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Neoadjuvant chemoradiotherapy (CRT) followed by surgery is recommended for patients with diagnosed rectal cancer UICC stage II/III. The present study aimed to evaluate the accuracy of preoperative staging with focus on tumor infiltration depth and lymph node status challenging the indication of neoadjuvant CRT. All consecutive rectal cancer patients who underwent surgical resection without neoadjuvant CRT at the Klinikum Stuttgart, Germany, between January 2015 and December 2018, were included into the study. Clinicopathologic features focusing on preoperative tumor staging and histological outcome were assessed. A total of 100/162 patients (61.7%) underwent primary surgical rectal resection with curative intent. Among these patients, 54/100 had a correct preoperative T-staging, while 34 were overstaged and 12 understaged. With regard to the nodal status, 68 were accurately staged, while 28 were overstaged and 4 understaged. Only 4/40 perirectal lymph nodes of more than 5 mm in diameter in preoperative MRI histologically revealed to be metastasis. For patients without neoadjuvant CRT, a tendency to preoperative overstaging was observed. Lymph node size alone did not reliably predict metastasis. According to current guidelines, 21/62 (33.9%) of these patients would have been overtreated by using CRT. On the background of relevant side effects, complications, and the limited benefit of CRT on overall survival, we suggest that primary surgical resection should be recommended more liberally for stages II and III rectal cancer.

Acute aortic syndrome, aortic aneurysm and stenotic aortic disease are significant challenges for state-of-the art imaging of the aorta. Over the last decade, advanced imaging methods such as multidetector computed tomography, high-resolution ultrasound including color-coded Doppler and contrast-enhanced B-mode imaging and magnetic resonance imaging have assumed an important role in identifying and describing many of the complex aortic pathologies. They play a fundamental role in decision making for treatment such as endovascular, or open surgical or conservative treatment. In this overview, a systematic description of all present imaging modalities is presented and their respective roles for the entire spectrum of aortic diseases are illustrated and defined in their relevance. Furthermore, future aspects such as virtual reality methods are presented.

Highlights • Intraductal tubular papillary neoplasm (ITPN) displays a very rare subtype of epithelial neoplasms of the pancreas. • To date, little is known about ITPN and particularly about pancreatic cancer arising in this tumor entity. • ITPN reveals a potential of malignant transformation. Radical surgical resection and oncologic follow-up is warranted. • When compared to ductal adenocarcinoma, patients with ITPN reveal less lymph node metastasis and a better overall survival., Background Intraductal tubular papillary neoplasm (ITPN) displays a very rare subtype of epithelial neoplasms of the pancreas. ITPN is characterized by intraductal tubulopapillary growth and cellular dysplasia. In contrast to intraductal papillary neoplasm (IPMN) no overt epithelial mucin production is observed. To date, little is known about ITPN and particularly about pancreatic cancer arising in this tumor entity. Case presentation A 68-year-old male presented at our hospital with a distal bile duct occlusion suspicious for adenocarcinoma of the pancreatic head. Preoperative staging revealed no signs of distant metastasis. The patient was surgically explored and pylorus preserving duodenopancreatectomy was performed for a solid pancreatic head tumor. Final histopathology surprisingly revealed an ITPN with an associated invasive carcinoma pT3, pN0 (0/12), R0, G2. Discussion Patients with ITPN frequently present with jaundice suspicious for a bile duct stenosis or a malignant tumor of the pancreatic head. Although, it is possible to diagnose ITPN by endoscopic retrograde cholangiopancreaticography, many tumors are found not before histopathological examination. Differential diagnosis includes ductal adenocarcinoma of the pancreas, neuroendocrine tumors, IPMN, distal bile duct tumors, and solid pseudopapillary neoplasms. Using immunohistochemistry, other entities of pancreatic tumors can be ruled out. In case of R0 resection oncological prognosis is described to be more favorable when compared to regular ductal adenocarcinoma. Conclusion ITPN displays a rare entity of pancreatic neoplasms. As shown in the present case report, there is a relevant potential of malignant transformation and therefore radical surgical resection and oncologic follow-up is warranted.

Complications of embolization and chemoembolization remain a problem even with the development of low-profile catheter material and the introduction of new embolization agents. In recent years many new embolization materials have become available for clinical use, so the possibilities and limitations of these new materials must be understood to allow safe and effective embolization. Although up to now some scientific work has been published reporting the basic risk of embolization procedures, the underlying pathomechanism remains the object of speculation. Besides complications like drug toxicity, allergic reactions, and bleeding of the puncture site, the characteristics of embolization materials must be known to understand the potential complications of nontarget embolization and reflux of embolization material. This article gives an overview of established and new embolization materials, their potential risks, and the underlying pathophysiology.

Objective: It was the aim of this study to evaluate a new infiltration score to determine the resectability of pancreatic carcinomas in preoperative planning. Materials and Methods: Eighty patients with suspected pancreatic tumor were examined prospectively using 16-row spiral CT. The scans were evaluated for the presence of pancreatic carcinoma, peripancreatic tumor extension and vascular invasion using a standardized questionnaire. Invasion of the surgically relevant vessels was evaluated using a new invasion score. The operative and histological findings and the clinical follow-up served as the gold standard. Results: Forty patients had a pancreatic carcinoma, 5 had metastasis of a different primary tumor, and in 35 patients, there was no malignant pancreatic disease. The sensitivity for tumor detection was 100%, with a specificity of 88% for differentiating between malignant and benign pancreatic tumors. Invasion of the surrounding vessels was evaluated correctly using the invasion score, with a sensitivity of 89% and a specificity of 99%. In evaluation of resectability, a sensitivity of 94% and a specificity of 89% were achieved. Conclusion: Using 16-row spiral CT, the invasion score is a valid tool for correctly assessing invasion in relevant vessels in cases of pancreatic carcinoma and for determining resectability.

An 11-year-old girl developed typical symptoms of bird breeder's lung after several years of contact with budgerigars and other birds. The clinical diagnosis was confirmed by immunological and lung-function tests. Despite exclusion of exposure to allergens and treatment with steroids and D-penicillamine no improvement occurred, the exogenous allergic alveolitis progressing to fibrosing alveolitis of which the girl died.

To report our experiences of catheter embolization of three acute bleeding giant renal angiomyolipoma and to discuss the diagnostic and interventional management of this tumor entity in an emergency and elective setting in review of the literature. Materials and methods Three female patients (43 ± 5.9 years) with giant renal angiomyolipomas (AML), two associated with tuberous sclerosis, presented with spontaneous acute perirenal hemorrhage and large retroperitoneal hematomas. Due to their age and intact parenchyma with normal renal retention parameters, they were treated with superselective transarterial embolization (TAE), applying a combination of particulate and liquid embolic material: 0.5–2 ml (300–500 μm/700–900 μm) Embospheres™ (Biosphere, France) were injected to block the tumor periphery followed by 0.2–1 ml mixture of Lipiodol™ (Byk Gulden, Germany) and Ethibloc™ (Ethicon, Germany) to occlude the feeder of the ruptured angiomyolipoma. All embolizations were successful and patients were discharged after 3–5 days. Follow-up MRI on discharge showed no bleeding and distinct atrophy of the embolized areas without impairment of normal renal parenchymal perfusion. Renal function remained normal during clinical and MRI follow-up (mean 28.3 ± 30.4 months). Conclusions In most patients with acute bleeding giant angiomyolipomas, it would be impossible to preserve the kidney by surgical attempts alone, so they should be, if technically possible, initially treated by selective arterial embolization. Catheter embolization should be considered as an elective therapy option in patients with symptomatic and/or large (>4 cm) AMLs. All AMLs associated with tuberous sclerosis should be monitored by annually MRI for lifetime to assess tumor growth and to predict complications.

Endoscopy plays an essential role in the diagnosis, management, prognosis, and surveillance of inflammatory bowel disease (IBD), but surprisingly there are few available guidelines.1,2 This prompted the ECCO Guidelines Committee (GuiCom) members to promote a Consensus on the appropriate indication and application of different endoscopic modalities in IBD. Since the development of guidelines is an expensive and time-consuming process, this Consensus may help to avoid duplication of effort in the future. It may also identify issues where the evidence is lacking and controlled studies are awaited. The strategy to reach the Consensus involved five steps: 1. Two members of the GuiCom (VA and RE) identified four main topics: a) Diagnosis and follow-up; b) Score of endoscopic activity; c) Small bowel endoscopy; and d) Surveillance. During 2012 a call for participants to the Guideline was made to ECCO members. In addition, expert endoscopists recognised for their active research in the field were invited. Participants were selected by the Guicom and four working groups were created. Each working group had a chair (VA, MD, MT, and RE), two ECCO members including young members (Y-ECCO) and one experienced endoscopist. For the development of the guideline, relevant questions on separate topics were devised by the chairmen and their working parties. The questions were focused on current practice and areas of controversy. Participants of the Consensus process were asked to answer the questions based on evidence from the literature as well as their experience (Delphi procedure)3; 2. The working parties working in parallel performed a systematic literature search of their topic with the appropriate key words using Medline/Pubmed and the Cochrane database, as well as other relevant sources; 3. Provisional guideline statements on their topic were then written by the chairmen. These were circulated and commented on first by working party members and …

Percutaneous transcatheteral embolizations of primary and secondary bone tumors are important minimal invasive angiographic interventions of the skeletal system. In most of the cases embolization is performed for preoperative devascularization or as a palliative measure to treat tumor-associated pain or other tumor bulk symptoms. The transarterial embolization of primary and secondary tumors of the skeletal system has been developed to a safe and very effective method. Indications, techniques, results and complications of this minimal invasive interventional therapy for treatment of primary and secondary bone tumors are described and discussed and compared with the newer literature and our own results.

The objective was to compare the radial strength and expansile precision of self-expanding stents and balloon-expandable stents in a human cadaver bifurcation model. Seven different self-expanding (LUMINEXX, JOSTENT SelfX, JOSTENT SelfX hrf, Sinus-Repo, Sinus SuperFlex, Easy Wallstent, SMART) and four different balloon-expandable stent models (Palmaz, Sinus Stent, SAXX Medium, JOSTENT peripheral), each type 10 stents (total n = 110 stents) were implanted into the common iliac arteries of human cadaver corpses. The maximum stent diameter was 10 mm for all models. After stent implantation, the specimens were filled with silicone caoutchouc. After 24 h, the vascular walls including the stents were removed from the hardened casts. Diameters were taken and the weight of the cast cylinders was measured in air and in purified water to calculate the volume of the bodies (according to Archimedes Law) as a relative but precise degree for the radial strength of the implanted stents. The cylindrical casts of the self-expanding stents showed lower mean diameters (8.2 ± 1.0 mm) and mean volumes (0.60 ± 0.14 ml/cm) than in the balloon-expandable stent group (10.1 ± 0.3 mm and 0.71 ± 0.04 ml/cm, respectively; p < 0.01). The nominal maximum diameter of 10 mm was not achieved in any of the self-expanding stents, but this was achieved in more than 70% (29/40) of the balloon-expandable stent specimens (p < 0.05). The variation between achieved volumes was significantly larger in self-expanding (range: 0.23–0.78 ml/cm) than in balloon-expandable stents (range: 0.66–0.81 ml/cm; p < 0.05). Self-expanding stents presented considerably lower radial expansion force and lower degree of precision than balloon-expandable stents.

Vorgelegt wird eine Ubersicht uber den gegenwartigen Stellenwert radiologischer Interventionen bei malignen Gallenwegstenosen, die nur bei 10–20% der Patienten heilbar sind. Wenn ein endoskopisch transpapillarer Zugang nicht moglich ist, z. B. bei hohen Obstruktionen oder nach fruheren Eingriffen, ermoglichen die perkutane transhepatische Punktion und Implantation von Metallendoprothesen eine gute Palliation. Die perkutane Gallengangdrainage und Stentplatzierung sind fur den erfahrenen, interventionell tatigen Radiologen wenig kompliziert und mit einer Erfolgsrate von 95–100% dem endoskopischen Vorgehen deutlich uberlegen. Morbiditat und Mortalitat der endoskopischen Verfahren waren in alteren Arbeiten noch geringer als die der perkutanen Methoden. Aktuellen Studien zufolge sind beide Verfahren gleichwertig, wahrscheinlich aufgrund technischer Verbesserungen der perkutanen Interventionen. Die technische Erfolgsrate bei der Stentapplikation liegt uber 95%. Mittels perkutaner transhepatischer biliarer Drainageneinlage (PTCD) eingelegte Metallstents bleiben haufiger und langer offen als Plastikstents. Bei entsprechender Lebenserwartung des Patienten ist ihr Einsatz daher trotz hoherer Kosten gerechtfertigt.

In this report, we describe successful treatment of a patient with hemoptysis by false lumen embolization of a type B aortic dissection.

Objectives To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis. Methods Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed. Results Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively. Conclusions Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I–IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis.

Cross-sectional imaging based on navigation and virtual reality planning tools are well-established in the surgical routine in orthopedic surgery and neurosurgery. In various procedures, they have achieved a significant clinical relevance and efficacy and have enhanced the discipline's resection capabilities. In abdominal surgery, however, these tools have gained little attraction so far. Even with the advantage of fast and high resolution cross-sectional liver and pancreas imaging, it remains unclear whether 3D planning and interactive planning tools might increase precision and safety of liver and pancreas surgery. The inability to simply transfer the methodology from orthopedic or neurosurgery is mainly a result of intraoperative organ movements and shifting and corresponding technical difficulties in the on-line applicability of presurgical cross sectional imaging data. For the interactive planning of liver surgery, three systems partly exist in daily routine: HepaVision2 (MeVis GmbH, Bremen), LiverLive (Navidez Ltd, Slovenia) and OrgaNicer (German Cancer Research Center, Heidelberg). All these systems have realized a half- or full-automatic liver-segmentation procedure to visualize liver segments, vessel trees, resected volumes or critical residual organ volumes, either for preoperative planning or intraoperative visualization. Acquisition of data is mainly based on computed tomography. Three-dimensional navigation for intraoperative surgical guidance with ultrasound is part of the clinical testing. There are only few reports about the transfer of the visualization of the pancreas, probably caused by the difficulties with the segmentation routine due to inflammation or organ-exceeding tumor growth. With this paper, we like to evaluate and demonstrate the present status of software planning tools and pathways for future pre- and intraoperative resection planning in liver and pancreas surgery.

Purpose To evaluate safety and mid term efficacy (> or = 1 year follow-up) of uterine fibroid embolization (UFE) using spherical particles (Embosphere) in a study applying criteria identical to those submitted to the FDA for initial material approval. Materials and methods Twenty of the first 26 consecutive patients referred for potential UFE were enrolled in the study. Pre-interventional MRI was used to assess morphologic contraindication to UFE. The embolization procedures were performed from a unilateral femoral approach using 4F selective catheters in straight vessels, > 2 mm in diameter, and micro-catheters in smaller and tortuous arteries. The endpoint of the "flow guided" embolization was defined by reaching the angiographic "pruned tree" appearance and sluggish flow in the main stem of the uterine artery. Assessment of morphologic mid term success was done by MRI 10 days, 3 months, 6 months, 9 months and 1 year after UFE. The clinical mid term success was assessed by having questionnaires completed for menstrual bleeding, retention of clinical (symptomatic) benefit and quality of life. Results Technical success was 100 %, with 8 minor (2 post-interventional collapses, 2 hematomas, 4 relevant post-embolizations syndromes, 1 spontaneous expulsion of a submucous myoma) and 3 major complications (1 hysterectomy because of vaginal bleeding for 5 weeks, 1 transient amenorrhea and 1 spontaneous expulsion of myoma with transient bleeding requiring admission). In 17 of 19 patients, MRI showed total fibroid devascularization throughout the entire follow-up. The average shrinkage of the dominant fibroid was 71.3 % at one year. The menstrual bleeding record in the cohort group fell from an average of 501.6 before treatment to 76.2 points at one year. At the same time, the clinical symptoms significantly improved. The patient satisfaction with the applied therapy was > 95 % at 1 year. One patient with residual fibroid perfusion underwent a second procedure, which achieved complete devascularization and adequate clinical success at one year. The second patient with incomplete devascularization had a persistent clinical benefit. Conclusion Under controlled study conditions, flow guided UFE with spherical particles achieves high overall success and patient satisfaction. MRI provides exact morphologic description of the fibroid for the initial evaluation and for post-procedural follow-up.

The preoperative measurement of liver volume is a predictive parameter for fewer postoperative complications, especially in living donor liver transplantation. Modern surgery-planning systems estimate these volumes from segmented image data. Most algorithms used for that purpose were evaluated only in the 1970s. This work is a structured analysis of different volume measurement algorithms and their evaluation with an in vivo pig model. We show that the current approaches are not appropriate for accurate volume estimation based on CT images. Therefore, we present a new algorithm that minimizes the measuring error and seems to be robust against inter- and intra-observer variabilities.

Objective:To modify an ex vivo test procedure for balloon expandable stents as a means to evaluate the mechanical properties of self-expanding stents.Methods:Ten stents each of 7 different stent models measuring 10 mm in diameter (LUMINEXX Vascular Stent/Memotherm-FLEXX Vascular Stent [identical to

Ziel der Arbeit war die Evaluation der beobachteten Komplikationen und Risiken der Myomembolisation. Dazu fuhrten wir eine Literaturrecherche der 50 am haufigsten zitierten Publikationen durch. Zusatzlich befragten wir die in der Myomembolisation sehr erfahrenen Kollegen R. Cursch, J. Lammer, J. Spies und J.P. Pelage hinsichtlich der von ihnen beobachteten Komplikationen und Risiken. Im Vergleich dazu analysierten wir die aufgetretenen Komplikationen in unserem Patientengut. Die haufigsten in der Literatur beschriebenen Komplikationen sind meist mit der Angiographie assoziierte wie Leistenhamatome oder leichte Leistenschmerzen, die sich schnell zuruckbilden. Die Uterusmyomembolisation (UFE) ist eine sehr sichere und risikoarme angiographische Intervention. Die moglichen Risiken und Komplikationen und die besten Vermeidungsstrategien mussen bekannt sein.

RATIONALE AND OBJECTIVES. To develop a new model for a more realistic evaluation of radial strength and elastic recoil of balloon expandable stents using a new ex vivo model in human cadaver bifurcations of the aorta. MATERIALS AND METHODS. Four different stents (each group n = 10) were implanted in cadaver common iliac arteries. Randomization was performed either to right or left iliac artery. The specimens were cast filled with silicone caoutchouc and after 24 hours the vascular walls including the stents were removed from the hardened casts. The weight of the cast cylinders of the stents was measured in air and in purified water: the difference of the two values resulted in the buoyancy force and because of that the volume of the bodies as a relative degree for the radial strength could be calculated. The findings were correlated with the workbench tests of the manufacturers. RESULTS. Manufacturer's workbench tests were incomparable because of wide spread specifications. There was a significant difference between the theoretical maximal volume (0.866 mL) and the real cast volumes (P < 0.025) that corresponds directly to the elastic recoil of the stents. The following mean real cast volumes were measured (corrected for 1 cm): Sinus-Stent 0.677 mL, Palmaz-Stent 0.708 mL, Jostent 0.715 mL, Saxx-Stent 0.732 mL, thus reflecting the various degree of radial strength; therefore, the ranking in radial strength resistance was Saxx, Jostent, Palmaz, and Sinus. CONCLUSION. High radial strength and low elastic recoil are important requirements of any stent design. Ex vivo tests unlike in vitro physical testing facilitate a realistic evaluation of the inherent stent characteristics. The model used in this study proved to be uniformly valid for physical stent design testing.

The transjugular intrahepatic stent-shunt (TIPSS) is a well accepted minimal invasive therapy for complications of portal hypertension: recurrent variceal bleeding, refractory ascites and liver failure due to the Budd-Chiari syndrome. The high frequency of shunt stenoses and occlusions makes regular follow up examinations essential. Despite modern non invasive imaging methods direct portography still is the gold standard for shunt surveillance in TIPSS. Ultrasound is helpful to detect shunt dysfunction, but nevertheless its failure rate is considerable despite the use of contrast enhancers such as Levovist because of anatomic and physical limitations, particularly when TIPSS-tracts deep in the liver are present. Reintervention rates approach 90-100% after 24 months, with 100% in child's A patients with comparatively good liver function. However, a strict shunt surveillance program with early portography and reintervention when necessary guarantees high clinical success rates associated with very low rebleeding rates below 10%. Overall the secondary success rate is 80%. Secondary failures are mainly caused by lack of patient compliance during follow-up. In a subgroup of patients no shunt maturation is observed, requiring multiple shunt revisions. In cases of recurrent shunt occlusions an association with bile leaks is presumed. In selected cases patients with chronically recurrent shunt stenosis or occlusions may benefit from placement of TIPSS stent grafts.

Ziel. Darstellung der Heidelberger Ergebnisse zur operativen und interventionellen Therapie der akuten Aortendissektion auf der Basis einer Analyse der Jahre 1999–2000. Material und Methode. 93 Patienten mit akuter Aortendissektion wurden im Untersuchungszeitraum durch Herzchirurgie, Gefaschirurgie und Interventionelle Radiologie mit dem Ziel einer optimierten Stufentherapie behandelt. Entsprechend der klinischen und morphologischen Situation erfolgte die Therapie klassisch offen (Typ A) mit Herz-Lungen-Maschine und seit der Verfugbarkeit groslumiger Stentgrafts endoluminal (Typ B) oder dann konservativ, wenn weder klinisch noch morphologisch eine invasive Therapie erforderlich erschien. Ergebnisse. 36 Patienten hatten eine A- und 57 eine B-Dissektion. Fast alle A-Patienten wurden operiert (32), 3 der nichtoperierten verstarben kurz nach Aufnahme. 20 der Patienten mit B-Dissektion wurden therapiert, davon 12 endoluminal. Die Mortalitat der A-Patienten lag insgesamt bei 35%, die der B-Patienten bei 15%, wobei allerdings die Mortalitat in beiden Gruppen bei den unbehandelten am hochsten war. Die Mortalitat der endoluminal behandelten Patienten war 0%. Der wichtigste Mortalitatsfaktor bei allen A-Patienten war die viszerale Ischamie, die trotz erfolgreicher Korrektur der Aorta ascendens durch symptomatischen ”True lumen collaps”, ggf. verscharft durch den Einsatz der Herz-Lungen-Maschine, in der unmittelbar postoperativen Periode entscheidend wurde. Paraplegische Kompliationen traten bei keinem Patient auf. Bei insgesamt 4 Patienten konnten erstmals Kombinationsverfahren aus offener Chirurgie und endoluminaler Korrektur der fortbestehenden (symptomatischen) B-Dissektion erfolgreich eingesetzt werden. Diskussion. Die Typ-A-Dissektion kann mit hoher technischer Erfolgsrate behandelt werden. Das Fortbestehen ungunstiger hamodynamischer Verhaltnisse in der distalen Aorta begunstigt jedoch Organmalperfusionen. Die erfolgreiche Kombination mit endoluminalen Verfahren legt nahe, ein solches Konzept einer breiteren klinischen Erprobung zu unterziehen. Akute und klinisch symptomatische B-Dissektionen konnen mit hoher technischer Erfolgsrate endoluminal behandelt werden. Ungeloste Fragen betreffen allerdings noch das endgultige Prothesendesign.

Allergic reactions to contrast media, preexisting renal dysfunction, and hyperthyroidism are relative contraindications for angiography with conventional contrast medium. Carbon dioxide (CO 2 ) angiography is an alternative method in high-risk patients because CO 2 is nontoxic, without allergic potential, and not iodic. CO 2 -related complications are extremely rare. Because renal insufficiency often occurs in vascular patients, this method will become increasingly important for endovascular surgery. We report on three consecutive patients with asymptomatic infrarenal aortic aneurysm and concomitant renal dysfunction or allergic reactions to standard contrast media. Aortic stent grafts were deployed under CO 2 angiographic control without complications or worsening of renal function. (J Vasc Surg 2001;33:646-9.)

Die Therapie von Lebertraumata ist wenn irgend moglich konservativ und orientiert sich initial an Kreislaufstabilitat, Fehlen einer Gerinnungsstorung und Transfusionsbedarf. Die operative Versorgung sollte dem Zweistufenprinzip folgen mit primarer Blutstillung oder Kompression und definitiver Versorgung unter stabilen Bedingungen. Beim kreislaufinstabilen Patienten sind gezielte Versuche intraparenchymatoser Blutstillung kontraindiziert. Gelingt eine Kontrolle der Blutung trotz Kompression nicht, mus reseziert oder sogar hepatektomiert werden mit anschliesender Transplantation. Gallelecks sind Ursache chronischer Komplikationen. Die aktuelle Therapie intraparenchymatoser Lasionen besteht in einer Langzeitdrainage bzw. Schienung in der Kombination radiologischer und endoskopischer Techniken. Pankreasrupturen ohne Gangbeteiligung werden konservativ oder durch alleinige Drainage behandelt. Gangrupturen mit persistierender Fistel werden lokalisationsabhangig therapiert durch Linksresektion mit Ubernahung, Pancreatico-Jejunostomie des verletzten Segmentes oder bei schwerer Laceration von Pankreaskopf, Duodenum und Gallengang partieller Pancreaticoduodenotomie.

PURPOSE The purpose of this work was to define the accuracy of helical hydro-CT (HHCT) in the diagnosis and staging of gastric carcinoma. METHOD One hundred twelve patients with gastric carcinoma were preoperatively imaged by HHCT. Gastric distension was achieved by ingestion of up to 1,500 ml of water. Bolus tracking was performed, and peristalsis was minimized by intravenously administered spasmolytics. Contrast material was then injected, and helical scanning was performed at the time of peak enhancement of the liver. CT images were analyzed for tumor infiltration of the gastric wall, and TNM staging criteria were applied according to the International Union Against Cancer (UICC) classification. The results were correlated with histopathologic findings. RESULTS One hundred two of 115 (89%) gastric carcinomas were correctly diagnosed by HHCT. Small malignant ulcers (< or =2 cm) that corresponded to early gastric carcinoma were not visible on CT scans. T and N staging accuracies were 51% each; abdominal M staging was correct in 79% of all cases. The positive and negative predictive values of HHCT to foresee curative resection of gastric carcinoma were 75 and 84%, respectively. CONCLUSION Mural thickening as well as marked contrast enhancement of the gastric wall are firmly related to gastric carcinoma. The accuracy of HHCT is acceptable for M staging but inadequate for local staging of gastric carcinoma. Nonetheless, HHCT is a useful guide for choosing between tumor resection and nonoperative treatment of patients. We therefore recommend HHCT as the method of choice for preoperative imaging of gastric carcinoma.

Die Planung der chirurgischen Resektion von Lebertumoren setzt ein genaues Verstandnis ihrer Lokalisation in Bezug zu den Lebergefasen voraus. Ziel unserer Studie ist die Entwicklung eines computergestutzten Systems zur praoperativen, quantitativen Operationsplanung auf der Basis volumenorientierter 3-D-Rekonstruktionen. Material und Methoden: Die Datenaquirierung erfolgt aus Kontrastmittel-verstarkten Spiral-CT. Die drei Gewebeklassen Leberparenchym, Lebergefase und Lebertumor werden semiautomatisch mittels „Region-growing-“ und „Kantenfinder-Algorithmen“ segmentiert. Die gefundenen Strukturen werden mittels des volumenorientierten „Heidelberger Raytracing Algorithmus“ visualisiert. Neu entwickelt wurden spezielle Verfahren, um die Gefasbaume als Graph zu erfassen und deren Verzweigungsstruktur nachzubilden sowie Pfortader und Lebervenenbaume zu trennen. Die Sicherheitsabstande um den virtuellen Tumor werden definiert und das computergestutzte System reseziert virtuell die abhangigen Leber(sub)segmente. Ergebnisse: Die 3-D-Anatomie der Leber und der genaue Bezug der Lebergefase zum Tumor wird in hoher Qualitat mit resultierender guter Tiefenwahrnehmung dargestellt. Sicherheitsabstande werden demonstriert. Abhangiges Lebergewebe kann automatisiert auf der Basis der Gefasbaumanalyse erkannt werden. Das System bietet einen patientenindividualisierten Resektionsvorschlag unter Einschlus des Tumors, des Sicherheitsabstandes und des abhangigen Lebergewebes. Schlusfolgerung: Die 3-D-Darstellung der individuellen Leberanatomie erleichtert die raumliche Zuordnung der Pathologie. Die virtuelle Realitat erlaubt komplette Leberresektionen quantitativ zu berechnen und interaktiv zu modifizieren. Auf diese Weise wird die virtuelle Realitat in Zukunft die Ausbildung und die chirurgische Planung und Therapie verbessern helfen.

INTRODUCTION A study was carried out to determine whether an improvement in the detection of vascular signals in patients after orthotopic liver transplantation can be achieved by the use of ultrasound contrast medium in colour Doppler sonography. MATERIAL AND METHODS In the early postoperative follow-up of liver transplant recipients, 31 colour Doppler sonograms were obtained in 21 patients before and after intravenous injection of the ultrasound contrast agent Levovist (Schering, Berlin). A grading score with four categories was used to evaluate the sonograms with special regard to the visibility of colour and flow signals in the hepatic artery and also in the portal vein and the hepatic veins. The arterial and portal venous signals were evaluated in the hepatic portal and in the left and right lobe. RESULTS With contrast enhancement significantly better arterial signals were seen in 20 of 31 sonograms for the hepatic portal, in 22 for the right lobe and in 26 for the left lobe. Better portal vein signals were obtained in 17 of 31 examinations for the right lobe and in 16 for the left lobe; only little improvement was obtained for the main stem of the portal vein. For the hepatic veins there was no significant improvement. CONCLUSIONS Early vascular complications after liver transplantation usually occur in the hepatic arteries. With the use of contrast-enhanced colour Doppler sonography, better detection of arterial and peripheral portal signals can be achieved; peripheral portal vein branches can be helpful in finding small arteries.

Therapeutic interventions in the skeletal system are an essential part of interventional radiology. Although in terms of figures these procedures are applied less frequently, they are very effective. Percutaneous transarterial embolization of a spinal tumor is well-established interventional treatment. It is primary treatment for preoperative devascularization, but also for palliation of pain and for reduction of tumor volume. As an alternative access for embolization, direct percutaneous puncture of a vertebra is used. A new and promising technique is vertebroplasty, the percutaneous injection of acrylic surgical cement in destroyed vertebrae. The present paper discusses indications, technique, results and complications of these interventional therapeutic modalities in the treatment of primary and secondary spinal tumors.

Hintergrund: Die konventionelle gefaschirur-gische Therapie poplitealer arteriovenoser (a.v.-) Fisteln ist technisch aufwendig und komplikationstrachtig. Die endovaskulare Therapie mit einer transluminal eingebrachten Stentprothese stellt eine moglicherweise weniger invasive neue therapeutische Option dar. Kasuistik: Bei einem 26jahrigen Fusballspieler wurde 5 Jahre nach Kniegelenktrauma und operativer Versorgung eines vorderen Kreuzbrandrisses eine grose a.v.-Fistel zwischen A. und V. poplitea diagnostiziert. Klinisch bestand eine deutliche Umfangszunahme des betroffenen Beins und eine Vergroserung des Herzens. Therapie: Von gefaschirurgischer und radiologischer Seite wurde gemeinsam die Indikation zur endovaskularen Therapie gestellt. Ein Palmaz-Stent wurde in einer PTFE-Prothese fixiert und uber eine perkutan gelegt Schleuse uber die A. femoralis antegrad eingebracht. Aufgrund einer Fistelpersistenz wurde nach 6 Monaten ein zweiter „covered Stent“ implantiert und die a.v.-Fistel suffizient abgedichtet. Nach weiteren 12 Monaten ist der Stentgraft frei durchgangig und der Patient weiterhin beschwerdefrei ohne Anhalt fur eine weiter bestehende Fistel. Schlusfolgerung: Die endovaskulare Implantation einer Stentprothese stellt eine therapeutische Alternative in der Behandlung chronischer pop-litealer a.v.-Fisteln dar.

We report our experience concerning a young, white, healthy woman who had a typical blunt chest injury caused by a severe car accident. We had to evaluate and differentiate the initial roentgenographic post-traumatic mediastinal enlargement in order definitely to exclude a suspected covered rupture of the thoracic aorta or the heart caused by this high-velocity deceleration trauma. The difficulties encountered are critically discussed with regard to the unexpected primary thymoma that was diagnosed postoperatively. The diagnostic algorithm in blunt chest injury is also discussed. The controversy about the classification and management options of primary thymic tumors is also presented.

Bildgebende Verfahren ermoglichen differentialdiagnostische Aussagen zur Art eines Lebertumors und die Beurteilung von Grose, Zahl und Lokalisation der Lasionen und entscheiden damit uber das Ob und Wie der Operation. Die Diagnostik hat daneben zum Ziel, onkologische Kontraindikationen gegen eine Leberresektion zu erkennen. Neue technische Moglichkeiten der Bildgebung umfassen Verbesserungen der Ultraschalldiagnostik, der Computertomographie sowie schnelle Untersuchungssequenzen bei der Magnetresonanztomographie. Besondere Untersuchungstechniken und der Einsatz von Ultraschall- und Magnetresonanz-Kontrastmitteln haben hohe Praxisrelevanz. An Hand eigener prospektiver Studien wird die Leistungsfahigkeit bildgebender Verfahren dargestellt. Die Wahl des diagnostischen Verfahrens, dessen Durchfuhrung und Bewertung setzen hohe Expertise voraus. Die diagnostische Genauigkeit der Verfahren ist allerdings manchmal aus technischen und tumorbiologischen Grunden limitiert.

PURPOSE: For calculating cost-effectiveness in the context of diagnosis related groups (DRG) we analysed all radiological examinations for 56 consecutive liver transplantations during the primary stay in the surgical department (1052 chest x-rays, 296 ultrasonographies, 216 colour coded duplex sonographies, 72 cholangiographies, 35 CT, 23 angiographies, one MRI and one embolisation). METHODS: For calculation we used the reimbursement that the surgical wards received per patient day and the special fee for liver transplantation. We compared this with the refunds received by the department of radiology. RESULTS: The hospital was reimbursed a total of 143785.80 DM per patient. The diagnostic and interventional procedures that were requested for the 56 patients amounted to a total of 225118.63 DM and 4019.96 DM per patient, respectively. CONCLUSIONS: This means that only 2.8% of all the costs during and after liver transplantation were caused by the radiological examinations. This represents only a small portion of the expenses during the time in hospital, taking into account especially that patients after liver transplantation are at high risk for developing complications.

To investigate predilection sites of recurrence of pancreatic cancer by computed tomography (CT) in follow-up after surgery.Seventy seven patients with recurrence after pancreatic cancer surgery were retrospectively identified. The operative technique, R-status, T-stage and development of tumor markers were evaluated. Two radiologists analyzed CT scans with consensus readings. Location of local recurrence, lymph node recurrence and organ metastases were noted. Surgery and progression of findings on follow-up CT were considered as reference standard.The mean follow-up interval was 3.9 ± 1.8 mo, with a mean relapse-free interval of 12.9 ± 10.4 mo. The predominant site of recurrence was local (65%), followed by lymph node (17%), liver metastasis (11%) and peritoneal carcinosis (7%). Local recurrence emerged at the superior mesenteric artery (n = 28), the hepatic artery (n = 8), in an area defined by the surrounding vessels: celiac trunk, portal vein, inferior vena cava (n = 22), and in a space limited by the mesenteric artery, portal vein and inferior vena cava (n = 17). Lymph node recurrence occurred in the mesenteric root and left lateral to the aorta. Recurrence was confirmed by surgery (n = 22) and follow-up CT (n = 55). Tumor markers [carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA)] increased in accordance with signs of recurrence in most cases (86% CA19-9; 79.2% CEA).Specific changes of local and lymph node recurrence can be found in the course of the cardinal peripancreatic vessels. The superior mesenteric artery is the leading structure for recurrence.

This study presents a case of bifrontal intracerebral haemorrhage in a patient with heparin-induced thrombocytopenia type II (HIT II). HIT II was induced by treatment with low-molecular-weight heparin for recurrent deep vein thrombosis caused by essential thrombocytosis and accompanied by hepatic thromboembolism. This patient was treated with platelet substitution and neurosurgical haematoma evacuation. Anticoagulation with 2500 units danaparoid per day was sufficient for therapy of thrombosis and no rebleeding occurred.

Background/Aims: To determine whether intravenous morphine comedication improves bile duct visualization, diameter and/or volume applying intravenous CT cholangiography in a porcine liver model. Methods: 12 Landrace pigs underwent intravenous CT cholangiography. Eight minutes after initiation of the contrast material infusion, either morphine sulfate (n = 6 animals) or normal saline (n = 6 animals) was administered. Eighteen consecutive CT scans of the liver were acquired with 2-min intervals starting with initiation of the contrast material infusion. Maximum bile duct visualization scores, diameters and volumes and time to maximum bile duct visualization scores, diameters and volumes were determined. Results: Maximum bile duct visualization scores, diameters and volumes and time to maximum bile duct visualization scores, diameters and volumes were not significantly different when the morphine group was compared to the normal saline group. Maximum bile duct visualization scores ranged between 4.00 ± 0.00 and 2.83 ± 1.47. Maximum bile duct diameters ranged between 6.77 ± 0.40 and 2.10 ± 1.35 mm. Maximum bile duct volume was 16.41 ± 7.33 ml in the morphine group and 16.79 ± 5.65 ml in the normal saline group. Conclusion: Intravenous morphine comedication failed to improve bile duct visualization and to increase bile duct diameter and volume applying CT cholangiography.

Background Disease progression of hepatocellular cancer (HCC) in patients eligible for liver transplantation (LTx) occurs in up to 50% of patients, resulting in withdrawal from the LTx waiting list. Transarterial chemoembolization (TACE) is used as bridging therapy with highly variable response rates. The oral multikinase inhibitor sorafenib significantly increases overall survival and time-to-progression in patients with advanced hepatocellular cancer. Design The HeiLivCa study is a double-blinded, controlled, prospective, randomized multi-centre phase III trial. Patients in study arm A will be treated with transarterial chemoembolization plus sorafenib 400 mg bid. Patients in study arm B will be treated with transarterial chemoembolization plus placebo. A total of 208 patients with histologically confirmed hepatocellular carcinoma or HCC diagnosed according to EASL criteria will be enrolled. An interim patients' analysis will be performed after 60 events. Evaluation of time-to-progression as primary endpoint (TTP) will be performed at 120 events. Secondary endpoints are number of patients reaching LTx, disease control rates, OS, progression free survival, quality of live, toxicity and safety. Discussion As TACE is the most widely used primary treatment of HCC before LTx and sorafenib is the only proven effective systemic treatment for advanced HCC there is a strong rational to combine both treatment modalities. This study is designed to reveal potential superiority of the combined TACE plus sorafenib treatment over TACE alone and explore a new neo-adjuvant treatment concept in HCC before LTx.

A prospective study to determine the value of multidetector CT (MD-CT) in assessing the course of nonresectable pancreatic carcinoma during therapy.26 patients with nonresectable pancreatic carcinoma underwent MD-CT before and after therapy. The examinations were evaluated with regard to tumor size and vascular invasion using an invasion score (IS) by 2 radiologists independently (kappa analysis). Diagnosis was confirmed surgically, by biopsy or clinical course.Sensitivity for the assessment of irresectability was 100%. Following therapy, 54% of all the tumors were smaller (14/26), 42% had increased in volume (11/26), and one tumor remained stable (1/26). The IS (veins) during follow-up changed in 26 patients (portal vein: 5 higher (mean score 10.4/16.2), 4 lower (mean score 17.5/11.5); superior mesenteric vein: 12 higher (11/14.4), 5 lower (16.2/14.6); p = 0.026). The IS (arteries) changed in 13 patients (celiac trunk: 3 higher (3.3/10); hepatic artery: 4 higher (5.7/10.2), 3 lower (11.6/10.3); superior mesenteric artery: 2 higher (4.5/9.5), 1 lower (12/11)). The kappa values were calculated between 0.56 and 0.87.MD-CT is suitable for evaluating tumor spread during therapy for nonresectable pancreatic carcinoma. The IS is useful for assessing the degree of change in vessel invasion.

The purpose of this phase III clinical trial was to compare two different extracellular contrast agents, 1.0 M gadobutrol and 0.5 M gadopentate dimeglumine, for magnetic resonance imaging (MRI) in patients with known or suspected focal renal lesions. Using a multicenter, single-blind, interindividual, randomized study design, both contrast agents were compared in a total of 471 patients regarding their diagnostic accuracy, sensitivity, and specificity to correctly classify focal lesions of the kidney. To test for noninferiority the diagnostic accuracy rates for both contrast agents were compared with CT results based on a blinded reading. The average diagnostic accuracy across the three blinded readers ('average reader') was 83.7% for gadobutrol and 87.3% for gadopentate dimeglumine. The increase in accuracy from precontrast to combined precontrast and postcontrast MRI was 8.0% for gadobutrol and 6.9% for gadopentate dimeglumine. Sensitivity of the average reader was 85.2% for gadobutrol and 88.7% for gadopentate dimeglumine. Specificity of the average reader was 82.1% for gadobutrol and 86.1% for gadopentate dimeglumine. In conclusion, this study documents evidence for the noninferiority of a single i.v. bolus injection of 1.0 M gadobutrol compared with 0.5 M gadopentate dimeglumine in the diagnostic assessment of renal lesions with CE-MRI.

Using a pig model: (1) to evaluate the vascular distribution pattern, including the homogeneity and completeness of the intra-arterial microsphere distribution, of 40-120-microm trisacryl-gelatin microspheres (Embospheres) in acute whole-kidney embolization; (2) to evaluate the durability and biocompatibility of 40-120-microm trisacryl-gelatin microspheres (Embospheres) in chronic partial kidney embolization.Twenty-two animals were divided into four groups: group 1 (n = 4) underwent total arterial renal occlusion with immediate euthanasia. Groups 2-4 had chronic superselective and partial renal embolization with increasing follow-up times: group 2 (n = 2), 1 week; group 3 (n = 7), 4 weeks; and group 4 (n = 9), 14 weeks. Key endpoints in group 1 were homogeneity and completeness of acute embolizations. In groups 2-4 the key endpoints were durability of embolization and particle-related inflammation in chronic partial embolizations as assessed by quantitative angiography or histomorphometry. A numerical angiographic occlusion score (0.0 to 4.0, where 3.0 is optimal) was developed to assess and quantify the angiographic durability of superselective embolizations (groups 2-4).In group 1, a relatively homogeneous distribution of the particles from segmental arteries to the precapillary level was shown by histomorphometry. Some particles reached the glomerular vas afferens (10 microm diameter). In groups 2-4, a mild recanalization appeared during follow-up. The immediate average postembolization occlusion score of 3.18 +/- 0.73 was reduced to 1.44 +/- 0.73 (statistically significant). Microscopy revealed subtotal necrosis but no foreign body granuloma formation. The intra-arterial appearance of giant cells closely attaching to the surface of the embolic spheres inside the vessel lumen was noted. Vessel walls showed major ischemic reactions.Microspheres 40-120 microm in diameter might achieve total occlusion of the arterial kidney vasculature when injected centrally as a result of their fairly homogeneous distribution. Segmental renal infarction occurs after chronic partial embolization despite recanalizations during follow-up. Only mild specific intra-arterial foreign body reactions were found.

Renal transplantation is accepted as the preferred treatment for most cases of end-stage renal disease. Postoperative vascular complications include stenosis or thrombosis of the transplant renal artery or arteriovenous fistulas after biopsy. Impaired arterial perfusion of the transplant may be the leading cause for graft dysfunction or refractory hypertension. Therefore, non-invasive imaging modalities are required to detect and locate vascular complications with high accuracy. Doppler ultrasound is suited as a screening method for the detection of impaired graft perfusion. Magnetic resonance imaging (MRI) is used for an accurate diagnosis of vascular complications and to support decision for appropriate surgical or interventional treatment. Minimal invasive techniques like percutaneous transluminal angioplasty and stent placement have evolved as safe procedures with a high technical success rate reducing substantial morbidity. They can be considered as an alternative to surgical treatment of transplant renal artery stenosis (TRAS). Embolization of severe arteriovenous fistulas is the method of choice if the feeding artery can be occluded through a microcatheter. In selected cases, even catheter-guided fibrinolytic treatment of arterial thrombosis might be considered, if instantaneous surgery is considered a high-risk procedure. This article reviews the imaging features of common vascular complications after renal transplantation with focus on MRI. In addition, interventional radiological techniques are described for the treatment of TRAS, acute thrombotic occlusion, and arteriovenous fistulas.

Acute pancreatitis (AP) is a rare complication after liver embolization (LE) of primary and secondary liver tumors (approximately 1.7%), but it has a significant morbidity and mortality potential if associated with other complications. It usually develops early within 24 h after the LE procedure.To calculate the frequency of AP after LE in our institution and to analyze the factors involved in this procedure (anatomical features, embolization materials, cytostatic drugs, technical factors).118 LE (bland embolization and transarterial chemoembolization) were performed in our institution. The study group included 59 patients who met the following inclusion criteria: one or more LE events, with complete pre- and post-interventional laboratory studies including: serum Ca(2+), creatinine, blood urea nitrogen, glucose, lactate dehydrogenase, aminotransferases, alkaline phosphatase, amylase, lipase, C-reactive protein, hematocrit and leukocytes. The diagnosis of AP was established according to the criteria of the Atlanta system of classification. For the statistical analysis the association between two response variables (e.g. AP after embolization and risk factor during the embolization, AP after embolization and volume of embolic material) was evaluated using Pearson's chi(2) test and Fisher's exact test.The calculated frequency of AP after LE in our series was 15.2%. Amylase and lipase were elevated up to 8.7 and 20.1 times, respectively, 24 h after LE. We observed a statistically significantly lower incidence of AP in those patients who received 2 ml or less of embospheres compared with those with an embolization volume of2 ml (Pearson's chi(2) = 4.5000, Pr = 0.034, Fisher's exact test = 0.040). Although carboplatin was administered to 7 of 9 of the patients who developed AP after the embolization procedure, there was no statistical significance (Fisher's exact test = 0.197) for carboplatin as an AP risk factor when compared with all the patients who received this drug (n = 107).Although AP after LE seems to have a multifactorial etiology, both the toxicity of the antineoplastic drugs (carboplatin-related toxicity) as well as direct ischemic mechanisms (non-target embolization, reflux mechanisms) may be the most important causes of the inflammatory pancreatic reaction after LE. We suggest that systematic measurement of serum pancreatic enzymes should be performed in cases of abdominal pain following selective LE and transarterial chemoembolization in order to confirm acute pancreatitis after embolization, which can clinically mimic a postembolization syndrome.

Einleitung Dialysepatienten sind haufig von einer schweren extremitatenbedrohenden arteriellen Verschlusskrankheit (pAVK) betroffen. Die gefasrekonstruktive Behandlung dieser zumeist schwerkranken Patienten mit reduzierter Lebenserwartung stellt eine konzeptionelle und technische Herausforderung dar. Zur Einschatzung der gefaschirurgischen Vorgehensweise und aufgrund einer begrenzten Datenlage wurde das eigene Patientengut analysiert. Wir berichten uber die Prognose, den Gliedmasenerhalt, die Morbiditat und Letalitat in dieser selektiven Hochrisikogruppe.

TIPSS (transjugular intrahepatic portosystemic shunt) may be indicated to control bleeding from esophageal and gastric varicose veins, to reduce ascites, and to treat patients with Budd-Chiari syndrome and veno-occlusive disease. Numerous measures to improve the safety and methodology of the procedure have helped to increase the technical and clinical success. Follow-up of TIPSS patients has revealed shunt stenosis to occur more often in patients with preserved liver function (Child A, Child B). In addition, the extent of Liver cirrhosis is the main factor that determines prognosis in the long term. Little is known about the effects of TIPSS with respect to portosystemic hemodynamics. This report deals with a cirrhotic patient who stopped drinking 7 months prior to admission. He received TIPSS to control ascites and recurrent esophageal bleeding. Two years later remarkable hypertrophy of the left liver lobe and shunt occlusion was observed. The portosysterific pressure gradient dropped from 24 mmHg before TIPSS to 11 mmHg and remained stable after shunt occlusion. The Child's B cirrhosis prior to TIPSS turned into Child's A cirrhosis and remained stable during the follow-up period of 32 months. This indicates that liver function of TIPSS patients may recover due to hypertrophy of the remaining non-cirrhotic liver tissue. In addition the hepatic hemodynamics may return to normal. In conclusion, TIPSS cannot cure cirrhosis but its progress may be halted if the cause can be removed. This may result in a normal portosystemic gradient, leading consequently to shunt occlusion.

Department of Vascular and Endovascular Surgery, University of Heidelberg - Heidelberg--> - GERMANY (Kotelis, Drosos)

Metastases are the most common malignant tumors of the skeleton. Several imaging modalities can be engaged for the diagnosis of skeletal metastases. They may be combined, depending on the individual clinical setting. Plain films are used for evaluation of symptomatic regions of the skeleton. Sensitivity is low, but benign skeletal disorders causing clinical symptoms can usually be identified in plain films. Bone scintigraphy is employed for a survey of the entire skeleton with high sensitivity for the presence of metastases, but only poor specificity. Computed tomography (CT) and magnetic resonance imaging (MRI) are advanced diagnostic methods, essential particularly in the diagnosis of metastatic spinal disease. Using CT, additional percutaneous bone biopsies can be performed easily and safely. Of all imaging modalities, MRI has the highest sensitivity for skeletal metastases. Other advantages are the possibility of multidirectional slice positioning and excellent soft tissue contrast.

The study is a prospective evaluation of preoperative TNM staging of gastrointestinal tumors by hydrosonography (HUS).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.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.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.

From 1984 to 1991 20 multiple trauma patients with pelvic fractures and retroperitoneal bleeding from pelvic vessels underwent angiographic localization and embolization of massively bleeding arterial vessels. Nine patients survived (multiple trauma index grade III, Hanover polytrauma index), three patients with very severe injuries died immediately (multiple trauma index grade IV). After successful control of bleeding by embolization, three other patients died from severe brain injuries and five patients from septic multiorgan failure. The interval to definite localization and treatment of the bleeding source was three times shorter in the group of survivors, and the amount of transfusions needed was less by a factor of three. This underlines the importance of early angiography in multiple trauma patients with pelvic fractures and persisting hemorrhage. Embolization has proven to be effective in the treatment of such injuries.

The introduction of transjugular intrahepatic portal- systemic stent-shunt (TIPSS) has been a major breakthrough in the treatment of portal hypertension, which has evolved to a large extent, into a routine procedure. A 21-year-old male patient with progressive graft fibrosis/cirrhosis requiring TIPSS for variceal hemorrhage in the esophagus due to portal hypertension was unresponsive to conventional measures two years after living related liver transplantation (LDLT). Subsequently, variceal hemorrhage was controlled, however, liver function decreased dramatically with consecutive multi organ failure. CT scan revealed substantial necrosis in the liver. The patient underwent successful "high urgent" cadaveric liver transplantation and was discharged on postoperative d 20 in a stable condition.

Therapeutic interventions in the skeletal system are an essential part of interventional radiology. Although in terms of figures these procedures are applied less frequently, they are very effective. Percutaneous transarterial embolization of a spinal tumor is well-established interventional treatment. It is primary treatment for preoperative devascularization, but also for palliation of pain and for reduction of tumor volume. As an alternative access for embolization, direct percutaneous puncture of a vertebra is used. A new and promising technique is vertebroplasty, the percutaneous injection of acrylic surgical cement in destroyed vertebrae. The present paper discusses indications, technique, results and complications of these interventional therapeutic modalities in the treatment of primary and secondary spinal tumors.