Über die Perigraftreaktion von unbeschichteten und antibakteriell beschichteten Silber- und Rifampicin-Dacron-Gefäßprothesen : Eine quantitative Analyse am tierexperimentellen Rückenhautkammermodell der Maus

Über die Perigraftreaktion von unbeschichteten und antibakteriell beschichteten Silber- und Rifampicin-Dacron-Gefäßprothesen. Eine quantitative Analyse am tierexperimentellen Rückenhautkammermodell der Maus Um geschädigte Arterien zu ersetzten muss häufig auf synthetische Gefäßprothesen zurückgegriffen werden, obwohl diese mit einer deutlich höheren Inzidenz an Infekten einhergehen als dies für autologe Venen der Fall ist. Bei vielen gefäßchirurgischen Patienten stehen zum Beispiel aufgrund von Alter oder Begleiterkrankungen keine entsprechenden Venen zur Verfügung die für einen Gefäßersatz notwendig wären. Für diese Patienten ist die Verwendung von Gefäßprothesen oft die einzig alternative Therapie. Das Risiko eines Gefäßprotheseninfekts liegt bei ungefähr 5% und ist mit einer hohen Morbidität und Mortalität verbunden. Zur Behandlung einer solchen Gefäßprotheseninfektion reicht eine systemische Antibiose alleine oft nicht aus. Teilweise müssen infizierte Prothesen entfernt und gegeben falls sehr aufwendig rekonstruiert werden. Als Ersatz der infizierten Prothese und zur direkten Therapie in situ haben sich DacronTM Prothesen etabliert, die mit antibakteriellen Eigenschaften ausgestattet sind. Das verbreitetste Konzept ist die Beschichtung einer DacronTM Prothese mit dem Antibiotikum Rifampicin. Ebenfalls ist die Beschichtung mit Silber erhältlich und auch eine Kombinationsbeschichtung aus Rifampicin und Silber auf einer DacronTM Prothese ist möglich. Diese speziellen Prothesen werden zunehmend auch zur Prophylaxe eingesetzt. Bei Rifampicin wird jedoch seit längerer Zeit eine antiangiogene und proliferationshemmende Wirkung beschrieben. Eine ausreichende Angiogenese, Proliferation und eine adäquate Inflammation sind jedoch für die suffiziente Integration einer Prothese in das umliegende Gewebe enorm wichtig, hierdurch können auch Gefäßprotheseninfektionen vermieden werden. Insofern wollten wir in unserer Studie untersuchen, ob sich eine Rifampicinbeschichtung negativ auf das Integrationsverhalten von Gefäßprothesen auswirkt. Hierfür wurden Rifampicinbeschichtete und unbeschichteten DacronTM sowie mit Rifampicinbeschichtete Dacron Silber+TM Prothesen verglichen. Für die Studie nutzen wir das Rückenhautkammermodell an C57BL/6 Mäusen. Durch diese Methode war eine in vivo Analyse über 14 Untersuchungstage mittels intravitaler Fluoreszenzmikroskopie (IVM) möglich. Hier konnten die Neoangiogenese und Inflammation als dynamische Prozesse beobachtet werden. Nach Ende der in vivo Messungen folgten ein immunhistochemische Auswertungen der Neoangiogense und Inflammation sowie von Proliferation und Apoptose. Wir konnten feststellen, dass Rifampicinbeschichtete Dacron™ Prothesen verglichen mit unbeschichteten DacronTM Prothesen die Neoangiogense und Inflammation signifikant hemmten. Diese Ergebnisse, eine signifikante Hemmung der Proliferation sowie eine signifikant erhöhte Apoptose, ausgelöst durch Rifampicin, konnte immunhistochemisch bestätigt werden. Der Vergleich von Rifampicinbeschichteten und unbeschichteten Prothesen mit Rifampicinbeschichteten Dacron Silber+ TM Prothesen ergab eine signifikant niedrigere Inflammation und Angiogenense verglichen mit unbeschichteten Prothesen. Im Vergleich mit Rifampicinbeschichteten DacronTM Prothesen war eine erhöhte Angiogenese und Inflammation im späten Verlauf des Versuchs messbar. Darüber hinaus konnten signifikant höhere Werte für Proliferation und signifikant niedrigere Werte für Apoptose im Vergleich mit Rifampicinbeschichteten DacronTM Prothesen erhoben werden. Dieses signifikant schwächere Integrationsverhalten von Rifampicinbeschichteten Gefäßprothesen könnte im direkten Zusammenhang mit der Hemmung des Vascular endothelial growth factor (VEGF) und der bekannten immundepressiven Wirkung von Rifampicin stehen. Vor allem eine frühe Neoangiogense und eine adäquate Inflammation sind für die Inkorporation von Gefäßprothesen wichtig. Eine suffiziente Inkorporation trägt zu einer verbesserten Offenheitsrate bei und senkt die Gefahr eines Protheseninfekts. Insofern sollte der Einsatz von Rifampicinbeschichteten Gefäßprothesen jeweils abgewägt werden. Insbesondere der prophylaktische Einsatz dieser Prothesen sollte überdacht werden.Perigraftreaction of uncoated and antibacterial coated Silver- and Rifampicin- Dacron-vascular grafts. A quantitative analysis using the dorsal skinfold chamber of mice. Synthetic vascular grafts are frequently used to replace damaged arteries, although they have higher incidences for vascular infections then autogenic used veins. Because of increasing age and comorbidities there are a lot of patients in vascular surgery who do not possess suitable veins to perform proper bypass surgery. For those patients, the use of synthetic vascular grafts is an alternative treatment. The risk for vascular prosthetic graft infections is approximately 5% and results in high rates of morbidity and mortality. For the treatment of a vascular prosthetic graft infection is a single antibiotic therapy often not effective. In some extent, the infected graft should be removed and the vessels should be reconstructed. For the substitution of the infected graft besides to have an antibacterial therapy directly in the contaminated tissue DacronTM vascular grafts are well established which show antibacterial properties. In this regard, the most used concept is the use of Rifampicin coated DacronTM grafts. Furthermore, there are silver acetate coated vascular grafts available and the combination of Rifampicin soaked, silver acetate coated vascular grafts. These particular grafts are also increasingly used for antibacterial prophylaxis. Rifampicin is known to reduce vascularization and proliferation. An adequate vascularization and proliferation besides a suitable inflammation of vascular prostheses during the early healing process is essential for a proper integration in addition for the prevention of perioperative or late graft infection. Thus, in this experimental study we analyzed whether this coating affects the early tissue incorporation of the grafts. There for we matched uncoated and Rifampicin coated grafts with Rifampicin soaked silver acetate coated vascular grafts. For our studies, we used the dorsal skinfold chamber model of C57BL/6 mice. This model permits an in vivo survey over an observation period of 14 days by using repetitive intravital fluorescence microscopy. With this method neovascularization and inflammation were examined as dynamical processes. After the in vivo experiments neoangiogenesis and inflammation as well as cell proliferation and apoptosis were analyzed immunohistochemically. Our results show that Rifampicin coated DacronTM vascular grafts compared to uncoated DacronTM grafts exhibit a significant reduced neovascularization and inflammation. Furthermore, a significant impaired proliferation and an enhanced count of apoptotic cells. The comparison between Rifampicin coated and uncoated DacronTM grafts with Rifampicin soaked Dacron Silver+TM grafts yielded a significant reduced inflammation and neovascularization compared to uncoated DacronTM grafts. Compared to Rifampicin coated DacronTM grafts we measured increased neovascularization and inflammation. In addition, we examined a significant increased proliferation and enhanced apoptosis compared to Rifampicin coated DacronTM grafts. The significant impaired incorporation of Rifampicin coated vascular grafts could be cohesive with the immune depressive effect of Rifampicin and in addition eventually with the down regulation of the vascular endothelial growth factor (VEGF) by Rifampicin. Especially the rapid graft vascularization and inflammation are thought to be highly important for the incorporation of vascular grafts. Thus a sufficient Incorporation contributes to a higher patency rate and lower risks of vascular graft infections. On this account, the use of Rifampicin coated vascular grafts should reconsidered. Exceedingly the use of Rifampicin coated grafts for antibacterial prophylaxis should be reevaluated particularly in cases of elective arterial reconstruction in noninfected environments

Angiosarcoma of the Left Atrium: A Case Report

Background Primary cardiac tumors are rare, andmany diagnosed tumors are benign with an incidence of 0.001% to 0.03%. The primary angiosarcoma is one of the malignant entities. Discussion We discuss a case report of a 76-year-old male who underwent a preoperative diagnosis for an upcoming shoulder operation when his cardiologist diagnosed a large cardiac tumor. The patient was referred to our department where he received further diagnostics. The transesophageal echocardiography and the cardiac-magnetic resonance imaging showed a massive tumor with a dimension of 8.6 x 5.6 cm with no signs of malignity. Method The operation was performed by standard median sternotomy. The tumor was adherent to the septum and the left atrium, and we were able to remove the specimen in toto. Pathological examinations showed an angiosarcoma with neovascularization and core expression of ERG+ and cytoplasmic expression of CD31+/CD34+, due to the size of the mass. The resection of primary cardiac tumors is mostly the therapy of choice, but in this case concerning an angiosarcoma the prognosis is poor, considering that the angiosarcoma responds very badly to chemotherapy and radiotherapy

Constrictive pericarditis with a life-threatening giant pericardial cyst and pectus excavatum as unusual cause for malign cardiac arrhythmias

Pericardial cysts are rare, abnormal, benign and usually congenital anomalies with an estimated incidence of 1:100.000 and are caused by an incomplete coalescence of foetal lacunae of pericardium development. The size of pericardial cysts varies from 1 to 5 cm and generally do not cause any symptoms. Pectus excavatum is one of the most frequent chest wall abnormalities with a caved-in appearance of the chest and mostly of unknown pathogenesis. We present a rare case of constrictive pericarditis with a huge pericardial cyst (11.6 x 8.7 x 7.1 cm) and pectus excavatum which led to compression of the heart and life-threatening cardiac arrhythmias

Minimally invasive resection of a giant left atrial myxoma: a case report

Cardiac tumors are a rarity. Most diagnosed primary tumors of the heart are benign, with an incidence ranging between 0.001% and 0.03%. Cardiac myxoma is one of these benign entities. A 44-year-old Caucasian woman who presented with symptoms of a common cold was diagnosed with a massive obstructing myxoma of the left atrium. Despite its large size, the tumor was completely removed using minimally invasive access through right anterior thoracotomy. However, the myxoma was adherent to the left atrial septum and was excised in toto. Pathological examinations confirmed the diagnosis of a primary cardiac myxoma. Total resection of obstructive cardiac myxomas is the therapy of choice, whereas minimally invasive surgical approach might be feasible despite large size and septal localization, but is technically challenging

Complications associated to wound drainages in tumor spine surgery: a multicenter surveillance study from the German Spine Registry (DWG-Register)

There is an ongoing debate whether a surgical drainage is beneficial to prevent local accumulation of hematoma and to reduce the rate of wound infections, and neurological deficits. Data from the German Spine Society (DWG) registry were filtered for surgically treated spine tumor cases between 2017 and 2021. Cases were categorized into with (Group I) and without (Group II) placement of a surgical drainage. Subgroups were compared for demographic data, type of surgery, experience of the surgeon and postoperative surgical complications. 10,029 cases were included into final analysis (Group I: 3007; Group II: 7022). There was no significant difference between both groups regarding age or gender distribution. Average morbidity of patients was significantly elevated in Group I (p < 0.05) and the rates of invasive surgery were significantly increased in this group (p < 0.001). Overall complication rates were reported with 12.0% (Group I) and 8.5% (Group II). There were significantly more epidural hematoma (p < 0.001) and motor dysfunction (p = 0.049) as well as deep wound infections (p < 0.001) and implant failures (p = 0.02) in Group I. A surgical wound drainage cannot prevent epidural hematoma

Stage I and II Small-Cell Lung Cancer-New Challenge for Surgery

Purpose The recommended treatment for small-cell lung cancer (SCLC) currently is surgery in stage I disease. We wondered about stage II SCLC and present a meta-analysis on mean-survival of patients that underwent surgery for stage I and II compared to controls. Methods A systematic literature search was performed on December 01st 2021 in Medline, Embase and Cochrane Library. We considered studies published on the effect of surgery in SCLC since 2004 and assessed them using ROBINS-I. We preformed I-2-tests, Q-statistics, DerSimonian-Laird tests and Egger-regression. The meta-analysis was conducted according to PRISMA. Results Out of 6826 records, seven studies with a total of 11,241 patients ('surgery group': 3911 patients; 'non-surgery group': 7330; treatment period: 1984-2015) were included. Heterogeneity between the studies was revealed in absence of any publication bias. Patient characteristics did not differ between the groups (p-value > 0.05). The mean-survival in an analysis of patients in stage I was 36.7 +/- 10.8 months for the 'surgery group' and 20.3 +/- 5.7 months for the 'non-surgery group' (p-value = 0.0084). A combined analysis of patients in stage I and II revealed a mean-survival of 32.0 +/- 16.7 months for the 'surgery group' and 19.1 +/- 6.1 months for the 'non-surgery group' (p-value = 0.0391). In a separate analysis of stage II, we were able to demonstrate a significant survival benefit after surgery (21.4 +/- 3.6 versus 16.2 +/- 3.9 months; p-value = 0.0493). Conclusion Our meta-analysis shows a significant survival benefit after surgery not only in the recommended stage I but also in stage II SCLC. Our data suggests that both stages should be considered for surgery of early SCLC

Major Bleeding after Surgical Revascularization with Dual Antiplatelet Therapy

Objective Patients with acute coronary syndrome are treated with dual antiplatelet therapy containing acetylsalicylic acid (ASA) and P2Y12 antagonists. In case of urgent coronary artery bypass grafting this might be associated with increasing risks of bleeding complications. Methods Data from 1200 consecutive urgent operations between 2010 and 2018 were obtained from our institutional patient database. For this study off-pump surgery was excluded. The primary composite end point major bleeding consisted of at least one end point: transfusion >= 5 packed red blood cells within 24hours, rethoracotomy due to bleeding, chest tube output >2000mL within 24hours. Demographic data, peri-, and postoperative variables and outcomes were compared between patients treated with mono antiplatelet therapy, ASA+clopidogrel (ASA-C) +ticagrelor (ASA-T) or +prasugrel (ASA-P)<72hours before surgery. Furthermore, we compared patients with dual antiplatelet therapy with ASA monotherapy. Results From 1,086 patients, 475 (44%) received dual antiplatelet therapy. Three-hundred seventy-two received ASA-C (77.7%), 72 ASA-T (15%), and 31 ASA-P (6.5%). Major bleeding (44 vs. 23%, p <0.0001) was more frequently in patients receiving dual therapy with higher rates of massive drainage loss within 24hours (23 vs. 11%, p <0.0001) of mass transfusion (34 vs. 16%, p <0.0001) and rethoracotomy (10 vs. 5%, p =0.002) when compared with ASA. In this analysis, ASA-T and ASA-P were not associated with higher bleeding complications compared with ASA-C. Conclusion Dual antiplatelet therapy is associated with higher rates of major bleeding. Further studies should examine the difference in the prevalence of major bleeding complications in the different dual antiplatelet therapy regimes in patients requiring urgent surgery

Redefining the role of surgery in early small-cell lung cancer

Purpose Resection is guideline recommended in stage I small-cell lung cancer (SCLC) but not in stage II. In this stage, patients are treated with a non-surgical approach. The aim of this meta-analysis was to assess the role of surgery in both SCLC stages. Surgically treated patients were compared to non-surgical controls. Five-year survival rates were analysed. Methods A systematic literature search was performed on December 01, 2021 in Medline, Embase and Cochrane Library. Studies published since 2004 on the effect of surgery in SCLC were considered and assessed using ROBINS-I. We preformed I-2-tests, Q-statistics, DerSimonian-Laird tests and Egger-regression. The meta-analysis was conducted according to PRISMA. Results Out of 6826 records, we identified seven original studies with a total of 15,170 patients that met our inclusion criteria. We found heterogeneity between these studies and ruled out any publication bias. Patient characteristics did not significantly differ between the two groups (p-value > 0.05). The 5-year survival rates in stage I were 47.4 +/- 11.6% for the 'surgery group' and 21.7 +/- 11.3% for the 'non-surgery group' (p-value = 0.0006). Our analysis of stage II SCLC revealed a significant survival benefit after surgery (40.2 +/- 21.6% versus 21.2 +/- 17.3%; p-value = 0.0474). Conclusion Based on our data, the role of surgery in stage I and II SCLC is robust, since it improves the long-term survival in both stages significantly. Hence, feasibility of surgery as a priority treatment should always be evaluated not only in stage I SCLC but also in stage II, for which guideline recommendations might have to be reassessed

Neoadjuvant chemoimmunotherapy as a potential therapeutic option in NSCLC UICC stage IIIA with multilevel N2 disease

Lung Cancer is still one of the leading causes for cancer related death worldwide. The determina-tion of an adequate therapeutic approach requests a precise staging, which contains computed to-mography (CT) of the thorax, positron emission tomography computed tomography (PET-CT), cerebral magnetic resonance imaging (cMRI) and pulmonary function testing as well as the pa-tient's opinion. In UICC stages I and II, if there is functional operability and technical resectabil-ity, the treatment of choice is primary surgery followed by adjuvant therapy depending on lymph node status, while patients in the metastatic stage IV, or with locally advanced, nonresectable dis-ease are more likely to receive definitive chemoradiation therapy. The UICC Stage III (8th edi-tion) combines a heterogeneous group of patients that remains the focus of discussion regarding the optimal therapeutic regimen, which ranges from primary surgical care to a neoadjuvant ther-apeutic approach, to definitive conservative treatment. Since March 2020, we have been treating a patient on an interdisciplinary basis who initially had a UICC stage IIIA multilevel N-2 pul-monary adenocarcinoma and finally underwent successful surgery after a very good response to neoadjuvant chemoimmunotherapy. Our latest follow-up showed no evidence of recurrence. Sim-ilar to current ongoing studies our case shows, that neoadjuvant immunotherapy is a reasonable alternative to conventional neoadjuvant chemotherapy

The value of thymectomy in the treatment of non-thymomatous myasthenia gravis

The value of thymectomy in the treatment of non-thymomatous myasthenia gravis has been controversially discussed. The relatively low incidence and prevalence of this disease, the inconsistent documentation in various studies and the necessity of a long-term follow-up to assess the therapeutic effects has made the generation of valid data difficult. The publication in 2016 of the MGTX trial in the New England Journal of Medicine delivered the first randomized controlled data in which patients aged 18-65 years with generalized myasthenia gravis and positive for acetylcholine receptor antibodies showed a significant benefit after surgical resection of the thymus via median sternotomy. Despite a lack of validation of the advantages of thymectomy by minimally invasive surgery from randomized controlled studies, this technique seems to positively influence the outcome of certain patient groups in a similar way. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) using subxyphoidal and transcervical access routes showed not only esthetic advantages but also showed no relevant inferiority in the influence on clinical outcomes of myasthenia gravis compared to median sternotomy; however, not only the benefits and the esthetic results show differences but also the advantages in the various subtypes of myasthenia gravis show divergent prospects of success with respect to remission. The clinical spectrum of myasthenia is heterogeneous with respect to the occurrence of antibodies, the body region affected and the age of the patient at first diagnosis. Ultimately, thymectomy is an effective causal treatment of myasthenia gravis