Bernardo Franssen

Differences in surgical outcomes between hepatitis B- and hepatitis C-related hepatocellular carcinoma: a retrospective analysis of a single North American center.

Objective:Compare surgical outcomes for hepatitis B virus (HBV)-hepatocellular carcinoma (HCC) versus hepatitis C virus (HCV)-hepatocellular carcinoma (HCC). Background:HCC is the second leading cause of death from cancer worldwide and is associated with hepatitis virus infection in 80% of cases. Methods:Between 1997 and 2011, 1008 patients with hepatitis B (HBV, n = 431) or hepatitis C (HCV, n = 577) underwent resection (n = 567) or transplantation (n = 441). Resection was indicated for Childs A patients with single HCC; transplantation was indicated for patients within Milan criteria. Univariate and multivariate analyses were performed as well as survival and recurrence analysis using log-rank test. Results:Based on uniform application of these criteria, resection: transplantation ratio was 3.6 for patients with HBV and 0.67 for patients with HCV. Resection: Patients with HBV had larger tumors and higher &agr;-fetoprotein but less satellites and macrovascular invasion; 68% of HBV versus 89% of HCV were cirrhotic. Survival was better (P < 0.001) and recurrence was lower (P = 0.009) for HBV. Independent predictors of death included HCV (P = 0.024), transfusion (P = 0.013), and HCC of greater than 5 cm (P = 0.013). Limiting analysis to patients with cirrhosis, survival with HBV remained superior (P = 0.020) but recurrence did not. Transplantation: Tumors were similar in HBV and HCV. Survival was better (P = 0.002) for HBV; recurrence was similar. Independent predictors of death were HCV (P < 0.001), poor differentiation (P = 0.049), vascular invasion (P = 0.002), and outside Milan (P = 0.032). Limiting analysis to patients within Milan, HBV survival remained better for both resection (P = 0.030) and transplantation (P = 0.002). Conclusions:Survival after both resection and transplantation for HCC was better in HBV- than in HCV-related HCC whereas recurrence was also lower for HBV-HCC in the resection group, these differences are influenced by both liver and tumor factors.

Transition from a low- to a high-volume centre for bile duct repair: changes in technique and improved outcome

BACKGROUND Improvements in bile duct injury repairs have been shown in centres with specialized surgeons. The aim of the present study was to demonstrate the temporal change in the pattern of referral, technical variation associated with repair and long-term outcome of bile duct injuries at a tertiary referral centre in Mexico City. METHODS A retrospective case note review was performed. Patients were divided into two groups: group I (GI) 1990 to 2004 and group II (GII) 2005-2008, and appropriate statistical analysis undertaken. RESULTS Over a 20-year period, 312 patients with iatrogenic bile duct injuries required surgical treatment (GI = 169, GII = 140 patients). All injuries were reconstructed using a Roux-en-Y hepaticojejunostomy. The proportion of patients who had undergone a laparoscopic cholecystectomy increased from 24% to 36% (P = 0.017) over the two time periods. In the second time period there was an increase in segment IV and V partial resections (P = 0.020), a reduction in the use of transanastomotic stents (42% to 2%, P = 0.001) and an increase in the proportion of patients requiring a neoconfluence (2% to 11%, P = 0.003). In the second time period, the number of patients requiring a hepatectomy during repair (2% to 1%, P = 0.001), a portoenterostomy (16% to 9%, P = 0.060) or a double-barrel hepatico-jejunostomy (5% to 1%, P = 0.045) significantly decreased. During follow-up, patients in the second time period had a reduction in the incidence of post-operative cholangitis (11% to 6%, P = 0.310) and the frequency of post-operative anastomotic stenoses (13% to 5%, P = 0.010). Mortality remained low throughout the series but was absent in the second group. CONCLUSIONS Changes in technique and growing experience of the multidisciplinary team improved operative and long-term results of bile duct injury repair.

Outcomes for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the elderly.

BACKGROUND Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) has gained acceptance in the treatment of peritoneal carcinomatosis (PC) with reported morbidity and mortality rates of 27-56% and 0-11% respectively. The safety and outcome of such major operation in the elderly remains unclear. We report our experience at a high volume tertiary center. METHOD A total of 170 consecutive patients underwent CRS-HIPEC for peritoneal carcinomatosis between March 2007 and July 2012. Mitomycin C (88.8%) was administered intraperitoneally at 42 °C for 90 min. Patients were categorized into two groups according to the age at the time of surgery: Group 1 (≤65 years-old) and Group 2 (>65 years-old). Differences between the groups were analyzed. Univariate and multivariate analyses were performed to identify variables associated with major morbidity. RESULTS Of the 170 patients, 35 were older than 65 years. The two most common tumor sites were colorectal and appendiceal cancer. The perioperative morbidity and mortality rates in the elderly were 18.8% and 8.6% respectively. Gender, tumor type, estimated blood loss >400 mL, intraoperative blood transfusion, operative time >6 h, bowel anastomosis, intraoperative PCI >16, and extent of cytoreduction (Δ PCI) were not associated with major morbidity in the older group (p > 0.05). At a median follow-up of 15.7 months (0.2-53.5 months), recurrence rate for colorectal/appendiceal PC at 1 year was 48.0% in Group 1 and 44.3% in Group 2 (p = NS). Median survival for the colorectal/appendiceal carcinomatosis patients in Group 1 (n = 81) was 29.79 (SE 4.7) months and in Group 2 (n = 20) was 21.2 (SE 3.0) months, (p = 0.06, NS). CONCLUSION CRS-HIPEC procedures for peritoneal carcinomatosis in the elderly demonstrate comparable perioperative outcome in well-selected patients. Optimal cytoreduction was achieved in the majority of cases and survival was not significantly different from that of the younger group.

Outcomes following resection of intrahepatic cholangiocarcinoma

OBJECTIVES The aim of this analysis was to examine prognostic features and outcomes in patients undergoing resection for intrahepatic cholangiocarcinoma (ICC). METHODS A retrospective chart review was performed in all patients who underwent R0 or R1 resection for primary ICC between 1995 and 2011. Clinical data were abstracted and statistical analyses were conducted in the standard fashion. RESULTS A total of 82 patients underwent curative hepatectomy for primary ICC; 51 patients in this cohort developed recurrence. The median follow-up of survivors was 27 months (range: 1-116 months). Recurrences were intrahepatic (65%), associated with multiple tumours (54%) and occurred during the first 2 years after hepatectomy (86%). The main factor associated with recurrence after resection was the presence of satellite lesions. Overall 5-year disease-free survival after primary resection was 16%. Factors associated with poor survival were transfusion and perineural invasion. Treatment of recurrence was undertaken in 89% of patients and repeat surgical resection was performed in 15 patients. The 3-year survival rate after recurrence was 25%. Prolonged survival after recurrence was associated with a solitary tumour recurrence. CONCLUSIONS Despite curative resection of ICC, recurrence can be expected to occur in 79% of patients at 5 years. Predictors of survival and recurrence after resection vary in the literature. In patients with recurrence, selection of the optimal treatment remains challenging.

Actual 10-year survival following hepatectomy for hepatocellular carcinoma

OBJECTIVES This study was conducted to compare 10-year survivors with patients who survived <10 years in a large Western series of patients submitted to hepatectomy for hepatocellular carcinoma (HCC). METHODS A retrospective review of a series of hepatic resections conducted in a referral centre for HCC between January 1987 and October 2002 was conducted. RESULTS A total of 176 patients were analysed. Twenty-eight patients survived ≥ 10 years (Group A) and were compared with the 148 patients who did not (Group B). Group A had smaller tumours (5.7 cm versus 8.2 cm; P = 0.001) and a lower incidence of microvascular invasion (18.5% versus 37.1%; P = 0.004). Recurrence did not differ significantly (Group A 18/28, 64.3% versus Group B 94/148, 63.5%). Median time to recurrence was longer in Group A (70 months versus 15 months; P < 0.0001), and more patients in Group A were able to undergo curative treatment for recurrence (88.8% versus 40.4%; P < 0.0001). Multivariate analysis showed that lack of vascular invasion (P = 0.020), absence of perioperative transfusion (P = 0.014), and recurrence at >2 years after primary resection (P = 0.045) were significantly associated with 10-year survival. CONCLUSIONS Ten-year survival after liver resection for HCC can be expected in approximately 15% of patients. Recurrence does not preclude longterm survival. Recurrence at >2 years after resection, absence of vascular invasion, and absence of perioperative transfusion are independently associated with 10-year survival.

Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy in patients with peritoneal hepatocellular carcinoma

The benefit of Sorafenib is not well described in patients with peritoneal hepatocellular carcinoma (HCC). Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown favorable outcomes in certain malignancies, their role in peritoneal HCC remains unknown. We present a series of patients with peritoneal HCC treated with CRS +/− HIPEC and evaluate their clinicopathologic characteristics and outcomes.