[Pneumoretroperitoneum and bilateral pneumothorax after endoscopic biliary sphincterotomy]. / Pneumoretroperitoneum und beidseitiger Pneumothorax nach endoskopischer Sphinkterotomie.

HISTORY AND ADMISSION FINDINGS: A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable. INVESTIGATIONS: An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT. THERAPY AND CLINICAL COURSE: Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention. CONCLUSION: Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.

[Recurrent upper gastrointestinal bleeding in a 61 year-old man with infrarenal abdominal aortic aneurysm]. / Rezidivierende obere gastrointestinale Blutungen bei einem 61-jährigen Patienten mit infrarenalem Bauchaortenaneurysma.

A 61-year-old man was admitted to hospital due to recurrent upper gastrointestinal bleeding. Four weeks ago, he had been treated with epinephrine and endoclips by endoscopy due to an arterial gastrointestinal bleeding. The patient had a history of coronary and peripheral artery disease, diabetes, and an abdominal aortic aneurysm. Urgent endoscopy suggested the presence of an ulcus Dieulafoy but no definitive bleeding source could be seen. Due to ongoing melena an abdominal computer tomography was performed and a primary aortoduodenal fistula was suspected caused by the infrarenal abdominal aortic aneurysm. Laparatomy was undertaken emergently and an aortoduodenal fistula was found in the descending part of the duodenum. Repair of the duodenal rent was performed and the aortic aneurysm was replaced by a Dacron prosthesis. The patient was transferred to the intensive care unit. 4 days after initial admission, he died due to septic shock.

[Erionite-induced pleural plaques. Exposition to urban pollution in a female Turkish migrant in Germany]. / Erionitinduzierte Pleuraplaques. Urbane Belastung bei einer türkischen Migrantin.

Erionite is a zeolite mineral of volcanic origin which contains no asbestos. It is found in different regions of the world, including southeast Turkey in ash and dust, from which it can cause inflammatory pleural plaques or malignant pleural mesothelioma (MPM). We report a female Turkish migrant exposed to urban pollution in her home country who decades later suffered from pleural plaques with a nonspecific chronic inflammatory disease. The differential diagnosis of inflammatory pleural plaques was assumed radiologically and confirmed by video-assisted thoracoscopic biopsy. Short-term clinical and radiologic control of the patient will be necessary because of the risk of MPM. For epidemiologic considerations discussed referring to current literature, a growing incidence of this type of disease in migrants from high-risk areas must be reckoned with in Germany, even without exposition to asbestos.

[Unilateral swollen leg caused by a retroperitoneal ganglioneuroma]. / Retroperitoneales Ganglioneurom als Differenzialdiagnose einer einseitigen Beinschwellung.

HISTORY AND ADMISSION FINDINGS: An 84-year-old man was admitted to our hospital because of a swollen left leg resembling deep venous thrombosis. Clinical conditions favoring thrombosis such as surgery, trauma, malignant tumor or immobilization were not evident. His medical and family history were non-contributory. He denied bowel or bladder dysfunction and did not complain of any back pain, discomfort or neurological symptoms. The enlargement of the leg was painless and unilateral. There were no deficits on physical examination. The neurological status of the patient was unremarkable. INVESTIGATIONS: Ultrasonography was performed because deep vein thrombosis was suspected. Color-coded duplex revealed no thrombus in the veins of the left leg. Both femoral veins were compressible. The flow in the femoral vein was much less than in the other leg. Computed tomography demonstrated a solid lesion located in front of the spine displacing the inferior vena cava. CT-guided biopsy was performed. On histological examination it proved to be diagnostic of a ganglioneuroma. TREATMENT AND COURSE: Initially low molecular weight heparin was administered. Surgical resection was recommended, but the patient opted not to undergo any further treatment at that time. Phenprocoumon was recommended to prevent deep vein thrombosis. CONCLUSIONS: Ganglioneuroma is a rare, benign, well-differentiated, slow-growing tumor composed of sympathetic ganglion cells and mature stroma with a good prognosis. Its appearance in elderly persons is extremely rare and may imitate deep vein thrombosis caused by vessel compression. The appropriate treatment is surgical and complete excision is curative.

[A 16-year-old patient with dysphagia]. / Dysphagie bei einem 16-jährigen Patient.

A 16-year-old man with an 8-year history of progressive dysphagia was referred to hospital. There was no specific finding in his family history. Physical examination was unremarkable. Complete blood count, serum electrolytes, and liver and kidney function tests were normal. Barium swallow revealed an extrinsic impression of the upper esophagus posteriorly. Magnetic resonance angiography demonstrated an aberrant origin of the right subclavian artery, leaving the aorta below the left subclavian artery. The artery had a retroesophageal course, causing the esophageal narrowing. Due to the persistence and worsening of the patient's symptoms, resection and reconstructive bypass surgery were recommended. Surgical correction was performed through a combined right supraclavicular incision and left posterolateral thoracotomy. After application of a vascular clamp, the aberrant right subclavian artery was ligated almost at its origin, and an end-to-side anastomosis was made with the right common carotid artery. At the end of the operative procedure, good pulses were palpated in the right radial artery. Postoperatively, the patient tolerated a regular diet without symptoms of dysphagia and was discharged on postoperative day 7.

[Fibrinogen-guided thrombolysis with urokinase of a portal and mesenterial venous thrombosis during an acute episode of ulcerative colitis]. / Fibrinogengesteuerte Urokinaselyse einer Portal- und Mesenterialvenenthrombose bei akutem Schub einer Colitis ulcerosa.

HISTORY AND ADMISSION FINDINGS: A 23-year-old woman with a 5-year history of ulcerative colitis was admitted to our hospital because of bloody diarrhea. Two years previously she had undergone a hemicolectomy for a right colonic stricture. A recurrence of inflammatory bowel disease was suspected and treatment with prednisolone begun. The symptoms improved gradually, but 7 days later she complained of lower abdominal pain. Physical examination revealed a soft abdomen, but bowel sounds were reduced. INVESTIGATIONS: The abdominal X-ray was unremarkable, but ultrasonography revealed moderate ascites and no blood flow in the portal vein on Doppler examination. The spleen was slightly enlarged. Contrast-enhanced abdominal magnetic resonance imaging (MRI) was performed immediately, revealing thrombosis of the portal and mesenteric veins. TREATMENT AND COURSE: As there was no suggestion of intestinal necrosis, laparatomy was not considered necessary. Intravenous thrombolytic treatment with urokinase was given continuously (bolus of 250,000 units, followed by 200,000 units per hour), in order to lower the fibrinogen level to 100 - 150 mg/dl, together with unfractionated heparin, maintaining the activated partial thromboplastin time between 60 and 85 seconds. The thrombolytic treatment had to be stopped several times because of bloody diarrhea, but no transfusion was necessary. Two days after the start of thrombolytic treatment the abdominal pain and ascites ceased. Doppler sonography now demonstrated hepatopetal flow in the previously occluded portal vein. 4 days later, MRI revealed that the thrombus in the portal vein had dissolved and the portal vein was fully patent. The mesenteric vein was partially perfused, a residual thrombus extending into the portal vein. Tests for thrombophilia were negative. The thrombolytic therapy was stopped after 112 hours and the patient was treated with oral anticoagulation for 6 months. The patient recovered completely, with no evidence of portal hypertension during the following 6 months. CONCLUSIONS: Thrombolysis with urokinase, guided by the level of fibrinogen, may be an alternative, semi-invasive treatment option in acute thrombosis of the portal and mesenteric veins.

[Ileus of the small intestine in intestinal marginal-zone B-cell lymphoma of mucoid-associated lymphoid tissue (MALT)]. / Dünndarmileus bei intestinalem Marginalzonen-B-Zell-Lymphom des MALT.

HISTORY AND ADMISSION FINDINGS: A 67-year-old man had complained of diffuse abdominal pain and constipation for 4 days without indication of any underlying disease. On admission there was no evidence of weight loss, fever or nocturnal sweating. INVESTIGATIONS: Physical examination revealed signs of an acute abdomen with high-pitched bowel sounds and diffuse abdominal guarding. The X-ray showed ileus of the small intestine which required emergency laparotomy. An obstructing conglomerate tumour was present in the area of the ileum, ca. 80 cm proximal to the caecum. It was removed by partial resection of the small intestine. DIAGNOSIS: Ileus of the small intestine with a low-malignant marginal zone B-cell (non-Hodgkin) lymphoma of MALT type (mucoid-associated lymphoid tissue). TREATMENT AND COURSE: Postoperative staging indicated no further manifestation of the lymphoma. As no radical operation in resecting the tumour had been performed, combined radio- and chemotherapy was undertaken. CONCLUSION: Marginal B-cell lymphomas of the small intestine are only rarely seen in central Europe. Despite its usually slow growth this non-Hodgkin lymphoma of low malignancy can produce an acute mechanical ileus without prodromal symptoms. A multimodal therapeutic approach is often employed, but there are no established treatment strategies.

Tracheal rupture caused by blunt chest trauma: radiological and clinical features.

The aim of this study was to assess radiomorphologic and clinical features of tracheal rupture due to blunt chest trauma. From 1992 until 1998 the radiomorphologic and clinical key findings of all consecutive tracheal ruptures were retrospectively analyzed. The study included ten patients (7 men and 3 women; mean age 35 years); all had pneumothoraces which were persistent despite suction drainage. Seven patients developed a pneumomediastinum as well as a subcutaneous emphysema on conventional chest X-rays. In five patients, one major hint leading to the diagnosis was a cervical emphysema, discovered on the lateral cervical spine view. Contrast-media-enhanced thoracic CT was obtained in all ten cases and showed additional injuries (atelectasis n = 5; lung contusion n = 4; lung laceration n = 2; hematothorax n = 2 and hematomediastinum n = 4). The definite diagnosis of tracheal rupture was made by bronchoscopy, which was obtained in all patients. Tracheal rupture due to blunt chest trauma occurs rarely. Key findings were all provided by conventional chest X-ray. Tracheal rupture is suspected in front of a pneumothorax, a pneumomediastinum, or a subcutaneous emphysema on lateral cervical spine and chest films. Routine thoracic CT could also demonstrate these findings but could not confirm the definite diagnosis of an tracheal rupture except in one case; in the other 9 cases this was done by bronchoscopy. Thus, bronchoscopy should be mandatory in all suspicious cases of tracheal rupture and remains the gold standard.

[Anesthesia with remifentanil combined with desflurane or sevoflurane in lumbar intervertebral disk operations]. / Anästhesie mit Remifentanil in Kombination mit Desfluran oder Sevofluran bei lumbalen Bandscheibenoperationen.

Recovery characteristics, haemodynamic profile, analgesic requirement and costs were evaluated and compared in patients undergoing elective lumbar discectomy with remifentanil-based anaesthesia using either desflurane or sevoflurane as the volatile anaesthetic agent. Sixty-two patients (ASA I/II status) were randomly assigned to receive either desflurane and remifentanil or sevoflurane and remifentanil (in oxygen/air) for anaesthesia. After induction with 0.5 microgram/kg/min remifentanil, 4 to 5 mg/kg thiopentone and 0.5 mg/kg atracurium, the patients received 0.25 microgram/kg/min remifentanil and 0.5 +/- 0.05 MAC of one of the volatile anaesthetic agents for further maintenance of anaesthesia. At the end of surgery, early emergence from anaesthesia was recorded by assessing the time to sufficient spontaneous respiration, eye opening and tracheal extubation. The total demand of piritramide in the postoperative period was determined using patient-controlled analgesia (PCA device). Quality of pain therapy was assessed via a verbal ranking scale (VRS). Side-effects such as postoperative nausea, vomiting or shivering were recorded in the postanaesthetic care unit. In both groups, the haemodynamic profile was nearly identical. Mean arterial pressure (-18%) and heart rate (-23%) were significantly reduced throughout anaesthesia in both groups. All recovery parameters were significantly shorter in the desflurane group in comparison with the sevoflurane group (e.g. time to tracheal extubation: 8.5 +/- 3.0 min vs. 11.9 +/- 4.6 min). No significant differences between the groups were observed concerning the amount of piritramide required, side-effects such as nausea and vomiting or the total cost of anaesthesia. In conclusion, both anaesthetic techniques provide adequate haemodynamic stability and postoperative pain control in a surgical procedure with minimal trauma. Incidence and severity of side-effects such as nausea, vomiting or shivering did not differ between the groups and were acceptable under clinical conditions. Costs for desflurane were significantly higher than those for sevoflurane, but total costs were not different between the groups. Concerning recovery profile, desflurane/remifentanil seems to have small advantages over sevoflurane/remifentanil in patients undergoing lumbar vertebral disc resection.

Percutaneous transhepatic catheterization of the portal vein: A combined CT- and fluoroscopy-guided technique.

Combined CT- and fluoroscopy-guided transhepatic portal vein catheterization was performed in 44 patients selected for pancreatic islet cell transplantation. The method allowed catheterization with a single puncture attempt in 39 patients. In four patients two attempts and in one patient four attempts were necessary. One minor hematoma of the liver capsule occurred that required no further treatment. Compared with other methods the average number of puncture attempts was reduced.

Degenerative joint disease on MRI and physical activity: a clinical study of the knee joint in 320 patients.

We examined 320 patients with MRI and arthroscopy after an acute trauma to evaluate MRI in diagnosis of degenerative joint disease of the knee in relation to sports activity and clinical data. Lesions of cartilage and menisci on MRI were registered by two radiologists in consensus without knowledge of arthroscopy. Arthroscopy demonstrated grade-1 to grade-4 lesions of cartilage on 729 of 1920 joint surfaces of 320 knees, and MRI diagnosed 14% of grade-1, 32% of grade-2, 94% of grade-3, and 100% of grade-4 lesions. Arthroscopy explored 1280 meniscal areas and showed degenerations in 10%, tears in 11.4%, and complex lesions in 9.2%. Magnetic resonance imaging was in agreement with arthroscopy in 81% showing more degenerations but less tears of menisci than arthroscopy. Using a global system for grading the total damage of the knee joint into none, mild, moderate, or severe changes, agreement between arthroscopy and MRI was found in 82%. Magnetic resonance imaging and arthroscopy showed coherently that degree of degenerative joint changes was significantly correlated to patient age or previous knee trauma. Patients over 40 years had moderate to severe changes on MRI in 45% and patients under 30 years in only 22%. Knee joints with a history of trauma without complete structural or functional reconstitution showed marked changes on MRI in 57%, whereas stable joints without such alterations had degenerative changes in only 26%. There was no correlation of degenerative disease to gender, weight, type, frequency, and intensity of sports activity. Therefore, MRI is an effective non-invasive imaging method for exact localization and quantification of chronic joint changes of cartilage and menisci that recommends MRI for monitoring in sports medicine.

Metastatic RCC arising in a transplant kidney.

We report a case of metastatic renal cell carcinoma arising in a cadaver transplant kidney 6 years after transplantation. Due to molecular analysis of the tumor tissue we could prove that the carcinoma originated from the male donor. After tumor resection and interruption of immunotherapy, the concomitant bone and lymph node metastases resolved with alpha-interferon and interleukin-2-based immunotherapy.

[The fluoroscopy-guided implantation of subcutaneous venous ports: the complications and long-term results]. / Durchleuchtungsgesteuerte Implantation subkutaner Venenports: Komplikationen und Langzeitergebnisse.

PURPOSE: Evaluation of technical success rate, long-term outcome and initial complication rate in patients with fluoroscopically guided port implantation. MATERIAL AND METHODS: Between January 1994 and April 1997 124 ports were implanted under fluoroscopic guidance in 120 patients. Indications for port implantation were anti-cancer chemotherapy, antibiotic and supportive therapy in patients with tumours or cachexia. RESULTS: Implantation was technically successful in 98.4% of the patients. We had a 3.2% minor complication rate that did not necessitate further treatment. One pneumothorax required a chest tube (0.8%). During a total of 17,534 days, complications occurred in 10.8% of all ports, 6.9% of the ports had to be explanted because of these complications. CONCLUSIONS: Insertion of ports under fluoroscopic guidance has a low complication rate and good long-term results. The rate of 93.1% of functioning ports is superior to that reported in other studies. It is less costly and has a lower complication rate than surgical implantation. Therefore it seems to be the method of choice for patients requiring long-term subcutaneous venous access for chemotherapy or supportive therapy in malignant tumours or other emaciating diseases.

[Arteriovenous fistula after endoscopic dissection of the perforant vein of the lower leg with the neodymium:YAG laser in chronic venous stasis syndrome]. / Arterio-venöse Fistel nach endoskopischer Dissektion der Venae perforantes des Unterschenkels mit dem Neodym: YAG-Laser bei chronischem venösem Stauungssyndrom.

The endoscopic dissection of the perforating veins has been invented by Hauer in the last decade. He introduced the videoendoscopy to this surgical procedure. The avoidance of operative access through areas of trophic changes is very beneficial for reducing postoperative complications. Although postoperative thermic lesion have been reported on. Following an endoscopic laser coagulation of a Cockett perforating vein an arterio-venous fistula between the posterior tibial artery and vein developed by the mechanism mentioned. Persisting pain and the persistence of the ulcer led to several diagnostic measures including phlebography, digital subtraction angiography and CT-scan. After the fistula had been closed successfully by percutaneous embolization with four platin wires the ulcer disappeared.

Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry.

OBJECTIVES: The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism. BACKGROUND: The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated. METHODS: The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies. RESULTS: Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%). CONCLUSIONS: Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.

Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: results of a multicenter registry.

BACKGROUND: Thrombolytic treatment has been shown to accelerate resolution of major pulmonary embolism and lead to a rapid improvement of right-side hemodynamics. However, the association between these favorable effects and the clinical outcome of patients who have no severe hemodynamic compromise at presentation remains unknown. METHODS AND RESULTS: The present multicenter registry included 719 consecutive patients with major pulmonary embolism according to clinical, echocardiographic, scintigraphic, and cardiac catheterization criteria. Symptom onset was acute (<48 hours) in 63% of patients. All patients were hemodynamically stable (ie, without evidence of cardiogenic shock) at presentation. Primary thrombolytic treatment (within 24 hours of diagnosis) was given to 169 patients (23.5%), whereas the remaining 550 patients were initially treated with heparin alone. Overall 30-day mortality was significantly lower in the patients who received thrombolytic agents (4.7 versus 11.1%, P=.016). Clinical factors associated with a higher death rate were syncope (P=.012), arterial hypotension (P=.021), history of congestive heart failure (P=.013), and chronic pulmonary disease (P=.032). However, only primary thrombolysis was found by multivariate analysis to be an independent predictor of survival (odds ratio for in-hospital death, 0.46; 95% confidence interval, 0.21 to 1.00). Patients who underwent early thrombolytic treatment had a reduced rate of recurrent pulmonary embolism (7.7 versus 18.7%, P<.001) but also a higher frequency of major bleeding episodes (21.9% versus 7.8%, P<.001). Cerebral bleeding occurred in 2 patients in each treatment group, and 1 patient in each group died of a bleeding complication. CONCLUSIONS: The results of our study suggest that thrombolysis may favorably affect the clinical outcome of hemodynamically stable patients with major pulmonary embolism.