Endoscopic submucosal dissection is useful and safe for intramucosal gastric neoplasms in the elderly

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) has recently gained popularity for use against intramucosal gastric neoplasms in Japan, but few studies have examined whether ESD is feasible for elderly patients. This study aims are to evaluate the efficacy and safety of ESD according to age in consecutive elderly patients treated with ESD.

PATIENTS AND METHODS

Subjects comprised 116 patients (90 men, 26 women) with 125 lesions treated using ESD from November 2002 to March 2006 at Nagoya City University Hospital and Iwata Municipal Hospital, Japan. Patients were categorized into: Group A, <65-years-old (n=34); Group B, > or =65-years-old but <75-years-old (n=41); and Group C, > or = 75-years-old (n=41). En bloc resection rate and treatment time were examined according to age, tumour size and location, and frequency of complications was examined according to age.

RESULTS

Rate of concomitant disease was significantly higher in Group C than in the other groups. En bloc resection rates and median treatment times were 91.4% and 80 min in Group A, 91.1% and 97 min in Group B and 86.7% and 110 min in Group C, respectively. No significant differences were noted between groups, or for en bloc resection rate and treatment time according to tumour size and location, or between groups for frequency of complications.

CONCLUSIONS

ESD for gastric neoplasms is effective and safe in elderly patients, and may be positively recommended to elderly patients with intramucosal gastric neoplasms.

Effect on partial pressure of oxygen in arterial blood in percutaneous vertebroplasty

BACKGROUND AND PURPOSE

The purpose of this study is to estimate the change in partial pressure of oxygen (Pao(2)) during percutaneous vertebroplasty and also to examine the factors related to the change in Pao(2).

MATERIALS AND METHODS

We retrospectively reviewed preprocedural and postprocedural Pao(2) of 59 consecutive patients who underwent percutaneous vertebroplasty between November 2003 and April 2005 (11 men and 48 women; age range, 50-93; mean age, 75 years). Fifty-four patients were treated for osteoporosis-related fractures and 5 had malignant disease. Percutaneous vertebroplasty was performed in a conventional manner under local anesthetics and conscious sedation. Preprocedural and postprocedural blood drawing was performed 5 days to 30 minutes before percutaneous vertebroplasty and also at 30 minutes after the injection of bone cement. The difference between preprocedural and postprocedural data of Pao(2) was correlated with patients' age, number of treated vertebral bodies, presence of cement leakage, and presence of malignant neoplasm for each patient.

RESULTS

Mean pre-Pao(2) and post-Pao(2) were 80.9 +/- 1.4 and 70.6 +/- 1.3 mm Hg (mean +/- SE) respectively (P = .0001). Using analysis of variance, there was a significant difference according to the number of vertebral bodies. There was a positive trend of decrease in Pao(2) according to the number of vertebral bodies during percutaneous vertebroplasty. Using multiple linear regression and after adjusting by preprocedural Pao(2) and other variables, the number of vertebral bodies was still highly significant.

CONCLUSION

Pao(2) decreases during percutaneous vertebroplasty, and there is a correlation between the number of treated vertebral bodies and decrease in Pao(2).

Value of subtraction in fat-saturated three-dimensional contrast-enhanced magnetic resonance angiography of the hemodialysis fistula

PURPOSE

To evaluate image subtraction in a three-dimensional contrast-enhanced magnetic resonance angiography (3D CE-MRA) using fat suppression for the hemodialysis fistula.

MATERIAL AND METHODS

Fifteen patients suffering from hemodialysis fistula dysfunction were imaged with 3D CE-MRA using fat suppression and digital subtraction angiography (DSA). Non-subtracted and subtracted MRA images using maximum intensity projection (MIP) were constructed and the validity of the MRA interpretations of the degree of vascular stenoses was evaluated using DSA as the standard of reference. Image quality was assessed using qualitative analysis (vessel contrast) and quantitative analysis (contrast-to-noise ratio (CNR) of the vessel versus the background).

RESULTS

In the vessels with stenosis of 50% or greater, the sensitivity and specificity of the non-subtracted MRA were 89.5% and 81.8%, respectively, and of the subtracted MRA 89.5% and 86.4%, respectively. There was no significant difference in the detectability of stenoses between either MRA. The vessel contrast of the anterior interosseous artery and the CNR of the anterior interosseous artery versus the background on the subtracted MRA were significantly superior to those on the non-subtracted MRA. With regard to the radial artery and cephalic vein, there was no significant difference in the vessel contrast and CNR between either MRA.

CONCLUSION

Both subtracted and non-subtracted MRA techniques are useful in detecting hemodialysis fistula dysfunction.

Omental cyst: report of a case

We report the case of an omental cyst, a rare type of abdominal cystic lesion that is difficult to diagnose preoperatively. A 43-year-old man with no clinical symptoms was admitted to our hospital for investigation of an abdominal cyst detected by ultrasonography (US). We performed diagnostic examinations including US, computed tomography, and magnetic resonance imaging. An omental cyst was diagnosed because of its position and connection to the surrounding tissues. Pathological examination of the surgical specimen revealed endothelial cells on its internal wall and colonies of lymphocytes, confirming a diagnosis of lymphangioma, which is the most common type of omental cyst.

Is obesity a high-risk factor for laparoscopic colorectal surgery?

BACKGROUND

The aim of this study was to assess the outcome of laparoscopic colorectal surgery in obese patients and compare it to that of a nonobese group of patients who underwent similar procedures.

METHODS

All 162 consecutive patients who underwent an elective laparoscopic or laparoscopic-assisted segmental colorectal resection between August 1991 and December 1997 were evaluated. Body mass index (BMI; kg/m2) was used as an objective index to indicate massive obesity. The parameters analyzed included BMI, age, gender, comorbid conditions, diagnosis, procedure, American Society of Anesthesiologists classification score, operative time, estimated blood loss, transfusion requirements, intraoperative complications, conversion to laparotomy, postoperative complications, length of hospitalization, and mortality.

RESULTS

Thirty-one patients (19.1%) were obese (23 males and 8 females). Conversion rates were significantly increased in the obese group (39 vs 13.5%, p = 0.01), with an overall conversion rate of 18%. The postoperative complication rate in the obese group was 78% versus 24% in the nonobese group (p <0.01). Specifically, rates of ileus and wound infections were significantly higher in the obese group [32.3 vs. 7.6% (p <0.01) and 12.9 vs 3.1%. (p = 0.03), respectively]. Furthermore, hospital stay in the obese group was longer (9.5 days) than in the nonobese group (6.9 days, p = 0.02).

CONCLUSION

Laparoscopic colorectal segmental resections are feasible in obese patients. However, increased rates of conversion to laparotomy should be anticipated and the risk of postoperative complications is significantly increased, prolonging the length of hospitalization when compared to that of nonobese patients.

Distal migration of duodenal tumors: simple prolapse or intussusception?

BACKGROUND

To define radiographically simple prolapse or intussusception in cases of distal migration of duodenal tumors.

METHODS

In one pyloric and four duodenal tumors showing distal migration, the findings of gastrointestinal contrast examinations were retrospectively evaluated in relation to CT and operative findings.

RESULTS

All lesions were intraluminal growing and well demarcated, and they included two carcinoids, a papillary adenoma, a Brunner's gland adenoma, and a hyperplastic polyp. All lesions were accompanied by long mucosal stalks, and, in three, folding deformity of the proximal jejunum was observed. CT showed no target signs except for one with gastroduodenal intussusception. Intussusception was not verified surgically in any cases.

CONCLUSION

Distal migration of duodenal tumors can occur as the result of mucosal elongation and slipping. Duodenojejunal intussusception is not necessarily associated with that phenomenon.

Prostatic abscess in young males: a rare complication of Crohn's disease

We report a rare case of prostatic abscess with Crohn's disease in a 21-year-old male. Computed tomography showed a typical prostatic abscess. Moreover, filling of the abscess cavities with contrast medium was demonstrated after micturition, which represented the rupturing of the abscess into the urethra. Crohn's disease should be included in the differential diagnosis of prostatic abscesses even in young males.

Intrahepatic portosystemic venous shunts: spectrum of CT findings in external and internal subtypes

PURPOSE

The purpose of this work was to survey the spectrum of CT findings in intrahepatic portosystemic venous shunts (IPSVSs).

METHOD

One thousand consecutive liver CT scans examined with an enhanced helical technique were retrospectively reviewed on workstation to find IPSVSs.

RESULTS

IPSVSs were noted in 37 patients and divided into two subtypes according to the location of the communicating systemic vein, either outside (external type, n = 34) or within (n = 4) the liver (one patient had both internal and external types). All the external-type shunts were noted in cases with portal hypertension (n = 34). Most shunts (n = 30) ran through segment 4 and/or 3 and came out near the falciform ligament, but five shunts were noted in segment 2 communicating either with the systemic vein (n = 3) or probably with an enlarged left gastric vein (n = 2). Solitary portohepatic venous shunts (internal type) were noted in three cases with (n = 2) or without (n = 1) aneurysmal dilatation and many portohepatic venous shunts in another patient.

CONCLUSION

IPSVSs of the external type were far common than those of the internal type, always associated with increased pressure of the portal system and in specific sites probably lacking the hepatic capsule.

Utility of serum CA 19-9 monitoring in preoperative radiotherapy for pancreatic cancer

BACKGROUND/AIMS

Pancreatic cancer is extremely refractory even to aggressive treatments including surgery, resulting in early metastasis and/or local recurrence. We investigated changes in serum tumor marker CA 19-9 levels during preoperative radiotherapy in conjunction with initial treatment failure.

METHODOLOGY

Twenty-three patients presenting with localized disease and an increased serum CA 19-9 level, who were slated to undergo pancreatectomy and/or intraoperative radiotherapy following preoperative radiotherapy were reviewed. CA 19-9 response, the ratio of post-radiotherapy level before laparotomy to pre-radiotherapy level, was analyzed in relation to disease-control time and survival.

RESULTS

Eleven patients revealed metastasis at restaging or laparotomy; 12 patients (52%) completed aggressive treatments. Initial failure was identified at the liver (52%), peritoneum (52%), or local site (26%) with a median disease-control time of 91 days; 7 patients showed combined failure. All but 1 patient died of cancer with a median survival time of 264 days. CA 19-9 response (range: 0-1185%) did not correlate with disease-control time or survival; 8 progressive-disease patients (> 140% response), however, showed significantly shorter disease-control time than 15 nonprogressive-disease patients (< or = 140% response).

CONCLUSIONS

CA 19-9 monitoring is useful in preoperative radiotherapy for identifying patients who will not benefit by succeeding aggressive treatments by predicting early metastasis.

Arterioportal shunts in cirrhotic patients: evaluation of the difference between tumorous and nontumorous arterioportal shunts on MR imaging with superparamagnetic iron oxide

OBJECTIVE

The study objective was to distinguish between the features of tumorous and nontumorous arterioportal shunts on superparamagnetic iron oxide-enhanced MR imaging in patients with cirrhosis.

SUBJECTS AND METHODS

Ten arterioportal shunts in eight patients, including four tumorous and six nontumorous arterioportal shunts, were evaluated on T2-weighted turbo spin-echo and T2(*)-weighted gradient-echo sequences before and after administration of superparamagnetic iron oxide. Qualitatively, the relative signal intensity of the arterioportal shunt compared with that of the surrounding liver parenchyma was categorized into three grades: high, slightly high, and not detected. Quantitatively, signal-to-noise ratio, contrast-to-noise ratio, lesion-to-liver contrast, and percentage enhancement were calculated and compared between tumorous and nontumorous arterioportal shunts by a nonparametric statistical test (Mann-Whitney test).

RESULTS

Qualitatively, all four tumorous arterioportal shunts appeared as areas of slightly high or high intensity without and with superparamagnetic iron oxide on T2-weighted turbo spin-echo images and changed from isointensity to high intensity after the administration of superparamagnetic iron oxide on T2(*)-weighted gradient-echo images. All nontumorous arterioportal shunts except one could not be recognized without or with superparamagnetic iron oxide on either sequence. Quantitatively, with superparamagnetic iron oxide the contrast-to-noise ratio and the lesion-to-liver contrast of the tumorous arterioportal shunts were significantly higher than those of the nontumorous arterioportal shunts.

CONCLUSION

Tumorous arterioportal shunts are seen as areas of reduced signal loss, whereas most nontumorous arterioportal shunts are seen as areas of normal signal loss, like the normal liver parenchyma. The difference is more marked on T2(*)-weighted gradient-echo images than on T2-weighted turbo spin-echo images.

Ewing's sarcoma/peripheral primitive neuroectodermal tumor (pPNET) arising in the omentum as a multilocular cyst with intracystic hemorrhage

A rare case of Ewing's sarcoma/peripheral primitive neuroectodermal tumor arising in the greater omentum in a 41-year-old man is reported. The patient presented with a hemorrhagic mesenteric cyst that was disclosed by the results of an abdominal echogram, a computed tomography scan, and magnetic resonance imaging. A laparotomy showed a multilocular cyst with intra-cystic hemorrhage. Histologically, the tumor wall consisted of sheets of small round cells separated by thick desmoplastic stroma. Rosette formations or ribbon-like cell arrangements were absent. Further pathological examination revealed that the membrane of the tumor cells was positive for MIC-2, and negative for epithelial membrane antigen, cytokeratin, and desmin, which are usually positive in intra-abdominal desmoplastic small round-cell tumors. An EWS/FLI1 fused transcript was detected by reverse transcription-polymerase chain reaction. These findings confirmed the diagnosis of Ewing's sarcoma/peripheral primitive neuroectodermal tumor. The patient died of tumor recurrence 4 months after his first admission. The autopsied tumor tissue exhibited neural differentiation in certain regions. To our knowledge, this is the first case to be reported of Ewing's sarcoma/peripheral primitive neuroectodermal tumor arising in the omentum with unique pathological features and the occurrence of partial neural differentiation during the clinical course. This case pointed out to us, as gastroenterologists, that only thorough examination confirms a definitive diagnosis of small round-cell tumor of the abdomen, it also shows that Ewing's sarcoma/peripheral primitive neuroectodermal tumor should be included in the differential diagnosis of cystic lesions in the omentum.

MRI of gynaecological solid masses

Differential diagnosis of gynaecological masses is sometimes difficult, as there are so many histological types. However, magnetic resonance characteristics of some gynaecological tumours have been reported past several years. On the basis of the recent literature, we have made a decision tree for differential diagnosis of solid gynaecological tumours, in which there are some important divergences. Bilateral disease and invasive growth are malignant signs in most cases. Specific findings for different tumour types include: fibrovascular septa in dysgerminomas; preserving ovarian follicles in round cell tumours; pseudolobular patterns in young patients in sclerosing stromal tumours; and extremely hypointense masses on T2WI in Brenner tumours. Distinguishing between sex-cord stromal tumours, Brenner tumours and metastatic tumours may be hard, however, especially in middle age, because they all tend to show well-demarcated, hypointense masses on T2WI. Disproportionately clear zonal anatomy of the uterus, enlarged uterus and thickened endometrium, which are indirect findings of oestrogen-producing tumours, are useful diagnostic findings in children and postmenopausals.

Reevaluation of spiral CT cholangiography: basic considerations and reliability for detecting choledocholithiasis in 80 patients

PURPOSE

The purpose of this work was to reevaluate the characteristics and diagnostic accuracy of spiral CT cholangiography (CTC) for detecting biliary calculi.

METHOD

Spiral CTC was performed in 133 patients with suspected biliary or pancreatic diseases. All source images were reviewed by two radiologists who were unaware of final diagnoses. Attenuation values of bile were correlated with biochemical data and visualization of anatomic detail. The statistical measures in detecting the presence of choledocholithiasis were calculated in 80 patients with confirmed diagnoses.

RESULTS

Statistically significant correlations were found between the degree of biliary enhancement and both serum bilirubin and alkaline phosphatase levels. Of the 80 patients, 18 (23%) had choledocholithiasis and 62 did not. Observers diagnosed them with a sensitivity of 89% and a specificity of 98%. A mild adverse reaction to contrast material was observed in three (2.3%) patients.

CONCLUSION

Spiral CTC is a reliable, noninvasive, and accessible technique for detecting choledocholithiasis.

Superparamagnetic iron oxide-enhanced MR imaging for early and late radiation-induced hepatic injuries

Superparamagnetic iron oxide (SPIO)-enhanced MRI was performed in twenty-one patients undergoing proton-beam radiotherapy for hepatocellular carcinomas. Patients were divided into two groups: early and late phase hepatic injuries. Each group was investigated 3 to 9 weeks and 4 to 65 months after the start of irradiation, respectively. T(1)-weighted, T(2)-weighted, and T(2)*-weighted images were obtained before and after SPIO administration. In all postcontrast sequences in the early phase, irradiated livers demonstrated relatively higher intensity than nonirradiated livers and the radiation-to-liver contrast-to-noise ratio (C/N) was improved. Postcontrast T(2)*-weighted images showed the highest C/N. In the late phase, the irradiated areas showed high intensity on T(2)-weighted images and low intensity on T(1)-weighted images without SPIO, while high intensity on T(1)-weighted images with SPIO. The C/N increased with SPIO in all sequences and postcontrast T(2)-weighted images showed the highest C/N in the late phase. SPIO-enhanced MRI is useful to evaluate this entity both in the early and late phase of clinical studies.

Herniation through both Winslow's foramen and a lesser omental defect: report of a case

The herniation of small bowel through Winslow's foramen is a rare type of internal hernia which can cause ileus; however, a hernia traversing the lesser sac is even more unusual. To the best of our knowledge, only 25 cases of herniation through Winslow's foramen and 10 cases of lesser sac hernia have been reported in the Japanese literature. We describe herein the case of a 33-year-old man who presented to our hospital complaining of abdominal pain in whom a plain abdominal radiograph revealed small bowel gas with air-fluid levels, suggesting ileus. Following admission, an ileus tube was inserted, but the intestinal shadow did not improve and surgery was performed based on suspicion of an internal hernia. Approximately 100 cm of ileum was found to have herniated through a defect in the lesser omentum after passing through Winslow's foramen. Since the herniated bowel was viable, manual reduction without resection was performed. The patient had a satisfactory postoperative course, and was discharged on postoperative day 11. There are many unknown aspects surrounding the etiology of Winslow's foramen hernia and lesser sac hernia, and although internal hernia is a rare cause of ileus, its possibility should be kept in mind.

[Photodynamic diagnosis and photodynamic therapy for experimental hepatoma with ME 2906]

We studied the effects of photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in confirming the existence of hepatoma, using the new photosensitizer mono-L-aspartyl chlorine 6. Japanese white rabbits were selected for abdominal incision under intravenous anesthesia, and VX 2 tumor cells were transplanted into the left liver lobe to create a hepatoma model. In the experiment, hepatoma of 1 cm in diameter (at one week after transplantation) was radiated with a semiconducter laser (664 nm, 200 J/cm2) for treatment.

[Rapid production of gelatin sponge particles for transcatheter arterial embolization: pumping method]

We devised a simple "pumping" method to make gelatin sponge particles for transcatheter arterial embolization. As the frequency of pumping increased, the number of particles 0.2-1.6 mm in diameter increased, whereas no particles of more than 3.2 mm in diameter were present after 20 pumpings. After passing through the microcatheter, particles of less than 0.2 mm in diameter were relatively increased by about 10 points in both the pumping and cutting methods. It was histologically demonstrated that the size of embolized arteries corresponded well to the size of particles. These results suggest that our "pumping" method offers sufficient quality for transcatheter arterial embolization.

Highly enhanced hepatic masses seen on CT during arterial portography: early hepatocellular carcinoma and adenomatous hyperplasia

BACKGROUND

To describe computed tomographic (CT) features of highly enhanced hepatic masses as seen on CT during arterial portography (CTAP) and to survey the varieties of hepatic lesions associated with such findings.

METHODS

CTAP files for 400 patients were reviewed, on the basis of which six patients with highly enhanced hepatic masses were selected. These six patients also subsequently underwent CT during hepatic arteriography (CTHA) on the same day. All the patients had chronic liver damage, which was cirrhotic in five cases. Five had a current diagnosis and one had a history of hepatocellular carcinoma (HCC).

RESULTS

Solitary highly enhanced masses were observed on CTAP in three patients, three masses were seen in one patient and multiple (10-12) masses in the other two patients. All the CTAP-enhanced masses except one were round in shape and homogeneous in attenuation. The size of the mass ranged from 6 to 25 mm in diameter. In all except two nodules in one patient, the masses were hypoattenuated on CTHA. On histopathological examination of five nodules in three patients, the nodular lesions were consistent with so-called early HCC (well-differentiated HCC of Edmondson I) in four nodules and adenomatous hyperplasia in the other nodule.

CONCLUSIONS

Highly enhanced hepatic masses relative to the surrounding liver parenchyma have been sporadically noted on CTAP, especially in patients with liver cirrhosis. When present, such nodules are typically hypoattenuated on CTHA and histological features are consistent with early HCC and adenomatous hyperplasia.

Early radiation effects on the liver demonstrated on superparamegnetic iron oxide-enhanced T1-weighted MRI

Early radiation-induced liver injury during radiotherapy detected by a particulate reticuloendothelial MR contrast agent (superparamagnetic iron oxide; SPIO) is described in a patient with cholangiocarcinoma. The irradiated hepatic parenchyma appeared as a heterogeneous, less decreased signal intensity area than the nonirradiated area on MR images after SPIO administration. Resultant differences in signal intensity were better visualized on SPIO-enhanced T1-weighted images than SPIO-enhanced T2-weighted images, although SPIO-enhanced T2*-weighted fast field echo imaging was the most sensitive.

Transcatheter embolization of mycotic aneurysm of the subclavian artery with metallic coils

Mycotic aneurysms of the subclavian artery are rare. This report describes an experience of 2 rare cases in which transcatheter embolization with metallic coils was performed for the management of these lesions alternative to surgery. Two patients who had been treated with chemotherapy for malignant neoplasms were diagnosed as having mycotic aneurysms of the left subclavian artery. The causes of these lesions were presumed to be the invasion of the arterial wall by the pulmonary abscess in case 1, and wound infection after placement of the reservoir for intraarterial chemotherapy in case 2. In both cases, proximal and distal sites of the aneurysm were embolized with metallic coils. In case 1, the vertebral artery was also embolized with Guglielmi detachable coils to avoid retrograde blood flow. Both aneurysms were completely occluded by a single embolization. In case 1, although weakness and paresthesia of the left hand remained, lethal hemoptysis due to aneurysmal fistulization to the lung parenchyma ceased. In case 2, no neurological deficit except for mild paresthesia in the left thumb had been observed. Both patients died of primary disease 10 and 5 months after the procedure. Transcatheter embolization is technically feasible and effective enough to treat the mycotic aneurysm of the subclavian artery even in the situation in which the surgical option seems to be difficult or risky.

Subtraction CT with low-flow-rate arterial contrast injection to estimate drug distribution during balloon-occluded arterial chemotherapy infusion for bladder cancer

PURPOSE

To simulate drug distribution during balloon-occluded arterial chemotherapy infusion (BOAI) for urinary bladder cancer using subtraction computed tomography (CT) with low-flow-rate arterial contrast injection (S-CTLA).

METHODS

Ten patients with bladder cancer underwent S-CTLA, and the distribution of contrast agent during BOAI into both internal iliac arteries simultaneously was evaluated in nine pairs of internal iliac arteries and one single artery. For S-CTLA, spiral CT data were acquired before and after 0.2 ml/sec intraarterial injection of contrast material. The enhancement of the urinary bladder wall, the gluteal muscles, and the pelvic bones was categorized using a 4-grade scale. The grades were compared in each of the three pelvic components and differences were tested for significance using the Wilcoxon test for paired groups.

RESULTS

S-CTLA revealed the distribution of the contrast agent clearly. Gluteal muscles grades were significantly higher than those of the other two assessed components.

CONCLUSION

BOAI does not improve the concentration of contrast agent to the bladder wall over neighboring structures, suggesting that the balloon occlusion technique does not achieve its desired goal for chemotherapy targeting.

New methods of control against postoperative methicillin-resistant Staphylococcus aureus infection

The incidence of postoperative infections caused by methicillin-resistant Staphylococcus aureus (MRSA) in Japan has been increasing dramatically. In March 1990, we assigned special doctors in infection control (infection control doctor, ICD), and defined comprehensive controls against MRSA infection. A total of 3536 cases of digestive tract surgery performed at our department were studied during the period between September 1987 and August 1997. We changed the use of antibiotics to prevent postoperative infection. Cefazolin (CEZ) was employed for surgery of the upper digestive tract, including esophagus, stomach, duodenum, and gallbladder. Cefotiam (CTM) was employed for surgery of the lower digestive tract, liver, and pancreas. In esophageal resection, the tracheal tube was extracted during the early postoperative period, and for cervical esophagogastroanastomosis, the autosuture was changed to layer-to-layer anastomosis. We have achieved successful control of postoperative MRSA infection, the incidence having decreased to 0.3% (9/2703). In conclusion, our methods of control against postoperative MRSA infection implies that comprehensive measures of prevention, including the reviewed specification and usage of antibiotics and operation management, have been well implemented. This value is the lowest and the first of any domestic hospital or institute in Japan, suggesting a continued and significant decrease.

Pseudoaneurysm of the subclavian artery due to Xanthomonas pneumonia in a patient with acute myeloid leukemia: its rupture treated by transcatheter coil embolization

A 52-year-old male with acute myeloid leukemia developed pseudoaneurysm of the subclavian artery. Pneumonia due to Xanthomonas maltophilia, which was multi-drug resistant, progressed to a lung abscess even under administration of antibiotics. This lung infection contiguous to the left carotid and subclavian arteries was suggested to have caused the pseudoaneurysm of the subclavian artery. The rupture of the aneurysm by penetration to the trachea amounted to about 1,000 ml of bleeding; fortunately the bleeding ceased spontaneously. Nonetheless, an emergency transcatheter coil embolization prevented re-bleeding. Endovascular treatment should be considered especially for aneurysms which develop in patients with underlying diseases.

Outcomes of aggressive treatment of stage IV gallbladder cancer and predictors of survival

BACKGROUND/AIMS

Stage IV gallbladder carcinoma patients are rarely considered treatable by resection. They resign themselves to palliation because there is no long-term survival data available on the risks of morbidity and mortality following aggressive treatment. The aim of this study was to evaluate predictors of survival following aggressive resection surgery for stage IV gallbladder carcinoma.

METHODOLOGY

In this retrospective study, we examined 93 patients with stage IV gallbladder carcinoma who had undergone resections. Of the 93 patients, 69 had undergone liver resection to various extents together with hepaticocholedochus resection (HCR); 2 had undergone pancreaticoduodenectomy (PD) both with and without HCR; 31 had undergone hepatopancreaticoduodenectomy (HPD); 7 had undergone cholecystectomy together with HCR; 12 had undergone cholecystectomy; and 3 had undergone extended cholecystectomy. Fifty of the 93 patients had also undergone adjuvant radiotherapy. Using univariate and multivariate analyses, 13 clinicopathologic risk factors were analyzed to predict survival.

RESULTS

Operative morbidity and mortality rates were 17.2% and 5.4%, respectively. Overall, the 5-year survival rate and median survival time were 9.8% and 243 days, respectively. The 5-year survival rate was significantly higher in stage IVA (n = 17) than in stage IVB (n = 76), at 42.8% and 4.9%, respectively. Multivariate analysis revealed that sex, histopathologic type, lymph node involvement (N), subgroup of stage IV, post-resection residual tumors, and adjuvant radiotherapy were significant predictors of survival.

CONCLUSIONS

Long-term survival, with acceptable mortality and morbidity, can be expected in female patients who have stage IVA gallbladder cancer consisting of well-differentiated adenocarcinoma and who undergo either complete microscopic resection or grossly complete resection followed by adjuvant radiotherapy.

Transcatheter embolization of celiac artery pseudoaneurysm following pancreatico-duodenectomy for pancreatic cancer. A case report

A case of transcatheter embolization of a celiac artery pseudoaneurysm in a 70-year-old man is reported. The pseudoaneurysm was considered to be the result of pancreatic anastomotic leakage and an intra-abdominal abscess following pancreaticoduodenectomy with irradiation of 66 Gy for pancreatic carcinoma. To avoid recanalization of the pseudoaneurysm due to retrograde blood flow, first all branches of the celiac artery were embolized with metallic coils, and then the celiac trunk was also occluded. Hepatic arterial flow was preserved by the right hepatic artery arising from the superior mesenteric artery. After the procedure, the patient had no noticeable complications associated with the embolization nor any recurrence of the pancreatic cancer, and he achieved a 2-year survival.

Gamna-gandy bodies of the spleen depicted by unenhanced CT: report of two cases

We report two cases of Gamna-Gandy bodies (GGB) of the spleen, confirmed by MRI, in which unenhanced CT depicted multiple faint high-attenuation spots in the spleens. These spots were considered to represent the calcifications in GGB. CT and MRI reflect the different compositions of GGB. In a very limited number of patients with portal hypertension, unenhanced CT may detect GGB, and this entity should be included in the differential diagnosis of calcified foci of the spleen.

Ductectatic mucinous cystic neoplasms of the pancreas: evaluation with MR cholangiopancreatography

OBJECTIVE

We performed this study to describe the advantages of MR cholangiopancreatography and its findings in revealing ductectatic mucinous cystic neoplasms of the pancreas.

CONCLUSION

MR cholangiopancreatography using both projection and source images can reveal characteristic findings of a ductectatic mucinous cystic lesion of the pancreas and show the presence of the communicating duct between the cystic lesion and the main pancreatic duct.

A case of intravascular papillary endothelial hyperplasia (Masson's tumor) arising from renal sinus

A 55-year-old woman had a right renal tumor incidentally diagnosed by ultrasonography. CT revealed a perirenal low density mass 3 cm in diameter. Dynamic CT showed peripheral enhancement of the tumor in early phase and internal homogeneous enhancement in delayed phase. Since hemangioma was considered most likely, we performed tumor resection and spared the right kidney. The tumor was supplied by the superior ureteral artery from the right main renal artery which was considered to be derived from the renal sinus. The tumor was diagnosed as intravascular papillary endothelial hyperplasia (Masson's tumor). This is the first report of intravascular papillary endothelial hyperplasia existing in the perirenal space. Although preoperative diagnosis of intravascular papillary endothelial hyperplasia is difficult, intra-operative pathology and kidney-sparing treatment should be considered in such a case.

CT of the medial umbilical folds

PURPOSE

The goal of our study was to investigate the appearance of the medial umbilical folds on CT.

METHOD

We retrospectively reviewed the CT images of 30 consecutive patients with massive ascites. In addition, we inspected the inner pelvic wall in cadavers.

RESULTS

The medial umbilical folds were well recognized on CT in 21 of 30 patients, bilaterally in 20 and unilaterally in 1. In four patients the folds were undetectable after the ascites resolved. The CT findings were supported by those studied in cadavers, in which the folds were recognized as a peritoneal reflection in 13 of 20.

CONCLUSION

We concluded that medial umbilical folds could be commonly visualized on CT when ascites was present.

Ultrasonographic visibility of supraclavicular lymph nodes in normal subjects

We investigated the ultrasonographic assessment of the supraclavicular nodes in the neck of normal subjects. Supraclavicular areas were examined sonographically in 505 healthy persons using a 10 MHz transducer. The detection rate was 15.8%. In more than 90% of visible nodes, transverse diameters were less than 5 mm; no nodes were larger than 7 mm in transverse diameter. About half of nodes lacked the echogenic hilum and the mean longitudinal to transverse diameter ratio was 1.96. Although size was an important factor, presence of an echogenic hilum and the longitudinal to transverse diameter ratio were not considered adequate criteria for differentiating malignancy from benignity. Findings require careful assessment to avoid overinterpretation.

Bronchoarterial inversion: radiographic-CT correlation in combined right middle and lower lobe collapse

Pulmonary arteries of the right middle (RML) and right lower (RLL) lobes lie toward the lung periphery relative to their corresponding bronchi, i.e., along their lateral or posterior aspects. In contrast, those of the right upper lobe (RUL) tend to be located along the medial or anterior aspect of the bronchi. We postulate that a reversal of the normal bronchoarterial relationship at the lung base may indicate combined RML and RLL collapse. We evaluated bronchoarterial relation by computed tomography (CT) and posteroanterior (PA) chest radiographs n patients with combined RML and RLL collapse. On PA chest radiographs, an inverse bronchoarterial relationship could be recognized in the lower perihilar region in seven of 10 patients. In the 10 patients with complete collapse of both the RML and RLL, CT disclosed that the normal bronchoarterial relationship of the RUL was preserved, despite caudal extension of the RUL. In no case were arteries visible along the lateral aspect of bronchi. Thus, on frontal radiographs, when the bronchoarterial relationship in the right lower lung is inverse to that of normal subjects, combined collapse is strongly suggested.

Hepatic hemorrhage in malignant rheumatoid arthritis

Intrahepatic hemorrhage is a serious and life-threatening complication in liver disease. We describe a patient who had two episodes of intrahepatic hemorrhage after having malignant rheumatoid arthritis for 8 yr. Abdominal CT scans revealed a large intrahepatic, subcapsular hematoma. Arteriography demonstrated irregularity, caliber change, and pseudoaneurysms of the right hepatic artery, suggesting vasculitis as a cause of the bleeding. The hemorrhage was first treated with transcatheter arterial embolization, which failed to exert long term control, but arterial infusion of a large dose of prednisolone when the hemorrhage appeared was successful in managing it.

Early squamous cell carcinoma of the lung: CT and pathologic correlation

PURPOSE

To study the factors that influence computed tomographic (CT) visibility of early squamous cell carcinoma, which was defined as a lesion confined to the bronchial wall without lymph node metastasis.

MATERIALS AND METHODS

CT was performed in 18 patients with 18 early squamous cell carcinoma lesions. The 5.0-mm or thinner sections were reviewed independently by three observers who were aware of the bronchoscopic findings, and the visibility of the lesions was correlated with histopathologic findings.

RESULTS

Tumors consisted of 13 flat and five polypoid lesions. Three of the lesions were epithelial, eight were subepithelial, and seven were cartilaginous or extracartilaginous. Eleven lesions were visualized at CT as an endobronchial mass or focal bronchial wall thickening. Lesions with polypoid growth and/or cartilaginous or extracartilaginous invasion were all visualized, even on 5-mm-thick sections. Subepithelial lesions could be demonstrated when located at bronchi with craniocaudal orientation.

CONCLUSION

CT is a valuable tool for diagnosis of early squamous cell carcinomas, particularly when lesions show polypoid growth and/or invade the cartilaginous layer.

Hyperattenuating rim on noncontrast CT of the liver: probable peritumoral sparing of fatty infiltration

CT scans showing a hyperattenuating rim within the liver were retrospectively evaluated in 10 patients to clarify the character, aetiology and clinical significance. All patients had hepatic tumours (7 cavernous haemangiomas in 6 patients, 3 metastatic tumours and 1 hepatocellular carcinoma) as well as fatty infiltration of the liver. Typical features of the hyperattenuating rim on noncontrast CT of the liver included (1) attenuation similar to that of the spleen, (2) a circular or semicircular shape, (3) a width of a few millimeters, (4) peritumoral localization and (5) loss of visualization with contrast enhancement. No such rims were noted around hepatic tumours unassociated with fatty infiltration. Peritumoral sparing of fatty infiltration was inferred. A hyperattenuating rim on noncontrast liver CT, although rare, suggests the presence of a hepatic tumour in fatty liver.

Stent endoprosthesis for obstructing colorectal cancers

PURPOSE

Purpose of this study was to assess stent endoprosthesis for colorectal cancer (SECC) as an adjuvant to operative preparation in patients with obstructing colorectal cancers.

METHODS

A self-expanding stainless steel stent was inserted in 15 patients with obstructing colorectal cancers under colonoscopic observation and fluoroscopic control. Following successful SECC, the colon was mechanically prepared using polyethylene glycol. Definitive surgical treatment then was undertaken.

RESULTS

All 12 patients in whom the stent had been successfully placed recovered intestinal transit and tolerated mechanical preparation. A satisfactory preparation was confirmed during the operation. Two perforations and one dislocation were encountered.

CONCLUSION

SECC is a new method for operative preparation of patients with obstructing colorectal cancers, which may reduce morbidity and mortality associated with this difficult problem.

Effect of temporary occlusion of the hepatic vein on dual blood in the liver: evaluation with spiral CT

PURPOSE

To evaluate the contribution of hepatic veins to the dual blood supply in the liver under temporary hepatic venous occlusion.

MATERIALS AND METHODS

Selected hepatic veins in 23 patients with liver tumors were temporarily occluded with a balloon catheter. Computed tomography (CT) arteriography, CT during arterial portography (CTAP), or both were performed with a spiral technique with and without temporary occlusion of a hepatic vein.

RESULTS

After hepatic vein occlusion, a well-demarcated, wedge-shaped area of hypoattenuation was seen at CTAP and/or hyperattenuation was seen at CT arteriography in the following regions: left lobe (left hepatic vein), ventral part of the anterior segment and the medial segment except for the ventromedial part (middle hepatic vein), dorsal part of the anterior segment and the ventral part of the posterior segment (right hepatic vein), and dorsocaudal part of the right lobe (inferior right hepatic veins).

CONCLUSION

After hepatic venous occlusion, the portal veins become draining veins and the occluded area is supplied with arterial blood alone.

Fatty mass in the inferior vena cava at CT: lipoma or normal variant?

Fatty mass in the intrahepatic portion of the inferior vena cava (IVC) is an unusual lesion. We describe two cases of fatty mass appearing in the lumen of the IVC on CT and MRI study. We assume that this can be regarded as a benign process, and is mostly a normal variant.

Focal fatty masses of the pancreas

Five patients with solitary fatty mass of the pancreas examined with CT and ultrasound (US) were evaluated. The areas of fat replacement were located in the pancreatic neck, body or tail. The size ranged from 4 to 30 mm in the longest diameter. The shape varied from roundish, to ovoid to semicircular, and the contour was universally well defined. The internal structure was homogeneous in 3 patients, but in one case there were thin septa and, in another, a slightly hyperdense part in the peripheral portion. All the masses except the smallest one were in part contact with pancreatic fat. CT showed fat with the same density as the peripancreatic fat and low HU units. The mass was hypoechoic in 2 cases and hyperechoic in one. The masses in the tail of the pancreas were not detected by US.

Hepatobiliary cysts in patients with autosomal dominant polycystic kidney disease: prevalence and CT findings

OBJECTIVE

Hepatobiliary (intrahepatic and peribiliary) cysts have been described for patients with autosomal dominant polycystic disease. The purpose of this study was to determine the prevalence of these cysts and to describe the wide variation in their appearance on CT scans.

MATERIALS AND METHODS

We studied CT scans for 64 patients (31 men and 33 women) who either had known autosomal dominant polycystic kidney disease or had renal cysts and a family member with polycystic kidney disease. Contrast enhancement was used for 31 patients. CT scans were retrospectively evaluated by consensus by two experienced radiologists. The presence, number, and size of hepatobiliary cysts and the presence and appearance of the two variations, peribiliary and intrahepatic cysts, were analyzed. Peribiliary cysts were determined to be present when many small (< or = 10-mm) cysts were seen adjacent to the larger (up to the third order) portal triad. Cysts present in the hepatic parenchyma but not in contact with the larger portal triad were regarded as intrahepatic cysts.

RESULTS

CT showed hepatobiliary cysts in 56 of the 64 patients (24 men and 32 women; 88%). Intrahepatic cysts were noted in all 56 patients; peribiliary cysts were definitely seen on CT scans for 22 patients and were probably seen (fewer than five cysts and/or cysts located only on one side of the portal vein) on CT scans for 19 patients (73% of all patients with hepatobiliary cysts). Peribiliary cysts appeared as discrete cysts in 31 patients, as a string of cysts in six patients, and as a tubular structure in four patients. Intrahepatic cysts generally were round but occasionally were polygonal. They were variable in number, size, and location.

CONCLUSION

Hepatobiliary cysts were noted in 56 of 64 patients (intrahepatic cysts in all cases and peribiliary cysts in 73% of positive cases). Intrahepatic cysts varied widely in number, size, and location, whereas peribiliary cysts were small and appeared as discrete cysts, a string of cysts, or a tubular structure adjacent to the larger portal triad. It is important to be aware of the wide variety of findings for hepatobiliary cysts so that they are not confused with other abnormalities.

[Spatial and temporal alteration of the dual supply of the hepatic circulation with transient occlusion of the hepatic veins: spiral volumetric CT during arterial portography and arteriography]

To elucidate the contribution of hepatic veins to the blood flow of liver, CT arterial portography and/or arteriography was performed in eight patients having hepatocellular carcinoma with transient occlusion of the hepatic vein and eight without occlusion. In each patient with occlusion of the hepatic vein, CT showed a well-demarcated fan-shaped area of low density during arterial portography and increased density during arteriography in the corresponding area. Hepatic vein occlusion could result in the pooling of arterial blood in the liver parenchyma. Transient segmental hepatic venous occlusion might improve the results of transcatheter arterial infusion and transcatheter arterial embolization for liver tumors.

CT and MRI in detection of intrahepatic portosystemic shunts in patients with liver cirrhosis

OBJECTIVE

Our goal was to determine the prevalence and anatomic location of intrahepatic portosystemic shunts (IPSs) in patients with hepatic cirrhosis as shown by CT and MRI.

MATERIALS AND METHODS

We retrospectively reviewed CT and MR scans of 33 cirrhotic patients who had IPSs. In addition, two series of 100 consecutive CT or MR were reviewed to determine the prevalence of IPSs and the percentage of intrahepatic and extrahepatic paraumbilical veins.

RESULTS

Intrahepatic portosystemic shunts were divided into three groups according to the intrahepatic course: paraumbilical shunt between the left portal vein and the paraumbilical vein anterior to the liver (n = 29); inferior vena caval shunt between the posterior branch of the right portal vein and the inferior vena cava (n = 2); and miscellaneous (n = 2). Shunts of the paraumbilical type ran through the medial (n = 23), lateral (n = 3), or both medial and lateral (n = 3) segments of the left lobe of the liver. Twenty-five patients had one shunt, and four had more than one. Six cases were also associated with extrahepatic paraumbilical veins.

CONCLUSION

Intrahepatic portosystemic shunts, especially the paraumbilical type, were not infrequently visualized in patients with hepatic cirrhosis.

Peritoneal implants without ascites: preoperative CT diagnosis in colon carcinoma patients

We evaluated the preoperative CT findings in 10 patients with colon carcinoma in whom peritoneal metastases had been surgically confirmed. Seven patients lacked ascites. No CT findings suggestive of peritoneal metastasis were observed in two patients without ascites even by retrospective evaluation. A large mass was observed in the cul-de-sac in another. In the remaining four patients, small peritoneal metastases ranging from 8 to 11 mm in diameter were observed at the omentum in two, along the falciform ligament in one, and at both the omentum and the iliac fossa in one; three of these patients had received no prospective diagnosis of peritoneal metastasis prior to the surgery. In patients with advanced colon carcinoma with suspected serosal invasion, the entire peritoneal cavity should be carefully examined and interpreted using CT in order to detect small peritoneal implants even when ascites is absent.