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Is intra-operative ultrasound still useful for the detection of a hepatic tumour in the era of modern pre-operative imaging?

BACKGROUND The current role of intra-operative ultrasound (IOUS) is questioned because of recent progress in medical imaging. The aim of the present study was to determine the accuracy of IOUS in the detection of a hepatic tumour (HT) compared with a pre-operative multi-detector computed tomography (MDCT) scan and magnetic resonance imaging (MRI). METHODS This retrospective study included 418 patients evaluated using an 8-slice MDCT scan (SCAN8), 64-slice MDCT scan (SCAN64) and MRI alone or combined with a computed tomography (CT) scan. The pathological result was used as a gold standard. RESULTS Correlation rates for the number of detected lesions compared with pathology results were 0.627 for SCAN8, 0.785 for SCAN64, 0.657 for MRI and 0.913 for IOUS. Compared with pathology, the rate of concordance was significantly higher with IOUS (0.871) than with SCAN8 (0.736; P=0.011), SCAN64 (0.792; P<0.001) and MRI (0.742; P<0.001). IOUS was responsible for a change in operative strategy in 16.5% of patients. Surgery was extended in 12.4%, limited in 1.7% and abandoned in 2.4%. CONCLUSIONS Compared with cross-sectional pre-operative imaging, IOUS is still superior for the detection of HT and the planning of surgery. IOUS remains recommended as a routine procedure in patients having a hepatic resection in the era of modern pre-operative imaging.

Comparison of techniques for volumetric analysis of the future liver remnant: implications for major hepatic resections.

OBJECTIVE The purpose of this work was to compare measured and estimated volumetry prior to liver resection. METHODS Data for consecutive patients submitted to major liver resection for colorectal liver metastases at two centres during 2004-2012 were reviewed. All patients underwent volumetric analysis to define the measured total liver volume (mTLV) and measured future liver remnant ratio (mR(FLR)). The estimated total liver volume (eTLV) standardized to body surface area and estimated future liver remnant ratio (eR(FLR)) were calculated. Descriptive statistics were generated and compared. A difference between mR(FLR) and eR(FLR) of ±5% was considered clinically relevant. RESULTS Data for a total of 116 patients were included. All patients underwent major resection and 51% underwent portal vein embolization. The mean difference between mTLV and eTLV was 157 ml (P < 0.0001), whereas the mean difference between mR(FLR) and eR(FLR) was -1.7% (P = 0.013). By linear regression, eTLV was only moderately predictive of mTLV (R(2) = 0.35). The distribution of differences between mR(FLR) and eR(FLR) demonstrated that the formula over- or underestimated mR(FLR) by ≥5% in 31.9% of patients. CONCLUSIONS Measured and estimated volumetry yielded differences in the FLR of ≥5% in almost one-third of patients, potentially affecting clinical decision making. Estimated volumetry should be used cautiously and cannot be recommended for general use.

Validation of a Semiautomated Liver Segmentation Method Using CT for Accurate Volumetry

RATIONALE AND OBJECTIVES To compare the repeatability and agreement of a semiautomated liver segmentation method with manual segmentation for assessment of total liver volume on CT (computed tomography). MATERIALS AND METHODS This retrospective, institutional review board-approved study was conducted in 41 subjects who underwent liver CT for preoperative planning. The major pathologies encountered were colorectal cancer metastases, benign liver lesions and hepatocellular carcinoma. This semiautomated segmentation method is based on variational interpolation and 3D minimal path-surface segmentation. Total and subsegmental liver volumes were segmented from contrast-enhanced CT images in venous phase. Two image analysts independently performed semiautomated segmentations and two other image analysts performed manual segmentations. Repeatability and agreement of both methods were evaluated with intraclass correlation coefficients (ICC) and Bland-Altman analysis. Interaction time was recorded for both methods. RESULTS Bland-Altman analysis revealed an intrareader agreement of -1 ± 27 mL (mean ± 1.96 standard deviation) with ICC of 0.999 (P < .001) for manual segmentation and 12 ± 97 mL with ICC of 0.991 (P < .001) for semiautomated segmentation. Bland-Altman analysis revealed an interreader agreement of -4 ± 22 mL with ICC of 0.999 (P < .001) for manual segmentation and 5 ± 98 mL with ICC of 0.991 (P < .001) for semiautomated segmentation. Intermethod agreement was found to be 3 ± 120 mL with ICC of 0.988 (P < .001). Mean interaction time was 34.3 ± 16.7 minutes for the manual method and 8.0 ± 1.2 minutes for the semiautomated method (P < .001). CONCLUSIONS A semiautomated segmentation method can substantially shorten interaction time while preserving a high repeatability and agreement with manual segmentation.

Impact of peri-operative bevacizumab on survival in patients with resected colorectal liver metastases: an analysis of the LiverMetSurvey

BACKGROUND Peri-operative chemotherapy is recommended for the management of colorectal liver metastases (CRLM). The aim of this study was to examine the impact of peri-operative bevacizumab on survival in patients with resected CRLM. METHODS A multicentre retrospective cohort of patients with resected CRLM was analysed from the LiverMetSurvey Registry. Patients who received peri-operative FOLFOX (group A) were compared with those who received peri-operative FOLFOX and bevacizumab (group B). RESULTS In total, 501 patients were compared (A, n = 384; B, n = 117). Group A was older (68.3 versus 62.5 years, P < 0.01), had more rectal cancers (30.7 versus 18.8%, P < 0.01) and higher carcinoembryonic antigen (CEA) levels at diagnosis (17.0 versus 9.7 ng/ml, P = 0.043). No difference was observed regarding primary tumour stage, synchronicity and the number or size of metastases. Post-operative infections were more frequent in group B (4.7% versus 12.8%, P < 0.01). Peri-operative bevacizumab had no effect on 3-year overall survival (OS) (76.4% versus 79.8%, P = 0.334), or disease-free survival (DFS) (7.4% versus 7.9%, P = 0.082). DFS was negatively associated with primary tumour node positivity (P = 0.011) and synchronicity (P = 0.041). CONCLUSIONS The addition of bevacizumab to standard peri-operative chemotherapy does not appear to be associated with improved OS or DFS in patients with resected CRLM.

Liver segmentation: indications, techniques and future directions

AbstractObjectivesLiver volumetry has emerged as an important tool in clinical practice. Liver volume is assessed primarily via organ segmentation of computed tomography (CT) and magnetic resonance imaging (MRI) images. The goal of this paper is to provide an accessible overview of liver segmentation targeted at radiologists and other healthcare professionals.MethodsUsing images from CT and MRI, this paper reviews the indications for liver segmentation, technical approaches used in segmentation software and the developing roles of liver segmentation in clinical practice.ResultsLiver segmentation for volumetric assessment is indicated prior to major hepatectomy, portal vein embolisation, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and transplant. Segmentation software can be categorised according to amount of user input involved: manual, semi-automated and fully automated. Manual segmentation is considered the “gold standard” in clinical practice and research, but is tedious and time-consuming. Increasingly automated segmentation approaches are more robust, but may suffer from certain segmentation pitfalls. Emerging applications of segmentation include surgical planning and integration with MRI-based biomarkers.ConclusionsLiver segmentation has multiple clinical applications and is expanding in scope. Clinicians can employ semi-automated or fully automated segmentation options to more efficiently integrate volumetry into clinical practice.Teaching points• Liver volume is assessed via organ segmentation on CT and MRI examinations. • Liver segmentation is used for volume assessment prior to major hepatic procedures. • Segmentation approaches may be categorised according to the amount of user input involved. • Emerging applications include surgical planning and integration with MRI-based biomarkers.

Combined hepatocellular‐cholangiocarcinoma in a patient with Abernethy malformation and tetralogy of Fallot: A case report

Abernethy malformation is a rare congenital anomaly of the portal vein where the portal blood bypasses the liver. We report the first case of a patient with Abernethy malformation and tetralogy of Fallot associated with nodular regenerative hyperplasia and focal nodular hyperplasia (FNH), which finally evolved to a giant hepatocellular‐cholangiocarcinoma (HCC‐CC) of the liver, successfully resected. (Hepatology 2016;64:1800‐1802)

Heterotopic Pancreas Presenting as Suspicious Mass in the Gallbladder

CONTEXT Heterotopic pancreas is a rare entity. Thirty-three cases in the gallbladder have been reported. We describe the first case of heterotopic pancreas mimicking a gallbladder cancer, identified within a calcified lesion in the thickened posterior wall of the gallbladder. CASE REPORT A 72-year-old woman with right upper quadrant pain was referred with a suspicion of gallbladder neoplasia. A CT scan demonstrated a 1 cm thickened posterior wall of the gallbladder with a 2 mm punctate calcification. An open cholecystectomy was carried out without complication. The frozen section demonstrated pancreatic tissue. CONCLUSION Heterotopic pancreas of the gallbladder is highly uncommon. It can mimic a neoplastic process in the gallbladder, particularly in the context of calcification. Its malignant potential in the gallbladder is unknown, in contrast to previously described neoplastic transformation with gastric heterotopic pancreas.

Prediction of Hepatocellular Carcinoma Recurrence Beyond Milan Criteria After Resection: Validation of a Clinical Risk Score in an International Cohort

Objective: This study aims to validate a previously reported recurrence clinical risk score (CRS). Summary of Background Data: Salvage transplantation after hepatocellular carcinoma (HCC) resection is limited to patients who recur within Milan criteria (MC). Predicting recurrence patterns may guide treatment recommendations. Methods: An international, multicenter cohort of R0 resected HCC patients were categorized by MC status at presentation. CRS was calculated by assigning 1 point each for initial disease beyond MC, multinodularity, and microvascular invasion. Recurrence incidences were estimated using competing risks methodology, and conditional recurrence probabilities were estimated using the Bayes theorem. Results: From 1992 to 2015, 1023 patients were identified, of whom 613 (60%) recurred at a median follow-up of 50 months. CRS was well validated in that all 3 factors remained independent predictors of recurrence beyond MC (hazard ratio 1.5–2.1, all P < 0.001) and accurately stratified recurrence risk beyond MC, ranging from 19% (CRS 0) to 67% (CRS 3) at 5 years. Among patients with CRS 0, no other factors were significantly associated with recurrence beyond MC. The majority recurred within 2 years. After 2 years of recurrence-free survival, the cumulative risk of recurrence beyond MC within the next 5 years for all patients was 14%. This risk was 12% for patients with initial disease within MC and 17% for patients with initial disease beyond MC. Conclusions: CRS accurately predicted HCC recurrence beyond MC in this international validation. Although the risk of recurrence beyond MC decreased over time, it never reached zero.

Preliminary Experience in Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation

OBJECTIVE The use of cerebral near-infrared spectroscopy (NIRS) has become widespread in cardiac surgery after research demonstrated an association between perioperative cerebral desaturations and postoperative complications. Somatic NIRS desaturation also is associated with an increased risk of postoperative complications and mortality. The objective of this study was to explore the trends of both somatic and cerebral NIRS during liver transplantation. DESIGN A prospective, single-site, observational case series. SETTING Tertiary care center. PARTICIPANTS The study comprised 10 patients undergoing liver transplantation. INTERVENTIONS NIRS sensors were placed on the forehead (cerebral regional oxygen saturation [rSO2]) and on the right arm and right leg (somatic rSO2) to measure tissue perfusion. Desaturation was defined as a 20% decrease of baseline values for 15 seconds. MEASUREMENTS AND MAIN RESULTS In all patients, parallel changes in both cerebral and somatic rSO2 values were observed during phlebotomy, bleeding, transfusion, portal vein clamping, and the use of vasoactive agents. Induction of anesthesia increased cerebral rSO2 more than it did somatic values. However, ascites removal, abdominal manipulation, and clamping of the inferior vena cava (IVC) were associated with nonparallel changes in cerebral and somatic rSO2. Ascites removal was associated with increased somatic leg rSO2, and IVC clamping and abdominal hypertension were associated with a significant reduction in somatic leg rSO2. Somatic leg desaturation instead of arm or cerebral desaturation was associated with more postoperative complications. CONCLUSIONS The use of combined NIRS monitoring allows for the identification of the source of somatic or cerebral desaturation. Compromised venous flow from the IVC from clamping or abdominal compartment syndrome typically is associated with the appearance of more pronounced leg than arm desaturation.