Biomedical subjects
Publications and source records attributed to M Georgi.
A stereotactic apparatus for percutaneous needle biopsy under computed tomographic (CT) control is described. A program was developed that allows the transfer of CT data to the stereotactic apparatus. No artifacts of the CT images are caused by the stereotactic apparatus. Preliminary results in 36 patients (34 biopsies and two nerve blocks) are reported.
Intravenous Digital Subtraction Angiography (DSA) is described in a patient with severe fibromuscular renal artery dysplasia. DSA identified only a mild renovascular stenosis, while intraarterial angiography demonstrated multiple severe stenoses alternating with aneurysmatic segments. This case confirms the limitations of intravenous subtraction angiography. Higher spatial resolution is required if small stenoses are to be ruled out.
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Percutaneous transhepatic portal vein catheterisation with blood sampling from the various areas of drainage, especially the pancreatic veins, was undertaken in seven patients with insulinoma to diagnose its site. In six patients measurement of serum-insulin levels revealed an abrupt rise in the vascular area later found to drain the area of the insulinoma. Insulin measurement in one patient with insulinoma in the head of the pancreas falsely indicated an islet-cell tumour in the region of the tail of the pancreas. C-peptide concentration in serum followed the concentration of insulin, but did not show such a marked rise. The method of percutaneous transhepatic portal vein catheterisation with selective blood sampling for the measurement of hormonal concentration was superior to ultrasound, computer tomography or coeliacography for determining the site of the tumour.
Cystic diseases of the adrenal glands, which were thought to be rare, are being found more frequently nowadays by means of sonography and computer tomography. Our experience of fifteen cases is reported; of these, ten were confirmed at operation. Contrary to expectations based on the relevant literature, only one of the operated cases proved to be an endothelial cyst of lymphangiomatous origin. All other patients had pseudo-cysts of the adrenals. These are due to bleeding into a normal or tumour-containing gland. About one quarter of the pseudo cysts showed circular calcification on the plain films, although the incidence of this is given as 8-15% in the literature. The cystic nature of these lesions can be readily demonstrated by ultrasound or CT. The latter also provided information concerning the wall of the cyst and of the remaining adrenal tissue. An aspiration biopsy of the cyst can be carried out under ultrasound or CT control; cytological examination will confirm the benign nature of the lesion. A benign lesion without symptoms requires no further diagnostic or therapeutic measures. If there is hypertension, as may occur with a cystic phäeochromocytoma or lymphangioma, angiography is still indicated. Hormone assays are possible following catheterisation of the vena cava combined with adrenal phlebography. The origin and extent of a malignant pseudo-cyst can be demonstrated by arteriography, if this information is lacking following CT.
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Indicating sign: Esophageal hemorrhages in adolescence. Congenital hepatic fibrosis and infantile polycystic disease of the kidneys. A 17-year-old patient with hypersplenism and signs of portal hypertension came to clinical treatment after an esophageal hemorrhage. Rare syndrome of congenital hepatic fibrosis with portal hypertension and splenomegaly, with infantile polycystic disease of the kidneys and aneurysms of the splenic artery was recognizable by means of ultrasound, laparoscopy and angiography. Therapeutically splenorenal shunt and splenectomy were carried out.
The comparison of transvenous cholangiography (TVC) in 82 patients with percutaneous transhepatic fine needle cholangiography (PTFC) in 84 patients showed that TVC must be considered obsolete due to the complicated procedure with low success rate (56.9%). In one case it led to septicaemia followed by death. The total success rate was 84.5% in PTFC performed with an ultrathin needle (0.5 mm diameter); congested biliary ducts were successfully punctured in 87.9% and noncongested ducts in 72.2%. Severe complications consisted of one case of intraabdominal bleeding and one biliary extravasation. As shown in animal experiments, the superficial parenchymal lesion has not always the shape of a point. High accuracy also in noncongested biliary tracts and low mortality make PTFC superior to TVC and conventional percutaneous transhepatic cholangiography.
In 36 patients with clinical suspicion of liver tumours, pharmaco-angiography using adrenalin was added to the usual liver arteriography. In 31 of these patients rumour involvement of the liver was confirmed by surgery, laparoscopy or autopsy. In four out of ten patients with benign liver tumours, pharmaco-angiography lead to improved demonstration and therefore classification of the tumour. Four out of seven malignant primary tumours. Four out of seven malignant primary tumours of the liver were also better demonstrated by pharmaco-angiography. Amongst 14 patients with liver metastases, an improvement in the angiographic demonstration by pharmaco-angiography was achieved in nine. This was particularly the case in tumours showing tumour vessels. Neither benign nor malignant tumours showed constriction of their vessels as a result of pharmaco-angiography and this is therefore not able to differentiate between these. It was also found that tumours showing the the same histology could behave differently during pharmaco-angiography.
Report of the result of CT and venography in 12 patients with suspected adrenal disease, venography being combined with selective blood sampling for hormone analysis. In one patient CT showed a 1.6 cm big pheochromocytome in the left adrenal gland, not demonstrated by venography, but proven by analysis of the blood sample. Both methods showed hyperplasia of both adrenals in one patient with Cushing Syndrome with elevated Cortisol levels found in the analysis of the blood smples. Of 3 patients with hyperaldosteronism, venography was able to demonstrate 2 Conn adenomas, not seen on CT; whereas CT showed the third 2 X 1.5 cm big Conn adenoma hidden in an enlarged adrenal gland. Hormone analysis was helpful in 2 of these cases, while in the third it was misleading. The authors believe that both methods should be employed to localise over adrenal disease with endocrine activity.
In six patients with adrenal pheochromocytoma the tumors were localized by ultrasonography, phlebography of the adrenal glands and by estimation of plasma catecholamines selectively obtained from the vena cava and the adrenal gland veins. All tumors were localized by selective catecholamine estimation, five by ultrasonography, and four by phlebography. The smallest pheochromocytoma of 1.5 g weight was only localized by selective catecholamine estimation but not by ultrasonography or phlebography. This tumor, however, had been visualized by computed tomography. To avoid diagnostic errors by selective catecholamine estimation, it is important to withdraw blood from the adrenal gland veins prior to the injection of any radiographic contrast media, since this may result in an extremely enhanced secretion of catecholamines from the adrenal medulla.
Urinary catecholamines and urinary excretion of vanillylmandelic acid confirmed the diagnosis of phaeochromocytoma in ten patients. In two of seven a modified glucagon test significantly aided confirmation of the diagnosis. In all patients the tumour was localised both by catecholamine determination in blood from the vein draining into the inferior vena cava (IVC) and by adrenal phlebography. Site of the adrenal tumour was definitively determined by the high catecholamine level in the adrenal veins and by phlebography. Three extra-adrenal tumours, a thoracic and two abdominal ones, were localised by high catecholamine levels in blood from other veins draining into the IVC. Vanillylmandelic acid determinaion was unreliable in the diagnosis of small phaeochromocytomas.
In 68 patients arterial and portal blood flow were measured by angiodensitometry in the course of routine, indirect splenoportography. Results were compared with those already published, with investigations of a model and with animal experiments. It was shown that, given certain underlying conditions, reliable results can be obtained even in the presence of a pulsatile flow and incomplete contrast mixing. Compared with other procedures, the method has the advantage of providing a complete picture of liver haemodynamics in the course of routine splenoportography in a simple way and without affecting the patient further. As a result the indications for performing a shunt and the choice of the shunt technique can be more accurately determined.
Two patients with the Mirizzi syndrome are described and the findings on sonography and PTC care discussed. The difficulties of differentiating this from biliary obstruction due to tumour are stressed and treatment and prognosis are set out.