Surgical management of chest injuries in patients with multiple and/or severe trauma- a systematic review and clinical practice guideline update.

PURPOSE: Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. RESULTS: One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care. CONCLUSION: As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma.

[Evaluation of the infrastructure for clinical surgical studies in Germany : A nationwide survey of the surgical study network CHIR-Net]. / Evaluation zur Infrastruktur für klinisch chirurgische Studien in Deutschland : Eine bundesweite Umfrage des chirurgischen Studiennetzwerks (CHIR-Net).

BACKGROUND: In order to improve the quality and quantity of clinical trials in Germany a surgical study network called CHIR-Net funded by the Federal Ministry of Education and Research (BMBF) was established. The focus was on building an infrastructure for the performance of surgical multicenter, randomized controlled clinical trials with the inclusion of university and non-university hospitals. The education of clinicians with an interest in clinical research and the transfer of research ideas (as investigator initiated trials, IIT) were clear goals for this grant. The aim of this article is to evaluate the incentive measures by comparison of clinics with and without participation in CHIR-Net structures. MATERIAL AND METHODS: A nationwide online survey included a total of 475 heads of surgical departments of whom 268 worked in hospitals with participation in CHIR-Net structures and 207 at hospitals without. They were asked to answer 20 questions in the following categories: education and activities in clinical trials, number of publications and participation in grant applications at the BMBF and/or German Research Foundation (DFG). The evaluation of the survey was performed according to a priori defined criteria. RESULTS: The response rate was 23.4% and 68 CHIR-Net hospitals and 43 non-CHIR-Net hospitals participated in the survey. The comparison of the results between the hospitals showed that the network significantly contributed to improvement of the study culture, especially in the areas of education in clinical research, infrastructure for clinical trials, study activity, grant applications and publication rates. CONCLUSION: The hospitals that participate in CHIR-Net structures were superior to hospitals that do not participate in CHIR-Net structures regarding study activity, infrastructure for clinical trials, study-specific education of clinicians, grant applications and publication rates. The goal of the grant was achieved and the funding led to manifold, long-term cooperation and a clear improvement of the study culture in surgery.

[Drainages in abdominal surgery: (in)dispensable?] / Drainagen in der Viszeralchirurgie: (un)verzichtbar?

BACKGROUND: Prophylactic placement of intraperitoneal drains in elective abdominal surgery is still subject to scrutiny. OBJECTIVE: Do currently available data enable the practice of routine placement of abdominal drainages to be abandoned? METHODS: The databases of MEDLINE, PubMed and the Cochrane Library were systematically searched for clinical trials concerning the practice of routine drainage placement in elective abdominal surgery. The available evidence was summarized for cholecystectomy, colorectal surgery, gastrectomy and pancreatic surgery, as well as for liver resection. A total of 6 Cochrane reviews including 65 randomized controlled trials (RCTs) and 9 retrospective analyses, as well as 1 more recent RCT and 3 retrospective analyses that were not included in a meta-analysis were reviewed. CONCLUSION: There is evidence that drains should not be routinely used in elective abdominal surgery, such as cholecystectomy, colorectal resection and gastrectomy. Even for some cases of pancreatic and liver resection, there is growing evidence that routine placement of drains is not mandatory. In conclusion, there is a need for more prospective randomized controlled trials.

Moxifloxacin is not anti-inflammatory in experimental pneumococcal pneumonia.

OBJECTIVES: Anti-inflammatory functions of antibiotics may counteract deleterious hyperinflammation in pneumonia. Moxifloxacin reportedly exhibits immunomodulatory properties, but experimental evidence in pneumonia is lacking. Therefore, we investigated moxifloxacin in comparison with ampicillin regarding pneumonia-associated pulmonary and systemic inflammation and lung injury. METHODS: Ex vivo infected human lung tissue and mice with pneumococcal pneumonia were examined regarding local inflammatory response and bacterial growth. In vivo, clinical course of the disease, leucocyte dynamics, pulmonary vascular permeability, lung pathology and systemic inflammation were investigated. In addition, transcellular electrical resistance of thrombin-stimulated endothelial cell monolayers was quantified. RESULTS: Moxifloxacin reduced cytokine production in TNF-α-stimulated, but not in pneumococci-infected, human lung tissue. In vivo, moxifloxacin treatment resulted in reduced bacterial load as compared with ampicillin, whereas inflammatory parameters and lung pathology were not different. Moxifloxacin-treated mice developed less pulmonary vascular permeability during pneumonia, but neither combination therapy with moxifloxacin and ampicillin in vivo nor examination of endothelial monolayer integrity in vitro supported direct barrier-stabilizing effects of moxifloxacin. CONCLUSIONS: The current experimental data do not support the hypothesis that moxifloxacin exhibits potent anti-inflammatory properties in pneumococcal pneumonia.

[Pneumothorax]. / Pneumothorax.

The presence of air between the visceral pleura and the parietal pleura with consecutive retraction of the lung from the chest wall is called pneumothorax. Regarding the genesis of the pneumothorax, a distinction is drawn between spontaneous and traumatic pneumothorax. The spontaneous pneumothorax is, depending on whether a congenital or an acquired pulmonary disease can be found, grouped into a primary spontaneous pneumothorax (PSP) without underlying lung disease and a secondary spontaneous pneumothorax (SSP) with the presence of a known lung disease. The traumatic pneumothorax is classified, depending on the cause, into penetrating and non-penetrating (blunt) traumatic events. A special form of the traumatic pneumothorax is the iatrogenic pneumothorax occurring as a result of diagnostic and/or therapeutic interventions. Clinically, a pneumothorax can range from an asymptomatic to an acute life-threatening situation. The required initial measures depend primarily on the patient's clinical condition. They vary from immediate insertion of a chest tube to wait and see with monitoring. The insertion of a chest tube is still the accepted therapeutic standard, but other procedures like aspiration of air through a needle or small catheter, particularly for small spontaneous pneumothoraces, represent alternative therapy options as well. The short-term goal is to treat possibly existing dyspnea and pain; in the long run a recurrence of the pneumothorax should be prevented. Until now, no uniform treatment algorithms or standardised therapy principles exist to achieve the therapeutic intentions of lung expansion and freedom from pain and late relapse.

[Current evidence for laparoscopic surgery of colonic cancer]. / Evidenzlage der laparoskopischen Chirurgie beim Kolonkarzinom.

BACKGROUND: The development of modern videoendoscopy enables surgeons to perform laparoscopic resection of colonic cancer. AIM: This manuscript evaluated the literature concerning clinically relevant differences in the short and long-term course after laparoscopic or conventional resection of colonic cancer. METHODS: An investigation of meta-analyses from randomized controlled clinical trials comparing laparoscopic and conventional surgery for colonic cancer was carried out. RESULTS: The incidence of intraoperative complications was higher during laparoscopic surgery, the duration of surgery was increased and blood loss was less when compared to open surgery. Overall morbidity and the incidence of surgical complications were decreased after laparoscopic surgery. General morbidity and mortality were not different after laparoscopic or open resection of colonic cancer. Duration of hospital stay was shorter but was also associated with the type of perioperative care (i.e. traditional or enhanced recovery). Following minimally invasive or conventional resection, the incidence of tumor recurrence (local and distant) and the duration of survival (overall and disease-free) showed no differences. Wound implantations were rare after both operative techniques but with a tendency to occur more often after laparoscopic than open resection. CONCLUSION: Laparoscopic resection of colonic cancer has clinically relevant short-term benefits for the patients and long-term results are not different from open colectomy. However, most of the patients included in randomized controlled trials underwent right or left colectomy and sigmoid or rectosigmoid resections. Data with a high level of evidence concerning carcinomas of the flexures or the transverse colon do not exist. Suitable patients with colonic cancer should undergo laparoscopic resection by experienced surgeons.

[Why nurses fly and surgeons rotate. The surgical study network CHIR-Net]. / Warum Schwestern fliegen und Ärzte rotieren. Das chirurgische Studiennetzwerk CHIR-Net.

BACKGROUND: The German National Surgical Trial Network (CHIR-Net) which has been funded since 2006 by the Federal Ministry of Education and Research (BMBF, funding code 01GH1001A-01GH1001F, 01GH0702) is made up of eight regional surgical centers. The aim of the CHIR-Net is the design, implementation and publication of prospective, randomized, multicenter trials to support evidence-based medicine in surgery. Two main pillars of the CHIR-Net are the surgeon on rotation program and the flying study nurse program. With these two programs the surgical hospitals are supported in their trial working by educating competent investigators and the infrastructural support of flexible and mobile study nurses. METHODS: The surgeon on rotation program and the concept of the flying study nurse are presented descriptively. Furthermore, this paper provides reports of experiences of a surgeon on rotation and a flying study nurse of the CHIR-Net. Additionally, the results of an on-line evaluation of the regional surgical hospitals (belonging to the regional surgical center of the universities Witten/Herdecke and Cologne) regarding the needs and requirements of the regional surgical hospitals are presented. RESULTS: The surgeon on rotation program of the CHIR-Net offers investigators the possibility to acquire the basics of designing, developing and implementation of high quality clinical trials. In addition, their own study projects could be intensively driven forward. The flying study nurse program enables in particular non-university surgical hospitals to be supported competitively in performing their own study projects and participating in muliticenter clinical trials. The success of these two programs has been confirmed by the conducted evaluations and the presented field reports. CONCLUSION: The CHIR-Net is able to develop a high quality study culture in Germany with its surgeon on rotation and flying study nurse program. In addition to the funding period by the BMBF, the continuance of the CHIR-Net should be a primary aim of further measures.

Bilateral pneumothorax following a blunt trachea trauma.

A-13 year old boy had an accident with his bike with a blunt thorax trauma and presented shortly after with facial swelling. Due to respiratory insufficiency, intubation was done during the transport to the clinic. First, a chest radiograph was performed, which showed a unilateral pneumothorax. Later a CT scan revealed bilateral pneumothorax and pneumomediastinum. Bilateral chest tube insertions improved the respiratory situation. Bronchoscopy showed a tracheal lesion two cm posterior to the main carina. After good wound healing, the patient was dismissed after 21 days in good health. Conservative treatment can be recommended in selected patients with a tracheal lesion when having a stable respiratory situation. If the patient does not improve after 48 h or if the clinical condition worsens, surgical management should be considered.

[Clinical studies outside university clinics : What are the problems to implement this?]. / Klinische Studien ausserhalb von Universitätskliniken : Wo liegen Probleme bei der Durchführung?

The demand for high quality evidence-based surgical treatment in Germany and awareness of the poor quality of surgical trials highlight the basic necessity of randomized controlled trials. In six surgical trial centers a professional infrastructure for surgical trials is in the process of being established since 2006.The aim is the initiation of surgical multicenter trials which can be effectively conducted by local networking. To accomplish a timely recruitment of patients it is necessary to integrate surgical departments outside university hospitals into multicenter trials. With a questionnaire survey of non-university surgical departments in the federal states of Berlin and Brandenburg, interest, experience in clinical trials and structural conditions in these departments were evaluated. Based on the results of this survey the possibilities to integrate non-university surgical departments into multicenter trials and how a high recruitment of patients can be motivated will be discussed in this article.

Short-term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer.

BACKGROUND: Randomized trials in low-risk populations have failed to show any benefit for laparoscopic compared with open colorectal resection in terms of morbidity. Furthermore, it is not known whether laparoscopic colorectal resection would yield advantages if randomization were revealed during surgery after a diagnostic laparoscopy. METHODS: Patients with cancer of the colon or upper rectum were randomly assigned to laparoscopic or open resection. All patients underwent diagnostic laparoscopy to assess whether laparoscopic resection was feasible and the result of randomization was then revealed to the surgeon. Main endpoints were overall, general and surgical morbidity, and mortality. RESULTS: Some 679 patients underwent diagnostic laparoscopy which led to the exclusion of 207; 250 patients were allocated to laparoscopic and 222 to open resection. Conversion to laparotomy occurred in 28 patients (11.2 per cent). There were no differences in morbidity (overall 25.2 versus 23.9 per cent) or mortality (1.2 versus 0.9 per cent) between laparoscopic and open groups. Postoperative hospital stay was shorter after laparoscopic resection (median (range) 10 (1-123) versus 12 (4-109) days; P = 0.032). CONCLUSION: Laparoscopic resection of colorectal cancer is associated with increased operating time but does not decrease morbidity even in a moderate-risk population.

Hyaluronan levels during laparoscopic versus open colonic resections.

BACKGROUND: Plasma hyaluronan binds to fibrinogen, affecting intravascular fibrin polymerization and fibrin clot formation. It has been hypothesized that alterations in fibrin clot formation influence the risk of thromboembolism in those undergoing surgery. The aim of this study is to quantify the intravascular components, especially plasma hyaluronan levels, in laparoscopic and conventional colorectal resections that contribute to thromboembolism formation. METHODS: Prospective cohort analysis of consecutive patients which were participating in the prospective randomized multi-center trial Lapkon II comparing the long-term effects of laparoscopic and conventional resection for colon cancer. Plasma samples were obtained from 15 patients at the beginning and the end of laparoscopic or conventional colorectal resections. Concentrations and activities of tissue plasminogen activator(t-PA), plasminogen activator inhibitor type 1(PAI-1), t-PA/PAI complex, fibrinogen, d-dimers and hyaluronan were determined by using commercial enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: No differences in age, sex and type of resection between the laparoscopic and conventional-surgery groups were observed. Laparoscopic procedures lasted longer (p < 0.05). Concentration and activities of t-PA, PAI-1, t-PA/PAI complex, fibrinogen and d-dimers did not vary between the two groups. Plasma hyaluronan decreased from 28.6 to 17.9 IU/ml (p < 0.05) during laparoscopic compared to conventional procedures. Plasma hyaluronan levels were significantly different at the end of operation between the two groups (p < 0.05) . CONCLUSIONS: Plasma hyaluronan levels were decreased in patients undergoing laparoscopic colorectal resections, compared to those undergoing conventional procedures. Therefore, interactions between plasma hyaluronan and fibrinogen may be lower, with a sequential decrease in fibrin polymerization, and a possibly reduced risk of deep venous thrombosis.

[Value of laparoscopic surgery in elective colorectal surgery with "fast-track"-rehabilitation]. / Stellenwert der laparoskopischen Chirurgie im Rahmen der "Fast-track"-Rehabilitation nach elektiven kolorektalen Resektionen.

INTRODUCTION: Laparoscopic (LAP) versus open (CON) colonic resection with traditional perioperative care has some short term benefits postoperatively regarding functional recovery. Whether these benefits may also occur when all patients are treated with multimodal "fast-track"-rehabilitation programs is questionable. METHODS: Patients undergoing elective left sided colonic surgery were prospectively non randomised observed. The "fast-track" program included patient information, thoracic peridural analgesia, forced mobilisation and oral intake, and stress reduction. Endpoints were duration of postoperative ileus and hospital stay, general- and local complication, and pulmonary function. RESULTS: 147 consecutive patients were operated on, 47 open and 100 laparoscopically. The time until oral intake was completed seemed to be shorter in the LAP-group (p=0.07) followed by a shorter hospital stay (p<0.01). The pulmonary function was postoperatively improved in the LAP-group compared to the CON-group (p<0,01). General complications (LAP 9% vs. CON 17%) were non significantly increased in the CON-group. Local complications increased in the CON-group (LAP 13% vs. CON 28%, p<0,05). CONCLUSION: Even with perioperative "fast-track"-rehabilitation programs short term advantages were found in laparoscopic compared with open colonic surgery in a non randomised population. The clinical relevance should be examined in controlled randomised trials.

Systematic evaluation of different approaches for minimizing hemodynamic changes during pneumoperitoneum.

BACKGROUND: Capnoperitoneum (CP) compromises hemodynamic function during laparoscopy. Three therapeutic concepts were evaluated with an aim to minimize the hemodynamic reaction to CP: First, a controlled increase of intrathoracic blood volume (ITBV) by intravenous fluids; second, partially reduced sympathetic activity by the beta1-blocker esmolol; and third, a decrease in mean arterial pressure (MAP) by the vasodilator sodium nitroprusside. METHODS: For this study, 43 pigs were assigned to treatment with fluid and sodium nitroprusside (group A) or with esmolol (group B). In both groups, the pigs were assigned to head-up, head-down, or supine position, resulting in three different subgroups. Invasive hemodynamic monitoring was established including left heart catheter and cardiac oxygen lung water determination (COLD) measurements. Measurements were documented before CP with the animals in supine position, after induction of a 14-mmHg CP with the animals in each body position, after a 10% reduction in MAP by vasodilation, and after an increase in ITBV of about 30% by infusion of 6% hydroxyethylstarch solution. RESULTS: Increasing ITBV improved hemodynamic function in all body positions during CP. Esmolol reduced cardiac output and myocardial contractility. Sodium nitroprusside did not improve hemodynamic function in any body position. CONCLUSIONS: Optimizing volume load is effective for minimizing hemodynamic changes during CP in the head-up and in head-down positions. In general, beta(1)-blockers cannot be recommended because they might additionally compromise myocardial contractility and suppress compensatory reaction of the sympathetic nerve system. Vasodilation has not improved hemodynamic parameters during CP.

"Fast-track" rehabilitation after rectal cancer resection.

BACKGROUND AND AIMS: After rectal cancer surgery, postoperative general complications occur in 25-35% of all patients and postoperative hospital stay is 14-21 days. "Fast-track" rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Because the feasibility of "fast-track" rehabilitation in patients undergoing rectal cancer surgery has not been demonstrated yet, we demonstrate our initial results of "fast-track" rectal cancer surgery. PATIENTS AND METHODS: Seventy consecutive unselected patients undergoing rectal cancer resection by one surgeon underwent a perioperative "fast-track" rehabilitation. Demographic and operative data, pulmonary function, pain and fatigue, local and general complications and mortality were assessed prospectively. RESULTS AND FINDINGS: Thirty-six female and 34 male patients aged 65 (34-77) years underwent open (n=31) or laparoscopic (n=39) anterior resection with partial mesorectal excision (PME 27), anterior resection with total mesorectal excision and protective loop ileostomy (TME 29) or abdominoperineal excision with colostomy (APR 14). Overall, pulmonary function returned to >80% of preoperative value on day 2 (1-4) and the first bowel movement occurred on day 1 (0-3) after surgery. The incidence of local and general complications was 27 and 18%, respectively. Postoperative hospital stay was 8 (3-50) days overall, but shorter after PME [5 (3-47)] than TME [10 (5-42)] or APR [9 (5-50)] (p<0.01). INTERPRETATION AND CONCLUSION: "Fast-track" rehabilitation was feasible in patients undergoing rectal cancer resection. Local morbidity was not increased, while general morbidity and postoperative hospital stay compared favourably to other series with "traditional" perioperative care.

Fibrinolytic capacity in peritoneal fluid after laparoscopic and conventional colorectal resection: data from a randomized controlled trial.

BACKGROUND: A reduced peritoneal fibrinolytic capacity after surgery is currently accepted to be the main cause for postoperative adhesions. The aim of this prospective randomized trial was to determine the fibrinolytic activity in peritoneal fluid after laparoscopic as compared to conventional colorectal resection. METHODS: A randomized controlled trial in parallel with the multicenter trial Lapkon II was conducted. Peritoneal fluid was sampled via drain at 2, 8, and 24 h after elective laparoscopic (n=14; LAP) and conventional (n=16; CON) colorectal resections. Activities and concentrations of tissue plasminogen activator (t-PA), plasminogen activator inhibitor type-1 (PAI-1) and t-PA/PAI complex were determined in all specimen by ELISA kits. RESULTS: There was no difference in age, sex or body mass index between both groups. Postoperatively, t-PA activity decreased in both groups and was lower 2 h after closing the abdomen in the laparoscopic group (p<0.05). PAI-1 activity and concentration increased in both groups. Difference between the groups was measured for PAI-1 concentration after 24 h (p<0.05). There were no differences between the groups regarding t-PA concentrations, PAI-1 activity and t-PA/PAI complex. CONCLUSIONS: After closing the abdominal cavity, postoperative changes in fibrinolytic capacity of peritoneal fluid can be determined in samples collected by a drain. However, there were no major differences in the postoperative course of fibrinolytic capacity in peritoneal fluid after laparoscopic and conventional colorectal resections.

Short term benefits for laparoscopic colorectal resection.

BACKGROUND: Colorectal resections are common surgical procedures all over the world. Laparoscopic colorectal surgery is technically feasible in a considerable amount of patients under elective conditions. Several short-term benefits of the laparoscopic approach to colorectal resection (less pain, less morbidity, improved reconvalescence and better quality of life) have been proposed. OBJECTIVES: This review compares laparoscopic and conventional colorectal resection with regards to possible benefits of the laparoscopic method in the short-term postoperative period (up to 3 months post surgery). SEARCH STRATEGY: We searched MEDLINE, EMBASE, CancerLit, and the Cochrane Central Register of Controlled Trials for the years 1991 to 2004. We also handsearched the following journals from 1991 to 2004: British Journal of Surgery, Archives of Surgery, Annals of Surgery, Surgery, World Journal of Surgery, Disease of Colon and Rectum, Surgical Endoscopy, International Journal of Colorectal Disease, Langenbeck's Archives of Surgery, Der Chirurg, Zentralblatt für Chirurgie, Aktuelle Chirurgie/Viszeralchirurgie. Handsearch of abstracts from the following society meetings from 1991 to 2004: American College of Surgeons, American Society of Colorectal Surgeons, Royal Society of Surgeons, British Assocation of Coloproctology, Surgical Association of Endoscopic Surgeons, European Association of Endoscopic Surgeons, Asian Society of Endoscopic Surgeons. SELECTION CRITERIA: All randomised-controlled trial were included regardless of the language of publication. No- or pseudorandomised trials as well as studies that followed patient's preferences towards one of the two interventions were excluded, but listed separately. RCT presented as only an abstract were excluded. DATA COLLECTION AND ANALYSIS: Results were extracted from papers by three observers independently on a predefined data sheet. Disagreements were solved by discussion. 'REVMAN 4.2' was used for statistical analysis. Mean differences (95% confidence intervals) were used for analysing continuous variables. If studies reported medians and ranges instead of means and standard deviations, we assumed the difference of medians to be equal to the difference of means. If no measure of dispersion was given, we tried to obtain these data from the authors or estimated SD as the mean or median. Data were pooled and rate differences as well as weighted mean differences with their 95% confidence intervals were calculated using random effects models. MAIN RESULTS: 25 RCT were included and analysed. Methodological quality of most of these trials was only moderate and perioperative treatment was very traditional in most studies. Operative time was longer in laparoscopic surgery, but intraoperative blood was less than in conventional surgery. Intensity of postoperative pain and duration of postoperative ileus was shorter after laparoscopic colorectal resection and pulmonary function was improved after a laparoscopic approach. Total morbidity and local (surgical) morbidity was decreased in the laparoscopic groups. General morbidity and mortality was not different between both groups. Until the 30th postoperative day, quality of life was better in laparoscopic patients. Postoperative hospital stay was less in laparoscopic patients. AUTHORS' CONCLUSIONS: Under traditional perioperative treatment, laparoscopic colonic resections show clinically relevant advantages in selected patients. If the long-term oncological results of laparoscopic and conventional resection of colonic carcinoma show equivalent results, the laparoscopic approach should be preferred in patients suitable for this approach to colectomy.

[Fast track rehabilitation in colonic surgery: results of a prospective trial]. / Réhabilitation rapide en chirurgie colique: résultats d'une étude prospective.

OBJECTIVE: In elective large bowel surgery the incidence of general complications with standard perioperative care is up to 27%. Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection. The aim of a fast track management is to reduce the number of general complications and the length of hospital stay. MATERIAL AND METHODS: We prospectively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia, an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery. RESULTS: One hundred thirty-two consecutive patients aged an average of 66 years (range 22-88) were operated by laparotomy (n =71) or laparoscopy (n =61) and treated with the fast track rehabilitation protocol. Surgical complications occurred in 15 patients (11 %), four of these had an anastomotique leakage (3%). General complications occurred in 11 patients (8 %), the mortality was 1 %. The median length of hospital stay was four days (range 3-77) and 14 patients (11%) had to be readmitted. CONCLUSION: Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study.

[Establishing "fast-track"-colonic surgery in the clinical routine]. / Einführung der "Fast-track-Kolonchirurgie in den klinischen Alltag.

OBJECTIVE: A multimodal perioperative concept ("fast-track"-surgery) may decrease the incidence of general complications following elective colonic resections, accelerate rehabilitation and shorten postoperative hospital stay. During the introduction of this new "clinical pathway" several obstacles have to be overcome. This manuscript describes a practical way to establish "fast-track"-colonic surgery in the clinical routine. MATERIAL AND METHODS: After discussion of the many aspects of perioperative pathophysiology following abdominal surgery a "fast-track"-concept for colonic surgery was defined. Since 11.10.2001 the "fast-track" concept was applied to all patients treated by one attending surgeon. Experience with establishing this concept in the clinical routine was analysed. RESULTS: "Fast-track"-colonic surgery was established in close cooperation between surgeons, anesthesiologists and nurses. A written-down concept, the use of checklists and letters of information for patients, their relatives and general practicioners will simplify the introduction of the new perioperative treatment. Traditional practice (i. e. types of incisions, use of drainage, postoperative oral feeding) have to be modified. In 74 "fast-track"-colonic resections postoperative hospital stay was reduced to a median of 4 days, regardless of the way of access to the abominal cavity (laparoscopic or conventional). Postoperative morbidity was acceptable (local complications: 7 %; general complications: 7 %, but only 1 % without local complication). CONCLUSION: Establishing "fast-track"-colonic surgery requires close cooperation between surgery, anestehsiology and nursing personal. Most important is a surgeon prepared to overcome traditional concepts of perioperative care.