OBJECTIVE: This study aims to assess the diagnostic capability of CT to preoperatively detect evidence of locoregional spread of gallbladder cancer. PATIENTS AND METHODS: Two radiologists independently performed retrospe...OBJECTIVE: This study aims to assess the diagnostic capability of CT to preoperatively detect evidence of locoregional spread of gallbladder cancer. PATIENTS AND METHODS: Two radiologists independently performed retrospective review of CT scans on 20 patients who had undergone surgical resection for carcinoma of the gallbladder. Local spread was categorized by the TNM system and the results were correlated with surgical and pathologic findings. RESULTS: All cases of hepatic spread (14 cases), common bile duct extension (four cases), pancreatic spread (three cases) and duodenal spread (three cases) were correctly diagnosed by helical CT. One of three cases of peritoneal spread and two of three cases of gastric spread were misdiagnosed. CT evaluation of T stage (T1: one case [5%]; T2: four cases [20%]; T3: four cases [20%], and T4: 11 cases [55%]) was accurate in 85%. The sensitivity and positive predictive value (PPV) of T1-T2 lesions were 80%. The specificity and negative predictive value (NPV) were 93%. For T4 lesions sensitivity, specificity, PPV and NPV were 100%. CONCLUSION: Helical CT provided 85% accuracy in the diagnosis of the locoregional extent of gallbladder cancer. It allows an acceptable classification according to the TNM staging system and predicts prognosis.
OBJECTIVE: To evaluate a newly developed cholecystectomy technique which combines classical dissection with currently available mini-instrumentation (3 and 5 mm) and removal of the gallbladder through a short gastrotomy....OBJECTIVE: To evaluate a newly developed cholecystectomy technique which combines classical dissection with currently available mini-instrumentation (3 and 5 mm) and removal of the gallbladder through a short gastrotomy. METHODS: After a feasibility study, we set up a protocol for this procedure using instrumentation currently available on the market. The resected gallbladder was removed through a short gastrotomy on the anterior gastric wall, thereby minimizing abdominal wall trauma and permitting the patient to resume physical activity more quickly with no risk of trocar herniation. RESULTS: Cholecystectomy was performed by the described technique in 18 of 23 eligible patients between April 2008 and August 2008. There were seven males and 11 females with a mean age of 48 (range: 28-77); median BMI was 30 kg/m2 (range: 22-36). Eleven patients had a gallstone larger than 12 mm. There were no postoperative complications and recovery was rapid for all patients in our study. CONCLUSION: This procedure is technically feasible, safe and reproducible; results are good with minimal trauma to the abdominal wall. Normal physical activity can be rapidly resumed with no risk of incisional hernia.
Current recommendations for bariatric surgery are limited to patients older than 18 years. Two studies in 2007 showed that bariatric surgery improves survival in adults. Medical management of severe obesity in adolescent...Current recommendations for bariatric surgery are limited to patients older than 18 years. Two studies in 2007 showed that bariatric surgery improves survival in adults. Medical management of severe obesity in adolescents is all too often ineffective. For these reasons, early surgical intervention for adolescents with morbid obesity may be expected to prevent or avoid comorbidities, decrease mortality, and improve the quality of life. Several studies have demonstrated the feasibility of adolescent bariatric surgery with morbidity comparable to that seen in adult series. The earlier the surgery, the better the result in terms of prevention or reversal of comorbid conditions. In the USA, a consensus definition of adolescents eligible for bariatric surgery specifies attainment of Tanner Stage IV of sexual maturity and achievement of 95% of axial growth. Just as in adults, bariatric surgery in adolescents requires prolonged follow-up; it is important that such surgery be performed in centers specialized in adult bariatric surgery having the necessary multidisciplinary structure.
Severe postsurgical pain contributes to prolonged hospital stay and is also believed to be a risk factor for the development of chronic pain. Locoregional anesthesia, which results in faster patient recovery with fewer s...Severe postsurgical pain contributes to prolonged hospital stay and is also believed to be a risk factor for the development of chronic pain. Locoregional anesthesia, which results in faster patient recovery with fewer side effects, is favored wherever feasible, but is not applicable to every patient. Systemic analgesics are the most widely used method for providing pain relief in the postoperative period. Improvements in postoperative systemic analgesia for pain management should be applied and predictive factors for severe postoperative pain should be anticipated in order to control pain while minimizing opioid side effects. Predictive factors for severe postoperative pain include severity of preoperative pain, prior use of opiates, female gender, non-laparoscopic surgery, and surgeries involving the knee and shoulder. Pre- and intraoperative use of small doses of ketamine has a preventive effect on postoperative pain. Multimodal or balanced analgesia (the combined use of various analgesic agents) such as NSAID/morphine, NSAID/nefopam, morphine/ketamine improves analgesia with morphine-sparing effects. Nausea and vomiting, the principle side effects of morphine, can be predicted using Apfel's simplified score; patients with a high Apfel score risk should receive preemptive antiemetic agents aimed at different receptor sites, such as preoperative dexamethasone and intraoperative droperidol. Droperidol can be combined with morphine for postoperative patient-controlled anesthesia (PCA). When PCA is used, dosage parameters should be adjusted every day based on pain evaluation. Patients with presurgical opioid requirements will require preoperative administration of their daily opioid maintenance dose before induction of anesthesia: PCA offers useful options for effective postsurgical analgesia using a basal rate equivalent to the patient's hourly oral usage plus bolus doses as required.
Cancerous invasion of the celiac trunk is usually considered a contraindication to attempts at curative resection. Appleby was the first to propose an en bloc resection of the celiac trunk along with the celiac nervous p...Cancerous invasion of the celiac trunk is usually considered a contraindication to attempts at curative resection. Appleby was the first to propose an en bloc resection of the celiac trunk along with the celiac nervous plexus and lymph nodes for advanced gastric cancer. We describe a "modified Appleby technique" without gastrectomy for locally advanced cancer of the body of the pancreas. It accomplishes radical tumor resection, relieves pain, and improves the quality of life and overall prognosis. The principal complications are pancreatic fistula and gastric ischemia. Preoperative embolization of the common hepatic artery helps to develop favorable collateral blood flow and to avoid ischemia of the hepatobiliary system. A stomach-preserving" Appleby resection" may be appropriate treatment for selected nonaggressive cancers of the midpancreas; preoperative embolization of the common hepatic artery is an important adjunct of this technique.
Optimizing the perioperative (pre- and postoperative) management of patients undergoing surgery is a key step in improving the results of surgery. Immunonutrition, a nutritional therapy aiming to reinforce the immune sys...Optimizing the perioperative (pre- and postoperative) management of patients undergoing surgery is a key step in improving the results of surgery. Immunonutrition, a nutritional therapy aiming to reinforce the immune system's defenses, has a demonstrated impact on the reduction of infectious complications and the length of the hospital stay in patients with and without a degraded nutritional state after surgery for digestive cancer. In a question-and-answer format, we discuss the practical aspects of prescribing immunonutrition to provide assistance in this area and thus optimize the application of the guidelines and patient management.
The immunonutrients composing the immunonutrition solutions such as Impact have been demonstrated to reinforce the immune defenses and limit postoperative complications. This reduction in infectious morbidity may be rela...The immunonutrients composing the immunonutrition solutions such as Impact have been demonstrated to reinforce the immune defenses and limit postoperative complications. This reduction in infectious morbidity may be related to the ability of immunonutrients to prevent the postoperative imbalance of the T-CD4 lymphocyte subpopulations (Th1/Th2 ratio) and to modulate the inflammatory response. Immunonutrition also acts with the healing process, in particular with arginine, which promotes collagen synthesis. The beneficial effects of immunonutrition are important in all digestive cancer surgery, including esophageal surgery. It is administered preoperatively to all patients for at least 5 days and is recommended postoperatively for undernourished patients for at least 7 days. Finally, the reduction in postoperative morbidity decreases hospital costs, which easily compensates the additional cost of the pharmaconutrients, another argument in favor of prescribing them systematically in patients operated on for digestive cancer.
Improving perioperative nutritional management in patients undergoing surgery for severe digestive disease can reduce postoperative morbidity. This nutritional management comprises two facets: the pre- and/or postoperati...Improving perioperative nutritional management in patients undergoing surgery for severe digestive disease can reduce postoperative morbidity. This nutritional management comprises two facets: the pre- and/or postoperative detection (with the surgeon playing an important role because of the high prevalence of denutrition in digestive oncology) and correction of denutrition; the value of immunonutrition using nutrients that can reduce postoperative morbidity by modulating the immune response in patients with and without a degraded nutritional state. The tools available to the clinician to assess denutrition are detailed and the guidelines established in 2005 by the French Digestive Surgery Society are compared to the recent data from the literature.
Gouy S, Uzan C, Zafrani Y
… +5 more, Lhommé C, Pautier P, Duvillard P, Haie-Meder C, Morice P
J Chir (Paris)
· 2008 Dec · PMID 19194359
Uterine cancer can metastasize to both the pelvic and para-aortic levels. No one questions the diagnostic and prognostic value of lymphadenectomy, but its therapeutic value is still open to debate. In early cervical canc...Uterine cancer can metastasize to both the pelvic and para-aortic levels. No one questions the diagnostic and prognostic value of lymphadenectomy, but its therapeutic value is still open to debate. In early cervical cancer (<4 cm.), pelvic lymphadenectomy is a routine part of radical hysterectomy. If pelvic lymph nodes show involvement, one can propose an extension of the lymphadenectomy to the para-aortic level. Studies of sentinel lymph node identification and biopsy at this level are currently under way. The standard treatment of cervical cancer>4 cm is radiotherapy. A pre-radiation laparoscopy to investigate lymph node involvement at the lumbo-aortic level may help to define the extent of the radiation field. For endometrial cancer, the role and benefit of lymphadenectomy are much less clear since these patients often have major co-morbidities which increase the risk of complications from an extended lymph node dissection.
Ovarian cancer often invades regional lymph nodes but the patterns of involvement are variable; spread to para-aortic and pelvic lymph nodes can be unilateral, contralateral or bilateral. For staging purposes, complete l...Ovarian cancer often invades regional lymph nodes but the patterns of involvement are variable; spread to para-aortic and pelvic lymph nodes can be unilateral, contralateral or bilateral. For staging purposes, complete lymph node dissection seems more reasonable and effective than simple lymph node sampling. In early stage disease, lymph node dissection has both diagnostic and therapeutic value allowing identification and optimal management of Stage IIIc tumors with retroperitoneal spread; it may also have direct therapeutic value by removing retroperitoneal micrometastatic disease including cell clones which may be resistant to chemotherapy. Therefore, complete lymph node dissection is recommended in early-stage disease with the exception of stage I mucinous ovarian cancer. In advanced-stage disease, lymph node involvement is an additional factor of poor prognosis correlating with increased tumor aggressivity. Optimal debulking resection of all visible tumor offers the best chance for a prolonged disease-free interval if patient condition permits and morbidity can be limited. Survival benefit for complete lymph node dissection has not been evaluated by randomized controlled trials; but several non-randomized studies and two long-term prospective trials have shown objective improvement in disease-free survival and improved quality of life when debulking surgery leaves no residual tumor larger than 1 cm.
Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been conside...Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been considered. Mesorectal lymphadenectomy should remove the mesorectum systematically and should extend at least 5 cm distal to the tumor. Inferior mesenteric lymphadenectomy should extend at least to the origin of the left colic artery. Lateral lymphadenectomy removing iliac and obturator nodes results in complications and has not been shown to improve survival; it is not routinely recommended. Omission of lymph node dissection is only proposed for the smallest T1 tumors with favorable histology.
Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging o...Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.
Several factors argue for extended lymphadenectomy in surgery for pancreatic adenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumor recurrences are only loco-regional suggesting that initi...Several factors argue for extended lymphadenectomy in surgery for pancreatic adenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumor recurrences are only loco-regional suggesting that initial resection was insufficient; 3) some retrospective studies suggest that extension of lymphadenectomy improves post-resection survival. Extended lymphadenectomy, including circumferential dissection of both the celiac axis and the superior mesenteric artery and resection of para-aortic nodes, was evaluated by 4 randomized trials; globally there was no survival benefit. Extended lymphadenectomy increases, at least transiently, the risk of post-operative diarrhea. Its influence on the rate of loco-regional recurrences has not been evaluated. However, this technique should not be definitively and globally precluded since a more radical resection was associated with a trend toward better long-term survival in the trial with the largest number of patients.
Lymph node invasion is the principal prognostic factor in cancers of the stomach and esophagus which have a tendency to early lymphatic spread.The anatomy of regional lymph node groupings is described and standard and ex...Lymph node invasion is the principal prognostic factor in cancers of the stomach and esophagus which have a tendency to early lymphatic spread.The anatomy of regional lymph node groupings is described and standard and extended types of lymphadenectomy are defined. We discuss he role of lymph node dissection - particularly extended lymphadenectomy - and assess whether there is demonstrable benefit in terms of morbidity and mortality, loco-regional recurrence, and survival. Articles from the surgical literature with the highest levels of evidence are analyzed. Practical guidelines for treatment choice are proposed.
In theory, the concept of sentinel lymph node (SLN) biopsy can be applied to cancer surgery for all solid cancers. Yet sentinel lymph node biopsy has not become a standard part of gastrointestinal cancer surgery. It has...In theory, the concept of sentinel lymph node (SLN) biopsy can be applied to cancer surgery for all solid cancers. Yet sentinel lymph node biopsy has not become a standard part of gastrointestinal cancer surgery. It has been of value in the assessment of small early-stage gastric cancers, but has only achieved widespread practice in Japan. Studies of SLN biopsy in colon cancer have not shown it to be a reliable predictor of N+ status and therefore don't permit the omission of lymph node dissection in selected cases. On the other hand, as a form of intra-operative lymph node mapping, dye injection of the SLN may demonstrate aberrant lymphatic drainage and could occasionally permit the sparing of a middle colic artery whose sacrifice would otherwise be dictated by standard drainage patterns. SLN biopsy may have prognostic usefulness by demonstrating micrometastases; careful serial sectioning focussed on the SLN may detect nests of metastatic cells on HE staining, thereby converting a tumor from Stage I (TxN0M0) to Stage II (TxN1M0). This finding has been noted in 10-15% of cases. However, the prognostic value of micrometastases detected only by immunohistochemical staining or PCR has not been demonstrated. For cancers of the anal canal, SLN biopsy of inguinal nodes has been tested as a means of establishing the indications for inguinal lymph node dissection.
Thyroid cancers are the most common endocrine cancer. Cervical lymph node metastases are observed in 20 to 60% of patients with papillary thyroid cancer. In 2008, no prospective randomized study has defined whether proph...Thyroid cancers are the most common endocrine cancer. Cervical lymph node metastases are observed in 20 to 60% of patients with papillary thyroid cancer. In 2008, no prospective randomized study has defined whether prophylactic central neck dissection should be performed during initial surgery for papillary thyroid cancer. Prophylactic lymph node dissection remains controversial. Pros and cons for routine lymph node dissection of the central cervical compartment are discussed in this review of the literature which includes data from international and French consensus conferences.
Pagès F, Berger A, Zinzindohoué F
… +3 more, Kirilovsky A, Galon J, Fridman WH
J Chir (Paris)
· 2008 Dec · PMID 19194351
Lymph node dissection is an integral part of the surgical resection of colon cancers; it completes the wide regional resection of tumor and it allows prognostic evaluation through accurate staging. Studies have demonstra...Lymph node dissection is an integral part of the surgical resection of colon cancers; it completes the wide regional resection of tumor and it allows prognostic evaluation through accurate staging. Studies have demonstrated an immune reaction to the tumoral site which attests to an ongoing dialog between the tumor and systemic defenses. The regional lymph nodes constitute an important first line of immune defense where initial host response is initiated or, inversely, they may participate in a local state of immunosuppression. This article reviews current knowledge on intra-tumoral and nodal immune status in colorectal cancers and attempts to evaluate the potential immunologic implications of lymph node dissection.