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Ziel: Minimalinvasive Techniken, wie die videoassistierte Thoraxchirurgie (VATS), sind heutzutage zur Resektion vor allem peripher gelegener Rundherde Methode der Wahl. Um eine schnelle und sichere intraoperative Lokalisation zu gewahrleisten, haben sich diverse Markierungstechniken etabliert. Wir berichten uber die Erfahrungen bei 184 Markierungen mittels eines speziellen Lungenmarkierungsdrahts, der CT-gestutzt praoperativ an den Herd gebracht wird. Material und Methoden: Bei 184 Patienten (97 m, 87w, mittleres Alter: 58,1 ± 13,7 Jahre) wurde unmittelbar vor der VATS eine CT-gesteuerte Markierung des Rundherds mithilfe eines Spiraldrahts vorgenommen. Evaluiert wurden anschliesend die Erfolgsrate, die Sicherheit der Intervention, die Notwendigkeit eines Umstiegs zur Thorakotomie sowie die Histologie der Patienten. Ergebnisse: Der Markierungsdraht konnte in 181 Fallen (98,4 %) erfolgreich platziert werden. Eine Markierung musste aufgrund eines nicht beherrschbaren Pneumothorax abgebrochen werden. Geringgradige, methodisch nicht vermeidbare Komplikationen wie Mantelpneumothoraces (53,3 %) oder perifokale Blutungen (30,4 %) bedurften keiner Therapie. Die makroskopisch vollstandige Entfernung der markierten Herde gelang bei 98,4 % der Patienten. Aufgrund intraoperativer Komplikationen (Adhasionen, Blutungen, Drahtdislokationen) war in 29 Fallen (15,9 %) die Konversion zur Thorakotomie erforderlich. Die Histologie ergab in 96 Fallen (52,5 %) einen benignen Befund, in 87 Fallen (47,5 %) einen malignen, wobei insgesamt lediglich 21 Herde (11,5 %) einem primaren Lungenkarzinom entsprachen. Schlussfolgerung: Die Kombination aus CT-gesteuerter Herdfixierung mittels Spiraldraht und die anschliesende thorakoskopische Entfernung ist eine effiziente und sichere Methode zur Diagnostik von unklaren intrapulmonalen Rundherden, insbesondere fur periphere, subpleural gelegene Herde.

INTRODUCTION: Inspection and palpation of the ventilated and exhausted lung reflect the guideline-compliant surgery of pulmonary metastases. Because a huge number of pulmonary nodules are missed on preoperative CT, metastases must be diagnosed by the surgeon's examination of the lung under exclusion of the video-assisted approach. The purpose of our study was to assess whether a special multislice (MS) spiral CT may close this diagnostic gap and change the management of pulmonary surgery. PATIENTS AND METHODS: We performed a prospective study to address this question. Operative and histological results of 60 patients with pulmonary nodules (7 / 2002 and 12 / 2004) were compared with the preoperative predictions of MS-CT. RESULTS: In 81 operations, 166 pulmonary metastases were confirmed histologically. The MS-CT predicted 229 suspicious metastases; 38 % could not be confirmed histologically. However, in 14 % of surgically confirmed metastases the radiological correlate was absent. 44 % of these metastases were ≤ 2 mm, 30 % ≤ 4 mm, and 26 % > 4 mm; and were from the following primary entities: 48 % hypernephroma, 30 % sarcoma, 17 % colorectal carcinoma and 4 % breast cancer. The radiological prediction of 1 to 3 vs. 5 to 11 metastases implied 30 % vs. 70 % additional filiae, whereas radiologically non-described metastases were found in 12 % of all operations. In contrast, the group with radiopaque material showed only 5 % of metastases without a radiological correlate or 8 % of non-described metastases. The overall sensitivity of MS-CT was 86 %, whereas the group with radiopaque material had a sensitivity of 95 %. CONCLUSION: The preoperative MS-CT does not resolve the problem of overlooked metastases and has no influence on the management of pulmonary surgery.

Die videoassistierte Thoraxchirurgie VATS (video-assisted thoracoscopic surgery) ist als minimal-invasive Operation zur Resektion unklarer Lungenherde etabliert. Vorgestellt wird eine Prozedur fur Falle, in denen der zu operierende Herd wegen seiner Topographie voraussehbar endoskopisch nicht sichtbar ist. Bisherige Erfahrungen (von Mai 2000 an) umfassen 5 Patienten (4m, 1w) mit unklaren Lungeneinzelherden. In unmittelbarer Vorbereitung des videoassistierten chirurgischen Eingriffs erfolgte eine CT-gesteuerte Herdmarkierung sowohl mittels Lasermarkierungs- und Zielhilfe als auch mit einem speziellen Markersystem fur Lungenherde. Alle 5 Prozeduren waren erfolgreich, rasch und zielgenau durchfuhrbar. Mittels Lasermarkierungs- und Zielhilfe konnte der Lungenherd exakt markiert und angesteuert sowie mittels Spezialdraht transthorakal fixiert werden. Intraoperativ wurde der am Draht “hangende” Herd mit dosierter Kraft nach ausen gezogen, endoskopisch verifiziert und komplikationslos entfernt. Die kombinierte Anwendung von Lasermarkierungs- und Zielhilfe am CT, Herdfixation mittels Spezialdraht und videothorakoskopischer Entfernung von Lungenherden ist fur pleuraferne und daher oberflachlich nicht sichtbare Lungenherde empfehlenswert.

OBJECTIVE Linear and round shadows are very often revealed on chest radiographs. A rare entity most commonly appearing as branching linear shadows of calcific density involving a limited area of the lung is the so-called disseminated pulmonary ossification (DPO). Only 141 cases have been reported worldwide up to now since the first description. MATERIAL AND METHODS A study on 490 autopsies was performed to find out the frequency of DPO. In case of DPO we compared the structures with the chest radiographs and CT of the patients. Further, we evaluate clinical communities of patients with DPO. RESULTS From a total of 490 lungs eight were identified with DPO (1.6%). The mean age of patients with DPO was 80.2 years, the male/female ratio seven to one (mean age of all patients: 64.6 years, male/female ratio one to one). All cases were associated with hypertension followed by extreme arteriosclerosis. In 5 cases there was a proven extrapulmonary carcinoma and a renal insufficiency. In 4 cases we found diabetes mellitus. At postmortem radiographs and CT, a collection of small rounded calcific nodules and further linear shadows arranged in a branching or net-like configuration was identified. This was compared with the chest radiographs of the patients. There were no dysfunctions of lungs due to DPO. CONCLUSIONS In chest radiographs of elderly men the differential diagnosis "DPO" should be given more importance.

Minimally invasive techniques like video-assisted thoracoscopic surgery (VATS) are currently the method of choice for the resection of small pulmonary nodules, when they are located in the periphery of the lungs. To guarantee quick and safe intraoperative identification of the nodule, preoperative marking is necessary and sensible. We report about our experiences in 184 markings with a special lung marking wire, which is placed in or around the pulmonary nodule using CT guidance.In 184 patients (97 m, 87f, mean age: 58.1 ± 13.7 years) with pulmonary nodules, scheduled for resection with VATS, a special lung marking wire was placed preoperatively under CT guidance. We evaluated the technical success, safety, necessity of conversion to thoracotomy and histology in all patients.The marking wire could be positioned successfully in 181 cases (98.4 %). There was one major complication (uncontrollable pneumothorax). Minor adverse events like small pneumothorax (53.3 %) or a perifocal bleeding (30.4 %) did not necessitate treatment. Complete resection of the marked nodule was successful in 98.4 % of the patients. Conversion to thoracotomy was necessary in 29 patients (15.9 %) due to bleeding, adhesions, malignancy or wire dislocation. Histology revealed a benign nodule in 96 cases (54.4 %) and a malignant lesion in 78 cases (45.6 %), of which only 21 nodules (11.5 %) turned out to present a primary pulmonary carcinoma.CT-guided marking of pulmonary nodules using a special marking wire followed by thoracoscopic resection is an efficient and safe method for diagnosing suspicious nodules in the periphery of the lung.

Inspection and palpation of the ventilated and exhausted lung reflect the guideline-compliant surgery of pulmonary metastases. Because a huge number of pulmonary nodules are missed on preoperative CT, metastases must be diagnosed by the surgeon's examination of the lung under exclusion of the video-assisted approach. The purpose of our study was to assess whether a special multislice (MS) spiral CT may close this diagnostic gap and change the management of pulmonary surgery.We performed a prospective study to address this question. Operative and histological results of 60 patients with pulmonary nodules (7/2002 and 12/2004) were compared with the preoperative predictions of MS-CT.In 81 operations, 166 pulmonary metastases were confirmed histologically. The MS-CT predicted 229 suspicious metastases; 38% could not be confirmed histologically. However, in 14% of surgically confirmed metastases the radiological correlate was absent. 44% of these metastases wereor=2 mm, 30%or=4 mm, and 26%4 mm; and were from the following primary entities: 48% hypernephroma, 30% sarcoma, 17% colorectal carcinoma and 4% breast cancer. The radiological prediction of 1 to 3 vs. 5 to 11 metastases implied 30% vs. 70% additional filiae, whereas radiologically non-described metastases were found in 12% of all operations. In contrast, the group with radiopaque material showed only 5% of metastases without a radiological correlate or 8% of non-described metastases. The overall sensitivity of MS-CT was 86%, whereas the group with radiopaque material had a sensitivity of 95%.The preoperative MS-CT does not resolve the problem of overlooked metastases and has no influence on the management of pulmonary surgery.

Tracheobronchial ruptures are rare surgical emergencies with significant mortality. We present management and outcome of such ruptures treated at the University of Leipzig in Germany and propose a novel therapeutic algorithm-a new classification system for stratifying treatment of patients with tracheobronchial ruptures.We retrospectively studied 24 patients 19 to 88 years old who were treated in our institution for tracheobronchial injury.Eighty-seven percent of the injuries were caused iatrogenically. Fifty-four percent were type I injuries (isolated tracheal lesions), 38% type II (involvement of carina or main stem bronchi), and 8% type III (distal lesions of lobar or segmental bronchi). Seventy-five percent of the patients were operated via right-sided dorsolateral thoracotomy. In four (22%), insufficiency of the tracheal closure occurred, with mediastinitis possibly being a significant risk factor for this event (P0.001). In surgically treated patients, rupture-related and overall mortality were 5.5% and 28%, respectively, whereas in medically treated patients, mortality was 33%.The proposed classification of tracheobronchial injuries enables stratifying the treatment of patients with tracheobronchial ruptures. Type I lesions can be surgically closed either by a right-sided thoracotomy or transcervical-transtracheal approach. In contrast, surgical management of type II and III injuries always requires thoracotomy.

The temperature increase during the use of an ultrasonic surgery device was experimentally determined in vitro and in vivo with the aid of thermocouples of specific design. Temperature elevations by more than 40/spl deg/C were found at 1 mm distance from the blade, whereas at distances of more than 5 mm, perfusion removed the heat very efficiently. It is concluded that during application of the harmonic scalpel a safety margin of 3 mm from sensitive structures should be kept.

In the last few years the use of intraoperative electrophysiological monitoring of the recurrent laryngeal nerve (RLN) in thyroid gland surgery has become more and more important.In a prospective study 223 nerves at risk in 116 patients were monitored with the Neurosign(R)100 (Fa. Magstim Ltd., UK). We used intramuscular needle electrodes inserted into the vocal muscle through the conic ligament. Practicability, complications, acceptance and predictive value of the method were documented. Recurrent nerve palsy rate and complications were compared with a control group operated upon without monitoring.The intraoperative delay using this method was on average 8.9 minutes. There were problems with monitoring equipment avoiding use in 6.4 %. In 2 cases (1.7 %) an accidental lesion of endotracheal tube cuff was found related to malpositioning of the needle and in 7.7 % a hematoma of the vocal cords was observed. 73.3 % of the surgeons accepted the method to identify and control the nerve integrity. False-positive and false-negative signals may occur. In cases of a final real stimulus response a regular vocal cord motility was found in 95 %. If a nerve conduction block was noted an immobility of ipsilateral vocal cord was diagnosed postoperatively in 50 %. There was no decrease in transient recurrent palsy rate using monitoring (10.7 % vs. 9.6 % without monitoring) but in permanent paralysis (1.8 % vs. 3.0 %).It may be concluded that intraoperative electrophysiological monitoring of the RLN is a simple and accepted method with low complications reducing the incidence of permanent RLN palsy rate. We found the monitoring especially useful for operations of recurrent goiter and carcinomas of the thyroid gland as well as for learning thyroid gland surgery.

Video-assisted thoracoscopic surgery (VATS) is an established method for resection of suspicious pulmonary lesions. However, there are problems to detect small subpleural lesions. A procedure for localization of such lesions will be demonstrated. Since may 2000 our experience includes 5 patients (4m, 1f) suffering from solitary pulmonary lesions. In preparation of VATS a CT-guided marking was carried out using both a lasermarker system as well as a special marker system for lung lesions. All 5 procedures were successful. With the laser system the pulmonary nodule was exactly marked and the special wire was placed without any complications. Consequently, the pulmonary nodule was fixed. During video-assisted wedge resection the nodule can be tracted outside. Operating time was reduced in comparison to time consuming search of unmarked lesions. The combined application of CT-guided marking, transthoracic fixation of pulmonary nodule and VATS is recommended preoperatively. It should apply in lesions, which are located subpleural and thoracoscopically not visible.

Vocal cord paralysis is a important complication in thyroid gland surgery. A prospective study was conducted ascertain the frequency of laryngeal nerve palsy not caused by surgical trauma.Two hundred and ten patients were investigated laryngoscopically pre- and postoperatively after short-term intubation in the course of operations far removed from thorax or neck region. We noted the inner diameter of the tube, intubation problems, the qualification of the anaesthesiologist and the positioning of the patient.Preoperatively we found previously unknown unilateral laryngeal nerve palsy in 1.9% of cases. Postoperatively there were pathological findings of vocal cords in 13 patients (6.2%). In 10 patients a direct lesion (oedema, rubor, haematoma, granuloma) was established. Three patients (1.4%) were found to have a movement disorder caused by a neural lesion without morphological findings, leading to restitutio ad integrum in two of three cases after 6 months.The frequency of intubation-related recurrent nerve palsy is 1.4% transiently and 0.5% permanently. The reasons are discussed. Preoperative laryngoscopic investigation of vocal cords should be carried out before intubation.

Bilateral vocal cord paralysis is a rare but potentially dangerous postoperative complication in thyroid gland surgery. There is a controversial discussion about therapeutic management of postoperative bilateral vocal cord paralysis.We analysed the frequency of bilateral nerve palsy in 985 operations. The disease of thyroid gland, the operative procedure, the exposure of laryngeal nerve, the mobility of vocal cord detected by an otolaryngologist, clinical symptoms and therapy of patients with bilateral paralysis were analysed. All patients were examined immediately postoperatively and 5 days, 14 days, 6 and 12 months after resection.The overall transient bilateral palsy rate was 0.7%, the permanent 0.3%. The palsy rate depended on the disease of thyroid gland. After resection of simple goitre we found a 0.2% transient injury rate (0.1% permanent), after operation of thyroid cancer 2.0% transient (1.0% permanent) and in cases of recurrent goitre 5.9% transient (1.9% permanent) palsies. The immediate postoperative symptoms are also very different. There are patients suffering from stridor and dyspnoea, patients with dysphonia without dyspnoea and those without any symptoms. These different clinical symptoms are due to the different grade of laryngeal nerve damage and the resulting position of vocal cords. The bilateral paralysis was completely temporary in 4 cases. 12 months later 4 patients suffered from dysphonia. Only in 3 patients with thyroid cancer and a preoperative unilateral vocal cord paralysis tracheostomy was necessary after operation. The vocal cord mobility did not recover in these 3 cases after 12 months and the patients are not decannulated.Bilateral paralysis is only relevant in thyroid cancer and recurrent goitre. The symptoms varies and no patient should leave the hospital without examination of the vocal cords by an otolaryngologist. Because vocal cord paralysis is temporary in most cases an emergency tracheostomy is seldom indicated.

An 45 Ro-resezierten Patienten mit einer Nachbeobachtungszeit von 10–57 Monaten (Median 29%) mit Weichteilsarkom der Extremitaten wurde prospektiv die Bedeutung der Nachresektion nach unradikalem Ersteingriff untersucht. Von 32 Patienten mit primar radikaler OP verstarben im Nachbeobachtungszeitraum 9 (28,1%), unter den Patienten mit einer komplettierenden Nachresektion war der Anteil fast doppelt so hoch (n = 7 von 13; 53,9%). Hieraus leitet sich die Empfehlung ab, Patienten mit dem Verdacht auf ein Weichteilsarkom zur Vermeidung von Sekundareingriffen primar an ein Zentrum zu uberweisen.

The article deals with the case of an inflammatory pseudotumour of the lung in conjunction with histoplasmosis of the hilar lymph glands in a 35-year-old immunocompetent woman in a non-endemic area. She had been suffering from headaches and painful swelling of the lower legs, reddening and hyperthermia for 1.5 years. In addition to the above-mentioned symptoms she also complained of a typical flush syndrome which had begun a year later. The main paraclinical finding was a round mass in the right lung in chest radiography. After considering various differential diagnostic possibilities, thoracotomy and resection of the upper lobe of the right lung were performed. The histological diagnosis of the material removed was that of an inflammatory pseudotumour of the lung, combined with histoplasmosis of the hilar lymph glands. Following a postoperative period without complications, antimycotic treatment was performed. The discussion includes whether the simultaneous occurrence of these two diseases is coincidental or whether there is a causal relation between the two. The authors also discuss various treatments with reference to the relevant literature.

Linear and round shadows are very often revealed on chest radiographs. A rare entity most commonly appearing as branching linear shadows of calcific density involving a limited area of the lung is the so-called disseminated pulmonary ossification (DPO). Only 141 cases have been reported worldwide up to now since the first description.A study on 490 autopsies was performed to find out the frequency of DPO. In case of DPO we compared the structures with the chest radiographs and CT of the patients. Further, we evaluate clinical communities of patients with DPO.From a total of 490 lungs eight were identified with DPO (1.6%). The mean age of patients with DPO was 80.2 years, the male/female ratio seven to one (mean age of all patients: 64.6 years, male/female ratio one to one). All cases were associated with hypertension followed by extreme arteriosclerosis. In 5 cases there was a proven extrapulmonary carcinoma and a renal insufficiency. In 4 cases we found diabetes mellitus. At postmortem radiographs and CT, a collection of small rounded calcific nodules and further linear shadows arranged in a branching or net-like configuration was identified. This was compared with the chest radiographs of the patients. There were no dysfunctions of lungs due to DPO.In chest radiographs of elderly men the differential diagnosis "DPO" should be given more importance.

Cytological investigations are established in thoracic surgery beside intraoperative histological examinations. We use these intraoperative cytological investigations as an additional diagnostic option for surgical decisions at our hospital for more than 15 years. 1008 intraoperative cytological findings were compared with the final histological results in a retrospective study to investigate the security of these cytological findings. The diagnostical sensitivity for the detection of any malignancy was 97.7%. A correlation of cytological and histological results was found for benign tumors in 96.2% and for inflammatory diseases in 89.2%. The cytological and histological diagnoses regarding the real histological type of malignant tumors corresponded in only 667 of 834 cases. Due to these findings we conclude that intraoperative cytology is very useful to diagnose malignancy. However, additional diagnostic and clinical parameters have to be used for making final intraoperative decisions.

Weichteilsarkome (WTS) stellen die Tumorgruppe mit der grosten Vielfalt bekannter morphologischer Strukturbilder, auftretender Lokalisationen und moglicher klinischer Verlaufe dar [1]. Die exakte Tumorklassifikation gibt trotz verfeinerter histologischer Diagnostik auch unter Berucksichtigung von Tumorlokalisation, Tumorgrose und Patientenalter keine ausreichende Information uber Krankheits verlauf und Prognose sowie notwendige Therapiemodalitaten, weil das biologische Verhalten des Tumors im Einzelfall kein sicheres histomorphologisches Korrelat hat. Molekularbiologische Untersuchungen sind deshalb auch fur WTS immer mehr in den Mittelpunkt wissenschaftlichen Interesses geruckt. Mutationen im Tumorsuppressorgen p53 sind in etwa 50% aller Malignome nachweisbar [2]. Durch die Strukturaufklarung der Zentralregion des p53-Proteins (Codon 94–312) konnte die funktionelle Bedeutung unterschiedlicher Mutationen fur die Tumorgenese weiter aufgeklart und die Wichtigkeit exakter Mutationsanalysen unterstrichen werden [3]. Nur etwa 3% aller bekannten Mutationen entfallen auf WTS [2]. Die gefundene Mutationsfrequenz von maximal 20% liegt deutlich unter der der meisten Karzinome [2, 4, 5, 6, 7]. Ursachlich kommt hierfur in WTS eine eventuell haufiger auftretende p53-Inaktivierung durch Komplexierung mit dem mdm2-Genprodukt in Frage [5, 7, 8]. Ziel unserer Arbeit war es innerhalb der bezuglich p53-Mutationen bisher wenig untersuchten WTS an drei unterschiedlichen Entitaten mit abgestuftem Malignitatsgrad (malignes fibroses Histiozytom (MFH), Liposarkom (LS), Leiomyosarkom (LMS)) einen Beitrag zur weiteren Verifikation von p53-Mutationen in WTS zu leisten und dabei zu klaren ob es Hinweise auf entitatsspezifische Mutationen gibt und welche klinische Bedeutung nachweisbare Mutationen haben.

After presentation of postgastrectomy syndromes the methods for demonstrating the quantity of alkaline reflux are described. In 81 patients with gastrectomy the authors compare the reconstruction methods--named after Siewert/Peiper, Hunt/Lawrence, Schreiber and Schloffer--according to their reflux characteristics. The Y-Roux anastomosis shows better results than the Schloffer method.

Pretherapeutic parameters are demanded for the hormonal treatment of metastasing breast cancer. Many methods have proved to be ineffective in the assessment of the hormone sensitivity until now (determination of concentrations of steroid hormones in serum and urine or Barr's sex-chromatin). Investigations carried out hitherto on estradiol receptor content or on hormone sensitivity based on in-vitro cultures were promising. They caused us to compare both methods at the same mamma carcinoma tissue. The results of this study showed that no unequivocal correlation between receptor status and the results of in-vitro cell culture tests for hormone sensitivity could be found. Although all in all the results of both methods are almost identical in percentage, there are however substantial deviations between the results in the directly corresponding comparison of each single tissue sample.