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Background: Echinococcosis is a rare parasitosis in Germany for which the World Health Organization recommends stage-specific treatment strategies., Objective: The aim of this study was to analyze the treatment results of patients with hepatic echinococcosis at a German center of excellence for liver surgery., Methods: Patients who underwent surgery for hepatic echinococcosis between 2009 and 2018 at the University Hospital of Mainz (UMM) were included in this follow-up examination. The investigation included a magnetic resonance imaging (MRI) of the abdomen, documentation of the quality of life (QoL), serological and laboratory parameters. In addition, an online survey was performed among surgeons from Middle Rhein and gastroenterologists from Rhineland-Palatinate., Results: At the UMM 25 surgical interventions were performed for hepatic echinococcosis: 9 for cystic (CE) and 16 for alveolar echinococcosis (AE). The majority of the interventions were major liver resections with additional vascular and biliary procedures. The 90-day mortality was 0%, and 4 grade 3a and 1 grade 4b complications occurred. In contrast to AE 75% of the postoperative serological results of patients with CE remained positive for more than 1 year postoperatively. Most participants in the survey knew the imaging characteristics and treatment options of AE and CE; however, many participants were unaware of the cost of the treatment., Conclusion: From the perspective of surgeons, hepatic echinococcosis is a challenge, which however can be curatively treated with a low morbidity despite advanced disease in many patients. Due to the low incidence of the disease, the state of knowledge about AE and CE is limited among physicians.

Background: The prevalence of diabetes mellitus type 2 in the adult population is > 7 %. Despite new therapy options and modern insulins, the therapy remains a challenge. Especially in patients with obesity or high insulin resistance it is often difficult to achieve the necessary target values. In most cases the disease is initially asymptomatic so that the aim is the early recognition and avoidance of complications., Material and Methods: This article provides an update on the approach options of modern therapy forms in diabetes management., Results: The foundations of every treatment program are lifestyle interventions, including diabetes schooling. When these fail a pharmaceutical therapy must be initiated which among others is oriented to hemoglobin A1c (HbA1c). The HbA1c target value should take patient-specific circumstances into consideration and should be determined together with the patient. If no contraindications or intolerances are present, metformin is the medication of choice. Apart from metformin, the available data which can be used for guidance are limited. A combination therapy with one or two other oral or injectable medications is suitable to keep the side effects as low as possible. The advantages of other substances in individual cases could be a lower risk of hypoglycemia, reduced weight increase, oral administration and compatibility with renal insufficiency. Ultimately, insulin therapy will be necessary for many patients, either as monotherapy or in combination with other substances. Therapy decisions should be made together with the patient, taking personal preferences into consideration and should include age, body weight, comorbidities, occupational situation and compliance., Conclusion: The Reorganization of the Pharmaceutical Market Act represents a momentarily perceived clear barrier. In the interests of an individualized therapy and personalized disease management, a target-aimed flexibility in diabetes management should be possible in the future.

History and Admission Findings: An 81-year-old man presented with jaundice and a pancreatic tumor. 6 years ago transperitoneal nephrectomy had been performed because of a clear cell renal cancer (pT3b pN0 pM0)., Investigations: Laboratory tests showed normocytic anemia and signs of cholestasis. Abdominal ultrasonography revealed a well-defined mass of the head of the pancreas with a diameter of about 4 cm, and a previously diagnosed adrenal mass which had slightly increased in size. Contrast-enhanced ultrasound demonstrated a hyperenhancing of the pancreatic mass, untypical for primary adenocarcinoma of the pancreas. Endoscopic ultrasound-guided fine-needle aspiration disclosed a metastasis of the previously resected renal cancer., Treatment and Course: Bilary spincterotomy and stent insertion were performed. Because of proven pancreatic metastasis and suspected adrenal metastasis of renal cancer palliative treatment with multi-targeted receptor tyrosine kinase inhibitor sunitinib was initiated., Conclusion: Renal cell carcinomas are the most common primary tumors leading to pancreatic metastasis. In contrast to ductal adenocarcinoma pancreatic metastasis shows hyperenhancement when examined by using contrast-enhanced ultrasonography. Endoscopic ultrasound-guided fine-needle aspiration helps to confirm the suspected diagnosis., (© Georg Thieme Verlag KG Stuttgart · New York.)

History and Admission Findings: A 38-year-old woman (Pt. 1) and a 30-year-old man (Pt. 2) had been admitted, over a period of two months to the emergency unit. Pt 1. had complained of spasmodic pain with nausea and vomiting. A mass was palpated in the left upper abdominal quadrant. Pt. 2 had signs suggesting appendicitis, with pain in the right lower abdominal quadrant., Investigations: Abdominal ultrasound showed an intussusception with a typical multilayered bowel wall ("target-like" or "bull's eye") sign in both patients. The man also had a normally appearing appendix and enlarged mesenteric lymph nodes. TREATMENT, COURSE AND DIAGNOSIS: Pt. 1 had a laparotomy, which showed a leiomyoma of the small bowel. After resection the further course was uneventful. The intussusception of the 30-year-old man resolved spontaneously during the ultrasound examination. Further investigation revealed celiac disease., Conclusions: Intussusception is a possible cause of acute abdominal pain in adults. Ultrasonography should be the initial diagnostic investigation. Transient intussusceptions are seen in adults with celiac disease, in which case nonoperative treatment is possible., (Copyright Georg Thieme Verlag KG Stuttgart . New York)

Background and Objective: The frequency of diagnostic laparoscopy performed by internists has increased for several years once again -- especially performed as minilaparoscopy. A determination of the value of diagnostic laparoscopy is possible only with knowledge of the complication rate., Patients and Methods: We reviewed a consecutive series of 675 laparoscopies (422male, 253 female, age 15 - 85 ) from 1996 to 2003 in our clinic. Possible risk factors for complications were analyzed., Results: Minor complications occurred in 35/675 (5,2 %) laparoscopies, major complications in 8/675 (1,1 %) laparoscopies. There was no significant difference between conventional and minilaparoscopies. The existence of Child C cirrhosis was the only significiant risk factor identified for the occurrence of a major complication., Conclusion: Both conventional and minilaparoscopy have an acceptable rate of complications. When Child C cirrhosis is present, laparoscopy should be restricted to very few patients, as the complication rate is elevated in this condition.

Background: The superiority of laparoscopy with guided biopsy over biopsy alone is established. It is still uncertain if this is also true for midi-/ and mini-laparoscopy., Aim: The aim of this study was to determine the diagnostic gain of laparoscopic-guided biopsy for standard laparoscopy and the use of midi-/mini-laparoscopies. Characteristics of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis., Methods: In a consecutive series of 425 patients clinical, laparoscopic and histological findings were investigated. The length and fragmentation of the liver biopsies were investigated with regard to a missed diagnosis of cirrhosis., Results: The sensitivity of laparoscopy in the diagnosis of cirrhosis was 96 %, that of histology 68 %. The sensitivity of histology alone was especially low in macronodular cirrhosis. The sensitivity of both laparoscopy and histology improved from Child A to C. When cirrhosis was apparent, liver biopsies were shorter and more frequently fragmented. However, the diagnosis of cirrhosis was independent of these parameters., Conclusion: Mini-laparoscopy may replace standard laparoscopy and appears to be superior compared with histology alone.

Background: Mirizzi syndrome is a rare cause of biliary symptoms and jaundice. It describes an obstruction of the common hepatic bile duct by external compression caused by an impacted gallstone in the gallbladder neck or cystic duct. This setting is usually associated with cholecystolithiasis., Case Report: A 64-year-old caucasian woman with intermittent abdominal pain and newly diagnosed jaundice was admitted to our clinic. An ERC was performed a few weeks earlier because of similar complaints without jaundice. At that time there was no evidence of choledocholithiasis. Now ERC surprisingly showed a gallstone impacted in the cystic duct, leading to an external compression of the common hepatic bile duct (Mirizzi syndrome). Since an endoscopic stone extraction failed, surgical intervention was performed. A laparoscopic cholecystectomy was performed without trans-cystic stone removal. After removal of the bile duct drainage it became evident that the impacted stone was still located in the remaining part of the cystic duct. After successful endoscopic extraction of the impacted stone the patient remained free of symptoms without recurrent jaundice., Conclusion: In rare cases Mirizzi syndrome without cholecystolithiasis can cause biliary symptoms. A close interdisciplinary cooperation is necessary in order to guarantee an excellent therapeutic management.

Background and Objective: Clinical studies have demonstrated excellent success and low complication rates of endoscopic therapy of pancreatic pseudocysts. But it is not known, if these results can be reached in gastroenterological centers outside clinical studies., Patients and Methods: We investigated the outcome of endoscopic therapy in 21 patients (15 male, 6 female, age 40 - 81) with pancreatic pseudocysts treated in our clinic between 1997 and 2002. A follow-up examination was included., Results: Similar to the results of reported clinical studies the initial clinical success rate was 18/21 with symptomatic recurrences in two patients. All therapy-induced complications were successfully treated conservatively., Conclusion: Excellent results of endoscopic therapy of pancreatic pseudocysts can be reached in a gastroenterological center. Surgical treatment can be reserved for cases, when endoscopic therapy fails.

In general, hyperplastic polyps of the stomach are regarded as benign lesions. Still there is the chance to find carcinomas within them as documented in this case report. This finding can be interpreted as an incidental appearance. At the moment there are no standardized guidelines regarding diagnostics and therapy of gastric hyperplastic polyps. Referring to a short review of the literature endoscopic snare polypectomy seems to be a reasonable therapeutic option of hyperplastic polyps with a size of 0.5-1 cm. Although it is possible to determine the histology by forceps biopsy, it is possible to be misled by missing areas of focal carcinomas. Complications after polypectomy are rare and often no further intervention is needed. A further point for polypectomy is the fact that surfaces of hyperplastic polyps are eroded in about 90 % and therefore there is the risk of bleeding, chronic anaemia and positive stool tests for occult blood.

Despite the progress achieved in the fields of medical technology and quality assurance and extensive legal requirements there are still failures during the use of anaesthetic equipment which could be avoided. Describing well known failure modes the purpose of this paper is to sharpen the sense for their occurrence and avoidance and thus to contribute to their reduction. The first part of this paper introduces the safety concept of an anaesthetic workstation. Central issues are the intended use, the state of engineering, preparation and checking, and appropriate operator reactions. The second part deals with the interface between human being and machine. Following the modules of the anaesthetic workstation--breathing system, ventilator, dosage units for gases and anaesthetic agents, monitoring--we will consider representative failures and risks which may accrue during the different stages of use of the equipment.

AH 25086 B is a selective agonist of the newly determined 5-HT(1) receptors, which are sited mainly in the intracranial section of the carotid artery. According to experimental studies, the effect of AH 25086 B is decidedly more highly selective than that of ergotamine; the blood flow through the arteriovenous anastomoses of the internal carotid artery is clearly reduced, while the blood flow through the capillaries supplying the brain is increased. With AH 25086 B administered in an infusion rapid abolition of migraine attacks already in progress proved possible. The first 12 patients worldwide to receive this preparation were treated, some on several occasions, for a total of 21 migraine attacks: 7 received one infusion, 3 received two, 1 three, and 1 patient received five infusions. There were some side-effects with some infusions: nausea (18), vomiting (9), and photophobia (19). On average it took 31 min (range 10-60 min) for the headache to be relieved, regardless of the duration of migraine symptoms before the start of treatment. This was not a controlled study, but the results (14 very good, 6 good or satisfactory, in 21 attacks treated) were better than could have been expected by chance. Tolerance of the preparation was good, all side-effects being transitory and mild; with dosages up to 1.6 mug kg(-1) min(-1) no changes were seen in heart rate or blood pressure.