Susan J. Moug

Potential Value of Contrast-Enhanced Intraoperative Ultrasonography During Partial Hepatectomy for Metastases: An Essential Investigation Before Resection?

Objective:The aim of the study was to assess the clinical value of contrast-enhanced intraoperative ultrasound (CE-IOUS) as a novel tool in the hepatic staging of patients undergoing liver resection. Methods:Sixty patients scheduled to undergo liver resection for metastatic disease were studied. Preoperative staging with contrast-enhanced CT and/or MR scans was performed within 2 to 6 weeks of operation. Following exploration, intraoperative ultrasound (IOUS) was performed using an HDI-5000 scanner (Philips) and a finger-probe with pulse inversion harmonic (PIH) capability. CE-IOUS in the PIH mode was performed in a standardized protocol (low MI: 0.02–0.04) after intravenous injection of 3–4 mL of SonoVue (Bracco spa, Milan); all detected lesions on precontrast and postcontrast scans were counted and mapped. Any alteration in surgical management was documented following CE-IOUS compared with IOUS. Results:Three patients were excluded due to disseminated disease on exploration. CE-IOUS was significantly more sensitive than CT/MR and IOUS in detecting liver metastases (96.1% versus 76.7% and 81.5%, respectively) (P < 0.05); it altered surgical management in 29.8% (17 of 57) of cases, due to 1) additional metastases in 19.3% (11 of 57), 2) less metastases in 3.5% (2 of 57), 3) benign lesions wrongly diagnosed as metastasis on IOUS/CT in 5.3% (3 of 57), and 4) vascular proximity in 1.8% (1 of 57). Management was unchanged in 70.2% (40 of 57) despite additional lesions detected in 3.5% (2 of 57) and benign lesion wrongly diagnosed on IOUS and CT as metastasis in 1.8% (1 of 57). CE-IOUS altered combined IOUS/CT/MR staging in 35.1%. Conclusion:These preliminary results suggest CE-IOUS is an essential tool prior to liver resection for metastases.

Prospective Multicenter Trial Evaluating a Novel Method of Characterizing Focal Liver Lesions Using Contrast-Enhanced Sonography

OBJECTIVEnThe purpose of this study was to assess the clinical value and potential impact of SonoVue-enhanced sonography in the characterization of focal liver lesions.nnnSUBJECTS AND METHODSnThis study included 127 patients with 82 malignant and 52 benign lesions in the liver. Contrast-enhanced sonography was performed using nonlinear imaging modes at low mechanical index (0.1-0.3) to enable real-time visualization of arterial, portal, and late-phase enhancement. Digital recordings of unenhanced sonography and contrast-enhanced sonography were reviewed by on-site investigators and two off-site blinded interpreters. The final diagnosis was based on consensus interpreting of all examinations by another two expert observers with access to CT, MRI, and histologic data; the diagnostic accuracy of contrast-enhanced sonography in identifying the lesion as benign, malignant, or indeterminate and as actual tumor type was compared with baseline sonography.nnnRESULTSnFor on-site investigators, contrast-enhanced sonography reduced the number of indeterminate diagnoses by 67% and improved the sensitivity and specificity to 90.2% and 80.8%, respectively (p < 0.001). For off-site interpreters, contrast-enhanced sonography reduced the number of indeterminate diagnoses by 51-56% (p < 0.001); significantly improved sensitivity and specificity to 90.8-95.4% and 83.7-89.8%, respectively (p < 0.001); eliminated observers variability (kappa coefficient: 0.66-0.77); and showed no significant difference in all comparisons in the analysis of lesions measuring less than 1.5 cm, 1.5-2.5 cm, and all sizes combined. Contrast-enhanced sonography did not rely on availability of clinical history to enable the diagnoses, and it reduced the need for further imaging investigations 23.7% to 90.4%.nnnCONCLUSIONnContrast-enhanced sonography improves the characterization of focal liver lesions and may limit the need for further investigations.

Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: A case matched study

BACKGROUNDnTraditionally, a staged operative approach has been used for patients with synchronous colorectal cancer and liver metastases in the U.K. With improved outcomes from hepatic resection the role of a synchronous operative approach needs re-evaluated.nnnMETHODSn32 consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach were individually case matched (according to: age; sex; ASA grade; type of hepatic and colonic resection) with patients that had undergone a staged approach. The following variables were analysed: operative blood loss; in hospital morbidity and mortality; duration of hospital stay; disease free and overall survival.nnnRESULTSnOperative blood losses were: synchronous group, median 475mL (range 150-850mL) vs median 425mL (range 50-1700mL), (p>0.050). There were no significant differences in morbidity: (34% synchronous group vs 59%, p=0.690) with no recorded mortality. Synchronous group had a shorter hospital stay (median 12 days [range 8-21] vs 20 [range 7-51], p=0.008). There were no statistical differences between synchronous and staged patients for disease free and overall survival: 10 months (95% CI 5.8-13.7) versus 14 (95% CI 12.2-16.3; p=0.487) and 21% versus 24% at 5 years (p=0.838).nnnCONCLUSIONnThis present study provides supporting evidence for synchronous operative procedures in patients with colorectal liver metastases.

Radiofrequency ablation has a valuable therapeutic role in metastatic VIPoma

Background: Vasoactive intestinal peptide-secreting tumours (VIPomas) are rare islet cell tumours of the pancreas that can result in life-threatening biochemical abnormalities. The optimal intervention for metastatic VIPoma remains undecided. This case history documents the clinical role of radiofrequency (RF) ablation in the treatment of metastatic VIPoma. Case History: A primary pancreatic VIPoma was diagnosed in a 61-year-old female in 1998 and a distal pancreatectomy and splenectomy were performed. She remained disease-free for 44 months when she presented as an emergency with watery diarrhoea, hypokalaemia, renal failure and an elevated serum VIP level. CT scanning showed a liver metastasis and open RF ablation was performed with complete resolution of symptoms and biochemistry within 48 h. Post-ablation imaging confirmed complete ablation of the metastasis. She remained disease-free until 22 months later when watery diarrhoea resumed and a new hepatic metastasis was seen on CT. Percutaneous RF ablation was performed and follow-up CT scan showed complete ablation of the metastasis. The patient remains disease- and symptom-free 10 months after the second RF ablation. Conclusion: This case illustrates that the pronounced clinical and biochemical upset caused by metastatic VIPoma can be resolved safely, quickly and repeatedly by RF ablation.

Determinants of short- and long-term outcome in patients undergoing simultaneous resection of colorectal cancer and synchronous colorectal liver metastases.

PurposeThe optimal surgical strategy for patients presenting with colorectal liver metastases has yet to be determined. Short- and long-term outcomes must be considered if simultaneous resection of primary and liver metastases is to gain acceptance. We examine the prognostic value of patient and tumour characteristics in predicting short- and long-term outcomes following simultaneous resection for synchronous disease.MethodsForty-six patients undergoing simultaneous resection between April 2002 and June 2010 in a single institution were included. Patient characteristics included preoperative ASA grade and POSSUM. Tumour characteristics included TNM stage, Petersen Index and the Clinical Risk Score.ResultsThere were no postoperative deaths. The most common complications were atrial fibrillation (seven patients) and pneumonia (seven patients). Mean hospital stay with an uncomplicated postoperative recovery was 11xa0days versus 17xa0days with complicated recovery. Age (pu2009=u20090.015), ASA grade (pu2009=u20090.010) and POSSUM score (pu2009=u20090.032) were associated with postoperative complications. No pathological characteristics of the primary or secondary tumours related to surgical morbidity. Median follow-up was 37xa0months (5–87) during which 24 patients died, 23 from cancer. Twenty-seven had disease recurrence. N stage of the primary (pu2009=u20090.035), high-risk Petersen Index of the primary (pu2009=u20090.010) and Clinical Risk Scoreu2009≥u20093 (pu2009=u20090.005) were associated with poorer recurrence-free and cancer-specific survival.ConclusionsPost operative morbidity was determined by patient factors rather than operative or tumour characteristics. In addition to the Clinical Risk Score, pathological characteristics of the primary are important determinants of long-term outcome following simultaneous resection for synchronous disease.

The outcome of laparoscopic gastrojejunostomy in malignant gastric outlet obstruction

AbstractBackground and aims. The development of gastric outlet obstruction (GOO) in patients with advanced pancreatic cancer is regarded by some as a terminal event. There are several interventional options available, one of which is laparoscopic gastrojejunostomy (LGJ). To date, there are little data on the effectiveness of this intervention. Using patient records we sought to analyze our own experience of LGJ in patients with terminal pancreatic cancer.n Methods. A retrospective analysis of all patients with pancreatic or peri-ampullary cancer that under-went LGJ for GOO. All LGJ were performed by two consultant surgeons at Glasgow Royal Infirmary. Patient notes were assessed for survival time after LGJ; post-operative complications; resumption of oral intake; time to discharge and recurrence of GOO after surgery.n Results. A total of 18 patients underwent LGJ for GOO between 2000 and 2004. Median age at time of procedure was 66.5 yr (range 40 to 79). Two patients were converted to an open procedure for technical reasons, both of whom died in the post-operative period. Of the remaining 16, 15 had successful relief of GOO. The remaining patient underwent revisional open surgery 15 d post-operatively due to persistent GOO. Two patients died in hospital but 14 were discharged with symptom relief. Median survival for these patients was 59 d (range 12 to 248).n Conclusion. The development of GOO in pancreatic and peri-ampullary cancer should not be regarded as a terminal event. LGJ should be considered as a treatment option in these patients.

Socioeconomic deprivation has an adverse effect on outcome after ileostomy closure

Closure of loop ileostomy is a routine surgical procedure associated with appreciable postoperative morbidity and mortality rates1. Factors with the potential for a poor outcome include patient age, co-morbidity, time to closure and primary pathology. No single factor has been found to be primarily responsible for these poor results. Socioeconomic deprivation impacts on morbidity and mortality in various populations2–5. Research from the Scottish Cancer Intelligence Unit has shown that deprivation has an effect on incidence, mortality and survival rates related to cancer6. A recent publication found that socioeconomic deprivation adversely influenced outcome and time to reversal after a Hartmann’s procedure7. The aim of the present study was to assess the impact of socioeconomic deprivation on patient outcome after elective closure of loop ileostomy.

Contrast-enhanced ultrasonography during liver surgery (Br J Surg 2004; 91 : 1165-1167)

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Hepatobiliary and pancreatic: Extensive thrombosis in Budd–Chiari syndrome

A 41-year-old woman presented with a 1-week history of cholangitis. At endoscopic retrograde cholangiography, a benign biliary stricture was identified and treated with a stent. Unfortunately, sepsis persisted leading to the formation of multiple liver abscesses. Despite several courses of intravenous antibiotics, the patient remained bacteremic. To exclude endocarditis, an echocardiogram was carried out and revealed a 2 ¥ 2.4 cm mass in the right atrium. A magnetic resonance scan with T1-weighted images showed that the mass was a pedunculated thrombus that arose from the middle and right hepatic veins and extended into the inferior vena cava (IVC) and right atrium (Fig. 1). With T2-weighted images of the liver, abnormalities included a liver abscess (arrow), thrombosis in the middle hepatic vein (white signal when compared to patent vessels that are black) and edema in the territory of the middle hepatic vein (Fig. 2). Despite the extensive thrombosis, the patient had no clinical features of hepatic venous obstruction. Thrombolysis was excluded as a treatment option because of the risk of fatal pulmonary embolism. A decision was then made to perform an open thrombectomy via the supra-diaphragmatic IVC using general anesthesia with circulatory arrest. In addition, the liver abscesses were aspirated using ultrasound guidance. Histological evaluation revealed a large thrombus infected with fungi. Postoperatively, the patient was treated with a prolonged course of antibiotics. Budd–Chiari syndrome is a heterogenous group of disorders characterized by hepatic vein outflow obstruction. The disorder was first described by George Budd in 1844 and characterized by Hans Chiari in 1899. The natural history of the disorder is highly variable but unless venous obstruction and hepatic congestion are relieved, there is a high risk of hepatic failure and death. There are many predisposing factors, but to the authors’ knowledge, this is the only documented case with biliary sepsis as the causative agent.

M1550 Radiofrequency Ablation of Locally Advanced Pancreatic Cancer

stomy were applied prospectively to 20 consecutive patients undergoing pancreaticoduodenectomy. The pancreatic anastomosis was reconstructed with a duct-to-mucosa pancreaticogastrostomy into the posterior wall of the stomach. Internal pancreatic duct stenting were used in all cases. No prophylactic octreotide was administered in this study. Drain amylase were measured daily after the surgery until drain was removed on the postoperative day 5. The incidence of postoperative pancreatic fistula and other postoperative complication were recorded. Pancreatic fistula was defined as drain output amylase levels greater than 3 times than the upper normal serum amylase value on or after postoperative day3 and graded according to the International Study Group Pancreatic Fistula definition. Results: There were 11 males and 9 females (mean age 65 +/15). The mean operative time was 351 +/75 minutes. The pancreatic texture of the stump was “soft” in 16 cases. The median of the level of amylase in drain were 745 U/l on POD1, 427 U/l on POD2, 97 U/l on POD3, and 38 U/l on POD5. Only one patient (5%) developed grade A postoperative PF. The incidence of PF with clinically significant impact (grade B+C) was 0%. No patients required a change in management or adjustment in the clinical pathway. Other postoperative complications include one wound infection(5%) and one bile leakage (5%). Patient did not present any side effects related to the PGA and fibrin glue. There was no percutaneous drainage, readmission and reoperation. There was no mortality. Conclusions: Combination of bioabsorbable PGA felt and fibrin glue was extremely favorable for prevention of postoperative PF following PD.