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For many decades the coloanal anastomosis was traditionally created as an end-to-end anastomosis. Despite successful surgical restoration of the intestinal passage after low rectal resection and total mesorectal excision (TME), physiological continence and evacuation function cannot be achieved in many cases using end-to-end anastomosis. Subsequent complaints, such as fecal incontinence and urge problems, evacuation difficulties and high stool frequency (so-called low anterior resection syndrome, LARS) are the result. The combination of symptoms after TME known as LARS is described in the literature in up to 60% of cases. The increased occurrence of the imperative urge to defecate, frequent bowel movements and problems with fecal incontinence motivated surgeons to look for alternative anastomosis techniques. Side-to-end anastomosis, coloplasty pouch and colonic J‑pouch have been shown in various studies to be superior to end-to-end anastomosis in terms of functional results. Current studies could show that the side-to-end anastomosis (even if this is not a pouch in the actual sense) and the two pouch techniques show comparable results in terms of functional outcome and the rate of anastomotic leakage. The alternative to coloanal anastomosis after TME is the abdominoperineal resection. Most, especially younger patients, prefer to try to maintain continence with the risk of the described functional problems. If the patients are well selected, TME can be carried out with the current techniques in such a way that continuity is maintained and a good defecation function is achieved for a large proportion of patients using the pouch-anal anastomosis or the side-to-end techniques.Die koloanale Anastomosierung wurde über viele Jahrzehnte klassischerweise als End-zu-End-Anastomose angelegt. Trotz erfolgreicher chirurgischer Wiederherstellung der Darmpassage nach tiefer Rektumresektion und totaler mesorektaler Exzision (TME) kann eine physiologische Kontinenz- und Evakuationsfunktion mit End-zu-End-Anastomose in vielen Fällen nicht erreicht werden. Konsekutive Beschwerden wie fäkale Inkontinenz, Urge-Probleme, Evakuationsschwierigkeiten und hohe Stuhlfrequenz (sog. „low anterior resection syndrome“, LARS) sind die Folge. Das als „LARS“ bezeichnete Symptombild nach TME wird in der Literatur in bis zu 60 % der Fälle beschrieben. Das gehäufte Auftreten imperativen Stuhldrangs, häufiger Stuhlgänge und die Probleme mit fäkaler Inkontinenz haben die Chirurgen motiviert nach alternativen Anastomosentechniken zu suchen. Seit-zu-End-Anastomosierung, Koloplastiepouch und der Kolon-J-Pouch haben in verschiedenen Studien zeigen können, dass sie der End-zu-End-Anastomose bezüglich der funktionellen Ergebnisse überlegen sind. Aktuelle Studien zeigen, dass die Seit-zu-End-Anastomose (auch wenn kein Pouch im eigentlichen Sinn) und die beiden Pouchtechniken zu vergleichbaren Ergebnissen bezüglich des funktionellen Outcomes und der Rate an Insuffizienzen führen. Die Alternative zur koloanalen Anastomose nach TME ist die abdominoperineale Resektion. Die meisten, vor allem jüngeren Patienten präferieren den Versuch des Erhaltes der Kontinenz mit dem Risiko der geschilderten funktionellen Probleme. Werden die Patienten gut selektiert, kann mit den heutigen Techniken die totale mesorektale Exzision so durchgeführt werden, dass die Kontinuität erhalten bleibt und durch die pouchanalen Anastomosenoptionen sowie die Seit-zu-End-Anastomose eine für einen großen Teil der Patienten gute Defäkationsfunktion erreicht werden kann.

Verletzungen der Bauchhohle konnen durch stumpfe Gewalteinwirkung oder durch penetrierende Traumen entstehen. Im Vordergrund stehen das fruhe Erkennen und Behandeln einer vitalen Bedrohung, wobei die Diagnostik insbesondere bei Verletzungen der Hohlorgane Schwierigkeiten bereiten kann. Bei perforierenden Verletzungen kann die Eviszeration von Darmanteilen oder Entleerung von Darminhalt unmittelbar auf eine Hohlorganperforation hinweisen. Beim haufigeren stumpfen Abdominaltrauma offenbart sich die Verletzung von Hohlorganen haufig erst im Verlauf durch septische Entgleisung oder Peritonismus, insbesondere, wenn der Nachweis von freier abdominaler Luft initial fehlt. Bei Hohlorganverletzungen besteht die primare Herausforderung in der Beherrschung septischer Komplikationen. Hierbei gilt es, die chirurgische Therapie dem Verletzungsmuster sowie der Allgemeinsituation des Patienten anzupassen. Das Abdominaltrauma stellt nach wie vor eine Herausforderung in der Notfallversorgung dar. Es erfordert ein strukturiertes Management mit dem Ziel einer raschen Diagnostik und Therapie zur Senkung der Morbiditat und Letalitat. Insbesondere die Verletzung der parenchymatosen Organe bestimmt dabei entscheidend die Prognose und den Verlauf des Patienten. Bei Leber- und Milzverletzungen besteht die primare Herausforderung in der Beherrschung vital bedrohlicher Blutungen. Bei Pankreasverletzungen mussen insbesondere septische Komplikationen vermieden werden. Hierbei gilt es, die chirurgische Therapie dem Verletzungsmuster sowie der Allgemeinsituation des Patienten anzupassen.

Aim Deep rectovaginal fistulas are a rare entity and pose a delicate challenge for the surgeon. The present study introduces different operative interventions involved in transperineal omental flap surgery. Method A retrospective analysis of all patients treated with a low or mid rectovaginal or enterovaginal fistula at the Department of Surgery of the University Hospital of Schleswig-Holstein, Campus Luebeck, was performed. Treatment results were discussed with respect to aetiology, localization, morbidity and outcome. Results Between the years 2000 and 2010, a total of nine patients with a low or mid rectovaginal fistula were treated at our clinic. After local fistulectomy, all patients were additionally treated by a laparoscopically assisted omental flap reconstruction of the rectovaginal and perineal space. Eight of the nine patients received a protective ileostomy or colostomy. Only the patient with a history of Crohn’s disease had no ileostomy raised. At a median follow-up of 22 months, no patient experienced recurrence of a rectovaginal fistula. Perioperative mortality was zero and minor complications were observed in 22%. Major complications were an anastomotic insufficiency after low anterior resection that was treated without further interventions. Another complication was a persistent fistula within the sphincter that needed re-operation and bovine plug repair combined with a mucosa flap. Conclusions Complete omental reconstruction of the rectovaginal space appears decisive in the operative therapy of deep rectovaginal or enterovaginal fistulas. Comparative studies on standard therapies are necessary although direct comparison of case series is difficult.

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

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

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

Detection of colorectal cancer at an early stage or even before it occurs, is critical when curative treatment is intented. Despite all possibilties to screen for colorectal cancer, more than two thirds are diagnosed at advanced stages (UICC III and IV) of disease. This determines the growing demand for efficient diagnostic and prognostic markers. Proteomic research (“PROTEins expressed by a genOME”) approchaches issues like protein abundance, posttranslational polypeptide modification and protein-protein interaction as well as functional and dynamic processes within the cell and can therefore lead to biomarker discovery for early disease detection. Already now, proteomics based on 2-dimensional gel electrophoresis, masspectrometry (MALDI) and SELDI-technology, can distinguish a healty from the tumor patient with high sensitivity and specificity. The identification of tumor specific proteins will enable us to develop patient tailored treatment strategies, that have the potential to improve the survival of patients suffering from colorectal cancer. It can be foreseen that clinical medicine will integrate the results of proteome and genome research into daily routine. Within this transfer from “bench to bedside” the surgeon will play a pivotal role.

INTRODUCTION: In the past years, new insight into the immunological and haematological functions of the spleen as well as improved surgical techniques lead to increased importance of organ preservation after traumatic spleen injury. PATIENTS AND METHODS: The data of all patients who underwent surgery for splenic trauma within a 13 year period (1992-2004) were recorded prospectively and analyzed retrospectively concerning age, sex, type of operation, intra- and postoperative complications as well as general postoperative course. RESULTS: From 1992-2004, a total of 189 patients with splenic trauma underwent surgery. Spleen preservation via thermocoagulation, suture, glue sealant, splenorrhaphy, partial spleen resection and combined technologies was chosen in 66 patients (35%, group 1) over the complete time period. 3 of those patients could be treated laparoscopically. In 123 patients corresponding 65% (group2) spleenectomy was performed primarily. 4 patients of group 1 required a revision operation in which 2 newly glue sealant and 2 secondary splenectomies were carried out (3% of the orgen preservation group). DISCUSSION: Under consideration of the surgical segment anatomy of the spleen and use of the surgical techniques presented, organ preservation is possible with a high success even in cases of patients with high degree of splenic damage. In cases with stable circulation and favorable localisation, lesions can also be treated laparoscopically or conservatively. Splenectomy should be reserved for patients with complete fragmentation of the spleen or situations with circulatory instability combined with life-threatening injuries.

It is now well established that most colorectal carcinomas (CRCs) arise from benign adenomas, and that individuals having an adenoma are at higher risk of developing CRC.1,2 These epidemiological observations are based on the fact that the prevalence of adenomas within a population parallels geographically the prevalence of colon cancer.3 Furthermore, both conditions increase with age and adenomas have been found to precede carcinomas by five to 10 years. Clinical studies have also shown that removal of polyps prevents the development of colorectal cancer.4,5 Although adenomas are considered to be benign, 3–12% of the polyps are known to present as invasive carcinomas at the time of diagnosis.6,7 Even if it is not clear how benign adenomas develop into malignant lesions, genomic aberrations have been suggested to play an important role in malignant transformation because most of the CRCs (80–90%) show chromosomal instability. A proposal concerning the origin of this instability was presented in a classic study by Fearon and Vogelstein. These authors suggested that progressive histological abnormalities in adenomas coincide with the sequential accumulation of genetic defects within the cells.8 Traditionally, colorectal polyps are divided into two subtypes: hyperplastic polyps and adenomas (tubular, tubulovillous, and villous). Although hyperplastic polyps are regarded as non-premalignant lesions, they have recently been described as potential risk markers.9,10 The rate of invasive carcinomas within colorectal adenomas has been estimated to be 4–5% for tubular adenomas and 30% for adenomas with a villous component.1,11 In 1990, Longacre and Fenoglio-Preiser described polyps in which the epithelium showed a mixed feature of hyperplastic and adenomatous structures expressing cytologically neoplastic characteristics, which they termed “serrated adenomas” (SAs).12 They found intramucosal carcinomas in 10% of their SAs, whereas more recent investigators have reported malignancy in up to 20% of all SA cases.12,13 “It has been claimed that laminin 5 promotes cell migration and/or invasion after the γ2 chain has been cleaved by metalloproteinases” In the process of invasion, epithelial cancer cells need to penetrate the basement membrane and subsequently migrate into the extracellular matrix (ECM). Here, proteases, such as metalloproteinases (MMPs) and serine proteases, degrade or process the ECM for further dissemination of the cancer cells. Laminins are a group of matrix proteins localised at the basement membrane where they are involved in cell adhesion. The laminin (ln) family consists of cross shaped heterotrimers composed of α, β, and γ subunits. At present, 11 isoforms of the molecule have been described, reflecting diverse tissue specificities and biological functions, such as cell adhesion, migration, proliferation, growth, and differentiation.14–16 One isoform, ln-5, is composed of α3, β3, and γ2 chains, each encoded by different genes, namely: LAMA3 (18q 11.2), LAMB3 (1q 32), and LAMC2 (1q 25–31).17–19 Interacting with integrins, ln-5 anchors the epithelial cells to the basement membrane.20–26 Furthermore, it has been claimed that ln-5 promotes cell migration and/or invasion after the γ2 chain has been cleaved by MMPs (MMP-2 and membrane type 1 MMP) secreted by cancer cells or neighbouring stroma cells.27,28. Accumulating data suggest that ln-5 γ2 chain expression is increased during carcinogenesis.25,29–35 This is in accord with our studies, which show that ln-5 γ2 chain expression is upregulated during the progression of human colon cancer.36 In another study, we found that ln-5 may help to identify patients with ulcerative colitis who have an increased risk for CRC.37 The aim of our present study was to investigate the expression of the ln-5 γ2 chain in subtypes of colorectal polyps known to constitute different risk lesions.

Das Hamorrhoidalleiden exakt zu definieren ist schwierig, da hierzu das komplette Erfassen der Atiologie und Pathogenese unabdingbare Voraussetzung ist. Der von Stelzner beschriebene komplexe Verbund aus arteriovenosen Verbindungen in der Rectummucosa, mit einem Flechtwerk aus glatter Muskulatur, elastischen Fasern und Bindegewebe bildet die anatomische Grundlage des „Corpus cavernosum recti“ [16, 17]. Diese cavernosen Gefaspolster sind eine wichtige Komponente des Kontinenzorgans und gewahrleisten den gasdichten Verschluss. Nach Thomsons Studien sind Hamorrhoiden als Folge einer Desintegration der muskularen und elastischen Komponenten zu sehen, die durch eine Verlagerung der Gefaspolster nach distal entstehen [20]. Die Veranderungen konnen Grosenzunahme bis hin zum Prolaps bedingen und zu Blutung oder Kongestion fuhren. Die Grunde hierfur sind nicht abschliesend geklart. Eine gestorte Darmfunktion insbesondere obstipative Veranderungen mit harten Stuhlen scheinen ursachlich in Frage zu kommen. Die Mechanismen von Funktion und Kontrolle der arteriovenosen Verbindungen ebenso wie der Einfluss erblicher, sozialer und kultureller Disposition sind weiter unklar.

Im Rahmen interdisziplinarer Behandlungsstrategien zur Palliation gastrointestinaler Neoplasien kommen den chirurgischen Therapieoptionen wesentliche Aufgaben zu. Die Wiederherstellung der Passage, Gewahrleistung von Sekretabfluss und die Reduktion von Schmerzen stehen dabei im Vordergrund. Konventionelle, minimal-invasive und endoskopische Verfahren werden isoliert oder in Kombination unter Integration aller konservativen Therapiemoglichkeiten zum Einsatz gebracht. So kann in vielen Fallen eine unnotige Laparotomie mit hoher Morbiditat, Mortalitat und langer Hospitalisation vermieden werden. Die vorliegende Arbeit beschreibt und diskutiert die aktuellen chirurgisch-operativen und endoskopischen Techniken zur Palliation von Patienten mit gastrointestinalen Malignomen.

Anorectal outlet obstruction constitutes one form of chronic constipation. Combinations of morphological alterations of the pelvis, the pelvic floor and the colorectum are nearly always evident. The goal of the diagnostic work-up is to identify those patients who will profit from a surgical intervention. Resection rectopexy aims at restoring the physiological anatomy thereby ameliorating the functional interaction of structures effected with the laparoscopic approach entailing all advantages of minimally invasive surgery. Besides a detailed description of the surgical technique used and an algorithm for indications to operate we present our results after 19 years of experience. Throughout this period, 264 laparoscopic resection rectopexies for outlet obstruction were performed. With a mean follow-up of 58.2 months the rate of improvement of obstructive symptoms was 79.5 % (n = 128 of 161 available for follow-up). Present studies suggest that (laparoscopic) resection rectopexy entails better results in comparison to non-resecting procedures and procedures with the implantation of allogenic material. Certainly, in order to achieve these results a correct patient selection and an expertise in laparoscopic surgery are essential. Both the perioperative and the functional results of our own collective fortify the advantages of laparoscopic resection rectopexy in patients with an outlet obstruction.

Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called "Laparoscopic pancreatic surgery" was implemented to collect enough data in Germany to find out whether the resection is safe, feasible and beneficial for the patient.For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based data.It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.

Deep rectovaginal fistulas are a rare entity and pose a delicate challenge for the surgeon. The present study introduces different operative interventions involved in transperineal omental flap surgery.A retrospective analysis of all patients treated with a low or mid rectovaginal or enterovaginal fistula at the Department of Surgery of the University Hospital of Schleswig-Holstein, Campus Luebeck, was performed. Treatment results were discussed with respect to aetiology, localization, morbidity and outcome.Between the years 2000 and 2010, a total of nine patients with a low or mid rectovaginal fistula were treated at our clinic. After local fistulectomy, all patients were additionally treated by a laparoscopically assisted omental flap reconstruction of the rectovaginal and perineal space. Eight of the nine patients received a protective ileostomy or colostomy. Only the patient with a history of Crohn's disease had no ileostomy raised. At a median follow-up of 22 months, no patient experienced recurrence of a rectovaginal fistula. Perioperative mortality was zero and minor complications were observed in 22%. Major complications were an anastomotic insufficiency after low anterior resection that was treated without further interventions. Another complication was a persistent fistula within the sphincter that needed re-operation and bovine plug repair combined with a mucosa flap.Complete omental reconstruction of the rectovaginal space appears decisive in the operative therapy of deep rectovaginal or enterovaginal fistulas. Comparative studies on standard therapies are necessary although direct comparison of case series is difficult.

Durch die Fortschritte in der Molekularbiologie und deren Applikation in der Tumorforschung konnen die molekularen Mechanismen analysiert werden, die zu unkontrolliertem Zellwachstum fuhren und damit die Karzinogenese induzieren. Die Definition neuer molekularer Pathways eroffnet Moglichkeiten, neue Strategien fur Diagnostik, Intervention und Behandlung von Malignomen zu entwickeln. Das molekulare Verstandnis der Tumorentstehung zeigt, weshalb die Behandlung haufig hoch komplex ist. Es wird uns aber in Zukunft helfen, individuelle Diagnostik durchzufuhren und eine patientenbezogene Behandlungsstrategie zu entwickeln.

Zu den primaren Leberzelltumoren zahlen das hepatozellulare Karzinom (HCC), das Cholangiokarzinom (CC) sowie das Hepatoblastom und Hamangioendothelsarkom.

In laparoscopic colon surgery, endostaplers generate 2 parallel rows of staples. The aim of this paper is to analyse whether the introduction of a new endostapler generating a third row of staples influences the rate of anastomotic leakage and bleedings.362 patients of the Department of Surgery, University Clinic of Schleswig-Holstein, Campus Lübeck, were included in this study. All patients underwent colon resection with performance of double-stapling anastomosis. In Group I (n = 148; 7 / 2004 to 12 / 2005), the Endopath TSB 45 endostapler (2 rows of staples) was used, whereas in Group II (n = 214; 7 / 2006 to 12 / 2007), the Echelon60 EC60 stapler (3 rows of staples) was used. All further operational steps were identical for both groups. Target parameters were the postoperative anastomotic leakage and anastomotic bleeding rates.Between July 2004 and December 2005, the number of anastomotic leaks (Stapler Endopath, TSB 45) was n = 4 (2.7 %), for the second period (Stapler Echelon60 EC60), it was n = 9 (3.7 %) (not significant). Using the Endopath TSB 45 stapler, the number of anastomotic bleedings was n = 12 (8.1 %), and for the Echelon60 EC60 stapler, it was n = 8 (3.7 %) (p = 0.074; not significant). Within the 18-month period between July 2006 and December 2007, the number of endoscopic colon operations (n = 214) rose by 44.6 % compared to the 18-month period between July 2004 and December 2005 (n = 148).The application of the advanced Echelon endostapler has no impact on the number of anastomotic leaks, and reduces the number of anastomotic bleedings slightly but not significantly. The increased number of endoscopic procedures in the second period results both from the growing number of indications for the application of endoscopic techniques and the positive findings of recent studies carried out by our own and other working groups.

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

Diagnostics and therapy of anorectal disorders are still questions of surgery. Exact knowledge of functional anatomy and precise clinical examination constitute the basis for the resulting therapeutic strategies. Three-dimensional endosonography and technical advances in flexible endoscopy using high-resolution chromoendoscopy and narrow-band imaging enable exact staging and diagnosis, even of malignancies in earliest stages. Furthermore new in-vivo staining methods combined with high-resolution imaging facilitate the discrimination of inflammatory and neoplastic lesions, which often lead to diagnostic difficulties in chronic inflammatory bowel disease. Developments in neurologic testing, including surface electromyography and sacral nerve stimulation, complement the diagnostic armamentarium.

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

Applying the principle "practice makes perfect" to interventional medicine would mean that surgeons and departments with high treatment volumes for special procedures should have better results than low-volume institutions. In the last three decades several studies were published dealing with the association of therapy volume and treatment quality, e.g. in oncologic and vascular surgery as well as interventional cardiology. Concerning colorectal cancer it has been shown that an individual surgeon's case load is important but by far not the only therapy-associated prognostic factor. For example interdisciplinarity and multimodality including adequate pathological classification are no less important. For continual improvement of clinical outcome, quality management and control will grow in importance. Thus, it is necessary to develop structures and to specify standards for colorectal surgery. Based on the data available it is not yet possible to define minimum volumes for colorectal surgery.

Minimizing the access trauma of surgical interventions is becoming an essential task in modern surgery in order to make the treatment more comfortable for the patient. Minimally invasive surgery has had a major impact on the improvement of surgical results over the last decade. This is why such surgery is often named as the third patient friendly revolution in surgery after the introduction of asepsis and anesthesia. Operations that caused a huge strain on the patients in the past and led to immense costs for society because of the patient's lost working time and extensive rehabilitation, have lost their fear thanks to this technique. The physical strain is lower, the cosmetic effect is considerable and the costs for society might be reduced due to the significantly shorter duration of convalescence. Despite its known advantages, which have been reported in numerous studies, minimally invasive surgery has recently gained increased interest because of the installation of new accounting systems as well as strict budgeting and restricted resources. Realistic cost-benefit analysis and objectified quality controls are needed in order to guarantee innovative and patient friendly basic approaches in medicine in the future.

Acute abdomen is not a disease in itself but a description of a complex of symptoms combined with severe abdominal pain developed within a time frame of less than 24 h. All strategies for the management of acute abdomen underline the need for an interdisciplinary approach to diagnosis and therapy. This requires focused and intelligent use of efficient diagnostic procedures. Diagnostic laparoscopy may be a key to solving the diagnostic dilemma of unspecific acute abdomen. Furthermore, it allows not only direct inspection of the abdominal cavity but also surgical intervention, if needed. In particular the rate of negative laparotomies can be reduced.

One of the most controversial discussions on laparoscopic surgery deals with the question of whether to apply this technique to malignant disease and specifically to rectal cancer. The four major issues are the adequacy of oncologic resection, recurrence rates and patterns, long-term survival and quality of life. There is evidence, from nonrandomized studies, suggesting that margins of excision and lymph node harvest achieved laparoscopically reached comparable results to those known from conventional open resection. Our own experience of laparoscopic surgery on rectal cancer is based on 52 patients treated with curative intent. Focusing on the postoperative long-term run, we gained the following results: The median age of patients was 66.7 years and ranged from 42-88. Anastomotic leakage was seen in 6.1% of cases. In a median follow-up of 48 months (36-136), we reached an overall 3-year survival rate of 93% and a 5-year survival rate of 62%. Local recurrence was 1.9%, distant metastasis occurred in 11.5% of cases. We saw no port-site metastasis. To evaluate functional results following laparoscopic surgery a matched pair analysis was carried out. Matching of patients after laparoscopic and conventional open surgery was performed according to sex, age, type of resection, time period of surgery, and stage of disease classified by UICC. Regarding bladder and sexual dysfunction, using the EORTC QLQ CR38 score we found no statistical significant difference between the examined groups. As far as can be seen, laparoscopic surgery in rectal carcinoma may achieve the same or, in selected patients, even better results than open surgery. However, at present no published study has shown much evidence. Many more studies are necessary to define the place of laparoscopic technique in rectal cancer surgery, regarding appropriate selection of patients and evaluating adjuvant or neoadjuvant treatment in combination with the laparoscopic approach.

The laparoscopic resection of the colon and rectum is established for surgery of benign diseases. The main advantages compared to the open-conventional operation technique are reduced postoperative pain, reduced negative influences on pulmonary and gastrointestinal functions as well as a shorter reconvalescence. Minimally invasive curative resections of colorectal carcinomas are still controversially discussed concerning sufficient radicality and the spread of tumor cells. The given oncological standards of the conventional approach can be kept without restriction when resections of the colon and rectum are performed laparoscopically. Newer comparative studies do not describe raised recurrence or lower survival rates following the minimal-invasive procedure. In the coming years prospective randomized multicenter studies must give proof whether or not the long-term survival is comparable with the conventional approach.

Laparoscopic sigmoid resection is a well established procedure for surgical treatment of benign colorectal diseases. The aim of the present study was to assess the longterm quality of life of patients who underwent laparoscopic sigmoid resection for sigmoid diverticulitis. Differences in health related life quality to the open-conventional approach were evaluated in a matched pair analysis (age, gender, Hinchey-Stage, Type of Surgery) using a validated quality of life instrument.A total of 45 matched pairs (laparoscopic/open) operated for diverticulitis at stage I-IIa (Hinchey classification) were included in this study. The quality of life was measured with the Short-Form-36-Health Survey (SF-36), a standardized questionnaire with 8 scales and 36 items. The follow-up period was at least 2 years (mean 62.2 months).Pair members (n = 45) operated via laparoscopic or open approach for Hinchey I-IIa diverticulitis were of the same sex (21 female/24 male pairs) and age at time of surgery (range: lap.: 53.5-66 years; open: 53.5-67 years). Mean follow-up periods for patients operated laparoscopically and with open procedure were 2 (range: 1-3) and 7 (range: 5-9) years, respectively. The SF-36 scale scores for both groups appeared high and only slightly below a validated norm population. This represents a high quality of life after open as well as laparoscopic surgery for sigmadiverticulitis. No significant differences were apparent between the 45 matched-pairs. Pairs 65 years old or older presented no significantly different score values compared to those younger than 65 years.The long-term follow-up data in this age and sex matched pair analysis showed favorable results after open as well as laparoscopic surgery for sigmadiverticulitis. No statistically significant differences were observed between the two surgical techniques. Self-reports by the patient concerning his or her health condition, recovery and quality of life following any surgical procedure are needed to assess valid outcome data of new surgical treatments including a critical evaluation of all its benefits and burdens.

It is not easy to define haemorrhoidal complaints precisely since this automatically means the entire aetiology and pathogenesis. What Stelzner describes as a complex compound of arteriovenous links in the rectal mucosa with an interlace of unstriated muscles, elastic fibres and connective tissue forms the anatomic base of the "corpus cavernosum recti". This cavernous vascular padding is a crucial component of the continence organ and ensures a gas-tight seal. According to Thomson's studies, haemorrhoids are to be regarded as a consequence of the disintegration of muscular and elastic components, caused by a distal shift of the vascular padding. The changes can cause growth up to prolapse, as well as haemorrhage or congestion. The reasons have not yet been conclusively clarified. Malfunctioning intestines--in particular constipational changes with hard stool--seem to be causal factors. The mechanisms of function and control of arteriovenous links as well as the influence of hereditary, social and cultural disposition continue to be unclear.

The dramatic benefits of laparoscopic cholecystectomy or appendectomy for patients encouraged surgeons to use minimal access operative technique in the treatment of other more complex surgical procedures [2, 3]. The authors report on their experiences with 14 patients operated by hand-port assisted laparoscopic technique for benign colorectal diseases. The mortality rate was zero. The operation times compared to the laparoscopically operated previous 14 patients with equal diagnosis did not differ significantly (hand-port: 124-186 min; lap.: 121-176 min). The begin of bowel movements and the postoperative hospital stay were comparable to those of laparoscopic surgery. There were no major complications. No conversion to an open procedure was necessary. As the hand-port device allows the surgeon to insert his (usually non-dominant) hand into the abdominal cavity during the procedure, the hand-port device seems to combine the laparoscopic benefits with the advantages of a conventional open approach (manual exploration, blunt dissection, control of hemostasis) without loss of pneumoperitoneum [10]. Even though hand-assisted operations have not gained widespread acceptance, they recently demonstrated their value especially in more complex laparoscopic procedures like splenic and gastric resections, nephrectomy and colorectal surgery [6, 10, 18, 21, 23-24]. The regaining of tactile sensation which is an essential surgical tool may encourage less experienced colleagues to perform more complex operations. The authors suggest that the hand-port device could be a useful tool in the armentarium for colorectal surgery. Further randomized trials are needed to evaluate the benefits of this technique.

The onset of a malignant transformation in long-standing ulcerative colitis is difficult to predict. The value of the clinical and histomorphological parameters in current use is limited. It was thus aim of the present study to investigate the value of DNA-ploidy for the early detection of a malignant transformation in long-standing ulcerative colitis. This retrospective study comprised 20 patients with long-standing ulcerative colitis. The average observation time was 7.3 years (range: four to twelve years). All patients took part in a surveillance program and had between four and seven colonoscopies within a minimum period of time of five years. At these instances mucosal biopsies were taken in a standardized manner at eight different locations throughout the colon. These paraffin-embedded specimens (n = 542) were analyzed histomorphologically and DNA-cytometrically. During the observation time five patients developed an ulcerative colitis-associated colorectal carcinoma (UCA). In these patients epithelial dysplasias were not more common than in the remaining 15 cases. The vast majority of the specimen of the patients with UCA showed distinct DNA-cytometrical alterations, i.e. they were aneuploid. Such aneuploid mucosal cell populations were distributed over the whole colon, irrespectively of the later site of the carcinoma. These aneuploid lesions were found in one case eleven years, in an average seven years prior to the final diagnosis of a UCA. In contrast, the colon epithelium of the patients without UCA showed only proliferative-diploid DNA-distribution patterns during the observation time. In summary, affected patients had multiple highly aneuploid lesions of the colon mucosa at an average of seven years prior to the final diagnosis of UCA. These lesions came from macroscopically chronic inflamed tissue, and where histomorphologically without signs of dysplastic transformation. DNA-cytometrical investigations could thus be of additional predictive value for the individual risk assessment as regards an impending malignant transformation.

Malignant tumors require an exact staging in order to initiate individual tumor related therapeutic concepts to avoid unnecessary explorative laparotomy and to compare different treatment regimes. The assessment of the lymph node status with regard to tumor involvement using any of the actual imaging methods is quite unsatisfactory. For the improvement of the pretherapeutic tumor staging including N-classification the diagnostic laparoscopy and laparoscopic sonography are presently being evaluated. Both methods should be carried out according to a standardized investigation record. When limited to the pure diagnostic aspect, the morbidity is approx. 2%. Low patient figures with different tumor entities, insufficient information on the simultaneous occurrence of lymph node and distant metastases and/or of a peritoneal carcinomatosis as well as on the extent of the lymphadenectomy and histopathologic outcomes restrict the signifying value of many studies. It seems to be only clear that, when using the laparoscopic sonography, the sensitivity of the evidence of lymph node metastases increases in comparison with the sole laparoscopy. Definite recommendations based upon the outcomes with the required evidence, can presently neither be made with regard to the use of the method in general nor for the laparoscopic lymph node staging in particular. The use with regard to a lymph node assessment from today's point of view seems to be appropriate above all in case of: Suspect of an advanced tumor stage (existence of M1 lymphomas) For the indication in case of justified application of multimodal therapeutic concepts (exact tumor staging/N-classification). Beyond this, the laparoscopy for lymph node staging should only be used in conjunction with prospective randomized studies. Sufficient experience in the field of laparoscopic surgery and sonography as well as compliance with the rules of action for the prevention of tumor cell conveyance should be demanded.

Within the framework of interdisciplinary palliative treatment strategies for gastrointestinal neoplasms, surgical therapeutic options are of essential importance. They are dominated by the reconstruction of the gastrointestinal passage, ensuring drainage of secretion and the alleviation of pain. Conventional, minimal-invasive and endoscopic procedures are employed individually or in a combined way, integrating all conservative therapies. In many cases, an unnecessary laparotomy with its high morbidity, mortality and prolonged hospitalisation can thus be avoided. This paper describes and discusses current surgical and endoscopic techniques for the palliative treatment of patients suffering from advanced gastrointestinal malignant tumours.

Abdominoperineal excision of the rectum has been the surgical treatment of choice for rectal cancer of the middle and lower third for decades. However, subsequent to technical developments, particularly stapling instruments, sphincter saving procedures such as low anterior or intersphincteric resection superseded abdominoperineal excision in the majority of tumors of the middle and even lower third of the rectum. Within the last seven years (1990-1997), 253 patients with distal rectal cancer underwent surgery--in 204 patients surgery was carried out for the cure of malignancy, whereas in 49 patients surgery was performed for palliation. In the meantime, the rate of abdominoperineal excision with permanent stoma was steadily decreased from 25% (1990-1993) to 9% (1994-1997). Concerning oncologic quality, sphincter saving resections showed evidence that cure rates (3- and 5-year survival) were not compromised by these techniques; conversely, sphincter saving resections offered oncologic cure rates superior to abdominoperineal excision of the rectum. Complete lymphadenectomy with high ligation of the inferior mesenteric artery and total mesorectal excision (TME) are fundamental components of this approach. Moreover, the adverse effects of a permanent colostomy and the consecutively diminished quality of life following abdominoperineal excision can be avoided in approximately 80% of cases. In conclusion, at present 80-85% of rectal carcinomas of the middle or lower third can be surgically treated by sphincter saving low resections without compromising oncologic radicality.

Continence is highly appreciated in society and is a precondition for human socialization. Thus, in the history of surgery there have been numerous attempts to develop repair techniques for incontinence. They can roughly be divided into three groups: actively inflatable implants (plastic prosthesis), transfer of smooth muscles or transfer of striated, conditioned muscles. In the majority of cases these techniques may well prevent the strains associated with colostomy; however, the patients will remain incapable of recognizing and discriminating the cue of rectal distension. Consequently, repair of sphincter defects will continue to be of major concern in surgery.

Abdominal wall hernias are frequent findings after abdominal operations. The incidence has increased with each increment of abdominal surgical interventions. In the postoperative course, 5%–10% of the patients develop an incisional hernia [1, 2]; this rate increases up to 14% in patients undergoing a re-laparotomy [5]. The occurrence rate of such hernias is influenced by complications in wound healing or metabolic disorders such as diabetes, protein deficiency or renal insufficiency. Long-term respirator therapy or chronic-obstructive pulmonary disease are among the aetiological factors involved in the development of an abdominal hernia. In addition, there are a considerable number of large umbilical, inborn and acquired midline hernias. All these abdominal wall defects present a great individual and economical problem which should be overcome with appropriate surgical methods, including repair techniques with biological material.