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[Outpatient cholecystectomy as the next step? : Discussion and possible criteria in the selection of patients]. [门诊胆囊切除术是下一步吗:讨论和选择患者的可能标准]。
Pub Date : 2024-12-01 Epub Date: 2024-09-05 DOI: 10.1007/s00104-024-02167-x
Ines Photiadis, Daniel Eckhardt, Elena Loch, Felix J Hüttner, Markus K Diener, Patrick Heger

Background: While laparoscopic cholecystectomy has largely been performed in an outpatient setting in some countries for years, in Germany it is still generally performed on an inpatient basis; however, with the progressive ambitions for more outpatient treatment within the German healthcare system, laparoscopic cholecystectomy will (have to) increasingly be performed on an outpatient basis in the upcoming years.

Aim of the work: Presentation of the current framework conditions and the potential for outpatient performance of laparoscopic cholecystectomy in Germany. Presentation and discussion on the current state of knowledge regarding patient selection, treatment pathways and safety of outpatient laparoscopic cholecystectomy.

Results: The potential for outpatient management of laparoscopic cholecystectomy in Germany is high. Based on the current literature, there are no safety concerns regarding outpatient performance of laparoscopic cholecystectomy in selected patients.

Conclusion: Outpatient management of laparoscopic cholecystectomy is inevitably heading our way in the next years. The key to successful change will be comprehensive patient information, patient selection and structured outpatient treatment pathways.

背景:多年来,一些国家的腹腔镜胆囊切除术大多在门诊进行,但在德国,一般仍在住院治疗的基础上进行;然而,随着德国医疗系统逐步增加门诊治疗,腹腔镜胆囊切除术在未来几年将(必须)越来越多地在门诊进行:介绍德国目前腹腔镜胆囊切除术的框架条件和在门诊实施的潜力。介绍并讨论有关患者选择、治疗路径和门诊腹腔镜胆囊切除术安全性的知识现状:德国门诊腹腔镜胆囊切除术的潜力很大。结果:在德国,门诊管理腹腔镜胆囊切除术的潜力很大。根据目前的文献,对选定的患者进行门诊腹腔镜胆囊切除术不存在安全问题:结论:未来几年,腹腔镜胆囊切除术的门诊管理将不可避免地向我们走来。成功变革的关键在于全面的患者信息、患者选择和结构化的门诊治疗路径。
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引用次数: 0
Sinus pilonidalis-elastic ligature as an optimal outpatient treatment. 朝天鼻窦--弹性结扎是一种最佳门诊治疗方法。
Pub Date : 2024-12-01 Epub Date: 2023-12-14 DOI: 10.1007/s00104-023-02014-5
Ľudovít Danihel, Marián Černý, Matúš Rajčok, Kristína Mosná, Jihad Bou Ezzeddine, Ivor Dropco, Milan Schnorrer

Background: The incidence of pilonidal sinus shows a steadily rising tendency, especially in the patient age group of up to 40 years. Treatment of this condition is often protracted involving lengthy sick leave and an increased risk of recurrence. The optimal treatment of pilonidal sinus remains open to debate, but it should focus on decreasing the length of hospitalization, promoting a rapid return to daily life, maintaining low pain levels, and keeping costs at a minimum.

Materials and methods: In our study conducted between 2017 and 2021, we focused on treatment of pilonidal sinus. We performed 50 elastic ligature procedures with a median observation time of 30 months. The patients were divided into three groups according to the characteristics of pilonidal sinus: (1) acute primary abscess; (2) acute recurrent abscess; and (3) chronic fistula.

Results: Out of a total of 50 patients with a subsequent 30-month follow-up, we observed complete recovery in 47 patients and recurrence in three patients. Return to work was possible immediately after the operation, with an average total treatment time of 1 month for complete healing of the defect.

Conclusion: The current results suggest that the technique of elastic ligature is a desirable solution for pilonidal sinus, because of the initial low costs, no need for hospitalization, and good patient tolerance.

背景:朝天鼻窦的发病率呈稳步上升趋势,尤其是在 40 岁以下的患者中。这种疾病的治疗往往旷日持久,需要长时间的病假,复发的风险也会增加。朝天鼻窦的最佳治疗方法仍有待商榷,但其重点应是缩短住院时间、促进患者快速恢复日常生活、保持低疼痛水平并将费用降至最低:在 2017 年至 2021 年进行的研究中,我们重点关注了朝天鼻窦的治疗。我们进行了 50 例弹性结扎手术,中位观察时间为 30 个月。根据朝天鼻窦的特征将患者分为三组:(1)急性原发性脓肿;(2)急性复发性脓肿;(3)慢性瘘管:在对 50 名患者进行的 30 个月随访中,我们观察到 47 名患者完全康复,3 名患者复发。术后可立即重返工作岗位,缺损完全愈合的平均总治疗时间为 1 个月:目前的研究结果表明,弹性结扎技术是治疗朝天鼻窦的理想方法,因为其初始成本低,无需住院,患者耐受性好。
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引用次数: 0
[Trauma-associated vascular injuries and the vascular surgical/interventional options for vascular reconstruction]. [与创伤相关的血管损伤和血管重建的血管外科/介入方案]。
Pub Date : 2024-12-01 Epub Date: 2024-07-22 DOI: 10.1007/s00104-024-02124-8
U Barth, S Piatek, M Stojkova, H Krause, F Meyer, Z Halloul

Aim: The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations.

Method: A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options.

Results: The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival.

Conclusion: Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.

目的:这项工作旨在从血管节段或身体区域、事故机制和特定患者组合等方面说明血管损伤的多样性:方法:根据 PubMed 上当前的相关科学参考文献、自身的临床经验、血管外科手术和新型图像引导介入方案,汇编了一份具有代表性的病例集:结果:创伤和骨折情况下的血管损伤诊断以全面的体格检查为基础。此外,西方创伤协会首选的硬性和软性体征也应纳入诊断范围。对于疑似血管损伤,多普勒超声检查是最安全、最温和的无创检查方法,因为其测量结果具有可重复性和可比性。除非出现大量出血、低血容量性休克或血肿迅速扩散等情况,否则应尽可能在血管重建前使用外固定器稳定骨折。在小儿肱骨髁上骨折中,经常出现无血管损伤但无相关缺血的情况(粉红色无脉搏手)。在这种情况下,应首先缩小骨折,因为脉搏通常会恢复。由于血管内治疗技术越来越普及、技术操作性好、技术成功率高以及介入创伤相对有限,创伤性血管损伤的血管内治疗已被广泛接受。即使在事故现场,创伤性主动脉破裂的死亡率也很高。使用支架假体进行快速血管内治疗可大大增加伤者的存活机会:结论:伴有骨折或多处损伤的血管损伤需要相关专科之间的跨学科合作。
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引用次数: 0
[The GRAFITI trial: a nationwide prospective clinical trial on active surveillance in patients with non-intraabdominal desmoid-type fibromatosis]. [GRAFITI试验:一项针对非腹腔类脂膜型纤维瘤病患者进行积极监控的全国性前瞻性临床试验]。
Pub Date : 2024-12-01 Epub Date: 2024-11-19 DOI: 10.1007/s00104-024-02194-8
Franka Menge, Christoph Reißfelder, Jens Jakob
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引用次数: 0
[Chances and risks of conversion to outpatient treatment in trauma surgery and orthopedics]. [创伤外科和矫形外科转为门诊治疗的机会和风险]。
Pub Date : 2024-12-01 Epub Date: 2024-09-06 DOI: 10.1007/s00104-024-02165-z
N von Dercks, A Schuster, C Kleber, P Hepp

At the latest since the Medical Services Healthcare Insurance Reform Act (MDK), the declared will of the legislation is the conversion of operations previously carried out in an inpatient setting to an outpatient setting. In trauma surgery and orthopedics numerous operations are carried out that could principally also be performed in an outpatient setting; however, a prerequisite is a medical assessment of the suitability of patients as well as an economic and normative framework that makes outpatient surgery attractive. Both the Outpatient Surgery in Hospitals Catalogue (AOP-Katalog) and the first edition of the Hybrid Diagnosis-related Groups (DRG) define interventions in trauma surgery that could be carried out in an outpatient setting. Hospitals are therefore required to find solutions for these interventions under processual and economic provisos. These range from omission of outpatient operations to the expansion as a separate financial department in the hospital. With the introduction of the hybrid DRG, the legislation enables equal remuneration for outpatient versus short-term inpatient treatment and leaves the case management up to the hospital; however, the performance of the AOP in the setting of a hospital and also hybrid case flat rates are as a rule not economically viable and bear the risk of the failure of all efforts at conversion to outpatient settings. It is necessary to carry out a fundamental revision of the remuneration and framework conditions for outpatient operations in trauma surgery and orthopedics in hospitals, involving practitioners. This is the only way that the conversion to outpatient treatment can succeed.

最近,自《医疗服务医疗保险改革法》(MDK)颁布以来,该立法所宣称的意愿是将以前在住院环境中进行的手术转换为门诊环境。在创伤外科和矫形外科中,有许多手术原则上也可以在门诊进行,但前提条件是对病人的适宜性进行医学评估,以及建立一个使门诊手术具有吸引力的经济和规范框架。医院门诊手术目录》(AOP-Katalog)和第一版《混合诊断相关分组》(DRG)都定义了可在门诊环境下实施的创伤外科干预措施。因此,医院需要根据流程和经济条件为这些干预措施找到解决方案。这些解决方案包括省略门诊手术,或将其扩展为医院的一个独立财务部门。随着混合 DRG 的引入,法律允许门诊治疗与短期住院治疗享有同等报酬,并将病例管理权留给医院;然而,在医院环境中执行 AOP 以及混合病例统一费率在经济上通常是不可行的,并承担着将所有努力转为门诊治疗失败的风险。有必要对医院创伤外科和骨科门诊手术的薪酬和框架条件进行根本性修订,让从业人员参与其中。只有这样,转为门诊治疗才能取得成功。
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引用次数: 0
[Rectovaginal fistulas : Differentiated diagnostics and treatment]. [直肠阴道瘘:差异化诊断和治疗]。
Pub Date : 2024-12-01 Epub Date: 2024-09-16 DOI: 10.1007/s00104-024-02151-5
Oliver Schwandner

Rectovaginal fistulas (RVF) represent less than 5% of anorectal fistulas. The classification of RVF is based on the localization (low vs. high) and the etiology. The most frequent causes of RVF are birth trauma, Crohn's disease, previous surgery and pelvic irradiation. In most cases a clinical diagnostic assessment is sufficient. Additionally, endosonography is a reliable tool to detect sphincter defects. Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved for special situations (e.g., RVF related to anastomotic leakage, after pelvic irradiation or associated with complex perianal fistulizing Crohn's disease). The surgical treatment is primarily oriented to the localization and etiology. Surgical techniques range from local procedures (e.g., endorectal advancement flap repair, transvaginal or transperineal closure) up to more invasive tissue interposition (e.g., bulbocavernosus muscle fat tissue flap or transposition of the gracilis muscle). In "high" RVF transabdominal approaches such as coloanal anastomosis, pull through procedures or omental interposition are indicated. All surgical procedures show high recurrence rates. Several operations are mostly necessary and a stoma creation is often required.

直肠阴道瘘(RVF)占肛门直肠瘘的比例不到 5%。直肠阴道瘘的分类依据是定位(低位与高位)和病因。最常见的 RVF 病因是分娩创伤、克罗恩病、既往手术和盆腔照射。在大多数情况下,临床诊断评估就足够了。此外,内窥镜检查也是检测括约肌缺陷的可靠工具。计算机断层扫描(CT)和磁共振成像(MRI)适用于特殊情况(如与吻合口漏有关的 RVF、盆腔照射后或与复杂的肛周瘘化性克罗恩病有关)。手术治疗主要以定位和病因为导向。手术技术包括从局部手术(如肛门直肠内推进皮瓣修复术、经阴道或经会阴闭合术)到更具创伤性的组织插植术(如球海绵体肌脂肪组织瓣或腓肠肌转位)。在 "高 "RVF情况下,可采用经腹方法,如结肠肛门吻合术、拉通手术或网膜插置术。所有手术方法的复发率都很高。大多数情况下需要进行多次手术,通常还需要造口。
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引用次数: 0
[Status quo of operative training in emergency surgery in Germany]. [德国急诊外科手术培训现状]。
Pub Date : 2024-12-01 Epub Date: 2024-09-11 DOI: 10.1007/s00104-024-02178-8
Matthias Mehdorn, Patrick Sven Plum, Ines Gockel
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引用次数: 0
["Surgical foresight: beyond the routine" : The challenge of complex visceral surgical emergencies for young medical specialists and senior physicians]. ["外科前瞻:超越常规":复杂内脏外科急症对年轻专科医生和资深医生的挑战]。
Pub Date : 2024-12-01 Epub Date: 2024-09-02 DOI: 10.1007/s00104-024-02155-1
Anton Vernyk, Pascal Joachim Scherwitz, Nora Hanke
{"title":"[\"Surgical foresight: beyond the routine\" : The challenge of complex visceral surgical emergencies for young medical specialists and senior physicians].","authors":"Anton Vernyk, Pascal Joachim Scherwitz, Nora Hanke","doi":"10.1007/s00104-024-02155-1","DOIUrl":"10.1007/s00104-024-02155-1","url":null,"abstract":"","PeriodicalId":72588,"journal":{"name":"Chirurgie (Heidelberg, Germany)","volume":" ","pages":"1003-1006"},"PeriodicalIF":0.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142115582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
[Cytoreductive treatment with HIPEC and partial liver resection in patients with peritoneal and liver metastases from colorectal cancer]. [结直肠癌腹膜和肝脏转移患者的 HIPEC 和肝脏部分切除术的清创治疗]。
Pub Date : 2024-12-01 Epub Date: 2024-10-29 DOI: 10.1007/s00104-024-02192-w
Oliver Rohland, Michael Ardelt, Utz Settmacher
{"title":"[Cytoreductive treatment with HIPEC and partial liver resection in patients with peritoneal and liver metastases from colorectal cancer].","authors":"Oliver Rohland, Michael Ardelt, Utz Settmacher","doi":"10.1007/s00104-024-02192-w","DOIUrl":"10.1007/s00104-024-02192-w","url":null,"abstract":"","PeriodicalId":72588,"journal":{"name":"Chirurgie (Heidelberg, Germany)","volume":" ","pages":"1014-1015"},"PeriodicalIF":0.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142549282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
[Management of venous aneurysms and the vascular surgical treatment options : Selection of representative case constellations illustrating experiences at a center for vascular surgery]. [静脉动脉瘤的管理和血管外科治疗方案 :选择有代表性的病例组合,说明血管外科中心的经验]。
Pub Date : 2024-11-14 DOI: 10.1007/s00104-024-02191-x
U Barth, M Stojkova, F Meyer, Z Halloul

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.

简介静脉动脉瘤是血管外科中一种罕见的疾病,大多数病例都是在个人病例系列和由此产生的荟萃分析中描述的。治疗理念多种多样,手术治疗因其血栓形成和肺栓塞的风险而受到重视。关于术后抗凝治疗的必要性和持续时间仍存在争议:方法:对一家(高度专业化护理)血管外科中心过去18年来连续收治的静脉动脉瘤患者进行病例系列研究,包括:i)在日常血管外科实践中获得的自身经验;ii)对可能的、尤其是已确立的特定诊断治疗概念的相关参考文献进行精选和最新文献检索:2005 年至 2023 年间,共报告了 11 例静脉动脉瘤病例,患者年龄在 30-84 岁之间(平均:52.5 岁,中位数:50 岁),其中 1 例患者 2 年后复发,需要进行手术治疗。性别比例为 7:3(男:女),腘静脉是最常受影响的解剖区域,占 36.4%,其次是颈内静脉和腋下/锁骨下静脉,各占 18.2%。下腔静脉、髂总静脉和肘静脉动脉瘤仅发生过一次。对 9 例动脉瘤进行了手术治疗。采用的手术方法包括:i)切向切除动脉瘤壁并进行连续荷包缝合;ii)切除动脉瘤并植入 8 毫米 GORE-TEX® 血管移植假体(戈尔公司,德国普茨布伦);iii)结扎动脉瘤;iv)结扎后切除动脉瘤:结论:静脉动脉瘤的罕见性应成为集中登记这些病例的理由(可能的话,在全国范围内进行与诊断相关的登记)。手术治疗通常没有问题,并发症也很少。四肢、盆腔静脉和下腔静脉动脉瘤发生肺栓塞的风险似乎明显增加,而头颈部静脉动脉瘤发生肺栓塞的风险则明显降低。随着特异性抗凝剂和新型药物的开发,围手术期和术后抗凝治疗已得到调整,更倾向于使用直接口服抗凝剂(DOAC)进行治疗。根据个人经验,术后立即灌注肝素(小剂量),随后使用低分子量肝素进行治疗桥接,然后再改用抗凝剂进行门诊护理,这似乎可以保障围手术期保持较低的手术相关并发症发生率(如血栓形成、出血)。
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引用次数: 0
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Chirurgie (Heidelberg, Germany)
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