Preoperative Imaging Findings Research Articles

Complex Tears, Extrusion, and Larger Excision Are Prognostic Factors for Worse Outcomes 1 and 2 Years After Arthroscopic Partial Meniscectomy for Degenerative Meniscal Tears: A Secondary Explorative Study of the Surgically Treated Group From the Odense-Oslo Meniscectomy Versus Exercise (OMEX) Trial

Background: Few studies have examined morphological findings from preoperative magnetic resonance imaging (MRI) and arthroscopic findings as prognostic factors for outcomes 1 and 2 years after arthroscopic partial meniscectomy (APM). Purpose/Hypothesis: The purpose was to evaluate prognostic factors of preoperative findings from MRI and arthroscopic evaluation on lower extremity performance at 1 year and patient-reported outcomes at 1 to 2 years after APM. The hypothesis was that medial compartment abnormalities would be prognostic for 1- and 2-year functional outcomes. Study Design: Cohort study; Level of evidence, 2. Methods: This secondary analysis from the OMEX (Odense-Oslo Meniscectomy Versus Exercise) trial included 40 patients treated surgically. Regression analyses with adjustments for age, sex, and body mass index explored associations between MRI findings (tear complexity and extrusion), arthroscopic findings (tear length, cartilage injury, and amount of excised meniscal tissue), and the following: lower extremity performance tests and thigh muscle strength at 1 year and the 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales at 1 and 2 years. Results: A complex meniscal tear was a significant and clinically relevant prognostic factor for worse KOOS Symptoms subscores at 2 years (mean, 14.1 points [95% CI, 6.1-22.2]). Meniscal extrusion of at least 11%, 25%, and 20% were significant and clinically relevant prognostic factors for worse KOOS Activities of Daily Living (ADL) subscores at 1 year and worse KOOS Sports and Recreation (Sports/Rec) subscores at 1 and 2 years, respectively. Tear lengths of at least 7.0 mm, 6.7 mm, and 6.5 mm were significant and clinically relevant prognostic factors for better KOOS Symptoms subscores at 1 year and better KOOS Sports/Rec subscores at 1 and 2 years, respectively. A cartilage injury in the medial compartment was a significant and clinically relevant prognostic factor for worse KOOS ADL and Quality of Life (QoL) subscores at 2 years (mean, 10.4 and 19.4 points, respectively [95% CI, 3.4-17.4 and 7.7-31.1, respectively]). More than 20% meniscal tissue excised was a significant and clinically relevant prognostic factor for worse KOOS Pain, Symptoms, ADL, and Sports/Rec subscores at 1 and 2 years (mean, 8.9-41.5 points [95% CI, 2.2-15.5 to 21.0-62.0]) and worse KOOS QoL subscores at 2 years (mean, 25.3 points [95% CI, 13.6-37.0]). Conclusion: Complex meniscal tears, larger extrusion, cartilage injuries, and larger meniscal excision were significant and clinically relevant prognostic factors for worse outcomes 1 and 2 years after APM. Registration: NCT01002794 (ClinicalTrials.gov identifier)

Pre-Operative Interictal Discharge Patterns and Magnetic Resonance Imaging Findings Affect Prognosis of Temporal Lobe Epilepsy Surgery

Objective: This study investigated whether pre-operative interictal discharge patterns detected by electroencephalogram (EEG) and magnetic resonance imaging (MRI) findings affect the surgical prognosis in temporal lobe epilepsy (TLE) patients. Methods: A retrospective analysis of 115 cases of patients with refractory TLE was carried out from October 2010 to 2014 based on the classification of pre-operative interictal discharge patterns in EEG and MRI findings. The patients were followed up for 4 years after surgery. The ILAE method was used to assess differences in seizure-free rate among different types of interictal discharge pattern as well as in MRI findings. Results: A total of 115 cases were classified according to interictal discharge patterns in EEG, including normal cases, unilateral anterior discharge, unilateral multi-region discharge, and bilateral discharge. MRI findings were classified into negative results and positive results. Unilateral anterior and bilateral discharges showed statistically significant differences in post-operative seizure-free rates (p< 0.001). MRI-positive cases showed good overall post-operative outcome, irrespective of interictal discharge pattern in the EEG, whereas MRI-negative cases showed good overall prognosis if the interictal discharge pattern in EEG occurred in the unilateral anterior region. Conclusion: If the pre-operative interictal discharge pattern in EEG is confined to the unilateral anterior region, prognosis is good. If there are abnormalities in MRI findings, post-operative prognosis is good, regardless of pre-operative interictal discharge patterns in EEG. Surgical intervention is highly recommended for TLE patients with normal MRI findings and interictal discharge confined to the unilateral anterior region.

Optimizing Perioperative Outcomes with Selective Bowel Resection Following an Algorithm Based on Preoperative Imaging for Bowel Endometriosis

To validate the algorithm for selective bowel surgery based on preoperative imaging by comparing the perioperative outcomes of patients who undergo each type of bowel surgery for deep bowel disease, and secondarily to evaluate the incidence, factors, and subsequent outcomes when the actual procedure performed deviated from the preoperative surgical plan. Retrospective study comparing 3 surgical interventions in an intention-to-treat analysis. Tertiary care hospital. Women with significant pain (visual analog scale [VAS] >7) who were diagnosed with bowel endometriosis from preoperative imaging and underwent laparoscopic surgery for bowel endometriosis at a large referral center between 2014 and 2017. Laparoscopic shaving, disc resection, or full-segment resection and reanastomosis of bowel endometriosis. A total of 172 patients (mean age, 36.6 ± 5.2 years) underwent bowel surgery for endometriosis (n = 30 shaving, 71 disc, and 71 segmental resection). Total operative time was similar in the 3 group, but the mean length of hospital stay was longer in the segmental group (5.3 ± 1.0 days) compared with the disc group (4.6 ± 0.9 days) and the shaving group (3.8 ± 1.5 days) (p = .001). The surgical procedure was performed as planned according to the clinical algorithm in 86.5% of patients. Adherence to the proposed clinical algorithm resulted in a low incidence of overall complications (8.7% of total complications, 4.6% of minor complications, and 3.5% of major complications). The incidence of minor complications was higher in the segmental group (9.9%) compared with the discoid group (1.4%) and the shaving group (0%) (p = .0236), whereas the incidence of major complications were similar across the 3 groups (3.3%, 2.8%, and 4.2%, respectively; p = .899). There was a significantly higher frequency of pseudomembranous colitis in the segmental resection group (7 patients; 9.9%) compared with the discoid group (n = 1; 1.4%) and shaving group (0%) (p = .04). Owing to discrepancies between preoperative imaging and intraoperative findings after dissection and mobilization, deviation from the planned procedure occurred in a total of 25 of 172 cases (14.5%), with a less extensive procedure actually performed in 21 of 25 (84%) of the deviated cases. One of the 4 cases (25%) that involved a more extensive procedure resulted in a major complication of rectovaginal fistula. Selective bowel resection algorithm provides a systematic approach to the surgical management of patients with bowel endometriosis. Adherence to the surgical plan according to the preoperative imaging and criteria outlined in the algorithm can be accomplished in the majority of patients; however, the surgical team should be aware that upstaging or downstaging may be required, depending on the intraoperative findings. When feasible, the team should opt for a less extensive procedure to avoid complications associated with more radical surgery.

The Association Between Preoperative MRI Findings and Surgical Revision Within Three Years After Surgery for Lumbar Disc Herniation.

This cohort study was an analysis of prospectively collected data in the DaneSpine Database. The objective was to determine whether preoperative magnetic resonance imaging (MRI) findings were associated with the frequency of surgical revision due to recurrent lumbar disc herniation (LDH) within 3 years after first-time, single-level, simple lumbar discectomy. Because of a risk of poorer outcome in patients receiving revision surgery compared with first-time discectomy, there is a need to identify patients with LDH in risk of surgical revision prior to the primary discectomy. The association between preoperative MRI findings and revision surgery in patients with LDH has not been thoroughly studied. Following an interobserver reliability study preoperative MRIs were evaluated. Potential predictive variables for surgical revision were evaluated using univariate and multivariate logistic regression analysis. Also, a sum-score of the number of MRI findings at the involved level was assessed. In a study population of 451 operated patients, those who had surgical revision were significantly younger and were significantly less likely to have vertebral endplate signal changes Type 2 (OR 0.36 (95% CI 0.15-0.88)) or more than five MRI findings (OR 0.45 (95% CI 0.21-0.95)) at the involved level than the patients not undergoing surgical revision. Surgical revision was not significantly associated with any other MRI findings. In general, preoperative MRI findings have a limited explanatory value in predicting surgical revision within 3 years after first-time, single-level, simple lumbar discectomy. Both the single variable VESC Type 2 and a sum-score > 5 MRI findings at the operated level were found to be negatively associated with patients undergoing surgical revision. 3.

Risk Factors of Gangrenous Cholecystitis in Patients with Acute Cholecystitis: A Cross-Sectional Study

Introduction: The aim of this study was to determine factors affecting the development of acute cholecystitis toward gangrenous cholecystitis in an Iranian society.Materials and Methods: In this cross-sectional study, all patients who underwent cholecystectomy in the educational hospitals of Khorramabad from August 2013 to August 2016 were included in the study regardless of their age range. The data collected in each patient included demographic data, underlying illnesses, positive history and physical examination prior to surgery, early laboratory findings and preoperative imaging findings. Finally, patients were divided into two groups of acute Cholecystitis and Gangrenous Cholecystitis based on pathological findings after cholecystectomy. The data was finally analyzed using SPSS software.Results: 51 patients were examined during the study. Histological studies indicated the presence of microscopic evidence of acute cholecystitis in all patients, of which 19 had histological evidence of Gangrenous Cholecystitis. In this study, nine variables that could be effective on the prognosis of acute cholecystitis and its progression toward the Gangrenous Cholecystitis were identified. These variables included age, WBC count, diabetes mellitus and coronary artery disease, fluid accumulation around gallbladder, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lipase. Finally, multivariate analysis was performed using logistic regression. It was found that the age of ≥51 was effective in the development of diabetes mellitus.Conclusion: In this study, it was observed that high age, diabetes mellitus and leukocytosis could lead to the development of acute cholecystitis toward Gangrenous Cholecystitis, a finding that requires more extensive studies with more sample size.

A Prospective Clinical Trial to Determine the Effect of Intraoperative Ultrasound on Surgical Strategy and Resection Outcome in Patients with Pancreatic Cancer

Surgical exploration in patients with pancreatic or periampullary cancer is often performed without intraoperative image guidance. Although intraoperative ultrasound (IOUS) may enhance visualization during resection, this tool has not been investigated in detail until now. Here, we performed a prospective cohort study to evaluate the effect of IOUS on surgical strategy and to evaluate whether vascular involvement and radicality of the resection could be correctly assessed with IOUS. IOUS was performed by an experienced abdominal radiologist during surgical exploration in 31 consecutive procedures. IOUS affected surgical strategy by either (i) having no effect, (ii) determining tumor localization, (iii) evaluating vascular involvement or (iv) waiving surgery. Radicality of the resections and vascular contact were determined during pathologic analysis and compared with preoperative imaging and IOUS findings. Overall, IOUS influenced surgical strategy in 61% of procedures. In 21 out of 27 malignant tumors, a radical resection was achieved (78%). Vascular contact was assessed correctly using IOUS in 89% compared with 74% of patients using preoperative imaging. IOUS can help the surgical team to assess the resectability and to visualize the tumor and possible vascular contact in real time during resection. IOUS may therefore increase the likelihood of achieving a radical resection.

Comparison of quantitative measurements of central nervous system tumour consistency and the associated preoperative imaging findings

Purpose: Central nervous system (CNS) tumour consistency is one of the factors determining the difficulty of surgery for such lesions. We measured the consistency of surgically excised CNS tumour specimens using a hardness meter. The purpose of this study was to identify imaging parameters that reflect tumour consistency by comparing preoperative imaging findings with CNS tumour consistency measurements.Material and methods: Of 175 consecutive patients with CNS tumours who underwent surgery at our hospital between October 2012 and October 2018, 127 were included in this study (those whose specimens were difficult to measure were excluded). CNS tumour consistency was measured immediately after surgical excision using a hardness meter and compared with preoperative T1-weighted, T2-weighted (T2WI), fluid attenuated inversion recovery (FLAIR), diffusion-weighted imaging, gadolinium-enhanced magnetic resonance imaging, plain computed tomography (CT), and contrast-enhanced CT findings. Tumour consistency was also subjectively classified by the surgeon into soft, hard, or very hard.Results: The intracranial meningiomas were harder than the metastatic tumours and gliomas (p = 0.03 and p = 0.03, respectively). Among the intracranial meningiomas, the tumours that exhibited high intensity on T2WI were softer than those that displayed isointensity or low intensity (p < 0.001 and p < 0.001, respectively), and the isointense tumours were softer than the low intensity tumours (p = 0.02). Among the metastatic tumours, the tumours that exhibited high intensity on T2WI were softer than those that displayed isointensity or low intensity (p < 0.001 and p < 0.001, respectively). Among the intracranial meningiomas and metastatic tumours, significant correlations were detected between the T2WI findings and subjective tumour consistency according to the surgeon or quantitative tumour consistency (p = 0.01 and p = 0.03, respectively).Conclusions: The preoperative T2WI findings of intracranial meningiomas and metastatic tumours were significantly correlated with quantitatively measured tumour consistency and subjectively evaluated tumour consistency. Therefore, we concluded that T2WI findings are useful for preoperatively predicting the consistency of such tumours.

Headless double-threaded compression screws plus microplate for capitellar fracture of Ring typeII

Objective To investigate the clinical effects of headless double-threaded compression screws plus microplate for treatment of capitellar fracture of Ring type Ⅱ. Methods In the period from March 2015 to February 2018, 12 capitellar fractures of Ring type Ⅱ were treated at Department of Upper limb Orthopedics, Zhengzhou Orthopaedics Hospital. There were 8 men and 4 women, aged from 25 to 57 years (average, 35.4 years). There were 5 left and 7 right fractures. The fractures were exposed and reduced through the posterolateral elbow approach in 6 patients and through the lateral elbow approach in the other 6 ones. Fixation of all the fractures was conducted with headless double-threaded compression screws plus microplate. At the final follow-up, the elbow function was evaluated by the Mayo elbow performance score and the severity of traumatic arthritis by the Broberg & Morrey imaging criteria. Results All the patients were followed up for 9 to 36 months (average, 23 months). The fracture healing time ranged from 9 to 12 weeks (average, 10.6 weeks). The final follow-ups revealed fine stability of the affected elbow joint in all the patients, and no loss of reduction, loosening or breakage of internal fixators or ischemic necrosis in any case. At the final follow-ups, the elbow inflection angles ranged from 90° to 130° (average, 114.3°), the elbow extension angles from 0° to 20° (average, 12.4°), the forearm pronation angles from 50° to 85° (average, 70.5°) and the forearm supination angles from 45° to 80° (average, 64.3°). The Mayo elbow performance scores at the final follow-up averaged 93.2 points (from 85 to 100 points), yielding 8 excellent and 4 good cases. According to the Broberg & Morrey imaging criteria, 10 patients showed no regressive change and 2 patients change by one grade. Conclusions A proper surgical approach should be chosen according to the preoperative imaging findings. The fracture of articular surface can be firmly fixated by head-less double-threaded compression screws and the integrity of the distal lateral column of the humerus can be restored with a microplate to achieve a strong biomechanical fixation. Fine clinical outcomes can be obtained by early functional exercise. Key words: Elbow joint; Bone fixation, internal; Capitellar fracture; Headless double-threaded screws; Microplate

Clinical and Imaging Correlates of Pediatric Mucosal Appendicitis

BackgroundMucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. Materials and methodsAfter IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. ResultsOf 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). ConclusionsMucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.

BORDERLINE ACETABULAR DYSPLASIA: INDEPENDENT PREDICTORS OF HIP INSTABILITY VERSUS IMPINGEMENT

Background: Hips with borderline acetabular dysplasia (lateral center-edge angle, LCEA, between 20° and 25°) are challenging in terms of diagnostic and treatment decision-making. It is accepted that a portion of this population has primarily hip instability-based symptoms consistent with symptomatic acetabular dysplasia, while others have primarily hip impingement-based symptoms consistent with femoroacetabular impingement (FAI). Nevertheless, the diagnostic characteristics that differentiate hip instability and FAI have not been identified. The purpose of this study was to examine a cohort of patients with minor acetabular dysplasia features in order to identify the preoperative clinical characteristics and imaging findings that differentiate patients with hip instability from patients with FAI. Methods: A retrospective cohort study of patients with borderline acetabular dysplasia was performed. Utilizing our institution’s hip preservation database, we identified 143 consecutive hips in 134 patients undergoing hip preservation surgery in the setting of borderline acetabular dysplasia. All patients were identified by prospective radiographic evaluation with an LCEA between 20° and 25°. Inclusion criteria included age 14-40 years and primary surgical treatment. Medical records were reviewed to determine patient demographics, details of clinical presentation, baseline patient-reported outcome scores, physical exam findings, plain radiographic findings, and the operative procedures performed. Statistical analyses were used to compare the clinical features and imaging parameters of the symptomatic acetabular dysplasia and FAI subgroups. Results: Of the 143 hips in the cohort, 39.2% (n = 56) had the diagnosis of symptomatic instability, while 60.8% (n = 87) had the diagnosis of FAI. The cohort included 109 females (76.2%) and 34 males (23.8%). Hips with instability (compared to FAI) had a significantly lower LCEA (21.8° vs. 22.8°; p &lt; 0.001), lower ACEA (23.3° vs. 26.6°; p = 0.002), a higher AI (11.8° vs. 8.5°; p &lt; 0.001), and a lower maximum alpha angle (54.4° vs. 61.1°; p = 0.001). The odds of instability increased 1.7 times for each one-degree decrease in LCEA, 1.4 times for each one-degree decrease in ACEA, and 1.1 times for each one-degree increase in acetabular inclination (all p &lt; 0.003). Sex was strongly associated with the clinical diagnosis, with instability present in 48.6% of females compared to only 8.8% of males (p &lt; 0.001). Patients with instability presented with significantly greater disability, as indicated by the modified Harris hip score, UCLA activity, SF-12 physical function, and HOOS (pain, activities of daily living, sports and recreation, and quality of life) scores (all p = 0.05). The symptomatic acetabular dysplasia subgroup had significantly greater range of motion in terms of internal rotation in flexion (IRF, 22.7° vs. 12.4°, p &lt; 0.001) and total arc of rotational motion (IRF+ERF, 61.2° vs. 47.4°, p &lt; 0.001). Lateral hip pain was present in 42.9% (24/56) of hips in the instability group compared to 25.3% (22/87) of hips in the impingement group (p = 0.03). Conclusions: We found significant differences in the clinical characteristics and radiographic features of the symptomatic acetabular dysplasia and FAI subgroups within the borderline dysplasia cohort. Patients with symptomatic instability tend to have lateral hip pain, greater functional limitations, higher range of motion, and a greater AI, while patients with impingement symptoms tend to have more limited range of motion (especially IRF), a greater ACEA, and a greater alpha angle.

Prognostic significance of preoperative MRI findings in young patients with breast cancer

The objective is to evaluate the prognostic value of preoperative magnetic resonance imaging (MRI) findings in breast cancer patients aged less than 40 years. This retrospective, single-center study evaluated 92 women aged <40 years who received a diagnosis of invasive breast carcinoma between 2008 and 2012. These patients underwent a breast MRI before treatment and follow-up at the same institution. Kaplan-Meier survival curves were used to analyze overall survival, with the log-rank test used to compare different groups. Cox regression analysis was used to estimate hazard ratios (HRs) with 95% confidence interval (95% CI) values. The mean age of the patients was 34 years (range: 25–39 years) and the mean tumor size was 3.9 cm in maximal dimension (range: 0.7–10.5 cm). Recurrence was observed in 21 (22.8%) patients and 15 (16.3%) patients did not survive during a mean follow-up period of 5.4 ± 1.9 years. MRI findings associated with worse overall survival included tumor size >5 cm (HR:5.404; 95% CI:1.922–15.198; p = 0.017), presence of non-mass enhancement (HR:3.730; 95% CI:1.274–10.922; p = 0.016) and multifocal tumor (HR:3.618; 95% CI:1.151–11.369; p = 0.028). Inconclusion, MRI findings that are suggestive of more extensive disease were associated with worse overall survival in young breast cancer patients.

Abstract P3-03-31: Is sentinel lymph node biopsy necessary in all patients with early breast cancer?

Abstract Background and objectives : Since the results of the American College of Surgeons Oncology Group Z0011 published, the criteria for applying axillary lymph node (ALN) dissection was relaxed among early breast cancer patients who were scheduled for breast conserving surgery, adjuvant chemotherapy therapy, and adjuvant radiation therapy. SLNB criteria may be established if pathologic nodal status can be predicted. The aim of this study was to develop a nomogram for preoperative prediction of axillary node metastasis. Methods: The records of 1650 patients with T1, T2 primary invasive breast cancer who were treated between January 2013 and September 2016 were selected from the medical database of Yonsei University (Seoul, South Korea). Those whom a preoperative diagnosis of axillary node metastases were excluded. Two nomogram that predicted three or more axillary metastasis and one or more axillary metastasis were developed using a binary logistic regression model with a training cohort. Internal validation was carried out adopting bootstrap method by validation cohort 500 times resampling. Result: A total of 82 (4.8%) patients had three or more ALNs metastasis. Three hundred seventy five (17.4%) patients had one or more ALNs metastasis. Axillary metastasis was associated with Preoperative ALN suspicious image findings, clinical tumor size, Number of neoplastic foci, estrogen receptor status, Ki-67 expression, tumor marker. The nomogram was developed based on the clinical and statistically significant predictors. It had good discrimination performance (AUC 0.79, 95% CI, 0.73–0.85), (AUC 0.71, 95% CI, 0.67–0.74) and calibration fit. Conclusion:Our nomogram might help predict the ALN metastasis in breast cancer patients. Patients with a low probability of ALN metastasis could be spared SLNB. Citation Format: Yoon KH, Lee KB, Lee H, Lee J, Kim JY, Park HS, Park S, Kim SI, Cho YU, Park B-W. Is sentinel lymph node biopsy necessary in all patients with early breast cancer? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-31.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

Intramedullary spinal cord ependymoma and astrocytoma: intraoperative frozen-section diagnosis, extent of resection, and outcomes.

OBJECTIVEThe intraoperative differentiation of ependymomas from astrocytomas is important because neurosurgical strategies differ between these two tumor groups. Previous studies have reported that the diagnostic accuracy of intraoperative frozen sections of intracranial central nervous system (CNS) tumors is higher than 83%-97%, whereas that for spinal intramedullary tumors remains unknown. Herein, authors tested the hypothesis that intraoperative frozen-section diagnosis is the gold standard for a differential diagnosis of intramedullary spinal cord tumors.METHODSThe clinical characteristics, intraoperative histological diagnosis from frozen sections, extent of tumor resection, progression-free survival (PFS), and overall survival (OS) of 49 cases of intramedullary spinal cord ependymomas (n = 32) and astrocytomas (n = 17) were retrospectively evaluated.RESULTSThe frozen-section diagnosis and final diagnosis with permanent sections agreed in 23 (72%) of 32 cases of ependymoma. Of the 9 cases of ependymoma in which the frozen-section diagnosis disagreed with the final diagnosis, 4 were incorrectly diagnosed as astrocytoma and the other 5 cases had a nonspecific diagnosis, such as glioma. Nonetheless, gross-total resection was achieved in 6 of these 9 cases given the presence of a dissection plane. The frozen-section diagnosis and final diagnosis agreed in 12 (71%) of 17 cases of astrocytoma. Of the 5 cases of astrocytoma in which the frozen-section diagnosis disagreed with the final diagnosis, 1 was incorrectly diagnosed as ependymoma and the other 4 had a nonspecific diagnosis. Gross-total resection was achieved in only 1 of these 5 cases.A relationship between the size of tumor specimens and the diagnostic accuracy of frozen sections was not observed. Ependymal rosettes and perivascular pseudorosettes were observed in 30% and 57% of ependymomas, respectively, but were absent in astrocytomas.Progression-free survival and OS were both significantly longer in cases of ependymoma than in cases of astrocytoma (p < 0.001). Gross-total resection was achieved in 69% of ependymomas and was associated with longer PFS (p = 0.041). In the astrocytoma group, gross-total resection was achieved in only 12% and there was no relationship between extent of resection and OS. Tumor grades tended to correlate with OS in astrocytomas (p = 0.079).CONCLUSIONSThe diagnostic accuracy of intraoperative frozen sections was lower for intramedullary spinal cord ependymomas and astrocytomas in the present study than that for intracranial CNS tumors reported on in the literature. Surgical strategies need to be selected based on multiple factors, such as clinical characteristics, preoperative imaging, frozen-section diagnosis, and intraoperative findings of the tumor plane.

Accuracy of preoperative imaging in predicting optic nerve invasion in retinoblastoma: A retrospective study.

Purpose:Optic nerve invasion is an important cause of mortality in retinoblastoma. We aimed correlate preoperative imaging and surgical histopathology findings in enucleated eyes with retinoblastoma to determine the efficacy of preoperative imaging in predicting optic nerve invasion in retinoblastoma.Methods:A retrospective review of records of all patients undergoing primary enucleation for retinoblastoma at a tertiary eyecare system between March 2013 and December 2017 with all patients having undergone preoperative imaging, either CT scan or MRI. Data was analyzed statistically to determine the correlation between preoperative CT scan/MRI and histopathology.Results:Totally, 97 eyes of 97 patients were included in the study who underwent primary enucleation for unilateral retinoblastoma. The average age at presentation was 27.8 months with the chief complaint being leukocoria in all the cases. 14 patients (14.43%) had evidence of optic nerve involvement in preoperative imaging. 30 patients had optic nerve invasion on histopathology (laminar and retrolaminar). Spearman's rank correlation test revealed a significant correlation between MRI findings and HP and an insignficant correlation between CT findings and HP. The CT scan had a sensitivity of 20%, specificity of 88.89%, 50% positive predictive value and 66.67% negative predictive value. MRI had a sensitivity of 40%, specificity of 93.55%, positive predictive value of 66.67% and a negative predictive value of 82.86%.Conclusion:MRI showed significant moderate correlation with surgical histopathology for predicting optic nerve invasion in retinoblastoma whereas CT shows insignificant correlation with HPE. Therefore, we recommend MRI for predicting optic nerve invasion in cases of retinoblastoma.

Effect of Preoperative Uric Acid Level and Neutrophil / Lymphocyte Ratio on Preoperative and Postoperative Visual Analogue Pain Scores in Patients with Lumbar Disc Herniation: A Cross-Sectional Study.

To determine the relationship between the serum urate (SU) level, neutrophil / lymphocyte ratio (NLR), and pain severity using preoperative and postoperative visual analogue scale (VAS) scores in patients with lumbar disc herniation (LDH). This single-center, cross-sectional study included 20 consecutive patients who were operated for LDH by the same surgeon. The patients'pre- and postoperative UA levels, NLRs, and intensity severity VAS scores were investigated. Preoperative magnetic resonance imaging (MRI) findings, serum UA levels, and neutrophil and lymphocyte counts were recorded. Pain severity was recorded preoperatively and at 6 months postoperatively. Effects of the preoperative SU levels and NLRs on the pre- and postoperative VAS scores were statistically assessed. Statistically significant positive correlation coefficients were determined between NLR and the preoperative and postoperative VAS scores. Negative correlation coefficients were found between the SU levels and preoperative VAS scores; in contrast, positive correlation coefficients were found between the SU levels and the postoperative VAS scores. Our results demonstrate the importance of not ignoring the serum UA level and NLR in pre- and postoperative pain in patients with LDH. Nevertheless, further extensive studies are warranted.

The many faces of pseudomyxoma peritonei: a radiological review based on 30 cases.

Objective:To determine the most common imaging features of pseudomyxoma peritonei (PMP), as well as the histologic subtypes of the primary tumors.Materials and Methods:We reviewed 30 cases of women with pathologically confirmed PMP. Only computed tomography scans were available. All cases were retrospectively studied by four radiologists, working independently. We identified the most common imaging findings, the predominant primary site of the disease, and the growth pattern. The most common sites of recurrence were also analyzed.Results:The most common computed tomography finding was peritoneal/omental nodules (including “omental caking”), followed by visceral scalloping and non-mucinous ascites. The most common site of the primary tumor was the appendix (in 63.3%), followed by the ovaries (in 16.6%), and 16.6% of the tumors were of undetermined origin. There was one case of synchronous appendiceal and ovarian tumors. Low-grade mucinous neoplasm was the most common histologic subtype, accounting for 84.2% of the appendiceal tumors and 40% of the ovarian tumors.Conclusion:Although PMP is a relatively rare entity, radiologists must be aware of its possible imaging findings, common locations, and possible patterns of recurrence. The origin of the primary tumor should also be investigated. Future studies are needed in order to determine which preoperative imaging findings predict surgical outcomes and to characterize the main findings of radiological recurrence.

Outcome Analysis of Pediatric Pyeloplasty in Varied Presentation in Developing Countries

Objectives: The objective was to study the various presentations of pelviureteric junction (PUJ) obstruction in developing countries and its outcomes. Materials and Methods: We retrospectively reviewed the medical records of 239 children (260 renal units) who underwent surgery for PUJ obstruction between January 1994 and December 2016. Data on the patients presenting with symptoms and preoperative imaging findings of ultrasonography, intravenous urography, or diuretic renography were analyzed. Results: In all cases, we preferred dismembered Anderson-Hynes pyeloplasty with or without JJ stenting. Complications of pyeloplasty included prolonged urine leakage in 13 patients, of whom 4 responded to conservative management, 5 required percutaneous nephrostomy (PCN), and 4 were treated with endoscopic JJ stenting. Six patients had persistent obstruction: two responded to endopyelotomy, and in four, redo pyeloplasty was successful. Five patients with renal function of &lt;10% were initially treated with PCN and ultimately required nephrectomy. Conclusions: In patients born with PUJ obstruction and impaired renal function, pyeloplasty fails to significantly improve function, possibly because of cortical loss. However, in patients with antenatal PUJ obstruction managed expectantly, there is a small but significant risk of modest permanent loss of renal function.

Preoperative Assessment of the Peroneal Tendons in Lateral Ankle Instability: Examining Clinical Factors, Magnetic Resonance Imaging Sensitivity, and Their Relationship

The purpose of our study was to examine the preoperative clinical factors and magnetic resonance imaging (MRI) findings associated with peroneal pathology in chronic lateral ankle instability patients, as well as the clinical factors associated with peroneal lesions being detected on MRI. Peroneal pathology was determined from intraoperative findings. Patients with/without peroneal pathology were compared regarding their preoperative clinical findings. MRI reports were examined to determine the sensitivity of detecting peroneal pathologies. Clinical factors were compared between patients (N = 238) with undetected and detected peroneal lesions on MRI. Conservative treatment, preoperative physical therapy, and lack of a traumatic inciting event were associated with peroneal pathology. MRI had a sensitivity of 61.11% for detecting peroneal pathology. No clinical factors were significantly different between “detected” and “undetected” cases. Certain historical factors were associated with peroneal pathology in patients with chronic lateral ankle instability, and MRI had a high false-negative rate. Surgeons should exercise caution when ruling out peroneal pathology based on preoperative physical examination or MRI.

Surgical management of patellofemoral instability. I. Imaging considerations.

The patellofemoral joint is a complex joint that relies on both bone and soft tissues for its stability. Dysfunction of the patellofemoral joint, whether pain or instability, is a common cause of medial consultation. Thorough clinical and imaging assessment is important for managing these patients, who may require a combination of a bony and soft tissue surgical procedure. Trochlear dysplasia, a cause of anterior knee pain and patellar instability, has been classified using conventional radiography. Radiographic signs on a lateral projection, such as the "double contour" sign and the "crossing sign", can alert the radiologist to the grade of trochlear dysplasia. Magnetic resonance imaging (MRI) is the gold standard for accurately assessing the soft tissue around the patellofemoral joint, such as the medial patellofemoral ligament and the medial and lateral patella retinacula, especially in the context of a transient patella dislocation. Risk factors for patellofemoral instability, such as patella alta, an increased tibial tubercle to trochlear groove distance and trochlear dysplasia, can all be assessed on MRI. Advanced imaging techniques such as dynamic MRI and CT are able to demonstrate patellar maltracking. These techniques can also be employed to reliably assess the outcomes of treatment. In this article, we review the normal and abnormal pre-operative imaging findings of the knee extensor mechanism in relation to patellofemoral joint instability. This review provides a useful tool for the reporting radiologist and highlights the imaging findings that are of relevance to the orthopaedic surgeon.