[Portal vein embolization prior to liver surgery]. / Portal vene-embolisering før leverkirurgi.

Portal vein embolization is performed with the intention to occlude the portal veins to liver segments with malignancies and direct the portal flow to the healthy part (usually the left lobe) of the liver. Thus, hyperperfusion through the non-embolized part of the liver will create hyperplasia and hyperfunction, which allow extensive liverresection at a later stage in patients where it otherwise would have been contradictory to operate because of too small volume of the residual liver.

Potential impact of adding endoscopic ultrasound to standard imaging procedures in the preoperative assessment of resectability in patients with liver tumors.

OBJECTIVE: The value of endoscopic ultrasonography (EUS) in patients with liver diseases is limitedly described. The aim of this study was to evaluate the potential impact of adding EUS to standard imaging procedures in the evaluation of resectability in patients with liver tumors. MATERIAL AND METHODS: Patients who, based on the findings of CT and/or MRI, had been referred for curative resection of liver tumours were studied. Each patient underwent EUS before the final assessment of resectability, which was done by laparoscopic ultrasound or laparotomy. RESULTS: Sixty-four patients were included. Intended curative resection was performed in 19 (30%) patients. Thirty-five (55%) patients were considered to have non-curative malignant disease. In 10 (15%) patients, the tumor was judged to be benign and surgery was not performed. There were no complications related to EUS. The sensitivity, specificity, positive predictive value, and negative predictive value of EUS regarding prediction of non-resectability were 0.24, 0.94, 0.80 and 0.56 (tumor in right lobe), 0.50, 1.0, 1.0 and 0.75 (tumor in left lobe), and 0.60, 0.67, 0.86 and 0.33 (tumors in both lobes), respectively. Sixteen patients (25%) would have had changed their further management, if decision regarding non-resectability had been taken after EUS. DISCUSSION: Addition of EUS to a standard imaging set-up based on CT and/or MRI would have changed the management in 25% of the patients otherwise scheduled for resection of suspected liver tumors.

Combined pretherapeutic endoscopic and laparoscopic ultrasonography may predict survival of patients with upper gastrointestinal tract cancer.

BACKGROUND: The combination of endoscopic and laparoscopic ultrasonography (EUS-LUS) is accurate for resectability assessment of patients with upper gastrointestinal cancer (UGIC). But neither the ability of EUS/LUS to predict long-term prognosis nor the potential impact on patient survival using this selection strategy has been investigated. This prospective, single-center study evaluated whether pretherapeutic EUS-LUS stratification related to the prognosis in UGIC patients and whether patient selection by this strategy provided a prognostic outcome comparable with survival data from the literature. METHODS: Each patient had a pretherapeutic tumor node metastasis (TNM) stage and a resectability assessment assigned based on EUS-LUS findings. Survival curves were constructed and compared for each of the EUS-LUS TNM stage and resectability groups at the end of the observation period. Finally, the R0 resection rate, median, and 5-year survival rates were compared with the literature. RESULTS: This study enrolled 936 consecutive patients with esophageal (n = 256), gastric (n = 273), or pancreatic (n = 407) cancer. A statistically significant survival difference (p < 0.01) between the different TNM stages and resectability groups predicted by EUS-LUS was observed regardless of the cancer type. The poor prognosis for the patients with irresectable or disseminated UGIC was accurately predicted by EUS and LUS. The R0 resection rate as well as the median and 5-year survival rates were comparable with data from the literature. CONCLUSION: The pretherapeutic EUS-LUS patient stratification related significantly to the final prognosis for UGIC patients. An EUS-LUS-based patient selection strategy seemed to provide a prognostic outcome similar to data from computed tomography (CT)-based populations.

[Surgical treatment for locally advanced pancreatic cancer]. / Kirurgisk behandling ved lokalavanceret pancreascancer.

Treatment of patients with locally advanced pancreatic cancer remains a challenge, and the exact role of surgery with vascular resection remains unclear. Several studies on selected patient populations have addressed the problem, but with varying results. Although venous resection may be performed without increased morbidity and mortality, the majority of studies found no improved long-term survival when compared to oncological treatment.

[Prognosis following curative resection of the upper gastrointestinal tract cancer]. / Prognosen efter kurativ resektion af øvre gastrointestinal cancer.

INTRODUCTION: Cancer in the upper gastrointestinal tract has a poor prognosis and the best results are obtained by the few resectable patients. Earlier studies indicated that Danish survival might be inferior to that of other Scandinavian countries. The aim of this study was to evaluate the long-term survival after curative resections for these patients. MATERIAL AND METHODS: All patients referred for treatment of cancer of the oesophagus, stomach or pancreas were prospectively included. Data were registered with regard to pre-therapeutic examination and operative results. Deceased patients were found by comparison with the Danish Central Personal Register in January 2007. RESULTS: A total of 398 patients were included, of whom 164 were found to be possibly resectable. In total 118 (30%) patients underwent complete surgical resection. The median survival period for patients with oesophageal cancer, stomach cancer and pancreatic cancer was: 22.7 months (18.7-39.4), above 36 months and 31.4 months (19.2-) respectively. The observed 3-year survival was 40% (26-53), 56% (38-71) and 47% (31-62). The estimated 5-year survival was 35% (22-48), 56% (39-72), 43% (27-59). CONCLUSION: The observed long-term survival was comparable to international results. However, only one third of the patients were eligible for complete surgical resection. It is therefore important to establish a close cooperation between surgeons and oncologist to improve the overall survival for this group of patients.

[Glucagonoma syndrome without diabetes mellitus]. / Glukagonomsyndrom uden diabetes mellitus.

A patient developed depression, weight loss, ulcers and a migrating, denuded erythematous skin area. Punch biopsy revealed necrolytic migrating erythema. Computerised tomography and endoscopic ultrasound showed a solid tumour of the pancreas. A blood sample showed an increased level of glucagon without diabetes. Glucagonoma syndrome is characterized by glucagon overproduction, diabetes, depression, deep venous thrombosis and necrolytic migrating erythema. Glucagonoma is frequently diagnosed late which increases the risk of metastases. It is important not to rule out glucagonoma in patients with a relevant clinical picture but without diabetes.

[Endoscopic ultrasonography in patients suspected of neuroendocrine tumours]. / Endoskopisk ultralydskanning af patienter, hos hvem der er mistanke om neuroendokrine tumorer.

BACKGROUND: Endoscopic ultrasonography (EUS) is a valuable diagnostic tool for evaluating pathologies in or in relation to the upper gastrointestinal tract. The aim of this study was to evaluate the diagnostic yield of EUS in patients suspected of neuroendocrine tumours (NETs). MATERIALS AND METHODS: Retrospective analysis of data from the department's local EUS database and from hospital records. RESULTS: From November 2001 to December 2006, 21 patients were referred for EUS due to suspected neuroendocrine tumour. 17 patients were females and 4 were males. The median age was 48 years (range 14-93 years). 13 patients had symptoms (hypoglycaemia) suggesting that an insulinoma could be present. The remaining 8 patients had different kinds of symptoms including patients whose tumour was found by chance by another imaging modality. In 8 patients, EUS did not show any pathology. At follow-up, 6 of these were without any symptoms. One patient had died and one patient had subsequent surgery for intestinal obstruction due to a neuroendocrine carcinoma in the ileum and liver metastases. EUS revealed a mass lesion in 13 patients. 7 of these have had a CT scan which showed normal findings in 4. External ultrasound had been performed in 8 of the 13 patients, and showed normal findings in 4 out of the 8. All 13 patients with mass lesions had subsequent surgery showing different kinds of NETs in 11 patients, adenocarcinoma of the pancreas in one patient, and normal findings in one case. CONCLUSION: EUS may detect NETs which have not being visualised by other imaging modalities. EUS should be performed early in the diagnostic work up if a NET is suspected.

[Synchronous resection of colorectal cancer and liver metastasis]. / Samtidig operation for tarmkraeft og levermetastaser.

Twenty percent of colorectal cancer patients present disease in both bowel and liver. Traditionally, bowel cancer was resected and patients then re-staged for liver resection. This brief review presents literature to evaluate the support for either synchronous or staged operation. No randomised controlled studies have been published, but recently published case control trials show that synchronous resection can be performed with low morbidity and mortality. The question of whether the synchronous procedure is better than the staged operation is a non-solved matter in literature.

[Treatment of unresectable locally advanced pancreatic cancer with combined radiotherapy and chemotherapy]. / Kombineret strålebehandling og kemoterapi til patienter med ikkeresektabel lokalavanceret pancreascancer.

INTRODUCTION: Only 10-20% of patients with pancreatic cancer are offered operation with curative intent. If this is not possible, treatment with pre-operative radiotherapy in combination with chemotherapy offers the opportunity to reduce tumor size in patients with locally advanced disease, and possibly resection with curative intent afterwards. This treatment has been offered for the last three years at the Department of Oncology, Odense University Hospital. In the following we present our results. MATERIALS AND METHODS: A total of 26 patients with locally advanced unresectable pancreatic cancer were offered a combination of radiotherapy and chemotherapy. 4-6 weeks after treatment the patients were evaluated for resection. RESULTS: Of the 26 patients 24 completed planned treatment. Eight patients were subsequently assessed resectable. One patient refused surgery; the other 7 patients had a R0-resection. Median survival for the whole group is 12 months. Six of the patients who went through surgery are without signs of recurrent disease after median 16 months, one patient died with recurrent disease after 37 months. CONCLUSION: These results are similar to results from other countries. Therefore patients with locally advanced unresectable pancreatic cancer should be offered radiotherapy in combination with chemotherapy. Evaluation for surgery should be carried out 4-6 weeks after end of treatment. This strategy offers the opportunity for R0-recection and consequently cure.

[Gastro Intestinal Stromal Tumor--clinical and pathological presentation]. / Gastrointestinal stromatumor--klinisk og patologisk praesentation.

INTRODUCTION: Gastrointestinal stromal tumor (GIST) is a rare mesenchymal tumor identified by a positive immunostaining (KIT tyrosine kinase). Surgical resection is the primary treatment, but non-resectable and recurrent disease may be treated by specific tyrosine kinase inhibitors. This study evaluates the clinical and pathological presentation of a Danish GIST population. MATERIALS AND METHODS: Retrospective evaluation of patients diagnosed, treated and/or followed under the GIST diagnosis at the Department of Surgery, Odense University Hospital, during the period from January 1995 to September 2006. RESULTS: 41 patients with GIST were identified (25 males, 16 females, median age 62 years). The predominant symptoms leading to the diagnosis were upper gastrointestinal bleeding and abdominal pain. The majority of tumors were located in the stomach (63%) or in the small intestine (22%). 95% of the patients had a complete surgical resection, whereas resection was impossible in 2 patients. Approximately (2)/3 of the patients had a low or medium risk of developing metastases according to tumor size and number of mitoses. 1 in 4 patients was treated with a tyrosine kinase inhibitor during the course of the disease. CONCLUSION: GIST is a rare mesenchymal tumor but due to immunostaining methods the detection rate is increasing. The clinical and pathological presentation of this Danish GIST population is comparable to international data.

[Transgastric necrosectomy by open surgery in necrotising acute pancreatitis]. / Transgastrisk nekrosektomi ved nekrotiserende akut pankreatitis udført ved åben kirurgi.

INTRODUCTION: Conventional surgery for necrotising acute pancreatitis is often associated with high mortality and morbidity rates. The aim of this study was to describe the initial experience with a new and presumed lesser invasive surgical procedure. MATERIAL AND METHODS: The outcome of patients who underwent transgastric necrosectomy and subsequent marsupialisation due to necrotising pancreatitis was registered. RESULTS: Seven patients (five males, two females) with a median age of 47 years (range 32-62 years) had surgery. The reasons for pancreatitis were: gallstones (n = 4), idiopathic (n = 2) and alcohol (n = 1). The median time from onset of symptoms to surgery was 40 days (range 29-90 days). Four patients (57%) had an uneventful post-operative stay. Three patients (43%) had one or more complications requiring invasive therapy. Two of these patients needed repeated surgery. The median postoperative hospitalisation was 18 days (range 10-65 days). There was no post-operative mortality. At a three-month follow-up, one patient had exocrine pancreatic insufficiency, and one patient had both exocrine pancreatic insufficiency and diabetes mellitus. CONCLUSION: Transgastric necrosectomy seems to be associated with a low risk of complications for selected patients with necrotising acute pancreatitis. However, further experience with the procedure is needed in order to draw valid conclusions.