Chirurgie (Heidelberg, Germany)最新文献

Even in the ideal case of well-coordinated cooperation between anesthesiological and surgical as well as interventional colleagues, a departmental control unit is required to undertake the management of the central surgical unit. Conflict management and the communication of decisions represent only one part of the range of tasks of operating room (OR) management. In contrast, strategic planning, control of higher level patient flows within the entire hospital, capacity and personnel planning and the increasingly important quality management are the core competencies of a good OR manager. Where in the past the routine problems of the planning surgeon had to be fought out between professions and between hierarchies and always solved in a new way, nowadays there should be an OR statute, which ideally must be transparently implemented and openly communicated by the OR management.

Background: Malnutrition poses a significant risk for patients with non-small cell lung cancer (NSCLC). A reduced nutritional status is associated with functional decline and perioperative complications, thereby impairing treatment success and prognosis.

Methods: A retrospective single-center cohort study including 197 NSCLC patients who underwent curative surgery between 2015 and 2024 was conducted. The aim was to examine the relationship between preoperative nutritional status, postoperative outcome and long-term prognosis in NSCLC patients.

Results: Based on age-adjusted body mass index (BMI) 28.4% of patients were underweight, 35.5% normal weight and 36.1% overweight. Approximately one third of the patients had a nutritional risk scoring (NRS) ≥ 3 and 65% a Grazer malnutrition screening (GMS) ≥ 3, each indicating a risk of malnutrition. A C-reactive protein-albumin ratio (CAR) ≥ 0.144 was observed in 44.2% of patients. Severe postoperative complications (Clavien-Dindo classification, CDC ≥ °III) were associated with NRS ≥ 3, GMS ≥ 3 and CAR ≥ 0.144. Patients with elevated NRS and GMS scores showed a higher risk of recurrence and mortality. An increase in CAR by 1 was associated with a 41% higher mortality risk.

Conclusion: The preoperative nutritional status influenced postoperative outcomes after curative surgery. Given the predictive relevance of individual parameters, nutritional screening should be performed multiparametrically. Further studies are needed to translate these findings into clinical practice and prehabilitation-based nutritional strategies.

Using selected examples from the fields of disinfection, antiseptics, perioperative antibiotic prophylaxis, disposable medical gloves, workwear and protective clothing, air conditioning systems, architectural modifications and recycling of recyclable medical products used in surgery, it is shown that the carbon footprint of inpatient and outpatient surgical facilities can be reduced by implementing infection control measures appropriate to the indications without compromising the safety of patients and staff.

Pheochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors arising from chromaffin cells and are capable of producing catecholamines. The diagnostics rely on measurements of free plasma and urinary fractionated metanephrines, complemented by computed tomography (CT) or magnetic resonance imaging (MRI) for anatomical imaging. Up to 35% of PPGLs are hereditary and the underlying genetic background significantly influences both tumor biology and surgical strategy. Surgery remains the cornerstone of treatment. For adrenal tumors, laparoscopic or retroperitoneoscopic adrenalectomy represents the standard of care, while minimally invasive approaches are also feasible for many paragangliomas. Preoperative blood pressure optimization is essential, although the routine use of an alpha-blockade is increasingly questioned. Organ-preserving tumor extirpation should be considered whenever oncologically safe, particularly in patients with hereditary syndromes, bilateral tumors and younger age, in order to avoid postoperative adrenal insufficiency.

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.

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.

Background and objective: Soft tissue sarcomas are rare heterogeneous tumors that require extensive treatment and should only be treated in specialized sarcoma centers. Surgical R0 resection with negative margins is one of the most important positive predictors of disease-specific survival. Comprehensive healthcare economic analyses of inpatient treatment costs are largely lacking but are essential to ensure sustainable and cost-effective care.

Methods: This retrospective single center study analyzed the inpatient costs of 112 sarcoma cases treated at this university tumor center between 2020 and 2022. The statistical analyses were performed to identify variables that influence case underfunding. Additionally, the revenue distribution was examined with respect to the frequency and extent of underfunding using the cost matrix of the Institute for the Remuneration System in Hospitals (InEK).

Results: A negative revenue balance was observed in 66.1% of cases, leading to a total deficit exceeding € 222,000. Significant predictors of underfunding included prolonged operation times, duration of intensive care stay and exceeding the average length of stay. The highest negative revenues were identified in the categories of "infrastructure costs", "medical technical services" and "operating room costs".

Conclusion: The results reveal significant underfunding of surgical sarcoma treatment in a specialized university sarcoma center. Adjustments to diagnosis-related groups (DRG)-based reimbursement are urgently needed to ensure the economic sustainability of care while safeguarding patient safety, academic training and making clinical decisions.