Value of high-resolution MR in patients scheduled for cochlear implantation

Objective: To determine sensitivity and specificity of high-resolution MR imaging and of high-resolution axial CT (HRCT) and to compare the two modalities in predicting the surgical and functional success of cochlear implantation.

Material and Methods: The presurgical MR images (2D T2W TSE, 3D T2*W CISS, plain and contrast-enhanced 3D T1W MP-RAGE) and axial HRCT findings of 26 patients were evaluated with regard to the predictive value concerning the success of cochlear implantation.

Results: We found a high correlation between MR and HRCT and the success of cochlear implantation. In all 26 patients, the MR-based predictions concerning the success of cochlear implantation were correct. In 10 patients, MR gave additional information to HRCT. In all patients, MR gave sufficient information about the status of the inner ear, inner auditory canal and cochlear nerve to aid the surgeon during the operation.

Conclusion: A high-resolution MR protocol consisting of coronal 2D T2W TSE, 3D T2*W axial CISS, plain and contrast-enhanced sagittal T1W 3D MP-RAGE is recommended for the evaluation of candidates scheduled for cochlear implantation. It provides information which cannot be obtained by HRCT.

Analysis of the availability and completeness of pervious radiological examinations related to plain films

Purpose: To evaluate the availability and completeness of previous radiological examinations.

Material and Methods: Seven different types of examinations were analysed separately: 1) chest examinations, 2) bedside chest examinations, 3) skeletal examinations, 4) angiographic examinations, 5) mammographic examinations, 6) CT examinations, and 7) MR examinations. A retrospective part of the study covered the calendar year 1997, while a prospective part referred to 1998. The sample size in each modality and each part of the study was 100 observations, resulting in a total number of 1,400 examinations.

Results: The average availability and completeness of radiographs in the retrospective analysis was 96.9% in 1997. The average availability and completeness of radiographs in the prospective analysis was 85.5% for the year 1998. This applied to necessary previous examinations of the same or different modality irrespective whether the examination was conducted internally or externally.

Conclusion: The real loss rate of radiographs derived from the retrospective investigation was 3.1%. The prospective part of the study showed that 14.5% of the required previous internal and external examinations of the same or different modality were not available completely and in time to the examining radiologist.

Frequency of benign hepatic lesions incidentally detected with contrast-enhanced thin-section portal venous phase spiral CT

Purpose: To evaluate the frequency of benign focal hepatic lesions incidentally detected at contrast-enhanced thin-section portal venous phase spiral CT.

Material and Methods: Between January 1998 and February 1999, contrast-enhanced hepatic spiral CT examinations were performed in 1,892 patients. Out of these, only 100 patients fulfilled the following inclusion criteria: No underlying malignant disease, no liver cirrhosis, no suspected or known focal liver lesions. Standardized spiral CT parameters were applied. All CT studies were reviewed retrospectively by one radiologist. Any focal lesion was recorded and classified. Lesion size and number were noted.

Results: A total of 108 hepatic lesions were reported in 33 out of 100 patients (80 cysts; 18 hemangiomas; 3 focal fatty infiltrations; 2 focal non-tumorous perfusion defects; 1 calcification; and 4 non-classified lesions). The average lesion size was 9.4 mm (≤5 mm: n=40; 6-10 mm: n=30; 11-15 mm: n=28; >15 mm: n=10).

Conclusion: Benign liver lesions are probably a frequent incidental finding at abdominal spiral CT.

Characterization of microvascularization of liver tumor lesions with high resolution linear ultrasound and contrast enhanced ultrasound (CEUS) during surgery: First results

AIM

Evaluation of high resolution linear ultrasound and intra-operative linear contrast enhanced ultrasound (CEUS) and its benefit for the detection and characterization of tumor lesions.

MATERIAL AND METHODS

Twenty patients were investigated preoperatively regarding tumor detection using CT (n = 8) or MRI (n = 12) and image fusion (VNav) (n = 3). All patients had surgery for their hepatic tumor (hepatocellular carcinoma (HCC), cholangiocellular carcinoma (CCC), metastasis, and adenoma). Ultrasound was performed intra-operatively first with B-scan using a convex probe. Than multifrequency linear transmitters (6-9 MHz, 6-15 MHz, LOGIQ E9, GE) were applied for B-scan, coulor coded Doppler sonography (CCDS) and Power Doppler followed by dynamic CEUS with Contrast Harmonic Imaging (CHI) after bolus injection of a maximum of 15 mL SonoVue®.

RESULTS

In 9 cases with the use of intra-operative CEUS additional tumor lesions (diameter 4-15 mm) could be detected and were histologically confirmed after surgical resection (7 cases) or intra-operative biopsy (2 cases). Using intraoperative CEUS 64 tumor lesions could be detected compared to 51 tumor lesions detected by preoperative CT or MRI (p < 0.05). Using the 6-15 MHz multifrequency linear transducer with CHI, arterial perfusion of adenomas, neuroendocrine metastases and HCC lesions was detectable. In 3 cases a resection was not achievable. Two of these cases were treated with radio frequency ablation (RFA). The other case had no curable option due to multifocal tumor manifestation.

CONCLUSION

The intra-operative use of high-resolution linear transducer techniques with CEUS offers new diagnostic perspectives for an effective liver surgery.

Image fusion with volume navigation of contrast enhanced ultrasound (CEUS) with computed tomography (CT) or magnetic resonance imaging (MRI) for post-interventional follow-up after transcatheter arterial chemoembolization (TACE) of hepatocellular carcinomas (HCC): Preliminary results

AIM

The assessment of the immediate post-interventional microcirculation and perfusion following transcatheter arterial chemoembolization (TACE) with new real time imaging fusion technique (VNav) of computed tomography (CT) or magnetic resonance imaging (MRI) with contrast enhanced ultrasound (CEUS) compared to follow-up.

MATERIAL

Following TACE an image fusion of CEUS with CT or MRI of the liver was performed in 20 patients (18 men, 2 women; age 29-75 years) with confirmed hepatocelluar carcinoma (HCC) to evaluate the post-interventional tumor vascularization and perfusion of HCC tumor lesions. Image fusion with CEUS performed immediately was compared with the result at the end of TACE (DSA), with post TACE CT (non-enhanced CT within 24 hours) and with follow up CT (enhanced CT after 6 weeks) after embolization. Ultrasound was performed using a 1-5 MHz multifrequency SonoVue transducer (LOGIQ 9/GE) after a bolus injection of 2-4ml SonoVue® with contrast harmonic imaging (CHI). Thirteen examinations were fused with a contrast enhanced CT, 7 with a MRI performed before TACE.

RESULTS

The post-interventional volume navigation image fusion of CT or MRI with CEUS showed differences regarding the residual tumor perfusion compared to other modalities. The correlation (Spearman-test) between the perfusion result at the end of TACE, non-enhanced CT after TACE and image fusion with CEUS was 0.42 and 0.50. The difference between the result at the end of TACE and the fusion with CEUS was significant (p < 0.05, Wilcoxon-test). The correlation between fusion of CEUS with CT/MRI and follow-up CT (after 6 weeks) was 0.64, the difference was not significant (p > 0.05). The differences between native CT within 24 hours after TACE and follow up CT after 6 weeks or fusion of CEUS and CT/MRI were significant (p < 0.05). The inter-observer variability was 0.61 at the end of TACE, 0.58 at non-enhanced CT (within 24 hours), 0.87 at fusion CEUS with CT/MRI and 0.74 at follow up CT after 6 weeks (Cohens Kappa test).

CONCLUSION

Image fusion with volume navigation (VNav) of CEUS with CT or MRI allows an accurate localisation of foci in patients with HCC. This exact mapping permits an easier control and evaluation of the results after TACE. The fusion of CEUS and CT or MRI allows a better evaluation of the microcirculation and the residual tumor perfusion at an earlier point of time than usual modalities of therapy control like non-enhanced CT. This might lead to a more differentiated monitoring of therapy.

Severe acute pancreatitis requiring drainage therapy: findings on computed tomography as predictor of patient outcome

BACKGROUND/AIMS

To evaluate whether morphologic features on computed tomography (CT) correlate with outcome of patients with severe acute pancreatitis (SAP).

METHODS

80 patients with SAP requiring percutaneous drainage therapy were retrospectively analyzed. Twelve CT features beyond the CT severity index (CTSI) were studied. Endpoints for patient outcome were patient death, length of hospital and ICU stay. The twelve features and the CTSI score were correlated with mortality using Kaplan-Meier estimator and correlated with length of hospital and ICU stay using the χ(2) test. A p value ≤0.05 was considered statistically significant.

RESULTS

Two CT features exhibited a significant correlation with mortality: (1) the number of parts of pancreas (head, corpus, tail) that exhibited areas of necrosis and (2) the presence of distant fluid collections (posterior pararenal space and/or paracolic gutter). Mortality was 42% (21 of 50 patients) and 20% (6 of 30 patients) if two/all three parts or none/one part of the pancreas exhibited necrosis, respectively. Mortality was 46% (18 of 39 patients) and 22% (9 of 41 patients) if distant fluid collections were present or absent, respectively. All other imaging features including the CTSI showed no significant correlation with patient outcome.

CONCLUSION

We identified two morphologic features on CT that might be helpful to predict prognosis of patients suffering from SAP. and IAP.

Detection and characterization of endoleaks following endovascular treatment of abdominal aortic aneurysms using contrast harmonic imaging (CHI) with quantitative perfusion analysis (TIC) compared to CT angiography (CTA)

PURPOSE

To show the feasibility of the detection of endoleaks following endovascular treatment of aortic aneurysms using contrast harmonic imaging (CHI) in comparison to computed tomography angiography (CTA).

MATERIALS AND METHODS

51 patients with suspected endoleaks, who underwent previous endovascular treatment for abdominal aortic aneurysm, were examined using CTA and vascular ultrasound. Biphasic CTA in all cases and digital subtraction angiography (DSA) in 8 patients were evaluated by two radiologists in consensus and served as the standard of reference. Ultrasound was performed by an experienced examiner with a multi-frequency linear transducer (2 - 4 MHz) using CHI following bolus injection of 2.4 ml of SonoVue® IV (maximum 5 ml). All images were evaluated by two observers in consensus regarding the reperfusion of the abdominal aneurysm using time intensity curve (TIC) analysis.

RESULTS

In 30 of 51 patients, endoleaks were detected concordantly in CHI and CTA. In 20 of 51 patients, no endoleak was found in CHI and CTA/DSA. In one patient, a type II endoleak could initially only be detected in CHI and was later confirmed in follow-up examinations by CTA (sens. 99%, spec. 93%, NPV 99 %, PPV 95%). TIC analysis allowed evaluation of the perfusion dynamics of endoleaks in all patients. Significant differences were found (p < 0.05, Mann Whitney U Test) regarding the perfusion within the aneurysm when an endoleak was present (10.39 ± 4.29 dB) or not present (6.42 ± 2.86 dB).

CONCLUSION

CHI with perfusion analysis allows definite detection of endoleaks, especially if contraindications for CTA are present. CHI presents an alternative for follow-up monitoring.

MRI enterography: the future of small bowel diagnostics?

MRI plays an increasing role in small bowel imaging of Crohn's disease. MR enterography (MRE) without nasojejunal intubation and radiation exposure offers similar results compared to MR enteroclysis (with intubation) and should be therefore the preferred method. Sensitivity and specificity is comparable to that of CT enterography. Capsule endoscopy is obviously superior to MRE in detecting superficial lesions, but this is limited to the mucosa and stenosis has to be excluded before examination using imaging, like MRE. There are no convincing studies in the literature regarding assessment of disease activity with imaging. Moreover, there is no consensus in the literature about a suitable reference standard.

Multidetector computed tomography mesentericography for the diagnosis of obscure gastrointestinal bleeding

PURPOSE

To evaluate the diagnostic yield of 16-row multidetector computed tomography (CT) mesentericography in patients with obscure gastrointestinal bleeding.

MATERIALS AND METHODS

The radiological information system database was used to retrospectively identify all patients in whom CT mesentericography (CTM) was performed for the diagnosis of obscure gastrointestinal bleeding between July 2002 and September 2006. A subsequent prospective study was conducted between October 2006 and September 2009 to evaluate CTM in patients with major obscure gastrointestinal bleeding. The retrospectively identified patients (six patients) as well as the prospectively evaluated patients (seven patients) constitute the study population. Following mesenteric DSA the catheter was left in the superior mesenteric artery, the patient was transferred to the CT suite and CTM was carried out by scanning the abdomen after contrast material injection via the catheter. Active bleeding was suspected if a focal area of high attenuation consistent with contrast material extravasation was found within the bowel lumen.

RESULTS

CTM detected the site of active bleeding in three of 13 patients (23 %). In the subpopulation of patients who were prospectively evaluated, CT mesentericography identified the site of active bleeding in one of seven patients (14 %). Depiction of active bleeding by CTM prompted surgical intervention in each case and surgery confirmed the findings of CT mesentericography.

CONCLUSION

Due to the relatively low rate of positive findings and inherent drawbacks, we feel that CTM cannot be recommended in general. However, in selected patients who are continuously bleeding at a low rate and in whom iv-CT was negative, CT mesentericography might be helpful.

[Cost analysis of contrast-enhanced cranial MRI at a German university hospital]

PURPOSE

Detailed evaluation and cost analysis of a cranial contrast-enhanced MRI (c-ceMRI) in outpatients, inpatients, patients in an intensive care unit and children under anesthesia.

MATERIALS AND METHODS

Based on a detailed process-oriented model, we calculated the cost of a cranial MRI for the four situations mentioned above. A comprehensive evaluation of the overhead and personnel costs was performed.

RESULTS

We performed 5108 MRI examinations on 2 scanners in the year 2008. 2150 examinations (42 %) were identified as c-ceMRI. For inpatients we calculated a total cost of € 242.46 per examination with a personnel cost of € 81.71 for the radiological department. In outpatients we calculated total costs of € 181.97 with radiological personnel costs of € 68.67. Patients coming from an intensive care unit were treated by an intensive care team, which resulted in total costs of € 416.58 with € 283 in costs for radiological personnel (32.8 %). MRI examinations of children under anesthesia resulted in costs of € 616.79 for the hospital, of which € 285.78 were radiological personnel costs (34.5 %).

CONCLUSION

In this study we evaluated for the first time different radiological scenarios of a c-ceMRI at a university hospital. Considering the present reimbursement situation, all outpatients covered by statutory health insurance resulted in a deficit for the hospital. Particularly high costs for patients in intensive care units as well as for children under anesthesia have to be taken into account and are currently not adequately covered by care providers.

Primary percutaneous aspiration and thrombolysis for the treatment of acute embolic superior mesenteric artery occlusion

OBJECTIVES

To evaluate technical success rate and clinical outcome of patients with acute embolic superior mesenteric artery (SMA) occlusion who were treated with primary percutaneous revascularization.

METHODS

At three medical centers the radiological information system databases were used to identify all patients in whom primary percutaneous revascularization for the treatment of acute embolic SMA occlusion was attempted between 2001 and 2010. Percutaneous treatment was performed in 15 patients (median age 80 years, range 49-88 years). These patients represent the study population. Eleven patients reported abdominal pain. Five patients exhibited peritoneal signs. Revascularization was defined as complete technical success if (1) patency of the SMA with residual stenosis of not more than 30% in diameter and (2) sufficient perfusion of the entire bowel were obtained.

RESULTS

Complete technical success was achieved in eleven patients. After percutaneous revascularization laparotomy was performed in six patients and in three of them bowel resection was carried out (length of resected segments 20-80 cm). The 30-day mortality was 33% (five of 15 patients). None of the surviving patients exhibited short-bowel syndrome.

CONCLUSIONS

Primary percutaneous aspiration and thrombolysis constitutes a promising alternative to surgical revascularization in selected patients with acute embolic SMA occlusion.

Sono-hepatic-arteriography (Sono-HA) in the assessment of hepatocellular carcinoma in patients undergoing transcatheter arterial chemoembolization (TACE)

PURPOSE

The aim of our study was to evaluate sono-hepatic-arteriography in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization.

MATERIALS AND METHODS

We evaluated 15 patients with hepatocellular carcinoma undergoing TACE who presented in our institution from February 2006 to May 2008. All patients underwent a conventional B-mode ultrasound examination using a high-end machine and a multi-frequency transducer (2.5 - 4 MHz) before dynamic contrast-enhanced ultrasound examination was carried out. For the sono-hepatic-arteriography 1 ml SonoVue was injected as a bolus using the formerly placed intraarterial catheter. Biphasic enhanced computed tomography was performed using a 16-slice CT scanner up to 48 hours before transcatheter arterial chemoembolization and during follow-up.

RESULTS

The lesion size (of the largest lesion) ranged from 1 to 13 centimeters in their largest diameter (mean: 4.8 cm). Contrast-enhanced ultrasound diagnosed more lesions than B-mode sonography in eight cases and more lesions than computed tomography in 5 patients. The findings of sono-hepatic-arteriography were correct in fourteen cases (93.3 %). Direct impact on patient management was seen in eleven patients (73.3 %).

CONCLUSION

We were able to show that the application of an intraarterial sonographic contrast agent during embolization is able to diagnose new lesions on the one hand and to assess the embolization success on the other. This might improve transcatheter arterial chemoembolization results and patient outcome.

[PACS: acceptance by orthopedic surgeons]

PURPOSE

The goal of the study was to evaluate the acceptance of a web-based picture archiving and communication system (PACS) by orthopedic surgeons 1 year after implementation.

MATERIALS AND METHODS

One year after the implementation of a web-based PACS all physicians were surveyed with a standardized questionnaire. Questions included: speed of PACS, quality of clinicoradiological meetings, quality of monitors, PACS training, and performance. Data were evaluated separately for the Department of Orthopedic Surgery and the reference group of all other physicians.

RESULTS

Among the respondents, 92% of the orthopedic surgeons stated there was a reduction of time required to receive images, and 64% concluded that patient care was faster. Archived images were received in less than 5 min in 82% after PACS and in 8% before PACS. The clinicoradiological meetings improved with PACS in 100% due to beamer presentation. All would recommend a PACS. The equipment to view images in the operating theater was assessed as being good or very good by 83%; monitor quality was judged better for the outpatient clinics (100% good or very good). Conventional radiograms were missed at the ward rounds by 56%. Training for PACS was considered sufficient by 67%, and 15% asked for refresher courses. In the reference group 60% asked for refresher courses. In the comparison of orthopedic surgeons with the reference group PACS was judged better especially concerning the viewing software and quality of monitors.

CONCLUSION

There is an over all acceptance of PACS by physicians outside the radiology department. The availability of images was not only facilitated it was faster as well. However, the quality of monitors in the operating theater should be improved. To achieve sustained success of PACS consistent training on PACS and its features is necessary. Conventional radiograms were often missed at the ward rounds.

New perfusion imaging of tissue transplants with Contrast Harmonic Ultrasound Imaging (CHI) and Magnetic Resonance Imaging (MRI) in comparison with laser-induced Indocyanine Green (ICG) fluorescence angiography

PURPOSE

Evaluation of post-surgery tissue perfusion of free flaps of the lower leg with contrast enhanced harmonic imaging (CHI), laser-induced indocyanine green (ICG) fluorescence angiography and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

10 patients with free flaps of the lower limb were evaluated with CHI, ICG-fluorescence angiography and perfusion weighted MRI. Perfusion weighted MRI was performed after intravenous bolus injection of 25 ml Gd-DTPA. The ICG fluorescence was detected by a near-infrared-laser device (lambda em = 780 nm). Ultrasound was carried out by an experienced examiner with a linear probe after intravenous bolus injection of 2.4 ml SonoVue. For MRI time intensity curves as well as color-coded blood volume maps of the whole free flap were qualitatively evaluated. For CHI and ICG time intensity curves in selected regions of interest were analyzed. A score from 1-5 (1 = low, 5 = excellent) was used for analysis of perfusion images by three independent readers.

RESULTS

In 3 cases (radialis, parascapular and lateral thigh flap) CHI, MRI and ICG perfusion imaging showed an excellent (score 4-5) contrast enhancement of the cutaneous and subcutaneous part of the free flaps. In 2 cases of osteocutaneous flaps perfusion in central and distal parts of the free flaps was reduced (score 2). Correlation between CHI, MRI and ICG was 0.69-0.83 for the distal parts of the free flaps and 0.74-0.87 for the center of the flaps (Spearman test). Perfusion in the center of the free flaps was significantly different for MRI and ICG and also for MRI and CHI (p<0.05, Wilcoxon test).

CONCLUSION

These first results introduce CHI and MRI perfusion imaging as a promising post-surgery monitoring in patients with free flaps.

BLADE in sagittal T2-weighted MR imaging of the cervical spine

BACKGROUND AND PURPOSE

Image quality and diagnostic reliability of T2-weighted MR images of the cervical spine are often impaired by several kinds of artifacts, even in cooperative patients. The aim of this study was to evaluate if BLADE sequences might solve these problems in a routine patient collective.

MATERIALS AND METHODS

TSE and BLADE sequences were compared in 60 patients for T2-weighted sagittal imaging of the cervical spine. Image sharpness, motion artifacts, truncation artifacts, metal artifacts, CSF flow phenomena, contrast of anatomic structures (vertebral body/disk, spinal cord/CSF), and diagnostic reliability of spinal cord depiction were evaluated by 2 independent readers. Another 2 readers selected the sequence they would prefer for diagnostic purposes. Statistical evaluations were performed by using the Wilcoxon and the chi(2) test; differences with P < .05 were regarded as statistically significant.

RESULTS

BLADE was significantly superior to TSE regarding image sharpness, image contrast, diagnostic reliability of spinal cord depiction, motion artifacts, CSF flow phenomena, and truncation artifacts; for metal artifacts no significant improvements were found. In 50 of 60 patients, BLADE was preferred for diagnostic purposes, and TSE was favored in 3 patients. The number of examinations that were nondiagnostic due to impaired spinal cord depiction was reduced from 12 in TSE to 3 in BLADE, and nondiagnostic examinations due to overall motion artifacts were reduced from 2 to 1.

CONCLUSIONS

Using the BLADE sequence for sagittal T2-weighted imaging of the cervical spine proved to be advantageous to reduce various kinds of artifacts.

Microcirculation and perfusion with contrast enhanced ultrasound (CEUS) in Crohn's disease: first results with linear contrast harmonic imaging (CHI)

AIM

To evaluate a newly introduced high resolution linear transducer for vascularization and mural perfusion assessment using contrast harmonic imaging (CHI) with quantitative time intensity curve analysis (TIC) in patients with active Crohn's disease (CD).

MATERIAL AND METHODS

We prospectively evaluated 14 consecutive patients (7 women, 7 males, age range 19-42 years, median 28 years) with histologically proven CD having an acute episode of the disease applying contrast enhanced MRI and high resolution ultrasound. For the ultrasound we used a newly introduced high resolution linear multi-frequency transducer (6-9 MHz, Logiq 9, GE). Ultrasound was performed by an experienced radiologist applying color coded Doppler sonography (CCDS), power Doppler (PD) and contrast enhanced CHI using the 'true agent detection mode'. Additionally, 5 healthy volunteers were examined by ultrasound applying CCDS, PD and CHI. After the injection of 2.4 ml ultrasound contrast agent (SonoVue) the dynamic CHI cine sequences were recorded as digital raw data for 60 seconds. Therefore we were able to perform a quantitative perfusion analysis using TIC retrospectively. CCDS, PD and CHI with TIC were compared and analyzed.

RESULTS

In all 14 patients MRI showed inflammatory changes in the terminal or pre-terminal ileum. Using PD and CCDS enlarged vessels surrounding the bowel wall were visualized in all patients. PD as well as CCDS diagnosed just in 9 of 14 patients augmented mural vessels. Having CHI with TIC increased mural contrast enhancement was diagnosed in all 14 patients. Patients with CD showed a maximum enhancement 36 s after injection with 9 dB (range 5.9-13.2 dB), while healthy volunteers reached the maximum level of 2.8 dB (range 2-3.8 dB) after 23 s (p<0.05).

CONCLUSION

Using high resolution linear transducer mural perfusion changes in active Crohn's disease can be appreciated applying CHI with TIC. This technique could be an effective dynamic imaging modality for diagnosis and especially follow-up examination to monitor treatment in CD.

[Diagnosis of and therapy for gastric cancer--work-flow]

AIM

This review comments on the diagnosis and treatment of gastric cancer in the classical meaning--excluding adenocarcinoma of the -oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are presented. PREOPERATIVE DIAGNOSIS: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recommended for preoperative evaluation of tumours > T1, laparoscopy has become an effective stag-ing tool in T3 and T4 tumours avoiding unnecessary laparotomies and improving the detection of small -liver and peritoneal metastases.

TREATMENT

Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a / no ulcer / G1, 2 / Laurén intestinal / L0 / V0 / tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2 LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in -patients with favourable prognosis, this also -applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50 % of patients with liver metastases show concomitant peritoneal dissemination of the disease.

DISCUSSION AND CONCLUSIONS

Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4 tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoperative chemoradiotherapy may be debated.

Sequential Combination Therapy Leading to Sustained Remission in a Patient with SAPHO Syndrome

The SAPHO syndrome represents a variety of clinically similar disorders with the key features of hyperostotic bone lesions in combination with chronic pustular skin disease. The respective pathophysiology of bone and joint manifestations in SAPHO syndrome is still a matter of discussion. For example it does not appear to represent reactive arthritis and HLA B27 antigen, with the latter being typically present in patients with spondyloarthopathies. Treatment of SAPHO syndrome is also not well established and consists of various antiinflammatory and antirheumatic drugs. Here, we report a female patient with active SAPHO syndrome suffering from sternal swelling of unknown origin that had been known for 10 years and a 4-year-history of severe lower back pain. Remarkable were also a typical pustulous palmar erythema associated with swelling and decreased motility of both MCP-I joints. Inflammation parameters were high with an ESR 68 mm/1st hour and a CRP of 19.6 mg/l. She was initially treated with rofecoxib and doxycycline, followed by sulfasalazine with only partial clinical response. Thereafter, both articular symptoms as well as cutaneous lesions responded well to a combination therapy with methotrexate and sulfasalazine. Thus, the case illustrates nicely that methotrexate in combination with another DMARD can be successfully applied to patients with long-term active SAPHO syndrome.

[Stenting in the treatment of chronic mesenteric ischemia: technical and clinical success rates]

PURPOSE

To evaluate the technical and clinical success rates of percutaneous stent revascularization in the treatment of chronic mesenteric ischemia (CMI).

PATIENTS AND METHODS

17 patients (12 female) with typical symptoms of CMI were treated by percutaneous stent placement for stenoses of the splanchnic arteries (celiac trunk; superior mesenteric artery, SMA; inferior mesenteric artery, IMA). The primary and secondary technical success, primary and secondary clinical success, and the long-term clinical outcome were determined.

RESULTS

A total of 24 stents were implanted in 21 splanchnic arteries (12 stents in the celiac trunk, 11 in the SMA and 1 in the IMA). The primary technical success rate was 91% (19/21 arteries), the secondary technical success rate was 95% (21/22 arteries). Clinical follow-up was available for 16 patients. The primary clinical success rate was 81% (13/16 patients). Following two secondary interventions, the secondary clinical success rate was 94% (15/16 patients). Long-term clinical success was achieved in 15 of 16 patients (94%) with a mean follow-up of 26 months. One patient died within 30 days of the intervention and two patients demonstrated major complications (1 dissection, 1 stent dislocation). None of the patients required surgical revascularization and none of the patients died due to recurrent mesenteric ischemia.

CONCLUSION

Percutaneous stent placement for the treatment of CMI can be performed with a high technical and clinical success rate as well as an excellent long-term clinical outcome.