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Among radiological diagnostical procedures, the conventional chest X-ray has retained its significance as a screening investigation up to the present. Digital imaging does not reveal any advantages. Due to its higher resolution the CT scan, particularly the spiral CT scan, has markedly increased radiological possibilities, thus influencing surgical oncology significantly. Tumor invasion of the mediastinum, heart, and thoracic wall has become detectable, as well as enlarged lymph nodes and metastases. CT angiography permits a better assessment of large vessels by aortic rupture or dissection and pulmonary embolism, to name a few. MRI is inferior to CT scan in this respect, displaying a slight advantage in terms of detecting tumor infiltration of the nerval plexus, i.e. pancoast syndrome.

In a retrospective study, we analyzed prognostic factors in 143 patients with locally recurrent colonic cancer (excluding rectal cancer). We saw no influence of primary tumor state on long-term survival. In patients with curative resection the 5(3)-year probability of survival was significantly better than in patients with local palliative resection [45% (50%) vs. 5% (0%)]. In addition, we found striking differences in perioperative mortality which varied with therapeutic intention (37% for local palliative operations without resection, 16% in cases with palliative surgery with resection). No patient died after curative tumor resection.

Extracorporeal membrane oxygenation is a suitable technique for short-term treatment of resistant respiratory failure with a comparably low mortality rate of 32%. However, pulmonary complications are quite often encountered during ECMO therapy making thoracic interventions necessary. The most frequent of these complications is hemorrhage followed by lung fistula, which remain resistant to conventional therapy. The indication for operative lung resection during ECMO treatment must remain restricted to selected cases, since these procedures have a high morbidity.

In spite of increasing knowledge about the role of the sympathetic nervous system in autonomic disturbances like reflex sympathetic dystrophy, no functional test for the peripheral sympathetic system has been introduced into the clinical routine so far. In the development of a standardized bedside test, effects of arousal stimuli [inspiratory gasp (IG) and contralateral cooling (CC)] on blood flow in the fingertips (FTBF) were studied, using laser Doppler flowmetry (LDF). Fifty-two healthy subjects (ages 17 to 75) and 15 patients with sympathetic reflex dystrophy (SRD) underwent the diagnostic procedure. FTBF of healthy subjects during arousal maneuvers showed a reproducible decrease, which is related to a sympathetic vasoconstrictor response. The standardized test procedure with external body heating made interindividual test results comparable. Examination trials with 4 healthy subjects on 10 subsequent days showed good reproducibility. Mathematical analysis of the LDF curves was performed to calculate the degree of FTBF decrease (SRF = (Fmean - Fmin)/Fmean, QI = integral pre/integral post). In contrast to absolute flow values like Fmean and Fmin or time-related parameters like tdecrease and tregeneration, SRF and QI values presented small coefficients of variation (IG test, SRF 25.7, QI 21.7; CC test, SRF 20.0, QI 15.3). The typical decrease of the LDF signal after sympathetic stimulation was absent or diminished in patients with SRD. SRF and QI values showed statistically highly significant differences (P < 0.001) compared to healthy subjects. The presented test appears reliable for the assessment of peripheral sympathetic nervous function. The narrow physiological range of SRF and QI values enabled the differentiation of pathological sympathetic reactions. The test procedure is easy to perform, noninvasive, and practical even in patients with injuries of the upper limbs.

In a retrospective analysis, 140 patients with locoregional recurrence of rectal carcinoma were investigated in respect of prognostic factors. Neither classification of the primary tumor nor adjuvant therapies showed any significant influence on long-term survival, calculated according to the Cutler-Ederer method. The 3-(5-) year probability of survival of 52 (18) % is significantly better in cases with local curative operations than the 3 (0) % in cases with local palliative operations. Therefore, early indication for a possible radical resection of the recurrent tumor is essential. In 37.1%, local curative operations could be performed. The probability of long-term survival is significantly influenced by the kind of recurrence. Patients with local recurrence (anastomosis) after primary resection have the best prognosis with a 84 (33) % 3-(5-) year probability of survival. Independent of the kind of primary operation, the survival data on the remainder of patients after local curative operation for recurrent tumors are comparable. They are, however, still better than for non-curative operations. The striking differences in perioperative mortality (3 months) with regards to therapeutic intention (25% for local palliative operations without resection, 7.1% in cases of palliative surgery with resection and 1.9% in cases with local curative operations) must result in criteria for resectability being determined preoperatively on the basis of intensive diagnostic measures. Thus, the rate of palliative operations without benefit for the patient may be minimized.

Sarcoidosis is a rare indication for lung transplantation. In this article, our experiences with recurring sarcoidosis following lung transplantation are described. Literature concerning recurrence of the disease in kidney, liver, heart and lung transmission of sarcoidosis via transplanted organs are discussed.

We report four patients with primary vascular leiomyosarcoma of the inferior vena cava. Even after radical surgery the prognosis is serious because of local tumor recurrence and distant metastases. Although controlled studies are difficult because of the small number of patients, a multimodal therapeutic approach needs to be developed.

Measurements of blood flow velocity in the basal cerebral arteries during functional testing by means of transcranial Doppler sonography are reviewed. Special emphasis is placed on cerebrovascular reserve capacity, which we determined in two groups of patients with obstructive cerebrovascular disease and in normal persons. We discuss the value of functional testing during endovascular neuroradiological procedures.

Purpose: To assess the ability of color-flow Doppler sonography (CFDS) to detect plaque ulcerations in patients who had high-grade to thread-like carotid artery stenosis and who underwent carotid endarterectomy., Methods: CFDS is a noninvasive diagnostic technique that allows, in addition to spatial visualization of blood flow, the identification of abnormal blood flow patterns such as vortex formation. There is evidence that pathologic anatomic changes in the vascular wall (such as ulcerations) may result in characteristic hemodynamic alterations. Therefore, solely hemodynamic criteria (detection of vortices) were used to diagnose ulceration. The results of preoperative examinations were compared to the intraoperative findings in 89 patients in a prospective and blinded way., Results: CFDS proved highly sensitive (95.3%), specific (93.5%), and accurate (94.0%) for demonstrating ulcerative plaques., Conclusion: CFDS may be of significant advantage for examining plaque morphology in patients who have high-grade internal carotid artery stenosis, and in whom accurate, noninvasive diagnosis of plaque ulceration was previously difficult, if not impossible.

1. Transcranial flow velocity waves were measured via Doppler sonography of the middle cerebral artery during hypo-, hyper- and normo-capnia. Applying the principle of vascular impedance, flow velocity waves were analysed in 30 young subjects, 37 elderly subjects and 18 patients with high-grade unilateral internal carotid artery disease. 2. There was evidence that the relative peak-to-peak velocity in the middle cerebral artery could serve as an index of peripheral wave reflection and cerebral resistance (CRi). The response of CRi to changes in arterial CO2 concentration (CRi reactivity) showed a clear age-dependency. However, the absolute side-to-side asymmetry of CRi reactivity (delta R) did not vary with age and could be used to define a normal range (0-4%CRi/vol.%CO2). 3. Selective angiography demonstrated no cerebral cross-flow through the anterior part of the circle of Willis in nine patients with carotid artery stenosis whose absolute delta R was above the normal range and whose CRi reactivity of the affected hemisphere was lower than that of the healthy opposite hemisphere. Conversely, another group of nine patients, whose ipsilateral CRi reactivity was higher than the contralateral CRi reactivity, demonstrated cross-flow through the anterior part of the circle of Willis. 4. delta R may be used to identify patients who have high-grade internal carotid artery stenosis and present with low cerebral vascular resistance owing to poor intracerebral collaterals.

Crohn's disease of late onset (greater than 65 years) is rare condition. Typical features are the localisation in the distal gastrointestinal tract and the presence of associated diseases such as cardiovascular disorders and/or diverticulitis. In about 25% of the cases mild intestinal hemorrhage occurs. Delay in diagnosis is sometimes due to coexistent diverticulitis. Ischemia has been suggested to be responsible for the development of the histological changes which occur in Crohn's colitis. Therefore, we carried out a retrospective analysis of our patients treated between 1978-1988 to reevaluate the resected specimens. 10 patients (6.2% of all surgical patients with Crohn's disease) were at least 65 years old at the time of primary operation. In 5 cases hematochezia was one of the symptoms before operation, two patients presented with massive hemorrhage of the lower GI-tract. Granulomas were seen only in 5 patients, whereas in all specimens transmural inflammation was detected. In 8 out of 10 patients vascular lesions were seen, among those thickening of the intimal and medial layers, thrombosis or bleeding. Our findings support the thesis that ischemia might play a role in the pathogenesis of Crohn's disease of late onset.

Vascular reactivity to changes in arterial CO2 content can be measured by analysis of Doppler curves in the middle cerebral artery (MCA). Vascular reactivity indicates the capability of the cerebrum of controlling peripheral resistance. In patients with threatening cerebrovascular disease (CVD) vascular autoregulation may be reduced. The circle of Willis plays a central role in the pathophysiology of unilateral high-grade ICA-stenosis. Previous classification of the degree of stenosis or of the clinical stage does not allow to describe the actual pathophysiology or prognosis of CVD sufficiently.

Reconstructive surgery was performed on 93 patients with stage III cerebrovascular insufficiency, extracranial stenoses and (or) occlusions of the cerebral blood flow. Compared with the spontaneous course in acute stroke, results of surgery point towards recommending an aggressive procedure provided certain criteria are observed (time limit, absence of haemorrhagia), particularly in view of the potential mortality of the condition. Late prognosis, assessed on the basis of 40 patients subjected to neurological follow-up 4 1/2 years after the operation, can be considered favourable.

The use of cw-Doppler sonography and digital subtraction angiography (DSA) for diagnosis of cerebro-vascular insufficiency (CVI) was evaluated in a retrospective study. 113 findings obtained by DSA and 315 findings obtained by cw-Doppler sonography were compared to the corresponding intraoperative finding. Furthermore, we examined the incidence of accompanying intracranial stenoses of the carotid artery. The impact of these stenoses on the CVI stage was analyzed by means of 200 transcranial Doppler sonographic studies. Cw-Doppler sonography (sensitivity: 95%) was clearly superior to DSA (sensitivity: 70%) for diagnosis of high grade and subtotal stenoses of the internal carotid artery (ICA). Sensitivity of both methods was insufficient for diagnosis of low grade stenoses (cw-Doppler: 50%, DSA 25%). Analysis of 200 transcranial Doppler sonographic studies did not reveal pathologic changes of intracranial vessels in 67% of all cases. This finding did not depend on the condition of the extracranial vessels and did also not depend on the CVI stage. Additionally, there was no correlation between the incidence and degree of intracranial stenoses and the CVI stage or the degree of stenosis of the ICA. These results support the view that Doppler sonography is the method of choice for diagnosis of high grade stenoses of the carotid artery. The use of DSA is limited to cases in which kinking or occlusion is suspected. Additional intracranial changes did not correlate with the CVI stage.

Reported in this paper are 201 patients who had been treated for carcinoma of the cervix with recurrence and metastasation, between 1960 and 1970. -- Three quarters of all cases had been irradiated before. Standardised methods of metaphylaxis are described together with their relevance to early detection of recurrence. Reference is made also to the present approach taken to carcinoma of the cervix with recurrence and metastasation following exclusive surgical treatment or surgery plus irradiation or exclusive irradiation. Various radiotherapies, surgical techniques, and methods of treatment, using cytostatics, are expounded.

The neurovascular compression syndromes of the thoracic outlet are mainly characterised by pressure lesion of the brachial plexus and secondly in addition by vascular damages. An indication for surgery exists in cases of persistent or progressive complaints, loss of function of shoulder, arm or hand musculature as well as occurrence of vascular damage. The treatment of choice consists of transaxillary resection of the first rib. Irreversible vascular damage requires additional vascular surgery. Within 5 years 31 operations were performed in 27 patients with a thoracic outlet syndrome. Eleven patients became completely free of symptoms, nine showed clear-cut improvement. Four patients reported lack of improvement. Deterioration was seen in three patients. Preoperative atrophy of small hand muscles is associated with lack of complete functional restitution of nerves and muscles. Predominance of vascular symptoms permits complete restitution to be expected. Results in cases with predominantly neurological symptoms are unsatisfactory.