Laparoscopic therapy of the coeliac artery compression syndrome: a critical analysis of the current standard procedure.

INTRODUCTION: Median arcuate ligament syndrome has been known anatomically for approximately 100 years and results from a compression of the coeliac axis by fibrous attachment of the diaphragmatic crura. Owing to the rarity of the disease and limited available data, many aspects of treatment are controversial. Currently, laparoscopic decompression is considered by several authors as standard surgical procedure. We present an analysis of the clinical routine of MALS therapy. METHODS: We conducted a prospective observational trial in patients with MALS between March 2016 and August 2018, in which clinical symptoms, diagnostic evaluation, procedures with complication analysis and follow-up data were recorded. RESULTS: A total of 18 patients (12 female, 6 male) with MALS, aged between 15 and 65 years, were included in this study. All patients presented with long-standing abdominal pain. Preoperative Doppler ultrasonography showed a flow velocity of the coeliac artery averaging 289.9cm/second in mid-position of the diaphragm, 285.9cm/second in expiration and 199.0cm/second in inspiration. All operated patients underwent laparoscopic decompression; two patients received an angiographic intervention. Postoperatively, a significant decrease of the flow velocity in mid-position of the diaphragm was detected (P = 0.018). At follow-up after 5.2 months, 50.0% of the patients were pain-free, 37.5% reported symptomatic relief and 12.5% showed evidence for a recurrence. CONCLUSION: MALS is challenging both diagnostically and therapeutically. Laparoscopy with release of the median arcuate ligament is an essential part of the therapy and can be confirmed by Doppler ultrasonography. Disease outcome is also influenced by several predictive factors.

Technical note: Development and evaluation of a standardized technique to assess blood perfusion in teats of dairy cows using power Doppler ultrasonography.

Ample research has described the assessment of dimensional changes for different teat traits, whereas diagnostic techniques to reliably assess blood circulation in teats of dairy cows are limited. Here, we describe the development and evaluation of a scanning technique to quantify blood flow in teats of dairy cows using power Doppler ultrasonography. In 2 consecutive trials, 384 teat scans [trial 1, n = 256 (sagittal plane, n = 128; transverse plane, n = 128); trial 2, n = 128 (transverse plane)] from 16 cows were obtained by the same 2 operators. Perfusion intensity from single images (trial 1) and video images (trial 2) were assessed using a commercially available software program. Intraclass correlation coefficients (ICC) and concordance correlation coefficients (CCC) were used to assess interoperator reproducibility (agreement between measurements performed by different operators) and intraoperator repeatability (agreement between measurements performed by the same operator). In trial 1, interoperator ICC and CCC indicated poor agreement (ICC ≤0.26, CCC ≤0.26). Intraoperator ICC and CCC demonstrated poor agreement between duplicate measurements within operators (ICC ≤0.19, CCC ≤0.19). Modifications after trial 1 included (1) a different ultrasound device, (2) analysis of video clips rather than single images, (3) restriction to 1 sectional plane (i.e., transverse), and (4) a scanning sequence such that repeated scans within operators were measured one after another. Through these modifications, intraoperator repeatability in trial 2 yielded fair to good agreement, with intraoperator ICC and CCC over both operators ranging from 0.44 to 0.70 and from 0.57 to 0.69, respectively, whereas interoperator ICC and CCC showed poor agreement (ICC = 0.35, CCC = 0.34). We conclude that repeatable measurements of blood perfusion intensity of teats in dairy cows can be attained with power Doppler ultrasonography. Power Doppler ultrasonography is a suitable tool to quantify slow flow in small vessels and may be an acceptable diagnostic technique to assess changes in blood circulation that result from machine milking in teats of dairy cows, although further research is necessary to validate this hypothesis.

Color-Doppler sonographic tissue perfusion measurements reveal significantly diminished renal cortical perfusion in kidneys with vesicoureteral reflux.

Vesicoureteral reflux (VUR) and its sequelae may lead to reduced renal perfusion and loss of renal function. Methods to describe and monitor tissue perfusion are needed. We investigated dynamic tissue perfusion measurement (DTPM) with the PixelFlux-software to measure microvascular changes in the renal cortex in 35 children with VUR and 28 healthy children. DTPM of defined horizontal slices of the renal cortex was carried out. A kidney was assigned to the "low grade reflux"-group if the reflux grade of the voiding cystourethrogram was 1 to 3 and to the "high grade reflux"-group if the reflux grade was 4 to 5. Kidneys with VUR showed a significantly reduced cortical perfusion. Compared to healthy kidneys, this decline reached in low and high grade refluxes within the proximal 50% of the cortex: 3% and 12 %, in the distal 50% of the cortex: 21% and 44 % and in the most distal 20 % of the cortex 41% and 44%. DTPM reveals a perfusion loss in kidneys depending on the degree of VUR, which is most pronounced in the peripheral cortex. Thus, DTPM offers the tool to evaluate microvascular perfusion, to help planning treatment decisions in children with VUR.

Umbilical vein vasomotion detected in vivo by serial three-dimensional pixelwise spatially angle-corrected volume flow measurements.

OBJECTIVE: To explore changes in volume flow in the umbilical vein in healthy second-trimester fetuses. METHODS: This was a prospective observational pilot study performed at Stavanger University Hospital, Norway, between May and October 2013. Serial three-dimensional ultrasound recordings from the umbilical vein were acquired every 30 s in a 5-min period in 43 fetuses at 17-20 weeks' gestation. The recordings were analyzed with pixelwise spatially angle-corrected volume flow measurements. RESULTS: We observed variation in the umbilical vein volume flow in all fetuses, ranging from a mean minimum of 1.01 mL/s to a mean maximum of 2.60 mL/s. The minimum of all measurements was 57% compared with the mean value and the maximum was 148% of the mean value. The individual flow volume measurements ranged between 0.11 and 4.14 mL/s (mean, 1.76 mL/s). Within this range, an undulating course of all perfusion parameters was observed, with a full period of 4-5 min duration. CONCLUSION: Healthy second-trimester fetuses show cyclical variation in blood flow in the umbilical vein. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Color Doppler sonographic dynamic tissue perfusion measurement demonstrates significantly reduced cortical perfusion in children with diabetes mellitus type 1 without microalbuminuria and apparently healthy kidneys.

MOTIVATION: With respect to the devastating consequences of the increasing prevalence of diabetes mellitus, the main reason for end stage renal disease and dialysis in industrialized countries, and the very limited diagnostic and therapeutic possibilities to predict, monitor and prevent diabetic nephropathy (DN), new concepts for early recognition and quantification of the prevailing microvascular changes in DN are urgently needed. MATERIALS AND METHODS: We present the first study of renal cortical tissue perfusion measurement by means of standardized color Doppler sonographic videos evaluated with the PixelFlux software 1 for Dynamic Tissue Perfusion Measurement (DTPM) in 92 patients with DM1 without MA compared to 71 healthy probands. RESULTS: DTPM reveals a highly significant diminution of cortical perfusion in patients with DM1 compared to healthy probands by 31 %, most pronounced in the distal hemicortex (reduction by 50 %) compared to 21 % within the proximal hemicortex. CONCLUSION: Thus, DTPM offers a novel means of numerically describing the state of the renal microvasculature in DM in a patient-friendly, non-invasive, non-ionizing manner.

Pixelwise quantification of placental perfusion visualized by 3D power Doppler sonography.

PURPOSE: We present a new method for noninvasive automatic measurement of perfusion intensity (PixelFlux method) in standardized 3 D power Doppler sonography to quantify differences of perfusion intensities among different placental layers. MATERIALS AND METHODS: Power Doppler sonographic videos of anterior and central placentas were recorded at various gestational ages (13 to 38 weeks) under defined conditions in 22 women with uncomplicated pregnancies which ended in the delivery of an appropriately grown fetus. Tissue perfusion intensity in four placental layers was calculated as the product of the Doppler amplitude and the perfused area encoded by power Doppler signals related to the area of the respective layer. Measurements are given as the percentage of maximal possible perfusion. RESULTS: Significant differences in placental perfusion intensities in the uterine wall (6.6 %), the maternal flow within the intervillous space (2.4 %), the fetal flow within placental villi (1.6 %) and the chorionic plate (9.3 %) were demonstrated with a continuous increase in the uterine wall and the placental villi. CONCLUSION: Placental perfusion intensity was quantified noninvasively from 3 D power Doppler signal data in an easily accomplishable manner with a new software-based measurement procedure. There are significant differences in perfusion intensities among placental layers. Placenta perfusion measurement with the PixelFlux method is feasible and can discern significant perfusion differences among different placenta layers.

Three-dimensional volumetric spatially angle-corrected pixelwise fetal flow volume measurement.

PURPOSE: Early attempts to calculate fetal global perfusion used 2 D images. The results were not sufficiently reliable. That's why RI measurements are still in use despite the fact that they do not reflect the amount of blood passing through the fetus. We present a novel three-dimensional approach to overcome these limitations. MATERIALS AND METHODS: In 124 singleton pregnancies between the 23rd and 4st gestational week, a three-dimensional color Doppler sonographic record of the umbilical cord was made, resulting in 281 volume data sets. With dedicated software (PixelFlux) the spatial angle of the umbilical vein was calculated and the true global fetal perfusion was calculated from its horizontal transection as the product of the area of all pixels and the spatial angle-corrected velocity. To validate the PixelFlux technique, phantom flow measurements were carried out. RESULTS: Phantom flow measurements revealed a highly significant correlation of actual flow volumes and those measured by the PixelFlux technique (p < 0.001; rPearson = 0.987 - 0.991) with an even higher interobserver correlation (p < 0.001; rPearson = 0.997). We found a significant correlation of fetal volume flow to gestational age and weight (r = 0.529 at spatial angles below 30° to r = 0.724 at spatial angles below 5°) and a significant influence of the spatial angle on this correlation (p = 0.003; r = -0.865). CONCLUSION: Spatial angle-corrected global fetal perfusion measurement improves existing approaches to fetal perfusion evaluation, and is feasible, simple and fast. Thus, it can be recommended to explore the relationship of fetal perfusion and disturbances of fetal development.

Evaluation of portal blood flow using transcutaneous and intraoperative Doppler ultrasonography in dairy cows with fatty liver.

The objective of the study was to investigate portal blood flow (PBF) in dairy cows with fatty liver by means of Doppler ultrasonography. Eighty lactating German Holstein cows less than 100 d in milk were used (mean ± standard error of the mean; body weight: 583 ± 9 kg, age: 5 ± 0.2 yr, withers height: 145.4 ± 0.5 cm, milk yield: 9 ± 0.6 kg). All cows had left abomasal displacement and underwent omentopexy via right flank laparotomy. The size of the liver and the thickness over the portal vein were determined ultrasonographically. Doppler ultrasonographic examinations of PBF were carried out transcutaneously and intraoperatively directly via liver surface. The PBF velocities [peak maximum (v(max)), peak minimum (v(min)), and mean maximum (v(mean)) velocity] were recorded. Venous pulsatility index (VPI) was calculated. Because transcutaneous Doppler ultrasonography revealed images of very poor quality in 58 of the 80 cows, only data obtained intraoperatively were presented. Liver biopsies were used for hepatic triacylglycerol (TAG) determination and histological examination. Based on histopathologic and ultrasonographic examinations, none of the cows suffered from hepatic disorders other than hepatic lipidosis. Hepatic TAG content ranged from 5 to 292 mg/g of liver fresh weight (FW). Cows were allocated to 1 of 4 groups according to their hepatic TAG content (very severe: TAG >150 mg/g of FW, n=27; severe: >100-150 mg/g of FW, n=18; moderate: ≥ 50-100mg/g of FW, n=19; mild: <50mg/g of FW, n=16). The VPI decreased with increasing TAG content (r=-0.55). The VPI did not differ between cows with severe and very severe fatty liver but it differed between cows of these 2 groups and cows with mild and moderate fatty liver. Velocities of PBF (v(mean), v(min), v(max)) correlated negatively with hepatic TAG content (r=-0.26 to -0.37). Mean PBF velocity of the cows with very severe fatty liver differed from cows with severe, moderate, and mild fatty liver. Variables of PBF were inversely related to hepatic size and thickness (r=-0.06 to -0.35). In conclusion, the lower VPI and PBF velocities in cows with fatty liver and the negative correlations with the degree of hepatosteatosis may be explained by a reduction of vascular compliance in the liver because of fatty infiltration. These changes, which are believed to result from parenchymal swelling, were particularly pronounced when hepatic TAG content exceeded 150 mg/g FW.

Changes of renal flow volume in the hemolytic-uremic syndrome--color Doppler sonographic investigations.

Varying degrees of vascular occlusion can be found in the hemolytic-uremic syndrome (HUS). This is the rationale for Doppler sonographic investigations of renal blood flow in children with HUS. In 1989 a first report suggested a close relationship between normalization of the resistive index (RI) of renal blood flow with the restitution of urine flow in affected children. Later reports did not confirm these initial findings. The aim of this paper is to describe renal volume perfusion quantitatively in children with HUS. The renal arteries in 35 patients with HUS (1 month to 15 years) were investigated at the onset of HUS by color Doppler ultrasonography. Flow volume measurements were carried out in the 1st week and in the 2nd to 4th week after onset of the disease. These data were compared with measurements from a healthy pediatric population of 69 children. Statistically significant changes in renal perfusion occur in the flow volume of the kidneys. The flow volume dropped to 32% (34%) in the 1st week of the disease compared with the normal population and recovered in 2-4 weeks to 117% (65%) of the normal flow volume (left kidney in parentheses). The new technique of volumetric perfusion measurement overcomes some drawbacks of the traditional RI, which may have led to some confusion in the past.

Color Doppler sonographic determination of renal blood flow in healthy children.

The volumetric measurement of the real renal perfusion is of interest in many clinical situations. It promises better understanding of renal function and development in healthy children and in children with acute or chronic renal failure, inflammation of any type, scarring, swelling, trauma, operations, and other conditions. Until now only scintigraphic techniques allowed measurement of the renal plasma flow in clinical practice. With color Doppler sonography all relevant data to calculate the volume of blood that passes through the kidney in a certain time can be measured. The aim of this paper is to investigate the utility of color Doppler sonography in describing renal perfusion in 63 healthy children in four separate age groups. It can be shown that the perfusion volume related to the body surface area is constant throughout childhood. Its mean value is 383 ml/min x m2. The results of the new technique of color Doppler sonographic volumetric determination of renal blood flow are then compared in 21 pediatric patients with the results of scintigraphic determination of the renal perfusion by 123I-hippurate clearance. This way a significant correlation of both methods can be demonstrated.

Doppler studies in normal kidneys of healthy children.

Despite the widespread use of Doppler ultrasound in kidney diseases of adults and children, there are only a few, partially contradictory reports of normal values of resistance index (RI) and pulsatility index (PI) of renal perfusion in a healthy pediatric population. This study was carried out to determine normal values for these parameters in a larger group of probands. For the RI correlation with age was most pronounced in the right renal artery, with children over 6 years having a significantly lower RI than younger children. The PI was relatively independent of side and age. These results are somewhat different to previous reports. These differences may influence future Doppler sonographic investigations of acute and symmetrically affected kidneys (nephrological diseases). Our data suggest that the RI of the right renal artery might be most useful. In chronical or unilateral kidney diseases (unilateral ureteral obstruction, reflux, or operation) investigation of the PI in addition to the RI may aid diagnosis.

[Roberts syndrome with aneurysm of the interatrial septum, cow milk protein intolerance and absent swallowing reflex]. / Roberts-Syndrom mit Aneurysma des interatrialen Septums, Kuhmilchproteinintoleranz und fehlendem Schluckreflex.

A three years old girl with Roberts-syndrome is presented in this report. An aneurysm of the interatrial septum without hemodynamic significance was found besides the typical symptoms of the Roberts-syndrome. The child had to be fed by nasogastral tube for more than two years because of never feeling hungry and lacking reflex to swallow. A pulmonary and intestinal reaction during the provocation with cowmilkprotein-containing food was observed additionally, so that we had to give an cowmilkprotein-free diet until the age of 28 months. The majority of reported cases with Roberts-syndrome showed characteristic cytogenetic abnormalities. The karyotype of our patient was normal. Roberts syndrome is an autosomal recessive disorder. We recommended repeated ultrasound examinations during the next pregnancy because of the 25% recurrence risk on subsequent siblings. The prognosis quoad vitam in patients with Roberts-syndrome remains poor. However, the development in our patient stresses the eminent value of medical and social support for those seriously handicapped children.

Localization of the intestinal biopsy capsule in children by color-coded duplex sonography.

In 21 children from 3 months to 10 years and 5 months old, the position of the biopsy capsule before suction biopsy of the small intestine was examined by means of x-ray studies and both conventional and color-coded duplex sonography. In all cases, the biopsy capsule was correctly positioned under sonographic guidance. The sonographic finding was always confirmed by x-ray film and the histology of the tissue sample. The main obstacle for imaging the biopsy tube and capsule was intestinal gas due to crying and/or restlessness of infants under examination. However, it was always possible to define the position of the biopsy capsule sufficiently. These promising results allow us to recommend sonographic control of the intestinal tube before intestinal suction biopsy in infants and children. The advantages of this approach include lack of irradiation, which is especially important if the tube is an incorrect position after the first trial, bedside availability of sonographic equipment, lower risk of dislocation of the tube owing to shorter transport time, and continuous contact of medical staff with the infant.

[Arteriovenous fistula of the blood vessels of the neck--a rare differential diagnosis of venous hum in childhood]. / Arteriovenöse Fistel der Halsgefässe--eine seltene Differentialdiagnose des Nonnensausens im Kindesalter.

In a case report it is shown that in rare circumstances there might be an extracardial organic cause for heart murmurs sounding accidentally. In a child with the finding of a venous hum an arterio-venous fistula between the right common carotid artery and the right internal jugular vein could be demonstrated by colour-coded echocardiography. The clinical relevance of this finding is discussed.

[Ultrasonically-guided percutaneous puncture and drainage of a splenic abscess caused by Salmonella heidelberg in a child]. / Ultraschallgezielte perkutane Punktion und Drainage eines Milzabszesses durch Salmonella heidelberg bei einem Kind.

In a boy aged 9 years and 11 months pain developed in the left upper abdomen following Salmonella enteritis infection. Purulent splenitis was diagnosed by sonography. Ultrasonically guided percutaneous puncture and drainage, and appropriate chemotherapy led to a marked improvement in the clinical picture and finally to complication-free remission. In a review of the literature the problems associated with purulent splenitis and the possibility of treating it by percutaneous puncture are pointed out. Purulent splenitis should be considered in all patients with temperatures and unexplained abdominal pain.