Palliative gastrectomy in patients with stage IV gastric cancer--our recent experience.

BACKGROUND: Patients with metastatic gastric cancer are usually not good operative candidates. Recent improvements in surgical techniques allowed palliative gastric resection and other surgical procedures. METHOD: We have examined the place of palliative gastrectomy and its impact on survival in stage IV gastric cancer patients admitted in 2003-2008 period. RESULTS: From a total of 295 patients with gastric cancer, we found 140 patients with stage IV disease; 85 of them had no resection (45 received only chemotherapy) and 55 underwent palliative gastric resection with or without postoperative chemotherapy. Mean survival in non-operated patients with chemotherapy alone was 6.4 months, not significantly different to that of the patients with palliative surgery alone (8.9 months). The group with palliative surgery and adjuvant therapy had a significantly better mean survival (17.8 months). Mortality and morbidity rates associated with palliative surgery were 9% and 34.5%, respectively. CONCLUSIONS: These data suggest that palliative surgery associated with adjuvant chemotherapy can improve survival in patients with stage IV gastric cancer.

[Pyogenic liver abscesses]. / Abcesele hepatice piogene.

BACKGROUND: Pyogenic liver abscesses were a relative rare disease. In the last decades the management of the liver abscesses was changed due to the new imaging and surgical techniques. AIM: To evaluate the clinical features, imaging techniques and treatment of the liver abscesses. METHODS: We performed a retrospective study during the last twenty years (1987-2007). The patients were divided in two groups: group I treated during the period 1997-2007 and group II, 1987-1996. We compare the clinical features, biological tests, imaging techniques and the treatment. RESULTS: Of the 71 patients with liver abscesses, 39 (54.9%) were included in group I and 32 (45.1%) in group II. The male/female ratio was 49/22; liver abscesses were more frequent to the males, in group I (63.3%) and more frequent to the women, in group II (63.6%) (p = 0.035). The mean age was 47.49 +/- 2.09 years old (range 18-85) with no difference between the groups (p = 0.059). The symptoms were similar in the two groups. We noted, as associated disease: diabetes--16% (N = 12), liver cirrhosis--7% (N = 5), malignancies--4.2% (N = 3). White blood cells were higher than 10000/mm3 in 51 patients (71.83%); a severe anemia with hemoglobin levels less than 10 g/dL was found in 25 cases (35.21%). All cases were investigated by ultrasound exam, but CT scan was performed in only 25 cases (19.71%). The abscesses were situated into the right lobe in 53 cases (74.6%), into the left lobe in 13 cases (18.3%) and into the both lobes in 5 patients (7%). The etiology was diverse: 25.4% after hepatic hydatid cysts, 12.7% with biliary origin, 22.5% with hematogenous and phlebitis origin and 39.4% with unknown origin (cryptogenetic). Treatment of the liver abscesses was surgical, by open (87.3%) or laparoscopic approach (8.5%), and percutaneous (ultrasound guided punction)--2.8%. One case was medical treated (antibiotherapy). Bacteriological exam found aerobic germs in 45 patients (64.28%), anaerobic germs in 3 patients (4.28%); the pus was sterile in 22 patients (31.43%). The intraoperative mean dimension of the liver abscesses was 74.26 +/- 4.35 mm (range 30-160), similar with dimensions measured by echography 72.29 +/- 4.84 mm (range 12-179)--p < 10(-3). Intraoperative bleeding was noted in 29 patients (40.8%). Univariate analysis revealed as prognosis factors for intraoperative bleeding, diameter of the liver abscess (p < 10(-3)), dimension of the residual cavity (p < 10(-3)) and the pus volume (p < 10(-3)). The multivariate analysis, by logistic regression, revealed as prognosis factors for intraoperative bleeding, pus volume (p = 0.006) and hemoglobin level (p = 0.035). Postoperative morbidity was 43.7%. Univariate analysis and logistic regression revealed the pleural effusion as prognosis factors for postoperative complications (p = 0.046) and, respectively, intraoperative hemorrhage (p = 0.010) and splenomegaly (p = 0.007). Postoperative mortality rate was 2.81%. CONCLUSIONS: Pyogenic liver abscess is a challenging disease with high rate of postoperative morbidity. Most of the abscesses are unique and situated in the right lobe of the liver. The imaging techniques, especially ultrasound exam and CT-scan, are essential for the diagnosis and the treatment of liver abscesses. The treatment is usually surgical, by open or laparoscopic approach; in selected patients the percutaneous approach can be performed.