Delayed Diagnosis of Retained Surgical Blade 12 Years Post-Hysterectomy: A Rare Case Report

Imaging

Managing Urolithiasis

Feedback: Computed tomography for subarachnoid hemorrhage

Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.

Substantial effort is now under way to identify and follow up patients who have received a computed tomography (CT) scan, to determine whether any increased risk of cancer resulting from exposure to ionising radiation during a scan can be detected. CT scans are becoming an increasingly popular and effective diagnostic tool, and their usage has risen dramatically in economically developed countries (UNSCEAR 2010). Each CT scan delivers an effective dose of between several mSv and a few tens of mSv, depending on the type of scan (UNSCEAR 2010). The radiation risk models that have been developed from the epidemiological study of groups receiving moderate and high doses (such as the Japanese survivors of the atomic-bombings of Hiroshima and Nagasaki) imply that the excess risk of cancer resulting from the low doses received during a CT scan is small, so that large and carefully designed and conducted studies are necessary to discern this predicted small additional risk. Such studies are important because of the direct evidence that they can potentially provide on the levels of risk resulting from low doses of radiation. The findings of large studies of patients who have experienced a CT scan at a young age are starting to become available—studies of infants, children and adolescents are a sensible starting point because the risk of radiation-induced cancer is generally greater at younger ages at exposure (UNSCEAR 2013).

Objective To investigate the application value of the preoperative progressive pneumoperi-toneum (PPP) in parastomal hernia repair. Methods The retrospective cross-sectional study was conducted. The clinical data of 28 patients who underwent parastomal hernia repair using PPP in the Sixth Affiliated Hospital of Sun Yat-sen University from December 2014 to February 2017 were collected. Patients received abdominal computed tomography (CT) scan after admission, and volumes of the hernia sac and abdominal cavity and (volume of the hernia sac / total volume of the abdominal cavity)×100.0% were respectively calculated. Open or laparoscopic parastomal hernia repair was selected based on the effects of artificial pneumoperitoneum. Observation indicators: (1) PPP situations: ① completion; ② changes of volumes of the hernia sac and abdominal cavity before and after PPP; ③ adhesion and retraction of parastomal hernia contents after PPP; (2) surgical and postoperative recovery situations; (3) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative long-term complications and recurrence of parastomal hernia up to May 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Repeated measurement data were evaluated with the repeated measures ANOVA. Results (1) PPP situations: ① completion: 28 patients received successful ultrasound-guided indwelling catcher. Twenty-four patients completed PPP, with a completion rate of 85.7% (24/28)and an air injection volume of (3 995±531)mL, and 4 stopped PPP. Eighteen patients had varying degrees of abdominal pain, abdominal distension and scapular pain, including 17 with tolerance and 1 with disappearing of symptoms at day 6. Of 5 patients with shortness of breath, 3 were improved or well tolerated through breathing exercises, and symptoms of 2 disappeared at day 7 and 9. Three patients had mild subcutaneous emphysema. The arterial CO2 tension of 1 patient was high and then returned to normal at day 7. Some patients had simultaneously multiple adverse reactions. ② Changes of volumes of the hernia sac and abdominal cavity before and after PPP: volumes of the hernia sac before and after PPP were (699±231)mL and (993±332)mL, with a statistically significant difference (F=129.29, P 0.05). ③ Adhesion and retraction of parastomal hernia contents after PPP: results of abdominal CT showed anterior abdominal bulging, abdominal contents prostrated at the base of the abdominal cavity due to gravity, and gas was full of gaps. Abdominal adhesion signs: adhesions of banded fibrous connective tissue established a connection between the base of the abdominal cavity and anterior abdominal wall, and intestinal canals were found inside the adhesions. Parastomal hernia contents of 28 patients had varying degrees of retraction to abdominal cavity, including 9 with complete retraction, 13 with a great amount of retraction (retraction volume >50%) and 6 with a small amount of retraction (retraction volume <50%). Four patients were accompanied by incomplete stoma obstruction, and then obstruction disappeared or relieved after PPP. (2) Surgical and postoperative recovery situations: all the 28 patients underwent successful operations, without intestinal canal injury. Three patients received open parastomal hernia repair, including 2 receiving preperitoneal mesh repair using 8 layers Biodesign meshes (deep venous catheter for local drainage was placed and then removed at postoperative day 2 and 3) and 1 receiving Sugarbaker surgery using PCOPM mesh (peritoneal drainage-tube was placed and then removed at postoperative day 2). Other 25 patients received laparoscopic parastomal hernia repair and Sugarbaker surgery using PCOPM and Sepramesh meshes (no drainage-tube was placed). Bladder pressure of 28 patients at postoperative day 3 was (13±6)cmH2O (1 cmH2O=0.098 kPa), without an abnormal high pressure. Nine patients with postoperative complications were improved by conservative treatment, including 3 with seroma, 3 with delayed stoma defecation or incomplete intestinal obstruction, 2 with pulmonary infection and 1 with urinary tract infection. There were no occurrences of abdominal compartment syndrome, cardiac failure, lung failure, renal failure, other severe complications and perioperative death. Duration of postoperative hospital stay was (7.2±1.5)days. (3) Follow-up situations: 25 of 28 patients were followed up for 3-25 months, with a median time of 11 months. During follow-up, 2 patients had chronic pain around the operation and a sense of discomfort and then were improved by symptomatic treatment, and 1 with parastomal hernia recurrence at postoperative month 6 after open preperitoneal mesh repair underwent again open preperitoneal mesh repair, without recurrence. There were no occurrence of tardive mesh infection and other long-term complications. Conclusion PPP in the treatment of parastomal hernia repair is safe and feasible. Key words: Hernia; Stoma; Pneumoperitoneum; Hernia repair; Complications

مقدمه: اسکن توموگرافی کامپیوتری یک وسیله ارزشمند برای تشخیص موارد غیر طبیعی در مغز و یا نخاع می باشد زیرا در نمایش این بافتها دقت بالائی دارد. باتوجه به اهمیت موضوع، محقق برآن شده است تا با بررسی فراواني سی تی اسکن های غیر ضروری انجام شده جهت بیماران ترومایی از انجام غیرضروری این اقدام تشخیصی جلوگیری و از آسیب های احتمالی و بار مالی آن جهت بیمار و بیمارستان جلوگیری بعمل آورد. روش کار: در این مطالعه مقطعی نمونه ها از بیمارانی که بدلیل ترومای جمجمه و با سطح هوشیاری 15 به اورژانس مراجعه نموده بودند و برای آنان سی تی اسکن مغزی درخواست شده بود به روش تصادفی ساده انتخاب شدند. دلایل درخواست سی تی اسکن جمجمه از پزشک درخواست کننده از طریق مصاحبه در هنگام درخواست این پروسیجر، مورد پرسش قرار گرفت و طبق پرسشنامه علائم بالینی و مشخصات دموگرافیک نیز ثبت شد. یافته ها: 8/81 درصد (121 نفر) از بیماران سی اسکن طبیعی داشتند و بعد از آن شکستگی جمجمه و هماتوم آن بیشترین درصد عارضه بعد از تروما را نشان دادند. همچنین نتایج نشان داد که در8/60 درصد(90 نفر) موارد گرفتن سی تی اسکن جهت مستند سازی مسائل قانونی بوده و 9/14 درصد (22 نفر) از آنها به دلیل اصرار خود بیمار و غیر ضروری بوده است و تنها 6/17 درصد (26 نفر) از درخواست ها به درخواست پزشک ارشد بوده است که همگی نشان می ‌دهند انجاک سی تی اسکن همیشه ضروری نمی باشد. نتیجه گیری: بر اساس نتایج این مطالعه، 2/18 درصد از سی تی های انجام شده برای بیماران با ترومای خفیف سر دارای حداقل یک یافته پاتولوزیک بودند. شکستگی استخوان جمجمه و تشکیل هماتوم داخل جمجمه ای شایع ترین یافته پاتولوژیک در سی تی اسکن بیماران مبتلا به ضربه خفیف سر بود . به دلیل بالا بودن نتایج سی تی اسکن طبیعی، جهت کاهش دریافت میزان اشعه در بیماران و کاهش میزان سی تی اسکن های غیر ضروری پیشنهاد می شود که معیارهی سخت گیرانه تر و دقیق تری برای درخواست سی تی اسکن تنظیم شود.

The role of bedside ultrasonography, urinalysis, and computed tomography in the diagnostic evaluation of flank pain

Background/AimsIndividuals with atrial fibrillation (AF) may have filling defects in the left atrial appendage (LAA) caused by blood flow disturbances in the LAA as well as LAA thrombi development, detectable...

Practical Strategies to Reduce Pediatric CT Radiation Dose

The roles of repeat CT imaging and re-planning during the course of IMRT for patients with head and neck cancer

Computed gray levels in multislice and cone-beam computed tomography

Computed tomography (CT) has been a boon for medical care. By generating detailed anatomical pictures, the technology can improve diagnoses, limit unneeded medical procedures, and enhance treatment. However, CT scans also dose patients with ionizing radiation, a known human carcinogen, posing a potential downside for public health. Mounting health worries over radiation risks are now driving efforts to limit avoidable CT scans and to reduce radiation doses where possible. “There’s a national focus on this issue right now,” says Marilyn Goske, a professor of radiology at Cincinnati Children’s Hospital Medical Center and chairwoman of the Image Gently campaign, a pediatric education and awareness campaign from the Alliance for Radiation Safety in Pediatric Imaging. In December 2011 the Institute of Medicine (IOM) published a report concluding that ionizing radiation contributes more to the development of breast cancer than any other type of routine environmental exposure.1 About half the U.S. annual exposure to ionizing radiation comes from natural sources, including cosmic rays, but most of the rest comes from medical imaging and from CT scans in particular.1 The IOM cited research by Amy Berrington de Gonzalez, a senior investigator in the Radiation Epidemiology Branch of the National Cancer Institute (NCI), whose calculations suggest that the CT scans performed in the United States in 2007 might produce up to 29,000 cancers in the future, about 6% of them in the breast and the remainder in the lungs, brain, and other organs.2 But the spotlight on CT safety has also drawn a backlash from those who say the risks are overblown. On 13 December 2011 the American Association of Physicists in Medicine (AAPM) issued a statement claiming that risks from CT imaging are “too low to be detectible and may be non-existent.”3 The AAPM added that “speculative predictions about cancer incidence and death” should be discouraged because they generate sensationalist media coverage that deters some patients who need CT scans from having them. Donald Miller, acting chief of the Diagnostic Devices Branch of the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health, cites 2 basic principles for decreasing CT radiation risks. One is justification, which refers to prescribing a CT exam only when it is medically necessary. The other is optimization, which refers to adjusting and operating a CT scanner so that images adequate for diagnosis are obtained at the lowest possible dose. Justification is more difficult to address, Miller says, because it involves case-by-case decisions made by individual clinicians. More attention has been paid to optimization, he says, but both principles are equally important.

Emergency Department Physician Computed Tomography Utilization and Admission Rates

Chapter 7. Neuroimaging