CT-guided Thoracic Sympathicolysis versus VATS Sympathectomy in the Therapeutic Concept for Severe Primary Palmar Hyperhidrosis.

BACKGROUND: The objective was to compare computed tomography (CT)-guided thoracic sympathicolysis (CTSy) and video-assisted thoracoscopic sympathectomy (VATS) with regard to their feasibility, the occurrence of minor and major complications, and the clinical outcome. MATERIALS AND METHODS: In this study, 88 patients treated by CTSy and 86 patients treated by VATS were retrospectively included. CTSy was performed after establishing the entry plane below the level of the intervertebral space T2/3 via a dorsolateral approach using a 22-G coaxial needle. On average of 5 mL of a sympathicolytic mixture was instilled. VATS was performed under intubation anesthesia. After insertion of the instruments via a minithoracotomy, the parietal pleura was dissected and the sympathetic trunk severed below T2. The interventions were performed unilaterally, the contralateral side being treated after approximately 6 weeks. All patients evaluated their sense of discomfort before treatment as well as 2 days, 6, and 12 months after, on the basis of a Dermatology Quality of Life Index and additionally the side effects that occurred. RESULTS: Both treatments led to a marked reduction of symptoms, whereby mild recurrent sweating occurred over the further course, significantly higher in the CTSy patient group. Short-term miosis and ptosis were rarely found in both groups. As the most common side effect, transient compensatory sweating was reported by 16/88 patients after CTSy and 10/86 patients after VATS. Pneumothoraces developed postoperatively in 7/86 cases. Temporary pain after thoracotomy was experienced by 12/86 patients. CONCLUSION: For patients with palmar hyperhidrosis, CTSy and VATS represented a minimally invasive treatment option that provided a high and largely equivalent level of benefit.

CT-assisted thoracic sympathicolysis for therapy of primary hyperhidrosis palmaris-retrospective analysis of the influence of the amount and position of the sympathetic agent on the therapeutic outcome and side effects. / CT-gestützte thorakale Sympathikolyse zur Therapie bei primärer Hyperhidrosis palmaris ­ Retrospektive Analyse des Einflusses von Menge und Lage des Sympathikolytikums auf Therapieerfolg und Nebenwirkungen.

PURPOSE: The objective of the present study was to evaluate the benefit of a thoracic, computed tomography-guided sympathicolysis (CTSy) in patients with primary, focal hyperhidrosis of the hands. In addition, the influence of the amount and distribution of the administered sympathicolytic agent was to be assessed. PATIENTS AND METHODS: Retrospectively, 78 patients [13 (16.7 %) men, mean age 31.2 ±â€Š9 years and 65 (83.3 %) women, mean age 34.2 ±â€Š12 years], who had been treated using CTSy, were included in the study. The indication for treatment was primary focal palmar hyperhidrosis grade II and grade III after exhaustion of all conservative treatment options and a continued high level of suffering. CTSy was performed after establishing the entry plane at the level of the intervertebral space T2 / T3 via a dorsolateral approach using a 22-G coaxial needle. On average 5 (2-10) ml of a sympathicolytic mixture (10 ml consisting of 8 ml 96 % alcohol, 1.6 ml 0.5 % Carbostesin and 0.4 ml 0.9 % NaCl solution, with added amounts of contrast medium) were instilled. The volume of distribution of the sympathicolytic agent was determined in craniocaudal direction using CT images. The patients evaluated their sense of discomfort preinterventionally, 2 days postinterventionally, and 6 and 12 months after the intervention, on the basis of a Dermatology life Quality Index (DLQI) as well as the side effects that occurred. RESULTS: The technical success rate of CTSy was 100 %. No major complications occurred. The interventions performed led to a significant reduction (p < 0.001) in the preinterventional sense of discomfort 2 days, 6 and 12 months after CTSy. As the most common side effect, compensatory sweating was reported by 16/78 (20.5 %) of the patients over the further course. In all of these patients, the volume of sympathicolytic agent administered was below 5 ml. In no case did the sympathicolytic agent extend caudally beyond the base plate of Th 3. No compensatory sweating of the back was observed in 5/78 (6.4 %) patients; here the sympathicolytic volume was above 5 ml and extended significantly caudally below the baseplate of T3.Transient miosis and ptosis was found in 8/78 (10.3 %) patients. In all of these patients, the volume of sympathicolytic agent administered was above 5 ml and it extended markedly cranially beyond the upper plate of T2. A mild to moderate recurrent sweating developed in 35/78 (44.9 %) patients, which was more marked if the volume of sympathicolytic administered was below 5 ml and slightly more pronounced on the left than on the right. Given a high level of satisfaction overall, 71/78 (91.0 %) patients said that they would undergo the intervention again. CONCLUSION: For patients with primary, focal palmar hyperhidrosis CTSy represents a therapeutic option that offers good benefit and has few side effects. The amount and spatial distribution of the sympathicolytic agent has an influence on the therapeutic outcome and the side effects. KEY POINTS: · CT-assisted thoracic sympathicolysis is a minimally invasive, low-complication therapy for treatment of severe forms of primary hyperhidrosis palmaris.. · CT-assisted thoracic sympathicolysis can usually be performed on an outpatient basis.. · The quantity and local distribution of the sympathicolytic agent has an influence on the therapeutic outcome and the side effects.. CITATION FORMAT: · Andresen J, Scheer F, Schlöricke E et al. CT-assisted thoracic sympathicolysis for therapy of primary hyperhidrosis palmaris-retrospective analysis of the influence of the amount and position of the sympathetic agent on the therapeutic outcome and side effects. Fortschr Röntgenstr 2021; 193: 574 - 581.

Interventional Angiography: Radiation Protection for the Examiner by using Lead-free Gloves.

INTRODUCTION: The radiation exposure to unprotected parts of the body requires special attention for the interventional radiologist. During angiographic procedures, hands are exposed to the direct X-ray beam and scattered radiation. AIM: The aim of the study was to evaluate the radiation exposure of examiners hand with the use of lead-free X-ray protective gloves in clinical practice in terms of shielding and sense of touch. The aim of the study was to evaluate the radiation exposure of examiners hand with the use of lead-free X-ray protective gloves in clinical practice in terms of shielding and sense of touch. MATERIALS AND METHODS: Phantom measurements were conducted in the direct X-ray beam and the area of scattered radiation with and without shielding. Examiner measurements were determined in interventional angiographies in clinical routine of the lower limb in antegrade puncture technique through the femoral artery. In 24 out of 50 interventions, an elastic natural rubber latex glove with lead-free metal shielding against radiation was used. All measurements were performed with a direct dosimeter. After the intervention, an opinion of the examiner was requested for evaluation of the sense of touch. RESULTS: Phantom measurements; when using the protective glove in the direct X-ray beam, a significant increase of the Dose Area Product (DAP) (1084.2-1603.8 mGy*cm2; 67.6%; p<0.001) as well of the examiner's hand dose (143-221.8 µSv; 64.5%; p<0.001) was observed. A significant reduction of the examiner's hand dose was verifiable for scattered radiation (1.76-0.75 µSv; 42.6%; p<0.001). Examiner measurements; if protective gloves were used, a significant increase of the DAP (6183.2-10462.9 mGy*cm2; 59.1%; p<0.05) and decrease of the average dose rate (0.76-0.43 mSv/h; 56.6%) for the entire procedure was determined. The tactile sensitivity was assessed as not restricted (18/24). CONCLUSION: The new generation of protective gloves is characterized by a shielding effect against X-ray scattered radiation, without restricting the sense of touch. A significant reduction in radiation doses to the examiner can be accomplished with these gloves in the area of scattered radiation only. If the gloves were used in the direct X-ray beam, especially while the artery puncture was performed, a significant increase of the dose values was observed.

Haemostasis with the FISH Vascular Closure Device after 6 French Transfemoral Accesses in Interventional Radiology: Clinical Results.

INTRODUCTION: Endovascular procedures have increased for different indications over the recent years. To achieve a safe haemostasis after arterial puncture and for more comfort for the patients different vascular closure devices have been developed. AIM: To evaluate the effectiveness and safety of a percutaneous closure system based on a matrix patch for achieving haemostasis. MATERIALS AND METHODS: In this study from 2014 to 2015 a percutaneous vascular closure system Femoral Introducer Sheath and Haemostasis (FISH) was used in 54 patients (mean age 69.0±10.7 years), in an antegrade and retrograde technique within the context of an angiographic intervention. The system was used in conjunction with transfemoral approaches with a sheath size of 6F. Postinterventionally (on the following day and after 6 weeks), follow-up was conducted clinically and using colour coded ultrasound. RESULTS: Immediate haemostasis was achieved in 50/54 patients (92.6 %). In 4 cases, an immediate haemostasis was not achieved. In these cases, manual compression was successful. There was one major complication, a retroperitoneal bleeding requiring transfusion. Minor complications were not observed. CONCLUSION: Safe and effective haemostasis is possible with the percutaneous FISH closure system at puncture sizes of 6 F. An immediate re-puncture after using FISH is possible.

Ruptured, Intracranial Dermoid Cyst - A Visual Diagnosis?

Dermoid cysts are a very rare entity of intracranial tumours. The traumatic or non-traumatic rupture of the cyst wall is a serious complication that can be treated surgically or conservatively depending on the clinical symptoms. However, more common entities have to be considered as a differential diagnosis. We report on a female patient who was admitted with complaints of significant, prolonged headache and diffuse pain. Analysis of her blood and cerebrospinal fluid indicated no clear pathology. A CT examination of the head revealed a ruptured dermoid cyst adjacent to the left sphenoidal bone. An additional MRI was conducted to confirm the CT findings and rule out an intracranial ischemia or vasospasms. A conservative therapy was scheduled and the patient recovered well. Using current imaging techniques, especially magnetic resonance imaging, it is possible to identify a ruptured dermoid cyst by its pathognomonic signal behavior and rule out potentially life threatening complications.

Colon-Cut-off-Sign in the CT-Scanogram - Evidence of Pancreatitis?

One of the less considered but radiologically characteristic signs in conventional radiographic imaging of the abdomen in acute pancreatitis is the so-called colon-cut-off-sign. This sign refers to the abrupt termination of gas filling of the colon at the level of the left flexure. The more distal part of the colon usually shows a markedly reduced or a lack of gas filling. This bowel gas distribution, which feigns a constriction of the colon at the left flexure, has been observed within the context of acute pancreatitis for over 50 years. The frequency and sensitivity of the Colon-cut-off-sign fluctuate considerably in different studies. It can also be demonstrated in computed tomography (CT) and in the retrograde contrast medium filling of the colon. We report on a patient who was admitted to the department of internal medicine with pronounced, progressive upper abdominal pain, combined with fever, elevated CRP, lipase and amylase, and leukocytosis, with suspected pancreatitis. Colonoscopy was interrupted due to stenosis in the area of the left flexure, a stenosing tumour being suspected. Over the course of further diagnostics, the scanogram of the abdominal CT already showed a colon-cut-off-sign. In addition, exudative pancreatitis with a stenosing process in the area of the left colonic flexure was found. A solid tumour could be ruled out in repeated endoscopy.

Diagnosis and Treatment of Symptomatic Carpal Bossing.

CONTEXT: Carpal bossing is an osseous formation at the dorsal portion of the quadrangular joint, which rarely becomes symptomatic. However, in some patients it causes pain, restricted mobility and can lead to complications like tendon rupture, inflammatory and degenerative joint disease. AIM: In this article, we present our experiences with this rare disorder in order to improve diagnostic and therapeutic proceedings. SETTINGS DESIGN: This is a multicenter and interdisciplinary observation made by orthopaedic surgeons and radiologists in the years 2010 to 2015. Retrospective observational study. The follow up period was 2 years. MATERIALS AND METHODS: In the observed time period, eight patients were diagnosed with symptomatic carpal bossing. Symptoms were pain at palmar flexion and limited mobility of the wrist in combination with a palpable protuberance over the quadrangular joint. All patients underwent X-ray, CT and MRI examinations. A conservative treatment strategy was initiated for 6 weeks in all patients, followed by a wedge resection when symptoms were persisting and disabling. RESULTS: After the conservative treatment schedule, five patients were asymptomatic. Three patients had persisting pain and were thus recommended for surgery. In the postoperative course, two patients were asymptomatic. One patient developed a type 1 complex regional pain syndrome (CRPS) in the first postoperative year, which was successfully treated with pain-adapted physiotherapy, pharmacotherapy with analgesics and calcitonin, and a triple CT-guided thoracic sympathetic nerve blockade. CONCLUSION: Carpal bossing is a mostly asymptomatic entity, which in our experience gets symptomatic due to direct trauma or repetitive stress, especially in competitive racket sports players. It can be diagnosed by thorough clinical examination and multimodal diagnostic imaging. Conservative treatment comprises an excellent prognosis, however surgery, either wedge resection or arthrodesis, must be considered if the response is not positive after 6 weeks.

Ectopic mediastinal thyroid tissue with a normally located thyroid gland.

Ectopic thyroid tissue (ETT) is a rare entity and a challenging differential diagnosis. This is a report of a case of a mediastinal mass that was found to be an ectopic mediastinal thyroid tissue, in a 77-year-old woman who was admitted to our hospital for breast cancer management. The mediastinal mass was identified in the postsurgical computed tomography (CT) scan of the chest and was suspected as mediastinal lymph node metastasis. A CT-guided percutaneous transthoracic punch biopsy (CT-TPB) proved to be an adequate diagnostic tool to exclude malignancy and provide a definite diagnosis of the mediastinal mass. We find that CT-guided punch biopsy as a useful diagnostic alternative enabling histopathological specimens to be obtained from mediastinal masses and lymph nodes suspected of malignancy.

Laparoscopic Pylorus- and Spleen-Preserving Duodenopancreatectomy for a Multifocal Neuroendocrine Tumor.

BACKGROUND: In contrast to laparoscopic left pancreatic resection, laparoscopic total duodenopancreatectomy is a procedure that has not been standardized until now. It is not only the complexity that limits such a procedure but also its rare indication. The following article demonstrates the technical aspects of laparoscopic pylorus- and spleen-preserving duodenopancreatectomy. CASE REPORT: The indication for intervention in the underlying case was a patient diagnosed with a multiple endocrine neoplasia (MEN) I syndrome and a multifocal neuroendocrine tumor (NET) infiltrating the duodenum and the pancreas. The patient was post median laparotomy which was necessary after jejunal perforation due to a peptic ulcer. The resection was carried out entirely laparoscopically, and the reconstruction, which included a biliodigestive anastomosis and a gastroenterostomy, was carried out by means of a median upper abdomen laparotomy of 7 cm in length through which the resected specimen was also removed. The total operative time was 391 min. The blood loss accounted for 250 ml. The postoperative course was uneventful, and the patient was discharged on the eighth postoperative day. CONCLUSION: Laparoscopic pancreatectomy is a treatment option in carefully selected indications. The complexity of the operation demands a high level of expertise in the surgical team.

Irreversible electroporation ablation of malignant hepatic tumors: subacute and follow-up CT appearance of ablation zones.

PURPOSE: To describe findings on contrast-enhanced computed tomography (CT) images of malignant hepatic tumors 24-72 hours after percutaneous ablation by irreversible electroporation (IRE) and at midterm follow-up. MATERIALS AND METHODS: Retrospective analysis of 52 malignant liver tumors-30 primary hepatic tumors and 22 hepatic metastases-in 34 patients (28 men and 6 women, mean age 64 y) treated by IRE ablation was performed. Ablation zones were evaluated by two examiners in a consensus reading by means of a dual-phase CT scan (consisting of a hepatic arterial and portal venous phase) performed 24-72 hours after IRE ablation and at follow-up. RESULTS: During the portal venous phase, ablation zones either were homogeneously hypoattenuating (n = 36) or contained heterogeneously isoattenuating or hyperattenuating (n = 16) foci, or both, in a hypoattenuating area. Of 52 lesions, 38 included gas pockets. Peripheral contrast enhancement of the ablation defect was evident in 23 tumors during the arterial phase and in 36 tumors during the portal venous phase. Four tumors showed intralesional abscesses after the intervention. At follow-up (mean, 4.7 mo), the mean volume of the ablation defects was reduced to 29% of their initial value. CONCLUSIONS: Because normal findings on contrast-enhanced CT images after IRE ablation may be very similar to the typical characteristics of potential complications following ablation, such as liver abscesses, CT scans must be carefully analyzed to distinguish normal results after intervention from complications requiring further treatment.

CT-assisted sympathicolysis as an additional minimally invasive therapeutic option in primary focal plantar hyperhidrosis.

PURPOSE: The purpose of this retrospective study was to evaluate the benefit of lumbar computed tomography-assisted sympathicolysis (CTSy) in patients with primary focal hyperhidrosis of the feet. METHODS: A lumbar CTSy was conducted on 35 patients (mean age 36.6 ± 11.9 years) with primary focal hyperhidrosis of the feet, who experienced persistent symptoms after all conservative treatment options had been exhausted. The patients evaluated the severity of their symptoms before the intervention, 2 days after the intervention, and 6 and 12 months after the intervention on the basis of a Dermatology Quality of Life Index(©) (DLQI) and side effects experienced. RESULTS: The interventions performed led to a statistically significant decrease in the preinterventional severity of symptoms 2 days after the intervention, and 6 and 12 months after CTSy (p < 0.05). No major complications occurred. As the most common side effect, 12 of the patients reported compensatory sweating. CONCLUSIONS: After conservative measures have been exhausted or as a complement to the existing therapy regimen, CT-assisted sympathicolysis represents a therapeutic option low in side effects that provides a marked benefit to patients with primary, focal hyperhidrosis.

Endovascular treatment of aneurysms of the popliteal artery by a covered endoprosthesis.

PURPOSE: The current gold standard of popliteal artery aneurysm (PAA) treatment is saphenous vein bypass grafting. The aim of this retrospective single-center study is to investigate the safety and efficacy in the treatment of PAA by an endovascular implanted covered endoprosthesis. MATERIALS AND METHODS: Ten patients, mean age 64.6 (range, 52-78) years, with PAA were treated with an expanded Polytetrafluoroethylen (ePTFE)-covered stent graft (Viabahn(®), W.L. Gore and Associates Inc, Flagstaff, AZ, USA). In median, 1.4 prostheses were implanted with a median length of 180 mm. Follow-up visits included determination of ankle-brachial index (ABI) and color-coded duplex sonography. RESULTS: The technical success rate was 100% (10/10). Clinically, there was an increase in ABI from 0.62 ± 0.17 to 0.91 ± 0.15 postinterventionally and to 0.89 ± 0.16 after an average follow-up of 24.7 months. During the follow-up period, 2 (20%) stent occlusions occurred; both of them were treated with a bypass graft. CONCLUSION: The treatment of PAA with covered endoprosthesis is a safe and effective alternative to open surgical therapy, where open surgical therapy is contraindicated or patient refused open surgery.

Transpopliteal balloon-assisted excimer-laser atherectomy for the treatment of chronic femoropopliteal occlusions: feasibility and initial results.

PURPOSE: Recanalization of chronic total occlusions (CTOs) of the femoropopliteal arteries depends on a successful lesion crossing with the guide wire. The aim of this retrospective study was to evaluate the safety, feasibility, and the primary results of retrograde recanalization of CTOs with balloon-assisted excimer-laser atherectomy (ELA) via a transpopliteal approach after failed antegrade attempts. METHODS: A total number of 15 patients (10 male, 5 female) with a mean age of 68.5 years (range: 43-91 years) treated with retrograde transpopliteal ELA in the years 2009-2012 were included retrospectively. After unsuccessful antegrade recanalization attempts with conventional guide wires and catheters, patients were treated with a retrograde recanalization attempt via a transpopliteal access using an excimer laser, followed by pressure-only balloon angioplasty (POBA). The mean length of the CTOs in the femoropopliteal arteries was 17.8 ± 5.4 cm (range: 9-29 cm). RESULTS: Technically successful recanalization was achieved in 14 of 15 patients. Provisional stenting was done in two cases. There were no major adverse events regarding the laser atherectomy or popliteal access site. One acute reocclusion was observed in the first 48 hours after intervention. The ankle-brachial Index increased from preinterventional 0.45 ± 0.07 to 0.77 ± 0.29 (P < 0.05) in the follow-up period (1.5 months), resulting in a primary patency of 80%. CONCLUSION: The retrograde ELA for recanalization of chronic femoropopliteal occlusions via a popliteal access turned out to be a safe and effective procedure with promising primary results. Thus it may be an endovascular treatment option for long chronic occlusions after failed antegrade recanalization or in patients who are not suitable for surgery.

Rare case of a chondrosarcoma of the mandible in a child.

Chondrosarcoma of the mandible is rare, especially in children. The available literature consists mostly of a few case reports which are partly integrated in small studies. Growing this small pool of literature is helpful in solidifying knowledge about this disease and facilitating appropriate treatment for children. Therefore, we present such a case in a 12-year-old boy, exhibit comprehensive and relevant information concerning this entity, and discuss our findings in the context of other publications.

Transarterial Chemoembolization of Child-A hepatocellular carcinoma: drug-eluting bead TACE (DEB TACE) vs. TACE with cisplatin/lipiodol (cTACE).

BACKGROUND: This study is an outcome evaluation of the Drug-Eluting-Bead-Chemoembolization (DEB TACE) compared to conventional TACE (cTACE) with Cisplation and Lipiodol in patients with hepatocellular carcinoma (HCC) and Child-Pugh A Cirrhosis. MATERIAL/METHODS: A comparison of interventional therapy with either cTACE or DEB-TACE of 22 patients each with unresectable HCC and Child-Pugh A Cirrhosis was carried out. A comparison of therapy-associated complications, tumour response rates and mean survival was performed. Tumour response was evaluated in accordance with the European Association for the Study of the Liver (EASL) response criteria by two radiologists in consensus reading. RESULTS: The choice of TACE procedure (DEB TACE/cTACE) had no significant impact on therapy-associated complications. Objective Response (OR, complete response + partial response) for DEB-TACE was 22.7%; a further 68.2% was stable disease (SD). The respective response rates for the cTACE were OR 22.7 and SD 31.8%. Thus disease control was not significantly increased for DEB TACE (p=0.066). After DEB-TACE mean survival was significantly prolonged with 651 ± 76 days vs. 414 ± 43 days for cTACE (p=0.01). CONCLUSIONS: Associated with a similar safety profile and an at least comparable tumour response, the DEB-TACE is a method of treatment for HCC that has the potential to improve mean survival compared to cTACE with Cisplatin/Lipiodol.