Preface to the Fifth Edition

The preface to the first edition of Dynamic Radiology of the Abdomen: Normal and Pathologic Anatomy stated that this book introduces a systematic application of anatomic and dynamic principles to the practical understanding and diagnosis of intraabdominal diseases. The clinical insights and rational system of diagnostic analysis stimulated by an appreciation of the dynamic intraabdominal relationships outlined in previous editions have been universally adopted. Literally thousands of scientific articles in the literature have attested to their basic precepts. Formulations and analytic approaches introduced in the first edition are now widely applied in clinical medicine so that many of the terminologies, definitions, and concepts of pathogenesis have solidly entered the public domain. These insights lead to the uncovering of clinically deceptive diseases, the evaluation of the effects of disease, the anticipation of complications, and the determination of the appropriate diagnostic and therapeutic approaches. Spanish, Italian, Japanese, and Portuguese editions have encouraged more widespread application of the principles which in turn has led to further contributions to our understanding of the features of spread and localization of intraabdominal diseases. These principles have been applied to the full range of imaging modalities—from plain films and conventional contrast studies to CT, US, MRI and endo-scopic, laparoscopic, and intraoperative ultrasonog-raphy—leading to this fifth edition in 24 years.

In the pursuit of comprehending the pattern, all methods of investigation have been used, including (a) anatomic cross-sectioning of cadavers frozen to maintain relationships; (b) cadaver injections and dissections performed to determine preferential planes of spread along ligaments, mesenteries and extraperitoneal fascial compartments; (c) selected clinical cases with the fullest range of imaging studies including plain films, tomograms, and conventional contrast studies; presacral retroperitoneal pneumography and peritoneography; sinography which occasionally provided serendipitous display of normal and pathologic anatomy akin to an in vivo model; and computed tomography, ultrasonog-raphy, nuclear medicine studies, magnetic resonance imaging, and endoscopic ultrasonography; (d) peritoneoscopy; and (e) surgical operations, surgical pathology and autopsies.

The basic aims in writing this book have not changed from the first edition and it is produced in the same spirit as its predecessors. The quest ofscience has always sought the identification of a pattern of circumstances. With this recognition, there follows insight and understanding into the nature and dynamics of events and thereby their predictability, management, and consequences. This book establishes that the spread and localization of diseases throughout the abdomen and pelvis are not random, irrational occurences but rather are governed by laws of structural and dynamic factors.

To satisfy these aims, special attention has been given to keeping the book current with clinical and technological advances that have so dramatically altered the practice of abdominal imaging in the past several years. Six completely new chapters have been added and virtually all others have been extensively updated and enlarged. This edition is expanded by more than 180 pages and more than 520 new illustrations.

Many of the new chapters are by international authorities who have pioneered advances in the crucial appreciation and precise recognition of a wide spectrum of intraabdominal diseases. An introductory chapter on general considerations underscores the book's continuing thematic approach based upon anatomic relation viii • Preface to the Fifth Edition ships, dynamic factors, and visual perception of the image. This is followed by a chapter on clinical embryology, emphasizing an understanding of disease entities which often are only first clinically apparent in the adult. The manifestations of intraperitoneal air, often subtle on plain films but nevertheless highly significant, are precisely described and illustrated. A new chapter is devoted to oncoradiology and the TNM staging of gastrointestinal cancers, delineating the normal anatomic mural components by sectional imaging and the extent of intramural and regional neoplastic spread. Other chapters deal with the discrete identification of the pathways of lymph node metastases in cancers of the gastrointestinal and hepatobiliary tracts and the pathways of regional spread in pancreatic cancer.

Developments in understanding the intraperitoneal spread of infections include the normal and pathologic anatomy of the lesser sac. Features of the significance of the gastropancreatic plica, the superior and lower recesses of the lesser sac, and the imaging features of the dimensions and relationships of the foramen of Winslow are detailed. The clinical significance of the spread of infection via the perihepatic ligaments is greatly expanded.

Concepts of the pathways of dissemination of malignancies have been highly expanded and richly illustrated with the full range of imaging modalities. Normal and pathologic anatomy are made graphic by spiral CT with planar reconstructions, MR, endoscopic ultrasonog-raphy and laparoscopic ultrasonography. The position and nomenclature of lymph node stations in gastric carcinoma as classified by the Japanese Research Society for Gastric Cancer have been updated and correlation is made with the TNM staging system. Further advances in the understanding of the intraperitoneal spread of malignancies include features of seeded perihepatic and subdiaphragmatic metastases, subcapsular liver metastases, spread to anterior mediastinal lymph nodes, implantation on the falciform ligament and within the inter-hepatic fissures, hepatic invasion by advanced gastric cancer, Sister Mary Joseph's nodule, Krukenberg tumors of the ovaries, the pathogenesis and differential diagnosis of the omental cake and of peritoneal thickening and enhancement in peritoneal carcinomatosis; instrumental, operative and needle track seeding; hematogeous metastases to the small bowel from metastatic melanoma, breast carcinoma and bronchogenic carcinoma. Developments and advances in imaging the spread and localization of intraperitoneal malignancies are discussed and illustrated. The unifying perspective of the subperito-neal space of the abdomen and pelvis, establishing the discrete planes of subserous connective tissue and lymphatics, is extended to the thoraco-abdominal contin uum; this holistic concept provides an explanation for what has long been thought of as illogical circumstances.

Numerous major developments have also refined our precise evaluation of the extraperitoneal fascia and spaces. A new section defines the compartmentalization of the anterior pararenal space, in keeping with progressive application of embryologic/anatomic circumstances to clinical imaging. The section on the extraperitoneal paravesical pelvic spaces and their continuities with the abdominal spaces has been refined and expanded. Fundamental anatomic characteristics of the fascia and spaces are documented and their clinical relevance richly illustrated. These include the potential midline communication of the perirenal spaces, the inferior apex of the cone of renal fascia, the retromesen-teric plane, the attachment of the adrenal gland to the renal fascia superiorly, and the identification of the two lamellae of the posterior renal fascia. Further enlarged are the discussions and illustrations of the lumbar triangle pathway and its relationship to Grey Turner's sign in pancreatitis and retrorenal hemorrhage; and of extension along the perihepatic ligaments and its relationship to Cullen's sign. Occasional instances of splenic trauma leading to clinically masked extraperitoneal bleeding are explained. Staging of renal cell carcinoma is significantly updated, with comparison of Robson's classification and the TNM system and the value of magnetic resonance imaging. Perirenal diseases beyond abscesses and hemorrhage have been expanded to include perirenal metastases, lymphoma, extramedullary hematopoiesis and retroperitoneal fibrosis. The anatomy of the iliopsoas compartment is clarified and the features of psoas abscess are illustrated. Controversies regarding rupture of abdominal aortic aneurysms with extension of hemorrhage to the extraperitoneal spaces are resolved.

Other additions include discussions of renocolic fistulas; the precise anatomy and importance of the ligament of Treitz; characteristic localizing features of scleroderma, carcinoid and Crohn disease of the small bowel; and the CT features and differential diagnosis of internal paraduodenal hernias.

While diagnostic criteria are emphasized throughout the book, there is also discussion of foreseeable complications and appropriate management of many disease processes.

As in previous editions, great care has been taken with the layout to give prominence to selected illustrations and, most importantly, to position the figures as closely as possible to their citation in the text so that the reader's time and effort are not wasted referring to pages some distance apart.

The color atlas details anatomic features of clinical significance.

Preface to the Fifth Edition • ix

The references have been considerably expanded and continue to include both classic articles and recent citations. They are not restricted to the English language and, when pertinent, refer to the original descriptions. A lengthy index with cross-references provides immediate access to the detailed material presented.

Many persons have contributed importantly to the fifth edition and I thank them sincerely. I wish to express my particular appreciation to Angel Arenas, M.D., Hospital Universitario "12 de Octubre," Madrid, Spain; Yong Ho Auh, M.D., Asan Medical Center, Seoul, Korea; Emil Balthazar, M.D., New York University School of Medicine, New York City; James Brink, M.D., Yale University Medical School, New Haven, Connecticut; Gary G. Ghahremani, M.D., Evanston Hospital—Northwestern University, Evanston, Illinois; Jay P. Heiken, M.D., Mallinckrodt Institute of Radiology, St. Louis, Missouri; Dean T. Maglinte, M.D., Methodist Hospital, Indiana-

polis, Indiana; Hiromu Mori, M.D., Oita Medical University, Oita, Japan; Michael Oliphant, M.D., Crouse Hospital, State University of New York, Syracuse, New York; Richard C. Semelka, M.D., University of North Carolina Hospitals, Chapel Hill, North Carolina; Ann Singer, M.D., Cleveland Clinic Foundation, Cleveland, Ohio, and Francis Weill, M.D., University of Besançon School of Medicine, Besançon, France for their contributions. Additionally, I wish to express my gratitude to the contributing authors who have added luster to this edition.

I am distinctly grateful to Michiel A. M. Feldberg, M.D., Ph.D., University Hospital, Utrecht, Netherlands, for his selfless cooperation and the stimulating pleasure of sharing intellectual enthusiasms.

I have submitted this fifth manuscript to SpringerVerlag, confident that their skills have produced another edition of high technical quality.

Morton A. Meyers, M.D. Stony Brook, New York January, 2000

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