Chirurgie (Heidelberg, Germany)最新文献

Klatskin tumors are cholangiocarcinomas which arise at the biliary bifurcation (perihilar cholangiocarcinoma). Due to the close anatomical relationship to the liver parenchyma, portal bifurcation and hepatic arteries, the treatment of these tumors represents a major challenge. The only curative treatment option so far is the complete surgical removal of the affected bile ducts. This often warrants an en bloc liver resection sometimes in combination with resection and reconstruction of the portal vein and occasionally of the hepatic artery. A regional lymphadenectomy is mandatory. The operations are technically challenging and associated with a significant perioperative morbidity up to 50-60% and mortality of around 10%.

Robot-assisted surgical techniques have become increasingly established in general and visceral surgery over the past 15 years. This also applies to adrenalectomy, a purely resective procedure that does not require complex reconstruction. The current standard remains minimally invasive surgery, performed either laparoscopically or retroperitoneoscopically. Do a number of perceived advantages-such as stable three-dimensional visualization, articulated instruments, and an additional "hand" for the surgeon-justify the still considerably higher costs of robotic-assisted surgery? Current evidence suggests minor benefits of robotic surgery in certain operative and complication-related parameters, although these advantages appear to have limited relevance in everyday clinical practice. A broader perspective, however, indicates that the question raised will soon become obsolete, as robot-assisted techniques are likely to become standard practice in the near future.

Oligometastasis describes an intermediate stage between localized and systemic tumor disease, in which a limited number of metastases with restricted organ involvement still appear amenable to local treatment. Despite its growing relevance and numerous publications, a unified definition for gastrointestinal (GI) tumors is lacking. The aim of this work was to summarize the existing definitions and current therapeutic standards for oligometastasis in the GI tract. Based on current studies and guidelines it becomes evident that local treatment is currently being investigated for gastric, esophageal, colorectal, pancreatic, hepatocellular and cholangiocellular carcinomas. Initial data suggest a possible improvement in survival through combined systemic and local treatment approaches. The results of most prospective studies are still pending. In the future, molecular markers and biological tumor characteristics are expected to contribute to better patient selection and further improve the integration of local treatment.

In the highly complex environment of the operating room, the perioperative nursing personnel make an essential contribution to the quality, safety and efficiency of surgical procedures. Increasing specialization, technological development and rising demands for safety and cost-effectiveness position perioperative nursing as a central pillar of interprofessional care. This article highlights the key areas of responsibility and spheres of impact within perioperative nursing as well as the duties of nursing management. The focus is on patient safety, quality of care and sustainable process optimization.

The preoperative logistics for operating room preparation require interdisciplinary cooperation between surgery, anesthesia, nursing and administration as well as a clear standardization of procedures to ensure safety and efficiency. The starting point is the patient presentation with diagnostics and interpretation of the indications, followed by surgical and anesthesiological preparation, which focuses on the clinical examination, information, additional diagnostics and, if necessary, nutritional measures. This is supplemented by nursing assessments and the clarification of organizational issues, such as insurance status and optional services. Patient blood management for the early diagnosis and treatment of preoperative anemia and enhanced recovery after surgery (ERAS) concepts, which reduce postoperative complications and promote faster recovery through multimodal management, are of particular importance. In order to bundle these diverse processes, a centralized patient management provides an efficient interface that coordinates scheduling, diagnostics and resource allocation. As a result the preoperative preparation can increasingly be carried out on an outpatient basis, while inpatient admission is often only necessary on the day of surgery. This leads to shorter hospital stays, better use of resources and higher patient satisfaction.

A close interdisciplinary collaboration between anesthesia and surgery is essential to ensure that our mutual patients receive the best possible care throughout the entire surgical process. Both specialties have different tasks and perspectives and only when these are balanced with rather than against each other can the operating room, along with all related preoperative and postoperative measures, become a place where excellent medicine, patient safety and efficient management go hand in hand. Despite potential areas of conflict interdisciplinary cooperation between surgeons and anesthesiologists can be highly effective when mutual respect, structured communication and shared decision-making are upheld and cultivated. This article aims to provide an overview of some key prerequisites for successful collaboration in this context.

The suture to incision time (turnover time, TOT) is a key indicator of the efficiency of perioperative care and reflects the quality of numerous preceding organizational and logistical processes. In the field of visceral surgery optimizing the turnover time poses particular challenges due to the highly variable duration of procedures, complex surgical workflows and substantial requirements for postoperative intensive monitoring capacities. This narrative review summarizes the factors described in the literature as having a relevant influence on turnover time. These include patient flow from the wards to the operating theater, operating room preparation including material and equipment availability, suitable staffing and infrastructural resources as well as the integration of unplanned interventions, such as emergencies, revision procedures and transplantations. Furthermore, organizational strategies are presented that in various studies were found to be associated with an improvement in perioperative workflows, including standardized turnover processes, lean-based approaches, parallel task execution and digital support systems. Finally, the review discusses the role of operating room management that can be centralized, decentralized or as hybrid model depending on the local structure, with a focus on coordination, prioritization and the establishment of reliable communication pathways.

Background: Liver tumors in childhood are rare and associated with high treatment demands. Over the past decades substantial progress has been achieved through effective chemotherapies and improved surgical techniques as well as international collaborations. Nevertheless, the challenges for the surgical treatment remain high. In Germany additional specific difficulties arise in this context.

Objective: To summarize the current evidence on the surgical management of pediatric liver tumors, to analyze the care structures in Germany and to develop perspectives for optimizing treatment.

Material and methods: Narrative review of the current evidence, systematic analysis of the surgical results of previous hepatoblastoma studies, and evaluation of German care pathways in order to identify problems and perspectives.

Results: The improved prognosis of children with liver tumors (particularly hepatoblastoma) is mainly due to multimodal, risk-adapted treatment concepts and advances in surgical strategies. Because of the rarity of pediatric liver resections, pediatric liver tumor surgery in Germany is positioned at the intersection of pediatric, visceral and transplantation surgery. Surgically, strategies adapted to children are crucial to increase resection rates and avoid postoperative complications. A direct transfer of concepts from adult liver surgery carries substantial risks. In Germany the basic prerequisites are good but care can be further improved through better communication with reference structures, intelligent centralization approaches and investment in surgical training.

Discussion: Pediatric liver tumor surgery is associated with specific challenges due to the rarity and high demands. In Germany, strengthening multidisciplinary structures and communication as well as efficient centralization of treatment planning, can further improve patient safety and outcomes for children with liver tumors.