[Show abstract][Hide abstract] ABSTRACT: Objectives
Appropriate patient selection is important to achieving good outcomes and obviating futile surgery in patients with huge (≥10 cm) hepatocellular carcinoma (HCC). The aim of this study was to identify independent predictors of futile outcomes, defined as death within 3 months of surgery or within 1 year from early recurrence following hepatectomy for huge HCC.Methods
The outcomes of 149 patients with huge HCCs who underwent resection during 1995–2012 were analysed. Multivariate logistic regression analysis was performed to identify preoperative independent predictors of futility.ResultsIndependent predictors of 3-month mortality (18.1%) were: total bilirubin level >34 μmol/l [P = 0.0443; odds ratio (OR) 16.470]; platelet count of <150 000 cells/ml (P = 0.0098; OR 5.039), and the presence of portal vein tumour thrombosis (P = 0.0041; OR 5.138). The last of these was the sole independent predictor of 1-year recurrence-related mortality (17.2%). Rates of recurrence-related mortality at 3 months and 1 year were, respectively, 6.3% and 7.1% in patients with Barcelona Clinic Liver Cancer (BCLC) stage A disease, 12.5% and 14% in patients with BCLC stage B disease, and 37.8% (P = 0.0002) and 75% (P = 0.0002) in patients with BCLC stage C disease.Conclusions
According to the present data, among patients submitted to hepatectomy for huge HCC, those with a high bilirubin level, low platelet count and portal vein thrombosis are at higher risk for futile surgery. The presence of portal vein tumour thrombosis should be regarded as a relative contraindication to surgery.
[Show abstract][Hide abstract] ABSTRACT: Le shunt porto-systémique intrahépatique par voie transjugulaire (TIPS) est un traitement largement utilisé, depuis plus de 20 ans, dans les complications de l’hypertension portale telles que l’ascite réfractaire ou l’hémorragie digestive par rupture de varices œsophagiennes. L’encéphalopathie hépatique après TIPS est une complication fréquente mais rarement grave. Nous rapportons le cas d’un patient ayant présenté un état de mal épileptique révélant un œdème cérébral avec hypertension intracrânienne au décours de la pose d’un TIPS et faisons une revue de la littérature des cas rapportés. Nous décrivons le développement de l’encéphalopathie hépatique et de l’œdème cérébral dans les suites d’un TIPS chez les patients atteints d’une maladie chronique du foie.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
The aim of the study was to compare the long-term oncologic results of laparoscopic liver resection (LLR) versus open liver resection (OLR) for colorectal liver metastasis (CRLM) using a propensity score analysis.
Subjects and methods:
This propensity score matching (PSM) study was based on a prospective database of a single tertiary-care center. Patients with primarily resectable CRLM were selected for a 1:1 PSM between LLR and OLR. Covariates for PSM estimation were age, gender, body mass index, American Society of Anesthesiologists score, primary tumor location, CRLM presentation, location, size, and number. Moreover, the year of surgery was included in the PSM model. Operative, postoperative, and survival rates were compared between groups.
From 2000 to 2013, in total, 339 liver resections for CRLM met the selection criteria. Among these, 52 LLR patients were matched with 52 OLR patients. The two surgical approaches showed similar postoperative morbidity and mortality rates. LLR was associated with significantly less blood loss, less frequent need for and shorter duration of pedicle clamping, faster recovery, and shorter hospital stay. Moreover, the overall 3- and 5-year survival rates were, respectively, 83% and 76% for LLR and 87% and 62% for OLR (P=.51). The 3- and 5-year disease-free survival rates were, respectively, 28% and 21% for LLR and 31% and 21% for OLR (P=.71).
The LLR achieves similar oncological results to those of the standard open surgery for CRLM, with the additional benefit of significantly faster recovery.
[Show abstract][Hide abstract] ABSTRACT: Le lobe accessoire du foie est une variation morphologique rare et semble être lié à un développement excessif du foie. La présence d’un lobe hépatique accessoire est souvent diagnostiquée fortuitement et parfois révélée par une torsion, notamment dans les formes pédiculées. La plupart des lobes accessoires sont sous-hépatiques. Le lobe de Riedel est le plus connu des lobes accessoires du foie et correspond à une hypertrophie des segments V et VI. Les lobes accessoires peuvent simuler des tumeurs. À l’inverse, il a été rapporté des cas de tumeurs hépatocytaires situées sur ces lobes accessoires. Par une revue de la littérature, nous avons fait une mise au point sur les lobes accessoires du foie.
Journal de Chirurgie Viscerale 10/2014; 151(6). DOI:10.1016/j.jchirv.2014.09.005
[Show abstract][Hide abstract] ABSTRACT: Objective: To evaluate the prevalence of sarcopenia among European patients with resectable hepatocellular carcinoma (HCC) and to assess its prognostic impact on overall and disease-free survival. Background: Identification of preoperative prognostic factors in liver surgery for HCC is required to better select patients and improve survival. Recent studies have shown that preoperative discrimination of patients with low skeletal muscle mass (sarcopenic patients) using computed tomography was associated with morbidity and mortality after liver and colorectal surgery. Assessment of sarcopenia could be used to evaluate patients before hepatectomy for HCC. Methods: All consecutive patients who underwent hepatectomy for HCC in our institution, between February 2006 and September 2012, were included. Univariate and multivariate analyses evaluating prognostic factors of postoperative mortality and cancer recurrence were performed, including preoperative, surgical, and histopathological factors. Results: Among 198 patients who underwent hepatectomy for HCC, 109 patients had an available computed tomographic scan and represent the study cohort. After a median follow-up of 21.23 months, 27 patients (24.8%) died. There were 20 deaths among the 59 patients who had sarcopenia and only 7 deaths in the nonsarcopenic group. Sarcopenic patients had significantly shorter median overall survival than nonsarcopenic patients (52.3 months vs 70.3 months; P = 0.015). On multivariate analysis, sarcopenia was found to be an independent predictor of poor overall survival (hazard ratio = 3.19; P = 0.013) and disease-free survival (hazard ratio = 2.60; P = 0.001). Conclusions: Sarcopenia was found to be a strong and independent prognostic factor for mortality after hepatectomy for HCC in European patients and could be used to evaluate eligibility of patients with HCC before surgery.
Annals of Surgery 06/2014; 261(6). DOI:10.1097/SLA.0000000000000743 · 8.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Laparoscopic liver resection is considered a safe and feasible alternative to open surgery for malignant liver lesions. However, laparoscopic surgery in cirrhotic patients remains challenging. The aim of this retrospective case–control study was to compare morbidity, mortality, and long-term patient survival between laparoscopic liver resections (LLR) and open liver resections (OLR) for hepatocellular carcinoma (HCC) in patients with histologically proven cirrhosis.
A total of 45 patients treated with LLR were matched by cause of cirrhosis, Child-Pugh score, type of surgical resection (subsegmentectomy, segmentectomy, and bisegmentectomy), tumor number, tumor size, and alpha-fetoprotein value with 45 patients treated with OLR. Pre-, intra-, and post-operative variables were compared between groups.
Compared with OLR, the LLR group displayed a significantly shorter operative time (140 vs. 180 min; p = 0.02), shorter hospital stay (7 vs. 12 days; p
World Journal of Surgery 06/2014; 38(11). DOI:10.1007/s00268-014-2659-z · 2.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Infections remain a major cause of morbidity and mortality after liver transplantation. One possible cause of infection is preservation fluid contamination. Donor-derived pathogens, such as Candida albicans, have occasionally produced life-threatening complications in organ recipients, already described in renal transplantation. In the present case, we report the loss of a liver graft secondary to vascular complications because of C. albicans found in the preservation fluid. Our case report raises the question of implementing procedures, similar to those in renal transplantation, including early antifungal treatment and repeated radiological monitoring for the prevention and detection of vascular complications.
[Show abstract][Hide abstract] ABSTRACT: Standard total vascular exclusion (TVE) of the liver is indicated for resection of tumors involving or adjacent to the vena cava and/or the confluence of the hepatic veins. The duration of liver ischemia can be prolonged by combined portal hypothermic perfusion of the liver (in or ex situ). The use of a venovenous bypass (VVB) during standard TVE maintains stable hemodynamics as well as optimal renal and splanchnic venous drainage. When the hepatic veins can be controlled, TVE preserving the caval flow negates the need for VVB. However this technique remains limited in duration as it is performed under warm ischemia (so-called normothermia) of the liver. To prolong the ischemia time, we have designed a modification of TVE with preservation of the caval flow including the use of temporary porta-caval shunt (PCS) and hypothermic perfusion of the liver. We describe here the first two cases of this new technique. Two patients underwent left hepatectomy extended to segments 5 and 8 (also called extended left hepatectomy) for large centrally located tumors. TVE lasted seventy-two and seventy-nine minutes, respectively. The postoperative course was uneventful and both patients were discharged on day ten and day twenty-five respectively. Both are alive without recurrence at ten and seven months following surgery. Provided the roots of the hepatic veins can be controlled, this technique combines the advantages of standard TVE with in situ hypothermic perfusion and VVB and obviates the need and the subsequent risks of the latter.
[Show abstract][Hide abstract] ABSTRACT: Background
Hepatocellular adenoma (HCA) is a rare benign liver epithelial tumour that can require surgery. This retrospective study reports a 23-year experience of open and laparoscopic resections for HCA.Methods
Patients with a histological diagnosis of HCA were included in this analysis. Surgical resection was performed in all symptomatic patients and in those with lesions measuring > 5 cm.ResultsBetween 1989 and 2012, 62 patients, 59 of whom were female, underwent surgery for HCA (26 by open surgery and 36 by laparoscopic surgery). Overall, 96.6% of female patients had a history of contraceptive use; 54.8% of patients presented with abdominal pain and 11.2% with haemorrhage; the remaining patients were asymptomatic. Patients who underwent laparoscopy had smaller lesions (mean ± standard deviation diameter: 68.3 ± 35.2 mm versus 91.9 ± 42.5 mm; P = 0.022). Operatively, laparoscopic and open liver resection did not differ except in the number of pedicle clamps, which was significantly lower in the laparoscopic group (27.8% versus 57.7% of patients; P = 0.008). Postoperative variables did not differ between the groups. Mortality was nil. Two surgical specimens were classified as HCA/borderline hepatocellular carcinoma. At the 3-year follow-up, all patients were alive with no recurrence of HCA.Conclusions
Open and laparoscopic liver resections are both safe and feasible approaches for the surgical management of HCA. However, laparoscopic liver resections may be limited by lesion size and location and require advanced surgical skills.
[Show abstract][Hide abstract] ABSTRACT: En materia de trasplantes, el órgano es el quid de la cuestión. Sin él, no hay injerto. Cuando está disponible, debe ser perfecto desde los puntos de vista anatómico y funcional, pues la vida del receptor depende de ello. Esto requiere una extracción y conservación minuciosas. En el 90% de los casos, los órganos se extraen de un donante en estado de muerte encefálica y en dos tercios de los casos se trata de una extracción multiorgánica: corazón, pulmones, hígado, riñones, páncreas, intestino, hueso, córneas, vasos y, a veces, piel o incluso cara. La operación es compleja y en ella se reúnen varios equipos, por lo que hay que ser muy rápido. Por fortuna, está perfectamente sistematizada. Cualquier cirujano debe conocer sus detalles, porque es probable que algún día tenga que participar en una, con independencia de dónde ejerza. Evitar la pérdida de un órgano debido a un error técnico o a un desconocimiento de las reglas comunes es una de las misiones de esta exposición. Un artículo de técnicas quirúrgicas debe leerse intentando vivir la atmósfera que rodea al procedimiento. En este caso, hay que imaginar que la intervención tiene una dimensión especial. Una familia está en estado de duelo y un ser humano ha aceptado donar. La intervención del médico, que se realiza sobre un «muerto» va a dar la vida. Por último, hay que recordar que un «buen extractor» suele reconocerse por el conocimiento que tiene de la extracción de los órganos que no trasplanta.