Koray Güven

Intrahepatic biliary cystic neoplasms: Surgical results of 9 patients and literature review

AIM To investigate the eligible management of the cystic neoplasms of the liver. METHODS The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution. RESULTS All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepatic biliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up. CONCLUSION In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.

CT and MR characteristics of hibernoma: six cases

PURPOSE The purpose of this study was to describe the computed tomography (CT) and magnetic resonance (MR) imaging findings of hibernoma. MATERIALS AND METHODS We retrospectively evaluated imaging findings of CT and MR examinations of six patients (three men and three woman, aged 27-48 years) with histopathological diagnosis of hibernoma. RESULTS On CT examination, the lesions were slightly hyperdense, and on T1- and T2-weighted MR images, they were isointense or slightly hypointense compared to the subcutaneous fat. All of these lesions showed contrast enhancement and one out of the six lesions had internal linear septations. CONCLUSION Hibernoma has a wide spectrum of CT and MR imaging findings, which should be considered in differential diagnosis, especially with other lipomatous lesions.

Cystic Echinococcal Liver Disease: New Insights into an Old Disease and an Algorithm for Therapy Planning

Human cystic echinococcosis (CE) continues to be a major health problem in developing countries. A review of current literature discloses four alternatives for the management of active CE, consisting of surgery, percutaneous treatment (PT), chemotherapy, and follow-up without intervention, but no clear guidelines for directing patients to the different management options. Palliation of symptoms or prevention of complications is the main rationale for the treatment of CE. Surgery has long been considered as the gold standard treatment. However, a meta-analysis comparing the clinical outcomes of patients treated with PT with those of a control group treated with surgery found PT to be more effective, safer, and cheaper. Medical therapy is considered to be ineffective when the criterion of success is defined as the disappearance of the lesion. However, medical therapy seems to be effective when the goal of therapy is defined as the prevention of complications in asymptomatic patients. We propose an algorithm for therapy planning in CE where the first line of therapy for patients with active lesions is PT. Patients with lesions unsuitable for PT are directed to surgery if they are symptomatic, have complicated lesions or have lesions that are prone to rupture. Asymptomatic patients with uncomplicated lesions are directed to medical therapy. Medical therapy failures are redirected to surgery.

Non-invasive detection of infection in acute pancreatic and acute necrotic collections with diffusion-weighted magnetic resonance imaging: preliminary findings

PurposeThe purpose of this study was to evaluate the contribution of diffusion-weighted magnetic resonance imaging (DW-MRI) to the detection of infection in acute pancreatitis-related collections.MethodsA total of 21 DW-MRI, and computed tomography (CT) were performed on 20 patients diagnosed as acute pancreatitis with acute peri-pancreatic fluid or necrotic collections. Collections were classified as infected or sterile according to the culture and follow-up results. Collections with gas bubbles on CT images were considered to be infected. Collections with peripheral bright signals on DW-MRI images were considered to be positive, whereas those without signals were considered to be negative. Apparent diffusion coefficient (ADC) values of the peripheral and central parts of the collections were measured. Student’s t test was used to compare the means of ADC values of independent groups.ResultsApart from one false positive result, the presence of infection was detected by DW-MRI with 95.2% accuracy. The sensitivity and accuracy of DW-MRI were higher than CT for the detection of infection. The ADC values in the central parts of the collections were significantly different between the infected and sterile groups.ConclusionDW-MRI can be used as a non-invasive technique for the detection of infection in acute pancreatitis-associated collections.

Endovascular treatment of a superior mesenteric artery aneurysm secondary to Behcet's disease with Onyx (ethylene vinyl alcohol copolymer).

Behcet’s disease is a complex multisystemic chronic inflammatory disease that is characterized by oral and genital aphtous ulcers and vasculitis. Aneurysms of major arteries are the most important cause of mortality in Behcet’s disease. Four patients with superior mesenteric artery (SMA) aneurysms related to Behcet’s disease have been reported in the literature. We report here the first successful endovascular treatment of a giant, wide-necked SMA aneurysm secondary to Behcet’s disease. We performed a balloon-assisted embolization technique using ethylene vinyl alcohol copolymer (Onyx, ev3, Irvine, CA, USA). There were no signs of recurrence during 2-year follow-up.

Spontaneous thrombosis of uterine artery pseudoaneurysm: Follow‐up with doppler ultrasonography and interventional management

Iatrogenic uterine arterial injury is one of the possible causes of pseudoaneurysm formation occurring during pelvic or obstetrical surgery. Cesarean delivery is the commonest cause. Repeat vaginal bleeding is the most frequent symptom, but fever and lower abdominal pain have also been reported. Doppler sonography (US) has been used to detect a pelvic pseudoaneurysm. Transcatheter arterial embolization of the uterine artery is a highly effective, relatively minimally invasive method for treating such condition. A 21-year-old primigravida was admitted to our hospital with a history of repeated vaginal bleeding following a Cesarean section that she underwent 2 months earlier. Transvaginal color Doppler US (TV-CDUS) examination showed a 14 mm 12 mm pseudoaneurysm arising from the left uterine artery at the isthmic level. The pseudoaneurysm was located in the myometrium and had a thin, peripheral rim-like thrombosis (Figure 1). Catheter angiography performed 2 days later did not reveal filling of the pseudoaneurysm, and there was no extravasation of contrast. TV-CDUS immediately after angiography revealed a spontaneous total thrombosis of the pseudoaneurysm (Figure 2). The patient was clinically stable and vaginal bleeding had ceased for 36 hours. Because most of the pseudoaneurysm had thrombosed spontaneously and there was no angiographic finding, conservative management was recommended. On follow-up TV-CDUS 2 days later, a complete thrombosis of the pseudoaneurysm was observed but, 1 day later, the patient was readmitted with vaginal bleeding. Taking into account a possible hemorrhage from the other probably injured uterine artery (which could be occult on angiography and could also be due to rebleeding of the thrombosed pseudoaneurysm), transarterial embolization of both uterine arteries with gelfoam was undertaken. The patient has not suffered from any vaginal bleeding after the embolization. A pseudoaneurysm of the uterine artery is a rare complication of pelvic surgery but may result in life-threatening complications such as massive vaginal hemorrhage. In general, pseudoaneurysms are thrombosed in a centripetal manner (from the periphery to the center) like in our case. CDUS can elegantly demonstrate the sequence of steps leading to the complete thrombosis of the pseudoaneurysm. In some circumstances, a pseudoaneurysm cannot be demonstrated on angiography. Transarterial embolization of the uterine arteries is a safe and effective means of controlling secondary postpartum hemorrhage. In our case, according to TV-CDUS findings, the pseudoaneurysm completely thrombosed in a short period of time, and angiography was negative. We could not exclude hemorrhage from the contralateral uterine artery (which may have been injured during previous surgery), so bilateral uterine arteries were embolized. In conclusion, a spontaneous thrombosis of a uterine artery pseudoaneurysm can occur. TVCDUS provides sufficient information to detect and follow-up the progress of the thrombosis.

Atypical lung involvement in a patient with systemic juvenile xanthogranuloma

Juvenile xanthogranuloma (JXG) is a non-Langerhans cell histiocytosis characterized by xanthoma-like cutaneous lesions. It is a benign condition that is generally asymptomatic. Visceral involvement is uncommon, but when present may occur in various locations and in different combinations. Pulmonary involvement has been reported as bilateral, multiple micro- or macronodular lesions. We present a 10-year-old boy with systemic (skin, lung, liver and kidney) JXG who showed lung involvement with mainly an interstitial pattern. Bilateral multiple micronodules in both lungs and mediastinal adenopathy were also present.

Pushable springcoil embolization of pseudoaneurysms caused by gluteal stab injuries.

PURPOSE To retrospectively review the outcomes of 21 patients with stab wounds to the gluteal region who underwent embolization for pseudoaneurysms causing active bleeding. MATERIALS AND METHODS Between 1997 and 2007, 3 superior gluteal artery, 2 inferior gluteal artery and 16 deep femoral artery muscular branch pseudoaneurysms detected by digital subtraction angiography were selectively catheterized with diagnostic catheters with hydrophilic coating and embolized with pushable springcoils. 17 of the 21 pseudoaneurysms were located in a distal end of an artery where outflow vessels could not be depicted. The other 4 lesions were side wall injuries which required the placement of coils distal and proximal to the injury site. RESULTS Embolization was successful in controlling the bleeding in all of the patients. 16 patients required 1 or 2 coils, 4 patients required 3 coils and 1 patient required 5 coils. 2 patients had femoral puncture site hematomas which resolved spontaneously. 2 patients required surgical evacuation of large gluteal hematomas following the embolization because of symptoms second to mass effect. There were no procedure related major complications or mortality. CONCLUSIONS Our experience demonstrates that pushable coil embolization is a relatively simple, effective and economic method for the embolization of pseudoaneurysms caused by penetrating gluteal injuries. Experimenting with other embolization materials does not seem to be justified.

Multiple aortic pseudoaneurysms in a patient with Behçet's disease.

Vascular involvement in Behçet’s disease is rare but may be at the forefront of the clinical picture with possible life-threatening scenarios. Aneurysms in Behçet’s disease are prone to progress to pseudoaneurysms. The reported incidence of vascular complications in Behçet’s disease is variable, ranging from 3.6% to 24%, with large-vessel involvement in 1.3% to 2.2% of all patients. These aneurysms are significantly associated with poor outcome. Pseudoaneurysms are usually single. Our patient was found to have multiple pseudoaneurysms. A 30-year-old woman with Behçet’s disease and multiple spontaneous aortic pseudoaneurysms of varying sizes (A and B) is observed by our institution’s rheumatology and cardiovascular surgery clinics. She was initially diagnosed with the classic skin and eye manifestations, leading to incidental diagnosis of the aortic lesions by a nonspecific back pain that prompted a computed tomography scan. Orientation of the lesions with varying sizes is suitable for an endovascular intervention. She is currently under immunosuppressive therapy and close follow-up.

The influence of secondary reconstruction slice thickness on NewTom 3G cone beam computed tomography–based radiological interpretation of sheep mandibular condyle fractures

OBJECTIVE The objective of this study was to examine the diagnostic accuracy of the different secondary reconstruction slice thicknesses of cone beam computed tomography (CBCT) on artificially created mandibular condyle fractures. METHODS A total of 63 sheep heads with or without condylar fractures were scanned with a NewTom 3G CBCT scanner. Multiplanar reformatted (MPR) views in 0.2-mm, 1-mm, 2-mm, and 3-mm secondary reconstruction slice thicknesses were evaluated by 7 observers. Inter- and intraobserver agreements were calculated with weighted kappa statistics. The receiver operating characteristic (ROC) curve analysis was used to statistically compare the area under the curve (AUC) of each slice thickness. RESULTS The kappa coefficients varied from fair and to excellent. The AUCs of 0.2-mm and 1-mm slice thicknesses were found to be significantly higher than those of 2 mm and 3 mm for some type of fractures. CONCLUSION CBCT was found to be accurate in detecting all variants of fractures at 0.2 mm and 1 mm. However, 2-mm and 3-mm slices were not suitable to detect fissure, complete, and comminuted types of mandibular condyle fractures.