The Incidence of Retained Objects in Intraoperative X-rays for Missing Counts in Plastic Surgery: We Should Do Better.

Background: In the event of incorrect surgical counts, obtaining X-rays to rule out retained surgical items (RSI) is standard practice. However, these safeguards also carry risk. This study investigates the actual incidence of RSI in plastic reconstructive surgery (PRS) cases as measured on intraoperative X-rays and its associated modifiable risk factors. Methods: X-rays with indication of "foreign body" in PRS procedures from 2012 to 2022 were obtained. Reports with "incorrect surgical counts" and associated perioperative records were retrospectively analyzed to determine the incidence of retained surgical items. Results: Among 257 X-rays, 21.4% indicated incorrect counts during PRS operations. None were positive for RSIs. The average number of staff present was 12.01. This correlated to an average of 6.98 staff turnovers. The average case lasted 8.42 hours. X-rays prolonged the time under anesthesia by an average of 24.3 minutes. Free flap surgery had 49.1% prevalence of missing counts (lower extremity 25.5%, breast 20%, craniofacial 3.6%), followed by hand (14.5%), breast (10.9%), abdominal reconstruction (10.9%), craniofacial (9.1%), and cosmetic (5.4%). Conclusions: Although X-rays for incorrect counts intend to prevent catastrophic sequela of inadvertent RSIs, our results suggest the true incidence of RSI in PRS is negligible. However, intraoperative X-rays have potentially detrimental and pervasive consequences for patients, including increased anesthesia time, radiation exposure, and higher overall cost. Addressing modifiable risk factors to minimize unnecessary intraoperative X-rays is imperative while also considering whether this modality is an effective and appropriate tool in PRS procedures with incorrect surgical counts.

Utility of Restaging MRI Following Neoadjuvant Chemoradiotherapy for Stage II-III Rectal Adenocarcinoma.

Background Magnetic resonance imaging (MRI) is currently utilized for the pretreatment staging of locally advanced rectal cancer; however, there is no consensus regarding the utility of repeat MRI for restaging following neoadjuvant chemoradiotherapy (CRT). In this study, we aimed to investigate the clinical utility of restaging MRI after CRT in patients with clinical stage II-III rectal cancer. Methodology We performed a retrospective observational study at a tertiary care hospital. Our study population included patients with clinical stage II-III rectal cancer treated with neoadjuvant CRT who underwent both pre- and post-CRT MRI followed by surgical resection from 2012 to 2017. MRIs were reviewed by radiologists with an interest in rectal cancer MRI imaging using a standardized template. The utility of post-CRT MRI was evaluated by assessing its impact on change in surgical planning, concordance with pathologic staging, and prediction of surgical margins. Results A total of 30 patients were included in the study; 67% had clinical stage III and 33% had stage II disease based on pre-CRT MRI. Post-CRT MRI findings did not lead to a change in the originally outlined surgical plan in any patient. Compared to pre-CRT MRI, post-CRT MRI was not significantly more accurate in predicting T stage (k = 0.483), N stage (k = 0.268), or positive surgical margins (k = 0.839). Conclusions Due to poor concordance with pathologic staging, inability to more accurately predict surgical margin status and the absence of a demonstrable change in surgical treatment, post-CRT restaging with MRI, in its current form, appears to be of limited clinical utility.

Small bowel stricture is associated with abnormal motility on the cine MRI sequence in patients with Crohn's disease.

PURPOSE: A multiphasic cine sequence performed during magnetic resonance enterography (MRE) has been shown to increase diagnostic accuracy of MRE demonstrating limited movement in inflamed intestine in patients with Crohn's disease (CD). Our aim was to confirm in our study population that intestinal inflammation was associated with decreased motility and determine if factors suggestive of complicated disease such as the presence of a stricture or fistula were associated with decreased motility on the MRE cine sequence. METHODS: This was a retrospective study of 59 patients (mean age 40.8 ±â€¯16.1) with Crohn's disease who had a small bowel lesion on MRE. Two gastrointestinal radiologists independently scored MRE findings using a qualitative, subjective scoring system. Univariate and multivariable ordered logistic regression models were used to evaluate the associations between cine sequence score, radiologic image findings, and clinical data. RESULTS: On univariate analysis, radiologic findings reflecting active inflammation, the presence of a stricture, and penetrating disease were associated with decreased motility. On multivariable analysis, hyper-enhancement, the presence of a comb sign, and global evidence of active inflammation remained associated with decreased motility. Of the factors suggesting complicated disease, the presence of stricture (Odds Ratio 0.40, 95% Confidence Interval 0.17-0.95, p-value 0.038) was associated with decreased motility. CONCLUSIONS: As previously shown, well-established radiologic findings of bowel inflammation were associated with decreased small bowel motility. In this study, we have added that the radiologic finding of a fixed stricture is also associated with decreased motility.

Effective communication of cross-sectional imaging findings in Crohn's disease: comparing conventional EMR reporting to a published scoring system.

PURPOSE: The purpose of the article is to compare information regarding small bowel lesions in Crohn's disease (CD) patients communicated by a published scoring system and radiology reports from electronic medical record (EMR) of cross-sectional abdominal imaging. METHODS: Two gastrointestinal radiologists (reference readers) blinded to EMR reports scored cross-sectional imaging exams using a published scoring system. Investigators compared EMR and radiologist scores based on the mentioned findings and severity documentation of each variable. Statistical analysis involved means and difference in proportions and logistic regression modeling. RESULTS: Seventy-three CD patients, with average age 40.6 years (± SD 14.4), having 80 small bowel lesions on imaging were included. EMR reports reliably mentioned within the consensus score included thickness (79%, p = 0.000), enhancement (70%, p = 0.000), active inflammation (86%, p = 0.000), perienteric fluid (82%, p = 0.000), and presence of stricture (62%, p = 0.002). Minimal lumen diameter (19%, p = 0.000), comb sign (19%, p = 0.000), lesion length (57%, p = 0.06), and fistula (50%, p = 1.0) were reported less often. There was a strong association between the EMR and scoring scale in noting severity of active inflammation (88%, p = 0.000), perienteric fluid (76%, p = 0.000), and internal fistula (71%, p = 0.000). The proportion matching severity values of comb sign and minimal lumen were 24% and 21%, respectively (p = 0.000). Severity matches for stricture were less likely among the non-GI radiologists (odds ratio = 0.33, SE = 0.168, p = 0.029). The odds of reporting stricture and fistula severity were 3.6 and 5.7, respectively, on MRE. CONCLUSIONS: Findings and severity of inflammation were communicated consistently. Stricture severity including minimal luminal diameter, was less reliably reported, though its prognostic significance impacts management.

A Fixed Stricture on Routine Cross-sectional Imaging Predicts Disease-Related Complications and Adverse Outcomes in Patients with Crohn's Disease.

BACKGROUND: Patients with Crohn's disease (CD) typically undergo multiple cross-sectional imaging exams including computed tomography and magnetic resonance enterography during the course of their disease. The aim was to identify imaging findings that predict future disease-related poor outcomes. METHODS: This was a retrospective, case control study at a single tertiary center. Cases were CD patients diagnosed with complications (bowel obstruction, perforation, internal fistula, or abscess); controls were CD patients without complications. Two radiologists blinded to clinical outcomes, independently scored cross-sectional imaging examinations obtained before the complication. RESULTS: One hundred eight patients (67 F; 41 M) with CD (51 cases; 57 controls) were included. For the cases, 21 had internal fistulae, 15 had bowel obstructions, 13 had abdominal abscesses, and 2 developed bowel perforations. Patients with complications were more likely to have a fixed small bowel stricture on cross-sectional imaging (P = 0.01). A patient with a stricture and upstream dilatation was 3.4 times more likely to develop a complication in the next 2 years. When present in the setting of hypervascularity and/or evidence of active inflammation, the risk increased further to 15-fold. Cases were more likely to be active smokers (29% versus 12%, P = 0.033). Cases had more evidence of inflammation based on higher Harvey Bradshaw Index values and inflammatory biomarkers and lower hemoglobin values. CONCLUSIONS: Information from radiologic studies, especially the presence of fixed strictures, can predict future CD complications. These findings, along with smoking and ongoing inflammation, should alert the clinician to the possibility of future complications.

Email notification combined with off site signing substantially reduces resident approval to faculty verification time.

RATIONALE AND OBJECTIVES: Attending radiologist signature time (AST) is a variable and modifiable component of overall report turnaround time. Delays in finalized reports have potential to undermine radiologists' value as consultants and adversely affect patient care. This study was performed to evaluate the impact of notebook computer distribution and daily automated e-mail notification on reducing AST. MATERIALS AND METHODS: Two simultaneous interventions were initiated in the authors' radiology department in February 2010. These included the distribution of a notebook computer with preloaded software for each attending radiologist to sign radiology reports and daily automated e-mail notifications for unsigned reports. The digital dictation system archive and the radiology information system were queried for all radiology reports produced from January 2009 through August 2010. The time between resident approval and attending radiologist signature before and after the intervention was analyzed. Potential unintended "side effects" of the intervention were also studied. RESULTS: Resident-authored reports were signed, on average, 2.53 hours sooner after the intervention. This represented a highly significant (P = .003) decrease in AST with all else held equal. Postintervention reports were authored by residents at the same rate (about 70%). An unintended "side effect" was that attending radiologists were less likely to make changes to resident-authored reports after the intervention. CONCLUSIONS: E-mail notification combined with offsite signing can reduce AST substantially. Notebook computers with preloaded software streamline the process of accessing, editing, and signing reports. The observed decrease in AST reflects a positive change in the timeliness of report signature.