Resectable invasive IPMN versus sporadic pancreatic adenocarcinoma of the head of the pancreas: Should these two different diseases receive the same treatment? A matched comparison study of the French Surgical Association (AFC)

PURPOSE

To compare survival and impact of adjuvant chemotherapy in patients who underwent pancreaticoduodenectomy (PD) for invasive intraductal papillary mucinous neoplasm (IIPMN) and sporadic pancreatic ductal adenocarcinoma (PDAC).

METHODS

From 2005 to 2012, 240 patients underwent pancreatectomy for IIPMN and 1327 for PDAC. Exclusion criteria included neoadjuvant treatment, pancreatic resection other than PD, vascular resection, carcinoma in situ, or <11 examined lymph nodes. Thus, 82 IIPMN and 506 PDAC were eligible for the present study. Finally, The IIPMN group was matched 1:2 to compose the PDAC group according to TNM disease stage, perineural invasion, lymph node ratio, and margin status.

RESULTS

There was no difference in patient's characteristics, intraoperative parameters, postoperative outcomes, and histologic parameters. Overall survival and disease-free survival times were comparable between the 2 groups. In each group, overall survival time was significantly poorer in patients who did not achieve adjuvant chemotherapy (p = 0.03 for the IIPMN group; p = 0.03 for the PDAC group). In lymph-node negative patients of the IIPMN group, adjuvant chemotherapy did not have any significant impact on overall survival time (OR = 0.57; 95% CI [0.24-1.33]). Considering the whole population (i.e. patients with IIPMN and PDAC; n = 246), patients who did not achieve adjuvant chemotherapy had poorer survival (p < 0.01).

CONCLUSIONS

The courses of IIPMN and PDAC were similar after an optimized stage-to-stage comparison. Adjuvant chemotherapy was efficient in both groups. However, in lymph node negative patients, adjuvant chemotherapy seemed not to have a significant impact.

Assessment of high-priced systemic antifungal prescriptions

OBJECTIVES

To assess compliance with international guidelines for costly antifungal prescriptions and to compare these results with a first study performed in 2007.

METHODS

Retrospective study including all costly antifungal prescriptions made in surgical and medical intensive care units and in a hepatobiliary, pancreatic, and digestive surgery unit. Prescriptions were assessed in terms of indication, dosage, and antifungal de-escalation.

RESULTS

Seventy-four treatments were analyzed. Treatments were prescribed for prophylactic (1%), empirical (22%), pre-emptive (16%), or targeted therapy (61%). Caspofungin accounted for 68% of prescriptions, followed by voriconazole (20%) and liposomal amphotericin B (12%). Indication was appropriate in 91%, debatable in 1%, and inappropriate in 8%. Dosage was appropriate in 69%, debatable in 8%, and inappropriate in 23%. Prescriptions were inappropriate for the following reasons: lack of dosage adjustment in light of the hepatic function (10 cases), underdosage or excessive dosage by>25% of the recommended dose in seven cases. De-escalation to fluconazole was implemented in 40% of patients presenting with a fluconazole-susceptible candidiasis.

CONCLUSION

The overall incidence of appropriate use was higher in 2012 compared with 2007 (62% and 37% respectively, P=0.004). Nevertheless, costly antifungal prescriptions need to be optimized in particular for empirical therapy, dosage adjustment, and potential de-escalation to fluconazole.

Metabolomics approaches in pancreatic adenocarcinoma: tumor metabolism profiling predicts clinical outcome of patients

BACKGROUND

Pancreatic adenocarcinomas (PAs) have very poor prognoses even when surgery is possible. Currently, there are no tissular biomarkers to predict long-term survival in patients with PA. The aims of this study were to (1) describe the metabolome of pancreatic parenchyma (PP) and PA, (2) determine the impact of neoadjuvant chemotherapy on PP and PA, and (3) find tissue metabolic biomarkers associated with long-term survivors, using metabolomics analysis.

METHODS

1H high-resolution magic angle spinning (HRMAS) nuclear magnetic resonance (NMR) spectroscopy using intact tissues was applied to analyze metabolites in PP tissue samples (n = 17) and intact tumor samples (n = 106), obtained from 106 patients undergoing surgical resection for PA.

RESULTS

An orthogonal partial least square-discriminant analysis (OPLS-DA) showed a clear distinction between PP and PA. Higher concentrations of myo-inositol and glycerol were shown in PP, whereas higher levels of glucose, ascorbate, ethanolamine, lactate, and taurine were revealed in PA. Among those metabolites, one of them was particularly obvious in the distinction between long-term and short-term survivors. A high ethanolamine level was associated with worse survival. The impact of neoadjuvant chemotherapy was higher on PA than on PP.

CONCLUSIONS

This study shows that HRMAS NMR spectroscopy using intact tissue provides important and solid information in the characterization of PA. Metabolomics profiling can also predict long-term survival: the assessment of ethanolamine concentration can be clinically relevant as a single metabolic biomarker. This information can be obtained in 20 min, during surgery, to distinguish long-term from short-term survival.

Multicentre study of the impact of morbidity on long-term survival following hepatectomy for intrahepatic cholangiocarcinoma

BACKGROUND

The impact of morbidity on long-term outcomes following liver resection for intrahepatic cholangiocarcinoma is currently unclear.

METHODS

This was a retrospective analysis of all consecutive patients who underwent liver resection for intrahepatic cholangiocarcinoma with curative intent in 24 university hospitals between 1989 and 2009. Severe morbidity was defined as any complication of Dindo-Clavien grade III or IV. Patients with severe morbidity were compared with those without in terms of demographics, pathology, management, morbidity, overall survival, disease-free survival and time to recurrence. Independent predictors of severe morbidity were identified by multivariable analysis.

RESULTS

A total of 522 patients were enrolled. Severe morbidity occurred in 113 patients (21·6 per cent) and was an independent predictor of overall survival (hazard ratio 1·64, 95 per cent c.i. 1·21 to 2·23), as were age at resection, multifocal disease, positive lymph node status and R0 resection margin. Severe morbidity did not emerge as an independent predictor of disease-free survival. Independent predictors of time to recurrence included severe morbidity, tumour size, multifocal disease, vascular invasion and R0 resection margin. Major hepatectomy and intraoperative transfusion were independent predictors of severe morbidity.

CONCLUSION

Severe morbidity adversely affects overall survival following liver resection for intrahepatic cholangiocarcinoma.

Factors influencing recurrence following initial hepatectomy for colorectal liver metastases

BACKGROUND

Data on recurrence patterns following hepatectomy for colorectal liver metastases (CRLMs) and their impact on long-term outcomes are limited in the setting of modern multimodal management. This study sought to characterize the patterns of, factors associated with, and survival impact of recurrence following initial hepatectomy for CRLMs.

METHODS

A retrospective cohort study of patients undergoing initial hepatectomy for CRLMs at 39 institutions (2006-2013) was conducted. Kaplan-Meier methods were used for survival analyses. Overall survival landmark analysis at 12 months after hepatectomy was performed to compare groups based on recurrence. Multivariable Cox and regression models were used to determine factors associated with recurrence.

RESULTS

Among 2320 patients, tumours recurred in 47·4 per cent at median of 10·1 (range 0-88) months; 89·1 per cent of recurrences developed within 3 years. Recurrence was intrahepatic in 46·2 per cent, extrahepatic in 31·8 per cent and combined intra/extrahepatic in 22·0 per cent. The 5-year overall survival rate decreased from 74·3 (95 per cent c.i. 72·2 to 76·4) per cent without recurrence to 57·5 (55·0 to 60·0) per cent with recurrence (adjusted hazard ratio (HR) 3·08, 95 per cent c.i. 2·31 to 4·09). After adjusting for clinicopathological variables, prehepatectomy factors associated with increased risk of recurrence were node-positive primary tumour (HR 1·27, 1·09 to 1·49), more than three liver metastases (HR 1·27, 1·06 to 1·52) and largest metastasis greater than 4 cm (HR 1·19; 1·01 to 1·43).

CONCLUSION

Recurrence after CRLM resection remains common. Although overall survival is inferior with recurrence, excellent survival rates can still be achieved.

Improved survival in liver transplant recipients receiving prolonged-release tacrolimus in the European Liver Transplant Registry

This study was a retrospective analysis of the European Liver Transplant Registry (ELTR) performed to compare long-term outcomes with prolonged-release tacrolimus versus tacrolimus BD in liver transplantation (January 2008-December 2012). Clinical efficacy measures included univariate and multivariate analyses of risk factors influencing graft and patient survival at 3 years posttransplant. Efficacy measures were repeated using propensity score-matching for baseline demographics. Patients with <1 month of follow-up were excluded from the analyses. In total, 4367 patients (prolonged-release tacrolimus: n = 528; BD: n = 3839) from 21 European centers were included. Tacrolimus BD treatment was significantly associated with inferior graft (risk ratio: 1.81; p = 0.001) and patient survival (risk ratio: 1.72; p = 0.004) in multivariate analyses. Similar analyses performed on the propensity score-matched patients confirmed the significant survival advantages observed in the prolonged-release tacrolimus- versus tacrolimus BD-treated group. This large retrospective analysis from the ELTR identified significant improvements in long-term graft and patient survival in patients treated with prolonged-release tacrolimus versus tacrolimus BD in primary liver transplant recipients over 3 years of treatment. However, as with any retrospective registry evaluation, there are a number of limitations that should be considered when interpreting these data.

Compared efficacy of preservation solutions in liver transplantation: a long-term graft outcome study from the European Liver Transplant Registry

Between 2003 and 2012, 42 869 first liver transplantations performed in Europe with the use of either University of Wisconsin solution (UW; N = 24 562), histidine-tryptophan-ketoglutarate(HTK; N = 8696), Celsior solution (CE; N = 7756) or Institute Georges Lopez preservation solution (IGL-1; N = 1855) preserved grafts. Alternative solutions to the UW were increasingly used during the last decade. Overall, 3-year graft survival was higher with UW, IGL-1 and CE (75%, 75% and 73%, respectively), compared to the HTK (69%) (p < 0.0001). The same trend was observed with a total ischemia time (TIT) >12 h or grafts used for patients with cancer (p < 0.0001). For partial grafts, 3-year graft survival was 89% for IGL-1, 67% for UW, 68% for CE and 64% for HTK (p = 0.009). Multivariate analysis identified HTK as an independent factor of graft loss, with recipient HIV (+), donor age ≥65 years, recipient HCV (+), main disease acute hepatic failure, use of a partial liver graft, recipient age ≥60 years, no identical ABO compatibility, recipient hepatitis B surface antigen (-), TIT ≥ 12 h, male recipient and main disease other than cirrhosis. HTK appears to be an independent risk factor of graft loss. Both UW and IGL-1, and CE to a lesser extent, provides similar results for full size grafts. For partial deceased donor liver grafts, IGL-1 tends to offer the best graft outcome.

Distal pancreatectomy for pancreatic carcinoma in the era of multimodal treatment

BACKGROUND

Recent publications have suggested improvements in the outcome of distal pancreatectomy (DP) for cancer, but the series were small and heterogeneous. The aim of the present study was to assess perioperative and long-term outcomes of DP for pancreatic adenocarcinoma in the era of multimodal treatment in a major European country.

METHODS

This was a nationwide study of all patients undergoing DP for pancreatic adenocarcinoma between 2004 and 2009 in 28 centres in France. Postoperative and long-term outcomes were assessed retrospectively and outcome predictors were explored by multivariable analysis.

RESULTS

A total of 278 patients were enrolled. Multivisceral resections were performed in 58 patients (20·9 per cent), venous resections in 33 (11·9 per cent) and arterial resections in 11 (4·0 per cent). Neoadjuvant chemoradiotherapy was used in 20 patients. Postoperative complications occurred in 96 patients (34·5 per cent) and pancreatic fistulas developed in 76 (27·3 per cent). The postoperative 90-day mortality rate was 5·0 per cent. In univariable analysis, multivisceral resection was the only factor associated with postoperative morbidity (P = 0·048). Age 65 years or less, body mass index of at least 30 kg/m(2) and absence of preoperative chemoradiotherapy were associated with an increased risk of pancreatic fistula in multivariable analysis. Overall survival rates at 3 and 5 years were 44·9 and 29·5 per cent respectively. In multivariable analysis, only the presence of lymph node metastases was associated with poorer overall survival.

CONCLUSION

Postoperative morbidity and mortality associated with pancreatic fistula remain considerable after DP, but both short- and long-term survival have improved markedly.

Safety and outcome of combined liver and pancreatic resections

Background

In Western countries, combined liver and pancreatic resections (CLPR) are performed rarely because of the perceived high morbidity and mortality rates. This study evaluated the safety and outcomes of CLPR at a tertiary European centre for hepatopancreatobiliary surgery.

Methods

A review of two prospectively maintained databases for pancreatic and liver resections was undertaken to identify patients undergoing CLPR between January 1994 and January 2012. Clinicopathological and surgical outcomes were analysed. Univariable and multivariable analyses for postoperative morbidity were performed.

Results

Fifty consecutive patients with a median age of 58 (range 20–81) years underwent CLPR. Indications for surgery were neuroendocrine carcinoma (16 patients), biliary cancer (15), colonic cancer (5), duodenal cancer (1) and others (13). The type of pancreatic resection included pancreaticoduodenectomy (30), distal pancreatectomy (17), spleen-preserving distal pancreatectomy (2) and total pancreatectomy (1). Twenty-three patients had associated major hepatectomies, 27 underwent minor liver resections and 11 had associated vascular resections. Mortality and morbidity rates were 4 and 46 per cent respectively. Univariable and multivariable analysis showed no differences in postoperative morbidity in relation to extent of liver resection or type of pancreatic resection. Use of preoperative chemotherapy was the only independent risk factor associated with postoperative morbidity (P = 0·021).

Conclusion

CLPR can be performed with fairly low morbidity and mortality rates. Postoperative outcomes were not affected by the extent of liver resection or the type of pancreatic resection. Patients receiving chemotherapy should be evaluated carefully before surgery is considered.

Is port-site resection necessary in the surgical management of gallbladder cancer?

INTRODUCTION

Gallbladder carcinoma is frequently discovered incidentally on pathologic examination of the specimen after laparoscopic cholecystectomy (LC) performed for presumed "benign" disease. The objective of the present study was to assess the role of excision of port-sites from the initial LC for patients with incidental gallbladder carcinoma (IGBC) in a French registry.

METHODS

Data on patients with IGBC identified after LC between 1998 and 2008 were retrospectively collated in a French multicenter database. Among those patients undergoing re-operation with curative intent, patients with port-site excision (PSE) were compared with patients without PSE and analyzed for differences in recurrence patterns and survival.

RESULTS

Among 218 patients with IGBC after LC (68 men, 150 women, median age 64 years), 148 underwent re-resection with curative intent; 54 patients had PSE and 94 did not. Both groups were comparable with regard to demographic data (gender, age > 70, co-morbidities), surgical procedures (major resection, lymphadenectomy, main bile duct resection) and postoperative morbidity. In the PSE group, depth of tumor invasion was T1b in six, T2 in 24, T3 in 22, and T4 in two; this was not significantly different from patients without PSE (P = 0.69). Port-site metastasis was observed in only one (2%) patient with a T3 tumor who died with peritoneal metastases 15 months after resection. PSE did not improve the overall survival (77%, 58%, 21% at 1, 3, 5 years, respectively) compared to patients with no PSE (78%, 55%, 33% at 1, 3, 5 years, respectively, P = 0.37). Eight percent of patients developed incisional hernia at the port-site after excision.

CONCLUSION

In patients with IGBC, PSE was not associated with improved survival and should not be considered mandatory during definitive surgical treatment.

Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma

BACKGROUND

Indications for preoperative biliary drainage (PBD) in the context of hepatectomy for hilar malignancies are still debated. The aim of this study was to investigate current European practice regarding biliary drainage before hepatectomy for Klatskin tumours.

METHODS

This was a retrospective analysis of all patients who underwent formal or extended right or left hepatectomy for hilar cholangiocarcinoma between 1997 and 2008 at 11 European teaching hospitals, and for whom details of serum bilirubin levels at admission and at the time of surgery were available. PBD was performed at the physicians' discretion. The primary outcome was 90-day mortality. Secondary outcomes were morbidity and cause of death. The association of PBD and of preoperative serum bilirubin levels with postoperative mortality was assessed by logistic regression, in the entire population as well as separately in the right- and left-sided hepatectomy groups, and was adjusted for confounding factors.

RESULTS

A total of 366 patients were enrolled; PBD was performed in 180 patients. The overall mortality rate was 10·7 per cent and was higher after right- than left-sided hepatectomy (14·7 versus 6·6 per cent; adjusted odds ratio (OR) 3·16, 95 per cent confidence interval 1·50 to 6·65; P = 0·001). PBD did not affect overall postoperative mortality, but was associated with a decreased mortality rate after right hepatectomy (adjusted OR 0·29, 0·11 to 0·77; P = 0·013) and an increased mortality rate after left hepatectomy (adjusted OR 4·06, 1·01 to 16·30; P = 0·035). A preoperative serum bilirubin level greater than 50 µmol/l was also associated with increased mortality, but only after right hepatectomy (adjusted OR 7·02, 1·73 to 28·52; P = 0·002).

CONCLUSION

PBD does not affect overall mortality in jaundiced patients with hilar cholangiocarcinoma, but there may be a difference between patients undergoing right-sided versus left-sided hepatectomy.

Two-stage hepatectomy for multiple bilobar colorectal liver metastases

BACKGROUND

As surgical resection of colorectal liver metastases (CLM) remains the only treatment for cure, efforts to extend the surgical indications to include patients with multiple bilobar CLM have been made. This study evaluated the long-term outcome, safety and efficacy of two-stage hepatectomy (TSH) for CLM in a large cohort of patients.

METHODS

Patients undergoing surgery between December 1996 and December 2009 were reviewed. The early postoperative and long-term outcomes as well as the patterns of failure to complete TSH and its clinical implications were analysed.

RESULTS

Eighty patients were scheduled to undergo TSH. Sixty-one patients had completion of TSH combined with (58 patients), or without (3) portal vein embolization/ligation (PVE/PVL). Five patients were excluded after first-stage hepatectomy and 14 after PVE/PVL. The 5-year overall survival rate and median survival in patients who completed TSH were 32 per cent and 39·6 months respectively, and corresponding recurrence-free values were 11 per cent and 9·4 months respectively. Six patients were alive beyond 5 years after TSH. Multivariable logistic regression analysis showed that failure to complete TSH was driven by two independent prognostic scenarios: three or more CLM in the future remnant liver (FRL) combined with age over 70 years predicted tumour progression after first-stage hepatectomy, and three or more CLM in the FRL combined with carcinomatosis at the time of first-stage hepatectomy predicted the development of additional FRL metastases after PVE/PVL.

CONCLUSION

A therapeutic strategy using TSH provided acceptable long-term survival with no postoperative mortality. Further efforts are needed to increase the number of patients who undergo TSH successfully.

Prognostic value of jaundice in patients with gallbladder cancer by the AFC-GBC-2009 study group

INTRODUCTION

Jaundice is frequent in patients with gallbladder cancer (GBC) and indicates advanced disease and, according to some teams, precludes routine operative exploration. The present study was designed to re-assess the prognostic value of jaundice in patients with GBC.

METHODS

Patients with GBC operated from 1998 to 2008 were included in a retrospective multicenter study (AFC). The main outcome measured was the prognostic value of jaundice in patients with GBC focusing on morbidity, mortality and survival.

RESULTS

A total of 110 of 429 patients with GBC presented with jaundice, with a median age of 66 years (range: 31-88). The resectability rate was 45% (n=50) and the postoperative mortality and morbidity rates were 16% and 62%, respectively; 71% had R0 resection and 46% had lymph node involvement. Overall 1- and 3-year survivals of the 110 jaundiced patients were 41% and 15%, respectively. For the 50 resected patients, 1- and 3-year survivals were 48% and 19%, respectively (real 5-year survivors n=4) which were significantly higher than that of the 60 non-resected patients (31%, 0%, p=0.001). Among the resected jaundiced patients, T-stage, N and M status were found to have a significant impact on survival. R0 resection did not increase the overall survival in all resected patients, but R0 increased median survival in the subgroup of N0 patients (20 months versus 6 months, p=0.01).

CONCLUSION

This series confirms that jaundice is a poor prognostic factor. However, the presence of jaundice does not preclude resection, especially in highly selected patients (N0).

[Primary pancreatic sarcoma with liver metastases: is there a place for radical surgery?]

Pancreatic leiomyosarcomas are a rare neoplasm that accounts for 1/1000 of pancreatic cancers. In the literature, 23 cases of pancreatic leiomyosarcoma have been reported and the majority being diagnosed on autopsy. It has never been reported any radical curative surgery in presence of synchronous hepatic metastasis. We reported a case of a patient affected by a primitive pancreatic leiomyosarcoma with bilobar hepatic metastasis, who underwent distal splenopancreatectomy associated with the resection of multiple liver metastases.

Preliminary experience with the hanging maneuver for pancreaticoduodenectomy

BACKGROUND

Malignant periampullary tumours often invade retroperitoneal peripancreatic tissues and a positive resection margin following pancreaticoduodenectomy (PD) is associated with a poor survival. The margin most frequently invaded is the retroperitoneal margin (RM). Among the different steps of PD one of the most difficult and less codified is the resection of the RM with high risk of bleeding. We have developed a surgical technique - "hanging maneuver" - which allows at the same time a standardization of this step, a complete resection of the RM, and an optimal control of bleeding.

PATIENTS/METHODS

We described the surgical technique, and we reported our preliminary experience. Surgical data, postoperative outcome and pathological results of patients submitted to PD for pancreatic carcinoma using "hanging maneuver" technique between January 2007 and December 2007 were reviewed.

RESULTS

The hanging maneuver was performed in 20 patients without any intraoperative complication and massive bleeding. No patient required blood transfusion. After had inked the surgical margins, retroperitoneal peripancreatic tissue was invaded in 12 out of 17 patients with malignant diseases (70.5%). In only one case (6%), the retroperitoneal margin was involved by the tumour (R1 resection).

CONCLUSION

The "hanging maneuver" is a useful and safe technical variant and should be considered in the armamentarium of the pancreatic surgeons in order to achieve negative retroperitoneal margins.

Minimally invasive and selective hydrodynamic gene therapy of liver segments in the pig and human

This paper highlights our experience of the transfer of hydrodynamic gene therapy (HGT) from the large animal, the pig, into clinical practice. The modification of balloon catheters and the development of a minimally invasive technique to allow selective isolation of liver segments for HGT in the large animal and human are described. Finally, our preliminary results from a phase I clinical study of HGT for thrombopoietin (TPO) in cirrhotic patients with thrombocytopenia are discussed. Based on these provisional data, minimally invasive selective HGT of liver segments appears to be technically safe, but further work is required to optimize the efficiency of gene transfer in order to achieve clinical benefit.

A Metabolic Screening Study of Trichostatin A (TSA) and TSA-Like Histone Deacetylase Inhibitors in Rat and Human Primary Hepatocyte Cultures

Hydroxamic acid (HA)-based histone deacetylase (HDAC) inhibitors, with trichostatin A (TSA) as the reference compound, are potential antitumoral drugs and show promise in the creation of long-term primary cell cultures. However, their metabolic properties have barely been investigated. TSA is rapidly inactivated in rodents both in vitro and in vivo. We previously found that 5-(4-dimethylaminobenzoyl)aminovaleric acid hydroxyamide or 4-Me2N-BAVAH (compound 1) is metabolically more stable upon incubation with rat hepatocyte suspensions. In this study, we show that human hepatocytes also metabolize TSA more rapidly than compound 1 and that similar pathways are involved. Furthermore, structural analogs of compound 1 (compounds 2-9) are reported to have the same favorable metabolic properties. Removal of the dimethylamino substituent of compound 1 creates a very stable but 50% less potent inhibitor. Chain lengthening (4 to 5 carbon spacer) slightly improves both potency and metabolic stability, favoring HA reduction to hydrolysis. On the other hand, Calpha-unsaturation and spacer methylation not only reduce HDAC inhibition but also increase the rate of metabolic inactivation approximately 2-fold, mainly through HA reduction. However, in rat hepatocyte monolayer cultures, compound 1 is shown to be extensively metabolized by phase II conjugation. In conclusion, this study suggests that simple structural modifications of amide-linked TSA analogs can improve their phase I metabolic stability in both rat and human hepatocyte suspensions. Phase II glucuronidation, however, can compensate for their lower phase I metabolism in rat hepatocyte monolayers and could play a yet unidentified role in the determination of their in vivo clearance.

Laparoscopic radiofrequency-assisted liver resection

Laparoscopic liver resection has not yet gained wide acceptance among hepatic surgeons, mainly because of the difficulties encountered in dealing with possible intraoperative bleeding. A new technique of laparoscopic liver resection is presented. A 43-year-old man with a large and symptomatic hemangioma underwent a laparoscopic radiofrequency energy-assisted liver resection. After induction of pneumoperitoneum, four trocars were introduced and intraoperative ultrasonography and coagulative desiccation were performed along a plane of tissue 1 cm away from the edge of the lesion using the Cool-Tip radiofrequency probe and a 500-kHz, radiofrequency generator. The necrosed band of parenchyma then was divided and the specimen removed. The operative time was 300 min with a resection time of 240 min. The intraoperative blood loss was 75 ml. The postoperative course was uneventful and the patient was discharged on postoperative day 6. Laparoscopic radiofrequency-assisted liver resection is feasible, and with greater experience may contribute to the wider use of mini-invasive video-assisted liver surgery.

Simultaneous resection of colorectal primary tumour and synchronous liver metastases

BACKGROUND

The surgical strategy for treatment of synchronous colorectal liver metastases remains controversial. The outcome and overall survival of patients presenting with such metastases, treated either by simultaneous resection or by delayed resection, were evaluated.

METHODS

From 1987 to 2000, 97 patients presented with synchronous colorectal liver metastases, of whom 35 (36 per cent) underwent a simultaneous resection and 62 patients (64 per cent) a delayed resection. Simultaneous resection was considered prospectively for patients with fewer than four unilobar metastases.

RESULTS

Age, blood transfusion requirements, operating time, duration of inflow occlusion, hospital stay and mortality rate were similar in the two groups. The morbidity rate did not differ significantly (23 per cent after simultaneous resection and 32 per cent after delayed resection). The location of the primary tumour and extent of liver resection did not influence the morbidity rate significantly in the simultaneous resection group. The overall survival rate was 94, 45 and 21 per cent at 1, 3 and 5 years respectively after simultaneous resection, and 92, 45 and 22 per cent after delayed resection.

CONCLUSION

In selected patients, simultaneous resection of the colorectal primary tumour and liver metastases does not increase mortality or morbidity rates compared with delayed resection, even if a left colectomy and/or a major hepatectomy are required.

Cryopreservation of adult human hepatocytes obtained from resected liver biopsies

Isolated human hepatocytes have been shown to represent a valuable in vitro model to investigate the metabolism and cytotoxicity of xenobiotics. In addition, human hepatocyte transplantation and artificial liver support systems using isolated human hepatocytes are currently investigated as treatment for acute and chronic hepatic failure. In this regard, human hepatocyte banking by cryopreservation would be of great interest. In the present study, freshly isolated hepatocytes from resected liver biopsies of 28 separate donors (viability: 88 +/- 2%; plating efficiency: 79 +/- 5%) were cryopreserved using two different protocols, stepwise freezing (SF) or progressive freezing (PF), in combination (PF(+), SF(+)) or not (PF(-), SF(-)) with a 30 min preincubation in culture medium at 37 degrees C. Total recovery was higher after PF (38 +/- 3%) than after SF (12 +/- 2%). Preincubation prior to SF had no effect on plating efficiency of thawed hepatocytes (SF(-): 38 +/- 6% versus SF(+): 46 +/- 7%) while preincubation prior to PF increased plating efficiency of thawed hepatocytes (PF(-): 42 +/- 6% versus PF(+): 64 +/- 4%, p < 0.05). In attached cultured human cryopreserved/thawed hepatocytes (CH) from the PF(+) group, albumin production and glutathione content were not significantly different from those of the freshly isolated hepatocyte (FIH) cultures. Cells in CH monolayers appeared smaller than cells in FIH monolayers. In addition, the pattern of cytochrome P450- and UDP-glucuronosyl transferase-dependent isoenzyme activities and GST activity were different, suggesting a variability in the resistance to cryopreservation of the various liver hepatocyte populations. Taken all together, the results of the present study suggest that recovery of human hepatocytes after isolation prior to progressive freezing should allow human hepatocyte banking for use in pharmacotoxicology and cell therapy research purposes.

Analysis of allelic imbalance in patients with colorectal cancer according to stage and presence of synchronous liver metastases

OBJECTIVE

To investigate the relationship between number and location of allelic imbalances (AI) and local tumor progression according to Astler-Coller classification.

SUMMARY BACKGROUND DATA

Spontaneous errors in DNA replication (i.e., allelic imbalance or microsatellite instability) have been suggested to play an important role in carcinomatous transformation as reflecting alterations of gene function.

METHODS

One hundred two consecutive patients with colorectal carcinoma undergoing surgical resection were included in this study. Patients were distributed according to the Astler-Coller classification as stages A (n = 7), B1 (n = 15), B2 (n = 24), C (n = 31), and D (n = 25). Fluorescent polymerase chain reaction was performed on frozen tumor, normal colon mucosa, and blood DNA at 35 microsatellite markers. Allelic imbalance frequency was compared with tumor staging.

RESULTS

The percentage of AI was significantly higher in stage D than in A/B1 and B2. In addition, the percentage of AI was significantly higher in 10 synchronous colorectal liver metastases than in stage A/B1 and B2 tumors. However, the allelotyping revealed a subgroup of A/B1 tumors with a high AI frequency. Statistical analysis showed that the presence of AI at microsatellites D1S305, D2S138, D3S1282, D17S790, and D22S928 presented a significantly positive correlation with stages.

CONCLUSION

The frequency of AI significantly correlates with tumor progression of colorectal cancer. Primary tumors with synchronous colorectal liver metastases showed a higher percentage of AI, suggesting that a frequency of AI greater than 35% with this selection of markers indicates a high risk of local progression and of development of metastases.

Surgical repair after bile duct and vascular injuries during laparoscopic cholecystectomy: when and how?

Recent collective reviews have outlined when and how surgeons should treat patients with bile duct injuries after laparoscopic cholecystectomy (LC). However, little is described about other injuries combined with bile duct injuries, for example, hepatic arterial injury and secondary biliary cirrhosis. Fifteen patients with bile duct injuries following LC were referred and surgically treated from 1990 to 1998 in our institution. We report how patients with hepatic arterial injury combined with bile duct injuries during LC were treated. The present study also reports unusual complicated situations: one patient with biliary cirrhosis referred 4 years after LC, another treated with internal biliary metallic stent referred 2.5 years after LC, and another with isolated right hepatic ductal injury. Short- and long-term surgical outcomes after biliary repair were compared between simply referred patients and those with complicated history. Patients who were referred several years after LC and who were referred after primary hepaticojejunostomy were included with patients with complicated history (n = 4, group B), and the other patients were included with patients with simple history (n = 11, group A). Simultaneous right hepatic arterial occlusion was observed in 3 of these 15 patients, and arterial reconstruction was performed in 2 of the 3 patients in addition to biliary reconstruction. No postoperative complication occurred in these three patients. The patient with isolated injury of the right hepatic duct and the other with biliary cirrhosis were successfully treated with hepaticojejunostomy. The other patient treated with biliary stent underwent hepaticojejunostomy but a second operation was required because of later stenosis. Mean hospital stay was significantly longer in group B (30.3 +/- 6.9 days) than in group A (18.5 +/- 2.5 days, p< 0.05). Rehospitalization was more frequent in group B than in group A (p < 0.01). However, long-term outcome was successful in both groups. The present results showed that arterial reconstruction should be performed when the distal right hepatic artery can be exposed and reconstructed, and suggested that patients with bile duct injuries during LC should be immediately referred to surgical institutions in which surgeons have adequate experience of bile duct repair and hepatic arterial reconstruction.

Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile?

BACKGROUND

Whether or not superior mesentericoportal venous resection (SM-PVR) associated with pancreaticoduodenectomy (PD) is safe and worthwhile has not been fully confirmed. The aim of the present study was to investigate results of this surgical procedure performed for pancreatic head and periampullary neoplasms.

METHODS

As a first analysis, postoperative morbidity and mortality after PD with (n = 31) or without SM-PVR (n = 119) were investigated in 150 patients with pancreatic head and periampullary neoplasms. As a second analysis, rates of margin-negative resection and survival after SM-PVR (n = 21) and without SM-PVR (n = 66) were compared in 87 patients with pancreatic ductal adenocarcinoma of the pancreatic head. In these patients undergoing SM-PVR (n = 21), survival rate was investigated in patients who did (n = 13) and did not (n = 8) undergo a margin-negative resection.

RESULTS

In the first analysis, duration of surgery and volume of blood transfused perioperatively were higher in patients undergoing SM-PVR. However, mortality, morbidity rates, and mean hospital stay did not differ between patients who did undergo SM-PVR (31 patients, 3.2%, 48.4%, and 22.2 days, respectively) and who did not (119 patients, 2.5%, 47.1%, 25.9 days, respectively). No postoperative death occurred in the recent part of the present study, since 1994, in patients undergoing SM-PVR. In the second analysis of pancreatic ductal adenocarcinoma, rates of margin-negative resection and 2-year survival did not significantly differ between patients who did and did not undergo SM-PVR (62% and 22%, respectively, versus 73% and 24%). In patients undergoing SM-PVR, survival rate was significantly higher for patients undergoing a margin-negative resection (n = 13) than for patients undergoing a macroscopic or microscopic margin-positive resection (n = 8, 2-year survival = 57.1% versus 0%, P <0.05).

CONCLUSION

PD combined with SM-PVR can be performed safely. This surgical procedure is followed by a promising survival rate and can be recommended in order to obtain a margin-negative resection; however, candidates for SM-PVR should be carefully selected.

Is a proliferation index of cancer cells a reliable prognostic factor after hepatectomy in patients with colorectal liver metastases?

BACKGROUND

In spite of many reports focusing on prognostic factors after hepatectomy in patients with colorectal liver metastases, few studies have investigated pathological factors, eg, fibrous pseudocapsulation, growth pattern at the tumor margin, and proliferation activity of cancer cells, other than histological type and surgical margin. The aim of the present study was to investigate whether absence of pseudocapsulation, infiltrative growth pattern of metastases, and higher proliferation of cancer cells shown by Ki-67 immunohistochemical reactivity were associated with poorer survival after hepatectomy among patients with colorectal liver metastases.

METHODS

Between 1988 and 1998, 221 patients underwent hepatic resection of colorectal metastases with curative intent in our institution. Pathology analyses were focused on pseudocapsulation of liver metastases, growth pattern at the tumor edge, and Ki-67 labelling index (Ki-67 LI) of cancer cell nuclei. Univariate analyses of survival and of disease-free survival were performed for several clinicopathological factors, and multivariate analyses of survival and disease-free survival were also performed.

RESULTS

The univariate survival analyses showed that pseudocapsulation, growth pattern, and Ki-67 LI were significant prognostic factors, besides synchronous versus metachronous occurrence of metastases, carcinoembryonic antigen level before hepatectomy, and number of metastases. A multivariate analysis showed that Ki-67 labeling index was the most reliable prognostic factor of survival. In addition, Ki-67 LI and microscopic growth pattern were multivariately predictive factors of disease-free survival.

CONCLUSIONS

This large single-institution study showed that investigation of cancer cell proliferation and pathologic characteristics of the tumor margin are major prognostic factors.

Hepatic metastases of gastroenteropancreatic neuroendocrine tumors: safe hepatic surgery

Liver metastases of neuroendocrine tumors are usually slow-growing, and cytoreductive hepatectomy can help reduce the effects of endocrinopathies and increase life expectancy and symptom-free survival. However, it has yet to be fully investigated how hepatectomy for metastatic neuroendocrine tumors can be performed safely. Here we report the results of 13 patients with neuroendocrine liver metastases operated on in our institution and those of a French multicentric study that included 131 patients. Preoperative patient selection and appropriate surgical technique, sometimes combined with preoperative portal embolization and local tumor destruction (radiofrequency and cryotherapy), may increase the resectability and the safety of the procedure. The mortality rate after hepatectomy was 0% (2.3% in the French study); the 3- and 6-year survival rates were 91% and 68%, respectively, in our institution (the mean survival time was 66 months in the French multicentric survey). Significant prolonged survival with complete palliation of symptoms can be obtained after liver metastases resection with low mortality.

[Changes in homeostasis during surgical liver resection]

OBJECTIVES

To assess changes in haemostasis during liver resection and to discuss the indications for antifibrinolytic therapy.

STUDY DESIGN

Open prospective study.

PATIENTS

The study included 39 consecutive non-cirrhotic patients presenting for liver resection under portal triad clamping.

METHOD

General anaesthesia was obtained with thiopentone, fentanyl, vecuronium and isoflurane. Transfusion scheme was standardized. Aprotinin (5,000 kIU.kg-1 BW) was administered in case of unexplained bleeding in the operative field. Coagulation pattern was assessed by routine tests and thrombelastrography before surgery, before portal triad clamping, 5 min after reperfusion and at completion of surgery. Patients requiring aprotinin intraoperatively were compared to others.

RESULTS

In 32 patients no significant bleeding occurred. Their coagulation pattern was moderately changed and remained within the normal range. In seven patients severe bleeding occurred which was treated with aprotinin. Their coagulation tests were significantly modified, especially after reperfusion, associating an increase in aPTT, TT, FDP, DDim, r + k and a decreased platelet count.

CONCLUSION

These changes were more in favour of a dilution coagulopathy or a DIC than hyperfibrinolysis. Therefore substitutive therapy with coagulation factors should be preferred to an antifibrinolytic agent. A systematic administration of the latter for liver resection in non-cirrhotic patients is debatable, considering the allergic risk (reoperation for cancer recurrence), thrombosis facilitation (pedicle clamping) and high cost.

[Surgical strategy in the treatment of synchronous hepatic metastases of colorectal cancers. Analysis of a series of 59 operated on patients]

AIM OF THE STUDY

The surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer remains controversial. The retrospective analysis of our series of resectable synchronous hepatic metastases is focused on the percentage of simultaneous resections, the circumstances, the indications, and the results of the one-step procedure compared to the two-step strategy.

METHODS

From January 1st 1982 to December 31st 1996, 146 patients were operated on for resection of hepatic metastases of colorectal cancer. Fifty-nine (40%) presented with synchronous metastases, 28 (47.5%) of whom underwent simultaneous resection of the primary tumor and of the hepatic metastases (simultaneous resection group: SR). For the other 31 patients (52.5%), the hepatic resection was delayed for a mean interval of 6 +/- 4 months (delayed resection group: DR).

RESULTS

The mean age in the two groups was not significantly different (56 years vs. 60 years). The need for blood transfusion and the volume required were not significantly different between the two groups. The duration of each surgical operation was comparable between the two groups (320 +/- 76 min vs. 308 +/- 88 min). Postoperative complications were observed in 18% of patients in the SR group and in 16% of patients in the DR group (no significant difference). There was no postoperative mortality in either group. Survival was 86, 63 and 43% at 1, 2, 3 years respectively in the SR group, and 81, 51 and 36% in the DR group, with no significant difference between the groups.

CONCLUSION

Simultaneous resection of the primary tumor and the hepatic metastases does not increase neither mortality nor morbidity in our series. The best candidate for a one-step procedure is a patient with a right colonic tumor, in a good status, with liver synchronous metastases resectable by mean of a minor hepatectomy.

Hepatic and pulmonary metastases from a meningeal hemangiopericytoma and severe hypoglycemia due to abnormal secretion of insulin-like growth factor: a case report

A 42-year-old woman was hospitalized for severe hypoglycemic coma. She had a voluminous hepatic metastasis and multiple small lung metastases from a meningeal hemangiopericytoma initially operated on 11 years earlier. High blood levels of an abnormal form of insulin-like growth factor type 2 (IGF II) associated with low blood levels of insulin, growth hormone, IGF I, and IGF BP3 were observed. After surgical resection of the liver and pulmonary metastases, serum glucose levels and hormonal abnormalities returned to normal.

Hepatic and pulmonary metastases from a meningeal hemangiopericytoma and severe hypoglycemia due to abnormal secretion of insulin-like growth factor: a case report

A 42-year-old woman was hospitalized for severe hypoglycemic coma. She had a voluminous hepatic metastasis and multiple small lung metastases from a meningeal hemangiopericytoma initially operated on 11 years earlier. High blood levels of an abnormal form of insulin-like growth factor type 2 (IGF II) associated with low blood levels of insulin, growth hormone, IGF I, and IGF BP3 were observed. After surgical resection of the liver and pulmonary metastases, serum glucose levels and hormonal abnormalities returned to normal.

Long-term survival following resection of colorectal hepatic metastases. Association Française de Chirurgie

AIM

The aim of this study was to analyse characteristics of patients who survived more than 5 years after liver resection of colorectal metastases.

METHODS

A multicentre retrospective study collected 1818 patients who underwent curative resection of hepatic metastases between 1959 and 1991. Among the 747 patients operated on before 1987, 102 survived longer than 5 years, and were compared with patients who survived less than 5 years.

RESULTS

Three risk factors proved independently significant in multivariate analysis between the two groups: serosa infiltration (P = 0.003), involvement of peritumoral lymph nodes around the primary colorectal tumour (P = 0.04), and a liver resection margin of less than 1 cm (P = 0.02). There was no significant difference for other parameters studied (location of primary tumour, location, number and size of metastases, type of resection). A trend towards a shorter survival of patients with increased carcinoembryonic antigen serum level was observed.

CONCLUSION

Resection of colorectal hepatic metastases can provide long-term survival even in patients with poor prognostic factors. It seems justified to undertake resection of colorectal liver metastases whenever it may be performed safely as a curative treatment.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie

BACKGROUND

Five-year survival rates after resection of liver metastases from colorectal carcinoma are close to 25%. Recurrences occur in two-thirds of the patients after surgery. Selection of patients likely to benefit from surgery remains controversial and subjective.

METHODS

Data from 1568 patients with resected liver metastases from colorectal carcinoma were collected. The prognostic value of different factors was studied through uni- and multivariate analyses. A scoring system was developed including the most relevant factors.

RESULTS

Two- and 5-year survival rates were 64% and 28%, respectively, and were affected by: age; size of largest metastasis or CEA level; stage of the primary tumor; disease free interval; number of liver nodules; and resection margin. Giving one point to each factor, the population was divided into three risk groups three risk groups with different 2-year survival rates: 0-2 (79%), 3-4 (60%), 5-7 (43%).

CONCLUSIONS

A simple prognostic scoring system was proposed to evaluate the chances for cure of patients after resection of liver metastases from colorectal carcinoma. The comparison between expected survival and estimated operative risk can help determine on an objective basis whether surgery is worthwhile. This system needs further prospective validation.

[Surgical treatment of synchronous hepatic metastases of colorectal cancers. Simultaneous or delayed resection?]

The surgical strategy for resectable synchronous hepatic metastases of colorectal cancer remains controversial. The retrospective analysis of our series of resectable synchronous hepatic metastases focused on the percentage of simultaneous resections, the circumstances, the indications and the results of the one-step procedure compared to the two-step strategy. From January 1, 1982 to December 31, 1995, 129 patients were operated on for resection of hepatic metastases of colorectal cancer. Forty one patients (32%) presented with synchronous hepatic metastases, 20 of whom (49%) underwent simultaneous resection of the primary tumor and the hepatic metastases (simultaneous resection group: SR). For the other 21 patients (51%), the hepatic resection was delayed for a mean interval of 5.2 +/- 4.2 months (delayed resection group: DR). The mean age of the 2 groups was not significantly different (54 years versus 58 years). When the primary tumor was located on the ascending colon, the hepatic excision was performed simultaneously in 9 out of ten cases. The need for blood transfusion and the volume required were not significantly different between the two groups. The length of each surgical operation was comparable between the two groups (331 +/- 76 minutes SR vs 330 +/- 88 minutes DR). Postoperative complications were observed in 20% of patients in the SR group and 10% of patients in the DR group (no significative difference). There was no postoperative mortality in either group. Survival was 83%, 44% and 37% at 1, 2 and 3 years respectively in the SR group and 79%, 59% and 49% in the DR group, with no significant difference between the groups. These results show that simultaneous resection of the primary tumor and the hepatic metastases did not increase either morbidity or mortality in our study, and that it should be proposed especially to patients presenting with a primary tumor of the ascending colon with metastases resectable by means of a minor hepatectomy.