Adjacent Gastrointestinal Tract Research Articles

Feasibility estimation of injected hydrodissection before definitive radiotherapy of pancreatic adenocarcinoma.

Pancreatic adenocarcinoma is often not diagnosed until an advanced stage, and so most patients are not eligible for resection. For patients who are inoperable, definitive radiotherapy is crucial for local disease control. However, the pancreas is located close to other vulnerable gastrointestinal organs, making it challenging to deliver an adequate radiation dose. The surgical insertion of spacers or injection of fluids such as hydrogel before radiotherapy has been proposed, however, no study has discussed which patients are suitable for the procedure. In this study, we reviewed 50 consecutive patients who received definitive radiotherapy at our institute to determine how many could have benefitted from hydrodissection to separate the pancreatic tumor from the adjacent gastrointestinal tract. By hypothetically injecting a substance using either computed tomography (CT)-guided or endoscopic methods, we aimed to increase the distance between the pancreatic tumor and surrounding hollow organs, as this would reduce the radiation dose delivered to the organs at risk. An interventional radiologist considered that hydrodissection was feasible in 23 (46%) patients with a CT-guided injection, while a gastroenterologist considered that hydrodissection was feasible in 31 (62%) patients with an endoscopic injection. Overall, we found 14 (28%) discrepancies among the 50 patients reviewed. Except for 1 patient who had no available trajectory with a CT-guided approach but in whom hydrodissection was considered feasible with an endoscopic injection, the other 13 patients had different interpretations of whether direct invasion was present in the CT images. Our results suggested that about half of the patients could have benefited from hydrodissection before radiotherapy. This finding could allow for a higher radiation dose and potentially better disease control.

Innovative Combination Treatment to Expand the Indications of Particle Therapy: Spacer Placement Surgery Using Bio-Absorbable Polyglycolic Acid Spacer.

Particle therapy has favorable dose distribution and high curability. However, radiotherapy for malignant tumors adjacent to the gastrointestinal tract is contraindicated owing to its low tolerance. To overcome this, combination treatment with surgery to make a space between the tumor and adjacent gastrointestinal tract followed by particle therapy has been developed. Several materials have been used for the spacer and recently, we developed the absorbable polyglycolic acid (PGA) spacer, which has been used since 2019. This study is the first report of consecutive case series of spacer placement surgery using the PGA spacer. Fifty consecutive patients undergoing spacer placement surgery with the PGA spacer were evaluated. Postoperative laboratory data, morbidity related to the treatment, and spacer volume after treatment were evaluated. There were no treatment-related deaths, and all but 2 patients completed combination treatment. The median ratios of postoperative PGA spacer volume to the pretreatment volume were 96.9%, 87.7%, and 74.6% at weeks 2, 4, and 8, respectively. The spacer volume was maintained at 80% at 7 weeks and was predicted to be 50% at 15 weeks and 20% in 24 weeks. Spacer placement surgery using the PGA spacer was feasible and tolerable. The PGA spacers maintained sufficient thickness during the duration of subsequent particle therapy. Combination treatment using the PGA spacer is innovative and has the potential to become a new standard curative local treatment.

Ultrasound-guided microwave ablation in the individualized treatment of hepatocellular carcinoma adjacent to danger areas

Objectives To investigate the efficiency and safety of ultrasound-guided microwave ablation (MWA) for hepatocellular carcinoma (HCC) adjacent to danger areas. Methods The 106 patients with HCC treated by ultrasound-guided MWA were retrospectively included in our study. There were 149 lesions in total, including 8 lesions adjacent to gallbladder, 33 lesions adjacent to grade Ⅰ-Ⅱ bile duct, 39 lesions adjacent to diaphragm, 28 lesions adjacent to gastrointestinal tract and 41 lesions adjacent to hepatic capsule. The mean diameter of the tumors was (2.04±0.92)cm. Individualized treament strategies for different sites of the tumors were conducted. The early complete ablation rate of the tumors was assessed by enhanced computed tomography (CT) or magnetic resonance imaging (MRI) one month later and followed up regularly. Results The total inactivation rate was 89.9%. The early complete ablation rates of adjacent gallbladder, adjacent grade Ⅰ-Ⅱ bile duct, adjacent diaphragm, adjacent gastrointestinal tract and adjacent hepatic capsule were 100%, 84.8%, 89.7%, 92.9%, 90.2% respectively. The local progression rates were 0, 15.2%, 10.3%, 7.1%, 9.8%, respectively. The 1-, 2- and 3-year survival rates were 91.6%, 85.8% and 74.5%. Total cases were ablated 149 times. Serious complications accounted for 6.6%, including diaphragm injury, needle implantation, abdominal hemorrhage, severe infection, bile tumors. Conclusions Our study presented a novel individualized treament strategies using MWA in HCC patients. The individualized scheme effectively boosted the complete ablation rate of tumors and significantly improve the clinical outcome of HCC patients. Key words: Ultrasonography; Microwaves; Ablation techniques; Liver neoplasms

Recurrent Hematemesis in a Patient With Aorto-enteric Fistula

We report a case of an aorto-enteric fistula (AEF) in a patient with history of celiac artery aneurysm and graft repair. AEFs are a communication between the aorta and the adjacent gastrointestinal tract. AEFs are a rare, but life-threatening cause of upper gastrointestinal tract bleeding and should be on the differential in patients with history of abdominal vascular surgery. A 32-year-old woman underwent celiac artery aneurysm resection with aorto-common hepatic artery graft interposition. This was complicated by pancreatic head, common bile duct, and portal vein necrosis requiring Whipple pancreaticoduodenostomy, Roux-en-Y hepaticojejunostomy, and portal vein resection with graft interposition. She also developed a pancreatico-cutaneous fistula, eventually closed by EUS-guided pancreatic pseudocyst gastrostomy. The patient was later reassessed with EGD, which showed a gastro-jejunal (GJ) junction Forrest class III ulcer. The patient presented to our institution with hematemesis, melena, and hemoglobin of 4.2 g/dL. EGD showed the known GJ ulcer with new friability and was treated with epinephrine and argon plasma coagulation. However, the patient returned with hematemesis and repeat EGD showed the GJ ulcer had an adherent clot with a visible vessel which was clipped. Abdominal CT angiography (CTA) did not reveal evidence of acute hemorrhage. The patient returned with GI bleeding and repeat abdominal CTA showed a tubular structure concerning for AEF, with possible erosion of the celiac stump into the jejunal blind limb. Vascular surgery was consulted for endovascular graft of the AEF. AEFs can be spontaneous or secondary to a previous aortic surgery. Aortic pseudoaneurysms and/or grafts can cause fistula through aortic pulsation into the intestinal tract and present with GI bleeding. EGD, CT with contrast, and CTA are the most common imaging modalities that aid in diagnosis. EGD can be useful if a graft or pulsatile mass is visualized, but most AEFs occur in the distal duodenum and may not be seen on EGD. CT with contrast is relatively sensitive for signs of AEF such as loss of peri-aortic fat pad, gas around the graft, fluid or soft tissue collection around the aorta, and IV contrast extravasation into the bowel or around the aorta. As in our case, CTA can be helpful in patients with altered anatomy. In addition to CT findings typical for AEF, CTA has greater spatial resolution allowing better visualization of the aortic contour and side branches.Figure: Gas shadow and inflammation surrounding aorta at the level of celiac stump, likely indicative of anastomotic connection to walled off necrosis, which is adjacent to the jejunum.

Selective Regional Feeding Vessel Occlusion: A New Alternative for Percutaneous Ablation of Hepatocellular Carcinoma Adjacent to Gastrointestinal Tract when Artificial Ascites Failed

Conventional percutaneous radiofrequency ablation for peripheral hepatocellular carcinoma (HCC) has a high risk of injuring adjacent gastrointestinal tract. The aim of this study was to evaluate the efficacy and safety of selectively regional feeding vessel occlusion as a new alternative for treating HCC adjacent to gastrointestinal tract when artificial ascites failed. From June 2014 to January 2016, 9 patients with 9 hypervascular target HCCs (mean, 3.0±0.7cm) were included in this study. The target tumors were located at the hepatic marginal angle (segment 2/3/6) and adjacent to gastrointestinal tract. Structure of feeding vessels were identified with multimodal ultrasound technologies including color doppler ultrasound, 2-dimensional and 4-dimensional contrast-enhanced ultrasound. A unipolar Cool-tip electrode was used to selectively occlude the feeding vessel of a subsegmental and tumor-burden region. Initial complete response (ICR), local tumor progression (LTP), intrahepatic distant recurrence (IDR) and complications were observed. Successful occlusions were achieved in 7/9 (77.8%) of the tumors. ICR was achieved in 7/7 (100%) of the tumors in 1-month evaluation. After a mean follow-up period of 12.4±8.5 months, LTP was observed in 1/7 (14.3%) of the tumors after a delay of 4.7 months. IDR was observed in 5/7 (71.4%) of the tumors after a mean delay of 8.0±5.7 months. Minor complication occurred in 2/7 (28.6%) of the patients. No major complication occurred. Selective regional feeding vessel occlusion assisted by multimodal ultrasound has the potential to serve as an effective and safe alternative to treat HCC adjacent to gastrointestinal tract when artificial ascites failed.

Hyaluronic Acid Gel Injection to Prevent Thermal Injury of Adjacent Gastrointestinal Tract during Percutaneous Liver Radiofrequency Ablation

This study evaluated the safety, feasibility, and clinical utility of hyaluronic acid gel injection to separate the gastrointestinal tract from the tumor during liver radiofrequency ablation (RFA). Eleven patients with liver tumors measuring 0.9-3.5 cm (mean ± standard deviation, 2.1 ± 0.8 cm) that were adjacent to the gastrointestinal tracts received RFA after the mixture of hyaluronic acid gel and contrast material (volume, 26.4 ± 14.5 mL; range, 10-60 mL) was injected between the tumor and the gastrointestinal tract under computed tomographic-fluoroscopic guidance. Each tumor was separated from the gastrointestinal tract by 1.0-1.5 cm (distance, 1.2 ± 0.2 cm) after injection of hyaluronic acid gel, and subsequent RFA was performed without any complications in all patients. Although tumor enhancement disappeared in all patients, local tumor progression was found in a patient (9.1%, 1 of 11) during the follow-up of 5.5 ± 3.2 months (range, 0.4-9.9 months). In conclusion, hyaluronic acid gel injection is a safe and useful technique to avoid thermal injury of the adjacent gastrointestinal tract during liver RFA.

An unusual presentation of a cystic duplication of the sigmoid colon entirely lined with squamous epithelium

Alimentary tract duplications are rare congenital malformations that occur most commonly in the jejunoileal part of the gastrointestinal tract. Management of this pathologic condition is usually drawn up. We report a case of descending colonic communicating duplication in which clinical presentation and anatomopathologic results were unexpected. A slightly echogenic abdominal mass reaching 72 × 36 mm in the left flank was diagnosed in a female fetus during the third trimester ultrasound examination. At birth, volume of the mass rapidly evolved, and despite no intestinal obstruction was observed by compression of the adjacent gastrointestinal tract, abdomen was distended. Abdominal plain film showed a large air collection, and the barium enema demonstrated a slight leak of contrast in the aerated mass, suggesting a communication with the sigmoid colon. No other abnormalities were seen. The patient underwent surgery in emergency. The mass was then totally excised through an antimesenteric resection of the tubular tract joining cystic mass and sigmoid colon. A lateral suture of the colon was subsequently performed. The wall of the duplication is usually composed of a smooth muscle layer covered by an epithelium, mostly of intestinal type. Herein, we describe a descending colonic duplication completely lined with nonkeratinizing squamous epithelium. Therefore, the association of a colonic mucosa (of endodermic origin) and a squamous epithelium (derived from the ectoderm) in our case is an interesting finding and is not explained by the various theories. Furthermore, the clinical characteristics, diagnosis, and treatment of intestinal duplications are discussed with regard to literature.

Delayed spontaneous hepatogastric fistula formation following transcatheter arterial embolisation and radiotherapy for hepatocellular carcinoma

A 58-year-old male patient with an unresectable 10 cm liver lesion that was a histologically proven hepatocellular carcinoma (HCC) underwent transcatheter hepatic artery embolisation (TAE). 4 months later, the patient was referred for salvage radiotherapy owing to local recurrence. The HCC became an encapsulated tumour with central necrosis after radiotherapy. The patient enjoyed a normal lifestyle for 9 years, with local control achieved by radiotherapy, until a hepatogastric fistula developed. Although the hepatogastric fistula resolved with surgical drainage, the patient later died from septic shock. Hepatogastric fistula is a rare but serious complication after TAE and radiotherapy for HCC. Development of fever, abdominal pain and jaundice after an initial symptom-free interval should arouse suspicion of hepatogastric fistula formation from an encapsulated necrotic HCC or a ruptured liver abscess. Because the mortality is high, aspiration of a suspected necrotic lesion should be performed as soon as possible. Patients with risk factors, including liver cirrhosis and large lesions close to the adjacent gastrointestinal tract, are especially vulnerable. Gas formation within a necrotic liver tumour requires immediate drainage.

Foregut Derived Duplication Cyst Presenting as Abdominal Pain

Purpose: Enteric duplication cysts are rare congenital malformations that can occur anywhere from the mouth to the anus. Cystic duplications are endothelium lined and share a common muscular wall and blood supply with the adjacent gastrointestinal tract. We present the unique case of a foregut derived duplication cyst presenting as abdominal pain and elevated inflammatory markers in an adult patient. Methods: A 26 year-old Caucasian female presented to our gastroenterology clinic with 3 weeks of constant, non-radiating, epigastric abdominal pain. She denied weight change, nausea, emesis or dysphagia and had no past medical or surgical history. Medications only included lansoprazole 30 mg daily started 2 weeks prior by her primary care physician which provided no relief. She had moderate tenderness to palpation in the epigastrium and an otherwise normal physical exam. Laboratory tests were significant for WBC of 11, 300, CRP of 40.2 mg/L, and gastrin level of 156 pg/mL. Upper endoscopy revealed mild antral erythema and biopsies were consistent with non-specific gastritis. An abdominal CT demonstrated a cystic structure anterior to the gastro-esophageal junction and posterior to the left hepatic lobe measuring 1.7 × 1.6 cm (Fig. 18). The patient was then referred for exploratory laparoscopy which showed a smooth mass protruding through the gastrohepatic ligament. The mass was removed and grossly appeared to be a 2.7 × 2.5 × 1.5 cm cyst. The histology was consistent with a foregut derived duplication cyst of either bronchogenic or esophageal origin. Two weeks post-operatively her symptoms had resolved and laboratory values had normalized. Results: This case is a unique presentation of a foregut derived duplication cyst presenting as epigastric abdominal pain and elevated inflammatory markers, suggesting that duplication cysts be included in the differential diagnosis of abdominal pain. Conclusion: As the potential complications of enteric duplications include gastrointestinal bleeding and rarely malignant transformation, the recognition of duplication cysts must lead to prompt surgical evaluation.Figure 1

A case of biliary gastric fistula following percutaneous radiofrequency thermal ablation of hepatocellular carcinoma

Percutaneous radiofrequency thermal ablation (RFA) is an effective and safe therapeutic modality in the management of liver malignancies, performed with ultrasound guidance. Potential complications of RFA include liver abscess, ascites, pleural effusion, skin burn, hypoxemia, pneumothorax, subcapsular hematoma, hemoperitoneum, liver failure, tumour seeding, biliary lesions. Here we describe for the first time a case of biliary gastric fistula occurred in a 66-year old man with a Child's class A alcoholic liver cirrhosis as a complication of RFA of a large hepatocellular carcinoma lesion in the III segment. In the light of this case, RFA with injection of saline between the liver and adjacent gastrointestinal tract, as well as laparoscopic RFA, ethanol injection (PEI), or other techniques such as chemoembolization, appear to be more indicated than percutaneous RFA for large lesions close to the gastrointestinal tract.

腹部CT検査における内服させる造影剤濃度の研究

A problem of Pancreatic CT scanning is the discrimination between the pancreas and the adjacent gastrointestinal tract. Generally we administer a dilution of gastrografin internally to make the discrimination. The degree of dilution has been decided by experience at each hospital.When the consistency of the contrast medium is low in density, an enhancement effect cannot be expected, but when the consistency is high, artifacts appear. We have experimented on the degree of the dilution and CT-No to decide the optimum consistency of gastrografin for the diagnosis of pancreatic disease.Statistical analysis of the results show the optimum dilution of gastrografin to be 1.5%.

Dilute oral iron solutions as gastrointestinal contrast agents for magnetic resonance imaging; Initial clinical experience

Delineation of the gastrontestinal tract in magnetic resonance imaging (MRI) remains a problem. Ferric ammonium citrate is paramagnetic, producing a high MRI signal intensity by virtue of its spin-lattice ( T 1) relaxation rate enhancement properties. Water is diamagnetic, producing a low MRI signal intensity, especially with short TR and TE times. To compare efficacy for gastrointestinal contrast alteration, ferric ammonium citrate was administered to 18 patients and water was given to 10 patients. Spin-echo imaging at 0.35T was performed after administration of these agents. Ferric ammonium citrate produced high signal intensity within the esophagus, stomach, duodenum, and small intestine that aided in the differentiation of the gastrointestinal tract from adjacent tumors, vessels, and viscera. Delineation of the gut wall was superior using ferric ammonium citrate compared to that produced by water. Delineation of the margins of the pancreas, liver, and kidney from adjacent gastrointestinal tract was also better with ferric ammonium citrate. Optimal distinction between bowel and fat was better with water. Longer TE times (75 to 200 ms) may allow improved contrast between gut and intrabdominal fat using ferric ammonium citrate.