Defining the Need for Surgery in Small-Bowel Obstruction.

BACKGROUND: Small-bowel obstruction is a frequent disorder in emergency medicine and represents a major burden for patients and health care systems worldwide. Within the past years, progress has been made regarding the management of small-bowel obstructions, including the use of contrast agent swallow as a tool in the decision-making process. OBJECTIVES: This is a prospective controlled study investigating the central role of contrast agent swallow in the diagnostic and treatment algorithm for small-bowel obstruction at a university department of surgery. Endpoints were the correct identification of patients who needed operative treatment and the accuracy of a conservative treatment decision including the analysis of dropout from this routine algorithm. METHODS: We performed a single-center analysis of 181 consecutive patients diagnosed with a small-bowel obstruction based on clinical, radiologic, and sonographic findings. Patients with clinical signs of strangulation or peritonitis underwent immediate surgery (group 1). Patients without signs of peritonitis and incomplete stop in the initial abdominal plain film were considered eligible for Gastrografin® challenge (group 2). RESULTS: Seventy-six of the 181 patients (42.0%) underwent immediate surgery. A Gastrografin® challenge was initialized in 105 of the 181 patients (58.0%). Twenty of these 105 patients (19.1%) with persisting or progressive symptoms and absence of contrast agent in the colon after 12 and 24 h subsequently underwent surgery. Here, a segmental bowel resection was necessary in 6 of these 20 patients (30.0%). In 16 out of 20 patients (80.0%) who failed the Gastrografin® challenge, a corresponding correlate in terms of a strangulation was detected intraoperatively. The Gastrografin® challenge had a specificity of 96% and a sensitivity of 100%; accuracy to predict the need for exploration was 96%. CONCLUSION: A straightforward algorithm based mainly on contrast agent swallow for patients with small-bowel obstructions enabled a timely and very accurate differentiation between patients qualifying for conservative and operative treatment.

Ectopic Spleen Tissue - an Underestimated Differential Diagnosis of a Hypervascularised Liver Tumour.

BACKGROUND: Patients with liver cirrhosis have an increased risk of developing hepatocellular carcinoma (HCC). Implantation metastasis following diagnostic biopsy is a well-known complication. Therefore, primary resection of a hypervascularised tumour suspicious for HCC is often performed with curative intent. CASE REPORT: An exophytically growing mass was diagnosed between liver segments III and IVb by means of ultrasound in a 53-year old male patient with decompensated liver cirrhosis. Computed tomography confirmed a 3.5 cm large hypervascularised tumour with given resectability. Intraoperatively, the tumour appeared like a HCC. Thus, an atypical resection was performed. Histopathology revealed ectopic spleen tissue without any signs of malignancy. As enquiries revealed, the patient had undergone splenectomy after a blunt abdominal trauma 9 years prior to admission. CONCLUSION: In the present patient, hepatic splenosis in a cirrhotic liver was misinterpreted as HCC. In patients with a history of traumatic rupture of the spleen or splenectomy, splenosis has to be considered as a potential differential diagnosis of a hypervascularised tumour. Specific diagnostics should be performed to rule out splenosis.

Parachute implant: CT morphological criteria of our center to identify the suitable patient.

AIMS: In this study, we present and discuss our institutionalized and standardized computed tomography (CT) morphological criteria for the treatment of patients with a parachute device. METHODS AND RESULTS: After clinical and echocardiographic screening of 79 patients with ischemic heart failure, 28 were examined using multidetector computed tomography (MDCT) to assess their suitability for treatment with a parachute implant. From the 28 examined patients, nine were suitable for parachute implantation. Within the group of excluded patients, the cardiac diameters of one-third of the patients were too large, whereas for another third they were too small. Approximately 20% of the patients were rejected because of a deep insertion of the papillary muscles. Further reasons included left ventricular bands as well as mismatches between CT and echocardiographic measurements of left ventricular ejection fraction (LVEF). CONCLUSIONS: To ensure a safe parachute device implantation in patients with ischemic heart failure, only the CT at present offers the capability to obtain complete and dynamic three-dimensional (3D) measurements of the cardiac dimensions.