Duodenal angiolipoma -- endoscopic diagnosis and therapy.

We report on two patients with upper gastrointestinal bleeding owing to duodenal angiolipomas, and their endoscopic diagnosis and therapy. In both cases the bleeding source was a pedunculated tumour. Diagnosis and definitive therapy was made by endoscopic snare polypectomy. After stopping the bleeding from the mucosal defect by injection therapy in one patient, the further course was uneventful in both. A colonic angiolipoma in one of the patients was also treated by polypectomy. Gastrointestinal angiolipomas are exceedingly rare, however, these case reports show that duodenal angiolipomas do exist and that they, as lipomas, may lead to substantial gastrointestinal bleeding and may be treated successfully by standard polypectomy techniques.

Stereolithographic biomodeling to create tangible hard copies of cardiac structures from echocardiographic data: in vitro and in vivo validation.

OBJECTIVES: This study investigated the feasibility, accuracy and clinical potential of creating polymer hard copies of echocardiographic data using stereolithography. BACKGROUND: Three-dimensional (3D) echocardiography has so far been limited by the need to display reconstructed 3D objects on a two-dimensional screen. Thus, tangible stereolithographic polymer models created from echocardiographic data could enhance our spatial perception of cardiac anatomy and pathology. METHODS: Hard-copy replicas of water-filled latex balloon phantoms (n = 7) and porcine liver specimens (n = 12) were generated from echocardiographic images using stereolithography (computerized laser polymerization). In addition, we created 24 models of the mitral valve from 12 transesophageal studies (normal = 6, mitral stenosis n = 4, prolapse/flail leaflet n = 8, annular dilation n = 2, leaflet restriction n = 2 and following mitral valve repair n = 2). RESULTS: Excellent agreement was found for comparison of volumes (r = 0.98, SEE = 3.46 mm3, mean difference = 0.25 +/- 3.33 mm3) and maximal dimensions (r = 0.99, SEE = 0.16 cm, mean difference = 0.03 +/- 0.16 cm) between phantoms and their corresponding replicas. Visual and tactile examination of mitral valve models by two blinded observers allowed correct depiction of mitral valve anatomy and pathology in all cases. CONCLUSIONS: Stereolithographic modeling of echocardiographic images is feasible and provides tangible polyacrylic models that are true to scale, shape and volume. Such models offer accurate depiction of mitral valve anatomy and pathology in patients studied with transesophageal echocardiography. This technique could have substantial impact on diagnosis, management and preoperative planning in complex cardiovascular disorders.

[Surgical embolectomy after reanimation in central pulmonary embolism]. / Operative Embolektomie nach Reanimation bei zentraler Pulmonalembolie.

Central pulmonary embolism represents one of the most threatening complications in surgical patients. In most cases deep vein thrombosis of the lower extremities is the source of emboli. Despite the introduction of hypocoagulative drugs in standard surgical concepts the incidence of deep vein thrombosis remains about 10% in trauma patients. Estimated numbers of unknown cases of pulmonary embolism are supposed to be rather high too. In haemodynamically symptomatic pulmonary embolism events and especially when the patient has to be reanimated, mortality rates of up to 93% are reported in literature. After introduction of the heart- and lung-machine in the surgical concept of therapy, survival rates have increased significantly. We report on three cases of successful surgical embolectomy after CPR. In a review of literature current concepts of treatment in central pulmonary embolism are discussed.

[Diclofenac-associated acute cholestatis hepatitis]. / Diclofenac-assoziierte akute cholestatische Hepatitis.

Diclofenac is an anti-inflammatory analgesic which is widely used in the therapy of inflammatory joint pain. Diclofenac hepatotoxicity ranges from asymptomatic elevation of transaminase activity to significant liver disease. 31 cases of diclofenac-induced hepatitis with five associated deaths have been already reported in the English, French and Spanish literature. We report the case of a 64-year-old patient who was admitted to the hospital with an icteric hepatitis of sudden onset. The only drug that was taken before admission was diclofenac in a daily dose of 150-200 mg because of a spondylodiscitis. Work-up of the patient included ERCP, laparoscopy and liver biopsy and excluded other reasons of a cholestatic hepatitis. Discontinuation of diclofenac resulted in normalization of transaminase activity and bilirubin concentration within four months. The frequent use of diclofenac and the possibility of fatal liver damage highlights the need that diclofenac-toxicity should be considered in the differential diagnosis of acute cholestatic hepatitis.

Analysis of left ventricular function after emergency coronary artery bypass grafting for life-threatening ischaemia following primary revascularization.

OBJECTIVE: Severe ischemic injury in the first few hours following primary revascularization necessitates acute reoperation. To study the effect of emergency coronary artery bypass grafting, we followed 18 patients for up to 8 years, relating their changes of global and regional myocardial function during the acute event and after secondary revascularization to final outcome. METHODS: A total of 16 patients with coronary artery bypass grafting (CABG) and 2 PTCA were treated for coronary heart disease between 1989 and 1993 and experienced life-threatening ischemic events (94% cardiogenic shock, 39% ventricular fibrillation, 67% ischemic electrocardiograph (ECG) changes) within 2.3+/-1.6 h after primary revascularization. Reoperation was carried out 1.0+/-1.3 h after the occurrence of acute ischemia. Serial echoes were obtained during the acute event and after reoperation as well as during the follow-up period. RESULTS: Of the 18 patients, 8 are currently alive, 5 died within 30 days and 4 within the 1st year. There was one late death 5 years after surgery. Global and regional wall motion was evaluated using short axis views of transesophageal echoes taken during the acute event and after secondary revascularization, and compared with transthoracic echoes in long-term survivors up to 5 years after surgery. During the acute event left ventricular ejection fraction (LVEF) was reduced in 83% of the patients and improved significantly after reoperation (chi2 = 11.74, df= 2, P < 0.01). As to regional wall motion, 50% of the segments in non-revascularized areas remained abnormal. Regional wall motion after reoperation was significantly better in the surviving patients compared with patients dying in the post-operative course (chi2 = 6.23, df= 1, P < 0.05). The revascularization score ( > 75%) of abnormal contracting segments during the acute ischemic event was a significant determinant for long-term survival. CONCLUSION: We conclude that patient outcome is determined by the severity of regional wall motion abnormality during the acute ischemic event, the aggressiveness of the attempt to revascularize these perfusion territories and their improvement after revision. Long-term survival reflects, therefore, the extent of emergency revascularization and therefore the ability to identify ischemic perfusion territories for surgical strategy planning.

Infection of an intravenous port system with Metschnikowia pulcherrima Pitt et Miller.

A patient with short bowel syndrome as a consequence of multiple intestinal resections for Crohn's disease, had a port system implanted to improve her nutritional status. One year later she presented with fever, weakness and nighttime sweating. Metschnikowia pulcherrima Pitt et Miller was grown in blood cultures from the port system. After antifungal chemotherapy using fluconazole and removal of the implant, the patient's condition improved markedly and her fever and sweating disappeared. We conclude that Metschnikowia pulcherrima can turn into a human pathogen in patients with indwelling catheters for parenteral nutrition. Chemotherapy with fluconazole and, whenever possible, removal of the implant, appear to be adequate treatment.

Biochemical markers of perioperative myocardial ischemia in patients with coronary artery bypass grafting.

Aims of the study: The evaluation of significant perioperative ischemic processes after coronary artery bypass grafting from postoperative ECG, creatine kinase (CK) and CK iso-enzyme MB remains unreliable and, hence, insufficient. Additional, early available biochemical markers could improve the diagnostics of ischemia. Methods: In 86 patients with multiple vessel disease, activity of serum CK and CK-MB as well as mass of CK-MB, myoglobin and troponin-T were analyzed before and after surgery. Twelve-lead electrocardiograms were evaluated before surgery, 3h postoperatively, and before discharge from hospital. Results: In patients with signs of perioperative ischemia in the 3-hour ECG, primary postoperative peak values of myoglobin and CK were distinctly higher than in patients without signs of ischemia, with median values of 1437 ng/ml vs. 986 ng/ml for myoglobin and of 632 U/l vs. 481 U/l (n.s.) for CK. Sensitivity and specificity of myoglobin were 64 % and 69 %, followed by CK with 61 % and 62 %, respectively. Conclusions: Myoglobin, indicating the risk of perioperative ischemia approximately 45 minutes after declamping of the aorta, is suggested as a candidate for early available routine monitoring.

Characterization of normal leakage flow of monostrut tilting disk prosthetic mitral valves by multiplane transesophageal echocardiography.

To assess normal prosthetic mitral valve function, multiplane transesophageal Doppler echocardiographic studies were performed on 22 patients with Monostrut tilting disk valves. Mean follow-up after implantation was 63 +/- 12 months. Two holosystolic red low-velocity regurgitant jets were detected in all but one case. The length of these jets ranged from 0.8 to 6.9 cm and the area ranged from 0.5 to 10.1 cm2 in various planes. The origin of the jets was inside the rings of the prosthetic valves and started with a mosaic spot of 2 mm maximum diameter. In this mosaic spot, jet velocity by the high pulse-repetition frequency mode measured greater than 4 m/sec. Thin, high-velocity regurgitant jets originating outside the sewing ring were present in three cases. In one case we found a high-velocity turbulent jet originating outside the ring corresponding to a paravalvular regurgitation of moderate degree. The low-velocity jets were obscured in the patient with moderate paravalvular leak but not in patients with trivial paravalvular leaks.