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.

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.

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.

Impact of graft material configuration on stent-graft endoleak in vitro.

PURPOSE: To assess the effect of different attachment patterns between graft materials and stents on type I endoleak. MATERIALS AND METHODS: Nitinol stents were covered with a coating of Tegaderm in either a straight-edged pattern across the stent cells or a contoured zigzag pattern conforming to the stent skeleton's honeycomb-shaped cells. The stent-grafts were deployed in an ex vivo circuit across a gap of tubing to simulate an aneurysm cavity. Fluid leaking from the gap for more than 30 minutes was recorded as endoleak. Two contoured attachment patterns (short and long necks) and four straight-edged patterns with necks of varying length were tested. Each experiment was repeated 15 times. RESULTS: The length of the aneurysm neck covered by the graft material was inversely related to the rate of endoleak. The zigzag pattern of graft attachment demonstrated significantly less endoleak than the straight-edged pattern in the setting of a short aneurysm neck (0.25 mL vs 47.3 mL). CONCLUSION: Adopting the contoured (zigzag) attachment of graft material to stents minimizes endoleak in vitro, particularly in the setting of a short aneurysm neck.

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.

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.

Classifying complications of interventional procedures: a survey of practicing radiologists.

PURPOSE: To determine the variability of radiologists' classification of complications from interventional procedures. MATERIALS AND METHODS: Fifteen test cases were selected from a database of morbidity and mortality cases that occurred in our department during the past 2 years. Ten cases were selected randomly, and five were chosen because of classification difficulties within our department. A survey with the case descriptions was presented to 145 SCVIR members via the World Wide Web and 48 were distributed to participants at a statewide angiography club meeting. Participants were asked to complete a short assessment of the their clinical background and to classify each case as "no complication," "minor complication," or "major complication." RESULTS: Thirty-eight percent (74 of 193) of the surveys were completed. Seventy percent (52 of 74) of the respondents were affiliated with an academic program, 12% (nine of 74) were affiliated with private practice groups, and 18% (13 of 74) claimed both academic and private affiliation. The consensus rate in classifying the complications for the randomly selected cases varied from 50% to 95%, with a median of 69%, and the consensus rate in classifying the selected cases varied from 46% to 95%, with a median of 85%. The lowest consensus rates occurred when (i) a significant procedural event was followed by a normal outcome, (ii) when a procedure was aborted, and (iii) when a significant event occurred but did not prolong hospital stay. CONCLUSION: Current criteria for reporting complications are associated with moderate rates of disagreement among interventional radiologists.

Spontaneous dissection of the superior mesenteric artery.

Spontaneous dissection of the superior mesenteric artery (SMA) is a rare occurrence, especially when not associated with aortic dissection [1]. Currently, only 28 cases appear to have been reported. Due to the scarcity of cases in the literature, the natural history of isolated, spontaneous SMA dissection is unclear. CT has been reported to be useful for the initial diagnosis of SMA dissection [2-5]. We present two recent cases of spontaneous SMA dissection in which enhanced spiral CT was instrumental in following the disease process and guiding clinical decision making.

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.

Cost-effectiveness of hepatic arterial chemoembolization for colorectal liver metastases refractory to systemic chemotherapy.

PURPOSE: To calculate the cost-effectiveness of hepatic arterial chemoembolization (HACE) for the treatment of colorectal liver metastases (CLM) over a range of survival benefits and to determine the survival benefit that HACE must confer to meet three thresholds of cost-effectiveness. MATERIALS AND METHODS: A spreadsheet model was used to estimate the marginal direct cost of HACE compared with palliative care from a payer's perspective. Medicare reimbursement amounts represented costs, while probabilities of reembolization and complications were obtained from records of patients who underwent HACE. Marginal cost-effectiveness was calculated from marginal direct cost by varying the survival benefit of HACE compared with palliative care from 0 to 24 months. Break-even analyses were conducted to determine the survival benefit at which the cost-effectiveness of HACE would decrease below three threshold values derived from a literature review. RESULTS: The marginal cost-effectiveness of HACE compared with palliative care, given survival benefits of 3, 6, and 12 months, was $82,385, $41,193, and $21,045 per life-year (LY) gained, respectively. Cost-effectiveness thresholds of $20,000 (strict), $50,000 (moderate), and $100,000 (generous) per LY gained required survival benefits of 12.63, 4.94, and 2.47 months, respectively, more than the expected baseline. CONCLUSION: The cost-effectiveness of HACE for the treatment of CLM varies considerably according to the anticipated survival benefit. Results of future randomized controlled trials must demonstrate a survival benefit of nearly 5 months for HACE to meet the moderate cost-effectiveness standard of $50,000 per LY gained.

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."