Value of CT after laparoscopic repair of postsurgical ventral hernia.

BACKGROUND: We examined computed tomographic (CT) findings after laparoscopic repair of postsurgical ventral hernias in patients with and without symptoms. METHODS: Meshes were placed laparoscopically in 18 patients for incisional ventral hernia repair. CT of the abdominal wall was performed 1, 15, and 30 days after repair and when clinical findings indicated the procedure. RESULTS: Scans of four patients showed small fluid collections within the abdominal wall between the hernia sac and the mesh. These collections resolved within the first 30 days without aspiration. Scans of three patients with symptoms 4-8 months later showed fluid collections that required multiple aspirations in one patient and a recurrent hernia that was repaired laparoscopically in another patient. CONCLUSION: Preliminary results suggest that CT is a useful imaging tool in patients with laparoscopic repair of incisional vetral hernia. It showed the correct site of the mesh, subclinical fluid collections in the abdominal wall, and recurrent hernia.

Seroma in laparoscopic ventral hernioplasty.

SUMMARY: Seroma is a frequent complication of laparoscopic or open repair of ventral hernias using expanded polytetrafluoroethylene mesh. Aspiration of this seroma has the risk of introducing bacteria, resulting in infection and the recurrence of the hernia. Between May 1996 and December 2000, 51 patents who underwent 53 laparoscopic ventral hernioplasties (44 incisional, 5 large epigastric, and 4 large umbilical) were randomized to participate in a trial comparing the intraperitoneal onlay mesh repair with or without cauterization of the hernia sac. Group A (26 patients; 28 hernias) patients were operated on by using an expanded polytetrafluoroethylene Dual Mesh patch (Gore and Associates, Flagstaff, AZ, U.S.A.) inserted intraperitoneally and secured by full-thickness stitches and endoscopic clips to cover the hernia defect, while the sac was left intact. Group B (25 patients, 25 hernias) patients were operated on according to the same technique as those in group A, but the hernia sac was cauterized by monopolar cautery (5 cases) or harmonic scalpel (20 cases). After surgery, clinical examination and computed tomography scans were used to confirm or test the existence of seroma and recurrence. In group A, four clinically evident seromas were found. Two of them were resolved with no intervention. In the remaining two cases, multiple aspirations were needed for 4 and 7 months, respectively, but 2 and 3 months, respectively, after resolution of the seroma, a recurrence of the hernia was observed. There was one more recurrence without seroma and three with subclinical seromas (only observed on computed tomography scans). In group B, subclinical seroma (only observed in computed tomography scan) resolved in a few days, and one recurrence without seroma was observed. Although only a small number of patients were studied, our findings suggest that the cauterization of the hernia sac prevents seromas and reduces recurrences in laparoscopic repair of ventral hernias.

Bilateral papillary renal cell carcinoma.

Papillary renal cell carcinoma is a subgroup of malignant renal epithelial neoplasms. We report the clinical and imaging findings of a case with multifocal and bilateral renal cell carcinoma which are nonspecific.

Primary seminoma of the retroperitoneum.

A rare case of primary seminoma in the retroperitoneum is described. Ultrasound detected a huge hypoechoic mass and correlative computed tomography showed a midline, homogeneous, lobulated mass in a man who presented for anuria.

CT features of gastric lymphoma.

The gastrointestinal tract is the most frequent site of extranodal involvement by lymphoma and stomach is the most frequently involved. The incidence of gastric lymphoma appears to be rising as that of adenocarcinoma is declining. It produces a spectrum of radiologic appearances and its distinction from adenocarcinoma is difficult since their findings frequently overlap. The aim of this article is to present pictorially a spectrum of CT findings of the gastric lymphoma.

Intracystic pressure and viability in hydatid disease of the liver.

BACKGROUND: Knowledge on the viability of hydatid cysts of the liver during operation is important to the surgeon may dictate the peri-operative therapeutic manoeuvre undertaken. PATIENTS AND METHODS: A prospective study was performed on 23 patients with 28 hydatid cysts of the liver to assess whether intracystic pressure (ICP) could predict viability of protoscoleces. All patients received albendazole (10 mg/kg body weight/day) for 5 days pre-operatively. The ICP was measured from the apex of the cyst, after laparotomy, using a 16-G needle connected to a water manometer. After manometry, the cyst contents were aspirated and the viability of protoscoleces assessed by their flame cell activity, motility and ability to exclude 5% aqueous eosin. RESULTS: The median ICP was 54 +/- 21 cmH2O for 17 viable cysts and zero for 8 non-viable cysts, while 1 additional non-viable cyst and 2 sterilized cysts had high ICP (sensitivity, 100%; specificity, 72%; accuracy, 89%). The median diameter of the viable cysts was 9.3 +/- 3.5 cm and the non-viable cysts 10.7 +/- 2.6 cm. In the right lobe were located 12 viable and 8 non-viable cysts and in the left lobe, 5 viable and 3 non-viable cysts. No significant difference in diameter or ICP were noted between the hepatic lobes. CONCLUSIONS: These findings suggest that the measurement of ICP is a simple, cheap and reliable method for assessment of the viability of hydatid cysts of the liver.

CT of calcified liver metastases in colorectal carcinoma.

PURPOSE: To assess the incidence, characteristics and prognostic significance of calcification within colorectal hepatic metastases. MATERIALS AND METHODS: A retrospective analysis of CT in 265 patients with locally advanced or metastatic cancer was performed. Four groups were defined: (a) calcification within liver metastases prior to therapy, (b) noncalcified liver metastases with development of calcification on therapy, (c) noncalcified liver metastases, and (d) advanced local tumour without liver metastases. The number of calcified deposits in each patient was documented. A marker lesion was analysed for character, distribution and percentage of calcification. Survival between the four groups was compared. RESULTS: Twenty-nine (11%) patients had calcified liver metastases at presentation and 10 (4%) developed calcification during chemotherapy. Analysis of a marker lesion showed that the most frequent characteristic was fine calcification with a variable distribution. The most frequent change on treatment was alteration in the extent of calcification. Calcification developing on treatment was usually central. There was no difference in survival between groups 1, 2 and 3, but groups 1, 2 and 3 had a shorter survival than group 4. CONCLUSION: Calcification of liver metastases shows a variable pattern and may develop or change during therapy. Liver metastatic calcification may not carry any prognostic significance in colorectal cancer.

Usefulness of the non-distension of the stomach in the evaluation of perigastric invasion in advanced gastric cancer by CT.

The purpose of this study was to evaluate by CT the usefulness of the non-distension of the stomach in determining invasion of the gastric cancer into perigastric space and adjacent organs. Forty-eight patients with pathologically proved gastric cancer were studied by conventional CT. Patients were examined using two techniques: (a) non-distension of the stomach in the supine position and 34 patients additionally in prone position; and (b) distension of the stomach with water or air in the supine and/or prone position. CT findings by both techniques were separately analysed preoperatively and compared to surgical findings. Invasion of perigastric fat was better demonstrated by the non-distension technique in 15 of the 36 patients with pathologically proven fat infiltration. Non-distension technique was more accurate than distension in detecting: (a) involvement of gastric ligaments (80 versus 67% for gastrohepatic, 85 versus 73% for gastrocolic and 80% by both techniques for gastrosplenic ligament); (b) perigastric lymphadenopathy (86% by both techniques for lymph nodes sited at the gastrohepatic ligament, 85 versus 75% for gastrocolic and 85 versus 80% for gastrosplenic ligament lymph nodes, respectively); and (c) pancreatic invasion (86 versus 80%). The prone position with non-distended stomach was particularly helpful in excluding pancreatic invasion in five patients with carcinoma of the gastric body. The distension technique was more accurate in demonstrating perigastric extension in gastroesophageal junction tumors in two patients. In conclusion, additional CT of the non-distended stomach with the patient in prone position can provide further evidence about infiltration of the perigastric fat, ligaments, lymph nodes and pancreas, in patients with gastric carcinoma, with the exception of gastroesophageal junction tumors.

Crohn disease: CT findings after treatment.

Within a period of 5 years, we followed by computed tomography (CT) three patients with Crohn disease who were undergoing treatment. From the spectrum of disease abnormalities, some subsided and others remained. Bowel wall thickening was the most common pretreatment CT finding but was somewhat altered after treatment.

Modified Sugiura's procedure may improve liver function in portal hypertension.

BACKGROUND/AIMS: Sugiura procedure is an alternative in the treatment of the bleeding gastroesophageal varices. The postoperative alterations of CT and biochemical features versus pre-operative levels in patients operated on for haemorrhagic portal hypertension were studied. MATERIAL AND METHODS: Eight patients with liver cirrhosis and portal hypertension who underwent emergency or elective modified Sugiura's operation, were included in this study. The hepatic function and the CT scan ratio of transverse caudate lobe width to transverse right lobe width, pre-operatively and during the early and late postoperative period were studied. RESULTS: The hepatic function was aggravated during the immediate postoperative period but was remarkably improved, versus pre-operative status, after the first 15-30 postoperative days. The caudate to right lobe ratio from 0.66-1.7 pre-operatively, decreased to < 0.65 in all cases after the first postoperative month or year. One patient died on the 64th postoperative day from progressive hepatic failure, while all tests of the first postoperative month follow-up were improved. Another patient presented a light rebleeding 4 years after operation, while the hepatic tests were average. CONCLUSIONS: The modified Sugiura's procedure is an effective procedure in the disappearence of the oesophageal varices, followed by low mortality and low recurrent bleeding, but it mainly leads to an improvement of the hepatic function, probably due to improved hepatic portal blood flow.

Uncommon locations of hydatid disease: CT appearances.

Hydatid disease (HD), already known by Hippocrates, is prevalent and widespread in most sheep-raising countries in Asia, Australia, South America, Near East, and southern Europe. The disease is most commonly due to Echinococcus granulosus and may occur in any organ or tissue. The location is mostly hepatic (75 %) and pulmonary (15 %), and only 10 % occur in the rest of the body [1]. Imaging modalities such as US, CT, and MR imaging are helpful in diagnosing the disease. The reliability of each method depends on the cyst's location in the body [2-5]. The purpose of this essay is to illustrate the use of CT in depicting some unusual locations of HD besides the liver and lung.

CT evaluation of the resectability of gastric cancer postchemotherapy.

BACKGROUND: To determine the accuracy of CT in the postchemotherapy assessment of resectability of gastric cancer. METHODS: Thirty patients deemed to have unresectable gastric cancer on CT were studied. This was verified at laparotomy in 10 of these patients. Following initial assessment, all received three to eight cycles of chemotherapy aiming for disease control and potential resection. Serial CT examinations, endoscopy, and biopsy were performed after the fourth, sixth, and eighth cycle of treatment. The primary tumor and lymph nodes seen on CT were compared with operative findings. RESULTS: After completion of chemotherapy, CT findings were correct in 23 patients. Fourteen of them had operable tumors and nine were inoperable. However, the CT findings were either equivocal or incorrect in the remaining seven patients. CONCLUSION: Chemotherapy is now able to downstage a previously inoperable gastric cancer, and CT is an accurate method in identifying those patients who can proceed to resection.

Prognostic variable in patients with advanced colorectal cancer treated with fluorouracil and leucovorin-based chemotherapy.

Possible prognostic variables for tumor response, time to progression (TTP), and survival in 141 patients with advanced colorectal cancer treated with fluorouracil and leucovorin-based chemotherapy were analyzed. None of the variables examined for their possible influence on tumor response attained significance in the stepwise logistic regression. In the univariate analysis, variables found to be strongly associated with TTP were performance status (PS) (P = 0.0301), liver involvement (P = 0.030), and the initial values of WBC (P = 0.0319), lactic dehydrogenase (LDH; P = 0.0053), gamma-glutamyl-transpeptidase (gamma-GT; P = 0.0013), alkaline phosphatase (ALP; P = 0.0186), albumin (P = 0.0004), and carcinoembryonic antigen (CEA; P = 0.0014). In the Cox analysis, liver involvement (P = 0.0553), albumin (P = 0.0181), PS (P = 0.484), and ALP (P = 0.0553) were retained as independently significant variables. When only patients with liver metastases were included in the analysis, then only albumin (P < 0.001) demonstrated a prognostic significance. Also, in the univariate analysis, variables predicting survival were PS (P = 0.0230), grade (P = 0.00600), liver involvement (P = 0.0002), LDH (P = 0.0001), gamma-GT (P < 0.001), ALP (P = 0.0006), albumin (P = 0.0309), and CEA (P = 0.005). With the multivariate analysis, gamma-GT (P = 0.0004), albumin (P = 0.0634), and CEA (P = 0.0804) were selected as significant. In those patients who presented with liver involvement, variables predicted survival were gamma-GT (P = 0.0041), albumin (P = 0.0442), and the percentage of involved liver parenchyma (P = 0.0690). These results could be helpful for the stratification of future trials in advanced colorectal cancer.

Widespread Castleman disease: CT findings.

The widespread form of Castleman disease is a rare condition with aggressive, often fatal course. We describe the imaging findings of two patients with extensive Castleman lymphadenopathy. The duration of the disease was 8 years in one patient and 4.5 months in the other.

Perioperative benzimidazole therapy in human hydatid liver disease.

Primary treatment of liver hydatidosis is surgical, but the recurrence rate is about 10%. To minimize the risk of recurrence, 67 consecutive patients with liver hydatidosis were prospectively treated by mebendazole or albendazole for 5 days before surgery. During the operation the viability of the protoscoleces was assessed. Seventeen patients who had viable protoscoleces at the time of the operation received the same benzimidazole one extra month postoperatively, while the remaining 50 patients who had dead protoscoleces didn't receive postoperative therapy. None of the patients developed recurrence of the disease after a follow-up period of 15-67 months (average 41 months). These results suggest that a 5-day preoperative benzimidazole therapy either combined or not with a monthly postoperative course according to the viability of the protoscoleces at the time of operation, may erase the risk of recurrence after surgical treatment of the liver hydatidosis.

Case report: imaging of widespread plexiform neurofibromatosis.

Although the cutaneous, bony and retroperitoneal appearances of peripheral von Recklinghausen neurofibromatosis are well known, involvement of intra-abdominal organs and of the mediastinum is less well recognised. We present the case of a woman with peripheral neurofibromatosis who presented with loin pain. In addition to cutaneous neurofibromas, plexiform neurofibromas were present in the mediastinum, liver, mesentery and psoas muscles.