Andreas Volk

Quantitative Perfusion Analysis of Transabdominal Contrast-Enhanced Ultrasonography of Pancreatic Masses and Carcinomas

BACKGROUND & AIMS Preoperative differential diagnosis of pancreatic ductal adenocarcinoma (PDAC) and focal masses in patients with chronic pancreatitis (CP) can be challenging. There are fine differences in the vascularization of these lesions; ultrasound contrast agents can aid in their differentiation. We evaluated the value of software-aided quantitative analysis of transabdominal contrast-enhanced ultrasonography for differential diagnosis of PDAC vs focal masses. METHODS Sixty patients for whom it was not possible to differentiate between an inflammatory focal lesion of the pancreas and a pancreatic carcinoma underwent contrast-enhanced ultrasonography with a second-generation contrast agent. Time-intensity curves were obtained for all exams in 2 regions of interest within the lesion and within the normal pancreatic tissue. Images were processed using Axius ACQ software; the following parameters were obtained: maximum intensity, arrival time, time-to-peak, and area under the curve. Absolute values and differences between the lesion and the normal tissue were evaluated. RESULTS Histology analysis revealed 45 PDACs and 15 inflammatory masses in patients with CP. Time-dependent parameters (arrival time and time to peak) were significantly longer in PDACs compared to focal masses. Although markedly lower than in healthy pancreata, the maximum intensity and area under the curve parameters were not significantly different between PDACs and focal lesions in patients with CP. CONCLUSIONS In cases of CP, PDAC and focal masses exhibit different perfusion patterns at a capillary level that can be visualized using the small microbubbles of ultrasound contrast agents. Contrast quantification software supplements a subjective visual assessment with objective criteria to facilitate the differential diagnosis of focal lesions in pancreatic cancer and chronic pancreatitis.

Risk factors for morbidity and mortality after single-layer continuous suture for ileocolonic anastomosis

AimThe study was designed to determine the suitability of a single-layer continuous anastomosis for ileo-colonic anastomoses and to determine perioperative risk factors for morbidity and mortality in a teaching hospital.Patients and methodsPerioperative data of 463 patients undergoing colonic surgery with an ileocolonic anastomosis between 2000 and 2007 were retrospectively reviewed. Outcomes were compared using univariate and multivariate analyses to identify risk factors for morbidity, including anastomotic leakage, and mortality.ResultsThe overall anastomotic leakage rate was 2.1%. In more than 50% right hemicolectomies were performed for colonic cancer. Univariate analysis showed a significant association of the underlying diagnosis with the leakage rate (ischemia 3.0% vs. carcinoma 1.3%). Multivariate analysis identified age, ASA score, diagnosis, and urgency as risk factors for morbidity; and an urgent operation setting (vital indications), a body mass index >25, diabetes mellitus, and a hypotensive circulation upon admission as predictors of anastomotic leakage. The mortality rate was 20% (2/10) among patients with anastomotic leakage and 2.9% (13/453) in those without anastomotic leakage.ConclusionSingle-layer continuous anastomoses for ileo-colonic surgery can be safely performed, even in a teaching setting. Four preoperative risk factors for morbidity and four different factors for anastomotic leakage could be identified in multivariate analysis. If feasible, these factors should have an impact on the preoperative decision-making progress.

Surgical Therapy of Intrapancreatic Metastasis from Renal Cell Carcinoma

Background: Pancreatic metastases from renal cell carcinoma (RCC) are clinically rare but highly resectable. The aim of this article is to identify patients who profit from pancreatic resection of RCC despite the invasiveness of the surgery. Methods: Between January 1996 and December 2007, data from 744 patients were collected in a prospective pancreatic surgery database, and patients with metastasis into the pancreas from RCC were identified. Results: Resective surgery was performed in 14 patients with metastasis to the pancreas from RCC. Most patients were clinically asymptomatic. The median interval between primary treatment of RCC and occurrence of pancreatic metastasis was 94 months (range 32–158). The morbidity rate was 42.8%. Patients with a metastasis size <2.5 cm had a much better survival after resection (100 months) than those with a metastasis size >2.5 cm (44 months). Moreover, the number of metastases predicts the survival after resection. Conclusions: In patients with pancreatic metastases from RCC who have only limited disease, complete resection of all lesions can be successfully performed with a low rate of complications. Thus, patients with a history of RCC should be monitored for more than 10 years after nephrectomy to detect recurrence.

Prospective evaluation of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) in a surgical intensive care unit: Technique and results of the Fantoni tracheostomy

Controversy surrounds the safety and practicality of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) compared with other percutaneous methods.

Contrast-enhanced ultrasonography in pancreas transplantation.

Background Pancreas transplantation remains a major surgery with potential complications that require reliable imaging despite impaired kidney function. Contrast-enhanced ultrasonography (CEUS) has been proven to be an indispensable tool in the evaluation of the native pancreas. Here, CEUS studies are extended to pancreas transplants for the first time. Methods A total of 42 B-mode, duplex, and CEUS exams performed using 1 mL SonoVue (Bracco) on a Siemens Acuson Sequoia ultrasound machine were evaluated in 14 pancreas transplant recipients. Time-intensity curves and curve characteristics were calculated. The data were compared between normal pancreas transplants, grafts undergoing rejection, and grafts after successful treatment of the rejection episode. Results All of the grafts could be well visualized in all ultrasound exams. Although the arterial resistive index did not differentiate between rejection and the absence of rejection, in CEUS, the time-intensity curves showed a significantly slower ascent and diminished maximum intensity in pancreas grafts during rejection, with significantly reduced maximum intensity and time to reach peak intensity. After the successful treatment of rejection, these parameters were almost restored to initial values. Discussion CEUS displays the capillary perfusion of the tissue. Edema of the pancreas graft during rejection impairs capillary perfusion, reflected in the amount of contrast detected by CEUS and the dynamics of the influx of the contrast agent. Conclusion CEUS yields useful information after pancreas transplantation and has been proven a sensitive tool in the surveillance of pancreas grafts. Further studies will be needed to differentiate rejection from other posttransplantation complications using CEUS.

Impact of Intraoperative Re-resection to Achieve R0 Status on Survival in Patients With Pancreatic Cancer: A Single-center Experience With 483 Patients.

Objective: The aim of this study was to test the hypothesis that intraoperative frozen section (FS) and re-resection results to achieve R0 status are associated with different long-term outcomes in pancreatic cancer patients. Background: Recent data have challenged the survival benefit of additional resection in patients with pancreatic cancer in case of positive FS to achieve clear pathological section (PS). Methods: Patients who underwent surgery for exocrine pancreatic malignancy with curative intent were identified from a prospective database. Data were stratified by resection margin (group I: FS-R0 → PS-R0; group II: FS-R1 → PS-R0; group III: FS-R1 → PS-R1). Associations with survival were analyzed by univariate and multivariate analyses. Results: A total of 483 patients met the inclusion criteria. Of these, 61 patients were excluded due to R2 or Rx status. Three hundred seventeen (75%) patients were allocated to margin group I, 32 (8%) to group II, and 73 (17%) to group III. Median overall survival in group I, II, and III was 29, 36, and 12 months (P < 0.001). There was no significant difference in survival between patients in Group I and II (P = 0.849), whereas patients in group III had significantly poorer outcome than group I (P < 0.001) and II (P = 0.039). The prognostic value of margin group status was confirmed on multivariate analysis (hazard ratio = 1.694, 95% confidence interval 1.175–2.442). Conclusions: FS analysis with intraoperative re-resection should be performed routinely in patients undergoing pancreatic cancer surgery with the aim to achieve a R0 resection.

Impact of Bevacizumab on parenchymal damage and functional recovery of the liver in patients with colorectal liver metastases

BackgroundLittle is known about the safety of the anti-VEGF antibody bevacizumab in patients undergoing resection for colorectal liver metastases (CLM). This meta-analysis evaluates the impact of bevacizumab on parenchymal damage and functional recovery in patients undergoing resection for CLM.MethodsThe Medline, Embase and Cochrane Library were systematically searched for studies on preoperative chemotherapy with and without bevacizumab prior to resection of CLM. Studies that reported histological and/or clinical outcomes were eligible for inclusion. Meta-analyses were performed using a random effects model.ResultsA total of 18 studies with a total sample size of 2430 patients (1050 patients with bevacizumab) were found. Meta-analyses showed a significant reduction in sinusoidal obstruction syndrome (SOS) (Odds ratio 0.50 [95 % confidence interval 0.37, 0.67]; p < 0.001; I2 = 0 %) and hepatic fibrosis (0.61 [0.4, 0.86]; p = 0.004; I2 = 7 %) after preoperative chemotherapy with bevacizumab. The reduced incidence of posthepatectomy liver failure in patients with bevacizumab treatment just failed to reach statistical significance (0.61 [0.34, 1.07]; p = 0.08 I2 = 6 %). While there was no difference in perioperative morbidity and mortality, the incidence of wound complications was significantly increased in patients who received bevacizumab (1.81 [1.12, 2.91]; p = 0.02 I2 = 4 %).ConclusionsThe combination of bevacizumab with cytotoxic chemotherapy is safe but increases the incidence of wound complications after resection of CLM. The reduction of SOS and hepatic fibrosis warrant further investigation and may explain the inverse association of bevacizumab administration and posthepatectomy liver failure.

IAP Society News

Abstracts of the Joint Meeting of the European Pancreatic Club (EPC) and the International Association of Pancreatology (IAP) Lodz, June 25–28, 2008 www.pancreasweb.com/abstracts/abstracts.asps of the Joint Meeting of the European Pancreatic Club (EPC) and the International Association of Pancreatology (IAP) Lodz, June 25–28, 2008 www.pancreasweb.com/abstracts/abstracts.asp

Reproducibility of preoperative endoscopic injection of botulinum toxin into the sphincter of Oddi to prevent postoperative pancreatic fistula

Abstract Background: A postoperative pancreatic fistula (POPF) is the most common and potentially life-threatening surgical complication in pancreatic surgery. One possible pharmacological treatment could be the endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi to prevent POPF. Promising data reported a significantly reduced rate of clinically relevant POPF. We analyzed the effect of BTX injection in our patients undergoing distal pancreatectomy (DP). Methods: A retrospective analysis of patients undergoing DP was performed. Patients with preoperative endoscopic injection of BTX into the sphincter of Oddi were included. The end points were postoperative outcomes including POPF. BTX patients were compared with a historical cohort and matched in a 1:1 ratio using a propensity score analysis. Results: A total of 19 patients were treated with endoscopic injection of BTX before open (n=8) or laparoscopic (n=11) DP. The median age of the patients was 67 years and the mean body mass index was 25.9 kg/m2. In median, the intervention was performed 1 day (range, 0–14 days) before the operation. There were no intervention-related complications. The incidence of POPF was not statistically different between the two groups: a clinically relevant POPF grade (B/C) occurred in 32% (BTX) and 42% (control; p=0.737). Likewise, there were no significant differences in postoperative drain fluid amylase levels, morbidity, and mortality. Conclusion: The present study could not reproduce the published results of a significant lowering of grade B/C POPF. The explanations could be the timing of BTX injection before surgery and the endoscopic technique of BTX injection. However, the conflicting results after BTX injection in two high-volume centers prompt a randomized controlled multicenter trial with trained endoscopists.

Treatment of tailgut cysts by extended distal rectal segmental resection with rectoanal anastomosis

PurposeComplete surgical resection is the treatment of choice for tailgut cysts, because of their malignant potential and tendency to regrow if incompletely resected. We report our experience of treating patients with tailgut cysts, and discuss diagnostics, surgical approaches, and follow-up.MethodsWe performed extended distal rectal segmental resection of the tailgut cyst, with rectoanal anastomosis. We report the clinical, radiological, pathological, and surgical findings, describe the procedures performed, and summarize follow-up data.ResultsTwo patients underwent en-bloc resection of a tailgut cyst, the adjacent part of the levator muscle, and the distal rectal segment, followed by an end-to-end rectoanal anastomosis. There was no evidence of anastomotic leakage postoperatively. At the time of writing, our patients were relapse-free with no, or non-limiting, symptoms of anal incontinence, respectively.ConclusionsThis surgical approach appears to have a low complication rate and good recovery outcomes. Moreover, as the sphincter is preserved, so is the postoperative anorectal function. This approach could result in a low recurrence rate.