Assessment of magnetic resonance imaging derived fat fraction as a sensitive and reliable predictor of myosteatosis in liver transplant recipients.

BACKGROUND: Measures of skeletal muscle abnormalities are rapidly emerging as independent predictors of outcomes after liver transplantation (LT). We describe a simple, novel assessment of myosteatosis acquired prior to liver transplantation using Magnetic Resonance Imaging (MRI) derived fat fraction. METHODS: A retrospective longitudinal cohort study included clinical and biochemical data from patients who underwent liver transplantation at our institution between Feb 2008 and Aug 2014. Patients transplanted for a diagnosis of hepatocellular carcinoma were excluded from the study. The fat fraction of erector spinae muscles was estimated using MRI at the level where muscle volume was highest, with myosteatosis defined at a cut-off value of 0.8. RESULTS: 180 patients were included. At baseline, those with myosteatosis were, on average, older, more likely to be female, and more likely to receive a multi-organ transplant (p < 0.05). Patients with pre-transplant myosteatosis, as delineated by MRI derived fat fraction, also had increased length of hospital stay. CONCLUSION: This preliminary study suggests myosteatosis, as measured by fat fraction on MRI prior to LT, may be associated with increased graft loss and mortality after transplant.

Inguinoscrotal region as an unusual site of extra-pancreatic collections in infected pancreatic necrosis.

Severe acute pancreatitis often leads to pancreatic and peripancreatic collections but, rarely, it can lead to collections at sites remote from the pancreas. Three male patients presented with abdominal pain and inguinoscrotal swelling. They were initially misdiagnosed with obstructed inguinal hernia, epididymo-orchitis and hydrocele, respectively. Later, their diagnosis of acute pancreatitis was revealed on laparotomy in one patient and on computed tomography (CT) in the remaining two patients. All these cases had extensive peripancreatic necrosis and paracolic collections tracking along the psoas muscle, downwards towards the pelvis. These collections were initially managed by percutaneous drainage and saline irrigation as a part of the 'step-up' approach. Two of these patients required open necrosectomy, while all required incision and drainage of inguinoscrotal collections. All the patients were discharged in satisfactory condition. Inguinoscrotal swelling is unusual as a first presentation of acute pancreatitis. A high index of suspicion, with careful study of patient's history and examination along with CT, may provide an accurate diagnosis. Local drainage may be required to control sepsis and also provide an egress route for intra-abdominal collections.

Streptokinase may play role in expanding non-operative management of infected walled off pancreatic necrosis: preliminary results.

GOALS AND BACKGROUND: We evaluated ex and in vivo effect of streptokinase on pancreatic necrosum to improve the success rate of pigtail catheter drainage and irrigation in infected walled off pancreatic necrosis using step up approach and also looked at potential risk of bleeding. EXPERIMENT AND CLINICAL CASES: 1000 IU/ml of streptokinase was added to 10 g. of intra-operatively obtained fresh tissue of peripancreatic necrosis and results compared to treatment with saline. Mixture was incubated for 12 h in thermostat at 37.5 °C and subjected to histopathology. Subsequently streptokinase (50,000 units thrice a day for 5 days through PCD) was used in two patients with walled off pancreatic necrosis (WOPN) not responding to step up approach and who were being considered for surgery. Grossly there was fragmentation of necrosum in streptokinase treated tissue. Microscopically complete loss of supportive collagenous framework was noted in streptokinase treated necrosum with clumping of necrotic tissue into structure-less mass. No such changes were discernible in saline treated tissue. In two patients with WOPN there was clearance of debris after streptokinase instillation. None of the patients was on thromboprophylaxis and bleeding was not noticed in any of the patients. CONCLUSION: Based on ex vivo effect of streptokinase in dissolution of necrosum at periphery, we believe that in patients with walled off pancreatic necrosis (WOPN) not responding to pigtail catheter drainage and saline irrigation; streptokinase may prove to be useful adjunct.