[Radiofrequency ablation of hepatic metastases: clinical results].

AIM: To establish the effectiveness of radiofrequency ablation in the treatment of metastatic hepatic lesions. PATIENTS AND METHODS: 104 pts with 231 metastases were treated with RFA. The volume of achieved destruction was assessed using imaging method and cytology. Patients were followed-up for 1-37 months. RESULTS: 87.3% of metastases < 3.0 cm, 50.9% of tumors sized 3.0-5.0 cm and 14.3% of metastases > 5.0 cm were completely destroyed. Major complications occurred in 7.5% of the patients. 34% of the ablated tumors recurred. CONCLUSIONS: The effectiveness of RFA metastases depends on the size and location of the lesion. Lesions adjacent to the gallblader and main bile ducts are risky for manipulation.

[Bolus percutaneous ethanol injections in hepatocellular carcinoma--clinical results].

AIM: To establish the effectiveness of large-volume percutaneous ethanol injection under general anesthesia (Shot-PEI) as a local method for destruction of large hepatocellular carcinoma (HCC). PATIENTS AND METHODS: 46 patients with 48 HCC were treated with Shot-PEI. 1-4 sessions per lesion were performed with 12-138 ml ethanol per session. RESULTS: Complete destruction was achieved in 43.8% of the tumors. Major complications occurred in 10.9% of the patients. Local recurrences were 19%. CONCLUSION: Shot-PEI is an effective method for destruction of large tumors and multiplies the therapeutic options in HCC.

[Radiofrequency ablation of recurrent intrahepatic cholangiocarcinoma: a case report].

A 45-years-old patient with recurrent intrahepatic cholangiocarcinoma 3 years after resection is described. 2 sessions of percutaneous radiofrequency ablation (RFA) were performed and complete destruction of the tumor was achieved. The patient was followed-up for 15 months by means of power-Doppler, CT and tumor markers. No local or heterotopic recurrences were observed. The case demonstrates the possibilities of RFA in the management of postoperative recurrences of intrahepatic cholangiocarcinoma and confirms the significance of the method in the complex approach to the liver tumors.

[Classifications and prognosis of hepatocellular carcinoma]. / Klasifikatsii i prognoza na khepatotselularniia kartsinom.

In this study are included 78 patients with hepatocellular carcinoma (HCC). In 22 the diagnosis is verified pathologically (obduction), while in the other patients the diagnosis is made by laparoscopy, laparoscopical ultrasonography and morphological verification (through FNAB cytology and/or histology). In 69.2% HCC is associated with cirrhosis. The prognosis of HCC associated with cirrhosis is evaluated through the classification of S. Chevret et all., and is compared to the Child-Pugh scoring system. 38.9% of patients in Chevret's class C score are in class B in the Child-Pugh score, while 25.9% of patients are in class C in both classifications, but Child-Pugh's class C patients are most often in B-C transition. It might be assumed that the prognosis of HCC depends more on the tumor prognosis than on the prognosis of the liver cirrhosis itself. Every classification which does not take in to account the liver function (like TNM system) and the whole characteristics of the tumor, would be incomplete, in some extent, in the prognosis of HCC with cirrhosis. In HCC without cirrhosis, the BCLC classification reflects both the liver function and the tumor characteristics. In BCLC class A patients hepatic resection or transplantation is recommended but hyperbilirubinemia and ascites, which might be seen in A3 and A4 classes contraindicate resection of the liver. All scoring systems define lower HCC stage than it is really found (personal and reference data), so there are no arguments to take classification scores as absolute treatment decision making rules.

[Preoperative staging on liver metastasis from colorectal carcinoma]. / Predoperativno stadiirane na chernodrobnite metastazi ot kolorektalen kartsinom.

Preoperative staging of metastatic liver cancer (MLC) from colorectal carcinoma (CRC) is conducted with the purpose to identify potentially resectable MLC cases. Fifty-two patients undergo laparoscopic study (4.1% all endoscopies), and three--laparoscopic ultrasonography. Laparoscope E Wolf and 7.5 MHz linear transducer obtained from the Aloka Company are employed. The study covers 24 women and 28 men with mean age 61.6 years (range 23-87 y). MLC is diagnosed in 35.1% (13/37) of colonic, and in 73.3% (11/15) of rectal carcinoma cases. Furthermore, 69.3% of the patients (36/52) are in M-stage, accounted for by peritoneal or hepatic metastases. The size of lesions measures less than 2 cm in 25.0%, and less than 1 cm in 12.5% of the cases. Solitary metastasis is recorded in 8.3 per cent. In the event of isolated involvement of the left lobe the location of MLC is in the region of II-III segment. In one patient a single metastasis in VII segment, measuring 0.5/1.0 cm, missed by the imaging methods and laparoscopy, is documented by laparoscopic ultrasonography. Echographic diagnosis proves inaccurate in 16.7%, and false negative--in 12.5 per cent. In further three patients (12.5%) the conclusion reached is uncertain, with primary liver cancer being also considered. In 23.1% MLC from colonic carcinoma is situated entirely intrahepatally, and is not accessible to endoscopic inspection without laparoscopic and/or intraoperative ultrasonography; the latter is indicated in all T3 and T4 patients. Potential resectability is established in 16.7% of cases with liver metastases from CRC.

[Percutaneous puncture treatment of hepatic cystic echinococcosis under ultrasound guidance]. / Perkutanno punktsionno lechenie na kistichnata chernodrobna ekhinokokoza pod UZ kontrol.

Introducing of the alternative PAIR (puncture-aspiration-injection-reaspiration) method for treatment of hepatic echinococcosis in practice dates from 1992 year. A Working group dealing with the problems and standardization of the method has been created by WHO. The major aspects of this treatment are summarized in the bulletin of WHO of 1996 year. On the last World Congress of Ultrasound, held in Florence, Italy in 1999 this method was reported as safe and effective treatment modality. The necessity for further prospective studies was also emphasized. The aim of the Working group for performing of PAIR, created at the Clinical Centre of Gastroenterology, University Hospital "Queen Joanna" in 1999 is to report the preliminary results and declare the possibilities for its application. Nine patients (6 males, 3 females) with 11 cysts (I, II and IIIa types after Gharbi) measured 3-9 cm were punctured and followed up for a 6 months period. 95% ethanol was used as protoscolicidal agent with concomitant preventive oral treatment with Mebendazole. No serious complications were observed. In all patients separation of the germinative membrane was verified. 2/5 cysts < 3.5 cm completely disappeared, 7/11 diminished their size without signs of vitality, while 2/11 remained vital. One ofe the cysts had a biliary communication which necessitated the injection of 20% NaCl instead of ethanol. The serological ritres significantly decreased in all patients. The risk of anaphylaxis and seeding is negligible while keeping the technique of PAIR precisely. The PAIR treatment of hepatic echinococcosis presents great progress with its safety, low risk and excellent therapeutic results.

[Indications for preoperative laparoscopic ultrasonography]. / Pokazarniia za predoperativna laparoskopska ekhografiia.

109 laparoscopic ultrasound examinations are performed for a period of 7 years (1993-1999). Laparoscope R. Wolf and 7.5 MHz linear probe "Aloka" are used. On the basis of the results analysis the following indications for laparoscopic ultrasonography (LUS) are recommended: 1. Uncertain diagnosis; 2. Contradictory results of imaging technics; 3. Assessment of tumour's stage; 4. Early diagnosis; 5. Negative data for liver lesion on laparoscopic examination and established or suspected tumour by imaging technics; 6. Negative data of laparoscopy and uncertain evidence of the imaging technics for liver lesion in cases with advanced locoregional stage of extrahepatic primary carcinoma and small chance for palliate surgical treatment; 7. Positive laparoscopic data insufficient to determine tumour resectability; 8. Suspicion for endocrine tumour of the pancreas. Laparoscopy and LUS are indicated for staging of hepatocellular carcinoma; gastric and colorectal carcinoma, especially in T3 and T4 stage; "T4b" stage of gastric carcinoma without liver metastases; all cases of carcinoma of the body of pancreas without data of liver metastases. LUS is irreplaceable nonsurgical diagnostic method in deep placed intrahepatic lesions. The main contribution to diagnosis of laparoscopy and LUS is not only to establish the liver lesion but to give differential diagnosis of the lesion and determine the tumour stage.

[The diagnostic approach in hepatic lesions--the role and place of laparoscopy with laparoscopic echography]. / Diagnostichen podkhod pri chernodrobnite lezii--rolia i miasto na laparoskopiiata s laparoskopska ekhografiia.

The study is designed to cases the potentials of laparoscopy with laparoscopic echography, and the role they play in the diagnostic algorithm, with the purpose to develop an optimal therapeutic approach to hepatic lesions. Laparoscope R. Wolf and 7.5 MHz linear transducer, obtained from the Aloka Company are employed in work. A total of 303 patients presenting primary and metastatic carcinoma of liver (58 and 145, respectively), cholangiocarcinoma (11), hemangioma(28), adenomatous hyperplasia (38) and other lesions (23) are studied. Morphologic verification of the diagnosis is done in over one third of cases. In 30 to 40 per cent of the series reviewed laparoscopic echography supplements the laparoscopic finding depending on the type of lesion. Without pretending to create a diagnostic algorithm in individual hepatic lesions, abiding to the following diagnostic approach is strongly recommended: stage one--echography (a noninvasive, not irradiating, cheap, readily accessible and often resolving method), stage two--noninvasive, stage three--invasive, stage four--preoperative or final (laparoscopy plus laparoscopic echography). In the event of properly established indications, the invasive methods of study (thin-needle biopsy under ultrasonographic control plus laparoscopy) may be considered as a second stage, without any need to apply the complete spectrum of examination accessible. Not infrequently, laparoscopy with laparoscopic ultrasonography play a crucial role in diagnosing liver lesions, exact determination of the stage and resectability of the neoplastic process, planning and shortening the duration of operation with simultaneous identification of intractable patients.

[The role of laparoscopy and laparoscopic ultrasonography in the diagnosis and differential diagnosis of nodular hepatocellular lesions]. / Rolia na laparoskpiiata i laparoskopskata ekhografiia v diagnostikata i diferentsialnata diagnoza na nodularnite khepatotselularni lezii.

The diagnostic relevance of laparoscopy (LS) and laparoscopic echography (LE) in nodular hepatocellular lesions is studied. LS is done using a R. Wolf laparoscope, and LE--with a 7.5 MHz linear transducer, obtained from the Aloka Company. A total of 250 patients presenting 288 nodular hepatocellular lesions are investigated over 15 years (1983-1998), including: focal nodular hyperplasia (FNH)--1, nodular regenerative hyperplasia (NRH)--1, hepatocellular adenoma (HCA)--1, adenomatous hyperplasia (AH)--38, hepatocellular carcinoma (HCC)--58, Budd-Chiari syndrome--2, primary sclerosing cholangitis (PSCh)--2, and cirrhosis of liver--185. The lesions are distributed according to the updated classification of the International Working Party, published in 1995. In addition to the latter, a case of cholangiocellular adenoma undergoing malignant degeneration and a case presenting carcinoma, giving rise to differential diagnostic difficulties are also described. Some of the aforementioned diseases are reported for the first time in the Bulgarian literature. Emphasis is laid on the practicability of combining endoscopic with imaging diagnostics, attributable to laparoscopic echography and to the advantages of echolaparoscopic biopsy. Almost half of the foci (46.1%) are morphologically verified. The aim of cytological assessment is to establish the malignant character of the lesion, first and foremost, while the histological finding is essential for making a correct diagnosis.

[Laparoscopy and laparoscopic echography in the diagnosis of pancreatic diseases]. / Laparoskopiia i laparoskopska ekhografii v diagnostikata na pankreasnite zaboliavaniia.

The potentials of laparoscopy (LS) and laparoscopic ultrasonography (LUS) in diagnosing pancreatic diseases are assayed. The study covers forty-five patients of which 36 presenting carcinoma of the pancreas, and nine-acute peritonitis. APUD (VIP) is documented in one case. For the purpose laparoscope R. Wolf and 7.5 MHz echolaparoscopic linear probe obtained from the Aloka company are employed. The LUS technique used in pancreatic diseases is described in details. In the group of pancreatic carcinoma patients 72.2 per cent prove to be inoperable. Emphasis is laid on the superiorities of LUS over transabdominal echography and laparoscopy in diagnosing, staging and resectability evaluation of pancreatic carcinomas, as well as in terms of establishing the indications and practicability of the procedure in acute pancreatitis. LS and LUS are the only preoperative alternative to intraoperative echography, since imaging, endoscopic and histomorphological diagnostic methods are combined. LS in conjunction with LUS are no longer considered as a synonym of peritoneoscopy which in turn, considerably augments the possibilities of the method in handling diseases of the pancreas.

[Laparoscopy and laparoscopic echography in the diagnosis and staging of gastrointestinal carcinomas]. / Laparoskopiia i laparoskopska ekhografiia v diagnostikata i stadiiraneto na gastrointestinalnite kartsinomi.

The clinical relevance of laparoscopy (LS) and laparoscopic echography (LSEG) in diagnosing and staging gastrointestinal carcinomas is assayed in the light of diagnostic methods in current use. The study covers 257 patients undergoing LS, and 23-LSEG. For the purpose a rigid 7.5 MHz echolaparoscopic probe is used. In 16 per cent of the cases LS fails to resolve the basic diagnostic problems faced, whereas in 35 per cent it alters completely the preliminary clinical diagnosis. In over 90 per cent of cases LSEG supplements or modifies the laparoscopic diagnosis. Emphasis is laid on the role played by LSEG in defining the loco-regional stage of gastric and colorectal carcinomas, as well as on the contribution of the method to establish pancreatic carcinomas not lending themselves to resection. What is more, LSEG demonstrates inoperable cases by detecting small, unsuspected metastases, not prominating above the hepatic surface.

[Percutaneous puncture in hepatic echinococcosis]. / Perkutanna punktsiia pri chernodrobna ekhinokokoza.

This is a report on a case of severe anaphylactic shock and hemorrhage following liver puncture with diagnostic purpose. Based on literature data and personal experience, percutaneous puncture of a parasitic expanding cyst, done with diagnostic and therapeutic purpose, is discarded, assuming the method as an error of art. Its performing using updated imaging techniques--echography and computerized tomography--by no means reduce the risk of anaphylactic shock and secondary echinococcosis. In the event of being accidentally done, emergency operation followed by chemotherapy to preclude secondary echinococcosis is recommended. In cases with unspecified diagnosis, puncture under echographic control is done on the operating table with urgent cytological assessment of the punctate. The demonstration of echinococcosis is an indication for immediate operation. The percutaneous method is used in handling nonparasitic cysts.

[Laparoscopy and laparoscopic echography in the diagnosis of hepatocellular carcinoma]. / Laparoskopiia i laparoskopska ekhografiia v diagnostikata na khepatotselularniia kartsinom.

The role of laparoscopy and laparoscopic echography (LSEG) in the early diagnosis and staging of hepatocellular carcinoma (HCC) are discussed in the light of the diagnostic methods in current use. The study covers 62 patients of which thirteen are subjected to LSEG using rigid 7.5 MHz echo-laparoscopic probe. In 87.1 per cent of the cases HCC develops against the background of cirrhosis. Adenomatous hyperplasia is established in 21 of 54 patients presenting HCC, pointing to the stage character of cancerogenesis, and demonstrating the LSEG potentialities in diagnosing precancer, multicentric HCC, intrahepatic metastases from HCC and vascular tumor invasion. The superiorities of echo-laparoscopic biopsy and LSEG contribution to the early diagnosis of HCC, staging according to ther TNM system, and reliable demonstration of cirrhosis, its severity and prognosis, are underscored.

[Intraoperative anaphylactic shock following the percutaneous puncture of a hepatic echinococcal cyst]. / Intraoperativen anafilaktichen shok sled perkutanna punktsiia na chernodrobna ekhinokokova kista.

This is a report on a case of severe intraoperative anaphylactic shock, developing within several hours of percutaneous puncture of a liver hydatid cyst, performed under echographic control, necessitating recovery from the shock state and discontinuation of the operative intervention. Inferences are reached regarding the most adequate treatment tactics to be adopted in handling such cases. Percutaneous puncture is discarded as a therapeutic approach because of the great risk of anaphylaxis with eventual lethal outcome, and the likelihood of severe abdominal echinococcosis development at a later period.

[Treatment of hepatic and juxta-hepatic abscesses by puncture-drainage]. / Traitement des abcès hépatiques et juxta-hépatiques par ponction-drainage.

The aim of this study was to show the result obtained by ultrasound-- or CT--guided puncture, possibly associated with transcutaneous drainage, for the treatment of hepatic and perihepatic abscesses. Preoperative imaging guides this treatment. It may reveal cavities as small as 1.5 cm in diameter. This nonsurgical treatment is based on single or multiple punctures, possibly followed by a long percutaneous drainage. The ideal indication is isolate liver abscesses located near the surface, as well as all juxtahepatic suppurative collections. Our experience is based on 73 patients, 32 of them presenting with an intrahepatic abscesses and 41 with a subphrenic or juxtahepatic abscess. For intrahepatic abscesses, healing was obtained with the surgical treatment in 75.3% of all cases: with a single puncture in 5 cases, two or more punctures in 4, and transcutaneous drainage in 11. Out of the 34 cases of perihepatic abscesses that underwent nonsurgical treatment, surgery was avoided in 25 cases, ie. 73.5% of all. Four of them were treated with a single puncture, 3 with repeated puncture, and 18 with transcutaneous drainage. The success of this procedure depends both on the indication and, most importantly, on the accurate application of the procedure.

[Percutaneous puncture and drainage under ultrasonic control of pancreatic pseudocysts]. / Ponction et drainage percutané sous contrôle échographique des pseudo-kystes pancréatiques.

Eighty-seven pancreatic pseudocysts have been treated with a single or repeated puncture, which was or was not followed by percutaneous drainage. When the diameter of the cyst was smaller than 5 cm, it was healed in 83.3% of all cases. When the size of the cysts ranged from 6 to 10 cm, puncture alone allowed curing them in 57.1% of all cases, otherwise it had to be completed by drainage. On the other hand, puncture alone was not sufficient for cysts with a diameter exceeding 10 cm, and an associated suction or surgical drainage was required. In the light of this experience, we can bring out the respective indications of single and multiple puncture and of percutaneous drainage, while taking account both of the size and of the etiological and clinicopathological features of the pseudocysts. In addition, this study allows assessing the incidence of the complications associated to this type of treatment.

[Transcutaneous drainage of pancreatic pseudocysts]. / Chreskozhnoe drenirovanie pankreaticheskikh psevdokist.

The clinical study includes 76 pancreatic pseudocysts localized in the head (24), body (37), and tail (15). The effect of treatment by means of a single or repeated purposeful aspiration in ultrasonic control is discussed. Recovery occurred in 83.3% of cases with cysts measuring up to 5 cm, in 61.3% in those with cysts measuring from 5 to 10 cm, and in 11.1% of cases in which the cysts measured more than 10 cm. As the result of 15 draining manipulations of cysts which were irresponsive to aspiration (9 of them measuring from 5 to 10 cm and 6 larger than 10 cm) complete recovery occurred in 13 cases. The authors discuss the indications for single, two, and many punctures on basis of a complex appraisal of the gland, the size and type of the cyst, and the cytologic results. The indications for percutaneous drainage, the period and techniques of its performance and preliminary and postmanipulation treatment with drugs are determined and the occurring complications are shown.