Axillobifemoral Bypasses: Reappraisal of an Extra-Anatomic Bypass by Analysis of Results and Prognostic Factors.

BACKGROUND: Axillobifemoral bypass (AFB) is method of second choice. It is reserved for patients at high operative risk or to bypass infected vessels or grafts. In this study, we analyzed prognostic factors for AFB patency and limb salvage rate to facilitate the choice of procedure. METHODS: Between Jan 2006 and Aug 2013, 45 patients underwent AFB surgery in our department, 24 for critical limb ischemia (CLI) and 23 for infection. Endpoints of study were graft occlusion, graft infection, amputation and patient's death. Prognostic factors were compared by univariate analysis for each indication group. Mean follow-up was 40.2 (±23.2) months. RESULTS: Complication rate was significantly higher in infection group (88.0 vs. 54.4%, p = 0.003) and in emergency surgery (83.3 vs. 56.9%, p = 0.023). Overall primary patency rate after AFB procedures was 66.7% after 1, 3, and 5 years, while secondary patency rate was 91.1% after 1 year, 82.2% after 3 years and 80.0% after 5 years. The primary and secondary patency rates did not significantly differ between the both groups (p = 0.059 and p = 0.136). Following prognostic factors showed a statistically significant influence on patency rates in CLI group: >1 previous vascular surgical intervention, patch angioplasty at the distal anastomosis site, complications after previous vascular surgery, and perioperative intake of platelet aggregation inhibitor. Only the employed bypass material had a statistical significant influence on the secondary patency rates in the infection group. Overall limb salvage rate was 82.2% after 1 year, 80.0% after 3 years and 77.8% after 5 years. There were statistically significant differences in the limb salvage rates depending on emergency surgery and a 3-vessel-run-off in the lower leg in both indication groups. CONCLUSION: AFB have acceptable patency and limb salvage rates. AFB is a good alternative in patients with CLI at high operative risk or with infections of aortoiliac segments, even with endovascular approaches. They remain essential tools in vascular surgeon's repertoire.

Comparison of biological and alloplastic meshes in ventral incisional hernia repair.

PURPOSE: The aim of our retrospective analysis was to compare the results of incisional hernia repair by porcine small intestinal submucosa-derived (SIS) meshes with those obtained by alloplastic polypropylene-based (PP) meshes in comparable surgical indications by matched-pair design. We hypothesized that in incisional hernia, SIS mesh repair is associated with fewer recurrences and SSO than PP mesh repair in incisional hernias. METHODS: Twenty-four matched pairs (SIS vs. PP mesh repair between 1 January 2005 and 31 December 2013) were identified by matching criteria: gender, age, comorbidities, body mass index, EHS hernia classification, mesh implantation technique, CDC wound classification, and source of contamination/primary surgery leading to incisional hernia. Minimal follow-up time was 24 months. Means and standard deviations were compared by paired t test; categorial data were compared by McNemar's test. Poisson's distribution and negative binominal distribution were employed to detect significant correlation. RESULTS: There were no statistically significant differences between both groups in the pre- and perioperative factors and the follow-up times. There were significantly more wound complications (19 vs. 12, p = 0.041), longer hospital stay (22.0 ± 6.3 vs. 12.0 ± 3.1 days, p = 0.010), and significantly more recurrent hernias (25 vs. 12.5%, p = 0.004) after SIS mesh repair. Both the Poisson's distribution and the negative binominal distribution unveiled significantly more complication points (3-6 vs. 1-2) per month after SIS mesh repair. CONCLUSION: There is no advantage of SIS meshes compared to PP meshes in incisional hernia repair with different degrees of wound contamination in this matched-pair analysis. Further prospective and randomized trials or at least registry studies such as the EHS register with standardized and defined conditions are warranted.

[Ruptured Abdominal Aortic Aneurysm - Results and Prognostic Factors at a Certified Centre of Vascular Surgery]. / Das rupturierte abdominale Aortenaneurysma ­ Ergebnisse und prognostische Faktoren an einem gefäßchirurgischen Zentrum.

Introduction: Although the perioperative management has been optimised over the past few decades, there has not been a remarkable improvement in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA). The aim of this retrospective trial was to define pre-, intra- and postoperative parameters which influence the perioperative and long-term outcome of patients and which can be modified by the operating team. Methods: A retrospective database analysis was performed in 49 patients who had undergone an operation of rAAA in our certified centre of vascular surgery between the beginning of 2006 and the end of 2012. The minimal follow-up period was 30 months. The statistical analysis was done univariately using the Kaplan-Meier method and a log-rank-test, and multivariately with the Cox model. Results: Intrahospital mortality was 40.8 %, perioperative mortality (30 postoperative days) was 28.9 %. The survival rate for 1 year was 52.4 %; the survival rate for 5 years was 45.3 %. In the univariate analysis, significant differences in the early postoperative survival rates were found depending on preoperative systolic blood pressure, preoperative haemoglobin (< 10 vs. ≥ 10 g/dl), the intraoperative need of blood and frozen plasma transfusions, type of perforation, type of AAA, the need for further surgical interventions, postoperative MOF, acute kidney failure and postoperative septicaemia. The late survival rates were significantly influenced by the type of perforation and AAA, pre-existing coronary disease and diabetes mellitus in fully identified patients discharged from hospital (n = 27). In the multivariate analysis pursuant to the Cox model, patients with pre-existing coronary disease had a 3.9-fold higher relative risk to die after the operation of rAAA, while patients with a free perforation of the rAA had a 10-fold higher relative risk. Conclusion: The high mortality of rAAA is caused by haemorrhagic shock and its complications, which are mostly non-surgical. Therapeutic efforts should focus on those perioperative parameters which can be modified by the treating teams. Alongside the centralisation of rAAA in high-volume-departments of vascular surgery, the systematic sonographic screening for asymptomatic AAA in the population older than 65 years should be enforced. A possible advantage of EVAR in rAAA has yet to be shown by trials in progress such as IMPROVE, AJAX and RCAR.

The role of lymphoid tissue in the attenuation of the postoperative ileus.

Standardized intestinal manipulation (IM) leads to local bowel wall inflammation subsequently spreading over the entire gastrointestinal tract. Previously, we demonstrated that this so-called gastrointestinal field effect (FE) is immune-mediated. The aim of this study was to investigate the role of secondary lymphoid organs [mesenteric lymph nodes (MLN), gut-associated lymphoid tissue (GALT)] in IM-mediated FE by employing mice with deficient secondary lymphoid organs (aly/aly, MLN ex) or by administration of 2-amino-2-[2-(4-octylphenyl)ethyl]-1,3-propanediol (FTY720), an immunomodulating agent that inhibits emigration of lymphocytes out of lymphoid organs. Small bowel muscularis, and colonic muscularis from wild-type mice as control, from aly/aly mice, FTY720-treated mice (daily dose of 1.0 mg/kg mouse ip starting 3 days before surgical procedure), and wild-type mice that had undergone removal of mesenteric lymph nodes before IM (MLN ex mice) were obtained after selective IM of the jejunum or sham operation. FE was analyzed by measuring transit time of orally administered fluorescent dextran in the gastrointestinal tract [geometric center (GC) of fluorescent dextran], colonic transit time, infiltration of myeloperoxidase-positive cells, and circular smooth muscle contractility. Furthermore, mRNA levels of inflammatory cytokines [interleukin (IL)-6, tumor necrosis factor (TNF)-α, macrophage inflammatory protein (MIP)-1α] were determined by Taqman-PCR. We observed a significantly reduced upregulation of proinflammatory cytokines (IL-6, TNF-α, MIP-1α) in colonic muscularis of MLN ex mice, aly/aly mice, and FTY720-treated mice compared with wild-type mice. Contractility of circular muscularis strips of the colon but not the jejunum was significantly improved in aly/aly mice and FTY720-treated wild-type mice. Additionally, inflammation of the colon determined by the number of myeloperoxidase-positive cells and colonic transit time were significantly improved in aly/aly mice, FTY720-treated wild-type mice, and in MLN ex mice. In summary, lack of secondary lymphoid organs (MLN + GALT) in aly/aly mice or administration of FTY720 abrogated FE after IM as opposed to wild-type mice. These data demonstrate that secondary lymphoid organs are involved in the propagation of FE and postoperative ileus. FTY720 indirectly affects FE by inhibiting migration of activated T cells from the jejunum and adjacent secondary lymphoid organs to the colon. These findings support the crucial role of the adaptive immune system in FE, most likely by a sphyngosine 1-phosphate-dependent mechanism.

Impact of CCR7 on the gastrointestinal field effect.

Standardized intestinal manipulation (IM) leads to local bowel wall inflammation subsequently spreading over the entire gastrointestinal tract. Previously, we demonstrated that this so-called gastrointestinal field effect (FE) is immune mediated. This study aimed to investigate the role of CCR7 in IM-induced FE. Since CCR7 is expressed on activated dendritic cells and T cells and is well known to control their migration, we hypothesized that lack of CCR7 reduces or abolishes FE. Small bowel muscularis and colonic muscularis from CCR7(-/-) and wild-type (WT) mice were obtained after IM of the jejunum or sham operation. FE was analyzed by measuring gastrointestinal transit time of orally given fluorescent dextran (geometric center), colonic transit time, infiltration of MPO-positive cells, and circular smooth muscle contractility. Furthermore, mRNA levels of the inflammatory cytokine IL-6 were determined by RT-PCR. The number of dendritic cells and CD3+CD25+ T cells separately isolated from jejunum and colon was determined in mice after IM and sham operation. There was no significant difference in IL-6 mRNA upregulation in colonic muscularis between sham-operated WT and CCR7(-/-) mice after IM. Contractility of circular muscularis strips of the colon was significantly improved in CCR7(-/-) animals following IM and did not vary significantly from sham-operated animals. Additionally, inflammation of the colon determined by the number of MPO-positive cells and colonic transit time was significantly reduced in CCR7(-/-) mice. In contrast, jejunal contractility and jejunal inflammation of transgenic mice did not differ significantly from WT mice after IM. These data are supported by a significant increase of CD3+CD25+ T cells in the colonic muscularis of WT mice after IM, which could not be observed in CCR7(-/-) mice. These data demonstrate that CCR7 is required for FE and postoperative ileus. CCR7 indirectly affects FE by inhibiting migration of activated dendritic cells and of T cells from the jejunum to the colon. These findings support the critical role of the adaptive immune system in FE.

Case-control comparison of profundaplasty and femoropopliteal supragenicular bypass for peripheral arterial disease.

BACKGROUND: The aim of this study was to compare preoperative and postoperative findings, and clinical progress in patients with peripheral arterial occlusive disease undergoing femoropopliteal supragenicular bypass or profundaplasty in a case-control study. METHODS: Between January 2001 and June 2004, 171 patients with occlusion of the superficial femoral artery underwent surgery. A retrospective analysis of 28 matched patient pairs was performed. Endpoints were bypass occlusion, surgical revision, amputation and death. Mean length of follow-up was 36 months. RESULTS: At 3 years after surgery there was no statistically significant difference in outcome between femoropopliteal bypass surgery and profundaplasty. There was a trend towards improved results in patients who had bypass surgery for critical leg ischaemia. Preoperative patency of the crural outflow arteries was an independent prognostic factor in multivariable analysis. CONCLUSION: There were no significant outcome differences between supragenicular bypass surgery or profundaplasty in patients who had surgery for intermittent claudication or ischaemic rest pain. Patients with a single patent tibial artery and gangrene or ulceration appeared to benefit more from bypass surgery.

Treatment of high output cardiac failure by flow-adapted hepatic artery banding (FHAB) in patients with hereditary hemorrhagic telangiectasia.

Involvement of abdominal organs in Osler's disease may lead to the development of hepatic arteriovenous shunts with a dilatation of the hepatic artery. Right and subsequent global heart failure due to cardiac valvular insufficiency, pulmonary artery hypertension, and hepatomegaly as well as increased cardiac output may result. This hyperdynamic hepatic blood flow can be reduced by ligature or banding of the hepatic artery or by orthotopic liver transplantation. We report on two female patients suffering from Osler's disease (68 and 76 years old) with severe heart insufficiency (NYHA III-IV) caused by the high hepatic shunt volumes. A gradual banding of the hepatic artery directed by intraoperative flow measurement in the hepatic artery and control of the systemic hemodynamics by Swan-Ganz or COLD catheters was performed in these patients. The banding was achieved by encasing the hepatic artery in a PTFE cuff (length, 1.0 cm). The high cardiac output could be reduced from 11.2 to 7.0 l/min and from 10.7 to 6.0 l/min, respectively. The respective hepatic artery flow was reduced from 2.0 to 0.3 l/min and from 4.0 to 0.7 l/min. An improvement of heart insufficiency, a reduction in the severity of the cardiac valvular insufficiency, and a reduction of the pulmonary arterial hypertension could be already observed intraoperatively. One patient died of right cardiac failure after an orthotopic liver transplantation 7 months later. The other one died 3 years after the banding. The banding of the hepatic artery controlled by hepatic arterial flow measurement can be considered as an effective and safe palliative procedure in intrahepatic HHT compared to therapeutic alternatives such as hepatic artery ligation or embolization.

The role of dendritic cells in the gastrointestinal field effect.

INTRODUCTION: Intestinal manipulation leads to local bowel wall inflammation that subsequently spreads over the entire gastrointestinal tract. Previously, this gastrointestinal field effect had been demonstrated by us in a rodent model. We herein postulated an immunologic mechanism mediated by activated leukocytes. The aim of this study was to investigate the activation, maturation and migration of dendritic cells (DC) of the intestinal smooth muscle following surgical trauma and i.p. lipopolysaccharide challenge. METHODS: Mice underwent standardized intestinal manipulation or iP LPS administration and tissues (intestinal muscularis, Peyer's patches, mesenteric lymph nodes, and spleen) were obtained at various times after manipulation. DC were isolated by tissue digestion and separated by CD11c-iMAG. The harvested DC were analyzed by FACS. The activation pattern of DC was analyzed by polymerase chain reaction. RESULTS: We found a significant increase in DC within the intestinal muscularis, the Peyer's patches and the mesenteric lymph nodes at 6 and 12 hours following intestinal manipulation and injection of LPS. There was an upregulation of the costimulatory molecules major histocompatibility complex II, CD40, CD80, CD86, and CD205 in the DC after intestinal manipulation. CCR-2, CCR-5, CCR-7, CCL-19, and interleukin-12a were upregulated in a time- and tissue-dependent manner. CONCLUSION: Intestinal manipulation or LPS challenge induced a recruitment of DC into the muscularis externa and mesenteric lymph nodes combined with an upregulation of costimulatory immunocompetent molecules and migratory surface markers in DCs. These findings demonstrate a precondition for an immunologic response and a possible immunologically mediated gastrointestinal field effect.

[Complicated umbilical hernia in patients with decompensated liver cirrhosis. Concept for risk reduction of repair]. / Nabelhernien bei Patienten mit dekompensierter Leberzirrhose. Konzept zur Risikominderung der Reparation.

Umbilical hernia repair is often accompanied by complications in patients with liver cirrhosis and ascites. In recent years we have been using the following concept for treating umbilical hernias in such patients: repair of the hernia by direct sutures and concomitant implantation of two large bore Robinson drainage tubes until the wound healing was completed within the next postoperative 10-14 days. During this time the reconstruction of the abdominal wall is in our opinion as robust that the ascites no longer represents a risk. Preconditions to perform this procedure were the best medicamentous treatment of ascites as ever possible and the perioperative administration of prophylactic antibiotics like gyrase inhibitors to avoid spontaneous bacterial peritonitis. Over a period of 10 years (01.01.1997-31.12.2006) we operated on 22 patients suffering from liver cirrhosis and ascites because of a complicated umbilical hernia (incarceration, irreponibility, skin ulceration, leackage of ascites). One group of patients (n=10) was treated by umbilical hernia repair with the concomitant implantation of two drainage tubes and the other group (n=12) by umbilical hernia repair without draining off the ascites. Morbidity and mortality were compared in both groups in a retrospective analysis. The postoperative morbidity could be reduced from 25% to 10% by using the drainage tubes as well as the rate of recurrent hernias in the drainage group. Due to these experiences we use the concept as standard in such patients and would like to recommend it further. However, we would like to initiate a prospective, randomized, at best multicenter trial for further validation.

Postresection survival outcomes of pancreatic cancer according to demographic factors and socio-economic status.

AIM: Aim of the study was to evaluate the impact of demographic factors (DGF) and socio-economic status (SES) on survival after pancreatic cancer resection in a German setting. METHODS: Patients with pancreatic adenocarcinoma and pancreaticoduodenectomy were identified from our pancreatic resection database (1989-2008). DGF, SES, survival and tumor-related information were obtained from hospital records, a registry office questionnaire, and telephone interviews with patients, relatives and general practitioners. RESULTS: Follow-up was completed in 117 patients. Median overall survival and 5-year survival rate was 22 month and 10%, respectively. Survival significantly improved over time with a 16% 5-year survival and a median survival of 27 month for recent patients. The longest survival period with a median of 63 month was observed for patients with AJCC stage I. Tumor-related factors and treatment period, but not SES influenced survival after pancreatic cancer resection in our cohort. CONCLUSIONS: To our knowledge, this is the first study to explore survival from pancreatic cancer according to DGF and SES in a German setting. Disparities in survival among our patients depend solely on tumor-related factors and treatment period and could not be explained by SES including key factors like income or type of health insurance. The comparable postresection outcome of patients with low and high SES at our department could be in part due to the universal German multi-payer health system, based on compulsory enrolment for the majority, which seems not to support health care inequalities seen in other OECD countries.

[Interdisciplinary management of thoracic wall tumors: indication, technique, and results of interscapulothoracic amputation]. / Interskapulothorakale Amputation nach Berger : Indikationen, Techniken und Ergebnisse bei Thoraxwandtumoren.

Interscapulothoracic amputation of the upper extremity, described for the first time by Berger in 1887, has undergone a change of indication. Originally performed in traumatic injuries of the shoulder or arm, it has been done in radical resection of malignancies of the upper extremity, axilla, or the surrounding thoracic wall. Particularly it is performed in tumors which cannot be controlled by neoadjuvant therapies or locally by radiation. The indication, technique, and results of such amputation are discussed by presenting our patients operated on with the procedure. Although this treatment is combined with a loss of function and body integrity, it is safe and sufficiently radical. The loss of function and integrity may be compensated by prosthetic reconstitution.

Magnetic resonance (MR) imaging and MR angiography for evaluation and follow-up of hepatic artery banding in patients with hepatic involvement of hereditary hemorrhagic telangiectasia.

BACKGROUND: We describe findings obtained by magnetic resonance angiography (MRA) and magnetic resonance imaging (MRI) for evaluation and follow-up after hepatic artery banding in patients with hepatic involvement of hereditary hemorrhagic telangiectasia (HHT). METHODS: Abdominal MRA and liver MRI were performed in three patients with HHT as clinically defined by Curacao criteria. One patient underwent MRA and MRI twice for preinterventional evaluation and follow-up, one patient for preinterventional evaluation, and one patient for postinterventional evaluation. Hepatic vascular involvement of the disease and postinterventional vascular anatomy were evaluated by two radiologists by consensus. RESULTS: Hepatic vascular involvement with perfusion disorders and arteriosystemic shunts was found in all three patients. MRA and MRI allowed diagnostic characterization of hepatic vascular disease (three of three), preinterventional evaluation of complex vascular anatomy and variants (two of two), and postinterventional follow-up of hepatic artery banding (two of two). CONCLUSION: In preinterventional evaluation and postinterventional follow-up, MRA and MRI allows characterization of complex hepatic vascular alterations of HHT and, hence, is an alternative to other imaging modalities in the diagnosis, clinical decision making, and follow-up of HHT.

[The value of prognostic factors in patients who underwent a resection of pulmonary metastases]. / Der Aussagewert prognostischer Faktoren bei Tumorträgern nach Lungenmetastasenresektion.

155 patients were operated on pulmonary metastases in Jena during the period from 1.1.1984 to the 31.12.1994. The findings of 151 patients were analysed. 128 patients suffered from a carcinoma, 15 from a sarcoma, 6 from a malignant melanoma and 2 from a Wilms-tumor. The prognostic factors discussed in the international publications at present were investigated in those patients. Significant differences in the long-term survival were found for the following features: a possible radical resection, the tumor entity, the site, the histology and the grading of the primary tumor, the size and the site of the metastases and the resection of recurrent metastases. Tendencies are described for the type of dissemination and the staging of the primary tumor, the site of the pulmonary metastases in the lung lobes, solitary extrapulmonary metastases and more than 6 lung metastases. In addition patients who showed metastases of a renal cell carcinoma are considered separately.