Fecalith in the Proximal Area of the Appendix is a Predictor of Failure of Nonoperative Treatment for Complicated Appendicitis in Adults.

BACKGROUND: The management of complicated appendicitis remains controversial, since this disease has various clinical presentations and is associated with high rates of adverse events. Although initial nonoperative treatment is generally employed for complicated appendicitis, its clinical presentation and the predictors of nonoperative treatment failure are unclear. METHODS: Patients diagnosed with complicated appendicitis in our hospital between April 2015 and March 2020 were enrolled. In total, 113 patients were classified into three categories: emergency appendectomy, failure of nonoperative treatment and successful nonoperative treatment. The primary outcome was the rate of failure of nonoperative treatment, as assessed by logistic regression analysis. The secondary outcomes were the operative procedures and postoperative courses of the three groups. RESULTS: Of 113 patients, 45 (40%) underwent emergency appendectomy, 25 (22%) failed nonoperative treatment, and 43 (38%) had successful nonoperative treatment. Among these successful cases, 38 patients (88%) underwent interval appendectomy. In multivariate analyses, the presence of a fecalith in the proximal area of the appendix was an independent risk factor for failure of nonoperative treatment (odds ratio, 20.5; 95% confidence interval, 4.37-95.7, P < 0.001). Postoperative outcomes were more unfavorable in cases of failed nonoperative treatment than in cases of emergency and interval appendectomy. CONCLUSIONS: The presence of a fecalith in the proximal area of the appendix is an independent predictor for failure of nonoperative treatment for complicated appendicitis in adults. Patients with this risk factor should be considered candidates for surgical treatment.

Laparoscopic resection of an epidermoid cyst originating from an intrapancreatic accessory spleen: report of a case.

A 67-year-old man underwent an investigation of epigastric pain and weight loss. Preoperative imaging findings suggested the presence of a tumor, which developed as an epidermoid cyst and originated from an intrapancreatic accessory spleen; however, the possibility of malignancy could not be ruled out. We therefore performed a laparoscopic-assisted distal pancreatectomy with a splenectomy for both diagnostic and treatment purposes. Five laparoscopic ports were created. After the spleen and pancreatic tail were dissected from the retroperitoneum laparoscopically, they were pulled out through a 7-cm left subcostal incision and resected with an endoscopic linear stapler. The operative time was 227 min and the blood loss was 400 ml. The postoperative course was uneventful. The final pathological diagnosis was in agreement with the preoperative diagnosis. This case demonstrates that the minimally invasive approach of laparoscopic surgery can be used safely and successfully for difficult-to-diagnose pancreatic tumors. This is the first report describing a laparoscopic resection of an epidermoid cyst originating from an intrapancreatic accessory spleen.

Usefulness of multi-slice CT in a case with internal fistulas in Crohn's disease.

A case of Crohn's disease with an ileo-ileo fistula, ileal strictures and an ileo-cyst fistula is reported. Laparoscopic operation that included partial ileoectomy, ileal stricturoplasty and dissection of the ileo-cyst fistula was performed. Multi-slice computed tomography (MSCT) that was performed before the operation showed an ileo-cyst fistula that was not detected by small bowel follow-through or MRI. In this case, MSCT, including multi-planar reconstruction images, was significantly useful for evaluation of internal fistulas in Crohn's disease.

Arterial visualization by contrast-enhanced moving-table MR angiography: crossover comparison of 0.1 and 0.2 mmol/kg doses of meglumine gadopentetate in normal volunteers.

PURPOSE: To determine the appropriate dose of contrast medium for moving-table MR angiography (MT-MRA) from the abdominal aorta to the ankle by comparing visualization with different doses of meglumine gadopentetate (Gd-DTPA) administered in crossover fashion to normal volunteers. MATERIALS AND METHODS: Twelve healthy adults underwent imaging after crossover administration of 0.1 and 0.2 mmol/kg of Gd-DTPA in random order. Continuous MT-MRA was performed with a fast 3D spoiled gradient echo sequence without parallel imaging technique. Visualization was evaluated in a total of 252 arteries by three blinded readers who independently rated arterial visualization using a 5-grade scale. Signal intensity was determined and the blood concentration of Gd-DTPA was estimated. RESULTS: Arterial visualization in the lower leg region was significantly better with a dose of 0.2 mmol/kg than with 0.1 mmol/kg (P<0.001). For all regions assessed the estimated blood Gd-DTPA level was significantly higher with 0.2 mmol/kg than with 0.1 mmol/kg (abdominal aorta, P=0.030; superficial femoral artery, P<0.001; posterior tibial artery, P=0.039). The vascular signal enhancement ratio and artery-to-muscle signal ratio were significantly higher in the upper leg and lower leg regions at 0.2 mmol/kg. CONCLUSION: With continuous MT-MRA imaging from the abdomen to the ankle in normal volunteers, better arterial visualization and superior contrast were achieved with 0.2 mmol/kg of Gd-DTPA.

Questionnaire survey of acute and delayed adverse reactions to ferumoxides.

PURPOSE: The purpose of this study was to assess acute and delayed adverse reactions to ferumoxides. MATERIALS AND METHODS: 473 consecutive patients who underwent ferumoxides-enhanced MRI were enrolled in this study. Following non-contrast-enhanced MRI, patients were interviewed about their allergic history, and after ferumoxides-enhanced MRI, they were asked to fill out a questionnaire sheet to record any symptoms within one week. RESULTS: 345 of 473 questionnaires (72.9%) were returned. Fifty-eight of 345 patients (16.8%) showed some adverse reactions considered to be related to ferumoxides: 25 (7.2%) during administration, 25 (7.2%) later on the day of ferumoxides administration, and 17 (4.9%) within one week. Thirty-three patients (9.6%) showed only delayed adverse reactions. Delayed adverse reactions were more frequent in women than in men (p<0.01), and in patients with any allergic history than in those without such history (p<0.05). Acute adverse reactions tended to be more frequent in patients who had some adverse events to any contrast medium than in those with no such history (p=0.069). CONCLUSION: By using the questionnaire, the incidence of adverse reactions to ferumoxides (16.8%) was higher than previously reported from Japanese clinical trials.

Routine MR imaging protocol with breath-hold fast scans: diagnostic efficacy for focal liver lesions.

PURPOSE: To qualitatively and quantitatively evaluate the diagnostic efficacy of the breath-hold magnetic resonance (MR) imaging sequences in widespread clinical use for detection and characterization of focal hepatic lesions. MATERIALS AND METHODS: Fifty patients with 143 lesions [57 hepatocellular carcinomas (HCC), 10 borderline lesions, 18 metastatic tumors, 21 hemangiomas, and 37 cysts] underwent single-shot fast spin echo (SSFSE), fast spin echo (FSE), and gadolinium-enhanced dynamic fast spoiled gradient-recalled acquisition in steady state (FSPGR) breath-hold MR imaging of the liver. Alternative free receiver operating characteristic (AFROC) analysis was performed to independently and prospectively assess each sequence. RESULTS: For solid lesions, dynamic FSPGR allowed the most sensitive lesion detection and produced the highest lesion conspicuity and lesion-liver contrast-to-noise ratio (CNR). For non-solid benign lesions, SSFSE and FSE produced better results than dynamic FSPGR. SSFSE allowed the most sensitive detection and produced the best lesion conspicuity and lesion-liver CNR. CONCLUSION: SSFSE and dynamic FSPGR comprise the optimal imaging protocol for breath-hold MR assessment of focal hepatic lesions. This combination of sequences allows acquisition of critical diagnostic information about both inherent T2 and T1 lesion contrast and lesion vascularity.

Individualized total cavopulmonary connection technique for patients with asplenia syndrome.

BACKGROUND: Outcomes after univentricular repair for patients with asplenia syndrome remain unsatisfactory, not only because of clinical difficulties in patient selection, but also secondary to technical difficulties in the separation of the systemic and pulmonary circulations, particularly with the rerouting technique for the inferior systemic veins. METHODS: Between February 1995 and May 2000, a total of 14 consecutive patients with asplenia syndrome underwent bidirectional cavopulmonary connection with obliteration of additional pulmonary blood flow, followed by a total cavopulmonary connection. The rerouting technique for inferior systemic venous blood flow was individualized to optimize laminar nonturbulent flow characteristics in the pathway, and to minimize prosthetic load and suture load on the atrial wall. The lateral tunnel or tube conduit technique was used in an extraatrial, intra-extraatrial, or intraatrial fashion. No fenestration was applied. RESULTS: No hospital mortality was observed. Systemic venous flow was evaluated using magnetic resonance angiography, revealing no signs of obstruction, turbulence, or stasis either in or near the reconstructed pathways, irrespective of the rerouting technique. Postoperative catheterization revealed favorable hemodynamics including an inferior vena cava pressure of 13 +/- 2 mm Hg and arterial oxygen saturation of 93.4% +/- 3.5% at room air. All patients have remained free of symptoms, although 1 patient died of acute septic complications 3.5 years after the procedure. CONCLUSIONS: The complexity of cardiac anomalies in asplenia syndrome warrants individualization of the total cavopulmonary connection technique used in reconstruction of the inferior systemic venous pathway. Optimizing flow characteristics in the pathway should be a priority. A staging approach allows suitable selection of candidates for univentricular repair.

Superparamagnetic iron oxide-mediated hepatic signal intensity change in patients with and without cirrhosis: pulse sequence effects and Kupffer cell function.

PURPOSE: To analyze superparamagnetic iron oxide (SPIO)-mediated hepatic signal intensity change in cirrhotic and noncirrhotic liver and to investigate the relationship between pulse sequence effects in SPIO-enhanced magnetic resonance (MR) imaging for hepatic cirrhosis. MATERIALS AND METHODS: Twelve patients with and 12 patients without cirrhosis underwent T2-weighted fast spin-echo, T2*-weighted gradient-echo (GRE), and T1-weighted GRE MR imaging before and twice (early and late phase) after SPIO administration. To assess the effect of SPIO, postcontrast relative signal-to-noise ratio (SNR) changes were statistically analyzed with repeated measurements analysis of variance for each pulse sequence. RESULTS: No interaction was shown between groups and data time points for any pulse sequence. There was no significant difference in mean hepatic relative SNR change on T2-weighted fast spin-echo images between the cirrhotic group and noncirrhotic group (-38.6% and -40.7%, early phase; -42.2% and -49.6%, late phase, respectively). For GRE images, statistically significant differences in mean hepatic relative SNR change were found between the cirrhotic group and noncirrhotic group (-14.2% and -44.5%, early phase; -28.5% and -56.4%, late phase on T2*-weighted GRE images (P <.001); 31.8% and 12.9%, early phase; 23.8% and 2.2%, late phase on T1-weighted GRE images (P <.05), respectively. CONCLUSION: Decreased overall phagocytic activity in cirrhotic liver is more likely due to Kupffer cell dysfunction than to Kupffer cell depletion, since magnetic susceptibility effects on T2*-weighted GRE images depend on intracellular SPIO cluster size.