Liver resection for cystic lesions: a 15-year experience.

AIM: The aim pf this paper was to review the management strategies in patients who had hepatic resection for cystic lesions. If symptomatic, a simple liver cyst (SC) is best treated by unroofing. A hydatid cyst (HC) is treated by simple cystectomy or pericystectomy. Many procedures have been described for the management of complex non-HCS including aspiration, sclerosing therapy, drainage, unroofing, and resection. METHODS: A retrospective review of patients who had liver resection for cystic lesions between January 1, 1992, and December 31, 2006. The study was carried out at a University Hospital and a General Community Hospital affiliated with a University program. Management strategies were detailed, including clinical, biological, and imaging features. Operative morbidity and mortality as well as long-term outcome were also assessed. A comparison between preoperative and postoperative diagnoses was performed. RESULTS: Thirty-three patients (24 women and 9 men) underwent 39 liver resections, including 14 left lateral resections, 12 right hemi-hepatectomies, 7 left hemi-hepatectomies and 6 segmentectomies or wedge resections. The final diagnosis included hydatid cyst in 10 patients (30%), cystadenoma in 6 (18%), simple cysts in 6 (18%), Caroli's disease in 4 (12%), cystadenocarcinoma in 3 (9%) and miscellaneous in the 4 remaining (12%). There was no mortality and the postoperative morbidity rate was 15%. Long-term follow-up revealed that, besides patients with malignancies whose outcome was dismal, overall prognosis was positive with efficacious symptom control. CONCLUSION; Accurate preoperative diagnosis of liver cystic lesions may be difficult. However, liver resection for such lesions is a safe procedure that provides long-term symptomatic control in benign disease and may be curative in cases of underlying malignancy. Even if nearly 50% of liver cystic lesions treated by resection were either symptomatic SC or HC, we recommend en-bloc liver resection for all liver cystic lesions that are not clearly parasitic or simple cysts.

Cholangiocarcinoma: preoperative biliary drainage (Con).

AIM: In patients with malignant hilar obstruction, liver resection is associated with an increased risk of postoperative liver failure attributed to the need for major liver resection in a context of obstructive jaundice. To overcome this issue, most authors recommend preoperative biliary drainage (PBD). However, PBD carries risks of its own, including, primarily, sepsis and, more rarely, tumor seeding, bile peritonitis, and hemobilia. We, unlike most authors, have not used routine PBD before liver resection in jaundiced patients. MATERIAL AND METHODS: Our series includes 62 patients who underwent major liver resection for cholangiocarcinoma; 33 of these had elevated bilirubin (60-470 micromol/l) and were operated without PBD. There were 43 extended right hepatectomies and 18 extended left hepatectomies. RESULTS: Hospital deaths occurred in 5 patients (8%) including 3 of 33 jaundiced patients (9%, ns). All deaths occurred after extended right hepatectomy (12%), including 3 patients with a serum bilirubin level above 300 micromol/l and 2 with normal bilirubin. There were no deaths after left-sided resections, whatever the level of bilirubin. CONCLUSIONS: PBD can be omitted in the following situations: recent onset jaundice (<2-3 weeks), total bilirubin <200 micromol/l, no previous endoscopic or transhepatic cholangiography, absence of sepsis, future liver remnant >40%. These criteria include most patients requiring left-sided resections and selected patients requiring right-sided resections. In other cases, PBD is required, associated with portal vein embolization in the event of a small future liver remnant.

Robot-assisted laparoscopic mesh repair of incisional hernias with exclusive intracorporeal suturing: a pilot study.

BACKGROUND: The da Vinci robot laparoscopic incisional hernia repair with intracorporeal suturing may offer an alternative to transabdominal sutures and tackers. METHODS: From 2003 to 2005, 11 patients (median age, 71 years; median body mass index [BMI], 28) with small and medium-sized incisional hernias (median fascial defect, 19.6 cm2) were treated with the da Vinci robot system using intracorporeal mesh fixation with interrupted sutures. This pilot study aimed to assess the feasibility and report the morbidity with special reference to postoperative pain and long-term recurrence. RESULTS: The median operative time was 180 min. There was no conversion to open or standard laparoscopy and no postoperative mortality. The overall morbidity rate was 27%. One patient underwent reoperation on postoperative day 3 for peritonitis secondary to small bowel injury. The median visual analog pain score on postoperative day 1 was 3. Seven patients (63%) needed parenteral paracetamol until postoperative day 2. The median hospital stay was 3 days. During a median follow-up period of 25 months, no patient experienced recurrent hernia. One patient had a trocar-site herniation at 6 months. No patient experienced chronic suture site pain or discomfort. CONCLUSION: This is the first report of robot-assisted laparoscopic incisional hernia with exclusive intracorporeal suturing for mesh fixation in humans. The findings show that this technique is feasible and may not be associated with chronic postoperative pain. Further evaluation is needed to assess the benefit to the patient, but this investigation may be the basis for a future, prospective, randomized study.

Laparoscopy as a routine approach for left lateral sectionectomy.

BACKGROUND: Since 1997, the authors have performed laparoscopic left lateral sectionectomy of lesions of the liver in preference to open surgery. The aim of this study was to assess the outcome. METHODS: Between October 1997 and March 2005, 36 laparoscopic left lateral sectionectomies were performed using five trocars and a small incision for specimen retrieval. Liver resection was performed mainly using a harmonic scalpel and staplers. The Pringle manoeuvre was used in 24 patients. RESULTS: The mean patient age was 55.2 (range 31-80) years. Twelve patients had underlying cirrhosis. Surgery was performed for 20 malignant lesions and 16 benign lesions with a mean size of 42.7 (range 5-110) mm. Conversion to laparotomy occurred in one patient. The mean operating time was 171.5 (range 90-240) min. Operatiing time and use of the Pringle manoeuvre were significantly decreased in the second half of the series. Mean blood loss was 208 (range 50-600) ml. No transfusion was required. There were no deaths. Two patients had postoperative complications (one incisional hernia and one pneumonia). The median postoperative stay was 5.2 days. CONCLUSION: The laparoscopic approach to left lateral sectionectomy was safe and feasible in this series and could be considered as a routine approach in selected patients.

["Designer baby" changed to French for "double hope baby"]. / Du "bébé médicament" au "bébé du double espoir".

Scientific advances during the last decades regarding potential intervention on embryos arouse many questions in society to prepare the ground concerning the limits that should be set for these practices. For the first time in 1994, a parliamentary proceeding allowed the definition of a French model of bioethics through laws of the same name. These laws, among others, authorized in a well and strictly defined setting the practice of preimplantation genetic diagnosis (PGD). Because of technical progress concerning PGD, new questions arose, especially concerning the accomplishment of designer babies. The French Chamber of Representatives came in with a new law that banishes the concept of designer babies and replaces it with another concept: double hope babies, in French "bébé du double espoir". A first hope of a pregnancy giving birth to a healthy child and the second being that this child conceived with the aid of PGD could help treat an elder brother. Because of the issuing of two specific laws in a ten years interval, France occupies a privileged place in a Europe where bioethical issues continue to be debated, particularly PGD.

Multimodal therapy with intravenous biweekly leucovorin, 5-fluorouracil and irinotecan combined with hepatic arterial infusion pirarubicin in non-resectable hepatic metastases from colorectal cancer (a European Association for Research in Oncology trial).

BACKGROUND: The purpose of this study was to evaluate the tolerance and efficacy of combining i.v. irinotecan, 5-fluorouracil (5-FU) and leucovorin (LV) with hepatic arterial infusion (HAI) of pirarubicin in non-resectable liver metastases from colorectal cancer. PATIENTS AND METHODS: Thirty-one patients were included in a phase II trial with i.v. irinotecan/5-FU/LV administered every 2 weeks, combined with HAI pirarubicin 60 mg/m(2) on day 1 every 4 weeks. In most cases HAI was administered via a percutaneous catheter. RESULTS: The main grade 3/4 toxicity was neutropenia, encountered in 78% of the patients. When all patients were considered in the analysis, tumour response rate was 15 out of 31 [48%; 95% confidence interval (CI) 32% to 65%]. Liver resection was made possible in 11 patients (35%; 95% CI 21% to 53%). There were no toxic death. Median overall survival was 20.5 months, and median progression-free survival was 9.1 months. In patients with completely resected metastases, median overall survival was not reached and median progression-free survival was 20.2 months. CONCLUSION: The multimodality approach used in the present study was well-tolerated and yielded dramatic responses. An aggressive approach combining i.v. and HAI chemotherapy deserves further investigation.

[Laparoscopic treatment of an adult gastric duplication cyst]. / Traitement laparoscopique d'une duplication gastrique chez l'adulte.

We hereby report the case of a 24 years old woman with an adult gastric duplication cyst, a very rare congenital disease. Diagnosis was established on preoperative imaging tests. Complete resection of the duplication cyst was undertaken laparoscopically. To the best of our knowledge, this is the first report of laparoscopic resection of an adult gastric duplication cyst.

[Epidermoid carcinoma developing in a chronic anal fistula]. / Carcinome épidermoïde développé sur fistule anale chronique.

BACKGROUND: Malignant degeneration of anal fistula is a rare occurrence in the course of a common disease. Abdominoperineal resection offers the only hope of cure. CASE REPORT: A 41-year-old patient who was operated 14 years earlier for anal fistula presented recurrence treated by fistulectomy. Histology revealed a well-differentiated squamous-cell carcinoma. Radiotherapy (45 Gy) was added postoperatively. Five months later, local recurrence was treated by chemotherapy and abdominoperineal resection. Two months later the patient died from cachexia with local recurrence. DISCUSSION: Biopsies of anal fistula tract and histology of all fistulectomies are required for early diagnosis of possible carcinoma. Abdominoperineal resection offers the only hope of cure.