Bowel Obstruction: Sonographic Evaluation.

Learning objectives: Sonographic examination concept in the case of suspicion of bowel obstruction. Recognition of the sonographic criteria of a bowel obstruction. Ability to detect the level of a bowel obstruction. Sonographic detection of typical causes of bowel obstruction. Detection of sonographic signs of complicated bowel obstruction. Ability to sonographically define important differential diagnoses. Further diagnostic procedures in unclear situations.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

[Primary diagnostics of acute diverticulitis of the sigmoid]. / Primärdiagnostik der akuten Sigmadivertikulitis. Sonografie versus Computertomografie, eine prospektive Studie.

AIM: The initial diagnostics of acute diverticulitis of the sigmoid should render the correct diagnosis as well as assisting in the decision on the options of conservative or surgical treatment by ruling out or demonstrating complications. At present, sonography or computed tomography (CT) are the two competing diagnostic options. This study was designed to demonstrate that sonography could be used as the method of choice. METHOD: 63 patients with clinical suspicion of acute diverticulitis of the sigmoid were examined initially by sonography or CT in a prospective study. RESULTS: Sonography and CT showed a 97 % sensitivity and specificity for reaching the accurate and clinically plausible diagnosis. As to the demonstration of complications of the disease, sensitivity and specificity were comparably high for both diagnostic methods. CONCLUSIONS: Sonography can compete with the more complex CT examination and therefore represents the recommended primary diagnostic procedure.

[Emergency diagnostic imaging in mesenteric ischemia]. / Bildgebung im Rahmen der Notfalldiagnostik bei mesenterialer Ischämie.

Diagnostic imaging in patients with suspected acute mesenteric ischemia is started with abdominal ultrasound including duplex sonography of the mesenteric vessels. Despite low sensitivity even in experienced hands, ultrasound is used because operative treatment can be initiated without further imaging if a positive diagnosis is made. Plain abdominal X-rays are usually unspecific in acute mesenteric ischemia and are mainly used to rule out differential diagnoses. Spiral CT (ideally using a multislice technique) can accurately demonstrate morphology of the arterial and venous mesenteric vessels, changes in the bowel wall, and additional mesenteric or peritoneal findings. Therefore, CT has the potential for diagnosis of mesenteric ischemia on a pathological basis. Furthermore, CT is successfully used to confirm or exclude most other causes of acute abdominal conditions. Magnetic resonance imaging (MRI) may be as accurate as CT for the diagnosis of acute mesenteric ischemia and its differential diagnoses. However, MRI is not widely available and therefore not used as an emergency imaging modality so far. Catheter angiography remains the diagnostic gold standard for mesenteric vasculature when spiral CT is not available.

[Locally ablative therapies of hepatocellular carcinoma]. / Lokal ablative Therapien des hepatozellulären Karzinoms.

Locally Ablative Therapies of Hepatocellular Carcinoma Delayed diagnosis of hepatocellular carcinomas (HCC) leads to a poor prognosis with a median survival time of less than 10 months. Surgical resection of small HCCs is the treatment of choice in patients with good residual liver function. The recurrence-free 5-year survival rate after curative resection is 33%. Resectability of HCC is often limited by the low hepatic functional reserve. Only 20% of all HCC are resectable in spite of novel diagnostic tools, an intensified screening, and advances in surgical technique. Local methods for tumor ablation are promising extensions of tumor therapy, especially in patients with limited liver function, nonresectable tumors, or multifocal tumors. Vis-à-vis a change of therapeutic options, local methods of tumor ablation in combination with tumor resection promise a yet unknown improvement of the prognosis for patients with HCC. Controlled randomized studies comparing and validating these methods of local tumor ablation are eagerly awaited. In the following article different methods of tumor ablation are described. Percutaneous interventions can be distinguished into vascular regional (TAE = transarterial embolization and TACE = transarterial catheter embolization) and local ablative approaches like PEI (percutaneous ethanol instillation), LITT (laser-induced thermotherapy), Cryo (cryotherapy), and RFA (radio frequency ablation).

[Endosonography in epithelial rectal tumors. Value of a differentiated therapy concept]. / Endosonographie bei epithelialen Rectumtumoren. Stellenwert in einem differenzierten Therapiekonzept.

INTRODUCTION: Endorectal ultrasound (EU) is the most important examination for pretherapeutic stratification of primary rectal tumors. Preoperative histology and endosonography determine the therapeutic strategy by using the criteria of depth of infiltration (uT) and lymph node status (uN). METHODS: The effectiveness of endoluminal ultrasound in the preoperative differentiation between locally restricted tumors (adenomas and "low-risk" carcinomas, uT0/1, G1-2) and advanced rectal carcinomas (uT3) was assessed in a retrospective study of 284 patients. In the examination period (UZ) from 3/94 to 12/97 (UZ I) 104 patients (group 1) were examined with a 7-MHz endoprobe, and from 1/98 to 12/99 (UZ II), 116 (group 2) with a 10-MHz endoprobe. Additionally, in 64 patients (group 3) with an advanced uT3/4 or uN + tumor we compared the accuracy of ultrasound with computed tomography (CT). In this group 32 patients were restaged by EU and CT after preoperative chemoradiation. The results of präoperative endorectal ultrasound were correlated with the postoperative histological data. RESULTS: Concerning the whole period (UZ I and II) we achieved a total hit rate of 83.6% for adenomas and "low-risk" carcinomas (uT0/1, G1/2) by EU (79.8% in UZ I, 87.1% in UZ II). For advanced rectal carcinoma (> or = uT3) we found a total accuracy of 87.3% (82.7% in UZ I, 91.4% in UZ II). In 62 cases endosonographic lymph node status was correlated with postoperative histology during UZ II, with a hit rate of 64.5%. In group 3 (n = 64), in 32 patients without preoperative chemoradiation we found an accuracy for depth infiltration of 93% (EU) and 82% (CT). Concerning lymph node status there was a correlation of 57% (EU) and 64% (CT). After preoperative chemoradiation (n = 32) we found an accuracy of 91% (EU) and 73% (CT) for depth infiltration--for lymph node status 70% (EU) and 82% (CT). CONCLUSIONS: High accuracy in endoluminal ultrasound leads to a secure and differentiated stratification of therapy in primary rectal tumors. The hit rate concerning depth of infiltration is higher for EU than for CT both before and after chemoradiation, but not regarding lymph node status.

[Effect of ultrasonic diagnosis and incidence of appendectomy and laparoscopy]. / Einfluss der Sonographie auf Appendektomie und Laparoskopiefrequenz.

A total of 330 of 409 patients with suspected acute appendicitis were examined by ultrasound, and an appendectomy was performed in 146 patients. The negative appendectomy rate was 7% with preoperative ultrasound (n = 72) compared with 31% without (n = 74). Laparoscopy did not reduce the negative appendectomy rate, but was useful in patients with opposing clinical and sonographical findings.

[The multi-point contact (MPC) osteosynthesis plate. 2: Initial clinical results of therapy of forearm fracture with MPC plates]. / Die Multi-Point-Contact-(MPC-)Osteosyntheseplatte. Teil 2: Erste klinische Ergebnisse zur Therapie der Unterarmfraktur mittels MPC-Platten.

Plate osteosynthesis is a method of choice in the treatment of forearm fractures with senso-motorical impairment, poorly or non-reduceable, retained, fragmented and open fractures. Dislocated fractures of the forearm frequently cause problems because of their poor reduction and retention. In such cases, exclusively conservative treatment requires reduction and change of therapeutical approach to avoid functional limitations resulting from axial malpositioning. The sincere contact of bone fragments, accompanied by sufficient anatomical axial and conservative reduction techniques that maintain parossal perfusion as well as a limited osteosynthesis plate contact should be the aim of the operative strategy. The use of a new titanium osteosynthesis plate system with multi-point contact between bone and plate promotes the incorporation of vessels and callus formation at the bone-plate interface and leads to the realization of the aforementioned aim, which was revealed in animal studies before. In order to examine the results, 18 patients with forearm fractures were studied, which underwent reduction and internal fixation using this new titanium osteosynthesis plate, the multi-point contact plate (MPC) system. In these patients, functional and radiological results after plate removal were studied. Our initial clinical experiences with the MPC-plate for internal fixation confirm the animal study results. The in-growth of parossal vessels into the multiple inter-point spaces enhances the subimplant (bio-logical) formation of callus, which can be visualized radiographically and intraoperatively after plate removal. These results indicate that the MPC plate has marked advantages over conventional plates.

[Compression neuropathy of the median nerve at the wrist joint caused by chondroma]. / Kompressionsneuropathie des N. medianus am Handgelenk durch ein Chondrom.

The case is reported of a 75-year old patient with diabetes, who suffered from a typical carpal tunnel syndrome, which was diagnosed by a neurologist. On the X-rays of hand and wrist there were no pathological findings. A small, clinically almost inapparent induration at the palmar and radial side of the wrist was found. Ultrasonography and CT-scan showed a tumor with compression of the median nerve. At operation the authors excised a tumor which on histological investigation was compatible with a soft tissue chondroma. Full recovery followed local excision with decompression of the median nerve. Soft tissue chondromas localised to the hand and wrist are extremely rare. A few cases have been described in the literature which led to a nerve compression.

[Resorbable PDS splints in fracture stabilization and for arthrodeses of the hand]. / Resorbierbare PDS-Splinte zur Frakturstabilisierung und für Arthrodesen an der Hand.

Small rods of resorbable Polydioxanon (PDS-splints) are suitable for stabilizing fractures of a phalanx, either near the base or the head, be the fracture transverse or comminuted. Such internal splints are especially useful in replantation of clean amputations. Used in combination with intraosseous wiring, osteosynthesis can be achieved that is stable for exercise in all cases. Another use is in arthrodesis of the distal interphalangeal joints and the metacarpophalangeal joint of the thumb. Disadvantages that accompany Kirschner wire fixation are thus avoided. Case descriptions and results are presented.