A 69-year-old male patient with advanced lower sigmoid cancer was referred for endoscopic evaluation and potential resection of another small non-lifting lesion in the ascending colon after office-based surveillance colonoscopy.Histopathology at this stage indicated highgrade adenoma.The estimated 15-mm lesion close to the ileocecal valve exhibited central retraction and a scarred appearance (Fig. 1).In addition, surface and vessel pattern proved amorphous and/or absent in the center, which was substantiated by narrow-band imaging, classified as NICE3 (Narrow Band Imaging (NBI) International Colorectal Endoscopic classification), suggestive of, at least, deep submucosal invasive cancer (Fig. 2).Notwithstanding these untoward findings and under the premise that deviceassisted full-thickness resection (FTRD, Ovesco Endoscopy, Tübingen, Germany) was considered technically achievable, we proceeded with FTRD as per standard procedure.Macroscopic full thickness resection was successfully accomplished, as indicated by ample visible fat within the clip (Fig. 3).To our surprise, final pathology indicated R0 resection of a T3, L0, V0, G2-3 microsatellite-stable colorectal cancer harboring a BRAF V600E mutation, which may by itself, in part, account for the presumed discrepancy of small size vs. advanced T status.Recent data suggest that the impact of endoscopically appreciable submucosal infiltration depth as an independent risk factor for lymph node metastasis declines, such that advanced diagnostic endoscopic resections with therapeutic potential to allow for adequate patientstratification, may [1].

Summary Background The beneficial outcomes of hepatectomy in patients with colorectal metastases have encouraged the attempts of repeated hepatectomy in patients with recurrent disease. Although studies have provided encouraging results regarding perioperative outcomes and survival rates following repeated hepatectomy, it remains unclear whether the reported outcomes reflect the therapeutic results of redo hepatectomy or rather reflect the effect of selection bias. The aim of this study was to investigate differences among patients who underwent single and repeated hepatectomy and to hereby identify prognostic factors that contribute to the premises of repeated resection. Methods Patients who underwent hepatectomy due to colorectal metastases were listed in a retrospective database. Study participants were divided into a single partial hepatectomy group, a multiple partial hepatectomies group, and into subgroups of two or more than two hepatectomies. Results A total of 338 patients with 439 partial liver resections were included in the analysis. The overall survival rate after 1, 3, and 5 years was 89%, 56%, and 36%, respectively. The survival benefit in patients who underwent multiple partial liver resections versus those with a single partial resection was 10%, 16%, and 4% after 1, 3, and 5 years, respectively. Repeated hepatectomy was not associated with increased rates of surgical and non-surgical complications. Conclusion Beneficial outcomes have been found in terms of median overall survival and perioperative morbidity in patients with recurrence of colorectal hepatic metastases after partial and tissue-sparing repeated liver resections.

Purpose: Despite the advancements in the reinforcement and closure techniques available, complex abdominal wall reconstruction (CAWR) remains a challenging surgical undertaking with considerable risk of postoperative complications. Biological meshes were developed that may help to complement standard closure techniques and offer an alternative to synthetic meshes, which carry significant risks with their use in complex cases. Patients and Methods: A total of 114 patients underwent surgical treatment for CAWR with a Permacol (TM) (a biologic surgical implant). The study objective was to evaluate the short-term (6 months), mid-term (12-24 months), and long-term (36 months) clinical outcomes (through 36 months) associated with the use of a biologic surgical implant in these cases. Results: The cumulative hernia recurrence rate was 18.7% (17/91) at 24 months and 22.4% (19/85) at 36 months. Twelve (14.1%) subjects required reoperation for hernia repair within 36 months for repair of recurrent hernias. Between 6- and 36-months post-surgery, patients reported improvement in their Carolina comfort scale (CSS) measures of severity of pain, sensation of mesh, and movement limitations. Conclusion: A biologic surgical implant can provide long-term benefit to complex abdominal wall repairs in patients staged grade III according to the Ventral Hernia Working Group (VHWG).

Zusammenfassung Hintergrund Zur Vermeidung einer Narbe am Hals wurden alternative Verfahren zur Thyreoidektomie entwickelt. Ziel unserer Studie war es, die Bedeutung der Narbe und die Einflussfaktoren für die Zufriedenheit nach klassischer Thyreoidektomie im Langzeitverlauf festzustellen. Material und Methoden 228 Patienten, die sich zwischen 2001 und 2014 wegen einer gutartigen Schilddrüsenerkrankung einer partiellen oder totalen Thyreoidektomie unterzogen hatten, nahmen an einer telefonischen Befragung teil. Neben der Zufriedenheit der Patienten wurden demographischen Daten, das subjektive Erscheinungsbild der Narbe und subjektive Beschwerden erfasst. Ergebnisse 93,8 % der Patienten waren mit der Behandlung zufrieden. Weibliche und jüngere Patienten waren tendenziell unzufriedener als männliche und ältere. Die mittlere Narbenlänge betrug 6,03 ± 2,36 cm und die mittlere Narbenbreite 2,01 ± 1,46 mm. Die Länge der Narbe hatte keinen Einfluss auf die Zufriedenheit. Dagegen waren Patienten mit einer breiteren prominent oder auffällig verfärbten Narbe signifikant unzufriedener. Patienten, die postoperativ dauerhaft an Beschwerden wie Druckgefühl oder Schluckbeschwerden litten, waren ebenfalls signifikant unzufriedener. Kosmetische Probleme beeinflussen die Zufriedenheit stärker als funktionelle Probleme. Schlussfolgerungen Die Zufriedenheit nach Thyreoidektomie ist im Langzeitverlauf gut. Ob durch die Anwendung eines alternativen bzw. minimalinvasiven Verfahrens die Zufriedenheit weiter verbessert werden kann, ist fraglich. Diese Verfahren sind gegebenenfalls eine Alternative für jüngere und weibliche Patienten oder solche, die einen hohen Wert auf Kosmetik legen.

: Colorectal carcinoma is one of the most frequent tumor entities worldwide. The treatment of elderly and mostly polymorbid patients is an outstanding challenge in view of the demographic change with a continuously aging community. Due to the demographic changes the numbers of elderly (\u003e65 years) and very old (≥80 years) patients are steadily increasing in surgical cohorts. This has resulted in higher morbidity and mortality rates in comparison to younger patients, with increased wound healing and cardiovascular complications but with comparable numbers of anastomotic insufficiency. Multivariate analysis revealed age ≥80 years, higher ASA status and emergency operations as independent risk factors for increased in-hospital mortality. With respect to the localization of colorectal cancer a shift to the right has been observed with increasing patient age. Whether minimally invasive surgical techniques can reduce postoperative morbidity and mortality rates in elderly patients requires further evaluation. Nevertheless, a reduction of both was reported without compromising the oncological result. Elderly patients require individualized treatment modalities, which take the extent of comorbidities and personal environment into consideration. So far, the cohort of octogenarians has not been adequately considered in current guidelines; therefore, geriatric expertise is recommended to be able to make a better assessment of benefit-risk ratios, as age itself has no impact on the decision for therapy.

Zusammenfassung Das kolorektale Karzinom ist eine der häufigsten Tumorentitäten weltweit und stellt vor dem Hintergrund einer ständig alternden Gesellschaft die chirurgischen Disziplinen vor eine besondere Herausforderung bei der Behandlung älterer und zumeist polymorbider Patienten. Entsprechend des demographischen Wandels nimmt der Anteil alter (>65 Jahre) und sehr alter (≥80 Jahre) Patienten im Operationskollektiv kontinuierlich zu. Dies resultiert in höheren Morbiditäts- und Mortalitätsraten verglichen mit jüngeren Patienten, wobei Wundinfekte und kardiovaskuläre Komplikationen häufiger auftreten, nicht jedoch die Anastomoseninsuffizienz. In der multivariaten Analyse waren Alter ≥80 Jahre, höherer ASA-Status und Operation als Notfall unabhängige Risikofaktoren für eine gesteigerte In-hospital-Mortalität. Mit zunehmendem Patientenalter ist ein Rechts-Shift bezüglich der Tumorlokalisation des kolorektalen Karzinoms zu verzeichnen. Ob minimalinvasive Operationstechniken die erhöhten Morbiditäts- und Mortalitätsraten bei älteren Patienten reduzieren werden, lässt sich anhand der vorliegenden Studien noch nicht abschließend beurteilen. Eine positive Veränderung im Sinne einer Reduktion wird jedoch in zunehmenden Maß berichtet, ohne dass das onkologische Ergebnis beeinträchtigt ist. Ältere Patienten benötigen individualisierte Therapieentscheidungen, die das Ausmaß der bestehenden Begleiterkrankungen und der persönlichen Lebensumstände berücksichtigen. Bis dato ist die Kohorte der sog. „octogenarians“ (über 80-jährige Patienten) in den verfügbaren Leitlinien nur unzureichend berücksichtigt. Die Einbindung geriatrischer Expertise sollte angestrebt werden, um eine optimale Nutzen-Risiko-Bewertung vornehmen zu können, denn das Lebensalter selbst ist für die Therapiewahl ohne Bedeutung.

Das kolorektale Karzinom ist eine der häufigsten Tumorentitäten weltweit und stellt vor dem Hintergrund einer ständig alternden Gesellschaft die chirurgischen Disziplinen vor eine besondere Herausforderung bei der Behandlung älterer und zumeist polymorbider Patienten.

Optimal timing of liver surgery for synchronous metastases regarding a simultaneous or two-staged procedure is still controversially discussed. As randomized controlled trials are ethically disputable due to potential advantages of the simultaneous approach, the following matched pair analysis was performed to investigate feasibility and short-term outcome of the additional simultaneous hepatic approach compared to colorectal surgery alone.

Introduction Only around 20% of patients are diagnosed with a primarily resectable pancreatic ductal adenocarcinoma. However, some of these patients show intraoperatively the incidental finding of a solitary, resectable liver metastasis (LM). Another 15- 20% of tumors are locally- advanced or involving surrounding organs at diagnosis. The objective of this study was to investigate first if the long- term survival of these patients can be improved by an extended resection (ER) and second to point out the strongest predictors for long- term survival. Patients and methods All patients with locally- advanced tumors or those with intraoperatively diagnosed, unexpected, solitary LM between January 2002 and December 2013 were analyzed retrospectively. The ER was defined as the simultaneous resection of adjacent organs or solitary LM. For statistical analyses, these patients´ long- term survival was compared with the one of patients who did not undergo oncological tumor resection in case of locally- advanced cancer. Results 40 patients (17 men, 23 women, age 68 ± 9.5 years) underwent ER and another 40 patient’s only explorative laparotomy or palliative surgical treatment. After ER, patients had a significantly better longterm survival (10.8 ± 2.85 vs. 6.43 ± 2.43 months, p=0.02). The R0- resection and the application of a postoperative chemotherapy were the strongest predictors for long- term survival. Conclusion In case of locally- advanced ductal pancreatic adenocarcinoma or intraoperatively diagnosed, unexpected, solitary LM, selected patients can benefit from an extended resection in order to achieve clearness of tumor. The R0- resection and the use of postoperative chemotherapy are the strongest predictors for long- term survival.

Background: The treatment of acute cholecystitis has been controversially discussed in the literature as there are no high-evidence-level data yet for determining the optimal point in time for surgical intervention. So far, the laparoscopic removal of the gallbladder within 72 h has been the most preferred approach in acute cholecystitis. Methods: We conducted a systematic review by including randomized trials of early laparoscopic cholecystectomy for acute cholecystitis. Results: Based on a few prospective studies and two meta-analyses, there was consent to prefer an early laparoscopic cholecystectomy for patients suffering from acute calculous cholecystitis while the term ‘early' has not been consistently defined yet. So far, there is new level 1b evidence brought forth by the so-called ‘ACDC' study which has convincingly shown in a prospective randomized setting that immediate laparoscopic cholecystectomy - within a time frame of 24 h after hospital admission - is the smartest approach in ASA I-III patients suffering from acute calculous cholecystitis compared to a more conservative approach with a delayed laparoscopic cholecystectomy after an initial antibiotic treatment in terms of morbidity, length of hospital stay, and overall treatment costs. Concerning critically ill patients suffering from acute calculous or acalculous cholecystitis, there is no consensus in treatment due to missing data in the literature. Conclusion: Laparoscopic cholecystectomy for acute cholecystitis within 24 h after hospital admission is a safe procedure and should be the preferred treatment for ASA I-III patients. In critically ill patients, the intervention should be determined by a narrow interdisciplinary consent based on the patient's individual comorbidities.

BACKGROUND:The treatment of acute cholecystitis has been controversially discussed in the literature as there are no high-evidence-level data yet for determining the optimal point in time for surgical intervention. So far, the laparoscopic removal of the gallbladder within 72 h has been the most preferred approach in acute cholecystitis.METHODS:We conducted a systematic review by including randomized trials of early laparoscopic cholecystectomy for acute cholecystitis.RESULTS:Based on a few prospective studies and two meta-analyses, there was consent to prefer an early laparoscopic cholecystectomy for patients suffering from acute calculous cholecystitis while the term 'early' has not been consistently defined yet. So far, there is new level 1b evidence brought forth by the so-called 'ACDC' study which has convincingly shown in a prospective randomized setting that immediate laparoscopic cholecystectomy - within a time frame of 24 h after hospital admission - is the smartest approach in ASA I-III patients suffering from acute calculous cholecystitis compared to a more conservative approach with a delayed laparoscopic cholecystectomy after an initial antibiotic treatment in terms of morbidity, length of hospital stay, and overall treatment costs. Concerning critically ill patients suffering from acute calculous or acalculous cholecystitis, there is no consensus in treatment due to missing data in the literature.CONCLUSION:Laparoscopic cholecystectomy for acute cholecystitis within 24 h after hospital admission is a safe procedure and should be the preferred treatment for ASA I-III patients. In critically ill patients, the intervention should be determined by a narrow interdisciplinary consent based on the patient's individual comorbidities.

Background: The treatment of acute cholecystitis has been controversially discussed in the literature as there are no high-evidence-level data yet for determining the optimal point in time for surgical intervention. So far, the laparoscopic removal of the gallbladder within 72 h has been the most preferred approach in acute cholecystitis. Methods: We conducted a systematic review by including randomized trials of early laparoscopic cholecystectomy for acute cholecystitis. Results: Based on a few prospective studies and two meta-analyses, there was consent to prefer an early laparoscopic cholecystectomy for patients suffering from acute calculous cholecystitis while the term ‘early' has not been consistently defined yet. So far, there is new level 1b evidence brought forth by the so-called ‘ACDC' study which has convincingly shown in a prospective randomized setting that immediate laparoscopic cholecystectomy - within a time frame of 24 h after hospital admission - is the smartest approach in ASA I-III patients suffering from acute calculous cholecystitis compared to a more conservative approach with a delayed laparoscopic cholecystectomy after an initial antibiotic treatment in terms of morbidity, length of hospital stay, and overall treatment costs. Concerning critically ill patients suffering from acute calculous or acalculous cholecystitis, there is no consensus in treatment due to missing data in the literature. Conclusion: Laparoscopic cholecystectomy for acute cholecystitis within 24 h after hospital admission is a safe procedure and should be the preferred treatment for ASA I-III patients. In critically ill patients, the intervention should be determined by a narrow interdisciplinary consent based on the patient's individual comorbidities.

AIM:The aim of this paper was to compare healthy subjects and patients after total mesorectal excision concerning anal resting/squeeze pressure and surface-electromyography of the sphincter.METHODS:Forty patients (9 female/31 male) after total mesorectal excision due to low or middle rectal cancer were compared to a sex-, age- and BMI-matched group of healthy volunteers by means of anorectal pull-through manometry using a microtip-transducer system and by means of endoanal surface electromyography using a bipolar plug electrode.RESULTS:Resting pressure (59.2 ± 3.1 mmHg vs. 68.3 ± 4.3 mmHg; P=0.056) and squeeze pressure (127.3 ± 3.2 mmHg vs. 128.9 ± 4.6 mmHg; P=0.78) were comparable between patients after total mesorectal excision and healthy volunteers whereas surface electromyography amplitude (9.5 ± 0.4 µV vs. 13.9 ± 0.6 µV; P=0.01) was significant lower in patients after total mesorectal excision compared to healthy subjects. Correlation between squeeze and resting pressure as well as between squeeze pressure and surface electromyography were weaker in patients after total mesorectal excision compared to healthy controls.CONCLUSION:Objective measurable sphincter pressure after total mesorectal excision seems to be comparable to that of healthy subjects whereas surface-electromyography is significant higher in healthy subjects.

Background. In patients who suffered trauma-induced injuries of the extremities, 1-4 % have additional vascular injuries requiring surgery and in multiple trauma patients these occur in approximately 10 %. Initially, the time factor and also including the possibility of potential vascular injuries during diagnostic considerations are important for the prognosis of combined traumatic and vascular injuries.Objective. The aim of the study was the analysis of accompanying vascular injuries after limb trauma.Material and methods. Between January 2002 and January 2014 a total of 45 patients with traumatic vascular injuries of the limbs were treated at the University Hospital of Saarland.Results. Of the patients 60 % (n = 27) presented with vascular injuries of the lower extremities and 38 % (n = 17) of the upper extremities. The popliteal artery was affected in 24 % (n = 11) of the cases. Almost all injuries were reconstructed by autologous vein interposition when complete reconstruction was not possible. Only 7 % (n = 3) of the cases needed interposition of alloplastic material. With conversion of the diagnostic algorithm to include the routine use of computed tomography (CT) angiography in 2008, the time from hospital admission to primary vascular surgical treatment could be significantly shortened.Conclusions. The prognosis of traumatic injuries to the extremities with additional vascular injuries is dependent on rapid and ad-equate diagnostics and treatment. An interdisciplinary management has been shown to be a favorable organizational model to minimize the extent of posttraumatic ischemia and optimize the outcome. Overall, a coordinated sequence of diagnostics and treatment of complex injuries to the extremities is beneficial for the patient, which is reflected in a lower rate of major amputations.

Although randomized studies investigated the benefit of extended lymphadenectomy (ELA) compared to standard lymphadenectomy (SLA) for periampullary adenocarcinoma, these analyses failed to show overall advantage for ELA due to high heterogeneity of lymphadenectomy protocols. Therefore, the present single-center trial was designed using a standardized protocol for SLA with en bloc technique.

Apart from stapling methods, single- or double-layer continuous hand sutures are established techniques for colonic anastomoses. It is unclear which hand suture technique has superior anastomotic safety. This randomized trial evaluated the incidence of postoperative complications depending on anastomosis technique.