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Background Combining complete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a new approach allowing curatively intended treatment of multiple malignant peritoneal tumour seedings. This aggressive treatment is frequently followed by a complicated or an unusual postoperative course, that has yet to be described. Aim To describe the clinical and biological post-therapeutic course of patients treated with CCRS plus HIPEC, who were considered uncomplicated cases, and were discharged from hospital before the 15th postoperative day. Patients and methods Thirty-two patients were retrospectively selected on these criteria among 232 treated patients, most of whom had received intraperitoneal high-dose oxaliplatin and intravenous 5-fluorouracil. The daily postoperative clinical and biological parameters are presented in graphs using boxplots. Results Hyperthermia at 38 °C was the rule during the first postoperative week. The daily flow rate of the abdominal drains decreased progressively from 500 ml to 50 ml from day 1 to day 7. The flow rate of the nasogastric tube was high and close to 1000 ml/24 h until day 6. Resumption of digestive transit occurred between day 4 and day 6; it was always a diarrheic transit until day 12. Severe hypophosphoremia was observed at day 2 and day 3. White blood cells gradually decreased until day 12 to half the normal value, haemoglobin remained stable and the platelet count, which was low after surgery, continued to decrease progressively until day 3. Other data are presented. Conclusion These results, in this selected group of patients, allow a description of the “natural history” of CCRS plus HIPEC, which is not similar to classic uncomplicated postoperative courses following surgery. Knowledge of these “natural” changes may help avoid unnecessary explorations, and allow the early detection of postoperative complications.

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.

Resume Introduction. – Cette etude retrospective de 20 patients reoperes pour dysfonctionnement d'une anastomose biliodigestive comprend sept anastomoses choledocoduodenales (ACD) et 13 anastomoses hepatico- ou choledocojejunales (AHJ). Methodes et resultats. – Les dysfonctionnements ont ete reveles par des acces d'angiocholite (16 cas), un ictere nu (3 cas) et un syndrome abdominal aigu hyperalgique (1 cas). Parmi les sept ACD, le delai moyen de reintervention a ete de 14 ans, la reintervention a ete motivee par une atteinte biliaire dans cinq cas (stenose 1 cas, obstruction anastomotique 4 cas) ou par une stenose duodenale (2 cas). Les ACD ont ete transformees en AHJ. La mortalite operatoire a ete nulle, la morbidite de 14 %. Une recidive d'angiocholite a ete observee a long terme. Pour les 13 AHJ, le delai de reintervention a ete de six ans et neuf mois, la reintervention a ete motivee par une stenose anastomotique (7), un empierrement sans stenose (4) ou des anomalies de l'anse montee (2). L'anse en Y a ete allongee en cas de longueur insuffisante et l'anastomose refaite en cas d'anomalie. Les AHJ laterolaterales ont ete converties en terminolaterales. La mortalite operatoire a ete nulle, la morbidite de 8 %. A long terme, deux recidives de stenose et une recidive de lithiase ont ete observees. Conclusions. – Les dysfonctionnements des anastomoses biliodigestives se traduisent essentiellement par des acces d'angiocholite pouvant aboutir a une cirrhose biliaire secondaire. Le traitement des complications des ACD est simple et efficace, l'evolution apres reprise pour des complications d'une AHJ depend de la pathologie initiale.

The aim of this prospective study was to analyze the impact of second-look surgery in an attempt to treat peritoneal carcinomatosis (PC) at an early stage in a series of patients at high risk of developing PC from colorectal cancer.The prognosis of colorectal PC has recently been improved with hyperthermic intraperitoneal chemotherapy (HIPEC) after complete cytoreductive surgery (CCRS), and could be further improved if PC could be treated at an early stage. But, currently, the diagnosis of early PC is not accessible to imaging.From 1999 to 2006, 29 patients without any sign of recurrence on imaging studies underwent second-look surgery 13 months after resection of the primary tumor. Patients were selected according to primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n = 16), synchronous ovarian metastases (n = 4), perforated primary tumor (n = 9).PC was found and treated with CCRS plus HIPEC in 16 of 29 (55%) cases, corresponding to 10 of 16 patients with initial PC, 3 of 4 patients with synchronous ovarian metastases and 3 of 9 patients with a perforated primary tumor. There was no postoperative mortality, and morbidity (grade III/IV) occurred in 14% of cases. After a median follow-up of 27 months (range, 6-96), 8 of 16 patients treated with CCRS and HIPEC are free of disease, 4 relapsed in the peritoneum, and 4 developed isolated visceral metastases.Performing second-look surgery at 1 year in selected patients at high risk of developing PC allowed the early detection and treatment of PC in 55% of cases. Our preliminary results have encouraged us to pursue this strategy and to evaluate it in a prospective multicenter trial.

The liver surgeon's decision to operate is based on imaging studies. However, no clear practical guidelines are available enabling surgeons to safely predict tumor-free margins after a partial hepatectomy. The aim of this retrospective study is to provide surgeons with simple and easily applicable practical guidelines.We retrospectively stringently selected 42 anatomical right or left hepatectomies whose main characteristic was to pass along the median hepatic vein, which was preserved. This vein is an easily visualized anatomical landmark on preoperative imaging and is never transgressed by the surgeon. We compared the minimum distance between the tumor and this vein measured on preoperative imaging, and the minimum tumor-free excision margin measured on the specimen by the pathologist.The median tumor-free excision margin was 5 mm at pathological analysis, significantly different (P.0001) from the tumor-free margin measured on preoperative imaging (15 mm). The mean difference between these two measurements was 10 +/- 4 mm (median, 9 mm). This difference was partly the result of the transection and partly the result of technical deviations in relation to the ideal resection line.The liver surgeon must consider that roughly a 5 to 8 mm tumor-free margin will disappear during hepatectomy when comparing measurements on the basis of preoperative imaging versus tumor-free specimen margins. If the histologically assessed minimum 2-mm tumor-free margin is added, the surgeon must plan to have a 7 to 10 mm tumor-free margin on preoperative imaging. However, few technical solutions exist that would enable the surgeon to increase the safety margin in borderline cases.

Peritoneal carcinomatosis (PC), which has hitherto been regarded as a lethal entity, can now be cured with surgery (treating macroscopic tumor seeding) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) (treating residual microscopic disease). The purpose of this study was to analyze the morbidity and mortality of a particular approach associating optimal (R0-R1) cytoreduction, optimal HIPEC combining oxaliplatin and irinotecan, and an optimal homogeneous intraperitoneal temperature of 43 degrees C.A total of 106 consecutive patients were included in this prospective phase 2 study. After complete resection of the PC, HIPEC was performed by the Coliseum technique with oxaliplatin (360 mg/m2) combined with irinotecan (360 mg/m2) in 2 L/m2 of 5% dextrose, over 30 minutes at a real intraperitoneal temperature of 43 degrees C. During the hour preceding HIPEC, patients received 5-fluorouracil (400 mg/m2) and leucovorin (20 mg/m2) intravenously, resulting in tritherapy.Postoperative mortality and morbidity rates were 4% and 66%, respectively. The most frequent complications were digestive fistula (24%), lung infection (16%), and severe hematological toxicity (11%). Statistical correlation was evidenced between morbidity and the carcinomatosis score (P = .0008), the number of resected organs (P = .0001), the duration of surgery (P = .0001), and blood loss (P = .0001).This new approach, optimized in three respects (complete cytoreduction, combination oxaliplatin with irinotecan, and high temperature) has resulted in a relatively high but acceptable incidence of adverse events considering the expected advantage for survival.