Abdominal Site Research Articles

PO-1869 Synthetic 4DCT generation from 4DMRI of the abdominal site in Carbon Ion Radiotherapy

PO-1869 Synthetic 4DCT generation from 4DMRI of the abdominal site in Carbon Ion Radiotherapy

D162. Aesthetic Implications of the Profunda Artery Perforator Flap on Thigh And Buttock Proportions

PURPOSE: Profunda artery perforator (PAP) flaps are a secondary option for autologous breast reconstruction when abdominal donor sites are not available. The goal of this study was to investigate the impact of PAP flap reconstruction on aesthetic proportions of the proximal thigh and buttock. METHODS: A retrospective review of 151 patients who underwent PAP flap breast reconstruction (292 flaps) from 2012-2020 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized photographs were analyzed to identify postoperative changes to thigh and buttock contour. The patients’ perception of postoperative aesthetic changes was determined by an electronic survey. RESULTS: The patients’ mean age was 51 years and mean BMI was 26.3 kg/m2. Complications included major and minor wound complications (35.1%), cellulitis (12.6%), seroma (7.9%) and hematoma (4.0%). After reconstruction, patients were found to have aesthetically improved proximal thigh and buttock proportions, indicated by a wider thigh gap (thigh gap-hip ratio: 0.05±0.04 vs. 0.13±0.05, P < 0.0001) and reduction in lateral thigh-to-buttock ratio (0.85±0.05 vs. 0.76±0.05, P < 0.0001). Among the 85 patients who responded to the survey (56.3 % response rate), 70.6% felt that PAP surgery had aesthetically either improved (54.12%) or not had an impact on their thigh contour (16.47%), whereas only 29.4% reported a negative impact on their thigh contour. CONCLUSION: PAP flap breast reconstruction improves aesthetic proportions of the proximal thigh and buttock. This approach is ideal for patients with ptotic tissue of the inferior buttocks and medial thigh and inadequate anterior-posterior buttock projection.

Facilitated Central Pain Mechanisms Across the Menstrual Cycle in Dysmenorrhea and Enlarged Pain Distribution in Women With Longer Pain History

Dysmenorrhea (DYS), or recurrent menstrual pain, is a highly prevalent pain condition among otherwise healthy women. However, the progression of DYS over time and the influence of the menstrual cycle phases need to be better understood. While the location and distribution of pain have been used to assess pain mechanisms in other conditions, they are unexplored in DYS. Thirty otherwise healthy women with severe DYS and 30 healthy control women were recruited into 3 subgroups (n = 10) according to the length of their menstrual history (<5, 5–15, or>15 years since menarche). The intensity and distribution of menstrual pain were recorded. Pressure pain thresholds at abdominal, hip, and arm sites, pressure-induced pain distribution, temporal summation of pain, and pain intensity after pressure cessation over the gluteus medius were assessed at 3 menstrual cycle phases. Compared with the healthy control women, those with DYS showed lower pressure pain thresholds in every site and menstrual cycle phase (P < .05), enlarged pressure-induced pain areas during menstruations (P < .01), and increased temporal summation and pain intensity after pressure cessation in the overall menstrual cycle (P < .05). Additionally, these manifestations were enhanced during the menstrual and premenstrual phases compared to ovulation in women with DYS (P < .01). Women with long-term DYS demonstrated enlarged pressure-induced pain distribution, enlarged menstrual pain areas, and more days with severe menstrual pain compared to the short-term DYS subgroup (P < .01). Pressure-induced and menstrual pain distributions were strongly correlated (P < .001). These findings suggest that severe DYS is a progressive condition underscored by facilitated central pain mechanisms associated with pain recurrence and exacerbation. PerspectiveEnlarged pressure-induced pain areas occur in DYS, associated with the length of the condition and the distribution of menstrual pain. Generalized hyperalgesia is present throughout the entire menstrual cycle and intensifies during premenstrual and menstrual phases.

Risk Factors in Post Operative Wound Infections Following Elective Abdominal Operations

Introduction: Surgical site infections are common post operative complication and cause significant post operative morbidity and mortality, and have serious consequences for outcomes and costs. Different risk factors are involved, including age, sex, smoking, nutrition, diabetes, pre existing illness, pre operative hospital stay time, pre operative shaving, level of surgeon, length of incision, duration of operation, per operative blood transfusion, wound drainage and nature of wound. The objective of this study was to determine the risk factors affecting abdominal surgical site infections and their rate at Dhaka Medical College &amp; Hospital, a major referral teaching hospital in Bangladesh. Objectives: were to identify risk factors in post operative wound infections following elective abdominal surgery. Materials and Methods: A Cross sectional type of observation study was carried out among 153 patients in Department of Surgery, Dhaka Medical College Hospital, Dhaka from January 2008 to December 2009. Results: Patients (n = 153) who had undergone elective surgery were studied and the relationships among variables were analyzed by Student's t and Chi-square tests. To test the independence of the risk factors, the significant variables (p _.05) in the univariate analyses were entered into a stepwise logistic regression equation. Data were collected through pre and postoperative examinations. The subjects were followed till discharge. Of the 153 patients, 13 suffered from SSI (8.5%). Among the infections superficial SSI was in 8 cases (61.54%), deep SSI in 3 cases (23.08%), and organ/space SSI in 2 (15.38%) cases. There were 14 different variables in study to determine the risk factors. In univariate analysis ten risk factors were identified: age, underweight, diabetes, ASA score, pre operative hospital stay, per operative blood transfusion, length of incision, duration of operation, wound drain and contaminated wound. And in multivariate analysis duration of operation, diabetes mellitus and ASA score appeared to be independent risk factors for wound infection. Conclusion: The total elimination of wound infection is not possible, a reduction in the infection rate to a minimal level could have significant benefits in terms of both patient comfort and medical resources used. The SSI may be reduced to a more acceptable level by reducing the average operation time to less than 2 hours, pre operative hospital stay, and by reducing contamination during operation and wound drainage. Furthermore post operative study in large scale is recommended. Medicine Today 2023 Vol.35(1): 56-62

Abstract 49: Comparison of subcutaneous and orthotopic tumor growth in syngeneic mouse models of ovarian and renal cancer

Abstract Oncology drug development has markedly lower success rate (3.4%) than other indications (20.9%) as reported by Wong, Siah and Lo in 2019. Animal models are often pointed at as the culprits for failure in clinical trials. While better animal models for cancer are needed and constantly developed, the incentive of drug developers to use those might not be clear, because the regulatory authorities do not require it. Subcutaneous tumors have earned their place in drug development but adding more sophisticated models to the testing panel before entering the clinical phase should improve the success rate. We present here the properties of subcutaneous and orthotopic tumor growth in two syngeneic models. HM-1 murine ovarian cancer cells were inoculated subcutaneously (s.c.) and intraperitoneally (representing the stage of intraperitoneal carcinomatosis) and murine renal adenocarcinoma Renca cells s.c. and orthotopically within the renal capsule. Body weight and tumor growth were followed, and mice were sacrificed according to humane endpoint criteria. To compare tumor growth in s.c. sites and within the abdomen, the tumor weight at sacrifice was divided by the number of days since the inoculation. In the HM-1 model, the mice with intraperitoneal tumor were sacrificed due to build-up of ascites on average six days earlier that the mice with s.c. tumor. In s.c. HM-1 tumor-bearing mice, the reason for sacrifice was tumor ulceration. In the Renca model, the s.c. and intrabursal models were approximately the same length. There was a striking difference in the tumor growth rate (mg/day) in s.c. versus abdominal sites in both models. The growth was 4-5 times faster in the abdominal sites than subcutaneously, highlighting the effect of tumor specific microenvironment. It is easy to understand that having promising results might be easier in a slower growing model. However, since both ovarian and renal cancer show very different growth kinetics within the abdominal cavity, testing drug candidates aimed for those indications in orthotopic models before accessing the clinical trials could give a more relevant evaluation of the potency of the drug candidates. Citation Format: Mari I. Suominen, Justyna Zdrojewska, Yvonne Konkol, Katja M. Fagerlund, Mervi Ristola, Jukka P. Rissanen. Comparison of subcutaneous and orthotopic tumor growth in syngeneic mouse models of ovarian and renal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 49.

Introduction of the L-PAP Flap: Bipedicled, Conjoined, and Stacked Thigh-Based Flaps for Autologous Breast Reconstruction.

Thigh-based flaps are increasingly popular options for autologous breast reconstruction in the setting of abdominal donor-site inadequacy, previous surgery, or patient preference, but the volume and skin associated with these flaps are often lacking relative to the abdomen. An individualized, shared decision-making approach to donor-site selection was adopted based on body shape, surgical history, lifestyle, reconstructive needs, and patient expectations. Different thigh-based flaps combined in stacked, bipedicled, or conjoined configurations were selected to maximize efficient use of available soft-tissue skin and volume while optimizing donor-site aesthetics. A total of 23 thigh-based stacked, bipedicled, or conjoined profunda artery perforator (PAP), lateral thigh perforator (LTP), or gracilis musculocutaneous flap components were used in six patients. Configurations included bilateral stacked PAP and LTP flaps, bipedicled posterolateral thigh flaps based on the LTP and PAP (L-PAP), and bipedicled thigh flaps based on the gracilis and PAP pedicles. Most anastomoses were performed to the antegrade and retrograde internal mammary vessels; intraflap anastomoses were performed in one case. There were no partial or total flap losses. There was one donor-site seroma. Design of stacked, bipedicled, and conjoined thigh-based flaps using multiple conventional flap components allows for tailored approaches to donor-site utilization based on individual body shape in selected patients. Bipedicled design with the L-PAP flap represents one strategy in appropriate cases to overcome skin and volume deficiencies while facilitating coning and projection. Therapeutic, IV.

Functional constipation: A commonand often overlooked cause for abdominal pain in children.

The most common causes for chronic pain abdomen in pediatric practice are functional abdominal pain disorders, a subgroup of functional gastrointestinal disorders under the Rome IV classification. Constipation is usually associated with painful defecation, but abdominal pain as a predominant or presenting symptom of functional constipation (FC) is not very well recognized. We conducted this study to ascertain the prevalence of FC in chronic pain abdomen and proportion of FC children presenting with predominant complaints of pain abdomen. Prevalence of FC and functional abdominal pain was ascertained separately over a1-year in children > 4 years of age in our hospital. The number of children with FC presenting with abdominal pain was noted. Abdominal pain site and duration werenoted in the FC group and werecompared with those in the functional abdominal pain group to find out any significance. Diagnosis was based on Rome IV criteria, but relevant investigations to rule out organic pathology were done whenever clinically indicated. The prevalence of abdominal pain was 22% in our gastroenterology service and that of FC was 27%. Among the children presenting with chronic abdominal pain, FC was seen in 10% of the patients and functional abdominal pain disorders in 34%. Among children presenting with constipation, 12% had pain as the sole complaint. However, some form of pain or pain as one of the symptoms was seen in 47.5%. FC is a major cause for abdomen pain in children and is often overlooked. Not attributing pain to constipation may delay the diagnosis, which may have poor prognosis.

An international assessment of surgeon practices in abdominal wound closure and surgical site infection prevention by the European Society for Coloproctology.

The burden of abdominal wound failure can be profound. Recent clinical guidelines have highlighted the heterogeneity of laparotomy closure techniques. The aim of this study was to investigate current midline closure techniques and practices for prevention of surgical site infection (SSI). An online survey was distributed in 2021 among the membership of the European Society of Coloproctology and its partner societies. Surgeons were asked to provide information on how they would close the abdominal wall in three specific clinical scenarios and on SSI prevention practices. A total of 561 consultants and trainee surgeons participated in the survey, mainly from Europe (n= 375, 66.8%). Of these, 60.6% identified themselves as colorectal surgeons and 39.4% as general surgeons. The majority used polydioxanone for fascial closure, with small bite techniques predominating in clean-contaminated cases (74.5%, n= 418). No significant differences were found between consultants and trainee surgeons. For SSI prevention, more surgeons preferred the use of mechanical bowel preparation (MBP) alone over MBP and oral antibiotics combined. Most surgeons preferred 2% alcoholic chlorhexidine (68.4%) or aqueous povidone-iodine (61.1%) for skin preparation. The majority did not use triclosan-coated sutures (73.3%) or preoperative warming of the wound site (78.5%), irrespective of level of training or European/non-European practice. Abdominal wound closure technique and SSI prevention strategies vary widely between surgeons. There is little evidence of a risk-stratified approach to wound closure materials or techniques, with most surgeons using the same strategy for all patient scenarios. Harmonization of practice and the limitation of outlying techniques might result in better outcomes for patients and provide a stable platform for the introduction and evaluation of further potential improvements.

A randomized double-blind controlled proof-of-concept study of alanyl-glutamine for reduction of post-myomectomy adhesions

Study ObjectiveTo test the hypothesis that intraperitoneal instillation of a single bolus dose of l-alanyl-l-glutamine (AG) will reduce the incidence, extent and/or severity of adhesions following myomectomy and establish preliminary safety and tolerability of AG in humans. DesignPhase 1,2 Randomized, double-blind, placebo-controlled study (DBRCT). SettingTertiary care gynecology surgical centre. PatientsThirty-eight women who underwent myomectomies by laparoscopy (N = 38; AG-19 vs Placebo-19) or laparotomy (N = 10; AG-5 vs Placebo-5) with a scheduled second-look laparoscopy (SLL) 6–8 weeks later. Thirty-two patients in the laparoscopy arm completed SLL. InterventionsBolus dose of AG or normal saline solution control (0.9% NaCl) administered intraperitoneally immediately prior to suture closure of the laparoscopic ports. The average dose was 170 mL of AG or control based on a dosing scheme of 1 g/kg bodyweight. MeasurementsDigital recordings obtained for all procedures. The primary endpoint was reduction in the incidence, severity and extent of post-operative adhesions analyzed by intention-to-treat (ITT) approach. Three independent, blinded reviewers evaluated all operative video recordings to assess presence of adhesions. Post-hoc analysis assessed presence or absence of adhesions in the peritoneal cavity. Secondary endpoints assessed safety and tolerability of AG. Main resultsAdministration of AG reduced the incidence, severity and/or extent of post-operative adhesions (p = 0.046). The presence of adhesions in the AG group was lower than in the Control group (p = 0.041). Adhesion improvement was achieved in 15 of 15 (100%) in the AG group versus 5 of 17 (29.6%) in the placebo group. No serious adverse events were reported. No differences in safety parameters were observed. ConclusionsIntraperitoneal l-alanyl-l-glutamine reduced adhesion formation in all patients following laparoscopic myomectomy. Complete absence of adhesions was achieved at all abdominal sites in 93% of patients. Results confirm AG’s known effects on cellular mechanisms of adhesiogenesis and lay the foundation for new adhesion prophylaxis research and treatment.

The nuances of abdominal free flap harvest: Technical and patient factors affecting abdominal donor site morbidity in autologous breast reconstruction

Abdominal donor site morbidity after autologous breast reconstruction is common and often underreported. This work aims to compare prospectively collected technical details of the procedure and patient factors and their impact on the development of symptomatic and asymptomatic abdominal bulges (ASB and SB). A review of patients undergoing abdominal-based autologous breast reconstruction from May 2012 to October 2017 by two surgeons at a single institution was performed. Demographics, prior medical and surgical history, intraoperative data, and postoperative course were collected. Primary outcomes of interest were ASB or SB and wound healing complications. Overall, 196 free flaps from 117 patients were included. The average follow-up was 1.9±1.7 years. Thirteen (11.1%) patients developed ASB, and 13 (11.1%) patients developed SB. Patients with BMI ≥30, bilateral ms-TRAM reconstruction, and an onlay type of abdominal closure were 2×, 2.3×, and 8.1× more likely to develop a bulge, respectively (p=0.017, p=0.010, p=0.049). Every one-point increase in BMI above 30 increased the odds of developing a bulge by 10.8%. Prior abdominal surgery increased the risk of SB by 7-fold (p=0.017). The size of the harvested muscle, use of mesh, or nerve preservation did not affect the rate of bulge development. High BMI, bilateral ms-TRAM, onlay type of abdominal closure, and prior abdominal surgery increase the risk of ASB and SB development to varying degrees, while several other operative variables did not seem to make a difference. Breast reconstruction patients can use this information for preoperative counseling and intraoperative decision-making.

Efficacy and tolerability of sorafenib in desmoid-type fibromatosis: A need to review dose

BackgroundSorafenib is currently one of the recommended treatments for symptomatic patients with desmoid-type fibromatosis (DTF). In this study, we aim to assess the clinical efficacy and tolerability of sorafenib in DTF patients. MethodologyPatients aged>18 years with a histological diagnosis of DTF and who have received sorafenib were enroled in this prospective observational study. Demographic data, clinical profile, the initial dose of sorafenib, treatment-related toxicities, dose modifications, and responses were recorded. The primary objective was to assess the objective response rate (ORR). The secondary objectives were to evaluate progression-free survival (PFS), tolerability, and adverse effects of sorafenib. Response assessment was based on response evaluation criteria in solid tumours 1.1 criteria. Adverse effects were graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0 criteria. Time to event was calculated by Kaplan-Meier analysis, and survival was compared by log-rank test. Univariate and multivariable cox regression analysis were used to find independent predictors of relapse. ResultsA total of 104 patients were enroled in the study. The median age of the study population was 32 (range, 18–81) years, and 66.35% of patients were females. On response assessment, ORR was 46.1% and stable disease was observed in 31.7% patients. ORR was higher in the appendicular site (51.7%) compared to the abdominal site (27.2%). PFS at 1 and 2 years was 86.6% (79.6–92.7%) and 73.7% (62.4–82.8%), respectively. Two-thirds (66.6%) of patients had already received some form of treatment. At the time of analysis, 70 (67.3%) patients were continuing sorafenib. Only 4.8% stopped sorafenib due to progression, 10.5% due to intolerable adverse effects, and 17.3% due to other reasons. The common treatment-related toxicities were hand-foot skin reaction (HFSR) (89.4%), fatigue (79.8%), alopecia (70.1%), and diarrhoea (48.0%). In the patients with a starting dose of ≥400 mg (48.0% of patients), discontinuation was necessitated in 12% of patients, and further dose reduction was required in 58%, while only about 13% required dose reduction or discontinuation at a starting dose of 200 mg (51.9% of patients). Responses were not compromised due to lower starting doses. ConclusionsSorafenib has good activity in DTF, but it is associated with significant toxicity. The adverse effect profile is distinct in Indian patients with higher HFSR and alopecia. Due to the high rate of dose reduction/discontinuation with a starting dose of 400 mg, a starting dose of 200 mg may be recommended in Indian patients.

An individualised approach to reduce trocar site hernia

In systematic reviews, the calculated pooled prevalence of trocar site hernia (TSH) has been estimated at 0.5%. Increasing age, high body mass index, smoking, and wound infection potentially influence the incidence. Increasing trocar size, retrieval of specimens through trocar sites, excessive force used in manipulation of the trocar and frequent re-insertion of the trocar may also play a role in the enlargement of the muscolofascial defects. This paper reports a case of a Richter’s hernia within a 5 mm abdominal port site occurring in the early post operative period following laparoscopy. This is significant because it is an uncommon complication of a common procedure. We highlight that various factors may increase the likelihood of this uncommon condition, and provide a brief overview of TSHs.

Defining the Standard for DIEP Donor Site Outcomes: A Decade Long Study on Microvascular Breast Reconstruction and BREAST-Q Patient Satisfaction

Introduction: Previous studies have reported on abdominal donor site complications after DIEP breast reconstruction with a lack of standardization. The aim of this study is to be able to standardize reporting of abdominal donor site complications as well as include patient-reported outcomes based on these standards. Materials and Methods: This retrospective study was conducted on patients who underwent any type of DIEP flap breast reconstruction performed at an academic institution between January 2011 – December 2021. Patients were excluded if they had a history of breast reconstruction or abdominal surgeries, post-reconstruction radiation, or if underwent a concomitant autologous flap reconstruction. Primary outcomes of this study included abdominal donor site complications, treatment outcomes, and BREAST-Q survey responses. Results: 502 patients were evaluated in this study. Our complication rate was 35.3% of the study population, with minor complications making up 68.1% (n = 205) and major making up 31.9% (n = 96) of complications. A moderately strong association was noted between history of DVT/PE and major complications, φ = 0.174, p < 0.001. An association that was reaching significance was noted between umbilical preservation and minor complications, φ = 0.086, p = 0.055. In our logistic regression BMI, hypertension, and umbilical preservation were associated for increased association of minor complications, while BMI, race, hypertension, and history of DVT/PE were associated for increased risk of major complications. Patient cohort reported higher postoperative psychosocial well-being in minor complications (80.49, EMM) while higher postoperative physical well-being: abdomen in no complications (73.50, EMM). Conclusion: This is the first study of its kind discussing the topic of standardizing abdominal donor site complications after DIEP breast reconstruction. This form of classification can be used to dictate treatment options of patients as well as improve on factors that can reduce post-operative complications.

An unexpected cervical unicentric Castleman disease disguising as a lymph node metastasis of papillary thyroid carcinoma

The onset of cervical lymph nodes could be a turning point in the oncologic management of patients previously treated for differentiated thyroid cancer. Its accurate diagnosis may be challenging. A 56-year-old female patient was diagnosed with papillary thyroid carcinoma (PTC). The initial surgical procedure included total thyroidectomy and prophylactic bilateral central-compartment neck dissection. The pathologic examination featured a 3-centimeter left-sided encapsulated follicular variant of PTC, without vascular invasion nor lymph nodes (LN) metastases. The tumor was staged pT2N0M0 and considered as ATA low risk. We obtained a radioiodine remnant ablation following a cumulative dose of 100 mCi. The response to therapy was excellent: indetectable stimulated thyroglobulin (TgOFF), negative anti-thyroglobulin auto-antibodies (TgAB), and negative imaging. After a 10-year remission, follow-up neck ultrasonography detected solid left-sided lymphadenopathy of level III measuring 86 × 31 mm with slightly concomitant rising TgOFF and positive TgAB, suggesting a possible PTC LN metastasis. The patient underwent surgical resection with favorable outcomes. The recurrence of PTC in the absence of aggressive histological features is unlikely (< 5% of cases). The onset of enlarged cervical lymphadenopathy with biochemical signs of cancer activity in patients with underlying PTC suggests a disease relapse. The pathologic examination revealed a unicentric plasmacytic variant of Castleman disease (UCD), with no evidence of malignancy. Castleman disease (CD) represents a cluster of rare and heterogeneous disorders with distinctive LN histopathological abnormalities. CD can occur in a single LN station [unicentric CD] or involve multiple LN stations with systemic symptoms [multicentric CD]. Mediastinum (29%) and abdominal (21%) sites are the most commonly implicated. Since cervical UCD can potentially mimic PTC lymph metastasis, the distinction between these two conditions is challenging. Only biopsy and histological proof could establish a conclusive diagnosis, allowing appropriate management for each scenario.

ABDOMINAL SCAR ENDOMETRIOSIS AS A RARE AND LATE COMPLICATION OF CESAREAN SECTION- CASE REPORTS WITH REVIEW OF LITERATURE.

Abdominal scar endometriosis is the commonest extra pelvic site of the pathology, which follows the surgery on the uterus and fallopian tubes. Cesarean section is the commonest such procedure. Very low incidence may be explained by the recently found pathogenesis of genetic, epigenetic, molecular, and immunological changes. Reporting is important for statistical records and varied presentations. The usual presentation of this chronic gynecological pathology is pain and swelling at the abdominal scar site. Its diagnosis is clinical, complimented with Ultrasound and management is surgical excision. We present two post-cesarean cases with localized swelling and pain in the abdominal scar. Both were treated with wide excision of the lesion; the diagnosis was conrmed and malignancy was excluded by histopathology. No recurrence was noted on follow up. This chronic, progressive pain full condition needs prompt diagnosis and management. Patient counseling is mandatory as recurrence and the chance of malignancy are there in recurrent cases. We present here two such rare cases with the aim of statistical record as the reported incidence is &lt;1%, and its unusual presentation

Synthetic CT in Carbon Ion Radiotherapy of the Abdominal Site.

The generation of synthetic CT for carbon ion radiotherapy (CIRT) applications is challenging, since high accuracy is required in treatment planning and delivery, especially in an anatomical site as complex as the abdomen. Thirty-nine abdominal MRI-CT volume pairs were collected and a three-channel cGAN (accounting for air, bones, soft tissues) was used to generate sCTs. The network was tested on five held-out MRI volumes for two scenarios: (i) a CT-based segmentation of the MRI channels, to assess the quality of sCTs and (ii) an MRI manual segmentation, to simulate an MRI-only treatment scenario. The sCTs were evaluated by means of similarity metrics (e.g., mean absolute error, MAE) and geometrical criteria (e.g., dice coefficient). Recalculated CIRT plans were evaluated through dose volume histogram, gamma analysis and range shift analysis. The CT-based test set presented optimal MAE on bones (86.03 ± 10.76 HU), soft tissues (55.39 ± 3.41 HU) and air (54.42 ± 11.48 HU). Higher values were obtained from the MRI-only test set (MAEBONE = 154.87 ± 22.90 HU). The global gamma pass rate reached 94.88 ± 4.9% with 3%/3 mm, while the range shift reached a median (IQR) of 0.98 (3.64) mm. The three-channel cGAN can generate acceptable abdominal sCTs and allow for CIRT dose recalculations comparable to the clinical plans.

Periumbilical Anatomy of Scarpa's Fascia: Rationale Behind a "Modified Scarpa's" Abdominal Closure Technique.

Intraoperative observation of Scarpa's fascia (SF) has suggested attenuation in the periumbilical region. This study's purpose was to objectively evaluate SF anatomy in the periumbilical region and assess clinical outcomes of a novel, modified SF closure technique of transverse abdominal wall incisions that only reapproximates SF where it is definitively present. Women were identified who had undergone abdominal magnetic resonance (MR) angiography before their abdominal-based autologous breast reconstruction that used the modified SF closure technique. Statistical analysis of SF presentation on the MR images was performed. Intraoperative measurements from dissected panniculectomy specimens were used to validate MR analysis. Donor site complications were recorded in patients undergoing modified SF closure. Sixty-six patients were included in the retrospective MR imaging analysis; this revealed an average attenuation of SF of 4.7 cm (SEM = 0.25 cm), 4.5 cm (SEM = 0.23 cm), 4.6 cm (SEM = 0.23 cm), and 4.2 cm (SEM = 0.22 cm) to the left of, right of, cranial to, and caudal to the umbilicus, respectively. The mean surface area of radiologic SF absence was 56.3 cm 2 (SEM = 3.57 cm 2 ). There was a significant difference in SF presentation based on patient age ( P = 0.013) and body mass index ( P = 0.005). Five of the 66 patients (7.6%) experienced abdominal closure site complications. This study objectively confirms that there is attenuation of SF in the periumbilical region, describes a novel SF closure technique, and provides evidence to support its adoption when closing transverse abdominal wall incisions.

The usefulness of laparoscopic surgery for inguinal endometriosis

BackgroundInguinal endometriosis is a rare clinical disease with an unclear etiology and pathogenesis, and its diagnosis requires accurate medical history-taking and histological examination. However, surgical treatment for the condition has not yet been standardized. This report presents two cases of inguinal endometriosis.Case presentationThe first patient was a 36-year-old woman who complained of pain and swelling in her right inguinal region. Physical examination revealed a soft, tender right inguinal mass. The size of the mass repeatedly increased and decreased during menstruation and did not show swelling with abdominal pressure. Magnetic resonance imaging showed a 3.5 × 2.5 cm mass with high intensity on T2-weighted imaging in the right inguinal canal, and no communication was found between the lesion site and the abdominal cavity. We diagnosed this case as inguinal endometriosis and managed it using an anterior approach and laparoscopic observation. The second patient was a 51-year-old woman who presented with an intermittently painful mass in her right inguinal region. The mass tended to increase in size, with worsening pain before menstruation. Abdominal computed tomography revealed a 2 × 2 cm cystic mass in the right inguinal region. We made a diagnosis of inguinal ectopic endometriosis and decided to operate via the totally extraperitoneal (TEP) method for excision plus transabdominal observation. The postoperative course in both cases was uneventful with no recurrence.ConclusionsInguinal endometriosis is a rare entity that should be suspected in patients with cyclical symptoms of inguinal pain and swelling that correlate with their menstrual cycle, which might otherwise be attributed to inguinal hernia. It is crucial to make a preoperative diagnosis based on a careful medical review, physical examination, and imaging studies, and to make an appropriate surgical plan. Particularly, in the case of ectopic inguinal endometriosis involving the canal of Nuck, laparoscopic observation is useful for the intraoperative diagnosis of inguinal endometriosis to help rule out the involvement of other abdominal sites. However, it is important to select and modify the surgical technique to avoid rupturing the endometrisis mass and prevent postoperative recurrence.

Synthetic computed tomography generation for abdominal adaptive radiotherapy using low-field magnetic resonance imaging.

Magnetic Resonance guided Radiotherapy (MRgRT) still needs the acquisition of Computed Tomography (CT) images and co-registration between CT and Magnetic Resonance Imaging (MRI). The generation of synthetic CT (sCT) images from the MR data can overcome this limitation. In this study we aim to propose a Deep Learning (DL) based approach for sCT image generation for abdominal Radiotherapy using low field MR images. CT and MR images were collected from 76 patients treated on abdominal sites. U-Net and conditional Generative Adversarial Network (cGAN) architectures were used to generate sCT images. Additionally, sCT images composed of only six bulk densities were generated with the aim of having a Simplified sCT.Radiotherapy plans calculated using the generated images were compared to the original plan in terms of gamma pass rate and Dose Volume Histogram (DVH) parameters. sCT images were generated in 2s and 2.5s with U-Net and cGAN architectures respectively.Gamma pass rates for 2%/2mm and 3%/3mm criteria were 91% and 95% respectively. Dose differences within 1% for DVH parameters on the target volume and organs at risk were obtained. U-Net and cGAN architectures are able to generate abdominal sCT images fast and accurately from low field MRI.

Herniation and incarceration of the gallbladder through the abdominal drain site: A case report

Herniation and incarceration of the gallbladder through the abdominal drain site: A case report