Prospective respiratory triggering improves high-resolution brachial plexus MRI quality.

BACKGROUND: Oblique sagittal MRI sequences, orthogonal to the longitudinal axis of the brachial plexus, can reliably depict morphologic and signal abnormalities. However, nerve visualization may be obscured by ghosting artifact from periodic respiratory motion. Respiratory triggering (RT) with a thoracoabdominal bellows can reduce ghosting artifact, but it is not routinely used for brachial plexus MRI. Furthermore, the efficacy of prospective RT for brachial plexus imaging has not yet been reported. PURPOSE: To compare brachial plexus MRI sequences acquired with and without respiratory triggering. STUDY TYPE: Prospective. SUBJECTS: Five volunteers and 20 patients were included. Each subject was imaged with and without RT during the same session. FIELD STRENGTH/SEQUENCE: Proton density or T2 -weighted Dixon fat suppressed sequences were obtained at 3.0T using receive-only 16-channel flexible array coils. ASSESSMENT: Three musculoskeletal radiologists blindly evaluated each sequence using subjective scoring criteria for ghosting artifact, nerve conspicuity, and diagnostic confidence. Nerve conspicuity scores at three distinct plexus levels were summed to calculate an overall image quality score. STATISTICAL TESTS: Marginal proportional odds logistic regression models were used to compare all scores between RT and non-RT. Gwet's agreement coefficient was used to assess interobserver and intraobserver reliability. RESULTS: Mean scan time per sequence increased from 4:25 minutes (95% confidence interval [CI], 4:02-4:49 min) with non-RT to 6:09 minutes (95% CI, 5:42-6:35 min) with RT. RT reduced ghosting artifact (odds ratio [OR] = 0.21, 95% CI: 0.09-0.46, P < 0.001), improved overall image quality (OR = 4.88, 95% CI: 2.18-10.95, P < 0.001), and increased diagnostic confidence (OR = 3.72, 95% CI: 1.61-8.63, P = 0.002) for all readers. Interobserver agreement for ghosting artifact and image quality was substantial to almost perfect (AC2 = 0.74-0.85). Interobserver agreement for all other scores was moderate to almost perfect (AC2 = 0.61-0.82). Intraobserver agreement was substantial to almost perfect for all parameters (AC2 = 0.76-1.0). DATA CONCLUSION: Prospective RT with bellows can effectively minimize ghosting artifact and improve image quality for brachial plexus MRI within clinically optimal acquisition times. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2.

Laparoscopic repair of large hiatal hernia: impact on dyspnoea.

INTRODUCTION: This study aims to examine the impact of laparoscopic repair of large hiatal hernia on dyspnoea severity, respiratory function and quality of life. METHODS: From 2004 to 2008, 30 consecutive patients with large para-oesophageal hernia defined as >50% of stomach in the intra-thoracic cavity and minimum follow-up of 2 years were included in this study. All patients had a formal respiratory function test 1 week prior and 3 months after their laparoscopic hiatal hernia repair. Patients rated symptom severity and completed a quality-of-life questionnaire [Gastrointestinal Quality of Life Index (GIQLI)] pre-operatively, and post-operatively at 3 months, 6 months and yearly thereafter. RESULTS: There was no hospital mortality, and the morbidity rate was 10%. In 26 patients with pre-operative dyspnoea, 22 had complete resolution while the remaining 4 had improvement of dyspnoea severity post-operatively. The mean dyspnoea severity index reduced from 2.4 to 1.3 (P < 0.001). Overall, there was 1%, 3% and 3% post-operative increase in forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and diffusing capacity of the lung for carbon monoxide (DLCO) values for the whole group, none of which reached statistical significance. For patients with resolution or improvement of dyspnoea after laparoscopic repair, no significant change of respiratory function parameters was demonstrated. GIQLI score improved from a pre-operative value of 85.7 to 107.9 post-operatively (P < 0.001). CONCLUSIONS: We failed to show a significant change in post-operative respiratory function despite clearly demonstrated improvement of respiratory symptoms. Alternative explanations for reduction of dyspnoea severity should be sought.

Radiofrequency ablation of lung tumors: feasibility and safety.

BACKGROUND: Percutaneous image-guided radiofrequency ablation is being promoted as a novel technique with a low morbidity rate in the treatment of inoperable lung tumors. The purpose of this study was to assess the incidence and risk factors of various complications after radiofrequency ablation of pulmonary neoplasms. METHODS: The clinical and treatment-related data regarding 129 consecutive percutaneous radiofrequency ablation treatment sessions for 100 patients with inoperable lung tumors were collected prospectively. Univariate and multivariate analyses were conducted to identify significant risk factors associated with postprocedural overall morbidity, pleuritic chest pain, hemoptysis, pneumothorax, pleural effusions, and chest drain requirement. RESULTS: There was no postprocedural mortality. The overall morbidity rate was 43% (n = 55 of 129). The most common adverse effect was pneumothorax, occurring in 32% (n = 41 of 129) of treatment sessions. Other significant complications included pleuritic chest pain (18%, n = 23 of 129), hemoptysis (7%, n = 9 of 129), pleural effusions (12%, n = 15 of 129), and chest drain insertion (20%, n = 26 of 129). Both univariate and multivariate analyses identified more than two lesions ablated per session as a significant risk factor for overall morbidity, pneumothorax, and chest drain insertion, but not for pleuritic pain, hemoptysis, and pleural effusions. Length of the ablation probe trajectory greater than 3 cm was an additional independent risk factor for overall morbidity and pneumothorax. Hilar location of lung tumor/s was the only independent risk factor associated with the increased incidence of hemoptysis. CONCLUSIONS: Radiofrequency ablation for lung tumors can be considered as a safe and technically feasible procedure with acceptable incidence of complications.

A systematic review of radiofrequency ablation for lung tumors.

BACKGROUND: Radiofrequency ablation (RFA) has been increasingly utilized as a non-surgical treatment option for patients with primary and metastatic lung tumors. We performed the present systematic review to assess the safety and efficacy of RFA. METHODS: Searches for all relevant studies prior to November 2006 were performed on six databases. Two reviewers independently appraised each study using predetermined criteria. Clinical effectiveness was synthesized through a narrative review, with full tabulation of results of all included studies. RESULTS: A total of 17 of the most recent updates from each institution were included for appraisal and data extraction. All were case series and were classified as level-4 evidence. The mean number of lesions treated ranged from 1 to 2.8, and the mean size ranged from 1.7 cm to 5.2 cm. The overall procedure-related morbidity rate ranged from 15.2% to 55.6% and mortality from 0% to 5.6%. The most commonly reported complication was pneumothorax (4.5-61.1%). Most pneumothoraces were self-limiting and only 3.3-38.9% (median = 11%) required chest drain insertion. The local recurrence of tumors at the site of RFA ranged from 3% to 38.1% (median = 11.2%). The median progression-free interval ranged from 15 months to 26.7 months (median = 21 months), and 1-, 2- and 3-year survival rates were 63-85%, 55-65% and 15-46%, respectively. CONCLUSIONS: Only observational studies were available for evaluation, which demonstrated some promising safety profiles of RFA.

Recurrence and survival outcomes after hepatic resection with or without cryotherapy for liver metastases from colorectal carcinoma.

BACKGROUND: Some reports support resection combined with cryotherapy for patients with multiple bilobar colorectal liver metastases (CRLM) that would otherwise be ineligible for curative treatments. This series demonstrates long-term results of 415 patients with CRLM who underwent resection with or without cryotherapy. METHODS: Between April 1990 and January 2006, 291 patients were treated with resection only and 124 patients with combined resection and cryotherapy. Recurrence and survival outcomes were compared. Kaplan-Meier and Cox-regression analyses were used to identify significant prognostic indicators for survival. RESULTS: Median length of follow-up was 25 months (range 1-124 months). The 30-day perioperative mortality rate was 3.1%. Overall median survival was 32 months (range 1-124 months), with 1-, 3- and 5-year survival values of 85%, 45% and 29%, respectively. The overall recurrence rates were 66% and 78% for resection and resection/cryotherapy groups, respectively. For the resection group, the median survival was 34 months, with 1-, 3- and 5- year survival values of 88%, 47% and 32%, respectively. The median survival for the resection/cryotherapy group was 29 months, with 1-, 3- and 5-year survival values of 84%, 43% and 24%, respectively (P = 0.206). Five factors were independently associated with an improved survival: absence of extrahepatic disease at diagnosis, well- or moderately-differentiated colorectal cancer, largest lesion size being 4 cm or less, a postoperative CEA of 5 ng/ml or less and absence of liver recurrence. CONCLUSIONS: Long-term survival results of resection combined with cryotherapy for multiple bilobar CRLM are comparable to that of resection alone in selected patients.