Transarterial chemoembolization followed by moderately hypofractionated radiotherapy in hepatocellular carcinoma: Long-term results of RTF3 regimen

PURPOSE

In early-stage hepatocellular carcinoma (HCC) patients merely fit for surgery, transarterial chemoembolization (TACE) achieve low long-term disease control. We evaluated the efficacy and safety of its combination with moderately hypofractionated radiotherapy (hRT) using RTF3 regimen.

MATERIAL AND METHODS

Between 2006 and 2016, 61 consecutive patients treated in our single expert center for a Barcelona Clinic Liver Cancer (BCLC) A HCC by TACE followed by hRT 3Gy/fraction were retrospectively included.

RESULTS

Sixty of the 61 included presented Child-Pugh A cirrhosis (A5, n=41, 67.2%; A6: n=19, 31.1%). Fourteen patients (22.9%) were already treated for a HCC, mainly by radiofrequency (n=12). All patient received a TACE followed by 3Gy per fraction hRT. Mean radiation dose was 54Gy (range: 48-60). After a median follow-up of 118 months, median time-to-progression, progression-free survival (PFS) and overall survival (OS) was 21.3, 18.1, and 31.5 months, respectively. In univariate analysis, PFS was related to dose > 54Gy (HR: 2, P=0.036), and OS was correlated to Child-Pugh A6 or B7 (HR: 1.93, P=0.03) and overall hRT time (HR: 1.06, P=0.015). At progression, orthotopic liver transplantation was performed in 8 patients (13.1%). Severe symptomatic adverse events occurred in 12 patients (19.7%), mainly ascites (n=7).

CONCLUSION

In BCLC-A Child-Pugh A HCC patients ineligible to surgery or thermoablation, TACE-hRT is a safe and effective treatment. Prospective studies are needed to compare this association with radioembolization, TACE-stereotactic radiotherapy, and systemic treatments combinations.

Novel strategies in liver graft preservation - The French perspective

Given the increasing graft shortage, the transplant community is forced to use so called marginal liver grafts with a higher susceptibility to ischemia-reperfusion injury. This exposes the recipient to a higher risk of graft failure and post-transplant complications. While static cold storage remains the gold standard in low-risk transplant scenarios, dynamic preservation strategies may allow to improve outcomes after transplantation of marginal liver grafts. Two dynamic preservation strategies, end-ischemic hypothermic oxygenated perfusion (HOPE) and continuous normothermic machine perfusion (cNMP), have been evaluated in randomized clinical trials. The results show improved preservation of liver grafts after cNMP and reduction of post-transplant biliary complications after HOPE. In comparison to cNMP, HOPE has the advantage of requiring less logistics and expertise with the possibility to return to default static cold storage. Both strategies allow to assess graft viability prior to transplantation and may thus contribute to optimizing graft selection and reducing discard rates. The use of dynamic preservation is rapidly increasing in France and results from a national randomized trial on the use of HOPE in marginal grafts will soon be available. Future applications should focus on controlled donation after circulatory death liver grafts, split grafts and graft treatment during perfusion. The final aim of dynamic liver graft preservation is to improve post-transplant outcomes, increase the number of transplanted grafts and allow expansion of transplant indications.

Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association

AIM

It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies.

METHOD

From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively.

RESULTS

In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups.

CONCLUSION

The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

Surgical activity during the Covid-19 pandemic: Results for 112 patients in a French tertiary care center, a quality improvement study

BACKGROUND

After the emergence of Covid-19 in China, Hubei Province, the epidemic quickly spread to Europe. France was quickly hit and our institution was one of the first French university to receive patients infected with Sars-COV2. The predicted massive influx of patients motivated the cancellation of all elective surgical procedures planned to free hospitalization beds and to free intensive care beds. Nevertheless, we should properly select patients who will be canceled to avoid life-threatening. The retained surgical indications are surgical emergencies, oncologic surgery, and organ transplantation.

MATERIAL AND METHODS

We describe the organization of our institution which allows the continuation of these surgical activities while limiting the exposure of our patients to the Sars Cov2.

RESULTS

After 4 weeks of implementation of intra-hospital protocols for the control of the Covid-19 epidemic, 112 patients were operated on (104 oncology or emergency surgeries and 8 liver transplants). Only one case of post-operative contamination was observed. No mortality related to Covid-19 was noted. No cases of contamination of surgical care personnel have been reported.

CONCLUSION

We found that the performance of oncological or emergency surgery is possible, safe for both patients and caregivers.

Thirty-day mortality after emergency surgery for obstructing colon cancer: survey and dedicated score from the French Surgical Association

AIM

The aim was to define risk factors for postoperative mortality in patients undergoing emergency surgery for obstructing colon cancer (OCC) and to propose a dedicated score.

METHOD

From 2000 to 2015, 2325 patients were treated for OCC in French surgical centres by members of the French National Surgical Association. A multivariate analysis was performed for variables with P value ≤ 0.20 in the univariate analysis for 30-day mortality. Predictive performance was assessed by the area under the receiver operating characteristic curve.

RESULTS

A total of 1983 patients were included. Thirty-day postoperative mortality was 7%. Multivariate analysis found five significant independent risk factors: age ≥ 75 (P = 0.013), American Society of Anesthesiologists (ASA) score ≥ III (P = 0.027), pulmonary comorbidity (P = 0.0002), right-sided cancer (P = 0.047) and haemodynamic failure (P < 0.0001). The odds ratio for risk of postoperative death was 3.42 with one factor, 5.80 with two factors, 15.73 with three factors, 29.23 with four factors and 77.25 with five factors. The discriminating capacity in predicting 30-day postoperative mortality was 0.80.

CONCLUSION

Thirty-day postoperative mortality after emergency surgery for OCC is correlated with age, ASA score, pulmonary comorbidity, site of tumour and haemodynamic failure, with a specific score ranging from 0 to 5.

BRAF mutation is not associated with an increased risk of recurrence in patients undergoing resection of colorectal liver metastases

BACKGROUND

BRAF mutation is associated with a poor prognosis in patients with metastatic colorectal cancer. For patients with resectable colorectal liver metastases (CRLMs), the prognostic impact of BRAF mutation is unknown and the benefit of surgery debated. This nationwide intergroup (ACHBT, FRENCH, AGEO) study aimed to evaluate the oncological outcome of patients undergoing liver resection for BRAF-mutated CRLMs.

METHODS

The study included patients who underwent resection for BRAF-mutated CRLMs in 24 centres between 2012 and 2016. A case-matched comparison was made with 183 patients who underwent resection of CRLMs with wild-type BRAF during the same interval.

RESULTS

Sixty-six patients who underwent resection for BRAF-mutated CRLMs in 24 centres were compared with 183 patients with wild-type BRAF. The 1- and 3-year disease-free survival (DFS) rates were 46 and 19 per cent for the BRAF-mutated group, and 55·4 and 27·8 per cent for the group with wild-type BRAF (P = 0·430). In multivariable analysis, BRAF mutation was not associated with worse DFS (hazard ratio 1·16, 95 per cent c.i. 0·72 to 1·85; P = 0·547). The 1- and 3-year overall survival rates after surgery were 94 and 54 per cent respectively among patients with BRAF mutation, and 95·8 and 82·9 per cent in those with wild-type BRAF (P = 0·004). Median survival after disease progression was 23·0 (95 per cent c.i. 11·0 to 35·0) months among patients with mutated BRAF and 44·3 (35·9 to 52·6) months in those with wild-type BRAF (P = 0·050). Multisite disease progression was more common in the BRAF-mutated group (48 versus 29·8 per cent; P = 0·034).

CONCLUSION

These results support surgical treatment for resectable BRAF-mutated CRLM, as BRAF mutation by itself does not increase the risk of relapse after resection. BRAF mutation is associated with worse survival in patients whose disease relapses after resection of CRLM, as for non-metastatic colorectal cancer.

Multicentre study of the impact of morbidity on long-term survival following hepatectomy for intrahepatic cholangiocarcinoma

BACKGROUND

The impact of morbidity on long-term outcomes following liver resection for intrahepatic cholangiocarcinoma is currently unclear.

METHODS

This was a retrospective analysis of all consecutive patients who underwent liver resection for intrahepatic cholangiocarcinoma with curative intent in 24 university hospitals between 1989 and 2009. Severe morbidity was defined as any complication of Dindo-Clavien grade III or IV. Patients with severe morbidity were compared with those without in terms of demographics, pathology, management, morbidity, overall survival, disease-free survival and time to recurrence. Independent predictors of severe morbidity were identified by multivariable analysis.

RESULTS

A total of 522 patients were enrolled. Severe morbidity occurred in 113 patients (21·6 per cent) and was an independent predictor of overall survival (hazard ratio 1·64, 95 per cent c.i. 1·21 to 2·23), as were age at resection, multifocal disease, positive lymph node status and R0 resection margin. Severe morbidity did not emerge as an independent predictor of disease-free survival. Independent predictors of time to recurrence included severe morbidity, tumour size, multifocal disease, vascular invasion and R0 resection margin. Major hepatectomy and intraoperative transfusion were independent predictors of severe morbidity.

CONCLUSION

Severe morbidity adversely affects overall survival following liver resection for intrahepatic cholangiocarcinoma.

Long-term survival after pancreatic resection for renal cell carcinoma metastasis

BACKGROUND

Surgical resection of pancreatic metastasis (PM) is the only reported curative treatment for renal cell carcinoma. However, there is currently little information regarding very long-term survival. The primary objective of this study was to determine the 10-year survival of this condition using the largest surgical series reported to date.

METHODS

Between May 1987 and June 2003, we conducted a retrospective study of 62 patients surgically treated for PM from renal cell carcinoma at 12 Franco-Belgian surgical centers. Follow-up ended on May 31, 2012.

RESULTS

There were 27 male (44 %) and 35 female (56 %) patients with a median age of 54 years [31-75]. Mean disease-free interval from resection of primary tumor to reoperation for pancreatic recurrence was 9.8 years (median 10 years [0-25]). During a median follow-up of 91 months [12-250], 37 recurrences (60 %) were observed. After surgical resection of repeated recurrences, overall median survival time was 52.6 months versus 11.2 months after nonoperative management (p = 0.019). Cumulative 3-, 5-, and 10-year overall survival (OS) rates were 72, 63, and 32 %, respectively. The corresponding disease-free survival rates were 54, 35, and 27 %, respectively. Lymph node involvement and existence of extrapancreatic metastases before PM were associated with poor overall survival.

CONCLUSIONS

Aggressive surgical management of single or multiple PM, even in cases of extrapancreatic disease, should be considered in selected patients to allow a chance of long-term survival.

Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma

BACKGROUND

Indications for preoperative biliary drainage (PBD) in the context of hepatectomy for hilar malignancies are still debated. The aim of this study was to investigate current European practice regarding biliary drainage before hepatectomy for Klatskin tumours.

METHODS

This was a retrospective analysis of all patients who underwent formal or extended right or left hepatectomy for hilar cholangiocarcinoma between 1997 and 2008 at 11 European teaching hospitals, and for whom details of serum bilirubin levels at admission and at the time of surgery were available. PBD was performed at the physicians' discretion. The primary outcome was 90-day mortality. Secondary outcomes were morbidity and cause of death. The association of PBD and of preoperative serum bilirubin levels with postoperative mortality was assessed by logistic regression, in the entire population as well as separately in the right- and left-sided hepatectomy groups, and was adjusted for confounding factors.

RESULTS

A total of 366 patients were enrolled; PBD was performed in 180 patients. The overall mortality rate was 10·7 per cent and was higher after right- than left-sided hepatectomy (14·7 versus 6·6 per cent; adjusted odds ratio (OR) 3·16, 95 per cent confidence interval 1·50 to 6·65; P = 0·001). PBD did not affect overall postoperative mortality, but was associated with a decreased mortality rate after right hepatectomy (adjusted OR 0·29, 0·11 to 0·77; P = 0·013) and an increased mortality rate after left hepatectomy (adjusted OR 4·06, 1·01 to 16·30; P = 0·035). A preoperative serum bilirubin level greater than 50 µmol/l was also associated with increased mortality, but only after right hepatectomy (adjusted OR 7·02, 1·73 to 28·52; P = 0·002).

CONCLUSION

PBD does not affect overall mortality in jaundiced patients with hilar cholangiocarcinoma, but there may be a difference between patients undergoing right-sided versus left-sided hepatectomy.

Transthoracic approach for liver tumors

Abdominal approach is commonly used for resection of liver tumors. However, in rare cases, transthoracic approach may be a valuable option for management of lesions located in the hepatic dome or involving the cavo-hepatic junction for very selected patients. This approach can be an open procedure (thoracotomomy), a video-assisted minimally invasive technique (thoracoscopy), or a strictly percutaneously treatment (CT-guided radiofrequency ablation). This approach seems useful for high-risk patients, with previous major abdominal surgery, or awaiting for liver transplantation (bridge concept) with cranially located single lesions. A limited liver resection (tumorectomy or segmentectomy) can be performed, but this approach is also suitable for percutaneous ablation therapy (radiofrequency or cryotherapy), with an acceptable morbidity.

Le reflux biliaire duodéno-gastrique et gastro-œsophagien

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.

[Laparoscopic fundoplication: current data]

Laparoscopic fundoplication is as effective as its open counterpart, allowing reduced morbidity, shorter hospital stay and recovery, lower consumption of analgesics, and very low mortality, with no significant differences in early functional outcome. Rate of early recurrence is similar after partial and total fundoplication, but but the partial approach has a significantly reduced rate of reoperation for failure, mainly due to postoperative dysphagia. Long-term follow-up is required to evaluate dysphagia and quality-of-life.

[Reinterventions for complication and defect of coloesophagoplasty]

AIM OF THE STUDY

To report a series of 17 patients operated for a complication oesophagocoloplasty, with evaluation of therapeutic modalities, and both early and distant results.

MATERIALS AND METHOD

From 1985 to 2003, 17 patients with a mean age of 50 years (range: 23-76) were reoperated after coloplasty pediculated on left superior colic vessels. Initial diseases were caustic ingestion (N=7), cancer (N=6), oesophageal perforation (N=2), gastric lymphoma (N=1) and oesotracheal fistula (N=1). Coloplasty has been performed as a first-intent procedure in 13 cases and as a second-intent procedure after failure of a previous operation in 4 cases. Nine patients were initially operated in another center and were subsequently referred in our unit. Complications needing reoperation were graft necrosis in 8 cases (47%) and stricture in 9 cases (53%). All patients with necrosis were reoperated within the 10 first postoperative days.

RESULTS

Necroses were treated by complete (N=5) or partial (N=3) resection of the coloplasty. Strictures were treated by resection-reanastomosis (N=3), right ileocoloplasty (N=2), colic stricturoplasty (N=2), a free antebrachial flap (N=1) and a tubulized latissimus dorsi myocutaneous pedicled flap (N=1). The 30-day mortality rate was 12% (N=2) and the overall morbidity rate was 66%. All deaths occurred after reoperation for necrosis. Eleven patients (65%) kept or recovered digestive continuity (including the 9 with stenosis) and 8 (73%) eat normally. Four patients with transplant necrosis died before reestablishment. Four patients operated for necrosis died before restoration of digestive continuity and 2 patients are still awaiting restoration.

CONCLUSION

Use of colon as an oesophageal substitute is risky. Reoperations for stenosis allows satisfactory oral feeding, while reoperation for necrosis is associated with both high early mortality and a low rate of restoration or digestive continuity. This later requires a range of complex surgical procedures.

[Current management of pheochromocytoma: about 50 cases]

STUDY AIM

The aim of this retrospective study was to assess our experience of the laparoscopic surgery of pheochromocytoma. We report indications and results of laparoscopic and open adrenalectomy for pheochromocytoma.

PATIENTS AND METHODS

Between january 1994 and may 2002, 50 patients underwent laparoscopic or open adrenalectomy for pheocromocytoma. The perioperative hemodynamic parameters were assessed for each patient. In each case, urinary metanephrine levels were measured at the second month postoperatively. The long term outcome was assessed in 44 patients. The mean follow-up was 39 months.

RESULTS

Ten patients underwent open adrenalectomy: 8 patients for unilateral tumors (tumor size was > 8 cm in 7 cases) and 2 patients for bilateral tumors (1 recurrence and 1 cystic polylobed tumor). Fourty patients underwent laparoscopic adrenalectomy: in 32 cases, including 1 patient with a bilateral tumor, no conversion was performed (tumor size was < 5 cm in 29 cases). In 8 cases (20%), a conversion to an open operation was performed. The reasons to convert were bleeding and periadrenal fibrosis in 7 cases. In laparoscopic adrenalectomy group, hemodynamic troubles were not more frequent, the hospital stay was shorter and there was no recurrence.

CONCLUSION

Laparoscopic adrenalectomy is the Gold standard procedure for patients with pheochromocytoma. But open adrenalectomy is sometimes indicated: tumor size > 8 cm, periadrenal fibrosis, and recurrence tumor.

[Adrenocortical carcinoma: prognostic factors for local recurrence and indications for reoperation. A report on a series of 22 patients]

STUDY AIMS

The aim of this retrospective study was to identify prognostic factors on local recurrence in patients with adrenocortical carcinoma and to assess the effect of reoperations.

METHODS

From 1985 to 2001, 22 patients were operated for adrenocortical carcinoma. We evaluated the correlation between actuarial survival without local recurrence and tumor staging, Weiss criteria, mitotic index, extensive resection and Op'DDD therapy by univariate analysis. Then we evaluated the effect of reoperations on survival.

RESULTS

Local recurrence was observed in 7 patients and the 5-years actuarial survival without local recurrence was 50%. Tumor stage (I et II versus III et IV), Weiss criteria (< or = 6 criteria versus > 6) and mitotic index (< or = 20 mitoses/50 HPF versus > 20) affected survival without local recurrence. Extensive resection could reduce local recurrence rate. Op'DDD therapy was ineffective in prolonging survival without local recurrence. Four patients underwent repeat resections: 2 patients were still alive with disease free, 54 and 8 months after reoperations and 2 patients died, 19 and 25 months after reoperations. Three patients did not have repeat resection. They rapidly died within 8 months.

CONCLUSION

Pathologic features (tumor staging and mitotic index) affected local recurrence prognostic. But extensive resection to adjacent organs could facilitate complete resection tumor and reduce the local recurrence rate. Complete repeat resection of local recurrence can improve survival. The disabling effects of Op'DDD were important and its efficacy was not clear.

[IMesenteric and mesocolic cystic lymphangiomas. Diagnostic and therapeutic management]

STUDY AIM

Study of clinical, diagnostic and therapeutic aspects of mesenteric and mesocolic cystic lymphangiomas.

MATERIAL AND METHODS

15 cases were retrospectively analysed: 5 adults (mean age 36.8 years, range 26 to 46) and 10 children (mean age 23 months, range 0 to 5 years). Diagnosis was prenatal in 1 case. Symptoms were: abdominal pain (80%), fever (20%), abdominal mass (46%), occlusive syndrome (33%), chylous ascitis 1 case. Tumours were mesenteric (86%) or mesocolic (13%).

RESULTS

Complete resection was performed in 11 cases (including 10 bowel resections), incomplete resections in 3 and doxycycline sclerotherapy once. Mean follow-up is 5 years. One recurrence occurred 6 years after complete resection and 1 tumour increased after incomplete resection. Patient treated by sclerotherapy was non symptomatic with a 3.5 years follow-up after last injection.

CONCLUSION

Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy with doxycyclin is possible for unresectable lymphangiomas.

[Cryosurgery of primary and metastatic cancers of the liver]

Cryosurgery is a method of in situ destruction of tissue by a freezing process. Results of hepatic cryosurgery are now available for more than 2100 patients and allow to assess its place in the treatment of hepatic malignancies. Mechanisms of tissue destruction and indications of cryosurgery are detailed. With a peri-operative mortality rate of 1.5%, the safety of hepatic cryosurgery is now admitted. Cryosurgery has its own morbidity: increase of transaminases levels, platelets drop, myoglobinuria and rarely renal failure or cryoshock. In selected patients, hepatic cryosurgery is feasible with a laparoscopic or percutaneous approach. Long term results do not support cryosurgery as an alternative to liver resection. This technique enlarges possibilities of surgical treatment for patients with primary and metastatic liver cancers.

[Is preoperative localization of insulinomas necessary?]

STUDY AIM

To appreciate the impact of preoperative localization in surgical treatment of insulinomas.

PATIENTS AND METHOD

From 1986 to 2001, 29 patients were surgically treated for suspected insulinoma. Preoperative imaging assessment was performed in 26 patients: ultrasonography (n = 21), computed tomography (n = 23), endoscopic ultrasonography (n = 13), intraoperative ultrasonography (n = 22) (2 of them under laparoscopic approach).

RESULTS

The sensibility of the localization procedures was as follows: ultrasonography = 9.6%, computed tomography = 39%, endoscopic ultrasonography = 92.3%, surgical exploration 79.3%, intraoperative ultrasonography 86.3%. The sensibility of intraoperative palpation associated which intraoperative ultrasonography was 100%. Surgical procedures included: 11 enucleations, 10 segmental resections of the tail, 1 left pancreatectomy, 3 median pancreatectomies, 4 subtotal pancreatectomies. There was no postoperative mortality and postoperative morbidity rate was 17%, including 4 pancreatic leakages. Histological examination found solitary tumor in 22 patients (1 of them was a malignant tumor), multiple tumors (MEN 1) in 4 patients and factitious hypoglycemia in 3 patients. All the insulinomas were resected.

CONCLUSION

Intraoperative evaluation of the pancreas with intraoperative ultrasonography was associated which a right localization in 100% of insulinomas. The place for preoperative imaging seems to be limited. A laparoscopic approach in sporadic insulinomas could modify this attitude.

[Pretherapeutic assessment of esophageal carcinoma]

The prognosis of esophageal carcinoma is closely related to tumor stage and treatment modalities are applied according to the TNM stage of the disease and the performance status of the patient. Selecting the appropriate treatment based on accurate staging is of paramount importance. The subject of this review concerns advances in pretherapeutic assessment of esophageal carcinoma. Advantages and limits of pretherapeutic examinations are exposed with special interest to endoscopic and radiological investigations (sonography, computed tomography, magnetic resonance imaging, PET-scan, endoscopic ultrasonography, bronchoscopy.). Impact on therapeutic management is clarified.

Abdominal expansion using a polytetrafluoroethylene prosthesis in the treatment of Pepper syndrome

The authors report three cases of stage IV-S neuroblastoma in infants aged 4, 6, and 8 weeks, who despite chemo- and radiotherapy required surgical intervention to urgently relieve major thoracoabdominal compression secondary to massive hepatomegaly. The results were successful, with abdominal expansion being achieved by the introduction of a polytetrafluoroethylene prosthesis, which was removed during the 2nd, 3rd and 7th postoperative month, respectively, after tumor regression. Two children were in complete remission 32 and 38 months later, the 3rd died after 16 months of tumor progression.

[Management of Barrett's esophagus]

The subject of this review concerns advances in the diagnosis, etiology, complications, treatment and surveillance of Barrett's esophagus. Current management of Barrett's esophagus is discussed and indications of surgical treatment are clarified while specific destruction of Barrett's mucosa is possible by endoscopic management (laser or photodynamic therapy).

[Barrett's esophagus and antireflux surgery: a study of a series of 26 patients]

STUDY AIM

The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery.

PATIENTS AND METHODS

From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient.

RESULTS

Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma.

CONCLUSION

Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.

[Peritoneovenous diversion using the LeVeen shunt in the treatment of refractory ascites after liver transplantation]

Intractable ascites is a rare complication after liver transplantation. In this study, the authors report 2 cases of intractable ascites after liver transplantation. The authors discuss the etiology of ascites and the place of peritoneovenous shunt as a therapeutic option. From 1985 to 1996, 354 liver transplantations were performed. In two cases, liver transplantation was performed for post-VHC liver cirrhosis and giant hemangioma. Both patients developed intractable ascites and were successfully treated by peritoneovenous shunt. The etiologies of ascites after liver transplantations are multiple: mechanical after vascular complication; lymphatic leak after surgical dissection; metabolic disorder; intrahepatic lesion of the graft. In our cases, the etiology of ascites was intrahepatic lesion of the graft due to VHC infection in the first case and acute rejection in the second. Peritoneovenous shunt is a therapeutic option for the treatment of intractable ascites after liver transplantation. Its indication should be considered only for isolated intractable ascites without portal hypertension and without liver cell failure after liver transplantation.

[Thyroid cancer in children and adolescents. Clinical aspects, diagnostic problems and special therapeutics]

Twenty-five children undergoing surgery for thyroid carcinoma, were compared in a retrospective study. Clinical characteristics and disease course were detailed in three groups. In the first of 11 patients, a lobo-isthmusectomy was performed for a thyroid nodule, except two cases of total thyroidectomy (TT). Papillary carcinoma was diagnosed on histologic findings. Preoperative cytology and peroperative frozen section examination were inadequate for diagnosis. All children had a complete remission after treatment. In the second group, 10 children had evident thyroid carcinoma with cervical lymph node metastases, and lung metastases in two. Microscopicaly, there were diffuse sclerosing variant or multifocal papillary carcinoma. A TT with central node dissection was performed in all, with a lateral lymph node dissection in 9. Treatment included radioiodine therapy and thyroxin suppression therapy. Three patients had a postoperative recurrent laryngeal palsy, one hypoparathyroidism. Reoperation was carried out in 4 for cervicomediastinal lymph node recurrence. All patients are alive, with a complete remission, except for the two patients with lung metastases. In this group of aggressive tumors, a complete cure was possible with combination of extended, sometimes repeated, surgery and radioiodine therapy. In the last group, 4 patients had a medullary carcinoma. One presented with a thyroid nodule. The others were asymptomatic with a positive pentagastrin test during biological screening for familial disease. Two patients with lymph node metastases had a persistent pathologic calcitonin test despite a TT with complete central and lateral lymph node dissection. Early genetic screening in family members is the only way to perform a curative thyroidectomy in a prepathologic stage.