Intrahepatic cholangiocarcinoma - influence of resection margin and tumor distance to the liver capsule on survival.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is often diagnosed in advanced stage. Aim of this study was to analyse the influence of resection margins and tumor distance to the liver capsule on survival and recurrence in a single center with a high number of extended resections. METHODS: From January 2008 to June 2018 data of all patients with ICC were collected and further analysed with Kaplan Meier Model, Cox regression or Chi2 test for categorical data. RESULTS: Out of 210 included patients 150 underwent curative intended resection (71.4%). Most patients required extended resections (n = 77; 51.3%). R0-resection was achieved in 131 patients (87.3%) with minimal distances to the resection margin > 1 cm in 22, 0.5-1 cm in 11, 0.1-0.5 cm in 49 patients, and <  0.1 cm in 49 patients. Overall survival (OS) for margins > 0.5 cm compared to 0.5-0.1 cm or R1 was better, but without reaching significance. All three groups had significantly better OS compared to the irresectable group. Recurrence-free survival (RFS) was also better in patients with a margin > 0.5 cm than in the < 0.5-0.1 cm or the R1-group, but even without reaching significance. Different distance to the liver capsule significantly affected OS, but not RFS. CONCLUSIONS: Wide resection margins (> 0.5 cm) should be targeted but did not show significantly better OS or RFS in a cohort with a high percentage of extended resections (> 50%). Wide margins, narrow margins and even R1 resections showed a significant benefit over the irresectable group. Therefore, extended resections should be performed, even if only narrow margins can be achieved.

Two Cases of Perihepatitis With the Liver Capsule Irritation Sign: A New Physical Examination Technique.

Perihepatitis, including Fitz-Hugh-Curtis syndrome, is an uncommon, chronic manifestation of pelvic inflammatory disease usually affecting premenopausal women. It causes right upper quadrant pain due to inflammation of the liver capsule and adhesion of the peritoneum. Since delayed diagnosis of Fitz-Hugh-Curtis syndrome can lead to infertility and other complications, physical examination findings need to be investigated to predict perihepatitis in the early stages of the disease. Here, we hypothesized that perihepatitis is characterized by increased tenderness and spontaneous pain in the right upper abdomen when the patient is placed in the left lateral recumbent position (we termed this indication the "liver capsule irritation sign"). We examined the patients physically for the presence of this liver capsule irritation sign for an early diagnosis of perihepatitis. We report the first two cases of perihepatitis due to Fitz-Hugh-Curtis syndrome in which the liver capsule irritation sign observed during the physical examination was used for diagnosis. The liver capsule irritation sign is caused by two mechanisms: first, the liver falls gravitationally into the left lateral recumbent position, which makes the liver easier to palpate; and second, the peritoneum is stretched and thus stimulated. The second mechanism is that the transverse colon running around the right upper abdomen slumps gravitationally when the patient is in the left lateral recumbent position, allowing for direct palpation of the liver. The liver capsule irritation sign can be a useful physical finding, suggestive of perihepatitis due to Fitz-Hugh-Curtis syndrome. It may also be suitable in cases of perihepatitis caused by factors other than Fitz-Hugh-Curtis syndrome.

M probe comes first: Impact of initial probe choice on diagnostic performance of vibration controlled transient elastography.

BACKGROUND & AIMS: Probe choice (M or XL) in transient elastography can be made by the user's own measure of skin-to-liver-capsule distance (SCD) or with an automated tool (AUTO). We studied how AUTO depends on initial probe choice. METHODS: Three fictive clinics were considered: The "M-first clinic" uses AUTO from the M probe, the "XL-first clinic" uses AUTO from the XL probe and a "reference clinic" measures SCD independently. Agreement and discrepancies to the reference clinic were measured. RESULTS: 200 patients with chronic liver disease were prospectively included (58% female, 56 years, BMI 28.1 kg/m²). Fleiss' kappa for agreement in probe selection was 0.11 (95% CI -0.09 to 0.31), but accuracy was above 0.8 for both. Probe failure occurred for 16 (M-first clinic), 4 (XL-first clinic) and 3 patients (reference clinic). Use of XL probe given M probe failure improved performance of the M-first approach. The odds ratio for discrepancy in the XL-first vs M-first clinic is 2.4 (95% CI 1.2 to 5.2, p = 0.012) for liver fibrosis and 4.8 (95% CI 1.8 to 16.1, p < 0.001) for steatosis. CONCLUSIONS: Agreement in AUTO between M and XL probes is poor although each has acceptable accuracy. The M-first approach leads to fewer discrepancies and should be adopted as a standard.

A novel method for accurate extraction of liver capsule and auxiliary diagnosis of liver cirrhosis based on high-frequency ultrasound images.

Liver cirrhosis is a common chronic progressive disease with a high mortality rate. The early diagnosis and treatment of liver cirrhosis is an important research subject in the medical field. In this paper, a novel method is proposed for the accurate extraction of the liver capsule and auxiliary diagnosis of cirrhosis based on high frequency ultrasound images. First, a self-developed method is used to extract the predictive capsule of ultrasound images, which involves the detection of liver ascites with sliding windows, image enhancement with multiscale detail and fuzzy set, structure segmentation with morphological processing, and predictive capsule detection with traversal search method. Thereafter, the real capsule is obtained by the gray difference method according to different gray values between the liver capsule region of the original ultrasound images and the set threshold. Finally, according to the analysis of smoothness, as well as the continuity and fluctuation of predictive and real capsule, four novel features called NoL, VoS, CV, and NoF are proposed for the computer auxiliary diagnosis model. This model is designed on the basis of support vector machine and k-means clustering and can classify normal liver and three liver cirrhosis stages. The experimental results reveal that the accuracy of the liver capsule extraction using this model is 95.13% and final classification accuracy of four stages can reach 92.54%, 88.46%, 89.23% and 94.55%, respectively. The results also indicate that the method proposed in this paper can achieve the classification of liver cirrhosis stages much more accurately and efficiently compared with previously utilized methods.

Influence of Probe Pressure on Ultrasound-Based Shear Wave Elastography of the Liver Using Comb-Push 2-D Technology.

It has been postulated that in the liver, applying increased probe pressure during ultrasound-based shear wave elastography (SWE) might lead to a false increase in the SWE result. We aimed to determine the influence of increased intercostal probe pressure when performing SWE of the liver. We also investigated the number of measurements required to achieve technically successful and reliable SWE examinations. This prospective, clinical study included 112 patients and 2240 SWE measurements of the liver. We applied probe pressure intercostally, to reduce the skin-to-liver capsule distance (SCD), which could stabilize the SWE signal and thus increase the number of technically successful measurements. We performed 10 measurements with maximum probe pressure and 10 with normal pressure in each patient. Thus, two analysis groups were compared for differences. Compared with normal pressure, maximum probe pressure significantly reduced the SCD (p < 0.001) and significantly increased the number of technically successful measurements from 981 to 1098, respectively (p < 0.001). The SWE results with normal and maximum probe pressure were 5.96 kPa (interquartile range: 2.41) and 5.45 kPa (interquartile range: 1.96), respectively (p < 0.001). In obese patients, a large SCD poses a diagnostic challenge for ultrasound SWE. We found that maximum intercostal probe pressure could reduce the SCD and increase the number of technically successful measurements, without falsely increasing the SWE result. Only three measurements were required to achieve technically successful and reliable SWE examinations.

On Patient Related Factors and Their Impact on Ultrasound-Based Shear Wave Elastography of the Liver.

The aim of the study was to investigate patient-related factors associated with either reliable or poorly reliable measurement results of ultrasound-based shear wave elastography (SWE) of the liver. A total of 188 patients were analyzed prospectively with binary logistic regression using the interquartile range/median as cutoff to define two groups based on reliable and poorly reliable SWE results. SWE results correlated significantly with liver biopsy. Factors associated with reliable SWE results (i.e., no negative impact on measurements) were age, sex, cirrhosis, antiviral and/or cardiovascular medication, smoking habits and body mass index. Factors associated with poorly reliable SWE results were increased skin-to-liver capsule distance (odds ratio = 3.08, 95% confidence interval: 1.70-5.60) and steatosis (odds ratio = 2.89, 95% confidence interval: 1.33-6.28). These findings indicate that the interquartile range/median as a quality parameter is useful in avoiding poorly reliable SWE results. How best to examine patients with increased skin-to-liver capsule distance is a matter of some controversy, as the incidences of obesity, diabetes and metabolic syndrome are increasing worldwide; however, our results indicate that reliable SWE results can be obtained in this group of patients by using ultrasound-based SWE.

A rare case: Retrocecal appendicitis adherent to the liver capsule.

The cases of appendicitis take an important place in the hospital emergency departments and it must be kept in mind in the differential diagnosis of patients presenting with abdominal pain. Related to cecum, the appendix can be found in many different positions; however, it is mostly observed descending intraperitoneally (31-74%) and at the retrocecal region (26-65%). In this case report, we present the case of a 26-year-old female patient admitted to the emergency room with a colic pain in the right upper quadrant for about 2 days. Computed tomography revealed contamination in the fatty plans around the cecum and adhesive retrocecal appendicitis from the liver to the retroperitoneum. Appendectomy was performed. The pathology result was gangrenous appendicitis. In the literature, there is no similar case of appendicitis with hepatic adhesions. In conclusion, we want to emphasize that physicians and surgeons in the emergency departments must be more careful during the differential diagnosis of a patient with appendicitis and atypical symptoms and a more detailed investigation is required.

Geometry of an inflated membrane in elliptic bulge tests: Evaluation of an ellipsoidal shape approximation by stereoscopic digital image correlation measurements.

Elliptic bulge tests are conducted on liver capsule, a fibrous connective membrane, associated with a field measurement method to assess the global geometry of the samples during the tests. The experimental set up is derived from a previous experimental campaign of bulge tests under microscope. Here, a stereoscopic Digital Image Correlation (DIC) system is used to measure global parameters on the test and investigate some assumptions made on the testing conditions which could not been assessed with microscopic measurements. In particular, the assumption of an ellipsoidal shape of the inflated membrane is tested by comparing the actual sample shape measured by stereoscopic DIC with an idealized ellipsoidal shape. Results indicate that a rather constant gap exists between the idealized and actual position. The approximation in the calculation of a macroscopic strain through analytical modeling of the test is estimated here. The study of the liver capsule case shows that important differences can be observed in strain calculation depending on the method and assumptions taken. Therefore, analytical modeling of mechanical tests through ellipsoidal approximation needs to be carefully evaluated in every application. Here the field measurement allows assessing the validity of these modeling assumptions. Moreover, it gives precious details about the boundary conditions of the bulge test and revealed the heterogeneous clamping, highlighted by strain concentrations.

Affine kinematics in planar fibrous connective tissues: an experimental investigation.

The affine transformation hypothesis is usually adopted in order to link the tissue scale with the fibers scale in structural constitutive models of fibrous tissues. Thanks to the recent advances in imaging techniques, such as multiphoton microscopy, the microstructural behavior and kinematics of fibrous tissues can now be monitored at different stretching within the same sample. Therefore, the validity of the affine hypothesis can be investigated. In this paper, the fiber reorientation predicted by the affine assumption is compared to experimental data obtained during mechanical tests on skin and liver capsule coupled with microstructural imaging using multiphoton microscopy. The values of local strains and the collagen fibers orientation measured at increasing loading levels are used to compute a theoretical estimation of the affine reorientation of collagen fibers. The experimentally measured reorientation of collagen fibers during loading could not be successfully reproduced with this simple affine model. It suggests that other phenomena occur in the stretching process of planar fibrous connective tissues, which should be included in structural constitutive modeling approaches.

Characterizing liver capsule microstructure via in situ bulge test coupled with multiphoton imaging.

The characterization of biological tissue at the microscopic scale is the starting point of many applications in tissue engineering and especially in the development of structurally based constitutive models. In the present study, focus is made on the liver capsule, the membrane encompassing hepatic parenchyma, which takes a huge part in liver mechanical properties. An in situ bulge test experiment under a multiphoton microscope has been developed to assess the microstructure changes that arise with biaxial loading. Multiphoton microscopy allows to observe the elastin and collagen fiber networks simultaneously. Thus a description of the microstructure organization of the capsule is given, characterizing the shapes, geometry and arrangement of fibers. The orientation of fibers is calculated and orientation distribution evolution with loading is given, in the case of an equibiaxial and two non equibiaxial loadings, thanks to a circular and elliptic set up of the bulge test. The local strain fields have also been computed, by the mean of a photobleaching grid, to get an idea of what the liver capsule might experience when subjected to internal pressure. Results show that strain fields present some heterogeneity due to anisotropy. Reorientation occurs in non equibiaxial loadings and involves fibers layers from the inner to the outer surface as expected. Although there is a fiber network rearrangement to accommodate with loading in the case of equibiaxial loading, there is no significant reorientation of the main fibers direction of the different layers.

Influence of measurement depth on the stiffness assessment of healthy liver with real-time shear wave elastography.

The purpose of this study was to determine the measurement depth range within which liver stiffness can be reliably assessed using real-time shear wave elastography (SWE) technology. Measurements were performed on phantoms and healthy volunteers. In the first group of patients, measurements were performed at depths of 2-8 cm from the probe surface. In the second group of patients, measurements were conducted 0-7 cm below the liver capsule. Success rate of measurements (SRoM), success rate of patients (SRoS) and coefficients of variation (CVs) of repeated measurements were compared. The SRoMs at 3-7 cm and the CVs at 2-5 cm from the probe surface were significantly higher and lower than those at other depths (p < 0.001), respectively. SRoS was zero 0-1 cm below the liver capsule. Furthermore, the features of 2-D stiffness mapping images were also found to change with depth. According to our results, the depth range for the most reliable liver stiffness assessment using SWE should be 3-5 cm from the probe surface and simultaneously 1-2 cm below the liver capsule.

Compared prediction of the experimental failure of a thin fibrous tissue by two macroscopic damage models.

Several models for fibrous biological tissues have been proposed in the past, taking into account the fibrous microstructure through different homogenization methods. The aim of this paper is to compare theoretically and experimentally two existing homogenization methods - the Angular Integration method and the Generalized Structure Tensor method - by adapting them to a damage model for a planar fibrous tissue made of linear elastic and brittle fibers. The theoretical implementation of the homogenization methods reveals some differences once damage starts in the fibrous tissue; in particular, the anisotropy of the tissue evolves differently. The experimental aspect of this work consists in identifying the parameters of the damage model, with both homogenization methods, using inflation tests until rupture on a biological membrane. The numerical identification method is based on the simulation of the tests with the real geometry of the samples and the real boundary conditions computed by Stereo Digital Image Correlation. The identification method is applied to human liver capsule. The collagen fibers Young's modulus (19±6MPa) as well as their ultimate longitudinal strain (33±4%) are determined; no significant difference was observed between the two methods. However, by using the experimental boundary conditions, we could observe that the damage progression is faster for the Angular Integration version of the model.

Effect of oxycodone on percutaneous microwave ablation of liver cancer abutting capsule / 临床麻醉学杂志

Objective To evaluate the clinical effect and safety of oxycodone in the anesthesia for percutaneous microwave ablation (PMWA) in liver cancer when the scope of ablation involving liver capsule.Methods Thirty-eight patients scheduled for percutaneous microwave ablation of liver cancer abutting capsule, including 32 males and 6 females, aged 41-75 years, with ASA grade Ⅰ or Ⅱ.Patients were randomly divided into 2 groups:oxycodone group (group O,n=20) and fentanyl group (group F, n=18).Before the puncture, a loading dose of oxycodone 0.1 mg/kg was given intravenously in group O, a loading dose of fentanyl 1 μg/kg was given intravenously in group F.After successful puncture, both groups were induced by Propofol 1.5 mg/kg, followed by Propofol infusion at 4-7 mg·kg-1·h-1 in two groups.The changes of MAP, HR, SpO2 and RR before, during and after operation were recorded.Body movement and respiratory depression were recorded.The total amount of propofol,the postoperative recovery time, postoperative nausea and vomiting, and postoperative 4 h VAS scores were recorded.Results There was no significant difference in general condition and intraoperative condition of ablation operation between the two groups.The incidences of respiratory depression and body movement in group F were significantly higher than those in group O.There was no significant difference in the incidences of postoperative nausea and vomiting between the two groups.VAS score 4 h after operation in group F [(3.9±2.0) score] was significantly higher than that in group O [(1.7±0.9) score] (P＜0.01).There was no significant difference in HR between the two groups at each point.Compared with before surgery, the MAP during surgery in group F was significantly increased (P＜0.05),the RR during surgery in groups F and O were significantly lower (P＜0.01 or P＜0.05).The RR during surgery in group F was significantly lower than that in group O(P＜0.05),but there was no significant difference at the other points between the two groups.Conclusion Oxycodone can be used safely and effectively for percutaneous microwave ablation of liver cancer when the scope of ablation involving liver capsule.It has lower incidence of respiratory depression, effectively alleviates intraoperative pain and reduces postoperative pain.

Fibrocalcific Nodule in the Liver Capsule Caused by Ascaris Eggs: A case report

Ascariasis is probably the most common helminthic infestation of man, but it seldom causes severe illness. Pathologic conditions of Ascaris may be caused by adult worms, eggs or larvae. We describe a case of Ascaris egg granulomas that were found incidentally on the surface of the liver in a 75-year-old woman who had undergone a segmentectomy for an intrahepatic stone. Grossly, there were several yellowish calcific nodules of 0.4 cm in diameter on the lateral surface of the left lobe of the liver. Microscopically, the lesions were located in the hepatic capsule and consisted of fibrocalific nodules with many eggs. The eggs were round to oval, thick-shelled and measured 50~75x30~50 um. Most of the morphologically preserved eggs were fertilized eggs, but they had smooth shells without external protein coats. This case is of interest for the unusual location of the lesion, the presence of eggs without mammillation, and the association with the intrahepatic stone.