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A 77-year-old man was referred for a PET/CT 18F-FDG after incidental discovery of a lobulated jejunal lesion during surgery for an abdominal aortic aneurysm. The lesion was not removed due to the risk of digestive perforation. PET/CT 18F-FDG did not show pathologic hypermetabolism. Subsequently, we decided to perform PET/CT 18F-DOPA to better characterize this incidentaloma. A moderate uptake was showed, less than the pancreas. After multidisciplinary discussion, taking into account macroscopic and imaging aspects, the hypothesis of an ectopic pancreas was retained, allowing the exclusion of surgical excision.

We report the case of a 64-year-old woman with musculoskeletal pain and elevated serum parathyroid hormone who had undergone parathyroidectomy for primary hyperparathyroidism 4 years earlier. An 18F-choline PET/CT scan was performed and incidentally showed an intense uptake in a right upper lobe pulmonary nodule and in the right hilar, mediastinal, and cervical lymph nodes. Histopathological analysis confirmed the diagnosis of a small cell lung cancer. Clinical symptoms and recurrent hyperparathyroidism were therefore consistent with a paraneoplastic syndrome. A complete metabolic response was achieved on 18F-FDG PET/CT scan after chemotherapy.

Giant cell arteritis is not an uncommon disease, and its extension is furthermore finely assessed with new-generation PET/CT system. 18F-FDG PET/CT is increasingly used in case of large-vessel vasculitis for optimal diagnosis, activity monitoring (even when treated with interleukin 6 receptor inhibitor), and evaluation damage progression. We reported the case of a 61-year-old woman with common giant cell arteritis pattern on 18F-FDG PET/CT (aorta and large arteries) and uptakes in all aorta branches, mainly impressive and uncommon in the abdomen. After 2 years of therapeutic optimization including IV tocilizumab and monitoring with 18F-FDG PET/CT, a complete metabolical response was assessed.

Retransplantation is common after liver transplantation (LT). However, in the present era of organ shortages, every attempt to save the liver graft should be performed before considering retransplantation. We report our experience with right hepatic lobectomy (RHL) for liver graft salvage. In a retrospective series of 180 adult LTs, 4 patients underwent RHL (Couinaud's segments V, VI, VII, VIII) in the post-LT period. In all cases, the procedure was performed without Pringle's maneuver or mobilization of the left liver lobe to preserve its vascularization. Three liver graft recipients developed intrahepatic biliary strictures, mainly localized to the right lobe of the graft, and RHL was performed 14, 75, and 78 months after LT. These patients were alive at last follow-up without further episodes of cholangitis or retransplantation (mean follow-up, 38 months). The fourth patient developed early post-LT right liver necrosis with a functioning hepatic artery and underwent right lobectomy 48 hours after LT. He later developed cholangitis secondary to late hepatic artery thrombosis, requiring retransplantation after 18 months. We conclude that RHL can be considered a graft-saving option in selected liver transplant recipients with localized biliary strictures, with excellent patient and graft survival.

Anal fissure is one of the most common and painful proctological pathologies affecting mainly young individuals. The physiopathology in the development of a chronic anal fissure seems to be a combination of internal anal sphincter hypertonia and poor vascularization at the posterior midline. Treatment of acute fissures is conservative with supportive therapy, leading to healing in the majority of the patients. Open or closed lateral internal sphincterotomy is the treatment of choice for chronic anal fissures. In low pressure chronic fissures, sphincterotomy should be avoided and a V-Y island advancement flap may be an alternative procedure. Sphincterotomy can induce anal incontinence, a feared complication of this technique. Recent interest has developed in chemical sphincterotomy with local botulin toxin injections or glyceryl trinitrate application. Long-term follow-up is needed to evaluate these new therapeutic options.

Fulminant hepatic failure is an infrequent but dreadful disease, occurring usually in young patients. Despite fulminant hepatic failure is reversible in most of the cases, some patients develop brain edema and intracranial hypertension, which are the most common cause of death in these patients. Liver transplantation significantly improves the prognosis of selected patients in who precise criteria predict a low chance of survival. This review summarizes the modern standard of care of patients with fulminant hepatic failure, with particular underlining of the management of brain oedema and intracranial hypertension.

The case reports of three patients who received cancer-bearing organs at this institution are presented. A fourth recipient, who was to be transplanted with a cancerous kidney, was spared this disastrous complication. The relevant data regarding the donors is also alluded to, with special reference to the type and site of the primary malignancy. Following these case reports, the implications of these issues, their possible prevention, and further management are discussed.

Multiple organ procurement techniques are increasingly popular in many transplant centers. This paper describes a technique for multiorgan unit(s) explantation in rats. The procedure involves in situ preliminary dissection, cold perfusion of the thoracic and abdominal organ units as separate procedures, explantation, and finally the ex situ isolation of various organ units as single and/or multiple organ combination units. The procedure is feasible, allows for flexibility in the separation of combination organ units, and is reproducible. The exercise is provided as a training and research tool for clinical and research transplant surgeons. The technique is also presented as an animal model for clinical organ sharing. © 1993 Wiley-Liss Inc.

Strictureplasty for obstructive Crohn's disease is still controversial because lesions are left in place and the suture is performed on a diseased bowel. Many surgeons prefer to perform bowel resection, hoping for fewer complications and a lower recurrence rate. In this paper, the authors reports their strictureplasty experience. They performed a systematic retrospective review of the patients suffering from Crohn's disease who underwent strictureplasties during a 10-year period in the abdominal surgery department of the University Hospital of Liege Sart Tilman, and studied the short- and long-term clinical results of 68 strictureplasties performed in 18 patients. Median follow-up was 63 months (range 12 to 144). Mortality was 0% and septic morbidity was 11% (one wound abscess and one leakage). Among the 16 patients available for the latest follow-up, symptomatic stenotic recurrence had to be medically treated in hospital for 4 patients (25%) with a recurrence delay range of 19 to 49 months. Stenosis recurrence needed re-intervention in one patient 48 months after surgery: stenosis occurred at a distance from the corrected site. These results confirmed that strictureplasty is a safe and efficient procedure in selected patients undergoing surgery for obstructive Crohn's disease.

For about 15 years, inguinal hernias in adults have been treated preferentially in our institution by a short midline suprapubic approach (usually 8 cm) and the application of prosthetic material. The technique we use derives from that described originally by Stoppa et al. The preperitoneal dissection is carried out in the same manner. The difference is that the management of the hernia is achieved by a prosthesis considerably overlapping the hernial openings, one on each side in the case of a bilateral procedure. The prosthesis is fixed by a single suture in Cooper’s ligament and held in place principally by intraabdominal pressure. This technique has been spread through the Liege region largely by Lombard et al.

Objective: The aims of our study were to determine if using th e colon as a digestive transplant after oesophagectomy for cancer was associated with increased postoperative complications, and to assess the impact of preoperative radiochemotherapy on postoperative hospital outcome. Methods: From January 1990 to December 1998, 130 patients underwent oesophageal resection for malignancy. There were 103 males and 27 females (age: 61.3 ± 11.5 years). Indications were squamous cell carcinoma in 69 patients and adenocarcinoma in 61. Preoperatively 30 patients (eight in stage I IB, 18 in stage III, and four in stage IV) received radiochemotherapy. There were 84 subtotal oesophagectomies, with anastomosis in the neck in 44 patient s and at the thoracic inlet in 40, and 46 distal oesophageal resections. Digestive continuity was restored with the stomach in 92 patients (age: 63.4 ± 10.2 years) and the col on in 38 (age: 52.3 ± 12.8 years). With the excepti on of age ( P < 0.0001), there was no significant preoperative diff erence between gastric and colonic groups. Results: Hospital mortality was 8.5% (11 patients), decreasi ng from 18.5% (before 1993) to 3.8% (since 1993). One patient (2.5%) died in the colonic graft group and ten (11%) in the gastric pull-up group ( P = 0.17). Postoperative complications occurred in 40 patients (31%), respectively, in ten (26%) and 30 (33%) pat ients after colonic and gastric transplants ( P = 0.48), and were pulmonary insufficiency or infectio n in 29 patients, anastomotic fistula in six, myocardial infarction i n five, recurrent nerve palsy in four, renal insuff iciency in three, and cerebrovascular accident in one. All fistulas o ccurred in the gastric pull-up group. The incidence of postoperative pulmonary complications was 70% (21/30 patients) in the subgroup who received preoperati ve radiochemotherapy, as compared to 11% (5/44 patients) in the subgroup of comparable staging, but witho ut preoperative treatment ( P < 0.001). Conclusions: Colonic grafts are not associated with increased po stoperative mortality or complications. Our results suggest tha t preoperative neoadjuvant treatment significantly increases postoperative pulmonary complications.

Objective We evaluated prognostic factors in 34 patients discharged from hospital after surgical resection for oesophageal squamous cell carcinoma. Material and methods There were 22 males and 12 females; mean age was 59.3 years (range 42-77 years). Preoperative neoadjuvant treatment consisted in chemotherapy alone in three patients and in combined radiochemotherapy in 14. Digestive continuity was restored with a gastric transplant in 26 patients and a colonic graft in 8. Surgery was curative in 28 patients and palliative in 6. There were three stage I, 14 stage II, 13 stage III, and 4 stage IV diseases. In 19 patients the lymph nodes were invaded. The tumour was well differentiated in 17 patients, moderately in 9, and poorly in 8. Results Follow-up ranged from 2 to 100 months. Overall median postoperative survival was 21 months. By univariate analysis, factors influencing survival were curative surgery (p = 0.04), stage (p = 0.006), and nodal involvement (p = 0.0003). Nodal involvement was an independent prognostic factor by multivariate analysis (p = 0.0002). Patient age and sex, perioperative transfusion, digestive transplant, tumour local extension, grade of differentiation, and distant metastasis did not influence survival. Also, we did not observe any significant benefit of preoperative or postoperative chemotherapy or radiochemotherapy. Conclusions Nodal involvement was the most important prognostic factor influencing survival. Therefore, an earlier diagnosis of oesophageal cancer in a less advanced stage is important to improve survival rates. Our study could not confirm the benefit of neoadjuvant therapy in terms of late survival.

Summary Background Assessment of metastatic involvement of the liver remains a diagnostic challenge. The objective of this study was to evaluate the potential role of FDG PET in the detection of liver metastases. Patients and methods Sixty-four patients with malignancy and possible liver involvement were included. Liver metastases were present in 31 cases, demonstrated by histopathological analysis in 15 cases and by follow-up in 16 cases. The negative cases were confirmed by pathology in four cases, peroperative ultrasonography in 12 cases, and follow-up in 17 cases. Whole-body FDG PET was compared to CT (n = 53) and US (n = 43). Results PET demonstrated a 97% sensitivity, an 88% specificity and a 92% accuracy, compared to 93%, 75% and 85%, respectively, for CT (P = NS). Concordant results were obtained in 44 of 64 patients (69%; 19 TP, 25 TN). PET provided new and accurate information in 15 of 64 patients (23.4%). PET demonstrated liver metastases in 11 patients in whom conventional methods yielded negative (two cases) or doubtful (nine cases) results. Four patients free of liver involvement were correctly staged with PET, while CT/US were equivocal. PET was erroneous in five of 64 cases (7.8%, four FP, one FN). Conclusions FDG PET allows an accurate screening of liver involvement in patients with malignancy. Combined with CT, it provides additional diagnostic information that could directly affect the management of these patients.

TODAY, donor organ shortage has lead to an increased waiting period before transplantation and has promoted an increasing number of deaths among the patients awaiting transplantation. One of the solutions to increase the donor pool is to accept “suboptimal” donors who whould not have otherwise been suitable for organ donation only a few years ago. This policy of accepting older or suboptimal donors should promote an increase in the risk of accepting donors with infraclinic malignancies, thus an increase in the risk of transferral of undetected malignancies from the donor to the recipient. In our department in 1991, two recipients developed metastases of a misdiagnosed choriocarcinoma that had caused the death of the donor by cerebral hemorrhage of nontraumatic origin. 1 These dire complications commanded us a a severe policy of malignancy detection during organ procurements, and we report the results of this policy in this article.

Immunosuppressed patients are susceptible to complicated diverticulitis, but reports of this complication are scarce in heart graft recipients. To estimate the prevalence of acute diverticulitis in heart graft recipients, we retrospectively reviewed the cases of diverticulitis in a series of 143 patients who underwent orthotopic heart transplantation in a period of 10 years. Six (4%) of these developed acute diverticulitis and required colectomy. All of them were male patients and were older than 50 years. Four patients underwent urgent laparotomy and colon resection with end colostomy (Hartmann procedure). The two other patients suffered from diverticulitis without generalized peritonitis and underwent laparoscopic sigmoidectomy with direct transanal end-to-end anastomosis. The postoperative outcomes of these six patients were satisfactory. As are other immunosuppressed patients, heart graft recipients are susceptible to diverticulitis. Early surgical management may be safe in well-compensated patients.

Cytokines regulate both aspecific inflammatory responses and specific immune responses. Inflammatory changes occur in the organ transplant as a result of tissue trauma and ischemia/reperfusion in the organ donor and at the time of transplant operation. There is a possibility that cytokines play a role in mediating theses changes. These aspecific inflammatory changes may not only affect graft function but also influence graft immunogenicity (enhanced MHC and adhesion molecule expression) and thus, vulnerability to rejection. Cytokines orchestrate the specific immune response elicited by organ transplantation. Relevance of cytokines to the rejection reaction is multifactorial in nature: 1) promotion of the proliferation an differentiation of specific alloreactive T and B cells clones and differentiation and activation of CTL and NK cells, 2) chemotactic effect and induction of the expression of adhesion molecules, 3) enhancement of MHC class I and II expression, and 4) direct cytotoxic effect on the target grafted cells. Therefore, modulation of cytokine activity either specifically (monoclonal antibody, soluble receptor, etc.) or aspecifically (cyclosporin, FK 506, Rapamycin, steroids, etc.) is essential in controlling graft rejection. Determination of circulating cytokines and cytokines measurement within the biological fluids produced by an organ transplant may help in the diagnosis of rejection episodes and other complications following organ transplantation.

CURRENTLY, STANDARD immunosuppressive protocols for solid organ transplantation include a calcineurin inhibitor (CNI), either cyclosporine or tacrolimus. These drugs are powerful immunosuppressors but present significant immunological side effects. Among them, chronic nephrotoxicity represents a serious clinical challenge even years after transplantation. In particular, many liver transplant recipients who enjoy long-term survival develop progressive end-stage renal disease requiring dialysis and/or renal transplantation. With experience, transplant physicians have learned to use much lower doses of immunosuppressive drugs, thereby reducing the rate and severity of their side effects, but in the long run, low-dose CNI may still induce progressive impairment of renal function. Mycophenolate mofetil (MMF) is a potent inhibitor of inosine monophosphate dehydrogenase with a relatively selective effect on Tand B-lymphocyte activation and proliferation. MMF has no nephrotoxic side effect and seems to have superior immunosuppressive potency compared with azathioprine. In this nonrandomized, consecutive, prospective, pilot study, the authors offered CNI withdrawal to stable liver recipients who experienced progressive chronic renal failure years after successful liver transplantation. CNI was successfully replaced by MMF monotherapy, without signs of chronic graft rejection at follow-up, and with significant improvement of serum creatinine levels.

Hemodynamics during laparoscopic cholecystectomy under general anesthesia (isoflurane in N2O/O2 (50%)) were investigated in 15 nonobese ASA Class I patients by using invasive hemodynamic monitoring including a flow-directed pulmonary artery catheter. During surgery, intraabdominal pressure was maintained automatically at 14 mm Hg by a CO2 insufflator, and minute ventilation was controlled and adjusted to avoid hypercapnia. Hemodynamics were measured before anesthesia, after the induction of anesthesia, after tilting into 10 degrees head-up position, 5 min, 15 min, and 30 min after peritoneal insufflation, and 30 min after exsufflation. Induction of anesthesia decreased significantly mean arterial pressure and cardiac index (CI). Tilting the patient to the head-up position reduced cardiac preload and caused further reduction of CI. Peritoneal insufflation resulted in a significant increase (+/- 35%) of mean arterial pressure, a significant reduction (+/- 20%) of CI, and a significant increase of systemic (+/- 65%) and pulmonary (+/- 90%) vascular resistances. The combined effect of anesthesia, head-up tilt, and peritoneal insufflation produced a 50% decrease in CI. Administration of increasing concentrations of isoflurane, via its vasodilatory activity, may have partially blunted these hemodynamic changes. These results demonstrate that laparoscopy for cholecystectomy in head-up position results in significant hemodynamic changes in healthy patients, particularly at the induction of pneumoperitoneum.

SUMMARY We have compared metabolic and respiratory changes after laparoscopic cholecystectomy (n = 15) with those after open cholecystectomy (n = 15). The durations of postoperative i.v. therapy, fasting and hospital stay were significantly shorter in the laparoscopy group. During the first and second days after operation, analgesic consumption but not pain scores (visual analogue scale) were significantly smaller after laparoscopy, while vital capacity, forced expiratory volume in 1 s, and Pa02 were significantly greater. The metabolic and acute phase responses (glucose, leucocytosis, C-reactive protein) were less after laparoscopy compared with laparotomy. Although plasma cortisol and catecholamine concentrations were not significantly different between the two groups, after surgery interleukin-6 concentrations were less in the laparoscopy group.

In summary, we established that a significant production of the monokines interleukin-6, tumor necrosis factor apha, and interleukin-1 occurred during orthotopic liver transplantation whereas the lymphokines interferon gamma and interleukin-2 were not detected. Levels of interleukin-6 reached their maximum values before and especially at the end of the anhepatic phase. They remained high after the anhepatic phase, i. e. after reper-fusion of the new livers. Tumor necrosis factor alpha and interleukin-1 reached their maximum values after the anhepatic phase. Not only were interleukin-6, tumor necrosis factor apha, and interleukin-1 present in the serum but they could also be detected in the bile produced by these new livers. Mechanisms of monokine production during orthotopic liver transplantation is multifactorial in origin and further studies will have to evaluate the relative contribution of the various factors involved. The possibility of an association between peroperative monokines and transplant outcome and their potential clinical implication will have to be elucidated.

The influence of the length and origin of a small bowel graft on graft versus host disease (GVHD) was studied in 33 (Lewis x brown Norway) F1 hybrids transplanted with different types of Lewis small bowel grafts. Recipients of an entire small bowel graft (N = 9), a jejunal graft (N = 6), or an ileal graft (N = 6) displayed a similar acute lethal GVHD, with 100% mortality rate and equivalent survival time (15 +/- 0.7, 16.8 +/- 0.9, and 16 +/- 0.6 days, respectively) (P greater than 0.01). On the other hand, 80% of the recipients of a segmental jejunal graft (N = 10) recovered from a transitory form of GVHD and regained weight similarly to the isografted rats (N = 4). It was concluded that the entire small bowel, jejunum, and ileum can provoke an equivalent GVHD after transplantation, whereas a segment of jejunum decreases the intensity of GVHD, probably by reducing the amount of transplanted lymphoid tissue.

In this paper, we addressed the implications of misdi- agnosed malignancy in transplanted organs. As the best prevention for this dreadful complication of trans- plantation is detection of the malig- nancy in the donor, we recom- mended careful observation of the donor during procurement, an im- mediate frozen section of any

Les auteurs rapportent un cas de tumeur carcinoide de l’ampoule de Vater. L’histoire clinique a evolue pendant quatorze ans et a comporte un syndrome douloureux chronique de l’hypocondre gauche accompagne finalement d’une elevation des taux seriques des enzymes pancreatiques. La tomodensitometrie computee, la cholangio-wirsungographie retrograde, ont mis en evidence la dilatation des voies bilio-pancreatiques secondaires a une lesion de la papille. L’echec repete des biopsies, meme apres sphincterotomie endoscopique, a impose une duodenopancreatectomie cephalique qui a permis d’affirmer la nature carcinoide de la tumeur.

Objectives. We investigated endocrine correlates of the hemodynamic changes induced by carbon dioxide pneumoperitoneum (PNO). We then studied whether clonidine might modulate the hemodynamic changes induced by PNO by reducing release of catecholamines and vasopressin.Background. Both mechanical and neurohumoral factors contribute to the hemodynamic changes induced by carbon dioxide PNO. Several mediators have been proposed, but no study has correlated hemodynamic changes with changes in levels of these potential mediators.Methods. We conducted two studies, each including 20 healthy patients scheduled for elective laparoscopic cholecystectomy. In the first study serial measurements of hemodynamics (thermodilution technique) were done during laparoscopy and after exsufflation. Plasma concentrations of cortisol, catecholamines, vasopressin, renin, endothelin and prostaglandins were measured at the same time points. In the second study patients were randomly allocated to receive 8 μg/kg clonidine infused over 1 h or placebo before PNO. Hemodynamics and plasma levels of cortisol, catecholamines and vasopressin were measured during PNO and after exsufflation.Results. Peritoneal insufflation resulted in a significant reduction of cardiac output (18 ± 4%) and increases in mean arterial pressure (39 ± 8%) and systemic (70 ± 12%) and pulmonary (98 ± 18%) vascular resistances. Laparoscopy resulted in progressive and significant increases in plasma concentrations of cortisol, epinephrine, norepinephrine and renin. Vasopressin plasma concentrations markedly increased immediately after the beginning of PNO (before PNO 6 ± 4 pg/ml; during PNO 129 ± 42 pg/ml; p < 0.05). The profile of vasopressin release paralleled the time course of changes in systemic vascular resistance. Prostaglandins and endothelin did not change significantly. Clonidine significantly reduced mean arterial pressure, heart rate and the increase in systemic vascular resistance. Clonidine also significantly reduced catecholamine concentrations but did not alter vasopressin and cortisol plasma concentrations.Conclusions. Vasopressin and catecholamines probably mediate the increase in systemic vascular resistance observed during PNO. Clonidine before PNO reduces catecholamine release and attenuates hemodynamic changes during laparoscopy.

Immunocompromised patients are particularly at risk for complicated diverticulitis. They are more sensitive to infections and develop fewer abdominal symptoms. When they develop diverticulitis, the course of the disease is very often complicated by free colonic perforation and peritonitis leading to high mortality rates. The purpose of this paper was to review natural course and the management of diverticulitis in the immunocompromised patients.

Only a few cases of combined liver and heart transplantation have been reported in the literature, and no standard surgical procedure has yet been established. We report the successful transplantation of both liver and heart in a 28-year-old patient suffering from homozygous beta-thalassemia. We used Belghiti's technique of inferior vena caval flow preservation for liver transplantation, which avoids inferior vena cava occlusion by a side-to-side caval anastomosis. Applied to combined liver and heart transplantation, preservation of caval flow during liver transplantation may allow early discontinuation of cardiopulmonary bypass and, thus, minimize the general consequences of prolonged bypass.