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Alveolar echinococcosis is an indigenouszoonosis caused by the growth of the larval stage of a small tapeworm, Echinococcus multilocularis. Despite a low incidence in Belgium, with about 10 cases on average recorded per year, this parasitosis poses a real public health problem because it often remains difficult to diagnose and is potentially fatal in the absence of treatment. General practitioners are on the frontline, but they do not always know enough about the disease, which causes a delay in the diagnosis and impacts the prognosis. The present study aims to assess the level of knowledge of alveolar echinococcosis among general practitioners in the province of Liège via a questionnaire, on the one hand, and to increase their level of knowledge via a formative intervention using a video capsule, on the other hand. We have performed a randomized controlled experimental study, which showed that general practitioners in the province of Liège have limited knowledge on alveolar echinococcosis. This mainly concerns symptomatology, diagnostic tools and treatment. The formative intervention carried out allowed increasing their level of knowledge about this disease.

Delayed Graft Function (DGF) is defined as the need for dialysis during the first week after transplantation. DGF is frequent and mostly derived from the ischemia/reperfusion cascade to which the graft is subjected throughout the transplantation process. A graft biopsy is recommended after 7 days of DGF to exclude an episode of acute rejection. Note that DGF per se is associated with an increased risk of acute graft rejection, as well as with a shorter long-term graft survival. Several strategies are being studied to mitigate the ischaemic damage, thereby improving graft quality. Among these, cellular therapy using mesenchymal stromal cells (MSC) is promising, in particular via the administration of MSC in the machine perfusion during the preservation of the graft. We will discuss here the different definitions of DGF and the main predictive factors of DGF, as well as the impact on the graft outcomes. The current strategies to prevent DGF will be briefly reviewed.

Renal allograft rejection involves many mechanisms of innate and adaptive immunity, responsible for parenchymal inflammatory lesions that negatively impact the long-term outcomes of the renal allograft. The heterogeneous presentations of rejections in terms of clinical, biological and histological aspects make them difficult to manage in daily clinical practice. Indeed, current therapeutic strategies are disappointing in term of long-term outcomes, including graft survival. In this article, we will discuss the main effector mechanisms of rejection and their histological classification, as well as the existing treatments and those currently under evaluation.

Cellular immunotherapy consists in using the cells of the immune system as a therapeutic weapon. In this constantly evolving field, the therapeutic strategies developed at the University Hospital of Liege are hematopoietic stem cell transplantation, mesenchymal stromal cells and targeted therapy with CAR-T cells (Chimeric Antigen Receptor T cells). The first two modalities represent a form of non-targeted cell therapy that has been developed over the past decades. While hematopoietic stem cell transplantation is established as the reference treatment for many hematological diseases, mesenchymal stromal cells are still under investigation in various pathologies (notably Crohn's disease, organ transplantation, COVID-19 and pulmonary fibrosis). By contrast, CAR-T cells represent a recently developed and extremely promising targeted immunotherapy. This therapeutic approach has already revolutionized the treatment of B-cell lymphopathies, and has the potential to do the same for many other diseases in the near future.

The «Severe Acute Respiratory Syndrome coronavirus 2» (SARS-CoV-2) pandemic has disrupted medical care and intra-hospital organization during 2020, both in Belgium and throughout the world. Solid organ transplantation was not spared and in Belgium, the number of organ donors and transplants overall decreased by 20 % for livers and by 33 % for hearts between 2019 and 2020. The aim of this article is to summarize the experience acquired in 2020 and 2021 on the organizational and medical implications of the coronavirus disease 2019 (COVID-19) pandemic with regard to the care of patients transplanted or awaiting for organ transplants, and to draw conclusions both for the aftermath of COVID-19 but also for future pandemics. Vaccination against SARS-CoV-2 is highly recommended and particularly important in organ transplant recipients, even if the response rate is lower than in the non-transplanted population. A third injection is now advised in immunosuppressed patients.

In Belgium and around the world, the incidence of primary malignant liver tumours is increasing, both for hepatocarcinoma and cholangiocarcinoma. Their curative treatment is based on multidisciplinary and specialized care, of which surgery (including liver transplantation) remains the cornerstone, often associated with other logoregional treatments, as radioembolisation, radiofrequency ablation, and chemoembolisation. For advanced cases, the prognosis remains poor, in particular due to a certain chemoresistance of these tumours. New treatments include targeted therapies (including various tyrosine kinase inhibitors) and immunotherapy. A specialized multidisciplinary discussion is therefore necessary to define the best therapeutic management, individualized to each patient. In this article, the authors review the most recent data relating to the treatment of hepatocarcinoma and cholangiocarcinoma.

During the last decade minimal invasive approach progressed in all sectors of abdominal surgery. Technological improvements allowed to perform more complex procedures laparoscopically with increased safety. The implementation of pre-, per- and postoperative protocols with an adaptation of surgical, anesthetic and analgesia methods and the patient's involvement in the healing process led to enhanced recovery after surgery. The centralization of complex esophageal and pancreatic surgery established the CHU of Liège as a tertiary referral institution for complex oncological surgery thanks to a large cooperation with regional hospitals.

The success of solid organ transplantation induced an increased need for grafts and the necessary registration of transplant candidates on long waiting lists. Many patients die while waiting for transplantation, even in Belgium where the donation rates have been high these last years. In order to fight this lack of donor organs, the transplant centers widened donation criteria for brain dead donors, including older age and potential transmissible diseases. In addition, programs of donation after circulation death have been developed, first for kidneys, then for livers and recently for the hearts. Organ donation after euthanasia is also regularly performed in Belgium. All these policies lead to the fact that organ donation rates stay high in Belgium, and particularly in the Liege region, but efforts are still ahead if we aim to reduce waiting list mortalities.

Alcoholic hepatitis is a syndrome defined primarily by the clinical onset of jaundice in patients with a concomitant heavy consumption of alcoholic beverages. This pathology is managed by alcohol withdrawal with a 30-day survival rate of 90 %. For patients with severe alcoholic hepatitis, with a Maddrey score greater than 32 (taking into account bilirubin and prothrombin time), treatment with corticosteroids is discussed provided that a possible infection can be sufficiently excluded or adequately managed. The administration of corticosteroids is continued for 28 days if the Lille score, calculated after 7 days of treatment, is favourable (inferior to 0.45), leading to a survival rate of 80-90 %. However, if the Lille score is unfavourable (superior to 0.45), the prognosis is bad, with a survival of only 25-30 % at 6 months. Special attention needs to be paid to assure a sufficient caloric intake during the treatment period for a successful management. Liver transplantation, previously prohibited for this indication, can be discussed under certain circumstances. However, the success of treatment is contingent upon the alcohol withdrawal. Innovative drugs are currently under investigation to improve the prognosis of this condition.

In Belgium as in many other countries, alcohol is one of the leading causes of adult liver transplantation. Liver transplantation for terminal liver failure due to excessive alcohol intake raises clear ethical issues concerning the use of grafts to save patients suffering from a self-inflecting affection. Alcoholic liver disease is one of the best indications for liver transplantation, with excellent results in terms of length of survival and post transplantation quality of life, if this transplantation is proposed by a multidisciplinary team in a patient able to and helped by a supporting family and social environment.

Acute mesenteric ischemia is a real life-threatening emergency. Mode of presentation is severe abdominal pain with sudden onset. The etiology is most of the time embolus coming from the heart or thrombosis of atherosclerotic vessel wall concerning the superior mesenteric artery. The best investigation is computed tomography with intravenous contrast media injection. Treatment consists of revascularization by open surgery or endovascular approach. Bowel resection may be necessary, as well as delayed second look surgery. This paper aims to review etiologies and therapeutics options for acute mesenteric ischemia.

Alveolar echinococcosis is a zoonotic disease due to the tapeworm Echinococcus multilocularis. The definitive host is the red fox. Until recently, Belgium was considered a country at very low risk for alveolar echinococcosis. However, recent studies carried out in southern Belgium have revealed, through post-mortem examination, high prevalences (up to 62 %) in foxes. Cats and dogs can act as definitive hosts. Human are accidentally infected by ingestion of food contaminated by the feces. After a long incubation period, invasive hepatic lesions may appear, as well as extra-hepatic lesions. The disease may be fatal. The diagnosis is based on imaging techniques, serology and nucleic acid detection in tissues. Early diagnosis may allow surgical removal of the lesion associated with at least 2 years of albendazole postoperative treatment. In case of contraindication to surgery, a long term treatment with albendazole is necessary. Liver transplantation is sometimes necessary. This article presents the epidemiologic, clinical, diagnostic and therapeutics features of this zoonotic disease.

Mesenchymal stromal cells (MSC) are multipotent and self-renewing cells. MSC are studied for their in vivo and in vitro immunomodulatory effects, in the prevention or the treatment of isehemic injury, and for their potential properties of tissue or organ reconstruction. Over the last few years, the potential role of MSC in organ transplantation has been studied both in vitro and in vivo, and their properties make them an ideal potential cell therapy after solid organ transplantation. A prospective, controlled, phase 1-2 study has been initiated at the CHU of Liege, Belgium. This study assesses the potential risks and benefits of MSC infusion after liver or kidney transplantation. Even if the preliminary results of this study look promising, solely a prospective, randomized, large scale, phase 3 study will allow the clinical confirmation of the theoretical benefits of MSC in solid organ transplantation.

Cystic lymphangioma of the mesentery is a benign condition, probably of malformative origin, and frequently appearing in infancy. Its symptomatology can be very polymorphic. Its diagnosis is suspected by ultrasonography and computed tomography, and definitely confirmed by pathology. About a recent case of cystic lymphangioma of the mesentery diagnosed and operated on at the university hospital of Liège in an adult patient, the authors review its classification and its therapeutic strategy. Surgical resection is indicated in symptomatic cystic lymphangioma.

Digital clubbing is a clinical sign known for centuries. Though, no theory could yet explain this entire phenomenon, neither in its primary nor its secondary form. This article reviews the actual hypotheses bringing a plausible explanation, regarding the most current pathologies associated with digital clubbing. A focus is made on pulmonary and digestive pathologies, and particularly cirrhosis. The knowledge of the mechanisms underlying finger clubbing might lead, in the future, to an effective treatment.

Hepatocellular carcinoma is the main primitive tumor of the liver. It occurs in the setting of liver cirrhosis in more than 90% of the cases in developing countries. The prognosis depends on the size, number and extension of the tumor as well as on the severity of the underlying liver disease. The Barcelona Clinic Classification takes into account these different parameters and helps the clinician in the therapeutic decision. Some patients (around 25%) are amenable to therapy with a curative intent (liver transplantation, resection, destruction by radiofrequency). In patients with hepatocellular carcinoma at an intermediate stage, lipiodolized chemoembolization gives a survival advantage in comparison with placebo. No conventional regimen of chemotherapy has a proven survival benefit. In patients with a hepatocellular carcinoma at an advanced stage, sorafenib, an oral multi-targeted kinase inhibitor, is the first compound to demonstrate a significant effect on survival free of disease progression in a selected group of patients. Its toxicity profile is particularly favourable. Combination of surgical and medical therapies should be properly evaluated in clinical trials in the near future.

Curative management of early-stage hepatocarcinoma may include partial hepatic resection, liver transplantation or tumoral necrosis using radiofrequency ablation or alcoholisation. Until recently, no efficient therapeutic mean was available for advanced hepatocarcinoma. Sorafenib (Nexavar, Bayer) is a multikinase inhibitor that decreases tumoral proliferation and angiogenesis, and increases apoptosis in many cancer models. The results of a phase 3 randomized, multicentric, study, entitled SHARP, have now demonstrated that sorafenib increases survival in patients with advanced hepatocarcinoma developed in Child A cirrhosis. Mean survival gain was a little less than 3 months, without any radiologic response or improvement in the delay before symptomatic progression of the disease. The monthly cost of sorafenib is a little more than 5,000 euros. It is now crucial to evaluate the potential role of sorafenib in adjuvant therapy after liver resection or radiofrequency ablation of hepatocarcinoma. The CHU of Liège is taking part to a randomized, multicentric study evaluating the use of sorafenib after liver resection or radiofrequency ablation for hepatocarcinoma. Another future evaluation could be the association of sorafenib with other antitumoral agents.

The epithelioid hemangioendothelioma is a rare malignant vascular lesion that may occur within the liver. In the hepatic multifocal and bilobar forms, liver transplantation is indicated as the curative management. In this case report, the authors describe the diagnosis and the management of a 52-year-old woman who was diagnosed with hepatic epithelioid hemangioendothelioma and who underwent successful liver transplantation.

One promising avenue towards the development of more selective, better anticancer drugs consists in the targeted delivery of bioactive compounds to the tumor environment by means of binding molecules specific for tumor-associated biomarkers. Eligibility of such markers for therapeutic use implies ideally three criteria : (i) accessibility from the bloodstream, (ii) expression at sufficient level and (iii) no (or much lower) expression in normal tissues. Most current discovery strategies (such as biomarker searching into body fluids) provide no clue as to whether proteins of interest are accessible, in human tissues, to suitable high-affinity ligands, such as systemically delivered monoclonal antibodies. Innovative proteomic technologies are able to identify such accessible biomarkers and represent a key step in the clinical development of such target therapies.

6000 new cases of colorectal cancer are diagnosed each year in Belgium. 50% of these patients shall develop liver metastasis. Resection remains the only chance of long term survival and must be considered as an endpoint from the beginning of the treatment. It is the result of a multidisciplinary discussion and a global approach of the disease. It is rarely directly feasible, but there are many techniques which may make it achievable in the end. Today, resection criteria are exclusively technical and neither bad prognosis factors, nor the presence of extra-hepatic metastases should exclude liver resection. This resection must be assessed by a confirmed hepatobiliary surgeon and must be proposed to all patients whatever their age as long as their general state of health is good.

Over the last 20 years, significant improvements in hepatic surgery and transplantation have allowed better results. Better patients selection, new preoperative modalities aiming at modifying the volume of the liver or the tumour, new surgical techniques, and better postoperative management are the keys to improved outcome. These progresses are reviewed in this article. In hepatic surgery, the latest surgical improvements are the possibility of laparoscopic hepatic resection and of radiofrequency ablation. Modern neoadjuvant chemotherapy may in some cases allow a reduction of large liver colorectal metastases and render them resectable. Improved radiological techniques allow better planning of the surgical resections, reduction of the risks by calculation of the residual liver mass, and induction of liver hypertrophy by preoperative portal embolisation. In liver transplantation, the most significant changes were the use of living related liver donors and of non-heart beating donors to overcome the cadaveric organ donor shortage.

Enteric duplication cysts, and particularly caecal duplication cysts, are rare and generally benign congenital anomalies for which a diagnosis is difficult to make because they mimic other surgical diseases. A surgical management is the treatment of choice. The diagnosis can then be made or confirmed by histopathologic analysis.

Alveolar echinococcosis is a serious parasitic disease, leading to large hepatic lesions. It must be distinguished from cystic echinococcosis, or hydatic cyst, caused by Echinococcus granulosus. Early diagnosis may allow surgical removal of the lesions by segmental hepatectomy, the only curative treatment. Parasitostatic medical treatment with albendazole may promote stabilization of the disease. Until recently, Belgium was considered a country at very low risk for alveolar echinococcosis, as no human case was reported, despite up to 51% of fox infection in southern Belgium autopsy series. Recently four patients presented with alveolar echinococcosis at the University Hospital Center of Liege, leading to the fear of a possible alveolar echinococcosis endemy in southern Belgium. Two of these patients underwent curative hepatectomy, but the other two had already pulmonary metastases at diagnosis and received palliative albendazole therapy. This article presents these cases, and reviews the clinical features of this parasitic disease.

Pancreas transplantation has now become an established option in the treatment of diabetic complications. It normalizes glucose metabolism, prevents, stabilizes and improves the evolution of diabetes-associated lesions. Improvements in surgical procedure and in immunosuppression have better defined its indications. Combined kidney-pancreas transplantation appears today as the best treatment for the diabetic patient with end stage renal disease. Isolated pancreas transplantation is reserved to non-uremic patients with severe diabetic complications or with hyperlabile glycaemic control and severe impairment of quality of life.

Spontaneous rupture of the oesophagus, so called Boerhaave's syndrome, still remains a surgical emergency. Early diagnosis governs the appropriate repair and the vial prognosis.

The authors describe the case of a 17-year-old girl who suffered from end-stage liver failure due to chronic autoimmune hepatitis. Liver failure was complicated by severe portal hypertension, hypersplenism and refractory ascites. Liver transplantation was indicated. She was listed for cadaveric whole liver transplantation, but her infrequent blood group (B) increased waiting time. Her condition deteriorated to Child C liver failure and living related liver transplant was considered. Her father was compatible and proposed himself for donation. Right lobe procurement was decided in order to provide sufficient liver mass. No transfusion of red cells, platelets, or fresh frozen plasma was used either in the donor or the recipient. Both recipient and donor left the ward at postoperative day 14, without complication. They were both asymptomatic and with normal liver tests at one year follow-up. Living related liver transplantation using the right lobe may offer an alternative to liver transplant candidates in this period of organ donor shortage.

Important progress has been made in the treatment of liver metastases of advanced colorectal cancer. Surgery with curative intent, when possible, shows evidence of prolonged survival. Response rate and overall survival can be improved with modern polychemotherapy. Cytotoxic drug combinations and sequential treatments sometimes make surgery possible for initially non resectable lesions. Impact of loco-regional treatment such as hepatic arterial infusion chemotherapy must be defined in randomised trials. Radiofrequency ablation is also currently evaluated in clinical trials. In this review the benefit of each treatment is discussed.

Pancreatic injury after trauma can occur in the child as an isolated lesion after a minor injury. The consequences can be severe in the absence of prompt diagnosis and treatment. Determination of mechanism of injury, clinical examination, blood amylase levels and abdominal CT-scan are first line steps for the evaluation of the injury. ERCP and MRI can be useful tools to further document injury to the pancreatic duct. In the absence of duct injury, conservative treatment can be applied. For the other cases, the treatment is surgical although newer techniques may be applied in selected cases.

Ascites is the most common of the major complications of cirrhosis. The initial evaluation of a patient with ascites should include a history, physical evaluation and some investigations. Treatment should consist of treating the underlying liver disease, sodium restricted diet (2 g of Na+/day) and diuretics. This regimen is effective in 90% of patients. The treatment options for the diuretic resistant patients include serial therapeutic paracentesis, peritoneovenous shunting, TIPS and liver transplantation. The treatment and prophylaxis of spontaneous bacterial peritonitis which is a frequent and severe complication in cirrhotic patients with ascites is also important. The differential diagnosis with secondary bacterial peritonitis is essential because the latter usually does not resolve unless patients are surgically treated.

Alpha-1-antitrypsin deficiency is the most common inborn error of metabolism leading to liver transplantation, and the second cause of liver transplantation in children after biliary atresia. The authors report the case of a 6-year-old girl, who was suffering from end-stage liver disease secondary to alpha-1-antitrypsin deficiency. She was successfully treated by whole liver transplantation, the hepatic graft coming from a 3-year-old donor. Three months later she went back to school. The authors discuss the pathogenesis and the natural history of this frequent cause of liver transplantation in children.

Pancreas transplantation significantly improves the quality of life as well as the survival of the diabetic patient. It is also associated with stabilization and reversal of secondary diabetic complications. Improvements in organ preservation, surgical techniques and immunosuppression have achieved one-year graft survival of more than 90% for combined kidney-pancreas transplant and 80% for isolated pancreas transplantation. Recipient evaluation must weigh the benefits of the procedure with the risk associated with surgery and chronic immunosuppression. Combined kidney-pancreas transplantation appears today as the best treatment for the diabetic patient with end stage renal disease. Isolated pancreas transplantation is reserved to non-uremic patients with severe diabetic complications or with brittle glycaemic control and severe impairment of quality of life.

The orthotopic liver transplantation (OLT) program of the University of Liège was initiated in 1986. Between 1986 and December 1998, 150 adult OLT have been performed in our institution, including 18 liver retransplantations, 1 combined heart and liver transplantation and 3 combined liver and kidney transplantations. The aim of this study was to report the last 3 years of our experience. From January 1996 to November 1998, we performed 50 OLT on 49 patients. Three were retransplantations and two were combined liver and kidney transplantations. Fourty-three patients were transplanted for chronic liver disease and 6 for acute or subacute hepatopathy. Mean waiting time on the list was 4 weeks. Immunosuppression was based on triple therapy (cyclosporin A/tacrolimus, steroids, azathioprine), with steroid and azathioprine withdrawal in most of the patients after 3 months. In the chronic liver disease group, operative (< 30 days) survival was 95% (peroperative myocardial infarction in 2 patients). In the acute liver disease group, postoperative survival was 66%. No perioperative death occurred in 1997 and 1998. Actuarial one year survival was 87%. In our experience, OLT has become a safe procedure.

Transplantation of kidney grafts harvested in living donors has demonstrated better results than grafts harvested from brain dead donors. Recently, laparoscopic live donor nephrectomy has been introduced to reduce the live procurement morbidity. In 1997, we performed two laparoscopic live donor nephrectomy and we report the first case of this program in this paper.