Limbic frontal cortex in hominoids: a comparative study of area 13

Because intraoperative sonography displays segmental anatomy, allows discovery of more lesions than previously suspected from preoperative imaging, surgical inspection, or palpation, and permits more certain diagnosis of problematic masses, it facilitates surgical decision-making when liver resection or cryoablation is anticipated. Intraoperative sonography provides a guidance modality to accurately place cryosurgery probes in liver masses. More precise treatment of metastatic and primary tumors of the liver is possible with cryoablation because intraoperative sonography provides a means of monitoring the growth of the enlarging freeze zone to insure adequate surgical margins. Postoperative detection of acute complications after cryosurgery is best done with computed tomography. Normally cryosurgery defects shrink with time and lose the peripheral contrast opacification seen after surgery. Gas collections, seen as a result of tissue necrosis, must be discriminated from infection. Tumor recurrence can be detected well with computed tomography or magnetic resonance imaging following hepatic cryosurgery.     

Functional role of CD95 ligand in concanavalin A-induced intestinal intraepithelial lymphocyte cytotoxicity

OBJECTIVE: To update the analysis of technical and biologic factors related to hepatic resection for colorectal metastasis in a large single-institution series to identify important prognostic indicators and patterns of failure. SUMMARY BACKGROUND DATA: Surgical therapy for colorectal carcinoma metastatic to the liver is the only potentially curable treatment. Careful patient selection of those with resectable liver-only metastatic disease is crucial to the success of surgical therapy. METHODS: Two hundred forty-four consecutive patients undergoing curative hepatic resection for metastatic colorectal carcinoma were analyzed retrospectively. Variables examined included sex, stage of primary lesion, size of liver lesion(s), number of lesions, disease-free interval, ploidy, differentiation, preoperative carcinoembryonic antigen level, and operative factors such as resection margin, use of cryotherapy, intraoperative ultrasound, and blood loss. RESULTS: Surgical margin, number of lesions, and carcinoembryonic antigen (CEA) levels significantly control prognosis. Patients with only one or two liver lesions, a 1-cm surgical margin, and low CEA levels have a 5-year disease-free survival rate of more than 30%. Disease-free interval, original stage, bilobar involvement, size of metastasis, differentiation, and ploidy were not significant predictors of recurrence. The pattern of failure correlates with surgical margin. Routine use of intraoperative ultrasound resulted in an increased incidence of negative surgical margin during the period examined. CONCLUSIONS: Surgical resection or cryotherapy of hepatic metastasis from colorectal cancer is safe and curable in appropriately selected patients. Biologic factors, such as number of lesions and carcinoembryonic antigen levels, determine potential curability, and surgical margin governs the patterns of failure and outcome in potentially curable patients. Optimization of selection criteria and surgical resection margins will improve outcome.     

Assessment of a new ventricular contractile index obtained with transoesophageal echocardiography before and after cardiopulmonary bypass in cardiac surgical patients

Normal liver can tolerate even a right trisegmentectomy with caudate resection which results' in a reduction of liver volume by 80%, while a decompensated cirrhotic liver cannot tolerate even partial hepatic resection. This can be ascribed to decreased functional volume and the deterioration of individual hepatocyte function, which is caused and amplified by inappropriate intraoperative procedures and postoperative management. Problems related to liver diseases, including liver cirrhosis, jaundice and chronic active hepatitis, operative techniques and postoperative management should be considered during hepatic resection. Pathophysiology and tactics for handling these problems will be described.     

Selective attention to real phobic and safety stimuli

BACKGROUND: Improvements in the understanding of intrahepatic anatomy and radiographic technology have facilitated a segment-oriented approach to liver resection. This approach involves the resection of isolated anatomic segments or sectors of the liver as dictated by the extent of the intrahepatic pathology. Segment-oriented resection allows maximal conservation of normal liver parenchyma while clearing tumor. This report describes the technical features and the results of a prospective evaluation of segmental and sectoral resections in the treatment of malignant hepatic neoplasms. STUDY DESIGN: Patients with malignant hepatic neoplasms that were treated with a segment-oriented hepatic resection were identified from a prospective clinical data base. After undergoing segment-oriented liver resection, the patients were followed at regular intervals. Recurrent disease was the end point of the study. Followup is reported at a median of 12 months. This review outlines the technique of resection, intraoperative events, operating time, blood loss, and the ability to obtain negative resection margins. RESULTS: During the 5-year period between July 1992 and July 1997, 400 patients underwent liver resection for metastatic neoplasms and hepatocellular carcinoma (HCC). During this period, 79 patients (20%) were treated with a segment-oriented resection. These patients represent the study group for this report. The overall mortality rate was 2.5%; all postoperative deaths occurred in patients with HCC and cirrhosis. Overall morbidity was 26%. The median hospital stay was 8 days. Mean transfusion requirements were 1.0 +/- 0.3 U of packed red blood cells. Patients with HCC showed a greater transfusion requirement than did patients without HCC: 2.7 +/- 1.2 U versus 0.6 +/- 0.2 U (p < 0.05). Of the patients without HCC, 17% required transfusion. During the 12-month median followup period, the overall disease recurrence rate was 23%. Disease recurred at the hepatic-resection margin in 2.5% of the patients. CONCLUSIONS: Segmental resection is a safe technique that allows complete resection of liver tumors with preservation of normal liver parenchyma. Segmental resection is particularly useful for patients with HCC and patients undergoing repeat liver resections or bilobar resections.     

Resection for multiple metastatic liver tumors after portal embolization

BACKGROUND: Five patients with bilateral multiple liver metastases (3 to 12 lesions) from colorectal cancer who underwent extensive liver resection after portal embolization are described. METHODS: Portal embolization of the right portal branch was performed 9 days to 8 months before hepatic resection. The location and number of metastases were determined by intraoperative ultrasonography at the time of liver resection to accomplish complete resection of the tumors. Extended right lobectomy was carried out in four patients, two of whom underwent additional wedge resection of nodules located in the left lateral segment. The other patient underwent right lobectomy associated with local resection of the tumor in the left lobe. RESULTS: The postoperative course in the five patients was uneventful, with no serious complication or liver dysfunction. Although one patient died of recurrence 28 months after liver resection, the remaining four patients were alive and free of cancer between 36 and 74 months after hepatectomy. CONCLUSIONS: The presence of bilateral multiple (four or more) metastatic liver lesions from colorectal cancer is not considered a contraindication for hepatic resection if thorough examination of the liver is performed with intraoperative ultrasonography and the surgical risk is minimal. Portal embolization appears effective for increasing the safety of hepatectomy for patients with small metastases who require major right-sided resection combined with wedge resection of the left lobe.     

Neuroendocrine effect of a short-term treatment with DHEA in postmenopausal women

BACKGROUND: Most publications during the past decade have condemned the use of anatomic resection for liver trauma and advocated a conservative surgical approach when operative intervention was required. This policy has been supported by the high mortality rate reported by most authorities. The purpose of this study was to assess the results of anatomic hepatic resection for liver trauma in an institution in which the hepatobiliary surgeons are responsible for the management of severe liver injuries. METHODS: During the period 1983 to 1996, 287 patients with liver injuries were admitted to the hospital and 37 patients with severe liver trauma underwent anatomic resection. Demographic, clinical, operative, and postoperative data were collected and analyzed. The resections performed included right hemihepatectomy (n = 27), left hemihepatectomy (n = 1), left lateral segment resection (n = 5), and segmental resection (n = 4). RESULTS: There were three postoperative deaths after right hemihepatectomy (11.1%) and an overall mortality rate of 8.1%. There were no intraoperative deaths. Postoperative complications occurred in 22 patients (60%) and were most frequent in patients with concomitant injuries to other systems. Liver-related morbidity occurred in seven patients (19%). The median postoperative stay was 20 days. CONCLUSIONS: Anatomic hepatic resection for trauma is associated with low mortality and liver-related morbidity rates when performed by experienced hepatobiliary surgeons, and its role in the management of severe hepatic trauma should be reevaluated.     

A place called HOPE: group psychotherapy for adolescents of parents with HIV/AIDS

Intraoperative ultrasound, whether during celiotomy or laparoscopy, plays an important role in assisting the surgeon in directing appropriate therapy for intra-abdominal diseases, particularly primary or metastatic malignancies involving the liver and primary malignancies of the pancreas and upper gastrointestinal tract. It is the most sensitive imaging technique for detecting small intraparenchymal lesions of the liver, pancreas, and other solid organs. Owing to its increased sensitivity over all commonly used preoperative imaging studies, it is responsible for changing the intraoperative treatment plan of these tumors in a significant percentage of cases. This is particularly true with respect to resectability. In the era of laparoscopic surgery, it replaces the surgeon's inability to palpate the liver and other organs during surgery. As surgeons use a laparoscopic approach with increasing frequency to treat intra-abdominal disease, they will have an increasing need to master the use of intraoperative ultrasound in order to render optimal care to their patients.     

Appraisal of a manual blunt dissection for an intraoperative diagnosis of extrahepatic cancer invasion

BACKGROUND/AIMS: Liver cancer extension to the adjacent organs does not necessarily indicate tumor invasion. It is very hard to diagnose extrahepatic cancer invasion to the adjacent organs using preoperative imaging. This study was undertaken, therefore, to determine the real cancer invasion using a manual dissection. METHODOLOGY: Of the 51 consecutive patients with liver cancer, 6 cases with extrahepatically growing tumors were suspected to have cancer invasion both preoperatively and intraoperatively. Thus, we diagnosed whether or not any real extrahepatic cancer invasion was present by either removing the tumour by hand or by performing a blunt gauze dissection. RESULTS: Three hepatocellular carcinomas and one metastatic cancer were stripped off from the adjacent organ using a manual blunt dissection. However, the other two tumors could not be removed in the same manner and therefore a combined resection of the invaded portion had to be performed along with the hepatectomy. A postoperative detailed pathological examination revealed no cancer cells on the surface of the adjacent organ in the former 4 tumors. Cancer invasion was recognized, however, on the outside of the liver in the latter 2 combined resected tumors. CONCLUSIONS: An accurate intraoperative diagnosis of extrahepatic cancer invasion can be made using manual blunt dissection.     

Intraoperative determinants of unresectability for patients with colorectal hepatic metastases

BACKGROUND: Intrahepatic and extrahepatic factors are utilized by the surgeon in the decision-making process for the performance of hepatic resection for patients with colorectal metastases. Accurate preoperative and intraoperative staging are mandatory to avoid unnecessary surgery. In this report the intraoperative determinants of hepatic unresectability were evaluated. METHODS: This was a retrospective review of medical records from January 1985 to March 1996 of 62 patients with colorectal hepatic metastases who at the time of exploratory laparotomy were deemed to have unresectable disease based on intrahepatic or extrahepatic factors. The stage of the primary tumor, disease free interval, preoperative carcinoembryonic antigen, computed tomography portography, intraoperative ultrasound, and assessment of intrahepatic and extrahepatic tumor extension were evaluated. RESULTS: Intraoperative determination of the extent of required hepatic resection, including trisegmentectomy (9 patients; 15%) and total hepatectomy (10 patients; 16%), accounted for the majority of unresectable patients. Patients with > 4 metastases (8 patients; 13%) and satellitosis (6 patients; 10%) accounted for 23% of unresectable patients. Four patients had extensive nonmalignant hepatic parenchymal disease precluding resection. Thorough abdominal exploration revealed extrahepatic disease in 13 of 62 patients (21%). Routine periportal/celiac lymph node biopsies revealed metastases in an additional 12 patients (19%), 7 of whom (11%) had only periportal/celiac lymph node metastases. CONCLUSIONS: A meticulous abdominal exploration prior to hepatic resection for patients with colorectal metastases is essential to identify those patients with extrahepatic disease. Periportal and celiac lymph nodes commonly are involved by tumor. Therefore, routine periportal/celiac lymph node biopsies should be performed in the absence of other extrahepatic disease.     

Laparoscopy-assisted endoscopic removal of a stromal-cell tumor of the stomach

Endoscopic resection of gastrointestinal tumors is being performed with increased frequency. Submucosal mass lesions pose a particular problem, because of the risk of malignancy and the risk of complications associated with endoscopic removal. Increased incidences of both perforation and bleeding have been reported. We report here on a case in which we used a combined approach that included gastrointestinal endoscopy, laparoscopy, and laparoscopic ultrasound to resect a gastric leiomyoma. We consider that this approach enhanced our diagnostic capabilities, provided intraoperative options for resection, and enhanced the safety of the procedure.     

Prenatal detection of a solitary liver adenoma

Solitary liver adenomas are rare in children, especially in neonates, and can be difficult to distinguish from other more common liver tumors of newborns and infants. An otherwise healthy male neonate with a prenatal diagnosis of a liver mass underwent ultrasound and MRI followed by resection of the mass. The final histopathological diagnosis was hepatic adenoma. A discussion of the imaging evaluation, differential diagnosis, and literature review is presented.     

Are patients fed appropriately according to their caloric requirements?

The segmental localization of liver tumors is critical to planning appropriate resection. Couinaud's nomenclature is a surgically relevant system of hepatic segmental anatomy, which defines the liver segments by their relationships to vascular structures, hepatic ligaments, and the gallbladder. We demonstrate a way to accurately localize hepatic masses with sonography.     

Hepatic colorectal metastasis: current status of surgical therapy

Metastatic colorectal cancer to the liver develops in over 50,000 US patients each year and is rapidly fatal if untreated. Even the most active chemotherapeutic agents rarely prolong survival for more than 3 years. Liver resection is the only potentially curative treatment, affording 5-year survival in one-third of patients. The only absolute contraindications to liver resection are poor general health, clear evidence of wide disease dissemination, or inability to resect all liver disease. Close follow-up is warranted after liver resection since disease recurs in two-thirds of patients and recurrences can be successfully treated, possibly with curative potential. Cryosurgery is a promising ablative modality that needs to be compared to chemotherapy but has not been proven to be curative.     

Intracranial neurosurgery guided by functional imaging

Neurosurgery on eloquent cortex entails important risks of functional deficits complicating aggressive lesion resection. In this study, advanced biomagnetic functional imaging of somatosensory and motor cortex combined with surface rendered magnetic resonance imaging displays including vascular anatomy were used in conjunction with a new nonintrusive intraoperative guided instrumentation system to resect a tumor in eloquent cortex. Intraoperative verification of the accuracy of pre-operative motor localization demonstrated highly accurate results comparing direct stimulation and noninvasive presurgical mapping. The applicability of surface rendered combined functional and anatomic maps of cortex is directly evident on comparison of preoperative computer images and intraoperative pictures. This combination of new technologies has a significant potential for reduced risk and improved outcome in neurosurgery of eloquent cortex.     

Benign schwannoma of the liver with cystic changes misinterpreted as hydatid disease

The rare event of a benign mesenchymal tumor of the liver is described since its cystic transformation resembled hydatid disease through the presence of Echinococcus. Ultrasound and computerized tomography showed a cystic mass within the liver of a 57 year-old woman with upper abdominal pain. This was interpreted as hydatid disease and an evacuation procedure was performed. The histopathology of a minute specimen was interpreted as consistent with chronic inflammation in a cyst wall. Five years later, a recurrence of the parasite was suspected, and complete excision of the mass and resection of a bile fistula was performed. The histopathological examination revealed a large benign schwannoma with regressive cystic changes, proven by positive immunoreaction for the neurogenic marker S-100 protein. Revision of old paraffin blocks of tissue taken during the first operation was able to retrospectively confirm the identical tumor by the same markers. Occurrence of schwannomas in parenchymatous organs or the retroperitoneum is extremely rare and may lead to asymptomatic growth with cystic changes, causing considerable difficulties in imaging procedures. Overall, the primary complete excision of cystic masses within the liver seems to be the best approach in discovering their real nature and to ultimately cure them.     

Interactive intraoperative localization using an infrared-based system

We discuss new methods of localizing and treating brain lesions for both the conventional method of a base-ring fixed to the patient's skull (referred to as frame-based procedures) and the new method of frameless procedures (no base ring). Frame-based procedures are used for finding a precise instrument position during neurosurgical procedures, such as stereotactic biopsy of deep-seated lesions, placing electrodes for functional stereotaxis or catheters with radioactive seeds for brachytherapy, or even the placement of a stereotactic retractor or endoscope for removal or internal decompression of lesions. In such procedures, the intraoperative image localization of instruments becomes useful as it tracks instruments as they travel through the preplanned trajectory. Additional intraoperative digitization of surgical instruments, e.g., bipolar suction, biopsy forceps, microscope, ultrasound probe, etc, can be achieved during the stereotactic resection of eloquent areas or deep intracranial lesions by adding an infrared-based system. Frameless procedures broaden the range of surgical approaches, image guidance planning, and operative procedures, since no ring is attached to the patient's head which might interfere with the surgical approach, and offers logistic advantages in scheduling diagnostic studies. Frameless diagnostic studies employ anatomical markers and/or surface matching techniques for data registration in the computer software surgical preplanning program. This simplifies scheduling of the procedures since the image study does not need to be acquired the same day as surgery. Frameless diagnostic studies allow for the use of more than one type of imaging data for planning and optimization of surgical procedures, and greatly improve patient tolerance and comfort during these procedures and during surgery, as compared with frame-based procedures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical therapy for hepatocellular carcinoma with liver cirrhosis

Approximately 80% of hepatocellular carcinoma (HCC) patients in Japan have associated liver cirrhosis, which increases the difficulty of surgical treatment. Liver dysfunction associated with liver cirrhosis is one of the most important predictive prognostic factors for HCC patients. Percutaneous ethanol injection therapy (PEIT) is useful for patients with small HCC or with poor hepatic functional reserve. Transcatheter arterial chemoembolization (TACE) is also useful both for patients with unresectable HCC and patients with multiple intrahepatic recurrence. Liver resection, however, lead to better outcome than other treatments when liver function is maintained after surgery. To determine operative procedures, it is important to evaluate the exact function of remnant liver, based on the preoperative liver function test and the evaluation of tumor character. For advanced HCC patients with vascular invasion, non-surgical treatments such as PEIT or TACE are not indicated, and surgical intervention can be an effective modality to improve their survival. Improvements of surgical technique and perioperative management have decreased fatal complications at a major liver resection and allowed us to carry out liver resection on patients with advanced HCC.     

Differential attenuation imaging for the characterization of high intensity focused ultrasound lesions

High intensity focused ultrasound (HIFU) is an effective technique for creating coagulative necrotic lesions in biological tissue, with a view to treating localized tumors. Although good results have already been obtained, notably in urology, current systems lack a real time monitoring system to check the efficacy of the treatment procedures. This study describes the development and assessment of a noninvasive system for making local measurements of attentuation variations during HIFU treatment procedures. An apparatus (Ablatherm, Edap-Technomed, France), combining a 2.5 MHz therapeutic transducer and a 5.5 MHz twin plane imaging probe (connected to an ultrasound scanner), was used to produce lesions. The rf signals needed to calculate the attenuation were recorded as outputs from the ultrasound scanner, before and after the high intensity firing sequences, which were performed on ten pieces of porcine liver. Each firing sequence involved producing a lesion volume comprising 42 individual lesions. A number of recordings were also made without producing lesions, in order to test the reproducibility of the measurements. The attenuation function was evaluated locally using the centroid and the multinarrowband methods. Initially, changes in the integrated attenuation alpha (mean attenuation in the 4-7 MHz range) and the attenuation slope beta were examined for the lesion volume. beta values did not vary significantly within this range, whereas alpha values varied significantly (in the region of 86% of the initial level) in comparison to measurements performed without forming lesions. The differential attenuation delta alpha (representing local variations in alpha) was subsequently used to generate images revealing the lesion areas. There was a strong similarity between these 'delta alpha images' and the lesion volumes defined by the operator. 'delta alpha images' offer several advantages over existing attenuation imaging techniques. Any problems related to the heterogeneity of the medium are eliminated, since only the change in attenuation is taken into account. Furthermore, there is no need to compensate for diffraction when estimating delta alpha, as the rf signals are captured in exactly the same positions before and after treatment. This technique can be used during in vivo treatment procedures. It can be implemented in real time, since the computational algorithms (based primarily on FFT calculations) are very fast. The technique should provide clinical practitioners with valuable qualitative and quantitative information for use in HIFU ultrasound surgery.     

Prediction of surgical resectability in patients with hepatic colorectal metastases

OBJECTIVE: To evaluate the efficacy of two distinct imaging techniques to predict, before operation, unresectability compared with standard computed tomographic scan (CT). SUMMARY BACKGROUND: Accurate preoperative identification of the number, size, and location of hepatic lesions is crucial in planning hepatic resection for colorectal hepatic metastases. Although infusion-enhanced CT is the standard, its limitations are the imaging of relatively isodense and/or small (< 1 cm) lesions. The increased sensitivity of CT arterial portography (CTAP) may be offset by false-positive results caused by benign lesions and flow artifacts. METHODS: Fifty-eight selected patients considered to be eligible for resection by standard CT had laparotomy. Before operation and in addition to CT, all patients had CT arterial portography and hepatic artery perfusion scintigraphy (HAPS) using radiolabeled macroaggregated albumin. Early studies showed an increased sensitivity for detecting small lesions using the invasive CTAP. Similarly, the HAPS study has detected malignant lesions not observed by standard CT. RESULTS: Of 58 patients having laparotomy, 40 were resectable by either lobectomy (22) or trisegmentectomy (1) and the rest by single or multiple wedge resections. Eighteen patients could not be resected because of combined intra- and extrahepatic disease or the number and location of metastases. Standard CT detected 64% of all lesions (12% of lesions less than 1 cm). Unresectability was accurately predicted by CTAP and HAPS in 16 (88%) and 15 (83%), respectively, of the 18 patients considered ineligible for resection at laparotomy. Of the 40 patients who had resection for possible cure, CTAP and HAPS falsely predicted unresectability in 6 of 40 patients (15%) and in 10 of 40 patients (25%), respectively. The positive predictive value for unresectability of CTAP and HAPS was 73% and 60%, respectively. False-positive lesions after CTAP included hemangiomas, cysts, granulomas, and flow artifacts. False-positive HAPS lesions included patients in whom no tumor was found at surgery but with some identified by intraoperative ultrasound, blind biopsy, and blind resection. CONCLUSIONS: False-positive results by HAPS and CTAP may limit the ability of these tests to accurately predict unresectability before operation and may deny patients the chance for surgical resection. The HAPS study does, however, detect small lesions not seen by CT or CTAP. Standard CT, although less sensitive, followed by surgery and intraoperative ultrasound, does not necessarily preclude patients who could be resected.     

A transmission/disequilibrium study of the DRB1*04 gene locus on chromosome 6p21.3 with schizophrenia

The precise relationship of the components of the heart can be difficult to understand. With recent developments in cardiac ultrasound and other imaging modalities, most professionals need to be familiar with cross-sectional cardiac anatomy. We have created a teaching technique based on a normal human heart removed at autopsy. It was scanned using a computed tomography scanner and the images examined in different planes. The images were annotated and used in a computer-based teaching program to convey the details of cardiac anatomy. Images corresponding to planes typically used in echocardiography were also examined. The resulting images were of high resolution and illustrated many subtle structures rarely seen in conventional studies of cardiac anatomy. This system has benefits to both clinicians and anatomists.