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Reviewers The Journal of Surgical Radiology is pleased to acknowledge the following individuals for participating in the double-blind peer-review process in our publication. Drs. Vijay Agarwal, Mani Daneshmand, Melissa Danko, Diana Diesen, Prateek Gupta, Jack Haney, Eric Hanly, and Julie Thacker served as Reviewers for the journal in 2010.


CONTENTS

Guy de Chauliac Inventarium sive chirurgia magna 1363

COVER: ISTOCKPHOTO | CONTENTS: MEDICALRF

J Surg Rad

A good surgeon should be acquainted with liberal studies, with medicine and above all with anatomy.

70 Column How to Obtain Quality IT Help

74 Column A Quiet Revolution in EMR Usability

Make educated decisions and become a meaningful user of medical technology.

HITECH and the case for electronic medical records from an industry leader.

Shahid Shah

Glenn Laffel Contents 61


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62 October 2010


CONTENTS

1 October 2010

| 96

Jejuno-Uterine

Fistula Simon Eiref et al.

68 Editorial

The role of a multidisciplinary journal in surgery and radiology, and the impact it will have on surgeons and radiologists.

Cynthia Shortell

} 100

78 Technology

Magnetically-levitated ventricular assist device, Prevena incision management system, senobright spectral mammography, and concentric tube robots.

Gas Gangrene

Michael Feldman et al.

Tom Koenigsberger

| 102

Bile Leak After Fundoplication Prateek Gupta et al.

82 Original Article Infrared Thermal Imaging Thermography may be helpful for the study of thermoregulation and necrotizing enterocolitis in extremely low birthweight infants.

Henry Rice et al.

90 Original Article Radioactive Seed Localization

} 106

Pylephlebitis After Appendicitis

Radioactive seed localization is a safe, accurate, and effective technique for localizing and excising non-breast tumors.

Andre Teixeira et al.

Travis Grotz et al.

| 110

Delayed Splenic Rupture

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Prateek Gupta et al.

114 Original Article Splenic Vein Stenting Splenic vein stenting is an effective method of treating gastric varices and may offer an alternate option to splenectomy.

Amanda Hayman et al.

} 118

PET Guided Biopsy

Mark Joseph et al.

122 Future Directions High Resolution CT Imaging A prototypical platform for delivering more efficient health care in the near future.

Sapan Desai Contents

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Journal of Surgical Radiology Editor-in-Chief

Cynthia Shortell

Duke University Medical Center, Durham, North Carolina

Managing Editor Mark Shapiro

Duke University Medical Center, Durham, North Carolina

Hasan Alam Stanley Ashley David Bentrem Alasdair Conn Mitchell Cox James Cusack Jr. Daniel Dent Celia Divino N. Joseph Espat Steven Evans Thomas Fahey III Kevin Foster Richard Gray Ralph Greco Rajan Gupta Timothy Hall W. Scott Helton G. Chad Hughes Ronald C. Jones Charles Kim David King Christopher J. Kwolek Michael Leitman Matthew Menard Michael Miller Stephen Milner Eugene Moretti Theodore Pappas Jeff Pruitt Scott Pruitt Mo Shabahang Ranjan Sudan

Massachusetts General Hospital, Boston, Massachusetts Brigham and Women’s Hospital, Boston, Massachusetts Northwestern University, Chicago, Illinois Massachusetts General Hospital, Boston, Massachusetts Duke University Medical Center, Durham, North Carolina Massachusetts General Hospital, Boston, Massachusetts University of Texas Health Sciences Center, San Antonio, Texas Mount Sinai School of Medicine, New York, New York Roger Williams Medical Center, Providence, Rhode Island Georgetown University Medical Center, Washington, DC Weill Cornell Medical College, New York City, New York Arizona Burn Center, Phoenix, Arizona Mayo Clinic, Phoenix, Arizona Stanford University, Stanford, California Duke University Medical Center, Durham, North Carolina Stamford Hospital, Stamford, Connecticut Hospital of Saint Raphael, New Haven, Connecticut Duke University Medical Center, Durham, North Carolina Baylor University Medical Center, Dallas, Texas Duke University Medical Center, Durham, North Carolina Massachusetts General Hospital, Boston, Massachusetts Massachusetts General Hospital, Boston, Massachusetts Beth Israel Medical Center, New York City, New York Brigham and Women’s Hospital, Boston, Massachusetts Duke University Medical Center, Durham, North Carolina Johns Hopkins University, Baltimore, Maryland Duke University Medical Center, Durham, North Carolina Duke University Medical Center, Durham, North Carolina UT Southwestern Medical Center, Dallas, Texas Duke University Medical Center, Durham, North Carolina Texas A&M / Scott and White, Temple, Texas Duke University Medical Center, Durham, North Carolina

Jeffrey Nienaber Luigi Pascarella David Peterson Brian Untch Tammy Westmoreland

Mayo Clinic, Rochester, Minnesota Duke University Medical Center, Durham, North Carolina Stanford University, Stanford, California Duke University Medical Center, Durham, North Carolina St. Jude’s Children’s Research Hospital, Memphis, Tennessee

Danny O. Jacobs

Journal Editors

Associate Editors

Advisor to the Journal Duke University Medical Center, Durham, North Carolina

Executive Editor

Science Editor

Senior Staff Editor

Sapan Desai Surgisphere Corporation

Thomas Koenigsberger Surgisphere Corporation

Carol Fisher Surgisphere Corporation

64 Editors | October 2010


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Journal of Surgical Radiology Published by the Surgisphere Corporation

Chief Executive Officer Sapan S. Desai Chief Operations Officer Niketa Desai Chief Financial Officer Kishor Desai Managing Director Sachin Desai Executive Vice-President Vishal Shirke Director of Sales & Marketing Bernie Palmatier Science Editor Thomas Koenigsberger Senior Staff Editor Carol Fisher Associate Staff Editor Julienne Au Associate Staff Editor Michael Sakata Assistant Staff Editor Vivek Raj

President Vice-President and Director

Scott Vanderbilt Vance Allen

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Editor@Surgisphere.com advertising Ads@Surgisphere.com online www.SurgRad.com Copyright Š2010 by the Surgisphere Corporation. All Rights Reserved. Reproduction without permission is prohibited. The Journal of Surgical Radiology is a publication of the Surgisphere Corporation in association with Catalyst Publishers. Printed in the USA. email

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EDITORIAL

THE EDITOR u st a few mont h s ago, ou r i naug u ra l Ju ly i s sue i nt roduced a n i n novat ive concept of a f ree, web -ba sed publ ic at ion acce s sible to re ader s acros s t he g lobe t h roug h moder n med ia such a s i Pod s a nd PDA s. I n t h i s, ou r second i s sue, we cont i nue to develop t h i s concept. By recr u it i ng a nd rev iew i ng or ig ina l, releva nt re se a rch i n su r ger y a nd rad iolog y, you w i l l f i nd a r t icle s t hat lend t hem selve s to ou r u n ique bra nd of

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re a l-t i me i n st r u ment i s ava i l able to a nyone, a ny where, at a ny t i me.

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L ong-ter m succe s s requ i re s ad apt at ion to t he t rend s of t he moder n era, yet at t he sa me t i me, shou ld pre ser ve t he va lue s, met hod s, a nd t rad it ion s t h at h ave def i ned a nd suppor ted t he sc ience of med ic a l re se a rch a nd m ade it a venerable sou rce of k nowledge t h roug h t i me. The Jou r n a l of Su r g ic a l R ad iolog y st r ic t ly ad here s to t h i s g u id i ng pr i nc iple. We a re st r iv i ng to t a ke f u l l adva nt age of new tech nolog ie s a nd me d i a to m a ke t he t i me -honored ac adem ic, peer rev iew pro ce s s ava i l able to more people i n more way s. We cont i nue to m a i nt a i n t he met hodolog ie s of r igorou s sc r ut i ny of or ig i n a l re se a rch a nd c a se repor t s developed over t he ye a r s, but h ave rec re ated t he i n st r u ment w it h wh ich we sh a re t he m ater ia l w it h t he re ader. It i s a f i ne l i ne to wa l k . It m ay appe a r t rendy to promote a g l it z y new st yle of del iver i ng i n for m at ion; yet ou r content subst a nt i ate s ou r com m it ment to up hold i ng t he st a nd a rd s of e xcel lence t h at ou r predece s sor s a nd peer s h ave developed. The m a r r i age of tech nolog y a nd ac adem ic s t h at def i ne s ou r jou r n a l i s be aut i f u l ly i l lu st rated i n “I n f ra red Ther m a l I m-


ag i ng ( Ther mog raphy) of t he A bdomen i n E x t remely L ow Bi r t h-Weig ht I n fa nt s.” 1 The h ig h-re solut ion i m age s ava i l able on l i ne m a ke it pos sible to demon st rate t he se i m age s i n a way t h at a pr i nt jou r n a l cou ld never do. “The Use of R ad ioac t ive S eed L oc a l i z at ion for Non- Pa lpable Non- Bre a st L e sion s,” 2 “ Splen ic Vei n Stent Pl acement for R ef rac tor y G a st r ic Va rice a l Bleed i ng” 3 a nd “PE T- Gu ided Biops y of I sol ated B one Me t a st a si s i n GE Ju nc t ion Adenoc a rc i nom a”4 d i sc u s s e xc it i ng new u se s for e x i st i ng tech nolog ie s a nd tech n ique s. A nd, we sh a re c a se st ud ie s t h at prov ide a ler t s to at y pic a l C T f i nd i ng s; ra re sepsi s; a nd t he d a nger of redo su r ger y. O f cou r se, t he se a re merely h ig h l ig ht s; add it ion a l a r t icle s help t he prac t it ioner n av igate ch a l lenge s f rom t he off ice to t he operat i ng room. A s prom i sed, t he Jou r n a l of Su r g ic a l R ad iolog y i s t r u ly i nterac t ive. R e ader s a re i nv ited a nd encou r aged to com ment on ever y a spec t of ou r publ ic at ion, com mu n ic ate w it h t he aut hor s, a nd c i rc ul ate i n for m at ion t h roug h blog s. A s a re su lt , l a st mont h ’s a r t icle on elec t ron ic med ic a l record s ( E M R ) generated a good volu me of re ader re act ion. 5 We hope you f i nd a sat i sfac tor y re spon se i n “How to Obt a i n Q u a l it y I T Help,” 6 a colu m n t h at prov ide s sug ge st ion s a nd c aut ion s re ga rdi ng t he G over n ment’s I T i n it i at ive. It i s e xc it i ng to con sider t he pos sibi l it ie s of new i n novat ion s a nd f ut u re pa r t ner sh ips a nd we look for wa rd to sh a r i ng some new med ic a l d i scover y i n ever y i s sue. P rog re s s requ i re s a sol id fou nd at ion a nd ou r adva ncement of educ at ion a nd i nterd i sc ipl i n a r y med ic i ne w i l l rem a i n f i r m ly rooted i n t he e st abl i shed pr i nc iple s of med ic a l sc ience re se a rch.

References 1. Rice HE, Hollingsworth CL, Bradsher E, Danko ME, Crosby SM, Goldberg RN, Tanaka DT, and Knobel RB. Infrared thermal imaging (thermography) of the abdomen in extremely low birthweight infants. J Surg Radiol. 2010 Oct 1;1(2). 2. Grotz TE, Tortorelli CL, Degnim AC, Boughey JC, Whaley DH, and Jakub JW. The use of radioactive seed localization for non-palpable non-breast lesions. J Surg Radiol. 2010 Oct 1;1(2). 3. Hayman AV, Fisher MJ, Ryu RK, Bentrem DJ, Skaro AI, and Omary RA. Splenic Vein Stent Placement For Refractory Gastric Variceal Bleeding. J Surg Radiol. 2010 Oct 1;1(2). 4. Joseph M, Khandani AH, Clarke JP, and Meyers MO. PET Guided Biopsy of Isolated Bone Metastasis in GE Junction Adenocarcinoma. J Surg Radiol. 2010 Oct 1;1(2). 5. Shah S. Why MDs Dread EMRs. J Surg Radiol. 2010 Jul 1;1(1). 6. Shah S. How To Obtain Quality IT Help. J Surg Radiol. 2010 Oct 1;1(2).

Cynthia Shortell,

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How To Obtain Quality IT Help

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Pressure, Seduction, & Treachery

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Succumbing to the pressure on physicians to have a “meaningful use” (MU) strategy, you may be considering how to implement electronic health records (EHR) systems to achieve MU and receive incentive reimbursements. If you’re in the market for software, it’s likely you’re being inundated with case studies from vendors demonstrating how you, too, can attain the success their clients enjoy. Don’t be fooled; it’s highly unlikely that your experience will be the same as the doctors’ in the vendor-sponsored case study. Those select case studies are inevitably chosen to seduce you with stories of physicians who doubled their incomes allowing them luxuries such as vacationing more often. Those tales are rarely true. Unless every patient presents in the same fashion every time for every condition with every provider in your practice, adopting clinical systems into your care routine will be challenging. Rather than merely accepting the scenarios described in the case studies, it would be wise to employ outside help. Column | October 2010


v

Cautiously Start with Regional Extension Centers The MU government regulations, and the technology required to implement it, were expected to be too complicated for you to understand and implement on your own. Therefore, it’s beneficial for you to know that the 2009 Stimulus Bill funded the creation of the Health Information Technology Extension Program. Via this program, the Department of Health and Human Services is required to invest in Regional Extension Centers (RECs). RECs are designed to offer consulting and technical support to help accelerate adoption of Electronic Health Records (EHRs). RECs are responsible for offering advice and guidance regarding which products to buy; negotiation of price reductions for software through group purchase agreements; and technical assistance for implementation and deployment. Bear in mind that RECs are nonprofit organizations and are groups that responded to the grant request in a manner that fulfilled the documentation required by the government and, consequently, receive government money to help physicians become meaningful users. In the short run, these new RECs may not be much good to physicians as they will likely be inexperienced and, therefore, unable to offer much compared to other, more experienced, consulting shops. Since RECs will initially be paid by the government for each physician they sign on, they will be quite solicitous in conducting outreach to recruit your practice regardless of how well they can actually assist you. Still, it should cost you nothing to sign up and, again, the advice and aswww.JSurgRad.com

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• The MU consultant must be knowledgeable about your local (not national) rules, regulations, and technology providers.

sistance should be free to you. The good news is that the government has made it clear the RECs will be compensated in later years only if their clients become “meaningful users.” The bad news is that inexperienced management may be running your local RECs and the free advice could cost you in the long run.

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How to Choose Consultants

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After you’ve learned about RECs, investigate experienced, paid consultants by asking your colleagues. Many RECs will refer local consultants but you’ll need to vet them; RECs chose their consultants not because they are necessarily good at their jobs, but because they successfully marketed themselves to the RECs. One consultant won’t do -- you will need to include several specialty consultants in your search to cover various important functions: Column | October 2010

Meaningful Use (MU) Consultant. An MU consultant is necessary only if you’re pursuing government stimulus funds. This professional should understand the nuances of how a medical practice works as well as all the legal and regulatory details involved with Meaningful Use. This is not a typical IT contractor or technical consultant; it must be someone who is focused on MU. Since you will not receive increased government reimbursements unless you meet MU (simply installing the software does not qualify), the MU consultant may be more important than your IT consultant. The MU consultant should help determine whether or not you qualify for incentives, how to optimize the incentive program, how to utilize RECs, how to ensure that you qualify for MU without disrupting your practice and losing money, and finally, whether you should even care about MU.

• MU consultants should get some small upfront fees but should really get paid as you get paid; they should not be rewarded with full payment unless you receive incentive payments from the government. Remember that installing certified software will not get you to MU money; there is a great deal of labor involved to earn it even after the systems are implemented. EHR Consultant. If you’re ready to purchase an EHR, the MU consultant can help you choose the product. However, it may be worth investing in advice from an EHR-focused consultant familiar with the hundreds of packages available. Be careful if your EHR consultant is coming from a REC or a vendor. They should disclose any financial ties to the products they are advising you to select and should be able to tell you how many products they’ve worked with; some only know a couple of products so that’s all they can recommend. Choose the consultant based on the type of knowledge you’re lacking. Some are business-focused and others are technically-fo-

Disclosure: The Journal of Surgical Radiology receives no compensation for featuring these columns. The opinions herein are strictly those of the author and are not endorsed by the Journal of Surgical Radiology, its editors, authors, publisher, advertisers, or affiliates. iStockPhoto

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• A good MU Consultant will advise you when to implement MU and, just as importantly, when to decide against going after stimulus funds.


cused; if you’re great at technology, choose a business-focused consultant (and vice-versa). IT Consultant. This may be selfevident, but you should, indeed, seek advice on a whole host of requisite technological components including hardware, software, networking, telecommunications, Internet connectivity, and bandwidth analysis. Integration Consultant. Most people overlook this resource because the need is not obvious; this consultant is vital to ensuring that all the medical records data you’re collecting can be shared between your systems, your hospital, and the government. Integration con-

country and is, therefore, trying to incentivize you into becoming a “meaningful user” of certified technology.

significant benefit to others like local, state, and federal government users of medical data.

• You’ve been repeatedly told that IT can significantly improve productivity and perhaps you’ve made to seem foolish if you disagree.

• There is no compelling evidence to prove that implementation of electronic medical records necessarily has the same value to your practice.

• One would be hard-pressed to find any medical practice that does not currently employ the use of one or more computers for basic office automation. If you’re not already electronic, patients may have the impression that your clinical skills are as outdated as your office practice.

The government’s incentives won’t keep you in business, treating patients in a consistently profitable manner with a proper business strategy will. The government may compensate you for automation since, ultimately, you’re performing its data entry and providing valuable information; however, you may not see

The government is trying to incentivize you into becoming a “meaningful user” of certified technology. sultants must be well-versed in all the relevant standards such as HL7, DICOM, CCR, CCD, and XML, along with HL7 routers and the tools that share medical data records between your EHR, practice management system, and health information exchanges (HIEs).

Don’t Trust the Government to Help Make Your Decisions On the surface, the case for technology in your practice seems clear: • The government believes your use of technology benefits the

Beware, though, that while the purchase and use of computers and their associated software has been popular, there has possibly been very little strategic planning for exactly how computerization should be optimized. Most physician practices naturally increase their purchasing of almost all types of information technology as a result of incentives and initiatives from payers such as the federal government, their local hospital, or their insurance company. Here’s why these incentives are fraught with hidden dangers:

the same value unless you do your homework and return on investment analysis.

Shahid Shah

Chief Executive Officer Netspective Communications

• The installation and use of information technology in your practice will certainly provide www.JSurgRad.com

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A Quiet Revolution in EMR Usability Column | October 2010


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ecently, Shahid Shah, CEO of Netspective Communications, argued in this journal that physicians have shied away from electronic medical records (EMRs) because they have a negative impact on productivity.1 “It’s not about the money… money being thrown at physicians won’t solve bad [EMR] design,” said Shah, who was referring to HITECH, the federal government’s incentive plan to accelerate their adoption.

“If vendors respected service and product improvement as much as chasing new sales, [they would produce] minimally time-consuming software.”1 Shah’s summary of the user experience with legacy EMRs is spot on. In fact, he may have understated the problem. Poor usability associated with legacy EMRs not only reduces physician productivity, it can harm patients as well.2 Scores of reports on file at the Food and Drug Ad-

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In other instances on file with the FDA, “user unfriendly interfaces” and “extraneous and distractive” information caused pharmacists to miss changes in medication orders. In one case, the result was a “life threatening acute asthma attack.”3 Nevertheless, I remain optimistic that EMRs will soon achieve their potential to improve quality and efficiency in health information documentation. In fact, they are well on their way to doing so. Column | October 2010

Improving EMR Usability

Healthcare Research and Quality (AHRQ) funded study of certified EMR vendors, formal usability testing procedures, Let’s be clear. Legacy EMR employment of user-centered vendors know their products design principles and specific have usability problems. In resource personnel with experfact, Healthcare Information tise in usability engineering are and Management Systems Sonot common among EMR venciety (HIMSS)—a legacy vendors.4 dor trade group—said as much in its recent Task Force Report 3 Why would EMR vendors fail on the subject, the principal to improve the usability of their conclusion of which was: products when it appears to be in their best economic interests “EMR adoption rates have been to do so? Are technical chalslower than expected in the lenges too great given the 80’s United States, especially in comand 90’s vintage IT architecparison to other industry sectors ture underlying many legacy and other developed countries. EMR products? Do they worry A key reason, aside from initial that their customers will balk costs and lost productivity durat the costs and operational ing EMR implementation, is difficulties associated with uplack of efficiency and usability dating disparate servers and reof EMRs currently available.”3 training users? Yet, according to an Agency for Certainly the reason cannot be

Disclosure: The Journal of Surgical Radiology receives no compensation for featuring these columns. The opinions herein are strictly those of the author and are not endorsed by the Journal of Surgical Radiology, its editors, authors, publisher, advertisers, or affiliates. iStockPhoto

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ministration (FDA) prove that poor EMR usability can injure or kill patients. In one case, a hospital worker’s misinterpretation of a tiny font on an EMR screen led him to dispense ten times the prescribed dose of a medication. The error caused the patient to have a heart attack.2


that physicians’ cognitive workflows, or workflows of health systems in which they function, are too complex to permit significant improvements. We know this cannot be true because companies whose products support similarly complex workflows in other industries, such as nuclear power and aviation, have made stunning advancements in the usability of their products in just the past decade. As McKesson’s Beth Meyer points out, “the cockpit of a jet airliner looks fundamentally different today than it did 10 years ago. [It] is easier to learn, more intuitive and – as a result – safer to use. Doing the same for health IT is critical.”5 Whatever the reason for the ongoing usability problem in legacy EMR products, some argue that the matter represents a market failure necessitating regulatory intervention. In its recent report on EMR usability for example, the AHRQ concluded that usability should become part of the certification test for EMRs.4,6 I disagree. Regulatory intervention, whether it is overseen by the Office of the National Coordinator (ONC) or the FDA, will be terribly expensive, and it has no chance to impact EMR usability for the next five years; a critical delay given the government’s aspirations to foster rapid dissemination of EMRs via HITECH. Do you doubt that regulatory intervention will be associated with a five-year lag before usability improves? Have a look at what AHRQ did after recommending this strategy. It commissioned a project, in conjunction with the

National Institute of Standards and Technology (NIST) and ONC, to develop, test, and distribute EMR usability standards that vendors could use to evaluate their systems. Aside from the fact that such standards would be non-binding; federal agencies are woefully understaffed and focused on other matters at the moment. And factoring in required public comment periods and sundry delays, it would be at least two years before the standards could be completed. Add to this a staged implementation of the standards, similar to what we’ve seen with the ONC certification criteria for EMRs, and you get the picture. Aside from the delays themselves, the likely outcome of a regulatory process would almost certainly be criteria that are broad and bland enough to accommodate the spectrum of legacy EHRs on the market. That’s not even considering the flood of potential legal challenges that would threaten to countermand any useful criteria already promulgated.

Can a Market Strategy Work? A market strategy can work if Shahid Shah’s assertion that providers haven’t adopted EMRs because they are unserviceable is correct. Prospective EMR buyers should compare usability across EMR products, especially some of the newer Web-based products, and factor their findings into their buying decisions. Which system allows you to order medications most quickly? Which one

allows you to create the most elegant quality reports, share your records with other providers and look up lab results in the most intuitive fashion? Which vendor responds to your questions most quickly? Which vendor has the best track record for implementing user-generated suggestions? A combination of newly available, Web-based, user-friendly EMRs and customers that demand such products is the most efficient way to improve EMR usability and assure these products achieve performance levels that our patients and, indeed, the entire health system needs.

Glenn Laffel, MD, PhD

Sr. VP Clinical Affairs Practice Fusion EMR www.practicefusion.com

1. Shah S. Why MDs Dread EMRs. J Surg Radiol. 2010 Jul 1; 1(1). 2. Huffington Post. As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge. Available at http://huffpostfund. org/stories/2010/04/doctors-shift-electronic-health-systems-signs-harm-emerge. Accessed 8/2010. 3. Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating. HIMSS HER Usability Task Force. June 2009. 4. AHRQ. Available at http://healthit. a h r q. gov / p or t a l / s er ver.pt/ga teway/ P TA RG S _ 0 _ 1169 9 _ 9119 8 4 _ 0 _ 0 _ 18 / EHRVendorPractices&Perspectives.pdf. Accessed 8/2010. 5. HIMSS. Available at http://www.himss. org/ASP/ContentRedirector.asp?ContentId =74007&type=HIMSSNewsItem. Accessed 8/2010. 6. Healthcare Informatics. Available at http:// www.healthcare-informatics.com/ME2/ dirmod.asp?type=news&mod=News&mi d=9A02E3B96F2A415ABC72CB5F516B4C 10&tier=3&nid=72E050C0FFCB4C33A8 83419F3DE73DEB. Accessed 8/2010.

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A new ventricular assistance device (VAD), with only one moving part, is currently being clinically tested on seven patients. Developed by World Heart Corporation, Salt Lake City, this VAD promises to reduce damage due to blood clotting, and improved flow dynamics in a variety of clinical settings.1 The thin, magnetically levitated, DC motor centrifugally pumps blood continuously and is being utilized for later stage heart failure in small women and children. A pediatric model for children up to two years of age will also be available soon. 1. http://www.worldheart.com/technologies/levacor-vad.cfm

Disclosure: The Journal of Surgical Radiology receives no compensation for featuring these technological developments.

TECHNOLOGY

Magnetically Levitated VAD

Robotic Remote Surgery

J Surg Rad

Three small intestinal robotic capsules are being developed by the VECTOR (versatile endoscopic capsule for gastrointestinal tumor recognition and therapy) project. One is not new (a passive camera), a second has active locomotion and spectroscopic imaging, and a third planned capsule will include a biopsy tool as well as spectroscopic imaging. These capsules will be powered by external magnetic locomotion and motor driven actuator legs. These hybrid powered locomotive capsules will provide physicians with powerful non-surgical tools. An advanced concept self-assembling system of 10 to 15 capsules, forming a complex surgical tool, is now being investigated.1

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Technology | October 2010

Thomas Koenigsberger Science Editor

Company

1. Harada, et al. Wireless Reconfigurable Modules for Robotic Endoluminal Surgery. In Proceedings of the 2009 IEEE International Conference on Robotics and Automation, May 2009.


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Journal of Surgical Radiology Standards of Scientific Scholarship In accordance with the highest principles of publishing, editing, and scientific scholarship, the Journal of Surgical Radiology has adopted a number of policies that all authors and editors must adhere to. These policies are based off the National Library of Medicine and National Institutes of Health Fact Sheets regarding articles that are published in Medline / PubMed and the Council of Science Editors White Paper on Promoting Integrity in Scientific Journal Publications. All of our editors and contributors are required to comply with these guidelines.

Ethical Conduct in Scientific Scholarship The Journal of Surgical Radiology upholds the highest standards in scientific scholarship and publishing. Any author of a manuscript who is found to violate the highest standards of scientific scholarship will have their manuscript withdrawn or retracted until a comprehensive review of the manuscript can be completed by the Editor-in-Chief, Managing Editor, and the other authors of the manuscript. Scientific or academic misconduct of any sort will not be tolerated. Cases of scientific fraud will be reported to the Office of Research Integrity (ORI) and the author’s institution.

Institutional Review The Journal of Surgical Radiology endorses the institutional review policy published by the Council of Science Editors, specifically that “researchers must have conducted the study according to the approved protocol and acceptable research standards, including having obtained informed consent of study subjects. Although some IRBs may consider certain types of studies, such as case reports, to be exempt from their approval, IRB review may still be necessary to make that determination. Additionally, authors should obtain written informed consent from the subjects of case reports and written permission to use any identifiable images.” Clinical trials must be registered at www.ClinicalTrials.gov.

Errata In the event that there is an error discovered after a manuscript is published, an erratum will be published in the next print issue and a notice published alongside the digital publication. The source or nature of the erratum, if known, will also be given. In the rare event that there is an error in publishing for an article, it may be republished in its entirety in the next issue. A correction to the original digital article along with a notice will be published alongside the digital publication.

Retractions According to the National Library of Medicine, “Articles may be retracted or withdrawn by their authors, academic or institutional sponsor, editor or publisher, because of pervasive error or unsubstantiated or irreproducible data.” In accordance with NIH policy, the Journal of Surgical Radiology will publish retractions as a citable publication in the next print issue. A retraction will also be issued online alongside the digital publication. The source of the retraction (i.e. author, legal counsel, department head, editor, etc.) and the reason for the retraction (i.e. pervasive errors in logic, scientific misconduct, improper data analysis, duplicate publication, etc.) will be given.

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TECHNOLOGY

Images courtesy of Pierre Dupont, Professor of Surgery, Harvard Medical School and Pediatric Cardiac Bioengineering Chai

J Surg Rad

Concentric tube robots

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are a new instrument t beating-heart intracardiac repair of conditions such as atrial septal defects and

Virtopsy

diseased valves. Th vein is used for access, while a ser nickel-titanium tubes provide the flexibility to complete Technology | October 2010


Disclosure: The Journal of Surgical Radiology receives no compensation for featuring these technological developments.

The combination of a CT scanner and a robot that maps the contours of the body provides a three-dimensional reconstruction of the entire body and preserves a digital record without the use of a single scalpel. This virtual autopsy (“Virtopsy”) permits evaluation of the entire body, gives forensic pathologists the tools to uncover additional injuries, and allows the mapping of existing injuries in greater detail. The digital media permits investigators to return to the original record years later when new evidence may be uncovered. The Virtopsy was developed by the Centre of Forensic Imaging and Virtopsy at the Institute of Forensic Medicine, University of Bern, Switzerland. The technology is used by the US Air Force to complete postmortems in deceased soldiers.

Sapan Desai, MD, PhD Executive Editor

ir, Children’s Hospital Boston

technology that enable

he internal jugular ries of highly elastic e complex maneuvers. www.JSurgRad.com

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ORIGINAL ARTICLE

Infrared Thermal Imaging (Thermography) of the Abdomen in Extremely Low Birthweight Infants Henry E. Rice, MD… ∙ Caroline L. Hollingsworth, MD„ ∙ Elizabeth Bradsher, RNƒ… ∙ Melissa E. Danko, MD ∙ Stephanie M. Crosby, LPNƒ ∙ Ronald N. Goldberg, MDƒ… ∙ David T. Tanaka, MDƒ… ∙ Robin B. Knobel, PhD, RNC, NNP‚… Departments of Surgery, Pediatrics,ƒ and Radiology,„ Duke University Medical Center, Durham, North Carolina School of Nursing‚, Duke University, Durham, North Carolina Jean and George Brumley, Jr. Neonatal-Perinatal Research Institute,… Duke University School of Medicine, Durham, North Carolina

Abstract

Introduction Infrared thermal imaging (thermography) is a non-invasive method to measure skin temperature. The primary aim of this study was to examine the feasibility of thermography for the assessment of abdominal skin temperature in extremely low birthweight (ELBW) infants, with secondary aims to compare abdominal and thoracic skin temperature, and to explore potential relationships between abdominal skin temperature and necrotizing enterocolitis (NEC). Methods We prospectively examined clinical, radiographic, and thermal imaging data in 13 ELBW infants (< 1000 gm and < 29 weeks gestation) during the first month of life. Thermal imaging was performed using an infrared camera, with skin temperature measured over abdomen and thorax. Abdominal skin temperature was compared to thoracic skin temperature, and these findings further examined in infants with radiographic evidence of NEC as well as those without NEC. Results We found that thermal imaging in ELBW infants is feasible and can result in accurate measurements of skin temperature over anatomic regions. Overall, the mean abdominal skin temperature was lower than thoracic skin temperature (p<0.05 by paired Student’s t-test), although this difference appears due to NEC in some infants. Infants with radiographic evidence of NEC had a lower mean abdominal skin temperature compared to infants without NEC (p<0.05 by paired Student’s t-test). Conclusions In this study, we found that infrared thermal imaging is feasible in ELBW infants. Thermography may be helpful for the study of thermoregulation in ELBW infants and may provide new insight into the role of regional perfusion in NEC. Keywords necrotizing enterocolitis, thermography, infrared imaging, thermoregulation

J Surg Rad

Introduction

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Extremely low birth weight (ELBW) infants have abnormal regulation of body temperature (thermoregulation) Citation Rice HE, Hollingsworth CL, Bradsher E, Danko ME, Crosby SM, Goldberg RN, Tanaka DT, and Knobel RB. Infrared thermal imaging (thermography) of the abdomen in extremely low birthweight infants. J Surg Radiol. 2010 Oct 1;1(2). Correspondence Henry E. Rice, MD E-mail rice0017@mc.duke.edu. Received June 17, 2010. Accepted July 17, 2010. Epub July 31, 2010.

Original Article | October 2010

during the first week of life due to delayed maturation of neurologic control of central and peripheral perfusion.1-4 Immature control of perfusion is associated with abnormal control of body temperature, and may contribute to adverse outcomes in ELBW infants, including necrotizing enterocolitis (NEC).3,5‑7 Improved understanding of the relationships between skin temperature and perfusion may provide insight into the pathophysiology of NEC and control of regional blood flow in ELBW infants. Infrared thermal imaging (thermography) is a non-invasive technique which allows the temperature to be measured accurately and continuously over the entire visible body surface. Thermography measures the passive infrared radiation emitted by the target surface and converts


Rice et al. Thermography in ELBW Infants

Original Article

this radiation into a two-dimensional image relating to the temperature at the target. Thermography imaging has recently been shown to be useful for the assessment of skin temperature in adults in a variety of clinical and research settings, but only one single paper from 30 years ago has examined the early use of technology in ELBW infants.8-11 In this study, we hypothesized that thermography can be used in ELBW infants to accurately assess regional skin temperature. The primary aim of this study was to examine the feasibility of infrared thermal imaging for assessment of regional skin temperature in ELBW infants. Our secondary aims were to assess potential differences between abdominal and thoracic skin temperature, and to explore a potential association between abdominal skin temperature and NEC.

Materials and Methods We performed a prospective non-randomized study of ELBW infants to examine the feasibility of infrared thermal imaging in ELBW infants with secondary aims to identify differences between abdominal and thoracic skin temperature; and to explore potential associations between abdominal skin temperature and NEC. Participants: All infants admitted to the intensive care nursery at Duke University Medical Center (DUMC) between June 1, 2009, and Dec 31, 2009 were used to select study subjects, who were chosen by convenience sample for trial enrollment. Inclusion criteria included a birth weight < 1000 grams and 23-29 weeks gestational age. Gestational age was assigned by obstetrical dating. Exclusion criteria included any major congenital anomaly, genetic disorder, congenital intestinal anomalies, or congenital heart disease. During the study period, 55 infants met entry criteria, and 15 of these infants were considered for trial enrollment. Enrollment resulted in an initial cohort of 15 subjects, of which two subjects were excluded, leaving 13 subjects as our final study cohort (9 male, 4 female). The excluded infants include one infant who died of presumed NEC totalis before thermal imaging data could be recorded, and one infant who had an unsuspected intestinal atresia identified at laparotomy. The study protocol and informed consent form were approved by the Duke University Medical Center Institutional Review Board. The study was explained to parents of eligible infants by a member of the study team and enrollment began after one parent signed the IRB-approved informed consent form. No family who was offered study enrollment declined participation. Infant environment: Twelve infants of the 13 study infants were housed in a Draeger Caleo® incubator (Dräger Medical, Telford, PA) set on servo-control, with one infant housed in an exposed overhead warmer bed. The incubator controls includes a thermostat to regulate exogenous heat input by feedback based on axillary skin temperature as measured by a skin probe. This set-point was set at 36.7 ºC for infants in this

Figure 1. Thermal imaging of ELBW infant in supine position using hand held FLIR® SC640 infrared camera (FLIR, North Ballerica MA). We performed thermal imaging through the top of an incubator that had a custom made cut-out in the lid, covered with plastic wrap to preserve heat but allow transmission for thermal imaging. This technique allowed for imaging in 2-3 minutes without disturbing the normal thermal environment of the child Images were obtained with the camera positioned from a distance of approximately 1 meter, at a 90º angle over the infant. study. We recorded the axillary temperature as measured by the temperature probe at the time of thermal imaging studies to confirm accuracy of thermal imaging. NEC diagnosis and grading: We defined infants as having NEC based on radiographic findings of suspected or definitive pneumatosis intestinalis, portal venous gas, or pneumoperitoneum. This definition is consistent with a Bell’s II or III grade,12 which are currently used by several recent and ongoing large clinical studies to standardize the diagnosis of NEC.13 We did not include clinical variables such as feeding intolerance, bloody stools or abdominal distension for the diagnosis of NEC for this study, due to ambiguity in the medical record regarding the specific times that these clinical events occurred. Our comparison between abdominal skin temperature and NEC was confined to those infants (n=10) who had infrared thermal imaging as well as abdominal radiographs (anteriorposterior and either lateral or left-lateral decubitus views) www.JSurgRad.com

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Table 1. The Duke Abdominal Assessment Scale (DAAS) for assessment of radiographic findings associated with necrotizing enterocolitis (NEC). DAAS is a standardized 10-point radiographic scale that increases with NEC disease severity.14,15 Score

Finding

0

Normal gas pattern

1

Mild diffuse distention

2

Moderate distention or normal with bubbly lucencies that are likely stool

3

Focal moderate distention of bowel loops

4

Separation or focal thickening of bowel loops

5

Featureless or multiple separated bowel loops

6

Possible pneumatosis with other abnormal findings

7

Fixed or persistent dilation of bowel loops

8

Pneumatosis highly probable or definite

9

Portal venous gas

10

Pneumoperitoneum

performed on the same day. In the remaining three infants in the study, the thermal imaging and radiographs were not performed on the same day, and therefore these infants were not included in this portion of the analysis. Each two-view radiographic series was scored using the Duke Abdominal Assessment Scale (DAAS) scale by one of six attending pediatric radiologists, each of whom have at least 4 years experience using the DAAS system (Table 1).14,15 None of the radiologists had knowledge of the thermography results prior to the assignment of the DAAS scores. In previously published studies, substantial inter-observer agreement (ĸ = 0.89) was found between two radiologists when DAAS scores were assigned independently, and higher DAAS scores are associated with more severe NEC as measured by need for surgical intervention.14,15 In our current study, DAAS scores of 8-10 (suspected or definitive pneumatosis intestinalis, portal venous gas, or pneumoperitoneum) were collectively used to define infants with radiographic NEC. Thermal imaging: For thermal imaging, we used a FLIR® SC640 infrared camera (FLIR, North Ballerica, MA). The camera was factory calibrated within 0.2 ºC and then checked against a standard blackbody and skin temperature measured with external temperature probes. Each thermography pixel of area could be analyzed separately, with measurement of each area of skin temperature precise to 0.1ºC. Accuracy of temperature measurement was randomly checked on a regular basis, and the camera retained its calibration within 0.2 ºC against the blackbody and external temperature probes on all occasions. To minimize changes to the infants’ thermal environment during the imaging procedure, thermal imaging was performed through the top of an customized incubator that had a cutout in the lid, which was covered with plastic wrap to preserve heat yet allow transmission for thermal imaging. Images

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were obtained with the camera positioned from a distance of approximately one meter, at a 90º angle over the infant (Figure 1). The infant was imaged in a supine position, consistent with standard clinical care. The thermal environment of each subject was not disturbed during imaging. Subjects were followed for 2-10 days (maximum 30 days of life), with thermal imaging performed either daily or every other day (total days of imaging ranged from two to five per infant). Analysis of skin temperature over regions of interest: Infrared imaging data was downloaded into a laptop computer, and ExaminIR® (FLIR, North Ballerica, MA) software was used to measure the temperature at any single pixel on the picture. ExaminIR® software performs real-time image analysis and provides playback features to analyze image sequences stored on a camera or computer and will convert the passive infrared radiation emitted by the target surface to a two-dimensional image relating to the temperature distribution at the target surface. Skin temperature was measured to the nearest 0.1 ºC. To facilitate skin temperature analysis, we adopted previously published techniques to measure the mean skin temperature over a desired region of interest (ROI) using the ExaminIR® software.8,10 The software has analysis tools including spot, line, and area measurements of skin temperature. For our analysis, we used a segmentation tool to develop oval regions of interest over the majority of the abdomen or thorax. Within each ROI, the ExaminIR® software calculated the mean skin temperature using every pixel in the ROI, as well as additional metrics including the skin temperature maximum, minimum, and standard deviation. We compared the mean abdominal skin temperature (Tabdomen) to the mean thoracic skin temperature (Tnon-abdomen) within each ROI using paired Student’s t-test, with p < 0.05 considered significant. The thorax was chosen to confirm the accuracy of


Original Article

Rice et al. Thermography in ELBW Infants

Figure 2. Comparison of concurrent infrared thermal image (A) and abdominal radiograph (B) of a single ELBW infant with NEC. Images were taken on same day, with both images oriented with head superior. Thermography image is taken with FLIR SC640 camera (FLIR, North Ballerica MA) and expressed using color palette. Bright, red-yellow areas (i.e. over thorax) correlate with higher temperature compared to darker, blue areas (i.e. central area of abdomen, periphery around infant) which correlate with cooler temperature. Abdominal radiograph shows fixed featureless bowel segments, pneumatosis intestinalis and portal venous gas, consistent with NEC and graded using the Duke Abdominal Assessment Scale (DAAS) as grade 9.14,15 the thermography by comparing thoracic temperature to the readings obtained from the contiguous axillary temperature probe. The abdomen and thorax ROIs were kept consistent in shape and location among infants and were similar in size (abdominal 15,390 ± 1,206 pixels versus thoracic 15,091 ± 1,832 pixels, mean ± SD, p=NS by paired Student’s t test). All statistical analyses were performed with use of Microsoft Excel 2003 software (Microsoft, Redmond, WA). Association between abdominal skin temperature and NEC: In 10 infants, we had sets of thermal images and abdominal radiographs collected on the same day. Data from these 10 infants were used to identify an association between abdominal skin temperature and the radiographic diagnosis of NEC. Infants with a DAAS score 8-10 (suspected or definitive pneumatosis intestinalis, portal venous gas, and/or pneumoperitoneum) were defined as having radiographic NEC. We compared

the abdominal temperature of infants without radiographic NEC (n=7) to infants with radiographic NEC (n=3), using unpaired Student t-test, with a p value < 0.05 considered significant.

Results Participants: 13 ELBW infants satisfied entry criteria and completed the study, with a gestational age range from 25-29 weeks. Birth weight was 861 ± 154 grams (mean ± standard deviation). Five of the 13 infants were enrolled within 24 hours of life, and 8 infants were enrolled between days 7-21 of life. Ten (10) infants had radiographic and thermal imaging performed on the same day and were included in the analysis of association between abdominal skin temperature and conwww.JSurgRad.com

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Rice et al. Thermography in ELBW Infants taining infants in a supine position and removal of the diaper, no infant needed to be touched during the imaging. No change in axillary body temperature as a result of positioning the infant was recorded by nursing staff during thermal imaging. Measurement of skin temperature using thermal imaging: Using the ExaminIR® software, we were able to easily view stored thermal images. We used this software to view the abdomen in either black and white or color palettes. The scale and intensity of thermal images can be controlled by software analysis tools (Figure 2A), and thermal images can be compared to abdominal radiographs (Figure 2B). We calculated the mean skin temperature over either the abdomen or thorax region of interest using the ExaminIR® software (Figure 3). The thoracic temperature ROI was located adjacent to the axillary temperature probe. The thoracic skin temperature (36.8 ± 0.9 ºC) was equivalent to the axillary temperature (36.7 ± 0.9 ºC, p=NS by paired t-test).

Difference between abdominal and thoracic skin temperature: For the overall cohort of 13 infants (47 measurements), we found that the abdominal skin temperature (36.4 ± 0.9 ºC) was lower than the Figure 3. Definition of oval regions of interest (ROI) of a single ELBW infant with NEC. thoracic skin temperature (36.8 ROIs are easier to see using black and white palate, with ROI over the abdomen seen ± 0.9 ºC, p < 0.05 by paired Student’s t-test; Figure 4). in green, and thorax in red. current radiographic findings of NEC. Two infants with radiographic NEC underwent surgical intervention with either exploratory laparotomy and/or peritoneal drain placement. Thermal imaging: We obtained infrared thermal imaging pictures on several days (range 2-10 days) on the 13 ELBW infants, yielding 47 total images. The infrared camera performed well during this study. During the course of the study, the time to take thermal images decreased from 10 to about 3 minutes. As a result, we were able to conduct bedside imaging during periods of care such that infants were not moved or positioned separately from routine nursing care. There were no adverse events noted by either the nursing or physician staff during thermal imaging. Other than main-

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Association between abdominal skin temperature and NEC: We had concurrent thermal images and abdominal radiographs in ten infants, yielding 25 total measurements. In these 10 infants, we found that those with radiographic NEC (n=3) had lower abdominal skin temperature (35.3 ± 0.8 ºC, 6 measurements) compared to those without NEC (n=7) (36.6 ± 0.9 ºC, 19 measurements) (p < 0.05 by unpaired Student’s t-test, Figure 5). In view of this analysis, we subsequently reanalyzed the entire cohort of all 13 patients, and excluded those 6 measurements of infants with radiographic NEC. In the remaining measures without radiographic NEC (41 measurements), the abdominal and thoracic skin temperatures were similar (abdominal 36.6 ± 0.9 ºC, thoracic 36.8 ± 0.9 ºC, p=NS by paired t-test).


Original Article

Rice et al. Thermography in ELBW Infants

tral body temperature to become cold.2,3,24 These studies suggest that abnormal thermoregulation in ELBW infants may contribute to a variety of disease processes related to poor control of central and peripheral perfusion, including NEC.

Figure 4. Scatterplot of paired abdominal and thoracic skin temperature measurements in 13 ELBW infants (47 paired measurements) as determined by infrared thermography. The mean abdominal temperature (36.4 ± 0.9 ºC) was lower than the mean thoracic temperature (36.8 ± 0.9 ºC, p < 0.05 by paired Student’s t-test).

Discussion Infrared thermal imaging is a non-invasive technique to measure skin temperature over the visible body simultaneously.8 Thermography measures the passive infrared radiation emitted by the target surface, and converts this radiation into a two-dimensional image relating to the temperature distribution at the target surface. Infrared imaging has been shown recently to be a useful method to measure body surface temperature in adults in various clinical and research settings.8-10,16 Given the range of pathology in ELBW infants which may be related to poor perfusion such as NEC and brain injury, use of a non-invasive method to accurately assess regional thermal control may be helpful. Prior to our studies, only one single report from over 30 years ago with early use of this technology had examined thermal imaging in ELBW infants.11 The study of perfusion in infants has recently been examined by several other techniques, including Doppler ultrasonography17-19 and near infrared spectroscopy (NIRS).20,21 Although these studies have validated a role for Doppler ultrasound and NIRS to identify aspects of perfusion in ELBW infants, these technologies are expensive, require skilled technicians, and mandate prolonged contact with the infants, limiting their role in clinical research studies of ELBW infants. Thermoregulation in ELBW infants is controlled by complex neurologic mechanisms.5,7,22 Peripheral temperature correlates with peripheral perfusion,23 and peripheral vasoconstriction is necessary to maintain intestinal perfusion during periods of stress. Normal peripheral vasoconstriction responses are ineffective in some ELBW infants, allowing the infant’s cen-

Necrotizing enterocolitis (NEC) remains a difficult disease to understand.13 NEC results from a combination of loss of the intestinal epithelial barrier, dysfunction of the mucosal immune system and poor intestinal perfusion, although it is unclear why only some ELBW infants become affected.6,25,26 Given the recent studies which suggest that abnormal regulation of perfusion and body temperature occurs in some ELBW infants,1-4 our interests are in defining processes to accurately examine perfusion abnormalities in ELBW infants and further characterize the role of perfusion defects in NEC. Our current findings suggest that thermography may be a useful adjunct to study these physiologic processes, and may be helpful to define the association between the maturation of perfusion and NEC.

In our current study, we found that infrared thermal imaging is feasible to perform in ELBW infants. Our secondary findings showed infants with radiographic NEC have decreased abdominal skin temperature compared to infants without NEC, which is not surprising given the likely presence of advanced intestinal ischemia by the time NEC is definitively diagnosed. It must be emphasized that the current study was designed to assess the feasibility of thermal imaging, and should be considered similar to a Phase 1 trial to assess safety. Thus, this exploratory study was not powered to definitively address our secondary aims. Although beyond the scope of this study, it would be of considerable interest whether there are periods of low abdominal skin temperature which precede clinical or radiographic findings of NEC. We found that infants with radiographic NEC have decreased abdominal skin temperature compared to infants without NEC, which is not surprising given the likely advanced intestinal ischemia by the time NEC is definitively diagnosed. It is possible that detection of early changes in abdominal skin temperature may allow for interventions to ameliorate the onset or severity of NEC, such as implementation of bowel rest, antibiotics, etc. Moreover, it is unclear whether any of the known specific risk factors associated with NEC, such as early feedings or perinatal stress, also result in acute changes in abdominal skin temperature. Future studies of thermoregulation in ELBW infants will need to investigate all of these critical issues. In the course of this study, we learned several critical lessons for the use of thermography in ELBW infants. Most recent www.JSurgRad.com

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Original Article studies of thermal imaging in adults have relied on measurement of skin temperature over a specific single area of interest. However, measurements of skin temperature in infants kept within environmental-controlled incubators are affected by external heat input. Incubators work by the recognition of infant hypothermia, increasing ambient heat until the infant’s axillary temperature reaches the set-point of the incubator. This heat input represents a complex variable which affects skin temperature analysis. To address this issue, we found that by comparing two areas in each single infant, each infant could serve as their own control and thereby control for external heat input. However, it is likely that further physiologic analysis of regional skin temperature in ELBW infants will require sophisticated quantitative analysis of external heat input. In keeping with the exploratory nature of this study, we recognize that many questions remain concerning themoregulation in infants and NEC. For example, it is unclear whether decreased abdominal skin temperature is associated with abnormal peripheral vasoconstriction responses, which are traditionally measured by use of continuous monitoring with skin thermistor probes. Similarly, it remains to be shown whether the small differences in regional skin temperature seen in our study in children with NEC have significant physiologic importance. Finally, thermal imaging requires purchase of an infrared camera and software, which would minimize its role in routine clinical care. However, the ease of this technology and safety for use in frail infants should facilitate its role in neonatal research settings.

Rice et al. Thermography in ELBW Infants

References

1. Knobel R, Holditch-Davis D: Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low birth weight infants. J Obstet Gynecol Neonat Nurs 2007;36:280-287. 2. Knobel RB, Holditch-Davis D, Schwartz TA, Wimmer JE: Extremely low birth weight preterm infants lack vasomotor response in relationship to cold body temperature at birth. J Perinatol 2009;29:814-821. 3. Lyon AJ, Pikaar ME, Badger P, McIntosh N: Temperature control in very low birth weight infants during the first five days of life. Arch Dis Child Fet Neonat Ed 1997;76:F47-F50. 4. Knobel RB, Holditch-Davis D, Schwartz T: Optimal body temperature in transisitional elbw infants using heart rate and temperature as indicators. J Obstet Gynecol Neonat Nurs 2010;39:3-14. 5. Asakura H: Fetal and neonatal thermoregulation. J Nippon Med School 2004;71:360-370. 6. Nankervis CA, Giannone PA, Reber KM: The neonatal intestinal vasculature; contributing factors to necrotizing enterocolitis. Semin Perinatol 2008;32:83-91. 7. Soll RF: Heat loss prevention in neonates. J Perinatol 2008;28:S57-S59. 8. Jones BF: A reappraisal of the use of infrared thermal image analysis in medicine. IEEE Trans Med Imaging 1998;17:1019-1027. 9. Katz LM, Nauriyal V, Nagaraj S, Finch A, Pearlstein K, Szymanowski A, Sproule C, Rich PB, Guenther BD, Pearlstein RD: Infrared imaging of trauma patients for detection of acute compartment syndrome of the leg. Crit Care Med 2008;36:1756-1761. 10. Nhan BR, Chau T: Infrared thermal imaging as a physiological access pathway: A study of the baseline characteristics of facial skin temperatures. Physiol Meas 2009;30:N23-N35. 11. Pomerance JJ, Lieberman RL, Ukrainski CT: Neonatal thermography.

In conclusion, this study has confirmed the feasibility of thermal imaging for study of skin temperature in ELBW infants. Our secondary findings showed that there is a decrease in abdominal skin temperature compared to thoracic skin temperature in these infants, which appears to be due to the presence of NEC in some infants. Given the ease of the thermography in ELBW infants, further study of the relationship between thermoregulation and disorders of perfusion in ELBW infants may benefit from the use of infrared thermal imaging.

Disclosures This study was funded by the Children’s Miracle Network and the Jean and George Brumley, Jr. Neonatal-Perinatal Figure 5. Mean abdominal skin temperature in 10 ELBW infants who had concurrent infrared thermography images and abdominal radiographs (total 25 Research Institute (NPRI). measurements). Infants categorized using radiographic findings either having no NEC or as having NEC (based on suspected or definite pneumatosis intestinalis, portal venous gas, pneumoperitoneum, also characterized as DAAS grade 8-10).14,15 Error bars represent standard deviation. The mean abdominal skin temperature was higher in infants without NEC (36.6 ± 0.9 ºC, 19 total images) compared to infants with NEC (35.3 ± 0.8 ºC, 6 total images, p < 0.05 by unpaired Student t-test).

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Original Article

Rice et al. Thermography in ELBW Infants 12. Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L, Brotherton T: Neonatal necrotizing enterocolitis: Therapeutic decisions based upon clinical staging. Ann Surg 1978;187:1-7.

Pediatrics 1977;59:345-351.

20. Dave V, Brion LP, Campbell DE, Scheiner M, Raab C, Nafday SM: Splanchnic tissue oxygenation, but not brain tissue oxygenation, increases after feeds in stable preterm neonates tolerating full bolus orogastric feeding. J Perinatol 2009;29:213-218.

13. Blakely M, Lally K, McDonald S, Brown R, Barnhard D, Rickets R: Postoperative outcomes of extremely low birth weight infants with necrotizing enterocolitis or isolated intestinal perforation. Ann Surg 2005;241:984-994.

21. Fortune PM, Wagstaff M, Petros AJ: Cerebro-splanchnic oxygenation ratio (csor) using near infrared spectroscopy may be able to predict splanchnic ischaemia in neonates. Intensive Care Med 2001;27:14011407.

14. Coursey CA, Hollingsworth CL, Gaca AM, Maxfield C, Delong D, Bisset Gr: Radiologistsâ&#x20AC;&#x2122; agreement when using a 10-point scale to report abdominal radiographic findings of necrotizing enterocolitis in neonates and infants. Am J Roentgenol 2008;191:190-197.

22. Bini G, Hagbarth KE, Hynninen P, Wallin BG: Thermoregulatory and rhythm-generating mechanisms governing the vasocontrictor outflow in human cutaneous nerves. J Physiol 1980;306:537-552.

15. Coursey CA, Hollingsworth CL, Wriston C, Beam C, Rice H, Bisset G: Radiographic predictors of disease severity in neonates and infants with necrotizing enterocolitis. Am J Roentgenol 2009;193:1408-1413. 16. Adams AK, Nelson RA, Bell EF, Egoavil CA: Use of infrared thermographic calorimetery to determine energy expenditure in preterm infants. Am J Clin Nutr 2000;71:969-977. 17. Martinussen M, Brubakk AM, Linker DT, Vik T, Yao AC: Mesenteric blood flow velocity and its relation to circulatory adaptation during the first week of life in healthy term infants. Pediatr Res 1994;36:334339. 18. Leidig E: Pulsed doppler ultrasound blood flow measurements in the superior mesenteric artery of the newborn. Pediatr Radiol 1989;19:169172. 19. Papacci P, Giannantonio C, Cota F, Latella C, Semeraro CM, Fioretti M, Tesfagabir MG, Romagnoli C: Neonatal colour doppler ultrasound study: Normal values of abdominal blood flow velocities in the neonate during the first month of life. Pediatr Radiol 2009;39:328-335.

23. Martin H, Norman M: Skin microcirculation before and after local warming in infants delivered vaginally or by caesarean section. Acta Paediatr 1997;86:261-267. 24. Horns K: Comparison of two microenvironments and nurse caregiving on thermal stability of elbw infants. Adv Neonatal Care 2002;2:149-160. 25. Guner YS, Chokshi N, Petrosyan M, Upperman JS, Ford HR, Grikscheit TC: Necrotizing enterocolitis--bench to bedside: Novel and emerging strategies. Semin Pediatr Surg 2008;17:255-265. 26. Petrosyan M, Guner YS, Williams M, Grishin A, Ford HR: Current concepts regarding the pathogenesis of necrotizing enterocolitis. Pediatr Surg Int 2009;25:309-318.

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ORIGINAL ARTICLE

The Use of Radioactive Seed Localization for Non-Palpable Non-Breast Lesions Travis E. Grotz, MD ∙ Cindy L. Tortorelli, MD‚ ∙ Amy C. Degnim, MD ∙ Judy C. Boughey, MD ∙ Dana H. Whaley, MD‚ ∙ James W. Jakub, MD  Department of Surgery, Mayo Clinic, Rochester, Minnesota. ‚ Department of Radiology, Mayo Clinic, Rochester, Minnesota.

Abstract

Introduction There is an increasing use of advanced radiologic imaging for staging and surveillance of solid malignancies resulting in the identification of subclinical non-palpable metastases. Radioactive seed localization (RSL) is a safe and accurate method of localization of non-palpable breast cancers. The aim of this study was to evaluate the expansion of RSL to non-breast lesions. Methods We conducted a retrospective review of a prospective database of all RSL procedures performed at our institution from January 2007 to April 2010. All RSL performed for breast lesions were excluded. Results Eight patients underwent radiologic placement of a 125I seed using ultrasound or computed tomography (CT) guidance. Sites included the upper leg and shoulder, as well as, the internal mammary, infraclavicular and axillary lymph nodes. The mean size of the resected specimen was 2.74 cm in greatest dimension (range 0.6-7.1 cm). The surgeon used a handheld gamma probe for guidance to excise the seed and lesion with negative margins and minimal morbidity. Conclusions RSL is a safe, accurate, and effective technique for the localization and excision of non-palpable non-breast lesions. RSL has the potential to be adapted to many lesions amenable to a percutaneous approach as it permits convenient and accessible localization of the lesion via gamma probe, avoids the issues of wire management with wire localization, and maintains radiation safety through low radioactive seed doses. Keywords RSL, solid malignancies, lymph nodes, gamma probe

J Surg Rad

Introduction

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The role of routine surveillance to detect metastatic foci of cancer before they are clinically appreciated is controversial. A consistent argument against this approach contends that finding stage IV disease before clinical detection does not improve survival. In fact, it may serve only to inform patients they have incurable disease while they are asymptomatic, as opposed to symptomatic disease presenting just a few months later, had routine imaging not been performed. Others argue that, in some patients, Citation Grotz TE, Tortorelli CL, Degnim AC, Boughey JC, Whaley DH, and Jakub JW. The use of radioactive seed localization for non-palpable non-breast lesions. J Surg Radiol. 2010 Oct 1;1(2). Correspondence James W. Jakub, MD E-mail jakub.james@mayo.edu. Received June 19, 2010. Accepted July 21, 2010. Epub July 31, 2010.

Original Article | October 2010

routine surveillance can identify clinically occult locoregional or even oligometastatic stage IV disease that may result in improved survival if completely resected. Though this debate for individual solid tumor sites has not been resolved by evidence based approaches, the fact remains that advanced radiologic imaging for patients with high risk lesions is being performed as part of follow-up on a regular basis. The result is an increase in the identification of clinically occult single sites of metastasis in some patients.1 These sites of clinically occult metastasis may be diagnosed with [18F] fluorodeoxyglucose (FDG) positron emission tomography (PET), computed tomography (CT), ultrasound (US), or magnetic resonance imaging (MRI). This early detection challenges the radiologist to localize the lesion and direct the surgeon to allow intraoperative identification of the site for resection. Localization modalities include wire localization, intralesional injections of dye, intraoperative ultrasound guidance, and marking the overlying skin with indelible ink.2-5 Radioac-


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Table 1. Clinical characteristics of 8 patients who underwent RSL of non-palpable lesions outside of the breast. Size

Specimen (cm)

Metachronous Synchronous

Presence of Malignancy

2h

metachronous

negative

7.1 x 4.0 x 1.6

2h

metachronous

positive

US

1.5 x 1.3 x 1.2

12 h

metachronous

positive

in transit met

US

4.5 x 3.2 x 3.0

3h

metachronous

positive

adnexal apocrine carcinoma

axillary LN

US

1.0 x 0.9 x 0.6

20 h

metachronous

negative

47

recurrent breast cancer

infraclavicular LN

US

2.3 x 1.6 x 0.9

2h

metachronous

positive

75

melanoma

in transit met

US

1.5 x 1.0 x 0.5

16 h

synchronous

positive

36

advanced breast cancer

internal mammary LN

CT

0.6 x 0.4 x 0.3

66 h

synchronous

positive

of

Age

Diagnosis

Target Lesion

Imaging Modality

45

recurrent breast cancer

axillary LN

US

3.4 x 1.5 x 1.2

40

recurrent breast cancer

axillary LN

US

67

melanoma

in transit met

45

melanoma

25

tive seed localization (RSL) is a novel alternative to the above modalities for the localization of non-palpable lesions. Several studies have demonstrated the safety of the use of a125I titanium seed for localization of non-palpable breast lesions not only for the patient, but also the surgeon, surgical team, radiologist, and pathologist.6-9 RSL utilizes technology currently available in most operating rooms, specifically, a handheld gamma probe. These probes are commonly employed for sentinel lymph node (SLN) biopsy. They offer the advantage of providing constant real-time feedback to the surgeon allowing continuous reorientation to the non-palpable area of concern. When used for breast cancer, the RSL technique has resulted in retrieval of the targeted lesion and seed 100% of the time.7-9 Given the success of RSL in non-palpable lesions of the breast,

Deployment and Excision Interval

or

it seems only natural to expand this to other non-palpable lesions throughout the body. However, only one previous case report describes the use of RSL to localize in-transit metastasis deep within the subcutaneous tissue of the lower extremity.10 The aim of this study is to further describe the role of RSL to provide intraoperative localization for a variety of nonpalpable lesions.

Materials and Methods This retrospective study was approved by the institutional review board and all patients consented to the use of their medical records for research. Three hundred and twenty patients were identified from a prospective database of patients

Figure 1. F-18 FDG PET/CT scan with CT fusion imaging demonstrating a new soft tissue nodule in the medial aspect of the distal right thigh with avid FDG uptake measuring 2.3 cm transverse x 1.7 cm AP. Suspicious for in-transit metastatic melanoma. www.JSurgRad.com

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Grotz et al. Radioactive Seed Localization a non-palpable lesion outside of the breast. We retrospectively reviewed the medical records, radiological studies, operative reports, and pathological specimens of these eight patients. Given the small sample size only descriptive statistics were used.

Results Radioactive Seed Localization I labeled titanium seeds are FDA-approved for the interstitial treatment of prostate cancer. The use of the 125I seeds for localization is an off-label use. RSL was performed as previously described11 with 0.158 to 0.277 mCi of 125I encased in a small (4.5 x 0.8 mm) titanium seed; this isotope has a half life of 60 days. The radioactive seed is loaded into an 18-gauge needle by the radiologist after occluding the tip with sterile bone wax. The needle is then introduced into the target lesion using radiologic imaging (ultrasound, CT, or mammography) guidance. The seed is deployed by advancing the stylet. The needle is withdrawn and accurate placement of the seed is confirmed upon repeat imaging. The patient is then discharged and reports for surgery on the prescribed day (0-3 days later) with no restrictions. 125

Standard intraoperative handheld gamma probes were used by the surgeon to identify the seed within the target tissue. Most gamma probe systems allow the specific detection of numerous isotopes. By choosing Figure 2. A. Ultrasound guided 125I seed placement into an infraclavicular lymph node the 125I setting on the gamma (top). B. The seed appears as a linear echogenic focus with the node (bottom). probe, the surgeon can selectively identify and isolate the 27 keV who underwent RSL at the Mayo Clinic, Rochester between source, thus allowing simultaneous lymphatic mapping with January 2007 and April 2010. Over these 40 months the over99 Tc without interference between the two isotopes. The gamwhelming majority of RSL procedures were utilized for the ma probe and seed provide constant audible feedback during care of primary lesions in the breast (312 patients). In eight the procedure allowing continuous reorientation of the speci(2.5%) patients the indication for RSL was the localization of

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Grotz et al. Radioactive Seed Localization

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men. After removal, the gamma probe is used to confirm the removal of the seed and absence of residual radioactive activity in the surgical field. No signage or monitoring badges are required in the operating room. A specimen radiograph may be obtained to document removal of the seed and position within the specimen. The specimen is then transported to the pathology department where the pathologist dissects the seed from the specimen and places it in a lead container. Standard intraoperative pathologic processing is performed, including frozen section analysis at our institution. A member of the nuclear medicine staff retrieves the seed for long term storage and decay. No room signage or monitoring badges are necessary in the pathology suite.

Cases Eight patients underwent RSL for non-palpable, non-breast lesions during the study period. The mean age of the patients was 47 years of age (range 25-75 years old) at the time of the procedure, and the median follow up was 9.4 months (range 2-17.5 months). Five patients were female and three were male. Three patients had a primary diagnosis of melanoma, four patients had breast cancer, and one patient had an adnexal apocrine adenocarcinoma (Table 1). All of the radioactive seeds were placed under ultrasound guidance except one. CT was utilized secondary to inability to definitively identify the lesion on ultrasound. The time between placement of the seed and surgical resection was a mean of 15 hours with a range of 2-66 hours. The amount of 125I in each seed 125 I seed into suspicious internal mammary lymph node (top). ranged from 0.158 mCi to 0.277 Figure 3. A. CT guided B. Seed identified just anterior to suspicious the internal mammary lymph node on post mCi, with a mean of 0.21 mCi, localization CT (bottom). and all seeds were successfully www.JSurgRad.com

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Original Article recovered. The mean size of the resected specimen in greatest diameter was 2.74 cm (0.6 cm to 7.1 cm). Frozen section intraoperative pathologic analysis was performed, and the final margins were negative in all cases with no patients requiring a second operative intervention. However, two re-excisions were necessary under the same anesthetic secondary to a close margin (1 mm) identified intraoperatively. One patient who underwent simultaneous RSL of an intransit metastasis of the adductor magnus and inguinal lymphadenctomy developed a postoperative wound infection of the inguinal incision that was managed with oral antibiotics as an outpatient. Four patients did not undergo combined procedures and were discharged the day of surgery; the other four patients underwent simultaneous procedures requiring 1- to 2-day hospitalizations [mean length of stay (LOS) â&#x20AC;&#x201C; 1.25 days]. There were no mortalities and only one superficial wound infection as described above associated with this procedure. In this series, two intransit melanoma metastases, one internal mammary lymph node, two infraclavicular lymph nodes, and three axillary lymph nodes were localized using the radioactive 125I seeds. Both intransit metastases were located within the deep tissue of the upper thigh; one in the subcutaneous tissue and the other was intramuscular in the adductor magnus. The majority (75% n=6) of the resected lesions were for metachronous locoregional metastases diagnosed on surveillance PET(n=5) or MRI (n=1) imaging a mean of 48.6 months (range 1.4 - 126.4 months) after diagnosis. The two synchronous lesions were also identified on preoperative staging PET scan. The primary malignancy was histologically confirmed in all cases, however, none of the target lesions localized by RSL were biopsied preoperatively. In all cases there was no evidence of distant metastases. The final pathology confirmed oligometastatic disease in all cases except two. Both of these were reactive axillary lymph nodes with suspicious surveillance imaging (PET, MRI, and US) in patients who had previously undergone axillary lymphadenectomy without adjuvant radiation.

Discussion The advantages of RSL of non-palpable breast cancers have been well described.11 However, this is only the second report and first case series of the use of RSL for non-palpable lesions outside of the breast. We have demonstrated the safety and accuracy of RSL in this small series as we were able to accurately identify the target lesion and obtain negative margins in all cases using RSL with minimal morbidity. RSL provides a very focal point source for localization that allows the intraoperative identification of lesions as small as 6 x 4 x 3 mm in our study and 2 x 5 mm in a previous case report.10 Radioactive seed placement was performed the morning of surgery in some cases and up to three days prior to the operation in others, providing improved patient convenience. Uncoupling the operative and radiologic scheduling eliminates many conflicts, avoids the need for same day surgery, and allows a first case start time. The seeds were easily placed within the lesion in all instances using either ultrasound or CT guidance with

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Grotz et al. Radioactive Seed Localization no lost or displaced seeds. The technique of RSL uses a skill set familiar to both radiologists and surgeons. Needle localization with the radioactive seed employs standard image-guided percutaneous approach. Correspondingly, for the operative approach, the guidance is similar to SLN biopsy with which most surgeons are comfortable. Therefore, RSL was easily incorporated into a busy academic surgical practice. Intraoperative ultrasound for guidance is an option for some of these lesions but is limited in cases that cannot be visualized by this technology. Also, many surgeons are not adequately trained or comfortable identifying these lesions intraoperatively without reliance on a localization device. As a result, many of these lesions may require the presence of a radiologist in the operating suite if the surgeon is not specifically trained in ultrasonic evaluation, especially in small, difficult to visualize lesions. Wire localization (WL), another localization technique, has many disadvantages including wire misplacement, dislodgment and migration during post-localization imaging and patient transportation, as well as, wire transaction intraoperatively.5, 12-14 In the case of wire transection, not only does the surgeon lose all localization, but there is a potential for a retained foreign body within the patient. The distinct disadvantage to WL is that the ideal trajectory of skin entry to the target for the radiologist to place the wire may be less then optimal for surgical incision planning. In addition, the tip of the wire in the soft tissue is not palpable eliminating any feedback to assure the surgeon is beyond the tip before coming across the specimen. The accuracy of marking the skin overlying the lesion with indelible ink may be ideal in certain locations such as the internal mammary nodes but is fraught with potential operative mishaps in many anatomic sites due to changes in patient position and inability to appreciate the exact depth from a cutaneous marking. Injection of dye into the soft tissue for localization of non-palpable lesions is limited by its diffusion into the surrounding tissue. RSL has been demonstrated to be such an accurate method for localization of non-palpable breast cancers, as Gray et al. demonstrated in a randomized trial, that fewer additional margin resections were needed compared to WL (26% vs.  57%).7 A retrospective study demonstrated a 35% (p = 0.01) relative improvement in the rate of negative margins in the first specimen and a 62% (p = 0.01) reduction in the rate of reoperation for positive margins.8 A subsequent prospective multiinstitutional trial confirmed a lower positive margin rate with RSL compared to WL.9 In addition, RSL is efficient as it does not increase the operative time or the localization time.7 RSL is convenient as it can be scheduled days in advance (up to five days preoperatively at our institution) and therefore, convenient for the patient, surgeon, and radiologist. RSL also allows the radiologist the ability to approach the lesion from the easiest and safest angle without regard for the need of the surgeon to incorporate the wire trajectory (if using WL) in their incision. These factors resulted in RSL receiving higher convenience scores by the patient than WL (8.5 vs 7.4 p = 0.02).9 Handheld guidance by the gamma probe to identify the 125I seed is intuitive and provides constant feedback allowing the


Original Article

Grotz et al. Radioactive Seed Localization surgeon to determine the appropriate depth of the lesion ensuring when it is safe to transect the specimen under the deep margin of excision. No other current localization approach for non-palpable lesions provides this advantage. RSL has been demonstrated to be a safe method of localization. With this modality the radioactive seed is being utilized for localization and not as a therapeutic intervention for cancer. In brachytherapy for prostate cancer multiple (50-110) 125I seeds are utilized with higher radioactive activity (12.6-16.7 MBq) for a therapeutic radiation dose of 145 Gy.15 In contrast RLS utilizes one seed with less than 3.7 MBq for a short duration. The peak dose to residual tissue given by a 3.7 MBq seed excised 24 hours after implantation within an approximately 2 cm specimen results in as little as 2.8 cGy to the residual tissue.6 The radioactive dose to the residual tissue decreases substantially as the specimen size increases secondary to tissue absorption and the inverse square law. Regarding radiation exposure to the surgeon, surgical team, pathologist, and radiologist, given the seedâ&#x20AC;&#x2122;s low strength, the actual exposure at the skin surface is 0.2 mGy and, therefore, no special radiation safety precautions are routinely needed.6 The numerous advantages of RSL over conventional localization techniques in non-palpable breast cancers warrant further investigation of this novel technique for non-palpable lesions outside of the breast. This case series builds upon a previous case report to establish RSL as a viable option for localization of non-palpable oligometastatic disease in various regions of the body.10 As complete surgical resection becomes increasingly incorporated into the multidisciplinary management of patients with stage IV cancers, such as breast and melanoma, the need for an efficient and simple localization technique becomes more important. The results of this case series support the conclusion that RSL has the potential to be adapted to most lesions amenable to a percutaneous approach. However, these results are limited as this is a retrospective single institutional study and is, therefore, subject to selection bias. The small sample size also limits the confidence to make conclusions. Nevertheless, it should serve as an impetus for prospective studies with larger sample sizes to further investigate and validate the potential diverse applications of RSL. In conclusion, we have found RSL to be a promising technique that allows for the localization and excision of radiographically-identified but clinically occult lesions.

Disclosures The authors have no disclosures or conflicts of interest related to this manuscript.

References

1. Bastiaannet, E., et al., Prospective comparison of [18F]fluorodeoxyglucose positron emission tomography and computed tomography in patients with melanoma with palpable lymph node metastases: diagnostic accuracy and impact on treatment. J Clin Oncol, 2009. 27(28): p. 4774-80. 2. Ueno, E., et al., Ultrasonically guided biopsy of nonpalpable lesions of the breast by the spot method. Surg Gynecol Obstet, 1990. 170(2): p. 153-5. 3. Hall, F.M. and H.A. Frank, Preoperative localization of nonpalpable breast lesions. AJR Am J Roentgenol, 1979. 132(1): p. 101-5. 4. Makuuchi, M., H. Hasegawa, and S. Yamazaki, Intraoperative ultrasonic examination for hepatectomy. Ultrasound Med Biol, 1983. Suppl 2: p. 493-7. 5. Homer, M.J. and E.R. Pile-Spellman, Needle localization of occult breast lesions with a curved-end retractable wire: technique and pitfalls. Radiology, 1986. 161(2): p. 547-8. 6. Pavlicek, W., et al., Radiation safety with use of I-125 seeds for localization of nonpalpable breast lesions. Acad Radiol, 2006. 13(7): p. 909-15. 7. Gray, R.J., et al., Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: radioactive seed versus wire localization. Ann Surg Oncol, 2001. 8(9): p. 711-5. 8. Gray, R.J., et al., Radioactive seed localization of nonpalpable breast lesions is better than wire localization. Am J Surg, 2004. 188(4): p. 37780. 9. Hughes, J.H., et al., A multi-site validation trial of radioactive seed localization as an alternative to wire localization. Breast J, 2008. 14(2): p. 153-7. 10. Fleming MD, P.B., Hansen AJ, Gray RJ, Patel MD. , Radioactive seed localization for excision of melanoma. Radiology Case Reports, 2006. 1(8): p. 54-57. 11. Jakub, J.W., et al., Current status of radioactive seed for localization of non palpable breast lesions. Am J Surg. 199(4): p. 522-8. 12. Bronstein, A.D., R.F. Kilcoyne, and R.E. Moe, Complications of needle localization of foreign bodies and nonpalpable breast lesions. Arch Surg, 1988. 123(6): p. 775-9. 13. Homer, M.J., Transection of the localization hooked wire during breast biopsy. AJR Am J Roentgenol, 1983. 141(5): p. 929-30. 14. Davis, P.S., et al., Migration of breast biopsy localization wire. AJR Am J Roentgenol, 1988. 150(4): p. 787-8. 15. Moule, R.N. and P.J. Hoskin, Non-surgical treatment of localised prostate cancer. Surg Oncol, 2009. 18(3): p. 255-67.

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ORIGINAL ARTICLE

Jejuno-Uterine Fistula After Endovascular Embolization For Uterine Bleeding Simon D. Eiref, MD ∙ Scott Holekamp, MD ∙ John Koulos, MD‚ ∙ Gabriel Levi, MDƒ ∙ Marie Winestone, MD„ ∙ Alexander Kagen, MD„ ∙ I. Michael Leitman, MD Departments of Surgery, Obstetrics and Gynecology,‚ Pathology,ƒ and Radiology,„ Albert Einstein College of Medicine-Beth Israel Medical Center, New York, New York

Abstract

Overview Jejuno-uterine fistula is a very rare occurrence. The case presented described the development of a jejuno-uterine fistula following uterine artery embolization (UAE), which we believe is the first reported case. Keywords uterine artery embolization, endovascular, endometrial hyperplasia

Introduction Jejuno-uterine fistulas have rarely been described complications of curettage procedures. We describe the first case report of a jejuno-uterine fistula, which formed as a result of uterine artery embolization.

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A 37-year-old Asian female, G0P0, with a history of adenomyosis and endometrial hyperplasia, presented to the hospital with prolonged heavy vaginal bleeding and anemia. She underwent hysteroscopy, dilatation and curettage. Following the procedure, brisk hemorrhage from the uterine cavity lead to transfer to the interventional radiology suite. Definitive control of the bleeding was achieved by bilateral uterine artery embolization using Embospheres (BioSphere Medical, Inc. Rockland, MA). Although the recommendation was made for the patient to undergo a scheduled hysterectomy after discharge, the patient was lost to follow-up. Three months later, she returned to the hospital with Citation Eiref SD, Holekamp S, Koulos J, Levi G, Winestone M, Kagen A, and Leitman IM. Jejuno-uterine fistula after endovascular embolization for uterine bleeding. J Surg Radiol. 2010 Oct 1;1(2). Correspondence I. Michael Leitman, MD E-mail mleitman@chpnet.org. Received June 30, 2010. Accepted July 21, 2010. Epub August 1, 2010.

Original Article | October 2010

Figure 1. Coronal-oblique multiplanar reconstruction demonstrates fistulous connection between a loop of small bowel and the uterus (arrow). There is layering debris and air in the uterus (arrowhead).


Eiref et al. Jejuno-Uterine Fistula

Original Article

Figure 2. Intraoperative photograph of jejuno-uterine fistula. Figure 3. Intraoperative photograph of foreign body in small bowel distal to fistula.

complaints of a new onset of lower abdominal pain and painful vaginal discharge. The vaginal discharge increased markedly after eating and contained partially digested food particles. Physical exam was remarkable for a tender lower abdominal mass. CT scan of the abdomen/pelvis (Figure 1) confirmed a jejunouterine fistula. The patient underwent exploratory laparotomy, in which small bowel loops were found to be densely adherent to the fundus of the uterus. www.JSurgRad.com

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Figure 4. Intraoperative photograph of the uterus. The uterine fundus appeared necrotic and ruptured in the midline, appearing as a wedge-shaped defect. Dissection of the small bowel from the uterus revealed a jejuno-uterine fistula between a loop of jejunum (50 cm distal to the ligament of Treitz) and the uterine fundus (Figure 2). The uterine fundus appeared necrotic and ruptured in the midline, appearing as a wedge-shaped defect. The jejunum involved in the fistula was resected and intestinal continuity was reestablished with a primary small bowel anastomosis. Downstream, an 11 x 10 x 3.5 cm partially obstructing foreign body was palpable in the lumen of distal ileum, and was extracted via a separate enterotomy (Figure 3). A total hysterectomy was performed (Figure 4) with an unremarkable postoperative course. Pathology revealed a 2.5 cm diameter fistulous tract arising from an area of infarcted uterine myometrium to a segment of otherwise normal appearing jejunum. Embolization material was detected within the arteries of the infarcted myometrium, and more interestingly, found extending into the fistulous tract (Figure 5). Analysis of the foreign body removed from the lumen of the distal small bowel revealed that it was infarcted uterine myometrium, matching the wedge-shaped defect in the uterine fundus. There was no evidence of malignancy.

Discussion A fistula is an abnormal connection between two epitheliumlined organs or vessels that do not connect. In the case of the uterus, fistulas can develop to the bladder, colon, and small intestine. Enterouterine fistulas occur infrequently. Martin et al.1 published perhaps the largest review of enterouterine fis-

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tulas in 1956 which described 80 cases, 42 of which followed obstetric injury, 17 resulting from inflammatory processes, 12 following curettage, and nine related to carcinoma. In particular, jejuno-uterine fistulas are rare. We found only four case reports of jejuno-uterine fistula in the modern literature, each following curettage procedures, and involving the uterine fundus. McFarlane et al.2 described a jejuno-uterine fistula that developed two weeks after dilation and curettage performed for severe postpartum hemorrhage. Duttaroy et al.3 described symptoms of a jejuno-uterine fistula developing three months after dilation and evacuation for a spontaneous abortion. Singh et al.4 described a chronic jejuno-uterine fistula following termination of pregnancy, discovered after three consecutive abortions. Lastly, Vohra et al.5 described a jejunouterine fistula occurring six weeks after curettage for retained products of conception. All cases were managed by surgical repair. The role of uterine artery embolization (UAE) in causing jejuno-uterine fistula has not been previously reported. Nonetheless, significant complications have been described resulting from UAE including uterine necrosis, uterine rupture, and fistulization. Godrey and Zbella6 reported on diffuse uterine necrosis with extensive small bowel adhesions occurring 2 months after UAE of a large uterine leiomyoma. Shashoua et al.7 discussed a case of ischemic uterine rupture occurring 3 months after UAE for symptomatic uterine myomas. Ogliari et al.8 reported on several patients developing uterine cavity defects with cavity-myoma fistulas after UAE for symptomatic leiomyomas. In addition, Sultana et al.9 reported on a vesico-


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Figure 5. Embolization material is embedded within the inflammation of the small bowel fistulous tract. uterine fistula developing three months after UAE for myoma. In our case, the jejuno-uterine fistula followed both curettage and UAE. While curettage appeared to be the etiology of previously reported jejuno-uterine fistulas, we believe that the UAE was the etiology in this case. This was based on the embolization material found by pathology in the fistula tract and the necrotic myometrium discovered distally in the jejunum during surgery. We suspect that UAE led to necrosis of the uterine fundus in this patient, who had a large uterus and likely poor collateral blood supply. In turn, the necrotic myometrium caused adhesions to the surrounding jejunum, inflammation, and subsequent fistula formation. The presence of foreign body embolization material in the fistula tract would have made spontaneous closure of the fistula unlikely. This mechanism of fistula formation after UAE is in distinction to fistulas developing after curettage, in which the mechanism likely results from direct mechanical perforation of the uterus and possible concurrent injury to adjacent bowel. Management of jejuno-uterine fistula has traditionally been surgical involving resection of the fistula tract and involved structures followed by primary anastamosis. Recently, Józwik10 suggested that endometrium in the fistula tract may be amenable to hormonal regulation and therefore conservative treatment. The embolization material acting as a foreign body in our fistula tract made a conservative approach less attractive. The embospheres were too small to be seen during the

resection but were confirmed by pathology. Our surgical approach was similar to ones described by McFarlane, Duttaroy, and Martin. Due to the large defect, we did not attempt to repair the uterus.

References

1. Martin DH, Hixson CH, Wilson EC Jr. Enterouterine fistula; review; report of an unusual case. Obstet Gynecol. 1956 Apr;7(4):466-9. 2. McFarlane MEC, Plummer JM, Remy T, Christie L, Laws D, Richard H, Cherrie T, Edwards R. Coward C. Jejunouterine fistula: a case report. Gynecol Surg (2008) 5:173–175. 3. Duttaroy D. Jejuno-uterine fistula. European Journal of Obstetrics & Gynecology and Reproductive Biology 129 (2006) 92–99. 4. Singh RB, Pavithran NM, Parameswaran RM, Sangwan K. Chronic jejuno-uterine fistula: an unusual cause for recurrent second trimester abortions. Aust N Z J Obstet Gynaecol 2005 45(6);533-534. 5. Vohra PA, Kumar Y, Raniga S , Vaidya V, Verma S, Mehta CA Case Of Jejunouterine Fistula Ind J Radiol Imag 2005 15:4:427-428 6. Godfrey CD, Zbella EA. Uterine Necrosis After Uterine Artery Embolization for Leiomyoma. Obstet Gynecol 2001;98:950 –2. 7. Shashoua AR, Stringer NH, Pearlman JB, Behmaram B, Stringer EA. Ischemic uterine rupture and hysterectomy 3 months after uterine artery embolization. J Am Assoc Gynecol Laparosc 2002;9:217–220. 8. Ogliari KS, Mohallem SV, Barrozo P, Viscomi F. A uterine cavity–myoma communication after uterine artery embolization: two case reports. Fertility and Sterility Vol. 83, No. 1, (2005). 9. Sultana CJ, Golberg J, Aizenman L, Chon JK. Vesicouterine fistula after uterine artery embolization: a case report. Am J Obstet Gynecol 2002;187:1726 –7. 10. Józwik M, Józwik M.Hormonal dependence of fistulas communicating with the uterus. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Jul;18(7):719-20. Epub 2007 Mar 27.

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ORIGINAL ARTICLE

Gas Gangrene Michael J Feldman, MD ∙ Mark Prosciak, MD ∙ Zahra Maleki, MD‚ ∙ Stephen M Milner, MD Johns Hopkins Burn Center and Department of Pathology,‚ Johns Hopkins University, Baltimore, Maryland.

Abstract

Overview Infection with Clostridium septicum is only found in 1% of these cases and is typically related to trauma or cancer. While the presence of diffuse subcutaneous gas is an important clinical sign, air within the femoral vessels correlates with extensive soft tissue destruction. This process must be treated with wide excision of necrotic tissue and intravenous antibiotics. This article reviews the course of a patient without significant co-morbidities who developed C. septicum infection one week after stepping on a nail. This is important as C. septicum is one of a few Clostridial species that will cause myonecrosis and carries a higher mortality rate. Keywords Clostridium septicum, necrotizing fasciitis, subcutaneous gas, necrosis, myonecrosis

Introduction

Hgb 12.6 g/dL, creatinine 1.4 mg/dL, albumin 1.6 g/dL and platelets 266 K/mm3.

Gas gangrene is an infectious process due to the production of a toxin by a species of Clostridial bacteria. These toxins result in the destruction of soft tissue which creates gas within the subcutaneous plane.1,2 Patients with this disease are critically ill and require urgent excision of the necrotic tissue. While most cases are due to infection with Clostridium perfringens, we describe a patient who was infected with Clostridium septicum. A description of the case follows, with particular emphasis on radiologic findings that indicate extensive soft tissue destruction.

Intraoperatively, he was found to have extensive necrotic muscle in all thigh compartments, thrombosed vessels, and diffuse gas tracking along the entire femur. His leg was deemed non-salvageable and a right hip disarticulation was performed. He required full ventilatory and hemodynamic support postoperatively. The following day, further debridement of necrotic muscle was performed. He was subsequently weaned from the vasopressors and extubated five days later. He was discharged to a subacute care facility after one month. The hip disarticulation site required a skin graft for closure two months after admission. While his skin graft healed in several weeks, he is still undergoing therapy in a rehabilitation facility three months following his arrival to the emergency room. The long-term treatment plan includes fitting for prosthesis.

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A 52-year-old male with a history of depression presented to the emergency department with severe pain in his right thigh. He recalled stepping on a nail prior to his arrival but was unable to recall his name, date, or current location. His family informed us that he had stepped on a nail one week before these events while he was walking outside. The patient had extracted the nail himself and had not sought medical care at the time. Further examination revealed crepitus overlying his right thigh. A CT scan of the lower extremity showed diffuse subcutaneous air throughout the thigh as well as air within the femoral vein (Figure 1). A diagnosis of gas gangrene was made. Initial laboratory values were as follows: WBC 2220/mm3, Citation Feldman MJ, Prosciak M, Maleki Z, and Milner SM. Gas Gangrene. J Surg Radiol. 2010 Oct 1;1(2). Correspondence Michael J Feldman, MD E-mail mfeldman@mcvh-vcu.edu. Received July 18, 2010. Accepted July 21, 2010. Epub August 5, 2010.

Original Article | October 2010

Cultures of the wound grew out Clostridium septicum, which has been responsible for 1% of cases of gas gangrene.3 Histology was consistent with extensive muscle necrosis and an invasive gram positive bacilli infection (Figure 2).

Discussion These cases are typically associated with trauma or cancer.3 This particular species of Clostridium causes tissue necrosis by formation of toxins that disrupt the cell membrane.2 Identifying the type of Clostridial bacterium helps predict mortality as rates for C. septicum approach 63% in adults versus 11% in those infected with C. perfringens.4 There is no clinical difference between an infection with these two Clostridial species. Most patients present with nonspecific findings such as fever, leukocytosis, and pain.4 A number of cases of C. septicum infection have been reported in patients with hepatic metastases (gas-


Original Article

Feldman et al. Gas Gangrene

Disclosures The authors have no disclosures or conflicts of interest related to this manuscript.

References

1. Martí de Gracia M, Gutiérrez FG, Martínez M, Dueñas VP. Subcutaneous emphysema: diagnostic clue in the emergency room. Emerg Radiol. 2009 Sep; 16(5):343-8. Epub 2009 Jan 30. 2. Saleh N, Sohail MR, Hashmey RH, Al Kaabi M. Clostridium septicum infection of hepatic metastases following alcohol injection: a case report. Cases J. 2009 Dec 31; 2:9408. 3. Shade V, Roukis TS, Haque MM. Clostridium septicum necrotizing fasciitis of the forefoot secondary to adenocarcinoma of the colon: case report and review of the literature. J Foot Ankle Surg. 2010 Mar-Apr; 49(2):159.e1-8. 4. Myers G, Ngoi SS, Cennerazzo W, Harris L, DeCosse JJ. Clostridial septicemia in an urban hospital. Surg Gynecol Obstet. 1992; 174: 291- 296.

Figure 1. Lower extremity CT on initial presentation showed extensive subcutaneous air in the right thigh (arrowheads) as well as air within the right femoral vein (arrow). trointestinal primary),2 as fasciitis of the foot in a patient with adenocarcinoma of the colon,3 spontaneous aortic dissection from C. septicum aortitis,5 as well as a splenic abscess in a diabetic patient.5 Infection with C. septicum carries a high mortality rate especially if not recognized early within its course.6 The mortality is even greater with involvement of the femoral vessels. This process was described by Assadian et al. (2004), with intravenous drug abusers and C. perfringens infection. Involvement of the femoral vessels implies extensive infection beyond the expected myonecrosis typically seen with gas gangrene.7 Treatment options include a combination of wide surgical excision of the infected tissue and systemic antibiotics.

5. Yang Z, Reilly SD. Clostridium septicum aortitis causing aortic dissection in a 22-year-old man. Tex Heart Inst J. 2009; 36(4):334-6.

6. Imamura M, Shimomura K, Watanabe A, Negishi M, Akuzawa M, Takahashi M, Proks P, Shimomura Y. Sepsis and gas-forming splenic abscess by Clostridium septicum in a patient with type 2 diabetes. J Diabetes Complications. 2009 Mar 12: 1-3.

7. Assadian O, Assadian A, Senekowitsch C, Markistathis A, Hagmüller G. Gas gangrene due to Clostridium perfringens in two injecting drug users in Vienna, Austria. Wien Klin Wochenschr. 2004 Apr 30; 116(78):264-7.

These infections most likely present with pain out of proportion to the examination and altered mental status. The presence of crepitus can be a late finding so that absence of this sign should not sway one from pursuing this diagnosis.

Figure 2. Section of muscle showing numerous gram positive bacilli surrounding the disintegrating muscle bundles (Brown & HOPPS stain, magnification X600). www.JSurgRad.com

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Bile Leak After Laparoscopic Redo Fundoplication Prateek K Gupta, MD ∙ Brittany L Willer, MD ∙ Tommy H Lee, MD ∙ Sumeet K Mittal, MD Department of Surgery, Creighton University, Omaha, Nebraska.

Abstract

Overview Laparoscopic antireflux surgery is the gold standard treatment for gastro-esophageal reflux disease (GERD). The most commonly reported severe complications include pneumothorax, gastro-esophageal perforation, and splenic injury. Rare complications such as aortic injury, major liver injury, mesenteric artery thrombosis, ventricular laceration, and pancreatitis have also been reported. We describe the first reported case of a bile leak after redo laparoscopic Nissen fundoplication presenting as symptomatic right-sided bilious hydrothorax. This injury was most likely a result of dissecting the undersurface of the liver from adhesions formed after the previous fundoplication. Keywords bile leak, fundoplication, laparoscopic, Nissen, gastric wrap

Introduction

J Surg Rad

Since the first laparoscopic Nissen fundoplication in 1991, laparoscopic surgery has become the gold standard treatment of GERD.1-3 Compared to open procedures, the laparoscopic approach has been shown to significantly decrease hospital stay, reduce time to return to normal activity, and have fewer postoperative complications.4

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Due to the large number of laparoscopic fundoplications performed worldwide, rare and unusual complications are occasionally seen. Infrequent, but serious intraoperative complications have been reported. These include major liver injury (laceration, necrosis, and hematoma), ventricular perforation, esophagogastric perforation, aortic laceration, vena caval injury, and pancreatitis. Reoperative antireflux surgery has a higher incidence of intra- and postoperative complications, which may be attributed to the adhesions from prior fundoplications that significantly increase the difficulty of the procedure. It is necessary to report these complications to enable rapid recognition of similar problems in the future so as to enhance patient safety, help in management, and advise patients regarding procedure risks.5 Here, we present an unusual complicaCitation Gupta PK, Willer BL, Lee TH, and Mittal SK. Bile Leak After Laparoscopic Redo Fundoplication. J Surg Radiol. 2010 Oct 1;1(2). Correspondence Sumeet K Mittal, MD E-mail sumeetmittal@creighton.edu. Received July 10, 2010. Accepted August 4, 2010. Epub August 5, 2010.

Original Article | October 2010

tion of bile leak after laparoscopic redo Nissen fundoplication.

Case Report A 64-year-old female, with severely impaired lung function (COPD Gold stage 3),6 chronic cough, and pathologic reflux disease presented with symptoms of regurgitation, morning cough, and worsening asthma. She had undergone a laparoscopic Nissen fundoplication 10 years earlier at an outside facility with early surgical failure. Her symptoms were uncontrolled despite maximal medical therapy with high-dose proton pump inhibitor and H2 receptor antagonist at night. She reported sleeping in a recliner most evenings and was on 2 liters/minute of oxygen by nasal cannula. Other surgical history included laparoscopic cholecystectomy and a left video-assisted thoracoscopic lung biopsy for tissue diagnosis to rule out interstitial lung disease. She underwent a thorough preoperative evaluation for reoperative fundoplication. Endoscopy was performed which identified a disrupted fundoplication with the gastro-esophageal (GE) junction at 35 cm from the incisors and the crus at 39 cm, indicating a 4 cm recurrent hiatal hernia. The fundoplication was located at the level of the hiatus giving the patient a slipped fundoplication. Reflux esophagitis was noted on biopsies of the distal esophagus. Gastric emptying study and manometry were normal. A 24 hour pH study performed a year prior was grossly abnormal with a DeMeester score of 43. After adequate counseling and evaluation, a redo procedure for definitive


Gupta et al. Bile Leak After Fundoplication

Original Article cutaneous gastrostomy was placed endoscopically. This technique has been described in detail elsewhere.7 A swallow study on postoperative day number (POD #) 1 showed no leak; oral intake was subsequently started. The postoperative course was unremarkable except for a slight deterioration of pulmonary function requiring a short course of high-dose corticosteroids. The patient was discharged on POD #5, tolerating a soft diet and having normal bowel function. Chest X-ray on the day of discharge showed a moderate right-sided effusion, which we elected to observe.

Figure 1. HIDA scan showing radioactivity going from the proximal biliary tree toward the anterior margin of the left lobe of the liver. The tracer eventually leaks into the chest.

Five days later (POD #10), the patient developed chest tightness and shortness of breath at home, and went to an outside Emergency Department. Chest X-ray revealed a massive right pleural effusion. Tube thoracostomy was placed and returned bilious drainage. She was then transferred to our hospital for further management and started on broad-spectrum antibiotics and an antifungal, for a significant leukocytosis and bile leak. Contrast study with gastrograffin followed by thinned barium per oral and through the gastrostomy tube showed no evidence of a leak, with an intact fundoplication. Upper endoscopy confirmed the absence of perforation. A hepatobiliary iminodiacetic acid (HIDA) scan (Figure 1) was obtained which showed movement of radioactivity from

treatment of GERD was offered, in view of her worsening lung function. The patient underwent a laparoscopic repair of a recurrent hiatal hernia with takedown of previous fundoplication, redo Nissen fundoplication, and Stamm gastrostomy. Briefly, the steps included lysis of adhesions between the undersurface of the liver and stomach. Then, the hiatus was circumferentially dissected to identify the right and left limbs of the crus. A Penrose drain was placed encircling the stomach at the level of the crus. Using this for retraction, the herniated stomach was dissected out of the mediastinum. An extensive mediastinal dissection was performed to obtain adequate esophageal length. Both vagus nerves were carefully identified and preserved. The anterior and posterior limbs of the fundoplication were then identified and divided to completely undo the fundoplication. An intraoperative endoscopy confirmed that the fundoplication was completely dismantled and that there was no enteral injury. The crus was closed with a non-absorbable interrupted suture. The hiatus was then reinforced with mesh due to her increased risk for recurrent herniation, given her recent use of corticosteroids and chronic cough. A floppy Nissen fundoplication was created over a 60 Fr. Bougie. An endoscopy was done to evaluate the Figure 2. ERCP demonstrating leakage of bile from the left lobe of the liver fundoplication. The stomach was distended arising from a tributary of the left hepatic duct. Contrast can be seen leakunder water and no leak was noticed. A per- ing into the chest. www.JSurgRad.com

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Gupta et al. Bile Leak After Fundoplication

Figure 3. CT scan of the chest showing a loculated right pleural effusion. the proximal part of the biliary tree towards the anterior margin of the left lobe of the liver, and eventually into the chest. This represented a biliary leak from the region of the left lobe of the liver, possibly due to an injury to a major bile duct. Endoscopic retrograde cholangiopancreatogram (ERCP) confirmed it to be from the left liver lobe, arising from a tributary of the left ductal system. Contrast was seen leaking out of the distal left hepatic duct and into the thorax (Figure 2). The patient was started on oral and tube feeds and continued on antibiotics. Corticosteroids were stopped after tapering. The chest tube output was seen to gradually decline and tissue plasminogen activator (TPA) was administered. Computed tomography (CT) scan of the chest was obtained showing a loculated right pleural effusion (Figure 3). A pigtail was subsequently placed by interventional radiology to obtain better drainage and TPA was continued. A HIDA scan after a few days showed resolution of the bile leak. For the residual loculated fluid collection, we proceeded with a video-assisted thoracoscopic surgery (VATS) for definitive management. Over the next few days, output from the chest tube gradually decreased and it was removed. The patient was discharged on POD #34 tolerating a soft esophageal diet and supplemental tube feeds. Medications included PRN inhalers. The patient was seen in clinic six months later and reported resolution of cough and regurgitation. She was off corticosteroids, theophylline and used only inhalers as needed (roughly two times a day).

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Discussion With the increasing number of laparoscopic fundoplications being performed, unusual intraoperative complications have been reported in the literature. Some of these include omental hematoma, pancreatitis, ventricular laceration with cardiac tamponade, aortic injury, mesenteric artery thrombosis, as well as liver laceration, necrosis and hematoma.5,8-11 A bile leak after laparoscopic redo antireflux surgery has been previously reported as part of a larger case series.12 In our patient, a likely explanation for development of a bile leak after the procedure includes thermal/mechanical injury to the liver during dissection of the fundoplication off the undersurface of the left lobe of the liver. The increased adhesions encountered during a redo fundoplication make it more difficult to identify tissue planes. An injury may have been caused to the liver during the takedown of the adhesions. Another less likely explanation for the bile leak is injury to the liver by the liver retractor. At our institute, we use a Nathanson self-retaining liver retractor. This retractor is rod-shaped with a curve to facilitate entry through the abdominal wall. It lifts the liver on its undersurface, parallel to its edge, making it a safe instrument. Liver injuries are not uncommon during either antireflux surgery or laparoscopic surgery in general.8,13-17 Many of these reported cases of liver injury were attributed to retractors caus-


Gupta et al. Bile Leak After Fundoplication ing necrosis or parenchymal trauma due to pressure. Most of these cases involved fan-shaped retractors. Some injuries were also due to assistants manually holding the liver retractor. In our patient, ERCP showed the leak to be from the left liver lobe arising from a tributary of the left ductal system. Contrast was seen leaking out of a distal left hepatic duct tracking superiorly into the thorax. It would be hard to imagine the liver retractor causing a significantly large enough injury to result in a bile leak in the absence of evidence of liver parenchymal damage on the CT scan. It was more likely due to direct injury while taking down the fundoplication. The first step in management of bile leak after antireflux surgery is to rule out gastro-esophageal perforation. We elected to use both gastrograffin swallow and endoscopy to decrease the likelihood of missing a micro perforation. During endoscopy, it is imperative to retroflex and insufflate. Bile leaks identified postoperatively are typically managed using endoscopy coupled with adequate external drainage. If intra-operatively placed drains are not adequate, tube thoracostomy or image-guided drainage may be required. The philosophy of endoscopic procedures is to reduce the bile duct to duodenum pressure gradient and divert bile away from the leak site, hence promoting healing.18 These procedures include endoscopic sphincterotomy (ES) alone, ES with stenting or nasobiliary drain placement without stenting. The appropriate choice remains controversial, with no one method universally shown to be better than the other.18-22 To conclude, although laparoscopic redo antireflux surgery can be performed safely with low morbidity, complications do occur. Bile leak is an extremely rare potential complication. Care must be taken to minimize trauma to the liver during retraction and dissection, particularly in the setting of reoperative surgery. We recommend a multimodal approach to diagnosis including ERCP, CT scan, contrast esophagogram, and scintigraphy. With adequate drainage, conservative management can be successful.

Disclosures The authors have no disclosures or conflicts of interest related to this manuscript.

References

1. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991;1:138-143. 2. Hinder RA, Filipi CJ, Wetscher G, Neary P, DeMeester TR, Perdikis G. Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 1994;220:472-481. 3. Jamieson GG, Watson DI, Britten-Jones R, Mitchell PC, Anvari M. Laparoscopic Nissen fundoplication. Ann Surg 1994;220:137-145.

Original Article 4. Peters MJ, Mukhtar A, Yunus RM et al. Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery. Am J Gastroenterol 2009;104:1548-1561. 5. Hughes SG, Chekan EG, Ali A, Reintgen KL, Eubanks WS. Unusual complications following laparoscopic Nissen fundoplication. Surg Laparosc Endosc Percutan Tech 1999;9:143-147. 6. Gold PM. The 2007 GOLD Guidelines: a comprehensive care framework. Respir Care 2009;54:1040-1049. 7. Hinder RA, Filipi CJ. The technique of laparoscopic Nissen fundoplication. Surg Laparosc Endosc 1992;2:265-272. 8. Pasenau J, Mamazza J, Schlachta CM, Seshadri PA, Poulin EC. Liver hematoma after laparoscopic nissen fundoplication: a case report and review of retraction injuries. Surg Laparosc Endosc Percutan Tech 2000;10:178-181. 9. Firoozmand E, Ritter M, Cohen R, Peters J. Ventricular laceration and cardiac tamponade during laparoscopic Nissen fundoplication. Surg Laparosc Endosc 1996;6:394-397. 10. Leggett PL, Bissell CD, Churchman-Winn R. Aortic injury during laparoscopic fundoplication: an underreported complication. Surg Endosc 2002;16:362. 11. Mitchell PC, Jamieson GG. Coeliac axis and mesenteric arterial thrombosis following laparoscopic Nissen fundoplication. Aust N Z J Surg 1994;64:728-730. 12. Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Ikramuddin S, Schauer PR. Outcomes after minimally invasive reoperation for gastroesophageal reflux disease. Ann Thorac Surg 2002;74:328-331. 13. Medina LT, Veintimilla R, Williams MD, Fenoglio ME. Laparoscopic fundoplication. J Laparoendosc Surg 1996;6:219-226. 14. DePaula AL, Hashiba K, Bafutto M, Machado CA. Laparoscopic reoperations after failed and complicated antireflux operations. Surg Endosc 1995;9:681-686. 15. Erstad BL, Rappaport WD. Subcapsular hematoma after laparoscopic cholecystectomy, associated with ketorolac administration. Pharmacotherapy 1994;14:613-615. 16. Pietra N, Sarli L, Costi R, Violi V. Intrahepatic subcapsular hematoma. A rare postoperative complication of laparoscopic cholecystectomy. Surg Laparosc Endosc 1998;8:304-307. 17. Fusco MA, Scott TE, Paluzzi MW. Traction injury to the liver during laparoscopic cholecystectomy. Surg Laparosc Endosc 1994;4:454-456. 18. Aksoz K, Unsal B, Yoruk G et al. Endoscopic sphincterotomy alone in the management of low-grade biliary leaks due to cholecystectomy. Dig Endosc 2009;21:158-161. 19. Agarwal N, Sharma BC, Garg S, Kumar R, Sarin SK. Endoscopic management of postoperative bile leaks. Hepatobiliary Pancreat Dis Int 2006;5:273-277. 20. Marks JM, Ponsky JL, Shillingstad RB, Singh J. Biliary stenting is more effective than sphincterotomy in the resolution of biliary leaks. Surg Endosc 1998;12:327-330. 21. Costamagna G, Shah SK, Tringali A. Current management of postoperative complications and benign biliary strictures. Gastrointest Endosc Clin N Am 2003;13:635-48, ix. 22. Bose SM, Mazumdar A, Singh V. The role of endoscopic procedures in the management of postcholecystectomy and posttraumatic biliary leak. Surg Today 2001;31:45-50.

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ORIGINAL ARTICLE

Pylephlebitis With SMV Thrombosis After Perforated Appendicitis Andre Teixeira, MD ∙ Carrie Laituri, MD ∙ Dan Anderson, MD ∙ Patricio Quijada, MD Department of General Surgery, Orlando Health, Orlando, Florida.

Abstract

Overview Pylephlebitis or septic thrombophlebitis of the portal vein is an extremely rare and potentially fatal complication of appendicitis, which occurs secondary to infection drained by the portal venous system. We describe a case of pylephlebitis resulting from perforated appendicitis complicated by septic thrombosis. Diagnosis and progression was confirmed by computed tomography. The patient had a favorable outcome with medical and surgical therapy, prompting us to evaluate treatment of pylephlebitis. Keywords thrombophlebitis, superior mesenteric vein, portal vein, sepsis, thrombosis, CT

Introduction

Case Report

Pylephlebitis is described as septic thrombophlebitis of the portal vein or one of its tributaries.1,2 The exact incidence of pylephlebitis is unknown, but its diagnosis may be obscured by the primary disease. The morbidity and mortality associated with portal and mesenteric pylephlebitis may be high, as this may be an overlooked condition secondary to an infection in the drainage of the portal venous system.

A 33-year-old male came to the emergency department for evaluation of abdominal pain. He presented with acute onset of generalized abdominal pain that began three days prior to admission and was localized to the right lower quadrant. He had associated anorexia, nausea, and emesis. During the initial evaluation, the patient was laying supine on the stretcher with his bilateral lower extremities flexed at the knee and complaining of increasing abdominal pain. The patient was febrile with a temperature of 103 oF. His routine blood work revealed white blood cell count (WBC) of 9,000/dl. A CT scan of the abdomen and pelvis was obtained, revealing a perforated appendix with associated phlegmon; additionally no abnormalities were found in the liver or portal system (Figure 1). After surgical evaluation, the patient received preoperative antibiotics and was taken to the operating room where an open appendectomy was performed. Intra-operative cultures were obtained and demonstrated group C Streptococcus and Klebsiella pneumoniae. The patient was treated with antibiotics for five days. His immediate post-operative course was uneventful and he was subsequently discharged home.

J Surg Rad

Portal pylephlebitis is a described complication of appendicitis and other infective and inflammatory conditions affecting the small intestine, stomach, pancreas, and biliary tract.1 More infrequent causes include urogenital lesions, subphrenic abscesses, and various malignancies.3 Due to advances in management with earlier diagnosis of its underlying cause and the concurrent use of antibiotics, it is thought to be less common in the modern era.4 Greater use of diagnostic radiological imaging may lead to increased diagnosis of this infection. In this article, we report a case of ruptured appendicitis complicated by development of pylephlebitis with superior mesenteric vein (SMV) thrombosis.

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Citation Teixeira A, Laituri C, Anderson D, and Quijada P. Pylephlebitis With SMV Thrombosis After Perforated Appendicitis. J Surg Radiol. 2010 Oct 1;1(2). Correspondence Andre Teixeira, MD E-mail ateixeira200@yahoo.com. Received June 29, 2010. Accepted July 29, 2010. Epub August 5, 2010.

Original Article | October 2010

The patient returned to the emergency department four days later complaining of abdominal pain, fever, and drainage from the incision site. The previous incision was open and locally explored, noting no fascial defects. Blood work was obtained, which now demonstrated a leukocytosis of 12,000/dl and an elevated alkaline phosphatase level. A CT scan of the abdomen and pelvis was obtained to evaluate for a possible intraabdominal abscess (Figure 2), which was not evident. Surprisingly the CT scan demonstrated a dramatic increase in the size of the liver


Teixeira et al. Pylephlebitis After Appendicitis

Original Article

Figure 1. Computed tomography demonstrating intense right lower quadrant inflammatory reaction with changes consistent with likely perforated acute appendicitis and associated small fluid collection anterior to the rectum. compared to the pre-operative CT scan. Additionally, a filling defect was identified at the bifurcation of the right and left hepatic portal vein corresponding with a thrombus. Numerous lesions were seen throughout the liver and a focus defect measuring 7.7 cm by 5.7 cm was present in the posterior right lobe of the liver. With these new findings, the patient was hospitalized and

started on intravenous antibiotics and intravenous heparin anticoagulation therapy. During the first week of hospitalization, the patient was treated for a partial bowel obstruction, which resolved with nonoperative management. He continued to have intermittent high fevers, which resolved by the end of the first week. He subsequently began having recurrent abdominal pain and fevers up to 103 oF. Repeat cultures were negative. A repeat CT scan of the abdomen and pelvis

Figure 2. Computed tomography demonstrated abnormal filling defects within the left and right branches of the portal vein, which is more visible on the right than on the left. There are numerous lesions seen throughout the liver.

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Teixeira et al. Pylephlebitis After Appendicitis Figure 3. Computed tomography demonstrating an apparent thrombus within the hepatic portion of the portal venous system and a visible clot within the superior mesenteric vein. The spleen remains enlarged while the pancreas, adrenals, and kidneys appear normal. was obtained, which now demonstrated a thrombus within the superior mesenteric vein (Figure 3). Continuous heparin therapy and empiric broad-spectrum antibiotics were continued. By the end of his second week of hospitalization, the fevers and abdominal pain had resolved. The anticoagulation was transitioned and converted to Coumadin therapy for long-term anticoagulation, which was managed by his primary care physician. The patient was discharged home. Despite multiple attempts to contact him, we were unable to obtain any further follow-up.

Discussion Portal pylephlebitis is a rare complication of appendicitis and other inflammatory conditions that involve the portal drainage. The true incidence of pylephlebitis is unknown. Advancements in antibiotic therapy have presumably kept the incidence low in the modern era.1 Pylephlebitis should be considered in patients with evidence of intra-abdominal infection and bacteremia. A retrospective review of 18 cases in the literature reported the presence of associated bacteremia in 88% of the cases of confirmed pylephlebitis.4 However in our case, the presence of bacteremia was not confirmed as demonstrated by multiple negative blood cultures. Therefore, the absence of bacteremia should not deter one from postulating this diagnosis. Pylephlebitis secondary to infection can be distinguished from thrombosis due to other causes by its typically non-occlusive nature.5 Septic emboli may result from pylephlebitis, which may distribute within the liver producing intrahepatic abscesses.2,6 This occurrence was demonstrated radiographically as multiple intrahepatic abscess and partial occlusions of the left and right portal veins were presented on CT (Figure 2), as these hepatic abscesses were most likely due to septic emboli. It has been reported that anticoagulation therapy may decrease the incidence of septic embolization from the infected portal thrombi to the liver, thus preventing liver ab-

108 Original Article | October 2010


Original Article

Teixeira et al. Pylephlebitis After Appendicitis scesses.7 Anticoagulation therapy in a short duration can be used if thrombosis is associated with sepsis and not complicated by infarction or embolization.4 Although the benefit of adjunctive heparin therapy has not been clearly demonstrated in previous reports, some advocated its use as a primary treatment modality.1,4 An untreated portal or SMV thrombosis has an associated mortality rate of up to 32%, and this uniformly feared complication could be catastrophic.8 Harsh recommended anticoagulation therapy as a first-line treatment, based on the presumption that the untreated embolism might further progress causing enteric ischemia. Once the bowel has been compromised, operative and radiological interventions in the form of thrombectomy and thrombolysis with direct intravascular infusion of thrombolytics have been advocated for mesenteric and portal vein non-suppurative thrombosis.9 In our case, there was improvement of symptoms and no progression to bowel compromise with anticoagulation therapy. Therefore, we present this case as an interesting diagnostic dilemma with radiographic findings consistent with portal pylephlebitis and thrombosis secondary to perforated appendicitis. Consequently, general surgeons should be attentive to the possibility of this diagnosis.

Disclosures The authors have no disclosures or conflicts of interest related to this manuscript.

References

1. Bolt RJ. Diseases of the hepatic blood vessels, Chapter 169. In: Bockus Gastroenterology, Fourth Edition. Vol 5. Ed-in-Chief, Berk JE. Philadelphia: WB Saunders; 1985, p3259-69. 2. Klinefelter HF Jr, Grose WE, Crawford HJ. Pylephlebitis. Bull Johns Hopkins Hosp. 1960;106:65-73. 3. Mchardy G. The Appendix, Chapter 144. In: Bockus Gastroenterology, fourth ed. Vol 4. Ed-in-Chief, Berk JE. Philadelphia: WB Saunders; 1985, p2609-24. 4. Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): Diagnosis and management in the modern era. Clin Infect Dis. 1995; 21:1114-20. 5. Sakalkale R, Reeve P. Portal venous thrombophlebitis in a case of perforated appendicitis: lessons from a case. N Z Med J, 2006, 119:U1984 6. Demertzis S, Ringe B, Gulba D, et al. Treatment of portal vein thrombosis by thrombectomy and regional thrombolysis. Surgery. 1994; 115:389-93. 7. Harch JM, Radin RD, Yellin AE, et al. Pylethrombosis: serendipitous radiologic diagnosis. Arch Surg. 1987; 122:1116-9. 8. Kader HA, Baldassano, Harty MP, et al. Ruptured retrocecal appendicitis in an adolescent presenting as portal-mesenteric thrombosis and pylephlebitis. J Ped Gastroenterol Nutr. 1998; 27:584-8. 9. Baril N, Wren S, Radin R, et al. The role of anticoagulation in pylephlebitis. Am J Surg. 1996; 172:449-53.

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Andreas Vesalius, 1514-1564 De humani corporis fabrica libri septem.

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ORIGINAL ARTICLE

Delayed Splenic Rupture Prateek K Gupta, MD ∙ Janine Morris, MD‚ ∙ Bala Natarajan, MD ∙ Robert Bertellotti, MD ∙ R Armour Forse, MD, PhD Departments of Surgery, and Radiology,‚ Creighton University, Omaha, Nebraska.

Abstract

Introduction Computed tomography (CT) scans are very sensitive for detecting splenic injuries after trauma. Our objective was to present a case of the rare entity called ‘Delayed Splenic Rupture,’ which is the delayed manifestation of splenic injury following a trauma in which the initial CT scan showed a normal spleen. We also review the previous 13 cases and offer our recommendations. Case Report We present a case of a 42-year-old male with a motorcycle crash who presented with a normal spleen on CT scan and five days later was scanned again after a significant decrease in his hemoglobin revealing a large subcapsular splenic hematoma. Conclusion A normal appearing spleen on initial imaging should not sway one from considering delayed splenic rupture as a potential delayed complication of a traumatic event. Keywords splenectomy, trauma, hematoma, transfusion, splenic hematoma, DPL, AIS

Introduction The diagnosis of post-traumatic splenic injuries has made enormous progress: from the implementation of physical examination and diagnostic peritoneal lavage (DPL) through the most recent development and use of computed tomography (CT). Unfortunately, there are reports in the literature discussing isolated cases of ostensibly normal spleens which were subsequently found to have delayed rupture. Many of the initial reports were based purely on clinical examination, a few upon DPL. To date, there have been 13 reported cases in which the spleen appeared normal on the initial CT scan then consequently was found to be ruptured. This is in spite of CT having a sensitivity and specificity for detection of splenic injuries as high as 96% and 100% respectively.1,2 In this paper, we will present the case of a 42-year-old male, involved in a motorcycle accident, who presented with a normal spleen on initial CT scan. Five days later he was rescanned due to a decrease in hemoglobin. The follow-up scan revealed a large subcapsular splenic hematoma.

J Surg Rad

Case Report

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A 42-year-old male was brought to the trauma bay of our institution after involvement in a motorcycle crash. Upon Citation Gupta PK, Morris J, Natarajan B, Bertellotti R, and Forse RA. Delayed splenic rupture. J Surg Radiol. 2010 Oct 1;1(2). Correspondence Prateek K Gupta, MD E-mail prateekgupta@creighton.edu. Received June 27, 2010. Accepted July 29, 2010. Epub August 1, 2010.

Original Article | October 2010

arrival, the patient was amnesic for the accident with a Glasgow Coma Scale (GCS) score of 14 out of 15. His hemoglobin was 13.9 g/dl with normal coagulation parameters, and he was hemodynamically stable. He reported a left-sided nephrectomy done in childhood. After obtaining the history and completing the primary and secondary surveys, he was taken for a CT scan of the abdomen and pelvis (Figure 1). The images demonstrated a mildly heterogeneous appearance of the spleen consistent with expected variation seen during early arterial phase image acquisition. No fluid surrounded the spleen. Delayed images (Figure 2) obtained ten minutes after the administration of the initial contrast bolus showed homogeneous splenic parenchyma without contrast pooling. Additional injuries identified on the initial CT scan included a solitary right kidney with laceration of the inferior pole with moderate amount of surrounding hemorrhage along with multiple blood clots in the proximal ureter and bladder. He also had fractures of right 8-12 ribs, a minimally displaced right femoral neck fracture, comminuted right femoral diaphyseal fracture, and a medial malleolus fracture. The patient was admitted to the ICU and the next day, prior to intramedullary nailing of his right femur, his hemoglobin fell to 11.5 g/dL. Post-operatively, the hemoglobin level dropped to 7.4 g/dL. This fall in hemoglobin was attributed to several factors including the renal laceration and aggressive fluid resuscitation with seven liters of crystalloid/colloid; no blood products) in the operating room. Estimated blood loss in the operating room was 300 ml. During his ICU stay, his hemoglobin continued to drop and he received a total transfusion of three units of packed RBCs before stabilizing with a hemoglobin titer of 8.1 g/dL. He was then transferred to the floor on post trauma day four. The next day he experienced a syncopal


Original Article

Gupta et al. Delayed Splenic Rupture

Figure 1. Initial CT image obtained during arterial phase showing mildly heterogeneous appearance to the spleen consistent with variable contrast uptake with no surrounding hemorrhage and no findings consistent with splenic laceration (top). Figure 2. Delayed image showing normal spleen without contrast pooling (middle). Figure 3. Follow up CT image from five days after the original traumatic event showing splenic subcapsular hematoma (bottom). episode at which time his hemoglobin was found to be 6.7 g/dL with normal coagulation parameters. He was subsequently transfused with two more units of packed RBCs and a repeat CT scan was performed. The CT scan (Figure 3) showed interval development of a large subcapsular splenic hematoma measuring three centimeters in thickness with variable attenuation blood products. There was no active contrast extravasation or contrast pooling on delayed images. Increased free fluid was seen in the abdomen. The right renal subcapsular hematoma was stable. Splenic embolization was considered a significant risk given that he possessed only a single kidney, had progressively worsening renal function on laboratory evaluation, and had just received a contrast bolus for the follow up CT scan. Additionally, the CT scan did not show contrast extravasation to indicate active bleeding. Consequently, the patient was taken to the operating room for a splenectomy. During surgery, the lateral capsule of the spleen was found to be lacerated. There was significant hematoma around the spleen. Approximately one liter worth of blood was present but there was no active bleeding. He was transfused with seven units of packed RBCs and two units of fresh frozen plasma in the operating room. Postoperatively, the hemoglobin was 10.4 g/dL and it remained stable throughout his postoperative hospital stay. His urine function and creatinine remained stable as well. He was discharged on post trauma day 12.

Discussion Delayed splenic rupture (DSR) was defined by Benjamin as rupture of spleen more than 48 hours after trauma.3 The time period is based www.JSurgRad.com

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Table 1. Delayed splenic rupture with initial CT normal (NA = not available, Hgb = hemoglobin). Researcher/date

Patient

described

Change

in

Hgb (in g/dL)

Days

until follow-up

CT

findings

Management

Current study (2008)

42 y/o M

13.9 to 7.4

5

Subcapsular hematoma

Splenectomy

Sharma et al. (2005)18

NA

NA to 6.6

7

Grade 3 splenic injury

Conservative

75 y/o M

11.7 to 5.7

13

Subcapsular hematoma

Splenectomy

36 y/o F

14 to 7.8

2

Subcapsular hematoma

Splenectomy

31 y/o M

NA to 8

10

Subcapsular hematoma

Splenectomy

56 y/o F

NA to 8.5

14

Subcapsular hematoma

Splenectomy

56 y/o F

NA to 8

7

CT normal

Splenectomy

43 y/o

NA

19

Splenic rupture

Splenectomy

48 y/o

16 to 11

3

Subcapsular hematoma

Conservative

70 y/o

NA

21

Intrasplenic/subcapsular hematoma

NA

30 y/o

NA

30

Subcapsular hematoma

NA

Fagelman et al. (1985)6

83 y/o

NA

21

Subcapsular hematoma

Conservative

Taylor et al. (1984)1

39 y/o M

12.3 to NA

10

NA

Splenectomy

Toombs et al. (1981)5

NA

NA

NA

Hemoperitoneum, spleen normal

Splenectomy

Gamblin et al. (2002)12

Kluger et al. (1994)7

Farhat et al. (1992)13

Pappas et al. (1987)20

on the “latent period of Baudet” of 48 hours which Baudet described as time from injury to rupture.4 The first case of delayed splenic rupture documented by CT was reported in 1981 by Toombs.5 Several hypotheses as to the etiology of delayed splenic rupture have been offered. It has been suggested that if the CT scan is performed too early, hemorrhages contained within the splenic parenchyma may not be visualized and subcapsular hematomas may not yet be of significant size to be detected.6,7 In our case, the time from injury to arrival at the trauma bay was 42 minutes; an additional 37 minutes were spent in the trauma bay prior to the CT scan. The total time of approximately 80 minutes prior to scanning would seem to be ample time for the injury to produce diagnostic visual images. The problem could also lie not only in false negative CT scans secondary to artifacts, but in imaging obtained with early generation CT scanners.8 At our institution, all trauma patients are imaged with a 64 slice Toshiba Aquilion CT scanner (Toshiba America Medical Systems, Inc. Tustin, California). The use of inadequate contrast material or suboptimal timing of image acquisition may also account for failure of initial CT images to detect splenic injury. There is no uniform consensus on the ideal IV contrast, with various techniques being described in the late 20th century.9,10,11 Gamblin et al. describe their use of Novaplus omnipaque with 120 cc administered immediately before scanning and 30 cc given as the scan is begun.12 They also emphasize the timing of the contrast. Scanning prior to the arterial bolus peak may cause a mottled, irregular enhancement pattern of the spleen due to variations

112 Original Article | October 2010

in contrast uptake between the red and white pulp. Scanning past the bolus peak may cause subtle parenchymal lesions to ‘fill-in’ with contrast and be obscured. At our institute we administer 100 cc Isovue 370 bolus at 2 cc/ sec. The region of interest (ROI) selector is placed within the descending aorta at the level of the pulmonary artery bifurcation. Contrast is injected and when the ROI selector detects a value of 180 Hounsfield Units, CT image acquisition commences. Additional CT images of the abdomen are obtained after a ten minute delay. The follow-up CT images, five days after the trauma, were obtained during the portal venous phase. After Toombs’ article in 1981, 12 other cases of DSR had been reported; the last in 2002.5 Table 1 highlights these cases. The ages of the patients range from 30 to 83 years with motor vehicle crashes the mechanism of trauma in most of the cases. It is interesting to note that in two of these 13 cases, even the follow up CT scans were normal, with subcapsular splenic hematoma found in the operating room. This may have been due to the CT scan technology available at that time or for other reasons. Eight cases were managed with splenectomy, three cases were managed conservatively, and in two cases there was no report on the definitive management. The only mortality reported was by Farhat with the other patients having uneventful post-operative courses.13 Multiple studies have shown that the role of repeat CT in nonoperative management (NOM) of splenic trauma is limited for clinically stable patients, both adults and children.14-17 Indications for repeat CT scan in NOM have traditionally in-


Gupta et al. Delayed Splenic Rupture cluded hemodynamic instability and peritonitis or suspicion of blunt intestinal/mesenteric or pancreatic trauma on initial CT scan.18 Weinberg et al. recommended serial CT scans in all cases of NOM to identify latent formation of splenic artery pseudoaneurysms.19 While indications for repeat CT in splenic trauma are limited, DSR should always be considered a possibility in hemodynamically unstable patients. CT-proven delayed splenic rupture is a rare entity. Nevertheless, it is a process associated with significant morbidity and thus, it is essential to consider it in the list of differential diagnosis for abdominal pain and dropping hemoglobin. Furthermore, a normal appearing spleen on initial imaging should not sway one from considering delayed splenic rupture as a potential delayed complication of a traumatic event.

Disclosures The authors have no disclosures or conflicts of interest related to this manuscript.

References

1. Taylor CR, Rosenfield AT. Limitations of computed tomography in the recognition of delayed splenic rupture. J Comput Assist Tomogr. 1984 Dec;8(6):1205-7. 2. Fabian TC, Mangiante EC, White TJ, Patterson CR, Boldreghini S, Britt LG. A prospective study of 91 patients undergoing both computed tomography and peritoneal lavage following blunt abdominal trauma. J Trauma. 1986 Jul;26(7):602-8. 3. Benjamin CI, Engrav LH, Perry JF,Jr. Delayed rupture or delayed diagnosis of rupture of the spleen. Surg Gynecol Obstet. 1976 Feb;142(2):171-2. 4. Baudet R. Ruptures de la rate. Medicine Practique. 1907;3:565. 5. Toombs BD, Lester RG, Ben-Menachem Y, Sandler CM. Computed tomography in blunt trauma. Radiol Clin North Am. 1981 Mar;19(1):1735. 6. Fagelman D, Hertz MA, Ross AS. Delayed development of splenic subcapsular hematoma: CT evaluation. J Comput Assist Tomogr. 1985 Jul-Aug;9(4):815-6.

Original Article 7. Kluger Y, Paul DB, Raves JJ, Fonda M, Young JC, Townsend RN, et al. Delayed rupture of the spleen--myths, facts, and their importance: Case reports and literature review. J Trauma. 1994 Apr;36(4):568-71. 8. Jeffrey RB, Laing FC, Federle MP, Goodman PC. Computed tomography of splenic trauma. Radiology. 1981 Dec;141(3):729-32. 9. Federle MP, Brant-Zawadzki M. Computed tomography in the evaluation of trauma. Baltimore: Williams and Wilkins; 1986:192 10. Toombs BD, Sandler CM. Computed tomography in trauma. Philadelphia: Saunders; 1987:28 11. Conrad MR. Splenic trauma: False-negative CT diagnosis in cases of delayed rupture. AJR Am J Roentgenol. 1988 Jul;151(1):200-1. 12. Gamblin TC, Wall CE,Jr, Royer GM, Dalton ML, Ashley DW. Delayed splenic rupture: Case reports and review of the literature. J Trauma. 2005 Nov;59(5):1231-4. 13. Farhat GA, Abdu RA, Vanek VW. Delayed splenic rupture: Real or imaginary? Am Surg. 1992 Jun;58(6):340-5. 14. Shapiro MJ, Krausz C, Durham RM, Mazuski JE. Overuse of splenic scoring and computed tomographic scans. J Trauma 1999 Oct;47(4):651. 15. Haan JM, Boswell S, Stein D, Scalea TM. Follow-up abdominal CT is not necessary in low-grade splenic injury. Am Surg. 2007 Jan;73(1):138. 16. Rovin JD, Alford BA, McIlhenny TJ, Burns RC, Rodgers BM, McGahren ED. Follow-up abdominal computed tomography after splenic trauma in children may not be necessary. Am Surg. 2001 Feb;67(2):127-30. 17. Thaemert BC, Cogbill TH, Lambert PJ. Nonoperative management of splenic injury: are follow-up computed tomographic scans of any value? J Trauma. 1997 Nov;43(5):748-51. 18. Sharma OP, Oswanski MF, Singer D. Role of repeat computerized tomography in nonoperative management of solid organ trauma. Am Surg. 2005 Mar;71(3):244-9. 19. Weinberg JA, Magnotti LJ, Croce MA, Edwards NM, Fabian TC. The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look? J Trauma. 2007 May;62(5):1143-7; discussion 1147-8. 20. Pappas D, Mirvis SE, Crepps JT. Splenic trauma: False-negative CT diagnosis in cases of delayed rupture. AJR Am J Roentgenol. 1987 Oct;149(4):727-8.

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ORIGINAL ARTICLE

Splenic Vein Stent Placement For Refractory Gastric Variceal Bleeding Amanda V Hayman, MD ∙ Matthew J Fisher, MD ∙ Robert K Ryu, MD‚ ∙ David J Bentrem, MD ∙ Anton I Skaro, MD ∙ Reed A Omary, MD‚ Departments of Surgery and Radiology,‚ Northwestern University, Chicago, Illinois.

Abstract

Overview Traditionally, the most definitive option for treating active gastric variceal bleeding from splenic vein obstruction is splenectomy. Herein, we report a successful case of splenic vein stent placement to remedy sinistral portal hypertension with refractory gastric variceal bleeding resulting from splenic vein occlusion. Keywords splenic vein thrombosis, sinistral portal hypertension, gastric varices

Introduction

J Surg Rad

Splenic vein thrombosis (SVT) or occlusion has multiple etiologies, including chronic or acute pancreatitis, hypercoagulable and hemolytic states, portal hypertension, and extrinsic occlusion from an intraabdominal mass, either benign or malignant.1 The most common cause is pancreatitis, which has up to a 20% incidence of SVT.2 Other etiologies are less common, especially in the absence of portal vein thrombosis.

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Therapeutic options for persistent GV bleeding from SVT have classically been limited to splenectomy with or without distal pancreatectomy, splenic artery embolization, or, rarely, a distal splenorenal shunt. However, operative treatment can be technically difficult due to the presence of the varices and massive splenomegaly. To the best of our knowledge, we present the first known case report of successful splenic vein stent placement to treat persistent GV bleeding.

Splenic vein thrombosis or occlusion leads to splenomegaly and sinistral portal hypertension. Gastric varices develop as a consequence of elevated venous pressure within the short gastric veins, which are the remaining outflow of the spleen in the setting of SVT.3 Portal venous involvement can result in both esophageal and gastric varices in the region of the gastro-esophageal junction. Persistent gastric variceal (GV) bleeding from SVT poses a therapeutic challenge. Unlike esophageal varices (EV), GVs are not amenable to endoscopic intervention via banding, balloon tamponade,4 or esophageal stenting.5 Transjugular intrahepatic portosystemic shunts (TIPS), another tool used for persistent EV and GV bleeding from portal hypertension, is also ineffective, as the obstruction is proximal to the portal system, so-called sinistral portal hypertension. Citation Hayman AV, Fisher MJ, Ryu RK, Bentrem DJ, Skaro AI, and Omary RA. Splenic Vein Stent Placement For Refractory Gastric Variceal Bleeding. J Surg Radiol. 2010 Oct 1;1(2). Correspondence Amanda Hayman, MD E-mail a-hayman@md.northwestern.edu. Received July 20, 2010. Accepted August 4, 2010. Epub August 7, 2010.

Original Article | October 2010

Figure 1. Pre-procedure CT image of the splenic vein.


Original Article

Hayman et al. Splenic Vein Stenting

Figure 2. Images showing intact arterial flow to the spleen and subsequent filling.

Figure 3. Images showing splenic vein occlusion near the hilum of the spleen.

Figure 4. Patency of the splenic vein demonstrated with stent in place within this vessel. See full videos of above images at www.SurgRad.com.

Case Report A 42-year-old man with a past medical history of possible myelodysplastic syndrome presented to his primary care provider with a six-day history of melena. He had no history of peptic ulcer disease or heavy alcohol use. He developed hematemesis and was admitted for further workup. Upper endoscopy revealed active bleeding in the gastric fundus. A Dieulafoy lesion was suspected and was unsuccessfully clipped. He was transferred to our institutionâ&#x20AC;&#x2122;s medical intensive care unit for further care. Prior to transfer he had received five units of blood in the previous 48 hours. On physical exam, he had splenomegaly, was hemodynamical-

ly stable, and in no acute distress. Radiographic records from the referring institution included a duplex ultrasound record that showed a patent hepatic and portal venous system with hepatopedal flow, as well as splenomegaly with a longitudinal span of 17 cm. An abdominal and pelvic computed tomography scan again showed splenomegaly, as well as venous congestion without evidence of portal vein thrombosis or cirrhosis (Figure 1). On admission to the ICU, his laboratory studies included a hemoglobin level of 9.8 gm/dl, an international normalized ratio of 1.1, a serum lipase of 41 units/L (normal 7- 60), and a serum amylase of 212 units/L (normal 20-115). Due to ongoing need for blood transfusion and persistent, large volume hematemesis, the patient was brought emerwww.JSurgRad.com

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Original Article

Hayman et al. Splenic Vein Stenting Figure 5. Closer view of the stent with contrast flowing through the splenic vein. This venogram was completed through transhepatic portal vein access with the catheter terminating near the splenic hilum. gently to the interventional radiology (IR) suite for diagnostic and potentially therapeutic evaluation. Celiac arteriography via the right common femoral artery showed no arterial extravasation. The splenic artery was accessed, showing patent arterial flow to the spleen. Delayed imaging demonstrated that the splenic vein was patent near the portal confluence, but distal patency was difficult to assess. To better image the splenic vein closer to the splenic hilum, transhepatic portal vein access was obtained and the splenic vein accessed. A venogram showed a segmental occlusion of the splenic vein near the splenic hilum and filling of multiple gastric varices (see movies available online at www.SurgRad.com). A 0.014-inch diameter guidewire was placed across the lesion and angioplasty performed with a 5 mm diameter x 4 cm length balloon catheter. Next, a 12 mm diameter x 60 mm length S.M.A.R.T.Ž stent (Cordis Endovascular, Miami Lakes, FL) was deployed and dilated using a 10 mm diameter balloon catheter. A completion venogram showed a widely patent stent without filling of any collateral branches (see movies available online at www.SurgRad.com). Patient was subsequently placed on full antiplatelet therapy (daily aspirin 325 mg and clopidogrel 75 mg.). Subsequently, the patient had no more hematemesis, nor did he require any further blood transfusions. He was transferred out of the intensive care unit to the regular floor. Subsequent triphasic pancreatic computed tomography and a magnetic resonance cholangio-pancreatography scans were performed that demonstrated normal pancreas parenchyma with hypoenhancement of the pancreatic tail. Both studies were limited due to artifact from the stent. He was discharged hospital day six. The presumptive cause of his SVT was compression of the splenic vein from a distal pancreatic tail mass. He is scheduled to undergo endoscopic ultrasound as an outpatient.

Discussion Previous reports have demonstrated success with stenting portal venous obstructions from gastrointestinal malignancies,6 for obliterating surgically created splenorenal shunts,7 or for repairing traumatic arteriovenous fistulae involving the splenic vein.8 Also, there have been many cases of iliac vein stenting for May-Thurner syndrome,9 caused by obstruction from the iliac vein. However, to be the best of our knowledge, this case represents the first known report of splenic venous stent placement for the treatment of actively bleeding gastric varices from isolated SVT. Stenting the splenic vein is a quicker and much less in-

116 Original Article | October 2010


Original Article

Hayman et al. Splenic Vein Stenting vasive procedure than the alternative surgical options. It also avoids the risk of pancreatic leak that can complicate a distal pancreatectomy, as well as the increased risk of infection and sepsis after splenectomy. Drawbacks to stenting include the risk of contrast nephropathy and of stent occlusion, although this may be mitigated by antiplatelet medications. Further, if the patient fails endovascular therapy, he would likely require distal pancreatectomy and splenectomy after all, especially given the concern for a mass in the pancreatic tail. The presence of the stent could make the resection, especially if performed laparoscopically, technically more difficult as the margin would have to be more proximal on the splenic vein than is usual. The stent can also make the dissection more hazardous. As our facility with interventional techniques increases, we will continue to expand the indications for venous stent placement to treat a wider variety of disorders and subsequently spare patients from potentially more morbid and invasive procedures.

Disclosures The authors have no disclosures or conflicts of interest related to this manuscript.

References

1. F. M. Vanhoenacker, B. Op de Beeck, A. M. De Schepper, R. Salgado, A. Snoeckx and P. M. Parizel, Semin Ultrasound CT MR 2007, 28, 35-51. 2. A. K. Agarwal, K. Raj Kumar, S. Agarwal and S. Singh, Am J Surg 2008, 196, 149-154. 3. R. J. Thompson, M. A. Taylor, L. D. McKie and T. Diamond, Ulster Med J 2006, 75, 175-177. 4. N. C. McAvoy and P. C. Hayes, Nat Rev Gastroenterol Hepatol 2010, 7, 190-191. 5. G. Wright, H. Lewis, B. Hogan, A. Burroughs, D. Patch and J. Oâ&#x20AC;&#x2122;Beirne, Gastrointest Endosc 2010, 71, 71-78. 6. a) E. K. Hoffer, S. Krohmer, J. Gemery, B. Zaki and J. M. Pipas, J Vasc Interv Radiol 2009, 20, 1633-1637; b) C. M. Ellis, S. Shenoy, A. Litwin, S. Soehnlein and J. F. Gibbs, HPB Surg 2009, 2009, 426436. 7. S. Litvin, E. Atar, M. Knizhnik, E. Bruckheimer and A. Belenky, Diagn Interv Radiol 2009. 8. H. Al-Khayat, H. H. Haider, A. Al-Haddad and E. Ginzburg, Vasc Endovascular Surg 2007, 41, 559-563. 9. N. Moudgill, E. Hager, C. Gonsalves, R. Larson, J. Lombardi and P. DiMuzio, Vascular 2009, 17, 330-335.

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Partial Mastectomy Seishu Hanaoka, 1760-1835 Kikerabi kiroku (Selected Case Reports of Surgical Operations)

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ORIGINAL ARTICLE

PET Guided Biopsy of Isolated Bone Metastasis in GE Junction Adenocarcinoma Mark Joseph, MD ∙ Amir H. Khandani, MD‚ ∙ John P. Clarke, MD‚ ∙ Michael O. Meyers, MD Departments of Surgery and Radiology,‚ University of North Carolina, Chapel Hill, NC.

Abstract

Overview The advantages of PET/CT include identification of abnormalities which can be targeted for percutaneous biopsy to determine metastatic disease. However, it is difficult for both the clinician and patient when positive PET findings do not have a correlate identified on CT. We present the first published case of successful biopsy of an isolated PET avid bone lesion without a CT correlate in a patient with newly diagnosed esophageal adenocarcinoma using a PET guided biopsy technique. Keywords esophageal cancer, imaging, Positron Emission tomography, CT

Introduction

J Surg Rad

Positron emission tomography (PET), with the glucose analogue F-18-fluorodeoxyglucose (FDG) has become the standard of care for systemic staging especially in esophageal cancer.1 A major disadvantage, however, is the fact that this method yields only limited information on the exact anatomical location of the lesion.2 For this reason, the combination of PET and CT (PET/CT) has emerged as the diagnostic test of choice. The impact of PET/CT in initial staging, treatment response and in restaging of recurrent disease in esophageal cancer is now evident in that it has been shown to have superior accuracy when compared with PET and CT performed separately.3,4 When compared to PET reviewed side-by-side with CT, integrated PET/CT has been shown to be of more value in the interpretation of disease sites in the neck, locoregional lymph nodes, and in regions of postoperative or post treatment anatomical distortion in cases of esophageal cancer with additional suspicious malignant sites.3

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One of the challenges in determining appropriate management of the patient presenting with esophageal cancer is interpreting the data derived from cross-sectional Citation Joseph M, Khandani AH, Clarke JP, and Meyers MO. PET Guided Biopsy of Isolated Bone Metastasis in GE Junction Adenocarcinoma. J Surg Radiol. 2010 Oct 1;1(2). Correspondence Michael O. Meyers, MD E-mail mmeyers@med.unc.edu. Received July 26, 2010. Accepted August 9, 2010. Epub August 9, 2010.

Original Article | October 2010

imaging. PET/CT technology has improved the ability to definitively identify those patients who present with metastases not only in esophageal cancer but other cancers as well, without invasive surgical procedures thereby increasing accuracy over either PET or CT alone.3,5 PET, like any diagnostic study, can be fraught with false-positive findings, although the reported rate of false-positive PET findings in the setting of esophageal cancer is very low. In the most complete study examining PET staging in esophageal cancer, the false-positive rate was 3.7%.6 One of the advantages of PET/CT is that the abnormalities identified can often be targeted for biopsy, either percutaneously or surgically, in order to accurately determine whether they represent metastasis. However, this is not possible when there are limited areas of abnormality that are seen only on the PET portion of the study but there is no correlative finding on the CT portion. This situation leaves both the patient and the clinician in a difficult position, as the interpretation of the scan findings may significantly alter management. In this report, we present a case of a young patient with newly diagnosed adenocarcinoma of the distal esophagus who had an isolated area of abnormality in the iliac wing on the PET portion of a PET/CT scan, without any correlative findings on the CT portion. We biopsied this area under PET guidance to provide diagnostic material that confirmed stage IV disease.

Case Report We present a 54-year-old white female who presented with


Original Article

Meyers et al. PET Guided Biopsy.

Figure 1. Axial (top) and coronal (bottom) images of abdomen/pelvis showing metastatic deposit. a four week history of dysphagia, odynophagia and epigastric pain as well as a 15 pound weight loss history over a period of six to eight weeks. She underwent esophagogastroduodenoscopy (EGD) which showed an ulcerating lesion in the distal

esophagus with biopsies showing poorly differentiated invasive adenocarcinoma of the distal esophagus. CT scan findings included marked thickening of the distal esophagus and slightly enlarged lymph nodes at the gastrohepatic ligament. www.JSurgRad.com

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Figure 2. PET guided biopsy of metastatic lesion showing needle inserted into mass. This biopsy later revealed malignant cells consistent with metastatic adenocarcinoma. By endoscopic criteria she was staged as a T3 N1 Mx lesion. Further workup for metastatic disease included whole body PET/CT. Findings included increased uptake in the area of the distal esophagus, corresponding to the known primary as well in the gastrohepatic ligament region which was consistent with nodal metastases in the celiac region seen on EUS. There was also a focus of increased FDG uptake in the left iliac bone that was concerning for metastasis but did not correspond to any findings on the CT portion of the exam. (Figure 1A and Figure 1B) Without an obvious target on cross-sectional imaging to biopsy, it was elected to attempt biopsy of this lesion using PET guidance. (Figure 2) This yielded malignant cells consistent with metastatic adenocarcinoma of esophageal origin on pathologic analysis. Subsequent to the diagnosis of stage IV disease, the patient was treated with systemic chemotherapy followed by radiation therapy to control eventual progression of the primary tumor. The patient was spared a non-curative esophagectomy.

Conclusion Positron emission tomography (PET) is increasingly recognized as a powerful oncologic tool.3 PET enables detection of an increased glucose metabolism that is characteristic of most

120 Original Article | October 2010

malignant cells. Since PET takes advantage of the biochemical differences between normal and malignant tissues, it has been shown to be effective in identifying various types of primary and metastatic tumors.2,3,7 A major disadvantage, however, is the fact that this method yields only limited information on the exact anatomical location of the lesion.2 For this reason, fused PET and CT (PET/CT) scans are now the standard of care and have solved this problem in large part. However, circumstances still exist where PET findings do not have a correlative CT abnormality, making absolute evaluation of these findings difficult without a target for biopsy under cross-sectional imaging guidance. There are very few studies which describe the use of FDGPET in allowing image guided biopsies. PET guided biopsies have been used to target areas of high metabolic activity in the prostate and in the brainstem. It has also been shown to be helpful where previous biopsies were negative in prostate cancer and also has improved the diagnostic yield of stereotactic biopsy sampling in infiltrative brainstem lesions. However these biopsies all had corollary imaging with CT or MR.7,8 As such, our patient presented with a lesion seen only on PET without a CT correlate in which to target for biopsy. PET was utilized to guide biopsy of this lesion. We believe this the first reported use of PET guidance for biopsy to identify stage IV disease in a patient without obvi-


Original Article

Meyers et al. PET Guided Biopsy. ous distant metastasis elsewhere. This allowed us to properly stage the patient, ultimately making a dramatic difference in treatment modality and prognosis. Our experience shows that PET/CT can not only be used for initial staging and treatment, but PET may also be used to guide biopsy of suspicious or indeterminate lesions identified on staging. This shows the feasibility of biopsy using this technique and may be an important tool in absolute determination of findings obtained on staging studies. PET guided biopsy should be considered in circumstances where indeterminate findings are not accompanied by correlates on cross-sectional imaging, particularly when the results will dramatically alter management of the patient. Although this situation is not common, with increasing utilization of PET/CT in both the staging and follow-up of patients with cancer, it is likely that this will be more common in the future.

Disclosures The authors have no disclosures or conflicts of interest related to this manuscript.

References

1. Rohren EM, Turkington TG, Coleman RE. Clinical applications of PET in oncology. Radiology 2004; 231:305–332. 2. Sironi S, Buda A, Picchio M, et al. Lymph node metastasis in patients with clinical early-stage cervical cancer: detection with integrated FDG PET/CT. Radiology 2006; 238: 272–279. 3. Bar-Shalom R, Guralnik M, Tsalic M, et al. The additional value of PET/CT over PET in FDG imaging of esophageal cancer. Eur J Nucl Med Mol Imaging 2005; 32:918–24. 4. Kato H, Kimura H, Nakajima M. The additional value of integrated PET/CT over PET in initial lymph node staging of esophageal cancer. Oncol Rep. 2008 Oct; 20(4):857-62. 5. Wahl RL. Why nearly all PET of abdominal and pelvic cancers will be performed as PET/CT. J Nucl Med 2004;45:82–95. 6. Meyers BF, Downey, RJ, Decker PA, et al. The utility of positron emission tomography in staging of potentially operable carcinoma of the thoracic esophagus: results of the American College of Surgeons Oncology Group Z0060 trial. J Thorac Cardiovasc Surg. 2007 Mar; 133(3):738-45. 7. Massager N, David P, Goldman S, et al. Combined magnetic resonance imaging- and positron emission tomography-guided stereotactic biopsy in brainstem mass lesions: diagnostic yield in a series of 30 patients. J Neurosurg 2000; 93:951–57. 8. Igerc I, Kohlfurst S, Gallowitsch HJ, et al. The value of 18F-Choline PET/CT in patients with elevated PSA-level and negative prostate needle biopsy for localization of prostate cancer. Eur J Nucl Med Mol Imaging 2008; 35(5):976–983.

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“Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.” François-Marie Arouet (Voltaire), 1694-1778

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FUTURE DIRECTIONS

J Surg Rad 122

Future Directions | October 2010


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