Daniel Cherqui

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. Patients et Méthodes: Les patients étaient sélectionnés pour un traitement endoscopique de la nécrose lorsque l'infection de celle-ci était avérée ou fortement suspectée et lorsque la zone nécrotique se situait à proximité de l'estomac (Résultats: 7 patients ont été traités successivement. Quatre en état de choc septique avaient eu un premier geste de drainage simple endoscopique permettant une stabilisation clinique avant la nécrosectomie dans un deuxième temps. Cinq présentaient une nécrose glandulaire (dont un avec extension dans la gouttière pariéto-colique gauche et un avec extension dans la racine du mésentère) et deux une coulée de l'arrière cavité des épiploons. La nécrosectomie était réalisée en un temps d'une durée moyenne de 3 heures. Deux à 4 drains en double queue-de-cochon étaient posés. La cavitéétait ensuite lavée par sérum physiologique en continu pendant 72h par le drain naso-kystique. Une sphinctérotomie biliaire était réalisée en cas de lithiase. Une prothèse pancréatique était posée chez 5 patients pour rupture canalaire. Aucune complication liée au geste ne survenait, ni aucun décès. La durée totale moyenne d'hospitalisation était de 58 jours dont 30 après le geste. La durée moyenne d'hospitalisation en réanimation était de 28 jours dont 21 après le geste. Les drains étaient définitivement retirés après 6 mois, sans récidive de collection avec un recul moyen de 10 mois. Conclusion: Pour des patients sélectionnés, le traitement endoscopique de la nécrose pancréatique infectée est efficace et participe à la prise en charge multidisciplinaire de ces patients.

Most indications for liver resections include malignant disease. However, about 15% of hepatectomies are performed for benign liver tumors.^1,2 Laparoscopic liver resection was first reported in 1992,³ but unlike other areas of abdominal surgery, this approach has been developed in a very limited number of institutions.^4-10 Except for a few studies, most of the articles reported a limited number of patients, but it has been established that in select patients, laparoscopic liver resections, if performed in institutions with expertise in hepatic surgery and advanced laparoscopic procedures, are safe, with results identical to those of open surgery.^5-9,11,12 Resection for benign liver disease can represent a valid indication for the laparoscopic approach because of the absence of risk of tumoral dissemination. Furthermore, most of these patients are young and undergoing definitive surgery where the advantages and benefits of the laparoscopic procedure can be particularly clear.⁹ Indications for benign liver tumor resection include preoperative diagnosis of adenoma or cystadenoma, uncertain preoperative diagnosis, and presence of symptoms.^13-17 The aim of our study was to report the results of laparoscopic liver resections for benign disease performed at a single center with 10 years of experience in laparoscopic liver surgery.

Between 1997 and 2007, the celioscopic approach was used for 159 (23%) of the 698 hepatic resections performed at Henri Mondor Hospital. The main selection criteria were the location and size of the lesions. Most lesions were located in anterolateral segments (segments 2 to 6) and were smaller than 50 mm. With experience, the team started to perform major hepatectomies for more deep-seated lesions. The patients were 84 women and 75 men. The indications were benign in 65 cases (40%) and malignant in 94 cases (60%). The most frequent benign disorders were symptomatic hepatocyte tumors and tumors of uncertain nature (adenomas and focal nodular hyperplasia in 40 cases). The malignant lesions comprised 60 cases of hepatocellular carcinoma on a cirrhotic liver and 20 metastases of colorectal cancer. The tumors had a diameter of 44 mm (range 4-170 mm). The technique involved 5 trocars, pneumoperitoneum, and parenchymal section with a combination of a harmonic scalpel, an ultrasonic dissector, and automatic staplers. Intermittent pedicular clamping was used if necessary. The specimen was removed in a protective bag. Manual assistance was used in 14 cases (9%), while the other cases involved a pure coelioscopic approach. Major hepatectomy (three or more segments) was performed in 27 cases (17%) and minor resection in 132 cases (83%). There were 17 right hepatectomies, 11 left hepatectomies, 52 left lobectomies, 37 mono- or bisegmentectomies and 43 atypical resections. The overall laparotomic conversion rate was 10% (16 cases). The reasons for conversion were bleeding in 10 cases and inadequate exposure or progression in 6 cases. The mean operating time was 204 minutes. Nine patients (6%) received blood transfusions. There were no postoperative deaths and the morbidity rate was 18%. The mean resection margin for malignant tumors was 14 mm and there were no relapses on the trocar ports. This series demonstrates the feasibility of celioscopic hepatic resection in selected patients. These operations necessitate expertise in hepatic surgery and advanced coelioscopy, as well as sophisticated instrumentation. The advantages are those of minimally invasive surgery, and simpler re-operation for further hepatectomy or transplantation.

Report the midterm results of laparoscopic resection for hepatocellular in chronic liver disease (CLD). Surgical resection for hepatocellular carcinoma (HCC) in chronic liver disease (CLD) remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity. From 1998 to 2003, patients with HCC and CLD were considered for laparoscopic liver resection. Inclusion criteria were chronic hepatitis or Child's A cirrhosis, solitary tumor ≤5 cm in size, and location in peripheral segments of the liver. Mortality, morbidity, recurrence rates, and survival were analyzed. A total of 27 patients were included. Liver resections included anatomic resection in 17 cases and non anatomic resection in 10. Seven conversions to laparotomy (26%) occurred for moderate hemorrhage in 5 cases and technical difficulties in 2 cases. Mortality and morbidity rates were 0% and 33%, respectively. Postoperative ascites and encephalopathy occurred in 2 patients (7%) who both had undergone conversion to laparotomy. Mean surgical margin was 11 mm (range, 1–47 mm). After a mean follow-up of 2 years (range, 1.1–4.7), 8 patients (30%) developed intrahepatic tumor recurrence of which one died. Treatment of recurrence was possible in 4 patients (50%), including orthotopic liver transplantation, right hepatectomy, radiofrequency ablation, and chemoembolization in 1 case each. There were no adhesions in the 2 reoperated patients. Overall and disease-free 3-year survival rates were 93% and 64%, respectively. Our study shows that laparoscopic liver resection for HCC in selected patients is a safe procedure with very good midterm results. This approach could have an impact on the therapeutic strategy of HCC complicating CLD as a treatment with curative intent or as a bridge to liver transplantation.