Patrick Rogalla

Resection of ectopic mediastinal parathyroid glands with the da Vinci® robotic system

Mediastinal ectopic parathyroid adenoma is a frequent cause of persistent or recurrent hyperparathyroidism, traditionally treated by open surgery. Thoracoscopic access is associated with reduced morbidity in mediastinal surgery. The aim of this study was to evaluate the feasibility and effectiveness of robot‐assisted dissection for mediastinal ectopic parathyroid glands.

Tenecteplase for the treatment of massive and submassive pulmonary embolism.

Background: Data on thrombolytic therapy disclose benefits from thrombolytic therapy in patients with massive and submassive pulmonary embolism (PE). Previously published case reports have described the successful use of tenecteplase under these conditions.Methods: Four patients with massive and submassive PE received a weight-optimized dosing regimen of tenecteplase, administered as an intravenous bolus.Results: All patients experienced clinically relevant improvement of dyspnea following thrombus regression. Regression of right ventricular enlargement was documented in three cases. Tenecteplase was well tolerated and did not cause bleeding complications. Thirty-day mortality was zero.Conclusions: These data support the use of this new thrombolytic agent in patients with massive and submassive PE; however, sufficiently powered, randomized trials have not yet taken place for these indications.

Three‐dimensional ultrasonographic demonstration of agenesis of the 12th rib in a fetus with trisomy 21

Uhl’s anomaly is only one of many causes of right ventricular dilatation, including Ebstein’s disease, partial anomalous venous return, absence of the pericardium, pulmonary atresia, and aortic coarctation or aortic interruption. A correct prenatal diagnosis can be useful for selecting patients who need more attention, especially in the first months of postnatal life, to improve ventricular function, reduce complications and increase the chances of survival.

Inter- and intraobserver variability in the postoperative evaluation of transpedicular stabilization: computed tomography versus magnetic resonance imaging

BACKGROUND CONTEXT Computed tomography (CT) represents the state of the art for the postoperative verification of the implant position after transpedicular stabilizations. Magnetic resonance imaging (MRI) has not challenged the CT, yet, because of susceptibility artifacts but would be favorable as a diagnostic tool for its excellent soft-tissue qualities. PURPOSE A study that analyzed if an artifact-reduced MRI could overcome this problem and provide sufficient data for the postoperative assessment was conducted. STUDY DESIGN The study design was a radiologic comparison of CT and MRI techniques evaluating pedicle screw placement after spinal fusion. PATIENT SAMPLE Fifty consecutive patients were given an MRI and a CT after a transpedicular stabilization surgery. Thirty-eight patients suffered from degenerative spinal disorders; three surgeries had become necessary because of spondylodiscitis, eight patients suffered from metastatic vertebrae destruction, and one patient experienced a fracture. OUTCOME MEASURES Any contact of a malpositioned pedicle screw with the dura and/or radicular structures was identified as an implant-associated complication and was compared with postoperative clinical patient findings. METHODS In total, 338 pedicular screws were analyzed in regard to their intrapedicular position. The double-blind evaluation of MRI and CT data was carried out by two radiologists and two spine surgeons. Accuracy of the CT analysis was calculated based on the interobserver agreement of 100%. Magnetic resonance imaging accuracy was calculated. RESULTS The interobserver accuracy of the CT data amounted to a median of 89.8% and in the MRI data of 86.7%. Intraobserver comparisons showed a significant difference between CT and magnetic resonance evaluations in one observer (kappa=0.293). In all other observers, the results were concordant with kappa values from kappa=0.328 to kappa=0.702. There was a high degree of agreement regarding the diagnosis of malpositioned pedicle screw and corresponding clinical symptoms between both techniques. CONCLUSIONS The presented data show that artifact-reduced MRI is equivalent to CT imaging in the postoperative evaluation of titanium spinal rod-screw systems. We therefore conclude that MRI should be considered as an alternative tool for the golden standard CT for postoperative imaging controls for its advantages in soft-tissue analysis.

Malignant Melanoma Metastasis as a Cause of Small-Bowel Perforation

Background: Malignant melanoma is a disease with an increasing rate of incidence, currently at 10 cases per 100,000. In most cases, malignant melanoma metastasizes over the lymph vessels to parenchymal organs. Symptomatic metastases are found in the gastrointestinal tract in only about 2% of the patients. Case Report: A 43-year-old patient with a known metastasized malignant melanoma (brain, liver, bones) was admitted to the department of dermatology due to fatigue, headache and unspecified abdominal symptoms. Because of persistent abdominal symptoms, a computed tomography (CT) scan of the abdomen was performed, showing a perforation of the ileum with an abscess on the basis of multiple small-bowel metastases. A segmental small-bowel resection with primary anastomosis was performed. The postoperative course of the patient was complicated by a subcutaneous wound infection and a prolonged period of convalescence (due to multiple brain metastases). Conclusions: Novel therapy concepts and medication in the treatment of patients with malignant melanoma have improved life expectancy. These patients are therefore expected to suffer more frequently from complications of the primary disease. Interdisciplinary management and cooperation is required to adequately diagnose and handle such cases.

Minimally invasive thymus surgery

There are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.ZusammenfassungFür die chirurgische Therapie mit dem Ziel der kompletten Entfernung der Thymusdrüse gibt es absolute und relative Indikationen. In der komplexen Therapie der autoimmun bedingten Myasthenia gravis nimmt die mit relativer Indikation durchgeführte Thymektomie eine zentrale Stellung ein. Besteht mit oder ohne Myasthenie ein Thymom, ist die Thymektomie absolut indiziert. Daneben ist eine Thymusresektion in Fällen ektoper intrathymischer Nebenschilddrüsen bei Hyperparathyreoidismus oder im Rahmen bestimmter Formen einer multiplen endokrinen Neoplasie notwendig. Traditionell war die transzervikale Operationstechnik Ausdruck des gut begründeten Strebens nach minimaler Invasivität der Thymektomie. Aber wegen der Forderung nach Radikalität erfolgten die meisten Eingriffe transsternal. Mit dem Einzug der therapeutischen Thorakoskopie in die Thoraxchirurgie haben sich mehrere streng oder erweitert minimal-invasive Operationstechniken für eine Thymektomie entwickelt. Es werden thorakoskopische ein- und beidseitige, subxiphoidale und modifiziert transzervikale Techniken einzeln oder in Kombinationen benutzt. Kürzlich ist eine neue Entwicklungsstufe der besonders präzisen thorakoskopischen Operationstechnik in Form der roboterassistierten Chirurgie begründet worden. Diese Technik ist insbesondere für die Thymektomie vorteilhaft. Die vorliegende Arbeit gibt einen Überblick über die Entwicklung und die bisherigen Erfahrungen der minimal-invasiven Thymektomie. Es werden bis dato publizierte Daten der größten Serien präsentiert.AbstractThere are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.

Minimal-invasive Chirurgie des Thymus

There are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.ZusammenfassungFür die chirurgische Therapie mit dem Ziel der kompletten Entfernung der Thymusdrüse gibt es absolute und relative Indikationen. In der komplexen Therapie der autoimmun bedingten Myasthenia gravis nimmt die mit relativer Indikation durchgeführte Thymektomie eine zentrale Stellung ein. Besteht mit oder ohne Myasthenie ein Thymom, ist die Thymektomie absolut indiziert. Daneben ist eine Thymusresektion in Fällen ektoper intrathymischer Nebenschilddrüsen bei Hyperparathyreoidismus oder im Rahmen bestimmter Formen einer multiplen endokrinen Neoplasie notwendig. Traditionell war die transzervikale Operationstechnik Ausdruck des gut begründeten Strebens nach minimaler Invasivität der Thymektomie. Aber wegen der Forderung nach Radikalität erfolgten die meisten Eingriffe transsternal. Mit dem Einzug der therapeutischen Thorakoskopie in die Thoraxchirurgie haben sich mehrere streng oder erweitert minimal-invasive Operationstechniken für eine Thymektomie entwickelt. Es werden thorakoskopische ein- und beidseitige, subxiphoidale und modifiziert transzervikale Techniken einzeln oder in Kombinationen benutzt. Kürzlich ist eine neue Entwicklungsstufe der besonders präzisen thorakoskopischen Operationstechnik in Form der roboterassistierten Chirurgie begründet worden. Diese Technik ist insbesondere für die Thymektomie vorteilhaft. Die vorliegende Arbeit gibt einen Überblick über die Entwicklung und die bisherigen Erfahrungen der minimal-invasiven Thymektomie. Es werden bis dato publizierte Daten der größten Serien präsentiert.AbstractThere are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.