbers will be needed to refine the results.

Die transanale Staplerresektion des Rektums (STARR) ist ein gut evaluiertes Operationsverfahren zur Behandlung einer morphologischen Outletobstruktion im Rahmen eines konservativ refraktaren obstruktiven Defakationssyndroms (ODS). Entsprechend muss zunachst die Diagnose eines ODS gestellt und objektiviert werden, welches sich idealerweise durch Erhebung von speziellen Bewertungsbogen (Scores) realisieren lasst. Neben der allgemeinen koloproktologischen Abklarung ist die Defakografie wichtigstes bildgebendes Verfahren der praoperativen Diagnostik. Differenzialdiagnostisch gilt es insbesondere die Beckenboden-Dyssynergie und die Slow-Transit-Konstipation auszuschliesen. Die operative Therapie erfolgt von transanal als Vollwandresektion entweder konventionell durch 2 einzelne Resektate der vorderen und hinteren Zirkumferenz des Rektums (PPH01) oder als tubulare Monoblockresektion mit dem Contour Transtar®. Die Morbiditat des Verfahrens ist durch Analyse von n = 2838 konsekutiven Patienten des europaischen STARR-Registers mit einer Gesamtrate von 36 % ausgewiesen, wobei der unwillkurliche Stuhldrang mit 20 % und die Nachblutung mit 5 % den grosten Anteil davon ausmachen. In spezialisierten Zentren sind bei strenger Selektion der Patienten wesentlich bessere Ergebnisse erzielt worden. Die funktionellen Resultate in Bezug auf eine Verbesserung der Konstipation nach 1 Jahr und im Langzeitverlauf von aktuell bis zu 68 Monaten zeigen ein Ansprechen von bis zu 90 % bei einer Rezidivrate von 5–18 %. Zusammenfassend stellt die STARR-Operation ein gut evaluiertes operatives Verfahren zur Behandlung einer konservativ refraktaren Outletobstruktion dar mit einer hohen primaren Ansprechrate, einer akzeptablen Morbiditat und ersten Analysen nach offenbar mit einer guten Langzeiteffektivitat.

For rectal carcinoma the decision between primary resection, neoadjuvant therapy and local excision depends on an accurate local staging. Local staging includes digital examination, rigid rectoscopy and endorectal ultrasound (EUS). The rectal digitation allows clinical staging according to the mobility of the tumor in relation to the rectal mucosa or the rectal wall. The rigid rectoscopy determines the aboral distance of the tumor from the dentate line or the anal verge. The endorectal ultrasound determines the pre-therapeutic UICC stage on the basis of evaluating the pretherapeutic T and N categories. Results of EUS should be discussed on the background of neoadjuvant therapy including response evaluation and in comparison with the results of magnetic resonance imaging. In addition, there is only little information available concerning evaluation of the circumferential resection margin by EUS. Technical improvements, such as the 3D-EUS, might be appropriate in the future to provide enhancement of EUS staging of rectal tumors.

Aim The aim of the study was to assess the impact of stapled transanal rectal resection (STARR) on pre-existing faecal incontinence and quality of life in patients suffering from obstructive defaecation syndrome (ODS) and to evaluate the efficiency of sequential sacral nerve stimulation (SNS) for improvement of persistent incontinence after STARR. Method Thirty-one patients with ODS and major faecal incontinence prior to STARR were prospectively enrolled. The outcome was measured using the Cleveland Clinic Constipation and Incontinence score (CCS, CCIS), Faecal Incontinence Qualities-of-Life Index (FIQL), Patient Assessment of Constipation Quality-of-Life (PAC-QOL) and EuroQol visual analogue scale (EQ-VAS). Results The overall levels of constipation (CCS from 13.1 ± 3.8 to 6.2 ± 5.4; P 0.05). In group III (n = 7, 23%) there was no improvement at all. Sacral nerve stimulation was successfully carried out in six (85%) of seven patients in group II (post-SNS CCSI 6.1 ± 1.7; P = 0.01) but failed in five of five patients in group III. Conclusion Stapled transanal rectal resection improves quality of life in ODS patients with both severe constipation and faecal incontinence. Sacral nerve stimulation may efficiently improve persisting incontinence after STARR in selected patients.

This study evaluated continence, constipation, and quality of life (QoL) after laparoscopic resection rectopexy (LRR) for full-thickness rectal prolapse. Results were compared with existing data after perineal rectosigmoidectomy (PRS). From May 2003 to February 2008, consecutive patients suffering from full-thickness rectal prolapse undergoing LRR were retrospectively studied. A standardized questionnaire including the Cleveland Clinic Constipation and Incontinence Scores (CCCS and CCIS) as well as general and constipation-related QoL scores (EQ-5D and PAC-QOL) was administered. Results were compared with those after PRS. For statistic analysis, the Wilcoxon test (EQ-5D and EQ-VAS) and two-sample Student’s t test (CCCS, CCIS, and PAC-QOL) were used for LRR, for the comparison of both procedures Mann–Whitney test (EQ-5D) and two-sample Student’s t test (EQ-VAS, CCCS, CCIS, and PAC-QOL). Eighteen patients, 15 female, aged 58.1 (±20.2) years underwent LRR. Eleven patients completed follow-up. Postoperatively, neither functional outcome nor QoL improved. Two recurrences occurred, morbidity was n = 2, and mortality n = 1. In comparison, patients after PRS benefit from improved constipation, general QoL measures, status of health, and all dimensions of constipation-related QoL. Patients after LRR do not benefit from improved general nor constipation-related QoL nor improved functional results compared to PRS.

The purpose of this study is to elucidate the accuracy of a clinical classification system for acute diverticulitis with special regard to "phlegmonous diverticulitis".A consecutive patient series (n = 318; General Hospital Nuremberg, 1/2004-12/2006) was classified preoperatively (imaging with 4/16-slice spiral CT scanner) according to the Hansen and Stock (HS) classification which is commonly used in Germany and evaluated based on histopathology.Pre-treatment classification grouped 30 patients (9.4%) as uncomplicated diverticulitis (type I according to HS), for whom treatment was merely conservative. One hundred twelve patients (35.2%) were classified as phlegmonous diverticulitis (type IIA), 84 (26.4%) as "covered perforations" (type IIB) and 27 (8.5%) as "free perforations" (type IIC), and 54 (17.0%) as chronically recurrent diverticulitis (type III, 17.0%). The remaining 11 patients (3.5%) were not staged preoperatively. Accuracy of staging of complicated diverticulitis differed significantly between type IIC (100.0%), type IIB (91.0%), and type IIA (36.1%). The latter group was frequently understaged as it concealed a substantial number of patients (n = 44; 53.0%) with IIB disease. Neither laboratory tests (CRP/WBC) nor clinical parameters allowed distinction of correctly and falsely staged patients with type IIA disease.Patients with phlegmonous diverticulitis (type IIA) represent the most challenging group among patients with acute diverticulitis as they are frequently understaged and conceal cases with covered perforations (type IIB). This may support the view to subsume phlegmonous diverticulitis (type IIA) under complicated diverticulitis.

Aim Enterocele is common among patients suffering from obstructive defecation syndrome (ODS), but it is often considered a contraindication for stapled transanal surgery. The functional results and complication rates were compared in patients with or without enterocele who were treated with stapled transanal rectal resection (STARR) for ODS. Method Patients presenting with ODS were evaluated using standardized clinical and radiological investigations. A total of 170 patients were treated with either PPH01-STARR or Contour Transtar® and were followed up for a median of 18 months. Results On preoperative defecography, 55 (32%) of 170 patients were found to have an enterocele. The preoperative Cleveland Clinic Constipation Scores (CCCS) in patients with and without enterocele were (mean ± standard deviation) 15.9 ± 5.4 and 15.4 ± 5.2, respectively. At 18 months postoperatively the CCCS were 8.5 ± 2.7 and 8.1 ± 2.6 (P

INTRODUCTION: Fast track (FT) is a modern concept to enhance postoperative recovery after elective surgery. It has been approved during the last years. Beside its medical benefits, fast-track (FT) concepts may provide an economic incentive, -although a cost-benefit analysis in the daily clinical routine has not yet been realised. In addition to this an elevated consumption of resources is postulated. PATIENTS AND METHODS: In 2007 we prospectively studied the implementation of the FT concept for elective colonic surgery in the daily clinical rou-tine at the Department of General Surgery of Nurem-berg Hospital. In a representative subgroup of patients studied, we performed a cost-cost analysis by comparing these patients to a retro-spectively analysed group that had been treated in a conventional traditional manner in 2002. RESULTS: 369 patients were included and treated according to the FT concept. Discharge criteria were met at the 4 th postoperative day in median (SD 3.9 days, minimum 1, maxiumum 29 days). The rate of general postoperative complications was 24.4 % (16 % minor complications) for all pa-tients and 6.6 % in the group of patients who were discharged within 9 postoperative days or less (n = 182). With respect to the main FT items, implementation of the FT concept was considered as effective. Cost-cost analyses showed a cost reduction of 32 % in favour of patients treated with the FT concept. CONCLUSION: This study clearly shows the clinical and economic benefits of the FT concept consid-er-ing health services research. Therefore further clin-ical implementation of the FT concept seems beneficial, not only in the view of medical aspects, but also for economic reasons.

Aims: To evaluate the outcome after surgical resection in patients with gastrointestinal stromal tumors and to determine the factors influencing local tumor recurrence or distant metastatic disease after locally complete tumor resection (R0). Methods: Outcomes of 100 patients with primary gastrointestinal stromal tumors (GIST) surgically managed between 1997 and 2006 at a single institution were reviewed. Univariate and bivariate analyses were used to determine factors affecting recurrence-free and tumor-free survival. Results: All patients (n = 100) had c-kit-positive GIST. There were 17% (n = 17) very low risk, 41% (n = 41) low risk, 19% (n = 19) intermediate risk and 23% (n = 23) high risk GIST originating from the stomach, small bowel, colon and rectum. The median patient age was 68 years (range 39–92). Seventy-three percent of the patients had symptomatic local disease. Most (94%; n = 94) of them underwent R0 resections of their primary tumor. R0 resection was significantly associated with a lower tumor-related mortality rate (p = 0.0001). The patients with recurrence/metastases had significantly larger tumors (p = 0.0017) and a mitotic index higher than 5/50 HPF (p = 0.0001). Seven of 20 patients from the high-risk group and 2 of 7 patients with metastatic disease developed local recurrence or further metastatatic tumor spread following R0 resection. Conclusion: Surgical removal continues to be the mainstay of GIST treatment. R0 resection, tumor size and mitotic index are significant prognostic factors. Overall, more than 30% of the patients with high-risk GIST develop local recurrences and distant metastases despite R0 resection. Additional molecular pathological markers are needed to yield a more accurate tumor profile and to thus achieve a better predictability of the biological behavior of GIST.

The optimal procedure to be followed after colonoscopic polypectomy of malignant colorectal polyps with nontumour-free resection margins at histology is a matter of controversy. While some authors recommend merely local or segmental follow-up resection, others favour an oncological resection. One hundred five patients, each with a single malignant polyp, were investigated. Patients with a macroscopically evident malignant polyp and those in whom the endoscopist reported incomplete polypectomy were excluded from the study. Postpolypectomy morbidity was 4%, and postoperative was 14%. In only 39 cases were the resection margins adjudged to be tumour-free. Histology following subsequent surgery or the follow-up examinations revealed a local recurrence or residual carcinoma at the polypectomy site in only three (2.8%) cases and lymph node metastasis in eight (7.6%) cases. Five patients had remnant adenoma at the polypectomy site. Of the high-risk factors, histological incomplete removal (n = 66, p = 0.04, odds ratio (OR) 10.2) and lymph vessel infiltration (n = 7, p = 0.02, OR 9.2) revealed a significant correlation with lymph node metastasis, but not with remnant tumour. In the case of sessile polyp, the assessment of histological incomplete removal was highly significantly correlated with lymph node metastasis (n = 55, p = 0.007, OR 18.1). Polypectomy artefacts appear to be responsible for the discrepancy between histology and the tumour remnants actually present. On the other hand, histologically incompletely removed sessile malignant polyps represent an appreciably higher risk for lymph node metastasis. Such cases should, therefore, be submitted to further oncological resection.

Aim Stapled transanal rectal resection (STARR) is a promising new treatment for obstructed defecation syndrome (ODS). It may be performed using either a double-stapling technique (PPH-STARR) or with the new Contour Transtar (CT) device. The aim of this study was to evaluate the two techniques with respect to morbidity and functional outcomes. Method Patients presenting with ODS were evaluated using standardized clinical and radiological investigations and prospectively entered into a database. A total of 150 Patients were treated with either PPH-STARR (n = 68) or CT (n = 82) and further evaluated at 12 month postoperatively. Results The mean size of the resected specimen was 27 cm2 (SD ±4.86 cm2) in the PPH-STARR group and 46 cm2 (SD ±10.6 cm2) in the CT group [P

Die multimodale Therapie des fortgeschrittenen Rektumkarzinoms beeinhaltet eine optimierte Chirurgie mit totaler mesorektaler Exzision, eine (neo-/adjuvante) Radiochemotherapie und/oder eine systemische Chemotherapie. Dabei ist die integrale Betrachtung von Lebensverlangerung und Lebensqualitat (LQ) noch viel zu selten Grundlage der Therapieentscheidung. Ziel der vorliegenden Ubersichtsarbeit ist es, verschiedene Aspekte der LQ-Bestimmung bei der chirurgischen Therapie darzustellen. Generell ist die permanente Kolostomie im Gegensatz zur anterioren Rektumresektion nicht zwangslaufig mit einer schlechten postoperativen LQ assoziiert. Die Ruckverlegung einer protektiven Ileostomie erhoht bei Patienten mit Rektumkarzinom die LQ. Die laparoskopische totale mesorektale Exzision bietet in Bezug auf die LQ derzeit keine messbaren Vorteile im Vergleich zur konventionell offenen Operation. Wenn technisch moglich, bietet die Kolon-J-Pouch-Rekonstruktion messbare Vorteile der postoperativen LQ gegenuber Rekonstruktionsformen wie der geraden Anastomose und/oder der Koloplastie. Die Kenntnis der postoperativen Einschrankungen der LQ und eine konsequente praoperative Aufklarung helfen, die postoperative LQ der betroffenen Patienten zu verbessern.

The task force "workflow rectal cancer II" defined operative techniques in lower rectal cancer, especially the total mesorectal excision and an improved technique of abdominalperineal resection. New aspects for treatment of rectal cancer with primary distant metastases are described. Due to newer publications a concept of bidirectional procedure with surgery and radiochemotherapy is recommended, where the operation must not be inevitably the first step. In anastomoses below 6 cm of the anocutaneous verge a reservoir should be performed on principle due to better functional results. The colon-j-pouch with a maximal loop length of 6 cm is best investigated under these conditions, the other procedures should be further evaluated.

Diagnostic and treatment of rectal cancer need a continuous quality assessment. Indicators of quality were compiled as indicator profile for a summarizing evaluation. The indicators selected should potentially show an appreciable variation of the quality target and in addition should be decisive for the outcome. For the evaluation of the clinical diagnostic the frequency of the determination of the pretherapeutic T, N and M categories and the proportion of pT 1-tumors were chosen, for the pathological diagnostic the number of histologically examined lymph nodes and the proportion of lymphnode positive patients. Process quality of treatment was defined by the following indicators: proportion of tumor excision, of definite therapy by local tumor removal, of neo-adjuvant long-term radiochemotherapy, of adjuvant treatment in patients not selected for neoadjuvant therapy, of total / partial mesorectal excision, of abdomino-perineal resection, postoperative mortality, frequency of clinically apparent anastomotic leakage, and of neurogenic bladder dysfunction at hospital discharge. The indicators for the quality of the performance of treatment were differentiated between surrogate indicators that can be determined immediately after accomplishment of primary surgical therapy giving strong clues for the further course of disease at an early date, and definite indicators. Important surrogate indicators comprise the occurrence of intraoperative local tumor cell dissemination, R 1 / 2-resection, pathohistologically CRM-positive tumor resection, and the quality of mesorectal excision (proportion of incomplete mesorectal excision). The definite indicators include the 5-year local recurrence rate and the 5-year overall survival rate. The corresponding quantifying parameters for the individual indicators are specified in this paper with precise figures.

Background and Objectives Proliferation and synthesis of hepatocellular tissue after tissue damage are promoted by specific growth factors such as hepatic tissue growth factor (HGF) and connective growth factor (CTGF). Laser-induced thermotherapy (LITT) for the treatment of liver metastases is deemed to be a parenchyma-saving procedure compared to hepatic resection. The aim of this study was to compare the impact of LITT and hepatic resection on intrahepatic residual tumor tissue and expression levels of mRNA HGF/CTGF within liver and tumor tissue. Study Design/Materials and Methods Two independent adenocarcinomas (CC531) were implanted into 75 WAG rats, one in the right (untreated tumor) and one in the left liver lobe (treated tumor). The left lobe tumor was treated either by LITT or partial hepatectomy. The control tumor was submitted to in-situ hybridization of HGF and CTGF 24–96 hours and 14 days after intervention. Results Volumes of the untreated tumors prior to intervention were 38±8 mm3 in group I (laser), 39 ± 7 mm3 in group II (resection), and 42 ± 12 mm3 in group III (control) and did not differ significantly (P > 0.05). Fourteen days after the intervention the mean tumor±SEM volume of untreated tumor in group I (laser) [223 ± 36] was smaller than in group II (resection) [1233.28 ± 181.52; P

Long-standing fistulizing and stenotic proctitis (LFSP) in Crohn’s disease (CD) indicates the end stage of the disease. Definitive diversion such as proctectomy is considered to be the only surgical option. The impact of intersphincteric sphincter-sparing anterior rectal resection (IAR) as an alternative to proctectomy is unclear. The aim of this study was to evaluate feasibility, morbidity, outcome, and quality of life (QL) in patients with LFSP undergoing intended IAR. Out of a single institution database, 15 patients with LFSP intended for surgery from 856 patients with CD were selected for follow-up analyses. In 12/15 cases, IAR was carried out while 3/15 patients underwent primary proctectomy due to malignancy (n = 2) or due to patient’s wish (n = 1). In one case, IAR revealed unexpected malignancy, which led to secondary proctectomy. In patients with IAR, complete healing of fistulas and stenosis was observed in 46 % (n = 5) while 36 % (n = 4) of patients showed relapse of fistula and 18 % (n = 2) developed restenosis. Ileostomy closure was performed in seven patients from which six patients remained stoma free. QL and fecal incontinence measured by standardized scoring systems were unchanged while stool frequency was reduced after IAR in patients with ileostomy closure. The rate of malignancy in this cohort was 20 % (n = 3). LFSP in CD was associated with 20 % of malignant transformation. Although IAR fails to improve QL, it is a suitable procedure for the treatment of fistulas and stenosis associated with acceptable healing rates and can avoid a permanent stoma.

Restoration of continence remains a major challenge in patients after abdominoperineal rectal excision (APE) or with end-stage fecal incontinence. A new surgical technique, the neurostimulated levator augmentation, was introduced for pelvic floor augmentation using dynamic graciloplasty in order to restore anorectal angulation. The aim of this study was to assess feasibility and efficiency.From November 2009 to March 2014, n = 17 patients underwent neurostimulated levator augmentation (n = 10 after APE, n = 5 intractable idiopathic fecal incontinence, n = 2 traumatic anal amputation). Gracilis muscle was transposed through the obturator foramen into the pelvic cavity, positioned in a U-shaped sling behind the rectum, fixed to the contralateral os pubis to restore anorectal angulation, and then conditioned by neurostimulation. Questionnaires analyzing function and quality of life were administered.For neurostimulated levator augmentation, four patients suffered from complications that needed operative intervention (n = 3 wound infection, n = 1 colon perforation); three pharmacological treatment and two complications needed no further invasive intervention. One patient died due to causes unrelated to the operation, and no complication required intensive care management. Fecal incontinence in patients with idiopathic incontinence improved significantly after surgery as well as incontinence episodes, urgency, and disease-specific quality of life through all dimensions. Generic quality of life was significantly better after surgery in all patients. After median follow-up of 17 months (2-45), all but one patient would undergo the procedure again.Neurostimulated levator augmentation was feasible in all patients with acceptable morbidity. It may represent a new therapeutic option in selected patients with intractable fecal incontinence.

In situ ablation of colorectal liver metastases is frequently assessed for palliative treatment only. The establishment of clinically relevant lesion size and a lack of long-term survival data were regarded as main limitations to using them with curative intention. In contrast to surgical liver resection, whose oncological findings seem to have remained unchanged over the years, the in situ ablation methods have considerably changed technically and clinically in the last few years.The aim of the paper was to point out experimental and clinical data underlining the impact of in situ ablation for potentially curative treatment of colorectal liver metastases.On the basis of experimental data, the aim of complete local tumor control (R0 ablation) can only be obtained if additional energy is applied after reaching the tumor-adapted maximal coagulation volume. Analogous to the oncological safety margin in surgical resection, we defined this decisive energy difference as the "energy safety margin" for in situ ablation. The energy safety margin is the energy that must be additionally applied after reaching the plateau in the energy/volume curve to achieve complete tumor coagulation. In addition to that, in situ ablation should be combined with temporary interruption of hepatic perfusion whenever possible to prevent intralesional recurrences. In this way, the thermoprotective mechanism of hepatic perfusion can be effectively eliminated. With restrictions, the survival data after ablation in specialized centers is comparable to surgical resection with concomitantly lower morbidity and mortality. Based on recent findings and with the corresponding expertise in the field of ablation and state-of-the-art equipment, ablation is, thus, an alternative to surgical resection. The combined application of surgical resection and ablation is also a suitable method for increasing the R0 rate and thus helps improve the prognosis of treated patients. In summary, it can be said that in situ ablation is a useful expansion of the therapeutic spectrum of liver metastases and can be applied as an alternative to or in combination with surgical resection.

Background Only monopolar systems have thus far been available for radiofrequency ablation of liver tumors, whose application is restricted because of the incalculable energy flow, reduction of electrical tissue conduction, and limited lesion size. The aim of this study was to evaluate a novel internally cooled bipolar radiofrequency application device under in vivo conditions and to compare the effect of this system on lesion size when combined with hepatic arterial microembolization or complete hepatic blood flow occlusion. Materials and methods In a porcine liver model, RFA (60 W, 12 min) was performed with either normal (n = 12), partially interrupted (arterial microembolization via a hepatic artery catheter n = 12) or completely interrupted hepatic perfusion (Pringle’s maneuver, n = 12). RFA parameters (impedance, power output, temperature, applied energy) were determined continuously during therapy. RFA lesions were macroscopically assessed after liver dissection. Results Bipolar RFA induced clinical relevant ellipsoid thermal lesions without complications. Hepatic inflow occlusion led to a 4.3-fold increase in lesion volume after arterial microembolization and a 5.8-fold increase after complete interruption (7.4 cm3versus 31.9 cm3versus 42.6 cm3, P < 0.01). Conclusions The novel bipolar RFA device is a safe and effective alternative to monopolar RFA-systems. Interrupting hepatic perfusion significantly increases lesion volumes in bipolar RFA. This beneficial effect can also be achieved in the percutaneous application mode by RFA combined with arterial microembolization via a hepatic artery catheter.

Background and Objectives The therapeutic application of laser light is a promising alternative to surgical resection of colorectal liver metastases. The extent of tumor destruction achieved by this strategy depends primarily on light distribution in the target tissue. Knowledge about optical properties is necessary to predict light distribution in the tissue for careful irradiation planning. The aim of this study was to compare the optical behavior of healthy colon tissue with that of colorectal carcinomas and their hepatic metastases in the native and coagulated state in order to test the effect of malignant degeneration, metastasis, and thermal coagulation on optical parameters. Materials and Methods Ninety tissue samples were taken from patients with a colorectal carcinoma and concomitant liver metastases: healthy colon tissue (n = 30); colon carcinoma (n = 30); liver metastases (n = 30). Optical properties were measured according to the single integrating sphere principle in the native state and after thermal coagulation in the wavelength range of 800–1,100 nm and analyzed by inverse Monte Carlo simulation. Results The highest optical penetration depth for all tissue types was obtained at the end of the spectral range investigated. The highest penetration depths of 4.13 mm (healthy colon), 7.47 mm (colon carcinoma tissue), and 4.08 (liver metastases) were at 1,060 nm, although the values decreased significantly after thermal coagulation. Comparing healthy colon-to-colon carcinoma always revealed a significantly lower absorption and scattering coefficient in the tumor tissue. This resulted in a higher optical penetration depth of the laser light in the colon carcinoma tissue (P

Unter dem Begriff der „nichtoperativen Ablation“ werden eine Reihe heterogener Techniken zur Behandlung von Lebermetastasen zusammengefasst, wie beispielsweise die Radiofrequenztherapie (RF), die laserinduzierte Thermotherapie (LITT) und die Kryotherapie. Bislang galten die Verfahren im Wesentlichen als palliative Therapieoptionen. Wesentliche limitierende Faktoren waren die Induktion klinisch relevanter Lasionsvolumina und das Fehlen von Langzeitstudien. Innerhalb der letzten Jahre werden mit neu entwickelten Applikationssystemen der RF und LITT bemerkenswerte Ergebnisse erzielt, und erste klinische Studien zeigen bei selektierten Patienten vergleichbare Daten mit denen der chirurgischen Resektion. Die vorliegende Arbeit soll eine Ubersicht uber Moglichkeiten und Grenzen der nichtoperativen Ablation in Bezug auf den Einsatz unter kurativer Intention geben, wobei ein besonderes Gewicht auf die histopathologischen Grundlagen hyperthermer Lasionen sowie den klinischen Ergebnissen in Hinblick auf die „R0-Ablation“ und das Langzeituberleben gelegt wird.

Background: Unresectable locally advanced pancreatic cancer (LAPC) has an extremely poor prognosis. Results of neoadjuvant (radio-)chemotherapy approaches aiming at achieving resectability are currently not satisfactory. Case Report: We report the case of a 67-year-old woman with histologically confirmed pancreas carcinoma that was not resectable on first surgical exploration who achieved a well-documented complete pathological remission (pCR). The carcinoma became resectable after consecutive neoadjuvant treatment with nanoparticle albumin-bound (nab)-paclitaxel/gemcitabine and FOLFIRINOX chemotherapy regimens. Conclusion: This is the first reported LAPC case in which neoadjuvant chemotherapy alone has been shown to lead to demonstrated pCR. CA19-9 levels, but not imaging criteria, were useful for response prediction and timing of the Whipple's procedure. The findings in this case suggest possible conceptual changes in the treatment approach for LAPC, and indicate that the new effective chemotherapy regimens should be integrated into clinical trials for LAPC.

Background and Objectives In contrast to hepatic resection, thermally destroyed autologous tumor cells remain in situ after laser-induced thermotherapy (LITT). The aim of the study was to evaluate the effect of LITT and hepatic resection on the immune response to residual intrahepatic tumor tissue and the growth of untreated liver metastases. Study Design/Materials and Methods Two independent adenocarcinomas (CC531) were implanted into 60 WAG rats, one in the right (control tumor) and one in the left liver lobe (treated tumor). The left lobe tumor was treated either by LITT or partial hepatectomy. The control tumor was submitted to further investigation 24 hours, 96 hours, 7 days, and 10 days after treatment. Results Ten days after treatment, control tumor volumes were 296±46 mm_ after LITT and 1,181±192 mm_, 1,387±200 mm_ after hepatic resection and no treatment, respectively (P

Background The aim of this study was to evaluate the influence of in situ ablation and hepatic resection of experimental liver metastases on residual intrahepatic tumour growth and macroscopic peritoneal tumour spread. Methods Two colonic carcinomas (CC 531) were implanted into 90 WAG rat livers, one in the right liver lobe (untreated tumour) and one in the left liver lobe (treated tumour) of each rat. The animals were randomized into two test groups and a sham-operated control group. Animals in group 1 received in situ ablation (laser-induced thermotherapy) of the treated tumour. Rats in group 2 were submitted to partial hepatectomy. Untreated tumour volumes were calculated and the incidence of macroscopic peritoneal spread was determined at different times. Results After 21 days median (95 per cent confidence interval) volumes of untreated tumours were 507 (282) mm3 in group 1, 2096 (994) mm3 in group 2 and 1896 (755) mm3 in group 3. Compared with values obtained before treatment, growth of the untreated tumours had increased significantly after 4 days in group 2, after 7 days in group 3 and after 10 days in group 1. Macroscopic peritoneal tumour spread was detected in six of 30 animals in group 1 (laser), in 20 of 30 in group 2, and in 24 of 30 in group 3. Conclusion Compared with hepatic resection, in situ ablation of experimental liver metastases delays and reduces residual intrahepatic tumour growth and macroscopic peritoneal tumour spread.

Background and Objective The aim of this study was to evaluate the accuracy of Gd-DTPA MRI in the detection of recurrent tumor after laserinduced thermotherapy (LITT) of experimental liver metastases. Study Design/Materials and Methods LITT was performed at different energy levels in VX-2 tumor-bearing rabbits (n = 80). MRI and histology were placed at 0, 24, 96 hours, and 14 days. Signal intensities were calculated of the transition between thermally damaged and undamaged tissue (transition zone = TZ) and of the surrounding tissue (reference zone = RZ). Results Tumor recurrence was seen in 47 animals. At 24 hours sensitivity, specificity and accuracy was 92, 100, and 95% in TZ and 23, 100, and 50% in RZ. At 14 days sensitivity, specificity and accuracy was 100, 11, and 60% in TZ and 100, 89, and 95% in RZ. Conclusions Recurrence is best excluded in TZ at 24 hour and in RZ at 14 day with an accuracy up to 95%. Lasers Surg. Med. 30:280–289, 2002. © 2002 Wiley-Liss, Inc.

The impact of surgery in the treatment of inflammatory bowel disease (IBD) is considered as secondary whereas conservative treatment remains the first choice. Surgery is designated for a complicated or refractory disease course. Furthermore, there seems to be prophylactic aspects as well, such as ileocecal resection in Crohn's disease and prophylactic restorative coloproctectomy for intraepithelial neoplasia associated with ulcerative colitis.This review evaluates the impact of surgery in the treatment of Crohn's disease and ulcerative colitis in view of existing data in the literature.The results in the literature are reviewed and retrospective data from this institution are presented.The manifestation of Crohn's disease is mainly ileocecal, colorectal, enteric and anorectal. The role of surgery is discussed according to the localization, extent of the disease and the clinical course. The emphasis is on longstanding Crohn's proctitis with fistulas and stenosis which are still challenging. The results indicate that intersphincteric rectal resection with pull through of the rectum and hand-sewn anastomosis represents a good option in up to 67 % of cases to avoid permanent stoma in highly selected patients. In addition, this procedure provides high rates of fistula healing as well as low recurrence rate of the anorectal stenosis. Pouch surgery in ulcerative colitis can be offered in high volume centers with low morbidity and functional results remain stable over time. Postoperative quality of life seems to be good with regard to general and disease-related quality of life.Interdisciplinary approaches should increasingly focus on prophylactic aspects of surgical options while conservative treatment will be enhanced by new therapeutic agents.

Coloproctectomy is a visceral surgical intervention where the complete colon and rectum are removed up to the level of the pelvic floor or pectinate line and the anal canal. As a rule the anal canal and pelvic floor musculature including the anal sphincter muscle remain intact. The ileoanal J-pouch construction has become established as treatment of choice for reconstruction of the small intestine. This article presents the approach for open coloproctectomy with ileoanal J-pouch reconstruction by means of an operation video which is available on-line.