Zentralblatt fur Chirurgie最新文献

The recent introduction of chemoimmunotherapy has permanently changed the multimodal therapeutic options for operable non-small cell lung cancer (NSCLC). The aim of the working group of the German Society for Thoracic Surgery (DGT) was to develop consensus-based practical recommendations for the perioperative treatment of locally advanced NSCLC.A questionnaire was formulated by defined working groups, which was answered in two electronic rounds by Germany's leading thoracic surgeons. Controversial results with less than 75% agreement were subsequently discussed in an expert conference and a Delphi survey was conducted.Patients with confirmed N1 or N2 lymph node metastasis should be treated in a perioperative regimen. Technical and oncological operability are obligate criteria as well as negative molecular status (at least EGFR and ALK wild type). Mediastinal invasive restaging is not required in the absence of radiological progression after induction therapy. Even with a good radiological response, surgery cannot be avoided. Because of a lack of evidence, it cannot be concluded to what extent a reduction in the extent of resection below a lobectomy is oncologically justifiable. The participants agreed that adjuvant radiotherapy has no value in patients with complete mediastinal downstaging. Patients with persistent mediastinal lymph node metastases (ypN2) should be discussed for adjuvant radiotherapy on a risk-adapted individual basis.A broad consensus was reached at the expert conference on the topics discussed in the context of the new perioperative therapy concepts. These can therefore serve as practice-oriented support for the members of the DGT.

MR-defecography plays a key role in imaging complex pelvic floor dysfunction. Simultaneous detection of multiple findings in a complex anatomical setting makes correct analysis and clinical interpretation challenging. Thorough understanding of this imaging technique is essential for pelvic floor surgeons in order to make proper use of its advantages in the diagnosis of pelvic floor pathologies. We have reviewed the scientific literature on MR-defecography from recent years to sum up the most important aspects concerning patients' selection and preparation, examination procedure, standardised reporting and the most important pathological findings for pelvic floor surgery. MR-defecography is performed using static as well as dynamic MR sequences of high spatial resolution with excellent soft tissue contrast. The detection of pathological findings (pelvic floor relaxation, pelvic floor descent, rectocele, enterocele, peritoneocele, intussusception, rectal prolapse, dyssynergistic defecation) must always be correlated with clinical symptoms. It can provide information that is missed by other imaging modalities and hence it can alter therapeutic strategies in the interdisciplinary cooperation of pelvic floor surgeons, urologists and gynaecologists.

Gastroparesis is a disease in which gastric emptying is significantly decreased in the absence of a mechanical obstruction of the gastric outlet. In addition to conservative or pharmacological treatment options, gastric electrical stimulation (GES) is a possible alternative therapy for refractory courses of the disease. However, the available data from randomised controlled trials on efficacy do not permit an unqualified recommendation. The aim of this review is to introduce the clinical picture of gastroparesis, including the underlying pathophysiology, and to classify the therapeutic role of GES, based on the currently available literature. In particular, indications and limitations of the therapy are outlined that may lead to optimisation of the therapy, followed by an outlook on a potential new therapeutic procedure.

Treatment of rectal cancer is multimodal and based on tumour stage and location, as well as morphological and biological risk factors - using surgery, radiotherapy, and chemotherapy. In a large number of cases, there are several treatment options, some of which can cause similar and some of which can cause different functional limitations. Comparisons of functional outcomes between different treatment modalities are currently limited.This narrative review presents the functional outcomes of different treatment strategies for middle and lower third rectal cancer, as based on a literature search.This paper analyses the evidence on the functional outcomes of different treatment strategies, especially regarding fecal continence, urinary and sexual function. The functional outcome after organ-preserving strategies appears to be slightly better in terms of stool frequency compared to surgical therapy alone, but this has to be weighed up against chemotherapy-induced polyneuropathy and radiogenic toxicities such as cystitis, radionecrosis or fistula formation. In addition, the functional side effects of perioperative and surgical therapy accumulate in the event of incomplete remission. A few days of treatment during surgical therapy contrast with the significantly more protracted treatment of total neoadjuvant therapy. A conclusive evaluation based on the current evidence is only possible to a limited extent.This study emphasises the importance of providing patients with detailed information about the functional consequences, duration of treatment and possible complications and offers a decision-making aid for planning individual treatment, taking quality of life into account.

Incontinence - especially anal incontinence - poses a significant burden for those affected. It severely impacts the quality of life, leads to limitations in daily life, and can result in social isolation. The aetiology of anal incontinence is heterogeneous and often multifactorial. Depending on the specific genesis, the therapy requires both a high degree of personal responsibility and discipline from the patients, as well as acceptance of the condition and its causes. For the responsible professionals, it is essential to incorporate not only professional expertise but also empathy and patience into the care. It should be gently communicated to the affected individuals that a complete restoration of continence is not realistic in most cases. Anal incontinence can occur in the context of numerous systemic diseases, psychological disorders, as well as due to muscular, sensory, or neurogenic dysfunctions. It can also be a possible complication following surgical procedures. Therefore, a differentiated, interdisciplinary investigation of the causes and their interrelations is essential. Patients should be fully informed about the available therapeutic options as well as the possible limitations of treatment. The therapeutic focus remains on conservative measures. Surgical procedures should only be considered when a morphological correlate is present and the chances of success are deemed favourable. An exception is sacral nerve modulation, which can also be successfully applied in cases of idiopathic faecal incontinence. This article is intended as a practice-oriented review and is based on clinical experience as well as the analysis and summary of current scientific literature - taking into account valid guidelines.

Pelvic intraoperative neuromonitoring (pIONM) is emerging as a key tool to enhance functional outcomes following rectal cancer surgery. This paper synthesizes current evidence on pIONM, including findings from the multicenter, randomized NEUROS trial, which demonstrated significant benefits for urinary, sexual, and ano-(neo-)rectal functions. Additionally, the role of telementoring as a catalyst for standardized robotic assisted pIONM adoption is explored. Three case studies illustrate the low cognitive burden on surgeons during telemedicine-assisted monitoring, assessed via the NASA-TLX questionnaire (TLX-score varied from 5.0 to 24.3). The results highlight pIONM's potential to prevent nerve damage and improve patient quality of life, with telementoring poised to facilitate broader implementation.

Pleural mesothelioma (PM) is a highly aggressive tumour, mainly associated with prior asbestos exposure. Symptoms typically do not manifest until 20 to 50 years after exposure. Depending on the histological subtype of PM, the prognosis varies, though the median survival time is only 12-18 months. Imaging plays a central role in the management of PM patients, particularly in assessing operability and treatment response. However, PM presents a unique challenge for radiology due to its rarity, complex morphology, and tendency to invade multiple tissue layers simultaneously. Contrast-enhanced computed tomography (CT) is the central imaging modality in the diagnosis, preoperative planning and therapy monitoring of pleural mesothelioma (PM). Ideally, CT should include both the thorax and abdomen to capture the entire pleural space. Tumour thickness and volume, as determined by CT, are important prognostic factors for patient survival in PM. In addition, PET/CT, using radioactively labelled fluorodeoxyglucose (¹⁸F-FDG), offers additional valuable insights into tumour metabolism. Since PM is typically metabolically active, PET/CT is particularly effective in detecting smaller lesions, occult metastases, and assessing morphologically ambiguous lesions. Magnetic resonance imaging (MRI), on the other hand, offers distinct advantages over CT, due to its superior soft tissue contrast, particularly in visualizing tumour extent and infiltration of adjacent structures. Dynamic contrast-enhanced imaging, diffusion-weighted imaging, and 4D sequences provide valuable additional information. On the basis of the "Best Practices" of the expert panel from the International Mesothelioma Interest Group (iMig), we provide an overview of the common imaging modalities, including conventional X-ray, CT, MRI, and PET/CT. Additionally, we discuss staging based on the TNM classification (Tumour, Node, Metastasis), which evaluates the local invasion of the tumour (T), lymph node involvement (N), and the presence of metastases (M). We also present examples of assessing treatment response and highlight recent developments in diagnostic imaging.