Avneesh Gupta

Ileal Pouch–Anal Anastomosis Surgery: Imaging and Intervention for Post-operative Complications

Ileal pouch-anal anastomosis (IPAA) surgery preserves fecal continence for improved quality of life in patients who require proctocolectomy for treatment of severe bowel diseases such as inflammatory disease and familial adenomatous polyposis. In IPAA surgery, an ileal reservoir, or pouch, is created and anastomosed to the anal canal. Awareness of the surgical technique and the postoperative anatomy of the IPAA is important to identify complications at computed tomography (CT), magnetic resonance (MR) imaging, and fluoroscopy. Complications include anastomotic leak, abscess, pouchitis, venous thrombus, pouch fistula, and stricture. Leaks from the blind end of the pouch and the pouch-anal anastomosis often result in pelvic abscesses, which may require ultrasonography- or CT-guided drainage; judicious catheter management can help improve clinical outcomes and avoid excessive imaging. Pouchitis may be identified by the presence of a thickened enhancing pouch wall and associated inflammatory changes and lymphadenopathy. The venous system must be scrutinized for thrombi secondary to surgical manipulation and sepsis. Fistulas are likely because of the presence of chronic inflammation or infection and may be seen at MR imaging, CT, or fluoroscopy. Strictures appear as areas of focal luminal narrowing with proximal dilatation, which can lead to obstruction. To avoid repeated exposure to radiation, MR imaging may be performed in patients who must undergo frequent imaging.

Electromagnetic Navigation to Aid Radiofrequency Ablation and Biopsy of Lung Tumors

PURPOSE We evaluated an electromagnetic (EM) navigation system (Veran Medical Technologies Inc, St. Louis, MO) to determine its potential to reduce the number of skin punctures and instrument adjustments during computed tomographic-guided percutaneous ablation and biopsy of lung nodules. DESCRIPTION Ten patients undergoing lung percutaneous ablation were prospectively enrolled. The mean age was 70 years. Positioning of the needle device was verified with computed tomographic fluoroscopy prior to the execution of any biopsy or ablation. Each EM navigation-guided procedure was defined as an EM-intervention. EVALUATION Nineteen EM interventions were performed. When an EM-guided biopsy was performed, the intervention was done immediately prior to ablation. For all 19 EM interventions, only one skin-puncture was required. The mean number of instrument adjustments required was 1.2 (range, 0 to 2). The mean time for each EM intervention was 5.2 minutes (range, 1 to 20 minutes). Pneumothorax occurred in 5 patients (50%). Only the number of instrument adjustments was significantly related to the pneumothorax rate (p = 0.005). CONCLUSIONS The EM navigation is feasible and seems to be a useful aid for image-guided procedures. Early experience suggests a low number of skin-puncture and instrument adjustments using the EM navigation system. Instrument adjustments were a key factor in pneumothorax development.

Positron emission tomography combined with diagnostic chest computed tomography enhances detection of regional recurrence after stereotactic body radiation therapy for early stage non–small cell lung cancer

OBJECTIVE(S) Recommendations for surveillance after stereotactic body radiation therapy (SBRT) for early stage non-small cell lung cancer (NSCLC) are not well defined. Prospective studies evaluating the efficacy of SBRT have used interval posttreatment imaging with computed tomography (CT). We set out to determine whether positron emission tomography (PET) combined with diagnostic chest CT (PET/d-chest) can enhance detection of potentially salvageable recurrence after SBRT. METHODS We performed a retrospective analysis of posttreatment imaging for 35 patients consecutively treated with SBRT for biopsy-proven early-stage NSCLC. PET/d-chest was generally performed every 3 months after treatment. A board-certified radiologist who did not have access to the PET results retrospectively interpreted the CT scans. CT results were reported according to response criteria used in Radiation Therapy Oncology Group 0236 and compared with PET/d-chest readings. Local and regional recurrence-free survival was compared using the Mantle-Cox (log-rank) test. RESULTS Median follow-up was 12.8 months. Twenty-four patients had stage IA, 7 stage IB, 3 stage IIA, and 1 stage IIB biopsy-proven NSCLC. Two-year overall survival was 62%. CT scans indicated no regional recurrences. PET/d-chest indicated 10 regional recurrences. The 1-year rate of regional recurrence-free survival as evaluated by CT and PET/d-chest was 100% and 69.4%, respectively (P = .0045). Four of 10 patients with a diagnosis of regional recurrence underwent salvage treatment with definitive chemoradiotherapy. CONCLUSIONS PET/d-chest enhances the detection of regional progression of NSCLC after SBRT over currently recommended practices. In patients who are fit for salvage treatment, where early detection of recurrence can increase the likelihood of successful treatment, PET/d-chest appears critical for follow-up.

Use of Magnetic Resonance in Pancreaticobiliary Emergencies.

This article presents the magnetic resonance protocols, imaging features, diagnostic criteria, and complications of commonly encountered emergencies in pancreaticobiliary imaging. Pancreatic trauma, bile leak, acute cholecystitis, biliary obstruction, and pancreatitis are discussed. Various classifications and complications that can arise with these conditions, as well as artifacts that may mimic pathology, are also included.

The Diagnostic and Therapeutic Role of Imaging in Postoperative Complications of Esophageal Surgery

Esophageal surgeries are frequently employed in the management of gastrointestinal reflux disease and esophageal carcinoma. Imaging, in the form of computed tomography and fluoroscopy, is commonly utilized to evaluate for postoperative complications such as anastomotic leaks, abscess formation, pneumothorax, and pleural effusion. An understanding of both esophageal anatomy and the most commonly performed surgical techniques facilitates the diagnosis of these complications and governs their potential computed tomography-guided treatment.

Complications of Esophageal Surgery: Role of Imaging in Diagnosis and Treatments

Esophageal surgery is a common and integral component in the management of hiatal hernias, esophageal carcinoma, and esophageal perforation. Understanding the expected postsurgical imaging features of these common esophageal surgeries and postoperative complications is essential. Image-guided intervention can be used to aid the surgeon in the management of many post esophageal surgical complications. We discuss the imaging features of the postoperative esophagus and the use of imaging, including fluoroscopy and computed tomography, in the diagnosis of post esophageal surgical complications and treatment.

Radiology Residency Quality Improvement Curriculum: Lessons Learned

Quality improvement (QI) skills in radiology are required as part of the Accreditation Council for Graduate Medical Education Diagnostic Radiology Milestones competencies. Although feasibility of QI curricula has been demonstrated in radiology before, there are still barriers to widespread implementation. Here, we share our experience with designing the curriculum structure and selecting content. We describe the QI projects that have been performed and discuss lessons learned, including successes, challenges, and future directions. This information is relevant for many radiology programs currently planning to implement or revise existing QI curricula.

Imaging of Torso and Extremity Vascular Trauma

Evaluating vascular trauma to the torso and extremities has become an integral part in the work-up of trauma patients. Advancements in multi-detector computed tomography (MDCT) technology have permitted computed tomography angiography (CTA) to take on a larger role in the emergent setting. The utilization of specialized trauma imaging protocols permits accurate and timely investigation of a multitude of vascular injuries ranging from dissection to active extravasation. A thorough understanding of mechanisms of injury and common patterns of presentation informs the radiologist in searching for the initial insult as well as any possible complications or associated injuries. This has led to a paradigm shift in trauma management, with many patients now more accurately triaged into a non-operative course of management. As such, an understanding of vascular trauma imaging is essential to not just the care of individual patients, but the future direction of the field of trauma medicine at large.

Ileal pouch-anal anastomosis surgery: anatomy, postoperative complications, and image-guided intervention.

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) surgery has become the surgical procedure of choice for chronic ulcerative colitis and familial adenomatous polyposis. Since its introduction in 1978, the technique of ileal pouch-anal anastomosis has improved and is commonly performed. Although associated with low mortality, postsurgical complications are frequent with which the radiologist should be familiar. An understanding of surgical technique and postsurgical anatomy facilitates the diagnosis of these frequently encountered complications and governs their potential image-guided intervention.

Percutaneous thermal ablation for stage IA non-small cell lung cancer: long-term follow-up

Background Surgical resection is the most effective curative therapy for non-small cell lung cancer (NSCLC). However, many patients are unable to tolerate resection secondary to poor reserve or comorbid disease. Radiofrequency ablation (RFA) and microwave ablation (MWA) are methods of percutaneous thermal ablation that can be used to treat medically inoperable patients with NSCLC. We present long-term outcomes following thermal ablation of stage IA NSCLC from a single center. Methods Patients with stage IA NSCLC and factors precluding resection who underwent RFA or MWA from July 2005 to September 2009 were studied. CT and PET-CT scans were performed at 3 and 6 month intervals, respectively, for first 24 months of follow-up. Factors associated with local progression (LP) and overall survival (OS) were analyzed. Results Twenty-one patients underwent 21 RFA and 4 MWA for a total of 25 ablations. Fifteen patients had T1a and six patients had T1b tumors. Mean follow-up was 42 months, median survival was 39 months, and OS at three years was 52%. There was no significant difference in median survival between T1a nodules and T1b nodules (36 vs. 39 months, P=0.29) or for RFA and MWA (36 vs. 50 months, P=0.80). Ten patients had LP (47.6%), at a median time of 35 months. There was no significant difference in LP between T1a and T1b tumors (22 vs. 35 months, P=0.94) or RFA and MWA (35 vs. 17 months, P=0.18). Median OS with LP was 32 months compared to 39 months without LP (P=0.68). Three patients underwent repeat ablations. Mean time to LP following repeat ablation was 14.75 months. One patient had two repeat ablations and was disease free at 40-month follow-up. Conclusions Thermal ablation effectively treated or controlled stage IA NSCLC in medically inoperable patients. Three-year OS exceeded 50%, and LP did not affect OS. Therefore, thermal ablation is a viable option for medically inoperable patients with early stage NSCLC.