Traitement des carcinomes hépatocellulaires éligibles à une transplantation et à une résection (résultats carcinologiques et complications des deux stratégies)

Le traitement du carcinome hépatocellulaire (CHC) développé sur une cirrhose modérée reste débattu dans la littérature mais peu d'études ont comparé des patients à la fois résécables et transplantables. L'objectif de ce travail était d'analyser rétrospectivement les survies globale et sans récidive des patients éligibles à une résection (RH) et à une transplantation (TH). Entre 1998 et 2010, 187 patients ont été opérés d'un CHC dans notre service. Parmi ceux-ci, 97 (50 résections et 47 transplantations) étaient résécables et transplantables (lésions dans Up to seven , patients de moins de 70 ans et cirrhose Child A ou B). Les survies globales à 1,3 et 5 ans étaient de 89, 73 et 40% dans le groupe RH contre 80, 76 et 67% dans le groupe TH (p=0,08). Le taux de récidive était de 78% dans le groupe RH et 19,1% dans le groupe TH (p<0,001). Les survies sans récidive à 1, 3 et 5 ans étaient de 89, 73 et 30% après RH et 90, 88 et 76% après TH (p<0,001). Les facteurs associés à la récidive étaient la nature de l'intervention (p=0,009, OR=51, ICgs=2-1023) et la présence de nodules satellites (p=0,031, OR=10, IC9s=1,2-87,4). On n'observait pas de différence significative au niveau de la mortalité post-opératoire. Ce travail confirme les bons résultats carcinologiques de la TH. S'il n'y avait pas de pénurie de greffons, elle devrait plus largement être proposée en première intention. Si les marqueurs conventionnels n'ont pas montré ici leur influence sur la récidive, sans doute à cause de faibles effectifs, ce travail constituera la base d'une étude mettant en jeu les marqueurs de l'inflammation intra et péri-tumorale.The best treatment for early hepatocellular carcinoma (HCC) developed in patients with moderate cirrhosis still remains unknown. Only few studies have compared patients eligible to the two therapeutics namely liver resection (LR) or orthotopic liver transplantation (OLT). The aim of this work was to retrospectively analyse overall and disease free survivals of these patients. From 1998 to 2010, our institution has proposed surgical treatments of HCC to 187 patients. Among them, 97 were considered resecable and transplantable (lesions within "up to seven", age under 70 years old and Child A or B cirrhosis). Fifty resections and 47 transplantations were performed. The 1, 3 and 5 years overall survivals were 89, 73 and 40% after a resection versus 80, 76 and 67% after a transplantation (p=0,08). The recurrence rate was 78% in the LR group and 19% in the OLT group (p<0,001). The 1, 3 and 5 years disease free survivals were significantly worse in the case of resection (89, 73 and 30% Vs 90, 88 and 76% after transplantation, p<0,001). ln a multivariate analysis, the recurrence predictive factors were the procedure nature (p=0,009, OR=51, IC95=2-1023) and the presence of "satellite nodules" (p=0,031, OR=10, IC95 = 1,2-87,4). We did not observe any postoperative mortality differences. This study confirms the improved carcinologic results after transplantation compared to those of resection. If there was no shortage of available grafts, a transplantation should be more often proposed as the first choice of treatment for HCC. This work will be used in a study of the intra and peritumoral inflammation markers.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Development of miniaturized light endoscope-holder robot for laparoscopic surgery

PURPOSE: We have conducted experiments with an innovatively designed robot endoscope holder for laparoscopic surgery that is small and low cost. MATERIALS AND METHODS: A compact light endoscope robot (LER) that is placed on the patient's skin and can be used with the patient in the lateral or dorsal supine position was tested on cadavers and laboratory pigs in order to allow successive modifications. The current control system is based on voice recognition. The range of vision is 360 degrees with an angle of 160 degrees . Twenty-three procedures were performed. RESULTS: The tests made it possible to advance the prototype on a variety of aspects, including reliability, steadiness, ergonomics, and dimensions. The ease of installation of the robot, which takes only 5 minutes, and the easy handling made it possible for 21 of the 23 procedures to be performed without an assistant. CONCLUSION: The LER is a camera holder guided by the surgeon's voice that can eliminate the need for an assistant during laparoscopic surgery. The ease of installation and manufacture should make it an effective and inexpensive system for use on patients in the lateral and dorsal supine positions. Randomized clinical trials will soon validate a new version of this robot prior to marketing

Tumeurs bénignes hépatocellulaires du foie (prise en charge dans 2 centres chirurgicaux français)

Cette étude est rétrospective et bi-centrique (Grenoble, Lille) portant sur 144 patients, tous opérés d une tumeur bénigne hépatocytaire, définie sur la base de l anatomopathologie définitive. Soixante-dix sept patients étaient porteurs d au moins un AH (groupe AH), 67 patients d au moins une HNF (groupe HNF). Au total, la radiologie a classé correctement 49 patients sur 143 (34 %). Des analyses extemporanées ont été réalisées 15 fois en coelioscopie et 38 fois en laparotomie. Cinquante-sept patients ont été opérés par coelioscopie (1 hépatectomie majeure, 19 mineures, 20 tumorectomies et 17 biopsies), et 87 par laparotomie (22 hépatectomies majeures, 42 mineures, 16 tumorectomies, 7 biopsies). La mortalité était nulle, et la morbidité était de 43%. Le suivi moyen des patients était de 15+-19 mois dans le groupe AH et 18+-20 mois dans le groupe HNF. Les analyses immuno-histochimiques et les données de biologie moléculaire récentes ont permis de reclasser 9 patients (7 HNF en AH et 2 HNF télangiectasiques en HNF) et de connaitre les sous-types d AH. Les AH étaient classés en 5 sous-types selon la classification de Zucman-Rossi : 20 types 1 (AH mutés HNF1a, LFABP-), 4 types 2 (AH mutés b-caténine), 38 types 3 (AH inflammatoires, SAA+), 8 types 4 (AH inclassables), et 7 non classés. Les hémorragies ont concerné 40% des AH. Le seul facteur prédictif indépendant en analyse multivariée était la taille radiologique des lésions (p=0.008). Neuf lésions hémorragiques mesuraient moins de 5 cm en histologie. A la lumière de notre étude, nous proposons de discuter la résection chirurgicale des AH dès 3 cm en prenant en compte la simplicité de l éventuelle intervention.This study is retrospective and bi-centric (Grenoble, Lille) about 144 operated patients of a benign liver tumour, based on the pathologic diagnosis. Seventy-seven patients had at least 1 hepatic adenoma (AH group), 67 patients had at least 1 focal nodular hyperplasia (HNF group). Finally, radiologic examination has correctly classed 49 patients on 143 (34 %). Frozen section examinations were done 15 times in laparoscopic group, 38 times in the laparotomy group. Fifty seven patients were operated by laparoscopy (1 major hepatectomy, 19 minor, 20 tumorectomies and 17 biopsies), and 87 by laparotomy (22 major hepatectomies, 42 minor, 16 tumorectomies, 7 biopsies). There were no mortality and morbidity was 43%. Mean follow-up was 15+-19 months in the AH group and 18+-20 months in the HNF group. Immunohistochemistry and molecular biology analysis had permitted to better classify 9 patients (7 HNF to AH group, and 2 telangiectatic HNF in HNF) and to know exactly the sub-type of AH. AH were classified in 5 sub-types (Zucman-Rossi classification): 20 type 1 (HNF1a mutated, LFABP-), 4 type 2 (b-catenine mutated), 38 type 3 (inflammatory AH, SAA+), 8 type 4 (No mutations) and 7 non classified. Hemorrhages have concerned 40% of AH. The only independent factor in multivariate analysis was lesion radiologic size (P=0.008). Nine hemorrhagic lesions measured less than 5 cm on histologic examination. With this study, we propose to discuss surgical resection of AH from 3 cm taking in account the simplicity of the procedure.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Plaies opératoires des voies biliaires à l'ère de la coelioscopie

Les plaies des voies biliaires ont augmenté depuis que la coelioscopie est devenue la technique de référence de la cholécystectomie. A partir d'une étude rétrospective portant sur 30 patients que nous avons pris en charge de janvier 1996 à juillet 2003 dans notre service de chirurgie hépato-biliaire (Professeur Létoublon, Centre Hospitalo-Universitaire de Grenoble), ce travail s'est intéressé aux plaies des voies biliaires survenant au cours de la cholécystectomie coelioscopique. Après quelques rappels sur l'anatomie biliaire normale, ses variations et ses anomalies, nous avons essayé, à partir d'une revue de la littérature, d'analyser les plaies opératoires des voies biliaires à l'ère de la cholécystectomie laparoscopique : leurs différentes classifications, leur fréquence de survenue, leurs mécanismes, leurs facteurs de risque avec en particulier le rôle de la courbe d'apprentissage et l'expérience du chirurgie, l'influence de la cholangiographie peropératoire, les différentes modalités de traitement possible et leurs résultats : l'endoscopie, la radiologie interventionnelle, la chirurgie, les lésions associées de l'artère hépatique droite et leurs conséquences, leur prévention.Bile duct injuries had increased since laparoscopy became the gold standard for cholecystectomy.With a retrospective study from a serial of 30 patients that we had to treat from january 1996 to july 2003 in our hepatobiliary surgery unit (Professeur Letoublon, Grenoble's University Hospital), this work is interested in the bile duct injuries that occur during the laparoscopic cholecystectomy. After some reminds of normal biliary anatomy, its variations and its aberrations, we tried to analyse with an overview of the literature the bile duct injuries in the era of laparoscopic cholecystectomy : their different classifications, their frequency, their mechanisms, their risk factors and in particular, the role of the learning curve and the surgeon's experience, the influence of intraoperative cholangiography, the different modalities of treatment with their results : endoscopy, radiology and surgery., the right hepatic artery associated injuries and their consequences, how to prevent them.GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Computer-aided hepatic tumour ablation : requirements and preliminary results

Surgical resection of hepatic tumours is not always possible, since it depends on different factors, among which their location inside the liver functional segments. Alternative techniques consist in local use of chemical or physical agents to destroy the tumour. Radio frequency and cryosurgical ablations are examples of such alternative techniques that may be performed percutaneously. This requires a precise localisation of the tumour placement during ablation. Computer-assisted surgery tools may be used in conjunction with these new ablation techniques to improve the therapeutic efficiency, whilst they benefit from minimal invasiveness. This paper introduces the principles of a system for computer-assisted hepatic tumour ablation and describes preliminary experiments focusing on data registration evaluation. To keep close to conventional protocols, we consider registration of pre-operative CT or MRI data to intra-operative echographic data

Computer-aided hepatic tumour ablation : requirements and preliminary results

Surgical resection of hepatic tumours is not always possible, since it depends on different factors, among which their location inside the liver functional segments. Alternative techniques consist in local use of chemical or physical agents to destroy the tumour. Radio frequency and cryosurgical ablations are examples of such alternative techniques that may be performed percutaneously. This requires a precise localisation of the tumour placement during ablation. Computer-assisted surgery tools may be used in conjunction with these new ablation techniques to improve the therapeutic efficiency, whilst they benefit from minimal invasiveness. This paper introduces the principles of a system for computer-assisted hepatic tumour ablation and describes preliminary experiments focusing on data registration evaluation. To keep close to conventional protocols, we consider registration of pre-operative CT or MRI data to intra-operative echographic data

Computer-aided hepatic tumour ablation

Surgical resection of hepatic tumours is not always possible. Alternative techniques consist in locally using chemical or physical agents to destroy the tumour and this may be performed percutaneously. It requires a precise localisation of the tumour placement during ablation. Computer-assisted surgery tools may be used in conjunction to these new ablation techniques to improve the therapeutic efficiency whilst benefiting from minimal invasiveness. This communication introduces the principles of a system for computer-assisted hepatic tumour ablation

Place of arterial embolization in severe blunt hepatic trauma: a multidisciplinary approach.

International audienceThis study evaluates the efficacy of arterial embolization (AE) for blunt hepatic traumas (BHT) as part of a combined management strategy based on the hemodynamic status of patients and CT findings. From 2000 to 2005, 84 patients were admitted to our hospital for BHT. Of these, 14 patients who had high-grade injuries (grade III [n = 2], grade IV [n = 9], grade V [n = 3]) underwent AE because of arterial bleeding and were included in the study. They were classified into three groups according to their hemodynamic status: (1) unresponsive shock, (2) shock improved with resuscitation, and (3) hemodynamic stability. Four patients (group 1) underwent, first, laparotomy with packing and, then, AE for persistent bleeding. Ten patients who were hemodynamically stable (group 1) or even unstable (group 2) underwent AE first, based on CT findings. AE was successful in all cases. The mortality rate was 7% (1/14). Only two angiography-related complications (gallbladder infarction) were reported. Liver-related complications (abdominal compartment syndrome and biliary complications) were frequent and often required secondary interventions. Our multidisciplinary approach for the management of BHT gives a main role to embolization, even for hemodynamically unstable patients. In this strategy AE is very efficient and has a low complication rate

Internal biliary stenting in liver transplantation

International audienc