Fluoroscopically guided nose tube drainage of mediastinal abscesses in post-operative gastro-oesophageal anastomotic leakage

Objective

The aim of this study was to retrospectively evaluate the technical success rates and clinical effectiveness of fluoroscopically guided nose tube drainage of mediastinal abscesses and a nasojejunum feeding tube in post-operative gastro-oesophageal anastomotic leakage (GEAL).

Methods

From January 2006 to June 2011, 18 cases of post-operative GEAL with mediastinal abscesses after oesophagectomy with intrathoracic oesophagogastric anastomotic procedures for oesophageal and cardiac carcinoma were treated by insertion of a nose drainage tube and nasojejunum feeding tube under fluoroscopic guidance. We evaluated the feasibility of two-tube insertion to facilitate leakage site closure and complete resolution of the abscess, and the patients’ nutritional benefit was also evaluated by checking the serum albumin level between pre- and post-enteral feeding via the feeding tube.

Results

The two tubes were placed successfully under fluoroscopic guidance in 18 patients (100%). The procedure time for two-tube insertion ranged from 20 to 40 min (mean 30 min). 17 patients (94%) achieved leakage site closure after two-tube insertion and had a good tolerance of two tubes in the nasal cavity. The serum albumin level was significant, increased from pre-enteral feeding (2.49±0.42 g dl⁻¹) to the post-enteral feeding (3.58±0.47 g dl⁻¹) via the feeding tube (p<0.001). The duration of follow-up ranged from 1 to 49 months (mean 19 months).

Conclusion

The insertion of nose tube drainage and a nasojejunum feeding tube under fluoroscopic guidance is safe, and it provides effective relief from mediastinal abscesses in GEAL after oesophagectomy. Moreover, our findings indicate that two-tube insertion may be used as a selective procedure to treat mediastinal abscesses in post-operative GEAL.

Advances in knowledge

Directive drainage of mediastinal abscesses in post-operative GEAL may be an effective treatment.Mediastinal leakage occurs in about 7% of distal oesophageal resections and is associated with a mortality rate of up to 60% [1,2]. Although the amounts of post-operative anastomotic leakage can be rather slight, the leakage is a major source of mortality and morbidity [3]. The leading causes of death in patients with mediastinal abscesses are infection and nutritional deficiency [4,5]. Mediastinal abscesses form a potentially devastating condition in gastro-oesophageal anastomotic leakage (GEAL). Historically, intravenous antibiotics combined with surgical debridement have been the mainstay of therapy [6]. Rethoracotomy extended procedure, however, carries considerable risks for a critically ill patient [5]. Han et al [7] treated patients with mediastinal abscess with stent placement and nasal–oesophagal drainage, while percutaneous drainage was applied under the guidance of CT [8,9] or endoscopy [10,11]. Drainage may be a promising treatment for mediastinal abscess in GEAL. In this study, we determined the feasibility and effectiveness of using two-tube insertion under fluoroscopic guidance in the treatment of mediastinal abscess in GEAL. The effect of treatment was evaluated by time interval of the leaks’ closure and the effect on nutritional status was evaluated by serum albumin level.     

Fluoroscopically Guided Feeding Tube Insertion for Relief of Postoperative Gastrointestinal Anastomotic Obstruction and Leakage

Purpose To evaluate the feasibility and effectiveness of feeding tube insertion and enteral feeding for the treatment of postoperative gastrointestinal anastomotic obstruction and leakage. Materials and Methods From June 1999 to June 2002, thirty-four cases of postoperative gastrointestinal anastomotic obstruction and leakage after surgery for gastric carcinoma were treated by insertion of a feeding tube under fluoroscopic guidance. Twenty-one patients were male and 13 were female. The patients’ ages ranged from 39 to 74 years (mean age: 61 years). All the patients experienced vomiting, and 15 patients had anastomotic site or duodenal stump leakage. We evaluated the feasibility of feeding tube insertion for enteral feeding to improve the obstruction and facilitate leakage site closure, and the patients’ nutritional benefit was also evaluated by checking the serum albumin level between pre- and post-enteral feeding via the feeding tube. Results Thirty-two patients (94%) were successfully managed by feeding tube insertion, but the remaining two were not managed, and this was due to severe angulations at the anastomotic site. The procedure times for feeding tube insertion ranged from 15 to 60 minutes (mean time: 45 minutes). Twenty-eight patients experienced symptomatic relief of gastrointestinal obstruction, and they were able to resume a normal regular diet after feeding tube removal. Three patients underwent stent insertion due to recurrent symptoms, and one patient underwent jejunostomy feeding due to the presence of a persistent leakage site. Eleven patients achieved leakage site closure after enteral feeding via a feeding tube. The serum albumin level was significant, increased from pre-enteral feeding (2.65 ± 0.37 g/dL) to the post-enteral feeding (3.64 ± 0.58 g/dL) via the feeding tube (p < 0.001). The duration of follow-up ranged from one to 53 months (mean: 23 months). Conclusion The insertion of a feeding tube for enteral feeding under fluoroscopic guidance is safe, and it provides effective relief from gastrointestinal anastomotic site obstruction and leakage after gastric surgery. Moreover, our findings indicate that feeding tube insertion for enteral feeding may be used as the primary procedure to treat postoperative anastomotic obstruction and leakage.     

Fluoroscopy-Guided Percutaneous Gallstone Removal Using a 12-Fr Sheath in High-Risk Surgical Patients with Acute Cholecystitis

Objective

To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic cholecystolithotomy under fluoroscopic guidance in high-risk surgical patients with acute cholecystitis.

Materials and Methods

Sixty-three consecutive patients of high surgical risk with acute calculous cholecystitis underwent percutaneous transhepatic gallstone removal under conscious sedation. The stones were extracted through the 12-Fr sheath using a Wittich nitinol stone basket under fluoroscopic guidance on three days after performing a percutaneous cholecystostomy. Large or hard stones were fragmented using either the snare guide wire technique or the metallic cannula technique.

Results

Gallstones were successfully removed from 59 of the 63 patients (94%). Reasons for stone removal failure included the inability to grasp a large stone in two patients, and the loss of tract during the procedure in two patients with a contracted gallbladder. The mean hospitalization duration was 7.3 days for acute cholecystitis patients and 9.4 days for gallbladder empyema patients. Bile peritonitis requiring percutaneous drainage developed in two patients. No symptomatic recurrence occurred during follow-up (mean, 608.3 days).

Conclusion

Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath is technically feasible and clinically effective in high-risk surgical patients with acute cholecystitis.     

CIRSE Standards of Practice Guidelines on Gastrostomy

Purpose

Surgical Gastrostomy has been around since the 19th century but in 1980 the first successful percutaneous endoscopic gastrostomy was reported. A year later the first successful percutaneous gastrostomy was performed using fluoroscopic guidance. The technique for percutaneous insertion and the equipment used has been refined since then and it is now considered the gold standard for gastrostomy insertion. Here we present guidelines for image-guided enteral feeding tubes in adults.

Material and Method

We performed a review and analysis of the scientific literature, other national and international guidelines and expert opinion.

Results

Studies have shown fluoroscopic techniques have consistently higher success rates with lower rates of major complications than endoscopic techniques. However, the Achilles' heel of many fluoroscopic techniques is the requirement for smaller gastrostomy tube sizes resulting in them being more prone to blockages and thus requiring further intervention.

Conclusion

Radiological feeding tube insertion is a safe and effective procedure. Success rates are higher, and complication rates lower than PEG or surgical gastrostomy tube placement and innovative techniques for gastric and jejunal access mean that there are very few cases in which RIG is not possible. The principal weakness of radiologically inserted gastrostomies is the limitiation on tube size which leads to a higher rate of tube blockage. Per-oral image-guided gastrostomies have to an extent addressed this but have not been popularised. Currently many centres still consider endoscopic gastrostomies as the first line unless patients are too unwell to undergo this procedure or previous attempts have failed, in which case radioloically inserted gastrostomies are the technique of choice.

     

Newly Designed Sheaths for Gastroduodenal Intervention: An Experimental Study in a Phantom and Dogs

Objective

To evaluate the usefulness of newly designed sheaths for gastroduodenal intervention in a gastric phantom and dogs.

Materials and Methods

A regular sheath was made using a polytetrafluoroethylene tube (4 mm in diameter, 90 cm long) with a bent tip (4 cm long, 100 degree angle). For the supported type of sheath, a 5 Fr catheter was attached to a regular sheath to act as a side lumen. To evaluate their supportability, we measured the distance of movement of the sheath''s tip within a silicone gastric phantom for three types of sheath, the regular type, supported type, and supported type with a supporting guide wire. The experiments were repeated 30 times, and the results were analyzed using ANOVA with the postHoc test.In addition, an animal experiment was performed in six mongrel dogs (total: 12 sessions) to evaluate the torque and supportability of the sheaths in the stomach, while pushing a guide wire or coil catheter under fluoroscopic guidance.

Results

In the guide wire application, the distances of movement of the sheath tip in the three types of sheath, the regular type, supported type, and supported type with supporting guide wire, were 8.40±0.51 cm, 6.23±0.41 cm, and 4.47±0.32 cm, respectively (p < 0.001). In the coil catheter application, the corresponding values were 7.22±0.70 cm, 5.61±0.31 cm and 3.91±0.59 cm, respectively (p < 0.001).All three types of sheath rotated smoothly and enabled both the wires and catheters to be guided toward the pylorus of the dog in all cases.

Conclusion

The newly designed sheaths can be useful for gastroduodenal intervention.     

Transthoracic needle biopsy using a C-arm cone-beam CT system: diagnostic accuracy and safety

Objective

The purpose of this study was to evaluate the diagnostic accuracy and safety of performing transthoracic needle biopsy (TNB) under combined fluoroscopy and CT guidance using a C-arm cone-beam CT (CBCT) system.

Methods

We evaluated the diagnostic accuracy and safety of performing TNB using a C-arm CBCT system. We retrospectively evaluated 99 TNB cases performed in 98 patients using a C-arm CBCT system with an 18-gauge automated cutting needle. We reviewed the diagnostic accuracy according to the size and depth of the lesion, incidence of complications, additional treatment for complications, procedure time, number of needle passes per biopsy and radiation dose.

Results

The final diagnoses revealed 72 malignant and 27 benign lesions. The overall malignancy sensitivity, malignancy specificity and diagnostic accuracy were 95.8%, 100% and 97.0%, respectively, and those for small pulmonary nodules <20 mm in size were 94.1%, 100% and 96.6%, respectively. There was no significant difference in the correct diagnosis of malignancy according to lesion size (p=0.634) or depth (p=0.542). For benign lesions, a specific diagnosis was obtained in 14 cases (51.9%). TNB induced complications in 19 out of 99 procedures (19.2%), including pneumothorax (16.2%), immediate haemoptysis (2.0%) and subcutaneous emphysema (1.0%). Among these, four patients with pneumothorax required chest tube insertion (2.0%) or pig-tail catheter drainage (2.0%). The mean procedure time, number of needle passes and radiation doses were 11.9±4.0 min, 1.2±0.5 times and 170.0±67.2 mGy, respectively.

Conclusion

TNB using a C-arm CBCT system provides high diagnostic accuracy with a low complication rate and a short procedure time, particularly for small pulmonary nodules.Transthoracic needle biopsy (TNB) under image guidance is a well-known procedure for evaluating thoracic mass lesions, with a high diagnostic accuracy and a relatively low complication rate [1-5]. TNB can be performed under various types of image guidance, including fluoroscopy, CT and ultrasonography. The decision regarding which technique to use usually depends on the characteristics of the pulmonary lesions, such as size, location, the radiologist''s preference and the accessibility of imaging systems.Currently, CT or CT fluoroscopy is the most preferred method of image guidance for TNB. CT fluoroscopy provides real-time guidance of the biopsy needle in addition to the advantages of CT guidance, decreasing the procedure time and number of needle passes compared with CT-guided procedures [1]. However, significant radiation exposure to the operator''s hands is one limitation of this procedure.The C-arm cone-beam CT (CBCT) system is a form of flat-panel volume CT in which a cone-beam X-ray tube and a flat-panel detector are integrated within a C-arm gantry. This provides both CT and real-time fluoroscopic guidance for TNB [6].The purpose of this study was to evaluate the diagnostic accuracy and safety of performing TNB under combined fluoroscopy and CT guidance using a C-arm CBCT system.     

Fluoroscopy-guided jejunal extension tube placement through existing gastrostomy tubes: analysis of 391 procedures

PURPOSE

We aimed to evaluate the safety and efficacy of fluoroscopically placed jejunal extension tubes (J-arm) in patients with existing gastrostomy tubes.

METHODS

We conducted a retrospective review of 391 J-arm placements performed in 174 patients. Indications for jejunal nutrition were aspiration risk (35%), pancreatitis (17%), gastroparesis (13%), gastric outlet obstruction (12%), and other (23%). Technical success, complications, malfunctions, and patency were assessed. Percutaneous gastrostomy (PEG) tube location, J-arm course, and fluoroscopy time were correlated with success/failure. Failure was defined as inability to exit the stomach. Procedure-related complications were defined as adverse events related to tube placement occurring within seven days. Tube malfunctions and aspiration events were recorded and assessed.

RESULTS

Technical success was achieved in 91.9% (95% CI, 86.7%–95.2%) of new tubes versus 94.2% (95% CI, 86.7%–95.2%) of replacements (P = 0.373). Periprocedural complications occurred in three patients (0.8%). Malfunctions occurred in 197 patients (50%). Median tube patency was 103 days (95% CI, 71–134 days). No association was found between successful J-arm placement and gastric PEG tube position (P = 0.677), indication for jejunal nutrition (P = 0.349), J-arm trajectory in the stomach and incidence of malfunction (P = 0.365), risk of tube migration and PEG tube position (P = 0.173), or J-arm length (P = 0.987). A fluoroscopy time of 21.3 min was identified as a threshold for failure. Malfunctions occurred more often in tubes replaced after 90 days than in tubes replaced before 90 days (P < 0.001). A total of 42 aspiration events occurred (OR 6.4, P < 0.001, compared with nonmalfunctioning tubes).

CONCLUSION

Fluoroscopy-guided J-arm placement is safe for patients requiring jejunal nutrition. Tubes indwelling for longer than 90 days have higher rates of malfunction and aspiration.Since enteral nutrition is the preferred method of nourishment for all patients with adequate intestinal length and function, a variety of access methods to the gastrointestinal tract has been developed (1). Endoscopy-guided percutaneous gastrostomy (PEG) tubes are commonly placed in patients in whom oral intake is contraindicated. However, a PEG tube may not be preferred in mechanically ventilated or critically ill patients due to risk of aspiration; in these, administration of the nutrients directly into the jejunum through a nasojejunal tube or a percutaneously placed jejunostomy tube is recommended so that the stomach is bypassed and the risk for aspiration is decreased (2). Other indications for direct administration of nutrients into the jejunum include malfunction of the swallowing mechanism, gastric outlet obstruction, gastroparesis, pancreatitis, and the presence of esophageal fistulas or enteric foregut leaks (3–8).Jejunal feeding tubes can be placed via the nasogastric route, but are not tolerated in the long-term as they can have irritating effects on the nostrils, nasopharynx, and esophagus, and predispose the patient to reflux (9). Hence, a wide variety of other methods for placing jejunal tubes are available, including surgical, fluoroscopy-guided, and endoscopy-guided placement (5). The conversion of an already existing PEG tube into percutaneous endoscopic gastrojejunostomy (PEGJ) tube is also available (10, 11). Another method is placement of a jejunal extension tube (J-arm) through a PEG tube; this is most commonly done endoscopically, usually at the same time that the gastrostomy tube is placed, and known as the gastrojejunostomy tube (12). However, endoscopic advancement of jejunal extension tube through a PEG tube can be difficult, particularly when the operator has no access to fluoroscopy to determine its exact position within the bowel (11). Furthermore, the need for jejunal tube feeds can become apparent only after placement of the PEG tube, at which point the patient may return to the endoscopic suite or to the fluoroscopic suite for jejunal extension tube placement.At our institution, placement of a J-arm through an existing PEG tube by the radiologist under fluoroscopic guidance followed by affixation of the tube to the existing PEG tube has been a routine procedure for almost 10 years. The method does not involve removal of the PEG tube, and omits the use of endoscopy, which makes conscious sedation unnecessary and avoids the complications related to endoscopic placement. The purpose of our study was to establish the safety and efficacy of jejunal extension tube placement utilizing only fluoroscopic guidance.     

Incidence and Management of Bleeding Complications Following Percutaneous Radiologic Gastrostomy

Objective

Upper gastrointestinal (GI) bleeding is a serious complication that sometimes occurs after percutaneous radiologic gastrostomy (PRG). We evaluated the incidence of bleeding complications after a PRG and its management including transcatheter arterial embolization (TAE).

Materials and Methods

We retrospectively reviewed 574 patients who underwent PRG in our institution between 2000 and 2010. Eight patients (1.4%) had symptoms or signs of upper GI bleeding after PRG.

Results

The initial presentation was hematemesis (n = 3), melena (n = 2), hematochezia (n = 2) and bloody drainage through the gastrostomy tube (n = 1). The time interval between PRG placement and detection of bleeding ranged from immediately after to 3 days later (mean: 28 hours). The mean decrease in hemoglobin concentration was 3.69 g/dL (range, 0.9 to 6.8 g/dL). In three patients, bleeding was controlled by transfusion (n = 2) or compression of the gastrostomy site (n = 1). The remaining five patients underwent an angiography because bleeding could not be controlled by transfusion only. In one patient, the bleeding focus was not evident on angiography or endoscopy, and wedge resection including the tube insertion site was performed for hemostasis. The other four patients underwent prophylactic (n = 1) or therapeutic (n = 3) TAEs. In three patients, successful hemostasis was achieved by TAE, whereas the remaining one patient underwent exploration due to persistent bleeding despite TAE.

Conclusion

We observed an incidence of upper GI bleeding complicating the PRG of 1.4%. TAE following conservative management appears to be safe and effective for hemostasis.     

Establishment of a Protocol for Determining Gastrointestinal Transit Time in Mice Using Barium and Radiopaque Markers

Objective

The purpose of this study was to establish a minimally invasive and reproducible protocol for estimating the gastrointestinal (GI) transit time in mice using barium and radiopaque markers.

Materials and Methods

Twenty 5- to 6-week-old Balb/C female mice weighing 19-21 g were used. The animals were divided into three groups: two groups that received loperamide and a control group. The control group (n = 10) animals were administered physiological saline (1.5 mL/kg) orally. The loperamide group I (n = 10) and group II (n = 10) animals were administered 5 mg/kg and 10 mg/kg loperamide orally, respectively. Thirty minutes after receiving the saline or loperamide, the mice was administered 80 µL of barium solution and six iron balls (0.5 mm) via the mouth and the upper esophagus by gavage, respectively. Afterwards, the mice were continuously monitored with fluoroscopic imaging in order to evaluate the swallowing of the barium solution and markers. Serial fluoroscopic images were obtained at 5- or 10-min intervals until all markers had been excreted from the anal canal. For analysis, the GI transit times were subdivided into intestinal transit times (ITTs) and colon transit times (CTTs).

Results

The mean ITT was significantly longer in the loperamide groups than in the control group (p < 0.05). The mean ITT in loperamide group II (174.5 ± 32.3) was significantly longer than in loperamide group I (133.2 ± 24.2 minute) (p < 0.05). The mean CTT was significantly longer in loperamide group II than in the control group (p < 0.05). Also, no animal succumbed to death after the experimental procedure.

Conclusion

The protocol for our study using radiopaque markers and barium is reproducible and minimally invasive in determining the GI transit time of the mouse model.     

Percutaneous Radiofrequency Ablation with Multiple Electrodes for Medium-Sized Hepatocellular Carcinomas

Objective

To prospectively evaluate the safety and short-term therapeutic efficacy of switching monopolar radiofrequency ablation (RFA) with multiple electrodes to treat medium-sized (3.1-5.0 cm), hepatocellular carcinomas (HCC).

Materials and Methods

In this prospective study, 30 patients with single medium-sized HCCs (mean, 3.5 cm; range, 3.1-4.4 cm) were enrolled. The patients were treated under ultrasonographic guidance by percutaneous switching monopolar RFA with a multichannel RF generator and two or three internally cooled electrodes. Contrast-enhanced CT scans were obtained immediately after RFA, and the diameters and volume of the ablation zones were then measured. Follow-up CT scans were performed at the first month after ablation and every three months thereafter. Technical effectiveness, local progression and remote recurrence of HCCs were determined.

Results

There were no major immediate or periprocedural complications. However, there was one bile duct stricture during the follow-up period. Technical effectiveness was achieved in 29 of 30 patients (97%). The total ablation time of the procedures was 25.4 ± 8.9 minutes. The mean ablation volume was 73.8 ± 56.4 cm³ and the minimum diameter was 4.1 ± 7.3 cm. During the follow-up period (mean, 12.5 months), local tumor progression occurred in three of 29 patients (10%) with technical effectiveness, while new HCCs were detected in six of 29 patients (21%).

Conclusion

Switching monopolar RFA with multiple electrodes in order to achieve a sufficient ablation volume is safe and efficient. This method also showed relatively successful therapeutic effectiveness on short-term follow up for the treatment of medium-sized HCCs.     

Liquid-Crystal Display Monitors and Cathode-Ray Tube Monitors: A Comparison of Observer Performance in the Detection of Small Solitary Pulmonary Nodules

Objective

To compare observer performance using liquid-crystal display (LCD) and cathode-ray tube (CRT) monitors in the interpretation of soft-copy chest radiographs for the detection of small solitary pulmonary nodules.

Materials and Methods

By reviewing our Medical Center''s radiologic information system, the eight radiologists participating in this study (three board-certified and five resident) retrospectively collected 40 chest radiographs showing a solitary noncalcified pulmonary nodule approximately 1 cm in diameter, and 40 normal chest radiographs. All were obtained using a storage-phosphor system, and CT scans of the same patients served as the gold standard for the presence of a pulmonary nodule. Digital images were displayed on both high-resolution LCD and CRT monitors. The readers were requested to rank each image using a five-point scale (1 = definitely negative, 3 = equivocal or indeterminate, 5 = definitely positive), and the data were interpreted using receiver operating characteristic (ROC) analysis.

Results

The mean area under the ROC curve was 0.8901±0.0259 for the LCD session, and 0.8716±0.0266 for the CRT session (p > 0.05). The reading time for the LCD session was not significantly different from that for the CRT session (37.12 and 41.46 minutes, respectively; p = 0.889).

Conclusion

For detecting small solitary pulmonary nodules, an LCD monitor and a CRT monitor are comparable.     

Interventional Management of Malignant Colorectal Obstruction: Use of Covered and Uncovered Stents

Objective

We wanted to evaluate usefulness of uncovered stent in comparison with covered stent for the palliative treatment of malignant colorectal obstruction.

Materials and Methods

Covered (n = 52, type 1 and type 2) and uncovered (n = 22, type 3) stents were placed in 74 patients with malignant colorectal obstruction. Stent insertion was performed for palliative treatment in 37 patients (covered stent: n = 23 and uncovered stent: n = 14). In the palliative group, the data on the success of the procedure, the stent patency and the complications between the two groups (covered versus uncovered stents) were compared.

Results

The technical success rate was 89% (33/37). Symptomatic improvement was achieved in 86% (18/21) of the covered stent group and in 92% (11/12) of the uncovered stent group patients. The period of follow-up ranged from three to 319 days (mean period: 116±85 days). The mean period of stent patency was 157±33 days in the covered stent group and 165±25 days in the uncovered stent group. In the covered stent group, stent migration (n = 11), stent fracture (n = 2) and poor expansion of the stent (n = 2) were noted. In the uncovered stent group, tumor ingrowth into the stents (n = 3) was noted.

Conclusion

Self-expanding metallic stents are effective for relieving malignant colorectal obstruction. The rate of complications is lower in the uncovered stent group than in the covered stent group.     

Percutaneous Sclerotherapy of Renal Cysts with a Beta-Emitting Radionuclide, Holmium-166-chitosan Complex

Objective

To evaluate the usefulness of a beta-emitting radionuclide (holmium-166-chitosan complex) as a sclerosing agent for the treatment of renal cysts.

Materials and Methods

Using 10-30 mCi of holmium-166-chitosan complex, 20 renal cysts in 17 patients (14 male and 3 female patients, ranging in age from 47 to 82 years) were treated by percutaneous sclerotherapy under ultrasonographic guidance. The volume of the cysts before and after the sclerotherapy and the percentage change in volume were calculated in order to evaluate the response to therapy, which was classified as either complete regression (invisible), nearly complete regression (< 15 volume% of initial volume), partial regression (15-50 volume%) or no regression (> 50 volume%).

Results

The follow-up period ranged from 6 to 36 months (mean 28 months). Eighteen cysts (90%) regressed completely (n=11, 55%) or near-completely (n=7, 35%). Partial regression was obtained in one patient (5%) and there was no regression in one patient (5%). No significant complications were encountered.

Conclusion

The holmium-166-chitosan complex seems to be useful as a new painless sclerosing agent for the treatment of renal cysts with no significant complications.     

Noise-enhanced postural stability in subjects with functional ankle instability

Objective

To examine the effects of stochastic resonance (SR) stimulation on the postural stability of subjects with functional ankle instability (FAI).

Design

Experimental research design.

Setting

Sports medicine research laboratory.

Participants

12 subjects with FAI who reported a history of recurrent ankle sprains and “giving way” sensations at the ankle.

Interventions

Subjects performed 20 s single‐leg balance tests under SR stimulation at 0.05 mA and 0.01 mA and under control conditions. Testing order was randomised. Stimulators that delivered subsensory stimulation to ankle muscles and ligaments were worn. Subjects were blinded to the test conditions, as SR stimulation was subsensory and stimulators were turned off during the control condition.

Main outcome measures

Anterior/posterior and medial/lateral centre‐of‐pressure velocities (COPVs) were combined to form a resultant vector (COPV‐R). The COPV‐R differences between the optimal SR stimulation and control conditions were analysed. Optimal SR stimulation was defined as the SR stimulation input intensity level (0.05 mA or 0.01 mA) that produced the greatest percentage improvement in postural stability compared with the control condition. Slower velocities indicated enhanced postural stability.

Results

The optimal input intensity was 0.05 mA for nine subjects and 0.01 mA for the other three. The optimal SR stimulation significantly (p<0.05) improved COPV‐R compared with the control condition (6.60 (1.06) vs 7.20 (1.03) cm/s; mean (SD)).

Conclusion

SR stimulation may enhance signal detection of sensorimotor signals associated with postural stability. This result has clinical relevance as improvements in postural instability associated with FAI may decrease ankle sprain injury.     

Sclerotherapy of Peritoneal Inclusion Cysts: Preliminary Results in Seven Patients

Objective

To evaluate the technical feasibility and the clinical effectiveness of sclerotherapy for the treatment of peritoneal inclusion cysts (PICs).

Materials and Methods

Between June 1996 and February 2001, eight PICs in seven female patients aged 28-43 (mean, 36) years were instilled with sclerosant (povidone-iodine in three, ethanol in three, both povidone-iodine and ethanol in one). All seven patients subsequently experienced less abdominal pain. After drainage via an 8.5-Fr pigtail catheter inserted in the PICs (transabdominally in six cases, transvaginally in one), sclerosant equivalent in volume to about one-third that of drained fluid was introduced daily until the drained volume was less than 5ml. Follow-up by means of clinical procedures and ultrasound was performed every three months, at which time the success rate, possible complications and recurrence were determined.

Results

Sclerotherapy was technically successful in all seven patients, though immediately after the procedure, minor complications were noted in three patients (mild pain in two, mild fever in one). During the follow-up of 4-60 (mean, 24.7) months, sclerotherapy proved successful and without long-term complications in all seven patients: lower abdominal pain disappeared and the diameter of the cysts decreased more than 50%, with complete regression in four cases. During the follow-up period there was no recurrence.

Conclusion

Sclerotherapy following catheter insertion is technically feasible and effective for the treatment of PICs.     

Saline-Enhanced Radiofrequency Thermal Ablation of the Lung: A Feasibility Study in Rabbits

Objective

To assess the feasibility and safety of CT-guided percutaneous transthoracic radiofrequency ablation (RFA) with saline infusion of pulmonary tissue in rabbits.

Materials and Methods

Twenty-eight New Zealand White rabbits were divided into two groups: an RFA group (n=10) and a saline-enhanced RFA (SRFA) group (n=18). In the RFA group, percutaneous RFA of the lung was performed under CT guidance and using a 17-gauge internally cooled electrode. In the SRFA group, 1.5 ml of 0.9% saline was infused slowly through a 21-gauge, polyteflon-coated Chiba needle prior to and during RFA. Lesion size and the healing process were studied in rabbits sacrificed at times from the day following treatment to three weeks after, and any complications were noted.

Results

In the SRFA group, the mean diameter (12.5 ± 1.6 mm) of acute RF lesions was greater than that of RFA lesions (8.5 ± 1.4 mm) (p < .05). The complications arising in 12 cases were pneumothorax (n=8), thermal injury to the chest wall (n=2), hemothorax (n=1), and lung abscess (n=1). Although procedure-related complications tended to occur more frequently in the SRFA group (55.6%) than in the RFA group (20%), the difference was not statistically significant (p = .11).

Conclusion

Saline-enhanced RFA of pulmonary tissue in rabbits produces more extensive coagulation necrosis than conventional RFA procedures, without adding substantial risk of serious complications.     

Ultrasound guided dry needling and autologous blood injection for patellar tendinosis

Objective

To evaluate the efficacy of ultrasound guided dry needling and autologous blood injection for the treatment of patellar tendinosis.

Design

Prospective cohort study.

Setting

Hospital/clinic based.

Patients

47 knees in 44 patients (40 men, 7 women, mean age 34.5 years, age range 17 to 54 years) with refractory tendinosis underwent sonographic examination of the patellar tendon following referral with a clinical diagnosis of patellar tendinosis (mean symptom duration 12.9 months).

Interventions

Ultrasound guided dry needling and injection of autologous blood into the site of patellar tendinosis was performed on two occasions four weeks apart.

Main outcome measures

Pre‐ and post‐procedure Victorian Institute of Sport Assessment scores (VISA) were collected to assess patient response to treatment. Follow up ultrasound examination was done in 21 patients (22 knees).

Results

Therapeutic intervention led to a significant improvement in VISA score: mean pre‐procedure score = 39.8 (range 8 to 72) v mean post procedure score = 74.3 (range 29 to 100), p<0.001; mean follow up 14.8 months (range 6 to 22 months). Patients were able to return to their sporting interests. Follow up sonographic assessment showed a reduction in overall tendon thickness and in the size of the area of tendinosis (hypoechoic/anechoic areas within the proximal patellar tendon). A reduction was identified in interstitial tears within the tendon substance. Neovascularity did not reduce significantly or even increased.

Conclusions

Dry needling and autologous blood injection under ultrasound guidance shows promise as a treatment for patients with patellar tendinosis.     

Biplane fluoroscopy-guided radiofrequency ablation combined with chemoembolisation for hepatocellular carcinoma: initial experience

Objective

The purpose of this study was to assess the technical feasibility and local efficacy of biplane fluoroscopy-guided percutaneous radiofrequency (RF) ablation combined with transcatheter arterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC).

Method

Our retrospective study was approved by the institutional review board and informed consent was waived. 18 patients with 19 HCCs (mean 2.5 cm diameter; range 2–4.2 cm) were treated with percutaneous RF ablation combined with TACE. After segmental TACE, 18 (95%) of 19 HCCs were visible on fluoroscopy. Shortly (median 2 days; range 1–4 days) after TACE, percutaneous RF ablation was performed under real-time biplane fluoroscopic guidance. We evaluated major complications, rate of technical success at immediate post-RF ablation CT images and local tumour progression at follow-up CT images.

Results

Major complication was not observed in any patients. Technical success was achieved for all 18 visible HCCs. During the follow-up period (median 20 months; range 5–30 months), no local tumour progression was found.

Conclusion

Biplane fluoroscopy-guided RF ablation combined with TACE is technically feasible and effective for treatment of HCC.Percutaneous radiofrequency (RF) ablation has been widely implemented in the management of hepatocellular carcinoma (HCC) with promising results. Although its local efficacy for small tumours (i.e. <2 cm) is similar to surgical outcomes [1], results for medium-sized and large tumours are less robust. Thus, multimodal treatments such as combined percutaneous RF ablation with transarterial chemoembolisation (TACE) have been explored for medium or large HCCs in order to enhance the therapeutic effect. In a recent study, RF ablation combined with TACE was similar to surgical resection in patients with early-stage disease [2].Percutaneous RF ablation shortly following TACE has been usually performed under guidance of either ultrasonography or CT/CT fluoroscopy. Since intratumoural retention of radio-opaque iodised oil induced by TACE conveniently provides radiographic contrast to the index lesion, biplane fluoroscopy (anterior posterior and lateral projections) can be used as an alternative guiding modality for RF ablation combined with TACE. Easier targeting of dome lesions, often difficult to visualise on ultrasound, through an oblique approach without pleural transgression is one potential advantage of biplane fluoroscopy guidance. Also unlike on ultrasound, microbubble formation during ablation would not obscure the index lesion on biplane fluoroscopy, allowing easier and more spatially accurate application of overlapping ablations that are often needed for larger tumours. However, to our knowledge, there have been no studies investigating the role of biplane fluoroscopy as a guidance modality in this clinical setting. The purpose of our study was to retrospectively assess the technical feasibility and local efficacy of biplane fluoroscopy-guided percutaneous RF ablation combined with TACE for HCC ≥2 cm.     

Temporomandibular joint and 3.0 T pseudodynamic magnetic resonance imaging. Part 2: evaluation of articular disc obscurity

Objectives

This study examined the relationship between temporomandibular joint (TMJ) dysfunctions and obscurity grades of interpreted anterior and posterior borders of the articular disc (Da and Dp, respectively) by 3.0 T pseudodynamic MRI.

Methods

Da and Dp were classified into seven obscurity grades, and the Dp contour was classified into three types. The grades, types and TMJ function were compared by 3.0 T pseudodynamic MRI.

Results

Unobscured Da images at condylar positions posterior to the articular eminence were associated with normal TMJ function (P = 0.046 < 0.05). Unobscured Dp images at condylar positions anterior to the articular eminence were associated with normal TMJ function (P = 0.033 < 0.05). In addition, unobscured Dp images following flap insertion were associated with normal TMJ function (P = 0.043 < 0.05). There was no statistical relationship between Dp contour types and TMJ movement, but any change observed in the Dp contour during mouth opening was associated with abnormal TMJ function (P = 0.040 < 0.05).

Conclusions

Grading of Da and Dp obscurity based on how well the areas were defined in the images, identifying the condylar positions in relation to the glenoid fossa and articular eminences, and observing the changes in Dp contour types were useful for diagnosing TMJ abnormalities.     

The validation of a novel activity monitor in the measurement of posture and motion during everyday activities

Background

Accurate measurement of physical activity patterns can be used to identify sedentary behaviour and may facilitate interventions aimed at reducing inactivity.

Objective

To evaluate the activPAL physical activity monitor as a measure of posture and motion in everyday activities using observational analysis as the criterion standard.

Methods

Wearing three activPAL monitors, 10 healthy participants performed a range of randomly assigned everyday tasks incorporating walking, standing and sitting. Each trial was captured on a digital camera and the recordings were synchronised with the activPAL. The time spent in different postures was visually classified and this was compared with the activPAL output.

Results

Intraclass correlation coefficients (ICC 2,1) for interdevice reliability ranged from 0.79 to 0.99. Using the Bland and Altman method, the mean percentage difference between the activPAL monitor and observation for total time spent sitting was 0.19% (limits of agreement −0.68% to 1.06%) and for total time spent upright was −0.27% (limits of agreement −1.38% to 0.84%). The mean difference for total time spent standing was 1.4% (limits of agreement −6.2% to 9.1%) and for total time spent walking was −2.0% (limits of agreement −16.1% to 12.1%). A second‐by‐second analysis between observer and monitor found an overall agreement of 95.9%.

Conclusion

The activPAL activity monitor is a valid and reliable measure of posture and motion during everyday physical activities.