Postoperative Dumping Syndrome, Health-Related Quality of Life, Anxiety, Depression, and Eating Disturbances: Results of a Longitudinal Obesity Surgery Study.

INTRODUCTION: Given the lack of research on the relationship of post-surgery dumping syndrome and eating disturbances, the purpose of the present longitudinal study was to investigate whether dumping after obesity surgery is associated with pre-/postoperative eating disorder symptoms or addiction-like eating beyond the type of surgery, gender, health-realted quality of life (HRQoL) and anxiety/depressive symptoms. METHODS: The study included 220 patients (76% women) before (t0) and 6 months after (t1) obesity surgery (sleeve gastrectomy [n = 152], Roux-en-Y gastric bypass [n = 53], omega loop gastric bypass [n = 15]). The Sigstad Dumping Score was used to assess post-surgery dumping syndrome. Participants further answered the Eating Disorder Examination Questionnaire (EDE-Q), Yale Food Addiction Scale 2.0 (YFAS 2.0), Short-Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) at t0 and t1. RESULTS: The point prevalence of symptoms suggestive of post-surgery dumping syndrome was 33%. Regression analyses indicate an association of dumping with surgical procedure (bypass), female gender, reduced HRQoL, more anxiety/depressive symptoms, and potentially with binge eating but not with eating disorder symptoms in general or with addiction-like eating. CONCLUSION: The current study failed to show a close relationship between the presence of self-reported dumping syndrome and eating disorder symptoms or addiction-like eating following obesity surgery. Further studies with longer follow-up periods should make use of clinical interviews to assess psychosocial variables and of objective measures to diagnose dumping in addition to standardized self-ratings.

Bariatric Surgery as the One Route to Achieving Donor Heart Transplantation in a Patient with a Left-Ventricular Assist Device.

Bariatric and metabolic surgery is currently the most effective procedure of achieving and maintaining weight loss. In the case under discussion, a 48-year-old male patient with heart insufficiency and an implanted left-ventricular assist device (LVAD) wanted to reduce his high BMI (48.6 kg/m2), so as to qualify for the heart transplant waiting list. According to the guidelines, he underwent all the required preoperative testing, which included psychosomatic clarifications, determination of endocrinological causes, and a nutritional consultation. During laparoscopic sleeve gastrectomy, a cardiac technician was present to support the anesthetist. After inserting 3 trocars with no complications, the greater curvature was mobilized using Medtronic's bipolar electrothermal vessel-sealing instrument, LigaSure™. The resection was performed with an Ethicon™ endostapler. Postoperative monitoring showed no signs of hemorrhage. The patient's BMI on the day of surgery was 46.8 kg/m2 and consecutively fell to 26.7 kg/m2 1 year after the procedure. Follow-up appointments revealed that the patient was fit and in good health. Thus, the patient's aim of being listed on the transplant list was fulfilled, and at the time of this writing, he is ready to be matched with an organ donor. Because high-BMI patients with inserted LVADs are less likely to receive a donor graft and must remain longer on transplant waiting lists than normal-weight patients, bariatric and metabolic weight loss surgery may lead to a speedier resolution for these high-risk patients.

Primary Sleeve Gastrectomy and Leaks: The Impact of Fundus-Wall Thickness and Staple Heights on Leakage-An Observational Study of 500 Patients.

Introduction: The most feared complication of laparoscopic sleeve gastrectomy (LSG) is staple-line leakage. Staple height and fundus-wall thickness might influence such leakage, and this study examined their possible impact on leak incidence. Factors including gender, age, comorbidities, and reinforcement of the staple line were also investigated. Methods: A total of 500 patients between 17 and 71 years of age who were scheduled for LSG were selected to participate in the study. For technical reasons, 53 were excluded. The fundus-wall thickness of 447 patients after LSG was investigated. The impact of staple height, fundus-wall thickness, demographic and medical factors on leak incidence were investigated. Most of our patients (309) were female (69%), while 138 were male (31%). Results: The mean thickness of the proximal fundus wall was 2,904 µm, 3,172 µm in men and 2,784 µm in women. The leak rate was 4.9%. Age, fundus-wall thickness, and BMI showed a strong influence on leak risk, but this effect was significant only for age (p = 0.01). Patient gender and staple size showed no significant influence on the correlation between fundus-wall thickness and leak risk. Gender displayed a small effect of influence on this correlation, with η2 = 0.05. Discussion: Because older age had a significant effect on increasing the risk of staple-line leakage, there is a need for a more specific focus on these patients. Thinner fundus wall and female gender might predispose patients to staple-line leaks, but a significant value could not be reached. Therefore, staple size should remain the surgeon's choice based on clinical experience.

A rare case of hepatic metastasis 20 years after surgical resection of a thymoma: A case report.

INTRODUCTION: Thymoma is the most common solid, primary mediastinal tumour, accounting for 20% of mediastinal neoplasms. Malignant thymus tumours (thymomas and thymic carcinomas) metastasize primarily locally. Distant metastases, especially to liver are very rare. PRESENTATION OF CASE: We review the case of a 59 year-old female patient, who underwent resection of the thymus with a diagnosed type B2 thymoma 20 years ago. The patient was referred to our hospital with a newly discovered space-occupying lesion in the liver, which had been detected in a routine follow-up magnetic resonance imaging scan. Since a malignant tumour of the liver could not be excluded, a conventional left hemihepatectomy was performed. Histological examination revealed a liver metastasis of the type B2 thymoma, which had been removed 20 years ago. CLINICAL DISCUSSION: The case was discussed in the interdisciplinary tumour board. Based on the very long history of the primary removal of the thymoma as well as the R0 resection of the liver metastasis, a follow-up regimen with CT scans on a regular basis was recommended. CONCLUSIONS: Newly discovered lesions of the liver in patients even with a long history of a thymoma should raise the suspicion of a liver metastasis that should be surgically resected as the therapy of choice. Further, this case indicates the importance for long-term radiographic follow-up.

No addiction transfer from preoperative food addiction to other addictive behaviors during the first year after bariatric surgery.

OBJECTIVE: The aim of the present study was to investigate whether the remission of preoperative food addiction is associated with increases or new onset of other addictions within the first year following bariatric surgery. METHODS: One hundred and twenty-five bariatric surgery patients were assessed before surgery (t1) and at 6 months (t2) and 1 year (t3) follow-ups. The assessments included the Yale Food Addiction Scale 2.0 (YFAS 2.0) and standardized questionnaires to measure symptoms of problematic alcohol use, gambling disorder, internet-use disorder, buying-shopping disorder, hypersexual disorder and exercise dependence. RESULTS: Forty-nine (39.2%) patients were assigned to the food addiction (FA+ ) and 76 patients (60.8%) to the non-food addiction group (FA- ) based on their preoperative YFAS scores. Overall, BMI and symptoms of food addiction decreased significantly from baseline to follow-ups. Preoperative food addiction status was not associated with postoperative increases or new onset of other addictions. Elevated symptoms of buying-shopping disorder, internet-use and hypersexual behaviour at baseline in the FA+ -group decreased over time and were comparable to the FA- -group at follow-ups. CONCLUSION: The 'addiction transfer' or 'cross addiction' hypothesis was not supportive for alcohol addiction, gambling addiction or other behaviours that may be addictive. Further studies are needed that investigate larger samples and longer observation periods, as well as other substance-use disorders.

Psychosocial Predictors of Work Ability in Morbidly Obese Patients: Results of a Cross-Sectional Study in the Context of Bariatric Surgery.

BACKGROUND: Obesity is associated with a higher risk of work disability and premature early retirement. OBJECTIVE: The aim of this study was to examine psychosocial predictors for work ability prior to surgery. METHODS: Based on a sample of 197 surgery-seeking obese patients (preoperative body mass index [BMI] above 35 kg/m2) from a German bariatric surgery unit, the present cross-sectional study examined based on standardized self-rating measures whether depressive symptoms, dysfunctional eating behaviors, relationship satisfaction, and life satisfaction have a predictive value for work ability. RESULTS: Considerable impairment of work ability was found in 51.8% of morbidly obese participants (n = 102). Multiple regression analyses revealed that older age, greater depressive symptoms, and lower life satisfaction were significant predictors of preoperative work ability. BMI, gender, relationship satisfaction, and dysfunctional eating behaviors did not predict work ability. CONCLUSIONS: Our findings might indicate the use of further psychosocial measures following bariatric surgery to increase work ability.

Correction to: Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height-an Observational Cohort Study Fundus Wall Thickness and Leaks.

There is an error in the published article. One patient's gender was mistaken; it has been changed from female to male. Thus, the number of male and female patients in Tables 1 and 2, and the median and p value in Table 2 are incorrect.

Food addiction and other addictive behaviours in bariatric surgery candidates.

OBJECTIVE: The present study investigated the association between food addiction (FA) and other addictive behaviours in 216 bariatric surgery candidates (91.7% class 3 obesity; 80.1% women; age Mdn = 44.00 years, range 18-73). METHOD: Assessment included the Yale Food Addiction Scale 2.0 (YFAS 2.0) and standardized self-report questionnaires to measure symptoms of disorders related to substance use (alcohol and nicotine) and behavioural addictions (gambling, Internet-use, buying, hypersexual disorders, and exercise dependence). RESULTS: Bivariate correlations indicated a moderate relationship of YFAS 2.0 FA symptoms with buying disorder symptoms and a weak association with Internet-use disorder symptoms. Fifty-nine patients (27.3%) met the YFAS 2.0 threshold for FA, 1.9% for alcohol use disorder, 6.0% for nicotine use disorder, 17.3% for buying disorder, 2.3% for Internet-use disorder, and 1.4% for hypersexual disorder. None of the patients scored above the respective questionnaire thresholds for gambling disorder or exercise dependence. Patients with versus without YFAS 2.0 FA diagnosis did not differ with regard to prevalence estimates of addictive behaviours. CONCLUSIONS: Clinical implications and potential limitations of the findings are discussed. Future studies should address the potential risk of postoperative addiction transfer using long-term follow-ups and controlled study designs.

Development and Evaluation of the Quality of Life for Obesity Surgery (QOLOS) Questionnaire.

BACKGROUND AND AIM: Even though health-related quality of life (HRQOL) is considered an important component of bariatric surgery outcome, there is a lack of HRQOL measures relevant for preoperative and postoperative patients. The objective of the current study was to develop a new instrument assessing HRQOL prior to and following bariatric surgery, entitled Quality of Life for Obesity Surgery (QOLOS) Questionnaire. METHODS: Topics for the QOLOS were initially generated via open-ended interviews and focus groups with 19 postoperative bariatric surgery patients. Qualitative analysis resulted in 250 items, which were rated by patients (n = 101) and experts (n = 69) in terms of their importance. A total of 120 items were retained for further evaluation and administered to 220 preoperative patients and 219 postoperative patients. They also completed a battery of other assessments to analyze issues of construct validity. RESULTS: Analyses resulted in a 36-item section 1 QOLOS form targeting both preoperative and postoperative aspects across seven domains (eating disturbances, physical functioning, body satisfaction, family support, social discrimination, positive activities, partnership) and a 20-item section 2 QOLOS form focusing on postoperative concerns only (domains: excess skin, eating adjustment, dumping, satisfaction with surgery). Subscales of both sections showed acceptable to excellent internal consistency (Cronbach's α 0.72 to 0.95) and good convergent and discriminant validity. CONCLUSION: The QOLOS represents a reliable and valid instrument to assess HRQOL in preoperative and postoperative patients. Future studies should test the questionnaire in larger samples consisting of patients undergoing different types of surgery.

Laparoscopic Sleeve Gastrectomy: Investigation of Fundus Wall Thickness and Staple Height-an Observational Cohort Study : Fundus Wall Thickness and Leaks.

BACKGROUND: Staple line leakage is a well-known complication after laparoscopic sleeve gastrectomy (LSG). Gastric wall thickness and the staple height may be determining factors for the occurrence of insufficiencies. To investigate this problem, an observational cohort study was carried out. Investigation concentrated on the gastroesophageal junction close to the angle of His, since this area is at highest risk for a leakage. METHODS: Fundus wall thickness of 141 specimens after LSG was measured by light microscopy at a predetermined location by a blinded pathologist. Furthermore, fundus wall thickness was compared with demographic data, clinical outcome, and the rate of insufficiencies. RESULTS: One hundred forty-one patients, 38 male and 103 female undergoing LSG, between January 2014 and July 2015 were included in the study. Male gender was associated with thicker gastric fundus wall. Overall leak rate was 2.1% (3/141). Median wall thickness of the 3 patients with detected leaks in the study group was thinner compared to the non-leak group (2810 vs. 3249 µm, respectively). DISCUSSION/CONCLUSION: Only male gender correlated with higher wall thickness of the fundus. The fact that all three patients who developed a leak were female, and the fundus of female patients as well as those of the leak group was thinner, indicates that wall thickness may have an impact on the rate of staple line leakage. Further studies with larger patient cohorts are needed.

Health-Related Quality of Life, Anxiety, and Depression in Bariatric Surgery Candidates Compared to Patients from a Psychosomatic Inpatient Hospital.

BACKGROUND AND AIM: Past research indicated high psychiatric comorbidity and poor health-related quality of life (HRQOL) in patients seeking surgical treatment for obesity. This study investigated if preoperative bariatric surgery patients perceive equally poor HRQOL and increased levels of anxiety and depression as mentally ill patients. METHODS: The study included four groups: 192 bariatric surgery candidates (PRE, 71% women, BMI 48.35 ± 8.98 kg/m2), 96 psychotherapy inpatients with mental disorders (PSY, 77% women, BMI 27.12 ± 9.17 kg/m2), 103 postoperative bariatric surgery patients (POST, 78% women, BMI 30.38 ± 2.88 kg/m2), and a convenience sample of 96 non-clinical volunteers with pre-obesity or obesity grade 1 (CG, 52% women, BMI 29.22 ± 2.64 kg/m2). HRQOL was measured using the 12-item short form health survey (SF-12), and psychopathology was assessed with the hospital anxiety and depression scale (HADS). RESULTS: The PRE group exhibited the lowest physical HRQOL, and the PSY group the lowest mental HRQOL. The highest mental/physical HRQOL was reported by the POST group and the CG, without significant differences between these two groups. While the PSY group scored higher on HADS-anxiety scale than the PRE group, neither group differed with regards to symptoms of depression. The lowest levels of HADS-depression were found in the POST group and the CG. CONCLUSIONS: The present findings suggest that bariatric surgery candidates may suffer from equally high levels of depression as psychotherapy inpatients, but they perceive better mental well-being. Routine mental health evaluation should incorporate assessments for both psychopathology and HRQOL. TRIAL REGISTRATION: DRKS00009901.

Quantity-guided drain management reduces seroma formation and wound infections after radical lymph node dissection: results of a comparative observational study of 374 melanoma patients.

BACKGROUND: Lymphatic fistulas are common complications after lymph node dissections in melanoma patients. We investigated whether drain management could improve the patient's outcome. METHODS: Patients who underwent axillary or inguinal lymph node dissection (RALND or RILND) for malignant melanoma were recorded in a prospective database. Two different methods of drain management were compared. Either the drain was removed no later than the eighth postoperative day (period I, 2003-2007) or it was left in place until fluid flow was below 50 ml in 24 h for two consecutive days (period II, 2008-2011). The main outcome criterion was the incidence of seroma punctures after drain removal. RESULTS: 374 patients were analysed. The incidence of seroma punctures significantly decreased in period II. The number of patients with elevated lymphatic secretions rose by 41.3% (RALND) and 38.1% (RILND). With the exception of lymphatic fistulas, we observed significantly more local complications with need for treatment in period I (n = 104, 52%) than in period II (n = 31, 18%). In period II, the hospital stays after both procedures were significantly reduced. CONCLUSIONS: We conclude that quantity-guided drain management leads to a prolonged interval of drainage but is associated with a lower incidence of seroma formation and shorter hospital stay.

Postoperative surgical complications after radical axillary lymph node dissection in melanoma disease result in increased pain.

Postoperative pain is one of the major problems caused by the operative trauma. We recorded the postoperative pain of patients who underwent a radical axillary lymph node dissection (RALND) to evaluate the quality of our standardized perioperative pain management program and the influence of surgical complications. Between August 2003 and December 2007, we registered the postoperative level of pain of 111 patients who underwent a therapeutic RALND, using a visual analog scale (VAS). Patients received standardized perioperative pain therapy according to level I of the World Health Organization (WHO) ladder of pain. We registered a VAS score of 10 in patients at rest during the first 3 postoperative days, but after mobilization of the arm, patients had significantly more pain (P < 0.0001). Patients with a postoperative surgical complication needed significantly more central analgesia to reach the same level of pain (P = 0.04) as patients without complication. Level I of the WHO ladder of pain is not enough for patients after an RALND. Patients with a postoperative complication do have increased pain, and use of only peripheral analgesia is insufficient.

The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients.

OBJECTIVE: To analyze patient outcome in the first 14 months of the German natural orifice translumenal endoscopic surgery (NOTES) registry (GNR). SUMMARY BACKGROUND DATA: NOTES is a new surgical concept, which permits scarless intra-abdominal operations through natural orifices, such as the mouth, vagina, rectum, or urethra. The GNR was established as a nationwide outcome database to allow the monitoring and safe introduction of this technique in Germany. METHODS: The GNR was designed as a voluntary database with online access. All surgeons in Germany who performed NOTES procedures were requested to participate in the registry. The GNR recorded demographical and therapy data as well as data on the postoperative course. RESULTS: A total of 572 target organs were operated in 551 patients. Cholecystectomies accounted for 85.3% of all NOTES procedures. All procedures were performed in female patients using transvaginal hybrid technique. Complications occurred in 3.1% of all patients, conversions to laparoscopy or open surgery in 4.9%. In cholecystectomies, institutional case volume, obesity, and age had substantial effect on conversion rate, operation length, and length of hospital stay, but no effect on complications. CONCLUSIONS: Despite the fact that NOTES has just recently been introduced, the technique has already gained considerable clinical application. Transvaginal hybrid NOTES cholecystectomy is a practicable and safe alternative to laparoscopic resection even in obese or older patients.

Preemptive analgesia reduces pain after radical axillary lymph node dissection.

BACKGROUND: Analyzing prospective data of our melanoma patients, we registered a suboptimal pain score under mobilization after radical axillary lymph node dissection (RALND). We performed a randomized, double blinded clinical trial to investigate the effects of a preemptive Parecoxib analgesic during the perioperative course. MATERIALS AND METHODS: Between October 2006 and December 2007, 32 patients with stage III/IV melanoma underwent therapeutic RALND and were randomized into two groups. Patients received intravenously 40 mg Parecoxib or 0.9% normal saline solution 2 h before RALND. The postoperative treatment and analgetic regime was defined in the study protocol. Main outcome criterion was the pain under mobilization at the first postoperative morning registered via a visual analogue score. Minor criteria were the postoperative complications, fatigue, amount of analgesics, and the day of discharge. RESULTS: Patients receiving a preemptive analgesic had a better outcome after RALND. The pain after mobilization was significantly decreased at the first postoperative morning (P = 0.04). Patients had less fatigue as well (P = 0.05) and the amount of pain medication in the treatment group was reduced (P = 0.04). CONCLUSIONS: Preemptive application of Parecoxib enhances outcome after RALND. A preemptive analgesic with Parecoxib in the perioperative management after RALND of melanoma patients can be recommended.

Effects of cyclooxygenase inhibition on anastomotic healing following large bowel resection in a rabbit model--a randomized, blinded, placebo-controlled trial.

PURPOSE: We performed an experimental study in a rabbit model to investigate the effects of a selective Cox-2 inhibitor (Valdecoxib) on anastomotic healing following large bowel resection after 1 week. MATERIALS AND METHODS: Eighty New Zealand white rabbits were randomized into four groups and underwent a colon resection with end-to-end anastomosis. Group 1 (n = 20) was treated with Valdecoxib, group 2 with Metamizole (Novalgin), group 3 with Resveratrol (specific Cox-1 inhibitor), or a placebo vehicle with similar volume (group 4). Anastomotic healing was tested at the seventh postoperative day by measurement of the bursting pressure in vitro. Immunohistochemical staining of the anastomotic site was performed with polyclonal antibodies (CD31). RESULTS: There were no significant differences in anastomotic dehiscence, bursting pressure, or vessel density between the treatment and control groups. CONCLUSION: The application of Valdecoxib does not influence anastomotic healing or new vessel formation in the anastomotic region following large bowel resection.

Intraoperative application of fibrin sealant does not reduce the duration of closed suction drainage following radical axillary lymph node dissection in melanoma patients: a prospective randomized trial in 58 patients.

BACKGROUND: Patients suffering from malignant melanoma often require radical lymph node dissection of the axillary nodal basin. The effects of intraoperative application of fibrin sealant following radical axillary lymph node dissection (RALND) on the incidence of postoperative lymphatic secretion are discussed. To study the effect of intraoperatively applied fibrin sealant following RALND a randomized patient-blinded trial was carried out. METHODS: Fifty-eight patients with axillary lymph node metastases of malignant melanoma underwent therapeutic RALND and were randomized into two groups: 29 patients received 2 cc of fibrin glue intraoperatively and 29 patients were only irrigated with 0.9% saline. The amount of drainage was recorded every 24 h. The main outcome criterion was the duration of drain placement in the wound. Minor criteria were the total amount of fluid and the length of hospital stay. Statistical analysis was performed using Spearman's log-rank correlation and paired t-test. RESULTS: There was no significant difference between the nonfibrin group 5 days (range = 3.6-5.7 days) and the fibrin group 5 days (range = 4.1-8.5 days) (p = 0.701). The total amount of fluid for the nonfibrin group (410 cc, range = 362-727 cc) and that for the fibrin group (503 cc, range = 369-1098 cc) (p = 0.605) and the length of postoperative hospital stay of 6 days (range = 5.4-7) vs. 7 days (range = 5.9-10.7), respectively, were not different between both groups (p = 0.387). CONCLUSION: Considering our study results, we cannot recommend the use of 2 cc of fibrin glue intraoperatively in the prevention of lymphatic secretion in patients undergoing RALND for metastatic melanoma.

The ubiquitin- and proteasome-dependent degradation of COX-2 is regulated by the COP9 signalosome and differentially influenced by coxibs.

The cyclooxygenase-2 (COX-2) enzyme is induced upon inflammation and in neoplastic tissues. It produces prostaglandins that stimulate tumor angiogenesis and tumor growth. Therefore, destruction and/or specific inhibition of COX-2 should be an important aspect of future tumor therapy. Recently, clinical application of specific COX-2 inhibitors called coxibs became doubtfully because they produce serious renal and cardiovascular complications under long term application. The exact underlying mechanisms are poorly understood and the different effects of diverse coxibs are not explained. It has been demonstrated before that COX-2 is degraded by the ubiquitin (Ub) proteasome system (UPS). However, how ubiquitination is accomplished and regulated was unclear. An important regulator of the UPS is the COP9 signalosome (CSN), which controls the stability of many proteins. Here we show that the proteasome-dependent degradation of COX-2 in HeLa cell lysate and in HeLa cells was stimulated by curcumin, an inhibitor of CSN-associated kinases. These data suggest a function of the CSN in the degradation of COX-2. In addition, proteolysis of COX-2 was significantly accelerated by parecoxib, but not by celecoxib or rofecoxib. By density gradient centrifugation and immunoprecipitation we demonstrate that COX-2 physically interacts with the CSN. Moreover, COX-2 is associated with large complexes consisting of the CSN, cullin-RING Ub ligases and the 26S proteasome. Pulldown experiments with Flag-COX-2 revealed cullin 1 and cullin 4 as components of the large super-complexes. Cullin 1 and 4 are scaffolding proteins of Ub ligases that presumably ubiquitinate COX-2. Treatment of HeLa cells with parecoxib results in an accelerated degradation of endogenous COX-2 accompanied by an increase of COX-2-Ub conjugates. In HeLa cells parecoxib is converted to the selective COX-2 inhibitor valdecoxib. Addition of valdecoxib also stimulates COX-2 degradation in HeLa cells. We therefore conclude that valdecoxib specifically interacts with COX-2 and induces a conformation accessible for ubiquitination and degradation.

Laparoscopic sigmoidectomy in Germany--a standardised procedure?

BACKGROUND: Laparoscopic resection of the sigmoid colon is generally considered as feasible option to open surgery, but standardised guidelines on surgical details have not been adopted yet. The aim of this survey was to investigate which techniques were applied by laparoscopic surgeons who are members of the Surgical Working Group for Minimal Invasive Surgery (CAMIC) of the German Surgical Society. MATERIALS AND METHODS: In 2005, we conducted a written survey among all members of the CAMIC asking them for their routine surgical strategy of laparoscopic sigmoid resection in a standardised multiple-choice questionnaire. This questionnaire consisted of 20 questions covering main technical issues of laparoscopic sigmoid resection including trocar and team positioning, mobilisation and resection of the left colon, specimen retrieval as well as anastomosing technique. The results were classified into four levels of consensus depending on the level of agreement between participating surgeons. RESULTS: There were 292 surgeons who took part in the survey. Strong consensus (>95% agreement) was only found in 1 of 20 technical details: the operating surgeon standing at the patient right's side. Consensus (75-95% agreement) was found for: position of the first assistant standing to the patient's left side, size of the camera port is 10 mm, lateral mobilisation of the left hemicolon before ligating the inferior mesenteric artery, extracorporeal resection of the sigmoid via minilaparotomy, transrectal stapling of the colorectal anastomosis, intraoperative testing of the anastomosis for leakage, no regular suturing over the anastomosis and irrigating of the abdominal cavity after surgery. CONCLUSIONS: Variability of technical details of laparoscopic sigmoidectomy was surprisingly high among German laparoscopic surgeons. This fact should be considered when discussing clinical studies about laparoscopic sigmoidectomy because trocar position, type of minilaparotomy and dissection techniques may very well influence patient outcome after laparoscopic surgery. Therefore, publications of clinical results concerning laparoscopic sigmoid resection should include a precise description of the technical details of the operation.