Jean Michel Butte

Survival of Young Patients after Gastrectomy for Gastric Cancer

It has been suggested that gastric cancer has a worse prognosis in young patients, but the data are controversial. The aim of this study was to compare the 5-year survivals after gastrectomy for gastric cancer in two groups of patients (those ≤45 years of age and those (>45 years) and to determine some of the prognostic factors. The 5-year survival was significantly better for patients ≤45 years of age. Survival was also better for young patients with a curative resection and also for those with lymph node metastases. However, survival was not significantly different for the two groups when the resection was not curative and when the lymph nodes were not involved. Survival was no different for the two groups when compared at each stage, although a multivariate analysis showed that age >45 years, moderate or poor degree of differentiation of the tumor, advanced tumors, the presence of lymph node involvement, and a noncurative resection were independent negative prognostic factors. Long-term survival after gastrectomy for gastric cancer depends on the stage of the disease; the age of the patient is not a decisive factor.

Arteriovenous malformation of the pancreas: report of a case.

Arteriovenous malformation (AVM) of the pancreas (AVMP) is uncommon and generally asymptomatic; therefore, few cases have so far been reported. The symptoms of AVMP include gastrointestinal bleeding, pain, and portal hypertension. Definitive diagnosis is confirmed by angiographic study, and surgery is the only effective treatment. We report a case of AVMP confirmed by computed tomography, magnetic resonance imaging, and angiographic study of the abdomen, in a patient who presented to us with epigastric pain. He underwent a pancreaticoduodenectomy, following which his symptoms resolved.

Cervical metastases of glucagonoma in a patient with multiple endocrine neoplasia type 1: Report of a case

Multiple endocrine neoplasia type 1 (MEN 1) is a syndrome characterized by tumors of the parathyroid glands, pancreatic islet cells, duodenum, and pituitary gland. We report a case of cervical metastases of glucagonoma with MEN 1. The patient was a 34-year-old woman admitted to our hospital with epigastric pain. Her medical history included two resections of prolactinoma and two upper GI hemorrhages secondary to duodenal ulcers. Computed tomography (CT) showed two hypervascular lesions in the tail of the pancreas and cervical ultrasound showed multiple hypoechogenic ovoid images in the neck. A cervical CT scan confirmed two 15-mm lymph nodes in the left cervical region and 111In-DOTATOC imaging showed focal abnormal somatostatin expression in the pancreatic tail and the cervical nodes. The patient had asymptomatic hypoglycemic episodes, with blood sugar levels as low as 30 mg/dl, which raised our suspicion of MEN 1 associated with pancreatic insulinoma. Thus, we performed a distal pancreatectomy with bilateral cervical dissection and parathyroid gland resection. Histopathological examination revealed 12 pancreatic tumors as well as metastases in four cervical lymph nodes. The resected parathyroid glands had normal structure, suggesting parathyroid hyperplasia. A follow-up CT scan, 18 months after surgery, showed new tumors in the head of the pancreas and in the duodenal wall. A pancreatoduodenectomy was performed and histopathological examination revealed nine nonfunctioning endocrine tumors in the pancreas, one tumor in the duodenal wall, and metastases in two peripancreatic lymph nodes. The patient recovered well and remains asymptomatic.

Síndrome de Bouveret: Resolución endóscopica y quirúrgica de cuatro casos clínicos

Background: Bouveret syndrome is a duodenal obstruction caused by a biliary stone. Aim: To report patients with Bouveret syndrome. Material and Methods: Retrospective review of medical records of patients with Bouveret syndrome treated between 1976 and 2006. Results: We report three women and one man with a mean age of 62.5 years. None had a previous diagnosis of cholelithiasis. AH presented with colicky pain in the right upper quadrant and vomiting, suggesting gastric retention. The diagnosis was suspected after a barium meal in two patients and with a CT scan on the other two. The endoscopical extraction or fragmentation of stones was attempted in three patients but was successful only in one. Three patients were operated and a stone impacted in the first portion of the duodenum was identified, along with a cholecystoduodenal fistula. A duodenostomy and stone extraction was performed. One patient was subjected to a cholecystectomy fistula repair and gastrojejunoanastomosis. No patient died and all were discharged within 8 to 12 days after surgery. Conclusions: Bouveret syndrome is an uncommon complication of cholelithiasis. Endoscopy can be diagnostic and therapeutic. Surgery is the other therapeutic option

Avances en radiología del intestino delgado: enteroclisis por tomografía computarizada

Resumen La enteroclisis por tomografia computarizada (TC) es una nueva tecnica que consiste en una TC helicoidal con multiples detectores realizada tras la administracion de agua a traves de una sonda nasoyeyunal y medio de contraste intravenoso, lo que permite una adecuada distension y visualizacion del intestino delgado. El uso de esta tecnica esta especialmente indicado en pacientes con enfermedad inflamatoria intestinal, hemorragia digestiva de causa no precisada, obstruccion parcial de intestino delgado y sospecha de neoplasia intestinal. Un total de 100 pacientes consecutivos se sometieron a una enteroclisis por TC (multiples detectores: 8, 16 o 64) debido a la sospecha de lesion en el intestino delgado. De ellos, 31 presentaron lesiones en esa localizacion: enfermedad de Crohn (n = 17), tumores (n = 8), obstruccion intestinal (n = 2), enteritis actinica (n = 1), enfermedad celiaca (n = 1), neumatosis cistoide (n = 1) y dilatacion de asas (n = 1); 28 de los 31 casos fueron confirmados por anatomia patologica, hallazgos endoscopicos o seguimiento clinico.

Sobrevida alejada de pacientes operados por cáncer gástrico incipiente

BACKGROUND Early gastric cancer involves mucosa and submucosa, independent of lymph node involvement. Radical gastrectomy is the standard treatment. AIM To assess long term survival of patients operated for an early gastric cancer. MATERIAL AND METHODS Retrospective review of medical and pathology records of patients subjected to a gastrectomy for an early gastric cancer, between 1975 and 2002. All were treated using a standardized protocol and staged according to 2002 TNM classification of the American Joint Committee of Cancer (AJCC). Demographic and pathologic features, operation performed and long term survival were recorded. Survival was analyzed using Kaplan-Meier method. RESULTS The series is comprised by 64 males and 41 females aged 61 +/- 1 years. Tumor was located in the upper third of the stomach on 33 subjects and a total gastrectomy was performed in 53. Pathology showed an intestinal type adenocarcinoma in 82 and a diffuse type in 23. In patients with involvement of mucosa and submucosa, 24 +/- 14 and 22 +/- 14 lymph nodes were excised, respectively. Lymph node involvement was present in 8% and 22% of patients with involvement of mucosa and submucosa, respectively. Five years survival was 94% and 78% in patients without and with lymph node involvement, respectively. Survival among patients in stage IA and IB was 94% and 76%, respectively. Multivariate analysis showed that the lymph node involvement was an independent mortality risk factor. CONCLUSIONS Total gastrectomy in patients with early gastric cancer is associated with a good survival. Lymph node involvement is a mortality risk factor.

Resultados inmediatos y tardíos de la miotomía de Heller laparoscópica en pacientes con acalasia esofágica

Twenty seven patients aged 12 to 74 years (12 females)were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophagealsphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior tosurgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patientdied and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months,all patients are satisfied with the surgical results and the postoperative clinical score is 1. Onlyone patient with a mega esophagus maintained a clinical score of six.

Resultados del tratamiento quirúrgico de las metástasis hepáticas por cáncer colorrectal

Background: Surgical resection is the only treatment associated with long-term cure in patients with liver metastasis from colorectal cancer, achieving a 30% to 40% five years survival. Aim: To evaluate the results of liver resection for metastatic colorectal cancer in our centre. Patients and methods: Retrospective study. Epidemiological, perioperative and follow up data of patients undergoing liver resection for metastatic colorectal cancer between January 1990 and July 2007 were assessed. We compared the results between two periods; period 1 (1990-1997) and period 2 (1998-2007). Results: Sixty six patients aged 61±12 years (46 males) underwent 75 resections. An anatomical excision was performed in 54 (72%) cases, a right hepatectomy in 18, an extended right hepatectomy in 11, a left hepatectomy in 1, and a segmentectomy in 24. In 24 (32%) patients the liver resection was simultaneous with the colorectal cancer resection. Operative time was 221±86 min. Hospital stay was 11±5 days. Postoperative morbidity was 35% and surgical mortality was 0%. Resection margin was free of tumor in 53 (80%) patients. Five years overall and hepatic disease-free survival was 38% and 23%, respectively. In period 2, more anatomical resections than in period 1 were performed (77% and 55%, respectively, p =0.04), without an increase in complications (35% and 34%, respectively; p =ns), but with a better five years survival (45% and 21%, respectively, p =0.04). Conclusions: Five years survival for excision of liver metastatic colorectal cancer in our center is similar to that reported abroad. During the second period there has been a trend toward more extensive resections which was associated with a better survival, without an increase in complications or mortality (Rev Med Chile 2009; 137: 487-96). (Key words: Colorectal neoplasms; Neoplasm metastasis; Survival)

Radio-quimioterapia postoperatoria en cáncer gástrico localmente avanzado

BACKGROUND Overall 5 years survival for surgically excised gastric cancer is 30%. Adjuvant treatment may improve the surgical results. AIM To assess treatment results and toxicity in patients with surgically excised gastric cancer, treated with adjuvant radiotherapy and concomitant continuous 5-Fluorouracil (5-FU). MATERIAL AND METHODS Forty one patients aged 32 to 73 years (29 males) with stage II-IVA gastric cancer, subjected to a total or subtotal gastrectomy and D2 nodal dissection between 1997 to 2006, were studied. They received adjuvant radiotherapy to the gastric bed and draining nodes in a total dose of 50.4 Gy in 28 fractions and chemotherapy with continuous infusion 5-FU, 200 mg/m(2)/day. Results were compared to historical controls matched according to demographic parameters and tumor characteristics. RESULTS Eighteen patients were in stage II, 10 in stage IIIA, nine in stage IIIB and four in stage IVA. Twelve patients had an NO nodal status, 15 were NI, nine were N2 and five were N3. After a mean follow up of 32 months, 26 patients (63%) were alive. Five year overall survival was 49.6% for surgery plus radiochemotherapy compared to 30.7% for the historical group subjected only to surgery (p =0.002). Radiotherapy was associated with grade 1-2 toxicity and treatment was completed without interruptions in all patients. Chemotherapy was delayed temporarily in 3 patients. CONCLUSIONS Adjuvant radio-chemotherapy improved overall survival in gastric cancer, compared to historical controls subjected only to surgical treatment.

Adenocarcinoma gástrico treinta y dos años post linfoma gástrico

The association of gastric lymphoma and gastric adenocarcinoma in the same patient is uncommon. We report a 76 year-old male with a previous history of massive upper gastrointestinal bleeding who required a subtotal gastrectomy with Billroth II reconstruction in 1974. Pathology demonstrated a gastric lympho-histiocytic non-Hodgkin’s lymphoma. The patient received complementary radiotherapy and was followed with annual endoscopies for 23 years. In 2006, he presented with fatigue. An upper gastrointestinal endoscopy showed an ulcerated and proliferative lesion at the gastric stump. Biopsy demonstrated a gastric adenocarcinoma. Gastric stump resection with lymph node dissection was perfomed. Pathology of the excised specimen showed a moderately differentiated tubular adenocarcinoma of the gastrojejunal anastomoses which infiltrated up to the subserosa. Additionally, lymphatic permeations were observed and 10 of the 16 excised lymph nodes were invaded by the tumor (Rev Med Chile 2008; 136: 1317-20). (Key words: Lymphoma non-Hodgkin; Radiotherapy, adjuvant; Stomach neoplasms)