Spontaneous intramural small-bowel hematoma secondary to anticoagulant therapy: a case series.

Spontaneous small-bowel hematomas most commonly involve the jejunum, followed by the ileum and duodenum, and occur in patients who receive excessive anticoagulation with phenprocoumon/warfarin or who have additional risk factors for bleeding. We report three cases of intramural small-bowel hematoma, all complications of treatment with phenprocoumon, which nowadays is used extensively for therapeutic and prophylactic purposes. Diagnosis can be readily attained by sonography and confirmed using computed tomography. Early diagnosis is crucial because most patients can be treated successfully without surgery. Based on this experience and data from the literature, conservative treatment is recommended for intramural intestinal hematomas, when other complications needing laparotomy have been excluded.

[The Würzburg polytrauma algorithm. Concept and first results of a sliding-gantry-based computer tomography diagnostic system]. / Der Würzburger Schockraumalgorithmus. Gesamtkonzept und erste Ergebnisse einer "sliding-gantry-basierten" Computertomographiediagnostik.

BACKGROUND: The purpose of this study was to show the practicability of a new algorithm in the management of polytraumatized patients based on Advanced Trauma Live Support (ATLS) and using mobile whole body multislice CT (MMDCT) as the primary imaging system. PATIENTS AND METHODS: A series of 120 trauma patients referred to the Würzburg University Hospital Trauma Emergency Room were categorized into suspected polytrauma and suspected non-polytrauma groups. The polytraumatized patients were investigated using the Würzburg polytrauma-algorithm including whole body multislice CT with a 16-row-scanner. The algorithm is described. The time for the diagnostic procedure was measured and compared with data from the Trauma Registry of the German Society of Trauma Surgery. RESULTS: From 120 patients 78 (66%) underwent whole body CT. The diagnostic procedure was quick with significant advantages especially for cranial and trunk diagnostics. CONCLUSION: The Würzburg polytrauma algorithm worked well. There was excellent cooperation within the interdisciplinary leading team consisting of anaesthesiologists, surgeons, and radiologists. The principles of ATLS could be respected. Mobile whole body multislice CT was an effective tool in the diagnostic evaluation of polytrauma patients.

[Percutaneous hydromechanical thrombectomy in acute and subacute lower limb ischemia]. / Perkutane hydromechanische Thrombektomie bei akuter und subakuter arterieller Beinischämie.

PURPOSE: A prospective study should evaluate the primary and 2-year results of treating acute and subacute lower-limb ischemia with hydromechanical thrombectomy (HTE). MATERIALS AND METHODS: Consecutively 64 patients, 12 with viable and 52 with threatening limb ischemia and onset of symptoms within 8 +/- 9 days, were treated and controlled for 24 months. An 8 F hydromechanical thrombectomy device (HTK), was used. It sucks and shreds the thrombi. The shredded particles are transported to the outside. RESULTS: In 8 patients a total, in the others a partial restoration of the vessel lumen up to 70-50% was achieved in a mean time of 34 minutes. Residual thrombi, underlying atherosclerotic vessel disease and occluded arteries with a small diameter made adjunctive interventions (balloon angioplasty, percutaneous aspiration thrombectomy, lysis) necessary. Clinical symptoms and the ankle-brachial index improved significantly (p < 0.01). Primary patency was 72%, 70%, 67%, and 65%; the limb salvage rates were 81%, 78%, 75%, and 73% for one, 3, 12, and 24 months respectively. Device-induced complications did not occur. CONCLUSIONS: The HTK allowed a rapid reduction of fresh thrombotic material without complications. In 78% of the cases adjunctive therapies are required for wall-adherent thrombi and when tibial vessels with smaller lumina are included. Long-term results are comparable to literature data for fibrinolytic or operative regimens. The advantage, however of the HTK seems to be the reduction of intervention time and intra-arterial dosage of fibrinolytic drugs.

Shredding embolectomy thrombectomy catheter for treatment of acute lower-limb ischemia.

We undertook a prospective evaluation to prove a new mechanical thrombectomy device, the shredding embolectomy thrombectomy catheter (S.E.T. catheter), for the treatment of patients with acute lower-limb ischemia. The study evaluated the success, patency, mortality, limb salvage, and complication rates for 51 patients treated from January 1994 through June 1996, with this device, which was an 8-F three-lumen catheter. The onset of symptoms was 8.6 +/- 9 days. Thrombus length was 18 +/- 9 cm situated in 44 native vessels and in 7 bypasses, 42 limbs were graded as threatened. Hydromechanical thrombectomy with the S.E.T. catheter proved to be a quick and safe adjunct for therapy of acute femoropopliteal thromboembolic occlusions with a high initial success rate and an acceptable mid-term patency rate.

Interobserver agreement in defecography--an international study.

BACKGROUND: Defecography is considered to be an essential investigation in the evaluation of functional anorectal disorders, but the agreement between observers from different clinical centers has never been evaluated. METHODS: 14 defecographic studies were selected aimed to cover the most relevant defecographic findings responsible for disordered defecation. Eight studies were considered unequivocal, but six were thought to be controversial. All were sent to the ten participants in Europe and the US (five proctosurgeons, three radiologists, two gastroenterologists). They evaluated the studies using a previously agreed upon questionnaire. Interobserver agreement was quantified by kappa statistics and by the proportions of positive and negative agreement as compared to chance agreement, respectively. RESULTS: Overall, only the completeness of rectal emptying and the presence of a rectocele achieved acceptable kappa values above 0.4. When restricting the evaluation to the studies considered to be unequivocal, agreement improved considerably and was moderate to good for all items describing the images (kappa 0.43-0.63). However, whether proctosurgery should be performed and whether defecography contributed to the management of the particular patient remained controversial with very low kappa. CONCLUSIONS: It is doubtful whether defecography contributes substantially to the management of patients with disordered defecation.

[Surgical treatment of acute pericardial tamponade in an infestation of the heart by Echinococcus]. / Chirurgische Behandlung der akuten Perikardtamponade bei Echinokokkusbefall des Herzens.

HISTORY AND CLINICAL FINDINGS: A 56-year-old turkish patient, previously in good health, was admitted because of pain suggesting myocardial infarction. Physical examination of the heart, lungs and abdomen was unremarkable. INVESTIGATIONS AND DIAGNOSIS: The concentrations of myocardium-specific enzymes were not elevated and the ECG showed no signs of ischaemia. Echocardiography and magnetic resonance imaging ruled out acute aortic dissection, but demonstrated a round cystic space-occupying mass over the anterior wall of the heart. Hydatid cyst was suspected from the imaging results and the patient's origin from area endemic for Echinococcus. The diagnosis was confirmed by a titre of 1:6,400 (normal: 1: < 100) for Echinococcus antibodies. TREATMENT AND COURSE: Albendazole administration was initiated. Planned elective surgical removal of the hysatid cyst had to be performed urgently because of acute pericardial tamponade. Cyst rupture was suspected but an actually undamaged cyst was subtotally removed under cardiopulmonary bypass. The postoperative course was uneventful and albendazole treatment was continued. CONCLUSION: Because of the high incidence of fatal complications urgent surgical removal under cardiopulmonary bypass is the treatment of choice for hydatid cyst involving the heart. Perioperative albendazole administration is also essential.

[Percutaneous transluminal hydrodynamic thrombectomy--the initial results]. / Perkutane, transluminale hydrodynamische Thrombektomie--erste Ergebnisse.

PURPOSE: First clinical applications in the femoro-popliteal vessels of a new system for percutaneous, transluminal hydrodynamic thrombectomy are presented. MATERIAL AND METHOD: Three patients suffering from femoro-popliteal thromboembolic obstruction were treated. A new hydrodynamic 8-F catheter with two lumina was used. The jet leaving at the tip of the catheter shredded the thrombotic material. Using the Venturi effect the thrombus was collected. The shredded material was transported outside through the second channel of the catheter. RESULTS: All obstructions could be removed. Underlying degenerative vessel disease and older thromboemboli needed additional therapy like PTA or aspiration thrombectomy (PAT). CONCLUSIONS: The new catheter is helpful in removing arterial femoro-popliteal thromboembolic obstructions. Additional interventions may be necessary. More clinical experience is needed.

Intestinal pseudoobstruction as a feature of myotonic muscular dystrophy.

We report two cases of intestinal pseudoobstruction caused by visceral smooth muscle involvement due to myotonic muscular dystrophy. Two patients with myotonic muscular dystrophy presented with abdominal pain, distention, constipation, and vomiting. The exclusion of mechanical obstruction by plain abdominal radiography, contrast studies, and colonoscopy led to the diagnosis of intestinal pseudoobstruction. Diagnosis was confirmed by manometric and cineradiographic findings of abnormal intestinal motility. Conservative management including laxatives and cisapride led to the resolution of the pseudoobstruction syndrome and long-term remission without relapses during a two year follow-up. In patients with known myotonic dystrophy the occurrence of intestinal pseudoobstruction should be considered in order to avoid unnecessary laparotomies.

[Radiation exposure during defecography]. / Die Strahlenexposition bei der Defäkographie.

The introduction of a new radiological method requires the assessment of the advantage-risk ratio. On measuring the radiation doses during defecography, skin entrance and gonadal exposure values were found to be lower than during well-known and well-established examinations of the small pelvis, such as colon enema and CT of the lower abdomen. Defecography, as a radiological tool for diagnosing the anorectal function is, therefore, also suitable for young persons.

[Surgical indications in cricopharyngeal dysfunction]. / Operationsindikation bei cricopharyngealer Dysfunktion.

In 1989, five patients were treated for a cricopharyngeal dysfunction by cervical myotomy. In the past, due to extremely limited indications for surgery, repeated efforts of conservative treatment had been attempted in patients with idiopathic cricopharyngeal dysfunction and tracheopulmonary aspiration and/or permanent inability of oral nourishment. These patients underwent surgery after an interdisciplinary clinical assessment. Four out of five patients showed immediate improvement of their serious symptoms. Cervical myotomy is not expected to be successful in patients with insufficient oropharyngeal propulsion, as we could see in one female patient with severe upper oesophageal sphincter spasm. According to the literature and to our results, approximately 70 to 90% of the patients with idiopathic dysfunction of the cricopharyngeal muscle, who underwent surgery, showed significant improvement or even recovery. Due to the multifactoral genesis of the cricopharyngeal dysfunction it is understandable, that the surgical result is heavily dependent on the preoperative interdisciplinary diagnosis. In summary, for idiopathic cricopharyngeal dysfunction with complications we recommend the early and technically simple operation.

[Disorders of anorectal function]. / Anorektale Funktionsstörungen.

Since sophisticated function tests of the anorectal continence organ become more and more available, dysfunction of the anorectum is increasingly diagnosed and differentiated. The examination includes measurements of the pressure in the rectum and anal canal (anorectal manometry), rectal distension by an inflatable balloon to test the sensibility, electromyography and radiological defecography. By these methods the etiology and pathogenesis of the most important anorectal disorders, such as anal incontinence, different forms of constipation and rectal prolapse, may be differentiated. Nowadays, many of these disorders are successfully treated by a specific management which includes a special diet, drugs, surgery and biofeedback training programs.

[Observations on the ability to work surgically treated scoliosis patients during 1946-1966 (author's transl)]. / Beobachtungen zur Erwerbsfähigkeit an operativ behandelten Skoliosepatienten der Jahre 1946-1966.

Basing on follow-up observation of a group of 113 scoliosis patients who had undergone surgery during 1946 to 1966, the connection between scoliosis and ability to work is subjected to close scrutiny. The study shows that there is a connection between reduction in the ability to work and the scoliosis angle, the extent of stiffness and cardiopulmonary performance of the patients. We may well expect that improved results of surgery, as they are now obtained with the modern methods (Harrington), will result in improved physical ability and a less pronounced reduction in the patients' capacity for gainful employment.