Investigative Radiology

Gadolinium Deposition in the Brain in a Large Animal Model: Comparison of Linear and Macrocyclic Gadolinium-Based Contrast Agents Objective Recent studies reported a signal intensity increase in the deep cerebellar nuclei (DCN) on magnetic resonance images caused by gadolinium deposition after the injection of gadolinium-based contrast agents (GBCAs). There is an ongoing debate if the propensity of a GBCA to deposit gadolinium is primarily determined by its class as either linear or macrocyclic. In the current study, we aimed to compare the amount and the distribution of retained gadolinium of linear and macrocyclic GBCAs in the DCN after a single injection at a dose comparable to a human patient's in a large animal model. Materials and Methods Eighteen sheep were randomly assigned in 6 groups of 3 animals, which received a single injection of 0.1 mmol/kg body weight of either the macrocyclic GBCAs gadobutrol, gadoteridol, or gadoterate meglumine; the linear GBCAs gadobenate dimeglumine or gadodiamide; or saline. Animals were euthanized 10 weeks after injection. Local distribution and concentration of gadolinium and colocalization to other metals (iron, zinc, copper) in the DCN was assessed by laser ablation-inductively coupled plasma-mass spectrometry. Results Average gadolinium concentration for the macrocyclic GBCAs and the saline group was below the limit of quantification (5.7 ng/g tissue). In contrast, 14 (for gadobenate) and 27 (for gadodiamide) times more gadolinium than the limit of quantification was found for the linear GBCAs gadobenate (mean, 83 ng/g) or gadodiamide (mean, 155 ng/g brain tissue). Gadolinium distribution colocalized with other metals for linear GBCAs and a specific accumulation in the DCN was found. Discussion The current study supports the hypothesis that the amount of gadolinium deposited in the brain is primarily determined by its class as either macrocyclic or linear. The accumulation of gadolinium in the DCN for linear GBCAs explains the hyperintensities in the DCN found in previous patient studies with linear GBCAs. Received for publication January 26, 2019; and accepted for publication, after revision, March 27, 2019. Alexander Radbruch and Henning Richter contributed equally to this study. The study was not supported by any funding. Alexander Radbruch lectures for Guerbet and Bayer, and he is also part of the Advisory Boards for GE, Bracco, and Guerbet. This study was supported by Bayer and Guerbet. For the remaining authors, no conflicts of interest are declared. Correspondence to: Alexander Radbruch, MD, JD, Department of Diagnostic and Interventional Radiology and Neuroradiology, University Clinic Essen, Hufelandstraße 55, 45147 Essen, Germany. E-mail: a.radbruch@dkfz.de. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Computed Tomography Cholangiography Using the Magnetic Resonance Contrast Agent Gadoxetate Disodium: A Phantom Study Objective The purpose of this work is to determine whether low doses of gadoxetate disodium (Eovist; Bayer Healthcare LLC, Whippany, NJ), a gadolinium-based contrast agent used for magnetic resonance liver imaging, can be visualized for computed tomography (CT) cholangiography using a phantom setup. Materials and Methods Vials containing 4 concentrations of gadoxetate disodium (1.9, 3.4, 4.8, and 9.6 mg Gd/mL) were placed in a 35 × 26-cm2 water phantom and imaged on 2 CT scanners: Siemens Somatom Flash and Force (Siemens Healthcare, Erlangen, Germany). These concentrations correspond to the estimated concentration in the bile duct for a 40-, 70-, or 100-kg patient, and twice the concentration of a 100-kg patient, respectively. Single-energy (SE) scans were acquired at 70, 80, 90, 100, 120, and 140 kVp, and dual-energy scans were acquired at 90/150Sn (Force) and 100/150 (Flash) for 2 dose levels (CTDIvol 13 and 23 mGy). Virtual monoenergetic images at 50 keV were created (Mono+; Siemens Healthcare, Erlangen, Germany). The mean intensity and standard deviation for each concentration of gadoxetate disodium and the water background were extracted from each image set and used to compute the contrast and contrast-to-noise ratio (CNR). To determine whether the signal provided by gadoxetate disodium was clinically sufficient, the measures were compared with those acquired from 12 clinical CT cholangiography examinations performed with iodine-containing iodipamide meglumine. Results From the retrospective clinical cohort, mean contrast (± standard deviation) of 239 ± 107 HU and CNR of 12.8 ± 4.2 were found in the bile duct relative to the liver. Comparing these metrics to the gadoxetate disodium samples, the highest concentration (9.6 mg Gd/mL) surpassed these thresholds at all energy levels. The 4.8 mg Gd/mL had sufficient CNR in the Force, but not in the Flash. The 3.4 mg Gd/mL had clinically relevant CNR at low kV of SE (<100 kVp) and 50 keV of dual energy in the Force but was insufficient in the Flash. Images acquired by the Force had a lower noise level and greater CNR compared with the Flash. Similar trends were seen at both dose levels. Conclusions Gadoxetate disodium shows promise as a viable contrast agent for CT cholangiography, with CNR similar to those seen clinically with an iodine-based contrast agent. Dual-energy CT or low kV SE-CT is helpful to enhance the signal. Received for publication February 14, 2019; and accepted for publication, after revision, April 9, 2019. Selected sections presented during oral presentation at the RSNA Annual Meeting in November 2018. Conflicts of interest and sources of funding: Drs McCollough and Fletcher receive grant support given to our institution from Siemens Healthineers, the manufacturer for the computed tomography scanners used in this study. For the remaining authors, none were declared. No funding was provided for this work. Correspondence to: Lifeng Yu, PhD, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail: yu.lifeng@mayo.edu. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Can Virtual Contrast Enhancement in Brain MRI Replace Gadolinium?: A Feasibility Study Objectives Gadolinium-based contrast agents (GBCAs) have become an integral part in daily clinical decision making in the last 3 decades. However, there is a broad consensus that GBCAs should be exclusively used if no contrast-free magnetic resonance imaging (MRI) technique is available to reduce the amount of applied GBCAs in patients. In the current study, we investigate the possibility of predicting contrast enhancement from noncontrast multiparametric brain MRI scans using a deep-learning (DL) architecture. Materials and Methods A Bayesian DL architecture for the prediction of virtual contrast enhancement was developed using 10-channel multiparametric MRI data acquired before GBCA application. The model was quantitatively and qualitatively evaluated on 116 data sets from glioma patients and healthy subjects by comparing the virtual contrast enhancement maps to the ground truth contrast-enhanced T1-weighted imaging. Subjects were split in 3 different groups: enhancing tumors (n = 47), nonenhancing tumors (n = 39), and patients without pathologic changes (n = 30). The tumor regions were segmented for a detailed analysis of subregions. The influence of the different MRI sequences was determined. Results Quantitative results of the virtual contrast enhancement yielded a sensitivity of 91.8% and a specificity of 91.2%. T2-weighted imaging, followed by diffusion-weighted imaging, was the most influential sequence for the prediction of virtual contrast enhancement. Analysis of the whole brain showed a mean area under the curve of 0.969 ± 0.019, a peak signal-to-noise ratio of 22.967 ± 1.162 dB, and a structural similarity index of 0.872 ± 0.031. Enhancing and nonenhancing tumor subregions performed worse (except for the peak signal-to-noise ratio of the nonenhancing tumors). The qualitative evaluation by 2 raters using a 4-point Likert scale showed good to excellent (3–4) results for 91.5% of the enhancing and 92.3% of the nonenhancing gliomas. However, despite the good scores and ratings, there were visual deviations between the virtual contrast maps and the ground truth, including a more blurry, less nodular-like ring enhancement, few low-contrast false-positive enhancements of nonenhancing gliomas, and a tendency to omit smaller vessels. These "features" were also exploited by 2 trained radiologists when performing a Turing test, allowing them to discriminate between real and virtual contrast-enhanced images in 80% and 90% of the cases, respectively. Conclusions The introduced model for virtual gadolinium enhancement demonstrates a very good quantitative and qualitative performance. Future systematic studies in larger patient collectives with varying neurological disorders need to evaluate if the introduced virtual contrast enhancement might reduce GBCA exposure in clinical practice. Received for publication March 9, 2019; and accepted for publication, after revision, April 15, 2019. The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.investigativeradiology.com). Correspondence to: Jens Kleesiek, PhD, MD, Division of Radiology, German Cancer Research Center, Im Neuenheimer Feld 223, 69120 Heidelberg, Germany. E-mail: j.kleesiek@dkfz.de. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Real-Time Magnetic Resonance Imaging: Radial Gradient-Echo Sequences With Nonlinear Inverse Reconstruction Objective The aim of this study is to evaluate a real-time magnetic resonance imaging (MRI) method that not only promises high spatiotemporal resolution but also practical robustness in a wide range of scientific and clinical applications. Materials and Methods The proposed method relies on highly undersampled gradient-echo sequences with radial encoding schemes. The serial image reconstruction process solves the true mathematical task that emerges as a nonlinear inverse problem with the complex image and all coil sensitivity maps as unknowns. Extensions to model-based reconstructions for quantitative parametric mapping further increase the number of unknowns, for example, by adding parameters for phase-contrast flow or T1 relaxation. In all cases, an iterative numerical solution that minimizes a respective cost function is achieved with use of the iteratively regularized Gauss-Newton method. Convergence is supported by regularization, for example, to the preceding frame, whereas temporal fidelity is ensured by downsizing the regularization strength in comparison to the data consistency term in each iterative step. Practical implementations of highly parallelized algorithms are realized on a computer with multiple graphical processing units. It is "invisibly" integrated into a commercial 3-T MRI system to allow for conventional usage and to provide online reconstruction, display, and storage of regular DICOM image series. Results Depending on the application, the proposed method offers serial imaging, that is, the recording of MRI movies, with variable spatial resolution and up to 100 frames per second (fps)—corresponding to 10 milliseconds image acquisition times. For example, movements of the temporomandibular joint during opening and closing of the mouth are visualized with use of simultaneous dual-slice movies of both joints at 2 × 10 fps (50 milliseconds per frame). Cardiac function may be studied at 30 to 50 fps (33.3 to 20 milliseconds), whereas articulation processes typically require 50 fps (20 milliseconds) or orthogonal dual-slice acquisitions at 2 × 25 fps (20 milliseconds). Methodological extensions to model-based reconstructions achieve improved quantitative mapping of flow velocities and T1 relaxation times in a variety of clinical scenarios. Conclusions Real-time gradient-echo MRI with extreme radial undersampling and nonlinear inverse reconstruction allows for direct monitoring of arbitrary physiological processes and body functions. In many cases, pertinent applications offer hitherto impossible clinical studies (eg, of high-resolution swallowing dynamics) or bear the potential to replace existing MRI procedures (eg, electrocardiogram-gated cardiac examinations). As a consequence, many novel opportunities will require a change of paradigm in MRI-based radiology. At this stage, extended clinical trials are needed. Received for publication March 25, 2019; and accepted for publication, after revision, April 25, 2019. Conflicts of interest and sources of funding: The authors hold a patent and software knowhow about the real-time magnetic resonance imaging technique used here. M.U. gratefully acknowledges financial support by the German Centre for Cardiovascular Research. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.investigativeradiology.com). Correspondence to: Jens Frahm, PhD, Biomedizinische NMR, Max-Planck-Institut für Biophysikalische Chemie, Am Fassberg 11, 37070 Göttingen, Germany. E-mail: jfrahm@gwdg.de. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Multiparametric Quantitative MRI for the Detection of IgA Nephropathy Using Tomoelastography, DWI, and BOLD Imaging Objectives The aim of this study was to noninvasively evaluate changes in renal stiffness, diffusion, and oxygenation in patients with chronic, advanced stage immunoglobulin A nephropathy (IgAN) by multiparametric magnetic resonance imaging using tomoelastography, diffusion-weighted imaging (DWI), and blood oxygen level–dependent (BOLD) imaging. Materials and Methods In this prospective study, 32 subjects (16 patients with biopsy-proven IgAN and 16 age- and sex-matched healthy controls) underwent multifrequency magnetic resonance elastography with tomoelastography postprocessing at 4 frequencies from 40 to 70 Hz to generate shear wave speed (meter per second) maps reflecting tissue stiffness. In addition, DWI and BOLD imaging were performed to determine the apparent diffusion coefficient in square millimeter per second and T2* relaxation time in milliseconds, respectively. Regions including the entire renal parenchyma of both kidneys were analyzed. Areas under the receiver operating characteristic (AUCs) curve were calculated to test diagnostic performance. Clinical parameters such as estimated glomerular filtration rate and protein-to-creatinine ratio were determined and correlated with imaging findings. Results Success rates of tomoelastography, DWI, and BOLD imaging regarding both kidneys were 100%, 91%, and 87%, respectively. Shear wave speed was decreased in IgAN (−21%, P < 0.0001), accompanied by lower apparent diffusion coefficient values (−12%, P = 0.004). BOLD imaging was not sensitive to IgAN (P = 0.12). Tomoelastography detected IgAN with higher diagnostic accuracy than DWI (area under the curve = 0.9 vs 0.8) and positively correlated with estimated glomerular filtration rate (r = 0.66, P = 0.006). Conclusions Chronic, advanced stage IgAN is associated with renal softening and restricted water diffusion. Tomoelastography is superior to DWI and BOLD imaging in detecting IgAN. Received for publication February 16, 2019; and accepted for publication, after revision, April 25, 2019. Conflict of interest and sources of funding: This study was supported by the German Federal Ministry of Education and Research (LiSyM 031 L0057 to I.S.) and the German Research Foundation (DFG GU 1726/1-1 to J.G., BIOQIC GRK 2260 to I.S., SFB 1340 to B.H., I.S., J.B., and J.G.). Correspondence to: Stephan Rodrigo Marticorena Garcia, MD, Department of Radiology, Charité – Universitätsmedizin Berlin, coporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany. E-mail: stephan.marticorena-garcia@charite.de. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Magnetization Transfer Imaging Is Unaffected by Decreases in Renal Perfusion in Swine Objectives Multiparametric renal magnetic resonance imaging (MRI), including diffusion-weighted imaging, magnetic resonance elastography, and magnetization transfer imaging (MTI), is valuable in the noninvasive assessment of renal fibrosis. However, hemodynamic changes in diseased kidneys may impede their ability to measure renal fibrosis. Because MTI assesses directly tissue content of macromolecules, we test the hypothesis that MTI would be insensitive to renal hemodynamic changes in swine kidneys with acute graded ischemia. Materials and Methods Seven domestic pigs underwent placement of an inflatable silicone cuff around the right renal artery to induce graded renal ischemia. Multiparametric MRI was performed at baseline, 50%, 75%, and 100% renal artery stenosis as well as reperfusion. Measurements included regional perfusion, R2*, apparent diffusion coefficient (ADC), stiffness, and magnetization transfer ratio (MTR) using arterial spin-labeled MRI, blood oxygenation–dependent MRI, diffusion-weighted imaging, magnetic resonance elastography, and MTI, respectively. Histology was performed to rule out renal fibrosis. Results During graded ischemia, decreases in renal perfusion were accompanied with elevated R2*, decreased ADC, and stiffness, whereas no statistically significant changes were observed in the MTR. No fibrosis was detected by histology. After release of the obstruction, renal perfusion showed only partial recovery, associated with return of kidney R2*, ADC, and stiffness to baseline levels, whereas cortical MTR decreased slightly. Conclusions Renal MTI is insensitive to decreases in renal perfusion and may offer reliable assessment of renal structural changes. Received for publication April 4, 2019; and accepted for publication, after revision, May 9, 2019. Conflicts of interest and sources of funding: No conflicts of interest were declared. This study was partly supported by the National Institutes of Health grants DK104273, DK102325, DK120292, HL123160, HL130494, and C06-RR018898. Correspondence to: Lilach O. Lerman, MD, PhD, Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905. E-mail: Lerman.Lilach@mayo.edu. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Can Ex Vivo Magnetic Resonance Imaging of Rectal Cancer Specimens Improve the Mesorectal Lymph Node Yield for Pathological Examination? Purpose The aim of this study was to use 7 T ex vivo magnetic resonance imaging (MRI) scans to determine the size of lymph nodes (LNs) in total mesorectal excision (TME) specimens and to increase the pathological yield of LNs with MR-guided pathology. Materials and Methods Twenty-two fixated TME specimens containing adenocarcinoma were scanned on a 7 T preclinical MRI system with a T1-weighted 3-dimensional gradient echo sequence with frequency-selective lipid excitation (repetition time/echo time, 15/3 milliseconds; resolution, 0.293 mm3) and a water-excited 3-dimensional multigradient echo (repetition time, 30 milliseconds; computed echo time, 6.2 milliseconds; resolution, 0.293 mm3) pulse sequence. The first series of 11 TME specimens (S1) revealed the number and size of LNs on both ex vivo MRI and histopathology. The second series of 11 TME specimens (S2) was used to perform MR-guided pathology. The number, size, and percentages of yielded LNs of S1 and S2 were compared. Results In all specimens (22/22), a median number of 34 LNs (interquartile range, 26–34) was revealed on ex vivo MRI compared with 14 LNs (interquartile range, 7.5–21.5) on histopathology (P = 0.003). Mean size of all LNs did not differ between the 2 series (ex vivo MRI: 2.4 vs 2.5 mm, P = 0.267; pathology: 3.6 vs 3.5 mm, P = 0.653). The median percentages of harvested LNs compared with nodes visible on ex vivo MRI per specimen for both series were not significantly different (40% vs 43%, P = 0.718). By using a size threshold of greater than 2 mm, the percentage improved to 71% (S1) and to 78% (S2, P = 0.895). The median number of harvested LNs per specimen did not increase by performing MR-guided pathology (S1, 14 LNs; S2, 20 LNs; P = 0.532). Conclusions Ex vivo MRI visualizes more LNs than (MR-guided) pathology is able to harvest. Current pathological examination was not further improved by MR guidance. The majority of LNs or LN-like structures visible on ex vivo MRI below 2 mm in size remain unexplained, which warrants a 3-dimensional approach for pathological reconstruction of specimens. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Received for publication January 29, 2019; and accepted for publication, after revision, April 15, 2019. Conflicts of interest and sources of funding: Authors declare no conflicts of interest. This work was supported by the Department of Radiology and Nuclear Medicine at the Radboud University Medical Center. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.investigativeradiology.com). Correspondence to: Rutger Stijns, MD, Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Route 767, Geert Grooteplein Zuid 10, 6525-GA Nijmegen, the Netherlands. E-mail: Rutger.Stijns@Radboudumc.nl. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

How Should We Measure Neurotoxicity of Gadolinium-Based Contrast Agents? No abstract available

Computed Tomography for 4-Dimensional Angiography and Perfusion Imaging of the Prostate for Embolization Planning of Benign Prostatic Hyperplasia Objectives The aim of this study was to evaluate the feasibility of a computed tomography (CT) protocol enabling the visualization of the prostatic artery (PA) before prostatic artery embolization (PAE) in benign prostatic hyperplasia, which provides quantitative perfusion information of the prostate gland. Materials and Methods In this institutional review board–approved study, 22 consecutive patients (mean age, 67 ± 7 years) who were planned to undergo PAE underwent a dynamic CT scan of the pelvis (scan range, 22.4 cm; cycle time, 1.5 seconds; scan time, 44 seconds; 25 scan cycles; 70 kVp; 100 mAs) after the administration of 70 mL of iodinated contrast media (flow rate, 6 mL/s; 10 seconds' delay). Image postprocessing consisted of a spatiotemporal, frequency-depending multiband filtering technique with noise reduction, motion correction, resulting in (1) time-resolved, temporal maximum intensity projection (MIP) images from fusion of multiple arterial time points; (2) 4-dimensional (4D) CT angiography images after bone and calcium plaque removal; and (3) parametric perfusion maps of the prostate. Intraprocedural cone-beam CT was performed with a microcatheter in the PA. In both modalities, the contrast-to-noise ratio of the right internal iliac artery or the PA was calculated, respectively. Visibility of the PA was scored using a Likert scale (score 1 = not seen, to score 4 = intraprostatic PA branches seen). Quantitative perfusion analysis of the dynamic pelvic CT included calculation of the blood flow, blood volume, mean transit time, and flow extraction product. Results The average volume CT dose index and dose length product of CT was 35.7 ± 6.8 mGy and 737.4 ± 146.3 mGy·cm, respectively. Contrast-to-noise ratio of the pelvic vessels on temporal MIP images and cone-beam CT were 45 ± 19 and 69 ± 27, respectively (P < 0.01). The mean visibility score of the PA was 3.6 ± 0.6 for 4D-CT angiography and 3.97 ± 0.2 for cone-beam CT (P < 0.001). The PA was visualized in 100% of 4D-CT angiography examinations, with one PA being visible only proximally. Prostate CT perfusion analysis showed blood flow, blood volume, mean transit time, and flow extraction product values of 27.9 ± 12.5 mL/100 mL/min, 2.0 ± 0.8 mL/100 mL, 4.5 ± 0.5 second, and 12.6 ± 5.4 mL/100 mL/min, respectively, for the whole prostate gland. About half the patients showed a pronounced difference between the lobes. Conclusions We introduced a CT protocol for PAE planning providing excellent visualization of the PA on temporal MIP images and 4D-CT angiography at a reasonable dose and low contrast volume. In addition, quantitative perfusion information is available, which might be useful for outcome prediction after embolization. Received for publication March 11, 2019; and accepted for publication, after revision, April 16, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Hatem Alkadhi, MD, MPH, EBCR, FESER, Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland. E-mail: hatem.alkadhi@usz.ch. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Assessment of Hepatic Perfusion Using GRASP MRI: Bringing Liver MRI on a New Level Purpose The aim of this study was to demonstrate the feasibility of hepatic perfusion imaging using dynamic contrast-enhanced (DCE) golden-angle radial sparse parallel (GRASP) magnetic resonance imaging (MRI) for characterizing liver parenchyma and hepatocellular carcinoma (HCC) before and after transarterial chemoembolization (TACE) as a potential alternative to volume perfusion computed tomography (VPCT). Methods and Materials Between November 2017 and September 2018, 10 patients (male = 8; mean age, 66.5 ± 8.6 years) with HCC were included in this prospective, institutional review board–approved study. All patients underwent DCE GRASP MRI with high spatiotemporal resolution after injection of liver-specific MR contrast agent before and after TACE. In addition, VPCT was acquired before TACE serving as standard of reference. From the dynamic imaging data of DCE MRI and VPCT, perfusion maps (arterial liver perfusion [mL/100 mL/min], portal liver perfusion [mL/100 mL/min], hepatic perfusion index [%]) were calculated using a dual-input maximum slope model and compared with assess perfusion measures, lesion characteristics, and treatment response using Wilcoxon signed-rank test. To evaluate interreader agreement for measurement repeatability, the interclass correlation coefficient (ICC) was calculated. Results Perfusion maps could be successfully generated from all DCE MRI and VPCT data. The ICC was excellent for all perfusion maps (ICC ≥ 0.88; P ≤ 0.001). Image analyses revealed perfusion parameters for DCE MRI and VPCT within the same absolute range for tumor and liver tissue. Dynamic contrast-enhanced MRI further enabled quantitative assessment of treatment response showing a significant decrease (P ≤ 0.01) of arterial liver perfusion and hepatic perfusion index in the target lesion after TACE. Conclusions Dynamic contrast-enhanced GRASP MRI allows for a reliable and robust assessment of hepatic perfusion parameters providing quantitative results comparable to VPCT and enables characterization of HCC before and after TACE, thus posing the potential to serve as an alternative to VPCT. Received for publication March 19, 2019; and accepted for publication, after revision, April 18, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Jakob Weiss, MD, Department of Diagnostic and Interventional Radiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany. E-mail: Jakob.Weiss@uni-tuebingen.de. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Craniofacial Surgery

The Surgical Treatment of a Large Cortical Atherosclerotic Middle Cerebral Artery Aneurysm Presenting With Parietal Lobe Infarction Distal MCA aneurysms are rarely seen in daily neurosurgical practice and they are, more commonly associated with infectious processes. Here, the authors present a 65-year-old, patient who had an atherosclerotic M4 segment located aneurysm. It was confirmed, that the aneurysm was not related with any infectious process. The patient had, presented clinically by a parietal infarction and she had been successfully operated. The neuronavigation system for this particular case aided us for a precise localization of the aneurysm and gave a chance for a smaller craniotomy. Address correspondence and reprint requests to Gulden Demirci Otluoglu, MD, Merdivenkoy Mah. 23 Nisan Sk. No: 17, 34732. Kadiköy, Istanbul, Turkey; E-mail: guldendemirci@gmail.com Received 16 April, 2019 Accepted 4 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Anatomical Location of the Infraorbital Foramen in Infant Dry Skulls: Implications for Cleft Surgery Background: Infraorbital foramen (IOF) is an important anatomical landmark in cleft lip surgery. The location of IOF within the maxilla of infants is different from adults. However, little information about anatomy of IOF in infants exists in the literature. This study aims to determine the location of IOF in infant dry skulls based on key surgical landmarks. Methods: All dry skulls under age 2 years old were selected from the Hamann-Todd Human Osteological Collection at the Cleveland Museum of Natural History (Cleveland, OH). Specimens without cranial bones or complete maxilla were excluded. Seven anatomical measurements were taken on each side of the face for each individual skull (14 measurements for each skull). Anatomical landmarks used for the measurements included infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary buttress, anterior nasal spine (ANS), and inferolateral corner of the aperture piriformis. Results: Twenty-seven halves of 14 dry skulls were included in the final analysis. The mean age of specimens was 0.57 years. Mean distances from infraorbital foramen to infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary, and ANS buttress were 4.11 ± 0.82, 9.4 ± 1.62, 12.7 ± 2.71, 11.7 ± 1.54, and 18.4 ± 2.11 mm, respectively. Conclusion: This study also shows that the infraorbital foramen in infants is located at the level of the ANS or within 2 mm higher and that the distance between the infraorbital rim and foramen is only 3 to 4 mm. These findings should be applied to the cleft population with discretion. Address correspondence and reprint requests to Fatma Betul Tuncer, MD, 30 N 1900 E Rm, Salt Lake City, UT 84132; E-mail: fatma.tuncer@hsc.utah.edu, fbetultuncer@gmail.com Received 17 February, 2019 Accepted 22 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Characteristics of Lower Eyelid "Reverse Ptosis" After Reconstruction of Orbital Floor Wall Fracture Using Transconjunctival Approach The purpose of this study was to evaluate the changes of lower eyelid position and the incidence of reverse ptosis after reconstruction of orbital floor fracture. The authors retrospectively reviewed the clinical records of patients who received reconstruction of orbital floor wall fractures between 2014 and 2017. Digital photographs were taken preoperatively, and at 1 week, 1 month, and 3 months postoperatively. Main measurements were marginal reflex distance 2 (MRD 2), which was measured by analyzing the digital photographs using ImageJ software. Among 264 patients with orbital wall fracture, The authors enrolled 32 eyes (18 right eyes and 14 left eyes) of 32 patients (21 males and 11 females) with a mean age of 32.1 years (range, 16–57 years). 7 (21.9%) of 32 patients had reverse ptosis at postoperative 3 months. When MRD2 of affected eye was compared based on the fellow eye, 7 patients with reversed ptosis showed a definite MRD 2 decrease (>1 mm) of affected eye from postoperative 1 month. Age showed a significant negative correlation with the difference of MRD2 between affected and fellow eye at postoperative 1 and 3 months (r = −0.378, P = 0.033 and r = −0.372, P = 0.036, respectively). Postoperative complications were not observed in all patients. The transconjunctival access in orbital floor wall surgery is a safe and useful surgical approach. However, some may have a reverse ptosis postoperatively, especially older patients. Reverse ptosis is a major clinical finding that should not be overlooked in post-operative follow-up. Address correspondence and reprint requests to Sehyun Baek, Department of Ophthalmology, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul 02841, Korea; E-mail: shbaek6534@korea.ac.kr Received 8 October, 2018 Accepted 8 May, 2019 Conception and design of the study, conduct of study, collection and management of data, data analysis, data interpretation, preparation, review, and approval of the manuscript by JP, SK, and SB. The study was approved by the Institutional Review Board of Korea University Guro Hospital. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Brow Ptosis: Is Transblepharoplasty Internal Browpexy Suitable for Everyone? Purpose: Transcutaneous internal browpexy can provide patients with mild-to-moderate lateral brow ptosis, stabilization and modest lift of the lateral brow. Questions regarding effectiveness of this procedure and appropriate indications remain. Methods: The authors measured consecutive patients who underwent upper eyelid blepharoplasty with transblepharoplasty internal browpexy (TIB) September 2014 to December 2017. Pre- and postoperative brow elevation was assessed based on before and after photographs of each patient. Patient photographs were assessed for medial and lateral brow elevation, brow contouring and asymmetry. Optimal lateral brow elevation was classified as bilateral symmetrical and above the supraorbital rim for women, and symmetrical and at the supraorbital rim for men. Results: A total of 239 patients underwent bilateral TIB and 39 underwent unilateral TIB (517 eyelids in total). Pre- and post-operative measurements were taken in 98 patients (41%), with an average elevation of the lateral brow position of 2.54 mm. Six patients had an underlying infection in the first postoperative week that resolved completely. Three patients underwent a second stage direct brow lift repair and 3 needed unrecognized ptosis repair as a second stage. Conclusions: Transblepharoplasty internal browpexy is an important tool that can be used in most patients with lateral and central brow ptosis, asymmetric brow ptosis and irregular contour of the brow. Additionally, browpexy adds to the success and longevity of upper blepharoplasty, while preventing early recurrence of lateral upper eyelid hooding. Patients with significant ptosis, heavy brows, medial greater than lateral ptosis, and post-facial palsy may not be good candidates for this procedure. Address correspondence and reprint requests to Arie Y. Nemet, MD, Department of Ophthalmology, Meir Medical Center, Kfar Sava, Israel; E-mail: nemet.arik@gmail.com Received 27 December, 2018 Accepted 24 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Incidence of Preventable Nonfatal Craniofacial Injuries and Implications for Facial Transplantation Introduction: The number of patients who may benefit from evaluation for face transplantation in the United States (US) remains largely unknown. The goal of our study was to better delineate the pool of patients who might benefit from face transplant evaluation based on the characteristics and mechanisms of injury of previously reported face transplant recipients. Methods: The authors utilized data from the National Electronic Injury Surveillance System-All Injury Program in this study. The US Census Bureau data were used for population estimates. Inclusion and exclusion criteria were determined based on the characteristics of face transplant recipients to date, and the mechanisms of injury they sustained ultimately necessitating face transplantation. Statistical significance was reached if P <0.05. Results: The estimated annual incidence of preventable craniofacial injuries from firearms (44,266–58,299; 31.7% increase), burns (5712–19,433; 240.2% increase), and animal attacks (5355–14,666; 173.9% increase) increased from 2005 to 2014, whereas the estimated annual incidence of craniofacial injuries from machinery (3927–2933; 25.3% decrease) decreased between 2005 and 2014. The authors estimate the annual incidence rate to fall between 32.1 per 100,000 and 58.1 per 100,000 among individuals aged 20 to 64 in the US. Conclusion: In this study, the authors estimate the annual incidence rate of individuals aged 20 to 64 in the US who may benefit from face transplant evaluation and believe that this quantification has the potential to initiate actionable discussions regarding geographical and financial factors affecting access to care in this patient population. Address correspondence and reprint requests to Eduardo D. Rodriguez, MD, DDS, Hansjörg Wyss Department of Plastic Surgery, Helen L. Kimmel Professor of Reconstructive Plastic Surgery NYU Langone Health, 305 East 33rd Street, New York City, NY, 10016; E-mail: Eduardo.Rodriguez@nyumc.org Received 7 November, 2018 Accepted 8 May, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Application of a Layered Muscle Flap Technique for the Reconstruction of the Cupid's Bow and Vermilion in the Repair of Secondary Cleft Lip Deformities In the repair of unilateral cleft lip, the Cupid's bow, and vermilion on the affected side are sometimes lowered excessively. Methods involving skin and mucosa flaps have been used to correct this issue, but they pose some risk of scarring. The authors here describe a layered muscle flap technique that was based on the anatomical research of nasal-labial muscles, especially the levator labii superioris alaeque nasi muscle. This technique can be used to suspend the Cupid's bow and vermilion in secondary unilateral cleft lip repair. Forty-five patients with secondary unilateral cleft lip with excessively lowered Cupid's bows and vermilion on the affected side were included in this study, which lasted 3 years. These patients were treated using the layered muscle flap surgical technique. The heights of specific bilateral landmarks were measured on patient photos and used to define the symmetry of bilateral Cupid's bow and vermilion. The comparison between post-operative and pre-operative symmetries was used to evaluate the post-operative results, and most of them were satisfactory. The results were also mostly well retained in follow-up investigations. This layered muscle flap technique could be effective in selected cases. Address correspondence and reprint requests to Bin Guo, MD, Department of Stomatology, General Hospital of Chinese People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, China; E-mail: guobin0408@126.com Received 17 August, 2018 Accepted 8 May, 2019 This work did not receive funding from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI) and other(s). The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Patient-Specific Reconstruction Utilizing Computer Assisted 3D Modelling for Partial Bone Flap Defect in Hybrid Cranioplasty Purpose: Decompressive craniectomy is a life-saving procedure in the setting of malignant brain swelling. Patients who survive require cranioplasty for anatomical reconstruction and cerebral protection. Autologous cranioplasty remains the commonest practice nowadays, but partial bone flap defects are frequently encountered. The authors, therefore, seek to develop a new technique of reconstruction for cranioplasty candidate with partial bone flap defect utilizing computer-assisted 3D modeling and printing. Methods: A prospective study was conducted to evaluate the outcome of a new reconstruction technique that produces patient-specific hybrid polymethyl methacrylate-autologous cranial implant. Computer-assisted 3D modeling and printing was utilized to produce patient-specific molds, which allowed real-time reconstruction of bone flap with partial defect intra-operatively. Results: Outcome assessment for 11 patients at 6 weeks and 3 months post-operatively revealed satisfactory implant alignment with favorable cosmesis. The mean visual analog scale for cosmesis was 91. Mean implant size was 50cm2, and the mean duration of intra-operative reconstruction was 30 minutes. All of them revealed improvement in quality of life following surgery as measured by the SF-36 score. Cost analysis revealed that this technique is more cost-effective compared to customized cranial prosthesis. Conclusion: This new technique and approach produce hybrid autologous-alloplastic bone flap that resulted in satisfactory implant alignment and favorable cosmetic outcome with relatively low costs. Address correspondence and reprint requests to Peh Hueh Low, MBBS, MS, Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia; E-mail: peh.hueh@gmail.com; Dasmawati Mohamad, PhD, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan, Universiti Sains Malaysia, Malaysia; E-mail: dasmawati@usm.my Received 22 March, 2019 Accepted 7 May, 2019 This study was supported by the Universiti Sains Malaysia (USM) Research University Grant (RUT grant) (1001/PPSG/852004) from Universiti Sains Malaysia (USM), Kubang Kerian, Kelantan, Malaysia. The third author was supported by USM fellowship scheme. The authors of this manuscript have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript. The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

The Healthcare Cost of Mandibular Nonunions The aim of this retrospective cohort study was to compare the costs and characteristics between isolated mandible fractures and mandibular nonunions. From October 2015 to December 2016, the National Inpatient Sample (NIS) was searched for patients admitted with a primary diagnosis of a mandible fracture. The sample was divided between those admitted for an initial evaluation of an isolated fracture and a fracture nonunion. Demographic descriptors, injury characteristics, and inpatient factors were recorded. A total of 1432 patients were included in the final sample, of whom 51 (3.6%) were admitted for a nonunion. Nonunion patients were significantly older (P < 0.01), and nonunions were more often localized to the body (24 vs 11%; P = 0.02). Compared to that of isolated fractures, a greater proportion of nonunions required open reduction and internal fixation (86 vs 59%; P < 0.01) and bone grafting (37 vs 1.4%; P < 0.01), and nonunions imparted +32.6% greater hospitals costs (median: $10,680 vs 14,162; P < 0.01). In conclusion, compared to isolated mandible fractures, mandibular nonunions occurred in older patients, had a higher frequency in body of the mandible, and utilized significantly more hospital resources per admission. Address correspondence and reprint requests to Kevin C. Lee, DDS, MD, 630 West 168th Street, New York, NY 10032; E-mail: kcl2136@cumc.columbia.edu Received 4 March, 2019 Accepted 25 April, 2019 There are no conflicts of interest declared by any of the authors. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Evaluation of the Foramen Magnum Area Calculated by Different Methods: A Radioanatomic Study Purpose: The main objective of the study was to evaluate the probable diversity in the area of the foramen magnum (FM) calculated by different measuring methods. Methods: The study was conducted on 24 dry skulls, present in the collection of the Anatomy Department, Faculty of Medicine, Mersin University. The area of FM was calculated by different measurement methods including automatic field setting, Teixeria and Radinsky formulas obtained from anatomic (ASM), photographic (PSM) and radiologic (RSM) skull measurements. Results: The areas of FMs calculated by Teixeria formula in RSM, PSM, and ASM were as follows: 857.96 ± 99.97 mm2, 796.68 ± 105.08 mm2, and 820.86 ± 96.40 mm2, respectively. The areas calculated by Radinsky formula in RSM, PSM, and ASM were as follows: 851.37 ± 99.68 mm2, 792.63 ± 104.18 mm2, and 814.85 ± 94.99 mm2, respectively. Lastly, the areas calculated by the automatic field setting of RSM and PSM software were as follows: 799.75 ± 103.38 mm2 and 752.83 ± 105.60 mm2, respectively. Conclusion: Statistical significance was observed between the areas of FM obtained from RSM, ASM, and PSM when calculated by the automatic field setting, Teixeria formula, and Radinsky formula. The authors think that considering the amorphous shape of FM, the automatic field setting of the software should be used to obtain the most accurate numerical data related to the area of FM. Address correspondence and reprint requests to Orhan Beger, Mersin University Faculty of Medicine, Department of Anatomy, Ciftlikkoy Campus, 33343, Mersin, Turkey; E-mail: obeger@gmail.com Received 27 February, 2019 Accepted 12 May, 2019 The authors declare no conflict of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Surgical Management of Large Odontogenic Cysts of the Mandible Introduction: Odontogenic cysts are defined as those cysts that arise from odontogenic epithelium and occur in the tooth-bearing regions of the jaws. Cystectomy, marsupialization, or decompression of odontogenic cyst are the most common treatments proposed for this pathology. The aim of this study is to retrospectively evaluate the result of decompression based on the volumetric reduction of the cystic cavity and new bone formation by cone beam computerized tomography (CBCT). Methods: The 16 patients affected by a large odontogenic mandibular cyst were enrolled in the study. All the patients underwent a surgical decompression of the cyst followed by the enucleation after a follow-up ranging from 6 to 9 months according to the volume's reduction and new bone formation. All the patients were evaluated with a CBCT before and after the surgical decompression to measure and analyze the percentage of reduction of the cystic volume before proceeding with the enucleation. Results: The decompression of the cyst showed a reduction of the cystic volume ranging from 38.2% to 54.4% proportionally to the treatment duration. The highest percentage of volume reduction observed was 54.4% in 1 patient followed-up for 9 months, before the surgical enucleation. Conclusion: In our experience, the decompression seems to be the most suitable technique for the primary treatment of large odontogenic cyst of the jaws followed by the enucleation after 6 to 9 months. The CBCT is an objective method to evaluate the cystic volume reduction after the decompression and helps the surgeon with the surgical planning. Address correspondence and reprint requests to Giovanni Dell'Aversana Orabona, Via Pansini 5, Naples, Italy; E-mail: dellaversana@unina.it Received 2 April, 2019 Accepted 9 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Trauma and Acute Care Surgery

LESSER SAC FLUID AFTER BLUNT TRAUMA No abstract available

Execute on the Vision: Pyramids and Mirages in Shifting Sands No abstract available

Patients with Acute Cholecystitis Should be Admitted to a Surgical Service Background In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis. Methods Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. 190 lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay, time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost. Results Patients admitted to surgical (n=106) versus medical (n=84) service had shorter mean LOS (1.4 vs 2.6 days), shorter time from admission to surgery (0.4 vs 0.8 days), and shorter time from surgery to discharge (0.8 vs 1.1 days). Surgical service patients had fewer CT (38% vs 56%) and MRI (5% vs 16%) studies. Cholangiography (30 vs 25%) and ERCP (3 vs 8%) rates were similar. Surgical service patients had 39% lower median total costs ($7787 vs $12572). Conclusions Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs. This is a retrospective comparative study without negative criterion and thus Level III evidence. The study type is "Therapeutic/Care Management." Presented at the 88th Annual Meeting of the Pacific Coast Surgical Association, February 17-20, 2017 in Indian Wells, California Ning Lu, Present address: Ryder Trauma Center, Jackson Memorial Hospital, 1800 NW 10th Ave, Miami, FL, 33136 USA Walter L. Biffl, Present address: Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., La Jolla, CA, 92037, USA No conflicts of interest. Funding: There are no sources of funding. Correspondence: Walter L. Biffl, MD, 9888 Genesee Ave., MC LJ601, La Jolla, CA 92037, 858-626-6362, 858-626-6354, Biffl.walter@scrippshealth.org © 2019 Lippincott Williams & Wilkins, Inc.

Evaluation and Management of Abdominal Gunshot Wounds: A Western Trauma Association Critical Decisions Algorithm No abstract available

Predisposed to Failure? The Challenge of Rescue in the Medical Intensive Care Unit Background Medical Intensive Care Unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases. Methods All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality. Results Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p<0.05). Damage control procedures were performed in 64 patients (34%), with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (OR 13.07, 95%CI 2.86,59.79). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (OR 5.13, 95%CI 1.11,23.77). Conclusions Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk. Level of Evidence Level III Prognostic and Epidemiological Name / Address for Correspondence: Alexandra Briggs, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. Tel: 603.650.8050. Fax: 603.650.8030 Presentation: Oral Presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma, September, 2018 in San Diego, California Disclosures: The authors have no conflicts of interest. © 2019 Lippincott Williams & Wilkins, Inc.

Financial Toxicity Is Associated With Worse Physical and Emotional Long-term Outcomes After Traumatic Injury Background Increasing healthcare costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health related quality of life outcomes (HRQOL). The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQOL. Methods Adult patients with an injury severity score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1, 2, 4 and 12 months. Screens for depression and post-traumatic stress syndrome (PTSD) were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time. Results 500 patients were enrolled and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80-85%). Factors independently associated with financial toxicity were lower age (OR 0.96 [0.94-0.98]), and lack of health insurance (OR 0.28 [0.14-0.56]) and larger household size (OR 1.37 [1.06-1.77]). After risk adjustment, patients with financial toxicity had worse HRQOL, and more depression and PTSD in a step-wise fashion based on severity of financial toxicity. Conclusions Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified and interventions to counteract the negative effects should be developed to improve long-term outcomes. Level of Evidence Prognostic/epidemiologic study, level III Corresponding author: Ben L. Zarzaur, MD, MPH, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. zarzaur@surgery.wisc.edu. (608)-265-9574 Funding Sources: Research reported in this publication was supported by the National Institute of General Medical Science of the National Institutes of Health under award number K23GM084427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Conference: Earl G. Young Resident Prize for Clinical Research Competition at the 49th Annual Meeting of the Western Trauma Association, March 03-08, 2019 in Snowmass, Colorado Conflicts of Interest and Source of Funding: None declared © 2019 Lippincott Williams & Wilkins, Inc.

Abdominal pain in an adult with congenital biliary atresia No abstract available

Obesity is Associated with Postinjury Hypercoagulability Background Obesity is linked to hypercoagulability with an increased risk of venous thromboembolic events (VTE) in the uninjured population. Therefore, we hypothesize that obesity (Body Mass Index (BMI) ≥30 kg/m2) is associated with a hypercoagulable state postinjury characterized by increased clot strength and resistance to fibrinolysis. Methods Our prospective Trauma Activation Protocol database includes all trauma activations patients for whom a rapid thrombelastography (TEG) is obtained within 60 minutes postinjury prior to any transfusions. The dataset was then stratified by BMI and subjects with BMI ≥ 30 kg/m2 were compared to those with BMI<30 kg/m2). The following TEG measurements were obtained: activated clotting time (ACT), clot formation rate (angle), maximum clot strength (MA), and % clot lysis 30 min after MA (LY30, %). Fibrinolysis shutdown (SD) was defined as LY30 < 0.6% and hyperfibrinolysis (HF) as LY30 > 7.6%. Continuous variables are expressed as median (IQR). Results Overall, 687 patients were included of whom 161 (23%) had BMI ≥ 30kg/m2 (BMI30). The BMI30 group was older, had a lower proportion of males and of blunt trauma, and were less severely injured. After adjustment for confounders, BMI30 was independently associated with lower odds of MA<55mm (OR 0.28; 95% CI 0.130.60) and of HF (OR 0.31; 95% CI 0.10- 0.97) and higher odds of SD (OR 1.82; 95% CI 1.09-3.05). No independent association was observed with angle<650 (OR 0.57 95% CI 0.30-1.05). While VTEs were more frequent among BMI30 patients (5.0 vs 3.3%), this did not reach significance after confounding adjustment (p=0.11). Conclusion Obesity was protective against diminished clot strength and hyperfibrinolysis, and obesity was associated with an increased risk of fibrinolytic shutdown in severely injured patients. These findings suggest a relative hypercoagulability. Although no difference in VTEs was noted in this study, these findings may explain the higher rate of VTEs reported in other studies. Level of Evidence Level III, retrospective cohort study, prognostic Financial Disclosures: The authors appreciate research support from Haemonetics with shared intellectual property. Presentation history: portions of this manuscript will be presented at the 20th European Congress of Trauma and Emergency Surgery in Prague, Czech Republic, May 7th – 9th Ernest E. Moore MD Member of Western Trauma Association Acknowledgments: Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health (T32 GM008315 and P50 GM049222), The National Heart, Lung, and Blood Institute (UM 1HL 120877) and the Department of Defense (USAMRAA, W81XWH-12-2-0028). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (or other sponsors of the project). Corresponding Author: Angela Sauaia MD, PhD – Address: 13001 E. 17th Place, B119 Bldg 500, E3309 Aurora, CO 80045 Phone: (303) 724-2498, Email: angela.sauaia@ucdenver.edu © 2019 Lippincott Williams & Wilkins, Inc.

RE: Organ injury scaling 2018 update: Spleen, liver, and kidney. No abstract available

Development and validation of a clinical risk calculator for mortality after colectomy for fulminant Clostridium difficile colitis Background Clostridium difficile colitis is an increasingly important cause of morbidity and mortality. FCDC is a severe form of the colitis driven by a significant systemic inflammatory response, and managed with a total abdominal colectomy. Despite surgery, postoperative mortality rates remain high. The aim of this study was to develop a bedside calculator to predict the risk of 30-day postoperative mortality for patients with fulminant Clostridium difficile colitis (FCDC). Methods After Institutional Review Board approval, the ACS-NSQIP database (2005-2015) was used to include adult patients who underwent emergency surgery for FCDC. A priori preoperative predictors of mortality were selected from the literature: age, immunosuppression, preoperative shock, intubation, and laboratory values. The predictive accuracy of different logistic regression models was measured by calculating the area under the receiver-operating characteristic curve. A cohort of 124 patients from Québec was used to validate the developed mortality calculator. Results A total of 557 patients met the inclusion criteria and the overall mortality was 44%. After developing the calculator, no statistically significant differences were found in comparison with the ACS-NSQIP probability of mortality available in the database (AUC 75.61 vs. 75.14, p 0.79). External validation with the cohort of patients from Quebec showed an area under the curve of 74.0% (95%CI 65.0-82.9). Conclusion A clinically applicable calculator using preoperative variables to predict post-operative mortality for patients with FCDC was developed and externally validated. This calculator may help guide preoperative decision-making. Level of Evidence Level III in prognostic and epidemiological study. Study type: Prognostic Corresponding author: Marylise Boutros, MD MSc, 3755 Cote Sainte Catherine Road, G-304, Montreal, Quebec, H3T 1E2, Canada. Tel: 514-340-8222 ex. 3141. Fax: 514-340-7560. mboutros@jgh.mcgill.ca Conflict of Interest: The authors have no conflicts of interest to disclose. Funding: Maria Abou Khalil is a Richard and Edith Strauss fellow for clinician scientists at McGill University and acknowledges this program for the continued support. Maria Abou Khalil has received a General Surgery grant from the American Society of Colon and Rectal Surgeons (2016) and thanks the society for their continued support. Disclaimers: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Presentation information: Presented as a poster at the Annual Meeting of the American College of Surgeons, October 22-26, 2017 in San Diego, CA. © 2019 Lippincott Williams & Wilkins, Inc.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Pediatric Surgery Case Reports

The rare case of a true rectovaginal fistula and its repair Publication date: September 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 48 Author(s): Carly R. Richards, Nicole R. Lafferriere, Sidney M. Johnson Abstract Background Within the spectrum of anorectal malformations, congenital rectovaginal fistulae are a rare but treatable entity. These less common variates can be treated much in the same fashion as other malformations such as imperforate anus or rectovestibular fistulae are repaired. Summary In the case presented here, diagnosis of a rectovaginal fistula was delayed despite repeated examinations until the patient reached a size where the fistula was easily identifiable. The patient had no other anorectal malformation and was otherwise in good health. Her repair was done as a same day surgery and the patient recovered without complication. Conclusion A rectovaginal fistula is a highly unusual clinical entity but one amenable to repair in the same fashion as other similar malformations.

Multicystic adenomatoid hamartoma of the pancreas Publication date: September 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 48 Author(s): Brian D. Hosfield, Britney L. Grayson, Attila Nakeeb, Eric A. Albright, Troy A. Markel Abstract Multicystic adenomatoid hamartoma is an extremely rare tumor of the pancreas, with only 4 other cases reported in the literature. We report a case of a 4-year old boy who presented with an 8 month history of abdominal pain, steatorrhea, and failure to thrive. Work-up showed severe pancreatic insufficiency and a large, multiseptated, cystic mass originating from the head of the pancreas and compressing the duodenum. The child underwent a classic pancreaticoduodenectomy with portal vein reconstruction. He tolerated the procedure well and has been seen in follow-up.

Superior mesenteric artery syndrome after severe head trauma Publication date: September 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 48 Author(s): Jurgita Gailiene, Ausra Lukosiute-Urboniene, Arturas Kilda, Vidmantas Barauskas Abstract Superior mesenteric artery syndrome (SMAS) is a very rare manifestation of duodenal obstruction with the incidence of 0.013–0.3% in adult population, but there are only few reports in the literature concerning children. SMAS can be related to a rapid loss of intraabdominal fat by severe, debilitating illnesses such as malignancy, burn, spinal cord injury, anorexia. As a result, compression of the third duodenal portion by the aorta and the overlying superior mesenteric artery occurs, when the angle formed by these two structures becomes smaller. We present a case of a 17-year-old boy who suffered a severe head trauma during a car accident. He had prolonged confinement in the supine position because of ongoing coma. The SMAS developed due to a progressive weight lost. Upper gastrointestinal Barium contrast study, fibroesophagogastroduodenoscopy (FEGDS), abdomen computed tomography scan (CT) were not specific and only, magnetic resonance imaging (MRI) findings suggested diagnosis of SMAS. As there was no response to the conservative treatment, surgical intervention of duodenojejunostomy was performed. The postoperative period was successful.

Small bowel obstruction secondary to Ascaris lumbricoides in the setting of prior exploratory laparotomy Publication date: August 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 47 Author(s): Cynthia Fata, Fouzia Naeem, Erik R. Barthel Abstract Ascaris lumbricoides is a parasitic roundworm that is transmitted via the fecal-oral route and is endemic in many areas around the world. At the end of its life cycle it resides in the small bowel, and while it can be asymptomatic, large masses of worms can result in intestinal obstruction, volvulus and perforation. While it is a common cause of mechanical obstruction in endemic areas, it is far less so in the developed world, where adhesions and other postoperative mechanical etiologies are more common. We present the case of a young man with a prior history of exploratory laparotomy for trauma, who had recently immigrated from the Philippines, where ascariasis is endemic, to the Central Valley of California in the United States. He presented with a small bowel obstruction, and at laparotomy was noted to have both a proximal Ascaris bezoar as well as a distal anastomotic stricture.

Displaced scapular body fracture treated with operative closed reduction Publication date: August 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 47 Author(s): Michael Ghassibi, Dhanunjay Sarma Boyalakuntla, Sheryl Handler-Matasar Abstract Case A majority of the pediatric scapula fractures sustained are scapular body fractures. There is a lack of literature concerning pediatric scapular body fractures and its management. We report the case of a scapular body fracture with significant angulation, our intraoperative closed reduction axillary fold approach under anesthesia, and the functional and radiologic outcomes post operatively. At 3 month and 2 year follow up, the patient was able to resume normal activities. Imaging demonstrated a completely healed, well aligned scapular body. Conclusions We suggest closed reduction as an option in significantly angulated isolated scapular body fractures.

Severe acquired tracheomalacia caused by a chronic esophageal foreign body Publication date: August 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 47 Author(s): Collin F. Mulcahy, Joseph C. Park, Eva I. Rubio, Allison L. Speer, Andrea Badillo, Maria Pena Abstract A 3-year-old otherwise healthy boy presented with new-onset progressive stridor that began 3 months prior. He was noted to have dyspnea on exertion, inspiratory stridor, and occasional regurgitation of undigested food. Direct laryngoscopy with bronchoscopy revealed tracheomalacia of the cervical trachea with marked compression extending down to 2 cm above the carina. Magnetic resonance imaging, computed tomography, and esophagram confirmed the presence of an esophageal foreign body with extensive inflammatory changes of the cervical and thoracic esophagus with mass effect causing compression on the trachea. Flexible esophagoscopy under sedation revealed a 2.9 cm × 2.5 cm hard plastic toy in the shape of rabbit ears, which was removed. The patient was extubated in the intensive care unit and was quickly advanced to a soft diet. He was asymptomatic at follow up 3 weeks after his procedure. Esophageal foreign bodies usually present with respiratory symptoms or feeding issues due to direct compression, and the presentation is typically acute. The finding of severe tracheomalacia has only been described in a few case reports. This is an unusual case of severe tracheomalacia secondary to a chronic esophageal foreign body.

Pneumatosis intestinalis and pneumoperitoneum secondary to Sapovirus colitis Publication date: August 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 47 Author(s): Thomas O. Xu, Daniel E. Levin Abstract Pneumatosis intestinalis (PI) with pneumoperitoneum are radiographic findings that may be associated with severe bowel compromise. Asymptomatic patients with benign pneumoperitoneum are well described and can typically be observed. Among symptomatic patients, these findings are more concerning and often mandate operative intervention. The common etiologies of PI with pneumoperitoneum in children can typically be determined by history, physical and imaging findings. Viral enteritis and colitis is an infrequent cause. Sapovirus is in the family Caliciviridae. It is similar to norovirus, a more common pathogen in acute gastroenteritis, but typically presents with less severe symptoms. Here, we describe the presentation of an 11 year old, immune competent boy with severe abdominal pain, PI and pneumoperitoneum. Diagnostic laparoscopy revealed viable bowel without the need for resection or diversion. Stool pathogen panel revealed Sapovirus infection. He made a complete recovery. To our knowledge, this is the first description of PI with pneumoperitoneum caused by Sapovirus infection.

Cautery versus laser excision of oral mucocele Publication date: August 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 47 Author(s): Parisa Foroughiasl Abstracts A mucous cyst is a benign cyst which is inside the thin capsule and it contains clear fluid. These masses appear from the disruption of minor salivary gland and it leaks to surrounding tissues. Most commonly it is localized on the lower lip. Mucoceles appear in a respond of traumatic injuries like sucking off the lip, biting lip, and trauma from orthodontic devices. The purpose of this study report is to describe two different methods of surgical excision to remove the mucoceles. In the first case, a standard electrocautery device and in the other case, l divide laser was used to excise the mucocele from the lower lip. Mucocele was removed from a 10-year-old patient with excision by scapale and the second case was 17-year-old patient with a carbon dioxide (CO2) laser. In both cases, excisions were applied after local infiltration with 1.8 ml 2% Lidocaine with 1:100,000 epinephrine. In the first case, the duration of healing was longer, and it affected the quality of life of patient post surgically. In the second case, the healing process was faster, no bleeding and the patient was comforted after a surgical procedure. In the final both cases, wounds healed well without relapse after 1 year.

Endovascular retrieval of difficult to remove port-a-caths Publication date: August 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 47 Author(s): Raghavendra Rao, Francis E. Marshalleck, Alan P. Ladd Abstract Long dwelling central venous lines develop intravenous adhesions or a calcified fibrous sheath causing difficulties in removal. Although such cases are rare, a few cases of endovascular retrieval have been reported in pediatric literature. We report our experience with 6 cases in children with port-a-caths. Transfemoral snare technique was effective in all but 1 patient. The mean age of the in dwelling port-a-caths was 5 years. One patient whose catheter could not be removed has developed no complications after a follow-up of 5 years. Review of literature suggests that while endovascular retrieval is not without risks, leaving a central line in situ has no major disadvantages. Heroic measures to remove such lines should be pursued only when absolutely necessary as in the case of an infected line.

Minimally invasive repair of the severe pectus excavatum in an infant Publication date: August 2019 Source: Journal of Pediatric Surgery Case Reports, Volume 47 Author(s): Muharrem Özkaya, Mehmet Bilgin Abstract Pectus excavatum is the most common congenital chest wall abnormality. Nuss et al., in 1998 described minimally invasive repair of pectus excavatum and this procedure is now the procedure of choice in many institutions for the surgical repair of pectus excavatum. However, since that time the optimal age and indications for surgical repair are still debate. Although there is no age limitation for the procedure, publications regarding the surgical management of infants with pectus deformities are few. We present a case of an 11-month-old girl with severe pectus excavatum who presented with a 3-day history of increasing dyspnea which was present since her birth. During her follow in pediatric intensive care unit she became apneic and underwent intubation. A chest tomography demonstrated pectus excavatum with right main stem bronchial compression and bilateral lower lobe pneumonia. She underwent minimally invasive repair of his pectus excavatum and was extubated on hospital day 10 and was discharged from the hospital on postoperative day 17.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

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