Chirurgie (Heidelberg, Germany)最新文献

Multimorbidity is characterized by the presence of at least 3 chronic diseases with a prevalence of more than 50% of patients over 60 years old. The Charlson comorbidity index (CCI) enables a description of the severity of the multimorbidity and also provides a correlation with the postoperative outcome after liver resection. According to this, multimorbid patients are at increased risk of morbidity and mortality after liver resection, mostly due to postoperative liver failure. In particular, open major liver resection with biliary reconstruction and primary liver tumors linked to metabolic associated fatty liver disease (MAFLD) pose an increased risk for multimorbid patients. In contrast, minimally invasive resection leads to a clear reduction in postoperative morbidity and mortality. Preconditioning of the liver and the implementation of perioperative strategies according to the enhanced recovery after surgery (ERAS) concept can also lead to an improvement of the postoperative outcome.

Background: Pancreatic surgery is still associated with significant morbidity. In a simultaneously increasingly ageing population with elevated morbidity, the risk stratification and indications for surgery are of particular importance.

Objective: Assessment of the impact of multimorbidity of patients on the postoperative outcome after pancreatic surgery.

Material and methods: Evaluation and summary of the available literature.

Results: The postoperative morbidity after pancreatic surgery remains high. Relevant comorbidities, such as liver cirrhosis, cardiac and pulmonary diseases and advanced renal insufficiency enormously increase the risk of perioperative morbidity and mortality; however, in high-volume centers with appropriate expertise in pancreatic surgery the mortality is below 5%.

Conclusion: Pancreatic surgery with severe comorbidity can be safely performed in centers with proven expertise. Nevertheless, a careful interpretation of the indications and good patient selection are essential for the postoperative outcome.

Background: Lymphedema is primarily treated conservatively using complex physical decongestion treatment (CDT). Lymphovenous anastomosis (LVA), vascularized lymph node transplantation (VLNT) and liposuction are available as surgical treatment methods; however, reimbursement in the diagnosis-related groups (DRG) system is sometimes inadequate or only possible following an individual application. The costs of these relatively new surgical procedures have not yet been set in relation to those of CDT.

Method: The costs of conservative treatment were determined in accordance with the guidelines. The costs for LVA, VLNT and liposuction of the upper and lower extremities were estimated on the basis of the DRG reimbursement per case and the expected reduction in conservative measures according to current knowledge. The annual treatment costs were then compared.

Results: The annual treatment costs of LVA and VLNT are already lower than conservative treatment alone in the second postoperative year. Liposuction reaches this point in the 6th (upper extremity) or 47th postoperative year (lower extremity).

Conclusion: The evidence for the positive effects of lymphatic surgery is still limited; however, it is recognizable that the curative surgical approach can significantly reduce the treatment costs and improve the quality of life of lymphedema patients; however, there is a lack of adequate reflection of the surgical effort in the reimbursement.

Augmented and virtual reality (AR and VR, respectively) are already being used or evaluated in some medical fields: however, the widespread application is still hampered by inconsistent and often confusing terminology, in particular for people who are not familiar with current developments. Additionally, the technical principles and requirements for its use are often insufficiently well known. This overview article therefore aims to clarify the most important terminology and presents the current technical state of the art, spanning from the requirements of medical imaging, through 3D models and the various forms of visualization to the interaction possibilities within VR and AR. This should help to facilitate a common language among developers and users and to ensure that the potentials offered by digital assistive technologies can be fully exploited in the future.

Digital technologies, such as virtual and augmented reality (VR and AR) are mainly used in the preclinical and clinical phases in neurosurgery and orthopedics. In contrast, they are used less frequently in visceral surgery as the intraoperative deformation is challenging for the clinical use. The application of VR is used successfully particularly in education and training. In addition to current areas of application, this article highlights the results of the Federal Ministry of Education and Research (BMBF) project "Versatile Immersive Virtual and Augmented Tangible OP (= surgery)" (VIVATOP). In this project AR and VR technologies in combination with 3D printing as demonstrators were newly or further developed. A VR planning tool for partial liver resection, the development of 3D holograms for intraoperative AR support and an avatar telemedicine function as well as a 3D printed model for training purposes were developed. The clinical results of the intraoperative AR support with the primary endpoint of operation duration and the secondary endpoints of the duration of hospitalization and intensive care unit stay as well as complication rates are compared with a historical cohort and the results are contextualized.

Anatomical structures of the liver could be reconstructed three dimensionally from preoperative cross-sectional imaging for over 20 years. This three-dimensional (3D) representation not only optimizes the preoperative planning options but also the communication of specific operation-relevant structures can be improved using 3D models. In addition to a plastic and interactive visualization of 3D organ models, the disruptive technology of virtual reality (VR) can also provide a possibility for structured training and further education regarding surgical anatomy of the liver and operation planning. This makes examinations in virtual reality also seem tangible. The latest prototypes even enable patient-specific simulation of intraoperative sonography. This review article provides an overview of the current status of available technologies for training and further education using VR exemplified by liver surgery.