Preoperative diagnosis of hiatal hernia: barium swallow X-ray, high-resolution manometry, or endoscopy?

BACKGROUND: The assessment of hiatal hernias (HH) is typically done with barium swallow X­ray, upper endoscopy, and by high-resolution esophageal manometry (HRM). The aim of this study was to assess the clinical utility of these methods in terms of HH detection and their correlation to gastroesophageal reflux disease (GERD). METHODS: A retrospective comparative analysis of patients with symptoms of GERD was carried out. The performance of endoscopy and HRM in diagnosing HH was assessed, taking barium swallow X­ray as a reference. Furthermore, statistically comparative analysis between detected hernias and the presence of reflux disease in ambulatory impedance-pH monitoring (MII) was performed. RESULTS: Overall, 112 patients were analyzed. Barium swallow X­ray showed no correlation either to HR manometrically or to endoscopically assessed HH. Significant accordance in the detection rate of HH was proved between HRM and gastroesophagoscopy (p < 0.001). Only endoscopically assessed HH showed a significant correlation with GERD (p = 0.047). No correlation between detected hernias and GERD could be found either with HRM or with barium swallow X­ray. CONCLUSIONS: Barium swallow X­ray provided the highest rate of HH detection (76.8%). For the reliable exclusion of HH prior to treatment, all three mentioned investigations appear to be necessary in order of low conformity.

Magnetic resonance-visible meshes for laparoscopic ventral hernia repair.

BACKGROUND AND OBJECTIVES: We aimed to evaluate the first human use of magnetic resonance-visible implants for intraperitoneal onlay repair of incisional hernias regarding magnetic resonance presentability. METHODS: Ten patients were surgically treated with intraperitoneally positioned superparamagnetic flat meshes. A magnetic resonance investigation with a qualified protocol was performed on postoperative day 1 and at 3 months postoperatively to assess mesh appearance and demarcation. The total magnetic resonance-visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces. RESULTS: We were able to show a precise mesh demarcation, as well as accurate assessment of the surrounding tissue, in all 10 cases. We documented a significant decrease in the magnetic resonance-visualized total mesh surface area after release of the pneumoperitoneum compared with the original mesh size (mean, 190 cm(2) vs 225 cm(2); mean reduction of mesh area, 35 cm(2); P < .001). At 3 months postoperatively, a further reduction of the surface area due to significant mesh shrinkage could be observed (mean, 182 cm(2) vs 190 cm(2); mean reduction of mesh area, 8 cm(2); P < .001). CONCLUSION: The new method of combining magnetic resonance imaging and meshes that provide enhanced signal capacity through direct integration of iron particles into the polyvinylidene fluoride base material allows for detailed mesh depiction and quantification of structural changes. In addition to a significant early postoperative decrease in effective mesh surface area, a further considerable reduction in size occurred within 3 months after implantation.

Relevance of surgery after embolization of gastrointestinal and abdominal hemorrhage.

BACKGROUND: Gastrointestinal and abdominal bleeding can lead to life-threatening situations. Embolization is considered a feasible and safe treatment option. The relevance of surgery has thus diminished in the past. The aim of the present study was to evaluate the role of surgery in the management of patients after embolization. METHODS: We performed a retrospective single-center analysis of outcomes after transarterial embolization of acute abdominal and gastrointestinal hemorrhage between January 2009 and December 2012 at the Sisters of Charity Hospital, Linz. Patients were divided into three groups, as follows: upper gastrointestinal bleeding (UGIB), lower gastrointestinal bleeding (LGIB), and abdominal hemorrhage. RESULTS: Fifty-four patients with 55 bleeding events were included. The bleeding source could be localized angiographically in 80 %, and the primary clinical success rate of embolization was 81.8 % (45/55 cases). Early recurrent bleeding (<30 days) occurred in 18.2 % (10/55) of the patients, and delayed recurrent hemorrhage (>30 days) developed in 3.6 % (2/55). The mean follow-up was 8.4 months, and data were available for 85.2 % (46/54) of the patients. Surgery after embolization was required in 20.4 % of these patients (11/54). Failure to localize the bleeding site was identified as predictive of recurrent bleeding (p = 0.009). More than one embolization effort increased the risk of complications (p = 0.02) and rebleeding (p = 0.07). CONCLUSIONS: Surgery still has an important role after embolization in patients with gastrointestinal and abdominal hemorrhage. One of five patients required surgery in cases of early and delayed rebleeding or because of ischemic complications (2/55 both had ischemic damage of the gallbladder) and bleeding consequences.

Multiparametric ultrasonography of the testicles.

Ultrasonography is the standard modality to image the scrotum because it can provide information about volume, echo texture, tissue stiffness and functional information that includes macrovascularization and microvascularization. Indeed, ultrasound imaging is indicated in the presentation of acute scrotal pain and swelling to differentiate between testicular torsion, infarction and inflammation, as well as being the modality of choice when an intrascrotal mass is suspected. Advances in ultrasonography technology have produced new innovative techniques for imaging the scrotum, including grey-scale ultrasound, Doppler ultrasonography, contrast-enhanced ultrasonography and real-time sonoelastography. Each of these techniques provides information that can be useful when diagnosing diseases and disorders of the testicles. Consequently, the standard approach to accurate diagnosis should rely on multiparametric ultrasonography techniques, rather than just one or two techniques in isolation.

Real-time sonoelastography for the evaluation of testicular lesions.

PURPOSE: To evaluate the feasibility of using real-time sonoelastography (RTE) for the differentiation and characterization of testicular lesions. MATERIALS AND METHODS: Institutional review board approval was obtained for this retrospective study, and the requirement to obtain informed consent was waived. Fifty patients (mean age, 42 years; age range, 18-81 years) with testicular lesions detected with gray-scale ultrasonography (US) and color and/or power Doppler US were evaluated with RTE between December 2004 and August 2010 to assess tissue elasticity of the testes. Stiff or "hard" lesions were suspected of being malignant. Testicular lesions with normal or decreased tissue stiffness ("soft" lesions) were considered benign. Findings from surgery and histopathologic examination were used as the reference standard in 34 cases, and findings from clinical and US follow-up were used as the reference standard in 16 cases. Sensitivity, specificity, negative predictive value, positive predictive value, and diagnostic accuracy were calculated. RESULTS: Thirty-four of the 50 lesions (68%) were testicular tumors and 16 (32%) were of nontumorous origin. RTE showed the presence of hard lesions in all cases of testicular tumors and three cases of nontumorous lesions. Four lesions with an uncertain diagnosis when tested with gray-scale US and color and/or power Doppler US alone were soft at RTE and showed nontumorous character at follow-up. RTE showed a sensitivity of 100%, a specificity of 81%, a negative predictive value of 100%, a positive predictive value of 92%, and an accuracy of 94% in the diagnosis of testicular tumors. CONCLUSION: RTE demonstrated all testicular tumors as lesions with increased tissue stiffness. Because of its higher specificity, RTE can provide additional information in cases with indeterminate US findings.

Potentials and limitations of real-time elastography for prostate cancer detection: a whole-mount step section analysis.

OBJECTIVES: To evaluate prostate cancer (PCa) detection rates of real-time elastography (RTE) in dependence of tumor size, tumor volume, localization and histological type. MATERIALS AND METHODS: Thirdy-nine patients with biopsy proven PCa underwent RTE before radical prostatectomy (RPE) to assess prostate tissue elasticity, and hard lesions were considered suspicious for PCa. After RPE, the prostates were prepared as whole-mount step sections and were compared with imaging findings for analyzing PCa detection rates. RESULTS: RTE detected 6/62 cancer lesions with a maximum diameter of 0-5 mm (9.7%), 10/37 with a maximum diameter of 6-10 mm (27%), 24/34 with a maximum diameter of 11-20 20 mm (70.6%), 14/14 with a maximum diameter of >20 mm (100%) and 40/48 with a volume ≥0.2 cm(3) (83.3%). Regarding cancer lesions with a volume ≥ 0.2 cm³ there was a significant difference in PCa detection rates between Gleason scores with predominant Gleason pattern 3 compared to those with predominant Gleason pattern 4 or 5 (75% versus 100%; P = 0.028). CONCLUSIONS: RTE is able to detect PCa of significant tumor volume and of predominant Gleason pattern 4 or 5 with high confidence, but is of limited value in the detection of small cancer lesions.

Assessment and characterisation of common renal masses with CT and MRI.

OBJECTIVE: Owing to the widespread use of abdominal imaging studies the detection rate of solid renal masses has increased, and an accurate characterisation of imaging features of renal masses has become more essential for case management. METHOD AND RESULTS: MR imaging (MRI) and computed tomography (CT) are frequently used modalities for detection and differentiation of renal masses. This article gives a review of imaging characteristics of benign and malignant renal masses, discussing their appearance in CT and MR imaging. Advanced MR techniques like diffusion-weighted imaging and apparent diffusion coefficient (ADC) mapping, which have shown promising results in the differentiation between benign and malignant renal lesions, will be introduced. CONCLUSION: MRI and CT are useful in the characterisation and estimation of the prognosis for renal masses.