Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1250_Библиотеки_им_академика_М_И_Перельмана.pdf
68 S. Sorensen and A. H. Dachman
Preparation of Patient
Do not eat or drink for several hours prior to the scan. Some medications and
vitamins can affect scans Diabetics may have special instructions. The agent may be
excreted in breast milk. Metal objects should be removed.
How the Procedure Is Performed
A PET scanner is a large machine with a doughnut shaped home in the middle.
Some PET scans are combined with CT in one unit called “PET/CT”. The PET
images are processed and fused with the CT images.
The desired radioactive agent in injected into a vein. It takes about an hour for
the agent to be absorbed by the body organs and by tumor. Scanning for the CT if
fast, but the PET scanning takes 20–30 minutes. Patients must remain still for the
scan. Sometimes delayed scans about to a few hours might be needed.
Typical Abnormal Findings
See examples in the book for carcinomatosis.
Complications
Allergic reactions are rare. There is a low level of radiation within the patient until
the agent is excreted. Wome n should not be pregnant or breastfeeding.
Additional Comments
The exam is expensive and time consuming but gives unique information in the
proper clinical context.
Ultrasound
Description of Procedure
Ultrasound of the abdomen and pelvis in a non-invasive test that uses a transducer
to generate sound waves and view the internal structures.
8 Radiography of the Mesentery 69
Indications
Ultrasound is commonly available and relatively inexpensive as compared to CT
and MRI. It is often used for the evaluation of focal or diffuse abdominal pain,
swelling or infection. It is helpful in looking for ascites and at the solid organs and
their blood flow. Some other examples of abdom inal conditions evaluated by US
are gallstones, kidney stones, abdominal aortic aneurysm, organomegaly and
abnormal liver function. US can be used for guidance of percutaneous biopsies.
Complementary Procedures
The relative contraindications below to not apply to CT and most do not apply to
MRI. These two exams are the principle complimentary tests.
Contraindications
There are no absolute contraindications.
Relative Contraindications
The sound waves must penetrate the body. Thus patients with very high body mass
index (BMI) may have non-diagnostic exams. Also gas interferes with transmission
of sound waves, thus patient with ileus or bowel obstruction may have gas filled
loops obscuring abdominal anatomy.
Preparation of Patient
Patients should be fasting to help avoid bowel gas that might interfere with the
exam. When the gallbladder is also evaluated, the patients should avoid any activity
that might cause gallbladder contraction, e.g., smok ing.
How the Procedure Is Performed
Ultrasound units come in many sizes and levels of sophistication. Most units are
portable and consist of a console, computer, video display and assorted transducers.
Patients lie recumbent and may be asked to turn on their sides. A warm water-based
gel is use to interface the skin with the surface of the transducer. The transducer is
moved to produce images. Breath holding is usually needed. Most exams take
30 minutes or less . Doppler US can used to evaluate blood flow with organs or
large blood vessels.
70 S. Sorensen and A. H. Dachman
Typical Abnormal Findings
As regards peritoneal disease, US can help determine if ascites is present and if it is
of sufficient volume to tap. US can characterize masses as solid or cystic and
sometimes determine the organ of origin.
Complications
None.
Additional Comments
US intravascular contrast agents are approved for use in the USA but are not
commonly used.
Suggested Reading
1. Musson RE, Bickle I, Vijay RK. Gas patterns on plain abdominal radiographs: a pictorial
review. Postgrad Med J. 2011;87(1026):274–87.
2. Rydberg J, Buckwalter KA, Caldemeyer KS, Phillips MD, Conces DJ, Aisen AM, Persohn SA,
Kopecky KK. Multisection CT: scanning techniques and clinical applications. RadioGraphics.
2000;20(6):1787–806.
3. Mattoon JS, Berry CR, Nyland TG. Abdominal ultrasound scanning techniques. In:
Ultrasound, 3rd ed. St. Louis. 2014. https://books.google.com/books?hl=en&lr=&id=
ot7TBQAAQBAJ&oi=fnd&pg=P94&ots=WbJEPa-KqR&sig=hRO1ASQ3BVc32flF_-4m5Zj
Bkx0#v=onepage&q&f=false.
4. Arraiza M, Metser U, Vajpeyi R, Khalili K, Hanbidge A, Kennedy E, Ghai S. Primary cystic
peritoneal masses and mimickers: spectrum of diseases with pathologic correlation. Abdom
Imaging. 2015;40(4):875–906.
5. Dillman JR, Smith EA, Morani AC, Trout AT. Imaging of the pediatric peritoneum, mesentery
and omentum. Pediatr Radiol. 2017;47(8):987–1000.
6. Copin P, Zins M, Nuzzo A, Purcell Y, Beranger-Gibert S, Maggiori L, Corcos O, Vilgrain V,
Ronot M. Acute mesenteric ischemia: a critical role for the radiologist. Diagn Interv Imaging.
2018;99(3):123–34.
7. Taffel MT, Khati NJ, Hai N, Yaghmai V, Nikolaidis P. De-misty-fying the mesentery: an
algorithmic approach to neoplastic and non-neoplastic mesenteric abnormalities. Abdom
Imaging. 2014;39(4):892–907.
8. Dubuisson V, Voïglio EJ, Grenier N, Le Bras Y, Thoma M, Launay-Savary MV. Imaging of
non-traumatic abdominal emergencies in adults. J Visc Surg. 2015;152(6 Suppl):S57–64.
Mesenteric Biopsy
Fons F. van den Berg and John C. Alverdy
Indications
Indications for a diagnostic mesenteric biopsy include the presence of a mesenteric
lesion suspected for advanced metastatic disease in confirmed cancer or a de novo
lesion of the mesentery without a history of cancer. In patients with significant
symptoms and unclear imaging, performance of a mesenteric biopsy is considered
acceptable. Mesenteric biopsies are performed are image-gui ded using ultrasound
(US) or Computed Tomography (CT). Tissue is collected using percutaneous core
biopsies and/or fine-needle aspiration (FNA). Reported technical and diagnostic
success rates are high. Core biopsies yield higher diagnostic accuracy and are often
needed for sub classification of the lesion. As an alternative, a surgical approach
under general anesthesia can be performed. Although open surgical biopsy has
historically been considered the gold standard method for this procedure, a diagnostic laparoscopy and mesenteric biopsy can be safely performed and is generally
preferred, especially in young, healthy patients. Reasons for these approaches when
obtaining a mesenteric biopsy include the need for visual inspection of the peritoneal cavity due to suspected peritoneal metastasis, or the necessity for urgent an
pathological diagnosis and chemotherapy due to malignant disease (i.e. high-grade
lymphoma). An open mesenteric biopsy is also preferable when mesenteri c lesions
are in close proximity to vital structures, such as major vessels, hollow organs of the
digestive tract, spleen, liver and pancreas.
9
F. F. van den Berg
Department of Surgery, Amsterdam UMC, University of Amsterdam, Gastroenterology,
Endocrinology, Metabolism, Amsterdam, North Holland, The Netherlands
J. C. Alverdy (&)
Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
e-mail: jalverdy@surgery.bsd.uchicago.edu
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_9
71
72 F. F. van den Berg and J. C. Alverdy
Contraindications
Contraindications for mesenteric biopsy are related to the risk of perforation or
excessive bleeding. Absolute contraindications include a platelet count less than
50 10
traindications are the presence of an uncorrected coagulopathy, absence of a safe
needle path or a patient that is uncooperative or has an uncontrolled movement
disorder.
9
/L and an International Normalized ratio (INR) above 1.6. Relative con-
Description of the Procedure
Preparation of Patient
Routine screening for coagulation status is advised. Patients are kept nil per oral
(NPO) after midnight of the procedure and undergo general anesthesia in cases that
an emer gency laparotomy may occur. A single dose of antibiotics is given in when
a solid organ, such as the colon, is traversed. Bowel prepar ation with purgative
agents and oral antibiotics is generally not required.
Image-Guided Percutaneous Mesenteric Biopsy
It is advised to use a coaxial technique with a 17-gauge introducer and 18-gauge
cutting needle for core biopsy, or 22-gauge needle for FNA specimens. The needle
is advanced into the target lesion under US or CT guidance. Immediately after the
biopsy, the patient should be monitored for signs of post-biopsy bleeding. An
example of a CT-guided mesenteric biopsy is shown in Fig. 9.1.
Diagnostic Laparoscopic Mesenteric Biopsy
The patient is positioned in Trendelenburg position and, depending on the size and
location of the mesenteric lesion, one 12-mm and two or more 5-mm trocars are
placed under general anesthesia. Core biopsies of the lesion are taken under visual
inspection, while suspect lymph nodes are removed in their entirety.
Potential findings from mesenteric biopsy are shown in Table 9.1.
9 Mesenteric Biopsy 73
Fig. 9.1 A 67-year-old male with a history of cecum adenocarcinoma underwent a partial
colectomy. A new 16 mm omental nodule was seen on follow up CT scan. CT performed during
the procedure showing a 16 mm target omental nodule (arrow) with a coaxial needle through it.
Biopay pathology showed metastatic adenocarcinoma. Reused with permission from: Vadvala, H.
V., et al. (2017). “Image-Guided Percutaneous Omental and Mesenteric Biopsy: Assessment of
Technical Success Rate and Diagnostic Yield.” J Vasc Interv Radiol 28(11): 1569–1576.
Copyright © Elsevier
Table 9.1 Neoplastic and non-neoplastic findings on mesenteric lymph node
Neoplastic Non-neoplastic
Metachronous peritoneal carcinomatosis Mesenteric panniculitis/Sclerosing
Lymphoma (follicular, Hodgkin’s, B-cell) Mesenteric lymphadenitis
Desmoid tumor Anastomosing hemangioma
Methotrexate-associated lymphoproliferative
disorder
mesenteritis
Peritoneal tuberculosis
Inflammatory granulation tissue/Suture
granuloma
74 F. F. van den Berg and J. C. Alverdy
Complications
The complication rate for image-guided mesenteric biopsy is generally low.
Reported complications include localized pain, visceral perforation, intraabdominal hemorrhage and abscess formation. There is small possibility of needle tract seeding in the case of locally aggressive tumor biology.
Suggested Reading
1. Vadvala HV, Furtado VF, Kambadakone A, Frenk NE, Mueller PR, Arellano RS.
Image-guided percutaneous omental and mesenteric biopsy: assessment of technical success
rate and diagnostic yield. J Vasc Interv Radiol. 2017;28(11):1569–76.
Diagnosing Mesenteric Diseases: Laparoscopy
John Anagnostakos and Joshua H. Wolf
Indications
There are a variety of conditions that may lead to laparoscopic exploration of the
abdominal mesentery. These will be discussed be low.
Traumatic Injury
Traditionally, in the setting of blunt abdominal trauma the standard of care for
treating suspected intraabdominal injury has been through exploratory laparotomy.
However, as surgeon comfort with laparoscopy has increased over the years, more
authorities have been advocating for a preliminary diagnostic laparoscopy.
Laparoscopy has been shown to be especially effective in diagnosing and treating
blunt, hollow viscous injuries and mesenteric injuries. A mesenteric injury grading
system was developed by Bekker et al. on a scale of 1–5 to describe the injury
during laparoscopy. A high score indicates a need for further intervention. High
grade mesenteric injuries or multiple injuries often require conversion to laparotomy to survey the abdomen to ensure there are no other injuries and to treat the
mesenteric injury. However, some injuries can be managed entirely laparoscopically with intracorporal suturing and laparoscopic bowel resection utilizing endoscopic staplers. In the hands of a skilled laparoscopic surgeon, laparoscopy can be
an effective way of treating acute traumatic abdominal injuries while avoiding the
morbidity associated with laparotomy (Fig. 10.1).
10
J. Anagnostakos
Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD, USA
J. H. Wolf (&)
Department of Surgery, LifeBridge Health, 2435 Belvedere Ave, Baltimore, MD 21215, USA
e-mail: yehoshuawolf@gmail.com
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_10
75
76 J. Anagnostakos and J. H. Wolf
Fig. 10.1 Trauma extravasation
Inflammatory Bowel Disease
The laparoscopic technique has been well described in diagnosis and treatment of
Crohn’s disease. Crohn’s disease can affect not only the bowel but also the surrounding mesentery. One of the more classic features of Crohn’s disease is
“creeping fat,” which is extension of the mesenteric adipose tissue along the
external circumference of the bowel wall. Some have argued that more complete
mesenteric resections can lead to reduced rates of recurrence in Crohn’s disease, but
this remains to be demonstrated more definitively in randomized prospective data.
Neoplastic Disease
Laparoscopy can also play a critical role in the treatment of abdominal malignancy.
Primary cancers of the abdomen can often metastasize locally to create peritoneal
carcinomatosis in which the cancer can deposit into multiple intraabdominal
structures including the mesentery. This problem may be a relative contraindication
for resection of primary tumors such as in pancreatic adenocarcinoma. Performing a
diagnostic laparoscopy to survey the abdominal cavity, including the mesentery, for
malignant deposits before performing a major elective tumor resection can prevent
10 Diagnosing Mesenteric Diseases: Laparoscopy 77
the patient from undergoing an extensive procedure that would offer them no
benefit. Other indications for laparoscopy in the setting of malignancy incl ude
determining the extent of resection for cytoreductive surgery, restaging after
neoadjuvant/adjuvant chemotherapy, and obtaining biopsies to determine primary
tumor origin (Fig. 10.2).
Neoplasms arising from the mesentery itself are not common. There are a variety
of cellular subtypes that can give rise to primary mese nteric neoplasms, including
peritoneum, adipose tissue, endothelium, neural tissue and inflammatory cells.
Exploratory laparoscopy can aid in diagnosis, excision, enucleation or biopsy as
indicated by tumor type.
Pediatric Applications
Although laparoscopy was first widely accepted for adult surgery, it also has many
applications for pediatric surgery. The technique for troca r placement is like that in
adults, however the size of the ports is usually smaller. Most commonly 4 mm or
5 mm trocars and instruments are used. Less abdominal insufflation pressure is
usually required as well, usually 8–9 mm Hg for pediatrics compared to about
15 mm Hg for adults. Laparoscopy in infants and children has several applications
including the treatment and diagnosis of mesenteric diseases. For example, congenital mesenteric malrotation, a disease process that involves the failure of the
intestines to successfully rotate clockwise during gesta tion around the axis of the
Fig. 10.2 Peritoneal carcinomatosis