La radioembolisation (RE) des tumeurs hépatiques (TH) par l’yttrium 90 vectorisé par des micro-sphères de résine (YMR) est une procédure complexe dont le succès est tributaire d’une gestion multidisciplinaire, regroupant l’oncologie, la radiologie et la médecine nucléaire. Les données récentes de la littérature rapportent des preuves suffisamment évidentes sur l’efficacité de la RE par l’YMR des TH non opérables. Nous décrivons l’expérience initiale de notre institution dans ce domaine, portant sur 8 patients qui présentent des TH non opérables, qui ont été colligés entre les mois de janvier et de novembre 2015. Notre série comporte 4 femmes et 4 hommes, de 68 ans d’âge moyen : 3 cas de cholangiocarcinome, 2 cas de carcinome hépatocellulaire, 1 cas de tumeur neuroendocrine, 1 cas d’adénocarcinome du pancréas et 1 cas de carcinome endométrial. Le bilan avant intervention incluait : (1) une TEP/TDM au 18FDG (TEP) ; (2) un cathétérisme pour délimiter les artères irriguant sélectivement les tumeurs ; (3) l’évaluation par scintigraphie du shunt dans les poumons et d’une éventuelle propagation des micro-sphères dans des organes non cibles tels que l’estomac et l’intestin grêle ; (4) la mesure du volume tumoral par reconstruction TDM en 3D ; (5) le calcul de l’activité thérapeutique en fonction du volume tumoral, de la surface corporelle, du pourcentage du shunt pulmonaire, et des tests biologiques du foie. Les activités de YMR reçues par les patients varient entre 0,5 et 1,9 MBq (moyen = 1,4 MBq). Les résultats de la RE ont été évalués après 2 mois de la RE par des imageries en coupes, y compris la TEP. La RE était tolérée chez tous les patients, il n’y avait pas de complications majeures post-thérapeutiques et la scintigraphie avec les photons de Bremsstrahlung a révélé une accumulation préférentielle dans les lésions hépatiques. Ce traitement a été efficace chez la majorité des patients puisque les TH ont diminué en nombre, en taille et en activité. En outre, un cholangiocarcinome récidivant chez une patiente a montré une atténuation complète de l’activité tumorale. Les TH demeurant actives ou nouvellement apparues ont été programmés pour une deuxième session de RE à 4 mois d’intervalle. Notre expérience clinique initiale avec la RE des TH par l’YMR est encourageante. Il y avait une très bonne tolérance par les patients de ce genre de traitement ciblé, dont les résultats peuvent indiquer un vrai potentiel d’amélioration de la survie.

Les techniques associant cytoréduction maximale tumorale à une chimiothérapie hyperthermique intrapéritonéale (CHIP) ont permis d’améliorer la survie des patients atteints de carcinose péritonéale (CP). Les examens morpho-biologiques actuels sont peu rentables pour le diagnostic de CP. L’objectif de cette étude prospective est de déterminer l’intérêt de la laparotomie de second regard (LSR) systématique associée à une CHIP dans le diagnostic et le traitement de la CP chez des patients à haut risque de récidive.De 2007 à 2011, une LSR a été effectuée après 12 cures de chimiothérapie intraveineuse chez 14 patients qui avaient bénéficié d’une chirurgie d’exérèse carcinologique initiale complète pour CP et/ou métastases ovariennes synchrones d’origine colique de découverte fortuite lors de la chirurgie du primitif. Lors de la LSR, une CHIP pouvait être associée.Soixante et onze pour cent des patients présentaient une CP confirmée histologiquement lors de la LSR avec un peritoneal carcinomatosis index (PCI) médian de 10. Il n’y avait aucune mortalité postopératoire et 7 % des patients ont présenté des complications de stade III–IV. À 2 ans, la survie globale et sans récidive étaient respectivement de 91 % et de 38 %. Une récidive péritonéale n’était observée que chez 8 % des patients avec CHIP.La LSR systématique avec CHIP après exérèse initiale de CP synchrone de cancer colique permet le diagnostic et le traitement de CP de faible score, génère peu de complications postopératoires et améliore la survie globale.Surgical procedures that combine both complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have improved the survival of patients with peritoneal carcinomatosis (PC). Current imaging and laboratory investigations are not very useful to diagnose PC. This prospective study sought to determine the usefulness of routine second-look surgery (RSLS) combined with HIPEC in the diagnosis and treatment of patients with PC at high-risk for recurrence.From 2007 to 2011, RSLS was performed on 14 patients who had undergone a complete initial oncological resection for synchronous colonic PC and/or ovarian metastasis with PC discovered during primary colon cancer surgery after a course of 12 cycles of intravenous chemotherapy, eventually associated with HIPEC.Pathology confirmed PC in 71% of patients during RSLS, with a median peritoneal carcinomatosis index (PCI) of 10. There was no postoperative mortality, while 7% of patients exhibited Dindo Grade III–IV complications. The 2-year overall survival and disease-free survival rates were 91% and 38%, respectively. Following RSLS and CCRS, peritoneal recurrence was observed in only 8% of patients who had undergone HIPEC.RSLS combined with HIPEC after initial resection of synchronous colonic PC allows diagnosis and treatment of low-score PC, with limited postoperative complications and increased overall survival rates.

and Childs A patients with tumor ≤3 cm may benefit from resection.These results could serve to provide honest, evidence-based information to early HCC-cirrhosis patients who are candidates for either resection or LT.

e14584 Background: The safety profile and efficacy of the Folfirinox regimen as first-line chemotherapy in metastatic pancreatic cancer (MPC) was previously reported in a phase II study (Conroy, J Clin Oncol, 2005:1228). We retrospectively studied the feasability and the efficacy of this regimen as second-line therapy in our institution. Methods: Twenty-seven patients (pts) with MPC were treated by Folfirinox between January 2003 and November 2009. The recommended schedule was oxaliplatin 85 mg/m2 d1 + irinotecan 180 mg/m2 d1 + LV 400 mg/m2 d1 followed by 5-FU 400 mg/m2 bolus d1 and 2,400 mg/m2 46h continuous infusion biweekly. Results: Pts characteristics: M/F = 13/14; median age = 63 years (45-83). Ten had a complete resection of primary tumor, 6 had a adjuvant chemotherpy by gemcitibine, and 4 had an adjuvant radiotherapy concomittant with capecitabine. All patients had a progressive disease after first-line chemotherapy by gemcitabine. Safety: A total of 167 cycles were delivered, with a median number of 6 cycles (1-29) per patient. One toxic death occurred (sepsis). Tolerance was excellent with a good respect of the dose density (Ox: 92.8%, Ir: 89.1%, 5-FU: 96.4%). Grade (G) 3-4 neutropenia occurred in 55.6% of pts, including 1 febrile neutropenia. 44.5% of patients received G-CSF. Other relevant toxicities were: G3-4 thrombopenia (14.8%), G3-4 fatigue (29.6%), G3-4 nausea- vomiting (18.5% pts), G3-4 diarrhea (11% pts) and G3 neuropathy (3.7% pts). Efficacy: 17 of 22 pts were evaluable (WHO and RECIST criterias). 5 PR and 12 SD were observed. Median PFS was 5.4 months. (0.7- 25.48) and median EFS was 3 months (0.5-24.9). Median overall survival was 8.5 months (0-26). Conclusions: These results confirmed the good safety profile and the efficacy of Folfirinox regimen in the treatement of MPC, which merits to be assessed in a phase III trial. No significant financial relationships to disclose.

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.

Introduction: Le traitement des pancréatites nécrosantes infectées repose essentiellement sur l'exérèse de la nécrose habituellement par voie chirurgicale. Quelques équipes ont décrit sur de courtes séries leur expérience de nécrosectomie par voie endoscopique transgastrique ou transduodénale. Nous exposons ici les résultats obtenus dans notre centre.

Introduction: Le traitement des pseudokystes (PK) symptomatiques du pancréas est souvent réalisable par voie endoscopique ou échoendoscopique avec une bonne efficacité et une morbidité faible. Un instrument, le Cystotome™ (Wilson-Cook, Winston-Salem, NC, USA), permet la ponction du PK et l'élargissement de l'orifice créé par électro-coagulation, avant la pose d'un drain en double queue de cochon. Nous rapportons les résultats obtenus chez les patients traités dans le service avec cet instrument.

Introduction: La pose d'une prothèse colique pour le traitement de l'occlusion par cancer est une alternative à la chirurgie. Elle constitue un traitement d'attente de la chirurgie curatrice pour les patients non métastatiques ou métastatiques résécables d'emblée. Le but de notre étude était de comparer les résultats des patients traités par prothèse puis chirurgie ou par chirurgie seule.

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.

Introduction: La prise en charge endoscopique des sténoses anastomotiques biliaires post transplantation hépatique (TH) impose habituellement une période de calibration de plus d'un an, impliquant de nombreuses CPRE. Le but de cette étude était d'évaluer la morbidité et l'efficacité (succès et durée de calibration) d'un traitement endoscopique «agressif» consistant à mettre en place simultanément 3 prothèses biliaires après une dilatation à fort diamètre de l'anastomose.

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.

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. Operating 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.

Dado que las resecciones hepáticas suelen requerir una exéresis simple sin reconstrucción, habría que considerarlas como buenas candidatas para la vía laparoscópica. Sin embargo, las resecciones hepáticas por vía laparoscópica no han alcanzado aún gran difusión y, hasta la fecha, sólo unos pocos equipos han evaluado sus posibilidades y resultados. Aunque la mayor parte de las experiencias iniciales tuvo que ver con lesiones benignas, ahora también se practican resecciones por tumores malignos (carcinomas hepatocelulares y metástasis hepáticas). Las primeras experiencias comunicadas demuestran que las exéresis laparoscópicas son factibles y también que son seguras si se seleccionan enfermos con lesiones de tamaño y topografía favorables (<5 cm, segmentos anteriores y laterales, lejos del hilio y de la vena cava). Por lo general, estas lesiones representan menos del 20% de las indicaciones de hepatectomía. En la mayor parte de los casos se trata de resecciones de menos de tres segmentos, aunque también pueden realizarse hepatectomías mayores. La más reproducible de todas las resecciones hepáticas laparoscópicas es la lobectomía izquierda. Además de las ventajas inherentes a las intervenciones laparoscópicas (preservación parietal, reanudación más temprana de actividades habituales), se observa una reducción de la morbilidad en los enfermos cirróticos y una facilitación de las posibles intervenciones ulteriores (hepatectomía iterativa o trasplante hepático). Conviene subrayar tres puntos esenciales: las indicaciones de resección, en particular las originadas en lesiones benignas, no deben modificarse por la posibilidad de un acceso laparoscópico; hay que hacer una rigurosa selección de los pacientes; los cirujanos necesitan una formación doble: en cirugía hepática abierta y en cirugía laparoscópica compleja.

BACKGROUNDThe 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 METHODSThirty-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.RESULTSThe 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.CONCLUSIONThe 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.

BACKGROUND:After technical advances in hepatic surgery and laparoscopic surgery, some teams evaluated the possibilities of laparoscopic liver resections. The aim of our study was to assess the results of laparoscopic left lateral lobectomy (bisegmentectomy 2-3) and to perform a case-control comparison with the same operation performed by open surgery. STUDY DESIGN:From 1996 to 2002, 60 laparoscopic resections were performed in selected patients, including 18 left lateral lobectomies. The resected lesions were benign tumors, hepatocellular carcinomas with compensated cirrhosis, and metastases. Surgical procedures were performed with a harmonic scalpel, an ultrasonic dissector, linear staplers, and portal pedicule clamping when necessary. Results were compared with those of patients who underwent open left lateral lobectomies selected from our liver resection database in a case-control analysis. Both groups were similar for age, type and size of the tumor, and presence of underlying liver disease. RESULTS:Compared with laparotomy, laparoscopic left lateral lobectomies were associated with a longer surgical time (202 versus 145 minutes, p < 0.01), a longer portal triad clamping (39 versus 23 minutes, p < 0.05), and a decreased blood loss (236 versus 429 mL, p < 0.05). There were no deaths in either group, and the morbidity rates were 11% in the laparoscopic group and 15% in the open group. There were no specific complications of hepatic resection after laparoscopy (no hemorrhage, subphrenic collection, or biliary leak), but some were observed in the open group. CONCLUSIONS:This study demonstrates the safety of laparoscopic left lateral lobectomy. Despite longer operation and clamping time, without any clinical consequences, the laparoscopic approach was associated with decreased blood loss and absence of specific complications of the hepatic resection.

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.

Objective: To assess the technical and oncologic results of anatomic hepatic bi- and trisegmentectomies.Summary Background Data: Regardless of their size, some tumors require extensive hepatectomy only because they are located centrally or in the vicinity of major portal pedicles or hepatic veins. Anatomic bi- and trisegmentectomy might represent an alternative to extensive hepatectomies in such cases.Methods: Of 435 liver resections, 32 cases (7%) included 2 or 3 adjacent segments (left lateral sectionectomies, ie, bisegmentectomies 2-3, excluded). There were 16 central hepatectomies (segments 4, 5, and 8), 7 right posterior sectionectomies (segments 6 and 7) and 2 central anterior (segments 4b and 5), 1 central posterior (segments 4a and 8), 2 right superior (segments 7 and 8), 3 right inferior (segments 5 and 6), and I left anterior (segments 3 and 4b) bisegmentectomies. Indications were malignant disease in 29 patients, including 15 with cirrhosis and 2 with benign tumors. External landmarks, selective devascularization, and intraoperative ultrasound were used to achieve anatomic resection.Results: Mortality, transfusion, and morbidity rates were 0%, 26%, and 19%, respectively. Mean section margin was 9 mm (range, 1-40 mm). Isolated intrahepatic recurrence occurred in 7 patients (24%) and 3 (43%) underwent repeat hepatectomy.Conclusion: Anatomic bi- or trisegmentectomy is a safe alternative to extensive liver resection in selected patients, avoiding unnecessary sacrifice of functional parenchyma and enhancing the opportunity to perform repeat resections in cases of recurrence.