30-yr course and favorable outcome of alveolar echinococcosis despite multiple metastatic organ involvement in a non-immune suppressed patient.

We report the 30-yr history of a well-documented human case of alveolar echinococcosis, with a lung lesion at presentation followed by the discovery of a liver lesion, both removed by surgery. Subsequently, within the 13 years following diagnosis, metastases were disclosed in eye, brain and skull, as well as additional lung lesions. This patient had no immune suppression, and did not have the genetic background known to predispose to severe alveolar echinococcosis; it may thus be hypothesized that iterative multi-organ involvement was mostly due to the poor adherence to benzimidazole treatment for the first decade after diagnosis. Conversely, after a new alveolar echinococcosis recurrence was found in the right lung in 1994, the patient accepted to take albendazole continuously at the right dosage. After serology became negative and a fluoro-deoxy-glucose-Positron Emission Tomography performed in 2005 showed a total regression of the lesions in all organs, albendazole treatment could be definitively withdrawn. In 2011, the fluoro-deoxy-glucose-Positron Emission Tomography showed a total absence of parasitic metabolic activity and the patient had no clinical symptoms related to alveolar echinococcosis.The history of this patient suggests that multi-organ involvement and alveolar echinococcosis recurrence over time may occur in non-immune suppressed patients despite an apparently "radical" surgery. Metastatic dissemination might be favored by a poor adherence to chemotherapy. Combined surgery and continuous administration of albendazole at high dosage may allow alveolar echinococcosis patients to survive more than 30 years after diagnosis despite multi-organ involvement.

Small-bowel obstruction from adhesive bands and matted adhesions: CT differentiation.

OBJECTIVE: The purpose of this study was to evaluate the CT findings that can help to differentiate small-bowel obstruction (SBO) due to adhesive bands from SBO caused by matted adhesions. MATERIALS AND METHODS: CT scans of 67 consecutive patients with adhesive SBO caused by either surgically confirmed adhesive bands or matted adhesions were analyzed. CT findings were compared between the two groups with regard to simple obstruction patterns (single abrupt transition zone, beak sign, "fat notch" sign), patterns of closed-loop obstruction (two adjacent beaks, C-shaped bowel, radial distribution of mesenteric vessels), the location of the obstruction in the abdominal cavity, and the presence of a whirl sign and a "small-bowel feces" sign. Statistical analyses were performed using the Fisher's exact test. RESULTS: Closed-loop patterns and a whirl sign were seen only in cases of SBO from adhesive bands. Compared with SBO cases from matted adhesions, significantly more SBO cases that were due to adhesive bands showed a beak sign (p = 0.0001) and fat notch sign (p = 0.0001). The small-bowel feces sign was more frequently seen in cases of SBO from matted adhesions (p = 0.014). Bowel ischemia and bowel necrosis were more frequent findings with adhesive bands than with matted adhesions (p = 0.011 and p = 0.049, respectively). The location in the pelvis of the adhesive structure (p = 0.039) and a higher rate of accidental bowel perforation (p = 0.031) were associated with matted adhesions. CONCLUSION: CT is useful for differentiating SBO caused by adhesive bands from SBO due to matted adhesions.

Small-bowel bezoar versus small-bowel feces: CT evaluation.

OBJECTIVE: The objective of our study was to evaluate the accuracy of CT for differentiating small-bowel bezoar from small-bowel feces in cases of small-bowel obstruction (SBO). CONCLUSION: In cases of SBO, although some CT features of bezoars and small-bowel feces overlap, a well-defined mass mottled with gas bubbles associated with an encapsulating wall, the newly described "floating fat-density debris" sign, and a lesion in the stomach that appears similar to the obstructing mass is typical of a small-bowel bezoar; an isolated amorphous mass mottled with gas bubbles is typical of small-bowel feces.

The pubic tubercle: a CT landmark in groin hernia.

The aim of our study is to investigate the pubic tubercle as a reliable CT landmark in distinguishing the three types of groin hernia. CT scans of 42 patients with surgically confirmed groin hernia were reviewed. For each patient, both the anatomical structure within the hernia and the state of the hernia to the inferior epigastric artery were specifically recorded. Hernias were also located within a schematic construction of orthogonal lines focused on the pubic tubercle. In this construction, inguinal hernias were ventral to the X-axis while femoral hernias were dorsal to the X-axis. Among the inguinal hernias, direct inguinal hernias were located strictly lateral to the Y-axis while indirect inguinal hernias medially crossed the Y-axis. All these CT results were compared to the surgical findings. The inferior epigastric artery was visualized in 90% patients and, in these cases, the situation of the hernia to the artery on CT showed no discordance with surgical findings. Within the schematic construction of orthogonal lines focused on the pubic tubercle, 50% were considered as indirect inguinal hernias, 31% as direct inguinal hernias and 19% as femoral hernias. For each patient, the CT diagnosis was consistent with the surgical report.

Current interventional strategy for the treatment of hepatic alveolar echinococcosis.

INTRODUCTION: The use of various types of invasive interventions combined with anti-infective drugs in the therapeutic strategy of alveolar echinococcosis (AE) has changed during the last 30 years. Areas covered: This article reviews the current respective indications of surgical, percutaneous and perendoscopic interventions in AE and proposes an integrative therapeutic strategy. Expert commentary: Hepatic resection is indicated whenever it is feasible and curative; palliative surgery should be avoided; percutaneous procedures are best adapted to the drainage of the necrotic cavity present in advanced cases; perendoscopic procedures with stenting are best adapted to alleviating the biliary complications that are common and life-threatening in AE patients. Continuous administration of albendazole or mebendazole, without interruption is mandatory in all cases, temporarily (recommended duration: 2 years) after radical lesion resection in patients without immune suppression; for life in all other cases. Long-term follow-up is essential.