Chirurgie (Heidelberg, Germany)最新文献

Introduction: Venous aneurysms are a rare entity in vascular surgery, which are mostly described in individual case series and meta-analyses generated from them. The treatment concepts are diverse and surgical treatment is highlighted due to the risk of thrombosis and pulmonary embolism. There is still an ongoing debate regarding the postoperative necessity and duration of anticoagulation.

Method: Case series of a consecutive patient cohort with venous aneurysms from the last 18 years in a center of (highly specialized care) vascular surgery including i) own experiences obtained in daily vascular surgical practice and ii) a selected and current literature search of relevant references on possible and, in particular, established diagnosis-specific therapeutic concepts.

Results: Between 2005 and 2023, a total of 11 cases of venous aneurysms were reported in patients aged 30-84 years (mean: 52.5, median: 50), with 1 patient requiring surgery for a recurrence after 2 years. The gender ratio was 7:3 (m:f) and the popliteal vein was the most frequently affected anatomical region with 36.4%, followed by the internal jugular vein and axillary/subclavian vein each with 18.2%. Aneurysms of the inferior vena cava, the common iliac vein and the cubital vein occurred only once. Surgical treatment of the aneurysms was performed in 9 cases. The surgical methods used were i) tangential resection of the aneurysm wall and continuous purse-string suture, ii) resection of the aneurysm and interposition of an 8‑mm GORE-TEX® vascular graft prosthesis (Gore, Putzbrunn, Germany), iii) ligation of the aneurysm and iv) ligation with subsequent resection of the aneurysm.

Conclusion: The rarity of venous aneurysms should be a reason to register these cases centrally (possibly, nationwide diagnosis-related register). Surgical treatment is usually unproblematic and associated with few complications. The risk of pulmonary embolism appears to be significantly increased in venous aneurysms of the extremities, pelvic veins and inferior vena cava, while venous aneurysms of the head and neck are significantly less prone to this. Perioperative and postoperative anticoagulation has been adapted to the development of specific anticoagulants and novel drugs, in favor of treatment with direct oral anticoagulants (DOAC). In personal experience, immediate postoperative heparin perfusion (low dose) and subsequent therapeutic bridging with low-molecular-weight heparin before switching to an anticoagulant for outpatient clinic-based care appears to safeguard the perioperative phase with respect to keeping the surgery-related complication rate (e.g., thrombosis, bleeding) low.

Pancreatic cystic lesions represent a challenging heterogeneous entity with a potential risk of malignant transformation. The diagnostics include in particular medical history taking with collection of relevant clinical information and high-resolution imaging, preferably using magnetic resonance imaging (MRI) with MR cholangiopancreatography (MRCP) and/or endoscopic ultrasonography. A differentiation between different cystic entities and identification of risk factors are crucial for making appropriate treatment decisions. Only a small proportion of pancreatic cystic neoplasms require surgery. Pancreatic cystic lesions with a relevant risk of malignancy, such as main duct intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and general cystic pancreatic lesions with risk factors regardless of the entity, should be resected, whereas an individualized approach is required for branch duct IPMN and serous cystic neoplasms (SCN) and dysontogenetic cysts require no treatment. Parenchyma-sparing and minimally invasive resection techniques should be preferred whenever possible for resecting pancreatic cystic tumors. Approximately 10% of patients develop recurrences over time.

The healing of gastrointestinal anastomoses is a complex biological process influenced by numerous factors. Various strategies to support healing and prevent anastomotic leakage (AL) exist, encompassing preoperative, intraoperative and postoperative measures. Preoperative interventions aim to optimize the patient and the tissue environment, particularly the gut microbiome. Intraoperative measures are technical in nature and include the choice of surgical access, the anastomotic technique and anastomotic reinforcement. Various procedures of the intraoperative diagnostics enable identification of such anastomoses requiring additional protective measures. Recently, indocyanine green (ICG) fluoroscopy has become established for evaluation of tissue perfusion, while newer techniques such as spectral microscopy offer promising possibilities. Postoperative diagnostic methods aim to identify potential AL as early as possible to enable initiation of therapeutic steps even before the onset of symptoms. These procedures range from various imaging techniques to innovative bioresorbable, pH-sensitive implants for early AL detection. Due to the multifactorial genesis of AL and the diverse technical possibilities, no single method will become established for prevention of AL. Instead, a combination of measures will ultimately lead to optimal anastomotic healing. The use of artificial intelligence and analyses based on the data promises a better interpretation of the vast amount of data and therefore to be able to provide general recommendations.

Anastomotic leakage in visceral surgery is associated with a large number of known and also unknown or even unmeasurable parameters. Furthermore, the associations between the individual factors are intertwined and complex. According to current data a preoperative prediction is not reliably possible and should be distinguished from intraoperative or postoperative prediction models. Most studies on this topic do not exceed an area under the curve (AUC) of 0.70. A thorough understanding of statistics and prediction models is necessary to correctly interpret the published works. Due to the relatively low incidence rate of anastomotic leakage from a statistical point of view, large datasets are required for adequate prediction. Multimodal data and complex algorithms can potentially handle big data more accurately and improve predictability; however, these models have so far not been applied in the clinical routine.

Surgical resection is the consistent component of curative treatment strategies for primary malignant diseases of the stomach and the esophagus. The placement of anastomoses for the necessary reconstruction still accounts for substantial morbidity and in the case of a failure to rescue also for mortality, especially for esophagojejunostomy and esophagogastrostomy. The diagnostics of anastomotic leakage routinely involve computed tomography and endoscopy and timely performance appears to be essential. Endoscopy can simultaneously initiate the essential treatment step. A major reason for the improvement of postoperative outcomes after resection in the upper gastrointestinal tract in the last decades is the successful and mostly endoscopically performed management of anastomotic leakage, whereby different endoscopic treatment options are now available. Endoscopic vacuum therapy has become established as the standard, normally with an endoscopic vacuum sponge technique but is also now supplemented by a combination system of vacuum sponge and stent. Furthermore, a foil-coated multiple lumen nasogastric tube represents another available option, which can possibly especially be used as a prophylactic measure. The longest established endoscopic therapy option for anastomotic leaks, the endoluminal metal stent, has been replaced as the standard by the vacuum treatment but is still used in suitable situations. Additionally, there are endoscopic suture devices that are currently only used very occasionally. Surgical revision is always available as treatment escalation but is only recommended for very early occurrences and possibly technically related anastomotic leakage and in the case of failure of endoscopic treatment. This article describes and summarizes the diagnostics and treatment of anastomotic leakages after surgical procedures of the upper gastrointestinal tract.