Ralph I. Rückert

Thoracoscopic Thymectomy with the da Vinci Robotic System for Myasthenia Gravis

Complete thymectomy (Thx) is a crucial part of treatment for myasthenia gravis (MG) and thymoma. The discussion about the necessity of radical, complete Thx and reduced invasiveness has led to no less than 14 different surgical approaches for Thx. The latest development is robotic‐assisted surgery. Though its impact on minimally invasive surgery is not yet clear, it seems to be most promising for surgery in remote, narrow anatomical regions like the mediastinum. One hundred six consecutive robotic‐assisted thymectomies (rThx) with the da Vinci robotic surgical system were performed between January 2003 and April 2007 in a prospective single‐center study. Postoperative morbidity was recorded according to the Myasthenia Gravis Foundation of America (MGFA) classification. With zero mortality, the overall postoperative morbidity rate was 2%. The cumulative complete stable remission rate of MG was > 40% for all patients, and there was no statistical difference as compared to non‐thymomatous MG patients. The cumulative rate of minimal manifestations (MM0–MM3) according to the MGFA classification showed a postoperative improvement in quality of life for most of the patients. The da Vinci robotic system allowed for technical refinements of the well‐defined operation technique of thoracoscopic Thx (tThx). From the technical point of view, rThx has advantages for mediastinal dissection. rThx had a shorter learning curve. There might be better outcome results for rThx in MG patients, as compared with nonrobotic tThx. Therefore, rThx is a promising technique for minimally invasive Thx.

Primary Hepatic Neuroendocrine Tumor: Successful Hepatectomy in Two Cases and Review of the Literature

Background/Aims: Primary hepatic neuroendocrine tumor represents an extremely rare clinical entity with only very few cases having been reported to date. Methods: The case histories of 2 patients with presumably primary hepatic neuroendocrine tumor were analyzed and a complete follow-up obtained. The literature was reviewed to provide comprehensive data collection. Results: Both patients underwent partial hepatic resection. Histomorphologic diagnosis revealed a neuroendocrine tumor in both cases. Extensive preoperative as well as intra- and postoperative search for the primary tumor did not identify another site of neuroendocrine tumor tissue. Six and ten years after hepatic segmentectomy, the 2 patients are alive and show no clinical signs of malignancy. Their most recent thorough follow-up included computed tomography and somatostatin receptor scintigraphy. Neither a nonhepatic primary neuroendocrine tumor site nor recurrent disease was found in the 2 patients. The literature review resulted in a complete survey of all previously reported cases of primary hepatic neuroendocrine tumors. Conclusion: We conclude that the liver was the primary site of the neuroendocrine tumor in both patients. Radical surgery was successfully performed as the only treatment option with curative intention.

Successful stent-graft repair of a vertebrojugular arteriovenous fistula.

Purpose: To describe an apparently unreported endovascular means of treating a vertebral arteriovenous fistula (AVF) using a small-caliber stent-graft to permanently reconstruct the involved vessels. Case Report: A 13-year-old girl presented with tinnitus caused by a high-flow AVF between the right extracranial vertebral artery and deep jugular vein arising from repeated internal jugular vein catheterization. A 4-mm-diameter balloon-expandable Jostent coronary stent-graft was placed in the vertebral artery via a percutaneous femoral access, with immediate and complete obliteration of the AVF and resolution of the tinnitus. Follow-up duplex ultrasonography at 15 months demonstrated patency and luminal integrity of the vertebral artery. Conclusions: Vertebrojugular AVFs are rare and usually treated with transcatheter embolization techniques, but percutaneous repair using a small-caliber stent-graft appears feasible. This minimally invasive treatment might become the method of choice for AVFs in other small-bore vessels.

Cystic adventitial disease of the popliteal artery.

A53-year-old man presented with intermittent claudication of his right leg and a painless walking distance of about 120 meters. On examination there were no stigmata of generalized arterial disease. The peripheral pulses were present with the limb extended but disappeared during knee joint flexion. Color-coded Doppler sonography resulted in the diagnosis of a high-grade stenosis of the supragenicular popliteal artery, which was confirmed by magnetic resonance angiography (Figure 1), demonstrating the scimitar sign, a curvilinear defect marking an eccentrically located, smoothly demarcated stenosis in an otherwise normal artery. Axial magnetic resonance imaging (Figure 2) revealed a cystic lesion (straight arrows) nearly occluding the popliteal arterial lumen (curved arrow). The high signal intensity on T1-weighted images suggested a rather high protein content of this lesion. Because of the typical location and clinical signs, cystic adventitial disease was suspected. At operation, after the popliteal artery had been exposed via a posterior approach, cystic advential disease was confirmed by the presence of its pathognomonic features. The arterial caliber showed a circumscribed enlargement, from which, on longitudinal incision, a yellowish-colored, pressurized, gelatinous, viscid, mucoid mass escaped (Figure 3). The adventitial layer was completely resected, preserving the arterial continuity and thereby restoring flow (Figure 4). No connection with the knee joint could be demonstrated in this case. After an uneventful postoperative course the patient is free of symptoms with a follow-up of 28 months.

Treatment of internal iliac artery aneurysms: single‐centre experience

Background:  The aim of the present study was to analyse the short‐term results of treatment of internal iliac artery aneurysms (IIAA).

A Method for Adjusting a Malpositioned Bifurcated Aortic Endograft

Purpose: To report the successful application of a method to adjust a malpositioned bifurcated stent-graft after endovascular aortic aneurysm repair. Method and Results: A 62-year-old male patient underwent endovascular repair of a 5.1-cm abdominal aortic aneurysm (AAA) with a Vanguard bifurcated stent-graft. After complete deployment of the stent-graft, the intraoperative completion angiogram disclosed unexpected occlusion of the left renal artery. Intra-aortic adjustment of the bifurcated graft was possible with a crossover guidewire, which was pulled caudally. The method worked perfectly to restore blood flow to the left renal artery. The patient is well 16 months postoperatively without any evidence of endoleak or graft migration; the left renal artery remains open. Conclusions: A technique is demonstrated for intra-aortic repositioning of a bifurcated stent-graft to correct insufficient deployment. If required, this technique should be attempted before conversion to an open procedure.

Long-term survival after radical resection of a primary angiosarcoma of the innominate vein.

The case updated here demonstrates the longest survival that has been observed so far after radical resection of primary angiosarcoma of the left innominate vein, which is the second case that has ever been reported to date. Radical resection was performed after preoperative radiotherapy. The venous continuity was restored by expanded polytetrafluoroethylene graft interposition. This case underscores that the prognosis of primary venous sarcoma, though fatal in the majority of patients, may be better in individual cases when radical surgery with curative intention is achieved.

Biphasic blood pool contrast agent-enhanced whole-body MR angiography for treatment planning in patients with significant arterial stenosis.

Objective:To prospectively evaluate diagnostic accuracy of first pass and combined first pass and steady state high-spatial-resolution whole-body magnetic resonance (MR) angiography with a blood pool contrast agent for quantification of arterial stenosis in different vascular territories. Materials and Methods:After Institutional Review Board approval and informed consent, 50 patients with known 50% or greater stenosis in at least one vascular territory; as shown by the standard-of-reference (14 digital subtraction angiographies, 4 computed tomographies, 32 ultrasound examinations), were included. The patients underwent MR angiography at 1.5 Tesla, using a standardized nonbody-weight-adapted i.v. bolus injection of 11 mL gadofosveset trisodium. First pass imaging with 4 different table positions in a whole-body MR scanner (MAGNETOM Avanto, Siemens Healthcare), using individual circulation time determined by a test bolus, was performed. Steady state imaging was performed using an isometric spatial resolution of 1.0 mm. Image quality was rated. Each vascular segment in MR angiography was evaluated by 2 independent and blinded reviewers and the stenosis degree was compared with the preferred standard-of-reference, using a 5-point scale. Differences between first pass and combined MR angiography were assessed with a 95% confidence interval (CI) by applying the adjusted modified &khgr;2 test. Changes in therapy based on the whole-body examination strategy were evaluated. Results:The number of nondiagnostic territories was 24 of 197 (12.2%) for first pass MR angiography and decreased to 3 of 197 (1.5%) after addition of steady state MR angiography. The diagnostic accuracy for quantification of arterial stenosis in combined MR angiography (94.7%; 95% CI: 92.4–97.1) was superior to first pass MR angiography (81.7%; 95% CI: 73.7–89.8; statistically significant). Patient management was changed in 12 of 49 patients, in 7 of 12 patients the change was applied to an additional lesion detected by the whole-body examination strategy. Conclusion:The quantification and detection of arterial stenosis is improved by the steady state high-resolution gadofosveset trisodium-enhanced MR angiography. Additional lesions detected by whole-body examination strategy or differences in stenosis quantification may lead to changes in therapy.

Weiterbildung in endovaskulären Techniken mit der privaten Akademie der DGG

ZusammenfassungDie endovaskulären Techniken sind integraler Bestandteil gefäßchirurgischer Tätigkeit. Sie sind in diesem Fachgebiet tief verwurzelt, aber noch nicht flächendeckend gleichmäßig verbreitet. Die Sektion „Endovaskuläre Techniken“ der Akademie für Forschung und Weiterbildung der DGG hat deshalb das Konzept einer strukturierten Weiterbildung in diesen Techniken entwickelt und mit einem Kurssystem hinterlegt, dass Gefäßchirurgen die komplette diesbezügliche Weiterbildung ermöglicht. Der Nachweis der erreichten Kompetenz kann durch die Zertifizierung zum „Endovaskulären Chirurgen“ oder „Endovaskulären Spezialisten“ geführt werden. Konzept, Kurssystem und der Weg zur Zertifizierung werden dargelegt.AbstractEndovascular techniques are integrated into vascular surgery. Vascular surgeons are deeply involved in using these techniques, but the techniques are not being spread everywhere. Therefore, members of the section for endovascular techniques of the private Academy for Research and Education of the German Society for Vascular Surgery developed a concept for structured education concerning endovascular activities. A system of workshops was developed to render this education feasible. To prove full endovascular competence, a vascular surgeon can achieve certification as an endovascular surgeon or endovascular specialist. The concept, workshops, and method of achieving certification are herein explained.

Monstrous aneurysm of the deep femoral artery

Deep femoral artery aneurysms are a rarity among arterial aneurysms. Based on a selected case of a patient who was treated at our clinic, clinical images are presented and treatment options are discussed.