Maxime Ronot

Effects of a Multimodal Management Strategy for Acute Mesenteric Ischemia on Survival and Intestinal Failure

BACKGROUND & AIMSnAcute mesenteric ischemia (AMI) is an emergency with a high mortality rate; survivors have high rates of intestinal failure. We performed a prospective study to assess a multidisciplinary and multimodal management approach, focused on intestinal viability.nnnMETHODSnIn an Intestinal Stroke Center, we developed a multimodal management strategy involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists; it was tested in a pilot study on 18 consecutive patients with occlusive AMI, admitted to a tertiary center from July 2009 to November 2011. Patients with left ischemic colitis, nonocclusive AMI, chronic mesenteric ischemia, and other emergencies were excluded. Patients received specific medical management: revascularization of viable small bowel and/or resection of nonviable small bowel; 12 patients received arterial revascularization. We evaluated the percentages of patients who survived for 30 days or 2 years, the number with permanent intestinal failure, and morbidity. Lengths and rates of intestinal resection were compared with or without revascularization, and in patients with early or late-stage disease.nnnRESULTSnPatients were followed up for a mean of 497 days (range, 7-2085 d); 95% survived for 30 days, 89% survived for 2 years, and 28% had morbidities within 30 days. Intestinal resection was necessary for 7 cases (39%), with mean lengths of intestinal resection of 30 cm and 207 cm, with or without revascularization, respectively (P = .03). Among patients with early or late-stage AMI, rates of resection were 18% and 71%, respectively (P = .049). Patients with early stage disease had shorter lengths of intestinal resection than those with late-stage disease (7 vs 94 cm; P = .02), and spent less time in intensive care (2.5 vs 49.8; P = .02).nnnCONCLUSIONSnA multidisciplinary and multimodal management approach might increase survival of patients with AMI and prevent intestinal failure.

Neither Preoperative Computed Tomography nor Intra-Operative Examination can Predict Metastatic Lymph Node in the Hepatic Pedicle in Patients with Colorectal Liver Metastasis

BackgroundIn patients operated on for colorectal liver metastasis (CRLM), metastatic lymph node (LN) of the hepatic pedicle is a major prognostic factor. Efficiency of preoperative computed tomography (CT) and intraoperative examination for the diagnosis of metastatic LN of hepatic pedicle is prospectively evaluated.MethodsFrom January 2008 to June 2010, 76 patients underwent liver resection for CRLM, with systematic LN pedicle dissection. Preoperative CT scan evaluated prospectively location, size, and aspect of LN, whereas the surgeon assessed size and consistency of LN Results of CT and intraoperative findings were compared with pathologic findings to determine sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV).ResultsA total of 241 nodes were analyzed (3.2xa0±xa02.1 LN per patient). Systematic LN dissection increased the operative time by a mean of 20xa0±xa012.5xa0min, without any specific morbidity or mortality related to the LN clearance. Metastatic LN in the hepatic pedicle was observed in 15 (20%) patients and were unrelated to the number, size, and location of CRLM. NPV and PPV of the preoperative CT scan was 85 and 56%, respectively. Intraoperative evaluation of LN had a high NPV of 91% with a low PPV of 43%. Even with the combination of CT and intraoperative evaluation, 27% of the patients with a pathological metastatic LN were not suspected.ConclusionsBecause neither the preoperative CT nor the surgical evaluation accurately predicts metastatic LN in the hepatic pedicle, accurate oncological staging require a systematic pedicular LN clearance during liver resection for CRLM.

Efficacy and Safety of Aspiration Sclerotherapy of Simple Hepatic Cysts: A Systematic Review

OBJECTIVEnAspiration sclerotherapy is a percutaneous procedure indicated for treatment of symptomatic simple hepatic cysts. The efficacy and safety of this procedure have been sources of debate and disagreement for years. The purpose of this study was to assess the long-term efficacy and safety of aspiration sclerotherapy in a systematic review of the literature.nnnMATERIALS AND METHODSnA systematic search was conducted of the electronic databases PubMed MEDLINE, Embase, Web of Science, and the Cochrane Library (until August 2015). Studies of proportional volume or diameter reduction after aspiration sclerotherapy of simple hepatic cysts were included for full-text evaluation. Case reports and case series were excluded. Risk of bias was assessed by use of the Newcastle-Ottawa scale.nnnRESULTSnFrom 9357 citations, 100 were selected for full-text assessment. We included 16 studies, which included 526 patients with a total of 588 treated cysts. Overall, risk of bias was high, with 12 of 16 studies having a score of poor. Proportional cyst volume reduction ranged between 76% and 100% after a median follow-up period of 1-54 months. Change in symptoms was evaluated in 10 studies: 72-100% of patients reported symptom reduction, and 56-100% reported disappearance. Postprocedural pain occurred most frequently, at a rate of 5-90% among studies. Ethanol intoxication occurred in up to 93% of cases and was reported more frequently in studies with either high ethanol volumes (133.7-138.3 mL) or long sclerotherapy duration (120-180 minutes).nnnCONCLUSIONnWe found excellent results with respect to long-term efficacy and safety after aspiration sclerotherapy of hepatic cysts. Nevertheless, because of the high risk of bias in the included studies, definite conclusions regarding efficacy cannot be drawn.

Colorectal Liver Metastases Growth in the Embolized and Non-Embolized Liver After Portal Vein Embolization: Influence of Initial Response to Induction Chemotherapy

PurposeTo compare tumor progression in both embolized and non-embolized liver lobes after portal vein embolization (PVE) in patients with bilobar colorectal liver metastases (CLM), according to the initial response to induction chemotherapy.MethodsFrom 2002 to 2012, a total of 42 consecutive patients with bilobar CLM initially treated using induction chemotherapy underwent right PVE to achieve adequate future liver remnant volume. Tumoral and liver parenchyma volumes, as well as their volume variations, were measured on computed tomography before and after PVE in both embolized and non-embolized. Patients were classified as fast (≤6xa0cycles of induction chemotherapy) and slow (>6xa0cycles) responders.ResultsOverall, 432 metastases were analyzed in 42 patients. Patients were slow responders in 29 (69xa0%) cases. Tumoral volume increased in 29 (69xa0%) cases in the embolized liver (+48xa0%; pxa0<xa00.0001), and in 28 (66xa0%) cases in the non-embolized liver (+31xa0%; pxa0<xa00.0001). Fast responders had a tumoral volume decrease in both embolized (−4xa0%) and non-embolized (−9xa0%) lobes. On the opposite side, slow responders had tumoral volume increase in both embolized (+79xa0%) and non-embolized (+32xa0%) lobes. On multivariate analysis, a ‘slow’ response to induction chemotherapy was the only factor associated with tumoral progression in both embolized (pxa0=xa00.0012) and non-embolized (pxa0=xa00.001) lobes.ConclusionTumor growth after PVE is observed in both embolized and non-embolized liver lobes in most patients but is significantly associated with slow response to induction chemotherapy.

TRIP: a pathological score for transarterial chemoembolization resistance individualized prediction in hepatocellular carcinoma

Although potentially very useful in optimizing patient selection and follow‐up, the individual response to transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC) is generally unpredictable. The aim of this study was to identify tissue predictors of tumour resistance to TACE for use in clinical practice on pretreatment biopsies.

Lemmel's syndrome as a rare cause of obstructive jaundice.

Obstructive jaundice is a frequent symptom most frequently resulting from choledocolithiasis or pancreatico-biliary and periampullary tumors. If duodenal diverticula are frequently asymptomatic, they can occasionally present with obstructive jaundice in the absence of lithiasis or another obstructing lesion such as a tumor in a presentation called Lemmels syndrome. We herein present a 70-year-old male with obstructive jaundice secondary to a periampullary duodenal diverticulum associated with hepatic abscess. Endoscopic sphincterotomy associated with percutaneous abscess drainage released patient from all symptoms. Lemmels syndrome as a rare cause of obstructive jaundice should be known in order to avoid mismanagement and therapeutic delay.

Imaging review of hepatocellular carcinoma after thermal ablation: The good, the bad, and the ugly.

Image‐guided thermal ablation is a well‐established locoregional technique for the treatment of hepatocellular carcinoma (HCC). HCC surveillance programs have led to an increase in the number of patients diagnosed at an early stage of the disease who are eligible for thermal ablation. Tumor response is assessed on imaging and requires extensive follow‐up; thus, radiologists play a key role in defining the technical success and efficacy of treatment as well as identifying progressive disease. Although they are rare, complications, such as secondary infections, must also be identified. Several contrast‐enhanced imaging techniques can be used at different postprocedural timepoints but magnetic resonance imaging (MRI) and computed tomography (CT), which allow both liver‐centered and whole‐body imaging are the cornerstones of follow‐up. This review describes the imaging features of HCC following thermal ablation. After describing the basic technical elements of follow‐up imaging, imaging findings are divided into three groups: normal and expected features (the good), abnormal features, uncontrolled disease, and complications (the bad), and atypical or rare presentations (the ugly). J. Magn. Reson. Imaging 2016;44:1070–1090.

Local venous thrombotic risk of an expanding haemostatic agent used during liver resection.

BackgroundFor patients undergoing liver resection that leaves an empty intraparenchymal cavity, traditional topical agents might be inadequate to achieve additional hemostasis. A new hemostatic expanding topical foam (BioFoam®) has been designed to provide a mechanical seal. The objective of this study was to report our preliminary results regarding the safety and the efficacy using this foam.MethodsBetween 2009 and 2011, BioFoam® was used to fill a three-dimensional defect following liver resection in 14 patients. The operative results and postoperative course of these patients were compared to those of 14 matched controls who underwent liver resection but did not receive BioFoam®.ResultsThe two groups were similar in terms of demographics, indications for liver resection, type of surgical procedure, and type and duration of clamping. BioFoam® patients experienced significantly less operative blood loss (275xa0vs. 630xa0ml, pxa0=xa00.032) but similar operative transfusion rates (28.6 vs. 35.7xa0%, pxa0=xa00.686) compared to no-BioFoam® patients. The postoperative mortality was nil and no patient developed postoperative hemorrhage. While the two groups shared similar overall (64.3 vs. 57.1xa0%, pxa0=xa00.599) and major (28.6 vs. 14.3xa0%, pxa0=xa00.357) complications rates, BioFoam® patients experienced significantly higher major vascular thrombosis compared to no-BioFoam® patients (29 vs. 0xa0%, pxa0=xa00.04). In the BioFoam® group, major vascular thrombosis was associated with exposure of the vessel along the transection plane.ConclusionWhile the clinical benefit of BioFoam® in high-risk liver resections leaving a deep parenchymal defect remains to be proven, the associated risk of vascular thrombosis should preclude its use in contact with major veins.

Focal Nodular Hyperplasia After Treatment With Oxaliplatin: A Multiinstitutional Series of Cases Diagnosed at MRI

OBJECTIVEnBenign hepatic lesions may occur after chemotherapy treatment and may mimic metastases at imaging. We describe focal nodular hyperplasia (FNH) lesions diagnosed at MRI that occurred de novo after treatment with oxaliplatin.nnnMATERIALS AND METHODSnThis is a multiinstitutional case series. We report 14 adult patients with cancer (eight men and six women) with a history of treatment with oxaliplatin and development of new hepatic lesions diagnosed as FNH at pathologic analysis or MRI or both. Imaging and pathology features of the included lesions, the interval since chemotherapy, and the temporal evolution were reviewed.nnnRESULTSnThe mean interval between the completion of oxaliplatin treatment and the identification of new hepatic FNH at imaging was 47.6 months. In seven of 14 (50%) patients, the index lesion was diagnosed at pathologic analysis (biopsy or resection) as FNH. In the remaining seven cases, the diagnosis was based on highly accurate MRI features (e.g., hyper- or isointensity of the lesion on hepatobiliary phase images). Lesion growth or occurrence of new lesions was present in 75% of patients at imaging follow-up.nnnCONCLUSIONnFNH lesions can occur de novo after treatment with oxaliplatin. Recognizing the typical MRI appearance of these lesions may avoid unnecessary biopsy or surgery and reduce patients anxiety.

Risks factors for severe pain after selective liver transarterial chemoembolization.

Post‐procedural pain is frequent after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC), and is only partially prevented by treatment selectivity. Our aim was to determine the risk factors of severe pain after selective TACE for HCC.