Hemorrhage control for laparoscopic hepatectomy: technical details and predictive factors for intraoperative blood loss.

BACKGROUND: Controlling bleeding during laparoscopic hepatectomy (LH) is technically demanding, but reportedly associated with less estimated blood loss (EBL) than open surgery. The present study aimed to describe and evaluate hemorrhage control techniques during LH and identify predictors of high intraoperative EBL. METHODS: The data of 438 consecutive patients undergoing LH between 1995 and 2012 were reviewed. Bleeding control was facilitated by the proper use of hemostatic devices and surgical maneuvers unique to LH and by preserving intra-abdominal pressure. EBL was evaluated among three groups of 146 patients in each group: 1995-2006 (group A), 2006-2009 (group B), and 2009-2012 (group C). We also sought factors that predicted EBL ≥800 mL. RESULTS: Mean EBL decreased overtime from groups A to C: group A, 378 ± 619 mL; group B, 293 ± 391 mL; groups C, 257 ± 366 mL; P = 0.127. Transfusion rate was 6.7 % in group A, 5.5 % in group B, and 4.8 % in group C (P = 0.743). Hypertension (odds ratio (OR) 2.82, 95 % confidence interval CI 1.37-5.78; P = 0.006), preoperative chemotherapy (OR 2.55, 95 % CI 1.26-5.31; P = 0.009), resection of posterosuperior segments (OR 3.73, 95 % CI 1.33-12.17; P = 0.012), and major hepatectomy (OR 4.21, 95 % CI 1.64-13.02; P < 0.001) independently predicted high EBL. CONCLUSIONS: Improvements in bleeding control techniques over time have reduced EBL during LH. The use of these techniques and an understanding of the predictive factors for high EBL will help surgeons improve outcomes after LH.

Laparoscopic major hepatectomy for colorectal liver metastases in elderly patients: a single-center, case-matched study.

BACKGROUND: The incidence of colorectal cancer liver metastases (CRLM) among elderly patients has increased; therefore, older patients are increasingly being considered for hepatic resection. However, data regarding the outcome of laparoscopic major hepatectomy (LMH) in elderly patients are limited. The aim of this study was to evaluate the safety and feasibility of LMH in elderly patients with CRLM. METHODS: From January 1998 to September 2013, a total of 31 patients aged ≥ 70 years (elderly group) were matched with 62 patients < 70 years (young group) by demographics, tumor characteristics, and details of surgical procedures. RESULTS: The elderly group was characterized by a higher incidence of hypertension (41.9 vs. 17.7 %, P = 0.022), ≥ 2 comorbidities (32.3 vs. 11.3 %, P = 0.021), and lower prevalence of metastatic rectal cancer (12.9 vs. 38.7 %, P = 0.015). Intraoperative variables, such as surgical duration (300 vs. 240 min, P = 0.920), blood loss (400 vs. 300 mL, P = 0.361), and transfusion rate (9.7 vs. 12.9 %, P = 0.726), were not notably different between the groups. Postoperative mortality (0 vs. 0 %), complications (54.8 vs. 41.9 %, P = 0.276), and major complications (27.4 vs. 16.1 %, P = 0.303, respectively) were comparable between the groups. The 3-year overall survival rates were 61.7 % in the young group (median 40 months) and 57.9 % in the elderly group (median 39 months), respectively (P = 0.842). CONCLUSIONS: Our results clearly demonstrated that LMH for CRLM could be safely performed in elderly patients; thus, advanced age itself should not be regarded as a contraindication for LMH.

Computed tomography versus water-soluble contrast swallow in the detection of intrathoracic anastomotic leak complicating esophagogastrectomy (Ivor Lewis): a prospective study in 97 patients.

PURPOSE: Water-soluble contrast swallow (CS) is usually performed before refeeding for anastomosis assessment after esophagectomy with intrathoracic anastomosis but the sensitivity of CS is low. Another diagnostic approach is based on analysis of computed tomography (CT) scan with oral contrast and of CT mediastinal air images. We undertook to compare them prospectively. METHODS: Ninety-seven patients with an esophageal carcinoma operated by intrathoracic anastomosis were included prospectively in a study based on a CT scan at postoperative day 3 (without oral and intravenous contrast) and CT scan and CS at day 7. CT scan analysis consisted of assessing contrast and air leakage. In case of doubt, an endoscopy was done. RESULTS: A diagnosis of anastomotic leak was made in 13 patients (13.4%), in 2 cases before day 7 and in 3 beyond day 7. At day 3, 94 CT scans were performed, but the diagnostic value was poor. In 95 patients with both CS and CT scan at day 7, CS disclosed a leak in 5 of 11, and CT scan was abnormal in 8 of 11. Leakage of contrast and/or presence of mediastinal gas had the best negative predictive value (95.8%). Endoscopy was done in 16 patients with only mediastinal gas at day 7 CT scan. It disclosed a normal anastomosis in 11, fibrin deposits in 4, and a leak in 1. CONCLUSIONS: In comparison with CS only, CT at day 7 improves the sensitivity and negative predictive value for diagnosing an anastomotic leak. In case of doubt endoscopy is advisable. This approach provides an accurate assessment of the anastomosis before refeeding.

Ocular adnexal lymphoma and Helicobacter pylori gastric infection.

There is a causal association between Helicobacter pylori (Hp) gastric infection and the development of gastric MALT lymphoma. In contrast, the link between Hp gastric infection and the development of extragastric lymphoma has not been thoroughly investigated. We, therefore, studied the prevalence of gastric Hp infection at initial diagnosis of ophthalmologic and nonophthalmologic extragastric lymphoma patients. Three cohorts of patients were studied: a first one of 83 patients with OAL, a second one of 101 patients with extraophthalmologic extragastric lymphoma, and a third one of 156 control individuals (control) without malignant lymphoma. Gastric Hp infection was investigated by histopathological analysis and Hp-specific PCR assay on gastric biopsy tissue samples. We found gastric Hp infection in 37 OAL patients (45%), in 25 extraophthalmologic extragastric lymphoma cases (25%), and in 18 controls individuals (12%) (P < 0.0001 OAL/C and P < 0.01 OAL/extra-OAL cases). Gastritis was found in 51% and 9% of Hp-positive and Hp-negative lymphoma patients, respectively (P < 10(-4)). Gastric Hp infection only correlated with MALT/LPL lymphoma (P = 0.03). There is a significant association between gastric Hp infection and MALT/LPL OAL. This suggests a novel mechanism of indirect infection-associated lymphomagenesis whereby chronic local antigen stimulation would lead to the emergence of ectopic B-cell lymphoma.

Operative techniques to avoid near misses during laparoscopic hepatectomy.

BACKGROUND: The lack of a complete hepatic overview and tactile feedback during laparoscopic hepatectomy may result in near misses or fatal intraoperative complications despite the advantage of a magnified laparoscopic view. The aim of the study is to describe operative techniques and guiding principles with which to address near misses unique to laparoscopic hepatectomy and evaluate the intraoperative complication rate overtime. METHODS: Data of 408 consecutive patients who underwent laparoscopic hepatectomy were reviewed. Representative operative techniques and guiding principles with which to address near misses and pitfalls unique to laparoscopic hepatectomy were evaluated among the patients by 2 surgeons. RESULTS: Most near misses were due to lack of understanding of both the laparoscopic view and anatomic aspects unique to laparoscopic hepatectomy. Operative techniques and/or guiding principles with which to address these issues were demonstrated as follows: starting parenchymal transection at the declivitous parts; no ligation of the right or left portal vein before confirming the bifurcation; dissection of the short hepatic vein using a sealing device; dissection of the root of the hepatic vein using scissors; exposure of the middle hepatic vein, which is anatomically close to the hilar plate; and identification of V8 using intraoperative ultrasonography. The intraoperative massive bleeding due to vessel injury or surgical clip slippage occurred in 25 patients (6.1%), and its rate had a significant trend to decrease with increasing years. CONCLUSION: We demonstrated operative techniques and guiding principles with which to address near misses in laparoscopic hepatectomy. The intraoperative massive bleeding rate trended to decrease over time.

[Morbidity/mortality reviews: assessment of their implementation in one hospital]. / Bilan de la mise en place de revues de mortalité morbidité au sein d'un établissement hospitalier.

OBJECTIVES: The objective of this study was to describe the steps involved in establishing a morbidity/mortality review committee (MMRC) to analyze the causes of avoidable deaths or life-threatening complications and the development of plans and protocols to avoid their recurrence. METHODS: The MMRC included physicians from each hospital department. Each member was responsible for organizing departmental meetings to analyze its avoidable deaths and life-threatening complications. RESULTS: During its meetings three times a year, the MMRC developed a method for analysis of these serious events. Each department organized 3 (range: 1-12) meetings a year and analyzed 1-3 cases at each. Over 30 months, 35,817 patients were admitted to the hospital and 341 (1%) died. The unexpected mortality rate varied by department and specialty (median: 27%, range: 6-65%). In all, 92 cases were referred to MMRC meetings (27%; range: 6-70% of hospital deaths), and 30% of them involvement nosocomial diseases. Heart disease was the primary cause of unexpected deaths. DISCUSSION: The principal improvements involved medical and surgical strategies, surgical techniques, drug prescriptions, and patient monitoring.

Pre-operative predictive factors of early recurrence after resection of adenocarcinoma of the esophagus and cardia.

OBJECTIVES: To determine pre-operative predictive factors of early recurrence in patients with esophageal and cardial adenocarcinoma. PATIENTS AND METHODS: We retrospectively analyzed consecutive patients who underwent resection for esophageal and cardial adenocarcinoma in our institution between October 1992 and October 2001. Patient files were studied and classified according to the occurrence of early recurrence (within one year) (group A) and patients without recurrence (group B). Pre-operative clinical, biological and radiological parameters were recorded. Both groups were compared in univariate and multivariate analysis. RESULTS: One hundred patients underwent surgical resection. Tumor was located in lower esophagus in 71 cases and at the cardia in 29 cases. R0 resection was feasible in 95 cases. Hospital mortality was 2%. Survival rate at 3 years was 56%. Recurrence before 1 year occurred in 28 patients (group A) and not in 72 (group B). In univariate analysis, younger age (P=0.01), dysphagia (P=0.04) and percentage of weight loss (P<0.0004) were significantly different between both groups. Weight loss more than 10% was observed in 2 patients of group B, and in 9 patients of group A. In multivariate analysis, weight loss more than 10% was the only pre-operative factor associated with early recurrence (P=0.018). CONCLUSION: Important weight loss could be a pre-operative predictive factor of early recurrence after resection of esophageal and cardial adenocarcinoma and surgery as first line treatment could be avoided in these patients.

Transient elastography: a new noninvasive method for assessment of hepatic fibrosis.

Chronic hepatitis is accompanied by progressive deposit of hepatic fibrosis, which may lead to cirrhosis. Evaluation of liver fibrosis is, thus, of great clinical interest and, up to now, has been assessed with liver biopsy. This work aims to evaluate a new noninvasive device to quantify liver fibrosis: the shear elasticity probe or fibroscan. This device is based on one-dimensional (1-D) transient elastography, a technique that uses both ultrasound (US) (5 MHz) and low-frequency (50 Hz) elastic waves, whose propagation velocity is directly related to elasticity. The intra- and interoperator reproducibility of the technique, as well as its ability to quantify liver fibrosis, were evaluated in 106 patients with chronic hepatitis C. Liver elasticity measurements were reproducible (standardized coefficient of variation: 3%), operator-independent and well correlated (partial correlation coefficient = 0.71, p < < 0.0001) to fibrosis grade (METAVIR). The areas under the receiver operating characteristic (ROC) curves were 0.88 and 0.99 for the diagnosis of patients with significant fibrosis (>/= F2) and with cirrhosis ( = F4), respectively. The Fibroscan is a noninvasive, painless, rapid and objective method to quantify liver fibrosis.

Totally laparoscopic right hepatectomy.

BACKGROUND: Since the first laparoscopic cholecystectomy was performed in 1987, the surgical applications of laparoscopy have grown to involve most areas of general surgery. Until recently, however, major liver surgery remained outside of the scope of minimally invasive surgery. Building on advances in laparoscopic equipment, techniques, and ongoing experience in hepatic surgery, major liver resection has been performed laparoscopically in some select centers. At our institute, a safe and standardized approach to minimally invasive major hepatectomy has been developed. This article illustrates the relevant technical maneuvers in the performance of a totally laparoscopic right hepatectomy. Common pitfalls and areas of concern are discussed. METHODS: A detailed description of a standardized procedure is presented. The technique was developed from a single-institution experience of 41 laparoscopic right hepatectomies performed in a tertiary care referral center for laparoscopic digestive surgery. The prevention of bleeding and gas embolism are discussed. CONCLUSIONS: The laparoscopic right hepatectomy is feasible and safe if the appropriate expertise and equipment are available. In selected patients, this new approach can be proposed by a surgeon experienced in laparoscopic and hepatic surgery as an alternative to conventional open liver resection.

Noninvasive assessment of liver fibrosis by measurement of stiffness in patients with chronic hepatitis C.

Liver fibrosis is the main predictor of the progression of chronic hepatitis C, and its assessment by liver biopsy (LB) can help determine therapy. However, biopsy is an invasive procedure with several limitations. A new, noninvasive medical device based on transient elastography has been designed to measure liver stiffness. The aim of this study was to investigate the use of liver stiffness measurement (LSM) in the evaluation of liver fibrosis in patients with chronic hepatitis C. We prospectively enrolled 327 patients with chronic hepatitis C in a multicenter study. Patients underwent LB and LSM. METAVIR liver fibrosis stages were assessed on biopsy specimens by 2 pathologists. LSM was performed by transient elastography. Efficiency of LSM and optimal cutoff values for fibrosis stage assessment were determined by a receiver-operating characteristics (ROC) curve analysis and cross-validated by the jack-knife method. LSM was well correlated with fibrosis stage (Kendall correlation coefficient: 0.55; P < .0001). The areas under ROC curves were 0.79 (95% CI, 0.73-0.84) for F > or =2, 0.91 (0.87-0.96) for F > or =3, and 0.97 (0.93-1) for F=4; for larger biopsies, these values were, respectively, 0.81, 0.95, and 0.99. Optimal stiffness cutoff values of 8.7 and 14.5 kPa showed F > or =2 and F=4, respectively. In conclusion, noninvasive assessment of liver stiffness with transient elastography appears as a reliable tool to detect significant fibrosis or cirrhosis in patients with chronic hepatitis C.

Prognostic factor analysis in advanced gastric cancer patients treated with hydroxyurea, leucovorin, 5-fluorouracil, and cisplatin (HLFP regimen).

This study was performed to determine the prognostic factors of 102 nonresectable locally advanced or metastatic gastric cancer patients prospectively treated with a multimodulation of 5-fluorouracil (5FU), hydroxyurea, leucovorin, and cisplatin. Response rate in 85 patients with measurable disease was 62.4% (95% confidence interval 51.9% to 72.9%). A weight increase (5% or more) was observed in 47% of patients, performance status improved in 70.6%, and symptoms disappeared in 69%. Median times for progression-free survival and overall survival were eight and 11 months, respectively. Liver metastases, more than two involved sites, and increased carcinoembryonic antigen (CEA) were found to be univariate adverse prognostic factors for survival. In a multivariate analysis, only the presence of liver metastasis was found to be an independent prognostic factor. Response rate and survival in patients with gastric linitis or diffuse forms were in the same range as in patients with intestinal forms of gastric adenocarcinoma.

Hereditary persistence of alpha-fetoprotein is due to both proximal and distal hepatocyte nuclear factor-1 site mutations.

BACKGROUND AND AIMS: The molecular mechanism of hereditary persistence of alpha-fetoprotein (HPAFP) has been previously described in a large Scottish family, consisting of a -119G>A substitution in the distal hepatocyte nuclear factor 1 (HNF-1) binding site of the alpha-fetoprotein (AFP) gene promoter. We report here the molecular mechanisms of HPAFP in 2 new unrelated families. METHODS: Family 1 was of Bengali origin, and family 2 was Italian. Four of 5 subjects (family 1) and 3 of 9 (family 2) showed HPAFP. The AFP gene promoter was studied in all available family members. RESULTS: All subjects with high AFP levels had mutated promoter sequences. Family 1 showed the reported -119G>A substitution. Family 2 showed -55C>A and -65C>T substitutions in the proximal putative HNF-1 binding region of the promoter. The -55C>A mutation increased the similarity of the proximal HNF-1 binding region to a consensus binding region. Gel shift assays confirmed its increased affinity toward HNF-1, and transfection experiments revealed an increased level of gene transcription. The -65C>T substitution theoretically created a CCAAT box. However, gel shift and transfection experiments failed to show any biological effect of this substitution that is associated with the -55C>A mutation. CONCLUSIONS: Two different mutations localized in either HNF-1 binding sites of the AFP gene promoter may result in HPAFP. This highlights the importance of HNF-1 in AFP gene expression. Unexplained persistent AFP should lead to family study and/or AFP gene promoter sequencing to avoid inappropriate explorations and treatment decisions.