POOPERATIVNA SLABOST IN BRUHANJE NELAGODJE IN STISKA OGROŽATA USPEH OPERATIVNEGA POSEGA PREPRECEVANJE Ena sama intravenska injekcija po 4mg pri uvajanju v anestezijo ,g ZDRAVLJENJE Ena sama intravenska injekcija po 4mg ondansetron Glaxo Podrobnejše informacije dobite pri: Glaxo Export Limited Podružnica Ljubljana , Cesta v Mestni log 55, 61115 Ljubljana, p.p. 17, Slovenija Telefon: (38661) 1231070, 1232097, 1232319 Telefax: (386 61) 123 25 97 RADIOLOGY AND ONCOLOGY Radiology and Oncology is a journal devoted to publication of original contributions in diagnostic and interventional radiology, computerized tomography, ultrasound, magnetic resonance, nuclear medicine, radiotherapy, clinical and experimental oncology, radiophysics and radiation protection. Editor in chief Tomaž Benulic Ljubljana, Slovenia Associate editors Gregor Serša Ljubljana, Slovenia Viljem Kovac Ljubljana, Slovenia Editorial board Marija Auersperg Ljubljana, Slovenia Matija Bistrovic Zagreb, Croatia Haris Boko Zagreb, Croatia Nataša V. Budihna Ljubljana, Slovenia Malte Clausen Kiel, Germany Christoph Clemm Miinchen, Germany Mario Corsi Udine, Italy Christian Dittrich Vienna, Austria Ivan Drinkovic Zagreb, Croatia Gillian Duchesne London, Great Britain Bela Fornet Budapest, Hungary Tullio Giraldi Udine, Italy Andrija Hebrang Zagreb, Croatia Durila Horvat Zagreb, Croatia Laszlo Horvath Pecs, Hungary Berta Jereb Ljubljana, Slovenia Vladimir Jevtic Ljubljana, Slovenia H. Dieter Kogelnik Salzburg, Austria Ivan Lovasic Rijeka, Croatia Marijan Lovrencic Zagreb, Croatia Luka Mi/as Houston, USA Maja Osmak Zagreb, Croatia Branko Palcic Vancouver, Canada Jurica Papa Zagreb, Croatia Dušan Pavcnik Ljubljana, Slovenia Stojan Plesnicar Ljubljana, Slovenia Ervin B. Podgoršak Montreal, Canada Jan C. Roos Amsterdam, The Netherlands Horst Sack Essen, Germany Slavko Šimunic Zagreb, Croatia Lojze Šmid Ljubljana, Slovenia Andrea V eronesi Gorizia, Italy Publishers Slovenian Medica/ Society -Section oj Radiology, Croatian Medica[ Association -Croatian Society oj Radiology Affiliated with Societas Radiologorum Hungarorum Friuli-Venezia Giulia regional groups of S.I.R.M. (Italian Society of Medica! Radiology) Correspondence address Radiology and Oncology Institute of Oncology Vrazav trg 4 61000 Ljubljana Slovenia Phone: + 386 61 1320 068 Fax: +38661 1314 18 0 Reader f or English Olga Shrestha Design Monika Fink-Serša Key words und UDC Eva Klemencic Secretaries Milica Harisch Betka Savski Printed by Tiskarna Tone Tomšic, Ljubljana, Slovenia Published quarterly Bank account number 5010167 848454 Foreign currency account number 50100-620-133-27620-5130/6 Nova Ljubljanska banka d.d. -Ljubljana Subscription fee for institutions 100 USD, individuals 50 USD. Single issue for institutions 30 USD, individuals 20 USD. According to the opinion of the Government of the Republic of Slovenia, Public Relation and Media Office, the journal RADIOLOGY AND ONCOLOGY is a publication of informative value, and as such subject to taxation by 5 % sales tax. Indexed and abstracted by BIOMEDICINA SLOVENICA CHEMICAL ABSTRACTS EXCERPTA MEDICA/ ELECTRONIC PUBLISHING DIVISION CONTENTS INTERVENTIONAL RADIOLOGY Laser angioplasty and thrombolytic treatment for femoral artery occlusion Otto W, Rowifiski O, Malkowski P, Paczkowski P, Pruszy,zski B, Karwowski A 185 ULTRASOUNJD ANJD COMPUTERISEJD TOMOGRAPHY Value of ultrasound in tile diagnosis of acute appendicitis Drinkovic l, Brkljacic B, Odak D, Hebrang A 190 Color-JDoppler in the diagnosis and postoperative follow-up of varicoceles Drinkovic l, Brkljacic B, Stepanic V, Hebrang A 194 Venous tluombosis of the portal system. Etiology, diagnosis and treatment -analysis of 225 cases Malkowski P, Michalowicz B, Pawlak J, Otto W, Leowska E, Rowifiski O, Paluszkiewicz R, Paczkowski PM, Zieniewicz K 198 JDirect sagittal computed tomography in diagnosis and treatment of intemal derangements of the temporomandibular joint Roic G, Klaric Jurkovic T, Panduric J, Cop S 203 EXPERIMENTAL ONCOLOGY Changes in some collon mucosal cells after irradiation Zorc-Pleskovic R 207 Glutathione concentration and glutathione S-transferase activity in gynecological normal and tumor tissues: A preliminary re1>0rt Osmak M, Babic D, Abramic M, Milicic D, Bizjak L, Beketic-Oreškovic L, Cepulic E, Oreškovic S, Jukic S, Eljuga D 211 CLINICAL ONCOLOGY High rate of complication in patients with carcinoma of the cervix surgicaly treated after radical radiotherapy Fras AP 218 Staging laparotomy for Hodgkin's disease in adults: One center experience Vovk M, Šumi-Križnik T, Jenko-Fidler M, Petric-Grabnar G, Kremžar M, Novak J, Sencar M, Zakotnik B, Vodnik-Cerar A, Jakšic B 223 Electrochemotherapy with bleomycin. The first clinical experience on malignant melanoma patients Rudolf Z, Štabuc B, Cemažar M, Miklavcic D, Vodovnik L, Serša G 229 Cytostatic chemotherapy for small celi lung cancer in patients of age 75 years or older Berzinec F, Kroslak M, Petricek S, Arpasova M, Kuzmova H 236 RADIOPHYSICS Analytical representations of clinical electron beam central axis depth doses Wierzbicki W, Podgorsak EB COMMUNICATIONS European Code Against Cancer Boyle P, Primic-Žakelj M REPORT Report from the ESO training course on tumor biology Cemažar M 250 NOTICES 253 The publication of the journal is subsidized by the Ministry of Science and Technology of the Republic Slovenia. Fundacija doc. dr. l. Cholewa, Ljubljana; Inštitut za diagnosticno in intervencijsko radiologijo, KC Ljubljana; Klinika za otorinolaringologijo in maksilofacialno kirurgijo, KC Ljubljana; Klinicki zavod za dijagnosticku interventnu radiologiju, KBC Rebro, Zagreb; Onkološki inštitut, Ljubljana Radio! Oncol 1995; 29: 185-9. Laser angioplasty and thrombolytic treatment f or femoral artery ocdusion Wlodzimierz Otto,1 Olgierd Rowinskit Piotr Malkowski, 1 Pawel Paczkowski, 1 Bogdan Pmszynski, , Andrzej Karwowski1 1 Clinic of General Surgery & Liver Diseases, 2 II Department of Rentgenodiagnosis, Medica[ Academy of Warsaw, Warsaw, Poland Among 27 patients with femoral artery occlusion that were treated by transluminal N d: Y A G laser angioplasty, in 16 patients the procedure was combined with intraarterial infusion of rTP A (Actilyse -Boehringer lng). In 5 out of II patients from the initial group recanalization was not successful. In 16 patients from rTP A group satisfactory immediate results were achieved in alf cases. In long tirne observations ranging from 9 to 24 months alf patients remained free from symptoms, although in 4 out of them angiography and Doppler ulirasound examination reveal no flow in femoral artery. In the remaining 12 patients (75 %), the previously occluded artery is patent. No complications of laser angioplasty nor intraarterial infusion of rTP A were noted in this series. Key words: arterial occlusive diseases-therapy; femoral artery; thrombolytic therapy; angioplasty, laser Introduction Laser angioplasty is the new method of treat­ment in some cases of arteriosclerotic occlusion of peripheral arteries, resulted in ischemia of lower extremities.1-4 Among different laser ap­plicators, the Neodymium: Yttrium -Alumi­nium -Garnet laser (Nd:YAG) appeared to be the most suitable instrument for such procedu­re. 5- 7 Compared to other lasers, the Nd:YAG is much more powerful and allows to perform angioplasty with sapphire or ceramic tips at the end of laser fiber. This contact method of laser Correspondence to: Wlodzimierz Otto, MD, Clinic of General Surgery & Liver Diseases, Medica! Academy of Warsaw, Babacha la, 02-097 Warsaw, Poland recanalization is performed in different centers and generaly accepted, as presented in many 10 publications. 3­ Many observations also indicate that mecha­nical or thermal methods of the artery recana­lization should be combined with thrombolytic treatment. The recombinant tissue-type plasmi­nogen activator (rTP A) seems to be the best agent in these cases, much more safe and effective that urokinase or streptokinase.11-14 We would like to present our own experience in the treatment of femoral artery occlusion with the method of laser angioplasty, combined in 16 cases with intrarterial infusion of rTP A. Materials und methods UDC: 616.137.87-005.6-08 In the Clinic of General Surgery & Liver Dise­ 186 Otto W et al. Figure l. Initial arteriography just before recanaliza­tion. ases and the II Department of Rentgenodiagno­sis, Medica! Academy of Warsaw, the procedu­res have been performed since 1991. We use SLT (Surgical Laser Technology), Nd:YAG laser and contact method of vaporization. The laser fiber is introduced to the lumen of artery in antegrade fashion by Seldinger techni­que, and angiography is performed to localize precisely the proximal wedge of occlusion. Then the sapphire tip is positioned close to it under fluoroscopy. Recanalization is proceeded in step by step fashion with 8 to 12 watts, at I seccond of power output. The position of the laser fiber tip and the state of recanalization is continously observed under fluoroscopy during the tirne of procedure. Arteriography is made as well, by means of infusion of small amount of contrast medium after each step of recanali­zation (Figure 1). When the recanalization of artery is succes­sfully achieved, the laser fiber is passed through the place of occlusion for severa! times to enlarge lumen of recanalized artery and make the canal more smooth. Despite of successful laser recanalization, the procedures were com­pleted with baloon angioplasty in ali cases (Fi­gure 2, Figure 3). The procedure was carried out in 27 patients, 20 males and 7 females. The average age was 58. In ali cases the diagnosis was established by arteriography and ultrasound Doppler exa­mination which indicated femoral artery occlu­sion, ranging from 2 to 16cm in Iength. Ali patients suffered from ischemia of lower extre­mity for severa! weeks and were in II -III stage of ischemia, according to Fontain scale. Ali of them were excluded from operative treatment due to respiratory and circulatory insufficiency, or did not want to be operated upon. A day prior to the procedure, ali patients received 3 tablets of aspirin. On the day of procedure, in the initial group of 11 patients we used heparin, administered as bolus injection in dose of 5 000 u., followed after recanalization by intra- Figure 2. Successfull recanalization was achieved. Laser angioplasty and thrombolytic treatment far femoral artery occlusion Figure 3. Laser procedure is completed with baloon angioplasty. venous infusion of heparin in dose of 1 000 u./hour during 2-3 days. In the next group of 16 patients laser angio­plasty was followed by infusion of rTP A (Acti­lyse -Boehringer Ing.) in dose of 2 mg / hour administered intraarterial during 10 hours. Ali patients were treated subsequently with dicumarol and the flow through the femoral artery was controlled by clinical and Doppler ultrasound examination. Results In the initial group of 11 patients, treated with laser angioplasty and heparin, in 5 patients the procedure failed. In 3 of them perforation of the artery occured, resulting in immediate leg amputation in 2 patients. In 2 others laser recanalization was not successful, followed the amputation of extremity soon. Two patients died. In 6 patients successful recanalization of the artery was achieved and they were discharged from hospital free from symptoms. In the group of 16 patients, treated with laser-baloon angioplasty and the infusion of rTP A, complications have not been noted. Full recanalization of artery and the release of sym­ptoms was achieved in all cases, as confirmed by arteriography done at the end of procedure in each patient (Figure 4, Figure 5). All patients who underwent successfuly reca­nalization, remained free from symptoms from 9 to 24 months, averagely 9 months. As confir­med by Doppler ultrasound examination, the Figure 4. Artcriography before and aftcr recanaliza­tion in patient with femoral occlusion. Figure 5. The same situation in patient with popliteal occlusion. 188 Otto W et al. artery is patent in 70 % , with normosystolic flow through the recanalized lumen. In 30 % , Doppler usg indicates structure or partial reoc­clusion of artery, however, there are no syp­toms of ischemia observed, at the 4,0 mm 4. perityphlitic abscess visualization The following equipment was used for exami­nation : the Radius CF GI, RT 4000, RT 3600, RT 2800, all provided with 7 ,5 MHz transducers and the first two also with additional 7 ,5 MHz intravaginal transducers. Results During a 10-year study 570 patients with clinical symptoms of appendicitis, accompanied with increased temperature and leukocytosis, were examined. Using ultrasonography, acute appen­dicitis was suspected in 385 patients by the above mentioned criteria, while in 185 patients the diagnosis of appendicitis was ruled out or was uncertain. Open or laparoscopic surgery was performed in 385 patients. In 11 patients ultrasound diag­nosis was not accurate, the picture of appendi­citis having been simulated by inflammatory bowel diseases, adentis, or inflammatory altera­tions in the small pelvis. A hundred and eighty-five patients ultrasono­graphically diagnosed without the signs of ap­pendicitis or with suspected appendicitis were followed-up intensively in the course of 5 days, and in 42 patients a clinical picture of appendi­citis eventually developed, in some of them subsequently recognized at sonography. These 42 patients were submitted to surgery. Sensitivity of the examination was 89 % , spe­cificity was 94 % and accuracy 90 % . Discussion Despite the apparently manifested symptoms of appendicitis in most of the patients, the diagno­sis of acute appendicitis can be difficult in a smaller group of patients including especially children, pregnant women and elderly people. Certain gastrointestinal diseases, genitourinary system diseases and obstretric and gynaecologi­cal diseases present particular problems in dif­ferential diagnosis. Even with ali laboratory and clinical examina­tions available 10-30 % of the patients diagnos­ed with appendicitis are operated on without a real reason as actually suffering from a disease other than appendicitis, eg. disease of some of the systems mentioned above. Using ultrasonography the number of unne­cessary operations on our patients was reduced to only 2.85 (11 % ) of patients. Figure l. Shows thc thickcncd wall of the appcndix > 4,00mm. Figure 2. Shows the thickened wall of the appendix up to 4,0 mm with formcd perityphlitic abscess. Drinkovic 1 et al. It shoud be mentioned that ultrasonography prevented 185 patients (32.4 % ) from being operated on due to failure to recognize or establish a certain diagnosis of appendicitis, and that intensive follow-up of patients enabled a stili timely operation in 42 of them (7 % ) . thus avoiding possible complications. The use of ultrasonography prevented an unnecessary operation in 142 (24.9 % ) patients. When assessing acute appendicitis all clinical and laboratory parameters, as well as ultrasono­graphic parameters of inflammation including the wall thickness greater than 4.0mm and liquid, ie. perityphlitic abscess formation should be observed. (Figure 1, 2) It is very important to use the dosed compres­sion technique with appendix visualization, as well as pain registration, which additionaly im­prove examination accuracy. Intravaginal ultrasonography was of great im­portance in diagnosing obstetric and gynaecolo­gical disorders in patients in whom it was not possible to diagnose appendicitis or the diagnos­is was not certain at transabdominal ultrasono­graphy. Uncertain ultrasonographic diagnoses of appendicitis despite well-founded clinical su­spicion, indicate on the basis of our results, the necessity of intensive follow-up of patients in the subsequent several days because of the inability of ultrasound to approach the retro­coecal location and atipical site of the appendix, and the possibility of paretic and thickened bowel loops to simulate appendicitis. According to our investigation, we recom­mend the ultrasonographic examination of acute appendicitis as a complementary diagno­stic method which by its advantageous possibi­lity of using the additional intravaginal examina­tion technique in doubtful cases, provides a significant reduction of unnecessary surgical procedures. In our study the use of intravaginal ultrasono­graphy has significantly reduced the number of positive diagnosis of appendicitis in women which suggests that this examination method should be used in this population of patients paralel to suprapubic examination. 11 Conclusion Ultrasonographic examination of the appendix has become a complementary diagnostic me­thod in the recognition of acute appendicitis. It is of a particular importance in children, pregnant women, elderly people, and in all patients with atipical clinical presentation. The use of intravaginal transducer and the 7 .5 MHz transducer in suprapubic examination improves the accuracy of the diagnostic procedure. This examination method reduced the number of unnecessary operations to only 2.5 % of patients and was inefficient in the detection of appendi­citis in only 7 % of patients. Satisfactory speci­ficity and sensitivity accompanied with sufficient accuracy argue for the desirability of the intro­ducing ultrasonography in the routine examina­tion procedure of acute appendicitis. References l. Wilson JL, JJ MC Donald. Abdominalna kirurgija -Kirurgija apendiksa. Med. knjiga Zagreb, 1969; 385-91. 2. Štulhofer M. Kirurgija probavnog sustava -Kirur­gija apendiksa; 893-914. 3. Athey PA, Hacken JB, Estrada R. Sonographic appearence of mucocele of the appendix. J Ciin Ultrasound 1984; 12: 333. 4. Beyer D, Richer O, Kaiser C, Horsch S. Real­time-Sonographie bei akuten Appendizitis. Unter­suchungstechnik -Sonomorphologie, Ergebnisse ciner prostektiven Studie, Ultraschall Klin Prax 1989; 4: 124. 5. Drinkovic I, Brkljacic B, Boko H, Odak D, Vidjak V, Anic P. The treatment od appendiceal abscess by ultrasonically guided drainage. Radio[ Oncol 1992; 26: 96-8. 6. Hapke MR, Bigelow B. Mucocele of the appendix secondary to obstruction by endometriosis Hum Pathol 1977; 8: 585-9. 7. Horgan JG, Chow PP, Richter JO, Rosenfield HT, Taylor KOW CT and sonography in the recognition of the mucocele of the mucocele of the appendix. AJR 1984; 143: 959-62. 8. Hulek M, Vagner Z. Grose Mukozele der Appen­dix imitiert eine Ovarialzyste. Zantralbl Gynahol 1978; 100: 186-186. 9. Rieber A. und Brambs H-J. Die Mukocele der Appendix in Ultrachall und CT. Ultrachall Klin Prax 1989; 4: 26-7. Value of ultrasound in the diagnosis of acute appendicitis 10 Richer OH, Beyer D, und Horsch S. Mukozele 11. Worrcll JA, Leo F, Drolshagcn, Thomas C. Kelly, der Appendix abs Differentialdiagnose der akuten David W. Hunton, Gudrn R. Durmon, Arthur C. Appendizitis Sonographie und kliniche Bedeu­Fleischer. Graded Compression Ultrasound in the tung. Ultraschall Klin Prax 1991; 6: 33-6. Diagnosis of Appendicitis Ultrasound Med 1990; 9: 145-50. Radio! Onco/ 1995; 29: 194-7. Color-Doppler in the diagnosis and postoperative follow-up of varicoceles Ivan Drinkovic, Boris Bddjacic, Vesna Stepanic, Andrija Hebrang Center for Ultrasound Diagnostics, Department of Radiology, University Hospital Merkur, Zagreb, Croatia Color-Doppler is a recent diagnostic method which besides palpation, ultrasonography, Doppler and phlebography is routinely used in the diagnosis of the varicocele of the testis, the disease which is the very common cause of sterility in males. In 39 completely examined patients, we performed the color-Doppler analysis of varicoceles prior to and following the surgery, as well as the follow-up examination using phlebography. Color-Doppler showed high sensitivity of 91 per cent and specificity of 83 per cent. At postoperative examination color-Doppler showed a persistent varicocele caused by accessory veins not visualized at phlebography in 6 per cent of patients. The importance of color-Doppler examination as a routine preoperative and postoperative diagnostic method, is presented in this paper. Key words: varicocele; ultrasonography, Doppler, color Introduction Varicocele is a disease caused by the incompe­tence of the valvular apparatus of the interna! spermatic vein accompanied by compromised venous blood flow through the testes and in­creased temperature of the scrotum, which is considered the main cause of disorders in sper­matogenesis. It is the cause of sterility in as much as 40 per cent of infertile males, 1• 2 and in fertile young males varicoceles can be found in 10-15 5 per cent of cases.3­ Correspondence to: Ivan Drinkovic, M. D., Ph. D., Center for Ultrasound Diagnostics, Department of Radiology, University Hospital Mercur, I. Zajca 19, Zagreb, Croatia. UDC: 616.147.22-073:534-8 The detection of a varicocele and its timely treatment can improve fertility in as much as 51-85 per cent of patients. Besides other available methods the diagnosis of varicocele is also possible with color-Dop­pler, while the phlebography of the interna! spermatic vein is the "golden diagnostic stan­dard" in its detection. In this study we present the value of color­Doppler in the detection of varicocele, as well as the feasibility of the application of this non-invasive method in determining the success of the operative procedure. Materials and methods In 39 patients treated endocrinologically for sterility varicocele was suspected as the main cause of sterility. 195 Color-Doppler in the diagnosis and postoperative follow-up of varicoceles Besides endocrinologic tests, palpation, co­lor-Doppler examination and phlebography of the internal spermatic vein were performed. Positive finding on the phlebography of the internal spermatic vein was an indication for surgery, and 4 days following the procedure all patients operated on were examined by color­Doppler to evalute the result of the procedure, ie. the existence of accessory veins. Patients ranged from 24 years to 42 years in age. Bimanual palpation of both testes was applied as the first diagnostic method. Color-Doppler examination in the prostrated and upright posi­tion with increased intra-abdominal pressure was performed after that. The same examina­tion procedure was repeated 4 days after the surgery. The scanner Radius CF with a 7 .5 MHz probe with possibility of low-velocity flow ana­lysis was used. Phlebography of the internal spermatic vein was performed using the standard technique: by introducing the catheter into the left then right internal spermatic vein and by their visua­lization with the radiologic contrast medium, followed by the determination of the venous insufficiency degree. Varicoceles confirmed at phlebography were operated according to the Palomo method con­sisting of the high ligation of the artery and spermatic vein. Results Comparing clinical findings with the findings of color-Doppler examination and spectral analy­sis, ie. monitoring the direction of venous blood flow and the finding of phlebography as the gold standard, we found out that in 39 patients the clinical finding at inspection and palpation was a suspected or palpated incipient varicoce­le. Retrograde blood flow, ie. a change of colour at the color-Doppler under increased abdominal pressure was visualized in 31 patients or 79 per cent, while in 8 patients or 20.5 per cent color-Doppler finding, ie. spectral analysis were not indicative of the existence of a varicocele. A follow-up phlebography, performed in all patients as a part of the routine preoperative treatment, revealed varicoceles in 33 patients (83.6 per cent), and normal finding in 6 patients (15.6 per cent). The positive finding at phlebography was an indication for operative treatment, and 33 pa­tients were operated on. Due to the possible incidence of accessory veins, ie. persistent vari­cocele, the color-Doppler examination was per­formed immediately after surgery to evaluate its success, as well as the accuracy of phlebo­graphy. The value of ultrasonography in the preope­rative treatment compared to phlebography showed sensitivity of 91 per cent and specificity of 83 per cent. In respect to phlebography 9.1 per cent were false negative, and 16. 7 per cent were false positive. Postoperative examination of 33 patients sho­wed that phlebography failed to reveal aberrant veins in 2 patients (6 per cent), and that a varicocele persisted further as a consequence of venous drainage by veins which were not visualized by phlebography. Discussiou Varicocele is a varicose condition of the veins of the pampiniform plexus mainly appearing on the left testis, and appearing also on the right testis, though in a smaller number of patients. Clinical symptoms can be different, varying from local discomfort to abnormal semenogram in younger males connected with infertility. Diagnostic procedure of varicoceles can in­dude palpation, termography, ultrasonographic examination, Doppler examination, color-Dop­pler examination and phlebography which is considered the golden standard for discovering varicocele, as well as for the gradation of vari­coceles, resulting in the possibility of interven­tional therapy during the examination.6 Palpation has proved an uncertin method, especially in small varicoceles. In our study we compared color-Doppler finding with the fin­ding of phlebography and spectral analysis of the Doppler curve and the result of monitoring the direction of blood flow with the contrast Drinkovic I et al. Figure 2. In the Valsalva's maneuver the red coloured pampiniform plexus is visualized above the testes which is shown in the black-and-white picture as a white shadow, and corresponds to the retrograde high velocity flow; it is an indication of the pampiniform plexus varicosity. radiographic visualization of the spermatic vein. (Figure 1, Figure 2). By comparing these diag­nostic modalities, the degree of their accuracy was found to be very similar. However, the advantages of color-Doppler are its non-invasi­veness, low cost and little tirne needed to perform the examination. In spite of phlebography being considered the golden standard in the diagnostics of varico­celes, color-Doppler examination must be addi­tionally performed after phlebography, as well as after surgery because of its ability to discover the existance of a persistent , aricocele, caused by the incompetence of the \'alvular apparatus in the accessory veins which often fail to be visualized at phlebography. High sensitivity and high specificity are comparable with the results of some other authors.7-9 Non-invasiveness of this diagnostic method, and good results in comparison with phlebo­graphy are suggestive of the need for introdu­cing such examination into the diagnostic proce­dure as a routine method in young males with spermatogenesis disordes. In our study, unlike other diagnostic methods, especially palpation, color-Doppler has proved a much more reliable diagnostic method. Postoperative color-Dop­pler examination of the patients in whom vari­coceles have been proved at phlebography, as well as at surgery, and of the patients treated by an interventinal radiographic procedure, is also mandatory because of the ability of color­Doppler to detect the existence of a persistent varicocele caused by the accessory veins which can further continue obstructing spermatogene­sis. References l. Dubin L, Amelar RD. Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 1971; 22: 469. 2. Greenberg SH, Lipshultz LI, Wein AJ. Experience with 425 subfertile male patients. J Urol 1978; 119: 507. 3. Uehling DT. Fertility in men with varicocele. Int J Fertil 1968; 13: 58. 4. Charny CW, Baum S. Varicocele and infertility. JAMA 1968; 204: 1165. 5. Oster J. Varicocele in children and adolescents. An investigation of the incidence among Danish school children. Scand J Ural Nephrol 1971; 5: 27. 6. Ahleberg NE, Bartley O, Chidekel N, Fritjofsson A. Phlebography in varicocele scroti. Acta Radio/ Diagn 1966; 4: 517. 7. Petros JA, Andriole GL, Middleton WD, Picus DA. Correlations of testicular color -Doppler ultranosonography, physical examination and veno­graphy in the detection of the left varicoceles in men with infertility. J Ural 1991; 145: 785. Color-Doppler in the diagnosis and postoperative follow-up of varicoceles 8. Geatti O, Gasparini D, Shapiro B. A Comparison 9. Basile-Fasolo C, Izzo PL, Canale D, Menchini of scintigraphy, termography, ultrasound and phle­Fabris GF. Dopplcr-sonography, contact scrotal bography in grading of clinical varicocele. JNM termography and venography: A comparative study 1991; 32: 2092. in evaluation of subclinical varicocelc. Int J Fertil 1986; 30: 62. Radio 011col 1995: 29: 198-202. Venous thrombosis of the portal system. Etiology, diagnosis and treatment -analysis of 225 cases Piotr Malkovski, 1 Bofdan Michalowicz,1 Jacek Pawlak1, Wlodzimierz Otto, 1 Elžbieta Leowska, Olgierd Rowinski, 3 Rafal Paluszkiewicz, 1 Pawel M. Paczkowski, 1 Krzystof Zieniewicz1 1 Department of General Surgery and Liver Diseases 2 Department of Nuclear Medicine 3 Department of Radiology, Medica! Academiy, 02-097 Warsaw, Banacha 1 a, Polanci. The authors presen/ the material of 225 patients, treated since 1975, with various forms of portal system venous thrombosis (PSTV), of various origin and etiology. The largest group (120 patients) were the young people suffering from portal hypertension due to pre-hepatic venous obstruction of uncertain etiology, lasting since childhood. The next group consisted of 75 patients with !iver cirrc/zosis coexisting with PSTV. In other cases PSVT was diagnosed as coincident with: Budd-Chiari Syndrome (8 cases), !iver tumors (9 cases), chronic pancreatitis (3 cases), and polycythemia (2 cases). In 3 cases PSVT developed postoperatively and in 5 was the result of oral contraceptives. The course of the disease depended on extensivity and dynamism of thrombosis, but consequently led to the development of portal hypertension. The most effective diagnostic procedures were: computed tomography (CT) and ultrasonography Doppler flowmetry (SG), detecting PSVT in 96 % and 95 % of cases, respectively. Bleeding esophagal varices required either sclerotherapy (152 cases) or surgical treatment-decompressive shunts (26 cases) or »non-shunts« procedures (20 cases). In the cases of recent thrombosis, without bleeding varices, thrombolytic therapy was effective in all 6 cases. Key words: portal vein: thrombois Intrnduction Portal system venous thrombosis ( PSVT) was believed to be a rare phenomenon. Not more than 1000 cases of this pathology have been reported in the literature since 1901. l-6 Recen­tly, thanks to the development of noninvasive diagnostic imaging procedures (Doppler ultra­sound and dynamic CT-scan) the diagnosis of PSVT is being established much more frequen­ tly. 3. s. 7-10 UDC: 616.147.4-005.6 Liver cirrhosis is recognised as the most com­mon condition coexisting with PSVT. 1• 3 • 6 De­crease of the portal blood flow is probably the main factor enhancing the development of thrombosis.4• 6·9 The frequency of PSVT in cir­rhotic patients is estimated by different authors 3 6 9 at 5 to 25 per cent. 1. ,-The clinical features of !iver cirrhosis coexisting with PSVT (»double block« of portal flow) do not essentially differ from those of portal hypertension caused by cirrhosis alone. The dominating symptoms are: large esophageal varices with high bleeding tendency and progressive impairment of !iver 9 function. 1• 6· Venous thrombosis of the portal system The other conditions predisposing to PSVT are !iver tumours ( often accompanying !iver cirrhosis), carcinoma of the gallbladder, pan­creas and stomach, inflammatory processes wit­hin the abdominal cavity (pancreatitis, peritoni­tis, Crohn disease).3• 9 • 1 1-13 In !iver tumours thrombosis involves mainly the intrahepatic branches of the portal vein, 12 • 14 while in the other cases its' main trunk and splenic vein. 13 The less frequent causes of PSVT are trauma, including iatrogenic lesions at the tirne of sur­ 16 gery (most commonly splenectomy)15· and hypercoagulation conditions (puerperium, poly­cythaemia, paroxysmal nocturnal hemoglobinu­ria and congenital antithrombin III deficien­ 16 17 cy) .· More recently the coexistence of PSVT with Budd-Chiari syndrome was reported. 16• 18 The increasing incidence of PSVT in young women using oral contraceptives is also note­ worthy. 7, 16, 18, 19 In a considerable number of cases of PSVT the etiology remains unknown. 16· 20 It concerns most of patients treated for portal hypertension due to pre-hepatic obstruction of portal flow, second, after cirrhosis, reason of gastroesopha­geal varices,2 1• 22 According to some authors the role of neonatal umbilical infection, resulting in umbilical and portal thrombosis is overesti­ 21 mated. 16· Retrospective investigations, only in some cases of pre-hepatic block, have proved it's relationship to umbilical infection or throm­bosis. 2 1· 22 Anyway, the etiology of pre-hepatic portal obstruction remains unclear.16• 21 In the symptomatology of PSVT, apart from the symptoms of primary disease (if present) the clinical features of portal hypertension do­minate. These include extensive collateral ve­nous circulation, gastroesophageal varices, and splenomegaly accompanied sometimes by abdo­minal pain, ascites and jaundice. Their intensity depends upon the degree of hemodynamic dis­orders of the portal venous system. 1• 6· 9 , 13, 16, 20 Material mul methods From 1975 to 1993 the diagnosis of PVST was established in 225 patients treated in the Depar­tment of General Surgery & Liver Diseases of Warsaw Medica! Academy. There were 100 females and 125 males aged from 17 to 74 (mean 38 years). In 197 cases the reason of admission was active or controlled bleeding from esophageal varices, accompanied in 35 % of patients by symptoms of !iver function im­pairment (jaundice, ascites, coagulopathy). Some of these patients had a long history of portal hypertension. Other indications for ad­mission were: suspected !iver tumour (9 cases), chronic pancreatitis (3 cases), upper abdominal pain (6 cases), ascites of unknown origin (6 cases), splenomegaly alone (3 cases) and ultra­sonographic suggestion of portal vein obstruc­tion (1 case). All actively bleeding patients were treated by esophageal balloon tamponade and/or emer­gency sclerotherapy with simultaneous i. v. infu­sion of Vasopressin. As soon as the bleeding was controlled and the patients recovered, they were submitted ( except the previously diagno­sed patients) to diagnostic procedures including Doppler sonography (SG-94 pts), CT-scan (CT­62 pts), celiac arteriography with venous phase (61 pts) and splenoportography (SPG-4 pts). Subsequently the patients were treated either surgically (26 decompressive shunting procedu­res and 20 non-shunt operations) or by repeated endoscopic sclerotherapy. Patients with portal and spenic vein thrombosis due to chronic pan­creatitis were treated conservatively. In 5 pa­tients with !iver tumors a partial hepatectomy was performe (in 4 cases the tumour were inoperable). Two patients with polycythaemia were referred to Hematology Department for chemotherapy. Ali patients with recent PSVT admitted du­ring 1975-1980 (3 with coexisting hepatic vein thrombosis and 2 with portal trunk thrombosis alone) were treated conservatively. Further 8 patients, hospitalised after 1980, were submit­ted to thrombolytic treatment with Streptoki­nase (3 cases) and recently with recombinant tissue plasminogen activator (rt-PA, Actilyse). The analysis of the above presented group of patients with PSVT included the results and reliability of diagnostic imaging procedures and results of treatment regarding the etiology of Malkovski P et al. Figure 1. CT -Portal vcin thrombosis. PSVT or coexistence with predisposing disea­ses. Results SPG showed the presence of portal obstruction in each of 4 cases. The venous phase of arterio­graphy was conclusive in only 38/61 cases ( 62 % ) . Apart from the SPG, which is not performed now, the highest reliability was attri­buted to SG and CT (Figure 1), detecting PSVT in 90/94 patients (96 % ) and 59/62 cases (95 % ) respectively. Results of various methods of treatment in particular groups of patients are presented in Table l. Discussion The most numerous was the group of patients presenting clinical symptoms of portal hyperten­sion due to pre-hepatic venous occlusion, in whom the diagnosis of PSVT was established in childhood and followed by long-lasting treat­ment including surgery and sclerotherapy. After having grown up they have been referred to us by pediatric centers for continuation of treat­ment. Most of them are young people in good general condition, often with partly recanalized portal system. They require, however, perma­nent medica! attendance and (not infrequently) repeated sclerotherapy. 21• 22 Regarding their past history, only few of them can be considered as candidates for surgical treatment. In our experience only in 5 cases we were able to perform a venous shunt; 2 patients with uncon­trollable recurrent variceal bleeding required a non-shunt surgery (splenectomy with gastroe­sophageal devascularisation, esophageal sta­pling). Generally, the results of treatment in this group are satisfactory, fatal cases of uncon­trollable hemorrhage bein rare.21• 22 The coexistence of PSVT with !iver cirrhosis ("double block") deteriorates the progno­sis. 1• 6• 9• 16 Gastroesophageal varices are usually very large and the frequency of recurrent mas­sive bleedings, followed by hepatic insufficiency is remarkably higher compared to other cases Table 1. Rcsults of various mcthods of treatment in particular groups of patients. Numbcr Treatment Etiology Sex Hospital of . . d. Surgical Non-surgical . or coex1stmg 1scasc deaths patlenls F M Shunt Non shunt ES,S-B,V Thrombolytic Other 75 Liver cirrhosis 23 52 21 8 16 (55%) 46 9 (20%) 120 Unknown ctiology 62 58 5 12 1 (5,8%) PSVT sincc childhood 103 4(3,8%) 9 Livcr tumors 3 6 5 2 4 2 8 Budd-Chiari 6 2 3 3 (100%) syndromc 3 SK, 3 rtPA o 5 Oral contraceptives 5 2 2 (100%) 3rtPA o 2 Polycythacmia 2 2 o 3 Intraopcr. trauma 1 2 3 o 225 Tota! 100 125 Balloon tamponadc, V= Vasoprcssin infusion, SK = Strcptokinasc, rtPA = Actilyse, ES = Endocsopic sclerothcrapy. S-B Venous thrombosis of the ponal system 9 of portal hypertension. 1• It was proved that the percentage of rebleedings and postoperative deaths is three times higher compared with patients with portal hypertension caused by !iver cirrhosis alone. 9 Intensive sclerotherapy improves the results of treatment of patients with "double block".9 In the group of patients with !iver tumours there were 4 cases of hepatoma in the cirrhotic !iver. Two patients required sclerotherapy. The resectability of the lesion depended on dimen­sions of the tumour itself, as well as the extent of intrahepatic portal thrombosis. The fina! intraoperative estimation has significantly im­proved since the intraoperative sonography is used. It enables the exact identification of the affected parts of the !iver tissue and occluded branches of portal vein. 13· 14 Our patients with PSVT and chronic pancrea­titis, as well as those observed by other authors, did not require any special treatment. 13 Spleno­megaly observed in 2 cases and ascites in 1 case, were slowly decreasing during 2 years of follow-up, as the recanalization of occluded veins progressed. Chemotherapy (Hydroxycarbamide) admini­stered to patients with polycythaemia led to regression of thrombotic occlusions after 6 and 9 months with decrease of ascites. One patient with PSVT, caused by intraoperative lesi on required sclerotherapy. In these cases thrombo­sis did not result in total portal occlusion and severe hemodynamic disorders, which explains a relatively mild course of the disease. Much more dramatic course, despite the ini­tially slight symptoms, was observed in patients PSVT, coexisting with trombosis of hepatic veins. All of 3 conservatively treated patients died of progressing !iver failure and massive variceal bleeding. Better results were achieved by thrombolytic treatment Streptokinase in 3 and rt-Pa in 2 cases.7• 18 Significant clinical improvement appeared in the first day of treat­ment with rt-PA and after 2-3 days of Strepto­kinase therapy. Although the full recanalization of the occluded veins was not recorded, the Doppler flowmetry allowed to document a sig­nificant increase of both portal and hepatic venous flow. Thrombolytic therapy with rt-PA was also administered in 3 cases of isolated portal throm­bosis caused by oral contraceptives. Ali these women had a short history (less than 1 month) of abdominal pain, splenomegaly and slight ascites.7 Also in these cases the therapy was started at the moment of diagnosis and resulted in rapid clinical improvement. In no case an immediate full recanalization of the thrombosed veins was seen at SG, but progressing improve­ment in portal flow was recorded at repeated Doppler examinations. After two years ali 3 patients are doing well, with proved repermea­bilisation of the portal system and hepatopetal blood flow. It has to be stressed that in none of our paticnts with esophageal variccs throm­bolytic thcrapy caused variceal blcecling. Conclusions The etiology of PSVT is not uniform, in many cases it remains unknown. In cirrhotic patients the diagnosis of coexisting PSVT seriously dete­riorates the prognosis. Clinical features of PSVT vary in dependence upon the extensive­ness and dynamism of thrombotic proccss, but sooner or later portal hypcrtension develops with all its conscquences. Mafkovski P et al. The most effective diagnostic methods are SG and CT, with preference for SG (Figure 2) because of it availability and safety. Repeated SG allovs a systematic monitoring of the disease and treatment results. In the cases of recent thrombosis early diagnosis enables effective treatment. In our opinion, every case of recent, progres­sing PSVT requires thrombolytic tgreatment, as the only means to achieve radical improvement, if not full recovery. References 1. Belli R, Romani F, Sansalone CV et al. Portal thrombosis in cirrhotics. A retrospective analysis. Ann Surg 1986; 203: 286-91. 2. Bockus HL. Diseases of the hepatic vessels and Cruveilhier-Baumgarten syndrome. In: Gastroen­terology. Philadelphia, London: WB Saunders, 1949; 224. 3. Nonami T, Yokoyama I, Iwatsluki S, Starzi TE. Vein thrombosis at )iver transplantation. Hepato­logy, 1992; 16: 1195-998. 4. Okuda K, Ohnishi K, Kimura K et al. Incidence of portal vein thrombosis in liver cirrhosis. An angiographic study in 708 patients. Gastroentero­logy 1985; 89: 279-86. 5. Perisic M, Colovic R, Milosavljevic T, Ivanovic L. Splenic vein thrombosis diagnosed with Dop­pler ultrasonography. Hepato-gastroenterol 1991; 38: 557-60. 6. Sarfeh IJ, Portal vein thrombosis associated with cirrhois. Arch Surg 1979; 114: 902-5. 7. AL Karawi MA, Quaiz M, Hilali A et al. Mesen­teric vein thrombosis. Non-invasive diagnosis and follow-up and non-invasivc thcrapy by streptoki­nase and anticoagulants. Hepato-gastroenterol 1990; 37: 507-9. 8. Haddad MC, Clark DC, Sharif HS ct al. MR, CT and ultrasonography of splanchnic venous throm­bosis. Gastrointest radio! 1992; 17: 34-40. 9. Ma!kovski P, Micha!owiez B, Pawlak J et al. Diagnosis and treatment of portal hypertension caused by concomittant !iver cirrhosis and throm­ bosis of the portal vein. Pol Przegl Chir 1993; 65: 131-8. 10. Tessler FN, Gehgring BJ, Gomes AS et al. Diag­nosis of portal vcin thrombosis: value of color Doppler imaging. AJR 1991; 157: 293-96. 11. Brinberg DE, Stefansson TB, Grcicius FA et al. Portal vein thrombosis in Crohn's disease. Ga­strointest Radio/ 1991; 16: 245-7. 12. Kumada H, Ozawa K, Okamoto K et al. Hepatic resection for advanced hcpatocellular carcinoma with removal of portal vcin tumor thrombi. Sur­gery 1990; 108: 821-7. 13. Rattncr DW, Warshaw AL. Venous, biliary and duodenal obstruction in chronic pancrcatitis. He­pato-gastroenterol 1990; 37: 301-6. 14. Lygidakis NJ, Makuuchi M. Clinical applications of perioperative ultrasonography in !iver surgery. Hepato-gastroenterol 1992; 39: 232-6. 15. Henderson JM, Millikan WJ, Chipponi J et al. The incidencc and natura! history of the portal vcin following distal splenorenal shunt. Ann Surg 1982; 196: 1-7. 16. Abbitt PL. Portal vcin thrombosis: imaging featu­rcs and associatcd etiologies. Curr Probl Diagn Radio! 1992; 21: 115-47. 17. Valla D, Casa Deuvall N, Lecombc CF. Primary myeloproliferative disorders and hepatic vein thrombosis. Ann Intem Med 1986; 103: 329­ 18. Pawlak J, Palester-Chlcbowczyk M, Micha!owicz B ct al. Thrombolytic treatment of thc Budd­Chiari syndrome with portal vcnous thrombosis. Pol Arch Med Wewn 1993; 89: 171-7. 19. Valla D, Lee MG, Poynard T. Risk of hepatic vcin thrombosis in relation to recent use of oral contraceptives. Gastroenterology 1986; 90: 807­ 20. Sugiura N, Matsutani S, Ohto M et al. Extrahepa­tic vein obstruction in adults detected by ultra­sound with frequent Iack of portal hypertension signs. J Gastroenterol Hepatol 1993, 8: 161-7. 21. Voorhees AB, Price JB. Extrahepatic portal hy­pertension. A retrospective analysis of 127 cases and associatcd clinical implications. Arch Surg 1974; 108: 338-41. 22. Pinkerton JA, Holcomb GW, Foster JH. Portal hypertension in childhood. Ann Surg 1972; 175: 870-6. Radio! Oncol 1995; 29: 203-6. Direct sagittal computed tomography in diagnosis and treatment of interna) derangements of the temporomandibular joint Goran Roic, 1 Tatjana Klaric Jurkovic,2 Josip Panduric,2 Slavko Cop1 2 Children's Hospital, Zagreb, Croatia, School o{ Dentistry, Department of Removahle Prosthodontic, Zagreb, Croatia Direct sagittal computed tomography (CTI), as a diganostic modality in the diagnosis and treatment of interna! derangements of the temporomandibular joint (TMJ), is reviewed. Direct sagittal CT demonstrates well the position and fitnclionil1g of the TMJ disc and is w1 excellent non-invasive diagnostic aid when using dental splint therapy to treat disc di.\jimctions and interna! derangements of the temporomandibular joint. Furthermore, this practicable non-invasive method al!ows direct visualisation and evaluation of the TMJ disc, hony structures and particular soft-tissue. lntrnduction Temporomandibular joint (TMJ) dysfunction causes a variety of symptoms in the masticatory system ancl kynesiologically relatecl regions of the bocly, particulary in the cranial and cervical regions. I-J The main symptoms described in the literature are: temporomanclibular sounds, sensitivity or pain in the masticatory muscles, temporomanclibular joint pain, impaired mobi­lity of the manclible and irregular path of move­ment of the mandible.4 Headache and facial pain are often described as being connected with functional disturbances of the masticatory system.5·6 Conventional radiographic metbocls do not permit aclequate evaluation of this com­plex joint. The use of computed tomography has been found to be superior to conventional radiography and tomography in evaluating in­ternat derrangements ol' the TMJ. Corrcspondcncc to: Dr. Goran Roic, Dcpartmcnt of Radiology, Childrcn's Hospital, Klaiccva 16, 41000 Zagreb, Croatia. Phonc: + 384 144161 l. UDC: 616.724-073.756.8 Two teclmiques of computed tomography of the TMJ have been described. Helms et al. 7 use multiple axial images of the TMJ, with computerized reconstructions in the sagital plain (Figure l). Since the resolution of recon- Figure l. Axial CT scan through thc tcmporomandibu­lar joint with sagittal rcconstruction. 204 Raic G et al. structed CT images is usually less than that of slices imaged in the primary direction, it has proved more useful to perform TMJ scanning 9 using a direct sagittal projection. 8• CT can show the position of the meniscus relative to the condyle and articular eminence, without the need of injecting intrnarticular rndiopaque contrnst media. The meniscus, as seen during CT imaging, has a density greater than the adjacent pterygoid musculature and surroun­ding adipose and connective tissue.9 Anatomy of the TMJ The TMJ is a complex synovial articulation between the mandibular condyle and the man­dibular fossa of the temporal bone. Interposed betwcen the head of the condyle and the surface of the tempornl bone is a biconcave articulating disk, or meniscus, that serves as a buffeting pad between the hcad of the condyle and the tem­pornl bone. The meniscus is thin in the center (1 mm) and thick periphernlly (2,8 mm poste­riorly and 2 mm anteriorly). 10 Of rndiographic interest is the relationship of the superior and inferior heads of the laterni pterygoid muscles. The superior head is attach­ed to the meniscus, and the inferior head is attached to the neck of the condyle. Between the two heads of the laterni pterygoid muscle is a layer of adipose and connective tissue.9 This structure has been identified by Manzione who designated it "as the laternl pterygoid fat pad". 8• 11 The fatty tissue serves as the anatomic basis for detection of internal dernngements of the disk during CT imaging. CT can show fine anatomic soft tissue structures because of its sensitive discrimination of density. The low­density adipose tissue of the laterni pterygoid fat pad may be seen easily within surrounding complex of bony, cartilaginous and muscle tissues. When the meniscus is displaced ante­riorly, the fat pad may be seen to be shifted anteriorly. 9 Technique of CT examination Direct sagittal computed tomography scanning of the TMJ provides exceptional detail of ana- Figure 2. Sagittal scoutvicw with cursor lincs covcring thc arca of thc TMJ. An attcmpt is madc to avoid scanning within thc orbit and cspccially to avoid thc lcns of thc cyc. tomic structures. Soft-tissue and bone algo­rithms, thin sections and multiple tomogrnphic images can be used to obtain details of osseous structures and the intrnarticular menisco-liga­mentous complex. Positioning is of critical im­portance in this study. An attempt is made to minimize radiation to the orbit, especially to the Iens of the eye. A sagittal scout view is obtained and cursor lines are placed through to the area of interest (Figure 2). The external auditory canal has been shown to be a helpful landmark for vizualizing the TMJ on the scout view. The patient must be turned to perform seans of the right and left sides. Radiographic evaluation of pathological changes of the TM Internal derrangement of the TMJ is defined as disc disfunction and damage. Anterior disc displacement is the most common type in TMJ disc, disfunction. This category of disfunction is easiest to diagnose with CT scanning. Charac­teristically, meniscus density is seen iri the an­terior perycondylar space separated from the condyle by a few milimeters of intervening normal soft-tissue density. 10 According to the Direct sagittal computed tomograplzy Figure 3. Dircct sagittal CT of thc TMJ, in closcd position thc disk is locatcd antcriorly to thc condylc Antcrior disk dislocation. literature anterior displacement of the TMJ disc can be subdivided into displacement with reduction and without reduction. 12 Anterior disc displacement with reduction means that disc is abnormaly located when the condyle is in the closed position but resumes a normal position at some point in condylar motion. Anterior disc displacement without reduction implies that the disc has migrated or slipped from its normal position between the articular surfaces of the mandibular condyle and tempo­ral bone without reduction at any point during joint movement. Anterior disc dislocation is a condition in which the meniscus density is scen in the ante­rior pericondylar space to varying degrees, depending on the amount of anterior displace­ment (Figure 3). This condition is generally preceded by a history of painful TMJ with clicking. La ter, the patient notices that there is no click and may complain of a "locked jaw". Patients also experience limited jaw opening during this phase. This is due to a laterni "balling up" of the meniscus in front of the condyle, which limits jaw opening because the condyle, impinges on the sofHissue of the menisco-ligamentous com­plex. With time, most patients regain more normal jaw opening as they push the menisco­ligamentous complex forward with repeatecl openings. Direct saggital computed tomography of tem­potomandibular joints also allows the assess­ment of therapeutic effects of dental splint by analysing position and movements of the in­traarticular disc ancl condyles as well as by direct measuring of the intraarticular distances (Figures 4 a, b). Mandibular anterior re- Figures 4 a, b. Antcriorly displaccmcnt of thc disk; rccapturing with oral splint in placc -a) thc closcd mouth vicw shows antcriorly displaccd disk that ap­pcars as an arca of incrcascd density, b) the closed mouth view with the oral splint in place shows reduc­tion of thc disk to a normal location posteriorly. 206 Roic G et 'al. positioning by dental splint therapy has been used successfully as a conservative treatment modality for anterior disc displacement with reduction and also in cases without reduction after mobilization of the TMJ. IO. 1 L 13 Conclusion Computed tomography is a useful noninvasive method of imaging complex anatomic structures such as temporomandibular joint. Direct sagit­tal CT has proved to be an excellent metl10d for the diagnosis of disc disfunction and interna! derrangements of the TMJ. Scanning directly in the plain of interest provides images of better spatial resolution than reconstructed sagittal images. Furthermore, direct sagittal CT scan­ning allows noninvasive evaluation of the disc, bony architecture and paraarticular soft-tissue. CT is also a practical diagnostic aid at the follow-up stage after treating anterior disc dis­placement by dental splint therapy. Used with clinical history and physical exami­nation, CT is an excellent diagnostic modality that can provide information important for the better care for patients with interna! derange­ment of the TMJ. References l. Friedman MH, Weisberg J. Application of ortho­pedie prineiples in evaluation of the temporoman­dibular joint. Phys Ther 1982; 62: 597-603. 2. Friedman MH, Waisbcrg J. Pitfalls of muscle palpation in TMJ diagnosis. J Proslhet Deni 1982; 48: 331­ 3. Danzing WN, VanDaykc, A, R. Physical therapy as as adjunet to temporomandibular joint thcrapy. J Prosthet Deni 1983; 49: 96-9. 4. Hclkimo M. Epidemiologieal surveys of dys­funetion of the mastieatory system. In: Zarb GA, Carlsson GE, eds. Temporomandibular Joint Function and clysfunction. Copenhagcn: Munks­gaard, 1979: 175-92. 5. Gclb H, Bernstein l. Clinieal cvaluation of two hundred patietns with temporomandibular joint syndromc. J Proslhet Dend 1903; 49: 234---43. 6. Reider CE, Martinoff. The prevalcnee of mandy­bular dysfunetion. Parl II: Amultiphasie dysfun­etion profile. J Prosthel Deni 1983; 50: 237-44. 7. Helms CA, Vogler JB, Morrish RBJr, Goldman SM, Capra RE, Proctor E. Temporomandibular joint interna! dcrangcmenls: CT diagnosis. Radio­logy 1984; 152: 459­ 8. Manzione JV, Seltzer RW, Katzberg SB, Hammcrschlag SB. Chiango BF. Direct sagittal computed tomography of thc temporomandibular joint. A.TR 1983; 140: 165-7. 9. Hoffman DC, Berlin er L, Manzionc J, Saeearo R, MeGivern BEJr. Use of direet sagitall eompu­ted tomography in diagnosis and treatment of interna! derangemcnts of thc temporomandibular joint. JADA; 113: 407-11. 10. Bell KA. Computed Tomography of the Temporo­mandibular Joint. In: eds. Palaeios E, Valvassori GE, Shanon M, Recd CF. Magnetic Resonance of 1/ze Temporomandibular Joint. Stuttgart, Georg Thicme Verlag, 1990: 28-39. 11. Manzione JV, Katzbcrg RW, Brodsky GL, Seltzer SE, Mellins HZ. Interna! derangement of tempo­romandibular joinl: diagnosis by direet sagittal eomputcd tomography. Radiology 1984; 150: 111­5. 12. Raustia AM. Diagnosis and treatmcnt of tempo­romandibular joint dysfunetion. Proc Finn Soc 1986; 82 (Suppl IX-X): 9-41. 13. Raustia AM, Pyhtinen J. Direet sagittal eomputed tomography as a diagnostie aid in the treatment of an anteriorly clisplaeed temporomanclibular joint disk by splint therapy. 71ze Jo urna/ of Cranio­mandibular Practice 1987; 5 (3): 241-5. Radio! Oncol 1995; 29: 207-10. Zorc-Pleskovic Institute of Histology and Embriology, Medica! Faculty, University of Ljubljana, Slovenia The aim o.f the present investigation was to study the histological and stereological changes in lymphocytes and mast cells a.fter irradiation. For experimental model we used 20 Beagle dogs, 1-2 years old. Ten dogs were irradiated 20 days with 32 Gy onto the whole pelvis and tail. Another JO dogs represented a control group. Histological and stereological analysis were pe1formed on a Wild sampling microscope M 501. In the nonirradiated group volwne, numerical density and average volume o.f lymphocytes were signi.ficantly lower in comparison with the irradiated group. Vohune density and average volume o.f mast cells were significantly lower in nonirradiated group. Numerical density o.f mast cells in this group was signi.ficantly higher. The results o.f our experiments show that mast cells and lymphocytes in the intestinal mucosa are deeply involved in the tissue .fibrosis occurring as the re.11Jonse to irradiation. Key words: colon-irradiation cffects; intestinal mucosa-pathology lntroductiou Severa! years after irradiation severe fibrous changes of the colon often cause for a surgeon an unsolvable problem in surgical intervention. The purpose of our stucly was to investigate experimentaly the histological and stereological changes in the colon occuring after irradiation in view of an early diagnosis and prevention of fibrosis. The intestinal epithelium is a tissue 2 3 most sensitive to irradiation. 1• · Individual cells in the intestinal mucosa such as lympho­cytes and mast cells participate in the defense system of the body or in the protection against Correspondence to: doc. dr. Ruda Zorc-Pleskovic, Institute of Histology and Embriology, Medica! Facul­ty, University of Ljubljana, 61000 Ljubljana, Slovenia UDC: 616.348-001.29 tumor invasion. Therefore we paid special at­tention to them in our study. The literature clata clescribe changes in the intestinal muco­ 1 456 sa, • · · yet no stereological clata coulcl be founcl in the available literature. Materials mul methods 20 Beagle dogs weighting 8 to 13 kg, 1 to 2 years olcl were incluclecl in our stucly. Ten clogs were irradiatecl (I) with y rays on telecobalt (Phillips) with 32 Gy over the pelvis regi on ancl tail. The size of the irracliatecl region on the skin was 10 x 15 cm. Ten clogs represented the nonirracliatecl group (N). Ten clays after conclu­decl irracliation, a 1-cm wicle piece of colon transversum was excisecl from the miclclle thircl of the colon of the anesthetizecl clogs. Tissue was fixecl in Bouin's fluicl, embecldecl in paraffin Zorc-Pleskovic R and cut in 5 µm step serial sections. The step section was 20 µm thick. The obtained prepara­tions were stained with hematoxylin-eosin (HE), toluidine-blue and solution alcian blue (SAB) reaction. An accurate histological analysis of the step serial sections was used to establish the changes in the mucosa of the colon in individual groups. The lymphocyte infiltration and presence, size, form as well as distribution of the mast cell's granules were studied. Histological analysis7 were performed on a Wild sampling microscope, using Weibel's test system. Volume density (Vv) of lymphocytes and mast cells were estimated at an objective magnification x40 using the M-42 test system. Numerical density (Nv) of I and m were estima­ted according to the Weibel-Gomez method at an objective magnification x40 using the M-100 test system. For these cells average volume was also calculated. The results were statistically evaluated. Signi­ficant differences were determined by Student's "t" test. Results Histological analysis In the N group lymphocyte infiltration of lamina propria in the intestinal mucosa was well ex­pressed while in the irradiated group (1) there were some rare lymphocytes only in the connec­tive tissue. The individual ones infiltrated the epithelium (Figure 1). In the N group the mast cells were equally distributed in the connective tissue. Their cyto­plasm was full of metachromatically stained granules. Oval nuclei were visible in the middle of cells (Figure 2). In the I group the mast cells were mainly in the connective tissue at a basal part of the cryptes. Their shapes were mainly irregular. Numerous metachromatic granules were dispersed around the cells (Figure 3). Stereological analysis In the N group ali the measured stereological values of lymphocytes such as Vv (Figure 4), Nv (Figure 5) and average volume of the indi- Figure l. Rarc lymphocytcs in thc irradiated group (HE, obj. 40x). Figure 2. Degranulatcd mast cells in the intcstinal mucosa in the irradiated group (SAB, obj. 40x). VVl(mrrP) . ------------------­-------·-­7 0.018 P < 0.0001 0.012 0.006 0.000 1 Figure 3. Volume density (Vv1) of lymphocytes in the nonirradiated (N) and the irradiatcd (I) group (Yv1 ±2SE). Changes in some collon mucosal cells after irradiation vidual lymphocytes V1 (Figure 6) were signifi­cantly lower in comparison with the I groups. Vv of mast cells (Figure 7) and V m mast cells (Figure 8) were significantly lower, while the Nv (Figure 9) was significantly higher in the N group compared to the I group. Discussion Stereological analysis of lymphocytes after irra­diation revealed reduction of Vv , Nv and V of lymphocytes. This demonstrates that irradiation reduces the number and the size of the cells. N + a, a. s(a.-1)) exp[ -(a, s + a, s' + a, s (a,) + a, s (a,)] + B (7) where Xm again is the depth of the Ficki sizc (c) ·;g !Oxl0cm2 110 c:5 o::: 4100 Electron cncrgy (McV) 80 0 4 " 8 60 o 12 6 18 II 22 40 o 4 „ 8 . 12 20 6 18 " 22 90 80 70 60 50 0 1 l 'f(it), 1 JU!!lt:-: 1 ":1...r 1 1 '--'-.'--'--'.--'-'.._L_._,__!_..L,_.c.L._._,,.-C.J..J 40 Depth in water (mm) Figure 2. Central axis pereentage depth doses for a eorresponding dose distributions calculated with Eq. field size of 10 x 10 cm2 and various clinical electron (12) are represented by solid curves. Parts (b) and ( d)beams produced by two linear accelerators: (a) and show in greater detail the build-up and dose maximum (b) Varian Clinac 2300C/D; and (c) and (d) Philipsregions of parts (a) and (c), respectively. SL-25. Measured data are shown as data points and Wierzbicki W and Podgorsak E B Table l. Optimized values of fitting parameters a, b, and e and measured parameters B and D, for 10 x cm2 electron bcams with various nominal energies for two commercial linear accelerators: a Varian Clinac 2300C/D and a Philips SL-25. Nominal Parameter elcctron encrgy (McV) a X 107 (mm-3) b X 108 (mm-4) C (mm) B D, VARIAN 6 1283.3 595.82 13.65 0.65 70.6 CLINAC 9 278.29 146.30 19.89 1.31 77.3 2300 C/D 12 15 76.647 24.050 42.505 15.052 25.96 27.71 2.14 3.44 83.4 90.3 18 11.810 6.1579 25.88 4.13 93.1 22 7.1493 2.2432 20.44 5.14 94.4 PHILIPS 4 3652.7 1295.1 8.86 0.036 74.7 SL-25 6 1104.0 406.77 12.5 0.54 77.3 8 369.59 135.71 16.74 1.08 80.5 10 178.34 78.031 20.54 81.8 12 85.550 39.118 23.54 2.49 85.2 15 33.882 16.287 24.52 3.12 90.4 18 15.922 8.5102 27.14 3.31 92.0 20 8.3512 4.1550 23.33 3.68 94.0 22 4.7616 l.9890 15.79 4.06 94.8 the fitting procedure. Equation (12) with four fitting parameters thus provides a relatively simple yet precise means for expressing clinical electron beams analytically. Conclusions Ever since electron beams have been used clinically, attempts have been made to describe analytically the measured central axis depth dose distributions. These distributions consist of four regions: dose buildup, dose maximum, dose falloff and bremsstrahlung contamination. Numerous analytical expressions to approxi­mate electron depth doses in ali four regions have been proposed to date. The quality of fitting generally improved with each new propo­sal but the curve fitting equations were beco­ming increasingly more complex as they de­pended on larger and larger numbers of fitting parameters. Analytical expressions developed in recent years for descriptions for electron beam depth doses provide an excellent fit to measured data. Improvements in this area can in the future sions which rely on a smaller number of para­meters. We have recently developed a relatively simple expression based on only four parame­ters. We show in this paper that the expression represents, with a high degree of precision, measured electron beam depth doses for various beam energies from two commercial linear ac­celerators. The conclusion can be made that the expression may be applied to describe the electron beam depth doses generally for any linear accelerator, any field size, and any beam energy. References l. Laughlin JS, Ovadia J, Beattie JW, Hendcrson WJ, Harvey BS, and Hass LL. Some physical aspccts of electron bcam therapy. Radio/ 1953; 60: 165-83. 2. Bagnc F. Electron beam treatment-planning sy­stem. Med Phys 1974; 3: 31-8. 3. Pacyniak JM and Pagnamenta A. Central axis percentage depth-dose for high energy electrons. Radiat Res 1974; 60: 342-6. 4. Jette D, Lanzl LH, Rozenfeld M, Pagnamenta A. Analytic represcntation of electron central-axis depth ·•··.···;. ;;::::::::u0::;:;:::.:r:!'.tit.t..w!i\) .... ·je zahtevno, zapleteno in natarz.cnq inte]ekt1J,CJJiio .. ;? ..i.. . .... ·.•••. delo, ki poleg radc/ve.nostt, lndi/atiJi)bsti/ tiifI,Jnoštf, •i ··i·· znanja in izkuše1iosti r.Zifkovaic'ažaht;vaiilct/ .·i·i ;;/1Ii.i:W:.t:!.!1e1I!l!lltl/lil!;:: .. ··· ... ···•. rakastih bolezni tudi Sloveriija'enakopr.edna drugfnipo·svetu. Raziskovalni rezultati slovenskihinari!)tvenikov prav<·· ·i..... · ······ : •.::.:: . • : .. • z biomedicine niso zanemarljivitudi zunaj meja vendar zaradi pomanjkanjafi:nqncnih sr.dst;J niso pravi odraz raziskova!tJ:lf?..ospp1J0§fL i •···.··· .... . • rakastih obolenj v Slovenijf1iar:i;l:šca}z Nda v.eto ....... ··.·•·i·i. ·i··i· ·i . Da bi bili pri zdravljenju bolnikov{e bo!jf;}5Jiik9iJiti,/·•· . se.mora}o.nai{idravniki.neprestano izobraževaiii ·.i.... in vkljt1,cevativ. ra:ds'fa1:i. ki pomagajo odkrivati ·i·i ·•.·•·.·inezriarzkf! bo!e.f.irfnove nacine zdravljf!nja. .. .i .i Žqotf{etr;(195?4oJ;,nski zdravniki aktivno z mnog{m{ii§/aijovami po svetu, ki.zdravijoiiifdziskujejo ·i ·i ··· rakaste bolezni. Leta 1991 se je Slovenija pridružilaevropskemu programu boja proti raku; njegovdo!f!tq 2.000 zman/i.l[u.rdivosi ;a rakom 15 odstqtkoil .. femu cilju;.:tifrz.9gocepribližati samo .z nepre$tfiitm žioln;.aževanje/r(zn raziskovalnim delom, kajti]e faziskdiJaiije prinaša nova vedenja in vodi k poljšemu razumevanju rakastih bolezni ter pomaga ··prt preprecevqrtju, zgodnjem ugotavljanju boleznii .·.·•····.•·.·•···· .. · · •. in ittfokovitem zdravljenju, ..$J;gndqcijo "Doc?nt dr.]. Cholewa11 .e/i1116.'.f;ato po.gdf(šp.šopriim raziskovalcem doPci.l.li;tl,ti znanje . .. • nding numhcrs in thc tcxt. Foliowing are some cxamplcs of rcfercnces from articlcs. books and book chaptcrs: 1.t Dent RG. Cole P. /11 1·irro maturation of monocy­tes in squarnous carcinoma of the lung. Br J Cancer 1981; 43: 486-95. 2. Chapman S. Nakielny R. A guide ro radiological proceduffs. London: Baillicre Tindali. 1986. :l. Evans R. Alexander P. Mechanisms of extracdlu­lar killing of nuclcatcd mammalian cells by macropha­gcs. In: Nelson DS ed. /111111u11ohiology of macrop!tagc. New York: Acadcmic Prcss. 1976: 45t-7-1. For reprinr inft1mwrio11 in Norrh America Conracr: /11/1'm11rio11al reprilll Corporarion 96S Admiral Callag­lwn l .1111c, # :!6S l'. O. Box I :!004, Vallejo. CA 94590, 'fi-1 .· 0!7/ 553 9]30, 1-iix: (707) 55:! 95:!4. © Eastman Kodak Company, 1990 Kodak systems provide dependable performance for advanced diagnostic imaging. Dur qua/ity components are made to work together from exposure to viewbox. Kodak X-Omat processors are the most respected in the field. Kodak X-Omatic cassettes are known the world over for unexcelled screen-film contact and dura­bility. Kodak multiloaders have earned an enviable reputation for reliability. The Kodak Ektascan laser printer is changing the look of digital imaging. The list goes on. There are quality Kodak products throughout the imaging chain. Equally important, they are made to work together to achieve remarkable performance and diagnostic quality. Contact your Kodak representative for more information. 1 NI lopami,[Q® 150 -200 -300 -370 mgl/ml FOR ALL RADIOLOGICAL EXAMINATIONS MYELOGRAPHY ANGIOGRAPHY UROGRAPHY C.T. D.S.A. THE FIRSli WATER1 SOLUBILE READV· T01 USE, · NON-IONIC CON[R.ASJ MEDIUM .anufacturer: Distributor: lracco s.p.a. 1a E. Folli, 50 Agorest s.r.l. Via S. Michele, 334 )134 -Milan -(1) .x: (02) 26410678 ilex: 311185 Bracco 1 )one: (02) 21771 e 34170 -Gorizia -(1) Fax: (0481) 20719 Telex: 460690 AF-GO 1 Phone: (0481) 21711 Nepotrebno je, da bolezen spremlja bolecina tramadol Moc opioidnega analgetika brez opioidnih stranskih ucinkov centralno delujoci analgetik za lajšanje zmernih in hudih bolecin ucinkovit ob sorazmerno malo stranskih ucinkih Indikacije: Srednje mocne do mocne akutne ali kronicne bolecine. Po tristopenjshi shemi Svetoclle zdmeswen<: m.qa11izac(f<: za lctj/icmjc' bolec"iu f>ri bolnil,ih z 1Y1kcwi111 obole11je111 lmmadol odpml'(ia sred1,ie hudo boledno ali bolecino dmgc• stopt(i<', Kontraindikacije: Zdravila ne smemo dajati otrokom, mlajšim od 1 leta. Tramadola ne smemo uporabljati pri akutni zastrupitvi z alkoholom, uspavali, analgetiki in drugimi zdravili, ki delujejo na osrednje živcevje. Med nosecnosljo predpišemo tramadol le pri nujni indikaciji. Pri zdravljenju med dojenjem moramo upoštevati, da O, l q{) zdravila prehaja v materino mleko. Pri bolnikih z zvecano obcutljivostjo za opiate moramo trarnadol uporabljati zelo previdno. Bolnike s krci centralnega izvora moramo med zdravljenjem skrbno nadmrovati. Interakcije: Tramadola ne smerno ur,orabljati skupaj z inhibitorji MAO. Pri socasni uporabi zdravil, ki delujejo na osrednje živcevje, je možno sinergisticno delovanje v obliki povecane sedacije, pa tudi ugodnejšega analgeticncga delovanja. Opozo1·ila: Pri predoziranju lahko pride do der,rcsije dihanja. Previdnost je potrebna pri bolnikih, ki so preobcutljivi za opiate, pri starejših osebah, pri mikseclemu in hipotiroidizrnu. Pri okvari jeter in ledvic je potrebno odmerek zmanjšati. Bolniki med zdravljenjem ne smejo upravljati strojev in motornih vozil. Doziranje in nacin uporabe: Odrash ill otroci, starej§i od 14 let: Injekcije: 50 do 100 mg Lv,,i.m.,s.c.; intravensko injiciramo pocasi ali infundiramo razredceno v infuzijski raztopini. Kapsule: l kar,sula z malo tekocine. Kapljice: 20 kapljic z malo tekocine ali na kocki sladkorja: ce ni zadovoljivega ucinka, dozo ponovimo cez 30 do 60 minut Svecke: 1 svecka; ce ni ucinka, dozo ponovimo po 3 do 5 urah. Otroci od 1 do 14 let: l do 2 mg na kg telesne mase. Dnevna doza pri vseh oblikah ne bi smela biti višja od 400 mg. Stranski ucinki: Znojenje, vrtoglavica, slabost, bruhanje, suha usta in utrujenost. Redko lahko pride do palpitacij, ortostatske hipotenzije ali kardiovaskularnega kolapsa. Izjemoma se lahko r,ojavijo konvulzije. Oprema:. ampul pol ml (.O mg/mil, 5 ampul po 2 ml (100 mg/2 ml), 10 ml raztopine (100 mg/1111), 20 kapsul ro 50 mg, 5 sveck po l 00 mg. PodrobJ1ejle iJ./brmacUe so 1lC1 l'o(jo /Jri proizucy·alcu. ...KRK. SLOVENIJA