[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]. / Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen (Neufassung 2019).

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]. / Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen (Neufassung 2019).

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]. / Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen (Neufassung 2019).

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

Influence of postoperative fluid management on pulmonary function after esophagectomy.

PURPOSE: The aim of this study was to investigate the effects of a restrictive vs. a liberal postoperative fluid therapy guided by intrathoracic blood volume index (ITBVI) on hemodynamic and pulmonary function in patients undergoing elective esophagectomy. Perioperative fluid therapy may influence postoperative physiology and morbidity after esophageal surgery. Definitions of adequate infusion amounts and evident rules for a fluid therapy are missing. METHODS: After esophagectomy, 22 patients were randomized either to a restrictive group (RG) with low range of ITBVI (600-800 ml/m2) or a liberal group (LG) with normal ITBVI (800-1000 ml/m2). Infusion regimen was modified twice a day according to transpulmonary thermodilution measurements until the 5th postoperative day. Primary endpoint was paO2/FIO2-ratio. Secondary endpoints were pulmonary function, fluid balance and hemodynamic as well as morbidity. RESULTS: Demographic and surgical details did not differ between both groups. The calculated sample size was not reached. There were no postoperative differences in paO2/FIO2-ratio, ITBVI, hemodynamic parameters, or morbidity either. Cumulative fluid uptake was 4.1 liter less in the RG on the 5th postoperative day (p = 0.01), and pulmonary function was better in these patients (area under curve day 2-7 for forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak expiratory flow (PEF) each <0.05). CONCLUSION: ITBVI guided restrictive infusion therapy yields a lower fluid uptake, but may not result in a difference of clinical relevant parameters. A fluid restriction after esophagectomy should always be combined with hemodynamic monitoring because additional infusions may be required.

[Perioperative nutrition - a nationwide web-based survey of German surgery departments]. / Perioperative Ernährung aus Sicht von Chirurgen - Eine deutschlandweite Online-Umfragen.

BACKGROUND: Insufficient nutrition in surgical patients increases perioperative morbidity, mortality, length of stay and therapy costs. Therefore, guidelines declare the integration of nutrition into the overall management as one of the key aspects of perioperative care. This study was conducted to evaluate the current clinical practice of clinical nutrition in surgical departments in Germany. METHODS: In 2009 German Surgical Society (DGCH) members in leading positions were surveyed with a standardised online questionnaire concerning their perioperative nutritional routines in elective surgery. RESULTS: From the addressed physicians n = 156 (6.24 %) answered. Of those, 86.9 % consider the nutritional status of their patients. Only 6 % use standardised nutritional screening tools. Short preoperative fasting for solid and liquid food is practiced by 65 % and 40 %, respectively. After the operation, 65 % allow intake of clear fluids on the day of surgery and 78 % initiate solid food on the day of surgery or the first postoperative day. Oral nutritional supplements are given only "sometimes" or "rarely" by 53.9 % of the respondents. CONCLUSION: The low response rate may imply the dilemma that the evidence-based benefit of perioperative nutrition does not meet sufficient interest. Even in case of a positive selection of "pro-nutrition respondents", standardised preoperative malnutrition screening is also rare. Aspects such as shorter perioperative fasting are already practiced more progressively. However, still greater efforts are needed to promote guideline-based clinical nutrition in surgical care in Germany.

Carbon storage, timber production, and biodiversity: comparing ecosystem services with multi-criteria decision analysis.

Increasingly, land managers seek ways to manage forests for multiple ecosystem services and functions, yet considerable challenges exist in comparing disparate services and balancing trade-offs among them. We applied multi-criteria decision analysis (MCDA) and forest simulation models to simultaneously consider three objectives: (1) storing carbon, (2) producing timber and wood products, and (3) sustaining biodiversity. We used the Forest Vegetation Simulator (FVS) applied to 42 northern hardwood sites to simulate forest development over 100 years and to estimate carbon storage and timber production. We estimated biodiversity implications with occupancy models for 51 terrestrial bird species that were linked to FVS outputs. We simulated four alternative management prescriptions that spanned a range of harvesting intensities and forest structure retention. We found that silvicultural approaches emphasizing less frequent harvesting and greater structural retention could be expected to achieve the greatest net carbon storage but also produce less timber. More intensive prescriptions would enhance biodiversity because positive responses of early successional species exceeded negative responses of late successional species within the heavily forested study area. The combinations of weights assigned to objectives had a large influence on which prescriptions were scored as optimal. Overall, we found that a diversity of silvicultural approaches is likely to be preferable to any single approach, emphasizing the need for landscape-scale management to provide a full range of ecosystem goods and services. Our analytical framework that combined MCDA with forest simulation modeling was a powerful tool in understanding trade-offs among management objectives and how they can be simultaneously accommodated.

Estimating landscape carrying capacity through maximum clique analysis.

Habitat suitability (HS) maps are widely used tools in wildlife science and establish a link between wildlife populations and landscape pattern. Although HS maps spatially depict the distribution of optimal resources for a species, they do not reveal the population size a landscape is capable of supporting--information that is often crucial for decision makers and managers. We used a new approach, "maximum clique analysis," to demonstrate how HS maps for territorial species can be used to estimate the carrying capacity, N(k), of a given landscape. We estimated the N(k) of Ovenbirds (Seiurus aurocapillus) and bobcats (Lynx rufus) in an 1153-km2 study area in Vermont, USA. These two species were selected to highlight different approaches in building an HS map as well as computational challenges that can arise in a maximum clique analysis. We derived 30-m2 HS maps for each species via occupancy modeling (Ovenbird) and by resource utilization modeling (bobcats). For each species, we then identified all pixel locations on the map (points) that had sufficient resources in the surrounding area to maintain a home range (termed a "pseudo-home range"). These locations were converted to a mathematical graph, where any two points were linked if two pseudo-home ranges could exist on the landscape without violating territory boundaries. We used the program Cliquer to find the maximum clique of each graph. The resulting estimates of N(k) = 236 Ovenbirds and N(k) = 42 female bobcats were sensitive to different assumptions and model inputs. Estimates of N(k) via alternative, ad hoc methods were 1.4 to > 30 times greater than the maximum clique estimate, suggesting that the alternative results may be upwardly biased. The maximum clique analysis was computationally intensive but could handle problems with < 1500 total pseudo-home ranges (points). Given present computational constraints, it is best suited for species that occur in clustered distributions (where the problem can be broken into several, smaller problems), or for species with large home ranges relative to grid scale where resampling the points to a coarser resolution can reduce the problem to manageable proportions.

Reduction of heart rate variability after colorectal resections.

BACKGROUND: Heart rate variability (HRV) is a sensitive marker of altered sympathetic-parasympathetic function and is reduced in inflammation, illness, and trauma. The effect of major abdominal surgery on the course of HRV parameters is still an issue requiring further investigation. MATERIALS AND METHODS: A prospective, observational study including 40 consecutive patients undergoing elective colorectal surgery under "fast-track" perioperative management. Time and frequency domain parameters of HRV were measured 1 day prior to operation and on days 1-5 postoperatively. General and surgical complications as well as the course of leucocytes and C-reactive protein (CRP) were documented and correlated to the HRV measurements. RESULTS: Time domain parameters of HRV showed a significant decrease compared to the preoperative values on postoperative day 1 and returned to baseline on day 2, demonstrating impaired autonomic regulation in the early postoperative period. No correlation to complications or course of leukocytes or CRP was significant in our study. CONCLUSIONS: Colorectal resections significantly influence the HRV course. The autonomic regulation is reduced in the early postoperative time and all parameters return to baseline until the third day.

A multispecies framework for landscape conservation planning.

Rapidly changing landscapes have spurred the need for quantitative methods for conservation assessment and planning that encompass large spatial extents. We devised and tested a multispecies framework for conservation planning to complement single-species assessments and ecosystem-level approaches. Our framework consisted of 4 elements: sampling to effectively estimate population parameters, measuring how human activity affects landscapes at multiple scales, analyzing the relation between landscape characteristics and individual species occurrences, and evaluating and comparing the responses of multiple species to landscape modification. We applied the approach to a community of terrestrial birds across 25,000 km(2) with a range of intensities of human development. Human modification of land cover, road density, and other elements of the landscape, measured at multiple spatial extents, had large effects on occupancy of the 67 species studied. Forest composition within 1 km of points had a strong effect on occupancy of many species and a range of negative, intermediate, and positive associations. Road density within 1 km of points, percent evergreen forest within 300 m, and distance from patch edge were also strongly associated with occupancy for many species. We used the occupancy results to group species into 11 guilds that shared patterns of association with landscape characteristics. Our multispecies approach to conservation planning allowed us to quantify the trade-offs of different scenarios of land-cover change in terms of species occupancy.

Laparoscopic sigmoid resection for diverticular disease has no advantages over open approach: midterm results of a randomized controlled trial.

PURPOSE: Elective laparoscopic sigmoid resection (LSR) for symptomatic diverticular disease is supposed to have significant short-term advantages compared to open surgery (open sigmoid resection (OSR)). This opinion is rather based on inferences from trials on colonic resections for malignant diseases or minor laparoscopic surgery. This randomized controlled trial was conducted to compare quality of life as well as morbidity and clinical outcome after LSR vs. OSR following a midterm follow-up period. METHODS: Patients presenting with a symptomatic sigmoid diverticular disease stage II/III (Stock/Hansen) were randomly allocated to LSR or OSR in a prospective multicenter trial. Endpoints included the quality of life assessed with a standardized questionnaire, postoperative mortality, and complications within the follow-up of 12 months after operation. RESULTS: A total of 143 patients randomized between 2005 and 2008 in 12 centers could be analyzed. The recruitment was aborted for nonachievement of the planned sample size. Seventy-five patients were allocated to LSR, and 68 received OSR. Nine operations were converted to OSR (9%) and analyzed as intention to treat. Groups were comparable for age, gender, body mass index, comorbidity, and indication for surgery. Operation time was longer for LSR (p < 0.001). Quality of life did not differ between LSR and OSR, either during the early postoperative course or after 12 months (p = 0.172). Also, mortality and morbidity, including subgroups of major and minor morbidity, were compared. CONCLUSION: LSR was not superior to OSR regarding postoperative quality of life and incidence of complications in this trial.

Effects of animal positioning on catecholamine and vasopressin levels in pigs undergoing laparoscopy.

BACKGROUND: The aim of this study was to determine the influence of different therapeutic interventions and positions on catecholamine and vasopressin levels in the pneumoperitoneum (PN) in a porcine model. METHODS: In 43 pigs, a 14-mm-Hg PN was established and plasma concentrations of epinephrine, norepinephrine and vasopressin were measured in head-up, supine and head-down positions. Additionally, the effects of the following changes were studied: (1) increase in intrathoracic blood volume (ITBV) by means of hydroxyethyl starch infusion; (2) vasodilatation induced by sodium nitroprusside, or (3) selective sympathicolysis induced by esmolol. Again, catecholamines (ELISA) and vasopressin (RIA) were determined. RESULTS: After PN, epinephrine levels did not significantly increase in the head-up position (p = 0.075) and remained also unchanged in the supine or head-down position. Plasma norepinephrine statistically significantly decreased in the head-up position (p = 0.046). Vasopressin concentrations remained unaltered. After increased ITBV, neither catecholamine nor vasopressin concentrations changed in any body position. Application of sodium nitroprusside or esmolol caused no changes. CONCLUSION: Changes in endogenous catecholamine levels safely prevent cardiocirculatory instability in small pigs. Volume substitution might reduce endocrine responses to PN in the head-up position.

Agraffectomy after low rectal stapling procedures for hemorrhoids and rectocele.

BACKGROUND: Various sequelae which might lead to reintervention have been described after stapled rectal mucosectomy for hemorrhoids. One potential treatment modality for persistent complaints after stapled hemorrhoidopexy (SHP) or stapling for rectocele is the so-called agraffectomy (removal of the retained staples). This treatment option means a further procedure that can range from removal of the staples through the anoscope to removal of the entire staple line with the associated scar tissue. METHODS: In order to review the published literature, we conducted a search on Medline, Pubmed, and Embase using different terms for "agraffectomy." RESULTS: Overall, fourteen reports were found, dealing with agraffectomy for various conditions after low rectal stapling for hemorrhoids or rectocele. Agraffectomy is a rarely mentioned treatment option for conditions after SHP. In rectal stenosis with complete occlusion of the rectal lumen, the removal of the stenotic anastomosis and remaining staples seems to be reasonable. The same can be said of the removal of retained staples for rectal bleeding or in order to avoid penile injuries in anal intercourse. In contrast, the collected published reports on agraffectomy in this review only provide low-level evidence that this procedure provides relief for other problems such as incontinence or chronic pain. CONCLUSIONS: There is no clear evidence that agraffectomy is indicated if not in case of rectal stenosis and hemorrhage caused by the staples.

Initial results after implementation of a multimodal treatment for peritoneal malignancies.

INTRODUCTION: Peritoneal carcinomatosis represents a clinical condition with a limited perspective concerning long term survival. The combination of surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) represents a complex multimodal therapeutic management concept with promising results for prolongation of survival. For the identification of pitfalls during implementation of the HIPEC procedure into clinical practice an observational study was conducted. METHODS: Between 2005 and 2009 data from all patients treated with cytoreductive surgery and HIPEC for peritoneal carcinomatosis was prospectively collected and analysed. RESULTS: During the observational interval a total of 42 patients underwent surgical treatment for peritoneal carcinomatosis. In 34 patients the complete procedure with surgical cytoreduction and HIPEC was performed. Perioperative mortality (6%) and morbidity (35%) was similar to other reported series. Twenty-five patients (76%) survived the 18 months follow-up period after complete procedure. CONCLUSION: The multimodal therapeutic treatment concept of surgical cytoreduction and following HIPEC leads to promising results for patients suffering from peritoneal carcinomatosis. However this treatment concept is afflicted with a relevant risk of postoperative complications.

[Recommendations on treatment of acute appendicitis : Recommendations of an expert group based on the current literature]. / Empfehlungen zur Therapie der akuten Appendizitis : Empfehlungen einer Expertengruppe vor dem Hintergrund der aktuellen Literatur.

The paradigm shift in the treatment concept for acute appendicitis is currently the subject of intensive discussions. The diagnosis and differentiation of an uncomplicated from a complicated appendicitis as well as the selection of an adequate treatment is very challenging, especially since nonoperative treatment models have been published. The laparoscopic appendectomy is still the standard for most cases. Guidelines for the treatment of acute appendicitis do not exist in Germany. Therefore, a group of experts elaborated 21 recommendations on the treatment of acute appendicitis after 3 meetings. After initial definition of population, intervention, comparison and outcome (PICO) questions, recommendations have been finalized through the Delphi voting system. The results were evaluated according to the current literature. The aim of this initiative was to define a basic support for decision making in the clinical routine for treatment of acute appendicitis.

[Implementation of a fast track program : Challenges and solution approaches]. / Implementierung eines Fast-Track-Programmes : Herausforderungen und Lösungsansätze.

BACKGROUND: For more than a decade the evolving concept of fast track surgery has been implemented, predominantly in colorectal surgery. The practice of fast track surgery has yielded excellent results concerning reduction of postoperative complications and hospital stay and has been shown to increase patient satisfaction; however, several studies have shown a sometimes alarmingly low rate of implementation of the individual fast track measures and the rate is a maximum of 44%. OBJECTIVE: In this review, obstacles for implementation of fast track surgery are investigated. Advice is given on possible solutions to circumvent obstacles and facilitate successful establishment of multimodal recovery protocols in individual institutions. MATERIAL AND METHODS: The current international literature is critically evaluated and discussed with a particular focus on prospective clinical trials and expert recommendations. RESULTS: The reasons for a lack of adherence to fast track surgery principles have been shown to be multifactorial. Time-consuming expenditure, logistic difficulties, lack of support by colleagues as well as limitations in the healthcare system and patient-dependent factors appear to complicate implementation of fast track programs. CONCLUSION: Successful implementation and long-term perpetuation can be achieved only by an interdisciplinary team with a low level hierarchy, continuous training and a positive feedback culture. An early inclusion and clarification of personnel and patients should be firmly integrated into the fast track concept. This results in a higher satisfaction of patients and personnel and subsequently stronger adherence to the fast track concept.

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

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

'Fast-track' colonic surgery in Austria and Germany--results from the survey on patterns in current perioperative practice.

OBJECTIVE: 'Fast-track' rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Despite this evidence, there is no information on the acceptance and utilization of these concepts among the entirety of Austrian and German surgeons. METHOD: In 2006, a questionnaire concerning perioperative routines in elective, open colonic resection was sent to the chief surgeons of 1270 German and 120 Austrian surgical centres. RESULTS: The response rate was 63% in Austria (76 centres) and 30% in Germany (385 centres). Mechanical bowel preparation is used by the majority (Austria, 91%; Germany, 94%); the vertical incision is the standard method of approach to the abdomen in Austria (79%) and Germany (83%), nasogastric decompression tubes are rarely used, one-third of the questioned surgeons in both countries use intra-abdominal drains. Half of the surgical centres allow the intake of clear fluids on the day of surgery and one-fifth offer solid food on that day. Epidural analgesia is used in three-fourths of the institutions. CONCLUSION: Although there is an evident benefit of fast-track management, the survey shows that they are not yet widely used as a routine in Austria and Germany.

Multimodal perioperative rehabilitation for colonic surgery in the elderly.

BACKGROUND: Traditional perioperative care for colonic surgery in elderly patients is associated with increased morbidity and mortality compared to that of younger patients. Although multimodal perioperative rehabilitation has evolved as a valid concept to improve postoperative outcome, its use has not yet been established for colonic surgery in the elderly. METHODS: Data from 24 German hospitals performing multimodal perioperative rehabilitation as the standard perioperative care for elderly patients who have undergone elective colonic resection was assessed in a prospective multicenter study between April 2005 and April 2007. RESULTS: A total of 742 patients aged > or = 70 were examined. Overall compliance with the multimodal care protocol decreased with increasing age. Although laparoscopic colonic surgery was performed in 39.1% of the septuagenarians, the number decreased to 25.1% in the very old patients. The overall complication rate was 22.9% in the septuagenarians (18.1% surgical and 11.6% general complications) and increased in the very old patients to 38.4% (28.0% and 23.6%, respectively) The overall mortality rate was 1.0% and showed no age-specific variations. CONCLUSIONS: Although the overall morbidity did increase with age, it was still less when compared to that of historical groups with traditional care. Therefore, multimodal perioperative rehabilitation should be recommended for the elderly.

[Perioperative discontinuation of antiplatelet therapy of patients with coronary stents. Reevaluating the risks]. / Perioperatives Pausieren der antithrombozytären Therapie bei Patienten mit koronaren Stents : Ein neu zu bewertendes Risiko?

According to the present guidelines, patients with coronary stents are to be treated with dual antiplatelet therapy. In case surgery is needed, the risk of a fatal stent thrombosis by withdrawing antithrombotics needs to be balanced in each individual case against the risk of haemorrhagic complications on continued antiplatelet medication. We present a case of fatal stent thrombosis and discuss the current evidence regarding perioperative continuation and interruption of antiplatelet therapy for this patient population. In summary the haemorrhagic risk with acetylsalicylic acid for secondary prevention seems very low, and it should be discontinued only in selected cases. Continued dual anticoagulation concepts are also discussed.

[Endoscopy, angiography, surgery: diagnostic and therapeutic algorithms for diverticular bleeding]. / Endoskopie, Angiographie, Chirurgie: Diagnostik- und Therapiealgorithmus bei Divertikelblutung.

Diverticular bleeding is a complication of diverticular disease but in contrast to diverticulitis, publications concerning diverticular bleeding are less common. Diverticular bleeding is the cause of approximately 20-50% of cases of lower gastrointestinal bleeding and in rare cases can be life-threatening. The main symptom of diverticular hemorrhage is painless hematochezia and the German guidelines recommend that further diagnostics of suspected diverticular bleeding should be performed in hospital. Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding. If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed. The 99mTc erythrocyte scintigraphy should only be performed if endoscopy and angiography are unable to identify the localization of the bleeding source. More than 90% of diverticular hemorrhages stop spontaneously; however, it is general agreed that an active diverticular bleeding detected during colonoscopy should be immediately treated endoscopically. Alternative radiological techniques for hemostasis are rarely needed and attention must be paid to the complications. In the rare case of severe bleeding that cannot otherwise be stopped or if the bleeding vessel cannot be located, laparotomy and total colectomy can be recommended. If the diverticular bleeding has definitely been identified or recurrent bleeding causes chronic anemia, segmental or total colectomy may be undertaken; however, the advantages and disadvantages of both types of surgery have to be thoroughly explained to the patient.