Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

Contrast-enhanced ultrasonography in patients with colorectal liver metastases after chemotherapy.

PURPOSE: A systematic single-center analysis was performed to evaluate the efficacy of contrast-enhanced ultrasonography (CEUS) in the detection of colorectal liver metastases in patients with systemic chemotherapy in their medical history. MATERIALS AND METHODS: Between May 2005 and December 2007, 48 patients were referred to our institution for further evaluation after chemotherapeutic pretreatment for colorectal liver metastases. In all cases, the liver was screened by both unenhanced and contrast-enhanced ultrasonography with SonoVue to detect focal liver lesions. The results of sonographic explorations were prospectively collected and compared with intraoperative findings including histopathological results as reference. RESULTS: A total of 40 patients underwent laparotomy and were included in the analysis. The rate of correct ultrasound findings (rate of detection) increased from 24 patients (60%) with 35 metastases (57.4%) to 31 patients (77.5%) with 50 metastases (82.0%) after administration of SonoVue. Thus CEUS showed a significantly improved sensitivity compared to unenhanced US in both patient-by-patient analysis (79.5 versus 63.2%, p = 0.041) and lesion-by-lesion analysis (82.0 vs. 60.3%, p = 0.0008). On the basis of the ultrasound results, the surgical strategy had to be changed in 16 (40.0%) cases examined by unenhanced US compared to only nine cases (22.5%) examined by CEUS (p = 0.002). In CEUS a higher number of lesions were identified with an increasing metastasis size. CONCLUSION: After chemotherapeutic pretreatment, unenhanced US should be replaced by CEUS for the detection of liver metastases from colorectal carcinoma.

The role of contrast-enhanced ultrasound for focal liver lesion detection: an overview.

The development of new ultrasound (US) contrast agents and sonographic techniques has considerably improved the possibilities of ultrasound in the assessment of liver tumors. An overview is given on diagnostic potential of contrast-enhanced US (CEUS) and real-time low mechanical index technique in the detection of various focal liver lesions compared with computed tomography, magnetic resonance imaging or intraoperative US. In two of our own studies that included 100 patients each we showed an increase of correct findings in CEUS compared with B-mode US from 64% to 87% and from 67% to 84% as confirmed by intraoperative evaluation of the liver. Especially after chemotherapy and in the case of small metastases, significantly more metastases were correctly detected by CEUS compared with B-mode US. These results and clinical study results in the literature show that CEUS allows tumor detection and direct visualization of the tumor vascularity and put contrast-enhanced sonography among recommended noninvasive imaging methods for focal liver lesions with improvements in diagnostic strategy.

Contrast-enhanced ultrasonography to detect liver metastases : a prospective trial to compare transcutaneous unenhanced and contrast-enhanced ultrasonography in patients undergoing laparotomy.

BACKGROUND/AIMS: The advent of contrast-enhanced ultrasound (CEUS) has called into question the efficacy of standard ultrasonographic techniques. In this study, we evaluated B-mode and color-duplex imaging and CEUS in the detection of liver metastases, using intraoperative and histological findings as a reference. MATERIALS AND METHODS: Before laparotomy, 108 patients suspected of having liver metastases were prospectively examined with B-mode and color-duplex imaging, followed by contrast-enhanced ultrasound (2.4 ml SonoVue). Patients with unresectable tumors (n=8) were excluded from the analysis. The sonographic diagnosis in the remaining 100 patients was compared to the intraoperative and histological findings. RESULTS/FINDINGS: CEUS improved the sensitivity for detecting liver lesions from 56.3% (B-mode) to 83.8% (CEUS) (p=0.004). In particular, the contrast agent led to an improvement in ultrasonographic detection in the following cases: nodular metastases smaller than one centimeter; after adjuvant chemotherapy; for tumors near the surface of the liver; and for lesions situated around the ligamentum teres. INTERPRETATION/CONCLUSIONS: CEUS provides significant improvement in the detection of liver metastases, and should therefore, be performed routinely in the surveillance of cancer patients.

[Detection of liver lesions by contrast-enhanced ultrasound -- comparison to intraoperative findings]. / Kontrastmittelsonographie in der Detektion von Leberraumforderungen -- Vergleich zum intraoperativen Befund.

AIM: Evaluation of b-mode and colour-duplex imaging, contrast-enhanced ultrasound (CEUS) and CT for the detection of liver lesions in comparison to intraoperative and histological findings. METHODS: Before laparotomy, 100 patients with suspected liver lesions were prospectively examined with b-mode and colour-duplex imaging followed by contrast-enhanced ultrasound (SonoVue) and CT-scan. Patients with nonresectable tumours (n=44) were excluded from the analysis. The diagnostic findings of 56 patients who displayed liver lesions were compared to the intraoperative and histological findings. RESULTS: CEUS enhanced the sensitivity for the number of detected lesions from 53 % (b-mode) to 86 % (CEUS) (p = 0.001), while CT-scan reached 76 %. The specificity of the three methods differed only slightly (87 % to 89 %). Contrast agents lead to an improvement in the results of ultrasound, particularly in cases of nodular metastases smaller than one centimeter (n = 7), after adjuvant chemotherapy (n = 4), near the surface (n = 6) and in lesions situated around the Lig. teres (n = 6). CONCLUSIONS: CEUS leads to a significant improvement in the detection of liver lesions. For patients after adjuvant chemotherapy as well as for cases of small nodular metastases a CEUS should be carried out as a routine.

[Therapeutic options in the treatment of pyogenic liver abscess]. / Ultraschall-, CT-gesteuerte und operative Therapie bei pyogenen Leberabszessen.

BACKGROUND/AIMS: Pyogenic liver abscess is a rare and life-threatening disease. Our aim is to discuss the aetiology and problems of diagnosis and treatment of this disease, based on our own clinical experience. We present and compare different therapeutic options, i. e. ultrasound-guided percutaneous abscess drainage, CT-guided drainage and open surgical drainage. PATIENTS/METHODS: In a time period of 8 years, 62 patients with pyogenic liver abscesses were treated. The therapeutic procedure used most frequently was ultrasound-guided percutaneous abscess drainage in 41 patients, followed by CT-guided drainage in 13 cases. 8 patients were primarily treated with surgical drainage or liver resection, respectively. RESULTS: With an overall mortality of 9.6 % we achieved an encouraging result. The comparison of mortality between groups treated with ultrasound-guided percutaneous abscess drainage (7.3 %) and CT-guided drainage (7.7 %) revealed no significant prognostic difference. The comparison of local complications and drainage failure between ultrasound-guided percutaneous abscess drainage (2.4 %) and CT-guided drainage (15.4 %), however, showed better results for the ultrasound-guided interventions (1/41 vs. 2/13 patients). Two patients undergoing open surgical drainage died due to an advanced septic shock syndrome. CONCLUSIONS: Our study suggests that ultrasound duplex imaging with percutaneous abscess drainage is a reliable and effective approach for the treatment of pyogenic liver abscess. Based on other studies in the literature and our own results we developed a diagnostic and therapeutic algorithm for the treatment of liver abscesses.

[The value of colour duplex sonography in the assessment of surgical resectability of pancreatic tumors]. / Farbduplexsonographie zur Beurteilung der Resektabilität von Pankreastumoren.

UNLABELLED: The Value of Colour Duplex Sonography in the Assessment of Surgical Resectability of Pancreatic Tumors. AIM: The aim of this study was to evaluate the assessment by modern colour duplex imaging (CDI) concerning the relation between tumour and vessels including haemodynamic parameters in the main abdominal arteries and the portal system, and to evaluate the influence of these results on surgical decision making. METHOD: From January 1997 to October 1998, 146 patients with a tumour of the pancreas were included in a prospective study. Tumour contact to vessels and to the retroperitoneum, data on the flow in the main abdominal arteries and the portal circulation (regional topography) as well as the detection of liver metastases, enlarged lymph nodes and peritoneal carcinomatosis were defined as representing criteria of resectability. The results were compared with the intraoperative situation and with the definite histological findings. RESULTS: In 57 resectable tumours, the portal system was found to be infiltrated by the tumour up to a length of 1.5 cm. The flow velocity reached between 4 and 53 cm/s (mean flow) and 9 to 105 cm/s (maximum flow). Out of 146 pancreatic tumours, 89 were found as being non-resectable. In these cases, the measured parameters differed depending on the degree of tumour infiltration in to the portal circulation. We measured values from 0 to 96 cm/s (mean flow) and from 0 to 201 cm/s (maximum flow) with loss of breath-dependent modulation. The contact area between tumor and portal vessel was longer than 2 cm. Pathological flow in the main abdominal arteries was only found in 2 of 13 cases. The local situation was assessed correctly in 140 out of 146 cases by CDI (sensitivity of 93.0 %, specificity of 97.8 %, positive predictive value of 96.4 %, negative predictive value of 95.6 %). Regarding the complete oncological status (local situation, metastases, lymph node involvement and peritoneal carcinomatosis), a sensitivity of 82.5 % and a specificity of 92.1 % (positive predictive value of 87.0 %, negative predictive value of 89.1 %) was found. CONCLUSION: Modern CDI can reliably assess the resectability of pancreatic tumours by the evaluation of morphological and haemodynamic parameters. There are still difficulties in the assessment of lymph node involvement as well as in the detection of small liver metastases and of peritoneal carcinomatosis without ascites.

[Radiofrequency ablation of liver tumours]. / Hochfrequenz-Thermoablation bei Lebertumoren.

BACKGROUND: A variety of local treatment modalities exists for the palliative therapy of inoperable primary or secondary liver tumours. In this connection the promising use especially of thermal ablation methods has been reported recently. Numerous procedures and technical terms have been mentioned in this context giving us the opportunity of a review on this subject. METHODS: From the literature of the last five years (Medline/PubMed) including the lists of references physical principles and application techniques, indications and contraindications, possibilities of evaluation and results of high frequency thermotherapy (HFTT) respectively radiofrequency ablation (RFA) were investigated and compared to our own first experiences. Survival and recurrence rates were estimated from the study results. RESULTS: Most authors describe the HF-thermoablative treatment as a technically uncomplicated and relatively low-risk procedure. After a mean follow-up of about 10 months the mean survival rate was about 90 % and tumor recurrence was seen in approximately 30 % of the patients. The main problems occurred in view of the complete registration of all tumors with imaging techniques before RFA and the complete ablation, especially of larger tumours. CONCLUSIONS: In most of the clinical studies RFA promises an advantage of survival and improvement of quality of life compared to the known courses of untreated liver tumours. Therefore this method should be practiced on a larger scale in suitable patients. At the same time its efficacy must be proven by comparative studies.

Liposarcoma of the diaphragm: CT and sonographic appearances.

Malignant tumors arising from the diaphragm are exceedingly rare. We describe the first case, to our knowledge, of a primary diaphragmatic liposarcoma and demonstrate computed tomographic and sonographic findings.

[Serous cystadenoma of the pancreas]. / Das seröse Cystadenom des Pankreas.

INTRODUCTION: Serous cystadenomas of the pancreas are rare tumors and thought to be almost always benign. METHODS: We report our experience in the diagnosis and surgical treatment of 12 patients with these tumors. RESULTS: Between October 1993 and December 1998, 41 patients with cystic tumors of the pancreas underwent surgical resection; in 12 cases (11 women, 1 man) a serous cystadenoma (10 micro-cystic, 2 oligo-microcystic) was found. Only 6 (50%) patients had symptoms. The mean tumor size was 4.8 (2.7-10) cm. Ultrasound, CT and MRT usually could detect the mass, but differentiation with other cystic lesions was not reliable. All tumors were resected: 4 Whipple procedures, 7 distal pancreatectomies and 1 segmental resection were performed. No patient died after surgery and none had to be reoperated on. CONCLUSIONS: Because of the difficulty in reliably differentiating benign and malignant lesions of the pancreas, we believe that cystic tumors of the pancreas should be resected.

[Early results and complications of surgery of liver metastases]. / Frühergebnisse und Komplikationen der Chirurgie von Lebermetastasen.

Following resection of liver metastases the overall prognosis still remains limited because of the lack of adjuvant therapy. The number of explorative laparotomies, non-radical resections and complications needs to be reduced. One hundred and ten laparotomies in 97 patients with liver metastases were performed with the intention to cure between October 1993 and February 1998. In a prospective analysis we reviewed: patient characteristics, characteristics of primary tumors and metastases, part and extent of liver resection, radicality, complications and mortality. Additionally, a prospective study about the value of ultrasonography and CT scan concerning the evaluation of preoperative liver findings was undertaken between January 1995 and February 1998. Altogether, resection of liver metastases was achieved in 75 cases (68.2%). Nineteen patients (25.3%) had postoperative complications. Two patients (2.7%) died following liver resection. Thirty-five operations (31.8%) had to be finished as only an explorative laparotomy. The major reason for these restricted operations was in 15 patients (42.9%) regional recurrence or peritoneal metastases. Preoperative determination of the liver finding (quantity, localization and size) by ultrasonography and CT scan achieved an accuracy of 68.9% each. The results of this analysis show that resection of liver metastases can be accomplished with minor morbidity and mortality. The high number of explorative laparotomies still remains a central problem in the surgery of liver metastases. By the introduction of duplex sonography and contrast-medium-enhanced helical CT scan, liver pathology can be defined more precisely in the preoperative evaluation. However, preoperative detection of regional recurrence or peritoneal metastases remains difficult.

[Color Doppler sonography in liver surgery. Status of perioperative monitoring]. / Farbdopplersonographie in der Leberchirurgie. Stellenwert im perioperativen Monitoring.

AIM: Resection of liver tumours is not always successful despite detailed diagnostic work-up preoperatively. In our study we compared the predictive value of colour Doppler imaging of the liver with other radiological examinations for tumour staging, surgical decision making and postoperative complications. METHODS: From 1/95 to 6/1997 we investigated 76 patients with liver tumours; 60 patients with liver metastases, 13 with primary liver carcinomas and 3 with benign lesions. Resectability was defined in colour Doppler imaging by tumour localisation, distance of the tumour to the central vessels and blood flow in the portal vein. CT-scan in all patients and angiography in patients with central tumour localisation was performed. The preoperative results were compared to intraoperative ultrasound and surgical examination. RESULTS: 108 out of 118 intrahepatic lesions were found preoperatively using high-resolution ultrasound. Ultrasound and CT-scan achieve comparable results in delineating pathologic changes in the liver. Considering only the liver findings and local resectability in 76 patients, the sensitivity achieved for B-mode-ultrasound was 77.6% (59/76); for CT-scan 78.9% (61/76) and for colour Doppler imaging 86.4% (66/76). 31 out of 76 laparotomies were terminated after exploration. Resectability was correctly predicted by ultrasound in 55 (72.4%) and by CT-scan in 57 (73.7%) patients. Colour Doppler imaging improved the ultrasound results in up to 62 (81.6%) patients. Unsuspected not resectable tumour growth was found in 9 patients with local/regional recurrences, in 4 patients with peritoneal spread and in one patient with multiple bilateral liver metastases. CONCLUSIONS: Using high-resolution ultrasound systems the preoperative detection of lesions in the liver achieves the results of CT-scan. Little isoechogenic lesions, peritoneal spread and locoregional recurrences can be missed by ultrasound examination. Colour Doppler imaging shows compared with B-mode and CT-scan a higher sensitivity for the detection of the infiltration of hilar structures and can take place of more invasive methods in preoperative liver investigations. Considering functional and morphological aspects colour Doppler imaging makes an essential contribution to the planning of liver surgery. Using lung passing contrast media the determination of tumour vascularisation and perioperative quantification of liver perfusion is possible. The use of the intraoperative ultrasound is justified to determine resection limits, detection of smallest non-palpable lesions and to control perfusion after vascular reconstruction. In experienced hands colour Doppler imaging gives valuable preoperative information with excellent cost-benefit ratio.

Spontaneous regression of hepatocellular carcinoma confirmed by surgical specimen: report of two cases and review of the literature.

Two cases with spontaneous regression of a histologically confirmed hepatocellular carcinoma (HCC) are presented. This rarely seen phenomenon of a spontaneous tumor involution is discussed and compared with the current literature. The clinical symptoms were very similar to that of a liver abscess. A 56-year-old male suffered from a multicentric, highly differentiated, trabecular HCC. First symptoms were epigastric pain, septic fever and arthritis. The tumor marker AFP was constantly normal and no hepatitis could be verified. A resection of the tumor was performed. In patient 2, a 74-year-old male, a multicentric, clear cell HCC was found. The patient had completely recovered from hepatitis type B and within the liver tissue no viruses could be identified. Clinical symptoms were mainly characterized by upper abdominal pain and septic fever. AFP was excessively elevated (3850 ng/ml) but returned to normal preoperatively. In both cases, the specimen showed a subtotal necrotic HCC with insignificant amounts of vital tumor cells. Neither patient had a liver cirrhosis macroscopically, however patient 2 had local periportal fibrosis histologically. After 24 and 41 months of follow-up, respectively, both patients are in good health

[Value of color Doppler ultrasound in preoperative planning of the resection of liver tumors]. / Stellenwert der Farbdopplersonographie in der präoperativen Planung zur Resektion von Lebertumoren.

New color Doppler sonography with high resolution improves the detection of liver tumors and provides better information on the hepatic vessels. Echo contrast agents which pass through the lungs open up new fields of application in the investigation of blood flow.

[Ultrasound differential diagnostic aspects in cystadenoma of the pancreas]. / Sonographisch-differentialdiagnostische Aspekte beim Zystadenom des Pankreas.

AIM: Assessment of differential diagnostic criteria of cystic adenomas of the pancreas. METHOD: We rechecked on all diagnostic criteria of patients with pancreatic pseudocysts retrospectively who had been treated in our department between 1981 and 1993. RESULTS: 12 patients with cystic adenomas of the pancreas had been treated in our department i.a. 7.8% of all cystic pancreatic tumours. Histopathologically 1 microcystic and 4 macrocystic adenomas as well as 7 cystic adenocarcinomas were seen. CONCLUSION: Diagnostic ultrasound criteria are discussed. Ultrasound-guided fine--needle-biopsy (FNB) is necessary to diagnose the content as well as the status of the pancreatic cysts. The ultrasound and the fine-needle-biopsy findings are important for differentiating between cystic adenomas and pseudocysts of the pancreas.

[Diagnosis of iatrogenic vascular injuries with color-coded duplex ultrasound]. / Diagnostik iatrogener Gefässverletzungen mit der farbkodierten Duplexsonographie.

Between January 1991 and October 1992, 1052 patients who had previously undergone coronarography were examined for iatrogenic lesions around the catheter entry point. Some 3% of them were found to have local complications in the form of haematomas, aneurysms, and arteriovenous fistulas. At the time of investigation 75% of patients with local complications were on oral anticoagulants. In over half of those who had complications on oral anticoagulants there was no alternative to surgical treatment. Colour duplex sonography has the advantage that it can be repeated as often as possible; thus, in cooperation with the cardiac surgeon, the necessity and urgency of surgical intervention in cardiac risk patients can be assessed on an ongoing basis.

Experimental studies of the influence of priming solutions on the systemic activation of complement during cardiopulmonary bypass: comparison between the use of albumin, hydroxyethyl starch and HWA-138.

Cardiopulmonary bypass surgery may be complicated by a systemic inflammatory reaction, which has been ascribed to activation of complement. For such activation, the choice of priming solution for the heart-lung machine may be of importance. The peripheral blood of three groups of eight donors was exposed to albumin, hydroxyethyl starch (HES) or to HWA-138 (pentoxifylline analogue) in addition to the priming solutions. The study confirmed that activation of complement is a consistent phenomenon during cardiopulmonary bypass surgery. The concentration of the C3 activation product C3a in the plasma was significantly increased after simulated extracorporeal circulation. However there were no differences within the increase of C3a concentrations between the various priming solutions.

[Results of sonographically-guided percutaneous procedures as therapy of liquid-filled space-occupying lesions in acute abdomen]. / Ergebnisse interventionssonographischer perkutaner Eingriffe zur Therapie liquider Raumforderungen beim akuten Abdomen.

In the period from 1985 emergency sonographic study has been performed in 56 patients. In 44 cases we found intraabdominal abscesses, in 5 liver cysts with internal bleeding, in 5 postoperative lymphatic cysts, and in 2 cases loculated pleural empyemas. In 35 patients ultrasound guided therapeutic procedures were performed; there were 13 punctures (some repeated) and 22 drainages. In 29 patients no further surgical treatment was necessary. The over all success rate was 82.9%. One patient developed bacteremia after percutaneous drainage and an other developed subcutaneous abscess (complication rate: 5.7%). When abscesses are sufficiently drained no antibiotic therapy is needed.