Case 295: Pseudomyxoma from Mucinous Adenocarcinoma of the Appendix Extending from the Retroperitoneum into the Thigh.

History A 57-year-old man with no remarkable past medical history presented to an outside institution with painless swelling in his right thigh of 6 months duration. He denied any trauma to the site. At that time, physical examination demonstrated swelling in his right upper thigh. All other work-up, including complete blood count and chest radiography, yielded negative results. The initial diagnosis was lymphangioma of the thigh. He continued to experience worsening swelling in his right upper thigh with no other symptoms over the next year. He was referred to our facility, where he underwent US evaluation of the thigh lesion, an MRI scan encompassing the entire extent of his thigh lesion, and a CT scan of his abdomen and pelvis.

Hemoperitoneum associated with uterine fibroids: A case report.

INTRODUCTION: Uterine fibroids, which are common benign tumors, rarely cause acute complications. We herein report a case of hemoperitoneum associated with uterine fibroid that could be diagnosed preoperatively with contrast-enhanced computerized tomography (CT). PATIENT CONCERNS: A 48-year-old woman with uterine fibroid developed extremely severe lower abdominal pain on the first day of her menstrual period. DIAGNOSIS: Ultrasonography and contrast-enhanced CT revealed a uterine fibroid and extravasation from the dilated vessels of the uterine fibroid. INTERVENTION: Emergent abdominal hysterectomy was performed. OUTCOMES: The total amount of bleeding was 4,600 mL. Intraoperative blood salvage (1,357 mL), 6 units of red blood cells, 4 units of fresh frozen plasma, and 20 units of platelet concentrates were transfused. The postoperative course was uneventful. Pathological examination confirmed a benign uterine fibroid. CONCLUSION: CT could be useful to determine a diagnosis for bleeding from ruptured subserosal uterine fibroid.

Quiste del canal de Nuck, a propósito de un caso / Canal of Nuck cyst; a case report

El descenso de estructuras inicialmente intraabdominales hacia la región inguinal arrastra consigo una evaginación de peritoneo parietal: el canal de Nuck. Su obliteración incompleta permitirá el paso de líquido o estructuras abdominales originando un hidrocele de dicho canal o hernias inguinales indirectas. El quiste del canal de Nuck se presenta como una masa fluctuante, elástica y no reductible, ecográficamente quística, bien delimitada, de pared ecogénica fina y contenido anecoico, sin señal Doppler color. El diagnóstico diferencial incluye hernias, adenomegalias, enfermedad vascular, tumoral, etc. Aunque el diagnóstico definitivo es histopatológico, la ecografía es una técnica accesible, eficiente y fiable, que permite el estudio dinámico y en tiempo real

The descent of initially intra-abdominal structures towards the inguinal region leads to an evagination of the parietal peritoneum, and is called the canal of Nuck. Its incomplete obliteration will allow the passage of liquid or abdominal structures, leading to a hydrocele of the said canal or indirect inguinal hernias. The canal of Nuck cyst appears as a fluctuating, elastic and non-reducible mass, cystic in the ultrasound, and well-defined with a thin echogenic wall and an anechoic content, with no colour Doppler signal. The differential diagnosis includes hernias, adenomegalies, vascular pathology, and tumours. Although the definitive diagnosis is histopathological, ultrasound is an accessible, efficient and reliable technique, which allows dynamic and real-time study

Resonancia magnética en pacientes con catéteres peritoneales autoposicionantes: ¿se puede? / Magnetic resonance imaging in patients with self-locating peritoneal catheters: Is it safe?

La presencia de una pieza de metal en el extremo de los catéteres autoposicionantes provoca dudas e incertidumbres a la hora de realizar una resonancia magnética (RM) a pacientes que portan este tipo de catéter. Simulamos un peritoneo con un catéter lastrado para comprobar el comportamiento del catéter durante la realización de una resonancia en equipos 1,5 T y 3 T. Y revisamos los casos en los que se realizaron RM en pacientes con este tipo de catéter. En la simulación, la punta del catéter peritoneal autoposicionante provoca un artefacto de susceptibilidad magnética que dificulta la visión de zonas cercanas, pero se comporta como dispositivo seguro para la RM. Se realizaron 14 RM en pacientes con catéteres autoposicionantes, ninguna en la zona abdominal. No hubo complicaciones en los pacientes ni en la técnica tras la realización de RM

The fact that self-locating catheters have a piece of metal at the tip leads to doubt and uncertainty around performing magnetic resonance imaging (MRI) in patients with this type of catheter. We simulated a peritoneum with a weighted catheter to ascertain how the catheter behaved during MRI scans in 1.5 T and 3 T machines. We also reviewed cases in which MRI had been performed in patients with this type of catheter. In the simulation, the tip of the self-locating peritoneal catheter caused a magnetic susceptibility artefact that made it difficult to see nearby areas, but it proved to be a safe device for MRI. 14 MRI scans were performed in patients with self-locating catheters, none in the abdominal area. There were no complications in the patients or the technique after performing MRI

Peritoneal cavity circumference on computed tomography predicts outcomes in acute pancreatitis.

OBJECTIVES: We investigated the role of novel intra-abdominal parameters measured by computed tomography (CT) in the prediction of clinical outcomes in acute pancreatitis (AP). METHODS: Patients with AP underwent an abdominal CT scan on admission to define different intra-abdominal parameters (abdominal circumference, peritoneal cavity circumference, intraabdominal visceral fat area, and subcutaneous fat area) at the L2-L3 level using the open-source image analysis software Osirix Lite v.11.0.4 to predict clinical outcomes. RESULTS: Eighty patients with AP were analyzed. Peritoneal cavity circumference (PCC) was the only variable independently associated with outcomes. PCC showed an area under ROC for prediction of severity in AP of 0.830. A PCC ≥ 85 cm increased the risk of severity of AP (RR 15.7), persistent systemic inflammatory response syndrome (RR 9.3), acute peripancreatic fluid collection (RR 6.4), necrotizing pancreatitis (RR 21.50), and mortality (RR 2.4). We found a 4.7-fold increase in the risk of developing severe AP for each 10 cm increase in PCC. CONCLUSIONS: PCC measurement at the L2-L3 level using a non-enhanced abdominal CT scan on admission in patients with AP is useful in the early prediction of severity, persistent systemic inflammatory response syndrome, local complications, and mortality.

Complicaciones vasculares tras paracentesis / No disponible

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The Lesser Sac and Foramen of Winslow: Anatomy, Embryology, and CT Appearance of Pathologic Processes.

OBJECTIVE. This article reviews the embryologic development, relevant anatomy, and imaging features, on CT, of pathologic processes involving the lesser sac and foramen of Winslow. CONCLUSION. The lesser peritoneal sac is an intricate anatomic region involved in many disease processes. It is a significant conduit for the spread of disease within the peritoneal cavity. The spectrum of pathologic processes pertaining to the lesser sac can be classified on the basis of the type of involvement, such as a fluid collection (e.g., transudate, exudate, bile, and blood), a mass (e.g., neoplastic or nonneoplastic conditions and lymphadenopathy), or an internal hernia into the lesser sac.

Free gas in the peritoneal cavity after colonoscopy. Indication for immediate action or incidental finding in imaging tests after uncomplicated colonoscopy? Literature review.

Colonoscopy is a routine diagnostic and therapeutic procedure. Along with the increase in the complexity of the procedures performed, the risk of complications increases. In 2017, WSES (World Society of Emergency Surgery) published the principles of safe colonoscopy. Intestinal perforation is one of the most common complications. The risk of perforation in treatment procedures such as mucosectomy or endoscopic dissection is significantly greater than the risk of diagnostic colonoscopy. The basic rule of the procedure in case of suspected perforation is close supervision over the patient's condition and the soonest possible repair of damage. The role of the endoscopist is not only early recognition, but also early treatment of damage. Immediate endoscopic treatment of lesions is an effective, final and acceptable management strategy. In patients who have undergone imaging diagnostics for another reason, free gas in the peritoneal cavity can be recognized. It does not have to mean the need for urgent surgical intervention. Patients with asymptomatic pneumoperitoneum after colonoscopy should, however, be treated as patients with suspected perforation of the large intestine and undergo careful clinical observation in accordance with WSES recommendations. Colonoscopy is a procedure with a risk of complications, which should be reported to patients qualified for endoscopy, but appropriate management reduces the risk of morbidity and mortality associated with this procedure.

Binding of Targeted Semiconducting Photothermal Polymer Nanoparticles for Intraperitoneal Detection and Treatment of Colorectal Cancer.

Nanoparticles offer many promising advantages for improving current surgical regimens through their ability to detect and treat disseminated colorectal cancer (CRC). Hybrid Donor-Acceptor Polymer Particles (HDAPPs) have recently been shown to fluorescently detect and thermally ablate tumors in a murine model. Here, HDAPPS were functionalized with hyaluronic acid (HA) to improve their binding specificity to CT26 mouse CRC cells using HA to target the cancer stem cell marker CD44. In this work, we compared the binding of HA functionalized HDAPPs (HA-HDAPPs) in in vitro, ex vivo, and in vivo environments. The HA-HDAPPs bound to CT26 cells 2-fold more in vitro and 2.3-fold higher than un-functionalized HDAPPs ex vivo. Compared to intraoperative abdominal perfusion, intraperitoneal injection prior to laser stimulation for nanoparticle heat generation provides a superior modality of HA-HDAPPs delivery for CRC tumor selectivity. Photothermal treatment of disseminated CRC showed that only HA-HDAPPs delivered via intraperitoneal injection had a reduction in the tumor burden, and these nanoparticles also remained in the abdomen following resolution of the tumor. The results of this work confirm that HA-HDAPPs selectively bind to disseminated CRC, with ex vivo tumors having bound HA-HDAPPs capable of photothermal ablation. HA-HDAPPs demonstrated superior binding to tumor regions compared to HDAPPs. Overall, this study displays the theranostic potential of HDAPPs, emphasizing their capacity to detect and photothermally treat disseminated CRC tumors.

Experimental studies on computed tomographic peritoneography. Peritoneal and residual renal function tolerance to iodinated contrast media injected into the peritoneal cavity.

Computed tomographic (CT) peritoneography has been widely used as reference standard to evaluate continuous ambulatory peritoneal dialysis-related complications. However, given the varying CT peritoneography approaches used across different institutions, there is no standard value for non-ionic iodinated contrast media (ICM) concentration. Few studies have currently investigated whether non-ionic iodinated contrast media (non-ionic ICM) affects peritoneal function or residual renal function (RRF). This study aimed to determine whether different non-ionic ICM concentrations affect peritoneum and RRF and attempted to evaluate CT peritoneography images to identify the optimal non-ionic ICM concentrations in animals. To this end, 25 male Sprague-Dawley rats were used to establish uraemic models, after which they were injected with a 40-mL mixture of peritoneal dialysate and iohexol at varying concentrations prior to CT peritoneography. Thereafter, two experienced radiologists blinded to the rat groupings evaluated image quality, peritoneal morphology and thickness were assessed using hematoxylin and eosin and Masson staining, and RRF was evaluated using serum creatinine levels hematoxylin and eosin staining of pathological kidney sections. Briefly, non-ionic ICM had negligible effects on the peritoneum and RRF. Our results suggest that a mixture containing 50 mL (350 mgI/mL) iohexol/2 L peritoneal dialysate can be used as reference in rats.

Three-dimensional morphogenesis of the omental bursa from four recesses in staged human embryos.

The omental bursa (OB) is a complex upper abdominal structure in adults. Its morphological complexity stems from embryonic development. Approximately 200 years ago, the first theory regarding OB development was reported, describing that the OB developed from changes in the position of the stomach and its dorsal mesentery. Thereafter, the second theory reported that the OB originated from three recesses: the right pneumato-enteric recess (rPER), hepato-enteric recess (HER), and pancreatico-enteric recess (PaER). However, the first theory, focusing on the rotation of the stomach, is still described in certain modern embryology textbooks. These two coexisting embryological theories deter the understanding of the anatomical complexity of the OB. This study aimed to unify these two theories into realistic illustrations. Approximately 10 samples per stage among Carnegie stage (CS) 13 and CS21 were microscopically observed and histological serial sections of the representative samples were aligned using the new automatic alignment method. The aligned images were segmented computationally and reconstructed into 3D models. The rPER and the HER encompassed the right half circumference of the esophagus and the stomach at CS13 and CS14, the PaER spread dorsal to the stomach and formed a discoid shape at CS15 and CS16, the infracardiac bursa (ICB) was separated by the diaphragm at CS17 and CS18, and the fourth recess, which we called the greater omental recess (GOR), extended caudally from the PaER among CS19 and CS21. The present results indicate that the fourth recess is also the origin of the OB. These two theories over 200 years can be generally unified into one embryological description indicating a new recess as the origin of the OB.

Desmoplastic small round-cell tumour of the peritoneal cavity: case report and literature review.

Desmoplastic small round-cell tumour is a very rare neoplasm, which usually arises from the abdominal or pelvic peritoneum of adolescents and young adults. Early diagnosis is difficult, because most tumours present with non-specific gastrointestinal symptoms after a long asymptomatic period. It is generally a very aggressive tumour, which grows rapidly with poor prognosis and an overall five-year survival rate of 15% despite multimodal treatment. Despite multiple treatment strategies, the management of desmoplastic small round-cell tumour still remains a clinical challenge and no consensus about a therapeutic protocol has been established. A 35-year-old man presented with mild abdominal pain, constipation and weight gain, and was eventually diagnosed with desmoplastic small round-cell tumour, which was shown to be limited to the abdomen. After incomplete debulking surgery, radiotherapy and chemotherapy, he developed multiple metastatic nodular foci in chest and the pleura and, unfortunately, he died due to disease progression.

Value of magnetic resonance/computed tomography peritoneography technique in the evaluation of dialysate leakage and hernia following peritoneal dialysis.

Magnetic resonance and computed tomography peritoneography are diagnostic imaging procedures that involve the intraperitoneal administration of a mixture of contrast material and dialysate for direct visualization of the peritoneal cavity and assessment of the integrity of peritoneal membrane. In a clinical series of patients with end-stage renal disease treated with continuous ambulatory peritoneal dialysis, who presented with genital or low abdominal edema, advanced peritoneographic imaging studies allowed direct visualization of the dialysate leakage and peritoneal hernias. Both magnetic resonance and computed tomography peritoneographic procedures allowed accurate diagnosis of continuous ambulatory peritoneal dialysis-related complications that may need to be addressed promptly so that the effectiveness of continuous ambulatory peritoneal dialysis is not compromised.

New, simple and reliable volumetric calculation technique in incisional hernias with loss of domain.

INTRODUCTION: The management of hernias with loss of domain is a challenging problem. It has been shown that the volume of the incisional hernia/peritoneal volume ratio < 20% was a predictive factor for tension-free fascia closure, after pre-operative pneumoperitoneum preparation (Goni Moreno technique). In this study, we propose an easy, reliable and fast technique to perform volumetric calculation, by the surgeon alone. MATERIALS AND METHODS: 3D slicer software (free open-source software) was used to calculate with precision the intra-peritoneal and intra-hernia volumes, and to create a 3D reconstruction of both volumes. The measurement technique is described step by step using detailed figures and videos. RESULTS: The method was used to calculate the volumes for five consecutive patients, managed between January 2018 and March 2019. All the five patients had a ratio greater than 20% and, therefore, received a PPP program. The effectiveness of the procedure is objectified by the increase of the intraabdominal volume and the reduction of the incisional hernia/peritoneal volume ratio. The feasibility of a tension-free fascia closure was confirmed for the five patients. CONCLUSION: In addition to a standardized definition of "loss of domain", a standardized volumetric technique, easy to reproduce, needs to be adopted. Our method can be done by any surgeon with basic computer skills and radiological knowledge in an autonomous and a fast manner, thus helping to select the right technique for the right patient.