Innovative Surgical Sciences最新文献

The therapeutic landscape in nearly every therapeutic line in advanced/metastatic patients with squamous cell carcinoma (SCC) and esophagogastric adenocarcinoma (EGC) is enriched by recent approvals of immune checkpoint inhibitors (ICIs). In curative intended therapy, patients without pathological residual disease of SCC or GEJ (esophagogastric junction) cancer after preoperative chemoradiation and complete resection have access to adjuvant immunotherapy (independent of PD-L1 (programmed cell death protein 1) status, nivolumab, CHECKMATE 577). For metastatic SCC in the first-line, nivolumab combined with chemotherapy or with ipilimumab (TPS (tumor proportion score) ≥1 %, SCC, CHECKMATE 648) are approved, as well as second-line nivolumab alone regardless of PD-L1 status (ATTRACTION 03). For both, locally advanced or metastatic SCC and EGC, chemotherapy with pembrolizumab is available for patients with CPS (combined positive score) ≥10 (KEYNOTE 590) and for adenocarcinoma with nivolumab (CPS ≥5, CHECKMATE 649). Recent added approvals are chemotherapy with pembrolizumab in CPS ≥1 patients (KEYNOTE 859) and the addition of trastuzumab for personalized therapy in HER-2 positive/CPS ≥1 gastric and GEJ patients (KEYNOTE 811).

Introduction: Anomalies of jaw position and shape affect approximately 10 % of the population. They can have a significant impact on quality of life, which is why the continuous improvement of therapeutic approaches is a key concern in oral and maxillofacial surgery. The aim of this narrative review article is to examine the development of orthognathic surgery in the context of traditional and innovative methods.

Content: A Pubmed-based selective literature search was performed considering literature predominantly from 2022 to 2023. Search terms were "orthognathic surgery" in combination with "virtual surgical planning" and "3D printing".

Summary: Depending on the extent of the existing anomalies, there are purely orthodontic or combined orthodontic-surgical treatment approaches. Technological innovations in particular are changing both the therapeutic approach and the planning of surgical treatment to an almost completely digital workflow. This change can lead to greater precision in treatment and more efficient planning, resulting in reduced costs and an overall improvement in clinical outcomes, including patient satisfaction.

Outlook: This study presents an overview of the field of orthognathic surgery and discusses developments and challenges for the future. With traditional approaches being time-consuming and prone to error digital technologies like VSP, AI and PSIs improve accuracy and efficiency, though challenges persist.

Objectives: After pancreatoduodenectomy (PD) due to pancreatic cancer, recurrence is frequent in almost half of the patients. The rate of R0 resections is associated with the probability of local recurrence and overall survival. A potential intervention to improve the rate of R0 resections is a more radical resection along the superior mesenteric artery (SMA); however, randomized data of such an approach are lacking. Therefore, we conducted the randomized, controlled PancER trial to evaluate the effect of an extended PD compared with conventional PD.

Methods: Patients were randomized to either an extended PD consisting of a modified Kocher maneuver with partial resection of the prerenal fascia, an uncinate process first approach with systematic mesopancreatic dissection along the SMA equivalent to level III dissection according to Inoue, or conventional PD. The primary endpoint, rate of R0 resections, and other perioperative outcomes were compared.

Results: A total of 50 patients were randomly assigned to extended PD (n=24) or conventional PD (n=26). R0 resections were 10 % more frequent in the extended PD group than in the conventional group (75.0 vs. 64.7 %), which was not statistically significant (p=0.59). Patients self-reported more diarrhea symptoms following extended PD after 30 days (p<0.01). Other perioperative outcomes as well as long-term outcomes were comparable between the two groups.

Conclusion: The PancER trial shows that extended PD with more radical resection along the SMA can be performed with comparable perioperative outcomes to conventional PD. Although the intervention improved the R0 resection rate by 10 %, this increase was below expectation. Therefore, an even more radical PD resection technique involving not only the SMA but also the celiac and hepatic artery (TRIANGLE operation) was developed at Heidelberg University. The TRIANGLE operation is currently being evaluated in a randomized controlled multicenter trial. The results of the PancER trial served as pilot data for this subsequent study.

The treatment of severe burn injuries is an essential part of plastic-reconstructive surgery. Severe burned patients are treated in burn centers, which have highly specialized technical and personnel equipment. In addition to clear recommendations for prehospital management, intensive care therapy is usually required for extensive burn wounds. Shock therapy in burns primarily involves balanced fluid resuscitation according to hemodynamic monitoring, vasopressor support, pain management, temperature regulation, oxygen therapy, and comprehensive supportive care to stabilize the patient's condition. Surgical treatment is still based on wound debridement and the gold standard of autologous split-thickness skin grafting. Besides skin transplantation, surgical management of burns may also involve the application of various topical therapies to promote wound healing, reduce pain, and prevent infection. These therapies may include antimicrobial dressings, skin substitutes, growth factors, or specialized wound care products. Once the acute treatment has been completed, multidisciplinary rehabilitation treatment takes place, which begins in the acute hospital and continues in the outpatient and inpatient rehabilitation areas. Surgical treatment of the secondary complications of burns and scars is also an important component of burn care. Comprehensive knowledge of the various components and players involved in the care of severely burned patients is, therefore, required in order to achieve the best possible outcome for the patient.

Introduction: Abdominal surgery in children may disrupt normal gut function, necessitating prolonged fasting, which can lead to complications such as dehydration and nutritional deficits. Early enteral nutrition (EEN) after surgical procedures can enhance wound healing, prevent malnutrition, and expedite recovery. Although concerns exist regarding the risk of complications associated with EEN, current evidence suggests that it is not linked to increased perioperative complications.

Content: This scoping review provides an overview of the role of EEN in pediatric abdominal surgery, exploring its benefits and risks within the context of recent literature from 2021 to 2024. A systematic literature search was conducted using the PubMed database in April 2024 and the identified studies were compared. The search revealed 586 results, wherefrom eight studies (three systematic reviews and five clinical studies) fulfilled the inclusion criteria. Five studies were added since 2021. Overall, EEN may reduce the length of hospital stay, time to full oral intake, and return of bowel function. It does not seem to increase the rate of anastomotic leakage. EEN is associated with lower rates of surgical site infections and wound dehiscence as well as fewer septic complications. One study showed an increase in nausea/vomiting and abdominal distension in the EEN group, which did not lead to further complications.

Summary and outlook: Current evidence suggests that EEN after abdominal surgery in pediatric patients is not associated with a higher rate of complications. In fact, EEN seems to be beneficial and lead to improved patient outcomes and shorter hospital stays. Emphasis on patient and parent comfort, individualized feeding initiation based on clinical factors, and standardized postoperative feeding protocols are recommended to optimize outcomes in pediatric abdominal surgery.

Subepithelial esophageal tumors (SET) are normally benign intramural esophageal lesions of mesenchymal origin. Although rare, the incidence of SET has increased in recent decades due to the more widespread use of endoscopy and diagnostic imaging. The current review aims to provide an overview of the histopathologic spectrum and the most frequent entities including leiomyoma and gastrointestinal stromal tumor (GIST), diagnostic workup, and multidisciplinary treatment options. Staging for SET should include endoscopy, endoscopic ultrasonography (EUS), and tissue sampling. Current consensus guidelines recommend that SET suggestive of gastrointestinal stromal tumor (GIST) larger than 20 mm or lesions with high-risk stigmata should undergo tissue sampling. Most SET have an excellent long-term outcome, but malignancy may be present in certain subtypes. Asymptomatic SET without high-risk stigmata discovered incidentally usually do not require specific treatment. However, depending on the size and location of the lesion symptoms may occur. Therapeutic interventions range from endoscopic interventional resections to major surgical procedures. Enucleation via minimally invasive or robotic-assisted access remains the standard of care for most SET sub-entities.

Objectives: Medical photography is ubiquitous and plays an increasingly important role in the fields of medicine and surgery. Any assessment of these photographs by computer vision algorithms requires first that the area of interest can accurately be delineated from the background. We aimed to develop deep learning segmentation models for kidney and liver organ donation photographs where accurate automated segmentation has not yet been described.

Methods: Two novel deep learning models (Detectron2 and YoloV8) were developed using transfer learning and compared against existing tools for background removal (macBGRemoval, remBGisnet, remBGu2net). Anonymised photograph datasets comprised training/internal validation sets (821 kidney and 400 liver images) and external validation sets (203 kidney and 208 liver images). Each image had two segmentation labels: whole organ and clear view (parenchyma only). Intersection over Union (IoU) was the primary outcome, as the recommended metric for assessing segmentation performance.

Results: In whole kidney segmentation, Detectron2 and YoloV8 outperformed other models with internal validation IoU of 0.93 and 0.94, and external validation IoU of 0.92 and 0.94, respectively. Other methods - macBGRemoval, remBGisnet and remBGu2net - scored lower, with highest internal validation IoU at 0.54 and external validation at 0.59. Similar results were observed in liver segmentation, where Detectron2 and YoloV8 both showed internal validation IoU of 0.97 and external validation of 0.92 and 0.91, respectively. The other models showed a maximum internal validation and external validation IoU of 0.89 and 0.59 respectively. All image segmentation tasks with Detectron2 and YoloV8 completed within 0.13-1.5 s per image.

Conclusions: Accurate, rapid and automated image segmentation in the context of surgical photography is possible with open-source deep-learning software. These outperform existing methods and could impact the field of surgery, enabling similar advancements seen in other areas of medical computer vision.

Half of the patients with esophageal cancer, cancer of the gastro-esophageal junction and gastric cancer present metastasis at the time of diagnosis. In addition, even patients originally thought to be free of metastasis will present metachronous metastasis in the course of the disease. These patients are considered incurable and current standard of care for metastatic esophageal, gastro-esophageal junction and gastric cancers is a systemic therapy without curative intention. However, patients presenting only a low metastatic load are now defined as oligometastatic disease and should benefit from an aggressive, multimodal therapy. We present here a review of recent publications investigating multimodal therapies for oligometastatic disease and showing that a systemic therapy combined with a resection of the primary tumor together with metastasis is associated with a better prognosis than a systemic therapy alone. We also give a precise focus on esophageal squamous cell carcinomas and adenocarcinomas of the gastro-esophageal junction and of the stomach. Interestingly, patients with oligometastatic cancer of the esophago-gastric junction can even be treated in curative intention with such a multimodal therapy as we present here in a short case report. In conclusion, new therapeutic strategies including multimodal approaches for oligometastatic disease have shown promising results in the last years and ongoing randomized prospective trials will provide us the evidence to include them in future European guidelines.

Objectives: Quality assurance strategies for head and neck surgery can improve patient outcomes. This study aims a perioperative analysis of indicators in the quality of outcome in oral cancer patients with special focus on patient`s resilience and satisfaction before and after surgery.

Methods: Patients with oral cancer (OCP) and indication for surgical resection were included in a prospective study. General and disease-related data as well as parameters of patient-specific resilience (RS-11 questionnaire) and physical strength (ECOG-Score) were collected. Importance and satisfaction using the nine items family/friends, sports activities/physiotherapy, participation in culture, professional perspectives, sexuality, enjoyable food, external appearance, social recognition and independence were analysed. The data collection took place pre- and postoperatively (mean: 10th postop day) during the inpatient stay.

Results: Twenty-eight patients with oral cancer (OCP) were analysed (male: n=23, female n=5). The rate of R0 resections was 92.6 %. The average length of stay was 21 days. n=16 of all patients was tracheotomised postop (preop: n=0). n=0 patients confirmed psycho(onco)logical support preop (postop: n=19). Sports activities/physiotherapy was provided to n=3 patients preop (postop: n=21). The mean pre and postop pain perception was 3/10. The RS-11 score decreased significantly postoperatively (p=0.01). A significant loss of satisfaction was seen in the areas of enjoyable food (p<0.001), social recognition (p=0.01), external appearance (p=0.01) and independence (p<0.001).

Conclusions: Supportive therapy measures to promote mental and physical fitness of oral cancer patients are part of inpatient care at our clinic. However, there is no standardised monitoring of these therapies. Digitally supported and standardised programmes to increase mental and physical fitness in both prehospital and inpatient care might lead to an improvement in the quality of outcome despite shortage of resources in terms of time, costs and personnel. A minimally invasive approach to tracheal cannula management and lymph node management in the treatment of OCP can help to reduce the length of stay in the intensive care unit.

Objectives: Due to the close topographical relationship of functional relevant anatomic structures, limited space and cosmetic aspects orbital surgery will remain a challenging discipline. Therefore, novel technical capabilities are necessary for further surgical progress. We here tested the integration of augmented reality and optical navigation in one workflow for interdisciplinary decision-making, feasibility and intraoperative guidance.

Methods: High-resolution contrast-enhanced MRI and CT scans were automated and manual-assisted segmented to achieve a detailed three-dimensional (3D) model of the individual patho-anatomical relationships. Augmented reality was used for interdisciplinary preoperative planning and intraoperative intuitive navigation. Mayfield clamp head holder in combination with optical surface matching registration assured navigation assisted microsurgery.

Results: Combinations of different MRI-sequences and CT-scans were necessary for detailed 3D-modeling. Modeling was time consuming and only viable in the hands of medical, surgical and anatomical trained staff. Augmented reality assured a quick, intuitive interdisciplinary orientation. Intraoperative surface matching registration enabled precise navigation in the orbital space.

Conclusions: Optical Navigation and microscope integration achieved a straightforward microsurgical workflow and should be implemented regularly. Augmented reality represented a useful tool for preoperative interdisciplinary planning and intraoperative intuitive orientation. It further stated an excellent educational tool.