S. Benoist

Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.

BACKGROUND Recent reports highlighting reduced mortality rates to less than 1% after hepatic resections have evaluated the management of selected patients. The current risk of liver resection in unselected patients needs to be more clearly defined to appreciate the actual risk of new indications. STUDY DESIGN From 1990 to 1997, 747 consecutive patients, including 16 operated in emergency, underwent hepatic resection. Resection was indicated for malignancy in 473 patients (63%). Major resections were performed in 333 patients (45%). An underlying liver disease, including cirrhosis (n = 239) and obstructive jaundice (n = 4), was present in 253 patients (35%). Multivariate analysis of the risk factors for postoperative mortality, morbidity, and transfusion after stratifying patients for the circumstance of the operation and the pathological changes of the remnant liver was performed. RESULTS There was no intraoperative death and the overall mortality rate was 4.4%. This rate was 25% after emergency liver resection and 3.9% after elective liver resection (p < 0.001). After elective resection, mortality was significantly higher in patients with cirrhosis (8.7%) or obstructive jaundice (21%) than in patients with a normal liver (1%; p < 0.001). Analysis of this subgroup of 478 patients with normal liver showed that the mortality rate was 0% in 220 patients operated for a benign disease and in 263 patients who underwent minor resections. All five deaths occurred in patients with a malignancy and resulted from extrahepatic complications. In patients with a malignancy, the only independent predictor of death was an associated extrahepatic procedure. The incidence of postoperative complications was 22% and was influenced by the American Society of Anaesthesiology (ASA) score, extent of resection, presence of a steatosis, and an associated extrahepatic procedure. The incidence of major complications was 8% and of reoperation 3%. Perioperative blood transfusion was required in 112 of 478 (23%) and was not associated with increased mortality. CONCLUSIONS The 1% basic risk of elective liver resection on normal liver suggests that indications of resection for malignancy could be extended, unless an associated extrahepatic procedure is needed. Because of this low basic risk, future studies evaluating resection on normal liver should not consider in-hospital mortality as the only end point.

Original scientific articleSeven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection1

BACKGROUND Recent reports highlighting reduced mortality rates to less than 1% after hepatic resections have evaluated the management of selected patients. The current risk of liver resection in unselected patients needs to be more clearly defined to appreciate the actual risk of new indications. STUDY DESIGN From 1990 to 1997, 747 consecutive patients, including 16 operated in emergency, underwent hepatic resection. Resection was indicated for malignancy in 473 patients (63%). Major resections were performed in 333 patients (45%). An underlying liver disease, including cirrhosis (n = 239) and obstructive jaundice (n = 4), was present in 253 patients (35%). Multivariate analysis of the risk factors for postoperative mortality, morbidity, and transfusion after stratifying patients for the circumstance of the operation and the pathological changes of the remnant liver was performed. RESULTS There was no intraoperative death and the overall mortality rate was 4.4%. This rate was 25% after emergency liver resection and 3.9% after elective liver resection (p < 0.001). After elective resection, mortality was significantly higher in patients with cirrhosis (8.7%) or obstructive jaundice (21%) than in patients with a normal liver (1%; p < 0.001). Analysis of this subgroup of 478 patients with normal liver showed that the mortality rate was 0% in 220 patients operated for a benign disease and in 263 patients who underwent minor resections. All five deaths occurred in patients with a malignancy and resulted from extrahepatic complications. In patients with a malignancy, the only independent predictor of death was an associated extrahepatic procedure. The incidence of postoperative complications was 22% and was influenced by the American Society of Anaesthesiology (ASA) score, extent of resection, presence of a steatosis, and an associated extrahepatic procedure. The incidence of major complications was 8% and of reoperation 3%. Perioperative blood transfusion was required in 112 of 478 (23%) and was not associated with increased mortality. CONCLUSIONS The 1% basic risk of elective liver resection on normal liver suggests that indications of resection for malignancy could be extended, unless an associated extrahepatic procedure is needed. Because of this low basic risk, future studies evaluating resection on normal liver should not consider in-hospital mortality as the only end point.

Impact of obesity on surgical outcomes after colorectal resection.

BACKGROUND As the impact of obesity on surgical outcomes after colorectal resection is not well known, this study was designed to compare the results of colorectal resection in obese and nonobese patients. METHODS From 1990 to 1997, 584 consecutive patients underwent elective colorectal resection in our department. Of these, 158 (27%) were obese (body mass index >27). Obese and nonobese patients were well matched for demographic data and surgical procedures. RESULTS After right or left colectomy, no difference was noted between obese and nonobese patients for overall mortality, morbidity, or leakage rates. However, after left colectomy, postoperative intra-abdominal collections requiring treatment were significantly more frequent in obese than in nonobese patients (10% versus 2%; P <0.05). After proctectomy, the mortality rate was 5% (3 of 61) among obese patients and 0.5% (1 of 185) among nonobese patients (P <0.02). The anastomotic leakage rate was 16% (5 of 58) for obese patients and 6% (11 of 169) for nonobese patients (P <0. 05), and the corresponding proportions of transfused patients were 43% and 19%, respectively (P <0.02). After proctectomy, multivariate analysis showed that for obese patients, diabetes mellitus (P <0.05) and American Society of Anesthesiologists (ASA) status >2 (P <0.05) were significant risk factors for anastomotic leakage; age >60 years (P <0.01) and ASA status >2 (P <0.05) were significant risk factors for perioperative blood transfusions. CONCLUSIONS Our study suggested that, for obese patients, (1) right colectomy can be performed in the same manner as for nonobese patients; (2) after left colectomy, abdominal drainage may be indicated, and (3) after proctectomy, a defunctioning stoma should be recommended when diabetes mellitus or ASA status >2 is present, and an autologous blood transfusion could be discussed for patients >60 years old or with ASA status >2.

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.

Functional results two years after laparoscopic rectopexy

BACKGROUND Rectopexy is one of the accepted treatment options for full-thickness rectal prolapse, but the details of the technique remain controversial. This unit has adopted a laparoscopic approach as an alternative to open surgery, and has used three techniques: mesh, suture, and resection. This retrospective study compares the long-term outcome. METHODS From 1993 to 1995, 14 patients underwent a laparoscopic posterior mesh rectopexy. From 1996 to 1999, 34 patients underwent laparoscopic suture rectopexy with (n = 18) or without sigmoid resection (n = 16). RESULTS There was no postoperative mortality, and morbidity was similar in the three groups, ranging from 11 to 19%. The mean follow-up was 47, 24, and 20 months for mesh, suture, and resection rectopexy, respectively. During follow-up, 1 patient in each group developed mucosal prolapse. There was no difference between the three groups for incontinence rate, which improved in more than 75% of patients who had impaired continence preoperatively. Postoperative constipation was observed in 2 patients (11%) after resection rectopexy, in 10 (62%) after suture rectopexy (P < 0.01 versus resection), and in 9 (64%) after mesh rectopexy (P < 0.01 versus resection). CONCLUSIONS Our results show that the addition of sigmoid resection to laparoscopic rectopexy is safe and could contribute to reduce the risk of severe constipation after operation. Laparoscopic mesh rectopexy confers no advantage over the sutured technique, which we now use as our fixation method of choice.

Adipose Tissue Is a Neglected Viral Reservoir and an Inflammatory Site during Chronic HIV and SIV Infection

Two of the crucial aspects of human immunodeficiency virus (HIV) infection are (i) viral persistence in reservoirs (precluding viral eradication) and (ii) chronic inflammation (directly associated with all-cause morbidities in antiretroviral therapy (ART)-controlled HIV-infected patients). The objective of the present study was to assess the potential involvement of adipose tissue in these two aspects. Adipose tissue is composed of adipocytes and the stromal vascular fraction (SVF); the latter comprises immune cells such as CD4+ T cells and macrophages (both of which are important target cells for HIV). The inflammatory potential of adipose tissue has been extensively described in the context of obesity. During HIV infection, the inflammatory profile of adipose tissue has been revealed by the occurrence of lipodystrophies (primarily related to ART). Data on the impact of HIV on the SVF (especially in individuals not receiving ART) are scarce. We first analyzed the impact of simian immunodeficiency virus (SIV) infection on abdominal subcutaneous and visceral adipose tissues in SIVmac251 infected macaques and found that both adipocytes and adipose tissue immune cells were affected. The adipocyte density was elevated, and adipose tissue immune cells presented enhanced immune activation and/or inflammatory profiles. We detected cell-associated SIV DNA and RNA in the SVF and in sorted CD4+ T cells and macrophages from adipose tissue. We demonstrated that SVF cells (including CD4+ T cells) are infected in ART-controlled HIV-infected patients. Importantly, the production of HIV RNA was detected by in situ hybridization, and after the in vitro reactivation of sorted CD4+ T cells from adipose tissue. We thus identified adipose tissue as a crucial cofactor in both viral persistence and chronic immune activation/inflammation during HIV infection. These observations open up new therapeutic strategies for limiting the size of the viral reservoir and decreasing low-grade chronic inflammation via the modulation of adipose tissue-related pathways.

Can failure of percutaneous drainage of postoperative abdominal abscesses be predicted

BACKGROUND Percutaneous drainage (PD) of complex postoperative abscesses associated with a variety of factors such as multiple location or enteric fistula remains a matter of debate. Accordingly, this retrospective study was designed to determine the predictive factors for failure of PD of postoperative abscess, in order to better select the patients who may benefit from PD. METHODS From 1992 to 2000, the data of 73 patients who underwent computed tomography (CT)-guided PD for postoperative intra-abdominal abscess, were reviewed. PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. The possible association between failure of PD and 27 patient-, abscess-, surgical-, and drainage-related variables were assessed using univariate and multivariate analysis. RESULTS Successful PD was achieved in 59 of 73 (81%) patients. The overall mortality was 3% but no patient died after salvage surgery. Multivariate analysis showed that only an abscess diameter of less than 5 cm (P = 0.042) and absence of antibiotic therapy (P = 0.01) were significant predictive variables for failure of PD. CONCLUSIONS CT-guided PD associated with antibiotic therapy could be attempted as the initial treatment of postoperative abdominal abscesses even in complex cases such as loculated abscess or abscess associated with enteric fistula.

Plain Abdominal Radiography as a Routine Procedure for Acute Abdominal Pain of the Right Lower Quadrant: Prospective Evaluation

The aim of this prospective study was to determine whether plain abdominal radiographs (PAX) are helpful in the management of adult patients presenting with acute pain of the right lower quadrant (RLQ). A questionnaire was filled in for each patient admitted to our hospital for acute abdominal pain of the RLQ, before and after PAX were obtained. The initial questionnaire indicated the suspected diagnosis and a provisional therapeutic option. A total of 104 consecutive patients were included in this study, 76 of whom underwent surgery. The negative laparotomy rate was 22%. PAX changed the suspected diagnosis and management for six patients (6%), leading in one case to negative laparotomy. Of the remaining five patients, three were operated (two for acute appendicitis and one for small bowel obstruction), and two were treated conservatively for ureteral calculi. This prospective study seems to demonstrate that the indiscriminate use of PAX is not helpful for most patients with acute pain of the RLQ. However, it may be performed in selected patients with clinically suspected small bowel obstruction or urinary symptoms.

Surgical treatment of anoperineal Crohn's disease : Can abdominoperineal resection be predicted?

BACKGROUND Anoperineal Crohns disease (APCD) runs an unpredictable course. Although this course is relatively benign in most patients, some will eventually require abdominoperineal resection (APR). The aim of this study was to identify prognostic factors of longterm APR in patients with APCD. STUDY DESIGN From 1980 to 1996, 119 patients were operated on for APCD (mean +/- SD age 30 +/- 13 years; range 11 to 96 years). Patients were divided into two groups: those undergoing APR and patients without APR at the end of followup. The following prognostic criteria were studied: (1) age at onset of Crohns disease (CD) and at the first manifestation of APCD, gender, APCD as the first manifestation of CD, and interval between the onset of CD and the first manifestation of APCD; (2) for the first manifestation of APCD, the type and number of lesions and the results of surgical treatment; and (3) associated intestinal localizations of CD and the type and number of manifestations of APCD during followup. RESULTS Mean followup from the first manifestation of APCD was 93 months (range 1 to 398 months). At the end of followup, 30 patients had undergone APR (25%). Logistic regression analysis showed that four criteria seemed to be associated with an increased risk of APR: age at first APCD (p < 0.02), fistula as the first manifestation of APCD (p < 0.04), more than three APCD lesions during followup (p < 0.01), and rectal involvement by CD (p < 0.000001). When, as in eight patients, these criteria were all present, APR was performed during followup in 100% of patients. In the absence of all four criteria (eight patients), APR was never performed. CONCLUSIONS This study allowed us to identify patients with APCD at high risk of APR. For these patients, early prevention of CD recurrence should be attempted by aggressive medical therapy.

New treatment for ileal pouch-anal or coloanal anastomotic stenosis

Persistent anastomotic stricture following ileal pouch-anal or coloanal anastomoses can be treated by transanal resection using a stapler or a more complex procedure, such as transanal pouch advancement with neoanastomosis. We propose an easier and faster technique, which does not require any particular device. Its long-term functional results are satisfactory in most patients.