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ERAS® (Enhanced Recovery After Surgery) describes a multimodal, interdisciplinary, and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures. Goal of the work. The aim of this article is to examine the economic feasibility of the ERAS® concept in the German DRG (diagnosis-related groups) system.Since August 2019, patients have been treated in our clinic according to the later certified ERAS® concept. The last 50 patients before ERAS® implementation are compared below with 50 patients after ERAS® implementation, who were identified using a matched pair analysis. In addition to the comparison of costs and revenues, the clinical outcome of the patients is also presented.The cases of the patients in the pre-ERAS® cohort caused median costs of € 7432.83. BWR (valuation ratio) of 3.38 were billable. The resulting DRG revenue for the patients in this group amounted to € 11,325.78. The proceeds generated in the end amounted to € 4575.14. The cases of patients in the ERAS® cohort resulted in costs of € 5582.96. BWR of 2.84 could be billed. The DRG proceeds for the patients in this group therefore amounted to € 10,014.18. The profit generated was thus € 4993.84.The cost reduction generated by ERAS® was more pronounced than the "loss" due to the decrease in BWR. ERAS® is therefore also possible in the German DRG system at absolutely cost-covering levels.

Purpose The effectiveness of modern perioperative treatment concepts has been demonstrated in several studies and meta-analyses. Despite good evidence, limited implementation of the fast track (FT) concept is still a widespread concern. To assess the status quo in Austrian and German hospitals, a survey on the implementation of FT measures was conducted among members of the German Society of General and Visceralsurgery (DGAV), the German Society of Coloproctology (DGK) and the Austrian Society of Surgery (OEGCH) to analyze where there is potential for improvement. Methods Twenty questions on perioperative care of colorectal surgery patients were sent to the members of the DGAV, DGK and OEGCH using the online survey tool SurveyMonkey®. Descriptive data analysis was performed using Microsoft Excel. Results While some of the FT measures have already been routinely adopted in clinical practice (e.g. minimally invasive surgical approach, early mobilization and diet buildup), for other components there are discrepancies between current recommendations and present implementation (e.g. the use of local nerve blocks to provide opioid-sparing analgesia or the use of abdominal drains). Conclusion The implementation of the FT concept in Austria and Germany is still in need of improvement. Particularly regarding the use of abdominal drains and postoperative analgesia, there is a tendency to stick to traditional structures. To overcome the issues with FT implementation, the development of an evidence-based S3 guideline for perioperative care, followed by the founding of a surgical working group to conduct a structured education and certification process, may lead to significant improvements in perioperative patient care.

Purpose: In Germany, colorectal robot-assisted surgery (RAS) has become common [1]. We investigated whether RAS can be extensively combined with enhanced recovery after surgery (ERAS®) in a large prospective patient group. Methods: Using the DaVinci Xi surgical robot, all colorectal RAS from 09/2020 to 01/2022 were incorporated into our ERAS® program. Perioperative data were prospectively recorded using a data documentation system. The extent of resection, duration of the operation, intraoperative blood loss, conversion rate, and postoperative short-term results were analyzed. We documented the postoperative duration of Intermediate Care Unit (IMC) stay and major and minor complications according to the Clavien–Dindo classification, anastomotic leak rate, reoperation rate, hospital-stay length, and ERAS® guideline adherence. Results: One hundred patients (65 colon and 35 rectal resections) were included (median age: 69 years). The median durations of surgery were 167 min (colon resection) and 246 min (rectal resection). Postoperatively, four patients were IMC-treated (median stay: 1 day). In 92.5% of the colon and 88.6% of the rectum resections, no or minor complications occurred postoperatively. The anastomotic leak rate was 3.1% in colon and 5.7% in rectal resection. The reoperation rate was 7.7% (colon resection) and 11.4% (rectal resection). The hospital stay length was 5 days (colon resection) and 6.5 days (rectal resection). The ERAS® guideline adherence rate was 88% (colon resection) and 82.6% (rectal resection). Conclusion: Patient perioperative therapy per the multimodal ERAS® concept is possible without any problems in colorectal RAS, leading to low morbidity and short hospital stays.

Purpose The COVID-19 pandemic has led to global changes in healthcare systems. The purpose of this study was to investigate the effects on surgical care of patients. Methods We performed a retrospective analysis of routine data from the largest hospital group in Germany (68 acute hospitals). Included were inpatients who underwent cholecystectomy between March 19, 2020 (beginning of the first lockdown in Germany) and September 22, 2020. These patients were compared with those treated in the same interval in 2019. Results In the 2020 study period, 4035 patients met the inclusion criteria (2019: 4526 patients). During the first lockdown, there was a significant reduction in the number of cholecystectomies performed (51.1% decrease). More patients with a higher risk profile underwent urgent operations, which were accompanied by a significant increase in conversion from laparoscopic to open cholecystectomy. The patients were treated as inpatients for a longer duration than 2019, and the mortality rate increased significantly to 1.3% (2019: 0.1%). The complication rate also showed a significant increase. After the end of the first lockdown, daily admission rates normalized very quickly. However, it was not possible to fully address the backlog of operations. Conclusion There is still a “patient stagnation” 6 months after the first German lockdown. Extrapolated to the national level, this corresponds to almost 21,000 fewer cholecystectomies performed in Germany in 2020. It remains to be seen whether surgical rates will return to pre-pandemic levels and whether complications will arise in the future due to the lack of operations.

ZusammenfassungCOVID-19 hat zu umfassenden Veränderungen der Welt, wie wir sie bisher kannten, geführt. Durch den starken Anstieg intensivpflichtiger COVID-Patienten wurden beispielsweise elektive Aufnahmen und Eingriffe verschoben. Aber auch Notfälle wie Myokardinfarkte gingen zurück. Die hier vorliegende Studie hat sich mit den Auswirkungen der COVID-Pandemie auf viszeralchirurgische Notfälle anhand von 5 Indikatoroperationen beschäftigt. Dafür wurden Routinedaten aus 73 Akutkrankenhäusern der Helios-Gruppe ausgewertet. Eingeschlossen wurden die Eingriffe, die zwischen dem 13.03.2020 und 12.03.2021 durchgeführt wurden. Verglichen wurden die Daten mit dem Zeitraum vom 13.03.2019 bis zum 12.03.2020.Die Anzahl der Eingriffe bei schwerwiegenden Notfällen (Ileus, mesenteriale Ischämie und Ulkusperforation) sind konstant geblieben. Die Liegedauer im Krankenhaus war im Pandemiejahr 2020 jedoch signifikant kürzer als im Vergleichsjahr 2019. Die Anzahl der Cholezystektomien und Appendektomien war im Pandemiejahr signifikant geringer als im Vergleichsjahr 2019. Die Outcome-Parameter intensivmedizinische Betreuung, invasive Beatmung und Krankenhausmortalität waren zwischen den beiden Zeiträumen für die untersuchten Eingriffe vergleichbar.

ERAS (Enhanced Recovery After Surgery) describes a multimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures.The aim of this article is to examine the economic feasibility of the concept in the German DRG system.Since August 2019, patients have been treated in our clinic according to the later certified ERAS concept. The last 20 patients before ERAS implementation are compared below with 20 patients after ERAS implementation, who were identified using a matched pair analysis. In addition to the comparison of costs and revenues, the clinical outcome of the patients is also presented.The cases of the patients in the pre-ERAS cohort caused median costs of € 7432.83. BWR of 3.38 were billable. The resulting DRG revenue for the patients in this group amounted to € 11325.78. The proceeds generated in the end amounted to € 4575.14. The cases of patients in the ERAS cohort resulted in costs of € 5582.96. BWR of 2.84 could be billed. The DRG proceeds for the patients in this group therefore amounted to € 10014.18. The profit generated was thus € 4993.84.The cost reduction generated by ERAS was comparable to the "loss" caused by the BWR decrease. ERAS is therefore also possible to cover costs in the German DRG system.ERAS (Enhanced Recovery After Surgery) beschreibt ein multimodales, interdisziplinäres und interprofessionelles Behandlungskonzept, welches die postoperative Rekonvaleszenz des Patienten durch den Einsatz evidenzbasierter Maßnahmen optimiert.Ziel dieses Artikels ist es, die ökonomische Abbildbarkeit des Konzeptes im deutschen DRG-System zu untersuchen.Seit August 2019 werden Patienten in unserer Klinik nach dem später zertifizierten ERAS-Konzept behandelt. Die letzten 20 Patienten vor ERAS-Implementierung werden im Folgenden mit 20 Patienten nach ERAS-Implementierung verglichen, die über eine Matched-Pair-Analyse identifiziert wurden. Neben dem Vergleich von Kosten und Erlös wird auch das klinische Outcome der Patienten dargestellt.Die Fälle der Patienten der präERAS-Kohorte haben mediane Kosten von 7432,83 € verursacht. Abrechenbar waren BWR von 3,38. Der daraus resultierende DRG-Erlös für die Patienten dieser Gruppe belief sich auf 11325,78 €. Der letztlich generierte Erlös belief sich somit auf 4575,14 €. Die Fälle der Patienten der ERAS-Kohorte haben Kosten von 5582,96 € verursacht. Abrechenbar waren BWR in Höhe von 2,84. Der DRG-Erlös für die Patienten dieser Gruppe belief sich demnach auf 10014,18 €. Der erwirtschaftete Gewinn betrug somit 4993,84 €.Die durch ERAS generierte Kostenreduktion war vergleichbar zum „Verlust“ durch den BWR-Rückgang. ERAS ist demnach auch im deutschen DRG-System kostendeckend möglich.

Zusammenfassung Hintergrund ERAS (Enhanced Recovery After Surgery) beschreibt ein multimodales, interdisziplinäres und interprofessionelles Behandlungskonzept, welches die postoperative Rekonvaleszenz des Patienten durch den Einsatz evidenzbasierter Maßnahmen optimiert. Ziel der Arbeit (Fragestellung) Ziel dieses Artikels ist es, die ökonomische Abbildbarkeit des Konzeptes im deutschen DRG-System zu untersuchen. Material und Methoden Seit August 2019 werden Patienten in unserer Klinik nach dem später zertifizierten ERAS-Konzept behandelt. Die letzten 20 Patienten vor ERAS-Implementierung werden im Folgenden mit 20 Patienten nach ERAS-Implementierung verglichen, die über eine Matched-Pair-Analyse identifiziert wurden. Neben dem Vergleich von Kosten und Erlös wird auch das klinische Outcome der Patienten dargestellt. Ergebnisse Die Fälle der Patienten der präERAS-Kohorte haben mediane Kosten von 7432,83 € verursacht. Abrechenbar waren BWR von 3,38. Der daraus resultierende DRG-Erlös für die Patienten dieser Gruppe belief sich auf 11325,78 €. Der letztlich generierte Erlös belief sich somit auf 4575,14 €. Die Fälle der Patienten der ERAS-Kohorte haben Kosten von 5582,96 € verursacht. Abrechenbar waren BWR in Höhe von 2,84. Der DRG-Erlös für die Patienten dieser Gruppe belief sich demnach auf 10014,18 €. Der erwirtschaftete Gewinn betrug somit 4993,84 €. Diskussion Die durch ERAS generierte Kostenreduktion war vergleichbar zum „Verlust“ durch den BWR-Rückgang. ERAS ist demnach auch im deutschen DRG-System kostendeckend möglich.

Fast-track concepts have fundamentally changed the perioperative care of patients in the last 30 years. Sufficient evidence is available for these concepts.The aim of this article is to evaluate the dissemination of fast-track concepts in Germany based on routine data.A retrospective analysis of all colorectal resections performed at the Helios Clinics in 2016-2021 was carried out. These were analyzed with respect to the length of hospital stay, intensive care unit occupancy, ventilation proportion, mortality, complication rate and access approach.A transfer to the intensive medical care unit is still the standard in Germany after colorectal resection. For oncological colorectal resection, in particular, two thirds of the patients are still perioperatively treated on the intensive care unit. The duration of inpatient hospital stay for colorectal resection is still excessively long in international comparisons and has also only diminished slowly in recent years (e.g. colon cancer 2016: 18.6 ± 11.9 days and 2021: 13.8 ± 9.3 days). The proportion of open surgical interventions is declining but still accounts for a relevant proportion even 30 years after the implementation of laparoscopy (e.g. colon cancer 2016: 71.10% and 2021: 56.44%). Therefore, the care of patients with colorectal resection still does not seem to be implemented according to the fast-track principle.HINTERGRUND: Fast-Track-Konzepte haben die perioperative Betreuung von Patienten in den letzten 30 Jahren grundlegend verändert. Evidenz für diese Konzepte ist ausreichend vorhanden.Ziel dieses Artikels war es, die Verbreitung von Fast-Track-Konzepten in Deutschland anhand von Routinedaten zu evaluieren.Es wurde eine retrospektive Analyse aller kolorektalen Resektionen der Helios-Kliniken der Jahre 2016 bis 2021 durchgeführt. Diese wurden bezüglich Krankenhausverweildauer, Intensivbelegung, Beatmungsanteil, Mortalität, Komplikationsrate und Zugangsweg analysiert.Eine intensivmedizinische Belegung nach kolorektalen Resektionen ist in Deutschland weiterhin die Regel. Insbesondere bei onkologischen kolorektalen Resektionen werden nach wie vor zwei Drittel der Patienten perioperativ intensivmedizinisch betreut. Die stationäre Liegedauer bei kolorektalen Resektionen ist im internationalen Vergleich weiter überdurchschnittlich lang und auch über die letzten Jahre nur langsam rückläufig (z. B. Kolonkarzinom 2016: 18,6 ± 11,9 Tage/2021: 13,8 ± 9,3). Der Anteil offen-chirurgischer kolorektaler Eingriffe ist rückläufig, macht aber auch 30 Jahre nach Einführung der Laparoskopie einen relevanten Anteil aus (z. B. Kolonkarzinom 2016: 71,10 %/2021: 56,44 %). Die Versorgung von Patienten mit kolorektalen Resektionen scheint demnach weiterhin nicht nach Fast-Track-Prinzipen umgesetzt zu sein.

Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.

ZusammenfassungModerne perioperative Behandlungskonzepte legen großen Wert auf eine aktive Rolle der Patienten. Um dies zu ermöglichen, ist eine intensive Patientenbegleitung notwendig. Aus dieser Notwendigkeit heraus hat sich die Position der ERAS®-Nurse entwickelt. Sie ist der primäre Ansprechpartner für den Patienten vor, während und nach der Operation. Die konzeptionelle Erstellung und fortwährende Weiterentwicklung eines ERAS-Konzeptes mag vor allem ärztliche Tätigkeit sein, die tagtägliche Arbeit am Patienten und die Füllung des Konzeptes mit Leben wird jedoch vor allem durch eine ERAS-Nurse bewerkstelligt. Ihre Hauptaufgaben liegen in der präoperativen Patientenaufklärung, der täglichen Visitation der Patienten während des stationären Aufenthaltes, dem Ausfüllen der Dokumentation, der fortwährenden Kommunikation mit Pflegekräften und dem Monitoring der Einhaltung der ERAS-Vorgaben aller beteiligten Teammitglieder. Entsprechend wichtig ist es, die Position der ERAS-Nurse zu schaffen und sie als wertiges Mitglied ins Team zu integrieren. Im folgenden Artikel, der auf unseren Erfahrungen als zertifiziertes ERAS-Zentrum beruht, wird das Berufsbild umfänglich vorgestellt, einschl. Aufgaben, Bedeutung und Lösungsvorschlägen für gängige Probleme.

Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade “A” was reported for 98 (61.3%), grade “B” for 41 (25.6%) and grade “C” for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, “abscesses with invasive therapy” (p < 0.001), “other surgical complications” (p < 0.001), prolonged “stays in ICU” (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance.

Purpose: Placement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness, and with an increased risk of bladder emptying disorders and a decrease of blood pressure, which all relate to delayed mobilization. Preliminary data show that EC placement may not be necessary in laparoscopic colon resections. The aim of this prospective study was to investigate how omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections.Methods: All laparoscopic rectal resections occurring between 2013-2020 were prospectively examined. Resections from 01/2013-02/2018 (group A) were compared with resections from 03/2018-12/2020 (group B; after internal change of the perioperative pain regime). In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain >3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, Intermediate care unit stay (IMC stay) in days and hospital length of stay in days.Results: In the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A, and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay, were significantly lower in group B (pConclusion: Omission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary.

Purpose:Anastomotic leak (AL) following colorectal resections can be treated interventionally. However, most cases require surgical intervention. Thus, several surgical techniques are available, which intend to affect the further course positively. The aim of this retrospective analysis is to determine which surgical technique proves to have the biggest potential in reducing the morbidity and mortality as well as to minimize the need of re-interventions after AL. Methods:All patients with a history of AL following colorectal resection between 2008 and 2020 were analyzed. Patient’s outcomes following surgical treatment of AL, including morbidity and mortality, clinical and para-clinical (laboratory examinations, ultrasound, and CT-scan) detection of AL recurrence, re-intervention rate, and the length of hospital stay were documented and correlated with the surgical technique used (e.g. simply over-sewing the AL, over-sewing the AL with the construction of a protective ileostomy, resection and reconstruction of the anastomosis, peritoneal lavage and transanal drainage, or taking the anastomosis down and constructing an end stoma).Results:A total of 2,656 colorectal resections were documented. AL occurred in 92 (4.4% AL occurrence-rate) and 31 (5.4% AL occurrence-rate) cases following colon and rectal resections, respectively. The anastomosis was not preservable in 52 and 17 cases following colon and rectal resections, respectively. Therefore, the anastomosis had been taken down and an end-stoma had been constructed. Over-sewing the AL with the construction of a protective ileostomy had the highest anastomosis preservation rate (14 of 18 cases) and lowest re-intervention rate (mean value of 1.5 re-interventions) following colon and rectal resections (7 of 9 cases; mean value, 1.5 re-interventions).Conclusion:In cases where an AL is preservable, over-sewing the anastomosis and constructing a protective ileostomy has the greatest potential for positive short-term outcomes following colorectal resections.

The perioperative management of colorectal resections is often dominated by traditional procedures and a strong focus on safety. Evidence-based measures such as those established in Fast Track or ERAS programs, are rarely applied in a standardised manner. As part of elective colorectal surgery, many patients therefore continue to routinely receive central venous access, peridural catheters, urinary catheters, drains and/or gastric tubes ("Big Five" of invasiveness). This article presents the currently available evidence on these measures in colorectal surgery. In addition, results relating to the "Big Five" from the author's own centre are presented. This review shows that the "Big Five" of invasiveness are clinically unnecessary or supported by evidence. In addition, they often impair the patient's function.Das perioperative Management bei kolorektalen Resektionen ist häufig durch tradierte Vorgehensweisen und ausgeprägtes Sicherheitsdenken gekennzeichnet. Evidenzbasierte Maßnahmen, wie sie in Fast-Track- oder ERAS-Programmen etabliert wurden, werden hingegen seltener standardisiert angewandt. Viele Patienten erhalten daher im Rahmen elektiver kolorektaler Chirurgie weiterhin routinemäßig zentralvenöse Zugänge, Periduralkatheter, Blasenkatheter, Drainagen und/oder Magensonden („Big Five“ der Invasivität). In dieser Arbeit wird die aktuell vorhandene Evidenz zu diesen Maßnahmen in der kolorektalen Chirurgie dargestellt. Zudem werden Ergebnisse mit Bezug zu den „Big Five“ aus dem eigenen Zentrum vorgestellt. Diese Arbeit zeigt auf, dass die „Big Five“ der Invasivität klinisch nicht erforderlich und mit fehlender Evidenz belegt sind. Zudem führen sie häufig zu einer Einschränkung des Patienten.

ZusammenfassungDas perioperative Management bei kolorektalen Resektionen ist häufig durch tradierte Vorgehensweisen und ausgeprägtes Sicherheitsdenken gekennzeichnet. Evidenzbasierte Maßnahmen, wie sie in Fast-Track- oder ERAS-Programmen etabliert wurden, werden hingegen seltener standardisiert angewandt. Viele Patienten erhalten daher im Rahmen elektiver kolorektaler Chirurgie weiterhin routinemäßig zentralvenöse Zugänge, Periduralkatheter, Blasenkatheter, Drainagen und/oder Magensonden („Big Five“ der Invasivität). In dieser Arbeit wird die aktuell vorhandene Evidenz zu diesen Maßnahmen in der kolorektalen Chirurgie dargestellt. Zudem werden Ergebnisse mit Bezug zu den „Big Five“ aus dem eigenen Zentrum vorgestellt. Diese Arbeit zeigt auf, dass die „Big Five“ der Invasivität klinisch nicht erforderlich und mit fehlender Evidenz belegt sind. Zudem führen sie häufig zu einer Einschränkung des Patienten.

COVID-19 has led to profound changes in the world as we have known it. Due to the sharp increase in intensive care, COVID patients, elective admissions and interventions have been postponed. But emergencies such as myocardial infarction have also decreased. The present study deals with the effects of the COVID pandemic on visceral surgical emergencies on the basis of 5 indicator operations. Routine data from 73 acute hospitals of the Helios Group were evaluated for this purpose. The interventions that were carried out between March 13, 2020 and March 12, 2021 were included. The data was compared with the period from March 13, 2019 to March 12, 2020. The number of interventions in serious emergencies (ileus, mesenteric ischemia and ulcer perforation) has remained constant. However, the length of stay in hospital in the pandemic year 2020 was significantly shorter than in the reference year 2019. The number of cholecystectomies and appendectomies in the pandemic year was significantly lower than in the reference year 2019. The outcome parameters intensive care, invasive ventilation and hospital mortality were comparable for the two periods for these interventions.COVID-19 hat zu umfassenden Veränderungen der Welt, wie wir sie bisher kannten, geführt. Durch den starken Anstieg intensivpflichtiger COVID-Patienten wurden beispielsweise elektive Aufnahmen und Eingriffe verschoben. Aber auch Notfälle wie Myokardinfarkte gingen zurück. Die hier vorliegende Studie hat sich mit den Auswirkungen der COVID-Pandemie auf viszeralchirurgische Notfälle anhand von 5 Indikatoroperationen beschäftigt. Dafür wurden Routinedaten aus 73 Akutkrankenhäusern der Helios-Gruppe ausgewertet. Eingeschlossen wurden die Eingriffe, die zwischen dem 13.03.2020 und 12.03.2021 durchgeführt wurden. Verglichen wurden die Daten mit dem Zeitraum vom 13.03.2019 bis zum 12.03.2020.Die Anzahl der Eingriffe bei schwerwiegenden Notfällen (Ileus, mesenteriale Ischämie und Ulkusperforation) sind konstant geblieben. Die Liegedauer im Krankenhaus war im Pandemiejahr 2020 jedoch signifikant kürzer als im Vergleichsjahr 2019. Die Anzahl der Cholezystektomien und Appendektomien war im Pandemiejahr signifikant geringer als im Vergleichsjahr 2019. Die Outcome-Parameter intensivmedizinische Betreuung, invasive Beatmung und Krankenhausmortalität waren zwischen den beiden Zeiträumen für die untersuchten Eingriffe vergleichbar.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most common complications after pancreatic head resection. It leads to increased length of hospital stay, high costs for healthcare systems and reduced quality of life. The primary aim of the study was to assess the impact of pylorus preservation, respectively resection on the occurrence of DGE in patients undergoing pancreaticoduodenectomy (PD). METHODS: All cases of pylorus-resecting PD (PRPD) and pylorus-preserving PD (PPPD) entered in the StuDoQ|Pancreas nationwide registry of the German Society of General and Visceral Surgery from 01/01/2014 until 31/12/2018 including demographics, surgical techniques, histopathological and perioperative data were retrospectively analyzed. This study was approved by the ethics committee of the Ruhr-University Bochum, Germany. RESULTS: Data of 5,080 patients were enrolled. PPPD was the method of choice (70.4%). Pylorus preservation had no impact on the occurrence of DGE (20.3% vs. 21.5%, P=0.33), but further risk factors could be identified. The comparison of PPPD and PRPD groups showed statistically significant differences in the surgical approach (primary open approach, 94.8% vs. 98.0%, P

Modern concepts of perioperative treatment place great value on the active role of the patient. In order to make this possible, intensive patient support is necessary. The position of the ERAS nurse has developed from this necessity. She is the primary contact for the patient before, during and after the operation. The conceptual creation and continuous further development of an ERAS concept may primarily be a medical activity, but the day-to-day work on the patient and filling the concept with life is mainly done by an ERAS nurse. Her main tasks are preoperative patient education, daily patient visits during the inpatient stay, filling in the documentation, ongoing communication with nursing staff and monitoring compliance with the ERAS requirements of all team members involved. It is accordingly important to create the position of an ERAS nurse and to integrate her as a valuable member of the team. In the following article, which is based on our experience as a certified ERAS centre, the job description in detail is presented, including tasks, importance and suggested solutions for common problems.Moderne perioperative Behandlungskonzepte legen großen Wert auf eine aktive Rolle der Patienten. Um dies zu ermöglichen, ist eine intensive Patientenbegleitung notwendig. Aus dieser Notwendigkeit heraus hat sich die Position der ERAS

Purpose As an essential part of the health care system, the requirements for specialist training are subject to a continuous process of change. The aim of the present study was to evaluate the current specialist training situation of all departments in a tertiary care hospital in Germany. Differences between assistant and chief physicians should be pointed out. Materials and methods The analysis of the current training situation was carried out on the basis of an individually created questionnaire. The questionnaire content included career goal and specialism. The characteristic values initial training (IT), training structure (TS) and training content were measured on a numeric scale from 1 to 5. In addition, an overall assessment of the trainers’ competences was performed. The questionnaire was sent to 208 assistant physicians (AP) and 34 chief physicians (CP). Results Totally 92 APs (44.2%) and 22 CPs (64.7%) participated. Senior physician was the most common career goal (34.1%), followed by the branch (28.6%). The importance of the topics initial training (IT) and training structure (TS) were evaluated as mean value: ITCP=1.5, ITAP=1.6; p=0.701 and TSCP=1.4, TSAP=1.5; p=0.669. The results concerning the implementation of the topics IT and TS in the daily routine show significant differences between APs and CPs (ITCP=2.0, ITAP=3.2; p=0.002; TSCP=1.9, TSAP=3.0; p Conclusion Our data underline the importance of specialist training subjects. These are partly perceived very differently by APs and CPs. Innovative concepts for the induction phase, well-structured training curricula, providing management skills, the overall use of skills labs and digital documentation might support the satisfaction and the outcome of specialist training. This could also improve quality in patient care.

Background Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease. Methods This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease. Results Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails. Conclusion The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.

Major limitations of conventional RFA are vascular cooling effects. However, vascular cooling effects are supposed to be less pronounced in multipolar RFA. The objective of this ex vivo study was a systematic evaluation of the vascular cooling effects in multipolar RFA.Multipolar RFA with three bipolar RFA applicators was performed ex vivo in porcine liver (applicator distance 20 mm, energy input 40 kJ). A saline-perfused glass tube ('vessel') was placed parallel to the applicators in order to simulate a natural liver vessel. Five applicator-to-vessel geometries were tested. A liquid-filled glass tube without perfusion was used as a dry run. Ablations were orthogonally cut to the applicators at a defined height. Cooling effects were analysed qualitatively and quantitatively along these cross sectional areas.Thirty-six ablations were performed. A cooling effect could be seen in all ablations with perfused vessels compared to the dry run. While this cooling effect did not have any influence on the ablation areas (859-1072 mm(2) versus 958 mm(2) in the dry run, p 0.05), it had a distinctive impact on ablation shape. A vascular cooling effect could be observed in all ablations with perfusion directly around the vessel independent of the applicator position compared to the dry run (p 0.01).A vascular cooling effect occurred in all multipolar RFA with simulated liver vessels ex vivo independent of the applicator-to-vessel geometry. While the cooling effect did not influence the total ablation area, it had a distinctive impact on the ablation shape.

Background Postoperative pancreatic fistula (POPF) is a major factor for morbidity and mortality after pancreatic resection. Risk stratification for POPF is important for adjustment of treatment, selection of target groups in trials and quality assessment in pancreatic surgery. In this study, we built a risk-prediction model for POPF based on a large number of predictor variables from the German pancreatic surgery registry StuDoQ|Pancreas. Methods StuDoQ|Pancreas was searched for patients, who underwent pancreatoduodenectomy from 2014 to 2016. A multivariable logistic regression model with elastic net regularization was built including 66 preoperative und intraoperative parameters. Cross-validation was used to select the optimal model. The model was assessed via area under the ROC curve (AUC) and calibration slope and intercept. Results A total of N = 2488 patients were included. In the optimal model the predictors selected were texture of the pancreatic parenchyma (soft versus hard), body mass index, histological diagnosis pancreatic ductal adenocarcinoma and operation time. The AUC was 0.70 (95% CI 0.69–0.70), the calibration slope 1.67 and intercept 1.12. In the validation set the AUC was 0.65 (95% CI 0.64–0.66), calibration slope and intercept were 1.22 and 0.42, respectively. Conclusion The model we present is a valid measurement instrument for POPF risk based on four predictor variables. It can be applied in clinical practice as well as for risk-adjustment in research studies and quality assurance in surgery.

Hintergrund Die Narbenhernie gehort zu den haufigsten Komplikationen nach viszeralchirurgischen Eingriffen, und die Narbenhernienreparation ist eine Operation mit einer relevanten Komplikationsrate. Daher sollte die Indikation zum Narbenhernienverschluss exakt gestellt werden. Aktuell ist die Indikationsstellung zur Operation unzureichend evidenzbasiert. Die AWARE-Studie pruft den Spontanverlauf bei Patienten mit oligosymptomatischer Narbenhernie im Vergleich zur Standardtherapie, d. h. der operativen Versorgung.

Die operative Verfahrenswahl bei Patienten mit Sigmadivertikulitis muss drei wesentliche Aspekte beachten: die Wahl des geeigneten Zugangsweges, das korrekte Ausmas der Resektion und die Art der Kontinuitatsherstellung. Beim Zugangsweg hat sich die laparoskopische Sigmaresektion als Standardverfahren in den meisten Kliniken etabliert. Dies gilt mit zunehmender Expertise in laparoskopischer Chirurgie auch fur komplizierte Verfahren und Akutsituationen. Das Resektionsausmas umfasst den betroffenen Darmabschnitt mit der akuten oder stattgehabten Entzundung. Eine Resektion aller Divertikel nach proximal ist nicht erforderlich. Dagegen muss die Resektion nach distal bis in das obere Rektumdrittel ausgedehnt werden, um die Hochdruckzone mit zu entfernen. Nach der Resektion hat sich die Wiederherstellung der Kontinuitat durch eine End-zu-End-Anastomose als Routineverfahren durchgesetzt und sollte auch in der Akutsituation der Diskontinuitatsresektion vorgezogen werden. Im Falle einer Peritonitis mit septischem Krankheitsbild, bei hoher Komorbiditat und beim Vorliegen von Risikofaktoren sollte auf eine Anastomose verzichtet oder diese sollte nur unter Stomaschutz angelegt werden.

Die Koloproktomukosektomie (CPM) gilt als Verfahren der Wahl fur die chirurgische Therapie der Colitis ulcerosa (CU). Bei ausgepragter Immunsuppression (IS) wird dabei haufig ein dreizeitiges (3Z) Vorgehen gewahlt, bei dem eine subtotale Kolektomie der ileoanalen Pouchanlage (IPAA) und abschliesenden Ileostomaruckverlagerung vorangestellt wird. Im Vergleich zum zweizeitigen (2Z) Vorgehen wird dadurch eine Reduktion der perioperativen Komplikationen erwartet, allerdings ist ein zusatzlicher stationarer Aufenthalt und operativer Eingriff erforderlich. Ziel der hier vorliegenden Studie war es, die beiden Vorgehensweisen im Hinblick auf das klinische Outcome nach IPAA zu vergleichen, um die tatsachliche Effektivitat dieser beiden Konzepte uberprufen zu konnen. Zwischen 1997 und 2010 wurden insgesamt 225 Patienten mit IPAA operiert und einem 2Z oder 3Z Verfahren unterzogen. Zur Erfassung des klinischen Outcomes wurde der operative Schritt der Pouchanlage und IPAA gewertet. Die Datenerhebung erfolgte im Rahmen einer prospektiven Studiendokumentation. Von 225 Patienten mit CPM mussten 66 aufgrund einer anderen Diagnose als CU (FAP, Colitis indeterminata, Morbus Crohn) sowie Patienten mit definitiver ILS-Anlage ohne Moglichkeit oder Wunsch einer IPAA (n = 54) ausgeschlossen werden. Untersucht wurden 71 Patienten mit einem 2Z (w = 30, m = 41) und 34 Patienten mit einem 3Z Vorgehen (w = 21, m = 13). Das 3Z Vorgehen wies im Vergleich zum 2Z eine kurzere Operationszeit (246 vs. 296 min; p

Hintergrund Nach wie vor gibt es eine kontroverse Diskussion uber das korrekte therapeutische Management bei der akuten Sigmadivertikulitis (SD). Wesentlich fur den Therapieerfolg ist vor allem die langfristige Beschwerdefreiheit der Patienten nach operativer bzw. konservativer Therapie. Ziel dieser Studie war es daher, das Langzeitoutcome von Patienten mit einer akuten SD nach konservativer und operativer Therapie zu vergleichen.

Die laparoskopische Sigmakontinuitatsresektion stellt das Standardverfahren fur die Behandlung der Divertikulitis dar. Sie gilt als klassische Einsteigeroperation fur die kolorektale minimalinvasive Chirurgie. Indiziert ist der Zugangsweg v. a. in der Elektivsituation bei chronisch rezidivierenden bzw. chronisch komplizierten Stadien. In der Notfallsituation entscheidet die Expertise des Operateurs uber die Wahl des Zugangsweges. Entscheidend bei der laparoskopischen Resektion ist die Mitnahme des rektosigmoidalen Ubergangs. Eine Entfernung aller Divertikel oral des Entzundungstumors ist nicht erforderlich. Dieses Kapitel stellt die praoperative Diagnostik, die Indikationsstellung, das perioperative Management und technische Vorgehen bei der laparoskopischen Sigmaresektion sowie die potentiellen intraoperativen Komplikationen vor.

Bipolar radio-frequency-induced thermofusion (BiRTh) of intestinal tissue might replace conventional stapling devices which are associated with technical and functional complications. Previous results of our study group confirmed the feasibility to fuse intestinal tissue using BiRTh-induced thermofusion ex vivo. The aim of this study was now to evaluate the efficacy of fusing intestinal tissue in vivo by BiRTh-induced thermofusion.In male Wistar rats a blind bowel originating from the caecum was closed either by BiRTh (n = 24) or conventional suture (n = 16). At 6 h, 48 h, 4 days, and 2 weeks after the procedure caecum bursting pressure was measured to compare both groups.In total 18 of 21 (85.7%) thermofused and 15 of 16 (93.7%) sutured cecal stumps were primarily tight and leakage-proof (p0.05). The operative time was comparable in both groups without significant differences. Both groups showed increases in bursting pressure over the post-operative period. The mean bursting pressure for thermofusion was 47.8, 48.3, 55.2, and 68.0 mmHg, compared to 69.8, 51.5, 70.0 and 71.0 mmHg in the hand-sutured group (p 0.05) after 6 h, 48 h, 4 days, and 2 weeks, respectively.These results suggest that BiRTh-induced thermofusion is a safe and feasible method for fusing intestinal tissue in this experimental in vivo model and could be an innovative approach for achieving gastrointestinal anastomoses.

Coloproctomucosectomy (CPM) with ileopouchanal anastomosis (IPAA), as the procedure of choice for surgical management of ulcerative colitis (UC), is commonly performed either as a 2- or 3-staged procedure. For patients with considerable immunosuppression, reduced nutritional or general health status, and as part of emergency treatment, a 3-staged (3S) procedure is recommended by guidelines to minimize perioperative complication rates compared to 2-staged (2S) procedure. However, the necessity of additional hospitalization and surgery is suspect to affect quality of life (QoL). In this prospective, observational study, we evaluate the long-term QoL after 2- and 3-staged interventions of CPM with IPAA for patients with UC.Between 1997 and 2011, a total of 233 patients underwent CPM and had a 2- or 3-staged procedure. In 108 patients, surgical procedure was completed, and evaluation of QoL was performed by specific questionnaires (IBDQ, FIQoL, SF-12, CCS) up to 20 years after ileostomy closure. Data were collected within the framework of a prospective study.Observing a total of 84 patients (2S: n = 59; 3S: n = 25), QoL measured by IBDQ was higher after CPM, compared to preoperative (2S: 15 → 31; 3S: 17 → 28; p 0.01), with no differences between 2S or 3S procedures (p 0.05). Specific QoL assessment concerning incontinence and stool frequency (CCS, FIQoL) did not differ either (CCS: 2S:3S = 12:15; p 0.05). General health-related QoL, determined by SF-12 score, did not differ between 2S or 3S procedures.The indication for a 2-staged or 3-staged procedure should be adjusted to the severity of the underlying disease, nutritional status of the patient, and the extent of immunosuppression at the time of surgery. It should not be affected by the fear of complications or a reduced quality of life by additional surgery in 3-staged versus 2-staged procedures.

Virtual reality simulators (VRS) can acquire specific performance parameters for laparoscopic surgery. The aim of this study was to evaluate the suitability of a VRS for the assessment in a surgical skills course. One hundred five attendees of a 7-day surgical skills course were tested with a VRS at the beginning (T1) and at the end (T2) of the course. Two standard VRS tasks (lifting and grasping (LG) and fine dissection (FD)) with two scores and 21 individual parameters were used. VRS performance was correlated to laparoscopic experience and experience in playing video games in order to assess the influence of preexisting skills. The participants improved significantly in both scores and in 19/21 VRS parameters between T1 and T2. Laparoscopic experts were significantly better than novices only for the parameter tissue damage on T1 in LG (41.4 %, P

Hintergrund: Training und Simulation spielen eine zunehmende Rolle in der chirurgischen Ausbildung. Virtuelle OP-Simulatoren bieten heute anspruchsvolle laparoskopische Trainingsszenarien und detaillierte Bewertungsmoglichkeiten. Damit bieten sich die Gerate auch zur Verwendung in chirurgischen Trainingskursen an. Ziel der vorliegenden Studie war es, die Eignung eines OP-Simulators zum Training und zur Leistungsbewertung in einem etablierten chirurgischen Trainingskurs zu untersuchen. Material und Methoden: Die Studie wurde wahrend des „Praktischen Kurses fur Viszeralchirurgie“ in Warnemunde durchgefuhrt. 36 von 108 Kursteilnehmer wurden zufallig fur die Teilnahme ausgewahlt. Die Teilnehmer trainierten uber 15 Trainingssessions in 5 Tagen an 4 identischen OP-Simulatoren (LapSim) mit 2 standardisierten Ubungen. 16 Trainingsparameter und 2 errechnete Scores wurden erfasst. Mit Fragebogen wurden die laparoskopische Erfahrung, die Ausbildungssituation und die Akzeptanz der Simulatoren erfragt. Die Daten wurden mit nicht-parametrischen Tests analysiert, zudem wurde eine Subgruppenanalyse nach laparoskopischer Erfahrung zur Beurteilung der Konstruktvaliditat durchgefuhrt. Ergebnisse: Das Alter der Teilnehmer lag bei 32 (27 – 41) Jahren, die Berufserfahrung bei 3 (1 – 11) Jahren. Am Simulator zeigten sich typische laparoskopische Lernkurven mit initialer signifikanter Verbesserung der Scores und nachfolgender Plateauphase uber 5 Trainingstage. Es konnten rhythmische Leistungsschwankungen fur die Einzelsessions gemessen werden, wobei ein verkurzter Nachtschlaf eine deutliche Leistungseinschrankung nach sich zog. Die unterschiedliche laparoskopische Erfahrung der Teilnehmer konnte signifikant differenziert werden ( ≤ 20 vs. > 20 laparoskopische Operationen; p ≤ 0,001). Die Befragung zeigte, dass die Mehrzahl der Teilnehmer in Ihren Kliniken kaum Trainingsmoglichkeiten hatte. Die Akzeptanz des Simulatortrainings war sehr hoch, allerdings schatzten die Teilnehmer die tatsachlichen Kosten der Gerate wesentlich zu niedrig ein. Schlussfolgerung: Die Lernkurve am Simulator konnte wahrend des Kurses erfolgreich durchlaufen werden. Die Konstruktvaliditat wurde im Kursrahmen nachgewiesen. Das verwendete Bewertungssystem kann zur laparoskopischen Leistungsbewertung in Trainingskursen beitragen. Die Akzeptanz des Simulatortrainings ist hoch, die Kosten der Simulatoren sind zur Verwendung in einem grosen Trainingskurs derzeit jedoch zu hoch.

Recurrent Crohn's disease activity at the site of anastomosis after ileocecal resection is of great surgical importance. This prospective randomized multi-center trial with an estimated case number of 224 patients was initially planned to investigate whether stapled side-to-side anastomosis, compared to hand-sewn end-to-end anastomosis, results in a decreased recurrence of Crohn's disease following ileocolic resection (primary endpoint). The secondary endpoint was to focus on the early postoperative results comparing both surgical methods. The study was terminated early due to insufficient patient recruitment and because another large study investigated the same question, while our trial was ongoing.Patients with stenosing ileitis terminalis in Crohn's disease who underwent an ileocolic resection were randomized to side-to-side or end-to-end anastomosis. Due to its early discontinuation, our study only investigated the secondary endpoints, the early postoperative results (complications: bleeding, wound infection, anastomotic leakage, first postoperative stool, duration of hospital stay).From February 2006 until June 2010, 67 patients were enrolled in nine participating centers. The two treatment groups were comparable to their demographic and pre-operative data. BMI and Crohn's Disease Activity Index were 22.2 (± 4.47) and 200.5 (± 73.66), respectively, in the side-to-side group compared with 23.3 (± 4.99) and 219.6 (± 89.03) in the end-to-end group. The duration of surgery was 126.7 (± 42.8) min in the side-to-side anastomosis group and 137.4 (± 51.9) min in the end-to-end anastomosis group. Two patients in the end-to-end anastomosis group developed an anastomotic leakage (6.5%). Impaired wound healing was found in 13.9% of the side-to-side anastomosis group, while 6.5% of the end-to-end anastomosis group developed this complication. The duration of hospital stay was comparable in both groups with 9.9 (± 3.93) and 10.4 (± 3.26) days, respectively.Because of the early discontinuation of the study, it is not possible to provide a statement about the perianastomotic recurrence rates regarding the primary endpoint. With regard to the early postoperative outcome, we observed no difference between the two types of anastomosis.

Die Kolondivertikulose gehort zu den haufigsten Erkrankungen des Gastrointestinaltrakts weltweit mit einer ansteigenden Inzidenz. Wahrend der weit uberwiegende Teil der Divertikulosetrager asymptomati

Die akute mesenteriale Ischamie (AMI) gehort zu den seltenen Ursachen des akuten Abdomens. Verbunden mit einem hohen Patientenalter, einer unspezifischen klinischen Symptomatik und einer erheblichen Komorbiditat ist die Erkrankung mit einer hohen Letalitat zwischen 60 und 85% assoziiert. Bei einer Kombination aus kardialer Vorerkrankung, Herzrhythmusstorungen und plotzlich einsetzenden abdominellen Schmerzen sollte eine AMI embolischer Ursache immer ausgeschlossen werden. Die kontrastmittelgestutzte CT-Untersuchung hat die Angiographie dabei als primares Diagnostikum weitgehend verdrangt, da hiermit sowohl intravaskulare als auch intraabdominelle Pathologien diagnostizierbar sind. Beim Vorliegen eines akuten Abdomens oder fehlendem unmittelbarem Zugang zur Diagnostik sollte die rasche chirurgische Exploration vorgezogen werden. Die chirurgische Therapie umfasst die Embolektomie und Resektion ischamischer Darmabschnitte, wobei die Indikation zur Second-Look-Operation groszugig zu stellen ist. Insgesamt bleibt der wichtigste prognostische und auch einzig beeinflussbare Faktor die Zeit bis zur chirurgischen Therapie. Die praoperativ verloren gegangene Zeit und die daraus resultierende verschlechterte Prognose kann durch keine Masnahme im weiteren Verlauf wettgemacht werden.

Background The prevalence of thyroid nodules ranges between 2% and 60% depending on the population studied. However, minimally invasive procedures like radiofrequency ablation (rfA) are increasingly used to treat tumors of parenchymatous organs, and seem to be suitable for singular thyroid nodules as well. Their successful clinical application depends on the induction of sufficiently large lesions and a knowledge of the energy parameters required for complete thermal ablation. The aim of this study was to establish a dose-response relationship for rfA of thyroid nodules. Material and Methods Thermal lesions were induced in healthy porcine thyroid glands ex vivo ( n = 110) and in vivo ( n = 10) using a bipolar radiofrequency system; rf was applied in a power range of 10–20 watts. During the ablation, continuous temperature measurement at a distance of 5 and 10 mm from the applicator was performed. The transversal and axial lesion diameters were measured, and the volume was calculated. Furthermore, enzyme histochemical analysis of the thyroid tissue was performed. Results The inducible lesion volumes were between 0.91 ± 0.71cm 3 at 20W and 2.80 ± 0.85cm 3 at 14W. The maximum temperatures after rf ablation were between 44.0 ± 9.7°C and 61.6 ± 13.9°C at a distance of 5mm and between 30.0 ± 8.6°C and 53.5 ± 8.6°C at a distance of 10mm from the applicator. The histochemical analysis demonstrates a complete loss of nicotinamide adenine dinucleotide phosphate-oxidase (NADPH) dehydrogenase activity in thermal lesions as a sign of irreversible cell damage. Conclusion This study is the first to demonstrate a dose-response relationship for rfA of thyroid tissue. rfA is suitable for singular thyroid nodules and induces reproducible, clinically relevant lesions with irreversible cell damage in an appropriate application time.

Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (

Background Sigmoid diverticulitis (SD) is common in the West; its incidence is increasing as the average age of the population increases. The aim of this study was to assess the clinical outcomes of patients with acute SD and to determine whether emergency operation was associated more often with previous episodes of acute diverticulitis. Methods All consecutive patients admitted for acute SD were recruited prospectively over an 11-year period from January 1998 to December 2008. Multiple logistic regression was used to identify risk factors for free perforation. Results We included 934 patients (490 men and 444 women; median age, 59.2 years): 450 (48.2%) presented for their first SD episode and 484 (51.8%) had a prior history of SD. Free perforation occurred in 152 patients: during the first episode of SD in 114 patients (25.3%), during the second in 29 (12.7%), during the third in 8 (5.9%), and during the fifth in 1 patient (0.9%; P 5 previous episodes of SD had free perforation. All 152 patients with free perforation required emergent operative intervention. After initial conservative therapy in 782 patients, 82 required early elective operative intervention owing to exacerbation of infection under antibiotic treatment. Late elective colectomy was performed in 299 patients during the inflammation-free interval, and operative intervention was recommended in 345 patients owing to complicated diverticulitis. Uncomplicated SD in 56 patients was managed conservatively. Comorbidity (>1 disorder) and the first episode of SD were identified as risk factors for free perforation on multiple logistic regression. Conclusion The risk of free perforation in acute SD decreases with the number of previous episodes of SD. The first episode thus is the most dangerous for a free perforation. The indication for colectomy should not be made based on the potential risk of free perforation.

Alternative minimally invasive treatment options such as radiofrequency ablation (RFA) or laser-induced thermotherapy (LITT) are at present under investigation for achieving a nonsurgical targeted cytoreduction in benign and malignant thyroid lesions. So far, studies have not been able to show a secure advantage for neither LITT nor RFA. The aim of this study was to compare the two ablation procedures in terms of their effectiveness. Thermal lesions were induced in porcine thyroid glands either by LITT or bipolar RFA ex vivo (n = 110 each) and in vivo (n = 10 each) using power settings between 10 and 20 W. Temperature spread during application was documented in 5- and 10-mm distance of the applicator. Postinterventional lesion diameters were measured and lesion size was calculated. Furthermore, enzyme histochemical analysis of the thyroid tissue was performed in vivo. Lesion volumes induced by LITT ranged between 0.74 ± 0.18 cm(3) (10 W) and 3.80 ± 0.41 cm(3) (20 W) with a maximum of 5.13 ± 0.16 cm(3) at 18 W. The inducible lesion volumes by RFA were between 2.43 ± 0.68 cm(3) (10 W) and 0.91 ± 0.71 cm(3) (20 W) with a maximum of 2.80 ± 0.85 cm(3) at 14 W. The maximum temperatures were 112.9 ± 9.2°C (LITT) and 61.6 ± 13.9°C (RFA) at a distance of 5 mm and 73.2 ± 6.7°C (LITT) and 53.5 ± 8.6°C (RFA) at a distance of 10 mm. The histochemical analysis demonstrates a complete loss of NADPH dehydrogenase activity in thermal lesions as a sign of irreversible cell damage both for LITT and RFA. This study is the first to compare the effectiveness of laser-induced thermotherapy and radiofrequency ablation of thyroid tissue. LITT as well as RFA are suitable for singular thyroid nodules and induces reproducible clinically relevant lesions in an appropriate application time. The maximum inducible lesion volumes by LITT are significantly larger than by RFA with the devices used herein.