Bjørn Skjoldbye

Liver Resection and Local Ablation of Breast Cancer Liver Metastases ? A Systematic Review

AIM To analyze surgical treatment of breast cancer liver metastases (BCLM) regarding selection criteria, outcome and prognostic parameters. METHODS We searched Embase and Medline for all studies published 1999-2010. RESULTS Resection was associated with a median survival (MOS) of 20-67 months and 5-year survival of 21-61%. Local ablation also had a favorable outcome; MOS was 30-60 months and 5-year survival 27-41%. Regarding selection, no specific limits regarding the number and size of BCLM can be given. Features of the primary breast cancer (BC) were not significant for the prognosis. Microscopically radical (R0) resection is a positive prognostic factor, while the effects of disease interval, hormone receptor status and response to preoperative chemotherapy were divergent. The presence of EHD had a negative effect on survival in some studies, but failed to have so in other studies. CONCLUSIONS Surgical therapy may benefit a subset of patients with BCLM. Resection may be indicated, if an RO-resection can be done with a low risk of mortality. Liver resection in the presence of extrahepatic disease remains controversial, while patients with BCLM and bone metastases could possibly be managed differently than other EHD.

Intramuscular Myxoma and fibrous dysplasia of bone — Mazabraud's syndrome A case report

We present a case of Mazabrauds syndrome, a rare benign disease, with multiple intramuscular myxomas of the thoracic wall associated with fibrous dysplasia of bone. CT, MR imaging and ultrasonography (US) of the thorax showed 2 well circumscribed homogeneous intramuscular tumors. A US-guided needle biopsy with a large-core needle (2.0 mm) and a fine needle (0.8 mm) showed that the tumors were intramuscular myxomas with no sign of malignancy. 99mTc bone scintigraphy showed a markedly increased uptake in the right lower skull, and multiple smaller foci. CT of the skull revealed a right-sided unilateral bone thickening of the orbit and the ethmoidal cells, and right-sided exophthalmia. This case history suggests that patients with multiple intramuscular myxomas should be preoperatively examined for osseous lesions. A postoperative follow-up should also be performed to detect other soft-tissue myxomas not as yet clinically detectable, or rare osseous complications.

Real-time sonography of anterior translation of the shoulder : an anterior approach

Abstract Objective: In this prospective study, we established and evaluated an ultrasound technique to demonstrate anterior passive translation of the shoulder, using a new anterior approach. Methods: A preliminary in vitro study was performed, with anterior ultrasound scanning of a skeleton in a waterbath. Forty shoulders in twenty normal subjects were then examined with a 3.5 MHz linear transducer, using the same anterior approach. The anterior range of motion (ROM) was measured during passive anterior translation. Results: Anatomical landmarks were identified anteriorly on the humerus and the scapula, to define a scanning plane, in which ROM was measured to 1.8 ± 0.1 mm (mean ± S.E.M.) (range 0.4–4.1 mm). The difference in ROM between the two shoulders of each subject (Δ ROM) was calculated: 0.7 ± 0.1 mm (range 0.1–1.9 mm). Conclusion: The anterior translation of the shoulder can be assessed objectively, non-invasively and rapidly by ultrasonography. We found ROM to be less than 4 mm, and A ROM to be less than 2 mm. The interobserver variability of the method remains to be investigated, as is its usefulness in the diagnosis of chronic anterior shoulder instability.

Perioperative Doppler Ultrasonography: Renal Detection of Renal Graft Perfusion

Irreversible damage of renal transplants may be prevented if insufficient graft perfusion can be detected perioperatively. Colour and spectral Doppler ultrasonography were performed in 30 consecutive renal transplants. The perfusion of the graft and the Resistive Index (RI) were evaluated perioperatively (perioperatively and less than 15 min postoperatively) and 24 h after the operation in all patients. In four cases (13.3%) RI > 0.9 was detected and immediate surgical correction of the cause led to a normalization (RI < 0.8) in all four cases. A RI < 0.9 required no intervention in 26 cases (86.7%). All renal grafts in this series were functioning 1 month postoperatively. In a comparative group, 30 consecutive transplants carried out at our institution without perioperative Doppler ultrasonography evaluation, a loss of four renal grafts perioperatively was recorded retrospectively. We conclude that perioperative ultrasonography Doppler evaluation may provide an easy applicable and reliable method for early detection of insufficient renal graft perfusion, allowing surgical correction before irreversible damage of the graft occurs. RI > 0.9 is pathological. A continuation of the study is required to clarify the long-term value of perioperative Doppler ultrasonography graft monitoring.

Percutaneous Gastrostomy Guided by Ultrasound and Fluoroscopy

Percutaneous gastrostomy, utilizing a dedicated catheterization kit, with a combination of ultrasonographic (US) and fluoroscopic guidance, was carried out in 27 patients. The main indication for gastrostomy was the need for nutritional support in malignant esophageal stricture. After distending the stomach with water via a nasogastric tube, the gastric antrum was punctured under US guidance and a guide wire was inserted, followed by fluoroscopically guided tract dilatation and insertion of a 2.5-mm Cope-loop catheter. In all patients but one (96%) the procedure was successfully completed in one or 2 attempts. Two complications occurred: one case of a small subcutaneous abscess near the puncture site, and one late incident of dislodgement of a catheter without string-loop fixation, which had been inserted at a catheter exchange after 6 weeks. Percutaneous gastrostomy guided by US and fluoroscopy is a safe and efficacious alternative to endoscopic and surgical gastrostomy.

Rectal compliance determined by rectal endosonography: A new application of endosonography

PURPOSE: The aim of this study was to develop a method for determination of rectal compliance that allows direct measurement of corresponding changes in the rectal crosssectional area or perimeter and rectal pressure. METHODS: We developed an anal probe for transrectal endosonography. The probe was testedin vitro,and rectal compliance of six healthy patients was determined. RESULTS:In vitromeasurements proved the method to be well reproducible. The method allowed calculation of an endosonographic rectal compliance, which correlated well with rectal compliance measured by the standard method. CONCLUSION: Endosonographic determination of rectal compliance is possible, and the endosonographic method may give a more precise and reproducible estimation of rectal compliance.

Ultrasound-guided drainage of deep pelvic abscesses: experience with 33 cases.

The aim of this study was to demonstrate and evaluate the ultrasound-guided drainage of deep pelvic abscesses in which transabdominal percutaneous access could not be performed because of overlying structures. A retrospective analysis of 32 consecutive patients with 33 deep pelvic abscesses was performed. The underlying causes of the abscesses included postsurgical fluid collection or surgical complications in 18 of the 32 patients, and 11 of these patients underwent recent rectal cancer surgery. The locations of the abscesses, which had a median diameter of 6 cm (range 2-10 cm), were as follows: perirectal (n=13), presacral (n=9), pouch of Douglas (n=7), internal genitals (n=2) and between the bowel loops (n=2). The abscesses were all drained using ultrasound (US) guidance with a transrectal (n=18), transvaginal (n=11), transperineal ( n=2) or transgluteal (n=2) approach. Of the larger abscesses (median diameter 7 cm), 19 were treated with catheter drainage and 18 of these cases resulted in favorable clinical outcomes. Of the smaller abscesses (median diameter 4 cm), 14 were treated with needle drainage. In two of these cases, follow-up US showed that a repeat puncture and drainage was necessary. All needle drainages resulted in favorable clinical outcomes. Sixteen of the 29 transrectal or transvaginal drainage procedures were performed without any anesthesia (10 were performed with a needle and six were performed with a catheter). Apart from minor discomfort during the drainage procedure and the subsequent in-dwelling catheter period, there were no serious complications related to the drainage procedures. We conclude that ultrasound-guided transrectal, transvaginal, transperineal and transgluteal drainage of deep pelvic abscesses are safe and effective treatment approaches. Based on our findings, needle drainage will be our most common first-line treatment approach because of the simplicity of the procedure, improved patient comfort and reduced costs. Catheter drainage will be reserved for large multiloculated abscesses.

Doppler ultrasound assessment of TIPS patency and function--the need for echo enhancers.

Purpose: the aim of this study was to illustrate the versatility of an i.v. administered echo enhancer for Doppler US assessment of TIPS patency and function. Material and Methods: A total of 22 Doppler US evaluations of TIPS patency and function were performed in 5 patients with alcoholic cirrhosis and recurrent oesophageal bleeding who had been treated with TIPS. TIPS patency was evaluated by means of colour or power Doppler US. the volume flow (VF) was assessed in the TIPS and in the portal vein by spectral Doppler. the ratio of the VF in the TIPS to the VF in the portal vein (T/P ratio) was used to express the functional status of the TIPS. If Doppler signals were inconclusive or absent, echo-enhanced US was performed. Results: In 22 follow-up Doppler US examinations, echo-enhanced Doppler US was required in 7 cases (29%). the Doppler enhancement persisted in the range of 3–5 min. No adverse effects were observed. An apparently normal TIPS function reflected a T/P ratio in the range of 0.44-1.10, median 0.78 ± 0.20 (2SD). Conclusion: the i.v. administration of echo enhancers would seem to be indicated in the assessment of the TIPS function if conventional Doppler US fails to prove normal TIPS patency and function. the T/P ratio may be a convenient monitoring parameter for reflecting the TIPS function.

Preoperative CT versus diffusion weighted magnetic resonance imaging of the liver in patients with rectal cancer; a prospective randomized trial.

Introduction. Colorectal cancer is one of the most frequent cancers in the world and liver metastases are seen in up to 19% of patients with colorectal cancers. Detection of liver metastases is not only vital for sufficient treatment and survival, but also for a better estimation of prognosis. The aim of this study was to evaluate the feasibility of diffusion weighted MRI of the liver as part of a combined MR evaluation of patients with rectal cancers and compare it with the standard preoperative evaluation of the liver with CT. Methods. Consecutive patients diagnosed with rectal cancers were asked to participate in the study. Preoperative CT and diffusion weighted MR (DWMR) were compared to contrast enhanced laparoscopic ultrasound (CELUS). Results. A total of 35 patients were included, 15 patients in Group-1 having the standard CT evaluation of the liver and 20 patients in Group-2 having the standard CT evaluation of the liver and DWMR of the liver. Compared with CELUS, the per-patient sensitivity/specificity was 50/100% for CT, and for DWMR: 100/94% and 100/100% for Reader 1 and 2, respectively. The per-lesion sensitivity of CT and DWMR were 17% and 89%, respectively compared with CELUS. Furthermore, one patient had non-resectable metastases after DWMR despite being diagnosed with resectable metastases after CT. Another patient was diagnosed with multiple liver metastases during CELUS, despite a negative CT-scan. Discussion. DWMR is feasible for preoperative evaluation of liver metastases. The current standard preoperative evaluation with CT-scan results in disadvantages like missed metastases and futile operations. We recommend that patients with rectal cancer, who are scheduled for MR of the rectum, should have a DWMR of the liver performed at the same time.

Ultrasound guided fine needle aspiration biopsies, from the liver. How many needle passes?

A retrospective study was designed to compare the diagnostic yield of US-guided (FNAB) fine needle aspiration biopsy (N = 92) from clearly defined hepatic lesions with diameters of 2 cm or larger, when one, two or three needle passes were performed. No significant diagnostic loss was detected when the number of needle passes was reduced from three to two (Sensitivity = 0.985, Specificity = 1.0, Pos. predictive value (PPV) = 1.0, Neg. predictive value (NPV) = 0.81). However, an unacceptable diagnostic loss was seen when only one needle pass was evaluated (Sensitivity = 0.81, Specificity = 1.0, PPV = 1.0, NPV = 0.69). We conclude that two needle passes can be recommended as a standard procedure for US-guided fine needle aspiration biopsy from hepatic lesions larger than 2 cm in diameter provided the procedure is performed routinely.