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Houssaini K, Lahnaoui O, Souadka A, Majbar MA, Ghanam A, El Ahmadi B, Belkhadir Z, Amrani L, Mohsine R, Benkabbou A.

Background: The aggregate root cause analysis (AggRCA) was designed to improve the understanding of system vulnerabilities contributing to patient harm, including surgical complications. It remains poorly used due to methodological complexity and resource limitations. This study aimed to identify the main patterns contributing to severe complications after liver resection using an AggRCA.

Methods: This was a retrospective qualitative study aimed to identify the main patterns contributing to severe complications, defined as strictly higher than grade IIIa according to the Clavien-Dindo classification within the first 90 days after liver resection. All consecutive severe complications that occurred between January 1st, 2018 and December 31st, 2019 were identified from an electronic database and included in an AggRCA. This included a structured morbidity and mortality review (MMR) reporting tool based on 50 contributory factors adapted from 6 ALARM categories: « Patient », « Tasks », « Individual staff », « Team », « Work environment », and « Management and Institutional context ». Data resulting from individual-participant root cause analysis (RCA) of single-cases were validated collectively then aggregated. The main patterns were suggested from the contributory factors reported in more than half of the cases.

Results: In 105 consecutive liver resection cases, 15 patients (14.3%) developed severe postoperative complications, including 5 (4.8%) who died. AggRCA resulted in the identification of 36 contributory factors. Eight contributory factors were reported in more than half of the cases and were compiled in three entangled patterns: (1) Disrupted perioperative process, (2) Unplanned intraoperative change, (3) Ineffective communication.

Conclusion: A pragmatic aggregated RCA process improved our understanding of system vulnerabilities based on the analysis of a limited number of events and a reasonable resource intensity. The identification of patterns contributing to severe complications lay the rationale of future contextualized safety interventions beyond the scope of liver resections.

Dig Surg. 2011;28(2):114-20. doi: 10.1159/000323819. Epub 2011 Apr 29.

Gaujoux S(1), Goéré D, Dumont F, Souadka A, Dromain C, Ducreux M, Elias D.

Department of Surgical Oncology, Institute Gustave Roussy, Villejuif, France.

Missing metastases, also called vanishing or disappearing liver metastases, concern about 5% of patients with colorectal liver metastasis undergoing chemotherapy, and this phenomenon is likely to become more frequent in the near future, with the widespread use of highly efficient chemotherapy. As their definition is highly dependent on the quality of initial imaging, a DLM on preoperative computed tomography scan should be systematically confirmed by a second imaging modality, ideally magnetic resonance imaging. It is important to note that a complete clinical response does not mean a complete pathologic response. Currently, there are no absolute criteria of a complete pathologic response. However, treatment with neoadjuvant and adjuvant hepatic arterial infusion in patients <60 years old with an initially low carcinoembryonic antigen level that normalizes under chemotherapy and who have no detectable lesion on both computed tomography and magnetic resonance imaging is probably more likely to yield a complete pathologic response. Whatever their treatment, patients with  DLM run a high risk of recurrence that could be decreased with the use of HAI. Despite a high recurrence rate, the overall 5-year survival rate of patients with DLM ranges from 40 to 80%. Having a DLM should no longer be a contraindication to hepatic surgery since long-term survival is expected in these highly chemosensitive patients. The use of adjuvant HAI in addition to efficient systemic chemotherapy could reduce the risk of hepatic relapse.

DOI: 10.1159/000323820

PMID: 21540596  [Indexed for MEDLINE]

Ann Surg. 2011 Jul;254(1):114-8. doi: 10.1097/SLA.0b013e31821ad704.

Goèré D(1), Gaujoux S, Deschamp F, Dumont F, Souadka A, Dromain C, Ducreux M, Elias D.

(1)Department of Surgical Oncology, Institut Gustave Roussy, Villejuif, Cedex, France. 

BACKGROUND: After chemotherapy, complete clinical responses of colorectal liver metastases (CRLMs) increasingly occur, but these responses are rarely complete pathological responses. The management of patients with missing metastases, that  is, CRLMs that disappear under chemotherapy are undetectable intraoperatively and finally left in place, continues to be controversial. The aim of this study was to assess the long-term outcome of patients with « missing CRLMs. »

PATIENTS: Between 1999 and 2007, among 523 patients operated on for CRLMs, 96 missing CRLMs were observed and left in place in 27 originally unresectable patients. All of these patients received preoperative chemotherapy. Hepatic arterial infusion (HAI) of oxaliplatin combined with systemic 5-fluorouracil was  administered in 23 patients, including 12 before hepatectomy and 11 after. Hepatic surgery was performed after a minimal interval of 3 months during which CRLMs had disappeared on imaging.

RESULTS: After a median follow-up of 55 months (24-137) after hepatic surgery, an intrahepatic recurrence was diagnosed in 14 (52%) patients, but the recurrence rate was significantly lower in patients who had received adjuvant HAI compared with the others (27% vs 83%, P = 0.006). Recurrences arose at the site of the missing CRLMs in 9 (33%) patients, but was associated in all cases with another recurrence in the liver. The 5-year overall survival rate of these 27 highly chemosensitive patients was 80%, and the 5-year disease-free survival rate was 23%.

CONCLUSION: Highly chemosensitive patients, whose initially unresectable CRLMs become resectable because of missing CRLMs left in place, have a favorable long-term outcome. Missing CRLMs should not be longer, a contraindication to hepatic surgery. Use of postoperative HAI of oxaliplatin can help to reduce the risk of hepatic relapse.

DOI: 10.1097/SLA.0b013e31821ad704

PMID: 21516034  [Indexed for MEDLINE]

Rafi H(1), Kabbaj N, Salihoun M, Amrani L, Acharki M, Guedira M, Nya M, Amrani N.


Author information:

(1)EFD-Hepatogastroenterology Unit, Ibn Sina Hospital, UM5S, Rabat, Morocco.

BACKGROUND AND STUDY AIMS: Hepatic steatosis seems to be frequently found histopathologically in chronic hepatitis C virus (HCV)-infected patients. The aim of this study is to determine the influence of steatosis on HCV disease severity  (fibrosis) and to evaluate its impact on sustained virological response (SVR) to  antiviral therapy.

PATIENTS AND METHODS: From April 2008 to April 2010, 148 consecutive adults (87 females (59%) and 61 males (41%); mean age: 55.2 years) with HCV admitted for liver biopsy were included in this retrospective study. At least one element of metabolic syndrome was identified in all cases: Obesity (n=44), hyperlipidaemia (n=40), hypertension (n=29) and diabetes (n=21). Liver fibrosis was classified according to the Metavir score and hepatic steatosis described as following: S0:  absent; S1: minimal (<30%); S2: moderate (30-60%); and S3: severe (>60%). Patients were divided into two groups: S0S1 group (absent or minimal steatosis) and S2S3 group (moderate to severe steatosis). Of the 148 patients, 53 were treated with pegylated interferon and ribavirin combination therapy.

RESULTS: Steatosis was found in 40 patients (27%): S1 in 72.5%, S2 in 17.5% and S3 in 10% of cases. The distribution of patients according to the degree of fibrosis was as follows: in the S0S1 group, F1=12.4%, F2=36.5%, F3=21.1% and F4=21.1% and in the S2S3 group, F1=9%, F2=45.5%, F3=18.2% and F4=27.3%. There was no difference between the two groups regarding the degree of fibrosis (p≥0.80). The rate of SVR was 64%: 63% in the S0S1 group and 75% in the S2S3 group. The difference was not statistically significant (p=1).

CONCLUSION: Steatosis was found in 25% of cases. Liver steatosis in chronic hepatitis C is not a negative prognostic factor of response to combined antiviral therapy. These results must be confirmed by a large series of patients.

Copyright © 2011 Arab Journal of Gastroenterology. Published by Elsevier Ltd.

All rights reserved.


DOI: 10.1016/j.ajg.2011.07.003

PMID: 22055591  [Indexed for MEDLINE]


Arab J Gastroenterol. 2011 Sep;12(3):136-8. doi: 10.1016/j.ajg.2011.07.003. Epub  2011 Sep 15.

Benkabbou A(1), Castaing D, Salloum C, Adam R, Azoulay D, Vibert E.

Author information:

(1)AH-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.

BACKGROUND: Roux-en-Y hepaticojejunostomy (RYHJ) is the most well-accepted treatment for most post-cholecystectomy bile duct injuries (BDI). RYHJ failure is a complex situation that requires expert planning and the possibility of using a  combination of operative, radiologic, and endoscopic techniques. The aim of this  study was to report our experience with a multidisciplinary approach to failed RYHJ after post-cholecystectomy BDI.

METHODS: Between January 1996 and March 2008, 44 consecutive patients were managed for RYHJ failure in our department. They presented with recurrent cholangitis in 40 patients (91%) and/or jaundice in 9 (20%). First-line treatment consisted of primary revisionary surgery in 26 cases (59%; repeat RYHJ in 22 and  hepatectomy in 4) and a percutaneous approach in 18 cases (41%; biliary interventions in 16 and portal vein embolization in 2).

RESULTS: Postoperative mortality was nil. Postoperative morbidity was 11% after repeat RYHJ without hepatectomy, 80% (bile leaks) after hepatectomy, and 10% (mild cholangitis and hemobilia) after a percutaneous approach. Delayed revisionary surgery with the intent to wait for bile duct dilation failed in all  5 patients. With a mean follow-up of 49 ± 40 months, second- or third-line treatment was attempted in 7 patients (16%). One patient (2%) died because of suicide. Overall clinical success defined by the absence of incapacitating biliary symptoms after treatment was achieved in 39 patients (89%).

CONCLUSION: An immediate, multidisciplinary approach including repeat biliary surgery and/or a percutaneous approach in a tertiary hepatobiliary center is required to obtain good, long-term results when treating the failure of RYHJ post-cholecystectomy BDI.

Copyright © 2013 Mosby, Inc. All rights reserved.

DOI: 10.1016/j.surg.2012.06.028

PMID: 23044267  [Indexed for MEDLINE]

Surgery. 2013 Jan;153(1):95-102. doi: 10.1016/j.surg.2012.06.028. Epub 2012 Oct 6.

Boursier J(1), de Ledinghen V, Sturm N, Amrani L, Bacq Y, Sandrini J, Le Bail B,  Chaigneau J, Zarski JP, Gallois Y, Leroy V, Al Hamany Z, Oberti F, Fouchard-Hubert I, Dib N, Bertrais S, Rousselet MC, Calès P; Multicentre group ANRS HC EP23 FIBROSTAR.

Collaborators: Poupon R, Poujol A, Abergel A, Bronowicki JP, Vinel JP, Metivier S, de Ledinghen V, Foucher J, Vergniol J, Goria O, Maynard-Muet M, Trepo C, Mathurin P, Guyader D, Danielou H, Rogeaux O, Pol S, Sogni P, Tran A, Calès P, Marcellin P, Asselah T, Bourliere M, Oulès V, Larrey D, Habersetzer F, Beaugrand  M, Leroy V, Hilleret MN, Boisson RC, Gelineau MC, Poggi B, Renversez JC, Guéchot  J, Lasnier R, Vaubourdolle M, Voitot H, Vassault A, Rosenthal-Allieri A, Lavoinne A, Ziegler F, Bartoli M, Lebrun C, Myara A, Guerber F, Pottier A, Beauvieux MC, Zafrani ES, Sturm N, Bechet A, Bosson JL, Paris A, Royannais S, Plages A.

Author information:

(1)Liver-Gastroenterology Department, University Hospital, Angers, France,

BACKGROUND: Liver stiffness evaluation (LSE) by Fibroscan is now widely used to assess liver fibrosis in chronic hepatitis C. Liver steatosis is a common lesion  in chronic hepatitis C as in other chronic liver diseases, but its influence on LSE remains unclear. We aimed to precisely determine the influence of steatosis on LSE by using quantitative and precise morphometric measurements of liver histology.

METHODS: 650 patients with chronic hepatitis C, liver biopsy, and LSE were included. Liver specimens were evaluated by optical analysis (Metavir F and A, steatosis grading) and by computerized morphometry to determine the area (%, reflecting quantity) and fractal dimension (FD, reflecting architecture) of liver fibrosis and steatosis.

RESULTS: The relationships between LSE and liver histology were better described using morphometry. LSE median was independently linked to fibrosis (area or FD), steatosis (area or FD), activity (serum AST), and IQR/LSE median. Steatosis area ≥4.0 % induced a 50 % increase in LSE result in patients with fibrosis area <9 %. In patients with IQR/LSE median ≤0.30, the rate of F0/1 patients misclassified as F ≥ 2 by Fibroscan was, respectively for steatosis area <4.0 and ≥4.0 %: 12.6 vs  32.4 % (p = 0.003). Steatosis level did not influence LSE median when fibrosis area was ≥9 %, and consequently did not increase the rate of F ≤ 3 patients misclassified as cirrhotic.

CONCLUSION: A precise evaluation of liver histology by computerized morphometry shows that liver stiffness measured by Fibroscan is linked to liver fibrosis, activity, and also steatosis. High level of steatosis induces misevaluation of liver fibrosis by Fibroscan.

DOI: 10.1007/s00535-013-0819-9

PMID: 23681425  [Indexed for MEDLINE]

J Gastroenterol. 2014 Mar;49(3):527-37. doi: 10.1007/s00535-013-0819-9. Epub 2013 May 17.

Benkabbou A(1), Abdelkader B(2), Souadka A(2).


Author information:

(1)University Mohammed Vth Souissi, Rabat, Medical School, Surgical Department A, Ibn Sina Hospital, Rabat, Morocco.

Electronic address:

(2)University Mohammed Vth Souissi, Rabat, Medical School, Surgical Department A, Ibn Sina Hospital, Rabat, Morocco.


DOI: 10.1016/j.surg.2014.01.001

PMID: 24661766  [Indexed for MEDLINE]


Surgery. 2014 May;155(5):958. doi: 10.1016/j.surg.2014.01.001. Epub 2014 Jan 16.

Benkabbou A, Souadka A, Serji B, Hachim H, El Malki HO, Mohsine R, Ifrine L, Belkouchi A.


BACKGROUND: Over past decades laparoscopic liver resection (LLR) has gained wide  acceptance among hepatobiliary surgeons community.

To date, few data are available concerning LLR programs in developing countries. This study aimed to assess feasibility and safety of LLR in a Moroccan surgical unit.

METHODS: From June 2010 to February 2013, patients that received LLR were identified from a prospective « liver resection » database and included in this study. Parenchymal transection was performed using Harmonic scalpel and bipolar clamp with no Intraoperative ultrasound use or systematic pedicle clamping. LLR difficulty was categorized into 3 categories according to Louisville-statement (I-III). Demographic informations, liver lesion informations, operative details, pathological tumor-margin and 1-months postoperative morbidity according to Clavien-Dindo(C-D) classification were analyzed.

RESULTS: Among 104 patients who underwent liver resection 13(12,5%) had LLR. There were 7 females and 6 males with mean age of 57,5 ± 17 years. LLR was performed for benign lesions in 3 cases and malignant ones in 10 (77%) patients:  hepatocarcinoma in 7 patients and synchronous rectal-liver metastasis in 3 patients. Lesions were solitary in 12 (92%) patients with median size of 50mm (15 mm-150 mm). Patients with liver metastasis received combined laparoscopic rectal  and liver resection. We used pure laparoscopic approach in 12 (92%) patients and  hybrid one in 1 patient. LLR difficulty was category I, II and II in respectively 3(23%), 6(46%) and 4(31%)patients. Conversion rate to open liver resection was 15%. Mean blood loss was 395 min ± 270 min with no hepatic pedicle clamping or peroperative blood transfusion. All resections were tumor free margin. Mortality  rate was nil and morbidity occurred in 4(30%) patients: ascites (C-D 2) and pelvic sepsis in combined resections (CD 3b). Median hospital stay was 6 days.

CONCLUSION: Laparoscopic liver resection in our context is safe in selected patients, since no operative mortality, blood transfusion requirement or palliative resection was recorded and liver related morbidity rate was low. Intraoperative ultrasound liver examination capacities are mandatory to improve laparoscopic liver resection program’s quality and extend indications.

PMID: 26815517  [Indexed for MEDLINE]

Tunis Med. 2015 Aug-Sep;93(8-9):523-6.

Goéré D(1), Souadka A, Faron M, Cloutier AS, Viana B, Honoré C, Dumont F, Elias D.

Author information:

(1)Department of Surgical Oncology, Gustave Roussy, Cancer Center, Villejuif Cedex, France,

BACKGROUND: The main prognostic factors after complete cytoreductive surgery (CCRS) of colorectal peritoneal carcinomatosis (PC) followed by intraperitoneal chemotherapy (IPC) are completeness of the resection and extent of the disease. This study aimed to determine a threshold value above which CCRS plus IPC may not offer survival benefit compared with systemic chemotherapy.

METHODS: Between March 2000 and May 2010, 180 patients underwent surgery for PC from colorectal cancer with intended performance of CCRS plus IPC.

RESULTS: Among the 180 patients, CCRS plus IPC could be performed for 139 patients (curative group, 77 %), whereas it could not be performed for 41 patients (palliative group, 23 %). The two groups were comparable in terms of age, gender, primary tumor characteristics, and pre- and postoperative systemic chemotherapy. The mean peritoneal cancer index (PCI) was lower in the curative group (11 ± 7) than in the palliative group (23 ± 7) (p < 0.0001).

After a median follow-up period of 60 months (range 47-74 months), the 3-year overall survival (OS) rate was 52 % [95 % confidence interval (CI) 43-61 %] in the curative group compared with 7 % (95 % CI 2-25 %) in the palliative group. Comparison of the survivals for each PCI (ranging from 5 to 36) shows that OS did not differ significantly between the two groups of patients when the PCI was higher than 17  (hazard ratio 0.64; range 0.38-1.09).

CONCLUSION: This study confirmed the major prognostic impact of PC extent. When the PCI exceeds 17 in PC of colorectal origin, CCRS plus IPC does not seem tooffer any survival benefit.

DOI: 10.1245/s10434-015-4387-5

PMID: 25631064  [Indexed for MEDLINE]

Ann Surg Oncol. 2015 Sep;22(9):2958-64. doi: 10.1245/s10434-015-4387-5. Epub 2015 Jan 29.

Benkabbou A(1), Awab AM(2), Koraichi A(2), Souadka A(3), Alilou M(2), Sbihi L(4), Moatassim N(4), Rhou H(5), Afifi R(6), Essaid A(6), Belkouchi A(1).

Tag: foie


Author information:

(1)Faculty of Medicine, Mohammed V University, Rabat, Morocco; Surgery Department, Ibn Sina University Hospital, Morocco.

(2)Faculty of Medicine, Mohammed V University, Rabat, Morocco; Intensive Care and Anesthesiology Department, Ibn Sina University Hospital, Morocco.

(3)Faculty of Medicine, Mohammed V University, Rabat, Morocco; Surgery Department, Ibn Sina University Hospital, Morocco.

Electronic address:

(4)Faculty of Medicine, Mohammed V University, Rabat, Morocco; Radiology Department, Ibn Sina University Hospital, Morocco.

(5)Faculty of Medicine, Mohammed V University, Rabat, Morocco; Nephrology and Renal Transplantation Department, Ibn Sina University Hospital, Morocco.

(6)Faculty of Medicine, Mohammed V University, Rabat, Morocco; Hepatology and Gastroenterology Department, Ibn Sina University Hospital, Morocco.


DOI: 10.1016/j.ajg.2016.02.001

PMID: 27026401  [Indexed for MEDLINE]


Arab J Gastroenterol. 2016 Mar;17(1):1-2. doi: 10.1016/j.ajg.2016.02.001. Epub 2016 Mar 23.

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