Guillaume Baudin

CT-Guided Percutaneous Catheter Drainage of Acute Infectious Necrotizing Pancreatitis: Assessment of Effectiveness and Safety

OBJECTIVE The purpose of this study is to assess retrospectively the effectiveness and safety of CT-guided percutaneous drainage and to determine the factors influencing clinical success and mortality in patients with infectious necrotizing pancreatitis. MATERIALS AND METHODS From April 1997 to December 2005, 48 consecutive patients (33 men and 15 women; median age, 58.5 years) with proven infectious necrotizing pancreatitis underwent percutaneous catheter drainage via CT guidance. Evaluated factors included clinical, biologic, and radiologic scores; drainage and catheter characteristics; and complications. Clinical success was defined as control of sepsis without requirement for surgery. Univariate analysis was performed to determine factors that could have affected the clinical success and the mortality rates. RESULTS Clinical success was achieved in 31 of 48 patients (64.6%) and was significantly associated with Ranson score (p = 0.01) and with the delay between admission and the beginning of the drainage (p = 0.005), with a calculated threshold delay of 18 days (p = 0.001). The global mortality rate (14/48 [29%]) was also influenced by the Ranson score (p = 01) and the delay of drainage (p = 0.04) with the same threshold delay (p = 0.01). Only two major nonlethal procedure-related complications were observed. CONCLUSION Percutaneous catheter drainage is a safe and effective technique to treat acute infectious necrotizing pancreatitis.

The value of pelvic MRI in the diagnosis of posterior cul-de-sac obliteration in cases of deep pelvic endometriosis.

OBJECTIVE The objective of our study was to define relevant MRI signs allowing preoperative diagnosis of posterior cul-de-sac obliteration in patients with deep pelvic endometriosis. MATERIALS AND METHODS This retrospective study included patients who underwent pelvic MRI completed by a laparoscopic examination. Three radiologists performed the MRI review blinded and recorded the following signs: sign 1, retroflexed uterus; sign 2, retrouterine mass; sign 3, displacement of intraperitoneal fluid; sign 4, elevation of the fornix; and sign 5, adherence of bowel loops. Laparoscopic results provided the criterion standard for diagnosis of posterior cul-de-sac obliteration. The performance of MRI was evaluated by calculating the average sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI results of the two more experienced radiologists for each sign and for combinations of signs. Interobserver agreement for each sign and impression for posterior cul-de-sac obliteration were calculated for all radiologists. RESULTS Sixty-three patients were included in the study. Posterior cul-de-sac obliteration was diagnosed in 43 patients at laparoscopy. The mean sensitivity, specificity, and accuracy of each sign and impression of posterior cul-de-sac obliteration were, respectively, as follows: sign 1, 24.4%, 77.5%, 41.3%; sign 2, 97.1%, 83.7%, 92.8%; sign 3, 95.0%, 88.7%, 93.1%; sign 4, 30.2%, 97.5%, 51.6%; sign 5, 83.7%, 91.2%, 86.1%; and impression of posterior cul-de-sac obliteration, 91.9%, 91.2%, 91.7%. Interobserver concordance varied from 0.26 to 0.81 with best results obtained with the combination of signs 2, 3, and 5. Best concordances for junior radiologist evaluations were obtained with assessment of sign 3. CONCLUSION MRI allows posterior cul-de-sac obliteration diagnosis. Pelvic fluid displacement may be the sign with greatest utility when considering both diagnostic accuracy and interobserver agreement.

Anévrisme de l'artère splénique: diagnostic et thérapeutique endovasculaire

Splenic artery aneurysm: diagnosis and endovascular therapy Splenic artery aneurysms are now diagnosed more frequently thanks to the increase and improvement in different imaging techniques. In case of rupture they are potentially life threatening and thus in certain cases may require appropriate preventive treatment. This treatment should be offered to patients with suspected pseudoaneurysms, with an aneurysm larger than 20mm in diameter, or which is progressing. The development of interventional endovascular radiology has provided new therapeutic options for the management of aneurysms, by excluding the sac from the arterial circulation with coil embolisation or with a covered stent. The success rate of these treatments is between 75 and 100% with significantly less morbidity and mortality than with surgical techniques.

Évaluation de deux systèmes de cotation des prolapsus pelviens en IRM dynamique

Evaluation of two classifications systems for pelvic prolapse on dynamic MRI Purpose To determine the usefulness of two classification systems for pelvic prolapse on MRI. Materials and methods Prospective study of 30 patients with symptoms of pelvic prolapse performed in a single center. All patients underwent clinical evaluation followed by dynamic pelvic MRI within 15 days. All MR examinations were reviewed by three readers using both classification systems based on different anatomical landmarks. The first used the pubococcygeal line and the second used the midpubic line. Results For prolapse detection, the correlation between clinical examination and MRI was good to very good, ranging between 74 and 89%. For prolapse staging, the correlation was poor to moderate. Inter-observer agreement was good to very good (kappa between 0.67 and 0.95). It was slightly better at the mid stage, with both systems (kappa between 0.83 and 0.97). Comparison of the inter-observer agreement between both MRI classification systems showed better results for the system using the pubococcygeal line (p Conclusion The classification system based on the pubococcygeal line appeared more reliable and simple for th eevaluation of pelvic prolapse on MRI.

Aspects tomodensitométriques et signification du gaz dans l’aire pancréatique

CT imaging features and significance of gas in the pancreatic bed The pancreas is an organ that normally does not contain gas. The purpose of this article is to reaffirm the value of CT to detect gas in abnormal locations and illustrate the different causes of gas collections in the pancreatic bed. Abscesses and infected pseudocysts are the most frequent causes of gas in the pancreatic bed followed by malignant and inflammatory fistulae. Iatrogenic etiologies should be considered along with the rare emphysematous pancreatitis associated with very poor prognosis. All of these entities shows multiple imaging findings, including the presence of gas in the pancreatic bed.

Intestinal Transplantation in a Patient with Superior Vena Cava Thrombosis

In patients undergoing small bowel transplantation, the current consensus is to avoid transplanting patients with insufficient vascular patency to guarantee easy central venous access for up to 6 months following transplantation. Here we present the case of a patient who received an intestinal transplant despite obstruction of the superior vena cava (SVC). The complicated post-operative outcome supports the view that these patients should be transplanted when easy central venous access is available.

ANAT-WP-2 Approche anatomique regionale du cou par echographie tridimensionnelle selon 5 acquisitions volumiques

Objectifs pedagogiques Savoir sectoriser F anatomie cervicale en etage sus-hyoidien, infra-hyoidien, loge parotidienne, axe vasculaire, axe visceral. Savoir numeroter les sites ganglionnaires du cou. Savoir identifier les principaux muscles du cou et du plancher buccal. Connaitre les rapports des glandes salivaires et en particulier de la parotide. Savoir identifier les structures nerveuses (nerf facial, X, nerf recurrent, plexus brachial). Messages a retenir La connaissance de la numerotation des aires ganglionnaires cervicales est indispensable pour la correspondance avec le clinicien. La parotide est traversee par le nerf facial qui n’est pas directement visualise mais le plan veineux est un plan de permettant de le situer. Les muscles de l’etage sus hyoidien forment le plancher buccal de la superficie vers la profondeur : digastrique, mylohyoidien, geniohyoidien, genioglosse. Le muscle mylohyoidien separe l’espace sublingual et l’espace submandibulaire. Le nerf x est visible et chemine le long de l’axe jugulocarotidien.

RI-WS-15 Ponction biopsie percutanee de tumeurs solides du pancreas : revue retrospective de 150 cas

Objectifs Evaluer l’efficacite et le taux de complication obtenue lors des biopsies percutanees des tumeurs solides du pancreas chez les patients presentant une suspicion de neoplasie non resecable. Materiels et methodes Etude monocentrique retrospective, de janvier 1999 a fevrier 2009, portant sur 150 cas de biopsies pancreatiques percutanees. Toutes les biopsies ont ete realisees sous anes-thesie locale, en utilisant des aiguilles automatiques ou semi automatiques, 18 ou 20G. Nous avons analyse les resultats anatomo-pathologiques, les comptes rendus radiologiques et les dossiers cliniques de chaque patient. Resultats Cinquante six biopsies ont ete effectues sous echographie et 94 sous fluoro-scanner. Le resultat anatomopathologique de malignite ou de benignite a ete obtenu avec une efficacite globale de 92 %. Aucun faux positif de cancer n’a ete retrouve. Une seule complication majeure (0,7 %) est survenue : hemoperitoine massif ayant necessite une embolisation en urgence. Conclusion Cette serie constitue la plus importante serie francophone proposee et confirme que la ponction biopsie percutanee des tumeurs solides du pancreas est un outil performant pour obtenir une preuve de malignite avec un taux de complication majeure quasi nul. De par sa simplicite et son efficacite, cette technique doit etre proposee en premiere intention pour obtenir l’histologie d’une tumeur pancreatique solide jugee non resecable.

Suivi en imagerie du CHC apres radiofrequence

Objectifs Connaitre les principes du traitement des tumeurs par radiofrequence. Connaitre les principales indications du traitement des CHC par radiofrequence. Decrire les aspects post-therapeutiques normaux en imagerie. Savoir reconnaitre les traitements incomplets, les reprises tumorales et les complications retardees. Messages a retenir Le traitement par radiofrequence consiste en une thermo-ablation tumorale. Ce traitement est pratique en premiere intention pour de nombreux patients porteurs de CHC. L’imagerie post-therapeutique consiste en une IRM, un scanner ou une echographie de contraste pratique 4 a 6 semaines apres la procedure puis tous les 3 a 6 mois. Les apsects post-therapeutiques normaux peuvent varier et des pieges d’interpretation existent. Resume Le traitement par radiofrequence est propose aux patients porteurs de CHCs peu evolues avec des resultats similaires a ceux obtenus avec les resections chirurgicales. Les reprises tumorales au site de thermo-ablation ainsi que les complications, bien que toutes deux rares, doivent etre reconnues. La zone de thermo-ablation obtenue est avasculaire de forme variable et est limitee pendant plusieurs heures ou jours par une couronne d’hyperhemie reactionnelle puis plus tardivement par du tissu de granulation. Ces phenomenes physiologiques peuvent constituer des pieges d’interpretation du site de thermo-ablation. D’autres pieges correspondent aux anomalies de la perfusion iatrogenes en rapport avec la creation de fistules arterio-veineuses ou de stenoses biliaires. Des complications retardees plus severes et pauci ou asymptomatiques peuvent etre decouvertes par l’imagerie de surveillance.

Faire et comprendre un scanner apres chirurgie du tube digestif

Objectifs Connaitre les principaux montages apres chirurgie non bariatrique de l’estomac, du grele, du colon et du rectum. Connaitre les indications de scanner apres ce type de chirurgie. Connaitre la technique de scanner a employer en fonction des indications. Connaitre les apects tomodensitometriques normaux. Savoir reconnaitre les complications post operatoires. Messages a retenir L’interpretation d’un scanner apres chirurgie du tube digestif doit se faire en connaissance du montage chirurgical realise. La complication la plus frequente est la fistule anastomotique. Certaines fistules peuvent rester asymptomatiques et regresser spontanement. Le scanner a une place centrale pour la prise en charge diagnostique, voire therapeutique, des complications non fonctionnelles. Resume La chirurgie du tube digestif est realisee en grande partie pour le traitement de cancers ou de maladies inflammatoires digesti-ves. De nombreux montages chirurgicaux sont disponibles ayant des caracteres communs et des particularites. En cas de suspicion de complication post-operatoire precoce ou retardee, un examen tomodensi-tometrique est le plus souvent realise. Ce type d’examen doit etre interprete en connaissance du type de montage chirurgical effectue. De nombreuses complications peuvent etre mise en evidence comme des fistules, abces, reprises tumorales, ou encore hernies. Certains abces peuvent etre draines dans le meme temps du diagnostic sous controle tomodensitometrique.