Cystic involvement of the roof of the main biliary convergence in adult patients with congenital bile duct cysts: a difficult surgical challenge.

BACKGROUND: Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care. METHODS: A retrospective multicenter study was conducted in 4 European surgical centers concerning their experience with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof of the MBC (defined as being BDC with MBC involvement subgroup). RESULTS: From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02). CONCLUSION: BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.

Skeletonizing en-bloc gastrectomy for adenocarcinoma in Caucasian patients.

BACKGROUND: The prognostic relevance of a Japanese-like lymphadenectomy for gastric adenocarcinoma is Caucasian patients is not well establishes. METHODS: Skeletonizing en-bloc gastrectomy (SEBG) (including removal of the stomach, excision of the potentially involved lymph nodes, and skeletonization of the main anatomic structures in the upper abdominal floor) was attempted in 216 consecutive patients with adenocarcinoma of the stomach. Gastrectomy was total in 143 patients, and subtotal in 72. One debilitated patient had a wedge resection of the gastric wall. RESULTS: SEBG was performed in 160 patients (74%), whereas 56 patients (26%) had a palliative gastrectomy (PG) without lymph node dissection. The feasibility rate of SEBG was influenced significantly ( P < 0.001) by the depth of wall penetration, so that it dropped from 97% in T1 tumors to 91%, 65%, and 17% in those classified T2, T3, and T4, respectively. The 5-year survival rate, including postoperative mortality (0.9%) was 48% for the whole series, 66% after SEBG, and 0% after PG. The 5-year survival rate after SEBG was related significantly to the lymph node involvement (N0, 75% vs N+, 54%; P = 0.008) and to its magnitude (N+, <5 metastatic lymph nodes, 62% versus N+, > or =5 metastatic lymph nodes, 39%; P = 0.018). Considering the fact that 9 patients died of an unrelated cause before the postoperative term of 5 years, the cancer-related survival rate 5 years after SEBG was 71% in the whole group of 160 patients. This survival rate was 82% in patients with normal lymph nodes, versus 56% in those with metastatic nodes ( P < 0.001). CONCLUSIONS: SEBG was feasible in three-quarters of a po-pulation of Caucasian patients operated on for gastric adenocarcinoma. SEBG provided a chance for a longterm favorable outcome in three-quarters of patients with normal lymph nodes and in more than half of those with metastatic lymph nodes. These results are similar to those achieved after radical gastrectomy in Japanese patients with gastric adenocarcinoma. The prognostic relevance of a Japanese-like lymphadenectomy for gastric adenocarcinoma in Caucasian patients is not well established.