Chirurg最新文献

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.

Lateral abdominal wall hernias are rare and inconsistently defined, which is why the use of the European Hernia Society classification makes sense, not least for the purpose of comparing the quality of surgical results. A distinction must be made between true fascial defects and denervation atrophy. Based on the available literature, there is generally a low level of evidence with no consensus on the best operative strategy. The proximity to bony structures and the complex anatomy of the three-layer abdominal wall make the technical treatment of lateral hernias difficult. The surgical variations include laparoendoscopic, robotic, minimally invasive, open or hybrid approaches with different mesh positions in relation to the layers of the abdominal wall. The extensive preperitoneal mesh reinforcement open, transabdominal peritoneal (TAPP) laparoscopic repair or total extraperitoneal (TEP) endoscopic repair has met with the greatest approval. The extent of the required medial mesh overlap is determined by the distance between the medial defect boundary and the lateral edge of the straight rectus abdominus muscles. The medially directed preperitoneal and retroperitoneal dissection can be extended into the homolateral retrorectus compartment by laterally incising the posterior rectus sheath or by crossing the midline behind the intact linea alba into the contralateral retrorectus compartment. The intraperitoneal onlay mesh (IPOM) technique is a suitable procedure only for smaller defects with possible defect closure but it is also important as an exit strategy in the case of a defective peritoneum. Individualized prehabilitative and preconditioning measures are just as important as the assessment of preoperative anamnestic and clinical findings and risks with radiographic cross-sectional imaging diagnostics.

Background: The increase of minimum volumes for complex esophageal resections decided by the Federal Joint Committee (GBA) in Germany is currently the subject of intensive discussions.

Objective: To shed light on the effects of minimum volume requirements from the perspective of a tertiary care hospital.

Results: Strict adherence to the valid minimum volume requirements for esophageal surgery would significantly reduce the number of hospitals offering these procedures in Germany. The associated loss of revenue should not have any relevant negative economic consequences for most hospitals; however, the loss of complex esophageal surgery may result in a competitive disadvantage for these hospitals in times of shortage of qualified medical personnel. Another point of criticism is the assumption that the treatment quality can be recognized based solely on the numbers of patients.

Conclusion: Despite the well-known volume-outcome relationship, minimum volume requirements do not define the lower limit of quality of surgical treatment. Therefore, additional evidence of treatment quality, such as structural or process quality as well as outcome parameters should be required, e.g. through certification. An obligatory synchronous certification could contribute to increasing the acceptance of minimum volume requirements in Germany.

Postoperative complications after the creation of an intestinal stoma have a considerable impact on the patient's quality of life. The accurate surgical technique is very important for their prevention and requires profound surgical knowledge as well as sufficient experience. The importance of the preoperative consultation as well as the postoperative care by stoma therapists is clearly proven. Depending on the severity of the complication, outpatient conservative treatment is initially indicated. A surgical local revision or laparotomy should only be considered if conservative treatment is no longer sufficient, whereby the indications for surgery should be set very cautiously. This article provides an overview of the current evidence regarding the prevention and treatment of postoperative stoma complications.

Introduction: Groin and lower trunk defects are common problems, especially for elderly patients. While groin defects are often due to prior vascular interventions, trochanteric defects are mainly caused by pressure sores. Plastic reconstructive methods are manifold; however, the pedicled anterolateral thigh (ALT) flap is supposed to be reliable with sustainable results.

Objective: We present our experiences using the pedicled ALT flap for soft tissue reconstruction in patients with large wounds of the medial and lateral proximal thigh.

Materials and methods: A total of 16 patients with groin and lower trunk defects due to prior vascular surgery or pressure sores received locoregional soft tissue reconstruction using a proximal pedicled ALT flap. Patient characteristics, defect size, surgery time, clinical outcome and complication rate were assessed.

Results: With the exception of two cases, sufficient soft tissue reconstruction was achieved. In all, 81,3% of patients were categorized as ASA (American Society of Anesthesiologists) 3. The average duration of surgery was 149 min. Length of stay was 18,3 days. A total of 31% needed revision surgery due to limited wound healing problems. Two patients died. All patients showed healed wound conditions when they were discharged.

Conclusion: The proximal pedicled ALT-flap is a reliable method for soft tissue reconstruction in groin and lower trunk defects. This reconstructive procedure enables reliable wound closure, especially in elderly patients with substantially reduced general health condition.