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>>>>> Chirurgie <<<<<
Dr. Abidin Geles
2019
Einleitung
Die chirurgische Behandlung der Patienten durch den operativen Eingriff gehört heutzutage zu den primären Behandlungsmöglichkeiten. Eine zunehmende Zahl der Patienten wird heutzutage kurativ behandelt. Die Vor- und Nachbehandlung mit Chemo- und/oder Strahlentherapie bzw. spezielle Therapie wie Immuntherapie (multimodal) zur Unterstützung der chirurgischen Ansätze ist ebenfalls für eine gute Prognose der Erkrankung sehr wichtig.
Die Komplikationen sind durch eine genaue Auslese der operablen Patienten sehr selten, aber nicht auszuschließen. Folgende sind einige der wichtigsten Komplikationen mit denen die Patienten rechnen müssen, wenn sie operiert werden:
* Verletzung der benachbarten Organe / Strukturen
* Durchstoßung (Perforation)
* Blutungen ( Vor chirurgischen Eingriffen muss die Gerinnung also PZ über 60 sein und INR unter 2,0)
* Operationsbedingte Folgeeingriffe
* Lagerungsschäden während der Operation: Druckschäden an den Nerven mit Empfindungsschäden, vorübergehenden oder bleibenden Lähmungen der Extremitäten, Haut- und Gewebeschäden, dauerhafte Narben
* Harnwegsinfekte
* Wundinfektionen, Wundheilungsstörungen: mit Abszess bis zum Sepsis, schmerzende und ästhetisch störende Narbenwucherungen mit Hautfärbungen (Kelloide), Bewegungseinschränkungen, Taubheitsgefühl im Bereich der Operationsnarbe
* Allergien, Überempfindlichkeitsreaktionen: Hautreaktionen, Schwindel, Erbrechen
* Organversagen, Lähmungen
* Thrombosen, Embolien: Venenverschlüsse durch Blutgerinnsel in den Venen zB Beinvenenthrombosen oder zu einem Lungenembolie (PAE) führen
* Infektionen nach Bluttransfusionen: Infektionsrisiko (Hepatitis-Viren, HIV (AIDS), Erregern von BSE, Creuzfeldt-Jakob-Erkrankung, oder bisher unbekannten Erregern.
* Postoperative Schmerzen,
* evtl. Nachblutung,
* Mögl. Einer Zweiteingriffes und damit verlängerter KH-Aufenthalt, Wundheilungsstörungen und die im Aufklärungsbogen beschriebenen Kompl.
* Spritzenabszesse, örtliche Gewebeschäden mit Nekrosen, Venenreizungen, bleibende Schäden (Schmerzen, Lähmungen) sind sehr selten
* Bei Wiederholungseingriffen höheres Risiko für Komplikationen
* Falls der Eingriff ambulant durchgeführt worden ist, ist ein/eine Begleitperson je nach Eingriff und Narkose für die nächsten Tage erforderlich. Verkehrstauglichkeit ist nach dem Eingriff durch die Narkose (Schmerzmittel- und Betäubungsmittel) eingeschränkt, daher 24 Stunden nach dem Eingriff keine Fahrzeuge fahren, keine gefährlichen Maschinen betätigen, keine wichtigen Entscheidungen treffen. Bei Fieber, Schmerzen oder Rötung der OP-Wunde, schwere Verstopfung oder massiven Bauchkrämpfen behandelnden Arzt aufsuchen.
Die Patienten müssen genauestens über den geplanten Eingriff sowie über mögliche Komplikationen bis hin zum Tod aufgeklärt werden. Wenn der/die Patient/in alles verstanden hat und eingewilligt hat und die Indikationen vorliegen kann er/sie dann operiert werden.
Wichtige Begriffe
oo Prävalenz: die Anzahl der Patienten, die an einem bestimmten Zeitpunkt von einer Erkrankung betroffen sind
oo Inzidenz: Neuerkrankungen pro 100.000 Einwohner pro Jahr
oo Epidemiologie: Häufigkeit, Geographische Daten, Alter
oo Ätiologie: Ursachen, Noxen
oo Mortalität: Anzahl der verstorbenen pro 100.000 Einwohner pro Jahr
oo Demographische Erfassung: Wichtig für die Qualität der epidemiologischen Daten eines Landes
oo Todesursachenstatistik: Gibt an wie viele Patienten an Krebs verstorben sind
oo Altersverteilung: Es sollten alterskorrigierte (=standartisierte) Daten verwendet werden
oo Zellteilungszyklus: G1-Phase (präsynthetische Phase), S-Phase (prämitotische Phase), M-Phase (Mitosephase), G0-Phase (Ruhephase, kann auch dauerhaft sein)
oo Tumorverdoppelungszeit: Zeit, in der das Tumor sich verdoppelt
oo Tumorinfiltration: durch Freisetzung von lytischen Enzymen Auflösen und Zerstören des infiltrierten Organes
oo Metastasierung: Tochtergeschwulstbildung, Wanderung von Tumorzellen in die Umgebung oder in andere Organe wie zB Lymphknoten über Lymphabflussbahnen, hämatogen übers Blut, Implantation (intrakavitär (Karzinose), intraluminal (zB Darmlumen), iatrogen (während der Operation).
oo Typing: Beschreibung des histologischen Tumortyps.
oo Grading: Beschreibung des histologischen Malignitätsgrades.
oo Staging: TNM, pTNM
oo Präoperatives Staging
oo Intraoperatives Staging
oo Postoperatives Staging (mit pTNM)
oo Inoperabilität: Aufgrund Tumorinfiltration lebenswichtiger Strukturen, (Metastasen), Begleiterkrankungen.
oo Palliative Therapie: Nicht kurativ, lebensverlängernde Maßnahmen bei guter Lebensqualität, symptomatische Behandlung. Palliative Chemotherapie bedeutet das Leben mit der Chemotherapie zu verlängern bei Inoperabilität oder R2-Resektion.
oo Adjuvante Chemotherapie: Bei kurativer Zielsetzung mit R0-Resektion wird zusätzlich eine Chemotherapie durchgeführt.
oo Neoadjuvante Chemotherapie: Chemotherapie vor der Operation.
oo Hormontherapie: Wenn Tumor hormonabhängig wächst.
oo Immuntherapie: Immunsystem wird gegen Tumor bestärkt bzw. angeregt
oo Psychotherapie: Wird meistens vom Arzt durchgeführt und es gibt mehrere Phasen: 1-) Verleumdung und Verdrängung, 2-) Auseinandersetzung, 3-) Akzeptanz.
Betäubungsverfahren: Deswegen wird der Patient präoperativ beim Narkosearzt vorgestellt und über die Narkose während der Operation aufgeklärt. Je nach Operation und PatientIn wird eine Narkoseverfahren ausgesucht sofern der Patient narkosetauglich ist.
Krebsphasen:
* Induktionsphase, dauert 15-30 Jahre
* In-situ-Phase, dauert 5-10 Jahre
* Infiltrationsphase, dauert 1-5 Jahre
* Disseminationsphase, dauert 1-5 Jahre
Das Wachstum des Tumors ist abhängig von vier Faktoren:
* Relation Tumorparenchym/Stroma,
* Anteil der Wachstumsfraktion des Tumorparenchyms,
* Dauer des Zellteilungszyklus,
* Anteil des Zellverlustes (Nekrose, Nekrobiose)
Diagnose:
1-) Anamnese, Symptome, körperliche Untersuchung, Inspektion, Palpation, Körperöffnung, Lyphknoten-Status
2-) Konventionelle Radiodiagnostik (Arterio-, Phlebo-, Lyphographie), Sonographie, CT, PET, MR
3-) Endoskopie, Tumormarker, Zytologie, Biopsie, Histologie
Jedes Malignom ist eine Systemerkrankung. Sie gehen über verschiedene Phasen bis zur Generalisierung. 80-90 % der Patienten mit einem Tumor werden mindestens einmal operiert, 40-50% werden durch die Operation geheilt.
Kurative Therapie: Heilung des Patienten wird angestrebt mit einer R0-Resektion in der intraoperativen Gefrierschnitdiagnostik (und radikaler Lymphadenektomie) und Sampling-Lymphadenektomie. Auch bei mono- oder oligotope Metastasen (Leber-, Lunge-, Hirnmetastasen) ist ebensfalls eine kurative Zielsetzung möglich wenn Metastasierung nicht diffus ist. Die Zellzahl muss auf null gesenkt werden. Ab einer Zahl von 10 hoch 6 werden körpereigene Abwehrkräfte aktiviert (Zellnachweisgrenze ist 10 hoch 9).
Chemotherapie: Manche Zellen sind chemotherapieresistent. Chemotherapien werden in zellzyklusspezifische und nicht-zellzykluspezifische Drogen bzw. nach biologischer Wirksamkeit unterschieden. Folgende sind die wichtigsten Chemotherapeutikagruppen:
o Alkylierend: verbinden sich mit DNAzB Cyklophosphamid (Endoxan)
o Antimetabolite: hemmen Biosynthese von Nukleinsäuren zB 5 Fluoruracil (5-FU)
o Mitosehemmer: Spidelgifte, zB Vincristin
o Tumorantibiotika: verbinden sich mit DNS und hemmen Synthese RNS-Synthese zB Doxorubicin (Adriamycin)
o Pflanzenalkaloide: zB Epipodophyllotoxine (VP 16-213)
o Cisplatin, DTIC,...
Strahlentherapie: Bestrahlung des Tumors mittels Stoßionisation (direkt ionisierende Strahlung) bzw. durch Photonenbestrahlung geladener Teilchen und lokaler Auslösung einer Stoßionisation (indirekt ionisierende Strahlung).
Die verschieden Erkrankungen werden heutzutage von verschiedenen Spezialbereichen behandelt.
1-) Allgemeinchirurgie
Die Allgemeinchirurgie beschäftigt sich mit:
der Visceralchirurgie:
* Gastrointestinale Funktionsdiagnostik
* Peritoneum
* Magen und Duodenum
* Dünndarm
* Chirurgie des Kolons
* Appendix
* Rektum und Anus
* Ileus
der Chirurgie der endokrinen Organe;
* Schilddrüse
* Hyperparathyreoidismus
* Nebenniere
* Tumore des gastroentero-pankreatischen Systems
* Multiple endokrine Neoplasien
* Brustdrüse
der Chirurgie der Hernien
der Leber- und Gallenwegschirurgie:
* Portale Hypertension
der Chirurgie des Pankreas
der Chirurgie der Milz
der Chirurgie der Weichteilsarkome
der Chirurgie des Bauchtraumas
der Minimal invasiven Chirurgie
der Manualtherapie in der Chirurgie
sowie mit:
der Onkologie,
Traumatologie
den entzündlichen und funktionellen Erkrankungen
den benignen Tumoren und den Fehlbildungen
2-) Unfallchirurgie
Die Unfallchirurgie beschäftigt sich mit der Versorgung der verunfallten Patienten wie zB
* Traumaversorgung
* Sportverletzungen versorgen
* Frakturenversorgung
* Verstauchung (Distortion) (Verdrehung)
* Schürfwundenversorgung
* Osteomyelitis, infizierte Frakturen
* ...
Die erste Untersuchung ist den Patienten im Gesamten anzuschauen.
* Man beginnt mit der Anamnese
o Unfallszeit
o Unfallsort
o Wie es passiert ist also Unfallhergang
o Wie es dem Patienten geht
o Wo genau er die Schmerzen hat
o etc.
Wenn der Patient nicht in der Lage ist selber eine Anamnese zu geben, ist man auf Fremdanamnese angewiesen (Unfallzeugen, Sanitäter, Polizei, Feuerwehr...)
Inspektion: Schauen ob der Patienten durch etwas ungewöhnliches auffällt wie zB
* Schwellungen
* Hämatome
* Wunden
* Abnorme Stellung der Extremitäten oder Knohen
* Deformitäten
* ...
Palpation: Um Skelett und Muskelveränderungen zu beurteilen, wie zB
o Krepitation
o Druckschmerzpunkte
o Gelenksergüsse
o Pulse
o ...
Motorik / Durchblutung / Sensibilät (MDS) ist ebenfalls anzuschauen.
Röntgen
Man macht Röntgenaufnahmen um knöcherne Verletzungen auszuschließen. Röntgenaufnahmen oft in zwei Ebenen anterior-posteriorer und seitlicher Strahlengang, beim Röntgen beschreibt man immer das distale Fragment der Fraktur. Es gibt verschiedene Dislokationsmöglichkeiten:
* Kontraktion (Verkürzung)
* Seitverschiebung: dislokatio ad latus, zB distaler Knochenanteil um Seitenbreite nach einer Seite dislokalisiert
* distaler Knochenanteil längst verschoben: Dislokatio longitudinem
* (Achsen)Knick (Varus oder Valgus): Dislokatio ad axim
* Rotation: Dislokatio ad peripheriam
* Dislokatio ad longitudinem cum contractione: Längstverschiebung mit Verkürzung
* Dislokatio ad longitudinem cum distractione: Längstverschiebung mit Verlängerung
Bei Schwerverletzten sind Röntgenaufnahmen des Schädels, der Wirbelsäule, des Thorax und Beckens umbedingt zu machen.
Computer Tomographie (CT)
Man macht mittels Röntgenstrahlen Schichtaufnahmen von den entsprechen Körperregionen, welche im Vergleich zu Röntgenaufnahmen eine sehr gute Qualität haben. Die CT erleichtert die Diagnose viel genauer vor allem bei knöchernen Strukturen und ist für die OP-Planung sehr wichtig
Magnetresonanztomographie (MRT)
MRT erleichtert die Diagnose der Weichteile viel genauer.
Sonographie
Um die inneren Organe zu beurteilen!
Angiographie
bei Verdacht auf Gefäßverletzungen.
Bildwandler
Frühseitige Behandlung der Gelenksverletzungen ist wichtig, weil sonst Arthrose-, Arthritisgefahr oder chronische Beschwerden auftreten können. Bei Gelenksverletzungen ist strenge Antisepsis wichtig, und Wunden sollten ausgeschnitten werden, Gelenksdrainagen also Redondrainagen, Wundnaht, Gips zur Ruhigstellung, Hochlagerung, Antibiogram und dann Antibiotika, Entzündungsparameterbestimmung, Blutsenkungsreaktion.
KpK: Gelenksinfekt, Empyem, Versteifung des Gelenks.
Bei Meniskus- oder Diskusverletzungen ist meist operative Behandlung nötig, weil diese nur in Randbereichen vaskularisiert sind und sonst ist der Stoffwechsel über Diffusion geht.
Knorpelverletzungen kann man konservativ oder operativ bedandeln, man kann auch autolologe oder homologe Knorpeltransplantationen durchführen.
Sehnenverletzungen: Schnittwunden, Riß bei den Ansatzstellen,
Schultergelenksverletzungen sind häufig.
3-) Orthopädie
Die Orthopädie beschäftigt sich mit den Fehlbildungen sowie degenerativen Erkrankungen des Stütz- und Bewegungsapparates.
4-) Thoraxchirurgie
Die Thoraxchirurgie beschäftigt sich:
in Bezug auf die Lokalisation mit:
Lunge
Mediastinum
(außer Herz)
Thoraxwand
(außer Mamma)
und in Bezug auf die Krankheit mit:
Onkologie (80% der Patienten)
Traumatologie
Entzündliche Erkrankungen
Funktionelle Erkrankungen
Benigne Tumore
Fehlbildungen
5-) Gefäßchirurgie
Die Gefässchirurgie beschäftigt sich mit den vaskulären Erkrankungen (Arterien, Venen und Lymphgefässen).
6-) Herzchirurgie
Die Herzchirurgie beschäftigt sich mit Erkrankungen des Herzens und des Perikards sowie der thorakalen Gefässe.
7-) Transplantationschirurgie
Die Transplantationschirurgie beschäftigt sich mit Transplantation verschiedener Organe. Folgende Organe können heutzutage transplantiert werden:
* Nieren
* Leber
* Pankreas
* Herz
* Lungen
Die transplantierten Patienten müssen Immunsupressiva nehmen um eine Abstoßungsreaktion zu verhindern.
Bei Fragen / Feedback bitte E-Mail an abidin.geles@gmail.com
DANKE
