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Purpose: Our aim was to update evidence-based and consensus-based recommendations for the surgical and interventional management of blunt or penetrating injuries to the chest in patients with multiple and/or severe injuries on the basis of current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. Methods: MEDLINE and Embase were systematically searched to May and June 2021 respectively for the update and new questions. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies and comparative registry studies were included if they compared interventions for the surgical management of injuries to the chest in patients with multiple and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, length of stay, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. Results: One study was identified. This study compared wedge resection, lobectomy and pneumonectomy in the management of patients with severe chest trauma that required some form of lung resection. Based on the updated evidence and expert consensus, one recommendation was modified and two additional good practice points were developed. All achieved strong consensus. The recommendation on the amount of blood loss that is used as an indication for surgical intervention in patients with chest injuries was modified to reflect new findings in trauma care and patient stabilisation. The new good clinical practice points (GPPs) on the use of video-assisted thoracoscopic surgery (VATS) in patients with initial circulatory stability are also in line with current practice in patient care. Conclusion: As has been shown in recent decades, the treatment of chest trauma has become less and less invasive for the patient as diagnostic and technical possibilities have expanded. Examples include interventional stenting of aortic injuries, video-assisted thoracoscopy and parenchyma-sparing treatment of lung injuries. These less invasive treatment concepts reduce morbidity and mortality in the primary surgical phase following a chest trauma. [ABSTRACT FROM AUTHOR]

Abstract: A-13 year old boy had an accident with his bike with a blunt thorax trauma and presented shortly after with facial swelling. Due to respiratory insufficiency, intubation was done during the transport to the clinic. First, a chest radiograph was performed, which showed a unilateral pneumothorax. Later a CT scan revealed bilateral pneumothorax and pneumomediastinum. Bilateral chest tube insertions improved the respiratory situation. Bronchoscopy showed a tracheal lesion two cm posterior to the main carina. After good wound healing, the patient was dismissed after 21 days in good health. Conservative treatment can be recommended in selected patients with a tracheal lesion when having a stable respiratory situation. If the patient does not improve after 48 h or if the clinical condition worsens, surgical management should be considered. [Copyright &y& Elsevier]

Die perioperative Morbidität nach elektiven Kolonresektionen beträgt bei Anwendung traditioneller perioperativer Therapiekonzepte in Deutschland derzeit etwa 20-30%. Durch multimodale perioperative Behandlungsstrategien zur Reduktion der traumatischen Stressreaktion konnte eine deutliche Senkung der Komplikationsrate auf 5-10% erreicht werden. Wesentliche Bestandteile dieser multimodalen perioperativen Frührehabilitation («Fast-track»-Rehabilitation) in der Kolonchirurgie sind Patientenschulung, atraumatische Operationstechniken, moderne Narkoseführung und Schmerztherapie, forcierte Mobilisation und frühzeitiger postoperativer Kostaufbau. Nur die konsequente Umsetzung aller Maßnahmen unter Nutzung synergistischer Effekte führt zur deutlichen Beschleunigung der postoperativen Rekonvaleszenz. Die Wirksamkeit einzelner Bestandteile des «Fasttrack »-Konzepts ist in randomisierten klinischen Studien verifiziert worden. Die enge Zusammenarbeit zwischen Chirurgen, Anästhesiologen und Pflegepersonal ist die Voraussetzung für die Umsetzung solcher multimodaler Behandlungskonzepte. [ABSTRACT FROM AUTHOR]

Hintergrund: Laparoskopische Kolonresektionen haben bei traditioneller perioperativer Therapie im Gegensatz zu offenen Operationen kurzfristige Vorteile im klinischen Verlauf. Es ist fraglich, ob sich die guten Ergebnisse der laparoskopischen Operationstechnik weiter verbessern lassen, wenn die Patienten nach «Fast-track»-Konzepten behandelt werden. Patienten und Methoden: In einer prospektiven, nicht randomisierten Beobachtungsstudie sollte der klinische Verlauf von Patienten mit elektiven laparoskopischen Sigma- und anterioren Rektumresektionen unter traditioneller oder «Fast-track»-Therapie untersucht werden. Essentielle «Fast-track»-Bestandteile waren unter anderem: Patientenschulung, Periduralanalgesie, forcierte Mobilisation und oraler Kostaufbau. Zielkriterien waren allgemeine und chirurgische Komplikationen und die forcierte Vitalkapazität (FVC). Ergebnisse: Von 116 Fällen wurden 33 Patienten traditionell und 83 Patienten nach «Fast-track» behandelt. Der orale Kostaufbau (p <> [ABSTRACT FROM AUTHOR]

Evidence should define and guide modern clinical care, yet many relevant questions in surgical practice remain unconfirmed by substantial data. Evidence-based medicine requires both the implementation of its principles in day-to-day work and the acquisition of new evidence preferably by randomized controlled trials and systematic reviews. Meaningful clinical research, however, is challenging to conduct, and its overall infrastructure in Germany was, until recently, considered poor compared to other leading countries. Although this has been significantly improved after the establishment of the Study Center of the German Surgical Society (SDGC) and the surgical clinical trial network CHIR-Net, limited focus has been put on the training, teaching, and recruitment of medical students to become competent clinical researchers and clinician scientists. To ensure continuing comprehensive clinical research in surgery, CHIR-Net aims to establish a student-driven multicenter research network in Germany, which is embedded in both the national CHIR-Net and the pan-European and international frameworks. Student-Initiated German Medical Audits (SIGMA) is a product of the strong collaboration between clinical scientists and medical trainees, enabling students to contribute to high-quality clinical trials. Additionally, participants are offered extensive training to support the next generation of research-active clinicians. Starting on 2018, SIGMA will perform its first multicenter observational study in Germany.

Objective: To estimate the value of estrogen receptor (ER) in benign breast diseases and to find out if the response of benign breast diseases to danazol depends on the ER status of the tissue. Design: Prospective study. Setting: University hospital, India. Material: Samples of tissue from benign breast lesions, 40 fibrocystic disease and 10 fibroadenomas. Interventions: Enzyme immunoassay for the presence of cytosolic ER. Main outcome measures: ER concentrations, and correlation with effect of treatment with danazol. Results: Fibrocystic disease and fibroadenomas showed 30% and 40% ER positivity, respectively. The mean (SD) ER concentration was significantly higher in premenopausal than postmenopausal patients 14.75 (3.79) fmol/mgm compared with 6.2 (1.59) fmol/mg (p < 0.05). All ten patients with mastalgia who had ER-positive lesions (n = 26) responded to danazol, compared with 6 of 16 patients who had ER-negative lesions (p < 0.05). Lesions with diffuse fibrosis (n = 14) and five with lymphocytic infiltration on histology were all ER-negative. Conclusion The patients with ER positive breast disease responded better to danazol than patients with ER negative breast disease. [ABSTRACT FROM AUTHOR]

Focuses on the use of thoracic epidural catheter in randomized trials. Insertion of the catheter between T7 and T9; Role of the postoperative skin prick testing; Detection of differences with a two-sided test.

Abstract Background Incisional hernia is a frequent complication in abdominal surgery. This article describes the development of a prospective randomized clinical trial designed to determine whether watchful waiting is an acceptable alternative to surgical repair for patients with oligosymptomatic incisional hernia. Methods/Design This clinical multicenter trial has been designed to compare watchful waiting and surgical repair for patients with oligosymptomatic incisional hernia. Participants are randomized to watchful waiting or surgery and followed up for two years. The primary efficacy endpoint is pain/discomfort during normal activities as a result of the hernia or hernia repair two years after enrolment, as measured by the hernia-specific Surgical Pain Scales (SPS). The target sample size of six hundred thirty-six patients was calculated to detect non-inferiority of the experimental intervention (watchful waiting) in the primary endpoint. Sixteen surgical centers will take part in the study and have submitted their declaration of commitment giving the estimated number of participating patients per year. A three-person data safety monitoring board will meet annually to monitor and supervise the trial. Discussion To date, we could find no published data on the natural course of incisional hernias. To our knowledge, watchful waiting has never been compared to standard surgical repair as a treatment option for incisional hernias. A trial to compare the outcome of the two approaches in patients with oligosymptomatic incisional hernias is urgently needed to provide data that can facilitate the choice between treatment options. If watchful waiting was equal to surgical repair, the high costs of surgical repair could be saved. The design for such a trial is described here. This multicenter trial will be funded by the German Research Foundation (DFG). The ethics committee of the Charité has approved the study protocol. Approval has been obtained from ten study sites at time of this submission. The electronic Case Report Forms have been created. The first patient was to be randomized November 14th, 2011. An initiation meeting took place in Berlin January 9th, 2012. Trial Registration ClinicalTrials.gov: NCT01349400

Abstract Background Wound infection affects a considerable portion of patients after abdominal operations, increasing health care costs and postoperative morbidity and affecting quality of life. Antibacterial coating has been suggested as an effective measure to decrease postoperative wound infections after laparotomies. The INLINE metaanalysis has recently shown the superiority of a slowly absorbable continuous suture for abdominal closure; with PDS plus® such a suture has now been made available with triclosan antibacterial coating. Methods/Design The PROUD trial is designed as a randomised, controlled, observer, surgeon and patient blinded multicenter superiority trial with two parallel groups and a primary endpoint of wound infection during 30 days after surgery. The intervention group will receive triclosan coated polydioxanone sutures, whereas the control group will receive the standard polydioxanone sutures; abdominal closure will otherwise be standardized in both groups. Statistical analysis is based on intention-to-treat population via binary logistic regression analysis, the total sample size of n = 750 is sufficient to ensure alpha = 5% and power = 80%, an interim analysis will be carried out after data of 375 patients are available. Discussion The PROUD trial will yield robust data to determine the effectiveness of antibacterial coating in one of the standard sutures for abdominal closure and potentially lead to amendment of current guidelines. The exploration of clinically objective parameters as well as quality of life holds immediate relevance for clinical management and the pragmatic trial design ensures high external validity. Trial Registration The trial protocol has been registered with the German Clinical Trials Register (DRKS00000390).