Chirurgie (Heidelberg, Germany)最新文献

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.

Background: Molecular imaging of adrenal tumors has become established in clinical routine, because they often cannot be characterized using morphological imaging alone. It can provide an important contribution to the localization and characterization of these lesions.

Objectives: The use of various radiopharmaceuticals forms the basis of molecular imaging via positron emission tomography (PET)/computed tomography (CT) and single photon emission computed tomography (SPECT)/CT.

Materials and methods: We conducted a literature search on established and novel PET- and SPECT-tracers used in adrenocortical tumors, pheochromocytomas, and paragangliomas.

Results: For distinguishing adrenocortical carcinomas from adenomas imaging of glucose metabolism using [¹⁸F]FDG-PET/CT (FDG: fluorodeoxyglucose) is helpful. CXC chemokine receptor type 4 (CXCR4)-targeting radioligands like [⁶⁸Ga]Ga-PentixaFor show good sensitivity for detection in primary hyperaldosteronism and are subject to clinical trials. In various studies, [¹¹C]metomidate PET/CT demonstrated high specificity and high sensitivity in the identification of unilateral aldosterone-producing adenomas in patients compared to invasive adrenal vein catheterization (AVS) and can be used as an alternative. PentixaFor PET/CT also demonstrated high sensitivity and specificity for the diagnosis of cortisol-producing adenomas in studies. Molecular imaging of pheochromocytomas and paragangliomas utilizes the uptake of catecholamine analogues or metabolites, [18F]F-DOPA, or somatostatin receptor expression.

Conclusion: Molecular imaging can make an essential contribution to the noninvasive diagnosis of adrenal tumors, pheochromocytomas, and paragangliomas by visualizing various metabolic processes.

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.

Neuroprosthetics represents a dynamic field at the interface of neurosciences, engineering and neurosurgery that is based on implanted devices for restoration or extension of neurological functions. Important advances involve brain-computer and brain-spine interfaces that enable communication, motor and sensory feedback in paralyzed or anarthric patients. Intracortical arrays, subdural electrocorticographic lattices and endovascular electrodes provide different access routes, supplemented by strategies, such as spinal neuromodulation and functional electrostimulation. Recent studies confirmed the restoration of grasping movements, standing and walking as well as fluid speech and text communication, sometimes via avatars. Bidirectional systems with sensory feedback enhance the naturalness and precision. There are challenges in signal stability, longevity and minimally invasive access routes. With interdisciplinary cooperation and technical maturity neuroprostheses can enrich the routine neurosurgical care in the future.

Introduction: Intensive care medicine in Germany has fundamentally developed in the context of medical progress and changed treatment requirements. Originally preceded by pioneer work in surgery, intensive medical care facilities are nowadays decisive cost drivers in patient care. Earlier models from around the 1930s were replaced by specialization and interdisciplinary cooperation. Against this background the present study investigated the current state of care, the structures for continuing education and the implementation of surgical intensive and intermediate care (IMC) wards.

Material and methods: Between 27 February 2023 and 8 May 2023, a representative sample of 1106 intensive care wards was pooled using an anonymous online survey on a German web server (lamapoli.de) and 181 complete replies could be evaluated. The survey incorporated 42 questions, which in addition to the demographic acquisition also requested data on the resources, leadership and continuing education modalities of personnel on independent surgical intensive care wards as well as interdisciplinary surgical intensive care wards (IOI) and IMCs.

Results: Approximately 17% of the hospitals surveyed had their own surgical intensive care ward, predominantly in university hospitals. These units are characterized by a high presence of the specialist discipline and qualified personnel with additional qualifications in intensive care medicine. In contrast, interdisciplinary intensive care wards were used in facilities with a lower level of care, frequently managed by anesthesiology departments. The continuing education times for assistant surgeons were in most cases longer than 6 months, which promotes an intensive transfer of knowledge and interdisciplinary cooperation. The IMC wards are also an integral component of surgical care even though they are personnel intensive and more economically challenging. The study shows that surgical intensive care medicine has a well-structured, discipline-specific care and training, especially at university locations. In facilities with lower levels of care interdisciplinary models dominate, which also enable an adequate training. Nevertheless, the debate on the retention of discipline-specific knowledge in intensive care medicine remains a current topic in order to ensure a high quality of perioperative care.

Background: Bariatric surgery is a key component of a multimodal treatment approach. In addition to surgery, conservative therapeutic options should be offered to promote preoperative weight loss and improve obesity-related comorbidities.

Objective: This review aims to present available preconditioning strategies and evaluate whether and to what extent they improve pre- and postoperative weight loss and reduce perioperative risks.

Materials and methods: Analysis and discussion of current literature on the topic.

Results: The data available are highly heterogeneous. Preoperative weight loss can be achieved through hypocaloric diets, intragastric balloon placement, or the addition of glucagon-like peptide‑1 (GLP-1) agonists to lifestyle interventions before bariatric procedures. However, studies have not yet confirmed a positive effect on perioperative risk or postoperative weight development.

Conclusion: Although some preconditioning strategies appear promising and are partly part of clinical routine, the current evidence base is insufficient to support uniform recommendations for preconditioning prior to bariatric surgery.