Hintergrund: In dieser Übersicht wird zu Epidemiologie, Diagnostik und allgemeinen Prinzipien des chirurgischen Managements bei Patienten mit akutem Abdomen Stellung genommen. Definition und Epidemiologie: Häufigste Ursache des akuten Bauchschmerzes ist der unspezifische Bauchschmerz, dessen Prävalenz in der Literatur mit 24 – 44,3 %, bezogen auf das jeweilige Gesamtkrankengut, angegeben wird, gefolgt von der akuten Appendizitis (15,9 – 28,1 %), dem akuten Gallensteinleiden (2,9 – 9,7 %) sowie Darmverschluss und Divertikulitis bei älteren Patienten. Speziell bei Kindern macht die akute Appendizitis ca. ⅔ aller Operationsindikationen bei akutem Abdomen aus. Diagnostik: Vorrangig ist die klinische Untersuchung, die mit einer Sonografie zu verbinden ist. Aus Gründen der Strahlenbelastung des Patienten und der Kosten sollte die CT sorgfältig indiziert werden, der in dieser Arbeit vorgestellte Ablaufpfad beschränkt die CT auf weniger als die Hälfte der Patienten mit akutem Bauchschmerz. Die explorative Laparoskopie ist erst indiziert, wenn nach bildgebender Diagnostik die Ursache des akuten Bauchschmerzes weiterhin unklar ist. Bei der Indikation ist zu berücksichtigen, dass bei Verdacht auf nicht spezifischen Bauchschmerz eine abwartende Haltung (klinische Beobachtung des Patienten für 24 – 48 h) immer noch Standard ist. Management: Der Stellenwert des laparoskopischen Zugangs zum akuten Abdomen ist beim Ileus nicht unumstritten, obwohl speziell beim Bridenileus hervorragende Ergebnisse berichtet wurden. Bei Patienten auf der Intensivstation mit unklarem Abdomen, Verdacht auf Sepsis abdomineller Genese, bei Verdacht auf Cholezystitis, Mesenterialischämie oder bei refraktärer Laktatazidose (speziell nach herzchirurgischen Eingriffen) wird die Bedside-Laparoskopie angeraten. Generell ist eine frühzeitige Analgesie bei Patienten mit akutem Abdomen angezeigt, da verschiedene Studien zeigen konnten, dass sich damit der Patientenkomfort erhöht, ohne die Sicherheit der Diagnostik wesentlich zu beeinträchtigen. Doch ist die Beeinflussung der diagnostischen Genauigkeit von der Dosierung, der Art der Schmerzmittelapplikation und der Grundkrankheit abhängig, sodass eine frühe Analgesie angemessen gehandhabt werden soll. Dies zeigen Umfragen bei Pädiatern und Chirurgen, die belegen, dass nicht mehr als 50 % der Chirurgen und Pädiater das Konzept der Frühanalgesie auch tatsächlich in der Routine regelmäßig umsetzen. Aim: This review comments on epidemiology, diagnosis and general principles of surgical management in patients with acute abdomen. Definition and Epidemiology: The most common cause of acute abdominal pain is non-specific abdominal pain (24 – 44.3 % of the study populations), followed by acute appendicitis (15.9 – 28.1 %), acute biliary disease (2.9 – 9.7 %) and bowel obstruction or diverticulitits in elderly patients. Acute appendicitis represents the cause of surgical intervention in two-thirds of the children with acute abdomen. Diagnosis: A standardised physical examination combined with ultrasonography (US) represents the initial investigation in patients with acute abdominal pain. Due to the risk associated with radiation and due to the costs, a selective use of CT imaging is recommended. The work-flow given in this paper restricts the use of CT imaging to less than 50 % of patients with acute abdominal pain. Diagnostic laparoscopy should be considered in patients without a specific diagnosis after appropriate imaging and as an alternative to active clinical observation which is the current practice in patients with non-specific abdominal pain. Management: Acute small bowel obstruction has previously been considered as a relative contraindication for laparoscopic management, but it has been shown in the meantime that laparoscopic treatment is an elegant tool for the management of simple band small bowel obstruction. Bedside diagnostic laparoscopy is recommended in intensive care unit (ICU) patients with acute abdomen or sepsis of unknown origin, in suspicion of acute cholecystitis, diffuse gut hypoperfusion and mesenteric ischaemia or in refractory lactic acidosis, especially after cardiac surgery. Early administration of analgesia to patients with acute abdominal pain in the emergency department will reduce the patient’s discomfort without impairing clinically important diagnostic accuracy and is recommended on the basis of some prospective randomised trials. However, the impact on diagnostic accuracy depends on dosage, kind of application and cause of acute abdominal pain. A practice of judicious provision of analgesia therefore appears safe. There are significant differences between the knowledge of the current literature and the routine practice of providing analgesia as a survey has shown demonstrating that less than 50 % of paediatric emergency physicians and paediatric surgeons are usually willing to provide analgesia before definitive diagnosis.

This review presents the surgical indications, surgical procedures, and results in the treatment of asymptomatic and ruptured abdominal aortic aneurysms (AAA). An updated search of the literature on screening, diagnosis, treatment, and follow-up of AAA, based on the German clinical practice guideline published in 2018. Surgery is indicated in men with an asymptomatic AAA ≥ 5.5 cm and in women, ≥ 5.0 cm. The indication in men is based on four randomized trials, while in women the data are not conclusive. The majority of patients with AAA (around 80%) meanwhile receive endovascular treatment (endovascular aortic repair, EVAR). Open surgery (open aneurysm repair, OAR) is reserved for patients with longer life expectancy and lower morbidity. The pooled 30-day mortality is 1.16% (95% confidence interval [0.92; 1.39]) following EVAR, 3.27% [2.7; 3.83] after OAR. Women have higher operative/interventional mortality than men (odds ratio 1.67%). The mortality for ruptured AAA is extremely high: around 80% of women and 70% of men die after AAA rupture. Ruptured AAA should, if possible, be treated via the endovascular approach, ideally with the patient under local anesthesia. Treatment at specialized centers guarantees the required expertise and infrastructure. Long-term periodic monitoring by mean of imaging (duplex sonography, plus computed tomography if needed) is essential, particularly following EVAR, to detect and (if appropriate) treat endoleaks, to document stable diameter of the eliminated aneurysmal sac, and to determine whether reintervention is necessary (long-term reintervention rate circa 18%). Vascular surgery now offers a high degree of safety in the treatment of patients with asymptomatic AAA. Endovascular intervention is preferred.

Hepatic resection is the procedure of choice for curative treatment of colorectal liver metastases (CLM). Objectives of surgical strategy are low intraoperative blood loss, short liver ischemic times and minor postoperative morbidity and mortality. Blood loss is an independent predictor of mortality and compromises, in common with postoperative complications, long-term outcome after hepatectomy for CLM. The type of liver resection has no impact on the outcome of patients with CLM; wedge resections are not inferior to anatomical resections in terms of tumor clearance, pattern of recurrence or survival. Despite the lack of proof of survival benefit, routine lymphadenectomy has been advocated, allowing the detection of microscopic lymph node metastases and with prognostic value. In experienced hands, minimally invasive liver surgery is safe with acceptable morbidity and mortality and oncological results comparable to open hepatic surgery, but with reduced blood loss and earlier recovery. The European Colorectal Metastases Treatment Group recommended treating up front with chemotherapy for patients with both resectable and unresectable CLM. However, neoadjuvant chemotherapy can induce damage to the remnant liver, dependent on the number of chemotherapy cycles. Therefore, in our opinion, preoperative chemotherapy should be reserved for patients whose CLM are marginally resectable or unresectable. A meta analysis of randomized trials dealing with perioperative chemotherapy for the treatment of resectable CLM demonstrated a benefit of systemic chemotherapy but did not answer the question of whether a neoadjuvant or adjuvant approach should be preferred. Analysis of the literature demonstrates that the results of specialized centers cannot be attained in the reality of comprehensive patient care. Reasons behind the commonly poorer results seen in cancer networks as compared with literature-based data are, on the one hand, geographical disparities in access to specialized surgical and medical care. On the other hand, a selection bias in the reports of the literature may be assumed. Studies of surgical resection for CLM derive almost exclusively from case series generally drawn from large academic centers where patient selection or surgical expertise is superior to what is found in many communities. Therefore, we may conclude that the comprehensive propagation of the standards outlined in this paper constitutes a major task in the near future to reduce the variations in survival of patients with CLM.

Purpose: The influence of cancer development on long-term outcome after elective endovascular (EVAR) vs. open repair (OAR) of non-ruptured abdominal aortic aneurysms (AAA) was investigated. Methods: Patient survival and cancer incidence were recorded for 18,802 patients registered with the AOK health insurance company in Germany who underwent EVAR (n = 14,218) and OAR (n = 4584) in the years 2010 to 2016 (men n = 16,086, women n = 2716). All patients were preoperatively and in their history cancer-free. Results: 30.1% of EVAR and 27.6% of OAR patients (p ≤ .001) developed cancer after a follow-up period of up to 9 years (Kaplan–Meier estimated). Patients with cancer had a significantly less favorable outcome compared to patients with no cancer (HR 1.68; 95% CI 1.59–1.78, p < .001). After 9 years, the estimated survival of patients with and without cancer was 27.0% and 55.4%, respectively (p < .001). Survival of men and women did not differ significantly (HR 0.94; 95% CI 0.88–1.00, p = .061). In the Cox regression analysis (adjusted outcomes by operative approach, gender, age, and comorbidities), the postoperative cancer incidence was not significantly different between EVAR and OAR (HR 1.09; 95% CI 1.00–1.18, p = .051). However, EVAR showed an increased risk of postoperative development of abdominal cancer (HR 1.20; 95% CI 1.07–1.35, p = .002). 48.0% of all EVAR patients and 53.4% of all OAR patients survived in the follow-up period of up to 9 years. This difference was not significant (HR 0.96; 95% CI 0.91–1.02, p = .219). Conclusion: Cancer significantly worsened the long-term outcome after EVAR and OAR, without significant differences between the two repair methods in the overall cancer incidence. However, the higher abdominal cancer incidence with EVAR can affect quality of life including oncological therapy and therefore should be considered when determining the indication for surgery, and the patient should be informed about it.

On the basis of the CRITISCH registry outcomes in patients with critical limb ischemia (CLI) undergoing lower extremity bypass surgery were analyzed according to the site of distal anastomosis and type of bypass material.