Die Chirurgie des Pankreaskarzinoms ist eine junge Chirurgie. Seit ca. 20 Jahren haben Pankreasresektionen zunehmende Akzeptanz erlangt und gelten nunmehr als sichere und effektive Behandlungsmethoden benigner und maligner Erkrankungen des Pankreas. Eine drastische Senkung der Mortalität von bis über 25% vor noch ca. 40 Jahren auf nunmehr unter 5% in vielen Zentren war erst in den vergangenen Jahrzehnten möglich. Schwerpunkt dieser Vorlesung soll die historische Entwicklung Chirurgie des Pankreas bilden, von den frühen Anfängen der anatomischen Beschreibung über die Namensgebung zur Entwicklung des pathologischen Verständnisses für das Organ und die ersten chirurgischen Maßnahmen. Die rund 2000 Jahre Medizingeschichte, die hier durchwandert werden, sollen sie nicht abschrecken, es geht auch nicht um Vollständigkeit, vielmehr will ich Ihnen die kleinen und großen Schritte verdeutlichen, die letztlich zum Erfolg der Pankreaschirurgie geführt haben.
Acute acalculous cholecystitis can be a complication of severe illness in patients who have undergone major surgery or have had extensive trauma. The incidence appears to have increased over the past 50 years. The aetiology is multi-factorial while the symptoms and signs, as seen in an Intensive Care Unit, are often less obvious and non-specific due to the use of analgesia and assisted ventilation. Patients and methods: This was a prospective study in patients who were admitted to a surgical Intensive Care Unit post-operatively or following major trauma who developed cholecystitis. The clinical results, laboratory analyses and diagnostic procedures were analysed and evaluated. Results: Even though there have been significant improvements in surgery, anaesthetics and Intensive Care Medicine the mortality of severly ill patients remains about 30%. The mortality of patients with cholecystitis is 8.5 %. Prompt surgery with cholecystectomy within 6 hours of diagnosis is crucial but in selected cases ultrasound guided cholecystostomy is necessary prior to cholecystectomy.
Das deutsche System der Facharztausbildung war einmal über William Halsted Vorbild für ganz Nordamerika, inzwischen könnten wir von vielen anderen Ländern lernen - allein es fehlt die Bereitschaft und das Problembewusstsein. Gähnend leer war der Saal beim Chirurgenkongress 2005, als Richard Reznick über die Vermittlung chirurgischer Fertigkeiten sprach. Kaum einer wollte den berühmten Pionier hören, dessen spannende Erkenntnisse jüngst selbst der Redaktion des New England Journal of Medicine eine Übersichtsarbeit wert war [4]. Dabei sind die Probleme der chirurgischen Weiterbildung in Deutschland offensichtlich. In einer ebenfalls 2005 publizierten Umfrage des Berufsverbandes BDC, die von 584 Assistenz- und Fachärzten anonym beantwortet wurde, gaben die Teilnehmer zu Protokoll [1]:
One reason for persisting hyperparathyreoidism is an ectopic adenoma not found during the operation. The case discussed here is that of a 51-year-old woman with the typical constellation of a primary hyperparathyreoidism. After revision PTH remained elevated. Further examination with MIBI-SPECT-scanning showed a focus in the left anterior mediastinum. After opening the pericard during the revision an adenoma of 1 cm size was found ventral to the ascending aorta. During follow-up PTH and calcium-levels remained stable at normal levels.
Die regelhaft ablaufende Anastomosenheilung am Gastrointestinaltrakt entspricht im Wesentlichen den Mechanismen der Wundheilung. Sie verläuft in drei sich überlappenden Phasen, aber schneller als die allgemeine Wundheilung. Ausgelöst werden diese Vorgänge durch das chirurgische Trauma. Folge jeder Anastomosierung ist eine mehr oder weniger ausgeprägte Entzündungsreaktion, die ihr Maximum in den ersten sieben Tagen erreicht. Das Ausmaß der Entzündung bestimmt entscheidend den Ablauf der Heilung. Dementsprechend können die einzelnen Phasen in Ausprägungsgrad und Dauer variieren. Makrophagen spielen regulativ eine entscheidende Rolle. Die exsudative Phase ist geprägt durch ein Ödem und die Exsudation von Fibrin und Blutbestandteilen mit Einwanderung von Entzündungszellen sowie Fibrinstabilisierung. In der proliferativen Phase findet die Bindegewebseinsprossung mit Gefäß- und Fibroblastenproliferation sowie Kollagenbildung statt. Die reparative Phase ist durch die Stabilisierung des Kollagens mit Reorganisation der Darmwandschichten charakterisiert. Resultat ist immer eine Defektheilung mit Narbenbildung. Im Zusammenhang mit dem Kollagenstoffwechsel kommt es bis zum dritten bis vierten Tag zu einem deutlichen Stabilitätsverlust. Nach 14 Tagen wird schließlich auch ohne unterstützendes Nahtmaterial eine ausreichende Stabilität erreicht.
in the therapy of advanced esophageal, gastric and pancreatic cancer palliative chemotherapy plays a very important role. The goals of these chemotherapies are to palliate symptoms and improve survival for a good quality of life. Because of low incidence of advanced esophageal cancer there exist no phase III-data from for the treatment of this disease. The combination of Cisplatin and 5-FU is an established and cost-effective regime. Future studies must identify the standard of care. The combination of epirubicin, cisplatin and 5-FU (ECF) has emerged as a standard therapy for the treatment of advanced gastric cancer. An improvement of practicability and adverse reaction is the combination of epirubicin, oxaliplatin and capecitabine (EOX), the outcome is suggested to be comparable. The previous standard in the therapy of advanced pancreatic cancer with gemcitabine could be improved by the addition of Erlotinib, especially for patients developing a rash II degrees.
Activity indices and scoring systems for Crohn's Disease and ulcerative colitis represent an important role in disease assessment in clinical studies particularly addressing effects of medical treatment. On the other hand, reliable and reproducible systems of disease activity estimation would be of great value in surgery in order to indicate and plan surgical therapy for both diseases. The present article provides an overview over presently available index and scoring systems for both Crohn's disease and ulcerative colitis and their potential reasonable applicability in surgical therapy planning and performance.
40 % of patients suffering from colorectal cancer will develop liver metastases during the course of their disease. Advances in both surgical technique and perioperative management lead to a decrease in postoperative morbidity and mortality. Against the background of an increasing understanding of tumor biology as well as excellent survival data following hepatic resection, the indication for liver resection has been extended in specialized surgical centers. Similarly the intention to treat changed from a standardized resection towards an individual and interdisciplinary therapy including preoperative chemotherapy, staged liver resection and resection of extrahepatic disease. The aim of this study is to investigate the current value of hepatic resection for colorectal liver metastases in the interdisciplinary oncological concept. It specially addresses these challenging situations where palliative chemotherapy seemed to be the only reasonable way of therapy in past.
The most important issues in perioperative complications of esophagectomy are prevention, early detection and appropriate management. Anastomotic leakage is the most frequent surgical complication. Early diagnostic comprises endoscopy, contrast radiography and CT-scan. Avoidance of tension or impaired vascularisation of the conduit and meticulous suture technique are the main issues to prevent anastomotic problems. Management includes early diagnosis, conservative treatment or endoscopic stenting of contained leakage, and reoperation of non-contained insufficiency. On the prerequisite of early intervention and consistent management most problems of esophageal anastomosis can be treated successfully today.
In the recent two decades liver surgery has gained tremendous progress due to developments in imaging modalities, perioperative management and surgical technique. Thus, overall mortality after liver resection has been reduced below 5 % allowing a more liberal indication for hepatic resection even in advanced and unfavorably located tumors. This paper gives an overview of the current status of liver resection for the three most frequent benign liver tumors, hemangioma, focal nodular hyperplasia and liver cell adenoma, for intrahepatic cholangiocellular carcinoma as well as for hepatocellular carcinoma with and without underlying cirrhosis including the rare type of fibrolamellar carcinoma.
Regardless of significant progress in surgical technique and perioperative management, pancreatic surgery still has a morbidity rate of 30 to 50 %. The main cause of postoperative complications remains the pancreatic anastomosis. Therefore, many different surgical techniques were developed, but none was definitely proven to be significantly better than others. Pancreaticojejunostomy seems to be the most established technique world-wide for pancreatico-intestinal reconstruction, and end-to-side anastomosis has become popular. Prophylactic use of Octreotid can be recommended particularly for soft pancreatic tissue without fibrosis. However, the benefit of ductal stents or external drainage of the pancreatic duct is not proven. Delayed gastric emptying remains the most common surgical complication after pancreatic surgery and should be treated conservatively. However, gastrostasis might often be a result of other local complications, such as pancreatic fistula, abscess and anastomotic leakage. Septic complications may all result in late postoperative haemorrhage which may occur as sentinel bleed, and which always needs an immediate diagnostic work up. Relaparotomies for local complications have become less frequent since interventional radiology has emerged (CT-guided drainage, transarterial embolization) and salvage- pancreatectomy has become a rare procedure in cases of anastomotic dehiscence or bleeding.
The treatment of adult inguinal hernias is one of the most common operations in Germany with approx. 200000 operations annually and as such it also represents an important economic factor in the health system. The development of a tension-free repair with the help of a polypropylene mesh by Lichtenstein [1] in 1986 caused a revolution in the operative process and resulted in a considerable reduction in the recurrence rate [2]. Due to constant discussions regarding the influence of implanted foreign material, this study deals with the influence of different meshs on post-operative pain, especially in chronic pain syndromes and the awareness of foreign bodies. 100 patients with primary hernias were prospectively divided into two groups at versus random and treated with different meshs (material-reduced: 55 g/m(2) vs. conventional: 85 g/m(2)). The patients were questioned both during their time in hospital and at their out-patient appointments about continued pain and the awareness of the foreign body. They were then examined both physically and via ultrasound. With regard to the reported pain levels the material-reduced net showed no advantage compared to the conventional net. Surprisingly, the patients in this group complained even more often about feeling aware of the foreign body. Therefore, in this experiment we were unable to recognise any advantage in the material-reduced nets.
The liver is the most common site of distant relapse after primary surgical therapy for colorectal cancer. Liver resection is the standard treatment for isolated and locally resectable liver metastases, with low perioperative mortality and significant long-term survival rates. Repeat liver resections for recurrent liver metastasis are feasible and have resulted in encouraging survival. The role of adjuvant chemotherapy after potentially curative resection of liver metastases is still uncertain, and patients should be included in clinical trials. This also applies to neoadjuvant chemotherapy. Local ablative techniques may be used instead of or in addition to surgical resection, but no evidence-based recommendations can be given at the time. OncoSurge (TM), a newly developed decision model based on available study results as well as expert consensus may allow for better patient selection for liver resection.
Although medical treatment for inflammatory bowel disease has become more effective, surgical interventions in patients particularly suffering from Crohn's disease are frequent. As surgery for Crohn's disease does not include definitive curation from the disease, restorative proctocolectomy with ileal-pouch-anal anastomisis is performed with curative intent. Most frequent indications for surgery in Crohn's disease include small bowel obstruction and fistulas. Main indications for surgery in ulcerative colitis are high-grade neoplasia (IEN) and colitis-associated carcinoma. Surgical strategy and technique are mainly determined by the type of disease, whereas the type of anastomosis (end-to-end vs. side-to-side), the role of stricturoplasty as well as innovative strategies for perianal fistula in Crohn's disease, and the role of anastomosis in ulcerative colitis are under controversial discussion. Specifically focussing on minimally invasive surgery, potential benefits of laparoscopic surgery in patients with inflammatory bowel disease include reduction of surgical trauma, fast recovery and improved cosmetic when compared to conventional approach. Most common laparoscopic procedures for Crohn's disease include ileocecal resection and stoma creation for fecal diversion, and laparoscopic-assisted proctocolectomy for ulcerative colitis. Data of comparative studies have shown that laparoscopic resection is not associated with increased morbidity rates. In general, the indication for surgery has not changed with the application of laparoscopy.
Over one-third of patients with Crohn's disease eventually will develop intestinal stenosis with the need for surgical intervention. While the pathophysiology of the inflammatory response in Crohn's disease has been investigated extensively, the knowledge of intestinal fibrogenesis is limited. Fibrotic organ remodelling results from a complex interplay of genetic factors, acute and chronic inflammation, activation of mesenchymal cells and the timely expression of several proinflammatory and profibrotic cytokines. The combination of those factors leads to enhanced deposition of extracellular matrix with consecutive fibrosis of the intestine. Through investigation of the pathophysiologic processes of the fibrogenesis in Crohn's disease the basis for specific antifibrotic therapies can be built.
The conservative therapy of inflammatory bowel disease is to a large extent symptomatically oriented, despite the fact that in the last years important progress in the understanding of the pathophysiology and the etiology of IBD was achieved. The clinical course and the extension of inflammation of both Crohn's disease and ulcerative colitis are very variable, which requires a differentiated therapy, which is oriented at individual conditions. The medical therapy is used for induction of remission during acute disease flares, for chronically active disease, as well as for maintenance of remission. Availably therapies include 5-amino-salicylates, glucocorticoids, immunosuppressants, probiotics and biologicals, which should be administrated with respect to disease extension and severity of symptoms. A long lasting steroid-therapy should be avoided. If the conservative medical therapy fails or when the complications occur surgery is indicated. Unfortunately surgical therapy is applied sometimes very late, although the surgical procedures have improved in the last years.
Surgical intensive care focuses on the therapy of secondary organ failure resulting from surgical complications or massive surgical trauma. Consequently, therapeutic success depends on the simultaneous efficacy of surgical therapy and intensive care which, however, cannot compensate for surgical errors. Both aspects of care need to be addressed for quality control. Quality control in intensive care includes the analysis of cost-effectiveness and the use of scoring systems and evidence-based guidelines. Thus far, cost-effectiveness has only been determined in a general sense for a few procedures. An analytical concept which would allow an individual analysis of cost-effectiveness for a single institution is still missing. The reliability of scoring systems is mostly restricted to comparisons within individual institutions since corresponding scores cannot yet account adequately for differences in case mixes between different institutions. For evidence-based therapy in critically ill patients more than 80 guidelines are currently available. Guidelines have to be distinguished from directives and represent decisional aids which have been developed systematically and which have to be perceived as recommendations from which one may diverge in well-founded cases. Introduction of guidelines into clinical routine has significantly improved the prognosis of surgical critically ill patients in the last years.
