Peritoneal Carcinomatosis Risk and Long-Term Survival Following Hepatectomy for Spontaneous Hepatocellular Carcinoma Rupture: Results of a Multicenter French Study (FRENCH-AFC).

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (HCC) remains a life-threatening complication, with a reported mortality rate of between 16 and 30% and an incidence rate of approximately 3% in Europe. Survival data and risk factors after ruptured HCC are lacking, especially for peritoneal metastasis (PM). OBJECTIVES: The aims of this study were to evaluate the pattern of recurrence and mortality after hepatectomy for ruptured HCC, and to focus on PM. METHODS: We retrospectively reviewed the files of patients admitted to 14 French surgical centers for spontaneous rupture of HCC between May 2000 and May 2012. RESULTS: Overall, 135 patients were included in this study. The median disease-free survival and overall survival (OS) rates were 16.1 (11.0-21.1) and 28.7 (26.0-31.5) months, respectively, and the median follow-up period was 29 months. At last follow-up, recurrences were observed in 65.1% of patients (n = 88). The overall rate of PM following ruptured HCC was 12% (n = 16). Surgical management of PM was performed for six patients, with a median OS of 36.6 months. An α-fetoprotein level > 30 ng/mL (p = 0.0009), tumor size at rupture > 70 mm (p = 0.0009), and vascular involvement (p < 0.0001) were found to be independently associated with an increased likelihood of recurrence. No risk factor for PM was observed. CONCLUSION: This large-cohort French study confirmed that 12% of patients had PM after ruptured HCC. A curative approach may be an option for highly selected patients with exclusive PD because of the survival benefit it could provide.

Bleeding Recurrence and Mortality Following Interventional Management of Spontaneous HCC Rupture: Results of a Multicenter European Study.

BACKGROUND: The incidence of spontaneous rupture of hepatocellular carcinoma (HCC) is low in Europe, at less than 3%. HCC rupture remains a life-threatening complication, with mortality reported between 16 and 30%. The risk of bleeding recurrence has never been clearly evaluated in such clinical situation. The objectives of this study were to evaluate the current risk of mortality related to HCC rupture and to focus on the risk of bleeding recurrence following interventional management. METHODS: All patients admitted to 14 French-Italian surgical centers for spontaneous rupture of HCC between May 2000 and May 2012 were retrospectively included. Clinical data, imaging features, relevant laboratory data, treatment strategies, and prognoses were analyzed. RESULTS: Overall, 58 of the 138 included patients (42%) had cirrhosis. Thirty-five patients (25%) presented with hemorrhagic shock, and 19% with organ(s) dysfunction. Bleeding control was obtained by interventional hemostasis, emergency liver resection, and conservative medical management in 86 (62%), 24 (18%), and 21 (15%) patients, respectively. Best supportive care was chosen for 7 (5%) patients. The mortality rate following rupture was 24%. The bleeding recurrence rate was 22% with related mortality of 52%. In multivariate analysis, a bilirubin level >17 micromol/L (HR 3.768; p = 0.006), bleeding recurrence (HR 5.400; p < 0.0001), and ICU admission after initial management (HR 8.199; p < 0.0001) were associated with in-hospital mortality. CONCLUSION: This European, multicenter, large-cohort study confirmed that the prognosis of ruptured HCC is poor with an overall mortality rate of 24%, despite important advances in endovascular techniques. Overall, the rate of bleeding recurrence was more than 20%, with a related high risk of mortality.

Energy vessel sealing systems versus mechanical ligature of the inferior mesenteric artery in laparoscopic sigmoidectomy.

PURPOSE: With the development of new devices, our ligation technique of the inferior mesenteric artery changed from mechanical ligature (ML) to energized vessel sealing systems (EVSS) ligature. The aim of this study was to determine if EVSS could be considered as safe and effective as the more convention ML of the inferior mesenteric vessels division during elective laparoscopic left colectomy. METHODS: Between 2001 and 2014, 200 consecutive patients (111 males) of mean age 54.1 years were operated laparoscopically for a symptomatic sigmoid diverticulitis. Vascular interruptions were performed using mechanical ligatures including double clipping, staples or surgical thread (100 patients) or, starting from 2006, with EVSS thereafter (100 patients). Section of the inferior mesenteric artery is performed systematically at its origin in our institution for teaching purposes. Technical results were prospectively collected perioperatively and postoperatively. RESULTS: There was no mortality. Mean operating time was 253.7 and 200.7 min in the ML and EVSS groups, respectively (p < 0.001). Mean hospital stay was 10.4 and 8.1 days (p < 0.001). Thirty-day complications occurred in 31 versus 25 % of patients (p = 0.26). Leakage with peritonitis occurred in 3 patients in the ML group. Hemorrhagic events occurred in both groups (2 in ML group versus 1 in EVSS group). Limitations of the study are its retrospective design and the bias due to the comparison of two historical cohorts. CONCLUSIONS: EVSS for the inferior mesenteric artery are as safe and effective as ML in elective sigmoidectomy for diverticular disease with lower operative time and hospital stay.

Laparoscopic anterior rectopexy to the promontory for full-thickness rectal prolapse in 175 consecutive patients: short- and long-term follow-up.

BACKGROUND: There are multiple procedures to treat full-thickness rectal prolapse. No consensus exists as to the best surgical option. All procedures have a significant recurrence rate. OBJECTIVE: The aim of this study was to report short- and long-term technical results following laparoscopic removal of the Douglas pouch peritoneum and anterior rectopexy in patients with total rectal prolapse. DESIGN: This study is a prospective evaluation of consecutive patients. SETTINGS: This investigation was conducted at a single academic colorectal unit. PATIENTS: Between May 1996 and June 2009, 175 consecutive patients (17 males) with a mean age of 58 years (range, 16-94) were operated on. INTERVENTION: The Douglas pouch peritoneum was excised, 2 synthetic meshes were fixated to the anterior part of the lower rectum with five 4-mm staples and to the promontory with 3 spiked chromium staples, and the peritoneum was closed over the meshes to isolate them from the abdominal cavity. MAIN OUTCOME MEASURES: Patients were reviewed at months 1, 6, 12, and then annually. Mortality, morbidity, and recurrence were analyzed. Median follow-up was 74 months (range, 24-181). Recurrence rate was calculated according to the Kaplan-Meier method. RESULTS: : There was no mortality. Morbidity (5.1%) consisted in temporary brachial plexus palsy in 2 cases, urinary infection in 3 cases, ureteral lesion in 1 patient having had a previous bone graft on the promontory for spondylolisthesis (JJ catheter), and perforation of the small bowel because of adhesions (laparoscopic suture) in 1 case. One patient presented with a rectal erosion at month 9 (transanal removal of the mesh). Two patients presented with a recurrence of the rectal prolapse at months 6 and 24 (recurrence rate of 3% at 5 years) that was treated with anal artificial sphincter in one and redo operation in the other. CONCLUSION: Laparoscopic removal of the Douglas pouch peritoneum and rectopexy to the promontory is a safe and efficient procedure to treat full-thickness rectal prolapse.