Liver resection or transplantation for hepatocellular carcinoma? Retrospective analysis of 215 patients with cirrhosis

BACKGROUND/AIMS

Currently, surgical treatment of hepatocellular carcinoma in patients with cirrhosis is not clearly defined. The objective of this study was, in patients with cirrhosis with hepatocellular carcinoma, to compare liver resection to transplantation assessed by patient survival and to determine whether the tumor recurrence might be influenced by prognostic factors.

METHODS

We have gathered all the available data from six French Medical Universities, for 215 patients with cirrhosis with hepatocellular carcinoma surgically treated either by liver resection (102) or by transplantation (113).

RESULTS

The overall 5-year survival rate was similar in the transplantation group and in the resection group (32% vs. 31%, p=0.7). However, the 5-year survival rate without recurrence was higher in the transplantation group than in the resection group (60% vs. 14%, p<0.001). Three independent prognostic factors influenced significantly the survival without recurrence: the surgical treatment by transplantation (p<0.001), the number of tumors (p<0.01) and the tumor size (p<0.001). With these factors we defined a prognostic index (Ip) which allowed assessment of the probability of survival without recurrence: Ip= (Xie. x 1.41)+(Nbr T. x 0.19)+(Size TV. x 0.16); Xie=surgical treatment (Xie=0 if transplantation, Xie=1 if resection), Nbr.T. and Size TV.=number of tumors and size of the most voluminous tumor, respectively, according to the histologic study.

CONCLUSIONS

These results and this prognostic index are encouraging for liver transplantation as treatment of hepatocellular carcinoma in selected patients with cirrhosis.

Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy

BACKGROUND

It remains debatable whether somatostatin can prevent pancreatic fistula and other pancreatic stump-related complications following pancreaticoduodenectomy. This study assessed the effects of somatostatin-14 (S-14) on pancreatic remnant exocrine secretion.

METHODS

This was a double-blind, randomized, placebo-controlled trial in patients undergoing pancreaticoduodenectomy for malignancy. Patients received a continuous infusion of S-14 (n = 38) or placebo (n = 37) for 7 days. Pancreatic juice and peripancreatic drainage fluid was collected and measured, and pancreatic enzymes were monitored daily. Postoperative complications were recorded.

RESULTS

S-14 infusion was associated with a decrease in median daily pancreatic juice and pancreatic amylase output. Amylase concentration and output in the peripancreatic drain fluid were significantly lower after S-14 infusion than in the control group (both P < 0.05). The incidence of clinical pancreatic fistula (two of 38 versus eight of 37; P < 0.05) and total pancreatic stump-related complications (five of 38 versus 12 of 37; P < 0.05) was lower in patients treated with S-14. Duration of hospital stay was shorter after S-14 (18 versus 26 days; P = 0.01).

CONCLUSION

Although the effect of S-14 on exocrine secretion remains difficult to demonstrate, it did reduce pancreatic juice leakage from the pancreatic remnant.

Dynamic analysis of hepatitis C virus replication and quasispecies selection in long-term cultures of adult human hepatocytes infected in vitro

Primary human hepatocytes were used to develop a culture model for in vitro propagation of hepatitis C virus (HCV). Production of positive- strand full-length viral RNA in cells and culture supernatants was monitored by PCR methods targeting three regions of the viral genome: the 5' NCR, the 3' X-tail and the envelope glycoprotein E2. De novo synthesis of negative-strand RNA was also demonstrated. Evidence for a gradual increase in viral components over a 3 month period was obtained by two quantitative assays: one for evaluation of genomic titre (quantitative PCR) and one for detection of the core antigen. Production of infectious viral particles was indicated by passage of infection to naive hepatocyte cultures. Reproducibility of the experiments was assessed using cultures from three liver donors and eleven sera. Neither the genotype, nor the genomic titre, nor the anti-HCV antibody content, were reliable predictive factors of serum infectivity, while the liver donor appeared to play a role in the establishment of HCV replication. Quasispecies present in hepatocyte cultures established from three different liver donors were analysed by sequencing hypervariable region 1 of the E2 protein. In all three cases, the complexity of viral quasispecies decreased after in vitro infection, but the major sequences recovered were different. These data strongly suggest that human primary hepatocytes are a valuable model for study of persistent and complete HCV replication in vitro and for identification of the factors (viral and/or cellular) associated with successful infection.

Predictive factors of type 2 diabetes remission 1 year after bariatric surgery: impact of surgical techniques

Type 2 diabetes (T2D) remission after bariatric procedures has been highlighted in many retrospective and some recent prospective studies. However, in the most recent prospective study, more than 50 % of patients did not reach T2D remission at 1 year. Our aim was to identify baseline positive predictors for T2D remission at 1 year after bariatric surgery and to build a preoperative predictive score. We analysed the data concerning 161 obese operated on between June 2007 and December 2010. Among them, 46 were diabetic and were included in the study-11 laparoscopic adjustable gastric banding (LAGB), 26 Roux-en-Y gastric bypass (RYGB) and 9 sleeve gastrectomy (SG). We compared anthropometric and metabolic features during 1 year of follow-up. A receiver operating characteristic analysis was performed to predict T2D remission. RYGB and SG were similarly efficient for body weight loss and more efficient than LAGB; 62.8 % of patients presented with T2DM remission at 1 year, with no significant difference according to the surgical procedure. A 1-year body mass index (BMI) <35 kg m(-2) was predictive of T2DM remission whatever the procedure. The preoperative predictive factors of diabetes remission were baseline BMI ≤50 kg m(-2), duration of type 2 diabetes ≤4 years, glycated haemoglobin ≤7.1 %, fasting glucose <1.14 g/l and absence of insulin therapy. A short duration of diabetes and good preoperative glycaemic control increase the rate of T2DM remission 1 year after surgery. Preoperative metabolic data could be of greater importance than the choice of bariatric procedure.

Greater weight loss with the omega loop bypass compared to the Roux-en-Y gastric bypass: a comparative study

BACKGROUND

Despite similar initial results on weight loss and metabolic control, with a better feasibility than the Roux-en-Y gastric bypass (RYGBP), the omega loop bypass (OLB) remains controversial. The aim of this study was to compare the short-term outcomes of the laparoscopic OLB versus the RYGBP in terms of weight loss, metabolic control, and safety.

METHODS

Two groups of consecutive patients who underwent laparoscopic gastric bypass surgery were selected: 20 OLB patients and 61 RYGBP patients. Patients were matched for age, gender, and initial body mass index (BMI). Data concerning weight loss, metabolic outcomes, and complications were collected prospectively.

RESULTS

Mean duration of the surgical procedure was shorter in the OLB group (105 vs. 152 min in the RYGBP group; p < 0.001). Mean excess BMI loss percent (EBL%) at 6 months and at 1 year was greater in the OLB group (76.3 vs. 60.0%, p = 0.001, and 89.0 vs. 71.0%, p = 0.002, respectively). After adjustment for age, sex, initial BMI, and history of previous bariatric surgery, the OLB procedure was still associated with a significantly greater 1-year EBL%. Diabetes improvement at 6 months was similar between both groups. The early and late complication rates were not statistically different. There were three anastomotic ulcers in the OLB group, in smokers, over 60 years old, who were not taking proton pump inhibitor medication.

CONCLUSIONS

In this short-term study, we observed a greater weight loss with OLB and similar efficiency on metabolic control compared to RYGBP. Long-term evaluation is necessary to confirm these outcomes.

Intraperitoneal treatment of incisional and umbilical hernias using an innovative composite mesh: four-year results of a prospective multicenter clinical trial

Intraperitoneal positioning of conventional parietal mesh provides efficient reconstruction but causes visceral adhesion formation in 80-100% of the cases. The purpose of this clinical trial was to assess the performance and tolerance of a new generation of polyester mesh protected by a hydrophilic resorbable film. Eighty patients were included in a prospective multicenter clinical trial. Patients were treated for ventral hernia via an open approach (64%) or laparoscopically (36%). All meshes were implanted in a midline intraperitoneal location. The main objective was to evaluate the anti-adhesive capability of the mesh in relation to the viscera. In order to assess the absence of visceral adhesion objectively, an ultrasound (US) specific examination was initially validated (pre-operative prediction vs. per-operative findings) and then used during the follow-up. The usual clinical parameters were also collected to follow the patients on a period up to 4 years. Pre-operative US prediction vs. per-operative macroscopic findings: sensitivity 79%, overall accuracy 76%, negative predictive value 85%. After 12 months, 86% of the patients were ultrasonically adhesion free. Early post-operative complications were: seroma/hematoma (16%), subcutaneous infection (4%), cutaneous necrosis (1%) and occlusions (outside the mesh) (2.5%). No mortality was reported. Clinically, after 12-month follow-up, no complication related to post-operative adhesions to the mesh was noted: (occlusion 0%, fistula 0%). Late complications were: mesh sepsis (1%), new defects (4%) and recurrence (2.5%). Finally, 56 patients (75.7%) were clinically evaluated with a mean follow-up of 48+/-6 months. One direct recurrence was noted while six patients experienced new defect outside the mesh. No long-term severe complication such as occlusion or enterocutaneous fistula was observed. Based on a mean clinical follow-up of 4 years, the results of this prospective multicenter clinical trial demonstrate the safety and the efficiency of this composite mesh in the intraperitoneal treatment of incisional and umbilical hernia. In particular there was no early or long-term main complication due to the intraperitoneal location of the mesh.

Factors associated with Clostridium difficile infection: A nested case-control study in a three year prospective cohort

BACKGROUND

Clostridium difficile infection (CDI) is a serious medical condition that is associated with substantial morbidity and mortality. Identification of risk factors associated with CDI and prompt recognition of patients at risk is key to successfully preventing CDI.

METHODS

A 3-year prospective, observational, cohort study was conducted in a French university hospital and a nested case-control study was performed to identify risk factors for CDI. Inpatients aged 18 years or older, suffering from diarrhea suspected to be related to CDI, were asked to participate.

RESULTS

A total of 945 patients were included, of which 233 cases had a confirmed CDI. CDI infection was more common in men (58.4%) (P = 0.04) compared with patients with diarrhea not related to C. difficile. Previous hospitalization (P < 0.001), prior treatment with antibiotics (P = 0.001) or antiperistaltics (P = 0.002), liver disease (P = 0.003), malnutrition (P < 0.001), and previous CDI (P < 0.001) were significantly more common in patients with CDI. Multivariate logistic regression analysis showed that exposure to antibiotics in the last 60 days (especially third generation cephalosporins and penicillins with β-lactamase inhibitor), chronic renal or liver disease, malnutrition or previous CDI, were associated with an independent high risk of CDI. Age was not related with CDI.

CONCLUSIONS

This study showed that antibiotics and some comorbid conditions were predictors of CDI. Patients at high risk of acquiring CDI at the time of admission may benefit from careful monitoring of antibiotic prescriptions and early attention to infection control issues. In future, these "high-risk" patients may benefit from novel agents being developed to prevent CDI.

3D gastric computed tomography as a new imaging in patients with failure or complication after bariatric surgery

The number of bariatric operations performed each year is increasing. As a result, a rising number of patients in possible need for revisional surgery are referred to bariatric surgeons. But the standard methods of evaluation are often insufficient, and the best strategy remains difficult to choose. In our centre, we have developed 3D gastric computed tomography with air (3D-GCT). The aim of this pilot study was to assess the usefulness of this new image modality as an aid in the decision-making process in patients with failure or complications after bariatric surgery. Twenty patients referred for failure or complications after various bariatric procedures were included in the study. 3D-GCT was performed on a multidetector CT scanner after absorption of effervescent salt diluted in 10 ml of water and IV injection of butylscopolamine. Thin-slice data were transferred to a dedicated 3D workstation creating three-dimensional volume-rendering images of the oesophagus, gastric cavities and anastomoses. The volume of the gastric pouches and the diameter of stoma or anastomoses were measured. No failure or complications were observed. In all patients, 3D-GCT resulted in very impressive precise 3D images of post-surgical anatomy of the stomach. Imaging findings allowed us to identify or to eliminate the common complications of each procedure with a good accuracy, resulting in an aid to choose the best strategy in each patient. In conclusion, our pilot study suggests that 3D-GCT is useful as a decision-making aid in patients with failure or complications after bariatric surgery.

Resection of hepatocellular carcinoma in cirrhotic patients: longterm results of a prospective study

BACKGROUND

Surgical resection of hepatocellular carcinoma in cirrhotic patients remains controversial because of a high reported recurrence rate. To assess the longterm results of resection, 37 patients included in a prospective study were followed for more than 5 years, with special interest in early detection of recurrence.

STUDY DESIGN

Resection was performed from 1986 to 1991 with the goal of sparing the functional liver parenchyma. The mean tumor diameter was 5.3 +/- 2.6 cm (range 2 to 11 cm). Nineteen patients had tumors smaller than 5 cm. No additional perioperative therapy was performed.

RESULTS

Evidence of intrahepatic recurrence was demonstrated in 26 of the 33 patients surviving the operation. Eight recurrences (31%) were diagnosed from the third to the fifth postoperative years. The recurrence-free survival rates at 1, 2, 3, 4, and 5 years were 68%, 40%, 26%, 13%, and 9%, respectively. Only 2 patients (7%) were alive and free of recurrence at 5 years. Some long survivals were observed after treatment of recurrence. The overall survival rates at 3 and 5 years were 35% and 24%, respectively. Tumor cell differentiation was the only significant prognostic factor for both recurrence and survival. Multifocal tumors were associated with a higher recurrence rate. Patients with good liver function had longer survivals that reached 38% in those with small solitary tumors. Study of the other dinicopathologic factors failed to demonstrate any prognostic value.

CONCLUSIONS

Only a few patients are alive and free of recurrence 5 years after resection. Some long survival can be observed after treatment. Assessment of prognostic factors remains difficult, but the best results of resection are obtained in patients with small solitary hepatocellular carcinoma function.

Pancreatic surgical complications--the case for prophylaxis

Pancreaticoduodenectomy (Whipple's procedure) represents a considerable surgical challenge. Postoperative complications are common and typically related to leakage of pancreatic exocrine secretions following anastomosis failure. Pancreatic proteases and lipase leaking from the organ remnant attack the surrounding tissue, potentially leading to severe inflammation, tissue necrosis, and fistula formation. In addition, the soft consistency of the normal pancreas can lead to difficulties in manipulating the organ and reduce the integrity of sutures. Pancreatic fistula is the most serious postoperative complication and especially common following resectional surgery for malignant disease. Through prophylactic inhibition of digestive secretions, it should be possible to reduce postoperative morbidity after pancreatic surgery. One such inhibitor is somatostatin-14, an endogenous peptide hormone with pronounced effects on secretion of pancreatic enzymes and hormones, gastrointestinal secretions, and pancreatic blood flow, all of which may decrease the risk of postoperative complications. A limited number of randomised controlled trials have investigated prophylactic administration of somatostatin-14 and the synthetic somatostatin analogue octreotide in reducing complications following pancreatic surgery. While the majority of studies with octreotide demonstrated a significant reduction in the overall complication rate, the benefits appeared less marked in relation to events specifically related to pancreatic secretion. However, preliminary results from a limited number of trials with somatostatin-14, administered as a continuous intravenous infusion, suggest that prophylactic pharmacotherapy produces a significant decrease in fistula formation and secretion related events after pancreaticoduodenectomy. Due to these promising data, further investigation of the role of somatostatin-14 prophylaxis in pancreatic surgery is warranted in large well controlled trials.

Woodchuck hepatitis virus-induced carcinoma as a relevant natural model for therapy of human hepatoma

BACKGROUND

Eastern American woodchuck (Marmota monax), naturally infected with woodchuck hepatitis virus, a virus similar to human hepatitis B virus, develops liver cancer with a high prevalence.

AIMS

The aim of this work was to assess Marmota monax as a model of human hepatocellular carcinoma, especially to assess new potential adjuvant therapies after surgical resection.

METHODS

Forty-four woodchuck hepatitis virus-infected animals were regularly screened by ultrasound examination from the age of 18 months and for a 30-month period. One or more liver tumors were diagnosed in 31 animals (70%). Five of them with multifocal tumor or poor general status were considered unsuitable for surgery. The other 26 were operated on. At laparotomy no tumor was found in three.

RESULTS

The 18 liver tumors studied were hepatocellular carcinomas, grossly and microscopically similar to human hepatocellular carcinoma. Peritumoral parenchyma studied in 13 specimens was always non-cirrhotic but adequate staining demonstrated patterns of fibrosis in four cases. Clear evidence of chronic active hepatitis, periportal hepatitis and steatosis were demonstrated in five, seven and one of the 13 specimens, respectively. Tumors were treated by tumorectomy in eight animals, by alcoholization in seven and by laser photocoagulation in one. A simple tumor biopsy was performed in the other seven. Ten animals died postoperatively. All the survivors in the tumorectomy group died from tumor recurrence within 10-18 months after surgery.

CONCLUSIONS

It is concluded that woodchuck hepatitis virus-induced liver carcinoma is a natural model of human hepatocellular carcinoma with similar pathology and natural history, including early ultrasonic detection and tumor recurrence after resection. Tumor excision is feasible in this animal model, which now provides the basis for assessment of new potential adjuvant therapies for human hepatocellular carcinoma in an attempt to reduce the high recurrence rate after surgical resection in humans.

Adenocarcinoma in columnar-lined Barrett's esophagus. Analysis of 13 esophagectomies

From 1977 to 1982, 13 patients with adenocarcinoma arising in the distal esophagus lined by columnar epithelium underwent esophagectomy with detailed analysis of the pathologic specimen. In three patients, microinvasive carcinoma was detected before dysplasia occurred. In five patients, the ectopic mucosa was discontinuous, prolonged cranially by islands of columnar epithelium scattered in the squamous mucosa. Variable degrees of dysplasia were found in the columnar epithelium in seven specimens in areas of intestinal metaplasia. In four patients with high-grade dysplasia, several foci of intramucosal carcinoma were identified. They were scattered over the whole length of the ectopic mucosa. These data strongly suggest that adenocarcinoma develops from dysplasia, the real premalignant lesion. Careful periodic screening must be carried out in patients identified as having Barrett's esophagus. Dysplasia may be detected and located by endoscopy with dye spraying with directed biopsies. Patients with high-grade dysplasia should undergo esophagectomy with resection of the whole ectopic mucosa because they are at high risk for development of carcinoma.

Impact of sleeve gastrectomy volumes on weight loss results: a prospective study

BACKGROUND

Causes of weight loss failure after sleeve gastrectomy (SG) are still controversial. The impact of the size of the sleeve continues to be debated.

OBJECTIVE

The aim of our study was to determine the impact of sleeve volumes assessed at 3 months using gastric computed tomography (CT) on weight loss at 18 months.

SETTING

University Hospital, France.

METHODS

Sixty-seven obese patients eligible for SG were prospectively evaluated. Sleeve volumes were assessed postsurgery using 3-dimensional gastric CT with gas at 3 months and weight loss outcomes recorded up to 18 months. The population was divided into 2 groups: the first tertile (n = 22) with the smallest gastric volume was defined as the "small sleeve" group (SSG) and the rest of the population (n = 45) was defined as the "without small sleeve" group (WSSG).

RESULTS

No patients were lost to follow-up. In the SSG, overall gastric volume was 133±7 mL versus 264±11 mL for the WSSG (P<.0001). Percentage excess body mass index loss (%EBMIL) during the first postoperative 18 months was significantly greater in the SSG compared with the WSSG (P = .04). Although the volume of the gastric tube was not correlated with weight loss (r =-.04, P = .78), there was a negative linear correlation between the volume of the antrum and the %EBMIL at 18 months (r =-.39, P = .005). A narrow gastric tube was also associated with a high digestive intolerance and reflux.

CONCLUSION

Our data suggest that performing the sleeve with a not-too-small bougie size and a radical antrectomy could improve weight loss and digestive tolerance.

High resolution esophageal manometry evaluation in symptomatic patients after gastric banding for morbid obesity

BACKGROUND

Dysphagia and vomiting are frequent after laparoscopic gastric banding (LAGB). These symptoms could be secondary to esophageal motility disorders. Our aim was to assess esophageal motility and clearance in symptomatic LAGB patients using high resolution manometry (HRM).

METHODS

Twenty-two LAGB patients with esophageal symptoms (dysphagia, vomiting, and regurgitations) were included. Esophageal motility was studied using HRM (ManoScan®, Sierra Systems) and classified according to the Chicago classification.

RESULTS

The median delay between surgery and manometry evaluation was 6.3 years (range 1-10). Manometric data were considered as normal in only 2 patients. Achalasia was diagnosed in 3 cases, functional EGJ obstruction in 15, hypotensive peristalsis in 2. During swallowing pan-esophageal pressurization was observed in 6 patients, hiatal hernia pressurization in 7 and gastric pouch pressurization in 2. The intra-bolus pressure was elevated in 18 patients. LAGB was deflated in 6 patients and removed in 12. In 2 patients with unchanged symptoms after LAGB removal motility disorders persisted (1 achalasia, 1 functional EGJ obstruction).

CONCLUSION

In symptomatic LAGB patients, esophageal dysmotility is frequent. High resolution manometry allows the assessment of esophageal clearance and provides guidance for the choice of treatment.

Dilatation of Sleeve Gastrectomy: Myth or Reality?

OBJECTIVES

The success of longitudinal sleeve gastrectomy (LSG) is perceived as being potentially limited by dilatation of the remaining gastric tube during the follow-up. The aim of this prospective study was to determine the incidence and the characteristics of sleeve dilatation during the first post-operative year.

MATERIALS AND METHODS

Gastric volumetry using 3D gastric computed tomography with gas expansion was performed in 54 successive subjects who underwent an LSG for morbid obesity at 3 and 12 months following surgery. Total gastric volume, volume of the gastric tube and the antrum, and diameter of the gastric tube were assessed after multiplanar reconstructions. An increase of at least 25 % of the total gastric volume was considered as sleeve dilatation. Percentage of excess BMI loss (%EBMIL) and daily caloric intakes were recorded during the first 18 months.

RESULTS

Sixty-one percent of the subjects experienced sleeve dilatation 1 year after surgery. The gastric tube was mainly involved in the sleeve dilatation process (+91 %). Sleeve dilatation occurred especially in subjects with smaller total gastric volume at baseline (189 vs 236 ml, p = 0.02). Daily caloric intake was similar between the groups at each point of the follow-up. No difference concerning %EBMIL was observed between the groups during the 18 months of follow-up.

CONCLUSIONS

Sleeve dilatation occurred in more than 50 % of the patients. Dilatation was not necessarily linked to an increase of daily caloric intake and insufficient weight loss during the first 18 months following surgery. Small LSG at baseline is at higher risk of dilatation.

[Laparoscopic pancreatic resections]

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.

Prospective longitudinal assessment of change in health-related quality of life after adjustable gastric banding

BACKGROUND

Gastric banding remains a common procedure worldwide. Improving health-related quality of life (HRQOL) has become a major goal in the treatment of patients with chronic diseases, yet there are few comprehensive data regarding the effect of gastric banding on HRQOL. The aim of this study was to evaluate the impact of laparoscopic gastric banding on HRQOL with particular regard to change over time.

METHODS

The 262 consecutive patients included between May 2005 and September 2006 in a French multicenter prospective study designed to assess the safety and efficacy of a gastric band were asked to complete the SF36 questionnaire preoperatively and each 6 months during 3 years. The HRQOL scores were compared with community norms, and their longitudinal change was assessed using cross-sectional analysis and mixed-effects linear modeling (individual growth model).

RESULTS

One hundred sixty-four patients (63%) provided a preoperative and at least one postoperative SF-36 questionnaire from 12 to 36 months and form the basis of the present study. In all dimensions, the scores of HRQOL were significantly impaired preoperatively and were significantly improved at 3 years. The increase in HRQOL scores was most marked during the first postoperative months; it continued more slowly after 6 months and stabilized after 1 year. The improvement in HRQOL was associated with the decrease in BMI, in all dimensions.

CONCLUSION

Gastric banding results in a significant improvement in HRQOL. A return to normal can be expected at 1 year and persists at 3 years. The postoperative improvement in HRQOL is strongly related to weight loss.

Pulmonary hemorrhage and glomerulonephritis in primary biliary cirrhosis

We observed life-threatening intrapulmonary hemorrhages and focal proliferative glomerulonephritis in a 41-yr-old woman with primary biliary cirrhosis. The severity of the symptoms necessitated blood transfusions and mechanical ventilation; the patient improved with the help of corticosteroid therapy. No formal evidence of either Goodpasture's syndrome or any other well-defined systemic vasculitis could be found. Neutrophil cytoplasmic antibodies were initially positive and became undetectable after 3 mo of immunosuppressive treatment without relapse. This association has not been described previously and may be added to the list of extrahepatic immune-mediated conditions associated with primary biliary cirrhosis.

[Natural history of the pancreatic stump after duodenopancreatectomy of the pancreatic head]

Major complications following pancreaticoduodenectomy are thought to be chiefly associated with exocrine secretion of the pancreatic remnant which is not well known. This work aims to assess the exocrine secretion of the pancreatic remnant within the early post-operative period.

PATIENTS AND METHODS

Seventy-five patients undergoing pancreaticoduodenectomy for presumed tumour were included in a prospective multicentre study. A tube was inserted in the pancreatic duct at the time of construction of the pancreatic anastomosis. Peripancreatic drainage was routinely used. Pancreatic juice and peripancreatic drainage fluid were collected and measured and pancreatic enzyme monitored. For 7 days patients received total parenteral nutrition and continuous infusion of randomly Somatostatin 14 (S-14) at a dose of 6 mg/24 h (days 1-6) and 3 mg/24 h (day 7) or matching placebo. Pancreatic fistula was defined as a daily drainage of more than 100 cc of amylase-rich fluid after day 3, persisting after day 12 or associated with symptoms or needing specific treatment.

RESULTS

Daily output of pancreatic juice was low during the first postoperative day and then increased gradually until day 5. A high enzyme concentration was observed in pancreatic juice on the first post-operative day. S-14 infusion resulted in a significant decrease of both pancreatic fistula rate and enzyme concentration in peripancreatic fluid.

CONCLUSIONS

During the first postoperative days, the outflow of the exocrine secretion of the pancreatic remnant is low but contains a high enzyme concentration with significant leaks within the peripancreatic area. S-14 infusion results in a decrease of pancreatic juice leaks from the pancreatic remnant.

Transthoracic approach for liver tumors

Abdominal approach is commonly used for resection of liver tumors. However, in rare cases, transthoracic approach may be a valuable option for management of lesions located in the hepatic dome or involving the cavo-hepatic junction for very selected patients. This approach can be an open procedure (thoracotomomy), a video-assisted minimally invasive technique (thoracoscopy), or a strictly percutaneously treatment (CT-guided radiofrequency ablation). This approach seems useful for high-risk patients, with previous major abdominal surgery, or awaiting for liver transplantation (bridge concept) with cranially located single lesions. A limited liver resection (tumorectomy or segmentectomy) can be performed, but this approach is also suitable for percutaneous ablation therapy (radiofrequency or cryotherapy), with an acceptable morbidity.

Cystic involvement of the roof of the main biliary convergence in adult patients with congenital bile duct cysts: a difficult surgical challenge

BACKGROUND

Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care.

METHODS

A retrospective multicenter study was conducted in 4 European surgical centers concerning their experience with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof of the MBC (defined as being BDC with MBC involvement subgroup).

RESULTS

From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02).

CONCLUSION

BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.