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Fistula in ano is a common condition mostly caused by inflammation of the proctodeal anal glands. This results in an acute anal abscess or chronic fistula. Anal fistulas are classified according to their relation to the anal sphincter muscles: subcutaneous, subanodermal, intersphincteric, transsphincteric, suprasphincteric or extrasphincteric. Distal fistulas including negligible amounts of sphincter muscle are treated by a lay-open technique (fistulotomy, fistulectomy), whereas proximal fistulas are cured using sphincter-saving procedures (advancement flap, fistulectomy with primary sphincter reconstruction, ligation of intersphincteric fistula tract, fistula plugs, fistula clip). The best surgical method balances the chance of healing and the risk of incontinence. An experienced colorectal surgeon also plays an important role.

Several surgical techniques for dealing with pilonidal disease (PD) exist. Primary closure allows for quicker healing. Off-midline closure provides for better healing rates compared with midline closure. Fewer recurrences occur with open healing compared with midline closure. Systematic reviews of each method are prone to bias. Many minor small variations in technique occur, adding to the great divergence of published results and in the understanding of the pathogenesis of PD. The literature suggests a trend away from wide excision and healing by secondary intention toward less invasive procedures. Flap techniques may be used for complicated recurrent PD. The Limberg flap is widely used and provides satisfactory results.

Fecal incontinence is not a rare condition; it is an often unvoiced disorder. Approximately 2 % of the general population is affected, and it is more frequent with increased age. Various classifications are used to reflect the severity of symptoms and their impact on quality of life. Diagnostic management leading to therapeutic interventions depends on disease stage; in the majority of patients diagnostic techniques are simple and therapy is conservative, following a pragmatic approach. Diagnostics may help to distinguish functional from morphological causes and thus direct treatment. Operative therapy is indicated if conservative treatment fails to adequately relieve symptoms. Interventions range from minimally invasive outpatient procedures to more extended surgery with sphincter replacement. The mainstays of surgery for fecal incontinence are sphincter repair and sacral nerve stimulation. Although the indications for the various surgical procedures can overlap, there are distinct conceptual differences. In addition, practitioners are increasingly coming to appreciate that, for some patients, only a combination of various therapeutic modes will improve symptoms.

Although constipation is no longer treated primarily with surgery, surgeons continue to regularly see patients with constipation in ward and ambulatory settings. It is therefore critical to have a practical approach with respect to diagnosis, investigation, and management. Further, recent pharmacological and surgical advances are giving new hope to some patients with disabling chronic symptoms. This chapter gives an overview of constipation in general and then focuses on the more surgically relevant problem of chronic constipation. The chapter deliberately excludes a detailed discussion of defecation disorders (covered in Chap. 11), although this distinction is actually relevant only when specific surgery is considered.

Defecation disorders refers to the inability to efficiently and rapidly empty the rectum of its contents on demand. Functional and anatomic abnormalities coexist to give combined symptoms of 'obstructed defecation' a source of discomfort and impaired quality of life. These symptoms include abnormal anal function (anismus), perineal descent, rectocele and enterocele, rectal intussusception, and overt prolapse. Management is based on a detailed assessment of the terminal bowel anatomy and function to identify a cause. Medical treatment and pelvic floor retraining are first-line treatment. Various types of surgical approaches currently designed to correct anatomic abnormalities in order to improve function can be carried out in selected patients. In this difficult area of functional pelvic floor disorders, a multidisciplinary approach as developed in “pelvic floor clinics” is a useful adjunct to the traditional colorectal approach. Providing information to the patient and his/her relatives is essential, especially when surgery is considered.

The understanding of the pathophysiology of rectal prolapse syndromes has progressed. Untreated total prolapse leads to fecal incontinence. Obstructed defecation and incontinence have been linked to internal rectal prolapse. Proper functional assessment should lead to a treatment tailored to the patient and will include surgery in a subgroup of patients.

Perineal approaches to rectal prolapse are still indicated in old and frail patients. Laparoscopic rectopexy techniques have become the standard of care. Laparoscopic ventral mesh rectopexy minimizes the mobilization of the rectum and allows prolapses of the middle and posterior pelvic compartment to be corrected. Therefore the technique can be used to treat not only rectal prolapse but also complex rectoceles and enteroceles.

There is ongoing debate regarding the type of mesh to be used to minimize the risk for mesh-related problems and to avoid prolapse recurrence. Despite improved surgical technique, not all patients experience a functional recovery, and there is a permanent need to monitor the functional sequelae of prolapse surgery.

Irritable bowel syndrome (IBS) is characterized by chronic abdominal symptoms and irregular bowel movements without any cause that can be revealed by routine diagnostic assessment. While its pathophysiology has come to be better understood, new therapeutic approaches have been developed and are summarized in the new interdisciplinary S3 guideline to give concrete recommendations for symptom-based diagnosis and treatment. The Rome classification system characterizes IBS in terms of multiple physiological determinants contributing to a common set of symptoms rather than a single disease entity.

To achieve the best diagnostic results, a careful history and physical examination should be supplemented by basic laboratory testing, abdominal ultrasound, and, in women, gynecological examination.

Treatment options should be chosen according to the symptoms and might include dietary recommendations, psychological components, and symptomatic medication in addition to the general therapeutic principles. The prognosis differs by individual, depending on the patient’s optimism expectations and successful management.

Ulcerative colitis is a chronic, relapsing idiopathic inflammation of the rectum and variable lengths of the adjoining colon. Onset usually occurs during the third and fourth decades of life and commonly presents with bloody diarrhea. A diagnosis is made using a combination of endoscopic and histological evidence to distinguish it from other inflammatory colitides, in particular Crohn’s disease. The extent of the disease in terms of the amount of colon involved and the severity of the attacks both vary, and treatment is tailored depending on both these factors. Ulcerative colitis predisposes individuals to colorectal cancer, and surveillance is required for most sufferers. Acute severe colitis is the most serious manifestation of the disease and initially requires hospital treatment with intravenous steroids. Emergency surgery in the form of a subtotal colectomy and end ileostomy is vital in those not responding to medical treatment to avoid colonic perforation. There are two major elective procedures: restorative proctocolectomy (ileoanal pouch procedure) and panproctocolectomy. Laparoscopic surgery is now an option for both emergency and elective procedures.

The exact etiology of Crohn’s disease remains unclear, but current evidence suggests that the intestinal mucosal barrier is compromised, allowing invasion of intestinal bacteria into the bowel. Conservative measures are the mainstay of treatment. Surgery is primarily used to treat complications of Crohn’s disease and to improve quality of life. Certain situations such as enterovesical fistulas are absolute indications for surgery. In isolated ileocecal Crohn’s disease, primary ileocecal resection is a therapeutic alternative equivalent to the escalation of medical treatment. Adequate preoperative preparation, including improving nutritional status, weaning off or stopping immunosuppressive medication, and preoperatively draining abscesses, can decrease complication rates of surgery for Crohn’s disease. Unless neoplasia is present, bowel-sparing techniques (strictureplasty, limited resections) should be used. The laparoscopic approach is possible for most indications; its superiority over the open approach has been shown for primary ileocecal resection. Seton drainage is a good option to retain quality of life for patients with complex perianal fistulas.

Indeterminate colitis is an exclusion diagnosis that is used for 10–15 % of patients who have had a colectomy for inflammatory bowel disease (IBD)–related colitis when there are no definite features of ulcerative colitis or Crohn’s colitis. The term is reserved for operated patients; those still not operated on and in whom the diagnosis is an uncertain are now considered to be 'IBD unclassified'. The specific diagnosis given to a patient with IBD colitis depends on the clinical course and features, the endoscopic appearance, and to a large extent the microscopic findings, though it is evident that there is room for judgment and uncertainty. Over time, many patients with an indeterminate colitis will be reconsidered and labeled with a definite diagnosis, often ulcerative colitis. With the advent of restorative proctocolectomy including a pelvic pouch, this diagnostic dilemma has become more important. Most surgeons will not recommend a pelvic pouch to a patient with a definite diagnosis of Crohn’s disease, since most studies report a higher risk of pelvic septic complications and pouch failure in these patients. However, most agree that the risk in a patient with an indeterminate colitis is considerably less, with an only a slightly increased complication rate, compared with those with an ulcerative colitis.

Colonic diverticulosis is among the most common diseases in developed Western countries, and its incidence is increasing as the average age of the population increases. Its etiology remains largely unknown. It is assumed that intestinal innervation disorders and structural alterations of the musculature induce abnormal contractile patterns with increased intraluminal pressure, thereby promoting the development of diverticula. The location of diverticula within the colon varies significantly among different regions of the world. In Western countries, primarily left-sided diverticulosis, particularly involving the sigmoid colon, has been well-described. This is in contrast to findings in Asia, where right-sided diverticulosis dominates. The actual prevalence of diverticulosis is difficult to determine because most individuals are asymptomatic. Acquired diverticular disease of the colon has been estimated to occur in 30 % of the population over the age of 45 years; 10–25 % of these individuals develop symptomatic diverticulitis. The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. Acute diverticulitis is treated according to severity. Computed tomography permits the complete evaluation of the location and extent of the inflammatory process, allowing appropriate, adapted clinical management. Treatment recommendations depend on the disease stage and include conservative approaches with observation and dietary modifications, as well as antibiotic treatment, abscess drainage, and surgery. A prerequisite for therapeutic decision making is an exact, comprehensive, and applicable classification of the disease before treatment. Several systems for classifying diverticular disease have been presented, but none of them has yet been universally adopted.

Colitis other than ulcerative colitis or Crohn’s disease affects a large group of patients. Etiology is multifactorial and includes infection, hyperosmolar formula feeding, a lack of breast milk, ischemia and reperfusion injury, Clostridium difficile, and viral and parasitic agents. The main symptoms are diarrhea; leukocytosis; fever; abdominal pain or cramping; bloody, mucoid, green, foul-smelling stools; the urge to defecate; and others such as dehydration, electrolyte disturbances, nausea, vomiting, malaise, anorexia, hypoalbuminemia, and anasarca. Diagnostic procedures include laboratory studies, endoscopy, plain abdominal radiography, computed tomography, and histology. Therapy depends of the exact diagnosis and may include conservative treatment; antibiotics causing the condition should be stopped and the patient should be rehydrated and given metronidazole/vancomycin). Surgery is required in rare cases to treat infections that worsen or do not respond to conservative treatment, or when there are any complications. Various approaches can be used, including early subtotal colectomy, colectomy, colostomy, ileostomy, and resection of the diseased bowel.

During the past decade, anti–tumor necrosis factor (TNF) agents and the emergence of new therapeutic concepts have dramatically modified inflammatory bowel disease (IBD) management, especially in the early phase. Salicylates remain the therapeutic basis in ulcerative colitis, whereas their efficacy in Crohn’s disease has not been confirmed. A rapid step-up approach is now considered for managing refractory IBD, providing early exposure to immunomodulators (i.e., conventional immunosuppressants and/or biologics in the case of a poor disease course). Some specific situations (severe, extended, or complicated forms) require the most efficient first-line therapy: the combination of anti-TNF agents and immunosuppressants. A close follow-up based not only on clinical symptoms but also on objective inflammatory tools (endoscopy, cross-sectional imaging, biomarkers) is needed to adjust medical therapy rapidly to prevent bowel damage and surgery.

Endometriosis is the presence of endometrial-like tissue outside the uterus. It is common affecting 6–10 % of women during childbearing years and is recognized as a condition with significant social impact as related symptoms may heavily impact on patient quality of life. The digestive tract is involved in approximately one quarter of cases.

The diagnosis is suggested by the history, symptoms and physical signs and is supported by physical examination and imaging techniques (transvaginal and endorectal ultrasound, magnetic resonance and CT scan). Confirmation of the diagnosis relies on histological examination of specimens collected at time of surgery.

The etiology of endometriosis is unknown therefore treatment is not directed at a cure but at reducing related symptoms and improving quality of life. Medical treatment should be considered initially and bowel surgery should be reserved for intractable symptoms. Surgery is often very challenging because the infiltration of various structures by endometriotic nodules. The potential advantages of surgery have to be balanced with the risk of complications. Surgical treatment needs a multidisciplinary approach and a surgical team well-trained in pelvic and laparoscopic surgery. A laparoscopic approach is preferable. No clear guidelines exist concerning the relative advantages of peeling, disk or segmental resection in the treatment of intestinal nodules. Complete resection of deep infiltrative endometriosis with a low complication rate is likely to result in significant symptom improvement and quality of life in usually young patients. Therefore such surgery has to be performed in referral centres.

Appendicectomy is the most common abdominal surgical procedure and is performed as an urgent or emergent procedure. The major difficulty in managing acute right iliac fossa pain is the broad differential diagnosis that can lead to a false-positive diagnosis in up to 30 % of patients. The availability of cross-sectional imaging has improved diagnostic accuracy, and laparoscopic techniques have reduced overall morbidity. Conservative management in selected patients may also be appropriate. In this chapter the evidence base for modern management of appendicitis is presented in the context of conventional clinical wisdom.

This chapter gives a short and understandable overview of benign colon tumors. Benign tumors can be separated roughly into two major groups, namely, epithelial and mesenchymal lesions. These two groups can be separated in multiple subgroups that are explained in detail within the chapter.

Polyp is a well-known term mostly connected with tumours of the colon. A polyps can be defined as a small clump of cells that form on the lining of the colon. Polyps show a certain diversity and hence can be classified by aspect, origin (cell type), and malignant potency. Therapy and follow-up can be planned based on these aspects.

Standard and uniform tumor classification is essential for the optimal care of patients with cancer. Both surgical and medical oncologists are increasingly using tumor classification along with genetic mutational analysis for prognostic and predictive purposes. Organizations such as the American Joint Committee on Cancer, World Health Organization, and Union for International Cancer Control are responsible for creating a common language for tumor classification and cancer staging. Appropriate standardized terminology is beneficial to all clinical practitioners. National pathology organizations are increasingly mandating standardized reporting of all cancer resection specimens.

The two main inherited colorectal cancer syndromes are familial adenomatous polyposis (FAP) and Lynch syndrome (hereditary nonpolyposis colorectal cancer [HNPCC]), which account for less than 1 % and 3 % of colorectal cancers, respectively. FAP is characterized by the occurrence of multiple colorectal adenomas that often start to develop during the teenage years. A germ-line mutation in the APC gene located on chromosome 5 is found in about 85 % of patients with this phenotype. Without prophylactic surgery, nearly all will develop colorectal cancer. Surgery, including restorative proctocolectomy or total colectomy with ileorectal anastomosis, has greatly reduced the death rate from colorectal cancer, and now prognosis is dependent on desmoid tumors and duodenal polyposis.

HNPCC syndrome is more complex than FAP because more genes are involved, penetrance is less complete, and expression varies more. The recommendation is to try to determine the microsatellite instability (MSI) phenotype to test patients showing an MSI. Screening guidelines are well defined. Surgical management of HNPCC using segmental versus total colectomy is still debated.

A third syndrome, the MYH-associated polyposis syndrome, related to germ-line biallelic mutation of the human MUTYH gene, is an autosomal-recessive colon cancer syndrome. Other syndromes such as Peutz Jeghers syndrome, juvenile polyposis, and hyperplastic polyposis are seen less frequently.

Bowel cancer is the second most common cancer in Europe. The great majority of colon cancers are sporadic, and only 5 % are associated with a recognized familial pattern of inheritance. Complete flexible colonoscopy is the gold standard in the early detection of colorectal neoplasia. Patients present with alteration in bowel habit, frank rectal bleeding, or anemia. Symptoms such as intermittent abdominal pain, nausea, and vomiting are often secondary to partial obstruction or peritoneal dissemination.

Primary treatment for colon cancer is surgical resection of the primary and lymph nodes. Open and laparoscopic approaches are equally safe. Chemotherapy improves outcome but the prerequisite for adjuvant therapy is complete removal of the primary tumor. Neoadjuvant treatment is debated.

Rectal cancer should be managed by a multidisciplinary team (MDT) that includes input from gastroenterology, radiology, pathology, radiation oncology, and oncology in addition to colorectal surgery. The workup of suspected rectal cancer includes digital rectal examination, rectoscopy (proctoscopy), and biopsy. Staging of the tumor requires thoracic/abdominal computed tomography, pelvic magnetic resonance imaging, and complete colonoscopy to assess local tumor growth, systemic spread, and synchronous colonic lesions. The findings should be discussed during an MDT conference to determine the optimal sequence of treatment and the timing and extent of surgical resection. Radiotherapy, which is best delivered preoperatively, reduces the risk of local recurrence and may enhance survival in high-risk patients. Concomitant chemotherapy is used to increase the effect of radiotherapy (chemosensitizing radiation). Complete resection of the rectum en bloc with the surrounding mesorectal envelope enclosing draining lymphatic tissue, called total mesorectal excision, is the gold standard to decrease the risk of local recurrence and avoid injury to adjacent pelvic structures. Rectal cancers in the middle and upper third of the rectum can be treated with sphincter-saving anterior resection and colorectal anastomosis. Cancer in the lower third of the rectum may be amenable to low anterior resection with coloanal anastomosis or require abdominoperineal excision. Tumors involving the pelvic floor or external anal sphincter are treated with extralevator abdominoperineal excision and permanent colostomy. Preoperative chemoradiotherapy may result in complete clinical and radiological response. Such patients may enter a watch-and-wait program of intensive surveillance to detect tumor regrowth. Review of the surgical specimen pathology during a postoperative MDT meeting is important to ensure treatment quality and to determine the potential need for adjuvant chemotherapy. Follow-up after treatment, to detect metachronous colorectal cancer, local recurrence, or systemic disease, should continue for 5 years. Surgery and radiotherapy have adverse effects on function of the bowel, urinary bladder, sexual organs, and gonads, which warrant attention both at the onset of treatment and during follow-up.

Within the past few decades the incidence of anal cancer has increased worldwide, especially among the male homosexual population (men who have sex with men [MSM]), with an incidence up to 225 in 100,000. Human papillomavirus (HPV) infections are a main risk factor for the occurrence of anal cancer. The prevalence of anal HPV infection in human immunodeficiency virus (HIV)–negative MSM is 50–60 %, whereas the prevalence reaches almost 100 % in HIV-positive MSM. Anal intraepithelial neoplasia (AIN), which is associated with HPV, has been identified as a precursor lesion for anal cancer. Approximately 20 % of HIV-negative MSM are diagnosed with AIN, and high-grade epithelial neoplasia is already present in 5–10 %. The prevalence of high-grade AIN among HIV-positive MSM is considerably higher and can reach 50 %. In hypothetical models, screening examinations such as anal cytology and high-resolution anoscopy have been shown to be cost-effective and efficient in MSM. Based on these findings, regular anal screening tests should be recommended for at-risk patients. If anal cancer is diagnosed, positron emission tomography/computed tomography is recommended for staging. Radiochemotherapy is the standard treatment for most patients. Surgery is only advisable in patients with small tumors (<2 cm) of the anal margin or as a salvage procedure. Follow-up should be performed for 3 years and should include digital rectal examination and palpation of inguinal lymph nodes.

The majority of patients with pseudomyxoma peritonei of appendiceal origin who have complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are cured. There is increasing evidence to support that similar principles of surgery and intraperitoneal chemotherapy can be effective in patients with peritoneal mesothelioma and colorectal peritoneal metastases. The key to a successful outcome is complete cytoreduction. This chapter discusses the evidence behind cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, mainly in colorectal peritoneal metastases, and the challenges associated in selecting patients in whom this strategy is appropriate.

Retro rectal tumors (RRTs) in adults are rare. The incidence of these tumors was estimated at 1 in 40,000. The majority of these tumors are benign (80 %) and asymptomatic, and therefore are mostly discovered incidentally. However, given the risk of chronic pain, bleeding, infection, compression of adjacent organs (with digestive, urinary, obstetric, and/or neurological disorders), and especially the risk of malignant transformation, the current consensus is to perform systematic complete resection of any RRT. Nevertheless, only retrospective series with relatively few patients are reported, and recommendations for management and surgical approaches remain controversial.

Stomas have been an important tool in the treatment of many colorectal disorders for decades. However, the role of a stoma, certain characteristics of this procedure, and the possibilities of stoma care have changed over time. Without doubt, the formation of a stoma leads to a marked change in patients’ quality of life (QOL); preoperative marking of the stoma site, proper surgical technique, and professional care and counselling by a stoma therapist are important conditions necessary to achieving an acceptable QOL following this procedure. This chapter deals with the principles of surgical stoma formation (ileostomy, colostomy) the prevention and management of the most common complications of stoma surgery (e.g., prolapse, parastomal hernia, retraction)

Endoscopy, allowing real-time examination of the large bowel, has evolved into a major diagnostic and therapeutic modality in coloproctology. Diagnostic colonoscopy with or without biopsy is generally a very safe procedure (<1 % risk of complication). Polypectomy, stricture dilation, coagulation of angiodysplasia, and stent placement through malignant strictures are major therapeutic interventions that can be undertaken during colonoscopy. Therapeutic procedures may lead to occasional complications, but when performed by appropriately trained clinicians, the expected benefits outweigh complication risks in patients with a clear indication.

Colonoscopy has a major role in patients follow-up after endoscopic polypectomy or colorectal cancer resection because of the risk of developing further advanced neoplastic lesions in these patients, as outlined in recent European guidelines.

Chromoendoscopy, involving applications of tissue stains or dyes to the gastrointestinal mucosa, has been used for several years to improve the detection and characterization of neoplastic lesions. New endoscopic imaging technology has recently been developed, aiming to improve mucosal visualization, including improvements in image resolution, software processing, and optical filter technology.

While accidental anal and rectal trauma is relatively rare, iatrogenic injuries to this region – particularly the anus – are quite common. This chapter describes the most frequent etiologies of anal/rectal trauma and the basic clinical and instrumental investigations necessary to provide the most appropriate treatment, particularly in emergencies, when saving patient’s life is a surgeon’s primary concern.

The surgical management of anal and rectal trauma and retention of foreign bodies in the rectum is discussed using a dedicate algorithm. Finally, the possible functional consequences of these traumas are reviewed and how to preserve fecal continence and normal evacuation is described.

Colonic/rectal obstruction, also known as large-bowel obstruction, is a serious condition that needs careful and prompt diagnostic and therapeutic measures to obviate harmful complications and even death. Colorectal cancer is the main cause of this obstruction in Western countries. Recent technological innovations (on-table lavage, colonic stents) have changed the therapeutic strategy, with a marked benefit for patient outcomes. Understanding the various etiological hypotheses, as well as the clinical presentation and the use of appropriate tests, make selecting the best treatment option possible. The preferred approach should be determined on an individual basis and tailored to the particular situation.

Lower gastrointestinal (GI) hemorrhage refers to bleeding that originates distal to the Treitz ligament. Although more than 80 % of these hemorrhages spontaneously resolve or respond to medical and/or endoscopic treatment, acute and massive hemorrhage may represent a life-threatening condition with a 5–10 % mortality. The colon is the first site of bleeding, and common causes include diverticula and angiodysplasia. In the case of occult or self-limited hemorrhage, the potential source is identified using endoscopy of a well-prepared bowel. For acute and massive lower GI bleeding, because colonoscopy may be hampered by the absence of preparation or poor visualization of the intestinal wall, multidetector computed tomography angiography (MDCTa) has progressively emerged as a highly efficient and useful triaging tool. MDCTa could become the investigation used first to identify the location and cause of lower GI bleeding and orient patients according to the different available therapeutic options, including endoscopy, transcatheter embolization, and surgery. Superselective embolization is highly successful and safe, with high technical and clinical success rates. Surgery is a last-resort option for uncontrolled bleeding. It requires a thorough examination of the bowel, including intraoperative enteroscopy with transillumination when the location of the bleed is unknown, which represents the worst situation. The use of segmental versus subtotal colectomy, both of which are associated with significant mortality, is debated depending on the certainty of the location and cause of the bleeding.

Chronic perineal pain is a common condition in patients suffering from pelvic floor disorders. Their management remains challenging and usually requires a long follow-up period and several therapeutic approaches to alleviate the symptoms. The first step is to make sure no organic lesions underlie this situation; imaging is mandatory to avoid any tumor or inflammatory disorder. In a second step, patients’ history and the characteristics of the pain must be precisely defined to offer appropriate therapeutic options. Finally, treatment should be adapted and carefully supervised for a long time to improve the situation.

New technologies and increasing surgical specialization have allowed surgeons to push the limits and perform increasingly complex surgical procedures even in elderly and frail patients. Recent improvements in perioperative care aim to reduce postoperative complications and thus to ameliorate and accelerate postoperative recovery.

Seemingly simple measures such as proper administration of antibiotic prophylaxis and skin disinfection have lowered surgical site infection rates. Perioperative nutritional support has been shown to reduce (infectious) complications, duration of hospital stay, and costs.

The underlying mechanism of many individual measures is to attenuate excessive postsurgical stress response. The best prevention is no doubt the reduction of surgical trauma; this explains the impressive results of minimally invasive surgery.

A comprehensive combination of multiple useful measures is an appealing approach to optimize perioperative care and hence postoperative outcomes. This idea has been realized and developed over the past decade with the advent of enhanced recovery pathways.

Standardization and improvement of perioperative management was followed by a reduction of the surgical stress response and consecutively a tremendous reduction of postoperative complications (by 50 %). The most welcome side effects were a shortened hospital stay and reduced health care costs.