Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results.

Two hundred and twenty patients with a total of 412 gall bladder stones of between 8 and 38 mm in size were treated with extracorporeal shock wave lithotripsy, using the overhead module Lithostrar Plus. Fifty six per cent of stones were solitary (mean (SD) diameter 23 (5) mm) and 9.5% of the patients had more than three stones. Stones were successfully disintegrated in 218 patients (fragmentation size less than 5 mm in 80%, less than 10 mm in 19%). Some 65% of patients required one treatment and the rest two or three. A mean (SD) of 4100 (1800) shock waves with a pressure of 700 bar were applied. Twenty four to 48 hours after lithotripsy a transient but significant increase in serum transaminase activities (31%) and in bilirubin (29%), urinary amylase (27%), and blood leukocyte (62%) values was observed. In 29% of patients there was a transient microhaematuria, in 2% transient macrohaematuria, and in 25% painless petechiae of the skin. Ultrasound showed temporary gall bladder wall oedema in 13%, temporary distension of the gall bladder in 11%, and transient common bile duct distension in 8% after treatment. After discharge from hospital, 31% of patients complained of recurrent colic that responded to simple analgesics. Four to eight weeks after therapy, four patients developed biliary pancreatitis and 11 biliary obstruction that was managed by endoscopy. To date, 105 patients have been followed for over 12 months. Sixty one of these had a solitary stone, 17 had two, and 27 had three or more stones. A total of 59 patients, including 44 with a primary solitary stone, eight with two stones, and seven with three or more stones are completely stone free.

[Technique of recurrent laryngeal nerve exposure within the scope of interventions of the thyroid gland]. / Zur Technik der Rekurrensdarstellung im Rahmen von Eingriffen an der Schilddrüse.

In anatomical preparations performed during autopsy we developed a well-defined approach for the identification of the recurrent laryngeal nerve during surgery on the thyroid gland. The principle of this concept is to visualize the nerve near the branching of the inferior thyroid artery, where it shows a 30 degree angle to the trachea in a direction running from caudal lateral to cranial medial and lies in front of, behind, or between the branches of the artery. This preparation mode has been prospectively performed in 100 patients undergoing thyroid surgery. In 159 (= 97.6%) sides of the neck out of 163 we identified the nerve at the typical site. The topographical relation of the recurrent nerve to the inferior thyroid artery revealed the following differences for the right and left side of the neck: On the right side the nerve was found to be behind in 48%, in front in 33% and between the branches of the artery in 15% of cases. In contrast, on the left side the nerve was found to be dorsal in 53%, ventral in 23% and between the branches in 23%. Of 163 nerves at risk we observed primary nerve palsy in 2 cases (1.2%), and a definitive palsy rate of 0.6% at the 3-month follow-up. In conclusion, we recommend the described approach for the identification of the recurrent laryngeal nerve during thyroid surgery whenever complete mobilisation of the thyroid lobe (e.g. thyroidectomy, lobectomy, resection of retrotracheal adenomas) is necessary.

[A combined endoscopic surgical treatment concept in acute biliary pancreatitis]. / Kombiniertes, endoskopisch-chirurgisches Behandlungskonzept bei akuter, biliärer Pankreatitis.

This paper presents the results of a combined endoscopic-surgical approach with management of acute biliary pancreatitis in 91 patients. The diagnosis was always made by means of endoscopic-retrograde cholangiography. Papillary or bile duct stones, or unmistakable signs of previous stone passage, and in exceptional cases flow obstruction due to preiampullary diverticuli were considered criteria for a positive diagnosis. All 91 patients were subjected to endoscopic sphincterotomy with/without stone extraction subsequent to the diagnostic cholangiogram. Endoscopic intervention was performed as soon as possible after admission to hospital, but by 48 hours at the latest. Cholecystectomy was carried out in all patients who were free of risk factors and without previous cholecystectomy, during the disease-free interval. The complication rate of this combined endoscopic-surgical approach amounted to 10.9%; the mortality rate was 3.3%. The achieved results suggest that endoscopic sphincterotomy with stone extraction in the acute phase of biliary pancreatitis is the method of choice in order to interrupt the process of this disease. In combination with the final surgical treatment of gallstone disease by cholecystectomy to avoid recurrences, the prognosis of acute biliary pancreatitis can be significantly improved by using this combined endoscopic-surgical management.

[Extracorporeal shock wave treatment of calcium containing gallbladder calculi]. / Die extrakorporale Stosswellenbehandlung von kalkhältigen Gallenblasensteinen.

A total of 50 patients--37 female and 13 male--with an average age of 50 +/- 27 years (23-86 years), suffering from rim-calcified gallbladder stones, underwent extracorporeal shock-wave lithotripsy (ESWL), using an ultrasound-guided overhead module of Lithostar Plus (Siemens Company). The total number of stones was 87, with an average diameter of 16 +/- 7 (7-38) mm. 29 patients had a solitary stone, 13 had two and 8 patients three or more stones. All patients received adjunct medication of 10 mg/kg body weight chenodeoxycholic and ursodeoxycholic acid 14 days prior to ESWL as a single bedtime dose. An average number of 5,300 +/- 2,200 shock waves (1,200-15,000) was applied for stone disintegration. The corresponding energy amounted to 750 bar. 29 patients needed one, 21 two or more treatments. After ESWL a variety of clinical abnormalities was observed: flank pain (15%), transient microhaematuria (33%) and transient macrohaematuria (2%). Subsequent to ESWL 5 patients suffered from complications such as biliary obstruction 3 weeks to 9 months after treatment and had to undergo ERCP. Three times endoscopic papillotomy was performed to remove stones from the common bile duct. Up to now 4 patients have undergone cholecystectomy: acute cholecystitis (n = 3), recurrent colicky pain (n = 1). 20 patients have been followed up over a 12-month period; 12 of them are completely free of stones and fragments.

[Reconstruction-plasty of iatrogenic choledochal stenoses using human pericardium. An experimental study in the domestic pig]. / Erweiterungsplastik von iatrogenen Choledochusstenosen mit Humanperikard. Experimentelle Studie am Hausschwein.

The effect of human pericardial patch plastic for reconstruction of iatrogenic common bile duct stenosis was investigated in experiments performed in pigs. All patches (n = 8) were overgrown with immature biliary epithelium detectable on light and electron microscopy within 6 weeks. No restenosis nor any fistula developed during this observation period. Liver function tests, especially bilirubin, were not suitable parameters for the detection of biliary obstruction (preoperative value 0.38 +/- 0.09 mg/dl; 1 week after subtotal stenosis 3.36 +/- 1.53 mg/dl; 2 weeks after subtotal stenosis 1.49 +/- 0.62 mg/dl; 3 weeks after subtotal stenosis 0.50 +/- 0.27 mg/dl; 6 weeks after pericardial patch plastic 0.33 +/- 0.05 mg/dl, mean +/- SD. Ultrasonographic measurement of the common bile duct diameter was the diagnostic method of choice. Preoperative dimension 4.5 +/- 0.5 mm; 1 week after subtotal stenosis 8.5 +/- 2.0 mm; 2 weeks after subtotal stenosis 10.5 +/- 1.8 mm; 3 weeks after subtotal stenosis 14.0 +/- 3.6 mm; 6 weeks after pericardial patch plastic 9.0 +/- 1.6 mm, mean +/- SD.

[Prevention and treatment of postoperative fistulae--new indications for fibrin gluing]. / Verhütung bzw. Behandlung postoperativer Fisteln--Neue Indikationen für die Fibrinklebung.

The additional sealing of bronchial and gastrointestinal sutures and anastomoses, respectively, by means of fibrin sealant helped to significantly reduce the postoperative dehiscence rate; this rate amounted to 3.6% for additionally sealed bronchus stump occlusions and to 4.2% in gastrointestinal operations, whereby naturally in emergency abdominal operations the rate was higher (7.7%) than in elective surgery (3.8%). Eight postoperative bronchus stump fistulae and eleven out of the twenty-five gastrointestinal anastomotic dehiscences could be closed using a fibrin clot. Furthermore, fibrin occlusion of the pancreatic duct following Whipple's operation for the protection of the pancreatic-digestive anastomosis (n = 67) has turned out to be a success, since no postoperative pancreatic fistulae occurred, which resulted in the very low mortality rate of 1.5%. One more indication for fibrin sealing was the prevention of postoperative lymph fistulae by additional wound sealing (n = 123) and the fibrin occlusion of these fistulae (n = 18); the postoperative lymph fistulae rate amounted to only 3.3%. All 4 cases, as well as 14 other cases of existing lymph fistulae were healed quickly by instillation of fibrin. These relatively new, partly endoscopic, procedures using fibrin sealing proved to be very successful, because on the one hand postoperative fistulae could be largely avoided and on the other hand they could be treated without further operation.

[Intermittent incomplete ileus of the small intestine. Sonographic diagnosis and trends]. / Der intermittierende inkomplette Dünndarmileus. Sonographische Diagnostik und Trendbeobachtung.

Intermittent incomplete intestinal obstruction was proven by sonography in 25 male and 48 female patients with an age range of 10 to 88 years. All of them suffered from intermittent colicky pain, nausea and meteorism followed by liquid stools. Only 52 patients had undergone a total of 69 abdominal operations. The pertinent symptoms could be traced back for 6 months to 10 years (4 +/- 3 years). In 47 patients, intake of bulky food during the last 12 to 48 hours triggered the onset of disorders. The preadmission diagnoses were: incomplete intestinal obstruction (only 21), gastroenteritis (15), biliary colic (13), peptic ulcer (10), renal colic (4), food intoxication (4), appendicitis (3), adnexitis (3). Sonographic findings were: inconstant lumen distension, visible bowel wall movements with contractions of 3 to 6 mm, food bolus, enhanced paradoxical peristalsis, proof of distended and collapsed gut segments, bowel wall edema and free peritoneal fluid. Based on these ultrasonic findings and trend observation, conservative treatment was successfully instituted. All patients were discharged symptom-free with no subsequent attacks for 12 months. 20 patients, subsequently suffering from complete intestinal obstruction after 1 to 3 years, were operated on, comprising 8 cases of intestinal resection, 7 cases of adhesiolysis and intestinal tube splinting, 3 cases of band dissection and 2 cases of palliative bypass procedures. The diagnostic accuracy of abdominal ultrasonography is clearly demonstrated by the fact, that 11 of these patients with intermittent incomplete intestinal obstruction and now suffering from complete obstruction had no previous abdominal surgery.

Electromagnetic shock-wave lithotripsy of gallbladder calculi. Multicentered preliminary report on experience with 276 patients.

The Lithostar Working Group reports on the first 276 patients who underwent lithotripsy of biliary calculi by means of an electromagnetic Lithotriptor (Lithostar Plus from Siemens). Some 66% (183/276) and 27% (75/276) of the patients had solitary and two or three stones, respectively while 7% (18/276) had more than three gallbladder calculi. Calcified calculi were found in 11% of the patients. On an average the patients were treated in 1.6 (range 1.4-2.15) sessions; with the exception of one user the maximal energy (setting 9) was applied. The upper limit of shock waves per session was 1500-6000 (x = 2189 +/- 1058). 17% and 48% of the patients were free from calculi after 3 and 6 months, respectively. During the follow-up period 14% of the patients complained of severe biliary pain and 1.5% suffered from pancreatitis, which was controlled by conservative treatment. In three out of five patients with a transitory cholestatic jaundice endoscopic papillotomy was necessary. Four patients underwent an elective cholecystectomy. Considering the selection of the patients, the results obtained are comparable with those found in other studies.

[Biliary extracorporeal shockwave lithotripsy in the surgical treatment concept of cholelithiasis]. / Biliäre extracorporale Stosswellenlithotripsie (BESWL) im chirurgischen Therapiekonzept der Cholelithiasis.

Extracorporeal shock-wave lithotripsy (BESWL) using the "Obertisch" module Lithostar Plus (Siemens AG) was carried out in 100 patients, comprising a total of 189 gallbladder stones with a size range from 8 to 35 mm. Chenodeoxycholic and ursodeoxycholic acid was given as adjuvant litholytic therapy, beginning 14 days before treatment. 53% of the patients suffered from radiolucent solitary stones with an average size of 21 +/- 6 mm. 14% had more than 3 stones, another 12% had solitary stones with a small rim calcification. In 99 patients all stones could be disintegrated. In 90% we achieved a fragment size smaller than 5 mm, in 10% smaller than 8 mm. 68 patients were treated in a single session, in 32% a 2nd or 3rd treatment was necessary. In the average 4100 +/- 2200 shock-waves with energy level 9 (650 bar) were applied. During treatment 15 patients suffered from slight right kidney pain. In the following 48 hours after BESWL we observed a transitory significant elevation of transaminases (32%), urinary amylases without clinical symptoms (31%), bilirubin (31%) and white blood cells (71%). A microhematuria was seen in 33%, a macrohematuria in 2%. Post-BESWL sonographically we found a transitory edema of the gallbladder wall in 18%, in 15% a hydrops, in 10% a dilatation of the common bile duct and in 4% free fluid surrounding the gallbladder. After dismission 31% of the patients suffered from slight colicky pain. In 3 patients acute biliary pancreatitis was observed 4 and 8 weeks after BESWL which could be treated by EPT and endoscopic stone removal.

[Ultrasonic diagnosis in appendiceal perforation]. / Ultraschalldiagnostik bei appendizitischer Perforation.

In a prospective study comprising 154 patients, the efficacy of clinical, sonographic and combined assessment of appendiceal perforation was evaluated. 39 patients had appendiceal perforation, 44 no signs of inflammation and 71 chronic appendicitis as proven by histologic examination. Cases of 'simple' acute appendicitis were excluded. Clinical assessment yielded with respect to appendicitis a sensitivity of 87%, a specificity of 97% and an accuracy of 94%. With respect to appendiceal perforation a sensitivity of 74%, a specificity of 97% and an accuracy of 91% were observed. Sonographic diagnosis of acute appendicitis as the cause of complaints gave a sensitivity of 85%, a specificity of 98% and an accuracy of 95%, and with special respect to real appendiceal perforation a sensitivity of 69%, a specificity of 98% and accuracy of 91%. By overlap of clinical and sonographic findings, diagnosis of perforation was feasible in 80%, diagnosis of acute appendicitis in 92%. Our results indicate that sonography is a valuable adjunct to clinical assessment, whereas clinical assessment alone seems to be superior to ultrasonography as an isolated procedure.

[Non-occlusive disease--ultrasound diagnosis and trend analysis as a treatment guideline]. / Non-Occlusive Disease (NOD)--Ultraschalldiagnose und Trendanalyse als Behandlungsgrundlage.

16 patients with angiographically proved NOD underwent immediate abdominal sonography (age: 76 +/- 24 years). All patients suffered from "low cardiac output syndrome". The sonographic criteria were as follows: bowel wall edema [16], hyper-peristalsis [16], free peritoneal fluid [14], and signs of incomplete ileus [14]. 11 patients were successfully treated with conservative therapy on the basis of followup ultrasound observation and analysis. 5 patients underwent operation because of worsening ultrasound findings. These patients died from the underlying cardiac illness.

[Experimental ultrasound analysis of the appendix. Contribution to improving the diagnosis of acute inflammation in routine clinical practice]. / Experimentelle Ultraschallanalyse der Appendix. Beitrag zur Diagnoseverbesserung akuter Entzündungen im klinischen Alltag.

Sonographic investigations of fresh operative specimens - 50 non-infected, 50 chronic and 50 acute inflammatory appendices - and also of 335 pertinent operated patients with "typical" appendiceal disorders were performed. All other entities, mimicking acute or perforated appendicitis were excluded from this study. Under experimental conditions, negative, chronic and acute or phlegmonous appendices appeared as "cockade" or "pseudokidney sign" with reflecting wall and echoless lumen. The application of a 5 Mz linear transducer made the differentiation of three wall layers feasible, in negative appendices as well as in dilated acute appendicitis, whereas in chronic inflammation and in obliterating acute appendicitis a wall layer stratification was not possible. In clinical application of 335 operated patients we only could demonstrate cases of acute or perforated appendicitis (n = 182/220), but no cases of non-infected appendix. In 57% of pertinent cases the objectivation of lumen dilatation, in 35% a wall layer stratification was feasible. Acute, phlegmonous or perforated appendicitis was proven by demonstrating an immobile "pseudotumor mass" with dominating constant hypodense reflex property. The pertinent diameters as measured in clinical acute appendicitis exceeded significantly the diameters observed in experimental sonography of negative appendices with a differential intact mobility. Intraluminary coproliths and hyperdense reflecting attached omental segments facilitated a sonographic diagnosis. In 101/115 patients correct negative diagnosis was established. On the basis of these criteria, a sensitivity of 83%, a specificity of 88% and a diagnostic accuracy of 85% related to the diagnosis of acute or perforated appendicitis was obtained in this study.

[Reactive acalculous cholecystitis: a bland and asymptomatic course--incidence of a classical stress disease]. / Reaktive steinfreie Cholecystitis: blande und asymptomatische Verlaufsform--zur Dunkelziffer einer klassischen Stresserkrankung.

A systematic search for reactive acalculous cholecystitis (RAC) performed from 11/85 until 11/87 rendered an incidence of 9 in 1272 patients recovering from surgery and 1 in 930 patients treated conservatively for various diseases. 8 patients presented with typical but discrete clinical symptoms whereas 2 remained asymptomatic. Abdominal sonography proved to be the most useful diagnostic procedure. The ratio of classic fulminant disease to cases presenting with lesser severity was calculated to be 1:50. All patients in this series were managed nonoperatively in respect to RAC. The pathoanatomic and pathogenetic context is reviewed and the author's impression corroborated that relevant cases may frequently go by unnoticed by clinicians.

Intermittent incomplete intestinal obstruction: a frequently mistaken entity. Ultrasonographic diagnosis and management.

Intermittent incomplete intestinal obstruction (IIIO) was diagnosed by sonography in 81 patients during the course of a study conducted from January 1984 to July 1988. The clinical presentation, history and characteristic sonographic findings are described. Successful conservative therapy was instituted in all patients based upon clinical and sonographic treatment response observations. Twenty-seven percent of patients returned with complete obstruction, necessitating surgery between 13 and 36 months later. Although conservative treatment uniformly renders relief from IIIO, elective surgery is indicated in patients whose IIIOs recur at progressively shorter intervals.

[Acute cholecystitis in cholelithiasis: importance of early surgery (a comparative study)]. / Akute Cholezystitis bei Cholezystolithiasis: zum Stellenwert der Frühoperation--Eine vergleichende Studie.

The results of early surgery (ES) for acute calculous cholecystitis obtained in 74 patients operated on between 3/78 and 12/87 were compared with relevant data obtained in 74 sex- and age-matched patients with a history of acute cholecystitis operated on for biliary colic or jaundice during the same period. Operative procedures, incidence of jaundice and common bile duct calculi, duration of operation, number of patients requiring blood transfusions, surgical and general complications and mortality showed no significant difference. Only operative blood loss was significantly higher in the ES group, but this was of no practical relevance. ES precludes the sequelae of emergency surgery in the delayed surgery group not infrequently necessary for failure of conservative treatment of acute cholecystitis, which necessarily precedes planned delayed surgery, and thus renders a significant reduction of over-all risk. This forms the rationale for ES as treatment concept.

[Percutaneous layer differentiation of the colonic wall by ultrasound. Clinical case examples and experimental results]. / Perkutane Schichtdifferenzierung der Kolonwand durch Ultraschall. Klinische Fallbeispiele und experimentelle Ergebnisse.

Based on 3 case observations, the feasibility of the percutaneous sonographic objectivation of a five-layer image of the colon wall using a 5 Mhz linear transducer is reported for the first time. Sonographic stratification is promoted by means of "ultrasound windows" or contrasting borderlines. Employing stepwise dissection of autoptic specimens and ultrasonic comparison, it was possible to identify the hypodense zones 2 and 4 as mucous membrane and muscle layer, divided by the reflecting submucous layer (zone 3). The hyperdense bands 1 and 5 were found to represent borderline echos of the large bowel wall. This preliminary report is a step towards an eventual percutaneous staging of colon neoplasms.

Ileus and intestinal obstruction--ultrasonographic findings as a guideline to therapy.

Between September 1, 1982 and January 31, 1986, a study was undertaken in a total of 111 patients to assess the efficacy of ultrasonography in diagnosing intestinal obstruction and ileus. In 109 cases (98%), ultrasonography provided the correct diagnosis. In one case, obstruction was correctly suspected. In another case, the diagnosis was false negative. In 51 cases (46%), ultrasonography yielded the causative diagnosis. Ultrasonography was especially rewarding in the diagnosis of X-ray-negative intestinal obstruction, very high obstruction, clinically concealed incarcerated femoral hernias and in the differentiation of intestinal obstruction and ileus in the postoperative course. Ultrasonographic differential diagnosis was a reliable guideline for adequate treatment modalities in pertinent cases, thus contributing to therapeutic success.

[Ultrasound study of "acute appendicitis," an elective procedure or obligation in general surgery. A prospective study]. / Ultraschalluntersuchung bei "Akuter Appendizitis", Kür oder Pflicht in der Allgemeinchirurgie. Eine prospektive Studie.

576 patients admitted for suspected acute appendicitis were prospectively assessed by sonography following physical examination. The collective comprised - as proven by operation - 156 patients with acute appendicitis, 178 patients with chronic appendicitis or mesenteric lymphadenitis, as proven by observation, 186 patients suffering from gastroenteritis. 56 patients suffered from other diseases and 21 of them required urgent surgery. Based on clinical symptoms, correct diagnosis had been made in 433 patients (75%): gastroenteritis n = 186, chronic appendicitis or lymphadenitis n = 111 and acute appendicitis n = 136 (87%). In 123 patients the diagnosis was false positive, in 20 patients false negative. Based on sonographic assessment, 537 patients (93%) were correctly diagnosed; thus, in 129 patients (83%) an inflamed appendix was confirmed, in 56 patients; diagnosis of unrelated entities requiring urgent surgery correct in 21 cases. In 12 patients with mesenteric lymphadenitis - as proven by operation-a false positive, in another 27 patients with acute appendicitis a false negative diagnosis was made. The combination of clinical assessment and sonographic diagnosis yielded a correct diagnosis in 97% (560/576) comprising 414 true negative and 146 true positive results (94%) in respect of acute appendicitis.