Ralf Konopke

Quantitative Perfusion Analysis of Transabdominal Contrast-Enhanced Ultrasonography of Pancreatic Masses and Carcinomas

BACKGROUND & AIMS Preoperative differential diagnosis of pancreatic ductal adenocarcinoma (PDAC) and focal masses in patients with chronic pancreatitis (CP) can be challenging. There are fine differences in the vascularization of these lesions; ultrasound contrast agents can aid in their differentiation. We evaluated the value of software-aided quantitative analysis of transabdominal contrast-enhanced ultrasonography for differential diagnosis of PDAC vs focal masses. METHODS Sixty patients for whom it was not possible to differentiate between an inflammatory focal lesion of the pancreas and a pancreatic carcinoma underwent contrast-enhanced ultrasonography with a second-generation contrast agent. Time-intensity curves were obtained for all exams in 2 regions of interest within the lesion and within the normal pancreatic tissue. Images were processed using Axius ACQ software; the following parameters were obtained: maximum intensity, arrival time, time-to-peak, and area under the curve. Absolute values and differences between the lesion and the normal tissue were evaluated. RESULTS Histology analysis revealed 45 PDACs and 15 inflammatory masses in patients with CP. Time-dependent parameters (arrival time and time to peak) were significantly longer in PDACs compared to focal masses. Although markedly lower than in healthy pancreata, the maximum intensity and area under the curve parameters were not significantly different between PDACs and focal lesions in patients with CP. CONCLUSIONS In cases of CP, PDAC and focal masses exhibit different perfusion patterns at a capillary level that can be visualized using the small microbubbles of ultrasound contrast agents. Contrast quantification software supplements a subjective visual assessment with objective criteria to facilitate the differential diagnosis of focal lesions in pancreatic cancer and chronic pancreatitis.

Prognostic factors and evaluation of a clinical score for predicting survival after resection of colorectal liver metastases.

Background: Patient outcome after resection of colorectal liver metastases can be predicted by various prognostic factors.

Colorectal liver metastasis surgery: analysis of risk factors predicting postoperative complications in relation to the extent of resection

Background/aimsDespite advances in diagnosis and treatment, the rate of complications after resection for colorectal liver metastases remains high. An awareness of risk factors is essential for the rates of morbidity and mortality to fall to optimal levels.Materials and methodsOf the 240 patients who underwent resection for the first manifestation of colorectal liver metastases, 49 patients with lobectomy or extended hepatectomy (major resections) and 58 with wedge resections within only one liver segment (minor resections) form the basis of this report. A total of 16 variables were analyzed to find the risk factors linked to postoperative morbidity and mortality.Results/findingsThirty-four patients (31.8%) suffered postoperative complications, and one patient died during the hospital stay (0.9%). In the major resection group, multivariate analysis showed that neoadjuvant chemotherapy [odds ratio (OR): 2.4; p = 0.005], vascular clamping (OR: 1.4; p = 0.008), and intraoperative blood loss with transfusion of three to six packed red cell units (OR: 1.2; p = 0.029) were significantly associated with postoperative morbidity. Vascular clamping was an independent predictor for biliary fistula (OR: 1.2; p = 0.029). Postoperative temporary liver failure was influenced by neoadjuvant chemotherapy (OR: 3.4; p = 0.010), vascular clamping (OR: 1.5; p = 0.015), and requirement of blood transfusion (OR: 2.1; p = 0.016). After minor resections, only a decreased postoperative serum cholinesterase B level was an independent predictor for complications (OR: 2.2; p = 0.001), as well as for hemorrhage (OR: 1.6; p = 0.023). Postoperative mortality was not predicted by any of the factors that were analyzed.Interpretation/conclusionFactors for complications differ depending on the extent of colorectal liver metastasis resection. Only knowledge and particular consideration of these factors may provide for an optimal postoperative outcome for the individual patient.

Who profits from neoadjuvant radiochemotherapy for locally advanced esophageal carcinoma

Background:  Patients suffering from locally advanced esophageal carcinoma are generally treated using multimodal therapies. This prospective, non‐randomized trial was performed to evaluate the survival benefit of neoadjuvant radiochemotherapy prior to surgery in comparison with surgery only.

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group

PurposeCorrect diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year.Materials and methodsThe Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement).ResultsFull or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy.ConclusionThe GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.

Surgical Therapy of Intrapancreatic Metastasis from Renal Cell Carcinoma

Background: Pancreatic metastases from renal cell carcinoma (RCC) are clinically rare but highly resectable. The aim of this article is to identify patients who profit from pancreatic resection of RCC despite the invasiveness of the surgery. Methods: Between January 1996 and December 2007, data from 744 patients were collected in a prospective pancreatic surgery database, and patients with metastasis into the pancreas from RCC were identified. Results: Resective surgery was performed in 14 patients with metastasis to the pancreas from RCC. Most patients were clinically asymptomatic. The median interval between primary treatment of RCC and occurrence of pancreatic metastasis was 94 months (range 32–158). The morbidity rate was 42.8%. Patients with a metastasis size <2.5 cm had a much better survival after resection (100 months) than those with a metastasis size >2.5 cm (44 months). Moreover, the number of metastases predicts the survival after resection. Conclusions: In patients with pancreatic metastases from RCC who have only limited disease, complete resection of all lesions can be successfully performed with a low rate of complications. Thus, patients with a history of RCC should be monitored for more than 10 years after nephrectomy to detect recurrence.

Prospective evaluation of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) in a surgical intensive care unit: Technique and results of the Fantoni tracheostomy

Controversy surrounds the safety and practicality of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) compared with other percutaneous methods.

Location of liver metastases reflects the site of the primary colorectal carcinoma

Objective. The present study was designed to investigate whether the different venous return of different locations of colorectal carcinomas affects the lobar distribution of metastases to the liver, due to the “streaming” within the portal vein. Material and methods. The site of the primary colorectal carcinoma was divided into the right- and left hemicolon according to the different venous drainage via the superior and the inferior mesenteric/splenic vein. Both groups were analyzed for the distribution of the metastases in the liver. The anatomic site of the liver metastases was detected by intraoperative exploration and differentiated between the two lobes using the Cantlie line. Results. Out of a total of 178 patients, 109 men and 69 women with 264 metastases were eligible for the study. The ratio of metastases in the right and left hemiliver was 3.6:1 for 35 right-sided primary tumors (p=0.002) compared with 2.1:1 for 143 left-sided primary tumors (p=NS). No significant differences were evident for the sub-analysis of involved liver segments. Conclusions. The results of our study support the existence of the “streaming” effect in the portal vein. Right-sided colon carcinomas predominantly involve the right hemiliver, while left-sided colon carcinomas involve the liver homogeneously, considering the size ratio of the right to left liver lobe, which is about 2:1. Knowledge of streaming may help us to understand the spread of abdominal malignancies and may provide a reference concerning the possible primary site depending on metastatic distribution in the liver.

Frühergebnisse und Komplikationen der Chirurgie von Lebermetastasen

Summary. Following resection of liver metastases the overall prognosis still remains limited because of the lack of adjuvant therapy. The number of explorative laparotomies, non-radical resections and complications needs to be reduced. One hundred and ten laparotomies in 97 patients with liver metastases were performed with the intention to cure between October 1993 and February 1998. In a prospective analysis we reviewed: patient characteristics, characteristics of primary tumors and metastases, part and extent of liver resection, radicality, complications and mortality. Additionally, a prospective study about the value of ultrasonography and CT scan concerning the evaluation of preoperative liver findings was undertaken between January 1995 and February 1998. Altogether, resection of liver metastases was achieved in 75 cases (68.2 %). Nineteen patients (25.3 %) had postoperative complications. Two patients (2.7 %) died following liver resection. Thirty-five operations (31.8 %) had to be finished as only an explorative laparotomy. The major reason for these restricted operations was in 15 patients (42.9 %) regional recurrence or peritoneal metastases. Preoperative determination of the liver finding (quantity, localization and size) by ultrasonography and CT scan achieved an accuracy of 68.9 % each. The results of this analysis show that resection of liver metastases can be accomplished with minor morbidity and mortality. The high number of explorative laparotomies still remains a central problem in the surgery of liver metastases. By the introduction of duplex sonography and contrast-medium-enhanced helical CT scan, liver pathology can be defined more precisely in the preoperative evaluation. However, preoperative detection of regional recurrence or peritoneal metastases remains difficult.Zusammenfassung. Nach Resektion von Lebermetastasen bleibt die Prognose wegen einer fehlenden adjuvanten Therapie noch immer begrenzt. Die Zahl an Probelaparotomien, nicht radikalen Resektionen und Komplikationen sollte möglichst gering sein. Von Oktober 1993 bis Februar 1998 wurden bei 97 Patienten mit Lebermetastasen insgesamt 110 Laparotomien unter kurativem Ansatz durchgeführt. In einer prospektiven Analyse erfaßten wir: Patientendaten, Charakteristik der Primärtumoren und Metastasen, Anteil und Ausmaß der Leberresektion, Radikalität, Komplikationen und Letalität. Von Januar 1995 bis Februar 1998 wurde darüber hinaus eine prospektive Untersuchung zum Stellenwert von Sonographie und CT bei der Beurteilung des präoperativen Leberbefunds durchgeführt. Insgesamt konnte in 75 Fällen (68,2 %) eine Resektion der Lebermetastasen erreicht werden. Bei 19 Patienten (25,3 %) traten nach der Resektion Komplikationen auf. Zwei Patienten (2,7 %) starben nach Leberresektion. In 35 Fällen (31,8 %) wurde der Eingriff als Probelaparotomie beendet. Die Hauptursache für die Beschränkung auf eine explorative Laparotomie war bei 15 Patienten (42,9 %) ein locoregionäres Tumorrezidiv oder eine Peritonealcarcinose. Bei der präoperativen Beurteilung des Leberbefunds (Anzahl, Lokalisation, Größe) erreichten Sonographie und CT eine Genauigkeit von 68,9 %. Die Ergebnisse dieser Analyse zeigen, daß die Resektion von Lebermetastasen mit geringer Morbidität und Mortalität möglich ist. Ein zentrales Problem der Lebermetastasenchirurgie bleibt aber der hohe Anteil an Probelaparotomien. Durch die Einführung der Duplexsonographie und des Spiral-CTs mit Kontrastmittelbolus kann der Leberbefund präoperativ deutlich besser definiert werden. Das intraabdominale Tumorrezidiv außerhalb der Leber bleibt jedoch schwer nachweisbar.

Living with severe dysphagia for 10 years: consequence of misdiagnosis.

TO THE EDITOR: A 52-year-old woman with a longstanding history of slowly progressive stenosis of the cervical esophagus had been referred to us in June 2008. Analysis of her previous health record revealed that solid food dysphagia had appeared for the first time 2 years after subtotal thyroidectomy in 1996. Since then she had undergone numerous endoscopic balloon dilations, botulinum toxin injections and an incomplete esophageal myotomy for presumed peptic stricture. External histological examination of several specimens consistently showed distinct fibrosclerosis without evidence of malignancy. The most recent anamnesis pointed out that dysphagia had worsened. At the same time, loss of body weight exceeded 30 kg. Clinical examination and results of laboratory tests were unremarkable. Endoscopy revealed fibrotic stenosis located 19 cm distal from the incisor teeth. These fibrotic alterations had a length of »1 cm and were occupying more than three-quarters of the esophageal circumference. Ultrasonography and computerized tomography detected no evidence of nodal or visceral metastases. Magnetic resonance imaging showed hypointense wall thickening (»9 mm) of the proximal esophagus in T1and T2-weighted images with a protrusion into the tracheal lumen (Figure 1). These results, as well as the longstanding history of slowly progressive esophageal stenosis, were indicative of a benign, submucosal tumor. Therefore, we decided to perform a surgical resection through a collar incision. After mobilization of the esophagus from the prevertebral fascia, a 12-mm stenosis was found and confirmed by intraoperative esophagoscopy. Following complete lateral myotomy, rock-hard fibrotic tissue was removed. After freeing >180 of the circumference we confirmed good endoscopic patency. Histopathological examination of the specimen found a granular cell tumor with periodic acid–Schiff-positive cytoplasmic granules and strong immunoreactivity for S-100. No signs of malignancy were detectable. The postoperative course was uneventful. A follow-up after 6 months revealed no restrictions of food intake. Granular cell tumors (GCTs) of the esophagus are neoplasms that endoscopists rarely have to deal with [1]. Although having a typical macroscopic appearance, their diagnosis can potentially cause difficulties. This case depicts how misdiagnosis of such a lesion can dramatically affect quality of life as well as future clinical management. Because of the intramural location, the epithelium above these tumors is frequently hyperplastic and squamous. If biopsies taken during endoscopic examination are not deep enough, the GCT will be missed by histological examination. Occasionally, hyperplasia of the covering epithelium is pseudo-carcinomatous and may lead to a misdiagnosis of well-differentiated squamous cell carcinoma [2]. Therefore, the typical endoscopic appearance and endoscopic ultrasonography should be included in the diagnostic decision. In our case, the GCT had not been diagnosed for several years, despite the fact that the patient had consulted various physicians from different specialties. At the time the patient presented to us, the typical macroscopic appearance of a GCT could not be seen due to previous therapy. Because previous reports of external histological examination