The role of whole-body positron emission tomography with [18F]fluorodeoxyglucose in identifying operable colorectal cancer metastases to the liver.

OBJECTIVE: To compare the accuracy of whole-body position emission tomography (PET)using [18F]fluorodeoxyglucose (FDG) with conventional radiological imaging techniques in identifying operable colorectal cancer metastases to the liver. DESIGN: A double-blind comparative study of FDG-PET as the criterion standard vs conventional radiological imaging methods as the criterion standard, in staging of recurrent colorectal cancer. SETTING: Institutional practice in a tertiary referral center. PATIENTS: Thirty-four consecutive patients with suspected colorectal cancer metastases recruited for the study between May 1993 and October 1994. INTERVENTIONS: Conventional radiological methods of cancer staging included abdominal computed tomography (CT) (n = 34), chest x-rays (n = 15), and chest CT (n = 19) to evaluate extrahepatic disease. Twenty-seven patients were subsequently considered to have apparently isolated cancer metastases to the liver. Anatomical resectability was assessed by magnetic resonance imaging (n = 24) or CT angiography (n = 3) in all study patients. The FDG-PET studies (n = 34) were performed within 8 weeks of conventional radiological imaging. MAIN OUTCOME MEASURES: Malignancy of suspected lesions detected by means of FDG-PET and conventional radiological imaging was confirmed by histopathologic examination of resected specimens and percutaneous biopsy specimens and by serial CT scans demonstrating progression of disease. RESULTS: Unsuspected extrahepatic malignant disease that was missed by conventional radiological imaging was detected by FDG-PET in 11 patients (32%). The PET-detected extrahepatic malignant disease included retroperitoneal nodal metastases (n = 6), pulmonary metastases (n = 3), and locoregional cancer recurrences (n = 2). The additional information afforded by PET consequently had an influence on the clinical management in 10 patients (29%). CONCLUSIONS: The FDG-PET method enabled selection of patients with apparently curable colorectal cancer metastases to the liver for hepatic resection.

Induction chemotherapy via hepatic artery for gallbladder carcinoma.

The prognosis after surgery for carcinoma of the gallbladder remains poor. Treatment failure is frequently due to loco-regional recurrence in the adjacent liver and regional lymph nodes. We report a case of gallbladder carcinoma with proven involvement of the cystic duct node (Nevin stage IV). Pre-operative intra-arterial induction chemotherapy using two cycles of cisplatin, 5-fluorouracil, doxorubicin and mitomycin C was administered via the common hepatic artery. A radical cholecystectomy was performed 4 weeks later, and histological examination of the resected specimen showed a near total response, with no residual nodal disease. The patient remains well and free of disease 3 years later. Intra-arterial induction chemotherapy warrants further evaluation.

Hepatic resection with vascular isolation and routine supraceliac aortic clamping.

BACKGROUND: Hepatic resection with total vascular isolation has been reported to reduce hemorrhage. Addition of supraceliac aortic clamping putatively avoids hemodynamic instability, but may increase morbidity. METHODS: This technique was used in 99 major liver resections utilizing scalpel division and suture hemostasis. RESULTS: Livers were normal in 86 patients, cirrhotic with no portal hypertension in 5, and cirrhotic with portal hypertension in 8. There was 1 death in 91 patients with no portal hypertension due to hepatic failure or bleeding esophageal varices. There were 59 hemihepatectomies and 40 segmentectomies. Median operating time was 145 and 110 minutes, respectively, and mean transfused blood was 4 and 0 units, respectively, with minimal morbidity. CONCLUSIONS: Use of total hepatic vascular isolation with routine supraceliac aortic clamping is a safe and expedient method of hepatic resection that limits blood loss and maintains hemodynamic stability, but does not increase morbidity. However, the presence of portal hypertension precludes safe resection.

Lessons learnt in the management of aortoenteric fistulae.

Secondary aortoenteric fistula may be treated directly by local repair or by excision of all prosthetic material with extra-anatomic revascularisation. We have reviewed our experience with 14 aorto-enteric fistulae encountered between 1960 and 1984. Two patients who were not treated surgically died. Direct repair was attempted in seven patients, two of whom had no prosthetic material present and survived. Five patients had prosthetic grafts which were not removed and four died from recurrent aortic haemorrhage. There were five other patients who had prosthetic grafts which were removed prior to extra-anatomic reconstruction. Three of these died in the peri-operative period, two from sepsis but only one from aortic stump bleeding. The operative mortality was 58%. The overall survival was only 36% (5 of 14 patients) but there was less chance of recurrent aortic haemorrhage when all prosthetic graft material was removed and direct repair avoided.

Endoscopic cautery using the heater probe as an alternative to operation for massive gastroduodenal haemorrhage.

Endoscopic cautery using the heater probe has been used by the author since 1981 for treatment of acute gastroduodenal haemorrhage. The technique has been used as an alternative to immediate operation in 175 patients who had clearly demonstrated a need for intervention. All 175 had suffered recurrent haemorrhage in hospital to a blood transfusion requirement of at least 3 litres. Ulcer patients were selected by being over 60 yrs old or otherwise unfit for operation. Early experience showed that the technique was not reliable for patients bleeding from large posterior duodenal ulcers, so 35 old or sick patients with duodenal ulcer were excluded from the series. There were no exclusions with patients bleeding from lesions proximal to the pylorus, and 82% of these were successfully treated. Even with avoidance of large posterior ulcers, only 47% of duodenal ulcer patients were able to safely avoid an operation. It is concluded that heater probe cautery can replace emergency operation in most patients bleeding from gastric lesions, but it has a limited role for patients bleeding from duodenal ulcer.

Laparoscopic splenectomy.

The innovations in laparoscopic technology have expanded the variety of general surgical procedures amenable to laparoscopic approach. An initial experience with eight cases of laparoscopic splenectomy is presented. The indications for splenectomy were immune thrombocytopenic purpura (ITP, n = 6), hereditary spherocytosis (n = 1) and enlarged spleen with filling defects (n = 1). There were six females and two males, aged 27 to 46 years. Seven patients had the spleen removed laparoscopically and one had laparoscopically assisted splenectomy. The operations took from 2 h 15 min to 3 h 30 min (mean 2 h 45 min). The spleens removed varied from 70 to 563 g (mean = 250). Blood loss ranged from insignificant to 1400 mL. Significant bleeding was encountered in three patients with moderate splenomegaly (240, 350, 563 g). Two patients received autologous blood transfusion. The average narcotic required was three doses. The patients were discharged after a mean postoperative stay of 3 days (range 2-4). One patient developed a below knee deep venous thrombosis. Laparoscopic splenectomy is possible and promises to provide the advantages associated with other laparoscopic procedures. Patients with an enlarged spleen can present a technical challenge, and there is a potential for significant blood loss. The current technology and laparoscopic expertise means that this procedure should probably be limited to patients whose spleens are not palpable clinically.

Mesenteric cyst.

Mesenteric cyst is one of the rarest abdominal tumours, with approximately 820 cases reported since 1507. The incidence varies from 1 per 100,000 to 250,000 admissions. The lack of characteristic clinical features and radiological signs may present great diagnostic difficulties. The cyst may present in one of three ways: (i) non-specific abdominal features; (ii) an incidental finding; or (iii) an acute abdomen. Abdominal pain is the major presenting symptom. Abdominal mass is found in more than 50% of cases and 40% of cases are discovered incidentally. More than one aetiological mechanism is probably involved in the development of mesenteric cysts. Mesenteric cysts have been reported from the duodenum to the rectal mesentery but are most commonly located in the ileal mesentery. Malignant cysts occur in less than 3% of cases. Enucleation of the cyst is the treatment of choice. Knowledge of these tumours is important due to the various complications associated with suboptimal surgical management. Two cases of mesenteric cysts are presented including a recurrent mesenteric cyst in a post-partum woman demonstrating the inferior technique of internal marsupialization. The association of mesenteric cyst with pregnancy is discussed.

Laparoscopic endoluminal gastric surgery.

Laparoscopic endogastric surgery is a novel surgical approach that introduces the viewing laparoscope and instruments into the gastric lumen. The excellent visualization, improved instrument handling and versatility afforded by this technique enable local resection of mucosal lesions that are beyond the scope of peroral endoscopy. The authors describe this particular approach for the excision of gastric villous adenoma and early gastric cancer.

Percutaneous infraclavicular insertion of long-term central venous Hickman catheters.

Percutaneous infraclavicular subclavian vein insertions of single lumen Hickman right atrial catheters (n = 342) were performed on 308 patients at Royal Prince Alfred Hospital. The indications for insertion were administration of total parenteral nutrition (44.8%), intravenous chemotherapy (40.9%), intravenous therapy in patients with inaccessible peripheral veins (11.7%), and intravenous antibiotic administration (2.6%). Three percutaneous catheter insertions were complicated by pneumothorax (0.88%). There were no other complications of insertion. Catheters remained in situ for a median period of 30 days (range: 2-853 days). The majority of catheters (69.6%) remained functioning and complication-free until the completion of therapy or until the patient died of their original disease. Some catheters became infected (9.9%) and there was a 0.6% incidence of septicaemia due to infected catheters; 8.5% of catheters were removed because of a suspicion of infection that was not subsequently proven. The incidence of infection was highest within the first month after catheter insertion, and decreased thereafter. Percutaneous subclavian insertion of Hickman right atrial catheters appears to be the insertion method of choice in patients requiring long-term central venous access.

Sequential laparotomy and zipper closure in the management of gross peripancreatic sepsis.

Four cases of gross peripancreatic sepsis have been managed with repeated laparotomies and packing of the lesser sac. A zipper was used for abdominal closure in three patients and the abdomen was left open in one. Sequential laparotomy enabled repeated debridement of non-viable pancreatic and peripancreatic tissue and prevented intra-abdominal septic accumulations. An additional benefit of this technique was the frequent detection and correction of clinically unsuspected complications of the septic abdomen.

A case of lesser curve ulceration after combined highly selective vagotomy and abdominal aortic aneurysm resection.

A 71 year old white male is reported in whom ischaemic ulceration of the lesser curve of the stomach, a variant of lesser curve necrosis, occurred after the combined procedures of highly selective vagotomy (HSV) and abdominal aortic aneurysmectomy. Other operations, particularly fundoplication and incidental splenectomy, have been implicated in the aetiology of lesser curve ischaemia, an otherwise rare complication of HSV. This case suggests that concomitant aortic surgery may also increase the risk of lesser curve ischaemia after HSV. Careful endoscopic monitoring of patients undergoing these combined procedures is therefore recommended to better define the risk.

Proximal gastric vagotomy after five years.

A follow-up of 93 patients with chronic duodenal ulceration treated by proximal gastric vagotomy without drainage five to nine years previously shows a high incidence of confirmed recurrent ulceration of 16.1%. In addition, there have been patients with transient recurrent ulceration, and a small group with persistent dyspeptic symptoms but in whom no ulcer has been demonstrated. The operation is commendable for its lack of side-effects, but the high incidence of recurrent or persistent symptoms may lead to some reservations about its general application in the treatment of chronic duodenal ulceration.

Traumatic duodenal transection at the level of the ampulla of Vater: sphincteroplasty as a technical adjunct to primary repair.

Complete transection of the second part of the duodenum occurred as an isolated internal injury in a 20 year old female involved in a motor vehicle accident. Her terminal bile duct lay in the free edge of the proximal transected duodenum. A sphincteroplasty effectively shifted the termination of her bile and pancreatic drainage away from the free edge of the transected duodenum, simplifying repair of the injury. This avoided the more complex alternatives of duct reimplantation or pancreaticoduodenal resection.

The rational use of homologous blood in elective surgery.

The supply of homologous blood in Australia is limited, but the demand for blood and blood products is steadily increasing. Elective surgery is a major part of this demand. In many institutions the blood ordering practices for elective surgery have been haphazard. This study was undertaken to document current patterns of blood use in a major city teaching hospital. A retrospective analysis of blood ordering and transfusion for elective surgical procedures was carried out over a 12 month period. As in several previous studies, an inefficient use of blood was demonstrated. Possible strategies to rationalize the use of blood in elective surgery have been proposed. These include the use of a 'group and screen' procedure instead of a full cross-match when transfusion is unlikely to be necessary, and ordering according to a 'maximum blood order schedule' when transfusion is usually required for a procedure.

Percutaneous insertion of long-term venous access catheters via the external iliac vein.

Long-term venous access using Hickman catheters and implantable subcutaneous ports is a well established technique. These devices have customarily been inserted via the internal jugular, subclavian or cephalic veins. On occasions, these routes may be unavailable. This article reviews the outcome of 53 prolonged venous access catheters (39 Hickmans and 14 catheters attached to implantable ports) inserted percutaneously via the external iliac vein into 37 patients over a period of 5.7 years. The indications for insertion were chemotherapy (40%), total parenteral nutrition (36%), intravenous antibiotics (13%), poor venous access (7%) and bone marrow transplantation (4%). The main reasons for use of the external iliac vein were thrombosis of the subclavian veins or superior vena cava and subclavian central line sepsis. The only complication of insertion was one inadvertent puncture of the external iliac artery. Twenty-seven catheters (51%) remained complication free and functioning for the time for which they were required. Four catheters (7%) are still functioning in situ having been present for 1-5 years. Sixteen catheters (30%) became infected, with a 17% incidence of septicaemia. Venous thrombosis was associated with three catheters (6%). Catheters remained in situ for a median period of 30 days (range 5-569 days). The authors conclude that long-term venous access using percutaneous external iliac vein insertion is a useful technique when other routes are unavailable, but there is a relatively high incidence of catheter-related sepsis.

Endoscopic prediction of recurrent bleeding in peptic ulcers.

We performed endoscopy within 24 hours of admission in 292 unselected patients admitted to the hospital for acute gastrointestinal hemorrhage. In 132 patients endoscopy revealed peptic ulcers, and in 117 full examination of the crater was possible. Visible vessels were identified in 56 patients (48 per cent); other stigmata of recent bleeding (such as oozing from the ulcer crater) were present in 21 (18 per cent), and no stigmata in 40 (34 per cent). Among the patients with either visible vessels or other stigmata of recent bleeding, 47 were randomly selected to be observed (without treatment) for evidence of further bleeding. Nineteen of 34 patients with visible vessels (56 per cent) had rebleeding, as compared with one of 13 (8 per cent) with other stigmata of recent hemorrhage; no patients with ulcers without visible vessels or other stigmata of recent hemorrhage bled further. We conclude that after bleeding occurs, visible vessels can be identified in a much higher proportion of ulcers than previously reported, and that rebleeding occurs almost exclusively in this type of ulcer, although only half the ulcers with visible vessels do in fact bleed further.

Controlled trial of argon laser photocoagulation in bleeding peptic ulcers.

The efficacy of argon laser photocoagulation in the endoscopic control of haemorrhage from peptic ulcers was tested in a controlled trial at two centres in London. Of 330 patients consecutively admitted with acute upper gastrointestinal tract haemorrhage, 76 were seen at endoscopy to have a peptic ulcer accessible to laser therapy and stigmata of recent haemorrhage. These patients were included in the trial. Identification of the exact source of haemorrhage within the ulcer crater was achieved by use of standard endoscopes with careful washing. Patients were stratified into three groups: ulcers with a visible vessel (52 total, 11 actively spurting); those without a vessel (17); and those with an overlying clot persisting after washing (7). Of the 52 patients with visible vessel, 8 of 24 treated with the laser and 17 of 28 control patients had a further haemorrhage. 7 control patients died after an episode of rebleeding, but no treated patients. Treated and control patients were well matched for other factors known to influence the case fatality rate. This is the first controlled trial to demonstrate a significant reduction in mortality by the use of a non operative treatment in patients with bleeding peptic ulcers.

Complications associated with indwelling venous Hickman catheters in patients with hematological disorders.

During a 28 month period, 77 Hickman catheters were inserted in 66 patients with hematological disorders. Complete follow-up was possible for 72 catheter insertions. Catheters remained in situ for a median period of 77 days (range 5-474 days). Fourteen (19%) catheters required removal because of complications which included sepsis, blockage, or displacement. Catheter-related infection was the major complication and Staphylococcus epidermidis and diphtheroids (Corynebacterium species) were the organisms most commonly isolated.