F. Cauchy

Surgical treatment of hepatocellular carcinoma associated with the metabolic syndrome

The incidence of metabolic syndrome‐associated hepatocellular carcinoma (MS‐HCC) is increasing. However, the results following liver resection in this context have not been described in detail.

Risk factors and consequences of conversion in laparoscopic major liver resection.

Although recent reports have suggested potential benefits of the laparoscopic approach in patients requiring major hepatectomy, it remains unclear whether conversion to open surgery could offset these advantages. This study aimed to determine the risk factors for and postoperative consequences of conversion in patients undergoing laparoscopic major hepatectomy (LMH).

Selective Policy of No Drain after Pancreaticoduodenectomy Is a Valid Option in Patients at Low Risk of Pancreatic Fistula: A Case-Control Analysis

BackgroundAbdominal drainage is routinely performed after pancreaticoduodenectomy (PD), but this policy has recently been challenged. The aim of the present study was to assess whether abdominal drainage could be omitted after PD in patients at low risk of pancreatic fistula (PF).MethodsFrom 2009 to 2011, 27 consecutive patients underwent PD without abdominal drainage. Their preoperative characteristics and postoperative outcomes were compared to those of 27 matched patients undergoing PD with prophylactic drainage. Patients were matched 1:1 in terms of demographic data, preoperative weight loss, preoperative biliary drainage, surgical indication, and main risk factors of PF (pancreatic texture, main duct size, and body mass index).ResultsOverall morbidity rates (no drainage, 56xa0% vs. drainage, 70xa0%; pxa0<xa00.4) and operative mortality (1 patient in each group) were similar in both groups. The two groups did not differ significantly in terms of delayed gastric emptying (15 vs. 11xa0%; pxa0=xa00.68), and chylous ascites (4 vs. 15xa0%; pxa0=xa00.35). Radiological or surgical interventions for surgical complications were required in 2 patients (1 in each group). Pancreatic fistula rate (0 vs. 22xa0%; pxa0=xa00.009) and hospital stay (10 vs. 15xa0days; pxa0=xa00.004) were significantly reduced in the no drainage group as compared to the drainage group. The hospital readmission rate was similar in the two groups (no drainage, 3.7 vs. 0xa0%; pxa0=xa00.31).ConclusionsThis study suggests that abdominal drainage should not be considered routinely after PD in patients at low risk of PF. A no drain policy may reduce hospital stay after PD.

Colorectal Liver Metastases Growth in the Embolized and Non-Embolized Liver After Portal Vein Embolization: Influence of Initial Response to Induction Chemotherapy

PurposeTo compare tumor progression in both embolized and non-embolized liver lobes after portal vein embolization (PVE) in patients with bilobar colorectal liver metastases (CLM), according to the initial response to induction chemotherapy.MethodsFrom 2002 to 2012, a total of 42 consecutive patients with bilobar CLM initially treated using induction chemotherapy underwent right PVE to achieve adequate future liver remnant volume. Tumoral and liver parenchyma volumes, as well as their volume variations, were measured on computed tomography before and after PVE in both embolized and non-embolized. Patients were classified as fast (≤6xa0cycles of induction chemotherapy) and slow (>6xa0cycles) responders.ResultsOverall, 432 metastases were analyzed in 42 patients. Patients were slow responders in 29 (69xa0%) cases. Tumoral volume increased in 29 (69xa0%) cases in the embolized liver (+48xa0%; pxa0<xa00.0001), and in 28 (66xa0%) cases in the non-embolized liver (+31xa0%; pxa0<xa00.0001). Fast responders had a tumoral volume decrease in both embolized (−4xa0%) and non-embolized (−9xa0%) lobes. On the opposite side, slow responders had tumoral volume increase in both embolized (+79xa0%) and non-embolized (+32xa0%) lobes. On multivariate analysis, a ‘slow’ response to induction chemotherapy was the only factor associated with tumoral progression in both embolized (pxa0=xa00.0012) and non-embolized (pxa0=xa00.001) lobes.ConclusionTumor growth after PVE is observed in both embolized and non-embolized liver lobes in most patients but is significantly associated with slow response to induction chemotherapy.

Routine Pedicular Lymphadenectomy for Colorectal Liver Metastases

Even though the impact of extendedLNdissectiononsurvivalremainsunclearinhilarandgall-bladder cholangiocarcinoma, the finding that long-termsurvivalisachievableinpatientswithpara-aorticordistantmetastasis disease as well as the necessity to improve riskstratification led several authors to perform an aggressivesurgical procedure with extended LN dissections.

Preoperative tumour biopsy does not affect the oncologic course of patients with transplantable HCC

BACKGROUND & AIMSnPreoperative fine-needle aspiration biopsy (PFNAB) allows obtaining reliable hepatocellular carcinoma (HCC) diagnosis before liver transplantation (LT) in doubtful situations, but may result in higher recurrence rates following LT. This study aimed to evaluate whether PFNAB actually jeopardized the outcome of patients with transplantable HCC.nnnMETHODSnFrom 2002 to 2012, among 309 HCC patients listed for LT, 80 (26%) underwent PFNAB (PFNAB+). Their characteristics, modalities of recurrence, and survivals were retrospectively compared to those of the 229 (74%) patients without PFNAB (PFNAB-).nnnRESULTSnThe two groups (PFNAB+ vs. PFNAB-) were similar in terms of demography, rates of lesions within the Milan criteria (81% vs. 79%, p=0.676), and duration on the waiting list (7.0 vs. 6.9 months, p=0.891). Dropout following tumour progression was similar between both groups (6% vs. 11%, p=0.424). Among the 278 (90%) transplanted patients, pathological analysis revealed that 11 (4%) patients had non-HCC lesions including 10 in PFNAB- patients. Median follow-up was 34 months (12-135) and recurrence after LT was observed in 25 (9%) patients with no difference between both groups (9.3% vs. 8.9%, p=0.904). Parietal recurrence was observed in one PFNAB+ patient and in 2 PFNAB- patients after radiofrequency ablation (p=0.797). On an intention to treat basis, 1-, 3-, and 5-year overall survivals (89%, 69%, and 60% vs. 85%, 67%, and 61%, p=0.601) were not significantly different between PFNAB+ and PFNAB- patients.nnnCONCLUSIONSnThis study supports that preoperative tumour biopsy does not negatively influence the oncologic course of HCC patients eligible for LT. Hence, there is no argument to restrict biopsy in doubtful situations.

Liver resection for HCC: patient's selection and controversial scenarios.

Liver resection is a valuable curative option for patients with hepatocellular carcinoma (HCC). Yet, the balance between the operative risk following hepatectomy for HCC occurring on chronic liver disease and the oncologic prognosis of advanced lesions have led treatment recommendations to limiting the place of liver resection to selected patients with preserved liver function harbouring early-stage tumours. However, better understanding of the natural history of both tumour and underlying liver disease, sophisticated assessment of the liver function, improvements in the preoperative management of the patients with the use of liver volume modulation, refinements in surgical technique including anatomic resection and laparoscopic approach along with tailored management of recurrences have led expert centres to better define and extend the indications for liver resection. In this setting, the reported favourable operative results and long-term outcomes following resection of HCC in a number of controversial scenarios support that current guidelines could be refined.

Lemmel's syndrome as a rare cause of obstructive jaundice.

Obstructive jaundice is a frequent symptom most frequently resulting from choledocolithiasis or pancreatico-biliary and periampullary tumors. If duodenal diverticula are frequently asymptomatic, they can occasionally present with obstructive jaundice in the absence of lithiasis or another obstructing lesion such as a tumor in a presentation called Lemmels syndrome. We herein present a 70-year-old male with obstructive jaundice secondary to a periampullary duodenal diverticulum associated with hepatic abscess. Endoscopic sphincterotomy associated with percutaneous abscess drainage released patient from all symptoms. Lemmels syndrome as a rare cause of obstructive jaundice should be known in order to avoid mismanagement and therapeutic delay.

Resection, transplantation and local regional therapies for liver adenomas.

Hepatocellular adenoma (HCA) is a rare benign liver-cell neoplasm, occurring predominantly in young obese women using oral contraceptives. HCA is a heterogeneous disease, which includes four subtypes (including unclassified) associated with various risks of haemorrhagic complications and malignant transformation. Magnetic resonance imaging is the modality of choice for both diagnosis and subtype characterization of HCA whereas percutaneous biopsy has only limited impact on the therapeutic strategy. In men HCA should be always resected while in women surgery should only be considered for lesions ≥5 cm and after cessation of hormonal therapy. Women with single or multiple HCAs <5 cm may be followed with regular MRI imaging since the vast majority of HCA remains stable or decreases in size. Pregnancy should not be discouraged provided close sonographic surveillance is undertaken.

Local venous thrombotic risk of an expanding haemostatic agent used during liver resection.

BackgroundFor patients undergoing liver resection that leaves an empty intraparenchymal cavity, traditional topical agents might be inadequate to achieve additional hemostasis. A new hemostatic expanding topical foam (BioFoam®) has been designed to provide a mechanical seal. The objective of this study was to report our preliminary results regarding the safety and the efficacy using this foam.MethodsBetween 2009 and 2011, BioFoam® was used to fill a three-dimensional defect following liver resection in 14 patients. The operative results and postoperative course of these patients were compared to those of 14 matched controls who underwent liver resection but did not receive BioFoam®.ResultsThe two groups were similar in terms of demographics, indications for liver resection, type of surgical procedure, and type and duration of clamping. BioFoam® patients experienced significantly less operative blood loss (275xa0vs. 630xa0ml, pxa0=xa00.032) but similar operative transfusion rates (28.6 vs. 35.7xa0%, pxa0=xa00.686) compared to no-BioFoam® patients. The postoperative mortality was nil and no patient developed postoperative hemorrhage. While the two groups shared similar overall (64.3 vs. 57.1xa0%, pxa0=xa00.599) and major (28.6 vs. 14.3xa0%, pxa0=xa00.357) complications rates, BioFoam® patients experienced significantly higher major vascular thrombosis compared to no-BioFoam® patients (29 vs. 0xa0%, pxa0=xa00.04). In the BioFoam® group, major vascular thrombosis was associated with exposure of the vessel along the transection plane.ConclusionWhile the clinical benefit of BioFoam® in high-risk liver resections leaving a deep parenchymal defect remains to be proven, the associated risk of vascular thrombosis should preclude its use in contact with major veins.