Clinical Performance Status and Technical Factors Affecting Outcomes from Percutaneous Transhepatic Biliary Interventions; A Multicentre, Prospective, Observational Cohort Study.

PURPOSE: The purpose of this study was to evaluate the predictive value of a 'Modified Karnofsky Scoring System' on outcomes and provide real-world data regarding the UK practice of biliary interventions. MATERIALS AND METHODS: A prospective multi-centred cohort study was performed. The pre-procedure modified Karnofsky score, the incidence of sepsis, complications, biochemical improvement and mortality were recorded out to 30 days post procedure. RESULTS: A total of 292 patients (248 with malignant lesions) were suitable for inclusion in the study. The overall 7 and 30 day mortality was 3.1% and 16.1%, respectively. The 30 day sepsis rate was 10.3%. In the modified Karnofsky 'high risk' group the 7 day mortality was 9.7% versus 0% for the 'low risk' group (p = 0.002), whereas the 30 day mortality was 28.8% versus 13.3% (p = 0.003). The incidence of sepsis at 30 days was 19% in the high risk group versus 3.3% at the low risk group (p = 0.001) CONCLUSION: Percutaneous biliary interventions in the UK are safe and effective. Scoring systems such as the Karnofsky or the modified Karnofsky score hold promise in allowing us to identify high risk groups that will need more careful consideration and enhanced patient informed consent but further research with larger studies is warranted in order to identify their true impact on patient selection and outcomes post biliary interventions.

A rare case of splenobronchial fistula formation post-embolisation therapy following acute blunt trauma.

We present the case of a 26-year-old male who was referred to the Emergency department with frank haemoptysis, fever and abdominal pain. He had suffered from an acute splenic rupture secondary to blunt abdominal trauma 3 weeks previously, when he was treated with transfemoral embolisation therapy. On this previous admission his splenic injury was initially not detected owing to CT scanning technique focussed on imaging the thorax rather than the abdomen. On readmission, the initial chest X-ray pointed towards a likely pneumonia or empyema. However, upon CT scanning, the cause was found to be a splenic abscess that had extended through the diaphragm, pleura and entered the bronchial space, forming a 'splenobronchial' fistula. This is a rare complication of splenic artery embolisation. The aim of this case report is to raise awareness of the complications that acute trauma and embolisation therapy may cause.

Meta-analysis of sonography in the diagnosis of inguinal hernias.

Groin hernias are common conditions, and there is a need for accurate imaging when the clinical diagnosis is not clear. A meta-analysis was undertaken to investigate the diagnostic accuracy of sonography in the diagnosis of inguinal hernias. After review of literature searches, 9 original articles were included. Data were pooled and statistically analyzed. In the studies included, sensitivity ranged from 92.7% to 100%; specificity ranged from 22.2% to 100%; the positive predictive value ranged from 83.3 to 100%; and the negative predictive value ranged from 40 to 100%. Sonography has overall sensitivity of 96.6 %, specificity of 84.8%, and a positive predictive value of 92.6%. In cases of diagnostic uncertainty, sonography offers value as an initial imaging modality. It has advantages over other radiologic methods, as it is inexpensive and has minimal complications. When the clinical diagnosis of an inguinal hernia is uncertain, sonographic findings should be interpreted in conjunction with clinical judgment, as its diagnostic accuracy is reduced in the absence of any clinically palpable hernia.

A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia.

BACKGROUND: Inguinal hernias are a common cause of groin pain. Most hernias are detectable by clinical examination and many patients proceed to hernia repair on the basis of history and examination findings alone. However, a significant proportion of patients with symptoms suggestive of groin hernia are found to have a normal clinical examination. Several radiological techniques have been developed to solve the dilemma posed by occult inguinal hernias. No systematic review or meta-analysis has addressed this common clinical problem. METHODS: A systematic review and meta-analysis were undertaken of relevant articles in Medline, Embase, and the Cochrane database. Studies were assessed using the QUADAS tool. Statistical analysis was undertaken. RESULTS: We have shown in this meta-analysis that ultrasound has a sensitivity of 86% and a specificity of 77% in occult inguinal hernias. Computed tomography has a sensitivity of 80% and a specificity of 65%. Herniography has a sensitivity of 91% and a specificity of 83%. CONCLUSIONS: Based on this systematic review, herniography should be considered as the initial investigation for occult inguinal hernia where available. In centers where this is not available, ultrasound of the groin should be used with good clinical judgment. When there is still diagnostic uncertainty, further investigation with magnetic resonance imaging should be considered to exclude alternative pathology.

Stump appendicitis: a review.

Acute appendicitis is perhaps the commonest cause of acute abdomen and surgical intervention in the form of open or laparoscopic appendicectomy. Stump appendicitis is an uncommon late complication of appendicectomy; where inflammation occurs in the remaining appendicular stump. Delayed diagnosis of this condition may result in serious complications. This literature review has looked into the clinical presentation, diagnosis and treatment of Stump appendicitis.

The results of high-frequency duplex surveillance after iliac arterial stenting in a single center.

Frequent duplex surveillance after iliac arterial stenting is time-consuming and costly, so solid benefits of this approach must be available. Frequent duplex surveillance was performed at our center, this was reviewed retrospectively.A total of 117 stents were assessed. Duplex was done for 84 (71.8%) of 117 patients at 1 year and 25 (21.4%) of 117 at 5 years, mean follow-up 27.6 months. Totally, 456 scans were performed; 386 (84.6%) scans were normal, 43 (9.4%) showed an abnormality for which intervention was not necessary, 27 (5.9%) showed abnormalities which needed interventions. The maximum attendance of patients was 62%. In all, 18 patients had interventions unrelated to scheduled follow-up; 15 (83.3%) of 18 had no prior abnormalities on duplex, 3 (16.6%) of 18 had prior abnormalities which were not acted upon after clinical assessment. Our findings demonstrate a high nonattendance rate with frequent emergency presentations due to acute complications. We cannot, therefore, recommend frequent duplex surveillance program both in terms of results or resource allocation.

Covered metallic stents for the palliation of colovesical fistula.

Colovesical fistula is a distressing condition that is usually managed surgically. For some patients in whom surgery is not feasible, covered colonic stents offer palliation. We present two challenging cases with contrasting outcomes. The first case is a colovesical fistula secondary to malignancy with a successful outcome after stenting and the second a complex diverticular fistula with a poor outcome. From our limited experience, it is a useful technique but careful patient selection is essential to its safe application. There is little published experience of the use of these stents for colovesical fistula.

A Tender Pulsatile Epigastric Mass is NOT Always an Abdominal Aortic Aneurysm: A Case Report and Review of Literature.

Of greatest concern in the assessment of a patient with a tender pulsatile abdominal mass is the possibility of a leaking or ruptured Abdominal Aortic Aneurysm (AAA). Other serious abdominal pathologies may demonstrate the same clinical signs but require entirely different treatments. Even amongst patients with proven abdominal aortic aneurysms CT imaging findings may influence the timing and nature of surgery and provide useful prognostic information. We present a case in which a large abdominal tender pulsatile mass was not aortic in origin. The patient had a significantly large tender congested liver associated with right side heart failure due to progressive tricuspid valve regurgitation. We have also discussed the differential diagnoses which may mimic abdominal aneurysms and discussed the role of imaging in resolving these problems.

Duplex ultrasound scanning (DUS) versus computed tomography angiography (CTA) in the follow-up after EVAR.

INTRODUCTION: Computed tomography angiography (CTA) is the gold standard follow-up modality after endovascular aneurysm repair (EVAR). A potential alternative noninvasive and less expensive modality is duplex ultrasound scanning (DUS). METHODS: We studied 314 follow-up paired scans (DUS and CTA) in 59 patients with EVAR. RESULTS: Endoleak--Endoleak was detected in 23.7% patients. The sensitivity and specificity rates of DUS were 54% and 95.3%, respectively. All 9 endoleaks that needed secondary intervention were detected on DUS. Eight of those were identified within a year after EVAR. Sac size--The mean difference in maximum diameter between the DUS and CTA was < or =5 mm in 84.5% of cases and < or =10 mm in 97.1%. Graft patency--There was 100% agreement between CTA and DUS. CONCLUSIONS: Duplex ultrasound scanning was reliable as it detected all the leaks that needed reintervention after EVAR. Duplex ultrasound scanning showed similar results to CTA in detecting sac size and patency.

Complications of colonic stenting: a pictorial review.

Surgical resection of colorectal carcinoma is the only curative treatment currently available. In the elective setting peri-operative mortality is low and refinements in surgical technique and peri-operative care have resulted in high primary anastamosis rates and progressively reduced postoperative morbidity. In those presenting with large bowel obstruction the mortality and morbidity remains high. Many of those undergoing surgery will have incurable disease and a short life expectancy. Increasingly self-expanding metal stents are being deployed as either a 'bridge to surgery' or for palliation. This review covers the imaging appearances, detection and management of complications of colonic stenting.

Ulnar artery thrombosis due to hypothenar hammer syndrome.

Hypothenar Hammer syndrome' (HHS) describes the symptoms and signs produced by thrombosis or aneurysm of the ulnar artery as a consequence of repeated blunt trauma to the hypothenar eminence. We describe a case report of a man presenting with symptoms of ulnar artery thrombosis as result of blunt trauma secondary to his occupation and related patents. Radiological findings and management options are briefly discussed.

Outcomes of intra-arterial thrombolysis for acute limb ischemia.

Intra-arterial thrombolysis is an alternative treatment to surgery for acute limb ischemia. We report our own experiences by retrospectively assessing initial and long-term outcomes using this strategy. Patients (n = 48; 50 events) underwent thrombolysis according to our protocol (64.6% male, median age 68.5 years). Using thrombolysis as an initial treatment strategy, overall limb survival on index admission was 84%. Of this group who had successful limb salvage, 76% was attributable to thrombolysis alone, and 24% had limb salvage attributable to subsequent surgery after failed thrombolysis or anticoagulation. Significant complications occurred in 8% of cases, and no deaths were attributed to thrombolysis. Patients alive at 6 and 24 months after index admission who had limb salvage attributable to thrombolysis alone had limb survival rates of 89% and 82%, respectively. The majority of these patients had not required subsequent secondary procedures to maintain limb survival. Thrombolysis is an acceptable and less invasive treatment of acute limb ischemia, with many patients not needing subsequent surgery.

The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults.

This prospective study examined the accuracy of ultrasound in diagnosing occult groin hernias in adults. The study included 52 consecutive patients reviewed in the surgical out-patient clinic with a history suggestive of groin hernia but with a normal or inconclusive clinical examination. Each patient underwent a preliminary ultrasound examination by an experienced consultant radiologist who was aware that the patient had a history suggestive of a hernia but was blinded to the side of the symptoms. The patient then proceeded to herniography, and some patients also had surgical exploration. The results of the ultrasound were assessed in relation to the herniography, and the patients who proceeded to surgical exploration had further correlation with surgery. Ultrasound had a sensitivity of 29% and specificity of 90% compared with the herniography. Correlation with surgical findings showed ultrasound to have a sensitivity of 33% and a specificity of 100%. The sensitivity of ultrasound in detecting clinically occult hernias in a non-acute presentation is poor, and patients with normal ultrasound should be considered for further investigation.