Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy

STUDY PURPOSE

The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases.

METHODS

The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection.

RESULTS

Not applicable.

CONCLUSION

DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Thermal ablation combined with transarterial chemoembolization for hepatocellular carcinoma: What is the right treatment sequence?

BACKGROUND

The combination treatment regimen of thermal ablation (TA) and transarterial chemoembolization (TACE) has gained a place in treatment of hepatocellular carcinoma (HCC) lesions > 3 cm unsuitable for surgery. Despite a high heterogeneity in the currently used treatment protocols, the pooled results of combined treatments seem to outperform those of TA or TACE alone. TACE preceding TA has been studied extensively, while results of the reverse treatment sequence are lacking. In this retrospective cohort study we compared the two treatment sequences.

PATIENTS AND METHODS

38 patients (median age: 68.5 yrs (range 40-84), male: 34, liver cirrhosis: 33, early stage HCC: 21, intermediate stage HCC: 17) were included in two tertiary referral centers, of whom 27 were treated with TA and adjuvant TACE (TA + TACE). The other 11 patients received TA with neoadjuvant TACE (TACE + TA). Overall survival (OS), time to progression (TTP) and local tumor progression (LTP) free survival were determined for the entire cohort and compared between the two treatment sequences.

RESULTS

The median OS of all patients was 52.7 months and the median time to LTP was 11.5 months (censored for liver transplantation). No differences were found with respect to OS between the two treatment sequences. Median time to LTP for TACE + TA was 23.6 months and 8.1 months for TA + TACE (p = 0.19).

DISCUSSION

No statistical differences were found for OS, TTP and time to LTP between patients treated with TA combined with neoadjuvant or adjuvant TACE.

Percutaneous Versus Surgical Interventions for Hepatic Cystic Echinococcosis: A Systematic Review and Meta-Analysis

Purpose

This systematic review and meta-analysis summarises the current literature on invasive treatment options of cystic hepatic echinococcosis (CE), comparing percutaneous radiological interventions to surgery, still the cornerstone of treatment in many countries.

Methods

A literature search was conducted in Medline and EMBASE databases (PROSPERO registration number: CRD42019126150). The primary outcome was recurrence of cysts after treatment. Secondary outcomes were complications, duration of hospitalisation, mortality and treatment conversion.

Results

The number of eligible prospective studies, in particular RCTs, was limited. In the four included studies, only conventional surgery is compared directly to percutaneous techniques. From the available data, in terms of recurrence, percutaneous treatment of hydatid cysts is non-inferior to open surgery. With regard to complications and length of hospital stay, outcomes favour percutaneous therapy.

Conclusion

Although evidence from prospective research is small, percutaneous treatment in CE is an effective, safe and less invasive alternative to surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00270-021-02911-4.

Predictive Factors for Hypertrophy of the Future Liver Remnant After Portal Vein Embolization: A Systematic Review

This systematic review was conducted to determine factors that are associated with the degree of hypertrophy of the future liver remnant following portal vein embolization. An extensive search on September 15, 2020, and subsequent literature screening resulted in the inclusion of forty-eight articles with 3368 patients in qualitative analysis, of which 18 studies were included in quantitative synthesis. Meta-analyses based on a limited number of studies showed an increase in hypertrophy response when additional embolization of segment 4 was performed (pooled difference of medians = − 3.47, 95% CI − 5.51 to − 1.43) and the use of N-butyl cyanoacrylate for portal vein embolization induced more hypertrophy than polyvinyl alcohol (pooled standardized mean difference (SMD) = 0.60, 95% CI 0.30 to 0.91). There was no indication of a difference in degree of hypertrophy between patients who received neo-adjuvant chemotherapy and those who did not receive pre-procedural systemic therapy

(pooled SMD = − 0.37, 95% CI − 1.35 to 0.61), or between male and female patients (pooled SMD = 0.19, 95% CI − 0.12 to 0.50).

The study was registered in the International Prospective Register of Systematic Reviews on April 28, 2020 (CRD42020175708).

Radiofrequency ablation and chemotherapy versus chemotherapy alone for locally advanced pancreatic cancer (PELICAN): study protocol for a randomized controlled trial

Background

Approximately 80% of patients with locally advanced pancreatic cancer (LAPC) are treated with chemotherapy, of whom approximately 10% undergo a resection. Cohort studies investigating local tumor ablation with radiofrequency ablation (RFA) have reported a promising overall survival of 26–34 months when given in a multimodal setting. However, randomized controlled trials (RCTs) investigating the effect of RFA in combination with chemotherapy in patients with LAPC are lacking.

Methods

The “Pancreatic Locally Advanced Unresectable Cancer Ablation” (PELICAN) trial is an international multicenter superiority RCT, initiated by the Dutch Pancreatic Cancer Group (DPCG). All patients with LAPC according to DPCG criteria, who start with FOLFIRINOX or (nab-paclitaxel/)gemcitabine, are screened for eligibility. Restaging is performed after completion of four cycles of FOLFIRINOX or two cycles of (nab-paclitaxel/)gemcitabine (i.e., 2 months of treatment), and the results are assessed within a nationwide online expert panel. Eligible patients with RECIST stable disease or objective response, in whom resection is not feasible, are randomized to RFA followed by chemotherapy or chemotherapy alone. In total, 228 patients will be included in 16 centers in The Netherlands and four other European centers. The primary endpoint is overall survival. Secondary endpoints include progression-free survival, RECIST response, CA 19.9 and CEA response, toxicity, quality of life, pain, costs, and immunomodulatory effects of RFA.

Discussion

The PELICAN RCT aims to assess whether the combination of chemotherapy and RFA improves the overall survival when compared to chemotherapy alone, in patients with LAPC with no progression of disease following 2 months of systemic treatment.

Trial registration

Dutch Trial RegistryNL4997. Registered on December 29, 2015. ClinicalTrials.govNCT03690323. Retrospectively registered on October 1, 2018

Prevention of hepatic encephalopathy by administration of rifaximin and lactulose in patients with liver cirrhosis undergoing placement of a transjugular intrahepatic portosystemic shunt (TIPS): a multicentre randomised, double blind, placebo controlled trial (PEARL trial)

Introduction

Cirrhotic patients with portal hypertension can suffer from variceal bleeding or refractory ascites and can benefit from a transjugular intrahepatic portosystemic shunt (TIPS). Post-TIPS hepatic encephalopathy (HE) is a common (20%–54%) and often severe complication. A prophylactic strategy is lacking.

Methods and analysis

The Prevention of hepatic Encephalopathy by Administration of Rifaximin and Lactulose in patients with liver cirrhosis undergoing placement of a TIPS (PEARL) trial, is a multicentre randomised, double blind, placebo controlled trial. Patients undergoing covered TIPS placement are prescribed either rifaximin 550 mg two times per day and lactulose 25 mL two times per day (starting dose) or placebo 550 mg two times per day and lactulose 25 mL two times per day from 72 hours before and until 3 months after TIPS placement. Primary endpoint is the development of overt HE (OHE) within 3 months (according to West Haven criteria). Secondary endpoints include 90-day mortality; development of a second episode of OHE; time to development of episode(s) of OHE; development of minimal HE; molecular changes in peripheral and portal blood samples; quality of life and cost-effectiveness. The total sample size is 238 patients and recruitment period is 3 years in six hospitals in the Netherlands and one in Belgium.

Ethics and dissemination

This study protocol was approved in the Netherlands by the Medical Research Ethics Committee of the Academic Medical Centre, Amsterdam (2018-332), in Belgium by the Ethics Committee Research UZ/KU Leuven (S62577) and competent authorities. This study will be conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. Study results will be submitted for publication in a peer-reviewed journal.

Trial registration numbers

ClinicalTrials.gov (NCT04073290) and EudraCT database (2018-004323-37).

Doppler follow-up after TIPS placement is not routinely indicated. A 16-years single centre experience

BACKGROUND AND AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention to treat complications of portal hypertension. Since the introduction of polytetrafluoroethylene (PTFE)-covered stents, TIPS patency rates have improved, and the need for routine TIPS surveillance has become questionable. Aims of this study were to assess the indications, clinical outcome and survival, and yield of Doppler ultrasound follow-up in patients who received a TIPS in an academic centre.

METHODS

A retrospective cohort study of all adult consecutive patients who underwent PTFE-covered TIPS placement between 2001 and 2016. Clinical, biochemical, and imaging findings were reviewed and analysed.

RESULTS

A total of 103 patients were included for analysis. At one-year follow-up, control of bleeding was successful in 91% (41/45), and control of refractory ascites in 80% (8/10). In patients with variceal bleeding, a higher MELD score was a risk factor for 90-day mortality (HR 1.28 per point, p < 0.001) and one-year mortality (HR 1.24 per point, p < 0.001). In patients with refractory ascites, a higher MELD score was only a risk factor for 90-day mortality (HR 1.13 per point, p = 0.03). Doppler ultrasound investigations during follow-up revealed abnormalities in 4% (6/166), all of which were associated with clinical deterioration, while abnormalities were detected in 11.4% (19/166) of patients who presented with clinical symptoms of TIPS dysfunction.

CONCLUSION

The use of routine Doppler ultrasound follow-up after PTFE-covered TIPS placement seems unnecessary as it had a very low yield and abnormal Doppler findings were almost always associated with clinical symptoms of TIPS dysfunction.

Safety and efficacy of transarterial embolization of hepatocellular adenomas

BACKGROUND

Hepatocellular adenoma (HCA) larger than 5 cm in diameter has an increased risk of haemorrhage and malignant transformation, and is considered an indication for resection. As an alternative to resection, transarterial embolization (TAE) may play a role in prevention of complications of HCA, but its safety and efficacy are largely unknown. The aim of this study was to assess outcomes and postembolization effects of selective TAE in the management of HCA.

METHODS

This retrospective, multicentre cohort study included patients aged at least 18 years, diagnosed with HCA and treated with TAE. Patient characteristics, 30-day complications, tumour size before and after TAE, symptoms before and after TAE, and need for secondary interventions were analysed.

RESULTS

Overall, 59 patients with a median age of 33.5 years were included from six centres; 57 of the 59 patients were women. Median tumour size at time of TAE was 76 mm. Six of 59 patients (10 per cent) had a major complication (cyst formation or sepsis), which could be resolved with minimal therapy, but prolonged hospital stay. Thirty-four patients (58 per cent) were symptomatic at presentation. There were no significant differences in symptoms before TAE and symptoms evaluated in the short term (within 3 months) after TAE (P = 0·134). First follow-up imaging was performed a median of 5·5 months after TAE and showed a reduction in size to a median of 48 mm (P < 0·001).

CONCLUSION

TAE is safe, can lead to adequate size reduction of HCA and, offers an alternative to resection in selected patients.

Adjuvant hepatic arterial infusion pump chemotherapy and resection versus resection alone in patients with low-risk resectable colorectal liver metastases - the multicenter randomized controlled PUMP trial

Background

Recurrences are reported in 70% of all patients after resection of colorectal liver metastases (CRLM), in which half are confined to the liver. Adjuvant hepatic arterial infusion pump (HAIP) chemotherapy aims to reduce the risk of intrahepatic recurrence. A large retrospective propensity score analysis demonstrated that HAIP chemotherapy is particularly effective in patients with low-risk oncological features. The aim of this randomized controlled trial (RCT) --the PUMP trial-- is to investigate the efficacy of adjuvant HAIP chemotherapy in low-risk patients with resectable CRLM.

Methods

This is an open label multicenter RCT. A total of 230 patients with resectable CRLM without extrahepatic disease will be included. Only patients with a clinical risk score (CRS) of 0 to 2 are eligible, meaning: patients are allowed to have no more than two out of five poor prognostic factors (disease-free interval less than 12 months, node-positive colorectal cancer, more than 1 CRLM, largest CRLM more than 5 cm in diameter, serum Carcinoembryonic Antigen above 200 μg/L). Patients randomized to arm A undergo complete resection of CRLM without any adjuvant treatment, which is the standard of care in the Netherlands. Patients in arm B receive an implantable pump at the time of CRLM resection and start adjuvant HAIP chemotherapy 4–12 weeks after surgery, with 6 cycles of floxuridine scheduled. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival, hepatic PFS, safety, quality of life, and cost-effectiveness. Pharmacokinetics of intra-arterial administration of floxuridine will be investigated as well as predictive biomarkers for the efficacy of HAIP chemotherapy. In a side study, the accuracy of CT angiography will be compared to radionuclide scintigraphy to detect extrahepatic perfusion. We hypothesize that adjuvant HAIP chemotherapy leads to improved survival, improved quality of life, and a reduction of costs, compared to resection alone.

Discussion

If this PUMP trial demonstrates that adjuvant HAIP chemotherapy improves survival in low-risk patients, this treatment approach may be implemented in the standard of care of patients with resected CRLM since adjuvant systemic chemotherapy alone has not improved survival.

Trial registration

The PUMP trial is registered in the Netherlands Trial Register (NTR), number: 7493. Date of registration September 23, 2018.

Available ablation energies to treat cT1 renal cell cancer: emerging technologies

Purpose

An increasing interest in percutaneous ablation of renal tumors has been caused by the increasing incidence of SRMs, the trend toward minimally invasive nephron-sparing treatments and the rapid development of local ablative technologies. In the era of shared decision making, patient preference for non-invasive treatments also leads to an increasing demand for image-guided ablation. Although some guidelines still reserve ablation for poor surgical candidates, indications may soon expand as evidence for the use of the two most validated local ablative techniques, cryoablation (CA) and radiofrequency ablation (RFA), is accumulating. Due to the collaboration between experts in the field in biomedical engineering, urologists, interventional radiologists and radiation oncologists, the improvements in ablation technologies have been evolving rapidly in the last decades, resulting in some new emerging types of ablations.

Methods

A literature search was conducted to identify original research articles investigating the clinical outcomes of new emerging technologies, percutaneous MWA, percutaneous IRE and SABR, in patients with primary cT1 localized renal cell cancer.

Results

Due to the collaboration between experts in the field in biomedical engineering, urologists, interventional radiologists and radiation oncologists, the improvements in ablation technologies have been evolving rapidly in the last decades. New emerging technologies such as microwave ablation (MWA), irreversible electroporation (IRE) and stereotactic ablative radiotherapy (SABR) seem to be getting ready for prime time.

Conclusion

This topical paper describes the new emerging technologies for cT1 localized renal cell cancer and investigates how they compare to CA and RFA.

Systematic review of transarterial embolization for hepatocellular adenomas

Background

Hepatocellular adenoma (HCA) larger than 5 cm in diameter is considered an indication for elective surgery, because of the risk of haemorrhage and malignant transformation. Transarterial embolization (TAE) is used to manage bleeding HCA and occasionally to reduce tumour size. TAE might have potential as an elective therapy, but its current role in this context is uncertain. This systematic review provides an overview of clinical outcomes after TAE, in bleeding and non-bleeding HCA.

Methods

Two independent reviewers performed a systematic search of literature in PubMed and Embase. Outcomes were change in tumour size, avoidance of surgery, complications and malignant transformation after TAE in bleeding and non-bleeding HCA. The Critical Appraisal Skills Programme tool for cohort studies was used for quality assessment of included studies.

Results

From 320 potential articles, 20 cohort studies and 20 case reports including 851 patients met the inclusion criteria. TAE was performed in 151 of 851 patients (17·7 per cent), involving 196 tumours, of which 95 (48·5 per cent) were non-bleeding. Surgical treatment was avoided in 68 of 151 patients (45·0 per cent). Elective TAE was performed in 49 patients involving 66 HCAs, with 41 of these patients (84 per cent) not requiring surgery. Major complications occurred in eight of 151 patients (5·3 per cent); no death was reported. Among cohort studies, complete tumour disappearance was observed in 10 per cent of patients, and regression in 75 per cent.

Conclusion

Acute or elective TAE in the management of HCA is safe. In the elective setting, TAE provides a potential alternative to surgery.

Hepatocellular carcinoma: Dutch guideline for surveillance, diagnosis and therapy

Hepatocellular carcinoma (HCC) is rare in the Netherlands, even though the incidence has increased quite sharply in recent years. Standard treatment options consist of surgery, orthotopic liver transplantation, radiofrequency ablation, transarterial chemoembolisation (TACE) and systemic therapy with sorafenib. The consensus-based Dutch HCC guideline, established in 2013, serves to guide surveillance, diagnosis and treatment options: Surveillance should be performed by ultrasound at six-month intervals in well-defined cirrhotic patients and in selected high-risk hepatitis B carriers; A nodule > 1 cm in cirrhotic patients with arterial hypervascularity and venous or delayed phase washout at four-phase CT or MRI scan establishes the diagnosis of HCC; In patients with HCC without underlying cirrhosis, resection should be considered regardless of tumour size; In cirrhotic HCC patients, tumour stage, severity of underlying cirrhosis, and performance status determine treatment options. The algorithm of the Barcelona Clinic Liver Cancer (BCLC) staging system should be followed; Patients with Child-Pugh A-B cirrhosis (CP < 8 points) and performance status 0-2 are candidates for any active treatment other than transplantation; In early stage HCC (BCLC stage 0 or A, compensated cirrhosis without portal hypertension) surgical resection, liver transplantation, or radiofrequency ablation should be considered; In intermediate stage HCC (BCLC stage B) TACE and÷ or radiofrequency ablation should be considered; In advanced stage HCC (BCLC stage C) sorafenib should be considered.

CONCLUSION

The Dutch HCC guideline offers advice for surveillance, diagnosis and treatment of HCC.

Time to intervention in patients with splenic injury in a Dutch level 1 trauma centre

BACKGROUND

Timely intervention in patients with splenic injury is essential, since delay to treatment is associated with an increased risk of mortality. Transcatheter Arterial Embolisation (TAE) is increasingly used as an adjunct to non-operative management. The aim of this study was to report time intervals between admission to the trauma room and start of intervention (TAE or splenic surgery) in patients with splenic injury.

METHODS

Consecutive patients with splenic injury aged ≥ 16 years admitted between January 2006 and January 2012 were included. Data were reported according to haemodynamic status (stable versus unstable). In haemodynamically (HD) unstable patients, transfusion requirement, intervention-related complications and the need for a re-intervention were compared between the TAE and splenic surgery group.

RESULTS

The cohort consisted of 96 adults of whom 16 were HD unstable on admission. In HD stable patients, median time to intervention was 105 (IQR 77-188) min: 117 (IQR 78-233) min for TAE compared to 95 (IQR 69-188) for splenic surgery (p=0.58). In HD unstable patients, median time to intervention was 58 (IQR 41-99) min: 46 (IQR 27-107) min for TAE compared to 64 (IQR 45-80) min for splenic surgery (p=0.76). The median number of transfused packed red blood cells was 8 (3-22) in HD unstable patients treated with TAE versus 24 (9-55) in the surgery group (p=0.09). No intervention-related complications occurred in the TAE group and one in the splenic surgery group (p=0.88). Two spleen related re-interventions were performed in the TAE group versus 3 in the splenic surgery group (p=0.73).

CONCLUSIONS

Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with splenic surgery. Although no difference was observed with regard to intervention-related complications and the need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with TAE compared to patients treated with splenic surgery. We conclude that if 24/7 interventional radiology facilities are available, TAE is not associated with time loss compared to splenic surgery, even in HD unstable patients.

Reliability of injury grading systems for patients with blunt splenic trauma

OBJECTIVES

The most widely used grading system for blunt splenic injury is the American Association for the Surgery of Trauma (AAST) organ injury scale. In 2007 a new grading system was developed. This 'Baltimore CT grading system' is superior to the AAST classification system in predicting the need for angiography and embolization or surgery. The objective of this study was to assess inter- and intraobserver reliability between radiologists in classifying splenic injury according to both grading systems.

METHODS

CT scans of 83 patients with blunt splenic injury admitted between 1998 and 2008 to an academic Level 1 trauma centre were retrospectively reviewed. Inter and intrarater reliability were expressed in Cohen's or weighted Kappa values.

RESULTS

Overall weighted interobserver Kappa coefficients for the AAST and 'Baltimore CT grading system' were respectively substantial (kappa=0.80) and almost perfect (kappa=0.85). Average weighted intraobserver Kappa's values were in the 'almost perfect' range (AAST: kappa=0.91, 'Baltimore CT grading system': kappa=0.81).

CONCLUSION

The present study shows that overall the inter- and intraobserver reliability for grading splenic injury according to the AAST grading system and 'Baltimore CT grading system' are equally high. Because of the integration of vascular injury, the 'Baltimore CT grading system' supports clinical decision making. We therefore recommend use of this system in the classification of splenic injury.

Management of blunt renal injury in a level 1 trauma centre in view of the European guidelines

BACKGROUND

Debate continues about the optimal management strategy for patients with renal injury.

PURPOSE

To report the diagnostics and treatment applied in a level 1 trauma centre and to compare it to the recommendations of the European Association of Urology guidelines concerning blunt renal injury.

METHODS

The management of all patients with blunt renal injury, admitted to the level 1 trauma centre of the Academic Medical Centre, between January 2005 and December 2009 was reviewed retrospectively.

RESULTS

Median age and ISS of the 186 included patients were 40 and 17 years respectively. All but one haemodynamically stable patients with microscopic haematuria received nonoperative management. Sixty percent of the haemodynamically stable patients with gross haematuria underwent CT scanning. Patients with grade 1-4 renal injury received nonoperative management. Additionally, two patients with grade 3-4 renal injury received angiography and embolization (A&E). One patient with grade 5 injury underwent renal exploration and two A&E. Seven of the 8 haemodynamically unstable patients underwent emergency laparotomy and in 2 patients, haemodynamically unstable because of renal injury, A&E was performed as an adjunct to surgical intervention.

CONCLUSIONS

In the present study, violation of the guidelines increased with injury severity. A&E can provide both a useful adjunct to nonoperative management and alternative to surgical intervention in specialised centres with appropriate equipment and expertise, even in patients with high grade renal injury. We advocate an update of the guidelines with a more prominent role of A&E.

Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury

Introduction

Nonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center.

Methods

An analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment.

Results

A total of 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%.

Conclusions

SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United States.

Incidence and management of bile leakage after partial liver resection

BACKGROUND/AIMS

Bile leakage after partial liver resection still is a common complication and is associated with substantial morbidity and even mortality.

METHODS

A total of 234 consecutive liver resections without biliary reconstruction, performed between January 1992 and December 2004, were analyzed for postoperative bile leakage.

RESULTS

Postoperative bile leakage occurred in 6.8% of patients (16/234). In univariate analysis, male gender (p = 0.037), major liver resection (p = 0.004), right-sided hepatectomy (p = 0.005), prolonged operation time (p = 0.001), intraoperative blood loss >500 ml (p = 0.009), red cell transfusion (p = 0.02), tumor size (p = 0.026), duration of vascular occlusion (p = 0.03) and surgical irradicality (p = 0.001) were risk factors. No independent risk factors were associated with bile leakage after liver resection. Bile leakage originated from the resection plane in 10 patients (63%). Endoscopic biliary decompression was performed in 9 patients as initial treatment, and percutaneous drainage of the bile collection was used in 4 patients. Bile leakage resolved spontaneously in 3 patients.

CONCLUSIONS

Bile leakage is a persisting complication and in this study occurred in 6.8% of patients after partial liver resection. Percutaneous drainage of bile collection with or without endoscopic biliary decompression are effective interventions in the management of most cases of bile leakage.

[Pyelonephritis during pregnancy: a threat to mother and child]

Two pregnant women, aged 19 and 40 respectively, were diagnosed with pyelonephritis. The first patient was initially treated with amoxicillin; appropriate antibiotic treatment--consisting of amoxicillin and clavulanic acid--was delayed for 24 hours. The second patient immediately received appropriate treatment (ceftriaxone). The first patient eventually had a nephrostomy and died due to urosepsis with multiple organ failure. The second patient delivered a healthy son and recovered. Approximately 20% of the cases of pyelonephritis during pregnancy progress to urosepsis. Therefore, pregnant women with pyelonephritis should be treated immediately with an intravenous second- or third-generation cephalosporin or the combination ofamoxicillin and clavulanic acid. Treatment of pregnant patients with urosepsis should take place in an intensive care unit and include treatment of the underlying infection as well as support of vital functions. Nephrostomy in a pregnant patient with symptomatic hydronephrosis should only be performed when the symptoms persist despite adequate antibiotic treatment.

[Angiography and embolisation to control bleeding after blunt injury to the abdomen or pelvis]

Angiography and embolisation are being increasingly used to control bleeding following abdominal and pelvic trauma. CT is a useful tool to select patients for such intervention-radiological angiography. The application ofangiography and embolisation requires a specific local infrastructure, logistics and expertise on the part of the radiologist, traumatologist and anaesthetist. The main indications for angiography and embolisation are: contrast blush on the CT scan and clinical signs of ongoing bleeding; they are also indicated as an adjunct to damage control procedures. Angiography and embolisation are successful in about 90% of the patients; complications occur in < 10% of the patients. An accurate estimate of the patient's physical condition, a correct assessment of the severity of the injury, and a multidisciplinary approach are important factors in the success of embolisation therapy.

[Takayasu arteritis: a chronic vasculitis that is rare in children]

Takayasu arteritis was diagnosed in two children, a 15-year-old girl and a 10-year-old boy. The girl had suffered from fatigue, malaise, abdominal pain and weight loss for several months, but no clear cause could be found. A few weeks later, when a blood pressure of 222/155 mmHg was measured, the possibility of renal artery stenosis was considered and imaging studies revealed indications for Takayasu's disease. The patient was given methylprednisolone followed by a combination of prednisone and, initially, cyclophosphamide, later methotrexate. This resulted in a clinical remission of the inflammatory process. The boy presented with increasing fatigue and variable episodes of fever. After 3 years, sarcoidosis or Castleman's disease were considered. Imaging studies revealed aortic stenosis. He underwent stenting of the involved vessel segment. Takayasu arteritis is a chronic vasculitis of unknown origin, affecting mainly the aorta and its main branches. As a result of the inflammation, stenosis, occlusion or dilatation of the involved vessels may occur and cause a wide range of symptoms. Especially in the early phase, the symptoms often are non-specific. One should look for hypertension, blood pressure differences between the two arms, decreased peripheral pulsation or bruits over the aorta and its major branches. Radiological examination may consist ofangiography, magnetic resonance imaging or CT-scans. Treatment consists of corticosteroids and other immunosuppressants, such as cyclophosphamide, methotrexate, azathioprine, and antagonists of tumour-necrosis factor alpha. In addition, balloon dilatation or stenting is often necessary.

[Increasing role for angiographic embolisation in the treatment of gastrointestinal haemorrhage]

Endoscopy is the primary diagnostic and therapeutic modality for the vast majority of patients with haemorrhage of the upper or lower digestive tract. In many hospitals, surgery is the therapy of choice when endoscopy fails or is impossible. In patients who have considerable co-morbidity and who are actively bleeding from the digestive tract, surgery is associated with a relatively high morbidity and mortality. Angiographic embolisation for haemorrhage from the upper or lower digestive tract is effective, with success rates varying from 50 to 90%. The risk of ischaemic complications of the procedure is acceptably low (< 5%). Angiography is not very time-consuming and does not preclude subsequent surgical treatment ifangiographic embolisation does not succeed. However, performing embolisation requires skill and experience and the procedure is not available everywhere. Angiographic embolisation is a valuable alternative to surgery and should be considered in all patients with haemorrhage of the digestive tract who cannot be treated by means of endoscopy.

Pleural thickening in a construction worker: it is not always mesothelioma

We describe the case of a 45-year-old man presenting with chest pain and pleural effusions. These symptoms were progressive over a period of three years, with pericardial involvement and respiratory insufficiency finally resulting in death. Despite repeated diagnostic procedures, a final diagnosis could only be made at autopsy. Multisystem foamy histiocyte infiltration suggested the diagnosis of Erdheim-Chester disease.

Outcome of regional and local ablative therapies for hepatocellular carcinoma: a collective review

BACKGROUND

Transcatheter arterial (chemo) embolization (TACE), cryoablation (CA) and percutaneous ethanol injection (PEI) were the first regional and local ablative techniques that came into use for irresectable HCC. Radiofrequency ablation (RFA) and interstitial laser coagulation (ILC) followed and have now evolved rapidly. It would not be ethical to compare resection with ablation in patients well enough to undergo major surgery. Therefore, hepatic resection and hepatic transplantation remain the only curative treatment options for HCC.

METHODS

On the basis of a Medline literature search and the authors' experiences, the principles, current status and prospects of TACE and local ablative techniques in HCC are reviewed.

RESULTS

Complete tumour necrosis can be achieved in 60-100% of patients treated with PEI (70-100%), cryoablation (60-85%), RFA (80-90%) or ILC (70-97%). After TACE significant tumour response is achieved in 17-61.9% but complete tumour response is rare (0-4.8%) as viable tumour cells remain after TACE. Five-year survival rates are available for TACE (1-8%), PEI (0-70%) and cryoablation (40%). Only PEI and RFA were compared in one RCT. RFA was associated with fewer treatment sessions and a higher complete necrosis rate. Furthermore, all techniques are associated with low morbidity and mortality, but cryoablation seems to be associated with a higher morbidity rate.

CONCLUSION

TACE has shown to be a valuable therapy with survival benefits in strictly selected patients with unresectable HCC. RFA and PEI are now considered as the local ablative techniques of choice for the treatment of, preferably small, HCC. When tumours are located close to bile ducts or large vessels, PEI remains a valuable therapy. Completeness of ablation can be more easily monitored during cryoablation and another advantage of cryoablation is the possibility of edge freezing. The results of ILC are comparable to RFA with only few side effects and high tumour response rates.

Diagnostic laparoscopy for primary and secondary liver malignancies: impact of improved imaging and changed criteria for resection

BACKGROUND

Diagnostic laparoscopy (DL) combined with laparoscopic ultrasonography (LUS) has previously shown positive results as a staging modality for liver malignancies. Recent improvements in noninvasive diagnostic imaging techniques such as multiphasic spiral computed tomography, together with the policy that bilobar disease or the number of lesions is no longer considered an absolute exclusion criterion for curative resection, could reduce the additional value of DL. This study retrospectively analyzed the efficacy of DL combined with LUS for liver malignancies to assess the effect of improved imaging and changed criteria for resection.

METHODS

All patients with primary or metachronous secondary liver malignancy eligible for resection in 1997 to 2002 were included.

RESULTS

DL combined with LUS was performed in 84 consecutive patients (56 men and 28 women; mean age, 59 years) with primary (n = 33) or secondary (n = 51) liver malignancies. DL showed unresectability in 13 patients (39%) with primary malignancy. Exploratory laparotomy showed that an additional 5 (25%) of the remaining 20 patients had unresectable disease. DL showed unresectability in 5 patients (12%) with colorectal liver metastasis (n = 43). At laparotomy, another 7 (18%) of the remaining 38 patients had unresectable disease. In five patients (13%) from the latter group, LUS could not be performed because of adhesions from previous surgery.

CONCLUSIONS

DL combined with LUS is an adequate staging modality for primary liver malignancies. For colorectal liver metastasis, more liberal resection criteria, a high failure rate due to adhesions from previous surgery, and better preoperative imaging probably resulted in a lower efficacy.

Rupture of True Aneurysms of the Pancreaticoduodenal Arcade: Treatment with Transcatheter Arterial Embolization

We present 2 cases of ruptured true aneurysms of the pancreaticoduodenal arcade, underscoring the role of transcatheter arterial embolization (TAE) as the initial treatment of choice in pancreaticoduodenal arcade aneurysm. Ruptured true aneurysms of the pancreaticoduodenal artery (PDA) are uncommon and few cases have been reported, whereas false aneurysms are seen more often. The first patient we describe is a 63-year-old woman with an aneurysm of the PDA initially treated by TAE. The second case is a 67-year-old woman with an aneurysm of the inferior PDA post-operatively treated by TAE. In both patients TAE via a combined superior mesenteric artery and celiac axis approach was successful. Follow-up contrast-enhanced computed tomography showed prolonged occlusion of both aneurysms. A review of the literature concerning TAE supports our experience that TAE of ruptured aneurysms of the pancreaticoduodenal arcade, when feasible, is at least as effective as conventional surgery, but with lower morbidity and mortality. Therefore, TAE should be the initial treatment of choice in this group of patients.

Abnormal radiological findings and a decreased carbon monoxide transfer factor can persist long after the acute phase of Legionella pneumophila pneumonia

Pulmonary abnormalities may persist long after the acute phase of legionnaires disease (LD). In a cohort of 122 survivors of an outbreak of LD, 57% were still experiencing an increased number of symptoms associated with dyspnea at a mean of 16 months after recovery from acute-phase LD. For 86 of these patients, additional evaluation involving high-resolution computed tomography (HRCT) of the lung revealed pulmonary abnormalities in 21 (24%); abnormal HRCT findings generally presented as discrete and multiple radiodensities. Residual pulmonary abnormalities were associated with a mean reduction of 20% in the gas transport capacity of the lung. This latter sign could not be used to explain the increased symptoms of dyspnea reported by patients. Receipt of mechanical ventilation during the acute phase of LD, delayed initiation of adequate antibiotic therapy, and chronic obstructive pulmonary disease were identified as risk factors for the persistence of lung abnormalities.

Magnetic resonance angiography for the diagnosis of renal artery stenosis: a meta-analysis

AIM

To review the published literature comparing the diagnostic accuracy of magnetic resonance angiography (MRA) with and without gadolinium in diagnosing renal artery stenosis, using catheter angiography as reference.

MATERIALS AND METHODS

A meta-analysis was performed of English language articles identified by computer search using PubMed/MEDLINE, followed by extensive bibliography review from 1985 to May 2001. Inclusion criteria were: (1) blinded comparison with catheter angiography; (2)indication for MRA stated; (3) clear descriptions of imaging techniques; and (4) interval between MRA and catheter angiography < 3 months and only the largest of all studies from one centre was selected in the analysis.

RESULTS

A total of 39 studies were identified, of which 25 met the inclusion criteria. The number of patients included in the meta-analysis was 998: 499 with non-enhanced MRA and 499 with gadolinium-enhanced MRA. The sensitivity and specificity of non-enhanced MRA were 94% (95% CI: 90-97%) and 85% (95% CI: 82-87%), respectively. For gadolinium-enhanced MRA sensitivity was 97% (95% CI: 93-98%) and specificity was 93% (95% CI: 91-95%). Thus, specificity and positive predictive value were significantly better for gadolinium-enhanced MRA (P < 0.001). Accessory renal arteries were depicted better by gadolinium-enhanced MRA (82%; 95% CI: 75-87%) than non-gadolinium MRA (49%; 95% CI: 42-60%) (P < 0.001).

CONCLUSIONS

Gadolinium-enhanced MRA may replace arteriography in most patients with suspected renal artery stenosis, and has major advantages in that it is non-invasive, avoids ionizing radiation and uses a non-nephrotoxic contrast agent.

Percutaneous evacuation (PEVAC) of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first results of a modified PAIR method

BACKGROUND

Surgery is the treatment of choice in echinococcal cysts with cystobiliary fistulas. PAIR (puncture, aspiration, injection, and reaspiration of scolecidals) is contraindicated in these cases.

AIM

To evaluate a modified PAIR method for percutaneous treatment of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material.

PATIENTS

Twelve patients were treated: 10 patients with multivesicular cysts which contained non-drainable material and were complicated by spontaneous intrabiliary rupture, secondary cystobiliary fistulas, cyst infection, or obstructed portal or hepatic veins; and two patients with large univesicular cysts and a ruptured laminated membrane, one obstructing the portal and hepatic veins and one a suspected cystobiliary fistula.

METHODS

The methods used, termed PEVAC (percutaneous evacuation of cyst content), involved the following steps: ultrasound guided cyst puncture and aspiration of cyst fluid to release intracystic pressure and thereby to avoid leakage; insertion of a large bore catheter; aspiration and evacuation of daughter cysts and endocyst by injection and reaspiration of isotonic saline; cystography; injection of scolecidals only if no cystobiliary fistula was present; external drainage of cystobiliary fistulas combined with endoprosthesis or sphincterotomy; catheter removal after complete cyst collapse and closure of the cystobiliary fistula.

RESULTS

In all 12 patients initial cyst size was 13.1 (6-20) cm (mean (range)). At follow up 17.9 (4-30) months after PEVAC, seven cysts had disappeared and five cysts had decreased to 2.4 (1-4) cm (p=0.002). In eight patients with multivesicular cysts, a cystobiliary fistula, and infection, cyst size was 12.5 (6-20) cm, catheter time 72.3 (28-128) days, and hospital stay 38.1 (20-55) days. At 17.3 (4-28) months of follow up, six cysts had disappeared and in two cysts residual size was 1 and 2.9 cm, respectively (p=0.012). In four patients without a cystobiliary fistula, cyst size was 14.4 (12.7-16) cm, catheter time 8.8 (3-13) days, and hospital stay 11.5 (8-14) days. At 19.3 (9-30) months of follow up, one cyst had disappeared and three cysts were 85 (69-94)% smaller (2.2 (1-4) cm) (p=0.068).

CONCLUSION

PEVAC is a safe and effective method for percutaneous treatment of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material.

Laparoscopy and laparoscopic ultrasonography in staging carcinoma of the gastric cardia

OBJECTIVE

To investigate the role of diagnostic laparoscopy and laparoscopic ultrasonography in the staging of carcinoma of the gastric cardia that is involving the distal oesophagus.

DESIGN

Retrospective consecutive case series.

SETTING

Tertiary care centre, The Netherlands.

SUBJECTS

48 patients (34 men and 14 women, median age 63 years, range 39-84) who presented with tumours of the gastric cardia that involved the distal oesophagus and in whom non-invasive staging had not shown unresectable locoregional disease or distant metastases.

INTERVENTIONS

In addition to laparoscopy and laparoscopic ultrasonography, biopsy of all suspected lesions outside the area of potential resection.

MAIN OUTCOME MEASURES

Number of patients in whom the findings obviated the need for exploratory laparotomy.

RESULTS

There were no complications related to the laparoscopy. The investigation showed distant metastases (which were histologically verified) in 11 patients (23%, 95% confidence interval (CI) 16 to 30). These patients had non-operative palliation. Seven were identified by laparoscopy, and laparoscopic ultrasonography showed the other four. In three patients whose distant metastases had already been identified by laparoscopy, ultrasonography was omitted. Three additional patients had suspect lesions, but these were not confirmed histologically. However, these lesions were shown to be cancerous at laparotomy. One additional patient had an intra-abdominal metastasis which was missed by laparoscopy with ultrasonography.

CONCLUSIONS

Laparoscopy with ultrasonography safely detected metastases that had not been shown by conventional staging investigations in 23% of 48 patients with carcinoma of the gastric cardia. The investigation should therefore be added to the standard staging procedures in patients with carcinoma of the gastric cardia that is involving the distal oesophagus.

[Neuroradiologic intervention in two patients with cerebral sinus thrombosis]

Two patients with cerebral sinus thrombosis were successfully treated with neuroradiological intervention procedures, one with local thrombolysis and the other with mechanical thrombosuction using a hydrolyser catheter. The first patient, a 20-year-old woman, was treated with asparaginase for acute lymphatic leukaemia. She lapsed into coma with extensor posturing due to superior sagittal and right transverse sinus thrombosis. She recovered completely after local thrombolysis with 2,940,000 units urokinase, administered over a period of 40 hours. The second patient was a 29-year-old man who presented with clinical deterioration after seizures due to superior sagittal, left transverse and straight sinus thrombosis. A CT-scan demonstrated bilateral haemorrhagic cerebral infarctions. Since the risk of haemorrhage during thrombolysis with urokinase was considered to be high, mechanical thrombosuction with a hydrolyser catheter was performed. This procedure took only 4 hours. The patient recovered completely in two weeks. These cases add further evidence to the effectiveness of thrombolysis and thrombosuction in selected patients with severe cerebral sinus thrombosis.

[Catheter fracture and embolization: a rare complication of a permanent implanted intravenous catheter system]

An implantable venous access system was used in a 55-year-old woman with metastatic breast cancer for the delivery of chemotherapy. Four months after implantation the catheter was resistant to the injection of fluids. A chest X-ray showed fracture of the catheter with embolisation to the right pulmonary artery. Analysis of the fractured catheter after removal showed that the fracture was caused by catheter pinch-off. Catheter pinch-off is caused by friction of the catheter between the clavicle and the first rib. The incidence of this rare complication is estimated at 0.1-1%. The incidence of catheter pinch-off can be reduced by a lateral insertion technique and by radiographic monitoring after implantation.

Staging laparoscopy and laparoscopic ultrasonography in more than 400 patients with upper gastrointestinal carcinoma

BACKGROUND

Resection offers the only chance of cure to patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors. Staging is essential to select patients who will benefit from operation because palliation can also be performed nonoperatively. Several studies, including limited numbers of patients, have shown that laparoscopic staging prevents unnecessary laparotomies, but it is doubtful whether general application of this staging method can be advised. The aim of this study was to assess the benefit of diagnostic laparoscopy for staging patients with esophageal, gastroesophageal junction, and hepatopancreatobiliary tumors.

STUDY DESIGN

Between June 1992 and December 1996, 420 patients with a resectable tumor after conventional staging underwent diagnostic laparoscopy combined with laparoscopic ultrasonography. Histologic proof of metastases or ingrowth was used to cancel laparotomy.

RESULTS

Laparoscopic staging avoided laparotomy in 20% of patients (sensitivity 0.70): 5% with an esophageal tumor, 20% with a gastroesophageal junction tumor, 15% with a periampullary tumor, 40% with a proximal bile duct tumor, 35% with a liver tumor, and 40% with a pancreatic body or tail tumor. Complications and port-site metastases were seen in 4% and 2% of patients, respectively.

CONCLUSIONS

Laparoscopic staging is a safe procedure with low morbidity and without mortality in this series. It has shown no benefit in esophageal cancer, but seems beneficial for staging tumors located at the gastroesophageal junction, proximal bile duct tumors, liver tumors, and pancreatic body and tail tumors. The value of laparoscopic staging for patients with periampullary tumors is not as great as stated in previous studies and is still the subject of investigation.

Laparoscopic ultrasonography for abdominal tumor staging

In recent years, laparoscopic ultrasonography has been introduced as an adjunct to diagnostic laparoscopy for staging of tumors of the upper gastrointestinal tract, liver, biliary tree, and pancreas. It has proved feasible to visualize most anatomic structures in the upper abdomen consistently and in detail with laparoscopic ultrasonography. Recent publications indicate that laparoscopic ultrasonography may be useful for detecting small liver metastases, lymph node metastases, small primary tumors of the pancreas and bile ducts, and for the assessment of the local extension of tumors of the pancreas and stomach. The ongoing improvements in US technology and the results of larger studies will in the near future determine the precise place of this new imaging modality for staging of abdominal tumors.

Laparoscopic ultrasonography of abdominal lymph nodes: correlation with pathologic findings

The value of laparoscopic ultrasonographic criteria for distinguishing benign from malignant lymph nodes was assessed. The following criteria were evaluated in 41 lymph nodes: (1) long axis diameter, (2) short axis diameter, (3) long axis-short axis ratio, (4) nodal border delineation, (5) presence of hyperechoic hilar reflection, (6) echogenicity, and (7) inhomogeneity. Pathologic examination showed malignant infiltration in 11 lymph nodes and the absence of malignant infiltration in 30 lymph nodes. The presence of a hyperechoic center or a long axis-short axis ratio more than 2 suggested the absence of malignant infiltration, whereas inhomogeneity was suggestive of malignant infiltration. The other criteria did not seem useful in distinguishing benign from malignant lymph nodes.

The efficacy of laparoscopic staging in patients with upper gastrointestinal tumors

BACKGROUND

The major advantage of diagnostic laparoscopy for patients with a gastrointestinal tumor is the prevention of unnecessary explorative laparotomies. However, it is doubtful whether this procedure also prevents late laparotomies that are necessary for palliative treatment during follow-up.

METHODS

From January 1992 to July 1995, 233 consecutive patients with gastrointestinal malignancies underwent laparoscopy and laparoscopic ultrasonography after routine diagnostic procedures had shown potential curative disease.

RESULTS

After diagnostic laparoscopy, laparotomy was not performed in 21% of all patients (47 of 226) because of histologically proven, unresectable, mainly metastatic disease; 6% had esophageal tumors (4 of 64 patients), 43% had liver tumors (10 of 23), 43% had proximal bile duct tumors (9 of 21), 15% had periampullary tumors (17 of 111), and 43% had pancreatic body and tail tumors (3 of 7). Nonoperative palliation was successful in all patients. However, late laparotomies were necessary in 7 of these 47 patients (15%): 5 patients with periampullary tumors and 2 patients with proximal bile duct tumors. All 7 patients underwent a surgical bypass, most due to duodenal obstruction, 1 to 13 months after diagnostic laparoscopy.

CONCLUSIONS

In this study, diagnostic laparoscopy may have prevented unnecessary laparotomies for exploration or palliation in 18% of all patients (40 of 226). The procedure is of doubtful benefit for patients with esophageal tumors because the current findings show that only 6% of explorative laparotomies could be prevented. In patients with periampullary tumors, the initial benefit was 15%, but the risk of a late laparotomy is relatively high (30%).

Laparoscopic ultrasonography for abdominal tumor staging: technical aspects and imaging findings

Since 1992 diagnostic laparoscopy combined with laparoscopic ultrasonography has been performed in our center in more than 300 patients for staging of tumors of the liver, bile ducts, pancreas, esophagus, and gastric cardia. In this article our experience with laparoscopic ultrasonography for abdominal tumor staging is described, with particular attention for the technical aspects, imaging findings, limitations, and pitfalls.

Value of laparoscopic ultrasonography in staging of proximal bile duct tumors

The additional value of laparoscopic ultrasonography was evaluated prospectively in 35 patients undergoing diagnostic laparoscopy for a suspected potentially resectable proximal bile duct tumor. Findings were compared with transabdominal ultrasonography, laparoscopy, surgery, and pathology. Laparoscopic ultrasonography was able to visualize the presence and origin of small bile duct tumors or stones and small liver metastases, which could not be seen or could be visualized only doubtfully by ultrasonography and laparoscopy. Laparoscopic ultrasonography was more useful in staging of small tumors of the gallbladder or proximal common bile duct than in staging bifurcation (Klatskin) tumors. Additional information provided by laparoscopic ultrasonography led to a change in diagnosis or tumor stage in eight patients (23%) and to avoidance of laparotomy in three patients (9%).

Comparison of laparoscopic and transabdominal ultrasonography in staging of cancer of the pancreatic head region

The value of laparoscopic ultrasonography in the staging of cancer of the pancreatic head region was compared prospectively to that of transabdominal ultrasonography. Eighty patients underwent LUS, after ultrasonography had shown normal Doppler findings of portal vessels and no signs of metastatic disease. Presence of hepatic or lymph node metastases and vascular tumor infiltration were evaluated in 74 and 48 patients, respectively. Laparoscopic ultrasonography showed liver metastases in 10 patients (14%). Specificity and positive predictive value for the laparoscopic technique determining vascular ingrowth were 97% and 92%, respectively, versus 89% and 77% by sonography in patients with normal Doppler findings (difference not statistically significant). Laparoscopic ultrasonography has shown improved detection of hepatic metastases compared to sonography, but it still must prove its value, as compared to noninvasive methods, in local staging.

Laparoscopy and laparoscopic ultrasonography in staging of carcinoma of the esophagus and gastric cardia

BACKGROUND

The objective of this prospective study was to assess the contribution of laparoscopy combined with laparoscopic ultrasonography (LLU) in the preoperative staging of patients with carcinoma of the esophagus and cardia.

STUDY DESIGN

Preoperative LLU was performed in 56 patients who were selected for curative resection of carcinoma of the esophagus (n = 38) or gastric cardia with involvement of the distal esophagus (n = 18) after routine preoperative workup. During LLU, the peritoneal cavity was scrutinized for metastatic disease, and ultrasonography of the liver and celiac axis was performed. In all patients without histologically proven metastases, laparotomy was then performed.

RESULTS

The morbidity rate of the procedure was 3.5 percent (two superficial wound infections). In three (5 percent) of the 56 patients, laparotomy was excluded by the presence of intra-abdominal metastases. In three other patients, laparotomy was necessary to confirm the suspected hepatic or peritoneal metastases, or both, because histologic proof was not obtained at laparoscopy. In one patient, LLU failed to detect a small hepatic metastasis in segment VII. The preoperative stage was altered by laparoscopy in nine (17 percent) patients (M1 in six, T4 in three). Laparotomy was avoided in two (11 percent) and the preoperative stage changed in seven patients (41 percent), all of whom had carcinoma of the gastric cardia, as occurred in one (3 percent) and two (6 percent) patients with middle and distal carcinoma of the esophagus, respectively.

CONCLUSIONS

Preoperative staging by LLU is of little value in patients with carcinoma of the middle and lower esophagus. The probable role of LLU in the staging of patients with carcinomas of the gastric cardia remains to be confirmed in larger series.

Diagnostic laparoscopy combined with laparoscopic ultrasonography in staging of cancer of the pancreatic head region

The aim of this study was to assess the additional role of diagnostic laparoscopy combined with laparoscopic ultrasonography in the staging of patients with pancreatic head malignancy. Between January 1993 and June 1994, 73 patients with stage I cancer of the pancreatic head determined by preoperative investigation (endoscopic retrograde cholangiopancreatography and Doppler ultrasonography) were eligible for laparoscopic ultrasonography. The peritoneal cavity was investigated for peritoneal deposits, intrahepatic metastases, malignant infiltration of the portal and superior mesenteric vessels, and N3 lymph node metastases. All patients without histologically proven metastases proceeded to laparotomy. Seventy patients were eligible for evaluation. Sixteen of the 21 patients with distant metastases were diagnosed by laparoscopy with ultrasonography. Forty-nine patients had surgical exploration and trial dissection to assess local resectability. Twenty-nine patients (41 per cent) had resectable pancreatic head tumours. The positive predictive value of local ingrowth as determined by laparoscopic sonography was 93 per cent. Laparotomy was avoided in 19 per cent of patients and the preoperative stage was changed in 41 per cent. Laparoscopy including ultrasonography was effective in staging pancreatic head malignancy.

Colorectal carcinoma: preoperative TNM classification with endosonography

Transcolorectal endosonography (TES) with use of both a nonoptic instrument and an echocolonoscope was performed in 91 patients with colorectal carcinomas (61 rectal and 30 colonic). Correlation of results at TES with results of histologic analysis of resected specimens according to the 1987 TNM classification demonstrated that TES allowed accurate staging of all tumors except T2 carcinomas, which were often accompanied by peritumoral inflammation or abscesses. Overall, the accuracy of staging rectal and colonic carcinomas with TES was 81% and 93%, respectively; overstaging occurred in 13% and understaging in 2%. For regional lymph nodes, the accuracy of staging with TES was 70%, the sensitivity was 94%, and the specificity was 55%. Correlations between findings at TES and the Dukes classification were as follows: for rectal carcinoma, 48% for class A, 50% for class B, and 96% for class C; for colonic carcinoma, 67% for class A, 46% for class B, and 91% for class C. Overall accuracy was 67%. With the addition of abdominal computed tomographic or ultrasonographic examinations to evaluate distant metastases, TES should become an important imaging technique for clinical TNM staging of colorectal carcinomas.