Achalasia-an unnecessary long way to diagnosis.

Although achalasia presents with typical symptoms such as dysphagia, regurgitation, weight loss, and atypical chest pain, the time until first diagnosis often takes years and is frustrating for patients and nevertheless associated with high costs for the healthcare system. A total of 563 patients were interviewed with confirmed diagnosis of achalasia regarding their symptoms leading to diagnosis along with past clinical examinations and treatments. Included were patients who had undergone their medical investigations in Germany. Overall, 527 study subjects were included (male 46%, female 54%, mean age at time of interview 51 ± 14.8 years). Dysphagia was present in 86.7%, regurgitation in 82.9%, atypical chest pain in 79%, and weight loss in 58% of patients before diagnosis. On average, it took 25 months (Interquartile Range (IQR) 9-65) until confirmation of correct diagnosis of achalasia. Though, diagnosis was confirmed significantly quicker (35 months IQR 9-89 vs. 20 months IQR 8-53; p < 0.01) in the past 15 years. The majority (72.1%) was transferred to three or more specialists. Almost each patient underwent at least one esophagogastroduodenoscopy (94.2%) and one radiological assessment (89.3%). However, esophageal manometry was performed in 70.4% of patients only. The severity of symptoms was independent with regard to duration until first diagnosis (Eckardt score 7.14 ± 2.64 within 12 months vs. 7.29 ± 2.61 longer than 12 months; P = 0.544). Fifty-five percent of the patients primarily underwent endoscopic dilatation and 37% a surgical myotomy. Endoscopic dilatation was realized significantly faster compared to esophageal myotomy (1 month IQR 0-4 vs. 3 months IQR 1-11; p < 0.001). Although diagnosis of achalasia was significantly faster in the past 15 years, it still takes almost 2 years until the correct diagnosis of achalasia is confirmed. Alarming is the fact that although esophageal manometry is known as the gold standard to differentiate primary motility disorders, only three out of four patients had undergone this diagnostic pathway during their diagnostic work-up. Better education of medical professionals and broader utilization of highly sensitive diagnostic tools, such as high-resolution manometry, are strictly necessary in order to correctly diagnose affected patients and to offer therapy faster.

[Is the thyroidectomy a surgical standard procedure for therapy of Graves' disease?]. / Stellt die Thyreoidektomie ein Standardverfahren zur Behandlung des Morbus Basedow dar?

Surgery is an important therapeutic option in the treatment of Graves' disease. Nevertheless it is still controversial discussed wether the extent of resection correlates with the rate of surgical complications and the therapeutic success. Therefore we performed a retrospective analysis on 75 surgically treated patients. 58 of these 75 patients were examined after a median interval of 34.2 months. The examination focussed on the appearance of temporary and permanent palsy of the recurrent laryngeal nerve, hypoparathyroidism, recurrences, and on the postoperative course of thyroid-stimulating-hormone-receptor antibody (TSH-ab) titers. Total thyroidectomy has been performed in 51 and bilateral resection with a remnant thyroid volume less than 2 ml each side in 24 patients. We could not confirm a significant difference concerning the postoperative complication rates between both groups. In the bilateral resection group we saw 3 cases of recurrent goitre and a more unfavourable course of TSH-ab titers than in the thyroidectomy group. For these reasons we propose the total thyroidectomy as surgical standard procedure for therapy of Graves' disease.

[Laparoscopic heller cardiomyotomy either combined with a Dor or Toupet procedure in the treatment of achalasia]. / Die laparoskopische Heller-Dor-/Heller-Toupet-Prozedur in der Therapie der Achalasie.

INTRODUCTION: The treatment of achalasia has undergone a dramatic evolution over the past ten years with the introduction of advanced laparoscopic techniques beside the use of balloon dilatation and injections of botulinumtoxin. With the introduction of the laparoscopic Heller cardiomyotomy the question was raised again whether and if so which antireflux measures are meaningful in combination with the cardiomyotomy. PATIENTS AND METHOD: Since 1998, 51 patients underwent laparoscopic cardiomyotomy in the surgical department of the Marienhospital Herne, Ruhr University Bochum. To prevent postoperative gastroesophageal reflux we performed a Dor fundoplication in 13 patients and a Toupet fundoplication in 38 patients. The mean period of observations was 17 months (3-45 months). All patients were evaluated through a symptoms score. 16 patients could be clinically and objectively followed-up. RESULTS: The mean operation time was 170 min. (80-290 min). The intraoperative complications were 8 mucosal disruptions without further morbidity and 1 pneumothorax. Postoperative complications were 1 scarring restenosis and 1 wrap dislocation. Improvement of symptoms was reported in 94.2 % of patients with good or excellent results. In 5.8 % of patients symptoms of reflux were claimed. There was no significant difference in results between Dor- and Toupet-fundoplication. CONCLUSION: Laparoscopic Heller cardiomyotomy with either a Dor or Toupet fundoplication are equivalent with respect to short- and middle-term outcome and efficient procedures with low rate of morbidity and mortality in the treatment of achalasia. A long-term observation period is necessary for determining which type of fundoplication has to be performed particularly regarding restenosis and reflux rate.

[Reduction of radiation exposure for patient and investigator in interventional radiography]. / Reduktion der Strahlenexposition in der interventionellen Angiographie für Patient und Untersucher.

PURPOSE: In a retrospective analysis of vascular interventional procedures, relations between parameters of the examination and radiation exposure of patient and medical personnel are examined. MATERIAL AND METHOD: 1208 vascular interventional procedures are evaluated. Interventional procedures are divided into three groups: percutaneous transluminal angioplasty, implantation of a stent, thrombolysis. RESULTS: Mean values of the radiation dose of patient and radiology personnel are reported for these examinations. The mean value of the radiation dose of the physician was 7 microSv (maximum 24 microSv), that of the patient 1548 cGy.cm2 (maximum 8485 cGy.cm2). CONCLUSION: The quantity of X-rays to the patient may be lowered by using pulsed fluoroscopy and by reducing the number of radiographs. Reduction of the number of radiographs may be achieved by using the last-image hold and the road mapping mode. The operator's dose can be decreased by using additional radiation protection systems like a MAVIG-radiation protection wall. The radiation dose reduction was 61% for the physician and 17% for the patient.

Bilateral, tumorlike diabetic mastopathy-progression and regression of the disease during 5-year follow up.

Diabetic mastopathy is a recently described collection of radiographical and histological features found in dense fibrous masses of the breast in long standing Type I diabetes. We describe the first case of bilateral disease with the alternate progression and regression of the disease over a 5 year period. A 45-year-old woman has been affected of insulin dependent diabetes mellitus (IDDM) for 21 years. She developed palpable mass retromamillar of the right side, indistinguishable radiographically from cancer. The histology showed a diabetic mastopathy (DMP) with B-lymphocytic ductitis and lobulitis, a discrete monocellular vasculitis and a keloid-like fibrosis. After 22 months she developed a suspicious palpable mass contralateral on the left side. The FNAB presented an identical morphology on histology. Additionally 10 months later there were no palpable masses of both mammae. Mammographically no suspect alterations were observed. One year later the clinical and mammographical examination showed similar findings, mentioned before. The pathogenesis is still obscure and includes the hypothesis of extracellular accumulation, secondary to prolonged hyperglycemia in IDDM, production of alternated non-enzymatic glycosylated end products with neoantigen formation, B cell predominant inflammation with autoimmune response against neoantigens and cytokine release secondary to the autoimmune response.

Diagnostic value of 3D CT surface reconstruction in spinal fractures.

Our purpose was to evaluate the diagnostic value of three-dimensional (3 D) CT surface reconstruction in spinal fractures in comparison with axial and reformatted images. A total of 50 patients with different CT-proven spinal fractures were analysed retrospectively. Based on axial scans and reformatted images, the spinal fractures were classified according to several classifications as Magerl for the thoraco-lumbar and lower cervical spine by one radiologist. Another radiologist performed 3 D CT surface reconstructions with the aim of characterizing the different types of spinal fractures. A third radiologist classified the 3 D CT surface reconstruction according to the Magerl classification. The results of the blinded reading process were compared. It was checked to see in which type and subgroup 3 D surface reconstructions were helpful. Readers one and two obtained the same results in the classification. The 3 D surface reconstruction did not yield any additional diagnostic information concerning type A and B injuries. Indeed, the full extent of the fracture could be easier recognized with axial and reformatted images in all cases. In 10 cases of C injuries, the dislocation of parts of vertebrae could be better recognized with the help of 3 D reconstructions. A 3 D CT surface reconstruction is only useful in rotational and shear vertebral injuries (Magerl type C injury).

[Radiologic imaging of MALT lymphoma. (Comparison between stomach roentgen image, computerized tomography and magnetic resonance tomography]. / Radiologische Bildgebung eines MALT-Lymphoms. (Vergleich zwischen Magenröntgen, Computertomographie und Magnetresonanztomographie).

The new classification of primary lymphomas of the stomach according to the MALT concept is very promising in therapy planning and prognostic estimation. This new classification sets strict requirements for imaging diagnostics. Besides endosonography which allows the determination of the infiltration depth in stages E I1 and E I2 in an excellent manner, computed tomography and, possibly, magnetic resonance tomography are indispensible for evaluation of higher stages and of the resectability of a lymphoma. Further MRI examinations are recommended.

[Malignant melanoma of the gallbladder]. / Malignes Melanom der Gallenblase.

A 75 year woman developed a primary malignant melanoma of the gallbladder. The patient presented with abdominal pain in the upper right quadrant typically seen in acute cholecystitis. Neither intravesical concretions nor cholestasis was seen. Ultrasound demonstrated hyperechogenic intraluminal "school of fish" reflections, which are typical for metastatic melanoma to the gallbladder. Intravesical fluid collection was not present. The tumor did not expand past the wall of the gallbladder. The main sonographic features are hyperdense intraluminal strands of tumor and the lack of fluid. Computed tomography showed solid intraluminal masses with hypodensive and partially hyperdensive reticular structure.

Development and validation of a bioanalytical method for the quantification of diltiazem and desacetyldiltiazem in plasma by capillary zone electrophoresis.

A CZE method for the quantification of diltiazem and desacetyldiltiazem in plasma was developed and validated. Separation was accomplished at pH 2.5 in a 0.044 M phosphate buffer. Sample preparation was performed by liquid-liquid extraction and no interferences with plasma compounds were detected. The calibration graph is linear over the range 5-250 ng/ml with verapamil as internal standard. The precision and accuracy are better than 13% at 5 ng/ml, and better than 10% between 10 and 250 ng/ml. The long-term reliability of the CZE system was checked over a 3-month period. The CZE method is a useful alternative to the already established HPLC method.

[First experiences with electron beam computed tomography of the heart:comparison with heart catheterization and echocardiographic findings]. / Erste Erfahrungen bei Elektronenstrahl-CT-Untersuchungen des Herzens--ein Vergleich zu Herzkatheter und echokardiographischen Daten.

AIM: To evaluate the diagnostic value of ultrafast CT in comparison to established methods in cardiology. MATERIAL AND METHODS: Cine and flow studies were performed in 30 patients with cardiac diseases on evolution CT. Cardiac structure and function were analysed visually and quantitatively (left ventricular ejection fraction, left ventricular myocardial mass, patency of coronary arteries, perfusion of left ventricular myocardium). The CT findings were compared with echocardiographic and angiographic findings. RESULTS: Cardiac structure, functional parameters and disorders of myocardial contraction were clearly detectable by ultrafast CT, which proved inferior in assessing cardiac valves. The patency of the first and second third of normal main coronary arteries could be estimated correctly. The estimation of the distal third, of obstructed coronary arteries and of the role of collaterals was impossible. Ten of 16 areas of myocardial infarction showed low or no enhancement. CONCLUSIONS: Ultrafast CT excellently reflects cardiac structure and function. It is an alternative to echocardiography. In view of the results of coronary artery patency one can hope that part of cardiac catheterisation would be avoidable in future.

[The value of computed tomography in persistent balance disorders following the use of stapes prostheses]. / Stellenwert der Computertomographie bei persistierenden Gleichgewichtsstörungen nach dem Einsatz von Stapesplastiken.

10 of 150 patients had persistent vertigo after implantation of stapes prostheses. These patients were evaluated by high-resolution CT in the axial and coronal plane. Scans showed in all cases findings which related to the symptoms. The CT findings were proved intraoperatively in 9 cases. A new indirect sign of a perilymphatic fistula is described in form of an air bulla at the end of the prosthesis. Retympanotomy could be planned better with the help of HR-CT.

[Detection of coronary calcification by ultrafast CT compared with coronary angiography]. / Koronarkalksuche am Ultrafast-CT im Vergleich zur Koronarangiographie.

The angiographical findings of 24 patients with coronary artery disease were compared with qualitative and quantitative detection of coronary calcification by ultrafast CT. Doubts concerning the capabilities of the ultrafast CT for a screening of coronary artery disease arise when the results of one third false positive and false negative findings are considered. Variations in the quantification of coronary calcification were too great to allow a realistic assessment of the degree of stenosis of the coronary arteries.

[Osseous variations in the coronary CT of the paranasal sinuses]. / Knöcherne Variationen im koronaren Nasennebenhöhlen-CT.

Bony variations in the anterior ethmoids may, if severe, play an important role in the development of chronic sinusitis and present the surgeon with added risks during operation. We have, therefore, analysed 390 preoperative CT examinations of the sinuses performed in the coronary plane with respect to the frequency of bone variations. Concha bullosa, increased pneumatisation of the agger nasi, large ethmoidal bullae, Haller's cells and increased pneumatization of the sphenoid were found with equal frequency in about 20%. The most common variants occurred in the uncinate process (31.5%), less common were paradoxical curve of the middle turbinates (13.3%) and very rare were Onodi cells (1.3%).

[CT-Sellink--a new method of evaluating the intestinal wall]. / CT-Sellink--eine neue Methode der Darmwandbeurteilung.

34 patients were examined by CT following a modified enema (CT-Sellink) in order to demonstrate the gut. By introducing a "gut index" it is possible to define the tone of the gut providing its folds remain constant. By means of a radial density profile the gut wall can be defined objectively and in numerical terms. Gut wall thickness in the small bowel averaged 1.2 mm with a density of 51 Hu and gut wall thickness in the colon averaged 2 mm with a density of 59 Hu.

[Diagnosis of diseases of the large salivary glands of the head by ultrasound, sialography and CT-sialography. A comparison of methods]. / Die Diagnostik der Erkrankungen der grossen Kopfspeicheldrüsen durch Sonographie, Sialographie und CT-Sialographie. Ein Methodenvergleich.

In the present study 162 patients with clinically suspected diseases of the major salivary glands were examined via sonography (n = 162), sialography (n = 111) and CT-sialography (n = 49). The reliability of the three radiological procedures was assessed in diagnosing sialoadenitis, sialolithiasis and glandular and extraglandular tumors. Forty-seven patients were examined with all three methods, 64 patients with sonography and sialography, 2 patients with sonography and CT-sialography and 49 patients with only sonography. The results were compared retrospectively with histologically (70%), cytologically (26%) and clinically proven diagnoses. A sialoadenitis was diagnosed via sonography at a sensitivity of 58%. Sialography frequently produced a false diagnosis of "glandular tumor", which resulted in a comparatively lower sensitivity of 54%. This finding contrasted with the experiences of other authors. A glandular tumor was correctly diagnosed by all three methods and had approximately the same sensitivity (sonography 89%, sialograph 91% and CT-sialography 92%). The correct diagnosis of salivary gland tumors was found by sonography and CT-sialography in 76% of cases and by sialography in 83% of cases. CT-sialography was clearly the superior diagnostic method for detecting extraglandular tumors. Sonography proved its worth as the fundamental procedure for special diagnostic testings of the salivary glands. Sialography is necessary for obtaining important additional information, especially in cases with suspect glandular tumors. CT-sialography is indispensable in the diagnosis of tumors, especially if a malignant, extraglandular or medially localized process is suspected.

[Diagnosis and differential diagnosis of portal circulation disorders using serial CT]. / Diagnostik und Differentialdiagnostik portaler Zirkulationsstörungen mittels Serien-CT.

Density-time-series after intravenous injection of a contrast bolus allow a noninvasive evaluation of portal circulation function. Diagnostic accuracy was above 90%. We are reporting the diagnostic capabilities and limitations of CT in portal circulation disorder with special regard to a statistical evaluation of density-time-diagrams of liver and spleen by multivariate discriminant analysis.