Continuation of gas from the right perirenal space into the bare area of the liver

European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma

BACKGROUND

Radical surgery provides the best chance of cure for adrenocortical carcinoma (ACC), but perioperative surgical care for these patients is yet to be standardized.

METHODS

A working group appointed jointly by ENSAT and ESES used Delphi methodology to produce evidence-based recommendations for the perioperative surgical care of patients with ACC. Papers were retrieved from electronic databases. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, and were discussed until consensus was reached within the group.

RESULTS

Twenty-five recommendations for the perioperative surgical care of patients with ACC were formulated. The quality of evidence is low owing to the rarity of the disease and the lack of prospective surgical trials. Multi-institutional prospective cohort studies and prospective RCTs are urgently needed and should be strongly encouraged.

CONCLUSION

The present evidence-based recommendations provide comprehensive advice on the optimal perioperative care for patients undergoing surgery for ACC.

The superior aspect of the perirenal space: could it be depicted by dual-source CT in vivo in adults

OBJECTIVE

This study aims to observe whether the renal fascias could be effectively shown by dual-source CT (DSCT) and to explore the superior communication of the perirenal space (PS) in vivo in adults.

METHODS

275 cases were included in the normal group and 124 cases in the acute pancreatitis group in this study; all images obtained by DSCT were observed; the superior adherence of the renal fascias and the pattern of superior communication of the PS were judged; and the consistency between the two groups was compared.

RESULTS

The superior adherence of the renal fascias was reliably displayed in 57.8% of the normal group and 69.4% of the acute pancreatitis group, the anterior renal fascia (ARF) did not fuse with the posterior renal fascia superiorly. The left ARF fused with the posterior parietal peritoneum in 57.9% of the normal group and 45.3% of the pancreatitis group, where the left PS communicated with the subdiaphragmatic retroperitoneal space (SDRS). The left ARF fused with the peritoneum laterally and simultaneously with the inferior phrenic fascia medially in 42.1% and 54.7% of each group, respectively, where the left PS was open towards the SDRS laterally but sealed off from the SDRS medially. The right ARF fused with the peritoneum in all cases; and the right PS was open towards the bare area of the liver.

CONCLUSION

To some extent, DSCT can display renal fascia and its superior adherence and reflect the superior communication of the PS.

ADVANCES IN KNOWLEDGE

This study was conducted in vivo in adults by high-resolution DSCT, and more samples could be provided.

Surgical anatomy of the posterior liver surface: the retrohepatic lamina as the basis for mobilisation of the right liver

BACKGROUND

During right hepatectomies, dissection of the bare area is performed to obtain mobilisation of the liver. Fifty computed tomography scans of the upper abdomen of patients were examined. Specimens of supramesocolic compartment were sampled from 10 un-embalmed cadavers. Macrosections were cut for histotopographic study. In four cadavers, in situ dissection of the posterior liver surface was performed.

RESULTS

The hepatophrenic tissue showed a stratigraphic organisation resulting from the juxtaposition of thin layer of dense connective tissue corresponding to the inferior diaphragmatic fascia (mean thickness is 30 ± 4 μm); variable amount of fibroadipose tissue corresponding to retroperitoneal fibroadipose tissue (mean thickness is 34 ± 8 μm); two connective layers with nets of flat cells forming a fusion fascia, the retrohepatic lamina (mean thickness 24 ± 6 μm); and layer of connective tissue corresponding to the hepatic capsule. The juxta-caval portion of the retrohepatic lamina, connecting the right and left sides of the caval groove, forms the inferior vena cava ligament. During dissection, fluid injection developed a preferential plane between the two layers of the retrohepatic lamina, close to the hepatic surface, and no major or minor vessels were ever found along this plane.

CONCLUSION

During right hepatectomy, to reduce the risk of dissemination of tumour cells, the dissection plane should be performed between the two layers of the retrohepatic lamina.

Acute conditions affecting the perinephric space: imaging anatomy, pathways of disease spread, and differential diagnosis

The perinephric space is an important, central compartment of the retroperitoneum which may host various acute conditions. Imaging evaluation of the perinephric space requires an understanding of its anatomy and the pathways of disease spread to and from other retroperitoneal compartments. Numerous acute conditions can affect the perinephric space and may occur in isolation, extend from nearby retroperitoneal structures, or be part of a systemic condition. Familiarity with the key imaging findings of acute conditions affecting the perinephric space is imperative to facilitate diagnosis and guide treatment. The purpose of this article is to review and illustrate the relevant anatomy, pathways of disease spread, and acute pathology encountered during cross-sectional imaging evaluation of the perinephric space.

Recommendation for standardized surgical management of primary adrenocortical carcinoma

BACKGROUND

Operative resection is the only potentially curative treatment for primary adrenocortical carcinoma (ACC), but standards of operative care are not defined with regards to the extent of local resection. We propose recommendations for operative management.

METHODS

Anatomic and clinical literature review focusing on local management of ACC, including lymphadenectomy and resection of adjacent organs or large vessels.

RESULTS

First-order drainage nodes of the adrenal gland include the renal hilum lymph nodes, the celiac lymph nodes, and the para-aortic and paracaval lymph nodes, mainly above the renal pedicle and ipsilateral to the adrenal glands. Lymph node involvement occurs in about 20% of patients with ACC, and is an important prognostic factor, but lymphadenectomy is performed infrequently. The adrenal glands and kidneys are contained in the same anatomic space, but systematic en bloc nephrectomy has no proven benefits for survival. Direct invasion of the kidney or adjacent organs is rare, but major venous invasion with tumor thrombus is relatively common. Both are associated with decreased survival, but complete resection can lead to long-term survival.

CONCLUSION

Standardization of regional lymphadenectomy including first-order drainage nodes is proposed. Systematic nephrectomy is not necessary in the absence of gross local invasion, but locally involved organs or large veins should be resected en bloc, with tumor thrombus embolectomy, if R0 resection is possible. Operative standardization improves tumor staging, potentially decreases local recurrence, and may be associated with better survival. Evidence-based standards of operative care and prospective investigations within international collaborating groups are necessary.

Potential extraperitoneal space continuous with the peri-intestinal space: CT evidence and anatomical evaluation in patients with pneumatosis intestinalis without intestinal ischemia

PURPOSE

Extraperitoneal spaces, such as the mesenteric space and the retroperitoneal space, can serve as areas that enable a reduction in the pressure exerted by extraperitoneal fluid collection and infiltrating diseases. In clinical practice, understanding the existence of these decompression spaces (or pathways) is very important for making accurate diagnoses. Here, we evaluated potential anatomical extraperitoneal spaces based on the extraluminal gas distribution in patients with pneumatosis intestinalis without intestinal ischemia.

METHODS

The computed tomography scans of ten patients with pneumatosis intestinalis without intestinal ischemia were reviewed, and the anatomic location of the extraluminal gas distribution was investigated.

RESULTS

Four patients were diagnosed as having pneumatosis intestinalis of the small intestine and six were diagnosed as having pneumatosis intestinalis of the large intestine. Mesenteric pneumatosis was observed in nine (90%) of the ten patients. The potential anatomical extraperitoneal spaces (or decompression pathways) were classified as follows: mesenteric (n = 3), retroperitoneal (n = 4), and direct (n = 5).

CONCLUSIONS

The distributions of the extraluminal gas were classified into three categories, and each location may characterize a different decompression pathway. The existence of a potential extraperitoneal space continuous with the peri-intestinal space was confirmed in living subjects.

Extension of air into the right perirenal space after duodenal perforation: CT findings

PURPOSE

To determine the extraperitoneal distribution of air following perforation of the second portion of the duodenum.

MATERIALS AND METHODS

Institutional review board approval was obtained for this HIPAA-compliant study. The requirement for written informed consent was waived. Two reviewers who were aware of the presence of duodenal perforation after duodenal endoscopy retrospectively reviewed computed tomographic (CT) images in eight patients (one man, seven women; mean age, 68 years; age range, 27-88 years) to assess and categorize the location of extraluminal air.

RESULTS

Extraluminal air was detected in the following locations: right anterior pararenal space (n = 8), right perirenal space (n = 7), right posterior pararenal space (n = 4), right properitoneal compartment (n = 4), bare area of the liver (n = 6), right extraperitoneal pelvis (n = 7), hepatoduodenal ligament (n = 3), mesentery (n = 2), mediastinum (n = 4), portal venous system (n = 1), and peritoneal cavity (n = 1).

CONCLUSION

Air extended posteriorly into the right perirenal space in seven (88%) of eight patients following perforation of the second portion of the duodenum. Duodenal perforation introduces potential for direct communication between the right anterior pararenal space and the right perirenal space.

SUPPLEMENTAL MATERIAL

http://radiology.rsnajnls.org/cgi/content/full/2503080605/DC1.

Sectional Anatomy of the Peritoneal Reflections of the Upper Abdomen in the Coronal Plane

PURPOSE

The purpose of this study was to provide practical anatomic data for the imaging diagnosis and surgical treatment of the diseases of the subphrenic spaces.

METHODS

The sectional anatomy of the subphrenic spaces on the coronal plane was investigated on serial coronal sections of the upper abdomen of 30 Chinese adult cadavers.

RESULTS

The space between the anterior margin of gastropancreatic fold and the posterior layer of hepatogastric ligament is the only direct pathway between the superior and inferior recesses of the lesser sac. That pathway can be divided into 3 types on the coronal plane. The right layer of the gastrophrenic ligament is continuous with the posterior layer of the lesser omentum, and its left layer is continuous with the right layer of the phrenosplenic ligament and the posterior layer of the gastrosplenic ligament. The gastropancreatic fold is continued to the left and right layers of the gastrophrenic ligament upwards. The bare area of the stomach is located between the left and right layers of the gastrophrenic ligament; its existing rate is 100%. The bare area of the spleen is located among the phrenosplenic ligament, gastrosplenic ligament, splenorenal ligament, and splenocolic ligament. Its greatest width exists between the two layers of the splenorenal ligament. It can be divided into the splenic hilus and splenorenal parts.

CONCLUSION

The coronal section is dominant to show the anatomic relationships of the gastrophrenic ligaments and the gastropancreatic folds, and the bare area of the stomach.