P975 DYNAMIC CHANGES OF THE INFLAMMATION BASED INDEX (IBI) AS A PREDICTOR OF MORTALITY FOLLOWING TRANS-ARTERIAL CHEMOEMBOLIZATION FOR HEPATOCELLULAR CARCINOMA D.J. Pinato, G. Karamanakos, A. Goyal, D. Adjogatse, A.B. Siegel, J.L. Weintraub, J. Stebbing, J.W. Jang, R. Sharma. Division of Experimental Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom; Hepatobiliary Oncology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, United States; Department of Oncology, Imperial College London, Hammersmith Hospital, London, United Kingdom; Internal Medicine, Catholic University of Korea Incheon St. Mary’s Hospital, Seoul, Korea, Republic of E-mail: david.pinato09@imperial.ac.uk Background and Aims: Transarterial chemoembolization (TACE) is a standard treatment for unresectable, intermediate stage

OBJECTIVE:To assess the morbidity and its main risk factors after major hepatic resection.DESIGN:Retrospective study of prospectively collected data.SETTING:University hospital, France.SUBJECTS:100 consecutive patients who underwent major hepatic resections, 1989-95.INTERVENTIONS:Major hepatic resection, defined as resection involving 3 or more segments according to Couinaud's classification, in all cases.MAIN OUTCOME MEASURES:All complications that affected outcome or prolonged hospital stay. Risk factors identified by univariate and multivariate analysis.RESULTS:45 patients developed at least 1 complication and 7 died. The most common complications were: pleural effusion (n = 21), hepatic failure (n = 12), and ascites (n = 9). Univariate analysis showed that the following variables were significantly related to the morbidity: age >55 years, American Society of Anesthesiologists (ASA) grade II or more, bilirubin >80 micromol/L, alkaline phosphatase activity more than double the reference range, malignant tumours, abnormal liver parenchyma, simultaneous surgical procedures, operative time >4 hours, and perioperative blood transfusion > or =600 ml. The extent of resection did not correlate with postoperative complications. Multivariate analysis showed that volume of blood transfusion > or =600 ml and simultaneous surgical procedures were the most important independent risk factors for complicated outcome.CONCLUSIONS:The morbidity associated with major hepatic resections remains high, and the main determinants of outcome are intraoperative surgeon-related factors.

Introduction. - The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue. Current knowledge and key points. - Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease: and secondly, in an acceptable risk taking manner. Major criterias for indication in the most common liver diseases can be summerized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 mu mol/L is generally required; c) apart from <<small>> hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications, d) acute liver failure requires early referral to a liver transplant center for potential emergency indication. Future prospects and projects. - In an organ shortage situation which is likely to perdue, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure. (C) 1998 Elsevier. Paris.

Introduction. — L’augmentation du nombre de transplantations hépatiques est limitée par l’insuffisance des ressources en donneurs. La nécessité impose donc un choix parmi les patients susceptibles de bénéficier de ce traitement — les cas plus graves? ou ceux qui ont les meilleures chances de guérir? — et une évaluation optimale du moment de la transplantation dans l’histoire de la maladie: ni trop tôt, ni trop tard.

Three cases of giant hemangioma of the liver associated with clinical and laboratory signs of inflammatory process, including low-grade fever, weight loss, abdominal pain, accelerated erythrocyte sedimentation rate, anemia, thrombocytosis, and increased fibrinogen level with normal white blood cell count are described. One patient presented with slight cholestatic jaundice because of tumor-related bile duct compression, but the other two patients had normal liver function tests, except for a slight increase in gammaglutamyl transferase. Clinical and laboratory abnormalities disappeared after surgical excision. Inflammatory manifestations have rarely been reported during giant liver hemangioma. Intratumoral inflammation necrosis or bleeding could explain the symptoms but histological signs of inflammation were not detected in two of three surgical specimens. The release of immune mediators by liver endothelial cells lining the hemangioma is an alternative explanation. The incidence of inflammatory process complicating giant hemangioma is probably underestimated because our three cases were observed within a span of only 3 years.

Recurrence rates after curative resection of colorectal adenocarcinoma remain steady at 50 per cent. Thirty per cent of the deaths are linked to locoregional recurrence. The aim of this study was to evaluate the results of resection for locoregional recurrence.

Acute gastric ischemia rarely occurs because of the rich vascular supply of the stomach and the vascular reserve of the intramural anastomosis.1 The first report of spontaneous gastric infarction was that of Cohen who, in 1951, reported three cases of complete and one case of partial gastric infarction from a series of 23,836 autopsies performed over 12 years.2 More recent studies have confirmed the difficulty in the diagnosis of gastric infarction and have revealed the association of digestive as well as diffuse arteriopathy which increase the gravity of this event.

INTRODUCTION:The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected, or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue.CURRENT KNOWLEDGE AND KEY POINTS:Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease; and secondly, in an acceptable risk taking manner. Major criteria for indication in the most common liver diseases can be summarized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred, is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 mumol/L is generally required; c) apart from "small" hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications; d) acute liver failure requires early referral to a liver transplant center for potential emergency indication.FUTURE PROSPECTS AND PROJECTS:In an organ shortage situation which is likely to perdure, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure.

Background/Aims: To evaluate the reliability of stapled esophagojejunostomy.Material and Methods: We studied a non-selected prospective series of 176 consecutive total gastrectomies (169 cancers, 7 benign pathologies).Results: Hand-sewn esophagojejunostomy was performed 5 times after failure of the stapled esophagojejunostomy. There were fourteen hospital deaths (8%), and 63 patients (36%) presented complications. There were 5 anastomotic leaks (2.8%) but non, were responsible for deaths. In these 5 cases, there had been an incident during construction of the esophagojejunostomy. Such an, incident was the only significant risk factor for an anastomotic leak: 17% after an incident and 0% in the absence of an incident (p<0.001). We observed no cases of anastomotic stricture.Conclusion: Stapled esophagojejunostomy is a reliable technique when, technical precautions are taken. It is easier to reproduce than hand-sewn esophagojejunostomy and has demonstrated low specific morbidity and no direct mortality.

The authors report the case of a man operated by coronary artery bypass graft using the right gastro-epiploic artery. Laparoscopic cholecystectomy had to be performed postoperatively because of cholecystitis. Surgeons must be aware of the possibility of coeliotomy in the context of coronary artery surgery: this is a small incision, the sternotomy incision is only slightly lengthened towards the epigastrium. A history of such surgery requires certain precautions during subsequent abdominal incisions, particularly laparoscopic, and during dissection of the porta hepatis.

Two new applications of the endo-GIA technique are presented for endoluminal intrarectal resection of benign or malignant tumors of the lower or middle part of the rectum, These procedures allow resection of sessile lesions with a large implantation base, Depending on the pathology and the type of implantation, resection can either be total or via the musculosa, Results have been good with this simple procedure which allows total tumor resection and an uneventful post-operative period.

Two new applications of the endo-GIA technique are presented for endoluminal intrarectal resection of benign or malignant tumors of the lower or middle part of the rectum. These procedures allow resection of sessile lesions with a large implantation base. Depending on the pathology and the type of implantation, resection can either be total or via the musculosa. Results have been good with this simple procedure which allows total tumor resection and an uneventful post-operative period.