[Transcutaneous electric stimulation of the heart]. / Transkutane elektrische Stimulation des Herzens.

Transcutaneous cardiac pacing had been introduced in the 1950s, but was given up because of severe side-effects. In the 1980s, this technique became again popular thanks to technical improvement. These are the indications: Adams-Stokes syncope, hemodynamically significant SA or AV blocks, significant bradycardias, overdrive-stimulation in tachycardiac arrhythmias. In cardiocirculatory resuscitation, this method is not very successful (as are all other techniques of cardiac stimulation), if electromechanical dissociation has occurred. This shows, that this method has to be employed without delay, especially since there are new models, which can easily be used in the ambulance. One can only conclude, that all ambulances and helicopters staffed with physicians trained in emergency medicine should carry this equipment. The article reports on the technique, the handling and the literature on transcutaneous cardiac pacing.

[Importance of cardiocirculatory and pulmonary monitoring in endoscopic retrograde cholangiopancreatography (ERCP)]. / Bedeutung der kardiozirkulatorischen und pulmonalen Uberwachung bei endoskopisch-retrograden Cholangiopankreatikographien (ERCP).

Among the side effects of endoscopy, cardiopulmonary complications are particularly important. This risk appears to be greatest in endoscopic retrograde cholangio- and pancreaticography (ERCP) because of the patient's prone position, iv sedatives and analgetics and the relatively long duration of the examination. We studied 75 patients (50 patients without and 25 patients with premedication) who were to undergo ERCP and looked at these data: age, weight, premedication, accompanying diseases, reason for this examination, blood count, oxygen saturation SaO2 (pulse oximeter), pulse, blood pressure and length of the examination. Overall, the oxygen saturation decreased considerably and two patients only had 69%. Pulse rate increased and one patient had 205 beats per minute, one 172. We looked for a correlation between SaO2, pulse rate and blood pressure and studied the patients' usual medication, the length of the ERCP, the indication for ERCP, age and hemoglobin. There was no correlation. But all patients suffering from a compromised cardiopulmonary status had received a rather heavy premedication and the ERCP was longer than in other patients. Since it is not clear which patients may develop cardiopulmonary complications, it is advisable to monitor all patients by pulse oximeter in order to avoid these complications. This seems also advisable because the rooms where the examination takes place are darkened and the patient is in a prone position so he cannot be seen clearly.

Comparison study of the Hepcon System Four and the Hemostasis Management System.

Milwaukee Heart Surgery Associates, in affiliation with St. Mary's Medical Center, were asked to be clinical investigators for a comparison study of the current Hepcon System Four (HSF) and the next generation Hemostasis Management System (HMS) manufactured by HemoTec, Inc. The HSF has been in place at St. Mary's Medical Center for the past three years in a programme that performs approximately 900-1100 cardiac procedures a year. Heparin assays and high range activated clotting times (HR-ACTs) are performed routinely on all patients placed on cardiopulmonary bypass (CPB). This study will evaluate the results based upon the two systems run in tandem on a series of patients undergoing cardiac surgery with no exclusions, i.e. valve repair or replacement and myocardial revascularization. The study sets out to determine whether or not the new generation HMS has any distinct advantages over the HSF and whether it is or is not suitable for this clinical setting.

[Pancreatitis-induced pseudocysts of the spleen: a rare complication]. / Pankreatitisinduzierte Pseudozysten der Milz: Eine seltene Komplikation.

Secondary splenic cysts usually occur following blunt abdominal trauma. In rare cases, the spleen can be affected in pancreatitis. Since the clinical findings are fairly uncharacteristic, this was a difficult diagnosis to make before imaging examination techniques became available. These cysts only became apparent as a result of their complications. Today, thanks to sonography and abdominal CT-scan, these cysts can be detected in their asymptomatic stage. Furthermore, interventional sonography allows the puncture and drainage of these cysts, and this technique is thus an alternative to surgery. Two cases of pancreatitis with splenic involvement are presented.

Supportive angioplasty utilizing the Bard cardiopulmonary support device.

Bearing in mind that one case does not make a study, we would briefly like to elaborate on our exposure to cardiopulmonary support (CPS) at Milwaukee Heart Surgery Associates. CPS, in our opinion, is something that we will have to deal with whether we share the same cardiological philosophy or not. In order to provide the same standard of care to patients in the catheterization laboratory as we do for patients in surgery, it is incumbent upon us as perfusionists to be as knowledgeable and skilled as possible. A good rapport with the cardiologist and surgeon is essential in developing a workable protocol so as to avoid abuse of the technique. Direct visualization, with respect to cannulation and surgeon participation, is an ideal situation and is the standard of care in our practice. The cardiologist cannot perform supportive angioplasty utilizing CPS without consulting a surgeon, thereby minimizing some of the vascular complications that can arise as a result of nonsurgeon participation.

[Transpapillary cholangioscopy. A new diagnostic and therapeutic dimension]. / Die transpapilläre Cholangioskopie. Eine neue diagnostische und therapeutische Dimension.

Transpapillary cholangioscopy (TCS) was performed in 52 patients (12 men, 40 women; mean age 61.6 [39-86] years) in whom endoscopic retrograde cholangiography had not provided a firm diagnosis. TCS was unsuccessful in five patients for technical or anatomical reasons. In 33 of the remaining 47 patients (70%) the procedure gave diagnostically or therapeutically useful results: In seven patients with tumour in the biliary tract biopsies were obtained, while in eight with extraductal stenoses cholangiography was made possible and provided the diagnosis. In eight patients residual gall stones were removed; in three cholangioscopically guided lithotripsy was successful. TCS proved to be a simple method with few complications; it significantly improved the diagnosis and treatment of diseases in the biliary tract.

[Endoscopic balloon dilatation of benign choledochal stenosis]. / Endoskopische Ballondilatation einer benignen Choledochusstenose.

A 68-year-old woman was admitted because of septicaemia after cardiac valve replacement. Cause of the septicaemia was a proximal filiform common bile duct stenosis with recurrent gallstones and secondary cholangitis. A single pneumatic balloon dilatation widened the common bile duct. At the same time, specific antibiotic treatment cured the septicaemia. Nine months later no further dilatation has been necessary.

Through-the-scope balloon dilatation of benign pyloric stenoses.

In 9 patients with benign pyloric stenosis, the stenosis was dilated using through-the-scope (TTS) balloon catheters (diameter 1.5 to 1.8 cm), which can be passed through the biopsy channel of a standard fiberscope under direct vision. In all cases, the stenosis was secondary to fibrous changes in peptic ulcer disease. In addition, all patients had active ulcers. All dilatation treatments were primarily successful: the stenoses were opened for the passage of the fiberscope. There were no complications; even with active ulcers there were no side effects. The treatment was followed by immediate symptomatic relief. On prospective evaluation over a period of 7 months (mean), 6 patients remained asymptomatic, 2 patients had to be dilated again for restenosis and have since been asymptomatic for 1 and 12 months, respectively. One patient had to undergo surgery after 7 months for ulcer perforation into the common bile duct. The TTS technique has considerable advantages over the methods requiring a guide wire. This technique with its easy practicability and low incidence of complications may become a valid alternative to surgical procedures if the good initial results can be confirmed in further studies.

[Palliative laser therapy of advanced rectal carcinoma]. / Palliative Lasertherapie fortgeschrittener Rektumkarzinome.

During a 20 months period (1. 10. 1985-31. 5. 1987) 20 patients with advanced rectal carcinoma received palliative treatment by laser (Neodymium-YAG), 18 for subtotal rectal stenosis, two for profuse bleeding from an exophytic tumour. Re-establishment of intestinal passage or stoppage of bleeding was achieved in all patients, after a mean of 3.4 (1-5) applications. The treatment was well tolerated, cured the anaemia, removed the obstruction and ended painful stool evacuation. To-date 11 patients have died, seven of the malignant tumour. Nine patients are still alive. The mean survival time for all 20 patients is 5.3 months so far, similar to that after a palliative colostomy. There were no complications.

[Heterotopic gastric mucosa in the upper gastrointestinal tract: endoscopic incidence, appearance and clinical significance]. / Magenschleimhautheterotopien im oberen Gastrointestinaltrakt: Endoskopische Häufigkeit, Erscheinungsbild und klinische Bedeutung.

Heterotopia is understood as the occurrence of locally atypical tissue. Heterotopic gastric mucosa may occur throughout the whole GI-tract. In an unselected series of upper GI-endoscopies 6.3% of heterotopic gastric mucosa could be detected. Main localisation was the upper esophagus with 70%, followed by the duodenal bulb with approximately 25%. In 86% histological proof of ectopic mucosa was possible. In the esophagus the lesion looks like a red spot, in the duodenal bulb in contrast more like polypoid formations without discoloration. In our experience there is no significant relation of heterotopic mucosa to clinical symptoms. The clinical significance of heterotopic gastric mucosa however may be underscored by its possible complications.