Augmented reality in liver surgery

INTRODUCTION

During an operation, augmented reality (AR) enables surgeons to enrich their vision of the operating field by means of digital imagery, particularly as regards tumors and anatomical structures. While in some specialties, this type of technology is routinely ustilized, in liver surgery due to the complexity of modeling organ deformities in real time, its applications remain limited. At present, numerous teams are attempting to find a solution applicable to current practice, the objective being to overcome difficulties of intraoperative navigation in an opaque organ.

OBJECTIVE

To identify, itemize and analyze series reporting AR techniques tested in liver surgery, the objectives being to establish a state of the art and to provide indications of perspectives for the future.

METHODS

In compliance with the PRISMA guidelines and availing ourselves of the PubMed, Embase and Cochrane databases, we identified English-language articles published between January 2020 and January 2022 corresponding to the following keywords: augmented reality, hepatic surgery, liver and hepatectomy.

RESULTS

Initially, 102 titles, studies and summaries were preselected. Twenty-eight corresponding to the inclusion criteria were included, reporting on 183patients operated with the help of AR by laparotomy (n=31) or laparoscopy (n=152). Several techniques of acquisition and visualization were reported. Anatomical precision was the main assessment criterion in 19 articles, with values ranging from 3mm to 14mm, followed by time of acquisition and clinical feasibility.

CONCLUSION

While several AR technologies are presently being developed, due to insufficient anatomical precision their clinical applications have remained limited. That much said, numerous teams are currently working toward their optimization, and it is highly likely that in the short term, the application of AR in liver surgery will have become more frequent and effective. As for its clinical impact, notably in oncology, it remains to be assessed.

Risk factors for major complications after liver resection: A large liver resection study from Morocco and audit of a non-Eastern/non-Western experience

BACKGROUND AND STUDY AIMS

In developing countries, endemic indications, blood shortages, and the scarcity of liver surgeons and intensive care providers can affect liver resection (LR) outcomes, but these have been rarely addressed in the literature. Therefore, in this study we determined risk factors for major complications after LR in a North African general surgery and teaching department.

PATIENTS AND METHODS

From January 2010 to December 2015, 213 consecutive LRs were performed on 203 patients. All patients underwent a postoperative follow-up of >90 days. Postoperative complications were assessed according to the Clavien-Dindo (CD) classification of surgical complications. A score of CD ≥III is considered as major postoperative complications. In this study, we analyzed the variables assumed to affect these complications.

RESULTS

The overall 90-day complication rate was 35.7% (n = 76), including a CD ≥III of 14% (n = 30) and a mortality rate of 6.1% (n = 14). According to the multivariate analysis, a preoperative performance status (PS) of ≥2 (P = 0.011; odds ratios [OR], 6.8; 95% confidence intervals [CI], 1.55-29.8), an estimated intraoperative blood loss of >500 ml (P = 0.002; OR, 3.71; 95% CI, 1.23-11.20), and bilioenteric anastomosis (P < 0.004; OR, 7.76; 95% CI, 1.5-3.89) were independent risk factors for major complications after LR.

CONCLUSION

We recommend that, in the setting of a non-Eastern/non-Western general surgery and teaching department, patients with a PS of ≥2 should undergo a specific selection and preoperative optimization protocol; intermittent clamping indications should be extended; and special attention should paid to patients undergoing LR associated with biliary reconstruction, such as for perihilar cholangiocarcinoma.

Laparoscopic versus open resection of intrahepatic cholangiocarcinoma: nationwide analysis

BACKGROUND

The relevance of laparoscopic resection of intrahepatic cholangiocarcinoma (ICC) remains debated. The aim of this study was to compare laparoscopic (LLR) and open (OLR) liver resection for ICC, with specific focus on textbook outcome and lymph node dissection (LND).

METHODS

Patients undergoing LLR or OLR for ICC were included from two French, nationwide hepatopancreatobiliary surveys undertaken between 2000 and 2017. Patients with negative margins, and without transfusion, severe complications, prolonged hospital stay, readmission or death were considered to have a textbook outcome. Patients who achieved both a textbook outcome and LND were deemed to have an adjusted textbook outcome. OLR and LLR were compared after propensity score matching.

RESULTS

In total, 548 patients with ICC (127 LLR, 421 OLR) were included. Textbook-outcome and LND completion rates were 22.1 and 48.2 per cent respectively. LLR was independently associated with a decreased rate of LND (odds ratio 0.37, 95 per cent c.i. 0.20 to 0.69). After matching, 109 patients remained in each group. LLR was associated with a decreased rate of transfusion (7.3 versus 21.1 per cent; P = 0.001) and shorter hospital stay (median 7 versus 14 days; P = 0.001), but lower rate of LND (33.9 versus 73.4 per cent; P = 0.001). Patients who underwent LLR had lower rate of adjusted TO completion than patients who had OLR (6.5 versus 17.4 per cent; P = 0.012).

CONCLUSION

The laparoscopic approach did not substantially improve quality of care of patients with resectable ICC.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial

Background

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.

Methods

This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.

Conclusion

This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey

BACKGROUND

The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.

METHODS

This retrospective study included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short-term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection.

RESULTS

Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010).

CONCLUSION

Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.

Multicentre study of perioperative versus adjuvant chemotherapy for resectable colorectal liver metastases

Background

It is not known whether perioperative chemotherapy, compared with adjuvant chemotherapy alone, improves disease‐free survival (DFS) in patients with upfront resectable colorectal liver metastases (CLM). The aim of this study was to estimate the impact of neoadjuvant 5‐fluorouracil, leucovorin and oxaliplatin (FOLFOX) on DFS in patients with upfront resectable CLM.

Methods

Consecutive patients who presented with up to five resectable CLM at two Japanese and two French centres in 2008–2015 were included in the study. Both French institutions favoured perioperative FOLFOX, whereas the two Japanese groups systematically preferred upfront surgery plus adjuvant chemotherapy. Inverse probability of treatment weighting (IPTW) and Cox regression multivariable models were used to adjust for confounding. The primary outcome was DFS.

Results

Some 300 patients were included: 151 received perioperative chemotherapy and 149 had upfront surgery plus adjuvant chemotherapy. The weighted 3‐year DFS rate was 33·5 per cent after perioperative chemotherapy compared with 27·1 per cent after upfront surgery plus adjuvant chemotherapy (hazard ratio (HR) 0·85, 95 per cent c.i. 0·62 to 1·16; P = 0·318). For the subgroup of 165 patients who received adjuvant FOLFOX successfully (for at least 3 months), the adjusted effect of neoadjuvant chemotherapy was not significant (HR 1·19, 0·74 to 1·90; P = 0·476). No significant effect of neoadjuvant chemotherapy was observed in multivariable regression analysis.

Conclusion

Compared with adjuvant chemotherapy, perioperative FOLFOX does not improve DFS in patients with resectable CLM, provided adjuvant chemotherapy is given successfully.

Neoadjuvant chemotherapy response influences outcomes in non-colorectal, non-neuroendocrine liver metastases

BACKGROUND

Indications for surgical resection of non-colorectal, non-neuroendocrine (NCNNE) liver metastases are unclear. This study analysed the influence of response to neoadjuvant chemotherapy and the presence of extrahepatic disease (EHD) on outcomes.

METHODS

Patients who underwent hepatic resection for NCNNE liver metastases and who received neoadjuvant chemotherapy at a single centre between 1982 and 2016 were analysed retrospectively. Patients were classified as having no EHD, controlled EHD or non-controlled EHD.

RESULTS

Hepatic resection was performed in 199 patients (81·2 per cent) after partial or complete response to chemotherapy or disease stabilization, and 46 patients (18·8 per cent) after tumour progression. Patients with progressive disease after chemotherapy had worse overall survival than those without (23 versus 50·4 per cent at 5 years; P = 0·004). Median survival was 63·6 (range 31·1-94·8) months for patients without EHD, 34·8 (19·2-49·2) months for those with controlled EHD and 7·2 (1·2-13·2) months for patients with non-controlled EHD (P = 0·004). In multivariable analysis, EHD (P = 0·004), response to chemotherapy (P = 0·004) and resection margins (P = 0·002) were all independent predictors of overall survival, regardless of primary tumour site.

CONCLUSION

The prognosis of patients with NCNNE liver metastases is influenced by preoperative chemotherapy and resectability.

Risk score to predict biliary leakage after elective liver resection

Background

Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL.

Methods

In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated.

Results

A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P &lt; 0·001; 15 versus 3·1 per cent in the validation cohort, P &lt; 0·001).

Conclusion

The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.

Neoadjuvant chemotherapy for initially unresectable intrahepatic cholangiocarcinoma

BACKGROUND

Locoregional extension of intrahepatic cholangiocarcinoma (ICC) at the time of diagnosis results in a low resectability rate and poor prognosis. The aim of this retrospective study was to assess the efficacy of neoadjuvant chemotherapy for locally advanced ICC.

METHODS

All consecutive patients with ICC between 2000 and 2013 were included prospectively in a single-centre database and analysed retrospectively. Patients with locally advanced ICC considered as initially unresectable received primary chemotherapy, followed by surgery in those with secondary resectability. Results of patients who underwent surgery for locally advanced ICC were compared with those of patients with initially resectable ICC treated by surgery alone.

RESULTS

A total of 186 patients were included in the study. Of 74 patients with locally advanced ICC, 39 (53 per cent) underwent secondary resection after a median of six chemotherapy cycles. Patients in this group were younger (P = 0·030) and had more advanced disease than those who had surgery alone, and presented more frequently with lymphadenopathy (P = 0·010) and vascular invasion (P = 0·010). Postoperative morbidity and mortality were no different between the groups. The median survival of patients who had surgery after chemotherapy was 24·1 months, and that of patients who had surgery alone was 25·7 months (P = 0·391).

CONCLUSION

Patients with locally advanced ICC treated by surgery following neoadjuvant chemotherapy had similar short- and long-term results to patients with initially resectable ICC who had surgery alone. Neoadjuvant chemotherapy as a first-line treatment for locally advanced ICC may be an effective downstaging option, facilitating secondary resectability in patients with initially unresectable disease.

Long-term outcomes of radiofrequency ablation combined with hepatectomy compared with hepatectomy alone for colorectal liver metastases

Background

Combining radiofrequency ablation (RFA) with hepatectomy may enable treatment with curative intent for patients with colorectal liver metastasis (CRLM). However, the oncological outcomes in comparison with resection alone remain to be clarified.

Methods

Patients who underwent a first hepatectomy between 2001 and 2012 for CRLM were enrolled. Short- and long-term outcomes of patients who underwent hepatectomy plus RFA were compared with those of patients who had hepatectomy alone using propensity score matching.

Results

Of a total of 553 patients, hepatectomy + RFA and hepatectomy alone were performed in 37 and 516 respectively. Before matching, patients in the hepatectomy + RFA group were characterized primarily by a larger tumour burden. After matching of 31 patients who underwent hepatectomy + RFA with 93 who had hepatectomy alone, background characteristics were well balanced. In the matched cohort, overall and disease-free survival in the hepatectomy + RFA group were no different from those among patients who had hepatectomy alone (5-year overall survival rate 57 versus 61 per cent, P = 0·649; 5-year disease-free survival rate 19 versus 17 per cent, P = 0·865). Local recurrence at the ablated site was observed in four of 31 patients (13 per cent). Although overall local recurrence (ablated site and/or cut surface) was more frequent in the hepatectomy + RFA group (9 of 31 (29 per cent) versus 11 of 93 (12 per cent); P = 0·032), there was no difference in intrahepatic disease-free survival between the two groups (P = 0·705).

Conclusion

Hepatectomy + RFA achieved outcomes comparable to hepatectomy alone. Combining RFA with hepatectomy should be considered as an option to achieve cure.

Liver transplantation for "very early" intrahepatic cholangiocarcinoma: International retrospective study supporting a prospective assessment

The presence of an intrahepatic cholangiocarcinoma (iCCA) in a cirrhotic liver is a contraindication for liver transplantation in most centers worldwide. Recent investigations have shown that "very early" iCCA (single tumors ≤2 cm) may have acceptable results after liver transplantation. This study further evaluates this finding in a larger international multicenter cohort. The study group was composed of those patients who were transplanted for hepatocellular carcinoma or decompensated cirrhosis and found to have an iCCA at explant pathology. Patients were divided into those with "very early" iCCA and those with "advanced" disease (single tumor >2 cm or multifocal disease). Between January 2000 and December 2013, 81 patients were found to have an iCCA at explant; 33 had separate nodules of iCCA and hepatocellular carcinoma, and 48 had only iCCA (study group). Within the study group, 15/48 (31%) constituted the "very early" iCCA group and 33/48 (69%) the "advanced" group. There were no significant differences between groups in preoperative characteristics. At explant, the median size of the largest tumor was larger in the "advanced" group (3.1 [2.5-4.4] versus 1.6 [1.5-1.8]). After a median follow-up of 35 (13.5-76.4) months, the 1-year, 3-year, and 5-year cumulative risks of recurrence were, respectively, 7%, 18%, and 18% in the very early iCCA group versus 30%, 47%, and 61% in the advanced iCCA group, P = 0.01. The 1-year, 3-year, and 5-year actuarial survival rates were, respectively, 93%, 84%, and 65% in the very early iCCA group versus 79%, 50%, and 45% in the advanced iCCA group, P = 0.02.

CONCLUSION

Patients with cirrhosis and very early iCCA may become candidates for liver transplantation; a prospective multicenter clinical trial is needed to further confirm these results. (Hepatology 2016;64:1178-1188).

Outcome after associating liver partition and portal vein ligation for staged hepatectomy and conventional two-stage hepatectomy for colorectal liver metastases

BACKGROUND

Although associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been increasingly adopted by many centres, the oncological outcome for colorectal liver metastases compared with that after two-stage hepatectomy is still unknown.

METHODS

Between January 2010 and June 2014, all consecutive patients who underwent either ALPPS or two-stage hepatectomy for colorectal liver metastases in a single institution were included in the study. Morbidity, mortality, disease recurrence and survival were compared.

RESULTS

The two groups were comparable in terms of clinicopathological characteristics. ALPPS was completed in all 17 patients, whereas the second-stage hepatectomy could not be completed in 15 of 41 patients. Ninety-day mortality rates for ALPPS and two-stage resection were 0 per cent (0 of 17) versus 5 per cent (2 of 41) (P = 0·891). Major complication rates (Clavien grade at least III) were 41 per cent (7 of 17) and 39 per cent (16 of 41) respectively (P = 0·999). Overall survival was significantly lower after ALPPS than after two-stage hepatectomy: 2-year survival 42 versus 77 per cent respectively (P = 0·006). Recurrent disease was more often seen in the liver in the ALPPS group. Salvage surgery was less often performed after ALPPS (2 of 8 patients) than after two-stage hepatectomy (10 of 17).

CONCLUSION

Although major complication and 90-day mortality rates of ALPPS were similar to those of two-stage hepatectomy, overall survival was significantly lower following ALPPS.

Nomogram for prediction of prognosis in patients with initially unresectable colorectal liver metastases

BACKGROUND

Although recent advances in surgery and chemotherapy have increasingly enabled hepatectomy in patients with initially unresectable colorectal liver metastases (CRLM), not all such patients benefit from surgery. The aim of this study was to develop a nomogram to predict survival after hepatectomy for initially unresectable CRLM.

METHODS

Patients with initially unresectable CRLM treated with chemotherapy followed by hepatectomy between 1990 and 2012 were included in the study. A nomogram to predict survival was developed based on a multivariable Cox model. The predictive performance of the model was assessed according to the C-statistic, Kaplan-Meier curve and calibration plots.

RESULTS

Of a total of 439 patients, liver and globally completed surgery was achieved in 380 (86·6 per cent) and 335 (76·3 per cent) patients respectively. The 5-year overall and disease-free survival rates were 39·9 and 10·0 per cent respectively. Based on the Cox model, the following five factors were selected for the nomogram and assigned specific scores: node-positive primary, 5; more than six metastases at hepatectomy, 7; carbohydrate antigen 19-9 level at hepatectomy above 37 units/ml, 10; disease progression during first-line chemotherapy, 9; and presence of extrahepatic disease, 4. The model achieved relatively good discrimination and calibration, with a C-statistic of 0·66. The overall survival rate for patients with a score greater than 16 was significantly worse than that for patients with a score of 16 or less (5-year survival rate 4 versus 46·3 per cent respectively; P < 0·001).

CONCLUSION

The nomogram facilitates personalized assessment of prognosis for patients with initially unresectable CRLM treated with chemotherapy and with planned resection.

Systematic computer tomographic scans 7 days after liver transplantation surgery can lower rates of repeat-transplantation due to arterial complications

Arterial complications are a major cause of graft lost after liver transplantation (LT). The aim of our study was to assess the clinical impact of systematic early postoperative injected computed tomographic (CT) scans after LT rather than its performance on demand in the event of abnormalities. Two series of consecutive transplantation patients in different periods (1997-1999, 231 patients versus 2008-2010, 250 patients) were analyzed. During the first period, an injected CT scan was only performed in the event of clinical, biological, or ultrasound abnormalities revealed by tests performed daily during the first week after surgery. During the second period, in addition to standard follow-up examination, an injected CT scan was performed systematically at approximately postoperative day 7. During the first (versus the more recent) period, both recipients (whose ages were 46 ± 13 years versus 50 ± 12 years; P = .004) and donors (whose ages were 42 ± 17 versus 52 ± 17 years; P = .0001) were younger and end-stage liver disease was more common (34% versus 12%; P = .0001), but hepatocellular carcinoma (7% vs 26%; P = .0001) and retransplantation (2% versus 7%; P = .01) were less frequent. Postoperative mortality was higher during the first period (14% versus 4%; P = .0003). The incidence of early arterial thrombosis (<1 month) was similar (1.3% versus 1.6%; P = .78), but that of arterial stenosis was higher with a systematic CT scan (1.7 versus 4.4; P = .07). As a consequence of the early detection and treatment of arterial abnormalities, the repeat LT rate due to late arterial thrombosis was nil in the second period and 2.1% (5/231) in the first period. In conclusion, a systematic CT angiogram at the end of the first postoperative week reduced retransplantation rates due to late hepatic artery thrombosis by detecting patients at risk who required specific treatment.

Portal biliopathy as a complication of extrahepatic portal hypertension: etiology, presentation and management

Portal biliopathy (PB) refers to the biliary abnormalities of the biliary ducts observed in patients with extrahepatic portal hypertension. Although majority of patients are asymptomatic, approximately 20% of these patients present with biliary symptoms (pain, pruritus, jaundice, cholangitis). The pathogenesis of PB is uncertain but compression by dilated veins into or around common bile duct may play the main role. CT-scan, MR cholangiopancreatography with MR portography should be the initial investigations in the evaluation of PB. Treatment is limited to symptomatic cases and is dictated by clinical manifestations and complications of the disease. Treatment of PB could be done by endoscopy (sphincterotomy, stone extraction or biliary stenting of the common bile duct) or surgery (definitive decompression by porto-systemic shunt followed by bilioenteric anastomosis, if necessary). This review describes pathogenesis, clinical features, investigation and management of portal biliopathy.

Indocyanine green fluorescence imaging in the surgical management of liver cancers: current facts and future implications

Imaging detection of liver cancers and identification of the bile ducts during surgery, based on the fluorescence properties of indocyanine green, has recently been developed in liver surgery. The principle of this imaging technique relies on the intravenous administration of indocyanine green before surgery and the illumination of the surface of the liver by an infrared camera that simultaneously induces and collects the fluorescence. Detection by fluorescence is based on the contrast between the (fluorescent) tumoral or peri-tumoral tissues and the healthy (non-fluorescent) liver. Results suggest that indocyanine green fluorescence imaging is capable of identification of new liver cancers and enables the characterization of known hepatic lesions in real time during liver resection. The purpose of this paper is to present the fundamental principles of fluorescence imaging detection, to describe successively the practical and technical aspects of its use and the appearance of hepatic lesions in fluorescence, and to expose the diagnostic and therapeutic perspectives of this innovative imaging technique in liver surgery.

Reversibility of acquired amyloid polyneuropathy after liver retransplantation

Domino liver transplantation (DLT) has become an accepted procedure designed to address problems with organ limited supply. However, cases of acquired amyloid neuropathy are increasingly being recognized following this procedure. Until now, only one patient had undergone liver retransplantation and follow-up findings were not reported. We describe the case of a 72-year-old patient with partial recovery from acquired amyloid neuropathy following retransplantation with a deceased donor 7 years after DLT performed for end-stage liver disease. His clinical and paraclinical improvement is described, and the impact of this case on the indication for a domino procedure and the challenges linked to retransplantation are discussed.

Hepatocellular carcinoma: Western and Eastern surgeons' points of view

Hepatocellular carcinoma (HCC) is the third leading cause of cancer mortality worldwide. Developed on a pathological liver in 90% of cases, theoretically liver transplantation (LT) is its best treatment because it cures both malignancy and cause of malignancy, the underlying pathological liver. Cadaveric donors are the main source of liver in Western countries as France and living donors are the rules in Eastern countries as Japan. Because organ shortage could impact choices in HCC treatments, it was interesting to compare a Western and Eastern surgeon's points of view about treatment of HCC to assess if the source of organs has modified therapeutic strategies. Hence, aim of this work was to compare points of view of two hepatobiliary and transplant surgeons specialized in the treatment of HCC in France and Japan concerning five keys points that are decisive to choose one of the two curative treatments in HCC on pathological liver: liver resection or LT. These questions included the definition of an oncological treatment of HCC, the assessment of liver function, the treatment of HCC recurrences, the incidence of pathological information on therapeutic strategy and potential future therapeutics strategies.

Comparison of simultaneous or delayed liver surgery for limited synchronous colorectal metastases

BACKGROUND

The optimal surgical strategy for patients with synchronous colorectal liver metastases (CLMs) is still unclear. The aim of this study was to compare simultaneous colorectal and hepatic resection with a delayed strategy in patients who had a limited hepatectomy (fewer than three segments).

METHODS

All patients with synchronous CLMs who underwent limited hepatectomy between 1990 and 2006 were included retrospectively. Short-term outcome, overall and progression-free survival were compared in patients having simultaneous colorectal and hepatic resection and those treated by delayed hepatectomy.

RESULTS

Of 228 patients undergoing hepatectomy for synchronous CLMs, 55 (24.1 per cent) had a simultaneous colorectal resection and 173 (75.9 per cent) had delayed hepatectomy. The mortality rate following hepatectomy was similar in the two groups (0 versus 0.6 per cent respectively; P = 0.557), but cumulative morbidity was significantly lower in the simultaneous group (11 per cent versus 25.4 per cent in the delayed group; P = 0.015). Three-year overall and progression-free survival rates were 74 and 8 per cent respectively in the simultaneous group, compared with 70.3 and 26.1 per cent in the delayed group (overall survival: P = 0.871; progression-free survival: P = 0.005). Significantly more recurrences were observed in the simultaneous group at 3 years (85 versus 63.6 per cent; P = 0.002); a simultaneous strategy was an independent predictor of recurrence.

CONCLUSION

Combining colorectal resection with a limited hepatectomy is safe in patients with synchronous CLMs and associated with less cumulative morbidity than a delayed procedure. However, the combined strategy has a negative impact on progression-free survival.

Progression of alphafetoprotein before liver transplantation for hepatocellular carcinoma in cirrhotic patients: a critical factor

Liver transplantation (LT) for cirrhotic/Hepatocellular carcinoma (HCC) is associated with reduced survival in patients with poor histological features. Preoperative levels of alphafetoprotein (AFP) could predict negative biological features. AFP progression could be more relevant than static AFP levels in predicting LT outcomes. A total of 252 cirrhotic/HCC patients transplanted between 1985 and 2005 were reviewed. One hundred fifty-three patients were analyzed, 99 excluded (for nonsecreting tumors and/or salvage transplantation). Using receiver operating characteristics analysis for recurrence after LT, 'progression' of AFP was defined by >15 microg/L per month before LT. A total of 127 (83%) were transplanted under and 26 (16%) over this threshold. After 45 months of follow-up (median), 5-year overall survival (OS) and recurrence free-survival (RFS) were 72% and 69%, respectively. Five-year survival in the progression group was lower than the nonprogression group (OS 54% vs. 77%; RFS 47% vs. 74%). Multivariate analysis showed progression of AFP>15 microg/L per month and preoperative nodules>3 were associated with decreased OS. Progression group and age>60 years were associated with decreased RFS. Male gender, progression of AFP and size of tumor>30 mm were associated with satellite nodules and/or vascular invasion. In conclusion, increasing AFP>15 microg/L/month while waiting for LT is the most relevant preoperative prognostic factor for low OS/DFS. AFP progression could be a pathological preoperative marker of tumor aggressiveness.

Adult liver transplantation: the Paul Brousse experience

During the past 3 decades, more than 2,250 liver transplants were performed at Paul Brousse Hospital. Overall patient survival was 82% at one year, 71% at 5 years and 64% at 10 years. Our group has developed a variety of approaches to liver transplantation, including: 1. Anti HBs immunoglobulin prophylaxis for the prevention of HBV recurrence. Combination prophylaxis with lamivudine and anti HBs immunoglobulins reduced the rate of HBV re-infection to 20%. 2. Transplantation of HIV-HCV and HIV-HBV infected patients. These transplants are feasible and we achieved 2- year survival rates of 70% and 90%, respectively. The main problem was HCV recurrence which was more severe in HIV co-infected patients. 3. Transplantation for hepatocellular carcinoma on a cirrhotic liver with a single tumor <5 cm or <3 tumors <3 cm. 4. Transplantation for familial amyloidotic polyneuropathy (FAP). The 5- and 10-year survival rates were 76% and 72%, respectively. More than 100 livers obtained after hepatectomy from FAP patients were transplanted as "domino" living donor livers to patients with unresectable liver cancers with a 5-year survival rate of 64%. In some domino recipients, symptoms of FAP disease occurred more rapidly than expected and this could be an indication for a second transplantation of a non FAP-liver. 5. Split-liver transplantation for pediatric patients. This has increased the number of transplantable livers for children by 28%. 6. Split-liver transplantation for 2 adults. The grafts were prepared by ex-vivo or in-situ splitting and the overall 5-year survival rate was 56%. 7. Adult -to-adult living-related liver transplantation. There has been no mortality nor late complications in donors and the overall 5-year survival rate among recipients was 73%. 8. Liver retransplantation with good results in the elective situation. Retransplantation should be used with discretion in the emergency setting.

Laparoscopic liver resection

BACKGROUND

This paper describes a 10-year experience of laparoscopic liver surgery, including several major hepatectomies for malignant tumours.

METHODS

Of 243 hepatectomies carried out between January 1995 and December 2004, 113 (46.5 per cent) were performed by laparoscopy and 89 were included in this retrospective study.

RESULTS

Twenty-four laparoscopic hepatectomies (27 per cent) were for benign disease and 65 (73 per cent) for malignant tumours, including hepatocellular carcinoma (HCC) in 16 patients and colorectal metastasis (CRM) in 41. Minor hepatectomy was performed in 51 patients and major hepatectomy (three or more Couinaud segments) in 38. Conversion to laparotomy was necessary in 12 patients and perioperative blood transfusion in eight. One patient with cirrhosis who underwent right hepatectomy for HCC with conversion to open surgery died 8 days after surgery. Major morbidity occurred in eight patients (16 per cent) having minor hepatectomy and in 11 (29 per cent) of those having a major resection. The 3-year overall and disease-free survival rates for patients with CRM (mean follow-up 30 months) were 87 (11 patients at risk) and 51 (6 patients at risk) per cent respectively. Corresponding values for patients with HCC (mean follow-up 40 months) were 85 (10 patients at risk) and 68 (5 patients at risk) per cent.

CONCLUSION

In experienced hands, the results of laparoscopic liver surgery are similar to those for laparotomy.

L'index « AFC » colorectal : un index préopératoire reproductible en chirurgie colorectale

INTRODUCTION

Evaluation of outcome after colorectal surgery is always necessary. A new index which permits to appreciate preoperatively postoperative mortality after colorectal resection in colorectal cancer (CRC) and in diverticular disease has been published (i.e., Association Française de Chirurgie, AFC colorectal index).

PATIENTS AND METHODS

From November 2002 to July 2004, in-hospital mortality was analysed on 253 patients who underwent colic resection (N = 220, 87%) or rectal resection, with anastomosis (N = 175, 70%). Mortality was analysed according to emergency resection, neurological co morbidity, lost of weight more than 10% of weight, age older than 70 years.

RESULTS

Mean age of patients was 63 +/- 18 years (17-92) (45% older than 70 years), 26% of patients were ASA >or= III, 35% underwent surgery in emergency, and 12% underwent laparoscopic surgery. One hundred and fifteen (45%) patients underwent surgery for CRC and 50 (20%), for diverticular disease and 11 patients underwent surgery for ischemic colitis. Overall mortality rate was 10% (N = 26), it was 19% in emergency surgery versus 5% after elective surgery. Global morbidity was 38%, percentage of anastomotic leak was 8% (N = 14/175), reoperation was necessary in 14%. The mean length of stay was 13 +/- 8 days. Ten percent of patients necessitated unplanned readmission. After surgery for CCR or diverticular disease. -i) overall mortality was 9% - ii) among patients who had 0, 1, 2, or 3 predictive risk factors of mortality; mortality was 0% , 5% 15% and 33%. After surgery for other aetiology than CCR or diverticular disease, among patients who had 0, 1, 2, or 3 predictive risk factors of mortality; mortality was 0%, 12% 36% and 25%.

CONCLUSIONS

These results showed the reproducibility of the AFC colorectal index and its potential application in all aetiologies after colorectal surgery.

[Morbi-mortality after Hartmann procedure for peritonitis complicating sigmoid diverticulitis. A retrospective analysis of 85 cases]

INTRODUCTION

Hartmann's procedure (HP) is a simple operation, which can be performed by all the surgeons. However, it remains criticized (high morbimortality, low rate of intestinal continuity restoration). The aim of this study was to analyse natural history of HP and intestinal continuity restoration for sigmoid diverticulitis, and to assess risk factors for mortality, morbidity and absence of intestinal continuity restoration.

PATIENTS AND METHODS

In three centers, from 1992 to 2002, 85 patients underwent HP. A retrospective analysis was performed on mortality, early and late morbidity of HP and intestinal continuity restoration.

RESULTS

22% of patients (mean age, 68 years) presented comorbidity, 17% of them, an altered immunity, and 3 or 4 Hinchey score for 64%. ASA score was > or =3 in 49% of the cases. Mean AFC and Mannheim scores were 2 and 21 respectively. Mortality rate was 14% and in-hospital morbidity, 50%. Main complications were: cardiorespiratory (18%), wound abcess (14%) and stomal (6%). No rectal stump fistula was noted. Mean hospital stay was 19+/-13 days. Late morbidity rate was 29%, mainly due to stomal complications (12%) and small bowel obstruction (7%). Intestinal continuity restoration was done in 77% of the cases, followed by only 1 fistula. Mortality rate for intestinal continuity restoration was 0% and morbidity was 13%. Mean hospital stay was 10+/-3 days. Age >75 years, ASA score > or =3 and comorbidity were risk factors for morbidity and mortality and for absence of intestinal continuity restoration.

CONCLUSIONS

HP is associated with a high morbidity and mortality rates. Intestinal continuity restoration rate was high in this series. HP is a simple operation in high-risk patients with advanced peritonitis. This study allows to precise natural history of HP. Knowledge of this history is crucial for choosing the best operation (between HP and anastomosis) for patient with peritonitis complications sigmoid diverticuitis.

[Laparoscopic liver surgery for metastases of colorectal cancer: analysis of a monocentric experience]

BACKGROUND

Advances in laparoscopic techniques, refinements of instruments and growth of practical experience in liver surgery during the last decade have prompted some surgeons to develop the laparoscopic approach for hepatic metastases of colorectal cancer (MCRC).

AIMS

Primary end points of this clinical study were safety and effectiveness of laparoscopic hepatectomy for MCRC, including early postoperative results and long-term outcomes (overall survival and disease-free survival).

DESIGN

Retrospective analysis of data (clinicopathologic, operative, perioperative ad late results) collected in a prospective database.

PATIENTS

Between January 1997 and December 2004, 37 non-consecutive (selected) patients underwent curative laparoscopic hepatic resection (n = 42) for MCRC at Montsouris Institut of Paris. Resection was considered when all liver metastases can be totally removed with clear margins, and in absence of nonresectable extrahepatic diseases. Among them were 24 males and 13 females with average ages of 63.4 years (range, 42-78).

RESULTS

Metastases were metachronous in 18, multiple in 21, bilateral in 12, and <5 cm in diameter in 30. There were 21 major hepatectomies (n = 3 Couinaud's segments or more), 4 anatomical minor resections, and 12 wedge resections. Mean operative time was 324 +/- 105 mins. Conversion to laparotomy was necessary in 6 patients (16%), due to massive intractable bleeding in 3 patients, multiples adhesions in 1 patient, technical reasons (location of the lesion) in 1 patient, and for presence of localized carcinosis in 1 patient. Portal triad clamping was performed in 6 patients. Mean operative blood loss was 797 +/- 645 ml, and transfusions were required in 4 patients (11%). Clear resection margins (> 5 mm) were observed in 94%. Postoperative mortality was nil. The overall morbidity rate was 35%, with 2 early reoperations due to hemorrhage and postoperative ileus. Overall and disease free survival at 36 months were 87% and 55%, respectively. Five patients who had a recurrence of metastatic liver disease were referred to a second laparoscopic resection.

CONCLUSION

This clinical study suggests that laparoscopic liver surgery for metastatic colorectal cancer can be accomplished safely, in selected patients and by experienced surgeons, with good early results and without detrimental consequences on survival.

[Pancreas divisum and the dominant dorsal duct syndrome]

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.

Traitement de la sténose biliaire par prothèse métallique

A patient presented with a cholangiocarcinoma of the common bile duct; it was initially considered unresectable leading to the placement of the metallic stent whose upper end extended beyond the convergence of the hepatic ducts. The metallic biliary stent became obstructed and so encrusted as to be unremovable; the patient required a left hepatectomy with resection of the stent and the biliary convergence in addition to a pancreatoduodenectomy in order to resect his primary lesion This difficult situation emphasizes that, whenever there is doubt as to the resectability of a biliary lesion, the decision to place a metallic stent should be the fruit of a thorough medico-surgical discussion; where there is any doubt, a plastic stent which is more easily removable should be placed.

Syndrome occlusif chez une femme enceinte révélant une hernie diaphragmatique post-traumatique méconnue

We describe a case of late post-traumatic diaphragmatic hernia revealed during pregnancy by bowel obstruction. The diagnosis was made during exploratory laparotomy at 29 weeks. After surgical repair of the hernia the pregnancy went to term uneventfully. A healthy baby was delivered at 39 weeks by elective cesarean section.

Cancer de la vésicule biliaire révélé par un ictère dû a un thrombus tumoral endobiliaire

Main bile duct neoplasic thrombosis is a rare cause of jaundice in case of gallbladder cancer. We report the case of 27-year-old woman in whom the endoluminal biopsy of biliary thrombus confirmed the suspected diagnosis of gallbladder cancer. An initial laparoscopic exploration found a localized peritoneal carcinomatosis. However, in this exceptional situation with an unknown prognostic, a surgical procedure has been performed including hepatectomy IV-V with biliary principal bile duct removal, hepatico-jejunal anastomosis (Roux-en-Y), with complete resection of localized peritoneal carcinomatosis. Post-operative course were uneventful and this patient was asymptomatic under chemotherapy with a six month follow-up.

Hémobilie après traumatisme hépatique ferme : une complication parfois tardive

Haemobilia is a rare but serious complication of hepatic blunt trauma. Its diagnosis can be difficult because the delay between initial trauma and haemobilia ranges from few days to several months. Once the diagnosis is considered, a diagnostic and therapeutic arteriography must be performed as soon as possible. We reported the case of a patient who developed hemobilia 2 months after hepatic blunt trauma, due to pseudoaneurism of the anterior branch of the right hepatic artery; haemostasis was successfully obtained by arteriographic embolisation.

[Rupture of a jejunal artery pseudo-aneurysm after a cephalic duodenopancreatectomy]

Arterial pseudo-aneurysms complicating pancreaticoduodenectomy are rare but have a poor prognosis. They usually result from arterial erosion due to pancreatic fistula. The authors report a pseudo-aneurysm with an uncommon localization (first jejunal artery), diagnosed after a negative first arteriography, and successfully treated by radiological embolization. Special features of pseudo-aneurysms complicating pancreaticoduodenectomy are reviewed.

[Technique of medial pancreatectomie]

Medial pancreatectomy is indicated for resection of benign or low-malignant tumors located in the middle part of the pancreas and not treatable by enucleation. This unfrequent procedure, the alternative of which is mainly left pancreatectomy, aims to preserve at the most pancreatic function.

[Post-operative small bowel obstruction: spiral computed tomography]

INTRODUCTION

The aim of this study was to evaluate prospectively the impact of the routine use of abdominal spiral computed tomography (SCT) in patients with postoperative small bowel obstruction (SBO) for whom initial conservative treatment was proposed.

PATIENTS AND METHODS

We have compared the management of SBO in patients with clinical stable condition in two successive periods : from 1989 to 1998, 127 patients (preSCT group) for whom management was based on standard clinical-biological-radiological assessment (CBRA) et from 1999 to 2000, 30 patients (SCT group) for whom management included SCT. The decision of surgical team was correlated with the type of small bowel obstruction at laparotomy : closed-loop obstruction without intestinal necrosis (true-positive), intestinal necrosis as a consequence of delayed diagnosis defined as false-negative, diffuse adhesion defined as false-positive et patient non operated defined as true-negative.

RESULTS

Among the 127 patients from the preSCT group, 87 were treated conservatively and 40 were operated : SBO with closed-loop obstruction without intestinal necrosis (n = 29,72%), SBO with diffuse adhesion (n = 4, 10%) and SBO with intestinal necrosis (n = 7, 17%). Among the 30 patients from the SCT group, 16 were treated conservatively and 14 were operated: SBO with closed-loop obstruction without intestinal necrosis (n = 8, 57%), SBO with diffuse adhesion (n = 6,43%) and SBO with intestinal necrosis (n = 0,0%; NS). Both groups were similar for rates of patients with SBO with or without necrosis and rate of patients treated conservatively (NS). In SCT group, there was significantly more patients operated for diffuse adhesions (p < 0,01). Negative predictive value of CBRA + TDM was significantly higher than those of CBRA alone (p = 0,041).

CONCLUSION

Due to a very high sensibility, TDM increase probably the rate of early laparotomies, maybe unnecessary, in patients without any sign of SBO due to closed-loop obstruction. Thus, systematic use of TDM in patients with clinical suspicion of SBO remains to be evaluated.

[Alithiasic cholecystitis in the adult: etiologies, diagnosis and treatment]

Acalculous cholecystitis represents 2% to 14% of cholecystectomies performed for acute cholecystitis. Its main etiology is ischemia of the gallbladder wall, which mainly occurs in critically ill patients, particularly in case of cardiovascular previous disease or diabetes. Acalculous cholecystitis associated with VIH are rare and have a better prognosis. Other etiologies are exceptional. Diagnosis of acalculous cholecystitis is difficult, with a lack of specificity of abdominal ultrasound for the diagnosis of ischemic cholecystitis. In all cases, cholecystectomy is a definitive treatment allowing certain diagnosis. Percutaneous drainage must be reserved to patients whose general condition does not allow general anesthesia. Medical treatment alone is not indicated in acalculous cholecystitis.

[Acute pancreatitis after surgical treatment of abdominal aortic aneurysm]

INTRODUCTION

Acute pancreatitis after surgical treatment of non ruptured aneurysm of abdominal aorta is a rare complication, considered to be due to pancreatic ischemia or peroperative trauma of pancreas. The aim of this study is to describe 4 new cases of this complication and to discuss its etiology.

PATIENTS AND METHODS

From January 1995 to November 2000, 365 patients underwent elective surgery for a non ruptured abdominal aorta aneurysm. Four (1.1%) men, aged 66 to 79 years and operated for an aneurysm which diameter ranged from 60 to 77 mm, developed postoperative acute pancreatitis. The abdominal approach was a midline incision in 3 cases and a retroperitoneal lombotomy in one case. Superior pole of the aneurysm always adjoined or involved the right renal artery. The aortic clamping was supra-renal in 3 cases and celiac in one case. Diagnosis of acute pancreatitis was established at days 2, 4, 12, and 23 after surgery on abdominal computed tomography in 3 cases and at reoperation in one case.

RESULTS

Three patients died, including 2 from early multiple organ failure and one peroperatively during surgical attempt to treat a prostheto-digestive fistula. One patient was alive and asymptomatic with a 2-years follow-up.

CONCLUSION

Acute pancreatitis is a rare and serious complication after surgical treatment of abdominal aorta aneurysm. Its diagnosis is often delayed. The main etiological factor of this complication could be trauma of pancreas during supra-renal clamping through a midline incision.