[Retroperitoneal extravasation as the primary symptom of a pancreatic carcinoma]. / Retroperitoneale Extravasation als primäres Symptom eines Pankreaskarzinoms.

Adenocarcinoma of the pancreas has a low 5-year survival rate of approximately 5%. Early diagnostics of pancreatic carcinoma during early tumor stages is made difficult by the lack of symptoms. In particular, individuals suffering from carcinomas located within the pancreatic tail are at high risk of a missed diagnosis. The early symptoms are usually nonspecific (e.g., nonspecific upper abdominal complaints, decrease in weight, loss of appetite, and impaired performance) and are characteristic only in carcinomas of the pancreatic head with painless icterus. If the patient complains of low back pain, a severe infiltration with no chance of a complete surgical resection is found in most cases. An adenocarcinoma of the pancreatic tail was diagnosed in this case report based on a large retroperitoneal extravasation missing further symptoms. The extravasation found represented a primary infiltration of the left ureter which was not diagnosed in primary computed tomography.

[Pharmacologic modification of postprandial bile duct kinetics--ultrasound measurement of the lumen of the bile duct]. / Pharmakologische Beeinflussung der postprandialen Gallengangskinetik--Sonographische Lumenmessung des Gallenganges.

UNLABELLED: The physiological correlate of biliary colic is a rapid increase in pressure in the presence of biliary obstruction. The relaxing action of hymecromone on the biliary tract provides a pharmacotherapeutic approach. PURPOSE: Since the symptoms usually occur postprandially, we used ultrasonography to examine whether hymecromone could reverse the contraction of the common bile duct (CBD) after ingestion of a standardised test meal. METHOD: The study was designed as a prospective, double-blind randomised cross-over study versus placebo in 20 healthy volunteers. The width of the CBD was measured ultrasonographically in the fasting subjects and 1, 3, 5, 10, 15 and 20 minutes after ingestion of a test meal. The subjects were then given either 400 mg of hymecromone or placebo i.v. and the measurement series was repeated. RESULTS: After ingestion of the test meal the width of the CBD decreased by a maximum of 20% after 15 minutes. While there was only a slight increase in the width of the CBD after subsequent administration of placebo, a maximum increase of 36% was measured 10 minutes after administration of hymecromone. CONCLUSION: The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone. Sonography proved a suitable tool for examining the physiological changes.

[Necrotizing fasciitis of the lower extremity]. / Die Fasciitis necroticans im Bereich der unteren Extremität.

Three cases of a necrotizing fasciitis, a rare but life- and limb-threatening infection, were treated in the Department of Surgery at the University Hospital of the Ruhr University Bochum (MHH) between October 1992 and January 1994. We compare our experiences with regard to bacteriological etiology, risk factors, localization, and place of entry, course, therapy and mortality with those in the literature.

[Value of mediastinoscopy versus thoracic CT for prediction of mediastinal tumor lymph nodes]. / Stellenwert der Mediastinoskopie versus Thorax-CT zur Vorhersage mediastinaler Tumorlymphknoten.

The value of mediastinoscopic staging in bronchial carcinoma is evaluated controversially. The literature gives a wide range of specificity of CT scans, varying from 30%-100% and 29%-95%, respectively [1, 2, 3]. We have reviewed a consecutive series of 182 patients who underwent a high-resolution mediastinal CT scan followed by mediastinoscopy (MS) because of pulmonary or mediastinal disease. The specificity of CT versus MS revealed 32% versus 100% and the sensitivity 47% versus 74%. Although we have observed complications and a limited histological prediction in the MS within the paratracheal area on the left side, we continue to recommend a standard staging MS, taking this area into careful consideration.

[Surgical management of bone metastases of the lower extremity with AO interlocking nail]. / Zur operativen Versorgung von Skelettmetastasen der unteren Extremität mittels AO-Verriegelungsmarknagel.

Between January 1991 and June 1995 we have operated on 19 patients (9 male, 10 female) with 22 skeletal metastases of the lower limb (19 femora, 3 tibiae) using a static interlocking nail. Closed intramedullary nailing without resection of the metastasis has been established as our standard procedure. We have stabilized 15 patients with advanced osteolysis and seven pathological fractures. Sixteen patients underwent postoperative local radiation therapy with 40 Gy. As intraoperative complications we have observed one fracture of an osteolysis and one death due to fat embolism. Postoperatively there were observed one seroma, one haematoma and one patient with non fatal pulmonary embolism following DVT. Two patients died within the first 30 postoperative days because of tumor progression. All patients surviving longer than 30 days could be mobilized under full weight-bearing. Morphine like analgetics for metastasis related pain were no longer needed. A secondary instability has not been observed within a mean survival time of 199 days (811 longest follow up). Closed intramedullary nailing in combination with postoperative local radiation therapy seems to be an appropriate and technically non demanding procedure to stabilize skeletal metastases of the lower limb in patients with a short or medium-term expectation of life.

[Torsion of the gallbladder--a rare cause of acute cholecystitis]. / Die Torsion der Gallenblase -- eine seltene Ursache der akuten Cholecystitis.

Torsion of the gallbladder with onset of gangrene is a rare condition which is generally due to an abnormal anatomical variation: loss of the fixation of the organ to the inferior margin of the liver with the presence of a long mesocyst. This case shows that ultrasound is able to make the right diagnosis which was so often confirmed not before laparotomy. In the future lethality should be reduced by early operation.

[Pump-assisted intraoperative colon lavage]. / Pumpenassistierte intraoperative Colonlavage.

We report about a time saving method of on-table lavage of the colon. For irrigation a balloon-catheter is inserted into the colon through a small caecotomy. This catheter is connected to an irrigation pump which we usually use for abdominal lavage in peritonitis. After mobilisation the oral end of the later colonic anastomosis is led over the lateral abdominal wall into a plastic tube. Now a continuous irrigation with a controlled flow-rate of 1 l/min is achieved with the aid of the lavage pump. As irrigation liquid we use Ringer's solution. Pressure is limited by an overflow mechanism. In addition after rearrangement the high irrigation flow of the system allows a thorough cleansing of the rectal stump. Between 1992 and 1995 we carried out intra-operative colonic irrigation using the method set out above in 24 patients. The average volume was 8.9 l of Ringer's solution. The irrigation itself lengthened the operation time by an average of 10 min.

[Effect of intestinal ultrasound on choice of surgical procedure in acute abdominal pain]. / Der Einfluss der Darmsonographie auf die chirurgische Verfahrenswahl beim akutem Bauchschmerz.

UNLABELLED: Differential diagnosis in patients with acute abdominal pain represents a difficult assignment in surgery involving the indication for urgent operation and the operation technique. AIM: The value of sonography in diseases of the bowels for correct indication for early laparotomy was investigated. METHOD: In a retrospective analysis we compared the result of sonography on 159 patients with acute abdominal pain with the first clinical assessment. RESULTS: The sensitivity of this technique was found to be 38.9% for acute appendicitis, 57.1% for diverticulitis and 76.9% for obstructive ileus. The specificity ranged above 90% in each case. In consideration of more than two sonomorphological criterias for pathological alterations of the intestines the positive predictive value achieved 100%. CONCLUSION: Low diagnostic sensitivity with high specificity implies the necessity to intensity routine ultrasonic investigation of the gut.

Postprandial bile-duct kinetics under the influence of 4-methylumbelliferone (hymecromone).

The physiological correlate of biliary colic is a rapid increase in pressure in the presence of biliary obstruction. The relaxing action of hymecromone on the biliary tract provides a pharmacotherapeutic approach. As the symptoms usually occur postprandially we used ultrasonography to examine whether hymecromone was able to reverse the contraction of the common bile duct (CBD) after ingestion of a standardized test meal. The study was designed as prospective, double-blind randomized crossover study versus placebo in 20 healthy volunteers. The width of the CBD was measured ultrasonographically in the fasting subjects and at 1, 3, 5, 10, 15 and 20 minutes after ingestion of a test meal. Then the subjects were given either 400 mg of hymecromone or placebo and the measurement series was repeated. After ingestion of the test meal the width of the CBD decreased by a maximum of 20% after 15 minutes. While there was only a slight increase in the width of the CBD after subsequent administration of placebo, a maximum increase of 36% was measured 10 minutes after administration of hymecromone. The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone.

[Baker's cyst in osteoarticular tuberculosis of the knee joint]. / Baker-Zyste bei osteoartikulärer Tuberkulose des Kniegelenkes.

A Baker cyst (synovial cyst) in the right knee-joint was demonstrated by ultrasound in a 70-year-old woman with recurrent knee-joint effusions after minimal trauma to the knee. Radiological examination in two planes showed degenerative changes corresponding to age. Needle puncture of the knee-joint demonstrated numerous neutrophil granulocytes. As the effusion recurred after one week, despite rest and avoidance of weight bearing, arthroscopy with removal of the cyst was indicated. But surprisingly histological examination of synovial tissue revealed epithelioid granulomas and Langerhans giant cells. Culture of fluid obtained on repeat puncture finally grew Mycobacterium tuberculosis. There was no evidence of pulmonary tuberculosis. The knee-joint tuberculosis healed completely without residual damage on antituberculosis treatment, initially 600 mg rifampicin daily, 300 mg isoniazid daily and 2.5 g pyrazinamide daily for 3 months, followed by rifampicin and isoniazid for a further 6 months.

31-P mr spectroscopy of a leg lymphangiosarcoma.

In a 64 year old man with a large, low grade lymphangiosarcoma of the right thigh, we correlated the results of in vivo 31-P-magnetic resonance spectroscopy (MRS), proton magnetic resonance imaging (MRI), and digital subtraction (DSA) with the pathologic specimen and histology. The 31-P MRS spectra of the tumor showed well-resolved peaks as follows: intense PCr (phosphocreatine), PDE (phosphodiester) and Pi (inorganic phosphate), and low PME (phosphomonoester). The Pi peak revealed an intratumor pH of 6.96 compared with 7.16 of normal skeletal muscle. The lower PME signal was consistent with low histopathologic mitotic activity of the tumor.

[Baker's cysts. A follow-up study after surgical therapy]. / Baker-Zysten. Eine Verlaufsbeobachtung nach operativer Therapie.

Baker's cysts have to be regarded as a secondary phenomenon of knee-joint diseases. In the treatment of Baker's cysts, therefore, arthroscopy should be done before extirpation. In our study we wanted to look at the results of this therapeutic concept. In the surgical clinic within the Ruhr University of Bochum 34 patients with Baker's cysts underwent an operation between 1985 and 1992. In 22 patients the main symptom was swelling in the hollow of the knee, while the others reported effusions of the knee joint, pain or restricted joint movement. In 27 cases the diagnosis was made by ultrasound alone; in the others arthrography or NMR tomography was necessary. Arthroscopy was performed in all patients, revealing lesions of the meniscus in 12 cases, rupture of the cruciate ligament in 1, degenerative changes in 15 and chronic polyarthritis in 1. In 5 patients we could not find any pathologic changes. We observed 1 severe postoperative complication in the form of a joint infection. Histological examination of the cysts showed chronic synovialitis in 21 patients and tuberculous arthritis in 1. In 25 of our patients clinical and ultrasound examination were then performed on average of 34 months after their operations. In 4 patients we found recurrence of cysts: 2 of these patients were found to be suffering from chronic knee-joint disease with effusions; 1 had recurrent hydrarthrosis together with chronic renal insufficiency; and the fourth patient had constant knee pain, though the arthroscopy did not show any pathologic changes. In the last case our diagnosis was therefore called in question.(ABSTRACT TRUNCATED AT 250 WORDS)

[Appendicitis in the aged]. / Die Altersappendizitis.

From 1984 to 1989 78 patients over the age of 60 years were operated on acute appendicitis. Compared to appendicitis in younger people these older patients showed 3 times longer an interval between the first appearance of symptoms and their contact to the doctor, or surgical treatment. As result of this longer period appeared the high perforation rate 53.8%. In this group of patients with perforation the complication rate was 4 times higher than the intraoperative and histologically confirmed acute appendicitis. From these facts results a mortality rate of 4%. In the retrospective evaluation was also seen that there was no conclusion between the laboratory parameters, the physical symptoms and the degree of the inflammation of the evidence of perforation with local or diffused peritonitis. The inclusion of appendicitis in the differential diagnosis of acute abdominal pain in older people offers the chance of an earlier surgical treatment, so reducing the risk of postoperative complication and mortality.

Implantation technique and complications of totally implanted arterial access systems for long-term therapy in patients with occlusive vascular disease.

Twenty-six totally implantable catheter systems for intra-arterial infusions were used in patients with peripheral arterial occlusive disease. A total of 606 short-term infusions were administered via the system. The patients were observed up to 22 months. There was an over-all rate of complications in 15.3%. The complications described were: one catheter occlusion, one dislocation, one case of local infection and one case of arterial thrombosis. The latter was successfully treated with local lysis therapy. The system is distinguished from conventional methods of arterial access by its long-term use and the low incidence of complications. The system was extremely well accepted by the patients.

[Fully implantable catheter systems for arterial extremity infusion]. / Vollständig implantierbare Kathetersysteme zur arteriellen Extremitäteninfusion.

Twenty totally implanted arterial access systems for drug administration were used in 19 patients with peripheral arterial disease. A total of 458 short-term infusions were administered through the systems. The observation period was maximally 13 months. Infection occurred in one patient (5%), as well as one catheter occlusion and one arterial thrombosis, which was successfully treated by local thrombolysis. Long period usability with low complication rate distinguishes the system from conventional arterial access. Patient's acceptance was excellent.

[Quantifying mineralization processes in post-traumatic algodystrophy using computerized tomography densitometry]. / Quantifizierung von Mineralisationsprozessen bei posttraumatischer Algodystrophie mittels computertomographischer Densitometrie.

Computed tomography examinations have been made in 12 patients with posttraumatic algodystrophy. Significant differences of sides were found to be a measure of demineralisation by CT densitometry. 7 patients could be repeatedly examined during up to 60 weeks after the trauma. CT-integrated densitometry enables to quantify the process of de- and remineralisation and to objectify the disease according to the spongiosa bone. It seems to be possible to value the process of mineralisation by this method.

[Intra-arterial infusion therapy of progressive diabetic foot gangrene with prostaglandin E1 amd cefotaxime]. / Intraarterielle Infusionstherapie der fortgeschrittenen diabetischen Fussgangrän mit Prostaglandin E1 und Cefotaxim.

15 patients with severe diabetic gangrene were treated with a combined intra-arterial PGE1/Cefotaxime infusion therapy. There was no indication for vascular reconstructive surgery. The average treatment took 24.7 days. 11 of the 15 patients were responsive to the therapy. Nevertheless 5 of these 11 patients had to be amputated below-knee in the further course of treatment. In 6 cases we succeeded in preserving the affected extremity in a state of acceptable use. One patient died during the study. No complications due to the therapy were seen. Considering that all patients were near to amputation when entering the study the result to have saved the extremities in 40% of the cases must be regarded as a success.

Influence of prostaglandin E1 on muscular tissue-PO2 in patients with diabetic gangrene.

Intraarterial infusions of short acting vasoactive drugs have been established in the treatment of peripheral occlusive disease. We studied the effect of prostaglandin E1 on the tissue pO2 of the tibialis ant. muscle. Using a fast responding polarographic pO2-probe of the hypodermic needle type, tip diameter 300 microns, we made tissue pO2 investigations in 9 patients with diabetic gangrene. pO2-measurements were done before, during and after administration of 0.2 microgram PGE1/min i.a.. PGE1 led to a slight decrease of the mean muscular pO2 during application followed by a reincrease after the end of infusion. It is known that intraarterial PGE1 infusion leads to an increase of transcutaneous pO2 of the forefoot. Our results show, that there is no increase of tissue pO2 of the tibialis ant. muscle. The reason might be a changed distribution of blood flow in favour of an increased oxygenation of the skin due to PGE1 administration.