Arne R. Rosseland

Intradermal ras peptide vaccination with granulocyte‐macrophage colony‐stimulating factor as adjuvant: Clinical and immunological responses in patients with pancreatic adenocarcinoma

K‐RAS mutations are frequently found in adenocarcinomas of the pancreas, and induction of immunity against mutant ras can therefore be of possible clinical benefit in patients with pancreatic cancer. We present data from a clinical phase I/II trial involving patients with adenocarcinoma of the pancreas vaccinated by i.d. injection of synthetic mutant ras peptides in combination with granulocyte‐macrophage colony‐stimulating factor. Forty‐eight patients (10 surgically resected and 38 with advanced disease) were treated on an outpatient basis. Peptide‐specific immunity was induced in 25 of 43 (58%) evaluable patients, indicating that the protocol used is very potent and capable of eliciting immune responses even in patients with end‐stage disease. Patients followed‐up for longer periods showed evidence of induction of long‐lived immunological memory against the ras mutations. CD4+ T cells reactive with an Arg12 mutation also present in the tumor could be isolated from a tumor biopsy, demonstrating that activated, ras‐specific T cells were able to selectively accumulate in the tumor. Vaccination was well tolerated in all patients. Patients with advanced cancer demonstrating an immune response to the peptide vaccine showed prolonged survival from the start of treatment compared to non‐responders (median survival 148 days vs. 61 days, respectively; p = 0.0002). Although a limited number of patients were included in our study, the association between prolonged survival and an immune response against the vaccine suggests that a clinical benefit of ras peptide vaccination may be obtained for this group of patients.

Laparoscopic liver resection for malignant and benign lesions: ten-year Norwegian single-center experience.

BACKGROUND The introduction of laparoscopic liver resection has been challenging because new and safe surgical techniques have had to be developed, and skepticism remains about the use of laparoscopy for malignant neoplasms. We present herein a large-volume single-center experience with laparoscopic liver resection. DESIGN Retrospective study. SETTING Rikshospitalet University Hospital. PATIENTS One hundred thirty-nine patients who underwent 177 laparoscopic liver resections in 149 procedures from August 18, 1998, through October 14, 2008. One hundred thirteen patients had malignant lesions, of whom 96 had colorectal metastases. INTERVENTION Laparoscopic liver resection for malignant and benign lesions. MAIN OUTCOME MEASURES Perioperative and oncologic outcomes and survival. RESULTS Five procedures (3.4%) were converted to laparotomy and 1 (0.7%) to laparoscopic radiofrequency ablation. The remaining 143 procedures were completed laparoscopically, during which 177 liver resections were undertaken, including 131 nonanatomic and 46 anatomic resections. The median operative time and blood loss were 164 (50-488) minutes and 350 (<50-4000) mL, respectively. There were 10 intraoperative (6.7%) and 18 postoperative (12.6%) complications. One patient (0.7%) died. The median postoperative stay and opioid requirement were 3 (1-42) and 1 (0-11) days, respectively. Tumor-free resection margins determined by histopathologic evaluation were achieved in 140 of 149 malignant specimens (94.0%). The 5-year actuarial survival for patients undergoing procedures for colorectal metastases was 46%. CONCLUSIONS In experienced hands, laparoscopic liver resection is a favorable alternative to open resection. Perioperative morbidity and mortality and long-term survival after laparoscopic resection of colorectal metastases appear to be comparable to those after open resections.

Diagnostic Laparoscopy in 1043 Patients with Suspected Acute Appendicitis

OBJECTIVE To evaluate the efficacy of diagnostic laparoscopy in patients with suspected acute appendicitis, the number of complications associated with the laparoscopic technique, and the effect of leaving a macroscopically normal-looking appendix in place. DESIGN Three prospective protocols. SETTING Three departments of surgery, one in Norway and two in Sweden. SUBJECTS 1043 patients aged 15 years or over. INTERVENTIONS Diagnostic laparoscopy in patients with signs and symptoms of acute appendicitis who were to be operated on. MAIN OUTCOME MEASURES Morbidity, mortality, and histological appearance of removed appendices, and outcome whether or not the patient was operated on. RESULTS 819 patients had appendectomies (61% laparoscopically and 39% by conversion to open operation) with a total complication rate of 10%. In 211 patients a diagnostic laparoscopy was done as a single procedure. There were 181 women in this group and 86 of them had gynaecological disorders. The complication rate was 2% among these 211 patients and after a follow up of two years no patients had been readmitted for appendicectomy. 13 patients were subjected to other open procedures. The overall mortality was 0.4%. CONCLUSION Diagnostic laparoscopy is safe and can be recommended in patients with suspected acute appendicitis, particularly in women. A macroscopically normal-looking appendix can be left in place.

Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome.

Objective: To analyze the immediate and long-term outcome after laparoscopic resection of colorectal liver metastases and difference between observed and predicted [Fongs and Basingstoke Predictive Index (BPI) scores] survivals. Background: Laparoscopic liver resection has been reported safe and feasible and improves postoperative course. The oncologic outcomes after resection of colorectal metastases are poorly reported. Methods: Between August 1998 and January 2010, 122 patients underwent laparoscopic resection for colorectal liver metastases during 135 procedures at Rikshospitalet. Patients undergoing surgery between August 1998 and June 2009 were included in research analysis. The patients had median Fongs and BPIs scores of 2 (0–5) and 7 (0–23), respectively. Mainstream analysis of hospital data was done on intent-to-treat basis. Intraoperative incidents and postoperative complications were analyzed according to the Satava and Clavien-Dindo classifications. Median follow-up was 24 (0–100) months. Results: One hundred fifty-one liver resections were performed in 107 patients during 118 procedures: 117 nonanatomic and 34 anatomic liver resections. There were 5 conversions to laparotomy (4.2%). The resection margin was free of tumor tissue in 141 (93.4%) of 151 specimens, and the distance between the resection margin and tumor tissue was median 6 (0–40) mm. Intraoperative incidents occurred in 14 cases (11.9%), including 5 (4.2%), 8 (6.8%), and 1 (0.8%) cases of grades I, II, and III, respectively. Postoperative complications were observed in 16 cases (14.3%), including 2, 3, 7, 3, 0, and 1 cases of grades I, II, IIIa, IIIb, IV, and V, respectively. During follow-up, 21 patients received repeat liver resection of recurrences (11 by laparoscopy and 10 by laparotomy). The 5-year overall survival rates were 51% as laparoscopically completed cases and 47% as intent-to-treat. The observed actuarial survival values exceeded the values expected by Fongs and BPIs score, with 10.2% and 6.7% as laparoscopically completed cases and with 3.8% and 2.4% as intent-to-treat, respectively. Conclusions: Laparoscopic resection is a favorable alternative to open liver resection for patients with colorectal liver metastases. The observed actuarial survival values after laparoscopic resection surpass the values expected by major scoring systems.

Endoscopy-related Bacteremia

A prospective study was undertaken to investigate the frequency of bacteremia after endoscopy of the gastrointestinal tract. In one out of 100 patients undergoing gastroscopy and in one out of 25 patients undergoing coloscopy, positive blood cultures could be demonstrated. In both cases anaerobe lactobacilli were recovered. No bacteremia was demonstrated in 25 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

Single-centre experience of laparoscopic pancreatic surgery†

Laparoscopic resection is regarded as safe and feasible in selected patients with benign pancreatic tumours. Few data exist on laparoscopic surgery for malignant lesions and larger neoplasms in unselected patients.

Laparoscopic and open operation in patients with perforated peptic ulcer

OBJECTIVES To compare the results of laparoscopic and open operations in patients with perforated peptic ulcer. DESIGN Retrospective analysis. SETTING Central hospital, Norway. SUBJECTS 74 patients (36 men, 38 women, median age 69.5 years (18-86)) admitted with perforated peptic ulcers from November 1991-May 1996. INTERVENTIONS Suture of the ulcer, patching with the greater omentum and lavage, in 49 by open operation and 25 laparoscopically. MAIN OUTCOME MEASURES Duration of postoperative hospital stay, operating time, number of doses of analgesic, postoperative body temperature, complications, and mortality. RESULTS There was a significant difference (p = 0.0001) in median operating time: 100 minutes (range 48-160) in the laparoscopic group and 50 minutes (range 20-160) in the open group. The median hospital stay was 8 days in both groups: range 3-23 days in the laparoscopic group and 2-28 days in the open group. There were no significant differences between the two groups with regard to median number of doses of analgesic, median body temperature, complications or mortality. CONCLUSION Laparoscopic operation for perforated peptic ulcer can be considered as safe as open operation.

Laparoscopic resection of exocrine carcinoma in central and distal pancreas results in a high rate of radical resections and long postoperative survival

BACKGROUND The role of laparoscopic resection in patients with pancreatic cancer remains to be clarified, because previous reports have not clearly defined oncologic outcomes. The objective of the present study was to investigate this question with the rate of R0 resection and long-term survival as endpoints. METHODS This retrospective observational study included prospectively collected data from 40 patients operated laparoscopically with curative intent for exocrine pancreatic malignancies identified among 250 consecutive patients undergoing laparoscopic pancreatic operations since 1997. All 40 patients had histologically verified exocrine pancreatic carcinoma. RESULTS Ten patients (25%) with typical ductal adenocarcinoma of the pancreas were deemed nonresectable by laparoscopic staging. Laparoscopic distal pancreatectomy was performed in 29 patients; 8 resections were combined with resections of adjacent organs and 1 removal of a malignant intraductal papillary mucinous neoplasm what appeared to be ectopic pancreatic tissue. In 1 patient, the resection was completed by hand-assisted technique, and 1 procedure was converted to open resection. Postoperative morbidity was 23% (n = 7). The median hospital stay was 5 days (range, 1-30). The rate of R0 resections was 93%. Postoperative 3-year survivals rates were 36% for the entire cohort (n = 30) and 30% in typical ductal adenocarcinoma (n = 21). CONCLUSION Laparoscopic distal pancreatectomy for exocrine pancreatic carcinoma is comparable with outcomes after open surgery and supports the concept that laparoscopic distal pancreatectomy is a safe, oncologic procedure.

Should we use laparoscopic adrenalectomy for metastases? Scandinavian multicenter study

Laparoscopic adrenalectomy for metastases is considered controversial. Multicenter retrospective study was performed to gain new knowledge in this issue.

Gallbladder and Duodenal Bacterial Flora after Papillotomy in Rabbits

Gallbladder and duodenal bacteria were studied in New Zealand white rabbits 1 and 4 weeks after papillotomy. The gallbladder bile was sterile in all animals before papillotomy. One and 4 weeks after papillotomy growth of both aerobic and anaerobic bacteria was found in the gallbladder bile in five of eight test animals and in none of the control rabbits. The number of bacteria in the duodenum increased in rabbits that developed growth of bacteria in the gallbladder bile after papillotomy. In the test rabbits that did not develop bacteria in the gallbladder bile and in the control group no changes in duodenal bacteria were observed.