Evaluation of the role of CT in the assessment of response to selective internal radiation therapy in patients with colorectal liver metastases.

Selective internal radiation therapy (SIRT) is a relatively new method for treating non-resectable liver tumours. There is reason to believe that conventional assessments of response by CT scan may underestimate the efficacy of this treatment. A study was undertaken in 54 patients to evaluate CT changes after SIRT for advanced colorectal cancer and to compare these with tumour marker (carcinoembryonic antigen (CEA)) changes to determine how best to assess whether a response has occurred. Computed tomography scans were carried out before treatment and at 3-monthly intervals thereafter. Serial CEA measurements were undertaken at 4-weekly intervals. Index lesions were identified and their size was assessed on serial scans by three independent, blinded investigators. Per cent changes in CEA levels after SIRT were calculated for all patients. Disappearance of all index lesions was noted in five patients (9.3%). A decrease in the size was seen in a further 41 patients (76%), no change was seen in five (9.3%), and an increase in size was noted in three (5.4%). The time taken for the maximum decrease in size to occur ranged from 3 to 21 months (median 12 months). Carcinoembryonic antigen changes were more dramatic, with a reduction of more than 75% within 2 months in 35 of 50 patients (70%) and a rise in only 3 of 50 patients (6%). Early assessment of response by CT scan may be misleading because of the time taken for size reduction to occur. Response to SIRT is more accurately judged in the early stages by tumour marker data.

Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed.

AIM: To document the prevalence and to evaluate the management strategies of haemorrhagic complications following pancreaticoduodenectomy (PD). METHODS: All patients who underwent PD from 1/2000 to 10/2005 and experienced at least one episode of haemorrhage during the 30 first days postoperatively were recorded. Etiology of haemorrhage, treatment strategy and mortality rate were recorded and analyzed. RESULTS: A total of 362 patients underwent PD during this period and 32 (8.8%) had haemorrhage postoperatively of whom 15 died (47% mortality rate). Primary intraluminal haemorrhage was recorded in 13 patients, primary intra-abdominal haemorrhage in 5 patients and secondary haemorrhage in 14 patients. Successful management of haemorrhage with angioembilization occurred in 2 patients in the study group. Statistical analysis revealed sepsis and sentinel bleed as risk factors for post-PD haemorrhage and pancreatic leak and sentinel bleed as risk factors for secondary haemorrhage (p < 0.05). CONCLUSIONS: Haemorrhage after PD is a life-threatening complication. Sepsis, pancreatic leak, and sentinel bleed are statistical significant factors predicting post-PD haemorrhage. Sentinel bleed is not statistically significant associated with postoperative mortality, but with the onset of secondary haemorrhage. The effectiveness of therapeutic angioembolization was not demonstrated in our study.

Selective internal radiation therapy (SIRT): a new modality for treating patients with colorectal liver metastases.

BACKGROUND: Selective internal radiation therapy (SIRT) is a new and developing modality for treating non-resectable liver tumours. Evidence is emerging that it is very efficacious in patients with hepatocellular cancer and colorectal liver metastases. DISCUSSION: SIRT generally involves a single delivery of (90)yttrium micro-spheres into the hepatic artery. Preferential uptake is achieved into liver tumours, because of their predominant hepatic arterial blood supply. Average tumour doses of radiation in excess of 200 Gy are achieved. The treatment is generally well tolerated and has been documented by a number of groups internationally to achieve response rates of around 90% in patients with extensive colorectal cancer (CRC) liver metastases. Since the product obtained FDA approval in the USA in 2002, it is being more widely employed and investigated. Unlike other ablative therapies being applied to non-resectable liver tumours, SIRT is indicated even in patients with an extensive burden of liver tumour. Indications, dosing schedules and expected outcomes will become better defined as more groups take up the treatment.

Insulin resistance in the severely obese and links with metabolic co-morbidities.

BACKGROUND: The association between insulin resistance (IR) and obesity and its causal relationship with type 2 diabetes is well recognized. The possibility of an association, causal or otherwise, with other obesity-related co-morbidities warrants consideration. METHODS: IR was calculated pre-operatively in 80 patients undergoing gastric bypass surgery for severe obesity, using the homeostasis model assessment (HOMA) method, and again in 70 patients on at least one occasion post-operatively within 12 months. Correlations with weight parameters and pre-existing co-morbidities including diabetes, hypertension, dyslipidemia and hepatic steatosis were made. RESULTS: 78/80 patients had IR pre-operatively which did not correlate with pre-operative weight or BMI. As expected, there were positive correlations between pre-operative IR and abnormal glucose tolerance and diabetes. A positive correlation was also found between IR and hepatic steatosis, but no correlation was noted between IR and hypertension or fasting levels of cholesterol, triglycerides or Chol/HDL cholesterol ratios. Improvement in IR was uniformly seen after gastric bypass, sooner than would be accounted for by weight loss alone. The degree of pre-operative IR was not a predictor of weight loss after gastric bypass in these patients. CONCLUSIONS: While IR is an almost universal accompaniment of severe obesity, it does not correlate with the degree of obesity in this group of patients. A number of important co-morbidities show a clear association with IR, and improvement in these after gastric bypass may well be related to striking and rapid changes in IR.

Peritoneovenous shunting for malignant ascites.

AIM: Malignant ascites may produce a cluster of symptoms including abdominal distension, early satiety, respiratory embarrassment, impaired mobility and lethargy. Successful relief of these symptoms is often difficult to attain. We report on the use of peritoneovenous shunting in a group of patients with troublesome malignant ascites with particular reference to the effectiveness and complications of the procedure. METHODS: Twenty one Denver peritoneovenous shunts were placed in 19 patients with malignant ascites. The patients included 16 females and three males and had a median age of 54 years. All had previously been treated with vigorous diuretic therapy and/or repeated paracentesis. Shunt insertion was carried out under general anaesthetic in a manner similar to that described by others. RESULTS: The procedure was well tolerated by most patients. Median hospital stay was 6 days. One patient died 11 days after her surgery from what was thought to be an unrelated cause. Another patient suffered major problems after shunt insertion from exacerbation of pre-existing pleural effusions. All other complications were minor and self limiting. Two shunts failed to function within the first week. Excellent shunt function with resolution of ascite and of associated symptoms was seen in 16 patients. In five late shunt occlusion occurred with resulting reaccummulation of ascites but in four of these shunt function was able to be restored. Median survival in the 18 patients who survived the procedure was 5.5 months and in 14 of these the shunt was functioning at the time of death with good control of ascites. CONCLUSION: Malignant ascites can result in very troublesome symptoms for patients who may otherwise have some time to live. Peritoneovenous shunting is a well tolerated relatively minor surgical procedure which can achieve excellent control of ascites in the majority of such patients.