Mesenteric ischemia after a cardiac operation: arteriosclerotic versus vasospastic etiology.

Gastrointestinal complications after extracorporeal circulation are rare but well known complications. We describe and illustrate 2 patients with occlusive intestinal ischemia of different origin presenting after cardiopulmonary bypass (CPB) and present the different therapeutic algorithm.

Therapeutic embolization of a systemic arterialization of lung without sequestration.

We report the case of a 51-year-old man with massive haemoptysis due to a systemic arterialization of lung without sequestration. Unlike bronchopulmonary sequestration there was a normal bronchial distribution and the involved lung parenchyma was normal. Therefore a therapeutic transarterial embolization of the aberrant systemic vessel from the distal thoracic aorta was performed. The embolization was successful and the patient did not suffer from further haemoptysis during the subsequent follow-up of ten months. A postembolization aortogram 6 months later demonstrated a complete occlusion of the embolized aberrant artery; in the lung perfusion scan there was only a small perfusion defect, but normal ventilation in the embolized basal part of the left lower lobe. Our case represents an alternative treatment to surgery for this rare anomaly.

[Ultrasound findings after shoulder dislocation]. / Sonographische Befunde nach Schulterluxation.

AIM: Sonography of the shoulder is an effective method for detecting tears of the rotator cuff and bone lesions. The purpose of this study was to evaluate prospectively the sonographic findings after shoulder dislocation. METHODS: Sonography was performed on 208 patients with 210 shoulder dislocations, which were all verified by radiography. RESULTS: We diagnosed 62 rotator cuff lesions (29.5%), which were all in the group with traumatic shoulder dislocation. The incidence of tears in patients with first traumatic dislocation (n = 134) was 36.5%. 12 tears (21.8%) of the rotator cuff were noted in recurrent dislocations (n = 55). 23 fractures or bony avulsions of the greater tuberosity of the humerus (11%) and 168 Hill-Sachs lesions (80%) were seen. CONCLUSION: Sonographic examination of the shoulder revealed a significant amount of information that would remain undetected without the aid of expensive and/or invasive diagnostic tools.

Mesenteric ischemia after a cardiac operation: conservative treatment with local vasodilation.

Acute mesenteric ischemia is a rare and often fatal event after cardiopulmonary bypass. We describe a diagnostic and therapeutic algorithm and present a patient with nonocclusive intestinal ischemia who had a successful conservative treatment.

[The treatment of stenosis of central veins using percutaneous implantation of self-expanding metal stents]. / Die Behandlung von Stenosen zentraler Körpervenen durch perkutane Implantation von selbstexpandierenden Metallendoprothesen.

16 patients with 14 stenoses of the superior vena cava and two stenoses of the iliac veins were treated with percutaneous dilatation and stent implantation. In 14 patients, this treatment resulted in complete relief of their venous obstructive syndrome within 6 to 24 hours. 13 patients remained free of symptoms of venous obstruction during an average follow-up time of six months. In agreement with similar results of other authors, percutaneous interventional therapy proves to be a very efficient alternative to conservative or surgical treatment of central venous obstruction.

[The value of defecography for diagnosis of rectocele and rectal prolapse]. / Die Bedeutung der Defäkographie für die Diagnose der Rektozele und des Rektalprolapses.

The role of defecography with respect to rectoceles and to any grade of rectal prolapses has not been defined so far. Therefore, we studied 42 out of 45 patients that were submitted to a defecography between 1988 and 1992 for defecation disorders of unknown origin. In particular, we compared the diagnosis obtained by anamnestic data and the physical examination with the defecographic results and the definitive diagnosis with regard to the chosen therapies and the results. Rectocele and rectal prolapse were very frequent pathologies with 69% and 33% respectively. Of 23 patients with a clinically palpable rectocele, defecography was false negative in 4 and moreover, it did not provide any information about the functional relevance of the rectocele. Yet, it disproved the clinically diagnosed prolapses in 6 of 15 subjects, but revealed one in 5 of 27 patients that were presumed normal. On the other hand, a previously not diagnosed rectocele was detected in 6 out of 19 patients by means of defecography, but none of them proved to be of any clinical relevance. Of all rectoceles, only 48% were regarded responsible for the patients' symptoms and were therefore operated. Hereby, the indication for a surgical approach based more on anamnestic data and the proctological examination than on radiographic findings. Contrarily, the indication for a rectopexy--even if given only in 4 of those 14 patients with any grade of invagination--mainly based on the dynamics during defecation as documented by defecography.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the Wallstent in the venous system including hemodialysis-related stenoses.

Eighteen patients with a total of 23 venous stenoses or occlusions were treated with the Wallstent. In 5 patients treated for malignant stenosis there was one primary failure due to insufficient stent expansion. The other 4 patients showed rapid relief of their inflow obstruction, all remaining asymptomatic despite later stent occlusion in 1 patient. Four patients were treated for benign postoperative stenoses of the iliac or femoral vein. All stents remained patent for a period of 6 weeks-58 months. Nine patients were treated for one or multiple stenoses along the venous outflow tract of hemodialysis fistulas. Of 14 lesions that were eventually stented, 12 are still patent after 3-27 months (mean 19). However, 10 secondary interventions (eight percutaneous transluminal angioplasty (PTA), two stents) and three additional stent procedures for new lesions were necessary. Although our experience is limited, we believe that patients with tumor compression or postoperative strictures of large veins benefit from treatment with stents. Stenting of venous outflow stenoses in hemodialysis fistulas can significantly prolong stent function, however, PTA should always be the first treatment of choice.

[The etiological differentiation of neuromuscular produced dysphagia by x-ray cinematography]. / Die ätiologische Differenzierung von neuromuskulär bedingten Schluckstörungen mittels Röntgenkinematographie.

850 patients with dysphagia were examined by x-ray cinematography. On the basis of these examinations the normal events of swallowing are compared with the abnormalities observed. The technique is described. An algorithm has been developed depending on the presence of symmetry or asymmetry of the abnormalities and on muscle tone, which permits classification of the various aetiological groups. In addition, specific features of individual diseases often make it possible to arrive at a definite diagnosis.

[Current possibilities in radiology for the diagnosis and therapy of gastrointestinal hemorrhage (roentgen diagnosis, nuclear medicine and interventional radiology)]. / Die heutigen Möglichkeiten der Radiologie zur Diagnostik und Therapie gastrointestinaler Blutungen. (Röntgendiagnostik, Nuklearmedizin und interventionelle Radiologie).

Especially in acute gastrointestinal bleeding, conventional x-ray examinations with barium sulfate contrast are obsolete. On the other hand, blood pool scintigraphy and selective angiography are efficient methods to localize bleeding sources that have not been identified by prior endoscopy. In the interval between acute bleeding episodes, only vascular or highly vascularised lesions--as aneurysms, angiomas and leiomyomas--can be demonstrated. In all other lesions, active bleeding during the examination is a prerequisite. Angiography has not only a diagnostic, but also a therapeutic potential. By preoperative hemostasis, the circulatory conditions of the patient can be stabilized and surgery can be performed with a lower mortality risk. In "poor risk" patients, transarterial therapy can replace surgical interventions.

Endovascular stenting of veins and grafts: preliminary clinical experience.

Stenotic lesions of veins and bypass grafts are often difficult to dilate and have a high frequency of recurrence. In an effort to provide an endoluminal mechanical support, the new concept of transluminal vascular stenting was applied in four patients with stenoses of nonarterial vessels, including two with postoperative venous stenoses, one with a stenosed mesenteric artery graft anastomosis, and one with a long stenosis of the basilic vein distal to a hemodialysis shunt graft. All four were successfully treated with percutaneous transluminal angioplasty followed by endovascular stenting. All but one of the stented segments were patent, with no significant restenosis after a follow-up of 4 1/2-12 months. There have been previous reports of transluminal vascular stenting in the arterial system, and the preliminary results from this study suggest that endovascular stenting also may play an important role in the treatment of venous and graft stenoses. However, further follow-up and careful patient selection will have to be done to establish the long-term benefit of this new procedure.

[Cricopharyngeal myotomy in dysfunction of the pharyngo-esophageal sphincter]. / Cricopharyngeus-Myotomie bei Dysfunktion des pharyngo-ösophagealen Uberganges.

Dysphagia due to upper esophageal sphincter dysfunction is usually diagnosed by cineradiography. If the treatment of an underlying disorder fails to improve swallowing or if the dysfunction is thought to be idiopathic, cricopharyngeal myotomy is considered the treatment of choice. In properly selected cases (i.e. significant dysphagia and radiological proof of pharyngo-esophageal dysfunction) cricopharyngeal myotomy offers complete or at least substantial relief of symptoms for three out of four patients. The use of an operating microscope is strongly advised.

[Angiographic, cavernosonographic and clinical differentiation of two forms of priapism with different prognoses]. / Angiographische, kavernosographische und klinische Unterscheidung zweier Priapismusformen mit unterschiedlicher Prognose.

Based on the findings upon arteriography, cavernosography and clinical features two different kinds of priapism are differentiated: Type I ("low flow priapism") is characterized by severe blood stasis within the corpora cavernosa and reduction of arterial perfusion through compression of the deep arteries of the penis. The penis is very hard and painful upon palpation. A delay of treatment over 48 hours will result in a damage of the corpora cavernosa and impotence. Type II ("high flow priapism") is characterized by arterial hyperperfusion. Outflow obstruction is absent. The penis is erected but of an elastic consistence, pain is absent. Even with a delay of treatment of up to 6 months the corpora cavernosa remain intact, normal erectile function is preserved.