A Case Report of Long-Term Survival following Hepatic Arterial Infusion of L-Folinic Acid Modulated 5-Fluorouracil Combined with Intravenous Irinotecan and Cetuximab Followed by Hepatectomy in a Patient with Initially Unresectable Colorectal Liver Metastases.

A 43-year-old women admitted to our hospital for weight loss, anorexia, and abdominal pain was diagnosed with sigmoid neoplasm and multiple bilobar liver metastases. This patient received six cycles of systemic FOLFOX prior to a laparoscopically assisted anterior resection of the rectosigmoid for a poorly differentiated invasive adenocarcinoma T2N2M1, K-RAS negative (wild type). Hepatic arterial infusion (HAI) of L-folinic acid modulated 5-fluorouracil (LV/5-FU) with intravenous (iv) irinotecan (FOLFIRI) and cetuximab as adjuvant therapy resulted in a complete metabolic response (CR) with CEA normalization. A right hepatectomy extended to segment IV was performed resulting in (FDG-)PET negative remission for 7 months. Solitary intrahepatic recurrence was effectively managed by local radiofrequent ablation following 6c FOLFIRI plus cetuximab iv. Multiple lung lesions and recurrence of pulmonary and local lymph node metastases were successfully treated with fractionated stereotactic radiotherapy (50 Gy) and iv LV/5-FU/oxaliplatin (FOLFOX) plus cetuximab finally switched to panitumumab with CR as a result. At present the patient is in persistent complete remission of her stage IV colorectal cancer, more than 5 years after initial diagnosis of the advanced disease. Multidisciplinary treatment with HAI of chemotherapy (LV/5-FU + CPT-11) plus EGFR-inhibitor can achieve CR of complex unresectable LM and can even result in hepatectomy with possible long-term survival.

Intragastric SILS for GIST, a new challenge in oncologic surgery: first experiences.

BACKGROUND: For treatment of Gastrointestinal Stromal Tumour (GIST) located in unreachable areas, such as the esophagogastric junction or pyloric ring, laparoscopic resection cannot be easily applied. We used single-incision laparoscopic surgery (SILS) for intragastric resection of GISTs. PATIENTS AND METHODS: We report on our cases (n=3) of GIST of the stomach treated with the SILS port placed intragastrically through the anterior wall of the stomach. A skin incision of only 2.5 cm was made to perform this intervention. RESULTS: The patients mean age was 68.1 years (range=53-86). The mean operative time was 74.6 (range=67-82) minutes. No intra-operative complications occurred. No conversion was needed. The mean tumor size was 3.8 cm (range=2.7-6.8 cm). All patients healed without any complications. Re-alimentation was started on the third postoperative day. The mean postoperative stay was five days (range: 4-6 days). CONCLUSION: This intragastric SILS procedure for GIST is feasible and safe, and offers a benefiet for further progress in oncologic surgery.

Laparoscopic versus open resection of gastrointestinal stromal tumors of the stomach.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgical treatment is the only chance of cure for patients with a primary localized GIST. A laparoscopic approach has been considered reasonable for these tumors of gastric origin. The current study compares the outcome of laparoscopic versus open resection of gastric GISTs and compares our series with the few published studies comparing the open versus the laparoscopic approach. METHODS: From a prospectively collected database, we found 53 primary gastric GIST resections that were performed in our department. Laparoscopic (LAP) resections were performed in 37 patients and traditional (OPEN) resections in 16 patients. Clinical and pathologic characteristics and surgical outcomes were analyzed according to surgical procedure. RESULTS: Patients who underwent LAP or OPEN resection of gastric GISTs did not differ with respect to age at operation, gender, clinical presentation, and tumor size. Operative time was significantly lower for LAP than for OPEN resection, with a mean duration of 45 and 132.5 min, respectively (p < 0.001). LAP resection yielded a significantly shorter length of stay (median 7 vs. 14 days; p = 0.007) and lower 30-day morbidity rate (2.7 % vs. 18.9 %; p = 0.077). The operative mortality was 12.5 % after OPEN resection and there was no operative mortality after LAP (p = 0.087). The recurrence rate was significantly lower after LAP surgery (0 % vs. 37.5 %; p < 0.001). All patients in the LAP group are alive without recurrence, and 25 % (4/16) of the OPEN group are alive with recurrence but in complete remission under imatinib mesylate treatment. Two patients of the open group died due to progression of GIST (p = 0.087). CONCLUSIONS: Compared to open resection, laparoscopic resection of gastric stromal tumors is associated with a shorter operation time, a shorter hospital stay, and a lower recurrence rate.

Early experience with single-incision laparoscopic surgery for the placement of a gastrostomy in a 10-year-old girl: a case report.

INTRODUCTION: Access procedures for alimentation have been performed both endoscopically and surgically. In patients in whom endoscopic gastrostomy feeding tubes cannot be placed, single-incision laparoscopic surgery gastrostomy is an alternative method. This minimally invasive approach is a new technique performed through a single umbilical incision and without the need for additional laparoscopic ports. CASE PRESENTATION: In this article we present a case of single-incision laparoscopic surgery gastrostomy performed with conventional laparoscopic instruments in a 10-year-old girl of Caucasian ethnicity who was not a candidate for a percutaneous endoscopic gastrostomy tube because of esophageal varices due to her advanced-stage cystic fibrosis with liver cirrhosis and portal hypertension. She also had an umbilical hernia, which was repaired during the same procedure through the same incision. Access and pneumoperitoneum were obtained through the umbilicus with the single-incision laparoscopic surgery port. The selected site for the feeding tube in the stomach was exteriorized through this incision and a feeding tube was placed. The stomach was returned into the abdomen. The fascial defect, and thus also the hernia, was repaired, and the 2cm umbilical incision was closed with endocutaneous sutures. The total operative time was 25 minutes. Our patient's intra-operative and post-operative course was uneventful. We were able to use the feeding tube on the first post-operative day with good intestinal function. Our patient and her parents were pleased with the cosmetic result. CONCLUSIONS: The single-incision laparoscopic surgery procedure seems to be a less invasive alternative to open placement of gastrostomy. This approach has the possible advantages of reduced post-operative pain, faster return to normal function, reduced port site complications, improved cosmesis and better patient satisfaction.

Unusual Appearance of a Pendulated Gastric Tumor: Always Think of GIST.

Objective. To investigate the clinicopathological characteristics of gastrointestinal stromal tumor (GIST) with significant cystic changes and to assess the molecular genetic characteristics. Methods. In a 68-year-old man, a large abdominal tumoral mass was discovered incidentally. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the presence of a large cystic lesion with multiple contrast-enhancing septae and papillary projections. No clear connection with any of the surrounding organs was identified. Malignancy could not be excluded, and surgery was indicated. During surgery, the large mass was found to be attached by a narrow stalk to the large curvature of the stomach. Results. The histological features and immunohistiochemical profile of the tumor cells (positivity for CD117 and CD34) were consistent with a gastrointestinal stromal tumor with a high risk of progressive disease according to the Fletcher classification. Diagnosis was confirmed by mutational analysis; this demonstrated mutation in exon 14 of PDGFRA. During the followup of 97 months, the patient had a cancer-free survival. Conclusions. This case demonstrates that gastrointestinal stromal tumors (GISTs) with extensive cystic degeneration should be considered in the differential diagnosis of a cystic abdominal mass.

Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy.

Deep sternal wound infection remains one of the most serious complications in patients who undergo median sternotomy for coronary artery bypass surgery.We describe our experience in treating 6 consecutive patients with our treatment protocol that combines aggressive débridement, broad-spectrum antibiotics, negative-pressure wound therapy, omentoplasty with laparoscopically harvested omentum, and the use of bilateral pectoral muscle advancement flaps.The number of débridements needed in order to attain clinically clean wounds and negative cultures varied between 1 and 10, with a median of 5. The length of stay after omentoplasty and bilateral pectoral muscle advancement flap placement varied between 11 and 22 days. One of the 6 patients developed a small wound dehiscence that was treated conservatively. No bleeding related to vacuum-assisted closure therapy was identified. Three patients had pneumonia. Two of the 3 patients had an episode of acute renal failure. The 30-day mortality rate was zero, although 1 patient died in the hospital 43 days after the reconstructive surgery, of multiple-organ failure due to pneumonia that was induced by end-stage pulmonary fibrosis. No patient died between hospital discharge and the most recent follow-up date (4-12 mo). Late local follow-up results, both functional and aesthetic, were good.We conclude that negative-pressure wound therapy-in combination with omentoplasty using laparoscopically harvested omentum and with the use of bilateral pectoral advancement flaps-is a valuable technique in the treatment of deep sternal wound infection because it produces good functional and aesthetic results.

Superior mesenteric arterial branch occlusion causing partial jejunal ischemia: a case report.

INTRODUCTION: Ischemic bowel disease comprises both mesenteric ischemia and colonic ischemia. Mesenteric ischemia can be divided into acute and chronic ischemia. These are two separate entities, each with their specific clinical presentation and diagnostic and therapeutic modalities. However, diagnosis may be difficult due to the vague symptomatology and subtle signs. CASE PRESENTATION: We report the case of a 68-year-old Caucasian woman who presented with abdominal discomfort, anorexia, melena and fever. A physical examination revealed left lower quadrant tenderness and an irregular pulse. Computed tomography of her abdomen as well as computed tomography enterography, enteroscopy, angiography and small bowel enteroclysis demonstrated an ischemic jejunal segment caused by occlusion of a branch of the superior mesenteric artery. The ischemic segment was resected and an end-to-end anastomosis was performed. The diagnosis of segmental small bowel ischemia was confirmed by histopathological study. CONCLUSION: Mesenteric ischemia is a pathology well-known by surgeons, gastroenterologists and radiologists. Acute and chronic mesenteric ischemia are two separate entities with their own specific clinical presentation, radiological signs and therapeutic modalities. We present the case of a patient with symptoms and signs of chronic mesenteric ischemia despite an acute etiology. To the best of our knowledge, this is the first report presenting a case of acute mesenteric ischemia with segmental superior mesenteric artery occlusion.

Delayed recovery following laparoscopic partial hepatectomy.

We present a 42-year-old woman with unexpected coma after laparoscopic partial hepatectomy. MRI demonstrated ischaemic cerebral lesions. Further investigation revealed a patent foramen ovale. Cryptogenic stroke arising from a paradoxical carbon dioxide embolism was diagnosed. After 5 days of intensive care, she made a near complete recovery. Perioperative stroke, paradoxical emboli during surgery, patent foramen ovale, carbon dioxide cerebral embolism and therapeutic strategies are discussed.

Long-term disease-free survival following dendritic cell therapy and resection of small bowel melanoma metastases - a case report.

BACKGROUND: Although the resection of solitary visceral melanoma metastases is indicated when possible, further progression of metastatic disease is seen in the vast majority of patients. New modalities of immunotherapy can offer durable disease control in a significant proportion of melanoma patients. CASE REPORT: A 28-year-old man was diagnosed with stage III melanoma in 2003 and was treated with autologous dendritic cells in the adjuvant setting. Five years later melanoma metastases causing small bowel obstruction were surgically removed and he was retreated with dendritic cells. Following 5 months without disease manifestations, the patient presented with intermittent abdominal discomfort. Following the visualization of a hot spot at the level of the jejunum on 18F-fluorodeoxyglucose position-emission tomography, the patient underwent a laparotomy, during which a solitary melanoma metastasis of the small bowel causing intussusception was resected. The patient has so far remained disease-free, more than one year after the latest surgical intervention. CONCLUSION: Combined modality treatment with surgery and immunotherapy may result in an improved long-term outcome for patients with metastatic melanoma.

Laparoscopic repair of diaphragmatic Morgagni hernia in children: review of 3 cases.

This article retrospectively reviews the laparoscopic repair of Morgagni hernias in 3 children. The surgical procedure was performed by closing the defect using extracorporeal, interrupted, nonabsorbable sutures. Recovery was uneventful in all 3 patients. There were no recurrences and the chest radiograph stayed normal during the postoperative follow-up.

Colonic ischemia and perforation associated with enteral feeding through an ileal tube.

Reported complications of enteral feeding through a jejunostomy include diarrhea, intraperitoneal leaks, bowel obstruction, fistula formation, wound infection, tube occlusion, and other mechanical malfunctions. However, the incidence of these complications is very low, and many physicians prefer to feed their patients by means of a jejunal tube instead of parenteral nutrition. A potentially lethal complication is ischemia of the bowel distal to the site of insertion of the feeding catheter. The described cases of bowel ischemia secondary to enteral nutrition invariably occurred at the level of the jejunum. This report describes an unusual case of perforation of the colon in a patient fed through an erroneously placed feeding catheter in the distal ileum, just proximal to the ileocecal valve. After weeks of continuous and intractable diarrhea and progressive weight loss, the patient developed diffuse colonic ischemia with subsequent free perforation of the left colon and peritonitis. Surgical treatment consisted of placement of a new feeding tube in the proximal jejunum and removal of the old one together with a short segment of small bowel, left hemicolectomy, and end colostomy. The patient tolerated the procedure well, the tube feedings were gradually restarted, and at the 6-month postoperative visit gastrointestinal function was normal. This case illustrates possible complications of an inadvertently placed feeding tube. Not only may it cause unexplained diarrhea and undernutrition, but it may lead to more serious events like colonic ischemia and perforation.

Outpatient gastroplasty for morbid obesity: our first hundred cases.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a safe and effective treatment for morbid obesity. The aim of the present study was to identify factors actually contributing to the feasibility or to the failure of performing this procedure in an outpatient setting. METHODS: In this prospective study, 100 ambulatory LAGB procedures were compared with 100 procedures performed in patients with an overnight stay. The recorded variables in both groups were first compared by univariate analysis. Logistic regressions were then calculated to analyse which of the variables were independently predictive. RESULTS: The mean time lapse between the end of surgery and discharge from hospital was 8.33 h in the outpatient group and no patient required readmission. Independent risk factors affecting same-day discharge were increasing age of the patient, higher BMI and diabetes. Other variables such as patient's gender, duration of surgery, distance home-hospital, number of previous abdominal procedures and other comorbidities did not demonstrate statistical differences between the two study groups. CONCLUSION: Gastric banding for the treatment of obesity can be safely performed in an outpatient setting. Advanced age, higher BMI and diabetes adversely affect same-day discharge and should be taken into consideration when planning an ambulatory LAGB.

Laparoscopically assisted ileocolectomy in patients with Crohn's disease: a study of 50 consecutive patients.

BACKGROUND: This study aimed to assess the feasibility, safety, and immediate postoperative outcome of laparoscopically assisted ileocolic resection for Crohn's disease. METHODS: Data were collected retrospectively from a database of 50 consecutive patients with Crohn's disease who underwent ileocolic resection between 1997 and 2007. The mean age of the patients was 40 years (range, 20-74 years), and 21 of the patients were men. Of the 50 patients, 18 had a history of abdominal surgery. The mean time from diagnosis to operation was 6.4 years (range, 1-31 years). The indications for surgery included subobstruction (48%), failure of medical treatment (20%), and internal fistulas (32%). RESULTS: The mean operating time was 150 min (range, 80-360 min), and the blood loss was 130 ml (0-400 ml). Only 1 of the 50 patients underwent conversion to laparotomy. Return of bowel movement occurred at a mean of 3 days (range, 1-7 days). The median hospital stay was 8 days (range, 5-130 days). There was no 30-day mortality. The minor complication rate was 20%. The complications included wound infection, pneumonia, urinary infection, postoperative bleeding, prolonged ileus, and fever of unknown origin. Major complications occurred for four patients, with three patients experiencing an anastomotic leak and one patient a leak after fistulectomy. CONCLUSIONS: The laparoscopically assisted approach to ileocolic Crohn's disease seems to be feasible and safe, with acceptable immediate postoperative outcomes.

Clinical relevance of laparoscopically diagnosed hiatal hernia.

BACKGROUND: To determine the clinical relevance of a laparoscopically diagnosed hiatal hernia. METHODS: Consecutive patients undergoing an elective laparoscopy were prospectively recruited. We assessed preoperative gastroesophageal reflux symptoms using a validated score, and documented the presence or absence of a hiatal hernia during laparoscopy. RESULTS: Of the 95 evaluable patients, 42 (44%) had a hiatal hernia. The mean age was 49.8 years. Logistic regression analysis indicated that three features were significantly and independently associated with hiatal hernia: a higher reflux score (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.48-4.05; p < 0.001), low body mass index (BMI) (OR 0.83; 95% CI 0.70-0.98; p = 0.029), and type of surgery (OR 0.34; 95% CI 0.14-0.92; p = 0.033). The diagnostic accuracy of a reflux score of more than 2 was 81%, with a sensitivity, specificity, positive predictive value, and negative predictive value of 76%, 85%, 80%, and 82%, respectively. The likelihood ratio for a positive result was 5.05. CONCLUSION: Hiatal hernia is common in this population of surgical patients undergoing an elective laparoscopy. Patients with reflux symptoms or a low BMI were more likely to have a hiatal hernia. With a reflux score of more than 2, the probability of finding a hiatal hernia during laparoscopy is 80%.

Cetuximab with hepatic arterial infusion of chemotherapy for the treatment of colorectal cancer liver metastases.

BACKGROUND: Both hepatic arterial infusion (HAI) of chemotherapy and cetuximab (CET) have interesting activity for the treatment of colorectal cancer liver metastases (CRC-LM). PATIENTS AND METHODS: Intravenous CET with HAI oxaliplatin (OXA) or i.v. Irinotecan (IRI) followed by HAI of infusion of folic acid modulated 5-fluorouracil 5-FU/l-FA was administered to patients (pts) with CRC-LM who had failed at least one line of prior chemotherapy. RESULTS: Eight pts received i.v. CET with HAI-OXA (5 pts) and i.v.-IRI (3 pts) and HAI-5-FU/l-FA. Adverse events: repeated grade 3 skin toxicity (1 pt), abdominal pain with elevated liver enzymes and asthenia (2 pts), duodenal ulcer (2 pts) with catheter migration and intestinal bleeding (1 pt), reversible interstitial pneumonitis (1 pt), and cystic bile duct dilatation (2 pts) with arteriobiliary fistulisation (1 pt). A partial response was documented in 5 pts (62%). The median time to progression was 8.7 months (95% confidence interval 8-14 months). CONCLUSION: Intravenous administration of CET with HAI of chemotherapy is feasible and has promising activity but is associated with specific toxicity.

Waist circumference is an independent risk factor for the development of parastomal hernia after permanent colostomy.

PURPOSE: This study was performed to evaluate the risk factors of parastomal hernia after abdominoperineal rectal amputation. METHODS: This was a retrospective study of consecutive patients who underwent abdominoperineal rectal amputation for rectal cancer between January 1999 and August 2006. The effects of age, sex, surgical approach, chemotherapy, waist circumference, and body mass index on the development of a parastomal hernia were analyzed. RESULTS: Forty-one patients underwent 19 open and 22 laparoscopic abdominoperineal rectal amputations. A parastomal hernia developed in 19 patients (46 percent) after a median follow-up period of 31 (range, 5-80) months. We observed ten hernias in the open group and nine in the laparoscopic group (P = 0.453). There were no significant differences in the type of surgical approach, age, sex, or adjuvant therapy in patients who developed a parastomal hernia compared with those who did not. Waist circumference proved to be an independent risk factor (P = 0.011). When the waist circumference exceeds the calculated threshold of 100 cm, there is a 75 percent probability to develop a parastomal hernia. CONCLUSIONS: Abdominal obesity increases the risk of developing a parastomal hernia, therefore, it might be advisable to place a prophylactic mesh during colostomy formation when the patient's waist exceeds 100 cm.

Phase II study of preoperative helical tomotherapy for rectal cancer.

PURPOSE: To explore the efficacy and toxicity profile of helical tomotherapy in the preoperative treatment of patients with rectal cancer. PATIENTS AND METHODS: Twenty-four patients with T3/T4 rectal cancer were included in this nonrandomized noncontrolled study. A dose of 46 Gy in daily fractions of 2 Gy was delivered to the presacral space and perineum if an abdominoperineal resection was deemed necessary. This dose was increased by a simultaneous integrated boost to 55.2 Gy when the circumferential resection margin was less than 2 mm on magnetic resonance imaging. Acute toxicity was evaluated weekly. Metabolic response was determined in the fifth week after the end of radiotherapy by means of fluorodeoxyglucose-positron emission tomography scan. A metabolic response was defined as a decrease in maximal standardized uptake value of more than 36%. RESULTS: The mean volume of small bowel receiving more than 15 Gy and mean bladder dose were 227 ml and 20.8 Gy in the no-boost group and 141 ml and 21.5 Gy in the boost group. Only 1 patient developed Grade 3 enteritis. No other Grade 3 or 4 toxicities were observed. Two patients developed an anastomotic leak within 30 days after surgery. The metabolic response rate was 45% in the no-boost group compared with 77% in the boost group. All except 1 patient underwent an R0 resection. CONCLUSIONS: Helical tomotherapy may decrease gastrointestinal toxicity in the preoperative radiotherapy of patients with rectal cancer. A simultaneous integrated radiation boost seems to result in a high metabolic response rate without excessive toxicity.

Correlation between beta cell mass and glycemic control in type 1 diabetic recipients of islet cell graft.

Islet grafts can induce insulin independence in type 1 diabetic patients, but their function is variable with only 10% insulin independence after 5 years. We investigated whether cultured grafts with defined beta cell number help standardize metabolic outcome. Nonuremic C-peptide-negative patients received an intraportal graft with 0.5-5.0 x 10(6) beta cells per kilogram of body weight (kg BW) under antithymocyte globulin and mycophenolate mofetil plus tacrolimus. Metabolic outcome at posttransplant (PT) month 2 was used to decide on a second graft under maintenance mycophenolate mofetil/tacrolimus. Graft function was defined by C-peptide >0.5 ng/ml and reduced insulin needs, metabolic control by reductions in HbA(1c), glycemia coefficient of variation, and hypoglycemia. At PT month 2, graft function was present in 16 of 17 recipients of >2 x 10(6) beta cells per kg BW versus 0 of 5 with lower number. The nine patients with C-peptide >1 ng/ml and glycemia coefficient of variation of <25% did not receive a second graft; five of them were insulin-independent until PT month 12. The 12 others received a second implant; it achieved insulin-independence at PT month 12 when the first and second graft contained >2 x 10(6) beta cells per kg BW. Of the 20 recipients of at least one graft with >2 x 10(6) beta cells per kg BW, 17 maintained graft function and metabolic control up to PT month 12. At PT month 12, beta cell function in insulin-independent patients ranged around 25% of age-matched control values. Thus, 1-year metabolic control can be reproducibly achieved and standardized by cultured islet cell grafts with defined beta cell number.