Innovative Surgical Sciences最新文献

Objectives: Clinical practice guidelines (CPGs) have a potentially important role regarding the assessment and communication of the risks of perioperative complications. This study aimed to (1) examine the content of German surgical CPGs in relation to surgical risks and (2) provide baseline results for future research in order to assess the development of surgical CPGs in Germany in relation to this issue.

Methods: In November 2015, all German surgical CPGs that provide guidance regarding illnesses that can be treated with a surgical procedure were collected from the websites of the German umbrella organisation of medical professional associations and the German Association for Cardiology.

Results: Data collection retrieved 230 CPGs of which 214 were included in the final analysis. The analysis identified four different groups: 1) 5% (10/214) of guidelines did not discuss "risks" or "complications" at all; 2) 21% (44/214) of guidelines discussed general risks that are not related to surgical complications; 3) 35% (76/214) of guidelines discussed surgical complications and often discussed their likelihood in terms of "high risk" or "low risk", but did not provide numeric estimates and 4) 39% (84/214) of guidelines discussed specific surgical risks and also provided numerical risk estimates. Guidelines with higher methodological quality more frequently included numerical risk estimates.

Conclusions: It is positive that the vast majority of German surgical CPGs address the issue of risks. However, it would be helpful if more German surgical CPGs provide explicit and evidence-based estimates and recommendations relating to the surgical risk to support surgeons in providing high-quality care and to meet their ethical obligations to patients.

Objectives: To evaluate how the certification of specialised Oncology Centres in Germany affects the relative survival of patients with colorectal cancer (CRC) by means of national and international comparison.

Methods: Between 2007 and 2013, 675 patients with colorectal cancer, treated at the Hildesheim Hospital, an academic teaching hospital of the Hannover Medical School (MHH), were included. A follow-up of the entire patient group was performed until 2014. To obtain international data, a SEER-database search was done. The relative survival of 148,957 patients was compared to our data after 12, 36 and 60 months. For national survival data, we compared our rates with 41,988 patients of the Munich Cancer Registry (MCR).

Results: Relative survival at our institution tends to be higher in advanced tumour stages compared to national and international cancer registry data. Nationally we found only little variation in survival rates for low stages CRC (UICC I and II), colon, and rectal cancer. There were notable variations regarding relative survival rates for advanced CRC tumour stages (UICC IV). These variations were even more distinct for rectal cancer after 12, 36 and 60 months (Hildesheim Hospital: 89.9, 40.3, 30.1%; Munich Cancer Registry (MCR): 65.4, 28.7, 16.6%). The international comparison of CRC showed significantly higher relative survival rates for patients with advanced tumour stages after 12 months at our institution (77 vs. 54.9% for UICC IV; raw p<0.001).

Conclusions: Our findings suggest that patients with advanced tumour stages of CRC and especially rectal cancer benefit most from a multidisciplinary and guidelines-oriented treatment at Certified Oncology Centres. For a better evaluation of cancer treatment and improved national and international comparison, the creation of a centralised national cancer registry is necessary.

Objectives: Indocyanine green (ICG) is a fluorescent dye which was initially used for liver functional assessment. Moreover, it is of value for intraoperative visualization of liver segments and bile ducts or primary and secondary liver tumors. Especially in minimally invasive liver surgery, this is essential to enhance the precision of anatomical guided surgery and oncological quality. As early adopters of ICG implementation into laparoscopic and robotic-assisted liver surgery in Germany, we summarize the current recommendations and share our experiences.

Methods: Actual strategies for ICG application in minimally invasive liver surgery were evaluated and summarized during a review of the literature. Experiences in patients who underwent laparoscopic or robotic-assisted liver surgery with intraoperative ICG staining between 2018 and 2020 from the Magdeburg registry for minimally invasive liver surgery (MD-MILS) were evaluated and the data were analyzed retrospectively.

Results: ICG can be used to identify anatomical liver segments by fluorescence angiography via direct or indirect tissue staining. Fluorescence cholangiography visualizes the intra- and extrahepatic bile ducts. Primary and secondary liver tumors can be identified with a sensitivity of 69-100%. For this 0.5 mg/kg body weight ICG must be applicated intravenously 2-14 days prior to surgery. Within the MD-MILS we identified 18 patients which received ICG for intraoperative tumor staining of hepatocellular carcinoma (HCC), cholangiocarcinoma, peritoneal HCC metastases, adenoma, or colorectal liver metastases. The sensitivity for tumor staining was 100%. In 27.8% additional liver tumors were identified by ICG fluorescence. In 39% a false positive signal could be detected. This occurred mainly in cirrhotic livers.

Conclusions: ICG staining is a simple and useful tool to assess individual hepatic anatomy or to detect tumors during minimally invasive liver surgery. It may enhance surgical precision and improve oncological quality. False-positive detection rates of liver tumors can be reduced by respecting the tumor entity and liver functional impairments.

Objectives: The most important goal of surgical treatment for spinal degeneration, in addition to eliminating the underlying pathology, is to preserve the biomechanically relevant structures. If degeneration destroys biomechanics, the single segment must either be surgically stabilized or functionally replaced by prosthetic restoration. This study examines how software-based presurgical simulation affects device selection and device development.

Methods: Based on videofluoroscopic motion recordings and pixel-precise processing of the segmental motion patterns, a software-based surrogate functional model was validated. It characterizes the individual movement of spinal segments relative to corresponding cervical or lumbar spine sections. The single segment-based motion of cervical or lumbar spine of individual patients can be simulated, if size-calibrated functional X-rays of the relevant spine section are available. The software plug-in "biokinemetric triangle" has been then integrated into this software to perform comparative segmental motion analyses before and after treatment in two cervical device studies: the correlation of implant-induced changes in the movement geometry and patient-related outcome was examined to investigate, whether this surrogate model could provide a guideline for implant selection and future implant development.

Results: For its validation in 253 randomly selected patients requiring single-level cervical (n=122) or lumbar (n=131) implant-supported restoration, the biokinemetric triangle provided significant pattern recognition in comparable investigations (p<0.05) and the software detected device-specific changes after implant-treatment (p<0.01). Subsequently, 104 patients, who underwent cervical discectomy, showed a correlation of the neck disability index with implant-specific changes in their segmental movement geometry: the preoperative simulation supported the best choice of surgical implants, since the best outcome resulted from restricting the extent of the movement of adjacent segments influenced by the technical mechanism of the respective device (p<0.05).

Conclusions: The implant restoration resulted in best outcome which modified intersegmental communication in a way that the segments adjacent to the implanted segment undergo less change in their own movement geometry. Based on our software-surrogate, individualized devices could be created that slow down further degeneration of adjacent segments by influencing the intersegmental communication of the motion segments.

Objectives: Boerhaave's syndrome is a life-threatening disease with high mortality and morbidity. Endoscopic negative pressure therapy (ENPT) can be used to treat oesophageal perforations.

Case presentation: We report on a case of oesophageal rupture with peritonitis in a 35-year-old male patient. The start of treatment was 11 h after the perforation event. The treatment of the perforation defect was performed exclusively by intraluminal ENPT, the treatment of peritonitis was performed by laparotomy with abdominal lavage. For ENPT we used two different types of open-pore drains. The first treatment cycle of four days was performed with an open-pored polyurethane foam drainage (OPD), which was placed intraluminal to cover the perforation defect and to empty the stomach permanently. The second treatment cycle of nine days was performed with a thin nasogastric tube like double-lumen open-pored film drainage (OFD). For suction OPD and OFD were connected with an electronic vacuum pump (-125 mmHg). OFD enables active gastric emptying with simultaneous intestinal feeding via an integrated feeding tube. Intraluminal ENPT with a total treatment duration of 13 days was able to achieve the complete healing of the defect. Surgical treatment of the perforation defect was not necessary. The patient was discharged 20 days after initial treatment with a non-irritating abdominal wound and a closed perforation.

Conclusions: In suitable cases, endoscopic negative pressure therapy is a minimally invasive, organ-preserving procedure for the treatment of spontaneous oesophageal rupture.