Solitary necrotic nodule of the liver: A riddle that is difficult to answer

Solitary necrotic nodule of the liver is an unusual lesion that is often an incidental finding on abdominal imaging, intraoperative examination, or post mortem. Most reported cases of solitary necrotic nodule have been in males, and over three quarters of these lesions have occurred in the right lobe of the liver. Pathologically, solitary necrotic nodule is a benign lesion characterized by a completely necrotic core that is often partly calcified, surrounded by a dense hyalinized fibrous capsule containing elastin fibres. The ultrasound appearance of solitary necrotic nodule is usually of a “target” lesion with a hyperechoic center, while on CT scan they appear as non-enhancing hypodense lesions that are typical of metastatic adenocarcinoma or peripheral cholangiocarcinoma. The impression of malignancy is further enforced with the finding of necrotic cellular material on biopsy and the macroscopically hard and “gritty” nature of the nodules. Currently, permanent histopathology of solitary necrotic nodules is the only accurate method of diagnosis. However, solitary necrotic nodules are usually of a bilobed or lobulated shape that is unusual for malignant liver lesions, and they often lie in close proximity to hepatic inflow structures. Solitary necrotic nodule should be suspected in liver lesions with this configuration, location, and on a biopsy showing a large amount of necrosis.     

A possible role for IGE-II: evidence in sheep for in vivo regulation of IGF-I mediated protein anabolism.

Using primed constant infusions of [14C]urea we assessed the effects in castrate male lambs of insulin-like growth factor (IGF) II infusion on protein metabolism during concurrent IGF-I infusion. A 300 minute infusion of IGF-I at 15 micrograms/kg.hour (n = 4) increased (p less than 0.001) the plasma IGF-I concentration from 72.5 +/- 6.4 ng/ml to 213.6 +/- 17.4 ng/ml and decreased (p less than 0.01) the rate of net protein catabolism (NPC) from 1.48 +/- 0.28 g/kg.day to 1.02 +/- 0.18 g/kg.day. Infusion of IGF-II at a dose of 50 micrograms/kg.hour concurrently with IGF-I at 15 micrograms/kg.hour (n = 4) was associated with a similar rise (p less than 0.01) in plasma IGF-I concentration from 79.4 +/- 4.1 ng/ml to 225.2 +/- 32.8 ng/ml. Plasma IGF-II increased (p less than 0.05) from 350.6 +/- 41.6 ng/ml to 746.7 +/- 165.5 ng/ml over the infusion. Coadministration of IGF-II completely blocked (p less than 0.01) the anabolic effect of IGF-I and the rate of NPC remained unchanged throughout the combined IGF-I and IGF-II infusion at a level comparable to saline infused controls (n = 4). This study suggests that IGF-II may play a physiological role as a circulating modulator of the anabolic effects of IGF-I.     

Quality performance indicators for hepato-pancreatico-biliary procedures: a systematic review

BackgroundThis systematic review was undertaken to define and summarize existing, proposed quality performance indicators (QPI) for hepato-pancreatico-biliary (HPB) procedures.MethodsA systematic literature review identified studies reporting on quality indicators for cholecystectomy, hepatectomy, pancreatectomy and complex biliary surgical procedures. The databases searched were MEDLINE, EMBASE, PubMed, and SCOPUS, with all literature available until the search date of 1 May 2020 included. The reference lists of all included papers, as well as related review articles, were manually searched to identify further relevant studies.ResultsForty-five publications report quality indicators for pancreatectomy (n = 22), hepatectomy (n = 7), HPB resections in general (n = 12), and cholecystectomy (n = 6). No publications proposed QPI for complex biliary surgery. The 45 papers used national audit (n = 18), consensus methodology (n = 5), state-wide audit (n = 3), unit audit (n = 9), review methodology (n = 9), and survey methodology (n = 1). Sixty-one QPI were reported for pancreatectomy, 22 reported for hepatectomy, and 14 reported for HPB resections in general, in domains of infrastructure, provider, and documentation. Fourteen infrastructure and provider-based QPI were reported for cholecystectomy.ConclusionsThere are few internationally agreed QPI for HPB procedures that allow global comparison of provider performance and that set aspirational goals for patient care and experience.     

Surgical management of neutropenic enterocolitis

Three cases of histologically confirmed neutropenic enterocolitis, each presenting as an acute abdomen in patients with leukaemia are presented. All three patients presented with fever and abdominal pain within 14 days of completing a course of chemotherapy. Signs of peritonitis localized to the right iliac fossa developed in each patient, in spite of aggressive antibiotic therapy and bowel rest. All three patients were found to have non-viable caecum at laparotomy and were treated by right hemicolectomy. Primary ileocolic anastomosis was performed in one patient, who recovered following a stormy postoperative course owing to sepsis. Two patients underwent formation of an ileostomy with distal mucous fistula and each recovered with minimal postoperative complications; secondary anastomosis was performed electively in both cases. The difficulty in diagnosing neutropenic enterocolitis preoperatively is discussed and the place of non-operative management is reviewed but we recommend surgical intervention as a means of ensuring removal of a localized septic focus until marrow regeneration occurs.     

Laparoscopy in the management of colorectal cancer metastatic to the liver

BACKGROUND: This investigation was undertaken to define the value of laparoscopy in the staging of patients with colorectal carcinoma metastatic to the liver. METHODS: The clinical details of 59 consecutive patients with colorectal liver metastases undergoing laparoscopy prior to planned hepatectomy were entered prospectively on a computerized database. All patients were staged preoperatively with thin slice (5-7 mm) helical computed tomography chest, abdomen and pelvis. Synchronous metastases were defined as those found during, or on imaging carried out within 1 month of, colorectal resection. Criteria for laparoscopic unresectability were: (i) histologically proven extrahepatic disease; (ii) bilateral inflow or outflow involvement; (iii) the presence of cirrhosis in patients requiring an extended resection (lobectomy or greater); or (iv) hepatic metastases involving more than six hepatic segments. RESULTS: In 24 patients with synchronous metastases (median age 65 years, range 32-81 years) all were resectable on laparoscopic criteria, of whom 21 were resected. Extrahepatic disease was found at laparotomy in three patients. In 35 patients with metachronous metastases (median age 64 years, range 32-81 years) laparoscopy could not be performed in five patients because of adhesions, and three patients were deemed unresectable on laparoscopic criteria. Of the remaining 27 patients, 25 underwent resection while two proved unresectable. Overall eight of 54 evaluable patients had unresectable disease and laparoscopy correctly identified three patients. CONCLUSIONS: Following computed tomography scan, 15% of patients with metastatic colorectal carcinoma will be found to have unresectable disease. Laparoscopy will identify approximately half. Laparoscopy is of no greater value in staging synchronous versus metachronous metastases.     

Relative importance of amino acid infusion as a means of sparing protein in surgical patients

We performed isotopic infusions in 51 surgical patients to investigate the effectiveness of different substrates to conserve protein. All patients were initially studied in the basal state and then the effects of glucose infusion (GL, N = 13), lipid infusion (LIP, N = 11), or amino acid infusion (AA, N = 17) were determined. Ten patients receiving total parenteral nutrition (TPN) were also studied. The basal value for net protein catabolism (NPC) in GL patients was 1.53 +/- 0.4 (SEM) g/kg/day decreasing to 1.39 +/- 0.4 g/kg/day during glucose infusion (p less than 0.01). The basal NPC in the LIP group was 2.04 +/- 0.4 g/kg/day decreasing to 1.72 +/- 0.3 g/kg/day during lipid infusion (p less than 0.01). In the TPN patients the NPC was 0.79 +/- 0.46 g/kg/day whereas in the AA patients the basal value for NPC was 1.37 +/- 0.14 g/kg/day decreasing to -0.77 +/- 0.11 g/kg/day during amino acid infusion (p less than 0.0005). From our study we conclude that: (1) All substrates commonly used in intravenous feeding have the capacity to spare protein. (2) Protein sparing was more pronounced when a balanced amino acid infusion was used than with either glucose or lipid infusion alone. (3) This effect is not solely due to insulin secretion as larger insulin responses were seen with both GL and TPN patients. (4) These results may have implications for peripheral vein feeding with amino acid solutions where there is a contraindication for full TPN or the lack of resources for administering it.     

Liver resections in Auckland 1998-2001: mortality, morbidity and blood product use.

AIMS: There has been a marked increase in the number of liver resections undertaken at Auckland Hospital since 1998. Low central venous pressure anaesthesia was routinely used for liver resection during this period. The aim of this study was to review this experience, with particular emphasis on the peri-operative outcomes of morbidity, mortality and blood product use. METHODS: All patients undergoing liver resection from January 1998 to May 2001 were included in the review. Standardised data were collated retrospectively from hospital records and transferred to an electronic database for analysis. RESULTS: Of 123 patients undergoing liver resection, 113 were elctive and ten were urgent operations. 65% had major resections and 10% had synchronous extrahepatic surgery. There were three post-operative deaths (mortality 2.4%) due to liver failure and sepsis. One or more complications occurred in 68 patients (morbidity 55%). 72% did not receive a blood transfusion during their hospital stay. Only two of 113 elective patients required a massive blood transfusion (ten or more units). CONCLUSIONS: Mortality in the study period was low but morbidity remains significant. Blood product use was low in elective patients. These results compare well with those of specialised hepatobiliary units internationally.