Prone Oblique Position Research Articles

Imaging anatomical study of kidney and colon position changes between the prone and low-arch oblique supine positions

Objective To provide imaging anatomy basis for percutaneous nephrolithotomy (PCNL) by measuring relative displacement and changes in anatomical position of kidney and colon under the prone and low-oblique supine positions. Methods Forty-six patients scheduled for PCNL underwent 64-slice spiral CT scan under the prone and low-arch oblique supine position before the PCNL.The horizontal distance of kidney and colon, the distance from colon and analog puncturing line, the distance between the kidney and colon were measured and compared between the 2 positions. Results The distance from colon and analog puncturing line under the low-oblique supine and prone positions were as follows, the left (26.56±15.36) mm versus (12.25±13.16) mm (t=3.527, P 0.05). Conclusions The distance between colon and analog puncturing line increases in the low-arch oblique supine position, because the colon shifts to the ventral.The PCNL in low-arch oblique supine position may reduce the incidence of colon injury, and improve surgical safety. Key words: Low-arch oblique supine position; Imaging anatomical study; Nephrostomy, percutaneous; Urinary calculi

Telovelar approach: technical issues for large fourth ventricle tumors

Fourth ventricle is conventionally accessed via resection of the part of the vermis for total excision of the tumors at the expense of significant morbidity. Numerous avenues have been identified to minimize the morbidity; some of which include transforaminal, subtonsillar, telovelar approaches, etc. These approaches are devised on the basis that accurate dissection along the natural avascular planes will avoid injury to the important structures in this area minimizing morbidity. We attempt to emphasize the technique of telovelar approach and the problems encountered while employing this technique for excision of large fourth ventricle tumors. Fifteen patients with fourth ventricle tumors were operated during January to September 2005 at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. Fourteen of these cases were medulloblastomas, and one was ependymoma. All the patients were operated in prone oblique position via telovelar approach. Clear understanding of the normal anatomy will help in meticulous dissection and will result in reduced morbidity. Significant incidence of postoperative ataxia and mutism is seen with this approach in large tumors, and this can be avoided by staged dissection of the uvulotonsillar cleft.

Complications of percutaneous nephrostomy in the treatment of malignant ureteral obstructions: single–centre review

The purpose of this study was to evaluate the incidence and type of complications connected with percutaneous nephrostomy (PCN) deployment by comparing two different techniques. In the last 3 years, 299 procedures of nephrostomy were performed on 201 patients (93 women, 108 men; mean age 65.7 years, range 32-102 years) at our Institute; all patients were affected by malignancy. In 44 cases (14.72%), patients presented grade IV hydronephrosis and in 255 cases (85.28%) grade II-III hydronephrosis. In 68 patients (23.07%), the procedure was carried out under emergency conditions because of the rapid worsening of renal function. All procedures were carried out in the angiography room, with the patient lying in a prone or prone-oblique position, under ultrasound and fluoroscopic guidance. Access to the pyelocalyceal system (intermediate or lower calices) was performed by using a Seldinger technique in 255/299 cases, or a one-step technique (OST) in 44 procedures when grade 4 hydronephrosis was present. Statistical analysis of results was performed using bilateral tests on proportions as well as chi2 test of independence for contingency tables. We observed no major complications. All in all, the rate of minor complications was 3.01% (9/299 cases): 8/255 (3.13%) cases with the Seldinger technique; 1/44 (2.27%) with OST. We observed 43/299 (14.4%) dislodgements: 32/255 (10.70%) with the Seldinger technique and 11/44 (3,68%) with OST. In 4/299 (1.33%), rupture of the catheter occurred, and in 2/299 (0.67%), kinking occurred (in all cases with OST). From the statistical analysis, we conclude that the examination technique modifies the percentage of complications; in particular, it significantly (p<0.05) influences complications connected with the catheter but not minor complications. In addition, the system of fixing does not affect the percentage of dislodgements. PCN is a method with a high percentage of technical success with low rate of complications thanks to combined use of sonographic and fluoroscopic guidance for the procedure. The OST technique is indicated for a highly remarkable hydronephrosis and in cases where the catheter is only placed for a short period. The Seldinger technique is carried out in patients with grades II and III hydronephrosis and if the disease is predicted to have a long duration.

Use of the prone oblique position in surgery for posterior fossa lesions

The lateral suboccipital approach has been conventionally performed with the lateral, park-bench, or sitting position and the midline suboccipital approach has been performed in the prone position. We attempt to show the advantages of the prone oblique position in the surgery for posterior fossa lesions. Twenty-two patients with posterior fossa lesions underwent surgery in the prone oblique position. The patients were fixed in the prone position while the operating table was rotated to raise the patient's shoulder. The surgeon sat beside the downward-shifted contralateral shoulder of the patient. With the lateral suboccipital approach, the neck of the patient was rotated to the side of the lesion. With the midline suboccipital approach, the neck was not rotated. With the lateral suboccipital approach, this position spread the transverse axis of the suboccipital triangle and eliminated the interference of the patient's shoulder, providing an operative field that is wider than the lateral position or park bench position in all cases. With the midline suboccipital approach, this position enabled the surgeon to operate on lesions located in the upper half of the posterior fossa, such as fourth ventricular lesions or infratentorial lesions, without the need for a looking up posture with overhanging of the operative microscope. The prone oblique position offers the operator a panoramic view of the posterior fossa.

Fluoroscopically guided scapulothoracic injections.

After informed consent was obtained from the patient, the patient was placed in a prone oblique position on the fluoroscopy table of a C -arm system (Angioskop D 33, Siemens Medical Systems, Erlangen, Germany). The patient was asked to place the arm of the painful side either above the head or at the side of the body to move the scapula away from the chest wall. The choice of arm position depended on which one was more comfortable for the patient and which one best opened the tender area between the scapula and the ribs. The C -arm was rotated until the scapula and the scapulothoracic space were seen in profile. In most patients, the fluoroscopy tube was angled cephalocaudally to profile the anterior and posterior portions of the rib of interest in the same plane, which produced a lordotic view of the ribs. This view helped prevent inadvertent needle puncture of the rib interspace. The patient was asked where the pain was centered while the radiologist palpated medial and deep in relation to the scapula. The site of maximal tenderness was chosen for the

Peritoneography (Herniography) for Detecting Occult Inguinal Hernia in Patients with Inguinodynia

To evaluate the usefulness of peritoneography in patients referred with inguinal pain (inguinodynia) and clinically absent inguinal hernia on physical examination. In patients with chronic groin pain, peritoneography is a seldom-used yet available technique that can detect an occult inguinal hernia. The value of peritoneography in the diagnosis of occult inguinal hernia has been previously shown. During a 60-month period, 80 consecutive patients with complaints of persistent inguinal pain (inguinodynia) without evidence of hernia on clinical examination were referred for outpatient evaluation by peritoneography. Twenty-nine patients had prior inguinal surgery in the region of their current pain. Peritoneography was performed using a midline or paraumbilical approach. Radiographs were obtained with patients in prone and prone oblique positions with the head elevated 20 degrees to 25 degrees, both with and without provocative maneuvers. All available records were retrospectively reviewed for radiographic findings and outcome. Of the 80 patients undergoing peritoneography, 36 (45%) were diagnosed radiographically to have inguinal hernias that were not detectable clinically. Twenty-seven of these patients subsequently underwent inguinal exploration, and a hernia was confirmed in 24 (89%). Of the patients having prior inguinal surgery in the region of their pain, 12/29 (41%) were diagnosed by peritoneography with a hernia. Two complications (2.5%), both colon perforations that did not require significant intervention, occurred as a result of peritoneography. Peritoneography is highly reliable for detecting clinically occult inguinal hernia and has a low complication rate. Its usefulness is shown in a prospective consecutive series for detection of occult hernias in patients with chronic inguinal pain. The authors conclude that peritoneography is a safe and useful diagnostic test in the setting of persistent inguinal pain and a negative clinical examination.

Radiographic detection of achalasia: Diagnostic accuracy of videofluoroscopy

To retrospectively evaluate the accuracy of videofluoroscopy in the diagnosis of achalasia. Videofluoroscopic studies of the oesophagus of 53 patients (25 males, 28 females; mean age, 49 years) with manometrically revealed diagnosis of achalasia were retrospectively evaluated. The videofluoroscopic examinations had been carried out with one swallow of low-density barium suspension in the erect and up to three swallows in the prone oblique position. Videofluoroscopically, a diagnosis of achalasia was made in 31 of the patients (58%) with manometrically proven achalasia, of whom only nine had oesophageal dilatation. Non-specific oesophageal motor abnormalities were diagnosed radiographically in 18 patients (34%) and a normal motility in four patients (8%). Videofluoroscopy is a valuable and sensitive technique for the detection of disordered oesophageal motility in achalasia.

Prone oblique positioning for computed tomographic arthrography of the shoulder

Computed tomographic arthrography (CTA) of the shoulder is currently the best investigation of the unstable shoulder. 47 patients had CTA in the prone oblique position to assess its ability to demonstrate both anterior and posterior capsular mechanisms simultaneously. The first five patients were also scanned supine oblique to allow direct comparison with the prone oblique position. All studies were reviewed retrospectively by three musculoskeletal radiologists with regard to how well the relevant structures were demonstrated. In the prone oblique position, the anterior capsule was well shown in 98%, anterior labrum 98%, posterior capsule 91%, posterior labrum 89%, subscapularis tendon 98%, biceps tendon 100% and biceps tendon proximal insertion 78%. In 86% of cases both anterior and posterior structures were well seen simultaneously. In the five cases that also had supine imaging the prone oblique images were superior. The cause of poor demonstration of structures was invariably insufficient intraarticular air. It is concluded that the prone oblique is an excellent technique for CTA of the shoulder and should become the standard position for assessing shoulder instability.

Esophageal motor disorders: videofluoroscopic and manometric evaluation--prospective study in 88 symptomatic patients.

Esophageal motor disorders are best evaluated with manometry, which, however, is time-consuming and not generally available. The authors prospectively investigated the yield of videofluoroscopy in detection of esophageal motor disorders in comparison with that of manometry. Eighty-eight patients with dysphagia, globus sensation, noncardiac chest pain, or progressive systemic sclerosis underwent both manometry and videofluoroscopy at 0-32-day intervals. Videofluoroscopy was performed with one swallowing study in the upright position and up to three swallowing studies in the prone oblique position. Manometric diagnoses of achalasia (n = 15), diffuse esophageal spasm (n = 1), nonspecific esophageal motor disorders (n = 44), and adynamic esophagus (n = 9) were made. Videofluoroscopically, 87% of the patients with achalasia, the one patient with diffuse spasms, 73% of the patients with nonspecific esophageal motor disorders, and all of the patients with adynamic esophagus received a correct diagnosis, for an overall sensitivity of 80%. The radiographic specificity was 79%. The authors conclude that videofluoroscopy is a valuable and reasonably sensitive technique for screening for esophageal motor disorders.

926 - Renal Laxity in the Prone Oblique Position: Implications for Percutaneous Nephrostomy

No AccessJournal of Urology1 Jun 1987Renal Laxity in the Prone Oblique Position: Implications for Percutaneous Nephrostomy Steven M. Barnett and Stanley J. Kandzari Steven M. BarnettSteven M. Barnett More articles by this author and Stanley J. KandzariStanley J. Kandzari More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)76075-2AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Renal Laxity in the Prone Oblique Position: Implications for Percutaneous Nephrostomy." The Journal of Urology, 137(6), p. 335A © 1987 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 137Issue 6June 1987Page: 335A Advertisement Copyright & Permissions© 1987 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Steven M. Barnett More articles by this author Stanley J. Kandzari More articles by this author Expand All Advertisement PDF downloadLoading ...

A safe alternative to endoscopic removal of blunt esophageal foreign bodies.

An alternative to the endoscopic removal of blunt esophageal foreign bodies is proposed. A Foley catheter is inserted into the esophagus and its balloon is utilized to extract the foreign body under fluoroscopic control. Experience with over 100 children with blunt esophageal foreign bodies has led us to conclude that the technique is easily performed, safe, and highly cost-effective. To protect the esophagus, care must be taken to ensure that the foreign body has no sharp or ragged edges, that it has been in place less than two weeks, and that there is no underlying esophageal disease. To ensure that no compromise of the airway occurs, several safeguards are employed, including orally inserting and withdrawing the catheter, monitoring the procedure fluoroscopically, and placing the patient in a prone oblique position with the fluoroscopic table steeply inverted.

Percutaneous nephrostomy--technique.

Percutaneous nephrostomy is increasingly used for temporary relief of upper urinary tract obstruction. The technique described involves the use of angiographic catheters and guides, and will provide drainage for several weeks or months. The patient is placed in the prone oblique position after intravenous contrast to opacify the kidneys. The oblique position ensures that a needle advanced vertically toward the kidney will pass along a posterior oblique line, entering the outer aspect of the kidney away from the hilum and directing guide wires and catheters toward the ureter. A fine needle is passed vertically into the kidney to determine its depth and to provide a pyelogram. A needle-cannula is then directed at the collecting system along a similar line until urine comes back. An angiographic J-guide is introduced and the needle exchanged for a series of vessel dilators, to dilate the track through the tissues. Finally, a catheter is passed over the guide wire into the collecting system, secured to the patient and attached to the drainage bag. Other maneuvers such as ureteral stenting can be added to this technique. The complications and technical difficulties are discussed.

Lymphangiographic demonstration of impression upon the duodenum by retriperitoneal lymph nodes.

Abstract Three patients with lymphoma were found to have deformity of the second part of the duodenum due to compression by adjacent retroperitoneal lymph nodes. This was confirmed by lymphangiography. Intravaneous pyelography was normal in all cases since these abnormal nodes lay superior to the kidney and ureter. Careful examination of the second portion of the duodenum especially in the prone oblique position may reveal early lymphoma, and using lymphangiography may avoid the need for surgical exploration.

Esophageal motility in diabetes mellitus.

There are few objective methods of diagnosing diabetic visceral neuropathy. In the past the author has encountered patients with diabetes mellitus who have shown abnormal esophageal motility in enough instances to lead him to suspect a significant association. Because of this he instituted a systematic radiographic study of esophageal motility in diabetes mellitus. During the course of this investigation a study was published indicating that 12 of 14 diabetics with neuropathy-gastroenteropathy manifested an abnormal esophageal motility pattern on cineradiographic study (1). This is the only previous publication pertaining directly to the problem. Method Esophageal peristalsis was observed in diabetic and in nondiabetic individuals in both prone oblique positions. The barium mixture used was the same as that routinely employed in our department. If a normal progressive peristaltic wave occurred, at least one was recorded cineradiographically. If no progressive peristaltic wave appeared, the patient was observed fluoroscopically during a number of deglutitions for five minutes. During this time, short sample periods were recorded cineradiographically. Other factors such as tertiary contractions, dilatation, hiatal hernia, reflux, and incomplete emptying were observed and recorded, but the presence or absence of an effective peristaltic contraction that traversed the length of the esophagus was most easily assessed and was assigned prime significance. Ninety-seven males were studied, 41 of whom had diabetes mellitus. The mean age of the 41 was fifty-five years (twenty-one to seventy-eight years) and of the 56 nondiabetics fifty years (thirty-one to seventy-three years). Results Table I shows the overall results, based on presence or absence of an effective progressive peristaltic contraction. Statistically, this difference is significant at the 0.01 probability level (χ2 = 6.62). The mean duration of diabetes mellitus in the patients with abnormal esophageal motility was eleven years (new to twenty-six years). Only one person in this group had had diabetes mellitus for less than six years, and he was seventy-three years old when the recent diagnosis was made. In the diabetics with normal motility the mean duration of disease was four and a half years (new to sixteen years); in 11 of these diabetes had been diagnosed for less than one year and in 4 cases it was detectable only with a glucose tolerance test. A study was then made of those patients in whom diabetes mellitus was known to exist for one or more years (Table II). Statistically, when the results in this group are compared to those in the non-diabetics, the difference becomes even more significant (χ2 = 10.9). The frequency of peripheral neuritis and∕or visceral neuropathy increases with the duration of diabetes mellitus.

Cinemyelographic examination of the cervical spinal canal and the craniovertebral junction: the dentate ligaments.

Abstract Cinemyelography of the cervical spinal canal is useful in demonstrating the dynamic aspects of the passage of Pantopaque into that region because a graphic recording of the influence of position, movement and strain can be obtained and examined repeatedly. The posterior cranial fossa, including the foramen magnum, the medullary and the great cistern, the pontine, cerebellopontine and the interpeduncular cistern can also be examined. The dentate ligaments and their appearance during various movements can be recorded and the details of their anatomy and their radiology are described in this paper, particularly in the cervical region. The technique of examination is set out. It consists essentially of the introduction of large quantities (about 15 ml.) of Pantopaque followed by tilting in the prone and both prone oblique positions with simultaneous cinefluorography at 16 f.p.s. The lumbar puncture needle is usually left in situ and the contrast medium removed at the end of the examination by syphonage.

DIAGNOSTIC ACCURACY IN CINEROENTGENOGRAPHIC EXAMINATION OF THE UPPER GASTROINTESTINAL TRACT. A COMPARATIVE STUDY OF CINE AND CONVENTIONAL ROENTGENOGRAPHY IN 103 PATIENTS.

The many articles in the literature concerning cineroentgenography of the gastrointestinal tract attest to continued interest in this technic (1, 2, 5–7, 9–11). Image intensifiers, to which cineroentgenography owes its practicability, are becoming standard equipment in both the hospital and office practice of radiology. Cineroentgenography has been advocated instead of spot-films at strategic intervals in the gastrointestinal examination (5). It has been used to supplement conventional roentgenography during rapid movements such as swallowing (1, 2, 6, 8, 9, 12). It probably is employed most often as a supplementary study, when the results of the conventional examination are inconclusive (3, 11, 12). Diagnoses based on cineroentgenography alone have been compared with those based on spot-films of the stomach and duodenum, and on a combination of spot-films and cineroentgenography (3). To our knowledge, however, no comparison has been reported between separate cineroentgenographic and conventional upper gastrointestinal roentgen studies (fluoroscopy, spot-films, and overhead tube films) in the same patient. Material and Methods One hundred and three patients who had been studied in a conventional roentgen examination were chosen for cineroentgenography by one of the authors (A. R. M.). In 75 a variety of gastric and duodenal lesions were demonstrated on the conventional films; in the remaining 28 the findings were normal. The roentgenographic diagnosis was the sole basis for selection; age, sex, or clinical condition of the patients was not considered. The investigator who performed and interpreted the cineroentgenographic study and reviewed the clinical and laboratory data was unaware of the findings of the conventional examination. Cineroentgenography was performed with a 9-inch Picker image intensifier, a Picker x-ray machine, and a 16-mm. Kodak Cine Special camera. The Kodak Plus X film employed was processed by a Picker automatic unit with Kodak Liquid Developer. The first films were made with the patient in the upright position and the stomach empty. The passage of the first swallow of barium through the cardioesophageal junction was recorded at the rate of 30 frames per second. The remainder of the examination was performed at 15 frames per second. The initial swallow was followed by a recording of the gastric rugal folds in both the upright and prone positions. The stomach was then filled and studied in the upright position. The gastric fundus and the antrum and duodenal bulb were examined in the supine position. This was followed by an examination of the lower esophagus in the prone oblique position. With the patient in the same position, the filled stomach was then scanned. Efforts to demonstrate a hiatus hernia were made in every instance.

A One-Year Experience with a Remote-Control Closed-Circuit Television System in a Private Office

One year's experience with a remote-control x-ray and closed-circuit television unit has offered us an opportunity to evaluate the newer image intensifier in the routine office practice of radiology. Our impressions regarding its value are offered in an individual and critical appraisal of the television viewing, photofluorography, and cine studies performed in over 1,000 upper gastrointestinal studies and approximately 500 colon examinations. Technic of Photofluorography and Cine Studies The examination of the stomach has been modified so that mucosal relief films could be obtained on 8 × 10-in. spot-films. After several swallows of barium, 1 radiograph is made in the upright position, 1 in the supine position, and then 2 oblique roentgenograms are taken, allowing the ingested air to fill the antrum and cap as well as the fundus and cardia. The patient then assumes the prone position for a roentgenogram which includes the antrum and duodenum. In this projection, the antrum is ironed out by the spine pressure. In the right oblique position, one or two divided 8 × 10-in. films are obtained to outline the duodenum and antral area of the stomach. Thus, 5 full 8 × 10-in. films and one or two divided 8 × 10-in. films with two exposures of the antrum and cap comprise the radiographic study. Cinefluorography subsequently records the fluoroscopic examination on 16-mm. films. To study the cardio-esophageal region, specifically for hiatus hernia, the patient is examined in the prone oblique position with a pressure sponge placed under the upper abdomen. While barium is being ingested through a straw, an automatically timed thirty-second exposure is made with 15 frames∕second speed set on the synchronized camera. The esophagus and cardia are filmed on the first run, and then another thirty-second exposure of the stomach including the duodenal loop is recorded. The colon examination is performed with some slight modifications. The patient lies on his left side and the barium flow in the lateral position is observed from the anus to the turn in the rectum or rectosigmoid area. At this point a 10 × 12-in. film is phototimed for recording. The patient is then placed on his back by the technician who stands at the foot end of the table while controlling the barium flow. Via an automatic pressure device, the sigmoid is uncoiled and high kilovoltage (130 kvp) 8 × 10-in. films are obtained in this region as well as about all the flexures. Finally, an 8 × 10-in. spot-film is made of the cecum and terminal ileum when the latter could be filled. Cine studies of the colon were performed only when disease was demonstrated or if a strip of film was desired for teaching purposes.