Add value to the colonoscopy by MSCT in exploring gross intestine and its vascular supply to plan autoprosthesis for total esophagectomy
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1 Add value to the colonoscopy by MSCT in exploring gross intestine and its vascular supply to plan autoprosthesis for total esophagectomy Poster No.: C-2164 Congress: ECR 2011 Type: Scientific Exhibit Authors: G. GUZZETTA, M. V. Guzzetta, B. Barusco, A. gasparetto, G zanchettin, G. P. Feltrin ; PADOVA/IT, Padova/IT, padova/it Keywords: Transplantation, Grafts, Computer Applications-3D, Colonography CT, CAD, Image manipulation / Reconstruction, CT-Angiography, CT, Vascular, Esophagus, Colon DOI: /ecr2011/C-2164 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 13
2 Purpose In esophagus-colon prosthesis, the distal colon is moving into mediatinum to replace the digestive tube in total esofagectomy. The preoperative study needs to establish study del colon, by colonography MSCT, but above all its arterial supply, by angio-tc to avoid consequences of possible ischemia during and after surgery. Colon interposition is the only possible surgeon technique if the stomach is not suitable. The main indications are: Patients with esophagus and stomach cancer, Esophagus and stomach lesion by caustic substances, Small stomach not easily reaching the neck in hypopharynx & cervical esophagus cancer Relapse (recidiva) in previous gastric prosthesis (gastric pull-up). For surgeon, it is very important to know colonic wall changes but above all they focus on adequate arterial supply of colon to plan autoprosthesis. The choice of colon tract for interposition is the left colon based firstly on the inferior mesenteric artery and in particularly on left colic artery and secondly on the superior mesenteric artery with its medium colic artery and Riolano Arcade. If left colon tract with its left colic artery is not valid for interposition, the surgeon chooses the right colon or the ileocolon. Fig.1 Images for this section: Page 2 of 13
3 Fig. 1: Arterial colon supply network. Page 3 of 13
4 Methods and Materials We studied 16 patients candidates to esophagectomy and following colon interposition.the colon and its arterial supply were analyzed by MSCT colonography and angiography obtained together. Before the exam through a digiunal-stomia, a positive contrast material (Gastrografin, Bracco) was introduced into intestine as fluid tagging necessary for the colon study. After air insufflations into the colon, the imaging study was constituted by two scans, the first in prone position with low dose Protocol and the second in supine one. The supine scan was obtained with contemporaneous infusion of iodine contrastment intravenous with flux 4 ml/sec, delay 10 sec and high dose protocol for angio-tc. The study was performed by 64 MDCT (Siemens Somaton Sensation64). Scanning parameters are: Collimation 0.65 mm; 120 kvp, 50 mas prone scan and 200 mas supine scan, rotation time 330 msec, Pitch 1,5; bolus tracking in descendent aorta above celiac tripod. The image data sets were processed on a separate workstation and analyzed using curved multiplanar MPR 2D and 3D reconstructions included the axial images. (Fig.1, Fig.2, Fig.3). Then we created MIP reconstruction of abdominal arterial network (Fig.4). After the colon study to verify the absence of colonic lesions, the analysis was pointed out on patency and size of superior and inferior mesenteric arteries on Riolano Arcade, as well as of the mesenteri network. Our intent was to opacify better the more distal colon arteries and for this purpose, we administrated splancnic (coronaro) vasodilator drugs as nitrates and hypoton-dilating (hyoscine butylbromide) and glucagon. Images for this section: Page 4 of 13
5 Fig. 1: 3D view gives roadmap of colonic anatomy. Page 5 of 13
6 Fig. 2: Colongraphy CT: 3D reconstruction. Page 6 of 13
7 Fig. 3: Multiplanar MPR 2D reconstruction. Page 7 of 13
8 Fig. 4: MIP reconstruction of abdominal arterial network. Page 8 of 13
9 Results Only 6/16 cases showed colonic lesions such as polyps and diverticola. The dilatation effects of the drugs (increate filling of the mesenteric arteries ) was useful in 4/16 patients (Fig. 1-2) but anyway we are not able to visualize adequately the Riolano Arcade. In the other patients we well visualized superior and inferior mesenteric arteries except for a case (Fig.3), which demonstrated at Angio-CT a poor vascularitation of inferior mesenteric artery, not confirmed at laparotomy. As matter of fact at laparotomy the mesenteric arteries visual inspection and pulse touching establish adequate vascular supply better than Angio-Tc. None of patients had immediate ischemic consequence after surgery dislocation, only one late fistula complicated a regional ischemia post surgery. Otherwise the adequate supply was not established by contrast-enhancement of the colonic wall, but it is due to the thinner layers and to the air artifacts. Images for this section: Page 9 of 13
10 Fig. 1: Composite images of colonic loops and arterial supply. Fig. 2: Composite images of colonic loops and arterial supply. Page 10 of 13
11 Fig. 3: Poor supply through inferior mesenteric artery. Page 11 of 13
12 Conclusion Mesenteric angiography CT together with Colonographt CT study can not allways be sufficient to plan colon surgical interposition, but often other evalutations could be necessary. So in order to increase the usefulness of both exams, is necessary that: 1- to find a more efficient vasodilators on vascular district, by exploring different drugs; 2- a more clear demonstration of arterial supply, near the colonic air artifacts could be useful to plan the operative strategiesis; 3- the total complete colonic study is another important step to program the surgical aim of all transplantation. References Bothereau H, Munoz-Bongrand N, Lambert B, Montemagno S, Cattan P, Sarfati E. Esophageal reconstruction after caustic injury: is there still a place for right coloplasty? Am J Surg 2007 Jun;193(6): Mine S, Udagawa H, Tsutsumi K, Kinoshita Y, Ueno M, Ehara K, Haruta S. Colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer. Ann Thorac Surg Nov;88(5): Chen SC, Lu DSK, Hecht JR et al. (1999) CT colonography: value of scanning in both the supine and prone positions. Am J Roentgenol 172: Laghi A, Passariello R. La colonscopiua virtuale. Springer-Verlag Italia, P. Lefere S. Gryspeerdt. Virtual Colonoscopy: A Practical Guide. Springer-Verlag Berlin Heidelberg Personal Information Page 12 of 13
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