Hepatic Compartment Syndrome Following Percutaneous Cholecystostomy: A Case Report.

OBJECTIVE: To describe a case of hepatic subcapsular hematoma causing an acute Budd-Chiari-like syndrome, leading to hepatic compartment syndrome, which combines compression of intrahepatic vessels on CT, acute liver failure, and refractory shock. DESIGN: Case report. SETTING: Surgical ICU of a university teaching hospital. PATIENT: Single case: A 64-year-old man hospitalized for 1 month in the ICU after multiple complications following bypass surgery, under anticoagulation after a recent aortic valve replacement and without a medical history of hepatic disease, underwent a percutaneous cholecystostomy for acute calculous cholecystitis. Fifteen days later, he presented with acute anemia, abdominal tenderness, severe hepatic cytolysis, metabolic acidosis, and hemodynamic dysfunction. CT showed a voluminous subcapsular hematoma compressing the hepatic parenchyma, which appeared ischemic with a flattened right lobar portal vein and vena cava without any visible active bleeding. INTERVENTIONS: Arteriography and evacuation of the hematoma under ultrasound guidance (while managing hemodynamic dysfunction) were preferred to surgery given the patient's instability and surgical history. MEASUREMENTS AND MAIN RESULTS: Evidence of vessels and parenchymal compression with no source of bleeding was found despite removal of the cholecystostomy catheter. Two right sectorial inferior hepatic arteries were embolized. Hematoma was punctured to relieve pressure on hepatic parenchyma, retrieving 300 mL of blood. Unfortunately, liver failure worsened dramatically while patient developed refractory shock and died. CONCLUSIONS: Hepatic compartment syndrome must be suspected when acute liver failure occurs in patients with subcapsular hematoma. Only early management may avoid a fatal outcome or the need for an emergency liver transplantation.

Predictive factors of postoperative mortality after junctional and gastric adenocarcinoma resection.

IMPORTANCE: Postoperative mortality after junctional and gastric adenocarcinoma resection remains a significant issue. OBJECTIVE: To identify factors predictive of mortality within 30 days of junctional and gastric adenocarcinoma resection in a large national multicenter cohort. DESIGN: A retrospective study collecting data from a multicenter database of patients who underwent resection for junctional and gastric adenocarcinoma from January 1, 1997, through January 31, 2010. A stepwise logistic regression model was built to identify, by multivariate analysis, variables independently predictive of 30-day postoperative mortality (POM). SETTING: Nineteen university teaching hospitals in France. PARTICIPANTS: Two thousand six hundred seventy patients with available data. MAIN OUTCOME MEASURES: The primary end point was POM. Secondary end points included (1) late mortality (30-90 days after resection) and (2) postoperative morbidity. RESULTS: One thousand eight hundred ninety-six patients (71.01%) had gastric adenocarcinoma and 774 (28.99%) had junctional tumors. Neoadjuvant treatment was given to 655 patients (24.53%), and 114 patients (4.27%) died within 30 days of surgery. Postoperative mortality was higher in patients who experienced grades III and IV toxic effects during neoadjuvant treatment compared with those who did not (8.7% vs 2.9%, respectively; P = .007). Multivariate analysis revealed metastatic disease at diagnosis (odds ratio, 9.13 [95% CI, 3.29-25.35]; P < .001) and poor tolerance of neoadjuvant treatment (3.33 [1.25-8.85]; P = .02) as being independently predictive of POM. Centers performing at least 10 resections per year were found to be protective against POM (odds ratio, 0.29 [95% CI, 0.12-0.72]; P = .008). CONCLUSIONS AND RELEVANCE: This large national cohort study confirms that advanced disease heightens the risk of POM; centralization of junctional and gastric adenocarcinoma resection is warranted. The novel finding that grades III to IV toxic effects during neoadjuvant therapy increase POM has significant implications for decision making in this subgroup of patients. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01249859.

Palliative resection for advanced gastric and junctional adenocarcinoma: which patients will benefit from surgery?

BACKGROUND: Whereas palliative chemotherapy offers a median survival of approximately 10 months in advanced gastric and junctional adenocarcinoma (AGJA), the survival impact of primary tumor resection is controversial. Our purpose was to identify which AGJA patients benefit from palliative resection. METHODS: In 3,202 AGJA patients scheduled for surgery in 21 French centers between 1997 and 2010, prognostic factors were identified in palliative group and the impact of each combination of these factors on survival was studied. RESULTS: Surgery was defined as palliative due to solid organ metastasis (5.6 %), localized (4.6 %) or diffuse (2.3 %) peritoneal carcinomatosis (PC), or incomplete tumoral resection (12.8 %). Median survival of AGJA patients resected with a palliative intent (n = 677) was longer than in nonresected patients (n = 532; 11.9 vs. 8.5 months, P < 0.001). Multivariable analyses identified ASA score III-IV (P < 0.001) as a predictor of postoperative mortality and solid organ metastasis (P = 0.009), localized PC (P = 0.004), diffuse PC (P = 0.046), and signet ring cell histology (SRC; P = 0.02) as predictors of survival. Only ASA I-II patients with incomplete resection without metastasis or PC, one site solid organ metastasis without PC, or localized PC without SRC had a survival benefit after palliative surgery with median survivals from 12.0 to 18.3 months. Nonresected ASA I-II patients with same risk factors had median survivals from 3.5 to 8.8 months (P < 0.05 for each). CONCLUSIONS: In AGJA, patient and tumor-related factors should be used to select candidates for palliative surgery in association with chemotherapy.

The impact of perioperative chemotherapy on survival in patients with gastric signet ring cell adenocarcinoma: a multicenter comparative study.

OBJECTIVE: The aim of this retrospective study was to evaluate the survival impact of perioperative chemotherapy (PCT) in patients with gastric signet ring cell (SRC) adenocarcinoma. BACKGROUND: PCT is a standard treatment for advanced resectable gastric adenocarcinoma (GA). SRC has a worse prognosis compared to non-SRC and the chemosensitivity of SRC is uncertain. METHODS: Among 3010 patients registered in 19 French centers between January 1997 and January 2010, 1050 (34.9%) were diagnosed with SRC. Of those treated with curative intent (n = 924), 171 (18.5%) received PCT with surgery (PCT group), whereas 753 (81.5%) were treated with primary surgery (S group). PCT was based mainly on a fluorouracil-platinum doublet or triplet regimen. RESULTS: The groups were comparable regarding age, gender, American Society of Anesthesiologists (ASA) score, malnutrition, tumor location and cTNM stage. 60 patients did not undergo resection because of tumor progression (10) or metastases (50) found at operation. The R0 resection rates were 65.9% and 62.3% in the S and PCT groups, respectively (P = 0.308). Fewer patients received adjuvant chemotherapy in the S group than in the PCT group (35.2% vs. 66.5%, P < 0.001). At a median follow-up of 31.5 months, the median survival was shorter in the PCT group (12.8 vs. 14.0 months, P = 0.043). On multivariate analysis, PCT was found to be an independent predictor of poor survival (HR = 1.4, 95% CI 1.1-1.9, P = 0.042). CONCLUSIONS: PCT provides no survival benefit in patients with gastric SRC. Clinical Trial.gov record: ADCI001, Clinical Trial.gov identifier NCT01249859.