Successful pregnancy complicated by persistent pneumothorax in a patient with lymphangioleiomyomatosis (LAM) on sirolimus.

We report a successful pregnancy in a patient with longstanding LAM on treatment with sirolimus. During temporary discontinuation fo sirolimus in early pregnancy, lung function declined but recovered after resumption of sirolimus. Pregnancy was complicated by a persistent pneumothorax which was treated surgically postnatally. The child has had a normal development despite exposure to low dose sirolimus intermittently during early embryonal and mid-fetal life.

Influence of blood transfusions on tumor recurrence and survival rate in colorectal carcinoma.

Determinants for homologous blood transfusion and its influence on postoperative and long-term results were evaluated in 439 curatively resected colorectal cancer patients. The rate of transfusion was significantly higher in rectal cancer, large tumors, advanced pT stage and extended resection but not in tumor stenosis, lower graded tumors, advanced Dukes stage or less experienced surgeons. Transfused patients showed significantly more postoperative complications, higher recurrence rates as well as less favorable long-term survival. Homologous blood transfusions are negatively correlated to survival rates.

Importance of microscopic residual disease at the bronchial margin after resection for non-small-cell carcinoma of the lung.

A total of 805 patients underwent lung resection for non-small-cell lung carcinoma at the University of Munich Medical Center, Klinikum Grosshadern, from 1978 through 1988. Microscopic residual disease at the bronchial margin was found in 21 patients (2.6%). The tumor residues showed either a mucosal (1%) or a extramucosal (1.6%) spreading pattern. Patients with extramucosal microscopic residual disease had a poorer prognosis (median survival 10.3 months) than patients with mucosal microscopic residual disease (median survival 25 months). The prognosis was better if the tumor was squamous cell as opposed to adenocarcinoma or large-cell carcinoma. The most important prognostic factor was tumor stage. Patients with microscopic tumor infiltration and stage I or II disease survived longer than the comparable stage III group. We suggest that these patients should undergo reoperation, if possible. Patients with stage III disease, mediastinal lymph node involvement, and microscopic residual disease have the same marked reduction in survival as patients with stage III disease but without microscopic tumor infiltration. We do not recommend a follow-up operation in these patients. Complete histologic examination of mucosal and extramucosal peribronchial tissues at the resection line by frozen section is mandatory to avoid leaving microscopic tumor behind, which may adversely affect patient survival.

[18F] 3-deoxy-3'-fluorothymidine positron emission tomography: alternative or diagnostic adjunct to 2-[18f]-fluoro-2-deoxy-D-glucose positron emission tomography in the workup of suspicious central focal lesions?

BACKGROUND: 2-[(18)F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography has been established as a standard diagnostic imaging method in the preoperative workup of suspicious pulmonary focal lesions, showing a sensitivity of more than 90% and a specificity of about 80%. Determination of malignant pulmonary lesions with FDG positron emission tomography depends on the assessment of glucose metabolism. However, false-positive findings can occur in inflammatory processes, such as sarcoidosis or pneumonia. The thymidine analogue 3-deoxy-3[(18)F]-fluorothymidine (FLT) is a new positron emission tomography tracer that more specifically targets proliferative activity of malignant lesions. The objective of this study was to determine whether FLT positron emission tomography, in comparison with FDG positron emission tomography, provides additional information in the preoperative workup of central pulmonary focal lesions. METHODS: In this prospective study FLT and FDG positron emission tomography examinations were performed as a part of the preoperative workup in 20 patients with histologically confirmed bronchial carcinoma, 7 patients with benign lesions, and 1 patient with an atypical carcinoid. Results were compared with final pathologic findings. RESULTS: For staging of the primary tumor, FLT positron emission tomography revealed a sensitivity of 86% and a specificity of 100% compared with a sensitivity of 95% and a specificity of 73% for FDG positron emission tomography. For N staging, the sensitivity of FLT positron emission tomography was 57% and the specificity was 100%, and for FDG positron emission tomography, the sensitivity was 86% and the specificity was 100%, respectively. CONCLUSIONS: Our preliminary findings indicate specific FLT uptake in malignant lesions. The number of false-positive findings in FDG positron emission tomography might be reduced with FLT positron emission tomography. Therefore positron emission tomography imaging with FLT represents a useful supplement to FDG in assessing the malignancy of central pulmonary focal lesions.

Prognostic value of deoxyribonucleic acid aneuploidy in primary non-small-cell lung carcinomas and their metastases.

The ploidy status of the deoxyribonucleic acid of a malignant lung tumor provides additional information besides histologic grading and tumor staging according to lymph node infiltration and tumor metastasis. Ninety-nine surgical specimens from patients with non-small-cell lung carcinoma were investigated by flow cytometry. Deoxyribonucleic acid aneuploidy was found in 48% of the primary tumors. Patients with deoxyribonucleic acid-euploid tumors showed better survival (p < 0.01) than those with deoxyribonucleic acid-aneuploid carcinomas independent of tumor stage. Deoxyribonucleic acid ploidy status of the primary tumor was compared with that of N2 lymph node metastases in 29 cases. Seven samples showed a change from deoxyribonucleic acid aneuploidy in the primary tumor to deoxyribonucleic acid euploidy in the lymph node metastases. Survival was significantly better for patients with euploid primary tumors and lymph node metastases, followed by patients with deoxyribonucleic acid-aneuploid primary tumors and euploid lymph node metastases. Survival was poorest in patients with deoxyribonucleic acid-aneuploid primary tumors and lymph node metastases. It was observed that only the simultaneous determination of deoxyribonucleic acid ploidy of primary tumors and lymph node metastases permits accurate prognostic evaluation in case of lymph node infiltration.

Lectins and immunohistochemistry of colorectal cancer, its recurrences and metastases.

In 31 patients resected specimens from primary colorectal cancers, corresponding liver metastases and local recurrences were investigated for the staining pattern of lectins (PNL, UEA, WGA, HPA, SBA, RCA) and tissue antigens (CEA, SP, ACT) by immunohistochemistry. Comparison of staining patterns showed a loss of marker expression from normal colonic mucosa to colorectal primary carcinomas, and a tendency to marker loss from the primary tumour to liver metastases. However, even a neo-expression of markers not present in the primary tumour could be observed. For clinical use, serum markers observed in patient follow-up may be valuable even where the findings are negative at the time of primary tumour surgery. In contrast to the heterogenous marker map of primary tumours and metastases, comparison of primary and locally recurrent tumour revealed a staining pattern that was almost always identical. This supports the hypothesis that locoregional recurrences develop from remnant cells of the primary tumour left behind at surgery. There is no support for the thesis that locoregional recurrences arise from mucosal changes at the anastomosis or from suture material.

Virtual intra-arterial angioscopy (VIA) of the carotid artery based on helical CT data.

The purpose of this study was to visualize both the vessel wall and atherosclerotic plaques in virtual intra-arterial angioscopy (VIA) based on helical CT data sets. To achieve this in vitro, the optimal reconstruction threshold of the vessel wall was determined to be 56.4% of the maximum enhancement. Using this threshold, 20 patients suffering from symptomatic carotid disease were examined in a helical CT scanner. The degree of stenosis was defined using the North American Symptomatic Endarterectomy Trial (NASCET) criteria and compared with results from digital substraction angiography (DSA). Grading of stenoses was only possible by adding the separately computed plaque geometry to the geometry of the vessel wall in a second step. Correlation between VIA and DSA in low grade, medium grade and high grade stenosis was 88%, 93% and 71%, respectively. Complete occlusions were diagnosed correctly in all patients. Sensitivity and specificity for the correct diagnosis of high grade stenosis was 93.7% and 91.3%, respectively. A realistic depiction of intraluminal structures in carotid arteries can only be generated by displaying both the vessel wall and plaque structures simultaneously.

Integrated optical density (IOD), syntactic structure analysis, and survival in operated lung carcinoma patients.

Histological sections of formalin fixed, paraffin-embedded tissue comprising 195 specimens of human lung carcinomas were Feulgen stained. The nuclei of the histomorphological images were segmented using an automated image analyzing system, and the attributed minimum spanning trees (MST) were calculated. Features related to the DNA-content of the nuclei (integrated optical density (IOD), IOD-entropy, S-phase related fraction, percentage > 5C, etc.), and structural parameters (minimum distance between tumor cell nuclei, minimum distance between tumor cells and neighboring lymphocytes, MST-entropy, MST-current of entropy (entropiefluss), distance between neighboring proliferating tumor cells, etc.) were measured. The following results were obtained: the measured IOD and MST features showed significant differences between the primary carcinomas and metastatic carcinomas in the intrapulmonary lymph nodes. The survival of patients was remarkably improved if the carcinomas displayed a low S-phase related fraction, a low percentage of tumor cells > 5C, a low number of stem lines, and a low MST-current of entropy.

[Non-invasive, multi detector row (MDR) CT based computational fluid dynamics (CFD) analysis of hemodynamics in infrarenal abdominal aortic aneurysm (AAA) before and after endovascular repair]. / Blutflusssimulation mittels Computational-Fluid-Dynamics an aus CT-Daten rekonstruierten Aortenaneurysmata vor und nach Stent-Graft Implantation.

PURPOSE: Simulation, description and analysis of dynamic pressure in infrarenal abdominal aortic aneurysms (AAA) before and after endovascular repair. MATERIALS AND METHODS: During March 1996 and May 2001, 13 patients with AAA underwent endovascular treatment. The MDR-CT scans of these patients were used for the non-invasive analysis of the hemodynamics in the aorta with CFD software before and after endovascular repair. One pre-interventional and three post-interventional CT scans were analyzed for each patient. RESULTS: Compared to the pre-interventional simulation, endovascular treatment led to an average dynamic pressure decrease of 1057 Pa in 10 of 13 patients. During the subsequent course, the median of the dynamic pressure decreased in 8 of 13 patients. Vulnerable regions initially identified as high-pressure regions, like the docking area or the second stent limb, adapted to the pressure in the surrounding tissue in the course of time. CONCLUSION: CFD-based blood flow simulation offers the opportunity to analyze dynamic pressure in AAA before and after endovascular repair and allows a prognostic statement as to the possible homogenization of the pressure in abdominal stent-grafts.

Treatment of thoracoabdominal aortic aneurysms with a combined endovascular and surgical approach.

AIM: The conventional approach for the repair of thoracoabdominal aneurysms remains complex and demanding and is associated with substantial morbidity and mortality. Moreover, in cases of reoperation the impact can be dramatic either in survival or in quality of life of the patients, albeit the use of adjuncts. A combined endovascular and surgical approach with retrograde perfusion of visceral and renal vessels has been realized in order to minimize intraoperative and postoperative complications. METHODS: Within an experience of 231 aortic stent-grafts between 1995-2000, 4 of the patients with thoracoabdominal aneurysms were treated with a combined endovascular and surgical approach. Three procedures were electively conducted and 1 on emergency basis. Two women, 59 and 68 years old, and 2 men, 68 and 73 years old (maximum aneurysm's diameter was 10, 6, 8 and 9 cm, respectively) were operated with the combined method (the first 2 patients had a previous open repair of a thoracoabdominal aneurysm). The surgical approach was executed in all patients without thoracotomy or re-do retroperitoneal exposure. Revascularization of renal, superior mesenteric (and celiac in 2 cases) arteries was accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was performed by stent-graft deployment. RESULTS: The entire procedure was technically successful in all patients. The 1(st) patient was discharged 6 weeks after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of leak or secondary rupture of the aneurysm; the patient died 3 months after the repair, due to rupture of an aneurysm of the ascending aorta. In the 2(nd) patient, 30 months after the operation, spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularized vessels. The 3(rd) patient died on the 6th postoperative day due to multiorgan failure after having developed ischemic-related pancreatitis, albeit the successful combined repair. The 4(th) patient followed an uneventful course. No patient experienced any temporary or permanent neurological deficit. CONCLUSION: The combined endovascular and surgical approach is feasible, without cross-clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems the appropriate strategy for high risk and previously operated, with a thoracoabdominal trans-diaphragmatic approach, patients.

Vacuum-sealed mesh graft transplantation in chronic cutaneous ulcers of the lower leg.

BACKGROUND: The covering of defects caused by chronic ulcers on limbs affected by peripheral arterial disease or chronic venous insufficiency is often difficult due to extensive secretion and edema, while chronic bacterial contamination of the wound bed further compromises the conditions for successful healing. PATIENTS AND METHODS: Vacuum-sealed dressing (VSD) offers the option of a closed dressing system for moist wound care that assures firm contact with the wound surface and protection against contamination with nosocomial microbes and decontamination of existing bacteria by means of constant drainage of secretion independent of gravity. VSD is particularly useful in difficult wounds featuring extensive secretion and unfavorable localization and offers many advantages over conventional dressing techniques in terms of improved healing of skin transplants. A total of 35 patients with chronic leg ulcers were treated with vacuum-sealed mesh graft transplantation. RESULTS: Complete healing of the mesh graft transplant was observed in 20 patients (57%). Twelve patients (34%) experienced partial healing (75-90%) of the transplant, while three patients exhibited less than 75% healing of the graft and therefore required a second mesh graft transplantation. CONCLUSIONS: VSD is a simple, quick and inexpensive technique that promotes excellent healing of skin transplants. It is particularly useful in difficult wounds with extensive secretion and/or contamination or infection.

[Interdiscplinarity in thorax operations-from the viewpoint of the surgeon]. / Operative Interdisziplinarität-Thorax. Aus der Sicht des Thoraxchirurgen.

Occasionally, thoracic interventions may require interdisciplinary teamwork with plastic surgery, heart and vascular surgery, or neurosurgery. Thoracic wall defects following excision of primary wall tumors or recurrent, ulcerating tumors of the breast may require full-thickness myocutaneous flaps, which can best be done with the help of plastic surgeons. In case of infiltration of the heart or thoracic aorta, the en bloc principle of T4 lung tumors occasionally requires the help of heart surgeons, for open atrial resection using the heart-lung machine, or vascular surgeons for aortic graft interposition. Paravertebral dumbbell tumors occasionally may infiltrate to the intraspinal space and therefore need removal by neurosurgeons. When and why other specialists are required for an interdisciplinary approach to diseases of the chest has not been clearly defined. Therefore it is wise to gain informed consent from the patient about the roles of different specialists in interdisciplinary treatment for his disease.

[What is the cost of vascular operations? A prospective cost analysis of conventional and combined endovascular interventions]. / Was kosten gefässchirurgische Operationen? Eine prospektive Kostenanalyse konventioneller und kombiniert endovaskulärer Eingriffe.

Current and future legislation demand improved efficiency in the medical services. The aim of this study was to analyse the costs of vascular surgery in order to reveal potential ways of reducing expense. Taking into account the staff, equipment and operating theatre supplies, we analyzed 58 elective operations comprising 47 conventional and 11 combined endovascular procedures. The mean overall costs calculated for the different operations were: 5.269 DM for a transfemoral embolectomy (n = 3), 8.504 DM for a patchplasik of the profunda arteria (n = 8), 10.265 DM for a femoro-popliteal bypass with a prosthesis (n = 6)--13.180 DM with a vein (n = 2), 9.864 DM for conventional iliac artery reconstruction (n = 7)--iliac endovascular combined procedure (n = 4) 14.494 DM, 14.951 DM for a Y-prosthesis in case of stenosis (n = 3)--13.288 DM in case of infrarenal aortic aneurysm (IAA, n = 4), 11.954 DM for a tube prosthesis in case of IAA (n = 3), 23.571 DMY-stent prothesis for IAA (n = 5), 19.914 DM stent for a thoracic aneurysm (n = 2), 7.153 DM a carotid thrombendarterectomy (n = 6), 5.503 DM for varicosis surgery (n = 5). Because of the high cost of materials, the total outlay for combined endovascular procedures appeared to be high when compared to conventional vascular surgery. Substantial savings concerning the operation may only be achieved if facility structure and qualification of staff meets the particular requirements.

[Effect of blood transfusion on tumor recurrence and rate of survival in colorectal cancer]. / Einfluss der Bluttransfusion auf Tumorrückfall und Uberlebensrate beim colorectalen carcinom.

In 439 curatively resected colorectal cancer patients determinants for homologous blood transfusion and its influence on postoperative and long-term results were evaluated. The rate of transfusion was significantly higher in women, rectal cancers, large tumors, advanced pT-stage and extended resections but not in tumor-stenosis, lower graded tumors, advanced Dukes-stage or less experienced surgeons. Transfused patients showed significantly more postoperative complications, higher recurrence rates as well as less favorable long-term survival. Homologous blood transfusions are correlated with survival rates.

[Endoluminal stent-assisted management of acute traumatic aortic rupture]. / Endoluminale stentgestützte Versorgung der akuten traumatischen Aortenruptur.

INTRODUCTION: Open repair of traumatic descending aortic rupture in trauma patients is associated with a mortality rate of 15-20% and a risk of paraplegia of 5-10%. Stent grafts may decrease the morbidity and mortality of these procedures by reducing blood loss and aortic occlusion time. MATERIAL AND METHODS: Within an experience of 52 thoracic stent grafts between 1995 and 2000, eight men with acute traumatic descending aortic rupture were conducted as emergencies without delay. All patients had severe coinjuries and presented with acute onset of mediastinal hematoma due to periaortic bleeding. Successful stent deployment was performed in all eight patients, seven of them required one single stent and one required two stents; within the aortic arch all stents covered the origin of the left subclavian artery. RESULTS: All acute aortic ruptures were sealed successfully. One death occurred in hospital from multiorgan failure. There was no conversion to open repair. Not one patient's condition resulted in temporary or permanent paraplegia. One endoleak required treatment by overstenting. Two patients required secondary surgical procedures (iliac access complication and revascularisation of left subclavian artery). Mean follow-up was 11 months (1-21 months). Mid-term freedom from endoleak was monitored in all patients. CONCLUSION: The treatment of acute traumatic descending aortic rupture with an endovascular approach is feasible and safe and may offer the best means of therapy. The mortality rate and risk of paraplegia are low compared with the risks associated with open operations. Continued surveillance is essential.

[Flow cytometric analysis in non-small-cell bronchial carcinoma and its prognostic significance]. / Durchflusscytometrische Analyse beim nicht-kleinzelligen Brochialcarcinom und deren prognostische Bedeutung.

Tumor and lymph node infiltration, and the DNA-ploidy status of a tumor contain prognostic information in addition to the information obtained by histological examination of surgical samples. Specimens from 112 patients with non-small-cell lung carcinoma obtained immediately after surgery were investigated by means of flow cytometry. DNA-aneuploidy was found in 43% of the primary tumors. Independent from tumor stage, patients with DNA-euploid tumors lived significantly longer (p less than 0.01) than with DNA-aneuploid carcinomas. In 29 cases the DNA-ploidy status of the primary tumor (PTU) could be compared with that of the N2 lymph node metastases (LM). 7 samples revealed a change from DNA aneuploidy in the PTU to DNA-euploidy in the LM. Patients with DNA-euploid PTU and DNA-euploid LM lived significantly longer than patients with DNA-aneuploid PTU/DNA-euploid LM, and patients with DNA-aneuploid PTU/DNA-aneuploid LM. In case of lymph node infiltration only the simultaneous measurement of DNA ploidy of PTU and LM offers an accurate prognostic evaluation. Local tumor recurrence exhibited stability of DNA ploidy, showing DNA euploidy in 12 out of 13 PTU and their corresponding recurrent tumor. Thus, the DNA-ploidy status offers additional prognostic informations which is useful for an extended tumor classification.

Management of descending aortic dissection.

The optimal timing of surgery with Stanford type B aortic dissection remains controversal. In acute-phase cases, surgical mortality is so high that medical treatment is preferable unless there are major complications. To guide the choice of medical versus surgical therapy we use survival analysis in patients with acute uncomplicated/complicated and chronic uncomplicated/complicated descending aortic dissection. Between 1992 and 1993 49 patients were diagnosed with Stanford type B aortic dissection. Emergent surgery was performed in 4 patients for rupture or impending rupture, elective surgery was done in 12 patients. The remaining 33 patients were treated medically. Our results support the continued use of medical management as the primary treatment for uncomplicated acute aortic dissection, with surgical therapy being reserved for those patients with complications such as rupture, expansion, continuing pain or ischemia of distal vascular beds.

[Chances in surgical treatment of bronchial carcinoma under palliative conditions]. / Chancen der operativen Therapie des Bronchialkarzinoms bei palliativer Indikation.

UNLABELLED: Palliative surgery aims at symptomatic relief in patients in whom curative therapy seems not feasible. When diagnostic imaging techniques describe advanced stage IIIa, IIIb or IV malignancy, despite of palliative intention curative resection may still be possible. Objective of the present study was to investigate lung cancer patients undergoing surgery with palliative intent and to compare their prognosis with patients whose tumor resection had been complete (R0) or incomplete (R1/R2). PATIENTS AND METHOD: Patients were assigned to one of the three groups on the basis of the following criteria: palliative intention with subsequent complete resection (group I, n = 11); curative intention with subsequent incomplete resection (group II, n = 38), palliative intention with incomplete resection (group III, n = 23). Additionally 3 patients were operated on by explorative thoracotomy. A total number of 75 patients was therefore investigated. Median follow-up period was 34.5 months. Survival rates were calculated using the Kaplan-Meier method. RESULTS: The following procedures involving resection of pulmonary tissue were performed: pneumonectomy (n = 10), extended pneumonectomy (n = 32), lobectomy (n = 5), extended lobectomy (n = 11), sleeve lobectomy (n = 7), bilobectomy (n = 3), extended bilobectomy (n = 4). The 30 days hospital mortality rate was 13%. Median survival times were 25.5 months in group I, 12.8 months in group II and 7.7 months in group III (statistical significance: group I vs. group II/III, p < 0.05). CONCLUSIONS: Results of the present study show that patients with bronchial carcinoma in advanced tumor stages III and IV may still benefit from pulmonary resection, particularly when reduction of their somatic complaints is considered. In 11 patients, R0 resection was feasible leading to a statistically significant prolongation of their survival rates.

[Bronchial stump insufficiency: treatment and results]. / Die Bronchusstumpfinsuffizienz: Behandlung und Ergebnisse.

A bronchopleural fistula following lung resection is a dangerous complication. Records from 25 patients with a bronchopleural fistula were followed up in order to propose a therapeutic concept. An early onset of fistula should be treated as an emergency. Late fistulas can be reoperated electively because they are most often rather small and the patients are in a better condition. The suture of the stump alone was successful in only 3 out of 13 cases. Patients with fistulas following lobectomy were reoperated by pneumonectomy with good results. In fistulas due to pneumonectomy the results of either an isolated muscle-flap or a thoracoplasty were disappointing. Instead, a closure of the stump was accomplished by the combination of thoracoplasty and muscle-flap in 3 out of 4 patients. However, 2 patients with an early fistula after pneumonectomy died from septic complications after the fistulas had already been managed. Endoscopic maneuvers like gluing and insertion of spongiosa did not show any success unless combined with operative measures but rather delayed the onset of re-intervention.