Celiac axis stenosis and digestive disease: Diagnosis, consequences and management.

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

Transitioning to Transradial Access for Cerebral Aneurysm Embolization.

BACKGROUND AND PURPOSE: Despite several retrospective studies showing the safety and efficacy of transradial access for cerebral angiography, neurointerventionalists are apprehensive about implementing TRA for neurointerventions. This reluctance is mainly due to anatomic factors, technical factors, and a long learning curve (relative to transfemoral access). We present here our experience of TRA transition for cerebral aneurysm embolization. Our aim was to demonstrate the feasibility and safety of radial access for consecutive embolizations of ruptured and unruptured cerebral aneurysms. MATERIALS AND METHODS: We performed a retrospective review of a prospective data base on cerebral aneurysm embolizations. Between April and December 2018, radial access was considered for all consecutive patients referred to our institution for cerebral aneurysm embolization. Technical success was defined as radial access with insertion of the sheath and completion of the intervention without a crossover to conventional femoral access. The primary safety end point was the in-hospital plus 30-day incidence of radial artery occlusion. Secondary end points included intraoperative complications and neurologic complications at discharge and in the following 30 days. RESULTS: Seventy-one patients with a cerebral aneurysm underwent 73 embolization procedures at our institution. The first-choice access route was the radial artery in 62 patients (87.3%) and the femoral artery in 9 (12.6%). Thirty-four embolizations were performed using coils, 22 used a balloon-assisted coil technique, 6 used a stent-assisted coil technique, and 2 used a flow diverter. Crossover to femoral access was observed in 2 patients (3.1%). Four patients developed coil-induced thrombi requiring intra-arterial tirofiban injections. In 1 case, an aneurysm ruptured during the operation but did not have a clinical impact. No cases of radial artery occlusion or hand ischemia were observed. CONCLUSIONS: A transition to radial access for cerebral aneurysm embolization is feasible and does not increase the level of risk associated with the procedure.

Natural history of percutaneous drainage of postoperative collection following colorectal surgery: in which patients can follow-up imaging be dispensed with before drain removal?

INTRODUCTION: Colorectal surgery is complicated by postoperative collections in up to 25% of cases depending on local conditions. The aim of this study was to identify predictive factors of success of percutaneous drainage of collections in order to avoid follow-up imaging. PATIENTS AND METHODS: All consecutive patients between January 2009 and December 2016, who had undergone elective or emergency colorectal surgery (colorectal surgery and appendectomy) complicated by a postoperative collection treated by percutaneous drainage with follow-up imaging prior to drain removal, were included in this single-center and retrospective study. The primary objective was to assess predictive factors of success of the first attempt of percutaneous drainage of collections. Secondary objectives were to describe the natural history of percutaneous drainage of postoperative collections after colorectal surgery and the overall success rate of percutaneous drainage. RESULTS: Fifty-three patients underwent percutaneous drainage of a postoperative collection during the study period and were included in this study. Complete resolution of the collection was observed on the first follow-up radiological examination in 36 patients (58%). In multivariate analysis, post-appendectomy collections (OR = 3.19 (1.14-9.27), p = 0.002) and reduction of the leukocyte count (OR = 3.22 (1.28-8.1), p = 0.013) were significantly associated with success of percutaneous drainage. CONCLUSION: This is the first study to address that follow-up imaging prior to drain removal might not be necessary in patients undergoing drainage of post-appendectomy collections and/or with more than 30% reduction of the leukocyte count at the first follow-up examination.

Distinguishing fecal appendicular peritonitis from purulent appendicular peritonitis.

INTRODUCTION: Fecal appendicular peritonitis (FAP) is a poorly studied, rare form of acute appendicitis, corresponding to peritoneal inflammation with the presence of feces secondary to ruptured appendix. The purpose of this study was to describe FAP and to compare FAP with purulent appendicular peritonitis (PAP). PATIENTS AND METHODS: This single-center, retrospective study was conducted in consecutive patients to compare the FAP group and the PAP group. The primary endpoint was the 30-day postoperative morbidity and mortality according to the Clavien-Dindo classification. The secondary endpoints were description and comparison of intraoperative data (laparoscopy rate, conversion rate, type of procedure and the mean operating time), and short-term outcomes (types of complications, length of stay, readmission rate, and reoperation rate), comparison of intraoperative bacteriological samples of FAP and PAP as well as the rate of resistance to amoxicillin and clavulanic acid, used as routine postoperative antibiotic therapy. RESULTS: Between January 2006 and January 2016, 2.2% of appendectomies were performed for FAP. Patients of the FAP group reported a longer history of pain than patients of the PAP group (mean: 58 h [range: 24-120] vs 24 h [range: 6-504], p = 0.0001) and hyperthermia was more frequent in the FAP group than in the PAP group (72% vs 26%, p = 0.0001). Mean preoperative CRP was also higher in the FAP group than in the PAP group (110 mg/L [range: 67-468] vs 37.5 mg/L [range: 3.1-560], p = 0.007). Significantly less patients were operated by laparoscopy in the FAP group (89.7% vs 96.6%, p < 0.0001). Mean length of stay was significantly longer in the FAP group than in the PAP group (10 days [range: 3-24] vs 5 days [range: 1-32], p = 0.001). The overall 30-day complication rate was significantly higher in the FAP group than in the PAP group (62.1% vs 24.7%, p = 0.0005). The readmission rate was not significantly different between the two groups (14% vs 11.2%, p = 0.2), but the reoperation rate was higher in the FAP group than in the PAP group (31% vs 11%, p = 0.01). No significant difference was observed between the FAP and PAP groups in terms of the positive culture rate (75.9% vs 65.6%, p = 0.3). No significant difference was observed between the two groups in terms of resistance to amoxicillin and clavulanic acid (18.2% vs 20.5%, p = 0.8). CONCLUSION: FAP is associated with significantly more severe morbidity compared to PAP. Clinicians must be familiar with this form of appendicitis in order to adequately inform their patients.

What are the predictive factors of caecal perforation in patients with obstructing distal colon cancer?

AIM: In the presence of large bowel obstruction, the choice of treatment is determined by the patient's general status, the tumour characteristics and the perceived risk of caecal perforation. This study was designed to evaluate the predictive factors of impending caecal perforation, and also investigated the use of caecal volumetry. METHOD: From January 2011 to June 2016, patients with obstructive distal colon cancer undergoing emergency laparotomy, for whom a pretreatment CT scan was available, were included in this retrospective, case-control, two-centre study. Two patient groups were defined: patients with and without impending caecal perforation. The primary end-point of the study was a determination of predictive factors for caecal perforation. RESULTS: A total of 72 patients (45 men, 62.5%) were included. Univariate analysis revealed that the presence of pericaecal fluid (P < 0.0001), caecal pneumatosis (P < 0.0001), mean maximum caecal diameter (P = 0.001), mean caecal diameter at the ileocaecal junction (P = 0.0001) and mean caecal volume (P = 0.001) were associated with caecal perforation. Receiver operating characteristic curve analysis revealed that a caecal volume greater than 400 cm3 (P < 0.0001), a maximum caecal diameter > 9 cm (P = 0.002) and a caecal diameter at the ileocaecal junction > 7.5 cm (P = 0.001) were associated with impending caecal perforation. In multivariate analysis, only caecal volume > 400 cm3 (P = 0.001) was correlated with the risk of impending caecal perforation. CONCLUSION: Caecal volumetry is an easy and useful tool to predict impending caecal perforation in patients with large bowel obstruction.

Conservative endoscopic management for pancreatic trauma.

Traumatic pancreatic injuries are rare: their severity correlates with main pancreatic duct involvement. We report the case of a 5-year-old child who presented with complete disruption of the main pancreatic duct, treated successfully with an endoscopically inserted double pigtail stent.

Percutaneous transgluteal drainage of pelvic abscesses in interventional radiology: A safe alternative to surgery.

AIM: Interventional radiology plays an important role in the management of deep pelvic abscesses. Percutaneous drainage is currently considered as the first-line alternative to surgery. A transgluteal computed tomography (CT)-guided approach allows to access to deep infected collections avoiding many anatomical obstacles (vessels, nerves, bowel, bladder). The objective of this study was to assess the safety and efficacy of a transgluteal approach by reviewing our clinical experience. MATERIALS AND METHOD: We reviewed medical records of patients having undergone percutaneous CT-guided transgluteal drainage for deep pelvic abscesses. We focused on the duration of catheter drainage, the complications related to the procedures and the rate of complete resolution. RESULTS: Between 2005 and 2013, 39patients (27women and 12men; mean age: 52.5) underwent transgluteal approach CT-guided percutaneous drainage of pelvis abscesses in our department. The origins of abscesses were postoperative complications in 34patients (87.2%) and infectious intra-abdominal disease in 5patients (12.8%). The mean duration of drainage was 8.3days (range: 3-33). Laboratory cultures were positive in 35patients (89.7%) and Escherichia coli was present in 71.4% of the positive samples. No major complication was observed. Drainage was successful in 38patients (97.4%). A transpiriformis approach was more significantly associated with intra-procedural pain (P=0.003). CONCLUSION: Percutaneous CT-guided drainage with a transgluteal approach is a safe, well-tolerated and effective alternative to surgery for deep pelvic abscesses. This approach should be considered as the first-line intention for the treatment of deep pelvic abscesses.

Ruptured Pancreaticoduodenal Artery Aneurysms Associated with Celiac Stenosis Caused by the Median Arcuate Ligament: A Poorly Known Etiology of Acute Abdominal Pain.

OBJECTIVE/BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysm is a rare but clinically important form of vascular disease. A small proportion of these aneurysms are caused by compression of the artery by the median arcuate ligament (MAL). The objective of the study was to establish whether it is feasible and effective to treat ruptured PDA aneurysms without treating the celiac stenosis caused by the MAL. METHODS: From January 2007 to November 2014, 10 patients were included. Standard embolization or surgical procedures were used to treat the ruptured aneurysms, but the celiac stenosis itself was not treated. The primary end point was the feasibility and efficacy of embolization for the treatment of ruptured PDA aneurysms. The secondary end points included clinical data, imaging findings, the success rate of embolization and the outcome during follow up. RESULTS: All patients presented with acute, non-specific epigastric pain with nausea. An abdominal computed tomography scan revealed peri-pancreatic hematoma in all cases, and PDA aneurysms were visible in six patients. The aneurysms ranged from 2 mm to 10 mm in diameter and were variously located on the anterior PDA (n = 1), the posterior PDA (n = 3), and the branch of the dorsal pancreatic artery (n = 6). Surgery was performed in two cases (with one death). Embolization was successful in the other eight cases. The median length of hospital stay was 10 days (range 8-25 days). Over a median follow up period of 11 months (range 5-48 months), none of the PDA aneurysms recurred. CONCLUSION: Rupture of a PDA aneurysm caused by the MAL should always be considered in the differential diagnosis of acute abdominal pain, because the condition requires specific management. Embolization is safe and has a high success rate. Surgery should only be performed when embolization fails.

An extremely uncommon variant of left hepatic artery arising from the superior mesenteric artery.

We report a new variation of the left hepatic artery arising from the superior mesenteric artery. The variant was discovered during radiological examinations in a patient presenting with ruptured hepatocellular carcinoma of the left liver lobe. Anatomical description was based on CT-scan and angiographic analysis. When present the left hepatic artery originates from the left gastric artery, with an incidence of 12-34 %. Knowledge of left hepatic artery anatomy is mandatory to optimize surgical and radiological management in complex clinical situations.

Radiologic drainage of post-operative collections and abscesses.

Since the initial studies published in the eighties, percutaneous radiologic drainage, is considered the first-line treatment of infected post-operative collections and is successful in over 80% of patients. Mortality due to undrained abscesses is estimated between 45 and 100%. Radiology-guided percutaneous drainage can be performed either with curative intent or to improve patient status prior to re-operation under better conditions. Cross-sectional imaging, using either ultrasound or computed tomography (CT), has changed the management of post-operative complications. Percutaneous drainage is most often performed by interventional radiologists and imaging is essential for road-mapping and guiding the puncture and drainage of intra-abdominal collections. Indeed, such imaging allows both identification of adjacent anatomical structures and determination of the best tract and the safest route. Cooperation between the surgeon and the interventional radiologist is essential to optimize the management and to avoid, if possible, surgery, which is so often difficult in this setting.

Laparoscopic sleeve gastrectomy: imaging of normal anatomic features and postoperative gastrointestinal complications.

Morbid obesity is a public health problem in the United States and Europe and its prevalence is on the increase. Despite certain progress the efficacy of medical treatment remains limited. Bariatric surgery has consequently become an effective alternative for patients with morbid obesity. The bariatric operations most frequently performed are laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (LGB), but laparoscopic sleeve gastrectomy (LSG) is increasingly popular with both bariatric surgeons and patients due to its simplicity, rapidity and decreased morbidity. The purpose of this pictorial essay is to familiarize radiologists with the normal postoperative anatomic features and the imaging findings of postoperative gastrointestinal complications of laparoscopic sleeve gastrectomy because little literature exists on this subject.

Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature.

AIM: Percutaneous drainage of abdominal and pelvic abscesses is a first-line alternative to surgery. Anterior and lateral approaches are limited by the presence of obstacles, such as the pelvic bones, bowel, bladder, and iliac vessels. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous, transgluteal approach by reviewing our clinical experience and the literature. MATERIALS AND METHODS: We reviewed demographic, clinical and morphological data in the medical records of 30 patients having undergone percutaneous, computed tomography (CT)-guided, transgluteal drainage. In particular, we studied the duration of catheter drainage, the types of microorganisms in biological fluid cultures, complications related to procedures and the patient's short-term treatment outcome. RESULTS: From January 2005 to October 2011, 345 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A transgluteal approach was adopted in 30 cases (10 women and 20 men; mean age: 52.6 [range 14-88]). The fluid collections were related to post-operative complications in 26 patients (86.7 %) and inflammatory or infectious intra-abdominal disease in the remaining 4 patients (acute diverticulitis: n = 2; appendicitis: n = 1; Crohn's disease: n = 1) (13.3 %). The mean duration of drainage was 8.7 days (range 3-33). Laboratory cultures were positive in 27 patients (90 %) and Escherichia coli was the most frequently present microorganism (in 77.8 % of the positive samples). A transpiriformis approach (n = 5) was more frequently associated with immediate procedural pain (n = 3). No major complications were observed, either during or after the transgluteal procedure. Drainage was successful in 29 patients (96.7 %). One patient died from massive, acute cerebral stroke 14 days after drainage. CONCLUSION: When an anterior approach is unfeasible, transgluteal, percutaneous, CT-guided drainage is a safe, well tolerated and effective procedure. Major complications are rare. This type of drainage is an alternative to surgery for the treatment of deep pelvic abscesses (especially for post-surgical collections).

Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?

Laparoscopic sleeve gastrectomy (LSG) has a specific morbidity profile in which gastric leak (GL) is the main complication. With a view to defining a standardized protocol for GL management, the present retrospective study sought to describe the clinical patterns of post-LSG GL and treatment of the latter in our university medical center. From July 2004 to December 2010, 25 patients were included. GL was described in terms of clinical presentation, time to onset, and location in the staple line. Treatment of GL with pharmacologic, radiologic, endoscopic, and/or surgical procedures was always validated by a multidisciplinary care team. "Treatment success" was defined as the absence of contrast agent leakage on CT and endoscopy after removal of covered metallic stent or pigtail drains. Systemic inflammation and peritonitis were the main signs for early-onset GL (56%), whereas pulmonary symptoms and intra-abdominal abscesses revealed delayed-onset GL (44%). Surgery was always performed for early-onset GL. In the total study population, the median number of endoscopic procedures was five (range, 1-11) per patient, of covered SEMS was three (range, 1-8), and of pigtail drains was three (range, 1-4). Nine (36%) patients presented endoscopic-related complications. Four (16%) patients with treatment failure underwent radical surgery. The mortality rate was 4% (n = 1). The management of post-LSG GL is challenging. Surgery was always performed for early-onset GL, whereas treatment of delayed-onset GL was based on endoscopy. Pigtail drains required fewer procedures per patient, were better tolerated, and had lower morbidity-mortality than covered SEMS.

Progressive preoperative pneumoperitoneum preparation (the Goni Moreno protocol) prior to large incisional hernia surgery: volumetric, respiratory and clinical impacts. A prospective study.

INTRODUCTION: Progressive preoperative pneumoperitoneum (PPP) is used to prepare incisional hernias with loss of domain (IHLD) operations. The aim of the present study was to analyze the effect of PPP on peritoneal volume [measured using a new computed tomography (CT)-based method] and respiratory function. METHODS: From July 2004 to July 2008, 19 patients were included in a prospective, observational study. The volumes of the incisional hernia (VIH), the abdominal cavity (VAC), the total peritoneal content (VP) and the VIH/VP ratio were measured before and after PPP using abdominal CT scan data. Spirometric parameters were measured before and after PPP, and postoperative clinical data were evaluated. RESULTS: Before and after PPP, the mean VIH was 1,420 cc and 2,110 cc (P  < 0.01), and the mean VAC was 9,083 cc and 11,104 cc (P < 0.01). The VAC increased by 2,021 cc (P < 0.01) and was greater than the mean VIH before PPP. After PPP, the spirometric measurements revealed a restrictive syndrome. The overall postoperative morbidity rate was 37%. CONCLUSIONS: PPP increased the hernia and abdominal volumes. PPP induced a progressive, restrictive syndrome.