Traction-induced aneurysm of an accessory left hepatic artery: a potentially fatal but synchronously treatable complication of a large hiatus hernia.

A 59-year-old man presented to our surgical clinic with a long-standing history of heart burn, and upper abdominal pain. Gastroscopy showed a large sliding hiatus hernia associated with severe reflux oesophagitis. Oesophageal pH manometry revealed a high DeMeester score of 36.03. A computed tomography (CT) scan was performed for preoperative hiatal hernia repair planning. This showed the incidental finding of an accessory left hepatic artery (ALHA) and an aneurysm of this accessory artery. The aneurysm occurred at the point where the ALHA traversed the diaphragmatic crus and was only present in association with the hiatus hernia. These observations suggest that the aetiology of the aneurysm was due to traction during development of the hiatus hernia. The patient went onto have a laparoscopic hiatus hernia repair and Toupet fundoplication with ligation of the accessory left hepatic artery and made an excellent recovery. ALHAs are not uncommon, occurring in around 15% of the general population, with aneurysms of the hepatic arteries accounting for about 20% of cases of visceral artery aneurysms. The case presented herein highlights the importance of performing an arterial phase CT when planning surgery for large hiatus hernias to detect more cases like this one. This would allow early detection and concurrent treatment of an associated aneurysm with repair of the hiatus hernia, to prevent aneurysmal complications later on.

Implementation of a new CT colonography service: 5 year experience.

AIM: To describe our experience using a 5 year audit of computed tomography colonography (CTC) practice and identify factors that influence diagnostic performance to guide implementation in other centres. MATERIAL AND METHODS: Consecutive patients referred for CTC at a single institution over a 5 year period were identified, and reporting rates and positive predictive value (PPV) calculated for small polyps, large polyps, and colorectal cancer. Diagnostic performance was compared using the Chi-squared test, and trends over time were examined with logistic regression. The effect of faecal tagging and an intravenous spasmolytic were investigated using Fisher's exact test. RESULTS: In total, 4355 CTC examinations were performed. Overall reporting rates and PPV were 17% and 92%, respectively. Negative predictive value (NPV) for cancer was 99.9%. A significant decrease in reporting rate (p < 0.001) was accompanied by an increase in PPV for small polyps (p = 0.02) following the introduction of faecal tagging. Adequacy rates for CTC improved over time (96% to 99%), with improved adequacy rates when using a spasmolytic, 98% versus 96% without. A significant difference in reporting rates, but not PPV, was found between radiologists. CONCLUSION: Accurate colonic investigation using CTC can be delivered safely to a high-risk patient population at a single centre. Faecal tagging and an intravenous spasmolytic improve diagnostic performance.

Subjective and objective quality assessment in wireless teleultrasonography imaging.

Mobile Robotic teleultrasonography is an emerging technology that can be applied in different clinical settings for remote ultrasound scanning without the need of the expert at the point of care. Guaranteed medical image quality for diagnostic purposes and their delivery in bandwidth limited wireless environments is a challenging issue. In this paper we present some of the subjective and objective image analysis acquired from a robotic teleultrasonography system operated remotely by the expert to provide an assessment of these medical imaging measures for such advanced wireless telemedical system.

False aneurysm of the pancreaticoduodenal artery complicating therapeutic endoscopic retrograde cholangiopancreatography.

A 76-year-old woman underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures for palliation of a carcinoma of the pancreas. At the first procedure a pre-cut sphincterotomy was performed because deep cannulation of the biliary tree was impossible. An endoscopic plastic biliary stent was inserted at the second ERCP. The patient developed abdominal pain and a post-procedure CT demonstrated a pseudoaneurysm. This was not present on the pre-procedure CT and was thought to arise from the pancreaticoduodenal artery as a complication of the pre-cut sphincterotomy. Visceral angiography confirmed the origin of the aneurysm from a branch of the inferior pancreaticoduodenal artery. The aneurysm was successfully embolised. To our knowledge, this is the first time that this complication has been reported.

The value of prone imaging in CT pneumocolon.

AIM: To evaluate the value of prone imaging in computed tomography pneumocolon. MATERIALS AND METHODS: In the U.K., patients commonly undergo computed tomography (CT) pneumocolon in the supine position alone. A prospective analysis of both supine and prone CT images was performed. The degree of distension and the presence/absence of fluid/faecal residue were documented. RESULTS: Twenty-five patients were examined in total. In all cases, all five segments of the colon were well visualized on combined assessment of supine/prone images. Diagnostic distension was obtained in all five segments of the bowel in 69% of cases in the prone position, but in only 24% of patients in the supine position. The rectum and sigmoid colon were well distended in 100 and 88%, respectively, on prone CT, but in only 58 and 35% of cases, respectively, on supine CT. Problems encountered by fluid/faecal residue were eliminated on prone CT. CONCLUSION: Adjunctive prone pelvic CT should be performed in all patients undergoing CT pneumocolon unless the supine images can be fully reviewed and shown to be satisfactory before the patient leaves the CT department. If a single positional sequence is to be performed, then prone CT is the position of choice.

Occult sphenoid sinusitis presenting clinically as parotid swelling: a case report.

A case of occult sphenoid sinusitis was diagnosed by an MRI scan in a patient who presented clinically with meningism and unilateral parotid swelling. Although the patient improved with a prolonged course of antibiotics complete resolution occurred only after surgical drainage of the affected sinus.

Barium enema preparation: a study of low-residue diet, "Picolax' and 'Kleen-Prep'.

A prospective, randomized three-arm trial is presented of 150 consecutive patients attending for double-contrast barium enema (BE). This compares 'Picolax' (a combined stimulant and osmotic agent), 'Picolax' following a 3 day low-residue diet and 'Kleen-Prep' (a polyethylene-glycol osmotic agent). Faecal clearance, mucosal coating and colon fluid were scored in four colonic segments by two radiologists working independently and blinded to the preparation used. Analyses of an elderly subgroup and of side effects was performed. Low-residue diet conferred no benefit to Picolax preparation, which was satisfactory (ability to exclude 5 mm polyps) in 80% of patients. Kleen-Prep failed to achieve adequate preparation in 46%, due to excess fluid and poor mucosal coating. Kleen-Prep caused more patient nausea, abdominal bloating and pain than Picolax. Patients 70 years and older had similar results. Low-residue diet need not be used in addition to Picolax. Kleen-Prep as a single agent is not recommended for BE preparation.

Paradoxical puborectalis contraction is a feature of constipation in patients with multiple sclerosis.

OBJECTIVE: To study the disturbed anorectal physiology associated with constipation in multiple sclerosis. METHODS: Anorectal function in 10 patients with clinically definite multiple sclerosis and constipation has been compared with 10 normal persons and 11 patients with idiopathic constipation, without multiple sclerosis. RESULTS: All 10 constipated patients with multiple sclerosis had difficulty evacuating barium paste during defaecography. In four of these there was complete failure of puborectalis relaxation when straining to defaecate, and in another four there was incomplete puborectalis relaxation. There was no evidence of lower motor neuron involvement of pelvic floor muscles in the multiple sclerosis group. CONCLUSIONS: Paradoxical puborectalis contraction is common in patients with multiple sclerosis in whom constipation is a symptom. This may be a feature of the disturbed voluntary sphincter control mechanism, analogous to detrusor sphincter dyssnergia in the bladder.

The use of air or CO2 as insufflation agents for double contrast barium enema (DCBE): is there a qualitative difference?

One hundred consecutive out-patients referred for double contrast barium enema (DCBE) were randomized in a double-blind prospective study to receive either air or CO2 as an insufflation agent. Each examination was performed by the same radiologist and radiographer. The two groups were equally matched for age and sex. Each completed examination was independently assessed by three radiologists for a variety of parameters. The results show that the patients receiving air as an insufflation agent had better overall colonic distension than the group receiving CO2 and that this was statistically significant (P = 0.0004). There was no significant difference in the mean time taken to perform the examination in the two groups nor was there any significant difference in mucosal coating or preparation. In conclusion, our results suggest that poor colonic distension is a potential problem when CO2 is used for DCBE and that this cannot be solely attributed to the time taken to perform the examination. Poor distension could lead to diagnostic errors and this may outweigh the advantages in patient acceptability when using CO2 as an insufflation agent.

Stapled laparoscopic rectopexy for rectal prolapse.

The widespread success of laparoscopic cholecystectomy has led to the development of a wide range of laparoscopic surgical procedures. Procedures for treating rectal prolapse (Procidentia) may constitute some of the best applications for colorectal laparoscopic techniques. A technique of laparoscopic rectopexy performed using the endo-stapler is described. Twenty-nine consecutive patients have undergone laparoscopic rectopexy. The median age was 71 years (52-89), and male:female ratio was 27:2. One procedure had to be converted to open due to ventilatory difficulties. The mean operative time was 95 minutes (50-190). The mean hospital stay was 5 days (4-15). There was no mortality in this series. Morbidity included incisional hernia through a port hole (n = 1), extraperitoneal haematoma (n = 1), and urinary tract infection with retention (n = 1). In conclusion, laparoscopic abdominal rectopexy is a safe and effective technique in the management of rectal prolapse.

Defecography in multiple sclerosis patients with severe constipation.

PURPOSE: To evaluate defecography in assessment of anorectal function in patients with multiple sclerosis (MS) who have intractable constipation. MATERIALS AND METHODS: Eleven patients with MS and constipation (10 women, one man) underwent defecography. A total of 130 mL of barium, liquid (20 mL) and paste, was introduced into the rectum. A dab of barium marked the external anal orifice, and, in the women, a tampon soaked with contrast medium marked the vagina. Video radiographic images and supplemental 100-mm static camera images were obtained. RESULTS: During defecation, six patients had no puborectalis muscle effacement, four patients had partial effacement, and one patient had complete effacement. No rectal emptying occurred in five patients, and emptying was incomplete in the rest. Three patients developed an intussusception, and two developed a posterolateral pouch. CONCLUSION: Defecography readily demonstrates rectal outlet obstruction and the failure of the puborectalis and anal sphincter muscles to relax. These are frequent findings in MS patients with intractable constipation.

Partial malrotation associated with pseudo-obstruction of the small bowel.

Intestinal pseudo-obstruction is defined as a syndrome in which there are signs and symptoms of intestinal obstruction without an actual obstructing lesion. In many cases it is associated with other disease entities but may be idiopathic. We report a case associated with partial malrotation of the gut which has not been described in the literature before.

Review article: endoscopic ultrasound of the stomach.

Endoscopic ultrasound (EUS) is the adopted term for the technique which enables endoluminal ultrasound to be performed using a specially designed endoscope with a fixed piezoelectric transducer. Since initial reports described the use of this technique in patients, its use in clinical practice in Europe, the Far East and the USA has been steadily increasing over the past few years. At present the technique is only practised in a very few centres in the UK but it is likely that this will increase in the future. This article describes the present day value of EUS in evaluating gastric pathology.

Ultrasound features of low power interstitial laser hyperthermia.

Low power interstitial laser hyperthermia (ILH) is a reliable means of producing in situ thermal necrosis. Ultrasonic studies have been carried out of the changes that occur in canine liver during ILH performed at laparotomy. With a single fibre delivering Nd-YAG laser at 1-1.5 W for 670 s an hyperechoic region developed at the fibre tip measuring 5-6 mm in diameter; around this developed an area of hypoechoic change (up to 500s) giving a total area of changed echogenicity of 14-16 mm. With a multiple fibre system using 4 laser fibres simultaneously the sonographic changes were a summation of the changes seen with a single fibre, the hypoechoic areas overlapping. With this four fibre system the creation of large (3.5 x 2.8 cm) areas of thermal necrosis was possible. There was good correlation between the sonographic and pathological measurements of the region of thermal change. The sonographic studies showed the extension and overlap of regions of thermal necrosis and allowed visualization and accurate measurement of the area undergoing change. The same combined technique has been successfully applied in a small number of clinical cases and may be of use in the treatment of tumours in solid organs.

Multiple-fibre low-power interstitial laser hyperthermia: studies in the normal liver.

Multiple four-fibre low-power interstitial laser hyperthermia was performed in the canine liver to establish the parameters with which large areas of thermal necrosis could be made. Using 1.5 W for 670 s (4020 J in total) and a fibre spacing of 1.5 cm, lesions with dimensions of 3.6 x 3.1 x 2.8 cm were achieved in 75 per cent of those attempted. There was no mortality and a low morbidity rate. These lesions could be visualized in both their development and resolution using ultrasonography. Healing occurred by 1 year. Temperatures in the centre of the heated region were 60 degrees C, which is more than enough to cause thermal cell death. There was good correlation between the temperatures recorded, the sonographic changes seen, and the pathological evidence of necrosis. Multiple-fibre low-power interstitial laser hyperthermia performed with ultrasonic guidance may be of use in the treatment of liver tumours.

Endoscopic ultrasound for localisation of islet cell tumours.

In a prospective study endoscopic ultrasound localisation of pancreatic endocrine tumours was attempted in 21 patients with clinically suspected islet cell tumours. Most patients were referred after the failure of conventional imaging methods. Endoscopic ultrasound correctly identified the site of 12 of 15 insulinomas, one glucagonoma, and a diffuse pancreatic abnormality in a patient with multiple endocrine adenopathy. There were two true negative examinations and one technical failure. The sensitivity of endoscopic ultrasound was much greater than that of computed tomography or conventional transabdominal ultrasonography.