Celso Matos

Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. A pilot study.

BACKGROUND Aseptic nontraumatic osteonecrosis of the femoral head is a disorder that can lead to femoral head collapse and the need for total hip replacement. Since osteonecrosis may be a disease of mesenchymal cells or bone cells, the possibility has been raised that bone marrow containing osteogenic precursors implanted into a necrotic lesion of the femoral head may be of benefit in the treatment of this condition. For this reason, we studied the implantation of autologous bone-marrow mononuclear cells in a necrotic lesion of the femoral head to determine the effect on the clinical symptoms and the stage and volume of osteonecrosis. METHODS We studied thirteen patients (eighteen hips) with stage-I or II osteonecrosis of the femoral head, according to the system of the Association Research Circulation Osseous. The hips were allocated to a program of either core decompression (the control group) or core decompression and implantation of autologous bone-marrow mononuclear cells (the bone-marrow-graft group). Both patients and assessors were blind with respect to treatment-group assignment. The primary outcomes studied were safety, clinical symptoms, and disease progression. RESULTS After twenty-four months, there was a significant reduction in pain (p = 0.021) and in joint symptoms measured with the Lequesne index (p = 0.001) and the WOMAC index (p = 0.013) within the bone-marrow-graft group. At twenty-four months, five of the eight hips in the control group had deteriorated to stage III, whereas only one of the ten hips in the bone-marrow-graft group had progressed to this stage. Survival analysis showed a significant difference in the time to collapse between the two groups (p = 0.016). Implantation of bone-marrow mononuclear cells was associated with only minor side effects. CONCLUSIONS Implantation of autologous bone-marrow mononuclear cells appears to be a safe and effective treatment for early stages of osteonecrosis of the femoral head. Although the findings of this study are promising, their interpretation is limited because of the small number of patients and the short duration of follow-up. Further study is needed to confirm the results.

Implications of SENSE MR in routine clinical practice

Sensitivity encoding (SENSE) uses multiple MRI receive coil elements to encode spatial information in addition to traditional gradient encoding. Requiring less gradient encodings translates into shorter scan times, which is extremely beneficial in many clinical applications. SENSE is available to routine diagnostic imaging for the past 2 years. This paper highlights the use of SENSE with scan time reduction factors up to 6 in contrast-enhanced MRA, routine abdominal imaging, mammography, cardiac and neuro imaging. It is shown that SENSE has opened new horizons in both routine and advanced MR imaging.

The role of MR imaging for the assessment of complicated duplex kidneys in children: preliminary report

Objective. To determine whether MR imaging, including MR urography, is able to assess complicated duplex kidneys and to determine the possible role of MRI compared to other imaging techniques in such uropathies. Material and methods. Twenty consecutive patients (age 1 month– 11 years) presenting with a suspicion of a complicated duplex kidney were prospectively studied with MRI and MR urography. The examinations were performed on a 0.5-T machine using routinely available sequences that were optimised to the patients age and size. MR images were reviewed separately by two observers blinded to the patient history. They were asked to assess the presence of a duplex kidney, the presence of an abnormality that may require surgery and to indicate the type of the inferior ureteric insertion. A qualitative gradation of these results was performed on the basis of the final diagnosis provided at endoscopy (n = 6) or surgery (n = 14). MR results were compared to those provided by US examinations and excretory urography, when available, and a non-parametric statistical analysis was performed. Results. MRI differentiated well between the upper and the lower poles of the kidneys and correctly answered the three questions in all 20 patients. The two observers agreed completely in all the 20 patients. MR was statistically superior to both US and excretory urography in the evaluation of the distal ureter (P < 0.05). Conclusions. MRI provides a precise assessment of the complications associated with duplex kidneys. Its optimal role seems to be the assessment of ectopic extra-vesical ureteric insertions and whenever an occult upper pole is suspected.

Endoscopic cystenterostomy of nonbulging pancreatic fluid collections

BACKGROUND A prerequisite for endoscopic drainage of pancreatic fluid collections without EUS is the presence of a visible bulge in the GI wall. Our experience with endoscopic cystostomy of nonbulging pancreatic fluid collections is described. METHODS Thirty-three patients underwent 34 endoscopic attempts at transmural drainage of nonbulging pancreatic fluid collections over a 2-year period. The etiology of the nonbulging pancreatic fluid collections was chronic pancreatitis in 26 cases and acute pancreatitis in 7. Indications for drainage included one or more of the following: abdominal pain, infection, biliary obstruction, and external fistula. The diameter of the collections ranged from 20 to 160 mm (median 52 mm). RESULTS Thirty-two of 34 drainage attempts were successful (94%). Eighteen cystostomies were performed under fluoroscopy alone and 14 by EUS together with fluoroscopy. Procedure-related complications occurred with 3 of 34 attempts (8%). Surgery was not required for treatment of the complications and there were no deaths from the procedure. Follow-up was available for 31 patients (median 21 months, range 9 to 40 months). One nonbulging pancreatic fluid collections recurred 7 months after drainage. CONCLUSIONS Endoscopic cystenterostomy of nonbulging pancreatic collections is feasible, and the results of the procedure are similar to those of cystenterostomy for bulging collections.

Pineal cyst: normal or pathological?

Review of 500 consecutive MRI studies was undertaken to assess the frequency and the appearances of cystic pineal glands. Cysts were encountered in 2.4% of cases. Follow-up examination demonstrated no change in these cysts and they were considered to be a normal variant. Size, MRI appearances and signs associated with this condition are reported in order to establish criteria of normality.

Endometriosis: Contribution of 3.0-T Pelvic MR Imaging in Preoperative Assessment—Initial Results

PURPOSE To determine the accuracy of 3.0-T pelvic magnetic resonance (MR) imaging in the preoperative assessment of endometriosis and to evaluate colon wall involvement after intrarectal gel administration. MATERIALS AND METHODS Institutional review board approval for this study was obtained, and each patient gave written informed consent. Forty-one consecutive patients with clinical suspicion of endometriosis underwent pelvic MR imaging at 3.0 T before surgery. Single-shot and high-spatial-resolution axial T2-weighted, sagittal fat-suppressed T2-weighted, and axial fat-suppressed T1-weighted sequences were performed. T2-weighted sequences were repeated after the rectum was filled with ultrasonographic (US) gel. Two blinded readers interpreted images independently. Image quality was scored by using a four-point scale. Detailed mapping of deep endometriosis was performed. Colon wall infiltration was graded (none, serosa, muscularis, submucosa, mucosa). MR imaging results were compared with surgical and pathologic findings. Interobserver agreement was assessed by using kappa statistics. Nonparametric tests were performed to compare colon wall infiltration scores without and those with US gel and between observers. RESULTS Twenty-seven of 41 patients had deep endometriosis at surgery and histopathologic examination. Sensitivity, specificity, positive and negative predictive values, and accuracy for the diagnosis of deep endometriosis at MR imaging were 96.3% (26 of 27), 100% (14 of 14), 100% (26 of 26), 93.3% (14 of 15), and 97.6% (40 of 41), respectively. kappa Values ranged from 0.65 to 1.0, depending on the location of deep endometriosis. Colon wall infiltration assessment by both readers correlated well with pathologic findings (Spearman coefficient, >0.93), although median wall involvement scores were lower at pathologic examination than for both readers both before (P = .042 and P = .011) and after (P = .079 and P = .011) intrarectal gel filling. CONCLUSION MR imaging of the pelvis at 3.0 T is accurate in the diagnosis and staging of deep endometriosis for the preoperative assessment of patients clinically suspected of having endometriosis.

MR urography in children.

Thanks to the development of rapid sequences with better resolution, applications of uro MR have rapidly increased in children. Difficulties that remain are related to the variable ages of the patients. It is therefore mandatory to standardize as much as possible the techniques that are used in order to obtain reproducible results. In this review, the examination protocols will be explained. In a second part the current applications in children will be illustrated and discussed, especially in comparison with the other imaging techniques.

Magnetic resonance cholangiopancreatography: interest of IV secretin administration in the evaluation of pancreatic ducts

Abstract. The aim of this study was to investigate whether IV secretin administration is useful to enhance the delineation of the main pancreatic duct (MPD) and its side branches, and if it provides additional information concerning signal voids and strictures. Twenty-seven patients referred for abdominal pain or laboratory abnormalities (group 1, n = 13) or for the follow-up of chronic pancreatitis (CP; group 2, n = 14) were studied. Magnetic resonance cholangiopancreatography was acquired at 1.5 T before and after IV secretin by a coronal 3D TSE T2-weighted sequence with maximum intensity projection postprocessing. In group 1 secretin provided a better visualization of MPD in 9 patients. In a patient with pancreas divisum, it allowed suggestion of stenosis of the accessory papilla, confirmed at endoscopic retrograde cholangiopancreatography (ERCP). In group 2 secretin provided a better visualization of MPD only in the 3 patients with mild disease. A mild dilation upstream a stricture occurred in 2 cases and a marked dilation appeared upstream a wallstent which was non-patent at ERCP. Few changes were noticed concerning side branches. These preliminary results indicate that in patients without CP, secretin improves MPD delineation avoiding invasive diagnostic ERCP. In patients with mild CP secretin does not improve the characterization of signal voids, but it may be useful to appreciate their significance and to follow-up stenosis.

Endoscopic technique for the management of pancreatitis and its complications

Therapeutic endoscopy is now increasingly used to treat gallstone pancreatitis, acute pancreatitis of other aetiologies, chronic pancreatitis and complications associated with acute or chronic pancreatitis. This chapter is a brief review of the endoscopic interventions currently performed in patients with acute or chronic pancreatitis. These interventions include biliary and pancreatic endoscopic sphincterotomy at the major or minor papilla, stricture dilatation on the common bile duct or main pancreatic duct, stent placement in the biliary or pancreatic ducts, stone extraction with or without extracorporeal shock wave lithotripsy, and transmural or transpapillary drainage of pancreatic fluid collections. As most of the studies reported were uncontrolled and retrospective, uncertainties persist with regard to the best approaches for treating the patients concerned. Appropriate patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential prerequisites of a high success rate in improving the clinical condition of these patients.

ENDOSCOPIC THERAPY FOR CHRONIC PANCREATITIS

When endoscopic therapy is used for the treatment of patients with painful chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL) can be proposed as a first-line approach when obstructive ductal stone(s) induce upstream dilation of the main pancreatic duct. Stone fragmentation by ESWL is followed by endoscopic ductal drainage using pancreatic sphincterotomy, fragmented stone(s) extraction, and pancreatic stenting in case of ductal stricture. After completion of endoscopic pancreatic ductal drainage, long-term clinical benefit can be expected for two thirds of the patients. Best clinical results are associated with absence or cessation of smoking and with early treatment in the course of chronic pancreatitis, while alcohol abuse increases the risks of diabetes, steatorrhea and mortality. The complications of chronic pancreatitis are mainly the development of pseudocyst secondary to the downstream ductal obstruction, and biliary obstruction caused by fibrotic changes in the head of the pancreas. Successful endoscopic pseudocyst drainage is currently obtained in most patients, and carries a low complication rate. Biliary stenting is a safe and effective technique for the short-term treatment of symptomatic bile duct stricture due to chronic pancreatitis, but permanent resolution is obtained in only 25% of cases. In conclusion, endoscopic management is now considered to be the preferred interventional treatment of chronic pancreatitis, for patients selected on the basis of the anatomical changes caused by the disease. This treatment is generally safe, minimally invasive, often effective for years, does not prevent further surgery, and can be repeated.