Thyroid Incidentalomas: Incidence and Oncological Implication in Patients with Esophageal Cancer.

INTRODUCTION: Thyroid incidentalomas are often encountered during imaging performed for the workup of esophageal cancer. Their oncological significance is unknown. This study aimed to establish incidence and etiology of thyroid incidentalomas found during the diagnostic workup of esophageal cancer. METHODS: All esophageal cancer patients referred to or diagnosed at the Amsterdam UMC between January 2012 and December 2016 were included. Radiology and multidisciplinary team meeting reports were reviewed for presence of thyroid incidentalomas. When present, the fluorodeoxyglucose-positron emission tomography/computed tomography (18FDG-PET/CT) or CT was reassessed by a radiologist. Primary outcome was the incidence and etiology of thyroid incidentalomas. RESULTS: In total, 1,110 esophageal cancer patients were included. Median age was 66 years, most were male (77.2%) and had an adenocarcinoma (69.4%). For 115 patients (10.4%), a thyroid incidentaloma was reported. Two thyroidal lesions proved malignant. One was an esophageal cancer metastasis (0.9%) and one was a primary thyroid carcinoma (0.9%). Only the primary thyroid carcinoma resulted in treatment alteration. The other malignant thyroid incidentaloma was in the context of disseminated esophageal disease and ineligible for curative treatment. CONCLUSION: In this study, thyroid incidentalomas were only very rarely oncologically significant. Further etiological examination should only be considered in accordance with the TI-RADS classification system and when clinical consequences are to be expected.

Structured CT reporting improves accuracy in diagnosing internal herniation after laparoscopic Roux-en-Y gastric bypass.

OBJECTIVES: To confirm that structured reporting of CT scans using ten signs in clinical practice leads to a better accuracy in diagnosing internal herniation (IH) after gastric bypass surgery, compared with free-text reporting. METHODS: In this prospective study, CT scans between June 1, 2017, and December 1, 2018, were included from a cohort of 2606 patients who had undergone laparoscopic gastric bypass surgery between January 1, 2011, and January 1, 2018. The CT scans were made for a suspicion of IH and structured reports were made using a standardised template with ten signs: (1) swirl sign, (2) small-bowel obstruction, (3) clustered loops, (4) mushroom sign, (5) hurricane eye sign, (6) small bowel behind the superior mesenteric artery, (7) right-sided anastomosis, (8) enlarged nodes, (9) venous congestion, and (10) mesenteric oedema. Furthermore, an overall impression of IH likelihood was given using a 5-point Likert scale. CT scans performed in 2011 until 2017, without structured reporting, were included for comparison. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated using two-way contingency tables; the chi-square test was used for calculating p value. Reoperation and 3-month follow-up were used as reference. RESULTS: A total of 174 CT scans with structured reporting and 289 CT scans without structured reporting were included. Sensitivity was 81.3% (95% CI, 67.7-94.8%) and 79.5% (95% CI, 67.6-91.5%), respectively (p = 0.854); specificity was 95.8% (95% CI, 92.5-99.1%) and 88.6% (95% CI, 84.6-92.6%), respectively (p = 0.016); PPV was 81.3% (95% CI, 67.7-94.8%) and 55.6% (95% CI, 43.3-67.8%), respectively (p = 0.014); NPV was 95.8% (95% CI, 92.5-99.1%) and 96.0% (95% CI, 93.5-98.6%), respectively (p = 0.909); and accuracy was 93.1% (95% CI, 88.0-96.2%) and 87.2% (95% CI, 82.7-90.7%), respectively (p = 0.045). CONCLUSION: Structured reporting for the diagnosis of internal herniation after gastric bypass surgery improves accuracy and can be implemented in clinical practice with good results. KEY POINTS: • Ten signs are used to aid CT diagnosis of internal herniation after gastric bypass surgery. • Structured reporting increases specificity and positive predictive value and thereby prevents unnecessary reoperations in patients without internal herniation. • Structured reporting by means of a standardised template can help less experienced readers.

Diagnosing internal herniation after laparoscopic Roux-en-Y gastric bypass: usefulness of systematically reviewing CT scans using ten signs.

OBJECTIVES: To evaluate if systematically reviewing CT scans using ten signs leads to a better accuracy in diagnosing internal herniation (IH), compared to the original report. Also, the difference in accuracy was analysed between experience levels. METHODS: Patients were retrospectively included if they had undergone laparoscopic gastric bypass surgery between 2011 and 2014, and if additional radiological examination was performed for suspected IH between 2011 and 2016. Out of 1475 patients who had undergone laparoscopic gastric bypass surgery, 183 patients had one or more additional radiological examinations. A total of 245 CT scans were performed. All were reassessed by an abdominal radiologist, a radiology resident and intern. Assessment was done using ten signs from previous literature. Overall suspicion of IH was graded using a 5-point Likert scale. Accuracy was calculated using two-way contingency tables. Interobserver agreement was calculated using Fleiss' kappa. RESULTS: After 70 reoperations an IH was diagnosed in 48.6% (34/70). There was an increase in specificity for diagnosing IH with reoperation as reference from 52.8% (19/36; 95% CI 35.7-69.2%) in the original report to 86.1% (31/36; 95% CI 74.8-97.4%) for the radiologist (p = 0.002), 77.8% (28/36; 95% CI 64.2-91.4%) for the resident (p = 0.026) and 77.8% (28/36; 95% CI 64.2-91.4%) for the intern (p = 0.026). Interobserver agreement was good. CONCLUSIONS: Systematically reviewing CT scans using a list of ten CT signs can improve specificity and thereby reduce unnecessary reoperations, especially in a high pre-test probability population. The tool can be easily taught to less experienced readers. KEY POINTS: • Computed tomography is useful to diagnose internal herniation(IH) after gastric bypass surgery • Ten signs are described to improve CT diagnosis of IH • Systematically reviewing CT scans improves specificity • There is no difference in experience levels when using these ten signs.

Early decreased neutrophil responsiveness is related to late onset sepsis in multitrauma patients: An international cohort study.

BACKGROUND: Severe trauma can lead to the development of infectious complications after several days, such as sepsis. Early identification of patients at risk will aid anticipating these complications. The aim of this study was to test the relation between the acute (<24 hours) inflammatory response after injury measured by neutrophil responsiveness and the late (>5 days) development of septic complications and validate this in different trauma populations. METHODS AND FINDINGS: Two prospective, observational, cohort series in the Netherlands and South Africa, consisting of severely injured trauma patients. Neutrophil responsiveness by fMLF-induced active FcγRII was measured in whole blood flowcytometry, as read out for the systemic immune response within hours after trauma. Sepsis was scored daily. Ten of the 36 included Dutch patients developed septic shock. In patients with septic shock, neutrophils showed a lower expression of fMLF-induced active FcγRII immediately after trauma when compared to patients without septic shock (P = 0.001). In South Africa 11 of 73 included patients developed septic shock. Again neutrophils showed lower expression of fMLF induced active FcγRII (P = 0.001). In the combined cohort, all patients who developed septic shock demonstrated a decreased neutrophil responsiveness. CONCLUSIONS: Low responsiveness of neutrophils for the innate stimulus fMLF immediately after trauma preceded the development of septic shock during admission by almost a week and did not depend on a geographical/racial background, hospital protocols and health care facilities. Decreased neutrophil responsiveness appears to be a prerequisite for septic shock after trauma. This might enable anticipation of this severe complication in trauma patients.

Similar change in platelets and leucocytes 24 h after injury is associated with septic shock a week later.

BACKGROUND: Septic shock is a severe complication in polytrauma patients. Early identification of patients at risk can guide future prevention strategies. Platelets (PLTs) and leucocytes presumably play an important role in the post-injury inflammatory response. The role of early changes in PLT and leucocyte counts was investigated in search for the aetiology of the development of septic complications. METHODS: Polytrauma patients (aged 16-80 years) admitted to the intensive care unit with an expected stay of at least 3 days were included. PLT and leucocyte counts were measured on a daily basis for 14 days. RESULTS: A total of 41 patients were included, of whom nine (22%) developed septic shock. There was no difference in (New) Injury Severity Score or Acute Physiology and Chronic Health Evaluation II scores between patients who developed septic shock and patients who did not. Three patients died, one of them in septic shock. Patients who developed septic shock during hospital stay had lower PLTs and a slower recovery to normal PLT counts than patients without septic shock. Patients who developed either a decrease in both PLTs and leucocytes or an increase in PLTs and leucocytes in the first 24 h after trauma were more likely to develop septic shock. This correlation was not found in patients who did not develop septic shock. CONCLUSION: A similar change in PLT and leucocyte counts in the first 24 h after trauma is associated with the development of septic shock after a week. This indicates an early interaction between PLTs and leucocytes, which needs further investigation to gain more insight in the aetiology of post-injury septic complications.