Subphrenic Region Research Articles

Effectiveness and safety of sequential transarterial chemoembolization and microwave ablation for subphrenic hepatocellular carcinoma: A comprehensive evaluation.

Subphrenic carcinoma has been identified as a significant risk factor for the thermal ablation of intrahepatic tumors, resulting in a high rate of residual tumor recurrence. Some studies have proposed that combination treatment with transarterial chemoembolization (TACE) followed by radiofrequency ablation is both feasible and safe for tumors in the subphrenic region. However, research specifically examining the therapeutic outcomes of combination therapy using TACE and microwave ablation (TACE-MWA) in subphrenic tumors is lacking. To evaluate the efficacy and safety of TACE-MWA in patients with subphrenic hepatocellular carcinoma (HCC). Between December 2017 and December 2021, 49 patients diagnosed with HCC ≤ 6 cm, who received TACE-MWA, were included in this retrospective cohort study. These patients were classified into subphrenic and non-subphrenic groups based on the distance between the diaphragm and the tumor margin. The rates of local tumor progression (LTP), progression-free survival (PFS), and overall survival (OS) were compared between the two groups. Complications were evaluated by using a grading system developed by the Society of Interventional Radiology. After a median follow-up time of 38 mo, there were no significant differences in LTP between the subphrenic and non-subphrenic groups (27.3% and 22.2% at 5 years, respectively; P = 0.66), PFS (55.5% at 5 years in both groups; P = 0.91), and OS (85.0% and 90.9% in the subphrenic and non-subphrenic groups at 5 years; P = 0.57). However, a significantly higher rate of LTP was observed in subphrenic HCC > 3 cm compared to those ≤ 3 cm (P = 0.085). The dosage of iodized oil [hazard ratio (HR): 1.52; 95% confidence interval (CI): 1.11-2.08; P = 0.009] and multiple tumors (HR: 13.22; 95%CI: 1.62-107.51; P = 0.016) were independent prognostic factors for LTP. There were no significant differences in complication rates between the two groups (P = 0.549). Combined TACE and MWA was practical and safe for managing subphrenic HCC. The efficacy and safety levels did not vary significantly when tumors outside the subphrenic region were treated.

MO697TUBERCULOUS PERITONITIS WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A PATIENT ON CONTINUOUS AMBULATORY PERITONEAL DIALYSIS: A CASE REPORT

Abstract Background and Aims Tuberculosis is a leading cause of morbidity and mortality worldwide. Tuberculous peritonitis in patients on Continuous Ambulatory Peritoneal Dialysis (CAPD), though uncommon, has been reported from different parts of the world. Hemophagocytic lymphohistiocytosis (HLH) is a rare systemic inflammatory disorder characterized by uncontrolled proliferation of lymphocytes & histiocytes and is reported to have high mortality. Secondary forms of HLH have been described for various diseases. Here, we report a case of HLH secondary to Tuberculous peritonitis in a patient of End Stage Renal Disease (ESRD) on CAPD. Method A 49 years old male ESRD patient, on CAPD presented with peritonitis and was initially managed with antibiotics. He required catheter explantation in view of refractory peritonitis and was switched to haemodialysis. The patient continued to have low grade fever, yellowish discharge from infra-umbilical CAPD catheter explantation surgical wound along with lower abdominal pain & tenderness. He was lost to follow up and presented again after 1 month with fever, weight loss, multiple cutaneous ecchymotic spots and copious amount of yellowish discharge from infra-umbilical surgical wound. On examination, he had fever, conjunctival pallor, hepatosplenomegaly and a 5 cm infra-umbilical midline poorly healed discharging surgical scar with surrounding skin erythema and induration. Blood investigations revealed Hb 5.1 gm/dl, TLC 1500/uL, Plts 32000/uL, Ferritin 1053 ng/ml, TG 350 mg/dl, LDH 650 U/l, Bil T/D 1.3/1.0 mg/dl, OT/PT 160/174 IU/l, ALP 219 U/l, GGT 238 U/l, TP/Alb 5.2/2.5 gm/dl, APTT C/T 27.9/63.0, INR 1.27. NCCT abdomen revealed hepatosplenomegaly, loculated collection in right subphrenic region extending into the abdominal and pelvic cavity, anterior abdominal wall defect infero-right lateral to the umbilicus and generalised increased density in mesenteric fat. Diagnostic sub-phrenic fluid Aspirate analysis revealed a yellow turbid fluid with TLC 22300, ADA 106 U/L and positive Real Time PCR for Mycobacterium tuberculosis complex. Aspirate pyogenic and fungal cultures were sterile. Bone marrow evaluation revealed marked degree of histiocytic hemophagocytosis. Patient fulfilled six out of eight criteria for diagnosis of HLH. He was started on Anti Tubercular Treatment along with dexamethasone. He gradually became afebrile with resolution of infra-umbilical wound discharge, improvement in clinical and laboratory parameters. Results We report a case of HLH secondary to Tuberculous peritonitis in a patient of ESRD. The patient was on CAPD and required catheter explantation in view of Refractory peritonitis. Despite explantation and adequate antibiotics, he continued to have fever, discharge from surgical wound, pain abdomen, weight loss and poor appetite. Further evaluation revealed evidence of Tuberculous Peritonitis. In addition, the patient fulfilled six out of eight criteria for diagnosis of HLH. The patient was managed with Anti Tubercular Treatment along with Dexamethasone and he showed a gradual improvement in overall clinical and laboratory parameters. Conclusion Secondary HLH may occur after Tuberculous peritonitis in patient of ESRD on CAPD. Refractory peritonitis with hyperferritenemia, cytopenias, hypertriglyceridemia should raise the suspicion for HLH. Timely identification and treatment of HLH may improve patient outcomes.

Successful Treatment of Bronchobiliary Fistula After Living Donor Liver Transplantation: A Case Report

A bronchobiliary fistula (BBF), which is defined by abnormal communication between the biliary system and the bronchial tree, is usually regarded as a consequence of local infection, such as hydatid or amebic disease of the liver, hepatic abscess, trauma, neoplasm, and other causes of biliary obstruction. We present a 40-year-old female patient who received a living donor liver transplantation for autoimmune hepatitis and who suffered from biliary stricture at the anastomosis, bile leakage in the right subphrenic region, and development of a BBF 1 year later. Magnetic resonance cholangiography (MRC) and fistulography showed a fistula between the subphrenic biloma and right lower bronchus. The patient was treated successfully by the subphrenic drainage tube and percutaneous transhepatic cholangial drainage (PTCD) crossing the biliary stricture. In conclusion, the BBF is an extremely rare complication after liver transplantation; and minimal-invasive procedures, such as percutaneous drainage and PTCD, are useful for the closure of BBF. This case report is approved by the Institutional Review Board (IRB) of Kaohsiung Medical University Chung-Ho Memorial Hospital, certifying that no prisoners were used in the case and that participants were neither paid nor coerced.

Stereotactic body radiation therapy vs. radiofrequency ablation in Asian patients with hepatocellular carcinoma

Few studies have been conducted to compare the efficacies of stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA). Thus, in this multinational study, we compared the effectiveness of SBRT and RFA in patients with unresectable HCC. The retrospective study cohort included 2,064 patients treated in 7 hospitals: 1,568 and 496 in the RFA and SBRT groups, respectively. More than half of the patients (56.5%) developed recurrent tumors, mainly after transarterial chemoembolization (44.8%). Propensity score matching was performed to adjust for clinical factors (n= 313 in each group). At baseline, the SBRT group had unfavorable clinical features compared to the RFA group, including BCLC stage (B-C 65% vs. 16%), tumor size (median 3.0 cm vs. 1.9 cm), and frequent history of liver-directed treatment (81% vs. 49%, all p <0.001). With a median follow-up of 27.7 months, the 3-year cumulative local recurrence rates in the SBRT and RFA groups were 21.2% and 27.9%, respectively (p <0.001). After adjusting for clinical factors, SBRT was related to a significantly lower risk of local recurrence than RFA in both the entire (hazard ratio [HR] 0.45, p <0.001) and matched (HR 0.36, p <0.001) cohorts. In subgroup analysis, SBRT was associated with superior local control in small tumors (≤3 cm) irrespective of location, large tumors located in the subphrenic region, and those that progressed after transarterial chemoembolization. Acute grade ≥3 toxicities occurred in 1.6% and 2.6% of the SBRT and RFA patients, respectively (p= 0.268). SBRT could be an effective alternative to RFA for unresectable HCC, particularly for larger tumors (>3 cm) in a subphrenic location and tumors that have progressed after transarterial chemoembolization. It is currently not known what the best treatment option is for patients with unresectable hepatocellular carcinoma. Here, we show that stereotactic body radiation therapy provides better local control than radiofrequency ablation, with comparable toxicities. Stereotactic body radiation therapy appears to be an effective alternative to radiofrequency ablation that should be considered when there is a higher risk of local recurrence or toxicity after radiofrequency ablation.

Retrospective analysis of stereotactic body radiation therapy efficacy over radiofrequency ablation for hepatocellular carcinoma

Background and purposeTo evaluate the efficacy of stereotactic body radiotherapy (SBRT) and radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). Methods and materialsPatients treated for HCC between 2012 and 2016 were reviewed. Among these, 668 patients who underwent RFA of 736 tumors and 105 patients who underwent SBRT of 114 tumors were included. Using propensity score matching (PSM) to adjust for clinical factors, 95 tumors were selected from each treatment arm. Freedom from local progression (the primary endpoint, FFLP) was compared before and after adjustment with PSM. ResultsAt baseline, SBRT-treated tumors were more advanced, larger (median, 2.4 vs. 1.6 cm), and more frequently located in the subphrenic region than RFA-treated tumors (P < .001). The median follow-up was 21.5 (interquartile range, 11.2–36.7) months. Before PSM, the 2-year FFLP rates were 76.3% for the SBRT group and 70.2% for the RFA groups, respectively. After PSM, the 2-year FFLP rates were 74.9% for the SBRT group and 64.9% for the RFA group, respectively. The local control rates were not significantly different. The Cox proportional hazards model revealed the treatment modality as an independent predictor of local recurrence favoring SBRT in the entire cohort and in the PSM model. Elevated tumor markers, tumor location (subphrenic region), and tumor size (>2.0 cm) were also independent predictors of local progression. ConclusionSBRT appears to be an effective alternative treatment for HCC when RFA is not feasible due to tumor location or size.

Gas-forming pyogenic liver abscess

Gas-forming pyogenic liver abscess (GFPLA) is uncommon and reported high mortality rate. Diabetes mellitus and Klebsiella pneumoniae are the most frequent associated conditions and causativeorganism. Gas collection is not often detected by plain film abdomen. On ultrasonography, gas appeared as hyperechoic foci with dirty shadowing, reverberation and ring-down artifacts. CT scan is the mostsensitive test for GFPLA. Early diagnosis, appropriate antibiotics, adequate drainage and plasma glucose control are essential management.&#x0D; Figure 1 Plain film abdomen พบ multiple round and oval hypodensity gas pockets with air-fluid levels at right subphrenic region&#x0D;

Advantages of radial volumetric breath-hold examination (VIBE) with k-space weighted image contrast reconstruction (KWIC) over Cartesian VIBE in liver imaging of volunteers simulating inadequate or no breath-holding ability.

To investigate the superiority of radial volumetric breath-hold examination (r-VIBE) with k-space weighted image contrast reconstruction (KWIC) over Cartesian VIBE (c-VIBE) for reducing motion artefacts. We acquired r-VIBE-KWIC and c-VIBE images in 10 healthy volunteers. Each acquisition lasted 24seconds. The volunteers held their breath for decreasing lengths of time during the acquisitions, from 24 to 0seconds (protocols A-E). Magnetic resonance images at the level of the right portal vein and confluence of hepatic veins were assessed by two readers using a five-point scale with a higher number indicating a better study. The mean scores for the complete r-VIBE-KWIC series (r-VIBEfull) and first r-VIBE-KWIC series (r-VIBE1) were not significantly lower than those for c-VIBE in any protocols. The mean scores for c-VIBE were lower than those for r-VIBEfull and r-VIBE1 in protocols C and D. The mean score for c-VIBE was lower than that for r-VIBEfull in protocol E. The mean score for the eighth r-VIBE-KWIC series (r-VIBE8) was lower than that for c-VIBE only in protocol B. r-VIBE-KWIC minimised artefacts relative to c-VIBE at any slice location. The r-VIBE-KWIC's sub-frame images during the breath-holding period were hardly affected by another failed breath-holding period. • A two-reader study revealed r-VIBE-KWIC's advantages over c-VIBE • The image quality of r-VIBE-KWIC's sub-frame images was maintained during breath holding • Full-frame r-VIBE-KWIC images minimized motion artefacts caused by breathing • A complete breath holding over half the acquisition time is recommended for c-VIBE • c-VIBE was susceptible to respiratory motion especially in the subphrenic region.

Surgical Treatment of a Patient with Diaphragmatic Invasion by a Ruptured Hepatocellular Carcinoma with Biliary and Portal Venous Tumor Thrombi

We describe the surgical treatment of a patient with diaphragmatic invasion by a ruptured hepatocellular carcinoma (HCC) associated with biliary and portal venous tumor thrombi. A 67-year-old man was admitted because of jaundice (total serum bilirubin, 6.6 mg/dL). The serum concentration of alpha-fetoprotein was 236.1 ng/mL. The anti-hepatitis C virus antibodies were present in the serum. Computed tomography showed a large hypervascular mass in the right subphrenic region, surrounded by local effusion. Endoscopic retrograde cholangiography revealed dilatation of the left intrahepatic bile duct caused by biliary tumor thrombi extending from the right hepatic duct to the common bile duct. Endoscopic nasobiliary drainage was performed, and the total serum bilirubin level returned to the normal range. Angiography revealed a hypervascular tumor without extravasation of contrast medium in the right lobe and obstruction of the right anterior branch of the portal vein. Right hepatectomy was attempted 15 days after drainage. Severe invasion of the diaphragm by the ruptured HCC was detected. Bleeding of the ruptured HCC stopped spontaneously. Partial resection of the diaphragm was performed, followed by primary suture, without an artificial patch. Tumor thrombectomy was performed from the common bile duct. Macroscopic examination revealed that the ruptured HCC had invaded the diaphragm. Biliary and portal venous tumor thrombi were present. Histopathological examination showed a moderately differentiated HCC with biliary and portal venous tumor thrombi. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Five months after the operation, local and intrahepatic recurrences of HCC were detected. Six months after operation, the patient died of liver failure. In conclusion, the outcome of a patient with diaphragmatic invasion by a ruptured HCC with biliary tumor thrombi was poor, even after curative hepatic resection.

Calcified metastases from ovarian carcinoma highlighted by F-18 FDG PET/CT: report of two cases

Two cases of postoperative female patients with ovarian serous papillary carcinoma were referred for F-18 Fluorodeoxyglucose (F-18 FDG) PET/CT to evaluate suspicious recurrence and/or metastasis. One patient presented with multiple extensive calcified lesions with increased FDG uptake in the abdominopelvic cavity and the series of PET/CT scans showed progression of disease after chemotherapy. The other patient presented with three calcified masses with intensive uptake of FDG located in the left pelvis, the right subphrenic region, and the right supradiaphragmatic area, respectively. These suggest that F-18 FDG PET/CT can be useful in identifying malignant calcification and assessing therapeutic response of calcified malignancy.

Early Results of Roux-en-Y Gastric By-Pass on Regulation of Diabetes Type 2 in Patients with BMI Above and Below 35 Kg/m2

The idea of surgical treatment of type 2 diabetes was established in the U.S. and was based on observation of patients after bariatric operations. Performed in cases of morbid obesity exclusion of the duodenum and anastomose the stomach with the central part of the intestines cause shortened absorbtion of nutrients, what showed a beneficial effect on weight loss, resolution of comorbidities and reduce the risk of developing cardiovascular diseases and cancer. Analysis of the results of surgical treatment of obese patients with type 2 diabetes confirmed the usefulness of surgical methods.The aim of the study was to evaluate the impact of Roux-en-Y gastric by-pass (RYGB) on diabetes in patients with BMI below and above 35 kg/m2. The study comprised 66 patients with DM2, who underwent Roux-en-Y gastric bypass due to morbid obesity (BMI above 35 kg/m2) and three patients with DM2 and BMI below 35 kg/m2. In patients with DM2 and BMI < 35 kg/m2 criteria for inclusion in the operational treatment were: DM2 difficult to be regulated pharmacologically lasting less than 10 years and BMI at the qualification about 35 kg/m2. Indications have been determined on the basis of three consecutive measurements of HbA1c values above 7%, and measurements of blood glucose (frequent fluctuations in blood glucose levels on the value of hypoglycemia to hyperglycemia). The criteria for diagnosing resolution of DM2 included the level of HbA1c < 6% and glucose fasting level below 100 mg/ dl. In a group of 66 patients with DM2 and obesity, regression of DM2 was observed in 48 patients (73%) as early as during the hospitalization. In 11 patients (16.7%) glycaemia and HBA1c were stabilized within 8 weeks after surgery. In 7 (10.6%) cases of patients with difficult to control DM2, there was still need for antidiabetic medication, but glycemic control was much more effective. After one year remission was observed in 89% of patients. In all three patients with DM2 and BMI < 35 kg/m2 total glycemic resolution of DM2 was observed during hospitalization. In this group there has been no postoperative complications. In the group of 66 obese patients with DM2 postoperative complications were found in 7 cases, they were related to infection and prolonged healing of surgical wound. One patient had an intraabdominal abscess located in the left subphrenic region, it was punctured under ultrasound guidance. The ultimate evaluation of this method demands several years of meticulous clinical studies. Despite of that, considering high cost of life-long conservative therapy of DM2 and its complications, severe impact on quality of life and serious consequences of the disease, the surgical metabolic intervention may become the most resonable solution in many cases.

Ventricular fibrillation caused by electrocoagulation in monopolar mode during laparoscopic subphrenic mass resection

BackgroundMonopolar is usually a safe and effective electrosurgical unit used in laparoscopic general surgery. However, it can cause adverse outcomes and even cardiac arrest. We present a video of laparoscopic subphrenic mass resection using monopolar coagulation during which ventricular fibrillation occurred and from which the patient was successfully resuscitated.MethodsOur patient was a 39-year-old man who was admitted to our institution for treatment of a liver mass. The mass was located in the left subphrenic region and was 3.31 cm × 2.7 cm according to B ultrasound. He had had a spleen resection after a car accident 14 years before. He was otherwise healthy and a physical examination was negative. He was scheduled for “laparoscopic exploration, mass resection.” General anesthesia was induced and the operation began. While dissecting the mass from the diaphragm there was some bleeding; monopolar electrocoagulation with 68 W was performed upon which ventricular fibrillation occurred. The operation was stopped and closed-chest compression began immediately. Defibrillation (200-J shock) was performed in 1 min and rhythm returned to sinus.ResultsThe operation was resumed carefully and uneventfully. The patient was sent to the postoperative acute care unit and was extubated 10 min after operation. The patient recovered uneventfully without any signs of permanent cardiac injury and was discharged on postoperative day 3. The final pathology was accessory spleen.ConclusionsWe present a video of a patient who experienced ventricular fibrillation during laparoscopic surgery which was successfully defibrillated leaving no permanent cardiac injury. We assume the reason for the ventricular fibrillation was the low-frequency leakage current from electrocoagulation which may be conducted by Swan-Ganz catheter to the heart. It is important that we be familiar with the character of electrosurgical unit when performing laparoscopic surgery. We should be careful when using an electrosurgical unit near the cardiac region, especially when the patient has an indwelling catheter. We recommend performing hemostasis in bipolar mode or use an ultrasonic scalpel if bleeding is close to the heart. Also, an easily available defibrillator should be ready for use.Electronic supplementary materialThe online version of this article (doi:10.1007/s00464-010-1157-0) contains supplementary material, which is available to authorized users.

The Intersegmental Plane of the Liver Is Not Always Flat—Tricks for Anatomical Liver Resection

To investigate the actual three-dimensional (3D) anatomy of the intersegmental plane of the liver to enable safe and precise anatomic resections of the portal territories. Anatomic resection of the liver requires the precise detection of the intersegmental plane. However, we have sometimes encountered a dissociation between conventional understanding of the anatomy of the intersegmental plane and its actual 3D shape. 3D simulations of the livers of 81 healthy donors for living donor liver transplantation were reviewed. Several key angles formed between the plane of each venous trunk and the actual intersegmental plane on 3D simulation images were measured. The relation between these angles and the volume ratio of the liver segments located on both sides of the intersegmental plane were also investigated. The dissociation between the plane of the venous trunks and the actual intersegmental plane was remarkable, especially in the subphrenic region of the right lobe. The volume ratio of segment VIII compared with segment VII was correlated with the degree of cranio-lateral protrusion of segment VIII (r=0.35, P=0.001); this finding was attributed to the intricate surface of the right portal scissura. The same tendency was observed in the left portal scissura between the angle and the volume ratio of segment III/II (r=0.23, P=0.049), whereas the main portal scissura exhibited a relatively flat surface compared with the other longitudinal scissurae. The intersegmental plane of the liver has an uneven and curved surface, especially in the right and left portal scissurae. The identification and exposure of the landmark vein on the cut surface is an important technique for avoiding disorientation during anatomic liver resection.

Contrast-enhanced ultrasonography revealed active thoracic bleeding.

A 61-year-old woman with a hepatocellular carcinoma located in the subphrenic region was treated by radiofrequency ablation (RFA) under artificial pleural effusion. During RFA, B-mode ultrasonography showed a swirling high echoic lesion in the artificial pleural effusion. A real-time scan performed using contrast-enhanced ultrasonography (CEUS) revealed a jet-like extravasation of contrast medium and pooling of microbubbles in the pleural cavity, which were confirmed by angiography. CEUS successfully identified the site of bleeding and can be regarded an effective tool for detecting active bleeding in an emergency.

Subphrenic Versus Nonsubphrenic Hepatocellular Carcinoma: Combined Therapy With Chemoembolization and Radiofrequency Ablation

This retrospective study was conducted to evaluate the clinical utility of the combination of chemoembolization and real-time CT fluoroscopically guided radiofrequency ablation in the treatment of patients with subphrenic hepatocellular carcinoma (HCC). Patients who had a single HCC with a maximum diameter of 5 cm or less were included in the study. None of the patients was a candidate for surgery, and all underwent combination therapy as initial treatment. The patients were divided into two groups based on tumor location. In all, the 93 men and 38 women (mean age, 67.9 +/- 9.4 years; range, 43-83 years) had 46 subphrenic HCCs and 85 nonsubphrenic HCCs. No differences were found in the pretreatment baseline characteristics of the two patient groups. Safety profiles, local tumor progression rates, and prognoses were compared. Tumor enhancement disappeared after 58 radiofrequency sessions (1.3 sessions/tumor) in patients with subphrenic HCC and after 104 radiofrequency sessions (1.2 sessions/tumor) in patients with nonsubphrenic HCC. The 5-year local tumor progression rates (subphrenic, 3% [95% CI, 0.2-12%]; nonsubphrenic, 9% [95% CI, 3-20%]; p = 0.31) and survival rates (subphrenic, 63% [95% CI, 36-81%]; nonsubphrenic, 69% [95% CI, 53-81%]; p = 0.55) were similar for the two patient groups. Although the incidence of self-limited pneumothorax was significantly higher among the patients with subphrenic HCC (13.8% vs 3.85%; p < 0.03), other complication rates were similar for the two patient groups. Combination therapy with chemoembolization and real-time CT-guided radiofrequency ablation is safe and useful even when HCC is in the subphrenic region.

Patient with perforation caused by emphysematous cholecystitis who showed flare on the skin of the right dorsal lumbar region and intraperitoneal free gas

We report an 84-year-old man with perforation caused by emphysematous cholecystitis who showed flare on the skin of the right dorsal lumbar region and intraperitoneal free gas. The patient was admitted for abdominal pain, abdominal swelling, and consciousness disorder 18 days after the onset. Abdominal computed tomography (CT) revealed emphysema in the gallbladder and a small amount of intraperitoneal free gas. Intraoperative findings suggested gangrenous cholecystitis. The gallbladder wall was perforated, and an abscess involving the right subphrenic region, the periphery of the liver and gallbladder, and the right paracolonic groove, was detected. The flare on the body surface may have reflected abscess formation in the right abdominal cavity. Emphysematous cholecystitis induces necrosis and perforation in many patients, and immediate strategies such as emergency surgery are important.

Symptomatic pleural effusion without intrathoracic migration of ventriculoperitoneal shunt catheter

Symptomatic pleural effusion following ventriculoperitoneal (VP) shunt insertion is very rare. The patient was an 8-year-old girl who had VP shunt for hydrocephalus as a result of aqueductal stenosis. Six weeks after surgery, she presented with headache, vomiting and drowsiness. She developed respiratory distress with pain in the right lower chest region and right hypochondrium on admission. Chest X-ray confirmed right hydrothorax and showed the tip of the peritoneal catheter in the right suprahepatic subphrenic space. Her symptoms abated after the catheter was repositioned from the subphrenic region to the general peritoneal cavity. Repeat chest X-ray confirmed the resolution of the hydrothorax. Shunt review without thoracocentesis or thoracostomy is an effective treatment of symptomatic hydrothorax following VP shunt, especially when there is no intrathoracic shunt migration.

The clinical characteristics and outcome of intraabdominal abscess in Crohn's disease.

We aimed to elucidate the incidence and natural course of abdominal abscess complicating Crohn's disease (CD). Of 352 patients with CD who were observed at our hospital between 1985 and October 2001, we studied 35 patients (9.9%) with abscesses in the mid-abdominal region (the abdominal wall, peritoneal cavity, retroperitoneum, and subphrenic region). The cumulative incidence of complication with an abscess was 9% and 25%, respectively, 10 and 20 years after CD onset. Of the 35 CD patients with abscess, 60% had had surgery by the time of the present study. The age when the abscess developed was 30.1 +/- 8.1 years, and the duration of illness from the onset of CD until development of an abscess was 10.8 +/- 6.3 years (range, 0-29 years). The location of involvement was: abdominal wall, n = 14 (40%); peritoneal cavity, n = 10 (29%); retroperitoneum or iliopsoas, n = 9 (26%); and subphrenic region, n = 2 (6%). In terms of location of abscess, it occurred most often on the right side (65.7%). Almost all abscesses occurred near the site of an anastomosis. Diseased segments of the bowel responsible for abscess formation were categorized radiographically as showing mild stenosis (6.5%), intermediate stenosis and/or simple fistula (41.9%), and severe stenosis and/or multiple fistulas (51.6%). Conservative treatment (including drainage of abscess) alone was effective in 7 patients (20%) and surgery was needed in 28 patients (80%). During the 5.3-year follow-up after treatment for the abdominal abscess, 9 of the 35 patients (26%) had recurrence of an abscess, mostly within 3 years. Abscess formation was noted in about 10% of patients with CD, with 46% of abscesses occurring in a diseased bowel segment near an anastomotic site. Of the diseased bowel segments responsible for abscess formation, half had neither severe stenosis nor multiple fistulas. Almost all patients underwent surgery for the abscess, and, in more than a quarter of the patients, there was recurrence within a few years after surgery.

Positron Emission Tomography with FDG in the Detection of Peritoneal and Retroperitoneal Metastases of Ovarian Cancer

Objective: The aim of this prospective study was to evaluate ¹⁸F-FDG-PET, in comparison with CT, for the detection of peritoneal and retroperitoneal metastases of ovarian cancer. Methodology: 13 patients with primary (n = 7) or recurrent (n = 6) ovarian cancer underwent an attenuation-corrected ¹⁸F-FDG-PET of the abdomen as well as a contrast-enhanced abdominal CT, followed by surgical staging. For data analysis, the abdomen was artificially divided into six regions (right and left subphrenic region, right and left paracolic gutter, retroperitoneum and central abdomen). All images were reviewed and each region was visually scored on ¹⁸F-FDG-PET as well as on CT. ¹⁸F-FDG-PET results were compared with those of CT, using the surgical data as gold standard. Results: 73 regions were evaluable surgically and or histologically. Sensitivity was slightly better for CT than for ¹⁸F-FDG-PET (74 vs. 66%). Metastases of <5 mm were missed with both techniques. Specificity, however, was clearly better for ¹⁸F-FDG-PET than for CT (94 vs. 77%), especially in patients with recurrent disease, where postoperative changes (hematomas, adhesions, etc.) caused more false positive results on CT. Retroperitoneal lymph node involvement was found in 3/13 patients. The result of ¹⁸F-FDG-PET for the retroperitoneal lymph nodes was correct in all cases, whereas CT was false positive in 2 patients. ¹⁸F-FDG-PET is relatively inaccurate for the right and the left subphrenic region (missing tumor involvement in 5 patients compared to 2 patients for CT). Conclusion: Given the low sensitivity of both ¹⁸F-FDG-PET and CT for the detection of peritoneal metastases, surgical staging remains the gold standard. Because of the better specificity, ¹⁸F-FDG-PET might be preferred for evaluating residual or recurrent disease after surgery. ¹⁸F-FDG-PET was more sensitive in the retroperitoneal region than intraperitoneal.

Radiofrequency ablation therapy for hepatocellular carcinoma located at subphrenic region: Value of artificial pleural effusion combined with contrast-Harmonic imaging

Radiofrequency ablation therapy for hepatocellular carcinoma located at subphrenic region: Value of artificial pleural effusion combined with contrast-Harmonic imaging

Actinobacillus actinomycetemcomitans Pneumonia with Chest Wall and Subphrenic Abscess

A 14-year-old girl had progressive dyspnea and right lower chest pain for about 1 1/2 months and a weight loss of 3 kg in 2 months. Chest X-ray revealed right pleural effusion and a round infiltration over the right lower chest, initially suspected to be malignant. Image study revealed consolidation in the right middle and lower lobes with abscess-like lesions around the right lower pleura and transdiaphrenic involvement to the subphrenic region. The lesion had also invaded the intercostal muscle. The pleural abscess was obtained by fiberoptic thoracoscopy, and culture of the pus grew typical colonies of Actinobacillus actinomycetemcomitans. After the causative microorganism had been identified, cefoxitin was given for 2 weeks followed by oral amoxicillin (250 mg/6 h) for a total period of 3 months. Follow-up chest X-ray revealed resolution of the lung lesions and the patient recovered gradually without any sequelae.