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Background To compare the outcomes of blunt splenic injuries (BSI) managed with proximal (P) versus distal (D) versus combined (C) splenic artery embolization (SAE). Methods This retrospective study included patients with BSI who demonstrated vascular injuries on angiograms and were managed with SAE between 2001 and 2015. The success rate and major complications (Clavien–Dindo classification ≥ III) were compared between the P, D, and C embolizations. Results In total, 202 patients were enrolled (P, n = 64, 31.7%; D, n = 84, 41.6%; C, n = 54, 26.7%). The median injury severity score was 25. The median times from injury to SAE were 8.3, 7.0, and 6.6 h for the P, D, and C embolization, respectively. The overall haemostasis success rates were 92.6%, 93.8%, 88.1%, and 98.1% in the P, D, and C embolizations, respectively, with no significant difference (p = 0.079). Additionally, the outcomes were not significantly different between the different types of vascular injuries on angiograms or the materials used in the location of embolization. Splenic abscess occurred in six patients (P, n = 0; D, n = 5; C, n = 1), although it occurred more commonly in those who underwent D embolization with no significant difference (p = 0.092). Conclusions The success rate and major complications of SAE were not significantly different regardless of the location of embolization. The different types of vascular injuries on angiograms and agents used in different embolization locations also did not affect the outcomes. Graphical abstract

Background: Concurrent acute cholecystitis and acute cholangitis is a unique clinical situation. We tried to investigate the optimal timing of cholecystectomy after adequate biliary drainage under this condition. Methods: From January 2012 to November 2017, we retrospectively screened all in-hospitalized patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and then identified patients with concurrent acute cholecystitis and acute cholangitis from the cohort. The selected patients were stratified into two groups: one-stage intervention (OSI) group (intended laparoscopic cholecystectomy at the same hospitalization) vs. two-stage intervention (TSI) group (interval intended laparoscopic cholecystectomy). Interrogated outcomes included recurrent biliary events, length of hospitalization, and surgical outcomes. Results: There were 147 patients ultimately enrolled for analysis (OSI vs. TSI, 96 vs. 51). Regarding surgical outcomes, there was no significant difference between the OSI group and TSI group, including intraoperative blood transfusion (1.0% vs. 2.0%, p = 1.000), conversion to open procedure (3.1% vs. 7.8%, p = 0.236), postoperative complication (6.3% vs. 11.8%, p = 0.342), operation time (118.0 min vs. 125.8 min, p = 0.869), and postoperative days until discharge (3.37 days vs. 4.02 days, p = 0.643). In the RBE analysis, the OSI group presented a significantly lower incidence of overall RBE (5.2% vs. 41.2%, p < 0.001) than the TSI group. Conclusions: Patients with an initial diagnosis of concurrent acute cholecystitis and cholangitis undergoing cholecystectomy after ERCP drainage during the same hospitalization period may receive some benefit in terms of clinical outcomes.

Background This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE). Methods We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE. Results In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p Conclusions Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI. Graphical abstract

Background: Hemorrhage after pancreaticoduodenectomy is an uncommon but fatal complication. In this retrospective study, the different treatment modalities and outcomes for treating post-pancreaticoduodenectomy hemorrhage are analyzed. Methods: Our hospital imaging database was queried to identify patients who had undergone pancreaticoduodenectomy during the period of 2004–2019. The patients were retrospectively split into three groups, according to their treatment: conservative treatment without embolization (group A: A1, negative angiography; A2, positive angiography), hepatic artery sacrifice/embolization (group B: B1, complete; B2, incomplete), and gastroduodenal artery (GDA) stump embolization (group C). Results: There were 24 patients who received angiography or transarterial embolization (TAE) treatment 37 times (cases). In group A, high re-bleeding rates (60%, 6/10 cases) were observed, with 50% (4/8 cases) for subgroup A1 and 100% (2/2 cases) for subgroup A2. In group B, the re-bleeding rates were lowest (21.1%, 4/19 cases) with 0% (0/16 cases) for subgroup B1 and 100% (4/4 cases) for subgroup B2. The rate of post-TAE complications (such as hepatic failure, infarct, and/or abscess) in group B was not low (35.3%, 6/16 patients), especially in patients with underlying liver disease, such as liver cirrhosis and post-hepatectomy (100% (3/3 patients), vs. 23.1% (3/13 patients); p = 0.036, p < 0.05). The highest rate of re-bleeding (62.5%, 5/8 cases) was observed for group C. There was a significant difference in the re-bleeding rates of subgroup B1 and group C (p = 0.00017). The more iterations of angiography, the higher the mortality rate (18.2% (2/11 patients)

Background: Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI. Method: A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models. Results: Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501–0.809) and 0.969 (95% CI: 0.920–0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011–0.071). Conclusion: In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI.

Simple Summary A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity. Abstract The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

Purpose Sentinel lymph node biopsy (SLNB) is the standard management for clinically node-negative cutaneous melanoma patients. This study aimed to evaluate the role of SLNB in Taiwanese melanoma patients and in particular, patients with acral lentiginous melanoma (ALM). Patients and methods We retrospectively analyzed the clinicopathological characteristics and survival outcomes of the patients who underwent primary surgery followed by either SLNB or nodal observation at the Linkou Chang Gung Memorial Hospital from January 2000 to December 2011. Results Among the total of 209 patients, 127 underwent SLNB and 51 underwent nodal observation only after primary surgery. There were no significant differences in clinicopathological features between the two groups except that patients who underwent SLNB were older and had a higher rate of ALM than those under nodal observation. The median follow-up time was 43.5 months until July 2013. The patients who underwent SLNB had significantly better disease-free survival (DFS) (57.1 vs 18.7 months, p 2 mm, or ulceration. Conclusion SLNB was associated with favorable outcomes in patients with clinically node-negative cutaneous melanoma, particularly in Taiwanese patients with ALM, Breslow thickness ≤2 mm, and nonulcerated melanoma.

Massive hepatic necrosis after therapeutic embolization has been reported. We employed a 320-detector CT scanner to compare liver perfusion differences between blunt liver trauma patients treated with embolization and observation. This prospective study with informed consent was approved by institution review board. From January 2013 to December 2016, we enrolled 16 major liver trauma patients (6 women, 10 men; mean age 34.9 ± 12.8 years) who fulfilled inclusion criteria. Liver CT perfusion parameters were calculated by a two-input maximum slope model. Of 16 patients, 9 received embolization and 7 received observation. Among 9 patients of embolization group, their arterial perfusion (78.1 ± 69.3 versus 163.1 ± 134.3 mL/min/100 mL, p = 0.011) and portal venous perfusion (74.4 ± 53.0 versus 160.9 ± 140.8 mL/min/100 mL, p = 0.008) were significantly lower at traumatic parenchyma than at non-traumatic parenchyma. Among 7 patients of observation group, only portal venous perfusion was significantly lower at traumatic parenchyma than non-traumatic parenchyma (132.1 ± 127.1 vs. 231.1 ± 174.4 mL/min/100 mL, p = 0.018). The perfusion index between groups did not differ. None had massive hepatic necrosis. They were not different in age, injury severity score and injury grades. Therefore, reduction of both arterial and portal venous perfusion can occur when therapeutic embolization was performed in preexisting major liver trauma, but hepatic perfusion index may not be compromised.

Background Hip fracture is the most common type of fracture in elderly individuals. Numerous deep learning (DL) algorithms for plain pelvic radiographs (PXRs) have been applied to improve the accuracy of hip fracture diagnosis. However, their efficacy is still undetermined. Objective The objective of this study is to develop and validate a human-algorithm integration (HAI) system to improve the accuracy of hip fracture diagnosis in a real clinical environment. Methods The HAI system with hip fracture detection ability was developed using a deep learning algorithm trained on trauma registry data and 3605 PXRs from August 2008 to December 2016. To compare their diagnostic performance before and after HAI system assistance using an independent testing dataset, 34 physicians were recruited. We analyzed the physicians’ accuracy, sensitivity, specificity, and agreement with the algorithm; we also performed subgroup analyses according to physician specialty and experience. Furthermore, we applied the HAI system in the emergency departments of different hospitals to validate its value in the real world. Results With the support of the algorithm, which achieved 91% accuracy, the diagnostic performance of physicians was significantly improved in the independent testing dataset, as was revealed by the sensitivity (physician alone, median 95%; HAI, median 99%; P Conclusions HAI currently impacts health care, and integrating this technology into emergency departments is feasible. The developed HAI system can enhance physicians’ hip fracture diagnostic performance.

BACKGROUND Hip fracture is the most common type of fracture in elderly individuals. Numerous deep learning (DL) algorithms for plain pelvic radiographs (PXRs) have been applied to improve the accuracy of hip fracture diagnosis. However, their efficacy is still undetermined. OBJECTIVE The objective of this study is to develop and validate a human-algorithm integration (HAI) system to improve the accuracy of hip fracture diagnosis in a real clinical environment. METHODS The HAI system with hip fracture detection ability was developed using a deep learning algorithm trained on trauma registry data and 3605 PXRs from August 2008 to December 2016. To compare their diagnostic performance before and after HAI system assistance using an independent testing dataset, 34 physicians were recruited. We analyzed the physicians’ accuracy, sensitivity, specificity, and agreement with the algorithm; we also performed subgroup analyses according to physician specialty and experience. Furthermore, we applied the HAI system in the emergency departments of different hospitals to validate its value in the real world. RESULTS With the support of the algorithm, which achieved 91% accuracy, the diagnostic performance of physicians was significantly improved in the independent testing dataset, as was revealed by the sensitivity (physician alone, median 95%; HAI, median 99%; PPPP CONCLUSIONS HAI currently impacts health care, and integrating this technology into emergency departments is feasible. The developed HAI system can enhance physicians’ hip fracture diagnostic performance.

Background In most institutions, arterioembolisation (AE) remains a standard procedure to achieve haemostasis in the resuscitation of patients with pelvic fractures. However, the actual benefits from AE are controversial. Methods We retrospectively reviewed data from patients with closed pelvic fractures between 2014 and 2017 in a single institute. The details of AE and clinical parameters were recorded and analysed to determine whether poor outcomes could be predicted. Results During the study period, 545 patients with closed pelvic fractures were enrolled. Angiography was performed in 131 patients, and 129 patients underwent AE. The patients who underwent AE had higher injury severity score, more numbers of shock status on arrival, and higher incidence of unstable fracture patterns when compared to non-AE group. A higher number of patients who underwent AE required osteosynthesis and experienced surgical site infection (SSI) after osteosynthesis than those who did not receive AE. Nonselective bilateral internal iliac artery embolisation (nBIIAE) was the major approach for AE (74%). Overall, 11 patients experienced SSI in the AE group, 9 of whom had received nBIIAE. The positive predictive value of contrast extravasation (CE) on computed tomography (CT) was 29.6%, with a negative predictive value of 91.3%. Mortality was higher in patients without CE on CT than patients with identifiable CE (30.0% vs. 11.0%, p = 0.03). Conclusion Using the finding of CE on CT examination as a decision for AE is not a reliable indicator because of its low positive predictive value. Considering the high incidence of SSI following nBIIAE, candidates should be carefully selected for this procedure. Other haemostasis procedures such as preperitoneal pelvic packing might be considered for select cases, given the high mortality rate among patients without CE during image studies, relative to patients with identifiable CE.

Purpose Sentinel lymph node biopsy (SLNB) is the standard management for clinically node-negative cutaneous melanoma patients. This study aimed to evaluate the role of SLNB in Taiwanese melanoma patients and in particular, patients with acral lentiginous melanoma (ALM). Patients and methods We retrospectively analyzed the clinicopathological characteristics and survival outcomes of the patients who underwent primary surgery followed by either SLNB or nodal observation at the Linkou Chang Gung Memorial Hospital from January 2000 to December 2011. Results Among the total of 209 patients, 127 underwent SLNB and 51 underwent nodal observation only after primary surgery. There were no significant differences in clinicopathological features between the two groups except that patients who underwent SLNB were older and had a higher rate of ALM than those under nodal observation. The median follow-up time was 43.5 months until July 2013. The patients who underwent SLNB had significantly better disease-free survival (DFS) (57.1 vs 18.7 months, p < 0.01) and melanoma-specific survival (MSS) (112.4 vs 45.2 months, p < 0.01) than those under observation. Improvement in DFS (HR: 0.51, p < 0.01) and MSS (HR: 0.60, p = 0.03) was observed even after adjusting for age and disease pathology by multivariate analysis. This benefit of clinical outcomes persisted in patients with ALM, Breslow thickness ≤2 mm, or no ulceration, but not in patients with non-ALM, Breslow thickness >2 mm, or ulceration. Conclusion SLNB was associated with favorable outcomes in patients with clinically node-negative cutaneous melanoma, particularly in Taiwanese patients with ALM, Breslow thickness ≤2 mm, and nonulcerated melanoma.

Expanding bile leaks after blunt liver trauma require more aggressive treatment than contained bile leaks. In this retrospective study approved by institution review board, we analyzed if non-invasive contrast-enhanced magnetic resonance cholangiography (CEMRC) using hepatocyte-specific contrast agent (gadoxetic acid disodium) could detect and characterize traumatic bile leaks. Between March 2012 and December 2014, written informed consents from 22 included patients (17 men, 5 women) with a median age of 24.5 years (IQR 21.8, 36.0 years) were obtained. Biliary tree visualization and bile leak detection on CEMRC acquired at 10, 20, 30, 90 minutes time points were independently graded by three radiologists on a 5-point Likert scale. Intraclass Correlation (ICC) was computed as estimates of interrater reliability. Accuracy was measured by area under receiver operating characteristic curves (AUROC). Biliary tree visualization was the best on CEMRC at 90 minutes (score 4.30) with excellent inter-rater reliability (ICC = 0.930). Of 22 CEMRC, 15 had bile leak (8 expanding, 7 contained). The largest AUROC of bile leak detection by three radiologists were 0.824, 0.914, 0.929 respectively on CEMRC at 90 minutes with ICC of 0.816. In conclusion, bile leaks of blunt liver trauma can be accurately detected and characterized on CEMRC.

Objectives This case series illustrates the feasibility of single-stage image-guided video-assisted thoracoscopic surgery for simultaneous localization and removal of small solitary pulmonary nodules (SPNs). The procedure was performed in a hybrid operating room using C-arm cone-beam computed tomography equipped with a laser-guided navigation system. Methods Between October 2016 and January 2017, 12 consecutive patients presenting with SPNs underwent image-guided video-assisted thoracoscopic surgery. The feasibility and safety of the procedure were assessed through a retrospective review of the patients' clinical charts. Results The median size of SPNs was 5.5 mm [interquartile range (IQR) 4-6 mm], whereas their median distance from the pleural surface was 11.7 mm (IQR 6-11.3 mm). All of the lesions were visible on intraoperative C-arm cone-beam computed tomography images, and localization was successful in 10 patients; thereafter, complete thoracoscopic resection was successfully performed. The median time required for the localization of SPNs was 45.5 min (IQR 36-60 min), whereas the median radiation exposure (expressed through the skin absorbed dose) was 223.2 mGy (IQR 180.3-321.3 mGy). Lesion localization was unsuccessful in 2 cases because to the development of pneumothorax induced by needle puncture. In such cases, a utility thoracotomy was required for the identification of SPNs. There was no operative mortality, and the median length of postoperative stay was 4 days (IQR 3.8-4 days). Conclusions The results of our case series support the feasibility of image-guided video-assisted thoracoscopic surgery for detection and removal of SPNs. Future efforts should be tailored to decrease localization time and minimize radiation exposure.

// Yon-Cheong Wong 1 , Cheng-Hsien Wu 1 , Li-Jen Wang 1 , Huan-Wu Chen 1 , Kuo-Ching Yuan 2 , Being-Chuan Lin 2 , Yu-Pao Hsu 2 and Shih-Ching Kang 2 1 Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan City, Taiwan 2 Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan City, Taiwan Correspondence to: Yon-Cheong Wong, email: ycwong@cgmh.org.tw Keywords: embolization technique, splenic injuries, efficacy, spleen infarct, splenic abscess Received: March 24, 2017 Accepted: September 20, 2017 Published: October 05, 2017 ABSTRACT Comparable failure rates of distal or proximal transcatheter arterial embolization (TAE) techniques for blunt splenic injuries have been reported. This study is to investigate the efficacy and complication of combining both TAE techniques. We included 26 patients of blunt splenic injuries for TAE therapy and randomized them into distal TAE and combined TAE groups. A prospective study was performed to compare their demographics, clinical parameters, hemograms, post-TAE splenic infarct volumes, splenic abscess and pancreatitis between the two groups. Of 26 patients, 17 received distal TAE, 9 received combined TAE. Their basic demographics, clinical parameters and hemograms did not differ. Mean systolic blood pressure of all patients was significantly elevated after TAE at 24 hours later. Three patients of distal TAE group had residual pseudoaneurysms in follow up. They were considered failures in distal TAE group as opposed to all successes in combined TAE group. The risk difference of failure of distal TAE was 17.6%. None developed post-TAE splenic abscess, massive splenic infarct or pancreatitis. The mean splenic infarct volume of distal TAE (10.9%) versus combined TAE groups (6.6%) was not significant ( p = 0.481). Combined TAE is effective and safe to decrease the failure rates of non-operative management for blunt splenic injuries.

Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine carcinoma of the skin. The available reports of MCC in Asia are limited; in this study, we report the largest series of MCC in Taiwan to date.The series is composed by 24 pathologically proven MCC cases, which were retrospec

Background: Low-dose computed tomography (LDCT) techniques can reduce exposure to radiation. Several previous studies have shown that radiation dose reduction in LDCT does not decrease the diagnostic performance for appendicitis among attending radiologists. But, the LDCT diagnostic performance for acute appendicitis in radiology residents with variable training levels has not been well discussed. Objectives: To compare inter-observer and intra-observer differences of diagnostic performance on non-enhanced LDCT (NE-LDCT) and contrast-enhanced standard dose CT (CE-SDCT) for acute appendicitis among attending and resident radiologists. Patients and Methods: This retrospective study included 101 patients with suspected acute appendicitis who underwent NE-LDCT and CE-SDCT. The CT examinations were interpreted and recorded on a five-point scale independently by three attending radiologists and three residents with 4, 1 and 1 years of training. Diagnostic performance for acute appendicitis of all readers on both examinations was represented by area under receiver operating characteristic (ROC) curves. Inter-observer and intra-observer AUC values were compared using Jackknife FROC software on both modalities. The diagnostic accuracy of each reader on NE-LDCT was compared with body mass index (BMI) subgroups and noise using independent T test. Results: Diagnostic performances for acute appendicitis were not statistically different for attending radiologists at both examinations. Better performance was noted on the CE-SDCT with a borderline significant difference (P = 0.05) for senior radiology resident. No statistical difference of AUC values was observed between attending radiologists and fourth year resident on both examinations. Statistically significant differences of AUC values were observed between attending radiologists and first year residents (P = 0.001 ~ 0.018) on NE-LDCT. Diagnostic accuracies of acute appendicitis on NE-LDCT for each reader were not significantly related to BMI or noise. Conclusion: Attending radiologists could diagnose acute appendicitis accurately on NE-LDCT. Performance of senior residents on NE-LDCT is better than junior residents and comparable to attending radiologists.

Our study investigated whether tumor-associated macrophages (TAMs) in advanced non-small cell lung cancer (NSCLC) are related to treatment response to epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) and may be a predictor of survival. Of 206 advanced NSCLC patients treated (first-line) with an EGFR-TKI at the study hospital from 2006 to 2009, 107 with adequate specimens for assessing CD68 immunohistochemistry as a marker of TAMs were assessed. After EGFR-TKI treatment, response was observed in 55 (51%) patients, and the median follow-up period was 13.5 months. Most TAMs were located in the tumor stroma (>95%) and positively costained with the M2 marker CD163. TAM counts were significantly higher in patients with progressive disease than in those without (p < 0.0001), a trend that remained in patients with known EGFR mutation status (n = 59) and those with wild-type EGFR (n = 20). High TAM counts, among other factors (e.g., wild-type EGFR), were significantly related to poor progression-free survival (PFS) and overall survival (OS) (all p < 0.0001 for TAMs). Multivariate Cox analyses showed that high TAM counts and EGFR mutations were both independent factors associated with PFS [odds ratio (OR), 8.0; 95% confidence interval (CI), 2.87-22.4; p = 0.0001 and OR, 0.03; 95% CI, 0.003-0.31; p = 0.003, respectively] and OS (OR, 2.641; 95% CI, 1.08-6.5; p = 0.03 and OR, 0.14; 95% CI, 0.03-0.56; p = 0.006, respectively). TAMs are related to treatment response irrespective of EGFR mutation and can independently predict survival in advanced NSCLC treated with an EGFR-TKI.

The liver is one of the most frequently injured solid abdominal organs in the setting of blunt abdominal trauma (1). Fortunately, most patients with blunt hepatic trauma have relatively stable vital signs and need only supportive treatment or transarterial embolization (TAE) (1–9). Only 15% of patients, who present with hemodynamic instability or fail with nonoperative management, require operative intervention to manage their liver injury. Embolic therapy has been shown to have a high success rate in hemodynamically stable patients with blunt hepatic injury. TAE is associated with decreased abdominal infections, decreased transfusions, and decreased length of hospital stay compared with operative management (2, 3, 7). However, angiography can only detect bleeding from the hepatic artery; it cannot locate bleeding from the hepatic or portal vein. In the literature, portal vein injuries are not commonly described and most are the result of penetrating injuries to the extrahepatic portal veins. Mortality after a portal vein injury due to trauma is primarily due to hypovolemic shock and can be as high as 50% or greater (10, 11). Since the intrahepatic portions of the hepatic and portal veins are low pressure systems, they can bleed insidiously. Nevertheless, this subtle bleeding may require multiple transfusions and result in a prolonged hospital stay. Relative to an extrahepatic portal vein injury, patients with an intrahepatic portal vein injury may have relatively stable vital signs and slowly decreasing hemoglobin levels (10, 11). In addition, traumatic occlusion and/or thrombosis of the portal vein may cause large hepatic parenchymal infarction. Computed tomography arterial portography (CTAP) is a useful method based on portal enhancement of the liver by infusion of contrast material through the superior mesenteric artery for evaluating the portal venous system (12–15) and is widely used in patients with hepatic tumors with portal venous invasion (13, 16, 17). CTAP has a high sensitivity and specificity in the evaluation of portal vein thrombosis due to tumor (90% sensitivity, 99% specificity, 95% positive predictive value, 97% negative predictive value) (14). However, few studies have focused specifically on the utility of CTAP in the evaluation of portal vein injury as a result of trauma. The liver has a dual blood supply and receives between 66% and 75% of its blood supply from the hepatic portal vein with the remainder supplied by the hepatic artery (18). CTAP reflects only portal venous perfusion while reperfusion CTAP (rCTAP) reflects hepatic arterial reperfusion. Both rCTAP and conventional computed tomography (CT) are useful for determining certain liver injuries. However, they do not specifically evaluate the portal vein. The purpose of this study was to compare CTAP, rCTAP, and CT for diagnosing portal vein injuries after blunt hepatic trauma. We hypothesized that CTAP would be superior to rCTAP and CT in assessing portal vein injury after blunt hepatic trauma.

Background Septic cavernous sinus thrombosis (CST) is a rare and fatal disease. Clinical presentations in the early stage are nonspecific, and the sensitivity of cranial axial computed tomography (CT) with thick section is low. This study analyzed the clinical manifestation and neuroimaging findings in patients with septic CST in a medical center in Taiwan. Methods This retrospective case series included nine patients with septic CST who had typical symptoms and clinical course, evidence of infection, and imaging studies which demonstrated cavernous sinus lesion, and who were treated between 1995 and 2003 at National Taiwan University Hospital. Results Seven (77.8 %) patients were more than 50 years old. Five (55.6%) had diabetes, and three (33.3%) had hematologic diseases. All cases were associated with paranasal sinusitis. The most frequent initial symptom was headache (66.7%), followed by ophthalmic complaints (diplopia or ophthalmoplegia, 55.6%; blurred vision or blindness, 55.6%), and ptosis (44.4%). Initial cranial images failed to identify CTS in all patients. Subsequent magnetic resonance imaging (MRI) or coronal contrast-enhanced CT (CECT) with thin section confirmed the diagnosis. Fungi were the most common pathogens (55.6%). The inhospital case-fatality rate was high (44.4%). Conclusion Due to the high case-fatality rate and low yield rate of blood cultures, fungal CST should be suspected in an immunocompromised patient with ophthalmic complaints that progress from one eye to the other. Coronal thin-section CECT may be a useful alternative to MRI as a diagnostic modality for this condition.

OBJECTIVE To compare the ancillary CT findings between superior mesenteric artery thromboembolism (SMAT) and superior mesenteric vein thrombosis (SMVT), and to determine the independent CT findings of life-threatening mesenteric occlusion. MATERIALS AND METHODS Our study was approved by the institution review board. We included 43 patients (21 SMAT and 22 SMVT between 1999 and 2008) of their median age of 60.0 years, and retrospectively analyzed their CT scans. Medical records were reviewed for demographics, management, surgical pathology diagnosis, and outcome. We compared CT findings between SMAT and SMVT groups. Multivariate analysis was conducted to determine the independent CT findings of life-threatening mesenteric occlusion. RESULTS Of 43 patients, 24 had life-threatening mesenteric occlusion. Death related to mesenteric occlusion was 32.6%. A thick bowel wall (p < 0.001), mesenteric edema (p < 0.001), and ascites (p = 0.009) were more frequently associated with SMVT, whereas diminished bowel enhancement (p = 0.003) and paralytic ileus (p = 0.039) were more frequent in SMAT. Diminished bowel enhancement (OR = 20; p = 0.007) and paralytic ileus (OR = 16; p = 0.033) were independent findings suggesting life-threatening mesenteric occlusion. CONCLUSION The ancillary CT findings occur with different frequencies in SMAT and SMVT. However, the independent findings indicating life-threatening mesenteric occlusion are diminished bowel wall enhancement and paralytic ileus.

Hyperplastic gastric polyps account for the majority of benign gastric polyps. The vast majority of these lesions are small, asymptomatic, and found incidentally on radiologic or endoscopic examination. Giant hyperplastic gastric polyps are uncommon and most of them are asymptomatic. A 73-year-old man presented with a 6 cm pedunculated hyperplastic polyp that had led to progressive gastric outlet obstruction. It had a distinctive appearance on double-contrast barium studies, appearing as a conglomerate mass with smooth and multiple lobulated components and trapping of barium in the interstices between lobules. Endoscopy and computed tomography revealed similar features. Although hyperplastic gastric polyps are typically benign, total removal of this giant polyp should be undertaken in cases of symptomatic gastric outlet obstruction, followed by pathologic confirmation of benign nature.

Glucagonoma is a very rare endocrine pancreatic tumor. At diagnosis, most glucagonomas are malignant and often metastatic. Suspicion of glucagonoma is based on characteristic presentations known as "glucagonoma syndrome". Glucagonoma is often found in the pancreatic body and/or tail and is usually large enough to be localized by computed tomography. We report a case of diffuse glucagonoma necrolytic migratory erythema (NME) in a 45-year-old man with mild diabetes mellitus, mild anemia, and weight loss over 1.5 years. Diffused enlarged pancreas was noted on abdominal ultrasonography incidentally during a routine health check-up. The levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were within normal limits. No enlarged lymph node or extrapancreatic tumor mass was found by several imaging studies. Total pancreatectomy was performed, and the pathology revealed glucagon-producing islet cells and intrapancreatic vascular emboli of tumor cells. He died due to internal bleeding and sepsis after surgery. Presentation of diffuse malignant glucagonoma with tumor emboli but no metastasis or NME is unusual.

Background Seminal vesicle cysts rarely cause symptoms. Data on long-term follow-up from childhood to adulthood are lacking. The study analyzed the magnetic resonance imaging (MRI) and follow-up results of this condition. Methods From 1991 to 1996, seminal vesicle cyst was diagnosed in 13 boys (mean age, 12 years; range, 7-15 years), six of whom had long-term follow-up data. The clinical symptoms and MRI findings at diagnosis and at follow-up were analyzed. Results The seminal vesicle cyst was on the right side in six patients and on the left in seven. The size varied, ranging from 1.0 × 1.3 × 1.4 to 4.4 × 3.1 × 3.6 cm. All showed high signal intensity on T2-weighted images but variable signal intensity on T1-weighted images. Associated urinary tract anomalies included renal anomalies (dysplasia in 2 patients, agenesis in 11), ectopic ureteral orifice (11), hydroureter (6), and vertebral anomalies (2). One of the six patients with follow-up had repeated urinary tract infection and underwent surgical resection of the cyst 8 years after the diagnosis. The other five had no symptoms during the follow-up period. Three of the six patients had repeat MRI after a median of 11 years, which showed slight cyst enlargement and increased T1-weighted signal intensity. Conclusion Most seminal vesicle cysts were asymptomatic and did not change during long-term follow-up. MRI is a powerful tool for detecting seminal vesicle cysts and in delineating associated congenital anomalies of the urogenital tract.