Severe potential consequences of delayed diagnosis in patients with hip claudication.

Delayed diagnosis in patients with hip claudication can lead to severe consequences. We report on patients with ischaemic hip claudication which had primarily been attributed to coxarthrosis. One patient went through a variety of treatments including hip arthroplasty. The second patient had a life-threatening abdominal aortic aneurysm (AAA) which remained undiagnosed. Orthopaedic surgeons should maintain a high degree of suspicion for vascular disease. Moreover, we strongly advocate that all men over 60 years old who seek medical advice for whatever reason should be screened once for AAA by ultrasonography.

[Mesenteric cyst as the etiology of abdominal pain--a case report]. / Mesenteriale Zyste als Ursache von Abdominalschmerzen--Eine Fallbeschreibung.

INTRODUCTION: Mesenteric cysts are part of the differential diagnosis of abdominal tumors. We want to remember this diagnosis with the following case report. CASE REPORT: A 35-year-old woman was admitted for abdominal pain that had begun two weeks previously. Sonographic examination and CT scan of the abdomen showed a 14 x 12 x 3 cm abdominal tumor without any relation to the uterus, adnexa or organs of the epigastrium. Laparotomy was performed and the cystic tumor removed. DISCUSSION: Mesenteric cysts are rare. The pathogenesis is not uniform and the clinical and radiologic diagnosis is difficult. The symptoms of this condition vary from acute abdominal signs to non-specific abdominal features or incidental findings. Mesenteric cysts can be located anywhere in the mesentery from the duodenum to the rectum. The treatment of choice is resection. CONCLUSIONS: Mesenteric cysts are rare abdominal conditions. The resection of the cyst and the verification of the diagnosis is the treatment of choice.

[Krukenberg syndrome in metastatic gallbladder adenocarcinoma with unknown primary tumor]. / Krukenberg Syndrom bei metastasierendem Gallenblasenadenokarzinom mit inapparentem Primärtumor.

The casuistic describes a female patient, in whom a metastatic adenocarcinoma of the ovary was diagnosed 3 years after cholecystectomy due to cholecystolithiasis, which was compatible with metastases of a carcinoma of the gallbladder or the bile ducts. While clinical and imaging results suggested a primary ovarian carcinoma with inapparent primary tumor, the final diagnosis was obtained on the basis of histological findings. The case demonstrates that an ovarian metastasis can simulate a primary tumor according to clinical and imaging results. This fact can be of serious therapeutic consequences for the respective patient. Therefore, in the presence of a clinically inapparent primary tumor, the differential diagnosis of unclear ovarian masses should include metastatic adenocarcinoma in addition to primary ovarian carcinoma and other ovarian lesions.

Intestinal and peritoneal bleeding: detection with an intravascular contrast agent and fast three-dimensional MR imaging--preliminary experience from an experimental study.

PURPOSE: To assess the ability to detect and localize intestinal and peritoneal bleeding with an intravascular contrast agent and fast three-dimensional (3D) magnetic resonance (MR) imaging. MATERIALS AND METHODS: An intravascular contrast agent (NC100150 Injection) was administered into small-bowel specimens at five flow rates; the specimens were imaged with a 3D gradient-echo (GRE) sequence at 1-minute intervals. Radionuclide studies with technetium-99m pertechnetate were performed in the same manner. Subsequently, the MR imaging technique was assessed in vivo. Two intraluminal intestinal and one hepatic bleeding sites were created in an anesthetized pig. Three-dimensional GRE imaging data sets were acquired after intravenous injection of the contrast agent. Imaging findings were confirmed with macroscopic inspection. RESULTS: Contrast material injected at 0.5-2.0 mL/min was detected with both radionuclide and MR imaging after 1 minute. An accumulated volume of 0.2 mL was necessary to demonstrate the bleeding site. In vivo, all bleeding sites were readily detected on MR images. Contrast material accumulated in the intestines and peritoneal space. CONCLUSION: In conjunction with an intravascular contrast agent, 3D MR imaging allows detection and localization of gastrointestinal bleeding. The extent of the bleeding can be determined with repeat data acquisitions.

Percutaneous drainage of abdominal abscesses: are large-bore catheters necessary?

OBJECTIVE: To find out whether small-bore catheters (7 F) are as effective as the 14F sump drains generally used for drainage of abdominal abscesses. DESIGN: Retrospective review. SETTING: University hospital, Switzerland. SUBJECTS: 64 patients with intra-abdominal abscesses. INTERVENTIONS: 40 were drained with 7F pigtail catheters and 24 by 14F sump drains. RESULTS: Drainage was successful in 34/40 (85%) and 20/24 (83%), respectively. There were 3 recurrences in the small-bore and 1 in the large-bore group (p=0.4). Mean drainage time was 8 (SD 5) days and 11 (SD 11) days, respectively (p=0.29). One patient (3%) developed a complication in the small-bore group and 2 (8%) in the large-bore group. 4/6 failures in the small-bore group and 1/4 failures in the large-bore group were pancreatic abscesses. CONCLUSIONS: We conclude that percutaneous drainage with small-bore catheters is as effective as drainage with bigger tubes.

VATS resection of an oesophageal leiomyoma in a patient with neurofibromatosis Recklinghausen.

A series of reports in the literature suggest an association of neurofibromatosis Recklinghausen with intestinal tumors as carcinoids, leiomyomas and leiomyosarcomas. We present a case of a 23-year-old man with severe cutaneous manifestation of neurofibromatosis. Dysphagia was the main symptom. CT scan suggested the diagnosis of an oesophageal leiomyoma. The oesophageal muscle layers were split and the tumor was enucleated by video assisted thoracoscopic surgery (VATS). The postoperative course was uneventful. The patient was drinking liquids from day 1 and was eating a normal diet from day 3 postoperatively. He was dismissed from the hospital on the 4th postoperative day. We conclude that in patients with neurofibromatosis and oesophageal symptoms an intestinal manifestation of the disease in the oesophagus has to be considered and that VATS resection of intramural and extrinsic oesophageal leiomyomas is the treatment of choice.

Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver.

BACKGROUND: There is a necessity for an imaging method during laparoscopy to get a three-dimensional access to the target. In this study we evaluated laparoscopic interstitial laser therapy of the liver under magnetic resonance imaging guidance. METHODS: Five domestic pigs underwent laparoscopy in an open-configuration magnetic resonance system. Under simultaneous real-time magnetic resonance imaging interstitial laser therapy was applied to the liver. Magnetic resonance images, macroscopic aspects of the lesions, and light microscopic findings were compared. RESULTS: The interventions could be safely performed. There was no image artifact caused by instruments or by the carbon dioxide. Dynamic gadolinium-enhanced imaging proved to significantly predict the macroscopic volume of the laser lesions. CONCLUSIONS: Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver combines the advantages of minimal invasive surgery and magnetic resonance imaging. Further development should focus on laparoscopic instruments and temperature sensitive sequences.

Experimental cryosurgery of the liver under magnetic resonance guidance.

The feasibility and the advantages of magnetic resonance (MR)-guided interstitial cryosurgery of the liver in an 0.5 Tesla open MR system have been evaluated. Cryosurgery was performed using an Erbocryo PS system with a nonmagnetic cryoprobe of 6 mm diameter. The probe was inserted into the liver parenchyma under real-time MR control. Using continuous MR imaging two freezing cycles of 12 min each were applied. After conventional and dynamic gadolinium-enhanced MR imaging, the animals were sacrificed after 30 min, 3 hr, 24 hr, 7 days, and 21 days. Each lesion was analyzed using light microscopy. A total of seven cryolesions were made in five animals without any complications from cryosurgery. During real-time imaging, cryolesions appeared as a hemispherical growing signal loss with a mean volume of 16.4 cm3. Macroscopic volumes of the lesions showed a good correlation with dynamic enhanced MR images during follow-up, whereas real-time images usually showed an underestimation of the lesion volumes. Cryosurgery of the liver in an open-configuration MR system is a feasible and safe method. MR imaging allows the guidance and the follow-up of cryolesions of the liver with good accuracy.

[Magnetic resonance tomography and interventional measures]. / Kernspintomographie und interventionelle Massnahmen.

In contrast to conventional radiography or ultrasonography, magnetic resonance imaging (MRI) is influenced by different factors. As a consequence, tissues and fluids can be visualized using different techniques. Obviously MR imaging has a lot of advantages, but only a small number of disadvantages and contraindications. Without using X-rays, interventions can be done under real-time MR control. An open-configuration MR-system allows vertical access to the patient during interventions. The combination of laparoscopy and MR imaging enables the surgeon to observe organ surfaces as well as parenchymal structures at the same time. Depending on the high temperature sensitivity of MR imaging, this technique can be used to guide interstitial laser therapy or cryosurgical interventions.

Preoperative risk assessment in elective general surgery.

Despite improved surgical techniques there is still a risk of mortality in elective general surgery. In a prospective study preoperative data from 3250 patients were collected and compared with postoperative systemic complications, using univariate chi 2 analysis. Highly significant (P < 0.00001) variables were subjected to stepwise logistic regression analysis. The severity of operative procedure, higher American Society of Anesthesiologists (ASA) grade, symptoms of respiratory disease and malignancy were found to be significant risk factors predicting postoperative morbidity (P < 0.05). Using these four variables, a simple preoperative risk scoring system has been defined. Class A (up to 5 points) was defined as a low-risk group (systemic complication rate 5.0 per cent), class B (5-7 points) was intermediate risk (systemic complication rate 17.9 per cent) and class C (8-10 points) was high risk (systemic complication rate 33.3 per cent). Patients at high risk for perioperative and postoperative complications are more likely to be identified by this analysis than by using the ASA classification alone.

Catheter fracture: a rare complication of totally implantable subclavian venous access devices.

Catheter fracture represents a rare problem among non-infectious complications following the insertion of totally implantable long-term central venous access systems for the application of chemotherapeutic agents. A literature survey revealed a total incidence of catheter fractures of 0-2.1%. Imminent catheter fracture can be identified radiologically, using different degrees of catheter narrowing between the clavicle and the first rib, called pinch-off sign. Two cases of catheter fracture are described and potential causes are discussed. Recommendations to avoid the pinch-off sign with the subsequent risk of catheter fracture and migration include a more lateral and direct puncture of the subclavian vein. In case of catheter narrowing in the clavicular-first rib angle, patients should be followed carefully by chest X-rays every 4 weeks. Whenever possible, the system should be removed within 6 months following insertion.

[Tumor staging and follow-up care in rectosigmoid carcinoma: colonoscopic endosonography compared to CT, MRI and endorectal MRI]. / Tumorstaging und Nachsorge des rektosigmoidalen Karzinoms: die koloskopische Endosonographie im Vergleich mit der CT, MRT und endorektalen MRT.

BACKGROUND AND STUDY AIMS: Endosonography has become the best available method for local staging of primary rectal cancer and diagnosing recurrent local tumor. The aim of this prospective study is to compare the accuracy of endoscopic ultrasound (EUS), using an echo colonoscope (CF-UM 3, CF-UM 20, Olympus optical) to computed tomography (CT), body coil magnetic resonance imaging (MRI) and endorectal coil magnetic resonance imaging (EMRI). PATIENTS AND METHODS: From February 1991 to July 1993 90 patients with primary rectosigmoidal tumors (n = 32: 9 women, 23 men, mean age 68 years [range 37 to 84]) or follow-up examinations for recurrent local cancer (patients: n = 58, examinations: n = 93; 41 women, 52 men, mean age 61 years [range 31 to 84]) were investigated. The results of preoperative examinations were compared to histopathological findings regarding T and N stages. RESULTS: In T staging, accuracy of EUS (78%) was superior to CT (50%) and equivalent to both MRI (75%) and EMRI (80%). The accuracy of EUS (84%) in assessing transmural tumor infiltration was superior to CT, MRT and EMRT (50%, 75% and 80%, resp.); however, CT (77%) and MRI (86%) were more accurate than EUS (64%) and EMRI (33%) in assessing N stages. Recurrent local cancer was found in 22 patients. All but one were detected by EUS. Sensitivity, specificity and accuracy in follow-up examinations for recurrent disease for EUS were 95%, 94% and 95%, for CT 75%, 73% and 74%, for MRI 57%, 100% and 70%, and for EMRI 83%, 100% and 90% resp. CONCLUSIONS: Endoscopic ultrasound proved to be a safe and accurate method of preoperative staging and early diagnosis of recurrent rectal cancer and was superior or at least equivalent to CT, MRI and EMRI.

[Minimally invasive surgery with MRI imaging]. / Minimal invasive Chirurgie unter MR-Bildgebung.

The main shortcoming of conventional laparoscopic procedures is the lack of a truely three-dimensional view. The development of a open-configured MR-imaging system (0.5 Tesla, General Electric, USA) with free access to the patient, allows the performance of minimal invasive procedures under MR-guidance. Advantages inherent to minimal invasive surgery can now be combined with the ideal tissue discrimination and the temperature sensitivity of MR-imaging. This new method can be used for diagnostic as well as for therapeutic interventions, especially interstitial therapy of inoperable metastases of parenchymal organs.

[Magnetic resonance controlled minimal invasive surgery: initial results and perspectives]. / Magnet-Resonanz-geführte minimal-invasive Chirurgie: Erste Resultate und Perspektiven.

The development of an open-configured MR-imaging system opens new perspectives in minimal invasive surgery. The combination of laparoscopy and real-time MR imaging allows the guidance of diagnostic interventions as well as interstitial therapies of parenchymal organs. In the near future, tumor diagnosis, therapy and follow-up can be done using the same technique.

Endoscopic ultrasound and endorectal magnetic resonance imaging: a prospective, comparative study for preoperative staging and follow-up of rectal cancer.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound has become the best available method for local staging of primary rectal cancer and diagnosing recurrent local disease. The aim of this study is to compare the value of endoscopic ultrasound (EUS) to magnetic resonance imaging with an endorectal coil (EMRI). PATIENTS AND METHODS: Twenty-one patients (11 women, 10 men, mean age 63 years, range 31-79) with primary rectal cancer (n = 6) or follow-up examinations for recurrent local disease (n = 15) were investigated by EUS using an echo colonoscope (CF-UM 20, Olympus Optical) and by endorectal coil MRI on a 1.5 tesla MR system (General Electric). T2-weighted and contrast-enhanced T1-weighted images were obtained. The results of preoperative examinations were compared to histopathological findings regarding the T staging, with special focus on the transmural tumor infiltration. RESULTS: EUS identified all tumors, whereas one tumor was missed by EMRI. EUS was superior to EMRI in T staging (accuracy 83%/40%), due to the better differentiation between T1 and T2 tumors, as the endorectal coil could not differentiate between stage T1 and stage T2. The accuracy of EMRI in assessing perirectal infiltration was 80%, compared to EUS with 100%. Local tumor recurrence was found in six of 15 patients, without endoscopic signs of recurrent disease in four of them. All were detected by EUS. Only one recurrence was missed by EMRI. Accuracy and positive and negative predictive values in follow-up examinations for recurrent disease for EUS were 93%, 86%, and 100%, and for both the T2-weighted and T1-weighted contrast-enhanced sequences of endorectal coil MRI, they were 93%, 100%, and 90%, respectively. CONCLUSIONS: Endoscopic ultrasound and endorectal coil MRI are comparable methods in the preoperative staging and early diagnosis of recurrent rectal cancer. The advantages of EUS are the small diameter of the instrument, availability, and lower costs. In contrast, EMRI is operator-independent, and may become important for combined local and distant staging and follow-up examination in rectal cancer, if contrast-enhanced imaging can improve the sensitivity for liver metastases.

[Thoracoscopic surgery--experiences with a practical training course using an animal models]. / Thoracoskopische Chirurgie--Erfahrungen mit einem praktischen Trainingskurs am Tiermodell.

Various thoracoscopic procedures have recently become an established method in thoracic surgery. However, a systematic teaching program is lacking. We present our experience with a 1-day training course, using anaesthetized pigs. Thoracoscopic operations, such as pericardial fenestration, wedge resection of the lung, subaortic and mediastinal lymph node dissection and pleurectomy have been exercised in groups of two. 7-12 months following the teaching course 40% of the participants had performed more than ten diagnostic or therapeutic thoracoscopic interventions in clinical situations. We conclude that our course helps participants to successfully apply this technique in clinical practice.

New anastomosis technique for (laparoscopic) instrumental small-diameter anastomosis.

This study presents a new technique for visceral anastomosis. The principle consists of connecting the two parts to be anastomosed around a reabsorbable stent which is transluminally introduced into small-diameter viscus, where it is fixed. Advancing a larger tube along the axis of the machine, the larger, perforated viscus is inverted and pulled over the stent, and finally a rubber band pops off the machine endoluminally in order to fix the intestinal walls in seroserosal contact onto the stent. To evaluate this "micro" anastomosis, a biliary bypass (choledochojejunostomy and roux-en-y-loop) was performed in ten pigs. Nine of ten animals showed biliary bypass with good runoff in contrast radiography and completely reabsorbed stent after a 3-month follow-up. Weight gain, bilirubin, and alkaline phosphatase were normal. This technology demonstrates a safe and quick way to perform instrumental "micro" anastomosis without remnant foreign material.

[Risk assessment before elective visceral surgery interventions]. / Risikoevaluation vor elektiven viszeralchirurgischen Eingriffen.

AIM OF THE STUDY: Since 1988 all our patients undergoing elective general surgery entered a prospective study, with the aim of identifying risk factors, responsible for a fatal postoperative outcome. METHODS: From 1988-1992 a total of 3250 patients (mean age 52.0 years [SD +/- 16.8]), 1750 male and 1500 female have been registered. RESULTS: General complications occurred in 10.4% of patients and local complications have been registered in 10.8% of cases. 29 patients (0,89%) died within 30 days following the operative procedure. The operation per se, the ASA-classification, a history of respiratory disease and an operation for a malignant disease could be identified as risk factors for general postoperative complications. CONCLUSIONS: The study design allows us to determine risk factors in elective general surgery. These risk factors can easy be used in clinical practice to evaluate the operative risk of a planned operative procedure.

[Reconstruction following distal gastrectomy: Billroth or Roux?]. / Rekonstruktion nach distaler Magenresektion: "Billroth" oder "Roux"?

Since the first gastric resection performed by Theodor Billroth in 1881, there has been discussion about the best method of reconstruction following gastric resection. Because of its high incidence of anastomotic ulcers, the method of Roux-en-Y reconstruction was abandoned at the beginning of the 20th century. In the late 1970s, when the first gastric stump carcinomas became known, Roux-en-Y reconstruction rose to become the method of choice for reconstruction following gastric resection. The main advantage of the method is in preventing high gastroduodenal reflux and thus averting the development of gastric stump carcinoma. When it is combined with total antrectomy and vagotomy, the rate of anastomotic ulcers is negligible and patients benefit from an improved longterm functional result.