James E. Huprich

Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate

BACKGROUND Recent studies based on symptomatic outcomes analyses have shown that laparoscopic repair of large type III hiatal hernias is safe, successful, and equivalent to open repair. These outcomes analyses were based on a relatively short followup period and lack objective confirmation that the hernia has not recurred. The aim of this study was to compare the outcomes of laparoscopic and open repair of large type III hiatal hernia using both symptomatic evaluation and barium study to assess the integrity of the repair. STUDY DESIGN Fifty-four patients underwent repair of a large type III hiatal hernia between 1985 and 1998. The surgical approach was laparotomy in 13, thoracotomy in 14, and laparoscopy in 27. An antireflux procedure was included in all patients. Symptomatic outcomes were assessed using a structured questionnaire at a median of 24 months and was complete in 51 of 54 patients (94%). A single radiologist, without knowledge of the operative procedure, assessed the integrity of the repair using video esophagram. Videos were performed at a median of 27 months (35 months open and 17 laparoscopic) and were completed in 41 of 54 patients (75%). RESULTS Symptomatic outcomes were similar in both groups with excellent or good outcomes in 76% of the patients after laparoscopic repair and 88% after an open repair. Reherniation was present in 12 patients and was asymptomatic in 7. A recurrent hernia was present in 12 of the 41 patients (29%) who returned for a followup video esophagram. Forty-two percent (9 of 21) of the laparoscopic group had a recurrent hernia compared with 15% (3 of 20) of the open group (p < 0.001 log-rank value on recurrence-free followup). CONCLUSIONS Laparoscopic repair of type III hiatal hernias is associated with a disturbingly high (42%) prevalence of recurrent hernia. More than half such recurrences have few, if any, symptoms.

Dual-Energy and Dual-Source CT: Is There a Role in the Abdomen and Pelvis?

Dual-energy CT refers to the use of CT data representing two different energy spectra and allows for the possibility of differentiating and classifying tissue to obtain material-specific images. Dual-energy CT data can be acquired using various CT hardware platforms, with numerous approaches also existing for display of anatomic and material-specific dual-energy information. Dual-source CT refers to the use of two x-ray sources and two x-ray detectors mounted on a single CT gantry and can be used in either a dual-energy or single-energy mode. This article summarizes and reviews current and potential applications for dual-energy and dual-source CT in the abdomen and pelvis.

Computed tomography of posterior fossa trauma.

Abstract A group of 1,700 cases of head trauma were reviewed to determine the incidence of posterior fossa injuries and to assess the value of computed tomography (CT) in their diagnosis and management. In 57 cases (3.3%), the most significant and primary injuries were within the posterior fossa. These included epidural hematoma (EDH), acute and chronic subdural hematoma (SDH), and parenchymal hemorrhage and contusion of the cerebellum and brainstem. The prognosis varies with the location and severity of the injury. Brainstem injuries are associated with a high mortality rate. Computed tomography proves particularly useful in the early recognition of brainstem injury. The demonstration by CT of obliteration of the cisterns surrounding the brainstem is a reliable sign of a grave prognosis in brainstem injury. Contrast enhancement is useful in demonstrating whether the dural sinuses are displaced, thus differentiating EDH from SDH. Except in the rare case of vascular injury unassociated with EDH, CT correlated with the neurological examination is an accurate method of determining the nature, location, and extent of significant posterior fossa injury. Scans of high quality are mandatory, and frequent supplementary contrast studies are recommended.

Diagnostic and prognostic implications of computed tomography of head trauma.

A total of 210 cases of head trauma were examined using noncontrast enhanced and contrast enhanced computed tomography scans. Evidence of contrast enhancement was seen in 97 cases (46%). Subdural hematoma and focal contusion were the most frequent entities demonstrating contrast enhancement. This finding was also frequently seen in patients with intraventricular hemorrhage (IVH) (5 of 17). Every one of the five patients in this series with IVH whose scans showed enhancement died, whereas out of the 12 whose scans showed no enhancement, five survived. Illustrative cases are presented. The authors feel that contrast enhanced scans are valuable in the evaluation of the full extent of head trauma.

Esophageal Disease and Testing

Esophageal disease and testing / , Esophageal disease and testing / , کتابخانه دیجیتال جندی شاپور اهواز

Tu1216 Retained Capsule Endoscopy in a Large Tertiary Care Academic Practice

Background/Aims: Capsule retention is a recognized complication of capsule endoscopy (CE) with reported rates between 1% and 13%. The objectives of this study were to determine the incidence, risk factors associated with, and clinical outcomes of capsule retention, and to define any cross-sectional imaging findings predictive of capsule retention. Methods: A retrospective review of all CE exams performed at our center from January 2002 to January 2013 was undertaken. Data on patient demographics, clinical history, CE indication and findings, and details of patient management, including capsule retrieval procedure, were abstracted from the medical records and analyzed. Radiologic images performed 6 months prior to CE were reviewed by experienced gastrointestinal radiologists. A control cohort of patients who had high risk features for capsule retention on cross-sectional imaging and passed the capsule was analyzed and compared to cases of CE retention. Results: A total of 5593 CEs were performed in the study period. Seventeen CE retentions (0.3%) occurred in 15 patients. The control cohort had 13 patients who passed the capsule, but had imaging features concerning for potential CE retention. Nine patients with CE retention were female (60%), with a median age of 54 years (range 37-80 years), and 5 patients had Crohns disease (33%). Obscure gastrointestinal bleeding (OGIB) (47%) was the most common indication in the CE retention group (Table 1). Outcomes of retained capsule included: passing of capsule after treatment of intestinal inflammation (n=3), surgical intervention (n= 9), endoscopic retrieval (n=2), spontaneous passage after conservative measures for small bowel obstruction (SBO) (n=1), unsuccessful endoscopic retrieval followed by surgery (n= 1) and loss to follow-up (n=1). Culprit lesions included small bowel inflammation (n=5), anastomotic strictures (n=4), and small bowel adenocarcinoma (n=1). A total of 10 patients with CE retention had cross-sectional imaging within 6 months. On retrospective review, patients with CE retention were more likely to have small bowel (SB) anastomoses (88% vs. 23%) than patients with high-risk features for capsule retention who passed the capsule (Table 2). Conclusion: In a diverse tertiary care population, capsule retention occurred in 0.3% of cases. This rate is low compared to previous cohorts, attesting to careful patient selection. Patients with CE retention were more likely to have SB anastomoses and strictures compared to patients who passed the capsule. Table 1: Baseline characteristics of patients with retained capsules and a control group with radiographic features worrisome for increased risk of capsule retention but who passed a capsule

Pilot Study of Radiological Assessment of Short-Term Corticosteroid Therapy on Esophageal Distensibility in Eosinophilic Esophagitis (EoE)

Background: Esophageal foreign body impaction (EFBI) is a major presentation of eosinophilic esophagitis (EoE), but the impact of the increasing prevalence of EoE on the epidemiology of EFBI is not known. Aim: To determine whether the number of EFBI cases has increased with the increasing prevalence of EoE, and to assess characteristics of patients presenting with EFBI. Methods: Cases of EFBI from 2002 to 2009 were identified by querying the University of North Carolina Hospitals billing database (2005-2009), clinical database (2006-2009), and endoscopy database (2002-2009) for all records with ICD-9 code “935.1foreign body in the esophagus.” Charts were reviewed to confirm EFBI and to extract all pertinent data. Cases of EoE were defined per 2007 consensus guidelines and cross-referenced with our EoE database. Results: Of the 479 cases of EFBI identified (59% male, 67% Caucasian, mean age 35 ± 30 yrs), 289 (60%) were food impactions, 107 (22%) were coin impactions, and 83 (17%) were other objects (ex: golf tee, tooth, staple) or not specified. Overall, 45 EFBI patients (9%) had EoE, 39 of whom were diagnosed after the EFBI episode. The number of EGDs performed for food impaction nearly quadrupled between 2002 and 2009, however increasing diagnosis of EoE did not fully account for this trend (see figure). Only 97 (32%) of the 303 patients undergoing EGD had esophageal biopsies, and 31 (32%) of those patients biopsied had EoE (19 children, 12 adults). The type of impacted item (food vs. other) was associated with obtaining esophageal biopsies during the EGD (35% vs. 20%, p=0.012), but the proportion of cases with biopsies did not change over time. More subjects with food impaction had EoE compared to those with other types of EFBI (12% vs. 4%; p=0.003); only one patient with a coin impaction had EoE. On multivariate logistic regression analysis, the presence of EoE was themost significant predictor of recurrent EFBI (OR 3.6, 95%CI: 1.7-7.6). Conclusions: The number of EGDs performed for EFBI has increased dramatically at our center, and the increasing prevalence of EoE in this patient population only partially explains this trend. However, because only a minority of patients had biopsies at the time of EFBI, the incidence of EoE in this population is likely substantially underestimated. Physician education regarding the high prevalence of EoE in subjects with food impaction may increase the proportion of subjects biopsied and the number of EoE diagnoses made in this patient population.