Percutaneous radiological gastrostomy in esophageal cancer patients: a feasible and safe access for nutritional support during multimodal therapy.

BACKGROUND: Percutaneous endoscopic gastrostomy is not widely used in malnourished esophageal cancer (EC) patients because of concerns about its feasibility in frequently obstructive tumors, suitability of the stomach as an esophageal substitute, and potential for metastatic inoculation. A percutaneous radiological gastrostomy (PRG) could be an optimal alternative. METHODS: Experience with PRG among 1,205 consecutive patients presenting with EC from 2002 to 2011 in our department was retrospectively reviewed. PRG was mostly utilized for malnourished patients for whom neoadjuvant chemoradiation was scheduled. The rates of both successful placement and major related complications (Dindo-Clavien ≥III) were analyzed. A matched cohort analysis was constructed in patients who underwent esophagectomy with gastroplasty (n = 688) to evaluate the impact of PRG placement on the suitability of the gastric conduit and on postoperative course. For 78 resected patients with PRG (PRG group), 156 randomly selected controls without PRG (no PRG group) were matched 2:1 for gender, age, ASA grade, clinical TNM stage, and neoadjuvant treatment delivery. RESULTS: PRG placement was planned in 269 (22.3 %) patients mainly with locally advanced EC (63.8 %). PRG placement was feasible in 259 (96.3 %) patients. Sixty-day PRG-related mortality and major morbidity rates were 0 and 3.8 % respectively. For resected patients, the PRG and no PRG groups were comparable regarding perioperative characteristics, except for malnutrition, which was more frequent in the PRG group (P < 0.001). At the time of operation, PRG takedown and site closure were uncomplicated and the use of the stomach was possible in all 78 patients. Despite a higher malnutrition rate at presentation in the PRG group, rates of overall morbidity, and morbidity related to esophageal surgery, were similar between the two groups (P > 0.258). CONCLUSION: PRG is feasible, safe, and useful in nonselected patients with EC and does not compromise the suitability of the stomach as an esophageal substitute in patients deemed to be resectable.

Solitary peritoneal metastases from ductal breast cancer.

Breast carcinoma remains the most common malignancy in women in western countries. The principal sites of metastases are the regional lymph nodes, liver, lung and bone; unusual sites of metastases are very rare. Infiltrating ductal carcinoma is the most common histological subtype (about 80%) as compared to lobular carcinoma (7-20%), which metastasizes more frequently to unusual sites. An 80-year-old female patient was submitted to resection of an infiltrating ductal carcinoma (stage I). After 4 years, the presence of a pelvic mass in the absence of local, distant or lymph node recurrence was found. Resection of the mass was performed. The pathological and immunohistochemical examination revealed a metastatic carcinoma compatible with a mammalian origin. After 36 months of follow-up the patient is alive and disease-free. Considering the age of the patient, the good performance status, the absence of other sites of relapse and the large size of the mass, surgery was performed. Surgery remains the only valid option when recurrence produces abdominal complications. In the absence of randomized prospective studies, however, we do not know whether this is always the correct therapeutic strategy.

[Massive intrahepatic haemorrhage responsible for an inferior vena cava syndrome: an exceptional complication of hepatocellular carcinoma]. / Hémorragie intra-tumorale massive responsable d'un syndrome cave: une complication rare d'un carcinome hépato-cellulaire.

Intralesional massive haemorrhage responsible for inferior vena cava syndrome is a very rare complication of hepatocellular carcinoma. A 36-year-old man with no past medical history was referred to hospital for abdominal pain with clinical and biological signs of internal bleeding. An abdominal CT scan showed a huge right liver mass, with regular margins and a fluid content, indicating a large intratumoral haemorrhage complicating hepatocellular carcinoma. Due to haemodynamic stability and the signs of inferior vena cava compression conservative management was chosen prior to surgical treatment of the tumour. Three months later, the huge liver mass remained unchanged but the inferior vena cava syndrome had decreased and the patient's condition improved. After evaluation of liver function and the extent of the tumour, a surgical procedure was performed via a subcostal incision with midline extension and sternotomy to control the intrapericardial inferior vena cava and perform a veno-venous bypass with the technique used for orthotopic liver transplantation. Then, right hepatectomy (segments V to VIII) was performed with an anterior approach. The postoperative course was uneventful. This two-step strategy allowed successful surgery for this rare complication of a hepatocellular carcinoma on a normal liver and could be recommended for the management of any unruptured intratumoral haemorrhages.

Feasibility of hanging maneuvers in orthotopic liver transplantation with inferior vena cava preservation and in liver surgery.

BACKGROUND/PURPOSE: The aim of this work was to study the feasibility and complication rates of liver hanging maneuvers: the Belghiti liver hanging maneuver (BLHM) in liver resection and the modified liver hanging maneuver (MLHM) in orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation. METHODS: From January 2001 to August 2003, BLHM was planned in 26 consecutive right hepatectomies and MLHM in 28 consecutive OLTs with IVC preservation. RESULTS: BLHM was performed in 24/26 patients (92%). In the 2 remaining patients, chronic biliary infection (n = 1) and intraparenchymal hemorrhagic hepatocellular carcinoma (n = 1) did not allow BLHM to be achieved. Bleeding during the BLHM procedure occurred in 1 patient (4%), with no need for interruption. MLHM was performed in all 28 patients, and in none of them was bleeding observed during the maneuver. CONCLUSIONS: BLHM and MLHM are important technical refinements with several advantages. Feasibility rates were 92% and 100%, respectively. Bleeding risk remained low (4%) for BLHM and was 0% for MLHM. The rate of BLHM failure suggests that the feasibility rate may be higher in normal liver parenchyma.

Rectal cancer surgery with sphincter preservation: functional results related to the level of anastomosis. Clinical and instrumental study.

BACKGROUND/AIMS: Unsatisfactory functional results have been reported not only after coloanal anastomosis, but also after anterior resection with colorectal anastomosis. The aim of this study is to establish functional outcome predictive factors related to surgical technique and especially the real impact of residual rectum length to identify patients who could benefit from colonic pouch reconstruction. METHODOLOGY: Sphincter preservation was achieved in 214 of 327 patients who underwent surgery for rectal cancer. Patients have been subdivided according to the level of anastomosis measured by a rigid proctoscope from the anal verge. In 93 patients functional results have been assessed by clinical control and anorectal manometry. RESULTS: Functional alterations such as leakage (13%), incontinence (5%), urgency (5%) and difficulty in evacuation (10%) appeared in patients who underwent anterior resection with anastomosis 4 to 6 cm from the anal verge. Nevertheless, comparing anterior resection with anastomosis 6 to 8 cm and that with anastomosis 4 to 6 cm rectal compliance was the only parameter whose difference is statistically significant. CONCLUSIONS: This result makes us to believe that patients who undergo anterior resection with no more than 2-3 cm of residual rectum could benefit from a colonic pouch reconstruction.

Malignant haemangiopericytoma of the mesorectum.

The authors report the case of a malignant haemangiopericytoma found in an uncommon location, namely the mesorectum. Haemangiopericytomas of the mesorectum are rare mesenchymal tumours of vascular origin that usually occur in the musculature of the extremities, retroperitoneum, pelvis (uterus, ovary and urinary bladder), head, neck and lungs. Rare sites include the liver, pancreas, stomach and greater omentum. Because of their rarity the overall experience has not been significant and little has been published concerning such tumours. In addition, the difficult interpretation of the histological evidence and the poor prognosis of the disease may still give rise to problems in terms of clinical management. Haemangiopericytomas of the retrorectal space, however, seem to behave like malignant tumours: the clinical course is poor and survival short, despite radical surgery, due to early distant metastases and local recurrence. Surgery still remains the mainstay of treatment. Adjuvant therapies should be considered.

[Liver transplantation in primary and secondary tumors of the liver. Review of the literature and perspectives]. / Il trapianto epatico nei tumori primitivi e secondari del fegato. Revisione della letteratura e prospettive.

Liver transplantation for malignancies still remains a controversial issue. There is concern for tumour recurrence, poor results and waste of organs, which in the sitting of organ shortage would penalize patients with non-malignant disease. Many centers worldwide perform liver transplantation (OLT) for hepatocellular (HCC) carcinoma associated with liver cirrhosis; the results in these cases are similar to those of patients transplanted for other indications. On the contrary are very few the centers that perform OLT for tumour other than HCC. This reflects that tumours other than HCC are less common and survival is poor compared to patients transplanted for non-malignant disease. Acceptable indications for OLT in case of tumours other than HCC are liver metastases from neuroendocrine tumours and epithelioid emangio-endothelioma. However should be kept in mind that OLT may offer the sole opportunity to cure the tumour and the underlying disease in some patients while providing meaningful palliation for others. At the present the overall experience with OLT for tumours other than HCC is still not significant and the results are discouraging. There is no evidence that OLT is beneficial for non-HCC tumours. Hopefully for the next future new adjuvant and neoadjuvant therapies combined with OLT would provide improved survival. Nevertheless, long-term survivors continue to be reported suggesting that OLT may be beneficial in individual selected cases with non-HCC tumour.

[Carcinoma of the pancreatic remnant developing after pancreaticoduodenectomy for adenocarcinoma of the head of pancreas]. / Carcinoma del moncone pancreatico dopo duodenocefalopancreasectomia per adenocarcinoma della testa.

In November 1996 a 44-year-old man with an adenocarcinoma of the pancreatic head (T2 N1 Mx- UICC 1998 Stage III) underwent a Traverso-Longmire pancreaticoduodenectomy. Early reoperation was required owing to postoperative acute pancreatitis and haemorrhage of the pancreatic remnant, after which he received chemo- and radiotherapy. Twenty-nine months later, an increase in the level of CA19.9 was observed with neither clinical nor radiological evidence of cancer recurrence. Forty months later, there was evidence of a new neoplasia of the pancreatic remnant. Since the recurrence involved only the pancreatic remnant with no evidence of metastases and the patient was in good condition and enough time had elapsed since surgical eradication of the primary cancer, we decided to perform an en bloc resection of the pancreatic body and tail and the spleen. Histologically, the tumour proved to be a pancreatic adenocarcinoma (T2). It is difficult to assess whether this cancer of the pancreatic remnant was a recurrence or a second primary cancer because of the long recurrence-free survival period, the absence of neoplastic invasion of the resection margins of the two surgical specimens and the absence of multicentricity both of the portion of the gland removed by the first operation and that removed by the second.