Achalasia-an unnecessary long way to diagnosis

Although achalasia presents with typical symptoms such as dysphagia, regurgitation, weight loss, and atypical chest pain, the time until first diagnosis often takes years and is frustrating for patients and nevertheless associated with high costs for the healthcare system. A total of 563 patients were interviewed with confirmed diagnosis of achalasia regarding their symptoms leading to diagnosis along with past clinical examinations and treatments. Included were patients who had undergone their medical investigations in Germany. Overall, 527 study subjects were included (male 46%, female 54%, mean age at time of interview 51 ± 14.8 years). Dysphagia was present in 86.7%, regurgitation in 82.9%, atypical chest pain in 79%, and weight loss in 58% of patients before diagnosis. On average, it took 25 months (Interquartile Range (IQR) 9-65) until confirmation of correct diagnosis of achalasia. Though, diagnosis was confirmed significantly quicker (35 months IQR 9-89 vs. 20 months IQR 8-53; p < 0.01) in the past 15 years. The majority (72.1%) was transferred to three or more specialists. Almost each patient underwent at least one esophagogastroduodenoscopy (94.2%) and one radiological assessment (89.3%). However, esophageal manometry was performed in 70.4% of patients only. The severity of symptoms was independent with regard to duration until first diagnosis (Eckardt score 7.14 ± 2.64 within 12 months vs. 7.29 ± 2.61 longer than 12 months; P = 0.544). Fifty-five percent of the patients primarily underwent endoscopic dilatation and 37% a surgical myotomy. Endoscopic dilatation was realized significantly faster compared to esophageal myotomy (1 month IQR 0-4 vs. 3 months IQR 1-11; p < 0.001). Although diagnosis of achalasia was significantly faster in the past 15 years, it still takes almost 2 years until the correct diagnosis of achalasia is confirmed. Alarming is the fact that although esophageal manometry is known as the gold standard to differentiate primary motility disorders, only three out of four patients had undergone this diagnostic pathway during their diagnostic work-up. Better education of medical professionals and broader utilization of highly sensitive diagnostic tools, such as high-resolution manometry, are strictly necessary in order to correctly diagnose affected patients and to offer therapy faster.

Stellt die Thyreoidektomie ein Standardverfahren zur Behandlung des Morbus Basedow dar?

Surgery is an important therapeutic option in the treatment of Graves' disease. Nevertheless it is still controversial discussed wether the extent of resection correlates with the rate of surgical complications and the therapeutic success. Therefore we performed a retrospective analysis on 75 surgically treated patients. 58 of these 75 patients were examined after a median interval of 34.2 months. The examination focussed on the appearance of temporary and permanent palsy of the recurrent laryngeal nerve, hypoparathyroidism, recurrences, and on the postoperative course of thyroid-stimulating-hormone-receptor antibody (TSH-ab) titers. Total thyroidectomy has been performed in 51 and bilateral resection with a remnant thyroid volume less than 2 ml each side in 24 patients. We could not confirm a significant difference concerning the postoperative complication rates between both groups. In the bilateral resection group we saw 3 cases of recurrent goitre and a more unfavourable course of TSH-ab titers than in the thyroidectomy group. For these reasons we propose the total thyroidectomy as surgical standard procedure for therapy of Graves' disease.

[Laparoscopic heller cardiomyotomy either combined with a Dor or Toupet procedure in the treatment of achalasia]

INTRODUCTION

The treatment of achalasia has undergone a dramatic evolution over the past ten years with the introduction of advanced laparoscopic techniques beside the use of balloon dilatation and injections of botulinumtoxin. With the introduction of the laparoscopic Heller cardiomyotomy the question was raised again whether and if so which antireflux measures are meaningful in combination with the cardiomyotomy.

PATIENTS AND METHOD

Since 1998, 51 patients underwent laparoscopic cardiomyotomy in the surgical department of the Marienhospital Herne, Ruhr University Bochum. To prevent postoperative gastroesophageal reflux we performed a Dor fundoplication in 13 patients and a Toupet fundoplication in 38 patients. The mean period of observations was 17 months (3-45 months). All patients were evaluated through a symptoms score. 16 patients could be clinically and objectively followed-up.

RESULTS

The mean operation time was 170 min. (80-290 min). The intraoperative complications were 8 mucosal disruptions without further morbidity and 1 pneumothorax. Postoperative complications were 1 scarring restenosis and 1 wrap dislocation. Improvement of symptoms was reported in 94.2 % of patients with good or excellent results. In 5.8 % of patients symptoms of reflux were claimed. There was no significant difference in results between Dor- and Toupet-fundoplication.

CONCLUSION

Laparoscopic Heller cardiomyotomy with either a Dor or Toupet fundoplication are equivalent with respect to short- and middle-term outcome and efficient procedures with low rate of morbidity and mortality in the treatment of achalasia. A long-term observation period is necessary for determining which type of fundoplication has to be performed particularly regarding restenosis and reflux rate.

[Reduction of radiation exposure for patient and investigator in interventional radiography]

PURPOSE

In a retrospective analysis of vascular interventional procedures, relations between parameters of the examination and radiation exposure of patient and medical personnel are examined.

MATERIAL AND METHOD

1208 vascular interventional procedures are evaluated. Interventional procedures are divided into three groups: percutaneous transluminal angioplasty, implantation of a stent, thrombolysis.

RESULTS

Mean values of the radiation dose of patient and radiology personnel are reported for these examinations. The mean value of the radiation dose of the physician was 7 microSv (maximum 24 microSv), that of the patient 1548 cGy.cm2 (maximum 8485 cGy.cm2).

CONCLUSION

The quantity of X-rays to the patient may be lowered by using pulsed fluoroscopy and by reducing the number of radiographs. Reduction of the number of radiographs may be achieved by using the last-image hold and the road mapping mode. The operator's dose can be decreased by using additional radiation protection systems like a MAVIG-radiation protection wall. The radiation dose reduction was 61% for the physician and 17% for the patient.

Bilateral, tumorlike diabetic mastopathy-progression and regression of the disease during 5-year follow up

Diabetic mastopathy is a recently described collection of radiographical and histological features found in dense fibrous masses of the breast in long standing Type I diabetes. We describe the first case of bilateral disease with the alternate progression and regression of the disease over a 5 year period. A 45-year-old woman has been affected of insulin dependent diabetes mellitus (IDDM) for 21 years. She developed palpable mass retromamillar of the right side, indistinguishable radiographically from cancer. The histology showed a diabetic mastopathy (DMP) with B-lymphocytic ductitis and lobulitis, a discrete monocellular vasculitis and a keloid-like fibrosis. After 22 months she developed a suspicious palpable mass contralateral on the left side. The FNAB presented an identical morphology on histology. Additionally 10 months later there were no palpable masses of both mammae. Mammographically no suspect alterations were observed. One year later the clinical and mammographical examination showed similar findings, mentioned before. The pathogenesis is still obscure and includes the hypothesis of extracellular accumulation, secondary to prolonged hyperglycemia in IDDM, production of alternated non-enzymatic glycosylated end products with neoantigen formation, B cell predominant inflammation with autoimmune response against neoantigens and cytokine release secondary to the autoimmune response.

[Radiologic imaging of MALT lymphoma. (Comparison between stomach roentgen image, computerized tomography and magnetic resonance tomography]

The new classification of primary lymphomas of the stomach according to the MALT concept is very promising in therapy planning and prognostic estimation. This new classification sets strict requirements for imaging diagnostics. Besides endosonography which allows the determination of the infiltration depth in stages E I1 and E I2 in an excellent manner, computed tomography and, possibly, magnetic resonance tomography are indispensible for evaluation of higher stages and of the resectability of a lymphoma. Further MRI examinations are recommended.

Diagnostic value of 3D CT surface reconstruction in spinal fractures

Our purpose was to evaluate the diagnostic value of three-dimensional (3 D) CT surface reconstruction in spinal fractures in comparison with axial and reformatted images. A total of 50 patients with different CT-proven spinal fractures were analysed retrospectively. Based on axial scans and reformatted images, the spinal fractures were classified according to several classifications as Magerl for the thoraco-lumbar and lower cervical spine by one radiologist. Another radiologist performed 3 D CT surface reconstructions with the aim of characterizing the different types of spinal fractures. A third radiologist classified the 3 D CT surface reconstruction according to the Magerl classification. The results of the blinded reading process were compared. It was checked to see in which type and subgroup 3 D surface reconstructions were helpful. Readers one and two obtained the same results in the classification. The 3 D surface reconstruction did not yield any additional diagnostic information concerning type A and B injuries. Indeed, the full extent of the fracture could be easier recognized with axial and reformatted images in all cases. In 10 cases of C injuries, the dislocation of parts of vertebrae could be better recognized with the help of 3 D reconstructions. A 3 D CT surface reconstruction is only useful in rotational and shear vertebral injuries (Magerl type C injury).

[Malignant melanoma of the gallbladder]

A 75 year woman developed a primary malignant melanoma of the gallbladder. The patient presented with abdominal pain in the upper right quadrant typically seen in acute cholecystitis. Neither intravesical concretions nor cholestasis was seen. Ultrasound demonstrated hyperechogenic intraluminal "school of fish" reflections, which are typical for metastatic melanoma to the gallbladder. Intravesical fluid collection was not present. The tumor did not expand past the wall of the gallbladder. The main sonographic features are hyperdense intraluminal strands of tumor and the lack of fluid. Computed tomography showed solid intraluminal masses with hypodensive and partially hyperdensive reticular structure.

Development and validation of a bioanalytical method for the quantification of diltiazem and desacetyldiltiazem in plasma by capillary zone electrophoresis

A CZE method for the quantification of diltiazem and desacetyldiltiazem in plasma was developed and validated. Separation was accomplished at pH 2.5 in a 0.044 M phosphate buffer. Sample preparation was performed by liquid-liquid extraction and no interferences with plasma compounds were detected. The calibration graph is linear over the range 5-250 ng/ml with verapamil as internal standard. The precision and accuracy are better than 13% at 5 ng/ml, and better than 10% between 10 and 250 ng/ml. The long-term reliability of the CZE system was checked over a 3-month period. The CZE method is a useful alternative to the already established HPLC method.

[First experiences with electron beam computed tomography of the heart:comparison with heart catheterization and echocardiographic findings]

AIM

To evaluate the diagnostic value of ultrafast CT in comparison to established methods in cardiology.

MATERIAL AND METHODS

Cine and flow studies were performed in 30 patients with cardiac diseases on evolution CT. Cardiac structure and function were analysed visually and quantitatively (left ventricular ejection fraction, left ventricular myocardial mass, patency of coronary arteries, perfusion of left ventricular myocardium). The CT findings were compared with echocardiographic and angiographic findings.

RESULTS

Cardiac structure, functional parameters and disorders of myocardial contraction were clearly detectable by ultrafast CT, which proved inferior in assessing cardiac valves. The patency of the first and second third of normal main coronary arteries could be estimated correctly. The estimation of the distal third, of obstructed coronary arteries and of the role of collaterals was impossible. Ten of 16 areas of myocardial infarction showed low or no enhancement.

CONCLUSIONS

Ultrafast CT excellently reflects cardiac structure and function. It is an alternative to echocardiography. In view of the results of coronary artery patency one can hope that part of cardiac catheterisation would be avoidable in future.

[The value of computed tomography in persistent balance disorders following the use of stapes prostheses]

10 of 150 patients had persistent vertigo after implantation of stapes prostheses. These patients were evaluated by high-resolution CT in the axial and coronal plane. Scans showed in all cases findings which related to the symptoms. The CT findings were proved intraoperatively in 9 cases. A new indirect sign of a perilymphatic fistula is described in form of an air bulla at the end of the prosthesis. Retympanotomy could be planned better with the help of HR-CT.

[Detection of coronary calcification by ultrafast CT compared with coronary angiography]

The angiographical findings of 24 patients with coronary artery disease were compared with qualitative and quantitative detection of coronary calcification by ultrafast CT. Doubts concerning the capabilities of the ultrafast CT for a screening of coronary artery disease arise when the results of one third false positive and false negative findings are considered. Variations in the quantification of coronary calcification were too great to allow a realistic assessment of the degree of stenosis of the coronary arteries.

[Osseous variations in the coronary CT of the paranasal sinuses]

Bony variations in the anterior ethmoids may, if severe, play an important role in the development of chronic sinusitis and present the surgeon with added risks during operation. We have, therefore, analysed 390 preoperative CT examinations of the sinuses performed in the coronary plane with respect to the frequency of bone variations. Concha bullosa, increased pneumatisation of the agger nasi, large ethmoidal bullae, Haller's cells and increased pneumatization of the sphenoid were found with equal frequency in about 20%. The most common variants occurred in the uncinate process (31.5%), less common were paradoxical curve of the middle turbinates (13.3%) and very rare were Onodi cells (1.3%).

[CT-Sellink--a new method of evaluating the intestinal wall]

34 patients were examined by CT following a modified enema (CT-Sellink) in order to demonstrate the gut. By introducing a "gut index" it is possible to define the tone of the gut providing its folds remain constant. By means of a radial density profile the gut wall can be defined objectively and in numerical terms. Gut wall thickness in the small bowel averaged 1.2 mm with a density of 51 Hu and gut wall thickness in the colon averaged 2 mm with a density of 59 Hu.

[Diagnosis of diseases of the large salivary glands of the head by ultrasound, sialography and CT-sialography. A comparison of methods]

In the present study 162 patients with clinically suspected diseases of the major salivary glands were examined via sonography (n = 162), sialography (n = 111) and CT-sialography (n = 49). The reliability of the three radiological procedures was assessed in diagnosing sialoadenitis, sialolithiasis and glandular and extraglandular tumors. Forty-seven patients were examined with all three methods, 64 patients with sonography and sialography, 2 patients with sonography and CT-sialography and 49 patients with only sonography. The results were compared retrospectively with histologically (70%), cytologically (26%) and clinically proven diagnoses. A sialoadenitis was diagnosed via sonography at a sensitivity of 58%. Sialography frequently produced a false diagnosis of "glandular tumor", which resulted in a comparatively lower sensitivity of 54%. This finding contrasted with the experiences of other authors. A glandular tumor was correctly diagnosed by all three methods and had approximately the same sensitivity (sonography 89%, sialograph 91% and CT-sialography 92%). The correct diagnosis of salivary gland tumors was found by sonography and CT-sialography in 76% of cases and by sialography in 83% of cases. CT-sialography was clearly the superior diagnostic method for detecting extraglandular tumors. Sonography proved its worth as the fundamental procedure for special diagnostic testings of the salivary glands. Sialography is necessary for obtaining important additional information, especially in cases with suspect glandular tumors. CT-sialography is indispensable in the diagnosis of tumors, especially if a malignant, extraglandular or medially localized process is suspected.

[Computerized tomography in the assessment of myocardial function--possibilities, limits and indications for the method]

The theoretical and methodical base of computed tomography evaluation of the myocardial function are demonstrated. The possibilities and limits of this investigation method are discussed and compared with the results of numerous own examinations and the literature. Present indications for cardiacomputed tomography are deduced with consideration of other noninvasive imaging techniques in cardiology.

[Value of computerized tomography and ultrasonic diagnosis in acute pancreatitis]

While the diagnosis of the acute pancreatitis is now as ever made clinically, the significance of ultrasound and computed tomography (CT) lies above all in the demonstration of morphologic changes and their extent. When the statements of the ultrasonic diagnosis are sufficient in easy stages of the acute pancreatitis and for the recognition of a more severe stage as well as for the control of the course, an evident assessment of the haemorrhagic necrotizing pancreatitis, in particular before operation, is possible only with the help of the CT. Only with its help we succeed in a comprehensive demonstration of the necroses, formations of abscesses, haemorrhages as well as of the ways of necrosis. The better availability and the riskless possibility of carrying out the ultrasonic diagnosis with altogether high evidence allow a narrow-meshed control of the course of the acute pancreatitis.

[Diagnosis of cardiac involvement in rheumatoid arthritis and some selected collagenoses]

The systemic character of the rheumatoid arthritis and the collagenoses includes an extraarticular organ manifestation. Since the symptomatology of an organ participation is often covered over with dominating joint troubles its diagnostics is difficult. In 34 patients (22 with rheumatoid arthritis, 12 with collagenoses) with the help of non-invasive methods (computed tomography and sonography) is tried to recognize a participation of the heart--particularly of the pericardium. Our examinations show that by means of the computed tomography in 13.6% of the cases an effusion in the pericardium (9.1% of them clinically not conspicuous) could be proved in rheumatoid arthritis, however, the frequency of 30% of the echocardiographically diagnosed pericardial effusions described in the literature could up to now not be confirmed. The classification of the changes of the pericardium as a complication of a rheumatoid arthritis or a collagenosis may be performed only in connection with the adequate clinical and biochemical immunological findings excluding other cardiac diseases.

[Confirming a mediastinal lipoma with cardiac computerized tomography]

It is reported on an at present 32-year-old male patient, in whom at the age of 30 years an excessive mediastinal lipoma was excised. For 12 years the cardiological diagnosis was not clear and could completely be clarified only with the help of the computed tomography of the heart.

[Computer tomography diagnosis of cardiac and pericardial space-occupying lesions]

Cardial and paracardial space occupations need a rapid, possibly non-invasive diagnosis. The echocardiography and the computer tomography are practically available. At the instance of 17 intracardial space occupations (4 solid tumours and 13 thrombi), which were found in a total number of 600 cardio-computer-tomographies, and several selected peri- und paracardial space occupations the high diagnostic significance of the computer tomography is demonstrated. With the computer tomography a standardized method independent of the investigator is available which in qualitative respect appears of the same value as to echocardiography in the diagnostics of the intracardial space occupations and in the peri- and paracardial space occupations the non-invasive method is the method of choice.

Arterial calcification in diabetics

Calcification of the media of the arteries of the lower limbs, giving a linear type of calcification roentgenologically is typical for diabetic arteriosclerosis. Spotty calcification of the arteries of the lower extremity, which histologically is found in the intima, is also seen a little more often in diabetics with gangrene. There are no major differences between the other histological vascular structures of diabetics and arteriosclerotics. Maximal stenosis of the lumen is found more peripherally in diabetics than in persons with normal carbohydrate metabolism. The results favour the idea of predominant femoropopliteal occlusion in arteriosclerosis and popliteal-tibial occlusion in diabetics.

[Radiologic studies of the correlation between the mineral content of the peripheral and axial skeleton]

Estimations of mineral content of normal human skeletons using three radiological methods have led to the following conclusions: 1. Bone density of vertebral bodies increases from T.6 to L.5. Average values for thoracic and lumbar vertebrae are 0.71 and 0.88 g./cm2. 2. There is no linear correlation between the mineral content of an easily accessible peripheral bone and of the vertebrae. 3. The method for bone mineral estimation, using thulium170, which was developed in Dresden, can be used for the peripheral and central skeleton. 4. 125-photon absorption us useful for measurements on the peripheral skeleton, where it is the most elegant and accurate method. It is, however, useless for measurements of the central skeleton.

[Computer tomographic evaluation of left ventricular kinetics]

The judgment of the function of the left ventricle is computer-tomographically possible using the ECG-regulated cardio-computer-tomography in a temporary resolution of about 0.1 sec. The qualitative and quantitative evaluation of the systolic and diastolic changes of the ventricle in patients with normal CT-findings, with idiopathic hypertrophic subaortic stenosis and with disturbances of motility in chronic ischaemic heart disease confirms the possible functional evidence known from literature. The quantitative parameters, in particular the systolic abbreviation of the axis, allow an estimation of the motility. The measurement of the thickness at the interventricular septum and at the lateral wall of the myocardium as well as the systolic abbreviation of the axis and the left-ventricular ejection fraction are essentially higher in the idiopathic hypertrophic subaortic stenosis than in the normal group. The values of the patients with disturbances of motility in the ischaemic heart disease were clearly below. The diagnosis of the idiopathic hypertrophic subaortic stenosis with response of the size of obstruction by the telesystolic and telediastolic pictures is possible in a high percentage. Sequelae of the chronic ischaemic heart disease, e.g. scars, become visible by a narrowing or an absence of the normal edge of the myocardium. Global and localized disturbances of motility are diagnosable by phase-referred systolic and diastolic ECG-regulated pictures.

[The value of computer tomography in the postoperative long-term surveillance of patients with a vascular prosthesis for aorta replacement]

Because of the possibility of life-threatening late complications by anastomotic aneurysms and the danger of their rupture, all patients in whom a coarctation of the aorta was resected and replaced by a vascular prosthesis must be followed up continuously for life. Their chest x-rays show-in addition to unequivocally normal or pathological findings-sometimes questionable variations of the aortic outline, which must be diagnosed definitely by further investigations. By means of computerized tomography, the suspicion of an anastomotic aneurysm can either be refuted or confirmed in almost all cases. Thus, the invasive examination by aortography, which is desirable before operation of an aneurysm, may be omitted in the group of unsuspicious patients. Out of 198 patients, who received a vascular prosthesis for correction of an aortic coarctation in the time from 1960 to 1980, 27 were examined by computerized tomography because of irregular findings in their chest x-rays. In 6 patients the suspicion of an anastomotic aneurysm was confirmed and could be proved by aortography and reoperation. In 21 patients an aortography could be omitted because of its unsuspicious findings by computerized tomography.

Severe late complications after operative correction of aortic coarctation by interposition of prosthesis

Out of 198 patients with aortic coarctation who were operated on with the implantation of an orthotopic bypass vascular prosthesis, 7 developed severe late complications 9-20 years postoperatively with late anastomosis dehiscence which resulted either in acute rupture and sudden death from massive hemorrhage (2 patients) or in false aneurysms with or without delayed rupture. Reoperation was done in 4 patients. After elective reoperation 2 of 3 patients survived, one elective and one emergency case died. The only evident reason for the late suture disruption was complete absorption of polyamide suture material in 6 cases. Therefore all patients with polyamide-sutured anastomosis should be followed-up thoroughly even in the late postoperative period in order to detect indications for elective reoperation. Suture material for anastomosis with any prosthesis must be nonabsorbable for lifetime.

[Comparison of the value of ERCP, angiography and scintigraphy in pancreatic diseases]

The endoscopic retrograde cholangiopancreaticography, angiography and scintigraphy have a different value in the diagnostics of chronic pancreatitis and carcinoma of the pancreas. The scintigraphy of pancreas has the lowest value. It should not alone be the basis for making the diagnosis or planning the treatment. In chronic pancreatitis the endoscopic retrograde cholangiopancreaticography has precedence of angiography. The chronic pancreatitis may angiographically be recognised only in the late phase. However, the angiography can give valuable references to the planning of the operation. At a suspicion of the pancreas malignoma the endoscopic retrograde cholangiopancreaticography and the angiography have nearly the same value in the plan of diagnostics and they both should be performed.

[Utilization and effectiveness of radiological study methods in the diagnosis of adrenal diseases]

In recent years the construction and increase of sensitiveness of clinical and biochemical test methods resulted in an essential improvement of the functional diagnostics of adrenal diseases. For the objectivation of the findings and for the preoperative localisation radio-morphological, nuclear-medical and sonographic investigation methods are used. The greatest certainty in the diagnostics also of relatively small changes of the adrenal glands is at present achieved by means of the selective, retrograde venography of the adrenal glands in connection with a selective withdrawal of venous blood for the analysis of hormones. The most essential field of indication for this investigation technique are overfunctions of the adrenal cortex as well as hormone-active and hormone-inactive tumorous (benign and malignant) adrenal processes.

[Interdisciplinary cooperation in the diagnosis and therapy of diseases of the adrenal glands and the parathyroid glands]

It is reported on the interdisciplinary cooperation between internists, radiologists and surgeons in the diagnostics and therapy of endocrinological diseases (suprarenal gland, parathyroid gland). On the basis of instances diagnostic step programmes are represented and first experiences of the cooperation are reported.