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Summary Background Surgical resection alone is regarded as the standard of care for patients with liver metastases from colorectal cancer, but relapse is common. We assessed the combination of perioperative chemotherapy and surgery compared with surgery alone for patients with initially resectable liver metastases from colorectal cancer. Methods This parallel-group study reports the trial's final data for progression-free survival for a protocol unspecified interim time-point, while overall survival is still being monitored. 364 patients with histologically proven colorectal cancer and up to four liver metastases were randomly assigned to either six cycles of FOLFOX4 before and six cycles after surgery or to surgery alone (182 in perioperative chemotherapy group vs 182 in surgery group). Patients were centrally randomised by minimisation, adjusting for centre and risk score. The primary objective was to detect a hazard ratio (HR) of 0·71 or less for progression-free survival. Primary analysis was by intention to treat. Analyses were repeated for all eligible (171 vs 171) and resected patients (151 vs 152). This trial is registered with ClinicalTrials.gov, number NCT00006479. Findings In the perioperative chemotherapy group, 151 (83%) patients were resected after a median of six (range 1–6) preoperative cycles and 115 (63%) patients received a median six (1–8) postoperative cycles. 152 (84%) patients were resected in the surgery group. The absolute increase in rate of progression-free survival at 3 years was 7·3% (from 28·1% [95·66% CI 21·3–35·5] to 35·4% [28·1–42·7]; HR 0·79 [0·62–1·02]; p=0·058) in randomised patients; 8·1% (from 28·1% [21·2–36·6] to 36·2% [28·7–43·8]; HR 0·77 [0·60–1·00]; p=0·041) in eligible patients; and 9·2% (from 33·2% [25·3–41·2] to 42·4% [34·0–50·5]; HR 0·73 [0·55–0·97]; p=0·025) in patients undergoing resection. 139 patients died (64 in perioperative chemotherapy group vs 75 in surgery group). Reversible postoperative complications occurred more often after chemotherapy than after surgery (40/159 [25%] vs 27/170 [16%]; p=0·04). After surgery we recorded two deaths in the surgery alone group and one in the perioperative chemotherapy group. Interpretation Perioperative chemotherapy with FOLFOX4 is compatible with major liver surgery and reduces the risk of events of progression-free survival in eligible and resected patients. Funding Swedish Cancer Society, Cancer Research UK, Ligue Nationale Contre le Cancer, US National Cancer Institute, Sanofi-Aventis.

article; AIM OF THE STUDY: Splenic artery embolization has been used as an adjunct to the non-surgical management of blunt splenic injury. No consensus on its indications has emerged from the literature. This multicentric study aimed to evaluate the results of this technique in France. PATIENTS AND METHODS: Between March 2000 and April 2006, 22 patients older than 15 years of age (mean age 29, range: 15-59) with splenicv rupture due to blunt trauma underwent splenic artery embolization in six Level I Trauma Centers in France. Splenic rupture was classified Moore II in 3 cases, Moore III in 12 cases, and Moore IV in 7 cases. Angiography was performed within 4 hours of admission in half of the cases. The main indications for splenic artery embolization were: extravasation of contrast medium on CT scan (10 cases, 45%); early pseudo-aneurysm (6 cases, 23%); hypotension despite fluid resuscitation and/or progressive need for transfusion (5 cases, 22%). RESULTS: There was no mortality. Nine patients experienced complications (41%) including 6 (27%) who developed left pleural effusion. Two patients eventually underwent splenectomy (one for persistent hemorrhage, one for splenic necrosis). The overall splenic salvage rate was 91%. CONCLUSION: Splenic artery embolization is a valuable techniche that hels to lower the rate of splenectomy for traumatic splenic rupture with relatively low morbidity.

In general, frontal sections of the liver in magnetic resonance imaging are used less than sections passing through other planes of space. Frontal sections of the trunk in magnetic resonance imaging involving the liver, performed in over 80 patients for various reasons, were compared with frontal sections of the trunk made in 10 cadavers. A general schema was established of the anatomy of the liver studied in the frontal plane. Frontal sections in magnetic resonance imaging make it possible to form a very good estimate of the structure and size of the liver, and to recognize individual variations. They clearly show certain inferior relations of the liver. In particular, frontal sections in magnetic resonance imaging make it possible to identify most of the main veins of the liver, the main lobar veins and branches of the portal vein, and to properly study the entire retrohepatic portion of the inferior vena cava. Some of the vascular images were found almost constantly in the sections of the various subjects. The right lobe of the liver is more accessible to such study than the left by reason of its structure and its venous arrangements. Frontal sections of the liver in magnetic resonance imaging constitute a preferential method for studying the anatomy of the liver. Together with transverse sections, they make it possible to specify the site and venous relations of a pathologic process within the liver, with a view to hepatectomy.

Anomalies of hepatic morphology, as opposed to anatomical variations, are rare. Nevertheless, knowledge of such anomalies is important since they do not always remain clinically latent. Four case studies of different types of anomalies encountered in surgical practice in the adult are reported herein. A general review of hepatic anomalies can be divided into two categories, i.e. anomalies due to defective development and anomalies due to excessive development of the liver. Such disturbances are sometimes associated with malformations of other structures, especially the diaphragm and suspensory apparatus of the liver. Defective development of the left lobe of the liver can lead to gastric volvulus. Conservely, defective development of the right lobe either remains clinically latent or leads to portal hypertension. Anomalies related to excessive development of the liver lead to formation of accessory lobes annexed to the liver. Despite their diversity of shape, size and location, such accessory lobes have common features allowing them to be considered as an entity. In most cases the accessory lobe is found in the infra-hepatic position. Riedel's lobe is the best known example of a sessile accessory lobe. Accessory lobes may also stimulate tumor. In cases where the accessory lobe has a pedicle, torsion is a common event leading to discovery of the abnormal mass. The origin of the anomalies of hepatic morphology occurring in the course of organogenesis remains to be elucidated. The use of ultrasonography should now allow identification of such anomalies prior to the occurrence of an acute complication and in the future to possibly detect them in the fetus.