Sarcopenia and body fat change as risk factors for radiologic incisional hernia following robotic nephrectomy.

OBJECTIVE: To assess the effect of body muscle and fat metrics on the development of radiologic incisional hernia (IH) following robotic nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent robotic nephrectomy for kidney tumors between 2011 and 2017. All pre- and postoperative CTs were re-reviewed by experienced radiologists for detection of radiologic IH and calculation of the following metrics using Synapse 3D software: cross-sectional psoas muscle mass at the level of L3 and L4 as well as subcutaneous and visceral fat areas. Sarcopenia was defined as psoas muscle index below the lowest quartile. Cox proportional hazard model was constructed to examine the association between muscle and fat metrics and the risk of developing radiologic IH. RESULTS: A total of 236 patients with a median (IQR) age of 64 (54-70) years were included in this study. In a median (IQR) follow-up of 23 (14-38) months, 62 (26%) patients developed radiologic IH. On Cox proportional hazard model, we were unable to detect an association between sarcopenia and risk of IH development. In terms of subcutaneous fat change from pre-op, both lower and higher values were associated with IH development (HR (95% CI) 2.1 (1.2-3.4), p = 0.01 and 2.4 (1.4-4.1), p < 0.01 for < Q1 and ≥ Q3, respectively). Similar trend was found for visceral fat area changes from pre-op with a HR of 2.8 for < Q1 and 1.8 for ≥ Q3. CONCLUSION: Both excessive body fat gain and loss are associated with development of radiologic IH in patients undergoing robotic nephrectomy.

Predicting Perceived Reporting Complexity of Abdominopelvic Computed Tomography With Deep Learning.

OBJECTIVE: The purpose of this pilot study was to examine human and automated estimates of reporting complexity for computed tomography (CT) studies of the abdomen and pelvis. METHODS: A total of 1019 CT studies were reviewed and categorized into 3 complexity categories by 3 abdominal radiologists, and the majority classification was used as ground truth. Studies were randomized into a training set of 498 studies and a test set of 521 studies. A 2-stage neural network model was trained on the training set; the first-stage image-level classifier produces image embeddings that are used in the second-stage sequential model to provide a study-level prediction. RESULTS: All 3 human reviewers agreed on ratings for 470 of the 1019 studies (46%); at least 2 of the 3 reviewers agreed on ratings for 1010 studies (99%). After training, the neural network model predicted complexity labels that agreed with the radiologist consensus rating on 55% of the studies; 90% of the incorrect predicted categories were errors where the predicted category differed from the consensus rating by one level of complexity. CONCLUSIONS: There is moderate interrater agreement in radiologist-perceived reporting complexity for CT studies of the abdomen and pelvis. Automated prediction of reporting complexity in radiology studies may be a useful adjunct to radiology practice analytics.

PET/CT Ultrasound Fusion for Percutaneous Biopsy: A Retrospective Single-Center Study and Review of the Literature.

PURPOSE: The aim of this study was to assess the diagnostic yield and complication rate of 18 F-FDG PET/CT ultrasound (US) fusion for percutaneous biopsy of FDG-avid lesions among patients with known or suspected malignancy. PATIENTS AND METHODS: We describe the clinical, imaging, and histopathologic features of 36 patients who underwent percutaneous biopsy using real-time PET/CT US fusion. In addition, we review the literature on PET/CT US fusion. Using Medline, the following MeSH terms were searched and relevant citations assessed: "fusion imaging," "PET/CT fusion," "PET/CT-guided biopsy," "PET/US fusion," "ultrasound fusion," and "ultrasound fusion-guided biopsy." RESULTS: A total of 36 patients (15 men, 21 women) with known or suspected malignancy and prior PET/CT imaging underwent percutaneous biopsy of FDG-avid lesions using PET/CT US fusion between October 2014 and July 2020. Coregistration was achieved using General Electric LOGIQ E9 software. Adequate tissue for analysis was obtained in all 36 patients. Histologic evaluation revealed malignancy in 14 patients (38.9%) and nonneoplastic tissue in 22 patients (61.1%). No intraprocedural or postprocedural complications were recorded. CONCLUSIONS: Fusion of PET/CT and US for percutaneous biopsy of FDG-avid lesions can be used to achieve excellent diagnostic yield with a low risk of complications.

Risk factors and natural history of parastomal hernia after radical cystectomy and ileal conduit.

OBJECTIVE: To investigate the incidence, risk factors and natural history of parastomal hernia (PSH). MATERIALS AND METHODS: We reviewed the records of patients who underwent radical cystectomy (RC) and ileal conduit (IC) procedure between 2007 and 2020. Patients who had available follow-up computed tomography (CT) imaging were included in this study. All CT scans were re-reviewed for detection of PSH according to Moreno-Matias classification. Patients who developed hernia were followed up and classified into stable or progressive (defined as radiological upgrading and/or need for surgical intervention) groups. Multivariable Cox regression was performed to identify independent predictors of hernia development and progression. RESULTS: A total of 361 patients were included in this study. The incidence of radiological PSH was 30%, graded as I (56.5%), II (12%) and III (31.5%). The median (interquartile range [IQR]) time to radiological hernia was 8 (5-15) months. During the median (IQR) follow-up of 27 (13-47) months in 108 patients with a hernia, 26% patients progressed. The median (IQR) time to progression was 12 (6-21) months. On multivariable analysis, female gender (hazard ratio [HR] 1.86), diabetes (HR 1.81), chronic obstructive pulmonary disease (COPD; HR 1.78) and higher body mass index (BMI; HR 1.07 for each unit) were independent predictors for radiological PSH development. No significant factor was found to be associated with hernia progression. CONCLUSION: Radiological PSH after RC and IC occurred in 30% of patients, a quarter of whom progressed in a median time of 12 months. Female gender, diabetes, COPD and high BMI were independent predictors for radiological hernia development.

Primary hepatic carcinoma with inhibin positivity in a young male patient: a rare tumor previously only reported in females-case report and review of literature.

Primary hepatic carcinoma with inhibin positivity is a rare aggressive liver tumor with seven cases described. The tumor presents at a younger age than primary hepatic carcinoma with all cases being females. RNA albumin ISH positivity suggests the tumor to be a primary hepatic carcinoma. The tumor is different from hepatocellular carcinoma as well as intrahepatic cholangiocarcinoma because of its distinct morphology, lack of hepatocellular differentiation, strong inhibin staining, and lack of typical mutations. A 26-year-old male presented with a 20-cm liver mass. The tumor progressed on therapy with development of multiple lung metastasis. Currently, the patient is enrolled in phase II clinical trial utilizing nivolumab and ipilumumab. While the tumor has a female preponderance, it is not exclusively found in females. Additional studies are necessary to determine the cause of inhibin staining, driving molecular alterations, natural history of this rare tumor, and to come up with consensus nomenclature.

Feasibility of Serial Ultrasound Measurements of the Rectus Femoris Muscle Area to Assess Muscle Loss in Patients Awaiting Liver Transplantation in the Intensive Care Unit.

End-stage liver disease (ESLD) patients requiring intensive care unit (ICU) care before liver transplantation (LT) often experience significant muscle mass loss, which has been associated with mortality. In this exploratory study, we primarily aimed to assess the feasibility of serial ultrasound (US) rectus femoris muscle area (RFMA) measurements for the evaluation of progressive muscle loss in ICU-bound potential LT candidates and describe the rate of muscle loss as assessed by sequential US RFMA measurements. Secondarily, we sought to identify patient characteristics associated with muscle loss and determine how muscle loss is associated with survival. METHODS: We prospectively enrolled 50 ESLD adults (≥18 y old) undergoing evaluation for LT candidacy in the ICU. A baseline computed tomography measurement of psoas muscle area (PMA) and serial bedside US measurements of RFMA were obtained. The associations between patient characteristics, PMA, RFMA, ICU stay, and survival were analyzed. RESULTS: Rapid decline in muscle mass by RFMA measurements was ubiquitously present and correlated to baseline PMA and length of ICU stay. RFMA normalized by body surface area decreased by 0.013 cm2/m2 (95% confidence interval, 0.010-0.016; P < 0.001) for each day in the ICU. Decreased RFMA normalized by body surface area was associated with poor overall survival (adjusted hazard ratio, 0.42; 95% confidence interval, 0.18-0.99; P = 0.047). CONCLUSIONS: In this exploratory, prospective study, serial US RFMA measurements in ESLD patients in the ICU are feasible, demonstrate progressive time-dependent muscle loss, and are associated with mortality. Further large-scale assessment of this modality compared with static PMA or performance-based dynamic assessments should be performed.

Congenital bladder exstrophy with uterine didelphys and prolapse of both uterine horns: a case report.

Congenital pelvic anomalies include disorders of both the urinary and reproductive tracts. These disorders often coexist due to the overlapping embryological development of both systems. Magnetic resonance imaging (MRI) is a useful tool for characterization of the reproductive tract and can play an important role in the preoperative evaluation of patients with known bladder exstrophy. Accurate delineation of reproductive tract anomalies is critical as it can influence the surgical approach and can have implications for fertility. Here, we present a case of a 50-year-old female with uterine didelphys and congenital bladder exstrophy, which is an uncommon association. Our case is unique as the MR appearance of bladder exstrophy with concurrent uterine didelphys has not been reported. Additionally, this represents the first reported example of congenital herniation of both horns of the didelphys uterus through the mons pubis in the setting of bladder exstrophy.

Natural History of Radiologic Incisional Hernia Following Robotic Nephrectomy.

Objective: To evaluate the incidence and natural history of radiologic incisional hernia (IH) in patients who underwent robotic partial or radical nephrectomy. Materials and Methods: We retrospectively reviewed the records of patients who underwent robotic partial or radical nephrectomy for kidney tumor in our institution between January 2011 and April 2017. All pre- and postoperative imagings were re-reviewed for detection of IH per Tonouchi classification. Patients who developed hernia were followed up and classified into stable or progressive group. Clinical findings and radiologic features of these patients are reported. Results: A total of 247 patients (169 partial and 78 radical nephrectomies) were included in the study. The incidence of radiologic IH was 27.53%, graded as early-onset (35.3%), late-onset (51.5%), and bowel/fat containing (13.2%). Median time to radiologic IH was 1.7 years. During the follow-up of 68 patients who developed hernia, 33 (48.5%) had progressive and 8 (11.7%) developed clinical hernia. Median time to progression was 1.5 years. On multivariable analysis, adjuvant therapy was an independent predictor for radiologic hernia development (HR 3.23). Pathologic T stage ≥2 and history of open abdominal surgery were also significantly associated with hernia progression (HR 3.93 and 3.47, respectively). Conclusions: Radiologic IH after robotic partial or radical nephrectomy is common. Progression rate is as high as 50% with median time to progression of 1.5 years. Adjuvant therapy is an independent predictor for IH development, whereas higher stage and history of open abdominal surgery are associated with IH progression.

Contrast-Enhanced Ultrasound Appearance of Hypervirulent Klebsiella pneumoniae Liver Abscesses.

There has been a paradigm shift with Klebsiella pneumoniae (KP) emerging as the most frequently isolated bacterium in pyogenic liver abscesses in immunocompetent patients. Colonization of this hypervirulent KP strain has led to community-acquired liver abscesses. Septic seeding to distant sites of the body has been recognized and is strongly associated with diabetes. Contrast-enhanced computed tomographic features have been described. Grayscale ultrasound (US) features remain inconclusive, with variable US appearances. Here we describe the contrast-enhanced US features of KP liver abscesses, which correlated with previously described computed tomographic findings. The use of contrast-enhanced US eliminates the need for radiation exposure.

"Bright Band Sign" A Grayscale Ultrasound Finding in Hepatic Infarction.

Hepatic infarction is infrequent due to the dual blood supply of the liver and the compensatory relationship between the hepatic artery and portal vein. Most cases occur in liver transplants due to vascular complications. Grayscale sonography combined with color and spectral wave Doppler can assess for vessel patency and parenchymal abnormalities. Liver infarctions appear as hypoechoic nonvascular regions on conventional and Doppler sonography. Here, we describe a grayscale ultrasound feature within liver infarctions in 2 liver transplants and in 1 native liver due to iatrogenic complication. This feature is similar to those described recently in the literature within splenic infarcts.

Gastric remnant perforation in a gastric bypass patient secondary to splenic artery pseudoaneurysm: radiologic-surgical correlation.

One of the more common effective surgical procedures performed today for obesity is the Roux-en-Y gastric bypass. Though effective, both early and late complications do occur. Gastric remnant hemorrhage after gastric bypass is an uncommon late complication, posing both diagnostic and therapeutic difficulties. We report a case of gastrointestinal bleed and gastric remnant rupture secondary to splenic artery pseudoaneurysm 14 years after initial bariatric surgery. Given altered surgical anatomy in gastric bypass procedures, diagnosis and treatment of the source of a gastrointestinal bleed in a Roux-en-Y gastric bypass patient may require a multimodality and multidisciplinary approach.

Refining Convolutional Neural Network Detection of Small-Bowel Obstruction in Conventional Radiography.

OBJECTIVE: The purpose of this study was to evaluate improvement of convolutional neural network detection of high-grade small-bowel obstruction on conventional radiographs with increased training set size. MATERIALS AND METHODS: A set of 2210 abdominal radiographs from one institution (image set 1) had been previously classified into obstructive and nonobstructive categories by consensus judgments of three abdominal radiologists. The images were used to fine-tune an initial convolutional neural network classifier (stage 1). An additional set of 13,935 clinical images from the same institution was reduced to 5558 radiographs (image set 2) primarily by retaining only images classified positive for bowel obstruction by the initial classifier. These images were classified into obstructive and nonobstructive categories by an abdominal radiologist. The combined 7768 radiographs were used to train additional classifiers (stage 2 training). The best classifiers from stage 1 and stage 2 training were evaluated on a held-out test set of 1453 abdominal radiographs from image set 1. RESULTS: The ROC AUC for the neural network trained on image set 1 was 0.803; after stage 2, the ROC AUC of the best model was 0.971. By use of an operating point based on maximizing the validation set Youden J index, the stage 2-trained model had a test set sensitivity of 91.4% and specificity of 91.9%. Classification performance increased with training set size, reaching a plateau with over 200 positive training examples. CONCLUSION: Accuracy of detection of high-grade small-bowel obstruction with a convolutional neural network improves significantly with the number of positive training radiographs.

Acute eosinophilic appendicitis: a radiologic-pathologic correlation.

Inflammation of the appendix is one of the most common conditions requiring emergent surgical intervention. Computed tomography commonly demonstrates a dilated appendix with adjacent inflammation. Traditionally, luminal obstruction of the appendix has been thought to be the primary etiology of appendicitis. However, current evidence suggests that etiology of appendicitis is multifactorial and can involve a number of different pathogenic pathways. Here we present a case of acute eosinophilic appendicitis with radiologic-pathologic correlation from a hypersensitivity reaction pathway. Acute eosinophilic appendicitis may represent an early precursor to conventional acute suppurative (phlegmonous) appendicitis, or a variant form of acute appendicitis.

Ultrasound, Computed Tomography, and Magnetic Resonance Imaging in a Patient With Medullary Cystic Kidney Disease.

Among the renal cystic diseases that result in end-stage renal disease, an important hereditary cause is medullary cystic kidney disease, which affects adults in an autosomal dominant pattern. It is characterized by progressive renal failure, tubulointerstitial fibrosis, and formation of small cysts in the renal medulla and corticomedullary junction. While the appearance of medullary/corticomedullary cysts may not be pathognomonic for medullary cystic kidney disease, encountering a patient with renal failure and medullary/corticomedullary cysts should prompt further investigation, given the implication of having the disease. Genetic testing can be used to identify potential renal donors as well as identify affected individuals in order to control risk factors for chronic renal disease that may mitigate the progression of the disease process. The treatment of choice is renal transplantation.

Detection of high-grade small bowel obstruction on conventional radiography with convolutional neural networks.

The purpose of this pilot study is to determine whether a deep convolutional neural network can be trained with limited image data to detect high-grade small bowel obstruction patterns on supine abdominal radiographs. Grayscale images from 3663 clinical supine abdominal radiographs were categorized into obstructive and non-obstructive categories independently by three abdominal radiologists, and the majority classification was used as ground truth; 74 images were found to be consistent with small bowel obstruction. Images were rescaled and randomized, with 2210 images constituting the training set (39 with small bowel obstruction) and 1453 images constituting the test set (35 with small bowel obstruction). Weight parameters for the final classification layer of the Inception v3 convolutional neural network, previously trained on the 2014 Large Scale Visual Recognition Challenge dataset, were retrained on the training set. After training, the neural network achieved an AUC of 0.84 on the test set (95% CI 0.78-0.89). At the maximum Youden index (sensitivity + specificity-1), the sensitivity of the system for small bowel obstruction is 83.8%, with a specificity of 68.1%. The results demonstrate that transfer learning with convolutional neural networks, even with limited training data, may be used to train a detector for high-grade small bowel obstruction gas patterns on supine radiographs.

Unintentionally retained vascular devices: improving recognition and removal.

The increased demand for minimally invasive placement of intravascular medical devices has led to increased procedure-related complications, including retention of all or part of the implanted device. A number of risk factors can predispose to unintentionally retained vascular devices (uRVD); most are technical in etiology. Despite best efforts to insert and remove vascular devices properly, uRVD still occur. Prevention or early identification of uRVD is ideal; however, procedural complications are not always recognized at the time of device insertion or removal. In these cases, early radiologic diagnosis is important to enable expeditious removal and reduction of morbidity, mortality, and medicolegal consequences. The diagnostic radiologist's role is to identify suspected uRVD and ensure proper communication of the findings to the referring clinician. The diagnostic radiologist can implement various strategies to increase detection of uRVD and advise the referring clinician regarding the use of minimally invasive percutaneous techniques for safe removal of uRVD.

Improvement in the Outcomes of MELD ≥ 40 Liver Transplantation: An Analysis of 207 Consecutive Transplants in a Highly Competitive DSA.

BACKGROUND: Organ donor shortages continue to persist, especially in regions of the United States where competition is highest and recipients frequently attain a Model for End-Stage Liver Disease (MELD) score of 40 or higher before transplantation. The benefits of Share 35 in highly competitive regions may be underestimated when examining the collective national experience. The purpose of this study was to examine the outcomes of liver transplantation in recipients with a MELD of 40 or higher after implementation of Share 35 in a single center located in region 5. METHODS: The method used in this study was single-center retrospective analysis of 207 liver transplant recipients who achieved MELD score of 40 or higher from April 21, 2002, to May 15, 2015. RESULTS: Multivariable analysis identified implementation of Share 35 as the strongest predictor of graft survival in MELD of 40 or higher liver transplantation. The post-Share 35, 1-year graft survival was 94% compared with 75% pre-Share 35 (P = 0.002). Post-Share 35 recipients waited significantly less time until transplantation (10 vs 16 days, P = 0.015), and fewer were hospitalized for more than 28 days before their transplant (6% vs 18%, P = 0.05). Multivariable analysis identified recipients with diabetes at the time of listing as the strongest predictor of posttransplant patient mortality. CONCLUSIONS: Implementation of the Share 35 allocation policy has a significant effect on outcomes by improving organ access and minimizing candidate waiting times. Recipients achieving a MELD of 40 or higher at our center post-Share 35 had an improved 1-year graft survival. However, nearly 40% remained hospitalized for more than 4 weeks posttransplant, and 20% were discharged to an acute care facility.

The portal vein-variceal anastomosis: an important technique for establishing portal vein inflow.

BACKGROUND: Adequate portal vein inflow is critical to successful orthotopic liver transplantation. While an end-to-end donor to recipient portal vein anastomosis is fashioned in the majority of liver transplant recipients, approximately 2% of recipients will require a complex vascular reconstruction due to inadequate recipient portal vein inflow. In this series, we describe our experience with five patients in which porto-variceal anastomosis was used to treat extensive porto-mesenteric thrombosis. METHODS: Charts for patients who underwent liver transplantation from January 1, 2006, to December 31, 2011, were reviewed for patients requiring porto-variceal anastomosis. RESULTS: Five patients had extensive porto-splenomesenteric thrombosis requiring utilization of a varix as portal inflow. An iliac vein graft was utilized in four patients, and a direct anastomosis was performed in one patient. The patient with the direct anastomosis required revision with the use of an iliac vein graft the following day. Follow-up imaging documented portal vein patency at a minimum of three months post-transplant. No patients suffered post-operative variceal hemorrhage and all five patients are alive with a functional primary graft at a median follow-up of 2.3 yr. CONCLUSIONS: A porto-variceal anastomosis should be feasible in the majority of patients with extensive porto-mesenteric thrombosis with excellent durability.

Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence--pictorial review.

OBJECTIVE: Unintentionally retained surgically placed foreign bodies have been associated with increased morbidity and mortality, as well as increased costs and medicolegal consequences. This article reviews some of the most commonly retained surgical devices and provides a structured approach to intraoperative image acquisition and interpretation. By increasing the awareness of surgically placed foreign bodies, our goal is to reduce the incidence of and the complications associated with this difficult clinical problem. CONCLUSION: Despite various systems and safeguards available, unintentionally retained surgically placed foreign bodies remain difficult to eliminate completely. Developing a standardized approach to the request, "intraoperative film, rule out foreign body," is essential to reduce the adverse outcomes associated with this problem.

Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence--self-assessment module.

The educational objectives of this self-assessment module are for the reader to exercise, self-assess, and improve his or her skills in diagnostic radiology with respect to the imaging of unintentionally retained surgically placed foreign bodies and to develop a standardized approach to the request for intraoperative imaging to rule out a foreign body.