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PURPOSE: To examine the clinical outcome of the balloon dilatation in stenosis of the canaliculus communis. METHOD: 18 nasolacrimal ducts with epiphora and proven obstruction of the canaliculus communis by dacryocystography (DCG) were treated with balloon dilatation in local anaesthesia. All patients were treated electively. RESULTS: In 16/18 cases the balloon dilatation was technically successful, in 2 patients the guide wire failed to pass the obstruction and the wire could not be placed in the nasal cavity. There were no complications. Over a mean follow-up of 6 months there were 2 reobstructions, one of these led to an occlusion of the canaliculus communis. 14/18 (77,8%) cases after DCP were treated successful, 11/18 cases were free of symptoms after DCP, in 4/18 cases the epiphora improved. CONCLUSIONS: Until recently in stenosis of the canaliculus communis the only therapeutic option was surgical procedure followed by silicone tube intubation. The results were often disappointing. In contrast to this balloon dacryocystoplasty is a minimally-invasive alternative in the therapy of stenosis of the canaliculus communis resulting in good clinical outcome during follow up.

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PURPOSE: To examine the clinical outcome of the ballon dilatation in stenosis and obstruction of the nasolacrimal duct. MATERIAL AND METHODS: 63 patients (69 nasolacrimal duct systems) with epiphora and proven obstruction of the nasolacrimal duct were treated with ballon dilatation, respectively Stentimplantation. In 55 cases there was a pre- or postsaccal stenosis, in 14 cases an occlusion of the nasolacrimal duct system. The diagnosis was established by dacryocystography. RESULTS: Technical success was obtained in 61 cases (n=50/55 stenosis; n=11/14 occlusions). Over a mean follow-up of 6 months patency of the nasolacrimal duct system was achieved in 83,6% (46/55) in stenosis. In occlusion the clinical outcome was 42,9% (6/14). CONCLUSION: Balloon dacryocystoplasty and Stentimplantation are minimal-invasive alternatives, performed in local anesthesia that recover the normal anatomy of the nasolacrimal duct system. They are a good alternative in the treatment of epiphora caused by nasolacrimal duct obstructions.

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The most common mechanism of pelvic fractures after blunt trauma is lateral compression of the pelvis. Most of these fractures are of slight severity but it is possible, that a life-threatening hemorrhage can appear. The inferior epigastric artery is an atypical bleeding site but it has to be considered in the search of the origin of the hemorrhage. Diagnostic tools are ultrasound, computed tomography and angiography. After external fixation of the pelvis and persistent haemodynamic active bleeding is the percutaneous transcatheter embolization (PTE) in our opinion the treatment of choice. The introduced case is confirm with this statement.

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PURPOSE: A prospective comparison of FNAB and TCB was performed in an identical set of patients and lesions. METHODS: In 103 patients focal lesions were biopsied by US- or CT-guidance with at least one FNAB and TCB each. Complications were registered and documented. Cytological and histological specimens were evaluated independently. A final diagnosis was then attempted by consensus. RESULTS: A total of 253 punctures was performed with sufficient tissue in 72.8% (FNAB) and 85.4% (TCB) of the cases. Diagnosis was possible in 68% (FNAB) and 80.6% (TCB). After combined evaluation of both specimens the diagnostic yield increased to 91.3%. Minor complications without clinical sequelae were observed in 21 patients. CONCLUSION: A diagnostic strategy with the combined use of FNAB and TCB increases the diagnostic yield in image-guided punctures. Even though this approach needs at least two separate punctures, the complication rate does not increase.

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To evaluate whether MRI is usefull in staging renal cell carcinomas with caval thrombus the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) in staging renal tumors with caval thrombus were preoperatively examined. Tumor staging by CT and MR imaging were correlated with histopathological tumor stadium. In MRI 4 out of 7 thrombi were correctly diagnosed with high accuracy, in CT none. In advanced renal carcinoma MRI with Gadolinium was superior to CT imaging, especially in diagnosing tumor thrombus. Consequently the extent of tumor thrombus may be assessed by MRI which therefore may replace conventional cavography.

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Yet being an uncommon disease in general, the manifestation of the fibromuscular dysplasia (FMD) in the upper extremities is exceedingly rare. Two patients with FMD of the brachial artery are presented and the literature concerned is reviewed. In this location the formation of microthrombi with subsequent embolization into the periphery instead of progressive vessel stenosis seems to be the leading pathophysiological principle. Therapeutic options are discussed.

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PURPOSE: To evaluate the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) in staging renal carcinoma. MATERIAL AND METHODS: 33 renal carcinomas were preoperatively examined for tumour staging by CT and MR imaging and correlated with histopathological staging. CT imaging was performed at first as a non-contrast scan. Finally incremental images (10 mm) after intravenous contrast injection were obtained. In MR imaging we performed a transversal T1-weighted GE sequence (112/5) with and without GDTPA, a transversal fat-suppressed double-echo sequence (3900/22/90), a coronal T1-weighted GE sequence with and without GDTPA and a coronal T2-weighted TSE sequence (2800/128). In addition, dynamic T1-weighted GE imaging after GDTPA injection as well as TOF angiography in coronal direction were performed. Finally CT and MRI findings were correlated with surgical and histopathological staging results. RESULTS: CT and MRI staging was correct in 27 and 28 of 33 tumours. Sensitivity and specificity for tumour stage T3b to T4 was for MRI and CT 88.9% and 95.8%. With MRI 4 out of 7 thrombi were correctly diagnosed with high accuracy, but via CT none. CONCLUSION: In early stage renal carcinoma CT and MR imaging yielded similar staging accuracies. In advanced renal carcinoma MRI was superior to CT imaging, especially in diagnosing tumour thrombus. Consequently the extent of tumour thrombus may be assessed by MRI which may therefore replace conventional cavography.

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PURPOSE: Evaluation of hydro-MRI in the diagnosis of chronic inflammatory bowel disease (IBD). MATERIAL AND METHODS: 33 patients with suspected Crohn's disease or ulcerative colitis were studied prospectively. After distension of the colon by a rectal enema, breathhold MR imaging was performed during bowel relaxation. Results were compared to the clinical diagnosis, endoscopy, barium studies and histopathology. RESULTS: 24/24 patients with active Crohn's disease were correctly diagnosed by MRI. Conversely, MRI was positive in only 2/5 patients with ulcerative colitis. In 5 patients the presence of IBD was excluded. There were no false positives. CONCLUSION: Hydro-MRI is a very reliable modality in the diagnosis of Crohn's disease. In the differentiation of Crohn's disease from ulcerative colitis, hydro-MRI seems to be a promising imaging procedure.

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PURPOSE: To evaluate the effects of radiofrequency heated bipolar probes on the human arterial wall. METHODS: Under standardised conditions, lesions were set on the inner layer of a piece of human cadaver arterial wall, using a radiofrequency-heated bipolar catheter. These lesions were measured and described both macroscopically and microscopically. Lesion size, applied energy levels and application conditions were correlated. RESULTS: The size of a lesion depended significantly on the size of the catheter, angle and pressure of catheter application (p < 0.05) and length of impulse (p = 0.002). There was no influence from the energy level employed. It proved impossible to treat calcified plaques. The depth of a lesion depended on the angle of catheter application only. No perforations were seen. CONCLUSIONS: Radiofrequency-heated bipolar catheters ablate the tissue of the arterial wall. Increasing tissue resistance resulting from higher energy levels prevents perforation in the experimental set-up. Calcified plaques cannot be treated by this method.

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PURPOSE: to demonstrate and document TIPSS-induced changes of the perfusion pattern of the liver with special reference to several rheologic, morphologic, functional and biochemical parameters. Our analysis was based on a study in 100 consecutive cases. PATIENTS AND METHODS: Evaluation and assessment of the following parameters before and within a 30-day post TIPSS period: portosystemic gradient; morphologic delineation of the portal circulation; invasive scintigraphic determination of the portal perfusion fraction (PPF) and the total liver perfusion (GLP); transcatheter intraarterial flow change measurement; serum levels of albumin and bilirubin; assessment of hepatic encephalopathy by appropriate testing; assessment of recurrent variceal bleeding RESULTS: by TIPSS variceal filling was widely reduced; as assessed morphologically and rheologically portal liver perfusion was significantly reduced. However, there was immediate onset of compensated liver perfusion by increased arterial inflow. Total liver perfusion was not significantly altered. In TIPSS portal decompression was readily achieved with reduction of the portosystemic gradient from an average of 24 mmHg to 10.5 mmHg. In our series we could not demonstrate an increased incidence of hepatic encephalopathy during the 30-day post TIPSS period. Bilirubin levels were significantly increased after TIPSS from 2.45 to 2.61 mg/dl (p = 0.0067), while albumin levels were not altered. Early mortality was 4% and early re-bleeding rate 3%, respectively. CONCLUSION: the concept of TIPSS represents an individually calibrated H-shunt. The significant reduction of post TIPSS portal perfusion appears to be compensated by increased arterial inflow. This is reflected by invasive flow measurement results and by the clinical results. Letality of TIPSS is low.

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PURPOSE: Our goal was to define the accuracy of MRI in the staging of gastric carcinomas. METHOD: Twenty consecutive surgical specimens were imaged immediately after gastrectomy for gastric carcinoma. Imaging was performed with a 1.0 T imaging system. T1-weighted, T2-weighted, and opposed phase images were acquired and analyzed for tumor infiltration of the gastric wall and the presence of perigastric lymph nodes. T and N stages were classified according to the International Union Against Cancer classification. Finally histopathologic staging of the specimens was compared with staging by MRI. RESULTS: In gastric specimens, three to five layers of the gastric walls were visible. There were typical signal intensity patterns on T1-weighted, T2-weighted, and opposed phase images. Tumor diagnosis and lymph node detection were best achieved by opposed phase imaging. Nineteen of 20 (95%) carcinomas were localized by MRI; T staging accuracy was 65%. The sensitivity to detect metastatic lymph nodes was 87%, specificity 60%. N staging accuracy (nodes positive versus negative) was 80%. CONCLUSION: High resolution MRI of gastric tumors is possible ex vivo. MRI enabled differentiation of up to five layers of the gastric wall, and therefore staging of gastric carcinomas is technically possible. However, to evaluate the exact role of MRI as a staging tool of gastric carcinomas, a correlation between MR morphology and the histologic structure of the gastric wall has to be achieved first.

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BACKGROUND: The study is a prospective evaluation of preoperative TNM staging of gastrointestinal tumors by hydrosonography (HUS). METHODS: Sixty patients with suspected gastric or colorectal cancer underwent HUS for TNM staging. All patients were operated on and the tumors completely removed when possible. HUS findings were correlated with histopathologic staging. RESULTS: HUS correctly localized tumors in 75% of patients. T stage accuracy was low for gastric cancers (41%). N staging of gastric cancers was accurate in 68% of all cases and was highly specific (100%). Staging was more accurate for colorectal tumors (70%), especially with respect to infiltration of other structures (sensitivity 100%, specificity 95%). N staging, however, was not reliable, mostly owing to impaired examination conditions. CONCLUSION: HUS easily misses tumors of the gastric cardia and distal part of the rectum. T staging of colorectal tumors with HUS is highly accurate, reaching 92% if the tumor is localized. T1 cancers of the stomach tend to be overstaged, and serosal infiltration by gastric cancers is often misjudged. With the exception of cardial gastric and distal rectal cancers, HUS comes close to endosonography for staging gastrointestinal tumors. HUS does not require intraluminal access.

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PURPOSE: Evaluation as to whether diagnosis of large bowel disease and TNM staging of colorectal carcinoma are possible by colorectal hydrosonography (HUS). METHOD: 52 patients with suspected neoplastic or inflammatory large bowel disease, underwent HUS. Before performing abdominal ultrasound, the colon was filled with fluid. Morphological alterations of the bowel wall were judged benign or malignant. Colorectal carcinomas were classified according to the TNM system. RESULTS: Laparotomy was performed in 46 of 52 patients. Correlation with surgery and histopathology showed that 77% of morphologic alterations of the colonic wall were detected by HUS. While benign lesions of the colonic wall occasionally mimicked malignant disease, colonic carcinomas were reliably diagnosed by HUS, because destruction and invasion of the bowel wall was visible. Carcinomas of the lower part of the rectum, however, were missed in most cases. Accuracy to determine the infiltration depth of colorectal carcinomas was 89%, but hydrosonographic N-staging was unreliable. Inflammatory disease of the large bowel as well as changes complicating the inflammatory bowel disease were accurately diagnosed by HUS. CONCLUSION: In selected patients, colorectal HUS is suited for diagnosis and staging of colonic tumours. It also helps to evaluate inflammatory bowel disease, because small and large bowel can be reliably distinguished from each other and the degree of stenosis of inflamed colonic segments becomes visible. Furthermore, HUS increases the visibility of fistulas.

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High resolution ultrasound (5/7.5 MHz, linear array) allows imaging of the extracerebral space in infants. A standardised state-of-the-art imaging technique is described that can be performed during routine cranial sonography. Diagnosing dilated subarachnoid space is possible by comparison to normal values. Pathological findings of the subarachnoid and subdural space can be differentiated. Evaluation of the following conditions is possible: external hydrocephalus, cortical atrophy, pyogenic meningitis, subdural hematoma and hygroma. High resolution ultrasound can add helpful information in situations in which magnetic resonance imaging or computed tomography were previously needed. Since it is a noninvasive method, ultrasound is ideal for follow-up studies and hence the method of choice.

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Development of stenosis or occlusion of the transjugular intrahepatic portosystemic stent shunt (TIPSS) is one of the major limiting factors in the long-term viability of this procedure. The efficacy of anticoagulation with heparin which is used in different centers is still unclear. In the present study, we evaluated the effect of phenprocoumon on shunt patency after TIPSS placement using Palmaz stents; 49 patients with Child's A and B cirrhosis, who underwent successful TIPSS placement were randomized into the treatment group (n = 24) who received phenprocoumon and a control group (n = 25). After 11 to 13 weeks, all patients were admitted and had a reevaluation that included control angiography by transjugular approach. Phenprocoumon treatment was stopped after the first reevaluation and both groups were followed for 1 year after randomization. During the 3-month treatment period 11 of 22 patients of the treatment group and 12 of 23 patients of the control group required reintervention because of an increased portosystemic gradient. Five of the 12 patients in the control group showed complete occlusion of the shunt, whereas no occlusion in the treatment group was observed (P < .05). During the mean follow-up of 8 months after the treatment was stopped, in both groups stenosis occurred in 50% of patients, but no further occlusion of the stent was observed. These data indicate that occlusion of the stent is related to thrombosis, whereas stenosis does not appear to be dependent on blood coagulation. In patients with preserved liver function occlusion of the shunt may be prevented by phenprocoumon treatment in the first 3 months after TIPSS placement. Thereafter shunt occlusion was not observed and further phenprocoumon treatment seemed unnecessary.

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