[Surgical treatment of hepatocarcinoma in cirrhosis]. / Traitement chirurgical des hépatocarcinomes sur cirrhose.

In 1986, our institution published the first results of surgical résection of hepatocarcinoma in cirrhotic patients. The aim of this paper is to present long term results of this surgical management. From April 1978 to February 1992, 74 patients were operated on at the surgical clinic of University Medical Center of Rennes (35000) France. There were 60 hepatectomies and 14 transplantations. The mean age was 60.2 years-9 years and the sex ratio: 70 males and 4 females. The etiology was alcoholic in 43 patients (58%), post hepatitis (B and C) in 22 patients (30%) and due to hemochromatosis in 9 patients (12%). According to the Child Pugh classification, 48 patients were Child A, 11 Child B and one Child C in the hepatectomy group and 9 patients Child A and 5 Child B in transplantation group. The operative mortality was 10% in hepatectomy group and 35.7% in liver transplantation group. Overall survival was 61.8% at 1 year, 47.1% at 2 years, 38.2% at 3 years and 20% at 5 years. 5 year survival is 21.4% after transplantation and 18.5% after resection. This difference is not significant. In conclusion, according to 5 years survival and to operative mortality the treatment of choice is hepatectomy in HCC in cirrhotic patients. However the best treatment is the prevention of cirrhosis.

[Surgical treatment of hepatocarcinoma in cirrhosis]. / Traitement chirurgical des hépatocarcinomes sur cirrhose.

In 1986, our institution published the first results of surgical resection of hepatocarcinoma in cirrhotic patients. The aim of this paper is to present long term results of this surgical management. From April 1978 to February 1992, 74 patients were operated on at the surgical clinic of University Medical Center of Rennes (35000) France. There were 60 hepatectomies and 14 transplantations. The mean age was 60.2 years +/- 9 years and the sex ratio: 70 males and 4 females. The etiology was alcoholic in 43 patients (58%), post hepatitis (B and C) in 22 patients (30%) and due to hemochromatosis in 9 patients (12%). According to the Child Pugh classification, 48 patients were Child A, 11 Child B and one Child C in the hepatectomy group and 9 patients Child A and 5 Child B in transplantation group. The operative mortality was 10% in hepatectomy group and 35.7% in liver transplantation group. Overall survival was 61.8% at 1 year, 47.1% at 2 years, 38.2% at 3 years and 20% at 5 years. 5 year survival is 21.4% after transplantation and 18.5% after resection. This difference is not significant. In conclusion, according to 5 years survival and to operative mortality the treatment of choice is hepatectomy in HCC in cirrhotic patients. However the best treatment is the prevention of cirrhosis.

[Indications and results of hepatic transplantation for cancer]. / Indications et résultats de la transplantation hépatique pour cancer.

From April 1978 to 1st October 1990, 19 patients underwent liver transplantation for primary or secondary cancer of the liver. Eleven patients were transplanted for hepatocellular carcinoma secondary to cirrhosis, generally alcoholic (9 cases), hepatitis B (1 case) or secondary to haemochromatosis (1 cas). Three patients developed hepatocellular carcinoma in a normal liver, including one fibrolamellar cancer and three a proximal bile duct cancer. Lastly, two patients received a graft for secondary cancer from a colonic adenocarcinoma and a carcinoid tumour of the right colon. The operative mortality was nil for the transplantations for cancer in a normal liver, but there were 4 deaths out of the 11 cases of cancer secondary to cirrhosis. The actuarial survival of the overall series was 55% at 1 year and 31% at 2 years. The poorest survival was observed for cancers in a normal liver, with the exception of the fibrolamellar cancer in which recurrence was delayed. The longest survival was observed for cancers secondary to cirrhosis. At three years, the results of liver transplantation were equal to those of hepatic resections with a survival of 37%, despite the fact that the transplantation was generally performed for very large tumours.

[Uncommon arterial and venous reconstruction in liver transplantation]. / Reconstructions artérielles et veineuses inhabituelles en transplantation hépatique.

The aim of this work was to define the best technical options of reconstruction that we can proposed in front of an anatomical or parietal anomalies of venous or arterial system in hepatic transplantation. Through a retrospective study of 10 reconstructions performed between 1978 and 1989, we observed 5 cases of right hepatic artery from superior mesenteric artery of the donor. The two basic methods of reconstruction were either the "fold over" technic of Gordon or the realization of an end to end anastomosis between donor's right hepatic artery and donor's splenic artery. In 3 cases, the insufficiency of the hepatic arterial blood flow after classic anastomosis, led us to employ an arterial iliac graft between the recipient's aorta and the donor's coeliac patch. 2 patients with portocaval shunt or portal parietal defect underwent reconstruction by venous iliac graft. In conclusion, we emphasize the importance of a perfect reconstructed reconstruction as much on the anatomical level than functional.

[Surgical treatment of chronic pancreatitis. Indications and results. An experience of 246 cases]. / Traitement chirurgical de la pancréatite chronique. Indications et résultats--Expérience de 246 cas.

Between 1972 and 1986, 246 patients, mainly alcoholic, with a mean age of 44 years, underwent a total of 270 laparotomies. Parenchymal resections were carried out in 99 patients and drainage and diversion procedures were carried out in 159. Pain was the principal symptom and led to surgery in 60% of cases; biliary or duodenal obstruction was present in 40 and 23.5% of cases respectively. Operative mortality was 9% for resections and 5.8% for other forms of surgery. In the long term, the best results were obtained in patients in whom a Whipple procedure was performed.

[Surgical treatment of hepatoma on a cirrhotic liver]. / Le traitement chirurgical des hépatomes sur cirrhose.

From January 1, 1975 to July 1, 1984, 37 patients with a tentative diagnosis of hepatocarcinoma on cirrhosis were operated upon. There were 34 men and 3 women, aged from 32 to 82 years (mean: 60 years). The diagnosis of cirrhosis rested either on a history of liver failure associated with clinical and biochemical signs of hepatocellular dysfunction (4 cases), or on a positive liver biopsy (5 cases). In 20 cases the diagnosis was suspected on account of abnormal liver function tests, but in 8 patients it was revealed by macroscopic examination of the liver during surgery. Cirrhosis was attributed to chronic alcoholism in 25 cases, haemochromatosis in 11 cases and positive HBs antigen in 7 cases. The diagnosis of hepatocarcinoma, suggested by altered general condition or recent pain, rested on the finding of a tumoral image at scintigraphy (16 cases), ultrasonography (19 cases), computed tomography (7 cases), arteriography (17 cases) or laparoscopy (7 cases). In only 7/32 patients was the alpha-foetoprotein level higher than 500 ng/l. Surgery confirmed the diagnosis of hepatocarcinoma in every case but that of cirrhosis in only 14/37 cases; 10 patients had lesion of hepatic fibrosis and 1 had regenerative nodular hyperplasia. In 10 cases no accurate histological diagnosis could be made since the liver tissue sample had been taken too close to the tumour. The finding of normal liver tissue shows that one should not refrain from operating merely because the diagnosis of cirrhosis rests on clinical grounds. Since 1979, surgical treatment consists in an attempt to excise the tumour. Per-operative mortality is the same with excision surgery (21%) as with exploratory or palliative surgery (17%). Fourteen excisions were performed (i.e. aresectability rate of 38% for the series): 2 liver transplantations, 2 right hepatectomies, 2 left hepatectomies, 2 left lobectomies, 2 bisegmentectomies and 3 tumorectomies. The survival rate of 2 years was 27%, as opposed to 5% with exploratory or palliative surgery. Systematic monitoring of cirrhosis with ultrasonography should result in early diagnosis of hepatocarcinoma at a stage where limited hepatic excision is possible and the chances of surviving are highest.