Chirurg最新文献

The incidence of pancreatic ductal adenocarcinoma is continuously increasing and will become the second leading cause of cancer-related death in Europe and the USA by 2030. With a 5-year overall survival rate of less than 10% the prognosis remains poor. So far surgical tumor resection remains the only curative treatment option, which is now partially supported by multimodal neoadjuvant and adjuvant therapy concepts. Due to the aggressive tumor biology patients with advanced pancreatic cancer in particular can profit from these multimodal therapy concepts. Additionally, in recent years surgical treatment was optimized, the criteria for tumor resectablity were defined and minimally invasive surgery was widely introduced. This review article summarizes the newest developments and the new German S3 guidelines concerning surgery of pancreatic cancer.

Pancreatic cancer still has a very unfavorable prognosis. This is true even for the comparably small group of patients (maximum 15%) who are diagnosed with a clearly resectable tumor. The article provides information on the current statements of the S3 guidelines on adjuvant and neoadjuvant treatment of resectable pancreatic cancer and describes adjuvant and neoadjuvant treatment strategies. Furthermore, the article pursues the questions of if and for whom a total neoadjuvant treatment is suitable and which options of a personalized treatment are available for resectable pancreatic cancer.

Background: In the past, a reduced length of postoperative hospital stay was considered a sufficient trade-off to refinance the additional costs associated with minimally invasive surgery; however, with the implementation of the Nursing Personnel Strengthening Act and disincorporation of nursing costs, this argumentation needs to be fundamentally reevaluated.

Method: Using right-sided hemicolectomy as an example, a retrospective case analysis was conducted. Cost reductions associated with the length of hospital stay were compared before and after the introduction of the revised German diagnosis-related groups (aG-DRG) and offset against the increased material and personnel costs.

Results: Among the analyzed cases, the utilization of minimally invasive surgical techniques led to a substantial cost reduction per case compared to conventional surgical treatment. After the introduction of the aG-DRGs the financial benefits of a shortened hospital stay are greatly diminished and cannot be used to refinance the expenses necessary to perform minimally invasive surgery. From a strictly economical perspective, there is a strong incentive to only perform open surgical procedures.

Conclusion: Disincorporation of nursing costs has destabilized the fragile concept of indirect refinancing of advanced operative techniques by the financial incentives associated with a shorter hospital stay. In order to comply with statutory regulations to implicate a performance-based funding, there is an urgent necessity to adjust the grouping algorithms for minimally invasive surgical procedures to the corresponding flat rates.

Treatment modalities of lung cancer have rapidly evolved in recent years by the establishment of tumor-specific targeted drugs and immunomodulatory concepts and the complexity has rapidly increased. This development is accompanied by improved survival data and knowledge of other spectra of side effects and recurrence characteristics. This development requires that clinicians maintain a constant vigilance in the stratification of treatment options. This article gives an overview of the current clinically relevant approaches of targeted treatment of lung cancer and points out possible links to thoracic surgery. The presentation of the options of targeted therapy demonstrates which role they play in the adjuvant treatment in cases of proven mutations of epidermal growth factor receptor (EGFR), when a salvage operation can be used and how a curative treatment concept can be elaborated in individual cases through targeted treatment. Every lung cancer ultimately requires a molecular analysis of treatment-relevant mutation patterns at the earliest possible time in the diagnostics. Interdisciplinary concepts can individually guarantee the long-term survival of the patient.

Due to their increased detection pancreatic cystic space-occupying lesions are becoming increasingly relevant in the clinical routine and represent a morphologically and biologically heterogeneous and thus clinically demanding as well as potentially (pre)malignant entity. As a result, recommendations for the diagnostics and treatment of pancreatic cystic tumors have now been incorporated into the current German S3 guidelines on pancreatic cancer. The diagnostics of pancreatic cystic space-occupying lesions are based on the following three elements: collection of relevant clinical information, performance of high-resolution imaging procedures and if diagnostic uncertainty persists, puncture diagnostics. Differentiated diagnostics are of essential importance as these represent the basis for an adequate treatment decision. Pancreatic cystic lesions with a relevant risk of malignant transformation, e.g., main duct intraductal papillary mucinous neoplasms (IPMN), followed by mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and generally pancreatic cystic lesions with risk factors independent of the entity, should be resected, whereas a differentiated and individualized approach is necessary, especially for branch-duct IPMNs. The serous cystic neoplasms (SCN) have no malignant potential and do not require any treatment if they are asymptomatic. Important principles in surgery of pancreatic cancer, such as adequate surgical resection taking oncological standards into account and standardized appropriate histopathological processing of the specimens as well as intraoperative frozen section analysis also play an important role in pancreatic cystic space-occupying lesions. An annual follow-up seems to be meaningful, especially for IPMNs.

Anal incontinence describes the uncontrolled transanal passage of gaseous, solid or liquid intestinal contents. It can be a considerable psychosocial burden and impairment of the quality of life for those affected. The cause can be primary damage to the continence organ or incontinence can be a secondary symptom of other diseases. The detailed patient history and clinical examination document the severity of incontinence, impairment of quality of life and pathomorphological changes. The treatment is primarily conservative. A combination of conservative therapeutic approaches can often achieve satisfactory symptom relief. If conservative treatment remains insufficient, surgical measures can be considered. Sphincteroplasty and sacral neuromodulation are the preferred surgical interventions.

Fast-track treatment pathways reduce the frequency of postoperative complications in elective colorectal resections by approximately 40% and due to the rapid recovery reduce the postoperative duration of hospitalization by approximately 50%. Specialized nursing personnel (enhanced recovery after surgery, ERAS, nurses) have already been appointed internationally to accompany and monitor the execution of multimodal perioperative treatment. In November 2018 a fast-track assistant was appointed in the Clinic for General and Visceral Surgery of the Municipal Clinic in Solingen for coordination of the fast-track treatment pathway. The results confirmed that a high adherence to perioperative fast-track treatment concepts can also be achieved in the German healthcare system by the assignment of specialized nursing personnel, with the known advantages for patients, nursing personnel, physicians and hospital sponsors.

Background: Lesions of the extracranial carotid artery are the cause of 10-15 % of all cases of cerebral ischemia. The aims of the updated S3 guidelines are evidence-based and consensus-based recommendations for action on comprehensive care of patients with extracranial carotid stenosis in Germany and Austria.

Methods: A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews were carried out. Consensus answers to 37 key questions with evidence-based recommendations.

Results: The prevalence of extracranial carotid stenosis is approximately 4% and increases after the age of 65 years. The most important examination method is duplex sonography. Randomized controlled studies (RCT) have shown that carotid endarterectomy (CEA) of an asymptomatic 60-99% carotid artery stenosis reduces the absolute risk of stroke (absolute risk reduction, ARR) within 5 years in comparison to drug treatment alone by 4.1%. Due to an improved pharmaceutical prevention of arteriosclerosis, the S3 guidelines recommend a prophylactic CEA of a 60-99% stenosis only for patients without an increased surgical risk. Additionally, one or more clinical or imaging results should be present, which indicate an increased risk of carotid-related stroke in the follow-up. For medium-grade (50-69 %) and high-grade (70-99 %) symptomatic stenoses the ARRs after 5 years are 4.6% and 15.6%, respectively. Systematic reviews of RCTs have shown that CEA is associated with a ca. 50% lower periprocedural risk of stroke compared to carotid artery stenting (CAS). There are no differences in the long-term course. The CEA is recommended for high-grade asymptomatic, medium-grade and high-grade symptomatic carotid stenosis as a standard procedure, alternatively CAS can be considered. For both procedures the periprocedural stroke rate/mortality during hospitalization should be a maximum of 2% (asymptomatic stenosis) or 4% (symptomatic stenosis).

Conclusion: Both CEA and CAS necessitate a critical evaluation of the indications and strict quality criteria. Future studies should evaluate even better selection criteria for an individual, optimal, conservative, operative or endovascular treatment.