Christian R. Habermann

Postpancreatectomy Hemorrhage: Diagnosis and Treatment: An Analysis in 1669 Consecutive Pancreatic Resections

Background:To analyze clinical courses and outcome of postpancreatectomy hemorrhage (PPH) after major pancreatic surgery. Summary Background Data:Although PPH is the most life-threatening complication following pancreatic surgery, standardized rules for its management do not exist. Methods:Between 1992 and 2006, 1524 patients operated on for pancreatic diseases were included in a prospective database. A risk stratification of PPH according to the following parameters was performed: severity of PPH classified as mild (drop of hemoglobin concentration <3 g/dL) or severe (>3 g/dL), time of PPH occurrence (early, first to fifth postoperative day; late, after sixth day), coincident pancreatic fistula, intraluminal or extraluminal bleeding manifestation, and presence of “complex” vascular pathologies (erosions, pseudoaneurysms). Success rates of interventional endoscopy and angiography in preventing relaparotomy were analyzed as well as PPH-related overall outcome. Results:Prevalence of PPH was 5.7% (n = 87) distributed almost equally among patients suffering from malignancies, borderline tumors, and focal pancreatitis (n = 47) and from chronic pancreatitis (n = 40). PPH-related overall mortality of 16% (n = 14) was closely associated with 1) the occurrence of pancreatic fistula (13 of 14); 2) vascular pathologies, ie, erosions and pseudoaneurysms (12 of 14); 3) delayed PPH occurrence (14 of 14); and 4) underlying disease with lethal PPH found only in patients with soft texture of the pancreatic remnant, while no patient with chronic pancreatitis died. Conversely, primary severity of PPH (mild vs. severe) and the kind of index operation (Whipple resection, pylorus-preserving partial pancreaticoduodenectomy, organ-preserving procedures) had no influence on outcome of PPH. Endoscopy was successful in 3 from 15 patients (20%), who had intraluminal PPH within the first or second postoperative day. “True,” early extraluminal PPH had uniformly to be treated by relaparotomy. Seventeen patients had “false,” early extraluminal PPH due to primarily intraluminal bleeding site from the pancreaticoenteric anastomosis with secondary disruption of the anastomosis. From 43 patients subjected to angiography, 25 underwent interventional coiling with a success rate of 80% (n = 20). Overall, relaparotomy was performed in 60 patients among whom 33 underwent surgery as first-line treatment, while 27 were relaparotomied as rescue treatment after failure of interventional endoscopy or radiology. Conclusion:Prognosis of PPH depends mainly on the presence of preceding pancreatic fistula. Decision making as to the indication for nonsurgical interventions should consider time of onset, presence of pancreatic fistula, vascular pathologies, and the underlying disease.

Diffusion-Weighted Echo-Planar MR Imaging of Primary Parotid Gland Tumors: Is a Prediction of Different Histologic Subtypes Possible?

BACKGROUND AND PURPOSE: Our aim was to determine the value of echo-planar diffusion-weighted MR imaging (epiDWI) in differentiating various types of primary parotid gland tumors. MATERIALS AND METHODS: One hundred forty-nine consecutive patients with suspected tumors of the parotid gland were examined with an epiDWI sequence by using a 1.5T unit. Image analysis was performed by 2 radiologists independently, and the intraclass correlation coefficient was computed. Histologic diagnosis was obtained in every patient. For comparison of apparent diffusion coefficients (ADCs), a paired 2-tailed Student t test with a Bonferroni correction was used. RESULTS: In 136 patients, a primary parotid gland tumor was confirmed by histology. Among the observers, a high correlation was calculated (0.98). ADC values of pleomorphic adenomas were significantly higher than those of all other entities, except for myoepithelial adenomas (P = .054). ADC values of Warthin tumors were different from those of myoepithelial adenomas, lipomas, and salivary duct carcinomas (P < .001, 0.013, and .037, respectively). Mucoepidermoid carcinomas, acinic cell carcinomas, and basal cell adenocarcinomas were not differentiable from Warthin tumors (P = .094, .396, and .604, respectively). CONCLUSION: epiDWI has the potential to differentiate pleomorphic adenoma and myoepithelial adenomas from all other examined entities. Due to an overlap not only within the group of benign and malignant lesions but also between groups, diagnoses should not be addressed on the basis of ADC values solely. Therefore, further studies combining DWI, morphologic criteria, and probably other MR imaging techniques seem warranted.

Correlation of Inflammation Assessed by 18F-FDG PET, Active Mineral Deposition Assessed by 18F-Fluoride PET, and Vascular Calcification in Atherosclerotic Plaque: A Dual-Tracer PET/CT Study

Formation and progression of atherosclerotic plaque is a dynamic and complex process involving various pathophysiologic steps including inflammation and calcification. The purpose of this study was to compare macrophage activity as determined by 18F-FDG PET and ongoing mineral deposition as measured by 18F-sodium fluoride PET in atherosclerotic plaque and to correlate these findings with calcified plaque burden as assessed by CT. Methods: Forty-five patients were examined by whole-body 18F-FDG PET, 18F-sodium fluoride PET, and CT. Tracer uptake in various arterial segments was analyzed both qualitatively and semiquantitatively by measuring the blood-pool–corrected standardized uptake value (target-to-background ratio [TBR]). The pattern of tracer uptake in atherosclerotic lesions was compared after color-coded multistudy image fusion of PET and CT studies. The Fisher exact test and the Spearman correlation coefficient rs were used for statistical analysis of image-based results and cardiovascular risk factors. Intra- and interrater reproducibility were evaluated using the Cohen κ. Results: 18F-sodium fluoride uptake was observed at 105 sites in 27 (60%) of the 45 study patients, and mean TBR was 2.3 ± 0.7. 18F-FDG uptake was seen at 124 sites in 34 (75.6%) patients, and mean TBR was 1.5 ± 0.3. Calcified atherosclerotic lesions were observed at 503 sites in 34 (75.6%) patients. Eighty-one (77.1%) of the 105 lesions with marked 18F-sodium fluoride uptake and only 18 (14.5%) of the 124 lesions with 18F-FDG accumulation were colocalized with arterial calcification. Coincident uptake of both 18F-sodium fluoride and 18F-FDG was observed in only 14 (6.5%) of the 215 arterial lesions with radiotracer accumulation. Conclusion: PET/CT with 18F-FDG and 18F-sodium fluoride may allow evaluation of distinct pathophysiologic processes in atherosclerotic lesions and might provide information on the complex interactions involved in formation and progression of atherosclerotic plaque.

The Spectrum of Syndromes and Manifestations in Individuals Screened for Suspected Marfan Syndrome

The diagnosis of Marfan syndrome (MFS) is based on evaluating a large number of clinical criteria. We have observed that many persons presenting in specialized centers for “Marfan‐like” features do not have MFS, but exhibit a large spectrum of other syndromes. The spectrum of these syndromes and the distribution of “Marfan‐like” features remain to be characterized. Thus, we prospectively evaluated 279 consecutive patients with suspected MFS (144 men and 135 women at a mean age of 34 ± 13 years) for presence of 27 clinical criteria considered characteristic of MFS. The most frequent reasons to refer individuals for suspected MFS were skeletal features (31%), a family history of MFS, or aortic complications (29%), aortic dissection or aneurysm (19%), and eye manifestations (9%). Using established criteria, we confirmed MFS in 138 individuals (group 1) and diagnosed other connective tissue diseases, both with vascular involvement in 30 (group 2) and without vascular involvement in 39 (group 3), and excluded any distinct disease in 72 individuals (group 4). Clinical manifestations of MFS were present in all four patient groups and there was no single clinical criterion that exhibited positive and negative likelihood ratios that were per se sufficient to confirm or rule out MFS. We conclude that “Marfan‐like” features are not exclusively indicative of MFS but also of numerous, alternative inherited diseases with many of them carrying a hitherto poorly defined cardiovascular risk. These alternative diseases require future study to characterize their responses to therapy and long‐term prognosis.

18F-FDG PET/CT for detection and localization of residual or recurrent disease in patients with multiple myeloma after stem cell transplantation

PurposeThe aim of the study was to determine the diagnostic performance of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT for the detection and localization of residual or recurrent disease in patients with multiple myeloma (MM) after stem cell transplantation.MethodsA total of 197 whole-body 18F-FDG PET/CT scans were performed in 99 patients with MM at different time points in the course of disease after autologous or allogeneic stem cell transplantation. Post-transplant PET/CT scans and clinical remission status as determined by the clinical gold standard (Uniform Response Criteria) were analysed and compared.ResultsA total of 576 focal osseous and extramedullary lesions were detected in 79 scans. Additional diffuse bone marrow involvement was detected in 17 patients. 18F-FDG PET/CT had a sensitivity of 54.6%, a specificity of 82.1%, a positive predictive value of 82.3%, a negative predictive value of 54.2% and an overall accuracy of 65.5%. The sensitivity of 18F-FDG PET/CT was shown to depend on the disease category according to the Uniform Response Criteria for myeloma.ConclusionIn patients with MM in the post-transplant setting, 18F-FDG PET/CT may (1) contribute to the detection and localization of disease, (2) provide information about the extent of distinct myeloma manifestations and the total disease burden and (3) add information about the metabolic activity of disease, but (4) has substantially lower sensitivity for this purpose compared to the pretreatment setting.

Long-term follow-up in small duct chronic pancreatitis: A plea for extended drainage by "V-shaped excision" of the anterior aspect of the pancreas.

Background:A pancreatic duct diameter (PDD) ranging from 4 to 5 mm is regarded as “normal.” The “large duct” form of chronic pancreatitis (CP) with a PDD >7 mm is considered a classic indication for drainage procedures. In contrast, in patients with so-called “small duct chronic pancreatitis” (SDP) with a PDD <3 mm extended resectional procedures and even, in terms of an “ultima ratio,” total pancreatectomy are suggested. Methods:Between 1992 and 2004, a total of 644 patients were operated on for CP. Forty-one prospectively evaluated patients with SDP underwent a new surgical technique aiming at drainage of the entire major PD (longitudinal “V-shaped excision” of the anterior aspect of the pancreas). Preoperative workup for imaging ductal anatomy included ERCP/MRCP, visualizing the PD throughout the entire gland. The interval between symptoms and therapeutic intervention varied from 12 to 120 months. Median follow-up was 83 months (range, 39–117 months). A pain score as well as a multidimensional psychometric quality-of-life questionnaire was used. Results:Hospital mortality was 0%. The perioperative (30 days) morbidity was 19.6%. Postoperative, radiologic imaging showed an excellent drainage of the entire gland and the PD in all but 1 patient. Global quality-of-life index increased in median by 54% (range, 37.5%–80%). Median pain score decreased by 95%. Twenty-seven patients (73%) had complete pain relief. Sixteen patients (43%) developed diabetes, while the exocrine pancreatic function was well preserved in 29 patients (78%). Conclusion:“V-shaped excision” of the anterior aspect of the pancreas is a secure and effective approach for SDP, achieving significant improvement in quality of life and pain relief, hereby sparing patients from unnecessary, extended resectional procedures. The deterioration of exocrine and endocrine pancreatic functions is comparable with that observed during the natural course of the disease.

Analysis of phenotype and genotype information for the diagnosis of Marfan syndrome.

Sheikhzadeh S, Kade C, Keyser B, Stuhrmann M, Arslan‐Kirchner M, Rybczynski M, Bernhardt AM, Habermann CR, Hillebrand M, Mir T, Robinson PN, Berger J, Detter C, Blankenberg S, Schmidtke J, von Kodolitsch Y. Analysis of phenotype and genotype information for the diagnosis of Marfan syndrome.

Augmentation index relates to progression of aortic disease in adults with Marfan syndrome

BACKGROUND Noninvasive applanation tonometry (APT) is useful to assess aortic stiffness and pulse wave reflection. Moreover, APT can predict outcome in many conditions such as arterial hypertension. In this study, we test whether APT measurements relate to progression of aortic disease in Marfan syndrome (MFS). METHODS We performed APT in 50 consecutive, medically treated adults with MFS (19 men and 31 women aged 32 +/- 13 years), who had not undergone previous cardiovascular surgery. During 22 +/- 16 months of follow-up, 26 of these patients developed progression of aortic disease, which we defined as progression of aortic root diameters >or=5 mm/annum (18 individuals), aortic surgery >or=3 months after APT (seven individuals), or onset of acute aortic dissection any time after APT (one individual). RESULTS Univariate Cox regression analysis suggested an association of aortic disease progression with age (P = 0.001), total cholesterol levels (P = 0.04), aortic root diameter (P = 0.007), descending aorta diameter (P = 0.01), aortic root ratio (P = 0.02), and augmentation index (AIx@HR75; P < 0.006). Multivariate Cox regression analysis confirmed an independent impact on aortic disease progression exclusively for baseline aortic root diameters (hazard ratio = 1.347; 95% confidence interval (CI) 1.104-1.643; P = 0.003) and AIx@HR75 (hazard ratio = 1.246; 95% CI 1.029-1.508; P = 0.02). In addition, Kaplan-Meier survival curve analysis illustrated significantly lower rates of aortic root disease progression both with lower AIx@HR75 (P = 0.025) and with lower pulse wave velocity (PWV) values (P = 0.027). CONCLUSIONS We provide evidence that APT parameters relate to aortic disease progression in medically treated patients with MFS. We believe that APT has a potential to improve risk stratification in the clinical management of MFS patients.

Intraoperative Cone-Beam Computed Tomography in Oral and Maxillofacial Surgery Using a C-Arm Prototype : First Clinical Experiences After Treatment of Zygomaticomaxillary Complex Fractures

PURPOSE To describe the first clinical applications of intraoperative cone-beam computed tomography with an integrated flat-panel detector in oral and maxillofacial surgery after surgical treatment of zygomaticomaxillary complex fractures PATIENTS AND METHODS Nine cone-beam computed tomography datasets of patients with zygomaticomaxillary complex fractures were intraoperatively acquired using a mobile isocentric C-arm (PowerMobil; Siemens Medical Solutions, Erlangen, Germany), including a flat-panel detector. Datasets based on 400, 200, and 100 fluoroscopic images were performed with different tube currents (4.6 mA, 3.3 mA, 2.3 mA, 1.2 mA, and 0.5 mA) and a current tube voltage of 100 kV. Postprocessing resulted in 15 different datasets available for comparison with corresponding preoperative computed tomography datasets. Four oral and maxillofacial surgeons and 2 experienced radiologists evaluated each dataset regarding noise, transition, and the delimitation of landmarks. RESULTS All examinations were successfully performed. Reconstructed datasets showed high-resolution images of all midfacial osseous structures in near-computed tomography quality. Regarding high-contrast structures, detailed analyses of datasets acquired in this study suggest that the parameters 400 projections, 1.2 mA, and 100 kV are sufficient. In terms of soft-tissue visualization, a higher level of mA seems preferable. CONCLUSIONS The tested prototype predicts a new era in cone-beam computed tomography imaging. The integration of a flat-panel detector will overcome the limitations of current available systems. The size of the field of view is increased allowing regularly the visualization of the whole facial skeleton. Particularly in cases of open reduction of unilateral fractures, the assessment of symmetry is of clinical value.

Miliary never-smoking adenocarcinoma of the lung: strong association with epidermal growth factor receptor exon 19 deletion.

Miliary pattern of pulmonary metastases is a rarity in patients with lung cancer. We report five cases of patients with a never-smoking adenocarcinoma of the lung with such a pattern of metastases. In the tumor cells of all five patients, epidermal growth factor receptor (EGFR) mutation gene sequencing identified a deletion in exon 19 of the EGFR gene, and all five patients had a dramatic response to EGFR tyrosine kinase inhibitors. No echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) translocation was detected. We believe that the miliary never-soking adenocarcinoma of the lung is a distinct clinically relevant subgroup of the never-smoking non-small cell lung cancer. Physician should recognize this subgroup of patients with lung cancer when facing a picture of miliary pulmonary metastases in chest x-ray or computed tomography scan in patients with a history of never smoking and consider upfront therapy with EGFR tyrosine kinase inhibitors.