Zentralblatt fur Chirurgie最新文献

The advantages of minimally invasive surgical techniques are undisputed. With the introduction of robotic assistance systems, classic laparoscopy has been further developed and is now also being utilized in transplant surgery, which was previously mainly characterised by open surgical procedures, particularly in living donor liver and kidney donations. In order to assess the current implementation status of robotic assistance systems in transplant surgery, international studies in this field were summarized and correlated with a national survey on the use of robotic assistance systems in living donation.First, a narrative summary of the MEDLINE-listed publications on robotic living kidney and liver donation was carried out. In addition, an online survey was conducted among German transplant centres with ten questions on the utilization of robotic techniques in Germany.Retrospective cohort studies at a small number of transplant centres worldwide report particular advantages of robotics, especially regarding blood loss, patient comfort and length of hospital stay. One-third of German transplant centres already perform living kidney donations with robotic assistance, and one-fifth of centres even use this technique in over 90% of cases. In contrast, living liver donations are only performed in one German transplant centre using robotic assistance for left lateral liver resection of the donor.In the context of living donation, advocates of robotics emphasise technical advantages, greater patient comfort and a steeper learning curve. A persistent and significant point of criticism regarding robotic surgical techniques remains the prolonged warm ischemia time, especially during learning curves. The survey results presented here demonstrate that there is still a substantial need for discussion on this current topic. However, there is a lack of prospective randomised controlled studies.

Peripheral arterial disease (PAD) is mostly caused by stenotic atherosclerotic lesions of lower limb arteries. Intermittent claudication is the most common manifestation, while, in more advanced stages of the disease, chronic limb-threatening ischemia (CLTI) occurs. Optimal medical therapy is an essential cornerstone in all stages of PAD, while endovascular and open surgical revascularisation are of great importance - depending on the patient and lesion characteristics and can be used in a complementary manner. In patients with claudication, the improvement in the pain-free walking distance is the primary therapeutic goal, while, in patients with CLTI, amputation-free survival is most important. In both patient groups, there is a need for strict control of cardiovascular risk factors, including blood pressure and diabetes control, nicotine abstinence and reduction in cholesterol levels using intensive statin therapy, in accordance with national and international guidelines. Endovascular treatment of PAD is used widely and by various specialist disciplines. However, conventional endovascular therapy procedures have limitations in complex and heavily calcified lesions, so that, for example, classic balloon angioplasty in such lesions is associated with "recoil" and/or severe dissections, which usually require the placement of permanent metallic implants. Lesion preparation procedures, such as atherectomy and intravascular lithotripsy (IVL) can improve compliance of calcified arteries, by either creating microfractures at calcified sites or removing calcified material. In this way, balloon angioplasty can be performed with less barotrauma and the need for stent implantation can be reduced, while subsequent treatment with drug-coated balloons (DCB) is associated with potentially improved penetration of the drug into the vessel wall, and thus increases the effectiveness of the procedure by enhancing anti-restenotic effects. In this manuscript, the potential - but also the limitations - of different lesion preparation strategies are presented and discussed.

Robot-assisted (RATS) anatomical resection is a new method in the treatment of lung tumours, but is controversial due to its cost. The aim of our retrospective study was to compare the clinical results of the RATS and VATS anatomical resections.The first 100 VATS and RATS resections were analysed with regard to tumour stage, intra- and postoperative complications, conversion, operation time, hospital stay and length of drainage treatment, postoperative pain (numerical rating scale, NRS) and mortality. The results were compared using the chi-square, Fisher and independent t tests.In the VATS group, stage I was more frequent, stage II less frequent (stage I: 73.4%, stage II: 19.2%) than in the RATS group (stage I: 65.5%, stage II. 23%, p = 0.695). The operating time was longer with RATS (213.5 min vs. 190.3 min, p = 0.008), due to the docking and undocking time of the robotic system to the patient. The proportion of sublobar resections was significantly higher in the RATS group (28% vs. 7%, p < 0.001). The proportion of intraoperative complications (7% vs. 14%, p = 0.073) and conversion rate (9% vs. 11%, p = 0.407) were lower in the RATS surgery. The number of lymph nodes removed was high in both groups and not significantly different (VATS: 21.6, RATS: 22.1). The hospital stay was shorter after RATS (8.8 days) than after VATS (12.5 days, p < 0.001), as was the length of postoperative drainage treatment (5.6 vs. 8 days, p < 0.001). In the RATS group, postoperative pain on the 1st and 2nd postoperative day was significantly lower, as based on the numeric rating scale (1.68 vs. 2.83, p < 0.001, 0.99 vs. 2.41, p < 0.001). The complication rate was significantly higher after VATS than after RATS (57% vs. 33%, p = 0.001), and fewer reoperations were necessary after RATS (3%) than in the VATS group (8%, p = 0.121). Four patients died in the VATS group, none after RATS (p = 0.043).The robot-assisted technique enables anatomical resections with lower conversion, complication rates and mortality, as well as less postoperative pain. Robotic surgery has proven to be safe and oncologically comparable to anatomical VATS resections for lung cancer.

Sleeve lobectomy or resection with pulmonary artery reconstruction is a technique that allows for resection of locally advanced central lung carcinoma, preserving lung function, and is associated with lower morbidity and mortality than pneumonectomy. This survey aimed to assess the long-term survival comparing different types of sleeve lobectomy and identify risk factors affecting survival.All consecutive patients who underwent anatomical resection for primary non-small cell lung cancer with bronchial sleeve or pulmonary artery reconstruction in our department between September 2003 and September 2021 were included in this study. Cases with carinal sleeve pneumonectomy were excluded. Data were evaluated retrospectively.Bronchial sleeve resection was performed in 227 patients, double sleeve resection in 67 patients, and 45 cases underwent isolated lobectomy with pulmonary artery reconstruction. The mean follow-up was 33.5 months. The 5-year survival was 58.5% for patients after bronchial sleeve, 43.2% after double sleeve, and 36.8% after resection with vascular reconstruction. The difference in overall survival of these three groups was statistically significant (p = 0.012). However, the UICC stage was higher in cases with double sleeve resection or resection with vascular reconstruction (p = 0.016). Patients with lymph node metastases showed shorter overall survival (p = 0.033). The 5-year survival rate was 60.1% for patients with N0 and 47% for patients with N1 and N2 status. Induction therapy, vascular sleeve resection, and double sleeve resection were independent adverse predictors for overall survival in multivariate analysis.Sleeve lobectomy and resection with vascular reconstruction are safe procedures with good long-term survival. However, double sleeve resection and vascular sleeve resection were adverse predictors of survival, possibly due to a higher UICC stage in these patients.

For small lung carcinomas, sublobar resections allow the preservation of a greater pulmonary reserve than after lobectomy. It was unclear for a long time to what extent this would jeopardize the goal of curative, radical tumor removal. Current studies show under what conditions a sublobar resection should be carried out and under which circumstances lobectomy continues to be the required standard.

Central pancreatectomy is an excellent alternative to left pancreatectomy for symptomatic benign or premalignant lesions of the pancreatic body or tail. A key advantage of this technique lies in the preservation of pancreatic parenchyma, resulting in a lower rate of postoperative diabetes mellitus. However, this procedure requires more complex reconstruction, which in turn is associated with an increased risk of morbidity.Insulinoma in the pancreatic body.Robot-assisted central pancreatectomy with pancreaticojejunostomy using a modified Blumgart technique.Central pancreatectomy is a generally rare and challenging pancreatic procedure, but clearly plays a significant role in modern pancreatic surgery due to its functional advantages. When appropriate and technically feasible, central pancreatectomy should be preferred to the alternative of left pancreatectomy and whenever possible, performed minimally invasively.

With the beginning of the COVID-19 pandemic in March 2020, restrictions and challenges for elective and emergency vascular surgery as well as worse outcomes were reported. This study aims to compare our single-centre experience with carotid artery surgery during the pandemic and previous years.Our retrospective analysis included all consecutive patients undergoing carotid surgery for symptomatic and asymptomatic stenosis between January 2017 and December 2021. Caseload, operation specific parameters, and demographic data as well as in-hospital outcome were compared during the COVID-19 pandemic versus previous years.A total of 623 consecutive patients were included. The caseload comparison showed an average of 112 carotid artery surgeries per adjusted year (March 16th to December 31st) from 2017 to 2019, prior to the pandemic. The caseload reduction in the first year of the pandemic (2020) was 36.6% (n = 71) and 17.9% (n = 92) in the second year (2021). No rebound effect was observed. There was no significant difference (p = 0.42) in the allocation of symptomatic and asymptomatic patients (asymptomatic patients: 37.1% prior vs. 40.8% during the pandemic; symptomatic patients: 62.9 vs. 59.2%). Major adverse event rates in years prior to the pandemic were postoperative bleeding requiring revision: n = 31 (7.1%); stroke in symptomatic patients: n = 9 (3.3%) and stroke in asymptomatic patients: n = 4 (2.5%); symptomatic myocardial infarction (MCI): n = 1 (0.2%); death: n = 2 (0.5%). During the pandemic, major adverse event rates were postoperative bleeding requiring revision: n = 12 (6.5%); stroke in symptomatic patients: n = 1 (0.9%), stroke in asymptomatic patients: n = 1 (1.3%); symptomatic MCI: n = 1 (0.5%); death: n = 1 (0.5%).Since the beginning of the COVID-19 pandemic in March 2020, there has been a significant reduction in carotid artery surgery performed both in symptomatic as well as in asymptomatic patients. There was no worsening of the outcome of carotid surgery performed during the COVID-19 pandemic, and this remained safe and feasible.