Natural killer cell and alphabeta and gammadelta lymphocyte traffic into the liver graft immediately after liver transplantation

BACKGROUND

The persistence and migration of donor leukocytes has been well established, but cellular kinetics immediately after revascularization and the potential relevance of these different lymphocyte populations to spontaneous tolerance remain unclear. During the early hours of revascularization, there is a transitory "congestion" of the liver graft, which is evidence of an early phase that we have termed "first cellular contact."

METHODS

We have carried out by flow cytometry a prospective comparative study of the peak kinetics of lymphocyte subpopulations contained in: (a) peripheral blood and liver grafts at the time of multi-organ extraction from 14 brain-dead donors, (b) recipient peripheral blood before transplantation, and (c) recipient peripheral blood and liver grafts after (t=2 h) declamping and vascularization of the liver graft.

RESULTS

Before transplantation, the liver grafts contained large numbers of natural killer (NK) and NK-like cells with early lymphocyte activation. Immediately after revascularization, there was an influx of recipient NK and NK-like cells into the liver.

CONCLUSIONS

NK and CD3+CD56+ (NK-like) cells flooding into the liver graft immediately after revascularization could rapidly destroy allogeneic cells. However, spontaneous tolerance and the persistence of donor lymphocytes after orthotopic liver transplant could be a result of donor TCRalphabeta NK1.1 liver graft lymphocytes, which may be involved in the destruction of CD8+ T lymphocytes that would have received the apoptosis signal, and to NK and NK-like cell inhibition via inhibitory NK receptors. The decrease in gammadelta T lymphocytes in the two compartments suggests a mechanism of recirculation and capture in other lymphoid organs.

Human hepatocytes in primary culture predict lack of cytochrome P-450 3A4 induction by eletriptan in vivo

Eletriptan (Relpax) is a novel 5-hydroxytryptamine (serotonin)(1D/1B) agonist currently in development for the acute treatment of migraine. The aim of this work was to evaluate the relative induction potency of eletriptan in vitro compared with well characterized cytochrome P-450 (CYP) inducers with primary cultures of human hepatocytes and to relate this to the situation in vivo. Eletriptan was a weak inducer of CYP3A4 protein and cyclosporin A oxidation in four of the six cultures used, whereas rifampicin was a potent inducer in all cultures. Induction was concentration dependent and not detectable at eletriptan concentrations of 5 microM and lower. The amplitude of the increase in CYP3A4 protein and activity by 25 microM eletriptan was significantly lower, with a mean of 19 (P =.0015) and 26% (P =.0002), respectively, of that observed in response to 25 microM rifampicin. CYP2A6, a protein with minor pharmacological implication, also was induced by eletriptan and rifampicin in two cultures but was not detected in the others. The levels of other CYP proteins, including CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP2E1, were not affected by eletriptan. Because the maximum blood concentration of eletriptan in humans after a therapeutic dose (maximum 80 mg) is 0.5 microM, the in vitro model would predict no clinically significant induction of CYP3A4 protein in vivo. This has been confirmed subsequently in a clinical study, with 6beta-hydroxycortisol/cortisol ratios as marker of CYP3A4 activity. Eletriptan is therefore not an inducer of CYP3A4 at clinical doses.

Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava: review of 1361 cases

OBJECTIVE

The objective of this study was to describe the complications specifically related to orthotopic liver transplantation (OLT) with preservation of the inferior vena cava and to their therapeutic management. This preservation technique has considerably influenced the surgical phases of liver transplantation, increasing hepatectomy time and modifying the number of vascular anastomoses.

METHODS

Our retrospective multicentric study, based on data from 1361 adult patients that had undergone orthotopic liver transplantation with preservation of the inferior vena cava in France between 1991 and 1997, analyzed the concomitant surgical complications. Type of cavo-caval anastomosis performed (piggyback, end-to-side, or side-to-side), use of a temporary portacaval anastomosis, technique-related complications, and mortality, were investigated.

RESULTS

Cavo-caval anastomosis was side-to-side in 50.6% of cases (n=689), piggyback in 42.7% (n=582), and end-to-side in 6.6% (n=90). In total, 882 temporary portacaval anastomosis were carried out. Fifty-five patients presented with one or more complications related to the preservation of the inferior vena cava technique; i.e., overall morbidity was 4.1% (55/1361). Overall mortality was 0.7% (10/1361). Mortality rate for patients who presented with surgical complication was 18%. A total of 64 complications were recorded: 57 (89%) were in the perioperative or immediate postoperative period and 7 (11%) were postoperative.

CONCLUSIONS

These retrospective, descriptive results show significant advantages in favor of side-to-side anastomosis in terms of vascular complications. Certain factors should be evaluated specifically at pretransplant assessment to prevent certain serious complications; principally, these are anatomic factors of the recipient (inferior vena cava included in segment I, anatomic abnormalities of the inferior vena cava) and graft size. Depending on these factors, surgeons must be able to adapt the orthotopic liver transplantation, either before or during orthotopic liver transplantation, preferring the standard technique.

Alcoholic cirrhosis is a good indication for liver transplantation, even for cases of recidivism

BACKGROUND/AIMS

Alcoholic cirrhosis remains a controversial indication for liver transplantation, mainly because of ethical considerations related to the shortage of donor livers. The aim of this study was to review experience to date, focusing on survival rates and complications, and the effect of alcohol relapse on outcome and alterations in marital and socioprofessional status.

METHODS

The results for 53 patients transplanted for alcoholic cirrhosis between 1989 and 1994 were compared with those for 48 patients transplanted for non-alcoholic liver disease. The following variables were analysed: survival, rejection, infection, cancer, retransplantation, employment and marital status, alcoholic recurrence. The same variables were compared between alcohol relapsers and non-relapsers.

RESULTS

Recovery of employment was the only significantly different variable between alcoholic (30%) and non-alcoholic patients (60%). Two factors influenced survival in the absence of alcohol recidivism: age and abstinence before transplantation. For all other variables, there were no differences between alcoholic and non-alcoholic patients, and, within the alcoholic group, between relapsers and non-relapsers. The recidivism rate was 32%.

CONCLUSION

The data indicate that liver transplantation is justified for alcoholic cirrhosis, even in cases of recidivism, which did no affect survival and compliance with the immunosuppressive regimen. These good results should help in educating the general population about alcoholic disease.

The relationship among carbon dioxide pneumoperitoneum, vasopressin release, and hemodynamic changes

We assessed the role of vasopressin (VP) for the hemodynamic response to pneumoperitoneum in pigs. Four groups of anesthetized pigs were investigated. Nine pigs were intraabdominally insufflated with CO2 and eight were intraabdominally insufflated with argon; eight pigs received an i.v. injection of 1 mg/kg SR 49059, a VP antagonist, before CO2 insufflation; and six pigs received SR 49059 alone. Hemodynamics, plasma concentrations of VP and vasoactive hormones, and Paco2 were measured. Data were analyzed by using analysis of variance, Student's t-test, and Mann-Whitney U-test. Five minutes after insufflation, changes in systemic vascular resistance (SVR) were significantly correlated with changes in VP (r = 0.72; P = 0.005) but not with changes in epinephrine, norepinephrine, renin activity, or Paco2. SVR increased during CO2 insufflation but not during argon insufflation or CO2 insufflation with a preceding infusion of SR 49059. The SR 49059 injection itself resulted in increases in heart rate and cardiac output and decreases in blood pressure and SVR. We conclude that, during CO2 pneumoperitoneum in pigs, absorbed CO2 initiates a pathophysiological process that stimulates VP release. Hence, VP most likely plays a key role in the hemodynamic response to a CO2-induced pneumoperitoneum.

IMPLICATIONS

Intraabdominal insufflation of CO2 is associated with hemodynamic and hormonal changes. Investigating CO2 and argon-insufflated pigs and using a vasopressin antagonist, we found that CO2 insufflation released vasopressin, which, in turn, induced hemodynamic perturbances.

Delayed gastric emptying after pancreaticoduodenectomy and pancreaticogastrostomy

OBJECTIVE

To find out which factors influence the development of delayed gastric emptying (DGE) after pancreaticoduodenectomy with pancreaticogastrostomy.

DESIGN

Prospective clinical study.

SETTING

University hospital, France.

SUBJECTS

88 patients of 103 consecutive patients who had had pancreaticoduodenectomies, November 1991-November 1997.

INTERVENTIONS

Whipple resection, and parenteral and enteral nutrition.

MAIN OUTCOME MEASURES

Mortality, morbidity, and development of DGE (defined as the need for a postoperative nasogastric tube for 10 days or longer).

RESULTS

One patient died, and 44 developed postoperative complications. 36 patients (41%) developed DGE in 21 of whom (58%, 24% of the total) it was in isolation, with no other complication; and 52 (59%) did not. There were significant differences between those who developed DGE and those who did not: 30 men (83%) compared with 6 women (17%) developed DGE compared with 32 (62%) and 20 (38%) (p = 0.03;); 15 (42%) developed a complication as well as DGE compared with 8 (15%) (p = 0.005); 10(28%) who developed DGE required reoperation compared with 4(8%) (p = 0.011); mean (SD) hospital stay was 30(12) days among those with DGE compared with 17 (5) days (p= 0.0001); and their mean (SD) serum protein concentration on day 1 was 46 (1) compared with 51 (7) g/L (p=0.01). Multivariate analysis showed that three factors independently influenced the development of DGE: sex (p = 0.01), the need for reoperation (p = 0.03) and the mean serum protein concentration on day 1 (p = 0.04).

CONCLUSION

Postoperative complication and the need for reoperation remain the most common factors linked to the development of DGE. However, in a quarter of patients DGE was not associated with any postoperative complication.

Abdominal laparoscopic approach for thoracic epiphrenic diverticulum

The true incidence of epiphrenic esophageal diverticulum is unknown. Traditionally, diverticulectomy via a left thoracic approach has represented the gold standard. Trans-hiatal esophageal dissection under laparoscopy is feasible, but has not, to our knowledge, been applied before in the treatment of epiphrenic esophageal diverticulum.

Management of intraductal papillary mucinous tumours of the pancreas

OBJECTIVE

To focus attention on the management and outcome of patients with intraductal papillary mucinous tumours of the pancreas.

DESIGN

Retrospective study and analysis of published reports.

SETTING

University hospital, France.

SUBJECTS

111 patients (101 published cases and our own 10 cases) divided in two groups: the first including malignant tumours (n = 46), and the second group benign or in situ tumours (n = 61). In 4 patients the type of tumour was not known.

MAIN OUTCOME MEASURE

Resectability, mortality and recurrence.

RESULTS

More men had benign or in situ tumours [48/61 (79%) compared with 28/46 (61%), p = 0.054]. Pancreatitis was more common among benign than malignant tumours [34/61 (58%) compared with 21/46 (46%), p = 0.33]. In group I, 39 patients had diabetes. A total of 107 patients were operated on: pancreaticoduodenectomy (n = 54, 50%), distal pancreatectomy (n = 25, 23%), total pancreatectomy (n = 4,4%), bypass (n = 2,2%). The type of resection was not mentioned in 22 records (21%). Four patients were not operated on because of their poor general condition. The resectability rate was 98% (105/107). Eleven patients had died at the time of publication. Hospital mortality rate was 3% (n = 3), mainly because 2 of the 4 who had total pancreatectomy died. With a median follow-up of 37 months, recurrence was 5% (n = 5).

CONCLUSION

Intraductal papillary mucinous tumours of the pancreas are well known distinctive pancreatic tumours that are usually intraductal but may develop into invasive carcinoma. They should be resected, and have a good prognosis and low recurrence rate.

Diaphragmatic and subcutaneous seeding of hepatocellular carcinoma following fine-needle aspiration biopsy

AIMS/BACKGROUND

We report the discovery of associated metastatic subcutaneous and metastatic diaphragmatic nodules on the needle track after fine-needle biopsy aspiration under echography, which has not yet been reported in the literature.

METHODS

A 35-year-old man with non-replicating hepatitis B virus presented with a tumor that suggested hepatocarcinoma with cirrhosis. A diagnostic needle biopsy was carried out before surgery. Twelve months later, he presented with a series of four continuous metastatic diaphragmatic nodules on the inner wall lining the needle track. Surgery was performed, followed by external radiation (40 Gy).

CONCLUSIONS

The risk of seeding following fine-needle biopsy aspiration of hepatocellular carcinoma can no longer be considered negligable. The real risk is probably underestimated. Even for biopsy of lesions localized to the inferior part of the liver, diaphragmatic seeding is possible. This seeding necessitates surgical resection, increasing the therapeutic morbidity of hepatocellular carcinomas. We believe that in cases where investigation of a small hepatic tumor suggests a hepatocellular carcinoma that could be resected, or for candidate patients for liver transplantation. one should not puncture the tumor. If this diagnostic biopsy is essential, then the needle track could be resected upon surgery, after cutaneous external tattooing.

Activated sub-populations of lymphocytes and natural killer cells in normal liver and liver grafts before transplantation

AIMS/BACKGROUND

The anatomic structure of the liver suggests that it is a place of intense trafficking between intra-hepatic and peripheral blood compartment leukocytes. Furthermore, the liver contains a large number of passenger leukocytes that may play a role in the appearance of donor-type microchimerism after transplantation. In this study, we aimed to define the principal lymphocyte sub-populations contained in donor peripheral blood and liver grafts and in normal liver removed during minimally invasive surgery.

METHODS

Liver biopsies were taken at the time of vascular clampage during liver extraction from donors in a brain dead state (GI: n=14). Normal liver biopsies were removed during minimaly invasive surgery (GII: n= 10).

RESULTS

We observed evidence of the presence of lymphocytic activation associated with the two major CD8+ lymphocyte and natural killer (NK) cell populations in the two groups, with a significant increase in TCRgammadelta-bearing lymphocyte receptors between normal liver and the liver graft.

CONCLUSIONS

The presence of activated leukocytes in the graft could have a fundamental role in induction of peripheral tolerance. This activation could be the result of a basic immunological response linked to the interaction of T cells and NK cells, and of secondary activation due to stress and the conditions necessary for organ removal from donors in a brain dead state.

Results of pancreatogastrostomy after pancreatoduodenectomy in 160 consecutive patients

BACKGROUND

The advantages of pancreatogastrostomy over pancreatojejunostomy after pancreaticoduodenectomy are still debated. This study analyses the results of pancreatogastrostomy to identify factors that could influence immediate outcome.

METHODS

During a 10-year period, 160 consecutive patients underwent a pancreatogastrostomy. There were 109 men (68 per cent) and 51 women (32 per cent) with a mean(s.d.) age of 59(10) (range 22-82) years; 27 patients were older than 70 years. The following parameters were assessed: mortality rate, morbidity, reasons for reoperation, length of hospital stay, duration of nasogastric tube and drainage.

RESULTS

Hospital mortality rate was 3 per cent; overall morbidity rate was 30 per cent. The reoperation rate was 12 per cent, mainly because of bleeding at the pancreatic margin. Delayed gastric emptying occurred in 36 patients. The overall rate of pancreatic fistula was 2.5 per cent. Age, sex, indications for pancreatoduodenectomy, and the texture of the pancreatic remnant did not influence the occurrence of pancreatic fistula or delayed gastric emptying.

CONCLUSION

This study confirmed that pancreatogastrostomy is a safe procedure with low mortality and morbidity rates.

Experimental assessment of the risk of tumor recurrence after laparoscopic surgery

BACKGROUND

The aim of this experimental study was to evaluate the risk of tumor recurrence after laparoscopic cecal resection (LCR) of colonic carcinoma in the rat.

METHODS

The experimental cancer consisted of one million cells (DHK/K12), incorporated in an extracellular matrix, placed and secured to the cecal serosa in 110 BD9 rats. Four weeks later, all animals were reoperated through a laparotomy to control tumor growth, and animals with diffuse carcinomatosis were excluded. Eligible animals were randomized either to laparoscopic cecal resection (group LCR, n = 10), to open resection (group OCR, n = 13), or to a control group without resection (group C, n = 13). Resection was always considered as macrocopically complete. All animals were killed 4 weeks after the resection to determine the tumor recurrence and quantify carcinomatosis.

RESULTS

We noted diffuse carcinomatosis in 70% of rats in groups C and LCR versus 23% in group OCR (p = 0.038). For tumors noted as S- (not extending outside the serosa), diffuse carcinomatosis was observed in all animals of group C (3 of 3), in 6 of 8 in group LCR, and 0 of 6 in group OCR (p = 0.004). The rate of port site or incisional metastases was not significantly different between groups.

CONCLUSIONS

These preliminary results demonstrated the deleterious impact of the laparoscopy for resection of large bowel malignancy. LCR increased significantly the incidence of a diffuse carcinomatosis even when performed for locally noninvasive tumors (S-).

Prevalence of monoclonal immunoglobulins after liver transplantation: relationship with posttransplant lymphoproliferative disorders

BACKGROUND

A high incidence of serum monoclonal immunoglobulins (mIgs) has been described after solid organ transplantation. For transplant recipients, the prevalence of posttransplant lymphoproliferative disorders (PTLDs) has been reported to be between 2% and 6%. The relationship between the finding of serum mIg in transplant recipients and the subsequent development of PTLDs is not clearly documented.

METHODS

We retrospectively analyzed all cases of mIg and PTLD that occurred in 86 liver transplant recipients who survived more than 3 months. Patients were characterized by protein electrophoresis, immunofixation electrophoresis, pre- and post-liver transplantation Epstein-Barr virus (EBV) serology, EBV presence in lymphoproliferative tissues by in situ hybridization, type of infection episodes, rejection episodes, and immunosuppressive treatment.

RESULTS

Thirty-eight patients (44%) had abnormal immunofixation electrophoresis with an electrophoretic Ig peak. Twelve patients had a polyclonal Ig peak, and 26 patients had mIgs (30%). These 26 patients were divided into two groups: 13 patients had a transient mIg peak with a mean delay for normalization of electrophoresis of 2 months, and 13 patients had a permanent mIg peak. No correlation could be demonstrated between the appearance of abnormal banding and indications for transplantation, age of patients, and acute rejection rate. There was a strong correlation between occurrence of viral infections and presence of permanent mIg. Three patients with permanent mIg (23%) developed PTLD and died.

CONCLUSIONS

We concluded that the prevalence of mIg after liver transplantation was 30%. Viral infections increase the risk of developing mIg. Persistence of mIg beyond 7 months may be regarded as prelymphomas necessitating a careful follow-up in these patients.

Argon pneumoperitoneum is more dangerous than CO2 pneumoperitoneum during venous gas embolism

We investigated the possibility of using argon, an inert gas, as a replacement for carbon dioxide (CO2). The tolerance of argon pneumoperitoneum was compared with that of CO2 pneumoperitoneum. Twenty pigs were anesthetized with enflurane 1.5%. Argon (n = 11) or CO2 (n = 9) pneumoperitoneum was created at 15 mm Hg over 20 min, and serial intravenous injections of each gas (ranging from 0.1 to 20 mL/kg) were made. Cardiorespiratory variables were measured. Transesophageal Doppler and capnographic monitoring were assessed in the detection of embolism. During argon pneumoperitoneum, there was no significant change from baseline in arterial pressure and pulmonary excretion of CO2, mean systemic arterial pressure (MAP), mean pulmonary artery pressure (PAP), or systemic and pulmonary vascular resistances, whereas CO2 pneumoperitoneum significantly increased these values (P < 0.05). During the embolic trial and from gas volumes of 2 and 0.2 mL/kg, the decrease in MAP and the increase in PAP were significantly higher with argon than with CO2 (P < 0.05). In contrast to CO2, argon pneumoperitoneum was not associated with significant changes in cardiorespiratory functions. However, argon embolism seems to be more deleterious than CO2 embolism. The possibility of using argon pneumoperitoneum during laparoscopy remains uncertain.

IMPLICATIONS

Laparoscopic surgery requires insufflation of gas into the peritoneal cavity. We compared the hemodynamic effects of argon, an inert gas, and carbon dioxide in a pig model of laparoscopic surgery. We conclude that argon carries a high risk factor in the case of an accidental gas embolism.

The detection of carbon dioxide embolism during laparoscopy in pigs: a comparison of transesophageal Doppler and end-tidal carbon dioxide monitoring

BACKGROUND

The aim of the study was to compare the value of transesophageal Doppler and end-tidal carbon dioxide monitoring to detect venous carbon dioxide embolism in pigs during laparoscopic cholecystectomy.

METHOD

Ten pigs were anesthetized under constant ventilation, and instrumented for laparoscopic cholecystectomy. CO2 pneumoperitoneum was performed at 15 mmHg and then, successive increased intravenous gas boluses of 0.1 to 4 ml/kg injected through the femoral vein using a 55-mm long catheter. The responses indicative of embolism were defined as: 1) a change in Doppler tone placed facing the junction of the right atrium and inferior vena cava; 2) a change in end-tidal CO2 > or = 0.4 kPa.

RESULTS

Doppler was more sensitive in detecting 0.1, 0.2 and 0.4 ml/mg of CO2 embolism than end-tidal CO2 (P < 0.05). Over 0.4 ml/mg no differences in sensitivity were found but the Doppler signal modifications occurred earlier than the changes in end-tidal CO2. Moreover, these changes always consisted of a reduction of the value.

CONCLUSION

During laparoscopic cholecystectomy in pigs, transesophageal Doppler was a highly sensitive monitor which provided an earlier detection of CO2 embolism and at lower doses than end-tidal CO2 monitoring.

Contribution of primary cultures of adult human hepatocytes to the pathophysiology of hepatocellular carcinoma

BACKGROUND/AIMS

The mechanisms of hepatocarcinogenesis are still poorly understood. The development of hepatocellular carcinoma has recently been shown to be associated with increased DNA synthesis in cirrhosis. The aim of this work was to determine whether the high rate of hepatocyte regeneration observed in cirrhotic liver with hepatocellular carcinoma is associated with the presence of a growth factor that could be detectable in the serum.

METHODS

Adult human hepatocytes in primary culture, allowing the evaluation of the release of circulating hepatotrophic factors, were used. These cultures were treated for 48 h with serum from patients with cirrhosis with and without hepatocellular carcinoma, from patients with liver metastasis, and from healthy subjects. The rate of DNA synthesis in these cultures was assessed by measuring the amount of [3H]-thymidine incorporation into genomic DNA.

RESULTS

On average, the synthesis of DNA was increased 2.5-, 2.2-, 2.1-, and 2.3-fold, respectively, in response to serum from patients with cirrhosis with hepatocellular carcinoma, from patients with cirrhosis without hepatocellular carcinoma, from patients with liver metastasis, and from healthy subjects.

CONCLUSIONS

We conclude that the hepatotrophic activity of the serum is not significantly different in patients with cirrhosis with or without hepatocellular carcinoma. These results suggest that the increased DNA synthesis in hepatocytes of cirrhotic liver with hepatocellular carcinoma might be due to proliferative factor(s) acting by paracrine or autocrine pathways.

A phase II study of 5-fluorouracil, leucovorin and cisplatin (FLP) for metastatic gastric cancer

The modulation of 5-fluorouracil (5-FU) with folinic acid (leucovorin, LV) is more efficacious than 5-FU alone in the treatment of metastatic colorectal cancer, and the combination of 5-FU with cisplatin is currently one of the most active regimens in advanced gastric cancer. A phase II study was therefore conducted to test the efficacy and toxicity of the combination of 5-FU, LV and cisplatin (FLP) in metastatic gastric cancer. 28 patients entered the study. Metastatic sites were observed in the liver (in 21 patients), the peritoneum (in 8), the lymph nodes (in 7) or the bones (in 1) and a local recurrence was noted in 4 cases. The performance status (using World Health Organisation criteria) was 0 for 13 patients and 1 or 2 for the others. Cycles of treatment were administered every 28 days and consisted of LV 200 mg/m2/day for 5 days followed by 5-FU 400 mg/m2/day for 5 days with cisplatin 100 mg/m2 on day 2. The response rate for the 27 evaluable patients was 51.8% (95% confidence interval (CI), 33-70.6%). There were four complete responses (14.8%) and 10 partial responses (37%). Median survival was 11 months and 4 patients were alive at 2 years. Both response rate and survival were better for patients with a good performance status. The overall toxicity was very low, except for 1 patient who died of dehydration and cardiac failure. In conclusion, the FLP protocol was effective and well tolerated in patients with metastatic gastric cancer.

Surgery for left-sided pancreatic cancer

A total of 590 exocrine pancreatic cancers of the body or tail of the pancreas, operated on between January 1982 and December 1988, were analysed. There were 128 pancreatic resections (group 1), 164 palliative bypasses (group 2) and 293 exploratory laparotomies which included 74 splanchnicectomies (group 3). The mortality rate was lower in group 1 (9 per cent) than in group 2 (19 per cent) (P = 0.012). The mortality rate exceeded 40 per cent in groups 1 and 2 for patients aged more than 70 years with pre-existing organ failure. The morbidity rate was 32 per cent in group 1 and 29 per cent in group 2. Patients with metastases had a median survival of 3.4 months, whatever the operative treatment. In the presence of lymph node involvement there was no significant difference in survival between groups 1 and 2. Patients with no metastases and no lymph node involvement had 1- and 3-year survival rates of 38 and 12 per cent respectively after pancreatic resection. Only patients with a small tumour (< or = 4 cm), no lymph node involvement and no metastases achieved a significantly better survival after resection (P = 0.049). Curative resection should be reserved for a small tumour confined to the pancreas. Fewer than 10 per cent of patients will be suitable for surgery. For the other cases, resection must be considered as a palliative procedure without a significant improvement in survival. It seems justified to limit palliative surgery to candidates for digestive bypass and to use non-surgical palliation for the remainder.

[Value of percutaneous hepatic biopsy in the diagnosis of presumed benign tumors of the liver]

The purpose of this study was to assess the accuracy of guided hepatic biopsy (GHB) and imaging techniques for presumed benign liver tumours and to determine their impact on surgical treatment. The study was carried out retrospectively in a surgical series of 15 consecutive patients with presumed benign liver tumours. The final diagnosis was 8 cases of focal nodular hyperplasia (FNH), 6 hepatic adenomas (HA) and one association FNH-HA. No morbidity was related to guided hepatic biopsy. All FNH detected on radiologic imaging or pathological examination of the biopsy specimen were true positive diagnoses. This study demonstrates that combined results of imaging techniques and percutaneous GHB could correctly diagnose three quarters of FNH before surgery. GHB is also useful when MRI imaging is indeterminate allowing a conservative approach for undiagnosed FNH.

Various features and surgical approach of solitary pancreatic metastasis from renal cell carcinoma

In this paper we report three cases of solitary pancreatic metastasis from renal cell carcinoma (RCC), treated surgically. Various features and the surgical approach of these metastases are discussed with references to the 33 previous published cases collected in the literature. Having eliminated widespread distant metastases, it is reasonable to restrict surgical resection of the pancreas to selected patients having a single synchronous or metachronous metastasis, or those having several unilateral metastatic foci. At any rate a careful long-term follow-up for patients with a past history of RCC is mandatory.

Small hepatocellular carcinoma in patients undergoing liver transplantation: detection with CT after injection of iodized oil

PURPOSE

To assess computed tomography (CT) with iodized oil for depiction of small hepatocellular carcinoma (HCC) before liver transplantation.

MATERIALS AND METHODS

Thirty-five consecutive cirrhotic patients underwent CT with iodized oil to determine the presence, number, size, and location of possible nodules. All patients underwent liver transplantation within 4 months after CT. Explanted livers were cut in 8-mm slices that corresponded to axial CT scan planes. Comparison between CT staging and pathologic findings was made.

RESULTS

Pathologic studies showed 17 HCC nodules (diameter, 0.9-4.0 cm) in nine of the 35 livers. CT depicted nine of these 17 nodules. Lesion-by-lesion analysis revealed a sensitivity of 53%; CT falsely depicted three additional nodules not confirmed with pathologic findings. Patient-by-patient analysis revealed an 89% sensitivity and an 88% specificity.

CONCLUSION

CT with iodized oil, when assessed lesion by lesion, has a low sensitivity. These results must be considered when liver resection is proposed for HCC.

Value of CT in the diagnosis and management of patients with suspected acute small-bowel obstruction

OBJECTIVE

The purpose of this prospective study was to evaluate the role of CT in the diagnosis of patients with suspected acute small-bowel obstruction in whom clinical and plain radiographic findings were inconclusive.

SUBJECTS AND METHODS

Fifty-seven nonconsecutive patients with suspected acute small-bowel obstruction were referred for CT to differentiate small-bowel obstruction from ileus (33 patients) or to establish the cause of obstruction (24 patients). The final diagnosis was established either by surgery (42 patients) or by the clinical evolution (15 patients). The change in the prescan diagnosis as to the presence, cause, and severity (strangulation) of small-bowel obstruction made on the basis of the CT findings was noted. Finally, the changes in therapy resulting from the CT information were recorded.

RESULTS

CT correctly distinguished between small-bowel obstruction and ileus in all cases except one. CT enabled us to modify an erroneous clinical diagnosis correctly in 12 (21%) of 57 cases, including eight cases for which pre-CT diagnosis was ileus and four cases for which pre-CT diagnosis was small-bowel obstruction. CT allowed us to predict the cause of obstruction correctly in 33 (85%) of 39 patients with confirmed small-bowel obstruction but it failed to differentiate adhesions from internal hernias and radiation enteritis. The pre-CT diagnosis of the cause of obstruction was correctly changed because of CT findings in 17 (44%) of 39 patients with subsequently proved small-bowel obstruction. CT was able to identify strangulation in nine of the 12 patients with proved strangulation, which altered the pre-CT diagnosis in three patients. CT findings correctly modified the management in 12 (21%) of 57 patients, by changing either a conservative management to an operative one in 10 (18%), or an operative to a conservative one by differentiating ileus from obstruction in two patients.

CONCLUSION

Our findings show that CT is a valuable diagnostic procedure in patients with suspected acute small-bowel obstruction. CT not only is useful in distinguishing obstruction from paralytic ileus, but it frequently establishes the cause of the obstruction and the presence of strangulation. CT findings lead to decisions to treat patients surgically in a significant number of patients.

[Unusual locations of hydatid cysts]

The most common sites of hydatid disease (HD) are represented by the liver and the lungs. In 10% of cases, HD arises in unusual viscera: mainly spleen (0.9 to 8%) and also kidney, bones, heart, brain, peritoneum (0.5 to 5%). Other exceptional location was described in less than 1% of all cases of hydatid cysts. Ultrasonography and CTscan are highly suggestive of HD, while serologic tests are variable. The cysto-pericystectomy is the gold standard procedure but sometimes unsuitable for particular sites. In that cases a conservative approach (partial pericystectomy) is mandatory to preserve the organ function. The place of adjuvant medical treatment remains questionable.

Effect of anti-ulcer drugs on DNA synthesis in adult normal human hepatocytes in culture

The aim of this work was to investigate the effect of four H2 receptor antagonist, cimetidine, ranitidine, famotidine, nizatidine, and of two proton pump inhibitors, omeprazole and lansoprazole, on the mitotic response of human hepatocytes in primary culture. After plating at subconfluent density, cells were exposed to 0.2 to 20 mumol/L of these drugs for 48 hours, either in the absence or in the presence of epidermal growth factor (EGF). The rate of DNA synthesis was evaluated by [3H]-thymidine incorporation into genomic DNA. Both the basal rate of DNA synthesis and the extent of stimulation by EGF exhibited a wide interindividual variability, and were not correlated with the viability of freshly prepared cells. In contrast, the effects of anti-ulcer drugs on the rate of DNA synthesis were clearly reproducible from one culture to another. H2 receptor antagonists had no significant effect (P > .2) over the entire range of concentration tested, whereas omeprazole and lansoprazole significantly inhibited the rate of DNA synthesis by 60% to 90% at 30 mumol/L (P = .016). This effect was concentration dependent between 2 and 20 mumol/L. Neither of the drugs tested was cytotoxic under the conditions used in this work, as assessed by measurements of the do nov protein synthesis. We conclude that, in contrast to H2 receptor antagonists, omeprazole and lansoprazole are able to interfere with the replicative synthesis of DNA in human hepatocytes in culture, at suprapharmacological concentrations. Whether or not this effect is clinically significant remains to be established.

Tracheoesophagogastric anastomosis fistula: a rare complication of esophagectomy

Fistulas between trachea and esophagogastric anastomosis after esophagectomy are uncommon. We describe 2 patients with such a lesion successfully managed with single-stage repair. The fistula was divided, the tracheal defect was closed directly or with a free pericardial graft, and the esophagogastric anastomosis was redone. A muscle or pleural flap was used to separate the tracheal and digestive suture lines. This treatment of a potentially life-threatening condition yielded excellent results without postoperative complications.

Failure of ursodeoxycholic acid to prevent acute cellular rejection after liver transplantation

BACKGROUND/AIMS

Acute rejection is still a major problem after liver transplantation. Ursodeoxycholic acid has beneficial effects in cholestasis by reducing the expression of major histocompatibility complex antigens.

METHODS

We have performed a double-blind randomised study comparing ursodeoxycholic acid with placebo for the prevention of acute cellular rejection after liver transplantation. Twenty-six patients received ursodeoxycholic acid 600 mg per day and 24 patients received placebo for 2 months.

RESULTS

Neither rejection incidence nor rejection severity was significantly different in the two groups (p > 0.90).

CONCLUSIONS

We conclude that adjuvant ursodeoxycholic acid administration does not prevent rejection after liver transplantation.

Chest wall reconstruction for radionecrosis after breast carcinoma therapy

This study aimed at evaluating various reconstructive procedures for chest wall radionecrosis after breast carcinoma therapy. Four different techniques were performed between 1973 and 1992 in 120 patients: latissimus dorsi musculocutaneous flap (LDF; n = 81); transposed omentum and split-thickness skin graft (TGO; n = 20); fasciocutaneous flap (FCF; n = 10), and transverse rectus abdominis musculocutaneous flap (TRAM; n = 9). Initial dose of irradiation ranged from 60 to 110 Gy. The average interval between initial treatment and reconstruction was 11 years. Local recurrence was suspected in 26 patients and was histologically proven after removal in 36 (30%). Surgical procedure results were analyzed by mean hospital stay (8 days for LDF vs. 52 days for TGO), early (13% LDF vs. 60% TGO) and late (7% LDF vs. 35% FCF) complications, second surgery (15% LDF vs. 53% FCF), and functional and cosmetic outcomes. In our experience, the LDF was the first-line flap. The TRAM was used to cover very large defects and when breast reconstruction was needed. When these flaps were impossible or dangerous, we performed a TGO. These three procedures have replaced FCF indications.

Posttraumatic pancreatic fistula cured by endoprosthesis in the pancreatic duct

We report a case of pancreatic fistula attributable to posttraumatic rupture of the main duct that was undiagnosed before ERCP and was cured instantaneously by endoscopic placement of an endoprosthesis in the pancreatic duct after failure of conventional medical treatment.

Role of CT in the acute nontraumatic abdomen

The diagnostic workup of the acute abdomen always begins with a precise clinical history, a complete physical examination, and careful reading of plain films. Commonly performed additional imaging studies include contrast examination and, more recently, ultrasound. CT offers the advantage of allowing a comprehensive diagnostic evaluation of both solid and hollow viscera in neoplastic as well as in inflammatory and vascular disorders.

Pharmacologic heterogeneity of human lung and colon cells: effect of terfenadine and cetirizine

H1-blockers may have antiallergic properties which cause the blocking of eicosanoid release, and the effect of these drugs may differ according to the phenotype of mast cells. This study examined the ability of terfenadine and cetirizine to inhibit the release of arachidonic acid-derived mediators from human lung and colon cells. Dispersed cells were challenged with anti-IgE in the presence or absence of 10 microM of terfenadine or cetirizine, and the release of prostaglandin (PG)D2 and leukotriene (LT)C4/D4 was assessed by enzyme immunoassay (EIA). Terfenadine caused significant inhibition of both PGD2 and LTC4/D4 (49 +/- 9 and 29 +/- 19%, respectively) from human lung cells but had a less marked effect on PGD2 release from human colon cells (21 +/- 9% for PGD2 and 18 +/- 9% for LTC4/D4). In contrast, although cetirizine caused significant inhibition of both mediators measured in lung cells (38 +/- 16% for PGD2 and 34 +/- 19% for LTC4), it did not cause any significant inhibition of either mediator from human colon cells. These findings suggest that H1-antagonists may have additional properties, and the differential effects of cetirizine on lung and colon tissue may indicate differences in mast cell phenotype.

Lethal acute graft-versus-host disease in a liver transplant recipient: relations with cell migration and chimerism

We report herein the case of a patient who developed fatal acute graft-versus host disease (GvHD) after liver transplantation (LT). GvHD occurred 18 days after LT and was characterized by skin epidermolysis, diarrhea and leucopenia. Skin biopsy showed epidermal dyskeratosis with epithelial necrosis, a lesion consistent with GvHD. Despite immunosuppressive therapy, the patient died within 24 days. In our observation, GvHD occurred although five HLA compatibilities were identified between the donor and the recipient, an apparently favorable and uncommon situation. This case further supports the qualification that LT may be complicated by GvHD and strongly suggests that minor rather than major histocompatibility antigens are the main target of allogenic interactions of GvHD. The involvement of chimerism in GvHD is controversial and requires further investigation.

Leiomyosarcoma of the inferior vena cava presenting as Budd-Chiari syndrome. Vena cava replacement under veno-venous bypass and liver hypothermic perfusion

We report the first case of leiomyosarcoma of the middle and upper part of the vena cava successfully treated by surgical resection, complete vena cava replacement and disobliteration of the hepatic veins under veno-venous bypass and liver hypothermic perfusion as described in "ex situ, in vivo liver surgery".

[Gastroesophageal reflux. 2nd indication for digestive celioscopic surgery?]

Widespread us of laparoscopic surgery adds a new element to the debate over the choice between medical or surgical treatment for gastro-oesophageal reflux. Patients and gastroenterologists often favour medical management to avoid post-operative pain, a long recovery period, an abdominal scar or the risk of eventration but at the cost of long-term drug therapy and the need for repeated check-ups and endoscopy examinations. Yet surgery was found to give better long-term results in the only study comparing surgery and medical treatment. The question of cost and insurance coverage must also be considered. Although the indications for laparoscopic surgery would be identical to those for laparotomy it is probably possible that a wider population could benefit from this technique as laparoscopic cure can be indicated as an alternative in patients highly dependent on drug therapy. Relapse in patients with a long-term medical regimen is another recent indication. We should however always keep in mind that good outcome after laparoscopic surgery depends not only on a correct indication and evaluation of the oesophageal motricity but also on the skill and experience of the surgical team. Laparoscopic cure should certainly play a major role in the treatment of gastro-oesophageal reflux and will undoubtedly soon be the second most frequent laparoscopic technique performed after laparoscopic cholecystectomy.

Conservative surgery for low rectal carcinoma after high-dose radiation. Functional and oncologic results

OBJECTIVE

Using a prospective, nonrandomized study, the authors evaluated the morbidity and functional and oncologic results of conservative surgery for cancer of the lower third of the rectum after high-dose radiation.

SUMMARY BACKGROUND DATA

Colo-anal anastomosis has made sphincter conservation for low rectal carcinoma technically feasible. The limits to conservative surgery currently are oncologic rather than technical. Adjuvant radiotherapy has proven its benefit in terms of regional control, with a dose relationship.

METHODS

Since June 1990, 27 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 47 mm (27-57 mm), and none of the tumors were fixed (15 T2, 12 T3).

RESULTS

Mortality and morbidity were not increased by high-dose preoperative radiation. Twenty-one patients underwent conservative surgery (78%-17 total proctectomies and colo-anal anastomoses, 4 trans-anal resections). After colo-anal anastomosis, all patients with colonic pouch had good results; two patients had moderate results and one patient had poor results after straight colo-anal anastomosis. With a mean follow-up of 24 months, the authors noted 1 postoperative death, 2 disease-linked deaths, 1 controlled regional recurrence, 2 evolutive patients with pulmonary metastases, and 21 disease-free patients.

CONCLUSIONS

These first results confirm the possibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective, randomized trial could be induced to determine the real role of the 20 Gy boost on the sphincter-saving decision.

[Medicosocial consequences of permanent digestive stomas. A national multicenter retrospective study]

OBJECTIVES

To evaluate the medical (sexual dysfunction, psychological adjustment, stoma care) and social (working life, family life, leisure) consequences of definitive ileostomies or colostomies.

METHOD

From February 1992 to May 1992, 1082 live patients (978 colostomies and 104 ileostomies) who had undergone surgery at least 6 months earlier were assessed in a multicentre national inquiry.

RESULTS

More than 20% of the patients had not been informed before surgery of the possibility of a definitive stoma. In half of the cases, the stoma was well accepted psychologically and patient's primary reactions improved with time, especially in patients with ileostomy (p < 0.01) and patients under 60 years of age (p < 0.001). Patients were satisfied with their stoma appliance in 94% of the cases. Only 31% with colostomy performed irrigations. Life style was altered in 43% of the patients, especially those with ileostomies (p < 0.001). Sexual activity was disturbed in 55% of the colostomy patients and working life in 63% of the ileostomy patients. One-fourth of the patients were often followed by an enterostomal therapist and one-third were members of ostomate associations.

CONCLUSIONS

Ileostomy appears to be more disabilitating than colostomy due to patient age and, unlike colostomy, the impossibility of irrigation. These findings emphasize the contribution of enterostomal therapy and the justified role of ostomate associations.

Laparoscopic cholecystectomy in complicated cholelithiasis

From January 1990 to December 1992, 129 patients presenting complicated cholelithiasis were included in a prospective study to assess the feasibility and efficiency of laparoscopic cholecystectomy. There were 84 females (65%) and 45 males (35%). Mean age was 60 years (range from 23 to 88). There were 90 acute cholecystitis (70%), 14 empyema (11%), 14 cholecystitis on scleroatrophic gallbladder (11%), and 11 mucocele (9%) cases. Laparoscopic cholecystectomy has been successfully performed in 106 cases (82%) (group I). In this group of patients, morbidity and mortality were 4.7% and 0.9% (n = 1), respectively. Mean hospital stay was 4.7 days after uneventful postoperative course. Two patients required reoperation for complications (1.8%). Twenty-three patients (18%) required enforced conversion to laparotomy after unsuccessful laparoscopic procedure (group II). Mean hospital stay was significantly higher in group II (10.8 days, P = 0.0001). There was no difference between the two groups according to sex, previous surgery, or indications. Laparoscopic cholecystectomy may be attempted and successfully realized in complicated cholelithiasis without morbidity increase. Main advantages of this procedure are a shorter hospital stay and a better recovery period.

Carcinosarcoma of the gallbladder. A case report and review of the literature

We report a carcinosarcoma (CS) of the gallbladder in an 83-year-old woman. Ultrasonography found an enlarged gallbladder with thickened walls, a 3-cm gallstone, and a polypoid mass in the fundus. Pathological examination revealed neoplastic tissue composed of sarcomatous and glandular components. Twelve months later, the patient is alive. We review 24 other cases in the literature to outline the characteristics of this tumor.

Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.