Persistence of de novo donor specific HLA-Antibodies after lung transplantation: a potential marker of decreased patient survival.

The impact of de novo donor-specific anti-HLA antibodies (DSA) on outcomes in lung transplantation is still a matter of debate. We hypothesize that differentiating DSA by persistent and transient appearance may offer an additional risk assessment. The clinical relevance of HLA-antibodies was investigated prospectively in 72 recipients with a median follow-up period of 21 months. The presence of HLA-antibodies was analysed by single antigen bead assay prior to and after (3 weeks, 3, 6, 12 and 18 months) transplantation. In 23 patients (32%) de novo DSA were detected. In 10 of these patients (44%) DSA persisted throughout the follow-up period whereas 13 of these patients (56%) had transient DSA. There was a trend towards lower one-year-survival in DSA positive compared to DSA negative patients (83% versus 94%; p=0.199). Remarkably, patients with persistent DSA had significantly reduced survival (one-year survival 60%) compared with both patients without DSA and those with transient DSA (p=0.005). Persistent DSA represented an independent prognostic factor for reduced overall survival in multivariate analysis (HR 8.3, 95% CI 1.8-37.0; p=0.006). Persistence of DSA during the first year after transplantation seems to be more harmful for lung allograft function than transiently detected DSA at an early stage. This article is protected by copyright. All rights reserved.

Bronchiolitis obliterans syndrome due to donor-specific HLA-antibodies.

Chronic lung allograft dysfunction (CLAD) is a limiting factor for long-term survival in lung transplant recipients. Donor-specific human leukocyte antigen (HLA)-antibodies (DSA) have been suggested as potential risk factors for CLAD. However, their impact on clinical outcome following lung transplantation remains controversial. We performed a single-center study of 120 lung transplant recipients transplanted between 2006 and 2011. Patient sera were investigated before and after transplantation. The sera were screened by means of Luminex(®) technology (Luminex Inc., Austin, TX, USA) for IgG-HLA-class I and class II antibodies (ab). Using single antigen beads, DSA were identified and correlated retrospectively with clinical parameters. After transplantation 39 out of 120 patients (32.5%) were positive for HLA-ab. The incidence of de novo DSA formation was 27 of 120 patients (22.5%). Eleven of 27 (41%) of de novo DSA-positive patients developed BOS compared to 13 of 93 (14%) DSA-negative patients (p = 0.002). Furthermore, the generation of de novo DSA was independently associated with the development of BOS in multivariable analysis [hazard ration (HR) 2.5, 95% confidence interval (CI) 1.0-6.08; p = 0.046). Our results indicate that de novo DSA are associated with the development of BOS after lung transplantation. Monitoring of HLA-ab after transplantation is useful for identifying high-risk patients and offers an opportunity for early therapeutic intervention.

[New Applications and Indications for Contrast-Enhanced Sonography in Endovascular Aortic Repair]. / Neue Applikationen und Indikationen der Kontrastmittelsonografie im Rahmen des Aortenstentings.

After edovascular repair of infrarenal aortic aneurysms (EVAR) endoleaks may occur necessitating further therapy. Therefore a reliable method for follow-up imaging after EVAR for detection and control of endoleaks is of high importance. Contrast-enhanced sonography (CEUS) does not require the application of nephrotoxid contrast media and does not stress the patient. CEUS is increasingly used and enables a quick, non-invasive follow-up examination for patient after EVAR. In addition, interventions as therapy for endoleaks may be executed using ultrasound. Initial experience with CEUS-guided aortic stenting shows that the amount of contrast media as well as X-ray time may be reduced.

Value of high-resolution contrast-enhanced ultrasound in detection and characterisation of endoleaks after EVAR.

PURPOSE: To compare the value of high-resolution contrast-enhanced ultrasound in the detection and characterisation of endoleaks after EVAR. MATERIAL AND METHODS: In this retrospective study, a cohort of 80 patients underwent both standard examination using a curved array 5 MHz transducer and a second examination using a curved array 9 MHz transducer. The examination included B-mode, color Doppler and contrast-enhanced ultrasound using the Philips EPIQ 7 scanner. RESULTS: 80 patients were included in the study. CEUS was used as the preferred examination in determining the presence of an endoleak. The sensitivity and specificity for the detection of endoleak using the 5 MHz transducer was: CEUS (96.8%, 100%), Color Doppler (47.6%, 94.1%), B-mode (15.8%, 94.1%), while for the 9 MHz transducer: CEUS (100%, 100%), Color Doppler (39.7%, 94.1%), B-mode (23.8%, 24.1%). CONCLUSION: High resolution ultrasound (9 MHz) in detection and characterization of endoleaks after EVAR has some minor advantages in comparison to lower resolution ultrasound (5 MHz).

Resection of pulmonary metastases from colon and rectal cancer: factors to predict survival differ regarding to the origin of the primary tumor.

BACKGROUND: The purpose of the present study was to determine differences in prognostic factors for survival of patients with pulmonary metastases resected in curative intent from colon or rectum cancer. METHODS: Between 1980 and 2006, prognostic factors after resection of pulmonary metastases in 171 patients with primary rectum or colon tumor were evaluated. Survival of patients after surgical metastasectomy was compared with that of patients receiving standard chemotherapy by matched-pair analysis. RESULTS: Median survival after pulmonary resection was 35.2 months (confidence interval 27.3-43.2). One-, 3-, and 5-year survival for patients following R0 resection was 88.8, 52.1, and 32.9 % respectively. Complete metastasectomy (R0), UICC stage of the primary tumor, pleural infiltration, and hilar or mediastinal lymph node metastases are independent prognostic factors for survival. Matched-pair analysis confirmed that pulmonary metastasectomy significantly improved survival. Although no difference in survival for patients with pulmonary metastases from lower rectal compared to upper rectal or colon cancer was observed, factors to predict survival are different for patients with lower and middle rectal cancer (R0, mediastinal and/or hilar lymph nodes, gender, UICC stage) compared with patients with upper rectal or colon cancer (R0, number of metastases). CONCLUSIONS: Our results indicate that distinct prognostic factors exist for patients with pulmonary metastases from lower rectal compared with upper rectal or colon cancer. This supports the notion that colorectal cancer should not be considered as a single-tumor entity. Metastasectomy, especially after complete resection resulted in a dramatic improvement of survival compared with patients treated with chemotherapy alone.

[Computed tomography angiography as the basis for optimized therapy planning before endovascular aneurysm repair (EVAR)]. / CT-Angiographie als Grundlage der optimierten Therapieplanung vor endovaskulärer Aneurysmaausschaltung (EVAR).

Computed tomography angiography (CTA) of the aorta is an accepted standard diagnostic procedure for preoperative evaluation and planning of endovascular treatment of abdominal aortic aneurysms (endovascular aortic repair EVAR). The CTA method delivers all relevant anatomical and morphological information on the underlying pathology of the aorta and pelvic axes. Various software solutions are available for multiplanar reconstruction of the CT data for exact measurement of the access routes and landing zones and are essential components of individualized operation planning. The synthesis of all CT-based information allows a safe and exactly targeted release of the stent graft in the aorta. Furthermore, the periprocedural radiation dose can be reduced by a precise preoperative planning of the positions to be irradiated during implantation.

Classification of endoleaks in the follow-up after EVAR using the time-to-peak of the contrast agent in CEUS examinations.

PURPOSE: To evaluate the feasibility of the classification of endoleaks following endovascular aortic aneurysm repair using the time-to-peak of the contrast agent in CEUS examinations. MATERIAL AND METHODS: In this retrospective study, a cohort of 171 patients with a total of 489 CEUS follow-up examinations after EVAR were included. In 254 of the 489 examinations, an endoleak was seen and the time-to-peak was measured in seconds. Existence of an endoleak was confirmed by CT as the gold standard. RESULTS: We evaluated 254 CEUS video sequences showing an endoleak out of a total of 489 examinations. Kruskal-Wallis test revealed with p = 0.001 differences between the single endoleak types based on the time to peak. Correction after Bonferroni showed significant differences between type Ia compared to Ib and to IIa over inferior mesenteric artery (IMA) and IIa over lumbar artery (LA). There are also disparities between type Ib and type IIa IMA and type III, furthermore between type IIa IMA compared to IIa LA and type III as well as type IIa LA matched to type III. CONCLUSION: CEUS is an important method for the follow-up after EVAR. The time-to-peak does not seem to be a useful additional feature in classifying endoleaks, although there are differences between the time-to-peak of the single endoleak types and it is possible to make an order of the different endoleak types referring to the mean values.

[Emergencies in vascular surgery--a major challenge for the local infrastructure]. / Gefäßchirurgische Notfälle--eine große Herausforderung an die lokale Infrastruktur.

INTRODUCTION: Emergencies in vascular surgery are often life-threatening and require a timely and prompt treatment. Little information is available in the literature about which demands must be made for this on the personnel and infrastructural resources of a hospital. METHODS: All vascular surgical emergency operations of the Surgical University Hospital of Munich - Grosshadern over a period of 2 years were evaluated concerning the emergency category, the leading clinical symptomatology, the genesis, the affected stream area, the intervention time, as well as the need for postoperative intensive medical care. RESULTS: The prevailing procedures were arterial operations (76 %). Ischaemia with 37 % and bleeding with 29 % were the leading clinical symptomatology. Thrombotic events (34 %) showed the most frequent genesis followed by embolism (13 %), stenosis (11 %), aneurysms (10 %) and iatrogenic impairments (10 %). 68 % of the emergencies were treated outside of the daytime working hours. A total of 77 % of the patients needed intensive care treatment or observation after surgery. CONCLUSION: The spectrum and the frequency of emergencies in vascular surgery make high demands on local infrastructure of the hospital and require a fair number of intensive care beds and an adequate and highly trained staff. Only under these conditions can a high quality of treatment be guaranteed for the sometimes life-threatened patients.

Improving the follow up after EVAR by using ultrasound image fusion of CEUS and MS-CT.

PURPOSE: To evaluate whether the image fusion with contrast enhanced ultrasound (CEUS) and CT affects the diagnosis of endoleaks in unclear cases. METHODS AND MATERIALS: 35 patients with follow-up examinations after endovascular aneurysm repair (EVAR) were included in this retrospective study. Mean patient age was 73 years (range 54-83 y). B-scan, colour doppler and CEUS (1.2 ml SonoVue®, Bracco Imaging Germany) were performed in all patients by an experienced examiner using two different high-end ultrasound system (Siemens ACUSON S2000™, Siemens Healthcare, Erlangen, Germany or Logic E9, GE Healthcare, Milwaukee,WI, USA) with a multifrequency curved array transducer. The examiner was initially blinded to the CT results. Additional image fusion with CT-angiography (CTA) was then performed. The ultrasound examinations were later read by two blinded unbiased investigators with more than five years of clinical ultrasound in consensus. RESULTS: All patients were examined using all diagnostic ultrasound tools of the study. The results show that image fusion is easy and convenient to perform. Conventional ultrasound examination with B-scan and colour Doppler examination detected one Type I and one Type II endoleak, contrast enhanced ultrasound detected one Type I and three Type II endoleaks after EVAR whereas CTA depicted one Type I and two Type II endoleaks. Ultrasound image fusion with CT-angiography confirmed one Type I and three Type II endoleaks. CONCLUSION: In comparison to conventional ultrasound and CTA the use of CEUS improved the visualization and classification of endoleaks. CEUS shows even small blood flow which can be depicted due to the real time imaging of endoleaks. In unclear cases additional ultrasound image fusion with CEUS and CT angiography improves the visualisation of small endoleaks and this may cause a change in the follow-up interval. CEUS is a good alternative to CT in the detection and follow-up of endoleaks, especially in patients with contraindications to CT contrast agents due to allergies or renal failure, enabling reduced additional costs and exposure to radiation.

[Impact of systematic lymph node dissection in the resection of pulmonary metastases of solid extrapulmonary tumours]. / Bedeutung der systematischen Lymphknotendissektion im Rahmen der Resektion pulmonaler Metastasen solider extrapulmonaler Tumoren.

BACKGROUND: The systematic mediastinal and hilar lymph node dissection for the treatment of pulmonary metastases has, until now, not attracted much attention. A possible advantage of systematic lymph node dissection is an improved staging and a better locoregional tumour control due to resection of tumour micrometastases and the disintegration of lymphatic vessels. Aim of the study was to investigate the impact of mediastinal and hilar lymphnode metastases on the prognosis of the patient. METHODS AND RESULTS: Between 1978 and 2006, 249  patients underwent resection of pulmonary metastases from renal cell (91), colorectal (89), breast (45) and head and neck cancer (24), in combination with a systematic mediastinal and hilar lymphnode dissection. Survival was analysed by the Kaplan-Meier method. Multivariate analysis was performed using Cox regression analysis. Lymph node metastases were histologically demonstrated in 25.3 % of all patients. They did not correlate with the tumour grading and lymph node status of the primary tumour or the number of pulmonary metastases. Patients with lymph node metastases had a significantly shorter median survival than patients without (18 vs. 53  months, p < 0.001). Patients who underwent a systematic mediastinal and hilar lymph node dissection showed a trend to a prolonged survival (39.1 vs. 31.9  months, p = 0.089). CONCLUSION: Mediastinal and hilar lymph node metastases are significantly correlated with decreased survival. Systematic mediastinal and hilar lymphadenectomy provides valuable information for the staging and prognosis of patients with pulmonary metastases of kidney, head and neck, breast and colorectal cancers and may help to distinguish those patients who might profit from a more aggressive surgical therapy or an adjuvant therapy.

[Imaging of endoleaks after endovascular aneurysm repair (EVAR) with contrast-enhanced ultrasound (CEUS)]. / Kontrastmittelverstärkter Ultraschall im Follow-up nach endovaskulärer Stentversorgung eines infrarenalen Bauchaortenaneurysmas.

Endoleaks following endovascular aneurysm repair (EVAR) are common and present a diagnostic challenge in the follow-up after EVAR. Contrast-enhanced ultrasound (CEUS) is a promising new method for the diagnosis and follow-up of endoleaks. CEUS with SonoVue allows a rapid and non-invasive diagnosis in the follow-up after EVAR. The sensitivity and specificity of conventional ultrasound compared to the multislice CT angiography is estimated to be 33-63% and 63-93%, respectively. These values can be increased through the use of CEUS in up to 98-100% (sensitivity) and 82-93% (specificity). This article describes the etiology, classification and importance of different types of endoleaks. The value of CEUS in this clinical scenario will be discussed.

The time of diagnosis impacts surgical management but not the outcome of patients with gallbladder carcinoma.

BACKGROUND: Only 50% of gallbladder cancers (GBC) are recognized before operation and the remaining tumors are diagnosed during surgery or afterwards by the pathologist. These situations may demand substantial modifications of the proceeding during surgery as well as the need for reoperation in some cases. Therefore, the time of diagnosis may strongly influence the surgical management of GBC and the prognosis of the patients. METHODS: Records and follow- up of 152 patients with gallbladder carcinoma who underwent surgery between 1980 and 2004 were examined according to the time of diagnosis, TNM staging system, surgical procedures, morbidity and predictors of survival. There were 76 patients with preoperative diagnosis of GBC (50%; group1), 44 patients with intraoperative diagnosis (29%; group 2) and 32 patients (21%; group 3) with postoperatively incidental finding of GBC. In all cases radical resection of the GBC was intended, except in 5 patients from group 1. Surgical procedures comprised from simple cholecystectomy to multivisceral resections. RESULTS: Overall 5-year survival rate was 7% with a significantly better median survival in group 3 (53.2 month), when compared to only 6.1 month (group 2) and 5.4 month (group 1), respectively. Findings at operation forced significant modifications of the surgical strategy in 85%. Complete resection of GBC was achieved in 38% of the patients. Stage- dependent survival was comparable between the groups following R0 resection. Tumor stage, in particular the nodal status and radicality of the procedure, but not the time of diagnosis were the most powerful predictors of outcome. CONCLUSIONS: Complete tumor resection may provide long-term survival even in locally advanced GBC. Although the time of diagnosis of GBC causes significant changes of the intended procedures during and after surgery, it has no influence on the prognosis provided that radical (R0) resection was accomplished.

Surgical management of splenic echinococcal disease.

BACKGROUND: Infection of the spleen with echinococcus is a rare clinical entity. Because the diagnosis of a splenic infestation with echinococcus is sometimes delayed, large hydatid cysts or pseudotumors may develop, demanding a differential surgical approach to cure the disease. METHODS: In a retrospective study 10 patients out of 250 with abdominal echinococcosis (4%) were identified to have splenic infestation, either limited to the spleen (n=4) or with synchronous involvement of the liver (n=4), major omentum (n=1), or the liver and lung (n=1). Only one patient had alveolar echinococcosis whereas the others showed hydatid cysts of the spleen. Surgical therapy included splenectomy in 7 patients or partial cyst excision combined with omentoplasty in 3 patients. In case of liver involvement, pericystectomy was carried out simultaneously. RESULTS: There was no mortality. Postoperative complications were observed in 4 patients. Hospital stay and morbidity were not influenced when splenic procedures were combined with pericystectomies of the liver. Mean follow-up was 8.8 years and all of the patients are free of recurrence at this time. CONCLUSIONS: Splenectomy should be the preferred treatment of hydatid cysts but partial cystectomy is suitable when the cysts are located at the margins of the spleen. Due to low morbidity rates, simultaneous treatment of splenic and liver hydatid cysts is recommended.

Imaging of endoleaks after endovascular aneurysm repair (EVAR) with contrast-enhanced ultrasound (CEUS). A pictorial comparison with CTA.

Endoleaks following endovascular aneurysm repair (EVAR) are common and present a diagnostic challenge in the follow-up after EVAR. Contrast-enhanced ultrasound (CEUS) with low mechanical index (low MI) is a promising new method for the diagnosis and follow-up of endoleaks. CEUS with SonoVue allows a more rapid and noninvasive diagnosis, especially in critical patients owing to its bedside availability. This review describes the etiology, classification and importance of different types of endoleaks and compares CEUS findings with computed tomography angiography (CTA), allowing the reader to appreciate the usefulness of CEUS in this clinical situation.

[Acute pancreatitis: is there a need for surgery?]. / Akute Pankreatitis: Wann ist der Chirurg gefragt?

The treatment of acute pancreatitis is primarily non-surgical. An interdisciplinary approach as well as timely and aggressive intensive care has led to a significant improvement of the prognosis in severe necrotising pancreatitis. Early surgical procedures were associated with high morbidity and mortality and therefore were abandoned and replaced with forceful conservative treatment. However, there are still specific indications for surgery during the course of acute pancreatitis. These include cholecystectomy for biliary pancreatitis, surgical debridement of infected necrosis in septic patients and emergency operations for gastrointestinal perforations or haemorrhage. The following article focuses on surgical indications, optimal timing of surgery and competing surgical and non-surgical concepts like laparoscopic or endoscopic management. All mentioned procedures demand the cooperation of an experienced team of gastroenterologists, surgeons, radiologists and intensive care specialists, who are able to manage the potentially life-threatening complications of this disease. All patients with severe necrotising pancreatitis should be transferred to a specialised centre for interdisciplinary therapy.

Color duplex ultrasound and contrast-enhanced ultrasound in comparison to MS-CT in the detection of endoleak following endovascular aneurysm repair.

The purpose of this study was to compare Color Duplex Ultrasound (CDU), Contrast-Enhanced Ultrasound (CEUS) and Multislice Computed Tomography (MS-CT) angiography in the routine follow up of patients following Endovascular Repair (EVAR) of Abdominal Aortic Aneurysm (AAA).43 consecutive patients with AAA underwent endovascular aneurysm repair and were imaged with CDU, CEUS and MS-CT angiography at regular intervals after the procedure. Each imaging modality was evaluated for the detection of endoleaks. The presence of endoleaks was analyzed and the conspicuity of findings was assessed.CTA was used as gold standard in determining the presence of endoleaks. CDU was true positive for endoleaks in 5/43 patients (11.6%) and false positive for endoleaks in 2/43 patients (4.6%). The sensitivity of CDU was therefore 33.3% and its specificity 92.8%; the positive and negative predictive values were 0.71 and 0.72, respectively. CEUS was true positive for the detection of endoleaks in 15/43 patients (34.9%) and false positive in 2/43 patients (4.6%). The sensitivity of CEUS was therefore 100% and its specificity 93%; the positive and negative predictive values were 0.88 and 1. In the follow up the two false positive endoleaks in CEUS were confirmed as true positive endoleaks by CEUS and MS-CT. In our small patient group, contrast-enhanced ultrasound seemed to be more accurately in demonstrating endoleaks after EVAR than MS-CT angiography and may be considered as a primary surveillance modality whereas duplex ultrasound scanning alone is not as sensitive as CEUS and MS-CT angiography in detection of endoleaks. Especially in patients with contraindications for CT contrast agents (e.g. due to renal failure or severe allergy) CEUS provides a good alternative to MS-CT.

[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]. / Traumatische thorakale Aortenruptur: Präklinische Beurteilung, Diagnostik und Therapieoptionen.

Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.

[Hybrid operation for a distal aortic arch aneurysm causing left recurrent nerve palsy - Ortner's syndrome]. / Hybridoperation zur Behandlung eines distalen Aortenbogenaneurysmas mit linksseitiger Recurrensparese - Ortner-Syndrom.

BACKGROUND: A left recurrent nerve palsy caused by left atrium hypertrophy, dilatation of the left pulmonary artery or a thoracic aortic arch aneurysma is named Ortner's syndrome. CASE REPORT: We report the case of a 84-year old male patient with a posttraumatic aneurysm of the distal aortic arch known for 20 years, which became symptomatic by new presentation of an acute hoarseness caused by a left sided recurrent nerve palsy due to rapid aneurysma expansion. Because of the aneurysma localization, the advanced age and the patient?s morbidity he was treated by a hybrid procedure with an extrathoracic reconstruction of the supraaortic arteries by a right to left carotid-carotid bypass and transposition of the left subclavian artery followed by endovascular implantation of aortic stent grafts for aneurysma exclusion. The left recurrent nerve palsy remained unchanged until now. CONCLUSIONS: Aneursms of the distal aortic have to be considered as a rare cause of a left-sided recurrent nerve palsy. Recent advances in endovascular therapy combined with supraaotic vascular reconstruction offers a less invasive therapeutic option for some of these patients.