Hugues Levard

Laparoscopic liver resection.

This paper describes a 10‐year experience of laparoscopic liver surgery, including several major hepatectomies for malignant tumours.

Laparoscopic treatment of acute small bowel obstruction: A multicentre retrospective study

Background:  Laparoscopic surgery is thought to promote early recovery and quicker return to bowel function. The objective was to evaluate the rate and predictive factors of success, the causes of failure, the morbidity, and mortality during and after hospitalization, as well as to determine whether laparoscopic treatment of acute small bowel obstruction offers the same benefits as for other laparoscopic procedures.

5-Fluorouracil and Cisplatin as Palliative Treatment of Advanced Oesophageal Squamous Cell Carcinoma: A Multicentre Randomised Controlled Trial

OBJECTIVE To compare chemotherapy with no chemotherapy as palliative treatment for oesophageal squamous cell carcinoma. DESIGN Randomised study. SETTING Multicentre trial in France. SUBJECTS Of 161 patients with histologically confirmed oesophageal squamous cell carcinoma located more than 5 cm from the mouth of the oesophagus, five were withdrawn because of protocol violation. The remaining 156 patients, 149 men and 7 women, mean (SD) age 58 (9) years range 36 to 77, were randomly allocated to either a control group without chemotherapy (n = 84) or a group treated by chemotherapy (n = 72). Patients were divided into four strata: I = complete resection of the tumour but with lymph node involvement (n = 62); II = incomplete resection of tumour leaving gross tumour behind (n = 58); III = no resection because of local or regional invasion (n = 22) ; and IV = no resection because of distant metastasis (n = 14). Exclusion criteria were histologically confirmed tracheobronchial involvement, oesophagotracheal fistula, Karnosky score < 50, cerebral metastases, or hepatic metastases occupying more than 30% of the liver, peritoneal carcinomatosis, associated or previously treated ear-nose-throat carcinoma, or complete resection of tumour without lymph node involvement. INTERVENTIONS 5 fluorouracil (5FU) and cisplatin (CDDP) were given in 5-day courses, once every 28 days, for a maximum of eight cycles. 5 FU, 1 g/m2, was infused for 24 hours after a water overload, during five days. Cisplatin was given either in one dose of 100 mg/m2 at the beginning of the cycle or 20 mg/m2/day over three hours for five days. Duration of treatment ranged from 6-8 months. OUTCOME MEASURES Median and actuarial survival. The subsidiary endpoint was quality of survival judged by complications of treatment, swallowing disorders, and the duration of ability to feed normally. RESULTS There was no difference in survival, either overall (median = 12 months) or in any of the strata. There were however significantly more patients with neurological (p < 0.003), haematological (p < 0.0001), and renal (p < 0.0002) complications in the treated group compared with the control group. Four patients (6%) died of complications of chemotherapy. The course of swallowing disorders did not differ between the two groups. The duration of autonomous oral feeding was exactly the same in both groups (median = 10.5 months). CONCLUSION The results suggest that 5FU and CDDP do not help in patients with squamous cell carcinoma of the oesophagus whether or not the tumour has been resected.

Pre-operative predictive factors of early recurrence after resection of adenocarcinoma of the esophagus and cardia.

OBJECTIVES To determine pre-operative predictive factors of early recurrence in patients with esophageal and cardial adenocarcinoma. PATIENTS AND METHODS We retrospectively analyzed consecutive patients who underwent resection for esophageal and cardial adenocarcinoma in our institution between October 1992 and October 2001. Patient files were studied and classified according to the occurrence of early recurrence (within one year) (group A) and patients without recurrence (group B). Pre-operative clinical, biological and radiological parameters were recorded. Both groups were compared in univariate and multivariate analysis. RESULTS One hundred patients underwent surgical resection. Tumor was located in lower esophagus in 71 cases and at the cardia in 29 cases. R0 resection was feasible in 95 cases. Hospital mortality was 2%. Survival rate at 3 years was 56%. Recurrence before 1 year occurred in 28 patients (group A) and not in 72 (group B). In univariate analysis, younger age (P=0.01), dysphagia (P=0.04) and percentage of weight loss (P<0.0004) were significantly different between both groups. Weight loss more than 10% was observed in 2 patients of group B, and in 9 patients of group A. In multivariate analysis, weight loss more than 10% was the only pre-operative factor associated with early recurrence (P=0.018). CONCLUSION Important weight loss could be a pre-operative predictive factor of early recurrence after resection of esophageal and cardial adenocarcinoma and surgery as first line treatment could be avoided in these patients.

A critical appraisal of laparoscopic pancreatic enucleations: right-sided procedures (Pancreatic Head, Uncus) are not mini-invasive surgery.

Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few small-sized series show encouraging results, especially after enucleations performed for lesions located in the left part of the pancreas. The outcome of laparoscopic pancreatic enucleations was retrospectively evaluated by the analysis of prospectively collected parameters. Results of right-sided (head/uncus) and left-sided (neck/body/tail) enucleations were compared. From 1997 to 2010, 25 patients underwent laparoscopic pancreatic enucleation. The conversion rate was 12%, mean operating time was 158 minutes, and mean blood loss was 106 mL. Morbidity was 56% and the rate of pancreatic fistula 32%. Outcome differed between patients undergoing right-sided and left-sided enucleations, the operative time being 178 versus 132 minutes, morbidity 64% versus 45%, and median hospital stay 26 versus 9 days, respectively. Pancreatic enucleation is feasible by laparoscopy, with a high success rate and no mortality but significant morbidity. Laparoscopy seems to be of no use in right-sided procedures. Pancreatic fistula is still the main cause of long-lasting morbidity.

Ambulatory groin and ventral hernia repair

OBJECTIVE Ambulatory surgery is not commonly practiced in France today. The aim of this study was to prospectively evaluate the feasibility of ambulatory hernia repair in a consecutive series of unselected patients. PATIENTS AND METHODS From June 2008 to October 2009, 257 patients (238 men and 19 women, median age 65 years) were treated in a same-day surgery unit for 270 hernias (244 groin hernias, 25 ventral hernias and one Spiegelian hernia). RESULTS For groin hernia, the techniques included the totally extraperitoneal repair (TEP) in 108 cases, the transinguinal preperitoneal (TIPP) approach in 106 cases and other alternative techniques in 30 cases; for ventral hernias, the technique was an open suture in 20 cases, an open prosthetic repair in four cases and laparoscopic repair in one case. Anesthesia was general in 145 cases, local in 121 cases and spinal in four cases. Repair was completed in a same-day surgery setting in 242 (89.6%) cases; hospital stay greater than 23 hours was planned for 21 (7.8%) patients while non-programmed hospitalizations were necessary for seven (2.6%) patients. There were two (0.7%) readmissions and nine (3.3%) benign postoperative complications. CONCLUSION These results suggest that groin and ventral hernia repair can be performed in an outpatient setting in nearly 90% of unselected patients.

Laparoscopic minor pancreatic resections (enucleations/atypical resections). A long-term appraisal of a supposed mini-invasive approach.

Introduction A few retrospective, small, often multicentric studies show encouraging results of laparoscopic minor pancreatic surgery, but do not allow for an evaluation of feasibility and effectiveness. Aim Evaluation of the results of laparoscopic minor pancreatic resections (LMPR), including atypical resections and enucleations. Material and methods The outcome of all consecutive patients undergoing LMPR in a tertiary care university hospital specializing in the laparoscopic approach to solid organs (I.M.M., Paris – France) was retrospectively evaluated by the analysis of operating time, blood loss, conversion, morbidity, stay and late outcome. Results Thirty-three patients underwent LMPR (29 enucleations and 4 atypical resections) for various diseases. The conversion rate was 21%, mean operating time 189 min, and mean blood loss 133 ml. Morbidity was 60%; 10 patients (30%) presented a pancreatic fistula. Pancreatic fistula was independent of type of resection, technique of pancreas section, management of enucleated surface and somatostatin administration. Median stay for enucleations was 18 days. Mean follow-up was 61 months. Conclusions Laparoscopic pancreatic enucleation is feasible and safe, with no mortality, no lengthening of operating time and a high success rate. Conversely, it does not imply a reduction in complications or hospital stay at the present state of the art.

Accuracy of staging laparoscopy in detecting peritoneal dissemination in patients with gastroesophageal adenocarcinoma.

Despite staging laparoscopy (SL) with peritoneal lavage is recommended in US Guidelines in patients with potentially resectable gastroesophageal adenocarcinoma, this procedure is not systematically proposed in French Guidelines. Therefore, we decided to analyze the results of systematic SL in patients considered for preoperative chemotherapy. From 2005 to 2011, 116 consecutive patients with distal esophagus, esogastric junction, and gastric adenocarcinoma ≥T3 or N+ without detectable metastatic dissemination by computed tomography (CT) scan imaging underwent SL before neoadjuvant chemotherapy. Positive and negative SLs were compared according to tumor characteristics. SL was positive in 15 cases (12.9%) including 14 with peritoneal seeding (localized in five, diffuse in nine). SL was positive in 7 (24.1%) of 29 patients with poorly differentiated tumor, in 9 (32.1%) of 28 patients with signet ring cells, in 7 (50%) of 14 patients with gastric linitis tumor, and in 15 (16.3%) of 92 patients with T3 or T4 tumor. All the lesions of distal esophagus extending to the cardia had a negative SL. Among the 14 patients with peritoneal carcinomatosis at SL, nine (65%) had signs of peritoneal seeding on initial CT scan. One (0.8%) patient had a small bowel perforation closed laparoscopically. If systematic SL before preoperative chemotherapy does not seem justified because of its low accuracy, it should be performed in patients with poorly differentiated tumor, signet ring cell, and gastric linitis plastica components on biopsy and when CT scan is suggestive of T4 tumor, ascites, or peritoneal nodule.

Fatores preditivos de morbidade nas ressecções pancreáticas esquerdas

OBJECTIVE To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors. METHODS The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity. RESULTS Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations. CONCLUSION The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

CO.95 - Traitement par colle biologique des fistules post-opératoires en chirurgie colorectale

Resume La morbidite des fistules apres chirurgie colorectale est elevee et leur traitement est difficile. Leur obturation par injection de colle de fibrine a ete ponctuellement publiee. Ce travail presente les resultats d’une etude prospective chez 14 patients.