The efficacy of sacituzumab govitecan and trastuzumab deruxtecan on stable and active brain metastases in metastatic breast cancer patients-a multicenter real-world analysis

BACKGROUND

Fifteen to thirty percent of all patients with metastatic breast cancer (MBC) develop brain metastases (BCBMs). Recently, the antibody-drug conjugates (ADCs) sacituzumab govitecan (SG) and trastuzumab deruxtecan (T-DXd) have shown to be highly effective in the treatment of MBC. However, there are only limited data whether these macromolecules are also effective in patients with BCBMs. We therefore aimed to examine the efficacy of SG and T-DXd in patients with stable and active BCBMs in a multicenter real-world analysis.

PATIENTS AND METHODS

Female patients with stable or active BCBMs who were treated with either SG or T-DXd at three breast centers in Germany before 30 June 2023 were included. As per local clinical praxis, chemotherapy efficacy was evaluated by whole-body computed tomography and cranial magnetic resonance imaging at baseline and at least every 3 months according to local standards. Growth dynamics of BCBMs were assessed by board-certified neuroradiologists.

RESULTS

Of 26 patients, with a median of 2.5 prior therapy lines in the metastatic setting (range 2-15), 12 (43%) and 16 (57%) patients received SG and T-DXd, respectively. Out of the 12 patients who received SG, 2 (17%) were subsequently treated with T-DXd. Five out of 12 (42%) and 5 out of 16 (31%) patients treated with SG and T-DXd, respectively, had active BCBMs at treatment initiation. The intracranial disease control rate was 42% [95% confidence interval (CI) 13% to 71%] for patients treated with SG and 88% (95% CI 72% to 100%) for patients treated with T-DXd. After a median follow-up of 12.7 months, median intracranial progression-free survival was 2.7 months (95% CI 1.6-10.5 months) for SG and 11.2 months (95% CI 7.5-23.7 months) for T-DXd.

CONCLUSIONS

SG and T-DXd showed promising clinical activity in both stable and active BCBMs. Further prospective clinical studies designed to investigate the efficacy of modern ADCs on active and stable BCBMs are urgently needed.

Early prediction in acute pancreatitis: the contribution of amylase and lipase levels in peritoneal fluid

CONTEXT

Predicting the severity of acute pancreatitis early in the course of the disease is still difficult.

OBJECTIVE

The value of amylase and lipase levels in serum and peritoneal fluid might be of value in predicting the course of acute pancreatitis.

DESIGN

Prospective study.

PATIENTS

One-hundred and sixty-seven patients with acute pancreatitis as confirmed by computed tomography scan within 24 hours of admission were studied.

MAIN OUTCOME MEASURES

Each patient was given an enzymatic score which reflected the predominance of serum or peritoneal levels of amylase and/or lipase. Enzymatic score was 0 if neither enzyme was predominant in the peritoneal fluid, 1 if amylase or lipase alone were predominant and 2 if both enzymes were predominant. The predictive value of the enzymatic score or computed tomography scan for a severe attack was determined.

RESULTS

One-hundred and thirty-three attacks were graded as mild (79.6%) and 34 were considered as severe (20.4%). The frequency of severe acute pancreatitis significantly increased as the enzymatic score increased (5.4%, 12.5%, and 31.7% in 0, 1, and 2 enzymatic score patients, respectively; P<0.001). An enzymatic score greater than 0 predicted a severe outcome in 32 of 34 patients (sensitivity 94.1%, specificity 26.3%), whereas an enzymatic score of 2 predicted a severe attack in 26 of 34 patients (sensitivity 76.5%, specificity 57.9%). Edema on computed tomography scan was found in 97 of 129 mild attacks (specificity 75.2%) and necrosis in 25 of 33 severe attacks (sensitivity 75.8%), whereas all patients with severe attacks exhibited extrapancreatic acute fluid collection (sensitivity 100%, specificity 34.9%).

CONCLUSIONS

Peritoneal dialysis is less predictive and more cumbersome than a computed tomography scan in the early prediction of acute pancreatitis.

Colon cancers and peritoneal mesothelioma occurring 29 years after abdominal radiation for testicular seminoma. A case report and review of the literature

Secondary malignancies represent an increasing problem for long survivors of primary malignancies treated by chemo- and/or radiotherapy. The occurrence of secondary myelodysplasia and leukaemias after treatment for Hodgkin's disease is well established. Secondary solid tumors are mostly observed following radiation therapy. We report the case of a patient who presented 3 abdominal solid malignancies within 3 years, 29 years after abdominal radiotherapy for a testicular seminoma, namely 2 colon cancers and a peritoneal mesothelioma. Both types of cancer are independently reported in the literature to be more frequent in patients with a history of abdominal radiation than in the general population. To our knowledge there is no other reported case with 3, nearly simultaneously occurring separate solid tumors, which could all be related to former abdominal irradiation. Such a radiotherapy-related long-term side effect should be taken into account when considering adjuvant radiotherapy in patients with low-risk stage I testicular seminoma.

[Risk in major hepatectomy. A consecutive series of 113 extensive hepatectomies]

Up to now, liver resections have been the initial treatment of almost all cancers and benign tumors limited to a liver lobe. This retrospective review assesses the results of a consecutive series of 113 major elective hepatic resections during a ten-year period. Major hepatectomy was defined by the resection of at least 3 Couinaud segments. Mean age was 52 years (20 to 79 years). There were 62 women and 51 men. 35 resections were performed for colorectal metastases, 22 for a benign tumor, 20 for non-colorectal metastases, 11 for hydatid disease, 10 for hepatocarcinoma, 7 for cholangiocarcinoma and 8 for other indications. The resections performed were 86 right hepatectomies with 18 extended right hepatectomies, 24 left hepatectomies with 4 extended left hepatectomies and 3 trisegmentectomies. Total vascular exclusion was used in 22 patients (19%). Mortality rate was zero. Significant morbidity was encountered in 24 patients (21%). These results suggest that the mortality rate may be independent of the extent of liver resection, provided that hepatic function is normal and preoperative selection adequate. With improving surgical management and techniques, and the use of intra-operative sonography, extensive liver surgery can now be performed with a very low mortality rate.

[Cephalic duodenopancreatectomy for pancreatic adenocarcinoma]

Cephalic duodenopancreatectomy is certainly the operation of choice in cases of adenocarcinoma of the pancreatic head. We evaluated the results of this operation in order to justify its indication and to pinpoint the factors that have an influence on the patients' prognosis after the operation. From 1982 to 1992, 386 patients were hospitalized in our department with the diagnosis of pancreatic cancer, all histological types included. Of these, 21 men and 18 women, mean age 65 years, underwent cephalic duodenopancreatectomy for adenocarcinoma. Associated with these operations were 3 liver metastasis excisions, 2 vascular resections, 1 colectomy and 1 splenectomy. All the tumors were operated on whenever technically possible, except those associated with distant metastasis. Postoperatively, only one patient died (on the 29th day, of viral meningitis). Postoperative morbidity was 51% with 23% local complications. There was one leakage of the anastomosis. Age, weight loss, history of pancreatitis or cirrhosis, anesthetic risk (ASA) and tumor staging were not found to be factors increasing the risk of postoperative complications. Survival after 1 year was 34% and after 5 years 6%. The degree of histological differentiation was the only factor that had any significant influence on the postoperative survival rate in our study. We conclude that cephalic duodenopancreatectomy is the treatment of choice which is capable of improving the quality, and to a lesser extent the length, of survival of patients suffering from pancreatic cancer, with acceptable postoperative mortality and morbidity rates.

Surgery for adult polycystic liver disease

BACKGROUND

Occasionally patients with adult polycystic liver disease (APLD) have symptoms. For these patients surgery may represent a valuable therapeutic option to relieve symptoms.

METHODS

From September 1977 to August 1993 at our institution, 10 women with APLD were examined and surgically treated. They underwent a partial hepatic resection together with cyst fenestration. The surgical outcome and long-term follow-up were retrospectively analyzed.

RESULTS

Postoperative morbidity consisted of one case of pneumonia, and one case of acute pancreatitis with deep vein leg thrombosis. One patient died after acute Budd-Chiari syndrome developed as a result of liver collapse after fenestration of a posterior cyst. In the long term six of nine patients were symptom free. Late surgical complications included acute cholecystitis (one patient), small bowel obstruction (one), and incisional hernia (two).

CONCLUSIONS

A combined surgical approach of hepatic resection and cyst fenestration has proved feasible for patients with highly symptomatic APLD. Extensive fenestration of posterior cysts should be avoided; transverse hepatic resection (frontal hepatectomy) up to the costal margin is proposed. This therapy provides good results at long-term follow-up.

[Islets of Langerhans allografts in the pig: initial results]

Islet of Langerhans transplantation represents a promising treatment of diabetes. Use of porcine islets for xenotransplantation could offer a solution to shortage of organ donors. However, isolation of pig islets remains a real challenge because of their marked fragility. Using a modified automated method for islet isolation, we performed 10 intraportal islet allografts in pigs. Surgically pancreatectomized pigs were transplanted with purified islet preparations pooled from pancreases of 3 donors (slaughter-house pigs, age 5-8 months). Six recipients were not immunosuppressed and four received an immunosuppressive treatment of Cyclosporine and Azathioprine. In the first group (non-immunosuppressed recipients), insulin secretion was observed for a mean of 4.8 days after transplantation. In the second group (with immunosuppressive treatment) the recipients sustained an insulin secretion for 6-9 days. However, in both groups liver biopsies showed signs of acute rejection and destruction of the transplanted islets. Pig islet allotransplantation, using as recipients surgically pancreatectomized pigs, can be considered as a suitable model to assess the functional results of mass islet isolation. We were able to reverse diabetes transitory in a large animal, by transplantation of purified pig islet preparations. However, even when an immunosuppressive treatment was administered to the recipients, rejection seemed to represent an important factor in the functional outcome of the islet grafts.

Surgical pitfalls in a patient with type IV Ehlers-Danlos syndrome and spontaneous colonic rupture. Report of a case

PURPOSE

This paper intends to stress the importance of early diagnosis and discuss surgical treatment of Type IV Ehlers-Danlos syndrome (EDS-4), an autosomal dominant connective tissue disease characterized by typical features of the face and extremities, inappropriate and easy bruising, and extreme tissue fragility, which may lead to dramatic and often fatal complications, mostly spontaneous arterial or intestinal rupture.

METHODS

We report the case of a 41-year-old female who presented with spontaneous perforation of the sigmoid colon.

RESULTS

The patient was seen over a nine-year period, during which time she required six operations and presented with a great number of surgical complications including stenosis of an end-colostomy, repeated subocclusive episodes caused by intraperitoneal adhesions, and enterocutaneous fistulas, finally ending with an ileostomy and short bowel syndrome. It is only after a difficult laparotomy for ovarian cyst excision, marked by numerous adhesions and friable bowel, that the diagnosis of EDS-4 was considered and established.

CONCLUSIONS

In case of "idiopathic" spontaneous perforation of the colon in a young adult, features of EDS-4 should be thoroughly looked into and, if found, skin fibroblast culture with collagen Type III analysis performed. The surgical treatment of choice consists of subtotal colectomy and permanent end-ileostomy. In case of patient refusal, a second-stage ileorectal anastomosis can be performed but carries the high risk of anastomotic leakage.

Acute left colonic diverticulitis in young patients

BACKGROUND

This prospective study was done to compare acute left-sided colonic diverticulitis in young patients (50 years of age or less) and older patients (more than 50 years of age) for severity of disease and immediate and late outcome.

STUDY DESIGN

Of the 265 patients studied, 61 were 50 years of age or less; of these, 49 were men. In all instances, diagnosis was confirmed radiologically or histologically.

RESULTS

Operations were performed less often upon younger patients than older patients (15 versus 33 percent, p = 0.001). Severe diverticulitis was found more often in younger men than older men (39 versus 23 percent). After successful conservative treatment during the first hospitalization period, younger men had a statistically greater risk of poor outcome than older men (29 versus 5 percent, p = 0.003).

CONCLUSIONS

Although younger men have severe acute diverticulitis more often than older men, operative treatment during the first episode is less often needed. On the other hand, after conservative treatment, younger men have a statistically greater chance of poor secondary outcome than older men.

[Insulinoma: experience in our hospital]

Insulinoma is the most frequent endocrinal tumor of the pancreas despite its very low incidence. This lesion induces hyperinsulinism, which has an atypical clinical symptomatology consisting of neurological symptoms and of signs by stimulation of the adrenergic system. Biological analyzes serve to confirm the presence of uncontrolled hyperinsulinism. Preoperative abdominal echography, abdominal CT-SCAN, angiography and portal catheterization serve to detect the pancreatic site of the insulinoma only in about 3/4 of the cases. However, the perioperative combination of manual palpation and abdominal echography reveal the exact site in almost all cases. For all these reasons we do not recommend attempting preoperative localization of the insulinoma and propose surgery as the treatment of choice when the diagnosis is established by biological features. Medical treatment is only applied to inoperable cases or in the presence of metastatic lesions. Surgical treatment should be economical on the pancreas and should be based solely on resection of the lesion, simple enucleation being the treatment of choice when the neighboring vascularly, biliary and digestive structures do not represent any technical risk. Whenever this is impracticable, right or left pancreatectomy seems to be the best option. We report our experience with 25 patients and analyze the benefits of pre- and perioperative examinations in the localization of insulinomas.

Acute left colonic diverticulitis: a prospective analysis of 226 consecutive cases

BACKGROUND

The purpose of this prospective study was to evaluate the immediate and late outcome of acute left colonic diverticulitis and to correlate it with age (younger and older than 50 years of age), gender, and initial computed tomography (CT) findings.

METHODS

Analysis was made of data collected prospectively from all patients admitted because of acute colonic diverticulitis between October 1986 and January 1992. Diagnosis relied on results of operation, CT, and Gastrografin enema. Two hundred twenty-six patients were urgently hospitalized for acute left colonic diverticulitis; 47 were younger than 50 years of age (21%).

RESULTS

Sixty-six patients (29%) were operated on during their first hospitalization. The remaining 160 patients treated conservatively underwent CT and an enema within 72 hours of admission. Fifty-nine of 179 patients (33%) older than 50 years of age required operation during their first attack, compared with 7 in 47 patients (15%) younger than 50 years of age (p = 0.02), although on CT severe diverticulitis was found in 36 of 141 patients (26%) older than 50 years of age and in 16 of 43 patients (37%) younger than 50 years of age (p = 0.13). Of the 160 patients treated conservatively, 11 of 40 patients (28%) younger than 50 years of age experienced recurrences or complications after their first discharge, compared with 16 in 120 patients (13%) older than 50 years of age (p = 0.04).

CONCLUSIONS

Patients younger than 50 years of age were significantly more prone to recurrences and complications after conservative treatment of their diverticulitis, whereas older patients required operation significantly more often during their first hospitalization.

[Cytomegalovirus in liver transplantation: incidence and groups at risk]

Cytomegalovirus (CMV) belongs to the family of Herpes viridae and has become the single most important viral pathogen in clinical transplantation. This is an endemic and ubiquitous virus. After transplantation it is necessary to distinguish CMV infection (positive seroconversion and/or isolation of the virus in the blood, urine, sputum or tissues in the absence of clinical symptoms) from CMV disease, which is a clinical expression of viremia in association with a documented CMV infection. The overall incidence of CMV infection in transplant recipients is about 50% and the incidence of CMV disease ranges from 15 to 25% whatever the transplanted organ. In this study (52 liver transplantations in 48 patients), 12 patients had CMV infection and 10 patients developed CMV disease (24%). The onset of CMV disease was 33 +/- 7 days after transplantation. Cytomegalovirus hepatitis was observed 7 times, CMV pneumonia once and 2 CMV infections characterized by oscillating fever in association with a hematological syndrome. 8 patients were treated with intravenous gancyclovir (DHPG, 9-[1,3-dihydroxy-2-propoxymethyl]-guanine) for 15 days and 2 patients by reduction of their immunosuppressive therapy only. There were significantly more (p < 0.05) opportunistic infections and/or bacteremia in patients with CMV disease. The association of CMV IgG negative recipients and CMV IgG positive donors appeared to be a significant factor (p < 0.05) for CMV disease. The number of transfusions, the level of immunosuppression and the absence of prophylaxis did not influence the incidence of CMV disease. Despite prolonged hospitalization and increased morbidity, there were no deaths in patients who developed CMV disease, which is good evidence of the efficacy of gancyclovir.(ABSTRACT TRUNCATED AT 250 WORDS)

Left-sided colon and colorectal anastomoses: Doppler ultrasound as an aid to assess bowel vascularization. A prospective evaluation of 200 consecutive elective cases

Two hundred non-randomized left-sided colon and colorectal anastomoses were performed on 199 consecutive patients admitted over a 4-year period (107 men and 92 woman with a median age of 66 years). There were 117 high anastomoses (above the peritoneal reflection), 86 (74%) of which were hand sewn, and 83 low anastomoses, 78 (94%) stapled with an EEA instrument. Adequate blood supply was assessed with a Doppler ultrasound in all but 5 cases. In ten patients bowel edges to be anastomosed were recut because of a negative Doppler ultrasound reading. One hundred and eighty-nine anastomoses were radiologically controlled. In-hospital post-operative mortality was 2.5% and morbidity 20%. There were two (1%) clinical anastomotic leaks and three (1.5%) radiological leaks. Use of Doppler ultrasound is simple and safe to assess vascularization of the intestinal edges. It may have contributed to the low anastomotic complication rate observed in this series.

[Endocrine tumors of the pancreas. Status of the question]

Progress in radioimmunology and immunohistochemistry and the use of intraoperative ultrasonography has considerably improved the diagnosis of endocrine tumors. These advances have changed the prognosis of these tumors since the outcome directly depends on early diagnosis. Surgery is the treatment of choice, in many cases even in the presence of hepatic metastasis. Medical treatment should be used when surgery is contraindicated and includes cytostatic agents (e.g. streptozotocin, 5-FU) or interferons and drugs preventing hormone release such as long-acting somatostatin analogs (SMS 201-995). Finally, symptomatic treatment alone should be confined to cases of unresectable tumors with diffuse metastasis.

Computed tomography and fine-needle aspiration cytology for preoperative evaluation of cystic tumours of the pancreas

Cystic neoplasms of the pancreas are rare. They may present as a mucinous (malignant or potentially malignant) tumour or as benign serous cystadenoma. Accurate preoperative diagnosis is therefore essential, as an asymptomatic serous tumour may safely be followed clinically for years, whereas mucinous tumours require aggressive surgery. Thirteen patients with cystadenoma and cystadenocarcinoma of the pancreas were reviewed and how best to improve the rate of preoperative diagnosis was considered. Fine-needle aspiration cytology and computed tomography enable accurate preoperative distinction between mucinous and serous cystic tumours of the pancreas.

[Pneumoretroperitoneum: diagnostic and therapeutic approach]

This retrospective study deals with etiology, paths of extension, radiological signs and treatment of pneumoretroperitoneum. The 15 cases presented were seen over a 10-year period. Etiology was infectious in 6 patients, traumatic in 5, and iatrogenic in 4. Treatment applied was surgical in 12 patients, the remaining 3 (who all had their pneumoretroperitoneum secondary to endoscopy) could be handled conservatively. Even though pneumoretroperitoneum is seldom encountered, it should be quickly recognized in order to apply prompt adequate therapy.

Pathophysiology, recognition and management of pneumoretroperitoneum

The medical records of 15 patients found to have pneumoretroperitoneum in a 10-year period were reviewed. The cause of retroperitoneal emphysema was infection in six patients, trauma in five and iatrogenic in four. Emphysema was confined to the retroperitoneum in 11 patients, and extended to the mediastinum in four and to the soft tissue of the neck in three. Failure to diagnose pneumoretroperitoneum resulted in delayed intervention in two patients. One patient with pneumoretroperitoneum and pneumoperitoneum secondary to a lung lesion underwent unnecessary laparotomy. Outcome was favourable in these three patients. The presence of air in the retroperitoneum is not dangerous but its early recognition and detection of the source are important as septic conditions may be involved.

[Surgery of digestive system cancers in patients over 80 years of age]

231 patients over 80 years old were operated at the Clinique de chirurgie digestive of Geneva University Hospital between 1981 and 1990 for a malignant tumor of the gastrointestinal tract. The following parameters were studied: intra- and postoperative morbidity and mortality, duration and quality of survival. Surgery proved valid in this age group given its low mortality (15%). Postoperative morbidity (44%) did not prolong hospital stay, since 90% of all patients were discharged within one month of surgery. Following surgery, quality of life was excellent: 75% of patients returned home, and 80% were better off than pre-operatively. Such operations provide better results in term of mortality and survival when performed on an elective basis and curatively.

[Transplantation of islets of Langerhans in man]

Islet of Langerhans transplantation is an alternative to whole pancreas transplantation for type I diabetic patients, in whom exogenous insulin therapy has not prevented the occurrence of systemic complications. Thanks to a new isolation technique of human islets, 45 patients have been transplanted worldwide since 1988, of whom only 7 have become totally insulin-independent. Rejection and quality of the islet preparations are problems which remain to be solved. Autotransplantation of islets has been proposed in patients undergoing a pancreatectomy for benign disease. The present report concerns two of our patients who had a pancreatectomy with islet autotransplantation. Both patients are insulin-independent 3 and 11 months postoperatively, with satisfactory metabolic tests. Islet autotransplantation can be proposed when pancreatectomy for non-malignant disease is performed. This method may prevent the development of insulin-dependent diabetes, known to be particularly labile. Because of the sophisticated technical procedures required, human islet isolation is at present only performed in a small number of medical centers and still is in the field of medical experimentation.

[Value of computerized tomography in acute diverticulitis of the left colon]

This prospective study focuses on the prediction of late outcome after acute left colonic diverticulitis successfully treated conservatively and in which the diagnosis was confirmed radiologically (computed tomography [CT] and gastrografin enema [GE]). Acute diverticulitis was diagnosed in 226 patients. Sixty-six patients (29%) were operated on during their first hospitalization, and 2 of them died (3% mortality). The remaining 160 patients, successfully treated conservatively, had a CT and a GE within 72 hours of admission and entered this study. Signs of severity on CT included the presence of abscess(es) and/or extraluminal air and/or extraluminal hydrosoluble contrast (Gastrografin). Follow-up averaged 25 months (range 1 month to 5.3 years). Twenty-seven of these 160 patients (17%) had a poor outcome (persistent diverticulitis in 12, colonic stenosis in 6, recurrences in 7, residual parasigmoid abscess and colovesical fistula in one each). When comparing these 27 patients with the 133 others it appeared that: (1) men up to 50 years of age were significantly more prone to develop such complications (p = 0.003); (2) the probability of developing a complication was significantly greater when the initial CT had revealed an abscess and/or extraluminal air and/or extraluminal Gastrografin (p = 0.005). These results support the view that elective colectomy can reasonably be proposed after a first attack of acute left diverticulitis treated conservatively in men up to 50 years of age, and/or in patients whose initial CT revealed findings of severe diverticulitis.

[Islet of Langerhans transplantation in humans]

Islet of Langerhans transplantation is an alternative to whole pancreas transplantation for type I diabetic patients, in whom exogenous insulin therapy has not prevented the occurrence of systemic complications. Thanks to a new isolation technique of human islets, 45 patients have been transplanted worldwide since 1988, of whom only 7 have become totally insulin-independent. Rejection and quality of the islet preparations are problems which remain to be solved. Autotransplantation of islets has been proposed in patients undergoing a pancreatectomy for benign disease. The present report concerns two of our patients who had a pancreatectomy with islet autotransplantation. Both patients are insulin-independent 3 and 11 months postoperatively, with satisfactory metabolic tests. Islet autotransplantation can be proposed when pancreatectomy for non-malignant disease is performed. This method may prevent the development of insulin-dependent diabetes, known to be particularly labile. Because of the sophisticated technical procedures required, human islet isolation is at present only performed in a small number of medical centers and still is in the field of medical experimentation.

[Multiple tumors of colon and rectum]

The possible occurrence of multiple synchronous or metachronous malignant lesions in patients with carcinoma of the colon and rectum is a well known event. In this population-based study in the Geneva area from 1970 to 1986, the frequency of synchronous colorectal carcinomas was 1.1% and that of metachronous carcinomas 1%. The relative risk of metachronous colorectal carcinoma is higher than in the general population (colon after rectum 1.2, colon after colon 1.7 and rectum after rectum 1.4). A high association of adenomatous polyps with multiple colorectal carcinoma was observed. The 5-year actuarial survival in case of curative resection was 87% for metachronous carcinomas, 35% for single carcinomas and 33% for synchronous carcinomas. We conclude that complete preoperative colonoscopy, whenever possible, should be performed to screen patients with synchronous carcinomas. Finally, a lifelong follow-up of the residual colon or rectum should be planned to detect metachronous lesions.

[Multiple tumors of the colon and rectum]

The possible occurrence of multiple synchronous or metachronous malignant lesions in patients with a carcinoma of the colon and rectum is a well known event. In this population-based study in the Geneva area from 1970 to 1986, the frequency of synchronous colorectal carcinomas was of 1.1% and that of metachronous carcinomas of 1%. The relative risk of metachronous colorectal carcinoma is higher than in the general population (colon after rectum 1.2, colon after colon 1.7 and rectum after rectum 1.4). A high association of adenomatous polyps with multiple colorectal carcinomas was observed. The 5-year actuarial survival in case of curative resection was of 87% for metachronous carcinomas, 35% for single carcinomas and 33% for synchronous carcinomas. We conclude that complete preoperative colonoscopy, whenever possible, should be performed to screen patients with synchronous carcinomas. Finally, a lifelong follow-up of the residual colon or rectum should be planned to detect metachronous lesions.

Unexpectedly high rate of phlebographic deep venous thrombosis following elective general abdominal surgery among patients given prophylaxis with low-molecular-weight heparin

One hundred ninety-four patients undergoing elective general abdominal surgery were randomized in a single-blind study to receive one daily subcutaneous injection of a low-molecular-weight heparin, dalteparin sodium (2500 IU, n = 97) or nadroparin calcium (3075 IU, n = 97), two regimens that are approved in Europe to prevent deep venous thrombosis. On the eight postoperative day, bilateral ascending leg phlebography (n = 185) showed the presence of deep venous thrombosis in 45 cases (24.3%; 95% confidence interval, 18% to 31%), with a significantly higher rate (on intention-to-treat) among the patients who received the lower dosage (30 vs 15 deep venous thromboses). We conclude that the two regimens of low-molecular-weight heparin that were used in this study failed to prevent postoperative phlebographically proved deep venous thrombosis in one of four patients.

Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors

Results of elective open cholecystectomy in 1252 patients treated in a North American and a European center were examined using a recent standardized classification of complications. Although there were significant differences between centers in population age, rate of concomitant disorders, and numbers of operators, the frequency and severity of complications were comparable. There were no deaths, but 12% and 14% of the patients developed complications in the two centers. About 6% of the patients developed grade I complications. Grade II complications were noted in 6% and 8%, and grade III in 0% and 0.3%. Using univariate and multivariate analysis, individual risk factors for developing complications were found to be different in the two centers. Two preoperative scoring systems, ASA and a simplified APACHE II, were predictive for complications in both centers, but did not account for all risk in these patients. Data from the two centers could not be combined because of significant interaction between risk factors and center. Elective open cholecystectomy is a safe procedure, particularly in terms of highly morbid complications and death. Generalization of risk factors identified in a particular center may be misleading because local conditions may significantly affect risk factors for complications. The data also demonstrate the advantages of a uniform way of reporting surgical complications, which may permit meaningful comparisons among centers.

[Safety of cholecystectomy by laparotomy in elective situation and in emergency]

Cholecystectomy is the only effective treatment of gallbladder stones. A retrospective study was carried out on results of 658 cholecystectomies by laparotomy without choledochotomy performed between January 1987 and December 1989, to determine morbidity and mortality of elective and emergency surgery and by age. Operations for tumors of the gallbladder and choledolithiasis were not included in the analysis. During this period, cholecystectomy was performed electively in 387 cases and under emergency conditions in 261 patients. Mortality and post-operative morbidity were 0% and 14.7% respectively after elective surgery, increasing to 1.1% (Fisher = 0.0617) and 25.2 (p = 0.0004) respectively after emergency operations. This large increase in postoperative morbidity in urgent cases was due to an increase in systemic and not local complications, as a result of the higher proportion of emergency operations with advancing age. Since elective cholecystectomy is safe it can be proposed to patients with symptoms, including the elderly. It is difficult at present to compare results of cholecystectomy by laparotomy with those of laparoscopy since the average age of in the latter category is markedly lower and the number of acute cases still low. The principal advantage of celioscopy could be a long term reduction in systemic complications in emergency operations.

Incidence, outcome, and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis. A prospective study of 140 patients

In a prospective evaluation of 140 consecutive patients with acute left-sided colonic diverticulitis demonstrated by computerized tomography (CT) in all cases, 22 (16 percent) were found to have an associated abscess without peritonitis. Thirteen of these 22 required surgery (seven during the first stay and six from 2 to 11 months after the acute episode; median, three months). Nine patients were treated conservatively, eight of whom are now totally asymptomatic 24 months after the initial attack (range, 10-47 months). There were 10 mesocolic abscesses (seven treated with antibiotics alone), nine pelvic abscesses (seven requiring surgery), and three intra-abdominal abscesses, all operated upon. These results suggest that mesocolic abscesses can usually be managed conservatively without drainage; should surgery be necessary, en bloc resection with immediate anastomosis can usually be safely performed. Pelvic and intraabdominal abscesses behave more aggressively and usually require a two-stage surgical procedure when initial percutaneous drainage cannot be performed or is felt to be hazardous.

[Stomach adenocarcinoma: what form of gastrectomy?]

Three hundred and sixty consecutive cases of gastric adenocarcinoma were studied retrospectively between 1976 and 1987. Surgery was curative in 195 patients: 91 had a subtotal gastrectomy 83 a total gastrectomy and 21 a proximal gastrectomy. Subtotal and total gastrectomy were compared within this group in terms of postoperative morbidity and mortality, abdominal comfort and 5-year actuarial survival: Postoperative mortality was greater after total gastrectomy (9.6 vs 2.2%, p = 0.04), as were anastomotic leaks (19 vs 2%, p = 0.0009). Mean weight loss was greater after total gastrectomy (p = 0.005). Comparison of patients with similar tumor staging and localization did not show any significant difference in 5-year actuarial survival. If subtotal gastrectomy is certainly justified for distal gastric cancer, it should be considered for some proximal localization.

Results of surgical palliation for cancer of the head of the pancreas and periampullary region

Between 1977 and 1986, 101 patients underwent surgical bypass for periampullary carcinoma. The hospital mortality rate was 18 per cent and the morbidity rate 43 per cent. Mortality was not influenced by the extent of the tumour. Survival rates at 1,2 and 3 years were 28, 9 and 4 per cent, respectively. The median survival time was 17 months for localized tumours, 10 months for those that had invaded surrounding tissues, 6 months in the presence of lymph node involvement and 3 months with distant metastasis. The quality of survival was good for most patients with localized tumours but poor for those with parenchymal metastasis, in whom palliation was transient for 85 per cent and effective for less than half of their survival time for 60 per cent. These results suggest that patients with distant metastasis but without impending duodenal obstruction should undergo palliation by endoscopic or percutaneous routes while those with less advanced disease or with duodenal involvement remain candidates for surgical bypass.

Gallstone ileus and bowel perforation after endoscopic sphincterotomy

Gallstone ileus as a complication of endoscopic sphincterotomy (ES) is exceptional, and this is only the second reported case. The present case is unique in that there was no previous instrumentation to the papilla, the bowel was obstructed and perforated, and the patient survived. This case again points out the danger of performing ES for large common bile duct stones. When a large stone is not extracted after ES, close monitoring is mandatory until unequivocal stone passage through the intestine is proven. In both cases reported so far, the lack of adequate monitoring after failure of stone extraction by ES was critical to the severity of gallstone ileus.

Elective hepatic resection in the elderly

This retrospective review assessed the safety and validity of elective liver resection in patients older than 64 years of age. In all, 293 patients underwent elective liver resection over a 23-year period (1967-1990). Fifty-two patients (18 per cent) were older than 64 (maximum 84, mean 70.4) years and all but four of these did not have cirrhosis. In this older subgroup, indications for resection were liver metastases in 30 patients, primary malignancy in 16, benign tumours in five and multiple abscesses in one. There were 21 major resections, with two deaths from hepatic failure, and 31 minor resections, with one death from cardiac failure (total mortality rate 6 per cent). During the same period, there were seven deaths after elective resections performed in 222 patients without cirrhosis who were younger than 64 years (P = 0.39). Mortality rate and duration of postoperative hospital stay were not related to the extent of liver resection nor to patients' grading according to the American Society of Anesthesiologists' criteria. Intraoperative blood loss was the only parameter found to influence mortality rate (P = 0.008) and duration of hospital stay (P = 0.04). Elective liver resection can be safely undertaken in elderly patients without cirrhosis, provided that intraoperative blood loss is minimized.

[Who are the candidates for liver transplantation?]

Over the past 12 years, new immunosuppressive agents, better knowledge of anesthesiology and postoperative reanimation as well as refinement in surgical technics modified the indications for and results of orthotopic liver transplantation (OLT). At the beginning of the OLT era, liver tumors that could only be removed by total hepatectomy were one of the most frequent indications. Nowadays, this indication is mostly abandoned in view of a high rate of recurrence and poor long-term results. In contrast, the prognosis of fulminant hepatic failure has been dramatically improved by OLT, once efficient organization systems allowed adequate organ supply and emergency transplantation within a few hours. Three main groups of diseases (cholestatic diseases, inborn errors of metabolism and parenchymal diseases) can be treated by OLT with excellent results (actuarial survivals of 80 to 90% have been reported at one and 2 years). Later graft dysfunction is rare except for virus B recurrence. Primary biliary cirrhosis and the group of inborn errors of metabolism are regarded as the optimal indications of OLT in adults and children respectively. Precocious evaluation of patients, before advanced stages of the disease associated with multiple complications, should prevent them from dying on a waiting list and decrease operative as well as early postoperative risks. Not only does OLT provide mere survival (among 5 patients with lethal hepatic disease, 4 are alive at 2 years from OLT), it also provides a regained quality of life with a virtually normal (for the price of a daily medication intake) family, professional and sportive life. Such achievements prompt us today to propose early transplantation to these patients.