key: cord-0006793-jqtlwlhm
authors: Gmeiner, M.; Pfeifer, J.
title: Management of complications in surgery of the colon
date: 2007
journal: Eur Surg
DOI: 10.1007/s10353-007-0311-y
sha: 2c4f7ab83c2f6bcc8fbfaeb8bc5b9f511bc5f763
doc_id: 6793
cord_uid: jqtlwlhm

BACKGROUND: General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly. METHODS: We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads). RESULTS: Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision(®), Ligasure(®)) as well as a well coordinated team help to reduce complications and duration of surgery. CONCLUSIONS: To avoid is better than to repair. If complications do occur, appropriate surgical and intensive – care measures should be taken immediately.

Operationsteam Komplikationen reduzieren und die Operation beschleunigen.

Schlussfolgerungen: Vermeiden ist besser als Reparieren. Bei eingetretener Komplikation ist es aber wichtig, sofort die nö tigen chirurgischen und intensiv-therapeutischen Maßnahmen zu setzen.

Schlü sselwö rter: Komplikation, Kolonchirurgie, Stent, Fast Track.

Summary. Background: General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly.

Methods: We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads).

Results: Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative ''fast track nutrition'' should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision + , Ligasure + ) as well as a well coordinated team help to reduce complications and duration of surgery.

Conclusions: To avoid is better than to repair. If complications do occur, appropriate surgical and intensive -care measures should be taken immediately.

General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria [1] . As far as management of complications of colon surgery is concerned, the primary consideration should be their avoidance. This chapter therefore highlights possibilities for preventing complications and, if they occur, offers suggestions for their management.

A. General complications

As pulmonary complications such as pneumonia, pulmonary effusions or ARDS are among the most common causes of morbidity and mortality after abdominal surgery [2] , particular emphasis should be placed on identification of risk factors and preventive measures. If there is no history of pulmonary disease, no abnormal breath sounds on auscultation of the lungs and the patient has no problems in climbing at least two flights of stairs, it is likely that the patient has normal pulmonary function. Chronic cough, sputum production, dyspnoea on exertion, wheezing, haemoptysis, or a history of cigarette smoking are indications that the preoperative evaluation should be expanded to include pulmonary function tests, chest radiography, and perhaps determination of arterial gas levels to evaluate the individual risk level. However, it should be pointed out that anorectal surgery alone does not have the same pulmonary risks as abdominal colorectal surgery [3, 4] . From the surgical point of view, pulmonary complications are less likely to occur with incisions made as low in the abdominal wall as possible [5] .

Clinical history and physical examination should focus on careful assessment of any recent history of myocardial infarction or the presence of congestive heart failure (CHF). These are the two most important factors that place patients at risk for perioperative cardiac complications and death [6] . Myocardial infarction occurs in 0.13% of patients undergoing surgery without prior infarction, in 27-38% of patients undergoing surgery within 3 months after infarction, and in 11-16% of patients 3-6 months after infarction [6, 7] . Six months after infarction, the risk for repeat infarction stabilizes at about 5% [7] . Without a prior clinical history of heart disease, men are considered to be at risk from age 35 onward and women from age 40 and many preoperative anaesthesia protocols require an ECG for patients 40 years of age and older [6, 8] .

A careful history should also detect any symptoms of a transient ischemic attack (TIA). The carotid bifurcations should be evaluated for the presence of bruits. The presence of either TIA or bruit should prompt further evaluation, because 30-40% of patients with a history of TIA [9] will develop a serious stroke within 3-5 years of initial symptoms. The majority occur in the first year [6, [10] [11] [12] .

Hypercoagulability is defined as excessive activity of one or more procoagulant substances or a decrease in anticoagulant factors. Occult or known malignancy, obesity, age, infirmity, immobility, pregnancy, hypercoagulative disorders (including inflammatory bowel disease) [13] , deficiencies in protein C, protein S and antithrombin III, may all result in hypercoagulability and so predispose to thromboembolic events in patients undergoing major colorectal surgical procedures [14] .

A multicenter trial of 2070 patients who underwent elective abdominal surgery found that cancer alone was the strongest single risk factor for major postoperative venous thromboembolic events [15] . Other risk factors in this study included surgical procedures lasting over two hours, a previous history of major orthopaedic surgery, preoperative blood transfusions, and preoperative hospitalization of 6 days or more [16] .

Prophylaxis of deep venous thrombosis (DVT) is now an accepted standard for major abdominal surgery. Basically there are 2 options: low molecular weight heparin (LMWH) or unfractionated heparin (UFH). LMWH is preferred to UFH as it has a longer half life, can thus be administered just once per day and is less expensive. However, the combination of compression stockings and LMWH was better than low dose heparin alone in preventing DVT [13] .

Preexisting renal disease presents a special challenge to the surgeon. Foremost is the prevention of additional injury to the patient. Adequate hydration and monitoring of urine output (0.5-1.0 ml=kg=hr) as an indication of adequate perfusion are critical. Low-dose dopamin therapy (1-2 mg=kg=min) may be beneficial [17] .

Patients with uraemia who are receiving dialysis add further challenge and unique risks for complications. Of particular interest to the colorectal surgeon are gastrointestinal manifestations of uraemia: ammonia released by bacterial action on urea in the gut lumen may lead to oedema, ulceration, and haemorrhage [18] , postoperative ileus may be prolonged and patients with diverticulosis are at increased risk for acute infection and perforation [19] .

Other surgical considerations include anaemia, increased risk for bleeding due to use of heparin during dialysis, platelet dysfunction [20, 21] , secondary hyperparathyroidism, and bone demineralization. Compromised leukocyte and immunologic function increases risk for infection and impaired cellular immunity [22] ; antibiotic prophylaxis may be beneficial here.

The liver is the body's physiologic processing centre and performs many functions that have important implica-tions for the surgical patient. Dysfunction can lead to nutritional wasting, accumulation of toxic waste products, immunocompromise, and bleeding diatheses.

The capacity of hepatic reserve and regeneration is legendary. As a result, the early stages of liver disease may produce only subtle evidence of dysfunction, but a dysfunction that can easily be transformed into fulminating failure by seemingly minor events including the stress of anaesthesia and surgery. Concomitant histories of alcohol abuse, viral hepatitis (especially hepatitis B) as well as metastasis of colorectal cancer are in practice the most common situations, which the surgeon should approach with respect [23] .

Disturbance of fluid and electrolyte balance is common in liver disease, including sodium retention, potassium loss, and the development of ascites and oedema. In a patient with marginal hepatic reserve, ascites may become a problem after surgery even if not presented before. Careful attention to exact closure of the abdominal wound may prevent leakage of ascites in the postoperative period. Drains should be omitted [24, 25] .

Although malnutrition is a frequent pre-existing condition in hospitalized surgical patients, the effect on complications is unclear. Controversy persists as to whether such patients should receive preoperative nutritional supplementation, and whether it is possible to identify those patients who might benefit from both a physiologic and economic point of view [26] . It is estimated that 30-50% of hospitalized patients have a body mass index (BMI) of less than 18.5 and thus can be considered to be malnourished [27] . Clinically, cachexia can be a major problem, leading to a higher infection rate and prolonged recovery after emergency surgery [28, 29] .

The Canadian Clinical Practice Guidelines change the paradigm as far as nutritional support strategies for critically ill patients are concerned [3, 4] . The recommendation rather to apply enteral and not parenteral nutrition in patients with a functional gastrointestinal tract has to be considered a key issue of these guidelines. The role of parenteral feeding steps down from a standard to a supplementary procedure for cases of insufficient enteral intake. The early placement of a nasojejunal tube (i.e. within 24-48 h after admission) should become a routine procedure in ICUs of tertiary centres. Low volume jejunal feeding (starting with 10-20 ml=h) should be initiated immediately after admission, provided that there are no contraindications. By ''feeding the gut'' via the enteral route, the feeding strategy aims at maintaining intestinal barrier integrity. The enteral infusion rate should then be raised gradually, but should not provide more than 20-25 kcal per kg of body weight (''feed the patient''). The question when to start supplementary parenteral nutrition remains a matter of debate. The decision whether or not combined enteral and parenteral nutrition strategies will be commenced depends on the degree of gastrointestinal intolerance to enteral feeds, the severity of preexisting malnutrition, and the level of hypermetabolism [29] .

Kehlet and Wilmore have recently attempted to employ a multimodal rehabilitation program aimed at re-ducing both physiologic and iatrogenic factors delaying postoperative recovery after colon resection procedures [30, 31] . The key components of this ''fast track program'' are that the initial meal offered is full liquids followed by advancement to a GI diet as soon as tolerated. Furthermore, routine use of thoracic epidural anaesthesia and analgesia with local anaesthetics and adherence as far as possible to physiological principles (avoidance of long fasts before and after surgery, as well as drains, tubes, and catheters) are the main issues. With this approach, a hospital stay of two days after elective sigmoid colectomy is possible [32-34], but it has been associated with relatively high early readmission rates of 9-11% [35]. In addition, many of the protocols have altered discharge criteria from typically accepted thresholds by allowing discharge on clear liquids without any evidence of return of bowel function [36] . Finally, these pathways are generally reserved for patients undergoing relatively straightforward, uncomplicated colonic resections.

A similar conceptual approach to ''fast-track'' recovery after colectomy for both laparascopic resections and complex re-operative bowel resection and pelvic surgery is described by Zutshi et al. [37] . The key component of success in their experience has been to carefully explain the principles of the ''fast-track'' care to each patient prior to surgery. Furthermore it is important to describe to the patient the daily benchmarks to be expected (including discharge criteria), and to reinforce the same message daily.

The ''fast-track'' approach is applicable to the large majority of cases undergoing colorectal surgery. However, in contrast to the findings of Basse et al. [35, 36, 38] , who found that patients do equally well, whatever their status of co-morbidity, Senagore has determined that patients without co-morbidity do even better than those with co-morbidity and achieve hospital stays averaging only 3.5 AE 0.8 days [37, 39] . This is not affected by prior abdominal surgery and confirms that these clinical pathways should be available to all colectomy and pelvic surgery patients.

A balanced immune system is preferable but not standard. The numerous sources of immunocompromise in potential surgical patients may be primary or acquired. The defects in immunity may be primarily local, as in burns and wounds or loss of mucosal integrity, or systemic. Systemic immunocompromise may include one or any combination of cell mediated (T cell function), humoral (B cell function), phagocytosis (neutophils), or complement defects. Primary immunodeficiencies are relatively rare (1=10,000) and will not be encountered in most surgical practices [40] . Acquired immunodeficiences are common and range from mild defects to complete loss of immune function [41] . Age, malnutrition, obesity, malignancy, burns, sepsis, trauma, surgery, anaesthesia, blood transfusion, diabetes, renal failure, liver disease, splenectomy, radiation, and foreign bodies all modify the body's response to invasion [42] [43] [44] . Drugs including chemotherapeutic agents are probably the most frequently encoun-tered cause of severe immunocompromise manifested by profound neutropenia [45] .

The development of disease requiring surgical treatment in an immunocompromised patient presents a unique challenge. For the colorectal surgeon, this may be a perianal inflammation or an intraabdominal catastrophe. Some conditions, such as neutropenic enterocolitis [46] , are unique to the compromised state; others may simply be severe manifestations of common disease process. For example, neutropenia has been associated with increasing severity of complications in diverticular disease of the colon [47] .

The obvious risks to immunocompromised patients are postoperative sepsis and poor wound healing. In the case of anorectal pain and inflammation, local care and antibiotic therapy should prevail, with open drainage reserved for treatment of a fluctuant mass. If bowel resection becomes necessary, diversion of the faecal stream will most frequently provide the best management, depending on the degree of contamination, preparation of the bowel, presence of peritonitis, and projected duration of the neutropenia [48] . In general, the white blood cell count bottoms out 10-20 days after initiation of chemotherapy [49] .

Administration of broad-spectrum antibiotics, use of prophylactic antifungal therapies such as oral nystatin, and careful respiratory and haemodynamic monitoring are critical [50] .

Filgrastim, a granocyte colony-stimulating factor, decreases the duration of neuropenia and the prevalence of infection (compared with that in control groups in patients undergoing chemotherapy for small cell carcinoma of the lung and other nonmyeloid malignancies) [51] .

In an HIV positive or AIDS patient, an absolute CD4 count < 200 or a decreasing ratio of CD4 to CD8 (normal 1.8:2.2) is associated with a severe immunocompromise and subsequent risk for viral, fungal, protozoal and bacterial infections and prolonged wound healing.

In immunosuppressed lymphoma or organ-transplant patients, performing an anastomosis after a colectomy should not be forced [50] .

Mechanical bowel preparation has been standard for patients undergoing colon or rectal surgery for the last 40-50 years. The idea was to prevent postoperative septic complications, thereby decreasing morbidity and mortality [52] . This habit is supported by a survey of the American Society of Colon and Rectal Surgeons, which showed that 99% of the colorectal surgeons routinely employ mechanical bowel preparation [52] . One-third of the surgeons prefer a PEG solution.

Few studies have examined the differences in types of bowel preparation performed prior to elective colorectal surgery. In a prospective randomized study, Oliveira et al. compared oral sodium phosphate to polythylene glycol lavage solutions [53] . The sodium phosphate solution was better tolerated and provided better bowel quality. Otherwise, there was no difference in the septic complication rates between the two groups. Valverde et al. randomized 262 patients to receive either senna or PEG solutions [54] . All patients received perioperative antibio-tic prophylaxis. The authors found colonic cleanliness to be better in the senna group and found no difference in clinical tolerance. There was also no difference in anastomotic leak rate or postoperative infections [54] .

A Cochrane review examined all studies that randomized elective patients undergoing a colon or rectal resection either to bowel preparation or none [55] . The primary outcome used for the review was the rate of anastomotic leakage. This was defined as ''a discharge of faeces from the anastomosis site and the presence of peritonitis or pelvic sepsis confirmed by clinical or radiological investigation.'' Two surgical procedures were considered: low anterior resection (extra-peritoneal anastomosis) and colonic anastomosis (intra-peritoneal anastomosis). Secondary endpoints examined were mortality (within 30 days of surgery), peritonitis, re-operation, wound infection, infectious extra-abdominal complications, non-infectious extra-abdominal complications, overall infections in surgical sites.

Nine randomized controlled studies (out of eleven) with a total of 1592 patients were included in the review. There was a significantly lower anastomotic leak rate in the absence of bowel preparation (Table 1) .

Furthermore, there were no other significant differences between the two groups in any of the categories examined, including mortality rates and wound infections. When broken down into colonic anastomosis vs. low anterior resections, a significant difference with respect to anastomotic leak rate (low anterior resection: 9.8 vs. 7.5% (NS); colonic [56] reported on seven out of eleven trials with 1454 patients (Table 2) . Patients who underwent bowel preparation had a significantly higher anastomotic leak rate (5.6 vs. 3.2%; P ¼ 0.032). Other endpoints examined in the study included wound infection and other septic and nonseptic complications, all of them showed no significant difference between the groups. The authors also performed a subgroup analysis comparing patients who underwent bowel preparation with PEG solution with those who had no prep at all. Their conclusions were that mechanical preparation with PEG solution should be omitted before elective colorectal surgery.

There seems to be no benefit from mechanical bowel cleansing for elective colorectal surgery. Indeed there may be clear-cut disadvantages, with higher anastomotic leak rates in patients undergoing mechanical preparation. Though there does not appear to be a difference in septic complications depending on the type bowel preparation, sodium phosphate does appear to be better tolerated by the patient and to provide better subjective cleaning of the colon [53] . The presence of solid stool in the rectum will make it technically difficult to use an EEA stapler passed through the anus. At present, the literature data do not support the use of mechanical bowel preparation for elective colorectal surgery, thereby obviating the question of which mechanical agent is best for elective surgery [56] .

Septic complications are an ever-present danger for patients undergoing elective surgery for diseases of the large bowel. Frequently these infections are limited to the surgical wound, but other potential sites include the abdominal cavity, pelvis and bloodstream. Postoperative wound infections produce serious morbidity and mortality and drive up the cost of health care [57] . Many factors contribute to septic complications and not all of them are controllable. Currently, the use of antibiotics in addition to mechanical cleansing is the North American standard of care before colon surgery.

The antibiotics chosen should be active against both the aerobic and anaerobic colonic bacteria. The question whether an antibiotic agent should be administered intravenously or orally or both has been and is still the topic of some debate. The importance of reducing the number of microorganisms in the colonic lumen before opening the colon is typically emphasized by the advocates of oral administration [58] . In contrast, advocates of parenteral administration emphasize the importance of adequate tissue levels of the antibiotics [59] .

Oral non-resorbable antibiotics serve to reduce the concentration of colonic bacteria and have few, if any, systemic effects [60] . Systemic agents protect against the almost inevitable intraperitoneal bacterial contamination that occurs during colon surgery [59] . Improvement in bacteriologic culture techniques and the knowledge of the importance of the anaerobes in the development of postoperative sepsis have guided the evaluation of different prophylactic agents. Older publications have shown that an antibiotic, to be effective, must be present in the tissues in sufficiently high concentrations at the time of contamination. This idea concurs with the now accepted use of parenteral antibiotics for prophylaxis of surgical infections [58, 61] . While there is almost universal agreement that some type of antibiotic should be used, this route of administration has remained a topic for some debate.

The classic randomized, prospective study by Clarke et al. showed the effectiveness of oral nonresorbable agents in decreasing the septic complication of colon surgery using the ''Nichols-Condon'' preparation of erythromycin in combination with neomycin to cover both aerobic and anaerobic bacteria [60] . Over a decade later, Lewis could demonstrate that neomycin is unnecessary [62] . However, there is a true need for a broad spectrum anti-anaerobic antibiotic in colorectal surgery [63] .

In 1990, a survey revealed that parenteral antibiotics alone are used for preoperative colon preparation by fewer than 10% of active colon and rectal surgeons [59] .

Presently, most surgeons use both oral and parenteral antibiotic agents in addition to mechanical cleansing as preparation for elective colorectal surgery [64] .

Concerning timing, we distinguish between three types of surgery: emergency operations (immediate), urgent (within 24-48 hours) and elective surgery (more than Fig. 1 . Endoscopic image of colonic stent for acute management of tumor induced bowel obstruction, as described in the text 5-7 days after an acute attack). As emergency operations are often a challenge for the surgical team because of the high risk of morbidity and mortality [65] , the main interest must be to try to convert an emergency situation into an urgent one [66] . One of these possibilities in left-sided large bowel obstruction is placement of an expandable stent similar to stents used for esophageal malignancies (Fig. 1) . The metallic, expandable stent is passed through an obstructing tumour under endoscopic and fluoroscopic guidance [67] . Stent expansion will increase the luminal diameter and thus allow relief of the acute bowel obstruction (Table 3 ). Colonic stent placement has an excellent chance of providing a bridge to surgery so that emergency surgery with an unprepped patient can be avoided, allowing an elective operation. Bowel prep can be performed and the decompressed bowel will more often allow resection and primary anastomosis [89] .

Furthermore, in a palliative setting, long-term palliation can be achieved in 92% of patients suffering from recurrent cancer or metastatic cancer without requiring a laparotomy or stoma [85] .

G. Intraoperative complications: general remarks

Surgery is teamwork. A good outcome depends on a highly motivated and specialized team. This is especially true for laparoscopic operations [90] . In special situations (e.g. large bowel obstruction and a young resident or surgical nurse on duty), it might be wise to postpone an operation until the next morning, when an experienced, relaxed and motivated team will be available. In such a case of bowel obstruction, a decompression nasal tube might be helpful in the meantime [91] . It should be stressed that laparoscopy is not useful in emergency situations [92] . An exception might be an abdominal knife wound in a haemostable patient, where the goal is to exclude injury of the peritoneum with a diagnostic laparoscopy [92, 93] .

In emergency situations, we recommend placing the patient in supine position with the legs apart (''Lloyd Davies'' position). A long midline incision allows access to all quadrants of the abdomen and the smaller pelvis as well as the anus.

Adequate bowel mobilisations, appropriate illumination, correct positioning of assistants and retractors and good and careful handling of the tissue is the key to a successful operation. The small bowel especially should be treated carefully, using wet instead of dry pads in order to reduce damage to the bowel's serosa, which may lead to postoperative formation of adhesions [94] . Moreover, during lengthy colorectal surgery the bowel should be covered with warm, moist pads, which should be changed frequently to avoid hypothermia and evaporation. Generally, sharp dissection with blunt-tipped scissors (to avoid inadvertent bowel damage) under direct vision is preferred. Newer technologies including harmonic scalpel (Ultracision + ) or a vessel-sealing system (Ligasure + ) (Fig. 2) help to reduce blood loss [95] .

If inflammatory masses are present in the abdomen, it might be advisable to dissect bowel loops and intraabdominal abscesses mainly by blunt finger dissection [96] . High energy water jet dissection might also be helpful on special occasions [97] .

In the case of a patient with very severe multiple injuries, as from gunshot, with lacerations not just of the small and large bowel but also of other organs like the liver, pancreas and kidney, the concept of damage control should be used [93] . The idea is to do only as much as necessary to stop bleeding and further spillage of bowel content into the abdominal cavity, e.g. ligation of major vessels, closure of the bowel wall with staples, etc. Then the abdominal wall is temporarily closed and after medical resuscitation in the ICU (with stabilization of metabolic functions, temperature, electrolytes, etc.), usually after 6-12 hours a final operation with extensive resections can be performed with the patient in better general condition, and a better outcome achieved [98] .

Complications can often be prevented by adequate exposure of the surgical field. Traction and counter-traction comprise the key for precise dissection. However, excessive traction in the area of the left colonic flexure may inadvertently injure the spleen. In slender patients, correct dissection lines of the bowel mesentery are best determined by transillumination. In very obese patients, digital palpation of the vessels can help avoid damage. Avoiding tension on the anastomosis or stoma site can be prevented by good mobilization of the bowel (Figs. 3a  and b) . If a stoma is required, obese patients in particular may present problems with the blood supply to the ostomy limb, which can easily lead to retraction and=or necrosis of the stoma [99, 100] .

Every surgeon aims to operate as bloodlessly as possible as it is well known that blood units administered decrease the immunocompetence of the patient [101] . This is especially true in cancer patients; the outcome will be worse in the long run when blood units must be given during or after surgery [102] . In open colorectal surgery, there are some critical steps during dissection that should be highlighted.

The mobilization of the left colonic flexure, which is situated high up in the left upper quadrant of the abdomen, is often technically challenging, especially when fatty omental attachments are present. The view can be obstructed and bleeding may occur from manipulation alone. Usually, the surface of the lower pole of the spleen is damaged. The first steps are to tamponade the bleeding site and proceed with the operation. If necessary, the splenic laceration may be glued when dissection is completed [103] . With severe bleeding, we recommend a full mobilization of the spleen, inserting two large pads in the direction of the diaphragm and behind the organ to elevate it. The site of damage may be inspected more carefully and selective treatment applied (gluing, partial resection or splenorrhaphy). Splenectomy is rarely necessary except when the general situation demands a quick solution to finish surgery as soon as possible [104] .

Transsection and ligation of the major vessels (ileocolic artery, right colic and inferior mesenteric artery) are usually not too difficult. However, dissection of the middle colic artery and vein may sometimes present a problem, especially in the presence of multiple enlarged and cancerous lymph nodes at the transsection line. Small dissection steps with frequent stitches are required.

In the presence of an inflammatory mass or extensive cancer in the sigmoid colon, the left iliac vein may be at risk. Careful dissection under direct vision and soft manipulation will help to avoid more serious problems. If bleeding occurs, a 5-0 monofilament thread should be used to repair the defect.

Another problematic region is the presacral space. Massive life-threatening intraoperative pelvic bleeding from basivertebral veins may require a thumbtack occlusion [100] .

The principles of a good and reliable colo-colonic or colorectal anastomosis are as follows:

1. good exposure and access to large bowel (sufficiently long incision), 2. adequate blood supply to anastomosed stumps, 3. prevention of sepsis or gross faecal contamination Reality, however, is different. If an anastomotic leakage occurs, the causes are usually multifactorial and may include faulty technique with ischemia or excessive tension at the suture line. Other factors might be an anaemic and=or malnourished patient with several comorbidities or who is on high dose steroids or immunosuppressant drugs [106] . Anastomotic leakage after colorectal surgery is the major cause of postoperative morbidity and mortality [107] . It occurs more often after anterior resection than after colo-colonic anastomosis [108] . If there is rectal anastomotic insufficiency, in 60% of the cases leakage will cease with conservative treatment [108] . Colonic anastomoses are less prone to leak [55, 100] , but surgical correction is almost always necessary [100] . If re-laparotomy is necessary, morbidity and mortality increase due to peritonitis, fistula formation or abscess. A few practical tips for the operation are as follows: Always mobilize the bowel ends. To have an adequate blood supply, the cut ends of bowel should bleed before the anastomosis is created. Use non-crushing bowel clamps if necessary and close them lightly without including the mesentery. There are numerous variations in anastomosis technique. Most common are: end-to-end anastomosis (double layer, single layer full thickness, single layer extramucosal) and end-to-side anas-tomosis. It is generally accepted that the inversion techniques (running suture or interrupted stitches) should be employed for colorectal anastomosis [109] . It does not seem to matter whether a single or two layer technique is used for a colorectal anastomosis; it is a matter of the surgeon's preference. In the presence of local sepsis (e.g. perforated diverticulitis or colorectal cancer, colorectal trauma, gross faecal contamination during colorectal surgery), one should still try to re-anastomose as often as possible. Elderly patients especially will have problems learning to care for a stoma [110] . Only with severe faecal peritonitis or in patients with very fragile tissue (elderly patients, chronic use of corticosteroids, immunosuppressants, etc.) a primary anastomosis may not be a wise decision [111] . During creation of an anastomosis, the surgeon should avoid traction during manipulation and prevent infections by covering the neighbouring area with wet pads to stop spillage. Gloves should be changed after the anastomosis has been established. Though more costly, stapling devices will allow colonic or rectal closure and anastomosis to be performed more quickly than manually [112] . Furthermore, it is easier to perform a clean operation as spillage can be reduced by opening the bowel lumen just when the anastomosis is to be made, and not when the bowel is transsected. The Contour + (Johnson and Johnson) is especially useful in rectal surgery [113] . If a stapled anastomosis is performed, the largest calibre of stapler that can accommodate the bowel lumen should be used.

There are some important findings in the literature. According to Kusunoki, there are no significant differences in anastomotic dehiscence (5-7%) or recurrence of Crohn's disease between the stapling and hand-sewn procedures [114] . Furthermore, in 1998 Miettinen et al. demonstrated that preoperative bowel preparation seems to offer no benefit in elective open colorectal surgery with regard to mortality, wound infections and anastomotic leakage rate [115] . Defunctioning stoma does not reduce the incidence of major leakage; however, the risk of peritonitis and its consequences can be minimized [116] . It has been considered prudent to defunction the low rectal anastomosis below 6 cm from the anal verge, particularly after total mesorectal excision [117] . The presence of drains is associated with an increased incidence of anastomotic leakage. Thus drains may adversely affect anastomotic healing in colon surgery [118] .

The bleeding complication most often experienced in colorectal surgery is laceration of the spleen [119] but the inadvertently injured organ can usually be rescued (see above). b) Ureteric injuries: In contrast to a right-sided colectomy, a left-sided colectomy always requires identification of the ureter. The latter can easily be found running medial from the gonadal vessels where they cross the iliac artery. In addition, the ureter can be identified by its peristaltic response to light touch. A non-identified ureter might be an indication for conversion in laparoscopic-assisted colon surgery [120] . Ureteric injury is the most common intra-operative urologic complication. Typical lacerations would be at the crossing of the uterine vessels with the pelvic brim or next to the lateral ligaments of the rectum. Types of injuries include devascularization, crushing or transsection. If an injury has been identified intraoperatively, a primary re-anastomosis can often be done by an urologist without any further problems. c) Bladder injury: If the bladder is injured, the defect must be closed with a monofilic thread, usually in two rows. With a larger injury, a suprapubic catheter should be applied for a fortnight after prior consultation with an urologist. In case of a cancer with macroscopically unclear delimitation towards the bladder, the resection margin should comprise a primary multivisceral resection including partial bladder resection. The final outcome is then better than if inadvertent tumour spillage has occurred (5-year survival rate 71 vs. 25%) [121] .

Minimal invasive surgery was pioneered in the late 1980s and was very quickly adopted by surgeons for a variety of indications. Laparoscopic cholecystectomy was the breakthrough for minimally invasive techniques in general surgery. This technique has replaced the open cholecystectomy as the operation of choice for gallbladder disease and is now being practiced worldwide [122] . In contrast, laparoscopic colorectal surgery has been slower to evolve. The postoperative benefits demonstrated in laparoscopic cholecystectomy were not as obvious in colorectal surgery. In addition, reports on port-site metastasis in colorectal cancer patients have raised concern regarding the suitability of this approach in oncological cases [123] . Finally, the more complex nature of these procedures has contributed to their lower acceptance. Laparoscopic colorectal surgery is a technically challenging procedure because it involves difficult laparoscopic manoeuvres such as operating in different quadrants of the abdomen with a frequent need to reposition the patient and the instruments, controlling major blood vessels, extracting large specimens, identifying extraperitoneal structures (such as the ureters) and re-establishing bowel continuity [124] .

Nevertheless, laparoscopic colorectal surgery is growing in popularity as a procedure for the treatment of both benign and neoplastic intestinal diseases. Ever more large published series demonstrate that patients undergoing laparoscopic colorectal procedures have less discomfort and more rapid postoperative recovery [125] [126] [127] . Laparoscopic colorectal surgery for benign diseases has been proved to be as safe as open surgery with comparable mortality and morbidity rates [124, 125] . Oncologic standards of curative surgery for colorectal cancer include enbloc resection, no-touch isolation technique with primary ligation of the corresponding vessels, and systematic lymph node dissection. These principles are mandatory for both open and laparoscopic surgery.

It is important to realize that in laparoscopic surgery, everything is enlarged due to the zoom effect of the camera, and that even minor bleeding sites may look dangerous. Blood in the abdomen may reduce illumination, rendering dissection more difficult, and even small amounts of blood on the lens of the camera can obstruct the view. Particular prudence is essential, especially as small bleeding sites can be compressed by the pressure of the insufflated gas in the abdomen, but then bleeds postoperatively when the pneumoperitoneum is released. Cold insufflated gas may predispose the patient to bleeding [124] .

For practical reasons, a few issues must be discussed more extensively: a) Team: The factor that appears to have the most crucial effect on the complication rate is the cumulative experience of the surgeon and the team [128] . The surgeon's experience may be reflected in better technical skills, better patient selection and sometimes better technology. The best way to deal with complications is to avoid them by careful patient selection and adequate training with laparoscopic instrumentation and stapling devices. Especially in critical bleeding situations, everybody on the team should know what his=her job is, as a false camera position can be as dangerous as wrong assistance, and both can lead to emergency laparotomy [129] . b) Position and instruments: In laparoscopic (assisted) colon surgery an electronically operated table is useful as frequent changes in position are needed for laparoscopic colectomy. Good fixation of the patient on the OR table is crucial so that the table can be titled when necessary to use gravity to retract the intestines from the site of dissection. Because there is a limited access to the surgical site during laparoscopic surgery, instruments are a key to successful surgery. Essential equipment includes a high resolution video system with a good light source, monitoring and recording devices, as well as high-flow insufflators delivering at least 10 l of gas=min. Surgical instruments should be long enough, should be easy to manipulate and capable of 360 rotation with the surgeon's single hand. It is wise to position the patient and the team so that endoscopic access to the colorectum is possible if needed. The transanal endoscopic microsurgery (TEM) technique also requires special patient positioning, i.e. so that the lesion to be removed is always ''on the bottom'' (at 6 O'clock) of the operating scope. c) Trocar-related complications: Although relatively safe, the placement and use of trocars and pneumoperitoneum needles can cause complications. Injuries to the bladder, to solid organs and to major vessels have all been described [124] . Most trocar-related injuries result from technical problems such as inappropriate placement and=or inadequate skin incision, necessitating increased insertion force [130] . We recommend that the first trocar should always be inserted with an open technique (Hasson technique); an adequate pneumoperitoneum is then established which moves the abdominal wall away from the intraperitoneal organs and lessens the chances of organ injury. Further trocars are then positioned under direct camera vision. Good clinical practice teaches that trocars should not be located too close to each other as this could make it difficult to operate. The best position is when the camera and the working instrument have a common focal point, forming a triangle. If there is bleeding from the trocar site, it should be attended to and stopped immediately; otherwise, it can create problems throughout the whole operation. Abdominal wall bleeding from trocar sites used to be common early in the laparoscopic era. With increasing experience, this typical laparoscopic complication is now encountered less often. Port site bleeding can be avoided by placing the trocars preferably in the midline or lateral to the rectus muscle in order to reduce the risk of injuring the inferior epigastric vessels. If this nonetheless happens, the best thing is to enlarge the trocar opening, look for the stumps of the vessels and to sew or ligate them selectively. Injuries to larger intraabdominal vessels require immediate conversion to open surgery [124] . Laparoscopic dissection of the colonic mesentery may be difficult, especially when it is diseased and thickened. To avoid bleeding from large vessels, the vascular pedicle should be completely dissected and visualized before the vessels are clipped or stapled; this reduces the tissue bulk in the staples and so achieves more secure hemostasis. The use of newer vessel sealing systems like the Ultracision + or Ligasure + have also contributed to a decrease in bleeding complications [131, 132] . d) Anatomy: Sometimes anatomical orientation is difficult and the operation proceeds only slowly or approaches a standstill. Conversion to open surgery can be a very important tool in avoiding complications. In cases of unclear anatomy such as dense adhesions, obesity and severe inflammation the surgeon should not hesitate to convert to open surgery. Timely abandonment of a laparoscopic approach should be regarded as good surgical judgement rather than failure. If in laparoscopic surgery there is no progress within 30 minutes, conversion to open surgery is indicated. e) Organ injuries: Intraoperative identification of an injury can greatly help to minimize associated morbidity [133] . The two most typical intra-operative surgical complications are bleeding (intraabdominal and portsite) and bowel injury. The rate of intraoperative complications reported in some published series of laparoscopic colorectal surgery is about 5-7% [120, 128, 134, 135] . It is important to state that bleeding can be minimized with good and careful dissection with suitable instruments. Another important factor is the use of soft and non-crushing laparoscopic instruments to avoid tearing the bowel wall. In practice, we try to avoid touching the bowel wall itself, holding instead the mesentery of the bowel segment. If other organs like liver, gallbladder or ureters are injured, conversion is almost always a must [124] . f) Anastomosis: As it is usually very difficult to create an anastomosis intra-abdominally, the better and faster option seems to be an extracorporal anastomosis through the bowel extraction site. This can be done in the conventional way with suture or staplers if preferred. g) Malignant tumour: With the introduction of laparoscopic curative surgery in colorectal cancer, some concern was voiced regarding the ability to maintain the oncologic principles of open cancer surgery. It has been proven recently that laparoscopic oncological resections are possible with at least the same outcome as open conventional surgery [134, 136] .

h) Other complications: Less frequent surgical complications are instrument failure (stapling device failure), cutaneous emphysema due to trocar dislocation, rotated anastomosis and missed colonic lesions due to the lack of palpation [120, 135] . If small colonic lesions like polyps are to be removed, preoperative ink-marking of the diseased area seems to be helpful [136] . As in other laparoscopic procedures, nonsurgical complications may result from the intra abdominal pressure and the CO 2 insufflation during the procedure.

To avoid infection, pre-, intra-and postoperative antibiotics with focus on gram-positive and gram-negative colonic bacteria should be given [137] . However, the most important issue is to avoid spillage of bowel content during dissection and creation of the anastomosis. We therefore recommend a ''closed resection'' where both bowel ends are closed after transsection. Coverage of the neighbouring organs during anastomosis creation is important in open surgery, while plastic bags for extraction of the diseased bowel segment are useful in laparoscopic surgery [120] .

A. Early complications

As an anastomotic leak is one of the most dreaded postoperative complications, it is obvious that meticulous postoperative clinical and laboratory observation is necessary after colectomy. The most important clinical signs are fever, sweating, bloating and nausea, and laboratory findings of increasing leucocytes and=or CRP may be the first indication of an anastomotic leak. Determination of lysozyme content in the wound or in the effluent from pelvic drains can be useful in the early diagnosis of anastomotic dehiscence. Lysozyme is a component of local defence and is produced in macrophages. In patients with impending anastomotic leak, lysozyme activity is significantly increased as early as the first postoperative day in contrast to patients without any anastomotic complications [138] . Several systemic and local factors play a significant role in the aetiology of an anastomotic leak.

Local factors include bowel preparation, surgical anastomosis technique, intraabdominal sepsis and drains [139, 140, 141] . The following systemic factors have all been described in the literature: shock, sepsis, advanced age of patient (above 75 years), coagulopathy, steroids, anaesthetic drugs, advanced malignant disease, radioand chemotherapy, diabetes, uraemia, anaemia, iron, zinc, cystein, vitamin C depletion, malnutrition with hypoalbuminemia, congestive heart failure and chronic obstructive pulmonary disease [107, 111, 142, 143] .

The prompt diagnosis of anastomosis leak is of paramount importance for the patient. Contrast enema with either uropolin or gastrographine enables early diagnosis of anastomotic leak if the situation is clinically unclear [144] . Conservative treatment options are total parenteral nutrition, broad spectrum antibiotics and treatment of the septic shock [145] . However, in most cases prompt surgery (depending on patient status, drainage and diameter of fistula) is essential [111, 139, 144, 146] . Surgical possibilities are either a re-do of the anastomosis (often with a segmental resection) or a disconnection procedure with creation of a stoma and a blind closure of the distal bowel lumen (Hartmann procedure) [147, 148] .

Sepsis may be defined as a proliferation of bacteria in the bloodstream. It may be accompanied by fever, chills, leukocytosis, tachycardia, and in some cases, circulatory collapse and shock [57, 146] . Septicemia may be a direct complication of surgical procedure, resulting from an anastomotic leak or wound infection, or it may result from invasive studies or monitors such as an infected central line [149] . Elderly patients, poor nutrition, immunocompromised individuals, and co-morbidities may also affect the incidence and degree of sepsis [150] . The increasing occurrence of sepsis may be related to advances in critical care medicine as more patients now survive antibiotic resistant organisms [151] . Studies attempting to identify preoperative risk factors for patients undergoing elective colorectal surgery have identified only three: patient gender, physical status, and seniority of the surgeon. Female patients in poor physical health with a relatively inexperienced surgeon had a worse outcome and higher morbidity [44] .

The best method of treating sepsis is to prevent it in the first place. This may be accomplished by adherence to meticulous surgical technique [57] . Care should be undertaken to prevent bowel spillage upon resection and anastomosing. A bowel anastomosis must always be done without tension and with good blood supply. The bowel ends should be free of faecal matter. A low-lying bowel anastomosis should always be considered for a proximal diversion due to the higher leak rate associated with the former [144] . Radiated bowel as well as high risk patients, particularly immunocompromised individuals, should always be considered for proximal diversions [152] . Although proximal diversion will not prevent a distal leak, it will, however, prevent the devastating consequences of leak such as pelvic sepsis, or pelvic inflammation with subsequent fibrosis ultimately causing an anastomotic stricture, and possibly death [117] .

A study from Spain revealed that the five-year survival of patients with major septic complications (anastomotic leak or peritoneal abscess) was significantly lower than in non-complicated cases [57] .

Most importantly, however, the source of sepsis must be aggressively sought and corrected. Anastomotic leaks and intra-abdominal infections will never be adequately treated by fluids and antibiotics alone. Surgical intervention, whether by percutaneous or invasive open procedures, must be undertaken in order to remedy the situation and potentially salvage the patient [144, 153] . Percutaneous catheter drainage of intra-abdominal or pelvic infections, often done under ultrasonic or CT guidance, has largely replaced open drainage procedures [153] .

Postoperative haemorrhage is a dangerous complication that, if overlooked, can result in significant patient morbidity and mortality [154] . As the abdomen and pelvis represent large potential spaces for fluid accumulation and exsanguination can easily occur, postoperative clinical and laboratory control of bleeding is necessary. Furthermore, intra-abdominal haematomas may contribute to abscess formation [155] .

Traditionally, postoperative hospitalization following major gastrointestinal surgery has been between five and ten days. A variety of factors contribute to the length of stay including inadequate analgesia, nausea and vomiting, delay in ileus resolution, and stress-induced organ dysfunction [156] . In addition, iatrogenic factors including nasogastric tubes, transabdominal drains, and enforced malnutrition affect patient recovery after colectomy [8] . Recent years have seen a trend toward earlier feeding [8, 157, 158] . It is now well known that the fast track approach to feeding is applicable to the large majority of cases involving colorectal surgery [35, 36] . Another reason why the length of stay after colectomy could be reduced is the greater use of minimally invasive surgical techniques, with earlier return of bowel function than with conventional open technique [31, 33, 35, 36, 157] . Furthermore, epidural analgesia with local anaesthesia appears to reduce time to recovery from postoperative ileus [159] . The advent of new therapeutic drugs such as Ì-opioid receptor antagonists may provide further improvement in the outcome after major abdominal surgery [160] .

However, despite careful surgical technique, a postoperative mechanical ileus cannot be predicted or prevented in about 15% of cases [161] ; these require an early re-operation.

Several etiologies for postoperative stricture formation are discussed. Among them, injury, ischemia, inflammation, infection and neoplasm are most common [162] . If a stenosis in a Crohn's patient evolves according to the stricture site, operative treatment is indicated. In small bowel stenosis, strictureplasty is a good option, especially if multiple stricture sites are visible. In ileocolic or colonic strictures, either a bypass or a segmental resection should be done [163, 164] .

Ischemic strictures which are very low in the rectum may be treated with frequent dilatation and=or additional laser cutting [165] . Recently, strictures, mainly in the rectosigmoid, have been stented with great success (Table 3) . If conservative or semi-conservative treatment options fail, surgical resection is necessary.

Postoperative adhesions remain a significant source of morbidity and their prevention would significantly aid medical care. All abdominal surgical procedures have the potential for creating adhesions [166] . In the absence of surgery, abdominal and pelvic infections and therapy, such as peritoneal dialysis, may incite the inflammatory cascade. Clearly, the optimal solution is prevention. Diminishing the deposition of fibrin and enhancing fibrinolysis without interfering with wound healing are the goals. This may theoretically be achieved primarily by four means: 1) mechanical bowel fixation (e.g. long tubes, suture-pexy) to promote ''friendly'' or ''benign'' adhesions which will not lead to obstruction, 2) systemic pharmacologic therapy (e.g. anti-inflammatory medications), 3) intraperitoneal therapy or barriers (e.g. carboxymethylcellulose, sodium hyaluronate, irrigants), and 4) local factors (e.g. surgical technique, foreign bodies). While none of these will completely prevent adhesions, several have been found to be promising in retrospective and prospective studies [167, 168] .

The benefit of pexing or stenting is minimal, so, because of the potentially associated complications, they are generally not recommended for uncomplicated adhesive bowel obstructions. Some caution may be given for patients suffering from multiple episodes. Systemic therapy in an attempt to modify the inflammatory response has been investigated. Associated side effects include bleeding and poor wound healing with resultant anastomotic disruption and incisional dehiscence, and so the routine use of such therapy is not currently recommended [167, 169, 170] . Common practices such as suturing the peritoneum, using surgical gloves with talc and using non-absorbable suture should be eliminated entirely. There is clear evidence that these techniques are unnecessary and promote adhesions [171] . There are many simple techniques all surgeons should be aware of which may reduce the severity of adhesions. Primarily, these involve minimizing the presence of minimal adhesions by using wet pads during the operation, thereby reducing the amount of raw surfaces, and judicious use of prosthetic material, including suture [172] . When it is necessary to use prosthetic material, such as mesh, there are simple manoeuvres that may reduce the inflammatory reaction and the subsequent formation of adhesions. Modifications in the mesh, which reduce tissue in-growth, include lack of matrix in the material (Gore-Tex), use of absorbable mesh (polyglactin lined polypropylene) and interposition of a barrier between the mesh and viscera (omentum). Recently, a mesh with an adhesion material bonded to it (SepraMesh R, Genzyme, Cambridge, MA) has become available. First results are promising [173] .

Port-site incisional hernia may develop after laparascopy as a result of infection, premature suture disruption, or failure to adequately re-approximate the fascial wound edges [174] . A study found the incidence of port site hernias to be 6.3% in obese patients with BMI > 30 [175] .

The practice of using prosthetic material to obtain tension-free repair of incisional hernias is well established in open surgery. Applying the same principle, surgeons have utilized mesh in laparoscopic repair of various types of hernias; the use of an intraperitoneal onlay mesh (IPOM) was originally practiced for the repair of inguinal hernias, but was abandoned in favour of the transabdominal and totally extraperitoneal approaches [176, 177] . An IPOM repair remains the standard technique used in the laparoscopic repair of incisional hernias. Most authors advocate the use of expanded polyterafluoroethylene (PTFE) or a composite polyester mesh (Parietex, Sofradim, Villefranche-sur-Saone, France), as these have a low propensity for inducing intraperitoneal adhesions [176] [177] [178] . Chowbey et al. have recently reported a series of 34 patients in whom incisional hernias were repaired laparoscopically utilizing polypropylene mesh in a preperitoneal location [178] . This repair not only confers the benefits to the patient of a minimal assess procedure but also avoids the risk of bowel adhesions present with intraperitoneal placement of the mesh [176] [177] [178] .

Some surgeons advise creating a defunctioning stoma in order to prevent faecal contamination of an anastomosis and when anastomotic leakage appears [148, 149, 179] .

The decision whether to create a protective colostomy or ileostomy is often not rational but emotional, based on feelings that ''the operation was technically difficult to perform'', ''there was considerable blood loss'', ''the tumour was stuck in the pelvis'', the patient had many medical problems'', ''the anastomosis looked tenuous'', ''there was some tension across the anastomosis'', ''I didn't feel good about it,'' ''I'll sleep better tonight.'' All those are reasons for protecting the anastomosis with a proximal stoma. Probably the most common reason for a subsequent anastomotic complication is tension in the suture line (distraction, vascular insufficiency). If the above precautions are taken, a protective colostomy is usually unnecessary [139] . There are relative indications for protecting the anastomosis: pelvic sepsis, excessive blood loss and arterial hypotension, poor nutritional status and ultralow anastomosis (below 6 cm from the anal verge). It is generally believed that a temporary defunctioning colostomy is avoided more often if a stapled anastomosis is performed than if a hand-sewn technique is used [179, 180] . There is no evidence that protective stoma prevents anastomotic leak [153] .

When a stoma is created, it should be considered that the following late complications may occur: parastomal hernia in 5-14%, stoma prolapse in 2-13%, stoma stenosis in 3-9%, stoma retraction in 1% and peristomal dermatitis in 12-15% [110, 181] . The latter are usually the most troublesome as far as the patient's life quality is concerned [110, 181] .

Discussing treatment options for these complications, however, is beyond the scope of this manuscript.

The best ''treatment'' for colonic complications is their avoidance. If colonic complications do occur, it is important to manage them properly on the basis of clinical decision-making. route (enteral or parenteral) affects the plasma response of the dipetide Ala-Gln and the amino acids glutamine, citrulline and arginine, with the administration of Ala-Gln in preoperative patients. 

Indications for pulmonary function testing

Canadian Society of Colon and Rectal Surgeons

Practice parameters for the prevention of venous thromboembolism. Prepared by The Standards Task Force The

The prevention of pulmonary complications after upper abdominal surgery in patients with noncompromised pulmonary status

Major risk factors as antecedents of fatal and nonfatal coronary heart disease events

Myocardial re-infarction after anaesthesia and surgery

Multimodal approach to control postoperative pathophysiology and rehabilitation

The anesthesiologic risk patient. Preoperative evaluation, intraoperative management and postoperative monitoring

The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery

Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review

University of Texas Medical Branch at Galveston

Systematic review of thromboprophylaxis in colorectal surgery-an update

Protein C and=or S deficiency presenting as peripheral arterial insufficiency

Determination of perioperative cardiac risk by adenosine thallium-201 myocardial imaging

Risk factors for major thrombembolism and bleeding tendency after elective general surgical operations. The fragmin multicenter study group

Acute oliguria after cardiopulmonary complications bypass: renal functional improvement with low -dose dopamin infusion

Gastrointestinal lesions occurring in uremia

The gastrointestinal tract in uremia

Renal vein thrombosis and nephrotic syndrome. A prospective study of 36 adult patients

The effect of dialysis on platelet function of patients with renal failure

From basic science to clinical practice: use of cytokines and chemokines as therapeutic targets in renal disease

What anaesthetists need to know about viral hepatitis

Abdominal drainage after liver resection for hepatocellular carcinoma in cirrhotic patients: a randomized controlled study

Patterns of improvement in resection of hepatocellular carcinoma in cirrhotic patients: results of a non drainage policy

Influence of preoperative administration of omega-3 fatty acid-enriched supplement on inflammatory and immune responses in patients undergoing major surgery for cancer

The feeding

Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study

Length of stay has minimal impact on the cost of hospital admission

The primary immunodeficiencies

CD4þ T cell count as a tool to monitor HIV progression & anti-retroviral therapy

The effect of gender on postoperative mortality after emergency abdominal surgery

Poor nutritional habits are predictors of poor outcome in very old hospitalized patients

Significant risk factors in elective colorectal surgery

Epidemiology of anemia in human immunodeficiency virus (HIV)-infected persons: results from the multistate adult and adolescent spectrum of HIV disease surveillance project

The surgical complications of chemotherapy in the cancer patient

Acute diverticulitis: a complicated problem in the immunocompromised patient

The use of granulocyte colony stimulating factor to promote wound healing in a neutropenic patient after head and neck surgery

Decreased tumor blood flow as measured by positron emission tomography in cancer patients treated with interleukin-1 and carboplatin on a phase I trial

Economic evaluation of the treatment of systemic fungal infections in neutropenic patients: the role of itraconazole

Effect of granulocyte colony-stimulating factor on neutropenia induced by cytotoxic chemotherapy

Trends in preparation for colorectal surgery: survey of the members of the

Mechanical bowel preparation for elective colorectal surgery: a prospective, randomized, surgeon-blinded trial comparing sodium phosphate and polyethylene glycol-based oral lavage solutions

Senna vs polyethylene glycol for mechanical preparation the evening before elective colonic or rectal resection: a multicenter controlled trial. French Association for Surgical

Mechanical bowel preparation for elective colorectal surgery

Metaanalysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation

Prognostic significance of postoperative septic complications in surgery of rectal carcinoma

Is neomycin necessary for bowel preparation in surgery of the colon? Oral neomycin plus erythromycin versus erythromycin-metronidazole

Preoperative bowel preparation. A survey of colon and rectal surgeons

Preoperative oral antibiotics reduce septic complications of colon operations: results of prospective, randomized double blind clinical study

Initial results of a new procedure for treatment of malignant obstruction of the left colon

Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s

Antimicrobial bowel preparation. Oral, parenteral, or both?

Metronidazole in prevention and treatment of bacteroides infections in elective colonic surgery

Impact of emergency surgery in the outcome of rectal and left colon carcinoma

Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic

Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery-results of a multicenter study

Metal stents for palliation of rectal carcinoma: a preliminary report on 12 patients

Colorectal obstruction: treatment with metallic stents

Stent endoprosthesis for obstructing colorectal cancers

Expandable metal stents for the treatment of colonic obstruction: techniques and outcomes

Acute colonic obstruction: clinical aspects and cost-effectiveness of preoperative and palliative treatment with self-expanding metallic stents-a preliminary report

Acute colorectal obstruction: stent placement for palliative treatment -results of a multicenter study

Initial clinical experience with colonic stent placement

Self-expanding metal stents in the management of colorectal carcinoma -a preliminary report

Laparoscopic tension-free repair of anterior abdominal wall incisional and ventral hernias with an intraperitoneal Gore-Tex mech: prospective study and review of the literature

Covered metal stents for management of inoperable malignant colorectal strictures

Experience with endoluminal colonic wall stents for the management of large bowel obstruction for benign and malignant disease

Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation

Palliative stenting of malignant large bowel obstruction

Placement of self-expanding metal stents for acute malignant large-bowel obstruction: a collective review

The efficacy of metallic stent placement in the treatment of colorectal obstruction

Use of the Bard Memotherm self-expanding metal stent in the palliation of colonic obstruction

Self-expandable metallic stent placement as palliative treatment of obstructed colorectal carcinoma

Stents or open operation for palliation of colorectal cancer: a retrospective, cohort study of perioperative outcome and long-term survival

Metallic stents in large bowel obstruction: experience in a District General Hospital

Outcomes after placement of colorectal stents

Bowel function following insertion of self-expanding metallic stents for palliation of colorectal cancer

Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies

Obstructing colon cancer-what's the surgical strategy?

Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management

What is the potential for acute laparoscopy in penetrating abdominal injuries?

The role of laparoscopy in penetrating abdominal trauma

Reoperation for small intestinal obstruction

Experience with ultrasound scissors and blades (UltraCision) in open and laparoscopic liver resection

Digital blunt dissection technique to assist laparoscopic gonadectomy in inguinally located=adhered gonads

Dissection techniques in laparoscopic surgery: a review

Use of a critical pathway for colon resections

Stoma complications: a multivariate analysis

Complications in colon and rectal surgery. Early diagnosis and management

Immunomodulatory effect of blood components transfusions

Perioperative immunosuppression in cancer patients

The role of the Argon Beam Coagulator in splenic salvage

Abdominal trauma

The experimental basis of intestinal suturing. Effect of surgical technique, inflammation, and infection on enteric wound healing

Risk factors for clinical anastomotic leakage following the resection of sigmoid and rectal cancer

Wessex Colorectal Cancer Audit Working Group (2005) Prognosis after anastomotic leakage in colorectal surgery

Anastomotic leakage following anterior resection for rectal cancer

Single-layer continuous suturing for end-to-end anastomosis using a modified closed-bowel-technique

Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial

The dehiscence of colorectal anastomoses: the risk factors

Comparison of continuous single layer polypropylene anastomosis with double layer and stapled anastomoses in elective colon resections

The curved cutter stapler (Contour + )

A comparison of stapled and hand-sewn colonic anastomoses in Crohn's disease

Bowel preparation is unnecessary in elective open colon surgery. A prospective randomized study

Surgical strategies -anastomosis or stoma, a second look -when and why?

Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum

Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis

Spleen laceration, a rare complication of laparoscopy

Complications of laparoscopic colorectal surgery. Analysis and comparison of early vs. later experience

Treatment and outcome of right colon cancers adherent to adjacent organs or the abdominal wall

Formal training in advanced surgical technologies enhances the surgical residency

The role of laparoscopy in the multimodality treatment of colorectal cancer

Laparoscopic colorectal surgery: learning curve and training implications

Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared with laparotomy

Laparoscopic colectomy

Laparoscopic colon resection

The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies

The safety and efficacy of direct trocar insertion with elevation of the rectus sheath instead of the skin for pneumoperitoneum

Access related complications in laparoscopic surgery. Tips and tricks to avoid trocar complications

Real-time thermography during energized vessel sealing and dissection

The role of the ultracision technique in visceral surgery. Ligature-free operation-an illusion?

Management of iatrogenic ureteric injuries associated with gynecological surgery

Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery. Laparoscopic Colorectal Surgery Study Group (LCSSG)

Determinants of outcomes in laparoscopic colorectal surgery: a multiple regression analysis of 416 resections

Efficacy of transanal endoscopic microsurgery in the management of rectal polyps

Mechanical and antibacterial bowel preparation in colon and rectal surgery

Early detection of anastomotic leaks after low anterior resection of the rectum

Anastomotic leaks in colorectal cancer surgery: a risk factor for recurrence

Avoidance of anastomotic complications in low anterior resection of the rectum

Factors contributing to leakage of colonic anastomosis

Anastomotic integrity after operation for large bowel cancer-a multicentre study

Wessex colorectal cancer audit: anastomotic leakage following elective anterior resection

The diagnostic value of different imaging modalities in evaluation of bowel obstruction

Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity

A prospective controlled study of prophylactic drainage after colonic anastomosis

Hartmann procedure: place in surgery and what after?

Leakages after surgery of the lower gastrointestinal tract

Assessing, treating and managing patients with sepsis

The international sepsis forum consensus conference on definitions of infection in the intensive care unit

Healthcare-associated Staphylococcus aureus bacteremia and the risk for methicillin resistance: is the centers for disease control and prevention definition for communityacquired bacteremia still appropriate?

Risk factors for anastomosis dehiscence after very deep colorectal and coloanal anastomosis

Management of colorectal emergencies: percutaneous abscess drainage

Actual standards and controversies on operative technique and lymph-node dissection in colorectal cancer

Retroperitoneal collections -aetiology and radiological implications

Colon cancer Laparoscopic or Open Resection Study Group (COLOR) (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial

Factors affecting early postoperative feeding following elective open colon resection

Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial

The effect of epidural clonidine on perioperative cytokine response, postoperative pain, and bowel function in patients undergoing colorectal surgery

Alimopan, a novel peripherally acting mu opioid antagonist. Results of a multicenter, randomized, double-blind, placebo-controlled phase III trial of major abdominal surgery and postoperative ileus

Surgery for constipation: a review

The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: endoscopic findings, therapy, and complications

Role of strictureplasty in surgical treatment of Crohn's disease

Long strictureplasty is as safe and effective as short strictureplasty in small-bowel Crohn's disease

Treatment of malignant colonic obstructions with metal stents and laser

Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter Study

Contemporary adhesion prevention

Fewer intraperitoneal adhesions with use of hyaluronic acid-carboxymethylcellulose membrane: a randomized clinical trial

Orally and parenterally administered ibuprofen for postoperative adhesion prevention

Postoperative adhesion prevention with low-dose aspirin: effect through the selective inhibition of thromboxane production

Surgical gloves: current problems

Prevention of postoperative peritoneal adhesions: effects of lysozyme, polylysine and polyglutamate versus hyaluronic acid

Abdominal wall hernia repair: a long-term comparison of Sepramesh and Dualmesh in a rabbit hernia model

Strangulated incisional hernia at trocar site

Laparoscopic tension-free repair of anterior abdominal wall incisional and ventral hernias with an intraperitoneal Gore-Tex mesh: prospective study and review of the literature

Medium term follow up confirms the safety and durability of laparoscopic ventral hernia repair with PTFE

Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience

Laparoscopic ventral hernia repair with extraperitoneal mesh: surgical technique and early results

Anastomotic leak after double-stapled low colorectal resection of the rectum

Colonic anastomosis in the presence of fecal peritonitis using a disposable skin stapler

Prospective analysis of stoma-related complications