Laparoscopic omental filling with intraoperative endoscopy for a perforated duodenal ulcer.

As a surgical treatment for a perforated duodenal ulcer, duodenal omental filling is effective. However, filling the perforation site with a sufficient amount of omentum is difficult in some situations. We herein report that we successfully filled a perforated duodenal ulcer with a sufficient amount of omentum using intraoperative endoscopy. The operation was performed with three ports, the operation time was 110 min, and the estimated blood loss was small. The postoperative course was good. No stenosis of deformity of the duodenum was observed on follow-up endoscopy. Laparoscopic surgery has a shorter operation time, shorter postoperative hospital stay, and less postoperative pain than open surgery. The combined use of intraoperative endoscopy with laparoscopic surgery is effective for a large perforation, and it can be expected to reduce the rate of conversion to open surgery. This combined procedure is considered useful as a laparoscopic omental filling operation.

Case of cecal volvulus successfully treated with endoscopic colopexy.

We herein report a case of cecal volvulus successfully treated with endoscopic colopexy. A 73-year-old man with a high fever and abdominal fullness was diagnosed with ileus caused by cecal volvulus. CT showed a dilated cecum and small intestine without bowel strangulation as well as acute pneumonia. Because the pneumonia increased the risk associated with general anesthesia, we attempted decompression of the bowel using endoscopy to avoid surgery. On day 1, a transanal ileus tube was inserted to the terminal ileum through the dilated cecum. On day 7, the bowel torsion spontaneously released. On day 8, we performed percutaneous endoscopic colopexy to fix the cecum on the abdominal wall and prevent re-twisting. The patient was discharged on day 15 without postoperative complications. Percutaneous endoscopic colopexy for cecal volvulus may be a treatment option when the risk associated with general anesthesia or surgery is high because of a comorbidity.

Efficacy of the projection onto convex sets (POCS) algorithm at Gd-EOB-DTPA-enhanced hepatobiliary-phase hepatic MRI.

PURPOSE: To investigate the efficacy of the projection onto convex sets (POCS) algorithm at Gd-EOB-DTPA-enhanced hepatobiliary-phase MRI. METHODS: In phantom study, we scanned a phantom and obtained images by conventional means (P1 images), by partial-Fourier image reconstruction (PF, P2 images) and by PF with the POCS algorithm (P3 images). Then we acquired and compared subtraction images (P2-P1 images and P3-P1 images). In clinical study, 55 consecutive patients underwent Gd-EOB-DTPA (EOB)-enhanced 3D hepatobiliary-phase MRI on a 1.5T scanner. Images were obtained using conventional method (C1 images), PF (C2 images), and PF with POCS (C3 images). The acquisition time was 17-, 14-, and 14 s for protocols C1, C2 and C3, respectively. Two radiologists assigned grades for hepatic vessel sharpness and we compared the visual grading among the 3 protocols. And one radiologist compared signal-to-noise-ratio (SNR) of the hepatic parenchyma. RESULTS: In phantom study, there was no difference in signal intensity on a peripheral phantom column on P3-P1 images. In clinical study, there was no significant difference between C1 and C3 images (2.62 ± 0.49 vs. 2.58 ± 0.49, p = 0.70) in the score assigned for vessel sharpness nor in SNR (13.3 ± 2.67 vs. 13.1 ± 2.51, p = 0.18). CONCLUSION: The POCS algorithm makes it possible to reduce the scan time of hepatobiliary phase (from 17 to 14 s) without reducing SNR and without increasing artifacts.

Acute gastric volvulus in a patient with trisomy 21.

Acute gastric volvulus is a torsion of the stomach by more than 180° and a life-threatening condition. We present a 50-year-old male patient with acute abdominal pain who has Down syndrome/trisomy 21. Computed tomography showed a significant distended stomach with features of a severe gastric volvulus. Emergency operation in form of reduction and gastropexy was performed. We are not aware of any similar cases published in the English literature, where as gastric volvulus occurred in a patient with Down syndrome.

Contrast enhancement during hepatic computed tomography: effect of total body weight, height, body mass index, blood volume, lean body weight, and body surface area.

OBJECTIVE: The objective of this study was to evaluate the effect of total body weight, height, body mass index, blood volume, lean body weight, and body surface area (BSA) on aortic and hepatic contrast enhancement during hepatic computed tomography (CT). METHODS: We calculated the changes in the CT number per gram of iodine ((Δ Hounsfield units/g [ΔHU/g])) for the aorta and the liver during portal venous phase. We performed linear regression analyses between ΔHU/g and each of the body parameters. RESULTS: ΔHU/g and BSA showed the strongest inverse correlation. The correlation coefficients for the aorta and liver were 0.70 and 0.68 for ΔHU/g and total body weight, 0.41 and 0.37 for height, 0.54 and 0.55 for body mass index, 0.68 and 0.59 for blood volume, 0.70 and 0.62 for lean body weight, and 0.71 and 0.68 for BSA, respectively (P < 0.001 for all). CONCLUSION: Our study supports the use of a protocol with iodine dose adjusted for the patient BSA.

Successful conservative treatment of pneumatosis intestinalis associated with intraperitoneal free air: report of a case.

While pneumatosis intestinalis (PI) is a rare condition associated with a wide variety of underlying diseases, PI with intraperitoneal free air and ascites is extremely uncommon and is difficult to distinguish from diffuse peritonitis. We herein describe the case of an 87-year-old male who was admitted to our hospital with abdominal pain, distension and nausea. Abdominal plain radiography and computed tomography revealed intramural air collection in the entire intestine, intraperitoneal free air and ascites. Although we first suspected bowel necrosis and perforation, his physical findings and the properties of the diagnostic abdominal paracentesis did not support this diagnosis. Therefore, we selected conservative management, and the intramural air, intraperitoneal free air and ascites disappeared 1 week later. Recognition of the possible presence of non-surgical PI and intraperitoneal free air, although it is extremely rare, is important to avoid a misdiagnosis and the associated unnecessary surgical intervention.

Abdominal dynamic CT in patients with renal dysfunction: contrast agent dose reduction with low tube voltage and high tube current-time product settings at 256-detector row CT.

PURPOSE: To evaluate the feasibility of a low-contrast agent dose protocol at abdominal dynamic computed tomography (CT) with a low tube voltage high tube current-time product technique and a 256-detector row CT unit. MATERIALS AND METHODS: This prospective study received institutional review board approval; written informed consent to participate was obtained from all patients. The study included 151 patients; 117 had an estimated glomerular filtration rate (eGFR) greater than or equal to 60 mL/min/1.73 m(2). These patients were examined with the conventional 120-kVp protocol. The other 34 patients underwent scanning with an 80-kVp tube voltage, a high tube current-time product, and a 40% reduction in contrast agent dose. Effective dose (ED), image noise, attenuation, contrast-to-noise ratio (CNR), and figure of merit of the aorta in the arterial phase and of the portal vein and hepatic parenchyma in the portal venous phase in the two groups were compared with the Student t test. RESULTS: Estimated ED was about 20% lower with the 80-kVp protocol than with the 120-kVp protocol. There were no significant differences in CNR in any region of interest between the 80-kVp protocol and the 120-kVp protocol (abdominal aorta: 36.9 ± 9.7 [standard deviation] vs 36.1 ± 8.1, P = .63; portal vein: 13.4 ± 3.2 vs 13.1 ± 3.2, P = .65; hepatic parenchyma: 6.4 ± 2.6 vs 6.7 ± 2.3, P = .51). CONCLUSION: Contrast dose at hepatic dynamic 256-detector row CT in patients with renal dysfunction can be decreased by 40% with this protocol by using the 80-kVp setting and a high tube current-time product.

Resectable gallbladder cancer presenting with acute pancreatitis caused by hemobilia.

A 79-year-old female was transferred to our hospital because of suspicion that her acute pancreatitis was caused by stone impaction in the common bile duct (CBD). Laboratory examination showed aspartate aminotransferase, 1645 U/l; alanine aminotransferase, 476 U/l; amylase, 1365 U/l; and white blood cells, 10700/µl. Computed tomography (CT) showed an enhanced tumor in the neck of the gallbladder, an abnormal CBD filled with a high-density area, and localized swelling in the head of the pancreas. Magnetic resonance cholangiopancreatography also showed a low-intensity area in the CBD. Endoscopic retrograde cholangiopancreatography showed coagulated blood discharged from the papilla of Vater. The diagnosis was acute pancreatitis caused by impaction of coagulated blood from a gallbladder tumor. A curative operation was performed 10 days after endoscopic bile duct drainage. Gallbladder cancer (GBCa) has no special symptoms and is usually diagnosed at an advanced stage; however, hemobilia and acute pancreatitis are unusual as an initial presentation of GBCa.