Fig. 13

Satisfaction of search (type 10) error. A patient with gastric cardia tumor underwent total gastrectomy and distal esophagectomy. On the first postoperative day, dyspnea and abdominal pain developed. Anastomosis leakage was suspected, and thoracoabdominal CT with oral contrast agent was performed. The on-call radiologist noticed apparent contrast extravasation from esophagojejunostomy to the posterior mediastinum. The study was reported as “consistent with anastomosis leakage from esophagojejunostomy” (red arrows, a, b). Due to the “satisfaction of search” effect of this significant finding, the remainder of the examination was reported as normal. However, the patient’s abdominal complaints progressed, and the general condition of the patient deteriorated, so the patient was re-operated on, and additional jejunojejunostomy leakage was detected. When the preoperative CT was retrospectively evaluated, apparent signs of leakage in the jejunojejunostomy area were noticed. Linear hyperdensity consistent with leakage extending inferiorly from the anastomosis (blue arrows, c), extraluminal contrast material between jejunal loops (blue arrow, d), and pelvic fluid with relatively high density (red ROI mark, e) were overlooked findings