Ntourakis, Dimitris

2013-11-13, Cantù, Massimiliano, Piardi, Tullio, Sommacale, Daniele, Ellero, Bernard, Woehl-Jaeglè, Marie Lorraine, Audet, Maxime, Ntourakis, Dimitris, Wolf, Phillippe, Pessaux, Patrick

Background: Preoperative locoregional treatments (PLT) are performed to avoid progression before liver transplantation for hepatocellular carcinoma (HCC). The objective of this study was to analyze the prognostic factors affecting the outcome in patients who received PLT. Material/Methods: A retrospective analysis of patients who underwent liver transplantation (LT) was performed. All patients who underwent PLT with confirmed pathological diagnosis of HCC were included. The rate of tumor necrosis (TN) was assessed by microscopic histological examination. Results: From January 1997 to December 2010, PLT was performed in 154 patients ROC analysis individuated a TN cut-off value at 40%. Ninety-one patients (59.1%) of the patients presented TN>40%. At multivariate analysis, TN<40% (HR=1.76; p=0.04) and vascular invasion (VI) (HR=2.16; p<0.01) were associated with lower Overall Survival (OS). At multivariate analysis, TN<40% (HR=1.59; p=0.001) and VI (HR=2.51; p=0.001) were significant associated with lower Disease Free Survival (DFS). One, 3 and 5 years OS was 87.9%, 82.0% and 69.1% for patients with TN>40% and 82.5%, 64.2% and 53.2% for those with TN<40% (p=0.02). Tumour size <5 cm (p=0.02); age <55 years (p=0.02); absence of VI (p=0.02) and multiple procedures (p=0.04) were predictive factors for TN>40%. Conclusions: Response to preoperative locoregional treatment can be used as potential selection criteria for LT.

2016-12-01, Hallet, Julie, Sa Cunha, Antonio, Ádám, René A., Goéré, Diane, Azoulay, Daniel, Mabrut, Jean Yves, Muscari, Fabrice, Laurent, Christophe, Navarro, Françis, Pessaux, Patrick, Cossé, Cyril, Lignier, Delphine, Régimbeau, Jean Marc, Barbieux, Julien P., Lermite, Émilie, Hamy, Antoine P., Mauvais, François, Laurent, Christophe, Al Naasan, Irchid, Laurent, Alexis, Azoulay, Daniel, Compagnon, Philippe, Lim, Chetana, Mohammed, Sbai Idrissi, Martin, Frédéric, Atger, Jérôme, Mohammed, Sbai Idrissi, Martin, Frédéric, Baulieux, Jacques, Darnis, Benjamin, Mabrut, Jean Yves, Kepenekian, V., Périnel, Julie, Adham, Mustapha, Gléhen, Olivier J., Rivoire, Michel L., Hardwigsen, Jean, Palen, Anaïs, Grégoire, Émilie, LeTreut, Yves Patrice, Delpéro, Jean Robert, Turrini, Olivier, Herrero, Astrid, Navarro, Françis, Panaro, Fabrizio, Ayav, Ahmet, Bresler, L., Rauch, P., Guillemin, F., Marchal, F., Gugenheim, J., Iannelli, A., Bicêtre, K., Benoist, S., Brouquet, A., Pocard, M., Lo Dico, R., Gayet, Brice, Fuks, D., Pessaux, Patrick, Mutter, Didier, Marescaux, Jacques F., Raoux, L., Suc, B., Muscari, Fabrice, Elhomsy, G., Gelli, M., Sa Cunha, Antonio, Castaing, D., Cherqui, Daniel, Scatton, O., Vaillant, J.-C., Piardi, Tullio, Sommacale, Daniele, Kianmanesh, R., Comy, M., Bachellier, Philippe, Oussoultzoglou, Elíe, Addeo, Pietro F., Ntourakis, Dimitris, Pittau, G., Ciacio, O., Vibert, E., Elias, D., Goéré, Diane, Vittadello, F.

Background: Recurrence remains frequent after curative-intent hepatectomy for colorectal liver metastases (CRLM). We sought to define short- and long-term outcomes, and identify prehepatectomy factors associated with survival, following rehepatectomy (RH) for recurrence. Methods: We conducted a multi-institutional cohort study of hepatectomy for CRLM over 2006–2013. Second-stage resections were excluded. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS) assessed using Kaplan–Meier methods. Secondary outcomes included 30-day overall morbidity and mortality, and survival from recurrence. Outcomes of RH and initial hepatectomy (IH) were compared. Results: Of 2771 hepatectomies included in the study, 447 were RH. Median operative time, 30-day morbidity, mortality, and median length of stay did not differ for RH and IH. Five-year OS did not statistically differ, i.e. 56.5 % from RH and 67.6 % from IH [adjusted hazard ratio (HR) 0.9, 95 % confidence interval (CI) 0.5–1.7], and 5-year RFS was inferior after RH (18.5 vs. 28.8 %; adjusted HR 1.3, 95 % CI 1.0–1.7). In patients who eventually recurred, 5-year survival from the time of recurrence did not differ whether it was after RH (46.5 %) or after IH (60.3 %) (adjusted HR 1.1, 95 % CI 0.8–1.8). Rectal primary tumor (HR 1.4, 95 % CI 1.0–2.1) and metastasis ≥3 cm (HR 1.3, 95 % CI 1.1–2.7) were independently associated with RFS, but not OS, after RH. Conclusion: Short-term outcomes of RH did not differ from IH. While recurrence was more frequent after RH than IH, it did not impact OS. Survival from the time of recurrence did not differ whether recurrence occurred after RH or after IH. CRLM recurrence can be treated with curative intent with excellent long-term outcomes.

2016-02-01, Ntourakis, Dimitris, Méméo, Riccardo, Soler, Luc, Marescaux, Jacques F., Mutter, Didier, Pessaux, Patrick

Background: Modern chemotherapy achieves the shrinking of colorectal cancer liver metastases (CRLM) to such extent that they may disappear from radiological imaging. Disappearing CRLM rarely represents a complete pathological remission and have an important risk of recurrence. Augmented reality (AR) consists in the fusion of real-time patient images with a computer-generated 3D virtual patient model created from pre-operative medical imaging. The aim of this prospective pilot study is to investigate the potential of AR navigation as a tool to help locate and surgically resect missing CRLM. Methods: A 3D virtual anatomical model was created from thoracoabdominal CT-scans using customary software (VR RENDER®, IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM®, Karl Storz, Tüttlingen, Germany). Virtual and real images were manually registered in real-time using a video mixer, based on external anatomical landmarks with an estimated accuracy of 5 mm. This modality was tested in three patients, with four missing CRLM that had sizes from 12 to 24 mm, undergoing laparotomy after receiving pre-operative oxaliplatin-based chemotherapy. Results: AR display and fine registration was performed within 6 min. AR helped detect all four missing CRLM, and guided their resection. In all cases the planned security margin of 1 cm was clear and resections were confirmed to be R0 by pathology. There was no postoperative major morbidity or mortality. No local recurrence occurred in the follow-up period of 6-22 months. Conclusions: This initial experience suggests that AR may be a helpful navigation tool for the resection of missing CRLM.

2012-06-01, Piardi, Tullio, Gheza, Federico, Ellero, Bernard, Woehl-Jaeglè, Marie Lorraine, Ntourakis, Dimitris, Cantù, Massimiliano, Marzano, Ettore, Audet, Maxime, Wolf, Phillippe, Pessaux, Patrick

Background. Hepatocellular carcinoma (HCC) is an indication for liver resection or transplantation (LT). In most centers, patients whose HCC meets the Milan criteria are considered for LT. The first objective of this study was to analyze whether there is a correlation between the pathologic characteristics of the tumor, survival and recurrence rate. Second, we focused our attention on vascular invasion (VI). Methods. From January 1997 to December 2007, a total of 196 patients who had a preoperative diagnosis of HCC were included. The selection criteria for LT satisfied both the Milan and the San Francisco criteria (UCSF). Demographic, clinical, and pathologic information were recorded. Results. HCC was confirmed in 168 patients (85.7%). The median follow-up was 74 months. The pathologic findings showed that 106 patients (54.1%) satisfied the Milan criteria, 134 (68.4%) the UCSF criteria of whom 28 (14.3%) were beyond the Milan criteria but within the UCSF criteria, and 34 (17.3%) beyond the UCSF criteria. VI was detected in 41 patients (24%). The 1-, 3-, and 5-year overall survival rates were 90%, 85%, and 77%, respectively, according to the Milan criteria and 90%, 83%, and 76%, respectively, according to the UCSF criteria (P = NS). In univariate and multivariate analyses, tumor size and VI were significant prognostic factors affecting survival (P<0.001). Two factors were significantly associated with VI: alfa-fetoprotein level of >400 ng/ml and tumor grade G3. Conclusions. Tumor size and VI were the only significant prognostic factors affecting survival of HCC patients. Primary liver resection could be a potential selection treatment before LT

2013-11-01, Pessaux, Patrick, Van Den Broek, Maartje A.J., Wu, Tao, Damink, Steven W.M.Olde, Piardi, Tullio, Dejong, Cornelis H.C., Ntourakis, Dimitris, Van Dam, Ronald M.

Summary: Postoperative infectious complications (PICs) are associated with significant morbidity after abdominal surgery. Using multivariate analysis of data from a prospective database, our study focused on the risk factors for PICs and the prevention of these complications after hepatectomy, with the goal of improving outcomes and reducing the length of hospital stays. Background: PICs following surgery are associated with significant morbidity, increase the length of hospital stays, and have a negative impact on long-term oncological outcome. The aim of this study was to determine the risk factors for PICs following partial hepatectomy and to validate these results with an external database. Methods: Between January 2006 and December 2009, 555 patients underwent elective partial hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PICs, defined as development of one or more of the following conditions: pneumonia, sepsis, Central line-associated bloodstream infection, urinary tract infection, wound infection, and infected intra-abdominal fluid collection. PICs were devised in medical (PIMCs) and surgical (PISCs) complications. The incidence of PICs and validation of the predictive score were determined using an external prospective database of 342 patients. Results: The multivariate analysis identified three independent risk factors for PICs: the presence of a nasogastric tube (OR = 1.8), blood transfusion (OR = 1.9), and diabetes (OR = 2.4). The multivariate analysis identified only one independent risk factor for PISCs: an associated portal venous resection (OR = 5.5). The multivariate analysis identified four independent risk factors for PIMCs: presence of a biliary drainage (OR = 1.9), blood transfusion (OR = 2.1), diabetes (OR = 2.9), and presence of atrial fibrillation (OR = 3.6). According to the three predictive factors, the observed rates of PICs ranged from 18.8 % to 77.8 % and ranged from 24.2 % to 100 % in the external database. Predicted and observed risks of PICs were not statistically different. Conclusions: The correction of modifiable risk factors among the identified factors could reduce the incidence of PICs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

2011-12-01, Ferreira, Nélio, Oussoultzoglou, Elíe, Fuchshuber, Pascal R., Ntourakis, Dimitris, Narita, Masato, Rather, Mudassir, Rosso, Edoardo, Addeo, Pietro F., Pessaux, Patrick, Jaeck, Daniel, Bachellier, Philippe

Hypothesis: A splenic vein (SV)-inferior mesenteric vein (IMV) anastomosis reduces congestion of the stomach and spleen after pancreaticoduodenectomy with resection of the SV-mesenteric vein confluence but carries a risk of left-sided venous hypertension. Design: Comparative retrospective study. Setting: Department of Digestive Surgery and Transplantation, University of Strasbourg, Strasbourg, France. Patients: FromJanuary 1, 2002, to February 28, 2010, 39 patients underwent pancreaticoduodenectomy with resection of the SV-mesenteric vein confluence for pancreatic adenocarcinoma. All patients had a terminoterminal portalvein- superiormesentericveinanastomosis.TheSVblood flow into the portal vein was preserved in 11 patients by reimplantation of theSVinto the portal vein. Sixteen patients underwent surgical reconstruction of the SV-IMV confluence by anastomosis (group 1), and in 12 patients the natural SV-IMV confluence was preserved (group 2). Main Outcome Measures: Preoperative and postoperative spleen volume and platelet count. Results: Demographic characteristics, preoperative tumor staging, pathological outcome, and postoperative complications were comparable in both groups. There was no difference in platelet count between groups 1 and 2 preoperatively (mean [SD], 293.13 [125.37] vs 241.09 [49.12]×10 3/μL [to convert to ×10 9/L, multiply by 1.0], respectively; P=.21) or postoperatively (mean [SD], 231.75 [156.39] vs 164.31 [76.46]×10 3/μL, respectively; P=.32). Likewise, no difference was found in the spleen volume preoperatively (mean [SD], 258.96 [179.23] vs 237.31 [122.46] mL, respectively; P=.76) and on postoperative day 15 (mean [SD], 279.08 [158.10] vs 299.12 [153.11] mL, respectively; P=.78). Conclusion: Early assessment shows that SV-IMV anastomosis is as feasible and as safe as the preservation of a natural SV-IMV confluence in patients undergoing pancreaticoduodenectomy with vascular resection for pancreatic head adenocarcinoma.

2011-03-01, Ntourakis, Dimitris, Marzano, Ettore, De Blasi, Vito, Oussoultzoglou, Elíe, Jaeck, Daniel, Pessaux, Patrick

Solid pseudopapillary pancreatic tumors of pancreas are a rare entity, seen most often in females in their second or third decades. Although previously believed to be benign, this tumor is currently considered a low-grade malignant epithelial neoplasm with low metastatic rate and high overall survival.1,2 Its resection could be performed by robotic technique with respect to oncological principles to avoid tumor cell dissemination.3 In this multimedia article, we present a 28-year-old female with a history of hyperthyroidism who underwent a computed tomography (CT) scan because of a persistent high C-reactive protein level following caesarean section. This CT scan revealed a 7-cm cystic lesion of the pancreatic tail. The serum tumor marker CA 19-9 was normal. Further investigation with an magnetic resonance imaging (MRI) scan showed that the lesion was macrocystic with internal septas compatible with a solid pseudopapillary neoplasm.4 The patient was treated with robotic distal splenopanceatectomy (video). The operative time was 5 h with an estimated blood loss of 250 mL. No blood transfusion was necessary. The postoperative period was uneventful, and she was discharged on postoperative day 8. The histological finding revealed a solid pseudopapillary tumor of the pancreas pT2pN0 (0/14 lymph nodes removed). There was no evidence of clinical, biological, and radiological pancreatic fistula, and a control CT scan on postoperative day 8 did not show any abdominal fluid collection. The patient's 1 month follow-up was normal. The robotic distal splenopancreatectomy is a procedure that offers some technical and oncological advantages over the already described minimally invasive techniques for distal pancreatic tumors.5,6 These advantages are mainly due to the stability of the operative field, to the 3D and magnified vision, and to the articulated robotic arms.7-9 The 3D representation and the stability of the operative field facilitate the performance of operative steps, as the creation of the retropancreatic tunnel and vascular identification. Moreover, the robotic articulated arms permit a superior handling of vascular structures, allowing a fine dissection that is extremely useful during lymphadenectomy. Articulated instruments easily achieve the correct rotation axis, thus minimizing peri-pancreatic tissue retraction and manipulation of the pancreatic gland. This smooth and no-touch technique in theory minimizes the risk of pancreatic capsule rupture as well as tumor cell dissemination, respecting oncological surgical standards. However, robotic surgery needs an adequate learning curve, especially concerning the installation and the lack of force feedback. The robotic distal pancreatectomy is a possible minimally invasive technique for patients with solid pseudopapillary pancreatic tumors. It presents some advantages over the laparoscopic approach. Nevertheless its oncological indications are yet to be defined.10.

2011-03-01, Marzano, Ettore, Ntourakis, Dimitris, Addeo, Pietro F., Oussoultzoglou, Elíe, Jaeck, Daniel, Pessaux, Patrick

Background: Duodenal sporadic adenomatous polyps are rare findings during upper endoscopy. Resection is indicated due to their malignant potential. +Methods: A 55 year-old male patient was diagnosed with a 3 cm duodenal adenomatous polyp with low-grade dysplasia, which could not be safely resected by endoscopy. A transduodenal submucosal robotic-assisted polypectomy was performed. +Results: The operative time was 4.5 h, with an estimated blood loss of 200 ml. The patient had a normal bowel transit on postoperative day 3 and he was discharged on postoperative day 7. Three months follow-up was uneventful. The final histological finding revealed a completely resected duodenal adenomatous polyp without signs of malignancy. +Conclusion: Robotic-assisted resection of duodenal polyps is a feasible technique that may be indicated for the local excision of duodenal lesions that cannot be endoscopically resected. Compared to the open and laparoscopic approach, it offers many technical advantages.

2018-12-01, Esposito, Francesco, Lim, Chetana, Sa Cunha, Antonio, Pessaux, Patrick, Navarro, Françis, Azoulay, Daniel, Cossé, Cyril, Lignier, Delphine, Régimbeau, Jean Marc, Barbieux, Julien P., Lermite, Émilie, Hamy, Antoine P., Mauvais, François, Laurent, Christophe, Naasan, Irchid Al, Azoulay, Daniel, Salloum, Chady, Compagnon, Philippe, Idrissi, Mohammed Sbai, Martin, Frédéric, Atger, Jérôme, Baulieux, Jacques, Darnis, Benjamin, Mabrut, Jean Yves, Képénékian, Vahan, Périnel, Julie, Adham, Mustapha, Gléhen, Olivier J., Rivoire, Michel L., Hardwigsen, Jean, Palen, Anaïs, Grégoire, Émilie, LeTreut, Yves Patrice, Delpéro, Jean Robert, Turrini, Olivier, Herrero, Astrid, Panaro, Fabrizio, Ayav, Ahmet, Bresler, Laurent, Rauch, P., Guillemin, F., Marchal, F., Gugenheim, J., Iannelli, A., Benoist, S., Brouquet, A., Pocard, M., Dico, R.L., Gayet, Brice, Fuks, D., Scatton, O., Soubrane, O., Vaillant, J.-C., Piardi, Tullio, Sommacale, Daniele, Kianmanesh, R., Comy, M., Bachellier, Philippe, Oussoultzoglou, Elíe, Addeo, Pietro F., Ntourakis, Dimitris, Mutter, Didier, Marescaux, Jacques F., Raoux, L., Suc, B., Muscari, Fabrice, Elhomsy, G., Gelli, M., Cunha, A.S., Ádám, René A., Castaing, D., Cherqui, Daniel, Pittau, G., Ciacio, O., Vibert, E., Elias, D., Goéré, Diane, Vittadello, F., On behalf of the French Colorectal Liver Metastases Working Group, Association Francaise de Chirurgie (AFC)

Objectives: Multicenter studies comparing the reverse strategy (RS) with the classical strategy (CS) for the management of stage IVA liver-only colorectal cancer (CCR) are scarce. The aim of this study was to compare long-term survival and recurrence patterns following use of the CS and RS. Method: This retrospective multicenter review collected data from all consecutive patients with stage IVA liver-only CCR who underwent staged resection of CCR and liver metastases (LM) at 24 French hospitals between 2006 and 2013 and were retrospectively analyzed. Patients who underwent simultaneous liver and CCR resection, those with synchronous extrahepatic metastasis, and those who underwent emergent CCR resection were excluded. Overall survival (OS) and recurrence-free survival (RFS) rates and recurrence patterns were investigated before and after propensity score matching (PSM). Results: A total of 653 patients were included: 587 (89.9%) in the CS group and 66 (10.1%) in the RS group. Compared with the CS patients, RS patients were more likely to have rectal cancer (43.9 vs. 24.9%; p = 0.006), larger liver tumor size (52.5 ± 38.6 vs. 39.6 ± 30 mm; p = 0.01), and more positive lymph nodes (62.1 vs. 44.8%; p = 0.009). OS was not different between the two groups (75 vs. 72% at 5 years; p = 0.77), while RFS was worse in the RS group (24 vs. 33% at 5 years; p = 0.01). Time to recurrence at any site (1.8 vs. 2.4 years, p = 0.024) and intrahepatic recurrence (1.7 vs. 2.2 years, p = 0.014) were significantly shorter in the RS group than in the CS group. After PSM (63 patients in each group), no significant difference was found between the two groups in OS (p = 0.35), RFS (p = 0.62), time to recurrence at any site (p = 0.19), or intrahepatic recurrence (p = 0.13). Conclusions: In this study, approximately 10% of patients with CCR and synchronous LM were offered surgery with the RS. Both strategies ensured similar oncological outcomes.

2017-12-01, Hallet, Julie, Sa Cunha, Antonio, Cherqui, Daniel, Gayet, Brice, Goéré, Diane, Bachellier, Philippe, Laurent, Alexis, Fuks, David, Navarro, Françis, Pessaux, Patrick, Lignier, Delphine, Régimbeau, Jean Marc, Barbieux, Julien P., Lermite, Émilie, Hamy, Antoine P., Mauvais, François, Laurent, Christophe, Naasan, Irchid Al, Laurent, Alexis, Azoulay, Daniel, Compagnon, Philippe, Lim, Chetana, Idrissi, Mohammed Sbai, Martin, Frédéric, Atger, Jérôme, Baulieux, Jacques, Darnis, Benjamin, Mabrut, Jean Yves, Kepenekian, V., Périnel, Julie, Adham, Mustapha, Gléhen, Olivier J., Rivoire, Michel L., Hardwigsen, Jean, Palen, Anaïs, Grégoire, Émilie, LeTreut, Yves Patrice, Delpéro, Jean Robert, Turrini, Olivier, Herrero, Astrid, Navarro, Françis, Panaro, Fabrizio, Ayav, Ahmet, Bresler, Laurent, Rauch, P., Guillemin, F., Marchal, F., Gugenheim, J., Iannelli, A., Benoist, S., Brouquet, A., Pocard, M., Dico, R.L., Gayet, Brice, Fuks, D., Scatton, O., Soubrane, O., Vaillant, J.-C., Piardi, Tullio, Sommacale, Daniele, Kianmanesh, R., Roche-sur-Yon, L., Comy, M., Bachellier, Philippe, Oussoultzoglou, Elíe, Addeo, Pietro F., Ntourakis, Dimitris, Pessaux, Patrick, Mutter, Didier, Marescaux, Jacques F., Raoux, L., Suc, B., Muscari, Fabrice, Elhomsy, G., Gelli, M., Cunha, A.S., Ádám, René A., Castaing, D., Cherqui, Daniel, Pittau, G., Ciacio, O., Vibert, E., Elias, D., Goéré, Diane, Vittadello, F.

Introduction: While uptake of laparoscopic hepatectomy has improved, evidence on laparoscopic re-hepatectomy (LRH) for colorectal liver metastases (CRLMs) is limited and has never been compared to the open approach. We sought to define outcomes of LRH compared to open re-hepatectomy (ORH). Methods: Patients undergoing re-hepatectomy for CRLM at 39 institutions (2006–2013) were identified. Primary outcomes were 30-day post-operative overall morbidity, mortality, and length of stay. Secondary outcomes were recurrence and survival at latest follow-up. LRHs were matched to ORHs (1:3) using a propensity score created by comparing pre-operative clinicopathologic factors (number and size of liver metastases and major hepatectomy). Results: Of 376 re-hepatectomies included, 27 were LRH, including 1 (3.7%) conversion. The propensity-matched cohort included 108 patients. Neither median operative time (252 vs. 230 min; p = 0.82) nor overall 30-day morbidity (48.1 vs. 38.3%; p = 0.37) differed. Non-specific morbidity (including cardiac, respiratory, infectious, and renal events) decreased with LRH (11.1 vs. 30.9%, p = 0.04), while surgical-specific morbidity, including liver insufficiency, was higher (44.4 vs. 22.2%, p = 0.03). One ORH and 0 LRH suffered 30-day mortality. Median length of stay (9 vs. 12 days; p = 0.60) was comparable. At latest follow-up, 26 (96.3%) LRH and 67 (82.7%) ORH patients were alive. Eight (29.6%) LRH and 36 (44.4%) ORH patients were alive without disease. Conclusion: LRH for recurrent CRLM was associated with overall short-term outcomes comparable to ORH, but different morbidity profiles. While it may offer a safe and feasible approach, further insight is necessary to better define patient selection.