Guillaume Luc

Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients.

OBJECTIVES Current clinical studies report the results of laparoscopic resection of hepatocellular carcinoma (HCC) obtained in small cohorts of patients. Because France was involved in the very early development of laparoscopic surgery, the present study was conducted in order to report the results of a large, multicentre experience. METHODS A total of 351 patients underwent laparoscopic liver resection for HCC during the period from 1998 to 2010 in nine French tertiary centres. Patient characteristics, postoperative mortality and morbidity, and longterm survival were retrospectively reviewed. RESULTS Overall, 85% of the study patients had underlying liver disease. Types of resection included wedge resection (41%), left lateral sectionectomy (27%), segmentectomy (24%), and major hepatectomy (11%). Median operative time was 180 min. Conversion to laparotomy occurred in 13% of surgeries and intraoperative blood transfusion was necessary in 5% of patients. The overall morbidity rate was 22%. The 30-day postoperative mortality rate was 2%. Negative resection (R0) margins were achieved in 92% of patients. Rates of overall and progression-free survival at 1, 3 and 5 years were 90.3%, 70.1% and 65.9%, and 85.2%, 55.9% and 40.4%, respectively. CONCLUSIONS This multicentre, large-cohort study confirms that laparoscopic liver resection for HCC is a safe and efficient approach to treatment and can be proposed as a first-line treatment in patients with resectable HCC.

Salvage Surgery After Chemoradiotherapy in the Management of Esophageal Cancer: Is It a Viable Therapeutic Option?

PURPOSE The aim of this large multicenter study was to assess the impact of salvage esophagectomy after definitive chemoradiotherapy (SALV) on clinical outcome. PATIENTS AND METHODS Data from consecutive adult patients undergoing resection for esophageal cancer in 30 European centers from 2000 to 2010 were collected. First, groups undergoing SALV (n = 308) and neoadjuvant chemoradiotherapy followed by planned esophagectomy (NCRS; n = 540) were compared. Second, patients who benefited from SALV for persistent (n = 234) versus recurrent disease (n = 74) were compared. Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics. RESULTS SALV versus NCRS groups: In-hospital mortality was similar in both groups (8.4% v 9.3%). The only significant differences in complications were seen for anastomotic leak (17.2% v 10.7%; P = .007) and surgical site infection, which were both more frequent in the SALV group. At 3 years, groups had similar overall (43.3% v 40.1%; P = .542) and disease-free survival (39.2% v 32.8%; P = .232) after matching, along with a similar recurrence pattern. Persistent versus recurrent disease groups: There were no significant differences between groups in incidence of in-hospital mortality or major complications. At 3 years, overall (40.9% v 56.2%; P = .046) and disease-free survival (36.6% v 51.6%; P = .095) were lower in the persistent disease group. CONCLUSION The results of this large multicenter study from the modern era suggest that SALV can offer acceptable short- and long-term outcomes in selected patients at experienced centers. Persistent cancer after definitive chemoradiotherapy seems to be more biologically aggressive, with poorer survival compared with recurrent cancer.

24-hour pH-impedance monitoring on therapy to select patients with refractory reflux symptoms for antireflux surgery. A single center retrospective study

Treatment of gastro‐esophageal reflux refractory symptoms is challenging. This monocenter retrospective study assessed the value of preoperative pH‐impedance monitoring ‘on’ therapy to predict functional outcome after laparoscopic fundoplication in patients with refractory reflux symptoms.

Lymph node invasion might have more prognostic impact than R status in advanced esophageal adenocarcinoma.

BACKGROUND Advanced esophageal adenocarcinomas are associated with 5-year survival rates ranging from 14% to 35%. Nodal status and tumor clearance are the main prognostic factors. However, their respective prognostic values have not been compared to date. METHODS Seventy consecutive patients with stage T3 adenocarcinomas of the esophagus or gastric cardia were retrospectively assessed. Neoadjuvant therapy was indicated in all cases. Prognostic values of R0 resection and nodal status were evaluated using univariate and multivariate analyses. RESULTS Neoadjuvant therapy was achieved in 62 patients, 41 with radiochemotherapy and 21 with perioperative chemotherapy. Transthoracic esophagectomy and transhiatal esophagectomy were performed in 54 and 15 patients, respectively. Clavien-Dindo grade III or IV complications occurred in 16 patients (23%). Two patients died in the hospital (3%). In univariate and multivariate analyses, nodal status was the main independent factor predicting overall survival; tumor clearance (R0 or R1) had less prognostic impact and was not statistically significant. Furthermore, R1 resection was a prognostic indicator for metastatic recurrence. CONCLUSIONS These results indicate that nodal status has more prognostic impact than R status in stage T3 adenocarcinomas of the esophagus or gastric cardia. Thus, local control in R1 patients by postoperative radiotherapy is not justified.

Management of large para-esophageal hiatal hernias

Para-esophageal hernias are relatively rare and typically occur in elderly patients. The various presenting symptoms are non-specific and often occur in combination. These include symptoms of gastro-esophageal reflux (GERD) in 26 to 70% of cases, microcytic anemia in 17 to 47%, and respiratory symptoms in 9 to 59%. Respiratory symptoms are not completely resolved by surgical intervention. Acute complications such as gastric volvulus with incarceration or strangulation are rare (estimated incidence of 1.2% per patient per year) but gastric ischemia leading to perforation is the main cause of mortality. Only patients with symptomatic hernias should undergo surgery. Prophylactic repair to prevent acute incarceration should only be undertaken in patients younger than 75 in good condition; surgical indications must be discussed individually beyond this age. The laparoscopic approach is now generally accepted. Resection of the hernia sac is associated with a lower incidence of recurrence. Repair of the hiatus can be reinforced with prosthetic material (either synthetic or biologic), but the benefit of prosthetic repair has not been clearly shown. Results of prosthetic reinforcement vary in different studies; it has been variably associated with four times fewer recurrences or with no measurable difference. A Collis type gastroplasty may be useful to lengthen a foreshortened esophagus, but no objective criteria have been defined to support this approach. The anatomic recurrence rate can be as high as 60% at 12years. But most recurrences are asymptomatic and do not affect the quality of life index. It therefore seems more appropriate to evaluate functional results and quality of life measures rather than to gauge success by a strict evaluation of anatomic hernia reduction.

Re-operation for failed gastro-esophageal fundoplication. What results to expect?

UNLABELLED The aim of this study is to evaluate short and medium term results of re-operation for failed fundoplication in a retrospective monocentric cohort of 47 patients. PATIENTS AND METHODS Between 1995 and 2011, 595 patients underwent a laparoscopic primary fundoplication (PFP) for gastroesophageal reflux disease (GERD). During the same period, 47 patients required a re-operative fundoplication (RFP). In 11 patients, the original wrap had herniated into the thorax. All these revisions consisted of a complete takedown of the original wrap before constructing a tension-free wrap using a standardized technique. Patients with a follow-up of at least 2 years were matched to patients who had been operated only once to assess satisfaction and quality of life. RESULTS Short term: All patients were operated by laparoscopy with no conversion. There was no mortality. Two postoperative complications necessitating re-operation were observed (morbidity 4.3%): one complete aphagia and one gastric perforation. Long term: 29 re-operated patients with a follow-up of at least 2 years (mean: 4,5 years) (Group RFP) were compared to a matched group of 29 patients operated only once (Group PFP). These groups were comparable in age, sex ratio, BMI and follow-up. In both groups, all patients were operated by laparoscopy without conversion. Morbidity was 3.5% in the RFP group, none in the PFP group. There was no mortality in either group. The length of stay and operative time were significantly higher in the RFP group (4.6 vs. 2.6 days, p<0.05). Two RFP patients (5%) required re-operation at three and seven months vs. none in the PFP group. The long-term satisfaction was comparable in the two groups (78% vs. 85%, p=NS). Quality of life assessed by the GIQLI was significantly better in the PFP group (104 vs. 84, p<0.05). CONCLUSION Re-do fundoplication is a safe procedure and is feasible by laparoscopy. In the long-term, patient satisfaction is comparable to primary intervention with, however, a slightly poorer quality of life.

Esophageal tissue engineering

Esophageal tissue engineering is still in an early state, and ideal methods have not been developed. Since the beginning of the 20th century, advances have been made in the materials that can be used to produce an esophageal substitute. Three approaches to scaffold-based tissue engineering have yielded good results. The first development concerned non-absorbable constructs based on silicone and collagen. The need to remove the silicone tube is the main disadvantage of this material. Polymeric absorbable scaffolds have been used since the 1990s. The main polymeric material used is poly (glycolic) acid combined with collagen. The problem of stenosis remains prevalent in most studies using an absorbable construct. Finally, decellularized scaffolds have been used since 2000. The promises of this new approach are unfulfilled. Indeed, stenosis occurs when the esophageal defect is circumferential regardless of the scaffold materials. Cell supplementation can decrease the rate of stenosis, but the type(s) of cells and their roles have not been defined. Finally, esophageal tissue engineering cannot provide a functional esophageal substitute, and further development is necessary prior to conducting human clinical studies.

Facteurs prédictifs de récidive chez les patients porteurs d’un cancer de l’œsophage en réponse complète après radiochimiothérapie suivie d’une œsophagectomie : étude multicentrique

Rationnel Peu de donnees sont disponibles sur les facteurs predictifs de recidive chez les patients ypT0N0M0. Le but de cette etude etait d’identifier des facteurs predictifs de recidive chez les patients ayant une reponse complete (pCR) apres radiochimiotherapie et œsophagectomie pour cancer de l’œsophage. Methodes Parmi 2 944 patients porteurs d’un cancer de l’œsophage entre 2000 et 2010, les patients traites par radiochimiotherapie neoadjuvante suivi de chirurgie ayant une pCR ont ete analyses. Les facteurs associes a la survie et aux recidives ont ete estimes selon une regression logistique de Cox. Resultats Parmi 593 patients ayant beneficie d’une radiochimiotherapie neoadjuvante suivi d’une œsophagectomie, 191 (32,2 %) patients avaient une pCR. Cinquante-six patients (29,3 %) ont presente une recidive dont le delai d’apparition median etait de 12 mois. Les facteurs predictifs de recidive etaient les complications postoperatoires grade 3-4 (odds ratio [OR] : 2,100 ; Intervalle de confiance 95 % [IC] : 1,008–4,366 ; p = 0,048) et le type histologique adenocarcinome (OR : 2 008 ; 95 % C I : 0,1,06–0,3,80 ; p = 0,032). La survie globale etait de 63 mois (IC 95 % : 39,3–87,1), et la survie sans-recidive etait de 48 mois (IC 95 % : 18,3–77,4). L’âge (> 6 5 ans) (hazard ratio [HR] : 2,166 ; IC 95 % : 1,170–4,010 ; p = 0,014), les complications postoperatoires grade 3-4 (HR : 2 099 ; IC 95 % : 1,137–3,878 ; p = 0,018) et la dose d’irradiation ( Conclusion Parmi les patients pCR, 30 % presentent une recidive dont le delai median d’apparition est de 12 mois. Les facteurs predictifs de recidive sont les complications postoperatoires et le type histologique adenocarcinome. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.