Franco D

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study

BackgroundOnly a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections.MethodsPatients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors’ department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared.ResultsThe mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7xa0ml; pxa0<xa00.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (pxa0=xa00.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; pxa0=xa00.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; pxa0=xa01.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6xa0days; pxa0<xa00.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1xa0year, 74.4% at 3xa0years, and 59.5% at 5xa0years and, respectively, 81.8, 73, and 47.4% in the open surgery group (pxa0=xa00.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1xa0year, 60.9% at 3xa0years, and 45.6% at 5xa0years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (pxa0=xa00.29).ConclusionsLaparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.

Laparoscopic liver resection: results for 70 patients

BackgroundLaparoscopy is slowly becoming an established technique for liver resection. This procedure still is limited to centers with experience in both hepatic and laparoscopic surgery. Preliminary reports include mainly minor resections for benign liver conditions and show some advantage in terms of postoperative recovery. The authors report their experience with laparoscopic liver resection, the evolution of the technique, and the results.MethodsFrom 1999 to 2006, 70 laparoscopic liver resections were performed using a procedure similar to resection by laparotomy.ResultsThere were 38 malignant tumors (54%) and 32 benign lesions (46%). The malignant tumors were mainly hepatocellular carcinomas (19 of 24 patients had cirrhosis). The tumor mean size was 3.8xa0±xa01.9 cm (range, 2.2–8 cm). There were 19 major hepatectomies, 34 uni- or bisegmentomies, and 17 atypical resections. The operative time was 227xa0±xa0109 min. Conversion to laparotomy was required for seven patients (10%), mainly for continuous bleeding during transection. Nine patients (13%) required blood transfusion. One patient had both brisk bleeding and gas embolism from a tear in the section line of the right hepatic vein requiring laparoscopic suture. Blood loss and transfusion requirements were significantly lower in recent than in early cases and in resections with prior vascular control than in those without such control. Postoperative complications were experienced by 11 patients (16%), including one bleed from the hepatic stump requiring hemostasis and two subphrenic collections requiring percutaneous drainage. One cirrhotic patient died of liver failure after resection of a partially ruptured tumor. No ascites was observed in other cirrhotic patients. The mean hospital stay was 5.9 days.ConclusionThe study results confirm that laparoscopic liver resection, including major hepatectomies, can be safely performed by laparoscopy.

Diagnostic value of combining 11C-choline and 18F-FDG PET/CT in hepatocellular carcinoma

PurposeIn this prospective study, our goal was to emphasize the diagnostic value of combining 11C-choline and 18F-FDG PET/CTxa0for hepatocellular carcinoma (HCC) in patients with chronic liver disease.MethodsThirty-three consecutive patients were enrolled. All patients were suspected to have HCC based on CT and/or MRI imaging. A final diagnosis was obtained by histopathological examination or by imaging alone according to American Association for the Study of Liver Disease criteria. All patients underwent PET/CT with both tracers within a median of 5xa0days. All lesions showing higher tracer uptake than normal liver were considered positive for HCC. We examined how tracer uptake was related to biological (serum α-fetoprotein levels) and pathological (differentiation status, peritumoral capsule and vascular invasion) prognostic markers of HCC, as well as clinical observations at 6 months (recurrence and death).ResultsTwenty-eight HCC, four cholangiocarcinomas and one adenoma were diagnosed. In the HCCxa0patients, the sensitivity of 11C-choline, 18F-FDG and combined 11C-choline and 18F-FDG PET/CT for the detection of HCC was 75xa0%, 36xa0% and 93xa0%, respectively. Serum α-fetoprotein levels >200xa0ng/ml were more frequent among patients with 18F-FDG-positive lesions than those with 18F-FDG-negative lesions (pu2009<u20090.05). Early recurrence (n=2) or early death (n=5) occurred more frequently in patients with 18F-FDG-positive lesions than in those with 18F-FDG-negative lesions (pu2009<u20090.05).ConclusionThe combined use of 11C-choline and 18F-FDG PET/CT detected HCC with high sensitivity. This approach appears to be of potential prognostic value and may facilitate the selection of patients for surgical resection or liver transplantation.

Liver Atrophy and Encephalopathy after Portacaval Shunt in the Rat

The effect of various types of portal diversion (portacaval, mesocaval and pancreatico-splenocaval anastomoses, portacaval transposition and arterialization) on liver atrophy and post-shunt encephalopathy was studied in the rat. Among all diversions, only portacaval anastomosis produced dramatic liver atrophy and encephalopathy. Moreover, portacaval anastomosis was also the only portal diversion which induced low body weight gain. There was no correlation between blood ammonia levels and encephalopathy. Liver atrophy was always correlated to a decrease of hepatic blood flow. Diminution of liver blood flow was only slight following partial (either mesenteric or pancreatico-splenic) diversion of portal blood and nil after portacaval transposition or anastomosis. These results suggest that: (1) pancreatic (insulin-rich) blood is not essential for maintenance of liver trophicity. Hemodynamic factors seem to be predominant in the pathogenesis of post-shunt liver atrophy. (2) Post-shunt encephalopathy arises only when total diversion of the portal blood and liver atrophy are associated.

Comparison of a modified Sugiura procedure with portal systemic shunt for prevention of recurrent variceal bleeding in cirrhosis

BACKGROUNDnThere is no agreement on the management of patients with cirrhosis and recurrent variceal bleeding after failure of medical or endoscopic treatments or both. Portal systemic shunts are highly effective in preventing rebleeding but are associated with a high incidence of chronic encephalopathy. This study compared the results of a slightly modified Sugiura procedure (esophageal transection plus esophagogastric devascularization plus splenectomy) with those of nonselective portal systemic shunts in patients with previous variceal bleeding.nnnMETHODSnFifty-four patients were included in this randomized controlled study between January 1984 and April 1989. The major end point was chronic encephalopathy. Secondary end points were recurrent variceal bleeding, survival, ascites, and hepatocellular carcinoma.nnnRESULTSnTwenty-seven patients were assigned to each group. The rate of chronic encephalopathy was significantly (p = 0.002) lower after modified Sugiura procedure than after portal systemic shunt. Recurrent variceal bleeding was more frequent after modified Sugiura procedure than after portal systemic shunt, but the difference is not significant. One-, two-, and three-year survival rates were 93%, 81%, and 67%, respectively, in the modified Sugiura group and 78%, 66%, and 39%, respectively, in the portal systemic shunt group (p = 0.044).nnnCONCLUSIONSnThese results suggest that the modified Sugiura procedure is better overall than the nonselective portal systemic shunt in the management of patients with cirrhosis and recurrent variceal bleeding. Although the rebleeding rate is higher after the modified Sugiura procedure, this does not seem to affect mortality in these patients.

Ambulatory laparoscopic minor hepatic surgery: Retrospective observational study

INTRODUCTIONnOver the last decade, laparoscopic hepatic surgery (LHS) has been increasingly performed throughout the world. Meanwhile, ambulatory surgery has been developed and implemented with the aims of improving patient satisfaction and reducing health care costs. The objective of this study was to report our preliminary experience with ambulatory minimally invasive LHS.nnnMETHODSnBetween 1999 and 2014, 172 patients underwent LHS at our institution, including 151 liver resections and 21 fenestrations of hepatic cysts. The consecutive series of highly selected patients who underwent ambulatory LHS were included in this study.nnnRESULTSnTwenty patients underwent ambulatory LHS. Indications were liver cysts in 10 cases, liver angioma in 3 cases, focal nodular hyperplasia in 3 cases, and colorectal hepatic metastasis in 4 cases. The median operative time was 92 minutes (range: 50-240 minutes). The median blood loss was 35 mL (range: 20-150 mL). There were no postoperative complications or re-hospitalizations. All patients were hospitalized after surgery in our ambulatory surgery unit, and were discharged 5-7 hours after surgery. The median postoperative pain score at the time of discharge was 3 (visual analogue scale: 0-10; range: 0-4). The median quality-of-life score at the first postoperative visit was 8 (range: 6-10) and the median cosmetic satisfaction score was 8 (range: 7-10).nnnCONCLUSIONnThis series shows that, in selected patients, ambulatory LHS is feasible and safe for minor hepatic procedures.

Laparoscopic liver resection for localized primary intrahepatic bile duct dilatation

BACKGROUNDnPrimary intrahepatic bile duct dilatation (IHBD) may present as a localized form in which resection of the affected liver can prevent immediate and late complications. Laparoscopy has gained large interest in liver surgery. It also allows a safe and efficient exploration of the common bile duct.nnnMETHODSnWe performed 10 laparoscopic liver resections for localized IHBD, on 7 women and 3 men (mean age 47 years). Resections were 2 right hepatectomies, 4 left hepatectomies, and 4 left lateral sectionectomies. Three patients had associated common bile duct stones that were treated through intraoperative cholangioscopy.nnnRESULTSnThe mean operative time was 303.9 minutes. The mean blood loss was 217 mL. None of these patients required hand assistance or conversion to open surgery. One patient suffered a residual collection that was drained percutaneously. The postoperative course was uneventful in the other patients. The mean hospital stay was 5.3 days. No recurrence of cholangitis was observed during the follow-up period.nnnCONCLUSIONSnThe laparoscopic treatment of IHBD is safe and should be performed by teams with expertise in both hepatobiliary surgery and laparoscopy.

DIG18 Pathologie biliaire en IRM : morceaux choisis

Objectifs L’objectif de ce poster est d’exposer de facon didactique l’aspect semiologique des principales pathologies biliaires en IRM. Materiels et methodes Presentation des principales pathologies biliaires a partir d’une analyse retrospective des cholangio-RM effectuees ces 15 derniers mois dans notre service, totalisant une centaine d’examens. Ces examens ont ete realises selon un protocole standardise sur un imageur 1,5 T (Siemens), a l’aide d’une antenne en reseau phase, apres ingestion de jus d’ananas (sequences axiale et coronale HASTE, axiale TrueFISP, monocoupes 2D RARE et acquisition volumique 3D RARE avec reconstruction multiplanaire). Resultats Apres un rappel de l’anatomie normale des voies biliaires, description des principales pathologies biliaires a connaitre, primitives ou iatrogenes, en insistant sur les images pieges grâce a leur correspondance en TDM ou en echographie. Conclusion La semiologie des pathologies des voies biliaires en cholangio-RM necessite d’etre connue de tout radiologue en raison de sa place grandissante du fait de son innocuite face aux explorations endoscopiques.