The anterior abdominal wall and peritoneum

Fusion imaging is an emerging technique that combines real-time ultrasound examination with images acquired previously using other modalities, such as computed tomography (CT), magnetic resonance imaging and positron emission tomography. The primary aim of this study was to evaluate the feasibility of fusion imaging in patients with suspicion of ovarian or peritoneal cancer. Secondary aims were: to compare the agreement of findings on fusion imaging, CT alone and ultrasound imaging alone with laparoscopic findings, in the assessment of extent of intra-abdominal disease; and to evaluate the time required for the fusion imaging technique. Patients with clinical and/or radiographic suspicion of advanced ovarian or peritoneal cancer who were candidates for surgery were enrolled prospectively between December 2019 and September 2020. All patients underwent a CT scan and ultrasound and fusion imaging to evaluate the presence or absence of the following abdominal-cancer features according to the laparoscopy-based scoring model (predictive index value (PIV)): supracolic omental disease, visceral carcinomatosis on the liver, lesser omental carcinomatosis and/or visceral carcinomatosis on the lesser curvature of the stomach and/or spleen, involvement of the paracolic gutter(s) and/or anterior abdominal wall, involvement of the diaphragm and visceral carcinomatosis on the small and/or large bowel (regardless of rectosigmoid involvement). The feasibility of the fusion examination in these patients was evaluated. Agreement of each imaging method (ultrasound, CT and fusion imaging) with laparoscopy (considered as reference standard) was calculated using Cohen's kappa coefficient. Fifty-two patients were enrolled into the study. Fusion imaging was feasible in 51 (98%) of these patients (in one patient, it was not possible for technical reasons). Two patients were excluded because laparoscopy was not performed, leaving 49 women in the final analysis. Kappa values for CT, ultrasound and fusion imaging, using laparoscopy as the reference standard, in assessing the PIV parameters were, respectively: 0.781, 0.845 and 0.896 for the great omentum; 0.329, 0.608 and 0.847 for the liver surface; 0.472, 0.549 and 0.756 for the lesser omentum and/or stomach and/or spleen; 0.385, 0.588 and 0.795 for the paracolic gutter(s) and/or anterior abdominal wall; 0.385, 0.497 and 0.657 for the diaphragm; and 0.336, 0.410 and 0.469 for the bowel. The median time needed to perform the fusion examination was 20 (range, 10-40) min. Fusion of CT images and real-time ultrasound imaging is feasible in patients with suspicion of ovarian or peritoneal cancer and improves the agreement with surgical findings when compared with ultrasound or CT scan alone. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Dermatofibrosarcoma protuberans is a rare soft tissue sarcoma of low to intermediate malignant potential. Incidence is estimated to be 0.8 to 4.5 cases per million persons per year. The tumor is highly aggressive locally and is known to recur. Punch biopsy or excisional biopsy (in case of small tumors) are diagnostic. Computer tomography (CT) and magnetic resonance imaging (MRI) are useful in determining the size and extent of the tumor’s treatment is primarily surgical, with a wide local excision with at 2 cm margin. However, local recurrence after apparently adequate surgical excision is common. Mohs micrographic surgery has been recommended as it enables maximum preservation of tissue. When surgery is insufficient, imatinib mesylate is shown as a safe and effective treatment in dermatofibrosarcoma protuberans (DFSP), especially in cases of locally advanced or metastatic disease. Here, we report a case of a giant fibrosarcoma on the anterior abdominal wall, measuring 27×18×9 cm, which occurred in a recurrent dermatofibrosarcoma protuberans. Diagnosis was done by histopathological examination (HPE) of the previously excised tumor and CT was done. The tumor was excised with a 3 cm margin and extensive reconstruction of the anterior abdominal wall defect was done using synthetic mesh, myocutaneous flaps and split skin grafting. Keeping in view the recurrent nature of our case, large tumor size, DFSP-fibrosarcomatous (FS) transformation and close negative margins in the HPE of the postoperative specimen, the patient was planned for adjuvant radiotherapy.

Multidisciplinary treatment of abdominal wall endometriosis: A case report and literature review

Computed tomography (CT), especially contrast-enhanced CT (CECT), provides important information on the severity and prognosis of acute pancreatitis (AP). Magnetic resonance imaging (MRI) has become a useful tool as an alternative to CT in the assessment of AP. The primary aim of our study was to determine the diagnostic value of nonenhanced MRI (NEMRI) to assess severity and predict outcome in patients with AP from the third to fifth day after admission. We also correlated MRI findings with CT and biochemical parameters. The study included 101 patients (49 men, 52 women, median age 62 yr, range 20-82) with a diagnosis of AP admitted to our hospital between January 1, 2004 and June 31, 2005. The inclusion criteria consisted of a combination of clinical features, a typical case history, elevation of serum pancreatic enzymes, and diagnosis confirmed by imaging studies. Contrast-enhanced spiral CT exams were performed in all patients from the third to fifth day after admission, and Balthazar grade and CT severity index were calculated. All patients underwent NEMRI, and MR severity index (MRSI) was calculated. We also performed magnetic resonance cholangiopancreatography (MRCP) in all patients to detect bile duct lithiasis. Significant correlation between CECT and NEMRI was found for Balthazar grade (P<0.001) and the assessment of pancreatic necrosis (P<0.001), as well as between the combined severity indices (rho=0.819, P<0.001). MRSI correlated with Ranson score (rho=0.656, P<0.01), C-reactive protein (CRP) levels 48 h after admission (rho=0.502, P<0.01), appearance of systemic complications (rho=0.576, P<0.01), and length of hospital stay (rho=0.484, P<0.01). Considering the Atlanta criteria as the gold standard and the Ranson score, no difference in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the two methods was observed. Comparing the group of patients with presumed acute pancreatic hemorrhage with the group of patients with severe AP, we found a significantly higher APACHE II score on the first day (P<0.05), that the development of systemic complications was more frequent (P < 0.05), and that the hospital stay and ICU management of patients with MRI signs of pancreatic hemorrhage tended to be longer. NEMRI is comparable to CECT in the early assessment of the severity of AP, and both methods are equally efficient in predicting local and systemic complications of AP. MRI has a potential advantage over CT in detecting bile duct lithiasis and pancreatic hemorrhage.

1. The melanocytes and melanin in the skin of the ear, anterior abdominal wall, areola and sole of foot have been studied in pure black and pure red immature, mature and pregnant female guinea-pigs. The melanocytes were identified by using the dopa reaction. The melanocytes and melanin present in the hair follicles have not been examined in this investigation. 2. In the ear, areola and sole of foot the melanocytes were found to be concentrated in the epidermal ridges. In the anterior abdominal wall the melanocytes were situated in the epidermis and were arranged in rows lying at right angles to the slope of the hairs. The melanocytes were found to lie between the cells of the basal layer of the epidermis and the dendritic processes were seen to extend out laterally and upwards between the deeper cells of the epidermis. The majority of the melanocytes present in each skin region presented certain characteristics which were constant for that region and were found in all the animals examined. The size of the melanocytes within each skin region showed considerable variation. 3. In the normal mature female guinea-pig the melanocyte counts showed that there were wide individual and regional variations. The cell counts were greatest in the skin of the ear and areola and least in the anterior abdominal wall. In the sole of the foot accurate counting was not possible but more melanocytes appeared to be present in this region than elsewhere. There was no statistically significant difference between the counts in the red and black guinea-pigs in any of the regions studied although there was a tendency for the counts to be higher in the ear and anterior abdominal wall of the black animals. 4. In the immature animals the melanocyte counts were higher in the ear and lower in the areola than in the mature animals but in the anterior abdominal wall the counts were similar. In the immature animals the melanocytes had a more general distribution than those found in the mature animals and less free melanin was present in all the regions. 5. A comparison of the results with those already reported on the male guinea-pig showed that the counts were significantly higher in the anterior abdominal wall and areola of the mature female and that the latter also possessed more free melanin and larger melanocytes which contained more melanin and were darker in colour. The appearances of the melanocytes and melanin in the immature animals of both sexes were practically identical. 6. In the pregnant guinea-pig in all the regions the melanocyte counts were significantly higher than before the onset of pregnancy and this was accompanied by an increase in the amount and depth of colour of the melanin both within and outside the melanocytes. 7. The relationship between these findings and the influences of sex hormones on melanogenesis is discussed.

A 17-year-old boy presented with gradually increasing retrosternal bulge of four years duration. He developed multiple non-tender woody nodules and discharging sinuses over anterior chest wall over the years and presented with features of superior vena cava obstruction (Fig. 1). Multiple biopsies from nodules were inconclusive and he had received anti-tuberculosis treatment twice in the past. Contrast-enhanced computed tomography (CECT) revealed soft tissue density in the anterior and middle mediastinum (Fig. 2A). Magnetic resonance imaging (MRI) revealed hypointense mass in T2-weighted axial image (Fig. 2B). Fine needle aspiration cytology (FNAC) from a lump revealed actinomyces. He received ceftriaxone for 6 weeks followed by doxycycline for 1 year. The sinuses dried, the nodules softened and decreased in size with modest reduction in retrosternal bulge; however, dilated veins persisted. Surgical option was ruled out in view of extensive fibrosis encasing the major vessels. Fibrosing mediastinitis (FM) has been most commonly associated with histoplasmosis and tuberculosis. Other infectious causes implicated include aspergillosis, mucormycosis, blastomycosis, and cryptococcosis. Actionomycosis is a rare cause of FM and superior vena cava syndrome1,2. Fig. 1 shows retrosternal bulge, multiple discharging sinuses (black arrow) over anterior chest wall, non-pulsatile engorged neck veins (white arrow) and dilated, tortuous veins over the chest and abdominal wall with downward flow, suggestive of post-azygous ... Fig. 2A CECT scan of the chest shows soft tissue density in the anterior and middle mediastinum encasing the SVC, aorta and pulmonary artery. SVC is chinked (arrow) with formation of multiple collaterals in the chest wall (arrowhead). Fig. 2B MRI of the chest, T2-weighted axial image shows hypointense mass (arrow) suggesting its fibrotic nature.

Spigelian hernia is an uncommon form of abdominal wall hernia. The symptoms can be insidious but the commonest are abdominal pain or a lump on the anterior abdominal wall. Diagnosis can be challenging, but the use of ultrasonography and contrast enhanced CT (CECT) scan is essential to avoid diagnostic delays. In view of a high risk of incarceration and strangulation anticipated, urgent operative intervention is necessary. In this case report, a 42-year old multiparous woman presented with bilateral lumps on the abdominal wall and abdominal pain with no symptoms or signs of obstruction or strangulation. The clinical evaluation was suspicious of bilateral spigelian hernia. This was confirmed by CECT scan of abdomen as ultrasonography was inconclusive. This case report illustrates the diagnostic challenges of spigelian hernia and how early operative intervention is crucial to preventing strangulation.

Introduction. Ventral hernias are quite common, but liver herniation is an extremely rare case. This type of abdominal protrusion of part of the liver usually occurs through incisional weak spots on the abdominal wall. Incisional herniation of the liver usually occurs 2 to 3 years after an abdominal operation consequently leading to focal weakness of the abdominal wall. Case report. We present an extremely rare case of incisional herniation of part of the left and smaller part of the right liver lobe in a woman aged 64 years, as a consequence of a previous open cholecystectomy, creating a focal abdominal wall weakness. Abdominal CT scan was performed. Analysis of the CT scans, as well as of the reconstruction made in the coronal and sagittal plane was performed. Herniation of the left and the smaller part of the right liver lobe through an incisive focal weakness of the right upper quadrant of the abdominal wall was detected. Discussion. Incisional hernias are delayed complications of abdominal surgery. They can occur anywhere on the abdominal wall and are more frequently encountered in a vertical than in a transverse incision. Typically, incisional hernias occur during the first months following surgery, but later occurrence has been reported as well. Herniation of the liver through the anterior abdominal wall is an extremely rare condition and usually related to previous surgery on the upper abdomen. Due to its rarity it is both a diagnostic and therapeutic challenge. Conclusion. We can conclude that there is a connection between liver herniation through the upper abdominal wall and a previously performed open abdominal surgery. CT is the method of choice for diagnosis of liver herniation through the anterior abdominal wall.

Assessment of regional pulmonary perfusion as well as nodule and tumor perfusions in various pulmonary diseases are currently performed by means of nuclear medicine studies requiring radioactive macroaggregates, dual-energy computed tomography (CT), and dynamic first-pass contrast-enhanced perfusion CT techniques and unenhanced and dynamic first-pass contrast enhanced perfusion magnetic resonance imaging (MRI), as well as time-resolved three-dimensional or four-dimensional contrast-enhanced magnetic resonance angiography (MRA). Perfusion scintigraphy, single-photon emission tomography (SPECT) and SPECT fused with CT have been established as clinically available scintigraphic methods; however, they are limited by perfusion information with poor spatial resolution and other shortcomings. Although positron emission tomography with 15O water can measure absolute pulmonary perfusion, it requires a cyclotron for generation of a tracer with an extremely short half-life (2 min), and can only be performed for academic purposes. Therefore, clinicians are concentrating their efforts on the application of CT-based and MRI-based quantitative and qualitative perfusion assessment to various pulmonary diseases. This review article covers 1) the basics of dual-energy CT and dynamic first-pass contrast-enhanced perfusion CT techniques, 2) the basics of time-resolved contrast-enhanced MRA and dynamic first-pass contrast-enhanced perfusion MRI, and 3) clinical applications of contrast-enhanced CT- and MRI-based perfusion assessment for patients with pulmonary nodule, lung cancer, and pulmonary vascular diseases. We believe that these new techniques can be useful in routine clinical practice for not only thoracic oncology patients, but also patients with different pulmonary vascular diseases.

The diagnosis of retroperitoneal pathology has historically presented a challenge to physicians. The signs and symptoms of retroperitoneal diseases are myriad and often subtle. Cross-sectional imaging techniques have therefore had a major impact on retroperitoneal diagnosis. Computed tomography (CT) is currently the standard imaging technique for evaluating the retroperitoneum. Magnetic resonance (MR) imaging is also well suited for retroperitoneal imaging and has several advantages over CT. MR imaging is the preferred technique in patients with contraindications to iodinated contrast material due to renal dysfunction or allergy. It excels at evaluating the blood vessels, providing a reliable assessment of vessel patency, aneurysm, or dissection. The ability of MR imaging to acquire images without exposure to ionizing radiation facilitates imaging of obstetric and pediatric patients. The ability to acquire images in any plane is a distinct advantage for assessing the extent and origin of retroperitoneal pathology, although this can now be accomplished with spiral CT as well as MR imaging. The spatial resolution of CT is currently superior to MR imaging for most retroperitoneal studies, but this may change with continued technological advances such as improved phased array coil systems (Bidgood WD Jr, Schiebler ML. Retroperitoneum and mesentery. In: Ros PR, Bidgood WD Jr, eds. Abdominal magnetic resonance imaging. St. Louis: Mosby Year Book, 1993:310-47). Finally, MR imaging provides the flexibility to tailor each examination to the specific clinical question. With few exceptions, anything CT can do in the retroperitoneum, MR imaging can do as well or better.

Small hepatocellular carcinomas in cirrhosis: differences in contrast enhancement effects between helical CT and MR imaging during multiphasic dynamic imaging

Isolated abdominal wall metastasis 42years after curative surgery for ovarian cancer: A case report.

The intraperitoneal distribution of fluid and its detectability with a CT scanning were investigated in 13 patients during infusion of dialysate for peritoneal dialysis. An ascending pattern of spread i.e. from the lesser pelvis through the inframesocolic compartment to the supramesocolic compartment prevailed. Accumulation of fluid in the perihepatic space and in Morison's pouch as a function of fluid volume is at best approximated by a parabolic curve. Fifty to two hundred fifty ml. of fluid were detectable with a CT scanning in supine position in the majority of cases within the perihepatic space and Morison's pouch. The lowest amount of fluid detectable in the peritoneal cavity--25 ml. was found between the anterior abdominal wall and bowel loops in right decubitus.

Objective To evaluate the efficacy of ultrasound-guided transversus abdominis plane block for elderly herpetic neuralgia located in anterior abdominal wall. Methods A total of 112 elderly patients aged 65-75 years with less than 30 days of herpes zoster neuralgia located in anterior abdominal wall were enrolled for receiving a treatment of transversus abdominis plane block.Patients were randomly allocated into two groups: the control group(n=56)taking gabapentin and celebrex, and the observation group(n=56)receiving transversus abdominis plane block(three times per week for two weeks)as add on therapy to gabapentin and celebrex.Morphine 10 mg was ready for oral application in breakthrough pain.Pain was evaluated by McGill scores assessed by short-form of Mcgill pain questionnaire(SF-M PQ)and visual analogue scale(VAS)before(T0)and after 1(T1)and 2 weeks(T2)of transversus abdominis plane block, and 1(T3)and 8(T4)weeks after end of the treatment.Pain relief(PAR)was calculated by the formula: PAR=(VAS score before block--VAS score after block)/ VAS score before block × 100%.The morphine consumption and sleep quality were observed during the treatment and 1 week after treatment.Analgesic efficacy was graded 8 weeks after end of treatment.The effective rate and good response rate were calculated.Incidences of complications were recorded. Results There was no significant difference in the VAS score between the two groups before treatment(t=0.419, P>0.05), while VAS scores after treatment were lower in the observation group than in the control group(t=17.925, 19.662, 12.580 and 13.987, respectively, P 0.05). After treatment, the total scores of McGill were lower in the observation group than in the control group(t=18.612, 20.135, 13.213 and 12.356, respectively, P 0.05). While after treatment, the morphine consumptions were decreased in the observation group versus in the control group(t=22.341, 16.758, 17.827, 15.541 respectively, P<0.05). No punctures of abdominal cavity, chest cavity, internal organs or blood vessels by mistake occurred. Conclusions Ultrasound-guided transversus abdominis plane block is effective and has less adverse reactions in treating herpetic neuralgia located in anterior abdominal wall. Key words: Neuromuscular blockade; Ultrasonography; Herpes zoster; Neuralgia

Findings of anterior abdominal wall hernias at computed tomography and magnetic resonance imaging are well documented; however, little information is available about the depiction and characterization of such hernias in barium studies, primarily in small-bowel follow-through examinations. Such examinations are performed frequently, and radiologists should be familiar with the hernia features that may be observed. Anterior abdominal wall hernias are best recognized in profile on lateral spot images from a small-bowel follow-through study when one or more loops of bowel extend beyond the fascial planes of the anterior abdominal wall, with luminal narrowing at the entry or exit site of the hernia or at both sites. In some patients, the hernia also can be recognized indirectly on a frontal view because of the displacement and, often, extrinsic compression or deformity of herniated bowel loops. In such cases, additional views should be obtained with the patient in the lateral position to confirm the presence of the hernia with direct visualization of the herniated loops in profile. The reducibility of bowel from an anterior abdominal wall hernia also can be assessed with manual palpation of the abdominal wall while the patient is in the lateral position. Manual palpation performed during fluoroscopy helps determine whether the bowel loops can be returned to the proper location or are fixed in the hernia, an important observation because of the higher risk of obstruction or strangulation when the bowel is incarcerated. Fluoroscopy therefore is a useful technique for the detection and characterization of anterior abdominal wall hernias in barium studies.