Intraductal ultrasound substantiates diagnostics of bile duct strictures of uncertain etiology

AIM: To report the largest patient cohort study investigating the diagnostic yield of intraductal ultrasound (IDUS) in indeterminate strictures of the common bile duct.

METHODS: A patient cohort with bile duct strictures of unknown etiology was examined by IDUS. Sensitivity, specificity and accuracy rates of IDUS were calculated relating to the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery. Analysis of the endosonographic report allowed drawing conclusions with respect to the T and N staging in 147 patients. IDUS staging was compared to the postoperative histopathological staging data allowing calculation of sensitivity, specificity and accuracy rates for T and N stages. The endoscopic retrograde cholangio-pancreatography and IDUS procedures were performed under fluoroscopic guidance using a side-viewing duodenoscope (Olympus TJF 160, Olympus, Ltd., Tokyo, Japan). All procedures were performed under conscious sedation (propofol combined with pethidine) according to the German guidelines. For IDUS, a 6 F or 8 F ultrasound miniprobe was employed with a radial scanner of 15-20 MHz at the tip of the probe (Aloka Co., Tokyo, Japan).

RESULTS: A total of 397 patients (210 males, 187 females, mean age 61.43 ± 13 years) with indeterminate bile duct strictures were included. Two hundred and sixty-four patients were referred to the department of surgery for operative exploration, thus surgical histopathological correlation was available for those patients. Out of 264 patients, 174 had malignant disease proven by surgery, in 90 patients benign disease was found. In these patients decision for surgical exploration was made due to suspicion for malignant disease in multimodal diagnostics (computed tomography scan, endoscopic ultrasound or magnetic resonance imaging). Twenty benign bile duct strictures were misclassified by IDUS as malignant while 14 patients with malignant strictures were initially misdiagnosed by IDUS as benign resulting in sensitivity, specificity and accuracy rates of 93.2%, 89.5% and 91.4%, respectively. In the subgroup analysis of malignancy prediction, IDUS showed best performance in cholangiocellular carcinoma as underlying disease (sensitivity rate, 97.6%) followed by pancreatic carcinoma (93.8%), gallbladder cancer (88.9%) and ampullary cancer (80.8%). A total of 133 patients were not surgically explored. 32 patients had palliative therapy due to extended tumor disease in IDUS and other imaging modalities. Ninety-five patients had benign diagnosis by IDUS, forceps biopsy and radiographic imaging and were followed by a surveillance protocol with a follow-up of at least 12 mo; the mean follow-up was 39.7 mo. Tumor localization within the common bile duct did not have a significant influence on prediction of malignancy by IDUS. The accuracy rate for discriminating early T stage tumors (T1) was 84% while for T2 and T3 malignancies the accuracy rates were 73% and 71%, respectively. Relating to N0 and N1 staging, IDUS procedure achieved accuracy rates of 69% for N0 and N1, respectively. Limitations: Pre-test likelihood of 52% may not rule out bias and over-interpretation due to the clinical scenario or other prior performed imaging tests.

CONCLUSION: IDUS shows good results for accurate diagnostics of bile duct strictures of uncertain etiology thus allowing for adequate further clinical management.

Pretherapeutic evaluation of patients with upper gastrointestinal tract cancer using endoscopic and laparoscopic ultrasonography

BACKGROUND

A detailed and correct pretherapeutic evaluation of stage and resectability is mandatory for an optimal treatment strategy and results in patients with cancer of the esophagus, stomach or pancreas (UGIC). Curative surgery should only be attempted in patients with limited extent of their disease, patients with locally advanced disease should be allocated for neo-adjuvant therapy, while the remaining patients should be referred for palliative measures following a quick, lenient and correct pretherapeutic evaluation. This thorough evaluation and subsequent treatment assignment is also valuable in the identification of uniform patient cohorts for new treatment protocols as well as for the continuing comparison of research data. But despite the importance of accurate pretherapeutic assessment being repeatedly emphasized insufficient staging has been - and is still accepted as - leading to high rates of explorative surgery as well as heterogeneous selection of patients for new treatment trials. Based on the results from the authors PhD thesis he concluded that endoscopic ultrasonography (EUS) as a single imaging modality provided detailed information that hitherto had been inaccessible. EUS was considered a significant progress regarding the loco-regional assessment of stage and resectability, but it was also evident that EUS alone was incapable of providing all the necessary information. In addition, there were no evidence regarding the EUS safety profile, patient tolerance of the procedure and no data on the clinical impact of both EUS and EUS guided fine-needle aspiration biopsy (EUS-FNA) in UGIC patients. Therefore, the author chose to conduct additional EUS trials and to test the use of EUS-FNA, laparoscopy (LAP), laparoscopic ultrasonography (LUS) and LUS guided biopsy in order to improve the overall pretherapeutic evaluation and thus the patient selection. The aim of this thesis was to describe the sequential development, testing and clinical results of a new pretherapeutic evaluation strategy based on EUS and LUS.

DIAGNOSIS

The value of EUS and EUS-FNA in the primary diagnosis of esophageal and gastric cancer was limited, but EUS-FNA was diagnostically relevant in 25% of the patients with pancreatic lesions and malignancy was confirmed in 86% of these patients. Comparison with other studies were difficult since no other trials have specifically focused on the clinical need for EUS-FNA regarding the primary diagnosis and resectability assessment. Stage and resectability assessment: TN staging based on EUS only provided accuracies above 80% for all cancer types when compared with histopathological or intraoperative findings. A similar high overall accuracy of EUS regarding pretherapeutic resectability assessment dropped to a significantly lower value when re-evaulated in a larger study under routine settings. There may be several explanations for this observation, but the move from a protocolled trial to a routine setting and the possibility of using LAP and LUS in the latter material may have influenced the decision and thus the results. The number of patients where EUS-FNA was indicated and performed remained constant over time, indicating adherence to the stringent biopsy criteria also outside a protocolled setup. EUS-FNA demonstrated a small (12%) but significant impact on the staging/resectability assessment and subsequent patient management. There were no differences between the impact in esophageal, gastric and pancreatic cancer, and the EUS-FNA verification of distant lymph nodes metastases was the major contributor to these results. Although EUS could detect and biopsy lesions not seen by CT, these imaging modalities were considered supplementary, but neither of these nor a combination of both was able to perform a complete evaluation of the TNM stage or the resectability. EUS tolerability, complications and patient satisfaction: Minor transient complaints after the EUS procedure was seen in one-third of the patients, but re-admission (0.7%), or contact to the patients GP (6.1%) due to complaints thought to be related to the EUS procedure were seldom. Overall EUS related morbidity and mortality in UGIC patients were 0.61% and 0.07%, respectively, and this was comparable to later series. Two-thirds of the complications in this study occurred in esophageal cancer patients as potential life threatening perforations. The conduction and evaluation of patient satisfaction surveys are complex and with a high risk of bias. Despite the reported pain, anxiety and discomfort more than 90% were prepared to undergo another EUS examination, and a similar proportion of patients were satisfied with the level of information provided before and after the examination. Treatment impact of EUS and the combination of EUS and LUS: The impact of EUS on treatment decisions in UGIC patients seemed lower than would have been expected from the EUS test performance. This observation suggested that the final treatment decision was based on several parameters, but at the same time stressed the importance of stringent EUS statements based on predefined standards. Lack of knowledge regarding advantages and limitations of EUS, situations where EUS was performed by non-surgeons, confusing terminology and conclusions as well as different treatment traditions may have influenced the comparison of data on the clinical impact of EUS. The inter-observer agreement on the treatment of UGIC patients was improved by EUS, and the ability to detect patients with non-resectable disease was the main reason for this among the one-third of all patients where EUS led to a change in the treatment approach. The clinical effect of a wrong EUS conclusion was limited, but EUS false positive resectability assessment may have denied up to 2% of the patients of a potentially curative resection. The combination of EUS and LUS solved the majority of problems related to EUS as a single imaging modality and related to the lack of deep vision during laparoscopy. The combination of EUS and LUS predicted R0 resection in 91% of the patients, thus significantly increasing the overall accuracy when compared to EUS alone. The prediction of R1/R2 resections showed similar results but with wide confidence intervals. Following EUS and LUS the number of futile laparotomies was reduced to 5%, and this figure dropped to 2.4% when patients who needed surgical by-pass were excluded. LUS guided biopsy: After having developed and tested a new system for LUS guided fine-needle aspiration biopsy and true-cut biopsy the author evaluated the need for biopsy using the same stringent indications as for EUS-FNA. LUS guided biopsies were indicated in 12% of the patients with a final malignant diagnosis. The major overall indication was lack of biopsy from the primary tumour. Adequate material was obtained in 95% of the biopsies despite being taken by six different surgeons. The overall combined impact of laparoscopic and LUS guided biopsy in patient management amounted to 27%. Cost-effectiveness of different imaging strategies in the detection of patients with non-resectable disease: In a retrospective design monitoring the costs on a departmental level EUS and LUS - or a combination with either of these - was cost-effective regarding the detection of patients with non-resectable or disseminated disease. The combination of non-invasive methods (e.g. CT and EUS) seemed attractive from an economical view-point, but such a strategy would be associated with futile surgery in 20% of the patients. However, the combination of EUS and LUS almost eliminated futile laparotomies, and at the same time remained cost-effective. Although not reported the data proved resistant to significant changes in both costs and effect, and the sequential use of EUS followed by laparoscopy and LUS seemed to be a cost-effective strategy. Combined pretherapeutic EUS and LUS as predictors of long-term survival: The literature has suggested a correlation between specific pretherapeutic EUS findings and the prognosis in UGIC patients. Based on an improved evaluation by the combination of EUS and LUS it was relevant to relate the pretherapeutic findings of this strategy to the final prognosis, and to do a stratified analysis based on both the stage and the resectability assessment. The combined approach of EUS and LUS provided relevant and significant stratification estimates of the prognosis in all three cancer types whether based on stage or on resectability assessment. EUS and LUS seemed superior to other imaging strategies regarding the identification of patients who may undergo a "true" R0 resection. Thus, EUS and LUS may have a positive impact on the prognosis of R0 resected UGIC patients.

CONCLUSION

With the results from the present thesis the author has defined and tested a new evaluation strategy based on the combination of EUS and LUS. This combination was supplemented by EUS and LUS guided biopsies in those situations, where a malignant biopsy would change the subsequent treatment strategy. The combination of EUS and LUS was lenient, safe and cost-effective and at the same time provided additional, important pretherapeutic information regarding possible treatment options and the prognosis. It may be speculated if the improved patient selection has had a positive impact on the prognosis of the R0 resected patients. The combined strategy may also allow a more homogenous selection of patients for future treatment trials.

[Study on the timing of diagnosis and resection of lung nodules found during the postoperative observation of patients with cancer of the digestive tract]

We investigated 9 patients that had undergone resection of a pulmonary nodule discovered during postoperative observation after surgery for cancer of the digestive tract, in the past 9 years. Six of the primary lesions were colorectal carcinoma, and the others were 1 case each of esophageal carcinoma, hepatocellular carcinoma, and carcinoma of the papilla of Vater. Age at the time of first lung resection was 55 to 77 years (median 63), and the male to female ratio was 6:3. In 4 patients, pulmonary nodules were found within 1 year of primary lesion resection, and in 3 of these patients pulmonary resection was performed after it was confirmed that the nodule had increased in size. In 1 of the 4, biopsy was performed immediately after identification of a pulmonary nodule. The other 5 patients in this study were diagnosed with lung metastases between 2 and 7 years after resection of the primary lesions. Amongst this group, 7 patients had 1 nodule, whilst they were single cases of 2 and 3 nodules. In a patient with esophageal carcinoma, a right re-thoracotomy was performed. In all other patients, video-assisted thoracic surgery was performed. One patient who had had re-resection of a lung metastasis was subsequently found to have further lung metastasis. Survival after resection of the primary lesion was from 30 months to > 110 months (median survival: >82 months), whilst survival after pulmonary resection was from 6 months to >80 months (median survival: 26 months), and 5 patients are still alive. Histological examination of the resected lung lesion showed metastatic lung tumor in 7 cases, and primary lung cancer in 2 cases. It is better to perform the diagnostic biopsy before pulmonary resection in order to determine the best operative procedure, although it is difficult to perform biopsy on a small lung nodule. It is particularly important that any small pulmonary lesion found in the early postoperative period should be resected after confirming that it has increased in size.

[Carcinoids of pancreas and digestion canal clinical signs, diagnostics and surgical treatment]

The review of the literature is presented and results of diagnostics and treatment of 28 patients with carcinoid tumours of the digestion canal of various localization are analysed. Carcinoids were both hormone-active, and hormone-inactive. Before the operation the diagnosis of carcinoid syndrome has been established only for two patients. Carcinoid tumours of a liver were in 4 patients, a gall bladder - in 1, a pancreas - in 5, a stomach - in 1, a duodenum - in 1. Results of methods of laboratory and instrumental examination are given and corresponding conclusions are made.

[Management of postoperative chyle leak after surgery for digestive malignancies]

OBJECTIVE

To investigate the treatment of postoperative chyle leak after surgery for digestive malignancies.

METHODS

From December 2008 to February 2012, in the Sun Yat-sen Memorial Hospital of Sun Yat-sen University, clinical data of 19 patients with chyle leak after digestive system cancer surgery were retrospective analyzed.

RESULTS

Nineteen cases of chyle leak were all identified between the second and the fourth postoperative day and were all initially managed with conservative treatment including early fasting, parenteral nutrition(PN), 24-hour continuous infusion of somatostatin, and low pressure suction drainage. Eight patients were treated successfully for 6 to 10 days with a significant reduction of the daily drainage volume. Ten patients had enteral nutrition(EN) and their drain tubes were repeatedly washed with 30 ml of compound meglumine diatrizoate injection every day until the drainage volume decreased to 200 ml/day. The time to resolution of chyle leak in these ten patients ranged from 12 to 24 days. One patient had no significant decrease in fluid drainage and developed abdominal distension after one week of conservative treatment. Surgical closure of chyle leak was performed on the 11th postoperative day, abdominal cavity drainage tube was removed on the 4th postoperative day. The patient was discharged home in good condition.

CONCLUSION

Most postoperative chyle leak after surgery for digestive malignancies can be successfully managed with conservative treatment. Somatostatin and the drainage are the main therapeutic approaches. When chyle leak is not resolved with conservative treatment, surgical treatment should be considered to prevent serious complications.

Wirsungostomy as a salvage procedure after pancreaticoduodenectomy

BACKGROUND

  Mortality rates associated with postoperative peritonitis or haemorrhage secondary to pancreatic fistula (PF) after pancreaticoduodenectomy (PD) remain high. This study analysed the results of an alternative management strategy for these life-threatening complications.

METHODS

  All patients undergoing PD between January 2004 and April 2011 were identified. Patients who underwent further laparotomy for failure of the pancreatico-digestive anastomosis were identified. Since 2004, this problem has been managed by dismantling the pancreatico-digestive anastomosis and cannulating the pancreatic duct remnant with a thin polyethylene tube (Escat tube), which is then passed through the abdominal wall. Main outcome measures were mortality, morbidity and longterm outcome.

RESULTS

  From January 2004 to April 2011, 244 patients underwent a PD. Postoperatively, 21 (8.6%) patients required re-laparotomy to facilitate a wirsungostomy. Two patients were transferred from another hospital with life-threatening PF after PD. Causes of re-laparotomy were haemorrhage (n= 12), peritonitis (n= 4), septic shock (n= 4) and mesenteric ischaemia (n= 1). Of the 21 patients who underwent wirsungostomy, six patients subsequently died of liver failure (n= 3), refractory septic shock (n= 2) or mesenteric ischaemia (n= 1) and nine patients suffered complications. The median length of hospital stay was 42 days (range: 34-60 days). The polyethylene tube at the pancreatic duct was removed at a median of 4 months (range: 2-11 months). Three patients developed diabetes mellitus during follow-up.

CONCLUSIONS

  These data suggest that preservation of the pancreatic remnant with wirsungostomy has a role in the management of patients with uncontrolled haemorrhage or peritonitis after PF.

[Pathology of neuroendocrine neoplasms]

During the last 5 years the European Neuroendocrine Tumor Society (ENETS) has developed basic recommendations for a standardized pathological diagnosis and classification of neuroendocrine neoplasms (NEN) of the gastroenteropancreatic system. These were included in the novel classification of tumors of the digestive system by the World Health Organization (WHO 2010) and the TNM classification of the union for international cancer control (2009). This review presents the pathology diagnosis regarding (1) basic diagnosis, (2) clinically relevant optional diagnosis, (3) proliferation-based grading, (4) nomenclature and (5) TNM classification. It is emphasized that a standardized diagnosis of NEN, together with clinical and radiological findings, is crucial for prognostic stratification and optimal therapy of patients with NEN. Therefore a close interdisciplinary collaboration is essential.

[The pancreaticogastroanastomosis by pancreatoduodenal resection]

The 10 year experience of pancreatoduodenal resection, consisting of 63 operations was analyzed by the authors. The reconstructive stage of the operation included pancreaticojejunoanastomosis in 20 patients and pancreaticogastroanastomosis in the original modification in 43 patients. The method included the tamponization of the pancreatic stump with the mucosa layer of the gastric back wall. The suggested way of the pancreaticogastrostomy proved to shorten the operative time without increasing the postoperative morbidity and mortality rates.

Predictive risk factors for clinically relevant pancreatic fistula analyzed in 1,239 patients with pancreaticoduodenectomy: multicenter data collection as a project study of pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

BACKGROUND/PURPOSE

It is important to predict the development of clinically relevant pancreatic fistula (grade B/C) in the early period after pancreaticoduodenectomy (PD). This study has been carried out as a project study of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHPBS) to evaluate the predictive factors associated with clinically relevant pancreatic fistula (grade B/C).

METHOD

The data of 1,239 patients from 11 medical institutions who had undergone PD between July 2005 and June 2009 were retrospectively analyzed to review patient characteristics and perioperative and postoperative parameters.

RESULTS

A drain amylase level >4,000 IU/L on postoperative day (POD) 1 was proposed as the cut-off level to predict clinical relevant pancreatic fistula by the receiver operating characteristic (ROC) curve. The sensitivity, specificity, and accuracy of this cut-off level were 62.2, 89.0, and 84.8%, respectively. A multivariate logistic regression analysis revealed that male [odds ratio (OR) 1.7, P = 0.039], intraoperative bleeding >1,000 ml (OR 2.5, P = 0.001), soft pancreas (OR 2.7, P = 0.001), and drain amylase level on POD 1 >4,000 IU/L (OR 8.6, P < 0.001) were the significant predictive factors for clinical pancreatic fistula.

CONCLUSION

The four predictive risk factors identified here can provide useful information useful for tailoring postoperative management of clinically relevant pancreatic fistula (grade B/C).

[A case of recurrent intra-abdominal pediatric desmoid tumor undergoing surgical intervention for 6 times]

A 15-year-old male patient with palpable abdominal tumor presented to our hospital. CT scan revealed a giant tumor, 15 cm in diameter, with infiltration to the pancreas body. In addition, the tumor invaded to the greater curvature of the stomach and the transverse colon. We performed distal gastrectomy, distal pancreatectomy, splenectomy and transverse colectomy. The final diagnosis of histopathology was desmoid tumor. The tumor recurred locally 9 months after the surgery. Recurrent legion was unresectable because of the invasion to the orifice of SMV and weekly combination chemotherapy of VLB and MTX was started. Although a partial response was achieved for a local recurrent legion after 20 courses, CT scan showed other new recurrent multiple lesions in the abdominal cavity. Due to the severe abdominal discomfort and intestinal obstruction, a reduction surgery was performed 5 times in total. Endocrine therapy and administration of NSAID were not effective. Tumor progression was uncontrollable, and the patient died 5 years and 8 months after the initial surgery.

Somatostatin and dopamine receptor profile of gastroenteropancreatic neuroendocrine tumors: an immunohistochemical study

Somatostatin and its synthetic analogs act through five specific somatostatin receptors (sstr1-5), found on the cell membrane of various tumors, including endocrine ones. Dopamine--a known neurotransmitter--acts through five membranous dopamine receptors (D1R-D5R) which have recently been found to be expressed in endocrine tumors. We evaluated the immunohistochemical expression of the sstrs and D2R in a large series of gastroenteropancreatic neuroendocrine tumors (GEP-NETs). A total of 22 (28.94%) well-differentiated NETs (WDNETs), 6 (7.89%) WDNETs of uncertain biology, 26 (34.21%) well-differentiated neuroendocrine carcinomas, and 22 (28.94%) poorly differentiated neuroendocrine carcinomas were studied. Overall, 76.31% of the tumors were positive for different types of sstrs with variable intensity of the membranous staining whereas 36.95% were positive for D2R alone. The sstr2A was the most frequently expressed, followed by sstr2B, sstr1, and sstr5. Co-expression of sstrs and D2R was seen in 88.23% of positive tumors. The high rates of sstr2A and sstr2B and in a lower extent of sstr5 expression are of great importance for more accurate imaging, staging and targeted therapy of the disease. The co-expression of sstrs and D2R in a significant number of the studied cases offers a potential therapeutic alternative for GEP-NETs.

Morphology, TNM staging and survival with Pancreatico-duodenectomy specimens received at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan

BACKGROUND

Whipple specimens consists of duodenum from the pylorus to the ligament of Treitz, the head of the pancreas and distal extrahepatic biliary tract, sometimes with most distal portion of the stomach. Adequate gross handling of the specimen and assessment of histological variables is of prognostic importance.

METHODS

At the Pathology Department of Shaukat Khanum Memorial Cancer Hospital and Research Centre, we here evaluated survival with a total of 65 pancreaticoduodenectomy specimens from 2006 to 2010 with reference to histological parameters like tumour type, site, size, grade, pT, pN, margin status and perineural invasion, and compared our results with international data. Patients were followed up and P-values were calculated regarding association between survival and prognostic factors, Kaplan-meier survival curves also being plotted.

RESULTS

Most of the patients were males (60%), with a mean age of 50 yrs. The most frequent site was periampullary region (43.2%), with adenocarcinoma, NOS accounting for 72.4%. G2 was the most common grade (58.5%) and the most frequent pT was pT2 (52.4%), nearly half presenting with lymph node metastasis (47.7%). Significant associations (p<0.05) were noted for survival with grade, pT, pN, margins, tumor size and perineural invasion, but not tumor site, tumor type and age. Kaplan-Meier curve revealed that at end of 1 month, 70% of the patients were alive, this decreasing to 40%, 15% and 5% and at the end of 6 months, 1 year and 2 years.

CONCLUSION

Tumor size, type, pathologic T and N staging, margins and perineural invasion are directly related to survival with pancreatico-duodenal lesions.

[Gastropancreatoduodenal resection for malignant tumors, complicated with obstructive jaundice]

The experience of 329 gastropancreatoduodenal resections for malignant tumors of the periampullary zone has been reviewed. The obstructive jaundice complicated the disease in 237 (70%) patients. The fact required various modalities of the preoperative artificial bile drainage. To evaluate the jaundice influence on the perioperative period, patients were divided in 4 groups, considering the bile drainage modality and bilirubin blood levels. The early postoperative period was respectively analyzed, which led to the conclusion that bilirubin blood level has no influence on either intraoperative characteristics or postoperative morbidity and mortality. For the reason of that, radical treatment of the periampullary cancer, complicated by the obstructive jaundice, does not require preoperative bile drainage.

[Clinicopathologic features, diagnosis and treatment of 38 neuroendocrine carcinoma in the digestive system]

OBJECTIVE

To investigate the clinicopathologic features, diagnosis and treatment of neuroendocrine carcinoma (NEC) in the digestive system.

METHODS

Thirty-eight patients with NEC from Jan 1985 to Mar 2008 were analyzed retrospectively and the related literatures were reviewed.

RESULTS

There were 29 males and 9 females. Common symptoms were melena or hematochezia (n=21, 55%), abdominal pain (n=19, 50%), abdominal mass (n=15, 39%), constipation (n=14, 37%), rectal mass (n=12, 32%), abdominal distention (n=11,29%) and diarrhea (n=7,18%). All the patients received surgical treatment including 1 esophagectomy, 5 radical total gastrectomies, 1 palliation proximal gastric resection, 2 local gastric resections, 6 pancreaticoduodenectomies, 1 distal pancreatectomies, 3 partial small intestine resections, 7 radical right hemicolectomies, 5 Dixon operations, 3 Miles operations, and 4 local resections of rectal tumor. Thirty-six patients received follow-up. The follow-up time ranged from 3 months to 144 months (median, 70 months). The 1-, 3- and 5-year survival rates were 94.7%, 86.8%, and 57.9% respectively. The median survival time was 62 months. The survival time of the patients with carcinoma infiltration exceeding bowel muscularis propria was (36+/-5) months, significantly shorter than that of patients without carcinoma infiltration exceeding the bowel muscularis propria [(73+/-5) months, P<0.05]. The survival time of the patients with positive lymph node metastasis was (34+/-7) months, significantly shorter than that of patients with negative lymph node metastasis [(74+/-5) months, P<0.05].

CONCLUSIONS

Clinical symptoms, signs of neuroendocrine carcinoma in the digestive system are nonspecific. The correct diagnosis should depend on histopathologic examination. Systematic treatments including radical resection of NEC are the preferable treatment.

Reduced interleukin-12 release from stimulated monocytes in patients with sepsis after major cancer surgery

BACKGROUND

Major cancer surgery is a high-risk situation for sepsis in the post-operative period. The aim of this study was to assess the relation between the monocyte production of IL-12 and the development of post-operative sepsis in patients undergoing major cancer surgery.

METHODS

In 19 patients undergoing major cancer surgery, the production of cytokines by basal and lipolysaccharide (LPS)-stimulated monocytes was measured before and after (from day 1 to day 3 and day 7) surgery. Seven of them developed a post-operative sepsis. Ten healthy volunteers were used as controls for the assessment of pre-operative values.

RESULTS

Before surgery, the production of interleukin (IL)-12 p40 by LPS-stimulated monocytes was similar in the patients and the healthy volunteers. The production of IL-12 p40 by unstimulated monocytes was higher in the patients than in the healthy volunteers. IL-12 production did not differ between the septic and the non-septic patients. After surgery, the production of IL-12 p40 was dramatically reduced in the LPS-stimulated monocytes of the septic patients from day 1 to day 3, as compared with that of the non-septic patients. Before surgery, the production of IL-6, IL-10, and IL-1 receptor antagonist (IL-1ra) in the patients was significantly higher than that of the healthy volunteers for both stimulated and unstimulated monocytes. After surgery, the production of these cytokines by both stimulated and unstimulated monocytes of the septic patients was similar to that of the non-septic patients. Intragroup analysis showed significant changes for IL-6, IL-10, and IL-1ra under all conditions, with the exception of changes in unstimulated monocytes of septic patients that were not significant for IL-10 release.

CONCLUSION

After surgery, the septic patients showed drastic failure to up-regulate monocyte LPS-stimulated production of IL-12 p40.

Systemic therapy for neuroendocrine tumours of gastroenteropancreatic origin

Systemic therapy is one of a number of treatment options routinely used in the management of advanced, unresectable neuroendocrine tumours (NETs). In contrast to many of the other NET treatment modalities, there is at least some evidence base to justify its use. Even so, well-designed clinical trials are limited, since conducting clinical research in this complex group of rare cancers is challenging. The remit of this review article is to summarise the oncology literature and explain the role of systemic therapy in treating NETs of gastroenteropancreatic origin, identifying benefits and limitations. The molecular biology of NETs is now being unravelled, which affords new opportunities for development of mechanism-driven therapies. The rationale for some of the newer systemic targeted therapies that are showing promise in the clinic is discussed.

[Clinical characteristics of multiple endocrine neoplasia]

Multiple endocrine neoplasia type 1 (MEN1) and type 2 (MEN2) are autosomal dominant inherited multiglandular diseases with familial and individual age-related penetrance and variable expression. The most frequent endocrine features of MEN1 are parathyroid involvement (> 95%), duodeno-pancreatic endocrine tissue involvement (80%), pituitary adenoma (30%), and adrenal cortex tumors (25%), with no clear syndromic variants. Identification of the germline MEN1 mutation confirms the diagnosis, but there is no phenotype-genotype correlation. All patients with MEN2 have medullary thyroid carcinoma (MTC). The most distinctive MEN2 variants are MEN2A (MTC+pheochromocytoma+hyperparathyroidism), MEN2B (MTC+pheo), and isolated familial MTC (FMTC). The prognosis of MEN2 is linked to the progression of MTC, which depends mainly on the stage at diagnosis and the quality of initial surgical treatment. This emphasizes the need for early diagnosis and management. The specific RET codon mutation correlates with the MEN2 syndromic variant and with the age of onset and aggressiveness of MTC. Consequently, RET mutational status should guide major management decisions, such as whether and when to perform thyroidectomy.

Staging laparoscopy in digestive cancers

BACKGROUND. Laparoscopy and laparoscopic ultrasonography may assist in the more accurate staging of digestive cancers. We assessed the diagnostic value of staging laparoscopy in patients with cancers of lower esophagus, stomach, liver, biliary tract, pancreas and colon. MATERIAL AND METHOD. Extended staging laparoscopy, laparoscopic ultrasonography and peritoneal cytology were performed in 165 patients with primary digestive cancers, admitted between January 2006 and December 2008 at three tertiary referral hospitals participating in the study. Staging laparoscopy was immediately followed by open surgery in 63 patients without distant metastases or with uncertain primary tumor resectability, and in 20 colorectal cancer patients with resectable hepatic metastases. The sensibility, sensitivity and diagnostic accuracy of staging laparoscopy for distant metastases and tumor resectability were assessed against the findings on open surgery and the final pathological report. RESULTS. An unnecessary laparotomy was avoided in 36 of the 99 patients (36.4%) without distant metastases on imaging pre-therapeutic staging. The staging laparoscopy sensitivity for distant metastases varied between 66% and 100% and the diagnostic accuracy between 87% for the lower esophageal cancer and 100% for the biliary tract tumors. The overall morbidity of staging laparoscopy was 2.5% and the mortality 0. CONCLUSION. Staging laparoscopy avoids unnecessary laparotomies and changes the therapeutic plan in a significant number of patients. It can be performed just before the planned surgery or as a separate diagnostic procedure. The laparoscopy indications in digestive cancers are changing fast, with ongoing new developments in cancer treatment and laparoscopic technology.

[Treatment of neuroendocrine tumors of the digestive tract]

Neuroendocrine tumors of the digestive tract are relatively rare and comprise benign and malignant tumors. WHO classification system is based on recognized differences in morphology, function and clinical behavior. European Neuroendocrine Tumor Society(ENETS)proposed grading system and TNM classification system with disease staging for endocrine tumors of each organ which are both valid tools for prognostic stratification. The only curative therapy is the complete resection of the tumor. Endoscopic submucosal dissection(ESD)or local resection can be performed in low grade and early stage tumors; on the other hand, curative resection with lymph node dissection is recommended for neuroendocrine carcinoma. Complete surgical resection of liver metastases is associated with better long-term survival. Combination chemotherapy, such as Etoposide+Cisplatin/Carboplatin, is useful in treating unresected neuroendocrine carcinomas. Octreotide and Pasireotide (SOM230), somatostatin analogues, are reported to have the benefit of both hormonal symptom control and tumor growth suppression. Development of new effective drug is expected for the treatment of neuroendocrine tumors of the digestive tract.

Impact of hospital volume on outcomes for pancreaticoduodenectomy: a single UK HPB centre experience

BACKGROUND

High hospital volume has a favorable impact on outcomes for complex procedures including pancreaticoduodenectomy (PD); however, the temporal relationship has not been evaluated in a single centre.

AIM

To evaluate the impact of UK cancer outcome guidelines (COG) on outcomes for PD in a single UK HPB specialist centre.

PATIENTS AND METHODS

All patients with pancreatic pathologies undergoing surgery at our institution from 1999 to 2006 were identified, of which 140 underwent PD. The annual caseload for PD and corresponding outcomes for length of hospital stay, morbidity, mortality and survival were analysed during the period around the implementation of UK COG with an increase in the surgical workload correlating with catchment's population increase from 1.6 to 3.1 million.

RESULTS

Between January 1999 and December 2006, 140 patients underwent a PD (M:F 1.06:1; median age 64 (range 34-84) years). Median hospital stay was 16 days (range 7-318). The 30-day mortality was 2.8%, in-hospital mortality was 6.4% and morbidity was 37.1%. Pancreatic leak/fistula rate was 8.6%. Over the 7-year period, PDs per year increased 5.3 fold from 6 procedures in 1999 to 32 in 2006. Analysis of the data for 1999-2002-(pre-COG) and 2003-2006-(post-COG) showed a trend towards decrease in mortality (from 9.7% to 5.0%, p = 0.448: OR = 2.74 (95% CI, 0.58-12.88); Fisher's exact test) and morbidity (from 41.6% to 35.3%; OR = 1.29 (95% CI, 0.74-3.56); p = 0.565).

CONCLUSION

With COG implementation within a single UK pancreatic unit, the PD volume and staffing levels increased with a trend towards decreased morbidity and mortality.

[BNP measurement for perioperative management]

BACKGROUND

It is difficult to evaluate the tolerance to anesthesia of patients undergoing operations, who have risk factors of congestive heart failure, such as hypertension, old age or various cardiac diseases. BNP (B type natriuretic peptide) is a useful biomarker as a screening tool for LV dysfunction. Therefore we hypothesized that the measurement of BNP may be useful for perioperative management of these patients.

METHODS

Subjects were 101 (58 male and 43 female) gastro-intestinal cancer patients, aged 30 to 91 years (mean 63.9 +/- 12.4) scheduled for intraperitoneal surgery. All patients' plasma BNP concentrations were measured when the patient agreed to the operation. Forty-five patients were enlisted for remeasurements on 2 or 4 postoperative days. We checked patients' backgrounds, perioperative circulatory characteristics and cardiac events. The relationship of BNP to other characteristics and cardiac events were analyzed.

RESULTS

The preoperative mean BNP of patients under 55 years of age (n=20) was 20.4, in patients age 55 to 74 (n=60) it was 30.4, and in patients 75 years and over (n=21) it was 162.1. BNP in elderly patients was higher than in the younger. The mean BNP of the 44 patients with some complications (hypertension, ECG abnormality, cardiac disease etc.) was 97.8, as compared to 23.3 in the 57 patients without complications. The BNP was higher in patients who were elderly, had some cardiac disease, lower exercise capacity, chest X ray abnormality or who needed an echo cardiographic examination. Among the 45 patients who were checked pre and postoperatively, 19 patients' BNP increased postoperatively, while 26 patients showed no change or decrease. Excluding 2 patients, with newly onset congestive heart failure during the postoperative period, the preoperative mean BNP was 63.5, and the postoperative mean BNP was 54.6. During the perioperative period, there was no significant change of BNP. There was no relationship between the BNP and perioperative circulatory characteristics or cardiac events. There were 5 cases with high BNP levels (> 300). None of these patients had cardiac symptoms, and they had normal LV systolic function. It is probable that these patients had chronic heart failure due to LV diastolic dysfunction and risks of perioperative heart failure.

CONCLUSIONS

We cannot predict any circulatory characteristics and cardiac events from preoperative BNP measurement; however BNP measurement is useful for screening asymptomatic chronic heart failure due to LV diastolic dysfunction.

Laparoscopic gastrojejunostomy in patients with obstruction of the gastric outlet secondary to advanced malignancies

Surgical palliation is an important therapeutic goal in patients with gastric outlet obstruction from cancer. The use of laparoscopic approaches for this condition has not been well studied. Our objective is to compare surgical outcomes of laparoscopic and open gastrojejunostomies in patients with gastric outlet obstruction secondary to advanced malignancies. We did a retrospective review of 20 patients who underwent a palliative gastrojejunostomy as their primary surgical procedure. There were 10 patients in the laparoscopic group and 10 patients in the open one. We identified no significant difference between groups in mean surgery time (116 vs 116 minutes) (P = 0.99), blood loss (23 vs 142 mL) (P = 0.19), or length of stay (8 vs 14 days) (P = 0.14). We also identified no difference in median time to tolerate a regular diet (7 vs 8 days) (P = 0.49) and median survival (11.2 vs 9.0 months) (P = 0.83). Delayed gastric emptying was the most common complication occurring in four patients. There is no detectable difference in surgical outcomes between laparoscopic and open gastrojejunostomies in the management of patients with obstruction of the gastric outlet secondary to cancer. Laparoscopic gastrojejunostomy is a safe and feasible operation in this setting.

[The role of minimally invasive surgery in the diagnosis and treatment of tumors in children]

The paper aims to define the actual place and benefits of the minimal invasive techniques in the diagnosis and treatment of tumors in children. There are reviewed the indications, limits and complications of this method in digestive tract, liver, pancreatic, adnexal, testicular and renal tumors, in lymphomas, as well as in tumors with intra-thoracic location. The benefits of the minimal access approach, such as the decrease of the parietal complications as well as the negative impact of the surgical act upon the body have a particular significance in pediatric cancer patients. Their quicker recovery allows an early subsequent initiation of the chemo- or/and radiotherapy. Within the complex treatment of tumors in children, the minimal invasive surgery has a diagnostic value through inspection and directed biopsy. The laparoscopic inspection decreases the number of non-therapeutic laparotomies in non-operable patients with tumors that were not preoperatively diagnosed using imaging methods. The laparoscopic resection of the tumors within oncological limits is possible in the localized types (stage I). As a particular aspect of the laparoscopic approach in children, it is worth mentioning the difficulties related to the necessity of using adequate-size instruments and to the less favorable relation between the size of the tumor and the diminished working space.

[Hyponutrition prevalence among patients with digestive neoplasm before surgery]

OBJECTIVE

To analyze the prevalence and degree of hyponutrition among patients with resectable digestive neoplasm that will be submitted to surgery.

MATERIAL AND METHODS

Observational cross-sectional descriptive study carried out from november of 2005 to march of 2006, assessing the nutritional status of all patients aged > or = 18 years with resectable digestive neoplasm submitted to scheduled surgery at the General and Digestive Surgery Department of the Hospital Complex of Orense (Spain). Eighty patients were studied, 41 men and 39 women aged 27-92 years.

RESULTS

Diagnosis categorization was as follows: colonic neoplasm 27 patients, rectal neoplasm 24, gastric neoplasm 23, and pancreatic neoplasm 6. Fifty-three percent of the patients assessed had lost 5% of their usual weight within the previous 3 months. Serum albumin levels were lower than 3.5 mg/dL in 49% of the cases. Patient-Generated Subjective Global Assessment shows a hyponutrition prevalence of 50% (29% with moderate hyponutrition or at risk for hyponutrition and 21% with severe hyponutrition). Hyponutrition was related to age, increasing with increasing age (p < 0.05), and to the kind of digestive neoplasm (higher prevalence among patients with gastric neoplasm).

CONCLUSIONS

Hyponutrition prevalence among patients with resectable digestive neoplasm is high. There is a similarity between the relative data relating to percentage of weight loss, serum albumin levels, and nutritional assessment obtained by applying the Patient-Generated Subjective Global Assessment. Further studies on hyponutrition prevalence among oncologic patients at our setting would be desirable.

Treatment of gastroenteropancreatic neuroendocrine tumors

Neuroendocrine tumors are rare; thus, individual experience with the diagnosis and treatment of these tumors is mostly low, except in specialized centers. For histological diagnosis, standards have been described recently. Pathological classification and clinical staging influence diagnostic and therapeutic decisions. This chapter aims at demonstrating the importance of pathological and clinical classification of neuroendocrine tumors on therapeutic decisions, indicating the appropriate therapy for different stages of the disease. Surgical therapy will be discussed shortly, including palliative surgical strategies. However, the focus of the manuscript is medical therapy. Biotherapy, its effects, and remaining uncertainties are presented as well as different chemotherapeutic schemes. Finally, new options of palliative medical therapies like kinase inhibitors and anti-angiogenetic drugs will be discussed.

Interleukin-18 restores immune suppression in patients with nonseptic surgery, but not with sepsis

BACKGROUND

We investigated cellular immune responses, in particular interferon gamma (IFN-gamma) production, by peripheral blood mononuclear cells (PBMCs) in patients with septic and nonseptic surgical stress, focusing on interleukin (IL)-18 and its receptor (IL-18R).

METHODS

Thirty-two patients with alimentary tract carcinoma who underwent elective surgery (OP) and 26 septic patients (SP) with peritonitis were enrolled in this study. Blood was collected on the first postoperative day (POD1), POD5, POD10, and POD15 in the OP group and on the emergency admission in the SP group. Ten healthy volunteers served as controls. PBMCs were cultured in the presence of anti-CD3 antibody or IL-2 and IL-12, with or without additional IL-18 stimulation, to measure IFN-gamma production. IL-18R expression on CD56+ NK (natural killer) cells was evaluated by flow cytometry.

RESULTS

IL-2- and IL-12-induced IFN-gamma production by PBMCs was suppressed significantly in both the OP (POD5) and SP groups compared with that in healthy controls. Interestingly, additional IL-18 stimulation up-regulated IFN-gamma production by PBMCs in the OP group as well as the control group, but not in the SP group. IL-18R expression on CD56+ NK cells was maintained consistently in the OP group as well as the control group, but decreased in the SP group.

CONCLUSIONS

IFN-gamma production induced by cytokines (IL-2 and IL-12) was suppressed in PBMCs from both patients with sepsis and those who had undergone elective surgery. However, IL-18R expression on CD56+ NK cells was different between patients with sepsis and nonseptic surgical stress. Our results suggest that exogenous IL-18 administration may be effective in preventing immune suppression in patients with nonseptic elective surgery.

Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated?

BACKGROUND

This study analyzed presentation and management of hemorrhage after pancreaticoduodenectomy (PD) to determine the respective role of surgery and embolization.

METHODS

From January 1992 to March 2005, 411 patients underwent PD and were analyzed with regard to postoperative hemorrhage.

RESULTS

Hemorrhage occurred in 27 patients (7%), either within the first 3 postoperative days ("early" hemorrhage, n = 11) or after day 8 ("delayed" hemorrhage, n = 16, including 4 with "sentinel" bleeding). At the time of bleeding, 12 patients (44%) (all with delayed hemorrhage) had associated abdominal complications. Two patients had successful conservative treatment. Two stable patients with pseudoaneurysm, diagnosed by computed tomography scan, underwent successful embolization. Four patients with active bleeding underwent unsuccessful angiography. Overall, 23 patients were reoperated on without any completion pancreatectomy, 3 rebled, and 3 (11%) died (including 2 with delayed hemorrhage).

CONCLUSIONS

Both embolization and surgery have a role in the management of hemorrhage after PD. For early hemorrhage, reoperation is appropriate. In case of sentinel bleeding, pseudoaneurysms can be detected by computed tomography scan and treated by embolization. For delayed active hemorrhage, reoperation is still indicated.

Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases

OBJECTIVE

The objective of this study was to identify potential risk factors for mortality and morbidity after distal pancreatectomy, with special focus on the formation of pancreatic fistula.

SUMMARY BACKGROUND DATA

Distal pancreatectomy can be performed with low mortality and acceptable morbidity rates. Pancreatic fistulas, occurring in 10% to 20% of cases, remain a problem that contributes significantly to morbidity, length of stay, and overall costs.

METHODS

From November 1993 to February 2006, perioperative and postoperative data of 302 consecutive patients were recorded. Univariate and multivariate analyses of potential risk factors for morbidity and for the formation of pancreatic fistula were performed. The surgical techniques used for closure were categorized into 4 groups: 1) anastomosis, 2) seromuscular patch, 3) closure by suture, and 4) closure using a stapling device.

RESULTS

Indications for resection were pancreatic tumors in 62% of patients, nonpancreatic tumors in 23%, chronic pancreatitis in 12%, and others in 3%. The spleen was preserved in 24% of patients. The morbidity and mortality rates for distal pancreatectomy in this series were 35% and 2%, respectively. The prevalence of pancreatic fistula was 12%. Univariate and multivariate analyses indicated that closure using a stapling device and an operating time >or=480 minutes were associated with a higher incidence of pancreatic fistula (odds ratio = 2.6 and 4.2, respectively). Overall morbidity was mainly influenced by the extent of resection (multivisceral vs. conventional; odds ratio = 1.7).

CONCLUSION

Pancreatic leak remains a common complication after distal pancreatectomy. Our series suggests that stapler closure of the pancreatic remnant is associated with a significantly higher fistula rate.

Neutrophil elastase inhibitor (sivelestat) preserves antitumor immunity and reduces the inflammatory mediators associated with major surgery

PURPOSE

To examine the effects of the administration of perioperative sivelestat, a selective neutrophil elastase inhibitor, on tumor immunity and inflammatory mediators in patients who undergo major surgery.

METHODS

Thirteen patients admitted to the hospital for elective surgery were equally randomized into one of two groups: the Sivelestat group (n = 6) and the control group (n = 7). Thereafter, the immunosuppressive acidic protein (IAP), serum interleukin-6 (IL-6), and type 1/type 2 T-helper cell balance were all assessed at several time points before and after surgical intervention.

RESULTS

The serum IL-6 values at 1 and 12 h after surgery and on postoperative days 1 and 3 were all significantly lower in the sivelestat group than in the control group. The IAP values at postoperative days 7 and 28 in the sivelestat group were also significantly lower than those in the control group. There was a significant correlation between the IL-6 level at 1 h after surgery and the IAP level at postoperative days 7 and 28.

CONCLUSIONS

In this preliminary study, the perioperative administration of sivelestat was thus suggested to reduce surgical stress by decreasing the cytokine release and preserving the antitumor immunity.

The role of echo-laparoscopy in abdominal surgery: five years' experience in a dedicated center

BACKGROUND

For more than 20 years intraoperative ultrasonography (IOUS) has been considered an important diagnostic tool in abdominal surgery. In the last few years, with the spread of laparoscopic surgery, echo-laparoscopy (LIOUS) has gradually replaced open ultrasonography, aiming to achieve similar results.

METHODS

LIOUS was performed using an ALOKA 5.500 device, provided with a linear flexible laparoscopic probe that was compatible with a 10-mm port. IOUS was performed by means of a linear side-view, T-shaped or microconvex probe. The probes were sterilized with hydrogen peroxide. No water bath was used during the surgical examination, but full contact of the probe with the surface of the involved organ was always attempted. From 2001 to 2005, 36 liver resections, 40 pancreas procedures, 203 procedures for suspected common bile duct calculi, 541 colon and 82 stomach resections, and 82 adrenal surgery procedures were performed. IOUS or LIOUS was performed in 432 patients (43.8%). All livers and pancreases underwent intraoperative ultrasound, while biliary, colonic, gastric, and adrenal pathologies were selectively studied when there were doubts about the location and extension of the disease.

RESULTS

IOUS and LIOUS were valuable diagnostic procedures, supplying relevant clinical information in 65.1% of the patients and modifying the surgical approach in 17.2%. LIOUS was used instead of cholangiography to study bile ducts when lythiasis was suspected, achieving high diagnostic specificity (98%) and accuracy (100%). Surgical anatomy of the bile ducts was correctly identified by LIOUS in every case.

DISCUSSION

In our experience IOUS and LIOUS were of the utmost importance in better defining staging of disease, infiltration of neighboring structures, number and size of nodular lesions, and anatomy of the hepatic pedicle and intrahepatic structures, thus making it possible to more accurately plan surgical procedures.

[Erythropoietin levels in perioperative period in cancer patients]

Anemia is frequent in cancer patients, is the result of decreased erythropoietin production. In fact in cancer, alteration of immune system alters iron metabolism and inhibits erythropoietin production. In this study we proposed to determine the profile of erythropoietin secretion in anaemic cancer patients in the pre and postoperative period. Our prospective study from January to March 2005 included 41 anemic cancer patients from 30 to 79 years old and 31 healthy individuals with iron deficiency anemia. A measure of erythropoietin, CRP, ferritin, iron levels and hemoglobin were released in healthy individuals and in cancer patients in preoperative period (J0) and postoperative period (J3, J8, J21). In preoperative period, the increase of serum erythropoietin was significantly lower in patients than in healthy individuals. In postoperative period, the levels of erythropoietin at J3 and hemoglobin's at J8 and J21 were significantly higher than in preoperative period (J0) (p < 0.05). In conclusion, despite the presence of inflammatory syndrome caused by surgery, cancer patients with anaemia increase their erythropoietin production in immediate postoperative period.

Intraoperative assessment of the Whipple resection specimen

Intraoperative consultation for the Whipple resection procedure has evolved due to the increasing influence of imaging techniques in surgical planning and decision-making. The indications and utilisation of this service vary, at least to some degree, from one institution to the other. The following discussion is a single institutional approach, which is hoped to provide assistance to the practising pathologists in this field. Special emphasis is given to the relevant anatomical considerations and the most common indications for an intraoperative consultation.

Can pretreatment CT perfusion predict response of advanced squamous cell carcinoma of the upper aerodigestive tract treated with induction chemotherapy?

BACKGROUND AND PURPOSE

Treatment of advanced stage squamous cell carcinoma of the upper aerodigestive tract with nonsurgical organ preservation protocols demonstrates improved cure rates with fewer comorbidities compared with surgery and radiation. The purpose of this study was to prospectively assess whether pretreatment evaluation of the primary site with quantitative CT perfusion measurements predicted response to induction chemotherapy and to create a prediction model to predict the response to induction chemotherapy in future patients.

METHODS

Seventeen patients who were enrolled in a prospective trial assessing surgical intervention versus a nonsurgical protocol underwent a pretreatment CT perfusion followed by direct laryngoscopy. After induction chemotherapy, tumor response was determined by the surgeon's estimate of tumor volume. The CT perfusion parameters were correlated with the clinical response using a Wilcoxon rank-sum analysis. A logistic regression model was used to create a prediction based on the most significant CT perfusion parameter.

RESULTS

Elevated values of blood volume (P = .004) and blood flow (P = .03) were significantly correlated with >50% reduction in tumor volume after chemotherapy. A prediction model based on tumor blood volume demonstrated 91.7% sensitivity and 80.0% specificity, with an area under the receiver operating characteristic curve of 0.95.

CONCLUSION

Our preliminary data imply that tumors with elevated blood volume and blood flow were statistically associated with response to induction chemotherapy. These results suggest that pretreatment CT perfusion may be able to identify patients who will successfully respond to induction chemotherapy, which could potentially eliminate this step for subsequent patients when deciding on the appropriate treatment regimen.

The effect of stress-reducing, low-dose ethanol infusion on frequency of bleeding complications in long-term alcoholic patients undergoing major surgery

Perioperative low-dose ethanol infusion is a feasible option for stress reduction and prophylaxis of alcoholism-associated complications. Because alcohol has inhibitory effects on hemostasis, our study focused on the effect of perioperative low-dose ethanol infusion on bleeding complications, defined as transfused blood units and reoperations, in alcoholic patients undergoing major surgery. We included 44 long-term alcoholic patients scheduled for tumor resection of the aerodigestive and gastrointestinal tract. Patients were randomly assigned to the ethanol or control group. Ethanol infusion (0.5 g ethanol/kg body weight/24 hours) started before surgery and was continued until the postoperative Day 3. Regarding all patients, there was no statistically significant difference in the amount of transfused blood between the ethanol and control groups. However, the effect of ethanol infusion on bleeding complications depended on the site of surgery. Ethanol infusion resulted in an increased number of transfused blood units in gastrointestinal patients and a decreased number of transfused units in patients undergoing tumor resection of the aerodigestive tract. In conclusion, perioperative ethanol infusion in long-term alcoholic patients with tumor resections of the aerodigestive tract is an option for stress reduction without increased risk for blood transfusion. In contrast, ethanol infusion in patients with tumor resections in the gastrointestinal tract could increase the risk for bleeding complications.

Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis

OBJECTIVE

Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreaticoduodenectomy (PD). The ideal choice of anastomosis remains a matter of debate.

DATA SOURCES

Articles published until end of March 2006 comparing PJ and PG after PD were searched.

STUDY SELECTION

Two reviewers independently assessed quality and eligibility of the studies and extracted data for further analysis. Meta-analysis was performed with a random-effects model by using weighted odds ratios.

DATA EXTRACTION AND SYNTHESIS

Sixteen articles were included; meta-analysis of 3 randomized controlled trials (RCT) revealed no significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, intra-abdominal fluid collection, or mortality. On the contrary, analysis of 13 nonrandomized observational clinical studies (OCSs) showed significant results in favor of PG for the outcome parameters with a reduction of pancreatic fistula and mortality in favor of PG.

CONCLUSIONS

All OCSs reported superiority of PG over PJ, most likely influenced by publication bias. In contrast, all RCTs failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally good results. This meta-analysis yet again highlights the singular importance of performing well-designed RCTs and the role of evidence-based medicine in guiding modern surgical practice.

[Surgery]

Indications for minimal invasive surgery are increasingly numerous. The treatment of oesophageal cancer presents a significant example. New multidisciplinary modalities allow, from now on, to push back the limits and to improve the results of hepatobiliary surgery. Several studies show a decrease in the significance of age but underline the importance of comorbodities among elderly patients, and therefore significantly increase indications to pancreatic, hepatic or colorectal surgery in this age group. Elective laparoscopy is now accepted without age limit. Sacral nerve stimulation is an important alternative to classical treatment of fecal incontinence. Peripheral transcutaneous neuromodulation for this condition is effective on both continence and quality of life.

Interventional pancreaticojejunostomy after pancreatoduodenectomy

BACKGROUND

Leakage from the pancreaticoenteric anastomosis after pancreatoduodenectomy (PD) is closely associated with intra-abdominal hemorrhage with ensuing high mortality.

METHODS

Interventional pancreaticojejunostomy was performed in 10 patients with external drainage of pancreatic juice after two-staged PD or leakage from pancreaticojejunostomy after PD. The jejunum was punctured using a 22-gauge needle into the pancreatic fistula during endoscopic observation of the jejunal lumen, followed by the insertion of two 0.35-inch guide-wires into the jejunum and pancreatic fistula. Finally, a stenting tube was placed between the jejunum and pancreatic fistula.

RESULTS

No severe complications developed. Oral intake was instituted the following day in 8 of 10 patients, and on the 7th day in the remaining two patients.

CONCLUSION

This interventional procedure is considered to be safe and easy to perform, and in the future, it may permit a reduction in the number of second laparotomies in pancreatic fistula.

[Influence of blood transfusion on development of infection in patients with malignant neoplasms of the digestive system]

BACKGROUND

Anemia affects up to 90% of cancer patients, with more than 60% requiring blood transfusion during or after treatment.

AIM

To determine the influence of the allogeneic blood transfusion as a possible related factor to infection in patients with malignant neoplasms of the gastrointestinal system.

PATIENTS AND METHOD

Charts of 400 oncological patients were randomly selected and divided into two groups: group 1 (n = 200)--patients submitted to allogeneic blood transfusion and group 2 (n = 200)--non transfused patients. Both groups were evaluated and compared according to the presence and type of infection and a possible association with age, sex, types of tumors and therapeutics approach.

RESULTS

The relation between infection and blood transfusion, as well as age, sex, management and type of presented tumors were not significant. There was no difference in the incidence of infection between the non transfused patients (28) and those submitted to allogeneic blood transfusion (31).

CONCLUSIONS

In the present investigation allogeneic blood transfusion was apparently not related to development of infection in patients with malignant gastrointestinal tumors.

Single-photon emission computed tomography in the screening for postoperative pulmonary embolism

The aim of the study was to evaluate the usefulness of serial lung perfusion scintigraphy prospectively using single-photon emission computed tomographic image (SPECT) in screening for pulmonary embolism (PE) after elective surgery for gastrointestinal malignancy. PE was examined pre- and postoperatively with SPECT. Diagnosis of PE was based on segmental perfusion defect visualization in at least two of three planes on a SPECT image compared with preoperative SPECT images. Final diagnosis was determined by detection of embolus with multidetector helical CT (MDCT). No perioperative anticoagulant was used. Thirty-four patients were enrolled. One patient was excluded because of thrombophilia. In preoperative scans, nonsegmental defects were detected in 11 and a segmental defect in 1 patient, who was then diagnosed as PE preoperatively. Among 21 patients with normal preoperative SPECT, 2 had nonsegmental and 5 had segmental defects postoperatively. Among 11 patients with nonsegmental preoperative SPECT, 7 had nonsegmental and 4 had segmental defects postoperatively. Postoperative segmental defects were differentiated by their shape only and there was no need to compare pre- and postoperative SPECT. MDCT confirmed four patients with PE among nine with segmental defects postoperatively. Our results of screening for PE by visualization at least two planes of SPECT images suggest that postoperative SPECT scan is suitable for the diagnosis of postoperative PE.

Intrahepatic cholangiojejunostomy following hepatobiliary resection

Background

Although intrahepatic cholangiojejunostomy is technically difficult, with recent improvements in surgery it should be possible to perform the anastomosis safely. The aim of this study was to evaluate the incidence of anastomotic leak after intrahepatic cholangiojejunostomy and to identify risk factors for such leakage.

Methods

Intrahepatic cholangiojejunostomy was performed in 423 patients undergoing hepatobiliary resection between January 1991 and December 2005. Anastomotic leak was proven radiographically by leakage from the anastomosis of contrast medium introduced via a biliary drainage tube placed during surgery.

Results

Anastomotic leak occurred in 27 patients (6·4 per cent), and was not related to the number of bile ducts reconstructed. The leak rate decreased significantly from 9·5 per cent (19 of 199) in the first 10 years to 3·6 per cent (eight of 224) in the last 5 years. Anastomotic leak was often followed by infections such as wound infection, intra-abdominal abscess and bacteraemia. Multivariable analysis identified age and intraoperative blood loss as independent risk factors for anastomotic leak. All leaks were treated by maintaining a prophylactically placed drain near the cholangiojejunostomy; neither repeat laparotomy nor percutaneous transhepatic biliary drainage was required.

Conclusion

Although demanding, intrahepatic cholangiojejunostomy can be performed successfully with a relatively low failure rate. Routine use of prophylactic drains and anastomotic stenting allows safe management of anastomotic leak with conservative therapy.

[Role of antisecretory therapy in prophylaxis and treatment of postoperative stress ulcers of the digestive tract in patients with malignant tumors using preparation omez]

The prophylaxis and treatment methods of the gut stress ulcers and gastrointestinal bleeding in early postoperative period in patients suffering malignant tumors of abdominal cavity organs were presented. High efficacy of proton pump inhibitor Omez in the injection form was noted for prophylaxis of the gut stress ulcers and gastrointestinal bleeding in early postoperative period. There was shown, that Omez constitutes one of the main components of complex antisecretory therapy of the gut stress ulcers and gastrointestinal bleeding in persons, operated on for oncologic disease.

[Anemia in patients with resectable tumour of periampullar zone organs as a risk factor of postoperative complications occurrence and its complex correction]

Results of treatment of 39 patients, to whom pancreatoduodenal resection was performed for periampullar zone tumour, were analyzed. Anemia, revealed before the operation, had constituted the factor, which trustworthily increased the postoperative complications occurrence risk. Therapeutic course, using recombinant erythropoietins, was conducted for correction of anemia in 7 patients. This had promoted the hemoglobin level raising, the risk of postoperative complications occurrence lowering, but did not influence the intraoperative blood loss severity and perioperative hemotransfusion volume.