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Background Acute pancreatitis after liver resection is a rare but serious complication, and few cases have been described in the literature. Extended lymphadenectomy, and long ischemia due to the Pringle maneuver could be responsible of post-liver resection acute pancreatitis, but the exact causes of AP after hepatectomy remain unclear. Cases presentation We report here three cases of AP after hepatectomy and we strongly hypothesize that this is due to the bile leakage white test. 502 hepatectomy were performed at our center and 3 patients (0.6%) experienced acute pancreatitis after LR and all of these three patients underwent the white test at the end of the liver resection. None underwent additionally lymphadenectomy to the liver resection. All patient had a white-test during the liver surgery. We identified distal implantation of the cystic duct in these three patients as a potential cause for acute pancreatitis. Conclusion The white test is useful for detection of bile leakage after liver resection, but we do not recommend a systematic use after LR, because severe acute pancreatitis can be lethal for the patient, especially in case of distal cystic implantation which may facilitate reflux in the main pancreatic duct.

International audience; Background Laparoscopy is nowadays considered as the standard approach for hepatic left lateral sectionectomy (LLS), but its value in the prevention of incisional hernia (IH) has not been demonstrated. Methods Between 2012 and 2017, patients undergoing laparoscopic (LLLS) or open LLS (OLLS) in 8 centers were compared. Patients undergoing a simultaneous major abdominal procedure were excluded. The incidence of IH was assessed clinically and morphologically on computed tomography (CT) using inverse probability of treatment weighting (IPTW) and multivariable regression analysis. Results After IPTW, 84 LLLS were compared to 48 OLLS. Compared to OLLS, LLLS patients had reduced blood loss (100 [IQR: 50-200] ml vs. 150 [IQR: 50-415] ml,p = 0.023) and shorter median hospital stay (5 [IQR: 4-7] days vs. 7 [6-9] days,p < 0.001), but experienced similar rate of postoperative complications (mean comprehensive complication index: 12 +/- 19 after OLLS versus 13 +/- 20 after LLLS,p = 0.968). Long-term radiological screening was performed with a median follow-up of 27.4 (12.1-44.9) months. There was no difference between the two groups in terms of clinically relevant IH (10.7% [n = 9] after LLLS, 8.3% [n = 4] after OLLS,p = 0.768). The rate of IH detected on computed tomography was lower after LLLS than after OLLS (11.9% [n = 10] versus 29.2% [n = 14],p = 0.013). On multivariable analysis, the laparoscopic approach was the only independent factor influencing the risk of morphological IH (OR = 0.290 [95% CI: 0.094-0.891],p = 0.031). The 2 preferential sites for specimen extraction after LLLS were Pfannenstiel and midline incisions, with rates of IH across the extraction site of 2.3% [n = 1/44] and 23.8% [n = 5/21], respectively (p = 0.011). Conclusion The laparoscopic approach for LLS decreases the risk of long-term IH as evidenced on morphological examinations, with limited clinical impact. Pfannenstiel's incision should be preferred to midline incision for specimen extraction after LLLS.

Resume But de l’etude Le but de l’etude etait d’evaluer le role pronostique de 4 solutions de conservation en transplantation hepatique (TH). Patients et methodes Il s’agit d’une etude retrospective a partir de toutes les TH de tous les centres francais (n = 22) enregistrees dans la base de donnees prospective de l’Agence de la Biomedecine (Cristal) entre 2008 et 2013. Les solutions de preservation utilisees etaient : Celsior, IGL-1, SCOT 15 ou UW. Les criteres d’exclusion etaient : solution inconnue ou inhomogene ou solution HTK (3 % seulement des TH). Le critere principal de jugement etait la survie des patients. Les criteres secondaires etaient la survie des greffons et la duree de reanimation. Resultats Parmi 6347 TH realisees, 4928 ont ete incluses pour lesquelles la solution de preservation utilisee etaient Celsior (30 %), IGL-1 (44 %), SCOT 15 (10 %) et UW (16 %). La survie des patients etait de 86 %, 80 % et 74 % a 1, 3 et 5 ans, respectivement, sans difference entre les 4 solutions (p = 0,78). La survie des greffons etait respectivement de 82 %, 75 % et 69 % a 1, 3 et 5 ans, sans difference entre les 4 solutions (p = 0,80). Le sejour en reanimation etait different selon la solution utilisee en analyse univariee (p Conclusion Le type de solution de conservation utilisee (Celsior, IGL-1, SCOT 15 ou UW) n’a pas d’influence sur la survie des patients ou des greffons apres TH.

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).La fístula biliar es una de las complicaciones más comunes después de la hepatectomía. Este estudio evalúa el efecto del drenaje biliar transcístico durante la hepatectomía en la aparición de una fístula biliar postoperatoria. MÉTODOS: Este ensayo prospectivo aleatorizado y multicéntrico (Clinical Trial NCT01469442) con dos grupos de estudio (grupo transcístico versus grupo control) se llevó a cabo de 2009 a 2016 en 9 centros. Los pacientes fueron sometidos a una hepatectomía (≥ 2 segmentos) en hígados no cirróticos. El resultado principal fue la aparición de una fístula biliar después de la cirugía. Los resultados secundarios fueron la morbilidad, la mortalidad postoperatoria, la duración de la estancia hospitalaria, la reintervención, la necesidad de reingreso y las complicaciones causadas por los catéteres. Se realizaron análisis por intención de tratamiento y por protocolo.Un total de 310 pacientes fueron randomizados. Por intención de tratamiento, 158 pacientes fueron aleatorizados al grupo transcístico y 149 al grupo control. Siete pacientes fueron excluidos del análisis por protocolo por desviaciones del protocolo. La tasa de fístula biliar fue del 5,9% en el análisis por intención de tratamiento y del 6,0% en el análisis por protocolo. Esta tasa fue similar para el grupo transcístico y para el grupo control: 5,7% versus 6,0% (P = 1). No hubo diferencias en términos de morbilidad (49,4% versus 46,9%, P = 0,731), mortalidad (2,5% versus 4,7%, P = 0,367) y reintervenciones (4,4% versus 10,1%, P = 1). La mediana de la duración de la estancia hospitalaria fue mayor para el grupo transcístico (11 versus 10 días, P = 0,042). El riesgo de fístula biliar se correlacionó con el grosor y la longitud de la transección hepática. CONCLUSIÓN: Este ensayo aleatorizado no demuestra la superioridad del drenaje transcístico durante la hepatectomía para prevenir la fístula biliar. No se recomienda el uso de drenaje transcístico durante la hepatectomía para prevenir la fístula biliar postoperatoria.

Central hepatectomy (CH) is technically challenging and seldom-used to treat centrally located tumors. However, CH is a parenchyma-sparing resection that may decrease the risk of postoperative liver failure. This retrospective study presents our technique of CH and assesses the outcomes.All CH performed in our department over two decades (1997-2017) were identified. Indications and short-term outcomes were compared between the two decades. Long-term outcomes were assessed.Sixty-four patients underwent CH using a suprahilar approach for hepatocellular carcinoma (HCC: n = 30), metastasis (n = 23), intrahepatic cholangiocarcinoma (IHCCA: n = 9) or other diseases (n = 2). CH represented 6% of 1004 major hepatectomies, (7.4% (n = 35) before 2007 vs 5.4% (n = 29) after 2007). The mean operating time was 219 ± 56 min. A perioperative blood transfusion was required in 14 patients (22%). Intraoperative bile duct injuries occurred in 5 patients (8%), and they were repaired. One patient died postoperatively (1,5%). Ten patients (16%) experienced a major complication. Nine patients (14%) suffered from bile leakage, of which 6 healed spontaneously. Only one patient had low grade liver failure. The R0-resection rate was 69%. After 2007, there were no bile duct injuries (0/29 vs 5/35, p 0.05), and the average hospital stay was shorter but not significantly (11 vs 14 days). Actuarial 5-year survival was 56% for HCC patients and 34% for those with colorectal metastasis CONCLUSIONS: CH is associated with significant biliary morbidity and may increase positive surgical margins. Nevertheless, it should be recommended in selected patients to avoid the risk of postoperative liver failure.

Intrahepatic cholangiocarcinoma is a rare disease with a poor prognosis. In patients where surgical resection is possible, outcome is influenced by perioperative morbidity and lymph node status. Laparoscopic liver resection is associated with improved clinical and oncological outcomes in primary and metastatic liver cancer compared with open liver resection, but evidence on intrahepatic cholangiocarcinoma is still insufficient. The primary aim of this study was to compare overall survival for a large series of patients treated for intrahepatic cholangiocarcinoma by open or laparoscopic approach. Secondary objectives were to compare disease-free survival, predictors of death, and recurrence.Patients treated with laparoscopic or open liver resection for intrahepatic cholangiocarcinoma from 2000 to 2018 from 3 large international databases were analyzed retrospectively. Each patient in the laparoscopic resection group (case) was matched with 1 open resection control (1:1 ratio), through a propensity score calculated on clinically relevant preoperative covariates. Overall and disease-free survival were compared between the matched groups. Predictors of mortality and recurrence were analyzed with Cox regression, and the Textbook Outcomes were described.During the study period, 855 patients met the inclusion criteria (open liver resection = 709, 82.9%; laparoscopic liver resection = 146, 17.1%). Two groups of 89 patients each were analyzed after propensity score matching, with no significant difference regarding pre- and postoperative variables. Overall survival at 1, 3, and 5 years was 92%, 75%, and 63% in the laparoscopic liver resection group versus 92%, 58%, and 49% in the open liver resection group (P = .0043). Adjusted Cox regression revealed severe postoperative complications (hazard ratio: 10.5, 95% confidence interval [1.01-109] P = .049) and steatosis (hazard ratio: 13.8, 95% confidence interval [1.23-154] P = .033) as predictors of death, and transfusion (hazard ratio: 19.2, 95% confidence interval [4.04-91.4] P.001) and severe postoperative complications (hazard ratio: 4.07, 95% confidence interval [1.15-14.4] P = .030) as predictors of recurrence.The survival advantage of laparoscopic liver resection over open liver resection for intrahepatic cholangiocarcinoma is equivocal, given historical bias and missing data.

Background This study aimed to investigate the short- and long-terms outcomes of patients undergoing major hepatectomy (MH) with inferior vena cava (IVC) resection for intrahepatic cholangiocarcinoma (ICC). Methods Data from all patients who underwent MH for ICC with or without IVC resection between 2010 and 2018 were analysed retrospectively. Postoperative outcomes, overall survival (OS), and recurrence-free survival (RFS) were compared in the whole population. A propensity score matching (PSM) analysis and an inverse probability weighting analysis (IPW) were performed to assess the influence of IVC resection on short- and long-terms outcomes. Results Among the 78 patients who underwent MH, 20 had IVC resection (IVC patients). Overall, the mortality and severe complication rate were 8% and 20%, respectively. IVC patients required more extended hepatectomies (p = 0.001) and had increased rates of transfusions (p = 0.001), however they did not experience increased postoperative morbidity, even after PSM. The 1-, 3- and 5-years OS and DFS were 78%, 45%, and 32% and 48%, 20%, and 16%, respectively. IVC was not associated with decreased OS (p = 0.52) and/or RFS (p = 0.85), even after IPW. Conclusion MH with IVC resection for ICC seems to provide acceptable short- and long-term results in a selected population of patients.

We evaluated the feasibility and outcomes of immediate preoperative renal artery embolization (IPRAE) before complex nephrectomy for locally advanced RCC ± inferior vena cava thrombus (IVCT). A comparative retrospective (2007–2017) multicenter study which included 145 patients with locally advanced RCC ± IVCT: 99 radical nephrectomies vs. 46 radical nephrectomies with IPRAE identified in the prospective UroCCR national database (CNIL DR 2013–206; NCT03293563). IPRAE was performed under local anesthesia the day of nephrectomy (

Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding, and its impact on postoperative outcomes remains controversial. To compare short-term outcomes between laparoscopic versus open pancreaticoduodenectomy (OPD) in order to assess the safety of LPD. From 2002 to 2014, all consecutive patients undergoing LPD or OPD at two tertiary centers were retrospectively analyzed. Patients were matched for demographics, comorbidities, pathological diagnosis, and pancreatic texture. Results for the two groups were compared for postoperative outcomes. Sixty-five LPD were performed and compared to 290 OPD. In the whole population, postoperative pancreatic fistula (PF) was higher in the LPD group, but the proportion of ampullary adenocarcinoma (25 vs. 10%, p = 0.004) and soft pancreatic parenchyma (52 vs. 38%, p = 0.001) were higher in the LDP group. After matching (n = 65), LPD was associated with longer operative time (429 vs. 328 min, p

Background Delayed gastric emptying (DGE) is the most frequent pancreatic specific complication (PSC) after pancreaticoduodenectomy (PD). Several gastric decompression systems exist to manage DGE. Patients with a pancreatic tumor require prolonged nutrition; however, controversies exist concerning nutrition protocol after PD. The aim of the study was to assess the safety and efficacy of nasogastric (NG), gastrostomy (GT), and gastrojejunostomy (GJ) tubes with different feeding systems on postoperative courses. Methods Between January 2013 and March 2016, 86 patients underwent PD with pancreaticogastrostomy. Patients were divided into three groups: GJ group with enteral nutrition (EN, n = 12, 14%), NG (n = 31, 36%) and GT groups (n = 43, 50%), both with total parenteral nutrition (TPN). Results Patients in the GJ (n = 9, 75%) and GT (n = 18, 42%) groups had an American Society of Anesthesiologists (ASA) score of 3 more often than those in the NG group (n = 5, 16%, p ≤ 0.01). Multivariate analysis identified the GT tube with TPN as an independent risk factor of severe morbidity (p = 0.02) and DGE (p

International audience; Objective - The goal of this study was to evaluate the prognostic role of four preservation solutions in liver transplantation (LT). Patients and methods - This is a retrospective study originating from 22 French centers performing LT, registered in the prospective databank of the Cristal Biomedicine Agency between 2008 and 2013. The preservation solutions used were Celsior (CS), Institut Georges Lopez (IGL)-1, Solution de Conservation des Organes et des Tissus (SCOT) 15 and University of Wisconsin (UW) solutions. Exclusion criteria were preservation with unknown or inhomogeneous solutions, or Histidine-tryptophan-ketoglutarate (HTK) solution (representing only 3% of LT). Patient survival was the main endpoint. Secondary endpoints were graft survival and duration of stay in intensive care. Results - Of 6347 LT performed, 4928 were included in this study, for which the distribution of preservation solution was CS (30%), IGL-1 (44%), SCOT 15 (10%) and UW (16%). Patient survival was 86%, 80% and 74% at 1, 3 and 5 years after LT, respectively, without any statistically significant difference between the four solutions (P=0.78). Graft survival was 82%, 75% and 69% at 1, 3 and 5 years after LT, respectively, without any statistically significant difference between the four solutions (P=0.80). Duration of intensive care was different according to the solution used in univariate analysis (P

International audience; The observational CERTITUDE study follows liver transplant patients who completed the SIMCER trial. SIMCER randomized patients at month 1 after transplant to everolimus (EVR) with stepwise tacrolimus (TAC) withdrawal or to standard TAC, both with basiliximab induction and mycophenolic acid ± steroids. After completing SIMCER at 6 months after transplant, 65 EVR-treated patients and 78 TAC-treated patients entered CERTITUDE. At month 24 after transplant, 34/65 (52.3%) EVR-treated patients remained calcineurin inhibitor (CNI) free. Mean estimated glomerular filtration rate (eGFR) was significantly higher with EVR versus TAC during months 3-12. At month 24, eGFR values were 83.6 versus 75.3 mL/minute/1.73 m2 , respectively (P = 0.90) and adjusted mean change in eGFR from randomization was -8.0 versus -13.5 mL/minute/1.73 m2 (P = 0.15). At month 24, 45.9%, 31.1%, and 23.0% of EVR-treated patients had chronic kidney disease stages 1, 2, and 3, respectively, versus 25.7%, 45.7%, and 28.6% of TAC-treated patients (P = 0.05). Treated biopsy-proven acute rejection affected 4 EVR-treated patients and 2 TAC patients during months 6-24. Adverse events led to study discontinuation in 15.4% and 7.7% of EVR-treated and TAC-treated patients, respectively. Grade 3 or 4 hematological events were rare in both groups. A CNI-free EVR-based maintenance regimen appears feasible in approximately half of liver transplant patients. It preserves renal function effectively with good efficacy without compromising safety or hematological tolerance.

Although radical resections are recommended for the surgical management of liver hydatid disease (LHD), whether closed (CCR) or opened (OCR) cyst resections should be performed remains unclear. The aim of this study was to compare the postoperative and long-term outcomes of CCR and OCR for primary and recurrent LHD. Medical charts of patients who underwent surgery at a single centre were retrospectively reviewed and compared with respect to major postoperative complications and recurrence rates. Seventy-nine CCRs and 37 OCRs were included. The major morbidity rates were 19% and 5% in the OCR and CCR groups, respectively (P = 0.036). In multivariate analysis, OCR (P = 0.030, OR = 5.37) and the operative time (P

Objectif Evaluer les suites operatoires et la survie de patients operes d’hepatectomie majeure (HM) avec resection de la veine cave inferieure (VC) pour cholangiocarcinome intrahepatique (CIH). Materiel et methode Entre 2010 et 2018, 18 patients ont eu une HM avec resection de la VC (groupe VC) et ont ete compares aux patients operes d’HM pour CIH (n = 60) durant la meme periode. Les resultats postoperatoires, la survie globale (SG) et sans recidive (SSR) ont ete analysees. Resultats Douze patients ont eu une resection laterale et 6 patients un remplacement cave prothetique. Les suites operatoires ainsi que la mortalite a 90 jours etaient comparables. Seule la transfusion postoperatoire etait identifiee comme facteur de risque de mortalite a 90 jours (p = 0,015). La mediane de survie dans le groupe VC et controle n’etait pas differente statistiquement (48 mois vs 27 mois p = 0,32) de meme que le taux de SG a 1-, 3- et 5 ans (85/81 %, 50/23 %, et 30/8 %). La mediane de SSR etait de 11 mois dans les 2 groupes. L’atteinte ganglionnaire etait le seul facteur de risque de diminution de la survie globale (p = 0,042). Conclusion La resection de la VC au cours d’une HM pour CIH ne pejore pas les resultats a court et long terme.

IF 3.756; International audience; De novo malignancies are one of the major late complications and causes of death after liver transplantation (LT). Using extensive data from the French national Agence de la Biomédecine database, the present study aimed to quantify the risk of solid organ de novo malignancies (excluding nonmelanoma skin cancers) after LT. The incidence of de novo malignancies among all LT patients between 1993 and 2012 was compared with that of the French population, standardized on age, sex, and calendar period (standardized incidence ratio; SIR). Among the 11,226 LT patients included in the study, 1200 de novo malignancies were diagnosed (10.7%). The risk of death was approximately 2 times higher in patients with de novo malignancy (48.8% versus 24.3%). The SIR for all de novo solid organ malignancies was 2.20 (95% confidence interval [CI], 2.08‐2.33). The risk was higher in men (SIR = 2.23; 95% CI, 2.09‐2.38) and in patients transplanted for alcoholic liver disease (ALD; SIR = 2.89; 95% CI, 2.68‐3.11). The cancers with the highest excess risk were laryngeal (SIR = 7.57; 95% CI, 5.97‐9.48), esophageal (SIR = 4.76; 95% CI, 3.56‐6.24), lung (SIR = 2.56; 95% CI, 2.21‐2.95), and lip‐mouth‐pharynx (SIR = 2.20; 95% CI, 1.72‐2.77). In conclusion, LT recipients have an increased risk of de novo solid organ malignancies, and this is strongly related to ALD as a primary indication for LT.

To reduce the morbidity and mortality risk for the donor in living donor liver transplantation (LDLT), we previously identified 20% left portal vein (LPV) stenosis as an effective preconditioning method to induce cell proliferation in the contralateral lobe without downstream ipsilateral atrophy. In this study, we report the pathways involved in the first hours after preconditioning and investigate the changes in liver volume and function. Fourteen pigs were used this study. Five pigs were used to study the genetic, cellular and molecular mechanisms set up in the early hours following the establishment of our preconditioning. The remaining nine pigs were equally divided into three groups: sham-operated animals, 20% LPV stenosis, and 100% LPV stenosis. Volumetric scanning and 99 mTc-Mebrofenin hepatobiliary scintigraphy were performed before preconditioning and 14 days after to study morphological and functional changes in the liver. We demonstrated that liver regeneration triggered by 20% LPV stenosis in the contralateral lobe involves TNF-α, IL-6, and inducible nitric oxide synthase 2 by means of STAT3 and hepatocyte growth factor. We confirmed that our preconditioning was responsible for an increase in the total liver volume. Finally, we demonstrated that this volumetric gain was associated with an increase in hepatic functional capacity. NEW & NOTEWORTHY We describe a new preconditioning method for major hepatectomy that is applicable to hepatectomy for donation. We identified 20% left portal vein stenosis as effective preconditioning that is capable of inducing cell proliferation in the contralateral lobe without the downstream ipsilateral atrophy. In this study, we report the pathways involved in the first hours following preconditioning, and we confirm that 20% left portal vein stenosis is responsible for an increase in the functional capacity and total liver volume in a porcine model.

Background & Aims The main hindrance in promoting living donor liver transplantation remains the morbi-mortality risk for the donor. Considering the opposed remodeling influence of portal and hepatic artery flows, our working hypothesis was to identify a lobar portal vein stenosis capable of inducing a contralateral liver mass compensatory enlargement, without the downstream ipsilateral atrophic response. Methods Twenty-four pigs entered this study. Six of them were used to establish hemodynamic changes following a progressive left portal vein (LPV) stenosis, in blood flow, pressure and vessel diameter of the LPV, main portal vein and hepatic artery. Sixteen pigs were divided into 4 groups: sham operated animals, 20% LPV stenosis, 50% LPV stenosis, and 100% LPV stenosis. Daily liver biopsies were collected until post-operative day 5 to investigate liver regeneration and atrophy (Ki67, STAT3, LC3, and activated caspase 3) according to the degree of LPV stenosis. Finally, changes in liver volumetry after 20% LPVS were investigated. Results A 20% LPV stenosis led to dilatation of the hepatic artery and a subsequent four-fold increase in hepatic arterial flow. Concomitantly, liver regeneration was triggered in the non-ligated lobe and the cell proliferation peak, 5days after surgery, was comparable to that obtained after total LPV ligation. Moreover, 20% LPV stenosis preconditioning did not induce left liver atrophy contrary to 50 and 100% LPV stenosis. Conclusions A 20% LPV stenosis seems to be the adequate preconditioning to get the remnant liver of living donor ready to take on graft harvesting without atrophy of the future graft.

International audience; BACKGROUND & AIMS: Liver transplantation (LT) is the therapeutic option for severe complications of Wilson's disease (WD). We aimed to report on the long-term outcome of WD patients following LT. METHODS: The medical records of 121 French patients transplanted for WD between 1985 and 2009 were reviewed retrospectively. Seventy-five patients were adults (median age: 29 years, (18-66)) and 46 were children (median age: 14 years, (7-17)). The indication for LT was (1) fulminant/subfulminant hepatitis (n = 64, 53%), median age = 16 years (7-53), (2) decompensated cirrhosis (n = 50, 41%), median age = 31.5 years (12-66) or (3) severe neurological disease (n = 7, 6%), median age = 21.5 years (14.5-42). Median post-transplant follow-up was 72 months (0-23.5). RESULTS: Actuarial patient survival rates were 87% at 5, 10, and 15 years. Male gender, pre-transplant renal insufficiency, non elective procedure, and neurological indication were significantly associated with poorer survival rate. None of these factors remained statistically significant under multivariate analysis. In patients transplanted for hepatic indications, the prognosis was poorer in case of fulminant or subfulminant course, non elective procedure, pretransplant renal insufficiency and in patients transplanted before 2000. Multivariate analysis disclosed that only recent period of LT was associated with better prognosis. At last visit, the median calculated glomerular filtration rate was 93 ml/min (33-180); 11/93 patients (12%) had stage II renal insufficiency and none had stage III. CONCLUSIONS: Liver failure associated with WD is a rare indication for LT (\textless1%), which achieves an excellent long-term outcome, including renal function.

BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) prognostic scores could be useful in addition to the Barcelona Clinic Liver Cancer (BCLC) system to clarify patient prognosis and guide treatment decision. The NIACE (tumor Nodularity, Infiltrative nature of the tumor, serum Alpha-fetoprotein level, Child-Pugh stage, ECOG performance status) score distinguishes different prognosis groups among BCLC A, B, and C HCC patients. Our aims are to evaluate the NIACE score and its additive value in two HCC cohorts treated either by surgery or by chemoembolization, and then according to the BCLC recommendations. PATIENTS AND METHODS This was a retrospective multicenter study with two BCLC A, B, and C HCC cohorts treated either by surgery (n=207) or by chemoembolization (n=168) carried out between 2008 and 2013. We studied survival time according to the baseline NIACE score and compared it with the Cancer of the Liver Italian Program score and the BCLC system. RESULTS The NIACE score differentiates between subgroups of patients with different prognosis within each BCLC class. Among BCLC A patients treated by surgery and BCLC B patients treated by chemoembolization, the NIACE score differentiates between two subgroups with a significant difference in survival time: 68 (55-81) months versus 35 (21-56) months (P=0.0004) and 20 (17-24) months versus 13 (7-17) months (P=0.0008), respectively. Among those subgroups, the NIACE score has a significantly better prognostic value than the BCLC system or the Cancer of the Liver Italian Program score. CONCLUSION In this study, among HCC patients treated according to the BCLC recommendations, the NIACE score predicts more accurately than any other system the survival time.

Patients with hepatocellular adenomas are, in selected cases, candidates for liver resection, which can be approached via laparoscopy or laparotomy. The present study aimed to investigate the effects of the surgical approach on the postoperative morbidities of both minor and major liver resections. In this multi-institutional study, all patients who underwent open or laparoscopic hepatectomies for hepatocellular adenomas between 1989 and 2013 in 27 European centers were retrospectively reviewed. A multiple imputation model was constructed to manage missing variables. Comparisons of both the overall rate and the types of complications between open and laparoscopic hepatectomy were performed after propensity score adjustment (via the standardized mortality ratio weighting method) on the factors that influenced the choice of the surgical approach. The laparoscopic approach was selected in 208 (38%) of the 533 included patients. There were 194 (93%) women. The median age was 38.9 years. After the application of multiple imputation, 208 patients who underwent laparoscopic operations were compared with 216 patients who underwent laparotomic operations. After adjustment, there were 20 (9.6%) major liver resections in the laparoscopy group and 17 (7.9%) in the open group. The conversion rate was 6.3%. The two surgical approaches exhibited similar postoperative morbidity rates and severities. Laparoscopic resection was associated with significantly less blood loss (93 vs. 196 ml, p

International audience; OBJECTIVE:The aim of this study is to evaluate whether a parenchymal-sparing strategy provides similar results in terms of morbidity, mortality, and oncological outcome of non-PSH hepatectomies in a propensity score matched population (PSMP) in case of multiple (>3) bilobar colorectal liver metastases (CLM).BACKGROUND:The surgical treatment of bilobar liver metastasis is challenging due to the necessity to achieve complete resection margins and a sufficient future remnant liver. Two approaches are adaptable as follows: parenchymal-sparing hepatectomies (PSH) and extended hepatectomies (NON-PSH).METHODS:A total of 3036 hepatectomies were analyzed from a multicentric retrospective cohort of hepatectomies. Patients were matched in a 1:1 propensity score analysis in order to compare PSH versus NON-PSH resections.RESULTS:PSH was associated with a lower number of complications (≥1) (25% vs. 34%, p = 0.04) and a lower grade of Dindo-Clavien III and IV (10 vs. 16%, p = 0.03). Liver failure was less present in PSH (2 vs. 7%, p = 0.006), with a shorter ICU stay (0 day vs. 1 day, p = 0.004). No differences were demonstrated in overall and disease-free survival.CONCLUSION:In conclusion, PSH resection for bilobar multiple CLMs represents a valid alternative to NON-PSH resection in selected patients with a reduced morbidity and comparable oncological results.

Data on the conversion of patients to everolimus after liver transplantation are sparse. A multicenter, retrospective study followed 240 maintenance liver transplant patients to analyze the current indications for everolimus conversion, the employed regimens and exposure levels, and the impact on efficacy and safety. The mean time from transplantation to the introduction of everolimus was 4.9 ± 5.2 years. The mean everolimus trough level was 7.3 ± 4.1 ng/mL at month 1 and 8.1 ± 4.7 ng/mL at month 12. At 12 months, 61.6% of the patients were no longer receiving calcineurin inhibitor (CNI) therapy. The mean estimated glomerular filtration rate (eGFR) according to the Cockcroft-Gault formula was 64.2 ± 30.0 mL/minute on day 0 and 68.4 ± 32.5 mL/minute at month 12 (P = 0.007). Among patients with baseline serum creatinine levels ≥ 130 μmol/L, the eGFR values were 44.3 ± 15.7 mL/minute on day 0 and 53.7 ± 26.0 mL/minute at month 12 (P = 0.003). Four patients (1.6%) developed mild or moderate biopsy-proven acute rejection. Adverse events led to everolimus discontinuation in 12.9% of the patients. After the initiation of everolimus, the mean white blood cell count decreased significantly, and the total cholesterol and triglyceride levels increased significantly. In this retrospective analysis of the largest cohort of maintenance liver transplant patients analyzed after their conversion to everolimus, more than 60% of the patients were kept free of CNIs with a very low risk of acute rejection and with an acceptable safety profile. Randomized trials in which maintenance liver transplant patients are switched to everolimus in response to clinical indications or preemptively are warranted. Liver Transpl 17:905–913, 2011. © 2011 AASLD.

AIM: To generate a new score with improved accuracy compared with Milan criteria to select patients. PATIENTS: The training cohort comprised 373 patients transplanted for hepatocellular carcinoma (HCC) between 1988 and 1998 (cohort 1). An algorithm was derived from the analysis of patient data by the proportional hazard Cox regression model. The area under the receiver operating characteristic (AUROC) was used to determine a cut-off value. The validation cohort comprised 140 patients transplanted between 1999 and 2001 (cohort 2). RESULTS: Multivariate analysis identified three predictors of 5-year tumour-free survival: tumour differentiation (P=0.02), diameter (P

Calcineurin inhibitors (CNIs) contribute to renal dysfunction following liver transplantation. This prospective, randomized, multicenter, 6-month study (with an additional 6 months of follow-up) evaluated whether everolimus with CNI reduction or discontinuation would improve renal function in maintenance liver transplant recipients experiencing CNI-related renal impairment. Patients started everolimus therapy with CNI reduction or discontinuation (n = 72) or continued receiving standard-exposure CNI (n = 73). At month 6, 80% of the patients who had converted to everolimus had discontinued the CNI. The mean change in creatinine clearance (CrCl) from baseline to month 6 was similar between groups (everolimus, 1.0 +/- 10.2 mL/minute; controls, 2.3 +/- 7.8 mL/minute; P = 0.46), so the primary study endpoint (8 mL/minute difference in the change in CrCl) was not achieved. Among patients who continued everolimus according to the protocol, the mean increase in CrCl was 2.1 (n = 53) and 3.8 mL/minute (n = 38) at months 6 and 12, respectively, versus 2.4 (n = 68) and 3.5 mL/minute in controls (n = 51). The high frequency of CNI dose reductions in controls (77% of the patients) and the relatively long mean time post-transplant (>3 years) likely contributed to the small difference in CrCl. Biopsy-proven acute rejection occurred in 1.4% of the patients in each group, with no graft losses. Study drug discontinuation was higher in everolimus-treated patients, and adverse events were more frequent. These data demonstrate that everolimus allows for discontinuation or a major reduction of CNI exposure in liver allograft recipients suffering CNI-related renal dysfunction without a loss of efficacy. Trials targeting earlier conversion post-transplantation are required to confirm the efficacy and safety of everolimus for improving renal function after liver transplantation.

Resume Nous rapportons l’observation d’une patiente de 39 ans presentant des lesions kystiques anciennes, retroperitoneales et mediastinales evocatrices de lymphangiome kystique, revelees par des douleurs abdominales intermittentes. L’aggravation de la symptomatologie douloureuse a conduit a la realisation d’une fenestration cœlioscopique de decompression. L’evolution a ete marquee par un choc hemorragique necessitant une reprise chirurgicale en urgence avec exerese subtotale des lesions kystiques. Le diagnostic de lymphangioleiomyome a ete porte a l’examen anatomopathologique. Au 15 e jour postoperatoire, la patiente a presente un pneumochylothorax qui a necessite un drainage prolonge. L’association a des lesions kystiques diffuses du parenchyme pulmonaire a permis de porter le diagnostic de lymphangioleimyomatose. Les manifestations abdominales ont ete revelatrices de la lymphangioleimyomatose dans cette observation. Un diagnostic preoperatoire de la maladie aurait indique une exerese d’emblee complete des lesions.

Summary Background Few data are available on the incidence, risk factors and contamination pathways involved in acute indigenous hepatitis E in developed countries. Aims To draw up an overall picture of hepatitis E cases, to confirm whether or not the majority of the cases were indigenous and to attempt to identify the risk factors and contamination pathways involved in hepatitis E. Methods This study was performed in the framework of a national network (ANGH) including 96 participating centres. The 19 centres with at least one case of acute HEV reported a total number of 53 cases. Results A decreasing South-to-North geographic gradient was observed. A nonspecific clinical profile was observed in many cases. Acute hepatitis E was of indigenous origin in 90% of the patients. The most relevant and/or frequent possible risk factors among the 47 indigenous metropolitan cases were water consumption from a personal water supply, uncooked shellfish consumption and the recent acquisition of a pet pig. Conclusions This national survey confirmed that acute indigenous hepatitis E is an emerging disease in developed countries such as France, and suggests that various risk factors are responsible for acute indigenous hepatitis E contamination in non-endemic countries.

Aim To compare clinical presentation, operative management and short- and long-term outcomes of congenital bile duct cysts (BDC) in adults with children. Methods Retrospective multi-institutional Association Francaise de Chirurgie study of Todani types I+IVB and IVA BDC. Results During the 37-year period to 2011, 33 centers included 314 patients (98 children; 216 adults). The adult population included more high-risk patients, with more active, more frequent prior treatment (47.7% vs 11.2%; p < 0.0001), more complicated presentation (50.5% vs 35.7%; p = 0.015), more synchronous biliary cancer (11.6% vs 0%; p = 0.0118) and more major surgery (23.6% vs 2%; p < 0.0001), but this latter feature was only true for type I+IVB BDC. Compared to children, the postoperative morbidity (48.1% vs 20.4%; p < 0.0001), the need for repeat procedures and the status at follow-up were worse in adults (27% vs 8.8%; p = 0.0009). However, severe postoperative morbidity and fair or poor status at follow-up were not statistically different for type IVA BDC, irrespective of patients' age. Synchronous cancer, prior HBP surgery and Todani type IVA BDC were independent predictive factors of poor or fair long-term outcome. Conclusion BDC is a more indolent disease in children compared to adults, except for Todani type IV-A BDC.

The actual impact of transarterial chemoembolization before liver transplantation (LT) for hepatocellular carcinoma (HCC) on patient survival and HCC recurrence is not known. Between 1985 and 1998, 479 patients with HCC in 14 French centers were evaluated for LT. Among these 479 patients, this case-control study included 100 patients who received transarterial chemoembolization before LT (TACE group) and 100 control patients who did not receive chemoembolization (no-TACE group). Patients and controls were matched for the pre-LT tumor characteristics, the period of transplantation, the time spent on the waiting list, and pre- and posttransplantation treatments. Kaplan-Meier estimates were calculated 5 years after LT and were compared with the log-rank test. The mean waiting time before LT was 4.2 ± 3.2 months in the TACE group and 4.3 ± 4.4 months in the no-TACE group. The median number of TACE procedures was 1 (range: 1-12). Demographic data, median alpha-fetoprotein level (21.6 ng/mL and 22.0 ng/mL, respectively), and pre- and post-LT morphologic characteristics of the tumors did not differ in the TACE and no-TACE groups. Overall 5-year survival was 59.4% with TACE and 59.3% without TACE (ns). Survival rates did not differ significantly between the two groups with respect to the time on the waiting list, the tumor diameter, or the type of TACE (selective or nonselective). In the TACE group, 30 patients had tumor necrosis ≥80% on the liver explant with a 5-year survival rate of 63.2%, compared with 54.2% among their matched controls (P = 0.9). In conclusion, with a mean waiting period of 4.2 months and 1 TACE procedure, pre-LT TACE does not influence post-LT overall survival and disease-free survival. (Liver Transpl 2005;11:767–775.)

Hepatic gas gangrene is an uncommon situation mainly due to bacterial infection by Clostridium perfringens. It remains a life-threatening condition associated with a high mortality rate. Quick diagnosis and aggressive therapy including liver transplantation should be proposed to improve the outcome. This report describes a rare case of hepatic gas gangrene on native liver, secondary to iatrogenic hepatic artery thrombosis and instrumental biliary tree infection, which was successfully treated by liver transplantation.

Introduction Le syndrome de reperfusion (SR) est un etat d’instabilite hemodynamique post-declampage, considere comme un critere pejoratif sur les resultats de la transplantation hepatique (TH). But Evaluer l’impact du SR sur les resultats post TH. Methodes De septembre 2013 a avril 2016, toutes les TH de notre centre ont ete analysees. Le SR etait defini par une baisse de la pression arterielle moyenne de 30 % pendant 1 min durant les 5 minutes suivant la reperfusion hepatique. Resultats Au total, 145 TH ont ete realisees durant cette periode. Un SR etait present dans 30 % des cas (n = 41). Le SR etait associe a une augmentation de la mortalite a 90 j (15 % vs 4 %, p = 0,016), des complications majeures (58 % vs 35 %, p = 0,008), de dysfonction primaire (10 % vs 1 %, p = 0,008) et de perte du greffon a 6 mois (27 % vs 6 %, p = 0,001). Dans le groupe SR, il y avait plus de defaillance renale (30 % vs 56 %, p = 0,033). En analyse multivariee, le SR (OR = 5,4 IC 95 % : 1,7–17, p = 0,004), la transfusion (OR = 1,2 IC 95 % : 1,1–1,6, p = 0,004) etaient des facteurs independants de complications. Conclusion La presence d’un SR est un facteur de risque independant de complications majeures et de perte du greffon a 6 mois.

The role of extended resections in the management of advanced pancreatic neuroendocrine tumors (PNETs) is not well defined.Between 1995 and 2012, 134 patients with PNET underwent isolated (isoPNET group: 91 patients) or extended pancreatic resection (synchronous liver metastases and/or adjacent organs) (advPNET group: 43 patients).The associated resections included 27 hepatectomies, 9 vascular resections, 12 colectomies, 10 gastrectomies, 4 nephrectomies, 4 adrenalectomies, and 3 duodenojejunal resections. R0 was achieved in 41 patients (95%) in the advPNET. The rates of T3-T4 (73 vs 16%; p.0001) and N+ (35 vs 13%; p = .007) were higher in the advPNET group. Mortality (5 vs 2%) and major morbidity (21 vs 19%) rates were similar between the 2 groups. The 5-year overall survival (OS) of the series was 87% in the isoPNET group and 66% in the advPNET group (p = .006). Only patients with both locally advanced disease and liver metastases showed worse survival (p = .0003). The advPNET group developed recurrence earlier [disease-free survival (DFS) at 5 years: 26 vs 81%; p.001]. In univariate analysis, negative prognostic factors of survival were: poor degree of differentiation (p.001), liver metastasis (p = .011), NE carcinoma (p.001), and resection of adjacent organs (p = .013). The multivariate analysis did not highlight any factor that influenced OS. In multivariate analysis independent DFS factors were a poor degree of differentiation (p = .03) and the European Neuroendocrine Tumor Society stage (p = .01).An aggressive surgical approach for locally advanced or metastatic tumors is safe and offers long-term survival.

Resume But de l'etude Presenter les aspects epidemiologiques de cette affection reputee rare, la demarche diagnostique et les resultats du traitement chirurgical dans une population mediterraneenne. Patients et methodes Les observations des patients operes pour un carcinome hepatocellulaire entre 1987 et 1999, et qui n'avaient pas de cirrhose a l'examen histologique du parenchyme hepatique ont ete retenues. Les donnees ont ete collectees de facon prospective. Resultats L'âge moyen etait de 57,6 ans. II y avait 61 hommes (79 %) et 16 femmes mais un sex ratio de 1:1 pour les 22 patients d'âge Conclusion Le carcinome hepatocellulaire sur foie non cirrhotique n'est pas rare. II est habituellement decouvert a un stade avance, mais reste souvent resecable. La mortalite postoperatoire est faible et les taux de survie sont superieurs a ceux des resections pour carcinome hepatocellulaire sur cirrhose.

To assess the morbidity and its main risk factors after major hepatic resection.Retrospective study of prospectively collected data.University hospital, France.100 consecutive patients who underwent major hepatic resections, 1989-95.Major hepatic resection, defined as resection involving 3 or more segments according to Couinaud's classification, in all cases.All complications that affected outcome or prolonged hospital stay. Risk factors identified by univariate and multivariate analysis.45 patients developed at least 1 complication and 7 died. The most common complications were: pleural effusion (n = 21), hepatic failure (n = 12), and ascites (n = 9). Univariate analysis showed that the following variables were significantly related to the morbidity: age55 years, American Society of Anesthesiologists (ASA) grade II or more, bilirubin80 micromol/L, alkaline phosphatase activity more than double the reference range, malignant tumours, abnormal liver parenchyma, simultaneous surgical procedures, operative time4 hours, and perioperative blood transfusionor =600 ml. The extent of resection did not correlate with postoperative complications. Multivariate analysis showed that volume of blood transfusionor =600 ml and simultaneous surgical procedures were the most important independent risk factors for complicated outcome.The morbidity associated with major hepatic resections remains high, and the main determinants of outcome are intraoperative surgeon-related factors.

Resume But de l’etude evaluer la performance de la cholangio-IRM dans la recherche de variations anatomiques « potentiellement dangereuses » au cours des actes de chirurgie. Materiel et methode analyse retrospective realisee a partir de 45 cholangio-IRM indiquees pour l’exploration de pathologies benignes (n = 19) et malignes (n = 26). La population comportait 29 hommes et 16 femmes, d’une moyenne d’age de 57 ans. Les examens ont ete lus et interpretes par deux radiologues de maniere independante. Resultats des variantes anatomiques ont ete observees chez 9 patients (20 %), 6 interessant la convergence biliaire et 4 le canal cystique (un patient presentait 2 variantes associees). Les variantes anatomiques interessaient le canal lateral droit : 1 (2,2 %) glissement a gauche du canal lateral s’abouchant dans le canal hepatique gauche ; 2 (4,4 %) trifurcations et 3 (6,6 %) abouchements distaux du canal lateral. Pour le canal cystique ont ete observes 2 canaux avec abouchement distaux soit 7,44 %, et 3 insertions du canal cystique sur le bord gauche de la voie biliaire principale, soit 11,1 %. La concordance interobservateur a ete de 100 % pour l’identification des variantes anatomiques. Conclusion notre serie confirme l’interet de la cholangio-IRM dans l’exploration atraumatique des voies biliaires dans le bilan pre-operatoire afin de detecter des variations anatomiques pouvant compliquer l’acte operatoire.

Three cases of giant hemangioma of the liver associated with clinical and laboratory signs of inflammatory process, including low-grade fever, weight loss, abdominal pain, accelerated erythrocyte sedimentation rate, anemia, thrombocytosis, and increased fibrinogen level with normal white blood cell count are described. One patient presented with slight cholestatic jaundice because of tumor-related bile duct compression, but the other two patients had normal liver function tests, except for a slight increase in gammaglutamyl transferase. Clinical and laboratory abnormalities disappeared after surgical excision. Inflammatory manifestations have rarely been reported during giant liver hemangioma. Intratumoral inflammation necrosis or bleeding could explain the symptoms but histological signs of inflammation were not detected in two of three surgical specimens. The release of immune mediators by liver endothelial cells lining the hemangioma is an alternative explanation. The incidence of inflammatory process complicating giant hemangioma is probably underestimated because our three cases were observed within a span of only 3 years.

Background Recurrence rates after curative resection of colorectal adenocarcinoma remain steady at 50 per cent. Thirty per cent of the deaths are linked to locoregional recurrence. The aim of this study was to evaluate the results of resection for locoregional recurrence. Methods This retrospective review analysed a series of 120 patients who underwent resection of colonic (56) or rectal (64) locoregional recurrence. Sixty-nine resections were considered as curative. Sixty-one recurrences required extended resection. There were nine synchronous hepatic resections. Results The hospital mortality rate was 7 per cent and the morbidity rate was 40 per cent. The overall 5-year survival rate was 27 per cent. Survival was significantly higher: (1) after curative resection (44 versus 0 per cent after palliative resection, P < 0·0001); (2) in women (44 versus 11 per cent for men, P = 0·0036); and (3) after resection for intramural recurrence (45 versus19 per cent for extramural recurrence, P = 0·0024). Multifactorial analysis showed that curability of the resection was the most important prognostic parameter. Conclusion The results in this highly selected group seem to justify an attempt at reresection whenever possible. Long-term results may be improved by using adjuvant treatment.

La hernie du triangle de Jean Louis Petit, avec la hernie du quadrilatere de Grynfeltt, constituent le groupe des hernies lombaires, siegeant au niveau de la paroi abdominale posterolaterale. Plus de 300 cas ont ete rapportes, avec une predominance chez l’homme et pour le cote gauche [1-4]. Parmi les differentes etiologies, la hernie de Jean Louis Petit posttraumatique represente 26 % des cas [5, 6]. Elle est souvent consecutive a un traumatisme violent, dans le cadre d’un polytraumatisme. Le diagnostic est alors porte a distance de l’accident, il est souvent meconnu a la phase initiale en raison de la gravite des lesions associees dont le pronostic et le traitement sont prioritaires. Les techniques chirurgicales decrites pour traiter les hernies lombaires sont nombreuses. Alors que les plasties musculaires imposent des dissections etendues, l’approche coelioscopique apparait seduisante en raison de sa simplicite et de son caractere mini-invasif. Elle evite les dissections fastidieuses et offre une bonne exposition du collet de la hernie et de son contenu aisement reductible par cette voie d’abord [7]. Nous rapportons deux observations de patients presentant une hernie post-traumatique du triangle de Jean Louis Petit a revelation tardive, traitees avec succes par mise en place d’une plaque de renfort intra-peritoneale par voie coelioscopique. Le premier patient âge de 45 ans, avait ete victime d’un accident de la voie publique, responsable d’un polytraumatisme avec hemothorax gauche secondaire a une rupture de l’isthme aortique. En urgence un remplacement prothetique vasculaire a ete fait. Les suites operatoires ont ete compliquees par une contusion pulmonaire et un volet thoracique gauche, imposant un sejour en reanimation de 40 jours. Trois mois apres son accident, le patient a decouvert par autopalpation une tumefaction reductible de la region lombaire gauche, situee immediatement au dessus de la crete iliaque. Celle-ci a augmente progressivement de taille, entrainant une gene par son volume et responsable de douleurs aux efforts violents. L’examen clinique et une IRM (figure 1) ont confirme le diagnostic de hernie du triangle de Jean Louis Petit non compliquee. Une reparation par voie coelioscopique a ete proposee. L’exploration per-operatoire a trouve un collet de 5 cm de diametre et un glissement intra herniaire du colon sigmoide facilement reductible. Le sac peritoneal a ete reseque et la reparation parietale a consiste en la mise en place d’une plaque intra-peritoneale de materiel non resorbable en polypropylene, fixee en bas sur la crete iliaque et lateralement sur la partie charnue des muscles de la region au moyen d’agrafes coelioscopiques, sans peritonisation. Les suites operatoires ont ete simples, le patient a quitte le service a J1. Trois mois plus tard, le patient etait asymptomatique, il a pu reprendre une activite physique sans limitation. A la palpation on ne percevait pas de voussure du flanc. La seconde patiente, âgee de 58 ans, avait ete victime d’un polytraumatisme lors d’un accident de la voie publique, avec hemothorax gauche et hematome extra-dural, imposant un sejour de 15 jours en reanimation. Un mois apres la sortie de l’hopital est apparue une masse indolore du flanc gauche, au dessus de la crete iliaque, augmentant progressivement de volume. A l’examen clinique, cette masse etait impulsive a la toux et reductible. Le diagnostic de hernie d u triangle de Jean Louis Petit a ete evoque et confirme par tomodensitometrie. Une reparation sous coelioscopie a ete realisee. Apres resection du sac herniaire, la prothese intraperitoneale non resorbable en Prolene, a ete fixee par des agrafes coelioscopiques en bas sur la crete iliaque et lateralement sur les muscles grand dorsal et grand oblique. A un mois, la patiente a presente une occlusion intestinale du grele d’allure mecanique, secondaire a une bride developpee au depend d’une frange epiploique, imposant une viscerolyse. Les suites ont ete favorables par la suite.

Background The outcomes of pancreatic neuroendocrine tumors are extremely diverse, and determining the best strategy, optimal timing of therapy and the therapeutic results depend on understanding prognostic factors. We determined the clinical, radiological and histological factors associated with survival and tumor recurrence for patients with pancreatic neuroendocrine tumor. Methods From January 1, 1991 to December 31, 2011, 127 patients with pancreatic neuroendocrine tumor underwent pancreatectomy. The variables including clinical characteristics, surgical data and pathological findings were examined by univariate and multivariate analyses. Results There were 103 patients with non-functional tumors (81%). Sixty-four patients (50%) underwent left pancreatectomy, 51 (42%) patients underwent pancreatico-duodenectomy, 12 (9%) patients underwent enucleation and 2 patients (1%) underwent central pancreatectomy. Forty-eight patients (38%) had synchronous liver metastases. Six patients (5%) required portal vein resection, and 19 (15%) patients required enlarged “en-bloc” resection of adjacent organs. The overall morbidity and mortality rates were 48% and 2.3%, respectively. The 1-, 3- and 5-year overall survival rates were 94%, 84%, and 74%, respectively. In multivariate analyses, synchronous liver metastases ( p = 0.02) and portal vein resection ( p Conclusions Synchronous liver metastases and portal vein resection were found to be independent factors influencing survival.

Summary Background The purpose of this study was to assess the impact of transjugular intrahepatic portosystemic shunting (TIPS) on liver transplantation (LT). Methods Seventy-two patients transplanted after TIPS insertion between 1996 and 2008 were compared with 136 matched patients transplanted without prior TIPS. Results At time of LT, 10% of the TIPS were occluded and 32% were misplaced. Shunt removal was difficult in 17% of the TIPS patients and required vena cava clamping in 10%. Collateral venous circulation was less extensive and intra-operative portocaval anastomosis was required more frequently in the TIPS group. No significant difference in transfusion requirements and operative times were observed between the two groups. Postoperatively, liver and renal function tests, in-hospital stay, graft rejection, re-transplantation and 1-year mortality rates were not statistically different. Ascites volume in the first week was greater in the TIPS group (7.6 L vs 6.9 L, P = 0.036). In the TIPS group, ascites and collateral circulation were greater if the shunt was occluded at the time of LT. Shunt misplacement or occlusion was not associated with higher intra-operative or postoperative complication rates. Conclusion TIPS did not impair LT and can provide a safe bridge for LT in the end-stage cirrhotic patients.

International audience; BACKGROUND & AIMS: The aim of this study was to generate an improved prognostic model for predicting recurrence in liver transplant candidates with hepatocellular carcinoma (HCC). METHODS: Predictors of recurrence were tested by a Cox model analysis in a training cohort of 537 patients transplanted for HCC. A prognostic score was developed and validated in a national cohort of 435 patients followed up prospectively. RESULTS: α-Fetoprotein (AFP) independently predicted tumor recurrence and correlated with vascular invasion and differentiation. At a Cox score threshold of 0.7 (area under the receiver operating characteristic curve, 0.701; 95% confidence interval, 0.63-0.76; accuracy, 75.8%), a model combining log(10) AFP, tumor size, and number was highly predictive of tumor recurrence and death. By using a simplified version of the model, with untransformed AFP values, a cut-off value of 2 was identified. In the validation cohort, a score greater than 2 predicted a marked increase in 5-year risk of recurrence (50.6% ± 10.2% vs 8.8% ± 1.7%; P < .001) and decreased survival (47.5% ± 8.1% vs 67.8% ± 3.4%; P = .002) as compared with others. Among patients exceeding Milan criteria, a score of 2 or lower identified a subgroup of patients with AFP levels less than 100 ng/mL with a low 5-year risk of recurrence (14.4% ± 5.3% vs 47.6% ± 11.1%; P = .006). Among patients within Milan criteria, a score greater than 2 identified a subgroup of patients with AFP levels greater than 1000 ng/mL at high risk of recurrence (37.1% ± 8.9% vs 13.3% ± 2.0%; P < .001). Net reclassification improvement showed that predictability of the AFP model was superior to Milan criteria. CONCLUSIONS: Prediction of tumor recurrence is improved significantly by a model that incorporates AFP. We propose the adoption of new selection criteria for HCC transplant candidates, taking into account AFP.

New-onset diabetes mellitus (NODM) has important implications for long-term outcome following liver transplantation.To evaluate the impact of conversion from tacrolimus to cyclosporine in liver transplant patients presenting NODM.In a 12-month pilot study, 39 liver transplant patients with NODM were converted from tacrolimus to cyclosporine. Most patients (59%) were receiving antidiabetic therapy (18% insulin, 41% oral) and all patients had received dietary advice prior to the study.At month 12, NODM had significantly resolved (FBG7 mmol/L without treatment) in 36% of patients (95% CI 20.8-51.0%). In the 16 patients not receiving antidiabetic drugs at baseline, mean FBG decreased from 8.1 mmol/L to 6.6 mmol/L (P=0.008) and mean HbA(1c) decreased from 6.4 to 6.0% (P=0.05). Steroids were stopped rapidly in the nine patients receiving steroids at inclusion but NODM resolution was observed in only one of these nine patients. No significant factors were identified that could have affected NODM resolution. There were three episodes of biopsy-proven acute rejection (7.7%), no graft losses and one death. Overall, cyclosporine tolerance was good with no significant change in creatinine clearance at month 12. Total cholesterol increased from 4.6 mmol/L to 5.1 mmol/L (P0.001).These results suggest that liver transplant patients with NODM may benefit from conversion to cyclosporine from tacrolimus through improved glucose metabolism. Confirmation in a prospective, randomized comparative study is required.

Summary Objective The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy. Patients and methods Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken. Results Cholecystectomy was performed in 124 patients with symptomatic gallstones and no signs predictive of stones in the common bile duct. A stone was found fortuitously in the common bile duct in 12 patients. The control cholangiogram was normal in two of these patients on day two (16.7%) and in six others (50%) at the six-week control. All 12 patients remained free of symptoms suggesting the presence of a stone in the common duct. Presence of the drain had no impact on quality-of-life. Endoscopic extraction was finally performed for four patients (33.3%) to remove a stone from the common bile duct. Conclusion Early surgical or endoscopic extraction of stones in the common bile duct should not be undertaken systematically in asymptomatic patients. Spontaneous asymptomatic clearance of the common bile duct is observed in about half of patients.

The purpose of this study was to identify factors influencing prognosis after resection for hepatocellular carcinoma in the noncirrhotic liver and to measure the impact of moderate fibrosis on presentation and prognosis. A series of 116 primary procedures were performed for hepatocellular carcinoma in the noncirrhotic liver. These cases accounted for 42% of hepatic resections performed for hepatocellular carcinoma during the study period (1987-2005). Seventy-seven cases (58%) occurred in patients with nonfibrotic livers (Metavir score F0). The mean age was 61 years. The sex ratio was 3.5, with a female predominance before 50 years. Hepatitis B virus (HBV) or hepatitis C virus infection was found in 30% of patients. Symptoms were present in 64% of cases. Elevated serum alpha fetoprotein levels were observed in 44% of cases. Procedures involved minor hepatectomy in 40 cases, major hepatectomy in 72 cases, and transplantation in 4 cases. Postoperative mortality was 6% and morbidity was 31%. Complete resection was achieved in 90% of cases. The tumor was isolated in 72% of cases. The mean tumor diameter was 10.6 cm. Vascular invasion was observed in 48% of cases. Hepatocellular carcinoma in the nonfibrotic liver was associated with younger age and female sex, but there was no difference with other hepatocellular carcinoma with regard to histological or prognostic features. With a median follow-up of 79 months, overall survival was 40% for a median of 41 months. Multivariate analysis identified incomplete resection, vascular invasion, and HBV infection as independent factors of poor prognosis. In case of recurrence, repeat resection was feasible in 30% of cases with 69% survival at 5 years. Although hepatocellular carcinoma in the noncirrhotic liver is generally diagnosed at an advanced stage, its resectability remains high. As a result, hepatocellular carcinoma in the noncirrhotic liver accounts for a large proportion of cases in surgical series and has a better prognosis than hepatocellular carcinoma in the cirrhotic liver. Vascular invasion, incomplete resection, and HBV infection are independent factors of poor prognosis.

Radical nephrectomy with vena cava thrombectomy remains the treatment of choice in patients with renal cell carcinoma and inferior vena cava involvement. Surgery is performed with curative intent in patients without evidence of metastases or for cytoreduction, followed by possible immunotherapy in patients with distant metastases. The role of magnetic resonance imaging for evaluating the renal vein and/or IVC to detect thrombus and the proximal extent of thrombus is fully established. Surgical removal of these cancers through a transabdominal approach, even in patients with a level 2 thrombus (involving the retrohepatic IVC with close proximity to the main hepatic veins) is possible, avoiding the potential added morbidity of a throacoabdominal approach or median sternotomy. The application of liver transplant techniques and liver mobilization procedures not generally familiar to urological surgeons facilitates wide exposure and proximal control of the IVC for tumors cephalad to the confluence of the hepatic veins. As an initial step we believe that cephalad retraction of the liver with mobilization of the IVC by securing the lumbar, small hepatic and other unnamed venous collaterals may be tried to gain exposure of the retrohepatic IVC. Overall survival in patients with IVC involvement after complete surgical removal in the absence of metastatic disease justifies aggressive surgical management.

Introduction L’hepatectomie majeure (HM) sur foie de cirrhose reste une contre-indication pour de nombreuses equipes. Le but de ce travail est d’etudier la morbi-mortalite apres hepatectomie majeure sur cirrhose et d’identifier les facteurs de risque (FDR). Methodes L’ensemble des HM pour CHC sur cirrhose, entre 2000 et 2014, ont ete analysees a partir d’une base de donnees prospective. L’indication chirurgicale etait determinee par les donnees carcinologiques, l’operabilite dependait du score de Child (A ou B), de la clairance du vert d’indocyanine (CVI) et de l’absence de signe d’hypertension portale. L’analyse a porte sur la morbidite et la mortalite a 90 jours (M90). Les transplantations (TH) de sauvetage pour insuffisance hepatique postoperatoire (IHPO) ont ete incluses dans la M90. Resultats Soixante-quinze HM sur cirrhose ont ete incluses, dont 70 hommes (93 %), d’âge moyen 62 ans, Child A dans 97 % des cas (n = 73), avec une CVI 3) etait de 31 % (n = 23). Sept patients sont decedes en postoperatoire et 2 ont eu une TH de sauvetage (M90 = 12 %). En analyse multivariee, la transfusion (OR = 10,6 p = 0,02), et le sepsis (OR = 10,3 p = 0,02) etaient des FDR independants de M90. Conclusion Le risque operatoire des HM sur cirrhose est important mais pas prohibitif, le principal FDR reste l’hemorragie. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.