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1.
Langenbecks Arch Surg ; 406(3): 571-585, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33880642

RESUMO

BACKGROUND AND AIMS: The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS: Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS: During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION: Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.


Assuntos
Hiperparatireoidismo Primário , Cirurgiões , Criança , Humanos , Hiperparatireoidismo Primário/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Glândulas Paratireoides , Hormônio Paratireóideo , Paratireoidectomia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada
2.
Langenbecks Arch Surg ; 404(4): 385-401, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30937523

RESUMO

BACKGROUND AND AIMS: Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS: A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS: Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION: Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.


Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Procedimentos Cirúrgicos Endócrinos/métodos , Técnica Delphi , Medicina Baseada em Evidências , Alemanha , Humanos
3.
Chirurgie (Heidelb) ; 93(6): 596-603, 2022 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-34874460

RESUMO

BACKGROUND: Compared with malpractice claims in thyroid surgery, expert medico-legal reviews of surgery performed for hyperparathyroidism (HPT) that aim to prove or rebut surgical malpractice are rare. The aim of this analysis was to describe typical risk patterns for possible treatment errors and to generate recommendations for avoiding these treatment errors. MATERIAL AND METHODS: A total of 12 surgical expert medico-legal reviews, which were carried out by order of 9 arbitration boards and 3 courts between 1997 and 2020 were evaluated. RESULTS: If the indications for surgical treatment of hyperparathyroidism were present, the failure to identify a parathyroid adenoma or hyperplastic parathyroid glands was in the majority of cases not rated as a surgical treatment error, especially in atypical localizations. Unilateral recurrent laryngeal nerve palsy and postoperative bleeding cannot always be prevented, despite maximum diligence. In contrast, bilateral recurrent laryngeal nerve palsy can be prevented when intraoperative neuromonitoring is correctly applied. A lack of patient information regarding postoperatively persistent HPT, postoperative hypoparathyroidism following the removal of inconspicuous parathyroid glands and nonindicated lobectomy or total thyroidectomy, mostly performed under the assumption of an intrathyroid parathyroid adenoma, represented avoidable malpractice issues. CONCLUSION: Advanced knowledge of the pathophysiology of the disease and the anatomy of the parathyroid glands as well as the establishment of intraoperative and perioperative standards can prospectively greatly reduce avoidable errors in the surgical treatment and postoperative care of HPT.


Assuntos
Hiperparatireoidismo , Neoplasias das Paratireoides , Paralisia das Pregas Vocais , Humanos , Hiperparatireoidismo/cirurgia , Glândulas Paratireoides , Neoplasias das Paratireoides/cirurgia , Tireoidectomia/efeitos adversos , Paralisia das Pregas Vocais/cirurgia
4.
Chirurg ; 92(5): 448-463, 2021 May.
Artigo em Alemão | MEDLINE | ID: mdl-32945919

RESUMO

BACKGROUND: Since 2015 operations performed in the field of endocrine surgery have been entered into the European registry EUROCRINE®. The aim of this analysis was a description of the current healthcare situation for adrenal surgery in a homogeneous healthcare environment corresponding to the German-speaking countries-or to the presence of the working group on surgical endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)-and to assess the adherence to current international treatment guidelines. METHODS: An analysis of the preoperative diagnostics, the applied operative techniques and the underlying histological entities was carried out for all operations on adrenal glands in Germany, Switzerland and Austria, which were registered in EUROCRINE® from 2015 to 2019. RESULTS: In the total of 21 participating hospitals from the German-speaking EUROCRINE® countries, 658 operations on adrenal glands were performed. In 90% of cases unilateral adrenalectomy was performed, in 3% bilateral adrenalectomy and in 7% other resection procedures. In 41% the main histological diagnosis was an adrenocortical adenoma. In 15% malignant entities were detected on final histology, including 6% adrenocortical carcinoma (ACC) and 8% metastases to the adrenal glands. 23% of the operations were performed for pheochromocytoma. This entity was primarily resected using minimally invasive approaches (82%), whereas minimally invasive techniques were applied in 28% for ACC and in 66% for metastases to the adrenal glands. CONCLUSION: Surprisingly, following adrenocortical adenoma and pheochromocytoma, the third most common histological entity was metastasis of different extra-adrenal primary tumors to the adrenal gland. Of the operations for ACC 28% were scheduled for minimally invasive techniques, but conversion to open surgery was necessary in 20%. The analysis revealed discrepancies between treatment reality and international guideline recommendations that raise questions, which will be addressed by an updated version of the EUROCRINE® module for the documentation of adrenal surgery.


Assuntos
Neoplasias do Córtex Suprarrenal , Neoplasias das Glândulas Suprarrenais , Laparoscopia , Neoplasias do Córtex Suprarrenal/cirurgia , Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia , Áustria , Alemanha , Humanos , Suíça
5.
Chirurg ; 89(9): 699-709, 2018 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-29876616

RESUMO

Thyroid resections represent one of the most common operations with 76,140 interventions in the year 2016 in Germany (source Destatis). These are predominantly benign thyroid gland diseases. Recommendations for the operative treatment of benign thyroid diseases were last published by the CAEK in 2010 as S2k guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. [AWMF] 003/002) against the background of increasingly more radical resection procedures. Hemithyroidectomy and thyroidectomy are routinely performed for benign thyroid disease in practice. The operation-specific risks show a clear increase with the extent of the resection. Therefore, weighing-up of the risk-indications ratio between unilateral lobectomy or thyroidectomy necessitates an independent evaluation of the indications for both sides. This principle in particular has been used to update the guidelines. In addition, the previously published recommendations of the CAEK for correct execution and consequences of intraoperative neuromonitoring were included into the guidelines, which in particular serve the aim to avoid bilateral recurrent laryngeal nerve paralysis. Moreover, the recommendations for the treatment of postoperative complications, such as hypoparathyroidism and postoperative infections were revised. The updated guidelines therefore represent the current state of the science as well as the resulting surgical practice.


Assuntos
Doenças da Glândula Tireoide , Tireoidectomia , Alemanha , Humanos , Complicações Pós-Operatórias , Estudos Retrospectivos , Doenças da Glândula Tireoide/cirurgia , Paralisia das Pregas Vocais/etiologia
6.
J Thorac Cardiovasc Surg ; 104(2): 413-20, 1992 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-1495304

RESUMO

There is an increasing demand for accurate preoperative and intraoperative staging of bronchial carcinoma with respect to neoadjuvant therapy protocols and parenchyma-sparing operations. This study prospectively evaluated accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma in 108 consecutive patients. The stage of the primary tumor (T stage) was correctly determined in 85% of the patients, and surgical evaluation correctly determined the T stage in 92%. Invasion of major mediastinal structures posed a major problem for computed tomographic scan. On a node-by-node basis, computed tomographic scan predicted involvement of lymph nodes in 81% (sensitivity 29%, specificity 93%, positive predictive value 49%, negative predictive value 85%). The surgeon correctly determined the lymph node status in 69% of lymph nodes (sensitivity 90%, specificity 63%, positive predictive value 39%, negative predictive value 96%). On a patient-by-patient basis, computed tomographic scan correctly predicted the nodal status in 58% of patients. Accuracy of computed tomographic scan and surgical assessment in determination of the lymph node status strongly depended on tumor type and lymph node region (hilar or mediastinal region) studied. This was partly due to the fact that adenocarcinomas exhibited a high proportion of tumor-positive normal-sized lymph nodes, whereas squamous cell carcinomas showed a high proportion of enlarged tumor-free lymph nodes. In conclusion, computed tomographic scan and surgical assessment are sufficiently accurate for determination of the tumor stage but are insufficient in determining the nodal status.


Assuntos
Carcinoma Broncogênico/patologia , Neoplasias Pulmonares/patologia , Pulmão/patologia , Tomografia Computadorizada por Raios X , Carcinoma Broncogênico/diagnóstico por imagem , Carcinoma Broncogênico/epidemiologia , Feminino , Humanos , Pulmão/diagnóstico por imagem , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/epidemiologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade
7.
Arch Surg ; 127(4): 460-7, 1992 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-1348412

RESUMO

The relation of (multiple) organ failure (OF) to the release of inflammatory mediators and the incidence of infection and sepsis was studied prospectively in 100 patients with multiple trauma (injury severity score = 37). Sixteen patients died of OF, 47 patients survived OF, and 37 patients had no OF. Fifteen (24%) of the patients with OF showed no signs of infection. In patients with early onset of OF (n=45), infection followed with a lag of 2 or more days. In 16 (44%) of these patients, infection led to a deterioration in organ function. With late onset of OF (n=18), infection preceded OF in nine patients. Polymorphonuclear leukocyte-elastase, neopterin, C-reactive protein, lactate, antithrombin III, and phospholipase A discriminated significantly among the three outcome groups. Of all factors, only polymorphonuclear leukocyte-elastase showed a difference between patients with and without infection or sepsis, respectively. These data indicate that infection might not play a crucial role in the pathogenesis of posttraumatic OF in a substantial portion of patients with trauma. Early OF, especially, seems to be mainly influenced by the direct sequelae of tissue damage and shock (eg, the release of inflammatory mediators). Since infection and sepsis did not lead to an augmented release of mediators in patients with trauma, the role of both entities remains unclear.


Assuntos
Infecções Bacterianas/complicações , Insuficiência de Múltiplos Órgãos/imunologia , Traumatismo Múltiplo/imunologia , Elastase Pancreática/sangue , Adulto , Antitrombina III/análise , Infecções Bacterianas/imunologia , Biopterinas/análogos & derivados , Biopterinas/sangue , Proteínas de Transporte/sangue , Feminino , Humanos , Lactatos/sangue , Elastase de Leucócito , Masculino , Insuficiência de Múltiplos Órgãos/complicações , Insuficiência de Múltiplos Órgãos/etiologia , Traumatismo Múltiplo/complicações , Neopterina , Fosfolipases A/sangue , Estudos Prospectivos , Índice de Gravidade de Doença
8.
Surg Endosc ; 16(12): 1759-63, 2002 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-12140628

RESUMO

BACKGROUND: The success of parathyroid surgery depends on the identification and removal of all hyperactive parathyroid tissue. At this writing, bilateral cervical exploration and identification of all parathyroid glands represent the operative standard for primary hyperparathyroidism (pHPT). However, improved preoperative localization techniques and the availability of intraoperative parathyroid hormone monitoring prepare the way for minimally invasive procedures. METHODS: Patients with pHPT and one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, a rapid chemiluminescense immunoassay was used to measure intact parathyroid hormone (iPTH) levels shortly before and then 5, 10, and 15 min after excision of the adenoma. The operation was considered successful when more than a 50% decrease in preexcision iPTH levels was observed after 5 min. RESULTS: Between October 1999 and November 2001, 36 of 82 patients with pHPT were eligible for a minimally invasive approach. A conversion to open surgery became necessary in five patients because of technical problems. In three cases, intraoperative iPTH monitoring showed no sufficient decrease in iPTH values. In these cases, subsequent cervical exploration showed one double adenoma and two hyperplasias, respectively. In two patients we had difficulty interpreting intraoperative iPTH values, resulting in persistent pHPT. CONCLUSIONS: Despite the use of high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy, the presence of multiple glandular disease cannot be ruled out completely. Intraoperative iPTH monitoring to ensure operative success is indispensible for a minimally invasive approach. Despite our problems with iPTH monitoring in two patients, we believe that in selected cases, minimally invasive parathyroidectomy represents an attractive alternative to conventional surgery.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Monitorização Intraoperatória/métodos , Hormônio Paratireóideo/sangue , Paratireoidectomia/métodos , Cirurgia Vídeoassistida/métodos , Adenoma/complicações , Adenoma/diagnóstico por imagem , Adenoma/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hiperparatireoidismo/diagnóstico por imagem , Hiperparatireoidismo/etiologia , Hiperparatireoidismo/cirurgia , Imunoensaio/métodos , Medições Luminescentes , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/imunologia , Neoplasias das Paratireoides/complicações , Neoplasias das Paratireoides/diagnóstico por imagem , Neoplasias das Paratireoides/cirurgia , Cintilografia , Tecnécio Tc 99m Sestamibi/metabolismo , Ultrassonografia
9.
Surg Endosc ; 15(4): 409-12, 2001 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-11395826

RESUMO

BACKGROUND: The standard surgical procedure for parathyroidectomy consists of bilateral cervical exploration and the visualization of all four parathyroid glands. However, improved preoperative localization techniques and the availability of intraoperative intact parathyroid hormone (iPTH) monitoring now allow single adenomas to be treated with minimally invasive techniques. METHODS: Patients with primary hyperthyroidism (pHPT), who were found to have one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, rapid electrochemiluminescense immunoassay was used to measure iPTH levels shortly before and 5, 10, and 15 mins after excision of the adenoma. The operation was considered successful when a >50% decrease in preexcision iPTH levels was observed after 5 min. RESULTS: Between November 1999 and May 2000, 10 of 22 patients with pHPT were deemed eligible for the minimally invasive approach. In all cases, the adenoma was removed successfully. However, in two cases, intraoperative iPTH monitoring did not show a sufficient decrease in iPTH values. Subsequent cervical exploration revealed a double adenoma in one case and hyperplasia in the other. CONCLUSIONS: Even when high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy are used, the presence of multiple glandular desease cannot be ruled out entirely. When the minimally invasive approach is contemplated, intraoperative iPTH monitoring is indispensible to ensure operative success. However, in selected cases, minimally invasive parathyroidectomy represents an excellent alternative to the conventional technique.


Assuntos
Hiperparatireoidismo/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Paratireoidectomia/métodos , Cirurgia Vídeoassistida/métodos , Adenoma/diagnóstico por imagem , Adenoma/cirurgia , Adulto , Idoso , Feminino , Humanos , Hiperparatireoidismo/diagnóstico por imagem , Imunoensaio/métodos , Medições Luminescentes , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Hormônio Paratireóideo/sangue , Neoplasias das Paratireoides/diagnóstico por imagem , Neoplasias das Paratireoides/cirurgia , Cintilografia , Tecnécio Tc 99m Sestamibi , Resultado do Tratamento , Ultrassonografia
10.
Surg Endosc ; 17(2): 264-7, 2003 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-12399875

RESUMO

BACKGROUND: Minimally invasive techniques play an important role in adrenal gland surgery. The objective of this study was to compare laparoscopic transabdominal adrenalectomy in the lateral position to the open posterior adrenalectomy with respect to the intraoperative and the short-term postoperative course. METHODS: Forty laparoscopic adrenalectomies (LA) carried out between July 1998 and August 2001 were compared to 30 open posterior operations (PA) performed between July 1994 and June 1998. In all cases the indications for surgery was a benign lesion smaller than 8 cm. RESULTS: Age, gender, tumor size, and distribution of the tumor histology were comparable in both groups (LA vs PA). In favor of LA, statistically significant differences (p <0.05) were observed regarding the intraoperative blood loss (260 vs 380 mL), the postoperative narcotic equivalents (2.9 vs 6.4 mg), the morbidity rate (13 vs 27%), and the length of hospital stay (7 vs 10 days). Average operating time was significantly longer for LA (135 vs 106 min). There were two conversions to open adrenalectomy due to diffuse bleeding. Following LA, we observed one major complication (postoperative bleeding from the spleen making a laparotomy necessary) and four minor complications (one small retroperitoneal hematoma, two subcostal nerve irritations, one pleural effusion). PA resulted in one major (wound infection) and seven minor complications (two subcutaneous hematomas, two nerve irritations, two pleural effusions, one dystelectasis). CONCLUSIONS: Laparoscopic adrenalectomy proved as a safe and reliable procedure, displaying all advantages of minimal access surgery. In our institution, it has become the standard technique employed for benign adrenal disease. However, the operation is technically demanding, and as adrenal surgery is rare, it should be restricted to centers with special interest in laparoscopic and endocrine surgery.


Assuntos
Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Laparoscopia/métodos , Adenoma/cirurgia , Neoplasias das Glândulas Suprarrenais/classificação , Neoplasias das Glândulas Suprarrenais/metabolismo , Adrenalectomia/efeitos adversos , Adulto , Idoso , Aldosterona/metabolismo , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Feocromocitoma/cirurgia , Período Pós-Operatório , Postura , Estudos Prospectivos , Estudos Retrospectivos
11.
Pathol Res Pract ; 187(7): 906-11, 1991 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-1754515

RESUMO

Two consecutive publications appeared 1989 in the same number of a medical journal, which reported peculiar spindle-cell tumors with dense collagen or hyaline nodules, exclusively in inguinal lymph nodes of adults. The first series of 22 cases bore the title "Palisaded myofibroblastoma, a benign mesenchymal tumor of lymph node", the second with 6 identical cases "Intranodal hemorrhagic spindle-cell tumor with "amianthoid" fibers". The following case report deals with a similar tumorous lesion, with multiple small pulmonary nodules, without recognizable lymph node constituents.


Assuntos
Neoplasias Pulmonares/patologia , Biópsia , Feminino , Humanos , Imuno-Histoquímica , Pulmão/patologia , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/ultraestrutura , Microscopia Eletrônica , Pessoa de Meia-Idade , Radiografia Torácica
12.
Eur J Emerg Med ; 1(1): 1-8, 1994 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-9422129

RESUMO

In a prospectively studied trauma population from 1986 to 1991 the influence of early intubation (EI) within 2 h after the accident on post-traumatic (multiple) organ failure (M)OF was compared with delayed intubation (DI) in 131 patients with multiple injuries (Injury severity score (ISS) 37). Indications for intubation were unconsciousness following severe head injury in 45 cases (45 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and the severity of injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 10 DI). One hundred and six trauma victims (81%) have been intubated early and 19 patients (14.5%) required intubation and artificial ventilation later in the course, whereas 6 subjects (4.5%) could manage spontaneous breathing. The pattern of injured body regions and respiratory parameters on admission showed no remarkable difference in the two groups, but the severity of injury was significantly higher (p < 0.001) in the EI group (ISS 39) compared with the DI patients (ISS 29). Due to a significantly worse haemodynamic condition of the EI patients on admission, they showed significantly higher volume requirements throughout the resuscitation period. All patients were treated to a standard resuscitation protocol. Sixty-seven per cent of the EI patients developed at least one OF, 45% respiratory failure (RF), 28% multiple organ failure (MOF) and 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%) and an even higher (n.s.) incidence of MOF (37%) and mortality rate (26%). Corresponding to the significantly lower injury severity of the DI group, the observed OF and mortality rates are inappropriately high in comparison with the incidence of OF and death in the EI group. We conclude that EI of multiple injured patients within 2 h after trauma along with ventilatory support--even in alert patients without major chest trauma or signs of cardiocirculatory or respiratory insufficiency, but a known or suspected ISS > 24--may help to reduce post-traumatic organ failure and improve outcome.


Assuntos
Intubação Intratraqueal/métodos , Insuficiência de Múltiplos Órgãos/terapia , Traumatismo Múltiplo/terapia , Adolescente , Adulto , Idoso , Feminino , Humanos , Escala de Gravidade do Ferimento , Intubação Intratraqueal/mortalidade , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/mortalidade , Traumatismo Múltiplo/mortalidade , Estudos Prospectivos , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
13.
Chirurg ; 72(12): 1478-84, 2001 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-11824035

RESUMO

OBJECTIVES: Minimal invasive techniques are gaining more and more acceptance in adrenal gland surgery. In a matched case control study laparoscopic transabdominal adrenalectomy in the lateral position (LA) was compared to the conventional open dorsal technique (DA) with resection of the 11th or 12th rib. METHODS: Between July 1998 and March 2000, 26 LA in 24 patients (two bilateral) were prospectively documented and compared to 25 DA in 23 matched patients (two bilateral), who had been operated on between January 1995 and June 1998. Indications for adrenalectomy in all patients were benign adrenal lesions < 6 cm. RESULTS: Age, gender, average tumor size (3.5 cm/3.6 cm) and tumor types (Conn adenoma: 10/7; Cushing: 8/7, including 2 bilateral in each group; pheochromocytoma: 3/6, incidentaloma: 2/2; others: 3/3) were distributed in both groups (LA/DA) without statistical differences. However, statistically significant differences (P < 0.05) were present (LA vs DA) comparing intraoperative blood loss (200 vs 360 ml), postoperative narcotic equivalents (1.1 vs 6.2), morbidity (8 vs 30%), and length of hospital stay (5.5 vs 9 days). Average operating time was significantly longer in LA (130 vs 105 min), but decreased during the last LA cases to the DA level. One LA had to be converted to open surgery due to diffuse bleeding. Following LA we observed two minor complications (small retroperitoneal hematoma, nerve irritation below the 12th rib); following DA there were 6 minor (2 dorsal subcutaneous hematomas, 2 nerve irritations, dystelectasis, pleural effusion) and one major complication (wound infection). CONCLUSION: LA represents a safe procedure with all the common advantages of minimal access surgery. Based on our experience and that of others, laparoscopic adrenalectomy has become the gold standard for adrenalectomy in most cases of benign adrenal disease. As adrenal surgery is rare, at present LA should be restricted to centers with a special interest in endocrine and laparoscopic surgery.


Assuntos
Doenças das Glândulas Suprarrenais/cirurgia , Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Prospectivos , Estudos Retrospectivos
14.
Chirurg ; 71(2): 174-81, 2000 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-10734586

RESUMO

INTRODUCTION: Bile duct complications after laparoscopic cholecystectomy occur twice to three times more frequently than after an open procedure. Four different types of lesions may be differentiated by the Siewert classification: postoperative bile fistulas (type I), late strictures (type II), tangential injuries of the bile duct (type III) and defect lesions (type IV). The diagnostic and therapeutic management is demonstrated in relation to our own experience and the literature. METHODS: Eleven patients (median age 43.8 +/- 17.2) with bile duct complications after laparoscopic cholecystectomy were operatively treated between November 1993 and December 1998. Nine patients (four type-II lesions, five type-IV lesions) were referred from another hospital; 2 defect lesions out of 410 laparoscopic cholecystectomies (0.5%) were documented in our own patient group. RESULTS: Four patients with late strictures were operatively treated with a hepaticocholedochostomy (n = 2) or hepaticojejunostomy (n = 2) after 14.3 +/- 8.4 months and were discharged from hospital after 10.6 +/- 3.8 days. In both cases with type-IV lesion and a short defect, an end-to-end anastomosis was successful (hospital stay 11.6 +/- 1.0 days). However, a retrocolic Roux-Y end-to-side hepaticojejunostomy was performed in all cases with a larger defect (n = 5; hospital stay 14.8 +/- 2.0 days). The two defect lesions in our own group were detected by intraoperative cholangiography and immediately treated after conversion either with hepaticocholedochostomy or hepaticojejunostomy (hospital stay 11.2 +/- 0.6 days). CONCLUSIONS: The incidence of bile duct complications after laparoscopic cholecystectomy might be kept down by anatomic preparation, selective intraoperative cholangiography and early consideration of conversion to open procedure. The clinical course after biliary tract injury can be positively influenced only by a standard diagnostic and operative procedure and by an early transfer to a specialized center.


Assuntos
Fístula Biliar/cirurgia , Colecistectomia Laparoscópica , Colestase/cirurgia , Complicações Pós-Operatórias/cirurgia , Adulto , Idoso , Fístula Biliar/diagnóstico por imagem , Colangiopancreatografia Retrógrada Endoscópica , Colestase/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Reoperação , Esfinterotomia Endoscópica
15.
Chirurg ; 69(12): 1352-6, 1998 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-10023562

RESUMO

We report on our experience with a new ultrasonically activated scalpel that has been developed for laparoscopic surgery. It works by means of a longitudinally vibrating blade or scissors and can be used for tissue dissection, coagulation and preparation. The high-frequency vibration causes denaturation of protein and thus allows coagulation of small vessels up to 2-3 mm. The most important advantages compared to electrocautery are very limited heat generation, no production of smoke and the lack of current flow through the patient. Because of this, the ultrasonically activated scalpell is an excellent instrument for different types of laparoscopic surgery, as well as for open liver resection.


Assuntos
Hepatectomia/instrumentação , Laparoscópios , Hepatopatias/cirurgia , Neoplasias Hepáticas/cirurgia , Instrumentos Cirúrgicos , Terapia por Ultrassom/instrumentação , Adulto , Idoso , Desenho de Equipamento , Feminino , Hemostasia Cirúrgica/instrumentação , Humanos , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade
16.
Chirurg ; 69(7): 766-72, 1998 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-9738226

RESUMO

UNLABELLED: Incisional hernia repair with conventional techniques (simple closure, Mayo-technique) is associated with unacceptable recurrence rates of 30-50%. Therefore, surgical repair using different prosthetic biomaterials is becoming increasingly popular. Further to favourable results by French hernia surgeons, we studied the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias. METHOD: After preparation and excision of the entire hernia sac, the posterior rectus sheath is freed from the muscle bellies on both sides. The peritoneum and posterior rectus sheaths are closed with a continuous looped polyglyconate suture. The prosthesis used for midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The anterior rectus sheath is closed with a continuous suture. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. RESULTS: Between January 1996 and August 1997 we performed a total of 33 incisional hernia repairs (14 primary hernias, 19 recurrent hernias) using this technique (16 women, 17 men, mean age 56.19 +/- 12.92 years). Local complications occurred in four patients (12%): superficial wound infection (n = 2), postoperative bleeding, requiring reoperation (n = 1), minor hemato-seroma (n = 1). One patient suddenly died on the 3rd post-operative day from severe pulmonary embolism (mortality 3%). Twenty-two patients with a minimum follow up to 6 months were re-examined clinically. The average follow-up time for this group was 9 months (range 6-17 months). To date no recurrent hernias have been observed. There were only minor complaints like "a feeling of tension" in the abdominal wall (n = 3) and slight pain under physical stress (n = 6). CONCLUSIONS: The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high-risk patients (obesity, obstructive lung disease) and complicated hernias. The aforementioned technique of underlay prosthetic repair using polypropylene mesh fixed onto the posterior rectus sheath allows for anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates.


Assuntos
Hérnia Ventral/cirurgia , Polipropilenos , Complicações Pós-Operatórias/cirurgia , Telas Cirúrgicas , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Técnicas de Sutura
17.
Chirurg ; 72(5): 578-83, 2001 May.
Artigo em Alemão | MEDLINE | ID: mdl-11383071

RESUMO

OBJECTIVES: Intraoperative differentiation between adenoma and hyperplasia during surgery for primary hyperparathyroidism (pHPT) is sometimes difficult, but essential for good results. The aim of our study was to evaluate a new highly sensitive electrochemiluminescence immunoassay (ECLIA) for intraoperative monitoring of intact parathyroid hormone (iPTH) following parathyroidectomy as an adjunct for identification of solitary adenoma in patients with pHPT. METHODS: Thirty consecutive patients with pHPT (2 with recurrent pHPT) were examined following a standardized protocol: Immediately before and 5, 10 and 15 min following parathyroidectomy of the enlarged gland, iPTH was measured with a new ECLIA (Roche-Diagnostics, Mannheim, Germany). The results were available within 15-20 min. Besides 20 conventional bilateral neck explorations, parathyroidectomy was carried out in a minimally invasive video-assisted technique (MI-VAP) in 10 patients. RESULTS: Among the 30 patients we found 24 with solitary adenoma (80%), 5 with hyperplasia (17%) and one with a double adenoma (3%). Five minutes after removal of a solitary adenoma the level of iPTH had decreased by 65 (12)% [mean (+/- SD)], after 10 min by 76 (8)% and after 15 min by 81 (8)%. All patients with multiple gland disease could be clearly identified, as iPTH after 15 min did not fall below 50% of basal value. Only after removal of all hyperplastic glands did iPTH decrease to the normal range. Sensitivity and specificity for prediction of a solitary adenoma were 92% and 100% (decline of iPTH more than 50% from baseline value 5 min after parathyroidectomy). In one patient with recurrent pHPT intraoperative sampling from different sites in both internal jugular veins could predict the quadrant of the enlarged gland. Correlation (r) between the results of the quick and the conventional assay, which requires 24 h of incubation, was 0.955. All patients had normal or low calcium levels postoperatively. CONCLUSIONS: (1) Intraoperative monitoring of iPTH with this new quick assay allows safe identification of patients with solitary adenoma during surgery for pHPT. (2) It represents a valuable adjunct to surgical skill not only in primary operations for pHPT but especially in cases of recurrent surgery for pHPT. (3) With this test available minimally invasive techniques for parathyroidectomy may be employed in cases of preoperatively localized adenoma (ultrasound, sesta-mibi scan), avoiding bilateral neck exploration with its higher potential for complications.


Assuntos
Adenoma/cirurgia , Hiperparatireoidismo/cirurgia , Monitorização Intraoperatória , Hormônio Paratireóideo/sangue , Neoplasias das Paratireoides/cirurgia , Adenoma/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hiperparatireoidismo/sangue , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias das Paratireoides/sangue , Paratireoidectomia , Valor Preditivo dos Testes
18.
Chirurg ; 74(3): 248-52, 2003 Mar.
Artigo em Alemão | MEDLINE | ID: mdl-12647083

RESUMO

Adenomatoid tumors are uncommon, benign tumors of the genital tract which have also been reported to occur extragenitally. Case reports on adenomatoid tumors of the adrenal gland exist. Most of these are incidentally discovered at autopsy or after the resection of incidentalomas. We report on the case of a young man with epigastic pain and with the finding of a 4 cm heterogeneous right adrenal mass on abdominal CT scan. After endocrine activity had been ruled out, an inactive, benign adrenal tumor was suspected and laparoscopic right adrenalectomy performed. The specimen was found to be an adenomatoid tumor. We discuss the differential diagnosis and the possible embryological origin of these tumors. The feature of 'local invasive ability' does not imply malignancy. All cases discovered surgically and at autopsy have been benign. Local resection seems to be the appropriate therapy.


Assuntos
Tumor Adenomatoide , Neoplasias das Glândulas Suprarrenais , Tumor Adenomatoide/diagnóstico , Tumor Adenomatoide/diagnóstico por imagem , Tumor Adenomatoide/patologia , Tumor Adenomatoide/cirurgia , Neoplasias das Glândulas Suprarrenais/diagnóstico , Neoplasias das Glândulas Suprarrenais/diagnóstico por imagem , Neoplasias das Glândulas Suprarrenais/patologia , Neoplasias das Glândulas Suprarrenais/cirurgia , Glândulas Suprarrenais/patologia , Adrenalectomia , Adulto , Seguimentos , Humanos , Masculino , Radiografia Abdominal , Fatores de Tempo , Tomografia Computadorizada por Raios X
19.
Chirurg ; 62(6): 479-81, 1991 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-1914645

RESUMO

After resecting procedures to the parenchyma of the lung the resection site was sealed with a collagen vleece combined with fibrin glue in 26 patients. No patient exhibited rebleeding. An air leak was present up to the first postoperative day in 19 patients, up to the third postoperative day in 5 patients. In two patients, duration of air leak extended beyond the third postoperative day, this was defined as therapeutic failure. The use of collagen vleece combined with fibrin glue represents a valuable contribution in thoracic surgery.


Assuntos
Colágeno , Adesivo Tecidual de Fibrina/administração & dosagem , Hemostasia Cirúrgica , Pneumopatias/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Broncogênico/cirurgia , Cistos/cirurgia , Feminino , Hemorragia/cirurgia , Humanos , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Pleura/cirurgia , Pneumonectomia/métodos , Pneumotórax/cirurgia , Estudos Prospectivos
20.
Chirurg ; 63(3): 199-204, 1992 Mar.
Artigo em Alemão | MEDLINE | ID: mdl-1559402

RESUMO

A retrospective study on 68 patients with non-small-cell lung cancer (NSCLC) treated by extended resections is presented. Compared to simple resections extended resections carried a higher risk for postoperative complications, whereas 30-days-mortality was not influenced by type of resection. Analysis of survival rates after extended resections revealed no influence by T- or N-stage, whereas a residual tumor lowered the survival rates significantly. Overall, a 2-year-survival rate of 35% was observed after extended resections. In conclusion, even in locally advanced cases of NSCLC a resection with curative intent seems to be warranted, provided that a R0-stage can be achieved by surgery.


Assuntos
Carcinoma Broncogênico/cirurgia , Neoplasias Pulmonares/cirurgia , Pneumonectomia/métodos , Carcinoma Broncogênico/epidemiologia , Carcinoma Broncogênico/mortalidade , Carcinoma Broncogênico/patologia , Feminino , Seguimentos , Humanos , Complicações Intraoperatórias/epidemiologia , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Pneumonectomia/efeitos adversos , Pneumonectomia/mortalidade , Pneumonectomia/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida
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