Clinical Performance Status and Technical Factors Affecting Outcomes from Percutaneous Transhepatic Biliary Interventions; A Multicentre, Prospective, Observational Cohort Study

Purpose

The purpose of this study was to evaluate the predictive value of a ‘Modified Karnofsky Scoring System’ on outcomes and provide real-world data regarding the UK practice of biliary interventions.

Materials and Methods

A prospective multi-centred cohort study was performed. The pre-procedure modified Karnofsky score, the incidence of sepsis, complications, biochemical improvement and mortality were recorded out to 30 days post procedure.

Results

A total of 292 patients (248 with malignant lesions) were suitable for inclusion in the study. The overall 7 and 30 day mortality was 3.1% and 16.1%, respectively. The 30 day sepsis rate was 10.3%. In the modified Karnofsky ‘high risk’ group the 7 day mortality was 9.7% versus 0% for the ‘low risk’ group (p = 0.002), whereas the 30 day mortality was 28.8% versus 13.3% (p = 0.003). The incidence of sepsis at 30 days was 19% in the high risk group versus 3.3% at the low risk group (p = 0.001)

Conclusion

Percutaneous biliary interventions in the UK are safe and effective. Scoring systems such as the Karnofsky or the modified Karnofsky score hold promise in allowing us to identify high risk groups that will need more careful consideration and enhanced patient informed consent but further research with larger studies is warranted in order to identify their true impact on patient selection and outcomes post biliary interventions.

Percutaneous caecostomy for the management of closed loop large bowel obstruction: A delayed complication of severe gallstone pancreatitis

Colonic complications following pancreatitis are unusual events ranging from 1% to 15%. In a patient with a hostile abdomen and multiple previous laparotomies, surgical management of a closed-loop large-bowel obstruction risks significant morbidity and mortality for the patient, necessitating other strategies for management. Caecostomy in the management of large bowel obstruction is an often forgotten weapon in the general surgeons' armoury.

Balloon dilatation of benign rectal anastomotic strictures -- a review

BACKGROUND

The occurrence of anastomotic stricture at the level of the rectum gives rise to three broad therapeutic options, namely major pelvic and abdominal revisional surgery, faecal diversion (stoma), or local revision by transanal approaches (including endoscopic and fluoroscopic). This article updates the current evidence and focuses on the results of the balloon dilatation technique.

METHODS

A Medline search was carried out using the search terms (dilatation OR dilatation) AND (stricture OR strictures OR stenosis OR stenotic) AND (rectum OR rectal). In an effort to lessen publication bias, articles included at least 10 patients who were consecutively referred for treatment.

RESULTS/CONCLUSION

This review would suggest that probably relatively short strictures have been chosen for balloon dilatation and that the results have had a very low major morbidity (0.45%) and mortality (0%) rate.

Chemotherapy plus percutaneous radiofrequency ablation in patients with inoperable colorectal liver metastases

AIM: To access the efficacy of chemotherapy plus radiofrequency ablation (RFA) as one line of treatment in inoperable colorectal liver metastases.

METHODS: Eligible patients were included in three Phase II studies. In the first study percutaneous RFA was used first followed by 6 cycles of 5-fluorouracil, leucovorin and irinotecan combination (FOLFIRI) (adjunctive chemotherapy trial). In the other two, chemotherapy (FOLFIRI or 5-fluorouracil, leucovorin and oxaliplatin combination) up to 12 cycles was used first with percutaneous RFA offered to responding patients (primary chemotherapy trials).

RESULTS: Thirteen patients were included in the adjunctive chemotherapy trial and 17 in the other two. At inclusion they had 1-4 liver metastases (up to 6.5 cm in size). Two patients died during chemotherapy. All patients in the adjunctive chemotherapy trial and 44% in the primary chemotherapy studies had their metastases ablated. Median PFS and overall survival in the adjunctive study were 13 and 24 mo respectively while in the primary chemotherapy studies they were 10 and 21 mo respectively. Eighty one percent of the patients had tumour relapse in at least one previously ablated lesion.

CONCLUSION: Chemotherapy plus RFA in patients with low volume inoperable colorectal liver metastases seems safe and relatively effective. The high local recurrence rate is of concern.

Magnetic resonance imaging accuracy in assessing tumour down-staging following chemoradiation in rectal cancer

OBJECTIVE

Magnetic resonance imaging (MRI) is increasingly accepted as the radiological modality of choice staging rectal cancer but is subject to error. Neoadjuvant therapy is increasingly used in rectal cancer and MRI is used to stage response and occasionally plan surgery. We aim to assess the staging accuracy of MRI following chemoradiotherapy in rectal cancer.

METHOD

Retrospective analysis of 86 patients with MRI stage pre- and postlong-course chemoradiotherapy and comparison with pathological assessment.

RESULTS

Fourty-nine patients (34 men, 15 women) with median age 68 years (60-74) were analysed. The median time from completion of CRT to MRI was 32 days (16-37). Chemoradiotherapy led to significant down-staging (P < 0.001). MRI-staging accuracy was 43% (21/49) with over- and under-staging in 43% (21/49) and 14% (7/49) respectively. T-stage accuracy was 45% (22/49) with over-staging in 33% (16/49) and under-staging in 22% (11/49). MRI stage correlated poorly with pathological assessment for International Union Against Cancer (kappa = 0.255) and T stages (kappa = 0.112). MRI nodal assessment was 71% (35/49) accurate, with 82% (9/11) sensitivity, 68% (26/38) specificity and positive predictive value (PPV) of 43% (9/21) and negative predictive value of 93% (26/28). There was a significant difference in node positivity between MRI and pathological staging (P = 0.005, Fisher's exact). Complete radiological response was observed in 4% (2/49). Complete pathological response was observed in 10% (5/49), which were staged 0(1), I(1), II(2) and III(1) postchemoradiotherapy by MRI.

CONCLUSION

MRI staging following chemoradiation is poor. Over-staging occurs three times more commonly than under-staging. Over-staging is due to poor PPV of nodal assessment.

Routine use of gastrograffin enema prior to the reversal of a loop ileostomy

BACKGROUND/AIMS

Anastomotic failure occurs in up to 10% of patients following anterior resection. Selective use of a loop ileostomy may reduce the septic consequences of anastomotic leak. The use of gastrograffin enema to confirm the anastomotic integrity prior to ileostomy closure is still controversial. Our aim was to determine the impact of the routine use of gastrograffin enema on patients' management prior to ileostomy reversal.

METHODS

A review of 81 patients who underwent low anterior resection with loop ileostomy for rectal cancer over 3 years.

RESULTS

Gastrograffin enema was performed in 69 patients (85.2%). The mean time from operation to gastrograffin enema was 22 weeks. Four patients (5.8%) had a positive radiological leak without clinical suspicion of anastomotic problems, 2 patients (2.9%) of these subsequently had the ileostomy closed despite the positive result, 2 patients (2.9%) had a gastrograffin enema repeated which showed no leak and the patients are awaiting reversal.

CONCLUSION

The incidence of positive radiological leak in uncomplicated patients is low; such patients had their loop ileostomies closed with or without serial gastrograffin enema. Routine gastrograffin enema in the absence of a clinical suspicion of anastomotic failure would appear to be of little value.

Long-term results of percutaneous radiofrequency ablation of unresectable colorectal hepatic metastases: final outcomes

INTRODUCTION

Percutaneous radiofrequency ablation (PcRFA) provides alternative means of treating patients with unresectable colorectal liver metastases. We previously reported our initial experience in 30 patients treated with PcRFA. We present the final long-term results in these 30 patients.

METHODS

The final outcome of the 30 patients treated with PcRFA is reported, 30 months following the initial results published in 2004.

RESULTS

Thirty patients (21 males and 9 females), median age 74.5 (44-85) years, underwent PcRFA for 57 lesions in 60 sessions. The final results in this cohort of patients are reported: 28 dead and 2 lost to follow-up. Median follow-up was 22 (3-53) months. Median size was 31 (8-70) mm. Nineteen lesions required repeat PcRFA. Median ablation time per lesion was 12 (4.5-36) min. Eleven patients received chemotherapy pre-PcRFA and 15 received chemotherapy post-PcRFA. Three patients went on to have limited hepatectomies. Complications occurred in 3 (5%) and median hospital stay was 1 (1-7) day. The median hepatic disease-free survival was 12 (95% CI 6.1-17.9) months and actuarial survival was 23.2 (95% CI 18.5-27.8) months.

CONCLUSION

PcRFA is safe and associated with increased disease-free and overall survival in patients with unresectable colorectal hepatic metastases.

Percutaneous radiofrequency ablation of colorectal hepatic metastases - initial experience. An adjunct technique to systemic chemotherapy for those with inoperable colorectal hepatic metastases

BACKGROUND AND AIM

Most patients with hepatic metastases from colorectal carcinoma are unsuitable for resection. Radiofrequency ablation (RFA) has been applied to such lesions at laparotomy. This study aimed to evaluate the less invasive approach of percutaneous RFA.

METHOD

Patients with unresectable liver metastases identified on cross-sectional imaging were considered for percutaneous RFA either alone or in combination with systemic chemotherapy. Subjects with >6 lesions or lesions of maximum size >70 mm were excluded. Percutaneous RFA was applied under sedation and radiological guidance (CT/US). Treatment effect was determined by follow-up imaging. Actuarial survival was calculated by the Kaplan-Meier analysis.

RESULTS

Thirty patients (21 males), median age 74.5 years (range 44-85 years), underwent percutaneous RFA to 56 lesions during 54 treatment sessions. The median size of lesion was 30 mm (range 8-70 mm). Fifteen lesions were treated more than once because of recurrence or incomplete ablation. The median ablation time per lesion was 12 min (range 4.5-36 min). Eleven patients had pre-procedural chemotherapy and 15 patients received chemotherapy after treatment. There was minimal associated morbidity (5.6% of treatments). Median hospital stay per treatment was 1 day (range 1-7). Median actuarial survival from the date of first percutaneous RFA was 22 months (95% CI 12.9-31.1 months). Eleven patients were alive at the time of data collection.

CONCLUSION

Percutaneous RFA is a safe, well-tolerated intervention for unresectable hepatic metastases which can be repeated, if required. The technique may be associated with prolonged survival in this selected group of subjects. Future studies should consider the role of percutaneous RFA either in place of or as an adjunct to palliative chemotherapy.

Breach rhythm: the EEG related to skull defects

From 33 patients with skull defects 89 EEGs were recorded, most with X ray control of the electrode sites. In 10 patients records were made shortly before and about 10 days after bone replacement. The remaining cases had EEGs either with or without bone replacement. The amplitude of alpha and frontal fast rhythms might be increased over or near unilateral posterior and frontal defects respectively. This enhancement was by a factor of less than 3. Since the electrode involved might not be in the defect but on adjacent bone this does not seem to be an effect of greater proximity to the generators. In 21 cases with defects involving or near to electrodes C3(/) and T3(4) sharply focal mu-like rhythms at 6--11 c/sec, usually with faster components, were seen. They formed two groups, at C3(4), responsive to fist clenching and other stimuli (not to eye opening) and at T3(4), unresponsive to any stimulus. In both groups the waves often had spike-like negative phases, but true spikes and also random slow waves with the same restricted focus and responsiveness were sometimes seen. Because of this complexity we prefer the term breach rhythm to mu or mu-like. Bone (or acrylic) replacement abolished central breach rhythm in 3 cases, but not in others and it might or might not restore the symmetry of alpha rhythm or fast rhythm, but burr holes, saw cuts etc., always remain after craniotomy. It is argued that, with the possible exception of 2 patients, the breach rhythms described in this series do not represent enhanced normal mu rhythm. Breach rhythm, even when very spike-like, appears to have little relationship to epilepsy and is not an indicator of recurrence of a tumour.