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Hepatocellular adenoma resection and focal nodular hyperplasia supervision are widely recognized as the best management when these benign liver tumors are diagnosed. Differential diagnosis is thus mandatory.Twenty-nine patients with a presumed benign liver tumor were retrospectively analyzed.Histopathological analysis of these resected liver tumors demonstrated hepatocellular adenoma in 16 patients and focal nodular hyperplasia in 13. One hepatocellular carcinoma was disclosed into a hepatocellular adenoma and 2 hepatocellular adenoma showed foci of liver-cell dysplasia. Seven patients with hepatocellular adenoma (43%) had evidence of intratumoral hemorrhage, among which 3 patients were admitted with intraperitoneal tumoral rupture. Computed tomography, performed in 26 patients, was the most reliable examination to characterize these presumed benign liver tumors. Magnetic resonance imaging concerned only 5 patients but 3 hepatocellular adenoma and 1 focal nodular hyperplasia were diagnosed. The indications of focal nodular hyperplasia surgical resection were chronic pain (4 pts), hepatocellular adenoma diagnosis (4 pts), undeterminate liver mass (2 pts), a liver mass of unknown origin in patients with a neoplastic history (3 pts). A diagnosis of focal nodular hyperplasia assumed by the imaging work-up was always histologically confirmed. All the patients underwent hepatic resection with no mortality.This report underlines the risk of hemorrhage or malignant transformation of hepatocellular adenoma that justifies a safety surgical resection. An imaging work-up in favor of focal nodular hyperplasia allows radiological observation.

Partial hepatectomy (PH) or total hepatectomy and orthotopic liver transplantation (OLT) may be curative in selected patients treated for hepatocellular carcinoma (HCC). The analysis of clinical series may help in the choice of the more appropriate treatment.During the past 11 years, 40 patients with HCC were treated by PH and 16 patients underwent total hepatectomy and OLT. Selection criteria for transplantation were the liver function and the tumor resectability.The actuarial 1-, 3- and 5-year survival rates were 67%, 34% and 18%, respectively, after PH and 62%, 54% and 54% after OLT. The only prognostic factor after PH was the tumor extension to a single or both lobes. Patients with associated cirrhosis had significantly more post-operative complications, but a comparable long-term survival. The proliferative cell nuclear antigen labeling index (PCNA-LI), evaluated on tumoral tissue in 16 patients, showed that an index30% indicates a better prognosis for HCC developing in non-cirrhotic liver.For patients carefully pre-operatively evaluated, the presence of an associated cirrhosis does not seem to modify the long-term survival after PH, and OLT may offer more than 50% 5-year survival. A PCNA-LI30% appears to be a good prognostic factor in patients without cirrhosis.

The place of endoscopic retrograde cholangiopancreatography (ERCP) before open or laparoscopic cholecystectomy remains controversial. Most of the reports study highly selected series of patients and therefore do not give a survey of the actual situation in a general population. We describe here the therapeutic impact of preoperative ERCP in a continuous cohort of patients needing a cholecystectomy.Data concerning a 2-year continuous and unselected series of 452 patients undergoing cholecystectomy were evaluated.Two hundred ninety-three patients (65%) presented with a chronic symptomatic biliary lithiasis and 159 patients (35%) with a complicated biliary lithiasis. A preoperative ERCP was performed in 206 patients, all presenting with a suspicion of associated lithiasis of the common bile duct (CBD). An endoscopic sphincterotomy was performed in 106 patients: 44 patients presented with CBD stones (9.7%), all successfully cleared by endoscopy. Laparoscopic cholecystectomy has been attempted in 367 patients (81%) and successfully performed in 333 patients (74%). Laparotomy as a first-choice procedure was performed in 85 patients (19%). Surgical choledochotomy was never performed. Postoperative ERCP was needed in 4 patients (0.88%) and in only 1 of them for a retained CBD stone (0.22%).In a continuous series of patients needing a cholecystectomy, preoperative ERCP was performed on the basis of suspected CBD disorders. It allows CBD stone detection and extraction in almost 10% of the patients and avoids peroperative CBD exploration, with a very low rate of retained stones after surgery. The association of preoperative ERCP with subsequent laparoscopic cholecystectomy (when feasible) offers the patient a quick recovery and a short hospital stay.

Intra-arterial chemotherapy combined with haemofiltration enables the administration of drugs to confined neoplastic tissue while limiting the systemic drug exposure. During the procedure, the cytotoxic drugs are injected into the arterial supply of the tumour and the venous blood coming from the tumour bed is pumped out and filtered trough haemofiltration unit in order to extract the cytotoxic drug not fixed on the tumour. The patients selected for such treatment failed previous intravenous chemotherapy. Thirteen patients underwent intra-arterial chemotherapy injections combined with haemofiltration procedures: 8 unresectable liver metastases from colorectal cancer and 5 pelvic recurrences from rectal cancer. Fluorouracil, mitomycin C and doxorubicin were infused. One out of thirteen patients presented a complete regression of his liver metastases, 5/13 presented a partial regression, 2/13 patients did not show any significant modification of the size of their lesions and were classified as stable disease, 5/13 patients showed a progression of their neoplastic disease. No nephrotoxicity or major gastrointestinal side effects were observed. Intra-arterial chemotherapy combined with haemofiltration procedure is a therapeutic modality that could be considered in patients with locally advanced cancer who failed previous first line intravenous chemotherapy.

The authors report a case of sigmoid colon perforation post colonoscopic polypectomy. Such perforation is rare and has been estimated to occur between 0.1 and 3% of the time. Surgical treatment is necessary when there is deterioration of the clinical state. In this reported case, surgical closure of the perforation was achieved by laparoscopy. We believe that this approach is effective for colonic suture, peritoneal lavage, and drainage.

The association amoxicillin-clavulanic acid is a widely used medication. Only about 15 cases of cholestatic hepatitis were reported in Belgium between 1990 and 1993; about 100 cases have been reported to the pharmaceutical company. This effect is severe but reversible. The injury is probably idiosyncratic or immunologically based. Age, sex and treatment duration are as many agents of risk. The diagnosis is undertaken on basis of clinical examination, chronological study, biological evolution and histology.

Diaphragmatic rupture occurs in 25% of the thoracic and abdominal blunt injuries. It may be discovered immediately or sometimes several months or even years after the trauma. The diagnosis can be made easily on the basis of a standard chest X-ray. Barium swallow examination, computerized tomography Scan and especially Magnetic resonance imaging can be helpful for differential diagnosis. Surgical treatment is always necessary.

Duodenal diverticula are frequent, they are present in 22% of the cases at autopsy. However, radiological assessment demonstrates duodenal diverticula in 1 to 5% of the patients only. Perforation, the main complication, is very rare. Preoperative diagnosis is exceptional. In a 69-year patient admitted for diffuse abdominal pain, a computerized abdominal tomography, completed by opacification of the gastroduodenal transit allowed diagnosis. In the second case, diagnosis was made peroperatively. Based on these two observations, the authors review the elements of diagnosis and management in complicated duodenal diverticula.

During the past 13-years, 35 patients with hepatocellular carcinoma (HCC) were treated by hepatic resection. There were 11 females and 24 males, the age ranged from 17 to 82 years with a mean of 59 years. HCC was associated with liver cirrhosis in 17 patients (48%). Fifteen patients underwent a major hepatectomy, 18 patients a partial hepatectomy (single or bisegmentectomy) and 2 patients had a wedge resection. One patient presenting with a spontaneous tumor rupture died immediately after surgery. Out of the 34 others, 3 died in the postoperative period (8.8%). Early complications occurred in 57% of the patients. The actuarial 5-years survival rate is 30%. The only prognostic factor is tumor extension to a single or both lobes. A significant difference in the survival rate has been observed between patients with or without underlying cirrhosis. Our experience suggest that long-term survival can be expected after surgical resection for HCC.

We report our current management of variceal bleeding with endoscopic sclerotherapy. We emphasize the importance of resuscitation and of recording at time zero and within the first 72 hours clinical and laboratory indicators, as these influence the management of these patients. Primary sclerotherapy using Histoacryl for active bleeding and Ethoxysclerol for recent bleeding should be performed as soon as the patient is stable hemodynamically. As we have identified factors related to the severity of hemorrhage and of liver failure degree which can predict early failure of sclerotherapy, patients presenting with these findings should be, in the future, referred quickly toward alternative therapies among which non-surgical intrahepatic shunt appears a promising modality.

Intraductal mucin-hypersecreting neoplasms of the pancreas with extreme dilatation of the main duct were studied in eight patients. They included five men and three women, aged 47-85 years. Five patients had a history of symptoms mimicking pancreatitis; four developed steatorrhea and/or diabetes. At endoscopic retrograde pancreatography, five patients showed an open ampulla filled with mucin, and six patients showed patchy filling defects in the ectatic main duct. Morphological examination showed extreme dilatation of the entire pancreatic duct in six patients and its tail segment in two patients. The duct segments filled with viscous mucin were lined by well-differentiated mucin-secreting cells, forming papillary foldings and occasionally showing cellular atypia. None of the patients had invasive tumor or metastasis. Six patients whose lesions were resected are alive and doing well (mean follow-up, 5.5 years). It is concluded that intraductal mucin-hypersecreting neoplasm is a pancreatic tumor with favorable prognosis. Because it shares many features with intraductal papillary neoplasm, a common pathogenesis of these pancreatic tumors is suggested.

Somatostatin can be helpful after liver transplantation in some well-defined indications. In uncontrolled digestive haemorrhage, a short course of somatostatin therapy can be of great help in controlling the acute bleeding and to avoid emergency laparotomy. Somatostatin could also be helpful in bilio-pancreato-intestinal fistula, but in this case its advantage over elective surgical treatment remains to be confirmed.

In our early experience, orthotopic liver transplantation was found to be successful in fulminant and subacute hepatic failure due to viral hepatitis in adults, with 66% 1-year survival rate. In the future, more accurate prognostic criteria would probably improve overall survival rate in acute hepatic failure, by allowing better and earlier selection of patients requiring liver transplantation.

Home parenteral nutrition (HPN) must be reserved for patients with an dysfunctional bowel requiring a long-term nutritional support. We report a 2 year experience of HPN at Erasmus Hospital which includes seven patients. Indications and implications of HPN are also discussed.

Malignant epithelioid hemangioendothelioma of the liver is a recently recognized and uncommon neoplasm of vascular origin. Few cases have been reported and the treatment remains therefore difficult to define. A relationship to oral contraceptive use has been suggested but no other toxic agents have been incriminated. We report here the first case occurring after a close contact with vinyl chloride. Because of wide hepatic destruction and serious portal hypertension with bleeding varices, the patient underwent orthotopic liver transplantation. After a disease-free interval of 20 months, he died from variceal hemorrhage and encephalopathy due to local tumor recurrence with portal thrombosis. Nevertheless, orthotopic liver transplantation remains the only hope of salvage when extensive liver destruction and life-threatening complications are present.

The specific properties of Stomahesive tested in 116 stomal and 20 fistulous patients render it really useful in stomatherapy where it increases the comfort of the patients: 1. it offers an excellent peristomal skin protection whatever the nature of the stoma or origin of the fistula; 2. it promotes rapid healing of skin lesions, even in ileostomy, transverse colostomy, ureterostomy and fistula patients; 3. it ensures an effective degree of impermeability; 4. it provides a large base for adhesion of the collecting bag; 5. it can be kept on for about 6 days in most cases; 6. The local tolerance is excellent (Acta chir. belg., 1977, 76, 533-537).

Between 1978 and 1983, 32 patients underwent a proximal duodeno-pancreatectomy for malignant lesions of the ampullary region on head on the pancreas. Pre-operative diagnosis was made by endoscopic cholangio-pancreatography, echography, tomodensitometry and arteriography. 14 patients underwent a pre-operative endoscopic bile drainage procedure. The operative mortality was 6,2% and the morbidity 43%; the intensity of the icterus as well as the preoperative bile drainage procedure did not change these factors significantly. The pre-operative diagnostic procedures permitted a clear definition of the extent of the tumor and retrospective analysis demonstrated their prognostic significance with regard to long-term survival. 11 patients are still alive. The presence of histologically proven metastases reduce significantly the duration of survival. Surgical resection is the best treatment for malignant tumors of the ampullary region and the head of the pancreas without local or distant metastases.

Between January 1978, and December 1987, 79 patients underwent pancreaticoduodenal resection for pancreatic (44) or periampullary tumors (ampulla 18, common bile duct 9, duodenum 8). Fifty-five patients were icteric (55/79: 70%); 33 of them underwent preoperative biliary decompression (endoscopic procedures 29, percutaneous transhepatic drainage 3, laparotomy and T-tube placement. 1) After biliary drainage, bilirubin levels decreased from 12.4 +/- 1.3 mg/dl at admission to 5.1 +/- 1.1 mg/dl before surgery. Pancreaticoduodenal resection was performed within a mean of 15 +/- 13 days after biliary decompression. Twenty-seven patients had no complications, others developed one or more complications. The postoperative mortality was 5% (4/79). The influence of various clinical, biological and pathological factors on postoperative complications and long-term survival was studied. Neither jaundice nor preoperative biliary drainage had a statistically significant effect on overall morbidity and mortality. However, septic and hemorrhagic complications appeared to be more frequent with preoperative bilirubin levels above 20 mg/dl (0.05 less than P less than 0.1), while all postoperative pancreatic and biliary fistulas occurred in patients with a bilirubin level below 6 mg/dl (P less than 0.01). Biliary fistulas were also more frequent when anastomosis was performed on a non-dilated biliary duct (P less than 0.05). Overall actuarial survival was 58% at 1 year and 26% at 5 years. Node and/or contiguous tissue infiltration significantly decreased long-term survival (P less than 0.001). Seventy-one adenocarcinomas were reviewed and graded following a modified version of Klöppel's pathological classification.(ABSTRACT TRUNCATED AT 250 WORDS)

Advances in technology of flexible endoscopes have greatly changed the management of patients with adenomatous polyps of the colon and rectum. Some controversy still exists concerning the best treatment for invasive polyps. For some authors, invasive polyps need radical operation, while others think that unless cancer goes beyond the bounds of a removed polyp, endoscopic resection is an adequate procedure. We designed a study of 65 patients presenting an invasive carcinoma arising in adenomatous polyps and who underwent a colorectal resection thereafter, in order to determine which endoscopic and histological features correlated best with a curative treatment by polypectomy. When the group of "non-curative polypectomies", (carcinoma in the surgical specimen: 34 patients) was compared to the group of "curative polypectomies" (carcinoma in the surgical specimen: 31 patients), there was no significant difference in the number of pedunculated or sessile polyps but a polyp's size exceeding 30 mm was significantly more frequent in the group of "non-curative polypectomies" (P less than 0.005) as well as a tubulo-villous or villous histological type (P less than 0.001) and presence of vascular neoplastic invasion (P less than 0.01). In conclusion, a surgical resection after endoscopic polypectomy of a polyp containing an invasive carcinoma is necessary for a polyp's size exceeding 30 mm, for a villous or tubulo-villous type and in the presence of vascular neoplastic invasion in the pathological analysis of the removed polyp.

The interest of morphologic investigations in the diagnosis, the prognosis and the treatment of acute pancreatitis was analyzed in a series of 120 patients. The systematic endoscopy of the biliary tract yields a distinction between the biliary and the non-biliary sources of pancreatitis and can be followed immediately by an endoscopic sphincterotomy. Th morphological study of the bilio-pancreatic area can complete the prognostic indexes defined by the clinical and biological data, document the extension of the intra- and extrapancreatic necrosis and precise the indication and the choice of a surgical treatment.

In order to evaluate the operative possibilities in patients with obstructive carcinoma of the biliary tract a precise diagnosis of local extent of the tumor and metastasis is essential (cholangiography, US, CTscan). The treatment is preferably surgical whether the tumor be resectable or not. However some patients who, for any reason, are not surgical candidates can be helped by new endoscopic intubation techniques. Medical and surgical consultation is essential to set the criteria for the best treatment modality in all patients with this disease, especially those who are not surgical candidates.

We retrospectively studied a series of 70 patients admitted between 1977 and 1982 with an acute perforated ulcer. As compared to available data our patient's population is characterized by elevated mean age and by important delay between onset of symptoms and admission. Clinical diagnosis supported by plain X-rays and laboratory was confirmed in 91%. In one patient only, treatment was purely conservative; nine vagotomies, four gastrectomies and fifty-six suture plication were performed. Hospital stage was short (mean: 13,5 days) despite 37% morbidity. Mortality (10%) was close correlated with age and delay between onset of symptoms and treatment.

Between October 1, 1977 and June 30, 1983, 139 G.I. tract operations were performed in patients over 80 years-old. 45,3% were post-operatively admitted to the I.C.U.; the criteria for admission were emergency surgical interventions, the type and duration of the operation. The operative mortality was 15,8%. Contributory factors were the type of the intervention, its curative nature and the necessity for post-operative reanimation. The urgent nature of the intervention as well as the histology of the lesion had no bearing on the mortality. Local complications were noted in 34,5% of the cases and were mainly superficial and deep wound infections. General complications, mainly involving the cardio-pulmonary and urinary tract systems, occurred in 68,3% of the cases. Morbidity was mainly associated with the timing of the intervention.

Labetalol, an alpha and beta adrenergic blocking drug, was used during anesthesia for removal of a very large pheochromocytoma which was predominantly epinephrine secreting. The 70-year-old female patient suffered from angina pectoris and chronic bronchitis. A preoperative treatment including an alpha-adrenolytic drug was administered but beta-adrenergic blockers were avoided because of the risk of cardiac decompensation and bronchoconstriction. During the operation, hypertensive peaks were easily controlled by bolus injections of labetalol 20 mg. The removal of the tumor was followed by a transient moderate hypotension. Heart rate remained stable throughout the operation. No hemodynamic problems occurred during the postoperative period. With regard to this case, a summary of the literature concerning the properties of labetalol is presented.