Management of gallbladder dyskinesia: patient outcomes following positive ⁹⁹mtechnetium (Tc)-labelled hepatic iminodiacetic acid (HIDA) scintigraphy with cholecystokinin (CCK) provocation and laparoscopic cholecystectomy

AIMS

To evaluate clinical outcomes in patients with typical biliary pain, normal ultrasonic findings, and a positive (99m)technetium (Tc)-labelled hepatic iminodiacetic acid analogue (HIDA) scintigraphy with cholecystokinin (CCK) provocation indicating gallbladder dyskinesia, as per Rome III criteria, undergoing laparoscopic cholecystectomy (LC).

METHODS AND MATERIALS

Consecutive patients undergoing LC for gallbladder dyskinesia were identified retrospectively. They were followed up by telephone interview and review of the electronic case records to assess symptom resolution.

RESULTS

One hundred consecutive patients (median age 44; 80% female) with abnormal gallbladder ejection fraction (GB-EF <35%) were followed up for a median of 12 months (range 2-80 months). Following LC, 84% reported symptomatic improvement and 52% had no residual pain. Twelve percent had persisting preoperative-type pain of either unchanged or worsening severity. Neither pathological features of chronic cholecystitis (87% of 92 incidences when histology available) nor reproduction of pain on CCK injection were significantly predictive of symptom outcome or pain relief post-LC.

CONCLUSION

In one of the largest outcome series of gallbladder dyskinesia patients in the UK with a positive provocation HIDA scintigraphy examination and LC, the present study shows that the test is a useful functional diagnostic tool in the management of patients with typical biliary pain and normal ultrasound, with favourable outcomes following surgery.

Impact of margin status and neoadjuvant chemotherapy on survival, recurrence after liver resection for colorectal liver metastasis

BACKGROUND

This study was designed to determine the impact of positive margin and neoadjuvant chemotherapy (NAC) on recurrence and survival after resection of colorectal liver metastasis (CRLM).

METHODS

Prospective analysis of 1,255 patients undergoing resection of CLRM was undertaken. The impact of NAC, site of recurrence, and survival between R0 and R1 groups was analysed.

RESULTS

The R0 and R1 resection rates were 68.9 % (n = 865) and 31.1 % (390). The median OS for R0 group was 2.7 years (95 % CI 2.56-2.85) and R1 group 2.28 years (CI 2.06-2.52; P < 0.001). The median DFS for R0 group was 1.52 years (CI 1.38-1.66) and R1 group 1.04 years (CI 0.94-1.19; P < 0.001). The intrahepatic recurrence was higher in R1 group 132 (33.8 %) versus 142 (16.4 %) [P = 0.0001]. A total of 103 (11.9 %) patients in R0 group underwent redo liver resection for recurrence compared with 66 (16.9 %) patients in R1 group (P = 0.016). NAC did not impact recurrence rate (57.8 % vs. 61.5 %, P = 0.187) and redo liver surgery between R0 and R1 groups (13 % vs. 17 %, P = 0.092). Within the R1 group, the intrahepatic recurrence rates were similar with and without NAC (33.9 % vs. 33.7 %, P = 0.669). However, DFS was longer in the no chemotherapy group than the chemotherapy group.

CONCLUSIONS

R1 resections increase the likelihood of recurrence in the liver and redo liver surgery. NAC does not seem to improve survival in margin positive patients or have an impact on recurrence or reduce need for redo liver surgery for recurrence. In patients with R1 resection, neoadjuvant chemotherapy may have adverse outcome on disease free survival.

The risk of gallbladder cancer from polyps in a large multiethnic series

BACKGROUND

The aim of this study is assess whether patients with Indian ethnic background are at an increased risk of developing gallbladder cancer (GBC) if they have been diagnosed with ultrasonic abnormalities of the gallbladder.

METHODS

Between January 1998 and July 2006, 137,655 abdominal ultrasound examinations were performed in Leeds Teaching Hospitals NHS Trust. After the exclusion of repeat scans and those performed for renal or pelvic disease, 71,431 reports were included in this analysis. Patients in whom the diagnosis of GBC has been made without histology have been identified from the database of Northern and Yorkshire Cancer Registry and the presence of GBC was correlated with ultrasonic gallbladder abnormalities.

RESULTS

Gallbladder polyps (GBP) were detected in 3.3% of patients and these were larger than 10 mm in 0.1% of the cases. Age above 60 years, Indian ethnic background, single GBP larger than 10mm, the presence of gallstones, severe gallbladder wall thickening and irregular thickening were independently associated with the higher odds of developing GBC. The prevalence of malignancy in those with GBP was significantly higher among patients with Indian ethnic background compared to Caucasian patients, 5.5% versus 0.08%, p<0.001.

CONCLUSIONS

The presence of GBP, irrelevant of size, amongst patients of Indian ethnic decent, is an indication for further investigation and/or cholecystectomy.

Cyclooxygenase-2 expression in colorectal cancer liver metastases

Cyclooxygenase-2 (COX-2) is up-regulated in 85-90% of primary human colorectal cancers and is a putative target for the chemopreventative activity of non-steroidal anti-inflammatory drugs. However, COX-2 expression by human colorectal cancer liver metastases has been poorly characterized. We studied a consecutive series of 38 patients who underwent liver resection for metastatic disease, for whom long-term (up to 57 months), prospective follow-up data were available. Semi-quantitative immunohistochemistry for COX-2 was performed on 54 metastases from 35 patients, for whom adequate histological material was available. Diffuse cytoplasmic staining for COX-2 protein was detected in cancer cells in 100% of metastases (COX-2 score 1, n = 25; score 2, n = 29). There was no relationship between metastasis size or differentiation grade and the level of COX-2 protein expression. There was no difference in colorectal cancer-free or overall survival between patients with high (score 2) and low (score 1) COX-2 scores (Kaplan-Meier survival analysis and log rank test, both P = 0.97). Multivariate Cox regression analysis identified age, incomplete resection and presence of extra-hepatic disease as independent predictors of disease-free and overall survival following surgery. COX-2 protein was also localized to a subset of stromal fibroblasts and mononuclear cells within metastases as well as hepatocytes from resection specimens. COX-2 protein was expressed by cancer cells in all human colorectal cancer liver metastases which were studied. Investigation of the effect of selective COX-2 inhibition on metastasis growth and metastasis cancer cell proliferation/apoptosis in vivo are warranted.

Laser Doppler flowmetry is useful in the clinical management of small bowel transplantation. The Liver Transplant Group

OBJECTIVE

Laser Doppler flowmetry (LDF) has been used as a research tool to measure splanchnic perfusion. In this report, we aim to demonstrate the clinical value of this technique in perioperative monitoring of transplanted small bowel.

METHODS

A 24 year old man underwent small bowel transplantation using a previously described technique. Microvascular blood flow in the transplanted bowel was measured using an LDF splanchnic probe. Postoperatively this was applied to the stoma facilitating direct measurements of graft mucosal flow. Measurements (perfusion units (PU)) were documented prior to implantation, post-reperfusion, postoperatively, during graft ischaemia, and in response to therapeutic interventions (dopexamine and phenylephrine infusions).

RESULTS

Prior to transplantation, biological zero was established. Flow at five, 15, and 60 minutes after reperfusion was 74 (1.9) PU, 87.5 (3.3) PU, and 141.5 (2.5) PU, respectively. Postoperative mucosal flow was 141.6 (2.9) PU. Subsequent LDF measurement detected absence of flow even though clinical signs suggested only moderate reduction. This was confirmed on surgical re-exploration and facilitated prompt resection of a non-viable segment. Fluid and dopexamine administration resulted in a dose dependent improvement in flow, independent of blood pressure. Addition of phenylephrine increased total mucosal flow and unmasked a cyclical component.

CONCLUSION

This case demonstrates the clinical value of LDF as an "alarm" to indicate graft perfusion failure and as a monitor for therapeutic interventions. Phenylephrine and dopexamine may both be of value in improving mucosal flow in the transplanted small bowel.

Biliary strictures complicating pancreaticoduodenectomy

BACKGROUND

Biliary-enteric anastomotic strictures may complicate pancreaticoduodenectomy. Anastomotic ischaemia and reflux of gastric and enteric contents with secondary bacterobilia and cholangitis may contribute.

METHODS

Four patients (3 females, 1 male) with a mean age of 50 yr (range 26-73 yr) presented 1-12 yr following pancreaticoduodenectomy with features suggestive of biliary-enteric anastomotic stricture formation. These included recurrent cholangitis, obstructive jaundice, and liver abscess. Diagnosis was confirmed by percutaneous or endoscopic cholangiography. Endoscopic and radiological management were unsuccessful, and revision surgery in the form of a Roux-en-Y hepaticojejunostomy was required.

RESULTS

Three patients remain asymptomatic 10-30 mo postoperatively. Jaundice recurred at 15 mo in one patient owing to re-stricture formation and the development of secondary biliary cirrhosis; a liver transplantation is being considered.

CONCLUSION

Early diagnosis and prompt management of biliary-enteric stricture is essential if secondary biliary cirrhosis is to be avoided. Definitive therapy is best accomplished with a Roux-en-Y hepaticojejunostomy that places the gastric and biliary anastomoses onto separate jejunal limbs.

Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases

OBJECTIVE

To describe the surgical techniques and early results of inferior vena cava (IVC) resection in patients with advanced liver tumors.

SUMMARY BACKGROUND DATA

Involvement of the IVC by hepatic tumors, although rare, is considered inoperable by standard resection techniques. Concomitant hepatic and IVC resection is required to achieve adequate tumor clearance.

METHODS

Between February 1995 and February 1999, 158 patients underwent hepatic resection for colorectal metastases in the authors' unit. Eight patients, aged 42 to 80 years (mean 62 years), with hepatic metastases from colorectal cancer underwent concomitant resection of the IVC and four to six hepatic segments. Resections were carried out under total hepatic vascular exclusion in four patients and ex vivo in four patients. Between 30 degrees and 360 degrees of the retrohepatic IVC was resected and replaced with an autogenous vein patch (n = 1), a ringed Gore-Tex tube graft (n = 2), a Dacron tube graft (n = 1), or a patch (n = 3) or was repaired by primary suturing (n = 1).

RESULTS

There were two early deaths from multiple organ failure. One patient survived 30 months after ex vivo resection but died of renal cell carcinoma, and another died with recurrent disease at 9 months. The remaining four patients remained alive 5 to 12 months after surgery, with no hepatic failure or venous obstruction; tumor recurrence was present in two. Nonthrombotic occlusion of the neocava occurred in one patient and was stented successfully.

CONCLUSIONS

Although concomitant hepatic and IVC resection is associated with a considerable surgical risk, this aggressive surgical approach offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis. This procedure can be performed under total hepatic vascular exclusion, with or without venovenous bypass, and by ex vivo bench resection.

Hepatic lesion detection after superparamagnetic iron oxide enhancement: comparison of five T2-weighted sequences at 1.0 T by using alternative-free response receiver operating characteristic analysis

PURPOSE

To compare the accuracy of five T2-weighted sequences in the detection of liver lesion at magnetic resonance (MR) imaging after superparamagnetic iron oxide (SPIO) enhancement.

MATERIALS AND METHODS

Forty-nine candidates for hepatic resection with known coloretal metastases were examined. Before SPIO enhancement, fast spin-echo (SE) images were obtained. After enhancement, the same fast SE sequence and long; TR/short TE, short TE, long TR/TE, and T2-weighted fast low-angle shot (FLASH) sequences were used. All images were viewed independently by four observers who were blinded to the results of the other imaging sequences, the results of the other observers, and the findings at surgery and histopathologic examination. Four weeks after the initial reading, the combined long TR/short TE and long TR/TE dual-echo images were also viewed as an additional set. The alternative free response receiver operating characteristic (ROC) method was used to analyze the results, which were correlated with findings at surgery, intraoperative ultrasonography, and histopathologic examination.

RESULTS

Irrespective of lesion size, the accuracy of all sequences after enhancement was significantly greater than that of the nonenhanced fast SE sequence (P < .01). Dual-echo and FLASH sequences were significantly more accurate than the enhanced fast SE sequence (P < .03 or P < .02, respectively). For all lesions, lesions smaller than 1 cm, and lesions 1 cm or larger, mean accuracies were as follows: dual-echo, 0.75, 0.54, and 0.93; FLASH, 0.75, 0.54, and 0.95; and enhanced fast SE, 0.72, 0.49, and 0.92.

CONCLUSION

At 1.0 T, dual-echo and FLASH sequences are the most accurate pulse sequences after SPIO enhancement.

p53 but not bcl-2 is expressed by most cholangiocarcinomas: a study of 28 cases

AIMS

To examine the frequency and pattern of expression of p53 and bcl-2 in archival material from patients with cholangiocarcinomas and to evaluate their respective roles in its pathogenesis, diagnosis and prognosis.

METHODS AND RESULTS

Twenty-eight surgical cases of cholangiocarcinomas diagnosed at St James's University Hospital and 16 control cases were immunostained with monoclonal antibodies to p53 and bcl-2 using streptavidin-biotin complex method. Pressure cooker was used for antigen retrieval. Of the cholangiocarcinomas, 85.7% (24/28) overexpressed p53. The intensity of staining in these cases varied from 1+ in 2, 2+ in 10 and 3+ in 12 cases. None of the 28 tumours expressed bcl-2. The well differentiated nature of the tumour made assessment of dysplasia difficult, however, where present it did not express p53 or bcl-2. The bile duct epithelium adjacent to the tumour and in the control cases did not show any significant nuclear staining for either antigen.

CONCLUSIONS

Overexpression of p53 appears to play an important role as a late event in the pathogenesis of cholangiocarcinomas, while we found no evidence of bcl-2 overexpression. The expression of p53 in 86% of the invasive tumours, as compared to its lack in the adjacent normal bile duct epithelium, makes it potentially useful in the diagnostic histopathology of these cases.

Liver transplantation for metastatic hemangiopericytoma associated with hypoglycemia

We report a case of successful liver transplantation in a young man with metastatic hemangiopericytoma confined to the liver. He had a primary retroperitoneal hemangiopericytoma removed in 1982 and was diagnosed as having liver metastases 8 years later. Subsequently, he developed hypoglycemia, which did not respond to chemotherapy. Hepatectomy and transplantation resolved his hypoglycemic attacks. He remained well and symptom free for 4 years. Liver transplantation can provide effective palliation and should be considered in carefully selected patients with localized metastatic cancer.

Effect of rapamycin on renal allograft survival in canine recipients treated with antilymphocyte serum, donor bone marrow, and cyclosporine

Rapamycin (Rapa) monotherapy can promote renal allograft survival in dogs, but it is very toxic. To attempt to augment the effectiveness of Rapa and reduce its toxicity in a tolerance induction protocol, canine renal allograft recipients were treated briefly with antilymphocyte serum (ALS), donor bone marrow cells (BMC), and a limited course of cyclosporine (CsA). Rapa had little effect when CsA-treated recipients were given ALS on days -5 to -1 and BMC on day +1. When combined with CsA given days +13 to +42, ALS on days -5 to +7, and BMC on day +10, Rapa at 0.3 mg/kg on day +8 plus alternate days +15 to +39 significantly increased overall survival and was compatible with long-term survival after immunosuppression (6 grafts, 1 graft > 212 days, 1 graft > 470 days). Rapa appeared to prevent early rejections that can occur during treatment with these ALS/BMC/CsA protocols. Little toxicity of Rapa was observed with any treatment.

Meckel's diverticulum: a continuing dilemma?

Forty-three cases of Meckel's diverticulum (MD) encountered in an academic department of surgery over a 15-year period were reviewed. All of the patients and their general practitioners were contacted and long-term follow-up was obtained in 36 cases (85%). In 21 of 35 diverticulectomies, MD was an incidental finding. An overall complication rate of 26% was recorded over an average follow-up period of 8 years. In the asymptomatic group this rose to 30%. None of the eight cases in whom the diverticulum was not resected has developed early or late complications. Our findings suggest that an incidentally discovered Meckel's diverticulum should be left in situ.

Risk of neoplasia in renal transplant patients

Renal allograft recipients are at an increased risk of neoplasia, although the extent of the problem has not been established in a typical European transplant population. To assess this risk we did a comprehensive, retrospective study of 918 patients transplanted at one centre over 24 years. The centre (Leeds) serves Yorkshire and Humberside, a region in northern England with a population of 3.6 million. The search, which made use of six sources of information, revealed 70 patients (7.6%) who had developed a neoplastic lesion, 10 patients having more than one type. More than half (42) were cutaneous lesions (mostly squamous cell carcinomas). The risk of developing neoplasia in the first 10 years after transplantation was calculated to be 14%. By 20 years this had risen to 40% compared with a 6% cumulative risk of neoplasia in an age-matched control population (p < 0.005). The full extent of this problem in the European transplant population has been underestimated and, now that recipients are surviving longer, there is a clear need for both lifelong surveillance and closer investigation of these patients.