Hiatal hernia after oesophagectomy: a large European survey.

OBJECTIVES: Hiatal hernias (HH) after oesophagectomy are rare, and their surgical management is not well standardized. Our goal was to report on the management of HH after oesophagectomy in high-volume tertiary European French-speaking centres. METHODS: We conducted a retrospective multicentre study among 19 European French-speaking departments of upper gastrointestinal and/or thoracic surgery. All patients scheduled or operated on for the repair of an HH after oesophagectomy were collected between 2000 and 2016. Demographics, details of the initial procedure, surgical management and long-term outcome were analysed. RESULTS: Seventy-nine of 6608 (1.2%) patients who had oesophagectomies were included in the study. The postoesophagectomy diagnostic interval of an HH after oesophagectomy was ≤90 days (n = 17; 21%), 13 were emergency cases; between 91 days and 1 year, n = 21 (27%), 13 in emergency; ≥1 year, n = 41 (52%), 17 in emergency. The time to occurrence of HH after oesophagectomy was shorter after laparoscopy (median 308 days; interquartile range 150-693) compared to that after laparotomy (median 562 days, interquartile range 138-1768; P = 0.01). The incidence of HH after oesophagectomy was 0.73% (22/3010) after open surgery and 1.4% (26/1761) after laparoscopy (P = 0.03). Among the 79 patients, 78 were operated on: 35 had laparotomies (45%), 19 had laparoscopies (24%) and 24 (31%) had transthoracic approaches. Among the 43 urgent surgeries, 35 were open (25 laparotomies and 10 transthoracic approaches) and 8 were laparoscopies (conversion rate, 25%). Nine patients required bowel resections. Morbidity occurred in 36 (46%) patients with 1 postoperative death (1.2%). During the follow-up period, recurrent HH after oesophagectomy requiring revisional surgery developed in 8 (6 days-26 months) patients. CONCLUSIONS: Surgical management of HH after oesophagectomy could be done by laparoscopy in patients with scheduled surgery but laparotomy or thoracotomy was preferred in urgent situations. The incidence of HH after oesophagectomy is higher and its onset earlier when laparoscopy is used at the initial oesophagectomy.

Management of an Esojejunal Intrathoracic Leak Using an Endoscopic Vacuum-assisted Closure Technique.

Management of intrathoracic anastomotic leaks remains an important clinical challenge. We describe a case about a patient with intrathoracic esophageal anastomotic leaks after oesogastrectomy. Ndoscopic Vacuum-assisted closure technique today is an effective alternative in the treatment of anastomotic leaks after upper gastrointestinal tract surgery.

Affinity of Indocyanine Green in the Detection of Colorectal Peritoneal Carcinomatosis.

Indocyanine green (ICG) is increasingly being used in digestive oncology. In colorectal cancer, ICG can be used to detect lymph node metastasis and hepatic metastasis on the surface of the liver. In peritoneal carcinomatosis, it was previously suspected that the diffusion of ICG in the tumor mass was due to the enhanced permeability and retention effect; however, this phenomenon has not been clearly demonstrated. Using bevacizumab, an antibody directed against vascular endothelial growth factor that consequently inhibits neoangiogenesis, we sought to confirm the mode of ICG diffusion. We compared the fluorescence of peritoneal carcinomatosis nodules from patients who had previously received bevacizumab during their oncologic treatment with those who did not receive this therapy. The sensitivity of the carcinomatosis nodule fluorescence was higher in the patients who did not receive bevacizumab compared with those who received the drug (76.3% and 65.0%, respectively). The rate of false-negative results was higher in the bevacizumab group than in the group that did not receive the drug (53.8% and 42.9%, respectively). Using bevacizumab, we demonstrate that the enhanced permeability and retention effect causes ICG accumulation in peritoneal carcinomatosis resulting from colorectal cancer.

Laparoscopy could be the best approach to treat colorectal cancer in selected patients aged over 80 years: Outcomes from a multicenter study.

BACKGROUND: The efficacy and safety of treating elderly patients with colorectal cancer (CRC) is of concern. This study aimed to compare the short- and long-term outcomes of elective laparoscopic vs. open surgery to treat CRC in very elderly patients. METHODS: All patients aged >80 years and who had undergone a colectomy for CRC without metastasis between July 2005 and April 2012 were considered for inclusion. Demographic, clinical, operative, and postoperative data, plus overall and disease-free survival rates, were retrospectively collected and compared between two groups of patients that underwent an open procedure (OP group) or laparoscopy (LG). RESULTS: 123 patients were enrolled (55 OPG, 68 LG). Median age was similar between the groups (84 vs. 83 years, respectively; NS). Duration of surgery was significantly lower in OPG (170 vs. 200min; p=0.030). Overall mortality at 3 months was 8.3%: it tended to be greater in the OPG (16.5% vs. 1.5%, NS). Morbidity was significantly greater in the OPG compared to the LG (52.7% vs. 27.5%; p=0.021), resulting in significantly longer hospital stay (12 vs. 8 days, respectively; p<0.001). Pathological findings were similar between the two groups. Cumulative overall survival rates at 3 and 5 years were significantly greater after laparoscopy (85% and 72%) compared to open surgery (58.2% and 48%, respectively; p<0.001). CONCLUSIONS: Our study suggests that laparoscopy is safe and could increase overall survival compared to open surgery in elderly patients suffering from CRC. SUMMARY: This retrospective study compared the short- and longer-term outcomes of patients aged >80 years and undergoing elective laparoscopic or open surgery for CRC between 2005 and 2012.

Improving Surgical Resection of Metastatic Liver Tumors With Near-Infrared Optical-Guided Fluorescence Imaging.

Objective The aim of this study was to investigate the feasibility and future clinical applications of near-infrared (NIR) fluorescence imaging to guide liver resection surgery for metastatic cancer to improve resection margins. Summary Background Data A subset of patients with metastatic hepatic tumors can be cured by surgery. The degree of long-term and disease-free survival is related to the quality of surgery, with the best resection defined as "R0" (complete removal of all tumor cells, as evidenced by microscopic examination of the margins). Although intraoperative ultrasonography can evaluate the surgical margins, surgeons need a new tool to perfect the surgical outcome. Methods A preliminary study was performed on 3 patients. We used NIR imaging postoperatively "ex vivo" on the resected liver tissue. The liver tumors were preoperatively labelled by intravenously injecting the patient with indocyanine green (ICG), a NIR fluorescent agent (24 hours before surgery, 0.25 mg/kg). Fluorescent images were obtained using a miniaturized fluorescence imaging system (FluoStic, Fluoptics, Grenoble, France). Results After liver resection, the surgical specimens from each patient were sliced into 10-mm sections in the operating room and analyzed with the FluoStic. All metastatic tumors presented rim-type fluorescence. Two specimens had incomplete rim fluorescence. The pathologist confirmed the presence of R1 margins (microscopic residual resection), even though the ultrasonographic analysis indicated that the result was R0. Conclusions Surgical liver resection guided by NIR fluorescence can help detect potentially uncertain anatomical areas that may be missed by preoperative imaging and by ultrasonography during surgery. These preliminary results will need to be confirmed in a larger prospective patient series.

A palm-sized high-sensitivity near-infrared fluorescence imager for laparotomy surgery.

In laparotomy surgery guided by near-infrared fluorescence imaging, the access to the field of operation is limited by the illumination and/or the imaging field. The side of cavities or organs such as the liver or the heart cannot be examined with the systems available on the market, which are too large and too heavy. In this article, we describe and evaluate a palm sized probe, whose properties, weight, size and sensitivity are adapted for guiding laparotomy surgery. Different experiments have been performed to determine its main characteristics, both on the illumination and imaging sides. The device has been tested for fluorescent molecular probe imaging in preclinical procedures, to prove its ability to be used in cancer nodule detection during surgery. This system is now CE certified for clinical procedures and Indocyanine Green imaging has been performed during clinical investigations: lymphedema and surgical resection of liver metastases of colorectal cancers.

Metals distribution in colorectal biopsies: New insight on the elemental fingerprint of tumour tissue.

BACKGROUND: Some studies have linked colorectal cancer to metal exposure. AIMS: Our objective was to evaluate the element distribution in colorectal adenocarcinoma biopsies, adjacent non-tumour tissues, and healthy controls. METHODS: The study is a case-control study which compared the element distribution in colon biopsies from two groups of patients: with colorectal cancer (2 types of samples: colorectal cancer biopsies and adjacent non-tumour tissues) and healthy controls. Fifteen metal concentrations (Aluminium, Boron, Cadmium, Chromium, Copper, Iron, Magnesium, Manganese, Nickel, Lead, Selenium, Silicon, Titanium, Vanadium, and Zinc) were quantified by using inductively coupled plasma atomic emission spectrometry. RESULTS: 104 patients were included: 76 in the colorectal cancer group, 28 in the healthy control group. Among the 15 elements analyzed, only boron, chromium, zinc, silicon and magnesium were found at clearly detectable concentrations. Colorectal tumour biopsies had significantly higher concentrations of magnesium as compared to adjacent non-tumour or healthy tissues. Zinc concentration followed the same trend but differences were not statistically significant. In addition, concentration of silicon was higher in colorectal cancer tissue than in healthy non-cancer tissue, while chromium was mostly found in adjacent non-tumour tissue. CONCLUSION: Magnesium, chromium, zinc and silicon were found in noteworthy concentrations in colorectal tumour. Their potential role in colorectal carcinogenesis should be explored.

Vasculitis of the bladder: An extremely rare case report.

INTRODUCTION: Isolated vasculitis of the bladder is extremely rare. The main causes of which are auto-immune diseases and occasionally infections. Corticosteroid therapy plays a central role in treatment in the majority of cases. PRESENTATION OF CASE: We report a case of gross hematuria associated with irritative low urinary tract symptoms (LUTS) and an increase of biological parameters of inflammation. Radiologic studies suspected a pelvic tumor process. We performed a cystoscopy with multiple biopsies. The pathological findings of the chips were in favor of a thrombotic nongranulomatous vasculitis of small and medium caliber. In view of these findings, all systemic diseases and inflammatory diseases such as cryoglobulinemia, the anti-phospholipid syndrome, Crohn's disease were eliminated. The symptoms regressed completely under antibiotics and anticoagulants. DISCUSSION: Our treatment options were based on the extent of the acute phase reaction and the pelvic venous thrombosis. A few similar cases have been reported in the literature, particularly a case of isolated necrotizing vasculitis of the bladder involving small vessels with a mild laboratory acute phase reaction which was treated with corticosteroids and cyclophosphamide. CONCLUSION: It is important to differentiate this rare pathological feature of the bladder from other bladder tumors as the treatment is medical rather than surgical.

Comparison of adiponectin concentration between pancreatic cancer and colorectal cancer.

INTRODUCTION: Adiponectin (ADP) is an adipocytokine secreted by the adipose tissue which can be a useful marker in oncogenesis. Preliminary studies suggest that adiponectin rates differ according to the type of cancer. AIM OF STUDY: Compare ADP plasma levels in pancreatic cancer (PC) and colorectal cancer (CRC) in a prospective monocentric study. PATIENTS AND METHODS: The study included all the incident cases of PC gathered from a university hospital in France from January 2006 till September 2007. A control population of incident cases of colorectal cancer (CRC), matching on age, gender, and tumor staging was set in the same period. In addition to demographic data, the other parameters analyzed were: ADP rate, insulinoresistance (Homa-test), presence of a dysmetabolic syndrome, evolution of weight and data concerning the tumor (staging, tumor markers: ACE, CA19.9). RESULTS: 33 CRC and 53 PC were analyzed. Type 2 diabetes was found in 18.2% of the CRC cases and 39.6% of the PC (p = 0.037). The mean ADP level was significantly higher in PC versus CRC (20.9 microgram/l versus 15.9 microgram/l; p = 0.03). In multivariate analysis , after adjusting for gender, age, bilirubinemia and weigth loss, the variables independently associated with a high level of ADP (> 10 microG/L) were type 2 diabetes (OR = 0.05, p = 0.01), insulinoresistance (OR = 0.42, p = 0.05) and PC (OR = 12.03, p = 0.047). CONCLUSION: ADP concentration is higher in PC patients than in CRC patients. ADP concentration > 10 microgram/l was independently associated with pancreatic cancer. Our data confirm that adiponectin rates differ strongly according to the type of cancer.

Laparoscopic staging and radiofrequency of hepatocellular carcinoma in liver ci rrhosis. A "bridge" treatment to liver transplantation.

BACKGROUND/AIMS: Surgical resection and liver transplantation are the only curative treatments for hepatocellular carcinoma, although limited to early stage disease. Our objective was to assess a novel operative combination of laparoscopic ultrasound with laparoscopic radiofrequency ablation of small hepatocellular carcinoma in potential candidates to liver transplantation when radiological evaluation is equivocal. We also evaluated the feasibility and efficacy of laparoscopic radiofrequency ablation. METHODOLOGY: Over a 2-year period, a laparoscopic ultrasound exploration and a laparoscopic radiofrequency ablation was performed in 15 patients (mean age 57+/-5.4 years; male/female 13/2) with hepatocellular carcinoma in liver cirrhosis. RESULTS: LRFA procedure was completed in all patients and a thermoablation of 36 hepatocellular carcinoma nodules was achieved. Laparoscopic ultrasound identified 12 new malignant lesions (46.1%) undetected by preoperative imaging. Six patients were up-staged as a result of the procedure and 3 were precluded from liver transplantation listing. A complete tumor necrosis was observed in 32 thermoablated nodules (88.8%) via spiral computed tomography 1 month after treatment. Seven patients underwent liver transplantation after a 5.8-month mean interval, and pathological staging of the explants agreed with laparoscopic staging for number/size of hepatocellular carcinoma nodules in all cases. Residual tumor was found in 2/12 (16.6%) thermoablated nodules, in two different liver specimens. CONCLUSIONS: Laparoscopic ultrasound accurately staged hepatocellular carcinoma in advanced cirrhosis with minimal morbidity and it can be used in potential candidates to liver transplantation. Laparoscopic radiofrequency ablation of hepatocellular carcinoma proved to be a safe and effective technique, representing a valid "bridge" treatment to liver transplantation or an effective palliative option.

Laparoscopic US-guided radiofrequency ablation of unresectable hepatocellular carcinoma in liver cirrhosis: feasibility and clinical outcome.

BACKGROUND: Radiofrequency ablation (RFA) is a safe, effective treatment in patients with unresectable primary liver malignancies. The laparoscopic approach to RFA (LRFA) has proved to be superior to the percutaneous approach in lesions that are difficult or impossible to be treated in such a way or in severe liver disease. Recent advances in laparoscopic ultrasound (LUS) have greatly improved the accuracy in detecting intrahepatic hepatocellular carcinoma (HCC) nodules, many of which were missed by computed tomography (CT) or magnetic resonance imaging (MRI). Our aim was to assess the feasibility, clinical outcome, and efficacy of laparoscopic RFA under LUS guidance. METHODS: Between February 2006 and May 2007, 24 consecutive patients (male/female, 20/4) with unresectable HCC in liver cirrhosis were treated with LRFA under LUS guidance. Most patients were in Child-Pugh class A (54.1%). Mean age of the patients was 61.79 +/- 7.74 years (range, 45-76; median, 60). RESULTS: LRFA procedure was completed in all patients and a thermoablation of 62 HCC nodules was achieved. LUS identified 13 new malignant lesions (20%) undetected by preoperative imaging. Mean length of surgery was 148 minutes (range, 60-315). Six procedures were associated in 5 patients: adhesiolysis (3), liver resection (1), partial splenectomy (1), and cholecystectomy (1). A pneumothorax needing immediate drainage during the procedure occurred in 1 case. One patient died 4 weeks after surgery because of liver failure. Mean hospital stay was 6.9 days and postoperative morbidity rate was 4 of 24 (16.6%). A complete tumor necrosis was observed in 56 of the 62 thermoablated nodules (90.3%) through spiral CT 1 month after treatment. CONCLUSIONS: LRFA is a safe, feasible treatment modality to achieve tumor destruction in selected patients with unresectable HCC that are not treatable with the percutaneous approach. Further, LUS demonstrated great accuracy during the procedure permitting to detect new HCC nodules missed at preoperative imaging.