Pierre-Louis Fagniez

Laparoscopic Liver Resections: A Feasibility Study in 30 Patients

ObjectiveTo assess the feasibility and safety of laparoscopic liver resections. Summary Background DataThe use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. MethodsA prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2–6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. ResultsFrom May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. ConclusionLaparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.

Laparoscopic Liver Resection for Peripheral Hepatocellular Carcinoma in Patients With Chronic Liver Disease: Midterm Results and Perspectives

Objective:Report the midterm results of laparoscopic resection for hepatocellular in chronic liver disease (CLD). Summary Background Data:Surgical resection for hepatocellular carcinoma (HCC) in chronic liver disease (CLD) remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity. Methods:From 1998 to 2003, patients with HCC and CLD were considered for laparoscopic liver resection. Inclusion criteria were chronic hepatitis or Childs A cirrhosis, solitary tumor ≤5 cm in size, and location in peripheral segments of the liver. Mortality, morbidity, recurrence rates, and survival were analyzed. Results:A total of 27 patients were included. Liver resections included anatomic resection in 17 cases and non anatomic resection in 10. Seven conversions to laparotomy (26%) occurred for moderate hemorrhage in 5 cases and technical difficulties in 2 cases. Mortality and morbidity rates were 0% and 33%, respectively. Postoperative ascites and encephalopathy occurred in 2 patients (7%) who both had undergone conversion to laparotomy. Mean surgical margin was 11 mm (range, 1–47 mm). After a mean follow-up of 2 years (range, 1.1–4.7), 8 patients (30%) developed intrahepatic tumor recurrence of which one died. Treatment of recurrence was possible in 4 patients (50%), including orthotopic liver transplantation, right hepatectomy, radiofrequency ablation, and chemoembolization in 1 case each. There were no adhesions in the 2 reoperated patients. Overall and disease-free 3-year survival rates were 93% and 64%, respectively. Conclusion:Our study shows that laparoscopic liver resection for HCC in selected patients is a safe procedure with very good midterm results. This approach could have an impact on the therapeutic strategy of HCC complicating CLD as a treatment with curative intent or as a bridge to liver transplantation.

Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study.

: In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.

Randomized Trial of Choledochocholedochostomy With or Without a T Tube in Orthotopic Liver Transplantation

ObjectiveTo compare the incidence of biliary complications after liver transplantation in patients undergoing choledochocholedochostomy reconstruction with or without T tube in a multicenter, prospective, randomized trial. Summary Background DataSeveral reports have suggested that biliary anastomosis without a T tube is a safe method of biliary reconstruction that could avoid complications related to the use of T tubes. No large prospective randomized trial has so far been published to compare the two techniques. MethodsOne hundred eighty recipients of orthotopic liver transplantation were randomly assigned to choledochocholedochostomy with (n = 90) or without (n = 90) a T tube in six French liver transplantation centers. All types of biliary complications were taken into account. ResultsThe overall biliary complication rate was increased in the T-tube group, even though these complications did not lead to an increase in surgical or radiologic therapeutic procedures. The major significant complication was cholangitis in the T-tube group; this did not occur in the other group. The incidence of biliary fistula was 10% in the T-tube group and 2.2% in the group without a T tube. Other biliary complications were similar. The complication rate of cholangiography performed with the T tube was greater than with other types of biliary exploration. The graft and patient survival rates were similar in the two groups. ConclusionThis study is the first large prospective, randomized trial of biliary complications with or without a T tube. The authors found an increase in the biliary complication rate in the T-tube group, which was linked to minor complications. The T tube did not provide a safer access to the biliary tree compared with the others types of biliary explorations. The authors recommend the performance of choledochocholedochostomy without a T tube in liver transplantation.

Long-term results after curative resection for carcinoma of the gallbladder

background The surgical management of gallbladder carcinoma is controversial, especially as regards the indications for radical resection. The aim of this study was to evaluate the results of surgical treatment for gallbladder carcinoma with special reference to the extent of its histological spread.

Increased incidence of oropharyngeal squamous cell carcinomas after liver transplantation for alcoholic cirrhosis.

BACKGROUND THE aim of this study was to describe the features of posttransplantation tumors observed in a series of liver transplant recipients with special reference to patients receiving a transplant for alcoholic cirrhosis. METHODS Among 171 consecutive liver transplant recipients, 90 patients who had received a first liver allograft for cirrhosis were studied. After liver transplantation, detection of de novo malignancies was prospectively undertaken and the characteristics of the patients in whom tumors occurred were compared with those in whom tumors did not develop. RESULTS With a follow-up of 45.2+/-21.2 months, 11 tumors were observed in 90 patients (overall incidence of 12.2%). The incidence of tumors was higher in patients receiving a transplant for alcoholic cirrhosis than in patients receiving a transplant for nonalcoholic cirrhosis (26.7% vs. 5.0%, P<0.01). Squamous cell carcinoma (SCC) of the oropharynx or esophagus and posttransplant lymphoproliferative disorders were mainly observed. SCC (uvula in two cases, tongue in one case, esophagus in one case, pharynx in one case) occurred exclusively in patients transplanted for alcoholic cirrhosis (16.7% vs. 0%, P=0.001). The incidence of posttransplant lymphoproliferative disorders was similar in alcoholics and nonalcoholics (6.7% vs. 5%, NS). Survival was not influenced by the occurrence of SCC. CONCLUSION The incidence of oropharyngeal SCC could be high in patients receiving a transplant for alcoholic cirrhosis. This could be due to an additional effect of posttransplantation immunosuppression in patients exposed to alcohol and tobacco before transplant. Careful posttransplantation screening of oropharyngeal SCC is warranted after liver transplantation for alcoholic cirrhosis.

Hepatic Vascular Exclusion With Preservation of the Caval Flow for Liver Resections

OBJECTIVE To report the technique and results of an alternative method of vascular clamping during liver resections. BACKGROUND Most liver resections require vascular clamping to avoid excessive blood loss. Portal triad clamping is often sufficient, but it does not suppress backflow bleeding, which can be prevented only by hepatic vascular exclusion. The latter method adds clamping of the inferior vena cava, which results in hypotension, requiring invasive anesthetic management. There is growing evidence that intermittent clamping is better tolerated than continuous clamping, especially in the presence of underlying liver disease. METHODS Hepatic vascular exclusion with preservation of the caval flow (HVEPC) involved conventional inflow clamping associated with outflow control by clamping the major hepatic veins, thus avoiding caval occlusion. HVEPC was used in 40 patients undergoing major or complex liver resection, including 16 with underlying liver disease. HVEPC was total (clamping of the porta hepatis and all major hepatic veins) in 20 cases and partial (clamping of the porta hepatis and the hepatic veins of the resected territory) in 20. Clamping was continuous in 22 cases and intermittent in 18. Resections included 12 hemihepatectomies, 12 extended hepatectomies, 3 central hepatectomies, and 13 uni- or bisegmentectomies. RESULTS Hemodynamic tolerance of clamping was excellent in all cases, without the need for therapeutic adjustment. Median red cell transfusion requirements were 0 units, and 28 patients (70%) did not receive any transfusions during the hospital stay. There were no deaths, and the morbidity rate was 17.5%. Median hospital stay was 10 days. CONCLUSION HVEPC is a safe and effective procedure applicable to liver tumors without invasion to the inferior vena cava. It offers the advantages of conventional hepatic vascular exclusion without its hemodynamic drawbacks, and it can be applied intermittently or partially.

Orthotopic liver transplantation with preservation of the caval and portal flows. Technique and results in 62 cases.

Sixty-two OLTs in 61 patients were performed using a technical modification reported recently, including total hepatectomy with preservation of the inferior vena cava, partial clamping of the native vena cava, and side-to-side cavacaval anastomosis. We further modified the technique by adding the early construction of a temporary end-to-side portacaval shunt, and, more recently, by using an end-to-side caval reconstruction. With this technique, the caval and portal flows were maintained throughout the procedure. Hemodynamic parameters were analyzed prospectively during the operative period and remained stable at all stages of the procedure. Venous bypass was avoided in all cases without need for increased fluid infusion. Operative time and transfusion requirements were 6.8±1.6 hr and 9.8±4.3 U of packed RBC, respectively. There were no specific complications or deaths due to the technique used and hospital mortality was 10% (6/61). The technique used in this study is a safe adjunct to the technical armamentarium of clinical liver transplantation. Its main advantage seems to be hemodynamic stability throughout the procedure, obviating the need for venous bypass or fluid overload.

Anatomical Bi- and Trisegmentectomies as Alternatives to Extensive Liver Resections

Objective To assess the technical and oncologic results of anatomic hepatic bi- and trisegmentectomies. Summary Background Data Regardless of their size, some tumors require extensive hepatectomy only because they are located centrally or in the vicinity of major portal pedicles or hepatic veins. Anatomic bi- and trisegmentectomy might represent an alternative to extensive hepatectomies in such cases. Methods Of 435 liver resections, 32 cases (7%) included 2 or 3 adjacent segments (left lateral sectionectomies, ie, bisegmentectomies 2–3, excluded). There were 16 central hepatectomies (segments 4, 5, and 8), 7 right posterior sectionectomies (segments 6 and 7) and 2 central anterior (segments 4b and 5), 1 central posterior (segments 4a and 8), 2 right superior (segments 7 and 8), 3 right inferior (segments 5 and 6), and 1 left anterior (segments 3 and 4b) bisegmentectomies. Indications were malignant disease in 29 patients, including 15 with cirrhosis and 2 with benign tumors. External landmarks, selective devascularization, and intraoperative ultrasound were used to achieve anatomic resection. Results Mortality, transfusion, and morbidity rates were 0%, 26%, and 19%, respectively. Mean section margin was 9 mm (range, 1-40 mm). Isolated intrahepatic recurrence occurred in 7 patients (24%) and 3 (43%) underwent repeat hepatectomy. Conclusion Anatomic bi- or trisegmentectomy is a safe alternative to extensive liver resection in selected patients, avoiding unnecessary sacrifice of functional parenchyma and enhancing the opportunity to perform repeat resections in cases of recurrence.

Operative and long term results after surgery for chronic radiation enteritis.

BACKGROUND About one third of patients with chronic radiation enteritis will need to be operated on during follow-up. Morbidity and life expectancy after resection and conservative surgical management for chronic radiation enteritis have not been well documented. METHODS From 1984 to 1994, 109 patients were operated on with a mean follow-up of 40 months (range 1 to 293). Postoperative mortality, early and late morbidity, long-term survival were studied in patients after resection (n = 65) and after conservative surgical management (n = 42), and in patients after planned or emergency procedure. Existence of possible risk factors for reoperation after a first surgical procedure was analyzed. RESULTS Five (5%) patients died in the postoperative course. Operative mortality was significantly higher when the procedure was performed as an emergency (P <0.05). Although not statistically significant, mortality was higher in the resection group (5% versus 0%). Thirty-three (30%) patients experienced postoperative complications including anastomotic leak in 11. Morbidity was not statistically related to the nature of the treatment (ie, conservative versus resection) or to the indication (emergency versus elective). During follow-up, reoperation was required in 40% of the patients, because of recurrence of digestive symptoms suggestive of chronic radiation enteritis; the reoperation rate was higher in the patients of the conservative group (50% versus 34%). Overall survival, after a mean follow-up of 40 months in patients without cancer recurrence was 85% at 1 year and 69% at 5 years after surgery, respectively. Overall survival was influenced by the nature of the treatment with 51% and 71% 5-year survival after conservative and resection treatment, respectively. CONCLUSIONS Despite high initial mortality and morbidity rates, life expectancy in patients with chronic radiation enteritis without recurrence of their previous neoplastic disease was good. Resection seems to provide a smaller reoperation rate and a better 5-year survival, but a higher postoperative mortality.