Zentralblatt fur Chirurgie最新文献

Complex abdominal wall defects lead to significant morbidity and require interdisciplinary therapeutic approaches. Plastic surgical techniques and the evolvement of microsurgery can provide a reliable means of reconstruction. For large defects involving the M. rectus abdominis, the free functional M. latissimus dorsi flap serves as a workhorse. Through microsurgical tissue transplantation, the abdominal wall can be functionally reinforced and reinnervated, while also covering the associated soft tissue defect.This study presents an interdisciplinary approach to complex abdominal wall reconstruction using a case example.Particularly as a chimeric flap, in combination with the scapular/parascapular flap, even exceptionally large defects can be reconstructed safely. By utilising a common vascular pedicle, these flaps can be transferred together via the subscapular vessel axis. The coaptation of the thoracodorsal nerve, which innervates the latissimus dorsi muscle, with a motor nerve branch leading to the rectus abdominis muscle enables functional muscular stabilisation of the abdominal wall following reinnervation.To achieve the best possible outcome and reduce hospitalisation, the early integration of plastic surgery into interdisciplinary treatment concept is essential.

Academic career development in surgical oncology in Germany faces multiple challenges. Young surgeons are confronted not only with high clinical workloads but also with a lack of structured support, funding opportunities, and transparent career pathways. At the same time, there is a strong interest in academic work and specialized training programs such as fellowships. The aim of this study was to assess the current state of training opportunities, interests, and needs of early-career surgeons in surgical oncology in order to derive targeted strategies to support their clinical and academic career development.An online survey covering career planning, research interests, structural support, and training needs was developed and distributed via surgical societies and networks for young surgeons across Germany. The results were analyzed quantitatively.A total of 191 individuals participated, with most working at university hospitals (45.1%) or tertiary care centers (28.0%). The main challenges reported were high clinical workload (82.4%) and lack of time for research (66.0%). A strong interest in specialized fellowships was expressed by 85.4% of respondents, particularly in colorectal, hepatobiliary, or pancreatic surgery. Mentorship (90.9%) and protected research time (77.6%) were deemed essential. Research interests primarily focused on clinical (81.5%) and surgical-technical research (62.3%). The establishment of topic-specific subgroups within a future Early Career Group (ECG)-such as clinical trials, robotics, or mentoring-was considered helpful by the majority.The findings highlight a clear interest in academic engagement among young surgeons and the urgent need for structured support. However, current clinical working conditions often hinder active scientific involvement. The gap between motivation and structural limitations underlines the necessity for targeted measures in training, mentoring, and research support. Despite high motivation, young surgeons in Germany frequently lack sufficient support for pursuing an academic career.

Surgical correction of unilateral diaphragm paralysis is performed in many hospitals with a small number of cases. A randomised study or a guideline on this topic does not exist. The aim of the present consensus search was to develop uniform minimum requirements for the diagnosis, surgical therapy, and postoperative management of unilateral diaphragm paralysis, in order to improve the quality of care for this rare disease.In a structured, modified Delphi process, experts from the German Society for Thoracic Surgery (DGT) were interviewed on the surgical management of unilateral symptomatic diaphragm paralysis and recommendations were extracted with an agreement rate of ≥ 80%. All heads of thoracic surgery departments whose clinics were certified as lung cancer centres by the German Cancer Society were specifically included.After 2 online Q&A sessions and a working meeting of the experts, 14 recommendations for the surgical management of unilateral symptomatic diaphragm paralysis were agreed: For diagnostic purposes, a CM-CT of the neck and thorax and, if there are indications of obstructive sleep apnoea, a sleep laboratory diagnostic test should be performed. The indication for surgical diaphragmatic plication is based on the combination of diaphragmatic elevation, specific symptoms, and the presence of functional limitations. The use of the Diaphragm Paralysis Questionnaire (DPQ) is recommended. If there are indications of cervical disc herniation, the success of local treatment should first be awaited. In the case of unclear diaphragmatic paralysis, a waiting period of at least 6 months should be observed between the onset of symptoms and surgery. The operation should be minimally invasive without a diaphragmatic resection and adhesions should be adequately removed. Reinforcing suture patches should be used with the contraction sutures and an artificial mesh should be used according to the surgeon's assessment. One drainage tube is sufficient. Postoperative mobilisation and weight-bearing should be specifically adapted, but should take place early in the hospital after lung resection. A symptom-oriented follow-up examination is recommended after 6-12 months.14 minimum standards for the surgical management of unilateral diaphragm paralysis were agreed upon. These are recommended to the members of the DGT.

Restructuring of the German healthcare system necessitates adjustments in quality assurance, cost reduction, shortened length of stay, and professional staff retention. The structured Fast Track Implementation (FTI) for colorectal surgery meets these requirements through interprofessional team development.Fast Track was implemented in a structured procedure over the course of one year at the participating clinics. Fast Track adherence (= process quality) and data on functional recovery, morbidity, and mortality (= outcome quality) were reflected back to the teams for the periods before (preFTI), during (FTI), and after (postFTI) FT implementation, respectively.In 7 clinics, 1,550 elective colorectal resections were performed. Fast Track adherence increased from 52 % before (preFTI) to 83 % during (FTI) and 87 % after (postFTI) the structured Fast Track implementation (p < 0.01). Before the FT implementation, the recovery of patients' physical autonomy took 5 days, compared to 4 days during and only 3 days after the implementation (p < 0.001). The postoperative length of stay was reduced from 7 days (preFTI) to 6 days and then to 5 days (postFTI; p < 0.001). The rate of general complications simultaneously decreased from 12.6 % (preFTI) and 8.1 % (FTI) to 6.1 % (postFTI; p < 0.001).The structured Fast Track implementation for elective colorectal resections leads to improved process and outcome quality with a steep learning curve and can be considered as a template for project-oriented team development in other medical fields as well.

Thoracic spine metastases are a common manifestation of advanced malignancies and may in some cases require interdisciplinary management. Due to the complex anatomy of the thoracic region, particularly the proximity to mediastinal organs, major vessels, and the spinal cord, precise preoperative planning and surgical execution are essential. Thoracic surgical expertise is crucial for mobilising intrathoracic structures, securing vascular control, and establishing a safe anterior surgical corridor, especially in diseases involving thoracic organs and the spine. Neurosurgery focuses on decompression of neural elements, tumour resection, and biomechanical stabilisation of the spine. Different disciplines must work closely together, often simultaneously in the operating theatre, in order to achieve surgical, functional, and oncological goals. Advances in intraoperative imaging, navigation, robotics, and minimally invasive techniques have led to more individualised, safer, and more effective procedures than previously possible. Furthermore, the modern treatment of spinal metastases requires integration of oncology, radiation therapy and pain medicine. Studies demonstrate that structured, interdisciplinary care improves neurological outcomes, enhances quality of life, and facilitates timely continuation of systemic therapies. This article highlights the surgical intersection between thoracic and neurosurgery in the management of thoracic spine metastases, analyses established and emerging techniques, and illustrates how technological and organisational innovations enable high-quality, patient-centred treatment strategies.

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.