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PURPOSE The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). METHODS From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. RESULTS The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P

The Birmingham score predicts the risk of hospital readmission after pancreaticoduodenectomy (PD). This study aimed to validate the risk score in a different healthcare cohort.From 2017 to 2021, 301 patients underwent PD. The Birmingham score was applied to 276 patients. Postoperative deceased patients (n = 7) or those requiring a completion of pancreatectomy (n = 18) were excluded.Forty-seven (17%) patients were readmitted after a median delay of 9 (range 1-49) days and stayed for 5 (range 1-27) days; 4 (8.5%) died during the hospital stay. The leading cause of readmission was a septic condition (53%), mostly resolved by medical treatment (77%). A multivariate analysis identified the occurrence of a clinically relevant postoperative pancreatic fistula, the score criteria, and the score itself as independent factors favouring readmission. Readmission rates in patients with low [n = 97 (35%)], intermediate [n = 98 (36%)], and high [n = 81 (29%)] scores were 5%, 17%, and 31%, respectively (P 0.01).This study confirmed the relevance and robustness of the Birmingham risk score. Patients with a high risk of readmission after PD, identified based on the score, were discharged to a partnership medical centre close to the pancreatic centre to plan readmission and avoid futile unplanned hospitalisation.

Surgical field photography is a tough exercise: surgeons dedicate the required time for photography even during complex surgeries; the intense lighting of the operating field works against photography, and the surgeon has to utilise whatever equipment is available. We selected five complex interventions and two surgeons (one with an iPhone

Purpose: Using a standardized specimen protocol analysis, this study aimed to evaluate the resection margin status of patients who underwent resection for either distal cholangiocarcinoma (DC) or pancreatic ductal adenocarcinoma (PDAC). This allowed a precise millimetric analysis of each inked margin. Methods: From 2010 to 2018, 355 consecutively inked specimens from patients with PDAC (n = 288) or DC (n = 67) were prospectively assessed. We assessed relationships between the tumor and the following margins: transection of the pancreatic neck, bile duct, posterior surface, margin toward superior mesenteric artery, and the surface of superior mesenteric vein/portal vein groove. Resection margins were evaluated using a predefined cut-off value of 1 mm, however, clearances of 0 and 1.5 mm were also evaluated. Results: Patients with DC were mostly men (64% vs. 49%, p = 0.028), of older age (68 yo vs. 65, p = 0.033), required biliary stenting more frequently (93% vs. 77%, p &lt, 0.01), and received less neoadjuvant treatment (p &lt, 0.001) than patients with PDAC. The venous resection rate was higher among patients with PDAC (p = 0.028). Postoperative and 90-day mortality rates were comparable. Patients with PDAC had greater tumor size (28.6 vs. 24 mm, p = 0.01) than those with DC. The R1 resection rate was comparable between the two groups, regardless of the clearance margin. Among the three types of resection margins, a venous groove was the most frequent in both entities. In multivariate analysis, the R1 resection margin did not influence patient survival in either PDAC or DC. Conclusion: Our standardized specimen protocol analysis showed that the R1 resection rate was comparable in PDAC and DC.

Positive para-aortic lymph nodes (PALN) (station 16) are commonly detected in the final pathologic examination (ranging from 15 to 26%) among patients who undergo upfront pancreatoduodenectomy for resectable pancreatic ductal adenocarcinoma. However, after neoadjuvant treatment (NAT) the role of positive PALN as a watershed for surgical resection remains unclear. We aimed to determine the incidence of intraoperative detection of PALN after NAT with FOLFIRINOX for pancreatic head adenocarcinoma and its impact on survival, as our policy was to not resect the tumor in such situations. From January 2014 to December 2020, 136 patients with non-metastatic cancer who received neoadjuvant FOLFIRINOX and underwent explorative laparotomy were included. Intraoperative positive PALN were observed in 7 patients (5%). Patients had resectable (n = 5) or locally advanced (n = 2) disease at the time of surgery, but none of them underwent surgical resection. Positive PALN were significantly associated with a lower median number of FOLFIRINOX cycles (4 vs. 6, P = 0.05). There was no significant difference in overall survival between patients with positive loco-regional lymph nodes after resection and patients with non-resection owing to positive PALN (22 versus 16 months, P = 0.16), Overall survival with positive PALN, carcinomatosis, and liver metastasis was 16, 14, and 10 months, respectively (P > 0.05). Our results suggest that NAT may lower PALN involvement. We have modified our policy, positive PALN after NAT are no longer a contraindication to resection, rather a holistic picture of the disease guides management.

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.

Introduction Lors d’une pancreatectomie avec resection veineuse tronculaire, une reconstruction par interposition d’un greffon prothetique en polytetrafluoroethylene (PTFE) peut etre une option meme si un taux de thrombose eleve est souvent craint. Nous rapportons les resultats d’une serie monocentrique de reconstruction par PTFE avec un protocole d’anticoagulation postoperatoire standardise. Methode De 2014 a 2019, 19 reconstruction veineuse par PTFE ont ete realise. La permeabilite prothetique etait evaluee par scanner avant la sortie puis lors des consultations iteratives. Resultats La duodenopancreatectomie cephalique (DPC) representait l’intervention la plus realisee (15 patients, 79 %) et l’adenocarcinome etait l’histologie principale (17 patients, 89 %). La prothese avait un diametre et une longueur mediane de 1 cm et 8 cm, respectivement. La duree mediane de clampage etait de 25 min. La morbidite severe et la mortalite a 90 jours etaient de 21 % et 10 %, respectivement. Aucune infection de prothese n’a ete diagnostique meme en cas de fistule pancreatique ou biliaire. Il n’y a pas eu d’accident d’anticoagulation. Une thrombose precoce ( Conclusion La reconstruction veineuse par une prothese en PTFE au cours d’une pancreatectomie est efficiente et sans risque infectieux. Notre protocole standardise permettait une permeabilite a long terme acceptable. En cas de pancreatectomie gauche, une reconstruction autologue est a recommander.

International audience

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

Introduction La totalisation pancreatique (TP) en urgence apres duodenopancreatectomie cephalique (DPC) pour fistule grade C est une procedure difficile notamment pour les jeunes chirurgiens. Nous rapportons les resultats d’une technique standardisee en 4 etapes etablie afin de permettre une reintervention rapide meme par un chirurgien non-senior. Methode Lorsqu’une reintervention etait decidee, elle etait toujours validee par un chirurgien senior ; le chirurgien non-senior pouvait debuter l’intervention sans attendre l’arrivee du chirurgien responsable, qui venait toujours en renfort. La premiere etape est de deconnecter la gastro-entero-anastomose pour acceder rapidement a l’anastomose pancreatique et permettre ainsi une exposition adequate, particulierement en cas d’hemorragie active. La deuxieme etape, en cas d’anastomose pancreatico-jejunale, est de deconnecter l’anse pancreatique depuis l’anastomose hepatico-jejunale. Troisiemement, la totalisation pancreatique est effectuee avec ou sans preservation des vaisseaux spleniques et de la rate en fonction des conditions locales. Enfin, la quatrieme etape est la reconstruction digestive a l’aide d’une anse en Y, associee a un drainage large. Resultats De 2012 a 2019, 450 patients ont eu une DPC, et une reintervention pour fistule grade C etait decidee chez 30 patients : une TP a ete effectuee chez 21 patients (4,7 %) apres un delais moyen de 12 jours. Les pertes sanguines et la duree operatoire etaient de 600 mL et 4 h respectivement, en moyenne. La mortalite postoperatoire etait de 24 %. Conclusion La mortalite etait elevee mais inferieure a celle rapportee par d’autres series. Notre procedure standardisee semble donc fiable et reproductible, et peut etre particulierement utile pour les chirurgiens non-seniors.

Introduction En 2013, l’anastomose pancreatico-gastrique intussusceptee (PGI) etait decrite comme diminuant le taux de fistule pancreatique mais chez des patients ayant un risque variable. Le but de notre etude etait de comparer l’incidence de la fistule pancreatique cliniquement significative (FPC ; grade B ou C) chez les patients ayant une anastomose a haut risque (updated alternative-fistula risk score [ua-FRS] > 20 %) selon qu’ils aient eu une PGI ou une pancreatico-jejunale (PJ). Methodes De 2013 a 2019, 198 patients consecutifs ayant un ua-FRS moyen de 33 % ont ete inclus. Notre equipe avait une experience avec les PG directe mais une PGI n’etait realisee (n = 33) que lorsque les conditions etaient optimales (pancreas facilement mobilisable et exposition facile) en suivant la technique publiee. Les patients ont ensuite ete apparies sur l’IMC, le diametre du canal pancreatique, et l’ua-FRS avec 165 PJ. Resultats Pour l’ensemble des patients, une FPC etait diagnostiquee chez 42 patients (21 %), et une complication hemorragique chez 30 patients (15 %). La mortalite postoperatoire etait de 4 %. Le taux de FPC dans les groupes PJ et PGI etait de 19 % versus 33 % (p = 0,062), respectivement. Dans le groupe PGI, on notait une incidence plus elevee des FP grade C (24 versus 10 % ; p = 0,036), une duree operatoire plus longue (p = 0,019), et un taux de transfusion plus eleve (p Conclusion La PGI n’etait pas superieure a la PJ pour la prevention des FPC et, dans cette indication, a ete abandonnee par notre equipe.

Purpose This study proposes and details a simple and inexpensive protective technique of wrapping the hepatic and gastroduodenal artery stumps with a peritoneal patch during pancreatoduodenectomy (PD) in order to decrease post-pancreatectomy hemorrhage (PPH). Methods Among the 85 patients who underwent PD between July 2020 and March 2021, 16 patients with high-risk pancreatic anastomosis received a peritoneal patch. The Updated Alternative Fistula Risk Score (ua-FRS) was calculated. Post-operative pancreatic fistula (POPF) and PPH were diagnosed and graded according to the International Study Group of Pancreatic Surgery. The mortality rate was calculated up to 90 days after PD. Results The mean ua-FRS of the 16 patients was 43% (range: 21-63%). Among them, 6 (38%) experienced clinically relevant-POPF, and a PPH was observed in two patients (13%). In these two patients who required re-intervention, the peritoneal patch was remarkably intact, and neither the gastroduodenal stump nor hepatic artery was involved. None of the patients experienced 90-day mortality. Conclusion Although the outcomes are encouraging, the evaluation of a larger series to assess the effectiveness of the peritoneal protective patch for arteries in a high-risk pancreatic anastomosis is ongoing.

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.

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 restriction in the development of adult-adult Living Donor Liver Transplantation (LDLT) is the risk of morbidity and mortality for donors, which raises ethical questions. The objectives of this study are to review published studies dealing with morbidity and mortality in LDLT and to identify the proposed management and strategies for preventing donor mortality and morbidity in LDLT.Methods: The Medline database was searched from 2000 to 2017 using the MeSH terms “liver transplantation” and “morbidity” or “mortality” in combination with keywords “living donor liver transplantation”.Results: Among the 382 articles obtained, 43 articles were relevant for morbidity, 15 for mortality and 6 for both morbidity and mortality. Twenty-three papers reported donor deaths. The major cause of death was sepsis (30%). Morbidity ranged from 10% to 78.3% depending on the studies.Conclusions: The living donors’ morbidity and mortality is high, currently representing the main restriction in the development of LDLT. Some promising techniques, such as the donor portal vein flow modulation could lead to the further development of LDLT.

Background The benefit of performing major hepatic resection (MHR) for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial because of its high risk of posthepatectomy liver failure (PHLF). This study was conducted to assess the risk of MHR for HCC in patients with cirrhosis. Methods Patients with Child-Pugh A or B cirrhosis and HCC who underwent MHR from January 2000 to June 2014 were retrospectively identified. Risk factors for postoperative morbidity and mortality using univariate and multivariate analyses were evaluated. Results Seventy patients with Child-Pugh A (93%) and 5 (7%) with Child-Pugh B cirrhosis underwent MHR for HCC. Thirteen (17%) had Barcelona Clinic Liver Cancer (BCLC) stage A, 39 (50%) had BCLC B, and 23 (32%) had BCLC C disease. A perioperative blood transfusion was performed in 18 patients (24%). Ninety-day postoperative mortality was 9% (n=7). Major complications occurred in 16 patients (21%), including PHLF in 9 patients (12%). A multivariate analysis showed that perioperative blood transfusion was the main independent factor associated with mortality (OR= 6.5) and major morbidity (OR=10). Conclusion In selected patients with HCC and cirrhosis, MHR is feasible and has acceptable mortality, but careful perioperative management and limiting blood loss are required.

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.

Introduction : L’objectif de cette étude était de rapporter, à l’échelle nationale, les résultats de patients transplantés à partir de greffons ≥ 85ans depuis 2005 et d’identifier les caractéristiques pré-opératoires de mauvais pronostic à court et long terme. Matériel et méthode : Il s’agit d’une série rétrospective, multicentrique impliquant 15 centres de transplantation hépatique français. Les données issues des dossiers donneurs ainsi que les caractéristiques démographiques et péri opératoires de patients transplantés à partir de greffon ≥ 85ans entre le 1er janvier 2005 et le 31 décembre 2019 ont été colligées. La survie globale des patients a été calculée. Résultats : Trois cent cinquante-six patients ont été transplantés sur la période, l’âge moyen du greffon était de 86,8 ans. La principale indication était le carcinome hépato cellulaire (40%). Le MELD médian à l’inscription était de 14 (9-23). Les taux de non fonction et de dysfonction primaire du greffon étaient de 2,5% et 9% respectivement. Le taux de thrombose aiguë de l’artère hépatique était de 4% et 30% des patients ont présenté un évènement biliaire. La mortalité au cours de la même hospitalisation s’élevait à 9%. Les taux de survie à 1, -3 et -5 ans étaient respectivement de 80%, 68% et 60%. Vingt-sept (7,5%) patients ont nécessité une re transplantation. Conclusion : Au sein d’une population sélectionnée de receveurs, l’utilisation de greffons provenant de très vieux donneurs semble donner des résultats satisfaisants à court et long terme.