Letter to Editor - What makes a sustainable 24/7/365 Interventional radiology service.

In this Letter to the Editor, the writer, shares his experience on providing a sustainable 24/7/365 interventional radiology service. Sufficient manpower resources, adequate bandwidth for quality personal and family time, consistent work processes and a cohesive team with a "whole of the patient" approach were some of the reasons emphasised.

Step-up approach and video assisted retroperitoneal debridement in infected necrotizing pancreatitis: A case complicated by retroperitoneal bleeding and colonic fistula.

INTRODUCTION: Infected Necrotizing Pancreatitis carries a high mortality and necessitates intervention to achieve sepsis control. The surgical strategy for proven infected necrosis has evolved, with abandonment of open necrosectomy to a step-up approach consisting of percutaneous drains and Video-assisted retroperitoneal debridement (VARD). We present a case that underwent VARD complicated by bleeding and colonic perforation and describe its management. PRESENTATION OF CASE: A 38 year-old male with acute pancreatitis developed infected necrotizing pancreatitis. Initial treatment was by percutaneous drainage under radiological guidance and intravenous antibiotics. The infected retroperitoneal necrosis was then debrided using gasless laparoscopy through a mini-incision. Post-operatively, he developed peripancreatic bleeding which was controlled with angioembolisation. He also developed a descending colon fistula which was treated with laparotomy and defunctioning loop ileostomy. He recovered and subsequently had his ileostomy closed twelve months later. The colonic fistula recurred and was treated with endoscopic clips and histoacryl glue injection and finally closed. DISCUSSION: Step-up approach consists of the 3 D's: Delay, drain and debride. VARD is recommended as it is replicable in general surgical units using standard laparoscopic instruments. Bleeding and colon perforation are potential complications which must have multi-disciplinary input, aggressive resuscitation and timely radiologic intervention. Defunctioning ileostomy is recommended to control sepsis in colonic fistulation. Novel fistula closing methods using endoscopic clips and histoacryl glue are potential treatment options. CONCLUSION: Step-up approach and VARD is the new paradigm to treat necrotizing pancreatitis. Complications of bleeding and colon fistula are uncommon and require multi-disciplinary management.

Imaging of acute cholecystitis and cholecystitis-associated complications in the emergency setting.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting at the emergency department. Early diagnosis and recognition of associated complications, though challenging, are essential for timely management. Imaging studies, including ultrasonography, computed tomography and magnetic resonance imaging, are increasingly utilised for the evaluation of suspected cases of cholecystitis. These investigations help in diagnosis, identification of complications and surgical planning. Imaging features of acute cholecystitis have been described in the literature and are variable, depending on the stage of inflammation. This article discusses the spectrum of cholecystitis-associated complications and their imaging manifestations. We also suggest a checklist for the prompt and accurate identification of complications in acute cholecystitis.

Dislocation of the penis: a rare complication after traumatic pelvic injury.

Traumatic injury to the male external genitalia is frequently encountered, but acute traumatic dislocation of the penile structure is extremely rare, with only a few reports found in the literature. We herein report the case of a 21-year-old man who sustained blunt trauma to the pelvis following a motor vehicle accident, and had features suspicious of penile dislocation. With the use of computed tomography and bedside ultrasonography, a diagnosis of penile dislocation was made, which was subsequently confirmed intraoperatively. Immediate surgical intervention via gentle manipulation of the penile tissue back to its native position was performed in order to restore normal anatomy. The exact mechanism of penile dislocation is not known. However, circumferential laceration around the foreskin causing degloving injury of the penis is suggested in our patient.

Primary hepatic amyloidosis presenting as nodular masses on the background of diffuse infiltration and extreme liver stiffness on MR elastography.

Amyloidosis is characterized by the deposition of extracellular protein material, amyloid, in various organs. The clinical and imaging features of the disease are often nonspecific and a tissue biopsy is often required. We present the case of a 64-year-old man with biopsy proven amyloidosis of the liver. The patient presented with non-specific clinical symptoms. Routine imaging showed hepatomegaly with heterogeneous enhancement, and several large nodular space occupying lesions, mimicking neoplasm. MR elastography revealed an extremely stiff liver. Amyloidosis presenting as multiple nodular masses on the background of diffuse infiltrative pattern or demonstration of extreme stiffness in hepatic amyloidosis on MR elastography have not been described previously.

The filarial dance sign in scrotal filarial infection: a case report.

We describe a case of the filarial dance sign (FDS) in the epididymal region of a 22-year-old migrant worker from India who presented with a tender right scrotal swelling. Sonographic examination revealed multiple cystic lesions in the paratesticular region. The FDS was visualized within one of the cystic lesions. FDS is diagnostic of lymphatic filariasis in the appropriate clinical context.

Dual-energy and low-kVp CT in the abdomen.

OBJECTIVE: The purpose of this article is to discuss the influence of tube potential on CT images and explore the potential impact of dual-energy CT on imaging of the abdomen and pelvis. CONCLUSION: Low peak tube voltage (kVp) settings provide high conspicuity of contrast materials at CT but may result in high image noise, particularly in larger patients. Material decomposition at dual-energy CT can differentiate renal stones by their composition, quantify tissue iron stores, improve the detection of pathologic hyperenhancement, and reduce contrast material and radiation dose compared with conventional CT. Further clinical research and technique refinement will be needed as the usage of these exciting technologies spreads.

Endorectal MR imaging and MR spectroscopic imaging for locally recurrent prostate cancer after external beam radiation therapy: preliminary experience.

PURPOSE: To evaluate endorectal magnetic resonance (MR) imaging and MR spectroscopic imaging for the depiction of locally recurrent prostate cancer after external beam radiation therapy. MATERIALS AND METHODS: Endorectal MR imaging and MR spectroscopic imaging were performed in 21 patients with biochemical failure after external beam radiation therapy for prostate cancer. Two readers independently and retrospectively reviewed MR images and rated the likelihood of recurrent tumor on a five-point scale. Spectroscopic voxels were considered suspicious for malignancy if the choline level was elevated and citrate was absent. Receiver operating characteristic curve analysis was used to assess cancer detection in each side of the prostate with endorectal MR imaging and spectroscopic imaging at different thresholds based on the scores assigned by the two readers and on the number of suspicious voxels in each hemiprostate, respectively. The presence or absence of cancer at subsequent transrectal biopsy was used as the standard of reference. RESULTS: Biopsy demonstrated locally recurrent prostate cancer in nine hemiprostates in six patients. The area under the receiver operating characteristic curve for the detection of locally recurrent cancer with MR imaging was 0.49 and 0.51 for readers 1 and 2, respectively. By using the number of suspicious voxels to define different diagnostic thresholds, the area under the receiver operating characteristic curve for MR spectroscopic imaging was significantly (P < .005) higher, at 0.81. In particular, the presence of three or more suspicious voxels in a hemiprostate showed a sensitivity and specificity of 89% and 82%, respectively, for the diagnosis of local recurrence. Seven hemiprostates demonstrated complete metabolic atrophy at spectroscopic imaging and only postirradiation atrophy at biopsy. CONCLUSION: Preliminary data suggest that MR spectroscopic imaging, but not endorectal MR imaging, may be of value for the depiction of locally recurrent prostate cancer after radiation therapy.

MR renography using a dynamic gradient-echo sequence and low-dose gadopentetate dimeglumine as an alternative to radionuclide renography.

OBJECTIVE: Our aim was to evaluate the feasibility of acquiring an MR signal intensity-time renographic curve and dynamic serial images in a way similar to that of acquiring radionuclide renograms, with a dynamic gradient-echo sequence and a low-dose gadopentetate dimeglumine technique, using a commonly available 1.5-T MR scanner. SUBJECTS AND METHODS. Patients who underwent both radionuclide and MR renographic studies within a 3-month period were included in the analysis. This yielded 21 studies from 19 patients. Nineteen of the 21 studies were available for analysis. Two studies were excluded because of technical errors during MR renographic acquisition. Serial MR renograms were obtained using a dynamic two-dimensional spoiled gradient-echo fast low-angle shot T1-weighted sequence. Low-dose IV furosemide and gadopentetate dimeglumine (0.025 mmol/kg of body weight) were administered. Intensity-time curves were obtained from the manually selected regions of interest over the renal parenchyma and whole kidney for calculation of split renal function and assessment of urinary excretion, respectively. Results were compared with those obtained with radionuclide renography. RESULTS: Good correlation (Pearson's correlation coefficient, r = 0.97, p < 0.001) was observed when the volume-corrected split renal function acquired with MR renography was compared with that obtained with radionuclide renography. There was also good agreement in the excretory curve patterns (weighted kappa(observer 1) = 0.77 and kappa(observer 2) = 0.81) between the two techniques. CONCLUSION: Dynamic MR gradient-echo imaging with a low-dose gadopentetate dimeglumine technique can produce an intensity-time curve and serial dynamic images of the urinary system, in a way similar to that of radionuclide renography. This technique allows assessment of split renal function and urinary excretory status and is a feasible alternative to radionuclide renography.