Gastrocolic Ligament Research Articles

Primary Omental Pregnancy on the Gastrocolic Ligament

Omental pregnancy is an extremely rare form of abdominal pregnancy. Only 16 cases had been reported in the literature, and most were secondary omental pregnancies. We presented a case of primary omental pregnancy located on "gastrocolic ligament" diagnosed at surgical operation. The aim of this presentation is to remember that pregnancy can exist in unusual localizations, so abdominal observation and examination is very important during operations.

Laparoscopic Medial-to-lateral Approach for the Curative Resection of Right-Sided Colon Cancer

Our previous randomized clinical trial comparing the laparoscopic medial-to-lateral dissection with the more classic lateral-to-medial approach for resection of rectosigmoid cancer showed that the medial approach reduces the operative time and the postoperative proinflammatory response. Besides the oncologic advantages of an early vessel division and a "no-touch" dissection, we feel that the longer the lateral abdominal wall attachments of the colon are preserved, the better the exposure and the easier the dissection. Encouraged by the above-mentioned positive findings, we therefore further conduct this phase II clinical trial to examine the feasibility and surgical outcomes regarding the utilization of this medial-to-lateral laparoscopic dissection approach for the curative resection of right-sided colon cancer. A total of 104 patients (from December 2000 to January, 2005) with advanced right-sided colon cancer (TNM stage II: n = 56; stage III: n = 48) requiring a curative right hemicolectomy were subjected to the laparoscopic medial-to-lateral approach that included initial exploration and ligation of ileocolic, right colic, and middle colic vessels in no-touch isolation fashion, subsequent medial-to-lateral extension of retroperitoneal dissection along Gerota fascia, opening of lesser sac by transection of gastrocolic ligament, and the final mobilization of hepatic flexure and lateral attachments of ascending colon (Fig. 1). This study was approved by the institutional review committee of National Taiwan University Hospital. The surgical details were shown in the video. Postoperatively, adjuvant chemotherapy with Mayo Clinic Regimen was given in patients with stage III diseases. The functional recovery and surgical outcomes were prospectively evaluated. The laparoscopic medial-to-lateral approach for a curative right hemicolectomy can be preformed with acceptable operation time (192.6 +/- 32.8 min, mean +/- standard deviation) and little blood loss (48.4 +/- 14.4 ml) through a small wound (6.0 +/- 0.8 cm). The number of dissected lymph node was 16.0 +/- 2.8. The operative complications represented 5.7% of all cases, including anastomotic leakage in two cases (1.9%) and wound infection in four cases (3.8%). The patients have quick functional recovery, as evaluated by the length of postoperative ileus (60.0 +/- 12.0 h), hospitalization (9.0 +/- 1.5 days) and degree of postoperative pain (4.0 +/- 0.5, visual analogue scale). Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay an extra-expenses of NT$ 25,000.0 +/- 2,800.0 (1.0 US$ = 32.0 NT$). During the follow-up periods (median: 30 months, range 6-55 months), recurrence of tumor developed in 6 (10.7%) of stage II and 10 (20.8%) of stage III patients, with liver metastasis in six patients, lung metastasis in 4, liver and lung metastasis in 1, intraperitoneal recurrence in 2, bone metastasis in 1, brain metastasis in 1, and port-site recurrence in 1. By medial-to-lateral dissection method, the laparoscopic right hemicolectomy can be performed with technical efficiency, short convalescence, and acceptable short-term oncologic results. We therefore encourage the use of this approach for patients requiring a curative laparoscopic right hemicolectomy.

The Dagradi-Serio-Iacono Operation Central Pancreatectomy

Central pancreatectomy (CP) is a segmental pancreatic resection indicated to remove benign or low-grade malignant tumors of the isthmus and proximal part of the body of the pancreas. The main advantage of this operation compared with major resections is that it permits to spare normal pancreatic parenchyma; moreover, spleen and upper digestive and biliary tracts are saved. The description of the complete operation was reported for the first time by Dagradi and Serio in 1984 and subsequently spread worldwide by Iacono and Serio. In our opinion, it should be called the Dagradi–Serio–Iacono operation, by the names of the surgeons who first performed it (Dagradi and Serio), and by the names of the surgeons responsible for reporting it worldwide with precise indications (Iacono and Serio). Operation requires a midline or a bilateral subcostal incision; the lesser sac is entered through dissection of the transverse colon from the omentum or by transecting the gastrocolic ligament. The pancreatic segment harboring the lesion is then mobilized and its posterior surface carefully dissected from the splenic vein and artery. Subsequently, the pancreatic portion harboring the tumor is isolated at its superior margin from the splenic artery after the pancreas is transacted. The extent of the resection of the central segment is limited on the right by the gastroduodenal artery and on the left by the need to leave at least 5 cm of normal pancreatic remnant. The resected pancreatic specimen is sent to the pathologist for confirmation of diagnosis and to check if the resection margins are adequate. Hemostasis of the two raw surfaces is achieved with interrupted 5 or 4/0 nonabsorbable stitches. When it is not stapled, the Wirsung’s duct of the cephalic stump is sutured selectively with a figure-of-eight nonabsorbable stitch. An end-to-end invaginated pancreaticojejunostomy is carried out with a single layer of interrupted stitches. The operation is concluded with the construction of an end-to-side jejuno-jejunostomy about 50 cm distal to the pancreatic anastomosis. Other techniques for reconstruction of the distal stump using jejunum or stomach have been described. One or two soft drains are brought out on the right side. The fluid collected from this drain is checked for amylase level on postoperative days 3, 5, and 7; if the level is low or absent, the drain is removed. Central pancreatectomy is a safe technique for benign or low malignant tumors of the pancreatic neck that allows curing the tumor with evident functional results without increasing the risk for the patient. We can say that CP has a clear role like pancreaticoduodenectomy and distal pancreatectomy and we think that a pancreatic surgeon has to include this procedure in his/her technical skills. In order to obtain excellent results, correct indications and experience in pancreatic surgery are recommended.

Spontaneous gastrojejunal fistula is a complication of gastric ulcer

Spontaneous gastrojejunal fistula formation is an extremely rare complication of gastric ulcer disease. We report a 77-year old woman who presented with diffuse abdominal pain, weight loss, malaise, nausea, and occasional dark stools. Laboratory tests showed extreme hyposideremic anemia with inflammatory syndrome. In addition, biochemical parameters of malnourishment were presented. Upper endoscopy revealed the patent esophagus along the full length without any pathological changes. Large and deep ulceration with perforation in the small intestine was detected in the posterior gastric wall. The small intestine loop was reached by endoscope through spontaneously developed gastrojejunal fistula. Polytopic biopsies of described ulcerative change were carried out. Histopathologically reepithelialized ulcerous zone was seen in the gastric mucosa. Also, gastrojejunal fistula was visualized after wide opening of hepatogastric and gastrocolic ligament. Jejunal loop 25 cm from ligament of Treitz was attached to mesocolon and posterior gastric wall because of ulcer penetration. Postoperative course was uneventful. Per oral intake started on the 4(th) postoperative day, and the patient was discharged on the 8(th) postoperative day. In summary, this case indicates that persistent symptoms of peptic ulcer disease associated with nutritional disturbances may be caused by gastrojejunal fistula.

Computed tomography of gastrocolic ligament: involvement in malignant tumors of the stomach

This study investigated computed tomographic (CT) features and anatomic bases of gastrocolic ligament involvement in malignant neoplasms of the stomach. We retrospectively reviewed CT scans of 34 patients known to have gastric malignant neoplasm and gastrocolic ligament involvement. Emphasis was placed on direct invasion, lymph node metastasis, and omental seeding. CT manifestations of gastrocolic ligament involvement included direct invasion (38.2%, 13 of 34), enlargement of lymph nodes (50%, 17 of 34), "smudged" appearance (26.5%, nine of 34), "omental caking" (5.9%, two of 34), cystic mass (2.9%, one of 34), and varices of the omentum (2.9%, one of 34). We also found that gastric carcinoma and gastrointestinal stromal tumor invaded the transverse colon through the gastrocolic ligament in six patients (17.6%, six of 34). CT scan is useful for detecting gastrocolic ligament involvement in gastric malignant neoplasm. The imaging features consist of a mass sign, enlargement of lymph nodes, smudged appearance, omental caking, and so on. Gastric malignant neoplasm also may involve the transverse colon through the gastrocolic ligament.

Retrograde Gastric Intussusception After Myotomy for Achalasia

Retrograde gastroesophageal intussusception has been rarely reported in the literature. Risk factors include poor fixation of the stomach due to either long or loose mesenteric attachments; high intraabdominal pressure due to retching, physical exertion, or ascites; and hiatal hernia, which can lead to the development of a large gastroesophageal opening. An attempt at endoscopic reduction is reasonable, but laparotomy and manual reduction is usually required. We report a case of retrograde gastroesophageal intussusception in a patient with long-standing achalasia and two previous Heller myotomies.

Retroperitoneal Splenosis Simulating a Relapsing Renal Carcinoma

We present a case of retroperitoneal splenosis simulating a relapsing renal carcinoma. A 75-year-old male had undergone a left radical nephrectomy for a clear cell neoplasm, pT4 N0; during the operation a splenectomy for an unreparable spleen laceration had been performed. After 1 yr, the patient was asymptomatic; an abdominal CT evidenced a solid 24 mm diameter nodular formation of the left lumbar region, a suspected recurrence of renal carcinoma. This nodule was removed, it was capsulated and violaceous; the histologic examination demonstrated that it was typical splenic tissue. Splenosis nodules are generally due to “insemination” of splenic pulp after trauma or splenectomy, probably more frequent with laparoscopic surgery. The splenosis localizations can be either single or multiple, round in form, a few centimeters at its greatest diameter; the favorite seats are the peripancreatic region, the gastrocolic ligament and the great omentum. The splenosis is generally asymptomatic, but it can simulate tumors of various organs. The echotomographic and CT scan remarks can be aspecific. MRI can be more precise, with the ferumoxide-enhancement effect. The most reliable examination is the “heat damaged” Tc-99 labeled erythrocyte scintigraphy: 1 cm nodules appear evident. We recommend that the diagnosis of suspected neoplasm in splenectomized patients should include the heat damaged red cell scintigraphy.

Laparoscopic Medial-to-Lateral Approach for the Curative Left Hemicolectomy

Laparcoscopic curative left hemicolectomy requires the takedown of colonic splenic flexure and has been challenging. The present study aims to examine if the technical advantages of medial-to-lateral dissection method, as shown in our previous laparoscopic rectosigmoid resection, can be extrapolated to the laparoscopic left hemicolectomy. A total of 24 consecutive patients (from October 2004 to March 2005) with left-sided colon cancer requiring the takedown of colonic splenic flexure to facilitate a curative left hemicolectomy were subjected to this laparoscopic procedure that included initial incision on the mesentery medial to inferior mesenteric vein, ligation of vessels in no-touch isolation fashion, subsequent medial-to-lateral extension of retroperitoneal dissection along Gerota fascia, opening of lesser sac by transection of gastrocolic ligament, dissection of mesenteric root of distal transverse colon, and the final separation of splenocolic ligament and lateral attachments of descending colon. The technical efficiency, the number of cleared lymph node, and functional recovery of patients were prospectively evaluated. The laparoscopic medial-to-lateral approach is considered as highly efficient because it was preformed with acceptable operation time (214.4 ± 54.4 minutes, mean±standard deviation) and little blood loss (40.0 ± 14.0 ml) through a small wound (5.5 ± 0.6 cm). The number of dissected lymph nodes was 14.0 ± 3.0. There were no major complications. Moderate morbidity represented 8 percent of all cases, including minor leakage in 1 case (4 percent) and wound infection in 1 case (4 percent). The patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0 ± 12.0 hours), hospitalization (9.0 ± 1.0 days), and degree of postoperative pain (3.5 ± 0.5, visual analog scale). The overall costs were NT$194,000.0 ± 3200.0 (1.0 US dollar = 32.0 NT$). By medial-to-lateral dissection method, the laparoscopic takedown of colonic splenic flexure can be performed with highly technical efficiency, acceptable number of cleared lymph node, and short convalescence. We therefore recommend this dissection method to the expert surgeons, endeavoring to define a standard technique to curative surgery in the left-sided colon cancers, and especially to the beginners, seeking to shorten their learning curve of laparoscopic left hemicolectomy.

Congenital paraesophageal hiatal hernia: pitfalls in the diagnosis and treatment

Purpose The aim of this study was to analyze pitfalls in the diagnosis and treatment of congenital paraesophageal hiatal hernia (PEHH). Methods Between 1992 and 2004, the records of 5 infants with PEHH were retrospectively reviewed for age, sex, presenting symptoms, radiological studies, operative findings and approaches, and outcomes. Results All cases (3 male, 2 female) had right-sided hernias. They had clinical features of recurrent chest infections and intermittent vomiting that were present since birth in 3. Three presented acutely ill with findings of respiratory distress and vomiting. Three were referred with misdiagnoses of reflux disease, thoracic mass, and bronchopneumonia. On the chest x-rays of 3 cases, there were paracardiac opacities suggesting a mass lesion. According to the upper gastrointestinal series and/or computed tomography findings, 4 cases had a combination of sliding and paraesophageal hernia, and the remainder one had pure rolling hiatus hernia. Three had obstruction owing to organoaxial volvulus and required an emergency operation. All cases had a large hernia orifice. Four had gastroesophageal junction (GEJ) displaced into the thorax, and in 3, the stomach was found to be twisted, and transverse colon with omentum was also in the thorax in 2. In the remainder, the GEJ was in its normal position with herniated stomach. None of the cases had normal gastrosplenic and gastrocolic ligaments. Surgical repair included resection of the sac, closure of the hiatal defect, and Thal procedure. Two had intestinal malrotation, with right ovarian torsion and ventricular septal defect, respectively. Postoperative ventilation was required in one who later died. At a mean follow-up of 2 years, the other 4 had no symptoms related to the disease, and no evidence of recurrence or reflux was noted on control upper gastrointestinal series. Conclusion Congenital PEHH may be difficult to diagnose. It is frequently complicated and associated with morbidity and even mortality. If the defect is large and associated with displacement of GEJ into the thorax, adding an antireflux procedure to the repair is appropriate.

Gastropleural fistula due to gastric perforation after lobectomy for lung cancer

We report a case of acute gastropleural fistula due to gastric perforation after a left lower lobectomy for lung cancer. A 76-year-old male, who received a left hemicolectomy 20 years previously, came to our hospital for surgical treatment of lung cancer, which was performed uneventfully as a left lower lobectomy with combined resection of the diaphragm. On the postoperative day 2, acute dilatation of the stomach followed by gradual cardiopulmonary collapse, and then gastric perforation into the thorax occurred. The perforated stomach wall and diaphragm became paper-thin and necrotic, though the abdominal cavity was free of contamination. This life-threatening condition was treated by an emergency thoracotomy and partial gastrectomy through the thorax, as the left hemidiaphragm was remarkably elevated. An oeganoaxial torsion gastric volvulus caused by anatomic rotation following the lobectomy was speculated as the disease process, with loss of suspended tissue of the gastro-colic ligament from the left hemicolectomy being a possible predisposing factor. Such an episode is rare, however, it should be looked for during perioperative care following a lobectomy.

Combined Transmesocolic–Transomental Internal Hernia

Chou CK, Mark C-W, Wu R-H, Chang J-M nternal hernia of the small bowel into the lesser sac through a defect in the transverse mesocolon has been described [1–4]. The herniated small bowel may be seen above the gastric lower body and to the right of the gastric upper body on the anteroposterior projection and dorsal to the stomach and the transverse colon on the lateral projection of radiographs and barium studies. It may reenter into the greater peritoneal cavity via the foramen of Winslow or a defect in either the gastrohepatic or the gastrocolic ligament [5]. The imaging findings of these combined hernias are scant [4]. Because of the potential risks of small-bowel obstruction, strangulation, and gangrene, timely diagnosis is important. We report the CT findings, which have not been described to our knowledge, of a case of spontaneous herniation of the small bowel through a defect in the transverse mesocolon and the lesser omentum (the gastrohepatic ligament) into the right upper greater peritoneal cavity.

Laparoscopic management of an internal double omental hernia: A rare cause of intestinal obstruction

Internal hernia is a very rare cause of intestinal obstruction (0.2-0.9% of cases), associated with 45% mortality. A review of the literature revealed just eight reported cases of double omental hernia since 1950 of which our patient is the first case successfully treated laparoscopically. We report on a 29-year-old man who presented with signs and symptoms of intestinal obstruction. The patient underwent emergent exploratory laparoscopy. This revealed herniation of a 20-cm jejunal loop through the gastrocolic ligament and reemergence through a defect in the gastrohepatic ligament. The strangulated loop was reduced with slight traction, and the defect was repaired. The patient was discharged from hospital in just 5 days' time, and after 6 months of follow-up, the general condition of the patient was normal. Laparoscopy is a good technique with minimal complications compared with laparotomy. As many cases are missed due to nonspecific signs and symptoms, an urgent laparoscopy or laparotomy is highly recommended in such a situation.

Giant renal artery aneurysm

A hypertensive 67-year-old woman was admitted with a large, non-tender abdominal mass that caused a gross bulging of the abdominal wall. The patient was symptom-free except for occasional low back pain. She had been aware of the mass for over 5 years, but had not sought medical attention. Her family history was negative for significant vascular pathology. She had no history of trauma or instrumentation. Renal function was normal. Computed tomography scan (Cover) showed a giant aneurysm of the left renal artery (diameter 25 cm). The wall was calcified; thrombosis was extensive, but incomplete and dyshomogenous. The abdominal organs were dislodged to the right. No other aneurysmal locations were disclosed. Magnetic resonance angiography (A) showed the origin of the lumen of the aneurysm to be in the mid-left renal artery. Surgery was performed through a transverse laparotomy. The gastrocolic ligament was incised and the anterior wall of the aneurysm exposed and incised (B). The thrombus was removed from the sac and the origin of the aneurysm from the left renal artery exposed (C, arrow). A breach in the arterial wall was visible. The unclamped artery was digitally compressed for hemostasis while the artery was closed primarily. Pathologic examination confirmed a true atherosclerotic aneurysm. The patient is alive and well 6 months after the operation, with normal renal function. Aneurysms of the renal artery may occasionally reach large dimensions, but this case must be considered exceptional. It is actually extremely uncommon for aneurysms in any location to reach this size without rupturing. Giant renal artery aneurysms ( 5 cm. diameter) have been reported in fewer than 20 cases in the English literature. They may be pseudoaneurysms, usually secondary to invasive procedures such as percutaneous transluminal angioplasty or pyelolithotomy, or true aneurysms, often with parietal calcifications. The principal justifications for surgical treatment are ureteral obstruction, hypertension, pain, and elimination of the risk for rupture. Repair may require arterial reconstruction or even nephrectomy, but may also require only simple closure of the artery defect, as was possible here.

Internal hernia traversing the lesser sac

Congenital internal hernias are a rare cause of small bowel obstruction in adults and often present with complications. A high index of suspicion, occasionally aided by appropriate radiological imaging, may lead to early surgical intervention and reduce morbidity and mortality. A 25‐year‐old man presented with colicky abdominal pain and minimal signs on abdominal examination. Computed tomography showed features of a small bowel obstruction and prompted surgery. This revealed an internal hernia traversing the lesser sac through defects in both the gastrocolic ligament and lesser omentum. A gangrenous segment of small bowel incarcerated in the lesser omentum was resected and the patient made a full recovery. The published reports relating to lesser sac hernias are reviewed and features that may lead to early diagnosis identified.

Internal Hernia Presenting as Obstructive Jaundice and Acute Pancreatitis

We report the first case of obstructive jaundice and acute pancreatitis caused by herniation of the small bowel through the foramen of Winslow in a 45-year-old man. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed dilated small-bowel loops positioned in the gastrohepatic space, dilatation of the gallbladder and both intrahepatic bile ducts, and mild swelling of the pancreas. A small-bowel series revealed a cluster of small-bowel loops in the mid-upper abdomen, with displacement of the stomach to the left. At laparotomy, there was an internal herniation of jejunal loop through the defect of gastrocolic ligament into the lesser sac and finally passing through the foramen of Winslow. The common bile duct was compressed externally by the herniated bowel and the pancreas was mildly swollen. To the best of our knowledge, these complications of internal hernia have not been reported previously.

Laparoscopic Gastropexy by Abdominal Wall-Lifting Procedure for Acute Gastric Volvulus

We report on a 6-year-old girl with acute gastric volvulus treated successfully with laparoscopic anterior gastropexy by the abdominal wall-lifting technique. The gastrocolic ligament was poorly developed, which allowed mesenterioaxial volvulus. Anterior gastropexy was easily accomplished by direct suturing with extracorporeal knotting under normal pressure. This procedure, which produces a working space sufficient for the gastropexy, is simple, safe, and cost beneficial because there is no requirement for pneumoperitoneum. This experience impressed on us that an intraoperative upper gastrointestinal series should be used to help the surgeon fix the stomach in its anatomically correct position.

Hand-Assisted Laparoscopic Distal Pancreatectomy With Minilaparotomy for Distal Pancreatic Cystadenoma

Two patients with cystic tumors of the pancreas treated by laparoscopic distal pancreatectomy are presented. The first patient was a 34-year-old woman with a 6-cm cystadenoma of the tail of the pancreas treated with a complete laparoscopic distal pancreatectomy. After mobilization of the distal pancreas and spleen, the pancreas was transected proximally together with the splenic artery and vein using an endoscopic linear stapler. The second patient was a 71-year-old woman with a 6-cm cystadenoma of the body of the pancreas, treated by hand-assisted laparoscopic distal pancreatectomy with minilaparotomy because the tumor was adjacent to the portal vein and celiac axis. Using an upper median minilaparotomy, dissection of the gastrocolic ligament, division of the splenic artery, and transection and closure of the pancreas were performed. Division of the splenic vein and mobilization of the distal pancreas and spleen were performed via a hand-assisted laparoscopic approach. There were no postoperative complications (such as pancreatic fistulas) in either patient, and the postoperative courses were uneventful. The patients returned to normal activity within 1 week after the operation. Complete laparoscopic and hand-assisted laparoscopic distal pancreatectomy are preferable to conventional open surgery for benign tumors of the pancreas because of their less-invasive nature. Additionally, in tumors of the body of the pancreas, hand-assisted laparoscopic distal pancreatectomy might have the advantages of laparotomy and laparoscopy in terms of handling the splenic artery and vein just below the minilaparotomy site, suggesting an easier and safer procedure than complete laparoscopic distal pancreatectomy. Therefore, hand-assisted laparoscopic distal pancreatectomy can be recommended as a useful alternative to complete laparoscopic distal pancreatectomy for selected patients with benign tumors of the body and tail of the pancreas.

Exérèse vidéolaparoscopique des insulinomes. Étude de cinq observations *

Study aim Evaluation of the feasibility of the videolaparoscopic resection in pancreatic insulinomas, and reporting of five cases. Patients and method From 1996 to 1998, a videolaparoscopic resection was attempted in five patients with sporadic, unique and benign insulinoma. The insulinoma was recognised and localised by preoperative ultrasonography in the pancreatic head ( n = 1), body ( n = 3) or tail ( n = 1). For the videolaparoscopic procedure, three to five trocars were necessary. Cephalic and corporeal insulinomas were approached through an opening of the gastrocolic ligament and caudal insulinoma required mobilisation of the splenic flexure of the colon and dissection of the splenic pedicle. Peroperative ultrasonography was not used. Results Four resections were exclusively performed with videolaparoscopy: three enuclations and one distal pancreatectomy with splenic preservation. The cephalic insulinoma could not be found by laparoscopic exploration and required a laparotomy to be recognised and enucleated; it was located further down than expected. There were no postoperative complications in four patients. One enucleation was complicated by a pancreatic fistula that required reoperation. All the patients were cured with a 6- to 16-month follow-up. Conclusion Selected insulinomas may be operated on with videolaparoscopy. Preoperative endoscopic ultrasonography is necessary for this selection. Videolaparoscopic approach is contraindicated in multiple insulinomas, in insulinomas located on the posterior wall or deeply located in the head of the pancreas, and in malignant tumors. Videolaparoscopic resection is mainly indicated in unique and benign insulinomas, superficially located on the anterior wall of the pancreas, to be resected by enucleation or distal pancreatectomy. Disadvantage of laparoscopic approach compared to conventional approach is the absence of palpation and difficulty to explore the whole pancreas; advantage is the lack of parietal incision and the good postoperative comfort.

Percutaneous intervention in acute pancreatitis.

Interventional radiology has an important role to play in the management of local complications of acute pancreatitis, such as necrosis, pseudocyst, and abscess. Computed tomography (CT) is preferred for guiding pancreatic interventional procedures, with the most common access routes being through the left anterior pararenal space for pancreatic tail collections and through the gastrocolic ligament for pancreatic head and body collections. Pancreatic necrosis has a high mortality if infected, and the presence of infection must be determined with CT-guided needle aspiration. Careful planning of the access route is important to avoid the colon. Catheters of 8-12 F are usually sufficient for pseudocyst drainage. An average of 2-3 weeks drainage is required if there is no communication of the pseudocyst with the pancreatic duct and many weeks to months for pseudocysts with pancreatic duct communication. Percutaneous drainage of pseudocysts is associated with success rates of 80%-90%. Pancreatic abscess drainage has quoted success rates varying between 32% (infected necrosis) and 90% (pancreatic abscess). Use of large or multiple catheters is often required for complete drainage. The management of patients with severe acute pancreatitis is time-consuming and labor intensive for interventional radiologists, and a team approach with close communication with surgical personnel is required.

Primary synovial sarcoma of the gastrocolic ligament.

A case of primary synovial sarcoma of the gastrocolic ligament is reported in a 37-year-old woman. CT showed an encapsulated intraabdominal cystic tumour with an amorphous solid component. Barium studies showed a mass at the gastrocolic ligament which elevated the gastric antrum and displaced the transverse colon downwards. This is the first report of synovial sarcoma formation in the gastrocolic ligament. This tumour may have originated from pluripotential mesenchyme.