Use of preoperative liver biopsy to predict livers that have avoided chemotherapy-induced liver injury

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Background: Liver parenchymal damage caused by neoadjuvant chemotherapy may increase the surgical risk. The aim of the present study was to assess the performance of preoperative liver biopsy (PLB) in predicting the status of the liver parenchyma at the time of resection.

Methods: Among 40 patients who underwent liver resection after neoadjuvant chemotherapy for colorectal liver metastases (CLM) in 2009, 28 had percutaneous PLB from 2 to 6 weeks after onset of the treatment. Patients underwent a mean number of 9 cycles of chemotherapy (range 4-22). Chemotherapy included oxaliplatin (n=22), irinotecan (n=10), and bevacizumab (n=12). PLB and surgical specimens were compared according to the presence and rate of steatosis, sinusoidal obstruction syndrome (SOS) and chemotherapy-associated steatohepatitis (CASH).

Results: Surgical specimen analysis showed steatosis in 12 (43%) patients (ranging from 5 to 80%), SOS in 12 patients (43%) and CASH in 1 patient (3%). The sensitivity, specificity, positive predictive value and negative predictive value of PLB for steatosis were 67%, 81%, 73% and 77%, respectively. It was 50%, 94%, 86% and 71%, respectively for SOS and 0%, 100%, 0% and 96%, respectively for CASH. Performance of PLB was not related to the type of chemotherapy. Among the 28 patients, 8 patients had no abnormalities on PLB. In 7 of them, surgical specimen analysis was considered normal.

Conclusions: The accuracy of PLB in predicting chemotherapy- induced liver injury appears to be low. It is useful, however, given its high specificity when the PBL is normal, for encouraging hepatic resection without delay.

No significant financial relationships to disclose.

Regenerative nodular hyperplasia (RNH) induced by oxaliplatin-based chemotherapy for colorectal liver metastases (CRLM): A contraindication for major liver resection?

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Background: Oxaliplatin is recognized to induce vascular lesions in the nontumoral liver parenchyma. Regenerative nodular hyperplasia (RNH), the ultimate state of the vascular lesions, is very rare. In some reported cases, RNH was associated with severe lethal postoperative complications after hepatic resection. This study aimed to compare the postoperative course after major hepatectomy, in patients with colorectal liver metastases treated with oxaliplatin-based chemotherapy, with or without RNH in the resected specimen.

Methods: Between 2001 and 2009, among 420 patients who underwent liver resection for CRLM, 17 (4%) patients had RNH lesions (RNH+ group) on the resected specimen after right hepatectomy. These 17 patients were compared to another group of 20 patients with similar clinicopathologic data but without RNH (RNH- group) who underwent right hepatectomy. The mean age of the RNH + and RNH- groups was 57 years (range: 37-71 years) and 60 years (range: 43-73 years), respectively. Preoperatively the patients were treated with a mean number of 7 cycles of oxaliplatin (range: 3-12 cycles). The peroperative blood loss (560 vs. 830 ml) and blood transfusion (18% vs. 20%) were similar in the two groups.

Results: The mortality in the RNH+ group and the RNH- group (6% vs. 5%, respectively) were similar (p>0.005). The postoperative morbidity was 53% in the RNH+ group and 35% in RNH– group (p>0.005). The most frequent complications were biliary fistula (3 in the RNH+ group and 2 in the RNH- group) and pulmonary complications (6 in the RNH+ group and 5 in the RNH- group). However, the post operative ascites was significantly encountered in the RNH+ group with 70% of patients compared with 40% in the RNH- group. The number of patients who had a bilirubin level at day 5 superior to 50 was significantly higher in the RNH+ group (35%) compared with 15% in the RNH-group.

Conclusions: RNH lesions allow major hepatectomy without increased mortality but with increased postoperative ascites and jaundice justifying preoperative liver biopsy to detect this lesion with subsequent portal embolisation or sparing liver resection in order to avoid major resections.

No significant financial relationships to disclose.

Microbiological findings of culture-positive preservation fluid in liver transplantation

Bacterial and fungal infections are the leading cause of mortality in liver transplant (LT) recipients. Few studies have examined the incidence of culture-positive preservation fluid (PF) and the outcome of related recipients. The aim of this study was to determine the incidence and the microbiologic findings of PF positive cultures, and to evaluate the impact on morbidity and mortality of LT recipients. A retrospective analysis of PF cultures performed after 477 LTs from cadaveric grafts between January 2001 and February 2008 was conducted. Forty-five (9.5%) PFs were found to be positive with 1 or 2 pathogens. The demographic profiles of recipients of PF with positive or negative cultures were similar. Enterobacteriaceae species were the most frequent organisms (n = 30), followed by Staphylococcus aureus (n = 5), coagulase-negative staphylococci (n = 5), enterococci (n = 4), and yeasts (n = 3). Mortality rate at 1 month was not significantly different in recipients with positive or sterile PF cultures (88.1% vs. 87.7%, respectively). The rate of bacteremia among LT recipients with positive or negative PF cultures was not statistically different. Systemic infections caused by the pathogen cultured from the PF occurred in 8 (18%) of the 45 recipients, including bacteremia (4/8) or intra-abdominal sepsis (5/8). Causative organisms were Enterobacteriaceae species (n = 5), Candida species (n = 2), and Enterococcus faecium (n = 1). Among the 8 patients who developed infection with the PF organism, 4 (50%) died in the intensive care unit (ICU) vs. an ICU mortality rate of 8% (3/37) in those who did not develop infection with the PF organism (P < 0.05). Infection occurred less frequently in recipients who received antimicrobial therapy with activity against the PF isolate than in those without appropriate treatment (41% vs. 3.8%, P < 0.005). Those who develop infection with organisms recovered from PF cultures appear to have high early mortality rates; therefore, appropriate antimicrobial therapy against organisms cultured from PF should be given.

Increased expression of CD44v6 in endocrine pancreatic tumours but not in midgut carcinoid tumours

Aims/background-To analyse the different isoforms of CD44 in various types of endocrine pancreatic and gut carcinoid tumours and to investigate the relation between their expression and tumour dissemination. This study was prompted by the recent observation that inappropriate splicing of the CD44 gene was correlated with tumour progression and metastasis formation in a number of human cancers.Methods-Expression of CD44 isoforms was studied in 38 endocrine pancreatic tumours and gut neuroendocrine tumours using antibodies directed against products of exons v3, v4-v5, v6, v7-v8 as well as against the standard CD44 molecule (CD44H). CD44 gene expression was also analysed by reverse transcription PCR (RT-PCR) in nine endocrine and seven carcinoid tumours.Results-All gastrinomas except one (nine of 10) and about half of the other endocrine pancreatic tumours (seven of 15) expressed CD44v6. Most (10/11) midgut carcinoid tumours were CD44v6 negative, with no detectable immunostaining. CD44v3, CD44v4-v5 and CD44v7-v8 were not expressed in any of these tumours. CD44 mRNA analysis illustrated a complex splice pattern and expression of large CD44 isoforms in CD44v6 positive endocrine tumours, whereas the standard form only was detected in midgut carcinoid tumours. No correlation between CD44 variant expression and tumour metastasis was observed.Conclusions-CD44 variants encoding exon v6 are preferentially expressed both in gastrinomas and in most pancreatic endocrine tumours. In contrast to other tumours, the expression of CD44v6 in pancreatic neuroendocrine tumours does not seem to be correlated with tumour dissemination.

Hepatocellular carcinoma--what's new?

The increasing incidence of hepatocellular carcinoma (HCC) has led several countries to standardize and update its management. This review aims at summarizing these evolutions through six questions focusing on diagnosis and treatment. The radiological diagnosis of this tumor has been refined. Besides being hypervascular at the arterial phase, the "washout" in particular at the late phase of injection has become a prominent feature. Although routine ultrasound remains the corner stone of screening, contrast ultrasound has become a very reliable characterization tool as it allows continuous monitoring of the vascular kinetics. Biopsy of the tumor allows identification of conventional or molecular prognosis features, some of which could be used in current practice. The metabolic syndrome is an increasing etiology of HCC and carcinogenesis in this context may not always require the development of formal underlying cirrhosis. Associated (in particular cardiovascular) conditions account for an increased morbidity-mortality following surgery. Liver transplantation is the most effective treatment of early-stage tumors. The limited availability of grafts has led some countries including France to implement new allocation rules that are still evaluated and might need to be refined. Sorafenib is the first medical treatment shown to be effective in the treatment of HCC. This efficacy is however still limited and its indication is therefore restricted to Child-Pugh A, OMS 0-2 patients in whom a potentially curative treatment is contraindicated.

Clinical and imaging follow-up after exhaustive liver resection of endocrine metastases: a 15-year monocentric experience

Liver metastases are common in gastroenteropancreatic neuroendocrine tumors and significantly impair survival. Hepatic resection is the only potential curative treatment. The records of 41 consecutive patients undergoing exhaustive resection of liver-only endocrine metastases and followed between 1992 and 2006 were reviewed. Patient's outcome and diagnostic accuracy of somatostatin receptor scintigraphy (SRS) and morphological imaging (MI) for detection of recurrences during post-operative follow-up were assessed. All identified primary had been resected. MI studies including abdominal computed tomography (CT) and/or liver magnetic resonance imaging and thoracic CT if indicated were performed every 6 months; SRS timing was decided by referring clinician. Tumor recurrences were confirmed by pathology or subsequent imaging studies. The results of 136 MI and SRS examinations performed within a 30-day interval from each other were retrospectively compared. Median post-operative follow-up was 51 months (7-165). Recurrences developed in 32 patients (78%), mainly in the liver (n=24) after a median of 19 months (2-79). Five-year overall and disease-free survival rates were 79 and 3% respectively. For recurrence detection, sensitivity, specificity, and accuracy were 89, 94, and 91% for SRS, 68, 91, and 74% for MI respectively. In 11 out of 32 patients (34%), abdominal or extra-abdominal metastases were detected 15.5 months earlier by SRS than MI. In conclusion, despite exhaustive liver surgery for endocrine metastases, hepatic or extra-hepatic recurrences are frequent and develop early. SRS is highly accurate for the detection of recurrences during post-operative follow-up and permitted early diagnosis in one third of patients; therapeutic implications of this early diagnosis remain to be determined.

Long-term survival after portal vein arterialization for portal vein thrombosis in orthotopic liver transplantation

Portal vein thrombosis is a relatively common finding during liver transplantation. The management of portal vein thrombosis during liver transplantation is technically demanding and ensures adequate portal flow to the liver graft. Eversion thromboendovenectomy and bypass using a patent splanchnic vein and cavoportal hemitransposition are the most often used procedures to treat portal vein thrombosis. There have been anecdotal reports of portal vein arterialization. We report a case of portal vein arterialization during orthotopic liver transplantation for decompensated cirrhosis. When thromboendovenectomy failed to restore sufficient portal flow and completion of arterial anastomosis between the recipient hepatic artery and the donor celiac trunk, a calibrated end-to-side anastomosis between the donor splenic artery and the donor portal vein was performed. With a 6-year follow-up, there are no symptoms related to portal hypertension, liver function is normal. However, an aneurismal dilatation of the portal branches has progressively developed. Calibrated portal vein arterialization is a possible option for portal vein thrombosis in liver transplantation, allowing long-term patient and graft survival.

Use of partial liver resection according to carcinologic procedures as an alternative to liver transplantation for HCC

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Background: There are some arguments showing that anatomic resection, anterior approach and preoperative transarterial chemoembolization (TACE) with portal vein embolization (PVE) before major resection improves long term survival after partial liver resection for HCC. This oncologic approach could compete with liver transplantation (LT) which remains poorly accessible in western countries and inaccessible in the greatest part of the world.The aim of this study was to evaluate in patients with good liver function.the result of partial liver resection with an intended carcinologic approach. Methods: Between 1998 and 2007, among 210 patients resected for HCC, we selected a subgroup of 36 patients with single and small HCC (< 6 cm) developed on chronic liver disease (CLD) who underwent anatomic partial resection and anterior approach and TACE and PVE in case of major resection. Results: These 36 patients aged 37 to 76 years included 26 males (72%). Underlying CLD included hepatitis C in 16 (44%); hepatitis B in 8 (22%); alcohol in 9 (25%) and other in 3 ( 8%). The mean size of the tumor was 5.2 cm and 86% (n=31) had major resection. Operative mortality was 2.7% (n=1) and the overall 1-, 3- and 5-year survival rate were 92%,85%,73% while the disease free 1-, 3-, 5-year survival was 80%, 74%, 58%. Tumor recurrence occurred in 16 cases( 44%) after a mean delay of 21 months (ranging from 5 to 58 months). Recurrence was located out of the resected location in 6 cases. Conclusions: Partial liver resection for small tumors in patients with good liver function according to carcinologic procedures allow an excellent overall and disease free survival which can challenge LT. In the case of single HCC <6cm on chronic liver disease, this surgical approach may therefore be considered as a valuable alternative to LT within a curative intent.

No significant financial relationships to disclose.

[Limited pancreatic resections for intraductal papillary mucinous neoplasm]

INTRODUCTION

For non-invasive intraductal papillary and mucinous neoplasm (IPMN) with limited extent, pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) seem excessive due to the risk of pancreatic insufficiency. Enucleation (EN) or medial pancreatectomy (MP) are not commonly performed for IPMN. The aim of this study was to evaluate the feasibility and results of EN and MP for non-invasive IPMN.

PATIENTS AND METHODS

Of 249 patients with IPMN, we attempted a limited resection in 50 (20%) EN (n=31) or MP (n=20) with routine intra-operative frozen section pathology. One attempted EN was converted to MP. Indications for surgery were pain/pancreatitis (44%), suspicion of main duct involvement (28%), mural nodules in branch duct (14%), branch duct>30 mm (8%) or suspicion of mucinous cystadenoma (6%). Follow-up clinical assessment and MRI were performed on a yearly basis.

RESULTS

Of the 31 attempted enucleations, 5 (13%) were immediately converted (4 PD, 1 MP) due to technical reasons (n=3) or due to findings on frozen section (n=2). At definitive pathological examination (accuracy of frozen sectioning=98%), branch ducts were involved by mild (n=21), moderate (n=7) or high grade dysplasia (n=2). One patient underwent a double EN. Of 20 attempted medial pancreatectomies, 8 (40%) required additional segmental resection due to significant IPMN lesions at pancreatic margins; 3 of the additional resection margins were tumor-free, and 5 were involved by IPMN (4 conversions to PD or DP, one contra-indication to PD). Overall, 49 pancreatic margins were analyzed by frozen sectioning with 98% accuracy. Resected specimens of 16 MP showed involvement by mild (n=7), moderate (n=7) or high grade dysplasia (n=2). There was no postoperative mortality. Median length of stay was 21 and 30 days respectively after EN and MP. Pancreatic fistula rate was 54% and 81% respectively after EN and MP. Three patients underwent early re-operation for hemorrhage. Overall median follow-up was 24 months (3-121). All patients are alive, 2 patients (5%) have presented with recurrent pain and 4 have developed tumor recurrence on imaging follow-up (4/33=12%). Two patients (5%) developed de novo diabetes (one after EN combined with DP) and a third patient developed worsening of pre-existing diabetes plus exocrine insufficiency. No patient had surgery for recurrence.

CONCLUSIONS

EN and MP are feasible for non-invasive IPMN. Their significant early morbidity is counterbalanced by low rates of both long-term functional disorders and tumor recurrence.

Interest of BIS monitoring to guide propofol infusion during the anhepatic phase of orthotopic liver transplantation

OBJECTIVE

The anhepatic phase of orthotopic liver transplantation (OLT) is associated with significant changes in pharmacokinetics. The aim of this study was to compare the influence of this phase on propofol target concentrations during BIS guided target controlled infusion (TCI).

STUDY DESIGN

Prospective study.

PATIENTS AND METHODS

Eight patients aged 25 to 65 years, Child-Pugh status A-B scheduled for OLT were prospectively included. Anesthesia was performed using TCI of propofol (Diprifusor, Marsh pharmacokinetic model), sufentanil and cisatracurium. Propofol target concentration was adjusted to maintain BIS values between 40 and 50.

RESULTS

To maintain stable BIS values, propofol target concentrations should be decreased during the anhepatic phase versus the dissection one (2.0 microg/ml+/-0.8 versus 3.0 microg/ml+/-0.9, p<0.0001).

CONCLUSION

BIS could be useful to titrate propofol infusion during the anhepatic phase of OLT.

Hepatocellular carcinoma in Budd-Chiari syndrome: characteristics and risk factors

BACKGROUND AND AIMS

To analyse the characteristics of and the factors associated with the development of hepatocellular carcinoma (HCC) in patients with Budd-Chiari syndrome (BCS).

PATIENTS AND METHODS

97 consecutive patients with BCS and a follow-up > or = 1 year were evaluated retrospectively. Liver nodules were evaluated using serum alpha-fetoprotein (AFP) level and imaging features (CT/MRI). Biopsy of nodules was obtained when one of the following criteria was met: number < or = 3, diameter > or = 3 cm, heterogeneity, washout on portal venous phase, increase in size on surveillance, or increase in AFP level.

RESULTS

Patients were mainly Caucasian (69%) and female (66%). Mean age at the diagnosis of BCS was 35.8 (SE 1.2 years), and median follow-up 5 years (1-20 years). The inferior vena cava (IVC) was obstructed in 13 patients. Liver nodules were found in 43 patients, 11 of whom had HCC. Cumulative incidence of HCC during follow-up was 4%. Liver parenchyma adjacent to HCC showed cirrhosis in nine patients. HCC was associated with male sex (72.7% v 29.0%, p = 0.007); factor V Leiden (54.5% v 17.5%, p = 0.01); and IVC obstruction (81.8% v 4.6%, p < 0.001). Increased levels of serum AFP were highly accurate in distinguishing HCC from benign nodules: PPV = 100% and NPV = 91% for a cut-off level of 15 ng/ml.

CONCLUSION

The incidence of HCC in this large cohort of BCS patients was similar to that reported for other chronic liver diseases. IVC obstruction was a major predictor for HCC development. Serum AFP appears to have a higher utility for HCC screening in patients with BCS than with other liver diseases.

Predictors of long-term survival after liver transplantation for metastatic endocrine tumors: an 85-case French multicentric report

Liver transplantation (LTx) for metastatic endocrine tumors (MET) remains controversial due to the lack of clear selection criteria. From 1989 to 2005, 85 patients underwent LTx for MET. The primary tumor was located in the pancreas or duodenum in 40 cases, digestive tract in 26 and bronchial tree in five. In the remaining 14 cases, primary location was undetermined at the time of LTx. Hepatomegaly (explanted liver > or =120% of estimated standard liver volume) was observed in 53 patients (62%). Extrahepatic resection was performed concomitantly with LTx in 34 patients (40%), including upper abdominal exenteration (UAE) in seven. Postoperative in-hospital mortality was 14%. Overall 5-year survival was 47%. Independent factors of poor prognosis according to multivariate analysis included UAE (relative risk (RR): 3.72), primary tumor in duodenum or pancreas (RR: 2.94) and hepatomegaly (RR: 2.63). After exclusion of cases involving concomitant UAE, the other two factors were combined into a risk model. Five-year survival rate was 12% for the 23 patients presenting both unfavorable prognostic factors versus 68% for the 55 patients presenting one or neither factor (p < 10(-7)). LTx can benefit selected patients with nonresectable MET. Patients presenting duodeno-pancreatic MET in association with hepatomegaly are poor indications for LTx.

[Cholangiocarcinoma: epidemiology and global management]

SCOPE

Cholangiocarcinoma, or biliary tract tumors, are rare tumors for which survival is short, as diagnosis is often made at an advanced stage. Indeed, diagnosis remains difficult, since symptoms are often unspecific and appear at latest stages. This article presents an update of recent data and therapeutic options.

CURRENT SITUATION AND SALIENT POINTS

Several etiologic factors have been identified, but for most patients, none of these factors can be found. Prognosis is often poor, and remains difficult to establish because of the lack of sufficient large-scale studies looking at the impact on preexisting tumor characteristics on overall survival. Surgery remains when possible the gold standard. When tumor removal is impossible, due to a local extension, the appropriate care of patients remains to be defined. Chemotherapy has been proposed with evidence of objective response but limited data on its ability to prolong overall survival and to enhance quality of life. Active chemotherapies appear to be made from combination of an antimetabolite, such as 5-fluorouracile or gemcitabine, and a platinum drug.

PERSPECTIVES

In the near future, indications of chemotherapy could be enlarged and targeted therapy might also be used, since several molecules have been tested in preclinical studies, and be offered to patients in clinical trials.

Treatment before liver transplantation for HCC

Liver transplantation (LT) which is currently an established therapy for sma1l, early stage hepatocellular carcinoma (HCC) in patients with cirrhosis requires in most cases long waiting period. Tumor development during the waiting period may be associated with vascular invasion which is a strong factor of postoperative recurrence. Therefore, local treatment of the tumor including trans-arterial chemoembolization (TACE), percutaneous radiofrequency (RF) or partial liver resection can be used before transplantation. In the present paper we reviewed the efficacy of these treatments prior to LT. Although, TACE induced complete tumor necrosis in some patients there is no convincing arguments showing that this treatment reduces the rate of drop out before LT, nor improves the survival after LT. Although, RF can induce complete necrosis in the majority of small tumors (<2.5 cm), there is no data demonstrating that this treatment reduce the rate of drop out before LT, nor improves the survival after LT. It has been showed that both short and long term survival after LT was not compromised by previous partial liver resection of HCC. However, there is no data demonstrating that liver resection before LT, which can be used either as a bridge treatment or as a primary treatment, improves the survival after LT. The current data suggest that there is no role for pre-transplant therapy for HCC within Milano criteria transplanted within six months. On the opposite, if the waiting time is predicted to be prolonged, the risk of tumor progression and either drop-off from the list or interval dissemination with post-transplant tumor recurrence is recognized. In this setting, bridge therapy can reduce that risk but its efficacy has to be determined.

Is preoperative histological diagnosis necessary before referral to major surgery for cholangiocarcinoma?

Major surgical resection is often the only curative treatment for cholangiocarcinoma. When imaging techniques fail to establish the accurate diagnosis, biopsy of the lesion is unavoidable. However, biopsy is not necessarily required for topography of the cholangiocarcinoma (intrahepatic or extrahepatic). 1) In extrahepatic cholangiocarcinoma (ECC), clinical features and radiological imaging relate to biliary obstruction. Provided that between 8% and 43% of bile duct strictures are not ECC, the lesions mimicking ECC that should be ruled out are gallbladder cancer, Mirizzi syndrome, primary sclerosing cholangitis (PSC), autoimmune pancreatitis and portal biliopathy. Systematic biopsy is usually difficult and has poor sensitivity, but a good knowledge of these mimicking ECC diseases, along with precise analysis of clinical and imaging semiology, may lead to a correct diagnosis without the need for biopsy. 2) Intrahepatic cholangiocarcinoma (ICC) developing in normal liver appears as a hypovascular tumour with fibrotic component and capsular retraction that can be confused with fibrous metastases such as breast and colorectal cancers. The lack of the primary site, a relatively large tumour size and ancillary findings such as bile duct dilatation may provide a clue to the diagnosis. If not, we advocate local resection with lymph node dissection, since ICC is the most likely diagnosis and surgery is the only curative treatment. In the event of adenocarcinoma from unknown primary, surgery is an effective treatment even if prognosis is poor.

[Incidence of biological tests requested outside of written medical prescriptions in digestive surgical intensive care unit]

OBJECTIVES

Realization of biological tests in intensive care unit requires a written medical prescription. Requests of biological tests outside written medical prescription are sometimes observed. The aim of the survey was to evaluate their incidence and the reasons of these practices.

MATERIALS AND METHODS

The study was realized on a 14 days-period in a 8 beds intensive care unit of digestive surgery, in real situation and anyone was informed of the study. Nineteen patients were enrolled during the period of the study.

RESULTS

A request of biological tests outside written medical prescription was found in 78% of requests of tests (89/114). The incidence of requests of biological tests outside written medical prescription was 27%. Several reasons could explain these practices.

CONCLUSION

This study confirms that there is a high frequency of requests of biological tests outside written medical prescription and that several reasons could explain these practices in intensive care unit.

Breast cancer liver metastases (BCLM): What may be the role of surgery combined with chemotherapy?

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Background: Despite recent treatment improvements, the prognosis of BCLM is still poor. Hepatic resection (HR) has been associated with better outcome in selected patients, but its place in multimodality treatment of BCLM remains controversial. This study aimed to examine the outcome of a large cohort of patients selected for HR of BCLM and to define prognostic factors of survival, in a way to better define the place of surgery. Methods: A standardized questionnaire reviewing the main diagnostic and treatment modalities of primary tumor, liver metastases, response to medical therapies, type of surgical procedures, postoperative outcome, and survival following surgery, was sent to all contributing centers. Results: 460 patients treated with liver resection for BCLM from 1980 to 2000, were collected from 31 hepatobiliary surgery centers. Mean age was 51.8 years. Primary tumor, mainly adenocarcinoma, was treated by resection combined with chemotherapy and/or radiotherapy in most cases. Diagnosis of BCLM was made after an average of 54 months from the treatment of the primary tumor. BCLM were unique in 56% and associated to limited extrahepatic disease in 18.5% of patients. After initial treatment by systemic therapy (70% of patients), HR achieved a R0 resection in 82% of patients and was combined to extrahepatic resection for distant metastases in 9% of patients. Postoperative mortality (= 2 months) was 0.2%. Median survival was 45.4 months after HR, with an overall survival of 41% and 22% at 5 and 10 years, respectively. Disease-free survival rates were 14% and 10%, respectively. Four predictive factors were independently associated to an unfavourable outcome: tumor progression on chemotherapy before surgery (p = 0.0006, RR = 2.9), disease-free interval < 12 months after treatment of the primary tumor (p = 0.0003, RR = 2.1), extrahepatic metastases (p = 0.0002, RR = 1.9) and R2 liver resection (p < 0.0001, RR = 3.0). Conclusions: Inclusion of HR in the multimodality treatment of BCLM is safe and associated with a hope of long term survival (22% at 10 years). Surgery should be discussed on a multidisciplinary basis, particularly when potentially radical, in patients well controlled by chemotherapy with a long disease-free interval, and in the absence of extrahepatic disease.

No significant financial relationships to disclose.

Patterns and predictive factors of recurrences after complete resection for fibrolamellar hepatocellular carcinoma

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Background: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare subtype of primary HCC which often arises in young patients without underlying hepatic disease or viral infection. Clinical and pathological factors of prognosis are warranted. Methods: Descriptive, univariate and multivariate analysis of survival parameters were analyzed in a monocenter cohort of FL-HCC patients completely resected. Main variables were WHO-PS, age, AJCC stage, AFP level and detailed pathological features including EGFR, p- AKT, and PTEN expression. Results: 23 consecutive patients (median age: 30, M/F:6/17) with pathologically reviewed FL-HCC were analyzed. Median tumor size was 11 cm (range 4–23) and 6 patients had AFP>200ng/ml. two patients had respectable metastasis (lung or peritoneum), 5 patients had vascular invasion and 3 patients had lymph node metastasis achieving the following AJCC staging: I (70%), III (22%) and IV (8%). With median follow-up of 36 months, 3-year survival was 76% . Median time of recurrence was 23 months. Sites of first recurrence were hepatic in 5 patients, extra-hepatic in 4 patients, and both in 3 of 12 patients who recurred (52%). Metastasis occurred in lung, peritoneum, bone, skin and lymph nodes. Expression of EGFR, p-AKT, and PTEN was found in 94%, 69% and 0% of patients, respectively. None of the clinical parameters including AJCC staging predicted survival. In multivariate analysis, bad prognostic factors of recurrence were satellite micro-nodules (p=0.04) and micro-vascular tumor invasion (p=0.03) on pathological specimens. There was a trend toward a better survival in patients with <30% EGFR expression (p=0.06). Conclusions: FL-HCC patients with primary complete resection may develop extra-hepatic metastasis (58%) or isolated intra-hepatic recurrence (42%) within a median follow-up of 2 years. Prognostic factors of survival are pathological satellite nodules and micro-vascular tumor invasion.

No significant financial relationships to disclose.

Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection

Background

The value of routine nasogastric tube (NGT) decompression after elective hepatic resection has not been investigated.

Methods

Of 200 patients who had elective hepatic resection, including 68 who had previously had colorectal surgery, 100 were randomized to NGT decompression, where the NGT was left in place after surgery until the passage of flatus or stool, and 100 to no decompression, where the NGT was removed at the end of the operation.

Results

There was no difference between patients who had NGT decompression and those who did not in terms of overall surgical complications (15·0 versus 19·0 per cent respectively; P = 0·451) medical morbidity (61·0 versus 55·0 per cent; P = 0·391), in-hospital mortality (3·0 versus 2·0 per cent; P = 0·640), duration of ileus (mean(s.d.) 4·3(1·5) versus 4·5(1·7) days; P = 0·400) or length of hospital stay (14·2(8·5) versus 15·8(10·8) days; P = 0·220). Twelve patients randomized to no NGT decompression required reinsertion of the tube 3·9(1·9) days after surgery. Previous abdominal surgery had no influence on the need for NGT reinsertion. Severe discomfort was recorded in 21 patients in the NGT group and premature removal of the tube was required in 19. Pneumonia (13·0 versus 5·0 per cent; P = 0·047) and atelectasis (81 versus 67 per cent; P = 0·043) were significantly more common in the NGT group.

Conclusion

Routine NGT decompression after elective hepatectomy had no advantages. Its use was associated with an increased risk of pulmonary complications.