Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure.

BACKGROUND: Using tetrastarch for fluid resuscitation after a severe trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown. METHODS: A retrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF). RESULTS: We studied 271 patients who had sustained a severe blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2 days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with a crystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found a U-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023). CONCLUSIONS: There was a complex U­shaped association between the tetrastarch dose and morbidity/mortality of patients after a severe trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.

[Nonsurgical and surgical management of osteoporotic vertebral body fractures : Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)]. / Nichtoperative und operative Behandlung der osteoporotischen Wirbelkörperfraktur : Empfehlungen der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU).

STUDY DESIGN: Prospective clinical cohort study (data collection); expert opinion (recommendation development). OBJECTIVES: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures differ widely. Based on the current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification), the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. METHODS: A total of 707 clinical cases from 16 hospitals were evaluated. An OF classification-based score was developed for guidance in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X­rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scans. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. RESULTS: A score of less than 6 points advocates nonsurgical management; in cases with more than 6 points, surgical management is recommended. The primary goal of treatment is fast and painless mobilization. Because of the expected comorbidities in this age group, minimally invasive procedures are preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. The instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment, the necessity to fuse, multiple level fractures, consecutive and adjacent fractures and fractures in ankylosing spondylitis are addressed separately. CONCLUSIONS: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for the treatment choices available. However, intermediate clinical situations with a score of 6 points remain, allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the subsequent step, the recommendations presented will be further evaluated in a multicentre controlled clinical trial.

Female sex protects from organ failure and sepsis after major trauma haemorrhage.

INTRODUCTION: Biological sex is considered a risk factor for adverse outcome after major trauma. We hypothesized that female sex is protective against organ failure, sepsis and mortality in patients with traumatic haemorrhage. PATIENTS AND METHODS: We selected patients from TraumaRegister DGU(®) (TR-DGU) with primary admission for blunt trauma with an injury severity score ≥ 16 and an ICU stay ≥ 3 days that presented with relevant bleeding in the years 2007-2012. Relevant bleeding was defined as Abbreviated Injury Scale (AIS) ≥ 3 with an estimated blood loss exceeding 20%, any femoral shaft fracture, any pelvic clamp as surrogate for unstable pelvic fracture or the presence of at least one criteria of haemorrhagic shock: shock index of 0.8-1.4; base excess of -2.0 to -10.0 mmol/L; body temperature ≤ 34°C; transfusion of ≥ 4 units of packed red blood cells; application of recombinant activated factor VII; any embolization during trauma room phase and pre-hospital resuscitation volume ≥ 3000 ml or any catecholamine use during pre-hospital care in the absence of cardiopulmonary resuscitation. A total of 7560 males and 2774 females were selected and analyzed for sex differences. RESULTS: Higher rates of multiple organ failure (24.4 vs. 21.3%, Odds ratio [OR] 1.19 (95% confidence interval [95%CI] 1.07-1.33), p=0.001*) and sepsis (16.5 vs. 11.3%, OR 1.55 (95%CI 1.35-1.77), p<0.001*) were observed in males. Organ function of lung, cardio-circulatory system, liver and kidney were better in females, however, there was no difference in mortality. Stratification by age group revealed that in particular age-group 16-44 years was related to improved organ function which may indicate effects of sex hormones in females at reproductive age. Increased rates of sepsis in males were observed throughout virtually all age groups starting at 16 years of age, except in age group 54-64 years. This may suggest suppressive effect of testosterone on immune function. CONCLUSIONS: Our study supports the hypothesis that female sex is associated with improved organ function following traumatic injury and haemorrhagic shock, in particular in age groups that are at reproductive age. However, further studies are warranted before sex steroids can be deployed as therapeutic intervention in critically ill trauma patients.

Simvastatin reduces leucocyte- and platelet-endothelial cell interaction in murine antigen-induced arthritis in vivo.

OBJECTIVES: The use of statins in the prevention and treatment of cardiovascular diseases is well established. Their use as anti-inflammatory and immunomodulatory agents in the treatment of rheumatoid arthritis (RA) has also been investigated, with several clinical and experimental studies indicating an anti-inflammatory effect of statins for RA, but other studies showing no effect or even the opposite. The current study was designed to examine the effect of simvastatin in an in vivo murine model of arthritis using intravital microscopy. METHOD: We assigned four groups (n = 7, female C57Bl6 mice), two with and two without antigen-induced arthritis (AiA), from which one of the non-AiA groups and one of the AiA groups were treated with simvastatin 40 mg/kg i.p. daily for 14 consecutive days after induction of arthritis. Platelet- and leucocyte-endothelial cell interaction was assessed by measurement of rolling and adherent fluorescence-labelled platelets and leucocytes, functional capillary density (FCD) was evaluated, and knee joint diameter was determined as a clinical parameter. RESULTS: In arthritic mice treated with simvastatin, a significant reduction in platelet- and leucocyte-endothelial cell interaction was observed in comparison to arthritic mice treated with vehicle. In addition, a significant reduction in FCD was seen in arthritic mice treated with simvastatin, along with a reduction in knee joint swelling of the AiA mice. CONCLUSIONS: Treatment of AiA mice with simvastatin showed significant reductions in platelet- and leucocyte-endothelial cell interactions, in FCD, and in the swelling of the knee joint. These results support the hypothesis of the anti-inflammatory effects of statins in the treatment of RA.

Interdisciplinary expert consultation via a teleradiology platform--influence on therapeutic decision-making and patient referral rates to an academic tertiary care center.

In addition to teleradiological reporting as a nighthawking or a regular service, teleradiological communication can be used for interdisciplinary expert consultation. We intended to evaluate an interdisciplinary consultation system based on a teleradiology platform with regard to its impact on therapeutic decision-making, directed patient referrals to an academic tertiary care center and the economic benefit for the hospital providing the service. Therefore, consultations from five secondary care centers and consecutive admissions to an academic tertiary care center were prospectively evaluated over a time period of six months. A total of 69 interdisciplinary expert consultations were performed. In 54 % of the cases the patients were consecutively referred to the university hospital for further treatment. In all acutely life-threatening emergencies (n = 9), fast and focused treatment by referral to the academic tertiary care center was achieved (average time to treat 130 min). The admissions to the academic tertiary care center led to improved utilization of its facilities with additional revenue of more than 1,000000 euro p. a. An interdisciplinary expert consultation via a teleradiology platform enables fast and efficient expert care with improved and accelerated patient management and improved utilization of the service providing hospital.

[Randomized clinical trials in trauma surgery: decision-making in an area of conflict between eminence and evidence]. / Randomisierte klinische Studien in der Unfallchirurgie: Entscheidungsfindung im Spannungsfeld zwischen Eminenz und Evidenz.

Well-designed, prospective, multicenter, randomized clinical trials (RCTs) define the gold standard of evidence-based medicine. The results of such trials represent the most solid rationale for therapeutic recommendations in the S3 guideline of medical societies (http://www.leitlinie.de). The performance of studies according to good clinical practice (GCP) guidelines (Guidelines of the International Conference on Harmonization on Good Clinical Practice) is extremely demanding. The findings can shake long established principles and practices to the core. For more than 20 years now, the management of femoral shaft fractures in critically injured patients has been controversially discussed. There are two different concepts competing against each other: Early total care (ETC) aiming at definitive care by immediate femoral nailing and damage control orthopedics (DCO), where nailing is performed at a later time point after initial retention by the use of external fixation. In order to answer this still unresolved question, the Damage Control Study is currently under way involving 25 trauma centers throughout Germany. This study is funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Association), it is endorsed by the board of Deutschen Gesellschaft für Unfallchirurgie (DGU, German Society for Casualty Surgery) and it is embedded in a joint program of the DFG and the Federal Ministry of Education and Research (BMBF) to support clinical studies in Germany. Moreover, the study is supported by the ChirNet Site at Witten/Herdecke-Köln (http://www.chir-net.de). Without a doubt, this RCT is one of the most important studies carried out in the field of care for the critically injured patient, because the results will have a profound influence on the future management of femoral shaft fractures in multiple trauma patients and because successful completion of this study will underline the high scientific competence and skills claimed by German trauma surgeons. At the same time, ironically, the success of this study is endangered by the dilemma of an as yet insufficient recruitment of suitable patients to be enrolled into the trial. In this article possible explanations for this problem will be discussed based on a case report and the specific challenges in performing RCTs that scrutinize questions in the field of surgery will be analyzed.

[Midshaft clavicle fractures--classification and therapy. Results of a survey at German trauma departments]. / Die Klavikulaschaftfraktur--Klassifikation und Therapie. Ergebnisse einer Umfrage an unfallchirurgischen/orthopädischen Kliniken in Deutschland.

INTRODUCTION: The therapy of the midshaft clavicle fracture, in particular dislocated midshaft fractures, remains controversial. Therefore the objective of this study was to obtain data about the current treatment for midshaft clavicle fractures. METHODS: In a countrywide anonymous survey 240 German orthopaedic trauma departments were asked about their diagnostic and therapeutic procedures for midshaft clavicle fractures. A total of 142 questionnaires (59%) were returned and evaluated. RESULTS: More than 80% of the hospitals dispense with a standardised fracture classification for midshaft fractures. Simple fractures are generally conservatively treated, in the majority using a figure-of-eight bandage (88%). On average 26% of all clavicle fractures are operatively stabilized, independent of whether the treatment was performed at a trauma centre or any other hospital (p=0.45). Indications for operative treatment of midshaft fractures include severe additional injuries in the shoulder region (81-95%), young and active adults (52-64%) and dislocated midshaft fractures (56-75%). All departments use plate fixation for midshaft fractures; in particular the reconstruction plate (56%) is most frequently applied. Alternatively, if the fracture pattern is considered suitable for intramedullary fixation, this procedure is performed by 43% of the clinics, although this operative technique is used significantly more often in trauma centres (55%) than in other hospitals (31%) (p=0.01). CONCLUSION: This survey demonstrates a high rate (26%) of German trauma hospitals operating clavicular midshaft fractures. This result is consistent with recently published studies showing better results for operative treatment of dislocated midshaft clavicular fractures compared to conservative therapy.

The SCL +40 enhancer targets the midbrain together with primitive and definitive hematopoiesis and is regulated by SCL and GATA proteins.

The SCL/Tal-1 gene encodes a basic helix-loop-helix transcription factor with key roles in hematopoietic and neural development. SCL is expressed in, and required for, both primitive and definitive erythropoiesis. Thus far, we have identified only one erythroid SCL enhancer. Located 40 kb downstream of exon 1a, the +40 enhancer displays activity in primitive erythroblasts. We demonstrate here that a 3.7-kb fragment containing this element also targets expression to the midbrain, a known site of endogenous SCL expression. Although the 3.7-kb construct was active in primitive, but not definitive, erythroblasts, a larger 5.0-kb fragment, encompassing the 3.7-kb region, was active in both fetal and adult definitive hematopoietic cells. This included Ter119+ erythroid cells along with fetal liver erythroid and myeloid progenitors. Unlike two other SCL hematopoietic enhancers (+18/19 and -4), +40 enhancer transgenes were inactive in the endothelium. A conserved 400-bp core region, essential for both hematopoietic and midbrain +40 enhancer activity in embryos, relied on two GATA/E-box motifs and was bound in vivo by GATA-1 and SCL in erythroid cells. These results suggest a model in which the SCL +18/19 and/or -4 enhancers initiate SCL expression in early mesodermal derivatives capable of generating blood and endothelium, with subsequent activation of the +40 enhancer via an autoregulatory loop.

Biomechanical evaluation of a bioabsorbable expansion bolt for hamstring graft fixation in ACL reconstruction: an experimental study in calf tibial bone.

INTRODUCTION: The purpose of our study was to evaluate and compare the primary fixation strength of a novel bioabsorbable two shell expansion bolt (EB) with that of a well-established interference screw-fixation technique in hamstring reconstruction of the anterior cruciate ligament. MATERIALS AND METHODS: Thirty calf tibia plateaus (age 5-6 months) were assigned to three groups: In group I (n = 10) triple-stranded hamstring grafts were fixed with titanium interference screws (7 mm thread / 8 mm head x 25 mm). Specimens of group II (n = 10) received bioabsorbable poly-L-lactide interference screws (8 x 23 mm). In group III (n = 10), the grafts were fixed using bioabsorbable poly-D,L-lactide expansion bolts (5.8/8.5/10 mm x 35 mm). The tensile axis was placed parallel to the bone tunnel. The construction was then loaded until failure under a displacement rate of 1 mm per second. RESULTS: There were no significant differences concerning the maximum pullout force (group I: 357 N +/- 61; group II: 326 N +/- 92; group III: 343 N +/- 55). In case of the expansion bolt, we found the stiffness to be higher (61 N/mm) when compared to group I (48 N/mm), and group II (52N/mm) (P < 0.01 I vs. III). Using interference screws, we were able to demonstrate a strong correlation between torque and pullout forces (group I: r2 = 0.7; group II: r2 = 0.92). Ruptures of the suturing material occurred only in groups I and II. CONCLUSION: We conclude that hamstring graft fixation, using the presented expansion bolt, demonstrates fixation strength similar to the established screw fixation and can therefore be regarded as a reasonable alternative fixation method. Especially, since some specific disadvantages of screw fixation can be prevented by application of the bolt fixation.

Transcriptional regulation of the SCL locus: identification of an enhancer that targets the primitive erythroid lineage in vivo.

The stem cell leukemia (SCL) gene, also known as TAL-1, encodes a basic helix-loop-helix protein that is essential for the formation of all hematopoietic lineages, including primitive erythropoiesis. Appropriate transcriptional regulation is essential for the biological functions of SCL, and we have previously identified five distinct enhancers which target different subdomains of the normal SCL expression pattern. However, it is not known whether these SCL enhancers also regulate neighboring genes within the SCL locus, and the erythroid expression of SCL remains unexplained. Here, we have quantitated transcripts from SCL and neighboring genes in multiple hematopoietic cell types. Our results show striking coexpression of SCL and its immediate downstream neighbor, MAP17, suggesting that they share regulatory elements. A systematic survey of histone H3 and H4 acetylation throughout the SCL locus in different hematopoietic cell types identified several peaks of histone acetylation between SIL and MAP17, all of which corresponded to previously characterized SCL enhancers or to the MAP17 promoter. Downstream of MAP17 (and 40 kb downstream of SCL exon 1a), an additional peak of acetylation was identified in hematopoietic cells and was found to correlate with expression of SCL but not other neighboring genes. This +40 region is conserved in human-dog-mouse-rat sequence comparisons, functions as an erythroid cell-restricted enhancer in vitro, and directs beta-galactosidase expression to primitive, but not definitive, erythroblasts in transgenic mice. The SCL +40 enhancer provides a powerful tool for studying the molecular and cellular biology of the primitive erythroid lineage.

Bioabsorbable expansion bolt fixation in anterior cruciate ligament reconstruction.

The current study evaluated initial fixation strength of a bioabsorbable expansion bolt compared with interference screw fixation in anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft. Thirty calf tibial plateaus with adjacent patella and extensor ligaments were used. Bioabsorbable poly-L-lactide interference screws were used for graft fixation in Group I, titanium screws in Group II, and bioabsorbable poly-DL-lactide expansion bolts were used in Group III. The mean force-to-failure (+/- standard deviation) in the three groups was 487 +/- 205 N, 713 +/- 218 N, and 594 +/- 224 N, respectively. The differences between Groups I and II were significant. No statistical differences were found regarding stiffness. Graft damage was significantly less in Group III compared with screw fixation. The fixation concept of an expansion bolt shows similar fixation strength and less graft damage compared with the established interference screw fixation. Because of the total absence of torque forces in contrast to bioabsorbable screws, the risk of implant breakage is minimized.

[Surgical treatment of pulmonary metastases from renal cancer]. / Lungenmetastasenchirurgie beim Nierenzellkarzinom.

Based on a large single-center follow-up database, we evaluated the long-term results after curative resection of pulmonary metastases from renal cancer. During a 20-year period, 105 patients underwent a total of 150 resections with curative intention. Hospital mortality was 0.95%, 5- and 10-year survival rates were 40% and 33%, respectively. Significant prognostic relevance was shown for complete pulmonary resection, lymph node involvement upon primary resection as well as size of the resected lung metastasis. Our findings of low perioperative morbidity and mortality rates lead us to propose that in patients without additional metastases curative resection of pulmonary lesions should be considered. Moreover, recurrent pulmonary metastases should also be considered for surgical treatment since resection for cure significantly improves survival in these patients.

[Treatment of per- and subtrochanteric femoral fractures by gamma nails and modular hip prostheses. Differential indications and results]. / Versorgung der per- bis subtrochantären Femurfraktur durch Gammanagel und modulare Hüftprothese. Differentialindikation und Ergebnisse.

From January 1997 to August 1998 all stable and nonstable trochanteric femoral fractures (n = 72) were treated routinely by gamma nail using the correct operative technique. Patients showing additional osteoarthritis of the hip in radiographs hip replacement was performed by a cementless modular femoral hip prostheses from January 1996 to August 1998 (n = 28). Follow up period was 6 to 18 months. Operation time and blood loss were higher using the prostheses. However complications and lethality (< 5%) were not different during postoperative course. In each group three operative technical complications occurred. Using a modified Harris Hip Score (without range of motion, contractions) the score was decreased non significant comparing both groups first of all in unstable fractures until follow up. In each group one revision (loosening of prostheses, excessive shortening of femoral neck) was necessary. Using the correct operative technique, the gamma nail proved to be a save device with good outcome. Outcome using modular prostheses is comparable to gamma nail. Therefore the use of modular prostheses is justified in case of osteoarthrosis and in some cases of very unstable fracture.

Endoscopic osteosynthesis after thoracic spine trauma: a report of two cases.

Modern concepts of treating thoracic diseases suggest more and more the use of minimally invasive thoracoscopic techniques to reduce morbidity and save costs. For treatment of specific lesions at the thoracic spine, several thoracoscopic procedures have been performed successfully. The present report examines the feasibility of thoracoscopic osteosynthesis in two patients with ventral hyperextension injuries and anterior instability of the thoracic spine. After initial correction of the anatomical deformity, autologous bone was harvested from the anterior iliac crest. Using a ventral, thoracoscopic approach, the main location of the ventral, damaged spinal segment was identified by the covering pleural haematoma. After endoscopic ventral bone grafting, osteosynthesis was performed, using dynamic compression plates, cardan drills and screw drivers. The perioperative course was uneventful, and follow up examinations after 3 years and 9 months, respectively, revealed an unchanged stable spinal segment. Our results show thoracoscopic osteosynthesis to be technically possible, with a potential for yielding satisfying long-term results.

Kinetics of circulating adhesion molecules and chemokines after mechanical trauma and burns.

OBJECTIVE: To assess the role of circulating adhesion molecules and chemotactic cytokines within different settings of major trauma. DESIGN: Retrospective study. SETTING: Teaching hospitals, USA and Germany. SUBJECTS: Two groups of patients with multiple injuries (group I n = 155 and group II n = 12) with mean (SEM) injury severity scores (ISS) of 35 (4) and 32 (4) points, respectively, and 18 burned patients with a mean of ISS 38 (9) points. INTERVENTIONS: Serum samples were collected at the site of the accident and on admission to the (Group I) as well as during the post-trauma course in the hospital (Group II: days 1, 3, 5, 7, 10; Group III; weekly, up to week 10). MAIN OUTCOME MEASURES: Measurement of concentrations of soluble (s) adhesion molecules (sE-selectin, sP-selectin), and chemotactic cytokines (interleukin-8 [IL-8], epithelial cell derived neutrophil activating peptide 78 [ENA-78]) in serum after major mechanical trauma and burns. RESULTS: High concentrations of ENA-78 and sP-selectin were already present at the site of accident as well as one hour after injury. During recovery from the injuries, persistently high concentrations of IL-8, ENA-78, and sP-selectin were found, but sE-selectin was increased only during the first week after major trauma. CONCLUSION: Massive tissue trauma causes immediate activation of selected chemokines and adhesion molecules within minutes of the injury which will then persist depending on the type and severity of the injury for a substantial length of time. There was, however, no correlation between serum concentrations of the mediators investigated and susceptibility to complications or outcome.

[Results of operative therapy in sequential liver and lung metastasis]. / Ergebnise der operativen Therapie bei sequentieller Leber- und Lungenmetastasierung.

During the last 16 years, 15 patients with colorectal (n = 12), gastric (n = 1), renal cell (n = 1) and adrenal (n = 1) carcinoma underwent sequential resection of both hepatic and pulmonary metastases. Median survival after diagnosis of primary tumor was 80 months (range 23-183), after liver resection 23 (range 10-131), and after lung resection 18 months (range 5-87). Compared to patients with only hepatic (median survival: 38 months) or pulmonary metastases (median survival: 30 months) survival time was not significantly different (p = 0.18).

Surgical treatment of tumor metastases: general considerations and results.

The prerequisite for a curative resection of metastases is their restriction to the key organs, the liver and lungs, in the sense of a limited dissemination. For long-term prognosis, the type of primary tumor as well as the radical resection of lung and liver metastases is essential. To improve the process of surgical indication and therapy of tumors, clear definitions for the terms "tumor recurrence" and "metastases" have been agreed upon. Research and clinical investigation have led to a better understanding of tumor-regulating factors, some of which are briefly described: Metastasis promoting factors include the lack of E-cadherin, which leads to a local penetration of basal membranes by tumor cells; CD44 seems to play an important role in cell-cell and cell-matrix interactions, apparently increasing the metastatic potential of tumors and reducing the long-term survival of patients. High levels of urokinase in primary tumors are also associated with a poorer prognosis, as well as plasminogen inactivator inhibitor PAI II, which plays a crucial role in tumor growth. Positive findings in bone marrow aspirates of patients with different malignancies, stained for cytokeratin 18, either are associated with higher recurrence rates in colon and breast cancer or can be correlated to the prognosis of patients with gastric cancer. Technical aspects of surgery for hepatic, pulmonary and skeletal metastases are presented and discussed with respect to curative and palliative indications.

[Surgery of metastases--can surgery of metastases be radical?]. / Metastasenchirurgie--Kann Metastasenchirurgie radikal sein?

Resection of metastases gains more and more importance in day to day surgical work task. Mainly only liver- and pulmonary metastases can be resected with a curative aim, depending on the primary tumor and the metastasing cascade. According to tumor surgery a R0-resection is warranted. Whether a multimodal approach may improve long-term results by eliminating occult micrometastases should be answered by ongoing studies. Even in palliative situations complete resections of metastasis are preferred and in selected situations a multimodal approach may be chosen.