Chirurgie (Heidelberg, Germany)最新文献

Neurofibromatosis type 1 (NF1, formerly Recklinghausen's disease) is a genetic tumor predisposition syndrome in which the mutation of a tumor suppressor gene (neurofibromin) leads to the development of mostly benign neurofibromas of the skin and the central and peripheral nervous systems and malformations or tumors of other organ systems. Patients with NF1 should receive lifelong interdisciplinary care in specialized centers and important treatment decisions should be made by a regularly meeting interdisciplinary panel of experts. Plastic surgery plays an important role in the multidisciplinary management of all clinical forms of NF1-associated peripheral nerve sheath tumors, from cutaneous and subcutaneous to deep nodular and diffuse plexiform neurofibromas. Each patient requires individualized surgical planning, whereby the timing and extent of surgery are determined by the accompanying symptoms, functional and esthetic limitations, disease progression and potential malignant transformation. As any region of the body can be affected, the esthetic and reconstructive procedures required include a wide range of interventions, such as eyelid surgery and facial restoration to breast shaping and nerve reconstruction or motor replacement surgery. A timely surgical intervention can have a profoundly positive effect on the course of the disease and the quality of life of those affected and, in the case of transformation into a malignant peripheral nerve sheath tumor (MPNST), can even be lifesaving.

The prognosis for esophageal cancer is determined in particular by the depth of infiltration (T stage) and lymph node metastasis (N status). In patients with locally advanced tumors, surgical resection is the current standard. The extent of the lymphadenectomy depends on the localization of the tumor, analogous to the choice of surgical technique. For adequate tumor staging and achievement of pN0 status, seven lymph nodes without tumor metastases are necessary by definition but the current guidelines recommend 20 lymph nodes as a benchmark in an expert consensus. Despite the importance of the lymph node status for the prognosis of the patient and the already standardized use of targeted imaging of sentinel lymph nodes in other oncological disciplines, there is neither a validated method nor sufficient evidence for the benefit of lymph node mapping in esophageal cancer. The discussion about the prognostic advantage of lymphadenectomy is particularly interesting in T1 early stage cancer. Due to the technical advances of interventional endoscopy in recent years, organ preservation using endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) has not only become possible but also safe to carry out and thus established as the standard with better functional results; however, if one or more risk factors are present, endoscopic ablation is no longer defined as curative and should be supplemented by further treatment, usually non-organ-preserving resection. The step from organ-preserving interventional treatment with a low complication rate to a surgical procedure with significant mortality and morbidity as well as functional limitations seems immense and requires optimization, especially in view of the technical developments of surgery in recent years. This can either aim to identify the risk of lymph node metastases more precisely or to minimize the morbidity/mortality and functional limitations of additive treatment procedures. Approaches to this are currently the subject of research and have already been safely applied in individual pilot projects.

Pancreatic cancer is usually diagnosed at a late stage and is characterized by early systemic metastases, which can also be present in the form of micrometastases that are not primarily visible. Lymphatic metastases in pancreatic cancer are common. The extent of lymph node removal (lymphadenectomy, LAD) in pancreatic cancer is defined in the guidelines of the Association of the Scientific Medical Societies in Germany (AWMF) and according to currently available data has more diagnostic and prognostic relevance than therapeutic relevance; however, within the framework of modern multimodal treatment algorithms, radical surgery is the most relevant of all components of multimodal treatment with LAD playing an important role. According to current data, extended LAD without technical necessity in the surgery of the primary tumor brings no advantages for the patients but numerous limitations in the quality of life and should therefore not be performed as the standard. Important aspects of LAD for pancreatic cancer are the lymph node ratio, extended vs. standard LAD and innovations in LAD in the field of interaortocaval lymph nodes and the so-called triangle operation.

Background: Lymphadenectomy for rectal cancer is clearly defined by total mesorectal excision (TME). The analogous surgical strategy for the colon, the complete mesocolic excision (CME), follows the same principles of dissection in embryologically predefined planes.

Method: This narrative review initially identified key issues related to lymphadenectomy of rectal and colon cancer. The subsequent search was based on PubMed and focused on meta-analyses. The endpoints for rectal cancer were the benefit of high tie versus low tie and the indications for lateral pelvic lymphadenectomy. For colon cancer the evidence for CME, for the longitudinal extent of resection, for the dissection of infrapyloric and gastroepiploic lymph nodes, for the number of lymph nodes and for the sentinel lymph node technique were used as endpoints.

Results: An oncological benefit of the high tie cannot be derived from the current data. Lateral pelvic lymphadenectomy should only be selectively performed after chemoradiotherapy (CRT) in cases of remaining lymph nodes with suspected metastases. In most studies CME proved to be oncologically superior, especially in stage III. The longitudinal extent of resection should be at least 10 cm in both directions if the principles of CME are observed. Infrapyloric and gastroepiploic lymph node involvement is to be expected in 0.7-22% of cases, depending on patient selection, which justifies dissection, particularly in carcinomas of both flexure and the transverse colon. The minimum number of lymph nodes to be removed cannot be clearly derived from the available studies. Precisely performed CME and an optimal pathological work-up are important. The sentinel lymph node technique cannot currently be used as a criterion for limiting the extent of resection.

Conclusion: Both TME and CME are reliable standards for the lymphadenectomy in colorectal carcinomas. A lymphadenectomy that goes beyond this is reserved for selected cases and is partly the subject of currently ongoing studies.

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.

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.

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.