Hepatic Margin Research Articles

Injectable Hydrogels Including Magnetic Nanosheets for Multidisciplinary Treatment of Hepatocellular Carcinoma via Magnetic Hyperthermia.

Relapse and unresectability have become the main obstacle for further improving hepatocellular carcinoma (HCC) treatment effect. Currently, single therapy for HCC in clinical practice is limited by postoperative recurrence, intraoperative blood loss and poor patient outcomes. Multidisciplinary therapy has been recognized as the key to improving the long-term survival rate for HCC. However, the clinical application of HCC synthetic therapy is restricted by single functional biomaterials. In this study, a magnetic nanocomposite hydrogel (CG-IM) with iron oxide nanoparticle-loaded mica nanosheets (Iron oxide nanoparticles@Mica, IM) is reported. This biocompatible magnetic hydrogel integrated high injectability, magnetocaloric property, mechanical robustness, wet adhesion, and hemostasis, leading to efficient HCC multidisciplinary therapies including postoperative tumor margin treatment and percutaneous locoregional ablation. After minimally invasive hepatectomy of HCC, the CG-IM hydrogel can facilely seal the bleeding hepatic margin, followed by magnetic hyperthermia ablation to effectively prevent recurrence. In addition, CG-IM hydrogel can inhibit unresectable HCC by magnetic hyperthermia through the percutaneous intervention under ultrasound guidance.

Volume-based 18 F-FDG PET analysis of cardiac sarcoidosis using the descending aorta as a reference tissue.

18 F-FDG PET can be used to calculate the threshold value of myocardial volume based on the mean standardised uptake value (SUV mean ) of the aorta to detect highly integrated regions of cardiac sarcoidosis. The present study investigated the myocardial volume when the position and number of volumes of interest (VOIs) were changed in the aorta. The present study examined PET/computed tomography images of 47 consecutive cardiac sarcoidosis cases. VOIs were set at three locations in the myocardium and aorta (descending thoracic aorta, superior hepatic margin and near the pre-branch of the common iliac artery). The volume was calculated for each threshold using 1.1-1.5 times the SUV mean (median of three cross-sections) of the aorta as the threshold to detect high myocardial 18 F-FDG accumulation. The detected volume, correlation coefficient with the visually manually measured volume and the relative error were also calculated. The optimum threshold value for detecting high 18 F-FDG accumulation was 1.4 times that of the single cross-section of the aorta and showed the smallest relative errors of 33.84% and 25.14% and correlation coefficients of 0.974 and 0.987 for single and three cross-sections, respectively. The SUV mean of the descending aorta may be detected in good agreement with the visual high accumulation by multiplying the same threshold constant for both single and multiple cross-sections.

Assessment of Normal Liver Size among Adults by Ultrasonography in Kathmandu Medical College

Introduction: Ultrasonography is cheap, non-invasive, reliable, fast method of diagnostic investigation in the measurement of liver size. Normal range of liver size helps to diagnose hepatomegaly sonologically which may be clinically inapparent. Thus warrants further clinical evaluation and other investigations for the prevention of major hepatic comorbidities. Methods: A prospective, cross-sectional study was conducted on 400 adults with sonographic findings unrelated to liver pathologies. The liver was measured in right midclavicular line from hepatic dome to lower hepatic margin. The correlation between liver size and age, sex, weight, height, body mass index (BMI), and body surface area(BSA) was calculated. The data were properly analyzed in SPSS version 20 software. Results: Out of 400 patients, a male: female ratio of 1:1.25, and the age group was ranging from 20 years to 83 years with a mean age of 48.10±14.86 years were included. The mean liver length in males was 15.05 ± 0.27 cms, females were 14.32 ± 0.29 cms and the total population was 14.73 ±0.46 cms. There was a strong statistically significant correlation between liver size and height, weight whereas the correlation between liver span and BSA was moderate to weak but significant. Similarly, there was a weak but significant correlation between liver size and BMI with no significant association between liver size and age. Conclusion: Accurate assessment of liver size is of utmost importance in the evaluation of suspected hepatic pathologies.

RAVE-T2/T1 – Feasibility of a new hybrid MR-sequence for free-breathing abdominal MRI in children and adolescents

BackgroundThe new radial volumetric encoding RAVE-T2/T1 hybrid sequence is a modern three-dimensional sequence with multiparametric approach, which includes T2- and T1-weighted contrasts obtained in identical slice position during one measurement. However, the RAVE-T2/T1 hybrid sequence is not yet being used in clinical routine. PurposeThe aim of this study was to evaluate the RAVE-T2/T1 hybrid sequence in a pediatric population with a clinical indication for an abdominal MRI examination to demonstrate that the hybrid imaging may be less challenging to perform on children. Materials and MethodsOur retrospective observational study included pediatric patients of all age groups and required for an abdominal MRI examination. Non-contrast standard axial T1 DIXON and non-contrast RAVE-T2/T1 hybrid sequence were obtained at 3 T. MRI studies were analyzed independently by two pediatric radiologists using a 5-point Likert-type scale in five different categories. T1- and T2-weighted sequences were each compared with the RAVE-T2/T1-sequence using a Wilcoxon signed-rank test. ResultsThe analysis included 15 children (mean age, 11 years and 4 months, 7 girls and 8 boys). The Cohens Kappa of interrater agreement measured 0.62. The T2 weighted part of the RAVE-T2/T1 sequence was significantly better than the standard T2 HASTE sequence in four of five image quality categories: overall image quality (2.2 ± 0.7 vs 1.8 ± 0,7, p = 0.03), respiratory motion artefacts (3.8 ± 0.4 vs 2.0 ± 0.7, p <= 0.01), portal vein clarity (3.3 ± 0.8 vs 2.2 ± 0.7, p <= 0.01), hepatic margin sharpness (2.4 ± 1,0 vs 1.8 ± 0.7, p <= 0.01). The T1 weighted part of the RAVE-T2/T1 sequence was significantly better than the standard T1 DIXON weighted sequence in three of five image quality categories: respiratory motion artefacts (4.0 ± 0.2 vs 3.6 ± 0.8, p = 0.01), portal vein clarity (2.7 ± 0.9 vs 2.1 ± 0.7, p <= 0.01), hepatic margin sharpness (3.2 ± 0.7 vs 2.6 ± 0.9, p <= 0.01). ConclusionsThe RAVE-T2/T1 hybrid sequence is feasible and equal compared to standard T1- and T2-weighted sequences in the assessment of abdominal organs in a pediatric population. Due to non-inferiority to the current standard sequences for abdominal imaging, the RAVE-T2/T1 hybrid sequence is a good alternative for children who cannot be examined in breath-hold technique.

Is Hepatectomy Justified for BRAF Mutant Colorectal Liver Metastases?: A Multi-institutional Analysis of 1497 Patients.

To analyze clinical outcomes and prognostic variables of patients undergoing hepatic resection for BRAF mutant (BRAF-mut) colorectal liver metastases (CRLM). Outcomes following hepatectomy for BRAF-mut CRLM have not been well studied. All patients who underwent hepatectomy for CRLM with complete resection and known BRAF status during 2001 to 2016 at 3 high-volume centers were analyzed. Of 4124 patients who underwent hepatectomy for CRLM, 1497 had complete resection and known BRAF status. Thirty-five (2%) patients were BRAF-mut, with 71% of V600E mutation. Compared with BRAF wild-type (BRAF-wt), BRAF-mut patients were older, more commonly presented with higher ASA scores, synchronous, multiple and smaller CRLM, underwent more major hepatectomies, but had less extrahepatic disease. Median overall survival (OS) was 81 months for BRAF-wt and 40 months for BRAF-mut patients (P < 0.001). Median recurrence-free survival (RFS) was 22 and 10 months for BRAF-wt and BRAF-mut patients (P < 0.001). For BRAF-mut, factors associated with worse OS were node-positive primary tumor, carcinoembryonic antigen (CEA) >200 μg/L, and clinical risk score (CRS) ≥4. Factors associated with worse RFS were node-positive primary tumor, ≥4 CRLM, and positive hepatic margin. V600E mutations were not associated with worse OS or RFS. A case-control matching analysis on prognostic clinicopathologic factors confirmed shorter OS (P < 0.001) and RFS (P < 0.001) in BRAF-mut. Patients with resectable BRAF-mut CRLM are rare among patients selected for surgery and more commonly present with multiple synchronous tumors. BRAF mutation is associated with worse prognosis; however, long-term survival is possible and associated with node-negative primary tumors, CEA ≤ 200 μg/L and CRS < 4.

P062 Crohn's disease presenting as fever of unknown origin in a six-year-old male

BACKGROUND: Inflammatory Bowel Diseases (IBD) are rising in incidence in the pediatric population. While most present classically, some have limited findings. We present a case of pediatric Crohn's Disease (CD) diagnosed during a fever of unknown origin (FUO) evaluation. We aim to stress the importance of uncommon presentations of a diagnosis with significant implications and requiring prompt intervention. CASE: A 6-year-old male presented with 2 weeks of evening 104–106 F fevers, weakness, decreased intake, and weight loss. He also had one loose, non-mucous, non-bloody stool daily. Fevers failed to resolve with outpatient courses of antibiotics and CRP continued to rise. History revealed camping in North Carolina 2 weeks preceding symptom onset. Family history was unremarkable. No further symptoms, including abdominal pain, were elicited. Exam exhibited fever, tachycardia, tachypnea, uvular and palatal ulcers, dry mucous membranes, cervical, submandibular and inguinal lymphadenopathy. No skin, eye, joint, perianal or abdominal findings observed. Preliminary labs showed hypoalbuminemia (2.6), elevated CRP (7.4) and ESR (55), mild leukocytosis (14.9), and microcytic anemia (Hgb 10.1, MCV 71.8). An extensive FUO evaluation failed to identify a source and thus imaging was pursued. CT abdomen/pelvis showed terminal ileitis and free fluid along the right paracolic gutter and right hepatic margin. Endoscopic evaluation for IBD discovered esophagitis along with ulcerations, edema and friable mucosa in the terminal ileum. Pathology was significant for active chronic lymphoplasmacytic gastritis with eosinophils and subtle early granulomatous inflammation with multinucleated giant cells. Distal esophagus showed chronically active inflammation and lymphocytic esophagitis without granulomas. Terminal ileum biopsy revealed active, chronic granulomatous ileitis with ulceration and granulation. No organisms noted throughout. He was diagnosed with CD and initiated on steroids along with Mesalamine. DISCUSSION: One quarter of IBD is diagnosed by the age of 20, with 4% presenting before 5 and 18% before 10 years of age. Recent incidence reports show combined U.S. and Canadian data of 10 per 100,000. Prevalence in the U.S. alone is 100–200 per 100,000. Furthermore, IBD in those less than ten is becoming more common. With recent therapeutic advances, significant morbidity and mortality is preventable. However, treatment delays occur from a diagnostic lag in 20% when symptoms are ambiguous. This case highlights early onset IBD and brings attention to non-classic presentations. Our patient was diagnosed 1.5 months after initial symptoms. An average diagnosis lag time of about 3.4 months in pediatric CD has been documented, with further delay if pre-existing gastrointestinal symptoms exist (26 months). Whereas CD is considered when abdominal pain, diarrhea, and weight loss are identified, our patient presented with daily fever along with oral lesions, lymphadenopathy and weight loss. A few case reports cite FUO, another difficult and often unclear diagnosis, as the presentation for IBD. Fever as the sole initial symptom for IBD occurs in 10-15% of cases. IBD is a complicated illness, especially in the pediatric population. When considering effects on growth, psychosocial development and the long-term complications, we must consider IBD in the differential of pediatric patients with vague and persistent symptoms including FUO.

Circulating cell-free tumor DNA chromosomal instability and circulating tumor cells as tools to predict microvascular invasion of hepatocellular carcinoma.

e14524 Background: Extended hepatic surgical margins, especially anatomical resections, were suggested for hepatocellular carcinoma (HCC) patients with pathological microvascular invasion (MVI) to improve patient survival. Here we investigated plasma cell-free tumor DNA (ctDNA) and circulating tumor cells as a tool to evaluate MVI before surgery. Methods: 47 treatment-naïve patients with liver lesions were recruited since June 2018, Peripheral blood samples were collected before surgery for all the individuals. Plasma cfDNA was sent to low-coverage genome-wide sequencing, followed by chromosomal instability analyses by a customized workflow UCAD. Circulating tumor cells (CTC) were analyzed by CELLSEARCH@ System. MVI was reported by pathological examination after surgery. Results: Of the 47 patients recruited, there are 32 hepatocellular carcinoma (HCC), 8 intrahepatic cholangiocarcinoma (ICC), 4 benign lesions, 1 solitary fibrous tumor, 1 neuroendocrine tumor and 1 hepatic epithelioid cell tumor by pathological examinations. MVI was also reported for HCCs. Nineteen of 32 HCC patients (59.4%) was found with elevated chromosomal instability (CIN). The most frequent changed chromosomes include 1q, 6p and 8q. Nine of 19 (47.4%) elevated CIN patients were MVI positive by pathological examinations. Among them, 4 was confirmed as MVI = 2. The other 5 was MVI = 1. 11 of 13 (84.6%) patients with low CIN were MVI negative (MVI = 0) as reported by pathological examinations. The rest 2 were reported as MVI = 1. Two of 32 HCC patients (6.25%) was found with positive CTC (tumor cell count &gt; 0). The patient with CTC = 2 was reported as MVI = 1. The other one with CTC = 1 was MVI = 0. Taking together, 20 patients (62.5%) were found either elevated ctDNA or positive CTC. 9 were confirmed as MVI negative. The overall positive predictive value is 45.0%. 12 patients (38.7%) were both ctDNA CIN low and CTC negative. 10 were confirmed as MVI negative. The negative predictive value (NPV) is 83.3%. Conclusions: Elevated circulating tumor DNA chromosomal instability has good PPV and NPV in the predicting of MVI. In such patients, anatomical hepatic resections might be recommended to improve survival.

Ultrasonographic Characterization of Spleen and Liver in Clinically Healthy Camels

This study aimed to investigate the ultrasonographic position and characteristic appearance of spleen and liver in adult camels. The spleen was visualized on the left side from 9th to12th ICS. Many small sized echoes occupied uniform space were the characteristic constituent of splenic parenchyma and vessels seen as elongated or round to oval anechoic views within the parenchyma. The splenic dorsal margin and extent were largest at 9th ICS (66.75±1.47 and 17.1±1.01 cm) and smallest at 12th ICS (41.8±1.31 and 10±0.74 cm), respectively. The mean diameter of vessels of the spleen ranged from 0.21±0.03 to 0.4±0.01 cm. For the liver, it was scanned from the right side between 9th to 11th ICS. The shortest hepatic dorsal and ventral margins (37.07 ± 1.07 and 54.37 ± 1.76 cm) were found at 11th ICS, but cranially became greater to 9th ICS (43.84 ± 1.82 cm and 61.58 ± 1.17), respectively. The greatest hepatic extent was at 9th ICS (17.72 ± 1.68). The normal hepatic parenchyma was composed of large numbers of weak echoes evenly spread through the liver. We concluded that, the splenic and hepatic assessment by ultrasonography could provide an essential reference guide for diagnosing splenic and hepatic disorders in camels.

Experimental Evaluation of a New Tissue Factor-Based Topical Hemostat (TT-173) for Treatment of Hepatic Bleeding

Background: Excessive blood loss is a relevant complication of partial liver resection. Topical hemostatic agents have proven useful to improve the control of the bleeding in this among other surgical indications. Until now all of these products have been based on the action of thrombin. In contrast TT-173 is a new topical hemostatic agent based on recombinant tissue factor naturally incorporated into membrane vesicles. This work sought to assess the efficacy and toxicity of TT-173 in an animal model of liver resection.Materials and Methods: Procoagulant activity of 0.15, 0.41, and 1 mg of TT-173 was evaluated in pigs subjected the resection of hepatic lobe margins. The most effective of these doses was also compared against thrombin. In addition, the toxicity, local tolerance, systemic absorption, and immunogenicity of the product were investigated in rats subjected to liver biopsy lesion.Results: The three doses of TT-173 evaluated significantly reduced the bleeding time in liver lesions. The highest dose of product was significantly more effective than the others and thrombin. Application of high doses of TT-173 in rats did not cause any local or systemic alterations. Absorption into blood stream was negligible and no immunogenic reaction against the product was detected.Conclusions: TT-173 shows favorable pharmacodynamic properties for improving hemostasis in partial liver resection which support further investigation of the product in this surgical indication.

Chemoradiotherapy for positive hepatic margin on cholangiocarcinoma

Background: Positive hepatic margin in resected cholangiocarcinoma influence the stump recurrence. However, impact of chemoradiotherapy (CRT) for positive hepatic margin on survival and recurrence was not fully evaluated. Methods: Two hundred ninety-five patients with cholangiocarcinoma who underwent surgical resection between 2002 and 2013 were included in this retrospective study. Clinical effect of chemoradiotherapy for positive hepatic margin on survival and recurrence and prognostic factors of cholangiocarcinoma were evaluated. Results: Hepatic margin was negative (hm−) in 257 and positive (hm+) in 38. Of 38 patients with positive hepatic margin, 20 patients received postoperative chemoradiotherapy and 18 did not. Hepatic stump recurrence was occurred in 13 patients. The incidence was significantly higher in patients with positive hepatic margins (16%) than those with negative hepatic margins (3%) (p = 0.003). Among patients with positive hepatic margins, the incidence was almost identical between patients with and without chemoradiotherapy; 17% (3/18) in hm+/CRT− and 15% (3/20) in hm+/CRT+ patients (p = 0.616). Median survival time was 48 months in hm−, 38 months in hm+/CRT−, 50 months in hm+/CRT+ patients, respectively. The differences were not significant between each group. Multivariate analysis revealed that presence of lymph node metastasis, histologic grade of G2/G3, and combined portal vein resection as the significant prognostic factors. However, performance of postoperative adjuvant chemoradiotherapy did not contribute the prolongation of survival. Conclusion: Chemoradiotherapy for positive hepatic ductal margin was not effective in survival and stump recurrence.

Prognostic influence of hepatic margin after resection of colorectal liver metastasis: role of modern preoperative chemotherapy.

Modern chemotherapy (CTX) increases survival in stage IV colorectal cancer. In colorectal liver metastases (CLM), neoadjuvant (neo) CTX may increase resectability and improve survival. Due to widespread use of CTX in CLM, recent studies assessed the role of the hepatic margin after CTX, with conflicting results. We evaluated the outcome after resection of CLM in relation to CTX and hepatic resection status. Since 2000, 334 patients with first hepatic resection for isolated CLM were analyzed. Thirty-two percent had neoadjuvant chemotherapy (targeted therapy in 42%). Sixty-eight percent never had CTX before hepatectomy or longer than 6months before resection. The results were gained by analysis of our prospective database. Positive hepatic margins occurred in 8% (independent of neoCTx). Patients after neoCTX had higher numbers of CLM (p<0.01) and a longer duration of surgery (p<0.03). After hepatectomy, 5-year survival was 45% and correlated strongly with the margin status (47% in R-0 and 21% in R-1; p<0.001). Survival also correlated with margin status in the subgroups with neoCTX (p<0.01) or without neoCTx (p<0.01). In multivariate analysis of the entire group, hepatic margin status (RR 3.2; p<0.001) and age>65years (RR 1.6; p<0.01) were associated with poorer survival. In the subgroup of patients after neoCTX (n=106), only the resection margin was an independent predictor of survival (p<0.001). In patients with isolated colorectal liver metastases undergoing resection, the hepatic margin status was the strongest independent prognostic factor. This effect was also present after neoadjuvant chemotherapy for CLM.

Clinical efficacy of surgical treatment for stage IV gastric cancer after conversion therapy

Clinical efficacy of surgical treatment for stage IV gastric cancer after conversion therapy

Comparison of image quality between conventional VIBE and radial VIBE in free-breathing paediatric abdominal MRI

To compare the image quality between conventional volume interpolated breath-hold examination (VIBE) and radial VIBE in contrast-enhanced fat-suppressed T1-weighted images of paediatric abdominal magnetic resonance imaging (MRI) during free-breathing. Images from paediatric patients who underwent contrast-enhanced abdominal MRI with a 3T magnet using conventional VIBE (conventional group) and radial VIBE (radial group) while freely breathing were reviewed retrospectively. For objective analysis, the mean values of noise and signal-to-noise ratio (SNR) in the liver on contrast-enhanced fat-suppressed T1-weighted images were compared. For subjective analysis, overall image quality, respiratory motion, portal vein clarity, and hepatic margin sharpness were assessed using four-point scales. Nine patients (mean age of 2.8±2.3 years) in the conventional and 17 patients (mean age of 2.4±2.8 years) in the radial groups were included. According to the objective analysis, the noise was significantly lower and the SNR was significantly higher in the radial group than those in the conventional group (all, p<0.001). In the subjective analysis, overall image quality, respiratory motion, portal vein clarity, and hepatic margin sharpness were all significantly higher in the radial group (all, p<0.001). Paediatric abdominal MRI images with radial VIBE showed lower noise with higher SNR in objective analysis and higher image quality in subjective analysis, compared to conventional VIBE.

Extra-abdominal fibromatosis: Clinical and therapeutic considerations based on an illustrative case.

Extra-abdominal fibromatosis is a rare, benign disease that is characterized by a local but not metastatic invasivity. In particular, desmoid tumors of the chest wall represent only 10-20% of all deep fibromatoses. The disease occurs more often in females and has a higher incidence between puberty and the fourth decade of life. The present study reports the case of a 34-year-old female who came to our attention due to a voluminous mass in the right subcostal region. The magnetic resonance imaging of the upper abdomen confirmed the presence of a neoplasm localized between the anterior hepatic margin and the right costal plane. Through a right subcostal laparotomy, the voluminous 95×45×94-mm neoplasm was excised. Histological examination showed evidence consistent with extra-abdominal fibromatosis. The patient has not shown recurrence of the disease for 4 years since the surgery. Overall, radical surgery with disease-free resection margins is the prime treatment option for this disease. Other therapeutic options, such as radiotherapy, hormonal therapy or treatment with imatinib mesylate, can also be considered in certain cases.

The gallbladder of human foetuses: A morphological and morphometric study

IntroductionThe study aims in analyzing the gross development of human gallbladder and its variations. Methods92 foetuses, 59 males and 33 females, of different age groups were dissected for morphological analysis of gallbladder. The length and weight of foetal gallbladder, its relationship with the gallbladder fossa of liver and inferior hepatic margin, its lumen and wall, detection of bile and congenital anomalies are looked into the present study. ResultsIn foetus, the gallbladder is short of inferior hepatic margin. A sudden increase in mean length and weight of the gallbladder is observed as foetal age advances from 26–30 weeks to 31–35 weeks. . Bile staining of the wall of gallbladder is observed from 17-week old foetuses onwards Double gallbladder with common cystic duct, intraparenchymal gallbladder, a gallbladder on the inferior surface of liver along the line of attachment of falciform ligament (which is attached on the anterior surface of liver), a gallbladder with dilated body and neck, Phrygian cap, an enlarged gallbladder with wide lumen, thin wall and absence of bile stain were the variations observed in the present study. DiscussionFrom this study, the gross development of the gallbladder can be analyzed. The knowledge of the variations in development of human gallbladder will be helpful for clinical studies.

513 Prognostic Value of Hepatic Margin Status After Resection of Colorectal Liver Metastases After Preoperative Chemotherapy

Objective: MRI has been shown to be more accurate than CT in the diagnoses and characterization of hepatic lesions. However, it is unclear how MRI affects surgical decision making. The objective of this study is to identify the effect of MRI on clinical management of hepatic lesions after initial CT evaluation. Methods: A retrospective review of a prospective liver database between 2004 and 2013 was performed and a total of 102 cases in 101 patients were identified that underwent CT followed by MRI within 30 days to characterize hepatic lesions being evaluated for surgical treatment. The findings between CT and MRI were compared to identify differences in location, size, number and characterization of hepatic lesions. Diagnoses were confirmed by operative findings/pathology and follow up on imaging. The effect of MRI on management was classified into three categories: 1) No change from CT, 2) Diagnostic clarification leading to no surgery (A: unresectable, B: no indication for surgery, C: change in non-surgical treatment), and 3) Change in extent of surgical resection (A: larger resection, B: smaller resection) Results: In the 102 cases, the major tumor histology groups were as follows: benign [9 (9%)], colorectal metastases [47 (46%)], HCC/cholangiocarcinoma [26 (25%)], neuroendocrine metastases [12 (12%)], and other [8 (8%)]. Category 1 had 57 cases (56%), category 2 had 19 cases (19%), and category 3 had 26 cases (25%). Of the 19 category 2 cases, there were eight 2A, nine 2B and two 2C cases. Of the 26 category 3 cases, there were fifteen 3A cases and eleven 3B cases. The number of tumors on CT [Mean 1.6 (category 1) vs. 2.4 (categories 2 and 3), p=0.0034] was significantly associated with MRI imaging leading to a change in management. The maximum tumor size on CT [Mean 4.0 (category 1) vs. 2.7 (category 2 and 3), p=0.0714] suggested a trend towards MRI having an effect on surgical management. Factors such as age, gender, BMI, cirrhosis, prior chemotherapy, tumor histology, vascular invasion on CT, and tumor location on CT were not significantly associated with MRI category 2 or 3. Conclusion: The use of MRI in the surgical evaluation of hepatic lesions after initial CT scan changed management in 44% of cases. Multiple lesions and smaller lesions seen on CT may derive the most benefit from application of MRI imaging.

The Aberrant Aberration

Question: A 59-year-old man was referred for evaluation of a mass found during laparoscopic cholecystectomy performed 11 days prior. The patient initially sought medical evaluation for a palpable mass in his right upper quadrant in addition to a 25-lb weight loss. Ultrasonography revealed a dilated gallbladder with wall thickening and a 2.0 × 1.8 × 1.4-cm mass on the superolateral aspect. At the time of laparoscopic cholecystectomy, a mass adherent to the radial hepatic margin was identified and seemed to invade the perimuscular connective tissue. Pathology was interpreted as invasive, moderately differentiated adenocarcinoma. The patient was referred to our institution. Preoperative testing revealed a CA19–9 level of 277 U/mL (normal, <55 U/mL). He subsequently underwent locoregional lymphadenectomy and partial right hepatectomy (segments IVb and V) for complete oncologic resection. On postoperative day 5, increasing bilious output from his Jackson-Pratt (JP) drain was noted, raising suspicion for bile leak. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a bile leak from the cystic duct remnant (Figure A) and other notable findings (Figure B). The cystic duct remnant leak was initially treated with endoscopic sphincterotomy and placement of two 10-F, 9-cm plastic stents into the extrahepatic bile duct. Over the subsequent days, increasing output from the JP drain was noted. The high-volume drainage was noted to have an amylase concentration >17,000 U/L. The previously bilious effluent now appeared colorless and repeat ERCP was performed. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. In addition to the bile leak, there was radiographic evidence of pancreaticobiliary maljunction (PBM) with the pancreatic duct arising from a low-inserting cystic duct remnant (Figure C). Standard endoscopic management of the cystic duct leak using endoscopic sphincterotomy and biliary diversion through stenting (Figure B) was unsuccessful. At repeat ERCP, the anomalous pancreatic duct could not be accessed for diversion of flow through the duodenum; thus, a 7-F, 5-cm pancreatic stent with additional side-holes was placed into the cystic duct remnant. Two 10-F, 9-cm plastic stents were replaced in the extrahepatic bile duct for diversion and to prevent migration of the cystic duct stent. The drain output decreased to <20 mL and the patient was discharged. Repeat ERCP 1 month later revealed complete resolution of the leak. PBM has a prevalence of 0.03% and occurs frequently in patients with choledochal cysts.1Yamao K. Mizutani S. Nakazawa S. et al.Prospective study of the detection of anomalous connections of pancreatobiliary ducts during routine medical examinations.Hepatogastroenterology. 1996; 43: 1238-1245PubMed Google Scholar PBM is defined as a union of the pancreatic and biliary ducts outside the duodenal wall leading to a long common channel (often ≥15 mm). The junction is beyond the influence of the sphincter of Oddi, resulting in reciprocal reflux of biliary and pancreatic juices. Persistent reflux of proteolytic pancreatic enzymes and phospholipase A2 is postulated to injure the biliary epithelium and induce metaplasia or promote carcinogenesis.2Shimada K. Yanagisawa J. Nakayama F. Increased lysophosphatidylcholine and pancreatic enzyme content in bile of patients with anomalous pancreaticobiliary ductal junction.Hepatology. 1991; 13: 438-444Crossref PubMed Scopus (122) Google Scholar In addition to evidence of PBM the pancreas duct was directly arising from a low inserting cystic duct. This variant of PBM has not been previously described, but certainly resulted in direct reflux of pancreatic juices into the cystic duct and gallbladder, likely contributing to gallbladder cancer. The association of PBM and gallbladder cancer was established in the 1980s, and most reports cite an incidence of 10%–15% of gallbladder cancer arising in this setting.

METASTATIC PANCREATIC CARCINOMA AND BRONCHIOLOALVEOLAR ADENOMAS IN AN EGYPTIAN FRUIT BAT (ROUSETTUS AEGYPTIACUS)

An adult female, intact Egyptian fruit bat (Rousettus aegyptiacus) was presented for lethargy, anorexia, and markedly reduced flying activity. Physical and ultrasound examinations were suggestive of an abdominal mass with free fluid within the abdomen. Based on the poor and deteriorating clinical condition of the animal, euthanasia was elected. Gross necropsy revealed an irregular thickening at the root of the mesentery and a diffusely, dark-red liver with rounded hepatic margins. Histologic examination revealed extensive neoplastic effacement of the pancreas with invasion into the surrounding mesentery and mesenteric lymph nodes and metastatic spread to the liver. Based on the morphology of the neoplastic cells, the involvement of the pancreas, and immunohistochemistry, a diagnosis of metastatic pancreatic carcinoma was made. Additionally, two small neoplasms were identified in the lungs. These masses were distinct from the carcinoma, and their morphology was consistent with bronchioloalveolar adenomas. This is the first known report of either benign pulmonary lesions or pancreatic carcinomas in the order Chiroptera.

Avaliação morfométrica e hemodinâmica comparativa dos vasos envolvidos no shunt portossistêmico congênito em cães

Foram realizados o estudo morfométrico e o estudo hemodinâmico da veia porta em vinte cães clinicamente normais, de idade igual e inferior a 120 dias e em quatorze cães portadores de shunt portossistêmico, de idades entre 90 e 360 dias. Nos cães do grupo controle, as margens hepáticas apresentaram-se entre 1,50cm e 3,00cm caudalmente à margem costal. Os diâmetros médios da veia porta (VP), veia cava caudal (VCC) e aorta abdominal (AO) obtidas foram respectivamente, 0,38cm, 0,37cm e 0,41cm. As proporções entre os diâmetros médios VP/VCC e VP/AO apresentaram médias de 1,10 e 0,94, respectivamente. As médias das áreas da VP, VCC e AO resultaram respectivamente em 0,12cm² , 0,11cm² e 0,14cm². No estudo hemodinâmico da VP destes animais, utilizando-se o ultrassom Doppler, a velocidade média de fluxo sangüíneo portal (VMFSP) mediu 17,76cm/s. A média de fluxo sangüíneo portal (FSP) resultou em 83,11ml/min/kg. O índice de congestão (IC) apresentou média de 0,006. Para o grupo de cães portadores de shunt portossistêmico, o fígado apresentou redução de seu volume, sendo as margens hepáticas visibilizadas entre 1,00cm e 2,00cm cranialmente à margem costal. No estudo morfométrico, as médias dos diâmetros médios obtidos de VP, VCC e AO resultaram respectivamente em 0,40cm, 0,74cm e 0,56cm. As proporções entre os diâmetros médios VP/VCC e VP/AO resultaram respectivamente em 0,54 e 0,69. As médias das áreas de VP, VCC e AO resultaram respectivamente em 0,14cm², 0,31cm² e 0,25cm². Ao ultrassom Doppler a VMFSP mediu 22,29cm/s e a média do IC da VP obtido foi de 0,006.

Hepatic Resection is Safe for Metachronous Hepatic Metastases from Ovarian Cancer.

ObjectiveTo explore the efficacy of hepatic resection (HR) in a relatively unselected group of patients with ovarian cancer liver metastases (OCLM).MethodsA study was conducted between September 2000 and September 2011 on 60 ovarian cancer patients with hepatic metastases (24 solitary and 36 multiple), 40 of whom had extrahepatic metastases. HR was done in all patients provided that curative hepatic resection was feasible, and extrahepatic disease was controlled with medical and/or surgical therapy.ResultsMost patients (n=54; 90.0%) had a negative hepatic margin (R0), whereas 6 patients (10.0%) had microscopic disease at the margin (R1). The prognostic value of each study variable was assessed using log rank tests for univariate analysis and Cox proportional hazard models for multivariate analysis. The result was a median survival of 39 months and 5-year overall survival rate of 30%. Univariate analysis showed that surgery result (P=0.001), disease free interval (P=0.018) and the number of hepatic lesions (P=0.018) were significantly related to survival. Furthermore, the surgery result (P=0.004) remained significant for prognosis in multivariate analysis.ConclusionsFor patients with OCLM, HR is safe and may provide a significant survival benefit compared with medical therapy alone. A long interval time, the number of hepatic lesions, and surgery results are key prognostic factors. Favorable outcomes can be achieved even in patients with medically controlled or surgically resectable extrahepatic disease, indicating that surgery should be considered more frequently in the multidisciplinary care of patients with OCLM.