Innovative Surgical Sciences最新文献

Objectives: The COVID-19 pandemic has shown a wide range of direct and indirect influences on the health of the population. This study examines the impact of the COVID-19 pandemic on the amputation rate in Germany in patients with critical limb-threatening ischaemia (CLTI).

Methods: The epidemiological, pooled, and anonymised data of 476,168 CLTI patients from the Institute for the Hospital Remuneration System (InEK) were analysed for 2019-2023 at the federal level at weekly intervals and compared with epidemiological data for COVID-19 patients from the Robert Koch Institute (RKI) database, divided into the pandemic phases.

Results: The number of inpatient cases declined by -4.64 % (p>0.05) from 2019 to 2020 and increased significantly by +7.07 % (p=0.001) from 2020 to 2023. The incidence of all lower limb amputations increased from 2019 to 2022 (23.9 vs. 25.7 %, p=0.01) with no significant changes in 2023. Moreover, the incidence of minor amputations increased from 16.9 % in 2019 to a maximum of 18.9 % (p<0.001) in 2022, and then to 18.4 % (p=0.02) in 2023. In the short-term perspective, inpatient cases significantly decreased in phases 1 and 3, with a relevant increase in the subsequent phases. However, the incidence of all amputations, especially minor ones, is constantly increasing.

Conclusions: The COVID-19 pandemic has significantly indirectly impacted the management of CLTI patients, with a marked increase in the incidence of minor amputations, presumably due to the delayed presentation of patients with small necroses and due to limited access to healthcare.

Objectives: With the growing proportion of female practitioners in the medical field, management of pregnant medical doctors is an increasingly important concern. The 2018 amendments to the German Maternity Protection Act stipulate that pregnant doctors and students can and should be permitted to safely continue their work under strict protective measures. Despite these measures, the reality is that pregnancy still results in limits on professional advancement and attainment for many physicians. To improve this situation, we analyzed the current situation in Germany. Based on our analysis, we identified some areas in need of improvement and offered recommendations.

Methods: We performed a nationwide online survey that was sent to medical doctors and students via the physicians' union Marburger Bund members' mailing list. The survey's main focus was on which kinds of clinical duties the pregnant doctors were assigned to, subdivided into four different time periods (under the previous and amended Maternity Protection Act, during COVID-19 pandemic and after), from 2016 to 2022.

Results: Our survey included 4,748 female medical doctors and students, with a balanced distribution across the four different time periods. The most striking restriction reported by our participants was a ban on performing surgeries and invasive procedures, an experience reported by 57-65 % of pregnant doctors and medical students before the COVID-19 pandemic and nearly 80 % since the pandemic. In addition, since the COVID-19 pandemic, a complete employment ban has been enforced upon nearly 50 % of the pregnant doctors. More than 50 % of pregnant doctors considered their careers to have been obstructed or curtailed by their pregnancies prior to the pandemic, with that number growing to two-thirds since the pandemic.

Conclusions: Pregnancy negatively impacts doctors' training and careers. Many women are not allowed to perform surgeries and invasive procedures, even while some of these practitioners report that they wish to and are capable of continuing their work. Change is needed to support enthusiastic young female doctors and students and enable them to maintain their skills and professional advancement during pregnancy.

Esophageal cancer is an aggressive tumor entity, and oncologic esophagectomy with two-field lymphadenectomy after perioperative chemotherapy or chemoradiotherapy is the standard of care for curative treatment. Oncological esophagectomy is a complex procedure associated with a relevant surgical trauma. Complications, such as severe pulmonary infections and anastomotic leakage with mediastinitis lead to a high morbidity rate. To reduce the surgical trauma, the minimally invasive technique was introduced in esophageal surgery. Minimally invasive esophagectomy is associated with less postoperative pain and a reduced rate of pulmonary infections. Currently, there are two major different totally minimally invasive techniques, the conventional laparoscopic/thoracoscopic approach (MIE) and the robotic assisted approach (RAMIE). Both methods require teaching due to the flat learning curve associated with these complex procedures. However, both MIE and RAMIE are performed safely in specialized centers. They are associated with improved short-term outcome and similar oncological outcome compared to open esophagectomy. The robotic assisted approach has additional benefits that may be supported by the results of more randomized controlled trials in the future.

Objectives: Autologous fat transplantation is a promising source for cell therapy and tissue engineering. However, the physiological function and regulatory mechanisms of in vitro cell culture remain largely unexplored. Furthermore, no standard protocol for cell culture of human adipose-derived stem cells (hASC) has been described. Previous studies have reported the impact of media supplementation on the loss of stemness capacity.

Methods: In this study, we compared the expression of stemness-defining surface markers according to the minimal criteria definition (CD 11b⁻, CD 31⁻, CD 34⁻, CD 45⁻, CD 73⁺, CD 90⁺, and CD 105⁻) by flow cytometry analysis with the expression of stemness-related genes such as MCAM, OCT4, MYC, and cKit in hASCs cultured in either fetal calf serum (FCS) or human serum (HS) supplemented medium from passage 0 to 5.

Results: As expected, we found that hASCs in both groups retained their typical mesenchymal surface marker profile CD 73 and CD 90 (>95 %) in flow cytometry analysis, as well as the absence of CD 11b, CD 31, CD 34, and CD 45 (<5 %) until passage 5. However, in contrast to that, RT-PCR indicated a passage-dependent decline and medium-dependent changes in the transcriptome, in particular the loss of the stemness-related genes cKit and MCAM in both groups, while MYC and OCT4 showed unpredictable expression.

Conclusions: Summarized, these results indicate the need for standardized cell culture protocol, as the transcriptome seems to change during in vitro cultivation, although an ASC-typical pattern of surface markers remains. In this regard, our study aims to contribute to the establishment of a standard protocol to achieve reliability, validity, and objectivity for future cell therapy or clinical applications.

In the Western hemisphere, nonmetastatic locally advanced esophageal carcinoma is mostly treated in multimodal therapy protocols according to current therapy guidelines. In squamous cell carcinoma of the esophagus, neoadjuvant chemoradiation is the favorable option. Unimodal surgical and chemoradiation treatment alternatives show inferior results on this entity. For locally advanced adenocarcinoma of the esophagus perioperative chemotherapy and neoadjuvant chemoradiation have been competing treatment approaches in the recent past. Both are evidence based (class I evidence) and superior compared to unimodal surgery. However, the latest results of head-to-head comparative therapy studies show superior overall survival results for the FLOT regimen of perioperative chemotherapy. Furthermore, immunotherapy and targeted therapy with monoclonal antibodies have become a strong focus of current clinical research. Nivolumab as well as trastuzumab are already an important part of the current standard therapies. In both entities - SCC and AC - a significant quota of patients shows a locoregional complete remission of the tumor in the specimen after modern neoadjuvant therapy and surgical resection. The addition of immunotherapy and targeted therapy to neoadjuvant therapy further increases complete remission rates in defined subgroups according to the results of current studies. Currently, three prospective randomized trials are ongoing on the subject of future possibilities for organ-preserving concepts in case of complete clinical remission ("surgery as needed," "watch and wait"). It is to be expected for the future that curative short-term and long-term treatment results in locally advanced esophageal carcinoma will significantly improve, particularly due to the additional possibilities of immunotherapy and organ-preserving therapy concepts in postneoadjuvant complete remission.

Periprosthetic joint infections (PJIs) are dramatic complications after primary total joint arthroplasty. Despite increasing research in this field, the diagnosis, classification, and management of PJI remain a challenge. This is mainly due to the heterogenous clinical presentation of PJI in clinical routine and patient-related factors as secondary diagnosis and periprosthetic tissue condition. The early detection of PJI is essential for adequate treatment. However, there is no definition for PJI with 100 % sensitivity or a negative predictive value. This can potentially lead to a delayed or missed diagnosis of PJI. Furthermore, the surgical and antibiotic treatment is among the most discussed topics in PJI literature. There is no international consensus on the treatment of different PJI entities. Concludingly many aspects of PJI diagnostics and treatment remain controversially discussed and current studies are only comparable to a limited extent due to study heterogeneity and limited comparability.

Objectives: Non-technical skills (NTS) training of surgical staff is a quality improvement measure to improve patient safety. One factor that can compromise patient safety is impaired staff performance due to stressors such as tiredness. Awareness of the impact of such stressors is measured by the stress recognition (SR) domain of the Safety Attitudes Questionnaire (SAQ). The aim of this study was to assess whether NTS training improves SR scores and whether there are any groups with divergent SR scores.

Methods: A cross-sectional survey of all operating theatre staff in a German major trauma centre was undertaken using the stress recognition (SR) subscale of the SAQ. A multivariable linear regression was performed to assess which factors are associated with SR scores. Data are presented as median (interquartile range).

Results: From 226 invited staff members, 89 responses (39 %) were received. Twenty-eight respondents (31 %) had attended NTS training. The overall SR score was 4.3 (3.5-4.5). There was no effect of NTS training, age, gender, profession, or specialty on SR scores. Physicians in leadership positions had lower SR scores (3.4 (3.06-4.0)) than physicians without leadership positions (4.5 (4.3-5.0), p<0.001).

Conclusions: Attendance at NTS training courses did not improve SR scores in the clinical staff of operating theatres of a German major trauma centre. Interestingly, physicians in leadership positions had lower SR scores than other physicians. Further studies using the SAQ should discriminate between physicians in leadership positions and other physicians when reporting SR scores.

Neoadjuvant chemoradiotherapy in patients with esophageal- and gastroesophageal junction cancer induces tumor regression. In approximately one fourth of patients, this leads to a pathological complete response in the resection specimen. Hence, active surveillance may be an alternative strategy in patients without residual disease after neoadjuvant chemoradiotherapy. Previous studies have shown that the combination of esophagogastroduodenoscopy with bite-on-bite biopsies, endoscopic ultrasound with fine needle aspiration of suspected lymph nodes, and a PET-CT-scan can be considered adequate for the detection of residual disease. So far, it has been unclear whether active surveillance with surgery as needed is a safe treatment option and leads to non-inferior overall survival compared to standard esophagectomy after neoadjuvant chemoradiotherapy. This review will discuss the current status of active surveillance for esophageal and junctional cancer.

Objectives: The treatment of acute respiratory distress syndrome (ARDS) in burn patients remains a major challenge. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) is a standard treatment for severe ARDS today. But reports on survival outcome in burn patients remain variable in the literature. The aim of this study is to identify factors that may influence survival and therapy outcomes in this distinct patient population.

Methods: A single-center retrospective study was conducted in the burn intensive care unit (BICU). Inclusion criteria were the use of vv-ECMO for ARDS after burn injuries. The data analyzed included general medical data and various parameters from the BICU.

Results: Between January 2012 and December 2022, 21 consecutive adult patients were identified who underwent vv-ECMO treatment. Five patients (24 %) survived the therapy and could be discharged, and 16 patients (76 %) succumbed to their disease. A higher TBSA affected, lower pH in arterial blood gas analysis after 24 and 36 h, multiorgan dysfunction syndrome (MODS), renal insufficiency, and renal replacement therapy were significantly associated with a lethal outcome.

Conclusions: The data from the present study showed an overall mortality rate of 76 %, which is unsatisfactory compared to the literature. This could be explained by complicating factors such as MODS, renal failure, and renal replacement therapy. However, the indication for vv-ECMO must be adapted to the individual situation of the respective patient. Due to the additional higher risk for complications, the utilization of ECMO therapy should be reserved for specialized burn centers with an interdisciplinary setting.