Revisiting the Surgical Management of Giant Hepatic Hemangiomas: Enucleation Versus Anatomical Resection?

BACKGROUND: Resection is rarely indicated in giant hepatic hemangiomas (HHs) that are symptomatic. Enucleation (EN), compared with anatomical resection (AR), is considered the better technique to resect them as EN has been reported to have lower morbidity while conserving the normal liver tissue. But no study has yet clearly established the superiority of EN over AR. In addition, the independent predictors of postoperative morbidity have not been established. METHODS: All consecutive patients operated for HH at two specialized hepatobiliary centers were reviewed. Patient demographics, operative variables, and postoperative outcomes were analyzed and compared between two techniques. Postoperative complications were graded as per Clavien-Dindo classification of surgical complications. The aims of this study were to compare two techniques of HH resection with respect to postoperative outcomes and to identify the risk factors for 90-day major postoperative morbidity and mortality. RESULTS: A total of 64 patients, including 41 who underwent AR, 22 who underwent EN, and 1 who underwent liver transplantation, were operated for hemangiomas during the study period. Ten patients (9 who were operated for hemangiomas of size ≤4 cm and 1 who underwent transplantation) were excluded. Fifty-four patients, the majority being women (85%), with a median age of 48 years, were operated for giant HH. These patients were classified into two groups based on the technique of resection, namely, EN (22 patients) and AR (32 patients). Both groups were comparable in all aspects except that the number of liver segments resected was significantly more with AR. Postoperative outcomes were similar in both groups. Independent predictors of 90-day major complications including mortality were the use of total vascular exclusion (relative risk [RR]: 2.3, p = 0.028) and duration of surgery >4.5 h (RR: 2.3, p = 0.025). CONCLUSION: Both techniques yield similar results with respect to 90-day postoperative morbidity and mortality. The choice of technique should be based on the location of tumor and simplicity of liver resection.

NutriNet-Salud Mexico. Prospective study online: 2018-2028. Relationship between nutrition and health and determinants of dietary habits and nutritional status.

BACKGROUND: NutriNet-Salud Mexico is a digital health information system, e-epidemiology instrument, online, open and free, to recording and analysis the determinants of dietary habits and nutritional status of the Mexican population, for the prevention of overweight, obesity and noncommunicable diseases for the period 2018-2028. OBJECTIVE: Describe the design, development and implementation of NutriNet-Salud Mexico from the French model NutriNet-Santé France 2008-2018. METHOD: NutriNet-Salud Mexico platform is the basis for the development of health information system for prospective cohort study, scheduled for a period of 10 years (2018-2028), with a dedicated website, and its development will enable to have multiple study populations within an initial set of five self-applicable questionnaires validated in Mexican population. RESULTS: The information will enable to develop applied research, learn and monitor food contributions and nutritional status of the population, assess the impact of public health actions on feeding behavior and nutritional status, comparing populations between countries (Mexico, France, Belgium and Switzerland) and national institutes, universities and states. CONCLUSIONS: NutriNet-Salud Mexico will provide information for assist in research and public action, especially to guide public policies on nutrition Mexico. The scientific elements will make appropriate nutritional recommendations to different populations and access to a representative nominal population sample with low-cost, in real-time, and with dual approach to e-epidemiology: cohort study to identify causality and cross-sectional studies (descriptive research, monitoring and evaluation).

INTRODUCCIÓN: NutriNet-Salud México es un sistema de información en salud digital, instrumento de e-epidemiología, en línea, abierto y gratuito, para el registro y el análisis de los factores determinantes de los hábitos alimentarios y el estado nutricional de la población mexicana, para la prevención del sobrepeso, la obesidad y las enfermedades crónicas no transmisibles para el período 2018-2028. OBJETIVO: Describir el diseño, el desarrollo y la implementación de NutriNet-Salud México a partir del modelo francés NutriNet-Santé France 2008-2018. MÉTODO: La plataforma NutriNet-Salud México es la base digital para el desarrollo de un sistema de información en salud ­para un estudio de cohorte prospectivo programado para 10 años (2018-2028)­ con un sitio web dedicado cuyo desarrollo permite tener varias poblaciones de estudio que responden un conjunto inicial de cinco cuestionarios autoaplicables validados en población mexicana. RESULTADOS: La información obtenida permitirá desarrollar investigación aplicada, conocer y vigilar los aportes alimentarios y el estado nutricional de la población, evaluar el impacto de acciones de salud pública sobre el comportamiento alimentario y el estado nutricional, y comparar poblaciones entre países (México, Francia, Bélgica y Suiza) e institutos nacionales, universidades y Estados. CONCLUSIONES: NutriNet-Salud México permitirá coadyuvar en investigación y acción pública, especialmente en la orientación de políticas públicas de México en materia de nutrición. Los elementos científicos aportarán recomendaciones nutricionales adecuadas a diferentes poblaciones, y permitirán acceder a una representativa muestra poblacional nominal a bajo costo y en tiempo real con doble abordaje de e-epidemiología: estudio de cohorte para identificar causalidad y estudios transversales periódicos (investigación descriptiva, monitoreo y evaluación).

NutriNet-Salud México. Prospective study online: 2018-2028. Relationship between nutrition and health and determinants of dietary habits and nutritional status. / NutriNet-Salud México. Estudio prospectivo por Internet: 2018-2028. Relación de nutrición y salud y factores determinantes de los hábitos alimentarios y el estado nutricional

Background: NutriNet-Salud Mexico is a digital health information system, e-epidemiology instrument, online, open and free, to recording and analysis the determinants of dietary habits and nutritional status of the Mexican population, for the prevention of overweight, obesity and noncommunicable diseases for the period 2018-2028. Objective: Describe the design, development and implementation of NutriNet-Salud Mexico from the French model NutriNet-Santé France 2008-2018. Method: NutriNet-Salud Mexico platform is the basis for the development of health information system for prospective cohort study, scheduled for a period of 10 years (2018-2028), with a dedicated website, and its development will enable to have multiple study populations within an initial set of five self-applicable questionnaires validated in Mexican population. Results: The information will enable to develop applied research, learn and monitor food contributions and nutritional status of the population, assess the impact of public health actions on feeding behavior and nutritional status, comparing populations between countries (Mexico, France, Belgium and Switzerland) and national institutes, universities and states. Conclusions: NutriNet-Salud Mexico will provide information for assist in research and public action, especially to guide public policies on nutrition Mexico. The scientific elements will make appropriate nutritional recommendations to different populations and access to a representative nominal population sample with low-cost, in real-time, and with dual approach to e-epidemiology: cohort study to identify causality and cross-sectional studies (descriptive research, monitoring and evaluation).

Introducción: NutriNet-Salud México es un sistema de información en salud digital, instrumento de e-epidemiología, en línea, abierto y gratuito, para el registro y el análisis de los factores determinantes de los hábitos alimentarios y el estado nutricional de la población mexicana, para la prevención del sobrepeso, la obesidad y las enfermedades crónicas no transmisibles para el período 2018-2028. Objetivo: Describir el diseño, el desarrollo y la implementación de NutriNet-Salud México a partir del modelo francés NutriNet-Santé France 2008-2018. Método: La plataforma NutriNet-Salud México es la base digital para el desarrollo de un sistema de información en salud ­para un estudio de cohorte prospectivo programado para 10 años (2018-2028)­ con un sitio web dedicado cuyo desarrollo permite tener varias poblaciones de estudio que responden un conjunto inicial de cinco cuestionarios autoaplicables validados en población mexicana. Resultados: La información obtenida permitirá desarrollar investigación aplicada, conocer y vigilar los aportes alimentarios y el estado nutricional de la población, evaluar el impacto de acciones de salud pública sobre el comportamiento alimentario y el estado nutricional, y comparar poblaciones entre países (México, Francia, Bélgica y Suiza) e institutos nacionales, universidades y Estados. Conclusiones: NutriNet-Salud México permitirá coadyuvar en investigación y acción pública, especialmente en la orientación de políticas públicas de México en materia de nutrición. Los elementos científicos aportarán recomendaciones nutricionales adecuadas a diferentes poblaciones, y permitirán acceder a una representativa muestra poblacional nominal a bajo costo y en tiempo real con doble abordaje de e-epidemiología: estudio de cohorte para identificar causalidad y estudios transversales periódicos (investigación descriptiva, monitoreo y evaluación).

Impact of neoadjuvant chemoradiotherapy on postoperative outcomes after esophageal cancer resection: results of a European multicenter study.

OBJECTIVES: To assess the impact of neoadjuvant chemoradiotherapy (NCRT) on anastomotic leakage (AL) and other postoperative outcomes after esophageal cancer (EC) resection. BACKGROUND: Conflicting data have emerged from randomized studies regarding the impact of NCRT on AL. METHODS: Among 2944 consecutive patients operated on for EC between 2000 and 2010 in 30 European centers, patients treated by NCRT after surgery (n=593) were compared with those treated by primary surgery (n=1487). Multivariable analyses and propensity score matching were used to compensate for the differences in some baseline characteristics. RESULTS: Patients in the NCRT group were younger, with a higher prevalence of male sex, malnutrition, advanced tumor stage, squamous cell carcinoma, and surgery after 2005 when compared with the primary surgery group. Postoperative AL rates were 8.8% versus 10.6% (P=0.220), and 90-day postoperative mortality and morbidity rates were 9.3% versus 7.2% (P=0.110) and 33.4% versus 32.1% (P=0.564), respectively. Pulmonary complication rates did not differ between groups (24.6% vs 22.5%; P=0.291), whereas chylothorax (2.5% vs 1.2%; P=0.020), cardiovascular complications (8.6% vs 0.1%; P=0.037), and thromboembolic events (8.6% vs 6.0%; P=0.037) were higher in the NCRT group. After propensity score matching, AL rates were 8.8% versus 11.3% (P=0.228), with more chylothorax (2.5% vs 0.7%; P=0.030) and trend toward more cardiovascular and thromboembolic events in the NCRT group (P=0.069). Predictors of AL were high American Society of Anesthesiologists scores, supracarinal tumoral location, and cervical anastomosis, but not NCRT. CONCLUSIONS: Neoadjuvant chemoradiotherapy does not have an impact on the AL rate after EC resection (NCT 01927016).

Transtracheal esophageal stent removal: a case-series.

Benign esophagorespiratory fistula is a rare but often lethal affection and difficult to cure. Possible treatments are surgery or esophageal stenting but may fail and cause respiratory failure. Two patients with spontaneous esophagorespiratory fistula after chemoradiotherapy for an esophageal malignancy were both treated by esophageal exclusion but esophageal stent were left in place. The esophageal stents were transtracheally removed through the fistula. The removals were successful, patients could leave Intensive Care Unit and returned home. Transtracheal esophageal stent removal is technically possible but very risky. Such situations must be avoided: esophageal stents must absolutely be removed before esophageal exclusion.

Evaluation study of different strategies for detecting surgical site infections using the hospital information system at Lyon University Hospital, France.

OBJECTIVE: To evaluate different strategies for detecting surgical site infections (SSIs) using different sources (notification by the surgeon, bacteriological results, antibiotic prescription, and discharge diagnosis codes). BACKGROUND: Surveillance plays a role in reducing the risks of SSIs but the performance of case reports by surgeons is insufficient. Indirect methods of SSI detection are an alternative to increase the quality of surveillance. METHODS: A retrospective cohort study of 446 patients operated consecutively during the first half of 2007 was set up in a 56-bed general surgery unit in Lyon University Hospital, France. Patients were followed up 30 days after intervention. Different methods of detection were established by combining different data sources. The sensitivity and specificity of these methods were calculated by using, as reference method, the manual review of the medical records. RESULTS: The sensitivity and specificity of SSI detection were, respectively, 18.4% (95% confidence interval [CI]: 7.9-31.6) and 100% for surgeon notification; 63.2% (95% CI: 47.3-78.9) and 95.1% (95% CI: 92.9-97.1) for detection based on positive cultures; 68.4% (95% CI: 52.6-81.6) and 87.5% (95% CI: 84.3-90.7) using antibiotic prescription; 26.3% (95% CI: 13.2-42.1) and 99.5% (95% CI: 98.8-100) using discharge diagnosis codes. By combining the latter 3 sources, the sensitivity increased at 86.8% (95% CI: 76.3-97.4) and the specificity was lowered at 85.5% (95% CI: 82.1-89.0). CONCLUSIONS: SSI detection based on the combination of data extracted automatically from the hospital information system performed well. This strategy has been implemented gradually in Lyon University Hospital.

Cryopreserved iliac artery allograft for primary arterial revascularization in adult liver transplantation.

Arterial allograft represents a material of choice for primary arterial revascularization in liver transplantation (LT) when interposition of a vascular conduit is required. In case of non-availability of such graft, the use of cryopreserved vessels should be an interesting option. Three patients were grafted using a cryopreserved iliac artery allograft (CIAA) previously harvested and stored at -140°C in a tissue bank. An auxiliary partial LT was performed in one patient for acute liver failure. During follow-up, an efficient regeneration of the native hemi-liver was observed while atrophy of the auxiliary graft occurred, leading to functional portal vein and hepatic artery thrombosis at six and nine months, respectively. Two other patients presented with celiac trunk compression because of arcuate ligament without available arterial allograft in the donor. Late arterial thrombosis occurred at six months in one patient without impairment of graft function. The last patient was alive and symptom free 29 months after LT with a patent cryopreserved arterial conduit. Our preliminary results suggest that CIAA might represent an efficient solution as vessel interposition for primary arterial hepatic revascularization in LT setting when no other suitable graft is available. However, long-term patency of CIAA remains questionable.

[Malignant transformation of multiple isolated hepatocellular adenomas. Therapeutic implications of immunohistochemical and radiological findings]. / Risque de dégénérescence maligne de l'adénome hépatocellulaire solitaire et multiple. Confrontation des données immuno-histochimiques et radiologiques. Conséquences thérapeutiques.

Malignant transformation of hepatic adenoma (HA) is now a well-documented phenomenon. Recent pathological and immunophenotypic studies have identified several subtypes with different prognoses. In many cases the HA subtype can be determined by modern radiological methods, including contrast-enhanced ultrasonography (CEUS) and magnetic resonance imaging (MRI). Based on a series of 26 cases of HA studied with CEUS, MR1 histopathology and immunochemistry, we propose tailored therapeutic options. Watchful waiting is appropriate in some cases, while others require biopsy or resection. Management is more conservative than in previous years.

Surgery for hilar cholangiocarcinoma: a multi-institutional update on practice and outcome by the AFC-HC study group.

INTRODUCTION: Surgical resection is the only option for long-term survival in patients with hilar cholangiocarcinoma (HC), but it is associated with high morbidity and mortality. The aim of the present study was to prospectively assess the perioperative management and short-term outcomes of surgical treatment of HC in a recent, multi-institutional study with a short inclusion period. METHODS: Between January and December 2008, a register prospectively collected data on patients operated on for HC (exploratory or curative surgery) in eight tertiary centers. The register focused on perioperative management, resectability, surgical procedures employed, morbidity, and mortality. The study cohort consisted of 56 patients (40 men and 16 women) with a median age of 63 years (range, 33-83 years). RESULTS: Among the 56 patients, 47 (84%) were jaundiced and 42 (75%) tumors were classified as Bismuth-Corlette type III-IV. Nine patients (16%) underwent staging laparoscopy and four (7%) received neoadjuvant chemotherapy. Preoperative biliary drainage (endoscopy, 42%) was performed in 38 (81%) jaundiced patients and portal vein embolization (right side, 83%) was performed prior to surgery in 18 patients (32%). Among these 56 patients, curative resection was achieved in 39 (70%). All underwent major liver resection (>3 segments), bile duct resection, and lymphadenectomy. Thirteen patients (36%) underwent portal vein resection, one of whom also required pancreaticoduodenectomy. Eighty-two percent of resected patients (n = 32) had no proof of malignancy prior to hepatectomy. Clear surgical margins were obtained in 77% (n = 30). The postoperative mortality was 8% and complications occurred in 72% of the resected patients. Seven (25%) patients required reoperation, and 15 (54%) patients required percutaneous drainage. In a univariate analysis, the risk factors for morbidity were intraoperative blood transfusion (p = 0.009) and vascular clamping (p = 0.006). The median length of hospitalization was 20 ± 13 days. CONCLUSION: Curative resection for HC is associated with a high rate of R0 resection. However, surgery is associated with high levels of morbidity and mortality, despite intensive perioperative management.

Outcome of patients receiving chemotherapy for advanced biliary tract or gallbladder carcinoma.

PURPOSE: Patients with cholangiocarcinoma or gallbladder cancer have poor overall prognosis and their management is often complex. Currently, there is no standard chemotherapy for this disease, but several single agents and combinations have shown promising activity, most notably gemcitabine-based combinations. PATIENTS AND METHODS: We conducted a retrospective analysis of all cases of biliary tract cancer treated at two academic centers in Lyon, France: 127 cases were identified, 67 underwent primary surgery, 13 of which were deemed unresectable upon surgery and were treated medically; 60 patients received medical treatment only. Overall, 71 patients received chemotherapy for locally advanced or metastatic disease and are the subject of this report. RESULTS: The median age was 60.7 years, 47 (66%) patients were male and 55 (77%) patients had metastatic disease. Twenty-seven patients (38%) required biliary drainage before chemotherapy. Twenty-four patients received single-agent gemcitabine, 37 patients received gemcitabine-platinum combination and 10 patients received fluorouracil-based regimens. The response rates, median progression-free survival and overall survival times were 24%, 4.1, 7.5 months, respectively. There was a significant increase in the response rate with gemcitabine-platinum combinations compared with other regimens. Fluororuracil-based regimens provided lower response rates and shorter median progression-free survival and overall survival as compared with gemcitabine-based regimens (both single agents and combinations). CONCLUSION: Although retrospective, these data support the use of gemcitabine-containing regimens in patients with advanced biliary tract or gallbladder cancer. The benefit of adding oxaliplatin in this setting remains unclear.

Is pneumonectomy after induction chemotherapy for non-small cell lung cancer a reasonable procedure? A multicenter retrospective study of 228 cases.

INTRODUCTION: Pneumonectomy (PN) after induction chemotherapy (CT) for non-small cell lung cancer is controversial because high-mortality rates are still reported. METHODS: This multicenter retrospective study included all patients treated by induction CT then PN between January 1993 and April 2006 in four General and Thoracic Surgery Departments. Postoperative mortality and morbidity and long-term outcomes were studied. RESULTS: The study considered 228 patients. Doublets with cisplatin and vinorelbine or gemcitabine were used in 66% of cases. pTNM stages (World Health Organization, 1997) were 0 (2%), I (16%), II (25%), IIIA (29%), IIIB (16%), and IV (12%). The postoperative morbidity rate was 37% (84 of 228 patients). The independent risk factors identified for postoperative morbidity were chronic obstructive pulmonary disease, more than four cycles of induction CT or an association of cisplatin, and an old cytotoxic molecule, extended PN, and extended anesthesia time. Postoperative mortality rates were 5.3% at 30 days (12 of 228 patients) and 9.2% at 90 days (21 of 228 patients). The independent risk factors identified for operative mortality were chronic obstructive pulmonary disease, manual suture of the stump, and pTNM stage higher than IIIA. The 90-day mortality rates were 10.3% (12 of 117) for right PN and 8.2% (9 of 111) for left PN (p = 0.65). The overall survival (OS) rates were 68% at 1 year, 39% at 3 years, and 32% at 5 years. CONCLUSIONS: Induction CT was not found to compromise short- or long-term outcomes after PN in non-small cell lung cancer. The right or left PN performed by experienced surgeons after induction CT seems to be a reasonable procedure in case of tumor local extension.

Hepatic epithelioid hemangioendothelioma: long-term results of surgical management.

BACKGROUND AND OBJECTIVES: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular neoplasm of the liver. Its therapeutic management remains difficult to define in curative intent. The aim of this study was to report long-term results of surgically managed patients. METHODS: From 1990 to 2006, nine patients (25-64 years) were retrospectively enrolled in this study. Intrahepatic disease extent was monolobar and bilobar in two and seven patients, respectively. As primary treatment, liver resection (LR) and liver transplantation (LT) were performed in three (two monolobar and one bilobar extent) and six patients, respectively. RESULTS: Postoperative mortality was nil. During a median follow-up of 117 months, four patients developed intrahepatic and/or extrahepatic recurrence. One resected patient (with bilobar extent) presented with intrahepatic recurrence was secondary treated by LT. At the time of the follow-up, seven out of the nine patients treated (two after LR, and five after LT) were alive and disease-free. CONCLUSIONS: Surgical treatment offers good long-term results in patients suffering from HEHE when LR is tailored to the intrahepatic disease extent: LT has to be considered in patients with bilobar intrahepatic disease whereas LR should be strictly limited to patients presenting with localized and monolobar intrahepatic disease.

Characterization of hepatocellular carcinoma and colorectal liver metastasis by means of perfusion MRI.

PURPOSE: To characterize and compare hepatocellular carcinoma and liver metastases of colorectal metastatic cancer (CMC) by means of quantitative liver perfusion MRI. MATERIALS AND METHODS: Liver perfusion was assessed in 26 HCC and CMC patients (50 nodules) by means of contrast-enhanced MRI. Six perfusion parameters-hepatic perfusion index (HPI), mean transit time (MTT), distribution volume (DV), total blood flow (F(T)), arterial blood flow (F(A)), and portal blood flow (F(P))-were calculated in tumor nodules and the adjacent hepatic parenchyma. RESULTS: The values of F(T), F(A), F(P), and DV were significantly higher in the HCC than in the CMC group, whereas MTT was significantly higher in the CMC group. There was no significant difference in HPI. Arterial blood flow was higher than portal blood flow in the CMC group, while portal blood flow was slightly higher than arterial blood flow in the HCC group. CONCLUSION: The present work describes the use of dynamic MRI to quantitatively assess liver perfusion, which in the future may help studying liver cancers on the basis of their microvascular characteristics.

Safety and long-term outcome of a new concept for surgical adhesion-reduction strategies (Prevadh): a prospective, multicenter study.

BACKGROUND/AIMS: No agent has been consistently effective in preventing formation of peritoneal adhesions and postoperative bowel obstruction after abdominal surgery. The aim of this prospective multicenter study was to assess clinical safety and efficiency of a new adhesion-reduction barrier METHODOLOGY: Between September 2000 and April 2001, Prevadh was used in 78 patients. Operative procedures included 25 hepatic resections, 7 cholecystectomies, 32 colonic resections, 7 protectomies, 3 colostomy or recovery of continuity, 1 gynaecologic surgery and 3 others. Eleven patients were operated on by laparoscopy and 67 by laparotomy. RESULTS: The overall incidence of abscesses and wound complications was 2.4% and 9% respectively. After a mean follow-up of 36 months (range: 4-51 months), no patients experienced adverse events related to the adhesion barrier. Surgical reoperative procedures were performed in 10 patients for unrelated causes and no bowel obstruction occurred within the protected area. CONCLUSIONS: This study confirmed the safety of Prevadh adhesion barrier and suggested that this resorbable barrier might provide prevention from adhesion formation on peritoneal injured surfaces. However, a large randomized controlled trial remains necessary to prove the real effectiveness of adhesion barriers on clinical long-term outcome.

Multiple synchronous serous cystadenomas of the pancreas: uncommon CT and MRI findings.

Serous cystadenomas (SCAs) of the pancreas are benign cystic tumors. Although still controversial, asymptomatic SCAs, in contrast to their mucinous counterparts, can be treated conservatively. This attitude is mostly defendable for lesions of the pancreas head or multiple lesions distributed throughout the entire pancreas, as their surgical resection is still associated with significant morbidity. Thus, correct diagnosis is essential, and this relies on radiological and biological characteristics. Asymptomatic multiple SCAs are rare. Most cases described in the literature are either symptomatic, degenerated, or both. We present a case of huge (>10 cm), multiple asymptomatic SCAs, not associated with von Hippel-Lindau disease, involving the entire pancreas. The patient has been followed up for 3 years and remains asymptomatic. Tumor markers were within normal ranges. On abdominal computed tomography (CT) and magnetic resonance imaging (MRI), the lesions showed pathognomonic characteristics of SCAs, and their uncommon dimensions and number remained stable over time. 18-Fluorodeoxyglucose positron emission tomography (PET) scan performed at 3-year follow-up did not show hypermetabolic lesions.

Congenital intrahepatic bile duct dilatation is a potentially curable disease: long-term results of a multi-institutional study.

OBJECTIVE: To report clinical presentation, perioperative outcome, and long-term results of surgical management of congenital intrahepatic bile duct (IHBD) dilatations (including Caroli disease) in a multi-institutional setting. SUMMARY BACKGROUND DATA: Congenital IHBD dilatations are a rare congenital disorder predisposing to intrahepatic stones, cholangitis, and cholangiocarcinoma. The management remains difficult and controversial for bilobar forms of the disease or when concurrent congenital hepatic fibrosis is associated. METHODS: From 1976 to 2004, 33 patients (range 11 to 79 years) were retrospectively enrolled. Disease extent into the liver was unilobar in 26 patients and bilobar in 7 patients (21%). Cholangiocarcinoma, congenital hepatic fibrosis, and intrahepatic stones were present in 2, 10, and 20 patients, respectively. Transplantations or liver resections were performed in 5 and 27 patients, respectively, whereas 1 asymptomatic patient was managed conservatively. RESULTS: Postoperative mortality was nil. Postoperative complications occurred in 16 of 32 operated patients (50%) and additional procedures for residual stones were required in 5 patients. During a median follow-up of 80 months (1 patient being lost for follow-up) no patient developed metachronous carcinoma. Six patients (30%) developed recurrent intrahepatic stones but satisfactory late outcome was achieved in 27 patients (87%). CONCLUSIONS: Partial or total liver resection achieves satisfactory late outcome in congenital IHBD dilatations, when the affection is treated at an early stage and when the extent of liver resection is tailored to intrahepatic disease extent and takes into consideration the presence and severity of underlying chronic liver and renal diseases.

Cystic involvement of the roof of the main biliary convergence in adult patients with congenital bile duct cysts: a difficult surgical challenge.

BACKGROUND: Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care. METHODS: A retrospective multicenter study was conducted in 4 European surgical centers concerning their experience with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof of the MBC (defined as being BDC with MBC involvement subgroup). RESULTS: From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02). CONCLUSION: BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.

[Current management of uncomplicated gallstones and choledocolithiasis]. / Prise en charge de la lithiase biliaire symptomatique en dehors de l'urgence.

In case of clinical suspicion of symptomatic bile duct stones, percutaneous ultrasonography and liver function tests should be performed as a primary evaluation. In the absence of predictive factors of common bile duct stones, laparoscopic cholecystectomy represents the treatment of choice for symptomatic gallstones. In case of clinical, radiological or biochemical suspicion of common bile duct stones, endoultrasonography or magnetic resonance cholangiography are efficient to confirm choledocolithiasis. In this instance, surgical approach permits simultaneous treatment of both choledocolithiasis and cholecystolithiasis while endoscopic sphincterotomy has to be followed by secondary cholecystectomy in a 2-stage procedure. Laparoscopic common bile duct exploration should be preferred to endoscopic clearance of the common bile duct but requires specific equipment and surgical experience.