[Catheter ablation of ventricular tachycardia in patients with structural heart disease]. / Katheterablation von Kammertachykardien bei Patienten mit struktureller Herzerkrankung.

Ventricular cardiac rhythm disorders are potentially life-threatening arrhythmias. Ventricular tachycardia (VT) in patients with structural heart disease carries an increased risk of sudden cardiac death. Interventional radiofrequency catheter ablation is increasingly becoming the focus of treatment for ventricular arrhythmias. So far, no randomized study has been able to demonstrate a reduction in mortality; however, depending on the existing cardiomyopathy, interventional VT ablation has proven to be more effective for rhythm stabilization than antiarrhythmic therapy and is subsequently associated with improve quality of life through reduced implantable cardioverter defibrillator (ICD) treatment. The aim of this work is to discuss the pathophysiology, mechanism and treatment of VT with structural heart disease in order to define the role of catheter ablation.

[Pulmonary vein isolation in atrial fibrillation using pulsed field ablation]. / Pulmonalvenenisolation bei Vorhofflimmern mittels "pulsed field ablation".

Atrial fibrillation is the most common supraventricular arrhythmia with increasing incidence and prevalence. Until now, thermal energy sources such as radiofrequency or cryoablation have been used for pulmonary vein isolation of atrial fibrillation but these have led to indiscriminate tissue destruction in the target area. Pulsed field ablation (PFA) is an energy modality that does not utilize thermal effects. An ultrarapid electric field produces irreversible changes in cell membrane pores (irreversible electroporation) culminating in cell death. The myocardium is very sensitive to PFA compared to the esophagus, the pulmonary veins or the phrenic nerve. Consequently, it is possible to perform effective ablation of the pulmonary veins in a very short time and to make the treatment time more effective without causing relevant collateral damage. The treatment offers a potential paradigm shift from catheter ablation of cardiac arrhythmia.

[Differential diagnostics of unclear syncope]. / Differenzialdiagnostik unklarer Synkopen.

The clarification of syncope is a diagnostic challenge as possible causes often occur only intermittently. Therefore, a detailed and standardized anamnesis is essential as it 1) differentiates syncope from other transient losses of consciousness (TLOC) and 2) directly clarifies possible causes of syncope. The risk stratification plays a central and very important role in order to avoid unnecessary examinations in patients with benign syncope and to provide patients with life-threatening, mostly cardiac syncopal episodes with timely diagnostics and treatment. In cases where the cause of syncope is still unclear, a standardized approach is indicated using extended diagnostics, such as a tilt table examination, a carotid sinus pressure test, prolonged telemetric monitoring or clarification with an implantable loop recorder (ILR).

[Radio-guided parathyroidectomy: successful intraoperative parathyroid localization diagnosis with 99mTc-sestamibi in primary and recurrent hyperparathyroidism]. / Radio-guided Parathyreoidektomie: Erfolgreiche intraoperative Lokalisationsdiagnostik bei primärem und rezidivierendem Hyperparathyreoidismus mit 99mTc-MIBI.

INTRODUCTION: In addition to ultrasonography, CT scan, MRI and venous sampling, 99mTc-MIBI scintigraphy has gained increasing acceptance in preoperative localization of abnormal parathyroid tissue. The sensitivity of this radionuclide method is 87% in primary (p), 58% in secondary (s), and 75% in recurrent hyperparathyroidism (HPT). This study evaluated the use of intraoperative nuclear mapping in patients with HPT. METHODS: Retrospective analysis was performed in 24 patients with HPT (18 p, 4 s, 2 recurrent) undergoing a technetium-sestamibi-guided neck exploration during an 18-months period. Abnormal parathyroid tissue was localized using an intraoperative gamma probe detector 2 h after application of 700 MBq 99mTc-sestamibi and verified by pathology. RESULTS: Intraoperative nuclear mapping identified 15 of 18 adenomas in patients with pHPT. The target-to-background ratio was 1.3 to 4.1 in these patients compared to 1.0 to 1.2 in undetected adenomas. In 67% of these patients we performed a minimally invasive open parathyroidectomy. In two cases of recurrent HPT the scan-guided detection of ectopic parathyroid tissue was efficient. In contrast, the method was less helpful in four patients with multiglandular disease. CONCLUSION: The intraoperative use of a gamma probe detector is highly effective in identifying parathyroid adenomas in pHPT and recurrent HPT and supports minimally invasive techniques.

Extensive sterile abscess in an invasive fibrous thyroiditis (Riedel's thyroiditis) caused by an occlusive vasculitis.

Riedel's thyroiditis is a rare disease determined by an invasive fibrosclerotic transformation of the thyroid gland. It may be one manifestation of multifocal fibrosis with still unknown etiology. Because it mimics carcinoma, a biopsy must be performed to get the correct diagnosis. The condition is self-limiting when confined to the neck. Prognosis depends on the extent of extracervical fibrosclerosis. We present a patient with a huge cervical and mediastinal, unilateral thyroid mass expanding to the aortic curve, which led to tracheal deviation and compression with symptoms of stridor and dyspnea. These symptoms continued under a course of high-dose steroids; thus an operation was necessary to relieve the airway obstruction and limit inflammation. Intraoperative and pathological findings showed an inflammatory infiltration of the adjacent neck muscles and a sterile abscess caused by an occlusive vasculitis. Therefore, hemithyroidectomy had to be performed instead of a local limited resection.

[Dislocation of clips of the cystic duct stump]. / Dislokation von Clips am Cystikusstumpf.

The security of six different laparoscopic clips was investigated using 60 kryopreserved specimens of human cystic ducts. After fixation of the cystic duct the cross placed clips were distracted in axial direction and the maximum forces to remove the clip were registered. The mean dislocation-force was 4.6 Newton for titanium clips and 9.3 Newton for absorbable clips with a highly significant difference (p < 0.001, Wilcoxon-test). Additional to the advantage of complete biodegradibility these data favour the use of absorbable clips, because of a better hold force compared to titannium clips.

[Laparoscopically placed clips on the human cystic duct--an experimental comparison of dislocation between resorbable and titanium clips]. / Laparoskopisch applizierte Clips am humanen Ductus cysticus--Ein experimenteller Dislokationsvergleich zwischen resorbierbaren und Titan-Clips.

Kryopreserved specimens of cystic ducts were used for displacement tests to investigate the security of different laparoscopic clips. The cystic duct was fixed, and the transverse placed clips were distracted in axial direction and the forces registered. The median values of the six investigated clips ranged between 4.1 N and 11.2 N with a highly significant difference (P < 0.001, Kruskal-Wallis ANOVA). In detail, both resorbable clips (polydioxanone, polyglyconate/polyglycol acetate) were superior to the four titanium clips (P < 0.005, Wilcoxon test). In addition to the advantage of complete biodegradibility, these data favour the use of absorbable clips because holding force is better than that of titanium clips.

Occult epithelial tumor cells detected in bone marrow by an enzyme immunoassay specific for cytokeratin 19.

The presence of isolated carcinoma cells detected immunocytochemically in bone marrow has been shown to be of prognostic relevance for cancer patients. Unfortunately, the immunocytochemical method (ICC) is laborious and depends on the subjective interpretation of the individual investigator. Therefore, an immunoassay was designed for detection of cytokeratin 19 (CK19). By analyzing blood samples from 52 healthy volunteers and 40 bone-marrow aspirates from control patients, a cut-off point of 250 pg/ml CK19 was determined. Application of this cut-off point enabled a specificity of 95% to be shown for bone marrow and of nearly 100% for venous blood. The assay detected 10 HT-29 colon-carcinoma cells among 5 x 10(6) peripheral-blood leukocytes. In comparison with controls, bone-marrow samples of cancer patients were found to have significantly elevated levels of CK19 (p < 0.05). In the analysis of 386 marrow aspirates of cancer patients, a significant concordance of ELISA and ICC was observed (chi 2 = 18.3; p < 0.001). Both procedures, nevertheless, differed in 147 (38%) samples, of which more than two thirds (101) were only ELISA-positive. The CK status detected by ELISA did not correlate with the TNM stage and the histological grading. The established immunoassay allowed sensitive and specific detection of disseminated epithelial tumor cells and appeared to be faster, less laborious and more objective than ICC. Follow-up studies are required to assess the prognostic relevance of this ELISA before it can be applied as a routine method for monitoring of minimal residual epithelial cancer.

Advantages of one-stage repair in case of gallstone ileus.

BACKGROUND/AIMS: The commonly used procedure to treat gallstone ileus is enterolithotomy in combination with late cholecystectomy for persistent symptoms. It is related to a high mortality rate up to 20%. To date it has been impossible to reduce the mortality associated with this accepted surgical technique. PATIENTS AND METHODS: A seven-year retrospective study with a follow up over a period of four years and five months. Sixteen patients with gallstone ileus were entered into the study. Twelve patients were female and fourteen were more than 70 years of age. Fourteen patients were treated by enterolithotomy as well as additional cholecystectomy and resection of the fistula in a one-stage repair. RESULTS: Mortality during hospitalization amounted to one (6%) and postoperative complications to five patients (31%). Follow-up over a period of four years and five months showed one patient had died 3 years postoperatively of an advanced renal tumor. All other patients were alive and without symptoms. CONCLUSION: Our results prove that the concomitant one-stage repair for gallstone ileus significantly reduces the overall mortality rate compared to the single enterolithotomy alone and later cholecystectomy based on patient symptoms.

[Angiosarcoma of the spleen. Case report and review of the literature]. / Angiosarkom der Milz. Fallbericht und Literaturübersicht.

Angiosarcoma of the spleen is a very rare but highly malignant vascular neoplasm. So far only 140 cases have been reported. A 42-year-old patient is presented in which the radiologic imaging misled to the diagnosis of infiltrating echinococcosis. After splenectomy histological and immunohistochemical staining gave proof of metastatic angiosarcoma. The patient died three months later as a consequence of multiple organ dysfunction syndrome. The literature is reviewed in regard to clinical features, diagnosis and therapy.

A blended beam technique to decrease toxic effects of post mastectomy irradiation by combining and sequentially mixing electrons and photons.

We studied 24 patients with Stage II or Stage III breast carcinoma, post total mastectomy, who had received adjuvant loco-regional irradiation (16 patients) or were irradiated for chest wall recurrence (8 patients), along with systemic chemotherapy and/or hormonotherapy. A technique is described for combining and sequentially mixing electron and photon beams. This blended beam method results in less severe acute and chronic skin reactions. Dose distribution to the chest wall and mediastinum are improved compared to the traditional photon-only techniques. At a median followup of four years our expected loco-regional control rates are not compromised. This technique is recommended for selected post mastectomy patients to reduce toxic effects of chest wall irradiation, particularly when chemotherapy lowers skin tolerance and the reserves of the heart, lung and bone marrow.

[Simplified combination bypass or biliodigestive anastomosis alone in nonresectable carcinoma of the head of the pancreas?]. / Vereinfachter Kombinations-Bypass oder alleinige biliodigestive Anastomose bei nichtresektablem Pankreaskopfcarcinom?

Between January 1, 1986 and December 31, 1992 93 patients with irresectable carcinoma of the pancreatic head underwent surgical palliation: In group I (n = 51) a single loop biliary (BB)- and gastric bypass (GB) was performed. 34 times the gastrojejunostomy was performed prophylactically. In group II (n = 42) surgical palliation was carried out only by biliary decompression in Roux-Y technique. In 30.9% gastric outlet obstruction (GOO) developed during follow-up. Both groups were comparable according to effectiveness of biliary drainage (93% (n = 42) (I); 97% (n = 38) (II)) with median post-operative bilirubin levels of 3.21 mg/dl (I) and 4.1 mg/dl (II). Cholecysto-choledocho- and hepaticojejunostomy were equally effective. Median operative time, morbidity (19.6 (I) vs. 26.2 (II)) and postoperative hospitalization were similar. Since there is a high frequency of secondary GOO after single BB we think that GB should be performed in all patients that undergo BB because secondary gastrojejunostomy at a later stage significantly increases morbidity and mortality.

[Laparoscopic cholecystectomy with the ultrasound dissector]. / Laparoskopische Cholecystektomien mit dem Ultraschalldissektor.

Due to tissue selectivity the ultrasonic dissector facilitates anatomical clearance even in difficult situations. Although of no advantage in routine laparoscopic cholecystectomies and even more time consuming, it seems to be of considerable value in difficult laparoscopic cholecystectomies and offers more safety for the patient.

Differential expression of proliferation-associated molecules in individual micrometastatic carcinoma cells.

BACKGROUND: The development of monoclonal antibodies (MAbs) to cytokeratins, which are integral components of the epithelial cytoskeleton, has made possible immunocytochemical detection of epithelial tumor cells. Importantly, this technique allows the detection of epithelial tumor cells that have metastasized from primary adenocarcinomas to secondary sites such as the bone marrow. PURPOSE: The aim of the study was not only to detect micrometastatic cells in bone marrow, but also to assess the expression of nuclear proliferation markers (Ki-67 and p120) and the erbB2 oncogene (also known as ERBB2) in these cells and, thus, hopefully improve prognostic precision. METHODS: Bone marrow aspirates were obtained from both sides of the upper iliac crest of 532 patients having definitive diagnoses of either breast or gastrointestinal cancer. The presence of micrometastatic epithelial tumor cells in bone marrow was assayed using the MAb cytokeratin 2 (CK2) to cytokeratin component 18 (CK18), in combination with the alkaline phosphatase-anti-alkaline phosphatase immunostaining technique. After primary screening of all marrow samples with MAb CK2, representative subgroups of CK18+ samples were selected for co-labeling with MAbs either to ErbB (n = 16), ErbB2 (n = 121), Ki-67 (n = 33), or p120 (n = 36) protein. An alternative labeling protocol based on the combination of immunogold and immunoenzymatic techniques was utilized to confirm the results derived from immunoenzymatic double staining. RESULTS: In total, single CK18-positive tumor cells were detected in 180 (33.8%) of 532 bone marrow aspirates, with few differences among patients with breast or gastrointestinal cancer in TNM stage M0 (i.e., no distant metastasis). In patients with overt metastasis (stage M1), however, the incidence of metastatic cells in marrow increased to 73.7% in breast cancer, 52.5% in gastric cancer, and 39.0% in colon cancer. Whereas expression of Ki-67 or p120 on micrometastatic cells was observed only in 11 (15.9%) of 69 cancer patients analyzed, ErbB2+/CK18+ cells were found in 48 (67.6%) of 71 breast cancer patients and 14 (28.0%) of 50 patients with gastrointestinal cancer (P = .0001). The incidence of ErbB2+/CK18+ cells was positively correlated with the clinical stage of tumor progression. CONCLUSIONS: The high incidence of ErbB2 expression on micrometastatic breast cancer cells in the bone marrow suggests that these cells might have been positively selected during early stages of metastasis. The majority of these cells appear to be in a dormant state of cell growth. IMPLICATIONS: Although support from clinical follow-up is still needed, this study demonstrates that, beyond the mere presence of micrometastatic cells in bone marrow, useful prognostic information can be obtained by analysis of additional cell growth markers.

Prognostic significance of micrometastatic tumour cells in bone marrow of colorectal cancer patients.

Much of the information recorded at the time of surgery for malignant disease has been used, alone or in combination, to indicate the outlook for that patient, including probability of metastasis. However, direct evidence of tumour seeding in distant organs at that time is not available. An immunocytochemical assay for the epithelial cytokeratin protein (CK18) may fill this gap since it is a feature of epithelial cells but would not normally be in bone marrow. We looked for disseminated tumour cells preoperatively in bone marrow from 88 patients with radically resected colorectal carcinomas. Smears for 28 (32%) patients were positive for cells of epithelial origin, which were absent from aspirates taken from 102 controls with non-malignant disease. The prognostic value was assessed in a follow-up study with a median observation time of 35 (12-58) months. Patients who had bone marrow tumour cells in the aspirate showed a significantly shorter disease-free survival than those without tumour cells (p = 0.0084). In a Cox regression model multivariate analysis demonstrated that the finding of tumour cells in bone marrow is an independent, significant (p = 0.0035) determinant of relapse. Although the skeleton is not a preferred site of overt metastasis in colorectal cancer the demonstration of tumour cells in bone marrow has to be taken as evidence of the general disseminative capability of an individual tumour.