Transarterial chemoembolization for hepatocellular carcinoma: An old method, now flavor of the day.

Transarterial chemoembolization (TACE) is the recommended treatment for patients suffering from intermediate, B stage, hepatocellular carcinoma. Despite an undisputed pharmacokinetic advantage, TACE with microspheres has not been shown to be superior in terms of survival compared to conventional TACE using Lipiodol(®). The best guarantee to reduce toxicity and maximize the efficacy of TACE is to strictly observe the contraindications for the procedure (Child-Pugh>B8, reduced portal flow, very large tumor, any technical contraindication and renal impairment), and rigorous application of the administration requirements for the Lipiodol(®) emulsion or loaded microspheres (assessment of hepatic vascularization investigating for accessory vascularization, injection methods). Tumor response should be assessed after four weeks by CT or MRI using the modified RECIST criteria.

Routine postoperative upper gastrointestinal fluoroscopy after laparoscopic sleeve gastrectomy: Is there still a utility?

PURPOSE: To assess the performance of routine esophagogastric transit studies (OGT) performed between day 2 (D2) and day 4 (D4) following sleeve gastrectomy for the diagnosis of gastric fistula. PATIENTS AND METHODS: Single center study including 736 patients undergoing surgery for sleeve gastrectomy including 32 of whom developed gastric fistula. Seven hundred and twenty OGT on D2 and 86 abdominal and pelvic CT scans were performed to investigate for a fistula and whether or not a blood collection was present. Sensitivity, specificity, positive and negative predictive values, Youden index (YI) and dosimetry were calculated for both investigations. RESULTS: The sensitivity and specificity of OGT for the diagnosis of fistula were 7% and 98% respectively with a PPV of 18%, an NPV of 96% and YI of 0.06. The mean DSP was 5500µGy.m(2). Sensitivity, specificity, positive and negative predictive values and Youden index for CT were 55%, 100%, 100%, 81%, 0.55, respectively for the presence of a fistula; and 96%, 86%, 78%, 98%, 0.83 for the presence of a non-blood collection and; 100%, 86%, 78%, 100%, 0.86 for the presence of a non-blood collection and/or fistula. The mean DLP was 3700 mGy.cm. CONCLUSION: Because of its very poor sensitivity for the diagnosis of gastric fistula, the OGT on D2 needs to be reconsidered. CT performed on clinical suspicion appears to be a better diagnostic tool.

High resolution unenhanced computed tomography in patients with swollen legs.

PURPOSE: To evaluate the accuracy of computed tomography (CT) scan imaging in distinguishing lymphedema from deep venous thrombosis (DVT) and lipodystrophy (lipedema) in patients with swollen legs. MATERIAL AND METHODS: CT scans of the lower limbs were performed in 55 patients with 76 swollen legs (44 lymphedemas, 12 DVT and 20 lipedemas). Thirty-four normal contralateral legs were also similarly evaluated. Primary lymphedema was verified by lymphography or lymphoscintigraphy, whereas secondary lymphedema was documented by a typical clinical history. DVT was established by ultrasound Doppler imaging. The diagnosis of lipedema was made with bilateral swollen legs where lymphoscintigraphy and Doppler examination were both unremarkable. Qualitative CT analysis was based on skin thickening, subcutaneous edema accumulation with a honeycombed pattern, and muscle compartment enlargement. RESULTS: Sensitivity and specificity of CT scan for the diagnosis of lymphedema was 93 and 100%, respectively; for lipedema it was 95 and 100%, respectively; andfor DVT it was 91 and 99%, respectively. Skin thickening was found in 42 lymphedemas (95%), in 9 DVT (75%), and in 2 lipedemas (16%). Subcutaneous edema accumulation was demonstrated in 42 legs (95%) with lymphedema and in 5 (42%) with DVT but in none with lipedema. A honeycombed pattern was present only in lymphedema (18 legs or 41%); muscle enlargement was present in all patients with DVT, in no patient with lipedema, and in 4 (9%) with lymphedema. CONCLUSION: Edema accumulation is readily demonstrated with plain CT scan and is not present in lipedema. Specific CT features of the subcutaneous fat and muscle compartments allow accurate differentiation between lymphedema and DVT.

Utility of reassessment after neoadjuvant therapy and difficulties in interpretation.

We describe the main tools for MR assessment of the response of rectal cancer tumors after chemotherapy, before surgery. In locally advanced cases of rectal and lower rectal cancer, MR is useful in allowing the treatment strategy to be adjusted, enabling conservative surgery to be performed if the patient responds well. The different types of response (fibrous, desmoplastic and colloid), their appearances and difficulties in MR interpretation are described. We describe the features and performance of MR after neoadjuvant therapy for T and N staging, assessment of circumferential resection margin and diffusion weighted imaging. Quantitative (change in tumor volume) and qualitative (grade of tumor response) MR assessment can distinguish good responders from poor responders.

New CT scan classification of leak after sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has become one of the most common bariatric procedures. Even so, the gastric leak remains the most feared complication with a difficult, non-standardized treatment. The purpose of this study was to assess the feasibility of a new classification of leakage after LSG used in Montpellier University Hospital. We have studied the correlations between radiological findings and therapeutic outcome for the 20 gastric leaks. The presence of a leak was evaluated according to the day of appearance, the symptomatology, the location, severity on the CT scan, and the management. From May 2010 to September 2012, we prospectively collected data from 20 patients diagnosed with gastric leak after LSG. There were 16 women and 4 men with a mean age of 34 years old (range 21-52 years old). The fistula was diagnosed at postoperative day 28.1 days (range 3-77 days). Patients were grouped by the new classification in: 11-type I, 6-type II, 3-type III fistula, and 0-type IV. The visualization of leakage was observed for five cases (25 %). The initial surgical drainage was performed for 11 cases and the conservative treatment was preferred in 9 cases. Three cases necessitated a delayed surgical drainage after 1 week of conservative treatment. The surgical drainage was performed by laparoscopy in 12 cases and by laparotomy in 2 cases. The new CT scan classification of gastric leak could serve as a working basis for a consensus on the therapeutic management of this dreaded complication.

[Acute mesenteric ischemia: Value of cross-sectional imaging]. / Ischémie aiguë du mésentère : apports de l'imagerie en coupes.

Acute mesenteric ischemia (AMI) is a life-threatening emergency with prognosis directly correlated with the delay in diagnosis and treatment. Clinical and laboratory findings are nonspecific and it is imperative to look for findings of AMI on CT and ultrasound examinations performed in patients with acute abdomen. Arterial and venous ischemia are different entities with different clinical and imaging features, treatment and prognosis. The main causes of AMI are arterial thromboembolic disease and low-flow state. Venous ischemia is less frequent. Due to its high reported sensitivity (90%), CT should be performed as a firstline imaging modality when AMI is suspected. CT and ultrasound imaging features of AMI include: bowel wall thickness and enhancement abnormalities, pneumatosis, portal venous gas, demonstration of intravascular thrombus, bowel dilatation and ascitis.

Acute colonic diverticulitis: prospective comparative evaluation with US and CT.

PURPOSE: To compare the accuracy of ultrasonographic (US) and computed tomographic (CT) findings for diagnosis of acute colonic diverticulitis. MATERIALS AND METHODS: US and CT were prospectively performed in 64 consecutive patients suspected of having acute colonic diverticulitis. Images were interpreted independently in a blinded fashion. Imaging data were compared with the final diagnosis, which was based on initial clinical and follow-up examination results (n = 64) and pathologic (n = 22), endoscopic (n = 21), and contrast enema (n = 15) examination findings. RESULTS: Final diagnosis was acute colonic diverticulitis (n = 33), other acute abdominal condition (n = 24), or unknown (n = 7). Both CT and US findings yielded 84% accuracy. US and CT findings were not statistically significant different in terms of sensitivity (85% and 91%, respectively) and specificity (84% and 77%, respectively). Positive predictive value was 85% for US and 81% for CT; negative predictive value was 84% for US and 88% for CT. When determining alternative diagnoses, US and CT findings yielded sensitivity of 33% and 50%, respectively (difference not statistically significant). CT scans depicted a small pneumoperitoneum overlooked on plain radiographs and US scans. Six pericolic abscesses were depicted with both techniques; three were depicted with CT only. CONCLUSION: US and CT findings result in similar accuracy for the evaluation of patients suspected of having diverticulitis.