Distinguishing sterile inflammation from graft infection

We describe the case of a 68-year-old man who underwent ascending aortic replacement and thoracic endovascular aortic repair. Four years later, the patient developed neck pain on the right side and chest computed tomography showed expansion of fluid in the mediastinum which had extended to the neck. Echocardiography revealed advanced severity of aortic regurgitation and decreased ejection fraction. Given the progression of aortic regurgitation, decreased cardiac function, and rapidly expanding fluid accumulation causing neck pain, reoperation was indicated. All microbiological test including polymerase chain reaction were negative indicating absence of any infection. The patient is being followed-up without antibiotics and CT has not shown peri-graft fluid 2 years postoperatively. Since infection cannot be excluded completely, it is important to assess the condition with selective medium, extended culture periods, genetic testing, and consultations with microbiology laboratories when normal culture tests for general bacteria, and fungi are negative which can help avoid drug-resistant bacteria count, elevated medical costs, and drug side effects due to the improper use of antibiotics through proper diagnosis.

Early versus delayed EUS-guided drainage for postoperative pancreatic fluid collections: a systematic review and meta-analysis

BACKGROUND

Postoperative pancreatic fluid collections (POPFCs) are common adverse events (AEs) after pancreatic surgery and may need interventions. Endoscopic ultrasound (EUS)-guided drainage for POPFCs is increasingly reported, but its appropriate timing has not been fully elucidated. The aim of this meta-analysis was to evaluate treatment outcomes of POPFCs according to the timing of EUS-guided drainage.

METHODS

Using PubMed, Embase, Web of Science, and the Cochrane database, we identified clinical studies published until December 2022 with data comparing outcomes of early and delayed EUS-guided drainage for POPFCs. We pooled data on AEs, mortality, and technical and clinical success rates, using the random-effects model.

RESULTS

From 1415 papers identified in the initial literature search, we identified 6 retrospective studies, including 128 and 107 patients undergoing early and delayed EUS-guided drainage for POPFCs. The threshold of early and delayed drainage ranged from 14 to 30 days. Distal pancreatectomy was the major cause of POPFCs, ranging from 44 to 100%. The pooled odds ratio (OR) for AEs was 0.81 (95% confidence interval [CI] 0.40-1.64, P = 0.55) comparing early to delayed drainage. There was no procedure-related mortality. Technical success was achieved in all cases and a pooled OR of clinical success was 0.60 (95% CI 0.20-1.83, P = 0.37).

CONCLUSION

POPFCs can be managed by early EUS-guided drainage without an increase in AEs.

On the feeding biomechanics of nectarivorous birds

Nectar-feeding birds employ unique mechanisms to collect minute liquid rewards hidden within floral structures. In recent years, techniques developed to study drinking mechanisms in hummingbirds have prepared the groundwork for investigating nectar feeding across birds. In most avian nectarivores, fluid intake mechanisms are understudied or simply unknown beyond hypotheses based on their morphological traits, such as their tongues, which are semi-tubular in sunbirds, frayed-tipped in honeyeaters and brush-tipped in lorikeets. Here, we use hummingbirds as a case study to identify and describe the proposed drinking mechanisms to examine the role of those peculiar traits, which will help to disentangle nectar-drinking hypotheses for other groups. We divide nectar drinking into three stages: (1) liquid collection, (2) offloading of aliquots into the mouth and (3) intraoral transport to where the fluid can be swallowed. Investigating the entire drinking process is crucial to fully understand how avian nectarivores feed; nectar-feeding not only involves the collection of nectar with the tongue, but also includes the mechanisms necessary to transfer and move the liquid through the bill and into the throat. We highlight the potential for modern technologies in comparative anatomy [such as microcomputed tomography (μCT) scanning] and biomechanics (such as tracking BaSO4-stained nectar via high-speed fluoroscopy) to elucidate how disparate clades have solved this biophysical puzzle through parallel, convergent or alternative solutions.

CT Texture analysis and CT scores for characterization of fluid collections

Background

Texture analysis derived from Computed tomography (CT) might be able to better characterize fluid collections undergoing CT-guided percutaneous drainage treatment. The present study tested, whether texture analysis can reflect microbiology results in fluid collections suspicious for septic focus.

Methods

Overall, 320 patients with 402 fluid collections were included into this retrospective study. All fluid collections underwent CT-guided drainage treatment and were microbiologically evaluated. Clinically, serologically parameters and conventional imaging findings as well as textures features were included into the analysis. A new CT score was calculated based upon imaging features alone. Established CT scores were used as a reference standard.

Results

The present score achieved a sensitivity of 0.78, a specificity of 0.69, area under curve (AUC 0.82). The present score and the score by Gnannt et al. (AUC 0.81) were both statistically better than the score by Radosa et al. (AUC 0.75). Several texture features were statistically significant between infected fluid collections and sterile fluid collections, but these features were not significantly better compared with conventional imaging findings.

Conclusions

Texture analysis is not superior to conventional imaging findings for characterizing fluid collections. A novel score was calculated based upon imaging parameters alone with similar diagnostic accuracy compared to established scores using imaging and clinical features.

Wrapping the pancreas with a polyglycolic acid sheet before stapling reduces the risk of fluid collection on the pancreatic stump after distal pancreatectomy

Background

Postoperative pancreatic fistula (POPF) and postoperative fluid collection (POFC) are common complications after distal pancreatectomy (DP). The previous method of reducing the risk of POPF was the application of a polyglycolic acid (PGA) sheet to the pancreatic stump after cutting the pancreas with a stapler (After-stapling); the new method involves wrapping the pancreatic resection line with a PGA sheet before stapling (Before-stapling). The study aimed to compare the incidence of POPF and POFC between two methods.

Methods

Data of patients who underwent open or laparoscopic DPs by a single surgeon from October 2010 to February 2020 in a tertiary referral hospital were retrospectively analyzed. POPF was defined according to the updated International Study Group of Pancreatic Fistula criteria. POFC was measured by postoperative computed tomography (CT).

Results

Altogether, 182 patients were enrolled (After-stapling group, n = 138; Before-stapling group, n = 44). Clinicopathologic and intraoperative findings between the two groups were similar. Clinically relevant POPF rates were similar between both groups (4.3% vs. 4.5%, p = 0.989). POFC was significantly lesser in the Before-stapling group on postoperative day 7 (p < 0.001).

Conclusions

Wrapping the pancreas with PGA sheet before stapling was a simple and effective way to reduce POFC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08387-0.

Cranioplasty following ventriculoperitoneal shunting: lessons learned

OBJECTIVE

Cranioplasty (CP) is considered as a straightforward and technically unchallenging operation; however, complication rates are high reaching up to 56%. Presence of a ventriculoperitoneal shunt (VPS) and timing of CP are reported risk factors for complications. Pressure gradients and scarring at the site of the cranial defect seem to be critical in this context. The authors present their experiences and lessons learned.

METHODS

A consecutive series of all patients who underwent CP at the authors' institution between 2002 and 2017 were included in this retrospective analysis. Complications were defined as all events that required reoperation. Logistic regression analysis and chi-squared test were conducted to evaluate the complication rates according to suspected risk factors.

RESULTS

A total of 302 patients underwent cranioplasty between 2002 and 2017. The overall complication rate was 17.5%. Complications included epi-/subdural fluid collection (7.3%) including hemorrhage (4.6%) and hygroma (2.6%), bone graft resorption (5.3%), bone graft infection (2.0%), and hydrocephalus (5.7%). Overall, 57 patients (18.9%) had undergone shunt implantation prior to CP. The incidence of epi-/subdural fluid collection was 19.3% in patients with VPS and 4.5% in patients without VPS, OR 5.1 (95% CI 2.1-12.4). Incidence of hygroma was higher in patients who underwent early CP. Patients with temporary shunt ligation for CP did not suffer from complications.

CONCLUSION

CP in patients with a VPS remains a high-risk procedure. Any effort to understand the pressure dynamics and to reduce factors that may trigger the formation of a large epidural space must be undertaken.

Infected versus sterile abdominal fluid collections in postoperative CT: a scoring system based on clinical and imaging findings

PURPOSE

Characterization of intraabdominal fluid collections as postoperative complication is a challenging task. The aim was to develop and validate a new score to differentiate infected from sterile postoperative abdominal fluid collections and to compare it with a published score.

MATERIALS AND METHODS

From May to November 2015, all patients with postoperative CT and C-reactive protein (CRP) 24 hours before CT-guided drainage were retrospectively included (Group A). HU, gas entrapment and wall enhancement of fluid collections were evaluated in the CT. All parameters were correlated with microbiology. To validate the score and to compare it with a published score, a second patient cohort was retrospectively recruited (Group B; January 2013-April 2015; December 2015-September 2016).

RESULTS

In Group A (50 patients), univariate analysis confirmed that the four parameters were significantly associated with infected fluid collections. Based on binary logistic regression analysis, a score from 0 to 11 was developed (CRP </≥ 150 mg/l: 0/4 points; HU </≥ 20: 0/2 points; wall enhancement no/yes: 0/2 points; gas entrapment no/yes: 0/3 points). The best cutoff to diagnose infected fluid collections was ≥ 5 points (sensitivity 85%, specificity 79%, PPV 82%, NPV 79%). In Group B (425 patients), this score yielded sensitivity, specificity, PPV and NPV of 93%, 80%, 90% and 86%, respectively. For the published score, values were in the same range (93%, 44%, 77%, 77%).

CONCLUSION

The score provides good discrimination between infected and sterile postoperative abdominal fluid collections. It yields comparable accuracy as the published score.

Morison's pouch: anatomical review and evaluation of pathologies and disease spread on cross-sectional imaging

The peritoneum is a complex structure. Having a better understanding of this complex anatomy will enable the radiologist to accurately assess and diagnose the wide range of intra-abdominal pathologies. In this article, we review the anatomy, boundaries, and connections of Morison's pouch. In addition, we discuss the incidence and development of common pathological conditions within Morison's pouch and the role of multiple imaging modalities in assessment and diagnosis of these conditions.

Acute respiratory distress syndrome in acute pancreatitis

Development of organ failure is one of the major determinants of mortality in patients with acute pancreatitis (AP). Acute respiratory distress syndrome (ARDS) is an important cause of respiratory failure in AP and is associated with high mortality. Pathogenesis of ARDS in AP is incompletely understood. Release of various cytokines plays an important role in development of ARDS in AP. Increased gut permeability due to various toxins, inflammatory mediators, and pancreatic enzymes potentiates lung injury by gut-lymph-lung axis leading on to increased translocation of bacterial endotoxins. Various scoring systems, serum levels of various cytokines and lung ultrasound have been evaluated for prediction of development of ARDS in AP with varying results. Various drugs have shown encouraging results in prevention of ARDS in animal models but these encouraging results in animal models are yet to be confirmed in clinical studies. There is no specific effective treatment for ARDS. Treatment of sepsis and local complications of AP should be done according to the standard management strategies. Lung protective ventilatory strategies are of paramount importance to improve outcome of patients of AP with ARDS and therefore effective coordination between gastroenterologists and intensivists is needed for effective management of these patients.

Management of (Peri)Pancreatic Collections in Acute Pancreatitis

The development of (peri)pancreatic fluid collections are frequent local complications in acute pancreatitis. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection may require intervention. Interventions may include endoscopic or percutaneous catheter drainage, or in a next step endoscopic or surgical necrosectomy, minimally invasive or open. The best timing for the first intervention is still under investigation. Whereas some use antibiotics to postpone intervention until the stage of walled-off necrosis, others drain earlier. Endoscopic drainage of (peri)pancreatic fluid collections is now the preferred approach of drainage due to reduced morbidity as compared to surgical or percutaneous drainage. However, each collection must be treated according to a tailored approach. The final treatment should take into consideration anatomic characteristics, patient preference, comorbidity profile of the patient, and physician discretion. This review summarizes the current evidence on the treatment of (peri)pancreatic fluid collections.

The treatment indication and optimal management of fluid collection after laparoscopic distal pancreatectomy

BACKGROUND

Recently, laparoscopic distal pancreatectomy (LDP) has become the standard procedure for resection of left-sided pancreatic tumors. Fluid collection (FC) at the resection margin of the pancreatic stump after LDP is a frequent radiological finding. However, there have been few treatment guidelines and the optimal management for this clinical finding is unclear. The aim of present study is to define the incidence of FC and suggest the optimal management for FC after LDP.

METHODS

A total of 1227 patients who underwent LDP between March 2005 and December 2015 were collected. FC was considered present when the longest diameter of the lesion on CT scan was > 3 cm.

RESULTS

A follow-up with at least two CT image was available for 1102 patients. Of these, 689 (62.5%) patients showed initial fluid collection (IFC) at the pancreas resection site in immediate postoperative CT. IFC (+) group had higher proportion of men, BMI, and higher rate of concomitant splenectomy than IFC (-) group. Among patients with FC after LDP, the treatment group had more frequent leukocytosis and accompanying symptoms than the observation group. Seventy-seven patients underwent therapeutic interventions for FC after LDP. Among them, 55 (71.4%) patients underwent endoscopic ultrasonography-guided gastrocystostomy (EUS-GC). EUS-GC group had a higher success rate (85.6 vs. 63.6%, p < 0.033) and shorter hospital stay after the intervention (5.2 vs. 13.3 days, p < 0.001) than those who underwent other procedures.

CONCLUSIONS

High BMI, male, and concomitant splenectomy contribute to the occurrence of FC after LDP. In most cases, FC after LDP resolved spontaneously over time with observation. The patients with symptomatic FC ultimately required treatment. EUS-GC is the optimal intervention therapy for FC after LDP.

Management of chronic abdominal wall seroma with Doxycycline sclerotherapy using a Negative Pressure Wound Therapy System KCI-V.A.C.Ulta™-A case report

INTRODUCTION

Seroma is a common and challenging post-operative complication that surgeons are often faced with after performing procedures in which tissue dead spaces have been created. The management strategies consist of non-operative management, percutaneous drainage, or surgical drainage. Our case report discusses the use of Doxycycline sclerotherapy in the successful resolution of a chronic abdominal wall seroma.

PRESENTATION OF CASE

We present the case of a 50 year old patient with extensive history of multiple abdominal surgeries, including appendectomy, multiple hernia repairs with recurrent mesh replacement as a result of infection followed by post-operative formation of seroma after each repair. Recently, patient underwent panniculecotomy complicated by seroma that was successfully resolved with the use of doxycycline sclerotherapy.

DISCUSSION

Sclerotherapy has been used previously in the surgical field such as thoracic surgery, as a successful use of sclerosants in chronic pleural effusions has been documented. Sclerosants range from talc, tetracycline antibiotics, ethanol, polidocanol, erythromycin, OK-432, fibrin glue, and povidone-iodine, and are largely safe and easily applicable. Doxycycline in particular can be a simple and effective method for resolution of chronic seroma. This case demonstrates the successful use of doxycycline in the resolution of a chronic abdominal wall seroma.

CONCLUSION

Chronic and recurrent seroma after surgery can be difficult to deal with. Using sclerosants such as Doxycycline would be an effective solution to treat this chronic issue and to prevent its recurrence especially if it is used with a Negative Pressure Wound Therapy System.

Assessment of alternatives to environmental toxic formalin for DNA conservation in biological specimens

One essential step of museum and clinical specimen preservation is immersion in a fixative fluid to prevent degradation. Formalin is the most largely used fixative, but its benefit is balanced with its toxic and carcinogenic status. Moreover, because formalin-fixation impairs nucleic acids recovery and quality, current museum wet collections and formalin-fixed, paraffin-embedded clinical samples do not represent optimal tanks of molecular information. Our study has been developed to compare formalin to two alternative fixatives (RCL2® and ethanol) in a context of molecular exploitation. Based on a unique protocol, we created mammalian fixed collections, simulated the impact of time on preservation using an artificial ageing treatment and followed the evolution of specimens' DNA quality. DNA extraction yield, purity, visual integrity and qualitative and quantitative ability to amplify the Cox1 gene were assessed. Our results show that both RCL2 and ethanol exhibit better performances than formalin. They do not impair DNA extraction yield, and more importantly, DNA alteration is delayed over the preservation step. The use of RCL2 or ethanol as fixative in biological collections may insure a better exploitation of the genetic resources they propose.

[Spontaneous retroperitoneal biloma: A case report]

BACKGROUND

Non-traumatic spontaneous rupture of the biliary tract and retroperitoneal accumulation (retroperitoneal biloma) is an extremely rare condition.

CLINICAL CASE

A 57 year-old woman with no known biliary disease, started with intense pain in the right abdomen 30 days prior to consultation. She also had jaundice (4+). The initial hepatobiliary ultrasound reported choledocholithiasis and retroperitoneal fluid collection, which was confused with a peri-renal abscess. Guided puncture was performed and the presence of bile was evident. Dilation of the bile duct was observed in the computed tomography. The patient underwent laparotomy to correct both conditions.

CONCLUSION

The retroperitoneal biloma, also called choleretroperitoneum, is of multifactorial origin. Clinical presentation is non-specific, with diffuse abdominal distension and pain in all patients. The diagnosis is made based on ultrasonography and computed tomography, and can even be diagnosed intra-operatively. The treatment is based on liquid bile drainage and correction of the leak.

Predictors and outcomes of moderately severe acute pancreatitis - Evidence to reclassify

BACKGROUND/OBJECTIVES

After the creation of the moderately severe acute pancreatitis (MSAP) category in the Revised Atlanta Classification in 2012, predictors to identify these patients early have not been identified. The MSAP category includes patients with (peri)pancreatic necrosis, fluid collections, and transient organ failure in the same category. However, these outcomes have not been studied to determine whether they result in similar outcomes to merit inclusion in the same severity.

METHODS

Retrospective, review of 514 consecutive, direct admissions for acute pancreatitis from 2010 to 2013. Multivariate logistic regression identified predictors of MSAP.

RESULTS

Persistent SIRS was the best prognostic marker of MSAP with AUC 0.72. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for persistent SIRS to predict MSAP are: 55%, 88%, 40%, 93%, and 84%. Patients with necrosis had significantly longer length of stay (LOS) (p = 0.0001) and higher rates of ICU admission (p = 0.02) compared with patients with transient organ failure. Compared to those with acute fluid collections, patients with necrosis had longer LOS (p < 0.0001), higher rates of ICU admission (p = 0.0005), required more interventions (p = 0.001), and demonstrated higher mortality (0.003).

DISCUSSION

Moderately severe pancreatitis can be distinguished from mild pancreatitis on the basis of persistent SIRS but cannot be accurately distinguished from severe pancreatitis in the first 48 h (Peri)pancreatic necrosis demonstrates significantly more morbidity compared to the other components of MSAP of fluid collections and transient organ failure.

Fluid collection in the retropharyngeal space: A wide spectrum of various emergency diseases

Fluid collections in the retropharyngeal space (RPS) result from a wide spectrum of diseases, including retropharyngeal abscess, cervical osteomyelitis, and calcific tendinitis of the longus colli muscle. These conditions should be managed by different specialties; beginning with care in the emergency room, physicians from orthopedics, pediatrics, otolaryngology, and oncology are in charge of the treatment. Since these diseases demonstrate similar fluid collections in the RPS on computed tomography (CT) and magnetic resonance imaging (MRI), the radiologist's diagnosis based on the characteristic imaging findings is very important to identify the primary disease. Also, since some of the diseases require immediate surgical intervention to avoid life-threatening mediastinitis or airway obstruction, radiologists must distinguish these diseases correctly and provide recommendations for their management to physicians. Understanding clinical features and imaging findings of these fluid collections in the RPS is crucial for the best care.

Fluid collections associated with acute pancreatitis: a pictorial essay

The terminology and classification scheme of acute pancreatitis proposed at the initial Atlanta Symposium was reviewed, and a new consensus statement was recently proposed. Major changes include subdividing acute fluid collections in the first 4 weeks into "acute peripancreatic fluid collection" and "acute necrotic collection" based on the presence of necrotic debris. Delayed fluid collections have been similarly subdivided into "pseudocyst" and "walled-off necrosis." Correct use of the new terms that describe these collections is important because they lead to different treatment decisions. The purpose of this article is to present an overview of fluid collections associated with acute pancreatitis, with an emphasis on their prognostic significance and impact on clinical management, and to illustrate the new terminology.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Case report: Retroperitoneal biliary fluid collections secondary to common bile duct rupture - an unusual complication of choledocholithiasis in a child

Rupture of the common bile duct (CBD) in a child secondary to choledocholithiasis is a rare event. In this article, the authors describe a child who presented with an acute abdomen due to CBD rupture, with subsequent acute retroperitoneal fluid collections, all diagnosed preoperatively on CT scan. The aim of this article is to show the pathways that such collections can take in the retroperitoneum.