Surgical Management Plan Research Articles

Subcutaneous injection: learning from experience in other specialties

Abstract Haemophilia treatment is characterised by intravenous infusions of clotting factor concentrates, with nurses frequently taking the lead role in administration, patient training and patient care. In recent years, a number of novel factor and non-factor-based therapies delivered by subcutaneous injection have been developed. These therapies are now undergoing clinical trials and will shortly be available in clinical practice. The coming era of at least some haemophilia treatments being delivered by subcutaneous injection clearly represents a significant change not only for patients (for whom they may be more convenient) but also for haemophilia nurse practice, particularly with respect to bleed and surgical management plans, and hence for nurse training and education. This review describes evidence-based guidance on subcutaneous injection technique and summarises the implications for nurses.

Seminal vesicle‐rectal fistula: A review of an unusual complication following low anterior resection for rectal cancer

Low anterior resection is the most common operation in the USA for low rectal cancers. Seminal vesicle‐rectal (SV‐R) fistula is an extremely uncommon complication of this operation. The objective of the present literature review was to investigate risk factors that lead to the development of SV‐R fistula, clinical presentation, investigation and management options. There were nine articles of relevance which reported a total of 12 cases of SV‐R fistula. All other iatrogenic or cryptogenic fistula were excluded. Twelve cases were identified in the literature, and we describe one further case. Pneumaturia and fever were presenting symptoms in 10 of 13 cases; 69.2 per cent (n = 9) of cases presented within 2 weeks of the procedure. Computed tomography was the investigation of choice in nine of 13 cases. A variety of surgical and conservative management plans were utilized. Conservative management was successful in 46.1 per cent (n = 6) of cases. The present study provides the first concise review of SV‐R fistula following low anterior resection and adds a further case. It is also the first article of its kind to recommend a treatment algorithm that consists of a trial of conservative management.

Essential Components of Melanoma Histopathological Reporting: The Surgical Oncologist's Perspective.

Histopathological reporting plays a critical role in guiding the surgical oncologist's management plan in treatment of primary cutaneous melanoma. The International Collaboration on Cancer Reporting (ICCR) espouses various components of structured histopathological reporting as “essential” or “recommended.” From a surgical oncologist's perspective, we discuss the clinical relevance of each essential component, as well as prognostic and treatment implications with regard to treatment planning.

Clinical Value of CT Colonography Versus Preoperative Colonoscopy in the Surgical Management of Occlusive Colorectal Cancer.

CT colonography (CTC) has been recognized as a complementary approach to evaluating the entire colon after incomplete colonoscopy (IC) in patients with occlusive colorectal cancer (CRC). The objective of this study is to evaluate changes in preoperative surgical planning after CTC is performed for patients with occlusive CRC and IC in an oncologic hospital. This retrospective study included 65 consecutive patients with occlusive CRC who underwent CTC after IC at our institution from February 2000 to April 2016. CTC examinations and radiology reports were reviewed by an abdominal radiologist. Clinical information was obtained from a review of the electronic medical record. CTC contributed to a change in the initial surgical plan of the surgeon for 14 of 65 patients (21.5%). In these 14 patients, CTC detected five synchronous proximal colon polyps (35.7%), five synchronous proximal cancers (35.7%), two imprecise CRC locations (14.3%), one case of proximal colon ischemia (7.1%), and one instance of tumor infiltration of the urinary bladder (7.1%). All CTC findings were confirmed at surgery, and all proximal colon polyps were subsequently confirmed to be advanced adenomas. The preoperative CTC findings optimized the surgical management plan for 21.5% of patients with occlusive CRC and IC.

Diagnostic accuracy of touch imprint cytology for head and neck malignancies: a useful intra-operative tool in resource limited countries

BackgroundIntraoperative consultation is an important tool for the evaluation of the upper aerodigestive tract (UAT) malignancies. Although frozen section analysis is a preferred method of intra-operative consultation, however in resource limited countries like Pakistan, this facility is not available in most institutes; therefore, we aimed to evaluate the diagnostic accuracy of touch imprint cytology for UAT malignancies using histopathology of the same tissue as gold standard.MethodsThe study involved 70 cases of UAT lesions operated during the study period. Intraoperatively, after obtaining the fresh biopsy specimen and prior to placing them in fixative, each specimen was imprinted on 4-6 glass slides, fixed immediately in 95% alcohol and stained with Hematoxylin and Eosin stain. After completion of the cytological procedure, the surgical biopsy specimen was processed. The slides of both touch Imprint cytology and histopathology were examined by two consultant histopathologists.ResultsThe result of touch imprint cytology showed that touch imprint cytology was diagnostic in 68 cases (97.1%), 55 (78.6%) being malignant, 2 cases (2.9%) were suspicious for malignancy, 11 cases (15.7%) were negative for malignancy while 2 cases (2.9%) were false negative. Amongst the 70 cases, 55 cases (78.6%) were malignant showing squamous cell carcinoma in 49 cases (70%), adenoid cystic carcinoma in 2 cases (2.9%), non-Hodgkin lymphoma 2 cases (2.9%), Mucoepidermoid carcinoma 1 case (1.4%), spindle cell sarcoma in 1 case (1.4%). Two cases (2.9%) were suspicious of malignancy showing atypical squamoid cells on touch imprint cytology, while 13 cases (18.6%) were negative for malignancy, which also included 2 false negative cases. The overall diagnostic accuracy of touch imprint cytology came out to be 96.7% with a sensitivity and specificity of 96 and 100%, respectively while PPV and NPV of touch imprint cytology was found to be 100 and 84%, respectively.ConclusionOur experience in this study has demonstrated that touch imprint cytology provides reliable specific diagnoses and can be used as an adjunct to histopathology, particularly in developing countries, where the facility of frozen section is often not available, since a rapid preliminary diagnosis may help in the surgical management planning.

Invasive aspergillus sinusitis with orbitocranial extension.

Context:Invasive sinonasal aspergillosis is a silently progressive disease that, left untreated, may invade the adjacent intracranial and intra-orbital compartments incurring serious morbidity.Aim:To evaluate our results of a collaborative surgical management plans for patients with invasive sinonasal aspergillosis with orbitocranial extension.Setting and Design:Retrospective study.Materials and Methods:Between the years 2000 and 2012, 12 patients with Aspergillus sinusitis with orbitocranial extension were treated at our institution. Preoperative CT and MRI scans were done in all cases and cerebral angiography in two patients with subarachnoid hemorrhage (SAH). Surgical combined transcranial and endonasal approaches to the skull base were considered in all patients. Adjuvant antifungals were administered postoperatively with regular clinical and radiologic follow up.Results:All cases had a long history of headache and nasal obstruction (n = 12). Five presented with unilateral proptosis, one with meningitis, one with epilepsy, two with SAH, and one patient presented with trigeminal neuralgia. Craniotomy alone was chosen for the patients with isolated sphenoiditis (n = 2) while a combined cranial and endonasal approach was elected for the other patients (n = 10). Adjuvant antifungal therapy was used for 3-12 months. Patients were followed up clinically and radiologically for an average 36-month period (range = 12-50 months) with disease eradication achieved in eight patients (67%). Two died as consequence to SAH. Follow up also showed that three patients (25%) had sinunasal recurrence requiring evacuation through an endonasal approach.Conclusions:Surgical intervention, with adjuvant antifungal therapy, aiming for safe total removal of the fungal burden, whenever feasible, has a major role in the management of invasive sinonasal aspergillosis with orbitocranial extension with minimal morbidity and good outcomes.

Surgical Techniques for Dealing with Intraluminal Thrombus of Great Vessels in Advanced Differentiated Thyroid Carcinoma

ABSTRACT Aim We aim to define and refine the surgical technique for dealing with intraluminal thrombus of great vessels in advanced differentiated thyroid carcinoma (DTC) to reduce the morbidity. Background Venous tumor thrombus from DTC is a rare occurrence with sequelae that cause increased morbidity and early mortality. Management of such patients poses a challenge to surgeons. Materials and methods We define the surgical planning and road map for surgical management of advanced DTC with tumor thrombus involving the internal jugular vein (IJV) and superior vena cava (SVC) by sacrificing one IJV and retrieving the thrombus from the SVC by Fogarty catheter. This technique has minimal morbidity with good outcome. Conclusion By appropriate planning and meticulous surgical techniques, we can aggressively manage patients of advanced DTC with venous tumor thrombus and reduce the morbidity. Clinical significance By surgical techniques leading to complete surgical resections and saving native vital structures, we can aim for successful aggressive surgical management of advanced DTC with venous tumor thrombus. How to cite this article Dhanda M, Anand A, Vijayant D, Sonkar AA, Singh KR, Ramakant P, Mishra A. Surgical Techniques for Dealing with Intraluminal Thrombus of Great Vessels in Advanced Differentiated Thyroid Carcinoma. World J Endoc Surg 2017;9(3):115-117.

Pelvic Mass Lesions in Females: Tissue Characterization Capability of MRI.

Magnetic Resonance Imaging (MRI) of adult female pelvis is a well-established tool in the evaluation of utero-ovarian lesions and is often used to supplement ultrasonography. The need for diagnostic surgical intervention has largely been eclipsed with the advent of MRI, which has become the imaging modality of choice for characterization of pelvic masses. To assess the role of MRI in female pelvic mass lesions and to exploit the tissue characterization capability of MRI. A prospective observational study was done on all patients referred to Department of Radiodiagnosis, Krishna Hospital, Karad, for MRI pelvis with clinically suspected uterine and adnexal masses or with indeterminate diagnosis on ultrasonography. Study was conducted between September 2014 to August 2016 with a sample size of 100 patients. All patients were scanned using 1.5 Tesla Seimens Avanto (Tim+Dot) scanner with Body matrix coil Tim. Histopathology was taken as gold standard. Results on continuous measurements were presented on Mean±SD (Min-Max) and results on categorical measurements were presented in Number (%). Among 100 cases, on MRI, the maximum number of patients was having uterine lesions (48) followed by ovarian lesions (40), inconclusive adnexal/ovarian lesions (6), adnexal lesions (4). Two patients had normal findings. This correlated well with histopathology results, which showed the maximum number of patients were having uterine lesions (48) followed by ovarian lesions (41), adnexal lesions (5). Normal findings were observed in two patients. Due to excellent depiction of pelvic anatomy, non-invasiveness and absence of ionizing radiation, MRI is an excellent tool for assessment of utero-ovarian disorders, for detecting and characterization of various diseases, and staging patients with carcinomas where accurate diagnosis will make an impact on their surgical and medical management planning.

Preoperative MRI evaluation of mesorectum in cases of rectal carcinoma

Objectives The aim of this study was to evaluate the accuracy of MRI in preoperative staging, in the prediction of negative circumferential resection margin (CRM), and in the planning of surgical management for rectal carcinoma. Background Rectal cancer constitutes about one-third of all gastrointestinal tumors. Preoperative imaging for staging of rectal cancer has become an important aspect of the current approach to rectal cancer management because it helps to select suitable patients for neoadjuvant chemoradiotherapy and determine the appropriate surgical technique. The purpose of this study was to assess the accuracy of MRI in the preoperative staging of rectal carcinoma, in the prediction of negative CRM, and for planning its surgical management. To this end we aimed to study its efficacy in preoperative local staging of rectal carcinoma (T and N stages), in evaluating mesorectal fat and fascia involvement, and in the prediction of negative CRM. Patients and methods Thirty-seven patients with pathologically proven rectal carcinoma underwent pelvic MRI on a 1.5 T magnet with pelvic phased array coil with transrectal gel administration. The MRI protocol was adhered to. All cases were operated upon and their postoperative specimens were compared with preoperative MRI results. Results Comparable to histopathological examination, MRI correctly diagnosed in 34 out of 37 patients in different T stages (accuracy 91.9%) and in 32 out of 37 patients in different N stages (accuracy 86.5%). Accuracy in the evaluation of mesorectal fat invasion was 97.3%, that in the evaluation of mesorectal fascia invasion was 94.5%, and that in the evaluation of CRM was 97.3%. Conclusion MRI of rectal cancer is accurate for preoperative staging, evaluation of mesorectal fat and fascia, prediction of negative CRM, and evaluation of lymph node involvement.

Teaching Evidence Based Medicine in Surgical Education; the Challenges and Techniques in Training

Evidence Based Medicine integrates clinical expertise, best available clinical evidence, as well as patient’s values and preferences to manage the care of patients. Surgeons have traditionally performed surgery according to their mentor teachings, these techniques being passed down through several generations. Current surgeon culture must evolve to integrate EBM into their clinical practice. The knowledge and skills required for searching and appraising critical literature needs to be taught to enable surgeons to implement it effectively. Evidence based surgery (EBS) will encourage surgeons to apply the best up-to-date knowledge to find the most effective surgical management plan for their patients. Several methods of teaching EBS to surgical trainees have shown to be effective including workshops, small group discussions, lecture style teaching and courses involving a combination of techniques. Journal clubs have gained in popularity and provided excellent teaching environments for surgeons to learn critical appraisal. Recently EBM has been introduced into the undergraduate programme to provide young medical practitioners with a strong foundation in EBM competency, and a positive attitude towards applying EBM to clinical practice. In this review, we aim to provide an overview of the principles of EBM and the success and challenges of teaching methods to deliver EBM for the surgical field.

Outcome of cardiac surgery in patients with low preoperative ejection fraction.

BackgroundIn patients undergoing cardiac surgery, a reduced preoperative left ventricular ejection fraction (LVEF) is common and is associated with a worse outcome. Available outcome data for these patients address specific surgical procedures, mainly coronary artery bypass graft (CABG). Aim of our study was to investigate perioperative outcome of surgery on patients with low pre-operative LVEF undergoing a broad range of cardiac surgical procedures.MethodsData from patients with pre-operative LVEF ≤40 % undergoing cardiac surgery at a university hospital were reviewed and analyzed. A subgroup analysis on patients with pre-operative LVEF ≤30 % was also performed.ResultsA total of 7313 patients underwent cardiac surgery during the study period. Out of these, 781 patients (11 %) had a pre-operative LVEF ≤40 % and were included in the analysis. Mean pre-operative LVEF was 33.9 ± 6.1 % and in 290 patients (37 %) LVEF was ≤30 %. The most frequently performed operation was CABG (31 % of procedures), followed by mitral valve surgery (22 %) and aortic valve surgery (19 %). Overall perioperative mortality was 5.6 %. Mitral valve surgery was more frequent among patients who did not survive, while survivors underwent more frequently CABG. Post-operative myocardial infarction occurred in 19 (2.4 %) of patients, low cardiac output syndrome in 271 (35 %). Acute kidney injury occurred in 195 (25 %) of patients. Duration of mechanical ventilation was 18 (12–48) hours. Incidence of complications was higher in patients with LVEF ≤30 %. Stepwise multivariate analysis identified chronic obstructive pulmonary disease, pre-operative insertion of intra-aortic balloon pump, and pre-operative need for inotropes as independent predictors of mortality among patients with LVEF ≤40 %.ConclusionsWe confirmed that patients with low pre-operative LVEF undergoing cardiac surgery are at higher risk of post-operative complications. Cardiac surgery can be performed with acceptable mortality rates; however, mitral valve surgery, was found to be associated with higher mortality rates in this population. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcome.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0271-5) contains supplementary material, which is available to authorized users.

Evaluation of the Effect of Diagnostic Molecular Testing on the Surgical Decision-Making Process for Patients With Thyroid Nodules.

Diagnostic molecular testing is used in the workup of thyroid nodules. While these tests appear to be promising in more definitively assigning a risk of malignancy, their effect on surgical decision making has yet to be demonstrated. To investigate the effect of diagnostic molecular profiling of thyroid nodules on the surgical decision-making process. A surgical management algorithm was developed and published after peer review that incorporated individual Bethesda System for Reporting Thyroid Cytopathology classifications with clinical, laboratory, and radiological results. This algorithm was created to formalize the decision-making process selected herein in managing patients with thyroid nodules. Between April 1, 2014, and March 31, 2015, a prospective study of patients who had undergone diagnostic molecular testing of a thyroid nodule before being seen for surgical consultation was performed. The recommended management undertaken by the surgeon was then prospectively compared with the corresponding one in the algorithm. Patients with thyroid nodules who did not undergo molecular testing and were seen for surgical consultation during the same period served as a control group. All pertinent treatment options were presented to each patient, and any deviation from the algorithm was recorded prospectively. To evaluate the appropriateness of any change (deviation) in management, the surgical histopathology diagnosis was correlated with the surgery performed. The study cohort comprised 140 patients who underwent molecular testing. Their mean (SD) age was 50.3 (14.6) years, and 75.0% (105 of 140) were female. Over a 1-year period, 20.3% (140 of 688) had undergone diagnostic molecular testing before surgical consultation, and 79.7% (548 of 688) had not undergone molecular testing. The surgical management deviated from the treatment algorithm in 12.9% (18 of 140) with molecular testing and in 10.2% (56 of 548) without molecular testing (P = .37). In the group with molecular testing, the surgical management plan of only 7.9% (11 of 140) was altered as a result of the molecular test. All but 1 of those patients were found to be overtreated relative to the surgical histopathology analysis. Molecular testing did not significantly affect the surgical decision-making process in this study. Among patients whose treatment was altered based on these markers, there was evidence of overtreatment.

Preoperative staging and planning for sphincter sparing surgery in rectal carcinoma using high resolution T2WI following endorectal gel administration

PurposeTo assess the accuracy of high resolution T2WI with the addition of DWI in the preoperative staging, prediction of negative circumferential resection margin and planning of surgical management of rectal carcinoma. Patients and methodsSeventy-five patients (30 men and 45 women) with pathologically proven rectal carcinoma underwent high resolution MRI study with trans-rectal gel administration. The MRI staging was compared with the postoperative pathological staging. ResultsThe MRI Sensitivity was 98.63%, Specificity 97.3% and accuracy 97.96% in evaluation of T staging. For the assessment of lymph node involvement, the sensitivity was 98.18%, specificity 85.00%, and accuracy 94.67% in correlation with histopathological study. ConclusionHigh resolution MRI is accurate for preoperative staging, prediction of negative circumferential resection margin, lymph nodes involvement and planning the feasibility of sphincter-sparing surgery.

Accuracy of intraoperative frozen section for the evaluation of ovarian neoplasms: an institutional experience.

BackgroundOvarian neoplasms are a heterogeneous group of tumors including surface epithelial, germ cell and sex cord stromal tumors with a subset having low malignant potential (borderline tumors). While the surgical management plan differs in different categories of tumors, preoperative diagnosis is seldom available. In these circumstances, the role of frozen section becomes invaluable. In the current study, we aimed to evaluate the accuracy of the frozen section of ovarian tumors in our setup.MethodsIt was a retrospective study involving 141 cases of ovarian tumors undergoing surgical resection with frozen section evaluation from January 2009 to December 2014. After gross examination, one to five blocks were prepared on the frozen section depending upon the size of the specimen. After frozen section reporting, specimens were processed routinely for final paraffin section evaluation. Results of frozen and paraffin sections were categorized in benign, borderline, and malignant, and accuracy of frozen section was determined.ResultsOut of 141 cases, 107 were diagnosed as benign on final (paraffin) examination, while 6 were borderline and 28 were malignant. Out of 107 benign cases, 45 were non-neoplastic cystic lesions of the ovary including endometriotic, follicular, and corpus luteal cysts. The most common benign neoplastic tumor was mature cystic teratoma (20 cases) followed by mucinous cystadenoma (19 cases), serous cystadenoma (14 cases), sex cord stromal tumors (8 cases), and Brenner tumor (1 case). Among borderline cases, four cases were serous and two of mucinous neoplasms. The most common malignant neoplasm was serous carcinoma (11 cases) followed by mucinous carcinoma (6 cases). The overall accuracy of frozen section diagnosis is above 99 %. The sensitivity and specificity for benign tumors were found to be 100 and 97 %, respectively. The sensitivity and specificity for borderline tumors was 83 and 99 %, respectively, while for malignant tumors, it was 96 and 100 %, respectively.ConclusionsWe found a high sensitivity and specificity of frozen section for the diagnosis of ovarian tumors and to determine its malignant potential. Therefore, it should always be used when the preoperative diagnosis is not definite to govern extent of surgical resection. However, under-diagnosis can occur in tumors of borderline category which can be minimized by increased sampling on the frozen section.

Is Pre-Operative Axillary Staging with Ultrasound and Ultrasound-Guided Fine-Needle Aspiration Reliable in Invasive Lobular Carcinoma of the Breast?

Axillary ultrasound (US) with US-guided fine-needle aspiration (US-FNA) for suspicious lymph nodes is important for pre-operative staging and planning of surgical management. Invasive lobular carcinoma (ILC) metastases were previously thought to be difficult to detect, but with a limited amount of evidence. This study investigated the ability of US and US-FNA to detect ILC metastases by assessing 142 patients with ILC. The sensitivity of US in detection of metastasis was 52.3%, and US was able to exclude 96% of N2 and N3 axillary metastases. The false-negative rate of US-FNA in detection of metastasis for suspicious lymph nodes on US was 34.8%, and lymph nodes with longer maximal dimensions were associated with false-negative US-FNA results. Multiplicity of breast lesions and maximal cortical thickness ≥3.1 mm of lymph nodes were independently associated with metastasis. Although pre-operative US in ILC can reliably exclude advanced axillary nodal disease, US-FNA results should be carefully interpreted.

Personalized Letters Improve Patient Comprehension of Foot and Ankle Pathology and Procedures

The purpose of this study was to enhance patient comprehension of our institution’s communication materials, specifically the standardized forms and information leaflets used in obtaining consent to elective foot and ankle surgery. Studies have shown poor patient comprehension during the consenting process. Improved document readability has been recommended. We evaluated the readability of our existing consent forms and information leaflets using five standard indices: Flesch-Kincaid, Gunning fog, Simple Measure of Gobbledygook, Coleman-Liau, and automated readability. We compared the results with the readability of 50 personalized letters explaining the patient’s individual pathology and surgical management plan as an adjunct to the standard consenting process. Standardized consent forms had the poorest readability, being accessible only to patients having completed higher education. Readability of the patient information leaflets was better, requiring an average reading age of 15– 16 years, and that of the personalized letters better still (average reading age: 14–15 years), yet still markedly exceeding the recommended target age of 11–13 years. We conclude that personalized letters offer an effective low-cost boost to patient understanding of foot and ankle pathology and treatment, but that further improvement is essential if we are to approximate to the recommended targets.

Malignant brainstem tumors in children, excluding diffuse intrinsic pontine gliomas.

OBJECT Malignant tumors of the brainstem, excluding classic diffuse intrinsic pontine gliomas (DIPGs), are a very rare, heterogeneous group of neoplasms that have been infrequently described in the literature. In this paper, the authors present their experiences with treating these unique cancers. METHODS A retrospective chart review was conducted to identify eligible cases over a 15-year period. All tumors involving the pons were, by consensus, felt not to be DIPGs based on their neuroimaging features. Demographic information, pathological specimens, neuroimaging characteristics, surgical and nonsurgical management plans, and survival data were gathered for analysis. RESULTS Between January 2000 and December 2014, 29 patients were identified. The mean age at diagnosis was 8.4 years (range 2 months to 25 years), and 17 (59%) patients were male. The most common presenting signs and symptoms were cranial neuropathies (n = 24; 83%), hemiparesis (n = 12; 41%), and ataxia or gait disturbance (n = 10; 34%). There were 18 glial and 11 embryonal tumors. Of the glial tumors, 5 were radiation-induced and 1 was a malignant transformation of a previously known low-grade tumor. Surgical intervention consisted of biopsy alone in 12 patients and some degree of resection in another 15 patients. Two tumors were diagnosed postmortem. The median overall survival for all patients was 196 days (range 15 to 3999 days). There are currently 5 (17%) patients who are still alive: 1 with an anaplastic astrocytoma and the remaining with embryonal tumors. CONCLUSIONS In general, malignant non-DIPG tumors of the brainstem carry a poor prognosis. However, maximal cytoreductive surgery may be an option for select patients with focal tumors. Long-term survival is possible in patients with nonmetastatic embryonal tumors after multimodal treatment, most importantly maximal resection.

Incidental findings in CT angiograms for free DIEP flap breast reconstruction – Do they change our management?

BackgroundAbdominal CT angiography (CTA) has become an integral part of the pre-operative evaluation of patients undergoing free Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction. It aids accurate delineation of perforator anatomy, assists pre-operative decision making and reduces operative time. However, such detailed imaging invariably yields a variety of incidental findings, with quoted figures of 13–36% in this setting. The purpose of this study was to identify the rate of “incidentalomas” when using DIEP CT angiography and, review how such findings influence our management. MethodA retrospective review was performed, looking at pre-operative scan reports of 154 consecutive patients undergoing free DIEP flap breast reconstructions between July 2008 and June 2012. ResultsOf 154 CTA's reviewed, 116 (75.3%) demonstrated incidental findings. In 71 patients (46.1%), these “incidentalomas” were inconsequential. However, in 37 patients (24.0%) the CTA prompted further investigations, and notably in a further 8 patients (5.2%) metastatic disease or other significant pathology was discovered which changed the operative plan. ConclusionThe overall rate of “incidentalomas” presented in this study is substantially higher than other similar published series, and most importantly, significantly altered the surgical management plan in 5.2% of cases. As such we would advocate that a pre-operative “staging” CTA, imaging the chest, abdomen and pelvis is useful for more than just delineation of vascular anatomy in patients undergoing DIEP flap reconstruction.

Teratogens and Congenital Heart Disease

The antenatal diagnosis of fetal congenital heart disease (CHD) allows for identification of potentially life-threatening conditions that may occur in the early neonatal period. A suspicion of congenital heart disease often occurs during the routine fetal anatomical survey. Subsequently, fetal echocardiography allows for a more detailed assessment of the cardiac lesion that is necessary in order to plan for delivery and postnatal surgical management. To enhance detection of congenital cardiac anomalies, and in particular ones that are potentially serious, it is important for the obstetrical sonographer to have an understanding of potential teratogenic agents associated with an increased risk of congenital heart disease.

Adnexal Masses: Role of Supplemental Imaging With Magnetic Resonance Imaging

Sonography is the primary and often the only imaging modality used for evaluation of an adnexal mass. Grayscale sonography with color and spectral Doppler imaging is able to accurately characterize most of the adnexal masses. Supplemental imaging with computed tomography and magnetic resonance imaging (MRI) is useful in selected cases. Computed tomography is preferred for evaluation of bowel-related pathology masquerading as an adnexal mass and for staging of gynecologic cancers. Owing to its superior contrast resolution and multiplanar imaging capability, MRI is helpful in characterizing an indeterminate adnexal mass, as well as determining the organ of origin of an adnexal mass. MRI thereby allows planning of appropriate surgical or nonsurgical management of neoplastic and nonneoplastic conditions affecting the adnexa. Imaging evaluation of adnexal masses and the supplemental role of MRI in the management of adnexal masses are discussed.