Surgical Treatment of Severe Bowel Obstruction as a Rare Complication Following Allogenic Hematopoietic Stem Cell Transplantation

Gastrointestinal graft-versus-host disease (GVHD) and cytomegalovirus (CMV) disease are common complications occurring after allogeneic hematopoietic stem cell transplantation (allo-HSCT), and contribute to a high degree of morbidity and mortality associated with allo-HSCT. Herein, we present a patient with severe intestinal GVHD complicated by recurring CMV enteritis, which overall resulted in severe terminal ileum stenosis. The patient underwent laparoscopic ileocecal resection that significantly reduced symptoms and possibly prevented the development of fulminant ileus. Surgical treatment is rarely used in the treatment of gastrointestinal GVHD; however, the current patient history illustrates that patients with inadequate symptom control and severe inflammatory bowel stenosis can be successfully managed with surgery. We also review published case reports on surgical treatment for severe gastrointestinal GVHD.publishedVersio

Controlled Attenuation Parameter in Healthy Individuals Aged 8–70 Years

Purpose Controlled attenuation parameter (CAP) is a non-invasive method to assess the presence of liver steatosis. It has been evaluated in children and adults, mainly in either the obese or in subjects with suspected liver disease. Our aim was to describe CAP in healthy non-obese subjects without suspected liver steatosis and to suggest cutoff levels for steatosis. Materials and Methods We prospectively recruited 187 individuals aged 8–70 years. All underwent clinical examination, including height and weight measurement. Body mass index (BMI) was calculated and converted into z-scores. To exclude liver pathology, B-mode ultrasound and liver stiffness measurements were performed in all prior to CAP measurement. Blood was drawn for liver biochemistry in adults. Results CAP was associated with BMI z-score across all ages. CAP started to rise alongside BMI z-score already in subjects with a BMI below average. CAP values were higher in adults than in children (p<0.001), and higher in adult males than adult females (p=0.014). CAP did not correlate with age within the adult or pediatric cohorts. CAP was highly correlated with the fatty liver index. 18 and 23% of subjects showed CAP above the suggested cutoff value for children and adults, respectively. Conclusion CAP was correlated with BMI z-score, even in individuals with a below-average BMI . We found CAP above published cutoff values in a substantial proportion of presumably healthy, non-obese children and adults, warranting further research to clarify whether this represents non-obese non-alcoholic fatty liver disease or if reference values need adjustment.publishedVersio

Diagnostic accuracy of transabdominal ultrasound in chronic pancreatitis

The performance of transabdominal ultrasound (US) in chronic pancreatitis (CP) following the advances in US technology made during recent decades has not been explored. Our aim in this prospective study was to evaluate the diagnostic accuracy of modern abdominal US compared with the Mayo score in CP. One hundred thirty-four patients referred for suspected CP were included in the study. Fifty-four patients were assigned the diagnosis CP. After inclusion, transabdominal US was performed. Ductal features (calculi, dilations and caliber variations, side-branch dilations and hyper-echoic duct wall margins) and parenchymal features (calcifications, cysts, hyper-echoic foci, stranding, lobulation and honeycombing) were recorded. Features were counted and scored according to a weighting system defined at the international consensus meeting in Rosemont, Illinois (Rosemont score). Diagnostic performance indices (95% confidence interval) of US were calculated: The unweighted count of features had a sensitivity of 0.69 (0.54–0.80) and specificity of 0.97 (0.90–1). The Rosemont score had a sensitivity of 0.81 (0.69–0.91) and specificity of 0.97 (0.90–1). Exocrine pancreatic failure was most pronounced in Rosemont groups I and II (p < 0.001). We conclude that using both unweighted and weighted scores, the diagnostic accuracy of modern transabdominal US is good. The extent of pancreatic changes detected by the method is correlated with exocrine pancreatic function.publishedVersio

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Long Version) - General Aspects

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.publishersversionPeer reviewe

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Elastography in Non-Hepatic Applications : Update 2018

Funding Information: Odd Helge Gilja: Advisory Board/Consultant fee from: AbbVie, Bracco, GE Healthcare, Samsung, and Takeda Paul S. Sidhu: Speaker honoraria, Bracco, Siemens, Samsung, Hiatchi, GE and Philips Christoph F. Dietrich: Speaker honoraria, Bracco, Hitachi, GE, Mindray, Supersonic, Pentax, Olympus, Fuji, Boston Scientific, AbbVie, Falk Foundation, Novartis, Roche; Advisory, Board Member, Hitachi, Mindray, Siemens; Research grant, GE, Mindray, SuperSonic Vito Cantisani: Speaker honoraria, Canon/Toshiba, Bracco, Samsung Dominique Amy: Speaker honoraria, Hitachi, Supersonic, EpiSonica Marco Brock: Speaker honoraria, Hitachi Fabrizio Calliada: Speaker honoraria, Bracco, Hitachi, Shenshen Mindray Dirk Andre Clevert: Speaker honoraria, Siemens, Samsung, GE, Bracco, Philips; Advisory Board, Siemens, Samsung, Bracco, Philips Jean-Michel Correas: Speaker honoraria, Hitachi-Aloka, Canon/Toshiba, Philips, Supersonic, Bracco, Guerbet; Research collaboration, Bracco Sonocap, Guerbet NsSafe and Secure protocols Mirko D’Onofrio: Speaker honoraria, Siemens, Bracco, Hitachi; Advisory Board Siemens, Bracco Andre Farrokh: Speaker honoraria, Hitachi Pietro Fusaroli: Speaker honoraria, Olympus Roald Flesland Havre: Speaker honoraria, GE Healthcare, Conference participation support from Pharmacosmos, Ultrasound equipment from Samsung Medison André Ignee: Speaker honoraria: Siemens, Canon/Toshiba, Hitachi, Boston Scientific, Bracco, Supersonic, Abbvie Christian Jenssen: Speaker honoraria, Bracco, Hitachi, Canon/Toshiba, Falk Foundation, Covidien; Research grant, Novartis Maija Radzina: Speaker honoraria, Bracco, Canon/Toshiba Luca Sconfienza: Travel grants from Bracco Imaging Italia Srl, Esaote SPA, Abiogen SPA, Fidia Middle East. Speaker honoraria from Fidia Middle East Ioan Sporea: Speaker honoraria, Philips, GE, Canon/Toshiba; Advisory Board Member, Siemens; Congress participation support, Siemens Mickael Tanter: Speaker honoraria, Supersonic; Co Founder and shareholder, Supersonic; Research collaboration, Supersonic Peter Vilmann: Speaker honoraria, Pentax, Norgine; Advisory Board, Boston Scientific; Consultancy MediGlobe The following members declared no conflicts of interest: Adrian Săftoiu, Michael Bachmann Nielsen, Flaviu Bob, Jörg Bojunga, Caroline Ewertsen, Michael Hocke, Andrea Klauser, Christian Kollmann, Kumar V Ramnarine, Carolina Solomon, Daniela Fodor, Horia Ștefănescu Publisher Copyright: © 2019 Georg Thieme Verlag KG Stuttgart New York.This manuscript describes the use of ultrasound elastography, with the exception of liver applications, and represents an update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography.Peer reviewe

Tissue characterisation by ultrasound strain imaging. Methodological aspects and gastroenterological applications

Real-Time Elastography (RTE) is a new imaging modality that monitors tissue strain during applied stress. The aim of this thesis was to validate if RTE was a reliable modality to reflect pathologically induced differences in elasticity or tissue hardness and to interrogate if assessment of elastic changes by RTE could be used as a diagnostic tool in clinical practice. Particularly, we focused on the ability of RTE to differentiate between benign and malignant disease in intestinal and pancreatic lesions. Two validation studies were performed using a tissue-mimicking phantom containing inclusions with different size, depth and defined elastic properties. We evaluated the influence of different parameter settings on image quality, and intra- and interobserver variation was also assessed. Furthermore, we examined the impact of different size and depth of selected calculation areas in strain ratio (SR) measurements. In a sub-study on resected bowel specimens, elastograms were compared with histology in order to verify the ability to differentiate between benign and malignant disease and study mechanisms leading to changes in elastic properties. In a clinical study on focal pancreatic lesions, RTE was performed using endoscopic ultrasonography (EUS). In the evaluation of strain images from human tissue we applied a previously published visual categorical score (VCS), a visual analogue scale (VAS) and SR. The validation studies confirmed RTE’s ability to assess elastic properties in vitro with fair to good inter- and intraobsever agreement. The level of dynamic range influenced image quality but had no impact on SR measurements. On the other hand, we found that the reference areas’ distance from the US transducer but not the size influenced significantly on SR measurements. In resected bowel lesions, no significant strain difference was found between stenotic lesions caused by Crohn’s disease and adenocarcinomas. EUS-based RTE of pancreatic lesions showed significant strain difference between the entities of benign and malignant lesions, but the variation within the entities was substantial

Combined endorectal ultrasonography and strain elastography for the staging of early rectal cancer

Aim: Strain elastography is a novel approach to rectal tumour evaluation. The primary aim of this study was to correlate elastography to pT stages of rectal tumours and to assess the ability of the method to differentiate rectal adenomas (pT0) from early rectal cancer (pT1–2). Secondary aims were to compare elastography with endorectal ultrasonography (ERUS) and to propose a combined strain elastography and ERUS staging algorithm. Method: In all, 120 consecutive patients with a suspected rectal tumour were examined in this staging study. Patients receiving surgery without neoadjuvant radiotherapy were included (n = 59). All patients were examined with ERUS and elastography. Treatment decisions were made by multidisciplinary team (MDT) assessment, without considering the strain elastography examination. Results: Histopathology identified 21 adenomas, 13 pT1, 9 pT2, 15 pT3 and one pT4. Mean elastography strain ratios were predictive of T stage (P = 0.01). Differentiation of adenomas from early rectal cancer (pT1–2) had sensitivity, specificity and accuracy of 0.82, 0.86 and 0.84 for elastography and 0.82, 0.62 and 0.72 for ERUS. A combined staging algorithm was developed to identify tumours eligible for local resection. Based on MDT evaluation 32% of tumours later identified as pT0 or pT1 were treated with total mesorectal excision, even though a local excision might have sufficed. Combined ERUS and elastography evaluation would have significantly reduced this number to 9% (P = 0.008). Conclusion: Elastography may improve the staging of adenomas and early rectal cancer compared with ERUS alone. Combined ERUS and elastography assessment is likely to further improve the selection of patients for local resection

Liver elasticity in healthy individuals by two novel shear-wave elastography systems-Comparison by age, gender, BMI and number of measurements.

OBJECTIVE:Establishing normal liver stiffness (LS) values in healthy livers is a prerequisite to differentiate normal from pathological LS values. Our aim was to define normal LS using two novel elastography methods head-to-head and to assess the number of measurements, variability and reproducibility. MATERIALS AND METHODS:We evaluated shear wave elastography (SWE) methods integrated in Samsung RS80A and GE S8 by obtaining LS measurements (LSM) in 100 healthy subjects (20-70 years). Transient Elastography (TE) was used as reference method. Data were analyzed according to age, sex, BMI and 5 vs. 10 measurements. All subjects underwent B-mode ultrasound examination and lab tests to exclude liver pathology. Interobserver variation was evaluated in a subset (n = 24). RESULTS:Both methods showed excellent feasibility, measuring LS in all subjects. LSM-mean for GE S8 2D-SWE was higher compared to TE (4.5±0.8 kPa vs. 4.2±1.1, p<0.001) and Samsung RS80A (4.1±0.8 kPa, p<0.001). Both methods showed low intra- and interobserver variation. LSM-mean was significantly higher in males than females using 2D-SWE, while a similar trend for Samsung SWE did not reach significance. No method demonstrated statistical significant difference in LSM across age and BMI groups nor between LSM-mean based on 5 vs. 10 measurements. CONCLUSION:LSM was performed with high reproducibility in healthy adult livers. LSM-mean was significantly higher for GE S8 2D-SWE compared to Samsung RS80A and TE in healthy livers. Males had higher LSM than females. No method demonstrated statistical significant difference in LSM-mean across age- and non-obese BMI groups. Our results indicate that five LSM may be sufficient for reliable results