Giorgio Coscarella

Percutaneous Liver Biopsy Using an Ultrasound-Guided Subcostal Route

Percutaneous biopsy is considered one of the most important diagnostic tools to evaluate diffuse liver diseases. The introduction and widespread diffusion of ultrasounds in medical practice has improved percutaneous bioptic technique, while reducing postoperative complications. Although ultrasonography has become almost ubiquitous in prebiopsy investigation, only one third of biopsies are performed under ultrasound control. Moreover, the one-day procedure, reported in several studies to be safe and cost effective, accounted for only 4% of biopsies done. We report our experience of 142 percutaneous US-guided biopsies performed on 140 patients affected by chronic diffuse liver disease over a four-year period. Liver biopsies were performed under US guidance at the patients bed using an anterior subcostal route. We evaluated postoperative pain, modifications of blood pressure and red cell count, hospital stay, morbidity and mortality rates, and adequacy of specimens for histologic examination. There was no operative mortality. As for major complications, one case of hemobilia occurred. As for minor complications, two cases of persistent postoperative pain required analgesic therapy. Patients were discharged the day following the procedure in all cases but two, who were discharged on the third and fifth postoperative days. Liver specimens were suitable for histologic diagnosis in all but one case, in which there were no portal spaces. According to our experience, we believe that hepatic biopsy guided by ultrasonography could replace blinded biopsy in the diagnosis of diffuse liver disease. The procedure is suitable to be performed safely on an outpatient basis.

Radio frequency interstitial thermal ablation of metastatic liver tumours

Introduction: Radio frequency thermal ablation (RFA) of focal liver metastatic lesions has received much recent attention as minimally invasive treatment of such pathologic entities. The purpose of the study was to evaluate the efficacy of RFA in the treatment of liver metastases from different tumors. Methods: In the period October 1998–January 2001, 29 patients affected by 38 focal lesions, age range 31–86 years old, 16 males and 13 females were treated in our Institution by RFA. Sixteen patients had liver metastases from colorectal cancer, four from gastric cancer, three from breast, two from kidney, one from anal carcinoma, one from esophageal cancer, one from pancreas, and one undetermined. Average metastases size was 3.22 cm (range 1.7–6 cm). All patients, except three, had the primary tumor already resected before the treatment of liver metastases. In six cases, RFA was repeated to complete ablation for a total of 35 procedures. Eight treatments were performed under general anesthesia after laparotomy, 27 ultrasound-guided procedures were performed percutaneously, 6 of them in general and 21 under local anesthesia. Results: Mean follow up was 12.9±6.9 months (range 2–27 months). One patient who underwent liver resection plus RFA of a second lesion, had a subphrenic abscess treated by percutaneous computed tomography (CT)-guided drainage, another patient had left intra-hepatic portal branch thrombosis, which recovered spontaneously. One patient died 11 months after treatment, a second patient died after 6 months. A follow up CT scan was done in 25 of 29 patients. In those 25 patients, 31 focal lesions were treated. The amount of focal lesion necrosis based on CT scan was complete (100%) in 24 lesions, nearly complete (90–99%) in 1 lesion, and partial in 6 lesions (50–89%). Conclusion: RFA is an effective and safe treatment modality for metastatic liver tumors. Larger future studies and longer follow up will be needed to evaluate the impact on survival with respect to surgical resection.

Implantable endoscopic gastric bypass - device and experimental procedure

Malabsorptive bariatric surgery is an effective treatment option for morbid obesity, but may be associated with complications and side effects. We have developed a new experimental approach to creating a gastric bypass through an intraluminal access. The goal is to reduce postoperative complications and to reduce mid-term side-effects of malabsorptive bypass food passage and to allow easy reversion of the procedure. The new procedure is based on an implantable gastric bypass device, installed by combined transoral flexible and minimally invasive abdominal access. The newly developed device and procedure were studied in a pilot experimental trial in the porcine animal model (n=8). Endpoints were the feasibility of the technical procedure, the ability of the animal to eat and digest food, the implant functionality over the survival period and the absence of major complications over a short-term follow-up (one week). The procedure was technically successful in all eight animals. Animals were able to take in food and water till sacrifice. Four animals had major complications (one abdominal wall dehiscence, one invagination ileus of the small bowel, one dehiscence of the gastro-jejunal anastomosis and one myocardial infarction) and did not complete follow-up. In two cases migration of the device into the stomach was observed. The difference between our experimental technique and the gold standard surgical methods for gastric bypass consists of the endoluminal approach by implanting an intraluminal gastric bypass device. This concept avoids gastric transsection and an additional anastomosis and enables an adjustable food passage between the bypass and the natural duodenal passage. Further long-term follow-up studies are required.

Is digital image plethysmographic (DIP) acquisition a valid new tool for preoperative body composition assessment? A validation by dual-energy X-ray absorptiometry

Background: The increasing incidence of obesity and the wider acceptance of laparoscopic surgery, have lead to a 10-fold increase in bariatric operations in the last 10 years. Widely used indices of obesity (weight and body mass index – BMI) cannot adequately distinguish between fat mass (FM), represented by the sum of kilograms (kg) of lipid, and fat-free mass (FFM), inclusive of lean (kg of proteins), bone (kg of minerals), glycogen, and total body water (TBW), which are important parameters for clinical and physiological studies. Methods. Anthropometric variables were measured in 19 Caucasian Italian individuals according to standard methods. Body weight (kg) and height (m) were measured, and BMI was calculated as kg/m2. Body composition was evaluated, with a mean BMI of 25.95±5.04 kg/m2, by dual X-ray absorptiometry (DXA) and by digital image plethysmographic (DIP) acquisition with a digital camera. The clear-colored body of the subjects was automatically converted into a front and lateral red-shaped figure, and then through algorithms the 2 pictures were transformed into a nominal volume; body weight was then divided by the estimated volume, so that the body density could be obtained. DXA was used as a comparison to assess fat mass and fat-free mass. Radiation exposure was <0.6 mSv. Results: Significant positive correlation (R= 0.971, P<0.001) was found between data of body composition obtained by DXA and DIP. Conclusions: Body volume assessed using DIP or DXA did not differ. According to this validation study, DIP represents a new promising tool for clinical applications.

Percutaneous sclerosis of giant cavernous hepatic hemangioma: preliminary report of two cases

Abstract Purpose : To evaluate the feasibility of percutaneous treatment of large hepatic hemangiomas (HH) by producing sclerosis through percutaneous ultrasound (US)-guided alcohol injection. The rationale of the treatment is to induce progressive thrombosis by topic endothelial damage of vascular components of the lesion, obtaining reduction of the volume, of the mass effect and of the possible complications of HH. Method/materials : Two patients, affected by giant HH diagnosed by computed tomography (CT), were elected for percutaneous treatment to avoid lobar liver resection. The first patient had HH on the VI segment (diameter 10 cm), the other patient on the left lobe (diameter 12 cm). A percutaneous needle injection of 95% sterile alcohol was performed under real-time US control. Two different areas of the lesions were injected with 10 and 20 cm 3 of alcohol, respectively. No immediate or late complications were observed and the patients experienced only minimal burn during the alcohol injection. CT scans were performed in both patients at 3, 6 and 12 months after interventional procedure in order to evaluate the efficacy of treatment. Results : Progressive thrombosis of HH was demonstrated by the serial CT controls in both cases, resulting in a significant volume reduction. Over 95% volume reduction was achieved in the first patient within 6 months and this effect still remains after 3 years. The second patient showed extensive thrombosis in the center of the lesion (>40% in volume) at 8 months control. Conclusions : Our experience demonstrates the effectiveness of percutaneous sclerosis of giant HH in order to reduce the mass effect, the compression on the surrounding liver parenchyma, limiting the risk of rupture. This treatment is a good alternative to major surgical liver resections and shows low risk, costs and minimal discomfort for the patient.

Palliation of proximal gastric cancer

of the splenic vein appear to predispose to PVT. In Dr Atweh and associates’ patient, underlying diseases including malignancy, coagulation disorder, and thrombocytosis were not detected. At present it should not be concluded that splenectomy itself leads to PVT, because more evidence is required. It is still a controversial issue. Prospective studies are needed to determine the incidence, diagnosis, and treatment of PVT for patients who undergo splenecetomy, as Dr Atweh comments. Considering previously mentioned symptoms and associated conditions like abnormal coagulation, cirrhosis, or trauma, careful followup after splenectomy using Doppler ultrasonography may play an important role in the early detection and appropriate treatment for PVT.