Interventional radiology of the biliary system and pancreas.

In recent years, newer techniques have become available to the clinician for the diagnosis and treatment of biliary and pancreatic disease. This article emphasizes interventional procedures through the liver, such as percutaneous transhepatic cholangiography, percutaneous transhepatic biliary drainage, and ancillary techniques. Also discussed are the nonsurgical management of bile duct calculi and the diagnosis and treatment of pancreatic tumors, abscesses, and pseudocysts.

The effect of heparin on stress ulcer formation in rats.

The effect of heparin on acute gastric hemorrhagic lesions in rats induced by cold restraint stress was examined in relation to dose responsiveness. Prestress heparin with intravenous injection of either 50 or 500 U/Kg significantly reduced gastric bleeding (P less than 0.01). Treatment with the former dose inhibited the formation of gastric ulceration (P less than 0.01). Heparin poststress with both doses did not significantly affect either gastric bleeding or ulceration. In contrast, both heparin prestress and poststress at 5000 U/Kg intravenously markedly enhanced gastric bleeding (P less than 0.05 and P less than 0.01, respectively). The results encourage the use of low-heparin prophylaxis for stress ulcers in patients at high risk, and support the concept of a thrombotic etiology for this disease.

A simple method of determining the boundary between the antrum and corpus of the stomach. Part 2. Electric vagal stimulation in dogs.

Our previous work demonstrated that electric vagal stimulation in conjunction with Congo red as a dye-indicator is the faster and more reliable method for delineating the corpus-antral boundary in rats. Based on this finding, our study was extended to a larger animal model, the dog; this study proved the electrical vagal stimulation along with Congo red is a reliable method for adequate demonstration of this corpus-antral boundary. No untoward effect on the cardiac function was observed during stimulation of subdiaphragmatic portion of vagal trunks.

[Percutaneous transhepatic bile duct drainage for obstructive jaundice (author's transl)]. / Die perkutane transhepatische Gallengangsdrainage bei Stauungsikterus.

Palliative percutaneous bile duct drainage was carried out in five patients with obstructive jaundice due to inoperable tumours. In four patients drainage was continued for a long period, in one patient for only one day. The bile duct was punctured by transhepatic cholangiography. It was then catheterised and a drainage catheter introduced into the duodenum in order to produce both internal and external drainage. This procedure, which carries few complications, produces a rapid reduction of jaundice and disappearance of pruritus. It does not increase the expectation of life, which depends on the underlying disease. Experience with this method may be of value in benign stenoses or in pre-operative drainage.

Impotence after aorto-iliac surgery: current concepts.

The retrospective study of 38 male patients undergoing aorto-iliac reconstructive and abdominal aortic aneurysm surgery was carried out. The study demonstrates the deficiency in the pre-operative, intra-operative, and post-operative evaluation of these patients regarding the factors affecting impotence. Recommendations are made, and a flow sheet is compiled to assist the vascular surgeon in the evaluation and management of these patients.

The preventative effect of the antifibrinolytic agents, epsilon-aminocaproic acid and tranexamic acid, on stress ulcer formation in rats.

The effect of the antifibrinolytic agents, epsilon-aminocaproic acid (EACA) and tranexamic acid (t-AMCHA), on acute gastric ulcers induced by cold restraint stress in rats was studied. Intravenous administration of 500 mg/Kg of EACA and t-AMCHA before exposure to stress significantly reduced the severity of gastric bleeding and ulcer formation (P less than 0.01). These agents did not affect gastric acid secretion in pylorus-ligated rats. The results indicate that antifibrinolytic agents may be beneficial in the prevention of stress ulcers in man and support the concept that local gastric fibrinolysis may play a role in the pathogenesis of stress ulcers.

A simple method of delineating between the antrum and corpus of the stomach, part 1: A comparative study in rats.

A comparative study was performed in rats to find the fastest and most reliable method for delineating the corpus-antrum boundary using alcohol, betazole and electric vagal stimulation in conjunction with Congo red. This study demonstrated that electric vagal stimulation is the fastest and most reliable method.

[Sonographic percutaneous drainage of liver abscesses]. / Sonographische perkutane Drainage von Leberabszessen.

13 patients with pyogenic liver abscess and five patients with amoebic abscess underwent percutaneous drainage of the abscesses using the Seldinger (n = 8) or trocar technique (n = 11). The results showed that the trocar method was easier and faster to perform and well tolerated by the patients. No complications were observed despite of one case of transient peritonitis caused by a dislocated catheter. One patient with pyogenic liver abscess died of septic shock. All other patients were successfully treated, using local drainage and systemic antibiotic therapy.

[Routine determination of HB A1 by micro-column technique (author's transl)]. / Ein Routineverfahren zur chromatographischen HB A1-Bestimmung mittells Mikrosäulentechnik.

For routine determination of glycosilated hemoglobin (HB A1) it is necessary to have a quick and easy assay which allows analysis of a greater number of samples. Taking into consideration known methods for hemoglobin chromatography a micro-column technique has been developed, which separates the glycosilated hemoglobins AIa+b+c from the main hemoglobin fraction HB AII. Micro-columns (7.0 x 1.3 cm) are filled up to a bed-height of 3 cm with Bio-Rex 70. Hemoglobin is given to these in hemolysate from (1,8 mg/200 microliter) and separated with two buffers of different ionic-strength and different pH-values into two fractions HB A1 and HB AII. With exact standardisation of the elution volumes (18 ml), the elution temperature (21.5 degrees C) and pH-value (6.74) of the first elution buffer a high reproducibility of the results is possible (Intraassay-VK: 2.38%; Interassay-VK: 3.68%). The optical density of the hemoglobin fractions is read for cyanhemoglobin at 413 nm or 415 nm or for cyanmethemoglobin at 419 nm. The HB A1-concentration is given as a percentage of the total hemoglobin. This method enables the determination of HB A1-value of 40 blood samples in triplicate within four hours. The normal value derived from 25 healthy and normal weight volunteers is 6.88 +/- 0.41% (mean +/- S.D.), from which an upper normal range of 7.7% has been calculated. In 103 patients with unimpaired glucose tolerance values were observed in similar range: 6.45 +/- 0.61% (mean +/- S.D.). In 121 diabetic patients with varying metabolic control HB A1-values up to 20.58% were noted.

Is ultrasonography a reliable method for evaluation of fragment clearance after biliary ESWL? A prospective, blinded study of two independent ultrasound units.

Ultrasound is the preceding method for evaluation of fragmentation and subsequent fragment clearance from the gallbladder. Considering the methodological shortcomings of ultrasonography, this study was therefore designed to investigate the degree of conformity between two independent ultrasound units. In our protocol patients were evaluated for fragments two weeks and three, six, nine and twelve months after ESWL. A restricted number of experienced sonographers in two independent ultrasound units examined the patient without knowledge of the other unit's findings. A total of 62 examinations have been carried out so far. Complete or sufficient conformity with a difference in size of 0-3mm was achieved in 24 examinations. Seven examinations revealed differences of 4-13 mm. In 31 cases the diagnosis of a stone-free gallbladder has been made, but only in 25 cases this could be confirmed by the other ultrasound unit. In six examinations a small fragment of less than 5mm was found by the respective other sonographer. We conclude that the diagnoses of a stone-free gallbladder after ESWL should be reconsidered by a second independent and experienced sonographer.

[Chemoimmunotherapy of malignancies of the gastrointestinal tract]. / Chemoimmuntherapie bei Malignomen des Gastrointestinaltrakts.

Stimulation of the immune response could be obtained in outpatients with inoperable locally advanced or metastasizing gastrointestinal tumors (n = 56), who were palliatively treated with cyclophosphamide (cy), 350 mg/m2 i.v., thymostimulin, echinacin i.m. and in part additionally with epirubicin, 15 mg/m2 i.v. At present, outpatients with pancreatic (n = 7) or colon carcinomas (n = 1) receive interleukin 2 (IL-2) intralesionally, 2 x 10(5) Cetus units (CU), days 3, 5 and 7 after cy, and by portable continuous infusion systems i.v., 3 x 10(5) CU/day, days 3-8 after cy. Subsets of lymphocytes slightly decreased in the patients' peripheral blood, recall antigen reactivity slightly increased. Patients' mean survival time was 5.7 +/- 1.7 months.

[Askin tumor. Rare neurogenic tumor with metastasis to mouth, jaw and face regions]. / Der Askin-Tumor. Ein seltener neurogener Tumor mit Beteiligung der Mund-Kiefer-Gesichtsregion.

One case of a malignant peripheral neuroectodermal tumor of the thoracopulmonary region (Askin-Tumor) is reported. The tumor represents a distinct pathologic entity of neuroectodermal origin. The patient developed a metastasis in the upper jaw and in a lumbar vertebra. Morphologic and immunocytochemical findings of this extremely rare tumor were described and differential diagnosis from other soft-tissue round-cell sarcomas, such as Ewing's sarcoma and neuroblastoma are discussed. Problems associated with the clinical behavior and treatment are outlined. The prognosis in most cases of Askin-tumor is poor. The recommended therapy is radical resection, irradiation and combination chemotherapy containing anthracyclines and a high dose of alkylating agents.

Toxic shock-like syndrome due to severe hemolytic group A streptococcal infection.

A 33-year-old woman suffering from anal erosions developed severe illness with fever, diarrhea, ischalgia, hypotension, acute abdominal pain, dyspnea, renal and hepatic impairment, myalgia, desquamation of the skin, leukocytosis, anemia, hypocalcemia, decreased serum albumin, and cholesterol levels. Exploratory laparotomy did not reveal pathologic findings. Hemolytic group A streptococci were grown from peritoneal swabs and pleural exudate in bacteriologic cultures. The patient slowly recovered after intense penicillin and tobramycin therapy.

An unusual case of active tuberculosis of the oesophagus in an adult.

A case is reported of a 56-year-old woman of Libyan origin presenting with dysphagia, retrosternal pain and weight loss. Oesophago-gastroduodenoscopy revealed an ulcerated tumor in the upper oesophagus strongly suggesting a malignancy. A positive Mendel-Mantoux test along with histological evidence of epitheloid cell granulomas and clinical findings consistent with pulmonary and lymph node tuberculosis led to the presumptive diagnosis of oesophageal tuberculosis. The diagnosis was later confirmed by positive bacteriological cultures of oesophageal biopsies and gastric washings. It is very unusual for dysphagia to be the presenting symptom of active adult tuberculosis. Oesophageal tuberculosis is extremely rare and must be distinguished predominantly from oesophageal carcinoma.

Substitution of factor XIII: a therapeutic approach to ulcerative colitis.

Three patients with ulcerative colitis in the active stage demonstrated reduced levels of F XIII activity and F XIII subunit A (61 and 80.3%, respectively). Because of the lack of clinical improvement during conservative therapy, the patients were treated additionally with F XIII concentrate (Fibrogammin HS, Behring, FRG) for 10 days. The substitution resulted in an increase in F XIII activity (144.3%) and F XIII subunit A (238%) as well as in a marked improvement in symptoms.

Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography. Comparison with conventional sonography, computed tomography, and angiography.

In a prospective study, endoscopic ultrasonography was compared with transabdominal ultrasonography, computed tomography, and angiography in 60 consecutive patients with pancreatic (n = 46) and ampullary (n = 14) cancer considered to be candidates for surgery. The diagnostic value of these imaging procedures in determining local resectability was assessed. The diagnosis of ampullopancreatic malignancy was made by operation (n = 40) or puncture/biopsy (n = 20). In the 40 patients who underwent surgery, endoscopic ultrasonography was significantly superior to abdominal ultrasonography and computed tomography in determining tumor size and extent and lymph node metastases of pancreatic and ampullary cancer. Furthermore, involvement of the portal venous system as judged by histopathology or surgical exploration was correctly assessed by endoscopic ultrasonography in 95%, whereas angiography (85%), computed tomography (75%) and abdominal ultrasonography (55%) were less sensitive. Of 11 cases of portal venous infiltration found at surgery, endoscopic ultrasonography correctly predicted 10, abdominal ultrasonography only 1, computed tomography 4, and angiography 5 (P less than 0.05 for all three comparisons). Twenty patients did not undergo surgery for different reasons: of those, 9 patients were excluded from operation because of portal venous involvement as shown by angiography. Endoscopic ultrasonography detected portal venous invasion in all these cases. In contrast to the venous system, arterial encasement was less reliably detected by endoscopic ultrasonography. In conclusion, endoscopic ultrasonography is the most effective single imaging procedure for local tumor staging in pancreatic and ampullary cancer. Thus, endoscopic ultrasonography will improve the assessment of tumor resectability and further decrease the need for explorative laparotomy.

[The endosonographic staging of pancreatic carcinoma]. / Endosonographisches Staging des Pankreaskarzinoms.

Endoscopic ultrasound (EUS), conventional ultrasound (US), computed tomography (CT) and angiography were compared in their assessment of local resectability in 35 consecutive patients (19 men, 16 women; mean age 49.8 [42-821] years) with non-metastatic carcinoma of the pancreas. The findings were made prospectively and independently of each other. EUS proved to be superior to transabdominal US and to CT in the diagnosis of tumour infiltration of the portal and splenic veins. For the portal vein the sensitivity was 93% by EUS, 14% by US and 36% by CT. Corresponding figures for the splenic vein were 92%, 39% and 69%. EUS was markedly superior to angiography in the diagnosis of portal vein involvement (sensitivity of 93% and 36%, respectively), but the two methods had similar sensitivity regarding splenic vein infiltration (92 and 100%). Tumour involvement of the coeliac trunk was diagnosed with higher sensitivity angiographically (86%) than by EUS (57%), CT (71%) or US (29%). Regarding T and N staging, EUS was superior to both US and CT. These data indicate that EUS is the most accurate method for local tumour staging of potentially resectable pancreatic carcinoma. It can replace angiography in the diagnosis of portal vein infiltration.