Jean Lubrano

Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials.

OBJECTIVE To review prospective randomized controlled trials to determine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is associated with lower risks of mortality and pancreatic fistula after pancreaticoduodenectomy (PD). BACKGROUND Previous studies comparing reconstruction by PG and PJ reported conflicting results regarding the relative risks of mortality and pancreatic fistula after these procedures. METHODS MEDLINE, the Cochrane Trials Register, and EMBASE were searched for prospective randomized controlled trials comparing PG and PJ after PD, published up to November 2013. Meta-analysis was performed using Review Manager 5.0. RESULTS Seven trials were selected, including 562 patients who underwent PG and 559 who underwent PJ. The pancreatic fistula rate was significantly lower in the PG group than in the PJ group (63/562, 11.2% vs 84/559, 18.7%; odds ratio = 0.53; 95% confidence interval, 0.38-0.75; P = 0.0003). The overall mortality rate was 3.7% (18/489) in the PG group and 3.9% (19/487) in the PJ group (P = 0.68). The biliary fistula rate was significantly lower in the PG group than in the PJ group (8/400, 2.0% vs 19/392, 4.8%; odds ratio = 0.42; 95% confidence interval, 0.18-0.93; P = 0.03). CONCLUSIONS In PD, reconstruction by PG is associated with lower postoperative pancreatic and biliary fistula rates.

Liver resection for breast cancer metastasis: Does it improve survival?

PurposeTo assess the outcome and prognostic factors of liver surgery for breast cancer metastasis.MethodsWe retrospectively examined 16 patients who underwent partial liver resection for breast cancer liver metastasis (BCLM). All patients had been treated with chemotherapy or hormonotherapy, or both, before referral for surgery. We confirmed by preoperative radiological examinations that metastasis was confined to the liver. The survival curve was estimated using the Kaplan-Meier method. Univariate and multivariate analysis were conducted to evaluate the role of the known factors of breast cancer survival.ResultsThe median age of the patients was 54 years (range 38–68) and the median disease-free interval between the diagnoses of breast cancer and liver metastasis was 54 months (range 7–120). Nine major and 7 minor hepatectomies were performed. There was no postoperative death. The overall 1-, 3-, and 5-year survival rates were 94%, 61%, and 33%, respectively. The median survival rate was 42 months. Univariate analysis revealed that hormone receptor status, number of metastases, a major hepatectomy, and a younger age were associated with a poorer prognosis. The survival rate was not influenced by the disease-free interval, grade or stage of breast cancer, or intraoperative blood transfusions. The number of liver metastases was identified as a significant independent factor of survival according to the Cox proportional hazard model (P = 0.04).ConclusionsLiver resection, when done in combination with adjuvant therapy, can improve the prognosis of selected patients with BCLM.

Long-Term Outcome of Liver Resection for Hepatocellular Carcinoma in Noncirrhotic Nonfibrotic Liver with No Viral Hepatitis or Alcohol Abuse

BackgroundHepatocellular carcinoma (HCC) occurs primarily in cirrhotic liver, with less than 10% occurring in normal liver parenchyma. Limited studies have described the outcome of liver resection in strictly normal liver parenchyma with no cirrhosis, fibrosis, underlying viral hepatitis, alcohol abuse, or dysmetabolic syndrome.Materials and methodsBetween January 1986 and 2005, a total of 321 patients were referred to our institution for HCC. Of these patients, 20 (6.2%) underwent surgery for HCC arising in noncirrhotic nonfibrotic liver parenchyma; they comprise our study group. Pathology examinations were reviewed based on the Chevallier fibrosis score and the Metavir viral score. Pre-, per-, and postoperative data were collected to assess their influence on tumor recurrence and survival.ResultsThe median age was 57 years (35–80 years), and 71% patients were male. α-Fetoprotein serum levels were normal in 9 patients. A preoperative diagnosis was made in 14 cases. Morbidity and morality rates were 10% and 5%, respectively. The 1-, 3-, and 5-year survival rates were 85%, 70%, and 64%, respectively; and disease-free survivals at 1, 3, and 5 years were 84%, 66%, and 58%, respectively. Eight patients had a recurrence with a median delay of 15 months (2–70 months). Univariate analysis showed that survival was influenced by preoperative cytolysis, R0 resection, recurrence, and recurrence within 1 year. A multivariate analysis revealed that recurrence and recurrence within 1 year significantly decreased survival. The 1-, 3-, and 5-year survival rates of patients with recurrence were 75%, 37%, and 25%, respectively.ConclusionThese results for HCC in patients with normal liver parenchyma justify liver resection and underline the differences in outcome of patients with HCC in a cirrhotic liver.

Transjugular intrahepatic portosystemic shunt placement increases feasibility of colorectal surgery in cirrhotic patients with severe portal hypertension

BACKGROUND Colorectal resection in cirrhotic patients is associated with high mortality and morbidity related to portal hypertension and liver insufficiency. METHODS This retrospective study evaluated the clinical outcomes of cirrhotic patients who underwent transjugular intrahepatic porto-systemic shunt (TIPS) placement before colorectal resection for cancer. Main outcomes measures were postoperative morbidity and mortality rates. RESULTS TIPS placement was successful in all eight patients and significantly decreased the mean hepatic venous pressure gradient from 15.5 ± 2.9 to 7.5 ± 1.9 mmHg (p = 0.02). Surgical procedures included right colectomy (n = 3), left colectomy (n = 2), and proctectomy with total mesorectal excision (n=3). Post-operatively, two patients (25%) died of multiple organ failure. The overall postoperative morbidity rate was 75%, and major complications were seen in 25%. CONCLUSION Portal decompression via TIPS placement may enable selected cirrhotic patients with severe portal hypertension to undergo colorectal resection for cancer.

Down‐regulated expression of the TSAP6 protein in liver is associated with a transition from cirrhosis to hepatocellular carcinoma

Aims:  Hepatocellular carcinoma (HCC) results from cirrhosis and, in Western Europe, hepatitis C virus and alcoholism are the predominant causes of this disease. We recently documented a global transcript repression in hepatocarcinoma nodules. The tumour suppressor activated pathway‐6 (TSAP6) transcript codes for a transmembrane molecule that is an inducer of a caspase‐3‐dependent apoptotic pathway. The down‐regulation of TSAP6 transcripts in HCC and perinodular cirrhosis, which contrasts with a sustained transcript level in HCC‐free cirrhosis, has suggested that this hepatic protein level may provide a prognostic marker for HCC occurrence.

Delayed laparoscopic cholecystectomy increases the total hospital stay compared to an early laparoscopic cholecystectomy after acute cholecystitis: an updated meta‐analysis of randomized controlled trials

BACKGROUND The objective of this study was to review the available prospective, randomized, controlled trials to determine whether an early (ELC) or a delayed (DLC) approach to a laparoscopic cholecystectomy is associated with an increase in length of hospitalization after acute cholecystitis. METHODS Medline, the Cochrane Trials Register and EMBASE were searched for prospective, randomized, controlled trials (RCTs) comparing ELC versus DLC, published up to May 2014. A meta-analysis was performed using Review Manager 5.0. RESULTS Nine RCTs were included in a total of 617 who underwent ELC and 603 patients who underwent DLC after acute cholecystitis. The mean hospital stay was 5.4 days in the ELC group and 9.1 days in the DLC group. The meta-analysis showed a mean hospital stay significantly lower in the ELC group [medical doctor (MD) = 3.24, 95% confidence interval (CI) = 1.95-4.54, P < 0.001]. The major biliary duct injury rate in the ELC group was 0.8% (2/247) and 0.9% (2/223) in the DLC group. The meta-analysis showed no significant difference between the ELC and DLC groups [relative risk (RR) =0.96, 95%CI = 0.25-3.73, P = 0.950]. CONCLUSION DLC is associated with a longer total hospital stay but equivalent morbidity as compared to ELC for patients presenting with acute cholecystitis. ELC would appear to be the treatment of choice for patients presenting with ELC.

Ciliated hepatic foregut cyst discovered after kidney transplantation in a hepatitis C virus-infected patient: a report of one case and review of the literature.

Ciliated hepatic foregut cyst (CHFC) is a rare liver lesion derived from the embryonic foregut. In most cases, CHFC remains asymptomatic but some malignant transformations have been reported. Typical imaging features usually lead to diagnosis using ultrasonography, computed tomography scan examination or MRI. When the diagnosis remains uncertain, a fine needle aspiration with cytology is appropriate. The presence of ciliated epithelial cells with hepatocytes and mucous cells on aspiration cytology is enough to assess the diagnosis. Surgery is recommended when there is uncertain diagnosis or malignant lesion suspicion. We report herein, the case of a CHFC discovered in a hepatitis C virus-infected patient following a renal transplantation. To eliminate a lymphoma or a liver tumor arising because of patients immunosuppression status, a surgical resection of the lesion was performed. The surgical outcome was uneventful. Regarding this case, embryogenesis, morphological characteristics and treatment of the lesions are discussed.

Faisabilité d’une chimiohyperthermie intra-péritonéale itérative après chirurgie de cytoréduction pour récidive de carcinose péritonéale: A propos de 5 cas

Peritoneal carcinomatosis has been treated by extensive cytoreduction surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). We report here our experience of 5 patients treated twice or three times by recurrent procedure of HIPEC and cytoreduction. The mortality rate was 0% and morbidity one 30%. Three patients have died at 6, 10, 18 months respectively after the second cytoreduction surgery and HIPEC, and two patients are still alive at 40 and 67 months. Our results might suggest that recurrent peritoneal carcinomatosis after cytoreduction and HIPEC, could be usefully treated by another cytoreduction and HIPEC procedure in a curative approach superior to more conventional treatments.

Traumatisme splénique par cathéter de dérivation ventriculo-péritonéale

Ventriculoperitoneal shunt is used as a treatment of hydrocephalus. Although this procedure is usually safe, several abdominal complications have been reported in the literature. However, to our knowledge, a catheter-induced splenic trauma has not been previously described. We report here the case of a patient who presented with a spontaneous splenic trauma, 10 years after ventriculoperitoneal shunt insertion. A conservative treatment with careful monitoring was successful and the patient recovered without surgery.

Esophagopericardial fistula: an unexpected dreaded complication of treatment of leak following revisional sleeve gastrectomy by endoscopic internal drainage

Abstract Esophagopericardial fistula (EPF) is an uncommon but life-threatening complication of upper gastrointestinal tract surgery or endoscopy, which is related to anastomotic breakdown, chronic infection or esophageal traumatism. We first describe the first case of an EPF secondary to double pigtail drain migration: an endoscopic internal approach for the treatment of leak following revisional sleeve gastrectomy.