Christian Gouillat

Resection of hepatocellular carcinoma in cirrhotic patients : Longterm results of a prospective study

BACKGROUND Surgical resection of hepatocellular carcinoma in cirrhotic patients remains controversial because of a high reported recurrence rate. To assess the longterm results of resection, 37 patients included in a prospective study were followed for more than 5 years, with special interest in early detection of recurrence. STUDY DESIGN Resection was performed from 1986 to 1991 with the goal of sparing the functional liver parenchyma. The mean tumor diameter was 5.3 +/- 2.6 cm (range 2 to 11 cm). Nineteen patients had tumors smaller than 5 cm. No additional perioperative therapy was performed. RESULTS Evidence of intrahepatic recurrence was demonstrated in 26 of the 33 patients surviving the operation. Eight recurrences (31%) were diagnosed from the third to the fifth postoperative years. The recurrence-free survival rates at 1, 2, 3, 4, and 5 years were 68%, 40%, 26%, 13%, and 9%, respectively. Only 2 patients (7%) were alive and free of recurrence at 5 years. Some long survivals were observed after treatment of recurrence. The overall survival rates at 3 and 5 years were 35% and 24%, respectively. Tumor cell differentiation was the only significant prognostic factor for both recurrence and survival. Multifocal tumors were associated with a higher recurrence rate. Patients with good liver function had longer survivals that reached 38% in those with small solitary tumors. Study of the other dinicopathologic factors failed to demonstrate any prognostic value. CONCLUSIONS Only a few patients are alive and free of recurrence 5 years after resection. Some long survival can be observed after treatment. Assessment of prognostic factors remains difficult, but the best results of resection are obtained in patients with small solitary hepatocellular carcinoma function.

Adenocarcinoma in columnar-lined Barrett's esophagus: Analysis of 13 esophagectomies

From 1977 to 1982, 13 patients with adenocarcinoma arising in the distal esophagus lined by columnar epithelium underwent esophagectomy with detailed analysis of the pathologic specimen. In three patients, microinvasive carcinoma was detected before dysplasia occurred. In five patients, the ectopic mucosa was discontinuous, prolonged cranially by islands of columnar epithelium scattered in the squamous mucosa. Variable degrees of dysplasia were found in the columnar epithelium in seven specimens in areas of intestinal metaplasia. In four patients with high-grade dysplasia, several foci of intramucosal carcinoma were identified. They were scattered over the whole length of the ectopic mucosa. These data strongly suggest that adenocarcinoma develops from dysplasia, the real premalignant lesion. Careful periodic screening must be carried out in patients identified as having Barretts esophagus. Dysplasia may be detected and located by endoscopy with dye spraying with directed biopsies. Patients with high-grade dysplasia should undergo esophagectomy with resection of the whole ectopic mucosa because they are at high risk for development of carcinoma.

Achalasia-Like Disorder After Laparoscopic Adjustable Gastric Banding: a Reversible Side Effect?

Literature data concerning the effect of laparoscopic adjustable gastric banding (LAGB) on esophageal motility are conflicting. Achalasia-like disorder involving the absence of esophageal peristalsis and impaired esophago-gastric junction (EGJ) is probably under-estimated and can result in failure and band removal. The aim of our study was to focus on cases of achalasia-like disorder and study its evolution after band deflating or removal. LAGB patients with food intolerance and whose esophageal manometry confirmed dysmotility were selected from our database. Achalasia-like disorder was defined as the absence of esophageal peristalsis (< 20 % contraction waves) with impairment of EGJ relaxation. Manometric control was performed after removal or band deflating; functional results were assessed. Eleven patients among 20 (55 %) with esophageal motility disorders (EMD) fitted the manometric criteria of achalasia-like disorder with a mean EGJ resting pressure of 32.1 cmH2O and a EGJ relaxation pressure of 24.2. Nine patients out of 11 underwent band removal which resulted in the resolution of their symptoms. The other two underwent band deflation. Manometric control after band removal showed both a decrease in resting and relaxation EGJ pressures (mean of 9.5 and 6.5 cmH2O) and a recovery of wave contractions in 87.5 % of cases. Four patients underwent revision surgery due to weight regain with a successful outcome. Achalasia-like disorder is a manometric diagnosis and accounts for a significant part of symptomatic EMD after LAGB. It often results in band removal, allowing some reversibility of the disorders.

Results of Elective Nissen Fundoplication for Gastro-Oesophageal Reflux in Selected Patients

Eighty-one selected patients with documented gastro-oesophageal reflux were managed with standardized transabdominal Nissen fundoplication from 1973 to 1984 and regularly evaluated. None of the patien

Legal Claims in Bariatric Surgery

Dear Editor, Actually, bariatric surgery has grown spectacularly in recent years. In France, between 2002 and 2013, the number of procedures has tripled from 15,000 to 43,000 leaving in its wake litigation, the cost of which have tripled over 10 years [1]. It is unrealistic to underestimate this as it is apparent from a few figures. Bariatric surgery caused 129 deaths in 2013, and currently, it represents approximately 25% of all complaints from visceral surgery. It results in 1 request for an expert opinion on average every 2 years for each bariatric surgeon [2]. In France, the medical malpractice system was similar to that of the USA until 2002; patients could file medical malpractice suits in court, and either settle or proceed to trial. The legal rules made it difficult for patients to prevail in litigation against a physician. Changes instituted in 2002 introduced an out-of-court, no-fault system in which patients could bring claims before a regional government-appointed review board. The notion of a ‘medical accident without malpractice’ is intended for the occurrence, in the absence of any malpractice, of a medical risk, which is either totally unknown, or known but exceptionally rare. Furthermore, in France, the 2002 law relative to patients’ rights foresees the right to reparation through compensation from the national solidarity fund for medical accidents, iatrogenic disorders and nosocomial infections, in accordance with the recommendations of the French Reconciliation and Compensation Commissions (Commission de Conciliation et d’Indemnisation (CCI)) for medical accidents and nosocomial infections. The ability of patients to apply to the committees facilitates this approach as they do not need to identify which jurisdiction they come under. Very often the committee will instruct the necessary expert reports to establish any fault. Recourse to the law however remains open to the patient. There are therefore now two approaches open to the patient: a longer legal procedure (court referral with a judge) or on a faster and more amicable procedure through the commissions for faster settlement. After considering 59 expert dossiers, a large number of complaints following insertion of laparoscopic adjustable gastric band (LAGB) followed closely by Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG): All techniques combined, the most common complications were perforations (30 %), fistulae (27 %) and intestinal obstruction (14 %). Gastrointestinal obstructions (dysphagia, slip, prolapse stenosis and esophageal dilation) mostly followed insertion of a LAGB (66 %). Excessive tightening of the band was responsible for a case of gastric ischemia, an extremely rare event. Fistulae are seen with the RYGB or SG, usually as a result of dysunion of the anastomotic suture. It is not surprising to find a mortality rate of 22 %. Conversely, almost 70 % of complainants recovered completely (47 %) or only suffered minor lasting complications (22 %), * Lucile Tuchtan lucile.tuchtan@ap-hm.fr

Cystic Dilatation of the Common Bile Duct

The records of 13 adult patients operated on for a choledochal cyst were reviewed. The cyst was saccular in 6 patients and fusiform in 7. A fusiform enlargement of the main intrahepatic ducts was associated in 5 cases. In 5 patients the pancreatico-biliary ductal union occurred at a high position, forming an abnormally long common terminal duct. 11 patients underwent an excision of the cyst with Roux-en-Y hepaticojejunostomy. Microscopically, the wall of the cyst consisted of fibrous tissue usually devoid of epithelium and muscle layer. Recovery was uneventfull with good late results in most patients. A precise knowledge of its radiological features is necessary to recognize this anomaly and manage it adequately.