J. M. Little

Recurrence of hydatid disease.

Surgical management of hepatic hydatid disease has been associated with an overall local recurrence rate of approximately 10%. Local recurrence is rarely seen following complete resection of an intact cyst and is usually the result of spillage of live parasites or leaving a residual cyst wall containing germinal epithelium, daughter cysts, or protoscolices during surgery. Recurrence is frequently asymptomatic, so the diagnosis depends on dedicated follow-up of treated patients with serology and either ultrasonography or computed tomography. The management of locally recurrent disease should include administration of albendazole followed by the appropriate application of interventional radiotherapy or operation. As with the treatment of primary disease, the preservation of liver function and minimizing the risk to the patient remain the guiding principles of therapy of local recurrence. Human infection with Echinococcus granulosus typically results in a slowly growing parasitic cystic disease most frequently seen in the liver. The cysts may be asymptomatic for many years, and occasionally spontaneous regression has been noted. More commonly the disease is slowly progressive, and symptoms and complications eventually arise. Symptoms include pain from expansion or rupture, fever from pyogenic infection due to intrabiliary rupture and jaundice, or anaphylaxis from intrabiliary or extrahepatic rupture. The goals of therapy are to treat associated complications, eliminate local disease, and avoid recurrence while minimizing morbidity and mortality of the treatment itself. Over the past 30 years surgical intervention has been the conventional treatment [1–9]; however, the introduction of modern medical therapy with albendazole [10–14] and radiologic intervention employing percutaneous aspiration and scolicidal injection (PAIR) [15–20] have provided new therapeutic options. The number of therapies now available is testimony to the fact that none is ideal in every clinical situation, and there is a need to tailor treatment to the individual patient. The identification of recurrent disease in the liver or in extrahepatic locations is an important criterion of treatment efficacy. Recurrent disease may present with major complications including pyogenic infection, intrabiliary rupture, or anaphylaxis; however, it is usually initially asymptomatic, and therefore regular long-term follow-up should be routine after primary treatment. The various therapies for primary disease have been discussed elsewhere in this issue. The purpose of this paper is to offer an approach to the patient with recurrent hepatic hydatid disease. Recurrent Hepatic Hydatid Disease Recurrent disease is defined as the appearance of new active cysts after therapy of intrahepatic or extrahepatic disease. The failure to achieve permanent control of the primarily treated cyst is considered local recurrence. It occurs after surgical or radiologic intervention and manifests as reappearance of live cysts at the site of a previously treated cyst or the appearance of new extrahepatic disease resulting from procedure-related spillage. The development of new cysts remote within the liver or at remote extrahepatic locations, such as lung or bone, may not imply failure of the primary procedure but may simply reflect the manifestation of disseminated disease. The reason for local recurrence is failure to remove or kill all viable cysts and protoscolices at the time of the original operation. This virtually never occurs when the complete unopened cyst is resected [21–23]; however, with more conservative procedures, such as evacuation and partial cystectomy, there is a possibility of leaving viable material behind, especially in long-standing cysts where there may be penetration, or “budding,” through the pericyst into surrounding liver. It is important, therefore, to be meticulous when carrying out conservative surgery to avoid intraperitoneal spillage and to remove all cyst contents mechanically and through irrigation, including any cyst material that has penetrated the original pericyst. Despite numerous case series reported in the surgical literature, it is difficult to compare the effectiveness of the various treatment options regarding recurrence rates. There are no prospective trials of surgical therapy based on pretreatment selection criteria, and retrospective reviews are impossible to assess and compare because of case mix issues. Overall, the recurrence rate appears to be less than 10%, with the likelihood of recurrence made lower when complete cyst excision is possible [21–23]. In the case of radical procedures, there is a trade-off between a low recurrence rate and increased mortality from the procedure. Correspondence to: B. Taylor, M.D., e-mail: bryce.taylor@uhn.on.ca Diagnosis of Recurrence A standardized protocol employing ultrasonography (US) or computed tomography (CT) with follow-up for at least 3 years is essential for the documentation of therapeutic efficacy in this disease [24, 25]. Recurrence may occur many years later, however, and longer follow-up is recommended when possible. The onset of recurrent disease is frequently asymptomatic; and clinical evaluation, even supplemented by serum liver tests and serologic tests, may not be diagnostic [26]. Blood titers may decrease slowly over months to years even with complete removal of disease [20, 27]. A positive serologic test during follow-up is therefore not necessarily diagnostic of recurrence, but a rising titer is. The preferred methods for identifying recurrent disease, in addition to clinical and serologic evaluation, are US and CT scanning [28–33]. Both modalities are sensitive and reasonably specific for diagnosing primary hydatid disease. The radiographic appearance of postoperative cysts may vary significantly and is frequently time-dependent. Unremoved, treated cysts typically show disappearance of the cyst fluid, overall shrinkage, and thickening and irregularity of the cyst wall [30, 31]. Small cyst-like structures are often identified at the site of surgical cyst evacuation. These structures must be followed on serial examination to differentiate postoperative changes from either persistent or new, live parasites. The difficulty of differentiating effectively treated cysts and locally recurrent disease has been well documented. Growth of the cyst appears to be the best imaging marker for significant locally recurrent disease. Critical to advancing our understanding of recurrent hydatid disease is adoption of a uniform staging, classification, and reporting system. A simple system, modeled after those suggested for primary disease [34–37], is shown in Table 1. Therapeutic Options for Recurrent Disease Not every patient with documented recurrent active hydatid disease needs to be treated. Unlike recurrent malignant disease, hydatid disease progresses slowly and is rarely life-threatening. Asymptomatic patients with serious co-morbid conditions or advanced age are best followed and treated only for complications. In fit patients, documented recurrence should be treated regardless of whether symptomatic. Complications such as infection or biliary obstruction should, if possible, be treated first, i.e., with drainage, endoscopic retrograde cholangiopant creatography (ERCP), and bile duct clearance. Intrahepatic Recurrence The treatment options are generally the same for recurrent disease as for primary disease. The fact that appropriate primary treatment has failed, however, suggests that more radical treatment may be indicated in the case of recurrence, and that is our general policy. In highly complex liver hydatids, where the cyst is centrally placed and involves major biliary pedicles (and intimate to major vessels), it is occasionally necessary to treat recurrent disease repeatedly when it is symptomatic, without ever achieving complete eradication. Excellent long-term palliation with good quality of life is possible and is preferable to mortality following overly enthusiastic attempts to achieve cure by radical excisions in every case. The treatment options are listed in Table 2.Surgical management of hepatic hydatid disease has been associated with an overall local recurrence rate of approximately 10%. Local recurrence is rarely seen following complete resection of an intact cyst and is usually the result of spillage of live parasites or leaving a residual cyst wall containing germinal epithelium, daughter cysts, or protoscolices during surgery. Recurrence is frequently asymptomatic, so the diagnosis depends on dedicated follow-up of treated patients with serology and either ultrasonography or computed tomography. The management of locally recurrent disease should include administration of albendazole followed by the appropriate application of interventional radiotherapy or operation. As with the treatment of primary disease, the preservation of liver function and minimizing the risk to the patient remain the guiding principles of therapy of local recurrence.

TISSUE-CULTURE MICROTEST FOR PREDICTING RESPONSE OF HUMAN CANCER TO CHEMOTHERAPY

Abstract A semiautomated tissue-culture micro-test system has been developed to allow sensitivity screening of human cancer to chemotherapeutic agents. 13 microtests have been performed on specimens from twelve patients. The in-vitro and clinical results have been compared. In 8 instances microtest results suggested that no response would occur to the drug or drugs chosen for chemotherapy; in only 1 instance was a clinical response observed by the referring clinician. 5 tests suggested that the tumour examined would be responsive to the selected agents; in each case an objective clinical response was reported.

TRAUMATIC THROMBOSIS OF THE INTERNAL CAROTID ARTERY

Abstract Four previously unreported cases of traumatic thrombosis of the internal carotid artery are presented. The damage sometimes results from a blow to the neck, but often from only an injury to the face or head. It is suggested that the internal carotid, under these latter circumstances, is stretched over the bony prominences of the atlas and the axis when the head is hyperextended and rotated towards the side of injury, and possibly laterally flexed away from the side of injury. Stretch injury of this type may be more likely in younger people, before the carotid artery becomes tortuous with age.

PROGNOSTIC VALUE OF INTRAOPERATIVE BLOOD-FLOW MEASUREMENTS IN FEMOROPOPLITEAL BYPASS VEIN-GRAFTS

Abstract A prospective study has been carried out on 40 patients having saphenous-vein bypass grafts for femoropopliteal arterial obstruction. Records were kept of intraoperative mean blood-flow, measured with a square-wave electromagnetic flow-meter. Early graft-occlusion was defined as occurring within the first three months. A highly significant difference was found between the mean flow of grafts which occluded early and that of those that remained patent: an intraoperative graft-flow of less than 60 ml. per minute carried an 80% chance of early thrombosis, while a flow of 60 ml. per minute or more carried an 80% chance of patency for three months or more. The observed probability of early graft-occlusion fell as the intraoperative flow rose. The rank score based on the intraoperative mean flow correlated significantly with the ranked observed probability of early graft-occlusion.

Gallstone formation after major abdominal surgery

84 patients underwent multiple abdominal ultrasound examinations over a median of 36 months (range 6-140). 11 had gallstones at their first ultrasound examination, and were excluded from further analysis. Of the remaining 73 patients, 12 of 47 who underwent major abdominal surgery had gallstones within 14-36 months of operation, compared with 0 of 26 who did not undergo such surgery. The cumulative prevalence of new gallstones within 3 years of major surgery was 28%; no new gallstones were seen from 36 to up to 140 months postoperatively. By univariate and logistic regression analysis, age and major abdominal surgery were the only significant clinical determinants for the appearance of gallstones during follow-up. The findings of this retrospective study indicate that major abdominal surgery may accelerate the development of gallstones in some patients. If confirmed in a prospective study, it may be possible to define groups at high risk of gallstones after surgery and to institute prophylactic measures.

Impact of the CUSA and Operative Ultrasound on Hepatic Resection

New technologies have been developed for liver surgery, and, like all new technologies, they have a glamour which makes them seem desirable. There is an understanding abroad that they make liver surgery easier and open up the field to those without special training. But there is no proof that the new devices are in any way cost-effective, and certainly no proof that liver surgery has become safer since their advent. Fifty consecutive elective liver resections have been studied, almost half performed with the aid of the ultrasonic dissector and aspirator and diagnostic intraoperative ultrasound. There was no mortality in the whole group, but a 24% morbidity. Operative diagnostic ultrasound was thought to allow more precise planning of surgery. Its use was not associated with any increase in operative time, nor was there any increase in postoperative morbidity. The ultrasonic dissector and aspirator improved technique, reflected in a lower blood loss for each case, in fewer transfusions required, in a shorter postoperative hospital stay and in an ability to achieve these benefits in older patients. Neither device could be said to offer an entree to instant liver surgery. The use of the two devices apparently offered savings measured by a fall in the median postoperative hospital stay of 4.5 days, by a saving of 700 mls in median blood requirement and by a fall in transfusion rate from 64% to 9%.

Hepatic Focal Nodular Hyperplasia: A Benign Incidentaloma or a Marker of Serious Hepatic Disease?

Amongst 17 patients with hepatic focal nodular hyperplasia (FNH) encountered at Westmead Hospital between 1981 and 1990, FNH was found in association with hepatocellular carcinoma (HCC) in three (3/ 17), one male and two females, one of whom also had peliosis and an hepatic adenoma. FNH was also found in association with other conditions which may affect hepatic function, structure or circulation, including chronic obstructive airways disease (2), congestive cardiomyopathy (1), chronic active hepatitis (1), granulomatous hepatitis (1), coeliac artery stenosis (1) and metastatic malignant melanoma (1). This report, derived from our experience with FNH over 10 years draws attention to a possible link between FNH, hepatic malignancy and conditions which may disturb the hepatic circulation. We suggest that patients with FNH should be investigated thoroughly and an aggressive management policy should be adopted.

AMPUTATION OF THE TOES FOR VASCULAR DISEASE: FATE OF THE AFFECTED LEG

53 patients coming to amputation of one or more toes for the late results of degenerative vascular disease were studied prospectively. By a median time of thirteen months, 26 of the 53 had undergone a major amputation of the affected side. Diabetes was associated with the same prognosis as atherosclerosis obliterans uncomplicated by diabetes. A palpable pedal pulse or a functioning arterial reconstruction carried a virtual guarantee of success for the toe amputation. The presence of a popliteal pulse, however, was not associated with any better prognosis than the presence of a femoral pulse alone. Smoking seemed to exert little influence. With the passage of time, the major-amputation rate rose steadily, and by 3 1/2 years almost three-quarters of the patients had come to major amputation.

HEPATIC DYSTYCHOMA: A FIVE YEAR EXPERIENCE

In 5 years, 64 solid hepatic lesions have been referred for diagnosis and management which have been found unexpectedly on organ imaging in well patients. We have called this lesion a “dystychoma”. Patients have undergone a two phase investigation programme which allows a diagnosis without admission to hospital in about 50% of cases. About three quarters of patients (47/64) have had nonneoplastic lesions, and about half (33/64) have had haemangiomas. About one patient in four (17/64) has had a neoplasm, and the neoplasm has been malignant in about one in six (11/64) of all patients. We stress the need to pursue the diagnosis in these patients. There were no reliable clinical, biochemical or imaging characteristics which individually distinguished benign from malignant lesions. Age over 55 years, an enlarged liver or a palpable liver mass and a raised serum alkaline phosphatase were all significantly more frequent with malignant tumours. The risk of malignancy rose with the number of risk factors, and all patients with all three risk factors had malignant tumours. Only 11 of the 64 patients were judged to have benefited by significant increase in quality or quantity of life as a result of what was frequently inappropriate organ imaging. There is no strong argument for replacing history taking and physical examination by CT scanning, ultrasound examination or other organ imaging.

Duct obstruction with an acrylate glue for treatment of chronic alcoholic pancreatitis.

Six patients have been treated for chronic alcoholic pancreatitis by total obstruction of the pancreatic duct. In each instance the pancreatic duct was of near normal calibre, and any other procedure would have involved pancreatic resection. There has been little morbidity, and three of six cases have had complete pain relief.