[Impact of surgery in the management of pancreatic metastases of renal cell cancer]. / Place de la chirurgie dans la prise en charge des métastases pancréatiques des cancers du rein.

INTRODUCTION: Incidence of renal cell carcinoma (RCC) is increasing over the 25 last years. Pancreatic metastases of RCC are rare. The aim of this work was to study overall survival of patients operated for pancreatic metastases of RCC in Montpellier cancer institute. PATIENTS AND METHODS: Between 2000 and 2012, a retrospective monocentric study was performed at Montpellier cancer institute. We evaluated the outcomes of curative pancreatic metastases from renal primary and the impact of targeted therapies. RESULTS: Thirty-eight patients were treated in our center for pancreatic metastases of RCC. Twelve patients had a curative surgery of metachronous pancreatic metastases. Four patients were without recurrence after pancreatic resection (33.3%). None had adjuvant therapy. Six patients were treated by targeted therapies, because of metastatic progression. Five of 6 died, the sixth evolved with targeted therapies by thyrosine kinase inhibitor. Average deadline between appearance of metastases and death was 89.9 months for operated patients. Average deadline between appearance of c metastases and death was 33.1 months for the others (P=0.004). CONCLUSION: Surgical treatment of pancreatic metastases should increase life expectancy of patients. Others studies are necessary to prove the impact of targeted therapies in metastatics patients in this indication. LEVEL OF EVIDENCE: 5.

[Endocrine tumor arising in heterotopic gastric pancreas]. / Tumeur endocrine développée sur pancréas ectopique gastrique.

We report the case of a 49-year-old caucasian woman, in whom an endocrine tumor arising in gastric heterotopic pancreas was diagnosed. The patient was treated surgically with a gastric wedge resection. Heterotopic pancreas is a benign anatomic condition, probably widely underdiagnosed because usually asymptomatic. The malignant transformation of aberrant pancreas is very rare and almost always in adenocarcinoma. The endocrine tumors developed in heterotopic pancreas are exceedingly rare. Of our knowledge, only four cases have been published and only one case in the gastric location similar to this reported case.

Laparoscopic surgery and corticoadrenalomas.

BACKGROUND: Nowadays, laparoscopic adrenalectomy is the "gold standard" procedure for the treatment of benign lesions. However, the situation is not so clearcut when the issue is laparoscopic excision of malignant adrenal tumors. We present our results of laparoscopic adrenalectomy for treating malignant tumors over the past decade. METHODS: Between October 1995 and June 2004, 131 consecutive laparoscopic adrenalectomies were performed on 120 patients (11 synchronous bilateral procedures). All patients underwent a standardized investigation protocol during their workup for surgery. RESULTS: There were only two conversions to laparotomy (1.6%). Complications that occurred during the procedure were limited to six patients (5%). Postoperative 30-days mortality was nil. Postoperative complications occurred in five patients (4.7%) during the first 30 days of recovery. The median hospital stay for all patients was 2.5 days (range = 2-10 days). Twelve patients (9%) had a malignant tumor: nine corticoadrenalomas, one pleomorphic sarcoma, one metastatic deposit from a previously excised colonic cancer, and one malignant pheochromocytoma. At mean followup of 34 months, mean survival time was 42.3 months for corticoadrenalomas that had undergone laparoscopy versus 29.7 months for those who had had a laparotomy. Five of the nine patients are alive and well at a mean of 37 months following surgery. One patient developed pulmonary metastases one year postsurgery; they were responsive to mitotane. Five years later, the same patient had a reoperation for an intra-abdominal retrogastric recurrence of her tumor and continues to do well. Another patient developed pulmonary metastases 22 months following adrenalectomy. Two patients died of metastatic intra-abdominal disease 20 and 7 months postsurgery. CONCLUSION: When laparoscopic surgery is to used for cancer treatment, caution is the rule to maintain the primary objective of securing a survival rate at least as high as that for open surgery, without increased risk of recurrence. Considering the results presented within this study, it seems that the laparoscopic removal of a corticoadrenaloma should not worsen the prognosis, provided the surgeon respects the primary rules of oncologic resectional surgery. Any surgical conditions that would preclude the strict application of these criteria are contraindications to a laparoscopic procedure.

[Spontaneous haemoperitoneum due to a ruptured intra-abdominal varix with cirrhosis: report of two cases]. / Hémopéritoine spontané par rupture de varices intra-abdominales chez le patient cirrhotique.

Spontaneous haemoperitoneum due to ruptured intra abdominal varices with cirrhosis is rare and the diagnosis is generally difficult. Two cases of spontaneous intraperitoneal bleeding due to ruptures varices with cirrhosis are reported. One case is a ruptured portal cavernome and the other one is a ruptured varix of the gastrosplenic ligament. The combination of hypovolemic shock with increasing abdominal girth should impose the diagnosis. This is a surgical emergency and the mortality rate is high.

[Treatment of biliary injuries after laparoscopic cholecystectomy: retrospective study of 27 patients]. / Traitement des complications biliaires après cholécystectomie par coelioscopie: étude rétrospective de 27 patients.

UNLABELLED: Biliary injuries after laparoscopic cholecystectomy are rare but serious. Their mortality rate can reach 9%. AIM OF THE STUDY: Describe the management of biliary injuries after laparoscopic cholecystectomy in our center. PATIENTS: Between January 1995 and June 2005, 27 patients (13 women, 14 men) were treated. The mean age was 53 years old (range, 18-92 years). The biliary injuries were common bile duct sections (n=16, 60%), common bile duct stenoses (n=5, 18.5%), biliary fistulas from the cystic duct (n=4, 15%), and biliary fistulas from an aberrant biliary duct (n=2, 7.5%). RESULTS: Acute cholecystis was present in 40% of cases (n=11). An intraoperative cholangiography was done in 12 patients (44%). The mortality rate was 0%. Of the common bile duct sections, 43% were diagnosed during the cholecystectomy (n=7) or after the cholecystectomy within a mean of 11.2 days (n=9). Common bile duct injuries were treated in 16 cases with hepatojejunostomy and in five cases with an external biliary drain. Fistulas from the cystic duct were diagnosed within a mean 14.8 days. A fistula from an aberrant biliary duct was diagnosed during the cholecystectomy (n=1) or in the second postoperative day (n=1). Fistulas were treated with a clip on the cystic duct (n=2), an external biliary drain (n=1), a biliary endoprosthesis (n=1), and the biliary aberrant duct suture (n=2). CONCLUSION: Common bile duct injuries are a serious complication because their treatment is a hepaticojejunostomy in 75% of cases.

Immunodetection of estrogen receptor and 52,000-dalton protein in fine needle aspirates of breast cancer tumors.

The double immunohistochemical detection of estrogen receptor (ER) and the estrogen-regulated 52,000-dalton protein (52kDa-P) was performed on 35 fine needle aspirates of primary breast cancers. The nuclear ER, stained brown, was differentiated from the 52kDa-P, stained in red, in the cytoplasm of the same cells. The significant correlation obtained between the percentages of positive aspirated cells and the cytosolic concentrations of these two markers showed the validity of semiquantitative detection in fine needle aspirates, which appeared to be more representative of the content of these markers in tumors than was the detection in a single tissue section. Tumor heterogeneity also was defined by this double immunostaining, since among the tumors positive for both ER and 52kDa-P (18 of 35 cases), a heterogeneous group of 12 tumors contained the markers in two distinct cell populations, whereas a more homogeneous group of 6 tumors contained double-stained cells. The first information provided by this study is that the 52kDa-P is not correlated with the ER. This absence of correlation is in accordance with other studies and indicates that the 52kDa-P is associated with tumor proliferation and possibly invasion, rather than with hormone responsiveness or differentiation. The feasibility and validity of double immunostaining of these two markers in human breast cancer aspirates should stimulate larger studies--with clinical follow-up of the patients--aimed at establishing the clinical usefulness of this presurgical test.

[Surgical management of a preaortic paraganglioma: Report of one case]. / Prise en charge chirurgicale d'un paragangliome préaortique: à propos d'un cas.

Paragangliomas (PG) are rare and often diagnosed in the young adult. One case of retroperitoneal preaortic paraganglioma localised between the celiac trunk and the superior mesenteric artery is reported. The management of paraganglioma involves endocrinologists, geneticists and surgeons but the only potentially curative treatment remains surgical resection. Pathology reports can not always discriminate between benign or malignant tumors. Hereditary in paraganglioma occurs in approximately 25% of cases. Genetic investigation is therefore mandatory in all patients with PG. Since the type of genetic mutation is correlated with tumoral aggressiveness, genetic investigation results should be taken into account when a surgical procedure is planned.

Distribution of the Mr 52,000 estrogen-regulated protein in benign breast diseases and other tissues by immunohistochemistry.

A secreted glycoprotein with a molecular weight of 52,000 is induced by estrogen in breast cancer cells and has been purified to prepare monoclonal antibodies. The protein has been detected in some breast cancers but not in normal breast and uterus. In order to study its potential value as a marker, we have tested by immunohistochemistry frozen sections of several normal and malignant tissues and of benign mastopathies. Among different tissues tested, the Mr 52,000 protein was detected only in liver, sweat glands, and some sebaceous glands, and in malignant melanomas and some breast tumors. Other estrogen-responsive tissues (ovary, placenta, endometrium, etc.) gave negative results. Immunoradiometric assay of the Mr 52,000 protein in biological fluid revealed an elevated concentration in cyst fluid (0.5 to 7.4 micrograms/ml), pleural effusions of certain metastatic breast cancer, and sweat. By immunohistochemistry, the Mr 52,000 antigen was also detected in 42% of 129 benign mastopathies. Gynecomastia, fibrous disease, fibroadenoma, and adenosis were mainly negative, whereas ductal hyperplasia and cysts were positive. The Mr 52,000 protein was found mostly in proliferative ducts and in cysts but not in lobular hyperplasia and nonproliferative lesions without cyst. More Mr 52,000 protein was found in postmenopausal patients than in premenopausal patients. We conclude that the Mr 52,000 protein is a marker associated with mammary cysts and proliferative ducts. On the basis of the increased risk of breast cancer in proliferative mastopathies, we suggest that the Mr 52,000 protein is useful for predicting high-risk mastopathies acting as a marker associated with the proliferation of ductal tissue.

Immunohistochemical detection of the estrogen-regulated 52,000 mol wt protein in primary breast cancers but not in normal breast and uterus.

An estrogen regulated glycoprotein of molecular weight 52,000 is released by metastatic human breast cancer cells in culture. In order to detect this protein directly in human tissues, several high affinity monoclonal antibodies were produced against the 52,000 mol wt protein. Frozen sections of human breast cancer samples were stained by the peroxidase-anti-peroxidase method using these antibodies. In 20 of 25 samples, specific immunoperoxidase staining was observed in the cytoplasm of epithelial cells with six monoclonal antibodies to the 52,000 mol wt protein. The 5 samples that were not stained contained no detectable estrogen receptor. Epithelial cells were not stained in 6 normal mammary glands collected during reduction mammoplasties and in 9 normal uteri, whether tissues were collected during the follicular or luteal phase. The demonstration that the 52,000 mol wt estrogen regulated protein is present in the cytoplasm of some primary breast cancers but absent in normal mammary tissue and uterus indicates its possible use as a tumor marker.

A phase II study of 5-fluorouracil, leucovorin and cisplatin (FLP) for metastatic gastric cancer.

The modulation of 5-fluorouracil (5-FU) with folinic acid (leucovorin, LV) is more efficacious than 5-FU alone in the treatment of metastatic colorectal cancer, and the combination of 5-FU with cisplatin is currently one of the most active regimens in advanced gastric cancer. A phase II study was therefore conducted to test the efficacy and toxicity of the combination of 5-FU, LV and cisplatin (FLP) in metastatic gastric cancer. 28 patients entered the study. Metastatic sites were observed in the liver (in 21 patients), the peritoneum (in 8), the lymph nodes (in 7) or the bones (in 1) and a local recurrence was noted in 4 cases. The performance status (using World Health Organisation criteria) was 0 for 13 patients and 1 or 2 for the others. Cycles of treatment were administered every 28 days and consisted of LV 200 mg/m2/day for 5 days followed by 5-FU 400 mg/m2/day for 5 days with cisplatin 100 mg/m2 on day 2. The response rate for the 27 evaluable patients was 51.8% (95% confidence interval (CI), 33-70.6%). There were four complete responses (14.8%) and 10 partial responses (37%). Median survival was 11 months and 4 patients were alive at 2 years. Both response rate and survival were better for patients with a good performance status. The overall toxicity was very low, except for 1 patient who died of dehydration and cardiac failure. In conclusion, the FLP protocol was effective and well tolerated in patients with metastatic gastric cancer.

Natural killer cell and alphabeta and gammadelta lymphocyte traffic into the liver graft immediately after liver transplantation.

BACKGROUND: The persistence and migration of donor leukocytes has been well established, but cellular kinetics immediately after revascularization and the potential relevance of these different lymphocyte populations to spontaneous tolerance remain unclear. During the early hours of revascularization, there is a transitory "congestion" of the liver graft, which is evidence of an early phase that we have termed "first cellular contact." METHODS: We have carried out by flow cytometry a prospective comparative study of the peak kinetics of lymphocyte subpopulations contained in: (a) peripheral blood and liver grafts at the time of multi-organ extraction from 14 brain-dead donors, (b) recipient peripheral blood before transplantation, and (c) recipient peripheral blood and liver grafts after (t=2 h) declamping and vascularization of the liver graft. RESULTS: Before transplantation, the liver grafts contained large numbers of natural killer (NK) and NK-like cells with early lymphocyte activation. Immediately after revascularization, there was an influx of recipient NK and NK-like cells into the liver. CONCLUSIONS: NK and CD3+CD56+ (NK-like) cells flooding into the liver graft immediately after revascularization could rapidly destroy allogeneic cells. However, spontaneous tolerance and the persistence of donor lymphocytes after orthotopic liver transplant could be a result of donor TCRalphabeta NK1.1 liver graft lymphocytes, which may be involved in the destruction of CD8+ T lymphocytes that would have received the apoptosis signal, and to NK and NK-like cell inhibition via inhibitory NK receptors. The decrease in gammadelta T lymphocytes in the two compartments suggests a mechanism of recirculation and capture in other lymphoid organs.

Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava: review of 1361 cases.

OBJECTIVE: The objective of this study was to describe the complications specifically related to orthotopic liver transplantation (OLT) with preservation of the inferior vena cava and to their therapeutic management. This preservation technique has considerably influenced the surgical phases of liver transplantation, increasing hepatectomy time and modifying the number of vascular anastomoses. METHODS: Our retrospective multicentric study, based on data from 1361 adult patients that had undergone orthotopic liver transplantation with preservation of the inferior vena cava in France between 1991 and 1997, analyzed the concomitant surgical complications. Type of cavo-caval anastomosis performed (piggyback, end-to-side, or side-to-side), use of a temporary portacaval anastomosis, technique-related complications, and mortality, were investigated. RESULTS: Cavo-caval anastomosis was side-to-side in 50.6% of cases (n=689), piggyback in 42.7% (n=582), and end-to-side in 6.6% (n=90). In total, 882 temporary portacaval anastomosis were carried out. Fifty-five patients presented with one or more complications related to the preservation of the inferior vena cava technique; i.e., overall morbidity was 4.1% (55/1361). Overall mortality was 0.7% (10/1361). Mortality rate for patients who presented with surgical complication was 18%. A total of 64 complications were recorded: 57 (89%) were in the perioperative or immediate postoperative period and 7 (11%) were postoperative. CONCLUSIONS: These retrospective, descriptive results show significant advantages in favor of side-to-side anastomosis in terms of vascular complications. Certain factors should be evaluated specifically at pretransplant assessment to prevent certain serious complications; principally, these are anatomic factors of the recipient (inferior vena cava included in segment I, anatomic abnormalities of the inferior vena cava) and graft size. Depending on these factors, surgeons must be able to adapt the orthotopic liver transplantation, either before or during orthotopic liver transplantation, preferring the standard technique.

Prevalence of monoclonal immunoglobulins after liver transplantation: relationship with posttransplant lymphoproliferative disorders.

BACKGROUND: A high incidence of serum monoclonal immunoglobulins (mIgs) has been described after solid organ transplantation. For transplant recipients, the prevalence of posttransplant lymphoproliferative disorders (PTLDs) has been reported to be between 2% and 6%. The relationship between the finding of serum mIg in transplant recipients and the subsequent development of PTLDs is not clearly documented. METHODS: We retrospectively analyzed all cases of mIg and PTLD that occurred in 86 liver transplant recipients who survived more than 3 months. Patients were characterized by protein electrophoresis, immunofixation electrophoresis, pre- and post-liver transplantation Epstein-Barr virus (EBV) serology, EBV presence in lymphoproliferative tissues by in situ hybridization, type of infection episodes, rejection episodes, and immunosuppressive treatment. RESULTS: Thirty-eight patients (44%) had abnormal immunofixation electrophoresis with an electrophoretic Ig peak. Twelve patients had a polyclonal Ig peak, and 26 patients had mIgs (30%). These 26 patients were divided into two groups: 13 patients had a transient mIg peak with a mean delay for normalization of electrophoresis of 2 months, and 13 patients had a permanent mIg peak. No correlation could be demonstrated between the appearance of abnormal banding and indications for transplantation, age of patients, and acute rejection rate. There was a strong correlation between occurrence of viral infections and presence of permanent mIg. Three patients with permanent mIg (23%) developed PTLD and died. CONCLUSIONS: We concluded that the prevalence of mIg after liver transplantation was 30%. Viral infections increase the risk of developing mIg. Persistence of mIg beyond 7 months may be regarded as prelymphomas necessitating a careful follow-up in these patients.

Metabolism of the new immunosuppressor cyclosporin G by human liver cytochromes P450.

Cyclosporin G is a new immunosuppressor structurally similar to cyclosporin A. Although this drug is pharmacologically as active as cyclosporin A, it is less toxic, in particular at the kidney level. The aim of this work was to identify the enzyme system(s) involved in the oxidative metabolism of cyclosporin G in man: (1) in a bank of human liver microsomes (n = 22), cyclosporin G oxidase activity correlated significantly with cyclosporin A oxidase activity (P < 0.0001) and with the level of CYP3A4 (P < 0.002), determined by immunoblot; (2) specific inhibitors of CYP3A4, troleandomycin, and ketoconazole, inhibited cyclosporin G oxidase activity by more than 80%; (3) antiCYP3A4 antibodies specifically inhibited this activity by nearly 90%; (4) cyclosporin A was a competitive inhibitor of cyclosporin G oxidase and vice versa; (5). Among a battery of cDNA-expressed CYPs, only CYP3A4 was able to generate detectable amounts of metabolites of cyclosporin G and cyclosporin A with a turnover number close to that calculated from experiments with liver microsomes; (6) in human hepatocytes in culture, pretreatment of cells with rifampicin and phenobarbital, 2 inducers of CYP3A4, produced a great increase in cyclosporin G oxidase activity, while beta-naphthoflavone, an inducer of CYP1As, did not. We conclude that CYP3A4 is the major enzyme involved in the oxidative metabolism of cyclosporin G in human liver.

Metabolism of cyclosporine after orthotopic liver transplantation.

The aim of this work was to determine whether the extensive metabolism of cyclosporine, acquired in a donor by treatment with an inducer of cytochrome P450 3A (P450 3A) (cyclosporine oxidase), was transmissible to the recipient by orthotopic liver transplantation. For this purpose, male Wistar rats were divided into five groups including: control animals (group C), animals treated with dexamethasone (an inducer of P450 3A, 50 or 300 mg/kg/day, for 4 days, group D), animals transplanted with the livers of control rats (group G) or with the livers of dexamethasone-induced rats (group GD), and animals treated with beta-naphthoflavone (an inducer of P450 1A, group B). All animals received a single i.v. dose of 10 mg/kg cyclosporine 24 hr after either the last dose of inducer or the transplantation. For each group of animals, the area under the curve (AUC) of cyclosporine was calculated from the curves of blood cyclosporine levels (by radioimmunoassay) against time; liver microsomes were assayed for cyclosporine oxidase activity by HPLC, erythromycin demethylase and P450 3A level by western blot with specific anti-P450 3A antibodies. The decrease in the AUC in groups D and GD with respect to C and G was correlated with increased level of P450 3A (4-5-fold with respect to control) as well as of microsomal cyclosporine oxidase. In addition, cyclosporine oxidase activity of liver microsomes was specifically inhibited by anti-P450 3A antibodies and troleandomycin. The animals in group B did not exhibit increased metabolism of cyclosporine either in vivo or in vitro. We conclude that: (1) cyclosporine is predominantly oxidized in the rat liver by a form of P450 from the 3A subfamily; (2) the extensive metabolism of cyclosporine acquired by donor rats after treatment with dexamethasone is transmissible to the recipients through orthotopic liver transplantation.

Hepatitis C virus genotypes and quantification of serum hepatitis C RNA in liver transplant recipients. Relationship with histologic outcome of recurrent hepatitis C.

The reasons for wide variations in the severity of recurrent hepatitis C after liver transplantation are unclear. We studied liver transplant recipients to assess the effect of hepatitis C virus (HCV) genotype and HCV RNA quantification on histologic progression of recurrent hepatitis C after transplantation. Twenty-five patients underwent transplantation for HCV cirrhosis and were followed up with virologic and histologic assessments for a mean of 51 months. HCV genotype was determined by line probe assay. HCV RNA was quantitated in serum samples by nested polymerase chain reaction. The HCV genotype 1 was detected in 17 patients and other genotypes in 8. Acute lobular hepatitis developed in 17 patients 162 days posttransplantation on average. Long-term biopsy specimens (mean, 51 months after the date of liver transplantation; range, 24-86 months) showed chronic hepatitis in 19 patients (mild, 5; moderate, 9; and severe, 5, 2 with extensive scarring). The serum alanine aminotransferase level was correlated with hepatocyte necrosis (piecemeal and lobular) but not with portal inflammation or fibrosis. Patients infected with genotype 1 had a higher Knodell score, and the 5 patients with severe hepatitis C all were infected with genotype 1. HCV RNA levels were significantly higher in patients with genotype 1 than in patients with other genotypes, as were the severity of histologic recurrence and levels of viral replication.

Experimental assessment of the risk of tumor recurrence after laparoscopic surgery.

BACKGROUND: The aim of this experimental study was to evaluate the risk of tumor recurrence after laparoscopic cecal resection (LCR) of colonic carcinoma in the rat. METHODS: The experimental cancer consisted of one million cells (DHK/K12), incorporated in an extracellular matrix, placed and secured to the cecal serosa in 110 BD9 rats. Four weeks later, all animals were reoperated through a laparotomy to control tumor growth, and animals with diffuse carcinomatosis were excluded. Eligible animals were randomized either to laparoscopic cecal resection (group LCR, n = 10), to open resection (group OCR, n = 13), or to a control group without resection (group C, n = 13). Resection was always considered as macrocopically complete. All animals were killed 4 weeks after the resection to determine the tumor recurrence and quantify carcinomatosis. RESULTS: We noted diffuse carcinomatosis in 70% of rats in groups C and LCR versus 23% in group OCR (p = 0.038). For tumors noted as S- (not extending outside the serosa), diffuse carcinomatosis was observed in all animals of group C (3 of 3), in 6 of 8 in group LCR, and 0 of 6 in group OCR (p = 0.004). The rate of port site or incisional metastases was not significantly different between groups. CONCLUSIONS: These preliminary results demonstrated the deleterious impact of the laparoscopy for resection of large bowel malignancy. LCR increased significantly the incidence of a diffuse carcinomatosis even when performed for locally noninvasive tumors (S-).

Prevalence and mechanisms of small intestinal obstruction following laparoscopic abdominal surgery: a retrospective multicenter study. French Association for Surgical Research.

HYPOTHESIS: The prevalence and mechanisms of intestinal obstruction following laparoscopic abdominal surgery have not been studied extensively. DESIGN: Retrospective review of cases of intestinal obstruction after laparoscopic surgery. SETTING: Sixteen surgical units performing laparoscopy in France. PATIENTS: Twenty-four patients with intestinal obstruction. MAIN OUTCOME MEASURES: Prevalence values and descriptive data. RESULTS: The 3 most frequent primary procedures responsible for intestinal obstruction were cholecystectomy (10 cases), transperitoneal hernia repair (5 cases), and appendectomy (4 cases). Prevalences of early postoperative intestinal obstruction after these procedures were 0.11%, 2.5%, and 0.16%, respectively. Intestinal obstruction was due to adhesions or fibrotic bands in 12 cases and to intestinal incarceration in 11 cases. Obstruction was located at the trocar site in 13 cases (9 incarcerations and 4 adhesions), mainly at the umbilicus, and in the operative field in 10 cases (2 incarcerations in a wall defect after transperitoneal inguinal hernia repair, 4 adhesions, and 4 fibrotic bands). The small intestine was involved in 23 of 24 cases; the other was due to cecal volvulus following unrecognized intestinal malrotation. Intestinal obstruction was treated by laparoscopic adhesiolysis in 6 patients and by laparotomy in 18 patients, 6 of whom required small intestine resection. Three postoperative complications but no deaths occurred. CONCLUSION: Intestinal obstruction following laparoscopic abdominal surgery can occur irrespective of the type of operation; the prevalence is as high as (cholecystectomy and appendectomy) or even higher than (transperitoneal hernia repair) that seen in open procedures.

Tracheoesophagogastric anastomosis fistula: a rare complication of esophagectomy.

Fistulas between trachea and esophagogastric anastomosis after esophagectomy are uncommon. We describe 2 patients with such a lesion successfully managed with single-stage repair. The fistula was divided, the tracheal defect was closed directly or with a free pericardial graft, and the esophagogastric anastomosis was redone. A muscle or pleural flap was used to separate the tracheal and digestive suture lines. This treatment of a potentially life-threatening condition yielded excellent results without postoperative complications.

Leiomyosarcoma of the inferior vena cava presenting as Budd-Chiari syndrome. Vena cava replacement under veno-venous bypass and liver hypothermic perfusion.

We report the first case of leiomyosarcoma of the middle and upper part of the vena cava successfully treated by surgical resection, complete vena cava replacement and disobliteration of the hepatic veins under veno-venous bypass and liver hypothermic perfusion as described in "ex situ, in vivo liver surgery".