Tumour size over 3 cm predicts poor short-term outcomes after major liver resection for hilar cholangiocarcinoma. By the HC-AFC-2009 group

INTRODUCTION

As mortality and morbidity after a curative resection remains high, it is essential to identify pre-operative factors associated with an early death after a major resection.

METHODS

Between 1998 and 2008, we selected a population of 331 patients having undergone a major hepatectomy including segment I with a lymphadenectomy and a common bile duct resection for a proven hilar cholangiocarcinoma in 21 tertiary centres. The study's objective was to identify pre-operative predictors of early death (<12 months) after a resection.

RESULTS

The study cohort consisted of 221 men and 110 women, with a median age of 61 years (range: 24-85). The post-operative mortality and morbidity rates were 8.2% and 61%, respectively. The 1-, 3- and 5-year overall survival rates were 85%, 64% and 53%, respectively. The median tumour size was 23 mm on pathology, ranging from 8 to 40. A tumour size >30 mm [odds ratio (OR) 2.471 (95% confidence interval (CI) 1.136-7.339), P = 0.001] and major post-operative complication [OR 3.369 (95% CI 1.038-10.938), P = 0.004] were independently associated with death <12 months in a multivariate analysis.

CONCLUSION

The present analysis of a series of 331 patients with hilar cholangiocarcinoma showed that tumour size >30 mm was independently associated with death <12 months.

[Abdominoplasty complications: particularities of the post-bariatric patients within a 238 patients series]

BACKGROUND

Obesity is one of the health issues that is recently worldwide increasing, as well as in France. Variety of procedures of bariatric surgery have been developed over the past decade and are performed for morbid obesity hence. The demand of plastic surgery increased for body contouring and reshaping after dramatic weight loss, in which the abdominoplasty is considered as one of the most common procedures. The purpose of this study is to clarify the differences between the post-bariatric patients and others, and their influence on the occurrence of complications following abdominoplasty.

PATIENTS AND METHODS

Retrospective study involving a group of post-abdominoplasty patients collected from the same center between January 2000 and December 2010.

RESULTS

Among 238 reviewed patients' files; 114 of them are post-bariatric patients, and 124 are non-bariatric patients. Several differences were found between these two groups of patients including the maximum BMI, BMI at the time of surgery, the rates of cardiovascular risk factors, and a longer operative time in the post-bariatric group. The complication rate in these patients was significantly higher (55.3% against 26.6%) with mainly healing problems. Major maximum weight, obesity at the time of surgery, long operative time and postoperative drainage system are all considered as risk factors, which carry high rate of complications.

CONCLUSION

It appears that abdominoplasty in post-bariatric patients requires specific care because of particularities inherent in this population.

Comparison of the effectiveness of four bariatric surgery procedures in obese patients with type 2 diabetes: a retrospective study

AIM

The aim of the present retrospective study was to evaluate the efficacy of four bariatric surgical procedures to induce diabetes remission and lower cardiovascular risk factors in diabetic obese patients. Moreover, the influence of surgery on weight evolution in the diabetic population was compared with that observed in a nondiabetic matched population.

METHODS

Among 970 patients who were operated on in our center since 2001, 81 patients were identified as type 2 diabetes. Laparoscopic adjustable gastric banding (GB), intervention type Mason (MA), gastric bypass (RYGB), and sleeve gastrectomy (SG) were performed, respectively, in 25%, 17%, 28%, and 30% of this diabetic population.

RESULTS

The resolution rate of diabetes one year after surgery was significantly higher after SG than GB (62.5% versus 20%, P < 0.01), but not significantly different between SG and RYGB. In terms of LDL-cholesterol reduction, RYGB was equivalent to SG and superior to CGMA or GB. Considering the other cardiovascular risk factors, there was no significant difference according to surgical procedures. The weight loss was not statistically different between diabetic and nondiabetic matched patients regardless of the surgical procedures used.

CONCLUSION

Our data confirm that the efficacy of surgery to treat diabetes is variable among the diverse procedures and SG might be an interesting option in this context.

Is port-site resection necessary in the surgical management of gallbladder cancer?

INTRODUCTION

Gallbladder carcinoma is frequently discovered incidentally on pathologic examination of the specimen after laparoscopic cholecystectomy (LC) performed for presumed "benign" disease. The objective of the present study was to assess the role of excision of port-sites from the initial LC for patients with incidental gallbladder carcinoma (IGBC) in a French registry.

METHODS

Data on patients with IGBC identified after LC between 1998 and 2008 were retrospectively collated in a French multicenter database. Among those patients undergoing re-operation with curative intent, patients with port-site excision (PSE) were compared with patients without PSE and analyzed for differences in recurrence patterns and survival.

RESULTS

Among 218 patients with IGBC after LC (68 men, 150 women, median age 64 years), 148 underwent re-resection with curative intent; 54 patients had PSE and 94 did not. Both groups were comparable with regard to demographic data (gender, age > 70, co-morbidities), surgical procedures (major resection, lymphadenectomy, main bile duct resection) and postoperative morbidity. In the PSE group, depth of tumor invasion was T1b in six, T2 in 24, T3 in 22, and T4 in two; this was not significantly different from patients without PSE (P = 0.69). Port-site metastasis was observed in only one (2%) patient with a T3 tumor who died with peritoneal metastases 15 months after resection. PSE did not improve the overall survival (77%, 58%, 21% at 1, 3, 5 years, respectively) compared to patients with no PSE (78%, 55%, 33% at 1, 3, 5 years, respectively, P = 0.37). Eight percent of patients developed incisional hernia at the port-site after excision.

CONCLUSION

In patients with IGBC, PSE was not associated with improved survival and should not be considered mandatory during definitive surgical treatment.

An extremely uncommon variant of left hepatic artery arising from the superior mesenteric artery

We report a new variation of the left hepatic artery arising from the superior mesenteric artery. The variant was discovered during radiological examinations in a patient presenting with ruptured hepatocellular carcinoma of the left liver lobe. Anatomical description was based on CT-scan and angiographic analysis. When present the left hepatic artery originates from the left gastric artery, with an incidence of 12-34 %. Knowledge of left hepatic artery anatomy is mandatory to optimize surgical and radiological management in complex clinical situations.

Serum procalcitonin for predicting the failure of conservative management and the need for bowel resection in patients with small bowel obstruction

BACKGROUND

Ischemia and necrosis are complications of small bowel obstruction (SBO) and require rapid surgical treatment. At present, there are no sufficiently accurate preoperative biomarkers of ischemia or necrosis. The objective of the current study was to evaluate the value of serum procalcitonin levels for predicting conservative management failure and the presence of intraoperatively observed bowel ischemia (reversible or not) in patients with SBO.

STUDY DESIGN

One hundred and sixty-six participants of 242 in a randomized controlled trial focusing on the management of SBO (Acute Bowel Obstruction Diagnostic study [ABOD], NCT00389116) had available data on procalcitonin and were included in the study. The primary study objective was to determine whether serum procalcitonin could identify patients in whom conservative management (CM) failed (the surgical management [SM] group) and the subset of SM patients with intraoperatively observed ischemia (reversible or not). For the analysis, the patients were divided into subgroups according to the success or failure of CM and (for surgically managed patients) the presence or absence of intraoperative ischemia (reversible or not).

RESULTS

Procalcitonin levels were higher in the SM group (n = 35) than in the CM group (n = 131) (0.53 vs 0.14 ng/mL; p = 0.031) and higher in the group managed surgically with ischemia (n = 12) than patients managed surgically without intraoperative ischemia (n = 23) (1.16 vs 0.21 ng/mL, respectively; p < 0.001). A multiple logistic regression showed that procalcitonin is a risk factor for CM failure (odds ratio = 3.5; 95% CI, 1.4-8.5; p = 0.006) and for ischemia (reversible or not) (odds ratio = 46.9; 95% CI, 4.0-547.3; p < 0.001).

CONCLUSIONS

Procalcitonin can help predict CM failure and occurrence of bowel ischemia (reversible or not) in SBO patients, but additional studies are needed.

Complications associated with two laparoscopic procedures used in the management of rectal endometriosis

BACKGROUND

To evaluate intra- and postoperative complications associated with laparoscopic management of rectal endometriosis by either colorectal segmental resection or nodule excision.

METHODS

During 39 consecutive months, 46 women underwent laparoscopic management of rectal endometriosis and were included in a retrospective comparative study. The distinguishing feature of the study is that the choice of the surgical procedure is not related to the characteristics of the nodule.

RESULTS

Colorectal segmental resection with colorectal anastomosis was carried out in 15 patients (37%), while macroscopically complete rectal nodule excision was performed in 31 women (63%). No intraoperative complications were recorded. In the colorectal resection group, 3 women (18%) had a bladder atony (spontaneously regressive in 2 women), 4 women (24%) experienced chronic constipation, one had an anastomosis leakage (6%), while 2 women (13%) had acute compartment syndrome with peripheral sensory disturbance. In the nodule excision group, 1 woman (4%) developed transitory right obturator nerve motor palsy. Based on both postoperative pain and improvement in quality of life, all 29 women in the excision group (100%) and 14 women in the colorectal resection group (82%) would recommend the surgical procedure to a friend suffering from the same disease.

CONCLUSION

Our study suggests that carrying out colorectal segmental resection in rectal endometriosis is associated with unfavourable postoperative outcomes, such as bladder and rectal dysfunction. These outcomes are less likely to occur when rectal nodules are managed by excision. Information about complications related to both surgical procedures should be provided to patients managed for rectal endometriosis and should be taken into account when a decision is being made about the most appropriate treatment of rectal endometriosis in each case.

Reporting on quality of life in randomised controlled trials in gastrointestinal surgery

BACKGROUND

Although health-related quality of life (HRQOL) has become an important outcome measure in surgical trials, questions still remain about the quality of its reporting. The aim of this study was to evaluate HRQOL assessment methodology of randomised clinical trials concerning gastrointestinal surgery.

METHODS

All articles published in the calendar years 2006 and 2007 that purported to assess quality of life as end points or make some conclusion about quality of life were chosen for review from eight general surgical journals and four medical journals. Identified eligible studies were selected and then evaluated on a broad set of predetermined criteria.

RESULTS

Twenty-four published randomised controlled clinical trials (RCTs)s with an HRQOL component were identified. Although most trials exhibited good-quality research, some methodological limitations were identified: Only 21% of the studies gave a rationale for selecting a specific HRQOL measure, 46% of the studies failed to report information about the administration of the HRQOL measure, and 37% did not give details on missing data.

CONCLUSIONS

Although it is clear that HRQOL is an important end point in surgical RCTs because the information helps to influence treatment recommendations, a number of methodological shortcomings have to be further addressed in future studies.

Novel serum markers of fibrosis progression for the follow-up of hepatitis C virus-infected patients

Liver biopsy is considered the gold-standard method for the assessment of liver fibrosis during follow-up of hepatitis C virus-infected patients, but this invasive procedure is not devoid of complications. The aim of the present study was to identify novel non-invasive markers of fibrosis progression. By microarray analysis, we compared transcript levels in two extreme stages of fibrosis from 16 patients. Informative transcripts were validated by real-time PCR and used for the assessment of fibrosis in 23 additional patients. Sixteen transcripts were found to be dysregulated during the fibrogenesis process. Among them, some were of great interest because their corresponding proteins could be serologically measured. Thus, the protein levels of inter-alpha inhibitor H1, serpin peptidase inhibitor clade F member 2, and transthyretin were all significantly different according to the four Metavir stages of fibrosis. In conclusion, we report here that dysregulation, at both the transcriptional and protein levels, exists during the fibrogenesis process. Our description of three novel serum markers and their potential use as serological tests for the non-invasive diagnosis of liver fibrosis open new opportunities for better follow-up of hepatitis C virus-infected patients.

Transient and etiology-related transcription regulation in cirrhosis prior to hepatocellular carcinoma occurrence

AIM: To search for transcription dysregulation that could (1) differentiate hepatocellular carcinoma (HCC)-free from HCC-related cirrhosis (2) differentiate HCC-free cirrhosis related to HCV from that related to alcohol intake.

METHODS: Using microarray analysis, we compared transcript levels in HCC-free cirrhosis (alcoholism: 7; hepatitis C: 7), HCC-associated cirrhosis (alcoholism: 10; hepatitis C: 10) and eight control livers. The identified transcripts were validated by qRT-PCR in an independent cohort of 45 samples (20 HCC-free cirrhosis; 15 HCC-associated cirrhosis and 10 control livers). We also confirmed our results by immunohistochemistry.

RESULTS: In HCC-free livers, we identified 70 transcripts which differentiated between alcoholic-related cirrhosis, HCV-related cirrhosis and control livers. They mainly corresponded to down-regulation. Dysregulation of Signal Transduction and Activator of Transcription-3 (STAT-3) was found along with related changes in STAT-3 targets which occurred in an etiology-dependent fashion in HCC-free cirrhosis. In contrast, in HCC, such transcription dysregulations were not observed.

CONCLUSION: We report that transcriptional dysregulations exist in HCC-free cirrhosis, are transiently observed prior to detectable HCC onset and may be appear like markers from cirrhosis to HCC transition.

Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors

BACKGROUND

Pancreatic fistula (PF) is one of the most common postoperative complications of pancreatoduodenectomy (PD). A recent International Study Group on Pancreatic Fistula (ISGPF) definition grades the severity of PF according to the clinical impact on the patient's hospital course. Although PF is generally treated conservatively (grade A), some cases may require interventional procedures (grade B) or may be life-threatening and necessitate emergency reoperation (grade C). The aim of the present study was to evaluate the incidence of postoperative grade C PF after PD and to assess the prognosis and risk factors for this life-threatening condition.

STUDY DESIGN

Between January 2000 and December 2006, 680 consecutive patients underwent PD in 5 digestive surgery departments in the northwest region of France (Lille, Amiens, Rouen, and Caen). PF was defined as drain output of any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity (ISGPF guidelines). To identify possible risk factors for grade C PF, we reviewed the records of 111 (16.3%) patients with postoperative PF and compared grade C cases with grade A+B cases.

RESULTS

The median age was 59 years (range 22-87). The male-to-female ratio was 1.6:1. Fifty-six (50.4%) PDs were performed via pancreaticogastrostomy and 55 via pancreaticojejunostomy. Overall mortality was 2% (n = 14). Grade C PF was observed in 36 (32%) patients, of whom 17 (47%) had sepsis due to an abdominal collection, 16 (44%) had postoperative bleeding, 10 (27.7%) had bleeding associated with abdominal collection, and 3 (9%) had multi-organ failure due to other causes. Of these 36 patients, 35 (97%) underwent reoperation. The mortality rate in grade C PF patients was 38.8%. The major causes of death were sepsis (n = 6) and recurrent bleeding after reoperation (n = 5). Grade C PF increased the duration of postoperative hospitalization (46 vs 29 days, P < .001). Univariate analysis showed that peroperative soft pancreatic parenchyma, peroperative blood transfusion, and postoperative bleeding were significant risk factors for grade C PF, with P values of .011, .003, and .001, respectively. No risk factors for grade C PF were identified in a multivariate analysis. The sensibility, specificity, positive predictive value, and negative predictive value of the presence of the 3 risk factors for grade C PF were 13.89%, 100%, 100%, and 70.75%, respectively.

CONCLUSION

Sixteen percent of patients had PF after PD. Among them, 30% had grade C PF, with a mortality rate of about 40%. Achievement of a 100% predictive positive value for grade C PF after PD in individuals with 3 discriminant risk factors (peroperative soft pancreatic parenchyma, peroperative transfusion, and postoperative bleeding) is a first step towards the identification of high-risk patients who should be managed differently from other patients with PF during or after PD.

Genome-wide differences in hepatitis C- vs alcoholism-associated hepatocellular carcinoma

AIM: To look at a comprehensive picture of etiology-dependent gene abnormalities in hepatocellular carcinoma in Western Europe.

METHODS: With a liver-oriented microarray, transcript levels were compared in nodules and cirrhosis from a training set of patients with hepatocellular carcinoma (alcoholism, 12; hepatitis C, 10) and 5 controls. Loose or tight selection of informative transcripts with an abnormal abundance was statistically valid and the tightly selected transcripts were next quantified by qRTPCR in the nodules from our training set (12 + 10) and a test set (6 + 7).

RESULTS: A selection of 475 transcripts pointed to significant gene over-representation on chromosome 8 (alcoholism) or -2 (hepatitis C) and ontology indicated a predominant inflammatory response (alcoholism) or changes in cell cycle regulation, transcription factors and interferon responsiveness (hepatitis C). A stringent selection of 23 transcripts whose differences between etiologies were significant in nodules but not in cirrhotic tissue indicated that the above dysregulations take place in tumor but not in the surrounding cirrhosis. These 23 transcripts separated our test set according to etiologies. The inflammation-associated transcripts pointed to limited alterations of free iron metabolism in alcoholic vs hepatitis C tumors.

CONCLUSION: Etiology-specific abnormalities (chromosome preference; differences in transcriptomes and related functions) have been identified in hepatocellular carcinoma driven by alcoholism or hepatitis C. This may open novel avenues for differential therapies in this disease.

Evaluation of selective defunctioning stoma after low anterior resection for rectal cancer

BACKGROUND

Anastomotic leakage is a major concern after resection for low rectal cancer. Therefore, the use of a defunctioning stoma (DS) has been suggested, but limited data exist to clearly determine the necessity of a routine diversion. In our department, the indication of DS was evaluated subjectively by the operating surgeon. The aim of this study was to evaluate the selective use of fecal diversion.

MATERIALS AND METHODS

Retrospective chart review of patients who underwent low anterior resection for carcinoma was performed. The incidence and consequences of clinical leaks were determined in these patients who were considered in two groups: defunctioning stoma and no defunctioning stoma.

RESULTS

From 1995 to 2005, 132 consecutive patients underwent low anterior resection; a DS was performed in 42 patients (31.8%). Median level of anastomosis was 4 cm in both groups. Overall clinical leakage rate was 9.8%: 7.1% (n = 3) with a DS and 11% (n = 10) without a stoma. Mortality rate was 1.5% (n = 2), both in the unprotected group. No patient in the diversion group required a permanent stoma, contrasting with four unprotected patients in which continuity could not be restored after break down of the anastomosis.

CONCLUSION

Finding lower clinical leakage rate in a probable higher risk group and better outcome when a leak occurs in our study constituted strong evidence of the effectiveness of a DS. Selective use of a DS based on subjective assessment at the time of surgery could not allow experienced surgeons to perform single-stage procedure safely. Construction of a DS seems useful for patients with distal rectal cancer.

[Laparoscopic surgery of profund endometriosis with rectal affect]

OBJECTIVE

To present the principles of laparoscopic treatment for rectal endometriosis and to discuss possible postoperative outcomes.

MATERIAL AND METHODS

Our series included women managed for rectal endometriosis during consecutive 20 months in the Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen--France. Patient's characteristics, symptoms, imaging examination results, surgical treatment and postoperative outcomes were all evaluated retrospectively.

RESULTS

Sixteen patients presenting with rectal endometriosis were managed surgically, (mean age was 35.9 +/- 6.5 years). All women presented at least one severe painful symptom which was typical of a digestive involvement in 12 cases. MRI results suggested a rectal involvement in 14 cases, and endorectal ultrasound examination clearly showed rectal wall infiltration in all patients. The gynaecological stage of surgical treatment was carried out laparoscopically in 13 cases, and the digestive surgical stage in 7 cases. Two limited and 14 segmental rectal resections were performed. Transitory stoma was carried out in 9 women. The length of the surgical procedure depended on the number of endometriosis localizations with a median value of 6 h 30 min. Postoperative complications occurred in 6 women: 2 anastomosis stenosis, 1 anastomosis fistula, 1 abscess of the parietal wall and 1 bladder atonia. Complains of pain were completely or significantly improved in all cases.

CONCLUSION

Surgical treatment for rectal endometriosis may be carried out laparoscopically. It should be reserved for women presenting with severe painful condition and may contribute to significant improvement. However, the balance of benefit and risks must also be assessed on a case to case basis prior to any decision for or against surgical treatment.

Global gene repression in hepatocellular carcinoma and fetal liver, and suppression of dudulin-2 mRNA as a possible marker for the cirrhosis-to-tumor transition

BACKGROUND/AIMS

Whether the transcriptional reprogramming process induced by hepatocellular carcinoma recapitulates that of the developing liver is at present unclear.

METHODS

With a complete coverage of the liver transcriptome by microarray using adult livers as controls, we searched for similarities and differences in mRNA abundances between hepatocellular carcinoma nodules and fetal livers taken before (early) or after (late) the 22-24th week of gestation. Changes in some mRNA levels were studied in further liver samples by quantitative RT-PCR.

RESULTS

Altered gene expression in hepatocellular carcinoma mostly results in down-regulated mRNAs which largely overlap with those repressed in the late fetal liver. Different frequencies of transcription factor binding sites in the down-regulated genes vs control genes as well as changes in abundance of mRNAs for relevant transcription factors point to a transcriptional repression. The down-regulated mRNAs code for proteins involved in (i) transcription and translation, (ii) specific functions of the differentiated hepatocyte or (iii) activation of proliferation and apoptosis.

CONCLUSIONS

Apoptosis limitation is likely to predominate over active proliferation during liver development and hepatocellular carcinoma. Repression of the apoptosis-associated dudulin-2 mRNA points to a potential marker for the transition from a carcinoma-free to carcinoma-associated cirrhosis.

Cleft lip/palate and CDH1/E-cadherin mutations in families with hereditary diffuse gastric cancer

We report the association of CDH1/E-cadherin mutations with cleft lip, with or without cleft palate (CLP), in two families with hereditary diffuse gastric cancer (HDGC). In each family, the CDH1 mutation was a splicing mutation generating aberrant transcripts with an in-frame deletion, removing the extracellular cadherin repeat domains involved in cell-cell adhesion. Such transcripts might encode mutant proteins with trans-dominant negative effects. We found that CDH1 is highly expressed at 4 and 5 weeks in the frontonasal prominence, and at 6 weeks in the lateral and medial nasal prominences of human embryos, and is therefore expressed during the critical stages of lip and palate development. These findings suggest that alteration of the E-cadherin pathway can contribute to human clefting.

Colorectal cancer with non-resectable synchronous metastases: should the primary tumor be resected?

OBJECTIVES

In asymptomatic patients presenting with non-resectable synchronous metastatic disease from colorectal adenocarcinoma, the beneficial effect of resecting the primary tumor remains to be documented. The aim of this study was to compare survival of patients with metastatic colorectal cancer who underwent elective resection of the primary tumor to those who did not.

METHODS

A retrospective analysis of patients with metastatic colo-rectal cancer treated between June, 1996 and December, 1999 was performed. Overall survival was compared between patients who underwent first-line resection of the primary colorectal tumor (group 1) or those who did not undergo elective resection of the primary (group 2). The probability of surgical resection of the primary tumor for gastrointestinal complications in group 2 was evaluated.

RESULTS

Thirty-one and 23 patients were included in groups 1 and 2 respectively. Five patients (21.7%, 95% confidence interval CI95% 4.9-38.5%) in group 2 required surgical treatment for intestinal obstruction due to the primary tumor. Two clinical characteristics were significantly different between groups 1 and 2: rectal localization (9.7% versus 34.7%; P=0.03) and presence of fewer than three metastases (29.0% versus 4.3%; P=0.03). Survival curves were not significantly different (logrank). Median duration of survival was 21 and 14 Months, respectively (P=0.718).

CONCLUSION

In patients with non-resectable synchronous metastatic disease, non-surgical management of the primary tumor is a rational alternative if asymptomatic. A prospective randomized trial integrating the quality-of-life factor should be organized.

Expression of a functional C5a receptor in regenerating hepatocytes and its involvement in a proliferative signaling pathway in rat

Activation of the complement system generates the anaphylatoxin C5a whose activities are mediated through its binding to the widely expressed C5aR. C5aR mRNA and protein expressions are known to be induced in rat hepatocytes under inflammatory conditions. However, little is known about the role of the C5a/C5aR complex in liver and its involvement during a proliferative process. We have evaluated the expression of C5aR in regenerating rat hepatocytes following a partial hepatectomy and in hepatocyte cultures. C5aR induction was observed in hepatocytes from regenerating liver, as well as in normal hepatocytes under a culture-induced stress. The effect of a stimulation by a C5a agonist upon the synthesis of a growth factor/receptor pair (hepatocyte growth factor/c-Met) was also evaluated. Our data demonstrated an up-regulated expression of hepatocyte growth factor and c-Met mRNAs, but we failed to observe a direct mitogenic effect of C5a in culture. However, a significantly increased expression of cyclin E and D1mRNA levels, as well as an increased BrdU incorporation, were observed in rats given an i.v. C5a agonist injection following an 80% partial hepatectomy. These studies demonstrate for the first time that: 1) C5aR is up-regulated during liver regeneration, 2) the binding of C5a to C5aR promotes a growth response, and 3) C5aR is involved in a cell cycle signaling pathway. Taken together, these findings point to a novel role for the hepatic C5aR implicating this complement system in the context of normal or abnormal proliferative pathways.

Altered gene expression in acute systemic inflammation detected by complete coverage of the human liver transcriptome

The goal of the current study was to provide complete coverage of the liver transcriptome with human probes corresponding to every gene expressed in embryonic, adult, and/or cancerous liver. We developed dedicated tools, namely, the Liverpool nylon array of complementary DNA (cDNA) probes for approximately 10,000 nonredundant genes and the LiverTools database. Inflammation-induced transcriptome changes were studied in liver tissue samples from patients with an acute systemic inflammation and from control subjects. One hundred and fifty-four messenger RNAs (mRNA) correlated statistically with the extent of inflammation. Of these, 134 mRNA samples were not associated previously with an acute-phase (AP) response. The hepatocyte origin and proinflammatory cytokine responsiveness of these mRNAs were confirmed by quantitative reverse-transcription polymerase chain reaction (Q-RT-PCR) in cytokine-challenged hepatoma cells. The corresponding gene promoters were enriched in potential binding sites for inflammation-driven transcription factors in the liver. Some of the corresponding proteins may provide novel blood markers of clinical relevance. The mRNAs whose level is most correlated with the AP extent (P <.05) were enriched in intracellular signaling molecules, transcription factors, glycosylation enzymes, and up-regulated plasma proteins. In conclusion, the hepatocyte responded to the AP extent by fine tuning some mRNA levels, controlling most, if not all, intracellular events from early signaling to the final secretion of proteins involved in innate immunity. Supplementary material for this article can be found on the HEPATOLOGY website (http://interscience.wiley.com/jpages/0270-9139/suppmat/index.html).

Hepatocyte growth factor, transforming growth factor alpha, and their receptors as combined markers of prognosis in hepatocellular carcinoma

A change in the balance between proliferation and apoptosis in the course of hepatocellular carcinoma (HCC) development and progression has been suspected. We wanted to identify related genes whose mRNA levels could provide markers of severity and prognosis after resection. The extent of cell apoptosis, proliferation, and differentiation was measured with a terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate-biotin nick-end labeling assay, and the Ki-67 index was determined in paired tumor and cirrhotic tissue samples from patients who had undergone HCC resection after diagnosis of hepatitis C-related or alcoholism-related cirrhosis. These patients included two groups with highly versus poorly differentiated tumor cells, and the latter was split into two subgroups of those with versus without early recurrence. The mRNA levels for various apoptosis-related or proliferation-related genes and those for the growth factor/receptor systems were measured by quantitative reverse transcriptase-polymerase chain reaction in paired tumor and cirrhotic liver samples from every patient, and some of the corresponding proteins were detected by immunohistochemistry. In all instances, protein expression was highly heterogeneous within groups and similar between groups. In contrast, some differences in mRNA level between tumor and cirrhotic tissues were quite informative. Low levels of hepatocyte growth factor and transforming growth factor alpha mRNAs were found concomitantly in highly differentiated tumors, whereas overexpression of mRNAs for the cognate receptors c-met and epidermal growth factor receptor were found in poorly differentiated tumors and primarily in patients with early tumor recurrence. These results argue for growth factor-dependent HCC development and provide novel and combined prognosis markers after HCC surgery.

[Juvenile polyposis coli. The usefulness of a genetic study and the role of surgical treatment]

We report two cases of familial juvenile polyposis coli. SMAD4 gene mutation was found in our two patients, leading to the definite diagnosis. Colonic cancer occurred in the first patient. Long-term outcome was favorable after colectomy. In the second patient, prophylactic total colectomy was performed. Rectal bleeding, diarrhea, stomach obstruction and vomiting developed during the follow-up. Proctectomy, distal partial gastrectomy and total gastrectomy were successively performed.

Cell proliferation in colorectal adenocarcinomas: comparison between Ki-67 immunostaining and bromodeoxyuridine uptake detected by immunohistochemistry and flow cytometry

We compared three different means of assaying tumor proliferative activity in 30 human colorectal adenocarcinomas labeled in vivo with bromodeoxyuridine (BrdUrd). The labeling indices (LI) of BrdUrd obtained both by flow cytometry (FCM) and immunohistochemistry (IH) were also compared with the labeling index of Ki-67. These methods were then related to tumor ploidy and pathological features. Flow cytometry was performed in accordance with Begg's method after intravenous infusion of BrdUrd four hours before surgery. Immunohistology was carried out on paraffin-embedded sections with monoclonal antibodies against BrdUrd and Ki-67. A positive correlation was found between BrdUrd LI obtained by both FMC and IH (p<0.0001), a finding that complies with the literature. However, we report on a correlation between Ki-67 LI and BrdUrd LIs in colorectal tumors (p=0.012). The results were valid for all tumors when they were subdivided into diploid and aneuploid groups. The labeling indices were significantly higher in the aneuploid tumor group than in the diploid group (p=0.047). No relationship between proliferation parameters and tumor stage or grade was found. To our knowledge, this is the first report on a positive correlation between tumor proliferation indices in BrdUrd LIs and Ki-67 in colorectal carcinomas. This finding validates the value of Ki-67 immunostaining, which, however, should be confirmed in a larger series under the same technical conditions.

Gene transcription in hepatocytes during the acute phase of a systemic inflammation: from transcription factors to target genes

During an acute, systemic inflammation, the liver is triggered by blood-borne pro-inflammatory cytokines such as Tumor Necrosis Factor alpha, Interleukin-1beta and Interleukin-6. The end result is an up- or down-regulated synthesis and/or activation of liver-enriched transcription factors that in turn regulate many target genes coding for resident or secreted acute phase proteins. In this review, various classifications of these acute phase proteins are presented. Major inflammation-driven changes in the synthesis and/or activity of the hepatic transcription factors are illustrated. Some of their up- or down-regulated target genes are used as paradigms of the various transcriptional mechanisms that take place on gene promoters during an acute, systemic inflammation. Finally, further specific features of inflammation-associated gene transcription in liver from acute phase onset to resolution are provided.

Viability and drug metabolism capacity of alginate-entrapped hepatocytes after cryopreservation

In the present study we evaluated viability and detoxifying enzyme capacity of cryopreserved hepatocytes from various species, including man, immobilized in calcium alginate gels. Ethoxyresorufin O-deethylase, phenacetin deethylase, pentoxyresorufin O-dealkylase, tolbutamide hydroxylase, S-mephenytoin hydroxylase, dextromethorphan demethylase, and nifedipine oxidation corresponding to the major cytochromes P450 (CYP) involved in xenobiotic metabolism as well as whole glutathione S-transferase (GST) activity were measured using specific substrates and after exposure or not to prototypical inducers. After deep-freeze storage, viability of immobilized hepatocytes was only slightly reduced and most CYP-related monooxygenase activities were well preserved, being expressed at levels close to those measured in unfrozen hepatocyte monolayers. By contrast, total GST activity was decreased by around 50%. However, as did CYP1A- and 3A-related enzymes, rat GST remained capable of responding to prototypical inducers. The fold increases were comparable in unfrozen and frozen immobilized hepatocytes and in unfrozen hepatocyte monolayers. The duration of storage, even when exceeding one year, did not affect viability and functions. In conclusion, after cryopreservation, alginate-entrapped hepatocytes remain highly viable and capable of expressing most detoxifying enzymes at levels close to those expressed in corresponding unfrozen hepatocyte monolayers and of responding to prototypical inducers.

Pre-operative kinetic parameter determination of colorectal adenocarcinomas. Prognostic significance

BACKGROUND

The aim of this study was to test the prognostic value of pre-operative assessment of tumour kinetics in colorectal adenocarcinoma.

METHODS

The study of tumour kinetics was performed using an in vivo injection of bromodeoxyuridine. Endoscopic biopsies were obtained from the tumour and analysed using flow cytometry. This procedure enables calculation of the in vivo S-phase fraction labelling index (LI), the duration of S-phase (Ts) and the potential tumour doubling time (Tpot). Disease-free survival curves were calculated by a Kaplan-Meier method. The statistical significance between curves was tested by the log rank test. A multivariate analysis was performed using the Cox's proportional hazards model to determine the effect of pathological staging (lymph node involvement), ploidy and kinetic parameters.

RESULTS

Thirty-eight colorectal carcinomas were studied without prior chemotherapy or radiation therapy. In univariate analysis, lymph node involvement, labelling index > 10% and Tpot < 5 days were associated with poor prognosis, with P= 0.0006, 0.049 and 0.029 respectively; no significant differences were found in Ts (P = 0.214), and ploidy (P= 0.095). In multivariate analysis, lymph node involvement, ploidy and Tpot were found to be independent factors of colorectal cancer prognosis (P= 0.028, 0.032 and 0.035 respectively) in all tumours. Tpot was considered a independent prognostic factor in diploid tumours (P= 0.047) but not in aneuploid tumours (P= 0.345).

CONCLUSIONS

These results suggest that kinetic parameters determined by pre-operative biopsies of colorectal adenocarcinoma represent a prognosis factor, independent of pathological staging, particularly in diploid tumours.

Effect of radiation therapy on the potential doubling time of tumours in colorectal cancers

OBJECTIVE

The aim of the present study was to investigate the effects of standard fractionated radiation therapy on the kinetic parameters of colorectal adenocarcinomas.

METHODS

The study of tumour kinetics involved in vivo injection of bromodeoxyuridine. Endoscopic biopsies were obtained from the tumour and analysed with flow cytometry. This procedure provides a rapid calculation of qualitative parameters such as ploidy and quantitative parameters such as the in vivo S-phase fraction labelling index which indicates the percentage of cells that have entered into the cycle, the duration of S-phase (Ts) and the potential tumour doubling time (Tpot).

RESULTS

Thirty-eight colorectal carcinomas were studied without prior chemotherapy or radiation therapy (group 1) and ten rectal carcinomas were studied following radiation therapy (group 2). In diploid tumours, the labelling index was significantly lower in the post-radiotherapy group than in the pre-radiotherapy group (2.7 +/- 1.1% versus 6.4 +/- 4.2%, respectively; P= 0.01), and the Tpot was significantly longer after radiotherapy (group 2) (22.0 +/- 7.0 days versus 8.6 +/- 6.0 days, P = 0.002). Standard fractionated radiation therapy also appears to result in a longer Tpot in diploid adenocarcinomas of the colon and rectum. This effect was not observed in aneuploid tumours.

CONCLUSIONS

The effectiveness of hyperfractionated schedules of radiation therapy for aneuploid rectal tumours with short Tpot warrants further investigation in a larger patient population.

Ileoanal anastomosis for ulcerative colitis: results of an evolutionary surgical procedure

BACKGROUND/AIMS

Proctocolectomy with ileoanal anastomosis (IAA) has proved to be the most suitable surgical treatment for ulcerative colitis. The aim of this study was to compare the results of IAA according to the evolution of surgical procedures and particularly to compare the results of stapled versus hand-sewn anastomosis.

METHODOLOGY

From 1984 to 1996, 37 men and 31 women were operated on in our centre for ulcerative colitis. The anastomosis between the J pouch and the dentate line was handsewn in 35 patients (group 1) and stapled in 33 patients (group 2).

RESULTS

The mean operative time was significantly shorter in group 2 as compared with group 1 (265+/-59 vs. 323+/-53, p<0.01, respectively), whereas morbidity and functional results were comparable in both groups. In 10 patients with stapled IAA, a diverting ileostomy was not performed and the morbidity in this group did not increase.

CONCLUSIONS

These results suggest that stapled IAA anastomosis is a safe procedure. The stapling technique of IAA simplifies total excision of the rectum and could mean that a diverting ileostomy is not necessary.

Squamous cell carcinoma of the thoracic esophagus following radiation therapy for breast cancer

Between 1981 and 1995, 4 patients (3 females, 1 male; aged 48-80) were diagnosed with squamous cell carcinoma of the esophagus, following mediastinal irradiation for breast cancer. The interval between irradiation and the presentation of esophageal cancer was 10.75 years on average (7-19). The treatment consisted of: radiotherapy only; a partial esophagectomy with proximal gastrectomy without post-operative radiotherapy; laser photocoagulation for a superficial tumor; and, palliative treatment including gastrostomy, tracheal photocoagulation and chemotherapy for 1 patient suffering from advanced stage cancer with tracheal invasion, respectively. Radiotherapy of the esophageal cancer (exclusive or adjuvant) should take into account previous esophageal radiation therapy. The indications of curative excision surgery are the same as for other types of esophageal cancer, but the anastomoses should be performed in a non-irradiated area. Excision by esophageal stripping without thoracotomy is contraindicated because of the presence of peri-esophageal sclerosis. Preventive measures in radiation therapy for breast cancer are suggested.

Comparison between endoscopic and surgical sampling for the measurement of potential doubling time in colorectal cancer

In colorectal cancer, tumoral kinetic parameters could influence the therapeutic strategy. The aim of this study was to test the validity of a preoperative assessment of tumoral kinetics on biopsies obtained from endoscopic sampling. After infusion of 250 mg of bromodeoxyuridine (BrdUrd), tumor samples were taken. The following kinetic parameters were evaluated by Begg's method: labeling index (LI) of BrdUrd, duration of the S phase (Ts), and potential doubling time (Tpot). We compared the findings in preoperative endoscopic samples (t1), endoscopic samples (t2), and macrobiopsies of the tumor after surgical resection (t3) to test the effect of time, surgical procedures, and sampling mode on results. Eight diploid and 11 aneuploid colorectal cancers were studied. In diploid tumors, no difference in Tpot, Ts, or LI values was found among the three time intervals. In aneuploid tumors, Tpot value at t1 was lower than t3: 2.9 +/- 1.2 versus 4.5 +/- 1.4 days (P = 0.02). This difference seemed to be independent of sampling type but related instead to the time interval between BrdUrd infusion and biopsy and to the changes due to the surgical condition. On the other hand, LI seemed to be the most stable kinetic parameter. With a cutoff value of 4 days for Tpot and of 10% for LI to differentiate slow and fast growing tumors, the positive predictive values of LI were 90% at t1, 80% at t2, and 50% at t3 in aneuploid tumors.

Complement classical pathway expression by human skeletal myoblasts in vitro

Human myoblasts express immunological properties in vitro and we have previously reported that they produce Complement (C) components of the alternative pathway. Myoblasts activate the classical pathway but are fully protected against C attack by the expression of major C regulators. In order to fully understand the relationship between myoblasts and C, we here report the biosynthesis of C components of the classical pathway by skeletal muscle cells. Human myoblasts in vitro produced C1q, C1r, C1s, C2 and C4 constitutively and all syntheses were upregulated after stimulation with IFN-gamma. We suggest that human myoblasts may constitute a local source of C and therefore C could be implicated in inflammatory or physiopathological processes developed in skeletal muscle.

Liver preservation below 0 degrees C with UW solution and 2,3-butanediol

Long-term preservation of the liver is needed to transform liver transplantation from an emergency operation to an elective procedure and therefore to improve the results of liver transplantation. We explored the possibility of extending the cold ischemia time of the rat liver by using a preservation temperature below 0 degrees C together with the addition of a cryoprotective agent (2,3-butanediol) at a low concentration in the preservation solution. Rat livers were preserved for 72 h either with UW solution at +4 degrees C (group 1) or with a UW solution, to which 2,3-butanediol at 8% (at +4 degrees C (group 2) or at -4 degrees C (group 3, experimental group)) was added. Following the preservation process, the viability of the livers was assessed using the isolated perfused liver model. Enzymatic release, bile production, and portal venous flow were not significantly different between group 1 and group 3. In the two groups in which preservation included 2,3-butanediol, the enzymatic release was significantly greater when the preservation temperature was +4 degrees C. We conclude that, using this method, preservation of the rat liver below 0 degrees C seems feasible. However, despite its low concentration, some toxicity of 2, 3-butanediol was suspected. This would counterbalance the benefit resulting from the temperature-related decrease of the enzymatic activities involved in cold ischemia damage. The potential advantages of this method need to be confirmed by assessing liver viability using a liver transplantation model.

Alternative splicing of MLH1 messenger RNA in human normal cells

The hMLH1 protein, composed of 756 amino acids, is the human homologue of the bacterial DNA mismatch repair protein MutL, and germ line mutations of the hMLH1 gene have been identified in kindreds with hereditary nonpolyposis colorectal cancer. We have detected three alternatively spliced forms of hMLH1 mRNA in normal lymphocytes and tissues. One of the spliced forms lacks the coding region of hMLH1 from codons 227 to 295 and the two other transcripts are predicted to encode two truncated proteins retaining the 264 and 226 N-terminal amino acids of hMLH1, respectively. The biological significance of this alternative splicing remains to be established.

Human inter-alpha-inhibitor family in inflammation: simultaneous synthesis of positive and negative acute-phase proteins

The inter-alpha-inhibitor (I alpha I) family encompasses four plasma proteins, namely free bikunin as well as I alpha I, pre-alpha-inhibitor (P alpha I) and inter-alpha-like inhibitor (I alpha LI). Each of the last three proteins is a distinct assembly of one bikunin chain with one or more unique heavy (H) chains designated H1, H2 and H3. The three H chains and the bikunin chain are encoded by four distinct mRNAs. These molecules and chains, as well as the corresponding mRNAs, were quantified in sera and liver biopsies from a series of patients with or without mild or severe acute infection. The decrease or increase observed for a given molecule or chain in the serum was in agreement with a similar change in the corresponding liver mRNA. In acute inflammation the H2 and bikunin chains are down-regulated and the relevant molecules (I alpha I, I alpha LI) behave as negative acute-phase proteins, whereas the H3 chain is up-regulated and the corresponding P alpha I molecule is a positive acute-phase protein. Also, P alpha I displays a higher-than-usual M(r); this is probably due to ligand binding. The H1 gene does not seem to be affected by the inflammatory condition. The quantitative changes in RNA levels seen in vivo were confirmed in vitro in the human hepatoma Hep3B cell line prior to or after induction with the acute-phase mediators interleukin-1 and/or -6. These results provide the first example in humans of positive and negative acute-phase proteins that are encoded by evolutionary related genes.

Measuring the rupture stress point of biological sealant-collagen bonding: validation of a technique used after hepatectomy

The aim of this experimental study was to measure the rupture stress point of a fibrin clot situated on a liver, in realistic surgical conditions. The experimental method was carried out with a machined wooden cylinder bonded on the liver, connected with a wire to a setup and pulled at a constant speed, and a sensor was placed on the wire measuring the applied strength. This method, realized in the dog, made it possible to validate a precise and reproducible method designed for testing the adhesive characteristics of biological sealant-collagen bonding on the liver.

Is emergency aorto-superior mesenteric artery by-pass worthwhile?

Out of 9 superior mesenteric artery (SMA) revascularizations made in emergency, only an early direct aortic reimplantation was successful. The other cases were bypasses and their failures were due either to shock at revascularization (2 cases), or to thrombosis of a by-pass (4 cases), or to persistent ischemic lesions (2 cases). It is suggested: (1) that late mesenteric revascularization should be excluded and let place to extensive bowel resection, (2) that, in emergency, direct SMA aortic reimplantation is preferable to aorto-SMA by-pass.

[A case of hemangiopericytoma of the pelvis]

Haemangiopericytoma is an uncommon tumour of vascular origin. The authors report a case of one of the rarer sites of this tumour in man: paravesical pelvic haemangiopericytoma. Although modern imaging techniques have provided useful information concerning the hypervascular and clearly demarcated appearance of this tumour which displaces but does not invade adjacent organs, its diagnosis can only be established by histology. Its degree of malignancy and its invasive potential are unclear. The risk of local recurrence and metastases in more than one half of cases justifies wide surgical excision, possibly combined with adjuvant radiotherapy, and long-term follow-up.

Interleukin-6 (IL-6) and acute-phase proteins in rats with biliary sepsis

We measured serum interleukin-6 (IL-6) and acute-phase proteins, alpha 1-acid glycoprotein (AGP) and alpha 2-macroglobulin (alpha 2M), after a retrograde intrabiliary bacterial infection in rats with biliary obstruction. Maximum serum IL-6 was obtained at 6 h in rats following inoculation of bacteria (10(6) CFU/ml E. Coli) in the bile duct and it was higher than that observed in rats undergoing a bile duct ligation or a laparotomy. There was a strict relationship between the level of IL-6 at 6 h and the modified levels of AGP and alpha 2M at 48 h. AGP and alpha 2M levels were the highest in sera of rats with bile duct infection as compared with those found in sera of rats with bile duct ligation or laparotomy. After inoculation of E. Coli or E. Fecalis, blood IL-6 level was always higher at 6 h in inferior vena cava as compared with that found in the supra hepatic vein. These results indicate that IL-6 is synthesized after a biliary sepsis and that its blood level is higher in the systemic circulation than in the local circulation.

[Spontaneous rupture of subclavian artery disclosing Ehlers-Danlos disease. A case]

The authors report the case of a 30-year old man who suffered spontaneous rupture of the right subclavian artery. Treatment consisted of carotid-axillary graft since the fragility of the vessel precluded direct suture. The clinical symptoms, together with histological and ultrastructural examinations led to a diagnosis of Ehlers-Danlos syndrome with purely arterial manifestations.

[Cystic duplications of the esophagus in adults. Report of 2 cases]

Oesophageal duplications account for less than 10% of the benign tumors of the oesophagus and for 20% of intestinal duplications. They are most often seen during childhood. In the adult it is more often the non communicating cystic forms, which are prone to complication, which have been reported. Cervical localization is rare and up to now no case has been described in the adult. We report here an asymptomatic case. Our second patient, who had a duplication in the mediastinal region, presented with a cough and dysphagia which completely regressed after excision.