[Real-time contrast-enhanced ultrasound in the evaluation of focal liver lesions: diagnostic efficacy and economical issues from a French multicentric study]

The recent introduction of high-end ultrasound equipment combined with recent contrast agents provides marked improvements in the characterization of focal liver lesions as previously reported by monocentric studies. The aim of the present study was to evaluate the diagnostic performance of Contrast-Enhanced Ultrasonography (CEUS) using SonoVue as well as its medico-economic value for characterization of focal liver lesions. These nodules were not characterized on previous CT or conventional sonography. This prospective multicentric study conducted in 15 French centres found diagnostic performances similar to those reported for CT and MRI, with a concordance rate of 84.5%, sensitivity greater than 80% and specificity greater than 90% for all types of lesions. Higher acceptance was found for CEUS compared to other imaging modalities. Economical assessment based on examination reimbursment and contrast agent cost showed a lower cost for contrast ultrasound versus CT and MRI. This French multicentric study confirmed the high diagnostic value of CEUS for focal liver lesion characterization and demonstrated a lower economical impact compared to other imaging modalities such as CT and MRI.

Ultrasound detection of visceral adhesion after intraperitoneal ventral hernia treatment: a comparative study of protected versus unprotected meshes

Intraperitoneal (IP) ventral hernia repair has been proposed with the advantages of reducing dissection, operative time, and postoperative pain. The IP position of the mesh is suspected of increasing the risk of visceral adhesion and inducing complications. To overcome these drawbacks, a mesh protected on one side by a hydrophilic resorbable film (Parietex Composite) has been validated. Using a previously described ultrasound procedure, the purpose of this study was to compare the rate of visceral adhesion after intraperitoneal placement of a polyester mesh versus this protected mesh. Fifty-one patients who received a Parietex Composite mesh were prospectively compared to a retrospective series of 22 consecutive asymptomatic patients who received a Mersilene mesh. To objectively assess visceral adhesion toward the abdominal wall, an ultrasound (US) specific examination was firstly validated and secondly used to evaluate the adhesion incidence in both groups. Both groups were equivalent in terms of inclusion criteria and body mass index (BMI). Pre-operative US versus perioperative macroscopical findings determined the following parameters: sensitivity 83%, accuracy 78%, negative predictive value 81%. Using this procedure, 77% of the patients exhibited visceral adhesion to the mesh in the Mersilene group, against 18% in the Parietex Composite group (P<0.001, chi-square). US examination represents a suitable tool to evaluate postoperative adhesions to the abdominal wall. Using this procedure, a significant reduction of visceral adhesion in the Parietex Composite group was shown.

Transient Versus Two-Dimensional Shear-Wave Elastography in a Multistep Strategy to Detect Advanced Fibrosis in NAFLD

BACKGROUND AND AIMS

The combination of laboratory and elastography tests allows the accurate diagnosis of advanced liver fibrosis in patients with NAFLD. In this study, we compared the diagnostic performances of a two-step strategy (laboratory tests and vibration-controlled transient elastography [VCTE] or two-dimensional shear-wave elastography with SuperSonic Imagine [2D-SWE-SSI]) and the added value of a three-step strategy (laboratory tests and two elastography methods).

APPROACH AND RESULTS

From a prospective registry, we retrospectively selected 577 consecutive patients with suspicion of NAFLD who underwent laboratory tests to calculate the Fibrosis-4 (FIB-4) score, liver stiffness evaluation by VCTE (M and XL probes) and 2D-SWE-SSI, and liver biopsy. The diagnostic performances and need for liver biopsy in unclassified patients for the diagnosis of advanced fibrosis (F ≥ 3) in multistep strategies were compared. The area under the curve of FIB-4, VCTE, and 2D-SWE-SSI was 0.74, 0.82, and 0.88, respectively. Using the same thresholds, the FIB-4/2D-SWE-SSI and FIB-4/VCTE diagnostic performances were comparable (sensitivity, 71.4% and 66%; specificity, 91.4% and 91.5%; and accuracy, 83.7% and 81.4%; all P = not significant). Conversely, more patients required liver biopsy after 2D-SWE-SSI (24.6% versus 15.3%, P < 0.001). Performing a second elastography technique in patients with unreliable or gray zone (between 8 and 10 kPa) results greatly decreased the need for liver biopsy (42/577, 7.3%). The diagnostic performances (accuracy, sensitivity, and specificity) of FIB-4/2D-SWE-SSI/VCTE and FIB-4/VCTE/2D-SWE-SSI were comparable (81.1%, 71.5%, and 87.9% versus 81.3%, 69.7%, and 89.5%, respectively; all P = not significant).

CONCLUSIONS

Using the same cutoff values, 2D-SWE-SSI is as accurate as VCTE for advanced liver fibrosis diagnosis in NAFLD. The three-step strategy in selected patients strongly decreased the need for liver biopsy while maintaining excellent accuracy.

Permeability and functionality of pancreaticogastrostomy after pancreaticoduodenectomy with dynamic magnetic resonance pancreatography after secretin stimulation

BACKGROUND

The aim of this study was to evaluate pancreatogastrostomy (PG) permeability after duodenopancreatectomy (PD) and to determine a correlation with pancreatic endocrine and exocrine functions.

STUDY DESIGN

This prospective study included 19 patients who underwent PD with PG between 1992 and 1999. There were 12 men and 7 women, with a mean age of 58 years (range 35 to 76 years). The mean interval between operation and evaluation was 40.3 months (range 3 to 104 months). Indications for pancreatectomy were benign lesions (n = 13) or adenocarcinoma (n = 6). Histology of the pancreatic resection margin was normal in all patients with malignancy, and the pancreatic remnant was macroscopically normal without evidence of obstructive pancreatitis. Pancreatic exocrine and endocrine functions were respectively evaluated by fecal-1 elastase and fasting blood glucose concentrations. PG permeability was determined by secretin magnetic resonance cholangiopancreatography (Secretin-MRCP).

RESULTS

Anastomotic permeability was considered good in seven patients (group 1, 36.8%), moderately stenosed in six patients (group 2, 31.6%), significantly stenosed in four patients (group 3, 21.1%), and obstructed in two patients (group 4, 10.5%). Fecal-1 elastase concentration was decreased in 18 patients, with a mean concentration of 80 microg/g in group 1, 98 microg/g in group 2, 67 microg/g in group 3, and 0 microg/g in group 4. There was a statistically significant correlation between Secretin-MRCP group and fecal-1 elastase concentration. Results of fasting glucose estimation were normal for 14 of 19 patients. There was no correlation between pancreatic endocrine function and Secretin-MRCP group.

CONCLUSIONS

Exocrine pancreatic insufficiency was presented in 95% of the patients despite a PG permeability in 68.4%. These results may be explained in part by neutralization of pancreatic enzymatic secretions by gastric acid.

Predictive factors of splanchnic vein thrombosis in acute pancreatitis: A 6-year single-center experience

OBJECTIVE

Splanchnic vein thrombosis (SVT) is a potentially severe complication of pancreatitis. The aim of this single-center, retrospective cohort study was to investigate the incidence of SVT and to determine the connected risk factors.

METHODS

All consecutive patients with acute pancreatitis (AP) managed in our hospital were included. The primary outcome was the occurrence of SVT and data was collected in accordance with Ranson's criteria.

RESULTS

A total of 318 patients were included, of whom 124 (39.0%) were women. Biliary lithiasis was the main cause of pancreatitis (n = 156, 49.1%). A total of 19 (6.0%) SVT were identified. In univariate analysis, alcohol intake, smoking and male gender were associated with SVT (P = 0.005, 0.003 and 0.007, respectively). Biological parameters significantly associated with thrombosis were lactate dehydrogenase (LDH) < 500 U/L and hyperglycemia (≥ 10 mmol/L) (P = 0.009 and 0.016, respectively). In multivariate analysis, prothrombin time >75% was a protective factor against thrombosis (OR 0.148, P = 0.019). Leukocytes >10 × 10(9)/L (OR 6.397, P = 0.034), hyperglycemia (≥ 10 mmol/L) (OR 6.845, P = 0.023), LDH < 500 U/L ((OR 22.61, P = 0.001) and alcoholic etiology (OR 8.960, P = 0.041) were risk factors for SVT.

CONCLUSIONS

Alcohol intake, male gender and smoking should focus the physician's attention on the risk of SVT. When further associated with certain biological parameters, the physicians should consider therapeutic anticoagulation to prevent SVT.

Effect of carbon and nitrogen nutrition on growth and sporulation of Trichoderma viride Pers. ex Fries

Three isolates of Trichoderma viride Pers. ex Fries were grown in liquid cultures. The isolates grew best on media containing glucose, sucrose, cellobiose, and mannitol.Asparagine and ammonium nitrate proved to be the best sources of nitrogen for the three isolates although isolate 1503 did not show any significant preferences for the five sources of nitrogen. The amounts of carbon and nitrogen in the basal medium significantly influenced the growth of the three isolates. However, the addition of asparagine alone did not produce a better growth than in the control. There is no correlation between sporulation and dry weight of culture, the amounts of carbon in the medium, and C/N ratio. Implications of the findings are briefly discussed.

Intraoperative Contrast-Enhanced Ultrasound in Colorectal Liver Metastasis Surgery Improves the Identification and Characterization of Nodules

INTRODUCTION

The sensitivity of preoperative assessment of colorectal liver metastases (CRLM) ranges from 74 to 80%. Intraoperative ultrasound (IOUS) associated with contrast-enhanced intraoperative ultrasound (CE-IOUS) may be able to improve this. Thus, the aims of this study were to assess the value of IOUS and CE-IOUS for the surgical approach and to determine risk factors both for the detection of new nodules and for the modification of the surgical strategy.

MATERIALS AND METHODS

Forty-three patients who underwent CRLM surgery were included. These patients had an MRI in the 8 weeks preceding surgery and benefited from intraoperative IOUS and CE-IOUS.

RESULTS AND DISCUSSION

The use of IOUS/CE-IOUS permitted the identification of 43 additional lesions and an improved characterization of nodules in 23 patients with a resulting modification of surgical strategy. Lesions were down-staged in six patients and up-staged in six patients. Chemotherapy (p = 0.02) and the presence of nodules in the left lobe (p = 0.04) were predictive factors for finding new nodules at IOUS/CE-IOUS. The discovery of a new nodule systematically modified surgical management. IOUS/CE-IOUS improved intraoperative management of liver metastases. The techniques enable pertinent modification of surgical resections and a reduction of residual lesions.

[Percutaneous cholecystostomy for acute cholecystitis in high-risk patients]

AIM OF THE STUDY

The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia.

PATIENTS AND METHODS

From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases.

RESULTS

Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without).

CONCLUSION

Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Use of half-dose gadolinium-enhanced MRI and magnetization transfer saturation in brain tumors

The aim of this study was to search if half-dose gadolinium (Gd)-enhanced MR imaging with magnetization transfer saturation (MT) can replace standard-dose T1-weighted spin echo (SE) without MT saturation in brain tumors. Thirty patients with a total of 33 brain tumors (14 gliomas, 13 meningiomas, 6 metastases) were prospectively studied using T1-weighted SE half-dose of Gd with MT, and T1-weighted SE standard-dose Gd without MT. The contrast-to-noise ratio (CNR) of the two sequences was calculated and four radiologists reviewed qualitatively the images of the two sequences. There was no significant difference between both techniques for quantitative analysis (Wilcoxon test). However, there was a good agreement between sequences to evidence an intraclass correlation coefficient (r = 0.70) of all lesions. In cases of meningioma, the agreement was better (r = 0.84). The results show a difference in the qualitative data between the two sequences, suggesting the use of the T1-weighted MR images with MT and half-dose of Gd with good results in the whole tested parameters except the lesional edema and the presence of artifacts. Half-dose T1-weighted SE with MT can replace standard-dose T1-weighted SE without MT with no loss of contrast enhancement in investigation of meningiomas and saving 50% of the contrast material.

Arterial supply of the duodenal bulb: an anatomoclinical study

An anatomic and radio-anatomic study of 15 specimens enabled us to reconsider the arterial vascularization of the duodenal bulb and to propose a new classification based on anatomoclinical criteria. The two arterial pedicles (infra- and supraduodenal) reach the bulb on its posterior aspect; each pedicle is made up of two sorts of blood currents (right and left); the posterior aspect of the bulb seems to be the most vascularized one, explaining, apart from bleeding from gastroduodenal a. erosion, the hemorrhagic character of ulcers of the posterior aspect of the bulb. The predominance of the left-hand currents explains the possible ischemia of the duodenal bulb and/or rupture of the duodenal stump after their interruption.

Cancer of the gallbladder associated with pancreaticobiliary maljunction without bile duct dilatation in a european patient

A rare case of pancreaticobiliary maljunction (PBM) without dilatation of the biliary tract (DBT) associated with gallbladder carcinoma is described herein. A 62-year-old European woman with a long history of right upper abdominal pain was diagnosed as having PBM without DBT by endoscopic retrograde cholangiopancreatography and other examinations. Excision of the gallbladder and biliary duct with a Roux-en-Y hepaticojejunostomy was performed, and subsequent pathological examination of the surgical specimen showed a well differentiated adenocarcinoma of the gallbladder. She had no clinical symptoms for 58 months postoperatively. PBM allows reflux of pancreatic juice into the biliary tract. Recent findings support the idea that epithelial hyperplasia plays an important role in gallbladder carcinogenesis with PBM, and also support the concept that gene mutations are involved in the carcinogenesis of biliary epithelium in patients with PBM. For these reasons, we advocate that resection of the extrahepatic biliary tract in PBM patients without bile duct dilatation, rather than cholecystectomy alone, is the treatment of choice for preventing bile duct carcinoma.

Criteria to Determine Reliability of Noninvasive Assessment of Liver Fibrosis With Virtual Touch Quantification

BACKGROUND & AIMS

Virtual Touch Quantification (VTQ) evaluates liver fibrosis in patients with chronic liver diseases by measuring shear wave speed in the liver. We aimed to determine the reliability criteria of VTQ examination.

METHODS

We performed a prospective study of 1094 patients with chronic liver disease from November 2009 through October 2016 at Angers University Hospital, and between April 2010 and May 2015 at Bordeaux University Hospital, in France. All patients underwent liver biopsy analysis (reference standard), and VTQ examination was made by experienced operators on the same day, or no more than 3 months before or afterward. Advanced liver fibrosis was defined as fibrosis stage F ≥ 3 according to the scoring system of the Nonalcoholic Steatohepatitis Clinical Research Network, or fibrosis stage F ≥ 2 according to the Metavir scoring system. The diagnostic accuracy of VTQ in detection of advanced fibrosis or cirrhosis was assessed using the area under the receiver operating characteristic (AUROC) and the rate of correctly classified patients. Reliability criteria were defined from the intrinsic characteristics of VTQ examination, which were shown to influence the diagnostic accuracy.

RESULTS

VTQ identified patients with advanced fibrosis with an AUROC of 0.773 ± 0.014 and correctly classified 72.0% of patients using a diagnostic cut-off value of 1.37 m/s. VTQ identified patients with cirrhosis with an AUROC value of 0.839 ± 0.014 and correctly classified 78.4% of patients using a cut-off value of 1.87 m/s. The reliability of VTQ decreased with an increasing ratio of interquartile range/median (IQR/M) in patients with intermediate-high VTQ results. We defined 3 reliability categories for VTQ: unreliable (IQR/M ≥0.35 with VTQ result ≥1.37 m/s), reliable (IQR/M ≥0.35 with VTQ result <1.37 m/s or IQR/M 0.15-0.34), and very reliable (IQR/M <0.15). For advanced fibrosis, VTQ correctly classified 57.8% of patients in the unreliable group, 73.7% of patients in the reliable group, and 80.9% of patients in the very reliable group (P < .001); for cirrhosis, these values were 50.0%, 83.4%, and 92.6%, respectively (P < .001). Of the VTQ examinations made, 21.4% were unreliable, 55.0% were reliable, and 23.6% were very reliable. The skin-liver capsule distance was independently associated with an unreliable VTQ examination, which occurred in 52.7% of patients with a distance of 30 mm or more.

CONCLUSIONS

In a study to determine the reliability of VTQ findings, compared with results from biopsy analysis, we assigned VTQ examinations to 3 categories (unreliable, reliable, and very reliable). VTQ examinations with IQR/M ≥0.35 and ≥1.37 m/s had very low diagnostic accuracy. Our reliability criteria for liver fibrosis assessment with VTQ will help physicians to accurately evaluate the severity of chronic liver diseases and monitor their progression.

Radiofrequency thermal ablation of liver carcinoma

OBJECTIVES

The aim of this prospective study was to evaluate the feasibility of radiofrequency ablation of hepatic tumors. We studied the rates of mortality, morbidity, and recurrence and recorded overall and disease-free survival.

METHODS

All patients aged over 18 years with histologically proven malignant liver disease inaccessible to surgical treatment (one to four tumor localizations) were eligible for inclusion in the study. Child-Pugh score > B9, platelets count <or=50.103/mm3, prothrombin index <or=50% and pregnancy were exclusion factors.

RESULTS

Between July 2001 and June 2004, 51 patients (13 women, 38 men, mean age 66 +/- 9 years) were included and underwent 61 radiofrequency thermal ablation procedures for 82 hepatic lesions: hepatocarcinoma (N=44), cholangiocarcinoma (N=1), metastasic tumors (N=37). Hospital morbidity and mortality were 11.5% and 2% respectively. Recurrence rate at 3 years was 20.6%. In multivariate analysis, only tumor size > 3 cm was correlated significantly with recurrence (P=0.03). Actuarial 1-, 2- and 3-year survival rates in the hepatocarcinoma group (N=31) were 84.7%, 57.7% and 34.6% respectively. Actuarial 1-, 2- and 3-year survival rates in the metastasis from colorectal adenocarcinoma group (N=14) were 90%, 54% and 54% respectively (P=0.72).

CONCLUSION

Radiofrequency thermal ablation is an effective treatment for hepatic tumors measuring less than 3 cm. There is a low risk of complications and open surgery can be associated. However in the absence of randomized studies comparing radiofrequency and surgery, respective indications cannot be defined in detail.

Embolisation de varices stomiales par injection percutanée de colle biologique

In patients with cirrhosis and enterostomy, although bleeding stomal varices are rare, they can been severe and difficult to be treat. We report the first two cases of bleeding stomal varices treated by cyanoacrylate embolization, in patients with cirrhosis and colostomy. In each case, after pharmacological treatment of portal hypertension (propranolol) failed, embolization of the stomal varices by transdermal injection of biological glue effectively stopped the bleeding, without recurrence or side effects, after 8 and 16 months of follow-up. The embolization of stomal varices by biological glue is a safe, easy and efficient treatment for bleeding stomal varices.

[Nuclear magnetic resonance cholangiography in biliary disease. Prospective study in 60 patients]

PURPOSE

The aim of this prospective study was to evaluate a new MR cholangiography sequence, with thick slices, single shot fast spin echo (SSFSE) in biliary obstructive diseases.

PATIENTS AND METHODS

This study included 60 patients (36 males and 24 females, mean age: 69 years) with cholestatic syndrome and suspected bile duct obstruction. All patients were prospectively investigated with MR cholangiography using SSFSE sequence with thick slices. The gold standard was ERCP (n = 47), per cutaneous cholangiography (n = 1), and surgical intervention (n = 12). According to this gold standard, 22 patients had obstructive gallstones, 23 had neoplastic obstruction, eight had inflammatory or postoperative stenosis and 7 had normal bile ducts.

RESULTS

The sensitivity and specificity of MR cholangiography were 100 and 94% in the diagnosis of obstructive gallstones, and 95 and 97% in the diagnosis of neoplastic obstruction, respectively. A good agreement was observed between MR cholangiography and the gold standard, regardless of the site of obstruction (range of kappa value: 0.79-1).

CONCLUSION

MR cholangiography with SSFSE sequence is an effective and easy technique. Acquisition of thick slices in a very short time (< 2 sec) limits cardiorespiratory artefacts and eliminates the need for post-processing.

Aspects IRM de l’encéphalopathie anoxo-ischémique du nouveau-né à terme et du prémature

These past few years have seen an increasing role of MRI in the investigation of neonatal cerebral anoxic-ischemic pathology. This is due not only to greater precision in diagnosing lesion extension, but also to earlier detection of lesions with the diffusion of weighted imagery. The aim of this iconographic review is to illustrate the main MRI aspects of anoxic-ischemic encephalopathy in a pedagogical way. After a brief physiopathology reminder, the different cerebral lesions are studied in a first chapter on the premature newborn pathology and a second chapter on full-term newborn pathology.

Pancreatic arteriovenous malformation associated with duodenal ulcer and H. pylori infection

Pancreatic arteriovenous malformation (PAVM) is a rare condition that may cause duodenal ulcer. A 36-yr-old man with PAVM associated with duodenal ulcer and H. Pylori infection is described. The patient had recurrent episode of upper abdominal pain despite healed ulcer and H. Pylori eradication. The preoperative diagnosis was confirmed by computed tomography and the patient was treated with a pancreatoduodenectomy. Histological examination of the resected pancreas revealed a pancreatic arteriovenous malformation involving the adjacent duodenal wall.