Chirurgie (Heidelberg, Germany)最新文献

Background: The Russian invasion of Ukraine has confronted Germany with the realities of military conflict, including the medical care of seriously injured soldiers and civilians brought in through humanitarian efforts. This raises concerns about the preparedness of the German healthcare system for such scenarios, particularly in terms of personnel and structural resources for the treatment of penetrating injuries, which are typical for the military context.

Material and methods: An online survey was distributed via email to members of the German Society for General and Visceral Surgery (DGAV). Respondents were asked about structural prerequisites in emergency care capabilities at their institutions and personal experiences managing penetrating trunk injuries (n = 411; 94.6% from civilian hospitals).

Results: Despite increasing specialization 34% of visceral surgeons reported performing emergency thoracotomy themselves. Access to a thoracic surgeon is available in only 50% of the hospitals and to a cardiac surgeon in 26%. The majority of respondents felt inadequately prepared to manage penetrating injuries, especially those resembling military trauma patterns (e.g., shrapnel, blast injuries) as opposed to civilian gunshot wounds.

Conclusion: Given these findings and the evolving geopolitical and security landscape, basic military surgical knowledge must be more broadly disseminated and systematically integrated into national emergency preparedness and disaster response frameworks in order to strengthen the capability for treatment in exceptional situations.

Bone metastases are the most common malignant bone tumors and are often the first clinical sign of a malignant disease. Although the occurrence of bone metastases in a malignant disease usually means a palliative situation for patients, adequate treatment of the metastases can greatly improve the patient's prognosis and ensure that the quality of life is maintained. In addition to oncological and radiotherapeutic treatment options, there are many surgical treatment options available. For this reason, metastasis surgery is the most common oncological operation in musculoskeletal surgery. The indications for metastasis surgery should always be assessed in an interdisciplinary setting, taking the patient's life expectancy, physical limitations and wishes into account. This review article summarizes the various surgical treatment options for bone metastases depending on the region of the body.

Background: The surgical rotation during the final year of medical school (practical year, PJ) is intended to equip all medical students with essential elements of surgical practice; however, little is known about the practical surgery-related experience students have prior to starting this rotation.

Objective: The aim of this study is to systematically assess the practical prior experience of medical students at the beginning of the surgical rotation in the PJ.

Material and methods: Prior experience was recorded using the concept of Entrustable Professional Activities (EPA). Medical students in the surgical rotation at the Charité and its teaching hospitals documented their experience in a mandatory e‑portfolio. This portfolio is based on 10 EPAs and 20 procedures defined by the National Competence-based Catalogue of Learning Objectives (NKLM 2.0). The analysis focused on the level of independence with which students had already performed these EPAs and procedures before starting their first rotation.

Results: Data from 516 students between May 2023 and May 2025 were included. Overall, there was a high individual variability in students' practical experience across the different EPAs and procedures. A substantial proportion of students reported little or no prior experience with 7 of the 10 EPAs and 9 of the 20 procedures.

Conclusion: Students begin their surgical rotation in the PJ with varying levels of practical experience. A structured assessment of individual experience based on the EPA framework makes it possible to clearly identify competency levels, to tailor task assignments and supervision and develop personalized learning plans. In the long term this can contribute to more practice-oriented surgical teaching during the PJ and prepare students better for future medical practice, thereby also increasing interest in specialist training in surgery.

Brain metastases are the most frequent intracranial tumor entity and in most cases are a sign of advanced systemic cancer. Advances in neurosurgery, pathology, radiotherapy and oncology, especially with the introduction of immune and targeted systemic treatment, have significantly improved the prognosis for patients with brain metastases in recent years. Neurosurgical treatment plays a key role in symptom relief, reduction of the tumor burden and tissue acquisition for molecular analysis to enable patients to undergo postoperative radiotherapy and systemic therapy. The creation of an optimal patient-oriented treatment concept requires close interdisciplinary coordination and structured follow-up to make individualized and evidence-based treatment decisions.

Background: A prospective vascular trauma registry (VascTR-Aux) is being conducted at Augsburg University Hospital. This first evaluation of the registry data aims to present the treatment results after vascular extremity injuries at discharge.

Material and methods: From 1 January 2016 to 31 March 2024, a total of155 injured persons were included in the VascTR-Aux. Extremity vessels were affected in 83 patients.

Results: Of the 83 injured people included, 62 were male. The average age was 37 years. The vascular injuries affected the upper limb in 28 cases and the lower limb in 55 cases. In 14 cases, the injuries were severe. The patients presented clinically with 29 hemorrhages, 32 ischemia and 14 combinations of both entities and 7 cases were asymptomatic. Patients were treated surgically (n = 51), as a hybrid procedure (n = 7) and as endovascular procedures (n = 8). In 76 cases functional preservation of the extremity was possible. Major amputation was necessary in six cases and minor amputation in two cases. The average length of stay was 23 days.

Discussion: The initial treatment was often interdisciplinary, whereas inpatient follow-up care is often provided by specialist departments other than vascular surgery due to the concomitant injuries requiring treatment. The vascular surgery procedure for treatment and follow-up care must be discussed and communicated individually in the case of vascular injuries, and a vascular surgery follow-up protocol must be established for post-inpatient follow-up examinations. Both endovascular and open surgical treatment options should be available for the treatment of vascular limb injuries. The aim of the registry is to contribute to evidence for the treatment of vascular trauma and to collect long-term results for reconstructions after vascular trauma.

The transfer of knowledge, experience and practical skills in the care of patients in palliative settings takes place in a largely unstructured and sporadic manner in surgical resident training in Austria. The present work assesses the status quo using an online survey of residents in general and visceral surgery, presents their subjective experiences with palliative care and expectations on palliative care providers and their training needs. Over 80% of residents have frequent contact with patients in palliative settings and nearly 60% care for patients in end-of-life situations. Support from a palliative care team is experienced as helpful. Residents would like more support and articulate how they envision this form of support. They rate their own palliative skills as medium to good but 85% would still like additional training and 68% advocate for the integration of palliative care into the surgical curriculum.

The most frequent long-term complications following intestinal bypass procedures that require surgical treatment are internal hernia and treatment-refractory anastomotic ulcer. The risk of internal hernia after Roux-en‑Y gastric bypass ranges from 5-15% and, although it can be reduced by meticulous intraoperative closure of mesenteric defects, it cannot be entirely prevented. Internal hernia usually becomes clinically apparent after significant postoperative weight loss, typically within months to a few years and should ideally be managed by laparoscopic repositioning of the small bowel and closure of the mesenteric defect. Treatment-refractory anastomotic ulcer is most frequently associated with risk factors such as persistent nicotine use during a Helicobacter pylori infection and discontinuation of proton pump inhibitor (PPI) treatment. In addition, anatomical features such as a large gastric pouch or a circumferentially fashioned anastomosis predispose to ulcer formation. The reported incidence after gastric bypass varies considerably and ranges between 1% and 53%. Standard management consists of rigorous elimination of risk factors combined with PPI treatment. In cases of chronicity or (covered) perforation, surgical revision with resection and reconstruction of the anastomosis is required. Choledocholithiasis secondary to cholecystolithiasis represents a particular interdisciplinary challenge due to limited endoscopic access to the papilla of Vater. Established treatment options include endoscopic balloon enteroscopy, retrograde cholangiography via the gastric remnant, which is opened laparoscopically assisted, revision of the bile duct performed during laparoscopic cholecystectomy or percutaneous transhepatic cholangial drainage (PTCD). Management of these long-term complications should preferentially be carried out in certified centers for metabolic and bariatric surgery with appropriate specific expertise.

Background: Due to the generally increasing number of obese patients with obesity-associated comorbidities (e.g. type 2 diabetes mellitus and nonalcoholic fatty liver disease/steatohepatitis), they are increasingly becoming transplantation candidates; however, this patient cohort is more frequently affected by intraoperative and postoperative complications and poorer transplant outcome.

Objective: This article provides an overview of the indications, choice of procedure and outcome of bariatric surgery prior to solid organ transplantation.

Material and methods: The current literature was evaluated and discussed.

Results: Postoperative complications occur more frequently in bariatric patients with (terminal) organ dysfunction than without but the mortality remains low. On the other hand, these patients can be successfully transplanted significantly more often due to weight loss, with a better transplant outcome. In a not insignificant proportion of patients, the operation even leads to an improvement in the underlying disease, so that there is no longer an indication for listing. In the case of liver cirrhosis, bariatric surgery should only be performed in the compensated stage (Child-Pugh A and early B, no higher stage of portal hypertension). Sleeve gastrectomy and Roux-en‑Y gastric bypass are to be preferred. Multidisciplinary care at a center is particularly important in this patient group.

Discussion: Bariatric surgery as a bridging procedure to transplantation appears to be safe but data and evidence are limited due to low overall patient numbers and pending prospective randomized trials.