Georgios C. Sotiropoulos

Acute leukemoid reaction associated with liver surgery for metastatic colorectal cancer

Dear Editor: A 48-year-old woman was referred to our department for management of colorectal cancer metastatic to the liver. Past medical and hematological history was nonsignificant. Past surgical history included sigmoidectomy for colonic adenocarcinoma with synchronous bilobar liver disease 1 year ago in a peripheral hospital. Following surgery, she had received first line chemotherapy ensued by treatment with bevazicumab due to a favorable K-ras status. At presentation to our hospital, liver disease showed a 60 % response to chemotherapy. We planned a two-staged hepatectomy, a right portal vein ligation combined with left liver lobe metastasectomies followed by a right hepatectomy 5 weeks later. The first operation ran uneventfully, and we proceeded to the next stage after a preoperative CT confirming an adequate left hemiliver volume. The patient underwent an anatomical right hemihepatectomy. During the immediate postoperative period, she gradually developed an obstructive jaundice (peak value: total bilirubin 12 mg/dl, direct bilirubin 9 mg/dl). Her white blood cell counts ranged between 7× 10/L and 16×10/L during the same time period. Due to persistent hyperbilirubinemia, an abdominal ultrasound exhibiting notable intrahepatic biliary tree dilatation and a MRCP not illustrating the extrahepatic biliary structures, we decided to proceed to surgery. At relaparotomy, we observed a 180° malrotation around the common bile duct due to malposition of the liver remnant into the abdominal cavity. A Rouxen-Y hepatojejunostomy was tailored across segments II and III, and the hemiliver was repositioned. The patient was directly extubated and transferred to the surgical ward. Surprisingly, her first blood counts postoperatively showed marked leukocytosis [white blood counts (WBC):53×10/L], with a neutrophilic differential (neutrophils 93 %). Her WBC continued to increase during the following hours, peaking at 93×10/L on the second postoperative day. Of note, the patient was afebrile without any septic-related symptoms or signs during this time period. A hematology consultation was pursued. Her clinical examination was non-remarkable. No hepatosplenomegaly or lymphadenopathy was present. The white blood cell differential was as follows: 95 % neutrophils, 2 % bands, 2 % lymphocytes and 1 % monocytes. The blood smear showed mature normally lobated neutrophils without toxic granulation. Occasional bands were noted without a left shift. Red blood cells were of normal morphology without the presence of schistocytes. Platelets were within normal limits regarding number and morphology. At this juncture, a detailed work-up was undertaken to rule out infection and sepsis. C-reactive protein, blood cultures, disseminated intravascular coagulation panel, urinalysis, and culture, as well as chest X-ray were within normal limits. Her WBC gradually declined to normal level during the following 5 days, and the patient was discharged 2 weeks later. Persistent neutrophilic leukocytosis exceeding 50×10/L and peaking as high as 180×10/L in noninfected patients with malignant, non-hematopoietic neoplasias is termed a leukemoid reaction. The exact pathophysiology underlying this excessive leukocytosis is yet unclear. Various reports on solid tumors associated with neutrophilic leukocytosis suggest that paraneoplastic cytokine production by the primary tumor induces granulocytic overproduction, therefore resulting in a leukemoid reaction. Indeed, production of granulocyte colony-stimulating factor, granulocyte–macrophage–CSF, interleukin-1, and/or interleukin-6 by several aerodigestive G. C. Sotiropoulos (*) : P. Charalampoudis :G. Kouraklis 2nd Department of Propedeutic Surgery, University of Athens Medical School, Laikon Hospital, 17 Agiou Thoma Street, Athens 11527, Greece e-mail: georgios.sotiropoulos@uni-due.de

Microbe Isolation from Blood, Central Venous Catheters, and Fluid Collections after Liver Resections

BACKGROUND Our goal was to evaluate the microbe species responsible for bacteremia or infections related to central venous catheter (CVC) or fluid collections after liver resection. PATIENTS AND METHODS Data from 112 patients (68 males, 44 females) who underwent liver resection over a period of 63 months were reviewed. Patient and tumor characteristics, intra-operative and post-operative data, and the results from cultures of peripheral blood, CVC tips and drained intra-abdominal or intra-throracic fluid collections were collected. RESULTS There were positive blood cultures in 20 patients (17.9%). Coagulase-negative staphylococci (CoNS) and bacteria of enteric flora were the micro-organisms found most frequently and half of the cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis was an independent risk factor for microbe isolation in peripheral blood (odds ratio [OR]: 11, p = 0.01). Furthermore, there were positive cultures of the CVC tip in 14 patients (12.5%), with CoNS being the micro-organism found most frequently and most cases had only one isolated microbe species. No specific risk factor for catheter-related infections was detected. In addition, there were positive cultures of drained fluid collections in 19 patients (17%), with bacteria of enteric flora being the micro-organisms found most frequently and the majority of cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis (OR: 23.5, p = 0.002) and the laparoscopic approach (OR: 4.7, p = 0.0496) were independent risk factors for microbe isolation in drained fluid collections. Finally, the presence of positive blood cultures was associated with the presence of positive culture of CVC tips (p = 0.018) and drained fluid collections (p = 0.001). CONCLUSIONS Post-operative bacteremia, colonization of CVCs, and contamination of fluid collections occur frequently after liver resections and various microbe species may be involved. Patients who undergo hepatectomy and a synchronous construction of a bilioenteric anastomosis are at increased risk of bacteremia development and contamination of fluid collections.

Liver transplantation for hepatocellular carcinoma with live donors or extended criteria donors: a propensity score-matched comparison

Background To compare patient survival after liver transplantation (LT) for hepatocellular carcinoma (HCC) from live donors (LD) or extended criteria donors (ECD). Methods Data from consecutive LT procedures for HCC involving either LD or ECD were reviewed. Patient survival was our primary outcome. Re-transplantation (Re-LT), ischemic type bile lesions (ITBL), and tumor recurrence represented secondary outcomes. The primary outcome was statistically analyzed using Kaplan-Meier estimates and Cox proportional hazards regression; logistic regression analyses were used for statistical analysis of the secondary outcomes. Propensity score was calculated based on patient age, sex, hepatitis C viral infection (HCV), laboratory model for end-stage liver disease (labMELD) score, bridging treatment, Milan criteria, α-fetoprotein levels, and tumor grade. Results The study evaluated 109 recipients undergoing LT from either LD (n=57) or ECD (n=52). LT procedure (hazard ratio [HR] 2.349, 95% confidence interval [CI] 1.151-4.794, P=0.0190), age (HR 1.075, 95%CI 1.020-1.133, P=0.0074) and labMELD score (HR 1.082, 95%CI 1.021-1.147, P=0.0075) reached significance by Cox proportional hazards regression. After adjustment with the propensity score (stratification with 5 strata), the LT procedure was still significant (HR 2.401, 95%CI 1.114-5.175, P=0.0253). Tumor grade (odds ratio [OR] 9.628, 95%CI 1.120-82.752, P=0.0391), labMELD score (OR 1.224, 95%CI 1.019-1.471, P=0.0306), and Milan criteria (OR 6.375, 95%CI 1.239-32.796, P=0.0267) gained statistical significance by logistic regression analysis for Re-LT, ITBL, and tumor recurrence, respectively. Conclusions LT for HCC showed superior patient survival with ECD rather than LD grafts. Re-LT, ITBL, and tumor recurrence showed no significant differences between the two groups. However, the diverging criteria for the definition of ECD grafts represent a considerable limitation for the wide application of this policy.

Case Report: Laparoscopic hepatectomy in an elderly patient with major comorbidities

Surgeons have been hesitant to proceed to hepatectomy in elderly patients, due to the higher rate of comorbidities and the reduced reserves. An 81-year-old male with hepatocellular carcinoma in the segment VI of the liver and several major cardiovascular, pulmonary and metabolic comorbid illnesses was referred to our department for treatment. He underwent transarterial chemoembolization of the liver tumor and afterwards he underwent laparoscopic resection of the hepatic segment VI, with an uneventful postoperative course. This case indicates that laparoscopic liver resections could be applied even to elderly patients with major comorbidities after optimization of their medical status.

Peripheral hepatojejunostomy: a last resort palliative solution in Greece during the economic crisis

The geographical distribution of Greece and the growing proportion of uninsured patients make imperative the need for effective and efficient palliative solutions regarding obstructive jaundice due to hepatic malignancy, while repeated endoscopic interventions and all associated materials are either not accessible to the whole population or not even available on a daily basis due to the economic crisis and the difficulties on the hospital supply. On this basis, palliative hepatojejunostomy, introduced more than 50 years ago, could be revisited in the Greek reality in very selected cases and under these special circumstances. We report on two patients with locally advanced hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma, respectively, who were treated with a combination of double hepaticojejunostomy with peripheral hepatojejunostomy or peripheral hepatoejunostomy alone, respectively. Both patients experienced an adequate decompression of the biliary tract over more than a year. Palliative hepatojejunostomy could be an ultimate solution for selected patients and circumstances in Greece during the economic crisis.

Conventional transanal excision for a very low gastrointestinal stromal tumour

Gastrointestinal stromal tumour (GIST) represents a rare tumour entity, which has been more intensively investigated during the last decade. The rectum as the primary site of GIST is even uncommon. The space constraints in the pelvis renders optimal oncological surgery demanding and proximity of these lesions to the anal sphincter enhances the potential morbidity of any radical surgery. We herein report on a young patient with a >5 cm rectal GIST localised at 1 cm from the anorectal junction.

Organ donation during the financial crisis in Greece

1 Mock CN, Donkor P, Gawande A, et al. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet 2015; 385: 2209–19. 2 Weiser TG, Haynes AB, Molina G, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ 2016; 94: 201–09. 3 Uribe-Leitz T, Esquivel MM, Molina G, et al. Projections to achieve minimum surgical rate threshold: an observational study. Lancet 2015; 385 (suppl 2): S14. 4 Moris D, Zavos G, Menoudakou G, Karampinis A, Boletis J. Organ donation during the fi nancial crisis in Greece. Lancet 2016; 387: 1511–12. 5 Giannakopoulos G, Anagnostopoulos DC. Child health, the refugees crisis, and economic recession in Greece. Lancet 2016; 387: 1271. Global surgery initiative in Greece: more than an essential initiative

R0 and yR0 resections for colorectal liver metastases: need for a precise definition.

Dear Editor: Metastatic colorectal cancer in the liver represents an ideal paradigm for a well-structured multidisciplinary tumor board, where clinical and radiation oncologists, surgeons, and interventional radiologists contribute to the optimization of the outcomes of these patients. Modern surgical techniques and targeted chemotherapeutics with new components have dramatically changed the physical history of this metastatic disease, converting it to a chronic one with a 5-year survival reaching 50 % in surgical cases. Although liver resection— when possible—has a cardinal role to the whole management of these patients, much confusion is present in the corresponding literature concerning the extent of the surgical margin in the liver, especially in the cases where a downsizing has been achieved through neoadjuvant therapy. The residual tumor classification of the tumor-nodemetastasis system, described by the symbol R, although firstly initiated to apply only to the primary tumor, is currently applied more broadly to include surgery of the metastatic disease. The old consideration on liver resection for colorectal liver metastases, defined from what has to be removed, focused on the number/size of liver metastases, the presence of extrahepatic disease, and the achievement of a surgical margin in the liver of ≥1 cm. The new consideration, defined from what has to be preserved, focused on the liver remnant and the achievement of a clear microscopic surgical margin, i.e., a R0 resection. Even a surgical margin of 1 mm has been considered sufficient regarding the patient survival, recurrence risk or site of recurrence. Hence, the R0 resection probability for the liver metastatic disease was introduced as the main decision maker within the multidisciplinary tumor board, regardless of the surgical margin width. However, at the time of effective chemotherapy, with different components (plus/minus biological factors) and timing (pre/posthepatectomy) combinations, contradictory studies are published. Some authors report on the necessity of a wider surgical margin, in order to better control the local recurrence rate. Others report on acceptable outcomes even in R1 situations (similar overall and disease-free survival rates in comparison to R0 resection). The chemotherapy protocol (which, how many/how long, when/pre-postoperative) and the extraordinary downsizing which is documented in many cases, leading sometimes to disappearing metastases, provoke a modern problem in liver surgery for metastatic disease, of Bwhere^ and Bhow^ to cut. The confusion in reporting on the R-status after liver resection for colorectal liver metastases will go on, since authors continue to report in such heterogeneous matter on their metastasectomies. Based on an in-depth study of the literature and on personal surgical experience, we would like to propose a more precise definition for the extent of surgical margin in the liver, according to the performance or not of neoadjuvant chemotherapy prior to liver resection. In this confusion, assistance could be hold by the application of the y prefix of the TNM system, which is used during or following initial multimodality therapy, as in the case of colorectal liver metastases. If we combine the y prefix with the R symbol of the TNM system, we may define different resection margin requirements for BR0^ and ByR0^ liver metastasectomies. Actually, for the metastasectomies performed without preoperative chemotherapy, a BR0^ resection with a minimal resection margin of 1 mm may be efficient, and this applies to the * Georgios C. Sotiropoulos georgios.sotiropoulos@uni-due.de

A Huge Abdominal Mass

Second Department of Propedeutic Surgery, National and Kapodistrian University of Athens Medical School, Athens, Liver Clinic, First Department of Internal Medicine, General Hospital of Rhodes, Rhodes, Greece 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 Question: A 25-year-old male patient was admitted for weight loss and increasing abdominal discomfort. On physical examination, a large mass was palpated in the upper abdomen. Laboratory tests were all within normal range. Abdominal ultrasound and cross-sectional imaging (computed tomography, magnetic resonance imaging) revealed an enormous cystic tumor in right abdomen, 25 20 cm in size, occupying almost the half of the abdominal cavity (Figure A, B). Concomitant kidney or liver cysts were absent. At operation, a giant polycystic tumor producing considerable compression of neighbor organs was evident (Figure C). The tumor was completely removed. What is your diagnosis? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 94 95 96 97 98 99 100 Conflicts of interest The authors disclose no conflicts.

Colorectal surgery for a centenarian patient.

Dear editor: Recent developments in surgical techniques, anesthesia, and perioperative care have made surgical therapy approachable for the very aged patients. Surgical series on septuagenarians and octogenarians have already been published and patient age is not any more considered as a contraindication per se even for major operations. However, although the indication for surgery in advanced age is personalized, no upper limit has been determined yet. We report herein on a successful urgent operation in a 100-year-old patient. A centenarian was admitted to the emergency room of our hospital, suffering frommeteorismwithmild abdominal pain. He was in an acceptable general condition, well orientated, and not bedridden and was able to perform some basic activities in his daily life, according to the testimony of his nephew, who was living with him. Abdominal X-ray showed a massive large intestine ileus. Abdominal sonography documented the colonic ileus and the presence of ascetic fluid. A colonoscopic decompression was initiated, which failed due to a mechanical obstruction in the upper rectum. As the clinical condition of the patient was deteriorated, decision for operative management was taken. The patient underwent amini-upper abdominal laparotomy and a placement of a double-barreled transverse colostomy under general anesthesia. The patient tolerated the operation well and experienced an uneventful postoperative course. Hewas discharged on postoperative day 8 with dietary instructions. Further investigations and eventually oncologic treatment were denied from his family. The patient gradually restored his preoperative general condition and is alive 18 months post-surgery. This case underlines on the one hand the feasibility of performing colorectal surgery even in an emergency situation in a centenarian and on the other hand the slow growth of the presumed rectal tumor in this age. To the best of our knowledge, this is the first report of a successful colon operation, even in the form of colostomy, in a centenarian, with a postoperative follow-up of more than 1 year.