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A 64 year old male patient suffered from recurrent subphrenic abscesses following a complicated postoperative course after sigmoidectomy for chronic recurrent diverticulitis. Two previous attempts of abscess treatment by transcutaneous drainage had failed. Radiographic studies eventually showed a fistula of the descending colon leading to the abscess formation, which could be identified and confirmed endoscopically by installation of dye.Endoscopic application of an "over-the-scope clip" (OTSC) onto the anchor-retracted enteric fistula orifice led to complete closure of the fistula within four days as demonstrated by radiographic studies and repeat dye installation. Subsequently the transcutaneous drainage could be gradually retracted and eventually successfully removed within 14 days of OTSC application without recurrence of abscess formation.The OTSC is a recently developed endoscopic tool, allowing the application of a large claw-like clip for endoscopic closure of full thickness enteric wall defects and cessation of large vessel bleeding within the gastrointestinal tract. It is a novel tool which can be safely and successfully employed to endoscopically close a fistula of the lower intestinal tract. Future controlled multicenter-studies should address the usefulness of OTSC in the conservative-endoscopic management of intestinal fistulizing disease.

About 0.2 % of patients undergoing laparoscopic cholecystetomy will suffer from complications caused by lost gallstones. Diagnostic and therapeutic measures are correlated to the symptoms. At different locations, abscesses can arise, which can be treated by direct access through the -abdominal wall, laparotomy or laparoscopy. Two cases are presented with the especially grave sequels of subphrenic abscess, infiltration of the thoracic wall, and pleural empyema, which -respectively needed several successive operations -after ten years. In laparoscopic cholecystectomy, all detected stones should be removed. In the case of a failure, conversion to laparotomy is not essential. The loss of stones has to be formally -documented, the patient and family doctor are to be informed.

A 62-year-old lady presented with fever and abdominal pain. History revealed cholecystectomy two years ago due to cholecystolithiasis, complicated by perforation of the common bile duct, leading to hepaticojejunostomy, jejunocholedochostomy, endoscopic retrograde insertion of two plastic stents and percutaneous drainage of bilioma. The patient was lost to follow-up until she presented two years later in the emergency room. ERC was performed. Both stents were occluded. After extraction dirty bile popped out. Injection of contrast medium showed stones in the remaining common bile duct and dilatation of the intrahepatic bile ducts and the interposed jejunum. After stone extraction a subphrenic intrahepatic fluid collection became visible when injecting contrast medium in the intrahepatic bile ducts. Pus was aspirated. The abscess was drained with a nasobiliary tube. Antibiotics were given. Temperature and CRP normalized. The nasobiliary tube was removed when the biliary fluid was clear. Recovery was uneventful with complete resolution of symptoms.

Patients who endured complications due to a presumed or genuine medical error often request an extrajudicial medicolegal opinion. Frequently, the problems appear to originate from an insufficient (preoperative) information of the patient. These expert opinions are an instructive source of learning about possibly avoidable errors. Publishing such cases, in a completely anonymized form, should hopefully contribute to the prevention of the recurrence of certain mistakes. We present and comment on two postoperative events: (1) incisional hernias after abdominal hysterectomy and (2) a sub-diaphragmatic abscess after laparoscopic removal of a dermoid ovarian cyst with intraabdominal spillage of its content.

To control the position of a puncture needle on an access route, which is not parallel to the CT-scan, using control scans not showing start and target points.A software tool has been developed. After CT for biopsy planning x/y coordinates and table position of start and target points have to be determined on CT-scans. The software calculates x/y coordinates of the access route for every table position, which must be marked interactively on control scans. The accuracy of the programme was proven experimentally and the method was used in five patients.There was no difference between the calculated and measured access route in the experiment. Four of five patients were punctured successfully using our method.Our method is a promising procedure to control a CT-guided caudo-cranial biopsy access route.

To test the practicality of MRT-aided drainage using an open low-field magnet and to report on the early clinical results.So far seven patients have been treated (four subphrenic abscesses, two psoas abscesses and one pancreatic pseudocyst). The planning of the approach and catheter insertion were carried out under MRT control (Magnetom Open, 0.2 T). Subsequent treatment was controlled by CT and fluoroscopy. Initial puncture was carried out with a non-magnetic 18 gauge Chiba needle. The drainage catheter was introduced by Seldinger's technique in six cases and with a trocar in one patient.In all seven patients drainage could be started successfully. The design of the magnet and coils permitted adequate accessibility of the patient. There were no problems in visualising the puncture needle. Controlling the position of the catheter by MRT was, however, difficult.The first two steps in abscess drainage (planning the approach and inserting the catheter) can be carried out under MRT control. For further catheter control and observing the course of the disease we presently prefer CT or fluoroscopy.

We are reporting on a dorsolateral access left to the bursa omentalis and to the left subphrenium carried out in order to relieve infectious processes in this region. The access has proved a success above all in the later postoperative period, e.g. when the protecting conglutinations towards ventral isolate the process from the abdominal cavity. At the lying patient this access allows the drainage of the exsudation over the deepest point. The results of 23 surgical interventions are being demonstrated with references to possible complications caused by the intervention.

Traumatic hemobilia is a rare complication of deep and central liver injuries. Repeated and massive bleeding requires an active therapy. For diagnosis of the arterial-biliary fistula, most advantageous is a transcutaneous selective arteriography which can be used also for therapeutic embolization. Of surgical techniques, ligature of the art.hepatica comm. or propria and direct closure of the fistula in the liver parenchyma are recommended. The authors report on such a successful direct intervention in a 9-year-old girl.

The diagnosis of empyema following gastrointestinal operations is usually established at an early stage (Stage I/II in 23 of our own 29 patients). The decisive factor in therapy is the careful and precise insertion of a drainage tube under radiologic control (ultrasound, CT) followed by efficient suction drainage. Nevertheless mortality in this special group of postoperative septic complications was 56%, since extrathoracic sepsis could not always be eliminated promptly enough when diffuse peritonitis was the source of sepsis.

A total of 61 pancreatectomies for chronic pancreatitis are reported. The operative mortality rate was 21% and the later mortality rate 29%, although caused by diabetes. The results are so poor that this method should only be performed in extreme situations. Left or right resection of the main inflammation site is proposed as an alternative. To prevent recurrence of the pancreatitis, the in situ remaining part of the pancreas should be sclerosed by occlusion of the pancreatic duct system.

The literature concerning the definition, frequency, development and morphology of neurogenic gastric tumours is reviewed. The clinical, radiological and histological findings in eleven cases seen by the authors are described. The radiological differential diagnosis and errors in diagnosis are discussed. The significance of tumour perforation in making a type diagnosis is pointed out. There are few angiographic reports available at present.

A model for analysis, adapted to double contrast technique, is presented which helps to detect extrinsic lesions of the gastrointestinal tract. During retrospective evaluation of double contrast examinations of 73 patients this scheme enabled the correct diagnosis in 96%.

In 56 patients with abdominal abscess typical radiological abscess sings were analized to establish a rational and stepwise use of imaging procedures. Plain radiographs of the abdomen should be carried out at first because of their large diagnostic possibilities and standardized practicability. In addition with ultrasonography the diagnosis is possible in almost 90% of the cases. Contrast medium examination are rarely of diagnostic value. Computed tomography should be used in the remaining unclear cases and for planning of further surgical treatment.

The diagnosis of a subphrenic abscess by sonography is based mainly on the experience of the examiner. A short description of the normal subphrenium is given. The diagnostic criteria for a subphrenic abscess and the differentialdiagnosis are discussed. In 19 cases of subphrenic abscess in question the diagnosis was missed in two cases, giving a success rate of 89.5%.

A 47-year-old man who had undergone gastrectomy for duodenal ulcer required repeated hospitalization due to recurrent fistulas in the region of the laparotomy scar and increased cholestasis and cachexia. An intrahepatic and subphrenic abscess was diagnosed clinically and by liver scan and confirmed by laparotomy. The histologic findings revealed actinomycosis. Through early surgical drainage and administration of 20 million units penicillin G daily it proved possible to discharge the patient completely cured after 2 months. The pathogenesis of liver actinomycosis is discussed.

In a retrospective (n = 570) and prospective study (n = 86) early complications following splenectomy were registered in 127/570 (22.3%) resp. 33/86 (38.4%). The mortality rate was 6.6% resp. 6.9%. Recurrent hemorrhage was the most dangerous, infections (pleuropulmonary, wound healing, subphrenic abscess) were the most frequent complications. Their rate is related only to the underlying disease or operative indication (elective splenectomy with hematological diseases; ruptured spleen; incidental splenectomy).

Oesophageal perforation after vagotomy is a quite rare complication. We know figures between 0.4 and 0.8%. The radiodiagnostic verification has central significance for a possibly necessary reoperation, and hence the prognosis of the patient, if this perforation is not recognized under the operation, or necrosis of the wall should happen in the early post-operative phase. We give information about four own observations.

Following the discussion on special clinical issues with respect to patients in surgical and internal intensive care wards, technology and special methods used in conventional thorax and abdominal X-rays are elaborated on. The wide range of information obtained through large spectrum abdominal X-rays taken in the ventrodorsal direction with the patient lying on the left side is stressed. Small quantities of free air are visualized better in this position than in the upright one. The importance of additional X-rays of thorax and epigatrium in a seated position is accented. Subject of discussion is also the indication for visualizing by contrast medium and the selection of a contrast medium with due consideration of clinical criteria. The urgent need of an X-ray diagnosis in such a group of patients requires high standards in terms of techniques and methods used for examination--something that lies within the realm of the radiologist. Close cooperation with the attending team of physicians is a must if optimum interpretation of the X-rays is to be guaranteed.

61 patients with abdominal abscesses and fluid collections as a postoperative complication underwent percutaneous drainage. 60 abscesses, 11 haematomas, 3 steril seromas and 3 bile collections were drained. The fluid collections were associated with biliary or enteric fistulae in 16 cases. The percutaneous drainage was successful in 69%, additional surgery was required in 15%. The overall mortality rate was 13%. Reasons for drainage failure were infected clots, phlegmonic abscesses and pancreas involvement of the abscesses.

Between 1978 and 1983 fifty-two abdominal abscesses in 44 patients were drained percutaneously. 79% of the abscesses occurred as postoperative complications. The overall success rate was 60%, whereas only 42% of left subphrenic abscesses were cured. Complications were encountered in 4.5%. Reasons for drainage failures were: liver sequestration, loculation, fistulae and recurrences. Percutaneous abscess drainage is an alternative, and valuable addition, to surgery.

From 1976 to March 1987 intraabdominal or retroperitoneal abscesses were confirmed by ultrasound in 40 patients. 13 patients had surgical drainage with zero-mortality. 3 of 27 patients were treated with antibiotics (only systemically). 24 patients were treated by percutaneous catheter drainage or needle aspiration. Elective cholecystectomy was performed later in 3 patients. Nonsurgical treatment was successful in 22/27 cases. 3 patients died despite percutaneous drainage. Failure of percutaneous drainage required surgical intervention in 3 patients. The considerably poorer primary condition of the patients receiving nonsurgical treatment allows no comparison with the surgical group. Advantages of percutaneous drainage and needle aspiration are a high success rate and low mortality. These techniques can be used even in critically ill persons.

Because of the retroperitoneal situation of the kidneys, dorsoanterior echography suggests itself. The rapid B-picture process is particularly suitable for urology because the movements of the kidney due to respiration can be followed. "Silent kidney" can be explained. Space-occupying processes can be differentiated. Pararenal processes can be recognised through sonography. Further indications are postoperative monitoring after plastic operations on the efferent urinary passages. The kidney can be visualized without radiation load in allergy to contrast media or in pregnancy. Cyst puncture under echographic observation can contribute to differential diagnosis. Percutaneous nephrostomy under ultrasonic observation can avoid operative intervention.

After operations the early x-ray examen of the upper intestine may show complications in the operation field. It also permits to judge the bowl's function. Most valuable is to compare pictures of the patient in lying and upright position.

The results indicate that the low risk percutaneous drainage of subphrenic abscesses is only feasible in carefully selected patients. The surgical intervention remains the method of choice for the drainage of subphrenic abscesses in conditions such as multiple and complicated abscesses, unfavourable access to the abscess cavities or other pathological conditions. An early and decisive diagnosis is crucial for effective treatment of subphrenic abscesses either by percutaneous drainage or surgical intervention and antibiotic therapy.

The article reports on 37 patients subjected to sonographic examination because of the clinically suspected diagnosis of a "subphrenic abscess". In 7 of these patients, the diagnosis "subphrenic abscess" was arrived at via sonographic examination, and was confirmed in 6 cases by surgery and in one case by postmortem examination. The importance of ultrasound diagnosis for early identification of the subphrenic abscess is discussed and the high rate of accuracy is underlined. The author emphasises that even discreet x-ray film symptoms should prompt immediate ultrasonic examination.

We give an analysis of liver-rupture cases among our own patients and discuss the problems of diagnosis and surgical therapy. Total lethality is 29%; this is dependent on quick diagnostic procedure, the number and severity of accompanying traumas, and the type of liver rupture. The main diagnostic feature seems to be peritoneal lavage, Operative procedure depends on the type and severity of the liver rupture. We therefore propose a classification of the types of liver ruptures, together with their adequate surgical therapy. Some postoperative complications can also be avoided.

60 persons with a chest trauma were treated during the past years. In a number of cases the injuries and the resulting complications were of so serious a nature that their repair was attended by the greatest difficulties. The most serious and initially unrecognized complications comprised: 1) tracheo-bronchial defects, partly of traumatic origin and partly arising during intensive care; 2) failure to detect rupture of the diaphragm with displacement of visceral organs into the thoracic cavity; 3) insufficient evacuation of blood or fluid from the pleural cavity; 4) failure to diagnose irreparable damage to part of the lungs. Means to repair these lesions are reviewed; the necessity for long-term observation of these cases is emphasized.

Gamma-camera imaging after injection of radiolabelled autologous leucocytes can be very helpful in the diagnosis, localization and further clinical treatment of inflammatory diseases. We present a technique allowing sterile separation of white blood cells and labelling with 99mTc-phytate or -oxine and with 111In-oxine, -oxine sulphate or -tropolone. The method is non-invasive and the radiation dose amounts to less than 80 mrad using 100 microCi 111Indium. The use of radiolabelled granulocytes is of particular diagnostic value in patients with septicaemia of unknown origin. Whole body scanning allows not only visualization of enhanced splenic uptake in septicaemia, but also localization of an inflammatory process. Preferential indications for a diagnostic approach using radiolabelled granulocytes are inflammatory abdominal processes which cannot easily be documented by means of other non-invasive techniques, such as inflammatory bowel disease (Crohn's diseases and ulcerative colitis), arthritic processes and abscesses of the liver and spleen, as well as subphrenic and retroperitoneal abscesses. Untreated osteomyelitis can be located with the help of labelled granulocytes, but in patients treated with antibiotics a false negative result is obtained in approximately 50% of cases for as yet unknown reasons, even in the presence of a still active osteomyelitic process.

Main symptoms and causes of subphrenic abscess are described. Localization is possible using Gallium 67 scanning. Prophylaxis and surgical approach are illustrated. In 75 patients of the surgical clinic of the University of Hamburg, the subphrenic abscess was drained by an anterolateral extrapleural incision through the diaphragm. Positive identification and localization are necessary to prevent contamination of the peritoneal cavity. Scintigraphic Gallium 67 scanning is also useful to identify synchronous subphrenic (bilateral) abscesses.