Zentralblatt fur Chirurgie最新文献

Since the 1980 s, lung transplantation has evolved into an established therapeutic procedure, due to advancements in surgical techniques and the introduction of immunosuppressants such as cyclosporine. Despite improved short-term outcomes, the long-term prognosis remains limited, primarily due to immunological complications. With a median survival of approximately six years, the lung is the most immunogenic solid organ, owing to its constant exposure to environmental antigens and its extensive vascular endothelial surface. After lung transplantation, various forms of alloreactivity, including T cell-mediated acute and chronic rejection, play a central role. Additionally, humoral immune responses, characterised by the production of donor-specific and non-HLA antibodies, contribute significantly to graft injury. Recurrent tissue damage, such as ischemia reperfusion injury, leads to the exposure of cryptic antigens, promotes autoreactive processes, and facilitates the formation of tertiary lymphoid organs. These mechanisms sustain persistent inflammation, ultimately resulting in chronic graft dysfunction. Rejection reactions remain a major challenge. Acute forms, such as cellular and humoral rejection, require rapid and targeted therapies to prevent irreversible damage. Chronic rejection, particularly chronic lung allograft dysfunction (CLAD), progressively impairs lung function. In the main phenotypes of CLAD, bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), are crucial for prognosis and treatment. Nevertheless, therapeutic options remain limited, and retransplantation is often the last resort. Immunosuppressive therapy forms the cornerstone of rejection prevention, and typically employs a triple combination of calcineurin inhibitors, antiproliferative agents, and corticosteroids. Induction therapy frequently involves monoclonal or polyclonal antibodies. Modern strategies aim to effectively suppress immune responses while minimising severe side effects, such as infections, malignancies, and nephrotoxicity. Future research will focus on personalised immunosuppressive strategies, optimised diagnostics, and innovative therapies to improve the long-term prognosis of lung transplant recipients.

According to the current practice guidelines of the German Medical Chamber, intestinal transplantation is the only causal option for complicated chronic intestinal failure. However, due to demanding immunological, perioperative, infectious challenges, intestinal transplantation is a complementary treatment option secondary to intestinal rehabilitation, after overt failure of parenteral supplementation. This review contains a selected summary of international literature and guidelines, as well as the transplant practice guidelines of the German Medical Chamber. The field of intestinal transplantation comprises a variety of single and combined transplant procedures which are tailored to individual patients and their comorbidities secondary to complicated chronic intestinal failure. The indication is typically preceded by intense intestinal rehabilitation. Nowadays, around 100-150 intestinal transplants are performed worldwide, resulting in 1- and 3- year survival rates of almost 80 and 70%, respectively. This makes intestinal transplantation the rarest of all vascularised organ transplants which is typically only indicated after all modern measures of intestinal rehabilitation have been exploited.

Lung volume reduction surgery (LVRS) and lung transplantation (LuTX) are established therapeutic options for patients with advanced pulmonary emphysema. This review analyses both procedures with respect to indications, surgical techniques, outcomes, and complications. Special attention is given to the controversial sequential application as a bridge to transplantation. Evidence shows that both procedures can significantly improve lung function, quality of life, and survival when patients are carefully selected. Despite some overlap in indication criteria, most patients qualify for only one of the procedures as based on their specific clinical constellation. Recent research has challenged traditional contraindications such as pulmonary hypertension or homogeneous emphysema, and consequently, the indication spectrum for LVRS has been expanded. Contrary to earlier assumptions, current multicentre studies demonstrate that prior LVRS has no negative impact on subsequent transplantation outcomes, provided minimally invasive surgical techniques and modern perioperative management are employed. LVRS can delay the need for transplantation, which is a significant advantage given the shortage of donor organs. The key to success lies in interdisciplinary evaluation and personalized treatment planning. Both procedures should be understood as complementary rather than competing options. Future research should focus on predictive biomarkers, optimal timing, and combined patient-centred endpoints.

Bronchopulmonary carcinoids are rare neuroendocrine tumors, categorized as either typical (low-grade malignancy) or atypical (intermediate-grade malignancy), with an incidence of approximately 0.5 per 100000 people. One third of patients remain asymptomatic, while others may present with symptoms such as cough, hemoptysis, and recurrent infections, often resulting from bronchial obstruction. Endocrine syndromes, like carcinoid- or Cushing syndrome, are rare in pulmonary carcinoids.The prognosis of these tumors largely depends on histological classification and disease stage at diagnosis. Typical carcinoids, which are less aggressive, show higher 5- and 10-year survival rates compared to atypical carcinoids. Diagnostic factors such as tumor size, chromogranin A (CgA) levels, and clear differentiation from other lung pathologies, including carcinomas and metastases, are essential for accurate diagnosis and therapy planning.Due to the rarity of carcinoids, treatment requires an interdisciplinary approach. Surgical resection remains the preferred therapy for localized carcinoids, offering the potential for prolonged survival. Early detection and complete tumor removal are crucial to optimizing outcomes and minimizing the risk of recurrence.

Simultaneous pancreas-kidney transplantation (SPK) is the only established therapy of type 1 diabetes mellitus with diabetic nephropathy and preterminal/terminal kidney failure. Despite a high demand, with 551 patients on the waiting list in Germany in 2022, only about 42 pancreas transplants were performed in that year. As a result, with waiting times of 2-3 years, there is a significant number of deaths among patients on the waiting list. In addition to SPK, isolated pancreas transplantation (IPT) and pancreas transplantation after kidney transplantation (PAK) are only considered for specific indications. Strict selection criteria are essential, as patients with longstanding type 1 diabetes often have cardiovascular comorbidities, leading to an increased risk profile for intra- and postoperative complications. Donor selection is challenging, due to limited organ availability, and strict quality requirements. Improved training in highly specialised centres could help to maintain surgical expertise. Despite high perioperative and postoperative complication rates, SPK has favourable long-term outcomes, with an average graft survival of over 12 years, thus significantly improving long-term patient survival. SPK remains the gold standard for curing type 1 diabetes mellitus, but structural adaptations are needed to ensure its long-term implementation.

In the treatment of chronic intestinal failure/short bowel syndrome (CIF/SBS), the question of small bowel transplantation may arise. However, the results of small bowel and multivisceral transplantation are not satisfactory, particularly regarding long-term patient and organ survival. According to the expert consensus, the utilisation and combination of alternative methods (nutritional therapy, autologous intestinal reconstruction, chyme reinfusion, pharmacotherapy including GLP-2 analogues) leads to good and viable outcomes. The aims of all these therapeutic procedures, which are mostly indicated as being complementary to each other, are optimisation of enteral absorption, the best possible anatomical situation for absorption and home parenteral nutrition, and provide good long-term survival with the best possible quality of life. This holistic optimisation is described by the term "intestinal rehabilitation" and should restore the patient's nutritional autonomy, with a reduction or even complete weaning off parenteral nutrition. Patients with imminent failure of parenteral nutrition as a life-sustaining organ replacement therapy should nevertheless be presented at an early stage to a transplant centre with experience in multivisceral and small bowel transplantation, in order to prepare the change of strategy to life-saving transplantation in good time. According to international standards, patients with CIF/SBS should be treated in an interdisciplinary centre including visceral surgery, gastroenterology, psychology and nutritional medicine.

In 2023, the Hugo robotic-assisted surgery system was introduced to the field of general and visceral surgery. The Hugo robotic-assisted surgery system promises to further improve robotic surgery, through its modularity, flexibility, and open console design. However, due to the novelty of the system, there is currently little experience in its clinical application.The case report describes a patient with an AEG Siewert type 2. The staging revealed the following tumour stage: uT3; uN1, cM0. After neoadjuvant chemotherapy (4 cycles of FLOT), oncologic resection was indicated. Due to the reduced lung function, the patient was considered for a transhiatal extended oesophageal resection. The operation was performed using the Hugo robotic-assisted surgery system with 4 robotic arms and 2 assistant trocars.The operation time was a total of 240 min. The histopathological examination of the resection specimen confirmed an R0 resection. The resection was performed with robotic assistance, while the reconstruction (double-tract reconstruction) was performed via a mini-laparotomy.Here, we describe for the first time the surgical procedure of distal transhiatal oesophagectomy using the Hugo robotic-assisted surgery system in a patient with an AEG Siewert type 2.