Computed tomographic imaging findings of bowel ischemia

LEARNING OBJECTIVES: Learning objectives of this paper are to review and to summarize the pathogenesis of bowel ischemia and to describe its clinical, pathological, and radiological manifestations. BACKGROUND: Bowel ischemia is a common disorder produced by several causes, and it shows various clinical presentations connected with an high mortality. With the increase in average life expectancy, bowel ischemia represents one of the most threatening abdominal conditions in elderly patients. In the last decade, computed tomography has tremendously altered the diagnostic approach to bowel ischemia also influencing the therapeutic approach in the current practice. IMAGING FINDINGS: Computed tomographic imaging findings include bowel wall thickening, portal venous gas, intramural pneumatosis, engorgement of mesenteric veins, loss or increase of bowel wall enhancement, and infarction of other abdominal organs. CONCLUSIONS: Bowel ischemia shows a broad spectrum of radiological manifestations, and regardless of the primary causes, it produces similar radiological features. Bowel ischemia may simulate cancer or inflammatory conditions; so it is a mandatory tight integration between radiological and clinical signs.     

The representation of the visual field in three extrastriate areas of the ferret (Mustela putorius) and the relationship of retinotopy and field boundaries to callosal connectivity

We describe representations of the visual field in areas 18, 19 and 21 of the ferret using standard microelectrode mapping techniques. In all areas the azimuths are represented as islands of peripheral visual field surrounded by central visual field representation. The zero meridian was found at the 17/18 and 19/21 borders; at the 18/19 and anterior border of 21 the relative periphery of the visual field was found. In areas 18 and 19, elevations are represented in a smooth medio-lateral progression from lower to upper visual field. In several cases the elevations in area 21 evidenced a similar medio-lateral progression; however, in others the elevations exhibited a split representation of the horizontal meridian. Anatomically determined callosal connections coincided with the representation of azimuths near the zero meridian. Medio-lateral bands of callosal connectivity that straddle the 17/18 and 19/21 borders are connected by bridges of callosally projecting cells. Acallosal cortical islands corresponded to the peripheral visual field and were found straddling the 18/19 border and the anterior border of area 21. The results are discussed in relation to callosal connectivity and retinotopy in extrastriate visual cortex and to proposed homologies of carnivore and primate visual cortex.     

Arteroportal fistulas between the accessory right hepatic, gastroduodenal and superior mesenteric arteries and portal vein: a difficult technical problem to overcome in liver transplantation

BACKGROUND: Fistulous communications between the accessory right hepatic (ARHA), gastroduodenal (GD), and superior mesenteric (SMA) arteries and the portal vein (PV) may represent a contraindication for liver transplantation (LT). MATERIAL: A patient with HCV-related liver cirrhosis and progressive liver decompensation underwent preoperative LT work-up. Doppler ultrasound (DU), Angiography and MRI revealed arteroportal fistulas (APF) and diversion of mesenteric-splenoportal flow through spontaneous splenorenal shunts (SSRS) in the systemic circulation. The patient was transplanted and the ARHA and GDA were distally sectioned; the HA was anastomosed to the donor HA; the superior mesenteric vein (SMV) was detached from the splenopancreatic venous bed by sectioning and ligating the Henle trunk, by ligating an posterior-inferior pancreatic vein and, finally, by positioning an iliac vein interposition graft between the SMV and the donor PV. The postanastomotic SMV trunk and recipient PV were ligated below and above the pancreatic head, respectively. RESULTS: Reperfusion and late liver function were good. DU and MRI studies showed an effective portal flow and the maintenance of a normal splenopancreatic vein outflow through the SSRS. DISCUSSION: APF represent a serious clinical problem, particularly in patients who need LT. The persistence of arterial flow into the PV is dangerous for the long-term liver function. A particular surgical strategy, strictly tailored to the hemodynamic conditions, has to be planned. CONCLUSIONS: Extrahepatic multiple APF would no longer to represent a contraindication to LT, although this claim needs to be confirmed in the light of further experience and a longer-term follow-up.     

Left ventricle unloading by percutaneous pigtail during extracorporeal membrane oxygenation

Arterial-venous extracorporeal membrane oxygenation (ECMO) is more and more used as first line mechanical support in acute cardiopulmonary failure. Important pitfall of this technique is the inappropriate unloading of left ventricle (LV) in case of myocardial insufficiency, leading to pulmonary stasis and inadequate myocardial recovery. We report our experience of left side unloading by a 7-F pigtail, introduced in the LV through the aortic valve, connected to the venous drainage. Echographic guidance is sufficient to pigtail positioning and follow-up monitoring avoiding catheterization laboratory transport. With this approach we were able to support three different patients, resolving LV distension and preventing lung congestion, without major complication.     

Impact of venous tumour thrombus consistency (solid vs friable) on cancer-specific survival in patients with renal cell carcinoma

Background

To our knowledge, the impact of venous tumour thrombus (VTT) consistency in patients affected by renal cell carcinoma (RCC) has never been addressed.

Objective

To analyse the effect of VTT consistency on cancer-specific survival (CSS).

Design, setting, and participants

We retrospectively analysed 174 consecutive patients with RCC and renal vein or inferior vena cava (IVC) VTT who underwent surgical treatment between 1989 and 2007 at our institute.

Intervention

All patients underwent radical nephrectomy and thrombectomy.

Measurements

Pathologic specimens were reviewed by a single uropathologist. In addition to traditional pathologic features, the morphologic aspect of the tumour thrombus was evaluated to distinguish solid from friable patterns. The prognostic role of thrombus consistency (solid vs friable) on CSS was assessed by means of Cox regression models.

Results and limitations

The VTT was solid in 107 patients (61.5%) and friable in 67 patients (38.5%). The presence of a friable VTT increased the risk of having synchronous nodal or distant metastases, higher tumour grade, higher pathologic stage, and simultaneous perinephric fat invasion (all p < 0.05). The median follow-up was 24 mo. The median CSS was 33 mo; the median CSS was 8 mo in patients with a friable VTT and 55 mo in patients with a solid VTT (p < 0.001). On multivariable analyses, the presence of a friable VTT was an independent predictor of CSS (p = 0.02). The power of our conclusion may be somewhat limited by the relatively small study population and the retrospective nature of the study.

Conclusions

In patients with RCC and VTT, the presence of a friable thrombus is an independent predictor of CSS. If our finding is confirmed by further studies, the consistency of the tumour thrombus should be introduced into routine pathologic reports to provide better patient risk stratification.     

Long-term experience with early single Mitomycin C instillations in patients with low-risk non-muscle-invasive bladder cancer: prospective, single-centre randomised trial

Purpose  

To study the benefits of a single, early, intravesical instillation of mitomycin C(MMC) after transurethral bladder resection (TURB) in patients with low-risk non-muscle-invasive bladder cancer (NMIBC).     

Pregnant woman presenting with a gross retroperitoneal mass: surgical treatment with caval replacement

A 40-year-old woman in the twenty-fifth week of pregnancy presented with a gross retroperitoneal mass. At the end of the pregnancy, the patient was submitted to surgery, and the gross infiltration of the inferior vena cava wall required the resection of the vena cava with its prosthetic substitution. The histopathological examination demonstrated the presence of a leiomyosarcoma of the inferior vena cava. An electronic video supplement showing the most important intraoperative passages is available online at doi:10.1016/j.eururo.2008.06.074.