Endoscopic and Surgical Management of Non-Metastatic Ampullary Neuroendocrine Neoplasia: A Multi-Institutional Pancreas2000/EPC Study

INTRODUCTION

Ampullary neuroendocrine neoplasia (NEN) is rare and evidence regarding their management is scarce. This study aimed to describe clinicopathological features, management, and prognosis of ampullary NEN according to their endoscopic or surgical management.

METHODS

From a multi-institutional international database, patients treated with either endoscopic papillectomy (EP), transduodenal surgical ampullectomy (TSA), or pancreaticoduodenectomy (PD) for ampullary NEN were included. Clinical features, post-procedure complications, and recurrences were assessed.

RESULTS

65 patients were included, 20 (30.8%) treated with EP, 19 (29.2%) with TSA, and 26 (40%) with PD. Patients were mostly asymptomatic (n = 46; 70.8%). Median tumor size was 17 mm (12-22), tumors were mostly grade 1 (70.8%) and pT2 (55.4%). Two (10%) EP resulted in severe American Society for Gastrointestinal Enterology (ASGE) adverse post-procedure complications and 10 (50%) were R0. Clavien 3-5 complications did not occur after TSA and in 4, including 1 postoperative death (15.4%) of patients after PD, with 17 (89.5%) and 26 R0 resection (100%), respectively. The pN1/2 rate was 51.9% (n = 14) after PD. Tumor size larger than 1 cm (i.e., pT stage >1) was a predictor for R1 resection (p < 0.001). Three-year overall survival and disease-free survival after EP, TSA, and PD were 92%, 68%, 92% and 92%, 85%, 73%, respectively.

CONCLUSION

Management of ampullary NEN is challenging. EP should not be performed in lesions larger than 1 cm or with a endoscopic ultrasonography T stage beyond T1. Local resection by TSA seems safe and feasible for lesions without nodal involvement. PD should be preferred for larger ampullary NEN at risk of nodal metastasis.

Outcomes of rescue procedures in the management of locally recurrent ampullary tumors: A Pancreas 2000/EPC study

BACKGROUND

Ampullary lesions are rare and can be locally treated either with endoscopic papillectomy or transduodenal surgical ampullectomy. Management of local recurrence after a first-line treatment has been poorly studied.

METHODS

Patients with a local recurrence of an ampullary lesion initially treated with endoscopic papillectomy or transduodenal surgical ampullectomy were retrospectively included from a multi-institutional database (58 centers) between 2005 and 2018.

RESULTS

A total of 103 patients were included, 21 (20.4%) treated with redo endoscopic papillectomy, 14 (13.6%) with transduodenal surgical ampullectomy, and 68 (66%) with pancreaticoduodenectomy. Redo endoscopic papillectomy had low morbidity with 4.8% (n = 1) severe to fatal complications and a R0 rate of 81% (n = 17). Transduodenal surgical ampullectomy and pancreaticoduodenectomy after a first procedure had a higher morbidity with Clavien III and more complications, respectively, 28.6% (n = 4) and 25% (n = 17); R0 resection rates were 85.7% (n = 12) and 92.6% (n = 63), both without statistically significant difference compared to endoscopic papillectomy (P = .1 and 0.2). Pancreaticoduodenectomy had 4.4% (n = 2) mortality. No deaths were registered after transduodenal surgical ampullectomy or endoscopic papillectomy. Recurrences treated with pancreaticoduodenectomy were more likely to be adenocarcinomas (79.4%, n = 54 vs 21.4%, n = 3 for transduodenal surgical ampullectomy and 4.8%, n = 1 for endoscopic papillectomy, P < .0001). Three-year overall survival and disease-free survival were comparable.

CONCLUSION

Endoscopy is appropriate for noninvasive recurrences, with resection rate and survival outcomes comparable to surgery. Surgery applies more to invasive recurrences, with transduodenal surgical ampullectomy rather for carcinoma in situ and early cancers and pancreaticoduodenectomy for more advanced tumors.

Preoperative nutrition forseverely malnourished patients in digestive surgery: A retrospective study

INTRODUCTION

Malnutrition increases postoperative morbidity and mortality. The objective of this study was to evaluate preoperative refeeding in malnourished patients at risk of refeeding syndrome (RS).

METHODOLOGY

A retrospective study, conducted between June 2016 and January 2017, reported to the CNIL, compared two groups of malnourished patients: a group of refeeding patients (RP) and a group of non-refeeding patients (NRP). The inclusion criteria were weight loss of more than 10% or albuminemia less than 35g/L and RS risk factor. The primary endpoint was postoperative morbidity. The secondary endpoints were weight change and serum albumin over 6 months.

RESULTS

Seventy-three patients (30 RP and 43 NRP) were included. At the time of initial management, median weight loss was 18% [1-71], while albuminemia was 26g/L [13-40] in the RP group and 32.5g/L [32-48] in the NRP group (P=0.01). The overall postoperative morbidity rate was 88% (83% RP versus 90% NRP, P=0.47), and there was no significant difference between the 2 groups. The rate of anastomotic complications was 4% for RP versus 26% for NRP (P=0.03) after exclusion of liver surgery. Medium-term weight loss tended to be greater in RP (P=0.7). Nutritional support was continued until the third postoperative month in 13% of RPs vs. no NRPs (P=0.0002).

CONCLUSION

After preoperative renutrition, we did not observe a decrease in morbidity but rather a decrease in the rate of anastomotic complications in favor of the RP group. This study underscores the middle-term importance of nutritional management in view of preserving the benefits of preoperative renutrition.

Liver preservation with SCOT 15 solution decreases posttransplantation cholestasis compared with University of Wisconsin solution: a retrospective study

BACKGROUND

SCOT 15 is a new solution to preserve abdominal organs for transplantation. Its principal characteristic is the use of polyethylene glycol. Herein We report our experience using SCOT 15 compared with the reference University of Wisconsin (UW) solution for hepatic transplantation.

METHODS

We compared 2 groups: SCOT 15 (n = 33; 2009-2010) versus UW (n = 34; 2008-2010), which were paired for cold and warm ischemic times, donor ages, and graft weights. Endpoints were biologic tests in the first 2 months after the operation. A linear mixed model was used to evaluate longitudinal changes and influences of each solution.

RESULTS

No primary failure was observed. At postoperative day 0, transaminase values were higher in the SCOT 15 than in the UW group: aspartate transaminase: 2,435 ± 399 vs 589 ± 83 IU/L (P < .01); alanine transaminase: ALT: 1,207 ± 191 vs 484 ± 64 IU/L (P < .05), then returned to low levels in both groups. From day 0 to 8, coagulation factors reached normal values; there was no difference between the 2 groups. Total bilirubin decreased similarly in the 2 groups. However, from the second postoperative week (W1) to W8, the SCOT 15 group showed a slow decrease in the mean values of gamma-glutamyltranspeptidase (gGT) from 233 ± 125 to 130 ± 161 IU/L, which were significantly lower than those in the UW group, where the gGT remained around 300 IU/L (P < .01). The End-Stage Liver Disease, Child-Pugh, or United Network for Organ Sharing scores, primary liver diseases, hepatitic C virus status, arterial or biliary complications, and male/female ratio, which was different in the 2 groups, did not statistically influence these results.

CONCLUSIONS

The main effect of cold storage of human liver using SCOT 15 compared with UW solution was to decrease cholestasis following transplantation.

Elective subtotal colectomy with ileosigmoid anastomosis for colon cancer preserves bowel function and quality of life

AIM

We report on our experience of elective subtotal colectomy and ileosigmoid anastomosis for colon cancer with focus on postoperative results, function and quality of life.

METHOD

Between 1998 and 2011, 106 consecutive patients with colonic malignancy underwent this procedure electively. Function and quality of life (EORTC QLQ-C30) were evaluated retrospectively with questionnaires sent to all patients free of recurrence.

RESULTS

There were 62 men and 44 women (mean age 63 years). Postoperative mortality and morbidity rates were 1.9 and 26.4%, respectively. Persistent ileus was the main early complication (16%). After a mean follow-up of 67 ± 36 months, 50 (78.1) out of 64 patients have been evaluated for function and quality of life. The mean number of bowel movements per 24 h was 3 ± 2 and significantly lower when the length of the remaining sigmoid colon was more than 15 cm (P = 0.049). Compared with a European reference population for EORTC QLQ-C30 results, our patients had significantly more diarrhoea (26 vs 3, P = 0.0002) but less pain (10 vs 25, P < 0.0001) and better global quality of life (77 vs 62, P < 0.0001).

CONCLUSION

Elective subtotal colectomy for colon cancer is safe and associated with good function and quality of life. Ileosigmoid anastomosis should be discussed when extended colectomy is required, providing the rectosigmoid junction and its vascular supply can be oncologically preserved. For tumours located in the transverse colon or at the splenic flexure, this procedure may be the best surgical option.

Contribution of CXCR4 and SMAD4 in predicting disease progression pattern and benefit from adjuvant chemotherapy in resected pancreatic adenocarcinoma

BACKGROUND

Prognosis of patients with pancreatic adenocarcinoma is poor. Many prognostic biomarkers have been tested, but most studies included heterogeneous patients. We aimed to investigate the prognostic and/or predictive values of four relevant biomarkers in a multicentric cohort of patients.

PATIENTS AND METHODS

A total of 471 patients who had resected pancreatic adenocarcinoma were included. Using tissue microarray, we assessed the relationship of biomarker expressions with the overall survival: Smad4, type II TGF-β receptor, CXCR4, and LKB1.

RESULTS

High CXCR4 expression was found to be the only independent negative prognostic biomarker [hazard ratio (HR) = 1.74; P < 0.0001]. In addition, it was significantly associated with a distant relapse pattern (HR = 2.19; P < 0.0001) and was the strongest prognostic factor compared with clinicopathological factors. In patients who did not received adjuvant treatment, there was a trend toward decrease in the overall survival for negative Smad4 expression. Loss of Smad4 expression was not correlated with recurrence pattern but was shown to be predictive for adjuvant chemotherapy (CT) benefit (HR = 0.59; P = 0.002).

CONCLUSIONS

CXCR4 is a strong independent prognostic biomarker associated with distant metastatic recurrence and appears as an attractive target to be evaluated in pancreatic adenocarcinoma. Negative SMAD4 expression should be considered as a potential predictor of adjuvant CT benefit.

Passive transient transfer of peanut allergy by liver transplantation

We report a case of transient symptomatic transferred IgE-mediated peanut allergy after elective blood-group compatible liver transplantation. We show that the allergy was transient and therefore passive, authorizing further uneventful peanut consumption. Skin tests with commercial peanut extract and native peanut were performed in the recipient. Circulating specific IgE against peanut and recombinant peanut allergens (rArah1, rArah2, rArah3) was measured in stored serum samples collected from the recipient between 6 months before and 8 months after liver transplantation. Specific IgE levels in the donor were measured at the time of multiorgan donation. In the recipient, diagnosis of IgE-mediated peanut anaphylaxis was based on the clinical history and detection of specific IgE against peanut and recombinant major peanut allergens (rArah1, rArah2 and rArah3). Skin tests were negative and specific IgE undetectable 6 months after the clinical reaction. Oral peanut challenge was negative excluding persistent peanut allergy. This case confirms that IgE-mediated peanut allergy can be transferred by liver transplantation and shows that it may be transient and therefore passively acquired.

[Intensive care after digestive surgery: the outcome in elderly patients]

STUDY AIM

In surgical intensive care, the results must be analyzed both in terms of mortality and quality of life; this is particularly important in elderly patients for whom recovery remains uncertain. The aim of this prospective study was to assess the early and late prognosis in elderly patients (aged over 75 years) admitted to a digestive surgical intensive care unit (DSICU) for mortality, quality of life, patient autonomy, and also the predictive factors involved.

PATIENTS AND METHODS

Over a one-year period, 182 patients were admitted to a tertiary referral DSICU; 30 of these subjects were over 75 years old, and formed the basis of this study. The following data were analyzed: hospital mortality rate; mortality rate at six months, and quality of life at six months (Kamofsky scale). These factors were correlated with the severity of the patient's state at admission and also with the causal disease, circumstances connected with admission, and duration of stay in the DSICU.

RESULTS

The hospital mortality rate of patients was 23% (7/30 patients), and the overall mortality rate at six months was 40% (12/30 patients). Of the 12 patients who stayed in the DSICU for more than ten days with a simplified acute physiology score (APS) = 10, not one was alive at six months post-DSICU admission. The 18 remaining patients were still alive at six months, and 72% of them (13/18 patients) had regained their previous post-operative autonomy.

CONCLUSION

These results provide reference data for this patient category. The results concerning long-term survival and the good functional outcome are encouraging. If the prognostic criteria defined in this investigation are confirmed by further studies, they may help in making the sometimes difficult decisions regarding elderly patients hospitalized in a DSICU.

[Early debulking surgery after chemotherapy in advanced cancer of the ovary]

The main prognostic factor in advanced ovarian cancer is the volume of residual disease after the initial laparotomy. Early debulking surgery after several cycles of chemotherapy, before the emergence of resistant cell lines, could improve the prognosis of patients with bulky residual disease. This study concerns patients with advanced ovarian cancer entered into three prospective trials including IV cisplatin and anthracycline-based chemotherapy, early debulking surgery after three cycles of chemotherapy in case of initial residual disease superior 2 cm and intraperitoneal consolidation chemotherapy. Among 160 patients with stage III or IV, 80 (50%) had at least a residual tumor of more than 2 cm in diameter. Early debulking surgery was effectively performed in 54 patients (67.5%), leaving 39 patients with no residue over 2 cm. Twenty-one patients had no macroscopic residual disease. The median survival of all patients with initial residual disease over 2 cm was 23 months. Patients with no macroscopic residual disease at early debulking surgery had a median survival of 44 months. Early debulking surgery appears useful in advanced ovarian cancer with bulky residual disease. The objective of this operation is to achieve no macroscopic residual lesion.

Vegf, Vegf-B, Vegf-C and their receptors KDR, FLT-1 and FLT-4 during the neoplastic progression of human colonic mucosa

Because the crucial role of angiogenesis has been demonstrated in tumor growth and metastasis, the present study was undertaken to characterize the relative expression of vascular endothelial growth factors VEGF (vascular endothelial growth factor), VEGF-B, VEGF-C, and their receptors KDR (kinase insert domain-containing receptor), FLT-1 (fms-like tyrosine kinase), and FLT-4 in human colonic cancers, in relation to the Astler-Coller pathological classification, and to prognosis. VEGF and VEGF-B gene expression was quantified by Northern blot in 72 tumor samples matched with control tissues. VEGF gene expression was 1.4 times higher in adenocarcinomas than in control tissues (p = 0.02), but did not increase further between Astler-Coller tumor stages A and D, and did not correlate with disease recurrence for patients at stages B2 or C. In adenomas, VEGF mRNA levels were not significantly different from those in the paired control colonic mucosa. The expression pattern of VEGF isoforms, mainly identified by RT-PCR (reverse-transcriptase-coupled polymerase chain reaction) as VEGF121 and VEGF165 and to a lesser extent VEGF189, was comparable in tumor and control tissues. VEGF-B mRNA levels were unchanged during the neoplastic progression of colonic mucosa. In contrast to KDR and FLT-4, the expression of VEGF-C and FLT-1 genes increased in some pathological tissues. These results provide evidence that the early and sustained increase in VEGF transcripts and the expression of multiple angiogenic factors and receptors contribute to the development of colon cancer, and thus constitute a putative target for anti-angiogenic drug therapy.

Vegf, Vegf-B, Vegf-C and their receptors KDR, FLT-1 and FLT-4 during the neoplastic progression of human colonic mucosa

Because the crucial role of angiogenesis has been demonstrated in tumor growth and metastasis, the present study was undertaken to characterize the relative expression of vascular endothelial growth factors VEGF (vascular endothelial growth factor), VEGF-B, VEGF-C, and their receptors KDR (kinase insert domain-containing receptor), FLT-1 (fms-like tyrosine kinase), and FLT-4 in human colonic cancers, in relation to the Astler-Coller pathological classification, and to prognosis. VEGF and VEGF-B gene expression was quantified by Northern blot in 72 tumor samples matched with control tissues. VEGF gene expression was 1.4 times higher in adenocarcinomas than in control tissues (p = 0.02), but did not increase further between Astler-Coller tumor stages A and D, and did not correlate with disease recurrence for patients at stages B2 or C. In adenomas, VEGF mRNA levels were not significantly different from those in the paired control colonic mucosa. The expression pattern of VEGF isoforms, mainly identified by RT-PCR (reverse-transcriptase-coupled polymerase chain reaction) as VEGF121 and VEGF165 and to a lesser extent VEGF189, was comparable in tumor and control tissues. VEGF-B mRNA levels were unchanged during the neoplastic progression of colonic mucosa. In contrast to KDR and FLT-4, the expression of VEGF-C and FLT-1 genes increased in some pathological tissues. These results provide evidence that the early and sustained increase in VEGF transcripts and the expression of multiple angiogenic factors and receptors contribute to the development of colon cancer, and thus constitute a putative target for anti-angiogenic drug therapy.

Adjuvant intraperitoneal 5-fluorouracil in high-risk colon cancer: A multicenter phase III trial

OBJECTIVE

To evaluate the results of a prospective multicenter randomized study of adjuvant intraperitoneal 5-fluorouracil (5-FU) administered during 6 days shortly after resection of stages II and III colon cancers.

SUMMARY BACKGROUND DATA

Systemic adjuvant chemotherapy improves the survival of patients with stage III colon cancer receiving treatment for 6 months. Intraperitoneal chemotherapy theoretically combines peritoneal and hepatic effects.

METHODS

After resection, 267 patients were randomized into two groups. Patients in group 1 (n = 133) underwent resection followed by intraperitoneal administration of 5-FU (0.6 g/m2/day) for 6 days (day 4 to day 10). These patients also received intravenous 5-FU (1 g) during surgery. Patients in group 2 underwent resection alone (n = 134).

RESULTS

In group 1, 103 patients received the total dose, 18 received a partial dose as a result of technical or tolerance problems, and 12 did not receive the chemotherapy. Rates of surgical death and complications were similar in both groups. Tolerance to treatment was excellent or fair in 97% of the patients and poor in 3%. After a median follow-up of 58 months, 5-year overall survival rates were 74% in group 1 and 69% in group 2; disease-free survival rates were 68% and 62%, respectively. Survival curves were superimposed until 3 years after treatment and began diverging thereafter. Among patients receiving the full treatment, the 5-year disease-free survival rate was improved in the treatment group in patients with stage II cancers but was unchanged in patients with stage III cancers.

CONCLUSIONS

Chemotherapy with intraperitoneal 5-FU administered during a short period after surgery was well tolerated but was not sufficient to reduce the risk of death significantly. However, it reduced the risk of recurrence in stage II cancers. These results suggest that it should be associated with systemic chemotherapy to reduce both local and distant recurrences.

[Role of surgery in the treatment of refractory ascites in cirrhotic patients]

Ascites, generally directly reflecting portal hypertension, is the commonest cause of hospitalisation in patients with cirrhosis. In almost 10% of patients with ascites, optimal medical treatment combining bed rest, salt and water restriction, and diuretic treatment, is unable to induce sodium excretion and decrease the volume of the ascites, corresponding to the definition of refractory ascites. In other cases, it is the treatment of ascites itself (salt and water restriction and diuretics) which induce complications: water and electrolyte disturbances, functional renal failure, encephalopathy, the development of which also corresponds to refractory ascites. The therapeutic armamentarium for the management of refractory ascites remains varied, with the use of aspiration of ascites with compensation, peritoneovenous shunts, transhepatic or surgical porto-systemic anastomoses, and finally, liver transplantation. At the present time, each therapeutic measure must be taken while keeping in mind the possibility of subsequent liver transplantation and the potential risk of compromising liver transplantation by inappropriate treatments. In this context, the authors review and analyse the respective places of the various therapeutic modalities in the management of refractory ascites in cirrhotic patients.

Management and long-term results of surgery for localized gastric lymphomas

BACKGROUND

High- and low-grade gastric lymphomas (GL) differ in their behavior and chemosensitivity. Surgery has to be reevaluated according to the histologic grade of malignancy. We aimed to assess the place of surgery in the management of GL and its results after long-term follow-up.

METHODS

Among 54 patients with primary GL prospectively enrolled from 1984 to 1990, 45 with localized disease were studied. Primary resection was done whenever safe. All patients received chemotherapy adapted to the grade of malignancy and/or to the completeness of the resection.

RESULTS

Among 18 low- and 27 high-grade GL, 35 patients had primary resections; of those, 23 were complete. The complete response rate for all patients with low- and high-grade GL was 67% and 89%, respectively. After a median follow-up of 8 years, the disease-free survival rates for low-grade GL and high-grade GL were 94% and 89%, respectively. It was better after complete resection.

CONCLUSION

Complete resection is a major determinant of prolonged complete remission.

Possible first report of distant peritoneal metastases from a nodal mesenteric lymphoma after laparoscopic inguinal hernia repair

Laparoscopic surgery has gained wide acceptance. However, there is still debate as to its role in assessment and staging of gastrointestinal malignancies(1)since it may promote dissemination of cancer cells.(2)We report the first case of a low-grade mesenteric nodal lymphoma for laparoscopic hernia repair, complicated by distant implants both on the peritoneum and wall mesh.

Postoperative peritonitis originating from the duodenum: operative management by intubation and continuous intraluminal irrigation

BACKGROUND

The mortality rate associated with postoperative peritonitis remains high, especially when the source of infection cannot be eradicated. Such is the case with peritonitis arising from the duodenum, as primary closure is futile and intubation alone may be followed by local complications.

METHODS

Forty-nine consecutive patients with postoperative peritonitis originating from a duodenal leak and a mean Acute Physiology And Chronic Health Evaluation II score of 17.7 were treated according to the following procedure: a three-channelled spiral drain was inserted through the leak and extraluminal drains were placed near the duodenal defect. Intraluminal irrigation was undertaken immediately through the infusion channel of the spiral drain.

RESULTS

Eleven patients died and 26 suffered complications. The mean duration of intubation was 21 days.

CONCLUSION

Intubation with intraluminal irrigation has proved effective in a homogeneous group of patients with peritonitis due to duodenal leakage.

Efficacy of monoclonal antibody 131I-B72.3 immunoscintigraphy of pancreatic adenocarcinoma xenografts in nude mice

OBJECTIVE

To assess the efficacy of monoclonal antibody (MoAb) B72.3 for in vivo-immunoscintigraphy of pancreatic carcinoma in nude mice.

DESIGN

Experimental controlled animal study.

SETTING

University hospital, The Netherlands.

SUBJECTS

11 nude mice with subcutaneously xenografted human pancreatic carcinoma.

INTERVENTIONS

Specific MoAb B72.3 and non-specific MoAb MOPC21 were iodinated with 131I and injected intraperitoneally in nude mice. Scintigrams were taken on days 1-10 and tumour:non-tumour ratios of the regions of interest (tumour, thorax, abdomen, background) were calculated. The mice were then killed for in vitro tissue counts.

MAIN OUTCOME MEASURES

Tumour:non-tumour ratios in vivo and in vitro.

RESULTS

Results of immunoscintigraphy on days 1, 2, and 6 were compared. In the B72.3-group all ratios were only moderately raised, the tumour:background ratio being the highest (2.35 (SD 0.67)) on day 6. There were no obvious differences between the ratios of the B72.3-group and the MOPC21-group. The results of tissue counts done at the end of the study, showed that tumour:non-tumour ratios were twice as high in the B72.3-group, suggesting some specificity of this MoAb.

CONCLUSION

The results of our study suggest that MoAb B72.3 is not powerful enough for in vivo detection of pancreatic cancer as assessed in this xenograft model in nude mice.

Benign schwannoma of the digestive tract: a clinicopathologic and immunohistochemical study of five cases, including a case of esophageal tumor

We report five cases of schwannomas of the digestive tract. The patients were two men and three women, whose ages ranged from 56 to 74 years. Three cases arose in the stomach, one in the ascending colon, and one in the esophagus; the latter was a hitherto unreported location for this tumor. The schwannomas ranged from 2 to 11 cm in diameter. They were well circumscribed but not encapsulated, with interlacing bundles of spindle cells, nuclear atypia and no mitosis, interspersed with collagenous strands. Inflammatory cells were scattered throughout the tumors and a peripheral cuff of lymphoid aggregates was observed in all cases. Intracellular periodic acid-Schiff (PAS)-positive crystalloids were found in three cases; no skeinoid fibers were seen. A diffuse and intense positivity for vimentin and S-100 protein was detected in all five cases together with a variable and sometimes focal positivity for glial fibrillary acidic protein and neuron-specific enolase. None of the tumors showed expression of CD34 or the smooth muscle antigens tested. The four cases with a sufficient follow-up had a favorable outcome without any recurrence or metastasis. The morphologic and immunohistochemical features of digestive schwannomas were compared with those of other gastrointestinal stromal tumors. Schwannomas have many differences. Digestive schwannomas can be readily recognized on histologic and immunohistochemical examination. They are spindle cell tumors without epithelioid features, with a peripheral cuff of lymphoid tissue. Specific intracellular needle-shaped PAS-positive crystalloids are found in some cases, whereas skeinoid fibers are not. These tumors always express S-100 protein in a diffuse and strong manner, and they express glial fibrillary acidic protein but not express CD34. Digestive schwannomas usually are gastric tumors and have never been reported in the small bowel. They pursue a benign course and are far rarer than gastrointestinal autonomic nerve tumors.

Reoperation for severe pancreatitis: a 10-year experience in a tertiary care center

OBJECTIVES

To analyze the specific problems encountered in treating patients previously operated on for necrotizing pancreatitis and to determine the benefit of such a complex and demanding procedure.

DESIGN AND SETTING

Review of a case series in an academic tertiary care referral center.

PATIENTS

Forty-four consecutive patients referred and reoperated on in 10 years.

INTERVENTIONS

Reiterative laparotomy with complete debridement of all necrotic sites, followed by Mikulicz packing. Mikulicz packs were replaced by removable drains allowing both local prolonged lavage and open drainage of large solid necrotic debris. Enteral nutrition was performed through a feeding jejunostomy. Associated gastrointestinal tract lesions were simultaneously treated.

MAIN OUTCOME MEASURES

Operative findings, bacteriological status of necrosis, in-hospital mortality, length of hospitalization, and surgical complications and their management.

RESULTS

Necrosis was infected in 36 (82%) of the 44 cases and associated gastrointestinal tract lesions were found in 20 (45%) of these patients. Mortality was 23%, and was significantly (P = .03) related to the preoperative clinical status. Surgical complications occurred in 31 (70%) of the 44 patients necessitating surgical treatment in 18 (41%) of these patients. Mean (+/- SD) stay in the intensive care unit was 66+/-8 days for survivors.

CONCLUSION

This complex and demanding surgical procedure is worthwhile, yielding mortality rates comparable to those observed in de novo severe necrotizing pancreatitis.

[Tumoral angiogenesis: physiopathology, prognostic value and therapeutic perspectives]

INTRODUCTION

Angiogenesis activation plays a crucial role in tumoral growth and metastases dissemination. This review summarizes and analyzes current knowledge on molecular mechanisms related to angiogenesis and the prognostic value of its effectors. It also focuses on the therapeutical relevance of various drugs that might inhibit angiogenesic processes.

CURRENT KNOWLEDGE AND KEY POINTS

Tumor angiogenesis involves complex interactions between tumoral, stromal, endothelial cells, fibroblasts and the extracellular matrix. Normal and malignant angiogenesis depends on the balance of proangiogenic and antiangiogenic factors. Endothelial cells are activated by growth factors, such as Vascular Endothelial Growth Factor (VEGF), and proliferate; they release proteases able to induce degradation of the basement membrane and extracellular matrix, and undergo migration and tubulogenesis. Angiostatin and endostatin are two powerful inhibitors of angiogenesis in experimental models. Assessment of intratumoral microvessel density and quantification of angiogenic factors, including VEGF, are of prognostic value in most cancers, particularly in breast cancer. However, the use of these prognosis markers in clinical practice is still controversial due to the lack of prospective studies and to technical limits inherent to the scoring and standardization of immunohistochemical methods.

FUTURE PROSPECTS AND PROJECTS

Better understanding of the molecular basis of angiogenesis allows the development of new therapeutical strategies. Biochemical targets of antiangiogenic therapy are: the interaction between angiogenic factors and their receptors; the interaction of endothelial cells with the extracellular matrix; and intracellular signaling pathways. Angiogenesis inhibitors may not cause tumor regression, but inhibit cellular growth and produce "disease dormancy". Extensive phase I to III clinical trials involving antiangiogenesis therapy are in progress.

Microbiological hazards related to xenotransplantation of porcine organs into man

Pigs are emerging as the most likely providers of genetically engineered organs and cells for the purpose of clinical xenotransplantation. Introduction of clinical trials has been delayed primarily by uncertainties regarding the risk of swine pathogen transmission that could harm the recipient. The concern that xenotransplantation carries the potential for a new epidemic has been highlighted by recent experiences with both bovine spongiform encephalopathy and human immunodeficiency diseases. As clinical trials have been postponed and xenotransplantation teams are working actively to gather data for an estimation of the risk, this review provides the reader with a state-of-the-art estimation of the microbiological hazards related to xenotransplantation of porcine organs to man. Particular emphasis is put on viral and retroviral hazards. Both current diagnostic tools and those under development are described, along with breeding strategies to provide donor animals that would not put the recipient or the general population at risk.

[Adenocarcinoma of the pancreas. Therapeutic strategies]

SURGERY

Surgery whether curative or palliative, is the major modality of treatment. A complete resection is possible in about 20% of patients with a median survival of 12 to 16 months and a 20% five year survival. After complete resection 70 to 80% of patients develop a local recurrence. Biliary and gastro-intestinal bypasses as well as antalgic techniques are useful palliative procedures.

ADJUVANT AND NEOADJUVANT TREATMENT

Chemoradiotherapy is used either as adjuvant or neoadjuvant treatment. External beam irradiation techniques are used to deliver 45 to 50 Gy to the pancreas in five to six weeks. Concomitant fluorouracil is administered in bolus injections or better in continuous infusion,, either alone or in association with cisplatinum. Chemoradiotherapy reduces the local relapse rate and slightly, though significantly, increases the median survival. Therefore, after chemoradiotherapy, metastatic spread becomes the major cause of death.

PALLIATIVE TREATMENT

For locally advanced diseases, chemoradiotherapy has a true palliative effect with acceptable toxicity. Metastatic disease remains a challenge. Fluorouracil based chemotherapy with or without cisplatinum occasionally obtains effective palliation. Among new agents, only gemcitabine has proven clinical activity associated with low toxicity and is practical to use.

THERAPEUTIC STRATEGY

Presently, patients with resectable pancreatic carcinoma should be included in a prospective trial to receive combined modality treatment with adjuvant or neo-adjuvant chemoradiotherapy. The choice of treatment for patients with locally advanced or metastatic disease, should be based on the possibility of assuring a satisfactory quality of life. Present research should progress through controlled clinical trials to study original systemic treatment and combined modalities able to produce a lasting local control.

[Surgical morbidity of segmental colectomy ideally performed via laparotomy for complicated colonic diverticulosis]

OBJECTIVES

The appraisal of morbidity and mortality for one stage elective colectomy for complicated diverticulosis is difficult and often overestimated, due to the rarity of reports addressing this question. Our results for 100 patients on a recent 30 month period were studied retrospectively.

METHODS

One hundred patients were electively operated in a one-stage procedure for complicated diverticulosis in a single institution from January 1993 to June 1995. There were 66 females and 34 males (range: 31-81 years) with a mean age of 61 years. Main indications for surgery were repeated attacks (34 patients), chronic inflammatory mass (26 patients) and stenosis (22 patients). Seventy-eight patients had already been admitted for diverticulitis prior to surgery. There were 13 surgeons including 6 seniors and 7 fellows.

RESULTS

There was no mortality. Morbidity was 14% surgical and medical complications accounting for 8% and 6% respectively. One patient had an anastomotic fistula treated conservatively and another patient was reoperated on for early postoperative occlusion There was no perioperative bleeding requiring transfusion. There were no surgical trauma of spleen or uretera. Mean hospital stay was 10 days.

CONCLUSION

This study of a collective surgical experience demonstrates that elective one stage left colectomy for benign disease is safe, without mortality and with low morbidity.

Hepatectomy with hypothermic perfusion of the liver

Whereas most liver resections can be performed within 60 min, the period of vascular clamping and resulting ischemia may prove too short to allow complex major liver resections (MLR) especially on diseased livers. To overcome this problem, cooling of the liver with 4 degrees C preservations solution routinely used in liver transplantation may be used in three different approaches to MLR: I "In situ": the liver remains in the abdomen and integrity of afferent and efferent vessels is conserved. II "Ex situ-in vivo": the liver exteriorized from the abdomen by transecting all hepatic veins, remains connected to the porta hepatis. III "Ex vivo": the liver being removed from the abdomen, the MLR is performed extracorporeally. Of 15 MLR reported here, 11 were performed "in situ" and 4 "ex situ-in vivo"/Nowadays, the liver surgeon's "toolbox" must contain hypothermic liver perfusion. In carefully selected cases, these techniques allow MLR on diseases livers or mandating complex vascular procedures.

Long-term survival following resection of colorectal hepatic metastases. Association Française de Chirurgie

AIM

The aim of this study was to analyse characteristics of patients who survived more than 5 years after liver resection of colorectal metastases.

METHODS

A multicentre retrospective study collected 1818 patients who underwent curative resection of hepatic metastases between 1959 and 1991. Among the 747 patients operated on before 1987, 102 survived longer than 5 years, and were compared with patients who survived less than 5 years.

RESULTS

Three risk factors proved independently significant in multivariate analysis between the two groups: serosa infiltration (P = 0.003), involvement of peritumoral lymph nodes around the primary colorectal tumour (P = 0.04), and a liver resection margin of less than 1 cm (P = 0.02). There was no significant difference for other parameters studied (location of primary tumour, location, number and size of metastases, type of resection). A trend towards a shorter survival of patients with increased carcinoembryonic antigen serum level was observed.

CONCLUSION

Resection of colorectal hepatic metastases can provide long-term survival even in patients with poor prognostic factors. It seems justified to undertake resection of colorectal liver metastases whenever it may be performed safely as a curative treatment.

Overexpression of p53 mRNA in colorectal cancer and its relationship to p53 gene mutation

We analysed the frequency of p53 mRNA overexpression in a series of 109 primary colorectal carcinomas and its association with p53 gene mutation, which has been correlated with short survival. Sixty-nine of the 109 cases (63%) demonstrated p53 mRNA overexpression, without any correlation with stage or site of disease. Comparison with p53 gene mutation indicated that, besides cases in which p53 gene mutation and p53 mRNA overexpression were either both present (40 cases) or both absent (36 cases), there were also cases in which p53 mRNA was overexpressed in the absence of any mutation (29 cases) and those with a mutant gene in which the mRNA was not overexpressed (four cases). Moreover, the mutant p53 tumours exhibited an increase of p53 mRNA expression, which was significantly higher in tumours expressing the mutated allele alone than in tumours expressing both wild- and mutated-type alleles. These data (1) show that p53 mRNA overexpression is a frequent event in colorectal tumours and is not predictive of the status of the gene, i.e. whether or not a mutation is present; (2) provide further evidence that p53 protein overexpression does not only result from an increase in the half-life of mutated p53 and suggest that inactivation of the p53 function in colorectal cancers involves at least two distinct mechanisms, including p53 overexpression and/or mutation; and (3) suggest that p53 mRNA overexpression is an early event, since it is not correlated with Dukes stage.

Major extended hepatic resections in diseased livers using hypothermic protection: preliminary results from the first 12 patients treated with this new technique

BACKGROUND

Hepatic vascular exclusion allows the performance of major hepatic resections with minimal intraoperative blood loss. We have previously shown that normothermic ischemia can be tolerated by a healthy liver for up to 90 minutes, and this period is increased to 4 hours if the liver is cooled to 4 degrees C using University of Wisconsin solution.

STUDY DESIGN

This study assessed whether these techniques could be successfully applied for patients requiring resection of a diseased liver, which is more sensitive to ischemic damage. Between July 1990 and May 1994, 12 patients (6 men, 6 women; mean age, 57.8 years) in whom the planned hepatic resection was believed to require hepatic vascular exclusion for more than 1 hour were treated with perfusion with the University of Wisconsin solution. The surgical procedures were right hepatectomy (one patient), extended right hepatectomy (seven patients), and extended left hepatectomy (four patients). The underlying hepatic disease was cirrhosis or severe fibrosis with hepatocellular carcinoma (four patients), cholestasis (due to cholangiocarcinoma and biliary stricture, one patient each), and more than 30 percent steatosis after treatment of hepatic metastases with chemotherapy (six patients). The University of Wisconsin solution that had been cooled to 4 degrees C was perfused through a cannula placed in the portal vein or the hepatic arterial branch of the segment to be resected, but with flow directed toward the liver that should be retained and effluent fluid drained through a cavotomy. Before reperfusion, the liver was rinsed with Ringer's lactate solution, which was also 4 degrees C.

RESULTS

The mean duration of hepatic ischemia was 121 minutes (range, 65 to 250 minutes), and venovenous bypass was used in three cases. The mean amount of blood transfused intraoperatively was 4.3 +/- 4 U; four cases required no transfusion. One patient died on postoperative day seven of portal vein thrombosis. The median hospital stay was 21 days (range, 12 to 56 days). Postoperative complications consisted of pneumonia (one patient), liver insufficiency (one patient, who recovered spontaneously), and subphrenic abscess (one patient). The postoperative tests of hepatic function were altered to the same degree as that seen after hepatic vascular exclusion of less than 1-hour duration in healthy livers. All patients who left the hospital were alive at 1 year.

CONCLUSIONS

Cooling of the hepatic parenchyma allowed us to perform major hepatic resection in patients with diseased livers using hepatic vascular exclusion for longer than 1 hour without increased morbidity or mortality. However, because of particular difficulties due to the size or location of the lesions, the application of these new techniques should only be considered for the largest and most complex hepatic resections for which hepatic vascular exclusions longer than 1 hour are foreseen.

Surgical management of internal fistulas in Crohn's disease

BACKGROUND

Internal fistulas in Crohn's disease join a diseased intestinal segment to a "victim organ" (VO) that is affected by proximity. While the diseased segment is resected, the other can be sutured in selected cases.

STUDY DESIGN

Seventy-four patients with 100 internal fistulas were retrospectively reviewed to assess the results of this conservative operative approach.

RESULTS

Closure of the fistulous defect of the VO was achieved by resection (n = 41) or suture (n = 59). The VO was histologically unaffected by Crohn's disease in 86 cases. One patient died postoperatively. Three patients had postoperative fistulas after suture of the VO. There was no long-term recurrence of an internal fistula.

CONCLUSIONS

Surgical treatment of internal fistulas can be achieved safely by resection of the source of the fistula and suture repair of the VO when the latter is not affected by active Crohn's disease and when local conditions make it feasible.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Loss of sst2 somatostatin receptor gene expression in human pancreatic and colorectal cancer

Five somatostatin receptor subtypes (sst1 to sst5) have been cloned. We demonstrated previously that sst2 and sst5 mediate the antiproliferative effect of the somatostatin analogues octreotide and vapreotide. Using reverse transcription-PCR, we investigated gene expression of the five receptors in 47 human normal and cancerous tissues or cell lines from pancreatic and colorectal origin. mRNAs of somatostatin receptor subtypes were detected in 98% of samples, with more than two mRNA subtypes being expressed in 55% of cases. sst1, sst4, and sst5 were heterogeneously expressed in both normal and cancerous tissues; sst3 was rarely or not expressed. sst2 was present in normal pancreatic tissues but was absent in exocrine pancreatic carcinomas and their metastases. sst2 mRNAs were detected in normal colon, sporadic polyadenomas, and 50% of Dukes' stage B and 20% of Dukes' stage C carcinomas but were undetectable in Dukes' stage D carcinomas, hepatic metastases, and adenomas from familial adenomatous polyposis. The loss of sst2 expression could represent a growth advantage in these tumors and provide an explanation for the lack of therapeutic effect of somatostatin analogues in such adenocarcinomas. A subtyping of somatostatin receptors should be carried out before considering a somatostatin analogue treatment in patients with colorectal or pancreatic cancer.

Overexpression of nm23-H1 and nm23-H2 genes in colorectal carcinomas and loss of nm23-H1 expression in advanced tumour stages

Although a reduced expression of nm23 has been shown to correlate with a high metastatic potential in some human cancers, in colorectal cancers, conflicting data have been reported. As there are two homologous genes, nm23-H1 and nm23-H2, which encode the A and B subunits of nucleoside diphosphate kinase, efficient and simplified techniques were designed to selectively study nm23-H1 and -H2 expression in 35 colorectal cancers at both the protein and mRNA levels by immunoblotting, immunohistochemistry, and reverse transcription polymerase chain reaction (RT PCR) using specific antibodies and primers. Nm23-H1 and Nm23-H2 proteins were overexpressed in tumours compared with adjacent mucosa. This overexpression was lost, however, in some advanced cases: 89% and 81% of TNM (tumour, node, metastases) stages 0-II showed Nm23-H1 and -H2 overexpression, respectively, which significantly differed from 47% and 38% of stage III-IV tumours. Similar results were seen with nm23-H1 mRNA. Heterogenous labelling of tumoral cells was seen by immunohistological staining. This suggests a dichotomy: an overexpression of nm23-H1 and -H2 linked to early stages of cancer and a loss of nm23-H1 overexpression seen in more advanced stages. Therefore specific nm23-H1 determination should be evaluated as a prognostic factor in human colorectal carcinoma.

Surgical management of ileosigmoid fistulas in Crohn's disease: role of preoperative colonoscopy

PURPOSE

Surgical treatment of ileosigmoid fistulas in Crohn's disease remains controversial and can be radical (resection of both segments) or conservative (ileal resection with suture or wedge resection of the sigmoid). At our institution, the sigmoid defect is sutured if the sigmoid is not affected by primary Crohn's disease or by important stricture; otherwise, the sigmoid is resected. We reviewed our experience to evaluate our results with this procedure.

METHODS

Thirty patients with ileosigmoid fistulas underwent operation. Among them, 15 had a preoperative colonoscopy, whereas others had no endoscopic work-up. In nine patients, the sigmoid was thought to be affected by Crohn's disease (n = 7) or stricture (n = 2) and was resected. In 21 patients, the sigmoid was thought to be affected by proximity, and a simple suture (n = 15) or wedge resection (n = 6) was performed. Eleven patients had a temporary stoma (37 percent). One had coloprotectomy.

RESULTS

One patient died postoperatively. One patient had postoperative sigmoidocutaneous fistula after conservative treatment. Histology of the sigmoid specimen showed Crohn's disease in 8 patients (27 percent), including 5 of 9 resected specimens, and 3 of 21 conservative procedures. All patients with Crohn's misdiagnosis did not have preoperative colonoscopy. Nine of 11 stomas were closed in a median delay of four months. With a median delay of nine years, four patients have again undergone surgery for recurrent colonic Crohn's disease, all of whom underwent surgery initially without preoperative colonoscopy.

CONCLUSION

Preoperative endoscopic assessment of the colon is a reliable guide to use when choosing between sigmoid resection or a conservative approach and can result in reduced morbidity and improved long-term results.

[Treatment of metastases of colorectal cancers]

Important advances have been made in the management of advanced colorectal cancers during the past decade, even though prognosis remains poor. Quality of life, and sometimes overall survival have been increased. Surgery is the only potentially curative treatment of liver metastases from colorectal cancer. Radiation therapy is useful as a palliative local treatment for painful bone metastases or compressive nodes. Chemotherapy, still palliative, has been shown to improve the quality of life. Although 5-fluorouracil remains the drug of reference, various routes and schedules of administration (continuous infusion, hepatic artery infusion, chronotherapy) and biomodulation, mainly by folinic acid and methotrexate have led to a significant improvement in response rates.

Survival benefit of repeat liver resections for recurrent colorectal metastases: 143 cases. Association Francaise de Chirurgie

PURPOSE

Resection is the only chance for cure in patients with colorectal liver metastases (LM). Five-year survival rates are close to 25%. Unfortunately, recurrences occur in most patients. Some recurrent LM are technically resectable. The aim of this study was to determine the risks and benefits of repeat resections for recurrent LM.

PATIENTS AND METHODS

Data from 130 patients who received 143 repeat liver resections for recurrent LM were collected. In 116 patients, only the liver was involved, while 14 had both liver and extrahepatic recurrences.

RESULTS

In the first group, the operative mortality and morbidity rates were 0.9% and 24.7%, respectively. Two- and 3-year survival rates were 57% and 33%, respectively. Recurrences were observed in 66% of patients. Twelve patients underwent a third hepatectomy for recurrence. The mortality rate was nil, and the mean survival time was 12.5 months. In the group with liver and extrahepatic metastases, the operative mortality and morbidity rates were 0% and 25%. The mean survival time was 16 months. Eleven patients died and 13 had recurrences during the follow-up period.

CONCLUSION

Some hepatic recurrences after surgical excision of colorectal metastases can be resected with a low operative risk and with a long-term survival rate similar to that obtained after first resections. This emphasizes the need for a careful follow-up after hepatectomy for colorectal metastases to detect resectable recurrences.

Liver resection with normothermic ischaemia exceeding 1 h

A retrospective study was made of 34 patients who underwent major liver resection with a single period of vascular occlusion exceeding 60 min. The liver remnant was normal in all cases. Vascular occlusion was achieved by continuous portal triad clamping (15 patients), hepatic vascular exclusion (15) or a sequential combination of both procedures (four). Liver cooling was not used. The mean (s.e.m.) duration of continuous normothermic liver ischaemia was 73.6 (2.5) (range 60-127) min. The mean (s.e.m.) amount of blood transfused during operation was 5.3(0.8) units packed red cells. There were no deaths after surgery and the postoperative course was uneventful, or limited to asymptomatic pleural effusion, in 18 patients. Three patients suffered postoperative bleeding necessitating further surgery and one of these required reintervention for a prolonged bile leak. Four patients had transient liver failure that resolved spontaneously within 15 days. There was a 13-fold increase in serum transaminase activities and the proaccelerin level was 45 per cent that of normal on day 1 after operation. These changes were returning to normal levels within 15 days. Continuous vascular occlusion during major liver resection is a useful manoeuvre that may be performed safely on normal hepatic parenchyma for up to 90 min.

Pancreatico-duodenectomy for cancer and precancer in familial adenomatous polyposis

Duodenal adenomas occur in most patients with familial adenomatous polyposis and their potential for malignant transformation appears to be high. In case of rapid polyp growth or severe dysplasia, the place of surgical resection is controversial. We report 2 patients with familial adenomatous polyposis who underwent radical pancreatico duodenectomy several years after the treatment of colonic polyposis. The first patient had a pancreaticoduodenal resection performed for a duodenal adenocarcinoma. The second patient had a pancreaticoduodenal resection with pylorus preservation and pancreatogastric anastomosis performed for recurrent duodenal adenomas with severe dysplasia. Both remained alive without recurrence and with a good functional outcome 24 and 28 months after operation. We conclude that radical prophylactic surgery may be indicated for patients with familial adenomatous polyposis who have severe duodenal polyposis.

Repeat liver resection for recurrent colorectal metastases

Sixteen patients underwent 18 repeat liver resections for recurrence of colorectal hepatic metastases that had been previously resected. Only minor liver resection had been undertaken at the first operation; three were palliative. The second operation was major hepatectomy in ten patients, minor resection in five and orthotopic liver transplantation in one. In one patient, lung metastases were resected before the second operation. One repeat hepatectomy was palliative. After partial liver resection, there were no deaths and complications were observed in six of 15 patients. One patient died 2 weeks after liver transplantation. After the second resection, 2-, 3- and 5-year survival rates were 67, 57 and 30 per cent; the mean survival time was 33 (range 8-93) months. Tumour recurrence was observed in 11 of 14 patients 4-32 (mean 13) months after a second curative liver resection; two patients received a third curative operation for recurrent liver metastases. After the second curative hepatectomy, seven patients died from disease after a mean of 36 (range 14-61) months and seven are currently alive at a mean of 33 (range 8-93) months. Four of these patients are free from disease 26-93 months after resection and three are alive with recurrence. Repeat hepatectomy for recurrent colorectal metastases can prolong survival in selected patients and has low operative risk.

[Resection of liver metastasis of colo-rectal cancer]

Surgical resection currently represents the only available approach to improve the survival rate of patients with liver metastases from carcinoma of colon and rectum. The mean 5-year survival rate in patients treated with liver resection is 25% (with a range from 16 to 45%). Despite the lack of safe criteria for selection of patients with liver metastases, the following factors can give indications to surgical resection: evidence of single or multiple, but unilobar, metastases; lack of hepatic hilum metastases; easy approach; satisfactory liver function after resection; staging and grading of primary tumor, timing between resection of primary tumor and diagnosis of liver metastases; safe margin of liver resection (10 mm) from metastatic lesions. To improve the surgical treatment of liver metastases from colo-rectal cancer, larger series of patients and aggressive surgical approach are needed, with mortality rates acceptable for long-term better results.