[Treatment of an uncommon case of a cardiogenic shock : Simultaneous use of a VA-ECMO and an Impella-CP®]. / Die Behandlung eines ungewöhnlichen kardiogenen Schocks : Simultaner Einsatz einer VA-ECMO und einer Impella-CP®.

We report the case of a 48-year old woman where probably the intramuscular administration of glucocorticoids by an orthopedist induced a pheochromocytoma crisis. The development of a cardiogenic shock with a cardiac arrest made the use of a venoarterial extra corporeal membrane oxygenation (VA-ECMO, Cardiohelp®, Maquet, Rastatt) necessary. To treat a pulmonary edema under VA-ECMO an Impella-CP® (Abiomed, Aachen) was implanted. A coronary angiography, endomyocardial biopsies and a computer tomography were performed. Finally a 7 cm × 5 cm tumor mass in the left adrenal medulla was detected. The blood values presented high levels of catecholamines. The total results of the examinations led us to the final diagnosis of a pheochromocytoma which was finally surgical removed.

[Seminal vesicle cystadenoma as the cause of a retrovesical tumor]. / Zystadenom der Samenblase als Ursache einer retrovesikalen Raumforderung.

Tumors of the seminal vesicle are rare. Malignant tumors are more common than benign tumors. A seminal vesicle cystadenoma is a rarity. We report on a 41-year-old man with the incidental finding of an asymptomatic retrovesical tumor. The tumor, the seminal vesicle, and the abdominal part of the ductus deferens were surgically removed. The operative access is variable and surgical treatment is the method of choice. The patient's prognosis is good and there are no signs of recurrence.

Guidelines for the genetic diagnosis of hereditary recurrent fevers.

Hereditary recurrent fevers (HRFs) are a group of monogenic autoinflammatory diseases characterised by recurrent bouts of fever and serosal inflammation that are caused by pathogenic variants in genes important for the regulation of innate immunity. Discovery of the molecular defects responsible for these diseases has initiated genetic diagnostics in many countries around the world, including the Middle East, Europe, USA, Japan and Australia. However, diverse testing methods and reporting practices are employed and there is a clear need for consensus guidelines for HRF genetic testing. Draft guidelines were prepared based on current practice deduced from previous HRF external quality assurance schemes and data from the literature. The draft document was disseminated through the European Molecular Genetics Quality Network for broader consultation and amendment. A workshop was held in Bruges (Belgium) on 18 and 19 September 2011 to ratify the draft and obtain a final consensus document. An agreed set of best practice guidelines was proposed for genetic diagnostic testing of HRFs, for reporting the genetic results and for defining their clinical significance.

[Posthepatic icterus caused by a solitary granular cell tumor of the common bile duct]. / Posthepatischer Ikterus durch einen solitären Granularzelltumor des Ductus choledochus.

We report a case of a 26-year-old female patient who was referred to our hospital with a painless jaundice. By means of an ERCP we found a nearly complete occlusion of the common bile duct caused by a tumor. After stenting and normalization of the cholestasis parameters, additional investigations such as endosonography, cholangioscopy and MR angiography no longer showed any manifestation of the tumor. The histological and cytological specimens did not confirm a malignant process. As there was apparently only a solitary tumor a resection according to Whipple was performed. The histological examination showed a granular cell tumor. This case report demonstrates that a posthepatic icterus may rarely be caused by a granular cell tumor. Furthermore, it clearly shows the difficulty to correctly diagnose a tumor in the extrahepatic common bile duct as one may often have to rely solely on imaging procedures.

[Forensic aspects of complicated laparoscopic cholecystectomy]. / Forensische Aspekte der kompliziert verlaufenen laparoskopischen Cholecystektomie.

As laparoscopic cholecystectomy becomes more established, interest in legal aspects increases. The legal cases dealt with in Germany since the introduction of this laparoscopic method in 1989 were studied to determine the legal consequences of complications. Of 40 cases, 16 were judged to be cases of malpractice, whereas 24 were not. The most common cause was injury of the common bile duct (26 cases). Seven of these 26 cases were judged to be cases of malpractice, 2 of these as grave errors. The main reasons for the acceptance of a case as malpractice were delay in changing to conventional cholecystectomy, delayed revision, laparoscopic revisions and not reverting to conventional cholecystectomy in unclear situations.

[Quantitative assessment of catecholamine secretion as a rational principle of anesthesia management in pheochromocytoma surgery]. / Quantitative Erfassung der Katecholaminsekretion als rationale Grundlage des Anästhesiemanagements bei Phäochromozytomexstirpation.

AIM OF THE STUDY: Fifteen patients with phaeochromocytoma who underwent surgery were studied consecutively. METHODS: They received either (10) a balanced anaesthesia technique with isoflurane and fentanyl or (5) a combination of propofol and alfentanil for total intravenous anaesthesia. EEG processing was performed in order to guarantee adequate anaesthetic depth. Antihypertensive therapy was performed with sodium nitropusside. Continuous blood sampling was performed with a roller pump and an autosampler system in order to get high resolution measured of plasma catecholamines. Their concentration was measured by HPLC with electrochemical detection. RESULTS: There were 100fold differences in the maximal catecholamine concentrations during phaeochromocytoma resection between patients. In some cases adrenaline and noradrenaline levels exceeded normal values by a factor of 1000 to 1500. Secretion rates were calculated on a pharmacokinetic basis an revealed secretion rates of 0.3 to 97.3 micrograms/min for adrenalin and 6.7 und 402.8 micrograms/min for noradrenaline. If systolic blood pressures were greater than 160 mmHg sodium nitroprusside was given by infusion with a rate of 300 +/- 315 micrograms/min. Over a period of 69.2 +/- 39.8 min during resection of the tumor the total dose was 7017 +/- 12433 micrograms. CONCLUSIONS: There were positive correlations between plasma catecholamine concentrations, systolic blood pressure values, and infusion rates of sodium nitroprusside. The comparison of the two anaesthetic techniques resulted in a significant reduction of antihypertensive therapy and more stable haemodynamics in patients with total intravenous anaesthesia. However, the beneficial effect of this anaesthesia regimen has to be proven on a larger basis of patients in a randomized manner.

[Bile duct injuries after laparoscopic cholecystectomy]. / Gallengangsverletzungen nach laparoskopischer Cholezystektomie.

Injuries to the extrahepatic bile duct present a severe complication in laparoscopic cholecystectomy occurring in 0-2.6%. From June 1991 to September 1994 four patients were treated to the Department of Surgery at Bonn University with bile duct injuries after laparoscopic cholecystectomy. All had complete sections of the common bile duct. They were treated twice with a biliodigestive anastomosis and once by direct suturing of the d choledochus. One of our own patients suffered an injury of the right hepatic duct, most probably due to a thermic lesion. In all cases anatomy was irregular or unclear. To avoid these complications an intraoperative cholangiography should be performed in these situations. The reconstruction after inadvertent injuries of the bile duct depends on the localisation and the age of the lesion.

[Color-coded duplex sonography in postoperative evaluation of aortic aneurysms]. / Die farbkodierte Duplexsonographie in der postoperativen Beurteilung von Aortenaneurysmen.

One hundred patients with infrarenal abdominal aortic aneurysms were treated by surgery. Fifteen deaths occurred postoperatively. Eleven patients died during the follow-up of a medium period of 13 months. Three patients with a ruptured aneurysm died intraoperatively before the graft was implanted. Three patients were lost to follow-up. Sixty-four patients were examined with colour-coded Duplex sonography after surgical repair. Colour-coded Duplex sonography was able to image the aortic prostheses with the adjacent major vessels. Fifty-eight patients showed a normal prosthesis, 3 dilatation proximal of the prosthesis, 1 dilatation distal of the prosthesis, 1 mild stenosis, 1 haematoma. Colour-coded Duplex sonography imaged the intraluminal space of the prosthesis more easily than ultrasound. Colour-coded Duplex sonography was able to differentiate between intraluminal and extraluminal lesions.

Tc-99m labeled monoclonal antibodies against granulocytes (BW 250/183) in the detection of appendicitis.

Scintigraphy with Tc-99m labeled antigranulocyte antibodies (BW 250/183 MoABs) was performed in 32 patients with suspected appendicitis. Abdominal imaging (planar/SPECT) was performed 2 hours after injection of the tracer. All patients also had surgery and a histologic examination of the resected tissue. Of the patients, 17 suffered from "acute appendicitis" and 12 had right positive scans (sensitivity = 70.6%). In 15 patients, acute appendicitis could have been ruled out, and in 11 of these cases the scan was true negative (specificity = 73.3%). The overall accuracy was 71.8% (23/32 cases). The use of Tc-99m antigranulocyte MoABs may overcome the problems associated with the Tc-99m HMPAO granulocyte and In-111 oxine approaches, which include nonspecific intestinal activity or the lack of timeliness. The use of Tc-99m labeled antigranulocyte antibodies is suitable as an emergency procedure and may play a role in the management of patients with suspected appendicitis.

[MR venography in deep venous thromboses of the leg and pelvis. A comparison of 2D single layer images and 3D MIP reconstructions with phlebography]. / MR-Venographie bei tiefen Bein- und Beckenvenenthrombosen. Vergleich von 2D-Einzelschichtbildern und 3D-MIP-Rekonstruktionen mit der Phlebographie.

A total of 22 MR venograms were performed in 7 volunteers and 15 patients suspected of deep vein thrombosis of the lower limb and pelvis. MR findings were compared to conventional venography in all patients. MR venography is a reliable method for the exclusion of thrombosis proximal to the popliteal vein. In the calf veins, diagnosis of thrombosis is not yet reliable. For MR venography 2D-time-of-flight-inflow-technique and secondary 3D-MIP reconstructions were used and compared to each other. With both methods there were no false negative results in comparison to conventional venography. 2D single slice MR venography showed two false positive results in iliac and one in popliteal vein. MIP 3D reconstructions led to seven false positive results (three iliac, two femoral, two popliteal). The exclusive interpretation of MIP-3D reconstruction is not reliable for decision-making in deep venous thrombosis.

[99mTc-anti-granulocyte antibodies (BW 250/183) in the detection of appendicitis]. / 99mTc-Anti-Granulozyten-Antikörper (BW 250/183) zum Nachweis der Appendizitis.

Scintigraphy with 99mTc-labeled anti-granulocyte antibodies (AGAb) was performed in 50 patients with suspected appendicitis. Sequential and static imaging as well as SPECT of the pelvis and abdomen was performed 2 h p.i. In all patients the diagnosis was confirmed either histologically or by long-term follow-up. 13 patients had histologically proven acute appendicitis. In 11 patients the appendix scan had been positive and in 2 patients the scan had shown no significant tracer uptake in the right lower abdomen. The remaining 37 patients turned out not to have acute appendicitis. 29 out of these patients had negative and 3 had positive scan findings. In 5 patients the scan was equivocal. Out of these patients 2 had pathologic findings on the left side of the abdomen which turned out to be acute diverticulitis in one patient and acute peritonitis in the other. The remaining 3 patients with unclear scintigraphic findings had no acute appendicitis. Scintigraphy with AGAb is fast and easy to perform and thus superior to cell labeling methods for diagnosing acute appendicitis. Sensitivity for the diagnosis of acute appendicitis was 85% with a specificity of 91%. Chronic or scarred non-granulocytic appendicitis--in which there is often no definite indication for surgery--was negative in our study except for two cases.

[Boerhaave syndrome in pyloric hyperplasia]. / Boerhaave-Syndrom bei Pylorushyperplasie.

Boerhaave's-syndrome is a rare illness, usually caused when sudden intense vomiting leads to a spontaneous rupture of the healthy esophagus. Alcoholism and neurological diseases are considered to be the main predisposing factors. Because the complaint is so rare the casuistic of Boerhaave's-syndrome is described in connection with pyloric stenosis. In order to confirm the diagnosis the following practice is recommended: During gastrografin swallowing the pylorus should be examined in order to remedy the possible cause of the complaint when the operative therapy is carried out.

[Age determination of venous thrombi by ultrasound]. / Altersbestimmung venöser Thromben im Ultraschall.

In addition to diagnosing deep-vein thrombosis of the lower limb and pelvis, determination of the age of the thrombus is of considerable importance in guiding treatment. The present study was done to find out whether thrombus age can be determined by ultrasound morphology. 138 examinations were carried out on 76 lower limbs with phlebographically demonstrated thrombosed veins. Diameter of the thrombosed vein, echogenicity of the thrombus and demarcation of the venous wall from its surroundings were determined by colour-coded duplex sonography. The results were compared with histological evidence or with the age of the thrombus as determined by history and clinical course. The diameter of the thrombosed vein in conjunction with the history and clinical data makes it possible to determine the age of a thrombus. Echogenicity of the thrombus and demarcation of the venous wall do not provide any reliable information on thrombus age.

[Accomplishments of tumor surgery in tumors of the stomach]. / Leistungen der Tumorchirurgie bei Tumoren des Magens.

Accomplishments of gastric cancer surgery include (1) reduced operative risk, (2) surgical strategy based on histology and location of the carcinoma, (3) more operative radicalness (gastrectomy with extended lymph node dissection), (4) prolonged survival time and (5) adjuvant therapy (cytostasis, immunological treatment, intraoperative radiotherapy). In 1,070 patients the resection rate changed from 56% to 75%, the lethality rate of gastrectomy fell from 28% to 1.1% while the rate of gastrectomy increased from 21% to 68%. The stage of the tumor of operation influences the five-year-survival rate. As an additional treatment intraoperative radiotherapy has been introduced at our clinic.

[Roentgenologic contribution to the diagnosis of gallstone ileus]. / Röntgenologischer Beitrag zur Diagnostik des Gallensteinileus.

Between 1969 and 1982 8 patients of ours were operated on for gallstone ileus. Signs found in the preoperative x-ray examination indicating this condition are analyzed retrospectively. The frequency and specificity of the x-ray signs found in the abdominal survey radiograph are compared with those reported in the literature. The value of oral contrast media administration in the detection of a cholecystointestinal fistula and localization of the obstruction is discussed.

[Gastroduodenal surgery in patients over 80]. / Gastroduodenale Chirurgie bei Patienten über 80 Jahre.

Between 1969 and 1981 surgery was performed in 118 patients over eighty years old with gastroduodenal diseases. The main indications were carcinomas and ulcers. The combined mortality amounted to 34.8%. One of the main problems of surgery in elder patients turned out to be the simultaneous presence of accompanying diseases. Whenever possible surgery should be performed before the onset of complications.