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Normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) is a promising procurement strategy. However, a detailed analysis of graft utilization rates is lacking. This retrospective study included all cDCD donors proposed to a single center for NRP procurement of at least one abdominal organ from 2015 to 2020. Utilization rates were defined as the proportion of transplanted grafts from proposed donors in which withdrawal of life sustaining therapies (WLST) was initiated. In total, 125 cDCD donors underwent WLST with transplantation of at least one graft from 109 (87%) donors. In a total of 14 (11%) procedures NRP failure led to graft discard. Utilization rates for kidney and liver grafts were 83% and 59%, respectively. In 44% of the discarded livers, the reason was poor graft quality based on functional donor warm ischemia >45 min, macroscopic aspect, high-transaminases release, or pathological biopsy. In this study, abdominal NRP in cDCD lead to transplantation of at least one graft in the majority of cases. While the utilization rate for kidneys was high, nearly half of the liver grafts were discarded. Cannulation training, novel graft viability markers, and ex-vivo liver graft perfusion may allow to increase graft utilization.

The Enhanced Recovery After Surgery (ERAS) society published new recommendations for hepatectomy in 2016. Few studies have assessed their clinical impact. The aim of this monocentric study was to assess the impact of those guidelines on outcomes after liver surgery with a special focus on cirrhotic patients. Postoperative outcomes of patients undergoing hepatectomy 30 months before and after ERAS implementation according to the 2016 ERAS guidelines were compared after inverse probability of treatment weighting (IPTW). Primary endpoint was 90-day morbidity. From 2015 to 2020, 430 patients underwent hepatectomy including 226 procedures performed before and 204 after ERAS implementation. After IPTW, overall morbidity (42.5% vs. 64.7%, p

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.

Objective: To compare HOPE and NRP in liver transplantation from cDCD. Summary of Background Data: Liver transplantation after cDCD is associated with higher rates of graft loss. Dynamic preservation strategies such as NRP and HOPE may offer safer use of cDCD grafts. Methods: Retrospective comparative cohort study assessing outcomes after cDCD liver transplantation in 1 Swiss (HOPE) and 6 French (NRP) centers. The primary endpoint was 1-year tumor-death censored graft and patient survival. Results: A total of 132 and 93 liver grafts were transplanted after NRP and HOPE, respectively. NRP grafts were procured from younger donors (50 vs 61 years, P < 0.001), with shorter functional donor warm ischemia (22 vs 31 minutes, P < 0.001) and a lower overall predicted risk for graft loss (UK-DCD-risk score 6 vs 9 points, P < 0.001). One-year tumor-death censored graft and patient survival was 93% versus 86% (P = 0.125) and 95% versus 93% (P = 0.482) after NRP and HOPE, respectively. No differences in non-anastomotic biliary strictures, primary nonfunction and hepatic artery thrombosis were observed in the total cohort and in 32 vs. 32 propensity score-matched recipients Conclusion: NRP and HOPE in cDCD achieved similar post-transplant recipient and graft survival rates exceeding 85% and comparable to the benchmark values observed in standard DBD liver transplantation. Grafts in the HOPE cohort were procured from older donors and had longer warm ischemia times, and consequently achieved higher utilization rates. Therefore, randomized controlled trials with intention-to-treat analysis are needed to further compare both preservation strategies, especially for high-risk donor-recipient combinations.

International audience; In situ normothermic regional perfusion (NRP) and ex situ normothermic machine perfusion (NMP) aim to improve the outcomes of liver transplantation (LT) using controlled donation after circulatory death (cDCD). NRP and NMP have not yet been compared directly. In this international observational study, outcomes of LT performed between 2015 and 2019 for organs procured from cDCD donors subjected to NRP or NMP commenced at the donor center were compared using propensity score matching (PSM). Of the 224 cDCD donations in the NRP cohort that proceeded to asystole, 193 livers were procured, resulting in 157 transplants. In the NMP cohort, perfusion was commenced in all 40 cases and resulted in 34 transplants (use rates: 70% vs. 85% [p = 0.052], respectively). After PSM, 34 NMP liver recipients were matched with 68 NRP liver recipients. The two cohorts were similar for donor functional warm ischemia time (21 min after NRP vs. 20 min after NMP; p = 0.17), UK-Donation After Circulatory Death risk score (5 vs. 5 points; p = 0.38), and laboratory Model for End-Stage Liver Disease scores (12 vs. 12 points; p = 0.83). The incidence of nonanastomotic biliary strictures (1.5% vs. 2.9%; p > 0.99), early allograft dysfunction (20.6% vs. 8.8%; p = 0.13), and 30-day graft loss (4.4% vs. 8.8%; p = 0.40) were similar, although peak posttransplant aspartate aminotransferase levels were higher in the NRP cohort (872 vs. 344 IU/L; p < 0.001). NRP livers were more frequently allocated to recipients suffering from hepatocellular carcinoma (HCC; 60.3% vs. 20.6%; p < 0.001). HCC-censored 2-year graft and patient survival rates were 91.5% versus 88.2% (p = 0.52) and 97.9% versus 94.1% (p = 0.25) after NRP and NMP, respectively. Both perfusion techniques achieved similar outcomes and appeared to match benchmarks expected for donation after brain death livers. This study may inform the design of a definitive trial.

International audience; Partial liver grafts from ex situ splitting are considered marginal due to prolonged static cold storage. The use of ex situ hypothermic oxygenated perfusion (HOPE) may offer a strategy to improve preservation of ex situ split grafts. In this single-center pilot study, we prospectively performed ex situ liver splitting during HOPE (HOPE-Split) for adult and pediatric partial grafts over a 1-year period (November 1, 2020 to December 1, 2021). The primary safety endpoint was based on the number of liver graft-related adverse events (LGRAEs) per recipient, including primary nonfunction, biliary complications, hepatic vascular complications, and early relaparotomies and was compared with consecutive single-center standard ex situ split transplantations (Static-Split) performed from 2018 to 2020. Secondary endpoints included preservation characteristics and early outcomes. Sixteen consecutive HOPE-Split liver transplantations (8 HOPE-Split procedures) were included and compared with 24 Static-Splits. All HOPE-Split grafts were successfully transplanted, and no graft loss nor recipient death was encountered during the median follow-up of 7.5 months (interquartile range, 5.5-12.5). Mean LGRAE per recipient was similar in both groups (0.31 ± 0.60 vs. 0.46 ± 0.83; p = 0.78) and split duration was not significantly increased for HOPE-Split (216 vs. 180 min; p = 0.45). HOPE-Split grafts underwent perfusion for a median of 125 min, which significantly shortened static cold storage (472 vs. 544 min; p = 0.001), whereas it prolonged total ex vivo preservation (595 vs. 544 min; p = 0.007) and reduced neutrophil infiltration on reperfusion biopsies (p = 0.04) compared with Static-Split. This clinical pilot study presents first feasibility and safety data for transplantation of partial liver grafts undergoing ex situ split during HOPE and suggests improved preservation compared with static ex situ splitting. These preliminary results will allow to set up large-scale trials on the use of machine perfusion in pediatric and split-liver transplantation.

Resume Le syndrome Low-Phospholipid Associated Cholelithiasis (LPAC) est une maladie genetique responsable du developpement d’une lithiase intrahepatique. Elle est en lien avec une mutation du gene ABCB4 codant pour la proteine MDR3, un transporteur biliaire. Cette entite nosologique est definie par la presence de deux criteres sur les trois suivants : apparition des symptomes biliaires avant 40 ans, recidive des symptomes apres cholecystectomie, et existence de foyers hyperechogenes intrahepatiques en echographie. La plupart des formes cliniques sont simples, mais il existe des formes compliquees, avec lithiase intrahepatique etendue et ses consequences : migration lithiasique, angiocholite, abces intrahepatique. L’evolution chronique peut aboutir a une cholangite sclerosante secondaire ou une cirrhose biliaire secondaire. Dans de rares cas, on peut observer une degenerescence en cholangiocarcinome. Le traitement repose sur l’acide ursodesoxycholique qui permet une dissolution des calculs. Des therapeutiques interventionnelles, radiologiques, endoscopiques ou chirurgicales sont justifiees dans les formes compliquees. Cette mise au point illustre et resume l’ensemble de la pathologie, de la lithiase vesiculaire simple au cholangiocarcinome, en passant par la cirrhose biliaire secondaire requerant une transplantation hepatique, a l’aide de cas cliniques et d’iconographies de patients pris en charge au sein de notre service.

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.

OBJECTIVE: The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective. BACKGROUND: Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature. STUDY DESIGN: This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival. RESULTS: The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT. CONCLUSION: When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.

Article Summary In the context of the COVID-19 pandemic this study showed feasibility and efficacy of systematic preoperative screening for SARS-CoV-2 by chest CT and RT-PCR on nasopharyngeal swabs. This screening strategy allowed performing safely the majority of scheduled oncological interventions., Highlights TOC Statement- 20200658 In the context of the COVID-19 pandemic, this report shows feasibility and efficacy of systematic, preoperative screening for SARS-CoV-2 by chest computed tomography and real-time reverse transcriptase polymerase chain reaction on nasopharyngeal swabs. This screening strategy allowed performing the majority of scheduled oncologic interventions safely for both the patients and the staff.

Resume Introduction Le traitement chirurgical est le traitement de reference des volumineux carcinomes hepatocellulaires (VCHC) ≥ 5 cm. La fibrose peut constituer une contre-indication a la resection en raison du surrisque d’insuffisance hepatique postoperatoire mais son impact sur les suites postoperatoires et la recidive demeure mal defini. Notre objectif etait donc de comparer les facteurs pronostiques de survie chez les patients cirrhotiques ou non, apres hepatectomie pour VCHC. Methodes Les donnees des patients reseques pour VCHC entre 2012 et 2016 dans deux centres de reference ont ete analysees. Les resultats obtenus chez les patients cirrhotiques (fibrose F4) et non cirrhotiques (F0–F3) ont ete compares. Les patients ayant recu un traitement medical (sorafenib) ou radiologique (chimioembolisation intra-arterielle, radiofrequence) ont ete exclus. Resultats Soixante patients ont ete inclus. Les donnees preoperatoires et peroperatoires etaient identiques entre les deux groupes. Les patients cirrhotiques (n = 15) etaient plus souvent porteurs de nodules satellites a l’anatomopathologie definitive (73 % vs 44 % ; p = 0,073) mais leurs tumeurs etaient mieux differenciees que celles des patients non-cirrhotiques (p = 0,041). La survie mediane des patients cirrhotiques etait de 34 mois vs 29 mois chez les non-cirrhotiques (p = 0,8) et la survie sans recidive etait respectivement de 14 mois vs 18 mois (p = 0,9). Le degre de fibrose n’avait pas d’impact sur la survie globale (p = 0,2) ou la survie sans recidive (p = 0,6). Conclusion Le traitement chirurgical des VCHC chez les patients cirrhotiques permet d’obtenir des resultats oncologiques satisfaisants et comparables a ceux obtenus chez les patients non-cirrhotiques. Le traitement curatif des VCHC doit donc etre envisage, sous reserve d’une fonction hepatique conservee, quel que soit le degre de fibrose.

The impact of portal hemodynamic variations after portal vein embolization on liver regeneration remains unknown. We studied the correlation between the parameters of hepatic venous pressure measured before and after portal vein embolization and future hypertrophy of the liver remnant after portal vein embolization.Between 2014 and 2017, we reviewed patients who were eligible for major hepatectomy and who had portal vein embolization. Patients had undergone simultaneous measurement of portal venous pressure and hepatic venous pressure gradient before and after portal vein embolization by direct puncture of portal vein and inferior vena cava. We assessed these parameters to predict future liver remnant hypertrophy.Twenty-six patients were included. After portal vein embolization, median portal venous pressure (range) increased from 15 (9-24) to 19 (10-27) mm Hg and hepatic venous pressure gradient increased from 5 (0-12) to 8 (0-14) mm Hg. Median future liver remnant volume (range) was 513 (299-933) mL before portal vein embolization versus 724 (499-1279) mL 3 weeks after portal vein embolization, representing a 35% (7.4-83.6) median hypertrophy. Post-portal vein embolization hepatic venous pressure gradient was the most accurate parameter to predict failure of future liver remnant to reach a 30% hypertrophy (c-statistic: 0.882 [95% CI: 0.727-1.000], P0.001). A cut-off value of post-portal vein embolization hepatic venous pressure gradient of 8 mm Hg showed a sensitivity of 91% (95% CI: 57%-99%), specificity of 80% (95% CI: 52%-96%), positive predictive value of 77% (95% CI: 46%-95%) and negative predictive value of 92.3% (95% CI: 64.0%-99.8%). On multivariate analysis, post-portal vein embolization hepatic venous pressure gradient and previous chemotherapy were identified as predictors of impaired future liver remnant hypertrophy.Post-portal vein embolization hepatic venous pressure gradient is a simple and reproducible tool which accurately predicts future liver remnant hypertrophy after portal vein embolization and allows early detection of patients who may benefit from more aggressive procedures inducing future liver remnant hypertrophy. (Surgery 2018;143:1-2.).

Indications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures.Data were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group).Between 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP.Splenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT.

Background The relevance of laparoscopic resection of intrahepatic cholangiocarcinoma (ICC) remains debated. The aim of this study was to compare laparoscopic (LLR) and open (OLR) liver resection for ICC, with specific focus on textbook outcome and lymph node dissection (LND). Methods Patients undergoing LLR or OLR for ICC were included from two French, nationwide hepatopancreatobiliary surveys undertaken between 2000 and 2017. Patients with negative margins, and without transfusion, severe complications, prolonged hospital stay, readmission or death were considered to have a textbook outcome. Patients who achieved both a textbook outcome and LND were deemed to have an adjusted textbook outcome. OLR and LLR were compared after propensity score matching. Results In total, 548 patients with ICC (127 LLR, 421 OLR) were included. Textbook-outcome and LND completion rates were 22.1 and 48.2 per cent respectively. LLR was independently associated with a decreased rate of LND (odds ratio 0.37, 95 per cent c.i. 0.20 to 0.69). After matching, 109 patients remained in each group. LLR was associated with a decreased rate of transfusion (7.3 versus 21.1 per cent; P = 0.001) and shorter hospital stay (median 7 versus 14 days; P = 0.001), but lower rate of LND (33.9 versus 73.4 per cent; P = 0.001). Patients who underwent LLR had lower rate of adjusted TO completion than patients who had OLR (6.5 versus 17.4 per cent; P = 0.012). Conclusion The laparoscopic approach did not substantially improve quality of care of patients with resectable ICC.

The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.This retrospective study included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short-term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection.Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010).Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.El objetivo de este estudio fue analizar el impacto de la cirrosis en los resultados a corto plazo después de la resección hepática laparoscópica (laparoscopic liver resection, LLR) en un estudio de cohortes multicéntrico nacional. MÉTODOS: Este estudio retrospectivo incluyó todos los pacientes sometidos a LLR en 27 centros entre 2000 y 2017. La cirrosis se definió como fibrosis F4 en el examen histopatológico. Los resultados a corto plazo de los pacientes con hígado cirrótico (cirrhotic liver CL) (pacientes CL) y los pacientes con hígado no cirrótico (non-cirrhotic liver, NCL) (pacientes NCL) se compararon después de realizar un emparejamiento por puntaje de propension del volumen del centro, las características demográficas y del tumor, y la extensión de la resección.Del total de 3.150 pacientes incluidos, se realizó LLR en 774 (24,6%) pacientes CL y en 2.376 (75,4%) pacientes NCL. Las tasas de complicaciones graves y mortalidad en el grupo de pacientes CL fueron del 10,6% y 2,6%, respectivamente. La insuficiencia hepática posterior a la hepatectomía (post-hepatectomy liver failure, PHLF) fue la principal causa de mortalidad (55% de los casos) y se produjo en el 3,6% de los casos en pacientes CL. Después del emparejamiento, los pacientes CL tendieron a tener tasas más altas de complicaciones graves (razón de oportunidades, odds ratio, OR 1,74; i.c. del 95% 0,92-0,41; P = 0,096) y de PHLF (OR 7,13; i.c. del 95% 0,91-323,10; P = 0,068) en comparación con los pacientes NCL. Los pacientes CL estuvieron expuestos a un mayor riesgo de mortalidad (OR 5,13; i.c. del 95% 1,08-48,6; P = 0,039) en comparación con los pacientes NCL. Los pacientes CL presentaron tasas similares de complicaciones cardiorrespiratorias graves (P = 0,338), de fuga biliar (P = 0,286) y de reintervenciones (P = 0,352) que los pacientes NCL. Los pacientes CL tuvieron una estancia hospitalaria más larga (11 versus 8 días; P = 0,018) que los pacientes NCL. La experiencia del centro fue un factor protector independiente de PHLF (OR 0,33; i.c. del 95% 0,14-0,76; P = 0,010) pacientes CL. CONCLUSIÓN: La presencia de cirrosis subyacente sigue siendo un factor de riesgo independiente de peores resultados en pacientes sometidos a resección hepática laparoscópica, incluso en centros con experiencia.

Contexte La circulation regionale normothermique (CRN) et la machine de perfusion normothermique ex vivo (MPN) ont pour but d’ameliorer les resultats de la transplantation hepatique (TH) de greffons issus de donneurs decedes par arret circulatoire (DDAC). Cependant, ces 2 techniques n’ont jamais ete comparees. Methodes Cette etude multicentrique internationale a compare les resultats de la TH issue de DDAC apres CRN (6 centres francais, 2015–2019) versus MPN (cohorte de l’essai randomise COPE-ORGANOX, 2014–2016). Resultats Au total, 157 et 34 TH apres NRP et MPN ont ete effectuees, correspondant a des taux d’utilisation de 70 % vs 85 % (p = 0,056). Les 2 groupes etaient similaires pour la duree d’ischemie chaude fonctionnelle (22 vs 20 min, p = 0,170), le UK-DCD score (6 vs 6 points, p = 0,150), et le score MELD (12 versus 12 points, p = 0,99). Les greffons NRP etaient plus frequemment alloues a des receveurs presentant un carcinome hepatocellulaire (CHC) (62 % vs 21 %, p Conclusion La NRP et la MPN donnent d’excellents resultats apres TH de greffon DDAC, similaires et equivalents a la TH issue de donneurs en etat de mort encephalique.

Porcine models of extended hepatectomy and liver transplantation (LT) of reduced graft have been widely used for studying the small-for-size (SFS) syndrome and the various modalities of portal inflow modulation (PIM). However, considerable heterogeneity exists among the studies and their results. The aim of this review was to assess the main advantages and drawbacks of the different porcine models of SFS LT and SFS hepatectomy, and propose a standardized anatomical nomenclature for the various models. The MEDLINE database was searched for articles reporting porcine models of reduced graft LT or hepatectomy of more than 65%. Nineteen articles on SFS LT matched our inclusion criteria, including 10 articles reporting a model of PIM. Twenty-seven articles reporting a model of posthepatectomy SFS were identified, of which 16 reported a model of PIM. Subtotal hepatectomy (i.e. resection of all segments except segment 1) without inflow occlusion, left trisectionectomy with inflow occlusion, and LT of a right lateral section including the caudate lobe in a larger recipient appeared to be the most suitable porcine models for studying the SFS syndrome. All three models were appropriate for assessing the surgical and pharmaceutical PIM modalities, except for those involving the splenic flow.

Background Traumatic biliary neuromas (TBNs) represent a rare cause of biliary stricture (BS) after orthotopic liver transplantation (OLT). Diagnosis is challenging preoperatively and is most often made at pathology after resection. Herein, we report a 20-year experience of TBN-related BS. Patients and methods Medical records of 1030 adult patients undergoing OLT from 1991 to 2014 were reviewed. Patients with histologically proven TBN were identified among those presenting a BS. Results Over the study period, 52 patients developed an anastomotic BS. Of these, 17 had repeat surgery and specimen examination identified TBN in five instances. All five patients with TBN had a duct-to-duct biliary reconstruction during OLT. Median delay from OLT to onset of symptoms was 69 months (range 4–239). Preoperative imaging showed a compressive mass in one patient. Four patients underwent TBN resection combined with hepaticojejunostomy and had an uneventful postoperative course. One patient underwent TBN resection and duct-to-duct reconstruction; he died from acute pancreatitis on postoperative day 21. After a median follow-up of 40.5 months (range 10–54), no recurrent BS occurred. Conclusion Traumatic biliary neuromas represent a possible diagnosis for unexplained anastomotic BS after OLT. Surgical excision combined with hepaticojejunostomy is effective, allows histological diagnosis, and prevents from recurrence.

Aim: To report a preliminary experience of conformal radiotherapy (CRT) as bridge to orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). Methods: Data of 12 patients undergoing CRT for HCC followed by OLT between 2012 and 2014 were reviewed. Results: CRT was used in a neoadjuvant or downstaging setting in nine and three patients, respectively. No radiation-related systemic toxicity was observed. Median blood loss and operating time were 1450 ml (600–4000) and 420 min (240–510), respectively. Four patients had diaphragmatic injury. Complete histological response was observed in six patients, and partial response in five. Seven patients developed severe postoperative morbidity including five anastomosis-related complications and one death. Conclusion: CRT for HCC provides satisfactory histological response but may compromise OLT safety.

But La societe ERAS a publie des recommandations sur la chirurgie hepatique en 2016. Aucune etude n’a, pour l’instant evalue leur impact clinique. Le but de ce travail etait d’etudier leur impact sur la chirurgie hepatique. Materiel et methodes Les resultats des patients operes d’une hepatectomie 18 mois avant et apres l’implementation du protocole ERAS etaient comparees apres appariement selon score de propension. Resultats Deux cent quatre-vingt-huit patients ont beneficie d’une hepatectomie (147 dans le groupe ERAS, 141 temoins). Les patients ERAS avaient un âge median plus eleve (66 vs 62 ans, p = 0,01), un score ASA plus eleve (p = 0,01), plus de cirrhose (26 % vs 16 %, p = 0,03), et moins de cœlioscopie (31 % versus 46 %, p = 0,01). Apres appariement, la morbidite globale (41 % vs 64 %, p Conclusion En diminuant les complications medicales, le programme ERAS permet d’ameliorer les resultats postoperatoires de la chirurgie hepatique.

The aim of this study was to identify the risk factors and causes of unresectability in a large cohort of patients with peritoneal carcinomatosis (PC) selected for cytoreductive surgery (CRS), and to assess the contribution of the different imaging modalities to the patient-selection process. The pre- and intraoperative data of 533 consecutive patients with PC planned for CRS at a single institution were reviewed. All patients underwent computed tomography (CT) magnetic resonance imaging and/or positron emission tomography/CT within the 2 days prior to surgery. Among the 533 patients, 436 (82 %) underwent complete CRS, 86 (16 %) underwent exploratory laparotomy without CRS because of multiple small-bowel involvement (n = 31), invasion of different digestive segments (n = 15), an elevated PC index (n = 14), invasion of the mesenteric root (n = 12), or another cause (n = 14), and 11 (2 %) did not undergo laparotomy because of disease progression on preoperative imaging findings. On univariate analysis, elevated levels of tumor markers and a short delay between the last cycle of chemotherapy and the scheduled surgery were identified as predictors of unresectability for the colonic PC population, while a younger age was identified in patients with gastric PC. Multivariate analysis disclosed the use of neoadjuvant chemotherapy and a younger age as independent predictors of unresectability in the colonic PC population. The current modalities for the assessment of PC resectability, including functional imaging examinations, have a low impact on patient selection for CRS. New tools are needed to decrease the rate of open–close procedures.

Background Small-for-size syndrome (SFSS) is a feared complication of extended liver resection and partial liver transplantation. Swine models of extended hepatectomy have been developed for studying SFSS and its different treatment options. Although portal inflow modulation (PIM) by splenectomy or splenic artery ligation (SAL) has been proposed in humans to prevent SFSS, such procedures have not yet been evaluated in swine. Objectives The present study was designed to evaluate modifications in splanchnic haemodynamics yielded by extended hepatectomy with and without PIM in swine. Methods Nineteen animals underwent 70% hepatectomy (H70, n = 7), 90% hepatectomy (H90, n = 7) or sham laparotomy (H0, n = 5). Haemodynamic measurements were performed at baseline, after hepatectomy and after PIM by SAL and splenectomy. Results Portal vein flow increased after both H70 (273 ml/min/100 g versus 123 ml/min/100 g; P = 0.016) and H90 (543 ml/min/100 g versus 124 ml/min/100 g; P = 0.031), but the hepatic venous pressure gradient (HVPG) increased only after H90 (10.0 mmHg versus 3.7 mmHg; P = 0.016). Hepatic artery flow did not significantly decrease after either H70 or H90. In all three groups, neither splenectomy nor SAL induced any changes in splanchnic haemodynamics. Conclusions Subtotal hepatectomy of 90% in swine is a reliable model for SFSS inducing a significant increase in HVPG. However, in view of the relevant differences between swine and human splanchnic anatomy, this model is inadequate for studying the effects of PIM by SAL and splenectomy.

Background Biliary leakage is a major contributor to morbidity after hepatectomy. A score to predict severe posthepatectomy biliary leakage (PHBL) was recently developed by the French Association of Hepatopancreatobiliary Surgery and Transplantation (ACHBT). The aim of the study was to validate and optimize the score on an external cohort. Study Design The ACHBT score uses 5 factors (blood loss, remnant ischemia, anatomic resection of segment 8, transection along right aspect of the left intersectional plane and associating liver partition and portal vein ligation for staged hepatectomy) to predict severe PHBL. The score was tested on an external cohort of patients undergoing hepatectomy without hepaticojejunostomy between 1994 and 2016 at a single center. Association between the score, pre- and intraoperative variables, and severe PHBL was assessed in an attempt to improve the score. Results Among 778 procedures performed (including 679 [87.3%] laparoscopic and 260 [34.3%] major hepatectomies), 31 (4.0%) were complicated with severe PHBL. The ACHBT score showed good discrimination (AUROC [area under the receiver operating characteristic curve] 0.747, 95% CI 0.652 to 0.841), calibration and accuracy (diagnostic odds ratio for a score ≥1: 6.217 [95% CI 2.642 to 14.627], for a score ≥2: 6.059 [95% CI 2.858 to 12.846],and for a score ≥3: 9.589 [95% CI 2.868 to 32.066]). On multivariable analysis, the ACHBT score was the only predictor of severe PHBL. A model combining the ACHBT score and conversion to open surgery was significantly more discriminating than the ACHBT score alone (AUROC 0.790 [95% CI 0.711 to 0.870], Delong's test p = 0.002). Conclusions The ACHBT score represents an externally validated tool to predict severe PHBL. Inclusion of conversion to open surgery as an additional factor to the score allowed it to improve its performance to predict severe PHBL after laparoscopic hepatectomy.

Liver tumors bleed rarely; management has changed radically during the last 20years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.

RésuméL’hémorragie d’une tumeur hépatique est un événement rare, pour lequel la prise en charge a radicalement changé au cours des 20 dernières années, passant d’une urgence chirurgicale aux résultats médiocres, à une prise en charge multidisciplinaire. La première étape est le diagnostic et le contrôle de l’hémorragie. Un angioscanner abdominopelvien doit être réalisé si l’état hémodynamique du patient le permet. En cas de saignement actif visualisé, une embolisation artérielle la plus sélective possible est préférable, l’option chirurgicale n’étant réservée qu’aux cas d’instabilité hémodynamique sévère ou d’échec du traitement radiologique. Dans ce cas, une laparotomie écourtée avec tamponnement périhépatique est recommandée. La deuxième étape est le diagnostic étiologique et le traitement de la tumeur sous-jacente. L’adénome et le carcinome hépato-cellulaire sont les 2 tumeurs les plus fréquemment rencontrées dans ce contexte. L’IRM hépatique à distance de l’hémorragie permet généralement de confirmer le diagnostic, bien que son analyse puisse être perturbée par l’hématome. La décision de résection doit être prise précocement en cas de CHC, d’adénome atypique ou à risque de transformation en hépatocarcinome. En cas d’adénome non suspect, la résorption complète de l’hématome doit être attendue pour décider d’une éventuelle thérapeutique.SummaryLiver tumors bleed rarely; management has changed radically during the last 20 years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is the determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.

Introduction La pathologie herniaire represente une des premieres causes de chirurgie. Pour les patients asymptomatiques, une prise en charge chirurgicale est discutable. L’objectif de cette etude etait d’evaluer les pratiques d’une large population de chirurgiens digestifs devant une hernie non symptomatique. Methodes Entre octobre 2016 et mars 2017, une enquete en ligne a ete proposee a des chirurgiens francophones. L’attitude therapeutique etait evaluee pour 13 situations cliniques de hernies ou d’eventrations asymptomatiques. Une attitude consensuelle etait definie quand plus de 75 % des chirurgiens proposaient la meme decision therapeutique. Resultats Parmi les 204 chirurgiens, 44 % avaient moins de 45 ans. L’attitude therapeutique etait consensuelle dans 2 situations cliniques : l’abstention chirurgicale pour une hernie inguinale chez le sujet âge avec comorbidites ; et une chirurgie en cas d’eventration chez une patiente jeune en remission d’un cancer du pancreas. L’âge du chirurgien semble influence la decision chirurgicale, les chirurgiens de plus de 45 ans pronant plus facilement une surveillance. Conclusion Bien que frequentes, la prise en charge des hernies asymptomatiques ne fait pas consensus dans la communaute chirurgicale. Des recommandations precises sur les indications de prise en charge chirurgicale ou de surveillance active sont necessaires.

The aim of this study was to compare postoperative outcome and long-term results after management of liver hydatid cysts (LHC) by subadventitial cystectomy (SC) and resection of the protruding dome (RPD) in two tertiary liver surgery centers.Medical records of 52 patients who underwent SC in one center, and 27 patients who underwent RPD in another center between 1991 and 2011 were reviewed. Patients underwent long-term follow-up, including serology tests and morphological examinations.Postoperative mortality was nil. The rate of severe morbidity was 7.7 and 22% (p = 0.082), while the rate of serological clearing-up was 20 and 13.3% after SC and RPD, respectively (p = 1.000). After a mean follow-up of 41 months (1-197), four patients developed a long-term cavity-related complication (LTCRC) after RPD (including one recurrence) and none after SC (p = 0.012). All LTCRCs occurred in patients with hydatid cysts located at the liver dome; three required an invasive procedure by either puncture aspiration injection re-aspiration (N = 1) or repeat surgery (N = 2).RPD exposes to specific LTCRC, especially when hydatid cysts are located at the liver dome, while SC allows ad integrum restoration of the operated liver. Therefore, SC should be considered as the standard surgical treatment for LHC in experienced hepato-pancreato-biliary centers.

The benefit of placing a T-tube for duct-to-duct biliary reconstruction during orthotopic liver transplantation (OLT) remains controversial because it could be associated with specific complications, especially at the time of T-tube removal. While the utility of T-tube during OLT represents an eternal debate, only a few technical refinements of T-tube placement have been described since the report of the original technique by Starzl and colleagues. Herein, we present a novel technique of T-tube placement for duct-to-duct biliary reconstruction during OLT, using a tunneled retroperitoneal route. On the basis of our experience of 305 patients who benefitted from the reported technique, the placement of a tunneled retroperitoneal biliary T-tube appears to be safe and results in a low rate of biliary complications, especially at the time of T-tube removal.

Background Somatostatin may prevent the small-for-size syndrome in subjects undergoing extended hepatectomy by decreasing portal pressure. Methods Twenty pigs underwent 70% hepatectomy (H70 group, n=7), 90% hepatectomy (H90 group, n=7), or sham laparotomy (control group, n=6). Splanchnic hemodynamics was measured before and after an intraoperative infusion of somatostatin. Results The portal vein flow normalized to liver weight increased in both H70 and H90 groups (from 125 ± 42 to 342 ± 82 mL/min/100g, P = .031 and from 140 ± 46 to 530 ± 241, P = .016, respectively). The hepatic venous pressure gradient (HVPG) increased in the H90 group only (from 5.5 ± 5.8 to 13 ± 4.9 mm Hg, P = .004). Somatostatin decreased portal vein flow normalized to liver weight in both H70 and H90 groups (from 408 ± 224 to 360 ± 227 mL/min/100g, P = .031 and from 560 ± 190 to 466 ± 189 mL/min/100g, P = .016), and restored a normal HVPG in the H90 group (from 14.3 ± 4.8 to 7.7 ± 6.1 mm Hg, P = .047). Conclusions Somatostatin restores a normal HVPG in the setting of small-for-size syndrome and can be considered as an effective pharmaceutical modality of portal inflow modulation after extended hepatectomy.