The discriminatory capacity of BMD measurements by DXA and dual X-ray and laser (DXL) at the calcaneus including clinical risk factors for detecting patients with vertebral fractures.

UNLABELLED: Osteoporotic fracture risk depends on bone mineral density (BMD) and clinical risk factors (CRF). Five hundred and eighty-eight untreated female and male outpatient subjects were evaluated, 160 with vertebral fractures. BMD was measured both by using calcaneal dual X-ray and laser (DXL) and dual-energy X-ray absorptiometry (DXA), and CRF were evaluated. Detection frequencies for different BMD methods with or without CRF are presented. INTRODUCTION: Osteoporotic fracture risk depends on bone mineral density and clinical risk factors. DXA of the spine/hip is considered a gold standard for BMD assessment, but due to degenerative conditions, particularly among the older population, assessment of BMD at the lumbar spine has been shown to be of limited significance. Portable calcaneal dual X-ray technology and laser can be an easily obtainable alternative. METHODS: Vertebral fractures were evaluated in a baseline analysis of 588 females and males (median age 64.4, range 17.6-93.1 years), comparing BMD measurements by using DXL and DXA and CRF with/without BMD. One hundred and sixty subjects had radiological verified vertebral fractures. Area under receiver-operating characteristic curves (AUROCC) and univariate and multiple logistic regressions were calculated. RESULTS: AUROCC for detection of vertebral fractures was comparable for DXL at calcaneus and DXA at femoral neck (DXL 0.665 and DXA 0.670). Odds ratio for prevalent vertebral fracture was generally weak for DXA femoral neck (0.613) and DXL (0.521). Univariate logistic regression among CRF without BMD revealed age, prevalent fragility fracture, and body mass index significantly associated with prevalent vertebral fracture (AUROCC = 0.805). Combining BMD and CRF, a prognostic improvement in case of DXA at femoral neck (AUROCC 0.869, p = 0.02), DXL at calcaneus (AUROCC 0.869, p = 0.059), and DXA at total hip (AUROCC 0.861, p = 0.06) was observed. CONCLUSIONS: DXL was similarly sensitive compared with DXA for identification of subjects with vertebral fragility fractures, and combination of CRF with BMD by DXL or DXA further increased the discriminatory capacity for detection of patients susceptible to vertebral fracture.

Embolization of bone metastases.

PURPOSE: To assess the effectiveness and clinical usefulness of transcatheter embolization of bone metastases. PATIENTS AND METHODS: The procedures and outcome of 61 transcatheter embolization procedures performed in 51 patients with hypervascular skeletal metastases were retrospectively evaluated. Results from computed tomography, magnetic resonance imaging, and diagnostic angiography, performed before and after embolization, were reviewed. RESULTS: All embolizations were technically and clinically successful. Major blood loss during surgery was prevented in 32 cases; the size of viable tumor tissue in large, unresectable bone metastases was reduced before radiation or chemotherapy in 17 cases; and otherwise untreatable skeletal pain was decreased in 11 cases. Heavy bleeding from a metastasis was controlled in one case. The complications were temporary paresis of a lower extremity in three patients, cardiac arrest in one patients, and unintentional embolization of synthetic tissue adhesive in one patient. Median survival time was 28 months (range, 3-59 months). CONCLUSION: Transcatheter embolization is effective and reliable in the treatment of bone metastases.

[Sonographic findings following laparoscopic cholecystectomy]. / Sonographische Befunde nach laparoskopischer Cholezystektomie.

In a prospective study 500 patients were examined sonographically following laparoscopic cholecystectomy, 183 on several occasions. In the majority of patients (79.4%) there were no remarkable findings, either clinically or sonographically. In 102 patients (20.4%) there were sonographic abnormalities such as fluid collections in the gallbladder bed (13%), postoperative dilatation of the biliary passages (9.4%), free abdominal fluid (2%) or pleural effusions (1.2%). Only 25 patients (5%) showed clinical symptoms; there was complete agreement with the findings on ultrasound.

[Drain fistulography. Radiological sphincter identification in high anal fistulae]. / Drain-Fistulographie. Radiologische Sphinkteridentifikation bei hohen Analfisteln.

To warrant permanent surgical cure of high anal fistulae, while avoiding at the same time faecal incontinence due to inadvertent division of the puborectalis muscle, distinction between a trans- and suprasphincteric fistula track is essential. This differentiation is often crucial, since digital rectal palpation and conventional fistulography tend to be unreliable. Therefore we developed a radiological technique of imaging the anorectal fistulous track, "drain fistulography". After silicon drainage of the fistula the contrast visualization of anal canal, rectum and fistula drain allows to assess the topographic relation between fistula and anal sphincters as well as the sphincteric functional component above the fistula. A trans-sphincteric fistula track was demonstrated in 7 of 8 patients (5 with recurrent fistulae) by means of "drain fistulography", permitting complete laying open of each fistula in a second operation. In one patient a suprasphincteric fistula track was found and a "mucosal flap repair" was carried out. After a mean observation time of 53 months all patients are perfectly continent and free of recurrence. The method of "drain fistulography" is a valuable diagnostic tool to select the appropriate definitive surgical procedure in the treatment of high anal fistulae.

[X-ray measurement of the level of rectal carcinomas and its dependence on the functional status of the pelvic floor]. / Röntgenologische Höhenmessung von Rektumkarzinomen und ihre Abhängigkeit vom Funktionszustand des Beckenbodens.

The influence of the various functional states of the pelvic floor on the radiological assessment of the tumour levels and the distant tumour-free distance in rectum neoplasms was investigated. The parameters "anal canal length", "anorectal angle" and "impression of the puborectalis muscle" were measured in lateral distant views of the rectum in a series of healthy controls (n = 160). In addition, these parameters and the "distant tumour-free distance" were measured in patients with rectal cancer (n = 40). For each patient the lateral distant view at rest, during contraction and during maximal relaxation (straining) of the pelvic floor, were available for retrospective analysis. Depending on the various functional states of the pelvic floor, the differences between the same parameters were statistically significant (p less than 0.001). The average difference between the distal tumour-free distances during contraction and straining was 1.5 cm. Therefore, measurements of this distance in one lateral distant view exclusively may result in an inaccurate assessment of the tumour level. For the individual planning of extreme sphincter-saving surgery in low rectal cancer based on lateral distant view, the view at rest appears to be the most suitable. However, additional x-rays during contraction and maximal relaxation of the pelvic floor, respectively, should be available to identify the view at rest for an accurate assessment of the tumour level and to avoid misinterpretations which would have falsely influenced the planning of rectum surgery in 20% of our cases.

Sonographic demonstration of septicaemia with gas-forming organisms after liver transplantation.

Sepsis with gas-forming organisms, e.g. Clostridium perfringens and anaerobic streptococci occurred in three of 120 liver-transplant recipients (2.5%). The diagnosis was made in all three patients by bedside ultrasound, before blood cultures revealed bacterial growth. Floating high amplitude echoes within the extra- and intrahepatic portal veins and persistent small high amplitude echoes in the non-dependent portion of the liver are indicative of portal venous gas and should prompt further laboratory investigations.

Lymphoid follicular hyperplasia in excluded colonic segments: a radiologic sign of diversion colitis.

Double-contrast barium enema (DCBE) studies showed lymphoid follicular hyperplasia (LFH) in excluded colonic segments after colostomy in 12 of 40 patients. In most patients with LFH, more than 80% of the excluded colon was affected. In eight patients, regression of LFH was demonstrated with DCBE studies after reanastomosis. This work suggests that LFH is the most common DCBE study finding in diversion colitis.

The relationship between the common femoral artery, the inguinal crease, and the inguinal ligament: a guide to accurate angiographic puncture.

The variability of the extraperitoneal puncture space between the inguinal ligament and the inguinal crease was evaluated in 100 patients. The distance between the inguinal crease and the inguinal ligament varied from 0 to 11 cm (average 6.7 cm +/- 1.9 SD), the average value for women (7.5 cm +/- 1.9 SD) being significantly greater than that for men (6.3 cm +/- 1.9 SD, p = 0.0128). The bifurcation of the common femoral artery was found below the inguinal crease in 20%, at the same level in 3.5%, and above it in 76.5% of cases. Consideration of these results will help avoid intraperitoneal puncture and improve the rate of successful antegrade puncture of the femoral artery.

[Sonography of acute cholecystitis. A report on 58 cases with a correlation of pathomorphological and histological findings]. / Sonographie der akuten Cholezystitis. Bericht über 58 Fälle mit Korrelation zum pathomorphologisch-histologischen Befund.

Sonography has become the method of choice for evaluating acute diseases of the right upper quadrant. Prior to the ultrasound the diagnosis of acute cholecystitis was based on clinical and laboratory data. The pathohistomorphology of 58 opertively and histologically proven cases of acute cholecystitis has been correlated with preoperative sonography. An acute cholecystitis can be diagnosed based on the following sonographic criteria: Thickening of the wall of the gallbladder to more than 4 mm, sonolucent areas in or around the wall of the gallbladder, an increased ap. diameter of more than 4 cm as well as gallstones. A hyperechoic content of the gallbladder correlating to an empyema of the gallbladder was found in 31% and a perforation in 27.6% of the cases.

[Results of colo-anal anastomosis in deep-seated tumors of the rectum]. / Ergebnisse der coloanalen Anastomose bei tiefsitzenden Tumoren des Rectums.

Colo-anal anastomosis as surgical procedure for low rectal tumors was analysed in regard of complication rate, functional and oncological results. The sensibility of the method particularly in tumors near the anal sphincters, was assessed by means of a new radiological procedure (lateral distant view). From 1982 to 1985 colo-anal anastomosis was performed in 30 patients with rectal carcinoma. All tumors were within reach of the palpating finger. Tumor distance from the anal verge was measured endoscopically (6.4 +/- 1.5 cm) and radiologically (9.3 +/- 1.7 cm) (x +/- SD). The complication rate was comparable to that after anterior resection with conventional anastomosis. Inspite of problems with high frequency in the first months after surgery, all patients were satisfied with the functional result of the operation. Frequency decreased within a year to 4 stools/day. At present a reliable evaluation of the oncological results cannot yet be established.

Irradiation-induced changes in the subclavian and axillary arteries after radiotherapy for carcinoma of the breast.

Three case reports are reviewed to illustrate the possibility of treating irradiation-induced lesions of the subclavian-brachial vascular segment (aneurysm and segmental occlusions) 14, 20, and 26 years after radical mastectomy and subsequent radiotherapy. All patients had an extraanatomic vein bypass graft from the carotid to the brachial artery crossing the shoulder near the acromioclavicular joint, with the advantage that the tissue changed by radiotherapy or infected by ulceration could be circumvented. There were no postoperative complications, with adequate function of the grafts (follow-up, 17, 24, and 20 months, respectively).

[Roentgen studies (lateral distance image) for precise determination of tumors of the rectum]. / Röntgenuntersuchungen (seitliche Distanzaufnahme) zur exakten Höhenbestimmung bei Tumoren des Rektums.

The lateral distant view (LDV) of the rectum is proposed for more precise identification of localization of rectal tumors for preoperative planning and to increase the number of sphincter saving operations. In a prospective study 129 patients with rectal tumors were compared with radiologic and rectoscopic measurements and with the intraoperative tumor site. Other factors which may influence the resectability of tumors have been examined in a part of this patients by measuring the width of the presacral space, the anorectal angle and the pelvic diameters by radiological pelvimetry. Radiological measurement on the lateral distant view showed that tumors usually are located much higher (0.5 to 12.5 cm) than is suggested by rectoscopy. Unlike the rectoscopy, the lateral distant view also can be used for measuring the length of the anal canal. This measurement is most important for evaluating the distance between the tumor and the inner end of the anal canal and reflects the width of a possibly tumor-free margin. Sphincter saving operations could be predicted much better by the lateral distant view than by rectoscopy.

[Sonographic studies of the aorta after prosthetic replacement (follow-up of 112 patients)]. / Sonographische Untersuchungen der Aorta nach prothetischem Gefässersatz (Eine Nachuntersuchung von 112 Patienten).

Sonography should be routinely used for clinical follow up of patients with prosthetic grafts replacing the abdominal aorta and iliac vessels. 112 patients were investigated and the normal findings as well as pathological changes following aortic graft implantation are described and the difference between Dacron and PTFE-Y graft material discussed. Adequate visualization of anatomic detail of the graft was found in 82.1%. In the remaining patients the site of implantation was partly or completely overshadowed by bowel gas. 67.4% showed normal graft findings, whilst the remaining 32.6% exhibited incipient or manifest minor or major pathological changes such as dilatation of graft material, kinking, pseudoaneurysm, intraluminal thrombotic material and occlusion of parts of the implanted grafts. Dilatation was seen only with Dacron grafts and kinking only with PTFE-Y graft material. In combination with the clinical findings sonography helps to reduce the necessity of invasive angiographic procedures and allows early recognition of abnormal anatomical situations.

[Real-time sonography in breast diagnosis. Indication and value]. / Real-time-Sonographie in der Mammadiagnostik. Indikation und Stellenwert.

With improvement in ultrasound technique, sonography is gaining increasing importance in the evaluation of breast lesions. The following conclusions are drawn on the basis of experience in the use of real-time sonography in 200 patients. Palpable masses are most suitable for examination by sonography, whereas the diagnostic yield in diffuse breast disease is relatively low. The most important task is the differentiation between benign cystic and solid masses. Differential diagnosis of solid tumours may be difficult or even impossible and biopsy should not be carried out solely on the basis of a sonographic examination. Palpation and mammography must still be considered as basic methods of examination, which may be successfully complemented by sonography.

Postoperative assessment of below-knee bypass grafts.

Our results seem to demonstrate that, even when healthy or arteriosclerotic arteries tolerate knee flexion without any impairment of blood flow, all bypass materials, to a certain extent, have a tendency toward morphologic changes, such as kinking, looping, stenosis and decrease of peripheral blood flow. Reocclusion in below-knee reconstruction, which cannot be explained by poor outflow situation or technical faults, might be related to the graft material used as well as hemodynamic changes caused by flexion of the knee joint. With the use of ASV grafts, these changes are minimal and of little or no clinical importance; when HUV is used, these changes are more distinctive and might, in some instances, be the cause of reocclusion. This could explain the difference in the late results with the use of ASV or HUV. The results of reinforced PTFE still await evaluation. However, it should be kept in mind that the results in addition to the already mentioned influences are also caused by neointima proliferation and progression of the disease.

[The PTFE plastic prosthesis as an arterial replacement: experiences over a 5-year period]. / Die PTFE-Kunststoffprothese als arterieller Gefässersatz: Erfahrung über 5 Jahre.

Unilateral iliac femoral reconstructions with PTFE are yielding good results-similar to those with Dacron, with patency rates of 75, 67, and 65% at 1, 2 and 3 years, respectively (Kaplan-Meier). PTFE has additional advantages compared with other materials: a) no need of preclotting; b) smooth inner surface-easy thrombectomy in case of thrombosis and c) good handling characteristics. In view of the above-mentioned facts PTFE can be recommended without restriction for unilateral pelvic reconstructions. The functional early results of bilateral aorto-femoral Goretex-Y bifurcation grafts in 50 cases after 2 years are encouraging. Long-term results are still pending. Reports of other groups using this material as aorto-bifemoral substitute are not yet available. The functional results with PTFE for femoro-popliteal grafts are not satisfactory: 35% after 2.5 years. Extra-anatomical bypasses yielded 70% one-year functioning rate. Especially the ring-or spiral-armoured PTFE grafts seem to be suitable for these reconstruction procedures.

Lateral distant view for improved accuracy in locating rectal tumors.

The lateral distant view of the rectum is proposed for more precise identification of sites of rectal tumors for preoperative planning and to increase the number of sphincter-saving operations. In a prospective study of 39 patients with rectal tumors, radiologic and rectoscopic measurements of tumor levels were compared with each other and with the actual tumor site. Radiologic measurement on the lateral distant view showed that tumors usually are located much higher (2-11 cm) than is suggested by rectoscopic evaluation. Unlike rectoscopy, the lateral distant view also can be used for measuring the length of the anal canal. This measurement is important for evaluating the distance between the tumor and the inner end of the anal canal and reflects the width of a possibly tumor-free margin. Sphincter-saving operations could be predicted much better by the lateral distant view than by rectoscopy.

[The PTFE-Y bifurcation prosthesis: early results]. / Die PTFE-Y-Bifurkationsprothese: Frühergebnisse.

During the past 2 years (April 1981-March 1983) 50 PTFE Y-grafts were implanted. The early results are good. Except one graft limb occlusion (8 months postoperatively), which was successfully managed by thrombectomy, all grafts are functioning well or did so until death. 5 patients (age 70-84 years, aortic aneurysm, additional vascular surgery) died 1 day to 8 weeks postoperatively. The death was not specifically related to the material of the new prosthesis. Advantages of PTFE are: a) no need of preclotting; b) absolute tight body of the prosthesis even in the heparinized patient; c) thrombectomy is easy to perform. Important technical details, mandatory for a safe operative procedure and for good functional as well as morphological results, are reported.

False aneurysm treated by a combined approach of coil embolization and autologous vascular grafting.

A serious complication associated with vascular surgery is active or potential hemorrhage due to infected pseudoaneurysm. In two cases of false aneurysm, embolization with the Gianturco-Anderson-Wallace (GAW) coils was performed and blood supply was preserved by autologous vascular grafts, thereby emphasizing the feasibility of a combined approach in patient management.