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1.  Pictorial review of normal postoperative cross-sectional imaging findings and infectious complications following laparoscopic appendectomy 
Insights into Imaging  2014;6(1):65-72.
Laparoscopic appendectomy is increasingly accepted as the preferred surgical treatment for acute appendicitis and represents one of the most common emergency operations performed in both adult and paediatric populations. However, in patients with perforated appendicitis laparoscopy is associated with an increased incidence of postoperative intraabdominal infections compared to open appendectomy. Nowadays urgent imaging is commonly requested by surgeons when postoperative complications are suspected. Due to the widespread use of laparoscopy, in hospitals with active surgical practices clinicians and radiologists are increasingly faced with suspected postappendectomy complications. This pictorial essay illustrates the normal cross-sectional imaging findings observed shortly after laparoscopic appendectomy and the spectrum of appearances of iatrogenic intraabdominal infections observed in adults and adolescents, aiming to provide radiologists with an increased familiarity with early postoperative imaging. Emphasis is placed on the role of multidetector CT, which according to the most recent World Society of Emergency Surgery (WSES) guidelines is the preferred and most accurate modality to promptly investigate suspected intraabdominal infections and highly helpful for correct therapeutic choice, particularly to identify those occurrences that require in-hospital treatment, drainage or surgical reintervention. In teenagers and young adults MRI represents an attractive alternative modality to detect or exclude iatrogenic abscesses without ionising radiation.
Teaching points
• Laparoscopic appendectomy is the preferred surgical treatment for uncomplicated acute appendicitis
• In perforated appendicitis laparoscopy results in increased incidence of intraabdominal infections
• Multidetector CT promptly assesses suspected iatrogenic intraabdominal infections
• Interpretation of early postoperative CT requires knowledge of normal postsurgical imaging findings
• Postsurgical infections include right-sided peritonitis, intraabdominal, pelvic or liver abscesses
doi:10.1007/s13244-014-0369-6
PMCID: PMC4330234  PMID: 25431189
Appendectomy; Laparoscopic surgery; Acute appendicitis; Infectious complications; Abscess; Computed tomography (CT); Magnetic resonance imaging (MRI)
2.  Cross-sectional imaging of iatrogenic complications after extracorporeal and endourological treatment of urolithiasis 
Insights into Imaging  2014;5(6):677-689.
Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS) currently represent the mainstay treatment options for the vast majority of patients with urolithiasis, with limited contraindications and high success rates. However, minimally invasive extracorporeal and endourological treatments are associated with a non-negligible morbidity including occasional life-threatening occurrences. These complications represent a source of concern for urologists since they may result in prolonged hospitalisation, need for surgical, endoscopic or interventional treatment, long-term renal impairment, and sometimes even medical malpractice claims. Due to the increasing prevalence of urolithiasis and the large number of therapeutic procedures performed, in hospitals with active urologic practices radiologists are increasingly requested to investigate suspected post-procedural complications following ESWL, PCNL or ureteroscopic stone removal. Based upon our experience, this pictorial essay provides an overview of current extracorporeal and endourological treatment modalities for urolithiasis, including indications and possible complications according to the most recent guidelines from the European Association of Urology (EAU). Afterwards, we review the clinical features and cross-sectional imaging appearances of common and unusual complications with case examples, including steinstrasse, subcapsular, perirenal and suburothelial haemorrhages, severe urinary tract infections (such as pyeloureteritis, pyelonephritis, renal abscesses and pyonephrosis), ureteral injuries and delayed strictures.
Teaching points
• Extracorporeal lithotripsy, percutaneous nephrolitotomy and ureteroscopy allow treating urolithiasis.
• Minimally invasive extracorporeal and endourological treatment have non-negligible morbidity.
• Multidetector CT allows confident assessment of stone-free status and postprocedural complications.
• Main complications include steinstrasse, bleeding, severe infections, ureteral injuries and strictures.
• Imaging triage allows the choice among conservative, surgical, endoscopic or interventive treatment.
doi:10.1007/s13244-014-0355-z
PMCID: PMC4263803  PMID: 25256564
Urolithiasis; Lithotripsy; Ureteroscopy; Complications; Computed Tomography (CT)
3.  Images in medicine: Spontaneous aortocaval fistula complicating abdominal aortic aneurysm 
Aortocaval fistula represents a rare, life-threatening complication of abdominal aortic aneurysm that needs emergency surgical treatment. The presentation couples that of a rupturing aneurysm with other more characteristic features resulting from the massive arteriovenous shunt. Early recognition and emergency surgical treatment are essential in reducing mortality and morbidity. Prompt investigation with multidetector computed tomography (CT) angiography quickly and accurately establishes a precise preoperative diagnosis, thereby enabling proper planning of operative treatment.
doi:10.4103/0974-2700.130888
PMCID: PMC4013731  PMID: 24812461
Aortocaval fistula; abdominal aortic aneurysm; computed tomography (CT); inferior vena cava
4.  Acute nonsteroidal anti-inflammatory drug-induced colitis 
Resulting from direct toxicity on the bowel mucosa, nonsteroidal anti-inflammatory drug (NSAID)-induced colitis is an underestimated although potentially serious condition. Plain abdominal radiographs and multidetector computed tomography allow to identify a right-sided acute colitis with associated pericolonic inflammation, progressively diminished changes along the descending and sigmoid colon, and rectal sparing, consistent with the hypothesized pathogenesis of NSAID colitis. Increased awareness of this condition should reduce morbidity through both prevention and early recognition. High clinical suspicion and appropriate patient questioning, together with consistent instrumental findings, negative biochemistry, and stool investigations should help physicians not to miss this important diagnosis.
doi:10.4103/0974-2700.120389
PMCID: PMC3841543  PMID: 24339669
Colitis; computed tomography; nonsteroidal anti-inflammatory drugs; plain radiographs
5.  Urgent-setting magnetic resonance imaging allows triage of extensive penoscrotal hematoma following blunt trauma 
Although uncommon, blunt trauma to the perineum may cause serious injury to the penis. Differentiation between penile fracture with torn tunica albuginea versus extratunical or cavernosal hematomas is crucial because the former condition needs early surgical repair to avoid future deformity and erectile dysfunction, whereas approach is conservative with even large penoscrotal hematomas with albugineal integrity. Urgent-setting magnetic resonance imaging including multiplanar images of the injured penoscrotal region allows precise identification or exclusion of presence, site, and extent of tears of the tunica albuginea, providing a consistent basis for therapeutic choice.
doi:10.4103/0974-2700.120390
PMCID: PMC3841544  PMID: 24339670
Magnetic resonance imaging; penile fracture; penis; scrotum; testicles; trauma
6.  Multidetector CT imaging of post-robot-assisted laparoscopic radical prostatectomy complications 
Insights into Imaging  2013;4(5):711-721.
Background
Robot-assisted laparoscopic radical prostatectomy (RALRP) is currently accepted as the preferred minimally invasive surgical treatment for localised prostate cancer, with optimal oncologic and functional results. Despite growing surgical experience, reduced postoperative morbidity and hospital stays, RALRP-related complications may occur, which are severe in 5–7 % of patients and sometimes require reoperation. Therefore, in hospitals with an active urologic surgery, urgent diagnostic imaging is increasingly requested to assess suspected early complications following RALRP surgery.
Methods
Based upon our experience, this pictorial review discusses basic principles of the surgical technique, the optimal multidetector CT (MDCT) techniques to be used in the postoperative urologic setting, the normal postoperative anatomy and imaging appearances.
Results
Afterwards, we review and illustrate the varied spectrum of RALRP-related complications including haemorrhage, urinary leaks, anorectal injuries, peritoneal changes, surgical site infections, abscess collections and lymphoceles, venous thrombosis and port site hernias.
Conclusion
Knowledge of surgical procedure details, appropriate MDCT acquisition techniques, and familiarity with normal postoperative imaging appearances and possible complications are needed to correctly perform and interpret early post-surgical imaging studies, particularly to identify those occurrences that require prolonged in-hospital treatment or surgical reintervention.
Teaching points
• Robot-assisted laparoscopic radical prostatectomy allows minimally invasive surgery of localised cancer
• Urologic surgeons may request urgent imaging to assess suspected postoperative complications
• Main complications include haemorrhage, urine leaks, anorectal injuries, infections and lymphoceles
• Correct multidetector CT techniques allow identifying haematomas, active bleeding and extravasated urine
• Imaging postoperative complications is crucial to assess the need for surgical reoperation
doi:10.1007/s13244-013-0280-6
PMCID: PMC3781251  PMID: 24018752
Prostatectomy; Robotic surgery; Laparoscopic surgery; Complications; Haemorrhage; Anastomotic leak; Urine leak; Computed tomography (CT); Cystography
7.  Images in medicine: Diagnosis and pre-surgical triage of transanal rectal injury using multidetector CT with water-soluble contrast enema 
Transanal rectal injuries caused by foreign body insertion, sexual abuse, or iatrogenic procedures represent a very uncommon surgical emergency. Morbidity may be further increased by patient's embarrassment and delayed presentation. Since management decisions largely depend on anatomic and severity assessment, multidetector Computed tomography with rectally administered water-soluble iodinated contrast medium is highly valuable to accurately depict traumatic rectal injuries, and to distinguish between intraperitoneal vs extraperitoneal injuries that require different surgical approaches.
doi:10.4103/0974-2700.115350
PMCID: PMC3746446  PMID: 23960381
Computed tomography; contrast medium enema; foreign body; penetrating rectal trauma; rectal perforation; transanal rectal injury
8.  Early non-aneurysmal infectious aortitis: Cross-sectional imaging diagnosis 
In patients without history of vascular surgery, infectious aortitis is a very uncommon, life-threatening condition with nonspecific clinical manifestations, which exposes the patient to uncontrolled sepsis and to the risk of retroperitoneal rupture. State-of-the-art cross-sectional imaging with contrast-enhanced multidetector computed tomography and magnetic resonance imaging allows confident diagnosis and characterization of unsuspected aortitis in septic patients at an early stage before the development of aneurysmal dilatation. The asymmetric distribution of periaortic inflammatory tissue is helpful for the differentiation of this exceptional disorder from other periaortic abnormalities such as retroperitoneal fibrosis or lymphoma.
doi:10.4103/0974-2700.110811
PMCID: PMC3665067  PMID: 23723629
Aortitis; computed tomography; magnetic resonance imaging; sepsis; Staphylococcus aureus
9.  Spontaneous pneumobilia revealing choledocho-duodenal fistula: A rare complication of peptic ulcer disease 
Spontaneous pneumobilia without previous surgery or interventional procedures indicates an abnormal biliary-enteric communication, most usually a cholelithiasis-related gallbladder perforation. Conversely, choledocho-duodenal fistulisation (CDF) from duodenal bulb ulcer is currently exceptional, reflecting the low prevalence of peptic disease. Combination of clinical data (occurrence in middle-aged males, ulcer history, absent jaundice and cholangitis) and CT findings including pneumobilia, normal gallbladder, adhesion with fistulous track between posterior duodenum and pancreatic head) allow diagnosis of CDF, and differentiation from usual gallstone-related biliary fistulas requiring surgery. Conversely, ulcer-related CDF are effectively treated medically, whereas surgery is reserved for poorly controlled symptoms or major complications.
doi:10.4103/0974-2700.110814
PMCID: PMC3665068  PMID: 23723630
Biliary fistula; duodenal ulcer; peptic ulcer; pneumobilia
10.  Water enema multidetector CT technique and imaging of diverticulitis and chronic inflammatory bowel diseases 
Insights into Imaging  2013;4(3):309-320.
Background
Water enema multidetector computed tomography (WE-MDCT) is currently considered the most accurate imaging modality to provide high-resolution multiplanar visualisation of the colonic wall and surrounding structures.
Methods
This pictorial review presents our experience with WE-MDCT applications outside colorectal tumour staging, particularly for investigating diverticular disease and chronic inflammatory bowel diseases. A detailed explanation of the technique is provided, including patient preparation, the acquisition protocol, and study interpretation.
Results
WE-MDCT allows accurate preoperative visualisation of diverticular disease, acute and complicated diverticulitis. Ulcerative, indeterminate, or Crohn’s colitis can be assessed including longitudinal distribution, mural thickening and enhancement patterns, pseudopolyps, associated perivisceral changes, adjacent organ involvement, and features suggesting carcinoma. Elective WE-MDCT represents a useful complementary technique in patients with impossible, incomplete, or inconclusive endoscopy, can allow study of a stricture’s features and the upstream bowel, and helps planning medical, endoscopic, or surgical treatments.
Conclusion
Urgent WE-MDCT with limited or no bowel preparation may prove useful in acutely symptomatic patients, as it may obviate a risky or contraindicated endoscopy, can determine disease severity, and allows making correct therapeutic choices.
Teaching Points
• Water enema multidetector CT provides high-resolution multiplanar visualisation of the colonic wall.
• WE-MDCT allows accurate visualisation of diverticular disease, acute and complicated diverticulitis.
• In chronic inflammatory bowel diseases WE-MDCT depicts the distribution, mural and perivisceral changes.
• Elective WE-MDCT usefully complements incomplete endoscopy to assess strictures and upstream colon.
• Urgent WE-MDCT with limited or no bowel preparation in acute diseases may obviate endoscopy.
doi:10.1007/s13244-013-0239-7
PMCID: PMC3675246  PMID: 23508934
Contrast enema; Computed tomography (CT); Colonoscopy; Diverticular disease; Acute diverticulitis; Chronic inflammatory bowel diseases; Ulcerative colitis; Crohn’s disease; Indeterminate colitis
11.  Erratum to: MRI and CT of anal carcinoma: a pictorial review 
Insights into Imaging  2013;4(1):63.
doi:10.1007/s13244-013-0221-4
PMCID: PMC3579988  PMID: 23361151
12.  Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography 
Spontaneous esophageal perforation (Boerhaave syndrome) is a very uncommon, life-threatening surgical emergency that should be suspected in all patients presenting with lower thoracic-epigastric pain and a combination of gastrointestinal and respiratory symptoms. Variable clinical manifestations and subtle or unspecific radiographic findings often result in critical diagnostic delays. Multidetector computed tomography complemented with CT-esophagography represents the ideal “one-stop shop” investigation technique to allow a rapid, comprehensive diagnosis of BS, including identification of suggestive periesophageal abnormalities, direct visualization of esophageal perforation and quantification of mediastinitis.
doi:10.4103/0974-2700.106329
PMCID: PMC3589863  PMID: 23493470
Computed tomography; contrast medium; esophagography; esophageal perforation; esophagus
13.  MRI and CT of anal carcinoma: a pictorial review 
Insights into Imaging  2012;4(1):53-62.
Background
Squamocellular anal carcinoma is increasingly diagnosed in patients with risk factors.
Methods
State-of-the-art imaging with magnetic resonance imaging (MRI) using phased-array coils and volumetric multidetector computed tomography (CT) provides detailed visualisation of anal disorders, identification and extent assessment of neoplastic tissue, detection and characterisation of nodal and visceral metastases. MRI has been recommended by the European Society for Medical Oncology (ESMO) as the preferred modality of choice to stage anal cancer, taking into account the maximum tumour diameter, invasion of adjacent structures and regional lymph node involvement.
Results
Cross-sectional imaging techniques allow the identification of coexisting complications, and differentiation from other perineal abnormalities.
Conclusion
Cross-sectional imaging is useful for planning radiotherapy, surgical drainage or salvage abdomino-perineal resection. After chemo-radiotherapy, MRI follow-up provides confident reassessment of therapeutic response, persistent or recurrent disease.
Teaching Points
• Anal carcinoma is increasingly diagnosed in patients with human immunodeficiency virus (HIV), anoreceptive intercourse, chronic inflammatory bowel disease.
• An established association exists with human papillomavirus (HPV) infection and premalignant intra-epithelial dysplasia.
• Phased-array MRI is recommended as the preferred imaging modality for regional staging.
• Imaging allows detection of infectious complications, planning of radiotherapy or salvage surgery.
• Follow-up MRI allows reliable assessment of therapeutic response after chemo-radiotherapy.
doi:10.1007/s13244-012-0199-3
PMCID: PMC3579995  PMID: 23208584
Anal carcinoma; Anus; Human immunodeficiency virus; Chronic inflammatory bowel diseases; Computed Tomography (CT); Magnetic Resonance Imaging (MRI)
14.  Pulmonary cement embolism after pedicle screw vertebral stabilization 
Pulmonary arterial embolization of polymethylmethacrylate cement, most usually occurring after vertebroplasty or kyphoplasty, is very uncommon following vertebral stabilization procedures. Unenhanced CT scans viewed at lung window settings allow confident identification of cement emboli in the pulmonary circulation along with possible associate parenchymal changes, whereas hyperdense emboli may be less conspicuous on CT-angiographic studies with high-flow contrast medium injection. Although clinical manifestations are largely variable from asymptomatic cases to severe respiratory distress, most cases are treated with anticoagulation.
doi:10.4103/0974-2700.99710
PMCID: PMC3440899  PMID: 22988411
Vertebral stabilization; vertebroplasty; pulmonary embolism; polymethylmethacrylate bone cement
15.  Septic thrombophlebitis in a HIV-positive intravenous drug user 
Septic thrombophlebitis of the pelvic veins may occur secondary to non-sterile intravenous drug injection and represents an uncommon yet life-threatening condition, most usually manifesting with persistent spiking fever and limb edema. Risk is further increased in HIV-infected people. High clinical suspicion and prompt imaging assessment with contrast-enhanced multidetector CT are necessary for correct diagnosis and staging, since early treatment prevents further complications such as systemic embolization.
doi:10.4103/0974-2700.99711
PMCID: PMC3440900  PMID: 22988412
Computed tomography; human immunodeficiency virus infection; intravenous drug abuse; sepsis; thrombophlebitis
16.  Mycotic visceral aneurysm complicating infectious endocarditis: Imaging diagnosis and follow-up 
One of the rarest complications of endocarditis, infected (mycotic) aneurysms result from haematogenous dissemination of septic emboli and occur more frequently in patients with cardiac valvular abnormalities or prosthetic valves, intravenous drug abuse, diabetes and immunosuppression conditions such as HIV infection. Although often clinically unsuspected, mycotic aneurysms are potentially life-threatening because of disseminated sepsis and propensity to rupture. Contrast-enhanced multidetector CT provides prompt detection, characterization and vascular mapping of these lesions, allowing correct planning of surgical or interventional therapies and reproducible follow-up. Because of their characteristically unpredictable behaviour, mycotic aneurysms may undergo spontaneous thrombosis, size reduction, rapid enlargement or rupture, therefore strict imaging surveillance with CT and/or color Doppler ultrasound is necessary.
doi:10.4103/0974-2700.96501
PMCID: PMC3391851  PMID: 22787357
Endocarditis; mesenteric artery; mycotic aneurysm; sepsis; visceral aneurysm
17.  Multidetector CT cystography for imaging colovesical fistulas and iatrogenic bladder leaks 
Insights into Imaging  2012;3(2):181-187.
Multidetector computed tomography (MDCT) cystography currently represents the modality of choice to image the urinary bladder in traumatized patients. In this review we present our experience with MDCT cystography applications outside the trauma setting, particularly for diagnosing bladder fistulas and leaks. A detailed explanation is provided concerning exam preparation, acquisition technique, image reconstruction and interpretation. Colovesical fistulas most commonly occur as a complication of sigmoid diverticular disease, and often remain occult after extensive diagnostic work-up including cystoscopy and contrast-enhanced CT. We consistently achieved accurate preoperative visualization of colovesical fistulas using MDCT cystography. Urinary leaks and injuries represent a non-negligible occurrence after pelvic surgery, particularly obstetric and gynaecological procedures: in our experience MDCT cystography is useful to investigate iatrogenic bladder leaks or fistulas. In our opinion, MDCT cystography should be recommended as the first line modality for direct visualization or otherwise confident exclusion of both spontaneous enterovesical fistulas and bladder injuries following instrumentation procedures, obstetric or surgical interventions.
Main Messages
• Explanation of exam preparation, acquisition technique, image reconstruction and interpretation.
• Preoperative visualization of colovesical fistulas, usually secondary to sigmoid diverticulitis.
• Visualization or exclusion of iatrogenic bladder injuries following instrumentation or surgery.
doi:10.1007/s13244-011-0145-9
PMCID: PMC3314733  PMID: 22696044
Computed tomography (CT); Urinary bladder; Urinary bladder fistula; Colonic diverticulitis; Postoperative complications
18.  Multidetector CT cystography for imaging colovesical fistulas and iatrogenic bladder leaks 
Insights into Imaging  2012;3(2):181-187.
Multidetector computed tomography (MDCT) cystography currently represents the modality of choice to image the urinary bladder in traumatized patients. In this review we present our experience with MDCT cystography applications outside the trauma setting, particularly for diagnosing bladder fistulas and leaks. A detailed explanation is provided concerning exam preparation, acquisition technique, image reconstruction and interpretation. Colovesical fistulas most commonly occur as a complication of sigmoid diverticular disease, and often remain occult after extensive diagnostic work-up including cystoscopy and contrast-enhanced CT. We consistently achieved accurate preoperative visualization of colovesical fistulas using MDCT cystography. Urinary leaks and injuries represent a non-negligible occurrence after pelvic surgery, particularly obstetric and gynaecological procedures: in our experience MDCT cystography is useful to investigate iatrogenic bladder leaks or fistulas. In our opinion, MDCT cystography should be recommended as the first line modality for direct visualization or otherwise confident exclusion of both spontaneous enterovesical fistulas and bladder injuries following instrumentation procedures, obstetric or surgical interventions.
Main Messages
• Explanation of exam preparation, acquisition technique, image reconstruction and interpretation.
• Preoperative visualization of colovesical fistulas, usually secondary to sigmoid diverticulitis.
• Visualization or exclusion of iatrogenic bladder injuries following instrumentation or surgery.
doi:10.1007/s13244-011-0145-9
PMCID: PMC3314733  PMID: 22696044
Computed tomography (CT); Urinary bladder; Urinary bladder fistula; Colonic diverticulitis; Postoperative complications
19.  Hemoperitoneum from splenic rupture in an expatriate 
Splenic rupture with hemoperitoneum represents a life-threatening surgical emergency. Malaria should be highly suspected as the probable underlying disease in returning travellers, expatriates, or recent immigrants from endemic countries. Malarial complications involving the spleen occur even with appropriate prophylaxis or during antimalarial therapy. Among them, splenic infarction has a favourable course and is treated conservatively, whereas life-threatening rupture requires immediate or delayed splenectomy. Computed tomography (CT) allows confident differentiation between these two complications by identifying ruptured spleen with clotted hematoma and associated high-density peritoneal effusion; furthermore, CT allows differential diagnosis from other causes of spontaneous hemoperitoneum.
doi:10.4103/0974-2700.93100
PMCID: PMC3299142  PMID: 22416169
Malaria; plasmodium falciparum; splenic rupture; hemoperitoneum

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