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Intraoperative imaging diagnostics during open vascular surgical procedures aim to enhance diagnostic certainty during the operation, ensure quality control documentation and reduce avoidable complications; however, the evidence for the various diagnostic imaging procedures with respect to improvement of perioperative outcome is not confirmed for carotid endarterectomy or for infrainguinal bypass surgery. Nevertheless, an intraoperative diagnostic control is principally recommended. The advantage of intraoperative imaging is confirmed and essential for the surgical reconstruction of bypass occlusions and acute thromboembolic occlusions.

Background Asymptomatic carotid artery stenosis (ACS) has a low risk of stroke. To achieve an advantage over noninterventional best medical treatment (BMT), carotid endarterectomy (CEA) or carotid artery stenting (CAS) must be performed with the lowest possible risk of stroke. Therefore, an analysis of risk-elevating factors is essential. Grade of ipsilateral and contralateral stenosis as well as plaque morphology are known risk factors in ACS. Methods The randomized, controlled, multicenter SPACE-2 trial had to be stopped prematurely after recruiting 513 patients. 203 patients were randomized to CEA, 197 to CAS, and 113 to BMT. Within one year, risk factors such as grade of stenosis and plaque morphology were analyzed. Results Grade of contralateral stenosis (GCS) was higher in patients with any stroke (50%ECST vs. 20%ECST; p=0.012). Echolucent plaque morphology was associated with any stroke on the day of intervention (OR 5.23; p=0.041). In the periprocedural period, any stroke was correlated with GCS in the CEA group (70%ECST vs. 20%ECST; p=0.026) and with echolucent plaque morphology in the CAS group (6% vs. 1%; p=0.048). In multivariate analysis, occlusion of the contralateral carotid artery (CCO) was associated with risk of any stroke (OR 7.00; p=0.006), without heterogeneity between CEA and CAS. Conclusion In patients with asymptomatic carotid artery stenosis, GCS, CCO, as well as echolucent plaque morphology were associated with a higher risk of cerebrovascular events. The risk of stroke in the periprocedural period was increased by GCS in CEA and by echolucent plaque in CAS. Due to small sample size, results must be interpreted carefully.

Benign liver tumors are often detected during routine ultrasound examinations or as an incidental finding in radiological imaging. Only very few benign liver tumors are at risk of becoming malignant. In the majority of cases the differentiation from malignant tumors is currently carried out using imaging procedures. In a few cases of diagnostic uncertainty, a transcutaneous liver biopsy can lead to clarification. If the suspicion of malignancy is substantiated or this cannot be excluded with absolute certainty, the tumor should be removed by partial liver resection.

The German population is aging in accordance with the worldwide trend; however, in comparison to most other industrial countries the number of disease-free years of life gained by patients is significantly lower in Germany. Subsequently, the number of hospitalizations and necessary surgical treatment for older and especially frail patients is significantly increasing. Several frailty scoring systems have been published with the aim of improving the assessment of the perioperative risk for these patients; however, these systems for risk assessment have not yet become clinical routine in surgery and therefore this group of frail patients remains underdiagnosed in the field of surgery. Frail patients in particular often need individualized treatment or the adaptation of standard of perioperative care. It has already been clearly shown that frail patients have a markedly higher incidence for certain risk factors (e.g. postoperative delirium, hypovolemia, pharmacological side effects and drug interactions). Additionally, malnutrition is common at the time of hospital admission in up to 70% of this patient group. If not recognized and treated accordingly all these risk factors lead to a compromised rehabilitation, higher complication rates, a prolonged length of hospital stay and a higher mortality. Special preoperative risk assessment scores, which highlight physical, psychological and social evaluation should be widely implemented in surgical departments. A standardized risk assessment embedded in evidence-based prerehabilitation programs and implemented in geriatric surgery centers can help to improve the outcome in this group of fragile patients.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may significantly improve overall survival in selected patients with peritoneal metastases of colorectal cancer. For good oncological results complete macroscopic cytoreduction is crucial; furthermore, a linear correlation between peritoneal tumor load, as determined by the peritoneal cancer index (PCI) and overall survival has been demonstrated; therefore, surgical treatment should be initiated as early as possible. Synchronous resection of up to three liver metastases may be performed safely and with good results and no influence on the morbidity. With respect to intraperitoneal chemotherapy, mitomycin C and oxaliplatin are most commonly used and may be regarded as equal; however, for perioperative chemotherapy study results are so far inconclusive with some trials hinting at decreased overall survival following neoadjuvant chemotherapy. Adjuvant therapy is likely to improve overall survival if at least 6 cycles are applied. Early detection of peritoneal metastases is difficult at present but might be facilitated in the future by the use of liquid biopsies, which may detect circulating free tumor-specific DNA or RNA. In the meantime, planned second-look laparotomy should be considered for patients at high risk of peritoneal recurrence. In addition, several international studies are currently evaluating the concept of adjuvant or prophylactic HIPEC. The CRS and HIPEC may be repeated in cases of recurrence and should be considered in suitable patients, applying the same criteria as for primary CRS and HIPEC. A recurrence-free interval of2 years is associated with a significantly better prognosis.

Thorakale und thorakoabdominale Aortenaneurysmen werden bei steigender Inzidenz zunehmend operativ behandelt. Die Indikation zur Rekonstruktion besteht wegen der Rupturgefahr ab einem Durchmesser von 6 cm, bei Risikogruppen ab 5,5 cm. Die anspruchsvolle offene chirurgische Therapie ist bis heute mit einer relevanten Mortalitat und Morbiditat verbunden. Die sich als Alternative rasch entwickelnde endovaskulare Therapie, als komplett endovaskulare Operation oder in Kombination mit Debranching-Prozeduren durchgefuhrt, scheint ein im Vergleich dazu geringeres operatives Risiko aufzuweisen. Insbesondere fur Altere und Risikopatienten sowie fur die von der Morphologie optimal behandelbaren Befunde hat die endovaskulare Behandlung dieser Aneurysmen einen festen Stellenwert eingenommen. Dennoch erscheint aktuell ein kompletter Paradiagmenwechsel von der offenen zur endovaskularen Rekonstruktion fur alle Patienten, insbesondere bei komplexen Befunden, noch nicht begrundet.

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Bei allen Revisionseingriffen sowohl an der autologen wie an der PTFE-Interponat-Fistel gilt das Gebot des sparsamen Umgangs mit den Gefasen. Neben einem zu niedrigen Shuntfluss sind Intimahyperplasie und Stenose der protheto-venosen Anastomose haufige Grunde fur eine Shuntdysfunktion. Die Ergebnisse der duplexsonographischen Untersuchung geben den Weg der Revisionseingriffe vor. Ein fruhzeitiger Reeingriff vor Shuntverschluss und Shuntthrombose kann die Implantation zentralvenoser Katheter vermeiden. Die chirurgische Intervention sollte durch eine digitale Subtraktionsangiographie (DSA) kontrolliert werden, insbesondere wenn intraoperativ der Grund des Shuntverschlusses nicht ersichtlich wird und an eine zentralvenose Stenose gedacht werden muss, die mit der Duplexsonographie nur limitiert dargestellt werden kann. Chirurgisch kommen neben der offenen Revision auch perkutane und Hybridverfahren zum Einsatz. Stealsyndrome mit normalen und hohen Shuntflussen sollten chirurgisch unterschiedlich angegangen werden. Dabei stehen das DRIL-Verfahren und die Proximalisierung der Fistel zur Verfugung. Wahrend das DRIL-Verfahren bei hohen Shuntflussen einen Verschluss der distalen Arterie in Kauf nimmt, wird der Zufluss nach distal bei der Proximalisierung erhoht. Shuntinfektionen sind eine haufige und lebensbedrohliche Komplikation und sollten fruhestmoglich behandelt werden. Bei septischen Verlaufen einer PTFE-Infektion muss der Shunt ausgebaut werden. Shuntaneurysmen werden solange akzeptiert, wie der Shunt keine Dysfunktion aufweist. Neben einem chirurgischen Vorgehen steht zur Ausschaltung der Aneurysmen Stent und Thrombininjektion zur Verfugung. Perigraftreaktionen in Form einer Schwellneigung sind seltene Komplikationen, die bei Persistenz mit einem Austausch des Interponats behoben werden konnen. Sensible neurologische Ausfalle nach Shuntanlagen sind eine haufige Komplikation mit groser Ruckbildungstendenz. Motorische Ausfalle sind selten und sollten bei Persistenz neurochirurgisch versorgt werden.

In the 7th edition of the TNM classification, not only HCC with distant metastases but also those with regional lymph node metastases are classified as stage IV. From our prospectively recorded tumor registry, 138 patients (17 %) with HCC were in stage IV. Among those were 68 and 70, respectively, in stage IVA (regional lymph node metastases) and IVB (distant metastases). The tumors were less frequently treated with resection or local ablative treatment (chemoembolization, RFA, SIRT, percutaneous radiation) than patients in stage I–III. Ten HCCs were resected. Five of the resected patients were in stage IVA and five in stage IVB. After tumor resection, patients lived longer than those who underwent local or systemic treatment only (p = 0.003 or p = 0.001, respectively). In the univariate survival analysis, the stage IV patients’ long-term survival was decreased statistically significantly through elevated bilirubin, low albumin, Okuda stage III and BCLC stage D. Patients’ age and sex, pre-treatment AFP level, Child stage and the presence of venous invasion did not influence survival. In the multivariate analysis (Cox regression), tumor resection and BCLC stage were independent prognostic factors. Patients with HCC in TNM stage IV have a very poor prognosis. Only few patients are eligible for resection because of the extent of tumor growth, comorbidities and general condition. These, however, benefit markedly from tumor resection with lymph node dissection and possibly resection of distant metastases.

Arteriovenose Dialysezugange unter Verwendung von Gefasprothesen haben eine niedrigere Offenheitsrate und hohere Komplikationsrate als solche mit korpereigenen Gefasen und stellen deshalb insbesondere bei ungeeigneten oder verbrauchten oberflachlichen Armvenen eine sekundare oder tertiare Option des Gefaszuganges dar. Bei guter Planung unter Beachtung der patientenspezifischen Besonderheiten, sorgfaltigem operativem Vorgehen und adaquater Behandlung auftretender Komplikationen konnen bei einer Vielfalt moglicher Konfigurationen von Protheseninterponaten zwischen Arterie und einer meist tiefen Vene uber Jahre funktionsfahige Gefaszugange geschaffen werden. So haben diese prothetischen Gefaszugange weiterhin ihre Berechtigung, werden bei zunehmender Komorbiditat der Patienten eher an Bedeutung zunehmen und sind einem getunnelten Vorhofkatheter fur die dauerhafte Hamodialyse unbedingt vorzuziehen. Der vorliegende Beitrag stellt die Indikationen, operativen Moglichkeiten und Besonderheiten prothetischer Dialysezugange dar.

Background: We report a treatment option in surgical therapy of locally advanced renal cell carcinoma (RCC). Method: A 63-year-old patient with locally advanced RCC including an atrial thrombus underwent 2 cycles of neoadjuvant therapy (Sutent® 50 mg daily for 4 weeks followed by 2 weeks off) and then tumor surgery. Primary surgical therapy had to be delayed because of suspected bronchial carcinoma and additional diagnostics. After neoadjuvant therapy to downsize the tumor thrombus and exclusion of any additional malignant tumors, operation was done via abdominal access; no sternotomy was necessary. Results: Histopathological examinations of the primary tumor after tyrosine kinase inhibitor therapy were evaluated and compared to tumor biopsy material taken before therapy. Conclusion: Neoadjuvant therapy with Sutent® may represent a favorable treatment option in cases of locally advanced clear-cell RCC with extended tumor thrombus.

The incidence and operations of thoracic and thoracoabdominal aortic aneurysms have significantly increased. The indications for repair are considered to be a diameter of 6 cm or more and 5.5 cm for patient groups with increased risk of rupture. Complex open surgical repair is associated with significant mortality and complication rates. Total or hybrid endovascular repair seems to reduce early postoperative complications and mortality. The endovascular approach has evolved to be a good and predominant alternative to open repair of these aneurysms for older and high-risk patients as well as for aneurysms with optimal morphological suitability. Notwithstanding, at present a complete paradigm shift from open to endovascular repair for all patients, especially those with complex aneurysms, cannot yet be established.

In addition to the main indications pertaining to 95 % of all patients receiving liver transplantation in Germany, there are numerous other diseases that may become clinically evident in the adult age and may lead to the decision for liver transplantation. These may be metabolic diseases with their main defect located in the liver, malformations of liver cells, hepatic vascular diseases and rare tumours of the liver. Standard exceptions for the listing are in place only for a limited number of diseases. Exact diagnostics and the point in time for transplantation are crucial for the prognosis.

More than 20 years ago living donor liver transplantation was introduced into clinical practice. Specifics of this method were developed initially for children and later on for adults particularly in regions where a liver transplantation program using deceased donors was not readily available. The most sensitive aspect of living donation, namely the danger to a healthy relative in order to perform the transplantation is immanent in the system and, thus, it is definitively a secondary option as compared to deceased organ donation. Following worldwide initial euphoria the numbers have markedly decreased in the western world since the start of the new millennium. In Asian countries in particular, much work has been done to optimize the procedure so that the donor safety and the outcome quality for the recipient have been impressively demonstrated in large patient populations. There is still a severe donor organ shortage and the option to allocate an optimal (partial) organ on an individual basis by living donation has given new impact to the discussion about a further rise in the profile of living donations here as well. The new version of the German transplantation legislation implemented in summer 2012 requires a number of conditions with respect to insurance for living donors. The current state and perspectives are presented here.

Prosthetic arteriovenous grafts have an inferior patency rate and greater morbidity than those with autogenous vessels and are therefore considered as secondary or tertiary vascular access for hemodialysis in patients with fatigued or unsuitable superficial arm veins. Prior access planning in accordance of patient characteristics, careful operative procedure and appropriate revision of complications can ensure long-term functioning of a vascular access using a large variety of possible prosthetic conduits. Arteriovenous grafts remain essential in vascular access surgery and their role may be increasing with higher comorbidities of patients and should be preferred to tunnelled cuffed catheters. This article reviews the indications, alternative configurations and characteristics of arteriovenous grafts.

We report on two rare endovascular procedures concerning aneurysmatic complications of arterial homografts. In both cases infected aortobifemoral grafts were explanted und replaced by cryopreserved aortofemoral homografts on the left side. The revascularisations on the right side were performed with the deep femoral vein in one case, and by desobliteration of the iliac artery in the other case. After 4 and 10 months, respectively, we found aneurysmatic enlargements of the aortic anastomoses. In both cases we excluded a false aortic aneurysm by uniiliac stentgrafts in combination with a femoro-femoral cross-over bypass for the contralateral leg. Both operations were carried out successfully. However, one patient developed an infection of the stent graft. We explanted the stent graft und performed an aortobifemoral bypass procedure with arterial cryopreserved homograft once again.Both aneurysmatic complications after aortofemoral homograft implantation could be treated successfully by an endovascular approach. Possible late complications caused by the implantation of homografts or by endovascular procedures can be only detected in due time by a follow-up at short intervals.

A prospective, randomised study was undertaken to investigate the effect of intravenous infusion of either iloprost, the stable prostacyclin (PGI2) analogue, or alprostadil (prostaglandin E1) on peripheral resistance (PR) during femoro-distal reconstruction.A prospective randomised study was performed with 35 patients. The PR Measurement of peripheral resistance involved a silicon tube temporarily inserted between the donor and recipient vessel. A flowmeter probe and a pressure transducer were inserted into the tube. The peripheral resistance was calculated as a quotient of pressure and flow under approximate physiological conditions. Patients received either alprostadil (4.4 ng/min/kg) or iloprost (2 ng/min/kg) intravenously over ten minutes. After the end of the infusion, the measurements were taken for five minutes.Baseline peripheral resistance was similar for both groups (iloprost 0.76+/-0.54 mmHg/ml/min, alprostadil 0.72+/-0.35 mmHg/ml/min, p0.05). Following the measurement procedure, the final peripheral resistance in the iloprost group was reduced (0.57+/-0.33 mmHg/ml/min), but the difference to the alprostadil group (0.70+/-0.36 mmHg/ml/min) was not significant (p0.05). The different decrease of ratio peripheral resistance (quotient between final and baseline resistance times one hundred) was highly significant (iloprost: 79.4+/-13.4% vs alprostadil: 97.0+/-15.6%, p0.01).Intravenous application of prostanoids, infused with usual doses over ten minutes during femoro-distal reconstructions, produces significant differences in decrease of peripheral resistance. Alprostadil only causes a slight drop of resistance, whereas iloprost causes a significant higher reduction of peripheral resistance.

The paper presents a microplate hybridisation assay for the detection of codon 12 mutations of the K-ras protooncogene. Single-stranded target DNA, obtained from amplifying sample DNA with 5'-biotin and 5'-digoxigenin-labelled primers and subsequent strand separation, is hybridised with solid phase-fixed capture probes complementary to wild-type and mutated forms of K-ras. After stringent washing the duplex DNA is detected by an ELISA-like protocol incorporating photometric, fluorometric or luminometric detection. Application examples are shown in which the K-ras status was examined in peripheral blood cells, cell cultures, fresh and paraffin-embedded tumour tissue and in stool samples.

Cystic neoplasms of the pancreas are rare but in the last years more frequently detected. Within a 10-year-period we treated 30 patients, including 8 serous cystadenomas, 6 mucinous cystadenomas, 12 mucinous cystadenocarcinomas, 2 cystic neuro-endocrine tumors and 1 papillary cystic tumor respectively acinar cell cyst-adenocarcinoma. 80% of the patients had symptoms, experienced abdominal pain, weight loss, weakness or abdominal mass. In eight patients the tumors had been misdiagnosed as a pancreatic pseudocyst. The correct type of cystic tumor was diagnosed by preoperative investigations only a few cases. All patients with serous or mucinous cystadenomas are well and without evident recurrence after resection of the tumor. However the survival time of malignant cystic tumors varied strongly. The curative resection of these tumors give patients the chance of long-term survival.

17 patients with a Caroli's syndrome are reviewed with emphasis on clinical features and late results (follow-up: 2-10 years). The group consists of 9 women and 8 men ranging in age from 17 to 80 years (mean of 42.6). 14 patients had a diffuse form, 5 of whom had periportal fibrosis with secondary biliary cirrhosis, which in 3 cases resulted in a portal hypertension with hepatic failure. In only 3 cases the dilatation was limited to the left lobe of the liver. 9 of the patients had previously undergone surgery in the form of cholecystectomy and choledocholithotomy elsewhere. The disease was complicated by lithiasis (14 intrahepatic, 9 extrahepatic). Curative treatment was only possible in the 3 patients with unilobar Caroli's syndrome (partial liver resection). In 5 patients we performed a cholecystectomy and choledocholithotomy combined in 2 cases with a transduodenal sphincterotomy. There was no operative death. Endoscopic treatment consisted in removal of stones and decompression of the biliary tree by sphincterotomy in 9 cases and endoscopic retrograde biliary drainage (endoprosthesis) in 5 cases. Excepting the 3 curative operated patients who are asymptomatic respectively 2, 4 and 5 years after surgery, the remaining cases had repeated bouts of acute pains accompanied by recurrent episodes of cholangitis. A late mortality of 23.5% (4 patients) is proof of the poor prognosis of this disease.

A review of morbidity and mortality was performed for 84 patients over 70 years of age who underwent pancreaticoduodenectomy at our institution. Anastomotic leakage was the only significant complication. Operative mortality, although greater in this patient group, is acceptable

A review of morbidity and mortality was performed for 84 patients over 70 years of age who underwent pancreaticoduodenectomy at our institution. Anastomotic leakage was the only significant complication. Operative mortality, although greater in this patient group, is acceptable.

Surgical treatment of primary and secondary malignant chest wall tumors present various difficulties depending on their localisation in the anterior, lateral and posterior thoracic wall. The reconstruction and the flap-plastics have to fulfill the functional and cosmetic demands. We report on 35 patients, 22 female and 13 male, ranging in ages from 19-69 (mean 44.59) years. There were 17 primary and 18 secondary tumors. The operation included excision of the thoracic shield, partial or total breast-bone and clavicle resection. Materials used for reconstruction were PTFE-patches, lyophilized dura and ribs. Soft tissue reconstruction was performed by sliding-flap plastics. The one-year survival rate was 90.6%.

Von 1985 bis 1994 wurden an der Thoraxklinik, Heidelberg-Rohrbach 193 tumorbedingte Brustwandresektionen durchgefuhrt. Darunter waren 52 primare tumorose Raumforderungen, davon 28 maligne und 24 benigne. Die Prinzipien der operativen Therapie sind die radikale Resektion im Gesunden, die primare stabile Brustwandrekonstruktion und die ausreichende Weichteildeckung. Knocherne und Weichteil-defekte nahezu jeder Grose konnen stabil rekonstruiert werden. Dabei ist die nicht von der Defektgrose abhangige Lungenfunktionsbeeintrachtigung nur gering. Die Prognose hangt ab von der Grundkrankheit und der Radikalitat.

Arterielle Stenosen stellen in der Langzeitbeobachtung nach Lebertransplantationen eine seltenere Komplikation dar. Wir berichten uber 2 Patienten (mannlich, 36 und 48 Jahre alt) bei mehr als 120 durchgefuhrten Lebertransplantationen, die 6 bzw. 14 Wochen nach der Transplantation einen akuten Anstieg der Transaminasen und Cholestaseparameter zeigten. Mittels Duplexsonographie und Angiographie wurde eine Stenosierung der arteriellen Anastomose nachgewiesen. Der 1. Patient ist 12 Monate nach operativer Rekonstruktion beschwerdefrei und zeigt normale Leberenzyme. Der 2. Patient entwickelte trotz suffizienter Ballondilatation eine chronische Transplantatcholangiopathie, welche eine Retransplantation erforderlich macht.