Metastatic Colorectal Cancer Treated with Combined Liver Resection, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): Predictive Factors for Early Recurrence.

BACKGROUND: Selection of colorectal cancer patients with concomitant peritoneal (PM) and liver metastases (LM) for radical treatment with cytoreductive surgery (CRS), including liver resection and hyperthermic intraperitoneal chemotherapy (HIPEC), needs improvement. This retrospective, monocentric study was designed to evaluate the predictive factors for early recurrence, disease-free survival (DFS), and overall survival (OS) in such patients treated in a referral center. METHODS: Consecutive colorectal cancer patients with concomitant LM and PM treated with curative intent with perioperative systemic chemotherapy, simultaneous complete CRS, liver resection, and HIPEC in 2011-2022 were included. Clinical, radiological (before and after preoperative chemotherapy), surgical, and pathological data were investigated, along with long-term oncologic outcomes. A multivariate analysis was performed to identify predictive factors associated with early recurrence (diagnosed <6 months after surgery), DFS, and OS. RESULTS: Of more than 61 patients included, 31 (47.1%) had pT4 and 27 (40.9%) had pN2 primary tumors. Before preoperative chemotherapy, the median number of LM was 2 (1-4). The median surgical PCI (peritoneal carcinomatosis index) was 3 (5-8.5). The median DFS and OS were 8.15 (95% confidence interval [CI] 5.5-10.1) and 34.1 months (95% CI 28.1-53.5), respectively. In multivariate analysis, pT4 (odds ratio [OR] = 4.14 [1.2-16.78], p = 0.032]) and pN2 (OR = 3.7 [1.08-13.86], p = 0.042) status were independently associated with an early recurrence, whereas retroperitoneal lymph node metastasis (hazard ratio [HR] = 39 [8.67-175.44], p < 0.001) was independently associated with poor OS. CONCLUSIONS: In colorectal cancer patients with concomitant PM and LM, an advanced primary tumor (pT4 and/or pN2) was associated with a higher risk of early recurrence following a radical multimodal treatment, whereas RLN metastases was strongly detrimental for OS.

Neoadjuvant Chemotherapy Does Not Improve Survival in cT2N0M0 Gastric Adenocarcinoma Patients: A Multicenter Propensity Score Analysis.

BACKGROUND: According to current international guidelines, stage cT2N0M0 gastric adenocarcinoma warrants preoperative chemotherapy followed by surgery. However, upfront surgery is often preferred in clinical practice, depending on patient clinical status and local treatment preferences. OBJECTIVE: The aim of the present study was to assess the impact of neoadjuvant chemotherapy in overall survival (OS) and disease-free survival (DFS) of cT2N0M0 patients. METHODS: A retrospective analysis was performed among 32 centers, including gastric adenocarcinoma patients operated between January 2007 and December 2017. Patients with cT2N0M0 stage were divided into upfront surgery (S) and neoadjuvant chemotherapy followed by surgery (CS) groups. Inverse probability of treatment weighting (IPTW) was used to compensate for baseline differences between the groups. RESULTS: Among the 202 patients diagnosed with cT2N0M0 stage, 68 (33.7%) were in the CS group and 134 (66.3%) were in the S group. CS patients were younger (mean age 62.7 ± 12.8 vs. 69.8 ± 12.1 years for S patients; p < 0.001) and had a better health status (World Health Organization performance status = 0 in 60.3% of CS patients vs. 34.5% of S patients; p = 0.006). During follow-up, recurrence occurred in 27.2% and 19.6% of CS and S patients, respectively, after IPTW (p = 0.32). Five-year OS was similar between CS and S patients (78.9% vs. 68.3%; p = 0.42), as was 5-year DFS (70.4% vs. 68.5%; p = 0.96). Neoadjuvant chemotherapy was associated with neither OS nor DFS in multivariable analysis after IPTW. CONCLUSIONS: Patients with cT2N0M0 gastric adenocarcinoma did not present a survival or recurrence benefit if treated with perioperative chemotherapy followed by surgery as opposed to surgery alone.

Right Colectomy with Intracorporeal Anastomosis: A European Multicenter Propensity Score Matching Retrospective Study of Robotic Versus Laparoscopic Procedures.

BACKGROUND: This study aimed to compare the short- and long-term outcomes of robotic (RRC-IA) versus laparoscopic (LRC-IA) right colectomy with intracorporeal anastomosis using a propensity score matching (PSM) analysis based on a large European multicentric cohort of patients with nonmetastatic right colon cancer. METHODS: Elective curative-intent RRC-IA and LRC-IA performed between 2014 and 2020 were selected from the MERCY Study Group database. The two PSM-groups were compared for operative and postoperative outcomes, and survival rates. RESULTS: Initially, 596 patients were selected, including 194 RRC-IA and 402 LRC-IA patients. After PSM, 298 patients (149 per group) were compared. There was no statistically significant difference between RRC-IA and LRC-IA in terms of operative time, intraoperative complication rate, conversion to open surgery, postoperative morbidity (19.5% in RRC-IA vs. 26.8% in LRC-IA; p = 0.17), or 5-yr survival (80.5% for RRC-IA and 74.7% for LRC-IA; p = 0.94). R0 resection was obtained in all patients, and > 12 lymph nodes were harvested in 92.3% of patients, without group-related differences. RRC-IA procedures were associated with a significantly higher use of indocyanine green fluorescence than LRC-IA (36.9% vs. 14.1%; OR: 3.56; 95%CI 2.02-6.29; p < 0.0001). CONCLUSION: Within the limitation of the present analyses, there is no statistically significant difference between RRC-IA and LRC-IA performed for right colon cancer in terms of short- and long-term outcomes.

Impact of operation duration on postoperative outcomes of minimally-invasive right colectomy.

AIM: Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short-term outcomes of minimally-invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra-corporal anastomosis [EA]). METHODS: This was a retrospective analysis of the Minimally-invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used. RESULTS: The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135-199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC-EA, followed by LRC-IA (24.3%), RRC-IA (11.1%), and RRC-EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15-2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity. CONCLUSION: Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally-invasive right colectomy.

Augmented reality in laparoscopic liver resection evaluated on an ex-vivo animal model with pseudo-tumours.

BACKGROUND: The aim of this study was to assess the performance of our augmented reality (AR) software (Hepataug) during laparoscopic resection of liver tumours and compare it to standard ultrasonography (US). MATERIALS AND METHODS: Ninety pseudo-tumours ranging from 10 to 20 mm were created in sheep cadaveric livers by injection of alginate. CT-scans were then performed and 3D models reconstructed using a medical image segmentation software (MITK). The livers were placed in a pelvi-trainer on an inclined plane, approximately perpendicular to the laparoscope. The aim was to obtain free resection margins, as close as possible to 1 cm. Laparoscopic resection was performed using US alone (n = 30, US group), AR alone (n = 30, AR group) and both US and AR (n = 30, ARUS group). R0 resection, maximal margins, minimal margins and mean margins were assessed after histopathologic examination, adjusted to the tumour depth and to a liver zone-wise difficulty level. RESULTS: The minimal margins were not different between the three groups (8.8, 8.0 and 6.9 mm in the US, AR and ARUS groups, respectively). The maximal margins were larger in the US group compared to the AR and ARUS groups after adjustment on depth and zone difficulty (21 vs. 18 mm, p = 0.001 and 21 vs. 19.5 mm, p = 0.037, respectively). The mean margins, which reflect the variability of the measurements, were larger in the US group than in the ARUS group after adjustment on depth and zone difficulty (15.2 vs. 12.8 mm, p < 0.001). When considering only the most difficult zone (difficulty 3), there were more R1/R2 resections in the US group than in the AR + ARUS group (50% vs. 21%, p = 0.019). CONCLUSION: Laparoscopic liver resection using AR seems to provide more accurate resection margins with less variability than the gold standard US navigation, particularly in difficult to access liver zones with deep tumours.

Gastric Pneumatosis with Portal Venous Gas can be Treated Non-operatively: A Retrospective Multi-institutional Study.

BACKGROUND: Gastric pneumatosis (GP) is a rare radiologic finding with an unpredictable prognosis. The aim of this study was to identify mortality risk factors from patients presenting with GP on computed tomography (CT), and to develop a model which would allow us to predict which patients would benefit most from operative management. METHODS: Between 2010 and 2020, all CT-scan reports in four tertiary centers were searched for the following terms: "gastric pneumatosis," "intramural gastric air" or "emphysematous gastritis." The retrieved CT scans were reviewed by a senior surgeon and a senior radiologist. Relevant clinical and laboratory data for these patients were extracted from the institutions' medical records. RESULTS: Among 58 patients with GP, portal venous gas and bowel ischemia were present on CT scan in 52 (90%) and 17 patients (29%), respectively. The 30-day mortality rate was 31%. Univariate analysis identified the following variables as predictive of mortality at the time of the diagnosis of GP: abdominal guarding, hemodynamic instability, arterial lactate level >2 mmol/l, and the absence of gastric dilatation. Multivariable analysis identified the following variables as independent predictors of mortality: arterial lactate level (OR: 1.39, 95% CI: 1.07-1.79) and the absence of gastric dilatation (OR: 0.07, 95% CI: 0.01-0.79). None of the patients presenting with a baseline lactate rate<2 mmol/l died within 30 days following diagnosis, and no more than 17 patients out of 58 had bowel ischemia (29%). CONCLUSIONS: GP could be managed non-operatively, even in the presence of portal venous gas. However, patients with arterial lactate level>2 mmol/l, or the absence of gastric dilation should be surgically explored due to a non-negligible risk of mortality.

Extended right colectomy, left colectomy, or segmental left colectomy for splenic flexure carcinomas: a European multicenter propensity score matching analysis.

BACKGROUND: The surgical resection of the splenic flexure carcinoma (SFC) is challenging and the optimal surgical procedure for SFCs remains a matter of debate. The present study aimed to compare in a multicenter European sample of patients the short- and long-term outcomes of extended right (ERC) vs. left (LC) vs. segmental left colectomy (SLC) for SFCs. METHODS: This retrospective multicenter study analyzed the surgical and oncological outcomes of SFC patients undergoing elective curative intent surgery between 2000 and 2018. Descriptive and exploratory analyses were first conducted on the whole sample. Outcomes of the different procedures (ERC vs. LC vs. SLC) were then compared using propensity score matching for multilevel treatment. Overall (OS) and disease-free survival (DFS) were evaluated by Kaplan-Meier method. RESULTS: From a total of 399 SFC patients, 143 (35.8%) underwent ERC, 131 (32.8%) underwent LC, and 125 (31.4%) underwent SLC. Overall, 297 (74.4%) were laparoscopic procedures. An increase in operative time, time to flatus, time to regular diet, and hospital stay was observed with the progressive extension of SFC resection. ERC was associated with significantly increased risk of postoperative ileus compared to both LC and SLC. A significantly greater number of lymph nodes were retrieved by ERC, but the objective of at least 12 retrieved lymph nodes was achieved in 85% of patients, without procedure-related differences. No differences were observed in OS or DFS between ERC, LC, and SLC. CONCLUSION: The present study supports the resection of SFCs by colon-sparing surgical techniques, such as SLC.

Laparoscopic right hepatectomy using the caudal approach is superior to open right hepatectomy with anterior approach and liver hanging maneuver: a comparison of short-term outcomes.

BACKGROUND: A standardized laparoscopic right hepatectomy (LRH) approach named the "caudal approach" was recently reported. Yet, the value of this approach compared with state-of-the-art open right hepatectomy (ORH) remains unknown. The purpose of this study was therefore to compare the short-term outcomes of LRH using the caudal approach and ORH with anterior approach and liver hanging maneuver. METHODS: One-hundred eleven consecutive patients who underwent LRH with caudal approach were prospectively collected; 346 patients who underwent ORH with anterior approach and liver hanging maneuver were enrolled as a control group. Propensity score matching (PSM) of patients in a ratio of 1: 1 was conducted and the perioperative outcomes were compared. RESULTS: After PSM, two well-balanced groups of 72 patients each were analyzed and compared. The conversion rate in the LRH group was 18.1%. Perioperative blood loss and transfusion rates were significantly lower in the LRH group as compared to the ORH group (median, 200 ml vs. 500 ml, p < 0.001 and 9.9% vs. 26.8%, p = 0.009, respectively), while operation time was significantly longer (median, 348 min vs. 290 min, p < 0.001). Overall (26.4% vs. 48.6%, p = 0.006) and symptomatic pulmonary (6.9% vs. 19.4%, p = 0.027) complication rates were significantly lower in the LRH group. Hospital stay was significantly shorter in the LRH group (median, 8 days vs. 9 days, p = 0.013). CONCLUSIONS: LRH using the caudal approach is associated with improved short-term outcomes compared to state-of-the-art ORH in patients qualifying for both approaches, and can be proposed as standard practice.

Combined biembolization induces higher hypertrophy than portal vein embolization before major liver resection.

BACKGROUND: Combined preoperative portal and hepatic vein embolization (biembolization, BE) has been recently described and may further enhance preoperative FLR growth. The objective of this study was to compare the efficacy of combined preoperative biembolization and portal vein embolization (PVE). METHODS: This study was performed between 2010 and 2017. From 2010 to 2014, patients only underwent preoperative PVE. After 2014, BE was proposed as an alternative to PVE. Liver volumetry was assessed by a CT-scan before BE or PVE and then three weeks later. RESULTS: During the study period, 72 patients underwent radiological procedures that included 41 PVE (PVE group) and 31 BE (BE group). The time elapsing between the procedure and surgery was similar (p = 0.760). The mean percentage of FLR ratio hypertrophy in the PVE group was 31.9% (±34), but reached 51.2% (±42) in the BE group (p = 0.018) and this difference remained significant under multivariate analysis that included age, gender, body mass index, diabetes mellitus, cirrhosis and NASH. The kinetic growth rates were 19% (±17%) and 8% (±13%) in the BE and PVE groups, respectively (p = 0.026). CONCLUSION: This study shows that BE induces higher hypertrophy than portal vein embolization before major liver resection with no more morbidity.

Hepatopancreatoduodenectomy -a controversial treatment for bile duct and gallbladder cancer from a European perspective.

BACKGROUND: Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. METHOD: Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. RESULTS: In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. CONCLUSION: HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.

How Does Chemoradiotherapy Following Induction FOLFIRINOX Improve the Results in Resected Borderline or Locally Advanced Pancreatic Adenocarcinoma? An AGEO-FRENCH Multicentric Cohort.

BACKGROUND: Patients with borderline (BR) or locally advanced (LA) pancreatic adenocarcinoma (PAC) are often treated with induction FOLFIRINOX (FLX). However, the role of additional preoperative chemoradiotherapy (CRT) is controversial. The aim of this study is to evaluate its impact in patients who underwent resection after induction FLX. PATIENTS AND METHODS: Retrospective analysis of prospective consecutive surgical BR or LA PAC patients after induction FLX in 23 French centers between November 2010 and December 2015, treated with or without preoperative additional CRT (FLX vs FLX + CRT groups). RESULTS: Two hundred three patients were included (106 BR, 97 LA PAC). Median number of FLX cycles was 6 (range 1-30); 50% (n = 102) of patients received additional CRT. Median duration between diagnosis and surgery was 5.4 and 8.7 months (P = 0.001) in the FLX and FLX + CRT group, respectively. The 90-day mortality, major complications, and pancreatic fistula rates were 4.4%, 17.7%, and 5.4%, respectively. After 45.1 months follow-up, overall survival (OS) and disease-free survival were 45.4 months and 16.2 months, respectively. Patients with additional CRT had higher R0 resection rate (89.2% vs 76.3%; P = 0.017), ypN0 rate (76.2% vs 48.5%; P < 0.001), and higher rate of pathologic major response (33.3% vs 12.9%; P = 0.001). In the FLX + CRT group, patients had lower rate of locoregional relapse (28.3% vs 50.7%; P = 0.004). Patients with additional CRT had longer OS than those receiving FLX alone (57.8 vs 35.5 months; P = 0.007). CONCLUSIONS: Pathological results and survival data argue for interest in additional CRT. Prospective studies on an intention-to-treat basis are needed to confirm these results.

Differential Influence of Life Cycle on Growth and Toxin Production of three Pseudo-nitzschia Species (Bacillariophyceae).

We used a multistrain approach to study the intra- and interspecific variability of the growth rates of three Pseudo-nitzschia species - P. australis, P. fraudulenta, and P. pungens - and of their domoic acid (DA) production. We carried out mating and batch experiments to investigate the respective effects of strain age and cell size, and thus the influence of their life cycle on the physiology of these species. The cell size - life cycle relationship was characteristic of each species. The influence of age and cell size on the intraspecific variability of growth rates suggests that these characteristics should be considered cautiously for the strains used in physiological studies on Pseudo-nitzschia species. The results from all three species do not support the hypothesis of a decrease in DA production with time since isolation from natural populations. In P. australis, the cellular DA content was rather a function of cell size. More particularly, cells at the gametangia stage of their life cycle contained up to six times more DA than smaller or larger cells incapable of sexual reproduction. These findings reveal a link between P. australis life cycle and cell toxicity. This suggest that life cycle dynamics in Pseudo-nitzschia natural populations may influence bloom toxicity.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Elderly: Is It Reasonable? A Meta-Analysis.

BACKGROUND: Whether cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is safe and worthwhile for elderly patients remains unclear. This meta-analysis of outcomes after CRS plus HIPEC for the elderly aimed to generate a higher level of evidence and precise indications for these patients. METHODS: A systematic literature search for studies reporting postoperative outcomes after CRS plus HIPEC for elderly patients was performed in the MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Web of Knowledge Conference Proceedings Citation Index-Science, and Google Scholar databases. The included studies evaluated the overall 30-day postoperative morbidity, 90-day postoperative mortality, grade 3 or higher postoperative morbidity, rates of anastomotic leaks, reoperation and readmission, and length of hospital stay. RESULTS: The inclusion criteria were met by 13 retrospective studies involving 2544 patients. Considering only comparative studies, the 90-day postoperative mortality was significantly increased for elderly patients [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27-0.88; I 2 = 79%]. The 30-day grade 3 or higher postoperative morbidity was increased in the patients 70 years of age or older (14.5%; 95% CI 8.1-24.4 vs. 32.3%; 95% CI 22.4-44.0%; p = 0.004; I 2 = 85%). The overall 30-day postoperative morbidity, rates of anastomotic leaks, reoperation and readmission, and length of hospital stay were not affected by age. CONCLUSIONS: Treatment of the elderly with CRS plus HIPEC was associated with increased severe postoperative morbidity and mortality. However, these conclusions should be weighted given the existence of major biases in the included studies. Age alone probably would not be a formal contraindication, but frailty should be taken into account. Further prospective studies are needed.

Risk factors for postoperative ileus following elective laparoscopic right colectomy: a retrospective multicentric study.

PURPOSE: Postoperative ileus (POI) is associated with an elevated risk of other complications and increases the economic impact on healthcare services. The aim of this study was to identify pre-, intra- and postoperative risk factors associated with the development of POI following elective laparoscopic right colectomy. METHODS: Between 2004 and 2016, 637 laparoscopic right colectomies were performed. Data were analysed retrospectively thanks to the CLIHMET database. Potential contributing factors were analysed by logistic regression. RESULTS: Patients with POI (n = 113, 17.7%) were compared to those without postoperative ileus (WPOI) (n = 524, 82.3%). In the POI group, there were more men (62 vs 49%; p = 0.012), more use of epidural anaesthesia (19 vs 9%; p = 0.004), more intraoperative blood transfusion requirements (7 vs 3%; p = 0.018) and greater perioperative intravenous fluid administration (2000 vs 1750 mL; p < 0.001). POIs were more frequent when extracorporeal vascular section (20 vs 12%; p = 0.049) and transversal incision for extraction site (34 vs 23%; p = 0.044) were performed. Overall surgical complications in the POI group were significantly greater than in the control group WPOI (31.9 vs 12.0%; p < 0.0001). Multivariate analysis found the following independent POI risk factors: male gender (HR = 2.316, 1.102-4.866), epidural anaesthesia (HR = 2.958, 1.250-6.988) and postoperative blood transfusion requirement (HR = 6.994, 1.550-31.560). CONCLUSIONS: This study is one of the first to explore the CLIHMET database and the first to use it for investigating risk factors for POI development. Modifiable risk factors such as epidural anaesthesia and intraoperative blood transfusion should be used with caution in order to decrease POI rates.

Preliminary trial of augmented reality performed on a laparoscopic left hepatectomy.

BACKGROUND: Laparoscopic liver surgery is seldom performed, mainly because of the risk of hepatic vein bleeding or incomplete resection of the tumour. This risk may be reduced by means of an augmented reality guidance system (ARGS), which have the potential to aid one in finding the position of intrahepatic tumours and hepatic veins and thus in facilitating the oncological resection and in limiting the risk of operative bleeding. METHODS: We report the case of an 81-year-old man who was diagnosed with a hepatocellular carcinoma after an intraabdominal bleeding. The preoperative CT scan did not show metastases. We describe our preferred approach for laparoscopic left hepatectomy with initial control of the left hepatic vein and preliminary results of our novel ARGS achieved postoperatively. In our ARGS, a 3D virtual anatomical model is created from the abdominal CT scan and manually registered to selected laparoscopic images. For this patient, the virtual model was composed of the segmented left liver, right liver, tumour and median hepatic vein. RESULTS: The patient's operating time was summed up to 205 min where a blood loss of 300 cc was recorded. The postoperative course was simple. Histopathological analysis revealed the presence of a hepatocellular carcinoma with free margins. Our results of intrahepatic visualization suggest that ARGS can be beneficial in detecting the tumour, transection plane and medial hepatic vein prior to parenchymal transection, where it does not work due to the substantial changes to the liver's shape. CONCLUSIONS: As of today, we have performed eight similar left hepatectomies, with good results. Our ARGS has shown promising results and should now be attempted intraoperatively.

Indocyanine Green Retention Rates at 15 min Predicted Hepatic Decompensation in a Western Population.

BACKGROUND: ICGR15 is widely used in Asia to evaluate the liver reserve before hepatectomy, but not in Western countries where patients are selected using the MELD score and/or platelet count. Postoperative liver failure is rare nowadays, but hepatic decompensation (HD), defined by 3-month postoperative ascites, impairs quality of life and survival. The aim of this study was to evaluate the relevance of indocyanine green retention rate at 15 min (ICGR15) before liver resection in Western countries, in order to predict HD. METHODS: This prospectively designed study included consecutive adult patients undergoing hepatectomy for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) in three French HPB centres. RESULTS: Between 2012 and 2014, 147 patients were included (80% of HCC and 20% of ICC). The Child-Pugh status was grade A for all patients. In the overall population and in F3/F4 patients (n = 83), ICGR15 (P = 0.02) and platelet counts (P = 0.02) were predictive of HD under multivariate analysis. Among F3/F4 patients undergoing minor hepatectomy with preoperative ICGR15 > 15%, the rate of HD was 36%. In the overall population, ICGR15 was predictive of HD (P = 0.02) and postoperative ascites (P = 0.03). The ROC curve identified a cut-off point of 15% as being associated with increased HD, with good accuracy for ICGR15 in the study population (AUROC 0.73), mainly before minor hepatectomy (AUROC 0.79). CONCLUSIONS: In patients with HCC and ICC selected using the MELD score and platelet rate, an ICGR15 > 15% is a relevant, non-invasive and clearly accurate method to predict HD specially before minor hepatectomy.

Warmed and humidified carbon dioxide for abdominal laparoscopic surgery: meta-analysis of the current literature.

BACKGROUND: The creation of a pneumoperitoneum for laparoscopic surgery is performed by the insufflation of carbon dioxide (CO2). The insufflated CO2 is generally at room temperature (20-25 °C) and dry (0-5 % relative humidity). However, these physical characteristics could lead to alterations of the peritoneal cavity, leading to operative and postoperative complications. Warming and humidifying the insufflated gas has been proposed to reduce the iatrogenic effects of laparoscopic surgery, such as pain, hypothermia and peritoneal alterations. Two medical devices are currently available for laparoscopic surgery with warm and humidified CO2. METHODS: Clinical studies were identified by searching PubMed with keywords relating to humidified and warmed CO2 for laparoscopic procedures. Analysis of the literature focused on postoperative pain, analgesic consumption, duration of hospital stay and convalescence, surgical techniques and hypothermia. RESULTS: Bibliographic analyses reported 114 publications from 1977 to 2015, with only 17 publications of clinical interest. The main disciplines focused on were gynaecological and digestive surgery ). Analysis of the studies selected reported only a small beneficial effect of warmed and humidified laparoscopy compared to standard laparoscopy on immediate postoperative pain and per procedure hypothermia. No difference was observed for later postoperative shoulder pain, morphine equivalent daily doses, postoperative body core temperature, recovery room and hospital length of stay, lens fogging and procedure duration. CONCLUSIONS: Only few beneficial effects on immediate postoperative pain and core temperature have been identified in this meta-analysis. Although more studies are probably needed to close the debate on the real impact of warmed and humidified CO2 for laparoscopic procedures.

Combined Preoperative Portal and Hepatic Vein Embolization (Biembolization) to Improve Liver Regeneration Before Major Liver Resection: A Preliminary Report.

BACKGROUND: Insufficient volume of the future liver remnant (FLR) is a major cause of non-resectable disease in patients presenting with primary or metastatic liver tumours. The objective of this study was to evaluate the safety and efficacy of the combined preoperative portal and hepatic vein embolization (biembolization) before extended right liver resections. METHODS: This retrospective study was performed in a tertiary centre between 2014 and 2015. Combined right portal and hepatic vein embolization (biembolization) was proposed, as an alternative to ALPPS procedure, for all patients with primary or metastatic liver tumour, before right extended hepatectomy. CT scan liver volumetry was assessed before biembolization, three weeks after biembolization and one week after surgery. RESULTS: Seven patients underwent biembolization. All patients had right portal vein embolization (PVE) combined with right hepatic vein embolization (HVE, n = 4), median HVE (n = 2) and right + median HVE (n = 1). Three patients had preoperative liver disease and two received preoperative chemotherapy. No biembolization procedure-related complications occurred. The mean FLR regeneration rate was 52.6% (range: 18.2-187.9) after the biembolization. One patient with gallbladder carcinoma was not operated because of peritoneal carcinomatosis diagnosed after the biembolization. The remnant six patients did not develop postoperative liver failure. CONCLUSIONS: Biembolization seems to induce safe, reproducible and effective FLR growth before extended right hepatectomy, in patients with primary or metastatic liver tumour.

Does intraoperative closed-suction drainage influence the rate of pancreatic fistula after pancreaticoduodenectomy?

BACKGROUND: Although drainage of pancreatic anastomoses after pancreaticoduodenectomy (PD) is still debated, it remains recommended, especially in patients with a high risk of post-operative pancreatic fistula (POPF). Modalities of drainage of pancreatic anastomoses, especially the use of passive (PAD) or closed-suction (CSD) drains, and their impact on surgical outcomes, have been poorly studied. The aim was to compare CSD versus PAD on surgical outcomes after PD. METHODS: Retrospective analysis of 197 consecutive patients who underwent a standardized PD at two tertiary centers between March 2012 and April 2015. Patients with PAD (n = 132) or CSD (n = 65) were compared. RESULTS: There was no significant difference in terms of 30-day overall and severe post-operative morbidity, post-operative hemorrhage, post-operative intra-abdominal fluid collections, 90-day post-operative mortality and mean length of hospital stay. The rate of POPF was significantly increased in the CSD group (47.7% vs. 32.6%; p = 0.04). CSD was associated with an increase of grade A POPF (21.5% vs. 8.3%; p = 0.03), while clinically relevant POPF were not impacted. In patients with grade A POPF, the rate of undrained intra-abdominal fluid collections was increased in the PAD group (46.1% vs. 21.4%; p = 0.18). After multivariate analysis, CSD was an independent factor associated with an increased rate of POPF (OR = 2.43; p = 0.012). CONCLUSIONS: There was no strongly relevant difference in terms of surgical outcomes between PAD or CSD of pancreatic anastomoses after PD, but CSD may help to decrease the rate of undrained post-operative intra-abdominal collections in some patients. Further randomized, multi-institutional studies are needed.