Laurent Sulpice

Conservative surgical management of Boerhaave's syndrome: Experience of two tertiary referral centers

BACKGROUND Surgery is generally proposed for Boerhaaves syndrome, spontaneous rupture of the esophagus. But diagnosis can be difficult, delaying appropriate management. The purpose of the present study was to evaluate outcome of conservative surgery for primary or T-tube repair performed in two tertiary referral centers. METHODS From June 1985 to November 2010, among 53 patients presenting with Boerhaaves syndrome treated surgically, 39 underwent a conservative procedure. These patients were retrospectively divided into two groups by type of repair: primary suture (group 1, n = 25) or suture on a T-tube (group 2, n = 14). Patients in group 1 were further stratified into two subgroups depending on whether the primary suture was made with reinforcement (subgroup rS) or not (subgroup S). RESULTS Length of stays in hospital and intensive care were shorter in patients in group 1 (p = 0.037), but after a shorter delay before therapeutic management (p = 0.003) compared with group 2. For the other variables studied, outcome was more favorable in group 1, but the differences were not significant. Comparing subgroups rS and S showed that the rate of persistent leakage was significantly lower after reinforced suture (p = 0.021). CONCLUSIONS These findings from the largest reported cohort of Boerhaaves syndrome patients undergoing conservative surgery showed that primary and T-tube repair provide at least equivalent results. Reinforced sutures appear to provide better outcomes by reducing postoperative leakage.

Impact of age over 75 years on outcomes after pancreaticoduodenectomy

BACKGROUND The risks associated with pancreaticoduodenectomy (PD) in elderly patients continue to be debated. The aim of our study was to assess the incidence of death and postoperative complications following PD and identify the risk factors in patients >75 y. STUDY DESIGN All patients who underwent PD between January 2000 and September 2009 were analyzed retrospectively. Patients were divided into two groups according to age (Group 1: patients aged <75 y, and Group 2: patients aged ≥ 75 y). Morbidity and perioperative mortality risk factors were analyzed using univariate and multivariate analyses. RESULTS Among the 314 patients, 273 were included in Group 1 (sex ratio 1.4) and 41 in Group 2 (sex ratio 1). In multivariate analysis, postoperative hemorrhage (PH) (OR 6.61, IC95% [1.96; 22.31], P = 0.002) and age >75 y proved to be predictive factors for mortality (OR 11.04, IC95% [2.57; 47.49], P = 0.001). When compared with Group 1, Group 2 was associated with increased postoperative deaths (24.4% versus 3.66%, P < 0.001) and pancreatic fistulas (26.8% versus 13.2%, P = 0.041), in particular, Grade C fistulas (14.6% versus 4.4%, P = 0.023). In multivariate analysis, only PH proved to be an independent predictive factor for mortality (OR 12.9, IC95% [1.07; 155.5], P = 0.04). CONCLUSIONS PD in elderly patients aged over 75 y appears to be associated with an increased risk of postoperative death and pancreatic fistula. No single preoperative factor made it possible to predict this risk.

Extended liver resections for intrahepatic cholangiocarcinoma: Friend or foe?

BACKGROUND In patients with intrahepatic cholangiocarcinoma (ICC), extended liver resections (ELRs) increase the rate of resectability. The aims of the present study were to evaluate the morbidity and oncologic outcomes of ELR compared with other liver resections (LR) for ICC. METHODS All LR for ICC that were performed in our center between January 1997 and September 2013 and conducted with curative intent were included in this retrospective analysis. ELRs were defined by resections of ≥5 liver segments. The factors that influenced the occurrence of major complications (Clavien ≥ 3) and overall survival (OS) were tested with univariate and multivariate analyses. RESULTS One hundred seven patients (82 men and 25 women) were resected, and 27 (25.3%) underwent ELRs. Compared with the LRs, the ELRs were performed in larger tumors (P = .003) and were significantly associated with more complex surgeries such as vascular (P < .001) or biliary reconstructions (P < .001). Multivariate analysis revealed that ELR was an independent risk factor for major complications (odds ratio [OR], 6.2; 95% CI, 2.11-19.62; P < .001). Compared with the other LRs, ELRs had no effects on OS or disease-free survival (P = .881 and P = .228, respectively). Perioperative blood transfusion (Hazard ratio (HR), 2.51; 95% CI, 1.49-4.23; P < .001), the presence of >1 nodule (HR, 3.17; 95% CI, 1.67-5.97; P < .001), and age ≥65 years (HR, 1.72; 95% CI, 1.03-2.86; P = .036) were independent prognostic factors for OS. CONCLUSION This study suggests that ELRs performed for large ICCs do not affect negatively oncologic outcomes, despite the increased risk of major complications.

Intrahepatic cholangiocarcinoma: impact of genetic hemochromatosis on outcome and overall survival after surgical resection.

BACKGROUND The influence of genetic hemochromatosis (GH) on outcomes following surgical resections for intrahepatic cholangiocarcinoma (ICC) has not been evaluated. METHODS All patients with ICC who underwent a surgical resection between January 1997 and August 2011 were analyzed retrospectively. Risk factors were assessed by univariate and multivariate analyses. RESULTS Eighty-seven patients were analyzed; 16 of these patients (18.4%) had GH. Among the 71 non-GH patients, 52 (73.2%) and 19 (26.8%) had normal or cirrhotic parenchyma, respectively. There was no significant difference in survival between the GH and non-GH patients. A univariate analysis showed that major hepatectomy (P = 0.012), intraoperative blood transfusion (P = 0.007), tumor size >5 cm (P = 0.006), several nodules (P < 0.001), and microvascular invasion (P = 0.04) were significantly associated with poor survival. A multivariate analysis showed that intraoperative blood infusion (HR 0.37; CI 95% [0.19; 0.71]) and more than one nodule (HR 2.5; CI 95% [1.06; 5.8]) were associated with a lower survival rate. CONCLUSION Although the incidence of GH was high in our series, the presence of GH did not affect the outcomes after a liver hepatectomy for ICC. GH does not appear to increase recurrences or worsen the overall and disease-free survival.

Pancreatic head cancer in patients with chronic pancreatitis

BACKGROUND Chronic pancreatitis (CP) is a risk factor of pancreatic adenocarcinoma (PA). The discovery of a pancreatic head lesion in CP frequently leads to a pancreaticoduodenectomy (PD) which preceded by a multidisciplinary meeting (MM). The aim of this study was to evaluate the relevance between this indication of PD and the definitive pathological results. METHODS Between 2000 and 2010, all patients with CP who underwent PD for suspicion of PA without any histological proof were retrospectively analyzed. The operative decision has always been made at an MM. The definitive pathological finding was retrospectively confronted with the decision made at an MM, and patients were classified in two groups according to this concordance (group 1) or not (group 2). Clinical and biological parameters were analyzed, preoperative imaging were reread, and confronted to pathological findings in order to identify predictive factors of malignant degeneration. RESULTS During the study period, five of 18 (group 1) patients with CP had PD were histologically confirmed to have PA, and the other 13 (group 2) did not have PA. The median age was 52.5+/-8.2 years (gender ratio 3.5). The main symptoms were pain (94.4%) and weight loss (72.2%). There was no patients death. Six (33.3%) patients had a major complication (Clavien-Dindo classification ≥ 3). There was no statistical difference in clinical and biological parameters between the two groups. The rereading of imaging data could not detect efficiently all patients with PA. CONCLUSIONS Our results confirmed the difficulty in detecting malignant transformation in patients with CP before surgery and therefore an elevated rate of unnecessary PD was found. A uniform imaging protocol is necessary to avoid PD as a less invasive treatment could be proposed.

Multimodal therapy including yttrium-90 radioembolization as a bridging therapy to liver transplantation for a huge and locally advanced intrahepatic cholangiocarcinoma

Treatment of intrahepatic cholangiocarcinoma remains a major challenge. For an unresectable lesion without extrahepatic spread, liver transplantation could be a potential solution but it is still associated with poor oncologic results owing to the absence of effective neoadjuvant treatment. We report the case of a young man with locally advanced intrahepatic cholangiocarcinoma presenting with multiple intrahepatic metastases and vascular structure involvement. The lesion was significantly downstaged by a multimodal therapy including intra-arterial Yttrium-90 radioembolization, systemic chemotherapy and external radiotherapy, allowing liver transplantation. Three years after the procedure, oncologic outcome is excellent with no sign of recurrence. Multimodal therapy including Yttrium-90 radioembolization could be relevant as neoadjuvant treatment before liver transplantation for unresectable intrahepatic cholangiocarcinoma.

Hepatobiliary and Pancreatic: Leiomyosarcoma of the inferior vena cava

A 28-year-old woman was diagnosed with a leiomyosarcoma of the inferior vena cava in 2011. She was treated surgically with replacement of the inferior vena cava and a right nephrectomy. The tumor was classified histologically as Grade 2 according to the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC). The surgical margins were negative for tumor. A computerized tomography (CT) scan after the operation showed the caval graft and a left hepatic vein that was free of tumor (Figure 1 left). A repeat CT scan in 2013 revealed a retrohepatic vena caval mass. There was no significant response to chemotherapy. Because of this, vena caval replacement under veno-venous bypass was performed along with a left hepatectomy due to involvement of the left and middle hepatic vein. During the operation, the liver was perfused with hypothermic fluid. The surgical specimen in Figure 2 (upper) showed the left hepatectomy with a retrohepatic vena cava and previous caval graft. Figure 2 (lower) shows the right lobe of the liver with the right hepatic vein and caval graft. Histological evaluation of resected tissue confirmed the presence of leiomyosarcoma FNCLCC grade 3. Her post-operative course was uneventful and she was discharged on day 14 with normal hepatic function. A repeat CT scan showed appropriate flow in the right hepatic vein (Figure 1 right). She is currently in reasonable health with no evidence of tumor recurrence 6 months after surgery. Soft tissue sarcomas are an uncommon and heterogeneous group of tumors that comprise approximately 1% of all adult malignancies and 10% of pediatric cancers. They are usually classified according to the presumptive tissue of origin. In the case of leiomyosarcomas, the tumors are thought to arise from smooth muscle, particularly in veins. Approximately 50% are reported to arise from the inferior vena cava. The disease appears to be more common in women than in men (ratio 3 : 1) and there is a mean age at diagnosis of approximately 50 years. Most tumors grow extraluminally and may be relatively large (eg 10–15 cm) at the time of diagnosis. Radical surgery appears to provide the best chance of long-term survival with 5 and 10 year survival rates of 50% and 20% respectively in patients treated by resection without documented residual macroscopic disease. Factors associated with a poor prognosis include tumors in the suprahepatic portion of the inferior vena cava and tumors associated with hepatic decompensation.

Does an aberrant right hepatic artery really influence the short- and long-term results of a pancreaticoduodenectomy for malignant disease? A matched case-controlled study

BACKGROUND An aberrant right hepatic artery (ARHA) is a common anatomic variation. The risk associated with ARHA during pancreaticoduodenectomy (PD) continues to be debated. The aim of this study was to compare the clinical outcomes and survival after PD with ARHA against a matched cohort of patients without ARHA. METHODS PD with an ARHA performed between January 2000 and September 2009 were retrospectively analyzed. Patients with an ARHA (group 1) were matched (1:2) to patients without an ARHA (group 2) according to gender, age, body mass index, type of tumor, and lymph node status. Peri- and postoperative outcomes were compared between the two groups. Overall survival and disease-free survival were estimated by Kaplan-Meier method and compared with log-rank test. RESULTS A total of 29 patients (group 1) and 55 patients (group 2) were compared. In group 1, an ARHA entered the tumor in six cases (20.7%), was sacrificed in four cases, and repaired in two cases. There was no difference regarding the rate of intraoperative and postoperative variables between the two groups. The oncological clearance (P = 0.731) and survival (overall survival, P = 0.843; disease-free survival, P = 0.832) were also similar. CONCLUSIONS Our study showed that the presence of an ARHA during PD was not associated with worse postoperative outcomes or survival.

Extrahepatic Portal Vein Aneurysm

Portal vein aneurysms (PVAs) are usually incidental on imaging and asymptomatic. If it is symptomatic or associated with a pathologic finding, a treatment is recommended. We report a case of a 75-year-old Caucasian man presenting with symptomatic and size-increasing portosplenomesenteric aneurysms. Interventional radiology was not indicated because of the large size. A surgical approach was chosen for the patient. Surgical technique consists of an aneurysmorrhaphy in the first time and in the second time, a Goretex prosthesis placement involving the vein. Early complication was treated with a radiologic approach. Six months after surgery, patient had no more symptoms. PVA management remains a surgical challenge for surgeon, for timing and type of treatment.

An update on liver surgery for cholangiocarcinoma

Cholangiocarcinoma is a malignant neoplasm that originates from biliary epithelial cells. Complete tumor resection remains the most effective treatment of intra-hepatic or perihilar cholangiocarcinomas (PHCs). The objectives of this are to update and discuss methods that are likely to increase the resectability of cholangiocarcinomas, and to define the limits beyond which the risks of the treatments outweigh their benefits. We analyzed intra-hepatic cholangiocarcinomas and PHCs separately to determine the site of origin and the resectability of the tumor. We discussed the site at which to perform hepatic optimization prior to surgery, and whether liver transplantation might affect cholangiocarcinoma treatment.