Zentralblatt fur Chirurgie最新文献

Due to a legislative decision, a minimum volume for the surgical treatment of lung cancer has been applied since the beginning of 2024 in Germany. This has led to a change in care structure, with the result that some patients are now being treated further away from home in an unfamiliar environment.Patient survey using standardised questionnaires, descriptive analysis of results.No more anatomical lung resections were performed at the Donau Isar Klinikum in 2024, as a consequence of the minimum volume requirement. Since then, these procedures have been performed at the Clinic for Thoracic Surgery at the Munich Bogenhausen Clinic, a certified lung cancer centre. 68% of patients (n = 25) felt sufficiently informed in advance about why their operation could not be performed near their home. 80% of respondents had not heard about the new regulation beforehand. The fact that they would be operated on in a certified centre, but would have to travel a longer distance, provided reassurance among those affected (60%; 84% among relatives), but also uncertainty (24%), incomprehension (20%) and anger (12%). The average distance to the lung cancer centre was 143.4 km (∅ 1 h 48 min). All patients were satisfied with the contact and appointment process (1: very dissatisfied/10: very satisfied, ∅ 9.3), the information about the procedure (∅ 9.4), the overall stay (∅ 9.2), the medical and nursing treatment (∅ 9.7/9.3) and the rooms and catering (∅ 8.6). The majority (76%) did not experience the longer return journey as stressful. The communication and cooperation between the primary treating physicians and the lung cancer centre was rated as good; almost all would recommend the lung cancer centre.The feedback from the patients affected by the changed guidelines was positive. The perceived safety and quality of treatment at a centre of excellence compensated for the existing uncertainty about the unfamiliar environment and the disappointment about the associated inconvenience. Although the insights gained must be confirmed by an ongoing survey and the experiences of other centres, the concept of centring complex interventions in the field of surgical lung cancer therapy appears to be supported by those affected.

Wound care is an important medical skill that is not an important part of medical training. National and international studies show that the teaching of wounds is inadequate in medical curricula and that there is a desire for further training among students. Therefore the aim of this project was to improve students' expertise in surgical wound care.Following a survey of students in their 2nd clinical and practical year (n = 169) at the Faculty of Medicine in Kiel that addressed their level of knowledge of wound care, an innovative teaching concept was designed, including a practical section using real-life models. The pilot course was held in the summer semester of 2023 and the learning success was determined by a pre-post survey of the entire semester. The course was then implemented into the curriculum.The assessment of the level of knowledge revealed important uncertainties. In the practical year, 39.7% were confident in aseptic wound care. Training in wound care was rated as inadequate. Completion of our course resulted in an increase in the assessment of their own skills. The identified uncertainties were reduced by the training: 75% of students were confident in wound care.This course improves medical education, can be easily implemented in any faculty and could lead to improved patient care.

The centralisation of liver transplantation in Germany is seen as a promising approach to improve care quality through higher case volumes and specialised structures. However, it poses significant challenges for surgical training. Reduced availability of training positions, limited diversity of clinical experience, and the risk of capacity bottlenecks could impact the education of young transplant surgeons in the long term. This article explores the opportunities and risks of centralisation, particularly regarding surgical education. While higher case volumes are associated with better outcomes, it is argued that complementary measures such as regional support structures, rotation programs, and, where applicable, the use of practical training models are essential to ensure comprehensive education. The implementation of regulations of minimum case volume is also discussed as a potential regulatory tool. Finally, the article highlights the need for future studies to systematically evaluate the impact of centralisation on surgical education and to provide an evidence-based foundation for decision making.

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.

Lung transplantation has evolved continuously since its first successful procedures in the 1960 s. The current guidelines from the International Society for Heart and Lung Transplantation (ISHLT) emphasise increasingly individualised patient assessment, which, in addition to the underlying lung disease, considers factors such as comorbidities, frailty, age, and social aspects. The expanded indications for lung transplantation are reflected in the refined risk assessment, which particularly includes patients with advanced chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and pulmonary arterial hypertension (PAH). Furthermore, the criteria for patients with a history of cancer and those with infections such as HIV or multidrug-resistant organisms have been made more flexible, leading to a more inclusive transplantation policy. A key focus is on early transplant counselling, allowing patients the opportunity for transplantation before they develop acute exacerbations. These updated guidelines aim to maximise both the survival rates and the quality of life of transplant patients, through differentiated and risk-adjusted decision-making.

Pulmonary artery hypertension (PAH), a subtype of pulmonary hypertension, is a rare end-stage lung disease. Bilateral lung and combined heart and lung transplantation have long been considered as a gold standard therapy for PAH.This manuscript reviewed the most up-to-date literature on lung transplantation for PAH, focusing particularly on risk stratification, donor allocation, bridging to transplantation (BTT), and intra- and postoperative management in both adult and pediatric patients.The last two decades have witnessed an important shift in the transplant indications and strategy for PAH. Newly introduced antihypertensive drugs have postponed the time of transplantation in eligible patients, thus reserving transplantation for severely ill high-risk patients on triple antihypertensive therapy. Furthermore, the widespread peritransplant use of veno-arterial extracorporeal membrane oxygenation (ECMO) enables cardiac remodeling after bilateral lung transplantation.The change in transplant strategy from combined heart and lung transplantation to bilateral lung transplantation renders more organs available for transplantation in an era of organ shortage. ECMO-bridging is a life-saving tool in selected PAH patients although associated with higher complications. Better organ allocation in PAH patients at high risk of decompensation may reduce the need for ECMO-bridging and may further improve outcomes.

Lung transplantation is often the sole and final therapeutic option for patients with end-stage lung disease. In recent years, clinical outcomes have steadily improved, driven in part by advancements in extracorporeal mechanical support. These techniques have become an integral component of routine clinical practice, particularly in lung transplantation centres. Extracorporeal lung support systems range from relatively simple pumpless devices to complex cannulation techniques and device configurations. In particular, extracorporeal membrane oxygenation (ECMO) encompasses various configurations widely utilised in thoracic surgery, especially in lung transplantation. A distinction can be made between preoperative ECMO, referred to as bridge-to-transplant, and intraoperative ECMO support, which is employed during the transplantation procedure. In recent years, intraoperative ECMO has largely replaced the traditional heart-lung machine. Additionally, ECMO plays a critical role in the immediate postoperative period, both in preventing and managing primary graft dysfunction. Beyond lung transplantation, extracorporeal life support systems are also applied in complex thoracic surgical resections and procedures involving the central airways. In the future, technical advancements and improvements in treatment protocols are expected to further enhance the role of extracorporeal mechanical support in the management of thoracic surgical patients.