Surgical Treatment of Esophageal Perforation Caused by Balloon Catheter and Expandible Metal Stent in a Benign Distal Esophageal Stricture

An esophageal perforation is a condition requiring emergency treatment. Although previously spontaneous ruptures were the most common etiology, as endoscopic and radiologic diagnosis and treatment have developed recently, iatrogenic ruptures due to instrumentation have increased to become the most common cause of esophageal perforations. Generally, the treatment of esophageal stenosis is composed of esophageal dilatation using a Maloney or a Mercury dilator and medical treatment for reflux esophagitis. Recently, balloon-catheter dilatation of the esophagus has produced safe and excellent results, and self-expansible metallic stents has been very useful in controlling malignant strictures of the esophagus with low mortality and morbidity. We experienced an esophageal perforation after balloon dilatation and the insertion of a self-expanding silicone-covered Gianturco stent to the site of the esophageal stenosis which was due to reflux esophagitis. The abdomen was opened through an upper midline incision. There was a 3-cm-long longitudinal laceration on the distal esophagus which was closed transversely as with a Heinecke-Mikulicz pyloroplasty after a debridement. To reinforce the site of esophageal laceration and to prevent esophageal reflux, the gastric fundus was pulled and sutured over the esophageal sutures, and the second-layer mattress suture was made 1 cm proximal to the first sutures, including central ligaments of the diaphragm. To prevent bile reflux, we converted from a Billroth-II to a Roux- en-Y gastrojejunostomy. We followed up for 30 months and found no signs of any esophageal stenosis or gastroesophageal reflux.

Comparison of Single-Shot Fast Spin-Echo Sequence and T2-Weighted Fast Spin-Echo Sequence in MR Imaging of the Brain

PURPOSE: The purpose of this study was to evaluate the usefulness of the single-shot fast spin-echo (SS-FSE)sequence in comparison with the T2-weighted fast spin-echo (T2-FSE) sequence in brain MR imaging. MATERIALS AND METHODS: In 41 patients aged 15-75 years with intracranial lesion, both SS-FSE and T2-FSE images were obtainedusing a 1.5-T MR system. Lesions included cerebral ischemia or infarcts (n=23), tumors (n=10), hemorrhages (n=3),inflammatory diseases (n=2), arachnoid cysts (n=2), and vascular disease (n=1), and the MR images wereretrospectively evaluated. To calculate contrast-to-noise ratio (CNR), percentage contrast, and signal-to-noiseratio (SNR)-and thus make a quantitative comparison-the mean signal intensities of lesions, normal brain tissue,and noise outside the patient were measured. For qualitative comparison, the visbility, margin, and extent of thelesions were rated using a five-grade system, and the degree of MR artifacts was also evaluated. Wilcoxon's signedranks test was used for statistical analysis. RESULTS: The mean CNR of lesions was significantly higher on SS-FSE(31.3) than on T2-FSE images (27.5) (p= 0.0131). Mean percentage contrast was also higher on SS-FSE (159.0) thanon T2-FSE images (108.5) (p=0.0222), but mean SNR was higher on T2-FSE (80.3) than on SS-FSE images (53.5)(p=0.0000). No significant differences in lesion visibility were observed between the two imaging sequences,though margin and extent of the lesion were worse on SS-FSE images. For MR artifacts, no significant differenceswere demonstrated. CONCLUSION: For the evaluation of most intracranial lesions, MR imaging using the SS-FSEsequence appears to be slightly inferior to the T2-FSE sequence, but may be useful where patients are ill oruncooperative, or where children require sedation.

MR Imaging of Intracranial Calcification; Experimental and Clinical Studies

PURPOSE: This study was performed to evaluate MR signal intensity(SI) of calcification and to assess the capability of MRI in detection of various intracranial calcifications. MATERIALS AND METHODS: The MR findings and ROI value of experimental model of calcium carbonate suspension according to each concentration (20, 35, 50%) and diameter (1-10 mm) and hydroxyapatite suspension according to each concentration (10, 20, 30, 40, 50%) were analyzed. A specimen of calcification in cranio-pharyngioma was analyzed for its composition by XRD(X-ray diffractometer) and ICP(inductively coupled plasma) methods. MRI of 34 patients with intracranial calcifications were retrospectively analyzed for signal intensity of the calcification and its capability to detect calcifications according to size, location, and contrast with adjacent lesion. RESULTS: The calcium carbonate phantom with larger diameter and low concentration showed lower signal intensity on T2 than TlWl. Hydroxyapatite phantom showed high signal intensity in 10-30% concentration and low signal intensity in 40-50% concentration on T1 weighted image. The 5 cases of 34 intracranial calcifications showed high signal intensity on T1 weighted image. The capability of MRI in the detection of intracranial calcifications decreased in the circumstances such as small size(<2.5mm) and intraventricular location. Although the size of calcification was small, the detection was easy in the good contrast with adjacent lesion. However, the detection of the small sized calcification was easy if the contrast with adjacent lesion was good. CONCLUSION: lntracranial calcification shows generally low signal intensity on T1 and T2 weighted image with the exception of occasional high SI on TlWl. Detection of intracranial calcification in MRI is affected by its composition, size, location, and contrast with adjcent lesion.

Utility of Multiplanar Reformation Images of Helical CT in the Evaluation of Pancreatic Diseases

PURPOSE: The purpose of this study is to assess the clinical utility of multiplanar reformation images of helical CT in the evaluation of pancreatic diseases. MATERIALS AND METHODS: Helical CT scans of the pancreas were obtained in 30 patients with pancreatic diseases. Helical CT was performed with 5mm collimation at 5mm/sec table speed during rapid injection of intravenous contrast agent using power injector. After scanning, helical volume data were reconstructed at 2mm interval and then multiplanar reformation of the pancreas and adjacent structures was done. In both prospective reconstructed axial images and multiplanar reformation images, detection of pancreatic lesion, extent of lesion, and vascular and bile ductal changes were analyzed with a grading system of 1,2, 3. RESULTS: The mean grade of detection of pancreatic lesions was 2.37 in the prospective axial image and 2.83 in multiplanar reformation image, extent of diseases was 2.40 in prospective axial image and 2.97 in multiplanar reformation image, and vascular and bile ductal changes was 2.00 in the prospective axial image and 2.97 in multiplanar reformation image. All the differences were statistically significant (P<0.0001). CONCLUSION: Multiplanar reformation images of helical CT are useful in the evaluation of pancreatic diseases and especially in the demonstratibn of complex anatomic relationships between the pancreas and surrounding structures.