Impact of neoadjuvant chemoradiotherapy on postoperative outcomes after esophageal cancer resection: results of a European multicenter study.

OBJECTIVES: To assess the impact of neoadjuvant chemoradiotherapy (NCRT) on anastomotic leakage (AL) and other postoperative outcomes after esophageal cancer (EC) resection. BACKGROUND: Conflicting data have emerged from randomized studies regarding the impact of NCRT on AL. METHODS: Among 2944 consecutive patients operated on for EC between 2000 and 2010 in 30 European centers, patients treated by NCRT after surgery (n=593) were compared with those treated by primary surgery (n=1487). Multivariable analyses and propensity score matching were used to compensate for the differences in some baseline characteristics. RESULTS: Patients in the NCRT group were younger, with a higher prevalence of male sex, malnutrition, advanced tumor stage, squamous cell carcinoma, and surgery after 2005 when compared with the primary surgery group. Postoperative AL rates were 8.8% versus 10.6% (P=0.220), and 90-day postoperative mortality and morbidity rates were 9.3% versus 7.2% (P=0.110) and 33.4% versus 32.1% (P=0.564), respectively. Pulmonary complication rates did not differ between groups (24.6% vs 22.5%; P=0.291), whereas chylothorax (2.5% vs 1.2%; P=0.020), cardiovascular complications (8.6% vs 0.1%; P=0.037), and thromboembolic events (8.6% vs 6.0%; P=0.037) were higher in the NCRT group. After propensity score matching, AL rates were 8.8% versus 11.3% (P=0.228), with more chylothorax (2.5% vs 0.7%; P=0.030) and trend toward more cardiovascular and thromboembolic events in the NCRT group (P=0.069). Predictors of AL were high American Society of Anesthesiologists scores, supracarinal tumoral location, and cervical anastomosis, but not NCRT. CONCLUSIONS: Neoadjuvant chemoradiotherapy does not have an impact on the AL rate after EC resection (NCT 01927016).

Evaluation study of different strategies for detecting surgical site infections using the hospital information system at Lyon University Hospital, France.

OBJECTIVE: To evaluate different strategies for detecting surgical site infections (SSIs) using different sources (notification by the surgeon, bacteriological results, antibiotic prescription, and discharge diagnosis codes). BACKGROUND: Surveillance plays a role in reducing the risks of SSIs but the performance of case reports by surgeons is insufficient. Indirect methods of SSI detection are an alternative to increase the quality of surveillance. METHODS: A retrospective cohort study of 446 patients operated consecutively during the first half of 2007 was set up in a 56-bed general surgery unit in Lyon University Hospital, France. Patients were followed up 30 days after intervention. Different methods of detection were established by combining different data sources. The sensitivity and specificity of these methods were calculated by using, as reference method, the manual review of the medical records. RESULTS: The sensitivity and specificity of SSI detection were, respectively, 18.4% (95% confidence interval [CI]: 7.9-31.6) and 100% for surgeon notification; 63.2% (95% CI: 47.3-78.9) and 95.1% (95% CI: 92.9-97.1) for detection based on positive cultures; 68.4% (95% CI: 52.6-81.6) and 87.5% (95% CI: 84.3-90.7) using antibiotic prescription; 26.3% (95% CI: 13.2-42.1) and 99.5% (95% CI: 98.8-100) using discharge diagnosis codes. By combining the latter 3 sources, the sensitivity increased at 86.8% (95% CI: 76.3-97.4) and the specificity was lowered at 85.5% (95% CI: 82.1-89.0). CONCLUSIONS: SSI detection based on the combination of data extracted automatically from the hospital information system performed well. This strategy has been implemented gradually in Lyon University Hospital.

Cryopreserved iliac artery allograft for primary arterial revascularization in adult liver transplantation.

Arterial allograft represents a material of choice for primary arterial revascularization in liver transplantation (LT) when interposition of a vascular conduit is required. In case of non-availability of such graft, the use of cryopreserved vessels should be an interesting option. Three patients were grafted using a cryopreserved iliac artery allograft (CIAA) previously harvested and stored at -140°C in a tissue bank. An auxiliary partial LT was performed in one patient for acute liver failure. During follow-up, an efficient regeneration of the native hemi-liver was observed while atrophy of the auxiliary graft occurred, leading to functional portal vein and hepatic artery thrombosis at six and nine months, respectively. Two other patients presented with celiac trunk compression because of arcuate ligament without available arterial allograft in the donor. Late arterial thrombosis occurred at six months in one patient without impairment of graft function. The last patient was alive and symptom free 29 months after LT with a patent cryopreserved arterial conduit. Our preliminary results suggest that CIAA might represent an efficient solution as vessel interposition for primary arterial hepatic revascularization in LT setting when no other suitable graft is available. However, long-term patency of CIAA remains questionable.

[Malignant transformation of multiple isolated hepatocellular adenomas. Therapeutic implications of immunohistochemical and radiological findings]. / Risque de dégénérescence maligne de l'adénome hépatocellulaire solitaire et multiple. Confrontation des données immuno-histochimiques et radiologiques. Conséquences thérapeutiques.

Malignant transformation of hepatic adenoma (HA) is now a well-documented phenomenon. Recent pathological and immunophenotypic studies have identified several subtypes with different prognoses. In many cases the HA subtype can be determined by modern radiological methods, including contrast-enhanced ultrasonography (CEUS) and magnetic resonance imaging (MRI). Based on a series of 26 cases of HA studied with CEUS, MR1 histopathology and immunochemistry, we propose tailored therapeutic options. Watchful waiting is appropriate in some cases, while others require biopsy or resection. Management is more conservative than in previous years.

Revisiting the Surgical Management of Giant Hepatic Hemangiomas: Enucleation Versus Anatomical Resection?

BACKGROUND: Resection is rarely indicated in giant hepatic hemangiomas (HHs) that are symptomatic. Enucleation (EN), compared with anatomical resection (AR), is considered the better technique to resect them as EN has been reported to have lower morbidity while conserving the normal liver tissue. But no study has yet clearly established the superiority of EN over AR. In addition, the independent predictors of postoperative morbidity have not been established. METHODS: All consecutive patients operated for HH at two specialized hepatobiliary centers were reviewed. Patient demographics, operative variables, and postoperative outcomes were analyzed and compared between two techniques. Postoperative complications were graded as per Clavien-Dindo classification of surgical complications. The aims of this study were to compare two techniques of HH resection with respect to postoperative outcomes and to identify the risk factors for 90-day major postoperative morbidity and mortality. RESULTS: A total of 64 patients, including 41 who underwent AR, 22 who underwent EN, and 1 who underwent liver transplantation, were operated for hemangiomas during the study period. Ten patients (9 who were operated for hemangiomas of size ≤4 cm and 1 who underwent transplantation) were excluded. Fifty-four patients, the majority being women (85%), with a median age of 48 years, were operated for giant HH. These patients were classified into two groups based on the technique of resection, namely, EN (22 patients) and AR (32 patients). Both groups were comparable in all aspects except that the number of liver segments resected was significantly more with AR. Postoperative outcomes were similar in both groups. Independent predictors of 90-day major complications including mortality were the use of total vascular exclusion (relative risk [RR]: 2.3, p = 0.028) and duration of surgery >4.5 h (RR: 2.3, p = 0.025). CONCLUSION: Both techniques yield similar results with respect to 90-day postoperative morbidity and mortality. The choice of technique should be based on the location of tumor and simplicity of liver resection.

NutriNet-Salud Mexico. Prospective study online: 2018-2028. Relationship between nutrition and health and determinants of dietary habits and nutritional status.

BACKGROUND: NutriNet-Salud Mexico is a digital health information system, e-epidemiology instrument, online, open and free, to recording and analysis the determinants of dietary habits and nutritional status of the Mexican population, for the prevention of overweight, obesity and noncommunicable diseases for the period 2018-2028. OBJECTIVE: Describe the design, development and implementation of NutriNet-Salud Mexico from the French model NutriNet-Santé France 2008-2018. METHOD: NutriNet-Salud Mexico platform is the basis for the development of health information system for prospective cohort study, scheduled for a period of 10 years (2018-2028), with a dedicated website, and its development will enable to have multiple study populations within an initial set of five self-applicable questionnaires validated in Mexican population. RESULTS: The information will enable to develop applied research, learn and monitor food contributions and nutritional status of the population, assess the impact of public health actions on feeding behavior and nutritional status, comparing populations between countries (Mexico, France, Belgium and Switzerland) and national institutes, universities and states. CONCLUSIONS: NutriNet-Salud Mexico will provide information for assist in research and public action, especially to guide public policies on nutrition Mexico. The scientific elements will make appropriate nutritional recommendations to different populations and access to a representative nominal population sample with low-cost, in real-time, and with dual approach to e-epidemiology: cohort study to identify causality and cross-sectional studies (descriptive research, monitoring and evaluation).

INTRODUCCIÓN: NutriNet-Salud México es un sistema de información en salud digital, instrumento de e-epidemiología, en línea, abierto y gratuito, para el registro y el análisis de los factores determinantes de los hábitos alimentarios y el estado nutricional de la población mexicana, para la prevención del sobrepeso, la obesidad y las enfermedades crónicas no transmisibles para el período 2018-2028. OBJETIVO: Describir el diseño, el desarrollo y la implementación de NutriNet-Salud México a partir del modelo francés NutriNet-Santé France 2008-2018. MÉTODO: La plataforma NutriNet-Salud México es la base digital para el desarrollo de un sistema de información en salud ­para un estudio de cohorte prospectivo programado para 10 años (2018-2028)­ con un sitio web dedicado cuyo desarrollo permite tener varias poblaciones de estudio que responden un conjunto inicial de cinco cuestionarios autoaplicables validados en población mexicana. RESULTADOS: La información obtenida permitirá desarrollar investigación aplicada, conocer y vigilar los aportes alimentarios y el estado nutricional de la población, evaluar el impacto de acciones de salud pública sobre el comportamiento alimentario y el estado nutricional, y comparar poblaciones entre países (México, Francia, Bélgica y Suiza) e institutos nacionales, universidades y Estados. CONCLUSIONES: NutriNet-Salud México permitirá coadyuvar en investigación y acción pública, especialmente en la orientación de políticas públicas de México en materia de nutrición. Los elementos científicos aportarán recomendaciones nutricionales adecuadas a diferentes poblaciones, y permitirán acceder a una representativa muestra poblacional nominal a bajo costo y en tiempo real con doble abordaje de e-epidemiología: estudio de cohorte para identificar causalidad y estudios transversales periódicos (investigación descriptiva, monitoreo y evaluación).

Hepatic epithelioid hemangioendothelioma: long-term results of surgical management.

BACKGROUND AND OBJECTIVES: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular neoplasm of the liver. Its therapeutic management remains difficult to define in curative intent. The aim of this study was to report long-term results of surgically managed patients. METHODS: From 1990 to 2006, nine patients (25-64 years) were retrospectively enrolled in this study. Intrahepatic disease extent was monolobar and bilobar in two and seven patients, respectively. As primary treatment, liver resection (LR) and liver transplantation (LT) were performed in three (two monolobar and one bilobar extent) and six patients, respectively. RESULTS: Postoperative mortality was nil. During a median follow-up of 117 months, four patients developed intrahepatic and/or extrahepatic recurrence. One resected patient (with bilobar extent) presented with intrahepatic recurrence was secondary treated by LT. At the time of the follow-up, seven out of the nine patients treated (two after LR, and five after LT) were alive and disease-free. CONCLUSIONS: Surgical treatment offers good long-term results in patients suffering from HEHE when LR is tailored to the intrahepatic disease extent: LT has to be considered in patients with bilobar intrahepatic disease whereas LR should be strictly limited to patients presenting with localized and monolobar intrahepatic disease.

Safety and long-term outcome of a new concept for surgical adhesion-reduction strategies (Prevadh): a prospective, multicenter study.

BACKGROUND/AIMS: No agent has been consistently effective in preventing formation of peritoneal adhesions and postoperative bowel obstruction after abdominal surgery. The aim of this prospective multicenter study was to assess clinical safety and efficiency of a new adhesion-reduction barrier METHODOLOGY: Between September 2000 and April 2001, Prevadh was used in 78 patients. Operative procedures included 25 hepatic resections, 7 cholecystectomies, 32 colonic resections, 7 protectomies, 3 colostomy or recovery of continuity, 1 gynaecologic surgery and 3 others. Eleven patients were operated on by laparoscopy and 67 by laparotomy. RESULTS: The overall incidence of abscesses and wound complications was 2.4% and 9% respectively. After a mean follow-up of 36 months (range: 4-51 months), no patients experienced adverse events related to the adhesion barrier. Surgical reoperative procedures were performed in 10 patients for unrelated causes and no bowel obstruction occurred within the protected area. CONCLUSIONS: This study confirmed the safety of Prevadh adhesion barrier and suggested that this resorbable barrier might provide prevention from adhesion formation on peritoneal injured surfaces. However, a large randomized controlled trial remains necessary to prove the real effectiveness of adhesion barriers on clinical long-term outcome.

NutriNet-Salud México. Prospective study online: 2018-2028. Relationship between nutrition and health and determinants of dietary habits and nutritional status. / NutriNet-Salud México. Estudio prospectivo por Internet: 2018-2028. Relación de nutrición y salud y factores determinantes de los hábitos alimentarios y el estado nutricional

Background: NutriNet-Salud Mexico is a digital health information system, e-epidemiology instrument, online, open and free, to recording and analysis the determinants of dietary habits and nutritional status of the Mexican population, for the prevention of overweight, obesity and noncommunicable diseases for the period 2018-2028. Objective: Describe the design, development and implementation of NutriNet-Salud Mexico from the French model NutriNet-Santé France 2008-2018. Method: NutriNet-Salud Mexico platform is the basis for the development of health information system for prospective cohort study, scheduled for a period of 10 years (2018-2028), with a dedicated website, and its development will enable to have multiple study populations within an initial set of five self-applicable questionnaires validated in Mexican population. Results: The information will enable to develop applied research, learn and monitor food contributions and nutritional status of the population, assess the impact of public health actions on feeding behavior and nutritional status, comparing populations between countries (Mexico, France, Belgium and Switzerland) and national institutes, universities and states. Conclusions: NutriNet-Salud Mexico will provide information for assist in research and public action, especially to guide public policies on nutrition Mexico. The scientific elements will make appropriate nutritional recommendations to different populations and access to a representative nominal population sample with low-cost, in real-time, and with dual approach to e-epidemiology: cohort study to identify causality and cross-sectional studies (descriptive research, monitoring and evaluation).

Introducción: NutriNet-Salud México es un sistema de información en salud digital, instrumento de e-epidemiología, en línea, abierto y gratuito, para el registro y el análisis de los factores determinantes de los hábitos alimentarios y el estado nutricional de la población mexicana, para la prevención del sobrepeso, la obesidad y las enfermedades crónicas no transmisibles para el período 2018-2028. Objetivo: Describir el diseño, el desarrollo y la implementación de NutriNet-Salud México a partir del modelo francés NutriNet-Santé France 2008-2018. Método: La plataforma NutriNet-Salud México es la base digital para el desarrollo de un sistema de información en salud ­para un estudio de cohorte prospectivo programado para 10 años (2018-2028)­ con un sitio web dedicado cuyo desarrollo permite tener varias poblaciones de estudio que responden un conjunto inicial de cinco cuestionarios autoaplicables validados en población mexicana. Resultados: La información obtenida permitirá desarrollar investigación aplicada, conocer y vigilar los aportes alimentarios y el estado nutricional de la población, evaluar el impacto de acciones de salud pública sobre el comportamiento alimentario y el estado nutricional, y comparar poblaciones entre países (México, Francia, Bélgica y Suiza) e institutos nacionales, universidades y Estados. Conclusiones: NutriNet-Salud México permitirá coadyuvar en investigación y acción pública, especialmente en la orientación de políticas públicas de México en materia de nutrición. Los elementos científicos aportarán recomendaciones nutricionales adecuadas a diferentes poblaciones, y permitirán acceder a una representativa muestra poblacional nominal a bajo costo y en tiempo real con doble abordaje de e-epidemiología: estudio de cohorte para identificar causalidad y estudios transversales periódicos (investigación descriptiva, monitoreo y evaluación).

Cystic involvement of the roof of the main biliary convergence in adult patients with congenital bile duct cysts: a difficult surgical challenge.

BACKGROUND: Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care. METHODS: A retrospective multicenter study was conducted in 4 European surgical centers concerning their experience with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof of the MBC (defined as being BDC with MBC involvement subgroup). RESULTS: From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02). CONCLUSION: BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.

[Current management of uncomplicated gallstones and choledocolithiasis]. / Prise en charge de la lithiase biliaire symptomatique en dehors de l'urgence.

In case of clinical suspicion of symptomatic bile duct stones, percutaneous ultrasonography and liver function tests should be performed as a primary evaluation. In the absence of predictive factors of common bile duct stones, laparoscopic cholecystectomy represents the treatment of choice for symptomatic gallstones. In case of clinical, radiological or biochemical suspicion of common bile duct stones, endoultrasonography or magnetic resonance cholangiography are efficient to confirm choledocolithiasis. In this instance, surgical approach permits simultaneous treatment of both choledocolithiasis and cholecystolithiasis while endoscopic sphincterotomy has to be followed by secondary cholecystectomy in a 2-stage procedure. Laparoscopic common bile duct exploration should be preferred to endoscopic clearance of the common bile duct but requires specific equipment and surgical experience.

Familial adenomatous polyposis predisposes to pathologic exposure of the stomach to bilirubin.

BACKGROUND: The role of duodenogastric reflux in the genesis of gastric polyps in familial adenomatous polyposis (FAP), although suggested by scintigraphy scanning studies, remains unclear. METHODS: Twenty-four hour intragastric bilirubin monitoring with the Bilitec optoelectronic device was carried out in 25 FAP patients, of whom 19 had gastric polyps (fundic gland in 13, adenomatous in 2, and both histologic types in 4) on endoscopic examination. Gastric exposure to bilirubin was expressed as the percentage of total recording time that absorbance exceeded the threshold of 0.25 and was calculated in reference to values obtained from 25 healthy volunteers. Helicobacter pylori status of the stomach was checked as well. RESULTS: Gastric exposure to bilirubin was pathologic in 14 (56%) patients. Gastric exposure to bilirubin was of longer duration in FAP patients than in healthy volunteers (mean+/-SEM: 19%+/-4% vs 6%+/-2%) (P<.005). It increased from healthy volunteers (6%+/-2%) to FAP patients without gastric polyps (10%+/-3%), and to FAP patients with gastric polyps (22%+/-5%) (P<.004). Bilirubin exposure times were similar in FAP patients with fundic gland polyps only and in those having either adenomatous polyps only or both types of polyps (24%+/-7% vs 17%+/-4%). No patient with pathologic gastric exposure to bilirubin as well as none having gastric polyps, had H. pylori in the antrum. CONCLUSIONS: This study shows that gastric exposure to bilirubin is of longer duration in FAP patients than in healthy volunteers, and in FAP patients with gastric polyps than in those without polyps. This study supports the existence of a direct correlation between pathologic duodenogastric reflux (DGR), the absence of H. pylori in the antrum, and the presence of gastric polyps in FAP patients.

Long-term outcome of laparoscopic antireflux surgery in the elderly.

The aim of this retrospective study was to compare results and five-year surgical outcome of laparoscopic antireflux surgery (LARS) in patients younger than 65 years and elderly patients aged 65 years or older. From January 1992 to December 1998, 2684 patients underwent LARS in 31 surgical units; 369 elderly patients (group 1) were compared with 2315 younger patients (group 2). Elderly patients have a higher American Society of Anesthesiologists score (mean, 2.38 versus 1.98). The conversion rate was higher in group 1 (10.2%, n = 38 versus 6.1%, n = 142), as was the morbidity rate (7.6% in group 1 versus 4.5% in group 2). Mean hospital stay was longer for group 1 (7.6 +/- 5.6 days versus 5.9 +/- 2.8 days). Functional evaluation was excellent in both groups (91-93%) at 3 months and 2 and 5 years. LARS in the elderly is a safe and efficient procedure. Good results appear to be sustainable in the long term.

[Hepatic tuberculosis: case report of pseudotumoral form]. / Tuberculose hépatique. Un cas à forme pseudo-tumorale.

Inflammatory pseudo-tumors of the liver are rare and difficult to diagnose, mimicking malignant tumors. We report a patient, 42 year old with hepatic pseudo-tumor who was suspected to have pseudotumoral hepatic tuberculosis without immunodepression and treated by major hepatic surgery because no sure diagnosis. Therapeutic approach of hepatic inflammatory pseudotumors is often medical and surgical and may need major hepatic surgery in case of sure etiologic diagnosis.

[Spontaneous rupture of an intrahepatic aneurysme: radiological and surgical treatments]. / Rupture spontanée d'un anévrisme intra-hépatique. Traitement radiologique et chirurgical.

Spontaneous rupture of intrahepatic aneurysm is a rare life threatening condition because of the risk of spontaneous rupture. A 33 year old female patient presented with hemorrhagic shock. Angio-CT-scan revealed an intrahepatic ruptured aneurysm with a massive central and subcapsular haematoma of the liver. Percutaneous embolisation under ultrasound control was not possible because of the size of the subcapsular haematoma. Angiography showed a main arterial supply of this aneurysm from the anterior sectorial branch of the right branch of hepatic artery and selective embolisation was not possible because of anatomical configuration. Because of persistent bleeding, surgery was performed with evacuation of liver haematoma and a highly selective ligature of the main aneurysmal arterial supply. Post-operative angio-CT-scan showed revascularisation of the aneurysm through retrograde intrahepatic arterial supply. Ultrasound identification of the aneurysm was then possible and percutaneous embolisation was performed successfully. Intrahepatic aneurysms are usually treated by interventional radiological procedure. In case of failure, surgery should be considered. This case was original because it associated a combined therapeutic treatment pointing out the importance of multidisciplinary approach.

Improved sphincter preservation in low rectal cancer with high-dose preoperative radiotherapy: the lyon R96-02 randomized trial.

PURPOSE: The potential advantage of high-dose preoperative radiotherapy to increase tumor response and improve the chance of sphincter preservation for low rectal cancer remains controversial. The aim of this trial was to evaluate the role of escalating the dose of preoperative radiation to increase sphincter-saving procedures. PATIENTS AND METHODS: Patients with rectal carcinoma located in the lower rectum, staged T2 or T3, Nx, or M0 with endorectal sonography, and not involving more than two-thirds circumference, were randomly assigned to one of two groups: preoperative external-beam radiotherapy (EBRT; 39 Gy in 13 fractions over 17 days) versus the same EBRT with boost (85 Gy in three fractions) using endocavitary contact x-ray. RESULTS: Between 1996 and 2001, 88 patients were enrolled onto the study. A significant improvement was seen in favor of the contact x-ray boost for complete clinical response (24% v 2%) and for a complete or near-complete sterilization of the operative specimen (57% v 34%). A significant increase in sphincter preservation was observed in the boost group (76% v 44%; P =.004). At a median follow-up of 35 months, there was no difference in morbidity, local relapse, and 2-year overall survival. CONCLUSION: A dose escalation with endocavitary irradiation provides increased tumor response and sphincter preservation with no detrimental effect on treatment toxicity and early clinical outcome.

Triple antiviral therapy with amantadine for IFN-ribavirin nonresponders with recurrent posttransplantation hepatitis C.

BACKGROUND: HCV reinfection after liver transplantation is universal and has an accelerated course with a high risk of progression to cirrhosis. It is now established that combination therapy with interferon (IFN) alpha and ribavirin may achieve a sustained virological response in 20% of transplanted patients. However, the optimal therapy for nonresponders remains an unresolved issue. We conducted a pilot study to determine the efficacy and safety of triple antiviral therapy in IFN-ribavirin nonresponders with recurrent chronic hepatitis C. METHODS: Twenty-four nonresponders to the IFN-ribavirin combination were enrolled in this pilot study. Patients were treated with IFN-alpha (3 million units three times a week subcutaneously with ribavirin [800-1,000 mg daily]) and amantadine 200 mg daily for 48 weeks. The primary end point was the loss of HCV RNA 6 months after the end of treatment. RESULTS: Median age was 50 years; 72% were men and 82% had genotype 1. The median interval between the end of combination therapy and enrollment was 11 months. Twenty-four patients started therapy, but five (21%) withdrew due to side effects, including two with anemia. On an intent-to-treat basis, 18 patients (75%) had a biochemical response and 9 (37%) had a virologic response at the end of triple antiviral therapy. Eight of these nine patients (33%) had a sustained virological response. The mean METAVIR score improved from A 2.2 F2.1 before treatment to A 1.2 F1.9 in sustained virological responders. In virological nonresponders, inflammatory activity did not change, but fibrosis worsened. Several patients required treatment with erythropoietin for anemia. Triple therapy was well tolerated and neither increased the frequency nor severity of side effects. CONCLUSION: Our results show that triple antiviral therapy for 48 weeks induced a sustained virological response in 33% of IFN-ribavirin nonresponders with recurrent hepatitis C.

Laparoscopic pancreatic resection: results of a multicenter European study of 127 patients.

BACKGROUND: The reported experience with laparoscopic pancreatic resections (LPR) remains limited to case reports or small series of patients. METHODS: A retrospective multicenter study was conducted in 25 European surgical centers concerning their experience with LPR. Detailed questionnaires were used, focusing on patients, tumors, operative data, and late outcome. RESULTS: During the study period, 127 patients with presumed pancreatic neoplasms were enrolled in this series. Final diagnoses included benign pancreatic diseases in 111 patients (87%; insulinoma: 22, neuroendocrine neoplasm: 20, mucinous cystadenoma: 26, serous cystadenoma: 21, chronic pancreatitis: 11, others: 11), and 16 patients (13%) had malignant pancreatic diseases (insulinoma: 3, neuroendocrine neoplasm: 5, ductal adenocarcinoma: 4, cystadenocarcinoma: 2, renal metastases: 2). Five patients with presumed benign pancreatic disease had malignancy at final pathology. The median tumor size was 30 mm (range, 5-120 mm); 89% of tumors were located in the left pancreas. Laparoscopically successful procedures included 21 enucleations, 24 distal splenopancreatectomies, 58 distal pancreatectomies with splenic preservation, and 3 pancreatoduodenal resections. The overall conversion rate was 14%. There were no postoperative deaths. The rate of overall postoperative pancreatic-related complications was 31%, including a 17% rate of clinical pancreatic fistula. The surgical reoperation rate was 6.3%. In laparoscopically successful operations, the median postoperative hospital stay was 7 days (range, 3-67 days), decreased compared with patients requiring conversion to open pancreatectomy. During a median follow-up of 15 months (range, 3-47 months), 23% of the patients with pancreatic malignancies had tumor recurrence. Late outcome was satisfactory in all patients with benign diseases. CONCLUSIONS: LPR is feasible and safe in selected patients with presumed benign and distal pancreatic tumors. The management of the pancreatic stump remains a challenge. The role of LPR for pancreatic malignancies remains controversial.

Laparoscopic antireflux surgery: five-year results and beyond in 1340 patients.

BACKGROUND: Although the long-term results of open fundoplication for gastroesophageal reflux disease are well documented, few reports exist on the long-term results of laparoscopic fundoplication. DESIGN: Retrospective study with clinical evaluation or mailed survey for patients unable to return to the hospital center. SETTING: Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). PATIENTS: Between January 1992 and December 1998, 2684 patients with gastroesophageal reflux disease underwent laparoscopic fundoplication in 31 hospital centers. Outcome data covering a period of 5 or more years after surgery were available for 1340 patients: 711 who underwent complete fundoplication, 559 who underwent partial posterior fundoplication, and 70 who underwent partial anterior fundoplication. MAIN OUTCOME MEASURES: Evaluation of clinical and quality-of-life actions used to treat the symptoms of gastroesophageal reflux disease. RESULTS: The overall residual severe dysphagia rate was 5.1% (n = 68). A further surgical procedure was required for 59 patients (4.4%) for a total of 63 interventions. Subsequent operation was performed laparoscopically in 32 cases (50.8%). Twelve of these procedures were for the repair of a paraesophageal hiatus hernia, 11 were for dysphagia (4 because of a tight esophageal hiatus and 7 for conversion of Nissen fundoplication to a posterior partial fundoplication procedure), 31 were for recurrent reflux (wrap undone), 2 were for intestinal obstruction (adhesiolysis), 1 was for incisional hernia, 1 was for abdominal abscess (drainage), and 1 was for gastroparesis (pyloroplasty). The recurrence rate was 10.1% (n = 136), and 122 patients (9.1%) resumed taking antisecretory medication. Gas bloat syndrome was present in 101 patients (7.5%). A total of 93.1% of the patients were satisfied (Visick classification, grades 1 and 2) and 6.9% were unsatisfied, with no difference among the 3 procedures. CONCLUSION: After 5 years of experience, laparoscopic fundoplication remains an effective antireflux procedure.

Laparoscopic pancreatic resection: a preliminary experience of 15 patients.

BACKGROUND/AIMS: Worldwide experience with laparoscopic pancreatic resection remains limited. The aim of the study was to assess the feasibility, safety and outcome of laparoscopic pancreatic resection. METHODOLOGY: 15 consecutive patients suffering from benign cystic pancreatic (n=6), neuroendocrine tumors (n=8) or pancreatic metastasis from renal carcinoma (n=1) undergoing laparoscopic pancreatic resection were retrospectively collected from 5 academic hospitals. RESULTS: Laparoscopic procedure was completed in 10 patients, including 7 distal pancreatectomies (with 5 spleen preservation), 2 tumor enucleations and 1 partial cystic resection. Conversion was due to inappropriate operative finding for laparoscopic approach in 2 patients and for uncontrollable bleeding in 3 patients. Postoperative pancreatic-related complications included pancreatic fistula in 20% and peripancreatic collection in 13% of the patients. CONCLUSIONS: Laparoscopic pancreatic resection is feasible for distal pancreatic tumors. However, successful management of the pancreatic stump remains the challenge of this procedure, in order to achieve a clear benefit in the patient outcome.