Percutaneous trans-bladder drainage of a pelvic abscess caused by sigmoid diverticulitis: Two case reports.

Sigmoid diverticulitis can potentially lead to the development of pelvic abscesses. Mortality rate from intra-abdominal abscesses is as high as 35%, and patients with diverticulitis complicated by an abscess are at a high risk of recurrent diverticulitis. Recently, image-guided drainage has been performed using computed tomography or ultrasonography for the treatment of pelvic abscesses. Standard radiological pelvic abscess image-guided drainage methods consist of transabdominal, transgluteal, or cranio-caudal puncture approaches. However, these standard approaches have technical limitations due to intrapelvic organ structures. Therefore, we performed image-guided drainage using a percutaneous trans-bladder approach with a simpler 1-step puncture method and a less invasive 7-Fr drainage catheter in 2 cases of a 72-year-old female and a 53-year-old female with relapsed pelvic abscesses complicated by sigmoid diverticulitis due to difficulties involving the standard approach. The abscesses in both cases disappeared on follow-up computed tomography scans, demonstrating no pelvic abscess recurrence. Our results showed that trans-bladder image-guided drainage is an effective alternative method for treating pelvic abscesses.

Percutaneous transhepatic obliteration of a large portosystemic shunt associated with hepatic encephalopathy using a technique of n-butyl-2-cyanoacrylate injection inside hydrogel-coated coils: A case report.

Portosystemic shunts with cirrhosis may lead to hepatic encephalopathy (HE), which is often pharmacotherapy-resistant. We report a case of a 66-year-old female patient diagnosed with alcoholic cirrhosis and uncontrolled HE. She underwent percutaneous transhepatic obliteration (PTO) for treatment of a large portosystemic shunt from the left and right gastric veins to the azygos vein. We embolized the target veins using hydro-coated coils and filled them with n-butyl-2-cyanoacrylate (NBCA), leading to firmed obstruction of the large portosystemic shunt without NBCA migration, thus reducing the number of coils required. The HE symptoms improved after PTO and could thereafter be controlled with conservative therapy. Our results showed that PTO using an NBCA injection inside hydrogel-coated coils for a large portosystemic shunt associated with HE is effective and safe.

Efficacy and safety of endovascular therapy for delayed hepatic artery post-pancreatectomy hemorrhage: development of extrahepatic collateral circulation and complications of post endovascular therapy.

BACKGROUND: Endovascular therapy (ET) for delayed hepatic artery post-pancreatectomy hemorrhage (HA-PPH) may require complete hepatic artery occlusion (HAO). Nonetheless, the development of extrahepatic collateral circulation (EHC) and the relationship between radiological factors (EHC, portal vein stenosis, and HAO) and adverse hepatic events after ET remain unclear. This study aimed to evaluate the efficacy and safety of ET for delayed PPH and examine the development of EHC. METHODS: A total of 19 ET cases for delayed HA-PPH were reviewed. Hepatic adverse events, portal vein stenosis, HAO, and mortality rate after ET were evaluated. Moreover, EHC from the left gastric artery (LGA), right inferior phrenic artery (RIPA), left inferior phrenic artery (LIPA), right internal thoracic artery (RITA), left internal thoracic artery (LITA), renal artery (RA), omental artery (OA), intercostal artery (IA), and branch of superior mesenteric artery (BSMA) was assessed using angiogram and computed tomography angiography (CTA). RESULTS: All cases were successfully treated using transcatheter arterial embolization (n = 17) and stent-graft placement (n = 2) without mortality. EHC from the LGA (8/19), RIPA (10/19), LIPA (4/19), and RITA (3/19) was observed on post-ET CTA. The incidence of hepatic adverse events was significant in the group with both HAO and portal vein stenosis (p < 0.001) and absence of EHC from LIPA and RITA (p < 0.05). CONCLUSION: ET for delayed HA-PPH might be effective and safe. While avoiding both HAO and portal vein stenosis is important, the development of EHCs from LIPA and RITA may prevent hepatic adverse events after ET.

The "K-Sign"-A Novel CT Finding Suggestive before the Appearance of Pancreatic Cancer.

Pancreatic invasive ductal adenocarcinoma (PDAC) has a poor prognosis, and the detection of PDAC during the early stage is thought to improve prognosis. In this study, we retrospectively investigated pancreatic morphological abnormalities that lead to the early diagnosis of PDAC with computed tomography (CT) imaging. In total, 41 out of 308 patients diagnosed with pancreatic cancer between 2011 and 2017 in our institution were enrolled. As a control group for the group with pancreatic cancer, 4277 patients without pancreato-biliary diseases were enrolled. We retrospectively reviewed and analyzed the clinical data including patient characteristics, the clinical course and preoperative CT imaging with pancreatic morphological features. Out of 41 patients, 24 patients (58.5%) showed local K-shaped constriction of the pancreatic parenchyma "K-sign" on preoperative CT images. Eight patients (19.5%) showed localized fatty change. Out of 4277 control patients, seven patients (0.16%) showed K-sign. "K-sign" may be used for the early diagnosis of PDAC by CT imaging.

Surfers' knots in the anterior chest.

A history of frequent surfing can be a key finding when a patient comes in with subcutaneous lesions on bilateral anterior lower chest. MR imaging could lead to the diagnosis with its characteristic finding for collagenous mass lesions, though most cases do not require imaging unless with atypical presentation. This enables clinicians to avoid unnecessary invasive procedures.

Evaluation of Normal Epiglottis on Computed Tomography with Special Attention to Thickness.

To our knowledge, this is the first study to investigate the thickness of the normal epiglottis on computed tomography (CT) in a Japanese population. The focus was on determining the thickness of a normal epiglottis, which could then serve as a reference in detecting abnormalities. We believe that this would facilitate diagnosing and determining the extent of cancerous invasion of the supraglottis and secondary invasion of the epiglottis. This retrospective study was based on a review of radiographic data in patient charts. Cervical CT scans obtained from 79 Japanese patients (44 men [55.7%] and 35 women [44.3%]; age range, 28-85 years; mean, 58.9 years) showing a normal epiglottis under laryngoscopy were evaluated. The thickness of the epiglottis was measured on CT scans and the results analyzed with the Student's t-test, an analysis of variance, and the Tukey-Kramer test. The epiglottis in men was significantly thicker than that in women (p<0.05). A statistically significant difference was observed in thickness depending on longitudinal height (p=<0.001). The thickness at the median was larger than that bilaterally in all patients (p=<0.001). No statistically significant difference was observed in thickness depending on side or age. The thickness of the normal epiglottis was established at each level. We believe that these data could serve as a reference in diagnosing and detecting abnormalities of the epiglottis.

Convexity subarachnoid hemorrhage presented with loss of consciousness.

When patients present with transient loss of consciousness without headache and head computed tomography is performed, clinicians should pay attention to cortical high densities as convexity subarachnoid hemorrhage can be a differential diagnosis.

Undetectability of oral tongue cancer on magnetic resonance imaging; clinical significance as a predictor to avoid unnecessary elective neck dissection in node negative patients.

METHODS:: We retrospectively reviewed early stage oral tongue cancer patients treated with radical surgery with clinically N0, between May 2009 and February 2016. Collected data include age, sex, pathological DOI, DOI on MRI, locoregional control rate, disease-free survival rate, and overall survival rate. These data were statistically compared between the detectable lesion (DL) group and undetectable lesion (UL) group on MRI. Interobserver agreement in evaluation of detectability of the oral tongue cancer was assessed by k statistics. RESULTS:: Total of 53 patients were studied, and 28 were DLs and 25 ULs. Pathological DOI in UL was significantly smaller than that of DL (average 1.7 vs 4.6 mm, p < 0.001). Cut-off value between UL group and DL group was 3.5 mm (sensitivity 96 %, specificity 75 %). 96 % of ULs had pathological DOI smaller than 4 mm, the recommended cut-off value for neck dissection. There was no significant difference in locoregional control rate (p = 0.24), disease-free survival rate (p = 0.24) or overall survival rate (p = 0.92). Interobserver agreement in evaluation of detectability on MRI was very good ( k-value = 0.89, p < 0.001). CONCLUSIONS:: When oral tongue cancer is not detected on MRI, it indicates pathological DOI being smaller than 4 mm, which may imply that elective neck dissection is unnecessary.

Schwannoma assumedly originating from the submandibular ganglion or glandular branches radiologically mimicking a submandibular gland tumor.

Schwannoma is a benign nerve sheath tumor composed of Schwann cells. Schwannomas originating from ganglia are rare, and schwannomas of the submandibular ganglion or glandular branches have not been reported to date. We present a case of a Japanese woman in her sixties with a submandibular schwannoma originating from the submandibular ganglion, mimicking a submandibular gland tumor on radiological findings. As the radiological findings were nonspecific, the key finding in the present case may be the characteristic location of the tumor suspended from the undersurface of the lingual nerve and situated above the deep portion of the submandibular gland.

Essentials on Oncological Imaging: Postoperative Computed Tomography and Magnetic Resonance Imaging of Oral Tongue Cancer.

The contribution of diagnostic imaging in evaluating the pre- and postoperative status of tongue cancer is essential. Interpretation of postoperative images is made difficult by deformation; therefore, it is necessary to know how surgical technique, biological reaction, postoperative anatomy, and local recurrence are reflected on the images. This study explains the postoperative imaging features of tongue cancer to help in the early detection of local recurrence and avoid inappropriate treatment. We review schematic drawings of representative surgical procedures for tongue carcinoma, variable radiological features in postoperative conditions with or without complications, and typical features of local failures and their mimics. This article clarifies the important tasks of radiologists and clinicians in the postoperative evaluation of tongue carcinoma.

CT imaging features of antiresorptive agent-related osteonecrosis of the jaw/medication-related osteonecrosis of the jaw.

OBJECTIVES: Antiresorptive agent-related osteonecrosis of the jaw (ARONJ)/medication-related osteonecrosis of the jaw (MRONJ) include both bisphosphonate-related osteonecrosis of jaw (BRONJ) and denosumab-related osteonecrosis of jaw (DRONJ). The purpose of this study is to study radiological characteristics of ARONJ/MRONJ. These imaging features may serve as one useful aid for assessing ARONJ/MRONJ. METHODS: CT scans of 74 Japanese patients, who were clinically diagnosed by inclusion criteria of ARONJ/MRONJ, obtained between April 1, 2011 and September 30, 2016, were evaluated. We investigated the CT imaging features of ARONJ/MRONJ, and clarified radiological differentiation between BRONJ and DRONJ, BRONJ due to oral bisphosphonate administration and due to intravenous bisphosphonate administration, BRONJ with respective kinds of medication, BRONJ with long-term administration and short-term administration, BRONJ with each clinical staging respectively. Fisher's exact test, χ2 test, Student's t-test and analysis of variance were performed in the statistical analyses. RESULTS: Unilateral maxillary sinusitis was detected in all patients with upper ARONJ/MRONJ (100%). DRONJ showed large sequestrum more frequently than BRONJ (3/4, 75 vs 3/35, 8.6%, p < 0.05). DRONJ showed periosteal reaction more frequently than BRONJ (4/10, 40 vs 7/65, 10.1%, p < 0.05). Patients of BRONJ resulting from intravenous bisphosphonate administration showed larger and more frequent buccolingual cortical bone perforations than BRONJ resulting from oral bisphosphonate administration (7/8, 87.5 vs 11/30, 36.7%, p < 0.05). There was no significant correlation between CT findings and respective kinds of medication, long/short-term administration, clinical stages of BRONJ. CONCLUSIONS: ARONJ/MRONJ has characteristic CT image findings which could be useful for its assessment.

A rare presentation of Klippel-Trenaunay syndrome with bilateral lower limbs.

Klippel-Trenaunay syndrome (KTS) is a vascular lymphatic malformation underlying with bony and soft tissue hypertrophy. It is a rare condition presenting in 1 out of 10 000 people. The growth disturbance due to KTS is more commonly unilateral (85%) than bilateral (12.5%), and most rarely crossed-bilateral (2.5%). A man in his 40s presented to our hospital with a complaint of lower limb discomfort. Radiograph, ultrasonography, computed tomography venography, magnetic resonance (and venography) showed various radiological findings characteristic for KTS. Because the patient was symptomatic, he underwent stripping of bilateral great saphenous vein and varicectomy of bilateral legs. The surgical procedures were undertaken successfully, and there has been no recurrent symptom for about 2 years and a half. In this study, we report a very rare case of bilateral KTS diagnosed by radiological and clinical manifestations with some literature review.

Wandering carotid arteries: Reciprocating change between normal and retropharyngeal positions on serial CT studies.

Positional change in the retropharyngeal carotid artery, a rare phenomenon over time, is even rarer in previous reports, and it is important to be aware of this before any neck surgical procedure. A woman in her 50s underwent an anterior maxillectomy for upper gingival cancer, without neck dissection. The patient had medical histories of diabetes mellitus and liver dysfunction, with unremarkable family histories. Serial neck contrast-enhanced computed tomography for detecting locoregional recurrence had been performed as a follow-up during 4 years. A radiological course of moving carotid arteries in serial computed tomography studies showed reciprocating positional changes (wandering) between normal and retropharyngeal regions. There was no locoregional recurrence of the gingival cancer. This is the first case to describe a so-rare presentation of wandering carotid arteries. It is important for clinicians to be aware of a wandering carotid artery to avoid potentially fatal complications.

Totally implantable venous access port via the femoral vein in a femoral port position with CT-venography.

BACKGROUND AND PURPOSE: We aimed to determine the success rate and any complications using a percutaneous approach to the femoral vein (FV) for placement of a totally implantable access port (TIVAP), with a preoperative assessment of the femoral and iliac veins using computed tomography-venography (CT-V). METHODS: A prospective study of 72 patients was conducted where placement of a TIVAP was attempted via the right FV, with the port placed in the anterior thigh, when subclavian vein or jugular vein access was contraindicated. Preoperative assessment of the femoral venous plexus was performed with CT-V in 72 patients. RESULTS: CT-V success was achieved in 72 of 72 patients (100%). The average distance between the inguinal ligament and the saphenofeomral (FV-GSV) junction was 42.8 ± 12.9 mm. The FV approach had a 97% successful cannulation rate. Two patients had a thrombosis in either the femoral vein or the great saphenous vein. One procedural complication (1.4%) and one initial complication (1.4%) occurred. Late complications occurred in four patients (5.7%). CONCLUSIONS: The percutaneous FV approach with CT-V guidance is an option for patients with multiple central venous cannulations, as well as those with bilateral breast cancer, or those undergoing hemodialysis. J. Surg. Oncol. 2016;114:1024-1028. © 2016 Wiley Periodicals, Inc.

An Unusual Clinical Presentation of Kimura Disease Manifesting with a Typical Cephalocervical Lesion and an Atypical Subcutaneous Hip Mass Lesion.

Kimura's disease (KD) is a rare lymphoproliferative inflammatory disorder, typically presenting as firm, painless or pruritic single or multiple subcutaneous lesions in the head and neck, especially in the parotid and submandibular regions. We herein report a case of a 39-year-old Japanese man presenting with a typical cephalocervical KD lesion around the salivary glands with a rare association with a distant subcutaneous mass at the hip. We also emphasize the radiologically and clinically important features in the differential diagnosis and management. To the best of our knowledge, this case is the first report of KD manifesting with a typical cephalocervical lesion and an atypical subcutaneous hip mass lesion.

Petersen hernia after open gastrectomy with Roux-en-Y reconstruction: a report of two cases and literature review.

Petersen hernia is a rare internal hernia that occurs after Roux-en-Y (R-Y) reconstruction. To our knowledge, there are a few reports on internal hernia, especially Petersen hernia after open gastrectomy for gastric cancer. Two rare cases of Petersen hernia are presented in this report. A man in his 70s was referred to our hospital due to a complaint of postprandial sudden abdominal pain. He had a history of open total gastrectomy with R-Y jejunal reconstruction through the antecolic route for gastric corpus cancer. On computed tomography (CT), bowel obstruction and strangulation of the small intestine were suspected. Emergency laparotomy was done, and an internal herniation of the small intestine through Petersen space was observed. A man in his 50s was referred to our hospital due to a complaint of severe sudden abdominal pain. He had a history of open gastrectomy and abdominal/lower intrathoracic esophageal resection with R-Y jejunal reconstruction of an antecolic jejunal limb for esophagogastric junction carcinoma. On CT, internal herniation of the small intestine was suspected. During emergency laparotomy, an internal herniation of the bowel through the Petersen space was observed. Though history of R-Y reconstruction surgery may be helpful, preoperative diagnosis of Petersen hernia is difficult to establish. Here we present two rare cases of this type of internal hernia.

Computed tomography-gastro-colonography for percutaneous endoscopic gastrostomy using a helical computed tomography.

BACKGROUND: Despite the widespread use of percutaneous endoscopic gastrostomy (PEG) tubes, their placement may be associated with a variety of complications, including gastrocolic fistula. METHODS: In total, 48 individuals underwent computed tomography-gastro-colonography (CT-GC)-guided PEG placement. Study end points included success of CT-GC, inability to thread the PEG tube, the eventual tube location, tube adjustments needed, adverse events, operating time, and PEG tube-related infection. RESULTS: A successful CT-GC was achieved in all 48 patients (100%), and we successfully used a standard PEG technique to place the gastrostomy tube in 44 patients (92%). In 4 patients (8%), the laparoscopic-assisted PEG technique was used because the transverse colon became interposed between the abdominal wall and the anterior wall of the stomach. The overall procedure-related minor complication rate was 8%. CONCLUSION: CT-GC is an optional method for the estimation of intra-abdominal, anatomical orientations that may minimize the risk of complications before PEG placement.

Computed tomography (CT) venography using a multidetector CT prior to the percutaneous external jugular vein approach for an implantable venous-access port.

BACKGROUND AND PURPOSE: The objective of this study was to determine the success rate and complications of using the percutaneous approach of the external jugular vein (EJV) for placement of a totally implantable venous-access port (TIVAP) with a preoperative estimate of the detailed anatomical orientation of the cervical venous plexus using computed tomography venography (CT-V). METHODS: A prospective cohort study of 45 patients in whom placement of a TIVAP was attempted via the right EJV was conducted. The preoperative anatomical estimation of the cervical venous plexus was performed with CT-V using a Multidetector Helical 16-section CT. The angulation between the right EJV and the right subclavian vein, anterior jugular vein, transverse cervical vein, and suprascapular vein was estimated. RESULTS: CT-V success was achieved in 45 of 45 patients (100 %). A plexus of veins under the clavicle was most commonly responsible for the insertion of the central venous catheter. The EJV approach resulted in a successful cannulation rate of 93 %. No initial complications of pneumothorax or carotid artery puncture occurred during insertion procedures. Late complications occurred in three patients. These included one port erosion (2 %), one catheter occlusion (2 %), and one wound hematoma (2 %). Catheter-related infections were observed in one patient (2 %). CONCLUSIONS: The percutaneous EJV approach with CT-V guidance is an optional method for patients with multiple central venous cannulations, those in hemodialysis, or those with long catheter indwelling periods.

Central venous access via external jugular vein with CT-venography using a multidetector helical 16-section CT.

OBJECTIVE: To determine the success rate and complications of using the external jugular vein (EJV) for central venous access with a preoperative estimate of the detailed anatomical orientation of the cervical venous plexus using computed tomography venography (CT-V). DESIGN: Prospective, observational human study. SETTING: Surgical intensive care unit. PATIENTS: Fifty-two patients who were undergoing EJV cannulations with CT-V using a Multidetector Helical 16-section CT (MDCT). INTERVENTION: The preoperative anatomical estimation of the cervical venous plexus was performed with CT-V using an MDCT. In particular, the angulation between the EJV and the right subclavian vein (SCV) was measured. The anatomical abnormalities and the angulation between the EJV and the anterior jugular vein (AJV), transverse cervical vein (TCV), and suprascapular vein (SSV) were estimated. MEASUREMENTS AND MAIN RESULTS: The success of CT-V was achieved in 52 of 52 patients (100%). The mean angulation between the right EJV and the right SCV was 144 ± 36 degrees in the obtuse-angle cases (88%) and 72 ± 28 degrees in the sharp-angle cases (12%). A plexus of veins under the clavicle was most commonly responsible for insertion of the central venous catheter (CVC). The EJV approach resulted in a 93% rate of successful cannulations. No complications of pneumothorax or carotid artery puncture occurred during insertion procedures. CONCLUSIONS: The EJV route is associated with comparable technical success and lower major procedural complication. The EJV approach with CT-V guidance is an option as the initial method when central venous cannulation must be performed under suboptimal conditions.