Pancreatic Walled-Off Necrosis: Cross-Sectional Imaging Depiction of Debris Predicts the Success of Endoscopic Drainage Using Lumen-Apposing Metal Stents.

INTRODUCTION: The use of endoscopic ultrasound (EUS)-guided transmural stent placement for pancreatic walled-off necrosis (WON) drainage is widespread. This study retrospectively analyzed imaging parameters predicting the outcomes of WON endoscopic drainage using lumen-apposing metal stents (LAMS). METHODS: This study analyzed the data of 115 patients who underwent EUS-guided debridement using LAMS from 2011 to 2015. Pre-intervention CT or MRI was used to analyze the total volume of WON, percentage of debris, multilocularity, and density. Success measures included technical success, the number of endoscopic sessions, the requirement of percutaneous drainage, long-term success, and recurrence. RESULTS: The primary cause of pancreatitis was gallstones (50.4%), followed by alcohol (27.8%), hypertriglyceridemia (11.3%), idiopathic (8.7%), and autoimmune (1.7%). The mean WON size was 674 mL. All patients underwent endoscopic necrosectomy, averaging 3.1 sessions. Stent placement was successful in 96.5% of cases. Procedural complications were observed in 13 patients (11.3%) and 6 patients (5.2%) who needed additional percutaneous drainage. No patients reported recurrent WON posttreatment. Univariate analysis indicated a significant correlation between debris percentage and the need for additional drainage and long-term success (p < 0.001). The number of endoscopic sessions correlated significantly with debris percentage (p < 0.001). CONCLUSION: Pre-procedural imaging, particularly debris percentage within WON, significantly predicts the number of endoscopic sessions, the need for further percutaneous drainage, and overall long-term success.

Hepatic Steatosis After Partial Pancreatectomy in a Cohort of Patients with Intraductal Papillary Mucinous Neoplasm.

Background/Aims: Nonalcoholic fatty liver disease (NAFLD) has been observed in patients after partial pancreatectomy. Previous studies have been performed on oncologic patients who underwent partial pancreatectomy and received adjuvant chemotherapy. By studying a cohort of patients with intraductal papillary mucinous neoplasms (IPMNs) who did not receive chemotherapy, the authors investigate the isolated effect of partial pancreatectomy on the development of fatty liver. Methods: A retrospective search for patients with pancreatic IPMNs who underwent partial pancreatectomy at an academic center from 2006 to 2014 identified 63 patients, including 42 who had pancreaticoduodenectomy (PD) and 21 who had distal pancreatectomy (DP). Fourteen patients with preoperative hepatic steatosis, diabetes, obesity, on steroid therapy, history of malignancy, or incomplete data were excluded. No patient received chemotherapy. Liver fat signal fraction (LFSF) was computed by the Dixon method using pre- and postoperative in- and out-of-phase MRI. Results: Of the 49 patients included in the study, 29 (59%) underwent PD and 20 (41%) underwent DP. A total of 17 patients (34%) developed fatty liver after surgery. The entire cohort developed significant weight loss, 72.1 versus 69.4 kg (P < 0.01). Postoperatively, there was significant increase in LFSF, 1.3% versus 9.6% following PD (P < 0.01), and 2.1% versus 9.4% following DP (P = 0.01). Conclusion: Partial pancreatectomy increases the risk of NAFLD independent of chemotherapy-induced hepatotoxicity. The underlying mechanism remains unclear and possibly related to pancreatic exocrine insufficiency and malnutrition.

Preoperative splenic artery embolization for splenic ectopic pregnancy.

Primary splenic pregnancy is an extremely rare form of extra tubal ectopic pregnancy. Trans-arterial embolization is emerging as an effective treatment for ectopic pregnancy. Here, we present a 34-year-old G4P3003 woman who presented with vaginal bleeding and elevated serum quantitative human chorionic gonadotropin (beta-hCG). After initial workup showed no intrauterine pregnancy, MRI of the abdomen showed an ectopic gestational sac at the splenic hilum. A preoperative splenic artery embolization was performed successfully prior to open splenectomy for removal of the ectopic pregnancy to minimize operative blood loss. By sharing our experience in this case, we contribute to the validation of trans-arterial embolization as an effective adjunctive measure in treating ectopic pregnancy.

Impact of multidetector computed tomography scan parameters, novel reconstruction settings, and lung nodule characteristics on nodule diameter measurements: A phantom study.

PURPOSE: Novel CT reconstruction techniques strive to maintain image quality and processing efficiency. The purpose of this study is to investigate the impact of a newer hybrid iterative reconstruction technique, Adaptive Statistical Iterative Reconstruction-V (ASIR-V), in combination with various CT scan parameters on the semi-automated quantification using various lung nodules. METHODS: A chest phantom embedded with eight spherical objects was scanned using varying CT parameters such as tube current and ASIR-V levels. We calculated absolute percentage error (APE) and mean APE (MAPE) using differences between the semi-automated measured diameters and known dimensions. Predictive variables were assessed using a multivariable general linear model. The linear regression slope coefficients (ß) were reported to demonstrate effect size and directionality. RESULTS: The APE of the semi-automated measured diameters was higher in ground-glass than solid nodules (ß = 9.000, p < 0.001). APE had an inverse relationship with nodule diameter (mm; ß = -3.499, p < 0.001) and tube current (mA; ß = -0.006, p < 0.001). MAPE did not vary based on the ASIR-V level (range: 5.7%-13.1%). CONCLUSION: Error is dominated by nodule characteristics with a small effect of tube current. Regardless of phantom size, nodule size accuracy is not affected by tube voltage or ASIR-V level, maintaining accuracy while maximizing radiation dose reduction.

Intraosseous hemangioblastoma of the cervical spine: case report.

A 69-year-old woman presented with bilateral upper-extremity radiculopathy and neck pain after a mechanical fall. Admission CT and MRI of the cervical spine demonstrated a pathological C-4 fracture. Subsequent malignancy workup was negative. A CT-guided biopsy of the lesion showed intraosseous hemangioblastoma. Hemangioblastoma is a highly vascular, slow-growing tumor of the CNS; intraosseous location of this tumor is extremely rare. The authors review the diversity of its presentation and the treatment techniques of this rare tumor in an extremely rare location.

Detection of unsuspected pelvic DVTs on abdominopelvic CT scans: a potentially life-saving diagnosis.

Venous thromboembolism (VTE) is a serious common disorder with substantial cost and morbidity to society and can be life threatening in some cases. The majority of VTE is diagnosed on lower extremity ultrasound or CT pulmonary angiography, but some cases of deep venous thrombosis (DVT) may be occasionally diagnosed on CT of the abdomen and pelvis by the alert radiologist. The purpose of our study was to determine the fraction of new/unsuspected DVTs diagnosed on CTAP and the subsequent management and clinical course of these patients. After Institutional Review Board approval, a retrospective search of an institutional imaging database was performed for all cases of DVTs diagnosed on CTs of the abdomen and pelvis. Patients with positive studies were further investigated via clinical chart review for their subsequent management and clinical course. The 90-day mortality of the patients diagnosed with DVT on CTAP was also recorded. Sixty-two patients met the criteria for positive DVT on CTAP. Of these 62 cases, 26 (42 %) were new. Management was substantially changed in 24 out of 26 cases (92 %), most commonly initiation of anticoagulation. The 90-day mortality rate of patients diagnosed with pelvic DVTs on CTAP in our cohort was 21 %. Timely detection of pelvic DVTs can have serious implications for patient management, morbidity, and mortality. The pelvic veins should be included in the search pattern of all radiologists who review CTs of the abdomen and pelvis.

Acute nontraumatic splenic infarctions at a tertiary-care center: causes and predisposing factors in 123 patients.

Acute splenic infarcts classically present with left upper quadrant pain, but may be discovered incidentally in many hospitalized patients with otherwise vague complaints. The purpose of our study was to document causes or predisposing conditions in patients found to have acute splenic infarctions on imaging. Following IRB approval, a retrospective review of an imaging database from May 2008 to May 2015 was performed for cases of acute splenic infarctions. The electronic medical record was then reviewed for potential predisposing factors or known causes. Specific note was made of cases with active malignancy, vascular disorders, or inflammatory conditions with an increased risk of vasculopathy. Echocardiogram and electrocardiogram results were reviewed when available. One hundred twenty-three patients with acute splenic infarcts were identified, 65 female and 58 male. The average age was 57 years (range of 22 to 88). Active malignancy was present in 40 patients or 33 %. The most common malignancy in patient with nontraumatic splenic infarctions was pancreatic cancer, present in 16 patients (13 %). In these patients, splenic infarction was due to direct invasion of vessels in the splenic hilum. Acute pancreatitis (severe) was directly responsible for splenic infarction in seven additional cases (6 %). Additional visceral infarcts were present in 18 patients (15 %), most commonly concomitant hepatic or renal infarcts. Documented atrial fibrillation was present in 12 patients, but only 2 cases of left-sided cardiac thrombi were seen on CT (1 atrial, and 1 ventricular thrombus). Eight cases of endocarditis with valvular vegetations were documented on echocardiography (7 %). Splenomegaly was present in 32 patients (26 %) with acute splenic infarction. In patients with nontraumatic splenic infarctions, there appears to be a relatively high association with active malignancy (up to a third of patients). Pancreatic disorders, malignant and inflammatory, also appear to be an important cause of splenic infarction, presumably due to the close proximity of the pancreas to the splenic vessels.

SWI2/SNF2 chromatin remodeling ATPases overcome polycomb repression and control floral organ identity with the LEAFY and SEPALLATA3 transcription factors.

Patterning of the floral organs is exquisitely controlled and executed by four classes of homeotic regulators. Among these, the class B and class C floral homeotic regulators are of central importance as they specify the male and female reproductive organs. Inappropriate induction of the class B gene APETALA3 (AP3) and the class C gene AGAMOUS (AG) causes reduced reproductive fitness and is prevented by polycomb repression. At the onset of flower patterning, polycomb repression needs to be overcome to allow induction of AP3 and AG and formation of the reproductive organs. We show that the SWI2/SNF2 chromatin-remodeling ATPases SPLAYED (SYD) and BRAHMA (BRM) are redundantly required for flower patterning and for the activation of AP3 and AG. The SWI2/SNF2 ATPases are recruited to the regulatory regions of AP3 and AG during flower development and physically interact with two direct transcriptional activators of class B and class C gene expression, LEAFY (LFY) and SEPALLATA3 (SEP3). SYD and LFY association with the AP3 and AG regulatory loci peaks at the same time during flower patterning, and SYD binding to these loci is compromised in lfy and lfy sep3 mutants. This suggests a mechanism for SWI2/SNF2 ATPase recruitment to these loci at the right stage and in the correct cells. SYD and BRM act as trithorax proteins, and the requirement for SYD and BRM in flower patterning can be overcome by partial loss of polycomb activity in curly leaf (clf) mutants, implicating the SWI2/SNF2 chromatin remodelers in reversal of polycomb repression.