Multidetector computed tomography mesentericography for the diagnosis of obscure gastrointestinal bleeding.

PURPOSE: To evaluate the diagnostic yield of 16-row multidetector computed tomography (CT) mesentericography in patients with obscure gastrointestinal bleeding. MATERIALS AND METHODS: The radiological information system database was used to retrospectively identify all patients in whom CT mesentericography (CTM) was performed for the diagnosis of obscure gastrointestinal bleeding between July 2002 and September 2006. A subsequent prospective study was conducted between October 2006 and September 2009 to evaluate CTM in patients with major obscure gastrointestinal bleeding. The retrospectively identified patients (six patients) as well as the prospectively evaluated patients (seven patients) constitute the study population. Following mesenteric DSA the catheter was left in the superior mesenteric artery, the patient was transferred to the CT suite and CTM was carried out by scanning the abdomen after contrast material injection via the catheter. Active bleeding was suspected if a focal area of high attenuation consistent with contrast material extravasation was found within the bowel lumen. RESULTS: CTM detected the site of active bleeding in three of 13 patients (23 %). In the subpopulation of patients who were prospectively evaluated, CT mesentericography identified the site of active bleeding in one of seven patients (14 %). Depiction of active bleeding by CTM prompted surgical intervention in each case and surgery confirmed the findings of CT mesentericography. CONCLUSION: Due to the relatively low rate of positive findings and inherent drawbacks, we feel that CTM cannot be recommended in general. However, in selected patients who are continuously bleeding at a low rate and in whom iv-CT was negative, CT mesentericography might be helpful.

Characterization of microvascularization of liver tumor lesions with high resolution linear ultrasound and contrast enhanced ultrasound (CEUS) during surgery: First results.

AIM: Evaluation of high resolution linear ultrasound and intra-operative linear contrast enhanced ultrasound (CEUS) and its benefit for the detection and characterization of tumor lesions. MATERIAL AND METHODS: Twenty patients were investigated preoperatively regarding tumor detection using CT (n = 8) or MRI (n = 12) and image fusion (VNav) (n = 3). All patients had surgery for their hepatic tumor (hepatocellular carcinoma (HCC), cholangiocellular carcinoma (CCC), metastasis, and adenoma). Ultrasound was performed intra-operatively first with B-scan using a convex probe. Than multifrequency linear transmitters (6-9 MHz, 6-15 MHz, LOGIQ E9, GE) were applied for B-scan, coulor coded Doppler sonography (CCDS) and Power Doppler followed by dynamic CEUS with Contrast Harmonic Imaging (CHI) after bolus injection of a maximum of 15 mL SonoVue®. RESULTS: In 9 cases with the use of intra-operative CEUS additional tumor lesions (diameter 4-15 mm) could be detected and were histologically confirmed after surgical resection (7 cases) or intra-operative biopsy (2 cases). Using intraoperative CEUS 64 tumor lesions could be detected compared to 51 tumor lesions detected by preoperative CT or MRI (p < 0.05). Using the 6-15 MHz multifrequency linear transducer with CHI, arterial perfusion of adenomas, neuroendocrine metastases and HCC lesions was detectable. In 3 cases a resection was not achievable. Two of these cases were treated with radio frequency ablation (RFA). The other case had no curable option due to multifocal tumor manifestation. CONCLUSION: The intra-operative use of high-resolution linear transducer techniques with CEUS offers new diagnostic perspectives for an effective liver surgery.

Image fusion with volume navigation of contrast enhanced ultrasound (CEUS) with computed tomography (CT) or magnetic resonance imaging (MRI) for post-interventional follow-up after transcatheter arterial chemoembolization (TACE) of hepatocellular carcinomas (HCC): Preliminary results.

AIM: The assessment of the immediate post-interventional microcirculation and perfusion following transcatheter arterial chemoembolization (TACE) with new real time imaging fusion technique (VNav) of computed tomography (CT) or magnetic resonance imaging (MRI) with contrast enhanced ultrasound (CEUS) compared to follow-up. MATERIAL: Following TACE an image fusion of CEUS with CT or MRI of the liver was performed in 20 patients (18 men, 2 women; age 29-75 years) with confirmed hepatocelluar carcinoma (HCC) to evaluate the post-interventional tumor vascularization and perfusion of HCC tumor lesions. Image fusion with CEUS performed immediately was compared with the result at the end of TACE (DSA), with post TACE CT (non-enhanced CT within 24 hours) and with follow up CT (enhanced CT after 6 weeks) after embolization. Ultrasound was performed using a 1-5 MHz multifrequency SonoVue transducer (LOGIQ 9/GE) after a bolus injection of 2-4ml SonoVue® with contrast harmonic imaging (CHI). Thirteen examinations were fused with a contrast enhanced CT, 7 with a MRI performed before TACE. RESULTS: The post-interventional volume navigation image fusion of CT or MRI with CEUS showed differences regarding the residual tumor perfusion compared to other modalities. The correlation (Spearman-test) between the perfusion result at the end of TACE, non-enhanced CT after TACE and image fusion with CEUS was 0.42 and 0.50. The difference between the result at the end of TACE and the fusion with CEUS was significant (p < 0.05, Wilcoxon-test). The correlation between fusion of CEUS with CT/MRI and follow-up CT (after 6 weeks) was 0.64, the difference was not significant (p > 0.05). The differences between native CT within 24 hours after TACE and follow up CT after 6 weeks or fusion of CEUS and CT/MRI were significant (p < 0.05). The inter-observer variability was 0.61 at the end of TACE, 0.58 at non-enhanced CT (within 24 hours), 0.87 at fusion CEUS with CT/MRI and 0.74 at follow up CT after 6 weeks (Cohens Kappa test). CONCLUSION: Image fusion with volume navigation (VNav) of CEUS with CT or MRI allows an accurate localisation of foci in patients with HCC. This exact mapping permits an easier control and evaluation of the results after TACE. The fusion of CEUS and CT or MRI allows a better evaluation of the microcirculation and the residual tumor perfusion at an earlier point of time than usual modalities of therapy control like non-enhanced CT. This might lead to a more differentiated monitoring of therapy.

MRI enterography: the future of small bowel diagnostics?

MRI plays an increasing role in small bowel imaging of Crohn's disease. MR enterography (MRE) without nasojejunal intubation and radiation exposure offers similar results compared to MR enteroclysis (with intubation) and should be therefore the preferred method. Sensitivity and specificity is comparable to that of CT enterography. Capsule endoscopy is obviously superior to MRE in detecting superficial lesions, but this is limited to the mucosa and stenosis has to be excluded before examination using imaging, like MRE. There are no convincing studies in the literature regarding assessment of disease activity with imaging. Moreover, there is no consensus in the literature about a suitable reference standard.

Primary percutaneous aspiration and thrombolysis for the treatment of acute embolic superior mesenteric artery occlusion.

OBJECTIVES: To evaluate technical success rate and clinical outcome of patients with acute embolic superior mesenteric artery (SMA) occlusion who were treated with primary percutaneous revascularization. METHODS: At three medical centers the radiological information system databases were used to identify all patients in whom primary percutaneous revascularization for the treatment of acute embolic SMA occlusion was attempted between 2001 and 2010. Percutaneous treatment was performed in 15 patients (median age 80 years, range 49-88 years). These patients represent the study population. Eleven patients reported abdominal pain. Five patients exhibited peritoneal signs. Revascularization was defined as complete technical success if (1) patency of the SMA with residual stenosis of not more than 30% in diameter and (2) sufficient perfusion of the entire bowel were obtained. RESULTS: Complete technical success was achieved in eleven patients. After percutaneous revascularization laparotomy was performed in six patients and in three of them bowel resection was carried out (length of resected segments 20-80 cm). The 30-day mortality was 33% (five of 15 patients). None of the surviving patients exhibited short-bowel syndrome. CONCLUSIONS: Primary percutaneous aspiration and thrombolysis constitutes a promising alternative to surgical revascularization in selected patients with acute embolic SMA occlusion.

[Cost analysis of contrast-enhanced cranial MRI at a German university hospital]. / Kostenanalyse einer kontrastgestützten MRT des Schädels an einem Universitätsklinikum.

PURPOSE: Detailed evaluation and cost analysis of a cranial contrast-enhanced MRI (c-ceMRI) in outpatients, inpatients, patients in an intensive care unit and children under anesthesia. MATERIALS AND METHODS: Based on a detailed process-oriented model, we calculated the cost of a cranial MRI for the four situations mentioned above. A comprehensive evaluation of the overhead and personnel costs was performed. RESULTS: We performed 5108 MRI examinations on 2 scanners in the year 2008. 2150 examinations (42 %) were identified as c-ceMRI. For inpatients we calculated a total cost of € 242.46 per examination with a personnel cost of € 81.71 for the radiological department. In outpatients we calculated total costs of € 181.97 with radiological personnel costs of € 68.67. Patients coming from an intensive care unit were treated by an intensive care team, which resulted in total costs of € 416.58 with € 283 in costs for radiological personnel (32.8 %). MRI examinations of children under anesthesia resulted in costs of € 616.79 for the hospital, of which € 285.78 were radiological personnel costs (34.5 %). CONCLUSION: In this study we evaluated for the first time different radiological scenarios of a c-ceMRI at a university hospital. Considering the present reimbursement situation, all outpatients covered by statutory health insurance resulted in a deficit for the hospital. Particularly high costs for patients in intensive care units as well as for children under anesthesia have to be taken into account and are currently not adequately covered by care providers.

Sono-hepatic-arteriography (Sono-HA) in the assessment of hepatocellular carcinoma in patients undergoing transcatheter arterial chemoembolization (TACE).

PURPOSE: The aim of our study was to evaluate sono-hepatic-arteriography in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization. MATERIALS AND METHODS: We evaluated 15 patients with hepatocellular carcinoma undergoing TACE who presented in our institution from February 2006 to May 2008. All patients underwent a conventional B-mode ultrasound examination using a high-end machine and a multi-frequency transducer (2.5 - 4 MHz) before dynamic contrast-enhanced ultrasound examination was carried out. For the sono-hepatic-arteriography 1 ml SonoVue was injected as a bolus using the formerly placed intraarterial catheter. Biphasic enhanced computed tomography was performed using a 16-slice CT scanner up to 48 hours before transcatheter arterial chemoembolization and during follow-up. RESULTS: The lesion size (of the largest lesion) ranged from 1 to 13 centimeters in their largest diameter (mean: 4.8 cm). Contrast-enhanced ultrasound diagnosed more lesions than B-mode sonography in eight cases and more lesions than computed tomography in 5 patients. The findings of sono-hepatic-arteriography were correct in fourteen cases (93.3 %). Direct impact on patient management was seen in eleven patients (73.3 %). CONCLUSION: We were able to show that the application of an intraarterial sonographic contrast agent during embolization is able to diagnose new lesions on the one hand and to assess the embolization success on the other. This might improve transcatheter arterial chemoembolization results and patient outcome.

[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.

Semiquantitative characterization of hepatocellular carcinoma (HCC)--perfusion with contrast-enhanced ultrasound and perfusion analysis.

BACKGROUND: At the moment, there is only poor specificity of HCC-detection in tumors smaller than 2 cm in a cirrhotic liver. Thus, efforts have to be made to optimize the distinction between regenerative nodules and HCC. AIMS: The aim of our study was to describe the particular perfusion pattern of hepatocellular carcinoma using a specific quantification software. METHODS: We evaluated 25 patients with proven hepatocellular carcinoma, who underwent dynamic contrast-enhanced ultrasound (CEUS) using a second generation contrast agent (SonoVue, Bracco, Germany). Retrospectively, we applied the quantification software Qontrast (Bracco, Milan, Italy) to obtain contrast-enhanced sonographic perfusion maps for each lesion. RESULTS: We found a close positive correlation of the perfusion parameters peak, time-to-peak and regional blood volume between the entire tumors, the center (center/total) and the periphery of the tumors (periphery/total), respectively. Moreover, we found significant higher peak values, a significant higher regional blood volume and a trend to lower time-to-peak in the center of the tumors compared to the tumor periphery. CONCLUSION: These results suggest a better established vascular bed in the center of the tumors. This could be a sonographic marker of HCC in contrast to regenerative nodules.

BLADE in sagittal T2-weighted MR imaging of the cervical spine.

BACKGROUND AND PURPOSE: Image quality and diagnostic reliability of T2-weighted MR images of the cervical spine are often impaired by several kinds of artifacts, even in cooperative patients. The aim of this study was to evaluate if BLADE sequences might solve these problems in a routine patient collective. MATERIALS AND METHODS: TSE and BLADE sequences were compared in 60 patients for T2-weighted sagittal imaging of the cervical spine. Image sharpness, motion artifacts, truncation artifacts, metal artifacts, CSF flow phenomena, contrast of anatomic structures (vertebral body/disk, spinal cord/CSF), and diagnostic reliability of spinal cord depiction were evaluated by 2 independent readers. Another 2 readers selected the sequence they would prefer for diagnostic purposes. Statistical evaluations were performed by using the Wilcoxon and the chi(2) test; differences with P < .05 were regarded as statistically significant. RESULTS: BLADE was significantly superior to TSE regarding image sharpness, image contrast, diagnostic reliability of spinal cord depiction, motion artifacts, CSF flow phenomena, and truncation artifacts; for metal artifacts no significant improvements were found. In 50 of 60 patients, BLADE was preferred for diagnostic purposes, and TSE was favored in 3 patients. The number of examinations that were nondiagnostic due to impaired spinal cord depiction was reduced from 12 in TSE to 3 in BLADE, and nondiagnostic examinations due to overall motion artifacts were reduced from 2 to 1. CONCLUSIONS: Using the BLADE sequence for sagittal T2-weighted imaging of the cervical spine proved to be advantageous to reduce various kinds of artifacts.

Detection and characterization of endoleaks following endovascular treatment of abdominal aortic aneurysms using contrast harmonic imaging (CHI) with quantitative perfusion analysis (TIC) compared to CT angiography (CTA).

PURPOSE: To show the feasibility of the detection of endoleaks following endovascular treatment of aortic aneurysms using contrast harmonic imaging (CHI) in comparison to computed tomography angiography (CTA). MATERIALS AND METHODS: 51 patients with suspected endoleaks, who underwent previous endovascular treatment for abdominal aortic aneurysm, were examined using CTA and vascular ultrasound. Biphasic CTA in all cases and digital subtraction angiography (DSA) in 8 patients were evaluated by two radiologists in consensus and served as the standard of reference. Ultrasound was performed by an experienced examiner with a multi-frequency linear transducer (2 - 4 MHz) using CHI following bolus injection of 2.4 ml of SonoVue® IV (maximum 5 ml). All images were evaluated by two observers in consensus regarding the reperfusion of the abdominal aneurysm using time intensity curve (TIC) analysis. RESULTS: In 30 of 51 patients, endoleaks were detected concordantly in CHI and CTA. In 20 of 51 patients, no endoleak was found in CHI and CTA/DSA. In one patient, a type II endoleak could initially only be detected in CHI and was later confirmed in follow-up examinations by CTA (sens. 99%, spec. 93%, NPV 99 %, PPV 95%). TIC analysis allowed evaluation of the perfusion dynamics of endoleaks in all patients. Significant differences were found (p < 0.05, Mann Whitney U Test) regarding the perfusion within the aneurysm when an endoleak was present (10.39 ± 4.29 dB) or not present (6.42 ± 2.86 dB). CONCLUSION: CHI with perfusion analysis allows definite detection of endoleaks, especially if contraindications for CTA are present. CHI presents an alternative for follow-up monitoring.

[Radiological placement of peripheral central venous access ports at the forearm. Technical results and long term outcome in 391 patients]. / Radiologische Implantation zentralvenöser Portsysteme am Unterarm. Implantationsergebnisse und Langzeit-Follow-up bei 391 Patienten.

PURPOSE: To retrospectively analyze the technical result and long term outcome of central venous arm ports placed by radiologists. MATERIALS AND METHOD: Over a 5-year period, 399 arm ports were implanted by radiologists in 391 patients. The system consists of a low profile titanium chamber and a silicone catheter. Ports were placed at the forearm after puncture of a vein proximally to the elbow under fluoroscopic guidance. In a retrospective analysis the technical results and the long term outcome were evaluated. Complications were documented according to the standards of the society of interventional radiology. RESULTS: In 391 patients a total of 98 633 catheter days were documented (1 - 1325 days, mean 252 days). Primary technical success was 99.25 % (396 / 399) with a 100 % secondary technical success rate. No severe procedural complications, e. g. pneumothorax or severe hemorrhage, were found. A total of 45 complications occurred (11.28 %, 0.45 / 1000 catheter days), including 8 portal pocket infections (27 - 205 days, mean 115 days). Fifteen ports were explanted because of complications. The complication rate corresponds to the data from subclavian ports and is less than the complication rates published in large surgical trials. CONCLUSION: Implantation of central-venous arm ports by radiologists is safe and minimally invasive. No severe immediate procedural complications occur due to the peripheral implantation site. Long term complication rates are comparable to other studies of radiological or surgical port implantation at different sites.

Severe acute pancreatitis requiring drainage therapy: findings on computed tomography as predictor of patient outcome.

BACKGROUND/AIMS: To evaluate whether morphologic features on computed tomography (CT) correlate with outcome of patients with severe acute pancreatitis (SAP). METHODS: 80 patients with SAP requiring percutaneous drainage therapy were retrospectively analyzed. Twelve CT features beyond the CT severity index (CTSI) were studied. Endpoints for patient outcome were patient death, length of hospital and ICU stay. The twelve features and the CTSI score were correlated with mortality using Kaplan-Meier estimator and correlated with length of hospital and ICU stay using the χ(2) test. A p value ≤0.05 was considered statistically significant. RESULTS: Two CT features exhibited a significant correlation with mortality: (1) the number of parts of pancreas (head, corpus, tail) that exhibited areas of necrosis and (2) the presence of distant fluid collections (posterior pararenal space and/or paracolic gutter). Mortality was 42% (21 of 50 patients) and 20% (6 of 30 patients) if two/all three parts or none/one part of the pancreas exhibited necrosis, respectively. Mortality was 46% (18 of 39 patients) and 22% (9 of 41 patients) if distant fluid collections were present or absent, respectively. All other imaging features including the CTSI showed no significant correlation with patient outcome. CONCLUSION: We identified two morphologic features on CT that might be helpful to predict prognosis of patients suffering from SAP. and IAP.

Evaluation of malignant liver tumors: biphasic MS-CT versus quantitative contrast harmonic imaging ultrasound.

PURPOSE: It was the aim of our study to establish the extent to which contrast enhancement with SonoVue(R) in combination with quantitative evaluation of contrast-medium dynamics facilitates the detection of malignant hepatic tumors. MATERIALS AND METHODS: One hundred patients with histologically confirmed malignant or benign hepatic tumors (maximum size 5 cm) were analyzed. We used a high-end ultrasound machine (Logic 9, GE Healthcare, Milwaukee, WI, USA), with a multifrequency curved array transducer (2.5 - 4 MHz), Contrast-enhanced ultrasound (bolus injection 2.4 mL SonoVue(R)) was carried out with the intermittent breath-holding technique. Native vascularization was analyzed with power Doppler sonography. The contrast-enhanced dynamic ultrasound investigation was carried out with contrast harmonic imaging in the true detection mode during the arterial, portal venous and late phases. The mechanical index was set at 0.15. Perfusion analysis was performed by post-processing of the raw data (time intensity curve [TIC] analysis). Biphasic 16- or 64-slice multislice computed tomography served as reference method in nearly all cases. RESULTS: One hundred patients with 59 malignant (43 colon, 5 breast, 2 endocrine metastases, 7 hepatocellular carcinomas and 2 kidney cancers) and 41 benign (12 circumscribed fatty changes, 2 abscesses, 7 focal nodular hyperplasias, 5 complicated cysts and 15 hemangiomas) tumors were included. The CT classification was true positive in 71 of 92 patients, false negative in 8 cases, and in 13 cases no final diagnosis was possible; sensitivity was 96.7 % and specificity was 71.4 % for CT. The quantitative contrast harmonic imaging ultrasound classification was true positive in 98 of 100 patients and false negative in 2 cases; the sensitivity was 98.6 % and the specificity was 96.6 %. The Fisher test showed a significant difference at p < 0.05. No investigator-dependency was noted. CONCLUSION: In our study contrast-enhanced ultrasound was more accurate than multislice computed tomography in the prediction of malignancy and benignity of liver tumors.

[Evaluation of a liquid embolization agent (Onyx) for transcatheter embolization for renal vascular lesions]. / Endovaskuläre Behandlung akuter Nierenblutungen mit einem neuen Flüssigembolisat (Onyx): erste klinische Ergebnisse.

PURPOSE: To evaluate the therapeutic outcome after endovascular treatment of renal vascular lesions using the liquid embolization agent, Onyx. MATERIALS AND METHODS: Between 2004 and 2008 nine patients with renal vascular lesions were treated with transcatheter arterial embolization using Onyx. The renal vascular lesions consisted of 4 AV-fistulas, a pseudoaneurysm, bleeding from a single subsegmental artery, diffuse parenchymal bleeding after trauma, septic embolizations and multiple aneurysms in endocarditis. All patients underwent selective angiography of the renal artery. A dimethyl sulfoxide (DMSO)-compatible microcatheter was used and Onyx was injected. The technical and clinical success rate, examination time and procedure-related complications were documented. RESULTS: The overall technical and clinical success rate was 100 %. One patient had to be treated twice due to recurrent bleeding after an accidental puncture with a drainage catheter. No loss of viable renal tissue occurred in 4 cases. In 4 patients mild to moderate parenchyma loss was noted. In one patient having diffuse renal bleeding, occlusion of the main renal artery was performed. No procedure-related complications were noted. The mean examination time was 16.17 min when treating with Onyx alone and 60 min when using a combination of Onyx and coils. Within an average follow-up period of 21 months, no recurrent renal bleeding or recurrent AV-fistulas occurred. CONCLUSION: Onyx is an effective embolization agent for the treatment of renal vascular lesions. It allows controlled and quick application with low complication rates and a short examination time as a standalone agent or in combination with coils.

[Diagnosis of and therapy for gastric cancer--work-flow]. / Diagnostik und Therapie des Magenkarzinoms--Workflow.

AIM: This review comments on the diagnosis and treatment of gastric cancer in the classical meaning--excluding adenocarcinoma of the -oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are presented. PREOPERATIVE DIAGNOSIS: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recommended for preoperative evaluation of tumours > T1, laparoscopy has become an effective stag-ing tool in T3 and T4 tumours avoiding unnecessary laparotomies and improving the detection of small -liver and peritoneal metastases. TREATMENT: Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a / no ulcer / G1, 2 / Laurén intestinal / L0 / V0 / tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2 LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in -patients with favourable prognosis, this also -applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50 % of patients with liver metastases show concomitant peritoneal dissemination of the disease. DISCUSSION AND CONCLUSIONS: Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4 tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoperative chemoradiotherapy may be debated.

New perfusion imaging of tissue transplants with Contrast Harmonic Ultrasound Imaging (CHI) and Magnetic Resonance Imaging (MRI) in comparison with laser-induced Indocyanine Green (ICG) fluorescence angiography.

PURPOSE: Evaluation of post-surgery tissue perfusion of free flaps of the lower leg with contrast enhanced harmonic imaging (CHI), laser-induced indocyanine green (ICG) fluorescence angiography and magnetic resonance imaging (MRI). MATERIALS AND METHODS: 10 patients with free flaps of the lower limb were evaluated with CHI, ICG-fluorescence angiography and perfusion weighted MRI. Perfusion weighted MRI was performed after intravenous bolus injection of 25 ml Gd-DTPA. The ICG fluorescence was detected by a near-infrared-laser device (lambda em = 780 nm). Ultrasound was carried out by an experienced examiner with a linear probe after intravenous bolus injection of 2.4 ml SonoVue. For MRI time intensity curves as well as color-coded blood volume maps of the whole free flap were qualitatively evaluated. For CHI and ICG time intensity curves in selected regions of interest were analyzed. A score from 1-5 (1 = low, 5 = excellent) was used for analysis of perfusion images by three independent readers. RESULTS: In 3 cases (radialis, parascapular and lateral thigh flap) CHI, MRI and ICG perfusion imaging showed an excellent (score 4-5) contrast enhancement of the cutaneous and subcutaneous part of the free flaps. In 2 cases of osteocutaneous flaps perfusion in central and distal parts of the free flaps was reduced (score 2). Correlation between CHI, MRI and ICG was 0.69-0.83 for the distal parts of the free flaps and 0.74-0.87 for the center of the flaps (Spearman test). Perfusion in the center of the free flaps was significantly different for MRI and ICG and also for MRI and CHI (p<0.05, Wilcoxon test). CONCLUSION: These first results introduce CHI and MRI perfusion imaging as a promising post-surgery monitoring in patients with free flaps.

New real-time image fusion technique for characterization of tumor vascularisation and tumor perfusion of liver tumors with contrast-enhanced ultrasound, spiral CT or MRI: first results.

AIM: Evaluation and characterization of the vascularisation and perfusion of liver tumors by means of image fusion of dynamic contrast-enhanced ultrasound (CEUS), multidetector-CT (MD-CT) or magnetic resonance imaging (MRI) with the ultrasound navigation technique. MATERIAL: For interventional planning a real-time image fusion involving CEUS (LOGIQ E9, GE) was performed in 20 patients (12 men, 8 women, age 43-69 years, median 54) with histologically confirmed malignant liver tumors (9 x hepatocellular carcinoma (HCC), 5 x metastases, 2 x hemangiomas, 1 x cholangiocellular carcinoma (CCC), 1 x lymphoma, 1 x neuroendocrine tumor, 1 x focal nodular hypoplasia (FNH)). In 17 patients the real-time CEUS was fused with contrast-enhanced MD-CT and in three patients with contrast-enhanced MRI (Gd-DTPA and liver-specific contrast medium Resovist. All of the ultrasound examinations were performed by an experienced examiner with a multi-frequency probe (2-5 MHz, LOGIQ E9, GE); dynamic image sequences up to 3 minutes in true agent detection mode of contrast harmonic imaging (CHI) were documented. An evaluation of the tumor was performed by the characterization of the dynamics of the contrast medium and microperfusion with CEUS, fused with MD-CT or MRI. RESULTS: In 18/20 cases there was an accurate agreement with respect to the segmental localization of the tumor lesion. In 2/20 cases the localization was comparable with the image fusion of CEUS and reference imaging (a total of at least 65 lesions: 3 x 1 lesion, 5 x 2 lesions, 8 x 3 lesions, 2 x 5 lesions, 1 x 8 lesions, 1 x at least 10 lesions (multifocal)). With image fusion a certain characterization was attained in 17/20 cases. In 3/20 cases (lymphoma after liver transplantation, multifocal CCC, metastases of a neuroendocrine tumor) the diagnosis was at first doubtful and had to be confirmed histologically. In patients with HCC an evaluation of the tumor perfusion was feasible in all 9 cases (8/9 after local trans-arterial chemoembolization (TACE), 1/9 after radio frequency ablation (RFA)). A tendency toward the identification of more lesions with image fusion of CEUS and CT than with contrast-enhanced CT alone could be recognized (p=0.059). CONCLUSION: Applying a new real-time fusion technique of MD-CT or MRI with CEUS new possibilities for the evaluation, intervention and monitoring of the therapy of liver lesions were made possible, since the method also comprised the dynamic microperfusion.

[Onyx (ethylene-vinyl-alcohol-copolymer)--a novel approach to the endovascular treatment of acute bleeding]. / Onyx (Ethylen-Vinyl-Alkohol-Kopolymer)--Ein neuer Anwendungsbereich in der endovaskulären Behandlung akuter peripherer Blutungen.

PURPOSE: The purpose of our retrospective study was to determine the feasibility and efficacy of the endovascular embolization of peripheral acute arterial hemorrhage using Onyx. MATERIALS AND METHODS: Between October 2003 and February 2007, 14 patients with acute arterial bleeding underwent percutaneous arterial embolization using Onyx. Bleeding was caused by iatrogenic vessel injury (6 patients), malignancy/inflammation (5 patients) and trauma (3 patients). Hematomas were located in the pelvis (5 patients), followed by liver (3 patients), retroperitoneal space (2 patients), thorax (2 patients), pancreas (1 patient), and thigh (1 patient). The number of embolized arteries, the volume and viscosity of embolic agent (Onyx), the number of additionally used coils, the embolization time, and the technical and clinical outcome were documented. Procedure-related complications, recurrent bleeding during hospital stay and outcome were recorded. RESULTS: In 14 patients selective endovascular embolization of 15 arteries was performed. The average volume of injected Onyx was 1.3 +/- 0.8 ml. In 6 cases (42.9%) Onyx was used in conjunction with coils. The average time between the correct placement of microcatheter and complete embolization was 24.9 +/- 12.6 minutes. In 13 of 14 patients (92.8%), embolization was technically successful. In one case, procedure-related complications occurred and embolization was performed in a second session a day later. After technically successful embolization, no recurrent bleeding occurred during hospitalization. Out of 14 patients, six (42.9%) died 1 - 38 days after technically successful embolization due to multiple organ failure (2 patients), hypoxic brain injury (2 patients), septic shock (1 patient) or malignancy-associated death (1 patient). CONCLUSION: We conclude that transcatheter embolization with the new liquid embolic agent Onyx is technically feasible and effective in patients with acute arterial hemorrhage.