Can regional anaesthesia for lymph-node dissection improve the prognosis in malignant melanoma?

BACKGROUND: Optimized anaesthetic management might improve the outcome after cancer surgery. A retrospective analysis was performed to assess the association between spinal anaesthesia (SpA) or general anaesthesia (GA) and survival in patients undergoing surgery for malignant melanoma (MM). METHODS: Records for 275 patients who required SpA or GA for inguinal lymph-node dissection after primary MM in the lower extremity between 1998 and 2005 were reviewed. The follow-up ended in 2009. Survival was calculated as days from surgery to the date of death or last patient contact. The primary endpoint was mortality during a 10 yr observation period. RESULTS: Of 273 patients included, 52 received SpA and 221 GA, either as balanced anaesthesia (sevoflurane/sufentanil, n=118) or as total i.v. anaesthesia (propofol/remifentanil, n=103). The mean follow-up period was 52.2 (sd 35.69) months after operation. Significant effects on cumulative survival were observed for gender, ASA status, tumour size, and type of surgery (P=0.000). After matched-pairs adjustment, no differences in these variables were found between patients with SpA and GA. A trend towards a better cumulative survival rate for patients with SpA was demonstrated [mean survival (months), SpA: 95.9, 95% confidence interval (CI), 81.2-110.5; GA: 70.4, 95% CI, 53.6-87.1; P=0.087]. Further analysis comparing SpA with the subgroup of balanced volatile GA confirmed this trend [mean survival (months), SpA: 95.9, 95% CI, 81.2-110.5; volatile balanced anaesthesia: 68.5, 95% CI, 49.6-87.5, P=0.081]. CONCLUSIONS: These data suggest an association between anaesthetic technique and cancer outcome in MM patients after lymph-node dissection. Prospective controlled trials on this topic are warranted.

Hepatic transcatheter arterial chemoembolization alternating with systemic protracted continuous infusion 5-fluorouracil for gastrointestinal malignancies metastatic to liver: a phase II trial of the Puget Sound Oncology Consortium (PSOC 1104).

We assessed a regimen of alternating regional and systemic therapy in patients with gastrointestinal malignancies with liver-dominant metastases for feasibility, toxicity, response rate, response duration, patterns of progression, and progression-free and overall survival. Regional therapy comprised selective hepatic transcatheter arterial chemoembolization (TACE) using a suspension of cisplatin and particulate polyvinyl alcohol. This procedure was delivered between cycles of protracted continuous infusion 5-fluorouracil (PCI-5FU) as systemic chemotherapy. Patient eligibility criteria included: (a) having histologically documented adenocarcinoma arising from a gastrointestinal primary site with unresectable liver metastases bidimensionally measurable on computerized tomography scan; (b) age greater than 18 years; and (c) performance status 0-2 (Zubrod). PCI-5FU (250 mg/m2/day) was administered i.v. for 28 days, followed by the first TACE (TACE 1) delivered to the hepatic artery supplying the lobe with the greatest tumor burden. Restaging was performed before TACE 2 and TACE 3, which followed at monthly intervals. PCI-5FU for 21 days was sandwiched between each of the TACE treatments. After the final TACE, maintenance PCI-5FU was given for 28 days of each 35-day cycle until toxicity or progression. Between December 23, 1991, and January 19, 1995, 32 patients were registered in this trial, of whom 27 were eligible; 20 completed one or more treatment cycles and were evaluable for radiographic response. Patients with colorectal liver metastases predominated (74%). Twelve (44%) of 27 patients had failed one or more prior treatment regimens. There were no treatment-related deaths, and hematological and hepatic toxicities were generally manageable and reversible. Two patients, however, developed hepatic abscesses requiring drainage, and one patient developed an infarcted gallbladder, which necessitated cholecystectomy. There were no patients with complete responses; there were 8 (40%) with partial responses, 4 (20%) with minor responses, 2 (10%) with stable disease, and 6 (30%) who progressed on the treatment. The median duration of response for partial responders was 4.2 months (127 days; range, 56-245 days). The median reduction in carcinoembryonic antigen for responders was 87.5%. Two patients underwent subsequent resection of residual metastases; one of them is still alive at 58.4 months follow-up. The predominant site of disease progression was the liver; 25% of the patients progressed in extrahepatic sites. The median overall survival for the whole group is 14.3 months (95% confidence interval, 7.2-16.2). Actuarial overall survival for the whole group at 1 year and 2 years is 57 and 19%, respectively. Alternating systemic PCI-5FU and regional TACE (cisplatin/polyvinyl alcohol) is an active and feasible regimen with manageable toxicities in patients with metastatic gastrointestinal malignancies with liver-dominant disease and merits further investigation. The complications seen were in line with those reported at other specialized centers.

Treatment of inferior vena cava anastomotic stenoses with the Wallstent endoprosthesis after orthotopic liver transplantation.

PURPOSE: To evaluate the efficacy of the Wallstent endoprosthesis for treatment of stenotic or occlusive inferior vena cava (IVC) lesions refractory to balloon angioplasty in patients after orthotopic liver transplantation. MATERIALS AND METHODS: Wallstent endoprostheses were implanted in six patients with IVC anastomotic stenoses or occlusions that were refractory to balloon angioplasty. Follow-up included both duplex ultrasound (US) and clinical evaluations. RESULTS: Ten stents were successfully implanted in six patients. Five of six patients (83%) demonstrated primary patency on duplex US for a mean period of 11 months (range, 4-17 months). One patient's symptoms recurred within 3 weeks after intervention. This patient underwent repeated stent placement. Follow-up duplex US in this patient demonstrated primary assisted patency at 7 months. Mean clinical follow-up was 12 months (range, 7-18 months). Other than the previously described case, no patient developed recurrent symptoms of IVC stenosis or occlusion. Two patients who experienced hemorrhagic complications secondary to anticoagulation were treated successfully. CONCLUSIONS: The Wallstent endoprosthesis is a useful adjunct for treatment of IVC stenosis or occlusions in patients who have undergone orthotopic liver transplantation when these lesions are refractory to simple balloon angioplasty.

Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results.

OBJECTIVE: The objective of this paper was to assess the safety and efficacy of percutaneous catheter drainage for initial treatment of infected acute necrotizing pancreatitis. MATERIALS AND METHODS: Thirty-four patients with acute necrotizing pancreatitis shown with contrast-enhanced CT were treated for sepsis with percutaneous catheter drainage. Extent of necrosis was less than 30% in 10 cases, 30-50% in 10 cases, and greater than 50% in 14 cases. Fourteen patients had central necrosis. Eighteen patients were critically ill with multiorgan failure. RESULTS: Sixteen (47%) of the 34 patients were cured with only percutaneous catheter drainage, including four (29%) of the 14 patients with central gland necrosis and 12 (60%) of the 20 with body-tail necrosis. Sepsis was controlled (defervescence of fever and return of WBC to normal) in an additional nine patients, allowing elective pancreatic surgery for control of pancreatic duct fistula. Eight patients failed to show clinical improvement after drainage and required necrosectomy. No patient experienced catheter-related complications. Mortality was 12% (all four deaths occurred after necrosectomy because of multiorgan failure). CONCLUSION: Percutaneous catheter drainage is a safe and effective technique for treating infected acute necrotizing pancreatitis. Overall, sepsis was controlled in 74% of patients, permitting elective surgery for treatment of pancreatic fistula, and 47% of patients were cured with no surgery required. No catheter-related complications occurred.

Effects of transjugular intrahepatic portosystemic shunts on hepatic metabolic function determined with serial monitoring of arterial ketone bodies.

PURPOSE: To investigate the effects of transjugular intrahepatic portosystemic shunt (TIPS) on hepatic metabolic function by measuring serial arterial ketone body ratio (acetoacetate/-hydroxybutyrate; AKBR). MATERIAL AND METHODS: The arterial blood of 30 TIPS patients was assayed before TIPS, 30 minutes after TIPS, and 24 hours after TIPS for acetoacetate, beta-hydroxybutyrate, and glucose. The authors compared the AKBR values to clinical outcome stratified by Child class, emergent versus elective TIPS, and before-TIPS AKBR value < or = 0.5 versus before-TIPS AKBR value > 0.5. RESULTS: A significant change was noted between the AKBR values obtained before TIPS and values 30 minutes after TIPS (0.76 +/- 0.09 vs 0.61 +/- 0.05, P < .05) and between 30 minutes and 24 hours after TIPS (0.81 +/- 0.10, P < .001), but not between the value obtained before TIPS and that obtained 24 hours after TIPS. The 30-day mortality rate in emergency TIPS patients was 50% compared to 7% in the elective TIPS patients (P < .01). The pre-TIPS AKBR values were significantly suppressed in the emergency TIPS patients compared to the elective TIPS patients (0.56 +/- 0.04 vs 0.99 +/- 0.17, P < .005). The 30-day mortality rate in patients with a pre-TIPS AKBR value < or = 0.5 was 75%, which was significantly higher than the 14% rate in patients with a pre-TIPS AKBR value > 0.5 (P < .01). CONCLUSION: A low pre-TIPS AKBR may be predictive of poor outcome after TIPS. Furthermore, AKBR may be of value in determining the timing for performing an elective TIPS.

Transluminal treatment of a celiac artery pseudoaneurysm with a stent graft occlusion device.

This report describes the transluminal placement of a stent graft occlusion device to treat a celiac bypass graft pseudoaneurysm which was causing biliary and duodenal obstruction.

Transcatheter arterial embolization of two symptomatic giant cavernous hemangiomas of the liver.

Cavernous hemangiomas are usually asymptomatic; however, a small percentage may cause symptoms. This case report discusses palliation by transcatheter arterial embolization with polyvinyl alcohol particles.

Imaging of complications in liver transplantation.

Hepatic transplantations are being performed with increasing frequency, leading to greater demand for accurate evaluation of related complications. Ultrasonography (US) is the primary screening technique for detection of vascular complications of hepatic transplantation: angiography is used to confirm the US findings or when the US study is suboptimal. Hepatic artery thrombosis, the most common (as high as 42% of pediatric cases; 4%-12% of adult cases) and important vascular complication, may be associated with bilomas, infarcts, or abscesses at gray-scale US and absence of proper hepatic and intrahepatic arterial flow at Doppler analysis. Hepatic artery stenosis (seen in 11% of cases) is suspected if a focal accelerated velocity of greater than 2-3 m/sec with turbulence is seen at or distal to the stenosis or if a tardus parvus pattern of intrahepatic arterial flow is seen. In cases of inferior vena cava thrombosis and stenosis, US may show echogenic thrombus or obvious narrowing, with a substantially increased flow velocity through the stenosis or reversal of flow in the hepatic veins. Biliary complications occur relatively often (13%-25% of cases) after liver transplantation; bile leakage and biliary stricture, the most common biliary complications, are seen as a fluid collection and a stricture, respectively. Although acute rejection is one of the most serious complications affecting graft survival, it cannot be reliably detected with available diagnostic tests or radiologic methods.

Use of a Wallstent in successful treatment of IVC obstruction following liver transplantation.

Obstruction of the IVC occurs in only 1-2% of patients after liver transplantation. The mortality of this complication can be as high as 66%. This case report describes the use of a Wallstent for an IVC obstruction that was unresponsive to conventional balloon angioplasty.

Hepatic arterial anatomy in transplantation candidates: evaluation with three-dimensional CT arteriography.

PURPOSE: To assess the utility of three-dimensional (3D) hepatic helical computed tomographic (CT) arteriography as a replacement for conventional angiography in the evaluation of the arterial anatomy of patients being considered for liver transplantation. MATERIALS AND METHODS: Three-dimensional CT arteriograms were obtained in 115 patients. Seventeen patients also underwent conventional angiography, and 16 patients who did not undergo angiography underwent hepatic transplantation. RESULTS: Among the 3D CT arteriograms, 106 delineated the major arteries that supplied the liver. Nine were considered technical failures. In the 17 patients with angiographic correlation, there was only one marked disagreement with 3D CT arteriography. In the 16 patients with surgical correlation, no marked discrepancies were found. CONCLUSION: In transplantation candidates, successful 3D CT arteriography was as accurate as angiography in the assessment of hepatic arterial anatomy. It was also safer, more convenient, and more easily tolerated. Conventional CT plus 3D CT arteriography was only 25% as expensive as the cost of conventional CT and conventional angiography.

Evaluation of the portal venous system before liver transplantation: value of phase-contrast MR angiography.

OBJECTIVE: The purpose of this study was to assess the accuracy of phase-contrast MR angiography with gadolinium in evaluating the patency and blood flow direction of the portal venous system; the presence, extent, and type of varices; and the patency of surgical decompressive shunts in patients before liver transplantation. This information is essential in management and care of patients with chronic liver disease and portal hypertension and those who are candidates for liver transplantation. SUBJECTS AND METHODS: Twenty-four patients with portal venous hypertension were evaluated with phase-contrast MR angiography. Two patients had surgical splenorenal shunts and one had a mesocaval shunt. Phase-contrast angiograms were acquired as a series of two-dimensional sequential coronal sections during breath-holding and after IV administration of gadopentetate dimeglumine. Correlative findings from color flow Doppler sonography, contrast-enhanced CT scanning, and conventional angiography were available in 23, 20, and 10 patients, respectively, and were used as standards. The images from each technique were analyzed independently for patency of and flow direction in the portal vein, splenic vein, superior mesenteric vein, and surgically created shunts, and for detection, distribution, and extent of five variceal groups. RESULTS: Findings from phase-contrast MR angiography completely agreed with those of sonography, CT scanning, and conventional angiography. The main portal vein was patent in 18 patients, stenosed in one, partially thrombosed in one, and occluded in four. Phase-contrast MR angiography correctly showed hepatofugal flow in three patients and hepatopetal flow in 17 patients. Both the splenic and superior mesenteric veins were patent in 20, partially thrombosed in one, and occluded in three cases. Phase-contrast MR angiograms showed 85% of the variceal groups, and MR rating of variceal size was not significantly different from that of CT rating. Phase-contrast MR angiography correctly showed the patency of all three surgical decompressive shunts. CONCLUSION: Phase-contrast MR angiography is accurate for evaluating the patency and flow direction of the portal venous system, detecting and determining the distribution and extent of varices, and assessing the patency of surgically created shunts. Therefore, it is a reliable and noninvasive technique that can provide crucial information in the preoperative workup of liver transplant recipients.

Critical appraisal of the angiographic portacaval shunt (TIPS).

The transjugular intrahepatic portacaval shunt (TIPS) is a novel angiographic method for achieving portal decompression without operation. Fifty-nine consecutive patients underwent a total of 80 consecutive TIPS procedures. The procedure was unsuccessful in 4 patients (7%) and initially succeeded in 55 (93%). Eighteen patients (30%) underwent 2 or more TIPS procedures during the same hospitalization due to technical difficulties, early rebleeding, shunt stenosis, or thrombosis. Early TIPS occlusion occurred in seven patients (12%) and led to recurrent variceal hemorrhage in five. Forty-two percent of the cases of persisting or recurrent bleeding were nonvariceal. Procedure-related complications occurred in 10% of TIPS procedures or 14% of patients. Twenty-three patients (39%) were actively bleeding at the time of the procedure, and, in 6 of these (26%), bleeding was never controlled. In-hospital mortality (25%) was related only to the presence of bleeding at the time of TIPS (56% for emergent versus 5.5% for non-emergent, p < 0.0001). Mortality was not related to the Child-Pugh classification. Hemodynamic stabilization, vasoconstrictor therapy, balloon tamponade, and sclerotherapy were underutilized in 30% to 40% of patients prior to TIPS. Aggressive medical management should be used to stop variceal hemorrhage prior to TIPS in all patients, regardless of the Child-Pugh classification. Prospective trials comparing TIPS with sclerotherapy and surgical shunt are required to demonstrate the proper role of this procedure in the management of portal hypertension and variceal hemorrhage.

The Simpson atherectomy catheter in the management of complete obstructions.

The Simpson atherectomy catheter has been used successfully to recanalise eleven complete occlusions of the iliac and femoropopliteal arteries. Atherectomy and angioplasty were used in combination in 8 cases. Following atherectomy, all patients showed clinical improvement. Distal pulses returned in 7; rest pain and/or claudication disappeared in the other 4. Ischaemic ulcers healed in the 2 affected patients. Overall, ankle-arm indices (AAI) improved by an average of 0.43, with the improvement being greatest (0.55) in patients in whom the lumen was recanalised to within 91-100% of the native luminal diameter. Seven patients have remained with stable AAI values and without change in their clinical status at 18 months follow-up.

Meningioma of the internal auditory canal.

The great majority of tumors that arise in the internal auditory canal are schwannomas of the eighth cranial nerve (acoustic neuromas). Meningiomas constitute the second largest group of posterior fossa tumors. Meningiomas arise from arachnoid villae, the apparatus responsible for cerebrospinal fluid absorption, in proximity to a major vein or dural sinus in most cases. Arachnoid villae are also present along neural foramena at the base of the skull. They have been observed histologically in the internal auditory canal (IAC), and are the probable site of origin of meningiomas in this location. Larger cerebellopontine angle meningiomas occasionally possess a significant intracanalicular component; however, these lesions usually originate from the meningeal lining of the posterior petrous face adjacent to the sigmoid, superior petrosal, or inferior petrosal sinuses and prolapse into the IAC. Two meningiomas have recently been observed that extensively involved the IAC, one of which arose from the lining of the IAC. The clinical manifestations of these meningiomas mimicked those of acoustic neuromas. Preoperative radiographic studies, including magnetic resonance imaging, were unable to differentiate these from acoustic neuromas. Meningiomas have a higher rate of recurrence than acoustic neuromas and should be excised with surrounding dura and several millimeters of subjacent bone. Meningiomas that extensively involve the IAC have a tendency to invade the inner ear and the deeper portions of the temporal bone. In meningiomas that involve the lateral portion of the IAC, consideration should be given to exenteration of the cochlea and semicircular canals.