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A Sauvanet

Publications and source records attributed to A Sauvanet.

At least 55 records · Page 3Linked to original sources
PubMed2001

Feasibility and limits of caval-flow preservation during liver transplantation.

As promoters of orthotopic liver transplantation (OLT) with preservation of caval flow, we reviewed our 8-year experience to assess the feasibility and limits of this technique. Preservation of caval flow during OLT, which improves intraoperative hemodynamic stability, was not considered feasible in a significant proportion of transplant recipients. When transient clamping of caval flow is required, causes and consequences of this clamping during all phases of the procedure were not reported. Between 1991 and 1998, a total of 275 OLTs using a whole graft were performed in 259 patients with a policy consisting of a systematic attempt to preserve inferior vena cava (IVC) and caval flow. Preservation of IVC flow was possible in all cases, and no procedure was converted to the conventional technique. Caval flow was maintained throughout the procedure in 246 procedures (90%). Temporary IVC cross-clamping was required in 24 cases during hepatectomy because of difficult dissection and in 5 cases after graft reperfusion because of outflow obstruction; none required the use of a venovenous shunt. IVC cross-clamping during hepatectomy was required more frequently in cases of a large liver, with a mean duration of 11 +/- 4 minutes, but without significant influence on early postoperative risk, including one graft failure (4%) and one postoperative death (4%). Conversely, IVC cross-clamping after reperfusion, with a mean duration of 23 +/- 5 minutes, was associated with four graft failures (80%) and four deaths (80%). We conclude that IVC preservation is feasible in almost all candidates, allowing the use of split livers from cadaveric or living donors independently from their underlying disease. Although preservation of caval flow was possible in the large majority of cases, transient IVC cross-clamping during hepatectomy was well tolerated in contrast to caval clamping after graft reperfusion. Therefore, if necessary, we recommend transient IVC cross-clamping to perform a large cavocaval anastomosis.

Adolescent↗
PubMed2001

Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation.

OBJECTIVE: To compare the incidence of biliary complications after liver transplantation in patients undergoing choledochocholedochostomy reconstruction with or without T tube in a multicenter, prospective, randomized trial. SUMMARY BACKGROUND DATA: Several reports have suggested that biliary anastomosis without a T tube is a safe method of biliary reconstruction that could avoid complications related to the use of T tubes. No large prospective randomized trial has so far been published to compare the two techniques. METHODS: One hundred eighty recipients of orthotopic liver transplantation were randomly assigned to choledochocholedochostomy with (n = 90) or without (n = 90) a T tube in six French liver transplantation centers. All types of biliary complications were taken into account. RESULTS: The overall biliary complication rate was increased in the T-tube group, even though these complications did not lead to an increase in surgical or radiologic therapeutic procedures. The major significant complication was cholangitis in the T-tube group; this did not occur in the other group. The incidence of biliary fistula was 10% in the T-tube group and 2.2% in the group without a T tube. Other biliary complications were similar. The complication rate of cholangiography performed with the T tube was greater than with other types of biliary exploration. The graft and patient survival rates were similar in the two groups. CONCLUSION: This study is the first large prospective, randomized trial of biliary complications with or without a T tube. The authors found an increase in the biliary complication rate in the T-tube group, which was linked to minor complications. The T tube did not provide a safer access to the biliary tree compared with the others types of biliary explorations. The authors recommend the performance of choledochocholedochostomy without a T tube in liver transplantation.

Adolescent↗
PubMed2000

In situ split liver transplantation for two adult recipients.

BACKGROUND: Modifications of the in situ split liver technique are needed for safe transplantation in two adult recipients with a single donor. METHODS: The graft from a brain-dead donor, 187 cm tall and weighing 89 kg, was split in situ with a transection performed along the main portal fissure retaining the middle hepatic vein with the left graft. The right and left grafts, which weighed 985 and 760 g, respectively, were transplanted in two adult recipients weighing 70 and 56 kg, respectively. RESULTS: Both recipients had minor intraoperative blood loss and were discharged from intensive care on day 3. Both grafts were rapidly functional, and the two patients were in excellent condition with normal liver function tests 9 months after surgery. CONCLUSION: In situ split liver transplantation can be performed with the middle hepatic vein retained in the left graft to obtain a sufficient volume of the two grafts suitable for two adult recipients. This modification of the technique could expand the donor pool for adult recipients.

Adult↗
PubMed2000

Intrahepatic hemodynamic changes following portal vein embolization: a prospective Doppler study.

The aim of this study was to describe the intrahepatic hemodynamic modifications induced by right portal vein embolization (RPVE) using Doppler ultrasound. Eighteen patients with hepatocellular carcinoma (n = 8), liver metastases (n = 9), or multiple adenomas, underwent RPVE 1 month before right hepatectomy in order to increase the size of future remnant liver. Doppler ultrasound was performed before and 1 month after RPVE. The portal vein flow and the hepatic artery resistive index in right and left lobes (segments V and III) were calculated. We recorded simultaneously artery and portal vein of segment III to measure the arterioportal ratio calculated as follows: (maximal arterial systolic velocity minus maximal portal vein velocity)/maximal arterial systolic velocity. Results were compared in cirrhotic patients (group A) and in healthy liver patients (group B). In both groups, portal flow was not significantly modified following RPVE. In the left lobe, in both groups the hepatic artery resistive index was not significantly modified. In group B, the arterioportal ratio decreased significantly (0.71 +/- 0.18 and 0.42 +/- 0.23, respectively, before and after embolization; p < 0.01), whereas it was not statistically modified in group A (0.75 +/- 0.17 and 0.69 +/- 0.14, respectively, before and after embolization). The right hepatic arterial resistive index decreased significantly in both groups after embolization (0.74 +/- 0.07 to 0.66 +/- 0.07, p<0.05; and 0.66 +/- 0.07 to 0.61 +/- 0.06, p < 0.05, respectively, before and after RPVE for groups A and B). Total portal flow was unchanged after RPVE (750 +/- 337 ml/mn and 696 +/- 231 ml/mn, respectively, before and after RPVE). The hepatic artery resistive index was unchanged before and after embolization in the left lobe (0.75 +/- 0.13 and 0.74 +/- 0.14, respectively), but significantly decreased in the right lobe (0.7 +/- 0.08 and 0.62 +/- 0.06 respectively, p < 0.05). The left arterioportal ratio decreased significantly from 0.76 +/- 0.17 to 0.52 +/- 0.23 after PVE, p < 0.02). Our study confirms that right portal occlusion induces a decrease in hepatic artery resistive index in the right lobe and does not modify total portal flow. The left and right lobes of the liver have separate arterioportal regulation.

Carcinoma, Hepatocellular↗
PubMed2000

Intrahepatic lithiasis: a Western experience.

Intrahepatic lithiasis (IHL) is a very rare disease in Europe and no gold-standard treatment has yet been codified. The aim of our study is to report our personal experience of IHL detected in 20 patients (6 males [30%] and 14 females [70%]) between January 1982 and December 1991. Eleven (55%) of these cases presented with only IHL, 7 cases (35%) had IHL associated with gallbladder or common bile duct stones, while 2 (10%) were affected by secondary IHL caused by previous biliodigestive anastomosis-induced stricture. The diagnosis was determined by cholangiography in all patients, by ultrasound in 94.7%, and by computed tomography in 70%. The surgical procedures used were as follows: liver resection in 12 patients (60%); various types of biliodigestive anastomosis in 6 cases (30%); choledocholithotomy with a simultaneous removal of stones from the hepatic duct in 2 patients (10%). The intraoperative mortality rate was nil. Complications consisted of 2 subphrenic abscesses, 1 septicemia, and 1 bowel occlusion. Two patients (10%) dropped out of the follow-up, 2 (10%) died 2 years after surgery for reasons not connected with the disease, 1 (5%) died from suppurative cholangitis 6 months after surgery, 2 (10%) had recurrent stones and were treated by extracorporeal lithotripsy and endoscopic stone removal, while the remaining 13 patients (65%) are symptom-free at follow-up which varied between 6 months and 11 years. Liver resection is the treatment of choice when IHL is confined to one lobe of the liver. When IHL affects the entire liver, a resection of the main involved area should be performed whenever possible. Other options include hepatoduodenal anastomosis using the interposed jejunal loop to enable endoscopic or combined treatment of recurrent stones.

Adult↗
PubMed2000

[Treatment of adenocarcinoma of the lower esophagus and cardia: resection with or without thoracotomy?].

STUDY AIM: In the treatment of adenocarcinoma of the cardia and lower oesophagus, the choice of the approach (with or without thoracotomy) to perform a proximal oesogastrectomy (POG) is still debated. The aim of this retrospective study was to compare mortality, morbidity and long-term survival in a series of patients operated on with or without thoracotomy. PATIENTS AND METHOD: From January 1991 to June 1997, 59 patients (mean ages: 65 +/- 10 years, range: 30-83) underwent POG through a transthoracic (n = 31) or a transhiatal approach (n = 28). All patients underwent both coeliac and left gastric lymphadenectomy. A mediastinal subaortic lymphadenectomy was only performed in patients who had a transthoracic approach. Both groups were comparable concerning age, weight and height, and tumoral staging according to preoperative imaging and pathologic examination. The transhiatal group included more high-risk patients (respiratory insufficiency, ASA score = 3) (NS). RESULTS: Resection was palliative in four patients in the transthoracic group and two patients in the transhiatal group. Operative mortality was 9% in the transthoracic group and 0% in the transhiatal group (NS). Pulmonary complications were as frequent with and without thoracotomy (35% versus 32% respectively). Global (curative and palliative resections) 3-year actuarial survival was similar in both groups (transthoracic: 39% versus transhiatal: 46%, NS), as well as survival after curative resection (44% versus 49% respectively, NS). The operative approach did not influence survival in patients N+ (22% versus 17% respectively, NS) and in patients N- (86% versus 77% respectively, NS). CONCLUSION: These results suggest that, for adenocarcinoma of the cardia and lower oesophagus, the theoretical carcinologic benefit of mediastinal lymphadenectomy can be balanced with an higher operative risk related to the transthoracic approach.

Adenocarcinoma↗
PubMed2000

Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.

BACKGROUND: Recent reports highlighting reduced mortality rates to less than 1% after hepatic resections have evaluated the management of selected patients. The current risk of liver resection in unselected patients needs to be more clearly defined to appreciate the actual risk of new indications. STUDY DESIGN: From 1990 to 1997, 747 consecutive patients, including 16 operated in emergency, underwent hepatic resection. Resection was indicated for malignancy in 473 patients (63%). Major resections were performed in 333 patients (45%). An underlying liver disease, including cirrhosis (n = 239) and obstructive jaundice (n = 4), was present in 253 patients (35%). Multivariate analysis of the risk factors for postoperative mortality, morbidity, and transfusion after stratifying patients for the circumstance of the operation and the pathological changes of the remnant liver was performed. RESULTS: There was no intraoperative death and the overall mortality rate was 4.4%. This rate was 25% after emergency liver resection and 3.9% after elective liver resection (p < 0.001). After elective resection, mortality was significantly higher in patients with cirrhosis (8.7%) or obstructive jaundice (21%) than in patients with a normal liver (1%; p < 0.001). Analysis of this subgroup of 478 patients with normal liver showed that the mortality rate was 0% in 220 patients operated for a benign disease and in 263 patients who underwent minor resections. All five deaths occurred in patients with a malignancy and resulted from extrahepatic complications. In patients with a malignancy, the only independent predictor of death was an associated extrahepatic procedure. The incidence of postoperative complications was 22% and was influenced by the American Society of Anaesthesiology (ASA) score, extent of resection, presence of a steatosis, and an associated extrahepatic procedure. The incidence of major complications was 8% and of reoperation 3%. Perioperative blood transfusion was required in 112 of 478 (23%) and was not associated with increased mortality. CONCLUSIONS: The 1% basic risk of elective liver resection on normal liver suggests that indications of resection for malignancy could be extended, unless an associated extrahepatic procedure is needed. Because of this low basic risk, future studies evaluating resection on normal liver should not consider in-hospital mortality as the only end point.

Adolescent↗
PubMed2000

Functional and morphological changes in the pancreatic remnant following pancreaticoduodenectomy with pancreaticogastric anastomosis.

BACKGROUND: The aim was to evaluate pancreatic exocrine and endocrine function, pancreatic atrophy and main pancreatic duct dilatation in the pancreatic remnant following pancreaticoduodenectomy and pancreaticogastrostomy. METHODS: Nineteen patients who underwent pancreaticoduodenectomy and pancreaticogastrostomy for benign or malignant pancreatic tumours with a histologically normal pancreatic resection margin were studied prospectively. The median interval between operation and evaluation was 32 (range 12-120) months. Pancreatic exocrine insufficiency was assessed by measuring 72-h faecal fat concentrations and faecal-1 elastase. Fasting blood glucose, haemoglobin A1c, serum peptide C and insulin levels were used to assess endocrine function. Pancreatic parenchymal thickness and main pancreatic duct diameter were measured before operation and at evaluation using computed tomography (CT). RESULTS: Faecal fat excretion was raised in 16 of 17 patients; faecal-1 elastase was reduced in all 17 patients. None of the 17 non-diabetic patients had developed diabetes mellitus at follow-up. A significant decrease in pancreatic parenchymal thickness and increased dilatation of the main pancreatic duct were observed on CT at evaluation (P = 0.01 and P = 0.01 respectively). Pancreatic atrophy, assessed by subtracting the diameter of the pancreatic duct from the total gland thickness, tended to develop over time, but at the limit of statistical significance (P = 0.06). CONCLUSION: A median of 3 years following pancreaticoduodenectomy and pancreaticogastrostomy, patients remained free from diabetes but developed marked pancreatic exocrine insufficiency. Presented in part to the Societé Nationale Française de Gastroentérologie in Nantes, March 1999, and published in abstract form as Gastroenterol Clin Biol 1999; 23: A81

Adult↗
PubMed2000

Pancreatic involvement in von Hippel-Lindau disease. The Groupe Francophone d'Etude de la Maladie de von Hippel-Lindau.

BACKGROUND & AIMS: Pancreatic involvement in von Hippel-Lindau (VHL) disease, a genetic disorder with a dominant mode of inheritance affecting various organs, has rarely been studied. We assessed the prevalence, type of lesions, natural history, and impact of pancreatic involvement in patients with VHL. METHODS: A total of 158 consecutive patients from 94 families with VHL disease were studied in a prospective French collaborative study. All patients underwent systematic screening for VHL lesions, including computerized tomography (CT) scanning of the pancreas reviewed by an experienced radiologist. Clinical data, investigations, and treatments performed were also reviewed. RESULTS: Pancreatic involvement was observed in 122 patients (77.2%) and included true cysts (91.1%), serous cystadenomas (12.3%), neuroendocrine tumors (12.3%), or combined lesions (11.5%). The pancreas was the only organ affected in 7.6% of patients. Patients with pancreatic lesions had fewer pheochromocytomas than those without (14/122 vs. 16/36; P<0.0001), and patients with neuroendocrine pancreatic tumors had renal involvement less often than those without (8/99 vs. 6/20; P = 0.013). None of the patients with neuroendocrine tumors had symptoms of hormonal hypersecretion. Pancreatic lesions evolved in half of patients but required specific treatment in only 10 (8.2%) when they were symptomatic or for the resection of large neuroendocrine tumors. CONCLUSIONS: Pancreatic involvement is seen in most patients with VHL disease. Although symptoms are rare, specific treatment of pancreatic lesions is required in selected patients, mainly those with neuroendocrine tumors.

Adult↗
PubMed2000

Risk factors for diabetes mellitus in chronic pancreatitis.

BACKGROUND & AIMS: The influence of disease progression and pancreatic surgery on the appearance of diabetes mellitus in patients with chronic pancreatitis is unknown. METHODS: A prospective cohort study of 500 consecutive patients with chronic pancreatitis (alcoholics, 85%) followed up over a mean period of 7.0 +/- 6.8 years in a medical-surgical institution between 1973 and 1996 was performed. Multivariate analysis of risk factors for diabetes mellitus was performed after exclusion of 47 patients. Patients who underwent elective pancreatic surgery (n = 231, 51%) were compared with patients who never underwent surgery (n = 222, 49%). RESULTS: The cumulative rate of diabetes mellitus was 83% +/- 4% 25 years after the clinical onset of chronic pancreatitis (insulin requirement, 54% +/- 6%). The prevalence of diabetes mellitus did not increase in the surgical group overall but was higher 5 years after distal pancreatectomy (57% +/- 8%) than after pancreaticoduodenectomy (36% +/- 18%), pancreatic drainage (36% +/- 13%), or cystic, biliary, or digestive drainage (24% +/- 7%) (P = 0. 005), without difference in the latter ones. Pancreatic drainage did not prevent the onset of diabetes mellitus. Distal pancreatectomy (risk ratio, 2.4; 95% confidence interval [CI], 1.6-3.8; P < 0.0001) and early onset of pancreatic calcifications (risk ratio, 3.2; CI, 2. 2-4.7; P < 0.0001) were the only independent risk factors for diabetes mellitus. CONCLUSIONS: The risk of diabetes mellitus is not influenced by elective pancreatic surgical procedures other than distal pancreatectomy in patients with chronic pancreatitis. This risk seems to be largely caused by progression of the disease because it increased by more than 3-fold after the onset of pancreatic calcifications.

Adult↗
PubMed2000

Intraductal papillary mucinous tumors of the pancreas: pancreatic resections guided by preoperative morphological assessment and intraoperative frozen section examination.

BACKGROUND: We undertook this study to assess the results of a policy of limited pancreatic resections for intraductal papillary-mucinous tumors (IPMT), guided by a standardized preoperative morphological assessment and the frozen section histologic examination of pancreatic resection margins. METHODS: From 1991 to 1998, there were 41 patients who underwent resection of IPMT in our center after standardized morphological preoperative assessment, including abdominal computed tomography scans, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. All patients but one underwent a partial pancreatic resection. RESULTS: Preoperative assessment had an 89% diagnostic accuracy for IPMT. It detected malignant transformation with a 67% sensitivity and a 95% specificity, but failed to correctly assess ductal extension of the disease in 17 cases (41%). The diagnostic accuracy of frozen section histologic examination of the pancreatic resection margin was 92%. There was no recurrence in case of in situ carcinoma when epithelial lesions were completely resected (8 cases) nor in lower grades of dysplasia (23 cases). Conversely, recurrence was constant in invasive carcinoma (10 cases) regardless of the status of the pancreatic margin. CONCLUSIONS: Frozen section histologic examination of the pancreatic resection margin is useful and reliable to ensure a complete resection of IPMT by a partial resection that prevents recurrence of noninvasive lesions.

Adenocarcinoma, Mucinous↗
PubMed2000

Intraductal papillary mucinous tumors of the pancreas confined to secondary ducts show less aggressive pathologic features as compared with those involving the main pancreatic duct.

Intraductal papillary mucinous tumors (IPMTs) of the pancreas are rare tumors characterized by a malignant potential. Because of the progress of imaging procedures, smaller cystic pancreatic lesions are now detected and some of them correspond to IPMTs that involve ectatic pancreatic branch ducts but spare the main pancreatic duct. To investigate differences in morphology and clinical behavior of branch and main duct types of IPMT, a surgical series of 43 cases was studied. All pathologic specimens of IPMT, surgically resected in our institution between October 1987 and July 1998, were analyzed. In all cases, the entire pancreatic specimen was systematically examined. IPMT of the branch type was found in 13 (30%) patients, whereas IPMT of main pancreatic duct type that involved the main pancreatic duct and branch ducts was observed in 30 (70%) patients. Patients with IPMT of the branch type were younger (median age, 55 yrs vs 64 yrs), and all but one of the lesions were located in the head and neck of the pancreas (vs 17 of 30 patients with the main duct type). The size of the cysts ranged from 4 to 55 mm, and the major duct showed a mild dilation in most cases. In contrast to the main pancreatic duct type, which showed invasive carcinoma and in situ carcinoma in 11 (37%) of 30 patients and 6 (20%) of 30 patients, respectively, IPMT of the branch type showed significantly less aggressive histologic lesions with five (39%) patients with simple hyperplasia, six (46%) patients with atypical hyperplasia, and two (15%) patients with in situ carcinoma. No invasive carcinoma was observed in this group. IPMT of the branch type occurs in younger patients and is associated with less aggressive histologic features than is the main pancreatic duct type. Our findings raise the difficult issue of clinical management of IPMT of the branch type as a distinctive group.

Adult↗
PubMed2000

Intraductal papillary mucinous tumors of the pancreas: helical CT with histopathologic correlation.

PURPOSE: To evaluate the accuracy of preoperative computed tomography (CT) in predicting the location and type of ductal involvement and malignant transformation in intraductal papillary mucinous (IPM) pancreatic tumors and to determine the predictive factors for malignancy at CT. MATERIALS AND METHODS: The helical CT scans obtained in 36 operated on patients with a diagnosis of IPM pancreatic tumor were retrospectively assessed. CT-histopathologic correlation was then performed. RESULTS: The final diagnoses of IPM tumor were combined type (n = 26) and branch duct type (n = 10) lesions. Histologic analysis revealed adenocarcinoma (n = 9), hyperplasia (n = 8), low-grade dysplasia (n = 12), and high-grade dysplasia (n = 7). The lesions were located mainly in the head or uncinate process (n = 20) or were diffuse or multifocal (n = 12). In 12 patients (13 cases), CT-histopathologic correlation was poor, including that in the evaluation of ductal involvement (n = 7), evaluation of lesion location (n = 2), and diagnosis of malignant transformation (n = 4). The most specific predictive signs of malignancy were presence of diabetes and, at CT, a solid mass, main pancreatic duct dilatation greater than 10 mm, diffuse or multifocal involvement, and attenuating or calcified intraluminal content. CONCLUSION: The main causes of poor CT-histopathologic correlation were related to evaluation of main pancreatic duct involvement and diagnosis of malignant transformation. The association between diabetes and specific CT criteria was highly suggestive of malignancy.

Adenocarcinoma, Mucinous↗