Randomized clinical trial of laparoscopic ultrasonography before laparoscopic colorectal cancer resection.

BACKGROUND: Intraoperative ultrasonography during open surgery for colorectal cancer may be useful for the detection of unrecognized liver metastases. Laparoscopic ultrasonography (LUS) for the detection of unrecognized liver metastasis has not been studied in a randomized trial. This RCT tested the hypothesis that LUS would change the TNM stage and treatment strategy. METHODS: Patients with colorectal cancer and no known metastases were randomized (1 : 1) to laparoscopic examination (control or laparoscopy plus LUS) in three Danish centres. Neither participants nor staff were blinded to the group assignment. RESULTS: Three hundred patients were randomized, 150 in each group. After randomization, 43 patients were excluded, leaving 128 in the control group and 129 in the LUS group. Intraoperative T and N categories were not altered by LUS, but laparoscopy alone identified previously undetected M1 disease in one patient (0·8 per cent) in the control group and three (2·3 per cent) in the LUS group. In the latter group, LUS suggested that an additional six patients (4·7 per cent) had M1 disease with liver (4) or para-aortal lymph node (2) metastases. The change in treatment strategy was greater in the LUS than in the control group (7·8 (95 per cent c.i. 3·8 to 13·8) and 0·8 (0 to 4·2) per cent respectively; P = 0·010), but the suspected M1 disease was benign in half of the patients. CONCLUSION: Routine LUS during resection of colorectal cancer is not recommended. Registration number: NCT02079389 (http://www.clinicaltrials.gov).

Conservative treatment for acute rupture of the Achilles tendon.

Sixty-six patients with acute ruptures of the Achilles tendon were treated by immobilisation in a plaster cast for 12 weeks. Fifty-seven were followed up for a mean time of 70 months. Four re-ruptures occurred shortly after the initial treatment. Most patients had no or only slight complaints, three had moderate and one severe, problems. The activity level dropped slightly from 5.3 to 5.03 (Tegner score). The results are satisfactory with a low complication rate. The method is an alternative to operative repair, especially in patients declining operation and in those in whom operation or anaesthesia is contraindicated.

Intra-arterial injection of dextropropoxyphene into hand arteries.

We report a case of deliberate intra-arterial injection of dextropropoxyphene into the palms, leading to chronic oedema of both hands. The aetiology is discussed. This cause must be borne in mind in the diagnosis of chronic oedema of the hands.

CT of extraforaminal disc herniation with associated vacuum phenomenon.

Lumbo-sacral extraforaminal disc herniation with spinal nerve compression is a well recognized entity. The diagnosis is difficult, however, and the true incidence therefore unknown. We report a case where CT was diagnostic.

Adult manifestation of the Dandy-Walker syndrome. Report of two cases with review of the literature.

Two cases of Dandy-Walker syndrome that became manifest in adult life are reported. A review of the literature of Dandy-Walker syndrome revealed 13 additional cases with onset in adult life and three cases that could not be differentiated from arachnoid cysts. While shunting is the primary treatment in infantile Dandy-Walker, the usual treatment of adult Dandy-Walker has been excision of the membrane covering the enlarged fourth ventricle. The outcome of our two cases treated with membrane excision indicates that primary shunting should also be tried in adult Dandy-Walker.

CT appearance of the diaphragm varying with respiratory phase and muscular tension.

Two cases exhibiting great variability of diaphragmatic CT appearance are reported. The literature on the effect of respiratory phase and muscular diaphragmatic contraction on the CT presentation is discussed.

Wallerian degeneration of the corticospinal tract region of the brain stem: demonstration by computed tomography.

Pathophysiological and CT aspects of wallerian degeneration of the corticospinal tract in the brain stem were studied in patients with old hemispheric infarcts. There was found to be a clear relationship between (a) the location and size of the infarcts and (b) the presence or absence of wallerian degeneration. When most of the motor cortex is involved, degeneration can be seen at least as far as the mesencephalic level and sometimes down to the pontine level. Isolated capsular infarcts which spare the motor cortex are also associated with degeneration. No degeneration could be seen in patients with small infarcts.

Cerebral infarction in childhood bacterial meningitis.

Forty-nine children with complicated bacterial meningitis were studied. Thirteen had abnormalities on computed tomography compatible with the diagnosis of brain infarction; one had a brain biopsy with the histological appearance of infarction. Factors exist in childhood bacterial meningitis which are associated with the development of brain infraction.

Computed tomography in childhood bacterial meningitis.

Computed tomography has been applied to childhood bacterial meningitis in an attempt to analyze the structural basis for neurologic complications. The CT findings in meningitis patients include acute cerebral swelling; moderate widening of basal cisterns, interhemispheric fissue, and subarachnoid convexity space; ventricular widening; subdural collection; focal cortical necrosis; cerebral infarcts; contrast enhancing basal meninges, ependymitis, and generalized cerebral atrophy. Bacterial meningitis in childhood is more than an inflammation of the subarachnoid space. It is a disease process which often exerts a profound effect on the brain parenchyma.

Persistent otic artery.

A patient with a persistent otic artery is presented. The radiographic anatomy is presented in the anteroposterior as well as the lateral plane. The significance of the otic artery is twofold. First, it is important in understanding the embryogenesis of the cerebral vessels. Secondly, it is an anatomical variant that is important in performing and evaluating cerebral arteriograms.

Occipital encephalocele with holoprosencephaly and aqueduct stenosis.

A case is described in which an occipital encephalocele was removed in a newborn and in which a midline monoventricle did not appear until some months later, suggesting the diagnosis of holoprosencephaly. The relationship of encephaloceles and holoprosencephaly is discussed.

Subcortical arteriosclerotic encephalopathy (Binswanger): computerized tomography.

The subcortical arteriosclerotic encephalopathy of Binswanger is characterized clinically by hypertension, dementia, spasticity, syncope, and seizures. It is usually diagnosed pathologically by the finding in white matter of diffuse demyelination or foci of necrosis plus arteriosclerotic and hypertensive vasculopathy. We present a case in which the diagnosis was made on the basis of the clinical course and a computerized tomogram which demonstrated extensive white matter degeneration. Postmortem examination confirmed both the diagnosis and the extent of the degeneration as shown by CT scan.

Familial cavernous angiomas.

Cavernous angiomas are rare, surgically remediable vascular malformations of the CNS that may be characterized by hemorrhage, seizures, or focal neurologic deficits. Three families with cavernous angiomas have been described, and we report two more. In the first, the mother died suddenly with headache. A pontine cavernous angioma was found at autopsy in one son. His brother has similar pontine signs and a radiographically proved pontine mass. The brother's son has seizures and a calcified cerebral lesion. In the second family, the father had a cavernous angioma excised from the caudale. One of the daughters had a hemorrhagic mass removed from the spinal cord. Another daughter has seizures and a temporal lobe vascular lesion proved angiographically. Awareness of the possibility of familial involvement may aid in diagnosis of cavernous angioma.

The follow-up CT scan in childhood meningitis.

CT in childhood bacterial meningitis has indicated that bacterial meningitis is more than an inflammation of the subarachnoid space; it is a disease process which often exerts a profound effect on the brain parenchyma. In some cases ventricular widening may be a reflection of loss of brain substance rather than increased intracranial pressure. A vasculitis may occur in cerebral vessels with consequent ischemic infarct. The abnormalities found on CT during the acute illness are frequently persistent.

Descending tentorial herniation: findings on computed tomography.

Descending tentorial herniation (DTH) can be diagnosed by computed tomography. Encroachment upon the lateral aspect of the suprasellar cistern is an early sign of impending tentorial herniation. Actual herniation is evidenced by rotation and shift of the brain stem with consequent widening of the crural and ambient cisterns on the side of the space-occupying lesion. In a more advanced stage of herniation, obliteration of cisternal spaces at the tentorial level will occur. Aqueductal compression secondary to the herniation will cause increased intraventricular pressure with widening of those parts of the lateral ventricles that are not exposed to the compression by the mass; a characteristic finding is widening of the temporal horn on the side opposite the space-occupying lesion. Infarction in the territory of the posterior cerebral artery may complicate DTH.

Contralateral temporal horn widening in unilateral supratentorial mass lesions: a diagnostic sign indicating tentorial herniation.

Tentorial herniation secondary to supratentorial mass lesions will cause aqueductal compression and raised intraventricular pressure. Under ordinary circumstances, a raised intraventricular pressure will result in the development of hydrocephalus, but, in the presence of a large supratentorial mass, it is impossible for a generalized hydrocephalus to develop; only those parts of the ventricular system that are somehow shielded from the pressure effect of the mass lesion will be able to dilate. This dilatation will most frequently involve the contralateral temporal horn. Often, the atrium of the ventricle and the occipital horn will also be involved and, occasionally, the entire ventricle on the side opposite the mass will be dilated. The association of a large supratentorial mass with considerable shift of midline structures and computed tomography findings of a dilated contralateral temporal horn should be considered indicative of tentorial herniation, unless there are signs of preexisting atrophy or other preexisting disease processes that could have caused widening of the temporal horn.