Multicentre propensity score-matched study of laparoscopic versus open repeat liver resection for colorectal liver metastases

BACKGROUND

Repeat liver resection is often the best treatment option for patients with recurrent colorectal liver metastases (CRLM). Repeat resections can be complex, however, owing to adhesions and altered liver anatomy. It remains uncertain whether the advantages of a laparoscopic approach are upheld in this setting. The aim of this retrospective, propensity score-matched study was to compare the short-term outcome of laparoscopic (LRLR) and open (ORLR) repeat liver resection.

METHODS

A multicentre retrospective propensity score-matched study was performed including all patients who underwent LRLRs and ORLRs for CRLM performed in nine high-volume centres from seven European countries between 2000 and 2016. Patients were matched based on propensity scores in a 1 : 1 ratio. Propensity scores were calculated based on 12 preoperative variables, including the approach to, and extent of, the previous liver resection. Operative outcomes were compared using paired tests.

RESULTS

Overall, 425 repeat liver resections were included. Of 271 LRLRs, 105 were matched with an ORLR. Baseline characteristics were comparable after matching. LRLR was associated with a shorter duration of operation (median 200 (i.q.r. 123-273) versus 256 (199-320) min; P < 0·001), less intraoperative blood loss (200 (50-450) versus 300 (100-600) ml; P = 0·077) and a shorter postoperative hospital stay (5 (3-8) versus 6 (5-8) days; P = 0·028). Postoperative morbidity and mortality rates were similar after LRLR and ORLR.

CONCLUSION

LRLR for CRLM is feasible in selected patients and may offer advantages over an open approach.

Chronic hypokalemia due to gastric exclusion after bariatric surgery

Hypokalemia is a common complication of repeated vomiting or prolonged gastric suction. In the case we observed, a patient presented with chronic hypokalemia due to gastric dilatation and the development of a superior mesenteric artery syndrome several years after gastric banding. This paper presents pre-operative and post-operative illustrations of a rare but potentially serious entity.

Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection

Background

Previous studies have demonstrated that patient, surgical, tumour and operative variables affect the complexity of laparoscopic liver resections. However, current difficulty scoring systems address only tumour factors. The aim of this study was to develop and validate a predictive model for the risk of intraoperative complications during laparoscopic liver resections.

Methods

The prospectively maintained databases of seven European tertiary referral liver centres were compiled. Data from two-thirds of the patients were used for development and one-third for validation of the model. Intraoperative complications were based on a modified Satava classification. Using the methodology of the Framingham Heart Study, developed to identify risk factors that contribute to the development of cardiovascular disease, factors found to predict intraoperative complications independently were assigned points, and grouped into low-, moderate-, high- and extremely high-risk groups based on the likelihood of intraoperative complications.

Results

A total of 2856 patients were included. Neoadjuvant chemotherapy, lesion type and size, classification of resection and previous open liver resection were found to be independent predictors of intraoperative complications. Patients with intraoperative complications had a longer duration of hospital stay (5 versus 4 days; P &lt; 0·001), higher complication rates (32·5 versus 15·5 per cent; P &lt; 0·001), and higher 30-day (3·0 versus 0·3 per cent; P &lt; 0·001) and 90-day (3·8 versus 0·8 per cent; P &lt; 0·001) mortality rates than those who did not. The model was able to predict intraoperative complications (area under the receiver operating characteristic (ROC) curve (AUC) 0·677, 95 per cent c.i. 0·647 to 0·706) as well as postoperative 90-day mortality (AUC 0·769, 0·681 to 0·858).

Conclusion

This comprehensive scoring system, based on patient, surgical and tumour factors, and developed and validated using a large multicentre European database, helped estimate the risk of intraoperative complications.

Outcome after laparoscopic and open resections of posterosuperior segments of the liver

BACKGROUND

Laparoscopic resection of posterosuperior (PS) segments of the liver is hindered by limited visualization and curvilinear resection planes. The aim of this study was to compare outcomes after open and laparoscopic liver resections of PS segments.

METHODS

Patients who underwent minor open liver resection (OLR) and laparoscopic liver resection (LLR) between 2006 and 2014 were identified from the institutional databases of seven tertiary referral European hepatobiliary surgical units. Propensity score-matched analysis was used to match groups for known confounders. Perioperative outcomes including complications were assessed using the Dindo-Clavien classification, and the comprehensive complication index was calculated. Survival was analysed with the Kaplan-Meier method.

RESULTS

Some 170 patients underwent OLR and 148 had LLR. After propensity score-matched analysis, 86 patients remained in both groups. Overall postoperative complication rates were significantly higher after OLR compared with LLR: 28 versus 14 per cent respectively (P = 0·039). The mean(s.d.) comprehensive complication index was higher in the OLR group, although the difference was not statistically significant (26·7(16·6) versus 18·3(8·0) in the LLR group; P = 0·108). The mean(s.d.) duration of required analgesia and the median (range) duration of postoperative hospital stay were significantly shorter in the LLR group: 3·0(1·1) days versus 1·6(0·8) days in the OLR group (P < 0·001), and 6 (3-44) versus 4 (1-11) days (P < 0·001), respectively. The 3-year recurrence-free survival rates for patients with hepatocellular carcinoma (37 per cent for OLR versus 30 per cent for LLR; P = 0·534) and those with colorectal liver metastases (36 versus 36 per cent respectively; P = 0·440) were not significantly different between the groups.

CONCLUSION

LLR of tumours in PS segments is feasible in selected patients. LLR is associated with fewer complications and does not compromise survival compared with OLR.

Routine mini-laparoscopic cholecystectomy: Outcome in 200 patients

INTRODUCTION

In order to improve the outcome of classical laparoscopic cholecystectomy (CLC), surgeons have attempted to minimize tissue trauma. The aim of this study is to describe the technique of mini-laparoscopic cholecystectomy (MLC) and to report the outcome of this approach when used as a routine procedure.

METHODS

Since January 2012, all consecutive patients undergoing MLC were included in this study. Operative and perioperative data were prospectively collected. Additionally, cost analysis was performed.

RESULTS

From 2012 to 2015, 200 MLC were performed (F/M: 132/68, mean age 45±16 years). Mean operative duration was 97±32min for the first 50 patients and 75±25min for the subsequent 150 patients (P<0.0001). Modifications in the number or size of trocars were necessary in nine of the first 50 procedures and in seven of the subsequent 150 procedures (P=0.003). Perioperative morbidity included gallbladder perforation (n=28) or moderate (<50mL) bleeding (n=6). Postoperative morbidity was 4%. The mean global cost for a MLC procedure was 1757±1855 euros. This cost decreased from 2946±3115 euros in the first 50 patients to 1390±1278 euros in the subsequent 150 patients (P=0.001).

CONCLUSION

Mini-laparoscopy can be used for routine elective cholecystectomy. This approach is associated with low morbidity and good cosmetic results.

Liver regeneration following repeated reversible portal vein embolization in an experimental model

BACKGROUND

Portal vein embolization (PVE) is used routinely to prevent postoperative liver failure as a result of anticipated insufficient future liver remnant volume following resection. The authors have recently developed a technique for temporary PVE. The aim of this study was to assess the effect of repeated reversible PVE on hepatocyte proliferation and subsequent liver hypertrophy in rodents.

METHODS

Four treatments were compared (n = 21 rats per group): single reversible PVE, two PVEs separated by 14 days, partial portal vein ligation or sham procedure. The feasibility and tolerance of the procedure were assessed. Volumetric imaging by CT was used to estimate the evolution of liver volumes. After death, the weight of liver lobes was measured and hepatocyte proliferation evaluated by immunostaining.

RESULTS

Embolization of portal branches corresponding to 70 per cent of total portal flow was performed successfully in all animals. Repeated PVE induced additional hepatocyte proliferation. Repeated embolization resulted in superior hepatocyte proliferation in the non-occluded segments compared with portal vein ligation (31·1 versus 22·2 per cent; P = 0·003). The non-occluded to total liver volume ratio was higher in the repeated PVE group than in the single PVE and sham groups (P = 0·050 and P = 0·001 respectively).

CONCLUSION

Repeated reversible PVE successfully induced additional hepatocyte proliferation and subsequent liver hypertrophy. Surgical relevance Portal vein embolization (PVE) is used routinely to prevent postoperative liver failure as a result of anticipated insufficient future liver remnant volume following resection. In the present study, a technique of repeated temporary PVE was developed in a rat model; this induced additional hepatocyte proliferation and an increase in liver volume compared with single embolization. This novel approach might help induce major hypertrophy of the future remnant liver, which could increase the rate of patients amenable to major liver resections.

Treatment of Leaks Following Sleeve Gastrectomy by Endoscopic Internal Drainage (EID)

BACKGROUND

Leaks are considered one of the major complications of laparoscopic sleeve gastrectomy (LSG) with a reported rate up to 7 %. Drainage of the collection coupled with SEMS deployment is the most frequent treatment. Its success is variable and burdened by high morbidity and not irrelevant mortality. The aim of this paper is to suggest and establish a new approach by endoscopic internal drainage (EID) for the management of leaks.

METHODS

Since March 2013, 67 patients presenting leak following LSG were treated with deployment of double pigtail plastic stents across orifice leak, positioning one end inside the collection and the other end in remnant stomach. The aim of EID is to internally drain the collection and at the same time promote leak healing.

RESULTS

Double pigtails stent were successfully delivered in 66 out of 67 patients (98.5 %). Fifty patients were cured by EID after a mean time of 57.5 days and an average of 3.14 endoscopic sessions. Two died for event not related to EID. Nine are still under treatment; five failure had been registered. Six patients developed late stenosis treated endoscopically.

CONCLUSIONS

EID proved to be a valid, curative, and safe mini-invasive approach for treatment of leaks following SG. EID achieves complete drainage of perigastric collections and stimulates mucosal growth over the stent. EID is well tolerated, allows early re-alimentation, and it is burdened by fewer complications than others technique. Long-term follow-up confirms good outcomes with no motility or feeding alterations.

Laparoscopic liver resection: a review

Laparoscopic liver surgery was slower to develop than other fields of laparoscopic surgery because of a steep learning curve, and fear of uncontrolled bleeding or gas embolism. However, laparoscopic liver resection (LLR) is associated with significant advantages: faster recovery, less post-operative pain, less morbidity, easier subsequent surgery and better cosmetic results. Since the inception of this technique, more than 3000 procedures have been reported. The aim of this update was to review the literature in order to define the indications (malignant tumors, benign tumors, major resections), the advantages and limits of this approach as well as the expected value of new technology, such as intra-operative guidance or robotics, in the development of this branch of surgery.

Treatment of tumour recurrence after resection of hepatocellular carcinoma. Analysis of 97 consecutive patients

OBJECTIVE

To evaluate the long-term results of aggressive treatment of HCC recurrence.

METHODS

Two hundred and nine consecutive patients underwent hepatic resection for HCC in our hospital. Tumour recurrence was diagnosed in 97 (51%) of the 190 patients with curative resection. Sixteen underwent hepatic resection: two right hepatectomies, one three-segmentectomy, one left hepatectomy, five two-segmentectomies, six segmental resections and one subsegmentectomy. Two patients with metastasis in the spine were submitted to a vertebral body resection. Twenty-five patients were treated with percutaneous ethanol injection or intra-arterial chemoembolization. Fifty-four patients with a poor performance status and liver function or multiple extra hepatic recurrences did not receive any treatment.

RESULTS

There were no operative deaths. The postoperative mortality rate was 5.5% (one patient). The cumulative overall survival after the second resection was respectively 89%, 46% and 31% at 1, 3 and 5 years. There was a significant difference in survival between patients treated with repeat resection and those submitted to a non-surgical or conservative treatment (p<0.0001). There were no differences in operative deaths, postoperative mortality and morbidity between the first and second hepatic resection.

CONCLUSIONS

Aggressive management with combined resection or loco regional therapy for intrahepatic recurrence and resection of isolated extra-hepatic recurrence may offer long-term survival in selected patients. Second liver resection for recurrence of HCC can be safely performed.

Resection of hepatocellular carcinoma: the effect of surgical margin and blood transfusion on long-term survival. Analysis of 209 consecutive patients

BACKGROUND/AIMS

Certain prognostic factors affect the postoperative mortality and long-term survival of patients following hepatic resection for hepatocellular carcinoma (HCC) and may change the surgical strategy.

METHODOLOGY

209 consecutive patients underwent hepatic resection for HCC in our hospital. Seventy-three patients underwent major resection and 136 underwent minor resections. We looked for correlations between clinical, biological, surgical and pathological factors and postoperative mortality, disease-free survival and overall survival.

RESULTS

The postoperative mortality rate was 7.7% (it fell to 0% in the last two years). The cumulative overall five-year survival rate was 27% and the overall disease-free survival rate was 7.3%. Multivariate analysis identified: (1) two independent prognostic factors for postoperative mortality: age and tumor size; (2) one risk factor for tumor recurrence: intraoperative blood transfusion, and (3) three independent prognostic factors for overall survival: infiltrative tumor type, surgical margin <10 mm and intraoperative blood transfusion.

CONCLUSIONS

In addition to routine staging of the tumor, the preoperative evaluation of HCC patients should include tests to determine whether the tumor is infiltrative or expansive and whether it will be possible to obtain a surgical margin (>10 mm). This procedure should make it possible to propose an appropriate neoadjuvant treatment only to these patients. The prevention of intraoperative bleeding or blood transfusion should improve the disease-free and overall survival rates in HCC patients.

Laparoscopic liver resection: results for 70 patients

BACKGROUND

Laparoscopy is slowly becoming an established technique for liver resection. This procedure still is limited to centers with experience in both hepatic and laparoscopic surgery. Preliminary reports include mainly minor resections for benign liver conditions and show some advantage in terms of postoperative recovery. The authors report their experience with laparoscopic liver resection, the evolution of the technique, and the results.

METHODS

From 1999 to 2006, 70 laparoscopic liver resections were performed using a procedure similar to resection by laparotomy.

RESULTS

There were 38 malignant tumors (54%) and 32 benign lesions (46%). The malignant tumors were mainly hepatocellular carcinomas (19 of 24 patients had cirrhosis). The tumor mean size was 3.8 +/- 1.9 cm (range, 2.2-8 cm). There were 19 major hepatectomies, 34 uni- or bisegmentomies, and 17 atypical resections. The operative time was 227 +/- 109 min. Conversion to laparotomy was required for seven patients (10%), mainly for continuous bleeding during transection. Nine patients (13%) required blood transfusion. One patient had both brisk bleeding and gas embolism from a tear in the section line of the right hepatic vein requiring laparoscopic suture. Blood loss and transfusion requirements were significantly lower in recent than in early cases and in resections with prior vascular control than in those without such control. Postoperative complications were experienced by 11 patients (16%), including one bleed from the hepatic stump requiring hemostasis and two subphrenic collections requiring percutaneous drainage. One cirrhotic patient died of liver failure after resection of a partially ruptured tumor. No ascites was observed in other cirrhotic patients. The mean hospital stay was 5.9 days.

CONCLUSION

The study results confirm that laparoscopic liver resection, including major hepatectomies, can be safely performed by laparoscopy.

Low-cost laparoscopic cholecystectomy

BACKGROUND

Hospital managers are continually trying to decrease the cost of patient care. The aim of this prospective study was to propose changes that would decrease the operating room costs of laparoscopic cholecystectomy without affecting clinical results.

METHODS

The study included 112 consecutive patients who underwent an elective cholecystectomy between January 1997 and December 2000. The procedure was changed in eight ways: the American position, open laparoscopy, reusable trocars, reusable instruments, bipolar coagulation of the cystic artery, intracorporeal ligature of the cystic duct, no use of suction lavage apparatus, and use of a surgical glove as a bag to extract the gallbladder. Complete compliance with the procedure, whether any abnormal operative events or complications occurred, the duration of hospitalization, and the material and labour costs of the procedure were recorded.

RESULTS

There were no abnormal operative events. Only two patients suffered from postoperative complications. The mean duration of hospitalization was 55.8 h. Fifteen patients (13.4 per cent) were not hospitalized overnight. The operating costs fell from 560 euros before the study to 330 euros in 2000.

CONCLUSION

By applying simple measures, it is possible to decrease the operating room cost of laparoscopic cholecystectomy whilst maintaining good results. Such measures should be applied to other laparoscopic procedures.

[Peri-hepatitis abscess secondary to pelvic peritonitis]

OBJECTIVE

To report the case of a 42-year-old patient referred for exploration of a tumor of the right flank and evidence of inflammation.

MATERIAL

and methods. Ultrasonography and computed tomography showed a liver mass associated with a heterogeneous adnexal mass. Serum CA-125 was elevated and ovarian cancer with liver metastasis was suspected. An alternative diagnosis was salpingitis complicated by Fitz-Hugh-Curtis syndrome in this patient wearing an intra-uterine contraceptive device.

RESULTS

Exploratory laparoscopy was performed and confirmed the diagnosis of salpingitis complicated by an ovarian abscess and Fitz-Hugh-Curtis syndrome with rare abscess formation. Outcome was favorable after adapted antibiotic treatment.

CONCLUSION

Fitz-Hugh-Curtis syndrome can take on an atypical aspect and should be entertained as a possible diagnosis in young women presenting pain of the right flank and fever.

[Allotransplantation in utero and immortalization of primate fetal hepatocytes]

We are developing cell therapy approaches on non-human primates as a preclinical model for the treatment of hepatic metabolic diseases. In foetuses, the tissues, including liver, are in expansion, which should facilitate hepatocytes engraftment, and the immune system becomes fully mature only after birth. We have set out conditions for isolation of fetal hepatocytes from macaca mulatta at the end of the 2nd trimester of gestation (90-100 days), their cryopreservation and retroviral transduction. Two different routes of administration of hepatocytes were evaluated: the umbilical vein which was deleterious for the foetuses, and the intraparenchymatous injection which was well tolerated by the animals. Administration of hepatocytes into the hepatic parenchyma resulted in microchimerism and allogenic cells were visualized 9 days after transplantation. Another approach has been to immortalize simian foetal hepatocytes using a retroviral vector expressing SV40 Large T flanked by lox sites. A cell line has been established for 2 years, which is not tumorigenic when injected subcutaneously into nude mice and display characteristics of bipotent hepatoblasts, precursors of hepatocytes and biliary cells. After orthotopic transplantation into nude mice via the portal vein, these cells expressed albumin until the sacrifice of the animals (17 days). The next steps will be to define conditions for transplantation of retrovirally transduced fetal primary and/or immortalized hepatocytes into young foetuses (60 days of gestation) and post-natally.

Transplantation of hepatocytes in nonhuman primates: a preclinical model for the treatment of hepatic metabolic diseases

BACKGROUND

The transplantation of isolated hepatocytes in large animals, including nonhuman primates, must be evaluated before clinical trials are performed. However, in the absence of large transgenic animals and large-animal (as opposed to small-animal) models of genetic deficiencies, it is difficult to evaluate the fate of transplanted hepatocytes, their localization, survival, and function within the parenchyma of the host liver. In this work, we aimed to develop a technique for delivering hepatocytes to the liver of a nonhuman primate and to evaluate their localization and functionality in the short term.

METHODS

A 20% hepatectomy was performed in 34 cynomolgus monkeys (Macaca fascicularis) and hepatocytes were isolated. Hepatocytes were labeled in vitro with a recombinant retrovirus expressing the beta-galactosidase gene and returned to the liver by infusion through a portal catheter left in place. Liver biopsies were performed 4 and 7 d after transplantation.

RESULTS

Twenty-four monkeys underwent surgery to define the necessary technical adjustments and to optimize conditions. Six monkeys died. The whole protocol, including the transplantation of genetically marked hepatocytes and procurement of liver biopsies, was performed in the remaining 10 monkeys. In eight monkeys, transplanted hepatocytes expressing the beta-galactosidase gene were widely distributed in the portal tracts, sinusoids, and hepatocyte plates of the host liver 4 and 7 d after transplantation.

CONCLUSIONS

We have developed an experimental nonhuman primate model for the evaluation of hepatocyte transplantation. We demonstrated the engraftment and functioning of transplanted hepatocytes in the host liver 4 and 7 d after transplantation.

Abnormal von Willebrand factor in bleeding angiodysplasias of the digestive tract

BACKGROUND & AIMS

Involvement of an abnormal von Willebrand factor in the bleeding expression of gastrointestinal angiodysplasias has been suggested but not assessed by prospective studies.

METHODS

To address this issue, 27 patients with either nonbleeding (group A, n = 9) or bleeding (group B, n = 9) digestive angiodysplasias or telangiectasias or diverticular hemorrhage (group C, n = 9) were enrolled. In all patients, an analysis of von Willebrand factor and a screening for the most common disorders associated with an acquired von Willebrand disease were performed.

RESULTS

In all patients from groups A and C, von Willebrand factor was normal, and no underlying disease could be found. In contrast, all but 1 patient from group B had a variable selective loss of the largest multimeric forms of von Willebrand factor, associated in 7 cases with a stenosis of the aortic valve.

CONCLUSIONS

This study indicates that most patients with bleeding angiodysplasia or telangiectasia have a deficiency of the largest multimers of von Willebrand factor induced by a latent acquired von Willebrand disease. Because these multimers are the most effective in promoting primary hemostasis at the very high shear conditions related to these vascular malformations, we suggest that their deficiency is likely to contribute to the bleeding diathesis.

Properties of learning of a Fuzzy ART Variant

This paper discusses a variation of the Fuzzy ART algorithm referred to as the Fuzzy ART Variant. The Fuzzy ART Variant is a Fuzzy ART algorithm that uses a very large choice parameter value. Based on the geometrical interpretation of the weights in Fuzzy ART, useful properties of learning associated with the Fuzzy ART Variant are presented and proven. One of these properties establishes an upper bound on the number of list presentations required by the Fuzzy ART Variant to learn an arbitrary list of input patterns. This bound is small and demonstrates the short-training time property of the Fuzzy ART Variant. Through simulation, it is shown that the Fuzzy ART Variant is as good a clustering algorithm as a Fuzzy ART algorithm that uses typical (i.e. small) values for the choice parameter.

Thrombosed Björk-Shiley standard disc mitral valve prosthesis

Between April 1980 and June 1986, 274 patients underwent mitral valve replacement (MVR) with the Björk-Shiley (BS) standard disc mitral valve prosthesis at the American University of Beirut Medical Center (AUBMC). Eleven patients (3.9%) presented 6-41 months after surgery with prosthetic valve dysfunction due to thrombosis. Inadequate control of anticoagulation was the major factor predisposing to thrombosis in all except one. All patients had documented rheumatic valvular disease. Nine patients were operated on an emergency basis and two died before any surgical intervention was possible. Thrombectomy was performed on six patients with four survivors and MVR in three with two survivors. Two patients died intraoperatively (22%). Three pregnant patients underwent mechanical declotting; pregnancy was terminated by abortion in 2 and by caesarean section and live birth in one. We conclude that implantation of the BS mitral valve prosthesis mandates emphasis on anticoagulation and the difficulty encountered with continuous anticoagulant therapy in pregnancy.

Verapamil pretreatment before aortic cross-clamping in patients undergoing coronary artery bypass graft

In 12 of 22 patients with coronary artery disease undergoing elective coronary artery bypass graft (CABG), verapamil (0.075 mg/kg body weight) pretreatment was given on initiation of cardiopulmonary bypass (CPB) before aortic cross-clamping (ACC), whereas no verapamil was used in 10 control patients. The volume of cardioplegia solution required to achieve and maintain cardiac asystole during ACC while on CPB was not significantly different in the two groups. After the release of ACC, the energy of direct current countershock required for defibrillation, the incidence of heart block, and the need for pacemaker were not significantly different. However, defibrillation was more readily achieved by a single countershock in the verapamil group than in the control group. Also, the incidence of ST segment changes after defibrillation was significantly lower in the verapamil group, suggesting that verapamil pretreatment before ACC may potentiate the myocardial preservation achieved by the cardioplegia, and hence may decrease the incidence of ischemic changes during the critical reperfusion period.

Bilateral pulmonary varicosities associated with coarctation of the aorta

Varicosities of the pulmonary vein are rare. Twenty-eight cases confirmed anatomically or by angiography have been reported. In this paper the authors report a rather unique patient who had bilateral varices of the lungs in conjunction with coarctation of the aorta. The plain film and angiographic features of pulmonary varices are discussed. A brief review of the cases reported previously is also presented.