CT-Ultrasound Fusion for Abdominal Aortic Aneurysm Measurement.

OBJECTIVE. To evaluate the potential for surveillance of abdominal aortic aneurysms without ionizing radiation exposure and without the risks of iodinated contrast administration, the accuracy of fusion of CT angiography (CTA) with ultrasound (US) was compared with conventional US in 14 patients. CONCLUSION. The mean measurement difference between conventional US and CTA was 0.50 cm, compared with 0.13 cm between CT-US fusion and CTA (p < 0.0005). CT-US fusion was more accurate than conventional US, reduces operator dependence, and is promising for accurate measurement of aortic aneurysms.

Role of Doppler Ultrasound Combined With Clinical Features in the Diagnosis of Transjugular Intrahepatic Portosystemic Shunt Dysfunction in the Era of Covered Stents.

OBJECTIVES: Our goal was to discuss the role of Doppler ultrasound (US), combined with clinical features, in the diagnosis of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction in the era of covered stents. In light of the lack of research regarding the accuracy of Doppler US in TIPS dysfunction evaluations when using covered stents and a recent major meta-analysis, which primarily reviewed studies with bare metal stents but few with covered stents, we aimed to provide our single-center case study for further investigation. METHODS: All patients from 2010 to 2019 who underwent angiography for a covered stent preceded by a Doppler US examination in our institution were retrospectively reviewed. RESULTS: All of the Doppler US and angiographic examination results showed complete agreement, and 11 of 12 were positive for TIPS dysfunction. CONCLUSIONS: Combining the presence of positive clinical signs for TIPS dysfunction with Doppler US may increase its accuracy. Considering our results, there may be a need to reinvestigate Doppler US as a noninvasive, inexpensive, and available tool for the diagnosis of TIPS dysfunction in the era of covered stents, despite recent publications depicting Doppler US as inadequate for evaluating a TIPS.

Partial splenic embolization in the treatment of prolonged thrombocytopenia due to hypersplenism in metastatic cancer patients.

BACKGROUND: Hypersplenism-related thrombocytopenia (HST) may delay or preclude chemotherapy. Partial splenic embolization (PSE) has been used at our center to overcome prolonged HST. PATIENTS AND METHODS: Between November 2012 and April 2015, 11 PSE procedures were performed in 10 patients; 9 had metastatic colorectal cancer and 1 had widespread pancreatic cancer. PSE was performed by selective catheterization of the splenic artery followed by injection of embolic particles, ranging from 300-700 um, until a 50% reduction in the splenic parenchyma blush was achieved. RESULTS: Splenomegaly was evaluated by splenic index, mean value 970 cm3 (range, 358-2277 cm3), normal mean 120-480 cm3. Mean platelet count immediately prior to PSE was 64.5 K/UL (range, 17-104 K/UL); within 10-14 days following the procedure, it increased to 224 K/UL (range, 83-669 K/UL). Only one patient's count remained less than 100 K/UL 2 weeks after embolization. After the procedure, all patients complained of mild abdominal pain that lasted for a few days; one patient developed post-embolization syndrome. No other significant complications were observed. Mean hospital stay was 2.5 days (range, 2-5 days). Chemotherapy was resumed 7-53 days (mean, 18 days) after the procedure in nine patients. One patient did not receive chemotherapy; he underwent local treatment of liver metastasis. Prolonged thrombocytopenia recurred in four patients, one of whom was successfully retreated by PSE. CONCLUSIONS: PSE can be considered as a treatment option for HST.

Sonographic evaluation of renovascular hypertension in the pediatric population: State-of-the-art.

Hypertension in children affects 2-5% of the pediatric population. Identifying secondary causes of hypertension is crucial, as some of these entities may be treatable. Renovascular hypertension accounts for 5-10% of the secondary causes of hypertension in children and is mainly related to fibromuscular dysplasia and neurofibromatosis type 1. Ultrasonographic evaluation of the kidneys, including Doppler interrogation, is the recommended primary screening tool. A comprehensive study of the upper abdomen and retroperitoneum allows for identification of additional underlying etiologies. The purpose of this review is to emphasize the different causes of renovascular hypertension in children one can diagnose during the initial ultrasonographic evaluation. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:282-292, 2017.

Pouch Inflammation Is Associated With a Decrease in Specific Bacterial Taxa.

BACKGROUND & AIMS: Pouchitis is a common long-term complication in patients with ulcerative colitis (UC) undergoing proctocolectomy with ileal pouch-anal anastomosis. Because the inflammation occurs in a previously normal small bowel, studies of this process might provide information about the development of Crohn's disease. Little is known about the intestinal microbiome of patients with pouchitis. We investigated whether specific bacterial populations correlate with the pouch disease phenotype and inflammatory activity. METHODS: We performed a prospective study of patients with UC who underwent pouch surgery (N = 131) from 1981 through 2012 and were followed at Tel Aviv Medical Center. Patients were assigned to groups based on their degree and type of pouch inflammation. Patients with familial adenomatous polyposis after pouch surgery (n = 9), individuals with intact colons undergoing surveillance colonoscopy (n = 10), and patients with UC who did not undergo surgery (n = 9) served as controls. We collected demographic and disease activity data (based on the Pouchitis Disease Activity Index) and measured levels of C-reactive protein. Fecal samples were collected, levels of calprotectin were measured, and microbiota were analyzed by 16S ribosomal RNA gene amplicon pyrosequencing. RESULTS: Increased proportions of the Fusobacteriaceae family correlated with increased disease activity and levels of C-reactive protein in patients with UC who underwent pouch surgery. In contrast, proportions of Faecalibacterium were reduced in patients with pouchitis vs controls; there was a negative correlation between proportion of Faecalibacterium and level of C-reactive protein. There was an association between antibiotic treatment, but not biologic or immunomodulatory therapy, with reduced proportions of 11 genera and with increased proportions of Enterococcus and Enterobacteriaceae. CONCLUSIONS: Reductions in protective bacteria and increases in inflammatory bacteria are associated with pouch inflammation in patients with UC who underwent pouch surgery. The finding that antibiotics exacerbate dysbiosis indicates that these drugs might not provide long-term benefit for patients with pouchitis. Additional studies of this form of dysbiosis could provide information about the pathogenesis of Crohn's disease.

Hypervascular lesion in the head of the pancreas. Preoperative angiography and selective embolization results in bloodless operation.

CONTEXT: Pancreatic neuroendocrine tumors (PNETs) are rare tumors. These tumors are hypervascular in nature. Their surgical management is well described and practiced. Although hypervascular in their nature, preoperative angioembolization of the primary tumor is usually not indicated. CASE REPORT: We describe a case of an extremely hypervascular PNET in the head of the pancreas that was managed with preoperative angioembolization that was followed by a Whipple operation that resulted in excellent recovery. DISCUSSION: Pre-operative angioembolization of pancreatic tumors, although previously reported, is exceedingly rare. The use of this technique prior to surgery is feasible and may result in bloodless surgery and better outcome.

Short treatment of peripheral blood cells product with Fas ligand using closed automated cell processing system significantly reduces immune cell reactivity of the graft in vitro and in vivo.

Mobilized peripheral blood cells (MPBCs) graft and peripheral blood cells apheresis are used for bone marrow transplantation and for treatment of graft versus host disease (GvHD). We demonstrate that a short treatment of MPBCs with Fas ligand (FasL, CD95L) for 2 h using a closed automated cell processing system selectively induces apoptosis of specific donor T cells, B cells and antigen presenting cells, but, critically, not CD34+ hematopoietic stem cells and progenitors, all of which may contribute to an increased likelihood of graft survival and functionality and reduced GvHD. Treated cells secreted lower levels of interferon-gamma as compared with control, untreated, cells. Moreover, FasL treatment of immune cells increased signals, which led to their phagocytosis by activated macrophages. FasL treated immune cells also reduced the ability of activated macrophages to secrete pro-inflammatory cytokines. Most importantly, FasL ex vivo treated MPBCs prior to transplantation in NOD-SCID NSG mice prevented GvHD and improved stem cell transplantation in vivo. In conclusion, MPBCs, as well as other blood cell products, treated with FasL by automated manufacturing (AM), may be used as potential treatments for conditions where the immune system is over-responding to both self and non-self-antigens.

Implications of the inability of Listeria monocytogenes EGD-e to grow anaerobically due to a deletion in the class III NrdD ribonucleotide reductase for its use as a model laboratory strain.

Listeria monocytogenes is a Gram-positive facultative intracellular bacterium that causes life-threatening diseases in humans. It grows and survives in environments of low oxygen tension and under conditions of strict anaerobiosis. Oxygen-limiting conditions may be an important factor in determining its pathogenicity. L. monocytogenes serovar 1/2a strain EGD-e has been employed intensively to elucidate the mechanisms of intracellular multiplication and virulence. Listeria possesses genes encoding class I aerobic and class III anaerobic ribonucleotide reductases (RNRs). The class III RNR consists of a catalytic subunit NrdD and an activase NrdG. Surprisingly, L. monocytogenes EGD-e, but not other L. monocytogenes strains or other listerial species, is unable to grow under strict anaerobic conditions. Inspection of listerial NrdD amino acid sequences revealed a six-amino acid deletion in the C-terminal portion of the EGD-e protein, next to the essential glycyl radical domain. Nevertheless, L. monocytogenes EGD-e can grow under microaerophilic conditions due to the recruitment of residual class Ia RNR activity. A three-dimensional (3D) model based on the structure of bacteriophage T4 NrdD identified the location of the deletion, which appears in a highly conserved part of the NrdD RNR structure, in the α/ß barrel domain near the glycyl radical domain. The deleted KITPFE region is essential either for interactions with the NrdG activase or, indirectly, for the stability of the glycyl radical loop. Given that L. monocytogenes EGD-e lacks a functional anaerobic RNR, the present findings are relevant to the interpretation of studies of pathogenesis with this strain specifically, in particular under conditions of low oxygen tension.

From arteritis to mycotic aneurysm: visualization of the progression of mycotic aneurysm development following femoral arterial line insertion in an infant.

Although uncommon, mycotic aneurysms in infants can be lethal because of the high risk of rapid expansion and rupture. Most catheter-associated mycotic aneurysms reported in the first year of life develop following umbilical artery catheterizations. We describe the sonographic detection of an early stage mycotic aneurysm in a 4-month-old following femoral artery catheterization complicated by methicillin-resistant Staphylococcus aureus (MRSA) septicemia. We also describe the sonographic and radiographic progression of this mycotic aneurysm before surgery.

[Minimally invasive parathyroidectomy for treatment of primary hyperparathyroidism caused by parathyroid adenoma].

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is frequently used for the treatment of primary hyperparathyroidism (PHPT) caused by a single adenoma. This method depends on preoperative localization of the tumor by a sestamibi scan, cervical ultrasound, and intraoperative parathyroid hormone (PTH) measurements. When the sestamibi scan is negative, the classical 4-gland exploration is used instead of MIP. AIMS: a. To evaluate the effectiveness of MIP for treatment of PHPT caused by adenoma. b. To evaluate the use of PTH selective venous sampling (PTH-SVS) in patients with negative sestamibi scintigraphy. METHODS: MIP was performed in all patients in whom an adenoma was diagnosed by sestamibi scan and US. When the sestamibi scan was negative, PTH-SVS was performed preoperatively for localization of the adenoma. RESULTS: Parathyroidectomy was performed in 541 patients, 458 with PHPT and 83 with secondary hyperparathyroidism. In 345 of 380 patients (90.8%) with an adenoma, MIP was performed, and in 92 of these patients the operation was performed under local anesthesia. A total of 444 (97.0%) of the patients with PHPT were cured by the surgery. In 56 patients with a negative sestamibi scan, PTH-SVS was used preoperatively for localization of an adenoma. In 30 of these cases (53%) MIP was successfully performed in spite of a negative sestamibi scan. CONCLUSIONS: MIP is the treatment of choice for PHPT caused by a single adenoma. When the preoperative sestamibi scan is negative, the authors recommend the use of PTH-SVS for preoperative localization. This resulted in 53% successful MIP in patients with a negative sestamibi scan.

A first report of radioembolization for hepatic metastases from ocular melanoma.

BACKGROUND: Ocular melanoma (OM) metastasizes to the liver and is rapidly fatal despite aggressive therapy. Yttrium-90 microspheres (radioembolization) delivered via the hepatic artery is an established and effective approach for primary and metastatic hepatic tumors, although (90)Y use in OM has not been reported previously. METHODS: A retrospective review was performed for all patients with OM who received radioembolization at 5 centers. RESULTS: 11 patients received 12 treatments with a median activity of 1.55 GBq delivered per treatment. Toxicity was minimal, with PET/CT at 3 months posttreatment showing a response in all patients; 1 patient had a complete response. CONCLUSIONS: Radioembolization can control hepatic metastases of OM with very few side effects.

Multidetector CT angiography in the evaluation of acute mesenteric ischemia.

The aim of this study was to determine the accuracy of multidetector row CT angiography in the diagnosis of acute mesenteric ischemia. Ninety-three consecutive studies on 91 patients with clinically suspected acute mesenteric ischemia underwent abdominal CT angiography as the first, and usually the sole, diagnostic procedure. CT was performed with a multidetector 16-row CT system from the level of the diaphragm to the pelvis in two phases: early arterial and late portal phase. CT examinations were reviewed by the duty radiologist. Final diagnosis was established by a senior radiologist. CTA was diagnostic in 92 studies. Mesenteric ischemia was diagnosed in 18 patients, 14 of them were of the thromboembolic type and four from the nonocclusive type. Positive CTA findings were confirmed by surgery in 13 patients and by clinical follow-up in three cases. Other reasons for abdominal pain were diagnosed by CT in 38 patients out of the remaining 74. There were two false positive and two false negative CT results, resulting in an overall accuracy of 95.6%. Multidetector CT angiography is a fast and accurate investigation for the diagnosis of acute mesenteric ischemia and in most cases can be used as the sole diagnostic procedure.

Coping with war mass casualties in a hospital under fire: the radiology experience.

OBJECTIVE: We report the role of the imaging department at a level 1 trauma center during the Second Lebanon War (summer 2006). Our institution received 849 military and civilian casualties, an average of 25 war-injured patients per day, 338 with acute traumatic stress disorders and 511 physically injured, coming in waves after a rocket attack or a battle confrontation. About 12 potentially critical physically injured patients per day were referred to the imaging department for sometimes complex imaging procedures. The unpredictable waves of casualties and nature of the injuries forced us to reorganize our routine workflow to provide adequate care to casualties and to nonemergent patients. Our nurses' station was transformed into a small emergency department. The radiology staff was distributed into 12 diagnostic stations, providing 24-hour service. Communication was improved by means of walkie-talkies. Three ultrasound units were placed at the emergency department for immediate focused assessment with sonography for trauma performance enabling initial triage of patients. The site and extent of injuries were accurately diagnosed on CT and CT angiography. Digital angiography allowed definitive vascular diagnosis and interventional procedures. CONCLUSION: Adequate communication, strict workflow, and correct use of imaging protocols ensured optimal triage, diagnosis, and therapy of casualties while maintaining care for nonwar patients.

Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality. OBJECTIVES: To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG. SETTING: University hospital, Israel. METHODS: Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m2) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage. RESULTS: There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46). CONCLUSIONS: Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.

Hemorrhagic complications of minimally invasive urological surgeries, treated with selective endovascular embolization.

Minimally invasive urological procedures have gained in popularity and replaced open surgery in various urological procedures. Although considered minimally invasive, these procedures are not free from complications, and life-threatening hemorrhage may occur. Herein we describe 3 case series of patients who underwent minimally invasive urological surgeries that were complicated with bleeding. In all 3 patients we used super selective angiographic embolization to stop hemorrhage. Minimally invasive urological surgeries carry the risk of hemorrhage, and patients should be informed about this possibility. In hemodynnmic stable patients endovascular embolization allowed bleeding cessation with maximal preservation of the bleeding kidney tissue.

Congenital pulmonary venolobar syndrome: spectrum of helical CT findings with emphasis on computerized reformatting.

The term congenital pulmonary venolobar syndrome refers to a wide spectrum of pulmonary developmental anomalies that may appear singly or in combination. The main components of congenital pulmonary venolobar syndrome are hypogenetic lung (including lobar agenesis, aplasia, or hypoplasia), partial anomalous pulmonary venous return, absence of pulmonary artery, pulmonary sequestration, systemic arterialization of lung, absence of inferior vena cava, and accessory diaphragm. The recent introduction of multisection helical computed tomography (CT), combined with use of advanced postprocessing graphic workstations, allows improved noninvasive delineation of complex congenital anomalies. A single fast (5-15-second) CT scan now enables the radiologist to (a) generate angiogram-like images of the anomalous pulmonary arteries and veins; (b) demonstrate tracheobronchial abnormalities by generating simulated bronchographic or bronchoscopic images; and (c) depict associated parenchymal abnormalities on axial, coronal, or sagittal images, which once represented an important advantage of magnetic resonance imaging over CT. Multisection helical CT is a helpful diagnostic tool in the preoperative evaluation of patients with suspected congenital pulmonary venolobar syndrome.

Multiple sequential posttraumatic pseudoaneurysms following high-energy injuries: case report and review of the literature.

A 15-year-old boy sustained severe multisystem injuries from a satchel charge while in his native village in southern Lebanon. After evacuation and resuscitation measures, he had successful intensive multidisciplinary surgical care. His long-bone fractures were stabilized by tubular external fixation systems, and his lacerated right tibialis anterior artery was grafted. Twenty days after injury, he developed a pseudoaneurysm of the left distal ulnar artery, which was surgically resected and the ulnar artery proximally ligated. Two weeks later, a pseudoaneurysm of the left peroneal artery, distal to the knee and coupled with an arteriovenous fistula, was diagnosed. This was treated by fluoroscopic controlled embolization with placement of stents. The patient recovered uneventfully. He was last seen two years after surgery, and no gross vascular compromise of any of his limbs was evident. This appears to be the only reported patient with late-developing multiple posttraumatic pseudoaneurysms after severe blast and shrapnel injuries. This development suggests that late sequelae of blast injuries may be topographically widespread and can evolve months after the injury. As such, these patients should be followed closely with a high degree of suspicion for the appearance of new signs or symptoms.

Abdominal aortic aneurysm in Behçet's disease: new treatment options for an old and challenging problem.

BACKGROUND: Arterial involvement in Behçet's syndrome is rare. Aneurysms are common among the arterial lesions, affecting various arteries but mostly the abdominal aorta. Surgical interposition graft insertion is the treatment of choice for large aneurysms. However, vasculitis in these patients is the reason for the notorious surgical complications that result in up to 50% false aneurysms in anastomotic sites. Recently, endovascular repair for abdominal aortic aneurysms has been established. OBJECTIVES: To learn more about vascular Behçet's and, specifically, to compare the results of surgical treatment and endovascular repair of AAA in patients with Behçet's syndrome. METHODS: We retrieved the medical records of all 53 patients with Behçet's disease admitted to Rambam Medical Center during the years 1985 and 2001, and analysed the results and follow-up of open surgery versus endovascular repair of AAA in patients with known Behçet's syndrome. RESULTS: Of the 53 patients with Behçet's disease 18 had vascular manifestations (34%). AAAs were encountered in 8 patients (15%) and 5 were treated. Open surgery (group 1), under general anesthesia, lasted less than 3 hours with an average aortic damping time of 34 minutes (range 26-41 min) after which the patients were transferred to the intensive care unit for 24-48 hours. Endovascular treatment (group 2), although lasting about the same time without the need for intensive care, necessitated contrast media and fluoroscopy. The length of hospital stay was considerably shorter for patients after endovascular repair compared to open surgery (3 days vs. 6 days). Combined mortality and morbidity was higher in patients who underwent open surgery compared to endovascular repair (one death, one major amputation and three anastomotic pseudoaneurysms compared to one temporary contrast-induced nephropathy). CONCLUSIONS: Vasculo-Behçet's patients with AAA are better candidates for endovascular treatment than atherosclerotic patients. Combined morbidity (especially anastomotic pseudoaneurysms) and mortality of Behçet's patients after endovascular repair is considerably lower than after open surgery.

Methylene Blue injection via superior mesenteric artery microcatheter for focused enterectomy in the treatment of a bleeding small intestinal arteriovenous malformation.

INTRODUCTION: Obscure gastrointestinal bleeding from the small intestine may present the Acute Care Surgeon with a formidable diagnostic and therapeutic challenge. Despite the current array of diagnostic studies, localization of the causative pathology may be elusive, especially when the bleeding is intermittent. When a small intestinal arteriovenous malformation is the responsible lesion, a technique combining super-selective angiography with intra-operative methylene blue injection and focused enterectomy has been described in a number of case series. The current case report utilizes this same approach with emphasis on computed tomography angiography representing a key first step in the diagnostic algorithm. CASE REPORT: In this case report, we describe the diagnosis and treatment of obscure gastrointestinal bleeding emanating from an arteriovenous malformation in the small intestine of a 52 year old male. After an extensive work-up including upper and lower endoscopy, double balloon enteroscopy and capsule endoscopy, he was referred for computed tomography angiography. Though he was not actively bleeding, a jejunal arteriovenous malformation was localized on imaging. This prompted directed transfemoral angiography, placement of a super-selective microcatheter in the 4th jejunal arterial branch, intra-operative methylene blue injection and focused enterectomy with pathological confirmation. The patient was found to be free of gastrointestinal bleeding on 6 month follow-up. CONCLUSIONS: A step-wise, rational diagnostic approach should be utilized in the evaluation of obscure gastrointestinal bleeding. In the non-actively bleeding patient, computed tomography angiogram may facilitate the diagnosis of a small intestinal arteriovenous malformation. Methylene blue injection via a super-selective angiographic microcatheter may then allow for focused enterectomy.

Management of combat vascular injuries using modern imaging: are we getting better?

Background. Vascular injuries often result in life threatening hemorrhage or limb loss. When they present with a single entry or exit wound, surgery is immediately indicated. With multiple injuries, however, imaging such as CTA is necessary for diagnosis and choice of treatment. Methods. For all combat-related vascular cases admitted to our medical center during the Lebanon wars in 1982 and 2006, we compiled and compared presenting signs and symptoms, means of diagnosis, treatments, and results. Results. 126 patients with vascular injuries were admitted (87 in 1982, 39 in 2006). 90% were male; mean age of 29 years (range 20-53). All injuries were accompanied by insult to soft tissue, bones, and viscera. 75% presented with injury to arteries in the extremities. 75% of these patients presented with limb ischemia, and 25% sustained massive blood loss. Treatments included venous interposition graft, end-to-end anastomosis, venous patch, endovascular technique (only in 2006), and ligation/observation. Complications included thrombosis and wound infections. Mortality and amputations occurred only in 1982, and this may be attributed to the use of imaging, advanced technique, and shorter average time from injury to hospital (7 hours). Conclusions. We recommend CTA as the first line modality for diagnosis of vascular injuries, as its liberal use allowed for early and appropriate treatment. Treatment outcomes improved with fast and effective resuscitation, liberal use of tourniquets and fasciotomies, and meticulous treatment by a multidisciplinary team.