Chirurgie (Heidelberg, Germany)最新文献

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.

Background: Since the 2020 revision of the medical training regulations surgical training in Germany has been based on the acquisition of knowledge (cognitive and methodological competence) as well as experience and skills (practical competence). As in previous training catalogues, minimum numbers are defined for essential operations; however, these operation catalogues do not reflect the actual surgical competence of residents.

Objective: This paper highlights the current challenges faced by prospective surgeons. It presents a perspective on a core competency-oriented surgical training model using entrustable professional activities (EPAs) and provides suggestions for the implementation and digitalization of surgical education based on EPAs.

Material and methods: Overview in the sense of a narrative review.

Results: The EPAs are clearly defined clinical tasks in the medical practice that can be entrusted to residents, observed and evaluated. The purpose of EPAs is the structured and continuous assessment of individual competencies in medical training. They are specific, embedded in the surgical routine and can support supervisors in implementing competency-based training. The EPAs serve to assess and promote surgical skills. Through digitalization tools such as smartphone applications, these evaluations can be integrated into daily clinical practice.

Discussion: In the future, surgical education should evolve towards competency-based learning. The use of EPAs enables a more practice-oriented training approach: moving away from the quantitative focus of procedure catalogues toward a qualitative improvement of surgical training.

Non-Union is still a frequent and severe complication in fracture treatment and represents a major challenge for orthopedic trauma surgery. Due to chronic pain and loss of mobility, pseudarthrosis can lead to a considerable impairment of the individual quality of life and the often long duration of treatment represents a high socioeconomic burden. The lower extremities are most frequently affected due to the high biomechanical stress. A multimodal concept combining diagnostics and treatment is necessary to adequately address this complex clinical condition.

Reconstructive and plastic surgery plays an important role in the treatment of patients after bariatric surgery. The reconstruction of body form and function with body contouring procedures leads to a significant increase in the quality of life after achieving weight stability and stabilization of potential side effects of the bariatric treatment. From a surgical perspective tightening of the extremities and trunk play an important role. Precise knowledge of the anatomical structures and perfusion patterns of the generated skin flaps as well as a careful patient selection for reduction of perioperative complications are very important. In addition to the surgical procedures the accompanying measures with respect to dietary changes and exercise therapy are important keystones in the complex treatment of bariatric and postbariatric treatment patients.