Frédéric Borie

One hundred laparoscopic choledochotomies with primary closure of the common bile duct.

Background: Several technical approaches for laparoscopic CBD exploration (LCBDE) exist. Laparoscopic choledochotomy is required in some situations and whenever a transcystic approach fails. Biliary drainage after choledochotomy has a 5% morbidity rate and avoidance of biliary drains might therefore further improve the results of LCBDE. The authors report a prospective multicentric evaluation of laparoscopic choledochotomy with completion choledochoscopy and primary duct closure without any biliary drainage. Methods: Between October 1991 and December 1997, 100 patients from four surgical centers underwent this approach for CBD stones. Choledocholithiasis had been demonstrated preoperatively in 35 patients (35%), suspected in 52 and was incidentally found during routine intraoperative cholangiography in 13 patients. External ultrasound was the only preoperative imaging investigation in 87 patients. LCBDE was attempted irrespective of age, ASA score, or the circumstances leading to the preoperative diagnosis or suspicion of CBD stones (acute cholecystitis in 33% of patients, cholangitis in 10%, or mild acute pancreatitis in 6% of all patients). Results: The technique was equally feasible in all participating centers (University hospital, general hospital, or private practices). Vacuity of the CBD was achieved in all patients without mortality. Eleven patients had complications and 3 patients required a laparoscopic reintervention. Median postoperative hospital stay was 6 days (range: 1–26). No patient required additional CBD procedures during follow-up. Conclusions: In case of LCBDE, choledochotomy with primary closure without external drainage of the CBD is a safe and efficient alternative, even in patients with acute cholecystitis, cholangitis, or pancreatitis, provided that choledochoscopy visualizes a patent CBD. This technique is applicable in all types of medical institutions if required laparoscopic skills and equipment are available.

Treatment and prognosis of hepatocellular carcinoma: A population based study in France

Few data are available from population‐based statistics on hepatocellular carcinoma (HCC). The aim of this study was to report on their management and their prognosis in a French population.

Cost-effectiveness of two follow-up strategies for curative resection of colorectal cancer: comparative study using a Markov model.

The follow-up of patients with curative resection of colorectal cancer is still controversial. The means mobilized for postoperative monitoring come at a high cost. However, the modalities are neither formalized nor validated with regard to an improved 5-year survival rate. To compare the cost-effectiveness of both strategies for patient follow-up during the 7 years following curative resection of colorectal cancer, we performed a cost-effectiveness analysis adjusted for quality of life. Using data from the literature and a population study, a simulation of follow-up on patients who had undergone curative resection of colorectal cancer was carried out over a 7-year period using a Markov model. Two Markov processes were modeled to compare the cost-effectiveness ratio adjusted for quality of life in patients with a follow-up in accordance with the recommendations of the 1998 French Consensus Conference (standard follow-up) with the carcinoembryonic antigen (CEA) assay and a simplified follow-up. The influence of standard follow-up on the quality-adjusted life expectancy of patients who had Duke’s stage A and B colorectal cancer appears to be modest, with increases of 2.5 monthsand 1.3 months, respectively; it is more acceptable for patients who had had Duke’s stage C, with an increase of 11 months. The high variability of cost-effectiveness ratios (> 7 years) of ± 44,830 and 180,195 € per quality-adjusted life-years (QALY), respectively) did not favor the standard follow-up. The cost-effectiveness ratio (> 7 years) of patients having had Duke’s stage C colorectal cancer was 1,058 (sd: 2746) € per QALY and could favor the standard follow-up. This study showed that standard follow-up with CEA assay tended to preferentially improve the survival of Duke’s stage C patients. The type of examination needed and the frequency with which it has to be carried out should take account of the stage, treatment for the initial illness, and the patient’s age.

Minimally invasive transhiatal esophagectomy: lessons learned

BackgroundMinimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned.MethodsA retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival.ResultsEighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36–79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1–3), and 1 for high-grade dysplasia in Barrett’s. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180–450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10–39). The median number of nodes harvested was 10 (range = 2–26). At a median follow-up of 13 months (range = 4–42), 13 patients were alive.ConclusionsMinimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.

Patient’s Preference and Randomization: New Paradigm of Evidence-based Clinical Research

The limitations associated with the traditional randomized controlled design as applied to clinical surgical research must be recognized. The aim of randomization is to ensure initial comparability between groups of eligible patients for whom treatments are compared, thus eliminating their individual influence on outcome. Randomized controlled trials in the surgical literature are sparse; patient preferences might be a major obstacle to their performance. External validity of results of clinical trials depends on the representativity of patients who participate in trials: Compliance to participate through informed consent may act as a selection bias. In surgical randomized trials where it is not often possible for patients to remain blinded to the treatment to which they have been allocated, patient preferences can influence the effectiveness of treatments. In this setting, we need to look at alternatives and the potential advantages of adopting more flexible and clinically relevant approaches to the design of surgical trials. We have to accept the weight of the patient’s individual decision in everyday practice. Hence, to negate the importance of these individual choices when evaluating surgical outcomes is unrealistic. An original design reported herein might become a new paradigm for surgical evaluation.

Prognostic Factors for Early Gastric Cancer in France: Cox Regression Analysis of 332 Cases

Early gastric cancer (EGC) is defined as a lesion in which the depth of invasion is limited to the mucosa, submucosa, or both regardless of lymph node status; moreover, it has an excellent prognosis, with a 5-year survival rate of more than 90%. We aimed to determine the prognostic factors for EGC in a large Western series. Over a 10-year period from January 1979 to December 1988 a series of 332 patients (mean age 64 years) with EGC were operated on in 23 centers (two French Associations for Surgical Research). The clinicopathologic data retrospectively and screened it for prognostic effect. The mean follow-up for the 332 EGC patients was 80 months. Postoperative mortality was 4% among 243 partial and 89 total gastric resections. The overall 5- and 7-year survival rates were 82% and 72%, respectively. The cumulative 5- and 7-year survival rates (mean follow-up 80 months) were 92.0% and 87.5%, respectively, excluding both operative and unrelated mortality. There was no significant difference in survival between partial and total gastric resection for lesions located in the lower third of the stomach (p > 0.6). When survival data (excluding postoperative deaths) were analyzed using univariate analysis and Cox’s proportional hazards model, lymphatic involvement (p = 0.01), the site of the tumor in the upper two-thirds of the stomach (p = 0.02), and submucosal lesions (p = 0.049) showed a significant effect on predicting a poor prognosis. These results suggest that because of its prognostic value lymphadenectomy should be performed in addition to gastric resection for adequate classification of EGCs. Follow-up might be required only for patients with at least one poor prognostic factor.

Cost and effectiveness of follow-up examinations in patients with colorectal cancer resected for cure in a french population-based study

The cost of follow-up examinations for patients having undergone potentially curative surgery for colorectal cancer is considerable. The aim of this study was to provide a thorough assessment of the cost and effectiveness of the follow-up tests used during the 5 years after surgical resection for colorectal cancer and its recurrences. We studied medical and economic data from the records of 256 patients registered in the Herault Tumor Registry who underwent potentially curative surgical resection in 1992. Recurrence, curative recurrence, survival, and the cost of follow-up tests were assessed respectively for at least 5 years. We analyzed the cost and effectiveness of follow-up tests in patients who received either follow-up with carcinoembryonic antigen (CEA) monitoring as advocated by the 1998 French consensus conference recommendations (standard follow-up) or a more minimal follow-up schedule. Nine patients died in the postoperative period. The 5-year survival rates in the standard and minimal follow-up groups were 85% and 79%, respectively (p = 0.25). Cost-effectiveness ratios were 2123 in Dukes’ stage A patients, 4306 in Dukes’ stage B patients, and 9600 in Dukes’ stage C patients. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the standard follow-up group were 1238 and 2261.5, respectively. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the minimal follow-up group were 1478 and 573, respectively. There were no survivors 5 years after a recurrence when the recurrence was detected by physical examination, chest X-ray, and colonoscopy in either follow-up group. Dukes’ classification is a poor indicator of patient selection. The follow-up tests should only include CEA monitoring and abdominal ultrasonography for the diagnosis of recurrence.

How to Teach Evidence-based Surgery

The objectives of teaching evidence-based surgery (EBS) are to inform and convince that EBS is a method of interrogation, reasoning, appraisal, and application of information to guide physicians in their decisions to best treat their patients. Asking the right, answerable questions, translating them into effective searches for the best evidence, critically appraising evidence for its validity and importance, and then integrating EBS with their patients’ values and preferences are daily chores for all surgeons. Teaching and learning EBS should be patient-centered, learner-centered, and active and interactive. The teacher should be a model for students to become an expert clinician who is able to match and take advantage of the clinical setting and circumstances to ask and to answer appropriate questions. The process is multistaged.Teaching EBS in small groups is ideal. However, it is time-consuming for the faculty and must be clearly and formally structured. As well, evidence-based medicine (EBM) courses must cater to local institutional needs, must receive broad support from the instructors and the providers of information (librarians and computer science faculty), use proven methodologies, and avoid scheduling conflicts. In agreement with others, we believe that the ideal moment to introduce the concepts of EBM into the curriculum of the medical student is early, during the first years of medical school. Afterward, it should be continued every year. When this is not the case, as in many countries, it becomes the province of the surgeon in teaching hospitals, whether they are at the university, are university-affiliated, or not, to fulfill this role.

Primitive liver cancers: epidemiology and geographical study in France.

Objectives The objectives of this study are, first, to describe the incidence of primary liver cancer (PLC) and, second, to highlight its epidemiological characteristics from a geographical point of view. Methods The nine French administrative areas, which are covered by population-based cancer registries, diagnosed a total of 1100 new cases of PLC (of which 898 occurred in males), between 1997 and 1998; 91.5% of these were identified as hepatocellular carcinoma, and 6.2% corresponded to intrahepatic cholangiocarcinoma. The incidence rates of these new cases were studied as a function of their clinico-pathological features and geographical location. Results The age-adjusted incidence was 9.5 per 100 000 persons amongst males, and 3.1 per 100 000 persons amongst females. The origin of cirrhosis was found to be alcohol consumption (69%), followed by viral contamination, and lastly 4.9% for both. A north–south gradient was found for the age-standardized incidence rates in men (10.1 per 100 000 in the north vs. 6.5 per 100 000 in the south; P=0.029). Amongst men in the north, the most frequent etiological type was cirrhosis (79.8 vs. 72.5%; P=0.0018). The alcoholic origin of cirrhosis was more frequent in the north than in the south (66 vs. 27.5%; P<10−4). Viral cirrhosis was more frequent in the south than in the north (42.9 vs. 13.6%; P<10−4). Conclusion In France, excessive alcohol consumption remains the main risk factor for PLC, although the viral etiology of this disease is growing. An opposition was found between the two groups. North-men-alcoholic cirrhosis and south-women-viral cirrhosis.

Acute biliary pancreatitis, endoscopy, and laparoscopy

Current practices for diagnosis and treatment of common bile duct stones are not evidence-based. Acute billary pancreatitis (ABP) is a specific situation in which endoscopic procedures are either overused or misused. Pancreatitis is a poor marker for choledocholithiasis. Prognostic systems are accurate to discern those patients with ABP who do not need aggressive procedures. Patients with a benign ABP do not need an endoscopic approach. Laparoscopic common bile duct exploration is an underrated treatment for patients with choledocholithiasis. Laparoscopic approach to infected necrotic collections and pseudocysts warrant futher investigations.