Minimally invasive approaches to the management of anastomotic leakage following restorative rectal cancer resection.

AIM: Management of anastomotic leakage (AL) following rectal resection has evolved with increasing use of less invasive techniques. The aim of this study was to review the management of AL following restorative rectal cancer resection in a tertiary referral centre. METHOD: A retrospective review of a prospectively maintained database was performed. The primary outcome was successful management of AL. The secondary outcome was the impact of AL on oncological outcome. RESULTS: Five hundred and two restorative rectal cancer resections were performed during the study period. The incidence of AL was 9.9% (n = 50). AL occurred more commonly following neoadjuvant chemoradiotherapy (n = 31/252, 12.3%) than in those who did not receive neoadjuvant chemoradiotherapy (n = 19/250, 7.6%; P = 0.107); however, this was not statistically significant. Successful minimally invasive drainage was achieved in 28 patients (56%, radiological n = 24, surgical n = 4). Trans-rectal drainage was the most common drainage method (n = 14). The median duration of drainage was longer in the neoadjuvant group (27 vs 18 days). Surgical intervention was required in 11 patients, with anastomotic takedown and end-colostomy formation was most commonly required. Successful management of AL with drainage (maintenance of the anastomosis without the need for further intervention) was achieved in 26 of the 28 patients. There were no significant differences in overall or disease-free survival when patients with AL were compared with patients without AL (69.4% vs 72.6%, P = 0.99 and 78.7% vs 71.3%, P = 0.45, respectively). CONCLUSION: In selected patients, AL following restorative rectal resection can be effectively controlled using minimally invasive radiological or surgical drainage without the need for further intervention.

Ireland's recent contribution to the radiological literature; a bibliometric analysis.

The aim of this study was to identify and analyse all articles published by Irish radiology departments in the medical literature since the year 2000. The PubMed database was searched to identify and review all articles published by radiologists based in the Republic of Ireland or Northern Ireland. Citation counts were then obtained and the top ten most cited articles were identified. There were 781 articles published during the study period. Of these, 558 (71%) were published in radiology journals and the remaining 223 (29%) were published in general medical journals. Abdominal radiology was the most represented sub-specialty (33% of all articles). There was a general trend of increased publications per year. Only 75 (9.6%) of articles were collaborative efforts by more than one radiology department. Irish radiology departments have a considerable research output and this has increased since the year 2000. More collaborative research between Irish radiology departments is encouraged.

Inadvertent subclavian artery cannulation with a central venous catheter; successful retrieval using a minimally invasive technique.

A 48-year-old lady was referred to our department as an emergency following an unsuccessful attempt at central venous catheter insertion, resulting in cannulation of the subclavian artery. She underwent angiography with removal of the catheter and closure of the arteriotomy using an Angio-Seal device. While the optimal management of this scenario has yet to be defined, the use of this minimally invasive technique warrants consideration.

Imaging and video of late preterm delivery by midline laparotomy due to incarcerated uterus: A case report and literature review of a rare but morbid condition.

Incarcerated gravid uterus (IGU) is a rare and serious obstetric complication. IGU is defined as the entrapment of the gravid uterus between the pubic symphysis and the sacral promontory. The incidence of IGU is 1 in 3000-10 000 cases. IGU is associated with significant obstetric complications, including preterm labor, intrauterine fetal death, growth restriction, renal failure, uterine ischemia/rupture and thrombosis. Here, we present the case of a primigravida with urinary retention at 14 weeks. On transabdominal ultrasound at 19+5/7 weeks the cervix was difficult to visualize, and the anterior uterine wall appeared thickened. The bladder was elongated superior to the uterus and the placenta was low-lying. Initially the patient was managed with intermittent self-catheterization, and subsequently indwelling catheterization was required from 22 weeks. At 30 weeks, the patient was transferred to a tertiary center and magnetic resonance imaging (MRI) was preformed due to challenging visualization of the cervix on ultrasound and the patient's continued symptoms of constipation and recurrent urinary infections. The MRI found a retroflexed gravid uterus, with vagina and endocervix displaced anteriorly and compressed by the gravid uterus. The findings were consistent with an incarcerated uterus. The patient subsequently had positive urinary cultures for Pseudomonas and rising creatinine. Given the obstructive uropathy and associated morbidity and mortality, a plan for elective pre-term delivery at 33+6/7 weeks was made. Delivery was by midline laparotomy, normal anatomy was restored after manual evacuation of the fundus from below the sacral promontory, and an uncomplicated lower segment transverse uterine cesarean section was performed.

Clinical and Survival Outcomes Using Percutaneous Cholecystostomy Tube Alone or Subsequent Interval Cholecystectomy to Treat Acute Cholecystitis.

BACKGROUND: Percutaneous cholecystostomy (PCT) is a safe method of gallbladder drainage in the setting of severe or complicated acute cholecystitis (AC), particularly in patients who are high-risk surgical candidates. Small case series suggest that PCT aids resolution of acute cholecystitis in up to 90% of patients. However, reluctance is observed in utilising PCT more frequently, due to concerns that we are committing comorbid patients to an interval surgical procedure for which they may not be suitable. AIM: The aim of this study was to assess the clinical and survival outcomes of PCT use, with particular emphasis on a subgroup of patients who did not proceed to cholecystectomy. METHODS: A retrospective analysis was performed of all patients with severe acute cholecystitis who required PCT insertion in a tertiary referral hospital from 2010 to 2015. Patient demographics and clinical data including systemic inflammatory response (SIRS) scores at presentation, readmissions and clinical and survival outcomes were analysed. Statistical analysis was performed using SPSS v.22 and GraphPad Prism v.7. RESULTS: In total, 157 patients (59% males) with AC underwent PCT insertion during the study period. Median age at presentation was 71 years (range 29-94). A median SIRS score of 3 was noted at presentation. Patients required a median of two cholecystostomy tube changes/replacements (range 1-10) during treatment. Transhepatic tube placement was the preferred approach (69%) with 31% of tubes being placed via transabdominal approach. Only 55% proceeded to interval cholecystectomy. Of the 70 patients treated with PCT alone, their median age was 75 years. In this subgroup, only 12.9% (n = 9) developed recurrent biliary sepsis necessitating readmission following initial resolution of symptoms and tube removal. All episodes of recurrent biliary sepsis presented within 6 months of index presentation, and definitive PCT removal in this group was performed at a median of 3 months. No difference in survival was observed between both groups. CONCLUSION: Almost 90% of patients with AC who are managed definitively with a PCT will recover uneventfully without recurrent sepsis following PCT removal. This is a viable option for older, comorbid patients who are unfit for surgical intervention and is not associated with significantly increased mortality.

Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound.

The authors examined the role of ultrasound (US) in diagnosis and management of heel pain in chronic inflammatory arthritis. Nineteen patients underwent US examination. Eight patients (2 with previously unsuccessful nonguided injections), had 11 US-guided corticosteroid injections for treatment of retrocalcaneal bursitis (n = 6), plantar fasciitis (n = 3), and posterior tibial tenosynovitis (n = 2). US-demonstrated Achilles tendon rupture (n = 2), Achilles tendinitis (n = 8), posterior tibial tenosynovitis (n = 6), peroneus longus tenosynovitis (n = 2), retrocalcaneal bursitis (n = 13), and plantar fasciitis (n = 4). Loss of smooth bone contour (n = 13) correlated with bone erosions on plain radiographs in all but one case. Ten of 11 guided injections resulted in full resolution of heel pain. The diverse causes of heel pain are highlighted, and the ability of US to provide information with management implications is confirmed. US-guided corticosteroid injection is beneficial, especially after failure of nonguided injection.

Evolution of mycotic aortic aneurysm treatment by endovascular repair.

INTRODUCTION: Endovascular intervention for mycotic aortic aneurysms is now an alternative treatment option. CASE REPORT: An 83-year-old male presented with confusion and pyrexia of unknown origin. Acute deterioration and subsequent computed tomography scan of the abdomen revealed a contained rupture of a mycotic aortic aneurysm for which the patient had a successful endovascular repair. CONCLUSION: Endovascular management of aortic mycotic aneurysms provides an alternate and potentially safer method of intervention, particularly in patients deemed unsuitable for open repair.

Treatment of iatrogenic femoral pseudoaneurysms with percutaneous thrombin injection: experience in 54 patients.

PURPOSE: To assess the clinical success of ultrasonography (US)-guided thrombin injection for the treatment of iatrogenic femoral pseudoaneurysms and to identify criteria that may predispose to treatment failure. MATERIALS AND METHODS: Fifty-four iatrogenic femoral pseudoaneurysms were treated with US-guided thrombin injection. Forty-five were classified as simple (single lobe) and nine, as complex (at least two lobes and a single neck to the native vessel). Pseudoaneurysm volume, classification, thrombin dose, anticoagulation therapy status, and sheath size were compared between failed and successful cases. Seven- to 10-day follow-up US and a minimum 4-month clinical follow-up were also performed to evaluate success. RESULTS: Fifty of 54 pseudoaneurysms were successfully treated with topical thrombin without complication and included all 45 simple and five of nine complex pseudoaneurysms. US follow-up in all 50 successful cases and clinical follow-up in 37 of these revealed no recurrence. Only a complex pseudoaneurysm classification was significantly associated with failure (P<.01). Among the complex pseudoaneurysms, successful cases involved two injections and a total thrombin dose of at least 1,500 units. In failed cases, pseudoaneurysms were treated with a single injection of 1,000 units, initially thrombosed, and recurred. CONCLUSION: Simple iatrogenic femoral pseudoaneurysms, regardless of size or concomitant anticoagulation therapy, can be treated with a single injection of up to 1,000 units of topical thrombin and require no follow-up. Complex pseudoaneurysms will likely require a second injection (total thrombin dose of at least 1,500 units) and short-term clinical and US follow-up to ensure successful treatment.

Thrombus on indwelling central venous catheters: the histopathology of "Fibrin sheaths".

PURPOSE: Central venous catheters (CVC) may fail for many reasons, though "fibrin sheaths" blocking catheter ports are usually implicated. We examined the sheaths removed from dialysis catheters to determine their histopathology. METHODS: Ten catheter strippings were performed and the removed material was studied grossly and microscopically. RESULTS: The histologic specimens showed thrombus both with and without a proteinaceous sheath. CONCLUSION: Dialysis catheters fail because of thrombus formation. This can occur in either the absence or presence of a protein coating on the catheter, the so-called "fibrin sheath."

Semiquantitative assessment of uterine perfusion using first pass dynamic contrast-enhanced MR imaging for patients treated with uterine fibroid embolization.

The feasibility of using first pass dynamic contrast-enhanced MRI to monitor semiquantitatively the perfusion changes of the uterus after uterine arterial embolization is demonstrated. Ten women, who underwent uterine arterial embolization for fibroid treatment, were included in this study. To derive a perfusion index, an additional axial slice through the abdominal aorta was obtained simultaneously when acquiring MR perfusion data. This technique may prove valuable in monitoring the outcome of uterine arterial embolization and documentation of preserved uterine perfusion after this procedure. J. Magn. Reson. Imaging 2000;12:1004-1008.

Ocular trauma: evaluation with US.

PURPOSE: To examine the value of real-time ultrasonography (US) in the assessment of traumatized eyes with opaque ocular media. MATERIALS AND METHODS: Sixty-one eyes in 60 patients were prospectively examined with US; findings were correlated with findings of clinical and surgical follow-up. Patients with an intraocular foreign body (IOFB) also underwent computed tomography (CT). RESULTS: US demonstrated 56 vitreous hemorrhages, 21 retinal detachments, 12 vitreous detachments, five choroidal detachments, seven IOFBs, three dislocated lenses, and two retrohyaloid hemorrhages. Findings of US and surgery or clinical follow-up were in complete concurrence in 55 cases (90%) and partial concurrence in two cases (3%). US findings were incorrect in four cases (7%). In four cases, US allowed diagnoses that were unsuspected clinically. CONCLUSION: US accurately demonstrates ocular damage and may reveal unsuspected problems. US was superior to CT in demonstration of intraocular damage associated with IOFBs, although CT was superior in determination of the size and site of the IOFB. The presence of dense vitreous traction bands may indicate impending retinal detachment.

Technical report: ultrasound guidance for injection of soft tissue lesions around the heel in chronic inflammatory arthritis.

We describe the use of ultrasound guidance for local steroid injection of the retrocalcaneal bursa and the tibialis posterior tendon sheath in patients with chronic inflammatory arthropathy. Ultrasound guidance may be the injection technique of choice but is particularly indicated for patients with lesions unresponsive to injections guided by palpation.

Ocular sonography.

High-frequency ocular sonography is the ideal method for imaging the eye and intraocular structures. In the presence of opaque ocular media, a complete view of the fundus may be impossible ophthalmoscopically, and in these cases sonography is invaluable. Although high field strength MR imaging with surface coils provides excellent detail of normal and pathologic ocular structures, major shortcomings are lack of spatial resolution and poor specificity with certain lesions. Sonography is superior to CT or MR imaging in detecting ocular lesions such as small melanomas that are 2 mm or less in thickness. The eye can be examined dynamically during eye movements, which is of value in localizing abnormalities. The sonographic appearance of a variety of ocular pathologic conditions is illustrated in this essay.

MR imaging of tibial plateau fractures.

Magnetic resonance (MR) images of five patients with acute tibial plateau fractures are presented and correlated with both clinical examination and findings at surgical intervention. The role of MR imaging in the evaluation of both osseous and soft tissue deformity in acute trauma, specifically in patients with tibial plateau fractures is discussed. The value of MR imaging as an alternative to computed tomography and arthroscopic evaluation of these patients is emphasized.

Iatrogenic femoral pseudoaneurysms: thrombin injection after failed US-guided compression.

Fifteen iatrogenic femoral pseudoaneurysms failed ultrasonography (US)-guided compression treatments. Despite concomitant antiplatelet or anticoagulation treatment, the 15 pseudoaneurysms were successfully and definitively treated without complication with US-guided thrombin injection. Results in this preliminary study suggest US-guided thrombin injection is a safe, expeditious, low-cost, and comfortable definitive treatment for femoral pseudoaneurysms that has advantages over both US-guided compression and open surgical repair.

Hepatic chemoembolization: effect of intraarterial lidocaine on pain and postprocedure recovery.

PURPOSE: To determine if intraarterial lidocaine reduces pain during and after chemoembolization, and whether it influences postprocedure recovery. METHODS: Two patient cohorts undergoing selective hepatic chemoembolization were compared. Chemoembolization was performed without lidocaine (control group) in 27 patients and intraarterial lidocaine was used (lidocaine group) in 29 similar patients. Objective changes in patient management were assessed. Pain reduction in 31 more procedures with lidocaine (total 60) was assessed and related to tumor type. RESULTS: During chemoembolization, intraarterial lidocaine reduced the need for additional intravenous analgesics from 69% to 19%. After chemoembolization the mean Dilaudid dose in the first 24 hr was reduced from 9.5 mg to 4.15 mg; accordingly, the mean length of hospital stay was reduced from 67.5 to 53.5 hr. During the day of chemoembolization, the mean oral fluid intake increased from 420 ml (control group) to 487 ml (lidocaine group); the percentage of patients taking solid food on the day of chemoembolization increased from 3% to 43%. CONCLUSION: Intraarterial lidocaine during chemoembolization reduces the severity and duration of pain after chemoembolization resulting in faster recovery thus reducing the length of hospitalization.

SCVIR annual meeting film panel session: diagnosis and discussion of case 2: Left hepatic arterioportal fistula.

A 65-year-old man with cryptogenic cirrhosis initially underwent transjugular intrahepatic portosystemic shunt (TIPS) creation for variceal bleeding. For the following 16 months, variceal bleeding and intractable ascites persisted despite TIPS revision with variceal embolization. A surgical distal splenorenal shunt was then created, but, although there was initial improvement, intractable ascites recurred. At presentation at a different hospital, the patient gave a history of dyspnea on exertion and orthopnea. Physical examination demonstrated a distended abdomen, consistent with severe ascites, a large right pleural effusion, and bilateral peripheral edema.

Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms.

OBJECTIVE: To study the effect of accuracy on the clinical outcome of local steroid injections to the shoulder. METHODS: 37 patients with shoulder symptoms of at least two months' duration received local injections of a mixture of triamcinolone and radiographic contrast material using a standardised technique. Radiographs of the joint were taken immediately afterwards. Details of the patients' symptoms (assessed by visual analogue scales) and range of movement at the joint were obtained before and two weeks after the injection. At follow up the patients were also assessed by means of a five point global rating scale of maximum and current benefit. RESULTS: 14 of the 38 procedures (37%) were judged to be accurately placed: four of the 14 attempted subacromial injections (29%) and 10 of the 24 attempted glenohumeral injections (42%). There were significant differences in relation to outcome between the accurately placed and the inaccurately placed groups. CONCLUSIONS: Accuracy of steroid placement by injection in patients with shoulder symptoms may significantly affect the clinical outcome.