Normal Postoperative Changes Research Articles

Radiological imaging following pelvic prolapse surgery

Pelvic organ prolapse is acommon condition in women, for which both conservative and surgical interventions are available. Knowledge of the different surgical procedures and the materials used is essential for adequate radiological diagnosis after prolapse surgery in order to differentiate potential complications from normal postoperative changes. In the immediate postoperative period, computed tomography (CT) is often the modality of choice for evaluating acute complications such as bleeding or organ injuries. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and is therefore generally preferred for assessing subacute and chronic complications. Innovative techniques such as dynamic MRI protocols can improve the radiological assessment after prolapse surgery by enabling the evaluation of organ mobility. Radiological standard procedures such as computed tomography (CT) and MRI provide detailed and reliable information about the postoperative site and potential complications following prolapse surgery. Radiological imaging plays an important role in the evaluation of patients after prolapse surgery, particularly when complications are suspected. Accurate radiological diagnosis can guide further appropriate therapeutic measures.

Utility of endoscopic ultrasound for assessment of locoregional recurrence of pancreatic adenocarcinoma after surgical resection

Background and study aims Up to 80 % of patients with pancreatic adenocarcinoma develop locoregional recurrence after primary resection. However, the detection of recurrent pancreatic ductal adenocarcinoma (RPDAC) after pancreatic surgery can be challenging because of difficulty distinguishing locoregional recurrence from normal postoperative or post-radiation changes. We sought to evaluate the utility of endoscopic ultrasound (EUS), in detecting pancreatic adenocarcinoma recurrence after surgical resection and its impact on the clinical management of patients. Patients and methods This was a retrospective study of all pancreatic cancer patients who underwent EUS post-resection at two tertiary care centers between January 2004 and June 2019. Results Sixty-seven patients were identified. Of these, 57 (85 %) were diagnosed with RPDAC, resulting in change in clinical management of 46 (72 %) patients. EUS identified masses not seen on computed tomography, magnetic resonance imaging, or positron emission tomography in seven (14 %). Conclusions EUS is useful in detecting RPDAC after pancreatic surgery and can lead to significant impact on clinical management.

Taking a Big Breath: Identifying and Preventing Pulmonary Complications After Liver Transplantation.

In this issue of Transplantation, Oh et al1 describe the results of a retrospective study of postoperative pulmonary complications (PPCs) in 608 patients who underwent living donor liver transplantation over a period of 9 y. More than half of the patients developed pulmonary complications defined as respiratory failure, pneumonia, pulmonary edema, moderate-severe atelectasis, or pleural effusions within 7 d after the transplant. The authors found that a large number of intraoperative variables were associated with PPC including (not surprisingly) Model for End-stage Liver Disease score, ventilator driving pressures, positive end-expiratory pressure (PEEP) and compliance, fluid and blood administration, and duration of anesthesia. However, when using a multivariate analysis and focusing on intraoperative factors, greater driving pressure, and albumin levels at the end of surgery, prolonged hypotension and larger tidal volumes (but not PEEP) remained independently associated with PPC. Patient with PPCs had worse outcomes such as longer intensive care unit stay and worse graft and patient survival. This is the first, larger study of PPC after liver transplantation that investigates the effect of intraoperative variables and therefore factors that may be modifiable. Although any retrospective study can only identify associations and not prove causal relationships, this study provides us with evidence that may influence how we manage patients. Specifically, the association of driving pressures at the end of surgery confirms what we have learned from the nontransplant anesthesiology literature: intraoperative ventilator management matters. Almost 10 y ago, Futier et al2 demonstrated the benefit of intraoperative lung-protective ventilation including the use of PEEP to prevent PPC after abdominal surgery with the landmark randomized, controlled Intraoperative Protective Ventilation trial. The benefit of using PEEP shown in the Intraoperative Protective Ventilation trial could not be replicated in the present study. This may reflect more recent evidence that suggests that high driving pressure (and tidal volumes) and not just low PEEP are actually harmful,3 and PEEP should be individualized to the patient’s static compliance. The ongoing Prime-Air study (ClinicalTrials.gov Identifier: NCT04108130) is a large, multicenter, randomized, controlled trial of an anesthetic-center bundle of interventions that includes individualized PEEP. This study will likely provide us with a better understanding if and how individualized PEEP may be beneficial. Other factors identified by this study associated with PPCs such as low albumin levels at the end of surgery and intraoperative hypotension require more complex physiologic explanations and are not as easily modifiable. PPCs are usually defined as any serious respiratory complications after surgery independent of their etiology.4 Cardiogenic pulmonary edema, pneumonias, and pleural effusions are all considered PPCs, although they represent very different pathologies. PPC is a syndrome with often vague and subjective definitions. For example, the severity of atelectasis or pleural effusion is difficult to quantify and what some may consider normal postoperative changes may be considered PPC by others. The elegant solution to this problem by the present study was to assess for PPCs with radiograph and chart review by 2 pulmonologists. Although this method allows for the application of some common sense in the diagnosis of PPC, it is harder to quantify severity. For example, is severe atelectasis equally harmful than pneumonia? Unlike other organ injuries such as acute kidney injury or liver failure, there are no proven sensitive and specific biomarkers that allow us to identify PPCs and assess its severity. This should not discourage us as it is a great opportunity for future research that may dramatically transform clinical studies of PPCs and possible interventions. The present study is further encouraging as it demonstrates that interventions in the operating room affect complications and the anesthesiologist as an integral member of transplant team can contribute to better outcomes for our patients.

Doppler-ultrasound reference values after pediatric liver transplantation: a consecutive cohort study

ObjectivesDoppler ultrasound (DUS) is the main imaging modality to evaluate vascular complications of pediatric liver transplants (LT). The current study aimed to determine reference values and their change over time.MethodsA consecutive cohort of pediatric patients undergoing an LT were retrospectively included between 2015 and 2020. Timepoints for standardized DUS were intra-operative and postoperative (day 0), days 1–7, months 1 and 3, and years 1 and 2. DUS measurements of the hepatic artery (HA), portal vein (PV), and hepatic vein(s) (HV) were included if there were no complications during 2 years follow-up. Measurements consisted of: peak systolic velocity (PSV) and resistive index (RI) for the HA, PSV for the PV, and venous pulsatility index (VPI) for the HV. Generalized estimating equations were used to analyze change over time.ResultsOne hundred twelve pediatric patients with 123 LTs were included (median age 3.3 years, interquartile range 0.7–10.1). Ninety-five HAs, 100 PVs, and 115 HVs without complications were included. Reference values for HA PSV and RI, PV PSV, and HV VPI were obtained for all timepoints (4043 included data points in total) and presented using 5th–95th percentiles and threshold values. All reference values changed significantly over time (p = 0.032 to p < 0.001).ConclusionsDUS reference values of hepatic vessels in children after LT are presented, reference values change over time with specific vessel-dependent patterns. Timepoint–specific reference values improve the interpretation of DUS values and may help to better weigh their clinical significance.Key Points• Doppler ultrasound reference values of pediatric liver transplantations are not static but change over time. Applying the correct reference values for the specific timepoint may further improve the interpretation of the measurements.• The pattern of change over time of Doppler ultrasound measurements differs between the hepatic vessel and measurement; knowledge of these patterns may help radiologists to better understand normal postoperative hemodynamic changes.

Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery.

Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.

Postsurgical Ultrasound Evaluation of Patients with Prosthesis in Acellular Dermal Matrix: Results from Monocentric Experience.

Mastectomy and breast prosthetic reconstruction is the most common surgical treatment for women diagnosed with breast cancer. In the last few years, breast prosthetic augmentation in acellular dermal matrix (ADM) has been introduced. The aim of this study is to present our single-center experience in evaluating the outcome of patients who underwent breast reconstruction in ADM, using ultrasound (US) examination. US follow-up allows evaluating both normal postoperative findings and changes and potential local complications, demonstrating that ADM is a safe option for women candidates for mastectomy.

Diffusion-weighted magnetic resonance imaging for detection of postoperative intracranial pyogenic abscesses in neurosurgery.

Diffusion-weighted magnetic resonance imaging (MRI-DWI) is the modality of choice for detecting intracranial abscesses; however, it is unclear whether prior brain surgery has an influence on its diagnostic value. Thus, we assessed the robustness of MRI-DWI and determination of an ADC cutoff value for detecting intracranial abscesses in patients who underwent brain surgery. We retrospectively evaluated 19 patients prior to surgery for postoperative supratentorial parenchymal abscesses by means of MRI-DWI. Forty randomly selected patients with routine postoperative MRI-DWI were used for comparative analyses. Clinical and serum biomarkers (C-reactive protein, interleukin-6, white blood cell count) as well as from results of early postoperative imaging findings (computed tomography and/or MRI scan) were recorded. Additionally, ADC values, T1±gadolinium, and T2/fluid-attenuated inversion recovery sequences were investigated. After initial surgery, early postoperative control imaging showed evidence of hemorrhage and/or hemostatic agents within the resection cavity in 10/19 patients of the abscess group and in 16/40 patients of the control group. No postoperative ischemia was detected. Neither hemostatic agents nor blood affected the mean ADC values in both the reference group (blood 2.96 ± 0.22 × 10-3mm2/s vs. no blood 2.95 ± 0.26 × 10-3mm2/s, p = 0.076) and in the abscess group (blood 0.87 ± 0.07 × 10-3mm2/s vs. no blood 0.76 ± 0.06 × 10-3mm2/s, p = 0.128). The mean ADC value within the resection cavity was significantly lower in the abscess group (1.5T 0.88 ± 0.41 vs. 2.88 ± 0.20 × 10-3mm2/s, p < .01; 3.0T 0.75 ± 0.24 vs. 3.02 ± 0.26 × 10-3mm2/s, p < 0.01). The optimal ADC cut-off for the differentiation of an abscess from normal postoperative findings was found at 1.87 × 10-3mm2/s (area-under-the-curve 1.0, sensitivity = 100%, specificity = 100%). Moreover, no differences between the abscess patients and the control group were seen with respect to the analyzed serum biomarkers. MRI-DWI provides a robust tool to discriminate postoperative abscess formation from normal postoperative changes.

CT findings after pelvic exenteration: review of normal appearances and most common complications.

The aim of this review is to illustrate normal computed tomography (CT) findings and the most common complications in patients who underwent pelvic exenteration (PE) for advanced, persistent or recurrent gynecological cancers. We review the various surgical techniques used in PE, discuss optimal CT protocols for postsurgical evaluation and describe cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications. The interpretation of abdominopelvic CT imaging after PE is very challenging due to remarkable modifications of normal anatomy. After this radical pelvic surgery, the familiarity with expected CT appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent PE.

Computed tomography improves the differentiation of infectious mediastinitis from normal postoperative changes after sternotomy in cardiac surgery.

To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes. In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively. Overall 105 patients (82% men; 67.0 ± 10.3years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p < 0.001). In the CT, the presence of free gas, pleural effusions, and brachiocephalic lymph node size were independently associated with mediastinitis (multivariate ORs = 1.3-6.3; p < 0.001-0.039). Addition of these CT parameters to CRP increased the model fit significantly (X2 = 17.9; p < 0.001; AUC, 0.83 vs. 0.73). The presence of free gas, pleural effusions, and brachiocephalic lymph node size in CT is independently associated with infectious mediastinitis in poststernotomy patients with retrosternal mass. These imaging features may help to differentiate mediastinitis from normal postoperative changes beyond traditional clinical parameters such as CRP. • Presence of free gas, pleural effusions, and brachiocephalic lymph node size on CT are associated independently with infectious mediastinitis. • Combination of these CT parameters increases the discriminatory capacity of clinical parameters such as CRP.

Poststernotomy Complications: A Multimodal Review of Normal and Abnormal Postoperative Imaging Findings.

The purpose of this article is to review the normal postoperative appearance of various sternotomy configurations as well as the pathophysiologic and imaging characteristics of sternotomy complications on radiographs, MDCT, MRI, and scintigraphy. Clinical signs of sternotomy complications are nonspecific and often overlap with normal postoperative changes. Knowledge of normal and abnormal imaging findings is essential to guide management and treatment.

Urethrography for Assessment of the Adult Male Urethra: RadioGraphics Fundamentals | Online Presentation.

A better understanding of urethral anatomy, key features of underlying disease, and the appearance of normal urethral postoperative changes will aid in providing a complete evaluation and accurate ...

Utility of Endoscopic Ultrasound in Evaluating Local Recurrence After Surgery for Pancreatic Cancer

Pancreatic adenocarcinoma recurrence after surgery (PARaS) is associated with poor outcomes. PARaS is locoregional in 50%-80%, effecting the resection bed and adjacent lymphatics.1-3 Detection of PARaS via endoscopic ultrasound (EUS) is challenging because recurrent malignancy is difficult to distinguish from normal postoperative changes. Diagnosing PARaS is important, because salvage chemotherapy/radiation improves survival.4,5 The purpose of this investigation is to determine the clinical utility of EUS fine-needle aspiration (FNA) in patients with suspected PARaS.

MP91-19 NEOCLITORIS SIZE AND LOCATION: CAN THEY AFFECT TRANSSEXUAL WOMEN SEXUAL FUNCTION? A PRELIMINARY PELVIC MRI STUDY.

You have accessJournal of UrologySexual Function/Dysfunction: Medical, Hormonal & Non-surgical Therapy I1 Apr 2017MP91-19 NEOCLITORIS SIZE AND LOCATION: CAN THEY AFFECT TRANSSEXUAL WOMEN SEXUAL FUNCTION? A PRELIMINARY PELVIC MRI STUDY. Francesca Vedovo, Nicola Pavan, Giovanni Liguori, Stefano Bucci, Michele Bertolotto, and Carlo Trombetta Francesca VedovoFrancesca Vedovo More articles by this author , Nicola PavanNicola Pavan More articles by this author , Giovanni LiguoriGiovanni Liguori More articles by this author , Stefano BucciStefano Bucci More articles by this author , Michele BertolottoMichele Bertolotto More articles by this author , and Carlo TrombettaCarlo Trombetta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2859AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Clinical trials have shown that biological women with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. The aim of this study is to evaluate neoclitoris size and location with regard to sexual function in patients undergoing male to female (MtF) gender reassignment surgery (GRS). For the evaluation of the normal post-operative changes and presence of complications, in our Centre, patients underwent MtF GRS performed a pelvic non-contrast MRI at 2-4 weeks after surgery. METHODS From May to June 2015 we enrolled, during follow up visits, 40 Italian speaking transsexual women underwent MtF GRS and postoperative MRI in our Centre between 2004-2014. Sexual functioning was assessed using the Italian version of the Female Sexual Function Index (FSFI). MR Scans were acquired with a 1.5T superconductive equipment in sagittal and axial planes using a multichannel phased array coil for parallel imaging. TSE T2-weighed images were obtained with 3-4mm thick contiguous sections. The neovagina and the rectum were distended with gel or a vaginal tutor inserted. Individual pelvic MRIs were reviewed by blinded investigators, the three axes of the neoclitoris were measured and the volume calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was measured. Data included demographics, sexual history, previous surgery, partnership status, body mass index (BMI), past and current medical history, chronic medical treatments, education, job. RESULTS 22 patients completed the study. The mean age was 34 years (SD 7.44). The majority were Caucasians (N=20, 91%) and in a relationship (N=13, 51%). At the MRI neoclitoris mean volume was 1.18 cc (SD 0.43), coronal area 6.80 cm2 (SD 2.4) and 5.33 cm2 (SD 1.34) in sagittal view, the mean distance between neoclitoris and neovagina was 3.38 cm (SD 0.5). There is a statistically significant correlation between the parameter that evaluates the distance between the neoclitoris and the neovagina and the FSFI total score (p < 0.0001). Neoclitoris size did not significantly correlate with FSFI total score (p=0.76). CONCLUSIONS This study showed that, even in patients undergoing GRS, neoclitoris localization could be considered a parameter for evaluating sexual function and that a reduction of the distance between neovagina and neoclitoris is associated with greater sexual satisfaction. Neoclitoris size seems not to affect MtF sexual function. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1225 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Francesca Vedovo More articles by this author Nicola Pavan More articles by this author Giovanni Liguori More articles by this author Stefano Bucci More articles by this author Michele Bertolotto More articles by this author Carlo Trombetta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

CT and MR Imaging of the Postoperative Ankle and Foot.

A variety of surgical procedures exist for repair of both traumatic and degenerative osseous and soft-tissue pathologic conditions involving the foot and ankle. It is necessary for the radiologist to be familiar with these surgical procedures, so as to assess structural integrity, evaluate for complicating features, and avoid diagnostic pitfalls. Adequate interpretation of postoperative changes often requires access to surgical documentation to evaluate not only the surgery itself but the expected timeline for resolution of normal postoperative changes versus progressive disease. Appropriate use of surgical language in radiology reports is another important skill set to hone and is instrumental in providing a high-quality report to the referring surgeons. The pathophysiology of a myriad of surgical complaints, beginning from the Achilles tendon and concluding at the plantar plate, are presented, as are their common appearances at computed tomography and magnetic resonance imaging. Commonly encountered entities include Achilles tendon tear, spastic equinus, nonspastic equinus, talar dome osteochondral defect, tarsal tunnel syndrome, plantar fasciitis, pes planovalgus, pes cavovarus, peroneal tendinosis, lateral ligament complex pathology, Morton neuroma, plantar plate tear, and metatarsophalangeal joint instability. Computer-generated three-dimensional models are included with many of the procedures to provide a more global view of the surgical anatomy. Correlation with intraoperative photographs is made when available. When appropriate, discussion of postoperative complications, including entities such as infection and failure of graft integration, is presented, although a comprehensive review of postoperative complications is beyond the scope of this article. Notably absent from the current review are some common foot and ankle procedures including hallux valgus and hammertoe corrections, as these are more often evaluated radiographically than with cross-sectional imaging. ©RSNA, 2016.

Hyperammonemic Encephalopahty Can Result from a Duodenal Switch

A 41-year-old female had inadequate weight loss 2 years after a vertical sleeve gastrectomy. 1 year prior to presentation, she underwent revision to a duodenal switch with formation of a duodeno-ileal anastomosis. At presentation she had evidence for protein-calorie malnutrition. She denied alcohol use; total parenteral nutrition (TPN) was initiated. Upper endoscopy revealed a normal esophagus and post-operative changes of sleeve gastrectomy with duodenal switch; a nasoileal tube was placed to begin enteral nutrition. On day 9, the patient was moved to the intensive care unit after onset of catatonia and unresponsiveness. On exam, she had no signs of chronic liver disease. Her INR was 1.4, platelet count 237 and had minimal elevations of serum ALT and AST. She had no evidence for metabolic acidosis (AGAP-8 and lactic acid-1.1). CT scan of the head was unremarkable. There was no deficiency of vitamin B12, folate, copper, or zinc, but she had hyperammonemia with a blood level of 223 mcg/dl. The differential diagnosis for non-hepatic hyperammonemia includes medications, hyperalimentation, infections with urease producing bacteria, surgical-induced nutritional deficiency, and errors of metabolism. Other potential explanations were excluded for this patient. She was started on a protein restriction of 40 grams/day, lactulose enemas and high dose intravenous thiamine. She had a decrease in her serum ammonia levels with improvement in her mental status. A 24-hour urine collection revealed an elevated orotic acid level (2.9 mmol/mol Cr) supporting Ornithine Transcarbamylase Deficiency. She underwent revision of her ileo-ileostomy, and the common channel was increased in length. On day 30, TPN was discontinued. She was discharged on a protein limited diet and oral lactulose. This exceedingly rare phenomenon with similar presentations has been described previously involving predominantly female patients developing an often fatal hyperammonemic encephalopathy after gastric bypass surgery, which in some patients was up to 28 years post-operatively. The exact mechanism remains unclear, but this disorder is believed to involve unmasking of inborn errors of urea metabolism after bariatic surgery, the most common of which is Ornithine Transcarbamylase Deficiency. This case report demonstrates that this disorder can also occur after duodenal switch. Gastroenterologists need to be aware of this disorder due to the number of patients undergoing bariatric surgery.

MULTIDETECTOR COMPUTED TOMOGRAPHY IN POSTOPERATIVE ASSESSMENT OF CAROTID ARTERIES

Актуальность. Для профилактики нарушений мозгового кровообращения, до 80% которых носят ишемический характер, при наличии выраженного стено-окклюзирующего поражения сонных артерий проводится операция каротидной эндартерэктомии. В литературе нет подробного описания особенностей послеоперационных изменений сонных артерий в зависимости от метода оперативного вмешательства.

La columna poscirugía

Failed back surgery syndrome is the persistence or reappearance of pain after surgery on the spine. This term encompasses both mechanical and nonmechanical causes. Imaging techniques are essential in postoperative follow-up and in the evaluation of potential complications responsible for failed back surgery syndrome.This review aims to familiarize radiologists with normal postoperative changes and to help them identify the pathological imaging findings that reflect failed back surgery syndrome. To interpret the imaging findings, it is necessary to know the type of surgery performed in each case and the time elapsed since the intervention.In techniques used to fuse the vertebrae, it is essential to evaluate the degree of bone fusion, the material used (both its position and its integrity), the bone over which it lies, the interface between the implant and bone, and the vertebral segments that are adjacent to metal implants.In decompressive techniques it is important to know what changes can be expected after the intervention and to be able to distinguish them from peridural fibrosis and the recurrence of a hernia.It is also crucial to know the imaging findings for postoperative infections. Other complications are also reviewed, including arachnoiditis, postoperative fluid collections, and changes in the soft tissues adjacent to the surgical site.

Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications?

Many of the acute alterations after peroral endoscopic myotomy (POEM) may be of little clinical significance, while others may herald major clinical problems. The question whether pneumomediastinum/pneumoperitoneum is a normal postoperative finding after POEM, or should be regarded as a sign of a complication needs to be evaluated. Familiarity with these findings in computed tomography (CT) is essential for radiologists. To evaluate whether or not pneumomediastinum/pneumoperitoneum detected by chest CT is a sign of a complication after POEM using CO2 insufflation for esophageal achalasia. One hundred and eight patients with esophageal achalasia who underwent chest CT within 30 hours after POEM were included. CT findings were retrospectively reviewed by two radiologists in consensus. The correlation between pneumomediastinum and/or pneumoperitoneum shown on CT and the development of complications was analyzed. Abnormal findings were identified on post-treatment CT, including pneumomediastinum and/or pneumoperitoneum (53.7%, 58/108), pneumothorax (0.9%, 1/108), subcutaneous emphysema (29.6%, 32/108), pleural effusion (69.4%, 75/108), segmental atelectasis of lung tissue (29.6%, 32/108), minor inflammation of lungs (69.4%, 75/108), and ascites (0.9%, 1/108). Pneumomediastinum and pneumoperitoneum were observed simultaneously in 29 cases. The incidence rate of mild complications was high (79.6%, 86/108), while the rate of severe complications was low (2.8%, 3/108). There was no significant correlation between the occurrence of pneumomediastinum and/or pneumoperitoneum on CT and the development of complications (P = 0.542), or the development of severe complications including delayed hemorrhage, esophageal perforation, and retroperitoneal abscess. Pneumomediastinum and pneumoperitoneum detected by CT occur frequently after POEM and may be regarded as normal postoperative changes.

Imaging of Postoperative Cranium: Normal and Abnormal Appearance

: This presentation aims to describe the imaging patterns of normal postoperative (post-op) cranium and usual and unusual complications of various cranial surgeries. Many radiologists are dealing with imaging of postoperative cranium in their daily practice. They should be familiar with various types of cranial surgeries, including burr holes, craniotomy, craniectomy, and cranioplasty, as well as normal postoperative changes and complications of each cranial surgery. Findings and procedure details: Imaging is of significant importance in the routine postoperative follow-up of neurosurgical cranial procedures. Computed tomography (CT) is the first choice imaging modality. However, magnetic resonance imaging (MRI) may be needed for early or better detection of some complications, especially for ischemia or infections. The most important mainstay of interpreting a post-op cranium is to distinguish normal post-op changes from complications. The first step is familiarity with the normal anatomy. Although the vast majority of post-op CT or MR images are not normal looking, most of their changes are expected (normal) post-op changes which do not adversely affect the patient outcome. Scalp swelling, simple pneumocephalus, small size hemorrhages or edema in surgical site, extradural or subdural fluid collections and dural or surgical site enhancement in early post-op period are examples of normal post-op changes. Some complications are seen only in special procedures (such as plunging of burr holes or extracranial herniation, trephine syndrome, or external brain tamponade in craniectomy) and others are common for all procedures. Skull fractures, infection (extradural abscess, subdural empyema, and bone flap infection), hemorrhage (subdural, extradural, parenchymal hematoma) and pneumocephalous are common complications of all neurosurgical procedures. The most important role of radiologists is to recognize the less common, but life threatening, post-op complications such as tension pneumocephalus, external brain tamponade and paradoxical herniation. Early and accurate diagnosis is essential for improving the outcome. Since some findings may be seen in asymptomatic patients (pseudocomplications), one should always consider the patients clinical status when interpreting the post-op images. Interpretation of post-op cranium images requires knowledge of the normal anatomy, types of craniosurgery, and differentiating normal post-op changes from complications. Reporting a complication, especially a life threatening one, always should be done with clinical correlation.

Radionuclide Imaging of Inflammation and Infection in the Acute Care Setting

Although infection may be suggested by signs and symptoms such as fever, pain, general malaise, and abnormal laboratory results, imaging tests often are used to confirm its presence. Morphologic imaging tests identify structural alterations of tissues or organs that result from a combination of microbial invasion and the inflammatory response of the host. Functional imaging studies use minute quantities of radioactive material, which are taken up directly by cells, tissues, and organs, or are attached to substances that subsequently migrate to the region of interest. Bone scintigraphy is extremely sensitive and can be positive within 2 days after the onset of symptoms. With an accuracy of more than 90%, 3-phase bone scintigraphy is the radionuclide procedure of choice for diagnosing osteomyelitis in unviolated bone. In patients with acute renal failure, gallium imaging facilitates the differentiation of acute interstitial nephritis from acute tubular necrosis. Gallium imaging also is useful in the evaluation of pulmonary infections and inflammation. Many opportunistic infections affect the lungs, and a normal gallium scan of the chest excludes infection with a high degree of certainty, especially when the chest x-ray is negative. In the human immunodeficiency virus positive patient, lymph node uptake usually is associated with mycobacterial disease or lymphoma. Focal pulmonary parenchymal uptake suggests bacterial pneumonia. Diffuse pulmonary uptake suggests an opportunistic pneumonia. Gallium imaging provides useful information about other acute respiratory conditions, including radiation pneumonitis and hypersensitivity pneumonitis. In vitro labeled leukocyte imaging with indium-111 and technetium-99m labeled leukocytes is useful in various acute care situations. The test facilitates the differentiation of normal postoperative changes from infection and is useful for diagnosing prosthetic vascular graft infection. In inflammatory bowel disease, labeled leukocyte imaging is useful for initial screening, monitoring treatment response, detecting recurrent disease, and evaluating patients with discordant physical presentation and laboratory test results. Labeled leukocyte imaging, combined with bone marrow scintigraphy accurately diagnoses complicating osteomyelitis. Fluorine-18-fluorodeoxyglucose, imaging is rapidly completed and provides high-resolution images. This test is especially valuable in patients with fever of unknown origin, patients in septic shock, and mechanically ventilated patients suspected of harboring infection. Fluorine-18-fluorodeoxyglucose imaging also shows promise in inflammatory bowel disease.