Preoperative Ultrasound Examination Research Articles

Comprehensive ultrasound diagnosis for intraductal spread of primary breast cancer

The current capacity of preoperative ultrasound examinations to estimate the intraductal spread of primary breast cancer was evaluated. The current ultrasound examination has three modes, B-mode, vascularity, and elastography, and this study evaluated this comprehensive ultrasound examination. Of the patients undergoing breast cancer surgery for a breast mass at our department between April 2010 and March 2011, we evaluated 99 in whom breast-conserving surgery was scheduled, and performed preoperative ultrasounds and stored the digital ultrasound images and pathology data. ACR BI-RADS(®)-US lexicon elastography for the main mass and peri-tumoral ductal lesions (PTDL, defined in main sentence), and the vascularity and elasticity pattern (defined in main sentence) were evaluated. A cut end-negative resection at the first procedure after ultrasound estimation was achieved in 76.7%, and the breast was conserved by an additional resection with a negative margin in 90.6%. Shadowing of mass posterior acoustic features tends to indicate cut end-negative results significantly. There was a statistical difference between "vascularity in PTDL" and "elasticity pattern of PTDL". Using the recent comprehensive ultrasound examination with vascularity and elastography was useful for the preoperative estimation of intraductal spread of primary breast cancer in our retrospective study.

Value of High Frequency Ultrasonography in Diagnosis and Surgical Repair of Traumatic Finger Tendon Ruptures

Objective: To investigate the value of high frequency ultrasonography in the diagnosis of zone 2 flexor tendon injuries. Subjects and Methods: Ninety-two patients (49 males and 43 females, mean age 32.6 ± 11.2 years) with zone 2 flexor tendon injuries in one or more digits were randomly divided into a study (n = 46, 95 digits) and a control group (n = 46, 90 digits). In the study group, preoperative ultrasound was performed and surgical repair was conducted based on ultrasonographic findings. Diagnosis and surgical repair of the control group was based on history of trauma and physical examination. Results: Types of ruptures (complete or partial) and the location of the distal end of the ruptured tendon diagnosed by preoperative ultrasonography were consistent with surgical findings in all cases (95/95, 100%) of the study group, whereas the concordance rate between clinically diagnosed ruptures and surgical findings was only 34.4% (31/90) in the control group (p = 0.02). Conclusion: Preoperative high frequency ultrasound examination yielded excellent diagnostic accuracy for zone 2 flexor tendon injuries.

Adnexal masses suspected to be benign treated with laparoscopy.

Guidelines for referring women with pelvic masses suspicious for ovarian cancer to gynecologic oncologists have been developed by the American College of Obstetrician Gynecologists (ACOG). We set out to evaluate the negative predictive value of these guidelines and to assess a modified algorithm involving minimally invasive surgery in the treatment of women with masses suspected to be benign. 257 consecutive patients with adnexal masses of 8cm to 13cm on preoperative ultrasound examination meeting Triage Criteria set forth in ACOG Committee Opinion 280. Patients meeting the selection criteria were scheduled for operative laparoscopy, washings, adnexectomy, bagging, and colpotomy. A total of 240 patients successfully completed intended treatment (93.38%), and 234 of these did not require admission (97.5%). There was a low incidence of significant complications: 97.50% of women were successfully treated as outpatients, 97.92% of surgeries lasted <136 minutes, and <97.08% had blood loss <200mL. The negative predictive value of ACOG Committee Opinion 280 Triage Criteria as a deselector for having invasive ovarian malignancy in our population was 95.57% for premenopausal and 90.91% for postmenopausal women. Laparoscopic adnexectomy, bagging, and colpotomy is a desirable goal for patients with ovarian masses in the 8cm to 13cm range meeting selection criteria affording a minimally invasive approach with attendant benefits including outpatient treatment (97.5%), few complications, low likelihood of iatrogenic rupture of the ovarian capsule (1.25%), and low necessity for reoperation after final pathology is evaluated (6.03%). Negative predictive value of ACOG Committee Opinion 280 is confirmed in a community gynecology practice and is recommended to form the basis of a new treatment algorithm for women with adnexal masses.

Adenoma malignum of the uterine cervix: ultrasonographic findings in 11 patients

To evaluate the ultrasonographic features of adenoma malignum, a minimal deviation adenocarcinoma of the uterine cervix. Eighteen consecutive patients with pathologically confirmed adenoma malignum were enrolled in this study at two institutions. Preoperative ultrasound examination was performed and the results were available in 11 patients. We analyzed retrospectively the gray-scale ultrasound findings for the following morphologic characteristics: cervical enlargement, as well as size, location and ultrasonographic characteristics of lesions. In five patients we also evaluated Doppler features with regard to intralesional vascularity. The cervix was enlarged in 73% (8/11) of cases. The mean greatest tumor diameter was 4.2 (range, 2.5-6.8) cm. In five (45%) cases, the cervix was completely infiltrated by the tumor. At gray-scale ultrasound examination, three (27%) tumors were multilocular lesions, four (36%) were multilocular lesions with solid components and four (36%) were solid lesions. In the multilocular lesions with or without a solid component, locules tended to be 1 cm or less in average diameter (86%, 6/7 cases) and there tended to be 11-20 in number (57%, 4/7 cases). In most (57%, 4/7) cases the locular fluid was homogeneously hypoechoic. Most (75%, 3/4) solid lesions manifested heterogeneous echogenicity. The five (100%) tumors examined with Doppler manifested moderate or abundant color content on color or power Doppler. Adenoma malignum can appear sonographically as solid, multilocular and multilocular solid cervical lesions. Awareness of its clinical and ultrasonographic features might improve diagnosis before surgery.

Long Head of Biceps Brachii Tendon Evaluation: Accuracy of Preoperative Ultrasound

The purpose of this study was to investigate the ability of ultrasound to accurately identify long head of biceps brachii (LHB) tendon abnormalities. The surgical findings for 66 consecutive patients who underwent arthroscopic shoulder surgery were retrospectively compared with the findings of preoperative ultrasound examination. Patients were excluded if more than 200 days elapsed between ultrasound and surgery. Ultrasound images were obtained using high-frequency transducers and were compared with findings at arthroscopy for the presence of LHB tendon abnormalities, including full-thickness tears, partial-thickness tears, or nontear abnormalities, including tendinosis and tenosynovitis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for full- and partial-thickness tears. Ultrasound correctly identified 90% (35/39) of normal LHB tendons, 88% (7/8) of full-thickness tears, 27% (3/11) of partial-thickness tears, and 22% (2/9) of tendons with nontear abnormality in those patients who underwent surgery. In the ultrasound diagnosis of full-thickness tear versus other findings, sensitivity was 0.88, specificity was 0.98, PPV was 0.88, NPV was 0.98, and accuracy was 0.97; in the ultrasound diagnosis of partial-thickness tear versus other findings, sensitivity was 0.27, specificity was 1.00, PPV was 1.00, NPV was 0.88, and accuracy was 0.88, in those patients who underwent surgery. Shoulder ultrasound is an accurate method to confirm a normal biceps tendon or full-thickness tear, but is less accurate in the diagnosis of partial-thickness tear and nontear abnormalities.

OP24.03: Value of preoperative ultrasound examination in the selection of women with adnexal masses for laparoscopic surgery

OP24.03: Value of preoperative ultrasound examination in the selection of women with adnexal masses for laparoscopic surgery

Ultrasound Diagnosis of Acute Appendicitis: Impact on Cost and Outcome in Pediatric Patients

Background: There are only a few reports on the influence of ultrasound (US) diagnosis on the outcome of appendectomies in children. The purpose of this study was to define patterns of care and outcomes of appendectomies in children who underwent preoperative US examinations and compare them with children who did not in two consecutive periods of time. Materials and Methods: This study included 347 consecutive pediatric patients with clinically suspected acute appendicitis, of whom 200 subsequently underwent surgery and were proven to have appendicitis. Two pediatric surgeons clinically evaluated 113 patients (group A) without US examinations over 34 months. The other 87 patients (group B), enrolled in the following 24 months, were referred for US examination before surgery. Graded compression US examination was applied using 7.0–10-MHz linear array transducers. A detailed US examination of the right lower abdomen was followed by a general survey of the whole abdomen to decrease the possibility of misdiagnosis. Costs were compared in the two groups. Results: A total of 153 pediatric patients with acute appendicitis and adequate data were included for cost analysis, 91 in group A (mean age, 8.4 years) and 62 in group B (mean age, 8.2 years). Using the reimbursement code for 1998, the total savings per person was NT$2,210 (US$69) with US diagnosis. If this amount was applied to all 165 patients undergoing appendectomy in 1998 (not only children), the total savings for the year could be as high as NT$364,650 (US$11,395). If a special group of patients with more bizarre clinical patterns were included, the savings per patient would be NT$3,382 (US$106). The total length of hospital stay and complication rate in group A was significantly longer and higher, respectively, than in group B (p < 0.05). Conclusion: Routine US study in pediatric patients with suspected acute appendicitis is a worthwhile diagnostic procedure that may save money, shorten hospital stay, decrease the complication rate, and avert unnecessary surgery.

Targeted Duplex Ultrasound in a One-Stop Dialysis Vascular Access Assessment Clinic

Many duplex detectable factors have been shown to correlate with upper limb arteriovenous fistula (AVF) outcomes, and many practitioners now request preoperative duplex vessel mapping routinely before AVF surgery. We report outcomes from a "one stop" AVF assessment clinic in which the operating surgeons perform their own targeted preoperative ultrasound examinations. All patients undergoing assessment for formation of a new AVF were included in this prospective observational study. A plan was made for surgery based on the results of the physical examination performed by the surgeon and then reviewed in light of the findings from a targeted duplex ultrasound (DUS) that was performed by the surgeon in the clinic on portable ultrasound equipment. Ultimate choice of surgical site and the influence of the DUS were recorded along with postoperative outcomes. In all, 39 patients were included. Four (10%) of the patients received a more distal AVF and eight (20%) were converted to more proximal AVF because of unexpected adverse findings after targeted DUS. In one patient, no site could be confidently selected by physical examination alone. There was a 13% early failure rate with cumulative patency rates of 86% and 73% at 3 and 6 months, respectively. Targeted DUS identified findings that might adversely affect fistula function in one of four patients in this series, whereas one in 10 patients was able to have more distal fistulae formed because of improved confidence in the quality of distal vessels. Early failure and patency rates are comparable with those in units using formal routine ultrasound. These results would suggest that routine targeted DUS, performed quickly by surgeons in an outpatient clinic, can alter surgical planning in one of the three patients and is therefore advocated as a quick, relatively inexpensive and important adjunct to AVF planning.

Imaging of gynecological disease (6): clinical and ultrasound characteristics of ovarian dysgerminoma

To describe the clinical history and ultrasound findings in patients with ovarian dysgerminoma. This was a retrospective study of patients with a histological diagnosis of ovarian dysgerminoma who had undergone preoperative ultrasound examination. The patients were identified from the databases of 11 ultrasound centers. The tumors were described by the principal investigator at each contributing center on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. In addition, three authors reviewed all available electronic ultrasound images (gray-scale images and color/power Doppler images were available for 18 patients and 14 patients, respectively) and described them using subjective evaluation of gray-scale and color Doppler ultrasound findings (here called pattern recognition). Twenty-one patients with ovarian dysgerminoma were identified (including one woman with bilateral masses). Twenty patients had a primary ovarian dysgerminoma (including the one with bilateral masses) and one patient had a recurrence of dysgerminoma in her retained ovary. One of the 21 patients was pregnant. All tumors except one were pure dysgerminomas, one being a mixed germinal cell tumor with 30% dysgerminoma component. Median age was 20 (range, 16-31) years. Information on clinical symptoms was available for 18 patients. In four patients, the tumor was detected incidentally, whereas 14 patients presented with one or more of the following symptoms: acute pain (n = 4), chronic pain (n = 8), bloating (n = 8), menstrual disorders (n = 5) and infertility problems (n = 1). One (5%) patient had ascites. Using the IOTA terms and definitions, all but one dysgerminoma were moderately (43%) or very well (50%) vascularized solid tumors. One tumor was multilocular-solid. According to pattern recognition, most dysgerminomas were highly vascularized, purely solid tumors with heterogeneous internal echogenicity divided into several lobules, had a smooth and sometimes lobulated contour and were well-defined relative to the surrounding organs. The ultrasound finding of a highly vascularized, large, solid, lobulated adnexal mass with irregular internal echogenicity in a woman 20-30 years old should raise the suspicion of ovarian dysgerminoma.

Reconstruction of the Achilles Tendon with a Composite Anterolateral Thigh Free Flap with Vascularized Fascia Lata

Reconstruction of a segmental loss of the Achilles tendon combined with defects in soft-tissue coverage creates a challenge for the surgeon. We present the case of a patient who had combined loss of the Achilles tendon and overlying soft-tissue coverage. The patient was managed successfully with a single surgical procedure involving a composite anterolateral thigh free flap with vascularized fascia lata. The functional outcome of the reconstructed ankle and morbidity in the donor thigh were evaluated at one year with use of a kinetic dynamometer combined with magnetic resonance imaging. The patient was informed that data concerning the case would be submitted for publication, and he consented. A forty-eight-year-old man sustained a complete rupture of the left Achilles tendon during military service. Primary suture repair of the tendon was performed. Four months after that operation, a new rupture occurred when the patient returned to work, and a second tendon repair was performed to reconstruct the defect with the central part of the proximal part of the Achilles tendon (the Bosworth procedure). A large hematoma formed postoperatively, followed by skin necrosis, resulting in a 12-cm segmental tendon loss with an overlying soft-tissue defect measuring 8 × 3 cm. The wound site was debrided of all fibrous and necrotic tissue (Fig. 1). Because of the lack of suitable local tissue, a composite anterolateral thigh flap with attached vascularized fascia lata was harvested after a preoperative Doppler ultrasound examination. The main cutaneous perforator was located in the middle portion of a line between the anterior superior iliac spine and the lateral edge of the patella (Fig. 2). The skin paddle of the anterolateral thigh flap (17 × 8 cm) was designed to be slightly larger than the soft-tissue defect. It was harvested along with its vascular pedicle and a portion of the fascia …

Ultraschall zur Beurteilung des posterioren Ligamentkomplexes bei thorakolumbalen Wirbelsäulenfrakturen

thoracolumbar distraction injuries (AO classification type B) with damage to the posterior ligament complex (PLC) represent an indication for surgery but the use of X-ray and CT imaging often does not identify injuries of the PLC. The aim of this study was to evaluate the accuracy of ultrasound imaging in the assessment of the PLC status in thoracolumbar fractures of the spine. in a prospective study the findings of the preoperative ultrasound examination were compared to the intraoperative findings. over a period of 2 years a total of 24 patients with 27 thoracolumbar fractures (18 type A, 9 type B) were examined. In 22 cases ultrasound examination was possible and correct ultrasound findings were made in 20 cases (91%). The sensitivity was 83.3%, specificity 93.8%, positive predictive value 83.3% and negative predictive value 93.8%. the use of ultrasound examination in thoracolumbar fractures is a suitable diagnostic tool for injuries of the posterior ligament complex in addition to radiological imaging.

Cystic change in thyroid carcinoma: Prevalence and estimated volume in 360 carcinomas

The aim of this study was to determine the prevalence and amount of cystic change in thyroid cancer. This study also examined associated sonographic characteristics of cystic malignant thyroid nodules to help recognize these clinically important nodules. This study was a retrospective review of 360 malignant thyroid nodules surgically removed at our institution between January 1, 2002 and December 31, 2004. All patients had signed research authorization. All patients had preoperative sonograms and surgical pathologic proof of their thyroid malignancy. The 360 malignant nodules were found in 307 patients. All scans were performed using 7- to 15-MHz transducers, and most studies included a digital video clip of the cancer. The preoperative ultrasound examinations were retrospectively reviewed by three radiologists and a sonographer. An estimate of cystic component percentage was derived by consensus. The presence of a mural nodule, thick irregular wall, microcalcifications, and prominent vascularity was also recorded. Of the 360 carcinomas, 318 (88.3%) were solid to minimally (less than 5%) cystic, 33 (9.2%) were 6-50% cystic, 9 (2.5%) were 51-100% cystic. Of the nine (2.5%) malignancies that were greater than 50% cystic, all had other suspicious findings including mural nodules, microcalcifications, increased vascularity, and/or a thick irregular wall about the cystic portion. The vast majority (88%) of thyroid cancer is uniformly solid or has minimal (1-5%) cystic change by sonography. Marked cystic change (>50% of the nodule) occurred in only 2.5% of cancers, which had other sonographic findings worrisome for malignancy.

Prognostic implications of circumferential location of distal rectal cancer

This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. Two hundred and five patients with distal rectal cancer were operated on for a uT2-T4 tumour. Median follow up was 49 months. The location of the tumour was predominantly anterior, posterior or circumferential in 128, 49 and 27 patients, respectively. Anterior tumours were more likely to receive neoadjuvant therapy (P = 0.016) and perioperative blood transfusion (P = 0.012). No significant differences were observed between circumferential position and pT or pN stage, circumferential resection margin involvement or mesorectal excision quality. Sixty-three (30.7%) patients developed recurrence, which was local only in 16 (7.8%). Although tumours involving 360° of the rectal wall had a higher risk of local recurrence (P = 0.048), those with a predominant anterior or posterior position were not related to a higher risk of local or overall recurrence. Anterior rectal tumours do not differ in pathological characteristics from posterior tumours, and their prognosis is no worse when circumferential resection is complete.

Screening for deep venous thrombosis after idiopathic scoliosis surgery in children: a pilot study

Venous thrombosis remains an uncommon disorder in childhood. However, the incidence appears to be increasing for a multitude of reasons. The aim of the study was to detect asymptomatic deep venous thrombosis and prothrombotic diseases in nonsyndromic children undergoing scoliosis surgery. A prospective study including forty successive teenagers scheduled for posterior spinal fusion. Patients with scoliosis with a history of hemoglobinopathies, cardiac defects, blood clots, early onset osteoporosis, as well as patients with skeletal dysplasias and nonskeletal dysplastic syndromic entities have been excluded. The protocol was designed for active screening of deep venous thrombosis using color Doppler ultrasonography on a day before surgery and repeated on the 3rd, 7th and 15th day postoperatively. Evaluation of prothrombotic disorders included antithrombin and protein C activities, and total protein S antigen level. No patient has manifested clinical symptoms of venous thrombosis in our study. Preoperative Doppler and ultrasound examinations were normal in all patients. Although repeated Doppler ultrasonography demonstrated a transient small clot in two patients. Congenital antithrombin deficiency of 5% has been observed in one child only, without the development of deep venous thrombosis. Thromboembolic event seems to be rare after scoliosis surgery. Prophylaxis for venous thrombosis should not be recommended in such patient. But, larger series are required to confirm such results.

Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries

There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009). During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, "pubertal" (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, "pubertal" asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achive satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort. Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.

Imaging in gynecological disease (5): clinical and ultrasound characteristics in fibroma and fibrothecoma of the ovary

To describe the clinical and ultrasound features of fibroma and fibrothecoma of the ovary. Sixty-eight women with a histological diagnosis of fibroma or fibrothecoma of the ovary who had undergone a preoperative ultrasound examination between 1999 and 2007 were identified from the databases of four ultrasound centers. The tumors were characterized on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. In 51 patients, ultrasound information had been collected prospectively; in the remaining 17 cases it was retrieved retrospectively from ultrasound reports and images. In 44 cases, electronic ultrasound images of good quality were available. These were reviewed by two observers, who described them using pattern recognition. Of the 68 patients identified, 53 had fibroma and 15 had fibrothecoma. The mean patient age was 54 (range, 17-80) years. Sixty-three percent (41/65) were postmenopausal and 60% (39/65) had no symptoms. Most (75%; 51/68) fibromas/fibrothecomas were solid tumors and most (75%; 51/68) manifested minimal or moderate blood flow on color Doppler examination. Using pattern recognition, all solid fibromas/fibrothecomas were described as round, oval or slightly lobulated tumors. Most (66%; 29/44) were solid tumors, with regular or slightly irregular internal echogenicity with stripy shadows, and some contained cystic spaces. Others (23%, 10/44) were solid tumors with regular or slightly irregular internal echogenicity without stripy shadows and with or without cystic spaces. Two were solid tumors that were so dense it was difficult to assess their internal echogenicity, two were multilocular solid tumors with large cystic spaces and one was described as being mainly cystic. Half of the women with fibroma/fibrothecoma had fluid in the pouch of Douglas and 16% (11/68) had ascites; CA 125 titers > or =35 U/mL were found in 34% (17/50) of the cases in which CA 125 results were available. Most fibromas and fibrothecomas are round, oval or lobulated solid tumors that cast stripy shadows and are associated with fluid in the pouch of Douglas, and most manifest minimal to moderate vascularization. A fibroma/fibrothecoma with atypical ultrasound appearance may be mistaken for a malignancy, in particular if associated with fluid in the pouch of Douglas or ascites, high color content and raised CA 125 levels.

Primary Common Bile Duct Closure Is Safe Following Emergency and Elective Exploration

We read with interest the study by Ahmed et al. [1] reviewing the need for T-tube placement following common bile duct exploration [1]. We agree with their findings and conclusions to reserve T-tube placement for incomplete ductal clearance and for those patients with difficult access for endoscopic retrograde cholangiopancreatography (ERCP). However, we also feel it is just as imperative to clarify the use of primary closure in the emergency setting. A retrospective review was performed in our unit of all cases of primary closure following a laparoscopic common bile duct exploration from a prospectively collated database. A total of 81 cases (24 males, 57 females) between 1992 and 2006 were identified. The median age within this group was 66 (range = 22–90) years. From this group 60 (74%) patients underwent primary closure following exploration in the elective setting and 21 (26%) patients in the emergency setting. The presence of jaundice was confirmed preoperatively in 33% of the elective subgroup, and 38% of the emergency subgroup, and deranged liver function tests in 40% of the elective group and 43% of the emergency group. Preoperative ultrasound examination identified common bile duct calculi, or a dilated duct in 37% of the elective patients and 52% of the emergency patients. An on-table cholangiogram was performed in 74 cases, and laparoscopic common bile duct exploration was successfully performed in 80 patients with one conversion to open. There was no significant difference in the operative time between either group (mean elective = 150 min, emergency = 151 min). The mean postoperative hospital stay for the elective subgroup was 4.5 days and that for the emergency subgroup was 5.0 days. A total of nine patients (9/81) (elective = 6, emergency = 3) required an ERCP postoperatively, with three patients developing wound infections. There was no mortality in the total group of patients. These results further support findings of Alhamdani et al. [2] with a lower conversion rate achieved in this series. This confirms that no significant difference exists in the outcome measures between patients following primary closure of the common bile duct in either the elective or the emergency setting, and in the hands of an experienced laparoscopic surgeon this method is both safe and efficient. Furthermore, we were also concerned with the lack of use of the transcystic approach for exploration of the common bile duct by the authors. This method has been reported to achieve a high frequency of stone clearance (85%) with low morbidity and a shorter hospital stay. Therefore, it has been proposed to be an effective method for patients with smaller ductal stones [3]. The authors are kindly asked to comment on this issue.

The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy

To investigate the incidence, risk factors, and sonographic findings of maternal ovarian torsion in pregnancy. Retrospective study. Department of Obstetrics/Gynecology of a tertiary referral center. Thirty-three pregnant women with 38 episodes of surgically proven torsion between the years 1993 to 2007. Surgical confirmation and treatment of torsion. Clinical and sonographic findings of ovarian torsion in pregnancy. Sixteen (48.5%) pregnancies were conceived by ovulation induction or in vitro fertilization. Twenty-one torsion events occurred in the first trimester (55.3%) versus 13 (34.2%) and 4 (10.5%) in the second and third trimester, respectively. All patients were admitted with abdominal pain, whereas 22 (57.9%) reported nausea/vomiting. The preoperative ultrasound examination showed unilocular ovarian cysts in 15 (39.5%) cases, multicystic ovaries in 14 (36.8%), and normally appearing ovaries in 9 (23.7%) cases. The multicystic ovary was more common in the first trimester torsion, whereas the "normal" appearing ovary was more common in the second and third trimester torsion (47.6% vs. 23.5% and 14.3% vs. 35.3%, respectively). The median duration from admission to surgery was 6 hours (range, 1 hour to 3.7 days), being significantly shorter in the first trimester. Ovarian torsion in pregnancy is more common in the first trimester, and induction of ovulation is a major risk factor.

POSTOPERATIVE ULTRASONOGRAPHIC APPEARANCE OF UNCOMPLICATED ENTEROTOMY OR ENTERECTOMY SITES IN DOGS

The ultrasonographic findings in 20 dogs with 25 healing enterotomy and enterectomy sites resulting from the removal of foreign material or correction of intussusceptions are presented. In this prospective study, dogs had preoperative abdominal ultrasound examinations followed by sequential sonographic examinations on the first, third, sixth, and 10th days postenterotomy or enterectomy with an additional sonographic examination after 20 days postoperatively. Documented sonographic features included length and maximal intestinal wall thickness of the enterotomy or enterectomy sites, echogenicity of omental/mesenteric fat, amount of free gas and abdominal effusion, and gastrointestinal motility. Sonographically, 57% of enterotomies and 100% of enterectomies were visualized. Pneumoperitoneum, hyperechoic omental/mesenteric fat, and abdominal effusion did not appreciably hamper evaluation of the intestinal surgical site. Absent wall layering at the surgical site was noted in 96% of dogs at day 1 postoperatively. At the final sonographic examination, wall layering remained altered to absent in 100% of dogs and normal thickness was noted in only 20% of dogs. The median maximal wall thickness was 7 and 8 mm for enterotomies and enterectomies respectively, which occurred between days 1 and 3 and days 3 and 6 postoperatively. Effusion and increased echogenicity of omental/mesenteric fat localized to the surgical site were noted in 42% and 60% of dogs respectively at day 1 postoperatively, with resolution noted between days 3 and 10 postoperatively in 92% and 80% of dogs. Generalized abdominal effusion and pneumoperitoneum were seen in 100% of dogs immediately postoperatively and resolved in 80% by day 10.

Imaging of gynecological disease (4): clinical and ultrasound characteristics of struma ovarii

To describe the clinical history and ultrasound findings in women with struma ovarii. Women with a histological diagnosis of struma ovarii who had undergone preoperative ultrasound examination were identified from the databases of five ultrasound centers. The tumors were characterized on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. In addition, four authors reviewed all ultrasound images and described them using pattern recognition. Of 31 patients identified, 16 had pure struma ovarii (one malignant), whereas in 15 patients the struma ovarii were 'impure', constituting the major part of a dermoid cyst (all benign, bilateral in one case). Median age was 40 (range, 18-80) years and 22 (71%) patients were of fertile age. Thirteen patients (42%) were asymptomatic, nine (29%) presented with pain, six (19%) with bloating, two (6%) with irregular bleeding and one (3%) with thyreotoxicosis. Most pure struma ovarii (11/16 cases, 69%) contained solid components, but cystic components were always present. The color content at Doppler examination varied from none to abundant. Four patients had ascites. Using pattern recognition the most specific feature of pure struma ovarii was the 'struma pearl', i.e. a smooth roundish solid area, similar, but not identical, to the 'round white ball' seen in dermoid cysts. 'Struma pearls' were present in six cases of pure struma ovarii. Most (10/16, 63%) cases of impure struma ovarii manifested ultrasound features compatible with a dermoid cyst, but six manifested ultrasound features similar to those of pure struma ovarii, 'struma pearls' being seen in three of these. The sonographic features of struma ovarii vary. Struma ovarii may be suspected when a 'struma pearl' is seen. Whether 'struma pearls' are indeed a specific ultrasonographic feature of struma ovarii needs to be determined in a prospective study.