Chirurgie (Heidelberg, Germany)最新文献

The preoperative estimation of the volumetric and especially functional future liver remnant (FLR) is of particular importance before major liver resections to avoid posthepatectomy liver failure (PHLF). A postoperative regeneration of the liver is only possible if there is sufficient functional FLR. Laboratory parameter scores, such as the combined aspartate aminotransferase to platelet ratio index (APRI)/albumin-bilirubin grade (ALBI) score, can provide an initial assessment of the risk of PHLF. Other functional tests, such as the ICG-R15 test, the LiMAx® (Humedics GmbH, Berlin, Germany) test or scintigraphic procedures (e.g. technetium 99m mebrofenin secretion) can be used in the event of abnormal findings in order to assess liver function more precisely. In the case of inhomogeneous parenchymal quality, for example after portal vein embolization (PVE), knowledge of the segmental functional distribution is essential. This can be done by functional imaging techniques, such as the technetium 99m mebrofenin scintigraphy examinations in combination with magnetic resonance imaging (MRI). Although not yet approved for functional testing, MRI with the hepatocyte-specific contrast agent gadolinium provides a practicable surrogate parameter for parallel three-dimensional (tumor) imaging. This procedure is already well validated. In the future, deep learning algorithms will enable automated analyses of segmental liver function; however, surgical expertise remains decisive for assessing resectability. As a guideline the rule of thumb is at least 30% parenchymal reserve in patients with a healthy liver and 40% in risk constellations. This article provides an overview of current concepts and diagnostic procedures for the preoperative assessment of sufficient parenchymal reserve.

Minimally invasive procedures have been slowly gaining ground in liver surgery since the 1990s but have recently become increasingly more established. In Germany they are now used in around a quarter of all resections for colorectal metastases and much more often in specialized centers. In addition to less blood loss, the advantages include faster postoperative recovery with a correspondingly shorter hospital stay and all this with an oncological safety comparable to open procedures. Robotics provide additional advantages over laparoscopy, especially in complex resections such as posterosuperior segments or vascular and biliary reconstruction. At the same time, artificial intelligence, 3D reconstructions and augmented reality are becoming increasingly more important for planning, navigation and intraoperative safety. Robotics in particular will serve as a technical platform for the increasing digitalization and integration of modern imaging. Despite these advances, open surgery will remain the standard for selected highly complex procedures in the near future.

Background: While standardized treatment recommendations exist for colorectal liver metastases, non-colorectal liver metastases (NCRLM) remain a treatment challenge due to the heterogeneous biology and the lack of evidence-based guidelines.

Material and methods: This review article considers current systematic reviews, retrospective cohort studies and meta-analyses addressing surgical resection and local ablation of NCRLM.

Results: Retrospective data show that selected patients with NCRLM can benefit from local treatment. Favorable prognostic factors include a limited number of oligometastases, achievement of an R0 resection and the absence of extrahepatic tumor manifestations.

Discussion: In view of the limited evidence base, recent advances in minimally invasive surgery and modern systemic treatment, prospective studies are essential to validly define the oncological relevance of local treatment strategies for liver metastases.

Background: Posthepatectomy liver failure (PHLF) remains the leading cause of morbidity and mortality following major liver resection. The preoperative conditioning of the future liver remnant (FLR) is therefore essential to optimize the resectability and avoid postoperative complications.

Objective: The aim of this review article is the presentation and critical evaluation of current strategies for liver conditioning, including interventional, surgical and systemic strategies.

Material and methods: A selective literature search for databases was conducted in PubMed. The focus was on recent systematic reviews, randomized trials and registry analyses addressing portal vein embolization (PVE), liver venous deprivation (LVD), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), selective internal radiation therapy (SIRT) and neoadjuvant chemotherapy.

Results: The PVE procedure has been the established standard for decades, with proven safety and reliable induction of hypertrophy but shows limitations due to insufficient growth or tumor progression in up to 20% of patients. In numerous studies the LVD procedure demonstrated a more rapid and extensive hypertrophy of the FLR compared with PVE, without compromising safety. The ALPPS provides the highest regeneration dynamics but is associated with high morbidity and mortality and requires strict patient selection. The SIRT (radiation lobectomy) enables both tumor control and a relevant compensatory hypertrophy, even though prospective comparative trials are lacking. Neoadjuvant chemotherapy, particularly FOLFOXIRI plus bevacizumab or biomarker-based treatment regimen selection, leads to high conversion and resection rates in initially nonresectable metastases.

Discussion: The current evidence shows that individualized strategies for liver conditioning are decisive to enable a safe resection. The selection of the procedure should be oriented to the patient characteristics, tumor biology and interdisciplinary treatment algorithms.

Background: The number of thyroid gland operations in Germany has dropped continuously over the past 10 years. The typical complications of vocal cord paralysis, hypocalcemia, wound infection and postoperative bleeding still occur with variable incidences in the different hospitals.

Objective: Do the case numbers or hospital category have an influence on the complication rate and have the distribution of operations and the complication rates changed over the last 10 years?

Material and methods: This retrospective observational study is based on anonymized routine data of the General Local Health Insurance Company (Allgemeine Ortskrankenkasse, AOK) and analyses data of thyroid gland operations for benign diseases between 2011 and 2021.

Results and discussion: A continuous decrease in the frequency of operations for benign thyroid gland diseases over the course of 10 years in Germany could be confirmed. Additionally, a shift of operations towards hospitals with higher numbers of interventions could be demonstrated. The complication rates of permanent vocal cord paralysis and postoperative bleeding requiring revision have significantly declined. This reduction of complications could not be attributed to patient-specific risk factors or to the observed shift in the distribution of cases across hospitals.