Laparoscopic ultrasound vs triphasic computed tomography for detecting liver tumors

BACKGROUND

Accurate staging of malignant tumors in the liver has major implications in defining prognosis and guiding both surgical and nonsurgical therapy. Intraoperative ultrasound in open surgery compares favorably with computed tomography (CT) in the detection of liver tumors; however, there is little experience with laparoscopic ultrasound (LUS).

HYPOTHESIS

Laparoscopic ultrasound is more sensitive than triphasic CT for detecting primary and metastatic liver tumors.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Fifty-five patients with a total of 222 lesions, including primary and metastatic liver tumors, who underwent both CT examinations and LUS as a part of a tumor ablation procedure.

INTERVENTIONS

Triphasic spiral CT scans of the liver were obtained within 1 week before surgery. Liver LUS was performed with a linear 7.5-MHz side-viewing laparoscopic transducer.

RESULTS

The LUS detected all 201 tumors seen on preoperative CT and detected 21 additional tumors (9.5%) in 11 patients (20.0%). These tumors missed by CT ranged in size from 0.3 to 2.7 cm. Smaller tumors tended to be missed by CT scan (28.6% of the lesions <1 cm, 15.8% of those 1-2 cm, 4% of those 2-3 cm, and 0% of those >3 cm), as did those in segments III and IV. There was good correlation between the size of lesions imaged by the 2 modalities (Pearson r = 0.86; P<.001).

CONCLUSION

Laparoscopic ultrasound offers increased sensitivity over CT for the detection of liver tumors, especially for smaller lesions. This study documents the ability of LUS in detecting liver tumors and argues for more widespread use in laparoscopic staging procedures.

Laparoscopic management of a posterior mediastinal tumor mimicking an adrenal neoplasm

BACKGROUND

Rarely, a posterior mediastinal mass may mimic an adrenal tumor on preoperative computed tomography scan. The intraoperative discovery that a mass thought to be associated with the adrenal gland actually is above the diaphragm in the posteroinferior mediastinum poses a challenge for the laparoscopic surgeon. Conversion to a thoracotomy or to videothoracoscopy incurs additional morbidity and risk for the patient.

MATERIALS AND METHODS

We describe a technique for the transdiaphragmatic removal of a benign mass from the posterior mediastinum. A posterior mediastinal tumor was detected during a laparoscopic procedure for a suspected right adrenal tumor. Frozen section proved benign, and the mass was resected laparoscopically via transdiaphragmatic access to the posterior mediastinum.

RESULTS

No complications were noted during or after surgery. The patient was ready for discharge from the hospital on postoperative day 1.

CONCLUSIONS

Transdiaphragmatic resection was done successfully instead of conversion to a thoracotomy or thoracoscopic procedure for a benign posterior mediastinal tumor found incidentally during laparoscopic surgery for a presumed adrenal lesion. This transdiaphragmatic approach can be applied to selected benign mediastinal masses.

Laparoscopic radiofrequency ablation of primary and metastatic liver tumors. Technical considerations

BACKGROUND

Radiofrequency thermal ablation is a new technology for the local destruction of liver tumors. Since we first described laparoscopic radiofrequency ablation (LRFA) for the treatment of liver tumors, much has been learned about patient selection, laparoscopic ultrasound (LU) guided placement of the ablation catheter, monitoring of the ablation process, and patient follow-up.

METHODS

Since January 1996 we have performed LRFA of 250 tumors in 67 patients including 85 adenocarcinomas, 107 neuroendocrine tumors, 34 sarcomas, 1 melanoma, and 11 hepatomas. We used LU to guide placement of the ablation catheter and to monitor the ablation process. Most of the patients had two trocars (camera and laparoscopic ultrasound) with the 15-gauge ablation catheter (RITA Medical Systems, Mountain View, CA, USA) placed percutaneously.

RESULTS

The LRFA procedure was completed successfully in all patients, with 1 to 14 lesions per patient, ranging in size from 0.5 to 10 cm in diameter. The entire liver could be examined by LU via right subcostal ports. Criteria for successful ablation were 5-min ablation times at 100 degrees C with 1-min cool-down temperatures of 60 degrees to 70 degrees C. Outgassing of dissolved nitrogen, monitored by ultrasound, was useful in confirming the zone of ablation. Intralesional color-flow Doppler, seen before ablation, was eliminated after ablation. Placement of the grounding pad closer to the lesion on the back rather than the thigh resulted in more efficient energy delivery to the tumor. Lesions larger than 3 cm in diameter required overlapping ablations to achieve a 1-cm margin of normal liver. Most patients required overnight hospitalization, with no coagulopathy or electrolyte disturbances noted.

CONCLUSIONS

The LRFA procedure is a novel, minimally invasive technique for treatment of liver tumors that have failed conventional therapy. This study documents the technical aspects of targeting lesions and performing reproducible zones of ablation. Familiarity with these techniques should lead to more widespread application.

Local recurrence after laparoscopic radiofrequency thermal ablation of hepatic tumors

BACKGROUND

Since we first described laparoscopic radiofrequency ablation (LRFA) of liver tumors, several reports have documented technical and safety aspects of this procedure. Little is known, however, about the long-term follow-up of such patients.

METHODS

From January 1996 to February 1999, we performed LRFA on 250 liver tumors in 66 patients. Triphasic spiral computed tomographic scanning was obtained preoperatively and at 1 week, and every 3 months postoperatively. Lesion diameter was measured in the x- and y-axes and the volume estimated; 181 lesions in 43 patients for whom computed tomographic scans available were included in the study. The tumor types were as follows: 64 metastatic adenocarcinomas, 79 neuroendocrine metastases, 27 other metastases, and 11 primary liver tumors.

RESULTS

One week postoperatively, the ablated zone was larger than the original tumor in 178 of 181 lesions, which suggests ablation of the tumor and a margin of normal liver tissue. A progressive decline in lesion size was seen in 156 (88%) of 178 lesions, followed for at least 3 months (mean, 13.9 months; range, 4.9-37.8 months), which suggests resorption of the ablated tissue. Fourteen definite local treatment failures were apparent by increase in size and change in computed tomographic scan appearance, and eight lesions were scored as failures because of multifocal recurrence that encroached on ablated foci (22 total recurrences). Predictors of failure include lack of increased lesion size at 1 week (2 of 3 such lesions failed), adenocarcinoma or sarcoma (18 of 22 failures; P < .05), larger tumors (failures, M = 18 cm3 vs. successes, M = 7 cm3; P < .005) and vascular invasion on laparoscopic ultrasonography. By size criteria, 17 of 22 failures were apparent by 6 months. Energy delivered per gram of tissue was not significantly different (P = .45).

CONCLUSIONS

LRFA has a 12% local failure rate, with larger adenocarcinomas and sarcomas at greatest risk. Failures occur early in follow-up, with most occurring by 6 months. LRFA seems to be a safe and effective treatment technique for patients with primary and metastatic liver malignancies.

Interspecies differences in systemic drug availability following subcutaneous pulsatile administration in cattle, sheep, dogs, and rats

Rats, dogs, sheep, and cattle were implanted subcutaneously with stainless-steel tissue cages. Bolus injections of cefoxitin and ivermectin were administered to the interiors of the tissue cages 11, 32, and 60 days after implantation to simulate pulsatile drug release from an implanted device. Plasma drug levels were determined for 6 h for cefoxitin and up to 8 days for ivermectin. Tissue cages were retrieved 3 and 6 months after implantation for macroscopic and microscopic examination. In dogs and rats, plasma levels of both drugs following administrations to the tissue cages were significantly lower than those following subcutaneous injection, suggesting that the tissue growth around and in the cages posed a barrier to systemic drug availability in those species. In cattle and sheep, the tissue cages and associated tissue did not inhibit systemic availability of either drug as compared with routine subcutaneous administration.

Enhanced bioavailability of cefoxitin using palmitoylcarnitine. II. Use of directly compressed tablet formulations in the rat and dog

The performance of tablets containing the absorption enhancer palmitoylcarnitine chloride (PCC) and the antibiotic cefoxitin (CEF) was determined by direct placement of tablets in the rat stomach, small intestine, and colon. While the bioavailability (F) of tablets containing 12 mg CEF without PCC ranged from 0.6 to 3.9%, the addition of 24 mg PCC resulted in an enhanced CEF bioavailability in the rat colon (mean +/- SD: F = 57 +/- 19%) and rat jejunum (F = 71 +/- 16%) but not in the rat stomach. Following oral administration to dogs, tablets of 200 mg CEF without or with 600 mg PCC resulted in the same low bioavailabilities (7.0 +/- 10.3 and 7.0 +/- 3.6%, respectively). However, when these tablets were enteric coated, PCC improved CEF bioavailability from 2.44 +/- 1.84 to 29.0 +/- 13.4%. Therefore, the use of enteric-coated direct compressed tablets containing PCC and direct compression excipients improved the peroral bioavailability of a poorly absorbed compound.

Long-term effects of gastric surgery for treating respiratory insufficiency of obesity

The Pickwickian syndrome can be divided into two primary breathing disorders, which can affect patients alone or in combination: sleep apnea syndrome (SAS) and obesity hypoventilation syndrome (OHS). Between 1980 and 1990, 126 patients with respiratory insufficiency underwent gastric surgery for morbid obesity, 12.5% of the entire series. These patients weighed more (164 +/- 36 vs 135 +/- 25 kg, P less than 0.0001) and were more often men (62% vs 14%, P less than 0.001) than those without pulmonary dysfunction. Sixteen had OHS alone, 65 had SAS alone, and 45 had both. Of those with OHS, 38 have been followed for 5.8 +/- 2.4 y since surgery and 29 are currently asymptomatic. In the 12 patients in whom arterial blood gases were available greater than 5 y since surgery, the PaO2 increased from 54 +/- 10 to 68 +/- 20 mm Hg (P less than 0.0001) and PaCO2 fell from 53 +/- 9 to 47 +/- 11 mm Hg (P = 0.05). Of the 110 patients with SAS, 57 were available for follow-up an average of 4.5 +/- 2.3 y since surgery and 38 were completely asymptomatic, 15 had mild SAS, and 4 had both SAS and OHS. In 40 patients with pre- and post-weight reduction sleep polysomnograms, the sleep apnea index fell from 64 +/- 39 to 26 +/- 26 (P less than 0.0001). Although respiratory insufficiency of obesity patients had a higher operative mortality than did patients without pulmonary dysfunction (2.4% vs 0.2% after gastric bypass), weight loss was associated with significant improvements in sleep apnea, arterial blood gases, pulmonary hypertension, left ventricular dysfunction, lung volumes, and polycythemia.

The solubility-modulated osmotic pump: in vitro/in vivo release of diltiazem hydrochloride

A generalized method was investigated for conversion of controlled-porosity osmotic pump release profiles from first-order to zero-order kinetics using diltiazem.HCl as a model drug. Diltiazem.HCl has an aqueous solubility greater than 590 mg/ml (37 degrees C) and was released from controlled-porosity osmotic pump devices with first-order kinetics. This high solubility was markedly reduced (155 mg/ml; 37 degrees C) in the presence of NaCl (1 M). Based on theory for osmotically actuated drug release, this reduced solubility would be expected to result in a zero-order release profile of greater than 80% of an initial diltiazem.HCl load. Devices were prepared with cores that contained diltiazem.HCl and sufficient NaCl granules coated with a microporous cellulose acetate butyrate 381-20 film to maintain a 1 M NaCl concentration within the drug compartment over a 16-hr period. This resulted in release of approximately 75% of the initial diltiazem.HCl load with zero-order kinetics over a 14- to 16-hr period. The in vivo performance of these devices in beagle dogs was analyzed. The in vivo percentage diltiazem absorbed profiles were superimposable with the in vitro release profile. These results suggest that diltiazem release and absorption from the solubility modulated osmotic pump occur throughout the GI tract in a fashion predictable from in vitro dissolution data.

Performance of diltiazem tablet and multiparticulate osmotic formulations in the dog

The in vivo performance of two extended-release (ER) osmotic formulations of diltiazem were evaluated in the beagle dog. Both ER formulations had similar bioavailabilities (F) as the diltiazem solution. Although F was somewhat variable following ER administration, this variability may be related to the drug entity since intra- and interanimal variability of orally administered diltiazem solutions was substantial. Deconvolution of the ER plasma diltiazem data with absorption data from the orally administered diltiazem solutions provided an estimate of the in vivo drug release from the ER formulations. The two ER formulations, designed with different in vitro release profiles, reflected these differences in vivo, with nearly identical respective in vivo and in vitro release profiles.

Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty

The purpose of the study was to examine the gastrointestinal hormone responses to meals in morbidly obese patients before and after Roux-en-Y gastric bypass (GBP; n = 9) or vertical banded gastroplasty (VBG; n = 7). On consecutive days before and after operation, we measured changes in peripheral blood levels of glucose, insulin, enteroglucagon, serotonin, vasoactive intestinal polypeptide (VIP), and cholecystokinin (CCK) in response to a standardized glucose or protein-fat meal. The percentage of excess weight lost at 6 months after operation was 66.3% +/- 4% and 41.8% +/- 5% for GBP and VBG, respectively (p less than 0.01). The 3-hour integrated glucose response to a glucose meal decreased from 145.3 +/- 33.7 to 75.8 +/- 15.7 g min/L (p less than 0.02) after GBP. This was associated with a decrease in 3-hour integrated insulin response from 22.8 +/- 8.2 to 10.5 +/- 4.9 mU min/L. Vertical banded gastroplasty patients had lesser reductions of hyperglycemia and hyperinsulinemia. Neither the CCK, serotonin, nor VIP responses to meals were altered by either operation. The 3-hour integrated enteroglucagon response to glucose increased markedly in GBP patients after operation from 11.8 +/- 6 to 133.4 +/- 38 nmol min/mL (p less than 0.02). This increase in enteroglucagon occurred at the same time as development of dumping symptoms, which occurred exclusively in GBP patients after glucose but not protein. We conclude that (1) GBP surgery for morbid obesity results in amelioration of glucose intolerance and hyperinsulinemia, (2) CCK does not mediate an endocrine satiety effect of surgery, (3) GBP is associated with an exaggerated enteroglucagon response to glucose, and (4) enteroglucagon appears to be a marker of the dumping syndrome in GBP patients.

A comparison of oral and rectal absorption of L-dopa esters in rats and mice

Short-chain alkyl esters of L-dopa were administered to rats and mice via oral and rectal routes. Plasma L-dopa esters and L-dopa were determined in the systemic and portal circulation by HPLC. A comparison of isopropyl, butyl, and 4-hydroxybutyl esters of L-dopa demonstrated significantly higher levels of the esters in both systemic and portal blood samples following rectal administration than following oral administration. In most cases, oral administration resulted in nondetectable (less than 0.01 micrograms/ml) levels of the esters in plasma. Correspondingly, the plasma levels of L-dopa itself were consistently higher following rectal administration. At very high oral doses (500 mg L-dopa equivalents/kg body weight), systemic plasma levels of the butyl ester could be detected (1.25 micrograms/ml at 10 min), which might indicate saturation of the esterase activity of the small intestine. These studies indicate that the systemic availability of L-dopa from short-chain alkyl esters of L-dopa may be best optimized by rectal administration, which avoids the relatively high esterase activity characteristic of the small intestine.

Short-chain alkyl esters of L-dopa as prodrugs for rectal absorption

The bioavailability of L-dopa following rectal administration of a series of short-chain alkyl esters of L-dopa was determined in rats and dogs. The esters were stable (greater than 360 min) to hydrolysis in physiological buffer. In vitro enzymatic hydrolysis of the esters in plasma was species dependent, with the hydrolytic rate being faster in rat plasma (t 1/2 less than 5 min) than dog plasma (t 1/2 = 68-181 min) or human plasma (t 1/2 = 96-238 min). In vivo hydrolysis in dogs, as indicated by the L-dopa plasma profile following intravenous administration of the esters, was very rapid (high extravascular esterase activity). Significant L-dopa bioavailability was observed in rats following rectal administration of the methyl (46%), ethyl (14%), isopropyl (48%), butyl (100%), and 4-hydroxybutyl (13%) esters of L-dopa (rectal L-dopa absorption, less than 5%). In dogs, significant L-dopa bioavailability was also observed for the methyl (28%), isopropyl (30%), butyl (32%), and 4-hydroxybutyl (34%) esters of L-dopa in the presence of carbidopa. The data indicate that these highly water-soluble (greater than 600 mg/ml) esters of L-dopa are potential candidates for controlled-release rectal delivery systems designed to provide more constant plasma L-dopa levels.

Controlled gastric emptying. II. In vitro erosion and gastric residence times of an erodible device in beagle dogs

An erodible gastric retention device fabricated from various polymeric blends was examined in vitro for its dissolution properties and in vivo in fasting dogs for assessment of its gastric retention potential. Dissolution studies were conducted with extruded rods of polymer blends to assess their potential as candidates for the erodible component of a gastrically retained device. Based on results from dissolution studies, rods of poly(ortho ester)/polyethylene blends (POE/PE) (45% erosion at pH 1.5 and 24 hr) were used to fabricate arms for tetrahedron-shaped devices. Corners for the tetrahedral device were fabricated from Silastic 382 loaded with 15% barium sulfate for X-ray visualization. Beagle dogs were dosed with tetrahedron-shaped test devices administered in gelatin capsules and gastric retention monitored by X ray over a 24-hr period. A comparison of in vitro erosion rates and in vivo performance of various polymer blends indicated a definite trend for increased gastric retention of devices made from the more slowly eroding blends. The results indicate that the blending of erodible and nonerodible polymers is a valid approach for obtaining materials that will provide the necessary structural properties to achieve gastric retention yet lose integrity within a desired time.

Inhibition of HIV-1 proviral DNA synthesis and RNA accumulation by mismatched dsRNA

The antiviral activity of mismatched dsRNA of the form poly(I):poly(C12-U)n (Ampligen) against the human immunodeficiency virus type 1 (HIV-1) was investigated by RNA-RNA and RNA-DNA hybridizations. Mismatched dsRNA delayed the appearance of newly transcribed HIV-1 RNA as detected by liquid dot-blot hybridization in cultures of H9 T-lymphoblastoid cells following virus challenge. The appearance of proviral DNA as detected by Southern hybridization following virus challenge in H9 cells was also delayed. Mismatched dsRNA had no effect in syncytium inhibition assays performed by fusing MT-2 cells with H9/HTLV-IIIB cells. These results suggest that the in vitro anti-HIV-1 activity of mismatched dsRNA occurs, at least in part, at an early stage in the viral replication cycle following initial gp120-CD4 binding.

Controlled gastric emptying. 1. Effects of physical properties on gastric residence times of nondisintegrating geometric shapes in beagle dogs

The importance of three physical parameters (size, shape, and flexibility) on gastric retention in fasting dogs was examined to assess the feasibility of designing a dosage form to achieve a consistent and predictable residence in the stomach. Test shapes were molded from Silastic elastomer or made from extruded polyethylene or polyethylene blends and included 15% barium sulfate for X-ray visualization. Beagle dogs were dosed with test shapes administered in gelatin capsules. Gastric retention was monitored by X ray over a 24-hr period. Six shapes (ring, tetrahedron, cloverleaf, disk, string, and pellet) were screened in vivo for their gastric retention potential. The tetrahedrons (each leg 2 cm in length) exhibited 91-100% retention at 24 hr. The rings (3.6-cm diameter) provided 100% retention at 24 hr. Rings and tetrahedrons of varying flexural moduli were prepared by blending low-density polyethylene and ethylene:vinyl acetate copolymer. A positive correlation existed between flexural modulus and gastric retention. The results indicate that it is feasible to design a platform for a dosage form that can be administered to beagle dogs in capsule form and be retained for 24 hr.

Acylcarnitines: drug absorption-enhancing agents in the gastrointestinal tract

Acylcarnitines were tested as potential absorption-enhancing agents for drugs that are poorly absorbed from the gastrointestinal tract. Urethan-anesthetized Sprague-Dawley rats and conscious Beagle dogs were used. Palmitoyl-DL-carnitine was the most effective acylcarnitine tested, although significant increases in drug absorption were observed with acylcarnitines containing C12 through C18 fatty acid chains. Palmitoyl-DL-carnitine afforded significant increases in the absorption of cefoxitin, gentamicin, cytarabine, somatostatin analogue, and alpha-methyldopa. The response to palmitoyl-DL-carnitine was concentration dependent and reversible within 60-120 min. Histological examination of the intestinal tissue revealed no apparent change in mucosal structural integrity at doses of palmitoyl-DL-carnitine that resulted in increased drug absorption. The acylcarnitines were effective in increasing drug absorption from the small intestine and the rectal compartment of both rats and dogs. The data also demonstrated effectiveness with aqueous and solid dosage forms (Witepsol H-15 suppositories). The data suggest that acylcarnitines may be effective and safe absorption-enhancing agents for a variety of drugs.