Francis Navarro

Factors and consequences of conversion in laparoscopic sigmoidectomy for diverticular disease

The disadvantages of laparoscopic elective sigmoidectomy for diverticular disease include the risk of conversion to open operation and longer operative time. The aim of this study was to analyse the causes and consequences of conversion in 168 consecutive patients who underwent a laparoscopically assisted colectomy between January 1994 and June 2001.

Mycophenolate mofetil in combination with reduction of calcineurin inhibitors for chronic renal dysfunction after liver transplantation

The purpose of the study was to introduce mycophenolate mofetil (MMF) in liver transplant recipients with renal dysfunction to decrease calcineurin inhibitor (CNI) dosages without increasing rejection risk. In this prospective, multicenter, randomized study, chronic CNI‐related renal dysfunction was defined by an increase in serum creatinine with values >140 μmol/L and <300 μmol/L. Patients were randomized in 2 groups. Study group: combination of MMF (2 to 3 g/day) and reduced dose of CNI ≥50% of initial dose; control group: no MMF, but with the ability to reduce CNI doses, but not below 75% of initial dose. Fifty‐six patients were included, 27 in the study group and 29 in the control group. In the study group, there was a significant decrease in serum creatinine values, from 171.7 ± 24.2 μmol/L at day 0 to 143.4 ± 19 μmol/L at month 12 and a significant increase in creatinine clearance, from 42.6 ± 10.9 mL/min to 51.7 ± 13.8 mL/min. No rejection episode was observed in the study group. In the control group, there was no improvement of renal function, assessed by the changes in serum creatinine values, from 175.4 ± 23.4 μmol/L at day 0 to 181.6 ± 63 μmol/L at month 12, and in creatinine clearance, from 42.8 ± 12.8 mL/min to 44.8 ± 19.7 mL/min. The differences between the 2 groups were significant: P = 0.001 for serum creatinine, and P = 0.04 for creatinine clearance. In conclusion, the introduction of MMF combined with the reduction of at least 50% of CNI dose allowed the renal function of liver transplant recipients to significantly improve at 1 year, without any rejection episode and without significant secondary effects. Liver Transpl 12:1755–1760, 2006.

Isolation, Characterization, and Differentiation to Hepatocyte‐Like Cells of Nonparenchymal Epithelial Cells from Adult Human Liver

Activation and proliferation of human liver progenitor cells has been observed during acute and chronic liver diseases. Our goal was to investigate the presence of these putative progenitors in the liver of patients who underwent lobectomy for various reasons but did not show any hepatic insufficiency. Hepatic lesions were evaluated by histological analysis. Nonparenchymal epithelial (NPE) cells were isolated from samples of human liver resections located at a distance from the lesion that motivated the operation and were cultured and characterized. These cells exhibited a marked proliferative potential. They did not express the classic set of stem cell/progenitor markers (Oct‐4, Rex‐1, α‐fetoprotein, CD90, c‐kit, and CD34) and were faintly positive for albumin. When cultured at confluence in the presence of hepatocyte growth factor and either epidermal growth factor or fibroblast growth factor‐4, they entered a differentiation process toward hepatocytes. Their phenotype was quantitatively compared with that of mature human hepatocytes in primary culture. Differentiated NPE cells expressed albumin; α1‐antitrypsin; fibrinogen; hepatobiliary markers such as cytokeratins 7, 19, and 8/18; liver‐enriched transcription factors; and genes characterized by either a fetal (cytochrome P4503A7 and glutathione S‐transferase π) or a mature (tyrosine aminotransferase, tryptophan 2,3‐dioxygenase, glutathione S‐transferase α, and cytochrome P4503A4) expression pattern. NPE cells could be isolated from the liver of several patients, irrespective of the absence or presence of lesions, and differentiated toward hepatocyte‐like cells with an intermediate hepatobiliary and mature/immature phenotype. These cells are likely to represent a resident progenitor population of the adult human liver, even in the absence of hepatic failure.

Excessive alcohol consumption after liver transplantation impacts on long-term survival, whatever the primary indication

BACKGROUND & AIMS Beyond 5 years, poorer survival, related to alcohol relapse, is observed in patients with liver transplant for alcohol-related liver disease (ALD). However, alcohol consumption has been significantly understudied in non-ALD transplant recipients. We aimed at analyzing the impact of alcohol consumption on long-term survival irrespective of the indication for transplantation. METHODS This observational study included consecutive adult recipients of a primary liver graft between 1991 and 2007 in our hospital, who survived >6 months. Patients without ALD as primary indication, but with a history of excessive alcohol consumption before transplantation, were classified as secondary indication ALD. We studied the impact on survival of excessive consumption of alcohol after transplantation and several other variables. RESULTS The 441 patients had mean follow-up of 81.7 months. Among the 281 patients with excessive alcohol consumption before transplantation, 206 had ALD as primary indication. After transplantation, alcohol consumption was reported by 32.3% of the study population, 43.7% in primary indication ALD, and 24.3% in non-ALD patients. Survival was 82% at 5 years and 49% at 10 years for patients with excessive alcohol relapse, compared with 86% and 75%, respectively, for patients without persistent excessive alcohol relapse. By multivariable analysis, the independent risk factors of death were: excessive alcohol relapse, age >51 years, post-transplantation diabetes mellitus, cyclosporine-based immunosuppression, and non-hepatic cancer. CONCLUSIONS Excessive alcohol consumption has a negative impact on long-term survival after liver transplant, irrespective of the primary indication. Death is mainly due to recurrence of liver disease and non-hepatic cancer.

Delayed Gastric Emptying after Pancreaticoduodenectomy and Pancreaticogastrostomy

OBJECTIVE To find out which factors influence the development of delayed gastric emptying (DGE) after pancreaticoduodenectomy with pancreaticogastrostomy. DESIGN Prospective clinical study. SETTING University hospital, France. SUBJECTS 88 patients of 103 consecutive patients who had had pancreaticoduodenectomies, November 1991-November 1997. INTERVENTIONS Whipple resection, and parenteral and enteral nutrition. MAIN OUTCOME MEASURES Mortality, morbidity, and development of DGE (defined as the need for a postoperative nasogastric tube for 10 days or longer). RESULTS One patient died, and 44 developed postoperative complications. 36 patients (41%) developed DGE in 21 of whom (58%, 24% of the total) it was in isolation, with no other complication; and 52 (59%) did not. There were significant differences between those who developed DGE and those who did not: 30 men (83%) compared with 6 women (17%) developed DGE compared with 32 (62%) and 20 (38%) (p = 0.03;); 15 (42%) developed a complication as well as DGE compared with 8 (15%) (p = 0.005); 10(28%) who developed DGE required reoperation compared with 4(8%) (p = 0.011); mean (SD) hospital stay was 30(12) days among those with DGE compared with 17 (5) days (p= 0.0001); and their mean (SD) serum protein concentration on day 1 was 46 (1) compared with 51 (7) g/L (p=0.01). Multivariate analysis showed that three factors independently influenced the development of DGE: sex (p = 0.01), the need for reoperation (p = 0.03) and the mean serum protein concentration on day 1 (p = 0.04). CONCLUSION Postoperative complication and the need for reoperation remain the most common factors linked to the development of DGE. However, in a quarter of patients DGE was not associated with any postoperative complication.

Compared Efficacy of Preservation Solutions in Liver Transplantation: A Long-Term Graft Outcome Study From the European Liver Transplant Registry: HTK is Associated With Reduced Liver Graft Survival

Between 2003 and 2012, 42 869 first liver transplantations performed in Europe with the use of either University of Wisconsin solution (UW; N = 24 562), histidine‐tryptophan‐ketoglutarate(HTK; N = 8696), Celsior solution (CE; N = 7756) or Institute Georges Lopez preservation solution (IGL‐1; N = 1855) preserved grafts. Alternative solutions to the UW were increasingly used during the last decade. Overall, 3‐year graft survival was higher with UW, IGL‐1 and CE (75%, 75% and 73%, respectively), compared to the HTK (69%) (p < 0.0001). The same trend was observed with a total ischemia time (TIT) >12 h or grafts used for patients with cancer (p < 0.0001). For partial grafts, 3‐year graft survival was 89% for IGL‐1, 67% for UW, 68% for CE and 64% for HTK (p = 0.009). Multivariate analysis identified HTK as an independent factor of graft loss, with recipient HIV (+), donor age ≥65 years, recipient HCV (+), main disease acute hepatic failure, use of a partial liver graft, recipient age ≥60 years, no identical ABO compatibility, recipient hepatitis B surface antigen (−), TIT ≥ 12 h, male recipient and main disease other than cirrhosis. HTK appears to be an independent risk factor of graft loss. Both UW and IGL‐1, and CE to a lesser extent, provides similar results for full size grafts. For partial deceased donor liver grafts, IGL‐1 tends to offer the best graft outcome.

Abdominal laparoscopic approach for thoracic epiphrenic diverticulum

Abstract. The true incidence of epiphrenic esophageal diverticulum is unknown. Traditionally, diverticulectomy via a left thoracic approach has represented the gold standard. Trans-hiatal esophageal dissection under laparoscopy is feasible, but has not, to our knowledge, been applied before in the treatment of epiphrenic esophageal diverticulum.

Early and Long-term Oncological Outcomes After Laparoscopic Resection for Colorectal Liver Metastases: A Propensity Score-based Analysis.

OBJECTIVE To compare early and long-term outcomes in patients undergoing resection for colorectal liver metastases (CLM) by either a laparoscopic (LA) or an open (OA) approach. BACKGROUND The LA is still a matter of debate regarding the surgical management of CLM. METHODS Data of all patients from 32 French surgical centers who underwent liver resection for CLM from January 2006 to December 2013 were collected. Aiming to obtain 2 well-balanced cohorts for available variables influencing early outcome and survival, the LA group was matched 1:1 with the OA group by using a propensity score (PS)-based method. RESULTS The unmatched initial cohort consisted of 2620 patients (LA: 176, OA: 2444). In the matched cohort for operative risk factors (LA: 153, OA: 153), the LA group had shorter hospitalization stays [11.1 (±9) days vs 13.9 (±10) days; P = 0.01] and was associated with lower rates of grade III to V complications [odds ratio (OR): 0.27, 95% confidence interval (CI) 0.14-0.51; P = 0.0002] and inhospital transfusions (OR: 0.33 95% CI 0.18-0.59; P < 0.0001). On a prognostic factors well-balanced population (LA: 73, OA: 73), the LA group and the OA group experienced similar overall (OS) and disease-free (DFS) survival rates [OS rates of 88% and 78% vs 84% and 75% at 3 and 5 years, respectively (P = 0.72) and DFS rates of 40% and 32% vs 52% and 36% at 3 and 5 years, respectively (P = 0.60)]. CONCLUSIONS In the patients who are suitable for LA, laparoscopy yields better operative outcomes without impairing long-term survival.

Experimental assessment of the risk of tumor recurrence after laparoscopic surgery

BACKGROUND The aim of this experimental study was to evaluate the risk of tumor recurrence after laparoscopic cecal resection (LCR) of colonic carcinoma in the rat. METHODS The experimental cancer consisted of one million cells (DHK/K12), incorporated in an extracellular matrix, placed and secured to the cecal serosa in 110 BD9 rats. Four weeks later, all animals were reoperated through a laparotomy to control tumor growth, and animals with diffuse carcinomatosis were excluded. Eligible animals were randomized either to laparoscopic cecal resection (group LCR, n = 10), to open resection (group OCR, n = 13), or to a control group without resection (group C, n = 13). Resection was always considered as macrocopically complete. All animals were killed 4 weeks after the resection to determine the tumor recurrence and quantify carcinomatosis. RESULTS We noted diffuse carcinomatosis in 70% of rats in groups C and LCR versus 23% in group OCR (p = 0.038). For tumors noted as S- (not extending outside the serosa), diffuse carcinomatosis was observed in all animals of group C (3 of 3), in 6 of 8 in group LCR, and 0 of 6 in group OCR (p = 0.004). The rate of port site or incisional metastases was not significantly different between groups. CONCLUSIONS These preliminary results demonstrated the deleterious impact of the laparoscopy for resection of large bowel malignancy. LCR increased significantly the incidence of a diffuse carcinomatosis even when performed for locally noninvasive tumors (S-).

Argon Pneumoperitoneum Is More Dangerous than CO2 Pneumoperitoneum During Venous Gas Embolism

We investigated the possibility of using argon, an inert gas, as a replacement for carbon dioxide (CO2).The tolerance of argon pneumoperitoneum was compared with that of CO2 pneumoperitoneum. Twenty pigs were anesthetized with enflurane 1.5%. Argon (n = 11) or CO2 (n = 9) pneumoperitoneum was created at 15 mm Hg over 20 min, and serial intravenous injections of each gas (ranging from 0.1 to 20 mL/kg) were made. Cardiorespiratory variables were measured. Transesophageal Doppler and capnographic monitoring were assessed in the detection of embolism. During argon pneumoperitoneum, there was no significant change from baseline in arterial pressure and pulmonary excretion of CO2, mean systemic arterial pressure (MAP), mean pulmonary artery pressure (PAP), or systemic and pulmonary vascular resistances, whereas CO2 pneumoperitoneum significantly increased these values (P < 0.05). During the embolic trial and from gas volumes of 2 and 0.2 mL/kg, the decrease in MAP and the increase in PAP were significantly higher with argon than with CO2 (P < 0.05). In contrast to CO2, argon pneumoperitoneum was not associated with significant changes in cardiorespiratory functions. However, argon embolism seems to be more deleterious than CO2 embolism. The possibility of using argon pneumoperitoneum during laparoscopy remains uncertain. Implications: Laparoscopic surgery requires insufflation of gas into the peritoneal cavity. We compared the hemodynamic effects of argon, an inert gas, and carbon dioxide in a pig model of laparoscopic surgery. We conclude that argon carries a high risk factor in the case of an accidental gas embolism. (Anesth Analg 1997;85:1367-71)