Restored pelvic anatomy is preserved after laparoscopic and robot-assisted ventral rectopexy: MRI-based 5-year follow-up of a randomized controlled trial.

AIM: Our aim was to compare the long-term anatomical outcomes between robot-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for external or internal rectal prolapse. METHOD: This study is a follow-up of a single-centre randomized controlled trial (RCT). Thirty patients were randomly allocated to RVMR (n = 16) or LVMR (n = 14). The primary end-point was maintenance of the restored pelvic anatomy 5 years after the operation, as assessed by magnetic resonance (MR) defaecography. Secondary outcome measures included the Pelvic Organ Prolapse Quantification (POP-Q) measures and functional results assessed using symptom questionnaires. RESULTS: Twenty-six patients (14 RVMR and 12 LVMR) completed the 5-year follow-up and were included in the study. The MRI results, POP-Q measurements and symptom-specific quality of life measures did not differ between the RVMR and LVMR groups. The MRI measurements of the total study population remained unchanged between 3 months and 5 years. In the Pelvic Floor Distress Inventory (PFDI-20), the RVMR group had lower symptom scores (mean 96.0, SD 70.7) than the LVMR group (mean 160.6, SD 58.9; P = 0.004). In the subscales of pelvic organ prolapse (POPDI-6) (mean 23.2, SD 24.3 vs mean 52.4, SD 22.4; P = 0.001) and the Colorectal-Anal Distress Inventory (CRADI-8) (mean 38.4, SD 23.3 vs mean 58.6, SD 25.4; P = 0.009), the patients in the RVMR group had significantly better outcomes. CONCLUSION: After VMR, the corrected anatomy was preserved. There were no clinically significant differences in anatomical results between the RVMR and LVMR procedures 5 years after surgery based on MR defaecography. However, functional outcomes were better after RMVR.

A prospective pilot study on MRI visibility of iron oxide-impregnated polyvinylidene fluoride mesh after ventral rectopexy.

BACKGROUND: Magnetic resonance imaging (MRI) provides excellent information about pelvic anatomy after ventral rectopexy, but the position of the conventional mesh is not seen constantly. Iron oxide-impregnated polyvinylidene fluoride (PVDF) meshes are proven to have MRI visibility in hernia or vaginal reconstructive surgery. This prospective pilot study was designed to assess the visualization, position, and shape of the magnetic resonance (MR)-visible synthetic pelvic mesh used in minimally invasive ventral rectopexy. METHODS: Eight patients with pelvic organ prolapse were recruited for laparoscopic (LVMR) or robotic-assisted ventral mesh rectopexy (RVMR) with a synthetic MR-visible PVDF mesh. A follow-up visit was scheduled at 3 months after surgery. MR imaging was performed to evaluate the position and dimensions of the mesh and anatomical result. The visibility of the mesh in each sequence was assessed subjectively. RESULTS: The visibility of the mesh was best on T1-weighted flash images. The mesh was also well visualized on T2-weighted sagittal images. T2-weighted images, in general, provided best visualization of the surrounding anatomical structures and enabled assessment of the mesh fixation. CONCLUSIONS: T2 sagittal and T1-weighted flash images provide the best information about the position and integrity of the iron oxide-impregnated PVDF mesh after LVMR or RVMR with a short examination time.

Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial.

AIM: The purpose of this prospective randomized study was to compare robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using magnetic resonance (MR) defaecography. METHOD: Sixteen female patients (four with total prolapse, twelve with intussusception) underwent robot-assisted ventral mesh rectopexy (RVMR) and 14 female patients (two with prolapse, twelve with intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by MR defaecography, which was performed preoperatively and 3 months after surgery. RESULTS: Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomical defects of rectal prolapse, intussusception and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed with dynamic MR defaecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs one LVMR) and in one patient with primary intussusception (RVMR) (P = 0.60). Rectocele was reduced from a mean of 33.0 ± 14.9 mm to 5.5 ± 8.4 mm after RVMR (P < 0.001) and from 24.7 ± 17.5 mm to 7.2 ± 3.2 mm after LVMR (P < 0.001) (RVMR vs LVMR, P = 0.10). CONCLUSION: Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomical correction as assessed by MR defaecography, with no differences between the techniques.

Treatment response of colorectal cancer liver metastases to neoadjuvant or conversion therapy: a prospective multicentre follow-up study using MRI, diffusion-weighted imaging and 1H-MR spectroscopy compared with histology (subgroup in the RAXO trial).

BACKGROUND: Colorectal cancer liver metastases respond to chemotherapy and targeted agents not only by shrinking, but also by morphologic and metabolic changes. The aim of this study was to evaluate the value of advanced magnetic resonance imaging (MRI) methods in predicting treatment response and survival. PATIENTS AND METHODS: We investigated contrast-enhanced MRI, apparent diffusion coefficient (ADC) in diffusion-weighted imaging and 1H-magnetic resonance spectroscopy (1H-MRS) in detecting early morphologic and metabolic changes in borderline or resectable liver metastases, as a response to first-line neoadjuvant or conversion therapy in a prospective substudy of the RAXO trial (NCT01531621, EudraCT2011-003158-24). MRI findings were compared with histology of resected liver metastases and Kaplan-Meier estimates of overall survival (OS). RESULTS: In 2012-2018, 52 patients at four Finnish university hospitals were recruited. Forty-seven patients received neoadjuvant or conversion chemotherapy and 40 liver resections were carried out. Low ADC values (below median) of the representative liver metastases, at baseline and after systemic therapy, were associated with partial response according to RECIST criteria, but not with morphologic MRI changes or histology. Decreasing ADC values following systemic therapy were associated with improved OS compared to unchanged or increasing ADC, both in the liver resected subgroup (5-year OS rate 100% and 34%, respectively, P = 0.022) and systemic therapy subgroup (5-year OS rate 62% and 23%, P = 0.049). 1H-MRS revealed steatohepatosis induced by systemic therapy. CONCLUSIONS: Low ADC values at baseline or during systemic therapy were associated with treatment response by RECIST but not with histology, morphologic or detectable metabolic changes. A decreasing ADC during systemic therapy is associated with improved OS both in all patients receiving systemic therapy and in the resected subgroup.

Sweating impairment in patients with multiple sclerosis.

OBJECTIVES: To measure sweating in patients with multiple sclerosis (MS). MATERIALS AND METHODS: Sweating was measured by an evaporimeter after a heating stimulus in 29 MS patients and in 15 healthy control subjects. RESULTS: The MS patients sweated markedly less than the controls. After 10 min of heating the sweating was significantly lower in the forehead (P = 0.034), feet (right, P = 0.033; left, P = 0.037) and legs (right, P = 0.043; left, P = 0.029) of the MS patients than in those of the controls. After 15 min of heating the difference was statistically significant only in the feet (right, P = 0.043; left, P = 0.029). The Expanded Disability Status Scale score correlated inversely with sweating at 15 min of heating in the left hand (r = 0.42, P < 0.05), and in the left (r = 0.36, P < 0.05) and right foot (r = 0.37, P < 0.05). CONCLUSIONS: MS is associated with an impairment in thermoregulatory sweating which seems to be related to the disease severity.

Sympathetic skin responses in multiple sclerosis.

OBJECTIVES: This study assessed the sympathetic skin responses (SSRs) and their correlation with brain lesion volumes in patients with multiple sclerosis (MS). MATERIALS AND METHODS: The SSRs were measured in 27 patients with MS and 27 healthy controls. The volumes of the proton density-weighted MS lesions in the brain were measured using MRI. RESULTS: The SSRs were abnormal in 52% of the patients with MS, but absent only in clinically severe MS. The total lesion volume in the whole brain correlated significantly with both the severity of MS expressed by the EDSS score (P < 0.001) and the decreased SSR amplitudes in the feet (P < 0.01). Focal lesion volumes in the temporal lobe (P < 0.01), in the pons (P < 0.01) and in the cerebellum (P < 0.01) were also separately associated with abnormal SSR reflexes. CONCLUSIONS: Sudomotor regulation failure in MS is associated with certain focal MS lesions.

Local staging of rectal cancer using the black lumen magnetic resonance imaging technique.

BACKGROUND AND AIMS: The treatment of rectal cancer is comprised of surgery and possible adjuvant therapy depending on the stage of the tumour. This prospective study evaluates the accuracy of magnetic resonance imaging (MRI) in the preoperative staging of rectal cancer using an endorectal and intravenous contrast. MATERIALS AND METHODS: 37 consecutive patients with rectal cancer were imaged using a mixture of ferumoxsil and methylcellulose endorectally, and a gadolinium contrast intravenously. 33 tumours were resected and 4 tumours were considered unresectable during operation. The images were reviewed for local staging of the tumours. A tumour confined to the rectal wall was classified as a negative finding and a tumour invading through muscularis propria as a positive finding. The results were correlated with the histopathologic t stage (n = 33), or the clinical status (n = 4). RESULTS AND CONCLUSIONS: of 37 cases, 20 (51 %) were true positive, and 11 (28%) were true negative. There were 3 false negative and 3 false positive cases. The sensitivity was 87%, specificity 79%, and diagnostic accuracy 84%. for the non-contrast images the figures were 78%, 79% and 78%, respectively. We consider black lumen magnetic resonance imaging to be a useful method for preoperative local staging of rectal cancer.

Brain atrophy evaluated by computed tomography in independent and institutionalized hip fracture patients.

PURPOSE: To examine if there is an association between brain computed tomography (CT) findings and place of residence in a series of hip fracture patients. METHOD: The CT scans taken immediately after hip fracture of 215 patients (mean age 81.6 years) living in their own homes or otherwise independently (home-dwelling group) and 95 patients (mean age 82.5 years) permanently institutionalized (institutionalized group) were analysed. RESULTS: The institutionalized patients had significantly more cortical cerebral (frontal, p = 0.004; temporal, p = 0.007; parietal, p < 0.001) and central cerebral (third ventricle width, p < 0.001; frontal horn width, p < 0.001; midbody width, p < 0.001) atrophy than the home-dwelling ones. This was also true of atrophy in the white-matter (WM) area (p < 0.001). The institutionalized patients also had more atrophy of the cerebellar hemisphere (atrophy of the cerebellopontine angle cistern, p = 0.002, greater fourth ventricle width, p = 0.020). No significant difference was seen in the incidence of brain infarcts. CONCLUSIONS: Hip fracture patients living in institutions have more brain atrophy than those living independently. The brain atrophy may be one factor in the multiple mechanism underlying their institutional admission.

Pituitary size assessed with magnetic resonance imaging as a measure of growth hormone secretion in long term survivors of childhood cancer.

We investigated 37 long term survivors of childhood cancer to study the relationship among growth, GH secretion, and pituitary size. The median follow-up time after diagnosis was 13.2 yr. The pituitary gland was visualized with magnetic resonance imaging. Radiated patients (n = 25) had a reduced relative height and showed a greater reduction in relative height after diagnosis than nonradiated patients (n = 12). The patients had lower spontaneous nocturnal GH secretion than controls due to a reduced peak amplitude. Spontaneous GH secretion was lower in radiated patients than in nonradiated subjects. The patients had lower plasma insulin-like growth factor-I (IGF-I) and serum IGF-binding protein-3 (IGFBP-3) concentrations than the controls. Radiated subjects had decreased IGF-I and IGFBP-3 concentrations compared to nonradiated subjects. Half of the patients (20 of 37) evaluated with magnetic resonance imaging had a reduced pituitary size (pituitary height, < -2 SD score). Radiated subjects had smaller pituitary glands than nonradiated ones. Seventeen of 20 patients (85%) with reduced pituitary size had decreased nocturnal GH release. There was a positive correlation between nocturnal GH secretion, plasma IGF-I, and serum IGFBP-3 levels, on the one hand, and pituitary height, on the other. These results indicate that cranial radiation may result in tissue damage, leading to decreased pituitary size, reduced spontaneous GH secretion, and impaired linear growth. The finding of reduced IGF-I levels in both radiated and nonradiated patients combined with decreased IGFBP-3 concentrations in radiated patients, indicates that cytotoxic chemotherapy may induce hepatic damage resulting in decreased IGF-I synthesis.

Psychological findings in preterm children related to neurologic status and magnetic resonance imaging.

OBJECTIVE: Preterm children experience learning disabilities more often than full-term children, but detailed information on their neuropsychological and neurologic determinants is lacking. We therefore examined these problems more closely and also studied if clinical neurologic examination and/or magnetic resonance imaging (MRI) can be used as tools to screen the preterm children at risk for these problems. METHODS: In a population-based study, the psychological performance of 42 preterm children with a birth weight <1750 g and of their matched controls was assessed at 8 years of age and the findings were then related to clinical neurologic examination and MRI. Learning disabilities of these children, reported by the teachers, were also studied. RESULTS: The cognitive ability of the preterm children, although in the normal range, was significantly lower than that of the control children. They performed particularly poorly in tasks requiring spatial and visuoperceptual abilities, which were associated with the finding of periventricular leukomalacia in MRI, especially with posterior ventricular enlargement. The preterm children with minor neurodevelopmental dysfunction (MND) had the most problems in neuropsychological tests, whereas the clinically healthy preterm children and those with cerebral palsy had fewer problems. The problems of MND children emerged in the domain of attention. They also experienced the most problems at school. CONCLUSIONS: Visuospatial problems were associated with periventricular leukomalacia in MRI, but learning disabilities were most frequent among the preterm children with minor neurologic abnormalities. We recommend closer follow-up of preterm children with MND.

Brain perfusion after treatment of childhood acute lymphoblastic leukemia.

UNLABELLED: Children with acute lymphoblastic leukemia (ALL) have impairment in their neuropsychological functioning and morphological changes in their brain after cranial irradiation and chemotherapy. The aim of this study was to identify possible brain perfusion defects caused by different types of treatment and their association with abnormalities in cerebral MRI and neuropsychological and clinical neurological findings. METHODS: Twenty-five consecutive children with ALL at the cessation of chemotherapy or after 1 yr were included. All of the children were given intravenous and intrathecal methotrexate for central nervous system therapy, 13 of them received cranial radiation therapy. Brain SPECT, cerebral MRI, clinical neurological and neuropsychological evaluations were performed. RESULTS: Eleven of the 25 patients (44%) had brain perfusion defects in SPECT, eight of whom were treated with chemotherapy alone, and three received cranial irradiation. Two patients had small bilateral white matter changes on MRI; their brain SPECT scans were abnormal, although the findings were not related. Impairment of neuropsychological functioning was found in 86% of the patients tested. No significant difference between the patients with abnormal and normal SPECT were found. Those patients with abnormal SPECT were younger than those with normal SPECT and had received more frequent intravenous methotrexate infusions. CONCLUSION: Brain SPECT detected perfusion defects that had occurred after treatment for childhood ALL. These defects may be related to frequent administration of a combination of intravenous and intrathecal methotrexate and/or young age.

Cardiovascular autonomic dysfunction correlates with brain MRI lesion load in MS.

OBJECTIVE: The aim of the present study was to investigate the cardiovascular autonomic control in clinically definite multiple sclerosis (MS) patients with a standardised battery of cardiovascular tests and to correlate these findings with the brain magnetic resonance imaging (MRI) lesion load. METHODS: Fifty-one patients with MS and 50 healthy controls were studied. Brain MRI was performed in all patients showing typical MS lesions. The cardiovascular tests were carried out using a standardised battery. RESULTS: Heart rate (HR) responses to deep breathing (P < 0.05) and tilt table testing (P < 0.001) were significantly decreased in MS patients when compared to those of the controls. Blood pressure (BP) responses in the tilt table test were also impaired in MS patients (diastolic P < 0.001, systolic P < 0.05). Of the different brain areas investigated the total volume of the midbrain MRI lesions (P < 0.05) was the one most clearly associated with the impaired BP responses. CONCLUSIONS: MS results in both reduced HR variation and decreased BP reactions indicating disturbed cardiovascular regulation. In particular, the midbrain lesions found in MS are associated with cardiovascular dysfunction.

Decreased pituitary gland height after radiation treatment to the hypothalamic-pituitary axis evaluated by MR.

PURPOSE: To evaluate treatment-related changes in pituitary gland morphology after childhood cancer and to compare these findings with growth data. METHODS: Forty-three survivors of childhood cancer were evaluated by cranial MR imaging. Twenty-nine of the patients had received radiation therapy to the hypothalamic-pituitary axis with doses of 10 to 46 Gy. The height of the pituitary gland was measured from midline sagittal images and compared with age- and sex-matched controls. Pituitary gland heights were compared with body height standard deviation scores in patients. RESULTS: The patients who had received radiation therapy to the hypothalamic-pituitary axis had significantly smaller pituitary glands than patients in the nonirradiated group or their age- and sex-matched controls (mean, 3.5 mm versus 5.9 and 5.8 mm, respectively). They were also significantly shorter than patients in the nonirradiated group. CONCLUSION: Radiation therapy to the hypothalamic-pituitary area may lead to poor growth of the pituitary gland and short stature.

Post-traumatic findings of the spine after earlier vertebral fracture in young patients: clinical and MRI study.

STUDY DESIGN: A study comparing magnetic resonance imaging findings of degenerative changes in intervertebral discs in young patients with previous wedge-shaped compression fracture and age-matched and sex-matched control subjects. OBJECTIVES: To find out the role of fractures in disc degeneration and to assess the clinical outcome of the patients. SUMMARY OF BACKGROUND DATA: Several experimental studies have postulated that trauma is one of the major reasons for disc degeneration. Wedge compression fractures in vertebrae of children have been considered insignificant, but this has not been verified in the literature. METHODS: Fourteen patients 8.8 to 20.8 years of age (mean, 15.5 years) with a history of wedge-shaped vertebral compression fracture at least 1 year previously (mean, 3.8 years) and asymptomatic healthy control subjects were studied by thoracolumbar spine magnetic resonance imaging. The patients also underwent a clinical examination. RESULTS: Eight (57%) of the 14 patients had disc degeneration, and seven of them had it at the trauma level. Of these 7 subjects, 6 also had endplate damage at this level. The association between endplate damage and adjacent intervertebral disc degeneration was significant (P < 0.01). Only 2 of the patients were symptomatic. In the control group, only 1 subject had disc degeneration with endplate changes and disc herniation. CONCLUSIONS: The patients had more disc degeneration than did those in the control group. Endplate injury was strongly associated with disc degeneration. No correlation between previous vertebral fracture and back pain was seen in this study.

Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients.

STUDY DESIGN: A cross-sectional study in sciatic population. OBJECTIVES: To evaluate the separate roles of nerve root entrapment-based on magnetic resonance imaging-and other discogenic pain mechanisms on disability and physical signs among symptomatic sciatic patients. SUMMARY OF BACKGROUND DATA: Data symptoms of sciatica are generally understood to be generated by nerve root compression, but other pain mechanisms of sciatica have been suggested. METHODS: The authors obtained magnetic resonance scans from 160 patients with unilateral sciatic pain. The patients reported the intensity of their back and leg pain and their back-specific disability. Clinical examination and magnetic resonance imaging (1.5 T) was performed on every patient. The degree of disc displacement, neural enhancement, and nerve root compression was evaluated from magnetic resonance scans. The correlations of symptoms and signs with magnetic resonance imaging findings were calculated. RESULTS: The degree of disc displacement in magnetic resonance imaging did not correlate with any subjective symptoms, nor did nerve root enhancement or nerve compression. Magnetic resonance imaging classification was associated, however, with straight leg raising restriction. In regression analysis, straight leg raising restriction was best explained with a simple classification of nonherniations versus herniations. CONCLUSIONS: The results suggest that a discogenic pain mechanism other than the nerve root entrapment generates the subjective symptoms among sciatic patients. The findings of this study thus indicate that magnetic resonance imaging is unable to distinguish sciatic patients in terms of the severity of their symptoms.

Poor interobserver reliability of AO classification of fractures of the distal radius. Additional computed tomography is of minor value.

Interobserver reliability of the AO system of classification of fractures of the distal radius was assessed using plain radiographs and CT. Five observers classified 30 Colles'-type fractures using only plain radiographs; two months later they were reclassified using CT in addition. Interobserver reliability was poor in both series when detailed classification was used. By reducing the categories to five, interobserver reliability was slightly improved, but was still poor. When only two AO types were used, the reliability was moderate using plain radiographs and good to excellent with the addition of CT. The use of CT as well as plain radiographs brings interobserver reliability to a good level in assessment of the presence or absence of articular involvement, but is otherwise of minor value in improving the interobserver reliability of the AO system of classification of fractures of the distal radius.

Justification of CT examinations in young adults and children can be improved by education, guideline implementation and increased MRI capacity.

OBJECTIVE: To determine whether the justification of CT examinations performed on young patients can be improved by various interventions and whether these have an effect on the total number of CTs performed. METHODS: Specific interventions-education, guideline implementation and increased MRI capacity-were introduced at the Oulu University Hospital, Oulu, Finland, following a previous study demonstrating unjustified use of CT examination in young patients. In the present study, the justification of 177 CT examinations of the lumbar and cervical spine, head, abdomen, nasal sinuses and trauma performed on patients aged under 35 years in 2009 was analysed retrospectively by looking at requests and corresponding patient files. The indications of the examinations were compared with the referral guidelines recommended by the European Commission. Results from our previously published similar study carried out before the interventions were used as a reference. RESULTS: The proportion of justified CT examinations increased from 71% (141/200) in 2005 to 87% (154/177) in 2009 (p<0.001), and in the lumbar spine group from 23% (7/30) to 81% (22/27) (p<0.001). In the case of most of the unjustified examinations, MRI could have been performed instead. The total number of CT examinations carried out on young patients decreased by 7% (p=0.012) and in the lumbar spine group by 79% (p<0.001). CONCLUSION: The implemented interventions decreased the number of CT examinations performed on young patients, and the justification of the examinations improved significantly. ADVANCES IN KNOWLEDGE: This study demonstrates that it is possible to reduce the number of various CT examinations and to improve their justification in young patients by regular education, guideline implementation and increased MRI capacity.