M. Plasse

Liver Histology and Surgical Outcomes After Preoperative Chemotherapy With Fluorouracil Plus Oxaliplatin in Colorectal Cancer Liver Metastases

PURPOSE Preoperative chemotherapy for colorectal liver metastases (CLM) can produce histologic changes in the nontumor-bearing liver (NTBL) that may impact on surgical outcomes. PATIENTS AND METHODS From a cohort of 303 patients treated for CLM with liver resection, 92 patients (75 received preoperative chemotherapy: group C+; and 17 were chemotherapy naïve: group C-) were randomly selected for detailed pathologic analysis. Preoperative chemotherapy consisted of fluorouracil (FU)/leucovorin alone (23 patients, the majority chronomodulated) or in combination with oxaliplatin (52 patients, all chronomodulated). To determine associations between study factors, clinical and operative variables were compared with pathology data and surgical outcomes. RESULTS Although clinical and operative factors were similarly distributed, C+ patients, compared with C- patients, were more likely to receive intraoperative RBC transfusions (mean units: 1.9 v 0.5, respectively; P = .03) and to have vascular abnormalities in the NTBL (52% v 18%, respectively; P = .01). Presence of the most severe forms of vascular alterations was closely associated with RBC transfusion requirements (P = .04). In contrast, moderate to severe steatosis was similarly distributed (C- group, 12%; C+ group, 13%). Although perioperative mortality and morbidity rates were similar in all groups, more than 12 courses of chemotherapy, compared with < or = 12 courses, predisposed patients to reoperation (11% v 0%, respectively; P = .04) and to longer hospitalization (15 v 11 days, respectively; P = .02). CONCLUSION The main hepatic lesion induced by preoperative FU/oxaliplatin chemotherapy in patients with CLM is vascular and not steatosis. Detailed pathologic analysis determined that the most severe vascular lesions are associated with increased intraoperative transfusions. The risk for other postoperative complications is related to the duration of preoperative chemotherapy administration.

Treatment of post liver transplantation bile duct stricture with self-expandable metallic stent

OBJECTIVE The aim of this study is to report our experience using self-expandable covered metallic stents (Wallstent) to treat different types of biliary strictures after orthotopic liver transplantation (OLT). PATIENTS AND METHODS Between January 1999 and July 2004, 222 OLTs were performed with choledocho-choledochostomy (CC) bile duct reconstruction. An anastomotic biliary stricture was diagnosed and treated by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous procedures in 100 patients (45%). The group of 21 patients (mean age 57.0+/-5.6 years) that were eventually treated with a biliary Wallstent was studied retrospectively. RESULTS Significant persistent proximal or anastomotic strictures were diagnosed in 4 and 17 patients, respectively. A Wallstent was inserted by ERCP or through a percutaneous route in 18 and 3 patients, respectively. The mean interval between diagnosis and Wallstent insertion was 179.7+/-292.8 (0-1113) days. The mean total number of procedures required per patient was 7.4+/-5.5. The mean stent primary patency duration was 10.8+/-7.8 (0.9-25.1) months with a 24-month primary patency rate of 26% at a mean follow-up time of 37.8+/-17.2 months. A hepatico-jejunostomy was performed in five patients (24%). Two patients (10%) underwent retransplantation for diffuse ischemic cholangitis or chronic rejection. The overall complication rate was 4%. CONCLUSION Treatment of post-transplant biliary stenosis using a Wallstent is a valuable option for delaying or avoiding surgery in up to 70% of patients. Proximal stenosis can be treated in the same manner in selected patients with major comorbidities.

Effect of N-Acetylcysteine on Blood and Tissue Lipid Peroxidation in Lipopolysaccharide-Induced Obstructive Jaundice

In obstructive jaundice, free radical production is increased and antioxidative activity is reduced. N-Acetylcysteine (NAC) has a beneficial effect with anti-inflammatory and antioxidant activity, acting as a free radical scavenger. NAC inhibits inducible nitric oxide synthase, suppresses cytokine expression/release, and inhibits adhesion molecule expression and nuclear factor kappa B. The aim of this study was to investigate the effects of NAC on liver/renal tissue and serum lipid peroxidation in lipopolysaccharide (LPS)-induced obstructive jaundice. We randomized 60 rats into 6 groups: group 1, Sham; group 2, obstructive jaundice (OJ) induced after bile-duct ligation; group 3, OJ + NAC (100 mg kg− 1 subcutaneously); group 4, OJ + LPS (10 mg kg-1); group 5, OJ + NAC + LPS; and group 6, OJ + LPS + NAC. For each group, the biochemical markers of lipid peroxidation and the antioxidant products were measured in serum and liver/renal tissue after sacrifice. Almost all lipid peroxidation products levels were increased and antioxidant products levels were decreased in groups who received LPS (groups 4, 5, and 6), but the effect was less remarkable when NAC was administered before LPS (group 5). The same trend was seen for groups with OJ ± LPS who did not received NAC or received it after induced toxemia (groups 2, 4, and 6) as compared to groups 1 and 3. Moreover, in the case of OJ + LPS, rats treated with NAC before LPS (group 5) had lower lipid peroxidation products levels and higher antioxidant products levels as compared to those who did not received NAC (group 4). This phenomenon was not reproducible with NAC administered after LPS (group 6). Thus, results of this study showed that NAC prevents the deleterious effects of LPS in obstructive jaundice by reducing lipid peroxidation in serum and liver/renal tissue if administered before LPS. Nonetheless, NAC failed to prevent the lipid peroxidation in the case of established endotoxemia in obstructive jaundice.

Is intra-operative ultrasound still useful for the detection of a hepatic tumour in the era of modern pre-operative imaging?

BACKGROUND The current role of intra-operative ultrasound (IOUS) is questioned because of recent progress in medical imaging. The aim of the present study was to determine the accuracy of IOUS in the detection of a hepatic tumour (HT) compared with a pre-operative multi-detector computed tomography (MDCT) scan and magnetic resonance imaging (MRI). METHODS This retrospective study included 418 patients evaluated using an 8-slice MDCT scan (SCAN8), 64-slice MDCT scan (SCAN64) and MRI alone or combined with a computed tomography (CT) scan. The pathological result was used as a gold standard. RESULTS Correlation rates for the number of detected lesions compared with pathology results were 0.627 for SCAN8, 0.785 for SCAN64, 0.657 for MRI and 0.913 for IOUS. Compared with pathology, the rate of concordance was significantly higher with IOUS (0.871) than with SCAN8 (0.736; P=0.011), SCAN64 (0.792; P<0.001) and MRI (0.742; P<0.001). IOUS was responsible for a change in operative strategy in 16.5% of patients. Surgery was extended in 12.4%, limited in 1.7% and abandoned in 2.4%. CONCLUSIONS Compared with cross-sectional pre-operative imaging, IOUS is still superior for the detection of HT and the planning of surgery. IOUS remains recommended as a routine procedure in patients having a hepatic resection in the era of modern pre-operative imaging.

Hypertrophy of the non-embolized liver after chemotherapy.

BACKGROUND Neoadjuvant chemotherapy (NC(+)) and portal vein embolization (PVE) enables curative resection in more patients with colorectal-liver metastases (CRLM). However, after NC(+), structural alterations have been reported with the risk of post-operative hepatic failure. We undertook to determine if NC(+) toxicity limits future remnant liver (FRL) hypertrophy after PVE. METHODS PVE was performed in 20 patients, 13 (65%) of whom previously received a mean FOLFIRI (5-fluorouracil + leucovorin + irinotecan) regimen (NC(+)) of 6.6 cycles. The seven remaining patients served as the control group without NC (NC(-)). RESULTS CRLM were bilateral in 69% (NC(+)) and 57% (NC(-)), and synchronous in 84% (NC(+)) and 14% (NC(-)). The FRL hypertrophy rate was 54.1% (NC(+)) and 43.7% (NC(-)) (P= 0.3). CRLM were unresectable in four of our 20 patients, i.e. group NC(+): one insufficient FRL hypertrophy and one severe steatosis; and group NC(-): two tumoral progressions. In both groups, the operative parameters were comparable except for pedicular clamping: 8 (NC(+)) and 36 min (NC(-)), respectively (P < 0.05). Also, the surgical outcome rate and hospital stay were comparable. No significant pathological difference was observed between the two groups. No mortality occurred in either group. CONCLUSION In view of our limited experience, we conclude that hypertrophy of the non-embolized liver (FRL) is not altered after FOLFIRI-based NC.

Answer to Case of the Month #162: Emphysematous Infection of the Liver Parenchyma

A 53-year-old man presented with a nonspecific complaint of chills that persisted for 36 hours. Three months before this acute event, the patient had undergone a left hepatectomy with hepaticojejunostomy for hilar cholangiocarcinoma with left hepatic duct extension. Macroscopic invasion of the right posterior hepatic duct was seen on the excision specimen. A larger resection was then performed on the right posterior duct. The resection margins were free of tumour at histology. The postoperative course was complicated by a biliary leak that spontaneously resolved with conservative treatment. No chemotherapy was given in the follow-up. One week before the emergency visit, the patient had presented with cellulitis at the site of the surgical incision and was successfully treated with oral cephalexin. The remainder of the medical history was only remarkable for cigarette smoking. The patient was not known to have diabetes mellitus or clinically significant atherosclerotic disease. The patient was febrile (39.1 C), but other vital signs were normal. Icterus was the prominent feature on physical examination. Initial laboratory evaluation revealed marked leucocytosis (35.0 cells/10 L [reference range, 4.8e10.8 cells/10 L]), abnormal liver function tests (total bilirubin 140 mmol/L [reference range, 7e23 mmol/L], alanine transaminase 475 U/L [reference range, 11e51 U/L], and

Sclerosing encapsulating peritonitis presenting as acute-on-chronic small-bowel obstruction in a patient with history of peritoneal carcinomatosis

Abstract Sclerosing encapsulating peritonitis (SEP) is a whitish fibrous envelope that encapsulates intra-abdominal peritonealized organs. Although it pathophysiology is not well understood, several possible causes have been reported in the literature, including peritoneal dialysis, past abdominal surgeries, peritonitis, beta-blockers and peritoneal carcinomatosis (PC). Some idiopathic cases, with no apparent causes, were described. We present a SEP case in a 43-year-old woman with a surgical history of pancreatic and liver resection for metastatic pseudopapillary pancreatic tumor, followed by several peritonectomies for PC. She was admitted for acute-on-chronic small-bowel obstruction that did not resolve with conservative management. Surgical exploration revealed a fibrous sheath covering the small-bowel. Extensive dissection, along with small-bowel segmental resection and anastomosis, was performed. The specimen was cancer-free. The mechanism through which SEP develops in certain surgical patients is still unknown. This report presents a case of successful surgical management and a review of the literature.