Blunt bowel and mesenteric injury (BBMI) in the setting of trauma remains an underrecognized entity, and delays in diagnosis can significantly affect patient outcomes. Clinical findings are often unreliable because of associated distracting injuries and the delayed manifestation of abdominal signs. Computed tomography (CT) is the primary imaging modality for detecting blunt bowel and mesenteric injury. CT findings can be categorized into signs of bowel injury, signs of mesenteric injury, and ancillary imaging features that should prompt heightened suspicion for bowel and mesenteric trauma. Bowel findings can be further categorized into hard signs, which generally suggest the need for surgical intervention, and soft signs, which require integration with clinical and laboratory data. Awareness of the pearls and pitfalls of imaging can improve diagnostic confidence, reduce missed findings, and ultimately improve patient outcomes.

Background and goals: The outcomes of patients with primary sclerosing cholangitis (PSC) in central Missouri are unknown. The University of Missouri–Columbia services 600,000 individuals in central Missouri. Our aims were (a) to examine the outcomes of PSC patients receiving care at our academic institution, and (b) to identify the predictors of PSC-related serious adverse events. Methods: A retrospective study of patients with PSC in a non-transplant center. The primary outcome was the development of ≥1 of PSC-related serious adverse event for (1) progression to cirrhosis, or (2) development of cholangiocarcinoma. Results: From 2000 to 2018, 42 patients fulfilled the criteria for the diagnosis of PSC. A total of 55% of the patients were male, and 79% had associated inflammatory bowel disease (IBD). The median follow-up from time of diagnosis of PSC until the last follow-up or death was 5.5 years. A total of 57% of the patients developed ≥ 1 PSC-related adverse event; 36% (8/22) of those who progressed to decompensation underwent liver transplantation. The median time from diagnosis of PSC until progression to decompensation was 6.3 years; the median time from decompensation to transplantation was 10.8 years. A total of 12% of the patients developed ≥ 1 cancer (cholangiocarcinoma = 2; gallbladder cancer = 2; colon cancer = 1; and hepatocellular carcinoma = 1). The overall mortality was 9.5%. The median time from PSC diagnosis until death was 10.2 years. A Cox hazards regression analysis showed only age (HR = 1.16; p = 0.032; 95% CI, 1.01–1.13) and serum bilirubin (HR = 1.42; p = 0.036; 95% CI, 1.03–2.69) at the time of PSC diagnosis were independently associated with PSC-related serious events. Conclusions: Age and bilirubin are important predictors of PSC-related outcomes.

Acute gastrointestinal bleeding (GIB) is a common cause of emergency department presentation, with outcomes ranging from self-limited bleeding to potentially life-threatening hemorrhage. Based on location, acute GIB can be broadly categorized as upper gastrointestinal bleeding (UGIB), lower gastrointestinal bleeding (LGIB), or small-bowel bleeding (SBB). Understanding the clinical presentation and laboratory findings can help determine the appropriate next step in diagnostic evaluation and management. Imaging and endoscopy form the mainstay of evaluation and treatment. Multiphasic CT angiography (CTA), technetium-99 m–labeled red blood cell (RBC) scintigraphy, and catheter angiography are key imaging modalities in the workup of acute GIB. Recognition of common causes, appropriate modality selection, protocol optimization, and awareness of key interpretive pearls and pitfalls are essential for accurate radiologic interpretation and reporting, ultimately improving patient outcomes.

Background:A noninvasive, readily accessible, and quantitative methods are needed to evaluate changes in hepatic fat over time in patients undergoing bariatric surgery. Purpose:To measure the change in ultrasound-derived fat fraction (UDFF) in severely obese adults before and after bariatric surgery. Materials and Methods:Participants undergoing bariatric surgery were prospectively enrolled at a single center and evaluated at 3 time points: pre-surgery (before a 2-week pre-operative liquid diet), day of surgery (immediately following the liquid diet), and 6 months post-surgery. Measurements included UDFF (Siemens Healthineers ACUSON SEQUOIA), skin-to-liver capsule thickness, serum metabolic tests, liver function tests, and anthropometric data. Changes in these variables were analyzed using 2-sided paired t-tests. Pearson correlation analysis was used to evaluate associations between changes in UDFF and changes in skin-to-capsule thickness, waist circumference, and BMI. Results:Seventeen participants (mean age 47.41 ± 11.11 years, 15 women) completed the study. UDFF (mean ± SD) decreased significantly from 20.4 ± 8.41% pre-surgery to 11.08 ± 6.33% at 6 months post-surgery (P < .001). Skin-to-liver capsule thickness decreased from 4.06 ± 0.66 cm to 2.88 ± 0.55 cm (P < .001). BMI decreased from 46.27 ± 6.65 kg/m2 to 35.5 ± 6.64 kg/m2 (P < .001), and waist circumference decreased from 130.29 ± 13.49 cm to 111.98 ± 16.03 cm (P < .001). No significant changes were observed in UDFF, skin-to-liver capsule thickness, or waist circumference after the liquid diet phase. Strong positive correlation between UDFF and BMI reduction was observed (r = 0.75, P < .001). Conclusions:Bariatric surgery results in significant reductions in hepatic steatosis, as measured by UDFF, and reductions in skin-to-liver capsule thickness, BMI, and waist circumference at 6 months post-surgery. These findings suggest that UDFF could meet the clinical need for noninvasive monitoring of hepatic steatosis following bariatric surgery.

Magnetic Resonance Urography (MRU) is a comprehensive, non-invasive imaging technique that offers detailed anatomical and functional assessment of the urinary system without radiation exposure. It is particularly valuable in pediatric, pregnant, and renally impaired patients, and in those with CT contrast allergies. Multiparametric MRU sequences can evaluate congenital anomalies, functional obstruction, urothelial tumors, and postoperative anatomy. Advancements in imaging technology such as respiratory gating, compressed sensing, and motion correction, have significantly improved image quality and patient comfort. The introduction of the Vesical Imaging Reporting and Data System (VI-RADS) has standardized bladder cancer staging, aiding in inter-reader reproducibility and treatment planning. This review outlines MRU technique, protocol optimization, artifact mitigation strategies, and specific pediatric and oncologic applications. Illustrative cases highlight the versatility of MRU in clinical practice. With advanced MRI techniques, increasing expertise among radiologists and familiarity among urologists, MRU is emerging as a first-line modality in select urologic conditions.

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

Perforator flap magnetic resonance angiography (MRA) has emerged as a widely accepted and preferred modality for perforator flap mapping at several institutions. Autologous perforator flaps are a type of reconstructive microsurgical technique that involves transferring skin and fat from one part of the patient's body to another to replace tissue lost due to trauma, cancer resection, or other reasons. Autologous perforator flaps are based on a specific perforating blood vessel perfusing the transferred tissue. Hence, the surgery relies on the precise identification and mapping of perforating vessels to ensure successful outcomes. With its superior soft tissue contrast and multiplanar imaging capabilities, MRA has shown great potential in providing accurate and detailed visualization of perforator anatomy, size, and course. This review article summarizes the current literature on perforator flap MRA, including its technical considerations, imaging protocols, postprocessing, and reporting, specifically for autologous breast reconstructions. The advantages and limitations of MRA in evaluating perforator flaps are discussed, including its role in preoperative planning, intraoperative guidance, and postoperative assessment. Anatomy, brief surgical technique, specific technical modifications, and reporting of most commonly performed autologous breast flaps are described. Recent advancements in Perforator flap surgery and MRA techniques are discussed. Additionally, we examine the emerging role of artificial intelligence and machine learning in improving the accuracy and efficiency of perforator flap MRA interpretation. Level of Evidence 5 Technical Efficacy Stage 5

Although there are no known risk factors for uretero-inguinal hernias we note that BMI could attribute and this patient had a BMI of 45, classified as morbid obesity (1, 2). There are other cases of this rare hernia that were also observed in males with extremely high BMI (3). Management of any obstruction can be a challenge in this individual with anatomic complexity and other options may need to be considered including longer stent lengths and even antegrade ureteral access via nephrostomy tube. This patient was successfully managed with retrograde ureteroscopy with holmium laser lithotripsy of his stone and placement of a 6 French x 30 cm double-J ureteral stent. This was the longest stent size available and it was unable to completely reach the renal pelvis but was left for 3 days post-operatively to prevent distal ureteral obstruction after procedure. Although it is a rare occurrence, the availability of extra-long stents in hospitals may be necessary. To date, there has been no recurrence of urolithiasis for the patient but continued monitoring with intermittent imaging will be a necessity.

Cystic dystrophy of the duodenal wall (CDDW) is an uncommon pathological condition that may be a cause of symptomatic duodenal mass in some patients. CDDW and closely related conditions that involve the duodenal wall and the pancreatoduodenal groove have gone by a variety names in the literature. Though their pathophysiology is not fully understood, they are thought to be due to the presence of heterotopic pancreatic tissue that undergoes a degenerative process. A multimodal imaging approach paired with biopsy is often employed to rule out malignancy in these patients. This case report provides an account of the radiological and pathological findings that helped lead to the diagnosis of CDDW. A review of relevant literature and a discussion of the presented case are provided.

PURPOSE Post-thoracotomy pain syndrome is a common condition affecting up to 50% of post-thoracotomy patients. However, percutaneous computed tomography (CT)-guided intercostal nerve cryoablation may provide symptomatic benefit in chronic and/or refractory cases. METHODS A retrospective review of our institution's comprehensive case log from October 2017 to September 2018 for patients who underwent cryoablation was analyzed. Thirteen patients with post-thoracotomy pain syndrome, refractory to medical management, were treated with CT-guided intercostal nerve cryoablation. Most patients had treatment of the intercostal nerve at the level of their thoracotomy scar, two levels above and below. The safety and technical success of this technique and the clinical outcomes of the study population were then retrospectively reviewed. RESULTS Of the patients, 69% experienced significant improvement in their pain symptoms with a median pain improvement score of 3 points (range, -1 to 8 points) over a median follow-up of 11 months (range, 2-18.6 months). Complications included pneumothorax in 8% and pseudohernia in 23% of patients. CONCLUSION CT-guided intercostal nerve cryoablation may be an effective technique in the treatment of post-thoracotomy pain syndrome and requires further study.

Pseudolipomas of Glisson's capsule are rare benign subcapsular liver lesions that typically affect older men. They are composed of degenerating fat that is thought to originate from a detached epiploic appendage. On Computed Tomographic (CT) imaging, pseudolipomas of Glisson's capsule are well-circumscribed and hypoattenuating compared to the hepatic parenchyma. This case report examines three consecutive CT studies in the same patient that show the pseudolipoma migrating to a hepatic subcapsular location over a period of 4.5 months. To our knowledge, this is the first documented case of a pseudolipoma migrating over time and it supports the hypothesis of a migrating epiploic appendage forming a pseudolipoma of Glisson's capsule. A comprehensive review of relevant literature and a discussion of the presented case are provided.

Autologous breast reconstruction using muscle-sparing free flaps are becoming increasingly popular, although microvascular free flap reconstruction has been utilised for autologous breast reconstructions for >20 years. This innovative microsurgical technique involves meticulous dissection of artery–vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap; however, due to unpredictable anatomical variations, preoperative imaging of the donor site to select appropriate perforators has become routine. Preoperative imaging also reduces operating time and enhances the surgeon's confidence in choosing the appropriate donor site for harvesting flaps. Although computed tomography angiography has been widely used for preoperative imaging, concerns over excessive exposure to ionising radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made magnetic resonance angiography, the first choice imaging modality in our centre. Magnetic resonance angiography with specific post-processing of the images has established itself as a reliable method for mapping tiny perforator vessels. Multiple donor sites can be imaged in a single setting without concern for ionising radiation exposure. This provides anatomical information of more reconstruction donor site options, so that a surgeon can design a flap of tissue centralised around the best perforator, as well as a back-up perforator, and even a back-up flap option located on a different region of the body. This information is especially helpful in patients with a history of scar tissue from previous surgeries, where the primary choice perforator is found to be damaged or unsuitable intraoperatively. In addition, chest magnetic resonance angiography evaluates recipient site blood vessel suitability including vessel diameters, course, and branching patterns. In this article we provide a broad overview of various skin flaps, clinical indications, advantages and disadvantages of each of these flaps, basic imaging technique, along with advanced sequences for visualising tiny arteries in the groin and in the chest. Post-processing techniques, structure of the report and how automation of the reporting system improves workflow is described. We also describe applications of magnetic resonance angiography in postoperative imaging. Autologous breast reconstruction using muscle-sparing free flaps are becoming increasingly popular, although microvascular free flap reconstruction has been utilised for autologous breast reconstructions for >20 years. This innovative microsurgical technique involves meticulous dissection of artery–vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap; however, due to unpredictable anatomical variations, preoperative imaging of the donor site to select appropriate perforators has become routine. Preoperative imaging also reduces operating time and enhances the surgeon's confidence in choosing the appropriate donor site for harvesting flaps. Although computed tomography angiography has been widely used for preoperative imaging, concerns over excessive exposure to ionising radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made magnetic resonance angiography, the first choice imaging modality in our centre. Magnetic resonance angiography with specific post-processing of the images has established itself as a reliable method for mapping tiny perforator vessels. Multiple donor sites can be imaged in a single setting without concern for ionising radiation exposure. This provides anatomical information of more reconstruction donor site options, so that a surgeon can design a flap of tissue centralised around the best perforator, as well as a back-up perforator, and even a back-up flap option located on a different region of the body. This information is especially helpful in patients with a history of scar tissue from previous surgeries, where the primary choice perforator is found to be damaged or unsuitable intraoperatively. In addition, chest magnetic resonance angiography evaluates recipient site blood vessel suitability including vessel diameters, course, and branching patterns. In this article we provide a broad overview of various skin flaps, clinical indications, advantages and disadvantages of each of these flaps, basic imaging technique, along with advanced sequences for visualising tiny arteries in the groin and in the chest. Post-processing techniques, structure of the report and how automation of the reporting system improves workflow is described. We also describe applications of magnetic resonance angiography in postoperative imaging.

Pelvic trauma, especially in the setting of hemodynamic instability, results in high rates of morbidity and mortality. Proper management requires rapid identification of injured structures via appropriate diagnostic studies. This review primarily focuses on the initial evaluation of pelvic trauma, the vascular territories within the pelvis, angiographic and imaging findings of vascular pelvic injury, classification of pelvic injuries, and treatment of pelvic trauma.

Imaging is needed for diagnosis, treatment planning, and follow-up of patients with pathologies affecting upper extremity vasculature. With growth and evolution of imaging modalities [especially CT angiography (CTA) and MR angiography (MRA)], there is need to recognize the advantages and disadvantages of various modalities and obtain the best possible imaging diagnostic test. Understanding various limitations and pitfalls as well as the best practices to minimize and manage these pitfalls is very important for the diagnosis. This article reviews the upper extremity arterial vascular anatomy, discusses the CTA and MRA imaging, various pitfalls, and challenges and discuss imaging manifestations of upper extremity arterial pathologies.

Perforator flap-based breast reconstruction in a post mastectomy patient requires dissection of the artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap. Traditionally, these reconstructions were performed with the transverse rectus abdominis myocutaneous (TRAM) flap, but autologous breast reconstruction using muscle sparing free flaps has become steadily more popular in recent years. Preoperative imaging to locate and evaluate candidate perforators has become an essential step before patients undergo the microsurgical procedure. Preoperative mapping assists with operative planning, reduces operating times, and brings anatomical variations to their attention. Pre-operative imaging also assists in choosing the appropriate donor site for harvesting flaps. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been widely used for this type of preoperative imaging. Both MRA and CTA have their inherent advantages and disadvantages, and the preferred modality for this purpose varies by institution based on factors such as scanner availability, radiologist and surgeon experience, and comfort in interpreting the images. Concerns over excessive exposure to ionizing radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made MRA the first-choice imaging modality in many centers. The purpose of the article is to review technique and protocols for the pre-operative CTA/MRA in patients who are being considered for a deep inferior epigastric artery perforator (DIEP) or profunda artery perforator (PAP) flap and to familiarize the reader with the normal and variant anatomic features of the deep inferior epigastric and PAP vessels along with the anatomic and surgical considerations used in the selection of perforator flap donor site for breast reconstruction post mastectomy.

Perforator flap-based breast reconstruction in a post mastectomy patient requires dissection of the artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap. Traditionally, these reconstructions were performed with the transverse rectus abdominis myocutaneous (TRAM) flap, but autologous breast reconstruction using muscle sparing free flaps has become steadily more popular in recent years. Preoperative imaging to locate and evaluate candidate perforators has become an essential step before patients undergo the microsurgical procedure. Preoperative mapping assists with operative planning, reduces operating times, and brings anatomical variations to their attention. Pre-operative imaging also assists in choosing the appropriate donor site for harvesting flaps. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been widely used for this type of preoperative imaging. Both MRA and CTA have their inherent advantages and disadvantages, and the preferred modality for this purpose varies by institution based on factors such as scanner availability, radiologist and surgeon experience, and comfort in interpreting the images. Concerns over excessive exposure to ionizing radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made MRA the first-choice imaging modality in many centers. The purpose of the article is to review technique and protocols for the pre-operative CTA/MRA in patients who are being considered for a deep inferior epigastric artery perforator (DIEP) or profunda artery perforator (PAP) flap and to familiarize the reader with the normal and variant anatomic features of the deep inferior epigastric and PAP vessels along with the anatomic and surgical considerations used in the selection of perforator flap donor site for breast reconstruction post mastectomy.

Autologous breast reconstruction using muscle-sparing free flaps are becoming increasingly popular, although microvascular free flap reconstruction has been utilised for autologous breast reconstructions for >20 years. This innovative microsurgical technique involves meticulous dissection of artery-vein bundle (perforators) responsible for perfusion of the subcutaneous fat and skin of the flap; however, due to unpredictable anatomical variations, preoperative imaging of the donor site to select appropriate perforators has become routine. Preoperative imaging also reduces operating time and enhances the surgeon's confidence in choosing the appropriate donor site for harvesting flaps. Although computed tomography angiography has been widely used for preoperative imaging, concerns over excessive exposure to ionising radiation and poor iodinated contrast agent enhancement of the intramuscular perforator course has made magnetic resonance angiography, the first choice imaging modality in our centre. Magnetic resonance angiography with specific post-processing of the images has established itself as a reliable method for mapping tiny perforator vessels. Multiple donor sites can be imaged in a single setting without concern for ionising radiation exposure. This provides anatomical information of more reconstruction donor site options, so that a surgeon can design a flap of tissue centralised around the best perforator, as well as a back-up perforator, and even a back-up flap option located on a different region of the body. This information is especially helpful in patients with a history of scar tissue from previous surgeries, where the primary choice perforator is found to be damaged or unsuitable intraoperatively. In addition, chest magnetic resonance angiography evaluates recipient site blood vessel suitability including vessel diameters, course, and branching patterns. In this article we provide a broad overview of various skin flaps, clinical indications, advantages and disadvantages of each of these flaps, basic imaging technique, along with advanced sequences for visualising tiny arteries in the groin and in the chest. Post-processing techniques, structure of the report and how automation of the reporting system improves workflow is described. We also describe applications of magnetic resonance angiography in postoperative imaging.