Endovascular isolated hepatic perfusion under pneumoperitoneum.

AIMS: Isolated hepatic perfusion (IHP) allows loco-regional administration of high drug doses for cancer treatment. Minimally invasive endovascular occlusion techniques can be used for IHP, but control of leakage remains a major drawback. We hypothesized that the increased intraabdominal pressure generated by a CO(2)-pneumoperitoneum (PP) can reduce the leakage rate of hypoxic endovascular IHP by mechanical compression of the capillary beds connecting the liver to the systemic circulation. METHODS: IHP was performed on adult pigs through laparotomy using a fenestrated double balloon-catheter placed into the retrohepatic vena cava to collect the hepatic outflow which was reinfused into the hepatic artery through an extracorporeal circulation system. Each pig underwent IHP during four consecutive phases: abdomen open (Phase I), abdomen closed under a 15 and 20 mmHg pneumoperitoneum (Phase II and III, respectively) and abdomen re-opened (Phase IV). The leakage rate from the liver to the systemic circulation was continuously monitored using a nuclear medicine technique. The systemic arterial pressure, the IHP inflow and outflow pressures and the flow rate were recorded. RESULTS: Leakage from the hepatic extracorporeal circulation to the systemic circulation occurred in all animals during Phase I. Under PP (Phases II and III), two leakage profiles were observed: (1) a major increase of the leakage rate in two animals with a high differential pressure (>50 mmHg) between the IHP inflow and the systemic pressures; (2) no change or a decrease of the leakage rate in the other three animals who had a low or negative differential pressure (<30 mmHg). Leakage was undetectable in all animals after exsufflation of the PP (Phase IV). CONCLUSIONS: IHP under PP is feasible. Leakage is not reduced during PP. A high gradient between the IHP inflow and the systemic pressure increases systemic leakage during PP. Upon release of the PP, the leakage is most likely redirected towards the volume depleted low resistance portal territory.

Cystic pneumatosis of the colon after liver transplantation.

Cystic pneumatosis (CP) is an uncommon but significant condition in adults in which gas is found in a linear or cystic form in the submucosa or the subserosa of the bowel wall. The diagnosis was made by conventional X-ray and confirmed by abdominal computed tomography. Benign pneumoperitoneum due to CP should be considered in the differential diagnosis of free intra-abdominal air after chemotherapeutic or immunosuppressive therapy. As such, pneumatosis intestinalis is only a sign and must be interpreted in light of the clinical findings because it may be found in various scenarios: in patients who are otherwise healthy, and associated with pyloric stenosis, jejunoileal bypass, progressive systemic sclerosis, transplantation, chemotherapy, immunosuppression (including AIDS), obstructive pulmonary disease and finally, as in our case, after liver transplantation. Since there were no signs of secondary complications such as peritonitis, ischemia, or perforation, conservative treatment with broad-spectrum antibiotics and parenteral nutrition was initiated.

Postoperative chylous ascites after radical gastrectomy. A case report.

Postoperative chylous ascites is a classical but uncommon complication following extensive retroperitoneal or near the root of the mesentery dissection with an incidence ranging from 1.2 to 3%. Only 6 cases of chylous ascites have been described after ulcer surgery with troncal vagotomy associated with pyloroplasty and only 1 after gastrectomy. We report the second case of chylous ascites after a D2 distal gastrectomy. A 56-year-old female underwent a D2 distal gastrectomy and gastro-duodenostomy with omentectomy for a prepyloric T1N0M0 moderately differentiated adenocarcinoma. The patient was treated conservatively by both of parenteral nutrition and a fat free diet. By the end of 2(nd) postoperative week, the effusion became serous again and the output gradually ceased. The drain could be removed on the 20(th) postoperative day. Normal enteral nutrition was resumed, no recurrence of chylous ascites occurred. This conservative treatment proved to be effective as it as already be reported with resolution in almost 60% of the patients and remains the first choice option.

Isolated liver perfusion for non-resectable liver tumours: a review.

Many treatments have been proposed for non-resectable primary or secondary hepatic cancer but the results have generally been disappointing. Isolated Hepatic Perfusion (IHP) was first attempted four decades ago but it gained acceptance only recently, after spectacular tumour responses were obtained by isolated limb perfusion with melphalan and tumour necrosis factor (TNF) for melanomas and sarcomas. Surgical isolation of the liver is a technically demanding operation that allows the safe administration of high doses of chemotherapeutics and TNF. Percutaneous techniques using balloon occlusion catheters are simpler but result in higher leakage rates from the perfusion circuit into the systemic circulation. Several phase I-II trials indicate that IHP can yield high tumour response rates, even when there is resistance to systemic chemotherapy. However, no significant advantage in overall survival has been demonstrated so far. IHP offers unique pharmacokinetic advantages for locoregional chemotherapy and biotherapy. It might also allow gene therapy with limited systemic exposure and toxicity. At present, IHP nevertheless remains an experimental treatment modality which should therefore be used in controlled trials only.

Schistosomal appendicitis in pregnancy.

Acute appendicitis is the most common acute surgical infection during pregnancy. Although usually pyogenic in origin, parasitic infections account for a small percentage of cases. Despite the relatively high prevalence of acute appendicitis in our environment, it is not commonly associated with schistosomiasis. We report here the association of pregnancy and appendicitis caused by Schistosoma haematobium. Schistosomiasis is very common complication of pregnancy in hyperendemic areas. Schistosome egg masses can lodge throughout the body and cause acute inflammation of the appendix, liver and spleen. Congestion of pelvic vessels during pregnancy facilitates passage of eggs into the villi and intervillous spaces, causing an inflammatory reaction. Tourism and immigration make this disease a potential challenge for practitioners everywhere.

NPY regulates catecholamine secretion from human adrenal chromaffin cells.

The aim of the present work was to find out whether NPY synthesized in human adrenal chromaffin cells controls in an autocrine/paracrine fashion the release of catecholamines by these cells. Accordingly, the constitutive and regulated release of both NPY and catecholamines was measured simultaneously in cultured human chromaffin cells. In addition, by using both RT-PCR and a combination of specific agonists and antagonists, we characterized the expression of NPY receptors on these cells as well as their pharmacology. Our results were as follows. 1) Human chromaffin cells constitutively secrete NPY. 2) Nicotine elicits a rapid increase in the release of both catecholamines and NPY; this release of NPY is more sustained than that of catecholamines. 3) RT-PCR shows expression of Y1, Y2, Y4, and Y5 receptor mRNA by chromaffin cells; these receptors are functional, as various receptor specific agonists elicit an increase in intracellular calcium. 4) Peptide YY, in contrast to NPY, is not able to stimulate the release of catecholamines. This finding was corroborated by the observation that no receptor-specific antagonists were able to reduce constitutive catecholamine release, whereas an NPY-immunoneutralizing antibody markedly attenuated the secretion. Taken together, these data suggest that NPY originating from the adrenal medulla locally enhances the secretion of catecholamines, presumably by acting via the putative y3 receptor.

[Living donors in kidney and liver transplantation]. / Le donneur vivant: transplantation de rein et de foie.

The shortage of organs available for transplantation has rekindled the interest for the kidney living donor, and has recently induced the use of living donors for liver transplantation too. Both methods raise many medical and ethical interrogations. The aim of this paper is to analyse this type of organ harvesting, and to report our experience and results with kidney and liver living donors.

[Gene therapy and cancer]. / Thérapie génique et cancer.

Gene therapy by definition aims at modifying the genetic program of a cell towards a therapeutic or prophylactic goal. Several gene therapy strategies for cancer are currently under evaluation: 1) "suicide" gene therapy where an inactive prodrug is converted into a cytotoxic drug; 2) modification of the function of oncogenes and tumor suppressor genes; 3) modification of the host immune response towards the tumor; 4) disruption of the tumor neovascularisation; 5) lysis of tumor cells with replication-competent viruses. Recent results of phase I and II clinical studies have brought great hopes. However, the inefficiency of current gene vectors in infecting targeted cells and their inability to selectively access diseased cells distributed systemically are two major limitations that have to be overcome for further successful clinical applications.

[Surgical site infection surveillance: an effective preventive measure]. / La surveillance des infections du site opératoire: un moyen de prévention efficace.

Surgical site infection (SSI) is a feared complication of any surgical procedure. Despite clear progresses during the last decades, recent studies (some from Switzerland) show that many patients still suffer from SSIs and that SSIs have a huge impact for patients and public health. Thus, the prevention of SSIs must constitute a priority of nosocomial infections control in hospitals. In addition to classical approaches focusing on skin preparation, antibiotic prophylaxis, asepsis, and operative environment, surveillance has proved effective in decreasing the incidence of SSIs. The present paper reviews the principles and the main components of an SSI surveillance program.

[Surgical treatment of hepatic metastases]. / Le traitement chirurgical des métastases hépatiques.

The liver is a common site for metastases from various forms of primary tumors. Colorectal cancer most commonly, but also neuroendocrine tumors, gastrointestinal sarcoma, ocular melanoma and others metastasize to the liver. A complete staging is important before considering treatment options. Surgical resection is the only form of curative treatment for colorectal cancer metastases. Systemic or intraarterial hepatic chemotherapy may be an alternative for patients with unresectable disease. Other promising treatment options such as cryotherapy and radiofrequency ablation are curRently under evaluation. The treatment of metastases from neuroendocrine tumors and other noncolorectal primary malignancies has to be individualized based on the patient's clinical status and the extent of the disease.

[Advanced Trauma Life Support: towards a standardization of care for the trauma patient]. / ATLS: vers une standardisation de la prise en charge des traumatisés.

The ATLS concept is a strategy for the treatment of the injured patient and a teaching method. ATLS originates from the USA and it was introduced in the French speaking part of Switzerland two years ago. This article describes the principles that made ATLS successful, as well as its objectives and impact on the treatment of injured patients. As a consequence, a trend is now emerging towards a standardisation of care of the trauma patient.

[Validation of laparoscopic surgical techniques]. / La validation des techniques en chirurgie laparoscopique.

The use of laparoscopic surgery has increased rapidly. However, a technically feasible procedure is not automatically recommendable. Thus, if cholecystectomy and fundoplication are currently fully validated techniques, this does not hold true for gastroplasty and kidney harvesting for transplantation: these operations are feasible indeed but their efficacy remains to be proved. Laparoscopic oncology has been shown to be feasible too, but its efficacy has not been documented yet.