Contrast-enhanced ultrasonography in the diagnosis of upper urinary tract urothelial cell carcinoma: a preliminary study.

PURPOSE: The main objective was to assess the effectiveness of contrast-enhanced ultrasonography (CEUS) in the diagnosis of upper urinary tract malignancies by comparing with multidetector computed tomographic urography (MDCTU) and magnetic resonance urography (MRU). Secondary objectives were to compare the tumor size measured with CEUS, MDCTU and MRU and to assess the usefulness of CEUS in distinguishing high-grade tumors from low-grade ones. MATERIALS AND METHODS: In connection with this prospective study carried out from January 2009 to September 2011, 18 patients underwent MDCTU or MRU, grayscale ultrasonography (US), color Doppler ultrasonography and CEUS followed by surgery and histological examination of the specimen. Quantitative analysis was performed using perfusion software. Time intensity curves were extracted and the following parameters were considered: wash-in time, time-to-peak, maximum signal intensity and wash-out time. RESULTS: Grayscale US identified 15/18 lesions; color Doppler showed no flow signal in 8 lesions, low color signal in 9 lesions and an intense color signal in 1 lesion; CEUS identified 17/18 lesions with the undetected lesion being the smallest one (1.2 cm) located in the upper pelvicalyceal system. Semi-quantitative analysis produced different data for high-grade and low-grade urothelial cell carcinoma (UCC). All detected upper urinary tract masses were UCCs. MRU, MDCTU and grayscale US overestimated the tumor size, while CEUS was the most accurate. CONCLUSION: CEUS is useful for evaluating upper urinary tract masses as this method permits differentiation between high-grade and low-grade tumors as well as distinction of the tumor from the adjacent structures and accurate mass measurements.

False positive tardus-parvus waveforms after liver transplantation: a case of wide discrepancy between donor and recipient hepatic arteries mimicking anastomotic stenosis.

BACKGROUND: Parvus-tardus waveforms of the hepatic artery after liver transplantation usually indicate an arterial complication and severe impairment of hepatic arterial perfusion with a sensitivity of 91% and a specificity of 99.1%. Thus, it has been emphasized that detection of such waveforms should prompt emergency angiography. MATERIALS AND METHODS: Arterial reconstruction during a liver transplantation was successfully accomplished by an end-to-end anastomosis, performing a "flute-spout" widening of the anastomosis with a 7/0 prolene running suture between a small recipient proper hepatic artery and the donor common hepatic artery. RESULTS: On day 7 posttransplantation color Doppler ultrasonography revealed a parvus-tardus waveform pattern in the hepatic arterial flow. Computed tomographic (CT) angiography showed only a caliber discrepancy between the donor and recipient stumps, excluding an arterial stenosis or thrombosis. Since normal liver function persisted, the patient underwent routine follow-up. After 15 months the patient was alive and well; hepatic artery spectral waveforms were unchanged and liver functions were consistent with a mild hepatitis C virus (HCV) recurrence. CONCLUSIONS: This is a report of false positive tardus-parvus waveforms, due to a discrepancy between the donor and recipient arteries despite a wide anastomosis. Knowledge of technical reconstruction details may be helpful for correct interpretation of color Doppler findings. CT angiography should be considered before more invasive examinations.

Surveillance and rescue of pancreas grafts.

BACKGROUND: Technical failure rates are higher for pancreas allografts (PA) compared with other solid organs. Posttransplant surveillance and prompt availability of rescue teams with multidisciplinary expertise both contribute to improve this result. We herein report a single institution's experience with posttransplant surveillance and rescue of PA. METHODS: A retrospective survey was performed of a consecutive series of 177 whole organ pancreas transplants in 173 patients. Antithrombotic prophylaxis was used in all recipients and tailored on anticipated individual risk of thrombosis. During the first posttransplant week, all PA were monitored with daily Doppler ultrasonography. Surgical complications were defined as all adverse events requiring relaparotomy during the initial hospital stay or the first 3 posttransplant months. RESULTS: A total of 26 relaparotomies were performed in 25 patients (14.7%). One recipient needed two relaparotomies (0.6%). Graft rescue was attempted in patients without permanent parenchymal damage at repeat surgery and in 12 recipients diagnosed with nonocclusive vascular thrombosis. Overall 25 grafts (96.3%) were rescued and one was lost. One-year recipient and graft survivals in patients with versus without complications potentially leading to allograft loss were 92.6% and 63.0% versus 94.4% and 94.3%, respectively. Excluding complications for which graft rescue was not possible, 1-year graft survival rate increased to 78.7%. CONCLUSIONS: Close posttransplant surveillance can allow rescue of a relevant proportion of PA developing nonocclusive venous thrombosis or other surgical complications. Further improvement awaits better understanding of biological reasons for posttransplant complications jeopardizing PA survival and the development of more effective preventive measures.

Long-term survival in pancreatic cancer: pylorus-preserving versus Whipple pancreatoduodenectomy.

BACKGROUND: This study compared long-term survival in pancreatic or periampullary cancer treated with Whipple pancreatoduodenectomy (PD) and pylorus-preserving pancreatoduodenectomy (PPPD). METHODS: Two hundred twenty-one patients with pancreatic head or periampullary cancer were treated. Prognostic variables included age, gender, type and period of operation, and tumor stage. In the ductal adenocarcinomas variables also included tumor and node status, type of lymphadenectomy, pathologic grade, and presence of microscopic residual tumor. The end point was death as a result of neoplastic recurrence. Survival curves were estimated by using the Kaplan-Meier method, and multifactorial analysis was also performed on the data from the ductal adenocarcinoma group. RESULTS: The mortality rate was 8.2% in the PD group versus 7.0% in the PPPD group. Morbidity rates were 34.4% for PD and 45.8% for PPPD. Five-year survival was 9.6% in the ductal adenocarcinoma and 63.8% in the periampullary carcinoma groups. Univariate analysis failed to show statistically significant differences in survival curves between the two treatments in either patient group. Correcting for multiple variables in the ductal adenocarcinoma group did not reveal any significant differences in survival rates between the two treatments. CONCLUSIONS: PPPD was as successful as classic PD in the treatment of ductal adenocarcinoma and periampullary cancer of the pancreas. Long-term survival was not influenced by the type of resection.

Comparative evaluation of contact ultrasonography and transcystic cholangiography during laparoscopic cholecystectomy: a prospective study.

BACKGROUND: The role of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is controversial. While many advocate its routine use, others argue for a selective approach. Recent reports showed laparoscopic contact ultrasonography (LCU) as a viable alternative to IOC. However, no prospective data were available to compare the accuracy, efficacy, and safety of the two diagnostic procedures. OBJECTIVE: To evaluate the benefits and disadvantages of LCU and IOC during LC. METHODS: Seventy-eight patients who underwent LC at Pisa (Italy) and Dundee (Scotland) university hospitals were entered in a prospective data registry. Details of operative technique and results of LCU and IOC were analyzed by reviewing videotape recordings of each procedure. RESULTS: Laparoscopic cholecystectomy was achieved in 73 patients, with five requiring conversion to the open procedure. The success rate of IOC was 90% (64/71). Performance of IOC demanded more than twice the time needed for LCU. Eleven percent (8/71) of cholangiograms were abnormal, with a false-positive rate of 1% (1/71). Laparoscopic contact ultrasonography detected all four instances of unsuspected ductal stones but none of the three cases of anomalous biliary anatomy. Clinically relevant incidental findings were picked up by LCU in six patients. CONCLUSIONS: Laparoscopic contact ultrasonography proved to be extremely accurate in the detection of ductal stones but less reliable in the disclosure of anomalous biliary anatomy. The essential role of IOC in providing a clear spatial display of the biliary tract was confirmed. Since the two procedures are complementary, their combined use is advisable in difficult LC to avoid retained common bile duct stones and prevent iatrogenic complications.

Interventional ultrasound: experience in 426 orthotopic liver transplantations.

BACKGROUND: The purpose of this study was to analyze the role of interventional ultrasound in the treatment of nonvascular complications in liver transplant recipients. METHODS: Between August 1996 and May 2003, we performed 426 OLTs in 394 patients, 287 men (73%) and 107 women (27%), mean age of 50 +/- 9.5 years (range 17 to 68.2). A total of 2556 diagnostic ultrasound examinations were performed, resulting in a mean of 5.9 per patient (range 2 to 21). The interventional maneuvers included: echo-guided biopsies; drainage of abdominal or thoracic effusions; drainage of abdominal, intrahepatic, or splenic collections; positioning of biliary drains; and use of the "rendezvous" technique. RESULTS: Six hundred seventy-seven echo-guided interventional maneuvers were performed in 394 OTL patients, comprising 417 (61.6%) biopsies and 260 (38.4%) therapeutic maneuvers. Eighty-one ascite drains were positioned (31.1%); in 73 cases, pleural effusions were drained (28.1%). Sixty-seven abdominal or intrahepatic collections were drained (25.8%), of which 36 (53.7%) were due to bilomas or biliary peritonitis, 15 (22.4%) hematomas, 4 (5.9%) hepatic abscesses, 11 (16.4%) infected abdominal collections, and 1 (1.5%) splenic abscess. Thirty-nine cases (15%) of biliary drainage were performed. In 33 cases (7.9%), the parenchymal biopsies were not diagnostic because of an inadequate specimen. The treatment success rate was 96.1%. No complications related to the therapeutic maneuvers were recorded, but there were 5 biopsy-related complications (1.2%). CONCLUSIONS: Echo-guided interventional maneuvers are safe, produce a high success rate, and represent an important option in the management of OLT patients.

Giant pedunculated liposarcomas of the esophagus: literature review and case report.

Although liposarcoma is the second most common soft-tissue sarcoma in adults, its incidence within the gastrointestinal tract is distinctly low. Esophageal involvement is exceedingly rare and only four cases have been described so far. A fifth case is presented here along with a thorough review of the literature of polypoid lipomatous tumors of the esophagus. Diagnostic and therapeutical strategies of these tumors are discussed in detail.

Percutaneous cholecystostomy for acute cholecystitis in critically ill patients.

BACKGROUND/AIMS: The aim of this study was to ascertain the therapeutic efficacy of percutaneous cholecystostomy in a selected group of high-risk patients who were physiologically unable to tolerate an open procedure. METHODOLOGY: We reviewed the hospital records of 11 critically ill patients who underwent percutaneous cholecystostomy for acute cholecystitis during the intensive care unit course of major underlying diseases. RESULTS: Percutaneous cholecystostomy was easily performed in all cases (feasibility rate: 100%). No procedure-related death was recorded and minor complications occurred in 2 patients (18%). Percutaneous cholecystostomy led to resolution of the sepsis in all but 1 patient with gangrenous calcolous cholecystitis who required emergent cholecystectomy (success rate: 91%). Percutaneous cholecystostomy was the permanent treatment in all patients with acalcolous cholecystitis. Among patients with calcolous cholecystitis, 4 underwent delayed elective cholecystectomy, 1 required no further treatment, and 2 eventually died from the evolution of their underlying diseases. After a mean follow-up of 25 months (range: 12-32 months), none of the patients managed non-operatively required surgery or re-hospitalization. CONCLUSIONS: Ease of performance, low complication rate, and high success rate make percutaneous cholecystostomy the procedure of choice for critically ill patients with acute cholecystitis. Whenever possible, percutaneous cholecystostomy should be followed by elective cholecystectomy. However, especially in acalcolous cholecystitis, it may constitute the definitive treatment.

Transrectal ultrasonography and cervical neoplasia. A preliminary report.

Transrectal ultrasonography is a new diagnostic method recently introduced in the study of normal and pathologic pelvis. The Authors describe their preliminary experience with the use of a rectal linear probe in the evaluation of the carcinoma of the cervix. This ultrasonographic method has resulted very useful in providing an imaging of cervical cancer in evaluating its effective diffusion and in precising demeasurements of the neoplastic mass. The results are particularly encouraging and justify continued experimentation.

[The Halsted operation versus modified radical mastectomy: usefulness of patient selection as a function of the type and site of the tumor]. / Opération de Halsted versus mastectomie radicale modifiée: utilité d'une sélection des patients en fonction du type et de la localisation de la tumeur.

ystematic analysis of the pectoral muscle and fascia disclosed neoplastic infiltration in 6.2% of our stage T2a cases. Accordingly the authors propose a Halsted type resection in all cases staged T3, T2b and T2a when the tumor is located deep in the gland.

[Preservation of the pylorus in duodenocephalopancreatectomy in pancreatic and periampullary carcinoma]. / La duodenocefalopancreasectomia con conservazione del piloro (PPPD) nel carcinoma pancreatico e periampollare.

The aim of this retrospective study is to evaluate whether the pylorus preserving pancreatoduodenectomy (PPPD) is as safe as the standard Whipple's procedure (PD) in the treatment of pancreatic and periampullary cancer. Between January 1980 and December 1993, 473 patients with carcinoma of the head of the pancreas or periampullary region were admitted to the Department of General Surgery of Pisa University Hospital. 201 of these patients underwent pancreatoduodenectomy (115 ductal carcinoma, 61 periampullary cancer, 25 other neoplasms). In each group patients received a PPPD or a PD (ductal carcinoma 76 PPPD and 33 PD; periampullary cancer 46 PPPD and 15 PD). Overall, postoperative mortality rate for PPPD was 7.5% and for PD 8.9%, decreasing in the last 6 years to 3.2% (3 out of 92 consecutive cases). Variables examined were age, sex, T and N status, tumour stage, histological grade, residual tumour, cancer recurrence, death from recurrence and survival time. No patient was treated with antiblastic therapy. Survival times were estimated for both PPPD and PD using the Kaplan-Meier method and thereafter compared with each other using the Breslow and Mantel-Cox test. The 5-year survival rate in PPPD was 12.3% and 63.01% for ductal and periampullary carcinoma respectively. Survival time was not statistically different between PPPD and PD for both ductal and periampullary cancer. As regards pancreatic cancer, the presence of lymph node metastasis appeared to be a poor prognostic factor, even though it did not reach statistical significance (p = 0.075). In conclusion PPPD may be considered a valid surgical option even when dealing with pancreatic or periampullary cancer.

Pancreatic cancer and tumor markers: role of the newly identified CAR-3 antigen.

BACKGROUND AND AIM: The aim of this study is to assess the clinical usefulness of the serum assay for CAR-3 in the diagnosis and follow-up of pancreatic cancer. MATERIALS AND METHODS: Serum levels of tumor markers (CAR-3, Ca 19.9, Ca 195 and CEA) were measured in a total of 238 patients with various diseases of the gastrointestinal (GI) tract, including 61 pancreatic cancers. Cut-off levels were calculated on the basis of a non-parametric estimate of 90% specificity. After surgery, patients with pancreatic cancer underwent a combined serological and radiological (CT-scan) follow-up. RESULTS: At the cut-off level of 6.15 U/L, the sensitivity of CAR-3 was 62.3% (CA 19.9: 77%; Ca 195: 75.4%; CEA: 24.5%). In the differential diagnosis between pancreatic cancer and other GI diseases, significant differences were found. No association was discovered either between serum level of tumor markers and tumor stage or between short- and long-term survivors. In the follow-up, CT-scan was superior to serologic tests (sensitivity: 94.2%). Among tumor markers, CAR-3 achieved a sensitivity of 62.5% (Ca 19.9: 83.3%; Ca 195: 75%). DISCUSSION: CAR-3 is shed in the circulating stream in a much lower proportion of cases than that observed for antigen expression at immunohistochemistry. During the follow-up CT-scan was the most accurate diagnostic tool. However, the meagre therapeutical options for recurrent pancreatic cancer, do not justify such an aggressive follow-up. CONCLUSIONS: Ca 19.9 remains the tumor marker of choice for either the pre-operative work-up or the post-surgical follow-up of patients with pancreatic cancer.