Showing papers by "Philippe Bachellier published in 2004"

A Two-Stage Hepatectomy Procedure Combined With Portal Vein Embolization to Achieve Curative Resection for Initially Unresectable Multiple and Bilobar Colorectal Liver Metastases

Abstract: Liver resection has been recognized as the treatment of choice for patients with colorectal liver metastases (CLM), offering long-term survival and the only hope for cure.1–3 However, hepatectomy can be performed only in approximately 10% to 20% of patients with CLM.4 In the majority of cases, liver surgery is contraindicated due to too small future remnant liver (FRL).5–7 During the last years, new multidisciplinary therapies have been proposed to increase safely the resectability rate in patients with initially nonresectable CLM. They include portal vein embolization (PVE),8–10 systemic or arterial hepatic neoadjuvant chemotherapy,11,12 transarterial neoadjuvant immunochemotherapy,13 and local tumoral destruction.14,15 However, these adjuvant therapies do not allow to achieve a curative resection in all patients and particularly in patients with multiple bilobar CLM (MBCLM). In these patients, the resection of MBCLM would result in a too small FRL. A 2-stage hepatectomy procedure (TSHP) without PVE was advocated to treat patients with unresectable multiple metastases.16 However, after resection of MBCLM, high mortality (9%–15%) was reported.16,17 Liver failure due to insufficient functional volume of the FRL is the main cause of postoperative mortality. Preoperative PVE has been proposed to induce compensatory hypertrophy of the FRL.8,9 Some successful cases undergoing right hepatectomy and simultaneous left hemiliver wedge resections after PVE have been reported in patients with MBCLM.18 However, growth of metastatic nodules in the FRL after PVE can be more rapid than that of the nontumoral remnant hepatic parenchyma.19 Therefore, metastases located in the FRL should be ideally resected before PVE in a first-stage hepatectomy; a major hepatic resection can then be performed, after PVE, in a second-stage hepatectomy. Therefore, a new strategy design has been developed to treat patients with initially unresectable MBCLM. Our preliminary results were previously reported.20 The present study reports feasibility, surgical outcome, recurrence rate, and long-term survival of patients presenting initially unresectable MBCLM undergoing a TSHP combined with PVE.

Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy

Abstract: Hypothesis Pancreaticogastrostomy (PG) is associated with a lower relaparotomy rate following pancreaticoduodenectomy (PD) than pancreaticojejunostomy (PJ). Design Retrospective clinical trial. Setting Department of digestive surgery and transplantation. Patients Between 1987 and 2001, 250 consecutive patients underwent PD in our institution. Among them, 83 patients underwent PJ and 167, PG. Main Outcome Measures Preoperative clinicopathological features, intraoperative parameters, in-hospital mortality, postoperative morbidity, pancreatic fistula (PF), relaparotomy rates, and length of hospital stay were analyzed and compared between 2 reconstructive methods, PJ and PG, after PD. Results The morbidity rate, including PF, was lower in the PG group (38.3%) than in the PJ group (53.0%; P = .02). The mortality rate did not differ between the PG group (2.9%) and PJ group (2.4%). Conversely, the incidence of PF and the mean ± SD length of hospital stay were significantly lower in the PG group (2.3% and 17.2 ± 7.7 days) than in the PJ group (20.4% and 23.3 ± 11.7 days; P P = .001). Nine (52.9%) of 17 patients with PF in the PJ group underwent relaparotomy. These 9 patients underwent subsequent completion pancreatectomy (n = 7) or removal of peripancreatic necrotized tissue (n = 2) with a postoperative mortality rate of 22.2%. However, no patient required relaparotomy for PF in the PG group because medical therapy succeeded in all 4 patients with PF. Moreover, no mortality related to PF occurred in the PG group. Conclusion The PG procedure is a safe method of reconstruction after PD, with a significantly lower rate of PF and relaparotomy.

First and repeat resection of colorectal liver metastases in elderly patients.

Abstract: Hepatic resection is the only treatment that can offer long-term survival in patients with colorectal liver metastases.1–4 Hepatic resection is a safe procedure with a mortality rate of less than 5% and a morbidity between 20% and 30%.2,4–7 In studies reporting resection of colorectal liver metastases, age did not appear as a risk factor influencing short- and long-term outcome.1–4,6 Therefore, there does not exist a limit of age for resection. Studies reporting the natural history of colorectal liver metastases revealed that 33% to 50% of all patients presenting with liver metastases were older than 70 years.8–10 However, in studies about resection of colorectal liver metastases, only 8% to 20%2,7 of patients were older than 70 years. This difference may reflect a selection process favoring palliative medical treatment in the elderly. As life expectancy increases and colorectal cancer is a disease of the second part of life with an incidence increasing with age,11 surgical treatment of colorectal liver metastases in older patients will be more frequently considered and performed.12 The aim of this study was to evaluate the short- and long-term outcome after first and repeat hepatic resection for colorectal liver metastases in patients older than 70 years.