Risk factors for conversion and complications after unilateral laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of most benign adrenal tumours, with a reported overall complication rate around 10 per cent. The aim of this study was to determine predictive factors for postoperative complications and conversion to open surgery after unilateral LA.

METHODS

From 1994 to 2009, consecutive patients undergoing unilateral LA by the lateral transabdominal approach were analysed from a prospectively maintained database. A mass larger than 12 cm in diameter and suspected primary adrenal carcinoma were considered contraindications to LA. Predictive factors for postoperative complications and conversion to open surgery were analysed.

RESULTS

Some 462 patients were analysed. There were no postoperative deaths. Postoperative complications occurred in 53 patients (11·5 per cent), medical complications in 28, and surgical complications in 33 patients. Six patients underwent reoperation for complications. Multivariable logistic regression analysis showed that conversion to open surgery (odds ratio (OR) 6·20, 95 per cent confidence interval 2·08 to 18·53; P = 0·001) and left-sided tumour (OR 1·89, 1·02 to 3·52; P = 0·044) were independent predictive factors for overall complications. Conversion to open surgery was the only independent predictive factor for medical complications (OR 12·88, 4·21 to 39·41; P = 0·001), and left-sided LA was the only predictive factor for surgical complications (OR 2·22, 1·01 to 4·89; P = 0·047). No factor was predictive of conversion to open surgery.

CONCLUSION

In this single-institution study, conversion to open surgery and left-sided tumours were independent predictive factors for overall complications, but none of the variables analysed was predictive of conversion.

How to reduce the risk of recurrence after surgical treatment of colorectal liver metastases?

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Background: After surgery with curative intent for colorectal liver metastases (MHCCR), liver recurrence occurs in more than 60% of patients, despite the administration of adjuvant systemic chemotherapy. The objective of this study was to compare the prognosis of patients operated on MHCCR with high risk of recurrences in the liver, treated by postoperative chemotherapy hepatic arterial infusion (HAI) by oxaliplatin, to that obtained after adjuvant systemic chemotherapy.

Methods: From January 2000 to December 2009, 113 patients who underwent curative resection of more than 3 MHCCR, were selected from a prospective database. Among these 113 patients, 47 had received postoperative HAI associated with systemic chemotherapy (HAI+) and 66, systemic chemotherapy alone (HAI-).

Results: The two groups were comparable in age, sex, stage of primary, rates of synchronous (> 75%), and bilobar (> 90%) MHCCR. The number of MHCCR was significantly higher in the group HAI+ (p < 0.0001). Twenty-seven patients (57%) received more than 6 courses of HAI. HAI was discontinued in 6 patients (12%) due to technical problems with the catheter. After a median follow up of 75 months (7-125), the overall survival and recurrence-free survival at 5 years were higher for patients HAI+ compared to those HAI-, respectively 52.9% vs. 12.3% (p = 0.06) and 30.8% vs. 2% (p < 0.0001).

Conclusions: The postoperative administration of oxaliplatin-based HAI associated to systemic chemotherapy after cure of MHCCR, improves recurrence-free survival of patients at high risk of hepatic recurrence, compared to systemic chemotherapy alone.

No significant financial relationships to disclose.

[Pulmonary hypertension in pediatric and neonatal intensive care unit. Part I: Physiopathology]

Pulmonary hypertension may be encountered in the pediatric and neonatal intensive care unit. Managing these patients in the intensive care unit can prove extremely challenging, particularly when they become hemodynamically unstable. Pulmonary hypertension in pediatric patients is frequently associated with critical illnesses such as congenital heart disease, acute respiratory disease, and left heart failure. In neonates, pulmonary hypertension is idiopathic or related to respiratory distress or congenital heart failure. This review discusses the pathogenesis and physiology of pulmonary hypertension, the cardiopulmonary interactions in this pathology, and the adaptation to extra-uterine life.

[Clinical case of the month. Bilateral optic neuropathy secondary to biphosphonate therapy]

Ocular side effects associated with biphosphonates have been described. Conjunctivitis, uveitis and scleritis are the most common adverse events. We report a case of bilateral toxic optic neuropathy with optic dies edema occurring soon after a pamidronate intravenous infusion in a patient who previously presented both a conjunctivitis and an uveitis of moderate intensity associated with alendronate therapy.

A Hibiscus Abelmoschus seed extract as a protective active ingredient to favour FGF-2 activity in skin

In the skin, heparin, heparan sulphate and heparan sulphate proteoglycans control the storage and release of growth factors and protect them from early degradation. We developed a cosmetic active ingredient containing Hibiscus Abelmoschus seed extract (trade name Linefactor) that can maintain the FGF-2 content in the skin by mimicking the protective effect of heparan sulphate proteoglycans. By preventing the natural degradation of FGF-2, Hibiscus Abelmoschus seed extract maintains the bioavailability of this growth factor for its target cells, i.e. skin fibroblasts. Our in vitro evaluations showed that this ingredient exhibited heparan sulphate-like properties and dose-dependently protected FGF-2 from thermal degradation. We could also show that, in turn, the protected FGF-2 could stimulate the synthesis of sulphated GAGs, the natural protective molecules for FGF-2, thus providing a double protection. Finally, the in vitro results were confirmed in vivo thanks to a clinical study in which skin biomechanical properties and reduction in wrinkles were assessed.

Long-term survival after portal vein arterialization for portal vein thrombosis in orthotopic liver transplantation

Portal vein thrombosis is a relatively common finding during liver transplantation. The management of portal vein thrombosis during liver transplantation is technically demanding and ensures adequate portal flow to the liver graft. Eversion thromboendovenectomy and bypass using a patent splanchnic vein and cavoportal hemitransposition are the most often used procedures to treat portal vein thrombosis. There have been anecdotal reports of portal vein arterialization. We report a case of portal vein arterialization during orthotopic liver transplantation for decompensated cirrhosis. When thromboendovenectomy failed to restore sufficient portal flow and completion of arterial anastomosis between the recipient hepatic artery and the donor celiac trunk, a calibrated end-to-side anastomosis between the donor splenic artery and the donor portal vein was performed. With a 6-year follow-up, there are no symptoms related to portal hypertension, liver function is normal. However, an aneurismal dilatation of the portal branches has progressively developed. Calibrated portal vein arterialization is a possible option for portal vein thrombosis in liver transplantation, allowing long-term patient and graft survival.

Hepatic resection of initially unresectable liver metastases from colorectal cancer after hepatic arterial infusion of oxaliplatin and systemic 5-fluorouracil and leucovorin

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Background: About 80% of patients (pts) presenting colorectal liver metastases (CRLM) are initially unresectable. A subgroup will become eligible for surgery after chemotherapy administration. Efficacy of hepatic arterial infusion (HAI) of oxaliplatin with systemic 5-Fluorouracil and leucovorin (LV5FU2) in with unresectable CRLM was previously demonstrated. This study was performed to evaluate the resection rate of pts with initially unresectable CRLM after oxaliplatin HAI and systemic LV5FU2. Methods: Patients treated in our hospital with oxaliplatin HAI and systemic LV5FU2 for unresectable CRLM from May 1999 to May 2007 were analyzed. Inclusion criteria were : unresectable CRLM, no extensive extrahepatic disease, HAI performed in our hospital, minimal follow up of 24 months. Eighty-seven pts were selected from a prospective database Results: Hepatic arterial infusion was delivered after previous systemic chemotherapy failure in 69 pts (80%). Main criterion for unresectability was massive liver involvement (80%). CRLM were synchronous and bilateral in respectively 85% and 90% of pts. The median number of oxaliplatin HAI cycles was 8 (0- 25). Thirty-one pts experienced technical problems with the arterial catheter, which was responsible for HAI withdrawal in seven. A total of 23 pts (26.4%) were operated, leading to resection and/or radiofrequency ablation of CRLM in 21 pts. No post-operative mortality was observed and the morbidity rate was 30%. The 3-year overall survival for patients operated was 72.5% versus 12% for non operated pts (p<0.0001). After a median follow-up of 75 months [24–118], intra-hepatic recurrence occurred in 10 pts. Conclusions: Hepatic artery infusion of oxaliplatin and systemic LV5FU2 increase the resectability rate in pts with advance CRLM even after previous systemic chemotherapy failure. Future studies combining oxaliplatin HAI and recent IV chemotherapy are needing to achieve an increase disease-free survival.

No significant financial relationships to disclose.

Estimation of respiratory waveform and heart rate using an accelerometer

In this paper the use of an accelerometer to measure cardio-respiratory activity is presented. Movement of the chest was recorded by an accelerometer attached to a belt around the chest. The acquisition is realized in different status: normal, apnea, deep breathing or after exhaustion and also in different postures: vertical (sitting, standing) or horizontal (lying down). The resulting signal was compared with reference measurements. The results of experimental evaluation indicate that using a chest-accelerometer can correctly detect the respiratory waveform and heart rate (HR) signal. This method is therefore suitable for automatic identification some disease, for example arrhythmia or sleep apnea.

Specific activity of class II histone deacetylases in human breast cancer cells

Although numerous studies have underlined the role of histone deacetylases (HDAC) in breast physiology and tumorigenesis, little is known on the particular contribution of the various classes of HDACs in these processes. Using estrogen receptor-alpha (ERalpha)-positive MCF-7 breast cancer cells, the effects of MC1575 and MC1568, two novel class II-specific HDAC inhibitors, were analyzed on cell proliferation, apoptosis, and estrogen signaling. The specificity of these HDAC inhibitors was validated by measuring histone and alpha-tubulin acetylation and by the specific in vitro inhibition of recombinant HDAC4 using histone and nonhistone substrates, contrasting with the lack of inhibition of class I HDACs. In addition, MC1575 did not inhibit class I HDAC gene expression, thus confirming the specific targeting of class II enzymes. Similar to trichostatin A (TSA), MC1575 displayed a dose-dependent antiproliferative effect and induced cell cycle arrest although this blockade occurred at a different level than TSA. Moreover, and in contrast to TSA, MC1575 had no effect on MCF-7 cells apoptosis. Interestingly, MC1575 was able to increase p21(waf1/CIP1) mRNA levels but did not regulate the expression of other genes such as cyclin D1, p27, p14(ARF), Bcl2, Baxalpha, Trail-R1, and Trail-R2. Finally, MC1575 strongly induced ERbeta gene expression but did not decrease ERalpha expression, nor did it switch hydroxytamoxifen to an agonist activity. Altogether, these data suggest that the class II HDAC subfamily may exert specific roles in breast cancer progression and estrogen dependence.

The differential response to chemotherapy of ovarian metastases from colorectal carcinoma

PATIENTS AND METHODS

All patients with metastatic (ovarian and extraovarian) CRC who underwent resection of ovarian metastases in our institution from April 1988 to August 2006 were analyzed and the response to preoperative chemotherapy was evaluated according to the RECIST criteria, and analyzed with respect to the sites of metastases (ovarian and extraovarian).

RESULTS

The studied population consisted of 23 women. At presentation, 20 patients had symptoms. Preoperative chemotherapy resulted in tumor control of measurable extraovarian metastases in 65% of cases. In contrast, no objective tumor response of ovarian metastases was observed, disease stabilization was obtained in only 3 patients (13%), and progression or occurrence of new ovarian metastases were observed in 20 patients (87%) (p=0.0005). With a median follow-up of 54 months [15-229], median overall survival was 30 months, and 3-year overall survival was 18%.

CONCLUSION

Ovarian metastases are less responsive to chemotherapy compared to other sites. As these "metastatic sanctuaries" often cause symptoms, surgical resection should always be considered for ovarian metastases, even in the case of associated extraovarian metastases.

Response assessment in lymphoma with PET/CT

No abstact available.

Staging of breast cancer with PET/CT

No abstact available.

Comparison between the minimum margin defined on preoperative imaging and the final surgical margin after hepatectomy for cancer: how to manage it?

BACKGROUND

The liver surgeon's decision to operate is based on imaging studies. However, no clear practical guidelines are available enabling surgeons to safely predict tumor-free margins after a partial hepatectomy. The aim of this retrospective study is to provide surgeons with simple and easily applicable practical guidelines.

METHODS

We retrospectively stringently selected 42 anatomical right or left hepatectomies whose main characteristic was to pass along the median hepatic vein, which was preserved. This vein is an easily visualized anatomical landmark on preoperative imaging and is never transgressed by the surgeon. We compared the minimum distance between the tumor and this vein measured on preoperative imaging, and the minimum tumor-free excision margin measured on the specimen by the pathologist.

RESULTS

The median tumor-free excision margin was 5 mm at pathological analysis, significantly different (P < .0001) from the tumor-free margin measured on preoperative imaging (15 mm). The mean difference between these two measurements was 10 +/- 4 mm (median, 9 mm). This difference was partly the result of the transection and partly the result of technical deviations in relation to the ideal resection line.

CONCLUSIONS

The liver surgeon must consider that roughly a 5 to 8 mm tumor-free margin will disappear during hepatectomy when comparing measurements on the basis of preoperative imaging versus tumor-free specimen margins. If the histologically assessed minimum 2-mm tumor-free margin is added, the surgeon must plan to have a 7 to 10 mm tumor-free margin on preoperative imaging. However, few technical solutions exist that would enable the surgeon to increase the safety margin in borderline cases.

Differential Regulation of Estrogen Receptor α Turnover and Transactivation by Mdm2 and Stress-Inducing Agents

In mammalian cells, the level of estrogen receptor alpha (ERalpha) is rapidly decreased upon estrogen treatment, and this regulation involves proteasome degradation. Using different approaches, we showed that the Mdm2 oncogenic ubiquitin-ligase directly interacts with ERalpha in a ternary complex with p53 and is involved in the regulation of ERalpha turnover (both in the absence or presence of estrogens). Several lines of evidence indicated that this effect of Mdm2 required its ubiquitin-ligase activity and involved the ubiquitin/proteasome pathway. Moreover, in MCF-7 human breast cancer cells, various p53-inducing agents (such as UV irradiation) or treatment with RITA (which inhibits the interaction of p53 with Mdm2) stabilized ERalpha and abolished its 17beta-estradiol-dependent turnover. Interestingly, our data indicated that ligand-dependent receptor turnover was not required for efficient transactivation. Altogether, our results indicate that the Mdm2 oncoprotein and stress-inducing agents complexly and differentially regulate ERalpha stability and transcriptional activity in human cancer cells.

Aggregation in malaria parasites places limits on mosquito infection rates

Gametocytes are responsible for the transmission of malaria parasites, Plasmodium spp., from man to mosquito. Although transmission success, as measured by the proportion of mosquitoes infected, generally increases with gametocyte density, the proportion of parasites that are gametocytes is always paradoxically only a few percent of the asexual blood parasites. To address this paradox, we analyse transmission data sets from an urban and an adjacent rural setting in Cameroon to elucidate whether there are discernable lower and upper limits to Plasmodium falciparum gametocyte density that are linked to transmission success. We find that there exists a lower gametocyte density at which mosquito infection rates considerably increase. In addition, we identify upper gametocyte densities at which mosquito infection rates level off. Greatest increases in infection rates occur at low gametocyte densities and coincide with maximum oocyst aggregation within the infected mosquito population. This aggregated oocyst distribution remains despite increases in gametocyte density and ever-decreasing gains in mosquito infection rates. There is increasing suggestion that malaria parasites have evolved sex allocation strategies to ensure transmission in response to a changing, transmission-blocking environment. Here transmission-blocking immunity is proposed not only to ensure low density gametocyte transmission success but also to impose upper limits on transmission success.