[Big surprise in the lesser pelvis]. / Große Überraschung im kleinen Becken.

A 17-year-old young man presented at our clinic with asymptomatic microhematuria. Ultrasonography and computer tomography found an intraperitoneal lesion of unknown dignity located on top of the bladder. Surgical exploration and histological examination confirmed the diagnosis of a secondary pelvic spleen, a lien bipartitus.

[Intrathoracic hernia after laparoscopic nephrectomy: clinical manifestation and conservative management]. / Enterothorax nach laparoskopischer Nephrektomie : Klinische Manifestation und konservatives Management.

Diaphragmatic hernia can be inborn as well as acquired. We report on the manifestation of an intrathoracic hernia after laparoscopic nephrectomy. Intraoperative and postoperative complications could make intense medical treatment or further surgery necessary. In cases of lasting abdominal discomfort or pulmonary symptoms after abdominal surgery, radiological investigation to exclude intrathoracic hernia should be considered.

["Malignant" ARDS]. / "Malignes" ARDS.

Acute respiratory failure and the "acute respiratory distress syndrome" (ARDS) are frequent medical conditions in critically ill patients. Various causes can potentially result in the development of ARDS. Two cases are presented, in which malignant diseases were identified as causes of the respiratory failure. The first patient was diagnosed with an acute myeloic leukemia M5 (FAB). In the second patient, lung histology revealed an adenocarcinoma of the lung. These case reports show that in addition to the classical causes of ARDS, specific disease entities can mimic this form of respiratory failure. Beside solid cancers and lymphomas, acute and progressive forms of inflammatory, parenchymal lung diseases (such as acute interstitial pneumonitis, acute eosinophilic pneumonia, diffuse alveolar hemorrhagia, and acute hypersensitivity pneumonitis) can manifest with this picture. As a consequence, the diagnostic workup of respiratory failure of unknown cause should include these entities.

[Secretin-enhanced magnetic resonance cholangiopancreaticography: value for the diagnosis of chronic pancreatitis]. / Sekretinstimulierte Magnetresonanzcholangiopankreaticografie (MRCP): Wertigkeit in der Diagnostik der chronischen Pankreatitis.

Endoscopic retrograde cholangiopancreaticography (ERCP) is the morphologic gold standard for the diagnosis of chronic pancreatitis. Magnetic Resonance Imaging (MRI) enables the visualization of not only the pancreatic duct but also the surrounding parenchyma using T2- and T1-weighted sequences before and after the application of a contrast agent. Moreover, it allows the depiction of ductal segments distal to a stenosis or occlusion. However, conventional Magnetic Resonance Cholangiopancreaticography (MRCP) was not able to achieve accuracy similar to that of ERCP. Despite many technological innovations, such as fast breath-hold acquisitions or respiratory-gated 3D sequences, this drawback could not be overcome. In recent years, secretin-enhanced MRCP has been used for the diagnosis of chronic pancreatitis. A recent study showed that secretin not only improves the visibility of the pancreatic duct and its side branches but it also enhances the diagnostic accuracy of MRCP. The sensitivity, specificity, and positive and negative predictive values were improved by the application of secretin. Moreover, the agreement between independent observers increased after the use of secretin. In addition, quantitative post-processing tools have been developed that enable the measurement of the exocrine pancreatic output non-invasively using secretin-enhanced MRCP. These tools facilitate applications, such as functional follow-up after pancreaticogastrostomy and pancreaticogastric anastomoses, evaluation of the functional status of the graft after pancreas transplantation and follow-up of pancreatic drainage procedures and duct disruption.

[False aneurysm and bleeding caused by a secondary dislocated lesser trochanter fragment]. / Aneurysma spurium und verzögerte Blutungskomplikation durch ein sekundär disloziertes Trochanter-minor-Fragment bei pertrochantärer Femurfraktur.

A 92-year-old woman incurred an unstable pertrochanteric hip fracture with avulsion of the lesser trochanter (type 31-A2 according to the AO classification). The fracture was treated by gliding nail osteosynthesis, without fixing the minimally displaced lesser trochanter. No intra- or postoperative complications were detected. Suddenly, after 30 days, a swelling of the proximal femoral region, accompanied by signs of haemorrhage, occurred.CT-scans showed a false aneurysm of the deep femoral artery and a dorsal laceration of the artery proximal to the aneurysm. X-rays showed a further dislocation with rotation of the lesser trochanter fragment. Intraoperatively, the tip of the lesser trochanter fragment was identified to be responsible for the laceration of the artery. The false aneurysm was resected and the defect bridged by a vascular prosthesis while the fragment was removed. Follow-up showed no further complications. According to case reports from the literature, false aneurysms and laceration of the deep femoral artery caused by dislocated lesser trochanter fracture fragments are rare.

[A holder for standardized radiological detection of ulnar capsule-ligament lesions of the thumb base joint]. / Halteapparat zum standardisierten radiologischen Nachweis ulnarer Kapsel-Band-Läsionen am Daumengrundgelenk.

AIM OF THE STUDY: To evaluate the usefulness of a self-constructed holding device for standardized, investigator-independent radiodiagnostics for ulnar capsulo-ligamentous lesions of the thumb metacarpophalangeal joint compared to the uninjured side. MATERIAL AND METHODS: A holding device for stress roentgenograms was constructed. Normal abduction arcs were evaluated in 20 degrees flexion in 28 healthy volunteers. The investigator-dependent variance was assessed. The study group comprised 123 consecutive patients (68 male, 55 female, aged 7 to 68 years, mean age 30 years). RESULTS: The normal arc of abduction was calculated to be 12 degrees (range 3 degrees to 24 degrees), while the mean individual difference in side by side comparison in volunteers was 0.3 degree (SD 2.69 degrees, range 0 degree-8 degrees). A rupture was diagnosed in 47 patients; 41 were operated. The preoperative diagnoses confirmed correct in all operated patients. A difference of greater than 6 degrees is indicative of a rupture with a sensitivity of 66.7% and a specificity of 96.9%. CONCLUSIONS: In summary, the holding device is useful for the practical work. Individual differences of less than 4 degrees are negative, between 4 degrees and 7 degrees questionable positive, between 7 degrees and 12 degrees are positive and over 12 degrees proof indicator of a rupture of the ulnar collateral ligament of the thumb metacarpophalangeal joint.

Angiography, CT and MR imaging of a high vena cava inferior interruption in a patient with Hirschsprung disease.

We report on a high vena cava inferior interruption immediately at the insertion to the right atrium in a patient with Hirschsprung disease assessed by angiography, CT, and MRI. Hirschsprung disease is frequently associated with Down, Undine, Waardenburg, Bardet-Biedl, Smith-Lemli-Opitz and Goldberg-Sphrintzen syndromes. We suggest that the association of these two malformations are most likely interrelated and should be considered as a new syndrome.

Thrombotic pulmonary arteriopathy in polycythemia vera.

Pulmonary infarction and hemorrhage are important differential diagnoses in pulmonary coin lesions, especially in patients with underlying hematologic malignancies. We report a 58-year-old female patient suffering from polycythemia vera presenting with multiple pulmonary coin lesions. Open lung biopsy and subsequent histologic investigations showed organized pulmonary infarction and primary pulmonary thrombotic arteriopathy. Although histologic features are non-contributory in distinguishing organized thrombosis from organized thromboembolism, the clinical setting and localization of the lesions suggest that in the present case the vascular lesions are due to organized thrombosis.

Radical nephrectomy for renal cell carcinoma: Is adrenalectomy necessary?

OBJECTIVES: The role of simultaneous adrenalectomy in combination with radical nephrectomy in the treatment for renal cell carcinoma (RCC) remains controversial. With nephron-sparing surgery being commonly applied, the indication for adrenalectomy has to be critically assessed. PATIENTS AND METHODS: In a retrospective analysis the outcome of 589 patients, who underwent ipsilateral adrenalectomy along with radical nephrectomy in the treatment for RCC between 1985 and 1997 at our institution, was evaluated. The mean follow-up time was 34 months (range 1-95). RESULTS: Histologically an ipsilateral adrenal metastasis was found in 19/589 patients (3.2%). 16/19 patients had >/= T3, 3/19 had T1 tumours. The average size of the primary tumours with adrenal metastasis was 7.8 cm (range 2.3-13) in diameter with no preferential primary tumour site within the kidney (6/19 upper, 4/19 middle and 9/19 lower third). Only 4/19 patients had suspect adrenal findings in preoperative diagnostics (ultrasound, CT scan). 6/19 (31.5%) patients with adrenal metastasis are alive without evidence of disease at a mean of 41 months (range 11-95) after surgery for RCC. CONCLUSIONS: The probability of adrenal metastasis correlates with primary tumour stage, but not with its location within the kidney. The preoperative diagnostics are not reliable concerning small adrenal metastases. We thus still recommend simultaneous adrenalectomy in those cases where radical nephrectomy in patients with RCC is indicated.

[Control of percutaneous biopsy with CT fluoroscopy]. / Steuerung von perkutanen Biopsien mittels CT-Fluoroskopie.

PURPOSE: Clinical evaluation of CT fluoroscopy and comparison with conventional CT guidance for monitoring of non-pulmonary percutaneous biopsy procedures. MATERIALS AND METHODS: 20 non-pulmonary CT-guided biopsy procedures were prospectively performed either with CT fluoroscopy or with conventional CT guidance. CT fluoroscopy was performed using 120 kV and 50, 70 or 90 mA at a frame-rate of three or six images per second. Number of punctures and biopsies, procedure times, radiation doses and histologic results were analyzed separately for conventional CT guidance and for CT fluoroscopy. RESULTS: With CT fluoroscopy, yield of biopsies was improved (p = 0.005, t-test) and procedure times were shorter than for conventional CT guidance (11.4 +/- 6.0 vs. 23.6 +/- 13.8 min; p = 0.03, t-test). Analysis of procedure related radiation exposure and histologic outcome showed no significant difference between conventional and fluoroscopic CT-guided procedures (p > 0.05, t-test). CONCLUSIONS: CT fluoroscopy facilitates guidance of percutaneous biopsy procedures. Compared to conventional CT assistance, procedure times are decreased while yield of biopsies is improved.

[Calcaneus cyst--an indication for surgery? Case report and review of the literature]. / Die Kalkaneuszyste--Eine Indikation zur Operation? Fallbericht und Literaturübersicht.

Simple bone cysts are asymptomatic, benign lesions which are usually an incidental finding on a radiograph. Etiology and treatment are controversially discussed. The weight-bearing status of the calcaneus and possible pathologic fracturing lead many authors to recommend therapeutic measures after diagnosis has been made. We present a case report of an intact unicameral bone cyst of the calcaneus concomitant with tibial and talar fractures following crush trauma. Several types of treatment for simple bone cysts of the calcaneus have been suggested. The question whether treatment is unconditionally necessary is controversially discussed. It is the author's opinion, that asymptomatic bone cysts of the calcaneus require no further treatment.

Computer-tomographically guided fiberbronchoscopic transbronchial biopsy of small pulmonary lesions: a feasibility study.

Small pulmonary lesions localized in peripheral airways or lung parenchyma are mostly not visible by means of flexible or rigid bronchoscopy for they are distal to the inspectable airway caliber. Therefore fluoroscopy is necessary to direct the flexible biopsy forceps or biopsy needle to the lesion. Even a two-dimensional fluoroscopic guidance does not guarantee an access to the focus. Therefore we investigated a method to overcome these problems. In 9 patients with peripheral lung lesions where the conventional method had failed to provide sufficient biopsies CT-guided bronchoscopy was done. Central airways were carefully inspected, and the flexible forceps was introduced into the bronchial branch leading to the focus under fluoroscopic control. Then the forceps was localized in the axial plane by CT and guided directly to the lesion. Subsequently the forceps was opened and contact to the lesion was confirmed by CT scan before the biopsies were taken. Thus the three-dimensional control of the position of the forceps made it possible to get biopsies directly from the region of interest. The method provides the possibility of reaching even small peripheral lesions that have been missed by the conventional techniques, thereby, although technically more difficult for the examiner, providing a smaller risk of complications and no additional discomfort for the patient.

[Treatment of acute pulmonary infection in a mucoviscidosis patient with extracorporeal lung support]. / Behandlung eines akuten pulmonalen Infektes bei einem Mukoviszidose-Patienten mittels extrakorporaler Lungenunterstützung.

This is a report on a mucoviscidosis patient of 30 years of age suffering from refractory acute failure of pulmonary function during acute exacerbation of an infection with Pseudomonas aeruginosa. To avoid further barotraumatisation of the lungs due to continually increasing artificial respiratory pressure, and to set the lung at rest until subsidence of a concomitant severe bronchial obstruction, we performed modified extracorporal lung assist (ELA). The gas exchange improved rapidly with the help of relevant accompanying measures (including negative liquid balance, administration of antibiotics, etc.) and the pulmonary infection also subsided to a major extent. 26 days after the end of the bypass the patient could be transferred for lung transplantation.

Reproducibility of the pettersson scoring system. An interobserver study.

By means of the Pettersson scoring system, the degree of severity of haemophilic arthropathy in 128 knee, elbow and ankle joints was estimated by 5 radiologists. Their scores varied on average by approximately 3 points. Minimal and maximal joint involvement were scored consistently; exclusion of haemophilic arthropathy was possible with the highest degree of certainty. With regard to changes of a moderate degree agreement was seldom reached. With precisely defined characteristics, a high degree of consistency between observers was evident. Interobserver variation in the scoring was more marked in the ankle joint than in the other joints. Scoring was more consistent with the more experienced observers.

[Accidental finding of a giant retroperitoneal lipoma in a traumatic rupture of the renal parenchyma]. / Zufallsbefund eines retroperitonealen Riesenlipoms bei traumatischer Nierenparenchymruptur.

With a rate of 0.1-3% of all tumour cases primary retroperitoneal neoplasms are very rare. Malignant tumours predominate. Preoperative radiological clarification as regards tumour status is very unsafe unless there are indications of infiltrating growth and metastases. In some cases, computed tomography can supply pointers to the kind of the tumour.