Franklin N. Tessler

Internal Hernia After Gastric Bypass: Sensitivity and Specificity of Seven CT Signs with Surgical Correlation and Controls

OBJECTIVE The purpose of this study was to evaluate the sensitivity and specificity of seven CT signs in the diagnosis of internal hernia after laparoscopic Roux-en-Y gastric bypass. MATERIALS AND METHODS With institutional review board approval, the CT scans of 18 patients (17 women, one man) with surgically proven internal hernia after laparoscopic Roux-en-Y gastric bypass were retrieved, as were CT studies of a control group of 18 women who had undergone gastric bypass but did not have internal hernia at reoperation. The scans were reviewed by three radiologists for the presence of seven CT signs of internal hernia: swirled appearance of mesenteric fat or vessels, mushroom shape of hernia, tubular distal mesenteric fat surrounded by bowel loops, small-bowel obstruction, clustered loops of small bowel, small bowel other than duodenum posterior to the superior mesenteric artery, and right-sided location of the distal jejunal anastomosis. Sensitivity and specificity were calculated for each sign. Stepwise logistic regression was performed to ascertain an independent set of variables predictive of the presence of internal hernia. RESULTS Mesenteric swirl was the best single predictor of hernia; sensitivity was 61%, 78%, and 83%, and specificity was 94%, 89%, and 67% for the three reviewers. The combination of swirled mesentery and mushroom shape of the mesentery was better than swirled mesentery alone, sensitivity being 78%, 83%, and 83%, and specificity being 83%, 89%, and 67%, but the difference was not statistically significant. CONCLUSION Mesenteric swirl is the best indicator of internal hernia after laparoscopic Roux-en-Y gastric bypass, and even minor degrees of swirl should be considered suspicious.

Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee.

The incidental thyroid nodule (ITN) is one of the most common incidental findings on imaging studies that include the neck. An ITN is defined as a nodule not previously detected or suspected clinically, but identified by an imaging study. The workup of ITNs has led to increased costs from additional procedures, and in some cases, to increased risk to the patient because physicians are naturally concerned about the risk of malignancy and a delayed cancer diagnosis. However, the majority of ITNs are benign, and small, incidental thyroid malignancies typically have indolent behavior. The ACR formed the Incidental Thyroid Findings Committee to derive a practical approach to managing ITNs on CT, MRI, nuclear medicine, and ultrasound studies. This white paper describes consensus recommendations representing this committees review of the literature and their practice experience.

ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee

Thyroid nodules are a frequent finding on neck sonography. Most nodules are benign; therefore, many nodules are biopsied to identify the small number that are malignant or require surgery for a definitive diagnosis. Since 2009, many professional societies and investigators have proposed ultrasound-based risk stratification systems to identify nodules that warrant biopsy or sonographic follow-up. Because some of these systems were founded on the BI-RADS® classification that is widely used in breast imaging, their authors chose to apply the acronym TI-RADS, for Thyroid Imaging, Reporting and Data System. In 2012, the ACR convened committees to (1) provide recommendations for reporting incidental thyroid nodules, (2) develop a set of standard terms (lexicon) for ultrasound reporting, and (3) propose a TI-RADS on the basis of the lexicon. The committees published the results of the first two efforts in 2015. In this article, the authors present the ACR TI-RADS Committees recommendations, which provide guidance regarding management of thyroid nodules on the basis of their ultrasound appearance. The authors also describe the committees future directions.

Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee.

Ultrasound is the most commonly used imaging technique for the evaluation of thyroid nodules. Sonographic findings are often not specific, and definitive diagnosis is usually made through fine-needle aspiration biopsy or even surgery. In reviewing the literature, terms used to describe nodules are often poorly defined and inconsistently applied. Several authors have recently described a standardized risk stratification system called the Thyroid Imaging, Reporting and Data System (TIRADS), modeled on the BI-RADS system for breast imaging. However, most of these TIRADS classifications have come from individual institutions, and none has been widely adopted in the United States. Under the auspices of the ACR, a committee was organized to develop TIRADS. The eventual goal is to provide practitioners with evidence-based recommendations for the management of thyroid nodules on the basis of a set of well-defined sonographic features or terms that can be applied to every lesion. Terms were chosen on the basis of demonstration of consistency with regard to performance in the diagnosis of thyroid cancer or, conversely, classifying a nodule as benign and avoiding follow-up. The initial portion of this project was aimed at standardizing the diagnostic approach to thyroid nodules with regard to terminology through the development of a lexicon. This white paper describes the consensus process and the resultant lexicon.

The Common Duct Dilates After Cholecystectomy and With Advancing Age Reality or Myth

To evaluate changes in the common duct diameter on sonography over time in patients with and without cholecystectomy.

Ultrasound Quality and Efficiency How to Make Your Practice Flourish

ltrasound is the most widely used imaging modality in the world. Benefits include relative low cost, lack of ionizing radiation, no potential nephrotoxicity from contrast agents, and portability. With extensive recent technical improvements, the quality and breadth of ultrasound examinations have increased substantially. Ultrasound is no longer just a screening modality but a tool that can make a definitive, final diagnosis. Demand for ultrasound has risen substantially because of all of these factors. Despite the universal embrace of ultrasound, competition from modalities such as computed tomography (CT) and magnetic resonance imaging is high. The required CT examination time has drastically diminished; now it often takes longer to transfer a patient on and off the CT table than it does to perform the scan. Equivalent time-saving changes have not occurred in ultrasound to date. Current challenges facing the ultrasound department include maintaining high quality while increasing the number of examinations, all without adding sonographers or ultrasound scanners. The ever-increasing demands on physicians to do more work in less time mirror the pressure on the ultrasound department. Physician extenders can be useful in a well-controlled setting. Sonographer and resident training, accreditation, report turnaround time, and quality control are all vital ingredients in achieving excellence and success. The ultrasound section at the University of Alabama at Birmingham is flourishing despite these obstacles, with a continued annual growth rate of 7.7% per year over the past 17 years and 17.6 % growth over the past 2 years. In part, our success has resulted from the dedication of our faculty members, with a total of 112 years of postresidency experience. We have also benefited from extensive involvement in professional societies, such as the Society of Radiologists in Ultrasound and the American Institute of Ultrasound in Medicine. This involvement has permitted us to remain at the forefront of ultrasound practice. Michelle L. Robbin, MD Mark E. Lockhart, MD Therese M. Weber, MD Franklin N. Tessler, MD Michael W. Clements, BS, RDMS, RVT Felix A. Hester, BS, RDMS, RVT Lincoln L. Berland, MD

Fetal exposure from endovaginal ultrasound examinations in the first trimester

Ultrasonic obstetrical examinations during the first trimester are now often performed endovaginally with higher-frequency (5-7.5 MHz) transducers operating closer to the fetus than for transabdominal examinations. To estimate exposure to the fetus, propagation distances were obtained from a retrospective study of 100 normal first-trimester endovaginal B-mode examinations. No significant dependence of attenuation on gestational age was observed. The range of the attenuation estimates was 1.8-10.4 dB. A mean attenuation of 5.0 dB at 5 MHz for an average depth of 2.8 cm resulted in an attenuation coefficient of .36 dB/cm/MHz. Exposure (ISPTA) to the fetus at each gestational week from three ultrasound units was very similar: worst-case values of the 100 cases ranged from 1.2-1.9 mW/cm2, well within the Food and Drug Administration (FDA) guidelines of 94 mW/cm2 for derated focused transducers. Energy density deposited to the anterior surface of the fetus during a typical examination, assuming that the transducer is kept stationary over one area for the entire period of the examination (which is unlikely), ranged from 143-217 mJoules/cm2, within the American Institute of Ultrasound in Medicine (AIUM) recommendations.

Topics in ultrasound education: Use of patient models to teach endovaginal ultrasound skills.

Learning how to perform endovaginal pelvic ultrasound is often challenging for novices in a busy clinical practice. In this article, we describe a program in which we hired female patient models to help residents acquire basic endovaginal scanning skills.

ULTRASOUND EVALUATION OF THE ANAL SPHINCTER IN FECAL INCONTINENCE

Fecal incontinence due to anal sphincter disruption is a relatively common process affecting 2% of the population. While non imaging modalities have been utilized in the past, the recent development of endoanal ultrasound to evaluate the integrity of the anal sphincter is now becoming more commonly employed. Disruption of the sphincter using endoanal ultrasound techniques is accurately diagnosed in a high percentage of patients. In many instances, endoanal ultrasound has replaced or is used as an adjunct to non imaging techniques. This article discusses the clinical and imaging characteristics of fecal incontinence due to anal sphincter disruption.

Protected health information on ultrasound images: time to end the burn.

istorically, maintaining the confidentiality of patients’ protected health information on ultrasound images has not always been a high priority. When I began my career in radiology more than 30 years ago, it was not unusual to see names and other identifying data on sonograms shown at educational and scientific meetings. During the past decade, however, the passage of the Health Insurance Portability and Accountability Act in the United States and the adoption of similar regulations by other jurisdictions have appropriately focused attention on the need to eliminate private identifiers from medical images in situations in which the information is not required to deliver care. Doing so has been particularly challenging for ultrasound practitioners, because protected health information was essentially embedded or “burned” into the images. That made sense when sonograms were often printed on hard copy film because there was usually no other practical way to label them. However, this practice persisted even after the introduction of specialized and generalpurpose picture archiving and communication systems, which enable storage, transmission, and viewing of sonograms in the digital domain. Eliminating embedded protected health information presents challenges to physicians and others who need to use sonograms for education and research. Unfortunately, some of the methods that are still used to remove protected health information are far less effective than is commonly accepted. For example, users may crop or shift ultrasound images placed into PowerPoint (Microsoft Corporation, Redmond, WA) or Keynote (Apple, Inc, Cupertino, CA) presentations so that embedded protected health information cannot be seen by the audience. However, the information is still readily viewable by anyone who opens the presentation file. Similarly, placing opaque rectangles over protected health information on images after importing them does not actually erase the information but only hides it from view. These vulnerabilities were highlighted in an alarming study by Weadock et al,1 in which PowerPoint presentations that were downloaded from the Web were examined for Franklin N. Tessler, MD, CM Department of Radiology University of Alabama at Birmingham Birmingham, Alabama USA