Background and Aims: There are only few data on the influence of cinacalcet on the outcome of parathyroidectomy in patients with renal hyperparathyroidism. Indication and timing of surgery have changed since its introduction, especially with regard to kidney transplantation. Therefore, we retrospectively analyzed patients undergoing parathyroidectomy for renal hyperparathyroidism in our institution. Material and methods: Between 2008 and 2015, 196 consecutive operations in 191 patients were analyzed. About 80 operations (41%) were performed in patients receiving cinacalcet compared with 116 operations (59%) in patients without cinacalcet. Clinical data, preoperative medication, pre- and postoperative laboratory values, type and details of surgery including complications, as well as cardiovascular complications and kidney transplantation with graft function were recorded. Results: Demographical data were similar in patients with or without cinacalcet treatment. A total of 54% of patients received a kidney graft before or after parathyroidectomy. Pre- and postoperative parathormone levels were similar in both groups (preoperatively 755 vs 742 ng/L, postoperatively 50 vs 46 ng/L, p > 0.10), whereas patients with cinacalcet showed significantly lower calcium levels preoperatively (2.28 vs 2.41 mmol/L, p = 0.0002). There was no difference in recurrence or persistence of hyperparathyroidism, duration of surgery, hospital stay, or complication rate. Creatinine levels in patients with tertiary hyperparathyroidism were similar after 1-year follow-up. Conclusion: Cinacalcet did not influence outcome of patients with parathyroidectomy for renal hyperparathyroidism and can be safely offered to patients not responding to medical treatment.

BACKGROUND AND AIMS:The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK).METHODS:Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF).RESULTS:During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT.CONCLUSION:Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.

Eine transiente Hyperthyreose (Palpationsthyreoiditis) kann eine Komplikation nach Parathyreoidektomie sein, bedarf jedoch häufig keiner Therapie. Selten kommt es zu schweren Verläufen bis zur thyreotoxischen Krise.

Die Hyperspektralbildgebung („HyperSpectral Imaging“ [HSI]) erlaubt quantitative Gewebeanalysen über die Limitationen des menschlichen Auges hinaus. Somit dient es als neues Diagnostikinstrument der optischen Eigenschaften verschiedener Gewebe. Im Gegensatz zu anderen intraoperativen bildgebenden Methoden ist HSI kontaktlos, nichtinvasiv und bedarf keiner Kontrastmittelapplikation. Die Messungen nehmen nur wenige Sekunden in Anspruch und stören somit die Operationsabläufe unwesentlich. Erste HSI-Anwendungen in der Viszeralchirurgie sind vielversprechend mit dem Potenzial optimierter Ergebnisse. Aktuelle Konzepte, Möglichkeiten und neue Perspektiven der HSI-Technologie sowie deren Limitationen werden in dieser Arbeit diskutiert.

Background and aimsPrevious guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime.MethodsA PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting.ResultsOverall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided.ConclusionEffective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

Objective Adrenal vein sampling (AVS) represents the current diagnostic standard for subtype differentiation in primary aldosteronism (PA). However, AVS has its drawbacks. It is invasive, expensive, requires an experienced interventional radiologist and comes with radiation exposure. However, exact radiation exposure of patients undergoing AVS has never been examined. Design and methods We retrospectively analyzed radiation exposure of 656 AVS performed between 1999 and 2017 at four university hospitals. The primary outcomes were dose area product (DAP) and fluoroscopy time (FT). Consecutively the effective dose (ED) was approximately calculated. Results Median DAP was found to be 32.5 Gy*cm2 (0.3–3181) and FT 18 min (0.3–184). The calculated ED was 6.4 mSv (0.1–636). Remarkably, values between participating centers highly varied: Median DAP ranged from 16 to 147 Gy*cm2, FT from 16 to 27 min, and ED from 3.2 to 29 mSv. As main reason for this variation, differences regarding AVS protocols between centers could be identified, such as number of sampling locations, frames per second and the use of digital subtraction angiographies. Conclusion This first systematic assessment of radiation exposure in AVS not only shows fairly high values for patients, but also states notable differences among the centers. Thus, we not only recommend taking into account the risk of radiation exposure, when referring patients to undergo AVS, but also to establish improved standard operating procedures to prevent unnecessary radiation exposure.

Nebennierenrindenkarzinome (ACCs) sind seltene, aber sehr aggressive Tumoren. Die Abgrenzung kleiner, lokal begrenzter ACCs von gutartigen Adenomen ist schwierig. Malignitätszeichen, aber keineswegs beweisend, sind eine Dichte >10 Hounsfield-Einheiten im Nativcomputertomogramm sowie ein verzögerter „washout“ des Kontrastmittels. Präoperativ muss bei allen Nebennierentumoren eine Hormonanalytik erfolgen. Wichtig ist weiterhin die interdisziplinäre Erstellung eines Therapieplanes. Bei allen nichtmetastasierten Nebennierenkarzinomen (ENSAT-Stadium I–III) ist eine Operation indiziert, wobei eine R0-Resektion und die Intaktheit der Kapsel die wichtigsten Prognosefaktoren für das Überleben darstellen. Trotz nicht eindeutiger Datenlage sollte zumindest bei nachgewiesenen Lymphknotenmetastasen eine Lymphadenektomie periadrenal und im Nierenhilus erfolgen, optional auch paraaortal und parakaval. Die Rolle der prophylaktischen Lymphadenektomie muss anhand weiterer Studien geklärt werden. Goldstandard ist weiterhin die offene Operation. Bei entsprechender Expertise und unter Einhaltung der onkologischen Prinzipien kann vor allem in den ENSAT-Stadien I–II auch ein minimalinvasives Vorgehen gewählt werden, da dies vergleichbare Ergebnisse im Langzeitverlauf zeigt. Da Patienten, die an einem Zentrum (>10 Adrenalektomien/Jahr) operiert werden, seltener und später Lokalrezidive entwickeln, sollte die Resektion von einem erfahrenen Operateur durchgeführt werden.

Hyperspektral-Imaging (HSI) ist ein neues Bildgebungs-Verfahren in der Medizin. Die Technik kombiniert das Prinzip der Spektroskopie mit der Bildgebung. Dabei wird das untersuchte Gewebe mit Licht im visuellen und nah-infraroten Spektrum beleuchtet und das vom Gewebe reflektierte Licht gemessen. Die Aufnahme ist nicht-invasiv und kontaktlos. Ziel unserer Analysen war die Gewebs-Charakterisierung und -Klassifikation mittels Computer-assistierter Algorithmen aus intraoperativen HSI-Daten.

Nebennierenkarzinome sind seltene Tumoren. Bei großen Befunden kann eine Abgrenzung zu retroperitonealen Sarkomen, besonders zum neu definierten sarkomatoiden Nebennierenkarzinom, und auch in Einzelfällen zu Metastasen schwierig sein.

Enhanced-recovery-after-surgery (ERAS)-Programme sind der Standard im perioperativen Management. Berücksichtigt werden muss der immer wieder gezeigte Einfluss einer krankheitsassoziierten Mangelernährung auf die postoperative Morbidität und Letalität. So bedürfen Patienten mit metabolischem Risiko oder manifester Mangelernährung sowie solche Patienten mit postoperativen Komplikationen besonderer ernährungsmedizinischer Aufmerksamkeit.

Purpose: While enhanced recovery after surgery (ERAS) programmes are the standard of perioperative management special nutritional care has to be attributed to malnourished patients and those at metabolic risk with special regard to those with complications.Methods: Existing guidelines of the German and European societies of nutritional medicine (DGEM, ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF; German Association of the Scientific Medical Societies) and Arztliches Zentrum fur Qualitat in der Medizin (AeZQ; German Agency for Quality in Medicine) revised and extended.Results: Theworking group developed 41 consensus- based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant literature of good quality, at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) und 7x CCP (clinical consensus point).Conclusion: Even in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

Liver regeneration is a prerequisite for extended liver surgery. Several studies have shown that the bacterial gut flora is able to modulate liver function. Previously we observed that synbiotics could partly reverse the impaired mitosis rate of hepatocytes in a rat model of synchronous liver resection and colon anastomosis. The effect of synbiotics on liver function after hepatic resection has not been analysed yet. A prospective randomised double-blind pilot trial was undertaken in 19 patients scheduled for right hepatectomy. All patients received enteral nutrition immediately post-operatively. Comparison was made between a group receiving a combination of four probiotics and four fibres and a placebo group receiving the fibres only starting the day before surgery and continuing for 10 days. Primary study endpoint was the liver function capacity measured by 13 C-methacetin breath test and indocyanine green plasma disappearance rate. Portal vein flow, liver volumetry, laboratory parameters for liver function, length of hospital stay, post-operative complications and side effects of synbiotic therapy were recorded. Liver function capacity was comparable in both groups. Complications had a negative impact on liver function. Because complications were more severe in the verum group, a sub-analysis was performed. In case of an uncomplicated course, liver function capacity was better in the patients with synbiotics. No severe side effects occurred. Synbiotics might be able to increase liver function capacity in patients after liver resection, but patient numbers were too small and the clinical courses too heterogeneous to draw any definite conclusions.

Serious postoperative infections can inhibit regeneration after liver resection. It has been shown, that hematopoietic growth factors like GCSF (granulocyte colony stimulating factor) or erythropoietin (EPO) can beneficially influence the course of infections and of liver regeneration. In a rat model of delayed liver regeneration the effect of EPO and GCSF alone or in combination with the hepatoprotective antioxidant curcumin (Cur) on regeneration was evaluated. Methods: Male SD-rats (200–300 g) underwent 70 % liver resection with simultaneous cecal ligation and puncture (CLP). Rats were randomized either to control group (no treatment) or to one of the following interventional groups: GCSF (100 µg/kg i. p.), EPO (1000 units/kg i. p.) each alone or in combination with curcumin application (100 mg/kg p. o.). Six animals per group were harvested 24 and 48 h after surgery and blood and tissue samples were collected. The relative liver weight, mitotic index (per 2000 hepatocytes) and the Ki-67 positive growth fraction were determined as regeneration parameters. In addition, liver function was assessed by serum parameters and by determination of the bile flow and hepatocellular damage by measurement of serum ALT-activity and histomorphology. The mRNA expression of different cytokines was determined as well as the hepatic concentration of reduced and oxidized (GSSG) glutathione as marker of cellular redox state. Results: Liver regeneration could be improved only slightly by monotherapy with GCSF or EPO. EPO was more effective in terms of increasing the relative liver weight and the regeneration markers, but the difference was not statistically significant. Whereas liver regeneration was slightly inhibited by combination treatment with GCSF and curcumin and the liver enzymes were even increased in this group, combination treatment with EPO and curcumin significantly improved the regeneration parameters. This was accompanied by a reduced oxidative stress, measured by the hepatocellular GSSG concentration and an increased GSH to GSSG ratio. The liver function was similarly altered in all groups. Also the mRNA expression of pro-inflammatory cytokines was not significantly different in all treated groups, but markedly lower than in the control group. Conclusion: The present data show, that erythropoietin improves liver regeneration delayed by bacterial infections only insignificantly, but EPO was applied in a relatively low dosage compared to other rodent studies. In contrast, the combination of EPO and curcumin showed a synergistic effect with highly significant stimulation of liver regeneration after resection and simultaneous CLP.

Postoperative bile leakage is a typical complication in liver surgery. The influence of bile leakage and concomitant bile peritonitis on the regenerative capacity of the liver remnant has yet not been investigated thoroughly. Methods: SD rats were randomized to the following groups: Sham operation (Sh), 70 % liver resection (LR) and 70 % liver resection with simultaneous induction of a bile leakage (LR+BL) of the right liver lobes. Six rats per group were killed 6, 24, 48 and 96 hours after surgery. Liver regeneration was evaluated by relative liver weight, mitotic index, BrdU labelling index and Ki-67 index. Markers for liver function (thromboplastin time, bilirubin, albumin, ICG disappearance rate) and hepatocellular damage (transaminases, histomorphology) were evaluated as well. In addition, the inflammatory response was determined by measurement of IL-1β, TNF-α, IL-6 mRNA, TGF-β mRNA and myeloperoxidase activity. The bacterial concentration in different organs was quantified by routine microbiologic methods. Results: Liver regeneration was significantly delayed by postoperative bile leakage. After 24 hours, the mitotic index in the LR+BL group (9 ± 6) was significantly reduced compared to the group with LR only (83 ± 20). The relative liver weight (1,42 ± 0,05 %) and the overall-growth fraction (2 ± 1 %), determined by the number of Ki-67-positive cells, were also reduced in the LR+BL group after 24 hours, compared to the LR group (rel. liver weight 1,78 ± 0,04 %, growth fraction 24 ± 2 %). In the LR group regenerative markers declined 48 hours after surgery, whereas the regenerative process reached its maximum in the LR+BL group at that time. For instance, the Ki-67 index was significantly higher 48 h after LR+BL (38 ± 7 %) than after LR alone (21 ±5 %). 96 hours after LR+BL, increased regenerative activity of hepatocytes could still be observed, but the foremost proliferative activity was seen in non-parenchymal cells (as shown by BrdU-positive non-parenchymal cells), especially bile duct epithelial cells. In the LR+BL group, liver function was markedly impaired 24 and 48 hours after surgery, compared to LR only. At early examination times, bile flow was clearly reduced; serum bilirubin was elevated and the ICG disappearance rate was significantly impaired. At no time point, histomorphologic features of liver cell necrosis or significant differences in liver histology were observed in any of the groups. Following LR and BL, the postoperative transcription of cytokines, particularly IL-6, was markedly higher. A significant bacterial super infection in the first 24 hours could be excluded, since microbiologic examination — especially of the liver — revealed no increased bacterial concentrations compared to the LR group. Conclusion: The study shows, that the inflammatory response following intraabdominal bile leakage can promote suppression of liver function as well as impairment of the regenerative capacity of the liver. However, the involved mechanisms remain to be unravelled.

Summary Aim: In addition to planar parathyroid scintigraphy, SPECT and image fusion with CT/MR improve adenoma detection in primary hyperparathyroidism (pHPT). This study evaluated the use of a hybrid SPECT-CT device concerning image fusion and attenuation correction (AC). Patients, methods: The data of 26 patients with pHPT, preoperatively examined by 99mTc-sestamibi dual-phase scintigraphy plus SPECT-CT (low-dose CT), was retrospectively evaluated by two observers in a consensus reading. The images of planar scintigraphy, non-attenuation corrected SPECT (SPECTNAC), attenuation corrected SPECT (SPECTAC) and SPECTAC-CT were interpreted and compared to the results of surgery. The effect of AC on focus intensity was semiquantified by determination of the tumor-to-background (TB) ratio for SPECTAC and SPECTNAC. Finally, the TBAC/TBNAC-ratio was calculated for each focus and correlated to the distance of a focus from the body surface. Results: 20/26 (77%) patients were positive in planar scintigraphy. One focus was detected by SPECT only. AC of SPECT-data increased image contrast but had no impact on the detection rate. Additional SPECTAC-CT image fusion facilitated the localization of three mediastinal foci. In the semiquantitative analysis an increase in TB after AC was observed, although there was no strong correlation between depth of the focus (16-60 mm) and the TBAC/TBNAC-ratio (r = 0.213, p = 0.353). Conclusion: The detection rate of planar scintigraphy is only slightly improved by SPECT imaging. Due to the low spatial resolution of the CT component, the benefit of image fusion is limited to mediastinal foci. However, as TB and image contrast is measurably improved after AC there is a potential to improve the sensitivity of parathyroid SPECT.

Unter Langzeittherapie der Hepatitis B Virus (HBV) Infektion mit Lamivudin (LAM) wird häufig eine Resistenzbildung beobachtet. Adefovir Dipivoxil (ADV) hat sich als hochwirksam gegen Wildtyp- und LAM-resistente (LAM-R) HBV-Stämme erwiesen.

We report the case of a 59-year-old woman with a history of follicular thyroid cancer who had reoperation for suspected local tumor recurrence as laboratory (tumor marker), imaging findings (ultrasound, I-131 scintigraphy and Tc-99m-MIBI scintigraphy), and also fine needle aspiration (FNA) cytology were equivocal. However, postoperative histopathology revealed a parathyroid adenoma.

As cytomegalovirus (CMV) disease was a leading cause of death following liver transplantation in earlier reports, general CMV prophylaxis is widely used. We re-evaluated the impact of CMV in a recent time period under balanced immunosuppression and effective CMV diagnostics and therapy. A retrospective analysis of 1200 liver transplantations between 1988 and 2000 was performed comparing the incidence of CMV infection and disease and patient survival rates in two different time periods (before and after availability of the pp65-antigenaemia assay). In addition, risk factors for CMV in the recent time period were analysed. No ganciclovir prophylaxis was administered during the whole study period. The incidence of CMV tissue invasive disease decreased from 9.4% in period I to 2.7% in period II, whereas the incidence of viral syndrome was about 6% in both periods. Especially CMV pneumonia and generalized disease were almost abandoned in period II. Patients with tissue invasive disease, but not with infection or viral syndrome had reduced survival rates in both periods. However, the disease-specific mortality was 10% and 0% respectively. The overall rate of CMV infection in period II was low (25.9%). Risk factors for CMV infection in the univariate analysis were: Initial nonfunction, D+R- seroconstellation, acute liver failure, triple or quadruple immunosuppression, OKT3 or ATG treatment, transfusion of >10 packed red cells, steroid boluses, postoperative mechanical ventilation and retransplantation. In the multivariate analysis only quadruple or triple immunosuppression, OKT3-treatment, transplantation for acute liver failure and initial nonfunction. The incidence of CMV tissue invasive disease as well as the disease-specific mortality has markedly decreased during the last years. Using routine surveillance with the pp65-antigenaemia assay, CMV infection and disease rates compare well to data with long-term ganciclovir prophylaxis. As D+R- patients still more often develop symptomatic disease, pre-emptive therapy could be useful in this patient group.