[Consensus recommendations of the German Radiology Society (DRG), the German Cardiac Society (DGK) and the German Society for Pediatric Cardiology (DGPK) on the use of cardiac imaging with computed tomography and magnetic resonance imaging]

Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) have been developed rapidly in the last decade. Technical improvements and broad availability of modern CT and MRI scanners have led to an increasing and regular use of both diagnostic methods in clinical routine. Therefore, this German consensus document has been developed in collaboration by the German Cardiac Society, German Radiology Society, and the German Society for Pediatric Cardiology. It is not oriented on modalities and methods, but rather on disease entities. This consensus document deals with coronary artery disease, cardiomyopathies, arrhythmias, valvular diseases, pericardial diseases and structural changes, as well as with congenital heart defects. For different clinical scenarios both imaging modalities CT and MRI are compared and evaluated in the specific context.

Assessment of left ventricular function with steady-state-free-precession magnetic resonance imaging. Reference values and a comparison to left ventriculography

Ejection fraction (EF) and end-diastolic and end-systolic volume index (EDVI/ ESVI) derived from ventriculography are important prognostic parameters. Cine magnetic resonance imaging (MRI) using a steady-state, free-precession sequence (SSFP) offers excellent delineation of the endocardial borders and highly reproducible and accurate results for cardiac volumes. We evaluated MRI volumetry against routine x-ray ventriculography. In 200 patients EF, EDVI and ESVI were measured with MRI volumetry and x-ray ventriculography. The same MRI protocol was applied to 102 healthy persons in order to establish reference values. In healthy subjects mean EF was 68.8% +/- 5.4% (range 59-84%), mean EDVI 69 +/- 10 (43-90) and mean ESVI 22 +/- 5.8 (10-35 ml). In the patients, overall correlation (Spearman's R) of MRI with ventriculography was 0.86 for EF, 0.77 for EDVI and 0.88 for ESVI. For postextrasystolic beats (38% of the measurements), R was 0.73/0.65/0.73 for EF/EDVI/ESVI. MRI correlated best with biplane ventriculography during sinus rhythm (0.96/0.85/0.93); the worst correlation (0.78/0.81/0.83) resulted from patients with wall motion abnormalities in comparison to monoplane x-ray ventriculography.

CONCLUSION

Contemporary MRI volumetry compares well to invasive data obtained under optimal conditions. In view of the known limitations of single plane ventriculography, MRI seems to allow exact volumetry independent from regional wall motion abnormalities.

[Problems with the stoma. How you can advise your patients]

Stoma management is associated with various problems, depending on the type and location of the stoma and on the individual situation. Besides such general problems as smell, flatulence and local skin problems, typical surgical complications such as retraction and stenosis, prolaps and peristomal hernia are of major relevance. Many of these problems can be avoided by careful placement of the stoma and a meticulous surgical technique. Where indicated, the surgical correction of a problem is usually not very difficult, and is most helpful for the patient.

[Aortic calcification in CT. Correlation with risk factors and cardiovascular diseases]

Computed tomography is a much more sensitive method of identifying aortic calcification than conventional radiographic methods. The present study was undertaken to explore the importance of various cardiovascular risk factors with regard to their calcifying effect on the aorta. A total of 2,130 individuals, aged 8-88 years, were included. In all cases continuous 8-mm-thick CT slices were obtained from the thoracic inlet caudally to the adrenal glands. There was a significant relationship between aortic calcification and age, smoking habits, hypertension, diabetes, relative body weight, hyperlipidemia and alcohol consumption. Aortic calcification was demonstrated to be strongly associated with vascular disease.

Survival of operated bronchus carcinoma patients: a prospective study

Maximum diameter, tumour volume, and inflammatory response of host tissue in 282 surgical specimens with primary carcinoma of the bronchus were measured. Cell type, pT- and pN-stage, maximum diameter and volume of the primaries, and inflammatory response of host tissue were analyzed in respect to survival of the patients. Date of death was evaluated by quarterly communications with the house physicians. Survival rates were computed by use of Kaplan-Meier estimation. Mean survival of all patients was calculated at 480 days. Lymph node involvement and tumour volume were found to have a major influence on survival. In accordance with the weak contribution of maximum diameter of the tumour to survival, no major differences in survival between pT1- and pT2-stage were found. If severe inflammatory response at the tumour boundary was noted, patients showed slightly increased survival in all tumour stages. Cell type and tumour grading were found to be of minor influence in respect to survival.

[Bronchoplastic and angioplastic operations in bronchial carcinoma]

The various forms of bronchoplastic and angioplastic procedures are the best means of avoiding pneumonectomy. Essential indications are limited respiratory reserve and central site of a malignancy. In a retrospective study 248 broncho- and angioplastic operations carried out in the years 1973 to 1983 were analyzed. Reference date for the analysis of survival was January 1986. In consequence the minimum period of follow-up was two years. For all patients (n = 248) the 5-year-survival was 22% with a 30-day-lethality of 13%. The 5-year-survival of all bronchial sleeve resections operated radically (stage I and II of the TNM-classification) (n = 44) was 42% with a 30-day-lethality of 7%. The 5-year-survival of all bronchoplastic operations of stage I and II (n = 88) was 38% with a 30-day-lethality of 14%. Improved suture material and surgical techniques caused a reduction of operative lethality from 23% to 8% during the described period. In the first thirty postoperative days the following complications caused death: Hemoptysis (n = 5), insufficiency of the anastomosis (n = 3), right heart failure (n = 5), pulmonary embolism (n = 4) and sepsis (n = 1).

[Computed tomography of primary pulmonary sarcomas]

CT findings of 4 patients with primary pulmonary sarcomas are presented. In all cases there was a more than 5 cm large solid, circular configured, intrapulmonary growth without enlarged hilar and mediastinal lymph nodes and also without atelectasis.

[Postoperative enteral feeding following resection of the colon]

We tried to show that feeding via intrajejunal tube with a chemical defined diet (CDD) is an alternative to parenteral nutrition in the early postoperative period. We investigated 40 patients after colon surgery--randomized into two groups (group I: CDD, group II: control: total parenteral nutrition via central veins). It was shown that the patients in the CDD-group tolerated enteral feeding from the beginning without any problems. At the second postoperative day, the N-balance became positive in both groups. The given results proved that this form of tube feeding with a special diet is a definite alternative to parenteral nutrition.

[Experience with a simple form for the evaluation of surgical risk due to nutritional status]

The diagnosis and determination of the nutritional status for the evaluation of a surgical risk is achieved on the basis of a simple documentation scheme: The aim of the presented study was the characterization of this specific check-up protocol to find out the usefulness and applicability of this scheme and its value for the recognition of the nutritional status as one of the factors determining the outcome of surgical patients. The results show that this simple procedure allows an equivalent ranging of patients in different classes of nutrition related states as the highly sophisticated, time, costs and staff consuming protocols which were published to define nutritional states in the last years. When the exact and differentiated status is not necessary the simple protocol gives the same information to judge the possible risk by nutritional deficiencies as the complicated protocols.

Erfahrungen mit einem einfachen Schema zur Beurteilung eines ernährungsbedingten Operationsrisikos

Zur Erfassung eines evtl. bestehenden ernährungsbedingten Operationsrisikos sowie eines sich daraus bereits frühzeitig ableitenden Konzepts einer adäquaten Ernährungsbehandlung wird ein »einfaches Schema« dargestellt, das sich wie die vielfach in der Literatur angegeben, wesentlich aufwendigeren Dokumentationen zur Definition des Ernährungsstatus eignet. Zur genauen Protokollierung sowie zur Verlaufsbeurteilung als auch zur Erstellung prognostischer Angaben eignet sich dieses Schema jedoch nicht. Sollten sich bei der Auswertung des »einfachen Schemas« Hinweise für ein möglicherweise bestehendes ernährungsbedingtes zusätzliches Operationsrisiko ergeben, so sind zur Differenzierung aufwendigere Untersuchungen angezeigt, urn Ursache und Ausprägung der Mangel-bzw. Fehlernährung zu präzisieren.

[The role of the complement system in experimental pancreatitis (author's translation)]

Two different experimental procedures were used to induce pancreatitis in rats: distal ligature of the common bile duct and the Pfeffer method in modification of Nevalainen. It could be shown that consumption of complement can be demonstrated even in pancreatitis induced by other than immunological models. Further examination in decomplemented rats showed the possibility of inducing acute pancreatitis by the above-mentioned models, although of less intensity. Therefore, the complement system will be an important factor for the progress and intensity of the inflammation process.

[Intraluminal hypertension as a pathogenetic factor of acute pancreatitis in the rat (author's transl)]

By the use of various experimental procedures with rats, the significance of intraluminal hypertension, caused by ductal obstruction, reflux of bile and duodenal reflux were considered with regard to their capacity for producing pancreatitis. The extent of the histological changes in the pancreas after 48 hours as well as the period of survival in the individual experimental groups served as the parameters for the comparison. The results show that the rise in intraluminal pressure is alone enough to produce acute pancreatitis. It follows from this that rise of pressure in the duct system caused by ductal obstruction may be the triggering factor in the induction of pancreatitis. Reflux of bile, bacterial colonisation of the pancreas by duodenal reflux as well as activation of proteolytic enzymes were not necessary a prior factors but ones which have an aggravating effect in the development of the disease.

[Clinical and endoscopic radiologic results after transduodenal papilloplasty (author's transl)]

The study comprises 56 patients, who underwent transduodenal papilloplasty. More than 15% were symptom-free at least 4 years following surgery. All the symptoms the patients suffered from were nonspecific and the pathological findings of the blood samples were not correlated with the width of the orificium of the papilla of Vater or the diameter of the common bile duct. In 49 patients the ERCP was performed. In 48 cases the retrograde cholangiography was successful, in 1 case only the retrograde pancreatography was possible. In all patients we found normal efflux of contrastmedium out of the papilla. Bile stones, one localized in the common bile duct and the other in the cyst remnant were the most important findings. The diameters of the common bile ducts varied considerably and were not dependent on the velocity of the efflux of the contrast medium. Contrary to the observations of other authors, in only 15% of our patients free air bubbles were found in the bile tree. Peripapillary diverticula of the duodenum were detected in 15% of our patients, but did not lead to compression or obstruction of the common bile duct. Even without histologic examination of the liver, we believe that a broad papilloplasty of the papilla prevents an ascending cholangitis or other related complications.

[Surgical papillotomy, endoscopic-manometric and clinical results (author's transl)]

4--9 years after transduodenal papillotomy an endoscopic-manometric and clinical control of the surgical result was done in 49 patients. The pressure difference of common bile duct and duodenum was of great interest. There existed a correlation between the pressure difference and other parameters so far, as air was frequently seen in those patients without pressure gradient between common bile duct and duodenum. Pathological activity of gamma-GT and a decrease of Prothrombine-time was found after a high pressure difference. It may be possible that anatomical variations of the biliary system and the duodenum have some importance for the formation of stones.