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Background: Complete mesocolic excision is gradually becoming an established oncologic surgical principle for right hemicolectomy. However, the procedure is technically demanding and carries the risk of serious complications, especially when performed laparoscopically. A standardized procedure that minimizes technical hazards and facilitates teaching is, therefore, highly desirable.Methods: An expert group of surgeons and one anatomist met three times. The initial aim was to achieve consensus about the surgical anatomy before agreeing on a sequence for dissection in laparoscopic CME. This proposal was evaluated and discussed in an anatomy workshop using post-mortem body donors along with videos of process-informed procedures, leading to a definite consensus.Results: In order to provide a clear picture of the surgical anatomy, the "open book" model was developed, consisting of symbolic pages representing the corresponding dissection planes (retroperitoneal, ileocolic, transverse mesocolic, and mesogastric), vascular relations, and radicality criteria. The description of the procedure is based on eight preparative milestones, which all serve as critical views of safety. The chosen sequence of the milestones was designed to maximize control during central vascular dissection. Failure to reach any of the critical views should alert the surgeon to a possible incorrect dissection and to consider converting to an open procedure.Conclusion: Combining the open-book anatomical model with a clearly structured dissection sequence, using critical views as safety checkpoints, may provide a safe and efficient platform for teaching laparoscopic right hemicolectomy with CME. [ABSTRACT FROM AUTHOR]

Endoscopic full-thickness resection (EFTR) has emerged as a viable technique in the management of mucosal and subepithelial lesions of the gastrointestinal tract (GIT) not amenable to conventional therapeutic approaches. While various devices and techniques have been described for EFTR, a single, combined full-thickness resection and closure device (full-thickness resection device, FTRD system, Ovesco Endoscopy AG, Tuebingen, Germany) has become commercially available in recent years. Initially, the FTRD system was limited to use in the colorectum only. Recently, a modified version of the FTRD has been released for EFTR in the upper GIT as well. This review provides a broad summary of the FTRD, highlighting recent advances and current challenges., Competing Interests: Conflict-of-interest statement: Dr. Mun discloses no conflict of interest for this article; Dr. Wagh is consultant for Boston Scientific, Olympus, Medtronic, Fujifilm and ConMed., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Postoperative surgical site infections cause substantial morbidity, prolonged hospitalization, costs and even mortality, and remain one of the most frequent surgical complications. In prospective trials with adequate follow-up, more than 20 % of patients undergoing elective colorectal surgery are affected and methods to reduce surgical site infections are urgently needed. Negative-pressure incision therapy is a novel intervention that holds promise to reduce postoperative wound infection rates, but has not yet been rigorously tested in a randomized controlled trial.Methods/design: The aim is to investigate whether the postoperative application of a negative-pressure incision therapy device for 5-7 days reduces the rate of surgical site infections following open elective colorectal surgery by 50 %. This is a randomized, controlled, observer-blinded multicentre clinical trial with two parallel study groups. The primary outcome measure will be the rate of surgical site infections within 30 days postoperatively. Surgical site infections are defined according to criteria of the US Centers for Disease Control and Prevention. Statistical analysis of the primary endpoint measure will be based on the intention-to-treat population. The global level of significance is set at 5 % (two-sided) and the sample size (n = 170 per group) is determined to assure a power of 80 %.Discussion: The Poniy trial will explore whether the rate of surgical site infections can be reduced by the application of a negative-pressure incision therapy device in patients undergoing open elective colorectal surgery. Its pragmatic design guarantees high external validity and clinical relevance.Trial Registration: Deutsches Register Klinischer Studien DRKS00006199 . [ABSTRACT FROM AUTHOR]

The term fast-track describes the combination of several perioperative evidence-based measures to form a clinical pathway. The primary aim of fast-track is to optimize organ function after surgery in order to avoid general morbidity. At the same time patient recovery is dramatically enhanced and discharge from hospital is possible much earlier than with traditional perioperative care. This article describes the author's experience in implementing a fast-track program for elective colonic resection. It shows the current status of scientific evaluation of the fast-track concept and discusses typical obstacles during introduction of fast-track into the clinical routine in Germany. [ABSTRACT FROM AUTHOR]

Background and aims: Morbidity and Mortality meetings are an accepted tool for quality management in many hospitals. However, it is not proven whether these meetings increase quality. It was the aim of this study to investigate whether Morbidity and Mortality meetings as part of a PDCA cycle (Plan, Do, Check, Act) can improve the rate of anastomotic failure in colorectal surgery. Materials and methods: From January 1, 2004, to December 31, 2009, data for all anastomotic failures in patients operated on for colorectal diseases in the Department of Surgery (Klinikum Friedrichshafen, Germany) were prospectively collected. The events were discussed in Morbidity and Mortality meetings. On the basis of these discussions, a strategy to prevent anastomotic leaks and a new target were defined (i.e. 'Plan'). This strategy was implemented in the following period (i.e. 'Do') and results were prospectively analysed. A new strategy was established when the results differed from the target, and a new standard was defined when the target was achieved (i.e. 'Check, Act'). Results: The year 2004 was set as the base year. In 2005 and 2006, new strategies were established. Comparing this period with the period of strategy conversion (2007-2009), we found a significant decrease in the anastomotic failure rate in colorectal surgery patients (5.7% vs 2.8%; p = 0.05), whereas the risk factors for anastomotic failure were unchanged or unfavourable. Conclusions: If Morbidity and Mortality meetings are integrated in a PDCA cycle, they can decrease anastomotic failure rates and improve quality of care in colorectal surgery. Therefore, the management tool 'PDCA cycle' should be considered also for medical issues. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Data from the multicentric observation study Kolon/Rektum-Karzinome (Primärtumor) (primary colorectal carcinoma) are adduced to assess the status of surgical treatment of this condition in Germany and to compare different operative approaches in the emergency treatment of obstructive left-sided colon cancer, especially diversion (Hartmann''s procedure) and primary anastomosis. Patients and methods: Out of 15,911 patients with cancer of the left colon, recorded between 01.01.2000 and 31.12.2004, a total of 743 patients underwent emergency surgery for an obstructive tumour, performed as a radical resection. These patients were compared in respect of their risk profile and postoperative result. Results: In 57.9% (n =430) a one-stage operation (Group I), in 11.7% (n =87) a primary anastomosis with protective stoma (Group II), and in 30.4% (n =226), Hartmann''s procedure (Group III) was performed. In Group III more patients were male, overweight and multimorbid, and more had advanced-stage tumours. The morbidity and hospital mortality (overall hospital mortality, 7.7%; n =57) did not differ significantly between the groups. The insertion of a protective stoma did not affect the rate of anastomotic insufficiency (Group I, 7%; Group II, 8.0%). Conclusions: Primary anastomosis for emergency left colon carcinoma obstruction should only be regarded as indicated in cases where the risk profile is favourable. Our results suggest that in advanced obstruction and in high-risk cases Hartmann''s procedure should be used. A protective stoma did not appear to confer any advantage. [Copyright &y& Elsevier]

Objective  ‘Fast-track’ rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Despite this evidence, there is no information on the acceptance and utilization of these concepts among the entirety of Austrian and German surgeons. Method  In 2006, a questionnaire concerning perioperative routines in elective, open colonic resection was sent to the chief surgeons of 1270 German and 120 Austrian surgical centres. Results  The response rate was 63% in Austria (76 centres) and 30% in Germany (385 centres). Mechanical bowel preparation is used by the majority (Austria, 91%; Germany, 94%); the vertical incision is the standard method of approach to the abdomen in Austria (79%) and Germany (83%), nasogastric decompression tubes are rarely used, one-third of the questioned surgeons in both countries use intra-abdominal drains. Half of the surgical centres allow the intake of clear fluids on the day of surgery and one-fifth offer solid food on that day. Epidural analgesia is used in three-fourths of the institutions. Conclusion  Although there is an evident benefit of fast-track management, the survey shows that they are not yet widely used as a routine in Austria and Germany. [ABSTRACT FROM AUTHOR]

PURPOSE: The aim of this study was to assess the feasibility and safety of laparoscopic surgery for the cure of colorectal cancer with emphasis on oncologic follow-up in particular. METHODS: A study was performed of patients with colorectal cancer treated by laparoscopy in five German centers between May 1991 and September 1997. Surgical and pathologic data were recorded in an anonymous registry database and analyzed by type of resection. Standard procedures were sigmoid or left colectomy, anterior resection, abdominoperineal resection, and right hemicolectomy. Follow-up information included incidence of local, distant, and port site recurrence and cancer-related death. RESULTS: A total of 399 patients (212 females) with a mean age of 66.6 years underwent laparoscopic curative resections (sigmoid resection, 89; left colectomy, 11; anterior resection, 157; abdominoperineal resection, 102; right hemicolectomy, 40). Conversion was necessary in 6.5 percent (n = 25). Complications requiring reoperation occurred in 9 percent (n = 35). Complications that were treated conservatively occurred in 27.6 percent (n = 110). Thirty-day mortality was 1.8 percent (n = 7). First bowel movements resumed on the third postoperative day; patients did not use analgesics after a mean of five days. Mean postoperative hospitalization was two weeks. According to International Union Against Cancer classification, 147 patients had Stage I cancer, 35 had Stage II cancer, and 217 underwent curative resection for Stage III cancer. Mean number of lymph nodes resected was 12.1. At a mean follow-up of 30 months, one port site recurrence was documented. No local recurrence was observed after curative resection of Stage I colorectal cancer. Of 399 patients, local recurrence occurred in 6 patients (Stage II, 2; Stage III, 4), and distant metastases were documented in 25 patients (Stage I, 3; Stage II, 3; Stage III. 19). The highest incidence of cancer-related death occurred after abdominoperineal resection (4.9 percent). CONCLUSION: To assess the role of laparoscopic colorectal surgery for the cure of cancer objectively, prospective randomized trials are necessary. [ABSTRACT FROM AUTHOR]

Background: The risk for surgical site infections (SSIs) is influenced by patient- and procedure-related factors. Urgent surgery represents a challenge in operative medicine and is frequently linked to a variety of complications, including SSIs., Aim: We aimed to investigate whether urgency was significantly associated with SSI occurrence, and determine whether collection of this variable provided useful information for SSI surveillance., Methods: We performed a retrospective data analysis of caesarean sections (C-sections) and colon surgeries conducted between 2017 and 2019 within the German national SSI surveillance network. A multivariable logistic regression model was utilized to determine the influence of urgency on SSI occurrence. For this purpose, data on procedures and SSIs were associated with available department- and patient-related parameters., Findings: A total of 115,648 procedures were included in the analysis: 78,288 C-sections and 37,360 colon surgeries. For C-sections, the SSI rate per 100 procedures was 0.98 (95% confidence interval: 0.85-1.11) for urgent and 0.46 (0.40-0.53) for elective procedures (P<0.001). For open colon surgeries, SSI rates were 9.66 (8.89-10.49) for urgent and 8.60 (8.13-9.11) for elective procedures (P<0.001). For laparoscopic colon surgeries, SSI rates did not differ significantly. Multivariable analysis revealed that urgency significantly increased the likelihood of SSI occurrence only for C-sections., Conclusion: Urgency significantly increased the SSI risk of C-sections, but not colon surgeries. Hence, collection of this variable is useful for SSI surveillance of C-sections, but may be dispensable for other procedures. Future analyses on the matter should therefore focus on other procedure types., (Copyright © 2021 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Introduction: Given the sparsity of longitudinal studies on colonoscopy use, we quantified utilization of repeat colonoscopy within 10 years and the proportion of persons with polypectomies at first repeat colonoscopy using a large German claims database., Methods: Based on the German Pharmacoepidemiological Research Database, we identified persons who underwent colonoscopy between 2006 and 2015 (index colonoscopy) and assessed colonoscopies and polypectomies during follow-up. We defined 3 subcohorts based on available procedure/diagnosis codes at index colonoscopy: persons with snare polypectomy, which is reimbursable for lesions ≥5 mm in size (cohort 1), with a forceps polypectomy (cohort 2), and without such procedures/diagnoses (cohort 3). We stratified all analyses by diagnostic vs screening index colonoscopy., Results: Overall, we included 3,076,657 persons (cohort 1-3: 15%, 13%, 72%). Among persons with screening index colonoscopy (30%), the proportions with a repeat colonoscopy within 10 years in cohorts 1, 2, and 3 were 78%, 66%, and 43%, respectively, and a snare polypectomy at first repeat colonoscopy was performed in 27%, 17%, and 12%, respectively. In cohort 1, 32% of persons with a (first) repeat colonoscopy after 9 years had a snare polypectomy (after 3 years: 25%). Among persons with diagnostic index colonoscopies, 80%, 78%, and 65% had a repeat colonoscopy, and 27%, 17%, and 10% had a snare polypectomy at first repeat colonoscopy, respectively., Discussion: Our study suggests substantial underuse of repeat colonoscopy among persons with previous snare polypectomy and overuse among lower risk groups. One-quarter of persons with a snare polypectomy at baseline had another snare polypectomy at first repeat colonoscopy., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Introduction: Endoscopic full-thickness resection (EFTR) is a powerful option for resection of colorectal lesions not amenable to conventional endoscopic resection. The full-thickness resection device (FTRD) allows clip-assisted EFTR with a single-step technique. We report on results of a large nationwide FTRD registry., Methods: The "German colonic FTRD registry" was created to further assess efficacy and safety of the FTRD System after approval in Europe. Data were analyzed retrospectively., Results: Sixty-five centers contributed 1,178 colorectal FTRD procedures. Indications for EFTR were difficult adenomas (67.1%), early carcinomas (18.4%), subepithelial tumors (6.8%), and diagnostic EFTR (1.3%). Mean lesion size was 15 × 15 mm and most lesions were pretreated endoscopically (54.1%). Technical success was 88.2% and R0 resection was achieved in 80.0%. R0 resection was significantly higher for subepithelial tumor compared with that for other lesions. No difference in R0 resection was found for smaller vs larger lesions or for colonic vs rectal procedures. Adverse events occurred in 12.1% (3.1% major events and 2.0% required surgical treatment). Endoscopic follow-up was available in 58.0% and showed residual/recurrent lesions in 13.5%, which could be managed endoscopically in most cases (77.2%)., Discussion: To date, this is the largest study of colorectal EFTR using the FTRD System. The study demonstrated favorable efficacy and safety for "difficult-to-resect" colorectal lesions and confirms results of previous studies in a large "real-world" setting. Further studies are needed to compare EFTR with other advanced resection techniques and evaluate long-term outcome.

Background/aims: Ischemic colitis (IC) is most common in the elderly and patients with multiple comorbidities. It carries significant mortality. As yet no evidence-based therapeutic management exists. Aim of the study was to test therapeutic efficacy of a combination of prednisolone and antibiotics., Methods: Prospective cohort study with retrospective analysis performed in a single teaching hospital in Germany. Consecutive patients with strict diagnostic criteria of severe IC, including colonoscopy, histology, and laboratory tests, were recruited. Main outcome measures were in-hospital mortality and number of operations counted within the hospital stay. Severity scores were calculated and biomarkers determined during the course of the hospital stay., Results: A total of 342 patients with an International Classification of Diseases of IC were identified. About 151 patients met the diagnostic criteria and a total of 44 patients fulfilled all inclusion and exclusion criteria of severe IC and constituted the group of patients eligible for analysis. Five out of 44 patients (11.4%) died (in-hospital mortality). Surgery was performed in 3 patients (6.8%), 2 patients survived. The hospital stay lasted 14.0 ± 8.5 day and was significantly correlated with comorbidity (rs = 0.314, p = 0.038). No serious adverse events were observed., Conclusion: This is the first prospective study on therapeutic efficacy and safety in severe IC. The combination of intravenous antibiotics and intravenous prednisolone turned out to be safe and revealed promising efficacy., (© 2019 S. Karger AG, Basel.)

Background: There has been recent interest in indocyanine green (ICG) to assess anastomotic perfusion in colorectal surgery. We describe our experience using ICG when performing laparoscopic segmental colorectal resections with extracorporeal anastomotic technique and a highly standardized approach for clinically assessing blood flow., Methods: We recruited 20 consecutive patients to undergo segmental laparoscopic resection and determined an appropriate point to transect mesentery proximally confirming pulsatile arterial flow at this level. Once confirmed, we did a further perfusion study using ICG to ascertain if this would change intraoperative decision-making., Results: Twenty segmental colonic resections were assessed in nine female and 11 male patients aged 26-91 years. ICG administration was safe with no adverse outcomes documented. ICG demonstrated anastomotic perfusion in all cases. We observed no cases wherewith pulsatile blood flow at the cut edge of the mesentery, ICG showed inadequate perfusion at this level. We did find in 25% of cases ICG showed perfusion beyond the cut edge of the mesentery to a distance of up to 2.5 cm., Conclusion: ICG perfusion is safe and straightforward to carry out. However, when pulsatile arterial bleeding is demonstrated clinically it does not add anything to assessment of perfusion in our study. Furthermore, in 25% of cases perfusion can be demonstrated beyond the cut edge of the mesentery up to a distance of 2.5 cm. This raises the possibility that an organ well perfused with ICG may have less than ideal blood flow when assessing for this with a view to constructing an anastomosis., (© 2019 Royal Australasian College of Surgeons.)

Background: There are numerous published studies on patient-related risk factors for the development of anastomotic failure. We therefore investigated the influence of patient-unrelated risk factors for the development and course of treatment of anastomotic failure in colorectal surgery., Patient Sample: From May 1, 2015, until December, 31, 2016, n = 179 post-colorectal surgery patients were analysed. Overall, n = 14 patients suffered from anastomotic failure. These patients' course of treatment was analysed in a Morbidity and Mortality Conference (M+M conference) structured according to the London Protocol., Results: Irregularities in process quality were the most frequent analysis result (n = 8/14), followed by irregularities in post-treatment (n = 6/14). Irregularities in surgical technique (n = 2/14) and surgery procedure (n = 3/14) were less frequent. Future treatment approaches were identified for most patients (n = 11/14). On the basis of the analysis of data from four of these eleven patients, the strategy for future treatment was modified., Conclusion: Therapist- and environment-specific irregularities can be systematically identified in M+M conferences structured according to the London Protocol. This analysis is the prerequisite for quality improvement and must systematically complement the analysis of patient-related risk factors., Competing Interests: Der Autor gibt an, dass kein Interessenkonflikt vorliegt., (Georg Thieme Verlag KG Stuttgart · New York.)

A calendar of events regarding the international colorectal meetings is presented. The 33rd Deutscher Koloproktologen-Kongress will be held in Mannheim, Germany from March 15-18, 2007. The 11th National Meeting of the Spanish Society of Coloproctology will be held in San Sebastian, Spain from May 9-11, 2007. The American Society of Colon and Rectal Surgeons (ASCRS) Annual Meeting 2007 will be held from June 2-7, 2007.

Preliminary results of a questionnaire survey showed that gastric transposition is the technique of choice in Germany to restore alimentary continuity after esophageal resection. Experience with colon interposition grafting is low. Only 13% of all centers perform this technique. Despite this limited experience, there appears to be no difference in the complication rate between gastric pull-through procedures and colon interpositions. A modification of established colon interposition techniques is possible when the right colon is used if it is prepared in such a way that the left colonic artery is the blood supplying vessel. This modified technique may be simpler to perform than previous procedures for creating a colon interposition graft and may also facilitate esophageal replacement using colon interposition grafting. [ABSTRACT FROM AUTHOR]

Background: The German NOTES registry (GNR) is the largest published database for natural orifice transluminal endoscopic surgery (NOTES) worldwide. Although transvaginal cholecystectomy is the most frequent procedure in the GNR, the number of colorectal resections is increasing. The objective of this study was to analyze the first 139 colonic procedures of the GNR., Methods: All colonic procedures from the GNR were analyzed regarding patient- and therapy-related parameters. A multivariate analysis was conducted for transvaginal sigmoid resections regarding procedural time, hospital stay, conversion rate, and rate of complications., Results: From October 2008 to January 2013, 139 colon NOTES procedures (12 male, 127 female) were registered. Main diagnoses were sigmoid diverticulitis (85.6 %), colon carcinoma (9.4 %), and ulcerative colitis (3.6 %). Sigmoid resections (87.1 %), proctocolectomies (3.6 %), right-sided resections (2.9 %), left-sided resections (3.6 %), segmental resections (2.2 %), and 1 ileocecal resection (0.7 %) were performed. All procedures were conducted in transvaginal (87.8 %) or transrectal (12.2 %) hybrid technique, with a median of 3 percutaneous trocars. Conversions to laparoscopic technique were necessary in 3.6 % (none to conventional technique). Intraoperative complications were recorded in 2.9 % and postoperative complications in 12.2 %. The institutional case number in transvaginal sigmoid resections correlated negatively with procedural time (p = 0.041) and the number of percutaneous trocars (p = 0.002)., Conclusion: The analysis of the first 139 colon NOTES operations of the GNR shows the feasibility of co on operations in hybrid technique, especially for transvaginal sigmoid resection as the most frequent procedure.

Background: Colonic endoscopic submucosal dissection (ESD) is challenging as a result of the limited ability of conventional endoscopic instruments to achieve traction and exposure. The aim of this study was to evaluate the feasibility of colonic ESD in a porcine model using a novel endoscopic surgical platform, the Anubiscope (Karl Storz, Tüttlingen, Germany), equipped with two working channels for surgical instruments with four degrees of freedom offering surgical triangulation., Methods: Nine ESDs were performed by a surgeon without any ESD experience in three swine, at 25, 15, and 10 cm above the anal verge with the Anubiscope. Sixteen ESDs were performed by an experienced endoscopist in five swine using conventional endoscopic instruments. Major ESD steps included the following for both groups: scoring the area, submucosal injection of glycerol, precut, and submucosal dissection. Outcomes measured were as follows: dissection time and speed, specimen size, en bloc dissection, and complications., Results: No perforations occurred in the Anubis group, while there were eight perforations (50 %) in the conventional group (p = 0.02). Complete and en bloc dissections were achieved in all cases in the Anubis group. Mean dissection time for completed cases was statistically significantly shorter in the Anubis group (32.3 ± 16.1 vs. 55.87 ± 7.66 min; p = 0.0019). Mean specimen size was higher in the conventional group (1321 ± 230 vs. 927.77 ± 229.96 mm(2); p = 0.003), but mean dissection speed was similar (35.95 ± 18.93 vs. 23.98 ± 5.02 mm(2)/min in the Anubis and conventional groups, respectively; p = 0.1)., Conclusions: Colonic ESDs were feasible in pig models with the Anubiscope. This surgical endoscopic platform is promising for endoluminal surgical procedures such as ESD, as it is user-friendly, effective, and safe.

Colonoscopy with detection and removal of neoplasms strongly reduces risk of colorectal cancer (CRC). Nevertheless, CRCs occur after colonoscopic polypectomy. We assessed agreement beyond chance of location of polyps detected at colonoscopy and of subsequent CRCs to estimate the share of cancers that might be due to field effects or neoplasm recrudescence. In a population-based case-control study conducted in Germany (3,148 cases), detailed history and results of colonoscopies conducted within 10 years before cancer diagnosis were obtained by interview and from medical records. We determined the observed proportion of cancers for which a polyp had been detected at the same colorectal subsite at the preceding colonoscopy and compared it to the proportion expected by chance. A total of 155 cases with physician validated polyp detection at the preceding colonoscopy were identified. Among 148 cases with cancer restricted to a single subsite, 43 (29.1%) had a polyp detected in the same colorectal subsite at the preceding colonoscopy. Agreement of location of cancer occurrence and preceding polyp detection would have been expected by chance for 27 cases, and agreement beyond chance was estimated to account for 16 cases (10.8%, 95% confidence interval 2.7%-19.3%). Our study suggests that less than one of nine CRCs occurring within 10 years after colonoscopy with polyp detection may be due to field effects or polyp recrudescence., (© 2013 UICC.)

Background: There is no nationwide evaluation of the quality of anaesthesia in Germany. Thus, the aim of this study was to perform analyses using administrative routine data relating to this topic., Methods: Nationwide hospital claims data of patients insured with the local healthcare insurance fund (AOK) in the year 2007 were analyzed. Indicators from International Statistical Classification of Diseases and Related Health Problems-10, German modification (ICD-10-GM) diagnosis codes for possible anaesthesia complications were selected., Results: Based on the present data, it was not possible to validate indicators which can be applied to detect the quality of anaesthesia., Conclusions: Administrative data seem to be an appropriated basis for measurement of quality of outcome in anaesthesiology. Further investigations should be performed to include the diagnosis present on admission. Moreover, there is a need for comparing routine data to the standardized data set, known as the "core data set anaesthesia".

An increasing rate of infections with Shiga toxin/verotoxin-producing Escherichia coli (STEC/VTEC) O104:H4 has been observed in Germany since May 2011, with unusually high numbers of patients suffering from haemolytic uraemic syndrome (HUS). We report a STEC/VTEC O104:H4 case without HUS, presenting with colonic ischaemia demanding surgery. This atypical clinical presentation of STEC O104:H4 infection might indicate new severe complications associated with this uncommon strain, and highlights the importance of immediate interdisciplinary assessment of STEC/VTEC patients.

Aim: The study was designed to determine the suitability of a single-layer continuous anastomosis for ileo-colonic anastomoses and to determine perioperative risk factors for morbidity and mortality in a teaching hospital., Patients and Methods: Perioperative data of 463 patients undergoing colonic surgery with an ileocolonic anastomosis between 2000 and 2007 were retrospectively reviewed. Outcomes were compared using univariate and multivariate analyses to identify risk factors for morbidity, including anastomotic leakage, and mortality., Results: The overall anastomotic leakage rate was 2.1%. In more than 50% right hemicolectomies were performed for colonic cancer. Univariate analysis showed a significant association of the underlying diagnosis with the leakage rate (ischemia 3.0% vs. carcinoma 1.3%). Multivariate analysis identified age, ASA score, diagnosis, and urgency as risk factors for morbidity; and an urgent operation setting (vital indications), a body mass index >25, diabetes mellitus, and a hypotensive circulation upon admission as predictors of anastomotic leakage. The mortality rate was 20% (2/10) among patients with anastomotic leakage and 2.9% (13/453) in those without anastomotic leakage., Conclusion: Single-layer continuous anastomoses for ileo-colonic surgery can be safely performed, even in a teaching setting. Four preoperative risk factors for morbidity and four different factors for anastomotic leakage could be identified in multivariate analysis. If feasible, these factors should have an impact on the preoperative decision-making progress.

Background: Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany., Methods: In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection., Results: The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia., Conclusion: In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

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.

Background: Despite the evidence that fast-track concepts in colon surgery lead to an enhanced recovery rate, there is no information on the prevalence and utilization of such programs in Germany., Methods: Based on a conventional sigmoid resection, we asked 1,270 surgical departments in Germany to describe their standard surgical procedures in a questionnaire., Results: The response rate was 385 (30.31%). A total of 96% use a bowel preparation, 83% a vertical incision, 10% use a nasogastric decompression for longer then 1 day, 34% avoid intra-abdominal drains, 51% allow clear fluids on the day of surgery, 13% offer solid food on the first day after surgery, 75% use epidural analgesia and 47% discharge the patients by the seventh day after surgery., Conclusion: Although there is an evident benefit using fast-track concepts, they are not yet in wide use as a standard procedure. Further efforts have to be made to ensure that the majority of patients will benefit from these concepts.

The rates of postoperative local surgical complications (e.g. wound-infection, abscess, anastomotic leakage) and the postoperative mortality have markedly decreased over the past decades. However the occurrence of general medical complications (e.g. cardio-pulmonary or renal dysfunction, nosocomial infections, thromboembolism) after abdominal surgery is still frequent with an incidence of 20-60% (1-6). "Fast-track"-surgery, also called "Fast-track"-rehabilitation or "ERAS" (enhanced recovery after surgery) programme, is a combination of different pre- and intraoperative measures, which have been mainly validated in elective colonic surgery, but they can be principally employed in all surgical settings. With this approach it is possible to accelerate the postoperative convalescence and reduce the rate of general complications markedly (4, 7-10).

Intestinal transplantation is the only curative form of treatment for fulminant short bowel syndrome. Results have been hampered by frequent rejection episodes as well as technical and infectious complications. We report the first case of complete small bowel transplantation performed at our institution. A 37-year-old male patient suffered from massive gut infarction due to a superior mesenteric artery embolus from a thrombus in the descending aorta resulting from hereditary protein S and C deficiency. The primary surgery resulted in a duodenocolostomy requiring total parenteral nutrition. The course was further complicated by multiple central line infections and pre-renal kidney failure induced by dehydration. After 17 months, we performed a cadaveric small bowel transplant using systemic venous drainage. The ileum was anastomosed end-to-end to the recipient ascending colon. The proximal jejunum was used to create a jejunostomy, with an end-to-side duodenojejunostomy. Immunosuppression consisted of a single-administration of antithymocyte globulin (ATG), tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone given enterally from day 1. Biopsies of the upper jejunum showed no signs of rejection. The graft was monitored via capsule video endoscopy after 9 weeks and appeared normal. The patient was discharged on day 35, completely on an enteral diet and gaining weight with a good quality of life. Oral valganciclovir was given for the cytomegalovirus prophylaxis infection (donor-positive, recipient-negative constellation), with no clinical or serologic signs of infection. The early course after small bowel transplantation using a quadruple regimen was clinically successful. The use of video-capsules allows for noninvasive visual monitoring of bowel segments that cannot be reached endoscopically.

Aim: In contrast to other countries, no collective study of Rehbein's procedure in German-speaking nations has been performed. Therefore, our intention was, analogously to Goto and Ikeda's (10) Japanese study in 1984, Kleinhaus's (13) study on Swenson's procedure in 1979, Bourdelat's (2) French-Canadian investigation into Duhamel's technique in 1997 and Martuciello's (11) and Teitelbaum's (16) follow-up in the year 2000, to perform a follow-up study of Rehbein's technique of deep anterior resection., Methods: The data of 200 patients from 22 German-speaking centers in Switzerland, Austria and Germany were collected. These data were gathered by questionnaire and the children were followed up in the individual participating hospitals for at least 3.5 years after the procedure. The procedure was performed between 1993 and 1997, over a 5-year period. The questionnaire contained 74 items including anamnestic data, diagnostic postoperative treatment and reoperations., Results: Concerning the incidence of anastomotic leaks and resolving anastomotic strictures there was no significant difference between the results in our series and those of the collective analyses made by Hofmann von Kap-herr (7), Holschneider (9) and Sherman (18). In 6.6 % of the 191 patients an anastomotic leak and in 9.9 % a rectal stricture, which had to be dilated, was observed. Concerning late complications, 22.8 % of the children suffered from constipation, 4.3 % from encopresis, 10.6 % from enterocolitis and only 0.5 % from enuresis. The frequency of constipation diminishes over the years. A comparison of the different large series in the literature clearly shows that the incidence of constipation is higher after Rehbein's procedure and the frequency of urinary incontinence and encopresis higher following Swenson's, Soave's and Duhamel's techniques. The incidence of enterocolitis is less after Rehbein's procedure than after Swenson's, Soave's and Duhamel's techniques., Conclusions: The different results in the literature are due to the individual experience of the author, the very different follow-up methods and the date of follow-up. Therefore, the different results are hard to compare with our study. Nevertheless, Rehbein's anterior resection still could be presented as an adequate and important method to treat Hirschsprung's disease.

Current tumor management is increasingly founded on interdisciplinary cooperation. The main partners in cases of solid tumors are oncologic surgery, medical oncology,and radiotherapy, guided by pathology. The cooperative concept, particularly the individual strategy and selection of the most adequate approach, oriented on guidelines and therapeutic standards, depends on the quality of the involved components as well as personal abilities of the "actors." In addition to the personal qualification, decision making depends on both tumor stage and completeness of tumor removal. In this point, the overall quality of the therapeutic concept is based on an interaction between the operating surgeon and clinical pathologist that had seldom been taken into consideration. The basic rules of their cooperation and quality-focused implementation regarding tumor dignity, stage, and R classification are discussed based on the example of colorectal carcinoma. In particular, those pitfalls in tumor documentation are emphasized,which may appear less relevant for each partner individually, but bear the risk of misinterpretation and therefore misleading conclusions.

Aims: This study evaluated the techniques and short-term results of surgical treatment for esophageal cancer in Germany by a nationwide representative survey., Methods: In 2000 a questionnaire including 63 structured items concerning indication, technique, number of procedures, complications, and hospital mortality was sent to 308 randomly selected general, gastrointestinal, and thoracic surgeons and all university hospitals in Germany (20% of all surgeons). The response rate was 76% ( n=234)., Results: In 1999 the 56 participating hospitals performed approximately 370,000 procedures, including 1,677 operations for esophageal diseases, including 891 esophagectomies, 706 for esophageal cancer, 285 for cancer of the cardia. Gastric interposition was the most common technique to restore alimentary tract continuity (86%). Interposition of the colon (ascending colon 64%) is a common procedure only in 22 centers, indicating that experience with this means of esophageal reconstruction is limited. There were no significant differences in complication and mortality rates between gastric transposition and colon interposition. The overall complication rate was 61%, with 36% after gastric interposition and 42% after colon interposition. Anastomotic leakages occurred in 12% and 15%, respectively, and the rate of graft necrosis was 3% in both groups. Hospital mortality was 8% with gastric transposition and 11% with colon interposition. Mean postoperative hospital stay was 24 days., Conclusions: This study indicates that gastric transposition is frequently used for reconstruction after esophageal resection for malignant disease. It appears that the colon is not as accepted as the stomach for reconstruction, although the reported complication rates compare well with those reported after gastric transposition. This study allows a realistic evaluation of the overall risk of these surgical techniques.

Introduction: The objective of a multicentric observational study, that was performed in Germany between 1(st) September 1996 and 30(th) September 1997, was to assess postoperative infections as a function of risk factors and antibiotic prophylaxis under everyday clinical conditions. 2 481 patients from 114 centres who received infection prophylaxis prior to elective colonic resection were included. In the descriptive analysis of the study it was noted that 36.1 % of the patients had received no prophylaxis with metronidazole despite the fact that the study protocol recommended the use of this drug in preoperative antibiotic combinations. The present analysis therefore considers the influence of metronidazole on the postoperative infection rate., Methods: In order to exclude any bias due to intergroup differences in risk profile, the groups with and without metronidazole were subjected to a matched-pair analysis. Matching parameters were: duration of operation, blood loss, age, diabetes mellitus, hepatic, renal, or chronic airways disease, immunosuppressive therapy, and rectal resection. This led to the formation of 800 pairs that were matched with respect to these parameters. The 800 pairs were then stratified into the following treatment groups: Group 1 a and b: long-acting cephalosporine (ceftriaxone) with or without metronidazole (n = 2 x 491); Group 2 a and b: short-acting cephalosporines with or without metronidazole (n = 2 x 133); Group 3 a and b: broad-spectrum penicillines with or without metronidazole (n = 2 x 176)., Results: In all three treatment groups combination therapy with metronidazole was found to be significantly superior. Postoperative infection rates were 9.4 % and 18.7 % (p = 0.000) respectively in Group 1 a and b, 12.0 % and 25.6 % (p = 0.008) respectively in Group 2 a and b, and 19.9 % and 29.0 % (p = 0.009) respectively in Group 3 a and b., Conclusion: Preoperative administration of metronidazole in addition to an effective beta-lactam antibiotic is strongly advised in elective colonic surgery, as absence of antibiotic cover against anaerobic colonic flora leads to a significantly higher postoperative infection rate.