Background: Lymphatic leaks are well-known complications of major thoracic or abdominal surgeries, which significantly heighten morbidity and mortality rates. While the existing literature provides insights into managing these post-operative leaks, with a step-up approach from conservative measures (CMs) to surgical intervention, there are no standardized treatment guidelines. The purpose of this paper is to offer a management algorithm of post-operative lymphatic leaks based on a systematic literature review (SLR) of the therapeutic effect of Lipiodol lymphangiography (LL), completed by a case series of five patients who underwent LL in our department. Methods: In this IRB-approved study, we conducted an SLR following the PRISMA guidelines, using a PICOS. A quality assessment was performed for each study. The case series consisted of consecutive patients who underwent LL for diagnostic and therapeutic purposes at our institution between September 2018 and December 2020. Results: A total of 39 observational studies were included in the SLR comprising 11 retrospective case reviews (Group 1), and 3 case series as well as 25 case reports (Group 2). In total, these studies report cases of 557 patients (51.52% presenting oncological diagnoses; 43.98% having benefited from lymphadenectomy). Lymphatic or chylous fistulas were the most encountered complication, followed by chylothorax. The median volume of Lipiodol injected during lymphography was 11.7 mL (range: 9.8–75 mL). Overall, LL was technically successful in 77.7% (366/471) of patients. The clinical success of all technically successful LLs was 80.6% (295/366). Time-to-leak resolution after lymphography varied between 1 and 31 days. The factors associated with treatment failure were a high leak output (>500 mL/day) and Lipiodol extravasation on post-LL imaging. Our case series consisted of five patients (mean age: 62 ± 9.24 years; 20% female; 100% oncological diagnoses; 60% having beneficiated from lymphadenectomy). Technical and clinical successes were 80% (4/5) and 75% (3/4), respectively. Time-to-leak resolution varied between 1 and 4 days. The volume and technique of LL was not different from that identified in the SLR. Conclusions: LL is a safe procedure with high technical and clinical success rates that could be proposed as both a diagnostic and therapeutic solution for patients with post-operative central lymphatic lesions.

Approximately 7% of patients with rectal cancer experience local recurrence within 5 years of curative surgery. A positive circumferential resection margin (CRM) is among the most significant risk factors. Other reported risk factors include histopathologic type, anastomotic leakage, positive distal margins, and more recently, the anterior localization of the tumor. In this retrospective cohort study, we aimed to assess risk factors for local recurrence in our institution, with a focus on tumor localization as an independent negative predictive factor. From 2007 to 2018, all patients with stage II or III rectal cancer were included in this study. Patients underwent neoadjuvant chemoradiotherapy followed by surgical resection with total mesorectal excision. The tumor's anterior or posterior localization was assessed by preoperative endosonography or magnetic resonance imaging. Risk factors for local recurrence were assessed using univariate and multivariate regression analyses. A total of 128 patients were included. The 3-year and 5-year local recurrence rates were 4.7% and 7%, respectively. In univariate and multivariate analyses, the histologic type of a poorly differentiated tumor (P=0.001) and a positive CRM (P=0.001) were correlated with local recurrence. Tumor localization (anterior or posterior) was not identified as a statistically significant factor associated with local recurrence. Positive CRM and a poorly differentiated tumor histological subtype were found to be independent risk factors for local recurrence. In contrast to previous findings, anterior localization was not identified as an independent risk factor for local recurrence in our patient cohort.

To evaluate the diagnostic performance of iodine density map (IDM) using dual-energy CT (DECT) in differentiating colorectal cancer from benign colorectal wall thickening. This IRB-approved dual-center retrospective exploratory study included 71 consecutive patients with colorectal wall thickening due to tumoral or non-tumoral origin, confirmed by colonoscopy and assessed with DECT. Thirty-eight had pathology-proven colorectal adenocarcinoma, and 33 had non-neoplastic thickening (inflammation, physiologic collapse, or post-radiotherapy change). Iodine density values were measured from regions of interest on three consecutive CT slices on portal venous phase, normalized to aortic iodine concentration. Diagnostic performance was determined by ROC analysis, and inter-reader agreement was evaluated with intraclass correlation coefficients (ICC) and limits of agreement (LOA). Mean IDM value was significantly higher in tumors than in benign thickening (2.31 ± 0.42 vs 1.43 ± 0.24 mg/mL; p < 0.001). Mean normalized iodine density map (NIDM) value was likewise elevated in tumors (0.46 ± 0.10 vs 0.31 ± 0.07; p < 0.001). ROC analysis demonstrated excellent performance for both IDM (AUC 0.98; optimal cutoff 1.72 mg/mL; sensitivity 92.1%, specificity 90.9%, NPV 90.9%) and NIDM (AUC 0.88; cutoff 0.35; sensitivity 92.1%, specificity 69.7%, NPV 88.7%). There was no significant difference between the inflammatory and collapsed-wall subgroups. Inter-reader agreement was excellent (ICC: 0.93 for IDM; 0.92 for NIDM). IDM and NIDM on DECT provide robust, reproducible markers that differentiate colorectal carcinoma from benign wall thickening with high diagnostic accuracy. These quantitative parameters may improve diagnostic confidence and reduce unnecessary colonoscopies, supporting their integration into colorectal cancer evaluation.

We describe a case of an uncommon early pancreatic cancer presentation in a patient in his 60s who had haemorrhagic shock from extensive haematochezia and required blood transfusions as well as surveillance in an intensive care unit. A splenic artery pseudoaneurysm that had been effectively embolized by angiography was seen to be actively bleeding into the colon lumen on a computerized tomography (CT) scan along with a necrotic mass of the pancreatic tail. A pancreatic mucinous adenocarcinoma was diagnosed by a transgastric biopsy. A pancreatico-colic fistula was discovered by CT scan after a colic contrast enema. A transabdominal drainage of the necrotic collection and targeted antibiotic treatment had been performed with a satisfying patient outcome. In order to assess a potential secondary surgical resection, systemic chemotherapy was planned. In conclusion, haematochezia with hemodynamic instability originated from a splenic artery pseudoaneurysm fistulising into the colon (arterio-colic fistula) and sepsis originating from a tumoral pancreatic abscess fistulising into the colon (tumoral pancreatico-colic fistula).

Introduction: Spontaneous mesenteric hemorrhage (SMH) is a rare and potentially life-threatening cause of acute abdominal pain. It is defined as bleeding into the mesentery in the absence of trauma or iatrogenic injury. Diagnosis is challenging due to nonspecific clinical presentation and imaging findings that may mimic bowel ischemia or neoplasia. Case presentation: A 45-year-old man, known for heavy smoking and untreated hypertension, presented with acute diffuse abdominal pain following a forceful sneezing episode. Physical examination revealed localized peritoneal signs. Contrast-enhanced CT demonstrated a mesenteric hemorrhage associated with moderate hemoperitoneum and focal mural hypoenhancement of an ileal loop, without active arterial extravasation. Urgent surgical exploration revealed approximately 500 mL of hemoperitoneum, a large mesenteric hematoma, and an adjacent intestinal pseudodiverticulum. Segmental small bowel resection, including the diverticulum, was performed. Histopathological analysis confirmed fresh mesenteric hemorrhage and pseudodiverticular changes without evidence of malignancy, vasculitis, or vascular malformation. The immediate postoperative course was uneventful; nevertheless, the patient developed a symptomatic incisional hernia. Discussion: SMH is a rare cause of acute abdomen that may occur in otherwise healthy individuals. In this case, the condition was observed in temporal association with a forceful sneezing episode. The presence of an adjacent intestinal pseudodiverticulum and patient-specific vascular risk factors, including hypertension and heavy smoking, may have contributed to local vascular fragility and bleeding. However, a clear causal relationship cannot be established. Awareness of this rare entity may facilitate timely diagnosis and appropriate management. Conclusions: This case highlights a rare presentation of SMH, with multiple potential contributing factors.