Palliativtherapie der malignen Ösophagusobstruktion mit selbstexpandierenden Metallendoprothesen

A total of 23 self-expanding metal stents were implanted in 17 patients (12 men, 5 women; mean age 66 [44-83] years) with inoperable malignant obstruction of the oesophagus or the oesophago-gastric junction. A primary success was achieved in all, a good functional result in 16 (94%). There were no complications. In the follow-up period (mean of 15.2 +/- 13 weeks) re-obstruction by the tumour process occurred in three patients. Twelve patients died after a mean survival time of 15.8 +/- 14 weeks. In ten of these the stent was still patent at death, while two had again developed dysphagia. The cumulative patency rate of the stents was 79%. These observations indicate that self-expanding metal stents can achieve satisfactory palliation in dysphagia due to a malignancy. The mortality and morbidity rates of the method seem to be less than those of other palliative measures.

[Conventional local intra-arterial fibrinolysis, spray lysis and mechanically accelerated fibrinolysis. An assessment of their position in the spectrum of angioplasty technics]

Intra-arterial local fibrinolysis was performed in 72 patients (51 men, 21 women, mean age 66.8 years) during the course of 78 angioplasties. 11.1% were stage IIa (Fontaine), 38.9% were stage II b, 27.8% were stage III and 22.2% were stage IV. The methods used were conventional fibrinolysis (15.4%), spray lysis (47.4%) and mechanically accelerated fibrinolysis (37.2%). In 66.7% the urokinase dose was < 600,000 I.U., in 17.9% it was > 1,000,000 I.U. Additional balloon dilatation was performed in 72 cases, percutaneous aspiration of thrombo-embolic material in 41 cases and stent implantation in 7 cases. Angiographically the procedure was successful in 90.7%; the Doppler index rose from 0.47 +/- 0.27 to 0.85 +/- 0.3 (p < 0.001). At discharge, staging was: I = 38.9%, IIa = 38.9%, IIb = 5.6%, III = 1.4%, IV = 15.3%. There were no systemic bleeding complications. In 5.1%, complications had to be treated surgically.

[A prospective study to determine the recanalization time with a guide wire/recanalization catheter system in arterial occlusions]

The success rate and time taken for recanalization was determined in a prospective study of 82 consecutive unselected patients (53 men, 29 women; mean age 65.7 +/- 13, from 28 to 88 years). There were 106 complete occlusions of infrarenal arteries and a hydrophilic guide wire with a special 5-F recanalization catheter was used. Mean occlusion length was 12.97 +/- 10 cm (from 1 cm-45 cm). 79.3% of occlusions were in the femoro-popliteal territory, 6.6% were iliac and 14.1% tibial. 101 of the 106 occlusions were recanalized (95.3%). Mean recanalization time was 120.8 +/- 228.1 s (from 1 s-1440 s), mean recanalization velocity was 0.11 cm/s. The majority of obstructions could be recanalized in less than one minute. The five occlusions which could not be recanalized were distal lesions in the superficial femoral artery and which were longer than 10 cm; two were calcified. There were no complications resulting from the recanalization apart from three perforations which were clinically not apparent. Consequent angioplasty proved successful in 78.1% of these patients.

Self-expanding metal stents for palliation of malignant esophageal obstruction--a pilot study of eight patients

We sought to determine whether the application of a self-expanding metal stent enables palliation of malignant dysphagia with minimal risk. The results of pilot studies from two centers are reported. We treated 8 inoperable patients with a 14 mm self-expanding metal stent (Wallstent). The stent was applied without general anesthesia under mild i.v. sedation. The procedure was successful in all cases. No side effects were noted. In one patient, tumor ingrowth through the meshes of the stent occurred. This patient was additionally treated with a percutaneous gastrostomy. One patient experienced tumor overgrowth of the proximal end, necessitating laser treatment. Three patients were still alive after three months. The mean number of cumulative endoscopic interventions per patient was 2.2 (SD: +/- 2; median 2). The mean observation time was 10.7 weeks +/- 2 (median 12). Dysphagia was graded from 0 (normal swallowing) to 4 (inability to swallow saliva). Dysphagia was significantly (p less than 0.0005) reduced from grade 3.1 (SD: +/- 0.35) to 0.5 (SD: +/- 0.5) immediately after stenting. 62.5% of the patients were able to manage a virtually normal diet (in one of these patients dysphagia recurred six weeks after stent placement due to tumor ingrowth). Six patients (75%) were able to ingest all necessary calories orally. The application of a 14 mm self-expanding metal stent in cases of inoperable malignant esophageal obstruction seems to offer safe and effective palliation of malignant dysphagia.

Technical failure of biliary metal stent deployment in a series of 116 applications

Biliary metal stents are thought to offer improved long-term palliation of malignant biliary obstruction due to a lower incidence of migration and clogging. Placement of these stents is technically more complicated than that of plastic endoprostheses and requires two experienced physicians. We report the incidence and reasons for apparent malfunction of expandable metal stent deployment (Wallstents and Strecker stents). In 116 applications of 82 Wallstents (endoscopic approach: n = 33, transhepatic approach: n = 49), we observed 19 cases of stent malfunction due to technical problems of stent delivery. In 13 cases (15.8%), the restraining membrane of the Wallstent could not be retracted sufficiently to deliver the stent. There were 6 (17.6%) failures in 34 cases of Strecker stent deployment. In 3 cases, we noted difficult balloon removal, including avulsion of the balloon catheter shaft within the endoscope during attempted balloon removal in one case. In one case, the Strecker stent could only be released partially, requiring subsequent endoscopic extraction. In two patients, only partial expansion of one end of the Strecker stent could be achieved. Given the significant malfunction rate of expandable metal stents during stent delivery, further improvements in the delivery system of the metal stents are required.

[Metal or plastic endoprostheses in malignant obstructive jaundice. A randomized and prospective comparison]

In a prospective randomized trial 58 patients (24 men, 34 women, mean age 67 +/- 13 [42-89] years) with inoperable malignant jaundice were treated with synthetic (S; n = 29) or expanding metal endoprostheses (M; n = 29). After endoscopic retrograde cholangiopancreatography patients were divided into a group with hilar (K: n = 7; M: n = 6) or distal involvement (K: n = 22, M: n = 23). In two cases with hilar involvement (28%) a synthetic endoprosthesis could not be implanted, while early prosthesis occlusion (after 2 days) was observed in one case. But in this group it was possible to implant all metal stents. In the group with distal involvement both synthetic and metal endoprostheses were successfully implanted. In the M group the proportion of patients with prosthesis failure (13.6%) was significantly higher than in the S subgroup (40.9%). The cholangitis incidence was 9% in the M group, significantly less (P less than 0.05) than in the K group (40.9%). Duration of hospital stay to treat prosthesis-related complications was significantly less in the M group (average 2.9 days) than the K group (12.9 days). It would be a great advance in palliative tumour treatment if it were possible significantly to reduce, by means of metal stents, the incidence of late cholangitis and the duration of hospital stay necessary to treat late complications. But improvement in the technique of implanting metal stents would be essential before their general use in distal lesions can be recommended.

[Arterial embolization of an arteriovenous fistula with hemobilia after blind liver puncture]

Five days after percutaneous liver biopsy we observed in a 42-year-old man with alcoholic liver cirrhosis severe hemobilia requiring transfusions of packed red cells. By means of super-selective arterial embolization, using gelfoam, the bleeding source, an av-fistula, was successfully occluded. Iatrogenic hemobilia, although seen after percutaneous liver biopsy only in app. 0.005% of the cases, is today the most important cause of biliary bleeding, mainly as a complication (app. 3% of the cases) of the widespread use of interventional procedures of the biliary tree (e.g. PTCD). Therapeutically arterial embolization should be considered first if possible.

Road map application to the pulseless common femoral artery

There are several approaches to the catheterization of the pulseless common femoral artery. The road map technique is another approach that lends aid in juncturing the pulseless common femoral artery.

[Percutaneous aspiration thromboembolectomy: an additional transluminal angioplasty method]

Percutaneous aspiration-thromboembolectomy is a simple method for removal of thrombo-embolic material of diverse origin. It is highly effective with small material outlay. As a third angioplasty method it has considerably improved the success rates of balloon dilatation and local lysis treatment with urokinase or streptokinase. The procedure was used alone or in combination on 71 occasions involving 69 limbs in 66 patients. An angiographically demonstrable success was seen in 96% and clinical improvement in 91.6%. Local lysis treatment with streptokinase or urokinase was shortened, less hazardous and, because of removal of non-lysable material, more successful. Embolectomy with the Fogarty catheter remains the method of choice for treating emboli arising from the heart in vessels of the aorto-iliac system. For smaller vessels below the inguinal ligament, however, we consider the new, lesser invasive method to be an alternative to vessel surgery.

[Contrast medium concentration for intra-arterial digital subtraction angiography of vessels in the extremities]

The influence of iodine concentrations and different volumes of a conventional ionic contrast media and a contrast media with low osmolarity on the quality of the results of intra-arterial digital subtraction angiography of the lower extremities in patients who underwent percutaneous transluminal angioplasty (n = 52) are reported. According to our results, intra-arterial injections of a conventional ionic contrast medium diluted with 0.9% sodium chloride solution, resulting in an iodine concentration of 190 mg/ml injectable solution, reveals the best results when injected in an amount of 6 ml per injection. The use of low-osmolarity contrast-medium showed no advantages, the quality of the resulting pictures was inferior to that revealed with the ionic compound. Probably this is because the iodine concentration in the diluted low-osmolarity compound was less.

DSA evaluation of indwelling central venous catheters

Indwelling central venous catheters are widely used for the management of many disorders but have a high incidence of dislodgement, thrombosis, or occlusion. Contrast studies of these complications are hampered by difficulty injecting contrast through the catheters or peripheral veins. Use of digital subtraction angiography allows adequate visualization with small amounts of contrast and greatly facilitates the study of these catheters and the surrounding venous system.

[Conservative treatment of esophageal stenoses with balloon catheters]

A total of 92 dilatations using the balloon-catheter were carried out in 46 patients with oesophageal strictures. Of these 73 were in 36 patients having a benign primary disease, predominantly stenoses following anastomotic operations or with stenoses resulting from reflux oesophagitis. The average relapse-free period after balloon-catheter dilatation was 6.3 times greater than with bougienage. Balloon-catheter dilatation has proved to be a simple and safe procedure that can be applied inexpensively in an outpatient department. It has now become the method of choice in our hospital for the non-operative treatment of strictures of the oesophagus.

[Digital subtraction angiography in the diagnosis of kidney carcinomas]

We report on the results of a comparison of intravenous and intraarterial digital subtraction angiography (iv and ia-DSA) with conventional angiography in patients with known renal masses. Whereas more than 80% of the tumours were diagnosed via IV-DSA, none of the benign renal cysts were identified. The overall detection rate, therefore, is 65% in all patients (n = 21) of the study group. The value of ia-DSA as a time sparing procedure, saving film-cost and contrastmedia, is discussed. The diagnostic accuracy of selective renal angiograms in digital and conventional technique yields equal results in our comparative study.

Esophageal stenosis: treatment with balloon catheters

We have performed 84 balloon dilatations in 40 patients who had esophageal strictures. Of these patients, 31 who had benign diseases improved, and the procedure proved to be safe, reliable, and easy to perform; in 77% of these patients, only one or two dilatations were necessary. In 10 patients who had previously undergone treatment with bougienage, the symptom-free interval of 9.3 months following balloon dilatation is four times longer than that experienced following bougienage. In patients who have malignant disease, though the symptom-free intervals are short, the procedure can be repeated easily and is accepted well by patients so that palliation can be achieved. Since only readily controlled transverse forces act in the balloon therapy, rupture is virtually eliminated, while the use of a flexible angiographic guidewire to traverse the strictures practically excludes perforation. Balloon dilatation offers distinct advantages compared with bougienage for the treatment of esophageal strictures.

Dilation of esophageal stenosis by balloon catheter

Treatment of esophageal stenosis by large diameter balloon catheters offers significant advantages over bouginage. Catheter dilating force is confined to the affected segment and can be controlled by the patient's reaction. Perforation is practically excluded by the use of fluoroscopy, contrast media, flexible angiographic guidewires, and better control over the time and forces of dilation. Wider, more lasting dilation can be achieved. Forty-one dilations were done on 21 patients with this new procedure without complications and with improved relapse-free intervals.

[Initial results of digital subtraction angiography in the diagnosis of injuries]

Conventional angiography has an established value in the diagnostic evaluation of the injured patient, but its use as an invasive and time-consuming method is limited. Digital subtraction angiography (dsa) as a method of intravenous arteriography opens a new diagnostic approach. Among 800 patients examined by means of the dsa in 9 months we had 16 injured patients. The special value of this noninvasive and time-saving method has been shown in the diagnosis of suspected lacerations of the thoracic aorta.

[Digital subtraction angiography in percutaneous transluminal angioplasty of vessels of the extremities and renal vessels]

The new imaging method digital subtraction angiography (DSA) permits intravenous arteriography. 1259 patients were thus investigated over one year. The lower extremities comprised 21,4% of assessment areas. 120 investigations in 95 patients were based on an indication of percutaneous transluminal angioplasty (PTA). DSA can be used before and after the PTA. The small extent of invasiveness and the shortening of in-patient admission are particular advantages preoperatively. These advantages, in addition to the possibility of out-patient evaluation, are also true for DSA in comparison to the conventional arteriography. Thus the combination of both methods has been found to be very suitable.

[Indication and efficiency of computer tomography in general and abdominal surgery]

The efficacy of computed tomography in abdominal surgery must be compared with that of ultrasonography, which is more easily available, less expensive, and entails no radioactive risk. Both methods show high rates of sensitivity, specificity, and accuracy in the detection of parenchymatous lesions, tumors, local complications, tumor recurrences or metastases. Both can be combined with fine-needle biopsy. We think ultrasound scanning is more useful as a primary screening procedure and for follow-up studies, while CT gives a more detailed preoperative diagnosis, including tumor staging.

[Washed erythrocyte concentrate, degree of purity and cell vitality]

The reduction of leukocytes of packed red cells amounted to 70 +/- 8% (n = 29) by single removing of buffy coat and to 86 +/- 9% (n = 12) by additional washing in isotonic NaCl-solution with a loss of 23% of red cells. The ratio of granulocytes to lymphocytes increased The ratio of granulocytes to lymphocytes increased slightly by washing. Storage of washed red cells damaged their function in dependence on temperature and storage medium more than the washing procedure. The ATP content of washed red cells maintained at the normal level during 24 hr at 277 K (4 degrees C), but the 2.3-P2G level decreased to 1/3 of the normal value. The survival rate of washed red cells amounted to 86 +/- 7% (n = 7). The preparation of red cells poor in leukocytes in recommended by removing buffy coat and the upper 50 ml of red cells after single centrifugation of blood and adding 100 ml CDS-AG (citrate-glucose-sucrose-adenine-guanosine) preservation solution of packed red cells. A storage of 6 weeks is possible. Thus washing the red cells in isotonic NaCl-solution for the purpose of leukocyte reduction can be omitted.