Effect of Adjusted Positioning on Gastric Distention and Fluid Distribution During CT Gastrography

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1 CT Gastrograph y Gastrointestinal Imaging Technical Innovation Se Hyung Kim 1 Jeong Min Lee 1,2 Joon Koo Han 1,2 Jae Young Lee 1,2 Han Kwang Yang 3 Hyuk-Joon Lee 3 Kyung-Sook Shin 4 Byung Ihn Choi 1,2 Kim SH, Lee JM, Han JK, et al. DOI: /AJR Received November 23, 2004; accepted after revision January 10, Department of Radiology, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul , Korea. Address correspondence to J. M. Lee (leejm@radcom.snu.ac.kr). 2 Institute of Radiation Medicine, Seoul National University Hospital, Seoul, Korea. 3 Department of Surgery, Seoul National University Hospital, Seoul, Korea. 4 Department of Radiology, Chungnam National University Hospital, Daejeon, Korea. AJR 2005; 185: X/05/ American Roentgen Ray Society Effect of Adjusted Positioning on Gastric Distention and Fluid Distribution During CT Gastrography OBJECTIVE. We hypothesized that performing CT gastrography with the patient in the left posterior oblique (LPO) position would provide better distention and less residual fluid for the lower part of the stomach than CT gastrography with the patient in the standard supine position. CONCLUSION. The LPO position for CT guaranteed the distensibility of and minimal residual fluid in the lower part of the stomach, thus resulting in excellent 3D CT gastrographic images. ith the recent advances in W MDCT technology, the use of 3D applications to examine the gastrointestinal tract, such as CT colonography, CT enterography, and CT gastrography, is dramatically increasing. Optimizing patient preparation for gastrointestinal tract CT examinations is an important consideration to increase the performance of CT in various diagnostic fields. In particular, in the field of CT colonography, there has been considerable interest in achieving better preparation including maximizing distention, minimizing residual fluid or feces, patient positioning, use of hypotonia, and optimal choice of inflating agent (room air or carbon dioxide) [1 4]. By comparison, the necessity for refining CT gastrography techniques has been unnoticed. The recent popularity of minimally invasive surgery, such as laparoscopyassisted gastrectomy, has required accurate 3D reconstruction of the stomach and its surrounding structures to avoid complications caused by a limited field of view during laparoscopic surgery. Moreover, at many institutions, 3D CT gastrographic images, including surface-shaded or transparent volume-rendered images, have decreased the need for conventional double-contrast barium studies for global assessment of gastric diseases. In previous 3D CT studies of the stomach performed with the patient in the supine or prone position, tumors located at the antrum were not well delineated because of poor stomach distention or fluid retention [5, 6]. To circumvent this problem, we performed CT gastrography with the patient in the 30 left posterior oblique (LPO) position, which we defined as the CT LPO position. We hypothesized that performing CT gastrography with the patient in the LPO position would provide better distention of and less residual fluid in the lower part of the stomach than performing the examination with the patient in the standard supine position. Materials and Methods From February to July 2004, 85 consecutive patients with pathologically proven early gastric cancer (57 men, 28 women; mean age, 59 years; age range, years) who underwent CT gastrography were enrolled in our study. Eighty-five early gastric cancers were identified on histopathology. Among them, 40 lesions were confined in the mucosal layer and the remaining 45 lesions in the submucosal layer. The lesions were located on the fundus in three patients, the upper body in 10, the lower body in 20, the proximal antrum in 24, and the distal antrum in 28 patients. According to the morphologic classification, 45 of the 85 lesions were classified as early gastric cancer type IIc; 10 as stage I; seven each as IIa + IIc and stage IIc + IIa; four each as stage IIa, IIb + IIc, and stage IIb + IIa; and two each as stage IIa + IIb and III. Before CT examination, 10 mg of butyl scopolamine (Buscopan, Boehringer Ingelheim) was administered IV to decrease bowel peristalsis and to facilitate hypotonia. Then, to attain gastric distention, two packs of effervescent granules with minimal water (< 5 ml) were administered orally while the patient was on the CT table just before scanning. CT was performed using a 16-MDCT scanner (Sensation 16, Siemens Medical Systems). The CT parameters used were as follows: 120 kvp, 100 ef AJR:185, November 2005

2 CT Gastrography fective mas, mm detector configuration, 15 mm/sec table feed (beam pitch of 1.25), and 1- mm reconstruction with 30% overlap. The patients were randomly allocated into one of two groups according to the intended scanning position. The first group (n = 52) included patients undergoing CT in the CT LPO position. For this position, patients were first positioned in the left lateral decubitus position to shift the gastric contents from the lower two thirds to the fundus of the stomach; they were then immediately placed on the scanning table in a 30 LPO position by placing a pillow at their back [7] (Fig. 1). The second group of patients A B Fig. 1 CT gastrographic images of 64-year-old man in left posterior oblique (LPO) position. A, Axial CT scan obtained with patient in 30 LPO position for distention of distal half of stomach shows markedly distended lower body (arrowhead) and distal antrum (arrow) without any residual fluid within those segments. Grade 4 (> 75%) was assigned to those three segments with regard to both distention and residual fluid. B and C, 3D CT gastrography images resulting from use of surface-shaded (B) and transparent (C) volume-rendering technique show good distention of stomach except in gastric fundus. Note bubbly fluid (arrow, B) in fundus. (n = 33) included those who underwent CT in the standard supine position (Fig. 2). Each scan was completed within sec. CT images regardless of scanning position were obtained 70 sec after injection of 120 ml of nonionic contrast material (iopromide [Ultravist 370, Schering]) at a rate of 3 4 ml/sec. CT gastrographic images were created using a surface-shaded and transparent volume rendering technique by experienced 3D technicians using dedicated 3D software (Rapidia, Infinitt). Two reviewers evaluated the CT gastrographic data in consensus for the degree of gastric distention and the presence of residual fluid. For the sake of recording data, the stomach was divided into five segments that is, the fundus, upper body, lower body, proximal antrum, and distal antrum. Gastric distention and residual fluid were ranked on a 4-point scale. Gastric distention was recorded as 1 for less than 25% of the expected maximal luminal dimension, grade 2 for 25 50%, grade 3 for 51 75%, and grade 4 for more than 75%. Residual fluid in a gastric segment was measured relative to the maximum anteroposterior diameter of the segment: grade 1 for an air fluid level greater than 50% of the maximum anteroposterior diameter of the segment; grade 2 for 25 50%; grade 3 for 1 25%; and grade 4 for no residual fluid C AJR:185, November

3 (Figs. 1 and 2). The two groups were compared using the Mann-Whitney U test with respect to the two parameters. A p value of less than 0.05 was considered to indicate a statistically significant difference. Results The total grades for the two parameters to determine the adequacy of CT gastrography are summarized in Table 1 with the p values of the intergroup statistical analysis. For statistical analysis, scores of both gastric distention and residual fluid were averaged and assigned a total score. A C In terms of gastric distention, the mean scores for most of the segments were larger in the LPO group than in the supine group. The differences between the mean scores of the two groups were statistically significant in the lower three segments that is, the lower body, proximal antrum, and distal antrum (p < 0.004). Regarding residual fluid, the mean scores for the proximal and distal antrum were significantly larger in the LPO group than in the supine group (p < 0.03). For the remaining three segments, the mean scores in the LPO group tended to be larger Fig. 2 CT gastrographic images of 48-year-old man in standard supine position. A and B, CT scans obtained with patient in standard supine position show distal antrum (arrow, A) is severely collapsed and contains substantial amount of fluid within that segment; it was assigned grade 1 (< 25%) for both parameters. Note also slightly collapsed proximal antrum with small amount of fluid (arrow, B). Grade 3 (51 75%) was assigned to this segment regarding residual fluid. C, 3D CT gastrography image resulting from use of surface-shaded volume-rendering technique shows severely collapsed gastric antrum (arrow). This image provides only suboptimal quality for evaluation of that segment. than those for the supine group, but these differences were not statistically significant (p > 0.05). For the LPO group, the total scores averaged for both parameters were significantly higher than for the standard group in the lower three segments (p < 0.002). For the LPO group, the total score averaged for all five segments in both parameters was 3.6 ± 0.8 (mean ± SD), but was 3.2 ± 1.0 for the supine group. The difference was also statistically significant (p < ). Representative examples are shown in Figures 1 and 2. B 1182 AJR:185, November 2005

4 CT Gastrography TABLE 1: Gastric Distention and Residual Fluid Grades Assigned to Images Obtained with Patients in the Left Posterior Oblique (LPO) Position Compared with Those Assigned to Images Obtained with Patients in the Supine Position and Comparative Statistical Analysis Gastric Characteristic Fundus Upper Body Lower Body Proximal Antrum Distal Antrum Total Evaluated LPO Supine LPO Supine LPO Supine LPO Supine LPO Supine LPO Supine Distention a Grade Grade Grade Grade Mean ± SD 3.2 ± ± ± ± ± ± ± ± ± ± ± ± 0.9 p b < < Residual fluid c Grade Grade Grade Grade Mean ± SD 1.9 ± ± ± ± ± ± ± ± ± ± ± ± 1.1 p b < Total d Mean ± SD 2.6 ± ± ± ± ± ± ± ± ± ± ± ± 1.0 p b < < < a Grade 1, gastric distention was < 25% of the expected maximal luminal dimension; grade 2, 25 50%; grade 3, 50 75%; and grade 4, > 75%. b Obtained by comparing the CT left posterior oblique position and supine groups using the Mann-Whitney U test. c Grade 1, air fluid level > 50% of the maximum anteroposterior diameter of the segment; grade 2, 25 50%; grade 3, 1 25%; and grade 4, no residual fluid. d Total score was derived from the average score of both distention and residual fluid for each gastric segment. Discussion In this study, CT gastrography with the patient in the LPO position provided better gastric distention and less residual fluid in the lower part of the stomach than CT gastrography with the patient in the conventional supine position. On double-contrast barium study, it is well known that images obtained with the patient in the LPO position give an excellent double-contrast view of the distal half of the stomach [8]. In addition to good distention, no residual fluid should be retained for CT gastrography because if residual fluid is present, clinically important lesions could potentially be obscured due to interference from the proper lumen wall interface caused by the administration of effervescent agents. Unlike double-contrast barium studies in which imaging can be performed in multiple projections to allow the fluid to redistribute, scanning for CT gastrography should be limited to only one or two projections that is, the supine or LPO position and the right decubitus position. As shown in the Results section, positioning toward one s back in the LPO position just after turning onto one s left side can shift fluid in the gastric antrum to the gastric fundus and subsequently allow a clean image of the lower gastric portion to be obtained. The combined interpretation of axial and 3D volume-rendered images in CT gastrography is necessary to make an accurate diagnosis by allowing viewing of the intraluminal morphology and extraluminal characteristics of various gastric diseases [7]. In addition, during preoperative planning, accurate localization of the lesion is as important as tissue characterization. Conventional gastroscopy is extremely sensitive for gastric mucosal lesions. However, additional studies, such as double-contrast barium study or CT, are frequently needed to perform the full structural examination and to evaluate extraluminal conditions preoperatively. In the 3D volumerendered images we used, simultaneous evaluation of the local and the global views is possible during a single examination. These images allow the surgeon to perform preoperative planning including accurate localization. This information is more important for laparoscopy-assisted gastric surgery due to the lack of information usually obtained on tactile assessment. Therefore, appropriate preparation that is, good distention and minimal fluid for the distal half of the stomach in which most of lesions occur is necessary to obtain good CT gastrographic images. Several limitations of this study should be mentioned. First, we were not able to determine the exact volume of the residual fluid present within gastric segments at the time of CT gastrography. However, we think that our method for quantifying residual fluid provides a reasonable representation of the relative amounts. Second, because the position of the patients on the CT couch is obviously visible on the 2D CT gastrographic data set, the reviewers could not be totally blinded to scanning position. Third, although our results showed that the LPO position is helpful in obtaining good distention and minimal residual fluid for the gastric lower portion, it cannot be applied for the gastric upper portion. Theoretically, the evaluation of the fundus and the cardia would be potentially limited in both the LPO AJR:185, November

5 and standard supine positions. Therefore, further studies regarding the effect of other positions, such as the right decubitus or prone position, on the adequate preparation of the gastric upper portion will be needed. Finally, the objective of our study was not to evaluate the diagnostic performance of CT gastrography for detecting gastric lesions. Rather, our goal was to evaluate the feasibility of CT gastrography with the patient in a new position to achieve better gastric distention with less residual fluid compared with studies performed with the patient in the supine position. Although our initial results seem to be promising, further prospective studies with larger numbers of patients will be needed to assess the diagnostic performance of CT gastrography with the patient in the LPO position and to confirm the feasibility of performing CT gastrography with the patient in the LPO position. In conclusion, CT with the patient in the LPO position guarantees distention of the lower part of the stomach and retention of minimal residual fluid in the lower part of the stomach, thereby resulting in excellent 3D CT gastrographic images. References 1. Macari M, Lavelle M, Pedrosa I, et al. Effect of different bowel preparations on residual fluid at CT colonography. Radiology 2001; 218: Chen SC, Lu DSK, Hecht JR, Kadell BM. CT colonography: value of scanning in both the supine and prone positions. AJR 1999; 172: Yee J, Hung RK, Akerkar GA, Wall SD. The usefulness of glucagon hydrochloride for colonic distention in CT colonography. AJR 1999; 173: Rogalla P, Meiri N. CT colonography: data acquisition and patient preparation techniques. Semin Ultrasound CT MR 2001; 22: Lee DH, Ko YT. Advanced gastric carcinoma: the role of three-dimensional and axial imaging by spiral CT. Abdom Imaging 1999; 24: Lee DH, Ko YT. Gastric lesions: evaluation with three-dimensional images using helical CT. AJR 1997; 169: Kim SH, Han JK, Lee KH, Chung JW, Yang HK, Choi BI. Computed tomography gastrography with volume-rendering technique: correlation with double-contrast barium study and conventional gastroscopy. J Comput Assist Tomogr 2003; 27: Laufer I. A simple method for routine double-contrast study of the upper gastrointestinal tract. Radiology 1975; 117: AJR:185, November 2005

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