Trans-hiatal herniation following esophagectomy or gastrectomy: retrospective single-center experiences with a potential surgical emergency.

PURPOSE: Trans-hiatal herniation after esophago-gastric surgery is a potentially severe complication due to the risk of bowel incarceration and cardiac or respiratory complaints. However, measures for prevention and treatment options are based on a single surgeon´s experiences and small case series in the literature. METHODS: Retrospective single-center analysis on patients who underwent surgical repair of trans-hiatal hernia following gastrectomy or esophagectomy from 01/2003 to 07/2020 regarding clinical symptoms, hernia characteristics, pre-operative imaging, hernia repair technique and perioperative outcome. RESULTS: Trans-hiatal hernia repair was performed in 9 patients following abdomino-thoracic esophagectomy (40.9%), in 8 patients following trans-hiatal esophagectomy (36.4%) and in 5 patients following conventional gastrectomy (22.7%). Gastrointestinal symptoms with bowel obstruction and pain were mostly prevalent (63.6 and 59.1%, respectively), two patients were asymptomatic. Transverse colon (54.5%) and small intestine (77.3%) most frequently prolapsed into the left chest after esophagectomy (88.2%) and into the dorsal mediastinum after gastrectomy (60.0%). Half of the patients had signs of incarceration in pre-operative imaging, 10 patients underwent emergency surgery. However, bowel resection was only necessary in one patient. Hernia repair was performed by suture cruroplasty without (n = 12) or with mesh reinforcement (n = 5) or tension-free mesh interposition (n = 5). Postoperative pleural complications were most frequently observed, especially in patients who underwent any kind of mesh repair. Three patients developed recurrency, of whom two underwent again surgical repair. CONCLUSION: Trans-hiatal herniation after esophago-gastric surgery is rare but relevant. The role of surgical repair in asymptomatic patients is disputed. However, early hernia repair prevents patients from severe complications. Measures for prevention and adequate closure techniques are not yet defined.

Correlation of native T1 mapping with right ventricular function and pulmonary haemodynamics in patients with chronic thromboembolic pulmonary hypertension before and after balloon pulmonary angioplasty.

OBJECTIVES: The aim of this study was to assess native T1 mapping in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) before and 6 months after balloon pulmonary angioplasty (BPA) and compare the results with right heart function and pulmonary haemodynamics. METHODS: Magnetic resonance imaging at 1.5 T and right heart catheterisation were performed in 21 consecutive inoperable CTEPH patients before and 6 months after BPA. T1 values were measured within the septal myocardium, the upper and lower right ventricular insertion points, and the lateral wall at the basal short-axis section. In addition, the area-adjusted septal native T1 time (AA-T1) was calculated and compared with right ventricular function (RVEF), mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR). RESULTS: The mean AA-T1 value decreased significantly after BPA (1,045.8 ± 44.3 ms to 1,012.5 ± 50.4 ms; p < 0.001). Before BPA, native T1 values showed a moderate negative correlation with RVEF (r = -0.61; p = 0.0036) and moderate positive correlations with mPAP (r = 0.59; p < 0.01) and PVR (r = 0.53; p < 0.05); after BPA correlation trends were present (r = -0.21, r = 0.30 and r = 0.35, respectively). CONCLUSIONS: Native T1 values in patients with inoperable CTEPH were significantly lower after BPA and showed significant correlations with RVEF and pulmonary haemodynamics before BPA. Native T1 mapping seems to be indicative of reverse myocardial tissue remodelling after BPA and might therefore have good potential for pre-procedural patient selection, non-invasive therapy monitoring and establishing a prognosis. KEY POINTS: • BPA is a promising treatment option for patients with inoperable CTEPH • Native septal T1 values significantly decrease after BPA and show good correlations with right ventricular function and haemodynamics before BPA • Prognosis and non-invasive therapy monitoring might be supported in the future by native T1 mapping.

Multimodality imaging evaluation before transcatheter aortic valve implantation: incidence of contrast medium-induced acute kidney injury, risk factors and prognosis.

AIM: To evaluate the incidence, risk factors, and prognostic implications of contrast medium-induced acute kidney injury (CI-AKI) in patients undergoing transcatheter aortic valve implantation (TAVI) evaluation. MATERIALS AND METHODS: Datasets from 98 out of 207 consecutive patients referred for multidetector computed tomography (MDCT) for TAVI evaluation were eligible for evaluation and were analysed retrospectively. The incidence of CI-AKI was correlated to outcome and to potential risk factors: kidney function (estimated glomerular filtration rate [eGFR]), heart failure, diabetes, amount of contrast medium, and duration of examination period. RESULTS: CI-AKI occurred in 67 patients (68.4%) and mainly correlated with eGFR (p=0.01) and the amount of contrast medium as a function of eGFR (p=0.04). CI-AKI occurred before TAVI in 36 (53.7%) patients of which 13 (19.4%) did not undergo TAVI. In-hospital all-cause mortality was 21.4%, and of those 21 patients, 18 (85.7%) had CI-AKI and nine (42.9%) did not undergo TAVI. One-year all-cause mortality was 39.8%, and of those 39 patients who died within 1 year, 31 (79.5%) had CI-AKI. CONCLUSION: CI-AKI mostly occurs already before TAVI as a consequence of pre-procedural imaging, which therefore represents the main contributor for CI-AKI in relation to TAVI. Regarding the observation that some patients will ultimately have no benefit because TAVI is not performed and the poor prognosis linked to CI-AKI should encourage improvement in patient selection when referring to pre-procedural imaging.

Unusual gastric mucosal infiltration by a medullary thyroid carcinoma: a case report.

BACKGROUND: Medullary thyroid carcinoma accounts for approximately 1 to 2 % of all thyroid carcinoma cases. The most common route of dissemination is to locoregional lymph nodes. Distant metastases commonly affect bones, lungs, and liver. We present a case of a white woman with a 25-year history of medullary thyroid carcinoma on multiple medications including tyrosine kinase inhibitor therapy for the last 11 months, who exhibited unusual diffuse infiltration of advanced stage medullary thyroid carcinoma to her gastric mucosa. CASE PRESENTATION: A 53-year-old white woman presented with increasing fatigue, loss of appetite, and severe epigastric pain radiating to her back. She had a history of medullary thyroid carcinoma (pT2pN1b), diagnosed 25 years ago and treated by complete thyroidectomy and repeated bilateral cervical lymph node dissection. Medical therapy included octreotide 20 mg every 4 weeks, which was switched to the tyrosine kinase inhibitor vandetanib 300 mg/day 11 months ago when computed tomography scanning revealed progressive mediastinal lymph node and diffuse and symptomatic pulmonary metastases. Of note, she demonstrated macroscopically stable pulmonary and mediastinal lymph node metastases; however, her calcitonin serum levels dramatically increased. Computed tomography scanning revealed a single new intrahepatic lesion (4 mm) as well as multiple (>10) new supraclavicular lesions suggestive of medullary thyroid carcinoma progress. As proven by gastric biopsy and immunohistochemical evaluation, her epigastric pain was explained by a diffuse infiltration of her gastric mucosa by metastatic medullary thyroid carcinoma. Subsequently, she rapidly deteriorated and died. CONCLUSIONS: The current case report shows for the first time an unusual metastatic infiltration of the gastric mucosa by medullary thyroid carcinoma. When treating these patients, it is important to include this differential diagnosis during follow-up.

Development and Suggestion of a Cardiac CTA Scoring System for the Prediction of Revascularization Success in Chronic Total Occlusions (CTO) of the Coronary Arteries.

OBJECTIVE: Analyzing occluded segments with computed tomography angiography (CTA) prior to percutaneous coronary intervention (PCI) increased revascularization success in chronic total occlusions (CTO). The aim of our study was to develop a scoring system for the prediction of PCI success in CTO. MATERIALS AND METHODS: 41 consecutive CTO patients (30 male; 63.1 years +/- 8.3 standard deviation) underwent CTA prior to PCI. All CTOs were categorized by two radiologists in consensus regarding the presence of special features and without knowledge of PCI outcome. All outcome criteria were evaluated. Afterwards one point was assigned for each unequally distributed outcome criteria per CTO and all points were added up to a single score. RESULTS: Severe calcifications (failure group 68.8 % vs. success group 28.0 %; p < 0.02) and intraluminal calcifications (68.8 %; 40.0 %), tortuosity (25.0 %; 0 %; p < 0.02), linear intrathrombus enhancement (37.5 %; 60.0 %) and distal vessel disease (68.8 %; 44.0 %) were unequally distributed. By adopting a threshold of 4 points or higher (maximum 5 points), the results were: sensitivity 31.3 %, specificity 100 %, negative predictive value (NPV) 69.4 % and positive predictive value (PPV) 100 %. The PCI complication rate was 9.8 % and the mean contrast media amount was 234.4 ml. CONCLUSION: With the suggested scoring system, based on five CTA criteria, PCI failure could be predicted with high PPV and specificity in our group of patients, but the NPV and sensitivity are low. However, 5 unsuccessful PCIs (13.2 %) could have been avoided and none would have been wrongly omitted. Regarding the complication rate during PCI and the high amounts of contrast media needed, a prediction system appears to be desirable and should be the object of large-scale trials. KEY POINTS: Single predictors of revascularization success in CTO have been identified. Success rates are improved by analyzing CTA data sets prior to revascularization approaches. Prediction of revascularization success via a scoring system based on five CTA criteria seems promising. Patient selection for the right treatment options might be improved in the future due to application of the scoring system. Also risks, complications, contrast media amounts and radiation doses might be reduced.

Impact of unsuspected subsegmental pulmonary embolism in ICU patients.

BACKGROUND: Critically ill patients in intensive-care units are at high risk for pulmonary embolism (PE). As a result of modern multi-detector computed tomographic angiography (MDCT) increased visualization of peripheral pulmonary arteries, isolated subsegmental pulmonary embolisms (ISSPE) are increasingly being detected. AIM: The aim of this study was to investigate the rate, impact on treatment, and outcome of unsuspected ISSPE in critically ill patients receiving MDCT. The secondary aim was to investigate the potential impact of contrast media-induced nephropathy (CIN) in our cohort. METHODS: We conducted a retrospective single-centre analysis on critically ill adult patients treated between January 2009 and December 2012 who underwent a contrast-enhanced chest MDCT. We excluded patients with clinical suspicion of PE/ISSPE prior to CT and patients with MDCT confirmed central PE. Clinical findings, laboratory parameters, and outcome data were recorded. RESULTS: We identified 240 ICU patients not suspected for PE receiving MDCT. A total of 12 Patients (5%) showed unexpected ISSPE representing increased 24 h mortality (16.7 vs. 3.5%; p = 0.026) compared to non-ISPPE/non-PE patients. A 30-days mortality did not differ between the groups (33.3 vs. 33.8%; p = 0.53). Highest mean creatinine serum level in our cohort (n = 240) was found before MDCT with a significant decrease to day 5 (1.4 ± 1.1 vs. 1.1 ± 0.9 mg/dl: p < 0.0001) after contrast media administration. CONCLUSION: Critically ill patients are at relevant risk for ISSPE. ISSPE was associated with a poor 24 h outcome. In addition, in our cohort, contrast media application was not associated with increased serum creatinine.

T1, T2 Mapping and Extracellular Volume Fraction (ECV): Application, Value and Further Perspectives in Myocardial Inflammation and Cardiomyopathies.

UNLABELLED: Cardiac magnetic resonance imaging (CMRI) is a versatile diagnostic tool. One of its main advantages is the possibility of tissue characterization. T1-weighted images for scar and T2-weighted images for edema visualization are key methods for tissue characterization. Otherwise these sequences are strongly limited for the detection of diffuse myocardial pathologies. Recently, rapid technical innovations have generated new techniques. T1, T2 mapping and evaluation of the extracellular volume fraction (ECV) allow quantification of diffuse myocardial pathologies and showed great potential in the visualization of fibrosis, edema, amyloid, iron overload and lipid. In the future these techniques might enable the detection of early cardiac involvement, even act as a prognosticator. Moreover, therapy monitoring and follow-up might be possible due to versatile parameter quantification with these new techniques. KEY POINTS: CMR allows for tissue characterization via T1- and T2-weighted sequences. In cases of diffuse, global myocardial pathologies, correct image interpretation with traditional CMR sequences might be difficult. T1, T2 mapping and ECV can quantify diffuse, global myocardial pathologies. Alterations of myocardial T1 and T2 relaxation times occur in various myocardial diseases (e.g. acute myocarditis). In the future mapping might act as a prognosticator or therapy monitoring tool.

Cardiac MRI: diagnostic gain of an additional axial SSFP chest sequence for the detection of potentially significant extracardiac findings in the cardiac MRI examination setting.

PURPOSE: Cardiac MRI (CMRI) is an effective method for imaging of the heart. The aim of our study was to assess whether an axial chest sequence in addition to the standard CMR examination setting has advantages in the detection of potentially significant extracardiac findings (PSEF). MATERIALS AND METHODS: 400 consecutive patients were imaged at 1.5 T for clinical reasons. In addition to the standard long and short-axis views, an axial SSFP sequence was obtained covering the thorax from the lung apex to the diaphragm. All sequences were separately evaluated for PSEF. RESULTS: A total of 25 PSEF were diagnosed in 400 patients, including 16 pleural effusions, a pulmonary fibrosis, a spondylodiscitis, ascites, lymphadenopathies, relapse of a mamma carcinoma, growth of adrenal glands metastases and diaphragmatic elevation. All 25 PSEF were detected by reading survey sequences. 24 of the 25 PSEF were detected by the additional SSFP chest sequence as well as the CINE sequences. CONCLUSION: In our study the additional axial SSFP chest sequence didn't show a benefit in the detection of PSEF. With the survey sequences we were able to detect all PSEF. We conclude that survey images should be assessed for additional findings.