Gallbladder perforation: Diagnostic accuracy of new CT difficulty score in predicting complicated laparoscopic cholecystectomy.

PURPOSE: To formulate and evaluate the diagnostic performance and utility of a new CT difficulty score in predicting difficult laparoscopic surgery in cases of gallbladder (GB) perforation. METHODS: This prospective single centre study included a total of 48 diagnosed cases of GB perforation on CT between December 2021 and June 2023, out of which 24 patients were operated. A new 6-point CT difficulty scoring system was devised to predict difficult laparoscopic approach, based on patterns of inflammation around the perforated GB that were found to be surgically relevant. The pre-operative imaging findings on CT were studied in detail and correlation coefficients of various imaging findings were calculated to predict difficult surgery. RESULTS: On CECT, the type of perforation, according to the revised Niemeier's classification could be exactly delineated in all 48 patients. A CT difficulty score of ≥ 3 was found to a good predictor difficult laparoscopic approach, with statistical significance (p = 0.001), sensitivity of 94.44%, specificity of 83.33%, PPV of 94.44% and NPV of 83.33%. Inflammatory changes around duodenum showed maximum correlation coefficient of 0.744 (p = 0.0001), around colon showed a correlation coefficient of 0.657 (p = 0.0005), and in the omentum had a correlation coefficient of 0.5 (p = 0.013)). Inter-observer agreement was also calculated for various findings and it was found to have moderate to strong agreement (κ value 0.5-1.0). CONCLUSION: The CT difficulty scoring system can be an effective tool in predicting difficult laparoscopic surgery in cases of GB perforation in an emergency setting which can help in decision making and improved patient outcome.

Cutoff values of body fat composition to predict metabolic risk factors with normal waist circumference in Asian Indian population.

OBJECTIVES: The aim of the study is to see if visceral fat volume (VFV), subcutaneous fat volume (SFV), and visceral-subcutaneous fat ratio (VSR) can be used to detect metabolically obese normal weight individuals in Asian Indian population. METHODS: This is a single center prospective cross-sectional study and 80 cases having either hypertension, diabetes, or hyperlipidemia with normal waist circumference and 80 controls having normal metabolic parameters with normal waist circumference were evaluated. Visceral and subcutaneous fat volumes and visceral to subcutaneous fat ratios were determined by computed tomography (CT) at L4-L5 level with a slice thickness of 5 mm. RESULTS: Visceral fat volume, subcutaneous fat volume, and VSR are significantly higher in patients with metabolic risk factors as compared to those without risk factors. Volume of subcutaneous fat is significantly higher in females as compared to males. VSR is higher in males in our study. The cutoff values for VFV, SFV, and VSR to predict at least one metabolic syndrome are 8.5 cm3, 15.7 cm3, and 0.61 in males and 7.0 cm3, 16.5 cm3, and 0.44 in females. CONCLUSIONS: For individuals with normal waist circumference, VFV, SFV, and VSR can effectively predict the presence of one metabolic risk factor. KEY POINTS: • Visceral fat volume, subcutaneous fat volume, and visceral-subcutaneous fat ratio can predict individuals at risk of metabolic syndrome having normal waist circumference. • Higher VSR in Indian population is due to low reservoir of primary adipose tissue fat compartment which leads to diversion of adipocytes into the secondary adipose tissue fat compartment. • This data can be used as a screening tool in preventive radiology for identifying individuals at risk of developing metabolic syndrome.

MDCT evaluation of Dorsal Pancreatic Artery and Intrapancreatic arcade anatomy.

OBJECTIVE: The purpose of the study was to analyze the anatomy and variations in the origin of the dorsal pancreatic artery, greater pancreatic artery and to study the various types of arterial arcades supplying the pancreas on multidetector CT (MDCT). METHODS: A retrospective analysis of 747 MDCT scans was performed in patients who underwent triple phase or dual phase CT abdomen between December 2020 and October 2022. Variations in origin of Dorsal pancreatic artery (DPA), greater pancreatic artery (GPA), uncinate process branch were studied. Intrapancreatic arcade anatomy was classified according to Roman Ramos et al. into 4 types-small arcades (type I), small and large arcades (type II), large arcades (type III) and straight branches (type IV). RESULTS: The DPA was visualized in 65.3% (n = 488) of cases. The most common origin was from the splenic artery in 58.2% (n = 284) cases. The mean calibre of DPA was 2.05 mm (1.0-4.8 mm). The uncinate branch was seen in 21.7% (n = 106) with an average diameter of 1.3 mm. The greater pancreatic artery was seen in 57.3% (n = 428) predominantly seen arising from the splenic artery. The most common arcade anatomy was of Type II in 52.1% (n = 63) cases. CONCLUSION: Pancreatic arterial variations are not very uncommon in daily practice. Knowledge of these variations before pancreatic surgery and endovascular intervention procedure is important for surgeons and interventional radiologist.

Thick crusted plaques on the periorificial area in a young woman.

We report a young woman with periorificial erosions and thick crusts mimicking pemphigus foliaceous, who was found to have an underlying pancreatic malignancy with normal blood glucose and glycosylated haemoglobin levels. Click here for the corresponding questions to this CME article.

MDCT evaluation of pancreatic contour variations in head, neck, body and tail: surgical and radiological significance.

OBJECTIVE: The purpose of the study was to investigate the incidence of pancreatic contour variations on multidetector CT (MDCT) for abdominal examinations. METHODS: A retrospective analysis of 700 MDCT scans was performed in patients who underwent triple phase CT abdomen between October 2018 and January 2021. After excluding 176 patients, finally total of 524 patients were included in the study. For simplification, we classified the pancreatic contour variations as classified by Ross et al. and Omeri et al. Pancreatic head-neck variations was classified into Type I-anterior, Type II-posterior and Type III-horizontal variety. Pancreatic body-tail variation was divided into Type Ia-anterior projection; Ib-posterior projection and Type IIa-globular, IIb-lobulated, IIc-tapered, and IId-bifid pancreatic tail. RESULTS: The most common type of variation in the head was Type II (n = 112, 21.3%) followed by Type III (n = 37, 7%) and Type I (n = 21, 4%). The most common type of variation in the body of pancreas was Type Ia (n = 33, 6.2%) followed by Type Ib (n = 13, 2.4%). In the tail region of pancreas, the most common variation was Type IIb (n = 21, 4%) followed by Type IIa (n = 19, 3.6%). CONCLUSION: Pancreatic contour variations are not very uncommon in daily practice. Knowledge of these variations is important for surgeons, radiologists and avoids misjudgement of normal pancreatic tissue as tumor or lymph node especially on unenhanced or single phase MDCT.

Combined hyperdense gallbladder wall-lumen sign: new computed tomography sign in acute gangrenous cholecystitis.

PURPOSE: The objective of our study was to evaluate the combined hyperdense gallbladder wall-lumen sign on computed tomography (CT) in diagnosing gangrenous cholecystitis. MATERIAL AND METHODS: We retrospectively reviewed the unenhanced CT scans of surgically proven cases of acute gangrenous (GCh) and non-gangrenous cholecystitis (nonGCh). Eleven cases of pathologically proven acute gangrenous cholecystitis and 12 consecutive cases of surgically proven acute non-gangrenous cholecystitis that underwent CT at our institute were included in the study so as to have 1 : 1 control. The Hounsfield unit (HU) value of the gallbladder wall and intraluminal bile was measured. Interobserver variability for individual CT findings was also assessed. RESULTS: The gangrenous cholecystitis group had significantly higher HU values of wall and bile (median value of 33 HU vs. 21 HU and median value of 21 HU vs. 8.5 HU, respectively, p < 0.05). The area under the receiver operator characteristic curve for HU lumen was 0.80 (95% CI: 0.62-0.98, p = 0.014) with an ideal cut-off at 31.5 HU, where the sensitivity was 54.5% and specificity was 91.7%. HU lumen has an even better assessment for gangrenous cholecystitis with AUC of its ROC as 0.92 (95% CI: 0.80-1.00, p = 0.001) with an ideal cut-off at 12.5 HU, where the sensitivity was 81.8% and specificity was 91.7%. The combined wall-lumen cut-off is 35 HU with sensitivity of 100% and specificity of 75%. CONCLUSION: A cut-off CT density value of the gallbladder wall of more than 31.5 HU, intraluminal bile more than 12.5 HU, and combined wall-lumen HU of more than 35 can predict GCh.

Surgery after FOLFIRINOX treatment for locally advanced and borderline resectable pancreatic cancer: increase in tumour attenuation on CT correlates with R0 resection.

OBJECTIVES: To assess factors associated with radical resection (R0) of pancreatic ductal adenocarcinoma (PDAC) after induction treatment with FOLFIRINOX. METHODS: Patients with either locally advanced (LA) and borderline resectable (BR) PDAC undergoing surgical exploration after FOLFIRINOX were retrospectively enrolled. Two pancreatic radiologists reviewed the CT blinded to the final outcome and assessed chemotherapy response and resectability. Patients were then divided into R0 resected (group A) and not resected/R1 resected (group B), which were compared. RESULTS: Of 59 patients included, 19 were defined as unresectable (32%), 33 borderline resectable (56%) and 7 resectable (12%) during the blind radiological evaluation after FOLFIRINOX. Once in a surgical setting, 27% were non-resectable, whereas 73% received surgical resection with a 70% R0 rate. Consequent sensitivity and specificity were 86% and 29%. At imaging review, significant decreases in longest tumour dimension were observed in both groups: from 32 mm (95% CI 15-55) to 21 (10-44) in group A and from 34 (18-70) to 26 (7-60) in group B, p < 0.05. However, a significant increase in tumour attenuation in all phases was only observed for R0 resected, from 52 HU (26-75) to 65 (35-92) in arterial phase (p < 0.001) and from 62 (36-96) to 78 (40-120) in the venous (p = 0.001). CONCLUSION: After neoadjuvant FOLFIRINOX, CT predicted resectability with acceptable sensitivity but low specificity. The observation of increased tumour attenuation at CT scan after FOLFIRINOX treatment might represent a reliable predictor of R0 resection. KEY POINTS: • CT drives the assessment of PDAC resectability after FOLFIRINOX • CT predicts resectability with acceptable sensitivity but low specificity • Significant increase in tumour attenuation was only observed for R0 resected PDAC • Tumour attenuation after FOLFIRINOX represents a reliable predictor of R0 resection.

Morphometric analysis of cervical spinal canal diameter, transverse foramen, and pedicle width using computed tomography in Indian population.

BACKGROUND: Accurate and detailed measurements of spinal canal diameter (SCD) and transverse foraminal morphometry are essential for understanding spinal column-related diseases and for surgical planning, especially for transpedicular screw fixation. This is especially because lateral cervical radiographs do not provide accurate measurements. AIM:: This study was conducted to measure the dimensions of the transverse foramen sagittal and transverse diameters (SFD, TFD), SCD, and the distance of spinal canal from the transverse foramina (dSC-TF) at C1-C7 level in the Indian population. MATERIALS AND METHODS:: The study population comprised 84 male and 42 female subjects. The mean age of the study group was 44.63 years (range, 19-81 years). A retrospective study was conducted, and data were collected and analyzed for patients who underwent cervical spine computed tomography (CT) imaging for various reasons. RESULTS: One hundred and twenty-six patients were included in the study. Detailed readings were taken at all levels from C1-C7 for SCD, SFD, TFD, and dSc-TF. Values for male and female subjects were separately calculated and compared. For both the groups, the widest SCD were measured at the C1 level and the narrowest SCD at the C4 level. The narrowest SFD was measured at C7 for both male and female subjects on the right and left sides. The widest SFD was measured at C1 both for male and female subjects on the right and left side. The narrowest TFD on the left side was measured at C7 for male and at C1 for female subjects. The narrowest mean distance of dSC-TF was found to be at C4 for both male and female subjects on both left and right side. CONCLUSION: The computed tomographic (CT) imaging is better than conventional radiographs for the preoperative evaluation of cervical spine and for better understanding cervical spine morphometry. Care must be taken during transpedicular screw fixation, especially in female subjects, more so at the C2, C4, and C6 levels due to a decrease in the distance of dSC-TF.

Explant portal vein for reconstructing middle hepatic vein in right lobe living donor liver transplantation-outcome analysis.

BACKGROUND: The aim of the study was to study the four week patency rates of the reconstructed neo middle hepatic vein specifically using the explant portal vein (PV) in right hemiliver live donor liver transplantation (LDLT). We hypothesized that short term patency of the neo-MHV should result in good graft and patient outcomes. METHODS: Pre, intra and post operative variables were prospectively collected for 88 consecutive patients undergoing right hemiliver LDLT from January 2014 to October 2015. RESULTS: Explant PV was used to reconstruct neo-MHV in 76 (86.4%, 76/88) patients. Neo MHV patency rate at 28 days with explant PV was 89.4% (59/66) and with other conduit (PTFE) was 90.9% (10/11). All occlusions were detected after 7 days. There was no impact of the patency of the neo-MHV on the incidence of early allograft dysfunction, sepsis, rejection, morbidity or mortality, despite the contribution of the anterior sector to the graft volume being more than 50% in close to two-thirds of patients. CONCLUSION: The reconstructed neo-MHV has excellent short term patency rates at 4 weeks. Perhaps due to the absence of early occlusions, there was no impact on graft or patient outcomes in the study population.

Computed tomography imaging of ovarian peritoneal carcinomatosis: a pictorial review.

Gynaecological malignancies are the most common malignancies in women and also an important public health issue. In developing countries, there is a paucity of screening facilities and cancer awareness, so patients present at an advanced stage of disease, which severely limits the prognosis and clinical outcome. Among the gynaecological malignancies, ovarian malignancy has the second highest incidence in women according to the incidences. Ovarian malignancy is usually diagnosed at the advanced stages, and to improve the patient's survival, debulking surgery is very important. Advanced-stage disease is treated with either debulking surgery followed by adjuvant chemotherapy or initial neoadjuvant chemotherapy followed by debulking surgery. Imaging is very important in patient selection, in determining who will benefit from neoadjuvant chemotherapy just before debulking surgery. This article highlights the role of computed tomography (CT) in the detection of patterns of spread of ovarian malignancy, important for staging and management.

Autoimmune Pancreatitis.

Autoimmune pancreatitis (AIP) is a rare and underdiagnosed fibrosclerosing inflammatory variant of chronic pancreatitis. Its true incidence and prevalence in the general population is still not confirmed despite advances in medicine. Differentiating it from pancreatic cancer is of paramount importance. In this imaging review, we highlight the imaging findings of this intriguing entity.

Computed Tomography (CT) and Magnetic Resonance (MR) Findings in Xanthogranulomatous Cholecystitis: Retrospective Analysis of Pathologically Proven 30 Cases - Tertiary Care Experience.

BACKGROUND: To study CT and MR findings in xanthogranulomatous cholecystitis (XGC). MATERIAL/METHODS: Retrospective analysis of 30 histopathologically confirmed cases of XGC. Seventeen patients underwent CECT and 13 underwent MRI. The following features were studied - wall thickness, intramural nodules, pericholecystic stranding, wall thickness, THAD, fat in gallbladder wall, cholelithiasis, infiltration, biliary dilatation, lymph nodes, complications. RESULTS: The majority of cases (22/30) showed discontinuous mucosal lining. Discontinuous mucosal lining was seen in all cases with wall thickness >10 mm, 75% of cases with wall thickness between 3-10 mm and none in normal wall thickness (p=0.03). Diffuse wall thickening was seen in 23 cases, focal thickening in 3 and polypoidal wall thickening in 2 cases. Polypoidal thickening was seen in gallbladder carcinoma. Intramural nodules were present in 87.5% of cases with discontinuous mucosal lining. Pericholecystic stranding was seen in 19, biliary dilatation in 12, liver infiltration in 13 and fat in 7 cases. Lymphadenopathy was seen in 1 case with gallbladder carcinoma. Four cases showed a signal drop in the intramural nodules on chemical shift MRI. CONCLUSIONS: Discontinuous mucosal lining is evident in xanthogranulomatous cholecystitis. Diffuse wall thickening, intramural nodules, continuous or discontinuous mucosal lining and cholelithiasis may indicate XGC rather than gallbladder carcinoma. Based on correlation with pathophysiological findings, we conclude that discontinuous mucosal lining is not an unusual finding in cases of XGC. Advances in knowledge: Being aware of the radiological findings described in this article may be helpful in making preoperative radiological diagnosis of XGC. Mucosal lining may be continuous or discontinuous in XGC.

Supernumerary kidneys--a rare anatomic variant.

Supernumerary kidneys are a rare congenital anomaly with fewer than 100 cases reported over the years. A fused supernumerary kidney is a still rarer entity. We present imaging findings in two cases of supernumerary kidneys--the first case is a spectacular image of four kidneys in one patient seen in an excretory phase of intravenous urogram with only four cases described in the literature. The second case is that of three kidneys (fused supernumerary) seen in another patient.

Case Report: Salmonella typhi Iliopsoas Abscess with Concomitant Sacroiliitis in a Young Immunocompetent Male: A Rare Case.

Iliopsoas abscess is an infrequent condition characterized by the collection of pus in the iliopsoas compartment. The prevalence of the disease has been increasing in recent years with the emergence of various comorbidities and risk factors. The availability of newer imaging modalities has also improved the detection of new cases. Salmonellosis is an uncommon etiology in iliopsoas abscess and sacroiliitis. Most cases reported in the literature are associated with Staphylococcus aureus, Streptococci species, and Escherichia coli. Diabetes, hematological malignancies, HIV, and other immunocompromised states are important comorbidities/risk factors for iliopsoas abscess. We report a case of an 18-year-old male who presented with a history of fever and right hip pain for 10 days. Radioimaging revealed right sacroiliitis and iliopsoas abscess. Blood culture revealed pan-sensitive Salmonella typhi. After the prolonged course of antibiotics (intravenous ceftriaxone followed by oral levofloxacin), the patient improved with no further relapse in symptoms. Salmonella typhi should be an important differential of iliopsoas abscess in endemic regions after ruling out the common etiology such as S. aureus and Mycobacterium tuberculosis.

The Varieties of Ignorance: Imaging of Congenital Variants of Pancreas and Its Ductal System-A Pictorial Review.

Congenital variants of the pancreas are being increasingly detected with the widespread use of modern imaging techniques. The underlying embryologic aberration predicts the final appearance of pancreatic development. It is essential to recognize these congenital variants, as many of these have been proven to be associated with pancreatic diseases like recurrent pancreatitis and chronic abdominal pain. Cross-sectional techniques like multidetector computed tomography and magnetic resonance cholangiopancreatography are the most used imaging techniques for the pancreas, where a radiologist comes across these variants. This pictorial aims to classify the type of variant anatomy of the pancreas, their imaging appearances, and their clinical significance.