Traumatic pneumobilia after cardiopulmonary resuscitation

Pneumobilia is a rare pathological finding, which denotes an abnormal connection between the gastrointestinal and the biliary tract. In the absence of surgically created anastomosis between the bowel and the bile duct, the most common causes for pneumobilia are gallstone obstruction, endoscopic interventions, or emphysematous cholecystitis. We present this case of a middle-aged multiple-injured male who developed traumatic pneumobilia after cardiopulmonary resuscitation. We suppose that chest compression in combination with a sphincter of Oddi (SO) dysfunction forced intraluminal air retrograde through the SO into the biliary tract, since intraabdominal injury as well as former biliary pathology, inflammation, or biliary-enteric fistula were excluded.

Knochenneubildung durch Osteogenic Protein-1 und autogenes Knochenmark im Problemdefektmodell der Schafstibia

AIM

Osteogenic Protein-1 (OP-1) is known to be a very potent osteoinductive growth factor. However, experimental studies using critical-size defect models in the weight-bearing lower extremity show non-uniform results. Therefore, we studied the osteoinductivity of OP-1 in a tibial worst-case defect model in sheep. Potential improvement of OP-1 induced new bone formation using a composite graft with autogenous bone marrow was to be investigated.

METHOD

In 19 sheep a 5 cm segmental defect of the tibial diaphysis was treated by intramedullary nailing and filled with the following implants: 5 mg OP-1 + inactivated demineralized bone matrix (group 1; n = 6); 5 mg OP-1 + inactivated demineralized bone matrix + 5 ml autogenous bone marrow (group 2; n = 5); autogenous cancellous bone (group 3; n = 4), or inactivated demineralized bone matrix + 5 ml autogenous bone marrow (group 4; n = 4).

RESULTS

In total, 3 out of 10 defect sites treated with OP-1 were completely bridged radiographically by 12 weeks. Initially, x-rays showed accelerated new bone formation by use of the composite grafts containing OP-1 and autogenous bone marrow. However, 12 weeks post surgery 3D-CT-volumetry could not detect significant differences of new bone formation within the defect sites treated by OP-1 with or without bone marrow, while new bone formation by autogenous cancellous bone was better than by OP-1.

CONCLUSION

In our worst case defect model, the osteoinductive potential of OP-1 is initially accelerated but 12 weeks post surgery not increased when combined with autogenous bone marrow transplantation. So far, critical segmental bone defects of the weight-bearing lower extremity can not be bridged regularly in our model by use of OP-1. Therefore, for the treatment of such critical defects with rotational instability the examined application device of OP-1 can not yet be recommended.

[The quality of digital mammograms. Development and use of phantoms for optimal safety]

Digital imaging in mammography is becoming more and more accepted using both computed (CR) and direct radiography (DR). These techniques will soon be used in screening programs. Therefore, quality assurance for this technique is indispensable. The relevance of the current regulations, such as EPOC and the German QS-RL was investigated. For the investigation, a breast phantom and appropriate software were developed. Both were tested using digital mammography systems from six manufactures. Quality assurance parameters (such as contrast to noise ratio and contrast resolution) were calculated from these data sets. The results should be considered in future standards for mammography (IEC respectively DIN). In addition, this type of test procedure is time saving and enables a reduction in test devices, i. e. in costs.

3D-Ultraschall (3D-US) in der Diagnostik von Mammaherdbefunden

BACKGROUND

It was to analyse whether 3D breast US is able to enhance the diagnosis of focal breast lesions.

MATERIAL AND METHODS

60 patients were examined with 2D- and 3D US (GE logiq 9, 14 MHz). The solid lesions were analyzed by using the BIRADS classification. As standard of reference, histopathologic results were available in all cases.

RESULTS

38 malignant and 22 benign lesions were analyzed. With 2D US the sensitivity/specificity was 92/81%, with 3D US 97/72%, and by combination of 2D and 3D 97/81%. Characteristics of benign solid masses included a round or oval shape as well as clearly defined and sharply demarcated margins.

CONCLUSIONS

3D US allows to demonstrate breast masses in multiple planes. Distorsion of the surrounding soft tissues is an important sign indicative of malignancy.

[Studies on image quality, high contrast resolution and dose for the axial skeleton and limbs with a new, dedicated CT system (ISO-C-3 D)]

PURPOSE

Evaluation of 3D-CT imaging of the axial skeleton and different joints of the lower and upper extremities with a new dedicated CT system (ISO-C-3D) based on a mobile isocentric C-arm image amplifier.

MATERIAL AND METHODS

27 cadaveric specimes of different joints of the lower and upper extremities and of the spinal column were examined with 3D-CT imaging (ISO-C-3D). All images were evaluated by 3 radiologists for image quality using a semiquantitative score (score value 1: poor quality; score value 4: excellent quality). In addition, dose measurements and measurements of high contrast resolution were performed in comparison to conventional and low-dose spiral CT using a high contrast phantom (Catphan, Phantom Laboratories).

RESULTS

Adequate image quality (mean score values 3 - 4) could be achieved with an applied dose comparable to low-dose CT in smaller joints such as wrist, elbow, ankle and knee. A remarkably inferior image quality resulted in imaging of the hip, lumbar and thoracic spine (mean score values 2 - 3) in spite of almost doubling the dose (dose increased by 85 percent). The image quality of shoulder examinations was insufficient (mean score value 1). Phantom studies showed a high-contrast resolution comparable to helical CT in the xy-axis (9 lp/cm).

CONCLUSION

Preliminary results show, that image quality of C-arm-based CT-imaging (ISO-C-3D) seems to be adequate in smaller joints. ISO-C-3D images of the hip and axial skeleton show a decreased image quality, which does not seem to be sufficient for diagnosing subtle fractures.

[Detection of tibial condylar fractures using 3D imaging with a mobile image amplifier (Siemens ISO-C-3D): Comparison with plain films and spiral CT]

PURPOSE

To analyze a prototype mobile C-arm 3D image amplifier in the detection and classification of experimental tibial condylar fractures with multiplanar reconstructions (MPR).

METHOD

Human knee specimens (n = 22) with tibial condylar fractures were examined with a prototype C-arm (ISO-C-3D, Siemens AG), plain films (CR) and spiral CT (CT). The motorized C-arm provides fluoroscopic images during a 190 degrees orbital rotation computing a 119 mm data cube. From these 3D data sets MP reconstructions were obtained. All images were evaluated by four independent readers for the detection and assessment of fracture lines. All fractures were classified according to the Müller AO classification. To confirm the results, the specimens were finally surgically dissected.

RESULTS

97 % of the tibial condylar fractures were easily seen and correctly classified according to the Müller AO classification on MP reconstruction of the ISO-C-3D. There is no significant difference between ISO-C and CT in detection and correct classification of fractures, but ISO-CD-3D is significant by better than CR.

CONCLUSION

The evaluation of fractures with the ISO-C is better than with plain films alone and comparable to CT scans. The three-dimensional reconstruction of the ISO-C can provide important information which cannot be obtained from plain films. The ISO-C-3D may be useful in planning operative reconstructions and evaluating surgical results in orthopaedic surgery of the limbs.

[Introduction of a new mobile C-arm/CT combination equipment (ISO-C-3D). Initial results of 3-D sectional imaging]

Preclinical evaluation of a new mobile C-arm image amplifier with an option for three-dimensional computed tomography (CT) imaging (prototype Iso-C3D) with respect to high-contrast resolution and possible clinical applications. Cadaveric specimens (n = 30) of different joints of the lower and upper extremities and specimens of the spinal column were examined with the Iso-C3D and evaluated for image quality. In addition, using a high-contrast phantom (Catphan, Phantom Laboratory, Salem, N.Y., USA) and a fracture model of the femoral bone, measurements of high-contrast resolution were performed in comparison to spiral CT. With the exception of the shoulder, all joint regions including the entire spinal column could be examined. Adequate image quality could be achieved in smaller joints such as the wrist, elbow, ankle, and knee, whereas a remarkably decreased image quality was found when imaging the hip as well as the lumbar and thoracic spine. Images of the phantom study and high-contrast fracture model showed a high-contrast resolution comparable to helical CT (9 Lp/cm in xy-axis). In smaller joints, the image quality of the mobile C-arm CT imaging system (Iso-C3D) is comparable to that of helical CT. Image quality in examinations of the hip and lumbar and thoracic spine seems to be sufficient for intraoperative control studies of osteosynthesis. Problems still occur in shoulder examinations.

[3-D imaging with a mobile surgical image enhancement equipment (ISO-C-3D). Initial examples of fracture diagnosis of peripheral joints in comparison with spiral CT and conventional radiography]

To analyze a prototype mobile C-arm image amplifier (Iso-C3D) in the evaluation of different joint fractures of the upper and lower limbs using multiplanar reconstruction (MPR). Different cadaver joint specimens (n = 14) were examined with a prototype (Iso-C3D, Siemens AG, Erlangen, Germany), plain radiographs (CR), and spiral computed tomography (CT). The motorized C-arm provides fluoroscopic images during a 190 degrees orbital rotation computing a 119-mm data cube. These three-dimensional data sets yielded MPR images, which were evaluated by two readers for the detection and extent of fracture lines. Initial data show that fractures were easily depicted and correctly classified on MPR images with the Iso-C3D and that there was no difference between the Iso-C and CT in the detection of fractures. The preliminary results suggest a remarkably good detection of joint fractures with the Iso-C3D. Studies in an adequate number of patients are required to elucidate whether these promising results can also be obtained in a clinical setting.

Long-term stent implantation in a case of relapsing intrathoracic Ewing-sarcoma

The overall prognosis of relapsing Ewing sarcoma is poor and therapeutic options can be limited by extensive chemotherapeutic pretreatment. We report on a case of a 27-year-old male, presenting with a large mediastinal mass and malignant pleural effusions. 5 years prior peripheral Ewing sarcoma had been treated according to the CESS 86 protocol. Relapse chemotherapy was initiated (CESS protocol) but tumor progression led to stenoses of both main bronchi. At this critical point, 2 Strecker tantal stents were placed endoscopically to prevent suffocation and provide the time for further chemotherapy, regardless of the poor overall prognosis. Complete remission was achieved by high-dose ifosfamide, surgery, radiotherapy and adjuvant ifosfamide. In spite of possible complications of long-term stent implantation, the stents were not removed until 4 years later when stent dislocation occurred. After removal, the stents were epithelialized and electron microscopy demonstrated structural integrity of the stent. The patient has remained in complete remission since (6 years).

High-dose-rate brachytherapy: dose escalation in three-dimensional miniorgans of the human bronchial wall

PURPOSE

High-dose-rate (HDR) brachytherapy of human lung cancer is well established, however fractionation schemes and dosages are based mainly on experience. The aim of this investigation was to study the effects of different doses of HDR iridium-192 on normal human bronchial epithelium in three-dimensional miniorgans of the human bronchial wall.

METHODS AND MATERIALS

Forty-eight biopsies from normal bronchi were cultivated for 14 days and exposed at random to different doses of HDR iridium 192 (0 Gy, 30 Gy, 45 Gy, 60 Gy, or 75 Gy). Cell viability was assessed immediately after irradiation, after 4 or 18 days by fluorescent staining, and cell damage of the culture was analyzed by light microscopy. Lactate dehydrogenase (LDH) was measured in the supernatant for 4 days.

RESULTS

There was no histologically apparent tissue damage regardless of the irradiation dose. The number of nonvital cells increased in irradiated miniorgans depending on the dose used (p < 0. 05 at 75 Gy). This effect occurred early and was less pronounced with time. LDH measurements showed an increase only in the first 24 hours.

CONCLUSIONS

Our results confirm that normal bronchial epithelium has a high tolerance to early epithelial damage by irradiation. This model of human bronchial miniorgans is useful for further studies of the effects of irradiation on human bronchi.