Treatment of refractory ascites with an automated low-flow ascites pump in patients with cirrhosis.

BACKGROUND: Refractory ascites (RA) is a frequent complication of cirrhosis, requiring large volume paracentesis or placement of a transjugular intrahepatic portosystemic shunt (TIPSS). The automated low-flow ascites pump (alfapump, Sequana Medical AG, Zurich, Switzerland) is an innovative treatment option for patients with RA. AIM: To assess safety and efficacy of this treatment in patients with a contraindication to TIPSS. METHODS: Fifty-six patients (43 males; mean age 62 years) from centres in Germany, Switzerland, UK and Spain were included and followed for up to 24 months. Complications, device deficiencies, paracentesis frequency and patient survival were recorded. RESULTS: At the time of this analysis, 3 patients completed the 24-month observation period, monitoring of 3 was ongoing, 9 underwent liver transplantation, 17 patients were withdrawn due to serious adverse events and 23 patients died. Most frequently observed technical complication was blocking of the peritoneal catheter. Twenty-three pump-related reinterventions (17 patients) and 12 pump exchanges (11 patients) were required during follow-up. The pump system was explanted in 48% of patients (in 17 patients due to serious adverse events, in 9 at the time of liver transplantation and in 1 due to recovery from RA). Median frequency of paracentesis dropped from 2.17 to 0.17 per month. CONCLUSIONS: The alfapump can expand therapeutic options for cirrhotic patients with RA. Continuous drainage of ascites in a closed loop automated system led to significant reduction in paracentesis frequency. Technical and procedural improvements are required to reduce the rate of adverse events and reinterventions. https://clinicaltrials.gov/ct2/show/NCT01532427.

[Career perspectives of hospital health workers after maternity and paternity leave: survey and observational study in Germany]. / Weggegangen - Platz vergangen?

OBJECTIVE: A term of maternity and paternity (parental) leave becomes frequent on the career paths of medical personnel. Hospitals are highly competitive environments. The question employees universally face is how such a leave will alter their personal work situation and prospects upon return. DESIGN AND PARTICIPANTS: We questioned 709 leave-takers and 88 department heads of a German university hospital (2009-12; full data sets: n = 406 and n = 63) about their experiences. This data was validated by epidemiology data extraction and expert interviews, also in a Swiss and in a Norwegian institution. RESULTS: Parental leave elicited high emotionality (score: 4.0 +/- 2 out of 5). Superiors' appraisal of employees' parental leave was more positive than negative (p < 0.001, mean + 0.8 +/- 0.9 on a bipolar Likert scale (BLS) from - 2 to + 2). However, the annual labor turnover in leave takers doubled to 39 %; 51 % of leave-takers experienced significant task profile changes. 58 % of doctors thought about changing their employer and 17 % of leave-taking executives lost status after return. Employees' "power" and "influence" dropped significantly (p < 0.05; determined on BLS) whereas the "professional workload" increased (p < 0.001). Consequently, after return career perspectives (measured on a bipolar visual analogue scale from - 5 to + 5) were perceived significantly more negative than positive (p < 0.0001, mean: - 1.3 +/-  2), especially by high-commitment staff (i. e. female executives, mean: - 2.1 +/- 2, pΔ < 0.05 vs. others). These perceptions significantly influenced future choices concerning further terms of leave. The Swiss and Norwegian comparators appeared to have more liberal substitution and part-time schemes than the German institution. DISCUSSION: A competitive hospital environment can effectively demote leave-taking medical employees in their jobs. Despite sufficient financial arrangements high-commitment staff will only take parental leave of adequate length when an institutional framework protects their status. Data support four requirements: 1. Formal recognition of the leave taker's status pre-leave. 2. Establishment of a written ("claimable") return policy. 3. Substitution scheme for each individual, preferably by a locum. 4. Redirection of funds to facilitate part-time work schemes temporarily after return.

Identification of 48 homologues of phosphatidylethanol in blood by LC-ESI-MS/MS.

Phosphatidylethanol (PEth) is an abnormal phospholipid carrying two fatty acid chains. It is only formed in the presence of ethanol via the action of phospholipase D (PLD). Its use as a biomarker for alcohol consumption is currently under investigation. Previous methods for the analysis of PEth included high-performance liquid chromatography (HPLC) coupled to an evaporative light scattering detector (ELSD), which is unspecific for the different homologues--improved methods are now based on time of flight mass spectrometry (TOF-MS) and tandem mass spectrometry (MS/MS). The intention of this work was to identify as many homologues of PEth as possible. A screening procedure using multiple-reaction monitoring (MRM) for the identified homologues has subsequently been established. For our investigations, autopsy blood samples collected from heavy drinkers were used. Phosphatidylpropanol 16:0/18:1 (internal standard) was added to the blood samples prior to liquid-liquid extraction using borate buffer (pH 9), 2-propanol and n-hexane. After evaporation, the samples were redissolved in the mobile phase and injected into the LC-MS/MS system. Compounds were separated on a Luna Phenyl Hexyl column (50 mm x 2 mm, 3 microm) by gradient elution, using 2 mM ammonium acetate and methanol/acetone (95/5; v/v). A total of 48 homologues of PEth could be identified by using precursor ion and enhanced product ion scans (EPI).

Selective detection of phosphatidylethanol homologues in blood as biomarkers for alcohol consumption by LC-ESI-MS/MS.

A new validated method for the quantitation of the abnormal phospholipid phosphatidylethanol (PEth)--a biomarker for ethanol uptake--has been developed by LC-ESI-MS/MS following miniaturised organic solvent extraction and reversed phase chromatography with phosphatidylbutanol (PBut) as internal standard. PEth homologues with two fatty acid substituents-PEth 18:1/18:1, PEth 16:0/16:0-were determined in post-mortem blood collected from heavy drinkers at autopsy and also in whole blood samples from a volunteer after a single 60 g-dose of ethanol. Furthermore, PEth 18:1/16:0 or its isobaric isomer PEth-16:0/18:1 was detected. In comparison to previous high-performance liquid chromatography (HPLC) methods with evaporative light scattering detection (ELSD), the LC-MS/MS-method is more sensitive--with a limit of detection below 20 ng/ml--and more selective for single PEth homologues, while ELSD has been used for detection of the sum of PEth homologues with approximately 10 times less sensitivity. LC-MS/MS enables monitoring of PEth homologues as biomarkers for harmful and prolonged alcohol consumption as with HPLC/ELSD earlier, where PEth is measurable in blood only after more than 50 g ethanol daily intake for more than 2 weeks. Because of its higher sensitivity, there is a potential to detect single heavy drinking by LC-MS/MS, when PEth is formed in very low concentrations. This opens a new field of application of PEth to uncover single or multiple heavy drinking at a lower frequency and with a larger window of detection in blood than before by HPLC/ELSD or by use of other direct markers, e.g. ethyl glucuronide or ethyl sulfate.

[Cooperation model between an university clinic and a peripheral paediatric surgical department]. / Kinderchirurgische Kooperation zwischen einer Schwerpunktklinik und einem Versorgungskrankenhaus.

INTRODUCTION: The lack of young physicians in Germany, who are willing to train in surgery, is caused by several factors. Due to the demographic development and the specialisation in paediatric surgery in university institutions, attracting trained paediatric surgeons became difficult for non-specialised rural paediatric surgical departments, which is often also complicated by economic pressures. Strategies, such as cooperation between hospitals or departments, are required. We present a mid-term analysis of the first paediatric surgical cooperation between a university clinic and a rural paediatric surgical department in Lower Saxony. METHODS: The Department of Pediatric Surgery, Hannover Medical School (MHH), is a university centre with a case load of about 1,700 surgical procedures per year with a case mix index (CMI) of 1.3. The Department of Paediatric Surgery, St. Bernward Hospital Hildesheim (BK), is a peripheral institution with about 1,200 surgical procedures per year and a CMI of 0.5. A cooperation project was inaugurated in October, 2004, between the two departments. The aim of the cooperation was to support the head of the paediatric surgical department at the BK by rotating trained paediatric surgeons from the MHH. Simultaneously, it was planned to offer attractive conditions for research at MHH for participating surgeons. The cooperation further included sufficient economic cover of 1.5 posts for rotating medical staff by the BK. RESULTS: Three trained paediatric surgeons have so far been included in the rotation programme between the two cooperating paediatric surgical departments. The rotating medical staff costs were covered by the BK. Over a period of 2.5 years, MHH surgeons performed about 50 % of all surgical procedures at BK, while undertaking two-thirds of on-call duties there. Analysis of academic research revealed 3 accomplished experimental and 4 clinical studies, as well as 10 published articles. CONCLUSIONS: The paediatric surgical cooperation was rated as a success by the rotating trained paediatric surgeons, the heads of both departments and the hospital administrations. The academic link to a university clinic also increased the attractiveness to work in a paediatric surgical department at a rural hospital.

[Results of video-assisted thoracoscopic surgery for pneumothorax]. / Ergebnisse der befundadaptierten video-thorakoskopischen Pneumothorax-Operation.

INTRODUCTION: Video-assisted thoracoscopic surgery has been used in the treatment of pneumothorax since 1990. There is still no general agreement regarding the procedure to obliterate the pleural space or regarding the indication for wedge resection if no blebs or bullae can be found. PATIENTS AND METHODS: Clinical records referring to 100 video- assisted thoracoscopic operations for pneumothorax, performed in Berlin-Buch between 1998 and 2001, were retrospectively evaluated with regard to the rate of recurrences and postoperative complications in connection with the operative procedure. There were 70 male and 28 female patients aged from 16 to 78 years. The mean age was 34 years. The statistical significance was evaluated by the McNemar-test. RESULTS: 74 patients showed a regular postoperative course. Severe postoperative complications occurred in 9 patients: re-operation via thoracotomy n=5 (postoperative bleeding n=2, recurrence n=2, persistent air-leak n =1); re-thoracoscopy n=3 (postoperative bleeding n=2, recurrence n=1), pleural empyema n=2. The complication rate was significantly higher (p < 0.001) in patients with underlying pulmonary diseases (secondary spontaneous pneumothorax) or thoracic surgery in their history. Depending on the intraoperative situation, the cause of pneumothorax and the patient's general condition the pleural space was obliterated by the following procedures: apical parietal pleurectomy (n=85), electro-pleurodesis alone (n= 7), electro-pleurodesis and pleural abrasion (n=3), talcum poudrage (n=2). The rate of major complications was lower (p < 0.001) when pleurectomy was performed 8.2 % (7/85) compared to those operations performed without pleurectomy 13.3 % (2/15). The rate of re-operations for recurrences/persistent air leaks or empyemas following persistent air leaks was significantly lower (p < 0.001) when wedge resection 3.75 % (3/80) had been performed compared with operations without wedge resection 10 % (2/20). DISCUSSION: Apical parietal pleurectomy and wedge resection of blebs or bullae are effective methods to prevent recurrences. Considering the specific complications of parietal pleurectomy alternative methods to obliterate the pleural space should be used depending on the intraoperative situation. Among other factors underlying pulmonary diseases or thoracic surgery in the patient's history strongly influence the postoperative outcome independently of the operative procedure.

Apigenin--strong cytostatic and anti-angiogenic action in vitro contrasted by lack of efficacy in vivo.

The cancer chemopreventive agent apigenin also has strong cytostatic and anti-angiogenic effects in vitro. We now investigated its efficacy against experimental Lewis lung carcinomas (LLC), C-6 gliomas and DHDK 12 colonic cancers in vivo. Tumour bearing mice received 50 mg/kg/day apigenin in three different galenical formulations during 12 days in 8-hourly intervals. Only weak effects of apigenin on the size and the number of new tumour blood vessels of both established and newly transplanted tumours were recorded although the intratumoural necrosis was elevated (45 +/- 15% vs. 20 +/- 7% (control), p < 0.05%). These results contrast sharply with the high in vitro sensitivity of LLC, C-6, DHDK 12 and endothelial cells to apigenin where complete growth suppression occurs at concentrations beyond 30 g/ml. Possible causes are discussed.

Detection of amplifiable messenger RNA in the serum of patients with lung cancer.

Recently, in addition to the detection of circulating tumor cells in peripheral blood of patients with solid tumors, the presence of free circulating nucleic acids in the plasma and serum has also been described. We have focused on the possibility of isolating and amplifying intact extracellular, tumor-related mRNA from the plasma/serum of patients with lung cancer. For this purpose, we established several RT-PCR-based amplification systems for the detection of a panel of five different genes. The expression of these genes was either shown to be restricted to lung tissue or associated with malignancy. We examined two small groups of 18 patients with lung cancer before and during chemotherapy, respectively. The message for beta-actin (control for integrity of the RNA) was detected in all of the analyzed sera from the control group and patients with lung cancer. Analysis of CK-19 expression was positive in the majority of tumor patients, but positive results were also shown in all of the control sera. The expression of MAGE-2 and TTF-1 genes was not observed in any of the patients in either the lymphocyte preparations or serum samples. Expression of the PGP 9.5 gene was observed in the cells of all 18 patients, but mRNA in the serum was only detectable in one case. The hnRNP-B1 mRNA was detectable in 14/18 sera, and Her2/neu-specific mRNA could be amplified from the serum of 7/18 patients. Combining the last two markers, we were able to detect all patients with a malignant lung tumor.

Wolf in sheep's clothing: spilled gallstones can cause severe complications after endoscopic surgery.

Bile concrements may remain intraperitoneally after laparoscopic cholecystectomy. Previously, this was considered harmless, a view supported by some experimental studies. Recently, however, spilled gallstones have been identified as a source of rare but potentially serious complications. We report a case of a retrohepatic abscess and dorsal fistulation after laparoscopic cholecystectomy. Healing was achieved only by repeated surgery, including abscess drainage, stone removals, and fistula excision. Since 1990, 73 cases with gallstone-related complications after laparoscopic cholecystectomy have been reported in the literature. Among these complications, intra-abdominal abscesses and transabdominal fistulas were predominant. The interval between the cholecystectomy and the appearance of complications ranged from 4 days to 29 months, with a peak incidence at 4 months. Spillage of small bile concrements or fragments is, with the exception of multiple irremovable stones, not commonly an indication for conversion to an open procedure. However, the patient needs to be warned about the risk of gallstone loss and its associated complications at the time when informed consent is obtained. Furthermore, if gallstone loss has occurred, the patient should be informed, and the occurrence should be documented.

[Surgical treatment of malignant thoracic schwannomas]. / Chirurgische Therapie thorakaler maligner Schwannome.

UNLABELLED: The objective of this study is to evaluate the results after surgical treatment of malignant tumors arising from the peripheral nerves of the thorax under consideration of adjuvant therapy modalities. PATIENTS AND METHODS: Between 1988 and 1998, 9 patients (6 males, 3 females) underwent surgical treatment for MTNSO and 35 pts. for benign neurogenic tumors. The mean age in patients with malignant tumors was 45 years (range, 25 to 73 years). 3 pts. with MTNSO (33.3%) had neurofibromatosis (von Recklinghausen's syndrome) compared to 8.6% (3/35) in patients with benign neurogenic tumors. RESULTS: In patients with MTNSO partial chest wall resections (n = 4) including sternectomy (n = 1), lung resections (n = 2), paravertebral (n = 1) and mediastinal tumor resection (n = 1) and palliative resection of pleural recurrence (n = 1) were performed. Radical resection was achieved in 5 pts. (55.5%). There was no postoperative mortality. 3 patients (33.3%) had postoperative complications: wound infection (n = 2) and wound dehiscence due to fall with consequent pleural infection (n = 1). Adjuvant therapy was performed in two pts. (adjuvant radiotherapy/chemotherapy for metastatic disease n = 1; adjuvant chemotherapy/adjuvant radiotherapy after resection of recurrent tumor n = 1). Early recurrence is documented in 2 pts. (after 3 and 6 months). Two pts. are alive and free of disease at three years, and the patient after sternectomy with recurrent disease at 20 months. Three pts. died 8, 9 and 26 months after the primary surgical procedure. The first postoperative examination (at three months) in the remaining patient showed no evidence for recurrent disease. CONCLUSION: Patients with MTNSO have an unfavourable prognosis and local recurrence is frequent even after radical surgical therapy. Therefore an adjuvant treatment in these patients may be justified, even if the value of these therapy modalities is not proved yet. A tumor-free long-term survival especially after complete surgical resection is possible in selected cases.

Efficient suicide gene therapy of transduced and distant untransduced ovary tumors is correlated with significant increase of intratumoral T and NK cells.

Gene therapy using herpes simplex type 1 thymidine kinase gene (HSV1-TK) transfer followed by ganciclovir (GCV) treatment has revealed an important intratumoral and regional bystander effect that is at least partly immune-mediated. The aim of this work was to study the modifications of T lymphocyte subpopulations in a model of distant bystander effect occurring between ovary tumors. Bilateral ovarian tumors were generated in 21 WKY rats by injection in the ovarian pouch of either parental or HSV1-TK-expressing DWA-OC-1 ovarian cancer cells. After 14 days, rats were treated for two weeks with GCV (75 mg/kg x 2/d) or saline. All rats were killed at day 29 for pathological examination. The tumor-infiltrating mononuclear cells were analyzed by semi-quantitative immunohistochemistry. As compared to rats receiving saline, GCV-treated animals exhibited a complete disappearance of the HSV1-TK+ tumors with residual fibrotic scars (ovary weights: 0.46 +/- 0.4 g vs 10.11 +/- 1.5 g, P < 0.001). Interestingly, the contralateral HSV1-TK negative tumor showed a significant regression (12.39 +/- 1.93 g vs 22.24 +/- 237 g, P < 0.014). Furthermore, a lower incidence of tumoral ascitis was found in the GCV-receiving group (20% vs 90% P < 0.02). Within both TK- and TK+ tumors, there was a significant increase of CD4+, CD8+ and NK cells in the GCV-treated group compared to the saline-treated group. This study thus indicates that a distant bystander effect not only acts between close tumors within a given organ such as the liver, but also between more distant tumors in the peritoneal cavity. This effect is associated with significant infiltration of the tumor by immune system cells, supporting the notion that the distant bystander effect is immune-mediated.

Apigenin inhibits endothelial-cell proliferation in G(2)/M phase whereas it stimulates smooth-muscle cells by inhibiting P21 and P27 expression.

Apigenin is a plant flavonoid that is thought to play a role in the prevention of carcinogenesis. However, its mechanism of action has not yet been elucidated. Because of the importance of angiogenesis in tumor growth, we investigated the effect of apigenin on endothelial and smooth-muscle cells in an in vitro model. Apigenin markedly inhibited the proliferation, and, to a lesser degree, the migration of endothelial cells, and capillary formation in vitro, independently of its inhibition of hyaluronidase activity. In contrast, it strongly stimulated vascular smooth-muscle-cell proliferation. The molecular mechanisms of apigenin activity were analyzed in these 2 types of cells. Our results show that apigenin inhibits endothelial-cell proliferation by blocking the cells in the G(2)/M phase as a result of the accumulation of the hyperphosphorylated form of the retinoblastoma protein. Apigenin stimulation of smooth-muscle cells was attributed to the reduced expression of 2 cyclin-dependent kinase inhibitors, p21 and p27, which negatively regulate the G(1)-phase cyclin-dependent kinase.

Catamenial pneumothorax--3 case reports and view of literature.

INTRODUCTION: The unusual correlation between chronic recurring spontaneous pneumothorax and the menstrual cycle, was first presented by Maurer in 1958. In our clinic we had 3 cases in 5 years. The anamnesis shows that this syndrome is unknown to many of our colleagues. Not mentioned in several standard textbooks, warrants our attention. METHODS: In 5 years we had 3 cases of C.P., all of them had already on admission, at least one recurrence; all of them had right sided thoracic pain and dyspnoea. They undergone video-assisted thoracoscopy, with histological examination of diaphragm specimen. Gynaecological consultations was followed by hormonal therapy and follow up. RESULTS: In all 3 cases we found no signs of lung defects or bullae, instead, we identified diaphragm defects of different extension, even a liver prolapse in one of the cases. Endometriosis extra genitalis could be diagnosed in only one case which undergone a hysterectomy 8 years before. CONCLUSION: A spontaneous pneumothorax which recurs in correlation with menses has a pathogenesis which concern only women, that is why is referred to as catamenial. Our experience supports the hypothesis, that air in the pleural cavity originates from the peritoneal one, arriving here via uterus and tuba. Beside the symptomatic therapy ther is an etiological one, by inhibition the menstrual cycle. Thoracosurgical intervention could help preventing recurrence, and contributes in clarifying the pathogenesis.

Pulmonary leiomyomatosis in women after hysterectomy for uterine myoma. Benign metastasizing leiomyoma?

INTRODUCTION: Leiomyomas, which usually occur multilocular in uterus, can develop even if rarely in other organs with smooth muscle cells. The tumour is considered benign; 2 case reports supports the hypothesis that uterus myoma could metastasize, and in the metastasis sites grow invasively. METHODS: 2 female patients 44 y. and 29 y. old were admitted to our clinic for MPL. Due to increasing tumor size respectively dypnea, they were operated on. Multiple nodules of the left lung in one case, and a mediastinal tumour in the other were resected; resected tumour was histologically examined. RESULTS: In both cases it was a matter of well-differentiated leiomyosarcoma. The mediastinal tumour has already invade the N. phrenicus. Postoperatively there were no complications. Patients discharged in well-doing state, medical control one year later revealed no new growth. CONCLUSION: Multiple pulmonary leiomyomas are rare, they occur in sexually mature women in coincidence with uterus myoma. Even though many authors assume that MPL is a lung metastasis of benign tumours, the pathogenesis is still hypothetical. Supporting this thesis is the hormone dependence of both the uterine and the pulmonary tumours; against it, is that extrapulmonary locations are too rarely observed. The still open pathogenetical question has no therapeutical consequence. Whenever technically possible, a radical, parenchyma-saving surgical therapy should be the first choice. Otherwise hormon-ablation is a good alternative.

Liposomal encapsulation of ganciclovir enhances the efficacy of herpes simplex virus type 1 thymidine kinase suicide gene therapy against hepatic tumors in rats.

Suicide gene therapy based on ganciclovir (GCV) metabolism by transgene herpes simplex thymidine kinase (HSV-1 TK) has been used to selectively kill proliferating cells in clinical settings such as cancer, vascular restenosis, and immunological disorders. We investigated whether encapsulation of ganciclovir (GCV) into liposomes would improve its efficacy, especially against hepatic tumors. Large unilamellar liposomes containing GCV were prepared by reversed-phase evaporation. Pharmacokinetic studies in rats showed that, compared with free GCV, the intravenous injection of liposome-encapsulated GCV (lip-GCV) led to a faster decrease in GCV plasma concentrations, but higher liver-blood ratios. After treatment of syngeneic HSV-1 TK+ liver metastases in rats, histologically active tumors were found in 95% of the transplanted lesions when physiological saline had been given and in 50% when free GCV had been given at 90.2 microM/kg twice daily. This dose is known to be insufficient for the eradication of HSV-1 TK+ tumors. In contrast, only 5% viable tumors were found in rats receiving lip-GCV at this same concentration. Average tumor volumes were 19 +/- 15, 7 +/- 9, and <1 mm3 for the control, free GCV, and lip-GCV groups, respectively. GCV-related toxicity was no longer observed. The results demonstrate that liposomal encapsulation of GCV is feasible and significantly enhances its efficacy against HSV-1 TK+ hepatic tumors.

Postoperative complications after bronchoplastic procedures in the treatment of bronchial malignancies.

OBJECTIVE: The purpose of this study was to determine the frequency of postoperative complications after bronchoplastic procedures in the treatment of pulmonary malignant tumors and to analyze the factors influencing the complication rate. METHODS: During a 5-year-period (1992-1996) 79 patients (68 male, 11 female, mean age 57 years) underwent reconstructive operations for bronchial malignancies. We performed 58 bronchoplastic procedures and 21 combined broncho- and angioplastic procedures. Among the bronchoplastic procedures the number of sleeve resections (n = 44) and wedge resections (n = 35) were comparable. RESULTS: Fifty-nine patients (74,7%) showed a regular postoperative course; 12 patients (15,2%) had severe postoperative complications (death, re-operation). Concerning the primary operation the operative 30-day mortality was 5.1% (n = 4) and including the two deaths after re-operation it was 7.6% (n = 6). After subdividing the patients into three groups (severe, less severe and no complications) we tried to determine predictors for occurrence of postoperative complications. There was a higher rate of severe complications in the age group 61-70 years (6/25 = 24%) as compared with younger patients between 51 and 60 years (4/38 = 10,5%; P < 0,05). Concerning the location, the outcome was better after sleeve- or wedge lobectomies of the upper lobes (four complications/51 patients = 7.8%) compared with procedures of the lower lobes (3/14 = 21.4%). The data could not prove a lower frequency of severe postoperative complications or specific morbidity after pleural coverage following bronchial sleeve resection. The complication rate was higher when sleeve resection of the bronchus was performed (10/44 = 22.7%) as compared with wedge resections (2/35 = 5.7%; P = 0,011) and after resection of T3/T4 tumors (6/28 = 21,4%) compared with T1/T2 tumors (4/37 = 10.8%; P < 0,05). CONCLUSIONS: Bronchoplastic procedures represent a fairly safe therapy opportunity in patients with centrally localized bronchial carcinoma and compromised or uncompromised pulmonary function. In this study the complication rate was higher after sleeve resection of the bronchus as compared with wedge resection. Pleural coverage of the anastomosis was not effective to prevent major complications due to dehiscence of the bronchial anastomosis. A pedicled muscle flap could be a valuable alternative.

[Thoracic surgery relevant indications for adjuvant and/or palliative measures in breast carcinoma]. / Thoraxchirurgisch relevante Indikationen zu adjuvanten und/oder palliativen Massnahmen beim Mammakarzinom.

Metastatic lesions of breast cancer represent rare indications for operation in thoracic surgery. Only in case of persistent malignant pleural effusions or in case of tumour progress despite all other available therapy modalities thoracic surgery can be indicated. Over a period of 5 years between 1993 and 1997 53 patients with metastatic breast cancer were treated in our institution. 36 pts. suffered from persistent pleural effusions, 13 pts. had pulmonary metastases and 4 pts. had metastases involving the chest wall. In all these patients the disease could not be controlled by conservative measures. Our experiences are the following: Thoracoscopy is the diagnostic method of choice for pleural effusions in patients with malignant tumors. If a malignant pleural effusion is confirmed, a talc poudrage represents the most reliable treatment to palliate the dyspnea. The resection of a single solitary pulmonary metastasis can be indicated to confirm the histologic type of the nodule. Resections for centrally localized lesions causing hemoptysis or atelectasis represent rare occasions. Metastatic lesions of breast cancer involving the ribs or the sternum are resected in order to confirm the histologic diagnosis. According to the literature these procedures, with a 5-year survival rate of 50% and without perioperative mortality, can be beneficial.

[Surgical anatomy in lung resections]. / Chirurgische Anatomie resezierender Verfahren an der Lunge.

When thoracic/lung surgery is performed autodidactically, intraoperative catastrophes and complications are to be expected. Atypical partial resections must be distinguished from typical resections of anatomical parechyma units (standard operations). More extensive operations which involve additional lung structures (lung lobes, trachea, bronchi) or attached organs (chest wall, heart, diaphragm etc.) are technically demanding. The larger the anatomical unit, the closer to the heart all vessels have to be arranged and, not seldom this means intrapericardially with clamping of the left atrium. All structures of the hilus are suitable for closing with staplers or suture. In the case of pneumonectomies, central lung structures can be cut most easily by cutting ligaments (Lig. anterior superius, Lig. pulmonale inferius). Pictures and photographs demonstrate specialties of topography of bilateral central lung structures in the context of extended resections.