Role of Computed Tomography in Blunt Abdominal Trauma

Introduction: Blunt abdominal trauma is one of the commonly encountered surgical emergencies. The diagnostic modality that helps in optimum management of these patients includes chest and abdominal x-rays, Focused Assessment Sonography for Trauma scan and Computed Tomography. In selected hemodynamically stable patients who are candidates for non-operative management, Contrast Enhanced Computed Tomography is not considered essential and hence avoiding its own radiation hazards and decreasing extra financial burden to the patients. Aims: To evaluate whether Contrast Enhanced Computed Tomography is necessary or not in case of blunt trauma abdomen. Methods: This is a hospital based prospective study done in the department of surgery at Nepalgunj Medical College, Kohalpur conducted from October 2020 to March 2021. The patients with blunt abdominal trauma who were hemodynamically stable at the time of presentation and those who became stable after resuscitation were included. These patient’s detailed history was taken, clinical examination done. Focused Assessment Sonography for Trauma scan was done at the time of presentation along with chest x-ray and other necessary blood investigation. Data were analyzed with Statistical Package for Social Sciences version 25 and p-value <0.05 was taken as significant. Results: Out of total 53 patients, age group between 11-20 and 21-30 years comprising of 13 patients with male: female ratio of 1.94:1 were affected more. Fall injury, being the most common mode, comprised 20 patients. The commonest organ involved was spleen seen in 17 patients (32.1%), liver in 16 patients (30.2%). In 44 (83.0%) patients, Computed Tomography scan was done only in nine patients who were also managed conservatively, except one who underwent laparoscopic evacuation of collected blood. Seventeen (32.1%) patients underwent repeat ultrasonography without any new findings. Conclusion: Patients with blunt abdominal trauma with stable hemodynamics can be managed conservatively with limited use of Contrast Enhanced Computed Tomography scan.

Isolated perforation of fourth part of Duodenum following Blunt Abdominal Trauma

Introduction: Isolated duodenal injuries are rare in blunt abdominal trauma. These present a significant challenge for management because of the associated injuries and its difficult anatomical accessibility. Case presentation: A 20years male presented to the Emergency department following a bike accident sustaining injury over face, chest and abdomen, 6hours after the incident. His vitals were unstable so he was resuscitated and admitted in Intensive Care Unit. He had generalized abdominal tenderness without rigidity. Contrast enhanced computed tomography of abdomen and pelvis was suggestive of hollow viscus perforation. He underwent exploratory laparotomy and primary repair for isolated perforation at fourth part of duodenum. He was discharged on his ninth postoperative day. Conclusion: Rare injuries following blunt abdominal trauma should be considered and early intervention is necessary.

Myxoid liposarcoma of small bowel presenting with intussusception and obstruction: A case report

Gastrointestinal liposarcomas are extremely rare with the most common reported morphological subtype being dedifferentiated liposarcoma and well-differentiated liposarcoma. These tumors are rarely diagnosed preoperatively and diagnosis is only confirmed on histopathological analysis. Treatment of gastrointestinal liposarcomas consists of surgical excision with widely negative margins followed by post-operative irradiation and close follow-up. We report an exceedingly rare case of myxoid liposarcoma of the small bowel (ileum) presenting with an unusual presentation with intussusception and intestinal obstruction. A 42-year-old male presented to the emergency department with features of intestinal obstruction. Contrast-enhanced computed tomography abdomen revealed ileo-ileal intussusception with an endoluminal soft-tissue lesion at the leading edge. The patient was taken for surgical intervention and the involved segment of the bowel along with the lesion was resected and re-anastomosis done. Histological sections of the mass along with immunohistochemistry suggested the pathological diagnosis of myxoid liposarcoma.

Creation of synthetic contrast-enhanced computed tomography images using deep neural networks to screen for renal cell carcinoma

Objectives: To elucidate if synthetic contrast enhanced computed tomography (CECT) images created from plain CT images using deep neural networks (DNN) could be used for screening, clinical diagnosis, and postoperative follow up of small diameter renal tumors by comparing the concordance rate between real and synthetic CECT images and the diagnoses according to 10 urologists. Methods: This retrospective, multicenter study included 155 patients (artificial intelligence training cohort [n=99], validation cohort [n=56]) who underwent surgery for small-diameter (≤40 mm) renal tumors, with the pathological diagnosis of renal cell carcinoma, during 2010 to 2020. Preoperatively, dynamic plain CT and CECT images were obtained. We created a learned DNN using pix2pix. We examined the quality of the synthetic CECT images created using this DNN and compared them with real CECT images using the zero mean normalized cross correlation parameter. We assessed concordance rates between real and synthetic images and diagnoses according to 10 urologists by creating a receiver operating characteristic curve and calculating the area under the curve (AUC). Results: The synthetic CECT images were highly concordant with the real CECT images, regardless of the existence or morphology of the renal tumor. Regarding the concordance rate, a greater AUC was obtained with synthetic CECT (AUC=0.892) than with only CT (AUC=0.720; p<0.001). Conclusions: This study is the first to use DNN to create a high-quality synthetic CECT image that was highly concordant with a real CECT image. Synthetic CECT images could be used for urological diagnoses and clinical screening.

Cystic Adventitial Disease of the Common Femoral Artery: A Rare-Case Report

Herein, we report the case of a 59-year-old man with intermittent claudication of ~100 m, who complained of resting pain in his lower right extremity. A pelvic, contrast-enhanced, computed tomography scan showed the presence of cystic density in the lower segment of the right common femoral artery. Faced with the risk of acute limb ischemia, we navigated a challenging diagnostic procedure to choose an appropriate treatment for him. Additionally, we performed a pathological investigation of the excised common femoral artery following the excision bypass. On postoperative day 5, the patient was discharged from the hospital. During the 2-year follow-up, no new cysts were discovered, and the patient had favorable prognosis.

Rare Case of Gastric Schwannoma Simulating Gastrointestinal Stromal Tumour-A Case Report

Gastric schwannoma (GS) is a rare, benign, slow-growing neoplasm representing 0.2% of all gastric tumors. We report a rare case of Gastric schwannoma in a 56 year old woman who presented with abdominal discomfort and vomiting since few years. Contrast enhanced Computed Tomography showed a well-defined homogeneously attenuating lesion with homogenous enhancement. Wedge gastrectomy was done with a possible diagnosis of Gastrointestinal stromal tumor, but was confirmed to have Gastric schwannoma on histopathology showing spindle cells with peripheral cuff of lymphoid aggregates and S-100 protein positivity on immunohistochemistry. Gastric schwannoma should be included in the differential diagnosis of a gastric intramural or exophytic mass when Computed Tomography shows a well-defined homogeneously attenuating lesion with progressively increasing homogenous enhancement without hemorrhage, necrosis, and degeneration.

Pretreatment Contrast-Enhanced Computed Tomography Radiomics for Prediction of Pathological Regression Following Neoadjuvant Chemotherapy in Locally Advanced Gastric Cancer: A Preliminary Multicenter Study

BackgroundSensitivity to neoadjuvant chemotherapy in locally advanced gastric cancer patients varies; however, an effective predictive marker is currently lacking. We aimed to propose and validate a practical treatment efficacy prediction method based on contrast-enhanced computed tomography (CECT) radiomics.MethodData of l24 locally advanced gastric carcinoma patients who underwent neoadjuvant chemotherapy were acquired retrospectively between December 2012 and August 2020 from three different cancer centers. In total, 1216 radiomics features were initially extracted from each lesion’s pretreatment portal venous phase computed tomography image. Subsequently, a radiomics predictive model was constructed using machine learning software. Clinicopathological data and radiological parameters of the enrolled patients were collected and analyzed retrospectively. Univariate and multivariate logistic regression analyses were performed to screen for independent predictive indices. Finally, we developed an integrated model combining clinicopathological predictive parameters and radiomics features.ResultIn the training set, 10 (14.9%) patients achieved a good response (GR) after preoperative neoadjuvant chemotherapy (n = 77), whereas in the testing set, seven (17.5%) patients achieved a GR (n = 47). The radiomics predictive model showed competitive prediction efficacy in both the training and independent external validation sets. The areas under the curve (AUC) values were 0.827 (95% confidence interval [CI]: 0.609–1.000) and 0.854 (95% CI: 0.610–1.000), respectively. Similarly, when only the single hospital data were included as an independent external validation set (testing set 2), AUC values of the models were 0.827 (95% CI: 0.650–0.952) and 0.889 (95% CI: 0.663–1.000) in the training set and testing set 2, respectively.ConclusionOur study is the first to discover that CECT radiomics could provide powerful and consistent predictions of therapeutic sensitivity to neoadjuvant chemotherapy among gastric cancer patients across different hospitals.

Blunt Thoracic Aortic Injury and Contemporary Management Strategy

Thoracic aortic injury (TAI) is a leading cause of death in blunt chest trauma. Motor vehicle collisions are the commonest cause, and most patients die before receiving medical attention. Survivors who make it to the hospital also typically have other debilitating injuries with high morbidity. It is imperative to understand the nature of these injuries and implement current management strategies to improve patient outcomes. A literature review on contemporary management strategies on blunt thoracic aortic injuries was performed to evaluate the available evidence using online databases (PubMed and Google Scholar). We found that there has been an improved survival owing to the current advancement in diagnostic modalities, the use of contrast-enhanced computed tomography angiography, and contemporary management techniques with an endovascular approach. However, careful assessment of patients and a multidisciplinary effort are necessary to establish an accurate diagnosis. Minimal aortic injuries (intimal tear and aortic hematoma) can be managed medically with careful monitoring of disease progression with imaging. Endovascular approaches and delayed intervention are key strategies for optimal management of high-grade TAI.

Pilimiction, A Rare Presentation of Ovarian Teratoma: A Case Report

Background: Adnexal teratoma involving the urinary bladder is a very rare condition. Presentation is variable ranging from irritative LUTS (lower urinary tract symptoms) to pilimiction or trichiuria (passage of hair in the urine).Case presentation: We report a case of a 42-year-old woman who presented with pilimiction and lower abdominal pain. Contrast-enhanced computed tomography scan (CECT) and Cystoscopy were used for the diagnosis. Tumor markers were negative. Right side salpingo-oophorectomy and partial bladder wall excision were performed. Histopathology of the specimen showed features consistent with mature teratoma. The Patient-reported improvement of symptoms in the subsequent follow-up visits.Conclusion: Pilimiction is a pathognomonic sign of bladder teratomas. Therefore, it is wise to think of this pathology in patients who report the passage of hair through the urine (trichiuria or pilimiction), as in our case. Cystoscopy and cross-sectional imaging aided in the initial diagnosis. However, a definitive diagnosis was provided by histopathology.We performed right-side salpingo-oophorectomy and partial cystectomy. Transurethral resection is associated with a high recurrence rate and is not recommended for secondary bladder teratomas.

Diagnosis and Outcome of Cardiac Paragangliomas: A Retrospective Observational Cohort Study in China

Background: Cardiac paragangliomas (CPGLs) are rare neuroendocrine tumors that are easily overlooked and difficult to diagnose. Detailed comprehensive data regarding CPGL diagnosis and outcome are lacking.Methods: We retrospectively analyzed a cohort of 27 CPGL patients. This cohort represents the largest such cohort reported to date.Results: The prevalence of trilogy symptoms (concurrent palpitations, hyperhidrosis, and headache) was frequent (9/27, 33.3%). Sensitivity of echocardiography and contrast-enhanced computed tomography for localization of CPGL were 81.8% and 87%, respectively. Octreotide scintigraphy showed 100% sensitivity for detecting GPCLs, while sensitivity of I131-metaiodoben-zylguanidine scintigraphy was only 32.9%. Multiple tumors were found in 29.6% of patients. Most CPGLs originated from the epicardium or root of the great vessels (92.9%) and were mostly supplied by the coronary arteries and their branches (95.7%). Twenty-four patients underwent surgical treatment. Although local invasion was present in 40.0% of patients, it did not affect long-term outcome. Mean follow-up was 6.9 ± 3.6 years. Biochemical remission was achieved in 85% of patients. The recurrence rate was 15%.Conclusions: Manifestations of CPGLs are non-specific and they can be difficult to detect on imaging examinations. Octreotide scintigraphy should be performed in patients with suspected paragangliomas to screen for multiple lesions. Surgical resection of CPGLs can achieve symptom relief and biochemical remission.