Laparoscopic cholecystectomy. Postoperative sonographic findings

Seventeen consecutive patients undergoing elective laparoscopic cholecystectomy (LC) were serially evaluated with transabdominal ultrasound before, one day after, and six days after LC to document what, if any, changes occur in the surgical bed and surrounding parenchyma. The most common postoperative finding was focal sonolucency in the hepatic parenchyma adjacent to the gallbladder fossa in six (35%) of 17 patients. Five patients (29%) had postoperative fluid collections in the gallbladder fossa; in four of these five, it was technically difficult to dissect the gallbladder from the liver at the time of original surgery. In one patient the fluid resolved by the sixth postoperative day. It persisted in the remaining four. Two patients had transient ductal dilation and one had pneumobilia. Shadowing and ring-down artifact was identified in 12 patients due to surgical clips in the triangle of Calot. Because gallbladder fossa fluid may persist up to six days after uncomplicated laparoscopic cholecystectomy, caution should be used before attaching significance to isolated imaging findings. Clinical judgement remains the best means of selecting which patients need additional evaluation.

Microvascular reconstruction of the foot: weight-bearing patterns, gait analysis, and long-term follow-up

Between 1980 and 1989, 46 free-tissue transfers (32 skin flaps, 14 muscle flaps) were performed in 44 patients for foot reconstruction. Patient age averaged 25.8 years (range 2 to 74 years). Length of follow-up averaged 43 months. Flap survival rate was 96 percent. Debulking was done in 16 skin and 8 muscle flaps. The ulceration rate in 25 patients with weight-bearing flaps was 32 versus 11 percent in 19 patients with non-weight-bearing flaps. Time before ambulation averaged 6.4 months following weight-bearing reconstruction and 4.5 months following non-weight-bearing reconstruction. All patients with either abnormal foot-mat diagrams or major gait abnormalities had significant underlying radiologic foot abnormalities or nerve injuries. We conclude that both skin and muscle free flaps frequently need secondary debulking procedures to improve function. The ulceration rate tends to be higher in weight-bearing flaps than in non-weight-bearing flaps. Underlying bony architecture and nerve function affected weight-bearing patterns and gait more than type of wound coverage.

Early detection of occult colorectal hepatic metastases using duplex colour Doppler sonography

Previous studies have shown that overt intrahepatic tumours are associated with subtle changes in liver perfusion that can be measured directly using duplex colour Doppler sonography (DCDS). This study assessed the predictive value of DCDS in the early detection of occult colorectal hepatic metastases. Hepatic arterial and portal venous blood flow was measured in 50 control subjects and 135 patients with colorectal cancer, 67 with overt liver metastases and 68 with an apparently disease-free liver on the basis of computed tomography and laparotomy findings. The Doppler perfusion index (DPI), defined as the ratio of hepatic arterial to total liver blood flow, was calculated. Clear separation of the DPI values of controls and those of patients with overt metastases was observed (P < 0.0001). Thirty-eight of the 68 patients with a disease-free liver also had an abnormally high DPI value. After 1 year of follow-up, 21 patients with an abnormally high DPI at the time of apparently curative primary resection had developed liver metastases and a further four had died without post-mortem examination. The 30 patients with normal DPI remain disease-free. The data suggest that DPI is of value in the early detection of occult liver metastases.

Duplex/colour Doppler sonography: measurement of changes in hepatic arterial haemodynamics following intra-arterial angiotensin II infusion

Angiotensin II (AT-II) has been used to target regionally-administered cytotoxic microspheres in patients with intrahepatic tumours. The optimisation of vasoconstrictor targeting requires a knowledge of the blood flow changes induced by agents such as AT-II. We therefore assessed duplex/colour Doppler sonography (DCDS) as a means of evaluating the effects of AT-II infusion on hepatic arterial blood flow (HABF) and arterial resistance in patients with intrahepatic tumours. HABF was measured continuously in nine patients using DCDS before, during and after an infusion of AT-II (15 micrograms in 3 ml of saline over 90 s) via a hepatic artery catheter. In seven patients with less than 30% hepatic replacement by tumour, the baseline level of HABF was 331 +/- 85 ml min-1 (mean +/- s.d.), and this was reduced by 75-80% within 30 s of the start of AT-II infusion. HABF recovered rapidly from the end of the infusion, and increased by up to 20% above the baseline for approximately 2 min. In two patients with greater than 50% hepatic replacement, HABF showed no reduction but rose continuously from the start of AT-II infusion, increasing by a factor of 2-2.5 after 3-4 min. Arterial resistance showed reciprocal changes in all cases. We conclude that DCDS is effective in assessing the temporal changes in hepatic arterial blood flow caused by AT-II. In order to optimise tumour targeting, the injection of microspheres loaded with cytotoxic drugs should be completed before the end of the AT-II infusion. The targeting advantage of AT-II in patients with a high percentage hepatic replacement by tumour should be re-assessed.

Hepatic arterial haemodynamics changes following intra-arterial angiotensin II infusion: duplex/colour Doppler sonography

Previous studies have shown that the delivery of cytotoxic microspheres to liver tumours may be improved by manipulating the tumour to normal liver blood flow ratio using angiotensin II (AT-II). The optimization of this targeting requires the assessment of the temporal blood flow changes induced by agents such as AT-II. Duplex/colour Doppler sonography (DCDS) was evaluated as a means of studying the effects of AT-II infusion on hepatic arterial blood flow (HABF) and arterial resistance in patients with colorectal liver metastases. HABF was measured continuously in six patients with colorectal liver metastases using DCDS before, during and after an infusion of AT-II (15 micrograms in 3 ml of saline over 90 s) via a hepatic artery catheter. The baseline level of HABF was 320 +/- 87 ml/min (mean +/- S.D.), and this was reduced by 70-76% within 30 s of the start of AT-II infusion. HABF recovered rapidly from the end of the infusion, and increased by up to 20% above the baseline for approximately 2 min. Arterial resistance showed reciprocal changes in all cases. These changes were both quantitatively and qualitatively similar to intra-operative measurements previously performed in the same patients using a standard intra-operative flowmeter. The degree of concordance obtained from the intra- and post-operative measurements confirms the effectiveness of DCDS in assessing the temporal changes in hepatic arterial blood flow caused by AT-II. Prior to the start of therapy, the evaluation of vasoconstrictor agents should be carried out in individual patients to predict response, in order to establish the optimal phase for the injection of cytotoxic microspheres.

Image-directed Doppler ultrasonography: a novel technique for the diagnosis of colorectal liver metastases

Image-directed Doppler ultrasonography has been used to measure changes in hepatic arterial and portal venous blood flows in 22 controls and 88 patients with colorectal cancer. Doppler Perfusion Index, (DPI, ratio of hepatic arterial to total liver blood flow) and Doppler Flow Ratio (DFR, ratio of hepatic arterial to portal venous blood flow) of controls and patients with overt liver metastases were clearly separated (p < 0.0001). There was a significant reduction in the Hepatic Arterial Resistive Index (HARI) of patients with overt liver metastases (p < 0.0001). Percentage Hepatic Replacement (PHR) by metastases, measured using a computed tomography scanner, did not correlate with DFR or DPI. The results suggest that the measurement of hepatic perfusion changes using image-directed Doppler ultrasonography may be of value in the detection of small liver metastases.

Hepatic perfusion changes in patients with liver metastases: comparison with those patients with cirrhosis

Previous studies using dynamic scintigraphy have shown that the measurement of changes in hepatic perfusion may be exploited to detect liver metastases. Similar hepatic haemodynamic changes also occur in cirrhosis, however, thereby reducing the diagnostic power of the technique. The ability of duplex colour Doppler sonography (DCDS) to differentiate between the changes in liver perfusion in patients with cirrhosis and those with hepatic metastases was assessed. Hepatic arterial and portal venous blood flows were measured in 30 control subjects, 20 patients with cirrhosis, and 55 patients with overt liver metastases. The Doppler perfusion index (DPI) (the rate of hepatic arterial to total liver blood flow) and the congestive index (ratio of the cross sectional area of the vessel to time averaged velocity of blood flow in the vessel) of the hepatic artery (HCI) and portal vein (PCI) were calculated. The hepatic arterial blood flow of the cirrhotic and metastatic groups was significantly raised compared with that of controls, and the portal venous blood flow of the former groups were reduced (p < 0.0001). The DPIs of the cirrhotic and metastatic groups were therefore significantly raised compared with those of controls (p < 0.0001). No significant difference was noted in HCI values between the three groups. The PCI values of the cirrhotic group, however, were significantly raised compared with those of controls and patients with metastases (p < 0.0001). The data suggest that DCDS measurement of PCI may be of value in differentiating between the hepatic perfusion changes caused by cirrhosis and those resulting from hepatic metastases, thereby increasing the diagnostic power of this technique.

Closure of myelomeningocele using skin from stillborn twin

We report a case of homologous skin transplantation from a stillborn twin to the surviving twin for coverage of a myelomeningocele defect. Genetic studies were not available preoperatively, however, similar morphogenetic anomalies of the twins suggested monozygosity. Long-term follow-up revealed a well-healed graft. Cutaneous genetics and literature review of twin homologous skin transplantation are presented.

Intraoperative bile duct sonography during laparoscopic cholecystectomy: experience with a 12.5-MHz catheter-based US probe

During elective laparoscopic cholecystectomy, 20 patients underwent intraoperative evaluation of the biliary tract with a commercial 6.2-F, 12.5-MHz catheter-based ultrasound (US) probe. The study tested the feasibility of this technology for mapping the anatomy of the hepatoduodenal ligament and Calot triangle, assessing bile duct integrity, and detecting choledocholithiasis. The duct was studied with a transmural approach, the catheter being placed parallel to, but remaining outside, the bile duct. The common hepatic duct and common bile duct in the vicinity of the cystic duct were seen in all 20 patients; the junction of the cystic duct with the common hepatic duct was seen in nine patients (45%). After the cystic duct was clamped, no sonographic evidence to suggest bile duct injury was noted in any patient. The transmural imaging approach was tested in four pigs in whose common bile duct a single human calculus had been placed. In all instances the size and location of the calculus were accurately detected. Intraoperative US with a catheter-based system is a safe and effective means for interrogation of the extrahepatic biliary tree during laparoscopic cholecystectomy.

Monitoring blood flow to colorectal liver metastases using laser Doppler flowmetry: the effect of angiotensin II

Many colorectal liver metastases are hypovascular, and their low level of perfusion is associated with limited drug uptake and poor response rates with regional chemotherapy. We have previously shown that hepatic arterial vasoconstrictors may increase drug delivery to liver tumours, but the underlying haemodynamic changes have not been defined. Using intraoperative laser Doppler flowmetry (LDF) we have assessed the effect of intraarterial angiotensin II (AI) on tumour blood flow in ten patients with colorectal liver metastases. Measurements were performed during placement of infusion catheters for regional chemotherapy. Blood flow was recorded continuously with a Periflux PF3 perfusion monitor via a probe held on the tumour surface, following hepatic arterial infusion of 15 micrograms AII over 90 s. Six patients with isolated small metastases (< 5 cm in diameter) showed increases in flow, which reached a peak at 170-240 s from the start of AII infusion, and which were closely correlated with the corresponding increase in arterial pressure (r = 0.92, P = 0.009). Of the four patients with large confluent tumour deposits, two showed smaller transient increases in flow over the first 60 s of AII infusion and two had no measurable flow response. Increased blood flow following AII infusion may increase the exposure of tumour to therapeutic agents. This study suggests that both tumour size and the effect upon systemic arterial pressure may be important determinants of the blood flow response to AII. LDF may provide useful information about the potential of AII and other vasoconstrictors to enhance targeting precision.

Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection

During the years 1985 to 1989, 82 patients were included in the soft tissue sarcoma protocol. Preoperative irradiation (50-54 Gy) was performed in all patients before tumor extirpation. Microwave hyperthermia was performed in conjunction with radiation in patients who had gross tumor remaining after initial biopsy. Primary closure with vascularized tissue (flaps) in lieu of conventional wound closure by skin approximation led to less complications (19% versus 51%), fewer secondary procedures for wound closure (10% versus 35%), shorter average hospitalization (15 versus 48 days) and greater limb salvage rate (97% versus 91%). The authors conclude that vascularized tissue (flaps) for primary wound closure in irradiated tissue leads to improved wound healing, and should be considered the procedure of choice for heavily irradiated soft tissue sarcoma defects.

Flow measurement using duplex Doppler ultrasound: haemodynamic changes in patients with colorectal liver metastases

Duplex Doppler ultrasound has been used to make measurements of liver blood flow. The relationship between time average velocity as measured using pulsed Doppler and the true mean velocity was determined using a flow phantom. Correction factors were applied to measured time average velocities of blood in the hepatic artery and portal vein. Blood flow was calculated from the product of corrected velocities and the cross-sectional area of the vessels. There was no significant difference in total liver blood flow for patients with colorectal liver metastases when compared with controls. However, the ratio of the hepatic arterial flow to the sum of the portal and hepatic arterial flows (Doppler perfusion index, DPI) was markedly elevated (P < 0.0001) in the patients with metastases when compared with the controls. The DPI values for a third group of subjects who had undergone resection for colonic cancer but who had no proven liver metastases overlapped the values for the other two groups. When attention is paid to technique, the procedure can detect and quantify the changes in liver blood flow which occur in the presence of metastases.

Saphenous vein grafts for anatomical variations encountered at surgical insertion of a hepatic artery catheter

Fifty-five consecutive patients, with colorectal metastases confined to the liver, underwent surgical placement of a hepatic artery catheter. At angiography, abnormal hepatic arterial anatomy was present in 33% of patients. In the majority of patients, the hepatic artery catheter was inserted in the conventional manner. In eleven patients with unusual arterial anatomy, a saphenous vein graft was used to create a conduit for the catheter. Satisfactory perfusion was obtained in all patients.

Glass yttrium-90 microspheres for patients with colorectal liver metastases

Total calculated uniform liver doses of up to 150 Gy were achieved using glass yttrium-90 microspheres administered via the hepatic artery and targeted to tumour using angiotensin II in seven patients with colorectal liver metastases. No toxicity was observed. Hepatic metastatic progression was delayed in six patients. Median survival was 11 months (range 5-25 + months).

Psychological morbidity in the first year after breast surgery

In this prospective study, the psychological morbidity associated with the treatment of breast cancer was assessed. The study population comprised all patients referred to one centre with a recently diagnosed breast lump, who were to undergo surgery. Psychological morbidity was assessed preoperatively and at 6 and 12 months postoperatively by modified Rotterdam Symptom Checklist. Three hundred and twenty patients completed all three questionnaires: 93 women undergoing mastectomy, 73 women having conservation therapy for breast cancer and 156 women having biopsy for benign breast disease. Patients with a breast malignancy smaller than 4 cm in diameter were treated by lumpectomy and radiotherapy, anti-oestrogen therapy or chemotherapy alone or in combination. Psychological morbidity among patients with malignant disease was significantly greater than that seen in the group with benign disease. Among cancer patients, a significant decrease in anxiety and depression occurred during the year following surgery. The study failed to demonstrate any psychological advantage associated with breast conservation.

Parameters for predicting electromagnetic lithotripter failure: quality assurance implications

Despite the extensive use of lithotripsy for treating renal and biliary calculi, there has been little data reported regarding the causes and manifestations of lithotripter failure. The clinical and service records for 145 consecutive treatments performed with the Siemens Lithostar Plus were reviewed. Service record analysis revealed eight failures of shock wave generation during a 10-month period. Six of these failures were subtle and still allowed shock wave generation. There were five in-line ultrasound probe failures during this period. The most useful clinical parameter for predicting lithotripter failure was reduced severity of sonographically evident cavitation bubbles during treatment. Lack of stone fragmentation and unexpectedly low analgesia requirements at high-power levels were less useful in predicting lithotripter failure. All clinical parameters suffered from nonspecificity. Preliminary experience, with an ongoing quality assurance program using a test object hydrophone, suggests this is a useful method of predicting lithotripter function and avoiding compromised treatments.

An in vivo assessment of adriamycin-loaded albumin microspheres

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Does ispaghula husk stimulate the entire colon in diverticular disease?

The effect of ispaghula husk on colonic motility of the right and left side was examined in 10 patients with left sided diverticular disease using an untethered pressure sensitive radiotelemetry capsule. After treatment, ispaghula husk reduced mouth to rectum transit by a median of 8.8 hours and the time to midtransverse colon by five hours. In the right colon there was an increase in the median percentage activity of 7% and the median number of pressure waves greater than 5 mm Hg/hour rose by 35.3. Motility changes in the left colon were less pronounced. Five of the seven patients with abdominal pain and six of the nine patients with altered bowel habit responded to treatment. These results suggest that it is ispaghula husk's action on the right unaffected colon which alleviates the symptoms of left sided diverticular disease.

The effect of angiotensin II on tumor blood flow and the delivery of microparticulate cytotoxic drugs

Colorectal hepatic metastases have a notoriously poor response to conventional systemic chemotherapy. We have synthesised cytotoxic drug (doxorubicin and mitomycin C) containing spheres 40 microns in diameter, using human albumin and ethyl cellulose as matrices. Introduction of these cytotoxic microspheres into the hepatic artery should embolise to the tumor and provide a controlled release depot for the anticancer agent. The vasoconstrictor, angiotensin II (AII) has been shown to increase tumor blood flow relative to normal tissue when administered via the hepatic artery, therefore we have investigated the effect of AII on targeting of cytotoxic microspheres to hepatic metastases. Patients with hepatic metastatic colorectal carcinoma had hepatic arterial catheters inserted at laparotomy and connected to subcutaneous injection ports. Peroperatively, 99mTc-labelled albumin microspheres were administered via the arterial catheter. Fifteen minutes later, AII was infused (10 micrograms per minuter for 4 min) via the catheter and 131I-labelled albumin microspheres were administered as a bolus at the midpoint of the AII infusion. Multiple biopsies were taken of normal liver and tumor metastasis and the tissue radioactivity counted for 99mTc and 131I. Further studies were performed postoperatively in which 99mTc-labelled microspheres were administered via the hepatic artery catheter and their distribution was followed using tomographic SPECT scanning. Combined results of this study suggested that AII can increase tumor SPECT scanning. Combined results of this study suggested that AII can increase tumor blood flow rates relative to normal hepatic tissue by approximately 3-fold.

Detection of hepatic metastases using duplex/color Doppler sonography

Current imaging modalities are unable to detect small liver metastases because of limited resolution and contrast differentiation. The association between liver metastases and altered liver blood flow has been demonstrated by dynamic scintigraphy, but the clinical feasibility of this test has been questioned. In this study a novel approach to detecting liver metastases was assessed by measurement of liver blood flow using a duplex/color Doppler System. Hepatic arterial and portal venous blood flows were measured in 16 controls, 50 patients with gastrointestinal cancer, and 6 patients with breast cancer. The ratio of hepatic arterial to total liver blood flow (Doppler perfusion index, DPI) and the ratio of hepatic arterial: portal venous blood flow (Doppler flow ratio, DFR) were calculated. The DPI and DFR values of controls and patients with overt liver metastases were clearly separated (p less than 0.0001). The results suggest that duplex/color Doppler ultrasound measurement of hepatic perfusion changes may be of value in the detection of liver metastases.

Gallstone lithotripsy: results when number of stones is excluded as a criterion for treatment

The Siemens Lithostar Plus protocol (Siemens Medical Systems, Iselin, NJ) allows investigators to perform gallstone lithotripsy on patients regardless of the number of stones they have, provided the stones occupy less than 50% of the gallbladder lumen. The purpose of this study was to determine the interrelationships between stone burden, fragmentation response, and stone-free rates when treatment is not limited to three stones or fewer. Of 200 patients initially examined, 80 (40%) underwent lithotripsy. The mean number of treatments per patient was 2.1, and the mean number of shock waves per patient was 7386. In 60 patients in whom 6-month follow-up was available, the overall stone-free rate, based on actual results, was 32% (19/60). The stone-free rates for solitary stones, two or three stones, and four or more stones were 50%, 12%, and 26%, respectively. Regardless of number of stones, patients who ultimately became stone free had significantly smaller mean fragment size (0.25 cm) 2 weeks after lithotripsy than did those who did not become stone free (0.51 cm). Retrospective volume analysis showed that seven (47%) of 15 patients with multiple stones occupying less than 2000 mm3 were stone free; none became stone free when this volume was exceeded. Lithotripsy remains a practical option for patients with solitary stones. Comparable stone-free rates to those achieved for solitary stones can be obtained in patients with multiple stones, regardless of their number, provided treatment is aggressive and the stone aggregate is less than 2000 mm3.

Angiotensin II as a potential method of targeting cytotoxic-loaded microspheres in patients with colorectal liver metastases

Regional chemotherapy is commonly used to treat patients with colorectal liver metastases. However, improvement in survival has still not been demonstrated. Cytotoxic loaded albumin microspheres for arterial administration have been described as a means of improving the the therapeutic index, but their distribution depends upon the prevailing pattern of arterial blood-flow at the time of injection. In this study, the ability of the vasoactive drug angiotensin II to target arterially injected microspheres to colorectal liver metastases is assessed in nine patients using scintigraphic planar and tomographic imaging. The median tumour: normal ratio in nine patients with colorectal liver metastases was 3.4:1 before the administration of angiotensin II. The corresponding ratio after administration of angiotensin II was 7.3:1. The median improvement factor was 1.8 (P less than 0.05). The data suggest that worthwhile tumour targeting can be achieved with angiotensin II in patients with colorectal liver metastases.

Microvascular reconstruction of the lower extremity in the elderly

The natural changes of aging increase perioperative medical risk factors in the elderly population. Aggressive preoperative patient evaluation and perioperative monitoring can effectively decrease morbidity and mortality rates to equal those of younger patients. The surgical strategy must take into account the increased incidence of atherosclerosis in the inflow and free-tissue transfer recipient vessels. Lower extremity microvascular reconstruction can be performed safely and successfully in the elderly patient.

Detection of tissue injury after extracorporeal shockwave lithotripsy of gallstones

We evaluated seven patients undergoing gallstone lithotripsy for evidence of hepatic or renal trauma after each of 10 lithotripsy treatments. Postlithotripsy magnetic resonance imaging (MRI) and sonography showed no evidence of hepatic or renal injury as compared with baseline studies. Four treatments resulted in sonographic evidence of gaseous hepatic microbubbles (analogous to "the bends") due to cavitation effects of the shockwaves. Three of these four treatments produced serum glutamicoxaloacetic transaminase and -pyruvic transaminase elevation. One patient had microscopic hematuria. Minimal tissue damage results from gallstone lithotripsy. MRI and ultrasound, performed after lithotripsy, appear to be less sensitive than transaminasemia in detecting this low-grade injury.