Multidetector CT evaluation of the course of nonresectable pancreatic carcinomas with neoadjuvant therapy.

OBJECTIVE: A prospective study to determine the value of multidetector CT (MD-CT) in assessing the course of nonresectable pancreatic carcinoma during therapy. MATERIAL AND METHODS: 26 patients with nonresectable pancreatic carcinoma underwent MD-CT before and after therapy. The examinations were evaluated with regard to tumor size and vascular invasion using an invasion score (IS) by 2 radiologists independently (kappa analysis). Diagnosis was confirmed surgically, by biopsy or clinical course. RESULTS: Sensitivity for the assessment of irresectability was 100%. Following therapy, 54% of all the tumors were smaller (14/26), 42% had increased in volume (11/26), and one tumor remained stable (1/26). The IS (veins) during follow-up changed in 26 patients (portal vein: 5 higher (mean score 10.4/16.2), 4 lower (mean score 17.5/11.5); superior mesenteric vein: 12 higher (11/14.4), 5 lower (16.2/14.6); p = 0.026). The IS (arteries) changed in 13 patients (celiac trunk: 3 higher (3.3/10); hepatic artery: 4 higher (5.7/10.2), 3 lower (11.6/10.3); superior mesenteric artery: 2 higher (4.5/9.5), 1 lower (12/11)). The kappa values were calculated between 0.56 and 0.87. CONCLUSION: MD-CT is suitable for evaluating tumor spread during therapy for nonresectable pancreatic carcinoma. The IS is useful for assessing the degree of change in vessel invasion.

Successful arterial thrombolysis and percutaneous transluminal angioplasty for early hepatic artery thrombosis after split liver transplantation in a four-month-old baby.

Early HAT is the most frequent and severe vascular complication following liver transplantation. It is one of the major causes of graft failure and mortality. Endovascular thrombolytic treatment in patients with thrombotic complications after liver transplantation is an attractive alternative to open surgery as lower morbidity and mortality rates are reported for it. PTA following transcatheter thrombolysis has been successfully used to treat HAT in adults. To the best of our knowledge, there have not been any reports of a successful transcatheter thrombolysis using interventional radiological techniques in a patient only four months old. The present report describes the successful endovascular emergency treatment of a HAT three days after DD split liver transplantation.

[MR imaging in cardiac amyloidosis--morphology, function and late enhancement]. / Magnetresonanztomografie bei kardialer Amyloidose--Morphologie, Funktion und late enhancement.

PURPOSE: Since limited data is available using MR imaging in cardiac amyloidosis, the purpose of our study was to evaluate morphological and functional differences of the heart using cardiac MRI. MATERIALS AND METHODS: 19 consecutive patients (14 males, 5 females, mean age 59 +/- 6 years) with histologically proven cardiac amyloidosis were evaluated with MRI at 1.5 T. Results were compared with data of 10 healthy, age-matched control subjects (5 males, 5 females, mean age 60 +/- 6 years). Functional and morphological data including late enhancement (LE) was acquired. RESULTS: Compared to the control group, patients with cardiac amyloidosis had thickened atrial walls and dilated atriums. Both ventricles and the interventricular septum were thickened. The LV hypertrophy was focal in 11 / 19 (58 %) and global in 4 / 19 (21 %) of patients. A myocardial edema occurred in 2 / 19 patients with cardiac amyloidosis (11 %). An edema of the myocardium was visible in 2 / 19 (11 %) of patients. The LV ejection fraction was statistically significantly decreased. The prevalence of LE was 74 % (14 / 19 of patients). LE was detected predominantly in the LV anterior wall and in the interventricular septum. Within the segments LE was located predominantly in a subendocardial location. Between patients with and without LE no statistically significant differences of functional and morphological results were able to be established. CONCLUSION: There are three major outcomes of our assessment: 1. The LV hypertrophy is focal in the majority of patients with cardiac amyloidosis. 2. No statistically significant differences can be established in regard to the functional and morphological features between patients with and without LE. 3. Myocardial edema is a possible feature in cardiac amyloidosis.

[A radiological case collection with interactive character as a new element in the education of medical students]. / Eine radiologische Fallsammlung mit interaktivem Charakter als neues Element in der studentischen Ausbildung.

PURPOSE: Evaluation of an interactive, multimedia case-based learning platform for the radiological education of medical students. MATERIALS AND METHODS: An interactive electronic learning platform for the education of medical students was built in HTML format independent of the operating system in the context of the Heidelberg Curriculum Medicinale (HeiCuMed). A case collection of 30 common and authentic clinical cases is used as the central theme and clinical background. The user has to work on each case by making decisions regarding a selection of diagnostic modalities and by analyzing the chosen studies. After a reasonable selection and sequence of diagnostic radiological modalities and their interpretation, a diagnosis has to be made. An extensive collection of normal findings for any modality is available for the user as a reference in correlation with the pathology at anytime within each case. The case collection consists of 2053 files with 1109 Internet pages (HTML) and 869 image files (.jpeg) with approximately 10 000 crosslinks (links). The case collection was evaluated by a questionnaire (scale 1 - 5) at the end of the radiological student course. The development of the results of the radiological course exam was analyzed to investigate any effect on the learning performance after the case collection was introduced. RESULTS: 97.6 % of the course participants would use the case collection beyond the radiological student course to learn radiology in their medical studies. The handling of the case collection was rated excellent in 36.9 %, good in 54.6 %, satisfactory in 8 % and unsatisfactory in 0.4 %. 41 % felt that the case collection was overall excellent, 49.2 % good, 7.8 % satisfactory, 1.6 % unsatisfactory and 0.4 % poor. A positive trend in the development of the results in the radiological course exam with less variance after the introduction of the case collection was found but failed statistical significance. CONCLUSION: A platform-independent, interactive, multimedia learning platform with authentic clinical cases and multiple choice elements for the user is the ideal method for supporting and expanding medical education in radiology. The usefulness and the reasonable exertion of diagnostic modalities are conveyed in a practical context as teaching goals. The high acceptance among students is based on the interactivity and use of multimedia.

A new invasion score for determining the resectability of pancreatic carcinomas with contrast-enhanced multidetector computed tomography.

OBJECTIVE: It was the aim of this study to evaluate a new infiltration score to determine the resectability of pancreatic carcinomas in preoperative planning. MATERIALS AND METHODS: Eighty patients with suspected pancreatic tumor were examined prospectively using 16-row spiral CT. The scans were evaluated for the presence of pancreatic carcinoma, peripancreatic tumor extension and vascular invasion using a standardized questionnaire. Invasion of the surgically relevant vessels was evaluated using a new invasion score. The operative and histological findings and the clinical follow-up served as the gold standard. RESULTS: Forty patients had a pancreatic carcinoma, 5 had metastasis of a different primary tumor, and in 35 patients, there was no malignant pancreatic disease. The sensitivity for tumor detection was 100%, with a specificity of 88% for differentiating between malignant and benign pancreatic tumors. Invasion of the surrounding vessels was evaluated correctly using the invasion score, with a sensitivity of 89% and a specificity of 99%. In evaluation of resectability, a sensitivity of 94% and a specificity of 89% were achieved. CONCLUSION: Using 16-row spiral CT, the invasion score is a valid tool for correctly assessing invasion in relevant vessels in cases of pancreatic carcinoma and for determining resectability.

Efficacy and safety of percutaneous transhepatic portal embolization before right liver resection using an ethibloc/lipiodol mixture: a single-center experience.

AIM: The purpose of this study was to evaluate the safety and efficacy of percutaneous transhepatic portal vein embolization of the right portal vein with an Ethibloc/Lipiodol mixture to induce hypertrophy of the left liver lobe in patients with primarily unresectable liver tumor. METHODS: 15 patients (8 primary liver tumors, 7 liver metastases) underwent portal vein embolization. Liver volumetry, duration of hospitalization, complication rates, relevant laboratory values were documented. RESULTS: In 13/15 patients (84.6%) embolization could be performed with a median of 8.8 ml (range 1.5-28 ml) Ethibloc/Lipiodol. One minor procedure-related complication (subcapsular hematoma) occurred, which did not affect the two-step liver resection. No patient developed acute liver failure after embolization or liver resection. The volume of the left liver lobe increased significantly (p = 0.0015) by 25% from a median of 750 ml (587-1,114 ml) to 967 ml (597-1,249 ml). 11/13 (81.8%) of the embolized patients underwent liver resection at a median of 49 days after embolization. Median hospitalization time was 4 days after embolization and 7 days after liver resection. Median overall survival of the 11 operated patients was 376 days. CONCLUSION: Percutaneous transhepatic portal vein embolization using an Ethibloc/Lipiodol mixture is a safe, feasible, and efficient interventional procedure.

[Advances in the staging of renal cell carcinoma with high-resolution imaging]. / Fortschritte im Staging des Nierenzellkarzinoms mittels hochauflösender Bildgebung.

Modern imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) allow high-resolution imaging of the abdomen. Modern scanners made high temporal as well as high spatial resolution available. Therapeutic approaches to the treatment of renal cell carcinoma have been improved over the recent years. Besides conventional and open laparoscopic tumor nephrectomy and nephron sparing, surgical approaches such as local tumor cryotherapy and radiofrequency ablation (RF) are ablative modalities and are used increasingly. Improved anesthesiological methods and new surgical approaches also allow curative treatment in extended tumors. Prerequisites for preoperative imaging modalities include visualization of the kidney tumor as well as its staging. Tumor-related infiltration of the renal pelvis or invasion of the perinephric fat and the renal hilus has to be excluded prior to nephron sparing surgery. In cases with extended tumors with infiltration of the inferior vena cava, it is necessary to visualize the exact extension of the tumor growth towards the right atrium in the vena cava. The radiologist should be informed about the diagnostic possibilities and limitations of the imaging modalities of CT and MRI in order to support the urologist in the planning and performance of surgical therapeutical approaches.

[Clinical 3-year follow-up of uterine fibroid embolization]. / Klinische 3-Jahres-Ergebnisse nach Uterusmyomembolisation.

PURPOSE: The purpose of this study was to evaluate the clinical long-term success of uterine artery embolization (UAE) in patients with symptomatic fibroids using spherical particles (Embosphere). MATERIALS AND METHODS: 34 consecutive patients treated with UAE were initially enrolled in the study which had the following study goals 1) 1-year follow-up MRI evaluation of the fibroid behavior and 2) clinical long-term success due to standardized assessment of the main fibroid-related symptoms (hypermenorrhoea, dysmenorrhoea and dysuria) of the patients' individual overall health status and their therapy satisfaction at 1-year, 2- year and 3-year intervals after UAE. RESULTS: Technical success was achieved in all procedures. Four patients had to be excluded from the long-term evaluation schedule: one because of a hysterectomy due to bleeding after 6 weeks, 3 patients were not available for the designated minimum follow-up interval. The preinterventional severe hypermenorrhoea (n = 27) with a score of 4.4 +/- 0.7 (5 = extreme menstrual bleeding) decreased after one year to 2.1 +/- 0.5 (p = 0.0001), after two years to 1.7 +/- 0.5 (p = 0.0042) and after three years to 1.3 +/- 0.6 (p = 0.0001). The preinterventional dysmenorrhoea (n = 15) with a score of 3.1 +/- 1.5 (3 = distinctly increased dysmenorrhoea) decreased after one year to 1.1 +/- 0.3 (p = 0.0001), after two years to 1.2 +/- 0.2 and after three years to 1.2 +/- 0.4 (p = 0.148). The pretreatment dysuria (n = 12) with a preinterventional score of 3.1 +/- 1.5 (3 = distinctly increased dysuria) decreased after one year to 1.1 +/- 0.3 (p = 0.0069) and remained after two years at 1.1 +/- 0.2 and after three years at 1.2 +/- 0.4 (p = 0.905). The initial overall health status was 54.7 +/- 20.1 (maximal value 100). After one year it rised to 90.5 +/- 15.4 (p = 0.0001), was 91.8 +/- 5.6 after two years and was 91.3 +/- 8.5 (p = 0.8578) after three years. The satisfaction with the therapy was 2.9 +/- 0.2 after one year, 2.6 +/- 0.3 after two years and 2.7 +/- 0.5 (3 = extremely satisfied) after three years. We observed 12 minor and 3 major complications (one hysterectomy, one fibroid expulsion associated with a short bleeding episode and one transient amenorrhoea for three months). All patients benefited clinically from the procedure and a clinical benefit was achieved in all cases. CONCLUSION: Under controlled study conditions, flow-guided UAE with spherical embolization particles achieves high clinical success for all relevant clinical symptoms without negative changes during follow-up after at least 3 years. Accordingly, patient therapy satisfaction remained extraordinarily high even 3 years after UAE.

Acute pancreatitis after embolization of liver tumors: frequency and associated risk factors.

INTRODUCTION: Acute pancreatitis (AP) is a rare complication after liver embolization (LE) of primary and secondary liver tumors (approximately 1.7%), but it has a significant morbidity and mortality potential if associated with other complications. It usually develops early within 24 h after the LE procedure. STUDY PURPOSE: To calculate the frequency of AP after LE in our institution and to analyze the factors involved in this procedure (anatomical features, embolization materials, cytostatic drugs, technical factors). MATERIALS AND METHODS: 118 LE (bland embolization and transarterial chemoembolization) were performed in our institution. The study group included 59 patients who met the following inclusion criteria: one or more LE events, with complete pre- and post-interventional laboratory studies including: serum Ca(2+), creatinine, blood urea nitrogen, glucose, lactate dehydrogenase, aminotransferases, alkaline phosphatase, amylase, lipase, C-reactive protein, hematocrit and leukocytes. The diagnosis of AP was established according to the criteria of the Atlanta system of classification. For the statistical analysis the association between two response variables (e.g. AP after embolization and risk factor during the embolization, AP after embolization and volume of embolic material) was evaluated using Pearson's chi(2) test and Fisher's exact test. RESULTS: The calculated frequency of AP after LE in our series was 15.2%. Amylase and lipase were elevated up to 8.7 and 20.1 times, respectively, 24 h after LE. We observed a statistically significantly lower incidence of AP in those patients who received 2 ml or less of embospheres compared with those with an embolization volume of >2 ml (Pearson's chi(2) = 4.5000, Pr = 0.034, Fisher's exact test = 0.040). Although carboplatin was administered to 7 of 9 of the patients who developed AP after the embolization procedure, there was no statistical significance (Fisher's exact test = 0.197) for carboplatin as an AP risk factor when compared with all the patients who received this drug (n = 107). CONCLUSION: Although AP after LE seems to have a multifactorial etiology, both the toxicity of the antineoplastic drugs (carboplatin-related toxicity) as well as direct ischemic mechanisms (non-target embolization, reflux mechanisms) may be the most important causes of the inflammatory pancreatic reaction after LE. We suggest that systematic measurement of serum pancreatic enzymes should be performed in cases of abdominal pain following selective LE and transarterial chemoembolization in order to confirm acute pancreatitis after embolization, which can clinically mimic a postembolization syndrome.

Experimental evaluation of early and long-term effects of microparticle embolization in two different mini-pig models. Part I: kidney.

PURPOSE: Using a pig model: (1) to evaluate the vascular distribution pattern, including the homogeneity and completeness of the intra-arterial microsphere distribution, of 40-120-microm trisacryl-gelatin microspheres (Embospheres) in acute whole-kidney embolization; (2) to evaluate the durability and biocompatibility of 40-120-microm trisacryl-gelatin microspheres (Embospheres) in chronic partial kidney embolization. METHODS: Twenty-two animals were divided into four groups: group 1 (n = 4) underwent total arterial renal occlusion with immediate euthanasia. Groups 2-4 had chronic superselective and partial renal embolization with increasing follow-up times: group 2 (n = 2), 1 week; group 3 (n = 7), 4 weeks; and group 4 (n = 9), 14 weeks. Key endpoints in group 1 were homogeneity and completeness of acute embolizations. In groups 2-4 the key endpoints were durability of embolization and particle-related inflammation in chronic partial embolizations as assessed by quantitative angiography or histomorphometry. A numerical angiographic occlusion score (0.0 to 4.0, where 3.0 is optimal) was developed to assess and quantify the angiographic durability of superselective embolizations (groups 2-4). RESULTS: In group 1, a relatively homogeneous distribution of the particles from segmental arteries to the precapillary level was shown by histomorphometry. Some particles reached the glomerular vas afferens (10 microm diameter). In groups 2-4, a mild recanalization appeared during follow-up. The immediate average postembolization occlusion score of 3.18 +/- 0.73 was reduced to 1.44 +/- 0.73 (statistically significant). Microscopy revealed subtotal necrosis but no foreign body granuloma formation. The intra-arterial appearance of giant cells closely attaching to the surface of the embolic spheres inside the vessel lumen was noted. Vessel walls showed major ischemic reactions. CONCLUSION: Microspheres 40-120 microm in diameter might achieve total occlusion of the arterial kidney vasculature when injected centrally as a result of their fairly homogeneous distribution. Segmental renal infarction occurs after chronic partial embolization despite recanalizations during follow-up. Only mild specific intra-arterial foreign body reactions were found.

[Balloon kyphoplasty in the treatment of back pain]. / Die Ballonkyphoplastie in der Behandlung des Rückenschmerzes.

BACKGROUND: Experience of just under 5 years has shown that balloon kyphoplasty can be just as successfully employed as the longer-stablished vertebroplasty for the treatment of back pain due to recent or prior osteoporotic fractures as well as new traumatic fractures. MATERIAL AND METHOD: Among 345 patients with a total of 690 treated vertebral bodies, the change in pain symptomatology was analyzed for a follow-up period of 12 months in 40 study patients who underwent kyphoplasty and a control group of 20 patients. In addition, the pain experienced by a further 29 patients with new traumatic vertebral body fractures was monitored over a 12-month period. These fractures were partly managed by fixateur interne alone and by a combination of fixateur interne and kyphoplasty. RESULTS: The 40 patients treated by kyphoplasty had a baseline VAS score of 26.2+/-2.00, which increased to 44.4+/-3.11 after 12 months, while the respective scores for the control group were 33.6+/-4.21 and 34.3+/-4.35. In the 29 patients with new traumatic vertebral body fractures, the initial VAS score was 62 and after 12 months a distinct reduction of pain was noted with a score of 20 (100 = maximum pain, 0 = no pain). The number of times that the 40 patients managed by kyphoplasty had to consult their general practitioner was significantly reduced by the pain therapy. CONCLUSION: Balloon kyphoplasty verifiably improved the pain symptomatology after vertebral fracture over a period of 12 months. Comparison with the control group, which received the same osteoporosis drug therapy, confirmed the effect of this minimally invasive treatment form.

Comparison of CT during arterial portography and MR during arterial portography in the detection of liver metastases.

OBJECTIVE: This study compared MR during arterial portography (MRAP) with CT during arterial portography (CTAP) with regard to the detection and differentiation of liver metastases before surgery. MATERIALS AND METHODS: Fifteen patients with liver metastases were enrolled before surgery according to the guidelines of our institutional review board and good clinical practice. After mesentericography, unenhanced scans (Volume Zoom) were performed initially. For CTAP, the contrast medium was injected through the superior mesenteric artery. Images were acquired in portal and delayed enhancement. The MR protocol (1.5 T; Magnetom Symphony) started with T1-weighted fast low-angle shot (FLASH) T2-weighted turbo spin echo (TSE). MRAP followed with gadolinium-enhanced dynamic T1-weighted 3D FLASH. Delayed-phase T1-weighted 2D FLASH axial images were performed 2 min after IV injection of the contrast medium. Qualitative and quantitative evaluation of CTAP and MRAP was performed by three blinded radiologists regarding the number of lesions and their size, localization, and differential diagnosis. RESULTS: The overall sensitivity in detecting liver metastases was 97% with MRAP and 93% with CTAP (p > 0.05, not significant [n.s.]). The specificity was calculated to be 97% for MRAP and 82% for CTAP (p < 0.0001, statistically significant [s.s.]). The differences in sensitivity were more accentuated if only lesions 10 mm or smaller were considered (95% vs 88%, p > 0.05, n.s.), for which the respective specificities were 95% and 80% (p < 0.0014, s.s.). Improvements in sensitivity and specificity were associated with a higher lesion-to-liver contrast-to-noise ratio (59.4 +/- 51.0 for MRAP vs 10.4 +/- 7.3 for CTAP) and resulted in higher diagnostic confidence in the differential diagnosis of liver lesions (p < 0.001, s.s.) and better interobserver agreement (median kappa value, 0.88 vs 0.63). CONCLUSION: MRAP proved to be a reliable method in the preoperative detection of small liver metastases in particular, with a higher sensitivity and specificity than CTAP. If organizational difficulties of MRAP can be overcome, MRAP could be considered instead of CTAP in the preoperative invasive evaluation of metastatic liver disease.

[Preoperative and palliative embolization of renal cell carcinomas: follow-up of 49 patients]. / Präoperative und palliative Embolisation des Nierenzellkarzinoms: Nachsorge von 49 Patienten.

PURPOSE: To evaluate the influence of preoperative and palliative embolization of renal cell carcinomas on survival, intra- and post-operative procedures, and symptom control for palliative and preoperative indications. MATERIALS AND METHODS: 56 patients who underwent renal cell carcinoma embolization from 1981 to 1999 were included in this retrospective study. RESULTS: 24 women and 32 men were included (mean age 59.4 years). Complete follow-up data was available for 49 patients. 42 patients underwent preoperative embolization at different tumor stages (pT1: 1 patient, pT2: 6, pT3 a: 4, pT3 b: 19, pT3 c: 2, pT4: 5). 14 patients underwent palliative embolization (T1: 0 patients, T2: 5, T3: 4, T4: 4). Indications for preoperative embolization were bleeding of the renal tumor in 6 cases -- non-recurrent bleeding reported, flank pain in 4 patients -- 3 of 4 patients had no further symptoms, recurrent tumor embolization in 1 patient, and 2 patients who wanted to be treated without symptoms. The mean survival time of preoperative embolized patients was 3.1 +/- 5.11 years with a 5-year survival rate of 50 %. The mean survival time of palliative embolized patients was 0.67 +/- 0.76 years with initial metastases (n = 7) and 2.33 +/- 2.40 without metastases (n = 6). CONCLUSION: Palliative embolization of renal cell carcinomas is a safe therapeutic method to treat advanced renal cell carcinomas allowing control of symptoms such as hematuria and flank pain in more than 90 % of our cases. Preoperative embolization yields a patient survival time comparable to that of patients at earlier tumor stages and is dependent on the metastases.

Atypical manifestations of multiple myeloma: radiological appearance.

Diagnostic procedures performed on patients with multiple myeloma typically reveal lytic bone lesions, osteopenia or osteoporosis, bone marrow infiltration by plasma cells as well as overproduction of immunoglobulin or light chains in the serum or urine. Skeletal manifestations are extremely variable and the unusual forms have been described extensively. Extramedullary plasma-cell tumours (plasmocytoma) are found in about 5% of newly diagnosed patients with multiple myelomas. In this paper we present eight patients with atypical forms of multiple myeloma.

Transarterial embolization of primary and secondary tumors of the skeletal system.

Percutaneous transcatheteral embolizations of primary and secondary bone tumors are important minimal invasive angiographic interventions of the skeletal system. In most of the cases embolization is performed for preoperative devascularization or as a palliative measure to treat tumor-associated pain or other tumor bulk symptoms. The transarterial embolization of primary and secondary tumors of the skeletal system has been developed to a safe and very effective method. Indications, techniques, results and complications of this minimal invasive interventional therapy for treatment of primary and secondary bone tumors are described and discussed and compared with the newer literature and our own results.

[Interventions for benign biliary strictures]. / Interventionen bei benignen Gallengangstenosen.

Due to their potential for serious consequences, even including biliary liver cirrhosis, benign biliary strictures pose a considerable diagnostic and therapeutic challenge. In addition to inflammatory disease or an acute liver injury, iatrogenically caused biliary strictures following hepatobiliary surgery represent in 95% of cases the main cause for all benign entities. The diagnosis should be determined noninvasively with magnetic resonance cholangiopancreaticography (MRCP). Invasive techniques such as ERCP or percutaneous transhepatic cholangiography (PTC) should be reserved for unclear cases and first performed before the scheduled intervention. Depending on the site and cause of the stricture, surgical and interventional procedures are employed in the treatment of biliary strictures. The best results are obtained in short-segment strictures of the main bile duct. Interventional methods such as balloon dilation and/or stent application with concomitant drain insertion achieve patency rates of up to 75% after 5 and 55% after 12 years with a total complication rate of 5-8%. Due to the fact that most of the cases involve cicatricial fibroses, predisposition for recurrence of biliary strictures after interventional therapy can be very high, ranging up to 66% depending on the localization.

[Treatment of malignant biliary obstructions via the percutaneous approach]. / Interventionen bei malignen Gallenwegstenosen.

This paper gives an overview of experience and success of percutaneous transhepatic interventions in malignant biliary obstruction. Even after exhaustion of surgical and endoscopic therapy options, the percutaneously inserted stents provide effective palliation. The palliative treatment of malignant jaundice using a stent is an established procedure in clinical practice, particularly whenever the endoscopic, transpapillary approach is not possible due to high obstructions or previous surgery. The technical success rate is very high (about 95-100%), and the complication rate is about 10-30%. Since the patency rate of stents is higher than that of plastic endoprostheses, their primary use is justified despite higher costs, provided the patients are adequately selected.

[The role of 3-D imaging and computer-based postprocessing for surgery of the liver and pancreas]. / Bedeutung der 3-D-Bildgebung und computerbasierten Nachverarbeitung für die Chirurgie der Leber und des Pankreas.

Cross-sectional imaging based on navigation and virtual reality planning tools are well-established in the surgical routine in orthopedic surgery and neurosurgery. In various procedures, they have achieved a significant clinical relevance and efficacy and have enhanced the discipline's resection capabilities. In abdominal surgery, however, these tools have gained little attraction so far. Even with the advantage of fast and high resolution cross-sectional liver and pancreas imaging, it remains unclear whether 3D planning and interactive planning tools might increase precision and safety of liver and pancreas surgery. The inability to simply transfer the methodology from orthopedic or neurosurgery is mainly a result of intraoperative organ movements and shifting and corresponding technical difficulties in the on-line applicability of presurgical cross sectional imaging data. For the interactive planning of liver surgery, three systems partly exist in daily routine: HepaVision2 (MeVis GmbH, Bremen), LiverLive (Navidez Ltd, Slovenia) and OrgaNicer (German Cancer Research Center, Heidelberg). All these systems have realized a half- or full-automatic liver-segmentation procedure to visualize liver segments, vessel trees, resected volumes or critical residual organ volumes, either for preoperative planning or intraoperative visualization. Acquisition of data is mainly based on computed tomography. Three-dimensional navigation for intraoperative surgical guidance with ultrasound is part of the clinical testing. There are only few reports about the transfer of the visualization of the pancreas, probably caused by the difficulties with the segmentation routine due to inflammation or organ-exceeding tumor growth. With this paper, we like to evaluate and demonstrate the present status of software planning tools and pathways for future pre- and intraoperative resection planning in liver and pancreas surgery.