Meta-analysis of the outcomes of Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) for inguinal hernia.

OBJECTIVES: To evaluate the outcomes of Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) in patients undergoing elective inguinal hernia repair. METHODS: In compliance with PRISMA statement standards, electronic databases were searched to identify all studies reporting the outcomes of TREPP in patients undergoing elective inguinal hernia repair. The outcomes of interest included recurrence, chronic pain, haematoma, and wound infection. Proportion meta-analysis model was constructed to quantify the risk of postoperative complications and direct comparison meta-analysis model was constructed to compare the outcomes of TREPP and other open techniques. Random-effects modelling was applied to calculate pooled outcome data. RESULTS: Seven studies enrolling 1891 patients undergoing TREPP were included. The mean operative time was 26 min (95% CI 15-36). Pooled analyses showed that TREPP was associated with 3.00% (95% CI 1.00-6.00%) risk of recurrence, 3.00% (95% CI 2.00-6.00%) risk of chronic pain, 8.00% (95% CI 0.00-20.00%) risk of haematoma, and 3.00% (95% CI 0.00-6.00%) risk of wound infection. The results remained consistent through subgroup analysis of patients with primary hernias and those with recurrent hernias. Analysis of a limited number of comparative studies showed no difference between TREPP and Lichtenstein technique in terms of recurrence (OR 1.57, P = 0.26) and chronic pain (OR 1.16, P = 0.59). CONCLUSIONS: The best available evidence suggests that TREPP may be a promising technique for elective repair of inguinal hernias as indicated by low risks of recurrence, chronic pain, haematoma, and wound infection. The available evidence is limited to studies from a same country conducted by almost the same research group which may affect generalisability of the findings. Moreover, there is a lack of comparative evidence on outcomes of TREPP versus other techniques highlighting a need for high-quality randomised controlled trials for definite conclusions. Although the available evidence is not adequate for definite conclusions, the results of current study can be used for sample size calculation and power analysis in future trials.

MRI analysis of uterine ischaemia as a form of non-target embolisation following uterine artery embolisation: incidence, extent and outcome.

AIM: To study the incidence, extent and fate of uterine ischaemia as one of the forms of non-target embolisation following uterine artery embolisation (UAE), as detected on immediate post-embolisation and contrast-enhanced magnetic resonance imaging (MRI) examinations at the 3-month follow-up. MATERIALS AND METHODS: A retrospective study was undertaken comprising 43 women (mean age: 44.8 ± 3.79 years). MRI was performed before, immediately after (within 6 h), and 3 months after successful UAE. Areas of uterine ischaemia were identified on immediate post-embolisation MRI as regions of newly developed (compared to pre-embolisation MRI) absent enhancement within the uterus not corresponding to the location of the leiomyoma. The volume of the ischaemic region was calculated using the formula (height × length × width × 0.523). RESULTS: Uterine ischaemia was encountered in 29 patients (67.44%). The mean volume of the ischaemic region immediately after UAE was 29.29 ± 19.15 ml (range: 7.36-87.71 ml). At 3-month follow-up, it was 0.35 ± 0.95 ml (range: 0-3.5 ml) with 25 (86%) patients showing complete resolution of the ischaemia. The mean reduction in the volume of the ischaemic region at the 3-month follow-up was 98.24 ± 5.72% (range: 72-100%). This volume reduction was statistically significant (p<0.0001). CONCLUSION: Uterine ischaemia as a form of non-target embolisation following UAE might be encountered in up to two thirds of patients. These ischaemic areas are significantly reduced at the 3-month follow-up with up to 86% of cases showing complete reversibility of the ischaemia.

CT-guided hook-wire localisation prior to video-assisted thoracoscopic surgery of pulmonary lesions.

AIM: To assess the feasibility, safety, and efficacy of computed tomography (CT)-guided pulmonary nodule localisation using a hooked guide wire before video-assisted thoracoscopic surgery (VATS). MATERIALS AND METHODS: The study included 79 patients with a history of malignancies outside the lung associated with pulmonary nodules. Mean lesion size was 0.7 cm (range 0.5-1.8 cm) and the mean lesion distance to the pleural surface was 1.5 cm (range 0.2-5 cm). All lesions (n=82) were marked with a 22-G hook wire. The technique was designed to insert the tip of the hook wire within or maximally 1 cm from the edge of the lesion. The Mann-Whitney U-test was used for univariate analyses and Fisher's exact test for categorical values. RESULTS: The hooked guide wire was positioned successfully in all 82 pulmonary nodules within mean time of 9 minutes (8-20 minutes, SD: 2.5 minutes). The procedure time was inversely proportional to the size of the lesion (Spearman correlation factor 0.7). Minimal pneumothoraces were observed in five patients (7.6%). Pneumothorax was not correlated to the histopathology of the pulmonary nodules (p>0.09). Focal perilesional pulmonary haemorrhage developed in four patients (5%). Both haemorrhage and pneumothorax were significantly correlated to lesions <10 mm (p=0.02 and 0.01 respectively). The volume of resected lung tissue was significantly correlated to lesions of increased distance from the pleural surface ≥2.5 cm in comparison to lesions of <2.5 cm from the pleural surface. CONCLUSION: CT-guided pulmonary nodule localisation prior to VATS could enable safe, accurate surgical guidance for the localisation of small pulmonary nodules.

Pre-, Intra- and Post-Operative Imaging of Cochlear Implants.

The purpose of this review is to present essential imaging aspects in patients who are candidates for a possible cochlear implant as well as in postsurgical follow-up. Imaging plays a major role in providing information on preinterventional topography, variations and possible infections. Preoperative imaging using DVT, CT, MRI or CT and MRI together is essential for candidate selection, planning of surgical approach and exclusion of contraindications like the complete absence of the cochlea or cochlear nerve, or infection. Relative contraindications are variations of the cochlea and vestibulum. Intraoperative imaging can be performed by fluoroscopy, mobile radiography or DVT. Postoperative imaging is regularly performed by conventional X-ray, DVT, or CT. In summary, radiological imaging has its essential role in the pre- and post-interventional period for patients who are candidates for cochlear implants.

Acute intracranial hemorrhage in CT: benefits of sinogram-affirmed iterative reconstruction techniques.

BACKGROUND AND PURPOSE: Acute intracranial hemorrhage represents a severe and time critical pathology that requires precise and quick diagnosis, mainly by performing a CT scan. The purpose of this study was to compare image quality and intracranial hemorrhage conspicuity in brain CT with sinogram-affirmed iterative reconstruction and filtered back-projection reconstruction techniques at standard (340 mAs) and low-dose tube current levels (260 mAs). MATERIALS AND METHODS: A total of 94 consecutive patients with intracranial hemorrhage received CT scans either with standard or low-dose protocol by random assignment. Group 1 (n=54; mean age, 64 ± 20 years) received CT at 340 mAs, and group 2 (n=40; mean age, 57 ± 23 years) received CT at 260 mAs. Images of both groups were reconstructed with filtered back-projection reconstruction and 5 iterative strengths (S1-S5) and ranked blind by 2 radiologists for image quality and intracranial hemorrhage on a 5-point scale. Image noise, SNR, dose-length product (mGycm), and mean effective dose (mSv) were calculated. RESULTS: In both groups, image quality and intracranial hemorrhage conspicuity were rated subjectively with an excellent/good image quality. A higher strength of sinogram-affirmed iterative reconstruction showed an increase in image quality with a difference to filtered back-projection reconstruction (P < .05). Subjective rating showed the best score of image quality and intracranial hemorrhage conspicuity achieved through S3/S4-5. Objective analysis of image quality showed in an increase of SNR with a higher strength of sinogram-affirmed iterative reconstruction. Patients in group 2 (mean: 744 mGycm/1.71 mSv) were exposed to a significantly lower dose than those in group 1 (mean: 1045 mGycm/2.40 mSv, P < .01). CONCLUSIONS: S3 provides better image quality and visualization of intracranial hemorrhage in brain CT at 260 mAs. Dose reduction by almost one-third is possible without significant loss in diagnostic quality.

Repeated transarterial chemoembolisation using different chemotherapeutic drug combinations followed by MR-guided laser-induced thermotherapy in patients with liver metastases of colorectal carcinoma.

BACKGROUND: To evaluate a treatment protocol with repeated transarterial-chemoembolisation (TACE) downsizing before MR-guided laser-induced interstitial thermotherapy (LITT) using different chemotherapeutic combinations in patients with unresectable colorectal cancer (CRC) liver metastases. METHODS: Two hundred and twenty-four patients were included in the current study. Transarterial-chemoembolisation (mean 3.4 sessions per patient) was performed as a downsizing treatment to meet the LITT requirements (number5, diameter <5 cm). The intra-arterial protocol consisted of either Irinotecan and Mitomycin (n=77), Gemcitabine and Mitomycin (n=49) or Mitomycin alone (n=98) in addition to Lipiodol and Embocept in all patients. Post TACE, all patients underwent LITT (mean 2.2 sessions per patient). RESULTS: Overall, TACE resulted in a mean reduction in diameter of the target lesions of 21.4%. The median time to progression was 8 months, calculated from the start of therapy and the median local tumour control rate was 7.5 months, calculated as of therapy completion. Median survival of patients calculated from the beginning of TACE was 23 months (range 4-110 months), in patients treated with Irinotecan and Mitomycin the median was 22.5 months, Gemcitabine and Mitomycin 23 months and Mitomycin only 24 months with a statistically significant difference between the groups (P<0.01). CONCLUSION: Repeated TACE offers adequate downsizing of CRC liver metastases to allow further treatment with LITT. The combined treatment illustrates substantial survival rates and high local tumour control with statistically significant differences between the three protocols used. Further randomised trials addressing the current study results are required.

Role of uterine artery Doppler in the management of uterine leiomyoma by arterial embolization.

OBJECTIVES: To study Doppler changes in the uterine artery immediately following and 3 months after uterine artery embolization (UAE) and to test the feasibility of using uterine artery Doppler as a predictor of the predominant side of arterial supply to leiomyomas, amount of embolizing material needed and leiomyoma tumor volume at follow-up. METHODS: The study included 38 patients undergoing UAE for leiomyomas. Uterine artery Doppler was performed transabdominally before, within 6 hours after and 3 months after UAE to determine the peak systolic (PSV) and end-diastolic (EDV) velocities and resistance index (RI). Leiomyoma volume was measured using contrast-enhanced magnetic resonance imaging (MRI) before and 3 months after UAE. The predominant side of arterial supply to the leiomyoma was determined on digital subtraction angiography using the uterine artery diameter and tumor blush after contrast injection. For correlations with leiomyoma volume, the average PSV, EDV and RI of both sides was used, while for prediction of the predominant side of supply and for correlation with the amount of embolizing material needed, separate measurements from each side were used. RESULTS: Relative to the pre-embolization value, the uterine artery PSV and EDV were significantly reduced (P < 0.05) immediately following UAE, while the RI was significantly elevated (P < 0.05). For prediction of the predominant side of supply, the lowest RI showed the highest accuracy (81.6%). There was no significant correlation between the pre-embolization PSV, EDV or RI and the amount of embolizing material utilized. Immediately post-embolization EDV and RI values were statistically significantly correlated with the 3-month follow-up leiomyoma volume, with RI showing the strongest correlation (P = 0.0400 and 0.0002, rho = 0.34 and - 0.58, respectively). The leiomyoma volume was predicted to have reduced by 38-61% after 3 months if the immediate post-embolization average RI value was between 0.82 and 0.88. CONCLUSION: Pre-interventional Doppler assessment can be used to predict the predominant side of supply to leiomyomas but not the amount of embolizing material needed. Immediate post-interventional Doppler assessment can predict the leiomyoma volume after UAE.

[Chemoperfusion and embolization in the treatment of liver metastases]. / Chemoperfusion und -embolisation von Lebermetastasen.

Presentation of techniques and procedures for regional chemotherapy in the treatment of unresectable liver metastases from different primary tumors as a modality of interdisciplinary therapy management. Such transarterial therapy methods include hepatic arterial infusion (HAI), transarterial chemoembolization (TACE), chemoembolization with cytostatic-loaded microspheres (DEBs), transarterial embolization (TAE) and selective internal radiation therapy (SIRT). Regional chemotherapy procedures in the treatment of liver metastases represent a minimally invasive treatment option that can be successfully combined with surgical resection and/or radiofrequency (RFA), laser-induced thermotherapy (LITT), microwave ablation (MWA). These procedures allow optimization of the local control rate with strictly intrahepatic processes and lead to increased survival rates without any quality of life restriction.

[C-arm computed tomography for transarterial chemoperfusion and chemo-embolization of thoracic lesions]. / Transarterielle Chemoperfusion und -embolisation thorakaler Neoplasmen mittels C-Arm CT.

PURPOSE: To evaluate the role of C-arm CT for on-line fluoroscopy in regional transarterial chemoperfusion (TACP) and chemo-embolization (TPCE) of primary and secondary malignant thoracic lesions. MATERIALS AND METHODS: From September 2008 to March 2009 a total of 31 patients (20 males and 11 females, average age: 61.7 years, range 22-84 years) with 53 thoracic malignant lesions from different origins (primary or secondary pulmonary carcinoma n=37, pleural mesothelioma n=16) were treated with TACP or TPCE using flat-detector CT (FD-CT). C-arm CT of the latest generation was used to localize the lesion before local chemotherapy (Artis Zeego, Siemens, Erlangen). For TACP a 220 degrees rotation and a volume of 150 ml (ratio of 1:2 contrast/normal saline), delay 2 s and flow 12 ml/s was used. For TPCE a volume of 75 ml (ratio of 1:2 contrast/normal saline), delay 2 s and flow 3 ml/s was used. RESULTS: TPCE C-arm CT allowed the evaluation of the degree of perfusion of the tumor and the geographic areas of enhancement correlated with the post-interventional lipiodol uptake in MSCT. In TACP the intercostal arteries involved could be visualized and in 30% of interventions the catheter had to be repositioned for the following intervention. CONCLUSION: C-arm CT provides additional information on the vascular characteristics and perfusion of pulmonary lesions resulting in a change of interventional strategy in a relevant number of patients.

[Retrospective 5-year analysis of MR-guided biopsies in a low-field MR system]. / Retrospektive Analyse der 5-Jahres-Ergebnisse von MRT-gesteuerten Biopsien im Niederfeldsystem.

PURPOSE: The purpose of this study was to evaluate the safety and clinical value of MR-guided biopsies in an open 0.2 T low-field system. MATERIALS AND METHODS: A total of 322 patients with suspicious lesions of different body regions were biopsied in a low-field MRI system (0.2 T, Concerto, Siemens). The procedures were guided using T 1-weighted Flash sequences (TR/TE = 100/9; 70 degrees). The lesions were repeatedly biopsied using the coaxial technique with a 15-gauge (diameter 2 mm) puncture needle. Complications and biopsy findings were analyzed retrospectively. RESULTS: In all cases the biopsy procedures were successfully performed with MR guidance. In 298 patients diagnosis was able to be confirmed on the basis of the probes. The clinical follow-up showed that in 24 patients the lesions were missed by MR-guided biopsy. From this a sensitivity of 86%, a specificity of 87% and an accuracy of 93% were calculated. In two patients major complications were observed (morbidity rate 0.6 %). CONCLUSION: MR-guided biopsy can be performed safely and precisely in a low-field MR system and are a supplement to US or CT-guided biopsies.