Chirurgie (Heidelberg, Germany)最新文献

Total neoadjuvant therapy (TNT) refers to the addition of preoperative systemic therapy to preoperative radiotherapy (RT; 5 × 5 Gy) or chemoradiotherapy (ChRT) for rectal cancer. This can be administered either before RT/ChRT as induction therapy or after RT/ChRT as consolidation therapy. Randomized trials demonstrate improved tumor response (clinical or pathological complete remission) and a significant improvement in disease-free survival with TNT compared to neoadjuvant ChRT plus surgery with or without adjuvant chemotherapy. The updated S3 guidelines therefore recommend TNT, particularly for patients high-risk factors defined with magnetic resonance imaging (MRI, cT4, cN2, mrCRM+, EMVI+, lateral lymph node involvement). Following achievement of complete clinical remission after TNT organ-preserving (watch and wait) strategies are increasingly being favored and are being further optimized in ongoing clinical trials (e.g., ACO/ARO/AIO 18.1, JANUS, STELLAR II).

Mild autonomous cortisol secretion (MACS) is diagnosed in up to 50% of benign hormonally active adrenal tumors. Due to a growing number of detected adrenal incidentalomas a thorough diagnostic work-up is needed to critically decide on conservative or surgical treatment. In incidentalomas > 1 cm the 1 mg dexamethasone suppression test is recommended along with a native computed tomography scan. Patients without overt Cushing's symptoms but pathological results in dexamethasone suppression test (cortisol > 1.8 µg/dl) are labelled MACS. In these patients both mortality and prevalence of diabetes mellitus, arterial hypertension and dyslipidemia are elevated. In unilateral adenomas and the presence of comorbidities adrenalectomy should be discussed in an interdisciplinary panel. Postoperatively, an endocrinological follow-up is required to control the hypopituitary-adrenal axis. With a conservative approach endocrinological control is only recommended with deterioration of comorbidities. After adrenalectomy, improvement of arterial hypertension and bone mineral density have been shown in meta-analyses.

Peripheral arterial occlusive disease (PAOD) is a frequent manifestation of atherosclerosis associated with high morbidity and mortality. This article summarizes the current recommendations of the German S3 guidelines "Diagnostics, treatment and follow-up of PAOD" (Association of the Scientific Medical Societies in Germany, AWMF 2024) and discusses the implications of the ongoing hospital reform. Key diagnostic modalities include patient history taking, clinical examination, ankle-brachial index measurement and duplex ultrasonography. In cases of suspected chronic limb-threatening ischemia (CLTI), the WIfI score enables a structured risk assessment for amputation. Treatment management emphasizes strict secondary prevention (low-density lipoprotein, LDL < 3,1 mmol/l, smoking cessation), supervised exercise training and optimized antithrombotic therapy (clopidogrel is preferred; dual pathway inhibition for high-risk patients or after revascularization). Revascularization can be performed endovascularly or surgically and increasingly in specialized centers. The German Hospital Reform supports the centralization of complex procedures and the expansion of outpatient care, thereby underscoring the pivotal role of nonvascular surgical departments in early detection and coordinated referral.

Adrenocortical carcinoma (ACC) is among the rarest solid malignancies, but is characterized by pronounced biological aggressiveness and a high risk for recurrence. Complete tumor resection (R0) remains the only potentially curative treatment and is the primary determinant of long-term survival. Given the functional heterogeneity of ACC and the frequent presence of hypercortisolism or androgen excess, preoperative evaluation and perioperative management require close interdisciplinary management. Open adrenalectomy continues to be regarded as the gold standard, whereas minimally invasive techniques may be considered in strictly selected cases and within high-volume expert centers. The relevance of systematic lymphadenectomy is increasingly recognized, although its optimal extent remains a matter of debate. Postoperatively, adjuvant therapy is tailored according to individual risk profiles, with mitotane indicated for patients at intermediate or high risk of recurrence. Recurrence is common and should be managed surgically whenever technically feasible. In metastatic disease, multimodal treatment strategies-integrating surgical, interventional radiologic, and systemic approaches-play a central role. Although the overall prognosis remains limited, surgical expertise and treatment within specialized centers are the key for improved patient outcomes.