Band 5, Heft 1-2

Objectives The updated 8th edition of the tumor, node, metastases (TNM) classification system for non-small cell lung cancer (NSCLC) attempts to improve on the previous 7th edition in predicting outcomes and guiding management decisions. This study sought to determine whether the 8th edition was more accurate in predicting long-term survival in a European population of surgically treated NSCLC patients. Methods We scanned the archives of the Heckeshorn Lung Clinic for patients with preoperative clinical stages of IIIA or lower (based on the 7th edition), who received surgery for NSCLC between 2009 and 2014. We used pathologists’ reports and data on tumor size and location to reassign tumor stages according to the 8th edition. We then analyzed stage specific survival and compared the accuracy of the two systems in predicting long-term survival. We excluded patients with neoadjuvant treatment, incomplete follow-up data, tumor histologies other than NSCLC, or death within 30 days of surgery. Results The final analysis included 1,013 patients. Overall five-year survival was 47.3%. The median overall survival (OS) was 63 months (range 1–222), and the median disease-free survival (DFS) was 50 months (0–122). The median follow-up time for non-censored patients was 84 months (range 60–122). Conclusions We found significant survival differences between the newly defined stages 1A1, 1A2 and 1A3 (previously 1A). We also found that the 8th edition of TMN classification was a significantly better predictor of long-term survival, compared to the 7th edition.

Women represent the majority of medical students in several countries. In any surgical specialty and above all in surgical leadership positions, women still remain disproportionally underrepresented. The objective of this study was to investigate female surgeons’ career advancement and satisfaction with training. A standardized questionnaire was devised and sent out via the web-based survey tool SurveyMonkey ® to female surgeons in the German federal state of North Rhine-Westphalia. A total of 125 completed questionnaires were analyzed (response rate 40.8%). Female surgeons are at least largely (76%) satisfied with their surgical training. Increased time (>5 h/week) as the principal surgeon in the operating room significantly stimulates the satisfaction with the surgical training (86% vs. 68%, p = 0.0384). At the participants’ current workplace, the heads of departments are predominantly male surgeons (91%). Respondents not satisfied with their surgical training prefer a female head of department more frequently (24% vs. 2%, p = 0.0085). The majority of the respondents themselves aspire to become a consultant surgeon (56%), while only 12% intend to become a head of a department. Female surgeons aiming at leadership positions work overtime (≥50 h/week) significantly more frequently (81% vs. 57%, p = 0.0041). Favoritism of male colleagues is perceived by 34%. Respondents who do not perceive any preferential treatment are significantly more satisfied with their surgical training (88% vs. 57%, p = 0.0004). In conclusion, female surgeons seem positive about their career choice, once in the surgical profession, and aptly fill upcoming positions. Women interested in surgery are likely to pursue a surgical career despite the alleged workload, demonstrating the importance of professional self-fulfillment among female surgeons.

Objectives Worldwide, not only the number of female medical students, but also of female surgeons increases. Simultaneously, younger generations take a closer look to their work-life balance. With this in mind, it seems necessary to evaluate the expectations of female surgeons in particular with respect to pregnancy during their surgical career. Methods Therefore, a nationwide survey was conducted in Germany from July to December 2016 under the auspices of the German Society of Surgery as well as the Professional Board of German Surgeons. The questionnaire involved 2,294 female surgeons and 1,843 complete records were evaluated. Results Of the analyzed answers, 62% of the women (n=781) were operating during pregnancy. The joy of surgery (91.6%), followed by team spirit (57.1%), were the main motivations to perform operations while pregnant. Operative activity decreased from 30.8% in the first 3 months of pregnancy to 21.5% during the last three months. Regarding the possible complaints, e.g., leg edema, back pain, premature labor and vaginal bleeding, there were no significant differences between the women with or without activity in the operating room. Sick leave due to pregnancy (1–10 days) was stated by 40.4% of respondents. Conclusion Despite strong legal regulations for pregnant surgeons, the survey showed that most female surgeons are eager to operate despite their pregnancy. The results also demonstrate no significant differences regarding complications during pregnancy- or pregnant-dependent absence from work. Hospitals and surgical departments are asked to establish proper working conditions for pregnant surgeons and pregnancy should not be an obstacle for a career in surgery.

Operations in this area are demanding and require special experience in endocrine, thoracic and vascular surgery, an experienced anaesthesiologist, as well as the interdisciplinary cooperation with other medical specialists (nuclear medicine, oncology, radiology, otolaryngology). A reliable system of surgical guidelines has been developed from a few individual publications with special impact.

Objectives Assessing bowel perfusion with indocyanine green fluorescence angiography (ICG-FA) shows positive effects on anastomotic healing in colorectal surgery. Methods A retrospective evaluation of 296 colorectal resections where we performed ICG-FA was undertaken from January 2014 until December 2018. Perfusion of the bowel ends measured with ICG-FA was compared to the visual assessment before and after performing the anastomosis. According to the observations, the operative strategy was confirmed or changed. Sixty-seven low anterior rectal resections (LARs) and 76 right hemicolectomies were evaluated statistically, as ICG-FA was logistically not available for every patient in our service and thus a control group for comparison resulted. Results The operative strategy based on the ICG-FA results was changed in 48 patients (16.2%), from which only one developed an anastomotic leakage (AL) (2.1%). The overall AL rate was calculated as 5.4%. Within the 67 patients with LAR, the strategy was changed in 11 patients (16.4%). No leakage was seen in those. In total three AL happened (4.5%), which was three times lower than the AL rate of 13.6% in the control group but statistically not significant. From the 76 right hemicolectomies a strategy change was undertaken in 10 patients (13.2%), from which only one developed an AL. This was the only AL reported in the whole group (1.3%), which was six times lower than the leakage rate of the control group (8.1%). This difference was statistically significant (p=0.032). Conclusions Based on the positive impact by ICG-FA on the AL rate, we established the ICG-FA into our clinical routine. Although randomized studies are still missing, ICG-FA can raise patient safety, with only about 10 min longer operating time and almost no additional risk for the patients.

Objectives Cutaneous ischemia/reperfusion (CI/R) injury has shown to play a significant role in chronic wounds such as decubitus ulcers, diabetic foot ulcers, atherosclerotic lesions, and venous stasis wounds. CI/R also plays a role in free tissue transfer in reconstructive microsurgery and has been linked to clinical burn-depth progression after thermal injury. While the role of the complement system has been elucidated in multiple organ systems, evidence is lacking with respect to its role in the skin. Therefore, we evaluated the role of the complement system in CI/R injury. Methods Using a single pedicle skin flap mouse model of acute CI/R, we performed CI/R in wild-type (WT) mice and complement knock out (KO) mice, deficient in either C1q (C1q KO; classical pathway inhibition), mannose-binding lectin (MBL null; lectin pathway inhibition) or factor B (H2Bf KO; alternative pathway inhibition). Following 10 h ischemia and 7 days reperfusion, mice were sacrificed, flaps harvested and flap viability assessed via Image J software. The flap necrotic area was expressed as % total flap area. In another group, mice were sacrificed following CI/R with 10 h ischemia and 48 h reperfusion. Two cranial skin flap samples were taken for gene expression analysis of IL1b, IL6, TNFα, ICAM1, VCAM1, IL10, IL13 using real-time polymerase chain reaction (RT-PCR). Results Following CI/R, MBL null mice had a statistically significant smaller %necrotic flap area compared to WT mice (10.6 vs. 43.1%; p<0.05) suggesting protection from CI/R. A significantly reduced mean %necrotic flap area was not seen in either C1q KO or H2Bf KO mice relative to WT (22.9 and 31.3 vs. 43.1%; p=0.08 and p=0.244, respectively). There were no statistically significant differences between groups for markers of inflammation (TNFα, ICAM1, VCAM1, IL1b, IL6). In contrast, mRNA levels of IL10, a regulator of inflammation, were significantly increased in the MBL null group (p=0.047). Conclusions We demonstrated for the first time a significant role of MBL and the lectin complement pathway in ischemia/reperfusion injury of the skin and a potential role for IL10 in attenuating CI/R injury, as IL10 levels were significantly increased in the tissue from the CI/R-protected MBL null group.

Background Nasal deformity associated with cleft lip deformity is a challenging issue, encompassing controversies, theories, and a diversity of techniques. Historically, esthetic outcomes have ranged from being below expectations to barely acceptable. Method Based on the concept that the nasal cartilaginous framework in clefts is similar to that of a collapsing pyramid, a novel suspension technique has been described. The entire cartilaginous structure is lifted from the infratip segment with a loop suture and is secured in a cantilever fashion onto the periosteum overlying the nasal bone. This part of the operation is performed in a semiclosed manner. The technique is applied during primary surgery in bilateral and unilateral nasal cleft lip deformities, with changes in the orientation of the cantilever loop suture. Studies conducted by Masters S. Tajima, H. McComb, H. Thomson, D. Fisher, and J. Mulliken, which are most relevant to this article, have been reviewed and discussed throughout. Results The technique was first applied over 10 years ago. A case series of nine children whose parents consented to the developing technique is presented with follow-up ranging from months to years, along with technical descriptions and illustrative drawings. None of these cases had preoperative orthopedic correction, molding, or postoperative nostril splints. The esthetic outcome was optimal enough; none of the cases requested a secondary correction. Conclusion The nasal cantilever technique is a novel concept in cleft nasal deformity, which can be used in conjunction with an appropriate lip technique, per the surgeon’s discretion. Other than a learning curve, we believe that it provides a solid correction by securing the cartilaginous structures after they have been mobilized to a stable base, the nasion.

Purpose The purpose of this study was to describe a technique to catheterize antegrade branches of a branched aortic endograft by using a steerable sheath stabilized by a through-and-through wire via a femoral access. Technique After implantation of a branched endovascular graft, a steerable 8.5 F sheath is advanced from the femoral access. After placing the sheath proximal to the branches, a 0.014″ through-and-through wire is established to the contralateral femoral access which is held under slight traction after the curved tip of the sheath is brought into the 180° position. Then catheterization, wire exchange and deployment of the bridging stent is done in standard fashion. Conclusion The use of a through-and-through wire with a steerable sheath for retrograde femoral access adds stability and precision to this technique. It has the potential to reduce the risk of preoperative stroke in complex aortic endovascular repair by avoiding upper extremity access.

Objectives We describe the first application of intrauterine negative-pressure therapy (IU-NPT) for an early rupture of a uterine suture after a third caesarean section with consecutive peritonitis and sepsis. Because all four quadrants were affected by peritonitis, a laparotomy was performed on the 15th day after caesarean section. Abdominal negative-pressure wound therapy (A-NPWT) of the open abdomen was initiated. During the planned relaparotomy, a suture defect of the anterior uterine wall was identified and sutured. In the second relaparotomy, the suture appeared once more insufficient. Case presentation For subsequent IU-NPT, we used an open-pore film drainage (OFD) consisting of a drainage tube wrapped in the double-layered film. The OFD was inserted into the uterine cavity via the uterine defect and IU-NPT was established together with A-NPT. With the next relaparotomy, local inflammation and peritonitis had been resolved completely. IU-NPT was continued transvaginally, the uterine defect was sutured, and the abdomen was closed. Vaginal IU-NPT was also discontinued after another eight days. Conclusions By using IU-NPT, local infection control of the septic focus was achieved. The infectious uterine secretions were completely evacuated and no longer discharged into the abdominal cavity. As a result of the applied suction, the uterine cavity collapsed around the inlaid OFD. The total duration of IU-NPT was 11 days. The uterine defect was completely closed, and a hysterectomy was avoided. The patient was discharged four days after the end of IU-NPT. IU-NPT follows the same principles as those described for endoscopic negative-pressure wound therapy of the gastrointestinal tract.

Schwannomas are benign tumors in 95% of cases and very rarely occur in the retroperitoneum. We report the cases of a 35-year-old man with abdominal discomfort and a 50-year-old asymptomatic woman with large retroperitoneal masses. Both underwent multivisceral surgery to exclude an adrenal carcinoma, and the pathologic diagnosis showed schwannomas in both cases. Despite morphological imaging, it was not possible to get a clear diagnosis preoperatively.