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Background: Displacement of the heart is necessary to expose the target vessel for distal anastomosis to achieve successful multivessel off-pump coronary artery bypass (OPCAB) grafting. In addition to complete revascularisation of the heart, a main challenge during the operation is to maintain haemodynamic stability during this procedure. A new heart positioner (Tentacles) was tested., Methods: In a prospective clinical study we used the Tentacles device in 50 patients scheduled for multivessel OPCAB procedures and investigated the haemodynamic effects during displacement of the heart and while performing the anastomoses to the anterior, lateral and posterior wall. The following haemodynamic parameters were investigated: mean arterial blood pressure (MAP), cardiac index (CI) and stroke volume index (SVI). The incidence of myocardial ischaemia was monitored by transoesophageal echocardiography (TEE) and by ST-segment analysis in the electrocardiogram (ECG)., Result: The Tentacles device permitted rapid, secure and excellent exposure of the lateral and posterior wall of the heart. During exposure of the anterior wall there was a small decrease in MAP (77 ± 10 vs.71 ± 9 mmHg, P = 0.02) in combination with an increase in the CI (3.0 ± 0.7 l vs. 3.1 ± 0.8 l/min/m2, P = 0.03). When the lateral and posterior walls of the heart were exposed, the SVI decreased significantly (36 ± 11 and 38 ± 8 mL/m2, P < 0.01 and P = 0.04, respectively) compared to baseline (44 ± 11 mL/m2) while CI and MAP remained stable. The amount of norepinephrine administered during displacement of the heart was significantly higher in all three positions (0.05 ± 0.05, 0.06 ± 0.05 and 0.04 ± 0.03 µg/kg/min, P < 0.01) compared to the physiological position (0.02 ± 0.02 µg/kg/min). Sinus rhythm was maintained throughout the operation. Neither significant changes of the ST-segment in the ECG nor incidences of wall motion abnormality in TEE were observed. Six hours postoperatively the troponin I concentration was 11.7 ± 4.3 ng/mL., Conclusion: The Tentacles device provided excellent access in multivessel OPCAB surgery. Haemodynamic stability was maintained in all patients; however additional catecholamine support was used when the heart was displaced. This was the case when carrying out an anastomosis on the anterior, lateral, or posterior wall., (© Georg Thieme Verlag KG Stuttgart · New York.)

Castleman's disease is a rare cause for a retroperitoneal mass. The disorder can be classified into two histopathological groups: the hyalin-vascular and plasma-cell types. The former type, particularly in its localized form, is often asymptomatic and benign, the surgical therapy may cure the patient. The latter type is frequently associated with systemic manifestations and an uncertain prognosis. We present a case in which the diagnosis of localized Castleman's disease proved to be extremely difficult. In these cases, the correct diagnosis, however, is indispensable, as these patients can be cured by radical surgical tumor excision.

The hypophyses of 13 patients with Nelson syndrome following bilateral adrenalectomy were examined by MRI and CT. Diffuse enlargement of the hypophysis was demonstrated in 8 patients by CT and in 9 by MRI. Compared with CT, MRI provides better demonstration of tumour development, such as abnormal convexity of the cranial margin of the hypophysis (MRI 4/13, CT 1/13), displacement of the infundibulum (MRI 4/13, CT 0/13) or optic chiasm (MRI 2/13, CT 0/13). MRI also provides diagnostically important differentiation between scar tissue and recurrence of tumour following hypophysectomy (MRI 1/3, CT 0/3) and more accurate demonstration of infiltration of the cavernous sinus (MRI 4/13, CT 2/13). CT is superior only in showing the floor of the sella. MRI is the method of choice for imaging in cases of Nelson syndrome.

Diagnostic assessment of focal pleural mass requires CT examination, particularly in follow-up of anamnestic tumour conditions. Since 1976 well-delineated pleural masses that were suspicious for malignancy on chest films, were identified in 11 patients as lipomas, using CT. They showed semicircular, oval or polygonal shape, but no really "spheric" aspect on biplane chest films. Main diameters of these masses were 2.5 to 6 cm and only once 11 cm. Density values mostly ranged from -110 to -70 HE (min. -133, max. -22 HE) in nonenhanced CT studies. Findings were localised adjacent to the parietal pleura seven times (in one patient two separate findings) and to the diaphragmatic pleura five times. In 7751 CT examinations of the chest, the incidence of pleural lipomas was 0.14%, their prevalence concerning solid pleural lesions being 5.3%. Among all intrathoracic lipomas those in mediastinal and paracardial location respectively were definitely more often (30 patients).

A simple video densitometric method based on the indicator distribution principle in the region of interest permits the determination of the relative amount of regurgitation between the ascending aorta and the left ventricle in cases of aortic valve insufficiency. The experimental basis and early clinical measurements are described and are compared with the more conventional methods of cine angiography and radionuclide ventriculography.

Digital subtraction angiography, using a time interval difference mode in relation to a suitable mask, provides a means of showing the myocardium in every phase of the cardiac cycle. The endo- and peri-cardial contours and the thickness of the myocardium in both ventricles can be demonstrated accurately. Artifacts are usually due to displacements of the heart or to tachycardia.

The paper deals with the early clinical experience, using a new DSA installation with a specially programmed cardiological module. DSA provides very good contrast and special resolution and morphometric estimation of the ejection fraction and regional movement of the left ventricular myocardium derived from DSA. This is as good as the results of the left cardiogram. The significant advantage of DSA ist the ability to make a rapid and simple diagnosis. In addition, it is possible with densitometric methods to calculate ventricular volume curves and to provide phasic indications of the amplitude to contraction of the left ventricle. These investigations have so far proved valuable and provide new scope for the radiological evaluation of left ventricular function.

We carried out replacement of the oesophagus by transposing the stomach in 87 patients, 64 with carcinoma of the oesophagus. There is an immediate operative mortality of 20-30%, but this is followed by a relatively low morbidity, which is well demonstrated radiologically (stricture at the anastomosis, which can be mechanically dilated, about 22%; external fistula with a tendency to spontaneous closure about 25%; ectasia of the thoracic stomach, 15-25%). Average survival time is eight to ten months. There is a 24% risk of post-operative pulmonary oedema and daily chest x-rays are indicated.

The ulno-volar bayonet hand related to the mostly hereditary multiple exostoses is compared to Madelung's forearm deformity under clinical and roentgenological view in differential diagnosis. The ulno-volar bayonet hand is considerably more seldom, basing upon dysplasia of the lower part of the ulna, less inconvenient in function, and hardly tending to the development of early arthrosis.

The radiological changes in the kidneys and skeleton in primary oxalosis in a patient are described. Crystalline calcium oxalate deposits, which are a secondary phenomenon, are responsible for the findings, which are of great significance both functionally and prognostically. Hyperoxalaemia is due to an enzyme defect, which leads to hyperoxaluria; this causes a reduction in renal function and can lead to rapid progression of the condition.

Basing upon 77 patients examined the lateral cysturethrography with metallic bead chain is demonstrated as a special X-ray method in the diagnostic management of the female urinary incontinence in good reference to its diagnostic value in advance. A methodic limitation to the lateral voiding cysturethrography only means lack of information about the relations of the pathophysiologically important vesico-urethral connection in "relaxed" and "straining" state. The clinical graduation of stress urinary incontinence shows no proportionality in quantity according to the angles of the vesico-urethral connection revealable by roentgenogram.

One hundred and thirty-three patients with lymph node enlargement from various causes were examined by MR tomography, using 0.5 and 1.5 Tesla. Amongst these, there were 27 patients with chronically enlarged lymph nodes and histologically confirmed sarcoidosis; these showed characteristic T1 intervals. Enlarged lymph nodes due to chronic inflammatory conditions can be differentiated from lymph nodes with malignant lymphoma, or from lymph node metastases from carcinomas. Although there are problems with the determination of relaxation times on MR tomography, this may be a valuable method for the differential diagnosis of sarcoid.

Three patients were seen with angiomas of the pelvic bones; the radiological and clinical features are described and the literature reviewed. The patients had been observed for four to six years. The differential diagnosis includes infiltrating mesenchymal neoplasms and the histologically similar, but rare, Gorham-Stout syndrome. Recommended treatment is irradiation, which is effective up to a point.

In experience of generally increasing frequency of diaphragmatic injuries, nowadays mostly caused by blunt body traumata in traffic accidents, a review is made about diagnostic and morphologic aspects outlining syndromal relations of 70 cases treated from 1950 until 1980 in the Department of Surgery of the Bonn University. Diaphragmatic tears following indirect (closed) trauma are surely more often associated with a transposition of abdominal organs (73%) than those secondary to direct (penetrating) wounds with an amount to 23%. In typical associated injuries like multiple rib fractures (29%, in relation to blunt injuries even 42%) and pelvic fractures (24% resp. 35%) diaphragmatic damage has to be investigated for if there is any doubtful abdominal or cardiorespiratory symptom. Especially in less symptomatic intervals roentgenographic methods come to use predominantly.

Experiences in i.v. digital subtraction angiocardiography (DSAC) including so-called parametric imaging for morphological delineation of the right ventricle are illustrated. 32 patients with different anatomical and haemodynamic disturbances of the right ventricle were subjected to these examinations. Special emphasis is placed on pulmonary stenosis, particularly on its infundibular manifestations. For visualisation of muscular or fibrous bulging or other changes of the outflow tract of the right ventricle, analysis of the amplitudes is very suitable to produce cumulative pictures of ventricular wall motion during a cardiac cycle. Obstructive wall alterations within the infundibular part become visible even if they occur only during certain phases of the myocardial action, usually in late systole than otherwise.

One hundred and thirty-six patients with various cardiac abnormalities that had been diagnosed by standard methods, were examined by I-V DSA; images of the left and right ventricles during a representative cardiac cycle were submitted to amplitude and phase analysis, using a Fourier transformation. Temporal differentiation of ventricular function was derived from the best available right anterior oblique projection; the amplitude of cardiac movement of abnormal areas in the myocardium were obtained from a grey scale or colour coding at a fixed point. Comparison with a control group of 35 individuals showed the following pathological findings: hypokinetic segments (33 cases) showed delay, dyskinesias (20 cases) showed complete separation of maximal phases, frequently with a double peak in the phase histogram; disturbances of cardiac rhythm (14 cases) showed atypical localisation of initiation of contraction: in Wolfe-Parkinson-White syndrome this is basal-anterior, in left bundle branch block and VVI stimulation it is apical inferior; in hypertrophic obstructive cardiomyopathy (eight cases) it is postero-basal inferior with high, narrow peaks on the phase histogram. Differential phase analysis on I-V DSA enables one to define cardiac contraction in a simple manner.

One hundred and thirty examinations with oral gastrografin were performed in 110 patients with obstructive symptoms, who did not require immediate operation. They consisted of 49 patients with mechanical ileus, eighteen patients with paralytic ileus and 63 patients with incomplete mechanical ileus. All patients with complete mechanical and three patients with paralytic ileus were investigated surgically and treated in this way. Small bowel transit time longer than five hours provides considerable certainty of complete mechanical ileus. The method has been tried for four years; it makes few demands on the patient and has practically no contra-indications, except for deranged electrolyte balance. In children, the amount of contrast medium should be limited and it should be diluted or an isotonic contrast medium should be used. The method provides definite differentiation between mechanical and functional obstruction. In patients with adhesions and recurrent incomplete obstruction, further laparotomies may be avoided in this way.