SPECT/CT for SLN dissection in vulvar cancer: Improved SLN detection and dissection by preoperative three-dimensional anatomical localisation.

OBJECTIVE: In this study, we assessed the feasibility and clinical advantages of single photon emission computed tomography with CT (SPECT/CT) for sentinel lymph node (SLN) detection in vulvar cancer. METHODS: This is a unicentric prospective trial. Vulvar cancer patients underwent preoperative SLN marking (10MBq Technetium (TC)-99m-nanocolloid) and subsequent planar lymphoscintigraphy (LSG) and SPECT/CT for SLN visualization. Directly before surgery, a patent blue dye was injected. We assessed detection rates of SPECT/CT and those of planar LSG and intraoperative detection. We analyzed the sensitivity, negative predictive value and false negative rate. RESULTS: At Hannover Medical School, 40 vulvar cancer patients underwent SLN dissection after preoperative LSG and SPECT/CT. The mean diameter of all tumors in final histology was 2.23 (0.1-10.5) cm with a mean tissue infiltration of 3.93 (0.25-11) mm. In preoperative imaging, SPECT/CT identified significantly more SLNs (mean 8.7 (1-35) LNs per patient) compared to LSG (mean 5.9 (0-22) LNs, p<0.01). In addition, SPECT/CT led to a high spatial resolution and anatomical localization of SLNs. Thus, SPECT/CT identified aberrant lymphatic drainage in 7/40 (17.5%) patients. There were no significant differences, but significant correlation was found between SPECT/CT and intraoperative SLN identification. Regarding inguino-femoral LNs, for all patients who underwent complete groin dissection, sensitivity was 100%, NPV was 100% and false negative rate was 0%. CONCLUSION: SPECT/CT leads to higher SLN identification compared to LSG in vulvar cancer. Due to its higher spatial resolution and three-dimensional anatomical localisation of SLNs, SPECT/CT provides the surgeon with important additional information, facilitates intraoperative SLN detection and predicts aberrant lymphatic drainage.

Isthmocervical labelling and SPECT/CT for optimized sentinel detection in endometrial cancer: technique, experience and results.

OBJECTIVE: We evaluated the clinical feasibility of a new injection technique for sentinel detection in endometrial carcinoma (EC), transcervical subepithelial injection into the isthmocervical region of the myometrium. We compared detection of sentinel lymph nodes (SLN) by single photon emission computed tomography with CT (SPECT/CT) with planar lymphoscintigraphy. METHODS: This is a unicentric prospective study. In all patients, transcervical injection of 10 MBq Technetium-99m-nanocolloid was performed into the isthmocervical myometrium without anaesthesia. After 40 (30-60) min, lymphoscintigraphy and SPECT/CT were performed. Patent blue was administered before surgery. The number and localisation of SLN detected in SPECT/CT and lymphoscintigraphy were recorded and compared to the SLN and non-SLN dissected intra-operatively. RESULTS: Between August 2008 and March 2012, 31 patients with EC were enrolled. The new transcervical injection of labelling substances led to high intra-operative (90.3%) detection rates, pelvic bilateral (57%), para-aortic (25%). SPECT/CT significantly identified more SLN than lymphoscintigraphy (mean 2.2 (1-8) to 1.3 (1-7)) in more patients (29/31 (93.5%) to 21/31 (68%), p<0.01). If SLN were identified in one hemi-pelvis, the histological evaluation of the SLN correctly predicted lymph node (LN) metastases for this basin which led to sensitivity 100%, negative predictive value (NPV) 100%, and false negative results 0%. CONCLUSION: Transcervical SLN marking in combination with SPECT/CT is easily applicable and leads to high physiologic detection rates in pelvic and para-aortic lymphatic drainage areas. Non-affected SLN truly predicted a non-affected LN basin. Combining both methods SLN dissection may be a safe and feasible staging technique for clinical routine in EC.

Effects of autotransplanted lymph node fragments on the lymphatic system in the pig model.

Secondary lymphedema often develops after removal of lymph nodes in combination with radiation therapy, in particular in patients with breast cancer, inguinal cancer, cervical cancer and melanoma. No convincing treatment for the prevention and therapy of acquired lymphedema exists so far, therefore we wanted to show the reintegration of transplanted avascular lymph node fragments in the lymphatic system and positive effects of the transplanted fragments on the restoration of the lymphatic flow in this study. A total of 26 minipigs underwent lymphadenectomy of both groins. A minimum of one lymph node was retransplanted. The lymph nodes were cut into small pieces and retransplanted in the left groin (n = 17) or in both groins (n = 9). Different retransplantation techniques were investigated, transplantation of large versus small fragments, with and without capsule. The lymph flow was evaluated 5 and 8 months after surgery, using SPECT/CT and Berlin Blue. The results were confirmed by dissection. The lymph node transplants were assessed histologically. In contrast to the lymph flow in the transplanted groin, the lymph flow in the non-transplanted groin was often malfunctioning. Large lymph node fragments were found reintegrated in the lymphatic system more often than small slices of lymph node fragments. About 5 months after surgery impairment of lymph flow was seen especially after retransplantation of small slices of lymph node fragments. In seven out of eight minipigs a dermal backflow developed in the non-transplanted groin, 8 months after surgery. Only one minipig of these groups developed dermal backflow in both groins. All lymph node fragments showed an organized structure histologically. Autologous lymph node transplantation has positive effects on the regeneration of lymph vessels and restoration of lymph flow after lymphadenectomy.

Excision of the dilated pelvis is not necessary in laparoscopic dismembered pyeloplasty.

PURPOSE: The surgical treatment of choice for significant hydronephrosis is dismembered pyeloplasty. While in open surgery, extensive resection of the dilated pelvis is common practice, laparoscopically usually only a sparing resection is performed. We compared the treatment results of both techniques to investigate whether extensive resection is necessary or not in dismembered pyeloplasty procedures. METHODS: To obtain comparable renal units, matched pairs according to age and relative kidney uptake as shown by (123)J-orthoiodohippurate renography were selected out of a total of 76 patients who underwent dismembered pyeloplasty between 2000 and 2007. Twenty-four patients complied with the criteria for inclusion in the study. Changes in urinary drainage preoperatively and at three months postoperatively were compared between both groups. RESULTS: The mean age in the sparing resection group was 3.8 years (range 0.3 to 14 years); in the extensive resection group it was 3.4 years (range 0.5 to 10 years). Mean urinary drainage improved significantly in both groups from 35.1 +/- 10.7 % to 75.2 +/- 13.2 % (sparing resection) vs. 45.1 +/- 23.7 % to 70.2 +/- 22 % (extensive resection). There were no differences between the groups (p > 0.05). CONCLUSIONS: We conclude that extensive resection of the renal pelvis is not necessary in dismembered pyeloplasty procedures since there were no differences in the renographic outcome of comparable patients treated by the different surgical methods.

Early predictors of success of Kasai operation in children with biliary atresia.

AIM: Aim of the study was the evaluation of early predictive parameters of event-free survival (not listed for liver transplantation, not transplanted, no death) in children suffering from biliary atresia after hepatoportoenterostomy (Kasai procedure) in order to optimize pretransplant management. PATIENTS AND METHODS: Sixty-seven infants were treated with the Kasai operation at our institution over a 20-year period from 1978 until 1998. Median age at time of operation was 51 days after birth (range 19 - 180 days). Of these 67 infants, 24 children with complete datasets and an observation time of at least one year were evaluated retrospectively using a Cox regression model. The response variable was event-free survival after a median observation time of 4.9 years (1.11- 10.37 years). Six variables were entered as covariates: alanine aminotransferase (ALAT), cholinesterase activity, bilirubin, age at the time of Kasai operation and tracer excretion and uptake during hepatobiliary scintigraphy (HBSS). All variables were evaluated six weeks after operation. For subsequent cut-off determination, a receiver operating analysis (ROC analysis) was carried out. RESULTS: Tracer excretion shown by HBSS showed the highest prognostic power to predict event-free survival after Kasai operation (log rank 18.68, p < 0.0001) followed by bilirubin and ALAT as further significant parameters in the first univariate step of the Cox regression model. In the subsequent multivariate step, the prognostic power of HBSS was improved only by bilirubin (log rank 24.6, p < 0.0001). The ROC analysis determined a cut-off for bilirubin concentrations of 57 micromol/l for event-free survival with a sensitivity of 80 % and a specificity of 78.6 %. The five-year event-free survival-rate was 100 % in the group with good tracer excretion and a bilirubin concentration of 57 micromol/l and 27 % for the other group (log rank test, p < 0. 0001). CONCLUSION: Early predictors of success of the Kasai operation in children with biliary atresia are free tracer excretion as shown by HBSS and a serum bilirubin concentration < 57 micromol/l six weeks after the operation. Thus, children with bilirubin concentrations above this level should be carefully and frequently monitored with regard to a transplantation requirement in order to optimize pretransplant management.

Noninvasive measurement of lung carbon-11-serotonin extraction in man.

The fraction of serotonin extracted on a single passage through the lungs is being used as an early indicator of lung endothelial damage but the existing techniques require multiple arterial blood samples. We have developed a noninvasive technique to measure lung serotonin uptake in man. We utilized the double indicator diffusion principle, a positron camera, 11C-serotonin as the substrate, and 11CO-erythrocytes as the vascular marker. From regions of interest around each lung, we recorded time-activity curves in 0.5-sec frames for 30 sec after a bolus injection of first the vascular marker 11CO-erythrocytes and 10 min later 11C-serotonin. A second uptake measurement was made after imipramine 25-35 mg was infused intravenously. In three normal volunteers, the single-pass uptake of 11C-serotonin was 63.9% +/- 3.6%. This decreased in all subjects to a mean of 53.6% +/- 1.4% after imipramine. The rate of lung washout of 11C was also significantly prolonged after imipramine. This noninvasive technique can be used to measure lung serotonin uptake to detect early changes in a variety of conditions that alter the integrity of the pulmonary endothelium.

Hydroxyethyl starch and modified fluid gelatin maintain plasma volume in a porcine model of septic shock with capillary leakage.

OBJECTIVE: To compare the effects of different volume replacement therapies on maintenance of plasma volume in septic shock and capillary leakage syndrome. DESIGN AND SETTING: Prospective randomized, controlled animal laboratory study in a university animal laboratory. MEASUREMENTS AND RESULTS: Twenty-five fasted, anaesthetized, mechanically ventilated and multi-catheterized pigs (20.8+/-1.8 kg) received 1 g/kg body weight faeces into abdominal cavity to induce sepsis and were observed over 8 h. Five animals each received volume replacement therapy with modified fluid gelatin 4% or 8% (MFG4%, MFG8%), 6% HES 200/0.5, or Ringer's solution and were compared to controls receiving 6% HES 200/0.5. Infusion rate was titrated to maintain a central venous pressure of 12 mmHg. Plasma volume was determined using (51)Cr-labelled erythrocytes and standard formulae. Albumin escape rate was calculated using technetium (99m)Tc-labelled albumin. Colloid osmotic pressure, systemic haemodynamics and oxygenation were obtained before and 4 and 8 h after induction of sepsis. Plasma volume was reduced in the Ringer's solution group (-46%) but was maintained in HES (+/-0%), MFG4% (+4%), MFG8% (+23%) groups. Albumin escape rate increased in HES (+52%), MFG4% (+47%), MFG8% (+54%) and the Ringer's solution group (+41%) compared to controls. CONCLUSION: In this porcine septic shock model with concomitant capillary leakage syndrome, confirmed by an increased albumin escape rate, the artificial colloids HES, MFG4%, and MFG8% maintained plasma volume and colloid osmotic pressure. These results suggest the intravascular persistency of artificial colloids in the presence of albumin leakage. An editorial regarding this article can be found in the same issue (http://dx.doi.org/10.1007/s00134-002-1283-9)

Evaluation of noninvasive determinants for capillary leakage syndrome in septic shock patients.

OBJECTIVE: Capillary leakage syndrome (CLS) is a frequent complication in sepsis, characterized by loss of intravasal fluids leading to generalized edema and hemodynamic instability despite massive fluid therapy. In spite of its importance no standardized diagnostic criteria are available for CLS. DESIGN: Prospective clinical study. SETTING: 1,800-bed university hospital PATIENTS: Six septic shock patients with CLS were compared to six control patients. MEASUREMENTS AND RESULTS: CLS was clinically determined by generalized edema, positive fluid balance, and weight gain. Plasma volume was measured by indocyanine green, red blood cell volume by chromium-51 labeled erythrocytes, and colloid osmotic pressure before and 90 min after the administration of 300 ml 20% albumin. Extracellular water (ECW) was measured using the inulin distribution volume and bioelectrical impedance analysis. Red blood cells averaged 20.2 +/- 1.0 ml/ kg body weight in CLS patients and 23.3 +/- 4.1 in controls. ECW was higher in CLS patients than in controls (40.0 +/- 6.9 vs. 21.7 +/- 3.71; p< 0.05). ECW of inulin was correlated with that measured by bioelectrical impedance analysis (r = 0.74, p< 0.01). The increase in colloid osmotic pressure over the 90 min was less in CLS patients than in controls (1.1 +/- 0.3 vs. 2.8 +/- 1.3 mmHg;p< 0.05). CONCLUSION: These results suggest that measurements of an increased ECW using bioelectrical impedance analysis combined with a different response of colloid osmotic pressure to administration of albumin can discriminate noninvasively between patients with and those without CLS.

Sonographic pattern of focal nodular hyperplasia of the liver.

Focal nodular hyperplasia of the liver (FNH) is a histologically defined benign hepatic tumour, possibly associated with the use of oral contraceptives. The present study deals with the question whether FNH can be distinguished from other lesions of the liver by ultrasonography alone or by a combination of real-time sonography and radiologic procedures. Therefore 18 cases of FNH, 16 females and 2 males, are presented. We retrospectively reviewed the diagnostic results of real-time sonography, hepatic scintigraphy, computed tomography with dynamic CT-densitometry, and angiography on these 18 patients. Ultrasonography enables the identification of the lesion in all of the 18 cases. FNH appears to show varying degrees of echogenicity (slight hypoechoic in 6 cases, isoechoic in 6 cases, and slight hyperechoic in 4 cases). In most of the patients the tumour had similar acoustic characteristics as the surrounding normal liver. By ultrasonography alone there is no possible differentiation of FNH from other hepatic tumours. Both the echo pattern of FNH and the results of the ultrasonically guided cytopuncture are unspecific.

[Scintigraphic image of bile reflux following gastric and intestinal surgery]. / Szintigraphische Darstellung des Gallenrefluxes nach Magen- und Darmoperationen.

Bile reflux may occur after a variety of reconstructive procedures in the gastro-intestinal tract and biliary system. The present paper deals with reflux into the duodenum, jejunum, stomach, oesophagus and into blind loops. The demonstration of reflux by 99mTc labelled IDA acid derivatives, and a possible quantitative approach, are discussed. The advantages of an isotope method are: 1. Direct demonstration of bile reflux without any intervention in the physiological process and with little trouble to the patient, 2. The ability to use the method for various reconstructive procedures and 3. The additional information obtained which may help in the differential diagnosis of blind loops, biliary obstructions, cholecystitis or liver metastases if there has been a gastrectomy for a malignant tumour. In combination with a second administration of a radio-isotope tracer, one may be able to demonstrate abnormalities in the motility of the stomach or gut, or pyloric stenosis or gastro-oesophageal reflux.

[Dynamic reflux scintimetry for quantifying gastroesophageal reflux in patients with prolonged esophageal transit]. / Die dynamische Refluxszintimetrie zur Quantifizierung des gastroösophagealen Refluxes bei Patienten mit verlängertem ösophagealen Transit.

A combination of a radionuclide transit test and a dynamic gastroesophageal scan was evaluated in normal volunteers, in patients with achalasia treated by pneumatic dilatation (n = 34) or Heller myotomy (n = 21). Interpretation of 31 of 57 examinations done with usual scintiscan was not possible because of too high esophageal tracer retention. Only one case could not be interpreted with the modified technique. Gastroesophageal reflux was detected and quantified in this manner in 8 patients, 6 more than with the usual scintiscan. 7 of these 8 patients have had Heller procedure, 1 patient even combined with fundoplasty.

[Demonstration of postgastrectomy bile reflux by hepatobiliary sequential scintigraphy]. / Nachweis von Gallereflux nach Gastrektomie mit der hepatobiliären Sequenzszintigraphie (HBSS).

After gastrectomy and jejunal interposition by the Longmire technique, symptoms due to alkaline reflux oesophagitis may occur, which are caused by duodeno-jejunal and jejuno-oesophageal bile reflux. Twenty-seven patients who had gastrectomies performed for malignant tumours one to three years previously were examined by hepatobiliary sequential scintigraphy in order to see whether this is able to demonstrate bile reflux. In addition to endoscopies, biopsies and radiological examinations, 45 sequential scintigrams were carried out. Agreement of results during routine use was investigated for five observers. There were considerable variations in results amongst different observers. Nevertheless, in four out of the five observers, there was a significant correlation with the clinical findings (p less than 0.05). Only by using functional scintigraphy with digital data recording is it possible to demonstrate or exclude bile reflux with any degree of certainty. Eight out of twelve patients with marked symptoms, and four out of 28 without symptoms showed reflux into the interposed segment (correlation 0.7, p greater than 0.05). Patients with symptoms showed a high incidence of oesophagitis by the above-mentioned methods (correlation (0.52, p greater than 0.05). Correlation between the results of barium meals and clinical findings was considerably less (0.25) and was not significant. Sequential scintigraphy is therefore better for clarifying reflux symptoms than radiological examination or endoscopy and biopsy.

[Functional scintigraphy in the follow-up of transplants]. / Funktionsszintigraphie in der Transplantatnachsorge.

Nuclear medicine procedures have special indications in the follow-up of transplanted patients: In case of renal transplantation perfusion, function (glomerular filtration) and urinary flow measured by bolus application of 99mTc-DTPA is an important tool to detect and monitor acute tubular necrosis, rejection, urinary leakage, obstruction or vascular complications. This method is used for pancreatic grafts, too. To exclude rejection in case of heart transplantation more than one year after operation the antimyosin antibody scintigraphy is introduced avoiding biopsies. The radionuclide ventriculography is able to monitor heart function by determining the ejection fraction. Cholescintigraphy in liver transplants is sensitive to detect complications of bile flow. In case of an auxiliary liver transplantation a competition between two livers has been described. This method allows a distinction of functional performance of donor and recipient liver. The same problem is solved by ventilation-perfusion scan in lung transplants. Bone scintigraphy is of prognostic value for graft viability. Other radionuclide examinations have been developed to measure perfusion, glucose-, fat-metabolism to detect rejection episodes, abscesses or tumor recurrencies.

[Quality control of fractionated port scintigraphy in patients with head and neck neoplasms]. / Qualitätskontrolle der fraktionierten Port-Szintigraphie bei Patienten mit Kopf-/Hals-Karzinomen.

The purpose of this study was to evaluate the precision of a technique for shunt measurement and to quantify its relevant influencing factors. Therefore, 10 patients underwent firstly an intraarterial injection of 100 MBq 99mTc-MAA and secondly a fractionated intravenous injection of 4 x 10 MBq 99mTc-MAA. Calculations of the shunt volumina were done with Wheeler's algorithm. In addition the relative shunt volumina for all applications were computed and corrected for (a) tracer retention, (b) biological degradation, (c) physical decay, (d) remaining activities and (e) the combination of (a)-(d). The coefficient of variation was 9.4%. The influence of (a), (b) and (d) was significant and that of (c) not significant. If all influencing factors were ignored (e), no significant differences could be seen, compared to the fully corrected results. Therefore, fractionated shunt scintigraphy is a simple and rapid technique for precisely determining relative shunt volumina in patients under local chemotherapy.

[Ulcer detection using 99m Tc-sucralfate]. / Ulkussuche mit 99mTc-Sucralfat.

Sucralfate is an agent commonly used in the therapy of gastrointestinal ulcers. It binds itself to proteins in the ulcer crater. A selective labeling with pure 99mTc-pertechnetate is possible. For an unequivocal ulcer localization or exclusion, images have to be taken in the upright and supine positions. Encouragement of gastric emptying is useful. Images should be taken at least twice, the last one 4 h after ingestion. The method might be used when endoscopy is difficult, incomplete or contraindicated, and for follow-up during therapy. We recommend it also in the search for the cause of intermittent bleeding.

[Scintigraphy using 131I in oxyphilic carcinomas of the thyroid gland]. / Szintigraphie mit 131J bei oxyphilen Karzinomen der Schilddrüse.

The aim of the study was to ascertain the role of 131I scintigraphy (RIS) in the follow-up of oxyphilic thyroid carcinomas (OTC). It is discussed that metastases (M) and local recurrencies (LR) are incapable of accumulating 131I sufficiently; therefore, the usual strategy of RIS cannot be used for follow-up. The re-examination of 91 patients suffering from OTC showed that 10/20 patients with M/LR did have a positive uptake of 131I, which could be used for therapy in 8 patients. An ablation of M using high-dose 131I therapy could be demonstrated in three younger patients who had cervical lymph node M 3 months after thyroidectomy as an early manifestation of their disease. In three patients RIS first led to the metastatic site. The clinical course of patients with distant M that developed at a later stage was unfavourable, even though they did accumulate 131I. Patients with positive uptake of 131I in M/LR were significantly younger (55a) than patients who had no uptake (67a) and belonged more often to stage I and II of UICC, namely 7/10 vs 2/10. RIS should be used especially in an early interval after thyroidectomy and individually for follow-up: as a diagnostic method and therapeutic instrument.

[The clinical course of oxyphilic carcinoma of the thyroid]. / Klinisches Verhalten oxyphiler Karzinome der Schilddrüse.

In a total of 1665 patients with malignant thyroid neoplasms 90 oxyphilic thyroid carcinomas (OTC) were found of whom 55 could be re-examined and newly classified. Morphological and clinical parameters influencing the clinical course were determined. During a mean follow-up period of 6.5 y metastases or local recurrent disease occurred in 12 patients (24%). Apart from 3 early manifestations of metastases, 9 patients developed recurrent disease within, on average, 4.7 y after thyroidectomy: local lymph node metastases and local recurrences occurred within an average of 5.4 y, distant metastases after only 2.7 y. Thyroglobulin proved to be reliable for follow-up with a sensitivity of 88% on levothyroxine and 75% on endogenous TSH-stimulation (specificity: 98%). The frequency of metastases and local recurrences correlated with age at the time of tumor diagnosis, the degree of invasiveness and the local tumor extension (pT4 vs. pT1-3), whereas other factors such as the absolute diameter of the tumor or patient's sex had no influence on the clinical course. The survival probability for 5 and 10 years was 95 and 75%, respectively. All OTC patients should be examined regularly at least once a year by cervical sonography and thyroglobulin measurement. Because 18% recurrences occurred within 4.7 y such examinations should be repeated beyond year 5 after thyroidectomy.

[Scintigraphic method to test the function of intraperitoneal draining catheters for regional intraabdominal chemotherapy]. / Szintigraphische Uberprüfung der Funktion intraperitoneal liegender Katheter zur regionalen intraabdominellen Chemotherapie Scintigraphic Method to Test the Function of Intraperitoneal Draining Catheters for Regional Intraabdominal Chemotherapy.

AIM: Intraoperative peritoneal chemohyperthermia (IPCH) followed by one or more courses of closed intraperitoneal chemotherapy via peritonealdialysis-catheter (Zellermann) is a promising concept for treatment of peritoneal carcinomatosis. METHODS: To prove the functionality of the catheter a scintigraphic method is introduced using a liquid solution of sodium chloride-- Tc-99m-Diethylenetriaminepentaacetic acid (Tc-99m-DTPA) (500 ml). This study was aimed to look for problems over the period of application and to measure the intraperitoneal distribution and resorption of the fluid. RESULTS: One leakage and 3 revisible obstructions occured in 26 applications done in 20 patients. The upper right and the central abdomen was not reached as extensive as the other regions. The abdomen was divided into 9 regions of equal size. In 4 out of 19 patients (20%) the fluid tracer was missed in more than 3 regions (up to 40% of the total area). CONCLUSIONS: It is to early to decide whether methological modifications are necessary in these cases, but closed chemotherapies in patients with maldistribution may not be indicated. This will be in particular necessary if there is a relation between the maldistribution and the location of recurrencies. The demonstrated simple scintigraphic method, however, is able to recognize patients at risk.

[Early and late HMPAO-SPECT during an epileptic seizure]. / Frühe und späte HMPAO-SPECT während eines epileptischen Anfalls.

For presurgical evaluation of epilepsy a 44-year old patient with complex-partial seizures underwent HMPAO-SPECT. The morphology of the seizures, the MRI-scan, psychometry and ictal as well as interictal EEGs showed a left temporal origin of the seizures. Early images were obtained 20 min and late images 24 h following injection. On both scans a marked hyperperfusion was observed in the left temporal area. A crossed cerebellar diaschisis was also seen on both SPECTs. It could be shown that during ictal examinations there is no bloodflow-dependent wash-out from brain tissue.

[Nuclear medicine demonstration of esophageal bile reflux]. / Nuklearmedizinischer Nachweis des ösophagealen Gallerefluxes.

Biliary and pancreatic juice has been implicated as a cause of regional inflammation or carcinoma after gastric surgery. We studied 38 patients after gastrectomy using a modification of cholescintigraphy (185 mBq 99m-Tc-DESIDA i.v.). As soon as the tracer had reached the duodenum, a dynamic study (30 min, 120 frames) was started. Thereafter a static image of the epigastrium and thorax in the anterior view with more than 1000 cts/cm2 was recorded. This procedure was repeated after a meal. Of 29 patients without complaints only 4 had a reflux into the jejunal loop. By contrast in 7 of 9 patients with suggestive symptoms this examination demonstrated bile reflux which reached the oesophagus in 6 cases. A stenosis of the distal oesophagus prevented oesophageal reflux in one patient. 2 patients with oesophageal reflux had a history of oesophageal stenosis and oesophagitis confirmed by endoscopy. The remaining 2 patients without demonstrable reflux had neither oesophagitis nor radiologically verified reflux. Cholescintigraphy as modified by us may detect clinical relevant bile reflux into the oesophagus. This is important for surgeons selecting patients with potential benefit from a reoperation. Since most patients with complaints after gastrectomy have had demonstrable bile reflux, reflux-reducing surgical techniques should be used in all.