Radiotherapy as adjunct to surgery for malignant carotid body paragangliomas presenting with lymph node metastases.

PURPOSE: Three cases of malignant carotid body paragangliomas with nodal metastases are reported. PATIENTS AND METHODS: Between 1985 and 1994, 3 female patients (51 to 65 years of age) were referred for postoperative radiotherapy after complete (2) or incomplete (1) surgical excision of a malignant carotid paraganglioma (Shamblin III). Preoperative angiographic embolization of the tumor-supplying arteries was performed in all cases. In 2 patients resection of the internal carotid artery and reconstruction by saphenous vein graft was necessary. Continuous course radiotherapy of the tumor bed (50 to 56 Gy/2 Gy) and regional lymph nodes (50 Gy) using photon beams was delivered in 2 patients. The third patient having had incomplete resection cancelled radiotherapy after 4 Gy. RESULTS: Within an observation time of 110 and 119 months no evidence of recurrence was obtained in both patients irradiated postoperatively. The third patient died of progressive disease. Twelve months after the withdrawn irradiation she presented with a tumor progression into the brain and an ulcerated mass on the right side of the neck and was irradiated consecutively for palliation (Figures 1a to 1f). In none of the patients severe acute or late radiation-induced complications were observed. CONCLUSION: In patients with malignant paraganglioma moderate dose postoperative radiotherapy of the tumor bed and regional lymph nodes is well tolerated. It seems to be effective to prolong local control after surgery, to eradicate microscopic lymphatic disease and eventually to postpone further spreading.

Köhlmeier-Degos's disease with primary intestinal manifestation.

Disseminated intestinal and cutaneous thromboangiitis (synonyms: Köhlmeier-Degos's syndrome, malignant atrophic papulosis, progressive arterial mesenterial vascular occlusive disease) is a rare, systemic vascular disease that is mainly manifested in the skin, gastrointestinal tract, and nervous system. The disease first appears as a necrotizing papulous dermatosis; as it generalizes, infarcted necroses develop in internal organs. These ischemic complications are the reason for the usually fatal outcome of the disease. A case report of a primary intestinal manifestation of this disease illustrates the clinical course, diagnosis, histopathologic findings, and differential diagnosis, with consideration of the current literature. Deposits of acid mucopolysaccharides and humoral immune mechanisms appear to play a role in the etiology and pathogenesis of this usually fatal vascular disease.

Percutaneous endoscopic gastrostomy (PEG). 8 years of clinical experience in 232 patients.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is now a standard method for providing long-term enteral nutrition in patients who are unable to swallow. The aim of our study was to document clinical data that would allow prediction of a possible complicated clinical course. METHODS: The study was carried out retrospectively. Clinical data of patients having received a PEG tube by a single endoscopic technique were analyzed. RESULTS: Some 5. 17% of 232 patients showed complications requiring surgery including a mortality rate of 0.43%. Patients with complications had a significantly lower body mass index and there was a significantly higher complication rate in patients having obstructive malignancies compared with benign diseases. CONCLUSIONS: Low body mass index and advanced malignancies are predictors for complications after PEG application. Early installation should help prevent further nutritional deterioration and the related risk of complications.

Vascular complications in minimally invasive surgery.

Injuries to major vessels in the course of laparoscopic surgery are rare but serious, life-threatening complications. We report nine iatrogenic vascular injuries during minimally invasive surgery that occurred between January 1991 and December 1995 in surgical and obstetric-gynecologic services in the Austrian province of Styria. The total vascular complication rate is 0.08%. As these data show, the distal abdominal aorta and vena cava, as well as the large pelvic vessels, are especially susceptible to injury when the Veress needle and trocars are inserted into the abdomen. Surgical reconstruction of these eight arterial lesions required a polytetrafluorethylene (PTFE) patch in one case, and the resection of the damaged section of the artery and reanastomosis in two others. The remaining lesions, as well as an isolated vein injury, were corrected with direct suturing of the vessel. Pelvic circulation was completely restored in all patients, and permanent damage was avoided.

[Results of surgical treatment of pregnancy-associated pelvic vein thrombosis]. / Ergebnisse der chirurgischen Behandlung der schwangerschaftsassoziierten Beckenvenenthrombose.

We report the results of surgical treatment of iliofemoral vein thrombosis in 49 pregnant women in a seven years period. The patients mean age was 26.5 years (range 18-41 years). Isolated descending pelvic vein thrombosis (PVT) occurred between the 20th and 36th week of pregnancy and was located predominantly left sided. 89.8% of PVT developed in the late period of gestation, three cases of pelvic vein thrombosis were diagnosed after vaginal delivery. An iliac vein spur in one patient and an AT-III deficiency in two cases were registered as additional risk factors. After venous catheter thrombectomy an arteriovenous fistula between the superficial femoral artery and the femoral vein was performed to increase blood flow and velocity in the pelvic veins. Abdominal delivery was performed simultaneously, if thrombosis occurred after the 34th week of pregnancy. Late re-thrombosis was registered in 4 patients (9.0%) after a mean follow-up of 42 months. We have seen symptoms of mild, not life threatening pulmonary embolism in two patients on the first postoperative day (complication rate 4.0%). Re-occlusion rate was high (3/5) after surgical thrombectomy carried out between the 20th and 26th week of gestation. Risk factors were an AT III deficiency in two cases and the continued compression syndrome of the pelvic veins caused by the enlarging uterus. In the late period of gestation surgical thrombectomy of PVT is the preferential method of treatment in selected patients with good therapeutical results. The operation reduces the risk of future venous insufficiency and post-thrombotic syndrome in the young female patients.

[Isolated pelvic vein thrombosis in a young marathon runner]. / Isolierte Beckenvenenthrombose bei einer jungen Marathonläuferin.

The case of a 20-year old female patient who developed an isolated thrombosis of the pelvic vein after a marathon run, is presented. After surgical treatment and anticoagulation for one year, complete restitution was seen. The possible relation between marathon running and venous thrombosis without other risk factors is discussed.

[Vascular lesions in surgery of the hip joint]. / Gefässläsionen in der Hüftgelenkchirurgie.

The vascular anatomy in the acetabular region involves a certain risk of arterial and venous injuries complicating orthopaedic surgery. These complications have been grouped into four categories: lacerations, thrombosis, pseudoaneurysms and arteriovenous fistula. In a period of 5 years, three injuries of the external iliac artery and four lesions of the femoral artery associated with total hip arthroplasty were treated surgically at the Department of Vascular Surgery of the University Hospital in Graz. In one case a concomitant lesion of the pelvic vein was observed. The incidence of iatrogenic vascular injuries in total hip surgery is 0.3%. Combined injury of the external iliac artery and vein led to a life-threatening bleeding complication. The vascular lesion became manifest as acute ischaemia of the lower extremity or as an acute haemorrhage 30 min to 2 h after primary surgery. The late complication of a false aneurysm of the femoral artery occurred in one patient 3 weeks after total hip replacement. Reconstruction of the vascular lesions was performed by direct suture, except that two arterial lesions required the use of polytetrafluoroethylene (PTFE) vascular grafts. Vessels in the pelvic region are at high risk if screw fixation acetabular components are used. Perforation of the iliac artery by protruded methylmethacrylate polymer components of cement has been documented. The obturator vessels are in a vulnerable position if the acetabular floor has been broached by operative instruments or eroded by loosening of the prosthesis facilitated by osteoporosis, steroids or sepsis. Femoral vessels are endangered by Hohmann retractors that are not placed directly on bone. Though vascular injury during hip operations is rare, recognition of such complications is important as safe and satisfactory treatment can be achieved. Rapid identification and immediate surgical repair of these lacerations are essential for their management.

[Iatrogenic vascular lesions in laparoscopic interventions in gynecology]. / Iatrogene Gefässläsionen bei laparoskopischen Eingriffen in der Gynäkologie.

Injuries to major vessels in the course of gynecological laparoscopic surgery are rare but serious, life-threatening complications. We report on five iatrogenic vascular injuries during minimally invasive surgery that occurred between January 1991 and May 1996 in obstetrical-gynecological services in the Austrian province of Styria. The total vascular complication rate is 0.05%. As this data shows, the distal abdominal aorta and vena cava as well as the large pelvic vessels are especially susceptible to injury when the Veress needle and trocars are inserted into the abdomen. Surgical reconstruction of these five arterial lesions required a PTFE patch in one case and the resection of the damaged section of the artery and reanastomosis in a second case. The remaining lesions, as well as an associated injury to the pelvic vein in one case was corrected with direct suturing of the vessel. Pelvic circulation was completely restored in all patients and permanent damage was avoided.

[Preoperative angiographic embolization of carotid glomus tumors. A method for improving operability]. / Die präoperative angiographische Embolisation von Tumoren des Karotisglomus. Eine Methode zur Verbesserung der Operabilität.

During surgical resections carotid body tumors may bleed profusely due to their vascularity. Preoperative angiographic embolization of tumor-supplying arteries has reduced intraoperative blood loss significantly. The present study reviews our clinical experiences with 13 paragangliomas of the carotid bifurcation in 12 patients during the past 5 years. In 6 patients (46.1%) computed tomography and magnetic resonance imaging demonstrated extensive spread of the tumor up to the base of the skull. Tumors of this size were initially assessed as being inoperable but curative surgical resections were performed after embolization of tumor-supplying arteries by intravascular injections of Gelfoam and implantations of microcoils. Vascular reconstruction of the internal carotid artery by a saphenous vein graft was required in 4 patients (30.7%). In 3 malignant paragangliomas (23.0%) adjuvant radiotherapy of 50-60 Gy was administered to the tumor site after surgery. During an average follow-up of 29 months, one malignant paraganglioma was found to have recurred locally 13 months after initial therapy.

Paragangliomas of the carotid bifurcation: oncological aspects of vascular surgery.

The present study reviews in concise form the past 12 years of our clinical experience with paragangliomas of the carotid body. Every aspect of the anatomical, histological and biological and biological behaviour of paragangliomas of the carotid body has been recorded in order to be able to define better surgical management and the clinical prognosis. In addition to the conventional histological methods of investigation we also applied immunohistochemistry and made use of electron microscopy. Eighteen tumours of the carotid body in 12 female and four male patients with a mean age of 54 years (34 to 70 years) were treated surgically. Angiography of the aortic arch and supra-aortic branches was undertaken diagnostically in every case. In three patients computer tomography and magnetic resonance imaging demonstrated spreading of the tumour up to the base of the skull and pre-operative embolization of the arteries supplying the tumour was performed to decrease tumour vascularity. In four cases (22%) resection of the internal carotid artery and its reconstruction by a saphenous vein graft was required in order to achieve the therapeutic aim of a complete extirpation of tumourous tissue and preserving the vascular system of the internal carotid artery. In three cases (16%) there was histological evidence of a metastasizing process to the local lymph nodes of the neck and, due to this criterion of malignancy, 50-60 Gy of radiation was applied to the site of the tumour after surgery. Four patients experienced a transient neurological deficit in the supply area of the hypoglossal and the recurrent nerves. In one case, the vagus nerve could not be retained. In an average follow-up of 102 months we recorded one case of local recurrence 13 months after the initial resection and radiation treatment applied to a malignant paraganglioma. All the other patients were doing well without evidence of recurrent disease.

[Femoropopliteal vascular replacement: vein, ePTFE or ovine collagen?]. / Zur Problematik des femoropoplitealen Gefässersatzes: Vene, ePTFE oder ovines Kollagen?

In an eight year-period from 1988 to 1995 653 femoropopliteal and femorocrural bypasses were performed. 347 above-knee reconstructions 206 below-knee reconstructions and at last 100 femorocrural bypasses were analysed. The cumulative patency rate after a follow up of three years for above-knee vein bypasses was 90%, patency rate for PTFE grafts in the same period was 52%, for ovine collagen grafts 56%. For below-knee bypasses with autologous saphenous vein a function rate of 76% could be observed in the same period, the rate of PTFE grafts in this position was only 30%. In this position 3-year patency rates of 50% were achieved with ovine collagen grafts. This difference was statistically significant. Three years cumulative patency rate for femorocrural reconstructions with greater saphenous vein was 72%, the function rate for PTFE in this position was below 30% after a follow up of one year, with ovine grafts below 40%. Graft infection, aneurysm formation and postoperative mortality were low in all groups. Our data demonstrate, that patency rates of autologous vein bypasses could not be achieved with PTFE or ovine collagen prosthesis in any femoropopliteal the femorocrural position. We therefore cannot confirm the recommendation to use alloplastic grafts as primary choice for above knee bypasses to spare the saphenous vein.

[An interdisciplinary therapy concept in treatment of paragangliomas of the skull base--demonstrated with a case]. / Ein interdisziplinäres Therapiekonzept in der Behandlung von Paragangliomen der Schädelbasis--demonstriert anhand einer Kasuistik.

Surgical resection of paragangliomas in the cervical region is complicated due to the tumour vascularity and is associated with the risk of major intraoperative blood loss. Preoperative angiographic embolization of the tumour supplying arteries by intravascular injection of gelfoam and implantation of microcoils was performed to decrease tumour vascularity. We report the case of a 78 years old female patient suffering from a carotid body tumour. Computed tomography demonstrated spreading of the tumour from the carotid bifurcation up to the base of the skull. Primary surgical resection was aborted because of the bleeding tendency of the tumour. Tumour embolization was required in order to achieve the therapeutic aim of a complete extirpation of tumourous tissue by preserving the vascular system of the internal carotid artery. The reported case is completed by a review of literature.

Vascular complications of lumbar disc surgery.

Over a period of seven years nine patients with vascular complications after lumber discectomy received medical care at the Clinic of Vascular Surgery, University of Graz Medical School. We report five acute bleeding complications occurring during the operation and four late manifestations of vascular lesions. Five patients presented with acute life-threatening iatrogenic haemorrhages from pelvic vessels. Three patients made a complete recovery, one patient died from acute haemorrhagic shock, one further patient died from sepsis due to an associated complication-an injury to the ureter. Over a period of two to ten years after primary surgery we corrected late complications such as 1 case of posttraumatic aneurysm of the aortic bifurcation found to have eroded the body of the fifth lumbar vertebra, and three cases of arteriovenous fistula between the common iliac artery and the common iliac vein. The four cases described below are an attempt to document the vascular surgical procedures involved and to provide typical findings. The risk of injuring the pelvic vessels intra-operatively can be explained by the close anatomical relation between the retroperitoneal vessels and the vertebral column and furthermore not only by the fact that pre-existent deficiencies but also injury to the anterior longitudinal ligament give access to the retroperitoneal space.

[Local vascular complications after iatrogenic femoral artery puncture]. / Lokale Gefässkomplikationen nach iatrogener Femoralarterienpunktion.

Over a period of 5 years 81 vascular complications after 15,460 catheterizations of the femoral artery for diagnostic (n = 11,883) or therapeutic (n = 3577) procedures were registered. The following complications were observed in declining frequency: 1. False aneurysm (n = 65), 2. arterial occlusion (dissection, embolia, thrombosis) (n = 8), 3. vascular lesion causing profuse bleeding (n = 7), 4. AV-fistula (n = 1). The total complication rate was 0.52%. The complication rate was significantly higher in therapeutical procedures (1,03%) than in diagnostic investigations (0.37%). Pseudoaneurysms were complicated by thrombosis of the femoral vein (n = 3), lymphatic fistula (n = 3) and deep wound infection (n = 9); secondary complication rate 18.5%. Risk factors for local vascular complications are old age, female gender, high grade arteriosclerosis at the puncture site, overweight, manifest arterial hypertension and medication with cumarin, acetylsalicylic acid or heparin. Further complicating factors are connected with technical risks such as duration of the procedure. French size of the catheter, the catheter sheath and multiple punctures. Vascular repair was performed by simple angiography in most cases, but in 14.8% more extensive surgical procedures were required. In patients with signs of occlusive vascular disease the external iliac artery was replaced by a PTFE-vascular access graft in 4 cases and an arterioplasty of the deep femoral artery was performed in 2 patients. 36% of the operations were undertaken as emergencies. Reintervention was necessary for a postoperative bleeding complication in 1 case (surgical complication rate 1.2%). A female patient suffering from aortic valve stenosis died during emergency operation due to massive retroperitoneal hemorrhage after cardiac catheterization (mortality rate 1.2%). Over a median follow-up period of 37 months no late complications of the intervention were recorded, nor recurrences of peripheral arterial occlusive disease.

[Breast cancer in the male. A long-term follow-up study of 55 patients]. / Das Mammakarzinom beim Mann. Langzeitverlaufsbeobachtung an 55 Patienten.

Between 1964 and 1988, 55 male patients were treated for breast cancer. Fifty-one patients were treated by radical mastectomy; only four patients underwent a simple mastectomy. Nineteen cases received postoperative radiotherapy, eleven cases chemotherapy, six cases adjuvant hormonal therapy, and one patient was submitted to orchiectomy. The five-year survival rate for tumors with nodal metastases was 37%, as compared with 57% for patients with negative nodes.

[A solitary metastasis in the trapezium bone]. / Solitäre Metastase im Os trapezium.

Carpal bone is an uncommon location for metastases, and diagnostic problems can occur when a solitary metastasis mimics acute arthritis or osteomyelitis clinically as well as radiologically.