Single-centre experience of laparoscopic pancreatic surgery.

BACKGROUND: Laparoscopic resection is regarded as safe and feasible in selected patients with benign pancreatic tumours. Few data exist on laparoscopic surgery for malignant lesions and larger neoplasms in unselected patients. METHODS: The study included all patients admitted to Oslo University Hospital, Rikshospitalet, from March 1997 to March 2009 for surgery of lesions in the body and tail of the pancreas, and selected patients with lesions in the pancreatic head, who underwent surgery by a laparoscopic approach with curative intent. RESULTS: A total of 166 patients had 170 operations, including 138 pancreatic resections, 18 explorations, nine resections of peripancreatic tissue and five other therapeutic procedures. Four patients had repeat procedures. There were 53 endocrine tumours (31.0 per cent), 28 pancreatic carcinomas (16.4 per cent), five cases of metastases (2.9 per cent), 48 cystic tumours (28.1 per cent) and 37 other lesions (21.6 per cent). The total morbidity rate was 16.5 per cent. Fistula was the most common complication (10.0 per cent). Three patients needed reoperation for complications. There were three hospital deaths (1.8 per cent). Median hospital stay following surgery was 4 days. CONCLUSION: Laparoscopic resection of lesions in the body and tail of the pancreas in an unselected patient series was safe and feasible, and should be the method of choice for this patient group in specialized centres.

Randomised controlled trial of temoporfin photodynamic therapy plus chemotherapy in nonresectable biliary carcinoma--PCS Nordic study.

BACKGROUND: Photodynamic therapy (PDT) in combination with stent have shown promising results in the treatment of biliary tract cancer (BTC) in patients not suitable for surgery. Chemotherapy has been shown to improve survival in patients with local advanced and metastatic BTC. MATERIAL AND METHODS: In the current randomized trial the combination of chemotherapy and stent with and without temoporfin (Foscan) photodynamic therapy (PDT), with a primary endpoint on feasibility and safety, has been performed. Ten patients in each group. RESULTS: No serious, acute procedure-related complication related to PDT or the treatment combination was seen. The number of patients with cholangitis was equal in both groups. In the PDT group--arm A--two patients had cutaneous erythema after sun exposition, one of them with a localized blister. No neutropenic infection was seen. Quality of Life (QoL) was similar in both treatment groups. Progression free survival was numerically longer in the PDT group. CONCLUSION: The treatment combination was feasible. There was no serious complication related to PDT or the treatment combination. Number of cholangitis was equal in both groups, two abscesses were observed in the PDT group. Progression free survival was numerically longer in the PDT group.

Differential expression of miRNAs in pancreatobiliary type of periampullary adenocarcinoma and its associated stroma.

Periampullary adenocarcinomas can be of two histological subtypes, intestinal or pancreatobiliary. The latter is more frequent and aggressive, and characterized by a prominent desmoplastic stroma, which is tightly related to the biology of the cancer, including its poor response to chemotherapy. Whereas miRNAs are known to regulate various cellular processes and interactions between cells, their exact role in periampullary carcinoma remains to be characterized, especially with respect to the prominent stromal component of pancreatobiliary type cancers. The present study aimed at elucidating this role by miRNA expression profiling of the carcinomatous and stromal component in twenty periampullary adenocarcinomas of pancreatobiliary type. miRNA expression profiles were compared between carcinoma cells, stromal cells and normal tissue samples. A total of 43 miRNAs were found to be differentially expressed between carcinoma and stroma of which 11 belong to three miRNA families (miR-17, miR-15 and miR-515). The levels of expression of miRNAs miR-17, miR-20a, miR-20b, miR-223, miR-10b, miR-2964a and miR-342 were observed to be higher and miR-519e to be lower in the stromal component compared to the carcinomatous and normal components. They follow a trend where expression in stroma is highest followed by carcinoma and then normal tissue. Pathway analysis revealed that pathways regulating tumor-stroma interactions such as ECM interaction remodeling, epithelial-mesenchymal transition, focal adhesion pathway, TGF-beta, MAPK signaling, axon guidance and endocytosis were differently regulated. The miRNA-mRNA mediated interactions between carcinoma and stromal cells add new knowledge regarding tumor-stroma interactions.

Molecular signatures of mRNAs and miRNAs as prognostic biomarkers in pancreatobiliary and intestinal types of periampullary adenocarcinomas.

Periampullary adenocarcinomas include four anatomical sites of origin (the pancreatic duct, bile duct, ampulla and duodenum) and most of them fall into two histological subgroups (pancreatobiliary and intestinal). Determining the exact origin of the tumor is sometimes difficult, due to overlapping histopathological characteristics. The prognosis depends on the histological subtype, as well as on the anatomical site of origin, the former being the more important. The molecular basis for these differences in prognosis is poorly understood. Whole-genome analyses were used to investigate the association between molecular tumor profiles, pathogenesis and prognosis. A total of 85 periampullary adenocarcinomas were characterized by mRNA and miRNA expressions profiling. Molecular profiles of the tumors from the different anatomical sites of origin as well as of the different histological subtypes were compared. Differentially expressed mRNAs and miRNAs between the two histopathological subtypes were linked to specific molecular pathways. Six miRNA families were downregulated and four were upregulated in the pancreatobiliary type as compared to the intestinal type (P < 0.05). miRNAs and mRNAs associated with improved overall and recurrence free survival for the two histopathological subtypes were identified. For the pancreatobiliary type the genes ATM, PTEN, RB1 and the miRNAs miR-592 and miR-497, and for the intestinal type the genes PDPK1, PIK3R2, G6PC and the miRNAs miR-127-3p, miR-377* were linked to enriched pathways and identified as prognostic markers. The molecular signatures identified may in the future guide the clinicians in the therapeutic decision making to an individualized treatment, if confirmed in other larger datasets.

Outpatient laparoscopic splenectomy: patient safety and satisfaction.

BACKGROUND: We assessed the feasibility of outpatient laparoscopic splenectomy, as performed by an experienced laparoscopic term and combined with optimal anesthesia. METHODS: Inclusion criteria in the study was limited to patients not hospitalized before the procedure who had hematological or neoplastic indications for splenectomy and were classified as American Society of Anesthesiologists (ASA) I-III. They received general intravenous anesthesia with propofol and remifentanil and were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis against postoperative pain and nausea. Laparoscopic splenectomy was performed via three trocars. The specimen was removed via an incision in the left iliac fossa. RESULTS: Ten of the 12 patients were discharged 3-6 h postoperatively; the other two were admitted primarily to hospital. One was readmitted due to a fever, which was finally explained by measles. The median operative times was 58 min (range, 45-135). Patient satisfaction was excellent in nine and intermediate in two cases; it was poor in one case, due to postoperative pain. CONCLUSION: Laparoscopic splenectomy can be completed in a relatively short time; therefore, it is feasible, safe, and satisfactory for most patients as an outpatient procedure.

Outpatient laparoscopic adrenalectomy in patients with Conn's syndrome.

BACKGROUND: [corrected] We set out to record the operative times of an experienced laparoscopic team and assess the feasibility of outpatient laparoscopic adrenalectomy when optimal anesthesia was also offered to all patients. METHODS: The study included 13 patients with aldosterone/cortisone hypersecretion and/or adrenal gland tumors, excluding those with pheochromocytoma. They had to live within 30 min travel from the hospital, and adult company had to be present at home. All patients received general intravenous anesthesia with propofol and remifentanil and were given keterolac, propacetamol, droperidol, and ondansetron as prophylaxis against postoperative pain and nausea. Laparoscopic adrenalectomy was performed by the transabdominal lateral flank approach. Postoperatively, all patients were contacted by phone in the evening and the next morning. RESULTS: All 13 patients were discharged 3-6 h postoperatively. None were readmitted; thus, the day care success was 100%. The mean operative time was 38 min (range, 35-112). Patient satisfaction was excellent in all but one case, due to pain on the 1st postoperative day. CONCLUSION: Laparoscopic adrenalectomy can be a fast operation. It is feasible and safe and yields satisfactory results for patients as an outpatient procedure when the necessary surgical experience and optimal anesthesia are both available.

Outpatient laparoscopic surgery: feasibility and consequences for education and health care costs.

BACKGROUND: The purpose of this paper is to describe the outcome of ambulatory laparoscopic cholecystectomy (LC), antireflux surgery, adrenalectomy and splenectomy and possible implications for surgical education and health care costs. METHODS: Prospective, observational study 1994-2003. RESULTS: The success rate of ambulatory treatment was 83.5% in 1060 LC patients, 80% in 113 antireflux procedures, 100% in 22 laparoscopic adrenalectomies, and 75% in 12 laparoscopic splenectomies. In a total number of 1207 patients, health care costs were reduced by almost 700,000 dollars, compared to 1-day hospital stay. The educational potential of same-day surgery is large, due to high numbers of patients, and 80% of our educational potential has been exploited. CONCLUSION: Ambulatory laparoscopic surgery is cost effective, patient friendly, and appropriate for surgical resident training. Strict organization of security rules is mandatory.

Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome.

BACKGROUND: Laparoscopic resection is not an established treatment for tumors of the pancreas. We report our preliminary experience with this innovative approach to pancreatic disease. METHODS: Thirty two patients with pancreatic disease were included in the study on an intention-to-treat basis. The preoperative indications for surgery were as follows: neuroendocrine tumors ( n=13), unspecified tumors ( n=11), cysts ( n=2), idiopathic thrombocytopenic purpura with ectopic spleen ( n=2), annular pancreas ( n=1), trauma ( n=1), aneurysm of the splenic artery ( n=1), and adenocarcinoma ( n=1). RESULTS: Enucleations ( n=7) and distal pancreatectomy with ( n=12) and without splenectomy ( n=5) were performed. Three patients underwent laparoscopic exploration only. Four procedures (13%) were converted to an open technique. One resection was converted to a hand-assisted procedure. The mortality rate for patients undergoing laparoscopic resection was 8.3% (two of 24). Complications occurred after resection in nine of 24 procedures (38%). The median hospital stay was 5.5 days (range, 2-22). Postoperatively, opioid medication was given for a median of 2 days (range, 0-13). CONCLUSION: Resection of the pancreas can be performed safely via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

Pancreatic carcinoma: MR, MR angiography and dynamic helical CT in the evaluation of vascular invasion.

OBJECTIVE: To assess the value of MR angiography in combination with contrast-enhanced MR imaging, and to compare MR imaging including MR angiography with dynamic contrast-enhanced dual phase helical CT in the preoperative assessment of vascular invasion in patients with suspected pancreatic carcinoma. METHODS AND MATERIAL: MR imaging only, MR imaging including MR angiography and dynamic contrast-enhanced dual phase helical CT images of 48 patients who were operated due to suspicion of pancreas cancer were correlated with the surgery results in terms of vascular invasion. Pathologic diagnosis were pancreatic adenocarcinoma in 31 patients of which nine had surgically confirmed vascular invasion. Sensitivity, specificity, predictive values (including 95% confidence intervals) and accuracy of MR imaging only, MR imaging including MR angiography and helical CT were calculated. RESULTS: Sensitivity, specificity, positive and negative predictive values and accuracy were 56, 100, 100, 85, 87%; 67, 100, 100, 88, 90% and 67, 100, 100, 88, 90%, respectively, for MR imaging only, MR imaging including MR angiography and helical CT in the adenocarcinoma group. The corresponding figures in the overall study group were 56, 97, 83, 90, 90%; 67, 97, 86, 93, 92% and 67, 97, 86, 93, 92%. Confidence intervals (95%) showed that the differences in the diagnostic efficacy of the techniques were not statistically significant in the overall study group, but the confidence intervals were undefined in the adenocarcinoma group due to the small sample size. CONCLUSION: Diagnostic efficacy of MR imaging when combined with MR angiography is equal to that of dynamic contrast-enhanced dual phase helical CT in the assessment of vascular invasion of pancreatic tumors.

Bile duct injury in laparoscopic cholecystectomy.

Bile duct injuries in laparoscopic cholecystectomy are briefly reviewed. The Norwegian National Cholecystectomy Registry was started on April 1, 1993, to collect data from most Norwegian surgical departments. in the period April 1, 1993-May 31, 1995, common bile duct (CBD) injuries necessitating treatment were reported in 0.61% of 2,612 laparoscopic cholecystectomies and in 0.74% of 674 open cholecystectomies. Early diagnosis is mandatory and the treatment is then simple. Delayed diagnosis is dangerous and the treatment may then be difficult. This field seems to show a difference between publications and the real world.

Bile leak after cholecystectomy significance and treatment: results from the National Norwegian Cholecystectomy Registry.

From April 1993 to July 1995, altogether 3860 procedures were enrolled in the Norwegian National Cholecystectomy Registry (NNCR), 777 (20.2%) being open operations. 3083 (79.8%) were initiated laparoscopically, 313 (10.2%) of these converted to open technique. Mortality within 30 days after open cholecystectomy was 1.9%, after a converted procedure 1.0% and 0.14% after laparoscopic cholecystectomy (p<0.01). According to the intention to treat principle, converted procedures should be included in the laparoscopic group. This gives seven deaths after 3083 procedures, i.e. 0.23%. Postoperative death still occurs approximately 10 times more frequently after open cholecystectomy (p<0.01). However, this is partly due to selection of high risk cases to open technique. Postoperative bile leak was observed in 25 patients (0.9%) in the laparoscopic, 13 (4.2%) in the converted and 19 (2.4%) in the open group. Bile leak contributed significantly to serious complications. 37 major problems were observed in 25 of the patients (44%). Five patients died (8.8%). Among the 57 bile leak patients, common bile duct (CBD) injury was found in 13 (22.8%). Additional 19 CBD injuries occurred, presenting with other symptoms such as icterus, or being recognised during the first operation. The frequency of CBD injury in the laparoscopic group was 14 (0.5%), in the converted group 12 (3.8%) and in the open group 6 (0.8%). None of the patients with CBD injury underwent intraoperative cholangiography. The present results firstly show that open cholecystectomy cannot be considered a safe procedure for high risk patients, secondly, that postoperative bile leak contributes significantly to postoperative mortality and hence is a serious condition generating from CBD injury in about 1/5 of all cases.

Follow-up after curative surgery for pancreatic ductal adenocarcinoma: asymptomatic recurrence is associated with improved survival.

AIM: There is no consensus on the optimal follow-up schedule of patients after surgery for pancreatic cancer. In this retrospective study, recurrence and survival were investigated for patients presenting with either symptomatic or asymptomatic recurrence. Patient, tumor and treatment characteristics that predicted the length of postrecurrence survival were identified. METHODS: Clinical records of 164 patients who underwent a pancreatic resection (R0/R1) for pancreatic ductal adenocarcinoma from January 2000 to December 2010 were retrieved. Patients underwent a systematic follow-up program. Patient, tumor and treatment characteristics were compared between patients with asymptomatic and symptomatic recurrence. RESULTS: Of 164 consecutive patients, 144 patients (88%) had recurrence (29 asymptomatic, 115 symptomatic). The most frequent reported symptoms were abdominal pain, fatigue/weakness, back pain, weight loss, nausea/loss of appetite and jaundice. Median time to recurrence was 12.0 months for asymptomatic and 7.0 months for symptomatic patients (P = 0.036). Median postrecurrence survival was 10.0 months for asymptomatic and 4.0 months for symptomatic patients (P < 0.0001). Median overall survival was 24.5 months for asymptomatic and 11.0 months for symptomatic patients (P < 0.0001). Symptomatic recurrence, disease free survival <12 months, and no adjuvant chemotherapy were the only independent predictors of poor postrecurrence survival. 72% of asymptomatic and 37% of symptomatic patients received oncological treatment. CONCLUSIONS: Patients with asymptomatic pancreatic cancer recurrence have improved recurrence-free, postrecurrence and overall survival. Symptoms when recurrence is diagnosed are a good surrogate marker of biological aggressiveness. Detection of asymptomatic recurrence may facilitate patient eligibility for investigational studies or other forms of treatment.

Altered expression of genes in adipose tissues associated with reduced fat mass in patients with pancreatic cancer.

Loss of adipose tissue in patients with pancreatic cancer may involve altered gene expression. Peri-operative mRNA levels of 44 genes were analysed by RT-PCR in intra-abdominal (IAAT) and subcutaneous adipose tissue (SCAT) sampled from pancreatic ductal adenocarcinoma (PDAC) patients undergoing tumour resection (n = 20), and control patients without cancer (n = 11). Peri- and post-operative IAAT and SCAT masses were measured by computerized tomography. PDAC patients displayed 2.6- and 1.7-fold higher Zn-α2-glycoprotein (AZGP1) mRNA levels than controls in IAAT and SCAT, respectively (P < 0.01), but expression was not correlated with post-operative changes in fat masses. IAAT mass changes correlated with genes in lipid metabolism, inflammation and apoptosis: e.g. stearoyl-Coenzyme A desaturase 1 (SCD), tumour necrosis factor (TNF) and chemokine (C-C motif) ligand 2 (CCL2; MCP-1). Patients with PDAC displayed increased AZGP1 mRNA levels in both IAAT and SCAT, but expression of other genes may predict IAAT loss.

Secretin-stimulated magnetic resonance cholangiopancreatography of patients with unclear disease in the pancreaticobiliary tract.

PURPOSE: To explore the usefulness of secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) on different pathological entities in the pancreaticobiliary tract (PBT) MATERIAL AND METHODS: Sixty-two patients with unclear disease in the PBT were examined with S-MRCP as the final radiological procedure. Nine groups of referral diagnoses were identified, and clinical outcome was evaluated. RESULTS: In five patients with suspected pancreatic duct injury after blunt abdominal trauma, a negative predictive value of 100% was found after a median of 3.5 months of follow-up. In 22 patients with residual pain after cholecystectomy, investigated for sphincter of Oddi dysfunction (SOD), delayed dilatation of the PD and pain were documented in four patients. Three of these were treated with endoscopic papillotomy (EPT), and no recurrences were found during an average of 13.6 months of follow-up. Five cases of pancreas divisum not previously seen were identified, and of 12 patients with suspected postoperative stenosis, five were successfully treated after being identified with S-MRCP. Useful information was obtained in most of the patients, i.e., findings not observed in previous radiological examinations or clarifying uncertain previous findings. Nine patients were referred to other non-radiological examinations, identifying that the origin of disease was outside the PBT. CONCLUSION: S-MRCP has the potential to become the final part of diagnostic workup in difficult PBT diseases, but further investigation of usefulness regarding different referral reasons is mandatory.

Telomerase peptide vaccination of patients with non-resectable pancreatic cancer: A dose escalating phase I/II study.

Patients with inoperable pancreatic cancer have a dismal prognosis with a mean life expectancy of 3-6 months. New treatment modalities are thus urgently needed. Telomerase is expressed in 85-90% of pancreas cancer, and immunogenic telomerase peptides have been characterised. A phase I/II study was conducted to investigate the safety, tolerability, and immunogenecity of telomerase peptide vaccination. Survival of the patients was also recorded. Forty-eight patients with non-resectable pancreatic cancer received intradermal injections of the telomerase peptide GV1001 at three dose levels, in combination with granulocyte-macrophage colony-stimulating factor. The treatment period was 10 weeks. Monthly booster vaccinations were offered as follow-up treatment. Immune responses were measured as delayed-type hypersensitivity skin reaction and in vitro T-cell proliferation. GV1001 was well tolerated. Immune responses were observed in 24 of 38 evaluable patients, with the highest ratio (75%) in the intermediate dose group. Twenty-seven evaluable patients completed the study. Median survival for the intermediate dose-group was 8.6 months, significantly longer for the low- (P = 0.006) and high-dose groups (P = 0.05). One-year survival for the evaluable patients in the intermediate dose group was 25%. The results demonstrate that GV1001 is immunogenic and safe to use. The survival data indicate that induction of an immune response is correlated with prolonged survival, and the vaccine may offer a new treatment option for pancreatic cancer patients, encouraging further clinical studies.

Complications in laparoscopic and open cholecystectomy: a prospective comparative trial.

Laparoscopic cholecystectomy (n = 250) was compared with the open procedure (n = 250) in a prospective comparative study focusing on complications. Severity grade was classified according to the Toronto system. The frequency of severity grade 1 complications was equal after open and laparoscopic cholecystectomy (5.6%), but major complications (grade 2 and higher) were significantly more frequent in the open group (10.4 versus 3.6%). The only postoperative death occurred after open cholecystectomy. The conventional advantages of laparoscopic cholecystectomy were also verified: The need for postoperative analgesics was significantly reduced from 7 (range, 4-16) standard opiate doses in the open group to 3 (range, 0-7) in the laparoscopic group. Hospital stay was reduced from 6 (range, 4-31) days after open surgery to 2 (range, 1-7) days after laparoscopic surgery and sick leave from 28 (range, 18-48) to 10 (range, 2-21) days, respectively. The overall complication rate was significantly higher in the open group (16 versus 9%, p < 0.01). In our hands, laparoscopic cholecystectomy carries a lower risk of serious complications than the open procedure.

[Choledochal cysts in adults]. / Choledochuscyster hos voksne.

Based on a case report, we describe choledochal cysts in adults. Choledochal cysts are rare, and are often overlooked. The aetiology is unknown. The symptoms are pain or discomfort, episodes of jaundice, cholangitis and pancreatitis. Increased liver function tests and gallstone disease are common. There is an increased risk of malignant tumours in the cysts and adjacent organs. Ultrasonography, computer tomography, endoscopic retrograde cholangiopancreaticography, percutaneous cholangiography and magnetic resonance imaging with magnetic resonance cholangiopancreaticography are relevant diagnostic tools. Extrahepatic cysts should be operated with radical excision, with Roux-Y hepaticojejunostomy or other reconstructions allowing later diagnostic and therapeutic access to the bile ducts. Long term results are good.

Introduction of laparoscopic techniques in gastrointestinal surgery: experience at a Norwegian university hospital as revealed by prospective comparative studies.

Prospective studies compared (a) laparoscopic and open cholecystectomy and (b) laparoscopic and open appendectomy. A second purpose of this study was to assess the value of laparoscopic staging of pancreatic and liver tumors. A total of 141 cholecystectomy cases were studied, comprising a laparoscopic group (n = 50), an open prospective control group (n = 50), and historical controls (n = 41). The need for postoperative analgesics was significantly reduced with the laparoscopic procedure compared with open cholecystectomy. Hospital stay was 1 (1-5) day after laparoscopic cholecystectomy versus 6 (5-28) days after open cholecystectomy. Time away from work was 9 (4-21) versus 28 (21-60) days. These differences were statistically significant (p < 0.001). Complication rates were 8% in both prospective groups. A similar comparative study of laparoscopic appendectomy versus the open technique was undertaken, with 10 patients in each prospective group. Again, hospital stay and time away from work proved shorter for laparoscopic procedures. Finally, 15 staging procedures for pancreatic and liver cancers were performed. One patient with unresectable liver metastases was spared explorative laparotomy.

[Laparoscopic surgery in Norway. Operational statistics from surgical departments after 1990]. / Laparoskopisk kirurgi i Norge. Driftsstatistikk fra kirurgiske avdelinger etter 1990.

In October 1992 all Norwegian hospitals were asked whether or not they currently performed laparoscopic cholecystectomy. 36 hospitals performed laparoscopic surgery, 15 did not and 20 hospitals did not reply. During 1990 six hospitals began to use the laparoscopic technique. The number had increased to 21 hospitals in 1991. Altogether 497 cholecystectomies were performed laparoscopically i 1991, comprising 36% of all cholecystectomies in the 51 responding hospitals. In October 1992 the number of hospitals performing laparoscopic cholecystectomy had increased to 36, and the mini-invasive technique was used in 920 cases, i.e. in 68% of the total number of cholecystectomies. Only approximately 7.5% of all appendectomies were performed laparoscopically in 1992 as well as in 1991. Until 1992, cholecystectomy was the only operation where the mini-invasive technique is widely used in Norway.

[Surgical treatment of gastrointestinal malignant melanoma]. / Kirurgisk behandling av malignt melanom i bukorganer.

Malignant melanoma is the most common metastatic lesion of the intestine, found at autopsy in approximately 60% of patients who die from melanoma. Common symptoms include bleeding, perforation and ileus/subileus. Patients with such symptoms should be operated on immediately, if they are not too reduced because of advanced disease. Long-term survival (five years) has been achieved in 34 of 179 (19%) of stage IVA melanoma patients after a radical operation procedure. Surgical removal of gastrointestinal metastases provides effective palliation in 80-95% of patients, who undergo laparotomy. We describe two patients with gastrointestinal metastases from malignant melanoma. A 33 year-old man had a large melanoma metastasis removed (non-radically) from the small intestine. He recovered rapidly, and experienced good palliative effect for three months, but died from a recurrence of the disease six months after operation. The other patient had a melanoma metastasis in the right lobe of the liver, which was treated by right hemihepatectomy. There has been no recurrence ten months after operation. We recommend surgical removal of abdominal melanoma metastasis if the surgery can be performed without unacceptable risk.