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Hepatic artery embolization (HAE) is used commonly to treat liver tumors or hemorrhage. Infectious complications are rare but carry high rates of morbidity and mortality. Identification of clinical factors associated with postembolization abscess may improve management and outcome.Clinical and pathologic variables of patients treated with HAE were collected and analyzed to determine the etiology, incidence, and outcome of pyogenic hepatic abscess.From January 1998 to January 2010, 971 patients underwent 2,045 HAE procedures. Fourteen patients developed a pyogenic hepatic abscess after embolization, for an overall rate of 1.4%. Thirty-four patients (4%) had a history of bilioenteric anastomosis (BEA) and 21 patients (2%) lacked a competent sphincter of Oddi because of the presence of a biliary stent (n = 19) or a previous sphincterotomy (n = 2). Eleven of the 34 patients with a BEA (33%) and two of 21 patients with an incompetent sphincter (10%) developed abscesses, in contrast to only one abscess (0.05%) among the 916 patients with apparently normal sphincters (0.1%; odds ratio, 437.6; 95% CI, 54.2-3,533; P.0001). Gram-negative and Gram-positive aerobes were the most common bacteria isolated after drainage. Percutaneous drainage was the initial management strategy in all patients; two patients (14%) required subsequent surgical drainage and hepatectomy, and three (21%) died.Pyogenic hepatic abscess is rare after HAE. A history of BEA or an incompetent sphincter of Oddi caused by a biliary stent or previous sphincterotomy substantially increases the likelihood of this highly morbid and potentially fatal complication.

Objective To present the case of a man with a rightsided adrenocortical carcinoma that invaded the inferior vena cava and was managed by radical resection and vein patch repair. Methods We report the clinical, laboratory, imaging, and operative findings, and we highlight the pertinent features of this case. The literature is reviewed for the management of adrenocortical carcinoma in conjunction with inferior vena cava invasion. Results In a 34-year-old man with new-onset abdominal pain, abdominal imaging disclosed a large right adrenal mass with invasion into the inferior vena cava. Laboratory values revealed that the adrenal mass was likely nonfunctional. At surgical intervention with use of cardiopulmonary bypass, the mass was removed en bloc with the adrenal gland, right kidney, and the wall of the inferior vena cava, and the inferior vena cava was reconstructed with bovine pericardium. Conclusion Despite direct invasion or extension of tumor thrombus into the inferior vena cava (or both), complete (R0) resection can be obtained. Thus, this scenario should not preclude attempted curative resection in patients with adrenal cancer. (Endocr Pract. 2008;14: 721-725)

Viral oncolytic therapy has been pursued with renewed interest as the molecular basis of carcinogenesis and viral replication has been elucidated. Genetically engineered, attenuated viruses have been rationally constructed to achieve a therapeutic index in tumor cells compared with surrounding normal tissue. Many of these attenuated mutant viruses have entered clinical trials. Here we review the preclinical literature demonstrating the interaction of oncolytic viruses with ionizing radiation and provides a basis for future clinical trials.

Background Preoperative combined-modality therapy (CMT) is considered the treatment approach of choice for rectal cancer. To examine the effect of CMT on distal intramural spread (DIS), we determined the extent of DIS in rectal cancer specimens after CMT. Methods Specimens from 20 patients after preoperative CMT and total mesorectal excision for rectal cancer were analyzed for extent of DIS. Specimens were washed, fixed in formalin, and sectioned in 5-mm cuts from the distal border of the residual tumor to the distal resection margin. Results Eleven patients (55%) had DIS. Two patients had a complete pathologic response (10%). The mean extent of DIS was 0.50 cm (standard deviation, 0.64 cm; range, 0.0 to 2.5 cm). Only 1 patient in the study had DIS beyond 1 cm from the residual tumor. Six of the patients have died at a median of 30.4 months after operation (range, 19.0 to 51.1 months). No correlation was found between the extent of residual DIS and survival. Conclusions Our study shows that the vast majority of patients with rectal cancer after neoadjuvant CMT have no tumor cells beyond 1 cm from the residual tumor. Our data suggest that a 2-cm margin of resection when feasible from the macroscopic tumor margin after neoadjuvant CMT is adequate.

Introduction: The mainstay of treatment for pancreatic and gastric cancers is surgical resection. Unfortunately many of these patients present with locally advanced, unresectable or distant disease and therefore medical management may be of more benefit. Accurate staging of patients with pancreatic and gastric cancer is essential in determining the best treatment strategy. Despite preoperative imaging there remains a group of patients that have clinically occult metastatic disease. Positive peritoneal cytology is a poor prognostic indicator for survival in both gastric and pancreatic cancer. Surgical resection may not be of benefit in those with positive peritoneal cytology. At our institution, a diagnostic laparoscopy with peritoneal washings is performed prior to surgical resection. We performed a retrospective review to evaluate the accuracy of immediate peritoneal washing interpretation in both gastric cancer and pancreatic cancer. Results: There were 51 patients that underwent immediate peritoneal washing interpretations. There were 5 patients with gastric adenocarcinoma, 2 patients with cholangiocarcinoma, and 44 patients with pancreatic adenocarcinoma. Four of the patients had positive cytology for tumor cells with immediate interpretation, and 47 patients had cytology negative for tumor cells with immediate interpretation. There was only one patient with negative cytology on immediate interpretation with cytology positive for malignant cells on final pathologic results. There were many RBCs noted within the peritoneal fluid specimen, which is probably why the cancer cells were missed. Immediate peritoneal cytology results had a 100% positive predictive value, and a 97% negative predictive value. There were no false positive results. Discussion: Positive peritoneal cytology is considered a poor prognostic factor for survival in both gastric and pancreatic cancer. In pancreatic and gastric cancer, previous studies have shown resection in the presence of metastatic disease does not improve survival. Diagnostic laparoscopy has been used as an adjunct to help stage patients before proceeding with a radical resection that has an associated significant morbidity andmortality rate is futile and potentially harmful, delaying or obviating systemic therapy that may be of more benefit to the patient. Our results show that utilizing immediate interpretation of peritoneal cytology is reliable and accurate. There was only one patient with a false negative result and there were no false positive results. Therefore, prior to surgical resection immediate interpretation can be utilized. Conclusion: Diagnostic laparoscopy with peritoneal washings and immediate interpretation of cytology can be used prior to proceeding with surgical resection. A futile operation can potentially be avoided with the use of immediate interpretation of the peritoneal fluid.

Background: There is now increased awareness of the detrimental effects of transfusion in elective general surgical procedures. Our objectives are to determine 1) which preoperative clinical variables can predict the need for intraoperative transfusion and 2) the impact of transfusion on hospital costs and complications in pancreatectomy. Methods: Using our prospective institutional and ACS-NSQIP database, we identified 173 patients who had elective pancreatectomy from 9/2007 to 9/2011. Univariate and multivariate analyses were performed using 24 preoperative clinical variables to identify risk factors associated with transfusion. Preoperative severity of illness (SOI) and mortality risk were determined using the Agency for Health Research and Quality (AHRQ) Risk Adjustment Score, a standardized metric used by the University Health System Consortium. Hospital costs and operative complications were also evaluated. Results: Patients had left pancreatectomy (n=60) or pancreaticoduodenectomy (n=113) to treat malignant (n=134) or benign (n=39) disease. Median OR time was 7.4 hours (2.4-12.3). Median LOS was 10 days (4-77) and 51 patients (29%) spent at least one night in the ICU. 98 patients (56.6%) had a complication and 90day mortality was 2.9% (n=5). SOI at admission was minor in 21 patients (12.1%), moderate in 59 (34.1%), and major/extreme in 43 (24.8%). Risk of mortality at admission was: minor (n=91, 53%), moderate (n=58, 34%), and major (n=24, 14%). There were 78 patients (45%) who received at least 1 unit of blood and the median number of intraoperative transfusions was 3.0 units (1-55); 11 of these patients (6.4%) also received plasma. Mean total hospital costs observed was $39,434 ($13,285-$251,157). Compared to patients who did not receive a transfusion, those who received at least one blood product had a higher mean hospital cost and hospital charges (Table). Among transfused patients, 65% (n=51) experienced at least one complication vs. 49% (n=47) of patients not transfused (p=0.036), including infectious complications and pancreatic fistula/leak/abscess (Table). In multivariate analysis, independent predictors of increased transfusion likelihood included lower hematocrit, increased BMI, and worse AHRQ SOI and mortality risk scores. Age, gender, comorbidities, diagnosis, ASA class, procedure, OR time, and ICU stay were not independent predictors of transfusion risk. Conclusions: Blood transfusion is associated with increased hospital cost and morbidity in pancreatectomy. Factors associated with increased risk for transfusion such as preoperative hematocrit, BMI and AHRQ scores can be utilized to stratify patients in clinical trials and inform patients of their risk for transfusion. Further research is needed to determine the extent to which transfusion contributes to morbidity and cost independently of SOI. Table. Cost and complications associated with transfusion in pancreatectomy