Multidetector CT imaging of complications after laparoscopic nephron-sparing surgery.

PURPOSE: Laparoscopic nephron-sparing surgery (L-NSS) is increasingly performed to treat localised renal lesions. However, the associated morbidity is non-negligible, with a rate of major complications approaching 10 %. METHODS AND RESULTS: This paper provides an overview of indications, surgical techniques and results of L-NSS; explains the incidence, risk factors and manifestations of postoperative complications; discusses the preferred multidetector computed tomography (CT) acquisition techniques; illustrates the appearance of normal postoperative images following L-NSS; and reviews, with example images, the most common and unusual iatrogenic complications. These include haematuria, haemorrhage, vascular injuries, infections and urinary leaks. Most emphasis is placed on CT, which provides rapid, reliable triage and follow-up of iatrogenic complications after L-NSS, identifying occurrences that require transarterial embolisation or repeated surgery. CONCLUSIONS: Multidetector CT allows precise assessment of the surgical resection site; detection of pneumoperitoneum and subcutaneous emphysema; quantification of retroperitoneal blood; and identification of active bleeding, pseudoaneurysms, arterio-venous fistulas, abscess collections and extravasated urine. TEACHING POINTS: • Laparoscopic nephron-sparing surgery (NSS) is increasingly performed to treat renal lesions. • Radiologists are increasingly requested to investigate suspected post-surgical NSS complications. • Post-NSS complications include haemorrhage, haematuria, vascular injuries, infections and urinary leaks. • Multidetector CT allows choice between conservative treatment, transarterial embolisation or surgery.

Pictorial review of normal postoperative cross-sectional imaging findings and infectious complications following laparoscopic appendectomy.

Laparoscopic appendectomy is increasingly accepted as the preferred surgical treatment for acute appendicitis and represents one of the most common emergency operations performed in both adult and paediatric populations. However, in patients with perforated appendicitis laparoscopy is associated with an increased incidence of postoperative intraabdominal infections compared to open appendectomy. Nowadays urgent imaging is commonly requested by surgeons when postoperative complications are suspected. Due to the widespread use of laparoscopy, in hospitals with active surgical practices clinicians and radiologists are increasingly faced with suspected postappendectomy complications. This pictorial essay illustrates the normal cross-sectional imaging findings observed shortly after laparoscopic appendectomy and the spectrum of appearances of iatrogenic intraabdominal infections observed in adults and adolescents, aiming to provide radiologists with an increased familiarity with early postoperative imaging. Emphasis is placed on the role of multidetector CT, which according to the most recent World Society of Emergency Surgery (WSES) guidelines is the preferred and most accurate modality to promptly investigate suspected intraabdominal infections and highly helpful for correct therapeutic choice, particularly to identify those occurrences that require in-hospital treatment, drainage or surgical reintervention. In teenagers and young adults MRI represents an attractive alternative modality to detect or exclude iatrogenic abscesses without ionising radiation. Teaching points • Laparoscopic appendectomy is the preferred surgical treatment for uncomplicated acute appendicitis • In perforated appendicitis laparoscopy results in increased incidence of intraabdominal infections • Multidetector CT promptly assesses suspected iatrogenic intraabdominal infections • Interpretation of early postoperative CT requires knowledge of normal postsurgical imaging findings • Postsurgical infections include right-sided peritonitis, intraabdominal, pelvic or liver abscesses.

Hemorrhagic complications of anticoagulant therapy: role of multidetector computed tomography and spectrum of imaging findings from head to toe.

Highly effective in preventing and treating thromboembolic conditions in acute and chronic settings, anticoagulant therapy is associated with a non-negligible risk of hemorrhagic complications with a considerable clinical impact. Advanced age and comorbidities further increase the risk of bleeding during heparinization, treatment with low-molecular-weight heparins or long-term oral warfarin anticoagulation. Multidetector computed tomography represents the mainstay diagnostic technique to image-suspected hemorrhages in anticoagulated patients, as it can quickly assess presence, site, and extent of hemorrhage, identify active bleeding, and possible underlying diseases. Cross-sectional imaging appearances of the wide spectrum of anticoagulant therapy-related bleeding complications are hereby presented, including peripheral and thoracic-abdominal wall muscular hematomas, intrathoracic, abdominal, retroperitoneal genitourinary, gastrointestinal, and brain hemorrhages. Prompt recognition and comprehensive diagnostic assessment with multidetector computed tomography allow clinicians to correctly choose treatment modification or withdrawal, surgery, or interventional procedures as needed, with the aim to reduce the associated morbidity and mortality.

Mycotic visceral aneurysm complicating infectious endocarditis: Imaging diagnosis and follow-up.

One of the rarest complications of endocarditis, infected (mycotic) aneurysms result from haematogenous dissemination of septic emboli and occur more frequently in patients with cardiac valvular abnormalities or prosthetic valves, intravenous drug abuse, diabetes and immunosuppression conditions such as HIV infection. Although often clinically unsuspected, mycotic aneurysms are potentially life-threatening because of disseminated sepsis and propensity to rupture. Contrast-enhanced multidetector CT provides prompt detection, characterization and vascular mapping of these lesions, allowing correct planning of surgical or interventional therapies and reproducible follow-up. Because of their characteristically unpredictable behaviour, mycotic aneurysms may undergo spontaneous thrombosis, size reduction, rapid enlargement or rupture, therefore strict imaging surveillance with CT and/or color Doppler ultrasound is necessary.

Hybrid technique for total arch repair: aortic neck reshaping for endovascular-graft fixation.

PURPOSE: Endovascular repairs of the aortic arch aneurysms require correct placement and an appropriate landing zone for fixation, which are not present in the majority of cases. DESCRIPTION: We report a less invasive approach in 4 patients presenting an aortic arch aneurysm. We performed a hybrid procedure that is a combination of different techniques: a mid-sternotomy is performed, followed by transposition of the supra-aortic vessels, and neck reshaping with a proximal banding of the aortic arch. In particular, we banded the aorta to facilitate and optimize the endovascular fixation of the graft, reducing postoperative type-1 endoleaks. EVALUATION: The four procedures were uneventful with 1-day intensive care unit recovery. The postoperative and the 1-year follow-up CT scan did not reveal any endoleaks. CONCLUSIONS: Hybrid technique, combined with banding of proximal aortic arch and endovascular grafting are an alternative technique to the conventional open aortic repair. A polyester cloth banding of the ascending and proximal aortic arch allow the neck reshaping of the aorta optimizing the fixation of the endovascular stent graft.