Papillomatose et tumeurs mucineuses des voies biliaires

G. Pittau/ A Sa Cunha10/11 juin 2016Radiofrquence combine la rsectionTechnique des hpatectomies: comment prvenir linsuffisance hpatique post-opratoire et grer le petit foie restant

1

Introduction36000 nouveaux cas/an en France

15-20% des patients demble mtastatiques

Bnfice de la chimiothrapie systmique

Avec les thrapies cibles amlioration de la mdiane de survie jusquau 20 moisCancer colo-rectal Simmonds PC. BMJ 20001 Saltz LB NEnglJMed 2000;Heinemann V, Oncology 2010

2

IntroductionRsection hpatique seul traitement curatif des MHCCR

Survie 5 ans 50% quand combin la chimiothrapieDe Haas. Cancer 2010IsoniemiH,. Scand J Surg 2011Osterlund P,. Br J Cancer 2011

MHCCR

3

Meilleure valuation pre-opratoire de la fonction hpatique

Amlioration de la technique chirurgicale

Amlioration anesthsie per-opratoire

Traitement multidisciplinaireExtension indications Augmentation de la rscabilit

4

Elargissement des critres de rscabilittumeur de grosse taillelsions multipleslsions bilobairesAugmentation de la rscabilit Prvention insuffisance hpatique!

5

Prvention Insuffisance hpatique Hypertrophie foie restantEmbolisation portaleHpatectomie en deux tempsALPPSParenchyma sparing procedureDiffrents stratgies

Adam Ann Surg 2000Azoulay Ann Surg 2000Robles Br J Surg 2014Adam Ann Surg 2010Ducreux JCO 2005

6

Parenchyma sparing hepatectomy

OSRFSL-RFS

2016Parenchyma-sparing hepatectomy pas dimpact sur la survie!

7

Parenchyma sparing hepatectomy

2016

Augmente le taux de rscabilit des rcidives

8

Parenchyma sparing hepatectomy

9

RF + rsection Rsection pas toujours possible

Rf permets le contrle localTout en limitant le sacrifice parenchymateux

10

Parenchyma-sparing hepatectomy

Thermo ablationRF mono-polaireMicroonde

11

Parenchyma-sparing hepatectomy

RF

ncrose coagulative de la tumeur< 3 cm20 minutes

Microonde

Temprature plus leve Temps dexposition inf Absence de dissipation de chaleurlsions proches des vaisseaux

12La sonde est couple un gnrateur qui rgle le courant selon limpdnce dans le tissu

Rsultats de RF one stage vs two stage

2014

OSDFS

13

2014

Rsultats de RF one stage vs two stage

14Over the past decade, improvements in preoperative liver function assessment and multidisciplinary treatments have extended the indications for hepatic resection to includelarger tumours, multiple foci of disease and bilobar disease. These treatments include liver augmentation strategies such as portal vein embolization6,7 and associating liver partition with portal vein ligation for staged hepatectomy8, or tumour burden-reducing strategies such as systemic or hepatic arterial chemotherapy9 and ablative therapies10

Rsultats de Micro-onde one stage vs two stage

2016

P=NSP=NSMicroonde exclusive vs combin

15

2016Rsultats de Micro-onde one stage vs two stage

Mortalit et morbidit rduites et survie comparable aux deux temps

16The present CRA results were compared with datafor TSR reported recently by Tsai et al.19,Wicherts and colleagues18 and Brouquet and co-workers17 (Table 3). Overall, therewas a total of 141 patients in theTSRcohort, of whom 123 eventually completed the second-stage hep- atectomy for bilobar lesions. The

he com-binedmorbidity rate of both procedures in the TSR group was compared with the complication rate for CRA; based on this comparison, the complication rate for the TSR group was significantly higher: 631 per cent (89 of 141) versus 317 per cent (32 of 101) (P