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1.
Role of MRI in the Evaluation of Thoracoabdominal Emergencies.
Ludwig, DR, Raptis, CA, Broncano, J, Bhalla, S, Luna, A
Topics in magnetic resonance imaging : TMRI. 2020;(6):355-370
Abstract
Thoracic and abdominal pathology are common in the emergency setting. Although computed tomography is preferred in many clinical situations, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have emerged as powerful techniques that often play a complementary role to computed tomography or may have a primary role in selected patient populations in which radiation is of specific concern or intravenous iodinated contrast is contraindicated. This review will highlight the role of MRI and MRA in the emergent imaging of thoracoabdominal pathology, specifically covering acute aortic pathology (acute aortic syndrome, aortic aneurysm, and aortitis), pulmonary embolism, gastrointestinal conditions such as appendicitis and Crohn disease, pancreatic and hepatobiliary disease (pancreatitis, choledocholithiasis, cholecystitis, and liver abscess), and genitourinary pathology (urolithiasis and pyelonephritis). In each section, we will highlight the specific role for MRI, discuss basic imaging protocols, and illustrate the MRI features of commonly encountered thoracoabdominal pathology.
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2.
Evaluation of a child with suspected nephrolithiasis.
Reusz, GS, Hosszu, A, Kis, E
Current opinion in pediatrics. 2020;(2):265-272
Abstract
PURPOSE OF REVIEW As the incidence of nephrolithiasis in children doubles every 10 years it is becoming a common disease associated with significant morbidity along with considerable economic burden worldwide. The aim of this review is to summarize current data on the epidemiology and causes of renal stones in children and to provide a frame for the first clinical evaluation of a child with suspected nephrolithiasis. RECENT FINDINGS Dietary and environmental factors are the driving force of changing epidemiology. Diagnosis should be based on medical history, presenting signs, examination, first laboratory and radiological workup. Ultrasound should be the initial diagnostic imaging performed in pediatric patients while low-dose computed tomography is rarely necessary for management. Metabolic factors including hypercalciuria, hypocitraturia, low fluid intake as well as specific genetic diseases should be explored after the resolution of initial signs and symptoms. SUMMARY Appropriate initial evaluation, imaging technique, identification of risk factors and other abnormalities are essential for early diagnosis and prevention of stone-related morbidity in children with suspected nephrolithiasis.
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3.
Challenges in optimising recovery after emergency laparotomy.
Foss, NB, Kehlet, H
Anaesthesia. 2020;:e83-e89
Abstract
Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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4.
The Art and Craft of Reoperative Abdominal Surgery after Prior Trauma or Acute Care Surgery Operation.
Ball, CG, Feliciano, DV
Journal of the American College of Surgeons. 2020;(5):e1-e6
Abstract
BACKGROUND Reoperative abdominal surgery is one of the most challenging endeavors that general surgeons face. The aim of this narrative review is to offer a detailed and nuanced discussion of preoperative patient and surgeon preparation and intraoperative surgical technique. STUDY DESIGN The topics discussed in this review are based on both the current literature and the experiences of the authors with complex reoperations in general, trauma, acute care, and hepatopancreatobiliary surgery. RESULTS Ten essential steps for reoperative abdominal surgery include the following: 1. Review all previous operative notes and discharge summaries; 2. Review all prior outside and current in-house imaging; 3. Assess the patient's overall health status, reverse nutritional deficits, and explain risks of reoperation to the patient and family; 4. Refer the patient to a plastic surgeon when future skin coverage of a prosthesis in the abdominal wall may be needed; 5. Do a bowel preparation preoperatively; 6. Use selected Enhanced Recovery After Surgery protocols; 7. Operative technique matters; 8. Restoring gastrointestinal continuity simultaneously with abdominal wall reconstruction is not recommended; 9. Technical tips for complex reoperations; and 10. Plan well for the day of the operation. CONCLUSIONS Successful reoperative abdominal surgery in the most complex patients after previous trauma or acute care laparotomies demands adequate preoperative patient preparation, a clear-cut plan for operation, superb intraoperative technique, and solid decision-making; ie an unwavering commitment to making the patient whole again.
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5.
Contraindications and adverse effects in abdominal imaging.
Caraiani, C, Petresc, B, Dong, Y, Dietrich, CF
Medical ultrasonography. 2019;(4):456-463
Abstract
Ultrasound (US), computed-tomography (CT) and magnetic resonance imaging (MRI) are the most frequently used imaging techniques in abdominal pathology. US plays a pivotal role in evaluating abdominal disease, sometimes being sufficient for a complete diagnosis and has virtually no contraindications. The usage of US contrast agents will add useful diagnostic information in both hepatic and non-hepatic pathology. CT has, over MRI, the advantage of being readily available. The usage of ionizing radiation is the main pitfall of CT. Allergies and contrast induced nephropathy in patients with an impaired renal function are the major risks of contrast media administration in CT. Its excellent tissue resolution makes MRI a very useful technique in abdominal pathology, the major contraindications being the presence of MRI "unsafe" implants and devices and the presence of metallic foreign bodies, particularly close to vital structures like the eyes or major vessels. Contrast administration in MRI is restricted in patients with renal insufficiency due to the risk of nephrogenic systemic fibrosis. Allergies to MRI contrast media are rare and less important compared to allergies due to CT contrast media.
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6.
Dual-Energy CT in Evaluation of the Acute Abdomen.
Murray, N, Darras, KE, Walstra, FE, Mohammed, MF, McLaughlin, PD, Nicolaou, S
Radiographics : a review publication of the Radiological Society of North America, Inc. 2019;(1):264-286
Abstract
Evaluation of the nontraumatic acute abdomen with multidetector CT has long been accepted and validated as the reference standard in the acute setting. Dual-energy CT has emerged as a promising tool, with multiple clinical applications in abdominal imaging already demonstrated. With its ability to allow characterization of materials on the basis of their differential attenuation when imaged at two different energy levels, dual-energy CT can help identify the composition of internal body constituents. Therefore, it is possible to selectively identify iodine to assess the enhancement pattern of an organ, including the identification of hyperenhancement in cases of inflammatory processes, or ischemic changes secondary to vascular compromise. Quantification of iodine uptake with contrast material-enhanced dual-energy CT is also possible, and this quantification has been suggested to be useful in differentiating inflammatory from neoplastic conditions. Dual-energy CT can help determine the composition of gallstones and urolithiasis and can be used to accurately differentiate uric acid urinary calculi from non-uric acid urinary calculi. Moreover, dual-energy CT is capable of substantially reducing artifacts caused by metallic prostheses, to improve the imaging evaluation of abdominopelvic organs. The possibility of creating virtual nonenhanced images in the evaluation of acute aortic syndrome, gastrointestinal hemorrhage and ischemia, or pancreatic pathologic conditions substantially reduces the radiation dose delivered to the patient, by eliminating a true nonenhanced acquisition. Finally, by increasing the iodine conspicuity, contrast-enhanced dual-energy CT can render an area of free active extravasation or endoleak more visible, compared with conventional single-energy CT. This article reviews the basics of dual-energy CT and highlights its main clinical applications in evaluation of the nontraumatic acute abdomen. ©RSNA, 2019.
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7.
The Impact of Total Body Prehabilitation on Post-Operative Outcomes After Major Abdominal Surgery: A Systematic Review.
Luther, A, Gabriel, J, Watson, RP, Francis, NK
World journal of surgery. 2018;(9):2781-2791
Abstract
BACKGROUND Despite advances in perioperative care, post-operative clinical and functional outcomes after major abdominal surgery can be suboptimal. Prehabilitation programmes attempt to optimise a patient's preoperative condition to improve outcomes. Total body prehabilitation includes structured exercise, nutritional optimisation, psychological support and cessation of negative health behaviours. This systematic review aims to report on the current literature regarding the impact of total body prehabilitation prior to major abdominal surgery. METHODS Relevant studies published between January 2000 and July 2017 were identified using MEDLINE, EMBASE, AMED, CINAHL, PsychINFO, PubMed, and the Cochrane Database. All studies published in a peer-reviewed journal, assessing post-operative clinical and functional outcomes, following a prehabilitation programme prior to major abdominal surgery were included. Studies with less than ten patients, or a prehabilitation programme lasting less than 7 days were excluded. RESULTS Sixteen studies were included, incorporating 2591 patients, with 1255 undergoing a prehabilitation programme. The studies were very heterogeneous, with multiple surgical sub-specialties, prehabilitation techniques, and outcomes assessed. Post-operative complication rate was reduced in six gastrointestinal studies utilising either preoperative exercise, nutritional supplementation in malnourished patients or smoking cessation. Improved functional outcomes were observed following a multimodal prehabilitation programme. Compliance was variably measured across the studies (range 16-100%). CONCLUSIONS There is substantial heterogeneity in the prehabilitation programmes used prior to major abdominal surgery. A multimodal approach is likely to have better impact on functional outcomes compared to single modality; however, there is insufficient data either to identify the optimum programme, or to recommend routine clinical implementation.
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8.
Imaging with ultrasound contrast agents: current status and future.
Chong, WK, Papadopoulou, V, Dayton, PA
Abdominal radiology (New York). 2018;(4):762-772
Abstract
Microbubble ultrasound contrast agents (UCAs) were recently approved by the Food and Drug administration for non-cardiac imaging. The physical principles of UCAs, methods of administration, dosage, adverse effects, and imaging techniques both current and future are described. UCAs consist of microbubbles in suspension which strongly interact with the ultrasound beam and are readily detectable by ultrasound imaging systems. They are confined to the blood pool when administered intravenously, unlike iodinated and gadolinium contrast agents. UCAs have a proven safety record based on over two decades of use, during which they have been used in echocardiography in the U.S. and for non-cardiac imaging in the rest of the world. Adverse effects are less common with UCAs than CT/MR contrast agents. Compared to CT and MR, contrast-enhanced ultrasound has the advantages of real-time imaging, portability, and reduced susceptibility to metal and motion artifact. UCAs are not nephrotoxic and can be used in renal failure. High acoustic amplitudes can cause microbubbles to fragment in a manner that can result in short-term increases in capillary permeability or capillary rupture. These bioeffects can be beneficial and have been used to enhance drug delivery under appropriate conditions. Imaging with a mechanical index of < 0.4 preserves the microbubbles and is not typically associated with substantial bioeffects. Molecularly targeted ultrasound contrast agents are created by conjugating the microbubble shell with a peptide, antibody, or other ligand designed to target an endothelial biomarker associated with tumor angiogenesis or inflammation. These microbubbles then accumulate in the microvasculature at target sites where they can be imaged. Ultrasound contrast agents are a valuable addition to the diagnostic imaging toolkit. They will facilitate cross-sectional abdominal imaging in situations where contrast-enhanced CT and MR are contraindicated or impractical.
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9.
Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials.
Sun, Y, Chai, F, Pan, C, Romeiser, JL, Gan, TJ
Critical care (London, England). 2017;(1):141
Abstract
BACKGROUND Goal-directed hemodynamic therapy (GDHT) has been used in the clinical setting for years. However, the evidence for the beneficial effect of GDHT on postoperative recovery remains inconsistent. The aim of this systematic review and meta-analysis was to evaluate the effect of perioperative GDHT in comparison with conventional fluid therapy on postoperative recovery in adults undergoing major abdominal surgery. METHODS Randomized controlled trials (RCTs) in which researchers evaluated the effect of perioperative use of GDHT on postoperative recovery in comparison with conventional fluid therapy following abdominal surgery in adults (i.e., >16 years) were considered. The effect sizes with 95% CIs were calculated. RESULTS Forty-five eligible RCTs were included. Perioperative GDHT was associated with a significant reduction in short-term mortality (risk ratio [RR] 0.75, 95% CI 0.61-0.91, p = 0.004, I 2 = 0), long-term mortality (RR 0.80, 95% CI 0.64-0.99, p = 0.04, I 2 = 4%), and overall complication rates (RR 0.76, 95% CI 0.68-0.85, p < 0.0001, I 2 = 38%). GDHT also facilitated gastrointestinal function recovery, as demonstrated by shortening the time to first flatus by 0.4 days (95% CI -0.72 to -0.08, p = 0.01, I 2 = 74%) and the time to toleration of oral diet by 0.74 days (95% CI -1.44 to -0.03, p < 0.0001, I 2 = 92%). CONCLUSIONS This systematic review of available evidence suggests that the use of perioperative GDHT may facilitate recovery in patients undergoing major abdominal surgery.
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10.
Meta-analysis of immunonutrition in major abdominal surgery.
Probst, P, Ohmann, S, Klaiber, U, Hüttner, FJ, Billeter, AT, Ulrich, A, Büchler, MW, Diener, MK
The British journal of surgery. 2017;(12):1594-1608
Abstract
BACKGROUND The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias. METHODS A systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence. RESULTS A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P < 0·001) and shortened hospital stay (mean difference -1·79 (95 per cent c.i. -2·39 to -1·19) days; P < 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non-industry-funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01). CONCLUSION Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).