Background Failure of laparoscopic fundoplication (LF) occurs in up to 10% and revisional laparoscopic fundoplication (RLF) becomes an option. Data on clinical and anatomical outcomes using computed tomography after RLF are limited. Methods All patients undergoing RLF for gastroesophageal reflux disease (GERD) and/or hiatal hernia (HH) between 2015 and 2022 were compared to primary LF-patients (PLF) using a 1:5 weighted propensity score matching. The primary outcome was 1-year recurrence of symptoms (in patients with GERD) or radiological wrap slippage or HH recurrence in patients with HH. Secondary outcomes included the Gastrointestinal Quality of Life Index (GIQLI) and perioperative and postoperative data. Results There were 31 RLF (6 GERD, 25 HH) and 120 (36 GERD, 84 HH) PLF cases. Symptomatic recurrence for GERD indication after 1 year was seen in 16.7% after RLF and 11.1% after PLF (p = 0.54). Radiological abnormalities in HH were seen in 36% after RLF (24% minor slippages and 12% recurrent hernias) and 15.5% after PLF (11.9% minor slippage and 3.6% recurrent hernias; p = 0.028). Operative time (188 min vs. 147 min, p < 0.001) and hospital stay (6.6 days vs. 3.8 days, p < 0.001) were significantly longer after RLF. Early complication rates were higher in RLF (16.1% vs. 3.3%, p = 0.007). GIQLI scores were comparable (122.6/144 after RLF vs. 124.4/144 after PLF, p = 0.58), with > 92% of patients in both groups reporting good/excellent outcomes. Conclusion RLF is associated with longer operative time, increased morbidity, and higher rates of CT abnormalities compared to PLF. Symptom control and quality of life were comparable.

Purpose: This study assesses whether automated segmentation allows evaluation of subtle changes in volume and intrinsic tissue characteristics in an obese patient population undergoing metabolic surgery. Materials and Methods: Multiorgan segmentation and intrinsic Hounsfield Unit (HU) analyses were performed in 1877 preoperative/ postoperative computed tomography (CT) examinations, processing nine compartments, organ systems, and musculoskeletal structures as follows: subcutaneous, peritoneal/retroperitoneal fat, skeletal muscle and liver, spleen, kidneys, pancreas, and first lumbar vertebral body. Statistical assessments utilized Wilcoxon signed-rank test and generalized linear mixed model comparisons successively using volumes and HU as dependent values, preoperative/postoperative state as fixed factor, and gender, age as covariates. Results: Metabolic surgery led to significant reductions of subcutaneous, retroperitoneal/peritoneal fat volumes averaging 25% and 29%, respectively, p < 0.001. Subcutaneous and retroperitoneal/peritoneal fat compartments differed significantly in HU, p < 0.001. Postoperative reduction in fat tissue was accompanied by a significant increase in corresponding median HU, increasing by 6% and 8%, respectively, p < 0.001. Volumes of liver, spleen, pancreas, and kidneys were significantly impacted by metabolic surgery with intraindividual shrinkages of 7-11% postoperatively, p < 0.001. Core striated musculature showed significant decreases in volume, averaging 4%, and a simultaneous significant increase in HU following metabolic surgery, averaging 4%. Throughout, gender was a significant covariate with larger volumes preoperatively, a more substantial volume loss postoperatively, as well as a higher HU increase, all observed in males. Conclusion: Simultaneously, operator-independent and automated compartmental quantitative segmentation allows for assessment of subtle changes in volume and intrinsic structural tissue characteristics over time in patients undergoing metabolic surgery. Our results underline the complex transformation of fat, organs, and muscles after surgery-induced weight loss.

Background Bariatric surgery is associated with decreasing bone mineral density (BMD). Objective To assess the long-term vertebral BMD, measured by opportunistic quantitative CT (QCT), and body mass index (BMI) in patients undergoing proximal laparoscopic Roux-en-Y surgery (LRYGB). Methods In 62 patients undergoing LRYGB, opportunistic QCT measurements were performed extracting BMD and BMI on day 1 and years 1, 3, and 5 postoperatively. Primarily, one-way analyses of variance were performed on dependent variables BMI and BMD, with imaging interval defined as an independent factor. Student-Newman-Keuls tests performed pairwise comparisons of imaging interval permutations for BMI/BMD. Secondarily, analyses of covariance were used on dependent variables BMI and BMD, with imaging interval as an independent factor and gender/age as well as BMD/BMI, respectively, as covariates. Results A total of 227 opportunistic QCT measurements in 62 patients were performed without the need of a phantom or extra software. The BMD decreased substantially and continuously during 1-, 3-, and 5-year follow-up observations, reaching statistical significance in pairwise comparisons for 3- and 5-year follow-up visits compared to initial BMD values as well as the 5-year follow-up visit compared to the 1-year BMD values, P < 0.001. Age and BMI were significant covariates, P < 0.001. The BMI decreased within 1 year and stayed constant until a slight increase at 5 years was observed. Statistical significance in pairwise comparisons for first-year and 3- and 5-year follow-up visits was reached compared to initial BMI values, P < 0.001. For the BMI assessment, none of the covariates reached statistical significance. Conclusion Opportunistic QCT is suited for the calculation and follow-up of BMD. There was a continuous decrease of BMD after LRYGB over 5 years post-surgery, whereas BMI decreased in the first year and stayed constant thereafter. Older patients with lower BMI seem particularly prone to an accelerated BMD loss.

Background: The surgical technique in large hiatal hernia (HH) repair is controversially discussed and the outcome measures and follow-up schemes are highly heterogeneous. The aim of this study is to assess the true recurrence rate using computed tomography (CT) in patients with standardized large HH repair. Methods: Prospective single-center study investigating the outcome after dorsal, mesh-enforced large HH repair with anterior fundoplication. Endoscopy was performed after 3 months and clinical follow-up and CT after 12 months. Results: Between 2012 and 2021, 100 consecutive patients with large HH were operated in the same technique. There were two reoperations within the first 90 days for cephalad migration of the fundoplication. Endoscopic follow-up showed a correct position of the fundoplication and no relevant other pathologies in 99% of patients. Follow-up CT was performed in 100% of patients and revealed 6% of patients with a cephalad slippage, defined as migration of less than 3 cm of the wrap, and 7% of patients with a recurrent hernia. One patient of each group underwent subsequent reoperation due to symptoms. There was no statistical correlation between abnormal radiological findings and clinical outcomes with 69.2% of patients being asymptomatic. Multivariate logistic regression did not show any prognostic factor for an unfavorable radiologic outcome. Ninety-four percent of patients rated their outcomes as excellent or good. Conclusion: Radiological follow-up after large HH repair using CT allows to detect slippage of the fundoplication wrap and small recurrences. Patients with unfavorable radiological outcomes rarely require operative revision but should be considered for further follow-up.

Background Diffuse parenchymal liver diseases are contributing substantially to global morbidity and represent major causes of deaths worldwide. The aim of our study is to assess whether established hepatic fat and iron quantitation and relaxometry-based quantification of hepatocyte-specific contrast material as surrogate for liver function estimation allows to evaluate liver fibrosis. Methods Retrospective consecutive study. Seventy-two healthy patients (mean age: 53 years) without known liver disease, 21 patients with temporary elevated liver enzymes (mean: 65 years) and 109 patients with biopsy proven liver fibrosis or cirrhosis (mean: 61 years), who underwent liver magnetic resonance imaging (MRI) with a hepatocyte-specific contrast agent [gadoxetate disodium, gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA), 0.25 mmol/mL Primovist, Bayer AG, Leverkusen, Germany] at 1.5 T (n=133) and at 3 T (n=69), were included. Fibrosis was classified using the histopathological meta-analysis of histological data in viral hepatitis (METAVIR) and the clinical Child-Pugh scores. Gd-concentration were quantified using T1 map-based calculations. Gd-concentration mapping was performed by using a Look-Locker approach prior to and 912±159 s after intravenous administration of hepatocyte specific contrast agent. Additionally, parenchymal fat fraction, R2*, bilirubin, gender and age were defined as predicting factors. Diagnostic accuracy was calculated in a monoparametric (linear regression, predictor: Gd-concentration) and multiparametric model (predictors: age, bilirubin level, iron overload, liver fat fraction, Gd concentration in the left and right liver lobe). Results Mean Gd-concentration in the liver parenchyma was significantly higher for healthy patients ([Gd] =0.51 µmol/L) than for those with liver fibrosis or cirrhosis ([Gd] =0.31 µmol/L; P<0.0001) and with acute liver disease ([Gd] =0.28 µmol/L), though there were no significant differences for the latter two groups. There was a significant moderate negative correlation for the mean Gd-concentration and the METAVIR score (ρ=−0.44, P<0.0001) as well as for the Child-Pugh stage (ρ=−0.35, P<0.0001). There was a significant strong correlation between the bilirubin concentration and the Gd-concentration (ρ=−0.61, P<0.0001). The diagnostic accuracy for the discrimination of healthy patients and patients with known fibrosis or cirrhosis was 0.74 (0.71/0.60 sensitivity/specificity) in a monoparametric and 0.76 (0.85/0.61 sensitivity/specificity) in a machine learning based multiparametric model. Conclusions T1 mapping-based quantification of hepatic Gd-EOB-DTPA concentrations performed in a multiparametric model shows promising diagnostic accuracy for the detection of fibrotic changes. Liver biopsy might be replaced by imaging examinations.

Objective Noncontrast computed tomography (NCCT) plus computed tomography angiography (CTA) is the standard imaging modality for acute stroke. We investigated whether there is an additional diagnostic value of supra-aortic CTA in relation to National Institutes of Health Stroke Scale (NIHSS) and resultant effective radiation dose. Methods In this observational study, 788 patients with suspected acute stroke were included and divided into 3 NIHSS groups: group 1, NIHSS 0–2; group 2, NIHSS 3–5; and group 3, NIHSS ≥ 6. Computed tomography scans were assessed for findings of acute ischemic stroke and vascular pathologies in 3 regions. Final diagnosis was obtained from medical records. Effective radiation dose was calculated based on the dose-length product. Results Seven hundred forty-one patients were included. Group 1 had 484 patients, group 2 had 127 patients, and group 3 had 130 patients. Computed tomography diagnosis of acute ischemic stroke was made in 76 patients. In 37 patients, a diagnosis of acute stroke was made based on pathologic CTA findings in case of an unremarkable NCCT. Stroke occurrence was the lowest in groups 1 and 2, with 3.6% and 6.3%, respectively, compared with 12.7% in group 3. If both NCCT and CTA were positive, the patient was discharged with a stroke diagnosis. Male sex had the highest effect on the final stroke diagnosis. The mean effective radiation dose was 2.6 mSv. Conclusions In female patients with NIHSS 0–2, additional CTA rarely contains relevant additional findings decisive for treatment decisions or overall patient outcomes; therefore, CTA in this patient group might yield less impactful findings, and the applied radiation dose could be lowered by approximately 35%.

To assess whether high temporal/spatial resolution GRASP MRI acquired during routine clinical imaging can identify several degrees of renal function impairment referenced against renal dynamic scintigraphy. This retrospective study consists of method development and method verification parts. During method development, patients subject to renal imaging using gadoterate meglumine and GRASP post-contrast MRI technique (TR/TE 3.3/1.6 ms; FoV320 × 320 mm; FA12°; Voxel1.1 × 1.1x2.5 mm) were matched into four equally-sized renal function groups (no-mild-moderate-severe impairment) according to their laboratory-determined estimated glomerular filtration rates (eGFR); 60|120 patients|kidneys were included. Regions-of-interest (ROIs) were placed on cortices, medullary pyramids and collecting systems of bilateral kidneys. Cortical perfusion, tubular concentration and collecting system excretion were determined as TimeCortex=Pyramid(sec), SlopeTubuli (sec−1), and TimeCollecting System (sec), respectively, and were measured by a combination of extraction of time intensity curves and respective quantitative parameters. For method verification, patients subject to GRASP MRI and renal dynamic scintigraphy (99mTc-MAG3, 100 MBq/patient) were matched into three renal function groups (no-mild/moderate-severe impairment). Split renal function parameters post 1.5–2.5 min as well as MAG3 TER were correlated with time intensity parameters retrieved using GRASP technique; 15|30 patients|kidneys were included. Method development showed differing values for TimeCortex=Pyramid(71|75|93|122 s), SlopeTubuli(2.6|2.1|1.3|0.5 s−1) and TimeCollecting System(90|111|129|139 s) for the four renal function groups with partial significant tendencies (several p-values <  0.001). In method verification, 29/30 kidneys (96.7%) were assigned to the correct renal function group. High temporal and spatial resolution GRASP MR imaging allows to identify several degrees of renal function impairment using routine clinical imaging with a high degree of accuracy.

Abstract Background Nissen and Toupet fundoplication are the predominant procedures in the treatment of large hiatal hernias. Nevertheless, these techniques may cause relevant side-effects such as increased bloating or dysphagia, thus impairing the patient's quality of life. Aims To evaluate the mid-term outcome after mesh-enforced hiatoplasty and anterior fundoplication in large hiatal hernia repair. Methods Prospective single-center study investigating the clinical, endoscopic and radiological outcome after laparoscopic, mesh-enforced hiatoplasty and anterior fundoplication in patients with large hiatal hernias. Results Ninety-nine patients were operated between 2012–2022 and met all the inclusion criteria including postoperative computed tomography (CT). 68% were female, mean age was 71 ± 10 years, 72% of the patients needed proton pump inhibitors (PPI) prior to surgery. In all patients, more than 20% of the stomach was located supra diaphragmatic, in 65% more than 50% of the stomach was herniated. Mean operation time was 152 ± 45 minutes, there were no major intraoperative complications and one short-term postoperative complication demanding operative revision due to early recurrence. Mean length of stay was 5.1 ± 1.9 days. Upper endoscopy was performed in 94% after 16 weeks and showed a correct position in all cases. Clinical and CT follow-up were obtained in all patients after 1.6 ± 1 years. 87% had a correct position of the fundoplication in CT, 6% had a slippage and 7% a recurrent hernia. Two patients needed operative revision. 84% of patients reported their clinical outcome as excellent, 10% as good. Mean Gastrointestinal Qualitiy of Life Index was 126 ± 14. 98% of patients would perform the surgery again. Conclusions Mesh-enforced hiatoplasty and anterior fundoplication in large hiatal hernia repair is safe and leads to a high rate of patient satisfaction. The radiological outcome poorly correlates with clinical symptoms or patient reported outcome.

In HRCT scans, the Type A CTJ showed an intercartilaginous space less than 1mm. In contrast, the Type B/C CTJ showed an intercartilaginous distance exceeded 1mm.

Only a few reports compare the mid- and long-term outcome of the minimally invasive deltoid split (MIDS) with the classic anterior deltopectoral (DP) approach for osteosynthesis in proximal humeral fractures. This study compared the mid-term functional and the radiological results in patients with proximal humeral fractures undergoing osteosynthesis with the proximal humeral internal locking system (PHILOS™).

AIM To evaluate upper abdominal computed tomography (CT) scan as primary follow-up after laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS This prospective study was approved by the Ethical Committee of the State of Zurich, and informed consent was obtained from all patients. Sixty-one patients who underwent LRYGB received upper abdominal CT on postoperative day 1, with the following scan parameters: 0.6 mm collimation, 1.2 mm pitch, CareKV with reference 120 mAs and 120 kV, and 0.5 s rotation time. Diluted water-soluble radiographic contrast-medium (50 mL) was administered to achieve gastric pouch distension without movement of the patient. 3D images were evaluated to assess postoperative complications and the radiation dose received was analysed. RESULTS From the 70 patients initially enrolled in the study, 9 were excluded from analysis upon the intraoperative decision to perform a sleeve gastrectomy and not a LRYGB. In all of the 61 patients who were included in the analysis, CT was feasible and there were no instances of aspiration or vomiting. In 7 patients, two upper abdominal scans were necessary as the pouch was not distended by contrast medium in the first acquisition. Radiologically, no leak and no relevant stenosis were found on the first postoperative day. These early postoperative CT findings were consistent with the findings at clinical follow-up 6 wk postoperatively, with no leaks, stenosis or obstructions being diagnosed. The average total dose length product in CT was 536.6 mGycm resulting in an average effective dose of 7.8 mSv. The most common surgical complication, superficial surgical site infections (n = 4), always occurred at the upper left trocar site, where the circular stapler had been introduced. CONCLUSION Early LRYGB postoperative multislice spiral CT scan is feasible, with low morbidity, and provides more accurate anatomical information than standard upper gastrointestinal contrast study.

OBJECTIVES/HYPOTHESIS:Young professional singers can easily reach very high pitches. In contrast, older singers often complain that they have to exert substantially more laryngopharyngeal force to reach the same high pitch compared with their earlier years. Various factors such as the property changes of the mucosa and ossification that impact the singing apparatus were suggested as explanations in the literature. The aim of this study was to analyze thyroid deformation-and thereby stiffness indirectly-during singing as a potential reason for this phenomenon. STUDY DESIGN:Prospective study. METHODS/DESIGN:We examined 44 female professional singers. High-resolution computed tomography scans were performed during singing at the fundamental mean speaking frequency and the first and second octaves above it. Digital Imaging and Communications in Medicine scan data were rendered and visualized 3-dimensionally using MIMICS software. By superimposition of the different 3-dimensional images, different positions of the thyroid were visualized. The distance from the posterior border of the thyroid was measured in all the examinations. RESULTS:All laryngeal cartilages could be three-dimensionally visualized. The magnitude of the thyroidal deformation significantly depends on pitch and significantly correlates with age (r2 = 0.7, P < 0.001). CONCLUSIONS:The thyroid cartilage is flexible and its formability is especially important during singing. At higher pitches, the cartilage was more deformed. The larynx in older singers showed less thyroid cartilage deformation.

Objective: Investigating the influence of increasing the intraabdominal pressure by Valsalva maneuvers and/or abdominal compression to reach best visualization of the entire urinary tract in computed tomography urography (CTU).Methods: After split-bolus technique, Valsalva maneuvers, compression or a combination of both were applied in 60 patients before late phase images were acquired. The degree of opacification and distension of three segments of the urinary tract were evaluated.Results: After split-bolus CT no significant difference among the groups regarding distention and opacification. A significant increase in distension and opacification was found during Valsalva and the combination of Valsalva and compression.Conclusions: A CTU protocol including a late phase scan with prior application of compression, Valsalva maneuvers or a combination of both showed beneficial effects for the distension and opacification, a significant difference was found by taking location as a covariate.

OBJECTIVE:Vocal folds are widely assumed to only elongate to raise vocal pitch. However, the mechanisms seem to be more complex and involve both elongation and tensioning of the vocal folds in series. The aim of the present study was to show that changes in vocal fold morphology depend on vocal fold elongation and tensioning during singing.STUDY DESIGN:This was a prospective study.METHODS:Forty-nine professional female singers (25 sopranos, 24 altos) were recruited and three-dimensional laryngeal images analyzed in a coronal view derived from high-resolution computed tomography scans obtained at the mean speaking fundamental frequency (ƒ0) and one (2ƒ0) and two octaves (4ƒ0) above ƒ0.RESULTS:The vocal fold angle, defined by a tangent above and below the vocal folds, was 58° at ƒ0, 47° at 2ƒ0, and 59° at 4ƒ0.CONCLUSION:The decreased caudomedial angle of the vocal fold from ƒ0 to 2ƒ0 (change in muscle belly from ";fat" to "thin") and increased angle from 2ƒ0 to 4ƒ0 (from "thin" to "fat") strongly supports the hypothesis that the vocal folds elongate and then tension when singing from ƒ0 to 4ƒ0. This is the first study to show this relationship in vivo.

Objective: To report first-hand narrative experience of autoimmune encephalitis and to briefly review currently available evidence of autoimmune encephalitis in cancer patients treated with immune checkpoint inhibitors. Setting: A case study is presented on the management of a patient who developed autoimmune encephalitis during nivolumab monotherapy occurring after 28 weeks on anti-PD-1 monotherapy (nivolumab 3 mg/kg every 2 weeks) for non-small cell lung cancer. Results: No substantial improvement was observed by antiepileptic treatment. After administration of 80 mg methylprednisolone, neurologic symptoms disappeared within 24 h and the patient fully recovered. Conclusions: Immune checkpoint inhibitor treatment can lead to autoimmune encephalitis. Clinical trial data indicate a frequency of autoimmune encephalitis of ≥0.1 to <1% with a higher probability during combined or sequential anti-CTLA-4/anti-PD-1 therapy than during anti-PD-1 or anti-PD-L1 monotherapy. Further collection of evidence and translational research is warranted.

Background Internal hernias (IH) after laparoscopic Roux-en-Y gastric bypass (LRYGB) have been reported with an incidence of 11 %. IH can lead to bowel incarceration and potentially bowel necrosis. The aim of this study was to analyze reoperations and intraoperative findings in a cohort of patients with unclosed mesenteric defects.Methods From a prospective database of patients with LRYGB, we selected as primary cohort patients with nonclosure of mesenteric defects and abdominal reoperation for analysis. The data included pre-, intra-and post-operative findings, computed tomogram results and laboratory test results. This group underwent a very very long limb LRYGB, at that time the institutional standard technique. Additionally, a more recently operated cohort with primary closure of mesenteric defects was also analyzed.Results We identified 146 patients with primary non-closure and reoperation, mean age of 43.8 years. The main indication for reoperation was unclear abdominal pain in 119 patients with 27 patients undergoing a reoperation for other reasons (weight regain, prophylactic surgical inspection of mesenteric defects). Median time and mean excess weight loss from RYGB to reoperation were 41.1 months and 62.7 %, respectively. The incidence of IH was 14.4 %, with all patients with an IH being symptomatic. Conversion rate from laparoscopic to open surgery was 5.5 %, mortality 0.7 % and morbidity 3.4 %. Thirty-one patients underwent a second re-look laparoscopy. Eleven patients had recurrent open mesenteric defects. Three hundred and sixteen patients who underwent primary closure of the mesenteric defects had a reoperation rate of 13.6 % and an IH rate of 0.6 %.Conclusion The incidence of IH in patients without closure of mesenteric defects and reoperation is high and substantially higher compared to patients with primary closure of mesenteric defects. Patients with or without closure of mesenteric defects following LRYGB with acute, chronic or recurrent pain should be referred to a bariatric surgeon for diagnostic laparoscopy.

ObjectiveThe vocal range of untrained singers rarely exceeds one and a half octaves, but professional singers have a range of at least two and a half octaves. The aim of this study was to better understand the muscle and cartilage movements responsible for the control of vocal pitch in singing.Study DesignProspective study.MethodsWe recruited 49 female professional singers (25 sopranos and 24 altos) and analyzed laryngeal three‐dimensional images derived from high‐resolution computed tomography scans obtained at the mean speaking fundamental frequency (F0) and at one (F1) and two octaves (F2) above this pitch.ResultsFrom F0 to F1, the only observable movement was a backward cricoid tilting caused by the cricothyroid muscles (CTMs), leading to vocal fold stretching. Above F1, a medial rotation and inward rocking of the arytenoid cartilages was observed, caused by the lateral cricothyroid muscles (LCAMs) and leading to inferior displacement of the vocal process of the arytenoid cartilage, and thus to further vocal fold stretching.ConclusionTrained singers achieve the first octave of pitch elevation by simple cricothyroid approximation. Further pitch elevation necessitates a complex movement of the arytenoids, first by CTM contraction and second by LCAM contraction.Level of Evidence4. Laryngoscope, 127:1639–1643, 2017

Objectives/Hypothesis. Biplanar imaging technique is not sufficient for an exact visualization and evaluation of the laryngeal biomechanics during speaking or singing. The aim of this pilot study was to test a 3D-visualization software MIMICS (Materialize Interactive Medical Image Control System, Materialize, Leuven, Belgium) for visualizing laryngeal cartilages and resonance space of living humans during singing based on high-resolution computed tomography (HRCT) and analyzing the biomechanics thereof.Study Design. This is a prospective pilot study.Methods. A total of 10 professional female singers (five sopranos and five altos) was scanned with HRCT in three singing positions fundamental frequency(fo), first octave (fo+1 8va) and second octave (fo+2 8va).Results. All relevant laryngeal structures and resonance space could be 3D visualized. Superimposing the different HRCT scans showed an inward rotation and rocking of the arytenoid cartilages from fo+1 8va to fo+ 2 8va and a backward tilting of the cricoid cartilage from fo+1 8va to fo+2 8va. Moreover, we could demonstrate a vocal fold elongation of 13% from fo to fo+1 8va and an additional elongation from fo+1 8va to fo+2 8va of 10% in type A cricothyroid joints (CTJ) A and 4% in CTJ's type B/C. There were no significant differences between sopranos and altos in all parameters (length of the glottis, subglottic diameter, distance between anterior commissure and cervical spine, and CTJ distribution).Conclusions. This noninvasive 3D-visualization technique with MIMICS allows the anatomical structures and landmarks of the larynx to be analyzed. We believe that this pilot study will serve as a basis for further biomechanical studies on speakers' and singers' larynges.

Fallbeschreibung ▼ Wir berichten über eine 20-jährige Patientin mit spinaler Muskelatrophie Typ II und restriktiver Ventilationsstörung bei schwerer Torsionskoliose, die mit Sepsis bei Influenza Typ A mit PneumokokkenSuperinfektion bei Pneumonie rechts der Intensivstation zugewiesen wurde. Eine antibiotische Therapiewurde u. a. mit Clarithromycin eingeleitet und bei respiratorischer Erschöpfung erfolgte die Intubation im Verlauf. Bei initialer Transaminasenerhöhung sowie steigendem Bilirubin und alkalischer Phosphatase wurde zum Ausschluss einer biliären Obstruktion und Beurteilung des Leberparenchyms ein Oberbauch-US durchgeführt. Sonografisch zeigten sich intrahepatisch multiple, teils konfluierende, hyperechogene Areale entlang der Portalvenen sowie multiple, intraluminale, hyperechogene, sich zentripetal in der Portalvene bewegende Reflexe (●▶ Abb. 1a, b). Das Leberparenchym war kaum abzugrenzen. Zwei Stunden nach dem Ultraschall erfolgte eine kontrastmittelverstärkte CT des Thorax und Abdomens mit Bestätigung einer bilateralen Pneumonie. Entgegen den Erwartungen stellten sich in der Abdomen-CT lediglich nur zwei Gasbläschen in den intrahepatischen Pfortaderästen peripher im linken Leberlappen dar (●▶ Abb. 2). Eine Obstruktion der Gallenwege konnte ausgeschlossen werden. Zudem war eine Hepatomegalie mit hypodensen Leberparenchym ersichtlich. Des Weiteren zeigte sich eine deutliche Dilatation des gesamten Kolonrahmens und eine geringe Pneumatosis intestinalis im Coecum (●▶ Abb. 3), wobei jedoch keine weiteren Zeichen einer Darmischämie (z. B. arterielle Okklusion, Darmwandverdickung) vorlagen. Die Koloskopie konnte keine mechanische Obstruktion nachweisen. Ein kleines coecales Schleimhautareal imponierte koloskopisch ischämisch. Dies konnte jedoch histologisch sowie in der Kontrollkoloskopie nicht bestätigt werden. Die Patientin konnte im Verlauf nach Hause entlassen werden.