Laparoscopic intra-operative ultrasound in liver and pancreas resection: Analysis of 93 cases

INTRODUCTION

Laparoscopic inspection before pancreatic and liver surgery is a widely accepted approach and has changed the surgical strategy in a growing number of patients for the last 10 years. The addition of intra-operative ultrasound to laparoscopy has further refined surgical judgments. The aim of this study was to evaluate the impact of open (IOUS) or laparoscopic (LIOUS) ultrasound in patients undergoing hepatic or pancreatic resection for benign or malignant lesions.

MATERIALS AND METHODS

In the years 2005-2008, 45 patients (aged 42-75 years) were selected for liver resection, and 48 others (aged 14-72 years) were selected for partial pancreatic resection. Intra-operative ultrasound was performed for surgical staging. An Aloka SSD-5500 scanner (Aloka, Tokyo, Japan) was used with a flexible laparoscopic multifrequency linear and an electronic T-shaped linear probe.

RESULTS

LIOUS prevented useless laparotomies in six patients (13.3%) with liver tumors and, coupled with IOUS, revealed previously undetected tumors that required a change in the surgical strategy in 5 others (11.1%). In patients with pancreatic disease, LIOUS excluded the possibility of radical surgery in 7 patients (14.4%) due to the presence of mesenteric vein infiltration, involvement of the celiac or para-aortic nodes, or the presence of liver or peritoneal micro-metastases. In 11 patients with benign lesions, it defined the lesions' relation to the Wirsung duct and splenic vessels, and in 6 others it provided guidance for aspiration of fluid for chemical and cytologic analysis.

CONCLUSIONS

LIUOS and IOUS can play fundamental roles in selecting patients for resective surgery and in planning the surgical approach. They provided information that affected surgical strategies in 11 patients with liver disease (24.4%) and 13 with pancreas disease (27%).

High resolution ultrasound for pre-operative detection of intraperitoneal adhesions: An invaluable diagnostic tool for the general and laparoscopic surgeon

INTRODUCTION

The possibility of predicting the presence of intra-abdominal adhesions in post-surgical patients undergoing further laparotomy or laparoscopy is of great interest for the general and laparoscopic surgeon. Inadvertent enterotomy during re-laparotomy or trocar insertion is a feared complication with a significant associated morbidity and mortality occurring in 20% in open surgery and between 1% and 100% in laparoscopy.

MATERIALS AND METHODS

Sonographic study of the visceral slide (i.e. the "back and forth" movement of the peritoneal layer in rhythm with respiration in relation to the steady inner fascial layer) was the hallmark for free access to the peritoneal cavity. In 60 consecutive patients, aged 28-77, who had previously undergone open abdominal surgery, pre-operative ultrasound (US) was performed on Aloka 5.500 device (Aloka, Tokyo, Japan) using convex and linear multifrequency probes.

RESULTS

The possibility of safely performing trans-umbilical open laparoscopy (TUOL) was US evaluated in 35 (58.3%) patients scheduled for various abdominal laparoscopic procedures. This approach was successfully performed in 26 patients (74.3%). In 2 (5.7%) it was attempted but had to be changed due to the presence of previously undetected adhesions. In 7 patients (20%) pneumoperitoneum was induced by means of a Veress needle positioned in the upper left quadrant due to the presence of midline adhesions, which were confirmed after trocar insertion. Among the remaining 25 patients who underwent re-laparotomy (41.6%), incision was performed outside the midline in 8 patients (32%) due to the presence of suspected midline adhesions, which were confirmed in 6 patients (24%).

CONCLUSIONS

In this study, pre-operative US evaluation showed a diagnostic accuracy of 93.3%.

Randomized trial of 8-week versus 12-week VNCOP-B plus G-CSF regimens as front-line treatment in elderly aggressive non-Hodgkin's lymphoma patients

BACKGROUND

Among the third-generation chemotherapy regimens specifically adapted in the last decade for elderly aggressive non-Hodgkin's lymphoma (NHL) patients, we designed an 8-week cyclophosphamide, mitoxantrone, vincristine, etoposide, bleomycin and prednisone (VNCOP-B) plus granulocyte colony-stimulating factor (G-CSF) regimen which, in a national multicenter trial, induced good complete response (CR) and relapse-free survival rates with only moderate toxic effects. Here we report a prospective, multicenter, randomized trial comparing the efficacy and toxicity of 8- and 12-week regimens of VNCOP-B plus G-CSF.

PATIENTS AND METHODS

From February 1996 to June 2001, 306 consecutive previously untreated stage II-IV aggressive NHL patients > or =60 years of age were enrolled from 12 Italian cooperative institutions. Of the 297 evaluable patients, 149 and 148 received 8- and 12-week regimens, respectively, of VNCOP-B.

RESULTS

The CR rates were 63% and 56% in the 8- and 12-week groups; at a median of 32 months (range 3-62 months), relapse-free survival rates were 59% and 55%, respectively. Hematological and non-hematological toxicities were similar in both treatment groups.

CONCLUSIONS

Our data show that extending induction treatment with the VNCOP-B plus G-CSF regimen from 8 to 12 weeks does not raise the CR rate or provide a more durable remission.

Randomized trial of fludarabine versus fludarabine and idarubicin as frontline treatment in patients with indolent or mantle-cell lymphoma

PURPOSE

A first comparative trial of fludarabine (FLU) alone versus FLU plus idarubicin (FLU-ID) for indolent or mantle-cell lymphomas.

PATIENTS AND METHODS

From September 1995 to July 1998, 199 patients aged 25 to 65 years (median, 54 years) with newly diagnosed stages II to IV indolent or mantle-cell lymphomas (standard risk according to the International Prognostic Index) were enrolled onto a multicenter, 1:1 randomized study. Of the 199 patients who were able to be assessed, 101 were assigned to the FLU group (six monthly cycles of FLU 25 mg/m(2)/d on days 1 through 5) and 98 to the FLU-ID group (six monthly cycles of FLU 25 mg/m(2)/d on days 1 through 3 and idarubicin 12 mg/m(2) on day 1).

RESULTS

In the FLU group, complete response (CR) and partial response rates were 47% and 37%, respectively, whereas in the FLU-ID group, they were 39% and 42%, respectively. In-depth analysis of the CR rate with respect to histologic type showed that FLU seemed to be superior to FLU-ID in treating follicular lymphomas (60% v 40%, respectively), whereas FLU-ID seemed to be more effective than FLU in treating nonfollicular lymphomas (small lymphocytic, 43% v 29%, respectively; immunocytoma, 38% v 23%, respectively; P = not significant), excluding the mantle-cell subset (in which there was no difference between the two groups). No striking differences were observed between the two protocols in terms of overall response or toxicity, which was generally mild. However, with a median follow-up of 19 months, only 29 patients (62%) who received FLU alone have maintained their initial CR, compared with 32 (84%) of those who received FLU-ID therapy (P =.021).

CONCLUSION

Although the FLU-ID regimen may not significantly improve the induction of CR in most indolent-lymphoma patients, our preliminary data do suggest that, with respect to FLU alone, it may be capable of conferring a longer-lasting CR and that it might be superior in terms of CR rate in small lymphocytic and immunocytoma subtypes.

Present results of the treatment of myelodysplastic syndromes with low-dose cytosine arabinoside. Preliminary results of a cooperative protocol (38 patients) and review of the literature

In vitro differentiating agents causing little bone marrow aplasia have been proposed as a specific therapy of myelodysplastic syndromes with excess of blasts. A critical review of the published data is presented. The preliminary results of a cooperative protocol using very low dosage of cytosine arabinoside (3mg/m2/twice daily) with or without androgens are given.

A study of the mechanisms and sites of action of desferrioxamine in thalassaemia major

The effects of slow subcutaneous (s.c.) infusions of desferrioxamine (Desferal: DF) on iron metabolism and excretion were studied in 6 thalassaemia major patients in the course of a ferrokinetic study with 59Fe as a label; s.c. DF infusions were performed every 4th day starting 4 days after that of the 59Fe injection. Serum iron and total iron binding capacity (TIBC) increased after s.c. infusion, whereas serum ferritin levels remained unchanged. 59Fe urinary specific activity decreased in all subjects from the first to subsequent infusions, whereas faecal specific activity remained almost constant throughout the experiment. These data support the hypothesis that iron reaching RE cells concentrates initially in a readily chelatable pool from which then it moves to a larger and not readily chelatable pool, whereas iron reaching parenchymal hepatic cells remains permanently available to chelant.

Chronic idiopathic thrombocytopenic purpura (ITP): site of platelet sequestration and results of splenectomy. A study of 197 patients

51Cr-platelet kinetics study was performed in 197 patients with chronic ITP after corticosteroid therapy had failed to induce a long lasting remission. The incidence of splenic, spleno-hepatic, hepatic and diffuse platelet sequestration site was 58%, 17%, 6% and 19%, respectively. Splenic and spleno-hepatic sequestration sites were more frequent in patients less than 30 years old and in patients with a platelet count lower than 50 x 10(9)/1. 111 patients were splenectomized shortly after the study. Normalization of the platelet count was obtained more frequently in patients with splenic and spleno-hepatic sequestration than in the others. Labelled platelet sequestration site was the best predictor of the outcome of splenectomy. Platelet kinetics is a non-invasive investigation that should be performed early after the diagnosis of chronic ITP in all patients eligible for splenectomy.

Acute non lymphoid leukaemia following Hodgkin's disease. Clinical, biological and cytogenetic aspects of 3 cases

In a groups of 254 patients treated for Hodgkin's disease with a follow up period of minimum 2 years, 3 cases of acute non lymphoid leukaemia (ANLL) were observed: erythroleukaemia, myelomonocytic and myeloblastic leukaemia, respectively. The crude incidence of leukaemia in all patients was 0.0128 and patient year risk was estimated to be 0.003652. All 3 patients had received radiation therapy and chemotherapy. In all cases of haemopoietic dysplasia preceded ANLL. Bone marrow chromosome investigations showed an abnormal karyotype in all patients: chromosomal changes were present in 100% of cells and revealed a non-random distribution, the most frequent involvement being clustered to chromosomes nos 11, 17 and 21. Hypodiploidy was prevalent and multiple structural rearrangements, such as markers, rings and minutes, were present in a high percentage of cells. Other changes involved chromosomes nos 5, 7 and 14. Our results are compared with other previously reported cases and possible pathogenetic implications are discussed.

'GPI Roma', a new glucose phosphate isomerase deficient variant: in vivo occurrence of postsynthetic modifications of the mutant enzyme

In a 5-year-old Italian girl with severe congenital hemolytic anemia, red cell GPI deficiency was proven, and found to be due to a new variant, 'GPI Roma.' The parents are first cousins and have been proven to be heterozygous for this variant. GPI Roma was slightly unstable to heat and exhibited a slightly increased Michaelis constant for fructose-6-phosphate. A single predominant fast-migrating GPI form existed in the patient's white blood cells, while the electrophoretic pattern in the red cells was composed, in addition to this 'fast band,' of a major band migrating as normal GPI and of an additional slow band. It is shown that this phenomenon may be ascribed to postsynthetic events modifying the charge of the mutant enzyme.