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Aim: locally advanced distal rectal cancer (LADRC) patients managed with non-operative management (NOM) with complete clinical response following neoadjuvant treatment will experience local regrowth in about 25% of cases. The long-term risks of this strategy or local regrowth treatment have not been well established, and the main concern is the probability of impaired oncological outcomes after salvage surgery. This study aimed to evaluate the feasibility and clinical outcomes of salvage surgery in LADRC patients with local regrowth following NOM. Method: all locally advanced, distal rectal cancer patients managed with NOM after neoadjuvant therapy with clinical complete response, who developed local regrowth during surveillance, between May 2016 and November 2018, were enrolled in the study. Patients were analyzed for the rate of salvage surgery, disease-free survival and overall survival. Results: eleven out of 63 (17.5%) patients developed local regrowth after a mean of 8.4 (3-15) months. The mean surveillance period was 31.8 (14- 50) months. Eleven (100%) patients underwent salvage surgery due to the principles of total mesorectal excision. LE was not performed. No patients experienced local recurrence and three out of eleven (27.3%) developed carcinomatosis peritonei and/or distant metastasis after a mean surveillance period of 12.2 (3-26) months. At 30 months, the local and/or systemic recurrence rate, disease-free survival, and overall survival in the patients undergoing surgical treatment were 100%, 73%, 73% and 91%, respectively. Conclusion: the vast majority of patients with regrowth following NOM were suitable for salvage surgery with curative intent and justifiable pelvic tumor control., NA

Acinar cystic transformation (ACT) of the pancreas is a rare non-neoplastic cystic lesion. It is most frequently observed in the head of the pancreas. Despite advances in radiologic imaging methods, preoperative diagnosis of acinar cystic transformation is difficult, it is often confused with other cystic lesions. Here, we report three cases of acinar cystic transformation, one of which showed diffuse involvement of the pancreas, and the remaining two were multilocular localized cystic lesions. We analyzed their histomorphologic and immunohistochemical features. The patients’ ages ranged between 15 and 43 years and the ratio of females to males was 2:1. On microscopic examination, the cysts were lined by a single layer of flattened-cuboidal or columnar epithelial cells. The epithelial cells were diffusely positive with trypsin and keratin 7, but patchy with keratin 19. Due to its rarity and lack of radiologic and clinical awareness compared with other pancreatic cystic lesions, preoperative diagnosis of acinar cystic transformation is difficult and not definitive. All cases reported to date have been clinically benign and there is no evidence of recurrence or malignant transformation. The optimal treatment and whether to perform surgery remain controversial.

Rupture of a metastatic liver tumor associated with laryngeal cancer is a very rare complication with no previous case in the literature. We present a case of ruptured liver metastases which was treated conservatively. Dynamic contrast-enhanced computed tomography demonstrated active extravasation and discontinuity of liver capsule. When the patient came to our hospital from the external medical center, we did not see active extravasation on control computed tomography. This case highlights the role of radiologic imaging in the diagnosis and follow-up of ruptured hepatic metastases.

OBJECTIVES Treating aortic arch aneurysms with conventional open surgical and endovascular stent graft procedures is challenging due to the complex anatomy of the arch and the arteries arising from it that nourish the brain. Cerebral protection is of the utmost importance during the treatment of thoracic aneurysms involving the aortic arch. METHODS Between May 2014 and November 2018, 7 patients with thoracic aortic aneurysms involving the aortic arch who underwent aortic arch cervical debranching with our technique were reviewed retrospectively. Because all the patients being considered for conventional surgical aortic arch replacement had serious comorbidities, they were selected to receive hybrid therapy. The mean age of the patients was 71.2 ± 9.4 years. One patient was a woman and 6 patients were men. One patient was given general anaesthesia; the remaining 6 patients had a regional block. A crossover temporary bypass was performed between the external carotid arteries with a 6-mm polytetrafluoroethylene graft for cerebral protection in all patients. Thoracic endovascular aortic repair (TEVAR) was successfully performed in all patients except 1 following debranching. RESULTS Neurological complications did not occur during the procedures. Patients were followed for a mean of 18.3 ± 4.9 months. One female patient died of exacerbating chronic obstructive pulmonary disease within the first follow-up year. Three other patients died: 1 died of natural causes; 1 died of pneumonia followed by multiorgan failure; and 1 died of myocardial infarction during the mid-term follow-up period. The remaining patients are still being followed and are event free. CONCLUSIONS Endovascular treatment of thoracic aortic diseases involving the aortic arch is facilitated when the aortic arch is debranched. Our cerebral protection method with a temporary crossover bypass between the external carotid arteries provides continuous pulsatile blood flow to the brain; hence, neurologically, it is a reliable procedure. The follow-up results of the patients who underwent aortic arch cervical debranching followed by TEVAR depended on their comorbidities.

Purpose To determine technical feasibility and results of stent-assisted coiling of visceral artery aneurysms (VAAs) with self-expandable LEO PLUS neurointerventional stent. Materials and Methods In this retrospective study, 11 consecutive patients (mean age 61.9 y ± 8.9; range, 45–76 y) with VAAs (splenic, n = 3; common hepatic, n = 2; renal, n = 5; celiac, n = 1) treated with neurointerventional stents were included. MR angiography was evaluated for aneurysmal occlusion and patency of the parent arteries. Results Technical success was 90.9%. A minor technical complication developed in 1 patient (9%), and thrombosis of the distal part of the stent was seen just after deployment in another patient, but it resolved after tirofiban injection. Complete occlusion was determined in all patients on MR angiography at 6-month follow-up. Conclusions Self-expandable LEO PLUS neurointerventional stents could become a useful tool in the treatment of VAAs. Studies with larger groups of patients, including control groups, are needed to assess the true outcome of this treatment method.

OBJECTIVE The aim of this study was to determine the nature of spontaneous regression of liver hemangiomas. PATIENTS AND METHODS The records of the liver hemangioma patients who attended the out-patient clinic between 1988 and 2018 were evaluated. The data of the 716 adult patients who were followed for at least 3 years with cross-sectional imaging were analyzed. RESULTS Spontaneous regression was documented in 46 patients (6.4%). Twenty-eight patients had a single hemangioma (61%), eight (17%) had two hemangiomas; the other 10 patients had 3-6 hemangiomas. Of the 87 lesions in 46 patients, 69 actually regressed during the study. Twelve patients with more than one lesion exhibited discordant courses - one of the hemangiomas of a patient with multiple lesions regressed, whereas the other enlarged or remained stable. Eleven of the regressed hemangiomas exhibited enlargement first, followed by spontaneous regression. Fourteen (20%) of the regressed hemangiomas acquired atypical characteristics that would have suggested a malignancy had the original films been unavailable. CONCLUSION Spontaneous regression of liver hemangiomas is an underrecognized phenomenon. Enlargement should not be a straightforward indication for intervention because it may be followed by regression. A regressed hemangioma should be considered in the differential diagnosis of liver lesions suspicious for malignancy.

Purpose Among various staple-line reinforcement methods applied during sleeve gastrectomy (SG), although data on full-thickness-continuous-suturing (FTCS) is nearly nil, it has been considered as potentially harmful. The safety/efficacy profile of FTCS is assessed. Methods All consecutive SGs completing 3-month follow-up were studied. Data on peri-operative parameters, complications, and follow-up were prospectively recorded. All reinforcements were completed by FTCS utilizing barbed suture. Super-super obese, secondary SGs, SGs performed in patients with prior anti-reflux surgery, and SGs performed with additional concomitant procedures were evaluated as “technically demanding” SGs. Student’s t/chi-square tests were used as appropriate. Results Between January 2012 and July 2020, 1008 SGs (941 “primary-standard,” 67 “technically demanding”) were performed without mortality/venous event. Single leak occurred in a patient with sleeve obstruction (0.1%). Thirteen bleedings, 4 requiring re-surgery (0.4%), and 17 stenoses (1.7%) were encountered. Four stenoses were treated with gastric bypass (1 emergency), 6 by dilatation(s), and one required parenteral nutrition. Six patients with stenosis chose not to have any treatment. No statistically significant difference was observed in postoperative complications between “primary-standard” and “technically demanding” SGs (p > 0.05). The median follow-up was 44 months. The excess weight loss % at 5th year was 80.1%. Suturing added 28.4 ± 6 minutes to the SG, 3 or fewer sutures were used to complete the reinforcement in > 95%. No mishap/complication occurred related to suturing. Conclusion FTCS produced excellent result in terms of leakage/hemorrhage with an acceptable stenosis rate at a low cost with half-an-hour increase in the operating time. In contrast to previous allegations, no harm attributable to stitching itself occurred. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02161-5.

Amaç: Bu çalışmada, torasik stent greft uygulanmış hastaların uzun dönem sonuçlarının değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Kliniğimizde sadece stent greft ile ya da hibrid yöntem (cerrahi sonrası endovasküler girişim) ile tedavi edilmiş torasik aort patolojili, yaş ortalaması 67,1 (20-82) olan 25 hastayı retrospektif olarak değerlendirdik. Bulgular: Hastalardan 23’ü elektif olarak tedavi edilirken, 2’si acil olarak işleme alınmıştır. Kontrol görüntülemelerde 5 hastada tip 1A endoleak izlenmiştir. Bu hastalardan 3’üne ek girişim uygulanmıştır. Hastalardan birisinde endoleak takip sırasında kendiliğinden regrese olmuştur. 1 hastada ise post-op 6. günde MI nedeniyle ex olmuştur. Toplam 7 hastada hibrid işlem uygulanmıştır. Debranching uygulanan hastalardan bir tanesinde endovasküler işlem sırasında majör komplikasyon gelişmiştir. Hibrid girişim uygulanan 7 hastadan 1’i olan tip B diseksiyon hastasında işlem sonrası kontroller sırasında nörolojik komplikasyon izlenmiştir. Sonuç: Endovasküler torakal stent greft işlemi torakal aort patolojilerinde yüksek teknik başarı ve sağ kalım oranları ile uygulanmaktadır. Tek başına TEVAR’a uygun olmayan anatomiye sahip hastalarda hibrid girişim tercih edilmektedir. Objective: The aim of this study was to evaluate the long-term results of patients who underwent thoracic stent grafting. Material and Method: We retrospectively evaluated 25 patients with a mean age of 67.1 (20-82) with thoracic aortic pathology treated with a stent graft or the hybrid method (endovascular intervention after surgery) in our clinic. Results: 23 patients were treated electively and 2 of them were treated urgently. Type 1A endoleak was observed in 5 patients in control imaging. Additional intervention was performed in 3 of these patients. In one patient, the endoleak spontaneously regressed during follow-up. One patient died on the 6th postoperative day due to MI. A total of 7 patients underwent hybrid procedures. One of the debranching patients developed major complications during endovascular procedure. In the type B dissection patients, neurological complications were observed during post-procedure controls in 1 of the 7 patients who underwent hybrid intervention. Conclusion: Endovascular thoracic stent grafting is performed with high technical success and survival rates in thoracic aortic pathologies. Hybrid intervention is preferred in patients with non-suitable anatomy for TEVAR alone.

Transarterial embolization of liver hemangiomas has not been considered to be consistently effective.The charts of 25 patients who underwent superselective transarterial chemoembolization with the bleomycin-lipiodol emulsion were evaluated retrospectively.Twenty-two patients had abdominal pain; asymptomatic/vaguely symptomatic enlargement was the treatment indication in three patients. A single session was conducted in 17 patients, two sessions in 7 and three sessions in one. After the first session, lesion volume decreased by median (range) 51% (10-92%) from median (range) 634 (226-8435) to 372(28-4710) cmTransarterial chemoembolization with the bleomycin-lipiodol emulsion is a potential alternative to surgery for symptomatic/enlarging liver hemangiomas. Volume reduction is universal, and symptom control is satisfactory. Centrally located and very large (1000 cm

Treatment of thoracic aortic aneurysms constitutes high mortality and morbidity rates despite improvements in surgery, anesthesia, and technology. Endovascular stent grafting may be an alternative therapy with lower risks when compared with conventional techniques. However, sometimes the branches of the aortic arch may require transport to the proximal segments prior to successful thoracic aortic endovascular stent grafting. Atherosclerosis is accounted among the etiology of both aneurysms and occlusive diseases that can coexist in the same patient. In these situations stent grafting may even be more complicated. In this report, we present the treatment of a 92-year-old patient with aortic arch aneurysm and proximal descending aortic aneurysm. For successful thoracic endovascular stent grafting, the patient needed an alternative route other than the native femoral and iliac arteries for the deployment of the stent graft. In addition, debranching of left carotid and subclavian arteries from the aortic arch was also required for successful exclusion of the thoracic aneurysm.

Amac: Diyabetli hastalarda baslica olum nedeni olan koroner arter hastaligi (KAH) hastalarin bir bolumunde sessiz seyreder. Bu calismanin amaci asemptomatik tip II diyabetli hastalarda gizli KAH prevalansini, mevcut plaklarin yayginligini, lokalizasyonunu ve ozelliklerini cok kesitli bilgisayarli tomografi anjiografi (CKBTA) ile degerlendirmektir. Gerec ve Yontem : Tip II diyabet tanili KAH acisindan asemptomatik olan 100 hasta CKBTA ile prospektif degerlendirildi. Kalsiyum skorlama amaciyla kontrastsiz goruntuler elde edildikten sonra i.v. kontrast madde verilerek 64 dedektorlu BT ile koroner anjiografik goruntuler alindi. Kontrastsiz goruntuler uzerinden koroner arter kalsiyum skoru hesaplandi ve plaklarin kalsiyum icerigi incelendi. Koroner angiografik goruntulerden elde edilen reformat goruntulerden ise plaklarin yayginligi, lokalizasyonu ve olusturduklari darlik dereceleri degerlendirildi. Kategorik degiskenlerin istatistiksel degerlendirilmesinde Pearson ki-kare testi ve Fisher gerceklik testi kullanildi. Bulgular: Calismaya dahil edilen 80 hastanin %72’si erkek (n=58) ve %27’si (n=22) kadindi. Ortalama yaslari 53±8 ve cekim esnasinda kalp hizlari ise 64±7 idi. 49 hastada (%61) aterosklerotik plak saptandi; Kalsifik plak en cok saptanan aterosklerotik plak tipiydi (%35), soft plak 9 (%11.3) hastanin en az bir koroner arter segmentinde saptandi. 14 (%17.5) hastada orta darlik, 11 (%13.7) hastada ciddi darlik ve boylelikle 25 (%31.3) hastada anlamli darlik (≥ %50) saptandi. Tek damar hastaligi (19, %23.7), iki damar hastaligi (15, %18.7), uc damar hastaligi (15, %18.7) saptandi. Sonuc: Diyabetli hastalarda asemptomatik KAH’in ortaya konmasinda CKBTA noninvazif ve guvenilir bir yontem olarak kullanilabilir

Dacron grafts are frequently used during surgical revascularization procedures. Complications including graft thrombosis and infection are well known; however, aneurysm formation is extremely rare. In this report, we describe dilatation of a Dacron graft detected four years after aortobifemoral bypass procedure in a 50-year-old male patient who was treated with endovascular stent grafting.

Background: Cardiac tamponade (CT) is a dreadful complication of laparoscopic antireflux surgery (LARS) with unknown incidence, and preventive measures are yet to be defined. Incidence during LARS with respect to usage/configuration of graft deployment is analyzed. Three-dimensional (3D) analysis of tack distribution provided anatomical insight to prevent cardiac injury. Materials and Methods: Data regarding the usage and configuration of graft deployment are retrieved from the prospective database. Grafting was posterior or posterior + anterior. Incidence of CT in all hiatoplasties is calculated. Tomography is reconstructed in 3D, showing the spatial distribution of the tacks. Tacks are numbered in the surgical video. Corresponding numbering is applied to the tacks in any particular tomography slice, utilizing the 3D images as an interface. A numbering-blinded radiologist is asked to identify the offending and the nonoffending tacks as the cause of tamponade. Tack-to-pericardium distances are recorded. Tacks having no measurable distance from the pericardium are regarded as offensive. Results: One CT occurred in 1302 consecutive LARS (0.076\%). The incidence is 0\% when no (379) or posterior (880) graft is used as opposed to 2.3\% rate in posterior + anterior (43) grafting. The distribution of offensive, nonoffensive but nearest, and safe tacks followed a pattern. All offensive tacks belonged to the anterior graft fixation, which we referred as the critical zone. Conclusion: CT during LARS is rare, and associated with graft fixation anterior to the hiatal opening. Avoiding graft fixation to the critical zone may prevent cardiac injury.

Background While administering medication through intramuscular injection, the ventrogluteal site must be used instead of the dorsogluteal site, and it is of great significance to locate the ventrogluteal site correctly. Objective To determine the reliability of two different methods used to determine the ventrogluteal site in intramuscular injection practice. Design A cross-sectional study. Settings A university hospital in Istanbul. Participants The study population comprised 120 randomly selected healthcare personnel at a university hospital. Methods The ventrogluteal site was determined using the geometric (G method) and V method and these sites were scrutinized under ultrasonography. It was investigated whether there was any anatomic vessels or neural structure present, and also determined the thickness of subcutaneous tissue, musculus gluteus medius, and musculus gluteus minimus. Results Of the participants, 65.8% were female and the average age was 32.30 years and body mass index was 25.31kg/m 2 . The results showed that G and V methods were statistically significant in terms of variables. It was also found that sex affects subcutaneous tissue thickness and the skin-bone margin in the G and V method, and that body mass index determines subcutaneous tissue, musculus gluteus medius thickness and skin-bone margin. Conclusion When the ventrogluteal site is used for intramuscular injection purposes, the site must be determined in line with the geometric method.

Duplicated common bile duct, often associated with conditions like lithiasis, biliary cysts and pancreatobiliary maljunction, could result in highly morbid and potentially fatal biliary injuries. Precise preoperative diagnosis and classification still remain a challenge. A female patient undergoing emergency laparoscopic cholecystectomy for acute calculous cholecystitis sustained iatrogenic bile duct injury. A drainage tube was placed into the injured duct for post-operative conservative management. Post-operative tube cholangiogram revealed a double common bile duct with cystic duct opening distally. This was identified as a new variant not previously reported or classified. However rare, duplicated common bile duct could result in serious iatrogenic bile duct injury if unidentified during surgery. Knowledge of its existence is essential to avoid such injuries as preoperative diagnosis still remains a challenge. A thorough clinical and morphological study of previously reported variants is needed for a comprehensive classification to encompass newly discovered variants.

Purpose The aim of our study is to demonstrate the feasibility of body diffusion weighted (DW) MR imaging in the evaluation of pancreatic islet cell tumors (ICTs) and to define apparent diffusion coefficient (ADC) values for these tumors. Materials and methods 12 normal volunteers and 12 patients with histopathologically proven pancreatic ICT by surgery were included in the study. DW MR images were obtained by a body-phased array coil using a multisection single-shot echo planar sequence on the axial plane without breath holding. In addition, the routine abdominal imaging protocol for pancreas was applied in the patient group. We measured the ADC value within the normal pancreas in control group, pancreatic ICT, and surrounding pancreas parenchyma. Mann–Whitney U-test has been used to compare ADC values between tumoral tissues and normal pancreatic tissues of the volunteers. Wilcoxon Signed Ranks Test was preferred to compare ADC values between tumoral tissues and surrounding pancreatic parenchyma of the patients. Results In 11 patients out of 12, conventional MR sequences were able to demonstrate ICTs succesfully. In 1 patient an indistinct suspicious lesion was noted at the pancreatic tail. DW sequence was able to demonstrate the lesions in all of the 12 patients. On the DW images, all ICTs demonstrated high signal intensity relative to the surrounding pancreatic parenchyma. The mean and standard deviations of the ADC values (×10−3 mm2/s) were as follows: ICT (n = 12), 1.51 ± 0.35 (0.91–2.11), surrounding parenchyma (n = 11) 0.76 ± 0.15 (0.51–1.01) and normal pancreas in normal volunteers (n = 12), 0.80 ± 0.06 (0.72–0.90). ADC values of the ICT were significantly higher compared with those of surrounding parenchyma (p Conclusion DW MR imaging does not appear to provide significant contribution to routine MR imaging protocol in the evaluation of pancreatic islet cell tumors. But it can be added to MR imaging protocol to detect the lesion in a limited number of patients with clinical suspicion for pancreatic ICT with negative or suspicious imaging findings.

Purpose To retrospectively review the outcomes of 21 patients with stab wounds to the gluteal region who underwent embolization for pseudoaneurysms causing active bleeding. Materials and methods Between 1997 and 2007, 3 superior gluteal artery, 2 inferior gluteal artery and 16 deep femoral artery muscular branch pseudoaneurysms detected by digital subtraction angiography were selectively catheterized with diagnostic catheters with hydrophilic coating and embolized with pushable springcoils. 17 of the 21 pseudoaneurysms were located in a distal end of an artery where outflow vessels could not be depicted. The other 4 lesions were side wall injuries which required the placement of coils distal and proximal to the injury site. Results Embolization was successful in controlling the bleeding in all of the patients. 16 patients required 1 or 2 coils, 4 patients required 3 coils and 1 patient required 5 coils. 2 patients had femoral puncture site hematomas which resolved spontaneously. 2 patients required surgical evacuation of large gluteal hematomas following the embolization because of symptoms second to mass effect. There were no procedure related major complications or mortality. Conclusions Our experience demonstrates that pushable coil embolization is a relatively simple, effective and economic method for the embolization of pseudoaneurysms caused by penetrating gluteal injuries. Experimenting with other embolization materials does not seem to be justified.

This prospective study was approved by the local institutional ethics committee, and written informed consent was obtained from all patients. The aim of this study was to determine whether the oral administration of a polyethylene glycol (PEG)-electrolyte solution induces adequate luminal distention for magnetic resonance (MR) colonography to be performed and to assess patient acceptance of this procedure. Fifty-five patients (26 women, 29 men; mean age, 60.5 years +/- 14 [standard deviation]; age range, 40-75 years) who were referred for optical colonoscopy (OC) owing to symptoms and findings that included rectal bleeding, altered bowel habits, and positive fecal occult blood test results participated in this study. Standard bowel preparation was performed 1 day before the procedure. MR colonography was performed and followed by OC on the same day. Before undergoing MR colonography, the patients received 2.0-2.5 L of the PEG-electrolyte solution orally. Adequate distention of all colonic segments was achieved in 50-53 (91%-96%) of patients imaged in the supine position and in 51-53 (93%-96%) of patients imaged in the prone position. Oral administration of the solution yielded uniform luminal darkening and sufficient colonic distention for MR colonography in 91%-96% of patients.

Horseshoe kidney is a rare congenital anomaly of the urinary system and a coexisting abdominal aortic aneurysm with a horseshoe kidney is associated with substantial surgical challenges. The horseshoe kidney has a variant arterial supply in the majority of patients with accessory renal arteries arising from the aorta or iliac arteries. These arteries are considered to be end arteries and renal tissue perfused with these vessels is under risk of infarction in case of compromise. Since the surgical approach is challenging and carries a high risk of complications, endovascular repair seems to be an attractive alternative when feasible. The purpose of this report is to describe our experience in the successful endovascular treatment of a patient who had the coexistence of an abdominal aortic aneurysm with a horseshoe kidney. The patient had an accessory isthmic artery which shared a common origin with the middle sacral artery which provided retrograde flow following stent-grafting. There was no loss of renal tissue following the intervention. This case demonstrates that accessory renal arteries in patients with horseshoe kidneys are not necessarily end arteries. Their careful analysis prior to the procedure is essential for rational therapy planning.

Virtual cystoscopy is a promising new technique based on computer-simulated rendering of the inner surface of the urinary bladder using volumetric magnetic resonance (MR) imaging data, thus enabling maneuvers that normally are not possible with conventional cystoscopy. Due to several distinct advantages over conventional cystoscopy such as minimal invasiveness, evaluation of the urethral orifice from a cranial point of view and an opportunity to observe diverticula formations and the inner urethral space, gadolinium-enhanced MR cystoscopy has a great potential for competing with conventional cystoscopy under some clinical circumstances. The recent improvement in MR scanners has significantly facilitated virtual cystoscopic evaluation of the urinary bladder lumen by MR imaging. Volumetric data associated with powerful postprocessing procedures allow imaging of the inner urinary bladder surface with excellent detail. In this article, imaging techniques and clinical applications of gadolinium-enhanced virtual MR cystoscopy are presented.

Multidetector computed tomography (MDCT) angiography has provided excellent opportunities for advancement of computed tomography (CT) technology and clinical applications. It has a wide range of applications in the abdomen including vascular pathologies either occlusive or aneurysmal; enables the radiologist to produce vascular mapping that clearly show tumor invasion of vasculature and the relationship of vessels to mass lesions. MDCTA can be used in preoperative planning for hepatic resection, preoperative evaluation and planning for liver transplantation. MDCTA can also provide extremely valuable information in the evaluation of ischemic bowel disease, active Crohn disease, the extent and location of collateral vessels in cirrhosis.

Background: Radical resection is the only potentially curative treatment for hepatic alveolar echinococcosis (AE). Although Turkey is an endemic region, population screening is not performed and early diagnosis is rare. Consequently, surgeons are compelled to explore possibilities such as near-total resection and biliodigestive anastomosis for palliation of jaundice. Methods: Surgery was performed in 32 patients with hepatic AE with the following indications: (1) resection; (2) palliation of jaundice; (3) definite assessment of operability; (4) failure in the management of cavity infection by percutaneous methods. Curative resection (R0 = complete resection of all parasitic mass [n = 9], and R1 = a resection in which a small remnant was left on a vital structure [n = 8]) were performed in 17 patients, intrahepatic cholangiojejunostomy in 7, laparotomy-external drainage in 7, and debulking in 1. Results: Perioperative mortality rates were 2/17, 0/7, 2/7 and 1/1, respectively. Twelve patients in the curative resection group are alive without recurrence/progression of the small remnant during a median follow-up of 59 (range 27–116) months. One patient developed an inoperable recurrence that was treated with albendazole. One patient was lost to follow-up. Long-term albendazole treatment was effective in all R1 patients except a patient who had slow asymptomatic progression. Successful palliation of jaundice was achieved in 5 of the 7 intrahepatic cholangiojejunostomy patients. Conclusions: The results of R1 resection in alveolar hydatid disease are similar to those of R0 resection; a small remnant is successfully controlled by albendazole. In patients with jaundice due to hilar invasion, biliary diversion from segment 3 or 5 is effective for palliation of the jaundice and facilitates albendazole treatment.

Purpose: Our center's experience with Ultraflex, Flamingo, SR stent and Flexstent for the palliation of malignant esophageal strictures is reported, and current pertinent literature is reviewed. Material and methods: Stents have been placed under fluoroscopic guidance between August 1993 and February 2002 for the palliation of malignant dysphagia in 116 patients. 59 patients received Ultraflex, 33 patients received Flamingo Wallstent, 20 patients received the SR stent and four patients received Flexstent. Results: Stent placement was successful in all the patients, with good symptomatic control in 123 out of 126 patients (98%) and no procedure-related complications. Four esophagorespiratory fistulas were successfully closed with covered Flamingo stents. Repeat intervention was necessary in 30 patients (51%) who received the Ultraflex stent, secondary to tumor ingrowth, overgrowth, ulceration, fistula and incomplete expansion. Two patients (6%) who received Flamingo Wallstent died due to gastrointestinal bleeding and one patient had proximal migration. Four patients (20%) who received the SR stent had complete migration of the stent. Conclusion: Covered stents were found to provide better long-term palliation compared to uncovered stents. The covered Flamingo Wallstent seems to be the best choice of stent for lesions where crossing the esophagogastric junction is not necessary. For lesions where it is mandatory to cross the junction it may be preferable to use a stent with an antireflux mechanism.

With the development of newer stent designs and delivery systems, metallic stents are currently established component of nonsurgical treatment of gastrointestinal obstructions. The use of metallic stents is not intended to be curative but palliative. This palliation may be intended for the rest of the patient's life with unresectable disease or as a temporary procedure prior to a definitive surgical procedure to allow time to improve the patient's overall medical condition or quick and noninvasive decompression of the intestinal obstruction.

Diagnosis of extrapulmonary tuberculosis is often difficult. Although positive chest radiographic findings or a positive tuberculin skin test supports the diagnosis, negative results do not exclude extrapulmonary tuberculosis. However, recognition and understanding of the radiologic findings of extrapulmonary tuberculosis can help in diagnosis. The spine is the most common site of skeletal involvement. The femur, tibia, and small bones of the hands and feet are most commonly involved by tuberculous osteomyelitis. Tuberculosis of the joints is characteristically monoarticular; the knee and hip are most frequently affected. Central nervous system tuberculosis takes various forms, including meningitis, tuberculoma, abscess, cerebritis, and miliary tuberculosis. Ileocecal involvement is seen in 80%-90% of patients with abdominal tuberculosis. The most common manifestation of abdominal tuberculosis is lymphadenopathy. Genitourinary tuberculosis is the most common manifestation of extrapulmonary tuberculosis. Lymphatic tuberculosis is more common among children, with cervical or supraclavicular nodes most frequently involved. Tuberculosis of the breast is extremely rare and occurs most often in young, multiparous, lactating women. The radiologic features of extrapulmonary tuberculosis mimic those of many diseases. A high level of suspicion is required, especially in high-risk populations. A positive culture or histologic analysis of biopsy specimens is still required in many patients for definitive diagnosis.

Thalassemia is a kind of chronic, inherited, microcytic anemia characterized by defective hemoglobin synthesis and ineffective erythropoiesis. In all thalassemias clinical features that result from anemia, transfusional, and absorptive iron overload are similar but vary in severity. The radiographic features of beta-thalassemia are due in large part to marrow hyperplasia. Markedly expanded marrow space lead to various skeletal manifestations including spine, skull, facial bones, and ribs. Extramedullary hematopoiesis (ExmH), hemosiderosis, and cholelithiasis are among the non-skeletal manifestations of thalassemia. The skeletal X-ray findings show characteristics of chronic overactivity of the marrow. In this article both skeletal and non-skeletal manifestations of thalassemia are discussed with an overview of X-ray findings, including MRI and CT findings.

This article presents a review of the literature regarding the use of transcatheter arterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC). There have been two different approaches to the treatment: (a) percutaneous tumor ablation methods which can be divided into injectable and thermal methods; percutaneous ethanol injection (PEI) is the most widely used method, and (b) TACE. PEI is the treatment of choice for single HCCs smaller or equal to 3 cm in size. For patients with large HCCs combined TACE and PEI is probably the most effective nonsurgical treatment. In the presence of multiple HCC nodules, TACE remains the treatment of choice.

The purpose of this study was to evaluate the CT findings of pulmonary artery aneurysms in patients being treated for Behçet's disease.Thirteen patients with Behçet's disease who had a total of 46 aneurysms were included in the study. All patients underwent helical CT before and after treatment. Both initial and follow-up CT scans were evaluated for location, number, and size of aneurysms and for thrombosis and pulmonary parenchyma changes.Thirty-five (76%) of the 46 aneurysms completely disappeared during the 3-42 months of treatment (mean, 21 months), and the remaining 11 aneurysms (24%) became smaller. Both disappearance and regression of aneurysms were preceded by thrombus formation. In 15 initially thrombosed aneurysms (33%), the thrombus increased in size during treatment. After treatment, the thrombus regressed and the pulmonary artery aneurysms disappeared. Thirty-one initially nonthrombosed aneurysms (67%) first became thrombosed during treatment; later, the thrombus regressed and the aneurysm decreased in size. Perianeurysmal consolidation and air-space nodules detected in seven patients disappeared in the early stages of treatment. Mosaic attenuation areas were seen in eight patients and disappeared in seven (88%) after treatment.Pulmonary artery aneurysms in Behçet's disease may become smaller or disappear with medical treatment. Mural thrombotic changes may be observed during the regression of pulmonary artery aneurysms. Helical CT is helpful in the diagnosis and follow-up of aneurysms and thrombosis in Behçet's disease.

The purpose of this study was to assess the usefulness of a new staging scheme for alveolar echinoccocosis un of the liver. A total of 28 patients with hepatic alveolar echinococcosis underwent CT examinations and were staged according to the proposed staging scheme (stage 1: lesion measuring less than 3 cm in diameter; stage 2: lesion greater than 3 cm, confined to less than three hepatic segments; stage 3 a: lesion with invasion of more than three hepatic segments; stage 3 b: invasion of liver hilum or suprahepatic vena cava; stage 4: invasion of surrounding organs and/or distant metastasis). Of the patients 16 underwent laparotomy, and results of the radiologic staging were correlated with surgical data. The CT findings correlated well with surgical findings. Patients were followed-up for a period of 6 months to 7 years. We concluded that the proposed staging scheme seemed to be useful for the therapeutic planning of patients with alveolar echinococcosis of the liver.

Congenital posterolateral diaphragmatic defects, such as Bochdalek hernias (BHs), usually present during the neonatal period with respiratory symptoms and are associated with significant mortality (1). However, a subset of patients with BHs may remain asymptomatic during childhood, and the condition may present as a surgical emergency in adulthood (2). Surgical repair of the defect is the recommended therapy for all patients with BHs, regardless of the presence of symptoms (3). Traditionally, the repair of diaphragmatic defects has been performed via laparotomy or thoracotomy, but the use of laparoscopy has challenged the use of these traditional procedures. However, the laparoscopic management of incarcerated BH is rarely reported. In the present paper, we report the case of a patient who presented with a partial colonic obstruction that was caused by an incarcerated transverse colon through a Bochdalek defect and treated using a laparoscopic approach.

Human cystic echinococcosis (CE) continues to be a major health problem in developing countries. A review of current literature discloses four alternatives for the management of active CE, consisting of surgery, percutaneous treatment (PT), chemotherapy, and follow-up without intervention, but no clear guidelines for directing patients to the different management options. Palliation of symptoms or prevention of complications is the main rationale for the treatment of CE. Surgery has long been considered as the gold standard treatment. However, a meta-analysis comparing the clinical outcomes of patients treated with PT with those of a control group treated with surgery found PT to be more effective, safer, and cheaper. Medical therapy is considered to be ineffective when the criterion of success is defined as the disappearance of the lesion. However, medical therapy seems to be effective when the goal of therapy is defined as the prevention of complications in asymptomatic patients. We propose an algorithm for therapy planning in CE where the first line of therapy for patients with active lesions is PT. Patients with lesions unsuitable for PT are directed to surgery if they are symptomatic, have complicated lesions or have lesions that are prone to rupture. Asymptomatic patients with uncomplicated lesions are directed to medical therapy. Medical therapy failures are redirected to surgery.

Summary Arterial manifestations of Behcet's disease consist of aneurysm formation, stenosis and occlusion. Aneurysms in Behcet's disease most commonly involve the pulmonary arteries and have been shown to resolve with medical treatment. However, this regression pattern with medical therapy has not been reported for aortic aneurysms to date. We present a 43-year-old man with bilateral abdominal aortic aneurysms resulting from Behcet's disease resolving with medical therapy.

To reveal the disease activity in Crohn disease by gray scale and Doppler ultrasonography of the superior mesenteric artery (SMA) and the affected bowel segments.Twenty-six patients (12 with active and 14 with inactive disease according to the Crohn disease activity index) were prospectively evaluated with gray scale and Doppler ultrasonography. The control group included 10 healthy subjects. In the SMA evaluation, anteroposterior diameter, resistive index (RI), and flow volume were measured. In the affected small-bowel segments, wall thickness, mural vascularity, RI, and extraintestinal findings were evaluated.Differences between the active and inactive groups but not between the inactive and control groups were statistically significant for mean SMA diameter, RI, and flow volume (P = .019; P.001; and P.001, respectively). Superior mesenteric artery flow volume values were higher than 500 mL/min in the active group except 2 patients (sensitivity, 83%; specificity, 100%). Increased gut wall thickness and vascularity were highly significant for patients with active disease (P.001). The mean SMA RI value of the active group was significantly lower (P.001). Doppler measures of vascularity were similarly affected in the SMA and the bowel wall in the active subgroup. In 10 patients with active disease and higher SMA flow volume (500 mL/min), the affected small-bowel segments also had increased wall thickness and vascularity.Evaluation of the SMA and the affected small-bowel segments together by gray scale and Doppler ultrasonography is a reliable quantitative method for determining Crohn disease activity. Findings obtained from both the SMA and the affected small-bowel segments showed parallel results about the disease activity.

To evaluate the diagnostic efficiency of multislice CT colonography in the detection of colorectal tumors by comparing it with conventional colonography in patients with high risk of colorectal cancer.Thirty-seven patients who had undergone conventional colonoscopy because of a suspicion of colorectal cancer were scanned with a four-detector multislice CT scanner with 4 x 1 mm detector collimation, 120 kV, 0.5 sec gantry rotation and 120 mAs scan parameters. Multiplanar reformatted images, virtual colonography and virtual colonoscopy images were compared with conventional colonoscopy. With conventional colonoscopy taken as the reference standard, the results were calculated with 95% confidence interval technique.Seventeen of the 23 polyps detected in conventional colonoscopy were identified correctly with multislice CT. Nine of 11 lesions with a diameter of 10 mm or greater (81%), three of four lesions with a diameter of 6-9 mm (75%), and five of eight lesions with a diameter of 1-5 mm (62%) were correctly identified with multislice CT.Multislice CT colonography is a good alternative to other colorectal screening tests because it has high sensitivity for polyps 10 mm or larger in diameter, is relatively safe and minimally invasive.

Aortic aneurysms and stenosis are widely treated with endovascular procedures in the current era. In this report, we present endovascular stent grafting for symptomatic treatment of severe thoracic aortic stenosis caused by an aortic sarcomatoid carcinoma in a 73-year-old female. The peri- and post-operative courses were complicated with tumor embolisms that were managed by both endovascular and surgical measures.

This article presents a review of the interventional radiological procedures in inflammatory pancreatic diseases including imaging guided biopsy, percutaneous aspiration and drainage, and transcatheter embolization of ruptured pseudoaneurysms.

Hydatid disease (HD) may develop in almost any part of the body. The liver is the most frequently involved organ (75 %), followed by the lung (15 %) and the remainder of the body (10 %). Hydatid cysts with unusual localizations may cause serious problems in the differential diagnosis. In this article the various imaging findings of hydatid cysts with unusual localizations are reviewed, based on our experience. Findings in brain, heart, pericard, kidney, intraperitoneum, retroperitoneum, bone, soft tissue, and breast are discussed. Hydatid disease should be considered in the differential diagnosis of all cystic masses in all anatomic locations, especially when they occur in areas where the disease is endemic. The combination of clinical history, imaging findings, and serologic test results usually help the diagnosis.

We reviewed the CT findings of 13 patients with histologically proved alveolar echinococcosis of the liver. Seven of these patients had hilar involvement, which caused dilatation of intrahepatic bile ducts and invasion of the portal vein or portal branches. In two of these patients we found marked atrophy of the right lobe and in one patient marked atrophy of the left lobe in addition to various CT findings previously reported for alveolar echinococcosis of the liver. The occurrence of lobar atrophy of the liver caused by alveolar echinococcosis has not been previously reported. We concluded that, when a mass lesion with hilar infiltration causing lobar atrophy is found in endemic areas, alveolar echinococcosis should be considered in the differential diagnosis in addition to malignant neoplasms.

Percutaneous aspiration of purely cystic liver lesions was performed in 15 patients aged 11-56 years. After aspiration under guidance with computed tomography (CT) in 12 patients, a membrane that is diagnostic for hydatid disease was visible in the lumen of the cyst on CT scans. Hypertonic saline was injected in the cystic cavities of these patients as a scolecidal agent. No major complications occurred during or after the procedures. In the follow-up period of 6-16 months, control CT and ultrasound scans revealed a progressive decrease in the size of the lesions and no evidence of peritoneal seeding. It is concluded that percutaneous aspiration and hypertonic saline injection for purely cystic hydatid disease of the liver seem to be an effective form of treatment and may eventually prove to be an alternative to surgical intervention.

The purpose of this study was to describe the magnetic resonance imaging (MRI) appearance of hepatic alveolar echinococcosis (HAE) on T(1)-weighted, T(2)-weighted and postgadolinium images. A total of 13 lesions were demonstrated in 13 patients. All patients underwent MR examination at 1 T imager. MR examinations included precontrast T(1)-weighted breathing averaged spin echo (SE), breath-hold spoiled gradient echo, T(2)-weighted TSE sequences with and without fat suppression, and T(1)-weighted breath-hold spoiled gradient echo (SGE) sequence following i.v. after gadolinium administration. All lesions were confirmed with histopathology. HAE hepatic lesions revealed geographic patterns of variable signal intensities on noncontrast T(1)- and T(2)-weighted images. Slightly hyperintense, iso- and hypointense signal on T(1)-weighted images corresponded to calcified regions, which appeared hypo-isointense signal on T(2)-weighted images. Necrotic areas were hypointense signal on T(1)-weighted and hyperintense signal on T(2)-weighted images. On postgadolinium images, lesions did not reveal enhancement. Dilatation of intrahepatic bile ducts distal to HAE abscesses were observed in five patients and portal vein invasion or compression was observed in four patients, lobar atrophy of the liver was coexistent finding in cases with portal vein compression. The MRI appearance of HAE abscesses included large irregularly marginated masses with heterogenous signal on T(1)- and T(2)-weighted images and lack of enhancement with gadolinium.

Purpose: To investigate the value of ultrasonography (US) in the diagnosis of sternal fractures. Material and Methods: Twenty-three patients (mean age 35.4 years) with a clinical suspicion of sternal fracture after blunt chest trauma were retrospectively reviewed. At admission, a.p. and lateral chest radiographies and sternal US were obtained. Sternal fractures were classified as nondisplaced or displaced. US and conventional radiographic findings were compared. Results: In 3/23 (13.0%) of the patients, no fracture was found by radiography or by US. Both radiography and US demonstrated sternal fractures in 16/23 (69.6%) of the patients. Sternal fractures were detected only by US while the conventional radiography was negative in 2/23 (8.7%) cases. Also in 2/23 (8.7%) of the patients with US positive for fracture, radiographies were suspicious. In 2 patients, the degree of fracture displacement on US was lesser than that found by radiography. Conclusion: US was better than lateral radiography to diagnose sternal fractures; however, conventional radiography remains the standard means of demonstrating grade of displacement.

Sarcoidosis is a multisystemic disease of unknown aetiology characterised by noncaseating granulomatous inflammation with varying presentation and prognosis. Osseous disease reported in 1-13 % of cases commonly involves hands and feet; however, vertebral sarcoidosis is rare. This report describes the radiologic, CT, MRI and radionuclide imaging findings of vertebral involvement of a case with sarcoidosis.

We evaluated the incidence and history of arteriovenous fistula (AVF) after kidney biopsy and assessed the use of superselective embolization for treatment.During the last 10 years, 896 kidney biopsies (age range of the patients: 1 month-18.6 years) have been performed in our institution under real-time ultrasonographic guidance with a 14 gauge cutting biopsy needle, and 32 of the patients had renal allografts (3.4%). We observed three cases of AVF (two in allograft kidneys, one in a native kidney) among all biopsies (0.34%), and the incidence of developing AVF after renal allograft biopsy was 6.3%. All three patients with AVF were symptomatic, and intravascular therapy was indicated.An angiographic study combined with endovascular treatment of the intrarenal AVF and pseudoaneurysm was performed in all three patients. Embolization was performed with bucrylate and lipiodol in two patients and with micro-coils in one. After successful embolization, all three patients became asymptomatic (in two renal bleeding stopped, in one patient with severe uncontrollable hypertension blood pressure returned to normal limits). No complications were observed secondary to the embolization procedure.The technique of superselective embolization using a coaxial catheter is an effective and safe method in the treatment of post-biopsy AVFs and pseudoaneurysm.

Purpose We examined the roles of gray-scale and color Doppler sonography in the diagnosis of granulomatous mastitis. Methods We retrospectively studied the clinical, mammographic, and sonographic findings in 10 women 24–57 years old (mean age, 35.9 ± 13.9 years) who had a histopathologic diagnosis of granulomatous mastitis. All patients underwent gray-scale sonographic examination, and 8 patients were further examined with color Doppler imaging. Seven patients had previously undergone mammography. Results Mammographic findings were nonspecific in all 7 patients. Gray-scale sonographic findings were compatible with mastitis in 6 (60%) of 10 patients. Doppler examination showed increased arterial and venous vascularization within and around the lesion in 5 of 8 patients, but the spectral analysis findings were not specific for granulomatous mastitis. Conclusions Neither mammography nor Doppler sonography plays a significant role in the differential diagnosis of granulomatous mastitis versus fibroadenoma or carcinoma. Gray-scale sonography shows findings specific for granulomatous mastitis in some cases, but all cases require histopathologic confirmation for final diagnosis. © 1999 John Wiley & Sons, Inc. J Clin Ultrasound 27:101–106, 1999.

From the Department of Radiology, Department of Gastroenterohepatology, and Department of General Surgery, Transplant Unit, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to submit items for consideration.

Replacement lipomatosis (RPL) is seen in patients in whom renal parenchyma is destroyed due to chronic calculous disease and inflammation. The triggering mechanism for xanthogranulomatous pyelonephritis (XGP) is also the same. We report a case in which RPL and XGP coexist in the same kidney. To our knowledge, this coexistence has not been previously reported.

A 69-year-old man with a history of a perforated gastric ulcer, necessitating operation 30 years earlier, presented to the emergency room with epigastric pain, nausea, and vomiting. Physical examination showed diffuse abdominal tenderness, rebound and defense. Abnormal laboratory findings were a white blood cell count of 8.7 10/L, total bilirubin level of 3.8 mg/dL (direct bilirubin 2.47 mg/dL), alkaline phosphatase level of 865 U/L, aspartate aminotransferase level of 297 U/L, an amylase level of 1114 U/L, and urine amylase level of 9459 U/L. Preliminary diagnosis of biliary pancreatitis was suggested due to the high amylase levels. However, diagnosis of afferent loop syndrome (ALS) was made on a multidetector computed tomography (CT) on the basis of the presence of a fluid-filled, tubular structure extending from the gallbladder

The availability of different therapeutic alternatives in hydatid liver disease necessitates a comprehensive classification system in order to evaluate indications and monitor results. We have proposed a new scheme in which lesions are graded 1–5 according to the morphology of the cyst and the presence of findings in favour of cyst rupture. Ultrasound (US), CT and cholangiographic findings in 214 hydatid liver lesions in 152 patients who underwent surgery within 15 days of their radiological examinations were evaluated retrospectively. Results of the radiological classification were correlated with surgical data. We found that purely cystic unilocular lesions never ruptured, that dilatation of biliary canaliculi around a lesion with a complex morphological appearance is a non-specific finding and that there was no reliable radiological sign for a simple biliary communication. US, CT and cholangiography were reliable in diagnosing intra-biliary and direct ruptures. We conclude that the proposed grading scheme could be useful in monitoring the results of different therapeutic modalities for hydatid disease of the liver and, with the accumulation of further data, could be helpful in allocating patients to therapeutic alternatives.