Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols.

PURPOSE: Different enhanced recovery after surgery (ERAS) protocols (EP) for radical cystectomy (RC) have been published. Protocols highly differ in number of included items and specific measures. MATERIALS AND METHODS: A systematic review and meta-analysis on EPs in RC were performed using the databases MedLine, Cochrane Library, Web of science, and Google Scholar. The specific ERAS measures of the protocols were extracted, analyzed, and compared. Pooling of available outcome data was performed for length of stay, complications, readmission rate, and time to defecation. RESULTS: The search yielded a total of 860 studies of which 25 studies were included in qualitative and 22 in quantitative analysis. Oral bowel preparation (BP) was omitted in 24/25 (96%) EPs, optimized fluid management was administered in 22/25 (88%) EPs and early mobilization (postoperative day 1) in 21/25 (84%). Gum chewing (n = 12, 46%), metoclopramide (n = 11, 44%), and alvimopan (n = 6, 24%) were the most common measures to prevent postoperative ileus. Our meta-analysis revealed a significant benefit in favor of EPs for the outcome parameters length of stay [mean difference (MD) - 3.46 d, 95% confidence interval (CI) - 4.94 to - 1.98, p < 0.01], complications [Odds ratio (OR) = 0.76, 95% CI 0.61-0.94, p = 0.01] and time to defecation (MD - 1.37 d, 95% CI - 2.06 to - 0.69, p < 0.01). Readmission rate did not show a significant difference (OR = 0.73, 95% CI 0.52-1.03, p = 0.07). CONCLUSION: Current EPs focus on omitting oral BP, early mobilization, and optimized fluid management while they differ in methods preventing postoperative ileus. Our meta-analysis revealed a benefit in introducing these protocols into clinical practice.

Lethal outcome after pelvic salvage radiotherapy in a patient with prostate cancer due to increased radiosensitivity : Case report and literature review.

BACKGROUND: In general, late side effects after salvage radiotherapy (RT) for prostate cancer are below 10%. Patients with impaired DNA repair ability and genetic instability can have significantly increased reactions after RT. CASE, CLINICAL FOLLOW-UP, AND EXAMINATION: We present a patient who experienced severe side effects after additive RT for prostate cancer and died from the complications 25 months after RT. Imaging (MR) is shown as well as three-color fluorescence in situ hybridization. The blood sample testing revealed that radiosensitivity was increased by 35-55%. We undertook a review of the literature to give an overview over the tests established that are currently considered useful. CONCLUSION: This case highlights that the identification of patients with increased radiosensitivity is an important task in radiation protection. Groups of patients who should be screened have to be found and corresponding research facilities have to be set up.

[Cystic tumor on the porta hepatis]. / Zystischer Tumor an der Leberpforte.

A cystic entity from the porta hepatis of a 64-year-old female patient was sent in for rapid section diagnostics with a clinical suspicion of pancreatic cancer. The rapid section diagnostics revealed aspects of glandular proliferation with mucous-like material in the lumina which led to the suspicion of infiltration of a highly differentiated mucinous adenocarcinoma. However, conventional paraffin-section histology and the immunohistochemical marker profile could not confirm this suspicion but an adenomatoid tumor was diagnosed. In typical locations in the genital area of both genders, this entity is a current differential diagnosis to infiltrations of an adenocarcinoma.

Impact of perioperative blood transfusions on oncologic outcomes after radical cystectomy: A systematic review and meta-analysis of comparative studies.

This study aimed at systematically analyzing and evaluating the impact of perioperative blood transfusions (PBT) on oncologic outcomes of patients undergoing radical cystectomy for bladder cancer. This systematic review follows the recommendations of the Cochrane Handbook for Systematic Reviews and Interventions and was conducted in line with the PRISMA statement and the AMSTAR II criteria. A comprehensive database search was performed based on the PICO criteria. Two independent reviewers performed all screening steps and quality assessment. Risk of bias and certainty in evidence were assessed with the Newcastle Ottawa Scale for non-randomized trials and the GRADE approach. Of 1123 identified studies 20 were eligible for qualitative analysis and 15 for quantitative analysis reporting on 21,915 patients. Receiving a PBT was associated with an increased risk of all-cause mortality (hazard ratio (HR) [95% confidence interval (CI)]: 1.29 [1.18, 1.40]; p < 0.001), cancer-specific mortality (HR [CI]: 1.27 [1.15; 1.41]; p < 0.001) and disease recurrence (HR [CI]: 1.22 [1.12; 1.34]; p < 0.001). Subgroup analysis of transfusion timing revealed a significantly increased risk of mortality with intraoperative or combined intra- and postoperative transfusions compared to postoperative transfusion only for all three outcomes (p < 0.001). Leukocyte-depletion was associated with increased all-cause mortality, but not cancer-specific mortality. The administration of PBT negatively impacts oncological outcomes after radical cystectomy. Therefore, careful treatment indication and strict adherence to transfusion guidelines is encouraged in order to avoid adverse effects during the perioperative course.

[PACS: acceptance by orthopedic surgeons]. / PACS: Akzeptanz bei Orthopäden und Unfallchirurgen.

PURPOSE: The goal of the study was to evaluate the acceptance of a web-based picture archiving and communication system (PACS) by orthopedic surgeons 1 year after implementation. MATERIALS AND METHODS: One year after the implementation of a web-based PACS all physicians were surveyed with a standardized questionnaire. Questions included: speed of PACS, quality of clinicoradiological meetings, quality of monitors, PACS training, and performance. Data were evaluated separately for the Department of Orthopedic Surgery and the reference group of all other physicians. RESULTS: Among the respondents, 92% of the orthopedic surgeons stated there was a reduction of time required to receive images, and 64% concluded that patient care was faster. Archived images were received in less than 5 min in 82% after PACS and in 8% before PACS. The clinicoradiological meetings improved with PACS in 100% due to beamer presentation. All would recommend a PACS. The equipment to view images in the operating theater was assessed as being good or very good by 83%; monitor quality was judged better for the outpatient clinics (100% good or very good). Conventional radiograms were missed at the ward rounds by 56%. Training for PACS was considered sufficient by 67%, and 15% asked for refresher courses. In the reference group 60% asked for refresher courses. In the comparison of orthopedic surgeons with the reference group PACS was judged better especially concerning the viewing software and quality of monitors. CONCLUSION: There is an over all acceptance of PACS by physicians outside the radiology department. The availability of images was not only facilitated it was faster as well. However, the quality of monitors in the operating theater should be improved. To achieve sustained success of PACS consistent training on PACS and its features is necessary. Conventional radiograms were often missed at the ward rounds.

Asymmetry between Left and Right Eyes in Keratoconus Patients Increases with the Severity of the Worse Eye.

PURPOSE: To evaluate whether the inter-eye asymmetry of keratoconus (KC) patients is different from a healthy control group and to investigate how asymmetry changes with increasing severity of the disease. METHODS: In this retrospective study, we included both eyes of 350 patients with KC (age 35 ± 13 years) and 68 candidates planned for refractive surgery (control group, age 37 ± 11 years). Inclusion criteria for the KC group were keratoconus in at least one eye with Pentacam Topographical Keratoconus Classification (TKC) of at least 0.5. Patients eligible for refractive surgery in both eyes were included in the control group. Corneal tomography as well as Ocular Response Analyzer measurements were compared between both groups. Subgroup analysis was performed with respect to the TKC staging. Asymmetry was provided as worse eye (defined by higher TKC) minus fellow eye. RESULTS: In the KC group, both eyes showed the same TKC staging in 30.6%, a difference of one stage in 34.0% and of two stages in 24.6% of the patients. The inter-eye asymmetry in the keratoconus group was significantly larger than that in the control group. Corneal power showed an asymmetry of 3.8 ± 4.0 D in keratoconus eyes versus 0.22 ± 0.17 D in the control group. Central corneal thickness (CCT) asymmetry was 34 ± 30 µm versus 6 ± 5 µm, respectively. The Keratoconus Match Index showed an asymmetry of 0.40 ± 0.35 versus 0.15 ± 0.14. The difference between both eyes increased with increasing TKC of the worse eye. CONCLUSIONS: Inter-eye asymmetry is larger in keratoconus than in normal eyes, and it increases with keratoconus severity in the worse eye.

Intra-arterial MR angiography in the iliac system: initial clinical experience with 25 patients.

The aim of this study was to evaluate intra-arterial magnetic resonance angiography (MRA) of the iliac arteries. Therefore, 25 consecutive patients (17 male, 8 female) suffering from symptomatic occlusive disease of the lower limbs were investigated prospectively. Catheter angiography was performed before MRA and served as the standard of reference. Contrast-enhanced intra-arterial MRA was performed using a 1.5 Tesla MRI system. Contrast agent (gadodiamide) was injected by a conventional pigtail-shaped angiography catheter placed in the abdominal aorta. Vascular lesions were assessed by four investigators. The degree of stenosis was compared with the findings of conventional catheter angiography. Additionally, the diagnostic quality of the MR angiograms was assessed by the investigators using a semi quantitative five-point scale. All lesions shown by catheter angiography were detected and correctly localized by intra-arterial MRA. MR angiograms exhibit a specificity of 95% and a sensitivity of 96% for stenoses of 50% or more. The diagnostic quality of the images was judged from good to excellent, on average. Intra-arterial MRA exhibits a specificity and sensitivity comparable with intravenous angiography. The image quality appears to be adequate for supporting MR-guided vascular intervention.

Vascularization of liver tumors - preliminary results with Coded Harmonic Angio (CHA), phase inversion imaging, 3D power Doppler and contrast medium-enhanced B-flow with second generation contrast agent (Optison).

PURPOSE: To investigate the dynamic value of contrast medium-enhanced ultrasonography with Optison for appraisal of the vascularization of hepatic tumors using harmonic imaging, 3D-/power Doppler and B-flow. MATERIALS/METHODS: 60 patients with a mean age of 56 years (range 35-76 years) with 93 liver tumors, including histopathologically proven hepatocellular carcinoma (HCC) [15 cases with 20 lesions], liver metastases of colorectal tumors [17 cases with 33 lesions], metastases of breast cancer [10 cases with 21 lesions] and hemangiomas [10 cases with 19 lesions] were prospectively investigated by means of multislice CT as well as native and contrast medium-enhanced ultrasound using a multifrequency transducer (2.5-4 MHz, Logig 9, GE). B scan was performed with additional color and power Doppler, followed by a bolus injection of 0.5 ml Optison. Tumor vascularization was evaluated with coded harmonic angio (CHA), pulse inversion imaging with power Doppler, 3D power Doppler and in the late phase (>5 min) with B-flow. In 15 cases with HCC, i.a. DSA was performed in addition. The results were also correlated with MRT and histological findings. RESULTS: Compared to spiral-CT/MRT, only 72/93 (77%) of the lesions could be detected in the B scan, 75/93 (81%) with CHA and 93/93 (100%) in the pulse inversion mode. Tumor vascularization was detectable in 43/93 (46%) of lesions with native power Doppler, in 75/93 (81%) of lesions after administering contrast medium in the CHA mode, in 81/93 (87%) of lesions in the pulse inversion mode with power Doppler and in 77/93 (83%) of lesions with contrast-enhanced B-flow. Early arterial and capillary perfusion was best detected with CHA, particularly in 20/20 (100%) of the HCC lesions, allowing a 3D reconstruction. 3D power Doppler was especially useful in investigating the tumor margins. Up to 20 min after contrast medium injection, B-flow was capable of detecting increased metastatic tumor vascularization in 42/54 (78%) of cases and intratumoral perfusion in 17/20 (85%) of HCC cases. All 19 hemangiomas were correctly classified by phase inversion imaging. CONCLUSIONS: Contrast medium-enhanced ultrasound investigation of liver tumors with Optison allowed reliable detection of tumor foci and, in most cases, appraisal of tumor vascularization. The time available for evaluation of tumor margin vascularization was substantially longer in B-flow.

Magnetic resonance monitoring of stent deployment: in vitro evaluation of different stent designs and stent delivery systems.

RATIONALE AND OBJECTIVES: To evaluate MR imaging features of commercially available stents before, during, and after in vitro deployment as a step toward MR-guided stent deployment. METHODS: Fourteen stents were deployed in a phantom under MR monitoring at 1.5 T by using a gradient-echo sequence. Device visibility was rated on a four-point scale (excellent, fair, poor, not visible). RESULTS: The Memotherm stent and the rolling membrane (RM) Wallstent showed excellent stent visibility and at least fair scores for artifact-induced narrowing of the stent lumen. Three stents (Palmaz, AVE, Easy Wallstent) showed excellent visibility of the stent but no visible lumen. Five stents (Strecker, Accuflex, Hemobahn, Passager, Sinus) displayed fair visibility. The delivery catheters of four stent systems (Smart, Vascucoil, Symphony, ZA) displayed severe black hole artifacts. CONCLUSIONS: The imaging features of several stent systems might be suitable for MR-guided intervention. The Memotherm and the Wallstent RM combine good visibility of the stent and the lumen.

Quantification of blood flow in the carotid arteries: comparison of Doppler ultrasound and three different phase-contrast magnetic resonance imaging sequences.

RATIONALE AND OBJECTIVES: To compare blood flow velocities in the carotid arteries measured with three different magnetic resonance (MR) phase-contrast imaging techniques and with percutaneous Doppler ultrasound. METHODS: Fourteen healthy male volunteers with a mean age of 33 +/- 3.8 years were studied. Ultrasound and MR phase velocity mapping of both common carotid arteries (n = 28) was performed within 5 hours. A two-dimensional fast low-angle shot sequence with retrospective cardiac gating, a sequence with prospective cardiac triggering, and a breath-hold sequence with prospective cardiac triggering were used. Resistance indexes and pulsatility indexes were calculated for all modalities. RESULTS: The comparison of flow velocities obtained with ultrasound and the different MR techniques led to a moderate correlation of the retrospective gated and prospective triggered MR techniques (eg, r = 0.73 for maximum systolic velocity). The worst correlation was found between the breath-hold technique and retrospective cardiac gating (eg, r = 0.004 for pulsatility index). There was a weak correlation of all three MR sequences compared with ultrasound (r = 0.19-0.60) CONCLUSIONS: A moderate correlation was found between velocities and indexes measured with the prospective cardiac-triggered phase-contrast MR technique and the retrospective cardiac-gated phase-contrast MR technique. A weak correlation was found between the three different MR techniques and ultrasound, as well as between the breath-hold prospective cardiac-triggered MR sequence and both of the other MR sequences. The influence of temporal and spatial resolution on MR phase-contrast velocity mapping was confirmed.

Appearance of vascular stents in computed tomographic angiography: in vitro examination of 14 different stent types.

RATIONALE AND OBJECTIVES: To evaluate the appearance of the vessel lumen after implantation of different vascular stents with the use of a computed tomographic (CT) angiography model. METHODS: A vascular phantom was studied with helical CT and different slice thicknesses (2 and 3 mm) and pitch values (1.0, 1.5, and 2.0). Original transverse CT images and coronal reformations were evaluated. Fourteen different stents were analyzed with regard to changes in the stent lumen (attenuation values, noise, and artificial lumen narrowing). RESULTS: Some stents caused artifacts resulting in potential errors during evaluation of their patency. Assessment of the lumen was impaired in two stents (Strecker tantalum and Passager). Increased attenuation values were measured in all stents (increase of 8%-145%). The degree of artificial lumen narrowing was 4.4% to 77.8%. CONCLUSIONS: In most stents, reliable evaluation of the stent lumen seems possible. However, knowledge of the artifacts caused by different stent types is useful for the assessment of stent patency with CT angiography.

Evaluation of arterial bypass grafts of the pelvic and lower extremities with gadolinium-enhanced magnetic resonance angiography: comparison with digital subtraction angiography.

RATIONALE AND OBJECTIVES: The aim of this study was to compare contrast-enhanced magnetic resonance angiography (CE MRA) with digital subtraction angiography (DSA) in the assessment of patency and stenoses in bypass grafts. METHODS: Fifteen patients were examined with both CE MRA and DSA. Fifteen bypass grafts were evaluated by four readers for potential stenosis in five locations. The stenoses were classified in five types: 1 (0% to 24% stenosis), 2 (25% to 49%), 3 (50% to 74%), 4 (75% to 99%), and 5 (occlusion). RESULTS: Using both techniques, 70 of 75 evaluated locations (93.3%) were classified identically. This included six stenoses < 50% and six stenoses > 50%, respectively. Four of five overestimations of stenoses were scaled in DSA as stenoses type 1. One stenosis was categorized as type 3 in DSA. Sensitivity for CE MRA for detecting stenoses >or= 25% was 100% and the specificity 90%. Interobserver agreement for all evaluations was 0.77 (Spearman rank correlation test). CONCLUSION: In the assessment of low-grade stenosis in bypass grafts, CE MRA overestimates stenoses slightly but yields good results in comparison with DSA.

Spinal metastases from renal cell carcinoma: effect of preoperative particle embolization on intraoperative blood loss.

BACKGROUND AND PURPOSE: Surgical repair of spinal metastases from renal origin is often complicated by excessive bleeding. The purpose of this study was to assess the effect of preoperative particulate embolization on intraoperative blood loss. METHODS: Twenty spinal metastases from renal origin (17 patients) treated by preoperative embolization with polyvinyl alcohol particles were analyzed retrospectively. Surgical decompression was performed within 2 days after embolization. A control group of 10 patients with 11 spinal metastases of renal origin underwent surgery without embolization. The effect of preoperative embolization, of completeness of embolization, and of particle size on the estimated intraoperative blood loss was analyzed using nonparametric statistical tests. RESULTS: Complete embolization was achieved in 10 cases and partial embolization in the other 10. The estimated blood loss of 19 embolized and 11 control cases was available from the surgical report. Median intraoperative blood loss in 19 embolized lesions was 1500 mL (range, 300-8000 mL), compared with 5000 mL (range, 1440-15000 mL) in the control group. Even after partial embolization, blood loss (median, 2000 mL) was significantly lower than in the control group. No significant differences in estimated blood loss were noted between the use of particles smaller than 250 microm and those larger than 250 microm. No embolization-related permanent neurologic deficit or skin or muscle necrosis occurred. CONCLUSION: Preoperative embolization of spinal metastases of renal origin with polyvinyl alcohol particles is safe and might reduce intraoperative blood loss significantly. Even partial embolization seems to be effective.

Comparison of two-dimensional gradient echo, turbo spin echo and two-dimensional turbo gradient spin echo sequences in MRI of the cervical spinal cord anatomy.

The aim of this study was to assess the detectability and distinguishability of the cervical spinal cord, the anterior and posterior spinal roots and of the internal anatomy of the cord (distinction of grey and white matter). For this purpose 20 healthy volunteers were examined using a 1.5 T MR unit with 20 mT/m gradient strength and a dedicated circular polarized neck array coil. Three T2* weighted (w). 2D gradient echo sequences, two T2 w. 2D turbo spin echo (TSE) sequences and one T2 w. 2D turbo gradient spin echo (TGSE) sequence were compared. The multiecho 2D fast low angle shot (FLASH) sequence with magnetization transfer saturation pulse (me FLASH+MTS) yielded the best results for liquor/compact bone, liquor/spinal cord and grey/white matter contrast, as found with regions of interest (ROI) analysis. The single echo 2D FLASH sequence was significantly poorer than the two me FLASH+/-MTS sequences. Two-dimensional TGSE as well as 2D TSE with a 256 matrix and with a 512 matrix yielded the poorest results. In the visual analysis the contrast between liquor and compact bone, liquor and cord as well as liquor and roots was best with me FLASH+MTS, whereas grey/white matter distinction was best using me FLASH-MTS. In conclusion, we would therefore recommend the inclusion of an axial T2* w. multiecho 2D spoiled gradient echo sequence with magnetization transfer saturation pulse and gradient motion rephasing in a MR imaging protocol of the cervical spine.

[CT-guided thoracal sympathicolysis for the treatment of peripheral arterial occlusive disease and chronic thoracal pain syndromes in 6 patients]. / CT-gesteuerte thorakale Sympathikolyse zur Behandlung der peripheren arteriellen Verschlusskrankheit und thorakaler Schmerzen in 6 Fällen.

UNLABELLED: CT-guided thoracal sympathicolysis for the treatment of peripheral arterial occlusive disease and chronic thoracal pain syndromes in 6 patients. PURPOSE: Retrospective evaluation of the safety and effectivity of CT-guided percutaneous thoracal sympathicolysis (CT-TSL) in the treatment of patients with peripheral arterial occlusive disease (PAOD) of the upper limb and chronic thoracal pain syndromes. Comparison of our own experience with literature reports. MATERIAL AND METHODS: Between 6/96 and 12/99, 4 patients with PAOD of the upper limb and two with chronic thoracal pain syndromes caused by herpes zoster were treated by unilateral CT-TSL. RESULTS: 18, 21 and 32 months after the intervention 3 out of 4 patients treated for PAOD reported subjective improvements, and one remained unchanged. Two patients treated for pain syndromes showed no long-term benefit of the procedure. There were no serious complications. CONCLUSION: The CT-TSL is an alternative method in the treatment of PAOD in patients who are unsuitable for treatment by revascularization.

[Radiologic implantation of central venous portal systems in the forearm]. / Radiologische Implantation zentralvenöser Portsysteme am Unterarm.

PURPOSE: To assess the safety and effectiveness of fluoroscopic guided brachial implanted central-venous miniport systems. PATIENTS AND METHODS: In 32 oncological patients a central-venous miniport system (Vital-Port, CPC-Cook) was implanted in the forearm. The group included 15 women and 17 men (range 33-78, mean 56 years). RESULTS: Technical success was 100%, in 6 patients vasospasm produced difficulties in catheter placement. In a total of 2878 patients days (range 3-445, mean 90 days) 5 complications occurred (15.6%, 1.7 on 1,000 catheterdays): In one patient (3.13%, 0.35/ 1000 d) the system was changed due to leakage of the catheter near the chamber. Four patients had minor complications: in one case excision of a suture line granuloma was necessary, one haematoma at the site of the chamber was treated with dressing, one patient had a wound dehiscence and one occluded catheter returned to patency by flushing the system with contrast material. Venous thrombosis, phlebitis, catheter dislocation, paravasation or system-related infection did not occur. CONCLUSION: Fluoroscopic guided peripheral central-venous port implantation is a safe and easy procedure with a high success rate and a low complication rate which can be performed in an outpatient setting.

[Cost analysis of radiological interventional procedures and reimbursement within a clinic]. / Innerbetriebliche Leistungsverrechnung am Beispiel radiologischer Interventionen.

PURPOSE: Analysis of costs for vascular radiological interventions on a per patient basis and comparison with reimbursement based on GOA (Gebührenordnung für Arzte) and DKG-NT (Deutsche Krankenhausgesellschaft-Nebenkostentarif). MATERIAL AND METHODS: The ten procedures most frequently performed within 12 months were evaluated. Personnel costs were derived from precice costs per hour and estimated procedure time for each intervention. Costs for medical devices were included. Reimbursement based on GOA was calculated using the official conversion factor of 0.114 DM for each specific relative value unit and a multiplication factor of 1.0. The corresponding conversion factor for DKG-NT, determined by the DKG, was 0.168 DM. RESULTS: A total of 832 interventional procedures were included. Marked differences between calculated costs and reimbursement rates were found. Regarding the ten most frequently performed procedures, there was a deficit of 1.06 million DM according GOA data (factor 1.0) and 0.787 million DM according DKG-NT. The percentage of reimbursement was only 34.2 (GOA; factor 1.0) and 51.3 (DKG-NT), respectively. CONCLUSION: Reimbursement of radiological interventional procedures based on GOA and DKG-NT data is of limited value for economic controlling purposes within a hospital.

[Percutaneous therapy of inoperable biliary stenoses and occlusions with a new self-expanding nitinol stent (SMART)]. / Perkutane Therapie inoperabler maligner Stenosen und Verschlüsse der Gallenwege mit einem neu entwickelten selbstexpandierbaren Nitinolstent (SMART).

OBJECTIVE: To evaluate the treatment of malignant biliary stenoses and occlusions using a new stent. METHODS: In a prospective study, 25 patients with malignant obstructive jaundice were treated with SMART(R) stents. The handling and the quality of stent expansion were documented. Stent function was assessed 2 - 4 days after intervention by cholangiography and laboratory tests. A follow-up was performed three months, after stent placement. RESULTS: All lesions were treated successfully, with a total of 35 stents implanted. In 14 patients a further balloon dilatation was performed after stent placement (8 - 10 mm diameter/ 40 - 80 mm length). The mean serum bilirubin level decreased significantly from 11.6 mg/dl to 4.6 mg/dl after intervention (p < 0.05). The follow-up showed a mean serum bilirubin level at 4.0 mg/dl. In 4 cases (16 %) a further intervention (PTCD or stent) was performed. Six patients died due to tumor progression. The stents proved to be patent in 79 % (n = 15) of patients alive at the time of follow-up. CONCLUSIONS: Placement of the SMART stent for the therapy of malignant biliary lesions yields good technical and clinical results.

[Evaluation of a hemostatic device with percutaneous collagen application (VasoSeal) compared to a mechanical compression system (Compressar) after transfemoral catheterization of patients suffering from arterial occlusive disease]. / Evaluation eines Verschlusssystems mit perkutaner Kollageneinbringung (VasoSeal) im Vergleich zu einem mechanischen Kompressionssystem (Compressar) nach Femoralispunktion bei Patienten mit AVK.

PURPOSE: Comparison of the efficacy of VasoSeal and a mechanical compression system (Compressar) for percutaneous hemostasis after femoral arterial catheterization of patients with arterial occlusive disease. MATERIALS AND METHODS: 60 patients underwent either diagnostic angiography or interventional procedures. The level of anticoagulation, blood pressure, and activation clotting time were recorded, and the time to hemostasis after sheath removal was measured. VasoSeal application was considered "successful" if the compression time was less than two minutes. On the subsequent day as well as 4 months later, color coded Doppler ultrasound was performed to register treatment success and potential (late) complications. RESULTS: 57 patients qualified for inclusion in this study. In 21 of the 26 patients who underwent the procedure with the VasoSeal, immediate hemostasis was achieved within 1.75 minutes. In all 31 patients who had the Compressar applied, hemostasis was successful with a mean compression time of 17.4 minutes. Thus, VasoSeal significantly reduced hemostasis time irrespective of anticoagulation status, but it had a much higher incidence of minor local complications (bleeding, hematoma) compared to the control group (34.6 % vs. 5.8 %). The technical success was lower with VasoSeal than with Compressar (81 % vs. 100 %). Both groups had no severe or late complications. CONCLUSION: According to our results, VasoSeal does not provide a suitable alternative compared to the effective, safe and cheap application of Compressar as a hemostatic device.

[Indirect MR-arthrography of the shoulder-value in the detection of SLAP-lesions]. / Indirekte MR-Arthrographie der Schulter-Wertigkeit im Nachweis von SLAP-Läsionen.

PURPOSE: A prospective study to assess the value of indirect magnetic resonance-arthrography (MR-Arthro) in the detection of lesions of the superior labrum (SLAP-lesions). MATERIALS AND METHODS: Unenhanced magnetic resonance imaging (MRI) and indirect MR-Arthro of the shoulder were performed in 35 patients (9 females and 26 males) with a history of acute or chronic shoulder disorder. The images of unenhanced MRI and indirect MR-Arthro were analyzed independently from each other for the occurrence of SLAP-lesions and the findings correlated with the arthroscopic results. For arthroscopy, MRI and MR-Arthro, the SLAP-lesions were categorized based on the classification system of Snyder. RESULTS: SLAP-lesions were diagnosed by arthroscopy in 22 of 35 patients (63 %). 9 of the 22 lesions (41 %) were classified as type 1, 9 (41 %) as type 2, three (13.5 %) as type 3 and one (4.5 %) as type 4. Using unenhanced MRI sensitivity, specificity and accuracy in the detection of SLAP-lesions were calculated to be 73 %, 85 % and 77 %. Indirect MR-Arthro showed a sensitivity of 91 %, a specificity of 85 % and an accuracy of 89 %. Unenhanced MRI revealed correlation to the arthroscopic classification in 9 of 22 cases (41 %) and indirect MR-Arthro in 18 of 22 cases (82 %). CONCLUSION: Indirect MR-Arthro is a non-invasive method which offers excellent sensitivity in the diagnosis of SLAP-lesions. It provides important preoperative informations with regard to the exact location and extent of a tear.