[Lymphedema as initial manifestation of malignancy]. / Lymphödem als erstes Zeichen eines Malignoms.

Lymphedema may result from various benign or malignant causes. In particular rapidly progressing central or unilateral lymphedema (even in case of only discrete clinical findings) should initiate an extensive diagnostic workup to detect underlying malignancies in order to enable early therapy.

[Young Women - Problematic Patients in Vascular Surgery]. / Junge Frauen - Problempatientinnen in der Gefäßchirurgie.

The treatment of peripheral arterial disease (PAD) in young women between 40 and 60 years of age represents a difficult challenge for the vascular surgeon. Excessive smoking, an early menopause and the unfavourable anatomic proportions of thinner arterial vessels or vein grafts during peripheral bypass-surgery lead to a higher rate of complications or re-occlusion following invasive therapy in comparison to male patients. A special anatomic manifestation appearing nearly only in women around the 6th decade is the so-called aortoiliac hypoplastic syndrome with a high rate of re-occlusion after balloon-dilatation or local thrombendarteriectomy and bypass grafting, respectively. Variabilities in coagulation and the undertreatment of classical risk factors of PAD by medical drugs lead to poorer results in the treatment of PAD in young women. Therefore a conservative therapy - whenever feasible - should be the first choice for treating PAD in young women.

[Endovascular therapy of an iatrogenic renal-artery-perforation after fenestrated-aortic-repair (fEVAR)]. / Endovaskuläre Therapie einer iatrogenen Nierenarterienperforation nach fenestrierter Aortenprothese (fEVAR).

HISTORY AND ADMISSION FINDINGS: A 75-year-old patient was initially hospitalized for therapy-evaluation of a an acquaint infrarenal abdominal-aortic-aneurysm, with a maximum diameter of 5.3 cm. Medical history showed a known contained rupture of the aneurysm. Except for a substituted Hypothyroidism and a COPD Stadium II (GOLD), there were no other previous diseases known. EXAMINATIONS: Laboratory showed a slight normochrome, normocytic anemia (hemoglobin 13 g/dl, MCV and MCH were normal) together with a decreased total amount of erythrocytes of 3.89/pl. TSH value was increased significantly at 7.960 mU/l. Initially creatinine was measured at 1.02 mg/dl. Sonography and CT-scan of the abdominal vessels had shown no new insights other than the aneurysm of the abdominal aorta. A surgical revision was indicated. TREATMENT AND COURSE: After primarily uncomplicated implantation of a fenestrated EVAR, the patient showed a progressive hemoglobin loss concomitant with a considerable increase of renal retention parameters. A "spurium"/false aneurysm of the right renal artery was found, which moreover showed a retroperitoneal bleeding. The patient subsequently underwent successful endovascular therapy in our clinic and was dismissed from the hospital in good condition and without further complications. Follow up controls showed no signs of new pathologies. CONCLUSION: "Direct" post-operative complications after EVAR are a rarity. In our case, the interventional endovascular approach of the bleeding from the right renal artery was a successful and sufficient treatment of the potentially life-threatening complication.

[Risk factors and pathogenic microorganisms in patients with insufficient esophagojejunostomy after gastrectomy]. / Risikofaktoren und pathogene Mikroorganismen bei Patienten mit insuffizienter Osophago-Jejunostomie nach Gastrektomie.

UNLABELLED: It was the aim of the study to find by retrospective analysis of data from totally gastrectomized patients risk factors for the development of esophago-jejunal anastomotic leakage, that may be avoidable or influenced therapeutically. PATIENTS AND METHODS: The study design was retrospective involving 838 patients with total gastrectomy for gastric cancer from the years 1973-1993. In 134 cases leakage of the esophago-jejunostomy occurred. The relative risk for the development of leakage associated with individual parameters was determined by comparing the data from 704 patients without leakage to the data from 134 patients presenting with this complication. For a subgroup of 86 patients with anastomotic leakage microbiological data of swabs taken from the anastomoses were available, which were evaluated with respect to potentially pathogenic bacilli. RESULTS: The overall leakage rate of esophago-jejunal anastomoses was 15.9% (n = 134). The mortality rate during this time period amounted to 14.3%. Leakage was a most highly significant factor for mortality (p = 0.0001). Significant risk factors for leakage of the esophago-jejunostomy were tumors of the cardia, splenectomy, a duration of operating time of more than 5 hours and manual suture technique compared to stapler anastomoses. Tumor unrelated associated disease, tumor stage and a history of other preexisting gastric diseases were not associated with an increased relative risk. At the time of the initial clinical manifestation of leakage the following pathogenic bacilli could be isolated from leaking anastomoses with decreasing incidence: E. coli, S. aureus, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae a.o. The bacterial spectrum has not changed during the observation period of 20 years. SUMMARY: With the exception of the choice of suture techniques the identified clinical risk factors cannot be avoided or influenced therapeutically due to a lack of potentially curative treatment alternatives. In contrast potentially pathogenic bacilli associated with leakage can be prevented from coming in contact with anastomoses thereby preventing infection and leakage.