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.

Long-term outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly patients.

AIM: Full-thickness rectal prolapse is common in the elderly, but there are no particular practice guidelines for its surgical management. We evaluated retrospectively the perioperative and long-term clinical results and function in elderly and younger patients with complete rectal prolapse after robotic-assisted laparoscopic rectopexy (RALR). METHOD: Seventy-seven patients who underwent RALR between 2002 and 2010 were divided into Group A (age < 75 years, n = 59) and Group B (age > 75 years, n = 18). Operative time, intra- and postoperative complications, length of hospital stay, short-term and long-term outcomes, recurrence rate and degree of satisfaction were evaluated. RESULTS: There was no significant difference between the groups regarding operation time, conversion, morbidity or length of hospital stay. At a median follow-up of 51.8 (5-115) months, there was no difference in the improvement of faecal incontinence, recurrence and the degree of satisfaction. CONCLUSION: Robotic-assisted laparoscopic rectopexy is safe in patients aged over 75 years and gives similar results to those in patients aged < 75 years.

Long-term outcomes after totally robotic sacrocolpopexy for treatment of pelvic organ prolapse.

PURPOSE: This study evaluated the feasibility, safety, effectiveness, and long-term results of pelvic organ prolapse surgery using the Da Vinci robotic system. METHODS: During a 7-year period, 52 consecutive patients with pelvic organ prolapse underwent robotic-assisted abdominal sacrocolpopexy. Clinical data were retrospectively collected and analyzed. RESULTS: All but two of the procedures were successfully completed robotically (96 %). Median operative time was 190 (range, 75-340) mins. There was no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 5 days. The median follow-up was 42 months. Five recurrent prolapses (9.6 %) were diagnosed. CONCLUSIONS: Our experience indicates that using the Da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse with good long-term results.

[Imaging of the postoperative biliary tract]. / Imagerie des voies biliaires opérées.

For a long time, imaging of the biliary tract after surgical procedures was performed with invasive procedures such as endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Due to recent advances in diagnostic imaging, non-invasive techniques are now favored. While US remains the initial imaging modality, it is frequently followed by CT and/or MRCP. Image interpretation should always be performed in keeping with clinical and laboratory findings as well as the type of surgical procedure. The most appropriate imaging modality is selected based on these data. In patients with jaundice or biliary tract stenosis, MRCP, with use of an optimal technique and 3D acquisition, is the imaging modality of choice. In non-jaundiced patients with non-distended biliary tract and suspected bile leak, MRCP should be completed by the injection of a liver-specific contrast agent with biliary excretion to achieve non-invasive biliary tract opacification. In patients with malignancy, CT is preferred due to its high spatial resolution and ability to demonstrate small anastomotic tumor recurrences. CT should also be performed in patients with suspected hepatic artery or portal vein injury in addition to biliary tract injury or to detect distant complications.

What is the quality of information about bariatric surgery on the internet?

BACKGROUND: The purpose of this study was to evaluate the role of Internet on patients scheduled for bariatric procedures and the quality of information available on different websites. METHODS: Between July 2003 to July 2005, patients undergoing bariatric surgical procedures completed a survey. Data were collected prospectively. One hundred valid surveys were returned. Independently, two bariatric surgeons evaluated available French and English websites using major search engines. RESULTS: Forty-two of 100 patients (42%) sought information about bariatric surgery on the Internet. Seventy-four percent of these patients (n = 31/42) used search engines with 81% visiting less than ten websites. According to the patient's evaluation, 58% of the websites visited did not provide technical details of any surgical bariatric procedures, and only 61% provided information regarding postoperative weight loss. Furthermore, 58% of websites did not provide information about the laparoscopic approach, and 54% did not give any information on potential postoperative complications. Bariatric surgeon's evaluation was similar except for two differences: laparoscopic approach and postoperative weight loss information were discussed in 90% (p < 0.001) and 43% (p < 0.1) of visited websites, respectively. CONCLUSION: When the Internet was used to search for information about bariatric surgery, search engines were preferentially used but search duration was short. Available Internet websites can be considered as moderately reliable; however, 25% of visited websites contain misleading information. Comparison between patients and surgeons views showed that patients were effective in detecting misleading information.

[Da Vinci robot-assisted thoracoscopy for primary hyperparathyroidism: a new application in endocrine surgery]. / Thoracoscopie robotique pour hyperparathyroïdie primaire: nouvelle application en chirurgie endocrinienne.

Primary hyperparathyroidism is a relatively frequent disease whose incidence is often underestimated. It is caused by one or more hyperfunctioning parathyroid glands. Almost all pathologic glands (hyperplasia or adenoma) are located in the neck but 1-2% may be located in the mediastinum and may require a sternotomy or thoracotomy approach for resection. The thoracoscopic approach was proposed in 1994 and the DaVinci robotic system allows performance of this thoracoscopic procedure with the benefits of 3-dimensional vision, and improved surgical dexterity and ergonomics. We report a case of a patient with a parathyroid adenoma located in the aorto-pulmonary window which was resected using a left thoracoscopic approach aided by the Da Vinci robotic system.

Robot-assisted adrenalectomy: indications and drawbacks.

Adrenal tumors can vary from a benign adrenocortical adenoma with no hormonal secretion to a secretory adrenocortical malignancy (adrenocortical carcinoma) or a hormone-secreting tumor of the adrenal medulla (pheochromocytoma). Currently, laparoscopic adrenalectomy is regarded as the preferred surgical approach for the management of most adrenal surgical disorders, although there are no prospective randomized trials comparing this technique with open adrenalectomy. However, widespread adoption of robotic technology has positioned robotic adrenalectomy as an option in some medical centers. Speculative advantages associated with the use of the robotic system have rarely been evaluated in clinical settings and cost increase remains an important drawback associated with robotic surgery. This review summarizes current available data regarding robotic transperitoneal adrenalectomy including its indications, advantages, limitations, and comparison with conventional laparoscopic adrenalectomy. We believe that the use of a robotic system seems to be useful especially in more difficult patients with larger tumors, truncal paragangliomas, and bilateral and/or partial adrenalectomies. Overall, we believe that overcosts due to robotic system use could be balanced by hospital stay decrease, patients' referral increase, improved postoperative outcomes in more difficult patients and ergonomics for the surgeon. However, we also believe that the current surgical intuitive business model is counterproductive, because there are no available strong clinical data that could balance overcosts associated with the use of the robotic system.

Early liver metastases in resectable periampullary cancer: Incidence and risk factors.

PURPOSE: The aim of the present study was to estimate the incidence of very early hepatic metastases (HMs) (<6 months) and their imaging patterns after cephalic duodenopancreatectomy (CDP) for periampullary carcinoma (excluding duodenal carcinoma) and to identify their associated risk factors. METHODS: From January 2003 to June 2016, all patients who underwent surgical treatment for periampullary carcinoma by CDP at our institution and with adequate pre- and postoperative CT scans were included. Univariate and multivariate logistic regressions were performed to determine factors associated with very early HM and recurrence. RESULTS: Of the 132 patients included retrospectively, 27 (20.5%) patients developed HMs. The mean time to diagnosis of HM was 103.9±55.2days. HMs were multiple in 81.4% of cases and bilobar in 59.3% of cases; their mean maximum size was 16.7±12.7mm. In univariate logistic analysis, lymphovascular emboli were significantly associated with HM (p=0.02). No independent risk factors for HM were found in multivariate analysis. In multivariate logistic analysis, two independent risk factors were identified for the occurrence of early recurrence: tumor size >23mm on preoperative CT scan (OR: 3.3; 95% CI: [1.2-9.3]; p=0.02) and tumor differentiation (poor vs. good: OR 15.5; 95 CI [1.5-158.3]; moderate vs. good: OR: 17.1; 95% CI: [1.9-154.4]; p=0.04). CONCLUSIONS: Nearly one in five patients developed HM after CDP within 6 months with a highly consistent pattern. A thorough preoperative assessment, combining CT scan and MRI with a delay of less than three weeks before surgery, appears essential. A routine systematic postoperative CT scan at 8 weeks is also required prior to initiating adjuvant chemotherapy. The type of surgical intervention does not seem to be a risk factor, although the risk of HM occurrence appears to be related to the lymphovascular invasion of the tumor and maybe its degree of differentiation, elements not assessable by imaging.

Extensive lymph node dissection during pancreaticoduodenectomy: a risk factor for hepatic steatosis?

PURPOSE: The first reports of hepatic steatosis following pancreaticoduodenectomy (PD) were published several years ago; however, clear risk factors remain to be identified. Therefore, the aim of this study was to identify the risk factors for hepatic steatosis post-PD. METHODS: We studied 90 patients who had undergone PD between September 2005 and January 2015. The inclusion criteria were as follows: available unenhanced CT within one month before PD and at least one unenhanced CT acquisition between PD and chemotherapy initiation. Using scanners, we studied the liver and spleen density as well as the surface areas of visceral (VF) and subcutaneous fat (SCF). These variables were previously identified by univariate and multivariate analyses. RESULTS: Hepatic steatosis occurred in 25.6% of patients at 45.2 days, on average, post-PD. Among the patients with hepatic steatosis, the average liver density was 52 HU before PD and 15.1 HU post-PD (p < 0.001). The Patients with hepatic steatosis lost more VF (mean, 28 vs. 11 cm2) and SCF (28.8 vs. 13.7 cm2) (p < 0.01 and p = 0.01, respectively). Portal vein resection and extensive lymph node dissection were independent risk factors in the multivariate analysis (odds ratio [OR] 5.29, p = 0.009; OR 3.38, p = 0.04, respectively). CONCLUSION: Portal vein resection and extensive lymph node dissection are independent risk factors for post-PD hepatic steatosis.

[Open minimally invasive parathyroid and thyroid surgery]. / Mini-incisions pour thyroïdectomies et parathyroïdectomies.

Open minimally invasive parathyroidectomy or thyroidectomy (small-incision technique) are frequently performed. Benefits and disadvantages of this approach are discussed in this review. Preoperative patients selection is mandatory and is also discussed.

[Is radionuclide imaging still usefull for thyroid nodule management? A surgical point of view]. / La scintigraphie thyroïdienne est-elle encore utile pour la prise en charge d'un nodule thyroïdien? Le point de vue du chirurgien.

Preoperative management of thyroid nodule is still controversial. Since 25 years ago, preoperative evaluation of thyroid nodule has been modified and improved. The aim of this study was to review, from a surgical point of view, the role of radionuclide imaging results in the management of patients with thyroid nodules.

MDCT features of hepatocellular carcinoma (HCC) in non-cirrhotic liver.

PURPOSE: To describe the multidetector row computed tomography (MDCT) imaging features of HCC that develops in patients who are free from underlying liver cirrhosis and to determine if the MDCT presentation of this specific tumor differs from that of the more common HCC that develops in patients with liver cirrhosis using a retrospective case-control study. PATIENTS AND METHODS: The MDCT examinations of 38 patients with HCC in non-cirrhotic liver (group 1) were quantitatively and qualitatively analyzed and compared to those obtained in 38 patients with HCC in cirrhotic liver (group 2) matched for age and gender. Quantitative and qualitative characteristics of HCC of both groups were compared using univariate analysis. RESULTS: HCCs were significantly larger in group 1 (81.5mm±55.5) than in group 2 (44.5mm±39.1 SD; P=0.0015). In group 1, HCCs were more frequently single tumors (87%) than in group 2 (37%) (P<0.0001), encapsulated (92% vs. 47% respectively; P<0.0001), had more frequently fatty component (24% vs. 8%, respectively; P=0.0279) and internal hemorrhage (29% vs. 3%, respectively; P=0.0033). No significant differences were found between the two groups for location, hyperenhancement of HCC during the arterial phase, washout during the portal phase, endoluminal portal involvement by HCC, endoportal cruoric thrombus, invasion of adjacent organs and underlying liver steatosis. CONCLUSION: HCC in non-cirrhotic liver are larger than those observed in cirrhotic liver and more frequently present as a single encapsulated tumor. They have the same patterns of enhancement than HCC that develops in cirrhotic liver.

CT imaging findings in patients with advanced hepatocellular carcinoma treated with sorafenib: Alternative response criteria (Choi, European Association for the Study of the Liver, and modified Response Evaluation Criteria in Solid Tumor (mRECIST)) versus RECIST 1.1.

PURPOSE: The first aim was to compare Response Evaluation Criteria in Solid Tumor (RECIST) 1.1, modified Response Evaluation Criteria in Solid Tumor (mRECIST), Choi and European Association for the Study of the Liver (EASL) evaluations to assess the response to sorafenib for hepatocellular carcinoma (HCC). The second aim was to describe the evolution of HCC and to identify whether some imaging features are predictive of the absence of response. MATERIALS AND METHODS: This retrospective study included 60 patients with advanced HCC treated with sorafenib. Patients must have undergone a scan prior to treatment to identify the number of lesions, size, enhancement and endoportal invasions, and repeat scans thereafter. Computed tomography (CT) scans were analyzed using RECIST 1.1, mRECIST, Choi and EASL criteria. Overall survival was analyzed. RESULTS: The median overall survival was 10.5 months. On the first CT reevaluation, the sorafenib response rates were 20%, 5%, 7% and 3% according to Choi, EASL, mRECIST and RECIST 1.1. The responders based on Choi exhibited significantly better overall survival compared with non-responders (20.4 months; hazard ratio (HR) 0.042, 95% confidence interval (CI): 0.186-0.94, p=0.035). A modification of imaging findings was observed in 48.3% of patients, and necrosis was present in 44.1% of patients. CONCLUSION: This study found a significant difference between Choi versus RECIST 1.1, mRECIST and EASL when evaluating the response to sorafenib in HCC patients.

Robotic-assisted pelvic organ prolapse surgery.

BACKGROUND: This study describes technical aspect and short-term results of pelvic organ prolapse surgery using the da Vinci robotic system. METHODS: During a 1-year period, 18 consecutive patients with pelvic organ prolapse were operated on using the da-Vinci system. Clinical data were prospectively collected and analyzed. RESULTS: All but one procedure was successfully completed robotically (95%). Performed procedures were colpohysteropexy (n = 12), mesh rectopexy (n = 2), or sutured rectopexy combined with sigmoid resection (n = 4). Average setup time was 21 min and significantly decreased with experience. Mean operative time was 172 min (range, 45-280). There were no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 7 days. At 6 months, all patients were free of pelvic organ prolapse and stated that they were satisfied with anatomical and functional results. CONCLUSION: Our experience indicates that using the da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse.

Second-stage robot-assisted biliopancreatic diversion with duodenal switch after sleeve gastrectomy.

Biliopancreatic diversion (BPD) was initially described in 1979 and consisted of a distal gastrectomy with a 250-mL stomach pouch and a distal intestinal bypass with a 50 to 100-cm common channel resulting in malabsorption of dietary fat (Scopinaro et al. Br J Surg. 66(9):618-20, 1979). Later, several modifications (sleeve gastrectomy, pylorus preservation, and duodenal switch) were proposed to improve incidence of postoperative dumping syndrome, diarrhea, and anastomotic ulcerations (Lagacé et al. Obes Surg. 5(4):411-8, 1995). Gagner et al. developed a simplified and reproducible approach for laparoscopic BPD with duodenal switch (BPD-DS) after sleeve gastrectomy (Ren et al. Obes Surg. 10(6): 514-23, 2000). BPD-DS has been considered as one of the most difficult bariatric procedures for its surgical complexity and postoperative metabolic complications management. In this regard, the number of BPD-DS has remained extremely low (<4 %). We hypothesize that robotic approach could facilitate the feasibility of BPD-DS procedure. In this multimedia video (8 min), we present a step-by-step robotic BPD-DS.

Risk Factors for Postoperative Morbidity After Totally Robotic Gastric Bypass in 302 Consecutive Patients.

BACKGROUND: Totally robotic gastric bypass (robotic Roux-en-Y gastric bypass, R-RYGBP) has been adopted in some centers on the basis of large retrospective studies. In view of some data showing higher morbidity and higher costs, some authors have considered that robotic gastric bypass may no longer be justified with the existing system. Although low postoperative complication rates after R-RYGBP have been reported, risk factors for postoperative morbidity have never been evaluated. The goal of this study was to identify risk factors for postoperative morbidity after R-RYGBP. METHODS: A retrospective analysis of a prospectively maintained database was performed and included 302 consecutive patients after R-RYGBP performed between 2007 and 2013. This subset of patients represented 34 % of all gastric bypass procedures performed during this study period. Univariate and multivariate analyses were performed in order to identify risk factors for postoperative overall morbidity (Clavien scores 1-4 versus 0) and major morbidity (Clavien score ≥3 versus 0-1-2). RESULTS: Postoperative morbidity and mortality rates were 24.4 and 0.6 %, respectively. In multivariate analysis, independent risk factors for overall morbidity were American Society of Anesthesiologists (ASA) score ≥3 (odds ratio (OR) 2.0) and previous bariatric surgery (revisional gastric bypass) (OR 2.0). Independent risk factors for major morbidity (Clavien ≥3) were previous bariatric surgery (revisional gastric bypass) (OR 3.7), low preoperative hematocrit level (OR 0.9), and revisional gastric bypass procedure with concomitant gastric banding removal (OR 5.7). CONCLUSIONS: R-RYGBP is prone to increased complications in the setting of a high preoperative ASA score and revisional surgery. This should be taken into consideration by clinicians when evaluating R-RYGBP.

[Usefulness of intraoperative 123I-MIBG during reoperation for malignant pheochromocytoma: a case report]. / Utilité de la détection 123I-MIBG peropératoire lors d'une réintervention pour phéochromocytome malin: á propos d'un cas.

Intraoperative MIBG radionuclear scanning has been used to improve pathological foci localization and surgical accuracy in patients with neural crest derived tumors. This intraoperative detection has been reported in less than 10 patients during reoperation for pheochromocytoma. We report a case of 123I-MIBG intraoperative detection allowing to improve surgical resection quality during reoperation for pheochromocytoma. The use of intraoperative MIBG radionuclear scanning is helpful when reoperation for pheochromocytoma is performed.

[Advantages of using robotic Da Vinci system for unilateral adrenalectomy: early results]. / Quels sont les avantages de l'utilisation du système robotique DaVinci pour réaliser une surrénalectomie unilatérale ? Résultats préliminaires.

STUDY AIM: The goal of this study was to report the early results of unilateral transperitoneal adrenalectomy using robotic Da Vinci system, and to compare them to the results of the laparoscopic standard adrenalectomy. METHODS: Prospective study included all patients operated on for unilateral laparoscopic or robotic adrenalectomy from November 2000 to November 2002. RESULTS: Twenty-eight patients underwent unilateral adrenalectomy using either standard laparoscopy (14 patients) or robotic Da Vinci system (14 patients). Mean duration of robotic adrenalectomy seemed to be longer than standard laparoscopy (111 vs. 83 min; P = 0.057). This tendency decreased while surgeons' experience was increasing. Mean duration of operating room activity was similar for both types of surgery. Peroperative events without conversion, conversion rate (7%), drainage, morbidity (21%), duration of hospitalisation were similar for both types of surgery. Duration of standard laparoscopic adrenalectomy was positively correlated to patients body mass index. This correlation was absent in patients operated on by robotic Da Vinci system. CONCLUSION: This preliminary study found no objective data demonstrating that robotic Da Vinci system was superior to standard laparoscopic approach for unilateral adrenalectomy. However, we think that it is necessary to continue further evaluation of this system to demonstrate its possible superiority.

[Endocrine tumors of the gastro-intestinal tract (Carcinoid tumors)]. / Prise en charge chirurgicale des tumeurs endocrines du tractus gastro-intestinal.

Surgical management of gastro-intestinal endocrine tumors has to be adapted to tumor localization and disease extension (local and general). The aim of this literature review was to define surgical management of these unfrequent tumors.

[Does the size of pheochromocytoma influence the results of its laparoscopic excision?]. / La taille d'un phéochromocytome influence-t-elle les résultats de son exérèse par voie laparoscopique?

BACKGROUND: The tumor size is considered as a limitation for laparoscopic adrenalectomy. The aim of this study was to assess diagnostic characteristics, hemodynamic modifications, and outcome of intraperitoneal laparoscopic adrenalectomy according to the size of pheochromocytoma. METHODS: Retrospective study from January 1997 to December 2000. Results were evaluated according to the size of pathologic study (< or > or = 5 cm). RESULTS: Forty two patients underwent laparoscopic adrenalectomy during this period. Among them, 11 (26%) were operated on for adrenal pheochromocytoma (6 patients < 5 cm and 5 patients > or = 5 cm). Preoperative systolic hypertension was 138 mmHg and 178 mmHg respectively (p = 0.01). Urinary metanephrine/normetanephrine rate was 1.259 and 0.268 respectively (p = 0.08). Capsular tumor effraction rate was 27%. Tumor size was 37% larger than that estimated by CT scan (24% versus 52%). Mean hospital stay was 10 days and 8 days respectively. Morbidity and mortality were 18% and 0%. All these criteria were not statistically significant among the two groups of patients. CONCLUSIONS: Pheochromocytoma size > or = 5 cm do not modify outcome of patients but is responsible for preferential noradrenaline secretion and stronger hemodynamic modifications. Tumor fragmentation rate and CT scan size underestimation seem important in this group of patients. These characteristics have to be integrated to improve laparoscopic adrenalectomy outcome of patients with pheochromocytoma > or = 5 cm.