Zentralblatt fur Chirurgie最新文献

Preventive thyroid surgery aims to prevent the occurrence of malignant diseases or improve their prognosis. The main indication is hereditary medullary thyroid carcinoma, which is caused by pathogenic RET germline variants. Other clinical manifestations can also occur in the context of multiple endocrine neoplasia. Early prophylactic thyroidectomy in the asymptomatic stage can make this tumour entity curable. The timing of surgery depends on the genotype and the associated risk classification and calcitonin levels, with particularly aggressive mutations requiring intervention as early as the first year of life.In contrast, the benefit of prophylactic lymph node dissection in papillary thyroid carcinoma remains controversial: While individual studies show a reduction in the recurrence rate, the risk of postoperative complications such as hypoparathyroidism or recurrent nerve palsy is increased. Therefore, the current guideline recommends an individualised approach with risk-adapted indications, taking into account tumour size, histology, and molecular markers.Although thyroid removal eliminates the risk of cancer, it requires lifelong hormone replacement therapy and close follow-up care. Extending the procedure to include prophylactic lymphadenectomy can increase morbidity.Future developments in molecular genetic diagnostics and refined risk stratification should help identify patients with high cancer risk even more precisely and, at the same time, avoid unnecessary interventions. Overall, preventive thyroid surgery is a successful example of personalised prevention, with indications that are becoming increasingly differentiated and patient-oriented.

One of the principal reasons for the poor prognosis of pancreatic carcinoma is its frequently late diagnosis. Consequently, prevention and early detection are of paramount importance. Preventive pancreatic surgery may be considered in individuals with markedly increased disease risk or with detectable morphological precursor lesions, although only approximately 20-30% of pancreatic carcinomas arise in this context.An increased risk may be conferred by germline mutations, hereditary syndromes, or a positive family history. The evidence supporting prophylactic resection in such settings remains exceedingly limited. Accordingly, surgical intervention is restricted to highly selected cases and should be undertaken solely after individualised, interdisciplinary evaluation within specialised centres. In the majority of cases, risk-adapted surveillance programmes constitute the standard of care.With respect to morphological precursor lesions, particularly cystic pancreatic neoplasms, the evidence base is considerably more robust. Over recent decades, international consensus guidelines with clearly defined risk criteria have been established, thereby facilitating precise stratification for either surgical resection or structured surveillance. Main-duct IPMN, MCN, SPN, as well as lesions fulfilling high-risk criteria, warrant early operative management. In contrast, the most frequent precursor lesions-pancreatic intraepithelial neoplasias (PanIN)-are generally not detectable in clinical practice and therefore currently have only limited relevance for preventive strategies.Future progress in genetics, diagnostic modalities, minimally invasive surgery, as well as prospective clinical trials and registry initiatives, is expected to render preventive approaches increasingly precise, safe, and evidence-based.

Bleeding and thromboembolism risks are among the key challenges in thoracic surgery. This CME article examines perioperative coagulation and anticoagulation management and provides practical information on anticoagulants, antiplatelet agents, and thrombosis prophylaxis, as well as specific clinical situations.

Unilateral perioperative paresis of the vocal fold (eSLP) in thoracic surgery harbours the risk of clinically relevant complications for the affected patients as a result of restrictions to vocal function. In addition to conservative voice therapy (speech therapy), vocal fold augmentation (SLA) offers an option for interventional therapy. The indication and timing are not handled uniformly and require expertise in phoniatric-phonosurgical.In a retrospective study, patients with a first diagnosis of eSLP before or after thoracic surgery with curative treatment intention in the period from 01/2010 to 12/2020 were analysed. The primary endpoint was defined as the time of SLA including the augmentation result. Secondary endpoints were the occurrence of eSLP, the indication for SLA and possible complications.Of a total of n = 939 included cases, eSLP was documented in n = 44 (4.7%) patients. Differentiation was made according to tumour entity: lung carcinoma n = 21 (47.7%), lung metastases n = 8 (18.2%), mediastinal tumour n = 13 (29.5%) and malignant pleural mesothelioma n = 2 (4.6%). While SLP was already present preoperatively in n = 15 patients, postoperative SLP occurred in 66% of cases (n = 29). Early SLA with hyaluronic acid was performed in n = 16 (36.4%) patients in the first postoperative days. SLA was indicated for vocal fold paresis in the paramedian (56%) or intermediate (31%) position with pronounced glottic closure insufficiency (100%) and clinically severe hoarseness (93.6%). The intervention achieved a medialisation of the paretic vocal fold in all cases and thus improved glottic closure. This led to an improvement in vocal tone and coughing.An eSLP occurred in 4.7% of cases in thoracic surgery and was successfully treated in 36% of cases during hospitalisation by means of complication-free SLA. An eSLP should be clarified at an early stage and, if indicated, promptly evaluated for early SLA.

In recent years, we have witnessed remarkable progress in organ donation and the preservation of donor lungs. Several transformative innovations have been particularly influential:1. Normothermic ex vivo lung perfusion (EVLP): EVLP is a groundbreaking advancement in lung transplantation. This technology not only enables expansion of the donor pool by reconditioning marginal lungs, but also improves transplantation outcomes, through optimised assessment and therapeutic intervention prior to implantation. Lungs considered high-risk or initially unsuitable for transplantation can be evaluated and, in many cases, rehabilitated using EVLP, resulting in post-transplant outcomes comparable to those of conventionally selected lungs. With ongoing technological advancements and increasing clinical acceptance, EVLP could soon become the standard of care in lung transplantation.2. Donation after circulatory death (DCD): DCD has emerged as an essential strategy to address the shortage of transplantable lungs. Despite logistical challenges and ethical considerations, transplantation outcomes using DCD lungs are comparable to those achieved with traditional donation after brain death. As research and technology continue to advance, DCD donors are expected to play an increasingly significant role in lung transplantation.3. Controlled hypothermic preservation at 10 °C: Controlled hypothermic storage at 10 °C offers extended preservation times, reduces cold-induced injury, and enhances flexibility in transplant scheduling. This method has the potential to revolutionise the currently rigid logistics of lung transplantation, allowing semi-elective procedures to be integrated into daily surgical programs as research progresses.With a particular focus on these innovations, we aim to summarise the current state of knowledge regarding lung donors and donor lung preservation.

Ergonomics remain an underestimated challenge in medicine, particularly in robotic surgery. Despite technical advances, surgeons often suffer from musculoskeletal disorders often involving the neck, back, and wrist. Previous studies have shown that a lack of knowledge and awareness of ergonomic recommendations for the use of the console, unnatural or poor physiological postures, and a lack of training are common causes of poor posture and associated complaints. A physiological posture is the basis for a healthy workspace, both when standing and sitting. Of particular relevance are a neutral head, pelvis, and spine position, as well as core stability and regular training of the critical muscles for a stable posture.A comparison of different robotic systems revealed significant differences in console design and associated ergonomic challenges. Systems with adjustable headpieces, for example, improve neck posture, while open consoles facilitate communication in the operating room.In addition, the role of the bedside assistant is critical from an ergonomic perspective. The discrepancy between the motor and visual axes quickly leads to discomfort in the neck, shoulder, and arm areas. Structured training curricula and ergonomic guidelines are lacking in everyday surgical practice.To prevent musculoskeletal pain and potential disorders, targeted stretching and mobilization exercises can be performed during so-called micro breaks, which have been proven to reduce pain and improve concentration and performance. Correct adjustment of the console can also significantly improve the ergonomics in the robotic operating theatre.

Vascular graft infections pose as severe complications in vascular surgery and are linked to high morbidity and mortality. Guidelines recommend resection of infected grafts and concomitant autologous reconstruction, though redo-surgery might not always be reasonable in high-risk patients with significant comorbidities. Additionally, conservative antibiotic treatment is hindered by increasing antibiotic resistance rates and biofilm formation.Bacteriophages are viruses that selectively infect and eradicate bacteria and are therefore a promising anti-infective therapeutic strategy. Though the therapeutic potential of bacteriophages has been known since the early 20th century, in western medicine only a few clinical studies on bacteriophage treatment in infectious diseases exist to date.This review aims to outline history, biology and challenges of bacteriophage therapy. It summarizes 9 cases published in literature as case reports or small case series in which the treatment of vascular graft infections with bacteriophages is used to circumvent high-risk graft explantation surgery.

Midaortic syndrome (MAS) is a rare vascular disorder characterised by segmental hypoplasia or stenosis of the thoracoabdominal aorta and possible involvement of renovisceral branches.In the case presented here, a 19-year-old female patient with thoracoabdominal aortic hypoplasia combined with multiple aortic and visceral aneurysms and a genetically confirmed COL3A1 variant (vascular Ehlers-Danlos syndrome) underwent open surgical thoracoabdominal type II aortic replacement.Using a multimodal neuro- and organ-protective approach, including perioperative CSF drainage, MEP monitoring, mechanical selective and distal extremity and organ perfusion, and targeted blood product and volume management, a complication-free thoracoabdominal reconstruction was performed.The postoperative course was normal but required subsequent interventional endovascular treatment of an anastomotic stenosis of the right renal artery.This case highlights the need for a tailored therapeutic approach for this complex, genetic aortic pathology. It demonstrates that not all aortic diseases are amenable to endovascular treatment and that open surgical treatment remains highly important, especially in younger patients with hereditary aortic diseases.