Pulmonary Metastasising Aneurysmal Fibrous Histiocytoma: A Case Report, Literature Review and Proposal of Standardised Diagnostic Criteria.

An aneurysmal fibrous histiocytoma is a rare cutaneous soft-tissue tumour which accounts for approximately 0.06% of all dermatopathologies. Metastasis is exceedingly uncommon, to the point that there have only been eight reported cases in the scientific literature. We present the case of a 25-year-old male with a primary aneurysmal fibrous histiocytoma located in the nuchal region which exhibited rapid growth and abrupt ulceration over a short time span and showed signs of locoregional aggressive infiltration. A subsequent histopathological analysis confirmed the presence of diffuse solid and cystic pulmonary metastases. Further genetic sequencing verified LAMTOR1-PRKCD fusion. This case report seeks to review the existing literature on aneurysmal fibrous histiocytoma, discuss the challenges of differential diagnosis and propose standardised diagnostic criteria.

Narrowing the therapeutic window?-A case-control study on the influence of the COVID-19 pandemic on the primary UICC stage of NSCLC.

Background: General clinical perception suggests a decline in the diagnosis and treatment of lung cancer during the SARS-CoV-2 pandemic. Early diagnosis of non-small cell lung cancer (NSCLC) is crucial in therapeutic regimes as early stages are potentially curable by operation alone or with combined therapy. Pandemic-triggered overload of the healthcare system may have prolonged the diagnosis of NSCLC, possibly leading to higher tumor stages at first diagnosis. This study aims to identify how COVID-19 affected the distribution of the Union for International Cancer Control (UICC) stage in NSCLC at first diagnosis. Methods: A retrospective case-control study was conducted, including all patients receiving their first diagnosis of NSCLC in the regions of Leipzig and Mecklenburg-Vorpommern (MV) between January 2019 and March 2021. Patient data were retrieved from the clinical cancer registries of the city of Leipzig and the federal state of MV. Ethical approval for this retrospective evaluation of archived, anonymized patient data was waived by the Scientific Ethical Committee at the Medical Faculty, Leipzig University. Three investigation periods were defined to study the effects of high incidences of SARS-COV-2: the curfew period as an enacted security measure, the period of high incidence rates and the period of the aftermath of high incidences. Differences in the UICC stages between these pandemic periods were studied by Mann-Whitney-U-Test. Pearson's correlation was calculated to examine changes in operability. Results: The number of patients diagnosed with NSCLC dropped substantially during investigation periods. There was a significant difference in the UICC status in the aftermath of high incidences and imposed security measures in Leipzig (P=0.016). N-status differed significantly in the aftermath of high incidences and imposed security measures (P=0.022) with a decrease of N0- and an increase of N3-status, respectively, while N1- and N2-status remained relatively unaffected. No pandemic phase showed a significant difference in operability. Conclusions: The pandemic led to a delay in the diagnosis of NSCLC in the two examined regions. This resulted in higher UICC stages upon diagnosis. However, no increase in inoperable stages was shown. It remains to be seen, how this will affect the overall prognosis of the involved patients.

Does health securitization affect the role of global surgery?

Aim: More and more frequently outbreaks of infectious diseases force the international community to urgent health action and lead to an increasing security focus on global health. Considering the limiting character of resource allocation, all other medical conditions must compete with the top spot of health security matters, as we currently see with the outbreak of COVID-19. Surgery is an integral part of universal health offering life-saving therapy for a variety of illnesses. Amidst the increasing nexus of infectious diseases and health security and in the view of Public Health Emergencies of International Concern (PHEIC), is there a risk of global surgery falling behind? Subject and Methods: While the global undersupply of surgical care is well recorded, contextual explanations are absent. Our research introduces the constructivist concept of securitization according to the Copenhagen School to explain the structural handicap of global surgery and by that presents a structural explanation. We investigate the securitizing potential of surgical diseases in comparison to infectious diseases. Results: Surgical conditions are non-contagious without the risk for disease outbreaks, hardly preventable and their treatment is often infrastructurally demanding. These key features mark their low securitizing potential. Additionally, as PHEIC is the only securitizing institution in the realm of health, infectious diseases have a privileged role in health security. Conclusion: Surgery substantially lacks securitizing potential in comparison to communicable diseases and by that is structurally given an inferior position in a securitized health order.

Elective surgery in times of COVID-19: A two-centre analysis of postponed operations and disease-related morbidity and mortality.

INTRODUCTION: COVID-19 had an impact on the whole range of worldwide medical services. Due to the high risk of in-hospital transmission and disproportionate perioperative rates of morbidity and mortality in occult COVID-19 patients surgeons were faced with the challenging triage of surgeries into emergency, urgent and elective. The present study investigates postponed elective surgery and its impact on the medical condition of patients in two high-volume departments of general, visceral, thoracic, transplant and vascular surgery. METHODS: Operations that have been postponed due to COVID-19 were recorded in the Departments of General-, Visceral-, Thoracic- and Vascular Surgery at the University Hospitals of Leipzig and Greifs-wald. Data was analysed descriptively concerning patient outcomes as well as emergency admissions and surgeries. RESULTS: In the Leipzig and Greifswald University Hospitals 89 and 92 elective surgeries were postponed, respectively. No patient needed an extension of surgical procedure when eventually operated. One patient with extensive obesity died early during the suspension period due to cardiac complications. Four patients needed emergency admission to hospital one of whom required urgent surgery. In neither of the two surgical departments did a patient acquire a nosocomial infection with COVID-19. DISCUSSION: While medical consequences of COVID-19 seem multidimensional and severe, our data indicate that the short-term postponement of elective surgery did not cause an unproportional increase of morbidity and mortality. Although the restrictions may have been fear-driven, given no confirmed cases and thus no concrete risk of infection, the early and well-coordinated action may have provided protection from uncontrolled interruption of medical services by loss of medical workforce or capacity. CONCLUSION: Well-organized and early suspension of elective surgery had no disproportionate impact on patient outcomes while averting nosocomial transmission of COVID-19.

The Learning Objective Catalogue for Patient Safety in Undergraduate Medical Education--A Position Statement of the Committee for Patient Safety and Error Management of the German Association for Medical Education.

BACKGROUND: Since the report "To err is human" was published by the Institute of Medicine in the year 2000, topics regarding patient safety and error management are in the focal point of interest of science and politics. Despite international attention, a structured and comprehensive medical education regarding these topics remains to be missing. GOALS: The Learning Objective Catalogue for Patient Safety described below the Committee for Patient Safety and Error Management of the German Association for Medical Education (GMA) has aimed to establish a common foundation for the structured implementation of patient safety curricula at the medical faculties in German-speaking countries. METHODS: The development the Learning Objective Catalogue resulted via the participation of 13 faculties in two committee meetings, two multi-day workshops, and additional judgments of external specialists. RESULTS: The Committee of Patient Safety and Error Management of GMA developed the present Learning Objective Catalogue for Patient Safety in Undergraduate Medical Education, structured in three chapters: Basics, Recognize Causes as Foundation for Proactive Behavior, and Approaches for Solutions. The learning objectives within the chapters are organized on three levels with a hierarchical organization of the topics. Overall, the Learning Objective Catalogue consists of 38 learning objectives. All learning objectives are referenced with the National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education. DISCUSSION: The Learning Objective Catalogue for Patient Safety in Undergraduate Medical Education is a product that was developed through collaboration of members from 13 medical faculties. In the German-speaking countries, the Learning Objective Catalogue should advance discussion regarding the topics of patient safety and error management and help develop subsequent educational structures. The Learning Objective Catalogue for Patient Safety can serve as a common ground for an intensified, constructive, subject-specific discussion about these topics at the medical faculties, and guide the implementation of hopefully multiple patient safety curricula in undergraduate medical education.

Evaluation of short-term and long-term results after laparoscopic antireflux surgery: esophageal manometry and 24-h pH monitoring versus quality of life index.

PURPOSE: The objective of this long-term study is to compare data on postoperative quality of life with objective functional measurements in patients with gastroesophageal reflux disease who have undergone laparoscopic antireflux surgery. METHODS: Between 1995 and 2005, 162 patients with gastroesophageal reflux disease underwent laparoscopic surgery. A minimum of 4 years after surgery, 60 patients were contacted at random, 29 of whom agreed to follow-up examination. The following examinations were performed preoperatively, 6 months postoperatively, and 4-12 years postoperatively: esophageal manometry, 24-h gastroesophageal pH-metry, and assessment of patient quality of life based on the gastrointestinal quality of life index (GIQLI). RESULTS: The number of postsurgical reflux episodes was reduced significantly, both at 6 months and at 4 or more years after surgery. The number of episodes dropped from 183 before surgery to 58 at 6 months after surgery and remained constant ≥ 4 years later. Surgery also produced a significant drop in reflux time, seen both 6 months and ≥ 4 years later. Six months after surgery, the median reflux time had fallen from 134 min (preoperatively) to 27 min, and at ≥ 4 years it was still significantly reduced at 35 min. Sphincter length (median preoperative length, 3 cm; median postoperative length (at 6 months and at ≥ 4 years), 4 cm) and sphincter pressure (median preoperative pressure, 3 mmHg; median at 6 months, 12 mmHg; median at ≥ 4 years, 10.9 mmHg) were significantly improved by surgery as well. Finally, surgery produced an improvement in quality of life. The median preoperative GIQLI was 102, while at 6 months after surgery it was 113 and at ≥ 4 years after surgery it was 124. CONCLUSION: Laparoscopic fundoplication guarantees long-term improvement in symptoms and quality of life for patients suffering from gastroesophageal reflux disease. The effectiveness of reflux surgery can thus be demonstrated by long-term quality of life assessments and postoperative functional measurements. No statistically significant correlation between total score (DeMeester) and GIQLI could be demonstrated.

Single-port versus standard laparoscopic resection for a gastric benign tumor in gastroscopic-laparoscopic rendezvous procedures using a laser-supported diaphanoscopy.

In this study, the standard laparoscopic technique versus the single-port approach was evaluated for the excision of benign gastric tumors using tissue-sparing laser-supported diaphanoscopy for localization. The first group consisted of 10 patients suffering from benign gastric tumors treated by standard laparoscopic resection. The second group included 10 patients treated using the single-port technique. All procedures were successfully completed. Histopathologic examination confirmed 15 cases of gastrointestinal stromal tumor, 3 cases of lipoma, 1 case of leiomyoma, and 1 case of high-grade dysplasia. There was no statistically significant difference for the operation times between both groups. Comparison of the largest and smallest resection margins achieved using the standard laparoscopic technique and single-port techniques showed no statistically significant differences between the groups. During follow-up, all patients were evaluated using the total body image and cosmesis questionnaire. Although scores of all body-image functions were similar, independent of laparoscopic technique, scores of all cosmetic functions in patients operated using the single-port technique showed a statistically significant higher degree of satisfaction with the scar (P<0185). The postoperative pain scores evaluated by the visual analog scale score were not significantly different between 2 groups. The single-port technique was found to be a feasible option for the resection of submucosal or mucosal tumors. However, this method is not intended to replace standard laparoscopic resections.

The role of the vagus nerve: modulation of the inflammatory reaction in murine polymicrobial sepsis.

The particular importance of the vagus nerve for the pathophysiology of peritonitis becomes more and more apparent. In this work we provide evidence for the vagal modulation of inflammation in the murine model of colon ascendens stent peritonitis (CASP). Vagotomy significantly increases mortality in polymicrobial sepsis. This effect is not accounted for by the dilatation of gastric volume following vagotomy. As the stimulation of cholinergic receptors by nicotine has no therapeutic effect, the lack of nicotine is also not the reason for the reduced survival rate. In fact, increased septic mortality is a consequence of the absent modulating influence of the vagus nerve on the immune system: we detected significantly elevated serum corticosterone levels in vagotomised mice 24 h following CASP and a decreased ex vivo TNF-alpha secretion of Kupffer cells upon stimulation with LPS. In conclusion, the vagus nerve has a modulating influence in polymicrobial sepsis by attenuating the immune dysregulation.

Rare case of a large mediastinal cyst involved in Hodgkin's lymphoma.

We report a case of a mediastinal cystic retrosternal process, discovered by magnetic resonance imaging (MRI) in a 19-year-old male patient, with unusual inhomogenous signals in both T1- and T2-weighted images and contrast-enhancing septation. Macroscopically, the tumor weighed 1330 g, and was constituted by one dominating cyst measuring 14 cm in diameter. Additional small cysts were seen microscopically. The cystic wall was continuously infiltrated by nodular sclerosing Hodgkin's lymphoma, also affecting adjacent lymph-nodes. Age and sex of the patient and the diagnosed subtype of Hodgkin's lymphoma are in line with previously reported rare cases of mediastinal cysts with Hodgkin's lymphoma. The cyst reported here, most likely a secondary thymic cyst, is larger than those reported before. The main reason for the development of these cysts might be the accompanying inflammation of the lymphoma. Little is known about the imaging features of mediastinal cysts caused by lymphoma. Plain thymic cysts are normally homogenous on T1- and T2-weighted images. Hodgkin's lymphoma might be homogenous on T1-weighted images and is mostly inhomogenous on T2-weighted images. In case of inhomogenous cysts with contrast-enhancing septation, one should consider the diagnosis of an associated neoplasm.

Spontaneous haemoptysis as a late complication of plombage in a tuberculosis patient.

The endemic spread of tuberculosis after World War II and the deficiency of appropriate antituberculous drugs had led to a renaissance of the surgical tuberculosis therapy until the early 1950s. Late complications of plombage performed decades before are rare and are mainly related to infection and/or migration of the inserted foreign material and are scarcely recognized today. We report on a 73-year-old male patient, who was admitted to the emergency room of our hospital with acute massive haemoptysis for four days. On physical examination the patient presented with decreased breath sounds over the left lung and an old left-sided thoracotomy scar. Radiological findings and bronchoscopy revealed an empyema and a fistula as late complications 53 years after collapse therapy with insertion of a plombage for the treatment of pulmonary tuberculosis. The endobronchial nylon threads in the left bronchial tree and the fistula ending in the left lower bronchus confirmed our diagnosis. The patient was successfully treated by resection of the affected lower lobe. The present casuistic demonstrates a rare cause of spontaneous haemoptysis: late complications after extrapleural pneumolysis and plombage for cavitary tuberculosis over 50 years after the initial operation.

Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts.

OBJECTIVE: The purpose of this article is to compare the technical success and guidance of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated and dilated bile duct systems using different techniques to supplement the conventional approach. MATERIALS AND METHODS: Between 2006 and 2008, 71 patients (mean age, 66.6 years) underwent PTBD with 97 interventions. According to sonographic evaluation of bile duct morphology, patients were divided into two groups: 50 patients with dilated and 21 patients with nondilated bile ducts. In a retrospective analysis, both groups were compared for technical success, fluoroscopy time, complications, and medical indications. The use of interventional guidance (deviations from the standard protocol) in patients with nondilated bile ducts was recorded. RESULTS: The technical success rate was 90% in patients with dilated bile ducts versus 81% in patients with nondilated ducts, with no significant difference (p = 0.36). The greater complexity of the intervention in patients with nondilated bile ducts resulted in longer fluoroscopy times (p = 0.04). Complication rates were not different between the two groups. The main indication for PTBD was relief of a compressed biliary system in patients with dilated ducts and postoperative management of complications or prevention of tumor-associated bile duct obstruction in patients with nondilated ducts. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage were performed in 16 of 21 interventions for patients with nondilated bile ducts, resulting in a 100% success rate, versus a success rate of 60% in the five PTBDs of nondilated ducts performed in the conventional manner. CONCLUSION: T-drainage, additional CT-guided puncture, and temporary gallbladder drainage improve the technical success of PTBD when used in patients with nondilated bile ducts. With these measures, technical success and complication rates in patients with nondilated ducts are comparable to those for PTBD of dilated bile ducts.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) improves the innate immune response and enhances survival in murine polymicrobial sepsis.

OBJECTIVE: To investigate the role of tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) in postoperative polymicrobial abdominal sepsis.Sepsis is the leading cause of death among critically ill surgical patients. TRAIL is commonly known as an apoptosis-inducing agent in cancer cells. It also plays an important role in the regulation of inflammatory reactions. The role of TRAIL in polymicrobial sepsis is still unclear. DESIGN: Experimental animal model. SETTING: University laboratory. SUBJECTS: C57BL/6 mice. INTERVENTIONS: Colon ascendens stent peritonitis (CASP) was induced in female mice. One hour, 24 hrs, and 48 hrs after induction of CASP, murine recombinant TRAIL was given intravenously. MEASUREMENTS AND MAIN RESULTS: This study demonstrates a protective effect of TRAIL in CASP, an experimental model of murine polymicrobial sepsis. Intravenous administration of recombinant TRAIL to mice after CASP induction led to highly significantly prolonged survival. The migration of effector cells into the peritoneal cavity was strongly enhanced. Consequently, TRAIL-treated mice eliminated bacteria significantly better from the peritoneal cavity, the source of infection. Systemic spread of gut bacteria was also reduced by several orders of magnitude. As a result of the reduced systemic spread of bacteria, the accumulation of neutrophils within the spleen and mesenteric lymph nodes was strongly decreased. CONCLUSION: TRAIL-treated mice are highly protected from abdominal sepsis. Because diagnosis and therapy are frequently delayed in human sepsis, it is remarkable that TRAIL is effective when given via a therapeutic approach. Therefore, this study suggests a therapeutic potential for TRAIL in human sepsis. This should be addressed in future trials.

Colon ascendens stent peritonitis (CASP)--a standardized model for polymicrobial abdominal sepsis.

Sepsis remains a persistent problem on intensive care units all over the world. Understanding the complex mechanisms of sepsis is the precondition for establishing new therapeutic approaches in this field. Therefore, animal models are required that are able to closely mimic the human disease and also sufficiently deal with scientific questions. The Colon Ascendens Stent Peritonitis (CASP) is a highly standardized model for polymicrobial abdominal sepsis in rodents. In this model, a small stent is surgically inserted into the ascending colon of mice or rats leading to a continuous leakage of intestinal bacteria into the peritoneal cavity. The procedure results in peritonitis, systemic bacteraemia, organ infection by gut bacteria, and systemic but also local release of several pro- and anti-inflammatory cytokines. The lethality of CASP can be controlled by the diameter of the inserted stent. A variant of this model, the so-called CASP with intervention (CASPI), raises opportunity to remove the septic focus by a second operation according to common procedures in clinical practice. CASP is an easily learnable and highly reproducible model that closely mimics the clinical course of abdominal sepsis. It leads way to study on questions in several scientific fields e.g. immunology, infectiology, or surgery.