[Balloon dilatation of the canaliculus communis for chronic epiphora]. / Therapie von Canaliculus-communis-Stenosen mittels Ballonkatheterdilatation.

PURPOSE: To examine the clinical outcome of the balloon dilatation in stenosis of the canaliculus communis. METHOD: 18 nasolacrimal ducts with epiphora and proven obstruction of the canaliculus communis by dacryocystography (DCG) were treated with balloon dilatation in local anaesthesia. All patients were treated electively. RESULTS: In 16/18 cases the balloon dilatation was technically successful, in 2 patients the guide wire failed to pass the obstruction and the wire could not be placed in the nasal cavity. There were no complications. Over a mean follow-up of 6 months there were 2 reobstructions, one of these led to an occlusion of the canaliculus communis. 14/18 (77,8%) cases after DCP were treated successful, 11/18 cases were free of symptoms after DCP, in 4/18 cases the epiphora improved. CONCLUSIONS: Until recently in stenosis of the canaliculus communis the only therapeutic option was surgical procedure followed by silicone tube intubation. The results were often disappointing. In contrast to this balloon dacryocystoplasty is a minimally-invasive alternative in the therapy of stenosis of the canaliculus communis resulting in good clinical outcome during follow up.

[Balloon dilatation and Stentimplantation of the nasolacrimal duct for chronic epiphora]. / Minimal-invasive Therapie der Epiphora durch Ballonkatheterdilatation und Stentimplantation.

PURPOSE: To examine the clinical outcome of the ballon dilatation in stenosis and obstruction of the nasolacrimal duct. MATERIAL AND METHODS: 63 patients (69 nasolacrimal duct systems) with epiphora and proven obstruction of the nasolacrimal duct were treated with ballon dilatation, respectively Stentimplantation. In 55 cases there was a pre- or postsaccal stenosis, in 14 cases an occlusion of the nasolacrimal duct system. The diagnosis was established by dacryocystography. RESULTS: Technical success was obtained in 61 cases (n=50/55 stenosis; n=11/14 occlusions). Over a mean follow-up of 6 months patency of the nasolacrimal duct system was achieved in 83,6% (46/55) in stenosis. In occlusion the clinical outcome was 42,9% (6/14). CONCLUSION: Balloon dacryocystoplasty and Stentimplantation are minimal-invasive alternatives, performed in local anesthesia that recover the normal anatomy of the nasolacrimal duct system. They are a good alternative in the treatment of epiphora caused by nasolacrimal duct obstructions.

Lack of a diurnal plasma adenosine 3',5'-monophosphate rhythm.

Plasma cAMP levels were measured using a protein-binding radioassay in nine healthy volunteer subjects over a period of 24 h under standardized conditions and also after an hour of orthostatism. No circadian variations of cAMP in plasma were observed. After orthostatism, however, there was a significant rise in cAMP concentrations.

Sources of error in arterial morphometric measurements.

The authors used radiopaque vascular casts to test a new computer-based analysis method that employs a densitometric profile to determine arterial diameters. Results from this method were compared with those obtained with caliper measurements of overhead projection images of the radiograph and direct caliper measurements of the vascular cast. In addition, the corresponding in vivo angiograms were compared with the measurements obtained from the vascular casts. Vessel diameters obtained from cast radiographs by caliper measurement, operator-determined and automated densitometric curve fitting showed excellent correlations with acceptable intraobserver and interobserver variation. All methods, however, underestimated arterial diameters by about 7% compared with diameters obtained from casts by direct caliper measurements. In vivo angiograms revealed smaller arterial diameters than those obtained from specimens. However, we observed higher correlations for measurements at stenotic sites than in non-stenotic regions. Our results suggest definite limitations for the often used direct comparison between in vivo angiographic and postmortem findings.

Adenosine and diltiazem. A new therapeutic concept in the treatment of intestinal ischemia.

To determine the therapeutic effect of two vasodilators, adenosine and diltiazem, in mesenteric ischemia, 13 dogs were treated with an intra-arterial perfusion of the drugs after digitalis intoxication. Blood flow was restored to the control value after a dose of 2 micrograms/kg/minute adenosine or 5 micrograms/kg/minute diltiazem. The advantage of adenosine is that its effect begins and ends very rapidly, but because doses of more than 2 micrograms/kg/minute may cause a drop in blood pressure, strict pressure control is mandatory when the drug is applied clinically. Its limited use is appropriate, for example, when operative measures cannot be excluded. Diltiazem can be used for long-term therapy with a reduced risk of a drop in blood pressure.

Interventional radiological treatment of malignant biliary obstruction.

Percutaneous transhepatic procedures have gained a strong position in the diagnosis and treatment of malignant biliary obstruction. Diagnostic cholangiography can easily be converted into therapeutic drainage, which is often the first step towards further diagnostic work-up (biopsy, percutaneous cholangioscopy) and tumour ablation and/or intraductal irradiation. Plastic endoprostheses and balloon- or self-expandable metallic stents are the therapeutic alternatives to achieve permanent internal drainage of bile.

[Fibromuscular dysplasia of the brachial artery--2 case reports and review of the literature]. / Fibromuskuläre Dysplasie der A. brachialis--zwei Fallberichte und Literaturübersicht.

Yet being an uncommon disease in general, the manifestation of the fibromuscular dysplasia (FMD) in the upper extremities is exceedingly rare. Two patients with FMD of the brachial artery are presented and the literature concerned is reviewed. In this location the formation of microthrombi with subsequent embolization into the periphery instead of progressive vessel stenosis seems to be the leading pathophysiological principle. Therapeutic options are discussed.

[The sonographic and computed radiographic findings in perigraft reactions after the surgical implantation of vascular prostheses]. / Sonographische und computertomographische Befunde bei Perigraftreaktionen nach operativer Implantation von Gefässprothesen.

Between January 1988 and January 1994, 24 patients with heterologous vascular bypasses were examined with suspected diagnosis of a perigraft reaction (PGR). All patients were subjected to ultrasound and CT. PGR ist defined as a sterile inflammation along the course of a vascular prosthesis. The typical clinical presentation is a fluctuating tumour with a localised painless swelling. In all cases liquid formations could be confirmed by diagnostic imaging procedures; signs of infection could be excluded. The synopsis of the clinical presentation, the time interval after implantation of the prosthetic material and the signs of sonography and CT can reliably exclude infection of the prosthesis and confirm the diagnosis of a PGR.

[MR of the urinary tract in pregnancy]. / MR der Harnwege in der Schwangerschaft.

A report on the application of standard 2D-FT MR combined with RARE-MR-Urography in a pregnant woman with right sided abdominal pain, dilated upper urinary tract and possible stone or inflammatory disease. This technique visualised the complete obstructed ureter in relation to the surrounding organs (uterus, vessels), allows precise diagnosis of the cause of the obstruction and avoids ionising radiation.

[Dissolution of a bile duct stone with methyl tert-butyl ether]. / Auflösung eines Gallengangsteines mit Methyl-tertiärem Butyläther.

Methyl-t-butylether is a new agent to dissolve gallstones. The substance proves to be very successful and acts very rapidly. A percutaneous transhepatic drainage supplies an adequate access route to dissolve calculi within the bile ducts. We report the case of a patient where before insertion of an internal stent a stone in the common bile duct was dissolved within 3 1/2 hours.

[Bipolar radiofrequency energy in arteries--the experimental results with a new catheter system]. / Bipolare Radiofrequenzenergie in Arterien--experimentelle Ergebnisse mit einem neuen Kathetersystem.

PURPOSE: To evaluate the effects of radiofrequency heated bipolar probes on the human arterial wall. METHODS: Under standardised conditions, lesions were set on the inner layer of a piece of human cadaver arterial wall, using a radiofrequency-heated bipolar catheter. These lesions were measured and described both macroscopically and microscopically. Lesion size, applied energy levels and application conditions were correlated. RESULTS: The size of a lesion depended significantly on the size of the catheter, angle and pressure of catheter application (p < 0.05) and length of impulse (p = 0.002). There was no influence from the energy level employed. It proved impossible to treat calcified plaques. The depth of a lesion depended on the angle of catheter application only. No perforations were seen. CONCLUSIONS: Radiofrequency-heated bipolar catheters ablate the tissue of the arterial wall. Increasing tissue resistance resulting from higher energy levels prevents perforation in the experimental set-up. Calcified plaques cannot be treated by this method.

[Magnetic resonance tomography of liposarcoma]. / Magnetresonanztomographie der Liposarkome.

PURPOSE: Liposarcoma is the most common soft tissue sarcoma in adults. The purpose of the study was to correlate MR imaging features with the four ICD subclasses. METHODS: 28 patients with liposarcoma were examined preoperatively on a 1.0 T MRI system, using spin echo sequences, gradient echo imaging and STIR sequences. In all patients, classification of the liposarcomas was made by histologic diagnosis (ICD-10-M-classification). RESULTS: Well differentiated liposarcomas (9 patients) showed a number of MRI features consistent with lipoma (well defined mass high signal intensity (SI) on T1 images, low signal on T2 images, no or only little signal increase of tumour tissue after contrast material application, no necrosis). Not well differentiated liposarcomas (myxoid 14 patients, pleomorphic three patients, round cell two patients) revealed the largest part of the mass to be of low SI on T1-weighted images. Only scattered fatty islands and septa (9 patients with myxoid liposarcoma had more SI in T1-weighted images. T2-weighted image showed most of the mass to be of intermediate to high SI are the fatty island of relatively low SI. The probability of tumor necrosis increased with lower tumour grading. CONCLUSION: MRI seems to be valuable to identify well differentiated liposarcomas.

[CT- and ultrasound-guided biopsies: prospective comparison of fine-needle aspiration with true-cut biopsy in 103 patients]. / CT- und Ultraschall-gesteuerte Biopsien: Prospektiver Vergleich von Feinnadelpunktion und Stanzbiopsie bei 103 Patienten.

PURPOSE: A prospective comparison of FNAB and TCB was performed in an identical set of patients and lesions. METHODS: In 103 patients focal lesions were biopsied by US- or CT-guidance with at least one FNAB and TCB each. Complications were registered and documented. Cytological and histological specimens were evaluated independently. A final diagnosis was then attempted by consensus. RESULTS: A total of 253 punctures was performed with sufficient tissue in 72.8% (FNAB) and 85.4% (TCB) of the cases. Diagnosis was possible in 68% (FNAB) and 80.6% (TCB). After combined evaluation of both specimens the diagnostic yield increased to 91.3%. Minor complications without clinical sequelae were observed in 21 patients. CONCLUSION: A diagnostic strategy with the combined use of FNAB and TCB increases the diagnostic yield in image-guided punctures. Even though this approach needs at least two separate punctures, the complication rate does not increase.

[Gastrointestinal diagnosis with hydrosonography and hydro-CT. 1: Stomach carcinoma]. / Gastrointestinale Diagnostik mit Hydrosonographie und Hydro-CT. Teil 1: Magenkarzinom.

PURPOSE: Hydrosonography (HUS) and hydro-CT (HCT) were evaluated for diagnostic accuracy and staging efficiency of gastric carcinomas. MATERIAL AND METHODS: 68 patients suspected for gastric carcinoma were examined. At HUS the gastric wall is distended by water, the tumour is localised and enlarged to judge the depth of infiltration. At HCT the stomach is filled with water and after paralysis of the gut a spiral-CT optimised for parenchymal and vessel contrast is performed. Gastric carcinomas were classified according to the TNM-system and histopathological correlation was achieved. RESULTS: The number of normal/pathologic examinations was 10/30 (HUS) and 9/31 (HCT), the detection rate of gastric tumours was 77% (HUS) and 94% (HCT). The T-stage was correctly determined in 27% (HUS) and 55% (HCT), the N-stage in 65% and 45% and the M-stage in 81% and 73% of all cases, respectively. CONCLUSION: HCT is a reliable screening method for gastric tumors. Staging of gastric carcinomas, however, is not improved. Tumour extension beyond the wall and metastases can be assessed by a single examination.

[Percutaneous therapy of malignant obstructive jaundice using expandable metal stents: a prospective study of 92 patients]. / Perkutane Therapie des malignen Verschlussikterus mit Metallgitterstents - Prospektive Studie an 92 Patienten.

PURPOSE: To evaluate the clinical efficiency of percutaneously placed metallic stents in patients with malignant biliary obstruction. PATIENTS AND METHODS: In a prospective study 92 consecutive patients with malignant biliary obstruction were treated percutaneously with expandable metallic stents. Technical and clinical parameters during the procedure and regular follow-up were evaluated. RESULTS: Technical and clinical success rates were 100 and 91% respectively. During stent implantation we observed no severe complications. 30-day morbidity and mortality were 12 and 13% respectively. Late complications occurred in 35%, in 20.7% due to reocclusion of the bile ducts which was treated successfully in 17/19 patients. 75% of patients benefited from the procedure. Primary and secondary patency were 79.3 and 97.8%, respectively. CONCLUSIONS: Percutaneous transhepatic implantation of expandable metallic stents is a reliable and safe therapy for malignant jaundice and has a definite positive impact on the patients quality of life.

[The staging of renal-cell carcinomas in MRT and CT--a prospective histologically controlled study]. / Staging von Nierenzellkarzinomen in MRT und CT--prospektive histologisch kontrollierte Studie.

PURPOSE: To evaluate the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) in staging renal carcinoma. MATERIAL AND METHODS: 33 renal carcinomas were preoperatively examined for tumour staging by CT and MR imaging and correlated with histopathological staging. CT imaging was performed at first as a non-contrast scan. Finally incremental images (10 mm) after intravenous contrast injection were obtained. In MR imaging we performed a transversal T1-weighted GE sequence (112/5) with and without GDTPA, a transversal fat-suppressed double-echo sequence (3900/22/90), a coronal T1-weighted GE sequence with and without GDTPA and a coronal T2-weighted TSE sequence (2800/128). In addition, dynamic T1-weighted GE imaging after GDTPA injection as well as TOF angiography in coronal direction were performed. Finally CT and MRI findings were correlated with surgical and histopathological staging results. RESULTS: CT and MRI staging was correct in 27 and 28 of 33 tumours. Sensitivity and specificity for tumour stage T3b to T4 was for MRI and CT 88.9% and 95.8%. With MRI 4 out of 7 thrombi were correctly diagnosed with high accuracy, but via CT none. CONCLUSION: In early stage renal carcinoma CT and MR imaging yielded similar staging accuracies. In advanced renal carcinoma MRI was superior to CT imaging, especially in diagnosing tumour thrombus. Consequently the extent of tumour thrombus may be assessed by MRI which may therefore replace conventional cavography.

[Therapeutic efficiency of of pulsed spray lysis in peripheral arterial occlusions]. / Therapeutische Effizienz der gepulsten Sprühlyse bei peripheren arteriellen Verschlüssen.

PURPOSE: To determine the clinical efficacy of pulse-spray thrombolysis. MATERIAL AND METHODS: In a prospective trial 28 patients with acute arterial (n = 14) and bypass (n = 14) occlusions of the lower extremities were treated with pulse spray thrombolysis. 23/28 legs were at risk. RESULTS: Technical and clinical success were 89% and 68% respectively. Time interval until restitution of antegrade flow was less than two hours, the median duration of the complete intervention was 17 hours. Two patients (7.1%) needed transfusions for inguinal haematomas. After six months 50% of occluded segments remained patent, secondary patency is comparable at 53%. Bypasses show significantly lower patency (p = 0.04) and higher amputation (p = 0.009) rates than native arteries. Bad run-off (< or = 1 artery patent) is a significant predictor for clinical failure and early amputation. CONCLUSIONS: The distinct advantage of pulse-spray thrombolysis is fast restoration of antegrade flow and thereby effective treatment of acute ischaemia. The complication rate is low without associated mortality.

[Gastrointestinal imaging with hydrosonography and hydro-CT]. / Gastrointestinale Diagnostik mit Hydrosonographie und Hydro-CT, Teil 2: Dickdarmkarzinom.

AIM: To determine the accuracy of hydrosonography (HUS) und hydro-CT (HCT) for staging colon carcinoma. MATERIAL AND METHODS: 74 patients in whom colorectal carcinoma was suspected were examined. At HUS the colonic wall ist distended by a methylcellulose/water suspension and the carcinoma is enlarged to perform staging of the tumour. HCT is a spiral-CT optimised for parenchymal and vessel contrast. Before the scan is started, up to two litres of fluid are given rectally and spasmolytics are administered to reduce peristalsis. Colorectal carcinomas were classified according to the TNM system and histopathologic correlation was achieved. RESULTS: Out of 43 (HUS) and 39 (HCT) colonic lesions 33 (77%) and 36 (92%), respectively, were diagnosed. T-stage accuracy was 88% (HUS) and 66% (HCT), N-stage accuracy 33% and 46% and M-stage accuracy 88% and 85%, respectively. CONCLUSION: The T-stage of sonographically visible tumours of the colon is determined precisely by HUS. In contrast to predicting lymph node involvement distant metastases are reliably detected by both methods. If performed together, HUS and HCT achieve high diagnostic accuracy for staging carcinoma of the colon.

[The role of embolization treatment of acute hemorrhage]. / Zum Stellenwert der Embolisationsbehandlung bei akuten Blutungen.

137 arteries of 95 patients were treated by transcatheter embolization for massive haemorrhage using Ethibloc, Gelfoam, wire coils and Tissucol (Fibrinogen + Thrombin). The bleeding was secondary to trauma in 23 patients, to neoplasms in 16 patients and to vascular malformations or chronic inflammatory processes in 41 cases. 15 patients were treated for iatrogenic bleeding following surgery. Bleeding was referred to haemoptysis (n = 27), pelvic (n = 24), renal (n = 16) or gastrointestinal haemorrhage (n = 13) as well as several other diseases (n = 15). Most patients were poor surgical candidates. The overall bleeding control rate was 89.5% with a incidence of recurrent bleeding in 14 out of 95 patients (14.7%) treated by re-embolization or surgery. 6 patients died (6.3%) due to intractable haemorrhage, 4 patients (4.2%) died of complications related to embolization procedure (4 x bowel infarction!) and 33 patients (34.7%) died of procedure-unrelated causes such as myocardial infarction, trauma, malignancy or other underlying diseases. 58 patients (61.1%) are still alive (follow-up 16.2 +/- 4.8 months). Significant complications (5.3%) included bowel necrosis (4x) and ischaemia of the spinal cord with incomplete paralysis in one patient. One patient suffered thrombosis of the common iliac artery due to angiography. On the basis of our results, peripheral embolization using Ethibloc can be recommended as palliative treatment for devascularisation of bleeding tumours. Satisfactory results are obtained in haemoptysis, renal and pelvic haemorrhage, but gastrointestinal bleeding should not be occluded by means of Ethibloc because of its considerable risk of bowel infarction.

[Intra-arterial chemotherapy in locally advanced breast carcinomas]. / Intraarterielle Chemotherapie bei lokal fortgeschrittenen Mammakarzinomen.

Transcatheter arterial chemotherapy with mitoxantrone was carried out in 9 patients suffering from advanced breast cancer. The anticancer agent was selectively injected in the internal mammary artery. In 2 cases the catheter was super-selectively advanced into a peripheral branch of the internal mammary artery supplying the breast carcinoma. No complication of the transcatheter treatment could be observed. CT examinations for controlling the catheter position showed perfusion of breast cancers between 40 and 90 per cent. Histological examinations of the 7 resected specimens revealed extensive necrosis in all cases. All 7 patients who underwent surgery have been without local recurrence for 3 to 12 months after treatment.