The Importance of Early Detection and Minimally Invasive Treatment of Pseudoaneurysms Due to Chronic Pancreatitis: Case Report.

The occurrence of the pseudoaneurysm of visceral arteries in the field of chronic pancreatitis is a very rare complication that represents a life-threatening condition. The higher frequency of this complication is in the necrotic form of pancreatic inflammation, especially in patients with formed peripancreatic necrotic collections. The degradation of the arterial wall leads to bleeding and transforms these necrotic collections into a pseudoaneurysm. Urgent endovascular angioembolization is the first choice in the therapeutic approach as a valid minimally invasive solution with very satisfactory immediate and long-term outcomes. This successfully avoids open surgery, which is associated with a high mortality rate in these patients, especially in acute-on-chronic pancreatitis.

Directionally Sensitive Fractal Radiomics Compatible With Irregularly Shaped Magnetic Resonance Tumor Regions of Interest: Association With Osteosarcoma Chemoresistance.

BACKGROUND: Computational analysis of routinely acquired MRI has potential to improve the tumor chemoresistance prediction and to provide decision support in precision medicine, which may extend patient survival. Most radiomic analytical methods are compatible only with rectangular regions of interest (ROIs) and irregular tumor shape is therefore an important limitation. Furthermore, the currently used analytical methods are not directionally sensitive. PURPOSE: To implement a tumor analysis that is directionally sensitive and compatible with irregularly shaped ROIs. STUDY TYPE: Retrospective. SUBJECTS: A total of 54 patients with histopathologic diagnosis of primary osteosarcoma on tubular long bones and with prechemotherapy MRI. FIELD STRENGTH/SEQUENCE: A 1.5 T, T2-weighted-short-tau-inversion-recovery-fast-spin-echo. ASSESSMENT: A model to explore associations with osteosarcoma chemo-responsiveness included MRI data obtained before OsteoSa MAP neoadjuvant cytotoxic chemotherapy. Osteosarcoma morphology was analyzed in the MRI data by calculation of the nondirectional two-dimensional (2D) and directional and nondirectional one-dimensional (1D) Higuchi dimensions (Dh). MAP chemotherapy response was assessed by histopathological necrosis. STATISTICAL TESTS: The area under the receiver operating characteristic (ROC) curve (AUC) evaluated the association of the calculated features with the actual chemoresponsiveness, using tumor histopathological necrosis (95%) as the endpoint. Least absolute shrinkage and selection operator (LASSO) machine learning and multivariable regression were used for feature selection. Significance was set at <0.05. RESULTS: The nondirectional 1D Dh reached an AUC of 0.88 in association with the 95% tumor necrosis, while the directional 1D analysis along 180 radial lines significantly improved this association according to the Hanley/McNeil test, reaching an AUC of 0.95. The model defined by variable selection using LASSO reached an AUC of 0.98. The directional analysis showed an optimal predictive range between 90° and 97° and revealed structural osteosarcoma anisotropy manifested by its directionally dependent textural properties. DATA CONCLUSION: Directionally sensitive radiomics had superior predictive performance in comparison to the standard nondirectional image analysis algorithms with AUCs reaching 0.95 and full compatibility with irregularly shaped ROIs. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 1.

Quality of life following two different techniques of an open ventral hernia repair for large hernias: a prospective randomized study.

BACKGROUND: We compare the health-related quality of life (QoL) of patients with incision hernias before and after surgery with two different techniques. METHODS: In this prospective randomized study, the study population consisted of all patients who underwent the first surgical incisional hernias repair during the 1-year study period. Patients who met the criteria for inclusion in the study were randomized into two groups: the first group consisted of patients operated by an open Rives sublay technique, and the second group included patients operated by a segregation component technique. The change in the quality of life before and 6 months after surgery was assessed using two general (Short form of SF-36 questionnaires and European Quality of Life Questionnaire-EQ-5D-3L), and three specific hernia questionnaires (Hernia Related Quality of Life Survey-HerQles, Eura HS Quality of Life Scale-EuraHS QoL, and Carolinas Comfort Scale-CCS). RESULTS: A total of 93 patients were included in the study. Patients operated on by the Rives technique had a better role physical score before surgery, according to the SF-36 tool, although this was not found after surgery. The postoperative QoL measured with each scale of all questionnaires was significantly better after surgery. Comparing two groups of patients after surgery, only the pain domain of the EuraHS Qol questionnaire was worse in patients operated by a segregation component technique. CONCLUSION: Both techniques improve the quality of life after surgery. Generic QoL questionnaires showed no difference in the quality of life compared to repair technique but specific hernia-related questionnaires showed differences.

Perforated Appendicitis and Bowel Incarceration within Morgagni Hernia: A Case Report.

Morgagni hernia (MH) is a result of abdominal organ protrusion through the congenital defect in the anterior retrosternal aspect of the diaphragm. The colon and omentum are the most commonly involved organs, followed by the small intestine, stomach and liver. Symptoms of MH may be absent, although the majority of patients will experience mild dyspnea or abdominal discomfort. We present a case of MH complicated with intrathoracic acute perforated appendicitis and intestinal obstruction.

Encapsulated Omental Necrosis as an Unexpected Postoperative Finding: A Case Report.

Postsurgical fat necrosis is a frequent finding in abdominal cross-sectional imaging. Epiploic appendagitis and omental infarction are a result of torsion or vascular occlusion. Surgery or pancreatitis are conditions that can have a traumatic and ischemic effect on fatty tissue. The imaging appearances may raise concerns for recurrent malignancy, but percutaneous biopsy and diagnostic follow-up assist in the accurate diagnosis of omental infarction. Herein we describe a case of encapsulated omental necrosis temporally related to gastric surgery. Preoperative CT and MRI findings showed the characteristics of encapsulated, postcontrast nonviable tumefaction in the epigastrium without clear imaging features of malignancy. Due to the size of the lesion and the patient's primary disease, tumor recurrence could not be completely ruled out, and the patient underwent surgery. Histopathological analysis confirmed the diagnosis of steatonecrosis of the omentum.

Successful Embolization of Posterior Inferior Pancreaticoduodenal Artery Pseudoaneurysm on the Grounds of Chronic Pancreatitis-Case Report and Literature Review.

Pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. In this paper, we present a case of a 74-year-old man, who was admitted to our clinic with a diagnosis of an acute on chronic pancreatitis complicated by walled-off-pancreatic-necrosis, with subsequent development of peripancreatic pseudoaneurysm. After initial conservative management, the patient recovered and was discharged from the hospital. However, he soon returned feeling anxious due to a pulsatile abdominal mass. Abdominal Color-Doppler examination, CT scan, and angiography revealed large pancreatic necrotic collection in the total size of 9 cm, with centrally enhancing area of 3.5 cm that corresponded to pseudoaneurysm originating from the posterior pancreaticoduodenal vascular arcade. Considering the size, location of the pseudoaneurysm, feeding vessel, and poor general patients condition, we opted for minimally invasive treatment. Pseudoaneurysm was successfully managed by endovascular coil embolization, i.e., "sandwich technique".

Pancreatic Hydatid Cyst Misdiagnosed as Mucinous Cystadenoma: CT and MRI Findings.

Isolated hydatid cysts of the pancreas are rare lesions, even in endemic regions. In this report, we present the case of a 76-year-old patient who was admitted to our clinic with a diagnosis of a cystic lesion in the tail of the pancreas. On preoperative computed tomography (CT) and magnetic resonance (MR) examination, the cyst was characterized as a mucinous cystadenoma. A laparoscopic distal pancreatectomy followed. A histopathological examination revealed a large hydatid cyst in the tail of the pancreas.

Rare histological subtype of pulmonary artery intimal sarcoma diagnosed by multidisciplinary approach.

Pulmonary artery intimal sarcoma (PAS) is a rare mesenchymal tumor mostly diagnosed in middle-aged women. In a 63-year-old female, the radiological findings showed cavitation in the left upper lobe of the lung and infiltrative tumor mass around the left pulmonary artery. PAS consisted of small, round tumor cells with about 80% of mitotic activity and with myxoid background and specific immunoprofile and diagnosed as undifferentiated sarcoma with round cell features type. The final diagnosis of PAS was established according to the pathohistological, chest computed tomography scan, and surgery finding.

Intrahepatic mass-forming cholangiocarcinoma and solitary hypovascular liver metastases: is the differential diagnosis using diffusion-weighted MRI possible?

Background Intrahepatic mass-forming cholangiocellular carcinoma (IMC) is the second most common primary liver tumor. The differentiation between IMC and solitary hypovascular liver metastases (SHLM) represents a diagnostic challenge due to many overlapping magnetic resonance imaging (MRI) features. Purpose To determine the value of diffusion-weighted imaging (DWI) in addition to conventional MRI for the distinction between intrahepatic mass-forming cholangiocarcinoma and solitary hypovascular liver metastases. Material and Methods Fifty-three patients with pathologically proven IMC (n = 31) and SHLM (n = 22) who had undergone MRI and DWI before surgery or percutaneous biopsy were enrolled in this study. The following MRI features were analyzed: the size and shape of the lesion, presence of capsular retraction and segmental biliary dilatation, T2-weighted (T2W) signal intensity, the presence of target sign on DWI and enhancement pattern. Apparent diffusion coefficient (ADC) values were calculated for each lesion ( b = 800 s/mm2). Univariate and multivariate logistic regression analyses were used to identify significant differentiating features between IMCs and SHLMs. Results Univariate analysis revealed that following parameters favor diagnosis of IMCs over SHLMs: lobulating shape, heterogeneous T2W signal intensity, capsular retraction, segmental biliary dilatation, target sign on DWI and rim-like enhancement on arterial phase followed by progressive enhancement in delayed phases. ADC values measured in the periphery of the lesion were significantly lower in IMCs in comparison to SHLMs. Multivariate analysis revealed that target sign on DWI was the most significant predictor of IMCs. Conclusion Qualitative DWI analysis with target sign significantly improves diagnostic accuracy for differentiation among IMC and SHLM lesions.

Endometrioid adenocarcinoma of the ovary: MRI findings with emphasis on diffusion-weighted imaging for the differentiation of ovarian tumors.

BACKGROUND: Preoperative differentiation of ovarian malignant tumors still remains a challenge. Diffusion-weighted imaging (DWI) provides information about cellularity of the lesion and might facilitate discrimination between different malignant ovarian lesions. PURPOSE: To evaluate magnetic resonance imaging (MRI) findings of endometrioid adenocarcinoma of the ovary and to determine the value of DWI in the differential diagnosis of malignant and benign adnexal tumors. MATERIAL AND METHODS: The following MRI findings were reviewed in 162 patients (21 endometrioid adenocarcinoma, 103 other malignant tumors, 38 benign tumors): lesion size, morphological appearance, T2-weighted (T2W) signal intensity, T1-weighted (T1W) signal intensity, contrast-enhancement pattern, DWI signals with apparent diffusion coefficient (ADC) calculated for b = 800 s/mm(2) in solid tumor components. RESULTS: The most common morphological appearance was predominantly cystic lesion, found in 90.3% of patients with endometriod adenocarcinoma. The solid parts were slightly hyperintense on T2W images in 19 patients with marked enhancement after contrast administration. No significant difference (P = 0.13) in conventional MRI features was found between endometrioid adenocarcinoma and other malignant ovarian tumors. Hyperintensity on DWI was more frequently observed in malignant tumors than in benign lesions (P < 0.001). ADC values were significantly lower in endometrioid adenocarcinoma than other malignant tumors (0.79 ± 0.21 vs. 0.90 ± 0.19; P = 0.04) and in all malignant lesions compared with benign tumors (0.88 ± 0.31 vs. 1.33 ± 0.17; P < 0.001). CONCLUSION: DWI with ADC measurement could indicate the presence of endometrioid adenocarcinomas due to a slightly but significantly lower ADC values compared to other malignant ovarian lesions. Thus, DWI is beneficial and should be part of a standard protocol for the evaluation of indeterminate adnexal lesions.

Validation and cross-cultural adaptation of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) in Serbian patients.

PURPOSE: To test the validity and reliability of the Serbian version of the interviewer-administered format of the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25). METHODS: The Serbian version of NEI VFQ-25 was translated in accordance with standard methods that have been adopted internationally. In order to assess the reliability and validity of the translated NEI VFQ-25, we used a sample of 105 patients with four different chronic ocular diseases. Cronbach's alpha coefficient was used to assess internal consistency for each subscale. To assess test-retest reliability, intraclass correlation coefficients were used. The test-retest data were obtained from clinically stable patients with age-related cataracts, in surveys performed 2 weeks apart. Rasch analysis was also applied as a modern methods of psychometric assessment of the questionnaire. RESULTS: Four groups of patients were studied and the most prevalent were patients with cataract 40 (38.1%), followed by diabetic retinopathy 31 (29.5%), age related macular degeneration 22 (21.0%) and glaucoma 12 (11.4%). The overall index score on the NEI VFQ-25 ranged from 65.3 to 67.8 with a mean of 67.4 ± 15.0. Cronbach's alpha coefficient (index of internal consistency reliability) ranged from 0.643 to 0.889 for the subscales. Evaluation of the validity of the Serbian version of NEI VFQ-25 is presented in the multi-trait-multi-method matrix and all items passed the convergent and discriminant validity tests. Rasch analysis showed a good measurement precision, but also demonstrated misfitting items and multidimensionality of the questionnaire. CONCLUSION: Although traditional validation method indicates that the Serbian version of NEI VFQ-25 is a valid and reliable instrument for the assessment of vision specific QoL in Serbian populations aged 40 years or older, Rasch analysis revealed a substantial weakness of the questionnaire that should be taken into consideration when interpreting the results.

Intracranial arterial variations: a comprehensive evaluation using CT angiography.

Background Intracranial arterial variations are a frequent finding in the general population. Knowledge of these vascular variations has significant clinical impact because some of them predispose patients to development of an aneurysm or cerebrovascular ischemic disease. The purpose of this study was to evaluate the frequency of intracranial vascular variations and associated vascular lesions on computed tomography angiography (CTA) examinations. Material and Methods CTA examinations performed by 16-detector computed tomography were prospectively reviewed in 455 patients for the presence of fenestrations, duplications, hypoplasia, aplasia, aneurysms, and other vascular lesions. Results Arterial fenestrations were found in 2.4% of patients, with the vertebrobasilar system as the most common location. The remaining fenestrations were located on the middle cerebral artery M1 segment (0.2%), anterior communicating artery (0.4%), and anterior cerebral artery A1 segment (0.6%). No associated aneurysms were noted in these patients. The prevalence of an azygos anterior cerebral artery was 1.5%. Bihemispheric anterior cerebral artery was found in 0.9%, hypoplastic A1 segment in 17.6%, and congenital absence of A1 segment in 0.4% of patients. Fetal origin of the posterior cerebral artery was found in 37% of cases. Hypoplastic vertebral artery terminating as posterior inferior cerebellar artery was observed in 9 patients, while transversal anastomosis between vertebral arteries was seen in only 1 patient. Conclusions CTA precisely demonstrates the diversity of intracranial arterial variations, whose overall frequency in this study is similar to previous radiological reports. Furthermore, our results do not show significant association between the frequency of aneurysms and cerebral arterial anomalies.

Impact of prolonged liver ischemia during intermittent Pringle maneuver on postoperative outcome following liver resection.

BACKGROUND: The aim of this study was to compare postoperative outcomes following liver resection between patients with prolonged cumulative ischemia time (CIT) which exceeded 60 min and patients with CIT less than 60 min. METHODS: Between March 2020 and October 2022, 164 consecutive patients underwent liver resection at the Unit for hepato-bilio-pancreatic surgery, University Clinic for Digestive Surgery in Belgrade, Serbia. Intermittent Pringle maneuver was routinely applied. Depending on CIT during transection, patients were divided into two groups: group 1 (CIT <60 min) included 101 patients, and group 2 (CIT ≥60 min) included 63 patients. RESULTS: Median operative time (210 vs. 400 min) and CIT (30 vs. 76 min) were longer in the Group 2 (p < 0.001). Intraoperative blood loss was higher in the Group 2 (150 vs 500 ml), p < 0.001. The perioperative transfusion rate was similar between the groups (p = 0.107). There was no difference in postoperative overall morbidity (50.5% vs. 58.7%, p = 0.337) and major morbidity (18.8 vs. 19%, p = 0.401). In-hospital mortality, 30-day mortality, and 90-day mortality were similar between the groups (p = 0.408; p = 0.408; p = 0.252, respectively). Non-anatomical liver resection was the only predictive factor of 90-day mortality identified by multivariate analysis (p = 0.047; Relative Risk = 0.179; 95% Confidence Interval 0.033-0.981). CONCLUSION: Intermittent Pringle maneuver with CIT exceeding 60 min is a safe method for bleeding control during liver resection with no impact on postoperative morbidity and mortality.

"Bezoar Egg"-A Rare Cause of Small Bowel Obstruction.

Small bowel obstruction is a frequent medical condition with various causes, the most common being postoperative adhesions, volvulus, intussusception, hernias, and tumors. A bezoar-induced blockage of the small intestine is a rare condition that accounts for approximately 4% of all small bowel obstruction cases. Herein, we present the case report of a 71-year-old patient with diffuse abdominal pain caused by a small bowel obstruction due to a calcified bezoar (bezoar egg) resulting from a post-radiation intestinal stricture. The patient underwent a small bowel excision with the extraction of the bezoar, after which a full recovery was made.

MR imaging of primary sclerosing cholangitis: additional value of diffusion-weighted imaging and ADC measurement.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a cholestatic liver disease with chronic inflammation and progressive destruction of biliary tree. Magnetic resonance (MR) examination with diffusion-weighted imaging (DWI) allows analysis of morphological liver parenchymal changes and non-invasive assessment of liver fibrosis. Moreover, MR cholangiopancreatography (MRCP), as a part of standard MR protocol, provides insight into bile duct irregularities. PURPOSE: To evaluate MR and MRCP findings in patients with primary sclerosing cholangitis and to determine the value of DWI in the assessment of liver fibrosis. MATERIAL AND METHODS: The following MR findings were reviewed in 38 patients: abnormalities in liver parenchyma signal intensity, changes in liver morphology, lymphadenopathy, signs of portal hypertension, and irregularities of intra- and extrahepatic bile ducts. Apparent diffusion coefficient (ADC) was calculated for six locations in the liver for b = 800 s/mm(2). RESULTS: T2-weighted hyperintensity was seen as peripheral wedge-shaped areas in 42.1% and as periportal edema in 28.9% of patients. Increased enhancement of liver parenchyma on arterial-phase imaging was observed in six (15.8%) patients. Caudate lobe hypertrophy was present in 10 (26.3%), while spherical liver shape was noted in 7.9% of patients. Liver cirrhosis was seen in 34.2% of patients; the most common pattern was micronodular cirrhosis (61.5%). Other findings included lymphadenopathy (28.9%), signs of portal hypertension (36.7%), and bile duct irregularities (78.9%). The mean ADCs (x10(-3)mm(2)/s) were significantly different at stage I vs. stages III and IV, and stage II vs. stage IV. No significant difference was found between stages II and III. For prediction of stage ≥II and stage ≥III, areas under receiver-operating characteristic curves were 0.891 and 0.887, respectively. CONCLUSION: MR with MRCP is a necessary diagnostic procedure for diagnosis of PSC and evaluation of disease severity. Moreover, DWI could be used in continuation with standard MR sequences for the evaluation of liver fibrosis stage and distribution.

Liver resection versus transarterial chemoembolisation for the treatment of intermediate hepatocellular carcinoma: a systematic review and meta-analysis.

BACKGROUND: Transarterial chemoembolisation (TACE) is the primary treatment for intermediate-stage hepatocellular carcinoma (HCC), according to the updated Barcelona Clinic Liver Cancer (BCLC) staging system. Although growing evidence favours liver resection (LR) over TACE for intermediate-stage HCC, the best treatment option remains controversial. This meta-analysis aimed to compare the overall survival (OS) after LR versus TACE for intermediate-stage HCC. METHODS: A comprehensive literature review of PubMed, Embase, Cochrane Library, and Web of Science was performed. Studies that compared the efficacy of LR and TACE in patients with intermediate (BCLC stage B) HCC were selected. According to the recent updated BCLC classification, intermediate stage of HCC was defined as follows: (a) four or more HCC nodules of any size, or (b) two or three nodules, but if at least one tumour is larger than 3 cm. The main outcome was OS, expressed as the hazard ratio. RESULTS: Nine eligible studies of 3355 patients were included in the review. The OS of patients who underwent LR was significantly longer than that of patients who underwent TACE (hazard ratio=0.52; 95% CI: 0.39-0.69; I2=79%). Prolonged survival following LR was confirmed after sensitivity analysis of five studies using propensity score matching (HR=0.45; 95% CI: 0.34-0.59; I2=55%). CONCLUSION: Patients with intermediate-stage HCC who underwent LR had a longer OS that those who underwent TACE. The role of LR in patients with BCLC stage B should be clarified in future randomised controlled trials.

The Role of MRI in the Diagnosis of Solid Pseudopapillary Neoplasm of the Pancreas and Its Mimickers: A Case-Based Review with Emphasis on Differential Diagnosis.

Solid pseudopapillary neoplasm (SPN) is rare pancreatic tumor occurring most commonly in young females. The typical imaging appearance of SPN is of well-defined, encapsulated, and large heterogeneous tumors, consisting of solid and cystic components due to various degrees of intralesional hemorrhage and necrosis. However, atypical imaging presentation in the form of small solid tumors or uniformly cystic lesions might also be seen, which can be explained by specific pathological characteristics. Other imaging features such as a round shape, the absence of main pancreatic duct dilatation, and slow growth, in combination with vague symptoms, favor the diagnosis of SPNs. Nevertheless, the radiological findings of SPN might overlap with other solid and cystic pancreatic neoplasms, such as neuroendocrine tumors, serous and mucinous neoplasms, and even small pancreatic adenocarcinomas. In addition, a few benign non-tumorous conditions including walled-of-necrosis, and intrapancreatic accessory spleen may also pose diagnostic dilemmas simulating SPNs on imaging studies. The aim of this manuscript is to provide a comprehensive overview of the typical and atypical imaging features of SPNs and to describe useful tips for differential diagnosis with its potential mimickers.

MRI Tumor Regression Grade Combined with T2-Weighted Volumetry May Predict Histopathological Response in Locally Advanced Rectal Cancer following Neoadjuvant Chemoradiotherapy-A New Scoring System Proposal.

Modern studies focus on the discovery of innovative methods to improve the value of post-treatment magnetic resonance imaging (MRI) in the prediction of pathological responses to preoperative neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC). The aim of this study was to assess the potential benefits of combining magnetic resonance tumor regression grade (mrTRG) with T2-weighted volumetry in the prediction of pathological responses to nCRT in LARC. This was a cohort study conducted on patients with histopathologically confirmed LARC in a period from 2020 to 2022. After histopathological verification, all patients underwent initial MRI studies, while the follow-up MRI was performed after nCRT. Tumor characteristics, MRI estimated tumor regression grade (mrTRG) and tumor volumetry were evaluated both initially and at follow-up. All patients were classified into responders and non-responders according to pathological tumor regression grade (pTRG) and mrTRG. A total of 71 patients, mostly male (66.2%) were included in the study. The median tumor volume reduction rate was significantly higher in nCRT-responders compared to non-responders (79.9% vs. 63.3%) (p = 0.003). Based on ROC analysis, optimal cut-off value for tumor volume reduction rate was determined with an area under the curve (AUC) value of 0.724 (p = 0.003). Using the tumor volume reduction rate ≥75% with the addition of response to nCRT according to mrTRG, a new scoring system for prediction of pTRG to preoperative nCRT in LARC was developed. Diagnostic performance of prediction score was tested and the sensitivity, PPV, specificity, and NPV were 81.8%, 56.3%, 71.4%, and 89.7%, respectively. The combination of mrTRG and T2-weighted volumetry increases the MRI-based prediction of pTRG to preoperative nCRT in LARC. The proposed scoring system could aid in distinguishing responders to nCRT, as these patients could benefit from organ-preserving treatment and a "watch and wait" strategy.