Nonoperative treatment of retained radiolucent foreign bodies in lower limbs

The management of radiolucent retained foreign bodies in feet is discussed. Two patients are presented in whom, despite negative initial exploration, cast treatment allowed the foreign bodies to extrude. Six further cases were discovered in a poll of other pediatric orthopedists. Cast treatment is an alternative to further surgery on the foot in search of the foreign body.     

Role of ultrasound in detection of radiolucent foreign bodies in extremities

Removal of foreign bodies from soft tissues in emergency is very challenging and becomes more problematic when it is radiolucent. Blind exploration is sometimes hazardous for patients especially when it is in proximity to a vessel or a nerve or an overlying tendon. The purpose of this study was to determine the accuracy of ultrasonography (USG) in detecting radiolucent soft tissue foreign bodies in the extremities. From January 2014 to January 2016, 120 patients with either a positive history or clinically suspected soft tissue foreign body and negative radiography were evaluated by USG with a high-frequency (13–6 MHz) linear-array transducer. The sonographic findings were used to guide surgical exploration. Out of 120 patients who underwent surgical exploration, USG was positive in 114 cases, and foreign body was retrieved in 108 cases, and among the six cases where USG was negative, foreign body was retrieved from one case. In one case with strong clinical suspicion of foreign body USG was falsely negative. Majority of foreign bodies were removed from foot (69 cases) and hands (26 cases), and rest of foreign bodies were removed from ankle (4 cases), wrist (3 cases), thigh (2 cases), leg (1 case), knee (2 cases), forearm (2 cases). Accuracy, sensitivity, and positive predictive value were determined as 94.16, 99.08, and 94.13%, respectively. The real-time high-frequency USG is a highly sensitive and accurate tool for detecting and removing radiolucent foreign bodies which cannot be visualized by routine radiography.     

16层螺旋CT后处理技术在气管异物检查中的应用

目的探讨16层螺旋CT后处理技术在气管及支气管异物检查中的方法,评价应用价值。方法对32例临床疑为气管、支气管异物的患者进行检查。首先进行常规成像,然后进行二维重建技术:多平面重建(MPR)、曲面重建(CMPR);三维重建技术:最小密度投影(MinIp)、容积再现(VR)及三维显示技术:CT仿真内窥镜(CTVE)等技术方法成像。结果 6例未发现异常,26例误吸异物存在于气管、支气管中。其中位于主气管4例,左主支气管8例,右侧主支气管13例;左、右主气管内均有异物的1例,均获得满意的后重建图像。后重建图像实现单独或联合显示气管、支气管树等结构,并任意切割、旋转及三维解剖测量,较常规图像清楚、直观,显示解剖、异物位置全面、准确。以上病例均行纤维支气管镜检查或临床证实。结论 16层螺旋CT扫描及多种后处理技术的运用是气管、支气管异物准确诊断的方法,无创伤、定位准、简便易行。后重建图像处理技术能很好显示气管、支气管树结构及异物的位置关系,为影像诊断及临床制定科学的方案提供可靠的解剖依据。     

Perioperative management of airway foreign bodies in 35 pediatric patients

We retrospectively reviewed 33 patients (35 cases) who underwent foreign body removal at our institution from 1995 through 2003. Male-female ratio was 21 : 12 and the most frequent age was one year. The most common foreign bodies (FBs) were nuts (n = 14) and plastics (n = 7). A repeater (3 cases) had mental retardation. Patients were referred to our institution with an average interval of 90 hours, and after 1.3 hospitals. All the patients were managed with general anesthesia. Direct laryngoscopy was performed to extract FBs in 11 cases suspected of having pharyngeal or laryngeal FBs. In 24 cases suspected of having tracheobronchial FBs, the trachea was intubated and a flexible fiberoptic bronchoscopy was performed to locate the FBs. FBs were found in the trachea in 2 cases and in the bronchus in 18 patients and were successfully extracted by rigid bronchoscopy in 10 cases. All the patients were admitted for fear of laryngotracheal edema. There were no significant postoperative complications.     

Clinical value of ultrasonography in the detection and removal of radiolucent foreign bodies

A series of 39 consecutive patients with a suspected retained foreign body in the hand and in whom standard soft issue radiographs were negative were examined by real-time, high-resolution ultrasound scan. At operation 20 patients had radiolucent foreign bodies (18 wood, 2 thorns) removed. Ultrasound scan correctly localized 19 of the foreign bodies before surgery and failed to detect one. No foreign body was found in 19 patients. Ultrasound scan falsely predicted the presence of a foreign body in two of these cases. High-resolution ultrasound scanning is a sensitive, accurate technique for diagnosing foreign bodies which are otherwise difficult to demonstrate by conventional radiographic techniques, and provides accurate three-dimensional localization of the object which is of value to the surgeon at operation.     

16层螺旋CT后处理技术诊断食源性食管异物

目的探讨16层螺旋CT后处理技术诊断食管异物的价值。方法对52例临床怀疑食管异物者均行X线平片、食管吞钡棉检查、CT平扫,比较不同方法对异物的检出率,并与食管镜或手术结果进行比较。CT后处理技术包括多平面重建（MPR）、最大密度投影（MIP）、容积再现（VR）等。结果经食管镜或手术证实的28例患者的食管异物为鸡骨、鸭骨、鱼刺等,形态、大小、长度及所在部位各异,均能被16层螺旋CT后处理技术清晰显示,X线平片发现5例,检出率为17.86%,食管吞钡棉检查发现8例,检出率为28.57%。结论16层螺旋CT后处理技术相对于X线平片、食管吞钡棉检查可明显提高食管异物的检出率,并可评价食管损伤程度及周围脓肿、食管气管瘘等并发症的情况及范围。     

Retained foreign bodies and associated risk factors and outcomes in pediatric surgical patients

Background

Retained foreign bodies discovered after surgery are documented as Agency for Health Care Quality and Research Patient Safety Indicators. Our goal was to identify pediatric patient and procedure risk factors and outcomes associated with RFB based on AHRQ Definitions.

Rigid bronchoscopic extraction of radiolucent foreign bodies in children: outcomes of early intervention

Objective

The purpose of this study was to evaluate the role of rigid bronchoscopy in diagnosis and treatment of aspirated radiolucent foreign body (FB) in children.

Patients and method

The study was conducted on 150 children with clinical suspicion of radiolucent tracheobronchial FB aspiration, between January 2011 and September 2013. There were 103 (68.7 %) boys and 47 (31.3 %) girls, with a male-to-female ratio of 2.1:1; their age ranged from 4 to 36 months. Removal of aspirated FB was performed under general anesthesia. Patients with favorable outcome were discharged within 24 h.

Results

The most common clinical findings were cough (70 %), wheezing (54 %), diminished breath sound (64 %), fever (42 %), and dyspnea (27.3 %) and cyanosis (22.7 %). Rigid bronchoscopy for aspirated tracheobronchial FBs was positive in 95.3 %. The extracted FB was organic (peanuts and fruits) in 95.8 %, and the most common location for FB was the right main bronchus (49.6 %). The most sensitive clinical findings were cough (71.3 %), and the most specific findings were wheezing (85.7 %). Wheezing was a statistically significant predictor of the positive FB (odds ratio?=?7.6, CI?=?0.89 to 64.9). There was a statistically insignificant difference in demographic and clinical findings between the two positive groups of bronchial and tracheal FBs. The post-procedural complications were encountered in 7.3 % which included pneumonia (3.3 %), hypoxemia (2.7 %), and pneumothorax (1.3 %). The rate of complications was higher and statistically significant with intravenous anesthesia than with inhalation anesthesia (14.5 versus 3.1 %, respectively).

Conclusion

Removal of radiolucent tracheobronchial FBs in children using rigid bronchoscopy can be performed safely with minimal risks and complications according to type, size, and location of FB. The index of suspicion is raised by careful history and physical examination.     

Bronchoscopic removal of bronchial foreign bodies through the laryngeal mask airway in pediatric patients.

The laryngeal mask airway was used to perform fiberoptic removal of bronchial foreign bodies (peanuts) in two pediatric patients. Laryngeal mask airway offers easy access to the airway, safe respiratory management and direct visualization of the airway during bronchoscopic procedures. Laryngeal mask airway allows the use of larger bronchoscopes than can usually be used for children when bronchoscopy is performed through an endotracheal tube. In each case, the peanuts were removed safely and easily using a Fogarty catheter through the fiberoptic bronchoscope. These cases suggest that laryngeal mask airway is useful in maintaining a secure airway during the removal of bronchial foreign bodies in children.     

Retained foreign bodies during surgery in pediatric patients: a national perspective

Background

Attention has been placed on surgical and medical errors, though there is a lack of data on the frequency of some complications.

Methods

International Classification of Diseases, Ninth Revision, Clinical Modification, code 998.4 and E code 871.0 were used to search a database from the United States.

Results

In the Kids' Inpatient Database 2003, there were 103 reports of retained foreign bodies after surgery (incidence, 0.0031%) with a mean age of 11.5 years. There was a wide range between the 36 states sampled. Total charges for a patient with this complication are $56,683 (95% confidence interval, $41,327-$72,039); mean length of stay is 10.5 days. There is an increased charge of $42,077 in patients who have this complication (P < .0001). Of the cases, 74% occurred at teaching institutions.

Conclusions

On a national perspective in the United States, the rate of a retained foreign body is 0.0031% or approximately 1 in 32,672 cases and is associated with an increased charge of $42,077 for this complication. Comparative data demonstrate that pediatric surgery in the United States is exceptionally safe with regard to retained foreign bodies.     

多层螺旋CT扫描在原发性小肠肿瘤诊断中的价值

目的评价多层螺旋CT对原发性小肠肿瘤的诊断价值及其临床意义。方法回顾性分析19例经X线检查及病理证实的原发性小肠肿瘤（十二指肠和壶腹周围肿瘤除外）的临床资料，并对术前影像学资料（全消化道钡餐X线造影、CT、B超检查）进行对比分析。结果本组19例原发性小肠肿瘤中小肠腺癌9例，间质瘤5例，恶性淋巴瘤4例，腺瘤1例，阳性检出比分别为：CT为79％；超声为16％；全消化道钡餐X线造影42％。多层螺旋CT对小肠肿瘤的检出率明显优于X线钡餐造影和超声，（P〈0．05或P〈0．01）。结论多层螺旋CT对小肠原发性肿瘤的诊断具有重要价值，已成为目前检查小肠原发性肿瘤最主要的方法。     

Bronchoscopic removal of bronchial foreign bodies through the laryngeal mask airway in pediatric patients

The laryngeal mask airway was used to perform fiberoptic removal of bronchial foreign bodies (peanuts) in two pediatric patients. Laryngeal mask airway offers easy access to the airway, safe respiratory management and direct visualization of the airway during bronchoscopic procedures. Laryngeal mask airway allows the use of larger bronchoscopes than can usually be used for children when bronchoscopy is performed through an endotracheal tube. In each case, the peanuts were removed safely and easily using a Fogarty catheter through the fiberoptic bronchoscope. These cases suggest that laryngeal mask airway is useful in maintaining a secure airway during the removal of bronchial foreign bodies in children.     

Retrospective analysis of incidental non-trauma associated findings in severely injured patients identified by whole-body spiral CT scans

Background

Whole-body Computed Tomography (CT) scan today is considered a crucial imaging technique in the diagnostic work-up of polytrauma patients implicating a potential survival benefit. Apart from prompt identification of life threatening injuries this imaging technique provides an additional benefit by diagnosing incidental non-trauma associated medical diseases. These incidental findings might be also life threatening and warrant urgent therapy. The downside of whole-body CT is a relatively high radiation exposure that might result in an increased life time cancer risk. The aim of this study was to investigate the frequency and type of non trauma associated incidental medical findings in relation to patient age and potential clinical relevance.

Methods

Between January 1^st 2011 and December 15th 2012, a total of 704 trauma patients were referred to our hospital’s emergency room that triggered trauma room alarm according to our trauma mechanism criteria. Of these 534 (75.8%) received a whole-body CT according to our dedicated multiple trauma protocol. Incidental Findings (IF) were assigned in three groups according to their clinical relevance. Category 1: IF with high medical relevance (urgent life threatening conditions, unless treated) needing early investigations and intervention prior to or shortly after hospital discharge. Category 2: IF with intermediate or low medical relevance, warranting further investigations. Category 3: IF without clinical relevance.

Results

Overall 231 IFs (43.3%) were identified, 36 (6.7%) patients had IFs with a high clinical relevance, 48 (9.0%) with a moderate or minor clinical relevance and 147 (27.5%) with no clinical relevance. The distribution of incidental findings with high or moderate relevance according to age showed an incidence of 2.6%, 6.6% and 8.8% for patients younger than 40 years, 40 to 60 years and older than 60 years, respectively.

Conclusion

Whole-body CT scans of trauma patients demonstrate a high rate of incidental findings. Potentially life-threatening, medical findings were found in approximately every 15th patient, predominantly aged over 40 years and presenting with minor to moderate injuries and an Injury Severity Score (ISS) of 10 or less.

     

Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results

Objectives. To determine the utility of hematuria testing in a large series of patients with suspected renal colic using unenhanced helical computed tomography (CT) as the reference standard.Methods. A retrospective review of the CT reports of all patients who underwent unenhanced helical CT for suspected renal colic at one institution during a 3.5-year period and who also underwent a formal microscopic urinalysis within 24 hours of the CT study was conducted. The sensitivity, specificity, positive predictive value, and negative predictive value of the presence of any blood on the urinalysis for renal colic were calculated.Results. Urolithiasis was present in 587 (62%) of the 950 patients, and 363 patients had negative examinations for renal colic, including 69 with significant alternative diagnoses in the latter group. Of the urinalyses, 492 were true-positive, 174 were true-negative, 189 were false-positive, and 95 were false-negative, yielding a sensitivity, specificity, positive predictive value, and negative predictive value of 84%, 48%, 72%, and 65%, respectively. Forty-six percent of the urinalysis results were negative for blood in the subset of patients with significant alternative diagnoses.Conclusions. The sensitivity of hematuria on microscopic urinalysis for renal colic using unenhanced CT as the reference standard was 84%, and the specificity and negative predictive value was low. The presence or absence of blood on urinalysis cannot be used to reliably determine which patients actually have ureteral stones.     

国人儿童正常肾动脉的多排螺旋CT测量

目的通过观测儿童正常肾动脉CT图像,得到不同年龄段儿童的肾动脉正常值。方法选取腹部CT增强扫描检查无肾脏疾病及其他相关疾病的儿童284名,按年龄分为5组,观测肾动脉支数、肾动脉起始位置、肾动脉主干与腹主动脉下夹角、肾动脉起始处内径、副肾动脉数目、副肾动脉起源、副肾动脉入肾部位,并进行统计分析。结果肾动脉以单支型最多见;右侧肾动脉高于左侧者较为常见;随着年龄增长,肾动脉起点与腹腔干距离逐渐增加（P〈0.05）;肾动脉干与腹主动脉下夹角在不同组间差异无统计学意义（P〉0.05）;各年龄组肾动脉干起始部内径的差异有统计学意义（P〈0.001）,随年龄增长,肾动脉干起始部内径增加,不同性别及左、右肾间差异无统计学意义（P〉0.05）;副肾动脉出现率为35.21%（100/284）,主要起源于肾动脉（66/134,49.25%）及腹主动脉（62/134,46.27%）,经肾上端（98/134,73.13%）及肾下端（28/134,20.90%）入肾。结论本研究初步得到不同年龄儿童肾动脉的相关正常值,有助于诊治儿童肾动脉相关疾病。     

Treatment of patients with foreign bodies in rectum

The analysis of treatment results in 112 patients with foreign bodies in the rectum, aged from 16 to 80 years, was carried out. 99.1% of the patients were men. All the patients were examined and treated in proctology department of the Moscow municipal clinical hospital N 67 from 1969 to 1998. The examination was made by standard scheme, including rectal touch, rectoromanoscopy, X-ray and ultrasonic examinations. In 107 patients the foreign body was removed without surgery, 5 patients required laparotomy. When possible it was removed by fingers and also with use of forceps. When small foreign bodies could not be reached by finger, they were removed through rectoscope. Foreign bodies of big sizes, proximal end of which was in the sigmoid colon, were removed under anasthesia with the help of the assistant who fixed the foreign body through the abdominal wall in the left ileac region. In impossibility of the subject removal by these methods and presence of complications (perforation, peritonitis), laparotomy with subsequent transanal subject removal without colon section was performed, in case of perforation--with wound suturing or colostomy.     

Esophageal foreign bodies in adults.

The main point in managing suspected impaction of esophageal foreign bodies is to decide whether the patient needs an esophageal endoscopy. Decision-making is based on clinical history, physical examination, and radiographic studies. We review 100 cases of adults having esophagoscopy for removal of esophageal foreign bodies. Fish bones were the most frequently responsible foreign body and the cervical esophagus was the most frequent level of impaction. Decision-making based on clinical history and patient-referred symptoms revealed a positive esophagoscopy in 72% of the suspected cases. Radiographic studies gave falsely positive and falsely negative information in 30% of the cases. Rigid esophagoscopy was used successfully for foreign body removal in 99% of the cases. Average hospital stay was 3.2 days. No complications associated with the use of a rigid esophagoscope were found.