3D CAT Scan and Gastric Volumetry in the Planning of Revisional Bariatric Surgery.

Background: The planning of revisional bariatric surgery is a complex process. The availability of accurate anatomical information is especially important for the planning of such challenging surgical procedures, we present our initial experience using three-dimensional-computed tomography (3D-CT) images to preoperatively assess the anatomy of patients before bariatric revisional surgery. Methods: We used 3D reconstructed images of CT scans to assess the anatomy and plan revisional surgery in 144 patients 98 of them had a previous sleeve gastrectomy 41 had a previous gastric by-pass and 4 Vertical banded gastroplasties. An effervescent preparation was used to distend the stomach and the proximal bowel allowing volume estimation. Results: Eleven sleeve patients underwent a re-sleeve gastrectomy and 44 were revised to a "Roux-en-Y" gastric bypass (RYGBP). Forty-two patients with a previous gastric by-pass were revised due to weight regain or other issues and 4 patients with previous vertical banded gastroplasty (VBGP) were revised to RYGBP. 3D-CT scans provided valuable information for the planning of all revisional procedures by offering accurate information about the existing anatomy and measures of the volume of the gastric pouch, the size of the gastro-jejunal anastomosis in gastric by-pass cases, or the volume and shape of the gastric tube in gastric sleeve cases. Conclusion: 3D-CT is a fast, widely available, reliable, and accurate tool to assess the anatomy after bariatric procedures. This noninvasive method can be particularly useful for the evaluation of postbariatric patients with failures, suboptimal results, and complications, and for the planning of revisional surgery.

Thyroid Fine Needle Aspiration: Successful Prospective Implementation of Strategies to Eliminate Unnecessary Biopsy in the Veteran Population.

OBJECTIVE: Thyroid nodules are prevalent in over half the general population. Several multidisciplinary societies have management recommendations. However, the majority of data to support these guidelines are derived from studies of predominantly younger and female populations. This study's aim was to evaluate characteristics of thyroid nodules in a largely older and male Veteran population and apply these findings prospectively to reduce unnecessary thyroid fine needle aspiration (FNA). MATERIALS AND METHODS: Over a 4-year period, all ultrasound-guided FNA of thyroid nodules performed in our department were reviewed. Sonographic features, patterns, and histopathology were evaluated. A prospective strategy of avoiding FNA in all lesions matching imaging patterns of benignity was implemented and positive predictive value (PPV) of malignancy was calculated and compared to the retrospective data. RESULTS: Retrospectively, FNA was performed on 351 successive thyroid nodules, 9 of which were malignant. Statistically significant malignant features include presence of microcalcifications, irregular or amorphous morphology, taller-than-wide shape, spiculated margins, vascularity, and lymphadenopathy. PPV of thyroid FNA was 2.6% in this period. Four sonographic patterns were 100% specific for benignity, including: "spongiform," "cyst with a colloid clot," "giraffe," and "white knight" patterns. Over 23 months, prospective avoidance of FNA of lesions characterized as a benign pattern (159 nodules) was implemented and PPV was calculated as 7.2% resulting in a cost savings of $477,000. CONCLUSION: Four sonographic patterns were 100% specific for benignity in the older and predominantly male Veteran population. Strict prospective application of avoiding biopsy in these benign patterns resulted in a decrease of unnecessary biopsies, decrease in patient morbidity, and improved allocation of health care resources.

Unruptured intracranial aneurysms conservatively followed with serial CT angiography: could morphology and growth predict rupture?

BACKGROUND AND PURPOSE: Despite several landmark studies, the natural history of unruptured intracranial aneurysms (UIA) remains uncertain. Our aim was to identify or confirm factors predictive of rupture of UIA being observed conservatively with serial CT angiography (CTA) in a North American patient population. METHODS: We performed a retrospective review of patients with UIA being followed with serial CTA studies from 1999 to 2010. The following features for each aneurysm were cataloged from the official radiologic reports and CTA images: maximum diameter, growth between follow-up studies, location, multiplicity, wall calcification, intraluminal thrombus and morphology. Univariate logistic regression analysis of the potential independent risk factors for aneurysm rupture was performed. Statistically significant risk factors from the univariate analysis were then entered into a multivariate logistic regression analysis. RESULTS: 152 patients with a total of 180 UIA had at least two CTA studies. Six aneurysms in six different patients ruptured during the CTA follow-up period for an overall rupture rate of 3.3% and an annual rupture rate of 0.97%. All ruptured aneurysms were ≥9 mm. In the univariate analysis, the statistically significant predictors of aneurysm rupture were aneurysm size (p=0.003), aneurysm growth (p<0.0001) and aneurysm multilobulation (p=0.001). The risk factors that remained significant following the multivariate analysis were growth (OR 55.9; 95% CI 4.47 to 700.08; p=0.002) and multilobulation (OR 17.4; 95% CI 1.52 to 198.4; p=0.022). CONCLUSIONS: Aneurysm morphology and interval growth are characteristics predictive of a higher risk of subsequent rupture during conservative CTA follow-up.