Meta-analysis: evaluation of adjuvant therapy after curative liver resection for hepatocellular carcinoma.

AIM: To evaluate adjuvant modalities after curative resection for hepatocellular carcinoma using a meta-analysis of randomized and non-randomized controlled trials. METHODS: In a first step, a meta-analysis of randomized controlled trials was carried out. Sensitivity analyses after inclusion of non-randomized controlled trials were performed. Four therapeutic modalities were evaluated: pre-operative transarterial chemotherapy, post-operative transarterial chemotherapy, systemic chemotherapy and a combination of systemic and transarterial chemotherapy. RESULTS: Only post-operative transarterial chemotherapy improved survival significantly at 2 years [difference, 22.8%; confidence interval (CI), 8.6-36.9%; P = 0.002] and 3 years (difference, 27.6%; CI, 8.2-47.1%; P = 0.005), and decreased the probability of no recurrence at 1 year (difference, 28.8%; CI, 16.7-40.8%; P < 0.001), 2 years (difference, 27.6%; CI, 8.2-47.1%; P = 0.005) and 3 years (difference, 28%; CI, 8.2-47.9%; P = 0.006). In a sensitivity analysis after inclusion of non-randomized controlled trials, post-operative transarterial chemotherapy still improved survival at 1 year (difference, 9.6%; CI, 0.8-18.3%; P = 0.03), 2 years (difference, 13.5%; CI, 0.9-26%, P = 0.04) and 3 years (difference, 18%; CI, 7-28.9%; P < 0.001), and decreased the probability of no recurrence at 1 year (difference, 20.3%; CI, 7.7-33%; P = 0.002), 2 years (difference, 35%; CI, 21.4-46.3%; P < 0.001) and 3 years (difference, 34.5%; CI, 18.7-50.3%; P < 0.001). CONCLUSION: Post-operative transarterial chemotherapy improved survival and decreased the cumulative probability of no recurrence. New randomized controlled trials evaluating this modality are required.

[Gastric conservation in severe caustic lesions of the digestive tract: is it legitimate?]. / Conservation gastrique dans les lésions caustiques sévères du tube digestif: est-elle légitime?

OBJECTIVE: To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries. METHODS: Among 40 patients with severe caustic gastric burns (> IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation. RESULTS: Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality. CONCLUSION: Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.

[Evaluation of verification of brain death and coordination with hospital organ procurement at the University Hospital at Lille]. / Evaluation du recensement des morts encéphaliques par la coordination hospitalière de prélèvement au CHU de Lille.

OBJECTIVES: To determine the incidence of brain death (BD) and to evaluate the registration of potential organ donors (PD) by the organ procurement team (OPT). STUDY DESIGN: Two-year prospective audit in the French university hospital of Lille. PATIENTS AND METHODS: All deaths occurring in the intensive care units or the emergency department were studied. If death was consecutive to brain damage, on-site review of medical records and charts was performed. Death cause, presence of criteria for brain death and reference to the OPT were recorded for each death. A medical expert staff evaluated the incidence of and reasons for unsuitability for organ donation. After 12 months of observation, a protocol for "systematic alert of the OPT when brain death is suspected" was broadcast and evaluated during the next 12 months. RESULTS: During the first period, 277 BD occurred and 119 PD were suitable for organ donation. The OPT recorded 80 PD (67.2% of all PD) and 45 multi-organ procurements (MOP) were performed. Physicians opposed two major reasons for not calling OPT: anticipation of a non-validated medical contraindication in 18 cases and approach of the family without the OPT team in 21 cases. After broadcast of the protocol, 110 PD were identified and the OPT was called in 93 cases (84.5% of all PD, p < 0.004 versus first period). Fifty-three MOP were performed. CONCLUSION: The OPT was not called to manage one-third of the PD. The protocol for "systematic alert of the OPT when brain death is suspected" improves the call of the OPT and increases MOP.

Heterozygous M3Mmalton alpha1-antitrypsin deficiency associated with end-stage liver disease: case report and review.

Alpha1-antitrypsin (alpha1AT) deficiency is an autosomal recessive disorder that can cause pulmonary emphysema and liver disease. We report here the case of a 59-year-old woman who was admitted to hospital for evaluation of jaundice. She had no history of hepatitis or childhood liver disease. She had never received a blood transfusion, nor had she abused drugs or alcohol. Transjugular liver biopsy was then performed and revealed a micronodular cirrhosis. Ten months later, because of persistent liver cell failure and ascites, she underwent an orthotopic liver transplantation. Investigation of alpha1AT system in the proband revealed a substantial decrease in serum alpha1AT associated with a low elastase inhibitory capacity. The Pi phenotype revealed a PiM-like profile. Sequencing of exons 1-5 demonstrated the presence of the M3 allele. Moreover, a triple nucleotide deletion was detected in exon 2 of one allele. This caused an "in-phase" frameshift, coding for a protein deficient in a single Phe residue, which corresponded to the Mmalton variant. After liver biopsy, periodic acid-Schiff-positive acidophilic bodies resistant to diastase digestion were observed in the cytoplasm of hepatocytes. These results demonstrated that our patient had a heterozygous M3Mmalton alpha1AT genotype related to a deficiency phenotype. This observation is the first of a patient with heterozygous Mmalton genotype associated with an alpha1AT deficiency that induced severe liver disease requiring orthotopic liver transplantation.

Negative immunohistochemical detection of CD103 (alphaEbeta7 integrin) in the infiltrates of acute rejection in liver and kidney transplantation.

BACKGROUND: The infiltration of epithelium by CD8+ T lymphocytes in human renal or liver allografts is a critical feature of acute rejection. CD103 expression can be acquired in vitro by CD8+ cytotoxic T lymphocytes in response to allogeneic renal epithelial cells and promotes their adhesion to epithelium and subsequent lysis of epithelial cells. We investigated the expression of CD103 in T-cell infiltrates during acute renal or liver rejection (grade < III). METHODS: Immunohistochemical detection of CD103 in 11 liver and 10 kidney transplant biopsies with histopathological diagnosis of acute rejection. RESULTS: None of the infiltrates expressed detectable CD103, although positive controls were stained under our conditions. CONCLUSIONS: Failure to detect CD103 in renal biopsies can be related to the early posttransplantation interval (<6 months) corresponding to a first rejection episode. In our hands, immunohistological detection of CD103 was not possible in the infiltrates of acute rejection in liver or kidney transplantation.

The role of mediastinoscopy in the diagnosis of mediastinal lymphadenopathy.

OBJECTIVE: The reported experience of axial mediastinoscopy (MDS) performed in a diagnostic purpose only (rather than prognostic) is limited. Therefore, we designated the present study to clarify morbidity, sensitivity and accuracy of MDS performed to diagnose various mediastinal lesions. METHODS: We prospectively performed 400 MDS in a diagnostic purpose on 398 patients for: (1) isolated mediastinal adenopathies in 271 patients (group 1), and (2) mediastinal adenopathies associated with a pulmonary or a hilar lesion of unknown aetiology in 127 patients (group 2). In group 1, most of the patients were suspected to have a sarcoidosis, a tuberculosis or a lymphoma. In group 2, most of the patients were suspected to have a lung cancer. In both groups, the other current diagnostic procedure usually used in each pathology had failed to give an accurate diagnosis. RESULTS: A total of 76% of the samples were performed in the right laterotracheal lymph node station, 12.5% in the lower subcarinal and superior subcarinal lymph node station and 7.8% in the left laterotracheal lymph node station. The per- and post-operative mortality rates were nil. The per-operative morbidity accounted for six cases (1.5% of the examinations). The post-operative morbidity accounted for three cases (0.75% of the examinations). MDS data radically modified the pre-operative suspected diagnosis in 74 patients (18.5% of the patients). There were 17 false negative results (4.3% of the patients). The global sensitivity of MDS was 94%, the global specificity was 100% and the accuracy was 95%. In group 1, the sensitivity was 96% and in group 2 it was 92%. CONCLUSION: According to the results, the few contraindications of the procedure and its low cost, we confirm that MDS is still the first choice procedure to diagnose lesions located in the axial mediastinum.

Adrenalectomy for a solitary adrenal metastasis from lung cancer.

BACKGROUND: Several case reports have shown that patients with truly solitary adrenal gland metastases can undergo resection with long-term survival. METHODS: We assessed consecutive patients with operable or operated non-small cell lung cancer in whom the presence of a unilateral solitary adrenal metastasis was confirmed histologically. Synchronous homolateral adrenal metastases were resected at the same time as the non-small cell lung carcinoma through a transphrenic approach. Synchronous contralateral or metachronous adrenal metastases were resected through an elective approach. RESULTS: Of 598 patients with operable or operated non-small cell lung carcinoma, 11 had a unilateral solitary adrenal gland metastasis and underwent adrenalectomy with no additional mortality or morbidity. One patient died of late postoperative complications and 7 patients died of other distant metastases between 4 and 24 months after adrenalectomy. Two patients are still alive and free of recurrent disease and 1 patient is still alive with brain metastasis 66, 6, and 10 months, respectively, after adrenalectomy. CONCLUSIONS: In the absence of selection criteria to identify the subgroup of patients who will benefit from surgical resection, we suggest the resection of synchronous lesions in patients without N2 involvement and the careful selection of patients with metachronous adrenal metastases according to the evolution of their disease.

Retroperitoneoscopy for the diagnosis of infiltrating retroperitoneal lymphadenopathy and masses.

BACKGROUND: Retroperitoneoscopy (RPS) is a form of direct vision endoscopy, used to explore the retroperitoneal space, and was first described by Bartel in 1969. METHODS: RPS was performed prospectively to diagnose infiltrating retroperitoneal lymphadenopathy or masses when needle aspiration biopsy under computed tomographic guidance (NABCT) failed to establish a definite diagnosis. RESULTS: From May 1985 to August 1995, RPS was performed in 118 patients (121 procedures). Mean hospital stay was 2.4 (range 2-5) days. The peroperative and perioperative morbidity rate was 6.6 per cent of the procedures. A precise diagnosis was obtained in 108 of the 118 patients. The sensitivity was 84 per cent for malignant lymphoma, 94 per cent for Hodgkin's lymphoma, 95 per cent for metastatic lymph nodes of carcinomas and 100 per cent for primary retroperitoneal tumours. The overall sensitivity was 91.5 per cent. CONCLUSION: RPS is an alternative procedure to NABCT when aspiration biopsy is not technically feasible because a lesion is too small to sample or failed to establish a precise histopathological diagnosis.

Consecutive successful pregnancies in a combined liver and kidney transplant recipient with type 1 primary hyperoxaluria.

Pregnancy is now a common, but high-risk event, in young women who have received transplants. Consequences to the fetus are known, but pregnancy may also interfere with graft function. We report the outcome of two successive and successful pregnancies in a 29-year-old woman with type 1 hyperoxaluria, who received a combined liver and kidney transplant. Two healthy children were born at 35 and 37 weeks of gestation, with low birth weight. Liver function remained normal before, during, and after pregnancies up to 52 months after transplantation. Renal function was impaired before the first conception, worsened during both pregnancies, and returned to the previous level in both immediate postpartum periods. However, renal function has declined 17 months after the last delivery. This report shows the feasibility of successive pregnancies in multiple organ transplant recipients, but raises the question of long-term maternal kidney graft survival.

Ten-year experience with extraperitoneal pelvioscopy for the lymph node staging of pelvic cancers.

BACKGROUND: In view of the surgical lymphadenectomy morbidity and of the low accuracy of the preoperatory radiological investigations, minimal access surgery procedures are needed to assess lymph node involvement in pelvic cancers. METHODS: Extraperitoneal pelvioscopy (EPP) is a direct vision endoscopy permitting the exploration of the retroperitoneal space of the pelvic area. Beginning 1/05/1995, 235 patients with apparently resectable tumors underwent EPP for lymph node staging of 133 bladder, 89 prostate, 12 cervix, and one endometrium cancers. RESULTS: Lymph node involvement was discovered in 68 cases; the absence of lymph node involvement was demonstrated in 155 cases; and there were 12 false-negative results of the procedure. The feasibility was of 98.3%. The global sensitivity and accuracy were, respectively, 85% and 94%. CONCLUSION: This study demonstrates that EPP is a safe and accurate procedure to evaluate the lymph node status of pelvic cancers.