Michael Sieb

Virtual neck exploration: a new method for localizing abnormal parathyroid glands.

Background Data:Computed tomography (CT) together with 99mTc-sestamibi single photon emission computed tomography (MIBI-SPECT) image fusion (CT-MIBI-SPECT image fusion) allows virtual exploration of the neck. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT and CT in detecting abnormal parathyroid glands in patients with primary hyperparathyroidism. Methods:CT-MIBI-SPECT image fusion for preoperative localization was performed in 116 patients with primary hyperparathyroidism (pHPT). Both investigations were performed with reproducible fixation of the patient on a vacuum mattress. At a special work station the neck was virtually explored by viewing the CT images in all 3 dimensions. The MIBI-SPECT images were superimposed on underlying CT images. Only patients with single-gland disease were evaluated (pHPT: 112, persistent pHPT: 1, recurrent pHPT: 1, persistent secondary hyperparathyroidism: 1, tertiary HPT after kidney transplantation: 1). CT-MIBI-SPECT image fusion results were compared with those obtained with CT alone and MIBI-SPECT alone. The predicted positions were correlated with the intraoperative findings. Results:CT-MIBI-SPECT image fusion was able to predict the exact position of the abnormal gland in 102 (88%) of the 116 patients, whereas CT alone showed in 75 (65%) patients and MIBI-SPECT alone in 64 (55%) patients the exact position of the abnormal gland. Sixty-two patients underwent minimally invasive surgery, namely in 21 patients with a unilaterally focused approach and in 33 patients with a bilateral approach (27 of these underwent simultaneous thyroid resection). Sensitivity for CT-MIBI-SPECT image fusion was 88%, for CT alone 70%, and for MIBI-SPECT alone 59%. Specificity for CT-MIBI-SPECT image fusion was 99%, for MIBI-SPECT alone 95%, for CT alone 94%. Overall accuracy for CT-MIBI-SPECT image fusion was 97%, for CT alone 89%, for MIBI-SPECT 87%. Conclusions:This study provides evidence that CT-MIBI-SPECT image fusion is superior to CT or MIBI-SPECT alone for preoperative localization of enlarged parathyroid glands in patients with single-gland primary hyperparathyroidism.

Target registration and target positioning errors in computer-assisted neurosurgery: proposal for a standardized reporting of error assessment.

Assessment of errors is essential in development, testing and clinical application of computer‐assisted neurosurgery. Our aim was to provide a comprehensive overview of the different methods to assess target registration error (TRE) and target positioning error (TPE) and to develop a proposal for a standardized reporting of error assessment.

CT-MIBI-SPECT image fusion predicts multiglandular disease in hyperparathyroidism

BackgroundTo perform focused or minimally invasive surgery for hyperparathyroidism (HPT) exact preoperative localization is mandatory. Computed tomography–99mTc-sestamibi–single photon emission computed tomography image fusion (CT-MIBI-SPECT) serves this difficult task in single gland HPT to a large extent. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone and CT alone in detecting abnormal parathyroid tissue in patients with multiglandular disease.Patients and methodsCT-MIBI-SPECT image fusion for preoperative localization was performed in 30 patients with multiglandular disease. There were six patients with primary hyperparathyroidism (four MEN I syndromes and two double adenomas; one of these patients has HRPT2 gene mutation), 14 with secondary, and eight with tertiary HPT, further one patient each suffering from persistent primary and persistent secondary hyperparathyroidism. In both persistent patients only one remaining gland was left from primary surgery. The results of MIBI-SPECT, CT, and CT-MIBI-SPECT image fusion were compared in these patients. The outcome and the exact predicted positions were correlated with intraoperative findings.ResultsIn five out of six patients with multiglandular primary hyperparathyroidism more than one gland was detected, thus multiglandular disease could be suspected preoperatively. Overall CT-MIBI-SPECT image fusion was able to predict the exact position of all abnormal glands per patient in 14 of 30 (46.7%) cases, whereas CT alone was successful in 11 (36.7%), and MIBI-SPECT alone just in four (13.3%) of 30 patients.ConclusionMultiglandular disease in primary hyperparathyroidism can be suspected preoperatively in a high percentage of patients. Additionally, this study shows that CT-MIBI-SPECT image fusion is superior to CT or MIBI-SPECT alone in preoperative localization of all pathologic glands in patients suffering from multiglandular disease.

Protein levels of heme oxygenase-1 during reperfusion in human kidney transplants with delayed graft function

Abstract: Introduction:  Delayed graft function (DGF) as a consequence of ischemia reperfusion injury (IRI) is associated with a decrease in long‐term allograft survival. Heme oxygenase‐1 (HO‐1) is a stress responsive gene that is highly expressed in multiple pathological processes. The aim of our study was to analyze whether HO‐1 protein levels in human kidney transplants during IRI correlate with the incidence of DGF.

Disappointing mid-term results after laparoscopic gastric banding in young patients

BACKGROUND When gastric banding was introduced as a bariatric operation about 12 years previously, its early results were promising, with a low complication rate. Only a few long-term studies on this subject have been published. This study was performed to assess our results with laparoscopic gastric banding in young patients after<or=10 years of follow-up. METHODS From January 1996 to December 2000, a total of 41 patients (83% female, 17% male)<25 years old underwent laparoscopic gastric banding at our institution. The patient data were derived from the electronic patient data system, paper charts, and a telephone interview. Psychosocial changes were analyzed using the Moorehead-Ardelt/Bariatric Analysis and Reporting Outcome System questionnaire. RESULTS The mean preoperative body mass index was 44.26+/-6.53 kg/m2, with a mean excess weight of 65.22+/-20.48 kg. The body mass index after 1, 5, and 7 years was 31.50+/-7.38 kg/m2, 31.12+/-7.10 kg/m2, and 32.88+/-5.68 kg/m2, respectively. The mean excess weight loss after 1 year was 60.07%+/-25.33%, and after 5 and 7 years, it was 64.84%+/-27.45% and 57.48%+/-28.07%, respectively. An improvement in obesity-related co-morbidities was observed in nearly all patients. Of our patients, 52% had complications requiring reoperation (27% pouch dilation, 10% band leakage, 5% intragastral band migration, 5% perforation of either the esophagus or the stomach, and 5% port disconnection). According to Bariatric Analysis and Reporting Outcome System, the long-term outcome was regarded as a failure in 40%, fair in 4%, good in 28%, very good in 20%, and excellent in 8% of patients. CONCLUSION Our mid-term results were disappointing, with a high complication rate and many dissatisfied patients.

Incidence and predisposing factors of cold intolerance after arterial repair in upper extremity injuries

OBJECTIVE The purpose of this report was to present abnormal posttraumatic cold intolerance in patients that previously underwent repair of arterial injuries after civilian upper limb trauma in our institution. METHODS All patients who underwent repair of arterial lesions after upper limb trauma since 1990 were reviewed, and clinical follow-up studies were performed. Patients were asked to complete the cold intolerance symptom severity (CISS) questionnaire to evaluate presence and severity of self-reported cold sensitivity, and the disabilities of arm, shoulder, and hand (DASH) questionnaire to analyze functional disability. Abnormal cold intolerance was defined as a CISS score over 30. Further analysis included evaluation of epidemiologic, clinical, and perioperative data for factors predisposing to abnormal cold intolerance. RESULTS A total of 87 patients with previous repair of upper limb arterial injuries were eligible to answer the CISS and DASH questionnaires, and 56 patients (64%; 43 men; median age: 31.9 years) completed both. In our cohort, blunt trauma was the predominant cause of injury (n = 50; 89%). Accompanying lesions of nerves (n = 22; 39%) and/or orthopedic injuries (n = 36; 64%) were present in 48 patients (86%). After a median follow-up period of 5.5 years (range, 0.5-19.7), 23 patients (41% of 56) reported on abnormal cold intolerance. Patients with cold intolerance had worse functional results (as measured by the DASH questionnaire; mean ± SD, 42.7 ± 29.7 vs 11.5 ± 23.9; P < .001) when compared with patients without. Cold intolerance was more frequently seen in patients with previous nerve lesion (P = .027) and in proximal injuries (subclavian or axillary vs brachial or forearm arteries: P = .006), but was not correlated to gender, age, involvement of the dominant or nondominant arm, and the presence of ischemia, bone injury, or an isolated vascular injury. CONCLUSIONS Abnormal cold intolerance is frequently seen in patients with a history of arterial repair in upper limb trauma. It is associated with significant functional impairment. Concomitant nerve injury and involvement of the subclavian or axillary artery are the major predisposing factors for development of cold intolerance after upper limb trauma.

Virtual neck exploration in patients with hyperparathyroidism and former cervical operations

BackgroundIn surgery for primary hyperparathyroidism, preoperative localization together with intraoperative parathyroid hormone assay is important when minimal invasive operations of the parathyroid glands are intended. In cases of reoperation, correct localization of the abnormal parathyroid glands is extremely instrumental. Computed tomography (CT)–99mTc-sestamibi (MIBI)–single photon emission computed tomography (SPECT) image fusion allows for a virtual exploration of the neck by showing the suspected gland three-dimensionally with all the anatomic landmarks in correct position. The aim of this study was to evaluate whether CT–MIBI–SPECT image fusion is superior to MIBI–SPECT alone in detecting abnormal parathyroid glands in patients with previous neck surgery.Patients and methodsIn a prospective study, CT–MIBI–SPECT image fusion for preoperative localization was performed in 28 patients with hyperparathyroidism and previous neck surgery. Twenty-one patients had thyroidectomy and seven patients had surgery for hyperparathyroidism. The results of MIBI–SPECT alone and CT–MIBI–SPECT image fusion were compared in these patients. The outcome and the exact predicted position, not just the predicted side, were correlated with intraoperative findings.ResultsCT–MIBI–SPECT image fusion was able to predict the exact position of the abnormal gland in 24 of 28 patients (86%), whereas MIBI–SPECT alone was successful in 12 of 28 cases (43%, p < 0.004) only. CT–MIBI–SPECT image fusion detected all three pathologic glands in their ectopic position. With MIBI–SPECT alone, just one ectopic pathologic gland was found.ConclusionThis study provides evidence that CT–MIBI–SPECT image fusion is superior to MIBI–SPECT alone in preoperative localization of enlarged parathyroid glands in patients with hyperparathyroidism and previous neck surgery. This should be kept in mind if the results are compared to earlier studies concerning CT–MIBI–SPECT image fusion.

Tacrolimus monotherapy following alemtuzumab induction in combined kidney-pancreas transplantation: results of a prospective randomized trial.

BACKGROUND We investigated the safety and efficacy of Campath induction and tacrolimus (TAC) maintenance therapy compared to ATG induction with TAC +MMF + steroids in de novo kidney-pancreas transplanted patients. MATERIAL/METHODS 14 patients (Group A) received Campath 30 mg + methylprednisolone 500 mg before revascularization followed by TAC monotherapy, and 16 patients (Group B) ATG 8 mg/kg with TAC + MMF+ steroids (withdrawn at month 3). TAC trough levels (ng/mL) of 12-15 were aimed for in both groups until month 6 and thereafter 6-12. RESULTS 1-year patient survival was 100% in both groups; kidney and pancreas survival in Group A was 93% each. In Group B 1-year kidney and pancreas survival was 100% and 87%, respectively. A total of three pancreas grafts were lost due to thrombosis of the graft vein within the first month. The only kidney loss was due to initial non-function. All biopsy-proven acute rejections of renal transplants (n=3 in Group A, n=0 in Group B) were reversible. No acute pancreas graft rejection was demonstrated. Infectious complications, lipid metabolism and blood pressure were comparable in both groups, as were other adverse events. No tumor occurred. At 12 months 13 patients in each group were steroid-free; the mean serum creatinine level was 1.44 mg/dL in Group A and 1.33 mg/dL in Group B. All patients were exogenous insulin-free. CONCLUSIONS At one year efficacy and safety of Campath +TAC monotherapy were comparable to those of ATG + TAC + MMF + steroids in a limited number of combined kidney-pancreas transplant recipients.

Study protocol: the effect of whole body vibration on acute unilateral unstable lateral ankle sprain- a biphasic randomized controlled trial

BackgroundAnkle sprains often result in ankle instability, which is most likely caused by damage to passive structures and neuromuscular impairment. Whole body vibration (WBV) is a neuromuscular training method improving those impaired neurologic parameters. The aim of this study is to compare the current gold standard functional treatment to functional treatment plus WBV in patients with acute unilateral unstable inversion ankle sprains.Methods/Design60 patients, aged 18–40 years, presenting with an isolated, unilateral, acute unstable inversion ankle sprain will be included in this bicentric, biphasic, randomized controlled trial. Samples will be randomized by envelope drawing. All patients will be allowed early mobilization and pain-dependent weight bearing, limited functional immobilization by orthosis, PRICE, NSARDs as well as home and supervised physiotherapy. Supervised physical therapy will take place twice a week, for 30 minutes for a period of 6 weeks, following a standardized intervention protocol. During supervised physical therapy, the intervention group will perform exercises similar to those of the control group, on a side-alternating sinusoidal vibration platform. Two time-dependent primary outcome parameters will be assessed: short-term outcome after six weeks will be postural control quantified by the sway index; mid-term outcome after one year will be assessed by subjective instability, defined by the presence of giving-way attacks. Secondary outcome parameters include: return to pre-injury level of activities, residual pain, recurrence, objective instability, energy/coordination, Foot and Ankle Disability Index and EQ 5D.DiscussionThis is the first trial investigating the effects of WBV in patients with acute soft tissue injury. Inversion ankle sprains often result in ankle instability, which is most likely due to damage of neurological structures. Due to its unique, frequency dependent, influence on various neuromuscular parameters, WBV is a promising treatment method for patients with acute unstable inversion ankle sprains.Trial registrationNCT01702597

Single shot of alemtuzumab as induction therapy after kidney transplantation is sufficient

In an earlier study, we were able to show that Tac monotherapy following 2 × 20 mg alemtuzumab induction is at least as effective as Tac‐based triple‐drug immunosuppression in cadaveric renal transplantation. We were interested to learn whether 1 × 30 mg of alemtuzumab is as effective as 2 × 20 mg. Patients of the initial study group (group A) received 20 mg alemtuzumab on days 0 and 2, and tac monotherapy from day 2 on. This group acted as control group for the new arm (group C), where patients were given only 1 × 30 mg alemtuzumab on day 0 followed by Tac monotherapy from day 2 on with the same target levels as in the control group. Frequency of rejection at 6 months was 15% in the control group compared to 6% in the study group and 20% at 12 months in group A versus 6% in group C (P = 0.034). Time to rejection was 4.9 months in group A and 0.8 in group C. One‐year patient survival was 98.5% in both groups, graft survival 96.9% in group A, and 98.5% in group C. Safety profile was similar in both groups apart from more viral and bacterial infections in group C. Single shot alemtuzumab induction of 30 mg is as effective as 2 × 20 mg in cadaveric renal transplantation.