C. Coimbra

Report of two cases of gastric cancer after bariatric surgery: lymphoma of the bypassed stomach after Roux-en-Y gastric bypass and gastrointestinal stromal tumor (GIST) after vertical banded gastroplasty.

We report two new cases of gastric cancer diagnosed after a bariatric operation. The first case is a 66-year-old male who 3 years after gastric bypass suffered from a perforation of the fundus that was found to be secondary to a diffuse large B-cell lymphoma of the distal stomach. The second case is a 47-year-old woman who presented 12 years after a vertical banded gastroplasty with a gastric pouch outlet obstruction caused by a gastrointestinal stromal tumor (GIST). Based on the few reports of cancer in the literature, analysis of these cases suggests that the main risk of gastric cancer after bariatric surgery comes from the delayed diagnosis of malignancy.

Risk of upper gastrointestinal cancer after bariatric operations

The authors discuss the potential influence of obesity surgery on the risk of cancer, focusing on the upper GI tract directly affected by operations. There is currently no substantiation for an increased risk of cancer after bariatric surgery, because there are only about 25 reports of subsequent cancer of the esophagus and the stomach. However, this review emphasizes the need to detect potential precancerous conditions before surgery. Candidates for postoperative endoscopic surveillance may include patients >15 years after gastric surgery, but also patients symptomatic for gastroesophageal reflux disease in whom a high incidence of Barretts metaplasia has been reported. The greatest concern is a delay in diagnosis from inadequate investigation due to mistaking serious upper GI symptoms as a consequence of the past operation.

Liver transplant donation after cardiac death : experience at the University of Liège

OBJECTIVE Donation after cardiac death (DCD) has been proposed to overcome in part the organ donor shortage. In liver transplantation, the additional warm ischemia time associated with DCD procurement may promote higher rates of primary nonfunction and ischemic biliary lesions. We reviewed the results of liver transplantation from DCD. PATIENTS AND METHODS From 2003 to 2007, we consecutively performed 13 controlled DCD liver transplantations. The medical records of all donors and recipients were retrospectively reviewed, evaluating in particular the outcome and occurrence of biliary complications. Mean follow-up was 25 months. RESULTS Mean donor age was 51 years, and mean intensive care unit stay was 5.4 days. Mean time between ventilation arrest and cardiac arrest was 9.3 minutes. Mean time between cardiac arrest and arterial flushing was 7.7 minutes. No-touch period was 2 to 5 minutes. Mean graft cold ischemia time was 295 minutes, and mean suture warm ischemia time was 38 minutes. Postoperatively, there was no primary nonfunction. Mean peak transaminase level was 2546 UI/mL. Patient and graft survival was 100% at 1 year. Two of 13 patients (15%) developed main bile duct stenosis and underwent endoscopic management of the graft. No patient developed symptomatic intrahepatic bile duct strictures or needed a second transplantation. CONCLUSIONS Our experience confirms that controlled DCD donors may be a valuable source of transplantable liver grafts in cases of short warm ischemia at procurement and minimal cold ischemia time.

Pylephlebitis of the portal vein complicating intragastric migration of an adjustable gastric band.

Pylephlebitis, or septic thrombophlebitis of the portal vein, is an infrequent but life-threatening complication of abdominal septic events. The authors report the occurrence of pylephlebitis and multiple liver abscesses induced by a neglected intra-gastric migration of an adjustable silicone gastric band. The patient was successfully treated by broad-spectrum antibiotics and total gastrectomy with Roux-en-Y esophago-jejunostomy. Postoperative recovery was marked by acute liver failure that was managed conservatively. The patient is alive and well at 1-year follow-up. This case emphasizes the interest in early removal of the band when intra-gastric migration is diagnosed.

Exocrine pancreas graft drainage in recipient duodenum through side‐to‐side duodeno‐duodenostomy

The interesting report by Hummel et al. in the Februaryissue of this Journal [1] confirmed our previouspublication indicating that, in pancreas transplantation,side-to-side duodeno-duodenal anastomosis is technicallyfeasible and allows easy access to the graft duodenalmucosa for repeated biopsies and rejection monitoring[2]. In our experience we prefer to anastomose the graftportal vein to the infrapancreatic superior mesenteric veinsimilarly to the technique described by Boggi et al. [3].With this procedure, the pancreas graft is positioned in apure retroperitoneal and physiologic location for bothendocrine and exocrine drainage, but it is uncertain ifthis fact has any influence on the functional results of thetransplantation.The main drawback of this technique is the potentialfor anastomotic leak that could be challenging to controlas the recipient duodenum cannot be resected. Directduodenal repair, plasty with a Roux-en-Y limb, orlaterolateral duodenojejunostomy may be surgical optionsto achieve recipient duodenal closure in case of anasto-motic leak [2].We considered using this technique in our last fivepancreas transplantations (three pancreas alone and twosimultaneous pancreas-kidney transplantations). In fourpatients, side-to-side duodeno-duodenal anastomosis wasperformed (three manually and one with a circularstapling device, according to the surgeon’s preference).Immunosuppression consisted of quadruple therapy,including induction with polyclonal antibodies andmaintenance with tacrolimus, mycophenolate mofetil andlow-dose steroids. These patients underwent regularprotocol duodenal biopsies, without any evidence of acuteor chronic rejection. Pancreas graft and patient survival is100% at follow-up. One patient required two re-laparoto-mies, for early non-infected peripancreatic hematoma andfor late (>6 months) mechanical intestinal occlusion. Nopatient experienced any complication linked to theduodenal anastomosis or to the vascular reconstruction.In the fifth patient recipient of simultaneous pancreas-kidney transplantation, pancreas graft duodenum wasfound to be badly preserved at reperfusion, and we thenchose to perform duodenal drainage through a Roux-en-Y jejunal limb. This patient developed anastomoticleakage requiring life-saving pancreas graft resection afterthree unsuccessful attempts of surgical correction.This small series of duodeno-duodenal drainage ofpancreas grafts, and the case described by Hummel,provide some evidence that this technique is feasible,appears to be safe in pancreas grafts with good duodenalpreservation, and provides easy access of the duodenalmucosa for rejection monitoring. All these pancreas graftsare functioning perfectly and did not develop any episodeof rejection. These promising results need to beconfirmed by larger series and controlled comparisonwith classical enteric drainage.Arnaud De Roover, Olivier Detry,Carla Coimbra, Jean-Paul Squifflet,Pierre Honore´ and Michel MeurisseDepartment of Abdominal Surgeryand Transplantation,University of Liege,Liege, BelgiumReferences1. Hummel R, Langer M, Wolters HH, Senninger N, Brock-mann JG. Exocrine drainage into the duodenum: a noveltechnique for pancreas transplantation. Transpl Int 2008;21: 178.2. De Roover A, Coimbra C, Detry O, et al. Pancreas graftdrainage in recipient duodenum: preliminary experience.Transplantation 2007; 84: 795.3. Boggi U, Vistoli F, Signori S, et al. A technique forretroperitoneal pancreas transplantation with portal-entericdrainage. Transplantation 2005; 79: 1137.

Prevalence, characteristics and risk factors of chronic post surgical pain after laparoscopic colorectal surgery: retrospective analysis

BACKGROUND The prevalence of chronic postsurgical pain (CPSP) is a critical medical problem with economic implications. Its prevalence after gastrointestinal surgery is not well documented, particularly when a laparoscopic approach is used. OBJECTIVE The aim of the study was to determine the prevalence, the characteristics and the risk factors for CPSP after laparoscopic colorectal surgery. DESIGN A retrospective analysis using a postal questionnaire. SETTING The study was conducted at a university teaching hospital. PATIENTS Patients who underwent laparoscopic colorectal surgery from April 2008 until December 2011 (n = 260). No epidural analgesia was used. MAIN OUTCOME MEASURES Postoperative pain intensity, incidence and characteristics of CPSP, and impact on quality of life and sleep. RESULTS Of 199 responses, 33 patients (17%) reported chronic pain at a median [interquartile range, IQR] of 38 [27 to 55] months after laparoscopic surgery with a median intensity of 4 [3 to 5]. CPSP had a negative impact on the quality of life in 84% of patients and on sleep in 43%. CPSP required regular analgesic(s) intake in 54% patients. Using a backward stepwise multivariate logistic regression model, the following variables were determined as independent risk factors for CPSP: redo surgery for anastomotic leakage (P = 0.01), inflammatory bowel disease (IBD) as the indication for surgery (P = 0.01) and preoperative pain (P = 0.05). CONCLUSION The incidence of CPSP after laparoscopic colorectal surgery (17%) is similar to those reported in the literature after laparotomy. Risk factors are redo surgery for postoperative peritonitis, IBD and preoperative pain. TRIAL REGISTRATION EudraCT 2012-005712-25.

Adjuvant hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) associated with curative surgery for locally advanced gastric carcinoma. An initial experience.

Abstract Aim of the study : After macroscopic radical (R0) surgery for advanced gastric carcinoma, 40 to 50% of the tumors recur in the abdomen as locoregional or peritoneal disease. We initiated a protocol in which patients with suspicion of macroscopic serosal, lymphatic or peritoneal invasion, treated with R0 resection, underwent adjuvant HIPEC. Methods : Between June 1998 and January 2003, 16 patients with locally advanced adenocarcinoma of the stomach were included in the study. Surgery consisted of a total gastrectomy with a D2 lymphadenectomy. Splenectomy (n = 1), splenopancreatectomy (n = 4), transverse colectomy (n = 3), left hepatectomy (n = 1), localized peritonectomy (n = 3) were associated to obtain a R0 resection. HIPEC protocol consisted of heated (42.5°C) intraperitoneal mitomycin C (15 mg/m2) for a planned duration of 90 minutes. Results : HIPEC median duration was limited to 73(20–90) min because of central hyperthermia recognition in half of the cases. One patient died in the postoperative period of sepsis secondary to a duodenal fistula. Postoperative morbidity included pancreatic fistula (n = 2), pulmonary oedema (n = 1), pulmonary embolus (n = 1) and transient renal failure (n = 1). UICC staging was IB (n = 2), II (n = 2), IIIA (n = 5), IIIB (n = 1), IV (n = 6). Nine of the 16 patients are alive without recurrence with a median follow-up of 52 months. Four patients developed a recurrence, intraperitoneal (n = 2), systemic (n = 1), or combined (n = 1). Two patients were lost to follow-up. Conclusions : Aggressive surgical therapy and HIPEC might represent the standard of care in a selected population with locoregional disease and for whom a r0 resection can be achieved. This protocol was associated in this study with a 75% 5-year survival with a low peritoneal recurrence rate and an acceptable morbidity.

A Retrospective Monocenter Review of Simultaneous Pancreas-Kidney Transplantation.

OBJECTIVE Herein we have reviewed a consecutive series of simultaneous pancreas-kidney (SPK) transplantations performed at our institution over a 6-year period. PATIENTS AND METHODS The study population included 22 patients (15 males and 7 females) who underwent SPK transplantation between 2001 and 2007. The mean recipient age was 47 years (range, 26-63 years). Eighteen patients suffered type 1 and 4 type 2 diabetes mellitus. The mean donor age was 33 years (range, 14-56 years). The mean HLA match was 2.1 (range, 1-5). Immunosuppressive treatment consisted of basiliximab induction followed by tacrolimus, mycophenolate mofetil, and prednisone. RESULTS The mean hospital stay was 20 days (range, 11-52 days). After a mean follow-up of 44 months (range, 17-88 months), patient, kidney, and pancreas graft survivals were 86%, 82%, and 73%, respectively. Two patients died in the immediate postoperative period due to, respectively, disseminated intravascular coagulation and pulmonary embolism. A kidney graft was lost due to early hyperacute rejection. Other early complications associated with the pancreas graft included 2 cases of immediate reperfusion defects that led to early vascular thrombosis in 1 patient and a duodenal graft fistula in the other patient; a third patient developed type 2 diabetes mellitus. Beyond the postoperative period, graft loss was limited to 1 case of noncompliance to the immunosuppressive medications and 1 death secondary to pulmonary infection with a functional allograft after 4 years. CONCLUSIONS SPK transplantation is a valid therapeutic option for patients with insulin-dependent diabetes mellitus and renal failure due to diabetic nephropathy. The main complications of SPK transplantation occur in the immediate postoperative period consequent to vascular or rejection processes.

Living related liver transplantation in adults: first year experience at the University of Liège.

Abstract Living related liver transplantation (LRLT) in adult recipients has been recently developed to overcome the organ donor shortage, but LRLT leaves the healthy donors at risk of serious post-operative complications, or even death. The aim of this paper is to report the prospective evaluation of the initial experience of adult LRLT at the University of Liège. From March 2002 till March 2003, in a consecutive series of 35 adult liver transplantations, five recipients (mean age: 51 years) underwent LRLT, including one retransplantation. Indications for transplantation were autoimmune hepatitis, hepatitis B virus related cirrhosis with hepatocarcinoma (two cases), hepatitis C virus related cirrhosis with hepatocarcinoma, and ischemic intrahepatic bile duct necrosis 10 years after primary liver transplantation. Mean age of the donors was 34 years (range: 21-53 years). All donation cases were intra familial at first degree. The right lobe was used as a graft in four cases and the left lobe in one case. All right lobe donors developed transient hyperbilirubinemia and hypocoagulation for 4 to 6 days. No severe complication (transfusion, bile duct fistula, reintervention, rehospital-ization) nor significant long-term sequelae were observed in the donors. In the recipients, graft function was immediate, and there was no small-for-size syndrome. One recipient developed biliary fistula treated by reoperation. One recipient died from invasive aspergillosis 11 days after the procedure. The four other recipients were alive without recurrence of the disease at follow-up. This report confirmed that LRLT may be a valuable alternative to cadaveric liver transplantation in the era of organ donor shortage. However, even if there was no severe complication for the donors in our preliminary experience, LRLT puts healthy living donors at risk of significant morbidity and even death.

Overlap syndrome consisting of PSC-AIH with concomitant presence of a membranous glomerulonephritis and ulcerative colitis

The association of primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) is known as an overlap syndrome (OS). OS can also be described in the setting of concomitant presence of AIH and PSC. These diseases can in some cases be associated with ulcerative colitis. In this case report we describe, to our knowledge, the first case in the literature of a young Caucasian male suffering from ulcerative colitis and an overlap syndrome consisting of an association between PSC-AIH, with the concomitant presence of a membranous glomerulonephritis.