Intraoperative chemiluminometric assay for simplified localization of parathyroid adenomas during surgery for primary hyperparathyroidism

Hyperparathyroidism is no longer considered an uncommon endocrinopathy. Between 1994 and 2002, 138 patients underwent neck exploration for primary hyperparathyroidism at the Department for Surgery in the University Hospital of Dresden. Common reasons for operation failure are usually hyperplasia or remnant parathyroid tissue, inadequate parathyroidectomy at initial operation or the occurrence of abnormal hyperfunctioning supernumerary glands. To reduce the operation time, as well as the failure rate that accompanies the incomplete excision of hypersecreting parathyroid tissue, we perform an intraoperative monitoring of parathyroid hormone with an immunochemiluminometric assay (Nichols Advantagetrade mark Intact PTH). With modification of this assay, it was possible to perform the assay in the operating theatre and to attain the hormone values within 10 min. In all cases of successful operation with excision of the adenomatous parathyroid gland the PTH values declined to under 20 percent of the initial intraoperative PTH values. Our results declare the intraoperative parathyroid hormone monitoring as a cost-effective method to control the effect of surgical treatment.

[Antithrombotic therapy after peripheral vascular treatment: what is evidence-based?]

Peripheral arterial occlusive disease is one manifestation of the systemic disease atherosclerosis. The initial therapy for every arteriosclerotic disease is aimed at reducing cardiovascular risk factors by lifestyle modification and medication. Patients who require surgical revascularisation need long-term antiplatelet therapy or anticoagulation. This therapy has to be differentiated according to the vascular territory involved and the method used for revascularisation. After local thrombendarterectomy, alloplastic bypass graft surgery of the aortic, aorto-iliac, aorto-femoral or femoro-popliteal region above the knee, long-term ASA 100 mg/d or clopidogrel 75 mg/d should be initiated. After alloplastic bypass grafting below the knee the combination of ASA 100 mg/d and clopidogrel 75 mg/d should be used. In contrast, after venous grafts the patency rate is improved by anticoagulation with vitamin K antagonists (INR 2-3), if there is a low risk of bleeding. If there is a contraindication to vitamin K antagonists, ASA 100 mg/d should be used. After revascularisation, a structured surveillance programme should be implemented aiming at controlling cardiovascular risk factors and monitoring the vascular state, as well as the anticoagulation and the antiplatelet therapy.

Presence of Borrelia burgdorferi sensu lato antibodies in the serum of patients with abdominal aortic aneurysms

Infectious agents are likely to play a role in the pathogenesis of chronic inflammatory diseases, including abdominal aortic aneurysms (AAAs). The goal of this study was to determine if Borrelia burgdorferi sensu lato (sl), a microorganism responsible for Lyme disease, is involved in the etiology of AAAs. The presence of serum antibodies against B. burgdorferi sl was measured with enzyme-linked immunosorbent assay (ELISA) and confirmed by Western blotting in 96 AAA and 108 peripheral artery disease (PAD) patients. Polymerase chain reaction (PCR) was used for the detection of Borrelia-specific DNA in the aneurysm wall. Among AAA patients 34% and among PAD patients 16% were seropositive for B. burgdorferi sl antibodies (Fisher's exact test, p = 0.003; odds ratio [OR] 2.79; 95% confidence interval [CI] 1.37-5.85). In the German general population, 3-17% are seropositive for Borrelia antibodies. No Borrelia DNA was detected in the aneurysm wall. Our findings suggest a relationship between AAAs and B. burgdorferi sl. We hypothesize that the underlying mechanism for B. burgdorferi sl in AAA formation is similar to that by the spirochete Treponema pallidum; alternatively, AAAs could develop due to induced autoimmunity via molecular mimicry due to similarities between some of the B. burgdorferi sl proteins and aortic proteins.

[Imaging diagnostics of osteitis, osteomyelitis and joint infections]

Imaging diagnostics and surgical treatment of bone and joint infections are of paramount interest. The main purpose of our survey is to give a detailed overview about methods, indications, image criteria and efficiency of imaging diagnostics as a state of the art presentation. In conclusion we attempt to give some recommendations for clinical scenarios and diagnostic procedures concerning bone and joint infections. This paper has been prepared under the patronage of the AG Septische Chirurgie of the Deutsche Gesellschaft für Unfallchirurgie in Germany. It is our aim to update the paper with respect to the technical and clinical improvements and to publish it again after a number of years.

Rupture prone aneurysm of the inferior mesenteric artery complicated by mid aortic syndrome with occluded celiac and superior mesenteric arteries

We present the case of a 45-year-old male patient with a large aneurysm of the inferior mesenteric artery complicated by mid aortic syndrome with occlusion of the celiac trunk and superior mesenteric artery. The vascular pathology was detected by CT imaging after presentation and hospitalization with symptoms of acute cholecystitis. After resolve of the acute symptoms, the aneurysm was resected and the proximal inferior mesenteric artery interponated with a reversed saphenous vein bypass graft. Besides presenting this case we review the literature concerning the rare descriptions of inferior mesenteric artery aneurysms.

Neurodegenerative diseases of the retina and potential for protection and recovery

Recent advances in our understanding of the mechanisms in the cascade of events resulting in retinal cell death in ocular pathologies like glaucoma, diabetic retinopathy and age-related macular degeneration led to the common descriptive term of neurodegenerative diseases of the retina. The final common pathophysiologic pathway of these diseases includes a particular form of metabolic stress, resulting in an insufficient supply of nutrients to the respective target structures (optic nerve head, retina). During metabolic stress, glutamate is released initiating the death of neurones containing ionotropic glutamate (N-methyl-D-aspartat, NMDA) receptors present on ganglion cells and a specific type of amacrine cells. Experimental studies demonstrate that several drugs reduce or prevent the death of retinal neurones deficient of nutrients. These agents generally block NMDA receptors to prevent the action of glutamate or halt the subsequent pathophysiologic cycle resulting in cell death. The major causes for cell death following activation of NMDA receptors are the influx of calcium and sodium into cells, the generation of free radicals linked to the formation of advanced glycation endproducts (AGEs) and/or advanced lipoxidation endproducts (ALEs) as well as defects in the mitochondrial respiratory chain. Substances preventing these cytotoxic events are considered to be potentially neuroprotective.

[Arterial injuries combined with open fractures--management and therapy]

Vascular injuries are an uncommon finding. In times of peace vascular injuries occur in approximately 1-4 % during traffic accidents. Especially challenging is the treatment of open fractures combined with arterial lesions. These fractures are usually accompanied with severe soft tissue damage and injuries to neurological structures. The overall prognosis of these trauma patients is dependent on fast and sufficient diagnostics and therapy. In particular, for unstable patients time-consuming diagnostics can be dispensed and a primarily operative therapy should be targeted. Vascular reconstruction by direct suture is sometimes only possible with interposition and should be the primary goal. Interposition should be performed with autologous vein material because of the high risk of infection. Here we demonstrate on the basis of our patients the interdisciplinary -management of such trauma patients in our hospital.

Isolated aneurysm of the internal jugular vein

True venous aneurysms are rare. We report the case of a 70-year-old male with the extremely uncommon finding of an aneurysm of the internal jugular vein. Due to their rarity, no general guidelines for the treatment of these aneurysms have been established. Upon surgical exclusion of the aneurysm, a progressive swelling of the right side of the face was noted in this patient leading to the decision to interpose a thin-walled ePTFE prosthesis for want of a suitable vein graft. Upon follow-up three years later, the patient is completely asymptomatic and the prosthesis is patent in Doppler sonography.

[Analysis of tissue inhibitor of metalloproteinase-2 gene polymorphisms in a caucasian population with abdominal aortic aneurysms]

BACKGROUND

The formation of sporadic abdominal aortic aneurysm (AAA) is explained by a remodelling of the extracellular matrix (ECM) and breakdown of structural components of the vascular wall. Matrix metalloproteinases are the principle matrix-degrading proteases and are known to play a major role in the remodelling of the extracellular matrix in arterial vessels. Their activity is controlled by tissue inhibitors of metalloproteinases (TIMPs). Decreased TIMP-1 and TIMP-2 expression in the extracellular matrix of the walls of AAAs has been demonstrated in several studies. This case-control study was designed to investigate the possible impact of genetic variants of the TIMP-2 gene in the aetiology of AAA and to reproduce a recently described significant difference in allele frequency of the SNP 303G>A in a German population.

METHODS

TIMP-2 single nucleotide polymorphisms (SNPs) were analysed in a study sample of 50 patients with AAA and 41 controls. Differences in genotype and allele frequencies of the identified polymorphisms were determined after sequencing the entire coding region and selected parts of the promoter using the automated laser fluorescence technique.

RESULTS

Six polymorphisms were identified, one of which is described for the first time, located in the intron, (231+23C>T). An association of the SNP 303G>A with the phenotype was not confirmed in our study (p=0.648). However, the CT genotype of the SNP -479C>T was more frequent in patients with AAA than in the control group (p=0.054).

CONCLUSIONS

In our analysis of the TIMP-2 gene, we identified one new SNP. A previously published association of the SNP 303G>A with the phenotype could not be validated in our population. However, we detected an association for the CT genotype of one polymorphism in the promoter region (g-479C>T) and AAA. This result has to be proved in a second study sample.

[Misleading anisocoria in a comatose 15-year-old with head injury]

Anisocoria after blunt head trauma, associated with altered vigilance, is not unusually assumed to expanding intracranial mass lesion. Obvious signs of head-trauma and vomiting might strengthen this diagnosis. We report from an unconscious 15-year-old girl (Glasgow-Coma-Scale score 3) that showed these symptoms secondary after head-trauma due to alcohol intoxication but turned out to be misleading after cranial computed tomography (CT). Surprisingly, an artificial eye was found that previously remained undetected in clinical examination. Artificial eyes implemented after enucleation therapy in retinoblastoma or eye-trauma are nowadays perfectly fitting. Prehospital discrimination of artificial eyes and natural eyes might be difficult in comatose emergency patients. Neurological examination should check corneal reflex and manual palpation of the bulbus. Independent from anisocoria, patients presenting GCS 3 and head injury need rapid admission to CT-diagnostic, neurosurgical treatment respectively.

[Ventral fusion of a fracture of the cervical spine in ankylosing spondylitis and struma permagna]

Fractures of the cervical spine in ankylosing spondylitis are rare. The rate of neurological complications is increased compared to fractures of the normal spine. Concerning its mechanical characteristics the ankylosing spine is similar to a long bone. Because of the deformity and the stiffness of the spine conventional orthoses do not provide enough stability and individualized techniques are necessary to perform safe rescue and transport. Because of severe instability an operation is indicated in most cases. The most stable fixation is the combined ventral and dorsal fusion. The dorsal approach is associated with an increased rate of complications, so we favour primary ventral fusion with long interlocking plates. This can be done even in difficult anatomic situations. If the screws can be tightened well, additional dorsal fusion is not necessary.

Contrast-enhanced ultrasonography to detect liver metastases : a prospective trial to compare transcutaneous unenhanced and contrast-enhanced ultrasonography in patients undergoing laparotomy

BACKGROUND/AIMS

The advent of contrast-enhanced ultrasound (CEUS) has called into question the efficacy of standard ultrasonographic techniques. In this study, we evaluated B-mode and color-duplex imaging and CEUS in the detection of liver metastases, using intraoperative and histological findings as a reference.

MATERIALS AND METHODS

Before laparotomy, 108 patients suspected of having liver metastases were prospectively examined with B-mode and color-duplex imaging, followed by contrast-enhanced ultrasound (2.4 ml SonoVue). Patients with unresectable tumors (n=8) were excluded from the analysis. The sonographic diagnosis in the remaining 100 patients was compared to the intraoperative and histological findings.

RESULTS/FINDINGS

CEUS improved the sensitivity for detecting liver lesions from 56.3% (B-mode) to 83.8% (CEUS) (p=0.004). In particular, the contrast agent led to an improvement in ultrasonographic detection in the following cases: nodular metastases smaller than one centimeter; after adjuvant chemotherapy; for tumors near the surface of the liver; and for lesions situated around the ligamentum teres.

INTERPRETATION/CONCLUSIONS

CEUS provides significant improvement in the detection of liver metastases, and should therefore, be performed routinely in the surveillance of cancer patients.

Matrix metalloproteinase 2 polymorphisms in a caucasian population with abdominal aortic aneurysm

BACKGROUND

The formation of sporadic abdominal aortic aneurysm (AAA) is explained by remodeling of the extracellular matrix (ECM) and breakdown of structural components of the vascular wall. Matrix metalloproteinase 2 (MMP2) is one of the principal matrix-degrading proteases and is known to play a major role in the remodeling of the extracellular matrix in arterial vessels. Increased MMP2 expression in the extracellular matrix of the walls of AAAs has been shown in several studies. To investigate the possible impact of genetic variants of the MMP2 gene in the etiology of AAA, we conducted this case-control study.

PATIENTS AND METHODS

We analyzed MMP2 single-nucleotide polymorphisms (SNPs) in 51 patients with AAA and 48 controls. Differences in genotype and allele frequencies of identified polymorphisms were determined after sequencing the entire coding region and three selected parts of the promoter.

RESULTS

Eighteen polymorphisms were identified, 6 of which are newly described, with 3 located in the introns (c.IVS1+31C>G, c.IVS7-18G>A, c.IVS10+26C>T) and 3 located in the coding region (c.124G>A, c.1368C>T, c.1860C>T). There were no statistically significant differences in genotype or allele frequencies between the two groups.

CONCLUSIONS

Our analysis of the entire coding region and three parts of the promoter of the MMP2 gene failed to show an association between genetic polymorphisms and AAA, suggesting that variations in the MMP2 gene do not contribute to the development of AAA.

[Therapeutic options in the treatment of pyogenic liver abscess]

BACKGROUND/AIMS

Pyogenic liver abscess is a rare and life-threatening disease. Our aim is to discuss the aetiology and problems of diagnosis and treatment of this disease, based on our own clinical experience. We present and compare different therapeutic options, i. e. ultrasound-guided percutaneous abscess drainage, CT-guided drainage and open surgical drainage.

PATIENTS/METHODS

In a time period of 8 years, 62 patients with pyogenic liver abscesses were treated. The therapeutic procedure used most frequently was ultrasound-guided percutaneous abscess drainage in 41 patients, followed by CT-guided drainage in 13 cases. 8 patients were primarily treated with surgical drainage or liver resection, respectively.

RESULTS

With an overall mortality of 9.6 % we achieved an encouraging result. The comparison of mortality between groups treated with ultrasound-guided percutaneous abscess drainage (7.3 %) and CT-guided drainage (7.7 %) revealed no significant prognostic difference. The comparison of local complications and drainage failure between ultrasound-guided percutaneous abscess drainage (2.4 %) and CT-guided drainage (15.4 %), however, showed better results for the ultrasound-guided interventions (1/41 vs. 2/13 patients). Two patients undergoing open surgical drainage died due to an advanced septic shock syndrome.

CONCLUSIONS

Our study suggests that ultrasound duplex imaging with percutaneous abscess drainage is a reliable and effective approach for the treatment of pyogenic liver abscess. Based on other studies in the literature and our own results we developed a diagnostic and therapeutic algorithm for the treatment of liver abscesses.

Quality of Life and Long-term Results After Ruptured Abdominal Aortic Aneurysm

OBJECTIVES

Quality of life as an endpoint of surgery and the long-term prognosis for patients who have survived surgery for a ruptured abdominal aortic aneurysm (RAAA) is not well-documented.

PATIENTS AND METHODS

The records of all patients from 1993 to 2000 who underwent resection of RAAA were reviewed. Survival data were calculated from direct contact with the patients or follow-up records. All patients who were alive at the time of our study were invited to participate in follow-up investigations. They received the internationally comparable WHO-QOL-BREF-test.

RESULTS

In a period of 7 years, 80 patients underwent surgery for RAAA. The average follow-up time was 5.1 years (1-7.9 years). Our data show that 51% of our patients died within 6 months postoperatively because of the complications of the aortic rupture (in-hospital mortality 39%). Patients who survived the first 6 months after surgery died for the same reasons as the normal population. However, patients who were younger than 75 at the time of RAAA had a higher relative survival rate than a matched sample of the population. There was no significant difference in the quality of life between the study group and the general population.

CONCLUSIONS

RAAA survivors had no difference in long-term survival as compared to the general population and also had very few long-term complications. The WHOQOL-BREF-test suggests that the quality of life of survivors of RAAA is similar to the general population.

Prevalence and treatment of bleeding complications in chronic pancreatitis

OBJECTIVES

As spontaneous major haemorrhage in patients with chronic pancreatitis is rare, limited data have been reported, and no evidence-based guidelines are currently available regarding the optimal treatment modality.

PATIENTS AND METHODS

We report our experience with 36 patients with severe bleeding complications from a series of 541 patients presenting with chronic pancreatitis (representing a prevalence of 6.7% of admitted patients), treated in one surgical department over a period of 9.5 years, with a median follow-up of 4.1 years.

RESULTS

Haemorrhage was indirectly related to chronic pancreatitis in eight patients (22.2%) with ulcer or variceal bleeding. Three patients (8.4%) demonstrated spleen infarction or rupture. The most common causes of major haemorrhage were pseudoaneurysms in 25 patients (69.4%). Nine of them were treated with primary embolization. Sixteen patients with pseudoaneurysms underwent surgery. The only mortalities (8.3%) observed were from bleeding-associated complications of pseudoaneurysms. Two patients died after surgery, and one after primary embolization. We observed a higher re-bleeding rate after surgery (25% vs 11% after embolization). The presence of haemorrhagic shock, and the amount of blood transfused, were significant determinants of hospital mortality. Patient age, pseudoaneurysm location, and treatment modality had no significant influence on mortality.

CONCLUSIONS

Any haemodynamically stable patient with haemorrhage due to arterial pseudoaneurysms should undergo angiography with embolization when technically possible. If there are no other pancreas-related indications for surgery, embolization remains the definitive treatment. If embolization is not available or has failed, surgery is indicated, although perioperative morbidity will be higher.

Das dermatologische Konsil

BACKGROUND

Dermatology and venereology, as a cross-sectional discipline, plays an important role in the interdisciplinary care of inpatients. Nonetheless, only a few studies on dermatological consultations have been performed. We reviewed the dermatological consulting service at the University Hospital of the Martin-Luther-University, Halle, Germany.

PATIENTS AND METHODS

All consultations performed in 2001 and 2002 were retrospectively assessed. In addition, the time spent in consulting activities was prospectively recorded over a period of six months (January-June 2003).

RESULTS

A total of 2390 consultations were evaluated. Most of the consultations (42.8%) were made on internal medicine wards, followed by pediatrics (11.7%), neurology (9.9%) and cardiothoracic surgery (5.7%). Infectious skin diseases accounted for the most frequent diagnosis at 24.4%. The time lapse between request and performance of the consultation averaged 1.1 days. Patients older than 40 years needed dermatological consultation more frequently than younger patients. The duration of consultation averaged 23 minutes (time to site, patient examination, documentation). Thus, the man-hours required for the consulting service is 33.6 per month.

CONCLUSION

The study emphasizes that dermatological consultation services make an important contribution to the care of inpatients. In light of increasing specialization in medicine, the consulting service guarantees interdisciplinary treatment of the patients and is thus an important quality parameter for inpatient care.

Infragenicular polytetrafluoroethylene bypass with tapered versus straight vascular grafts: results from a prospective multicenter cohort study

Both straight and tapered arterial grafts are commonly used for infragenicular bypass surgery. Opinions vary considerably regarding the use of each type of graft and depend on individual experience, as no trial yet has assessed clinical outcomes comparing both groups. We conducted a prospective, multicenter, cohort study to analyze results for each graft type. From a total of 81 patients, 50 underwent infragenicular bypass surgery with straight PTFE prostheses and 31 with tapered prostheses in a prospective, multicenter trial. Six different centers for vascular surgery took part in the trial. In clinical follow-up at discharge as well as 3, 6, 12, 18, 24, and 36 months after revascularization, various parameters were evaluated comparing patency rates, limb salvage, and major amputation rates. Significant differences were found in limb salvage rates between the two groups. Patients receiving a straight graft fared better in this regard. Further data suggest that short-term primary patency is also improved in straight prostheses. Sixty-four percent of these remained patent after 1 year, while only 50% of tapered prostheses were still patent. No differences between the groups were found for secondary patency. The advantages of straight prostheses seem to be reduction of thrombus formation and intimal hyperplasia. Furthermore, it appears that the surgeons participating in this study prefer the use of straight prostheses. Even though the group of patients that received tapered grafts had slightly more unfavorable preoperative conditions, the data still support the superiority of straight vascular grafts. However, prospective randomized trials are necessary to evaluate the benefit of different bypass designs definitively.

[Results and complications of ruptured abdominal aortic aneurysm repair]

During 1993 to 2000 85 patients were treated for a ruptured abdominal aortic aneurysm. The average age of the patients was 72.4 years (46-90). 71 patients showed an infrarenal rupture and the remaining 14 a suprenal rupture. 76 of 85 cases were covered ruptures. All patients were operated upon. A tube graft was required in 43 cases and 31 needed a bifurcated graft. In further two cases an extraanatomical bypass was necessary due to a mycotic aneurysm. The operation on 11 patients could not be completed and 21 patients died in hospital during the postoperative period. On the other hand, 53 patients survived the rupture of the aneurysm. The mortality rate was 37.6 %. The early non-surgical complications dominated during the postoperative period. Respiratory failure, renal failure and cardiac failure were responsible for the mortality rate. It is unforseeable which patients will survive the emergency operation. Therefore it is always appropriate to attempt the reconstruction of an acutely ruptured AAA.

[Jejunal reservoir for pouch. Anal reconstruction]

Jejunal reservoir for pouch. Anal reconstruction. For restaurative proctocolectomy the ileal J-pouch is a world-wide accepted procedure. In some cases the mesenteric vascular anatomy does not allow to bring the ileum down to the dentate line. In these patients a jejunal reservoir can be a good alternative. The different architecture of arteries and veins within the jejunal mesentery makes the bridging of a longer distance possible. Within a group of 38 restaurative proctocolectomies, jejunal pouch was performed in 2 cases. Failure of an ileal pouch was the reason in one patient. In the other, the ileal mesentery was too short to achieve a tension free ileal pouch-anal anastomosis. The functional result is good in both cases.

[Therapy of deep leg vein thrombosis. When is surgical therapy indicated?]

In spite of quite a few clinical trials the benefit of venous thrombectomy is seen controversially. The primary objectives of treating venous thrombosis are survival rate, prevention of pulmonary embolism and of postthrombotic syndrome. We report our experience with 47 patients who underwent venous thrombectomy. The mortality rate was 0%. We did not observe clinically relevant pulmonary embolism. After two years 90% of thrombectomised veins were patent. The mortality rates given in the literature of conservative treatment with heparin and following oral anticoagulation are 0.4 to 1.6%. Fibrinolysis shows mortality rates of 1 to 2.4, and thrombectomy of 3.8%, respectively. Venous thrombectomy is an effective treatment to prevent pulmonary embolism. In our own experience we saw no clinically significant pulmonary event. The danger of embolism rises with the proximity of the venous thrombus. Therefore those patients may have the greatest potential benefit from thrombectomy who present with a mobile inguinal thrombus or a thrombus in the iliac vein. So far there are no statistically sufficient data to support the indication of thrombectomy to prevent a postthrombotic syndrome.