[The problem of hemobilia after transhepatic endobiliary interventions]

OBJECTIVE

To study the causes of hemobilia occurring during percutaneous transhepatic drainage and to develop methods for its prevention.

MATERIAL AND METHODS

Treatment results were analyzed in 149 patients with tumors in the hepatopancretoduodenal area. Among the examined patients, there were 65 (43.6%) males and 84 (56.4%) females at the age of 33 to 91 years (mean 64.1 years) who underwent 881 different endobiliary interventions. The condition was severe in 46 (30.9%) patients, moderate in 89 (59.7%), and satisfactory in 14 (9.4%). Extensive abdominal surgery had been performed in 71 (47.6%) cases. The preadmission history of mechanical jaundice was 7 to 30 days (mean 18.5 days). Total bilirubin levels were in the range from 32.9 to 726 μmol/l (mean 249.4 μmol/l). Philips Allura V 3000 and Siemens Axiom Artis devices were used to exercise X-ray TV control during the interventions.

RESULTS

The bile ducts were stented applying various models of expanding metallic stents in 93 (62.4%) of the 149 patients. A one-stage stenting protocol was used in 24 (25.8%) of the 93 patients and two-stage endobiliary stenting was carried out in 69 (74.2%). The other 56 (37.6%) of the 149 patients underwent only external-internal biliary drainage. Ten (6.7%) patients were noted to have different hemorrhagic complications as venous (4.7%, n = 7) and arterial (2%, n = 3) hemobilia.

CONCLUSION

X-ray surgical hemostatic procedures can ensure a final positive effect of transhepatic bile duct compression.

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.