Mourad Boudiaf

Can failure of percutaneous drainage of postoperative abdominal abscesses be predicted

BACKGROUND Percutaneous drainage (PD) of complex postoperative abscesses associated with a variety of factors such as multiple location or enteric fistula remains a matter of debate. Accordingly, this retrospective study was designed to determine the predictive factors for failure of PD of postoperative abscess, in order to better select the patients who may benefit from PD. METHODS From 1992 to 2000, the data of 73 patients who underwent computed tomography (CT)-guided PD for postoperative intra-abdominal abscess, were reviewed. PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. The possible association between failure of PD and 27 patient-, abscess-, surgical-, and drainage-related variables were assessed using univariate and multivariate analysis. RESULTS Successful PD was achieved in 59 of 73 (81%) patients. The overall mortality was 3% but no patient died after salvage surgery. Multivariate analysis showed that only an abscess diameter of less than 5 cm (P = 0.042) and absence of antibiotic therapy (P = 0.01) were significant predictive variables for failure of PD. CONCLUSIONS CT-guided PD associated with antibiotic therapy could be attempted as the initial treatment of postoperative abdominal abscesses even in complex cases such as loculated abscess or abscess associated with enteric fistula.

Carcinoid tumors of the abdomen: CT features

Carcinoid tumors are rare neuroendocrine neoplasms that belong to a more general category of tumor called the APUDomas. Ninety percent of carcinoid tumors are located in the gastrointestinal tract. Abdominal carcinoid tumors are categorized according to the division of the primitive gut from which they arise. Carcinoid tumors originating from the foregut develop in the gastric wall, duodenum, and pancreas; those originating from the midgut develop from the small bowel, appendix, and right colon; and those originating from the hindgut develop from the transverse or left colon or from the rectum. This report illustrates the computed tomographic appearance of primary and metastatic carcinoid tumors of the abdomen. Among the different organs that may be involved by metastases from carcinoid tumor, special emphasis is placed on the liver.

Preoperative detection of hepatic metastases: Comparison of diffusion-weighted, T2-weighted fast spin echo and gadolinium-enhanced MR imaging using surgical and histopathologic findings as standard of reference

PURPOSE The purpose of this study was to retrospectively compare the respective sensitivities of diffusion-weighted (DW), T2-weighted fast spin-echo (T2WFSE) and gadolinium chelate-enhanced MR imaging in the preoperative detection of hepatic metastases using intraoperative ultrasonographic and histopathologic findings as the standard of reference. MATERIALS AND METHODS Twenty-seven patients with 64 surgically and histopathologically proven hepatic metastases had MR imaging of the liver, including DW, T2WFSE and dynamic gadolinium chelate-enhanced MR imaging. Images from each MR sequence were separately analyzed by two readers with disagreements resolved by consensus readings. The findings on MR images were compared with intraoperative ultrasonographic and histopathologic findings on a lesion-by-lesion basis to determine the sensitivity of each MR sequence. Statistical review of the lesion-by-lesion analysis was performed with the McNemar test. RESULTS DW, T2WFSE and gadolinium chelate-enhanced MR imaging allowed the depiction of 54/64 (84.4%; 95% CI: 73.1-92.2%), 44/64 (68.8%; 95% CI: 55.9-79.8%), and 51/64 (79.7%; 95% CI: 67.8-88.7%) hepatic metastases respectively. DW MR images allowed depiction of significantly more hepatic metastases than did T2WFSE and was equivalent to gadolinium chelate-enhanced MR imaging (P=.002 and P=.375, respectively). CONCLUSION DW MR imaging is superior to T2WFSE imaging and equivalent to gadolinium chelate-enhanced MR imaging for the preoperative detection of hepatic metastases. Further studies however are needed to determine at what extent DW MR imaging can be used as an alternative to gadolinium chelate-enhanced MR imaging for the preoperative depiction of hepatic metastases.

Obscure gastrointestinal bleeding: preliminary comparison of 64-section CT enteroclysis with video capsule endoscopy

ObjectiveTo retrospectively compare the diagnostic capabilities of 64-section CT enteroclysis with those of video capsule endoscopy (VCE) to elucidate the cause of obscure gastrointestinal bleeding.MethodsThirty-two patients who had 64-section CT enteroclysis and VCE because of obscure gastrointestinal bleeding were included. Imaging findings were compared with those obtained at double balloon endoscopy, surgery and histopathological analysis, which were used as a standard of reference.ResultsConcordant findings were found in 22 patients (22/32; 69%), including normal findings (n = 13), tumours (n = 7), lymphangiectasia (n = 1) and inflammation (n = 1), and discrepancies in 10 patients (10/32; 31%), including ulcers (n = 3), angioectasias (n = 2), tumours (n = 2) and normal findings (n = 3). No statistical difference in the proportions of abnormal findings between 64-section CT enteroclysis (11/32; 34%) and VCE (17/32, 53%) (P = 0.207) was found. However, 64-section CT enteroclysis helped identify tumours not detected at VCE (n = 2) and definitely excluded suspected tumours (n = 3) because of bulges at VCE. Conversely, VCE showed ulcers (n = 3) and angioectasias (n = 2) which were not visible at 64-section CT enteroclysis.ConclusionOur results suggest that 64-section CT enteroclysis and VCE have similar overall diagnostic yields in patients with obscure gastrointestinal bleeding. However, the two techniques are complementary in this specific population.

Suspected Anastomotic Recurrence of Crohn Disease after Ileocolic Resection: Evaluation with CT Enteroclysis

PURPOSE To determine the utility of computed tomographic (CT) enteroclysis for characterization of the status of the anastomotic site in patients with Crohn disease who had previously undergone ileocolic resection. MATERIALS AND METHODS Written informed consent was prospectively obtained from all patients, and the institutional review board approved the study protocol. CT enteroclysis findings in 40 patients with Crohn disease who had previously undergone ileocolic resection were evaluated independently by two readers. Endoscopic findings, histopathologic findings, and/or the Crohn disease activity index was the reference standard. Interobserver agreement between the two readers was calculated with kappa statistics. Associations between CT enteroclysis findings and anastomotic site status were assessed at univariate analysis. The sensitivity, specificity, and accuracy of CT enteroclysis, with corresponding 95% confidence intervals (CIs), for the diagnosis of normal versus abnormal anastomosis and the diagnosis of anastomotic recurrence versus fibrostenosis were estimated. RESULTS Interobserver agreement regarding CT enteroclysis criteria was good to perfect (kappa = 0.72-1.00). At univariate analysis, stratification and anastomotic wall thickening were the two most discriminating variables in the differentiation between normal and abnormal anastomoses (P < .001). Stratification (P < .001) and the comb sign (P = .026) were the two most discriminating variables in the differentiation between anastomotic recurrence and fibrostenosis. In the diagnosis of anastomotic recurrence, severe anastomotic stenosis was the most sensitive finding (95% [20 of 21 patients]; 95% CI: 76.18%, 99.88%), both comb sign and stratification had 95% specificity (18 of 19 patients; 95% CI: 73.97%, 99.87%), and stratification was the most accurate finding (92% [37 of 40 patients]; 95% CI: 79.61%, 98.43%). In the diagnosis of fibrostenosis, both severe anastomotic stenosis and anastomotic wall thickening were 100% sensitive (eight of eight patients; 95% CI: 63.06%, 100.00%), and using an association among five categorical variables, including severe anastomotic stenosis, anastomotic wall thickening with normal or mild mucosal enhancement, absence of comb sign, and absence of fistula, yielded 88% sensitivity (seven of eight patients; 95% CI: 47.35%, 99.68%), 97% specificity (31 of 32 patients; 95% CI: 83.78%, 99.92%), and 95% accuracy (38 of 40 patients; 95% CI: 83.08%, 99.39%). CONCLUSION CT enteroclysis yields objective and relatively specific morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site after ileocolic resection for Crohn disease. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091165/-/DC1.

Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization

The purpose of this retrospective study was to evaluate the role of transcatheter arterial embolization in the management of severe postpartum haemorrhage due to a ruptured pseudoaneurysm and to analyse the clinical symptoms that may suggest a pseudoaneurysm as a cause of postpartum haemorrhage. A retrospective search of our database disclosed seven women with severe postpartum haemorrhage in whom angiography revealed the presence of a uterine or vaginal artery pseudoaneurysm and who were treated using transcatheter arterial embolization. Clinical files were reviewed for possible clinical findings that could suggest pseudoaneurysm as a cause of bleeding. Angiography revealed extravasation of contrast material in five out of seven patients. Transcatheter arterial embolization allowed to control the bleeding in all patients and subsequently achieve vaginal suture in four patients with vaginal laceration. No complications related to transcatheter arterial embolization were noted. Only two patients had uterine atony, and inefficiency of sulprostone was observed in all patients. Transcatheter arterial embolization is an effective and secure technique for the treatment of severe postpartum haemorrhage due to uterine or vaginal artery pseudoaneurysm. Ineffectiveness of suprostone and absence of uterine atony should raise the possibility of a ruptured pseudoaneurysm.

Value of pelvic embolization in the management of severe postpartum hemorrhage due to placenta accreta, increta or percreta.

OBJECTIVES To evaluate the role, efficacy and safety of pelvic embolization in the management of severe postpartum hemorrhage in women with placenta accreta, increta or percreta. METHODS The clinical files and angiographic examinations of 12 consecutive women with placenta accreta (n=4), increta (n=2) or percreta (n=6) who were treated with pelvic embolization because of severe primary (n=10) or secondary (n=2) postpartum hemorrhage were reviewed. Before embolization, four women had complete placental conservation, four had partial placental conservation, three had an extirpative approach and one had hysterectomy after failed partial conservative approach. RESULTS In 10 women, pelvic embolization was successful and stopped the bleeding, after one (n=7) or two sessions (n=3). Emergency hysterectomy was needed in two women with persistent bleeding after embolization, both with placenta percreta and bladder involvement first treated by extirpation. One case of regressive hematoma at the puncture site was the single complication of embolization. CONCLUSIONS In women with severe postpartum hemorrhage due to placenta accreta, increta or percreta, pelvic embolization is effective for stopping the bleeding in most cases, thus allowing uterine conservation and future fertility. Further studies, however, should be done to evaluate the potential of pelvic embolization in women with placenta percreta with bladder involvement.

Serial computed tomography is rarely necessary in patients with acute pancreatitis : A prospective study in 102 patients

BACKGROUND CT has proved to be helpful in patients with acute pancreatitis for differentiating between mild and severe forms. Followup of acute pancreatitis with CT has been advocated but rarely studied. The aim of this study was to determine if late CT performed at day 7 might be helpful in establishing the prognosis or the type of complications, and to select a subgroup of patients in whom CT could be beneficial. STUDY DESIGN Contrast-enhanced CT was performed at the admission day and 7 days after admission in 102 patients admitted for acute pancreatitis. The extent of pancreatic inflammation was classified according to Balthazar grade, and intrapancreatic necrosis on these examinations was prospectively assessed and compared with clinical and biologic data and with patient outcomes. RESULTS Among 102 patients, complications developed in 24 (23%). Complications developed in only 8% of patients with Ranson score <2, making routine early CT unnecessary. For the patients with Ranson score <2 and Balthazar grades A and B at day 1 CT, late CT seemed to be useless. Complication was suspected by clinical and biologic tests before day 7 in 22 of 24 complicated patients (92%), suggesting that CT could be proposed only in cases of clinical or biologic deterioration. Late CT was correlated with a complicated course in patients with Balthazar grades D and E or intrapancreatic necrosis >50%. Late CT was predictive of complications in cases of intrapancreatic necrosis enlarging since the first examination. CONCLUSIONS Our study showed that in acute pancreatitis: 1) there is little justification for systematic early CT, especially in patients with Ranson score <2, and 2) late CT does not need to be performed routinely, but only in cases of clinical or biologic worsening.

Imaging of malignant neoplasms of the mesenteric small bowel: New trends and perspectives

This article describes the recent advances in radiological imaging of malignant neoplasms of the mesenteric small bowel and provides an outline of new trends and perspectives that can be anticipated. The introduction of multidetector row technology, which allows the acquisition of submillimeter and isotropic voxels, has dramatically improved the capabilities of computed tomography in the investigation of the mesenteric small bowel. This technology combined with optimal filling of small bowel loops through the use of appropriate enteral contrast agents has markedly changed small bowel imaging. Computed tomography-enteroclysis, which is based on direct infusion of enteral contrast agent into the mesenteric small bowel through a naso-jejunal tube, provides optimal luminal distension. By contrast, computed tomography-enterography is based on oral administration of enteral contrast agent. These two techniques are now well-established ones for the detection and the characterization of small bowel neoplasms. During the same time, combining the advantages of unsurpassed soft tissue contrast and lack of ionizing radiation, magnetic resonance imaging has gained wide acceptance for the evaluation of patients with suspected small bowel neoplasms. Rapid magnetic resonance imaging sequences used in combination with specific enteral contrast agents generate superb images of the mesenteric small bowel so that magnetic resonance-enteroclysis and magnetic resonance-enterography are now considered as effective diagnostic tools for both the detection and the characterization of neoplasms of the mesenteric small bowel. Recent improvements in image post-processing capabilities help obtain realistic three-dimensional representations of tumors and virtual enteroscopic views of the small bowel that are useful for the surgeon and the gastroenteroenteologist to plan surgical or endoscopic interventions. Along with a better knowledge of the potential and limitations of wireless capsule endoscopy and new endoscopic techniques, these recent developments in radiological imaging reasonably suggest that substantial changes in the investigation of small bowel tumors may be anticipated in a near future, thus potentially create a new paradigm shift after standard small bowel follow-through study has been universally abandoned.

Hepatic involvement in hereditary hemorrhagic telangiectasia: Helical computed tomography features in 24 consecutive patients

Objective: Among the various organs that may be affected by hereditary hemorrhagic telangiectasia (HHT), the liver can show various degrees of vascular and parenchymal involvement. The purpose of this prospective study comprising a large series of patients was to reassess the computed tomography (CT) features of hepatic involvement in HHT using helical CT. Methods: Twenty-four consecutive patients with HHT had prospective helical CT of the liver, including noncontrast, arterial-dominant, and portal-dominant phases. The CT images were analyzed by 2 readers in consensus to determine the presence of vascular and parenchymal abnormalities. The diameter of the proper hepatic artery in these 24 patients was compared with that in 24 healthy subjects (Student t test). Results: Helical CT was normal in 5 patients (21%) and abnormal in 19 patients (79%). Vascular abnormalities were found in 16 patients (67%), consisting of marked dilatation of the hepatic artery (n = 16), intrahepatic telangiectases (n = 12), arteriovenous shunting (n = 5), and arterioportal shunting (n=3). The diameter of the proper hepatic artery was greater in the patients with HHT than in control subjects (6.12 ± 2.52 mm vs. 3.29 ± 0.65 mm, respectively; P < 0.05). Helical CT showed nodular hyperplasia in 1 patient with vascular and parenchymal abnormalities, cavernous hemangiomas in 2 patients (1 in a patient with an enlarged hepatic artery, intrahepatic telangiectases, and arteriovenous shunting and 1 in a patient with an isolated enlarged hepatic artery), and biliary cysts in 3 patients (2 biliary cysts were present in 2 patients with an enlarged hepatic artery and intrahepatic telangiectases, and 1 biliary cyst was present without any manifestations in the third patient). Conclusions: Liver involvement in HHT is associated with a constellation of findings on helical CT, including significant dilatation of the proper hepatic artery, telangiectases, arteriovenous shunting, and focal liver lesions. Familiarity with these findings will result in more accurate diagnosis and allows better therapeutic options if necessary.