Comparison between CT volumetry, technetium99m galactosyl-serum-albumin scintigraphy, and gadoxetic-acid-enhanced MRI to estimate the liver fibrosis stage in preoperative patients

OBJECTIVES

To compare the efficacy of computed tomography volumetry (CTV), technetium99m galactosyl-serum-albumin (99mTc-GSA) scintigraphy, and gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic-acid-enhanced MRI (EOB-MRI) in estimating the liver fibrosis (LF) stage in patients undergoing liver resection.

METHODS

This retrospective study included 91 consecutive patients who had undergone preoperative dynamic CT and 99mTc-GSA scintigraphy. EOB-MRI was performed in 76 patients. CTV was used to measure the total liver volume (TLV), spleen volume (SV), normalised to the body surface area (BSA), and liver-to-spleen volume ratio (TLV/SV). 99mTc-GSA scintigraphy provided LHL15, HH15, and GSA indices. The liver-to-spleen ratio (LSR) was calculated in the hepatobiliary phase of EOB-MRI. Hyaluronic acid and type 4 collagen levels were measured in 65 patients. Logistic regression and receiver operating characteristic (ROC) analyses were performed to identify useful parameters for estimating the LF stage and laboratory data.

RESULTS

According to the multivariable logistic regression analysis, SV/BSA (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.003-1.02; p = 0.011), LSR (OR, 0.06; 95%CI, 0.004-0.70; p = 0.026), and hyaluronic acid (OR, 1.01; 95%CI, 1.001-1.02; p = 0.024) were independent variables for severe LF (F3-4). Combined SV/BSA, LSR, and hyaluronic acid correctly estimated severe LF, with an AUC of 0.91, which was significantly larger than the AUCs of the GSA index (AUC = 0.84), SV/BSA (AUC = 0.83), or LSR (AUC = 0.75) alone.

CONCLUSIONS

Combined CTV, EOB-MRI, and hyaluronic acid analyses improved the estimation accuracy of severe LF compared to CTV, EOB-MRI, or 99mTc-GSA scintigraphy individually.

CLINICAL RELEVANCE STATEMENT

The combined analysis of spleen volume on CT volumetry, liver-to-spleen ratio on gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic-acid-enhanced MRI, and hyaluronic acid can identify severe liver fibrosis associated with a high risk of liver failure after hepatectomy and recurrence in patients with hepatocellular carcinoma.

KEY POINTS

• Spleen volume of CT volumetry normalised to the body surface area, liver-to-spleen ratio of EOB-MRI, and hyaluronic acid were independent variables for liver fibrosis. • CT volumetry and EOB-MRI enable the detection of severe liver fibrosis, which may correlate with post-hepatectomy liver failure and complications. • Combined CT volumetry, gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic-acid-enhanced MRI (EOB-MRI), and hyaluronic acid analyses improved the estimation of severe liver fibrosis compared to technetium99m galactosyl-serum-albumin scintigraphy.

A proposed model on MR elastography for predicting postoperative major complications in patients with hepatocellular carcinoma

Objective

To develop a model for predicting post-operative major complications in patients with hepatocellular carcinoma (HCC).

Methods

In all, 186 consecutive patients with pre-operative MR elastography were included. Complications were categorised using Clavien‒Dindo classification, with major complications defined as ≥Grade 3. Liver-stiffness measurement (LSM) values were measured on elastogram. The indocyanine green clearance rate of liver remnant (ICG-Krem) was based on the results of CT volumetry, intraoperative data, and ICG-K value. For an easy application to the prediction model, the continuous variables were converted to categories. Moreover, logistic regression analysis and fivefold cross-validation were performed. The prediction model's discriminative performance was evaluated using the area under the receiver operating characteristic curve (AUC), and the calibration of the model was assessed by the Hosmer‒Lemeshow test.

Results

43 of 186 patients (23.1%) had major complications. The multivariate analysis demonstrated that LSM, albumin-bilirubin (ALBI) score, intraoperative blood loss, and ICG-Krem were significantly associated with major complications. The median AUC of the five validation subsets was 0.878. The Hosmer-Lemeshow test confirmed no evidence of inadequate fit (p = 0.13, 0.19, 0.59, 0.59, and 0.73) on the fivefold cross-validation. The prediction model for major complications was as follows: -2.876 + 2.912 [LSM (>5.3 kPa)]+1.538 [ALBI score (>-2.28)]+0.531 [Intraoperative blood loss (>860 ml)]+0.257 [ICG-Krem (<0.10)].

Conclusion

The proposed prediction model can be used to predict post-operative major complications in patients with HCC.

Advances in knowledge

The proposed prediction model can be used in routine clinical practice to identify post-operative major complications in patients with HCC and to strategise appropriate treatments of HCC.

Pharmacokinetic mass of fentanyl for postoperative analgesia in lean and obese patients † †Presented in abstract form at the Annual Meeting of the American Society of Anesthesiologists, Las Vegas, October 26, 2004

BACKGROUND

We previously proposed dosing weights for fentanyl, termed 'pharmacokinetic mass', that span the total body weight (TBW) range from 40 to 210 kg. In this study, we examined the relationships among fentanyl doses needed to achieve postoperative analgesia, corresponding plasma fentanyl concentrations, and pharmacokinetic mass in lean and obese patients undergoing abdominal surgery.

METHODS

A total of 69 patients were studied, with TBW ranging from 48 to 181 kg. Fentanyl infusion was used during surgery. After surgery, fentanyl infusion rates were titrated to achieve analgesia without significant respiratory depression. Plasma fentanyl concentrations were measured when an apparent steady analgesic state was obtained. Comparisons were made for dosing requirements and effective plasma concentrations for 37 lean patients (body mass index < 30, TBW < 85 kg) and 33 obese patients (body mass index > 30, TBW > or = 85 kg).

RESULTS

The average fentanyl dose (microg h(-1)) required to achieve and maintain analgesia over the 4 h postoperative period had a non-linear relationship to TBW; in comparison, fentanyl dose had a strong linear relationship to pharmacokinetic mass: dose (microg h(-1)) = 1.22 x pharmacokinetic mass - 7.5; r = 0.741, P < 0.001. Based on results from our earlier study, the corresponding values of TBW and pharmacokinetic mass are: 52 kg--52 kg; 70 kg--65 kg; 100 kg--83 kg; 120 kg--93 kg; 140 kg--99 kg; 160 kg--104 kg; 180 kg--107 kg; 200 kg--109 kg. In the group comparisons, there was no statistically significant difference in the postoperative fentanyl dose per unit of pharmacokinetic mass between lean and obese patients. The plasma concentration of fentanyl required for analgesia was approximately 1.5 ng ml(-1), and was similar in the two groups.

CONCLUSION

The relationship between dose and pharmacokinetic mass, compared with that of dose vs TBW, may provide confidence for the use of pharmacokinetic mass as a dosing approximation for fentanyl. Fentanyl dose based on TBW may cause overdosing in obese patients.

Bilateral Jejuno-mesenteric flap for reconstruction of complicated pharyngoesophageal defect

The surgical management of an infectious and fistulous wound with a pharyngoesophageal tumor is one of the greatest challenges for head and neck and plastic surgeons. The free jejunal transfer has been the standard technique for pharyngoesophageal reconstruction, and the free omental flap has been one of the most reliable methods for reconstructing contaminated wounds. A jejuno-mesenteric flap is suitable for such complicated wounds. Pharyngoesophageal defects are reconstructed by the jejunum, and contaminated and heavily irradiated neck wounds are covered with the mesenteric flaps connected with a revascularized jejunum. The technique described here possesses the advantages of both a free jejunal flap and an omentum flap. Therefore, it is a reliable method for reconstructing the pharyngoesophageal defects of complicated wounds.

[A questionnaire survey of the panel discussion at the annual meeting of the Japan Society of Anesthesiologists]

Two hundred questionnaire sheets were distributed to the audience of the panel discussion session titled "Progresses of balanced anesthesia" at the annual meeting of the Japan Society of Anesthesiologists. The audience was requested to rate their interest to the program and also rate the usefulness of the presentations by each panel. One hundred and seventeen questionnaire sheets (58%) were returned. Eighty five % of the returned survey expressed interests in the program. Forty three % expressed their interests in altering their anesthesia techniques along the line of the recommendation by the panels. These data suggest that the program met the educational need of the audience. Questionnaire survey may be useful in identifying the need of the members, and thus helpful in planning future meetings of the society.

A possible immunosuppressant, cycloprodigiosin hydrochloride, obtained from Pseudoalteromonas denitrificans

Cycloprodigiosin hydrochloride (cPrG.HCl), a member of the prodigiosin family, is a red pigment obtained from the marine bacterium Pseudoalteromonas denitrificans. cPrG.HCl markedly suppressed 3H-thymidine incorporation by concanavalin A stimulated murine splenocytes but had little effect on lipopolysaccharide dependent 3H-thymidine incorporation, indicating that cPrG.HCl acts as a selective inhibitor of T cell proliferation in the same way as other members of the prodigiosin family. cPrG.HCl inhibited the proliferation of the PMA stimulated Jurkat cells through an apoptotic process. Intriguingly, cPrG.HCl inhibited the H+ translocation by vacuolar type ATPase in chromaffin granule membranes without any effect on either its ATPase activity nor on the membrane conductance of phospholipid bilayers, suggesting that cPrG.HCl selectively uncouples H+ translocation from the ATPase reaction rather than acting as a non-specific ionophore. Since crystalline cPrG.HCl is highly stable, it raises the possibility of its therapeutic use as an immunosuppressant.

Do changes in end-tidal PCO2 quantitatively reflect changes in cardiac output?

In anesthetized patients, acute decreases in cardiac output (CO) are often reflected as decreases in end-tidal CO2 tension (PETCO2), but the quantitative relationship between the changes in CO and the changes in PETCO2 is uncertain. We hypothesize that a quantitative relationship can be demonstrated if timing of the measurements in each episode of hemodynamic perturbation is standardized. In 24 patients undergoing abdominal aortic aneurysm surgery with constant ventilation, we prospectively performed 33 measurements of CO, PETCO2, and CO2 elimination (VECO2) within 10 min of hemodynamic changes. The percent decrease in PETCO2 directly correlated with the percent decrease in CO (slope = 0.33, r2 = 0.82). Also, the percent decrease in VECO2 correlated with the percent decrease in CO similarly (slope = 0.28, r2 = 0.84). The changes in PETCO2 and VECO2 following hemodynamic perturbation were parallel. This finding suggests that decreases in PETCO2 quantitatively reflect the decreases in CO2 elimination.

Effects of fentanyl-diazepam-pancuronium anesthesia on heart rate variability: a spectral analysis

The effects of induction of anesthesia with fentanyl, 62.1 +/- 7.9 micrograms/kg, diazepam, 0.21 +/- 0.08 mg/kg, and pancuronium on beat-to-beat heart rate variations were studied in seven patients undergoing cardiac surgery. Spectral analysis was used to determine the intensity of the variations in each of the two main frequency bands in which variations are known to occur: (1) high-frequency band, mediated by the parasympathetic nervous system, at the frequency band of respiration, and (2) the low-frequency band, mediated by both sympathetic and parasympathetic nervous systems, at 0.04-0.12 Hz. Both the mean low- and high-frequency band areas were significantly decreased after induction of anesthesia. The ratio of high-to-low frequency band areas increased significantly after induction of anesthesia, from 45% to 62% (P less than 0.05). These results suggest that fentanyl-diazepam-pancuronium anesthesia decreases total autonomic nervous system activity and alters the balance between parasympathetic and sympathetic activities. Thus, spectral analysis of heart rate variations during anesthesia may provide a quantitative measure of assessing the activity of the autonomic nervous system.

[A case with hepatocellular carcinoma effectively treated by continuous hepatic arterial infusion of etoposide, epirubicin and CDDP]

A 53-year-old man who suffered from advanced hepatocellular carcinoma (HCC) was treated with hepatic arterial infusion (HAI) of Etoposide, Epirubicin and CDDP. Treatment consisted of a continuous HAI of Epirubicin (50 mg/body, day 1.7), CDDP (75 mg/body, day 2.8) and Etoposide (80 mg/body, day 4-6). He had two series of infusions and was treated by transarterial embolization using CDDP powder (100 mg) added to lipiodol and aluminum stearate as suspension following HAI. The tumor regression rate was about 60% after HAI, but the remaining tumor seemed to be almost necrotic. AFP and PIVKA-II reached the normal range after TAE. We could not find lipiodol accumulated in tumor on CT carried out eight weeks after TAE. No recurrence has been noticed in the following 8 months. Toxicity was not so severe and was well tolerated.

Chondrosarcoma of the parapharyngeal space

Chondrosarcoma is rarely found arising in the head and neck region. An unusual case arising in the parapharyngeal space in a male is reported and the differential diagnosis, pathology and treatment are discussed.

The changes in brain surface, intracerebral tissue, and transconjunctival oxygen tension during hypo- and hyperventilation

To evaluate the validity of organ surface oxygen tension monitoring for assessment of cerebral perfusion, the oxygen tension in brain surface (Pbs(O)(2)), intracerebral tissue (Pic(O)(2)), and conjunctiva (Pcj(O)(2)) were measured simultaneously during hypo- and hyperventilation in dogs, and the comparative study was done. Pbs(O)(2) and Pic(O)(2) significantly increased during hypoventilation and decreased during hyperventilation. And the values of Pbs(O)(2) and Pic(O)(2) were correlated to the corresponding Pa(CO)(2) values significantly ( P << 0.001 in each case). On the contrary, Pcj(O)(2) did not change significantly during hypo- and hyperventilation. These findings indicate that Pbs(O)(2) as well as Pic(O)(2) could reflect the changes in cerebral perfusion caused by induced hyper- and hypocapnia but that Pcj(O)(2) could not.

[Dentist's understanding on dental anesthesiology--on the basis of a questionnaire on post-graduation study]

We set out a questionnaire for 400 participants of the seminar, to investigate the thoughts of dental practitioners and dentists on duty with regard to the post-graduation study and training in particular, to dental anesthesiology. The results obtained were as follows. 1. Almost all of the dental practitioners felt necessary to receive the post-graduation study and training to brush up their techniques. 2. The dental practitioners felt defective in actual techniques prepared by post-graduation trainings now under way, and they desired a particular training in an actual technique specific to an emergency therapy. 3. Seminars for re-education they desired to attend were those related to anesthesia in majority, followed by prosthetics, maintenance and periodontosis, orthodontics, and surgery, implantodontics, and pedodontics. 4. Major curriculums of anesthesiology they desired to receive were systemic management, resuscitation, how to apply the first-aid medicine, and treatment for shock states. The number of those participants who desired to receive these curriculums was help or above of all members, followed by those in dental psychosomatic disease, treatment for senile patients and acupuncture anesthesia. 5. It was unexpected that those who had been aware of the concept of authorized dental anesthesiologist were confined to 54% of the participants. This led us to consider that clinical dentist should be re-educated regarding the system for authorized anesthesiologist. 6. Major participants answered nothing with regard to the advocated curriculums we questioned, so that it was postulated that none felt unsatisfactory of the advocated curriculums at present.

[Judgement on students' exercise for resuscitation using a manikin for CPCR exercise (1st report)]

We performed the training for resuscitation using dental students and used a manikin for CPCR Exercise before and after the training to investigate the result obtained. The results were as follows. 1. Although cases in which too much or too little ventilation in amount was judged showed no significant changes before and after the training, those judged too much in ventilation amounted to approx. 1/5 and those judged too little were approx. 1/2 of the total subjects. This suggests that it is preferable to instruct the students to maintain sufficient ventilation when allowing them to exercise artificial breathing of CPCR. But the instruction is somewhat difficult to take because inhibition of gastric distention should be taken into account. 2. Although no changes were shown before and after the training by cases judged too deep in the depth of thoracic oppression, the number of those cases amounted to approx. 4/5 of the total subjects. Cases judged too shallow in depth of thoracic oppression, on the other hand, were significantly decreased from approx. 4/5 before training to approx. 2/3 after training, suggesting that improvement of the shallow oppression initially made is easy rather than to improve the oppression unduly deepened. Accordingly, it appears effective for students to avoid undue oppression when they are trained. 3. Thoracic oppression at a correct position was increased significantly to approx. 1/5 of the total cases, although most of the subjects were in error to choose a correct position for thoracic oppression before training.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical level of oxygen delivery after cardiopulmonary bypass

The relationship between oxygen uptake (Vo2) and delivery (Do2) was examined in 64 patients immediately after cardiopulmonary bypass. In 44 patients with lactate levels below 2.5 mmol/L, Vo2 decreased proportionally when Do2 decreased below 300 ml/min X m2. At a Do2 over this level, Vo2 plateaued at 105 +/- 13 (SD) ml/min X m2. In a contrasting group of 22 patients with blood lactate levels above 2.5 mmol/L, Vo2 changes depended on changes in Do2 both alone and below 300 ml/min X m2.

Effects of intermittent positive-pressure ventilation on cardiac output measurements by thermodilution

Sequential thermodilution measurements of cardiac output in mechanically ventilated patients undergoing cardiac surgery demonstrated a cyclic modulation which correlated with changes in airway pressure, and was not affected by opening the pericardium. There was no satisfactory point for single measurements, which suggests that random thermodilution measurements of cardiac output during intermittent positive-pressure ventilation should be avoided, even when triplicate measurements are performed. To estimate the mean cardiac output, at least two measurements should be made at predetermined points of the ventilatory cycle. We recommend paired measurements at midinspiration and end-expiration.

Critical level of oxygen delivery in anesthetized man

Fifty-eight patients studied were anesthetized with diazepam, pancuronium, and a moderate dose of fentanyl; 99 sets of multiple hemodynamic variables were measured after sternotomy and before cardiopulmonary bypass. The relationship between oxygen consumption (VO2) and oxygen delivery (DO2) was studied. The critical value of DO2 was identified to be 330 ml/min X M2 or 8.2 ml/min X kg by an analysis of the regression lines. When DO2 was less than 330 ml/min X M2, the value of VO2 decreased in proportion to a decrease in DO2 and VO2 was expressed as: VO2 = 0.36 X DO2 - 11.20 (n = 30, r = 0.77, p less than 10(-6). At DO2 greater than 330 ml/min X M2, VO2 values plateaued at 109 +/- 16 (SD): n = 69; r = -0.02, p greater than 0.05; while mixed venous oxygen tension (PVO2) decreased in proportion to the decrease in DO2, suggesting compensatory increase of oxygen extraction. A decrease of VO2 at DO2 less than 330 ml/min X M2 suggests tissue oxygen deprivation occurred.

Hemodynamic and respiratory changes in surgery of the morbidly obese

The risk of surgery for the morbidly obese is well known. Suprisingly little information is available regarding the hemodynamic changes during surgery. This study provides data on this important subject and compares them with those of normal nonobese patients. Obese patients demonstrated signifying elevated preoperative, intraoperative, and postoperative right atrial, mean pulmonary artery, and pulmonary artery wedge pressures. Preoperatively, hemodynamic variables were in the high range of normal in obese patients. Significantly greater decreases in cardiac index, right ventricular stroke work (RVSW), and left ventricular stroke work (LVSW) were noticed intraoperatively. Although the RVSW returned to baseline values in the postoperative period, the cardiac index and LVSW remained depressed. Left ventricular function as assessed by Sarnoff curves demonstrated persistent shifts to the right during and after operation. No such shifts were noticed in nonobese patients. Although they were hemodynamically stable and without any other clinical evidence of cardiac abnormality, asymptomatic obese patients had reduced left ventricular contractility (LVSW/pulmonary artery wedge [PAW] pressure ratio) even in the resting state. Obese patients reacted to the stress of surgery and anesthesia by a more specific left ventricular dysfunction that was greater after intubation and in the immediate postoperative period.

Postoperative ventilatory failure in an obese, myopathic woman with periodic somnolence: A case report

An obese woman with periodic sommolence developed postoperative ventilatory problems following an uncomplicated cholecystectomy. A severe myopathic process involving the respiratory muscles was found at necropsy. A brother, who died a week later, had myotonic dystrophy.