[Diagnosis of acute cholecystitis. Ultrasound diagnosis is reliable]. / Diagnostik der akuten Cholezystitis. So treffsicher ist der Ultraschall.

In the presence of typical ultrasonographic signs (Murphy's sign, established pericholecystitis) in patients with a relevant history and clinical presentation, diagnosis of acute cholecystitis can be established with a high degree of accuracy. As a non-invasive method, ultrasound can be used at the bedside of the severely ill patients, thus enabling the more economical use of more sophisticated and expensive examination methods. In the acute stage, the urgency of surgical intervention can be assessed. During follow-up, the effectiveness of conservative measures can be checked, failed treatment detected early on, and complications avoided. In high-risk patients, interventional procedures (puncture, percutaneous drainage) can be performed under US-control. Thus, US is the diagnostic modality of first choice for the diagnosis of acute cholecystitis. It has relevance for decision-taking, and is an indispensable procedure in the emergency setting.

A new method for extracting wooden foreign bodies from the upper esophagus.

A foreign body impacted in the esophagus is an emergency case that requires immediate treatment. Often the foreign body can be removed easily using forceps or loops. Sometimes, however, safe grasping and extraction may become very difficult. A patient swallowed a chestnut which then stuck in the upper esophagus. The chestnut was removed with a gynecological instrument with a spiral tip used for myoma fixation. Thereafter this technique was applied to in vitro tests with various kinds of meat and wood. In the clinical case, the chestnut could be removed with the spiral tip of the instrument for myoma fixation, whereas in the in vitro tests it was impossible to grasp meat or cut it into pieces. The removal of foreign bodies, such as wood, with the spiral tip of the instrument for myoma fixation during rigid esophagoscopy is an alternative to extraction with forceps or loops. This method is ineffective for the removal of pieces of meat.

[Strategy and outcome of interdisciplinary therapy of ovarian carcinomas]. / Strategie und Ergebnisse der interdisziplinären Therapie von Ovarialkarzinomen.

In this retrospective trial we analyzed the data for 200 patients with serous papillary ovarian cancer. The patients were treated with various operation strategies following an interdisciplinary conference among a surgeon, a gynecologist, and an oncologist. Mean overall survival was 26 months. It was significantly better in patients with primary and secondary debulking operations in combination with sufficient postoperative chemotherapy. The morbidity rate reached 16.8%, the overal mortality rate was 5.7%. The mortality for the first surgical intervention was 0%.

[Instrumental diagnosis for therapy decision making in abdominal injuries]. / Apparative Diagnostik zur Therapieentscheidung bei Abdominalverletzungen.

The aim of diagnostic procedures following abdominal injuries is rapid assessment of the necessity for surgical intervention and specification of the organ lesion, thus reducing the number of negative laparotomies. The extent of the diagnostic approach must be reduced in unstable patients. Sonography is the standard procedure in stable as well as in unstable patients, both in the initial period and the subsequent follow-up. CT-scan is complementary to sonography in detecting organ lesions. Sonographically guided puncture has replaced diagnostic peritoneal lavage. Laparoscopy following blunt abdominal injuries is not useful; however, it may be helpful following penetrating abdominal trauma.

[Strategy and outcome in bowel injuries after blunt abdominal trauma]. / Strategie und Ergebnisse bei Darmverletzungen nach stumpfen Bauchtrauma.

In this retrospective trial, we examined 215 patients with bowel lesions following abdominal injuries. We analyzed the diagnostic procedures, the time to diagnosis, the subsequent surgical therapy, and complications. The diagnosis of bowel lesions remains a diagnostic challenge. All apparative diagnostic procedures (sonography, CT-scan, lavage, laparoscopy, X-ray) fail to diagnose bowel lesions. In our trial, most patients showed clinical signs of peritonitis leading to diagnosis. Ultrasonographically guided puncture was important, if clinical signs remained unclear. This study underlines the importance of repeated clinical examination for early diagnosis and treatment of bowel injury.

[Diagnosis and therapy of diaphragmatic rupture after blunt thoracic and abdominal trauma]. / Diagnostik und Therapie der Zwerchfellruptur nach stumpfem Thorax- und Bauchtrauma.

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries because diaphragmatic injury does not play an important role beside severe injuries of intrabdominal and/or thoracic organs. Between 1976 and 1993, 141 patients were treated for traumatic injury of the diaphragm. In 42 patients with penetrating injuries following stab or shot wounds diaphragmatic lesions were diagnosed by the emergent surgical therapy. 99 had diaphragmatic tears from blunt thoracic or abdominal trauma by accidents. 14 of 99 patients sustained isolated diaphragmatic rupture, in 85 the rupture was combined with other injuries, 24 had fractures of the pelvic ring. Preoperatively the following diagnostic procedures were performed: chest radiograph in 99 patients, abdomen radiograph in 75, contrast radiographs in 34, angiography in 9, sonography in 74 and computed tomography in 48. Sensitivity and specificity of these diagnostic methods depend on the dimension of intrathoracic prolaps of abdominal organs. The sensitivity of contrast radiographs ranged from 72-78%. With the additional experience of ultrasonography since 1985 the sensitivity came up to 82%. In 11 patients additional diaphragmatic rupture was diagnosed by laparotomy indicated by liver and/or splenic rupture. Therapy of diaphragmatic injury was performed in 83 patients within 4 days, in 9 within 4 months and in 7 later than one year. For diaphragmatic repair 87 patients underwent laparotomy and 12 thoracotomy. Local complications were found in 13 patients (13.1%). 19 patients (19.2%) died postoperatively due to accompanying injuries.

[Strategy and results of advanced tumors in emergency situations]. / Strategie und Ergebnisse bei fortgeschrittenem Tumorleiden in der Notfallsituation.

In this retrospective trial we examined 142 patients with advanced unresectable cancer, who had bowel obstruction, bleeding, bowel lesion and abscesses and who were treated with different surgical procedures (resection, bypass, enterostomy). Mean survival rate was 8.6 months (range: 0-57 months). The mortality rate reached 21.7%. Surgical reintervention was necessary in 15.8% because of bowel obstruction and did not influence the survival rate. Despite advanced tumor disease and intestinal obstruction most patients had a good quality of life after surgical intervention.

[Duplex ultrasound studies after organ saving intervention in traumatic splenic rupture]. / Duplexsonographische Untersuchungen nach organerhaltendem Eingriff bei traumatischer Milzruptur.

The increased risk of overwhelming postsplenectomy sepsis (OPSI) led to the development of organ preserving procedures. However, little is known about the long-term results of organ preserving. A reduced blood flow has been suspected. In the period from 1982 till 1990 144 patients were operated on for a ruptured spleen. Thirty patients had organ preserving procedures. These failed to stop the bleeding in eight patients. Two patients died. Nineteen patients (group A) out of twenty were reexamined clinically, by ultrasound and by Duplex sonography. They were compared with matched test persons. Three patients in group A complained of recurrent minor infections. Changes in the shape and the location of the spleen were a common sonographic finding. The diameter of the hilus was 3.8 +/- 0.5 cm and the blood flow was 221 +/- 75 ml/min in group A. There was no difference to group B with 3.8 +/- 0.6 cm and 224 +/- 76 ml/min, respectively. The hemodynamic preconditions necessary for a functioning spleen could be preserved in all patients.

[The value of colon contrast enema in ileus diagnosis]. / Bedeutung des Kolonkontrasteinlaufs in der Ileusdiagnostik.

In 115 patients with clinical and radiological signs of small and/or large bowel obstruction the contrast enema of the colon was evaluated prospectively to localize the site of occlusion in the colon. Contrast enema was performed in 76 patients with Gastrografin and in 39 with barium. In 22 of 24 patients with large bowel obstruction, in 7 of 11 with combined small and large bowel obstruction, in 4 of 14 with small bowel obstruction and in 19 of 66 with partial obstruction the site of obstruction was identified in the colon. In 107 of 115 patients the site of intestinal obstruction in the colon was either confirmed or excluded (sensitivity 89.2%, specificity 96.6%). In 6 patients the contrast enema failed due to incontinence, missing cooperation or insufficient preparation. In two cases with coprostasis the occlusion was missinterpreted as a carcinoma. Electrolytes and serum fluid concentration before and after the enema were not significantly influenced using the different contrast media. Contrast enema is indicated in patients with intestinal obstruction of unknown site, malignancies, after radiation therapy and recurrent partial obstruction.

[Sonographic acute and follow-up diagnosis after blunt abdominal trauma]. / Sonographische Akut- und Verlaufsdiagnostik nach stumpfem Bauchtrauma.

Experience with ultrasonographic acute and follow-up diagnostic as noninvasive imaging procedure for blunt abdominal trauma was analysed in a retrospective study. Between 1986 and 1989 166 organ lesions were noticed in 440 patients with clinically regarded diagnosis of a blunt abdominal trauma. 107 patients were laparotomised. Retrospectively, the sensitivity concerning free fluid in the abdominal cavity caused by lesion of an intrabdominal organ was 0.96 and the specifity 0.98. The predictive value of a positive test was 0.91 and the predictive value of a negative test was 0.99. The rate of negative laparotomy was 1.3%. Thus the sole use of ultrasonographic diagnostic and the non-use of peritoneal lavage seems justified in case of blunt abdominal trauma. Some figures illustrate typical cases and our own results.

[Extracorporeal piezoelectric gallstone lithotripsy: initial surgical experience with a new treatment. Technique and indications]. / Extrakorporale piezoelektrische Gallensteinlithotripsie: erste chirurgische Erfahrungen mit einer neueren Therapie. Technik und Indikationen.

The extracorporeal piezoelectric lithotripsy (EPL) is a new method for non-operative therapy of symptomatic gallbladder and problematic bile duct stones. The rare intrahepatic calculi were similarly disintegrated. Best results were reached with EPL as adjuvant measure or combined with oral cheno- and ursodeoxycholic acid therapy. EPL compared to other lithotripsy techniques is performed without any analgesia. That means advantage and patient's benefit.

Large-bile-duct stones--extracorporeal piezoelectric lithotripsy as adjuvant measure for endoscopic basket extraction.

Extracorporeal piezoelectric lithotripsy (EPL) was performed in 12 patients with large-bile-duct stones and intrahepatic stones. The Piezolith 2300 lithotripter (Wolf, Knittlingen, FRG) was used in all patients in whom routine endoscopic approaches for removal of the calculi had failed or were considered inappropriate because of large stone size or difficult localization. In 9 of the 12 patients the stones were fragmented. Complete stone clearance from the bile ducts was obtained in 8 of 10 patients by EPL alone or combined with one of the following: endoscopic extraction, mechanical lithotripsy or installation of solvents. Adjuvant EPL in conjunction with endoscopic therapy increased the success rate of nonsurgical treatment for bile duct stones from 73% to 95%. No clinically significant side effects or complications were noted.

[Epidemiology and pathogenesis of gallstones. Status of knowledge and therapeutic consequences]. / Epidemiologie und Pathogenese von Gallensteinen. Kenntnisstand und therapeutische Konsequenzen.

The prevalence of gallstones in Europe is 7% for mean and 12 to 14% for women with figures increasing with age. Most gallbladder stones remain asymtomatic, leading to complications in less than 2%, and to biliary pain in 18% of initially asymptomatic patients over a period of 20 years. On the basis of such observations it has been concluded that only symptomatic gallbladder stones need to be treated. Stones in the bile ducts, however, must be removed whether symptomatic or not. In Europe more than 80% of gallbladder stones are cholesterol stones. The remaining stones are black pigment stones, composed predominantly of calcium bilirubinate. Brown pigment stones usually occur in the pathogenesis of cholesterol stones, may lead to new therapeutic or prophylactic approaches.

[Significance of ultrasonic-guided pleural punctures/thoracic drainage after abdominal procedures and blunt abdominal/thoracic trauma]. / Bedeutung der ultraschallgesteuerten Pleurapunktion/Thoraxdrainage nach Abdominaleingriffen und stumpfem Bauch-/Thoraxtrauma.

The sensitivity of ultrasonographic diagnosis of pleural fluid accumulations and the value of ultrasonographically guided thoracentesis were studied prospectively. One hundred ten patients were examined after abdominal operations and chest trauma. Most of the examinations were performed in a half-sitting position. Pleural fluid of clinical relevance, diagnosed by real-time ultrasonography, was treated by thoracentesis under ultrasonographic guidance in 38 cases. The amount of aspirated fluid ranged from 150 to 1350 ml. The sensitivity of the method was 97.1%. The complication rate was 2.6%. There are now 240 patients treated by ultrasonographically guided thoracentesis and 160 cases with pleural drainage. In our view, ultrasonographically guided thoracentesis represents the method of choice in critically ill and immobile patients.

[Ultrasound diagnosis following blunt abdominal trauma. Sonography in acute and follow-up diagnosis]. / Ultraschalldiagnostik nach stumpfem Abdominaltrauma. Sonographie in der Akut- und Verlaufsdiagnostik.

Experience with ultrasonography as a non-invasive imaging procedure for acute and follow-up diagnostic evaluation of blunt abdominal trauma was analysed in a retrospective study. Between 1980 and 1988, more than 2,000 ultrasonographic investigations were performed for blunt abdominal trauma; 246 patients were laparotomized. Retrospectively, false results based on ultrasonography were less than 1% of all cases, so that the sole use of ultrasonographic diagnosis and the non-use of peritoneal lavage seems justified in cases of blunt abdominal trauma. A number of figures illustrate typical cases.

[Preoperative staging of rectal cancer: endosonography versus computerized tomography]. / Präoperatives Staging des Rectumcarcinoms: Endosonographie versus Computertomographie.

In a prospective study in 49 patients with rectal carcinoma the correlation of pre- and post-operative staging by CT and endorectal ultrasound (EU) was compared according to TNM-classification. With CT the pre/postoperative results correlated in T1 in 9/10, in T2 in 10/16, in T3 in 13/15 and in T4 in 6/8 patients. By EU identical results were found in all T1, in 10/12 T2, in 17/20 T3 and in 6/7 T4 stages. Overall, pre- and postoperative identical results were found by CT in 38 and by EU in 43/49 patients. Overestimation of the tumor stage was similar with both methods: 5 by CT and 4 by EU. Underestimation of the stage was more often by CT in 5 than by EU in 2 cases. (CT: accuracy 77.5%, sensitivity 88.3%, specificity 94.4%; ES: accuracy 87.7% sensitivity 91.5%, specificity 97.8%). Criteria for interpretation are discussed. In early tumor stages the depth of tumor invasion can be better evaluated by EU. In late stages both methods give important information for surgical strategy.

[The value of transrectal sonography and computerized tomography in the diagnosis of rectal cancer]. / Wertigkeit der transrektalen Sonographie und der Computertomographie in der Diagnostik des Rektumkarzinoms.

In a prospective study in 49 patients with rectal carcinoma the correlation of pre- and postoperative staging by CT and endorectal ultrasound was proven according to TNM-classification. With CT the pre/postoperative results correlated in T1 in 9/10, in T2 in 10/16, in T3 in 13/15 and in T4 in 6/8 patients. By endorectal ultrasound identical results were found in all T1, in 10/12 T2, in 17/20 T3 and in 6/7 T4 stages. Totally, pre- and postoperative identical results were found by CT in 38 and by endorectal ultrasound in 43/49 patients. Overestimation of the tumor stage was similar with both methods: 5 by CT and 4 by endorectal ultrasound. Underestimation of the stage was more often by CT with 5 than by endorectal ultrasound with 2 cases (CT: accuracy 77.5%, sensitivity 88.3%, specificity 94.4%; endorectal ultrasound: accuracy 87.7%, sensitivity 91.5%, specificity 97.8%). Criteria for interpretation are discussed. In early tumor stages the depth of tumor invasion can be better evaluated by endorectal ultrasound. In late stages both methods give important information for the surgical strategy.

[The value of ultrasound diagnosis in blunt abdominal and thoracic injuries]. / Die Wertigkeit der Ultraschalldiagnostik beim stumpfen Bauch- und Thoraxtrauma.

In a prospective study, real-time ultrasonography was applied as the initial imaging procedure in 103 consecutive patients with blunt abdominal or thoracic trauma. Additional peritoneal lavage was not performed. Pathological findings were present in 22 patients (21%). Sensitivity of the examination was 95.5%, with two false positive results, specificity was 97.5% with one false negative result. Lesions of intraabdominal or thoracic organs were demonstrated directly by ultrasonography in 14 patients. In the remaining patients free fluid was discovered in the abdominal cavity. Splenic and hepatic lesions occurred most frequently followed by hematothorax. Ultrasonography can be recommended as the initial imaging procedure, giving a high amount of information in the primary diagnosis of blunt abdominal thoracic trauma.

[Real-time controlled pleural puncture in surgical intensive care patients]. / Real-Time gesteuerte Pleurapunktion bei chirurgischen Intensivpatienten.

The sensitivity of ultrasonographic diagnosis of pleural fluid accumulations and the value of ultrasonography guided thoracentesis were studied prospectively. 110 patients were investigated after abdominal operation and chest trauma. Most investigations were performed in a half sitting position. Pleural fluid of clinical relevance diagnosed by real time ultrasonography was treated by thoracentesis under ultrasonographic guidance in 38 cases. The amount of aspirated fluid ranged from 150 ml to 1350 ml. Sensitivity of the method was 97.1%, complication rate was 2.6%. From our view ultrasonography guided thoracentesis represents the method of choice in critically ill and immobile patients.