Risikofaktoren intra- und postoperativer Komplikationen in der Chirurgie des Wilms-Tumors

BACKGROUND: Wilms' tumor is the most common renal tumor in childhood. Preoperative treatment is still under discussion. The aim of this study was to determine, using our own patient collective, the risk factors for and type of intraoperative complications which can occur. In addition, the influence of the surgical procedure and tumor size on the complications and survival rate was analyzed. METHODS AND MATERIALS: A total of 66 patients with Wilms' tumor were retrospectively analyzed. Evaluation included histology, size of the primary tumor as well as neoadjuvant and adjuvant chemotherapy. The total survival rate over periods of 5 and 10 years postoperatively were analysed using Kaplan-Meier survival probabilities. RESULTS: All patients underwent radical nephrectomy: 63 using the transperitoneal and three the lumbar approach. The tumors had a mean size of 9.8 cm (range 2.5-20.0). Twenty patients (30.3%) received neoadjuvant chemotherapy for tumor reduction, while 46 patients underwent surgery without preoperative chemotherapy. Complications occurred in eight patients (15.2%). In two, a the tumor ruptured under surgery, four patients developed an ileus and two suffered cardiac arrest. One patient had postoperative hypertonia and another an incisional hernia. All complications occurred with a tumor size >5 cm or in the patient group without neoadjuvant chemotherapy. The 10 year survival rate was 89.4%. CONCLUSIONS: The risk of complications is associated with the local size of the primary tumor. Through tumor reduction, neoadjuvant chemotherapy influences the expression of the such complications. Transperitoneal tumor nephrectomy is the method of choice in surgery for Wilms' tumors.     

Blutungsproblematik in der Leberchirurgie und Lebertransplantation

In liver resection, severe bleeding can be prevented by appropriate surgical techniques. These include adequate access and mobilisation, vascular occlusion, controlled dissection of the parenchyma, prevention of venous "over-filling" and secure hemostasis of the resection surface. Excessive bleeding, both in liver resection and liver transplantation, poses a major risk for the development of postoperative complications. In liver transplantation the surgeon is most often confronted with patients with chronic liver disease and portal hypertension. Coagulation disorders are the rule, and the surgery itself is more demanding because of fragile venous collaterals as a consequence of portal hypertension. With the use of extracorporeal venovenous bypass or newer techniques with preservation of the vena cava, some of these difficulties can be overcome. Pharmacological therapies like administration of aprotinin can reduce the fibrinolysis inherent in liver transplantation. However, surgical skill and experience are probably still the most important predictors of blood loss during surgery.     

Gerinnungsstörungen als Ursache postoperativer Blutungen

Ohne Zusammenfassung (a. E.)     

Dissektionstechniken in der Leberchirurgie

The first liver resection was performed in 1888. Since then a wide variety of dissection techniques have been introduced. The blunt dissection was replaced by novel methods, i.e. the CUSA technique and the Jet Cutter for major liver resections. These methods represent selective dissection techniques; whereas non-selective methods include the scalpel, scissors, linear stapling cutter, high-frequency coagulation, and the laser technique. The aim of this review article is the comparison of the different resection techniques in liver surgery, focussing on blood loss and resection time.     

58. Automatisierung von intra- und postoperativer Überwachung —Technischer Ausblick

Zusammenfassung Sofern eine sinnvolle Synthese zwischen ökonomisch vertretbarem, klinisch aussagekräftigem apparativem Aufwand und der Freisetzung für ärztliche Aufgaben bei maximal erreichbarer Patientensicherheit gelingt, ist eine weitere Automatisation des Monitoring sinnvoll. Eine Dynamisierung der diagnostischen und therapeutischen Möglichkeiten (on-line-Datenverarbeitung) ist ebenso unentbehrlich wie geräteinterne Prüfverfahren zur Gewährleistung von Alarmen, Ausfall- und Funktionssicherheit. Die Voraussetzungen hierfür sind durch eingehende klinische Spezifikationen zu schaffen.     

Diagnostik und Therapie abnormer Blutungen in der Chirurgie

Abnormal surgical bleeding may be caused by congenital or acquired plasmatic and/or thrombocytic coagulation disorders. They may be known at the time of operation, or they may occur during the perioperative course for the first time. A detailed identification of haemostatic defects can be performed by a diagnostic spectrum of multiple tests. However, in clinical practice global screening tests are used first. In diagnostic routine three groups of patients have to be considered: (1) patients with no personal or family history of bleeding and no operative bleeding risk; (2) patients with no history, but increased bleeding risk by the planned procedure; (3) patients with a known haemorrhagic diathesis in their own history. In all difficult situations a specialist in haemostasiology should be consulted, because only rational diagnosis and therapeutic monitoring achieve an optimal and cost-effective operative result. The surgeon should always be aware that surgical bleeding from an operative cause must be considered in the differential diagnosis.     

Zusammenhang zwischen postoperativer Liegedauer der Redon-Drainage und Wundheilung

The influence of the residual application of postoperative wound suction drainage devices on wound healing was examined in 150 patients with total hip replacement. The duration of continuous wound-draining as well as their bacterial contamination were analysed and the possible correlation was evaluated. Another aim of the study was to observe if the bacteriologic result is a proper method to obtain evidence about the wound situation. The 150 patients were divided in 3 groups. Two groups (of 50 patients each) had total hip replacement at the same time period. One group had postoperative wound complications or infection that had to be reoperated. The other 50 patients had normal wound healing without any complication. The third group of 50 patients with a shorter draining period was analysed and compared with the others. As a control factor the indication for operation, the sex and the age of the patients were similar in each group. We could show an increasing number of bacteriological contamination in drainage tubes which had a longer suction period than 3 days. In the reoperated group we found a significantly higher number of contaminated tips (37.4%) than in the groups with uncomplicated wound healing (8% and 2.8%). The comparison of the bacteriological examination of the drainages with the smear of reoperated wounds showed the same constellation of germs in 64.3% of the cases. It seems to be a good method to get information about the bacterial wound conditions.     

Virtuelle Operationsplanung in der Leberchirurgie

The operability of a liver tumour depends on its three-dimensional relation to the intrahepatic vascular trees which define autonomously functioning liver (sub-)segments. The aim of our study was to establish a computer-based three-dimensional volumetric operation planning system for the liver. METHODS: Using data from routine helical CT scans the three tissue subclasses of liver parenchyma, liver vessels and liver tumour were segmented semiautomatically. A dedicated segmenting tool was established using region growing algorithms in combination with an "intelligent" border finder. Visualisation is performed by the "Heidelberg Raytracer". The vascular trees are visualised as 3D graphs. Pseudoconnections between portal and hepatic venous trees are separated automatically. Security margins are calculated and the system presents a virtual resection proposal. RESULTS: The 3D anatomy of the liver can be visualised in high quality resulting in good depth perception. Security margins are demonstrated. Dependent liver parenchyma can be recognized automatically on the basis of the vascular trees. The system offers a individualised resection proposal including the tumour, security margin and dependent liver parenchyma. CONCLUSION: Three-dimensional presentation of the individual liver anatomy of a given patient facilitates the perception of the pathology. Virtual reality combined with artificial intelligence allows calculation of complete resection protocols, which can be quantified and modified interactively. This will make operation planning more objective; patient selection may be improved, and in cases of difficult tumour localisation different resection strategies may be tested. Thus virtual reality in liver surgery will improve teaching, surgical training and planning. It may lead to improved surgical care.     

Stand der laparoskopischen Leberchirurgie

Background

To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008.

Materials and Methods

A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously.

Results

A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551).

Conclusion

Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.     

Der zentrale Venendruck in der Leberchirurgie

Central venous pressure (CVP) is deemed to be an important parameter of anesthesia management in liver surgery. To reduce blood loss during liver resections, a low target value of CVP is often propagated. Although current meta-analyses have shown a connection between low CVP and a reduction in blood loss, the underlying studies show methodological weaknesses and advantages with respect to morbidity and mortality can hardly be proven. The measurement of the CVP itself is associated with numerous limitations and influencing factors and the measures to reduce the CVP have been insufficiently investigated with respect to hepatic hemodynamics. The definition of a generally valid target area for the CVP must be called into question. The primary objective is to maintain adequate oxygen supply and euvolemia. The CVP should be regarded as a mosaic stone of hemodynamic management.     

Technische Aspekte der laparoskopischen Leberchirurgie

Background

Laparoscopic surgery has become the standard for most visceral surgery procedures in many hospitals. Now, liver resections are also being increasingly carried out laparoscopically. The advantages of the laparoscopic technique have been demonstrated in numerous case series and in a recent randomized controlled trial.

Aims

The aim of this review article is to present the available techniques for laparoscopic liver surgery (LLS).

Methods

The technical variations reported in the literature as well as the own experience with LLS are reported.

Results

Optimal patient and trocar positions are crucial for successful LLS and they are chosen according to the planned type of liver surgery: the literature offers several options in particular for surgery of the cranial and dorsal liver segments. As for open liver surgery, a restrictive volume management and the application of the Pringle maneuver are helpful to reduce intraoperative blood loss in LLS. In addition, several dissection techniques have been adopted from open liver surgery. The Cavitron Ultrasound Surgical Aspirator (CUSA?) is particularly suitable for parenchymal dissection close to major vascular structures, since it guarantees a meticulous parenchymal dissection with minimal vascular injuries.

Conclusion

The developments of minimally invasive surgery nowadays allow complex liver resections, which can mostly be performed comparable to open liver surgery. Hopefully, minimally invasive liver surgery will further develop in Germany in the near future, since it offers several advantages over open liver surgery.

     

Management von Blutungen und Infektionen im Rahmen viszeralchirurgischer Operationen

Bleeding and vascular infections are serious potential complications during abdominal general surgery. The management of bleeding depends on the extent and localization and can range from the application of hemostatics to vascular sutures, interpositioning and ligatures. The use of prosthetic biomaterials implanted endoluminally or during open reconstruction permits palliation of potentially fatal conditions. The overall incidence of infections involving vascular prostheses is relatively low because of routine antibiotic prophylaxis prior to surgery, refinements in sterilization and packaging of devices and careful adherence to aseptic procedural and surgical techniques. When infections occur detection and definitive therapy of the vascular prosthesis are often delayed and the management is complex and tedious. Infections involving vascular prostheses are difficult to eradicate and in general, surgical therapy is required often coupled with excision of the prosthesis. Keys to success include accurate diagnostics to identify the organism and extent of graft infections, specific long-term antibiotic therapy and well-planned surgical interventions to excise and replace the infected graft and sterilize the local tissue. Regardless of the technique used to eradicate graft infections, success is measured by patient survival, freedom from recurrent infection and patency of revascularization. Even when treatment is successful, the morbidity associated with vascular graft infections is considerable. Aortoenteric fistulas (AEF) are a rare (incidence <?1.5?%) but often fatal complication. Primary diagnosis of AEF remains difficult. Computed tomography (CT) and fluorodeoxyglucose positron emission tomography CT (FDG-PET-CT) are the diagnostic tools of choice. Therapy consists of an urgent individualized interdisciplinary surgical approach with primary axillofemoral bypass and secondary prosthesis explantation or in situ replacement and subsequent bowel resection. Endovascular aortic repair (EVAR) is reserved for primary aortoenteric fistulas in patients with no signs of infection or in emergency cases as a bridging method.     

Erfahrungen mit der Szintigraphie und Angiographie bei chirurgischen Milzerkrankungen und intestinalen Blutungen

Ohne Zusammenfassung     

Leberchirurgie im technischen und konzeptionellen Umbruch

Ohne Zusammenfassung     

Die Blutungen der Harnorgane

Ohne Zusammenfassung