Subdiaphragmatic Region Research Articles

Retroperitoneal bronchogenic cyst: a case report and literature review

IntroductionRetroperitoneal bronchogenic cyst, typically situated in the subdiaphragmatic region, is a rare congenital benign developmental abnormality arising from dysplasia of the foregut and abnormal budding of the tracheobronchial tree. Due to its low incidence, there are limited reports regarding this condition.Case presentationFour retroperitoneal bronchogenic cysts near the left adrenal gland were identified without accompanying clinical symptoms. One case was misdiagnosed as an adrenal tumor prior to surgery, while the others were diagnosed as retroperitoneal cysts of uncertain origin. All cases underwent surgical resection, with three being performed laparoscopically and one utilizing robot-assisted techniques. Pathological reports confirmed the diagnosis of bronchogenic cyst in each instance. The prognosis was favorable for all four patients, with no complications or recurrences observed. Additionally, a literature review was conducted, encompassing 82 cases, which revealed similar characteristics and radiological manifestations in the majority of cases.ConclusionAlthough retroperitoneal bronchogenic cysts are rare developmental malformations lacking distinctive clinical and radiological features, reported cases exhibit similarities in certain clinical and imaging characteristics. This report offers additional insights into the diagnosis and management of this rare disease. Future reports are essential to enhance understanding of this disease.

Comparison of intraperitoneal instillation of Bupivacaine vs Normal Saline for postoperative pain relief after laparoscopic cholecystectomy.

Objective: To evaluate whether local irrigation of Bupivacaine reduces post-operative pain after cholecystectomy. Study Design: Prospective, Randomized Controlled Trial. Setting: Department of Surgery, Government Teaching Hospital, Shahdara Lahore. Period: June 2020 to December 2022. Methods: For this study, 86 participants were divided into two groups, each containing 43 participants (Bupivacaine vs. no Bupivacaine). The control group (Group A) received an infiltration of 15 ml of 0.5% bupivacaine in the sub-diaphragmatic region on the right side and at port sites, while normal saline was administered to Group B. The Visual Analogue Pain Score Scale was employed to assess pain levels at 0-3, 3-5, 5-7, and above 7-10 hours post-surgery (VAS). Results: In this study, the total number of included individuals was 86. Moreover, the overall mean and median ages in months for both groups were 47.7 ± 8.97 and 47 (18-60) respectively, with the majority of patients being male (59 individuals, 68.6%). Furthermore, there was a statistically significant mean difference in pain scores on the visual analogue scale at 0–3 hours, 3–5 hours, 5–7 hours, and 7–10 hours (p-value < 0.05). Similarly, there was a statistically significant mean difference in pain scores on the visual analogue scale after more than three to five hours, more than seven hours, and more than ten hours (p-value < 0.05). Conclusion: Consequently, we inferred that intraperitoneal and local infiltration of Bupivacaine following laparoscopic cholecystectomy significantly reduced the level of postoperative discomfort and the requirement for analgesics.

A case report of subdiaphragmatic right kidney as a positional variant of cephalad renal ectopia

ABSTRACT Renal ectopia refers to the abnormal position of the kidney outside the renal fossa. It may be in sacral, lumbar, thoracic, or subdiaphragmatic regions, of which the latter is extremely rare and may be associated with congenital abnormalities. High renal ectopia is a rare disease that affects 1 in every 22 ectopic kidney occurrences. During the routine cadaveric dissection of a 50-year-old male, we observed an uncommon case of high ascent of the right kidney, up to the bare area of liver. The right kidney was normal in size and shape, and received a renal artery positioned obliquely, 3 mm below the origin of the left renal artery and its vein drained into the hepatic portion of the inferior venacava (IVC). Knowledge about the variations in the positions of the kidneys is very important as cephalad ectopic kidney may pose a challenge for surgical and interventional procedures.

Exploring the Role of MRI in the Detection of Atypical Liver Hemangiomas and Exclusion of Metastases

Background: In this article, we highlight the importance of utilizing multiple imaging modalities, including CT, MRI, and abdominal Doppler ultrasound, to accurately differentiate between atypical liver hemangiomas (LH) and metastases. Case report: We introduce a 57-year-old male patient who presented with severe abdominal pain. Initial CT scan findings showed hypodense liver lesions and a well-defined hypodense mass in the sub-diaphragmatic region, raising suspicion for metastatic liver lesions, and prompting further evaluation. To differentiate between atypical hemangiomas and metastases, an MRI scan was performed, revealing a hyperintense signal on T2-weighted images and a hypointense signal on T1-weighted images, consistent with the characteristics of LH. These characteristic signal intensities aided in ruling out metastatic liver lesions, which typically present with a more solid and homogeneous appearance. Contrast-enhanced MRI played a crucial role in confirming the diagnosis. The liver lesions demonstrated moderate vascularization during the early phase of contrast enhancement, followed by progressive centripetal filling during the portal venous and delayed phases. This enhancement pattern is consistent with the slow flow within the dilated vascular spaces of liver hemangiomas. The lesion in the right liver lobe is almost completely filled with contrast, further supporting the diagnosis of hemangioma. Abdominal Doppler ultrasound can provide additional information regarding the vascularity of liver lesions. In this case, the Doppler examination likely helped to further confirm the presence of a hemangioma, as these lesions typically demonstrate increased vascularity compared to metastatic lesions. Conclusion: The comprehensive imaging evaluation utilizing CT, MRI, and abdominal Doppler ultrasound allowed for the confident differentiation of atypical liver hemangiomas from metastatic liver lesions in this case. This emphasizes the importance of a multimodal imaging approach in cases of liver lesions with overlapping features, leading to improved patient management and outcomes.

Anomalous origin of the left suprarenal, inferior phrenic arteries and left ovarian artery in a human cadaver.

This report addresses three variants identified within a female cadaver. Specifically, these were an anomalous origin of the right suprarenal artery, an abnormal bilateral ovarian vein branch, and a arterial tortuosity of the left ovarian artery. Indeed, the cadaver evinced abnormal origins in the case of the middle suprarenal artery (MSA), right inferior phrenic artery (IPA), and the renal capsule artery (emanating from the right renal artery). The MSA and IPA shared a common trunk with the inferior suprarenal artery. It was additionally observed that the right ovarian vein anastomoses the branches from the right kidney posterior inferior along with those to the renal fat capsule. Abnormal origin was evident in the case of the left ovarian artery, and arterial tortuosity was apparent in the lower region of the vessels. This report addresses both the clinical import of these variations and their likely causes. In the subdiaphragmatic region, surgical success and prognosis may be impacted by such anomalies; accordingly surgeons must be aware of anatomical variants of the ovarian and suprarenal arteries.

Multiple leiomyosarcomatous lesions arising from the mesentery in a young female: An unusual rare case presentation

Rationale: Primary mesenteric leiomyosarcoma is a very rare finding. It is seen predominantly in the seventh decade and is very rare in the young. Fine needle aspiration cytology is the initial diagnostic procedure in soft tissue lesions, followed by excision biopsy. Patient Concerns: Herein, we present a rare case of primary multiple mesenteric leiomyosarcoma in a 19 year old female, who presented with abdominal lump and pain since the last 4 months. Diagnosis: CT scan of abdomen showed multiple large multiloculated masses in the sub-hepatic space and sub-diaphragmatic region, which seemed to be arising from the mesentery. The uterus and cervix were normal. Fine needle aspiration cytology of the mass revealed fascicles of spindled cells with elongated, blunt ended fusiform nuclei admixed with dispersed cells or stripped nuclei. Some cells showed pleomorphism with occasional intranuclear vacuoles. Grossly the resected specimen was multiple nodular, brown, soft to firm, with the largest measuring 8.5x8x2.5 cm and the smallest 2.2x2.2x1 cm in size. On microscopic examination, sections showed fascicular pattern of atypical spindle cells having cigar shaped nuclei showing pleomorphism and eosinophilic fibrillary cytoplasm with 1-2 mitotic figures/10HPF. Immunohistochemistry with SMA showed strong diffuse cytoplasmic positivity and desmin showed mild focal cytoplasmic positivity in the tumor cells. A diagnosis consistent with primary multiple mesenteric leiomyosarcoma was given. Interventions: Wide surgical excision of the mass lesion was performed. The patient was subsequently administered 6 cycles of 5- Fluorouracil based chemotherapy. Outcomes: She is recovering well after 2 month of follow up period. Lessons: Our case will widen the vision of both physicians and pathologists to consider the possibility of primary mesenteric leiomyosarcoma in young females, presenting without any involvement of female genital tract, thus guide in the proper diagnosis and management of such lesions.

Detection of Locations of Pancreatic Pseudocysts using Computed Tomography: A Retrospective Study

Introduction: The most common cystic lesion of the pancreas are pseudocysts of the pancreas. They are frequently observed in the peripancreatic regions, however, they may appear elsewhere. Knowledge of their varied locations becomes crucial for estimating their size and organising surgical treatments with respect to their mode of drainage and also knowing the exact surgical planes. Aim: To determine the distribution of pancreatic pseudocysts using a computed tomography ( CT) scan. Materials and Methods: This was a retrospective observational time-bound carried out from December 2018 to December 2020 in Department of Radiology, Father Muller Medical College Hospital, Mangaluru, Karnataka, India. After obtaining ethical clearance, 56 patients with pancreatic pseudocyst diagnosed on ultrasound and later evaluated by CT were included. The protocol used was 128-slice Multidetector Computed Tomography (MDCT), plain and contrast axial images with multiplanar reformations. The primary outcome was to study the various locations in which these pseudocysts were present. The data was entered in a Microsoft Excel sheet. The frequency distribution of data was calculated. Results: Out of the 56 patients, 42 (75%) were males and 14 (25%) were females. Incidence of pseudocyst formation was highest in the age group 40-50 years 23, (41.07%). The most common location of pancreatic pseudocyst was the lesser sac 19 (33.92%). Other sites included peritoneum (n=7, 12.5%%), hepatic (n=8, 14.2%) and sub-hepatic (n=3, 5.36%), perinephric (n=5 , 8.92%), Intrasplenic and perisplenic (n=5, 8.92%), gastric (n=3, 5.36%), subdiaphragmatic regions (n=2, 3.57%), in the Psoas major (n=2, 3.57%) and mediastinum (n=2, 3.57%). Conclusion: The present study concludes that the most common location of a pancreatic pseudocyst is the lesser sac.

P180 Is gene sequencing only way forward?

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM IntroductionFungal peritonitis (FP) associated with peritoneal dialysis (PD) is an uncommon complication. Candida peritonitis accounts for 70%-90%. A total of 55 cases of Aspergillus peritonitis have been reported from 1968 to 2019 with A. fumigatus and A. niger as the most common isolates.FP is associated with high mortality and often results in discontinuation of PD and switching to hemodialysis (HD).ObjectivesTo identify and report the pathogen from peritoneal abscess.Methods and ResultsA 54-year-old post-menopausal lady, a known diabetic, hypertensive with chronic kidney disease (CKD) on PD for 2 years presents with acute onset breathlessness. She was dialyzed and improved. During her hospital stay, she developed a fever which was managed with intravenous antibiotics, piperacillin-tazobactam, teicoplanin, and fluconazole. The PD was bacterial culture negative. Patient improved on HD and was discharged.A total of 10 days later she was readmitted due to complaints of fever. Her PD fluid analysis was clear with high leucocyte count. The same was sent for the presence of acid-fast bacilli and aerobic bacterial culture, both of which were negative. Her blood was sent for automatic aerobic bacterial culture which yielded no growth. Patient developed pain in abdomen and PD catheter was removed. Abdominal Computed Tomography (CT) imaging revealed a thick-walled intra-peritoneal collection in the left subdiaphragmatic region. In view of persistent fever, antibiotics were changed to meropenem, metronidazole, and amikacin. Pus aspirated was received for aerobic bacterial culture and fungal culture. KOH—Calcofluor examination revealed septate fungal hyphae. Bacterial culture yielded Enterococcus species sensitive to penicillin and gentamicin. Patient was treated with amphotericin B and HD. Repeat aspirate also revealed septate fungal hyphae. However, on both occasions fungal cultures were negative. She improved symptomatically and was discharged.Sample was sent to Post Graduate Institute of Medical Education and Research, Chandigarh for the identification of the fungal pathogen directly from the sample using Gene sequencing. The pathogen was identified as A. niger.Conclusion Aspergillus peritonitis in a PD patient though rare is associated with high mortality and morbidity. They are often associated with concurrent or prior bacterial peritonitis. Treatment with antibiotics often predisposes to fungal peritonitis. Clinical presentation is similar to bacterial peritonitis, a high index of suspicion is warranted to establish the diagnosis. Identification of fungal pathogen to rule out species inherently resistant to certain classes of antifungals is critical for successful management. This is possible only by molecular methods, especially in culture-negative cases. In this case of culture-negative invasive fungal infection, the preliminary diagnosis was based on microscopic evidence of two consecutive samples. Gene sequencing helped us to confirm the diagnosis.

Nonimmune hydrops fetalis with intrauterine fetal demise presenting at 41-weeks gestational age: the ultrasonographic findings and case report

Hydrops fetalis is the abnormal accumulation of fluid in two or more different fetal compartments and most times associated with polyhydramnios and placental edema, and has an estimated incidence of about 1 in 3000 pregnancies. A 27-year-old multigravida; G8P7, was referred for the first ultrasonography in the Index pregnancy on account of not feeling/observing fetal movement for about two-weeks. The obstetric ultrasonography demonstrated a single fetus with absent fetal heartbeat, in hyper-flexed position, accumulation of fluid in the abdominal cavity; right sub-diaphragmatic region and in the right pleural cavity in keeping with fetal ascites and fetal effusion. There is overriding of fetal skull with Thickened/edematous placenta with a thickness of about 7cm, and fetal skin thickness of about 10mm. There is associated intrafetal gas. The estimated femoral length gave a gestational age approximating 41-weeks. A diagnosis of hydrops fetalis most likely non-immune form with fetal demise presenting at 41-weeks gestational age in a multiparous woman with features anemia presumably from sepsis and urinary tract infection (bilateral pyelonephritis and cystitis) in a setting of poor antenatal care was entertained. The fetus was expelled following induction of labor at the peripheral centre, the patient had transfusion done with commencement of antibiotics for correction of anemia and sepsis with plans of further clinical and laboratory evaluation. We present the ultrasonographic features of hydrops fetalis with intrauterine fetal demise due to its unique presentation

To evaluate of severity of post-operative pain in right sub-diaphragmatic region, shoulder tip, port site and its comparison with controls and the amount of analgesic usage post operatively laparoscopic cholecystectomy

Background & Method: 90 cases of symptomatic cholelithiasis admitted and operated upon during the period of two years from August 2014 to August 2016 at Bharati Hospital, Pune. The study will be conducted using a pre-tested proforma meeting the objectives and the postoperative pain will be evaluated using visual analog scale (VAS) and verbal rating score(VRS) for a period of 48 hours post operatively. The analysis of the results will be done statistically with relevant tests. Result: The mean ± standard deviation of age of the patients from Group A, Group B and Group C is 40.2 ± 12.1 years, 43.7 ± 13.6 years and 49.4 ± 17.3 years respectively. The age range for patients enrolled in the study was between 16 – 80, mean age being 42.78 years. 1) Values are Mean and standard deviation (SD). P-values by One-way analysis of variance (ANOVA) with Post-Hoc Boferroni’s test for multiple group comparisons. P-value

Recurrent infantile inflammatory myofibroblastic tumor of mesentery––Case report and review of imaging findings

Inflammatory myofibroblastic tumors (IMT) are rare soft tissue tumors of intermediate malignant potential with tendency for local recurrence. Although they can occur at all age groups, occurrence in infants is extremely unusual and their imaging characteristics are not well described. A 3-month-old female infant presented with gradually progressive abdominal distention without any fever or weight loss. She had a large ill-defined homogenous hypodense lesion of size 8.4 × 11.4 × 11.3 cm (APxTraxSag) in the abdomen showing mild delayed post contrast enhancement. She underwent exploratory laparotomy with gross total excision of mesenteric mass, histopathology of which was suggestive of IMT. She had recurrence within 6 months of complete resection with a well-defined heterogeneously enhancing lesion of size 1.8 × 1.8 × 2.3cm (APxTraxSag) in right paravesical region abutting the bladder without invasion with a similar lesion of size 4.4 × 2.1 × 3 cm (APxTraxSag) in left subdiaphragmatic region abutting superior surface of spleen (no invasion). Since, surgery in our patient would have entailed splenectomy and partial cystectomy, systemic therapy with ceritinib (anaplastic lymphoma kinase [ALK] inhibitor) was planned for her with which she had a near complete response after 2 months. A high index of suspicion is required to differentiate IMT from other common causes of mesenteric masses in children and role of radiologist is quintessential in this regard. Local recurrence with abutment but without invasion of surrounding structures points to the intermediate malignant pathology of IMT and may provide a clue to diagnosis. Systemic therapy is effective in patients who are ALK positive and destructive surgery should be avoided.

S2223 Dead End in the Small Bowel: Rare Case of Small Bowel Melanoma Presenting as Melena

INTRODUCTION: Malignant melanoma accounts for only 1% of all malignant tumors of the small bowel. The majority are usually metastatic from the skin eye or anorectum. Less than 50 cases of truly primary small bowel melanomas have been described in literature with overt bleeding as a presenting complaint even rarer. We present such a case of an elderly man with middle gastrointestinal bleeding who was found to have unresectable small bowel melanoma on device assisted enteroscopy. CASE DESCRIPTION/METHODS: An 80-year-old man with stage IV Chronic kidney disease presented to the hospital with a few months of dark tarry stools and symptomatic iron deficiency anemia refractory to iron supplementation needing up to 7 transfusions. He did not endorse Non-steroidal anti-inflammatory drug use. An esophagoduodenoscopy and colonoscopy at an outside facility was unremarkable. Video capsule endoscopy showed hematin in the the proximal jejunum with a possible ulcer more distally. A single balloon enteroscopy revealed a 10 mm cratered jejunal ulcer with slight pigmentation in the base (Figure 1). This was biopsied. Pathology revealed malignant melanoma with BRAF V600E mutation. Subsequent positron emission tomography (PET) showed a 6 cm small bowel mass compatible with primary site and metastatic lesions in the mesentery, perihepatic and subdiaphragmatic region (Figure 2). Following tumor board discussion, he was referred for palliative radiotherapy. DISCUSSION: Primary mucosal melanoma most commonly arises from the anal canal (31.4%), rectum (22.2%) and oropharynx (33%). Only 2.3% of cases have been reported from the small bowel. Presence of melanocytes has not yet been demonstrated in the small intestine, and the origin of primary melanoma of the small intestine remains unknown. Blecker et al. suggested a strict criteria for the diagnosis of primary intestinal melanoma: no evidence of concurrent cutaneous lesions, absence of extraintestinal metastatic spread of melanoma, and presence of intramucosal lesions in the overlying intestinal epithelium. This form of melanoma is more aggressive and associated with worse prognosis. Other factors of poor prognosis include lymph node involvement, advanced age and failure to undertake surgical resection (which remains the primary treatment option). Our case highlights the importance of keeping a broad differential in patients presenting with middle GI bleeding and aggressively pursuing tissue diagnosis in such cases.Figure 1.: Proximal Jejunum ulcer.Figure 2.: PET scan image with metastatic melanoma.

Lung and Intercostal Upper Abdomen Ultrasonography for Staging Patients with Ovarian Cancer: A Method Description and Feasibility Study.

A detailed transabdominal and transvaginal ultrasound examination, performed by an expert examiner, could render a similar diagnostic performance to computed tomography for assessing pelvic/abdominal tumor spread disease in women with epithelial ovarian cancer (EOC). This study aimed to describe and assess the feasibility of lung and intercostal upper abdomen ultrasonography as pretreatment imaging of EOC metastases of supradiaphragmatic and subdiaphragmatic areas. A preoperative ultrasound examination of consecutive patients suspected of having EOC was prospectively performed using transvaginal, transabdominal, and intercostal lung and upper abdomen ultrasonography. A surgical-pathological examination was the reference standard to ultrasonography. Among 77 patients with histologically proven EOC, supradiaphragmatic disease was detected in 13 cases: pleural effusions on the right (n = 12) and left (n = 8) sides, nodular lesions on diaphragmatic pleura (n = 9), focal lesion in lung parenchyma (n = 1), and enlarged cardiophrenic lymph nodes (n = 1). Performance (described with area under the curve) of combined transabdominal and intercostal upper abdomen ultrasonography for subdiaphragmatic areas (n = 77) included the right and left diaphragm peritoneum (0.754 and 0.575 respectively), spleen hilum (0.924), hepatic hilum (0.701), and liver and spleen parenchyma (0.993 and 1.0 respectively). It was not possible to evaluate the performance of lung ultrasonography for supradiaphragmatic disease because only some patients had this region surgically explored. Preoperative lung and intercostal upper abdomen ultrasonography performed in patients with EOC can add valuable information for supradiaphragmatic and subdiaphragmatic regions. A reliable reference standard to test method performance is an area of future research. A multidisciplinary approach to ovarian cancer utilizing lung ultrasonography may assist in clinical decision-making.

Incidence, Location, and Natural History of Perihepatic Fluid Collections after Orthotopic Liver Transplantation

Objective: The purpose of this study was to evaluate the common locations of perihepatic fluid collections after liver transplantation, assess their complexity, and understand their natural history and clinical significance. Materials and Methods: A retrospective analysis of 189 postoperative orthotopic liver transplant patients was performed using serial CT or MRI to characterize perihepatic fluid collections. Location, size, complexity of the collections, and clinical course were evaluated. Results: 76 patients (40%) presented with perihepatic fluid collections with a total of 116 collections. 45 pts (59%), had a one collection, 23 pts (30%) had two, 7 pts (9%) had three and one patient (1%) had four. Collections were seen in predictable locations, with 38 (33%) in segment 5/6, 37 (32%) in the ligamentum venosum/pericaval region, 12 (10%) in the porta hepatis, 11 (9%) the pericapsular/subdiagphramatic location, 10 (9%) along the fissure for ligamentum teres, and the remaining 8 (7%) collections in ‘other’ less frequent perihepatic locations. The vast majority, 100/116 (86%) of all collections were simple and 95/105 (90%) of the collections resolved, decreased or stable on follow up. Collections located in pericapsular /subdiaphragmatic region were significantly more likely to be complex. 16/116 (14%) of the collections were complex, and 4 of these required intervention. Conclusions: Perihepatic fluid collections are seen in 40 % of patients after liver transplant. Fluid collections are often in predictable locations, most commonly seen in segment 5/6, the ligamentum venosum/ pericaval region, the porta hepatis, and the fissure for ligamentum teres. Collections in these locations tend to be simple by imaging criteria and rarely require follow up. Radiologists interpreting post liver transplant patients should be familiar with the common locations of these collections, and when asymptomatic, recognize these as incidental. Further evaluation may be warranted if collections are symptomatic, enlarging, have complex imaging features, or located in an atypical location.

Electron Beam Intraoperative Radiotherapy (ELIOT) in Pregnant Women with Breast Cancer: From in Vivo Dosimetry to Clinical Practice

Background: The aim of this study was to confirm our preliminary results with in vivo dosimetry in non-pregnant breast cancer patients receiving electron beam intraoperative radiotherapy (ELIOT) and to report on the first treatment in a pregnant woman. Patients and Methods: Following our previous experience, 5 non-pregnant patients receiving ELIOT to the tumor bed after breast-conserving surgery (BCS) were studied with thermoluminescent dosimeters positioned in the subdiaphragmatic region, within the uterus, and in the ovarian region. In December 2011, the first pregnant breast cancer patient underwent BCS and ELIOT (21 Gy at 90% isodose) during the 15th week of gestation. Results: The mean dose to the subdiaphragmatic external region in the 5 non-pregnant patients was 5.57 mGy, while pelvic measurements were below 1 mGy. The actual dosimetry of the pregnant patient showed a mean subdiaphragmatic dose of 4.34 mGy, a mean suprapubic dose of 1.64 mGy, and mean ovarian doses of 1.48 mGy (right-sided) and 1.44 mGy (left-sided). The expected dose to the fetus was estimated as 0.84 mGy (0.004% of the prescribed dose). Conclusion: ELIOT as an anticipated boost to the breast could be considered in pregnant women in the early second trimester, postponing whole-breast irradiation after delivery.

Optimized feature selection-based clustering approach for computer-aided detection of lung nodules in different modalities

Early detection of pulmonary lung nodules plays a significant role in the diagnosis of lung cancer. Computed tomography (CT) and chest radiographs (CRs) are currently being used by radiologists to detect such nodules. In this paper, we present a novel cluster-based classifier architecture for lung nodule computer-aided detection systems in both modalities. We propose a novel optimized method of feature selection for both cluster and classifier components. For CRs, we make use of an independent database comprising of 160 cases with a total of 173 nodules for training purposes. Testing is implemented on a publicly available database created by the Standard Digital Image Database Project Team of the Scientific Committee of the Japanese Society of Radiological Technology (JRST). The JRST database comprises 154 CRs containing one radiologist-confirmed nodule in each. In this research, we exclude 14 cases from the JRST database that contain lung nodules in the retrocardiac and subdiaphragmatic regions of the lung. For CT scans, the analysis is based on threefold cross-validation performance on 107 cases from publicly available dataset created by Lung Image Database Consortium comprised of 280 nodules. Overall, with a specificity of 3 false positives per case/patient on average, we show a classifier performance boost of 7.7% for CRs and 5.0% for CT scans when compared to a single aggregate classifier architecture.

PET/CT for differentiating between tuberculous peritonitis and peritoneal carcinomatosis: The parietal peritoneum.

Objectives:Tuberculous peritonitis (TBP) mimics peritoneal carcinomatosis (PC). We aimed to investigate the discriminative use of PET/CT findings in the parietal peritoneum.Materials and Methods:Parietal peritoneal PET/CT findings from 76 patients with TBP (n = 25) and PC (n = 51) were retrospectively reviewed. The lesion locations were noted as right subdiaphragmatic, left subdiaphragmatic, right paracolic gutters, left paracolic gutters, and pelvic regions. The distribution characteristic consisted of a dominant distribution in the pelvic and/or right subdiaphragmatic region (susceptible area for peritoneal implantation, SAPI) (SAPI distribution), a dominant distribution in the remaining regions (less-susceptible area for peritoneal implantation, LSAPI) (LSAPI distribution), or a uniform distribution. PET morphological patterns were classified as F18-fluorodeoxyglucose (18F-FDG) uptake in a long beaded line (string-of-beads 18F-FDG uptake) or in a cluster (clustered 18F-FDG uptake) or focal 18F-FDG uptake. CT patterns included smooth uniform thickening, irregular thickening, or nodules.Results:More common findings in the parietal peritoneum corresponding to TBP as opposed to PC were (a) ≥4 involved regions (80.0% vs 19.6%), (b) uniform distribution (72.0% vs 5.9%), (c) string-of-beads 18F-FDG uptake (76.0% vs 7.8%), and (d) smooth uniform thickening (60.0% vs 7.8%) (all P < 0.001), whereas more frequent findings in PC compared with TBP were (a) SAPI distribution (78.4% vs 28.0%), (b) clustered 18F-FDG uptake (56.9% vs 20.0%), (c) focal 18F-FDG uptake (21.6% vs 4.0%), (d) irregular thickening (51.0% vs 12.0%), and (e) nodules (21.6% vs 4.0%) (P < 0.001, P < 0.05, P > 0.05, P < 0.05, P > 0.05, respectively).Conclusion:Our data show that PET/CT findings in the parietal peritoneum are useful for differentiating between TBP and PC.

An Ancient Method of Killing People Revived

Case Presentation: A male patient aged 50 years reported to the emergency of Glocal hospital in June 2016 presenting with signs and symptoms of acute abdomen. It transpired that he was assaulted with an 18” × 3” (approx.) foreign body forcibly pushed through his anal orifice. The patient was in shock; was admitted and resuscitated. CECT abdomen with contrast revealed a high up foreign body, actually a portion of banana stem, situated intraperitoneal sub diaphragmatic region. On laparotomy by a left para-median incision, it was seen that the huge foreign body has perforated through the sigmoido-rectal junction and resting in the high up subdiaphragmatic region with gross haemoperitonium. The foreign body was carefully removed from abdomen (Figure). Rectosigmoid rent (4” long) in the anterior wall with bleeding lacerated edges was repaired in layers with transluminal Foley’s catheter passed up through anus beyond the repaired area with the balloon inflated. The patient made speedy and uneventful recovery. The insertion of such foreign body is scarcely encountered. The method of introduction of sharp, lengthy, rigid and offending material for executing death sentence was prevalent in the ancient times (called SHUL). It is to utter surprise that such practice was revived in an attempt to kill someone,

Intrapancreatic Accessory Spleen: A Rare Cause of Recurrence of Immune Thrombocytopenic Purpura

A 44 years-old-woman was admitted to our clinic because of development of thrombocytopenia and skin purpura. Abdominal ultrasonography and Computed Tomography (CT) did not show spleen or liver disorder. First line treatment with orally steroids showed a transitory response, with thrombocytopenia relapse in few months. Then laparoscopic splenectomy was accomplished successfully. The patient developed relapse in platelet count after 45 days of procedure, requiring treatment with thrombopoietic drugs and new diagnosis procedures. Nuclear medicine scintigraphy using heat-damaged Tc99m-labeled red blood cells revealed two images of uptake in left subdiaphragmatic region. Then the patient underwent intraoperative gamma-probe guidance after injection of Tc99m-labeled denatured erythrocytes, through left subcostal laparotomy with resection of two accessory spleens, one of them inside the pancreatic tail. After this procedure, the platelet count remains stable with lower dose of steroid treatment.

Evaluation of postoperative analgesia with intraperitoneal ropivacaine instillation in videolaparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES: This study aimed at evaluating postoperative analgesia with ropivacaine instillation inside the peritoneal cavity in videolaparoscopic cholecystectomy. METHODS: This is a randomized clinical trial with 60 patients. The intervention group (RP, n = 30) received 0.5% ropivacaine instillation in right and left subdiaphragmatic regions and in gallbladder bed in equal volumes of 10 mL. The control group (SS, n = 30) received 0.9% saline solution instillation. Patients of both groups received multimodal analgesia. Scores of abdominal pain and referred pain in shoulder were evaluated at emergence and after 1, 2, 4, 12 and 24 hours, in addition to the need for rescue analgesia, opioid consumption and adverse events, considering statistically significant p<0.05. RESULTS: There has been no statistical difference between groups with regard to demographic data and anesthetic-surgical time. The intervention group had lower and statistically significant pain scores as compared to control group at emergence (p=0.001), 1 (p=0.019) and 2 (p=0.04) postoperative hours, in addition to lower opioid consumption at emergence (p=0.022) and in total in the first 24 hours (p=0.001). Time for first request for rescue analgesia was longer in the intervention group (p=0.001). CONCLUSION: Ropivacaine instillation inside the peritoneal cavity has decreased pain scores in the first 2 hours and postoperative opioid consumption.