Hintergrund Die Einführung VATS in der Thoraxchirurgie ist besonders an kommunalen Krankenhäusern strikten Kostenanalysen und Sicherheitsbedenken im Vergleich zur Standardoperation (Offen) unterworfen. Ziel dieser Studie ist es, eine differenzierte Analyse der VATS gegenüber der offenen Operation vorzustellen. Anhand eines repräsentativen Patientenkollektivs soll unter Betrachtung der Behandlungsdaten sowie einer akkuraten Kostenberechnung geklärt werden, ob die Etablierung der VATS sinnvoll ist.

We report a successful pregnancy in a patient with longstanding LAM on treatment with sirolimus. During temporary discontinuation fo sirolimus in early pregnancy, lung function declined but recovered after resumption of sirolimus. Pregnancy was complicated by a persistent pneumothorax which was treated surgically postnatally. The child has had a normal development despite exposure to low dose sirolimus intermittently during early embryonal and mid-fetal life.

The main indication for the use of thermal procedures in bronchology is the recanalization of a central airway stenosis or central airway occlusion. In stenoses caused by exophytic tumour growth and external compression, the thermal recanalization procedures can be combined with subsequent stent implantation. The thermal procedures most commonly used in bronchology are laser therapy and argon plasma coagulation. In routine clinical practice, availability, experience of the team of users with a particular method, and method-specific features are the criteria used to select a recanalization procedure. The use of cryoprobes for bronchial and transbronchial biopsy is the first thermal procedure to be described as a diagnostic method in bronchology.

Die Hauptindikation für die Anwendung thermischer Verfahren in der Bronchologie ist die Rekanalisation der zentralen Atemwegsstenose oder des zentralen Atemwegsverschlusses. Bei Stenosen, die durch exophytisches Tumorwachstum und durch Kompression von außen verursacht sind, können die thermischen Rekanalisationsverfahren mit einer anschließenden Stentimplantation kombiniert zur Anwendung kommen. Die am häufigsten in der Bronchologie zur Anwendung kommenden thermischen Verfahren sind die Lasertherapie und die Argon-Plasma-Koagulation. In der klinischen Routine sind die Verfügbarkeit, die Erfahrung des Anwenderteams mit einem Verfahren und methodenspezifische Eigenschaften die Kriterien für die Auswahl eines Rekanalisationsverfahrens. Mit der Anwendung von Kältesonden zur bronchialen und transbronchialen Biopsie ist ein thermisches Verfahren erstmals als diagnostische Methode in der Bronchologie beschrieben worden.

Anamnese: 44 jährige Frau mit progredienten atemabhängigen Schmerzen vor allem linksthorakal, Anämie und Gewichtsabnahme von 5kg in 2 Monaten. Die Pat. stammt aus Kasachstan, anamnestisch kein Tuberkulosekontakt, Nichtraucherin. Im Röntgen-Thorax und CT-Thorax beidseitige intrapulmonal und pleural gelegene Raumforderungen bis 7cm. Befunde: Bronchoskopie: endobronchial unauffälliger Befund. BAL linker Oberlappen mikrobiologisch und zytologisch unauffällig, insbesondere keine säurefesten Stäbchen. Pleurasonographie: links ventrolateral max. 55mm und dorsobasal max. 66mm messende echoarme Raumforderungen. Unter sonographischer Kontrolle entnommene transthorakale Biopsien ergeben histologisch einen „verkäsenden nekrotisierenden und vernarbenden granulomatösen Entzündungsprozess und eine granulomatöse Entzündung, vereinbar mit einer Tuberkulose“. Keine säurefesten Stäbchen. Verlauf: Nach Kontaktaufnahme mit dem Nationalen Referenzzentrum Beginn einer insgesamt 6-monatigen tuberkulostatischen Therapie, darunter Progress des radiologischen Befundes mit beidseits neu aufgetretenen intrapulmonalen Rundherden. Thoraxchirurgische Entfernung eines Rundherds, der den gleichen histologischen Befund wie vor Therapie zeigt, aber beim (Referenz-)Pathologen die Diagnose einer Sarkoiden Granulomatose ergibt. Kultur und PCR auf Tbc erneut negativ. Unter Corticosteroidtherapie im weiteren Verlauf weitgehend rückläufige pulmonale Herde mit klinischer Beschwerdefreiheit. Fazit: Die Sarkoide Granulomatose als Sonderform der Sarkoidose mit Vaskulitiskomponente stellt eine wichtige Differentialdiagnose granulomatöser Erkrankungen dar. Sie ist abzugrenzen von der Tuberkulose (kein Erregernachweis), anderen granulomatösen Infektionen wie Norkardiose und Histoplasmose sowie pulmonalen Vaskulitiden. Die Prognose der sarkoiden Granulomatose ist gut mit entweder spontan regredientem Verlauf oder gutem Ansprechen auf Corticosteroidtherapie.

Correction to: Blutflusssimulation mittels Computational-Fluid-Dynamics an aus CT-Daten rekonstruierten Aortenaneurysmata vor und nach Stent-Graft ImplantationRofo 2004; 177(01): 56-61DOI: 10.1055/s-2004-814667

OBJECTIVE:Children rarely undergo thoracic surgery. When they do, the procedures fall into five main groups: oncologic indications, immune defects, malformations, infections and trauma. In addition to considerations associated with the underlying indication, the different proportions of the anatomical structures in children require special modifications in both diagnostics and surgical technique compared to corresponding procedures in adults. METHODS:Of a total 2137 thoracic surgical procedures performed between 1992 and 2001, 49 were performed in children (n = 37; age: 3 months-15 years; median age: 8 years). Indications for surgery included underlying oncologic disease (n = 20), immunodeficiency (n = 5), thoracic or pulmonary malformation (n = 6) and trauma (n = 3). Patients' postoperative clinical course was analyzed retrospectively for all 49 procedures. Pre- and postoperative pulmonary function test results are available for 16 children. Data regarding quality of life were documented in 24 children. RESULTS:The following procedures were performed: 27 atypical resections, seven lobectomies, one pneumonectomy, three decortications, four mediastinotomies or mediastinoscopies and seven other procedures. Six procedures represented second or third procedures in the same patient. Two of six patients with immune defects died during the perioperative period. Eleven of 20 oncologic patients (55%) have remained free of recurrent disease. Quality of life, as assessed by the Karnowski index in 24 children, was at least 80%. CONCLUSIONS:Thoracic surgical procedures in children with underlying benign disease are associated with a good prognosis and high quality of life scores. Surgical treatment of pulmonary metastases is a feasible component of the overall oncologic therapy concept and can offer the only opportunity for curation for a selected group of patients. Because of high postoperative mortality, however, the indication for diagnostic thoracotomies in children with immunodeficiencies and poor general health should be weighed critically.

Occasionally, thoracic interventions may require interdisciplinary teamwork with plastic surgery, heart and vascular surgery, or neurosurgery. Thoracic wall defects following excision of primary wall tumors or recurrent, ulcerating tumors of the breast may require full-thickness myocutaneous flaps, which can best be done with the help of plastic surgeons. In case of infiltration of the heart or thoracic aorta, the en bloc principle of T4 lung tumors occasionally requires the help of heart surgeons, for open atrial resection using the heart-lung machine, or vascular surgeons for aortic graft interposition. Paravertebral dumbbell tumors occasionally may infiltrate to the intraspinal space and therefore need removal by neurosurgeons. When and why other specialists are required for an interdisciplinary approach to diseases of the chest has not been clearly defined. Therefore it is wise to gain informed consent from the patient about the roles of different specialists in interdisciplinary treatment for his disease.

ZusammenfassungDie Behandlung zur Erzielung des Wundverschlusses bei Ulcus cruris gestaltet sich oft problematisch, da durch lokale Minderdurchblutung und chronische bakterielle Kontamination erschwerte Einheilungsbedingungen bestehen. Ziel, Patienten, Methode: Die Vakuumversiegelung (VVS) stellt ein geschlossenes Verbandssystem zur feuchten Wundbehandlung mit festem Kontakt zur Wundoberfläche sowie Schutz vor Kontamination mit Hospitalkeimen und Dekontamination von Bakterien durch ständigen Schwerkraft-unabhängigen Sekretabtransport dar. Insgesamt wurden 55 Patienten mit einem chronischen Ulcus cruris mit einer Vakuumversiegelung versorgt. Ergebnisse: Zur primär vollständigen Einheilung des Meshgraft-Transplantats kam es bei 30 Patienten (54,5%). Bei 19 Patienten (34,5%) heilte es zu 75-90%, bei 6 (11%) zu weniger als 75% ein, so dass eine erneute Meshgraft-Transplantation erfolgte. Schlussfolgerung: Die Wundkonditionierung und anschließende Hauttransplantation nach ursachenabhängiger Vorbehandlung des Ulcus cruris mit der VVS stellt ein einfaches, schnelles und billiges Verfahren dar.

BACKGROUND:Mediastinal lymph node staging is essential to determine treatment options in patients with NSCLC. Positron emission tomography (PET) detects increased glucose uptake in malignant tissue using the glucose analogue 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG).PATIENTS AND METHODS:In the present study were evaluated 155 patients with focal pulmonary tumors who underwent both preoperative computed tomography (CT) and FDG-PET scanning (116 malignant and 39 benign lesions).RESULTS:Findings in 155 patients included 116 malignant and 39 benign lesions. For N-staging, FDG-PET showed a sensitivity of 88%, a specificity of 91%, and an accuracy of 89%. Corresponding figures for CT were 77%, 76%, and 77%, respectively.CONCLUSIONS:FDG-PET is an effective, noninvasive method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to operability, FDG-PET could differentiate reliable between patients with N1/N2 disease and those with unresectable N3 disease.

Treatment to achieve wound closure in ulcus cruris often presents problems because of the more difficult incorporation conditions resulting from locally reduced blood flow and chronic bacterial contamination. Aim, patients, methods: Vacuum sealing (VS) is a closed dressing system for moist wound treatment which ensures firm contact with the wound sur face and protects against contamination with hospital pathogens and provides antibacterial decontamination through constant gravity-independent secretion removal. Results: A total of 55 patients with a chronic leg ulcer have been treated with a vacuum sealing. In 30 patients (54.5%) there was full incorporation of the mesh graft transplant, in 19 patients (34.5%) an incorporation rate of 75-90% was achieved and, in 6 patients (11%), the incorporation rate was less than 75% with the result that another mesh graft transplant had to be carried out. Conclusions: Wound conditioning and subsequent skin grating after cause-dependent pre-treatment of the leg ulcer with VS is a simple, quick and inexpensive method.

PURPOSE:Simulation, description and analysis of dynamic pressure in infrarenal abdominal aortic aneurysms (AAA) before and after endovascular repair.MATERIALS AND METHODS:During March 1996 and May 2001, 13 patients with AAA underwent endovascular treatment. The MDR-CT scans of these patients were used for the non-invasive analysis of the hemodynamics in the aorta with CFD software before and after endovascular repair. One pre-interventional and three post-interventional CT scans were analyzed for each patient.RESULTS:Compared to the pre-interventional simulation, endovascular treatment led to an average dynamic pressure decrease of 1057 Pa in 10 of 13 patients. During the subsequent course, the median of the dynamic pressure decreased in 8 of 13 patients. Vulnerable regions initially identified as high-pressure regions, like the docking area or the second stent limb, adapted to the pressure in the surrounding tissue in the course of time.CONCLUSION:CFD-based blood flow simulation offers the opportunity to analyze dynamic pressure in AAA before and after endovascular repair and allows a prognostic statement as to the possible homogenization of the pressure in abdominal stent-grafts.

BACKGROUND:2-[(18)F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography has been established as a standard diagnostic imaging method in the preoperative workup of suspicious pulmonary focal lesions, showing a sensitivity of more than 90% and a specificity of about 80%. Determination of malignant pulmonary lesions with FDG positron emission tomography depends on the assessment of glucose metabolism. However, false-positive findings can occur in inflammatory processes, such as sarcoidosis or pneumonia. The thymidine analogue 3-deoxy-3[(18)F]-fluorothymidine (FLT) is a new positron emission tomography tracer that more specifically targets proliferative activity of malignant lesions. The objective of this study was to determine whether FLT positron emission tomography, in comparison with FDG positron emission tomography, provides additional information in the preoperative workup of central pulmonary focal lesions. METHODS:In this prospective study FLT and FDG positron emission tomography examinations were performed as a part of the preoperative workup in 20 patients with histologically confirmed bronchial carcinoma, 7 patients with benign lesions, and 1 patient with an atypical carcinoid. Results were compared with final pathologic findings. RESULTS:For staging of the primary tumor, FLT positron emission tomography revealed a sensitivity of 86% and a specificity of 100% compared with a sensitivity of 95% and a specificity of 73% for FDG positron emission tomography. For N staging, the sensitivity of FLT positron emission tomography was 57% and the specificity was 100%, and for FDG positron emission tomography, the sensitivity was 86% and the specificity was 100%, respectively. CONCLUSIONS:Our preliminary findings indicate specific FLT uptake in malignant lesions. The number of false-positive findings in FDG positron emission tomography might be reduced with FLT positron emission tomography. Therefore positron emission tomography imaging with FLT represents a useful supplement to FDG in assessing the malignancy of central pulmonary focal lesions.

Value of intraoperative pleural lavage in staging non-small cell lung cancer OE

Bei Mehrfachverletzungen mit tödlichem Ausgang ist das Thoraxtrauma unverändert in 25% der Fälle die Todesursache. Anhand eines Falles mit letalem Ausgang wird die Problematik dargestellt und unter Berücksichtigung der aktuellen Literatur diskutiert.

AIM:The conventional approach for the repair of thoracoabdominal aneurysms remains complex and demanding and is associated with substantial morbidity and mortality. Moreover, in cases of reoperation the impact can be dramatic either in survival or in quality of life of the patients, albeit the use of adjuncts. A combined endovascular and surgical approach with retrograde perfusion of visceral and renal vessels has been realized in order to minimize intraoperative and postoperative complications.METHODS:Within an experience of 231 aortic stent-grafts between 1995-2000, 4 of the patients with thoracoabdominal aneurysms were treated with a combined endovascular and surgical approach. Three procedures were electively conducted and 1 on emergency basis. Two women, 59 and 68 years old, and 2 men, 68 and 73 years old (maximum aneurysm's diameter was 10, 6, 8 and 9 cm, respectively) were operated with the combined method (the first 2 patients had a previous open repair of a thoracoabdominal aneurysm). The surgical approach was executed in all patients without thoracotomy or re-do retroperitoneal exposure. Revascularization of renal, superior mesenteric (and celiac in 2 cases) arteries was accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was performed by stent-graft deployment.RESULTS:The entire procedure was technically successful in all patients. The 1(st) patient was discharged 6 weeks after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of leak or secondary rupture of the aneurysm; the patient died 3 months after the repair, due to rupture of an aneurysm of the ascending aorta. In the 2(nd) patient, 30 months after the operation, spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularized vessels. The 3(rd) patient died on the 6th postoperative day due to multiorgan failure after having developed ischemic-related pancreatitis, albeit the successful combined repair. The 4(th) patient followed an uneventful course. No patient experienced any temporary or permanent neurological deficit.CONCLUSION:The combined endovascular and surgical approach is feasible, without cross-clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems the appropriate strategy for high risk and previously operated, with a thoracoabdominal trans-diaphragmatic approach, patients.

PURPOSE:The purpose is to present results of endovascular exclusion (stent-graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies.METHODS:Indications for stent-graft treatment were dependent on multislice angio-CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio-CT. Long-term follow-up consisted of evaluation with angio-CT after 6 and 12 months, and from there on once a year and with plain chest X-rays. Follow-up was achieved in all patients.RESULTS:Mean follow-up is 21 months (1-66); 30-day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left-hand ischemia or subclavian steal syndrome.CONCLUSION:Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well-defined morphologies. Mid-term results are promising but it has to be observed whether these will translate into long-term durability.

Background: The covering defects caused by chronic of ulcers on limbs affected by peripheral arterial disease or chronic venous insufficiency is often difficult due to extensive secretion and edema, while chronic bacterial contamination of the wound bed further compromises the conditions for successful healing.Patients and methods: Vacuum-sealed dressing (VSD) offers the option of a closed dressing system for moist wound care that assures firm contact with the wound surface and protection against contamination with nosocomial microbes and decontamination of existing bacteria by means of constant drainage of secretion independent of gravity. VSD is particularly useful in difficult wounds,featuring extensive secretion and unfavorable localization and offers many advantages over conventional dressing techniques in terms of improved healing of skin transplants. A total of 35 patients with chronic leg ulcers were treated with vacuum-sealed mesh graft transplantation.Results: Complete healing of the mesh graft transplant was observed in 20 patients (57%). Twelve patients (34%) experienced partial healing (75-90%) the transplant, while three patients exhibited less than 75% healing of the graft and therefore required a second mesh graft transplantation.Conclusions: VSD is a simple, quick and inexpensive technique that promotes excellent healing of skin transplants. It is particularly useful in difficult wounds with extensive secretion and/or contamination or injection.

The purpose of this study was to visualize both the vessel wall and atherosclerotic plaques in virtual intra-arterial angioscopy (VIA) based on helical CT data sets. To achieve this in vitro, the optimal reconstruction threshold of the vessel wall was determined to be 56.4% of the maximum enhancement. Using this threshold, 20 patients suffering from symptomatic carotid disease were examined in a helical CT scanner. The degree of stenosis was defined using the North American Symptomatic Endarterectomy Trial (NASCET) criteria and compared with results from digital substraction angiography (DSA). Grading of stenoses was only possible by adding the separately computed plaque geometry to the geometry of the vessel wall in a second step. Correlation between VIA and DSA in low grade, medium grade and high grade stenosis was 88%, 93% and 71%, respectively. Complete occlusions were diagnosed correctly in all patients. Sensitivity and specificity for the correct diagnosis of high grade stenosis was 93.7% and 91.3%, respectively. A realistic depiction of intraluminal structures in carotid arteries can only be generated by displaying both the vessel wall and plaque structures simultaneously.