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Der Einsatz temporarer extrakorporaler Herz-Kreislauf- und Lungenunterstutzungssysteme hat in den letzten beiden Dekaden erheblich zugenommen: Kam im Jahr 2007 noch etwa 1 Lungenersatzverfahren auf 100.000 Bundesburger, so waren es 2014 schon 2,4:100.000. Dies liegt v. a. an den grosen technischen Fortschritten, die in den letzten Jahren gemacht werden konnten – so sind die Systeme heutzutage (und im Gegensatz zu ihren Vorgangern) klein, transportabel, perkutan implantierbar, effektiv, weitaus sicherer und teilweise auch fur den Einsatz uber einen langeren Zeitraum konzipiert. Ihr Einsatzgebiet hat sich entsprechend erweitert: Neben der Anwendung als VA(venoarterielle)-ECMO (extrakorporale Membranoxygenierung ) zur kardialen Unterstutzung wird die VV(venovenose)-ECMO heute als High-Flow-Variante beim schweren ARDS („acute respiratory distress syndrome“) und als Low-Flow-Variante (VV-ECCO2R [„venovenous-extracorporeal CO2-Removal“]) beim fuhrend hyperkapnischen respiratorischen Versagen angewendet. Mit der zweiten grosen randomisierten Studie (EOLIA) zum Einsatz der VV-ECMO bei schwerem ARDS liegt mittlerweile eine hinreichende Evidenz fur den Einsatz in diesem Indikationsgebiet vor. Die Evidenz beim hyperkapnischen respiratorischen Versagen oder zur weiteren Protektion der Lungen bei moderatem bis schwerem ARDS fehlt momentan noch, sodass moglichst viele Patienten im Rahmen von Studien behandelt werden sollten. Trotz der hohen Wahrscheinlichkeit, dass die VV-ECMO bei schwerem ARDS die Prognose verbessern kann, ist es eine invasive Therapiemasnahme, die mit schweren Komplikationen einhergehen kann und ein hohes Mas an Fachexpertise erfordert.

Zusammenfassung Hintergrund: Die Diagnose einer Krebserkrankung in der Schwangerschaft ist selten, aufgrund einer Verschiebung des Alters der Erstgebärenden hin zum letzten Drittel des reproduzierfähigen Alters aber auch für Kopf-Hals-Tumorpatientinnen möglicherweise zunehmend relevant. Dabei besteht eine große Unsicherheit bezüglich des Nutzens und Risikos von diagnostischen oder therapeutischen Tumortherapiemodalitäten für das Ungeborene, sodass eine fundierte Empfehlung in diesen Fällen besonders schwer fällt. Nach neuen Literaturdaten scheint aber sogar eine multimodale Tumortherapie (Operation, Bestrahlung, Chemotherapie) trotz Schwangerschaft möglich und sollte streng gegen das Risiko einer Frühgeburtlichkeit abgewogen werden. Material und Methoden: Die Arbeit gibt eine Literaturübersicht über aktuelle Erkenntnisse zu diagnostischen Verfahren in der Schwangerschaft und zu dem Risiko von tumortherapeutischen Maßnahmen wie Bestrahlung und Chemotherapie für das Ungeborene. Die Erkenntnisse werden anhand eines konkreten Falls einer Schwangeren mit einem ausgedehnten Gehörgangskarzinom diskutiert und es werden Empfehlungen formuliert. Ergebnisse: Suffizient durchgeführte diagnostische Modalitäten erreichen die gefährdenden Uterusdosen praktisch nicht. Eine Reihe von Fallberichten und Beobachtungsstudien zeigen auch keinen Entwicklungsnachteil für die Kinder pränatal exponierter tumorkranker Mütter durch Bestrahlung oder Chemotherapie, wohingegen der langfristige Entwicklungsnachteil durch die Frühgeburtlichkeit nachgewiesen ist. Schlussfolgerung: Wenn während einer Schwangerschaft eine Tumorneuerkrankung im Kopf-Hals-Bereich festgestellt wird, erscheint auch die Durchführung einer etablierten Therapie mittels Operation und/oder Cisplatin-basierter Radiochemotherapie mit vertretbarem Risiko für das ungeborene Kind möglich.

Late enhancement (LE) multi-slice computed tomography (leMDCT) was introduced for the visualization of (intra-) myocardial fibrosis in Hypertrophic Cardiomyopathy (HCM). LE is associated with adverse cardiac events. This analysis focuses on leMDCT derived LV muscle mass (LV-MM) which may be related to LE resulting in LE proportion for potential risk stratification in HCM.N=26 HCM-patients underwent leMDCT (64-slice-CT) and cardiovascular magnetic resonance (CMR). In leMDCT iodine contrast (Iopromid, 350 mg/mL; 150mL) was injected 7 minutes before imaging. Reconstructed short cardiac axis views served for planimetry. The study group was divided into three groups of varying LV-contrast. LeMDCT was correlated with CMR.The mean age was 64.2 ± 14 years. The groups of varying contrast differed in weight and body mass index (p 0.05). In the group with good LV-contrast assessment of LV-MM resulted in 147.4 ± 64.8 g in leMDCT vs. 147.1 ± 65.9 in CMR (p 0.05). In the group with sufficient contrast LV-MM appeared with 172 ± 30.8 g in leMDCT vs. 165.9 ± 37.8 in CMR (p 0.05). Overall intra-/inter-observer variability of semiautomatic assessment of LV-MM showed an accuracy of 0.9 ± 8.6 g and 0.8 ± 9.2 g in leMDCT. All leMDCT-measures correlated well with CMR (r 0.9).LeMDCT primarily performed for LE-visualization in HCM allows for accurate LV-volumetry including LV-MM in 90% of the cases.• LeMDCT of relatively low contrast allows for LV planimetry in HCM. • The correlation of leMDCT-based LV volumetry with gold-standard CMR was excellent (r 0.9). • LeMDCT requires approximately 2.0mL/kgBW of dye to achieve acceptable contrast.

To analyze the efficacy of interventions in acute dysfunctional hemodialysis fistulas, if intervention is performed immediately as recommended by European Best Practice Guidelines for Hemodialysis.Over 3 years, all (n = 280) patients with an acute dysfunctional hemodialysis fistula were immediately referred to angiography, irrespective of the time of day. Angiography and, if possible, interventional revision (n = 241) were performed. Three groups of interest were established: interventionalist's experience (high/low), time of day (routine hours: 7 am-4 pm/emergency hours: 4 pm-7 am), lesion type (stenosis/fibrosclerotic occlusion/thrombotic occlusion/combined stenosis+thrombotic occlusion). For statistical analysis corresponding success rates, chi-square tests (p0.025) and logistic regression analysis (p0.05) were calculated.The total success rate was 62 % (149/241). The success rates were: interventionalist experience high/low 71 % (79/111)/54 % (70/130), p = 0.022; time of day routine/emergency hours 68 % (93/136)/53 % (56/105), p = 0.017; lesion type stenosis/fibrosclerotic occlusion/thrombotic occlusion/combined stenosis+occlusion 82 % (94/104)/39 % (13/33)/18 % (6/33)/59 % (36/61), p0.001. Relevant variables due to logistic regression analysis were high experience and the lesion types stenosis and combined stenosis+occlusion with odds ratios 2.300 (p = 0.012), 12.053 (p0.001), 3.189 (p = 0.003).Unrestricted implementation of immediate interventions in acute dysfunctional hemodialysis fistulas requires permanent availability of experienced interventionalists. The lesion types fibrosclerotic occlusion and thrombotic occlusion offer poor success rates for interventional revision.

Androblastomas of Sertoli-Leydig cell tumors of the ovaries are classified into the group of sex cord stromal tumors and represent an extremely rare form of tumor (0.2% of all ovarian tumors) in women. Their malignant potential is lower than that of epithelial ovarian cancer. They cause signs of virilization, although these are not obligatory. In many cases secondary amenorrhea is the only symptom of the disease. This leads to an intensive search for the source of the disorder. Frequently only the elevated production of androgens gives a preoperative clue to the tumor type. The recommendation to include the measurement of androgen levels in the routine diagnosis of secondary amenorrhea must therefore be endorsed. The tumors are usually sonographically identifiable; in differential diagnosis, hyperandrogenemia of other origins (e.g., Cushing's disease, adrenal hyperplasia, pituitary adenoma, other causes of ovarian and adrenal androgen hypersecretion, intersexuality, medically induced androgenization) have to be ruled out. In view of the good prognosis, the therapy of choice consists simply in adnexectomy of the affected side. With regular measurement of serum androgen levels an effective control of the course of the disorder is possible. A conclusive pathological diagnosis is difficult as heterologous tumors and mixed tumors exist and, furthermore, other tumor types are capable of imitating Sertoli-Leydig cell tumors.

Undifferentiated small-cell hepatoblastoma (HB) is a rare malignant tumor of childhood. The cell of origin is supposed to be a pluripotential, probably entodermal, stem-cell. Differential diagnosis of this type of HB is difficult among the group of small round and blue cell malignant tumors of children. The immunohistochemically determined coexpression of cytokeratin 8, 18, and 19 and of vimentin and actin, regularly in the absence of alpha-fetoprotein expression may be diagnostically helpful. We present the case of an undifferentiated small-cell HB of a 15-month-old girl with agenesis of the right kidney. As morphological peculiarity the tumor presented disseminated histiocytic giant cells.

We report on a 43-year-old man with a primary sarcoma of the liver. The patient was admitted to the hospital for evaluation of dyspnea, abdominal pain in the right upper quadrant, diarrhea, and fever. Physical examination revealed hepatomegaly. Increased laboratory values were found for gamma-GT, LDH, CA 125, and NSE, but not for aspartate and alanine aminotransferase. Computed tomography presented a tumor in the right lobe of the liver. Venous cavography revealed a caval tumor thrombus reaching up to the right atrium. Major liver resection combined with replacement of the vena cava inferior was proposed, but before operation the patient complained about shortness of breath. Spontaneous fragmentation of the tumor thrombus with consecutive embolization of the lungs was suspected. Despite lysis therapy the patient died because of right ventricular failure. Autopsy revealed a tumor measuring 8 cm in diameter, which was located in the right lobe of the liver and invaded the inferior vena cava. Because of multiple tumor aggregates seen in the left and right main pulmonary arteries acute tumor embolization of the lungs was regarded as cause of death. Histologically the tumor was composed of bizarre giant cells surrounded by irregular spindle cells. The positive immunoreactivity pattern of the tumor cells for vimentin, lysozym, and CD68 justified the diagnosis of a malignant fibrous histocytoma (MFH) of the liver.

Many transplant centers reject donor livers with severe steatosis (> 60%) due to the increased risk of primary graft dys- or nonfunction. However, the discrepancy between available donor organs and the rising number of transplant candidates is still unacceptable, because of the death of patients who are on the waiting list. Therefore, marginal donor livers are accepted increasingly to fight this dilemma. Our experience after transplantation of steatotic donor livers shows a recovery tendency with decreasing steatosis after primary graft dysfunction.

The Budd-Chiari syndrome is one cause of portal hypertension with multiple etiology and different therapeutic interventional strategies. We report on a 23-year-old female patient who developed de novo liver tumors 33 months after portocaval shunting for acute Budd-Chiari syndrome.

Zusammenfassung Ziel: In dieser Studie wird geprüft, ob die Normwertverteilung von Hirn-perfusionsmarkern bei Erwachsenen auf Kinder in der Altersgruppe von 4 bis 15 Jahren übertragen werden kann. Methoden: Bei 23 Kindern (Gruppe I) im Alter von 4-15 Jahren (MW 11 ±3 Jahre) ohne Anhalt für hirnorganische oder zerebrovaskuläre Erkrankungen wurden SPECT-Untersuchungen mit Tc-99m-ECD durchgeführt. Als Kontrollgruppe (Gruppe II) dienten 10 Erwachsene (Alter 27-56 Jahre, MW 45 ± 10 Jahre). Die Auswertung erfolgte semiquantitativ mit Normierung der lokalen kortikalen Aktivität auf die des Zerebellums (= 100%). Ergebnisse: In Gruppe I ergab sich im Vergleich zu Gruppe II durchweg eine höhere kortikale Aktivität, die größten Unterschiede waren parietal (107,6 ± 9,8 vs. 84,1 ± 12,4%), frontal (97,7 ± 6,7 vs. 79,4 ± 8,9%), links temporal (99,7 ± 7,4 vs. 84,9 ± 10,1 %) und im zingulären Kortex (112,1 ±9,1 vs. 95,9 ± 10,1%, p

Alterations in microvascular perfusion of the intestine after hepatic ischemia/reperfusion have been suggested as an important cause of postoperative septic complications. We therefore investigated small bowel microcirculation and mucosal injury after liver ischemia/reperfusion in a rat model. Furthermore, we analyzed the effects of the regulatory peptides vasoactive intestinal polypeptide and gastrin-releasing peptide for their splanchnic vasoactivity. Hepatic ischemia was induced by clamping of the left hepatic artery and vein for 40 min, followed by 60 min of reperfusion. The control group was treated similarly, but without clamping of the liver vessels. Ten minutes after clamping of the hepatic vessels, vasoactive intestinal polypeptide or gastrin-releasing peptide, respectively, were continuously infused intravenously in the experimental groups. Small bowel microcirculation and mucosal injury were assessed using intravital microscopy and the Chiu-score, respectively. The functional capillary density of the small intestine following ischemia and reperfusion of the left hepatic lobe significantly decreased compared to normal controls in both the mucosa and the smooth intestinal muscle. Red blood cell velocity decreased, whereas leukocyte–endothelium adherence, stasis index and the mucosal injury score increased. Administration of vasoactive intestinal polypeptide resulted in an increase of functional capillary density in the mucosa and of the red blood cell velocity and a decrease in the stasis index. The mucosal injury score was significantly higher in reperfused animals without treatment. The application of gastrin-releasing peptide resulted in an isolated increase of the red blood cell velocity. Leukocyte adherences could not be altered by the regulatory peptides. We conclude that hepatic ischemia/reperfusion injury leads to significant alterations of small bowel microcirculation and mucosal injury. Vasoactive intestinal polypeptide and gastrin-releasing peptide attenuate the damage in a different manner.

Background Intestinal ischemia-reperfusion injury (IRI) represents an exaggerated inflammatory cascade with a complex pathophysiology. IL-2, IL-6, HSP70, and INF-γ are mediators of the inflammatory process. Therefore, we investigated their kinetics and localization during intestinal IRI. Methods Pig intestinal specimens were obtained during cold preservation (cold ischemia time 2 hours) and extracorporeal perfusion. Mucosal damage was graded according to the Chiu classification. MRNA expression was determined by Northern blot (IL-2, IL-6, IFN-γ) or by quantitative RT-PCR (IL-6, HSP70) and localized by in situ hybridization. Results Histologically, mucosal damge occurred during reperfusion. Expression of IL-2 mRNA was up-regulated after HTK perfusion and was highest at the start and 7 hours after reperfusion. Expression of IL-6 mRNA increased at 2 hours after reperfusion and HSP70 at 3 hours after reperfusion. IFN-γ mRNA was expressed after HTK perfusion, with expression of this cytokine increasing to 1 hour after the start of reperfusion, and decreasing thereafter. IL-2 mRNA was localized to endothelial cells (EC) and leukocytes and in close relation to ganglion cells (GC): IL-6 mRNA in EC, smooth muscle cells (SMC), and GC: HSP70 mRNA in EC and SMC; and IFN-γ mRNA in leukocytes. Conclusion IL-2, IL-6, HSP70, and INF-γ are parameters of early mRNA expression during intestinal IRI. EC, SMC, leukocytes, and GC have been identified as sources of transcripts that might afford potential targets for intervention strategies to attenuate IRI.

Background Ischemia-reperfusion injury (IRI) can result in severe organ dys- or nonfunction. Interaction of leukocytes and endothelial cells mediated by E-selectin appears to be a key step for disturbed microcirculation. Therefore we studied gene and protein expression as well as localization of E-selectin during intestinal IRI. Methods Intestinal tissue samples were obtained from extracorporeal perfused intestines (cold ischemia time [CIT] 2 or 20 hours, each n = 5) and additionally in intestinal transplanted pigs (CIT 2 or 20 hours, each n = 1). Mucosal damage was graded according to the Chiu classification. E-selectin mRNA was determined by PCR and quantitative RT-PCR. Localization of E-selectin mRNA was performed by in situ hybridization and of the protein by immunohistochemistry. Results Histologically, mucosal damage occurred during reperfusion and was earlier and more severe after 20 hours of CIT. E-selectin mRNA expression was detected by PCR already after laparotomy and was elevated after reperfusion. Interestingly, mRNA expression was already increased after 20 hours of CIT. E-selectin mRNA was localized to the luminal surface of muscular, submucosal, and mucosal endothelial cells and the protein was detected on submucosal arterial endothelium as early as 2 hours after reperfusion. Conclusion Prolongation of CIT results in more severe mucosal damage during reperfusion, which is associated with protein expression of E-selection that might be used as a marker for activated endothelial cells. Increased E-selectin mRNA at end of 20 hours of CIT might indicate a preactivated state of endothelial cells potentially triggered by bacterial translocation or products.

We investigated the prophylactical administration of liposomal amphotericin B (Ambisome®) in the early phase after liver transplantation (LTx). Fifty-eight patients received Ambisome® prophylactically after LTx. Ambisome® (1 mg kg -1 day -1 ) was given intravenously for 7 days after LTx. Immunosuppressive prophylaxis was cyclosporin A (CsA) based in 11 patients. Forty-seven patients had a tacrolimus-based immunosuppressive regimen. CsA and tacrolimus dosages were adjusted to trough levels of 150-250 ng ml - (EMIT) and 5-15 ng ml - 1 (MEIA II) respectively. Three patients died from sepsis due to Aspergillus fumigatus infection. Reasons for a fatal outcome were foudroyant Aspergillus pneumonia in a patient transplanted for fulminant hepatic failure on post-operative day (pod) 8; Aspergillus sepsis with severe endocardidtis in a patient with two retransplantations for graft non/dysfunction on pod 24; and disseminated aspergillosis due to Aspergillus fumigatus in a patient retransplanted for primary non-function (pod 19). All three patients underwent haemofiltration for renal failure. One patient with Candida albicans sepsis (pod 4) recovered under increased dosage of Ambisome® (3 mg kg - 1 per day). Ambisome® (1 mg kg - 1 per day) seems to be beneficial against systemic Candida infections. However, the onset of systemic Aspergillus infections could not be prevented. Obviously, higher Ambisome® doses appear to be necessary against Aspergillus. We recommend the use of Ambisome® (3 mg kg -1 per day) for patients with risk factors such as graft dys-/non-function, retransplantation, haemofiltration and complicated acute liver failure to prevent invasive aspergillosis.