Background
Damage control surgery (DCS) was a major paradigm change in the management of critically ill trauma patients and has gradually expanded in the general surgery arena, but data in this ...setting are still scarce. The study aim was to evaluate outcomes of DCS in patients with general surgery emergencies.
Methods
Between 2005 and 2015, 164 patients (104 men, age 66) underwent DCS for non-traumatic abdominal emergencies. The decision to perform DCS was triggered by the presence of at least one trauma DCS criterion: hypotension (<70 mmHg), hypothermia (<35 °C), acidosis (pH < 7.25), coagulopathy (INR ≥ 1.7) and massive (>5 RBC) transfusion. Statistical tests were performed to identify risk factors for operative mortality. Observed outcomes were compared to those predicted by commonly employed scores (APACHE II, POSSUM, P-POSSUM, SAPS II).
Results
DCS was performed for acute mesenteric ischemia (
n
= 68), peritonitis (
n
= 44), pancreatitis (
n
= 28), bleeding (
n
= 14) and other (
n
= 10). Abdominal compartment syndrome was associated in 52 patients (32%). Seventy-four (45%) patients died and 150 patients (91%) experienced complications. On multivariate analysis, age (
p
= 0.018) and INR ≥ 1.7 (
p
= 0.001) were independent predictors of mortality. Mortality was 24% (13/55), 48% (22/46) and 62% (39/63) in patients with one, two and ≥3 DCS criteria, respectively. Comparison of observed and score-predicted mortality suggested DCS use resulted in significant survival benefit of the whole cohort and of patients with pancreatitis and postoperative peritonitis.
Conclusions
DCS can be lifesaving in critically ill patients with general surgery emergencies. Patients with peritonitis and acute pancreatitis are those who benefit most of the DCS approach.
Background
Pancreaticobiliary maljunctions (PBMs) are congenital anomalies of the junction between pancreatic and bile ducts, frequently associated with bile duct cyst (BDC). BDC is congenital ...biliary tree diseases that are characterized by distinctive dilatation types of the extra- and/or intrahepatic bile ducts. Todani’s types I and IVa, in which dilatation involves principally the main bile duct, are the most frequent. PBM induces pancreatic juice reflux into the biliary tract that is supposed to be one of the main factors of biliary cancer degeneration, although the diagnostic criteria of PBM that can be either morphological and/or functional are not well defined especially in Western series.
Objective
The aim of this study was to assess the relative prevalence of PBM in BDC in a large European multicenter study, to analyze the characteristics of PBM and try to propose diagnostic criteria of PBMs based on morphological and/or functional criteria and define the positive, negative predictive values, sensibility and specificity of either criteria.
Results
From 1975 to 2012, 263 patients with BDC were analyzed. Among them, 190 (72.2 %) were considered to present PBM. Types I and IVa had a similar rate of PBM association. According to the “AFC classification,” 57.2 % had a C–P type, 34.5 % a P–C type and 8.3 % a complex type (“anse-de-seau”). The median length of the common channel in patients with PBM was 15.8 ± 6.8 mm (range 5–40 mm). The median intrabiliary amylase and lipase levels were 65,249 and 172,104 UI/L, respectively. For the diagnostic of PBM, a common channel length of more than 8 mm and an intrabiliary amylase level superior to 8000 UI/L were associated with a predictive positive value and a specificity of more than 90 %. Synchronous biliary cancer had an incidence of 8.7 % in all patients with BDC and PBM 11.1 % in adults. Compared to type IV, the type I BDC was associated with statistically more cancer patients in the presence of PBM.
Conclusions
Characteristics of PBM associated with BDC in Western population are quite close to reported Eastern series. The results suggest considering both the intrabiliary value of amylase >8000 UI/L and a length of a common channel >8 mm as appropriate values for positive diagnosis of PBM.
OBJECTIVE:To assess clinical presentation and long-term results of surgical management of congenital intrahepatic bile duct dilatation (IHBDD) (Caroli disease and syndrome) in a multicenter setting.
...BACKGROUND:Congenital IHBDD predisposes to biliary stasis, resulting in intrahepatic lithiasis, septic complications, and cholangiocarcinoma. Although liver resection (LR) is considered to be the treatment of choice for unilobar disease extent into the liver, the management of bilobar disease and/or associated congenital hepatic fibrosis remains challenging.
METHODS:From 1978 to 2011, a total of 155 patients (median age55.7 years) were enrolled from 26 centers. Bilobar disease, Caroli syndrome, liver atrophy, and intrahepatic stones were encountered in 31.0%, 19.4%, 27.7%, and 48.4% of patients, respectively. A complete resection of congenital intrahepatic bile ducts was achieved in 90.5% of the 148 patients who underwent surgery.
RESULTS:Postoperative mortality was nil after anatomical LR (n = 111) and 10.7% after liver transplantation (LT) (n = 28). Grade 3 or higher postoperative morbidity occurred in 15.3% of patients after LR and 39.3% after LT. After a median follow-up of 35 months, the 5-year overall survival rate was 88.5% (88.7% after LT), and the Mayo Clinic score was considered as excellent or good in 86.0% of patients. The 1-year survival rate was 33.3% for the 8 patients (5.2%) who presented with coexistent cholangiocarcinoma.
CONCLUSIONS:LR for unilobar and LT for diffuse bilobar congenital IHBDD complicated with cholangitis and/or portal hypertension achieved excellent long-term patient outcomes and survival. Because of the bad prognosis of cholangiocarcinoma and the sizeable morbidity-mortality after LT, timely indication for surgical treatment is of major importance.
Background. An increased incidence of alveolar echinococcosis (AE) in patients with immunosuppression (IS) has been observed; our aim was to study this association and its characteristics. Methods. ...Fifty AE cases with IS-associated conditions (ISCs) before or at AE diagnosis were collected from the French AE registry (1982–2012, 509 cases). There were 30 cancers, 9 malignant hematological disorders, 14 chronic inflammatory diseases, 5 transplants, and 1 case of AIDS; 9 patients had ≥2 ISCs. Characteristics of the 42 IS/AE cases and the 187 non-IS/AE cases diagnosed during the period 2002–2012 were statistically compared. Results. There was a significant increase in IS/AE cases over time. Risk factors did not differ between IS/AE and non-IS/AE patients. However, AE was more frequently an incidental finding (78% vs 42%) and was diagnosed at earlier stages (41% vs 23%) in IS/AE than in non-IS/AE patients. Serology was more often negative (14% vs 1%) and treatment efficacy was better (51% regression after 1-year treatment vs 27%) in IS/AE patients. All IS/AE patients but 7 took IS drugs; 7 received biotherapeutic agents. When not concomitant, AE occurred in IS patients within a 48-month median time period. Atypical presentation and abscess-, hemangioma-, and metastasis-like images delayed AE diagnosis in 50% of IS/AE patients, resulting in inappropriate treatment. Liver images obtained for 15 patients 1–5 years before diagnosis showed no AE lesions. Albendazole efficacy was good, but 19 of 48 treated patients experienced side effects. Conclusions. Patients with immunosuppression are at increased risk for occurrence, delayed diagnosis, and progression of AE.
We report a case of hepatic brucelloma in France. This diagnosis may be suspected in any patient who has a liver abscess after traveling to a brucellosis-endemic area. Brucella spp. may be detected ...by PCR in the liver tissue or suppuration. Abscess drainage and prolonged antimicrobial therapy help achieve healing.
From the Centre de Recherches du Service de Santé des Armées, La Tronche, France (MD, J-FM; AP, FH); Unité de Thérapie cellulaire, Groupe Hospitalier Pitié Salpêtrière Paris, France (FN); Centre ...Hospitalo-Universitaire Grenoble, France (J-PZ, CL)
Correspondence: Michel Drouet, Experimental Radiohematology Unit, Centre de Recherches du Service de Santé des Armées, 24 Avenue des Maquis du Grésivaudan, 38702, La Tronche, France. E-mail: micheldrouet{at}crssa.net
The aim of this study was to search for hematopoietic potential in the liver of non-human primates. Lethally irradiated (2 x 5 Gy ) Cynomolgus macaques were given autologous hepatic mononuclear cells (HMNC) isolated from a liver lobe by perfusion and digestion with 0.1% collagenase. Two monkeys were given intramedullary injections of HMNC (18.6 x 10 6 /kg, 20.4 x 10 6 /kg) and two others were co-transplanted with HMNC (14.35 x 10 6 /kg, 96.5 x 10 6 /kg) and bone marrow mesenchymal stem cells (0.42 x 10 6 /kg, 1.16 x 10 6 /kg). All monkeys exhibited a transient neutrophil recovery from day 22 for 10 days, but failed to produce platelets and remained transfusion-dependent. In conclusion, adult liver stem cells from a monkey model show a low level of in vivo hematopoietic potential, suggesting ex vivo manipulation will be required before clinical use of such cells.
Key words: plasticity, liver, non-human primate, irradiation, mesenchymal stem cells.
Purpose: K-Ras mutations predict resistance to anti–epidermal growth factor receptor (EGFR) monoclonal antibodies. Because combinations
of anti-EGFR with 5-fluorouracil (5-FU)-based chemotherapy are ...promising treatments, we analyzed the effect of K-Ras mutations
in patients having received exclusive 5-FU therapy.
Experimental Design: This study was conducted on 93 stage IV colorectal cancer patients with unresectable measurable liver metastasis receiving
5-FU-leucovorin (56 men and 37 women; 77 cancer deaths). Liver metastases ( n = 93) along with primary tumors ( n = 48) were analyzed for K-Ras mutations (codons 12 and 13), p53 mutations (exons 4-9), p53 polymorphism (codon 72), thymidylate
synthase (TS) polymorphism (28-bp repeats including G>C mutation), methylenetetrahydrofolate reductase polymorphism (677C>T,
1298A>C), thymidylate synthase (TS) activity, dihydropyrimidine dehydrogenase activity, folylpolyglutamate synthase activity,
and p53 protein expression.
Results: Thirty-six of 93 (38.7%) metastases were K-Ras mutated (30 at codon 12 and 6 at codon 13). Mutated primary tumors (16 of
48) matched perfectly with mutated metastases. The additional analyzed tumor markers were not different between K-Ras mutated
and wild-type tumors. The objective response rate was 37%: 44.4% in K-Ras mutated versus 32.1% in wild-type K-Ras metastasis
( P = 0.27). Low TS activity in metastasis was the only significant predictor of tumor response ( P = 0.047). K-Ras status did not influence specific survival.
Conclusions: The present data indicate a perfect concordance of K-Ras mutations between primary and liver metastasis and suggest that
any predictive and/or prognostic value of K-Ras mutations in treatments combining anti-EGFR monoclonal antibodies with 5-FU
should be exclusively linked to the anti-EGFR agent.
This study evaluates the efficacy of arterial embolization (AE) for blunt hepatic traumas (BHT) as part of a combined management strategy based on the hemodynamic status of patients and CT findings. ...From 2000 to 2005, 84 patients were admitted to our hospital for BHT. Of these, 14 patients who had high-grade injuries (grade III n = 2, grade IV n = 9, grade V n = 3) underwent AE because of arterial bleeding and were included in the study. They were classified into three groups according to their hemodynamic status: (1) unresponsive shock, (2) shock improved with resuscitation, and (3) hemodynamic stability. Four patients (group 1) underwent, first, laparotomy with packing and, then, AE for persistent bleeding. Ten patients who were hemodynamically stable (group 1) or even unstable (group 2) underwent AE first, based on CT findings. AE was successful in all cases. The mortality rate was 7% (1/14). Only two angiography-related complications (gallbladder infarction) were reported. Liver-related complications (abdominal compartment syndrome and biliary complications) were frequent and often required secondary interventions. Our multidisciplinary approach for the management of BHT gives a main role to embolization, even for hemodynamically unstable patients. In this strategy AE is very efficient and has a low complication rate.
The aim of this multicenter prospective study was to evaluate the role of intratumoral parameters related to fluorouracil (FU) sensitivity in 103 metastatic colorectal cancer patients receiving ...FU-folinic acid.
Liver metastatic biopsy specimens were obtained for all patients and primary tumor biopsy specimens for 54 patients. Thymidylate synthase (TS), folylpolyglutamate synthetase, and dihydropyrimidine dehydrogenase were measured by radioenzymatic assays; TS promoter polymorphism (2R/2R v 2R/3R v 3R/3R) was determined by polymerase chain reaction; and p53 protein and mutations were analyzed by immunoluminometric assay and denaturing gradient gel electrophoresis, respectively.
p53 mutations were observed in 56.7% of metastases. TS activity was significantly higher in 2R/3R tumors as compared with 2R/2R or 3R/3R. TS activity in metastasis was the only parameter linked to clinical responsiveness (responders exhibited the lower TS, P =.047). Univariate Cox analyses demonstrated that TS activity in primary tumor (the greater the TS, the poorer the survival; P =.040), TS promoter polymorphism in primary tumor (risk of death of 2R/3R v 2R/2R, 2.68; P =.035), and p53 stop mutation in metastasis (risk of death of stop mutations v wild type, 3.14; P =.018) were the only significant biologic predictors of specific survival. Stepwise analysis did not discriminate between TS activity and TS polymorphism.
Present results confirm the value of tumoral TS activity for predicting FU responsiveness, point out the importance of detailed p53 mutation analysis for predicting survival, and suggest that TS genotype in primary tumor carries a prognostic value similar to that of TS activity.
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