Paradigm shift: should preoperative 3D reconstruction models become mandatory before hepatectomy for hepatocellular carcinoma (HCC)? Results of a multicenter prospective trial.

BACKGROUND: A preoperative surgical strategy before hepatectomy for hepatocellular carcinoma is fundamental to minimize postoperative morbidity and mortality and to reach the best oncologic outcomes. Preoperative 3D reconstruction models may help to better choose the type of procedure to perform and possibly change the initially established plan based on conventional 2D imaging. METHODS: A non-randomized multicenter prospective trial with 136 patients presenting with a resectable hepatocellular carcinoma who underwent open or minimally invasive liver resection. Measurement was based on the modification rate analysis between conventional 2D imaging (named "Plan A") and 3D model analysis ("Plan B"), and from Plan B to the final procedure performed (named "Plan C"). RESULTS: The modification rate from Plan B to Plan C (18%) was less frequent than the modification from Plan A to Plan B (35%) (OR = 0.32 [0.15; 0.64]). Concerning secondary objectives, resection margins were underestimated in Plan B as compared to Plan C (-3.10 mm [-5.04; -1.15]). CONCLUSION: Preoperative 3D imaging is associated with a better prediction of the performed surgical procedure for liver resections in HCC, as compared to classical 2D imaging.

Outcome after implementation of a clinical pathway for pancreaticoduodenectomy in a low volume centre.

Introduction: To study whether the implementation of a clinical pathway including some enhanced recovery after surgery (ERAS) items for pancreaticoduodenectomy (PD) in a low volume centre for pancreatic surgery was safe. Material and methods: Patients undergoing elective PD within a clinical pathway between 1 October 2013 and 30 September 2019 were considered for the study and the outcome was compared between the first and second period of the study. The primary endpoint was the achievement of postoperative key targets of the protocol. Secondary endpoints were complications, mortality and readmissions within 90 days postoperatively, and postoperative hospital stay. Results: Forty-five patients could be ana-lysed. The two groups were balanc-ed for demographic, clinical and histological variables. In the second period more patients achieved key targets: nasogastric tube removal at postoperative day (PoD) 2, oral fluidsat PoD 3, drain removal at PoD 5 and hospital discharge at PoD 9. The rates of postoperative complications, mor-tality and readmissions were not significantly different between the two groups and were similar to data reported for high volume centres. Conclusions: Our results show that the implementation of a clinical pathway following PD and including some ERAS items was feasible and safe in a low volume centre for pancreatic surgery.

Light beams with volume superoscillations.

Using a superposition of shifted Bessel beams with different longitudinal wave vectors and orbital angular momenta, we realize an optical beam having simultaneous axial, angular, and radial focusing narrower than the Fourier limit. Our findings can be useful for optical particle manipulation and high-resolution microscopy.

Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy: a propensity-score-matched case-control analysis.

BACKGROUND: Liver resection may be associated with substantial blood loss, and cell saver use has been recommended for patients at high risk. We performed a study to compare the allogenic erythrocyte transfusion rate after liver resection between patients who had intraoperative cell salvage with a cell saver device versus patients who did not. Our hypothesis was that cell salvage with autologous transfusion would reduce the allogenic blood transfusion rate. METHODS: Cell salvage was used selectively in patients at high risk for intraoperative blood loss based on preoperatively known predictors: right and repeat hepatectomy. Patients who underwent elective right or repeat hepatectomy between Nov. 9, 2007, and Jan. 27, 2016 were considered for the study. Data were retrieved from a liver resection database and were analyzed retrospectively. Patients with cell saver use (since January 2013) constituted the experimental group, and those without cell salvage (2007-2012), the control group. To reduce selection bias, we matched propensity scores. The primary outcome was the allogenic blood transfusion rate within 90 days postoperatively. Secondary outcomes were the number of transfused erythrocyte units, and rates of overall and infectious complications. RESULTS: Ninety-six patients were included in the study, 41 in the cell saver group and 55 in the control group. Of the 96, 64 (67%) could be matched, 32 in either group. The 2 groups were balanced for demographic and clinical variables. The allogenic blood transfusion rate was 28% (95% confidence interval [CI] 12.5%-43.7%) in the cell saver group versus 72% (95% CI 56.3%-87.5%) in the control group (p < 0.001). The overall and infectious complication rates were not significantly different between the 2 groups. CONCLUSION: Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy reduced the allogenic blood transfusion rate.

CONTEXTE: La résection hépatique peut s'accompagner de pertes sanguines importantes et l'utilisation d'un système de récupération de sang autologue est recommandée chez les patients à risque élevé. Nous avons procédé à une étude pour comparer le taux de transfusion de sang allogénique après la résection hépatique selon que les patients avaient ou non été soumis à une intervention de récupération de sang autologue. Notre hypothèse est que la récupération de sang autologue peropératoire pourrait réduire le taux de transfusion de sang allogénique. MÉTHODES: La récupération de sang autologue a été utilisée sélectivement chez des patients exposés à un risque élevé à l'égard de pertes sanguines peropératoires, en fonction de facteurs prédictifs préopératoires connus : hépatectomie droite et reprise de l'hépatectomie. Les patients ayant subi une intervention chirurgicale non urgente pour hépatectomie droite ou reprise d'hépatectomie entre le 9 novembre 2007 et le 27 janvier 2016 ont été considérés comme admissibles à l'étude. Les données ont été récupérées à partir d'une base de données sur la résection hépatique et analysées de manière rétrospective. Les patients soumis à la récupération de sang autologue (à partir de janvier 2013) ont constitué le groupe expérimental, et les autres (2007-2012) ont constitué le groupe témoin. Pour réduire le risque de biais de sélection, nous avons apparié les scores de propension. Le paramètre principal était le taux de transfusion de sang allogénique dans les 90 jours suivant l'opération. Les paramètres secondaires étaient le nombre d'unités transfusées, le taux de complications infectieuses et le taux global de complications. RÉSULTATS: Quatre-vingt-seize patients ont pris part à l'étude, 41 dans le groupe soumis à la récupération de sang autologue et 55 dans le groupe témoin. Parmi les 96 patients de l'étude, 64 (67 %) ont pu être assortis, 32 dans chaque groupe. Les 2 groupes étaient équilibrés aux plans des variables démographiques et cliniques. Le taux d'allotransfusions a été de 28 % (intervalle de confiance [IC] de 95 % 12,5 %-43,7 %) dans le groupe soumis à la récupération de sang autologue, contre 72 % (IC de 95 % 56,3 %-87,5 %) dans le groupe témoin (p < 0,001). Le taux de complications infectieuses et le taux global de complications n'ont pas été significativement différents entre les 2 groupes. CONCLUSION: La récupération de sang autologue peropératoire dans les cas d'hépatectomie droite ou d'hépatectomie répétée a réduit le taux de transfusion de sang allogénique.

Axial sub-Fourier focusing of an optical beam.

We demonstrate experimentally the generation of an optical beam having an axial focusing that is narrower than the Fourier limit. The beam is constructed from a superposition of Bessel beams with different longitudinal wave vectors, realizing a super-oscillatory axial intensity distribution. Such beams can be useful for microscopy and for optical particle manipulation.

Nutritional risk screening 2002 and ASA score predict mortality after elective liver resection for malignancy.

INTRODUCTION: The aim of the study was to evaluate whether Nutritional risk screening 2002 (NRS 2002) at hospital admission may predict postoperative mortality and complications within 90 days after elective liver resection for malignancy. MATERIAL AND METHODS: A retrospective cohort study of a prospective database was performed. Two-hundred and three patients with elective liver resection for malignancy between 9 November 2007 and 27 May 2014 were included. Clinical data, NRS 2002, surgical procedures and histology were recorded. The primary endpoint was 90-day mortality. Complications were registered within 90 days postoperatively according to the Clavien-Dindo classification. RESULTS: The 90-day mortality was 5.9% and the overall complication rate was 59.1%. Multivariate analysis identified NRS 2002 score ≥ 4 (odds ratio (OR) = 9.24; p = 0.005) and American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 6.20; p = 0.009) as predictors of 90-day mortality. The 90-day mortality was 27.6% (8/29) for patients with both risk factors (NRS 2002 score ≥ 4 and ASA score ≥ 3) vs. 2.3% (4/174) for patients without or with only one risk factor (p < 0.001). CONCLUSIONS: In the present study NRS 2002 score ≥ 4 and ASA score ≥ 3 were predictors of 90-day mortality after elective liver resection for malignancy.

Drug-induced cholestasis risk assessment in sandwich-cultured human hepatocytes.

Drug-induced cholestasis (DIC) is recognized as one of the prime mechanisms for DILI. Hence, earlier detection of drug candidates with cholestatic signature is crucial. Recently, we introduced an in vitro model for DIC and evaluated its performance with several cholestatic drugs. We presently expand on the validation of this model by 14 training compounds (TCs) of the EU-EFPIA IMI project MIP-DILI. Several batches of human hepatocytes in sandwich-culture were qualified for DIC assessment by verifying the bile acid-dependent increase in sensitivity to the toxic effects of cyclosporin A. The cholestatic potential of the TCs was expressed by determining the drug-induced cholestasis index (DICI). A safety margin (SM) was calculated as the ratio of the lowest TC concentration with a DICI≤0.80 to the Cmax,total. Nefazodone, bosentan, perhexiline and troglitazone were flagged for cholestasis (SM<30). The hepatotoxic (but non-cholestatic) compounds, amiodarone, diclofenac, fialuridine and ximelagatran, and all non-hepatotoxic compounds were cleared as "safe" for DIC. Tolcapone and paracetamol yielded DICI-based SM values equal to or higher than those based on cytotoxicity, thus excluding DIC as a DILI mechanism. This hepatocyte-based in vitro assay provides a unique tool for early and reliable identification of drug candidates with cholestasis risk.

Outcome 1 year after digestive surgery in malnourished, elderly patients, with an emphasis on quality of life analysis.

BACKGROUND: Quality of life data after digestive surgery in malnourished, elderly patients are rarely reported. What can we expect as 1-year outcomes in these high-risk patients after digestive surgery? METHODS: We conducted a prospective observational study in a digestive surgery department in a tertiary, nonacademic hospital in Mulhouse, France. Malnourished, older patients (according to the Nutritional Risk Index) undergoing digestive surgery between November 2007 and December 2008 were included and followed up for 1 year. Quality of life was measured by the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire at the end of the study period. RESULTS: We included 37 patients with a median age of 76 (range 66-86) years in our study. The mean global health status and quality of life score in 17 of 24 living patients 1 year after surgery was 68.6 (standard deviation [SD] 12.4), and no difference with the score of a reference population 70.8 (SD 22.1) was observed (p = 0.68). In-hospital mortality was 11% and morbidity was 70%. CONCLUSION: The present study suggests that despite high postoperative mortality and morbidity, an acceptable quality of life can be achieved in malnourished, elderly survivors of digestive surgery.

Carrier-bound fibrin sealant compared to oxidized cellulose application after liver resection.

OBJECTIVE: The aim of the study was to compare the incidence of post-operative complications between those patients that received TachoSil to the transection surface of the liver vs. those that received Surgicel. METHODS: Retrospective study of a prospective database in a tertiary hospital. Primary endpoints were overall complications. Secondary endpoints were liver surgery-specific composite endpoint, major complications and hospital stay. Uni- and multivariate analysis of predictive factors for complications and subgroup analysis were performed. RESULTS: One hundred thirty-three liver resections were performed between 9 November 2007 and 2 November 2011: 64 with TachoSil and 69 with Surgicel application. Both groups were equivalent concerning demographic, clinical and major intra-operative data. No significant differences were observed in overall complication rate (62.5% vs. 62.3%), liver surgery-specific composite endpoint (12.5% vs. 18.8%), major complication rate (18.7% vs. 24.6%) and median hospital stay (13 vs. 10 days) for TachoSil and Surgicel application, respectively. Predictive factors for complications in multivariate analysis were: American Society of Anesthesiology Score ≥3 and duration of surgery >240 min. Subgroup analysis found a reduced complication rate with TachoSil for major hepatectomy. CONCLUSION: The results of the present study suggest that the routine use of TachoSil after a liver resection does not reduce the overall complication rate compared with Surgicel application. However, TachoSil may be beneficial in a major hepatectomy.

Surgery for recurrence of periampullary malignancies.

AIM: Few studies have addressed the surgical treatment of recurrent disease after pancreatic resection. The aim of this study was to evaluate the indications, the short- and long-term outcome, and the prognostic factors impacting survival in patients undergoing a re-laparotomy for recurrence of periampullary malignancies. METHODS: Between 1990 and 2007, 16 re-laparotomies were performed in 15 patients (one patient had a second re-laparotomy) with a median age of 61 years (range 31-84). Patients were identified from a prospective database and records were reviewed retrospectively. RESULTS: Seven re-laparotomies were performed for a surgical emergency and nine patients had a re-laparotomy for recurrence found at imaging studies. Perioperative mortality was observed in three patients presenting with surgical emergency and a poor performance status (Eastern Cooporative Oncology Group score >or=3). Perioperative morbidity was 40%. Median survival after the first re-laparotomy for the 15 patients was 7.4 months, and was not different for patients presenting a surgical emergency versus no emergency. Patients with peritoneal carcinomatosis had a median survival of 1.4 month. In a univariate analysis of survival, a performance status of ECOG score >or=2 and a pre-operative hemoglobin level <12 g/dl were predictors of poor survival. CONCLUSION: In selected patients, a re-laparotomy for recurrence of periampullary malignancies is feasible. Peritoneal recurrence was not a good indication for surgery. The predictors of poor survival after the re-laparotomy were a poor performance status and a low preoperative hemoglobin level.

Impact of lymph node involvement on long-term survival after R0 pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas.

Pancreaticoduodenectomy remains the only potentially curative treatment for adenocarcinoma of the pancreas. The aim of this study was to analyze prognostic factors impacting survival after R0 pancreaticoduodenectomy for adenocarcinoma in the head of the pancreas. Between 1995 and 2002, a potentially curative (R0) pancreaticoduodenectomy with pancreatogastrostomy for ductal adenocarcinoma in the head of the pancreas was performed in 81 patients (42 women and 39 men) with a mean age of 64 years (range 35-84). Patients were identified from a prospective database and records were reviewed retrospectively. Postoperative mortality was 1%, and 40% of patients had complications. Median survival was 18 months, and the 5-year survival was 24%. Fifteen patients were alive at 5 years. Factors associated with poor survival in multivariate analysis were (1) two or more positive lymph nodes, (2) tumor diameter greater than 30 mm, and (3) age greater than 70 years. In patients with no or with one positive lymph node, the 5-year survival was 44%. On the other hand, in patients with two or more positive lymph nodes, both the 3- and 5-year survival was 5%. The main risk factor associated with poor survival after an R0 pancreaticoduodenectomy for adenocarcinoma in the head of pancreas was lymph node status: The presence of two or more positive lymph nodes was associated with decreased survival.

[Positron emission tomography of gastrointestinal carcinomas]. / Résultats de la tomographie par emission de positons dans les cancers de l'appareil digestif.

We evaluated positon emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in 120 patients with intestinal malignancies, focusing on its diagnostic yield and influence on the surgical strategy. PET had a sensitivity of 67% and a specificity of 100% for metastases in 28 patients with cardio-esophageal carcinoma. PET detected 64% of 22 primary pancreatic carcinomas, and had a sensitivity of 70% and a specificity of 83% for metastases. In two cases, PET showed false-positive signs of peritoneal metastasis (not found at laparotomy). Among 70 patients with recurrent or metastatic colorectal carcinoma, eight had signs of local recurrence of rectal carcinoma treated by abdominoperineal resection; PET gave four true-positive, one false-negative, and three false-positive results. PET was better than computed tomography (CT) for the diagnosis of peritoneal metastasis, but its sensitivity was only 58%. The diagnostic value of PET for hepatic metastases (87%) was similar to that of CT (77%) and sonography (87%). The diagnostic sensitivity of PET for pulmonary metastases (82%) was similar to that of CT (84%). PET modified the surgical strategy in two (7%) of 28 patients with cardio-esophageal carcinoma, one (5%) of 22 patients with pancreatic carcinoma, and 22 (33%) of 70 patients with colorectal carcinoma (appropriately in 11 cases, inappropriately in 11 cases). These disappointing results suggest that PET must be thoroughly evaluated in this setting before being widely adopted.

First and repeat resection of colorectal liver metastases in elderly patients.

OBJECTIVE: The objective of this study was to evaluate the short- and long-term outcome after first and repeat resection in patients older than 70 years. SUMMARY BACKGROUND DATA: Liver resection is the best treatment for colorectal liver metastases and is currently increasingly performed in elderly patients. The benefit of resection for these patients needs to be evaluated. METHODS: Between 1990 and 2000, 56 first and 16 repeat liver resections were performed in 61 patients older than 70 years. Patients were identified from a prospective database and records were reviewed retrospectively. RESULTS: First and repeat liver resection resulted, respectively, in a 0% and 7% postoperative mortality rate and a 41% and 38% complication rate, respectively. Median survival after first resection of 53 patients with R0 resection was 33 months, and the 5-year survival rate was 22%. Factors associated with poor long-term survival in multivariate analysis were extrahepatic disease, high carcinoembryonic antigen level over 200 ng/mL, and the presence of 3 or more liver metastases. Patients without these risk factors showed a median survival of 42 months and a 5-year survival rate of 36%. Repeat liver resection resulted in a median survival of 17 months and in a 3-year survival rate of 25%. CONCLUSION: First and repeat liver resection for colorectal liver metastases can be performed safely in patients older than 70 years. A 5-year survival rate similar to those of younger patients can be expected after first liver resection for patients without the presence of risk factors.

Cardio-esophageal cancer. Is 18Fluorodeoxyglucose positron emission tomography worthwhile?

BACKGROUND/AIMS: 18Fluorodeoxyglucose positron emission tomography has been proposed for the preoperative staging of carcinomas of the esophagus and gastric cardia. The aim of this study was to assess its diagnostic value and its influence on therapeutical decisions. METHODOLOGY: Twenty-eight patients with a cancer of the esophagus or gastric cardia underwent a 18Fluorodeoxyglucose positron emission tomography on a gamma camera with coincidence detection electronics, in addition to our standard preoperative procedures (barium swallow, liver ultrasonography, chest X-ray). Four types of lesions were searched for: primary tumor, abdominal and mediastinal lymph nodes, and distant metastases. Results of 18Fluorodeoxyglucose positron emission tomography were compared to pathological findings. RESULTS: Sensitivity for the primary tumor was 86%. Sensitivity for mediastinal and abdominal lymph nodes was 75 and 54%, respectively, whereas specificity was 100%. Distant metastases were detected in 4 patients: liver metastasis in 2 patients and bone metastasis in 2 patients. Results of 18Fluorodeoxyglucose positron emission tomography influenced therapeutical decisions for 2 patients. CONCLUSIONS: 18Fluorodeoxyglucose positron emission tomography seems to be worthwhile in the preoperative staging of carcinomas of the esophagus and gastric cardia, mainly because it may detect distant metastases.