Should ruptured liver haemangioma be treated by surgery or by conservative means? A case report.

Spontaneous rupture of a liver haemangioma is a rare but life-threatening acute clinical situation following haemorrhage within the liver, the subcapsular space and the peritoneal cavity in cases of capsular rupture. Rupture of a liver haemangioma has been reported to occur spontaneously in the majority of cases. In the past, prompt surgical treatment was recommended but was associated with high morbidity and mortality. Currently, conservative management and, in cases of recurrent haemorrhage, delayed surgery may be proposed. We report a case of spontaneous rupture of hepatic haemangioma treated by arterial embolisation and conservative means. The literature is also reviewed.

Intraperitoneal chemotherapy with cisplatin and melphalan.

Cisplatin and melphalan given ip exert a synergistic therapeutic effect against ascitic P388 leukemia in mice and have different dose-limiting toxic effects as well as favorable pharmacokinetic characteristics in ip phase I studies. We gave a total of 98 courses of cisplatin (escalated from 40 to 120 mg/m2) and melphalan (escalated from 12 to 30 mg/m2) to 30 patients with ip tumors, most of whom had residual ovarian cancer following iv cisplatin-containing regimens. Treatment was delivered in 2 L of 0.9% NaCl through a Tenckhoff catheter with or without a Port-a-Cath system every 28 days for one to nine cycles. Myelosuppression was dose-related and leukopenia was dose-limiting. The maximum tolerated dose was 120 mg of cisplatin/m2 and 20 mg of melphalan/m2. With the exception of treatment-induced nausea and vomiting, nonhematologic toxic effects were mild and no (or very little) local toxicity occurred. Pharmacokinetic analyses showed that the areas under the peritoneal concentration versus time curve averaged 16-fold and 17-fold more than the area under the plasma curve for cisplatin and melphalan, respectively. Objective responses were documented by third-look laparotomy in ovarian cancer patients with minimal (less than 2 cm) residual disease.

[Treatment of peritoneal carcinomatosis from colorectal and appendiceal cancer by extensive cytoreductive surgery combined with hyperthermic intraoperative intraperitoneal chemotherapy]. / Traitement a visée curative des carcinoses péritonéales d'origine colorectale et appendiculaire par chirurgie maximaliste et chimiothérapie hyperthermique intrapéritonéale peropératoire.

Peritoneal carcinomatosis (PC) from colorectal cancer is a dreadful situation characterized by a rapid and mortal evolution (median survival of 5 to 7 months amongst the series published in the literature). The classical treatment includes systemic chemotherapy whether or not associated with palliative surgery. Since the early nineties, locoregional treatments combining extensive cytoreductive surgery with intraperitoneal hyperthermic chemotherapy have been developed, affording some patients a cure and yealding a 5-year survival as high as 30 to 40% in some series. However, it is associated with high morbidity and mortality rates.

Grading dysplasia in colorectal adenomas by means of the quantitative binding pattern determination of Arachis hypogaea, Dolichos biflorus, Amaranthus caudatus, Maackia amurensis, and Sambucus nigra agglutinins.

The current study deals with the setting up of a new tool that enables the benign versus the malignant nature of colorectal adenomas to be determined accurately. The 2 objectives are to determine (1) whether adenomas should, or should not, be included in a 2- or a 3-tier grading system, and (2) whether severe dysplasias and carcinomas in situ share common or different biological characteristics. The levels of expression of different types of glycoconjugates were characterized in a series of 166 colorectal specimens, including 14 normal, 90 dysplastic, and 62 cancerous cases. The glycoconjugate expressions were demonstrated for 5 lectins, namely, Arachis hypogaea (PNA), Dolichos biflorus (DBA), Amaranthus caudatus (ACA), Maackia amurensis (MAA) and Sambucus nigra (SNA). The glycoconjugates demonstrated by these 5 lectins belong to the family of the Thomsen-Friedenreich antigens. The binding patterns of the 5 lectins were quantitatively determined by means of computer-assisted microscopy. The quantitative data were submitted to discriminant analyses. Our results show that the specific glycochemical staining patterns could be identified unambiguously and without misclassification between benign (normal and low dysplasia) and malignant (ie, either as moderate/severe dysplasia, carcinoma in situ, or cancer) cases. The data also strongly suggested that (1) dysplasias seem to be distinguishable in 2 instead of 3 groups, that is, low versus moderate/severe (high); and (2) moderate/severe dysplasias are biologically distinct from carcinomas in situ. The methodology developed can be applied directly in routine diagnosis to identify moderate/severe dysplasia specimens already exhibiting features common to carcinomas, and which therefore should be treated consistently in view of the fact that our data strongly suggest that most moderate/severe dysplasias are still benign, whereas carcinomas in situ are real carcinomatous lesions.

Local excision as conservative treatment for small rectal cancer.

Twenty patients with small rectal cancer, characterized by a well differentiated tumour localized within 10 cm of the anal margin, and by penetration limited to the submucosa or to the muscular layer, were treated by local excision. Four of them, who presented with a deep tumour invasion in the rectal wall, also received adjuvant radiation therapy. Our experience proves the reliability of the selection criteria for patients who may benefit from this procedure. They all stand a fair chance of cure and the quality of their lives will improve because local tumour excision avoids anal sphincter resection. Two patients had local recurrences and had to undergo further curative local excision. The two who died from their tumours and who had distant metastases were unsuitable for both local resection and other therapeutic procedure. Finally, there was no postoperative morbidity.

Prolonged venous access in cancer patients.

One hundred and forty-eight Hickman-Broviac (HB) catheters and 299 Port-a-Cath R (PAC) were inserted over the past 5 years at the Institut Jules Bordet. The HB catheter was associated with a complication rate of 4.1/1000 days of access, of which infections were the most common, leading to catheter removal in 22% of patients. The average PAC remained in situ for 232.9 (range 1-1298) days; the complication rate was only 0.45/1000 days of access. The Hickman-Broviac catheter and the totally implanted port Port-a-Cath achieve safe and reliable venous access in cancer patients.

Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction.

OBJECTIVE: The aim was to identify the prognostic factors which relate to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with an occlusion. METHODS: The files of 109 patients with a neoplasm who were operated on for occlusion between 1990 and 2000 have been re-examined. The prognostic factors studied were age, sex, the location of the primary tumour, the extension of the cancer at the time of the operation, and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of transit and the return home. RESULTS: The median survival was 64 days and the peroperative mortality was 21%. The quality of life of patients has been improved in 65% of cases. The only factors clearly correlating to survival and the success of the operation are the aetiological diagnosis of the occlusion (local recurrence better than carcinomatosis) and the type of procedure it was possible to carry out (resection better than bypass). CONCLUSION: Palliative surgery can, in a certain number of cases, improve the quality of life of patients, but it has not been possible for us to demonstrate prognostic factors which would allow the selection of patients who could benefit the most from such surgery.

Controversies in the management of gastrointestinal non-Hodgkin's lymphomas.

Although more than a thousand GI non-Hodgkin's lymphomas have been reported, the literature does not indicate a clear optimal therapeutic approach. This is primarily due to histological confusion and to the absence of uniform staging procedures and therapeutic modalities. This overview attempts to summarize controversies in the multidisciplinary approach to GI non-Hodgkin's lymphomas and to introduce a European multicentric prospective randomized study for the treatment of this rare disease.

Hepatic artery ligation with and without portal infusion of 5-FU. A randomized study in patients with unresectable liver metastases from colorectal carcinoma. The E.O.R.T.C. Gastrointestinal Cancer Cooperative Group (G.I. Group).

The aim of this multicentric prospective randomized clinical trial was to study the efficacy of hepatic artery ligation (HAL) with and without portal infusion (PI) of 5-FU in patients with liver metastasis of colorectal origin. Seventy-four patients were randomized. Sixty-seven were fully evaluable. Thirty-five patients were eligible in the HAL + PI of 5-FU group and 32 in the HAL alone group. The 5-FU infusion had to be discontinued for technical reasons in 13 patients. Complications of HAL were relatively high, including four hepatic failures (WHO grading greater than 2). Side effects of chemotherapy were limited. Five patients out of 30 had a partial response (WHO criteria) and one patient had a complete response in the group treated by HAL and PI of 5-FU. Only one patient had a partial response in the HAL alone group. Median survival for both groups was 12 months. Median time to progression for both groups was 6 months. This study did not show any advantage of delivery using the portal route in addition to hepatic artery ligation in terms of progression nor in survival of patients.

Adjuvant radiotherapy and chemotherapy in resectable gastric cancer. A randomized trial of the gastro-intestinal tract cancer cooperative group of the EORTC.

One hundred and fifteen patients with curative and palliative surgery for gastric cancer were randomized to receive radiotherapy alone (1) or in combination with short-term (ST) 5-FU (2), long-term (LT) 5-FU (3), ST and LT 5-FU (4). The ST 5-FU was given at a daily dose of 575 mg/m2, every 4-6 h during the first 4 days of treatment before starting irradiation. The LT 5-FU was given at a dosage of 750 mg/m2 every 2 weeks for 18 months or until progression. The median survival times for treatment 1 to 4 was respectively 12, 10, 15 and 18 months. There was a statistically significant overall difference between the four treatments (P = 0.041). However, when the comparisons were adjusted for the most significant prognostic factors, the difference in survival disappeared. Moreover, no difference was found between treatments in terms of time progression. Nevertheless, among 22 patients with residual tumour, the three who were still alive without disease progression (with survivals of 19+, 49+ and 90+ months at the time of this analysis) had been treated with radiotherapy combined with ST and LT 5-FU.

Septicemias in cancer patients during parenteral nutrition: contributing factors and detection by weekly blood cultures.

Infections constitute the main complication of parenteral nutrition, particularly in cancer patients, but prediction of catheter-related septicemias (CRS) has been little investigated. We have evaluated, in 200 consecutive episodes of parenteral nutrition (PN) in cancer patients, the factors contributing to infectious complications, and the predictive value of weekly blood cultures performed through the nutrition catheter. The median duration of PN was 22 days with a total of 5816 patient-days of PN, neutropenia (neutrophils < 1,000/microl) being present in 872 (15%). Catheters were placed either in a jugular vein (71% single-lumen silicone catheters, 18.5% double-lumen Hickman-Broviac catheters) or in a femoral vein (10.5%). We observed 62 episodes of septicemia of which 22 were CRS (11% incidence for the 200 cycles) and 40 were non-CRS (20% incidence); CRS were mostly due to Staphylococcus epidermidis (14/22). Neutropenic patients as a group did not suffer more CRS than non-neutropenic patients, but the risk of CRS was slightly increased when expressed per day of neutropenia (8 CRS/872 days vs 14 CRS/4942 days without neutropenia, P < 0.05). On the other hand, a femoral insertion site was associated with a much higher incidence of CRS (9 CRS/21 femoral catheters vs 13 CRS/179 jugular catheters, P < 0.0001). It was possible to evaluate 20 episodes of CRS for their predictability by weekly blood cultures: the sensitivity for detecting CRS due to Staphylococcus epidermidis was 67%, the specificity 92%, the negative predictive value 98% and the positive predictive value 36%. The simple and widely available procedure of routine surveillance blood cultures performed through the PN catheter should be further investigated, because it could help the clinician to determine the origin of recent fever, particularly to exclude CRS and avoid unnecessary removal of PN catheters.

Peritoneovenous shunt in malignant ascites. The Bordet Institute experience from 1975-1998.

BACKGROUND/AIMS: This is the review of our experience in the treatment of malignant ascites using Le Veen and Denver peritoneovenous shunt. METHODOLOGY: From 1975-1998, 24 peritoneovenous shunts were inserted in 22 patients with malignant ascites. RESULTS: All patients benefited from the procedure. The principal cause of failure was shunt occlusion (n = 5). CONCLUSIONS: This study permits us to conclude that a preoperative appropriated selection of patients, should decrease failure rate. Patients should be sent to surgery as soon as the diagnosis of recalcitrant ascites is confirmed, to obtain a longer and more comfortable quality of life with terminal cancer.

Metastatic involvement of ceco-appendicular segment: a diagnosis of right lower quadrant abdominal pain in patient receiving chemotherapy.

Metastases are a common feature during the evolution of breast cancer. However, gastrointestinal metastases, and especially ceco-appendicular ones, are very rare. Melanoma however frequently metastasize in the gastrointestinal tract. Ceco-appendicular metastases do not display any specific signs in cancerous patients. These rare metastases must be considered in the diagnosis of right lower quadrant pain in cancerous patients. The main differential diagnosis includes neutropenic enterocolitis, acute appendicitis, malignant intestinal obstruction and perforation of the bowel. The morbidity of gastrointestinal complications in patients with metastatic cancer receiving chemotherapy is significant and surgery is often the only chance of survival. The major clinical decision is whether or not to operate.

[Development of surgical treatment of primitive and metastatic rectal cancer]. / Evolution du traitement chirurgical du cancer du rectum primitif et métastatique.

There are many ways by which the surgeon can optimize curative resection for rectal cancer. Appropriate margins with total mesorectal excision, should be the goals for tumors in the lower two-thirds of the rectum. Reconstruction should be performed, whenever technically possible, by a colonic J-pouch. Preservation of pelvic autonomic nerves is possible in most cases, reducing the risk of postoperative sexual and urinary dysfunction. New techniques increase the frequency of curative treatments of metastatic disease. Towards either the primary or the metastatic disease, the new therapeutic strategies offer an hope of cure, and a better quality of life, to an increasing number of patients.

Comparison of three fully implantable venous access systems. A randomized study.

Three different fully implantable venous access devices were randomly inserted in 72 patients. Comparison both from the point of view of their ease of insertion and their later use failed to show any significant difference between the three systems.

[Definitive colostomy and quality of life]. / Colostomie définitive et qualité de la vie.

The authors present their experience with permanent colostomy after abdominoperineal resection of the rectum. In order to avoid colostomy-related complications, pre- and postsurgical care are of paramount importance as well as a proper surgical technique. Extraperitoneal colostomy prevents the frequency described early and late complications. Learning colostomy irrigation helps the patient to overcome any physical or psychological problems related to colostomy.

[Long-term results of the surgical treatment of hiatal hernia using the Boerema technic]. / Résultats à long terme du traitement chirurgical de la hernie hiatale par la technique de Boerema.

The authors analyse the results of the surgical treatment of "symptomatic hiatus hernia" by the Boerema anterior gastropexy, in 69 patients. As compared to other techniques, the observed mortality and morbidity rates are similar. The postoperative delay is greater than 2 years in 95% of the patients and 83% of them are satisfied with the treatment. Better results are actually obtained with other techniques. Nevertheless, anterior gastropexy which remains the easiest and fastest technique, may still be used in elderly or high risk patients. The Nissen fundoplication is recommended for the majority of the patients suffering from "symptomatic hiatus hernia", especially when ulcerative reflux esophagitis is present.

Acute free perforation as first sign of Crohn's disease.

Free perforation with generalized peritonitis remains a rare manifestation of regional enteritis. Most of these perforations occur as complications of recurrent, well-diagnosed regional enteritis. A review of the literature reveals only 14 recorded cases of free perforation in patients without any previous abdominal complaints. The present report describes two more cases. Both of them were treated by resection of the involved segment with immediate anastomosis.

[The value of vaginoplasty in perineal cicatrization following amputation of the rectum via abdomino-perineal approach]. / Intérêt de la vaginoplastie dans la cicatrisation périnéale après amputation du rectum par voie abdomino-périnéale.

Advantage of vaginoplasty in perineum healing following abdominoperineal amputation of the rectum. Healing of the perineal wound following abdominoperineal amputation of the rectum is achieved by secondary intention within 6 to 12 weeks. To improve the tedious dressings and to minimise the duration of healing, resorting to primary healing of the perineum in the females is facilitated by a technique of vaginoplasty. Our observations through personal experience dealing with 24 patients matched those described by Johnston in 1969 and 1979. Perineal healing was obtained within 10-14 days. The vaginal floor epithelialization was obtained after a median duration of 32.7 days. No important complications were noticed in relation to this technique.

[Conservative treatment of small cancers located in the lower part of the rectum]. / Traitement conservateur des petits cancers bas situés du rectum.

This paper presents the experience of the "Institut Jules Bordet" in the treatment of small carcinomas located in the lower part of the rectum by transanal endoresection. This surgical procedure includes of a total resection of the tumor surrounded by normal tissue. It allows a detailed pathological study of the resected specimens and does not exclude the possibility of either a second surgical resection or an adjuvant radiotherapy. A better knowledge of the rectal cancer prognostic factors and a close cooperation between surgeon and pathologist spare a few patients a permanent colostomy and give them the same hope of cure as the more mutilation radical surgery.