Cornelis van Kuijk

Arm Raising at Exposure-controlled Multidetector Trauma CT of Thoracoabdominal Region: Higher Image Quality, Lower Radiation Dose

PURPOSEnTo evaluate the effect of arm position on image quality and effective radiation dose in an automatic exposure-controlled (AEC) multidetector thoracoabdominal computed tomography (CT) protocol in trauma patients.nnnMATERIALS AND METHODSnThis retrospective study of the data of 177 trauma patients (117 male; median age, 39 years) was approved by the institutional ethics board, with informed patient consent waived. Patients underwent scanning by using an AEC 16-detector thoracoabdominal CT protocol in which both arms were raised above the shoulder region (standard-position group, 132 patients), one arm was raised and the other was down (one-arm group, 27 patients), or both arms were down (two-arm group, 18 patients). Objective and subjective image quality was assessed. Individual effective radiation dose was calculated from the effective tube current-time product per exposed section. For this purpose, section location-dependent conversion factors were derived by using a CT dosimetry calculator. The effect of arm position on effective dose was quantified by using linear regression analysis with correction for patient volume and attenuation.nnnRESULTSnCompared with the image quality in the standard-position group, the image quality in the one- and two-arm groups was decreased but within acceptable diagnostic limits. The median corrected effective dose in the standard-position group was 18.6 mSv; the dose in the one-arm group was 18% (95% confidence interval: 11%, 25%) higher than this, and that in the two-arm group was 45% (95% confidence interval: 34%, 57%) higher.nnnCONCLUSIONnOmitting arm raising results in lower but acceptable image quality and a substantially higher effective radiation dose. Hence, effort should be made to position the arms above the shoulder when scanning trauma patients. Clinical trial registration no. NCT00228111.

Total-liver-volume perfusion CT using 3-D image fusion to improve detection and characterization of liver metastases

The purpose of this study was to evaluate the feasibility of a total-liver-volume perfusion CT (CTP) technique for the detection and characterization of liver metastases. Twenty patients underwent helical CT of the total liver volume before and 11 times after intravenous contrast-material injection. To decrease distortion artifacts, all phases were co-registered using 3-D image fusion before creating blood-flow maps. Lesion-based sensitivity and specificity for liver metastases of first the conventional four phases (unenhanced, arterial, portal venous, and equilibrium) and later all 12 phases including blood-flow maps were determined as compared to intraoperative ultrasound and surgical exploration. Arterial and portal venous perfusion was calculated for normal-appearing and metastatic liver tissue. Total-liver-volume perfusion values were comparable to studies using single-level CTP. Compared to four-phase CT, total -liver-volume CTP increased sensitivity to 89.2 from 78.4% (Pu2009=u20090.046) and specificity to 82.6 from 78.3% (Pu2009=u20090.074). Total -liver-volume CTP is a noninvasive, quantitative, and feasible technique. Preliminary results suggest an improved detection of liver metastases for CTP compared to four-phase CT.

Criteria for the selective use of chest computed tomography in blunt trauma patients

PurposeThe purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury.MethodsThis observational study prospectively included consecutive patients (≥16xa0years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre.ResultsWe included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age ≥55xa0years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <−3xa0mmol/l and haemoglobin <6xa0mmol/l). Of 855 patients with ≥1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant.ConclusionOmission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.

Radiofrequency ablation of large size liver tumours using novel plan-parallel expandable bipolar electrodes: Initial clinical experience

PURPOSEnAlthough radiofrequency ablation (RFA) is a promising method for local treatment of liver malignancies, with conventional monopolar systems recurrence rates for large size tumours (≥3.5 cm) remain high. The objective of this study was to evaluate the safety, feasibility and local effectiveness of a novel bipolar plan-parallel expandable system for these larger tumours.nnnMETHODS AND MATERIALSnEight consecutive patients with either unresectable colorectal liver metastases (CRLM in 6 patients), carcinoid liver metastases (1 patient) and hepatocellular carcinoma (HCC in 1 patient) of ≥3.5 cm were treated with bipolar RFA during laparotomy with ultrasound guidance. Early and late, major and minor complications were recorded. Local success was determined on 3-8 month follow-up CT scans of the upper abdomen.nnnRESULTSnNine CRLM, one carcinoid liver metastases and one HCC (3.5-6.6 cm) were ablated with bipolar RFA. Average ablation time was 16 min (range 6-29 min.). Two patients developed a liver abscess which required re-laparotomy. In both cases bowel surgery during the same session probably caused bacterial spill. There were no mortalities. The patients were released from hospital between 5 and 29 days after the procedure (median 12 days). The 6-12 month follow-up PET-CT scans showed signs for marginal RFA-site tumour recurrence in three patients with CRLM (3/11 lesions).nnnCONCLUSIONnPreliminary results suggest bipolar RFA to be a reasonably safe, fast and feasible technique which seems to improve local control for large size hepatic tumour ablations.

Comparison of MR enteroclysis with video capsule endoscopy in the investigation of small-intestinal disease

PurposeTo evaluate the diagnostic accuracy of MR enteroclysis and to compare it to video capsule endoscopy (VCE) in the analysis of suspected small-bowel disease.MethodsWe performed a retrospective analysis of 77 patients who underwent both MR enteroclysis and VCE and compared the findings of these studies with the findings of enteroscopy, surgery, or with the results of clinical follow-up lasting ≥2xa0years.ResultsFindings included malignant neoplasms (nxa0=xa013), benign neoplasms (nxa0=xa010), refractory celiac disease (nxa0=xa04), Crohn’s disease (nxa0=xa02) and miscellaneous conditions (nxa0=xa010). Specificity of MR enteroclysis was higher than that of VCE (0.97 vs. 0.84, Pxa0=xa00.047), whereas sensitivity was similar (0.79 vs. 0.74, Pxa0=xa00.591). In 2/32 (6.3%) patients with both negative VCE and negative MR enteroclysis a positive diagnosis was established, compared to 5/11 (45.5%) patients in whom VCE was positive and MR enteroclysis was negative (likelihood ratio 8.1; Pxa0=xa00.004), 9/11 (81.8%) patients in whom MR enteroclysis was positive and VCE was negative (likelihood ratio 23.5; Pxa0<xa00.0001), and all 23 patients in whom both VCE and MR enteroclysis showed abnormalities (likelihood ratio 60.8; Pxa0<xa00.0001).ConclusionsVCE and MR enteroclysis are complementary modalities. In our study-population, MR enteroclysis was more specific than VCE, while both produced the same sensitivity.

MWA Versus RFA for Perivascular and Peribiliary CRLM: A Retrospective Patient- and Lesion-Based Analysis of Two Historical Cohorts.

PurposeTo retrospectively analyse the safety and efficacy of radiofrequency ablation (RFA) versus microwave ablation (MWA) in the treatment of unresectable colorectal liver metastases (CRLM) in proximity to large vessels and/or major bile ducts.Method and MaterialsA database search was performed to include patients with unresectable histologically proven and/or 18F–FDG–PET avid CRLM who were treated with RFA or MWA between January 2001 and September 2014 in a single centre. All lesions that were considered to have a peribiliary and/or perivascular location were included. Univariate logistic regression analysis was performed to assess the distribution of patient, tumour and procedure characteristics. Multivariate logistic regression was used to correct for potential confounders.ResultsTwo hundred and forty-three patients with 774 unresectable CRLM were ablated. One hundred and twenty-two patients (78 males; 44 females) had at least one perivascular or peribiliary lesion (nxa0=xa0199). Primary efficacy rate of RFA was superior to MWA after 3 and 12xa0months of follow-up (Pxa0=xa00.010 and Pxa0=xa00.022); however, after multivariate analysis this difference was non-significant at 12xa0months (Pxa0=xa00.078) and vanished after repeat ablations (Pxa0=xa00.39). More CTCAE grade III complications occurred after MWA versus RFA (18.8 vs. 7.9xa0%; Pxa0=xa00.094); biliary complications were especially common after peribiliary MWA (Pxa0=xa00.002).ConclusionFor perivascular CRLM, RFA and MWA are both safe treatment options that appear equally effective. For peribiliary CRLM, MWA has a higher complication rate than RFA, with similar efficacy. Based on these results, it is advised to use RFA for lesions in the proximity of major bile ducts.

Subtraction-multiphase-CT unbeneficial for early detection of colorectal liver metastases

PURPOSEnTo assess the value of multiphase-subtraction-CT for early detection of colorectal-liver-metastases (CRLM).nnnMETHODS AND MATERIALSnIn 50 patients suspected of CRLM a routine pre-operative 4-phase-CT-scan of the upper abdomen was obtained. All 12 possible image subtractions between two different phases were constructed applying 3D-image-registration to decrease distortion artefacts induced by differences in inspiration volume. Two experienced radiologists initially reviewed the conventional 4-phase-CT for malignant and/or benign appearing lesions and at least 1-month hereafter the same 4-phase-CT now including the subtracted images. The results were compared to histology reports or to a combination of surgical exploration and intraoperative ultrasound together with results from pre-operative PET and follow-up examinations.nnnRESULTSnAlthough an additional number of 31 malignant appearing lesions were detected on the subtraction images, none proved to represent a true CRLM. Interobserver agreement (kappa) decreased from 0.627 (good) to 0.418 (fair).nnnCONCLUSIONnAdding linearly co-registered subtraction-CT images to a conventional 4-phase-CT protocol does not improve detection of CRLM.

WARRIOR-trial - is routine radiography following the 2-week initial follow-up in trauma patients with wrist and ankle fractures necessary: study protocol for a randomized controlled trial.

BackgroundExtremity fractures such as wrist and ankle fractures are a common and costly healthcare problem. The management of these fractures depends on fracture type and loss of congruity of the joint, resulting in cast immobilization or operative treatment. Loss of congruity or displacement leading to uneven joint loading, osteoarthritis and an increased probability of a poor functional outcome should be identified within the first 2xa0weeks post-trauma, based upon radiographs to determine optimal treatment. After this period, routine radiographs are scheduled for monitoring the bone-healing process. Current protocols describe imaging at 1, 2, 6 and 12xa0weeks post-trauma. However, it is questionable whether routine radiography following the initial follow-up ( 2-weeks post-trauma) is cost effective.The aim of this study is to determine whether a modification of the radiographic follow-up protocol can be conducted with no worse outcome and less cost than the current standard of care for patients with a wrist or ankle fracture.Methods/designIn a multicenter randomized controlled trial, 697 patients aged 18xa0years or older will be included: 385 wrist fracture- and 312 ankle fracture patients. Patients will be randomized into two groups: Group 1 receives usual care, consisting of radiographs 1, 2, 6 and 12xa0weeks post-trauma; Group 2 receives radiographs beyond the initial follow-up only when clinically indicated. The primary outcome is the overall extremity-specific function. For wrist fractures, this includes the Disabilities of the Arm, Shoulder and Hand Score; for the ankle fractures, this includes the Olerud and Molander ankle score. Secondary outcomes include: healthcare cost, the specific function measured with the Patient Rated Wrist and Hand Evaluation for wrist fractures and American Academy of Orthopaedic Surgeons foot and ankle questionnaire for ankle fractures, pain-intensity, health-related quality of life, self-perceived recovery, and complications. Both groups will be monitored at 1, 2, and 6xa0weeks and 3, 6, and 12xa0months.DiscussionThis study will provide data on (cost) effectiveness of routine radiography in the follow-up of wrist and ankle fractures, and could pave the way for a change in (inter)national protocols.Trial registrationNetherlands Trial Register NTR4610, registration date 22 June 2014.