Variations in the cystic duct: frequency and the relationship among insertion sides and heights on the bile duct.

BACKGROUND: Evaluation of the cystic duct anatomy prior to bile duct or gallbladder surgery is important, to decrease the risk of bile duct injury. This study aimed to clarify the frequency of cystic duct variations and the relationship between them. METHODS: Data of 205 patients who underwent cholecystectomy after imaging at Sada Hospital, Japan, were analyzed. The Chi-square test was used to analyze the relationships among variations. RESULTS: The lateral and posterior sides of the bile duct were the two most common insertion points (92 patients, 44.9%), and the middle height was the most common insertion height (135 patients, 65.9%). Clinically important variations (spiral courses, parallel courses, low insertions, and right hepatic duct draining) relating to the risk of bile duct injury were observed in 24 patients (11.7%). Regarding the relationship between the insertion sides and heights, we noticed that the posterior insertion frequently existed in low insertions (75.0%, P < 0.001) and did not exist in high insertions. In contrast, the anterior insertion coexisted with high and never low insertions. Spiral courses have two courses: anterior and posterior, and anterior ones were only found in high insertion cases. CONCLUSIONS: The insertion point of the cystic duct and the spiral courses tended to be anterior or lateral superiorly and posterior inferiorly. Clinically significant variations in cystic duct insertions are common and surgeons should be cautious about these variations to avoid complications.

Usefulness of several factors and clinical scoring models in preoperative diagnosis of complicated appendicitis.

BACKGROUND: The preoperative distinction between uncomplicated and complicated appendicitis is important to determine the appropriate treatments, such as antibiotics, surgery, or interval appendectomy. Computed tomography (CT) plays an important role; however, combining clinical and imaging factors may make preoperative evaluation more reliable. This study evaluated and analyzed cases and the usefulness of several preoperative factors and clinical scoring models to detect complicated appendicitis. METHODS: A total of 203 patients preoperatively diagnosed with acute appendicitis at our facility were included. Complicated appendicitis was defined as appendicitis with gangrene, perforated appendix, and/or abscess formation. Preoperative factors were collected from published clinical scoring models; patient information, symptoms, signs, results of laboratory tests, and findings of CT. Factors were analyzed using a chi-squared test and the Mann-Whitney U test. RESULTS: The preoperative factors were compared between 151 uncomplicated and 52 complicated appendicitis patients. The significant factors were age ≥40, duration of symptoms >24 hours, body temperature ≥37.3°C, high levels of CRP, findings in CT scan (appendix diameter ≥10 mm, stranding of the adjacent fat, presence of fluid collection, and suspicion of abscess or perforation). We also evaluated the usefulness of clinical scoring models for the detection of complicated appendicitis and found the Appendicitis Inflammatory Response score and two prediction models (Atema score and Imaoka score) showed significance (p < 0.05). High serum CRP level was significantly associated with complicated appendicitis (p < 0.001), and the predicted existence rates of complicated appendicitis were 52.7% for serum CRP level ≥50mg/L, 74.4% for ≥100mg/L, and 82.6% for ≥150mg/L. CONCLUSION: The results demonstrated several preoperative factors and clinical scoring models to increase suspicion of complicated appendicitis. Specifically, high serum levels of CRP may be a useful factor in predicting complicated appendicitis prior to surgery when supported by clinical findings and imaging; however, further research is needed.

Multiple Esophageal Squamous Papillomas.

We report a rare case of multiple esophageal squamous papillomas (ESPs). A 42-year-old man underwent a medical examination, and abnormalities of multiple elevated lesions were noted using a esophagogastroduodenoscope. He underwent upper gastrointestinal tract radiography with an orally ingested barium sulfate and gastrointestinal endoscopy, which revealed multiple elevated lesions in the esophagus, predominantly on the distal esophagus. We performed an endoscopic esophageal mucosal resection using a cap-fitted esophagogastroduodenoscope to obtain sufficient specimens. Based on the pathological findings, we diagnosed multiple ESPs. Although single ESPs or a few ESPs in a patient are often encountered, multiple ESP cases are rare.

Role of barium esophagography in patients with locally advanced esophageal cancer: evaluation of response to neoadjuvant chemoradiotherapy.

Purpose. This retrospective study examined the usefulness of barium esophagography, focusing on the luminal stenosis, in the response evaluation of neoadjuvant chemoradiotherapy (NACRT) in patients with esophageal cancer. Materials and Methods. Thirty-four patients with primary advanced esophageal cancer (≥T2) who were treated with NACRT before surgical resection were analyzed. All patients underwent barium esophagography before and after NACRT. The tumor length, volume, and percent esophageal stenosis (PES) before and after NACRT were measured. These values and their changes were compared between histopathologic responders (n = 22) and nonresponders (n = 12). Results. Posttreatment tumor length and PES in responders (4.5 cm ± 1.1 and 33.0% ± 18.5) were significantly smaller than those in nonresponders (5.8 cm ± 1.9 and 48.0% ± 12.9) (P = 0.018). Regarding posttherapeutic changes, the decrease in PES in responders (31.5% ± 13.9) was significantly greater than that in nonresponders (14.4% ± 10.7) (P < 0.001). The best decrease in PES cutoff with which to differentiate between responders and nonresponders was 18.8%, which yielded a sensitivity of 91% and a specificity of 75%. Conclusions. Decrease in PES is a good parameter to differentiate responders from nonresponders for NACRT. Barium esophagography is useful in response evaluation to NACRT in patients with locally advanced esophageal cancer.

Extent of arterial tumor enhancement measured with preoperative MDCT gastrography is a prognostic factor in advanced gastric cancer after curative resection.

OBJECTIVE: The objective of this study was to investigate the correlation between pathologic findings and arterial tumor enhancement at MDCT gastrography of patients with a prognosis of advanced gastric cancer after curative resection. MATERIALS AND METHODS: The cases of 41 patients with advanced gastric cancer (23 men, 18 women; age range, 35-92 years; median, 60 years) who underwent MDCT gastrography and optical endoscopy before surgery were retrospectively evaluated. Two radiologists reviewed virtual endoscopic and multiplanar reconstruction images to measure arterial phase CT values of the inner tumor margin and healthy gastric wall. They used consensus regions of interest on a cross-sectional image of the largest tumor diameter and then calculated tumor-to-normal wall enhancement ratio (TNR). Advanced gastric cancers were divided into high- and low-TNR groups with mean TNR as the cutoff. The correlations between groups and pathologic factors, patient survival, and mode of recurrence were studied. RESULTS: Multivariate logistic regression analysis showed that the arterial tumor enhancement ratio correlated with both microvessel density and lymphatic vessel invasion. The survival rate after curative resection was worse for the high-TNR group than for the low-TNR group. The rate of lymphatic and hematogenous recurrences was also higher in the high-TNR group. Multivariate survival analysis revealed that TNR was an independent prognostic factor. CONCLUSION: The extent of arterial tumor enhancement correlated with tumor angiogenesis and lymphatic vessel invasion and was a useful prognostic indicator after curative resection in patients with advanced gastric cancer.

Prediction of intraoperative bleeding during endoscopic treatment in patients with early gastric cancers: utility of contrast-enhanced MDCT gastrography and the wall-carving image technique.

PURPOSE: To assess the ability of the "wall-carving image (WC) technique," which uses vascular images from computed tomography (CT) gastrography, to predict bleeding during endoscopic treatment in patients with early gastric cancers (EGC). MATERIALS AND METHODS: We analyzed the CT enhancement on WC images of 30 patients with EGC who were treated with endoscopic submucosal dissection (ESD). Patients were divided into two groups-a no-bleeding group and a bleeding group-according to the degree of intraoperative bleeding during the ESD. Patient-related variables (age and sex), lesion-related variables (size, location, and morphological type), a procedure-related variable (procedure time), and the CT enhancement on WC images were compared between two groups. To assess the diagnostic performance of the CT findings in the prediction of intraoperative bleeding, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Lesion location, procedure time, and CT enhancement were all significantly associated with intraoperative bleeding, with p values of 0.046, 0.0007, and 0.0011, respectively. With a cut-off value of 4 or greater indicating positivity for contrast enhancement, the sensitivity, specificity, PPV, and NPV for predicting intraoperative bleeding were 64.3, 93.8, 90.0, and 75.0 %, respectively. CONCLUSIONS: Contrast enhancement of WC was significantly associated with intraoperative bleeding during ESD.

Contrast-enhanced MDCT gastrography for detection of early gastric cancer: Initial assessment of "wall-carving image", a novel volume rendering technique.

OBJECTIVE: We developed a new volume rendering technique, the CT gastrography wall carving image (WC) technique, which provides a clear visualization of localized enhanced tumors in the gastric wall. We evaluated the diagnostic performance of the WC as an adjunct to conventional images in detecting early gastric cancer (EGC). MATERIALS AND METHODS: Thirty-nine patients with 43 EGCs underwent contrast-enhanced MDCT gastrography for preoperative examination. Two observers independently reviewed the images under three different conditions: term 1, Axial CT; term 2, Axial CT, MPR and VE; and term 3, Axial CT, MPR, VE and WC for the detection of EGC. The accuracy of each condition as reviewed by each of the two observers was evaluated by receiver operating characteristic analysis. Interobserver agreement was calculated using weighted-κ statistics. RESULTS: The best diagnostic performance and interobserver agreement were obtained in term 3. The AUCs of the two observers for terms 1, 2, and 3 were 0.63, 0.73, and 0.84, and 0.57, 0.73, and 0.76, respectively. The interobserver agreement improved from fair at term 1 to substantial at term 3. CONCLUSIONS: The addition of WC to conventional MDCT display improved the diagnostic accuracy and interobserver reproducibility for the detection of ECG. WC represents a suitable alternative for the visualization of localized enhanced tumors in the gastric wall.

Unusual presentation of an esophageal foreign body granuloma caused by a fish bone: usefulness of multidetector computed tomography.

A 68-year-old woman had throat pain while eating fish. The pain gradually disappeared with no treatment. She visited her doctor for a medical checkup 1 year later, and an esophageal tumor was suspected. A double-contrast esophagogram revealed luminal stenosis with a mass-like defect in the middle esophagus. Esophagogastroduodenoscopy (EGD) showed smooth-surface stenosis with a retracted fold. Endoscopic ultrasonography (EUS) showed a hypoechoic mass in the submucosal layer and a well-defined linear hyperechoic structure forming a posterior acoustic shadow within the mass. A computed tomography (CT) examination was then performed using an Aquilion 64-detector row CT scanner, and a high attenuation linear structure was found in the lesion that was visualized as a fish bone-like structure on reconstructed CT images. Endoscopic removal of the fish bone was impossible, and a surgical operation would have been too invasive for a lesion suspected of being benign. The patient had no complaint related to the esophageal lesion itself and no sign of gastrointestinal tract complications. Accordingly, regular follow-up was recommended for the esophageal lesion. Follow-up examination including EGD, esophagography, and CT performed 1 year later showed that the lesion had decreased in size with no fish bone-like structure.

[Radiological imaging of small-bowel tumors].

While diagnosis of small-bowel tumors is clinically difficult, imaging examinations have a great role in it. Small-bowel enteroclysis allows viewing of the entire small-bowel for evaluating tumor location, size, and shape. CT gives information on both the intra- and extraluminal features of small-bowel tumors, mesenteric abnormalities, and distant organ spread. Multidetector- row computed tomography (MDCT) has improved image quality and reduced scan times. Furthermore, CT enteroclysis using MDCT with adequate visceral distension allows good visualization of small-bowel tumors. It is very important for clinicians to know the characteristic imaging findings of small-bowel tumors, although they are rare.

New prediction rule for mortality in acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia is potentially fatal, but prognostic factors have not yet been established. This study was undertaken to elucidate them. METHODS: This is a retrospective cohort study, consisting of 110 patients who had been treated in the past 5 years, from 26 national hospitals in Japan. RESULTS: The overall in-hospital mortality rate was 51%. Logistic regression analysis demonstrated two independent prognostic factors, electrocardiogram scale with an odds ratio of 1.7 (95% CI 1.2-2.4) and shock index of 11 (95% CI 1.5-80). A stepwise analysis gave a prediction equation for in-hospital mortality (R) using these variables and age score. We further modified this equation to a simpler scoring system (S) using the same variables. Both R and S showed a good discriminatory ability as determined by areas under the receiver-operating characteristic curve (0.83, 95% CI: 0.74-0.91 for R; 0.82, 95% CI 0.74-0.91 for S). The observed mortality rates increased as the R or S increased (19% at R <0.25, 41% at 0.25 < or = R <0.6, 85% at R > or =0.6; 19% at S < or =2, 37% at S of 3 or 4, 91% at S > or =5). CONCLUSION: The new prediction rules can be used at any hospital and may be promising tools for medical decision-making, informed consent and reviewing quality of care.

An analysis of the physiological FDG uptake pattern in the stomach.

The purpose of this study was to clarify the normal gastric FDG uptake pattern to provide basic information to make an accurate diagnosis of gastric lesions by FDG PET. We examined 22 cases, including 9 of malignant lymphoma, 8 of lung cancer, 2 of esophageal cancer, and 3 of other malignancies. No gastric lesions were observed in any of the 22 cases on upper gastrointestinal examinations using either barium meal or endoscopic techniques. The intervals between FDG PET and the gastrointestinal examination were within one week in all cases. The stomach regions were classified into the following three areas: U (upper)-area, M (middle)-area, and L (lower)-area. The degree of FDG uptake in these three gastric regions was qualitatively evaluated by visual grading into 4 degrees, and then a semiquantitative evaluation was carried out using the standardized uptake value (SUV). Based on a visual grading evaluation, the mean FDG uptake score in the U-, M-, and L-areas was 1.14 +/- 0.96, 0.82 +/- 0.96, and 0.36 +/- 0.49 (mean +/- S.D.), respectively. The FDG uptake scores obtained in the three areas were significantly different (Friedman test, p < 0.05). Furthermore, the rank order of the FDG uptake score in each case (U > or = M > or = L) was found to be statistically significant (Cochran-Armitage trend test, p < 0.05). The mean SUVs of 11 cases in the three areas were 2.38 +/- 1.03, 1.91 +/- 0.71, and 1.34 +/- 0.44 (mean +/- S.D.), respectively. The SUV in the U-area was significantly higher than that in the L-area (Friedman test, p < 0.05). A significant difference in FDG uptake was observed among the three gastric areas, and the FDG uptake extent in all cases was U > M > L. In conclusion, the physiological gastric FDG uptake was significantly higher at the oral end. A stronger gastric FDG uptake at the anal end may therefore be suggestive of a pathological uptake.