F. Fornari

Thermal Lesions Induced by 480 KHz Localized Current Field in Guinea Pig and Pig Liver

We evaluated the type, dimension and histopathological evolution of thermal lesions induced in guinea pig and pig liver by radiofrequency electrode needles at various temperatures for different exposure times. The greatest useful necrosis volume was induced by a needle of 1.1 mm diameter and exposed tip 10 mm long at 90 °C and 120 seconds exposure time. It was an ellipsoid with the biggest diameter of about 14 mm diameter and length of about 18 mm. It seems possible that liver tumors of not more than 20 mm diameter in patients without surgical prospects could be destroyed, ultrasonography guiding the needle into the tumor and using the temperature and exposure time mentioned above.

Ultrasound-guided fine-needle biopsy of focal liver lesions: techniques, diagnostic accuracy and complications: A retrospective study on 2091 biopsies

Two thousand and ninety-one ultrasound-guided fine-needle biopsies were performed in 1946 patients to diagnose focal liver lesions. The diagnostic accuracy of fine-needle biopsies is very high (only one false positive was observed), both for aspiration biopsy (93.4%) and for cutting biopsy (95.1%). The difference is not statistically significant. In cases of hepatocellular carcinoma (but not in cases of metastasis or hepatic lymphoma), double biopsy (aspiration and cutting) showed higher diagnostic sensitivity than single methods. A certain number of benign focal liver lesions were also diagnosed. In the present series, no case of death following liver puncture was observed. Intraperitoneal hemorrhage was the most common complication. The risk with a cutting needle being higher than with an aspirative needle.

Complications of ultrasonically guided fine-needle abdominal biopsy: results of a multicenter Italian study and review of the literature

This report describes the complications following 10,766 ultrasonically guided fine-needle biopsies performed from 1979 to 1987 in 33 Italian echographic units. The mortality was 0.018%: the two reported deaths were due to hemoperitoneum and occurred in patients with hepatocellular carcinoma arising in a cirrhotic liver. Twenty patients (0.18%) had major complications. This series confirms that abdominal biopsy with fine needles is safe, even though our death rate was higher than in previous reports. Among the other nine fatalities following fine-needle abdominal biopsy reported in the literature, seven were secondary to hemorrhage. The biopsy of pancreatic carcinoma was more dangerous for needle-tract seeding (five of eight reported cases, including one in our series).

Long term effectiveness of resection and radiofrequency ablation for single hepatocellular carcinoma <= 3 cm. Results of a multicenter Italian survey.

BACKGROUND & AIMS The aim of this study was to compare liver resection and radiofrequency ablation in patients with single hepatocellular carcinoma ≤3 cm and compensated cirrhosis. METHODS The study involved 544 Child-Pugh A cirrhotic patients (246 in the resection group and 298 in the radiofrequency group) observed in 15 Italian centers. Overall survival and tumor recurrence rates were analyzed using the Kaplan Meier method before and after propensity score matching. Cox regression models were used to identify factors associated with overall survival and tumor recurrence. RESULTS Two cases of perioperative mortality were observed in the resection group and the rate of major complications was 4.5% in the resection group and 2.0% in the radiofrequency group (p=0.101). Four-year overall survival rates were 74.4% in the resection group and 66.2% in the radiofrequency group (p=0.353). Four-year cumulative HCC recurrence rates were 56% in the resection group and 57.1% in the radiofrequency group (p=0.765). Local tumor progression was detected in 20.5% of ablated patients and in one resected patient (p<0.001). After propensity score matching, both survival and tumor recurrence were still not significantly different although a trend towards lower recurrence was observed in resected patients. Older age and higher alpha-fetoprotein levels were independent predictors of poor overall survival while older age and higher alanine-aminotransferase levels resulted to be independent factors associated with higher recurrence rate. CONCLUSIONS In spite of a higher rate of local tumor progression, radiofrequency ablation can provide results comparable to liver resection in the treatment of single hepatocellular carcinoma ≤3 cm occurring in compensated cirrhosis.

Predicting Mortality in Non-Variceal Upper Gastrointestinal Bleeders: Validation of the Italian PNED Score and Prospective Comparison With the Rockall Score

OBJECTIVES:We sought (i) to validate a new prediction rule of mortality (Progetto Nazionale Emorragia Digestiva (PNED) score) on an independent population with non-variceal upper gastrointestinal bleeding (UGIB) and (ii) to compare the accuracy of the Italian PNED score vs. the Rockall score in predicting the risk of death.METHODS:We conducted prospective validation of analysis of consecutive patients with UGIB at 21 hospitals from 2007 to 2008. Outcome measure was 30-day mortality. All the variables used to calculate the Rockall score as well as those identified in the Italian predictive model were considered. Calibration of the model was tested using the χ2 goodness-of-fit and performance characteristics with receiver operating characteristic (ROC) analysis. The area under the ROC curve (AUC) was used to quantify the diagnostic accuracy of the two predictive models.RESULTS:Over a 16-month period, data on 1,360 patients were entered in a national database and analyzed. Peptic ulcer bleeding was recorded in 60.7% of cases. One or more comorbidities were present in 66% of patients. Endoscopic treatment was delivered in all high-risk patients followed by high-dose intravenous proton pump inhibitor in 95% of them. Sixty-six patients died (mortality 4.85%; 3.54–5.75). The PNED score showed a high discriminant capability and was significantly superior to the Rockall score in predicting the risk of death (AUC 0.81 (0.72–0.90) vs. 0.66 (0.60–0.72), P<0.000). Positive likelihood ratio for mortality in patients with a PNED risk score >8 was 16.05.CONCLUSIONS:The Italian 10-point score for the prediction of death was successfully validated in this independent population of patients with non-variceal gastrointestinal bleeding. The PNED score is accurate and superior to the Rockall score. Further external validation at the international level is needed.

Laparoscopic ablation of liver adenoma by radiofrequency electrocauthery

Two percutaneous and minimally invasive means of ablating small hepatocellular carcinomas (HCC) are (1) injection of ethanol guided by ultrasonography (US),1 and (2) interstitial hyperthermia induced by an electrode needle activated by radiofrequency (RF) or by insertion of a laser fiber, also under US guidance. 2, 3 The extent of necrosis induced by interstitial hyperthermia is exactly predictable. The size of the thermally induced lesion depends on the needle size, the temperature of the needle tip, and the e xposure time (however, exposure in excess of 120 seconds does not cause a further increase in the volume of necrosis). Keeping the tip temperature below 100 ° C at hottest focus within t he lesion will avoid boiling or sticking and the associated risks. 4, 5 The use of interstitial RF hyperthermia is similar to that employed in neurosurgery. 5 An RF electrode needle or laser fiber also may be inserted in the course of laparoscopy. A recent report described laser-assisted excision of a liver cyst using a laparoscopic approach. 6 We report here a case of adenoma, superficially located in the liver, treated by laparoscopically guided RF interstitial hyperthermia.

High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: A multicentre, randomized study

BACKGROUND:The most effective schedule of proton pump inhibitor (PPI) administration following endoscopic hemostasis of bleeding ulcers remains uncertain.METHODS:Patients with actively bleeding ulcers and those with nonbleeding visible vessel or adherent clot were treated with epinephrine injection and/or thermal coagulation, and randomized to receive intravenous PPIs according to an intensive regimen (80 mg bolus followed by 8 mg/h as continuous infusion for 72 h) or a standard regimen (40 mg bolus daily followed by saline infusion for 72 h). After the infusion, all patients were given 20 mg PPI twice daily orally. The primary end point was the in-hospital rebleeding rate, as ascertained at the repeat endoscopy.RESULTS:Bleeding recurred in 28 of 238 patients (11.8%) receiving the intensive regimen, and in 19 of 236 (8.1%) patients receiving the standard regimen (P = 0.18). Most rebleeding episodes occurred during the initial 72-h infusion: 18 (7.6%) and 19 events (8.1%) in the intensive and standard groups, respectively (P = 0.32). Mean units of blood transfused were 1.7 ± 2.1 in the intensive and 1.5 ± 2.1 in the standard regimen group (P = 0.34). The duration of hospital stay was <5 days for 88 (37.0%) and 111 patients (47.0%) in the intensive and standard groups (P = 0.03). There were fewer surgical interventions in the standard versus intensive regimen (1 vs 3). Five patients in each treatment group died.CONCLUSIONS:Following endoscopic hemostasis of bleeding ulcers, standard-dose PPIs infusion was as effective as a high-dose regimen in reducing the risk of recurrent bleeding. (ClinicalTrials.gov number, NCT00374101).

Real time contrast enhanced ultrasonography in detection of liver metastases from gastrointestinal cancer

BackgroundContrast enhanced ultrasound (CEUS) is an imaging technique which appeared on the market around the year 2000 and proposed for the detection of liver metastases in gastrointestinal cancer patients, a setting in which accurate staging plays a significant role in the choice of treatment.MethodsA total of 109 patients with colorectal (n = 92) or gastric cancer prospectively underwent computed tomography (CT) scan and conventional US evaluation followed by real time CEUS. A diagnosis of metastases was made by CT or, for lesions not visibile at CT, the diagnosis was achieved by histopathology or by a malignant behavior during follow-up.ResultsOf 109 patients, 65 were found to have metastases at presentation. CEUS improved sensitivity in metastatic livers from 76.9% of patients (US) to 95.4% (p <0.01), while CT scan reached 90.8% (p = n.s. vs CEUS, p < 0.01 vs US). CEUS and CT were more sensitive than US also for detection of single lesions (87 with US, 122 with CEUS, 113 with CT). In 15 patients (13.8%), CEUS revealed more metastases than CT, while CT revealed more metastases than CEUS in 9 patients (8.2%) (p = n.s.).ConclusionCEUS is more sensitive than conventional US in the detection of liver metastases and could be usefully employed in the staging of patients with gastrointestinal cancer. Findings at CEUS and CT appear to be complementary in achieving maximum sensitivity.

Ultrasonically guided percutaneous splenic tissue core biopsy in patients with malignant lymphomas.

Ultrasonically [US] guided percutaneous tissue core biopsy of the spleen was done on 46 patients with malignant lymphomas. The biopsies were undertaken as a staging procedure in 32 patients, as a restaging procedure in 7, during follow‐up in 2, and as a diagnostic step in 5 [previously undiagnosed cases with clinically and ultra‐sonographically suspected lymphoma]. In 45 patients, the tissue core specimens obtained by US‐guided biopsies were sufficient for a correct histologic examination; in one patient, the specimen was considered inadequate. The tissue core specimens showed splenic involvement in 12 patients and normal splenic tissue in the other 33. These latter cases were confirmed by splenectomy, by lap‐aroscopy with larger splenic biopsy needles, and by clinical and US follow‐up over a period of 6 to 30 months. In all previously undiagnosed patients [five], splenic biopsies allowed histologic subtyping. Additional immuno‐logic subclassification into B‐cell and T‐cell types of lymphomas was done in two instances. There were no complications in this series. These results suggest that percutaneous US‐guided splenic tissue core biopsy is a useful and safe technique for the diagnosis, staging, and follow‐up of malignant lymphoma.

Incidence of gallstones in a population of patients with cirrhosis.

One hundred and sixty-five patients with cirrhosis were prospectively investigated, by regular ultrasonographic follow up, to assess the incidence of gallstones. The mean length of follow up was 33 months (range 12 to 108). Cholelithiasis was diagnosed in 31 patients (18.8%), with a cumulative incidence over 84 months of 38.3% (4.7% yearly incidence). The risk of gallstones was similar in males (38%) and females (38.3%), although the final cumulative incidence was reached at 72 months in males. The percentage of patients with new stones was higher in alcoholic cirrhosis (28.9%) (with a cumulative incidence of 48.8% at 84 months) and lower in hepatitis-related cirrhosis (1.9%) (only one new case at 96 months of follow up) (p < 0.001). The cumulative incidence of gallstones in the Childs C group reached 49.3% at 48 months versus 24% in Childs B and 6.4% in Childs A (p < 0.0001). At multivariate analysis, Childs C and alcoholic cirrhosis were shown to be the independent variables significantly associated with a high risk of development of cholelithiasis. This study confirms that cirrhosis represents a high risk factor for gallstones. The risk is greater for alcoholic cirrhosis and increases with the severity of the disease.