Morbid obesity increases death and dropout from the liver transplantation waiting list: A prospective cohort study

Liver transplant (LT) candidates with a body mass index (BMI) over 40 kg/m² have lower access to a liver graft without clear explanation. Thus, we studied the impact of obesity on the waiting list (WL) and aimed to explore graft proposals and refusal.

METHOD

Data between January 2007 and December 2017 were extracted from the French prospective national database: CRISTAL. Competing risk analyses were performed to evaluate predictors of receiving LT. Competitive events were (1) death/WL removal for disease aggravation or (2) improvement. The link between grade obesity, grafts propositions, and reason for refusal was studied.

RESULTS

15,184 patients were analysed: 10,813 transplant, 2847 death/dropout for aggravation, 748 redirected for improvement, and 776 censored. Mortality/dropout were higher in BMI over 35 (18% vs. 14% 1 year after listing) than in other candidates. In multivariate analysis, BMI>35, age, hepatic encephalopathy, and ascites were independent predictors of death/dropout. Candidates with a BMI ≥ 35 kg/m² had reduced access to LT, without differences in graft proposals. However, grafts refusal was more frequent especially for 'morphological incompatibility' (14.9% vs. 12.7% p < 0.01).

CONCLUSION

BMI over 35 kg/m² reduces access to LT with increased risk of dropout and mortality. Increased mortality and dropout could be due to a lower access to liver graft secondary to increased graft refusal for morphological incompatibility.

Laparoscopic versus open resection of intrahepatic cholangiocarcinoma: nationwide analysis

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 management of gallbladder polyps

Neoplastic gallbladder polyps (NGP) are rare; the prevalence in the overall population is less than 10%. NGP are associated with a risk of malignant degeneration and must be distinguished from other benign gallbladder polypoid lesions that occur more frequently. NGP are adenomas and the main risk associated with their management is to fail to detect their progression to gallbladder cancer, which is associated with a particular poor prognosis. The conclusions of the recent European recommendations have a low level of evidence, based essentially on retrospective small-volume studies. Abdominal sonography is the first line study for diagnosis and follow-up for NGP. To prevent the onset of gallbladder cancer, or treat malignant degeneration in its early phases, all NGP larger than 10mm, or symptomatic, or larger than 6mm with associated risk factors for cancer (age over 50, sessile polyp, Indian ethnicity, or patient with primary sclerosing cholangitis) are indications for cholecystectomy. Apart from these situations, simple sonographic surveillance is recommended for at least five years; if the NGP increases in size by more than 2mm in size, cholecystectomy is indicated. Laparoscopic cholecystectomy is possible but if the surgeon feels that the risk of intra-operative gallbladder perforation is high, conversion to laparotomy should be preferred to avoid potential intra-abdominal tumoral dissemination. When malignant NGP is suspected (size greater than 15mm, signs of locoregional extension on imaging), a comprehensive imaging workup should be performed to search for liver extension: in this setting, radical surgery should be considered.

Bevacizumab Associated with Chemotherapy for Initially Non-resectable Liver Metastases from Colorectal Cancer: a Case-Control Study

BACKGROUND

The place of bevacizumab in therapy of patients with initially non-resectable liver metastases from colorectal cancer (CRC) remains debated. Bevacizumab may increase the efficacy of chemotherapy but it may also maintain dormant micrometastases in a dormant state, eventually increasing the long-term likelihood of tumor relapse. The aim of this study was to explore this hypothesis.

PATIENTS AND METHODS

A retrospective case-control study was performed in patients with initially non-resectable CRC liver metastases. Metastases were rendered resectable after chemotherapy with (cases) or without (controls) bevacizumab. Cases and controls were matched for synchronicity, number and maximal size of metastases. The main objective was the disease-free survival (DFS).

RESULTS

A total of 82 patients were enrolled (41 in each group). The median DFS was 12.0 months in the bevacizumab group, and 10.2 months in the group treated with chemotherapy alone (p=0.26).

CONCLUSION

We observed no significant effect on DFS for bevacizumab when added to chemotherapy in patients with initially non-resectable liver metastases. Prospective trials on this issue are warranted.

Multicentre study of the impact of morbidity on long-term survival following hepatectomy for intrahepatic cholangiocarcinoma

BACKGROUND

The impact of morbidity on long-term outcomes following liver resection for intrahepatic cholangiocarcinoma is currently unclear.

METHODS

This was a retrospective analysis of all consecutive patients who underwent liver resection for intrahepatic cholangiocarcinoma with curative intent in 24 university hospitals between 1989 and 2009. Severe morbidity was defined as any complication of Dindo-Clavien grade III or IV. Patients with severe morbidity were compared with those without in terms of demographics, pathology, management, morbidity, overall survival, disease-free survival and time to recurrence. Independent predictors of severe morbidity were identified by multivariable analysis.

RESULTS

A total of 522 patients were enrolled. Severe morbidity occurred in 113 patients (21·6 per cent) and was an independent predictor of overall survival (hazard ratio 1·64, 95 per cent c.i. 1·21 to 2·23), as were age at resection, multifocal disease, positive lymph node status and R0 resection margin. Severe morbidity did not emerge as an independent predictor of disease-free survival. Independent predictors of time to recurrence included severe morbidity, tumour size, multifocal disease, vascular invasion and R0 resection margin. Major hepatectomy and intraoperative transfusion were independent predictors of severe morbidity.

CONCLUSION

Severe morbidity adversely affects overall survival following liver resection for intrahepatic cholangiocarcinoma.

FOLFOX4 versus sequential dose-dense FOLFOX7 followed by FOLFIRI in patients with resectable metastatic colorectal cancer (MIROX): a pragmatic approach to chemotherapy timing with perioperative or postoperative chemotherapy from an open-label, randomized phase III trial

BACKGROUND

Perioperative FOLFOX4 (oxaliplatin plus 5-fluorouracil/leucovorin) chemotherapy is the current standard in patients with resectable metastases from colorectal cancer (CRC). We aimed to determine whether a sequential chemotherapy with dose-dense oxaliplatin (FOLFOX7) and irinotecan (FOLFIRI; irinotecan plus 5-fluorouracil/leucovorin) is superior to FOLFOX4. The chemotherapy timing was not imposed, and was perioperative or postoperative.

PATIENTS AND METHODS

In this open-label, phase III trial, patients with resectable or resected metastases were randomly assigned either to 12 cycles of FOLFOX4 (oxaliplatin 85 mg/m(2)) or 6 cycles of FOLFOX7 (oxaliplatin 130 mg/m(2)) followed by 6 cycles of FOLFIRI (irinotecan 180 mg/m(2)). Randomization was done centrally, with stratification by chemotherapy timing, type of local treatment (surgery versus radiofrequency ablation with/without surgery), and Fong's prognostic score. The primary end point was 2-year disease-free survival (DFS).

RESULTS

A total of 284 patients were randomized, 142 in each treatment group. Chemotherapy was perioperative in 168 (59.2%) patients and postoperative in 116 (40.8%) patients. Perioperative chemotherapy was preferentially proposed for synchronous metastases, whereas postoperative chemotherapy was more frequently used for metachronous metastases. Two-year DFS was 48.5% in the FOLFOX4 group and 50.0% in the FOLFOX7-FOLFIRI group. In the multivariable analysis, more than one metastasis [hazard ratio (HR) = 2.15] and synchronous metastases (HR = 1.63) were independent prognostic factors for shorter DFS. Five-year overall survival (OS) rate was 69.5% with FOLFOX4 versus 66.6% with FOLFOX7-FOLFIRI.

CONCLUSIONS

FOLFOX7-FOLFIRI is not superior to FOLFOX4 in patients with resectable metastatic CRC. Five-year OS rates observed in both groups are the highest ever reported in this setting, possibly reflecting the pragmatic approach to chemotherapy timing.

CLINICAL TRIALS NUMBER

NCT00268398.

Prognostic implications of preoperative aerobic capacity and exercise oscillatory ventilation after liver transplantation

Our aim was to determine preoperative aerobic capacity (oxygen uptake [V'O2 ]) and prevalence of exercise oscillatory ventilation (EOV), underlying clinical characteristics of patients with EOV, and significance of reduced aerobic capacity and EOV in predicting mortality after liver transplantation. We prospectively studied 263 patients who underwent elective liver transplantation. Patients were followed up for 1 year. Despite minor impairment of resting cardiopulmonary function, preoperative aerobic capacity was reduced (peak V'O2 : 64 ± 19% predicted). EOV occurred in 10% of patients. Model for End-Stage Liver Disease score tended to be higher in patients with EOV compared to patients without, but failed to reach significance (p = 0.09). EOV patients had lower peak V'O2 and higher ventilatory drive. EOV was more frequent in nonsurvivors than in survivors (30% vs. 9%, p = 0.01) and was independently associated with posttransplant all-cause 1-year mortality. Reduced peak V'O2 best predicted the primary composite endpoint defined as 1-year mortality and/or prolonged hospitalization and early in-hospital mortality. Multivariate analysis revealed EOV (χ(2), 3.96; p = 0.04) and V'O2 (χ(2), 4.28; p = 0.04) as independent predictors of mortality and so-called primary composite endpoint, respectively. EOV and reduced peak V'O2 may identify high-risk candidates for liver transplantation, which would motivate a more aggressive treatment when detected.

Pathology report assessment of incidental gallbladder carcinoma diagnosed from cholecystectomy specimens: results of a French multicentre survey

AIMS

To assess the accuracy of pathology reports on gallbladder specimens from patients operated on for incidental gallbladder carcinoma.

METHODS

Demographic data, details on pathological reports including gross and microscopic features section were recorded in 100 selected patients with incidental gallbladder carcinoma diagnosed from 2004 to 2007.

RESULTS

Pathology reports had a conventional format in 93% of cases, without any standardization. Turnaround time ranged from 1 to 35 days. Frozen sections were performed in 20% of cases. The reports failed to give information on prognostic histological factors: exact tumour site (missing in 55% of cases), depth of tumour infiltration within the gallbladder wall (missing in 10%), surgical margins (missing in 40% for the cystic duct margin), tumour differentiation (missing in 28%), vascular invasion (missing in 52%) and perineural invasion (missing in 51%). Lymph node status could be assessed in 44% of cases. Distances between the tumour and the cystic duct and circumferential margins were not specified in 68% and 84% of cases. Only 29% of the reports clearly stated the pTNM stage in the conclusion section. The pT stage with margin status and tumour site was only mentioned in 30% of the reports.

CONCLUSION

Pathology reports on gallbladder carcinoma from participating centres frequently lacked important information on key prognostic histological factors.

Hepatic artery ligation for arterial rupture following liver transplantation: a reasonable option

Hepatic artery (HA) rupture after liver transplantation is a rare complication with high mortality. This study aimed to review the different managements of HA rupture and their results. From 1997 to 2007, data from six transplant centers were reviewed. Of 2649 recipients, 17 (0.64%) presented with HA rupture 29 days (2-92) after transplantation. Initial management was HA ligation in 10 patients, reanastomosis in three, aorto-hepatic grafting in two and percutaneous arterial embolization in one. One patient died before any treatment could be initiated. Concomitant biliary leak was present in seven patients and could be subsequently treated by percutaneous and/or endoscopic approaches in four patients. Early mortality was not observed in patients with HA ligation and occurred in 83% of patients receiving any other treatment. After a median follow-up of 70 months, 10 patients died (4 after retransplantation), and 7 patients were alive without retransplantation (including 6 with HA ligation). HA ligation was associated with better 3-year survival (80% vs. 14%; p=0.002). Despite its potential consequences on the biliary tract, HA ligation should be considered as a reasonable option in the initial management for HA rupture after liver transplantation. Unexpectedly, retransplantation was not always necessary after HA ligation in this series.

Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma

BACKGROUND

Indications for preoperative biliary drainage (PBD) in the context of hepatectomy for hilar malignancies are still debated. The aim of this study was to investigate current European practice regarding biliary drainage before hepatectomy for Klatskin tumours.

METHODS

This was a retrospective analysis of all patients who underwent formal or extended right or left hepatectomy for hilar cholangiocarcinoma between 1997 and 2008 at 11 European teaching hospitals, and for whom details of serum bilirubin levels at admission and at the time of surgery were available. PBD was performed at the physicians' discretion. The primary outcome was 90-day mortality. Secondary outcomes were morbidity and cause of death. The association of PBD and of preoperative serum bilirubin levels with postoperative mortality was assessed by logistic regression, in the entire population as well as separately in the right- and left-sided hepatectomy groups, and was adjusted for confounding factors.

RESULTS

A total of 366 patients were enrolled; PBD was performed in 180 patients. The overall mortality rate was 10·7 per cent and was higher after right- than left-sided hepatectomy (14·7 versus 6·6 per cent; adjusted odds ratio (OR) 3·16, 95 per cent confidence interval 1·50 to 6·65; P = 0·001). PBD did not affect overall postoperative mortality, but was associated with a decreased mortality rate after right hepatectomy (adjusted OR 0·29, 0·11 to 0·77; P = 0·013) and an increased mortality rate after left hepatectomy (adjusted OR 4·06, 1·01 to 16·30; P = 0·035). A preoperative serum bilirubin level greater than 50 µmol/l was also associated with increased mortality, but only after right hepatectomy (adjusted OR 7·02, 1·73 to 28·52; P = 0·002).

CONCLUSION

PBD does not affect overall mortality in jaundiced patients with hilar cholangiocarcinoma, but there may be a difference between patients undergoing right-sided versus left-sided hepatectomy.

Laparoscopic spleen-preserving distal pancreatectomy followed by intramuscular autologous islet transplantation for traumatic pancreatic transection in a young adult

CONTEXT

Pancreatic injuries caused by blunt trauma are often treated conservatively, except for the highest grades of these.

CASE REPORT

We report a case of complete transection of the distal pancreas in a young adult which was successfully managed by spleen-preserving laparoscopic distal pancreatectomy followed by an islet autotransplantation in the patient's forearm striated muscle.

CONCLUSION

We describe a mini-invasive approach for pancreatectomy with restoration of resected islets to the patient.

Assessment of pathology reports on hilar cholangiocarcinoma: the results of a nationwide, multicenter survey performed by the AFC-HC-2009 study group

BACKGROUND & AIMS

To assess the accuracy of pathology reports in patients operated on for hilar cholangiocarcinoma.

METHODS

Pathology reports for 263 patients operated on in 22 tertiary hepatobiliary centers were reviewed. The report format, turnaround time, tissue specimens, intraoperative consultations, macroscopic and microscopic descriptions, and conclusions were assessed.

RESULTS

Surgeons provided pathologists with pertinent clinical and imaging data in only 14% of cases and gave information on specimen orientation in only 24% of cases. The reports frequently failed to give information on prognostic histological factors: tumor differentiation (missing in 27% of cases), vascular invasion (45%), tumor thickness (99%), and infiltration of the bile duct surgical margins (4%). Distances between the tumor and the vessel margin, liver margin and the periductal soft tissue circumferential margin were not specified in 87%, 79%, and 89% of cases, respectively. Only 21% of the reports gave the pTNM stage in the conclusion section. A lack of information prevented retrospective pTNM staging in 48% of cases. Three percent of the reports had discrepancies in their conclusion section.

CONCLUSIONS

Our French, nationwide study revealed that pathology reports on hilar cholangiocarcinoma frequently lack important information on the main prognostic histological factors and pTNM staging. We recommend the use of a standardized pathology report in this context.

Hepatic venous pressure gradient in the assessment of portal hypertension before liver resection in patients with cirrhosis

BACKGROUND

Preoperative measurement of hepatic venous pressure gradient (HVPG) is not performed routinely before hepatectomy in patients with cirrhosis, although it has been suggested to be useful. This study investigated whether preoperative HVPG values and indirect criteria of portal hypertension (PHT) predict the postoperative course in these patients.

METHODS

Between January 2007 and December 2009, consecutive patients with resectable hepatocellular carcinoma (HCC) in a cirrhotic liver were included in this prospective study. PHT was assessed by transjugular HVPG measurement and by classical indirect criteria (oesophageal varices, splenomegaly and thrombocytopenia). The main endpoints were postoperative liver dysfunction and 90-day mortality.

RESULTS

Forty patients were enrolled. A raised HVPG was associated with postoperative liver dysfunction (median 11 and 7 mmHg in those with and without dysfunction respectively; P = 0·017) and 90-day mortality (12 and 8 mmHg in those who died and survivors respectively; P = 0·026). Oesophageal varices, splenomegaly and thrombocytopenia were not associated with any of the endpoints. In multivariable analysis, body mass index, remnant liver volume ratio and preoperative HVPG were the only independent predictors of postoperative liver dysfunction.

CONCLUSION

An increased HVPG was associated with postoperative liver dysfunction and mortality after liver resection in patients with HCC and liver cirrhosis, whereas indirect criteria of PHT were not. This study suggests that preoperative HVPG measurement should be measured routinely in these patients.

Prognostic value of jaundice in patients with gallbladder cancer by the AFC-GBC-2009 study group

INTRODUCTION

Jaundice is frequent in patients with gallbladder cancer (GBC) and indicates advanced disease and, according to some teams, precludes routine operative exploration. The present study was designed to re-assess the prognostic value of jaundice in patients with GBC.

METHODS

Patients with GBC operated from 1998 to 2008 were included in a retrospective multicenter study (AFC). The main outcome measured was the prognostic value of jaundice in patients with GBC focusing on morbidity, mortality and survival.

RESULTS

A total of 110 of 429 patients with GBC presented with jaundice, with a median age of 66 years (range: 31-88). The resectability rate was 45% (n=50) and the postoperative mortality and morbidity rates were 16% and 62%, respectively; 71% had R0 resection and 46% had lymph node involvement. Overall 1- and 3-year survivals of the 110 jaundiced patients were 41% and 15%, respectively. For the 50 resected patients, 1- and 3-year survivals were 48% and 19%, respectively (real 5-year survivors n=4) which were significantly higher than that of the 60 non-resected patients (31%, 0%, p=0.001). Among the resected jaundiced patients, T-stage, N and M status were found to have a significant impact on survival. R0 resection did not increase the overall survival in all resected patients, but R0 increased median survival in the subgroup of N0 patients (20 months versus 6 months, p=0.01).

CONCLUSION

This series confirms that jaundice is a poor prognostic factor. However, the presence of jaundice does not preclude resection, especially in highly selected patients (N0).

AJCC 7th edition of TNM staging accurately discriminates outcomes of patients with resectable intrahepatic cholangiocarcinoma: By the AFC-IHCC-2009 study group

BACKGROUND

This year, the 7th edition of the AJCC staging manual has for the first time attributed a unique pTNM staging to intrahepatic cholangiocarcinoma (IHCC) that is intended to replace the 2 Western and ideally also the 2 Eastern systems currently in use. This proposal, which has not yet been validated, was tested in the current study.

METHODS

Among 522 patients operated on with curative intent for an IHCC between 1994 and 2008 in tertiary hepatobiliary centers, those with mass-forming-type IHCCs, an R0 resection, and accurate pathological node staging were retained for evaluation. The distribution of these patients and their actuarial survival in the new TNM stages (as well as in the 4 previous ones) were compared.

RESULTS

Only 163 patients fulfilled the inclusion criteria, mainly because of the lack of routine lymphadenectomy, but patients and tumors characteristics of this population were representative. These patients were evenly distributed between AJCC 7th edition stages (stage I, 28%; stage II, 32%; stage III, 35%), which was not the case for the other systems. With an average follow-up of 34 months in survivors, the AJCC 7th edition was more discriminating than the others in predicting survival (median for stage I not reached; for stage II, 53 months, P = .01; for stage III, 16 months, P < .0001). Survival of these patients according to the 2 Japanese classifications was identical to that anticipated.

CONCLUSIONS

The 7th edition is clinically relevant and may be applicable worldwide, provided routine lymphadenectomy at the time of surgery for IHCC becomes the standard of care.

Pre-operative management is associated with low rate of post-operative morbidity in penetrating Crohn's disease

BACKGROUND

Ileocaecal resection for penetrating Crohn's disease is still challenging with a high rate of post-operative morbidity and faecal diversion.

AIM

To report retrospectively the results of pre-operative management for penetrating Crohn's disease focusing on the rate of post-operative major morbidities and need for faecal diversion.

METHODS

Between 1997 and 2007, 78 patients with penetrating Crohn's disease underwent a first ileocaecal resection after a pre-operative management consisting in bowel rest, nutritional therapy, intravenous antibiotics, weaning off steroids and immunosuppressors, and drainage of abscesses when appropriate.

RESULTS

Resection was performed for terminal ileitis associated with (n = 41), abscesses (n = 37) or both (n = 5). A pre-operative nutritional therapy was performed in 50 patients (68%) for 23 days (range, 7-69 days) along with a weaning off steroids and immunosuppressors. A diverting stoma was performed for six patients (7.7%). There was no post-operative death. Post-operative complications were classified as minor in 10 patients (12.8%), and major in four patients (5%). Overall, the post-operative course was uneventful in 58 patients (74%).

CONCLUSION

Pre-operative management for penetrating Crohn's disease allowed ileocaecal resection with low rates of post-operative morbidity and faecal diversion.

[Daily life, pregnancy, and quality of life after liver transplantation]

It is now accepted that patients with a liver transplantation regain the ability to lead a normal life within months of surgery, but at the price of lifetime immunosuppressive treatment and specific regular surveillance. A balanced and diversified diet, together with regular physical activity is necessary to prevent, limit, or delay the development of the cardiovascular complications that determine the prognosis for long-term survival. Attenuated live vaccines are contraindicated in patients treated with immunosuppressants to avoid the risk of reversion of the attenuation of the virus or bacteria. Travel abroad is possible to places with good sanitary conditions, if the patient increases his or her vigilance for any contagious infection. The global incidence of cancer is higher than in the general population, justifying specific and regular testing and clinical monitoring. A planned pregnancy is possible in patients stabilized after liver transplantation, and prognosis is most often good for mother and child. Early multidisciplinary management is essential because of the elevated risks of fetal growth restriction and preterm delivery. The global perception of quality of life increases after liver transplantation, but remains lower than in healthy subjects.

Mycophenolate mofetil monotherapy for severe side effects of calcineurin inhibitors following liver transplantation

Withdrawal of calcineurin inhibitors (CNI) followed by mycophenolate mofetil (MMF) monotherapy after liver transplantation (LT) remains controversial due to the increased risk of acute rejection and graft loss. The aim of the present study, performed in a large cohort of liver-transplanted patients with severe CNI-induced side effects, was to assess renal function recovery, and safety in terms of liver function, of complete CNI withdrawal and replacement by MMF monotherapy. Fifty-two patients treated with MMF monotherapy for CNI-induced toxicity were analyzed. Mean estimated glomerular filtration rate (eGFR) increased significantly during the period of MMF monotherapy, from 37 +/- 10 to 44.7 +/- 15 mL/min/1.73 m(2) at 6 months (p = 0.001) corresponding to a benefit of +17.4% in renal function. eGFR stabilized or improved in 86.5%, 81% and 79% of cases, and chronic renal dysfunction worsened in 13.5%, 19% and 21% of cases, at 6, 12 and 24 months after CNI withdrawal, respectively. Only two patients experienced acute rejection. MMF monotherapy may be efficient at reversing/stabilizing CRD, and appears relatively safe in terms of liver graft function in long-term liver-transplanted patients. However, clinicians must bear in mind the potential risk of rejection and graft loss, and should be very cautious in the management of such 'difficult-to-treat patients'.

Fatal hemophagocytic syndrome related to human herpesvirus-6 reinfection following liver transplantation: a case report

Human herpesvirus-6 (HHV-6) has been identified as the causal agent of exanthema subitum in early childhood (also called sixth disease or roseola), a mononucleosis-like disease in adults, and as an opportunistic pathogen in transplant recipients. In the latter setting, most infections are caused by reactivation of the latent virus in the recipient and generally have a paucisymptomatic course. Only limited data on HHV-6 infection are available for liver transplant recipients. Herein we have reported a case of fatal hemophagocytic syndrome related to HHV-6 reactivation 2 weeks after liver transplantation (LT). This case suggests that this virus may be a serious and potentially life-threatening pathogen following LT.

Inhibition of tissue factor-factor VIIa proteolytic activity blunts hepatic metastasis in colorectal cancer

BACKGROUND

Expression of the principal initiator of coagulation, tissue factor (TF), by colorectal cancer (CRC) cells is involved in tumoral angiogenesis and metastasis progression, after binding of factor VIIa (FVIIa) to TF and generation of TF-FVIIa activity. We thus hypothesized that inhibition of the TF pathway by active site-blocked FVIIa (FFR-FVIIa) may prevent the development of hepatic metastasis in CRC.

METHODS

Rat tumoral cells (DHDK12 proB cells) expressing high levels of TF were injected in the portal vein in syngenic BDIX rats. Rats received intraperitoneal injection of either FFR-FVIIa, from d 3 to d 7 (adjuvant treatment) (n = 19), or solvent buffer (n = 18) (control group). Additionally, cancer cells were infused subcutaneously in 20 other rats, which were assigned to FFR-FVIIa adjuvant treatment (n = 10), or buffer treatment (n = 10). Macroscopic and histological analysis was performed at d 14.

RESULTS

In the control group, infusion of cancer cells resulted in development of macroscopic hepatic tumors in 17/18 rats. In the adjuvant FFR-FVIIa group, macroscopic hepatic tumors were visible on the liver surface in 3/19 rats (P = 0.002 versus control). All rats with subcutaneous injection of proB cells exhibited macroscopic tumors, with no significant difference between the control and the treated ones.

CONCLUSION

Inhibition of the proteolytic activity of TF-FVIIa complex blunted hematogenous hepatic metastasis, suggesting that TF-FVIIa is a relevant target for the prevention of hepatic metastasis in CRC. TF-blocking agents should be investigated as adjuvant treatment in this setting.

Predictors of long-term survival after liver transplantation for metastatic endocrine tumors: an 85-case French multicentric report

Liver transplantation (LTx) for metastatic endocrine tumors (MET) remains controversial due to the lack of clear selection criteria. From 1989 to 2005, 85 patients underwent LTx for MET. The primary tumor was located in the pancreas or duodenum in 40 cases, digestive tract in 26 and bronchial tree in five. In the remaining 14 cases, primary location was undetermined at the time of LTx. Hepatomegaly (explanted liver > or =120% of estimated standard liver volume) was observed in 53 patients (62%). Extrahepatic resection was performed concomitantly with LTx in 34 patients (40%), including upper abdominal exenteration (UAE) in seven. Postoperative in-hospital mortality was 14%. Overall 5-year survival was 47%. Independent factors of poor prognosis according to multivariate analysis included UAE (relative risk (RR): 3.72), primary tumor in duodenum or pancreas (RR: 2.94) and hepatomegaly (RR: 2.63). After exclusion of cases involving concomitant UAE, the other two factors were combined into a risk model. Five-year survival rate was 12% for the 23 patients presenting both unfavorable prognostic factors versus 68% for the 55 patients presenting one or neither factor (p < 10(-7)). LTx can benefit selected patients with nonresectable MET. Patients presenting duodeno-pancreatic MET in association with hepatomegaly are poor indications for LTx.

Comparison of two techniques of transarterial chemoembolization before liver transplantation for hepatocellular carcinoma: a case-control study

Supraselective transarterial chemoembolization (STACE) more efficiently targets chemotherapy delivered via the feeding arterial branches of the tumor than does conventional transarterial chemoembolization (TACE). However, the hypothesis of its greater efficacy compared with the latter is subject to controversy. The aim of the present study was to compare STACE to conventional TACE in a controlled study of candidates for liver transplantation (LT) for hepatocellular carcinoma (HCC). Patients were matched for factors associated with HCC recurrence and survival. Sixty patients were included: 30 who were treated with STACE and 30 treated with conventional TACE. The 2 groups were similar in terms of matched criteria. In the overall population (uni- and multinodular HCC), there was no marked difference between the 2 groups in 5-year disease-free survival: 76.8% vs. 74.8%. In sensitivity analysis of patients considered to be the best candidates for TACE (uninodular HCC < or =5 cm), there was a trend toward significance between STACE and TACE in 5-year disease-free survival: 87% vs. 64% (P = 0.09). The only factor associated with complete tumor necrosis was STACE in the overall population (30.8% vs. 6.9%, P = 0.02), with a similar trend in the subgroup of patients with a single nodule (33.3% vs. 6.7%, P = 0.06), whereas the mean number of procedures was similar in the 2 groups (mean, 1.3 procedures; range 1-5 procedures; P = NS). STACE is more efficient at inducing complete tumor necrosis in the liver. This study observed trends toward improvement in the disease-free survival of patients with uninodular HCC < or =5 cm. Future studies focusing on such patients are warranted.

Conversion to sirolimus: a useful strategy for recalcitrant cutaneous viral warts in liver transplant recipient

Dermatological complications following transplantation are very common and the majority of immunosuppressed transplant recipients develop some to many warts due to human papillomavirus (HPV) infection. In the setting of immunosuppression, therapeutic management may be disappointing because of the extent of the lesions in patients unable to develop a sufficient immune response directed against HPV. We report here a case of a young liver transplant recipient who developed diffuse recalcitrant HPV-induced warts leading to an impairment of her quality of life. Taking into account the antiproliferative and cytostatic properties of the target-of-rapamycin (TOR) inhibitors, a new class of immunosuppressive drug, we significantly modified the immunosuppressive regimen. Conversion to sirolimus was followed by a rapid improvement of cutaneous state suggesting that this strategy may be useful for recalcitrant cutaneous viral warts in transplant recipient.

Non-invasive prediction of fluid responsiveness during major hepatic surgery

BACKGROUND

The aim of this study was to evaluate potential predictors of fluid responsiveness obtained during major hepatic surgery. The predictors studied were invasive monitoring of intravascular pressures (radial and pulmonary artery catheter), including direct measurement of respiratory variation in arterial pulse pressure (PPVart), transoesophageal echocardiography (TOE), and non-invasive estimates of PPVart from the infrared photoplethysmography waveform from the Finapres (PPVfina) and the pulse oximetry waveform (PPVsat).

METHODS

We conducted a prospective study of 54 fluid challenges (250 ml colloid) given for haemodynamic instability in eight patients undergoing hepatic resection. Fluid responsiveness was defined as an increase in stroke volume index (SVI) >or=10%. The following variables were recorded before each fluid challenge: right atrial pressure (RAP), pulmonary artery occlusion pressure (PAOP), PPVart, PPVfina, PPVsat, and the TOE-derived variables left ventricular end-diastolic area index (LVEDAI), early/late (E/A) diastolic filling wave ratio, deceleration time of the E wave (MDT) of mitral flow and the systolic fraction of the pulmonary venous flow (SF).

RESULTS

Only PPVfina, PPVart (both P<0.001), PPVsat (P=0.02), LVEDAI and MDT (both P=0.04) were different in responder vs non-responder fluid challenges. The areas under the receiver operating characteristic (ROC) curves were 0.81 (PPVfina), 0.79 (PPVart), 0.70 (LVEDAI), 0.68 (PPVsat and MDT), 0.63 (RAP), 0.62 (E/A), 0.55 (PAOP) and 0.42 (SF). The areas under the ROC curves for RAP, E/A, PAOP and SF were significantly less than that for PPVfina (P<0.05 in each case). Only PPVart (r=0.59, P=0.0001) and PPVfina (r=0.56, P=0.0001) correlated with the fluid challenge-induced changes in SVI.

CONCLUSIONS

PPVart and PPVfina predict fluid responsiveness during major hepatic surgery. This suggests that intraoperative monitoring of fluid responsiveness may be implemented simply and non-invasively.

Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis

Transjugular intrahepatic portosystemic shunt (TIPS) is a more effective treatment for refractory ascites than large volume paracentesis (LVP), but the magnitude of its effect in terms of control of ascites, encephalopathy and survival has not been established.

AIM

This meta-analysis compare TIPS to LVP in terms of control of ascites at 4 and 12 months, encephalopathy and survival at 1 and 2 years.

RESULTS

Five randomized controlled trials involving 330 patients were included. In the TIPS group, control of ascites was more frequently achieved at 4 months (66% vs 23.8%, mean difference: 41.4%, 95% confidence interval (CI): 29.5-53.2%, P < 0.001) and 12 months (54.8% vs 18.9%, mean difference: 35%, 95% CI: 24.9-45.1%, P < 0.001), whereas encephalopathy was higher (54.9% vs 38.1%, mean difference: 17%, 95% CI: 7.3-26.6%, P < 0.001). Survival at 1 year (61.7% vs 56.5%, mean difference: 3.2%, 95% CI: -14.7 to 21.9%) and 2 years (50% vs 42.8%, mean difference: 6.8%, 95% CI: -10 to 23.6%) were not significantly different.

CONCLUSIONS

TIPS is a more effective treatment for refractory ascites than LVP. However, TIPS increase encephalopathy and does not improve survival.

Renal function outcome in pediatric liver transplant recipients

The orthotopic liver transplantation (OLT) allows survival of children followed for severe hepatic injury, provided that the immunosuppressive treatment is prolonged. The nephrotoxicity of cyclosporine predicts the long-term outcome of the adult patients receiving a liver transplant. The aim of this study was to determine the long-term outcome of renal function in children receiving OLT. This study included 12 children, with a median for age of 7.1 yr (2-15 yr) at the time of OLT. The duration of follow-up was at least 4 yr, being 7 yr in 10 patients and more than 10 yr in seven. Renal function was evaluated with the serum level of creatinine, calculated glomerular filtration rate (cGFR), and measurement of glomerular filtration rate using chrome 51 ethylenediaminetetraacetate ((51)Cr EDTA) clearance performed at least once during follow-up. The doses and the serum concentrations (C(0)) of cyclosporine were reported at each study time. The cGFR decreased significantly 2 yr after the OLT [median (range): 106 mL/min/1.73 m(2) (71-150) at the time of OLT vs. 85 mL/min/1.73 m(2) (57-128) 2 yr after the OLT, p = 0.03], and decreased again between 7 and 10 yr after OLT [median (range): 99 mL/min/1.73 m(2) (76-125) 7 yr after OLT vs. 81 mL/min/1.73 m(2) (66-140) 10 yr after OLT, p = 0.04]. Six patients developed chronic renal failure (cGFR from 57 to 80 mL/min/1.73 m(2)) 2 yr after OLT associated with high doses of cyclosporine [median (range): 8.8 mg/kg/day (3.5-13)]. The cGFR overestimated renal function by 16% compared with the isotopic measurement of GFR (p = 0.03). Using the (51)Cr EDTA measurement, six of seven patients followed up more than 10 yr after OLT presented mild (n = 3) or moderate (n = 3) chronic renal failure. In our study, the majority of OLT recipients developed a chronic renal failure 10 yr after transplantation. Cyclosporine seems to be the most important factor responsible for the impairment of renal function. The use of the mycophenolate mofetil, a new immunosuppressive agent, allowing a reduction in the dose of cyclosporine, could minimize renal dysfunction. While awaiting the results of a prospective long-term study, close drug monitoring is advised.

Traumatismes graves fermés du foie : à la recherche de critères décisionnels pour le choix du traitement non-opératoire. À propos d'une série de 88 cas

AIM OF THE STUDY

To analyze the predictive value of computed tomography (CT) and initial physiologic and laboratory data findings in the immediate operative (OP) or non-operative (NOP) management of blunt liver injury (BL).

METHODS

Eighty-eight BL, grade III (51), grade IV (28) and nine grade V (9), aged 26.2 years (16-75) were identified. Hemoperitoneum on CT, hemodynamic status, physiologic and laboratory data <24 hours or preoperative (transfusion, vascular filling) and follow-up >48 hours were analyzed.

RESULTS

Data of 71/88 (80%) NOP and 17/88 (20%) OP patients were reviewed. A secondary laparotomy or laparoscopy was necessary in 11/71 TNO. Six OP (35%) and 1 NOP patients died. Blood units transfused were 1.33 (0-10) vs 5.9 (0-22) and vascular filling 1.45 (0.5-5.5) vs 3.6L (2-12) (P<10(-6), P<4.10(-3) respectively). NOP patients had less severe hemoperitoneum (31 vs 94%, P<10(-5)) and hemodynamic instability (8.5 vs 94%, P<10(-4)). But, there was an overlap of values of blood units transfused, amount of vascular filling and initial haemoglobin levels between NOP and OP patients and among CT grades of liver injury. No cut-off values could be determined: 33% NOP received >4 blood units and >3 L vascular filling; 30% had severe hemoperitoneum. In OP group 23.5% patients had lower values and no severe hemoperitoneum.

CONCLUSION

In the management of BL, vascular filling and blood transfusion increased with the grade of CT liver injury and were globally more elevated in the operative group but did not individually correlate with hemodynamic stability and did not authorize, by themselves, to decide between operative versus non-operative management.

Prise en charge et traitement de l’adénomatose duodénale de la polypose adénomateuse familiale

AIM OF THE STUDY

To review our global management of duodenal adenomas in patients with familial adenomatous polyposis and report the results of different therapeutic approaches. To present the outcome and possible sequels of pancreaticoduodenectomy.

PATIENTS AND METHODS

We identified five cases of duodenal adenomas in patients with familial adenomatous polyposis over a period of 10 years (1992-2001), we followed the progression of their Spigelman score. Results of conservative and surgical treatment were collected.

RESULTS

Duodenal adenomas were discovered 5-33 years after the first operation for colonic polyposis. The score of Spigelman was as follows: 2, stage 2; 3, stage 3; 1, stage 4. Endoscopic laser therapy followed by Sulindac prescription was proposed in three cases, with only one success. Duodenopancreatectomy was performed in four patients: once the diagnosis of adenoma was made in one patient, due to Spigelman stage 4 with severe dysplasia, because development of intramucosal carcinoma under surveillance in one patient, and after failure or complication of conservative treatment in two others. Worsening of Spigelman score was observed in two out of four patients submitted to conservative therapy. Correlation between Spigelman score and final examination of the specimen was correct in two cases. There was neither significant morbidity nor long-term nutritional sequel after pancreaticoduodenectomy.

CONCLUSION

Duodenal adenomas may recur or progress into malignant degeneration under conservative treatment. The pancreaticoduodenectomy is an acceptable solution for stage 4 of Spigelman, especially when severe dysplasia is present.

[Gastric conservation in severe caustic lesions of the digestive tract: is it legitimate?]

OBJECTIVE

To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries.

METHODS

Among 40 patients with severe caustic gastric burns (> IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation.

RESULTS

Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality.

CONCLUSION

Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.

[Evaluation of verification of brain death and coordination with hospital organ procurement at the University Hospital at Lille]

OBJECTIVES

To determine the incidence of brain death (BD) and to evaluate the registration of potential organ donors (PD) by the organ procurement team (OPT).

STUDY DESIGN

Two-year prospective audit in the French university hospital of Lille.

PATIENTS AND METHODS

All deaths occurring in the intensive care units or the emergency department were studied. If death was consecutive to brain damage, on-site review of medical records and charts was performed. Death cause, presence of criteria for brain death and reference to the OPT were recorded for each death. A medical expert staff evaluated the incidence of and reasons for unsuitability for organ donation. After 12 months of observation, a protocol for "systematic alert of the OPT when brain death is suspected" was broadcast and evaluated during the next 12 months.

RESULTS

During the first period, 277 BD occurred and 119 PD were suitable for organ donation. The OPT recorded 80 PD (67.2% of all PD) and 45 multi-organ procurements (MOP) were performed. Physicians opposed two major reasons for not calling OPT: anticipation of a non-validated medical contraindication in 18 cases and approach of the family without the OPT team in 21 cases. After broadcast of the protocol, 110 PD were identified and the OPT was called in 93 cases (84.5% of all PD, p < 0.004 versus first period). Fifty-three MOP were performed.

CONCLUSION

The OPT was not called to manage one-third of the PD. The protocol for "systematic alert of the OPT when brain death is suspected" improves the call of the OPT and increases MOP.

[Hemorrhagic digestive metastases from testicular choriocarcinoma]

The metastasis of testicular choriocarcinoma are often hemorrhagic, primarily of cerebral or pulmonary seat. The secondary digestive localizations are rare and of bad forecast when they bleed. The surgical operation by laparotomy allows the topographic diagnosis and the treatment, but was made responsible for hemorrhagic decompensation of other metastatic localizations engaging the vital forecast.

Heterozygous M3Mmalton alpha1-antitrypsin deficiency associated with end-stage liver disease: case report and review

Alpha1-antitrypsin (alpha1AT) deficiency is an autosomal recessive disorder that can cause pulmonary emphysema and liver disease. We report here the case of a 59-year-old woman who was admitted to hospital for evaluation of jaundice. She had no history of hepatitis or childhood liver disease. She had never received a blood transfusion, nor had she abused drugs or alcohol. Transjugular liver biopsy was then performed and revealed a micronodular cirrhosis. Ten months later, because of persistent liver cell failure and ascites, she underwent an orthotopic liver transplantation. Investigation of alpha1AT system in the proband revealed a substantial decrease in serum alpha1AT associated with a low elastase inhibitory capacity. The Pi phenotype revealed a PiM-like profile. Sequencing of exons 1-5 demonstrated the presence of the M3 allele. Moreover, a triple nucleotide deletion was detected in exon 2 of one allele. This caused an "in-phase" frameshift, coding for a protein deficient in a single Phe residue, which corresponded to the Mmalton variant. After liver biopsy, periodic acid-Schiff-positive acidophilic bodies resistant to diastase digestion were observed in the cytoplasm of hepatocytes. These results demonstrated that our patient had a heterozygous M3Mmalton alpha1AT genotype related to a deficiency phenotype. This observation is the first of a patient with heterozygous Mmalton genotype associated with an alpha1AT deficiency that induced severe liver disease requiring orthotopic liver transplantation.

Successive emergence of two CD8 subsets in primary CMV infection of allograft recipients

Allograft recipients with cytomegalovirus (CMV) infection develop increased proportions of circulating CD8+ lymphocytes. A longitudinal study of 11 kidney and 5 liver allograft recipients with primary CMV infection but no other aetiological factor to explain graft dysfunction revealed selective imbalances in peripheral blood CD8+ T cell subsets. Initially, CMV viraemia was associated with elevated CD8+bright T cell numbers and T cell activation. Activation markers fell to normal when viral cultures became negative (before the end of the 1st month). During the 2nd-6th months, most (12/16) patients continued to have high CD8+ T cell counts (1050-2900 CD8+ cells/mm3), comprising an uncommon CD8+ T cell subset, as 45-73% of CD8+bright lymphocytes were CD3+ and TCRalphabeta+ but were not stained by anti-CD28, CD11b, CD16, CD56 and CD57 antibody. Unexpectedly, CD8+ CD57+ T cells, a hallmark of CMV infection, did not appear until the 2nd-6th months of primary CMV infection, and their numbers increased progressively thereafter. They became the predominant CD8+ T cell subset after about 6 months of infection and their persistence for several (up to 4) years was strongly correlated (r = 0.87) with expansion of CD8+ cells. Persistence of CD8 lymphocytosis was, thus, directly related to the rate of expansion of an uncommon CD8+ CD57- subset and its progressive replacement by CD8+ CD57+ T cells that were chronically elicited by CMV.

Prolongation of cardiac allograft survival by selective injection of donor liver leukocytes in non-immunosuppressed rats

Liver grafts are spontaneously accepted in several animal combinations and are able to induce acceptance of another organ originating from the same donor, which would be rejected when transplanted alone. However, the exact mechanism of this unique tolerance induction capability remains unclear. The aim of our study was to investigate the ability of nonparenchymal liver cells to induce tolerance when they were separated from their parenchymal environment. In the murine combination we used (BN --> LEW), heart transplants were constantly tolerated after combined liver plus heart grafting, but rejected when transplanted alone. Nonparenchymal liver cells were isolated from BN rat livers by enzymatic digestion and injected, at different times, to LEW rats, which were recipients of BN heart transplants. The average number of mononuclear cells obtained after isolation was 20 x 10(6)/5 g of rat liver. Immediate trypan-blue exclusion test showed more than 95% of viable cells. Phenotypic studies showed a predominant (47%) lymphocyte population, 7% were monocytes and 46% were cellular debris. Among the lymphocyte population, the majority of cells were bearing the NKR-P1 receptor and about 30% CD3 receptors. Inoculation of nonparenchymal liver cells 7 and 30 days prior to heart transplantation significantly prolonged graft survival compared to controls (14.6 and 12.7 vs. 8.1 days; p = 0.0008 and 0.0059, respectively), whereas simultaneous injection (day 0) had no effect. Injection of donor splenocytes or nonparenchymal liver cells from a third party, at any time, had no effect on rejection. These results provide some more evidence about the specific role of liver lymphocytes in allogenic unresponsiveness. They also suggest that the hepatic parenchymal environment is necessary for the optimal development of this phenomenon.

Liver transplantation eliminates insulin needs of a diabetic patient

Organ transplantation and subsequent therapeutic agents may induce or worsen preexisting diabetes mellitus. We report the case of a diabetic patient whose insulin needs disappeared after liver transplantation. Non insulin-dependent diabetes mellitus was diagnosed when she was 47, and was treated by hypoglycemic drugs and then insulin. Chronic post-hepatitis C cirrhosis was diagnosed at the age of 55 and required liver transplantation 2 years later. During the postoperative course, the insulin doses required to maintain normal glucose levels progressively decreased, and insulin became completely unnecessary by the 29(th) postoperative day. After insulin was stopped, glucose levels remained within normal ranges for the 5-year-long follow-up, despite the worsening of a preexisting diabetic nephropathy and the occurrence of a diabetic retinopathy. This case highlights the fact that liver transplantation may eliminate insulin needs in a diabetic patient but also shows that degenerative complications may occur despite apparent remission of diabetes.

Negative immunohistochemical detection of CD103 (alphaEbeta7 integrin) in the infiltrates of acute rejection in liver and kidney transplantation

BACKGROUND

The infiltration of epithelium by CD8+ T lymphocytes in human renal or liver allografts is a critical feature of acute rejection. CD103 expression can be acquired in vitro by CD8+ cytotoxic T lymphocytes in response to allogeneic renal epithelial cells and promotes their adhesion to epithelium and subsequent lysis of epithelial cells. We investigated the expression of CD103 in T-cell infiltrates during acute renal or liver rejection (grade < III).

METHODS

Immunohistochemical detection of CD103 in 11 liver and 10 kidney transplant biopsies with histopathological diagnosis of acute rejection.

RESULTS

None of the infiltrates expressed detectable CD103, although positive controls were stained under our conditions.

CONCLUSIONS

Failure to detect CD103 in renal biopsies can be related to the early posttransplantation interval (<6 months) corresponding to a first rejection episode. In our hands, immunohistological detection of CD103 was not possible in the infiltrates of acute rejection in liver or kidney transplantation.

Natural killer cell and alphabeta and gammadelta lymphocyte traffic into the liver graft immediately after liver transplantation

BACKGROUND

The persistence and migration of donor leukocytes has been well established, but cellular kinetics immediately after revascularization and the potential relevance of these different lymphocyte populations to spontaneous tolerance remain unclear. During the early hours of revascularization, there is a transitory "congestion" of the liver graft, which is evidence of an early phase that we have termed "first cellular contact."

METHODS

We have carried out by flow cytometry a prospective comparative study of the peak kinetics of lymphocyte subpopulations contained in: (a) peripheral blood and liver grafts at the time of multi-organ extraction from 14 brain-dead donors, (b) recipient peripheral blood before transplantation, and (c) recipient peripheral blood and liver grafts after (t=2 h) declamping and vascularization of the liver graft.

RESULTS

Before transplantation, the liver grafts contained large numbers of natural killer (NK) and NK-like cells with early lymphocyte activation. Immediately after revascularization, there was an influx of recipient NK and NK-like cells into the liver.

CONCLUSIONS

NK and CD3+CD56+ (NK-like) cells flooding into the liver graft immediately after revascularization could rapidly destroy allogeneic cells. However, spontaneous tolerance and the persistence of donor lymphocytes after orthotopic liver transplant could be a result of donor TCRalphabeta NK1.1 liver graft lymphocytes, which may be involved in the destruction of CD8+ T lymphocytes that would have received the apoptosis signal, and to NK and NK-like cell inhibition via inhibitory NK receptors. The decrease in gammadelta T lymphocytes in the two compartments suggests a mechanism of recirculation and capture in other lymphoid organs.

[Congenital hernia of the diaphragm. A retrospective study of 123 cases recorded in the Neonatal Medicine Department, URHC in Lille between 1985 and 1996]

BACKGROUND

During the last ten years, new therapeutic strategies have been used in order to improve the management of congenital diaphragmatic hernia (CDH). CDH is associated with pulmonary hypoplasia, abnormal pulmonary vascular reactivity and pulmonary immaturity. Between 1985 and 1990, mechanical hyperventilation and early surgery were provided systematically. Since 1991, the management of CDH in our institution has involved a preoperative stabilization with exogenous surfactant replacement, gentle ventilation, high-frequency oscillation, nitric oxide or extracorporeal membrane oxygenation.

PURPOSE

To analyse the impact of the new therapeutic strategy on the survival and outcome of newborns with CDH.

METHODS

Retrospective review of all infants with CDH admitted to our institution from 1985 through 1996. Mortality and morbidity were compared between period I (1985-1990) and period II (1991-1996).

RESULTS

Between 1985 and 1996, 123 neonates were admitted to our Neonatal Department. Nine of them had another severe congenital malformation and were excluded from the study. Survival was 23% (12/52) in period I and 56% (35/62) in period II (p < 0.001). In period II, complications were more frequent among survivors in whom an extracorporeal membrane oxygenation was required (13 infants): bronchopulmonary dysplasia 77% (10/13), gastroesophageal reflux 61% (8/13), and hypotrophy 61% (8/13).

CONCLUSION

These data demonstrate a significant improvement in survival in CDH since the implementation of new therapeutic modalities. Nevertheless, a significant morbidity exists among the infants who survive a severe respiratory failure.

[Adjuvant intra-arterial chemotherapy after curative resection of liver metastasis from colorectal cancer. Results of a pilot study in 30 patients]

OBJECTIVE

Five-year survival after simple resection of liver metastases from colorectal carcinoma ranges from 20 to 40%. The aim was to study the reliability and long term results of adjuvant intra-arterial chemotherapy after resection of colorectal liver metastases.

PATIENTS AND METHOD

From 1991 to 1997, 30 patients after a complete resection of liver metastases from colorectal cancer were included (16 men, 14 women, mean age: 62 years). There were 2 stage I, 19 stages II, 2 stages III, 5 stages IV and 2 stages V according to Gayowski staging system. During laparotomy, a catheter was placed in the gastroduodenal artery in order to perfuse the proper hepatic artery. Chemotherapy included 5 Fluorouracil (12 mg/m2) and Leucovorin (200 mg/m2) and was administered once a week during six months. Mean follow-up was 52 months.

RESULTS

Adjuvant intra-arterial chemotherapy had to be interrupted before six months in 9 patients because leukopenia (n = 2), infection or obstruction of the catheter (n = 5), duodenal migration of the catheter (n = 1) and occurrence of multiple extrahepatic metastases (n = 1). No death was in relation with the method. Five-year survival rate was 41.8% for the global series. Five-year disease free survival rate was 21.4%. Causes of death were: hepatic recurrence only (n = 3), extrahepatic + hepatic recurrence (n = 4), extrahepatic recurrence (n = 2). Two patients died of another carcinoma (esophagus, ovary), without evidence of recurrence of the colorectal carcinoma. At the present, there is a recurrence in 4 living patients.

CONCLUSION

Although the benefit on survival is not significant, these results suggest a longest time of remission in patients with adjuvant intra-arterial chemotherapy. Trials comparing and/or combining this method to intravenous chemotherapy should be proposed in patients after resection of colorectal liver metastases.

Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava: review of 1361 cases

OBJECTIVE

The objective of this study was to describe the complications specifically related to orthotopic liver transplantation (OLT) with preservation of the inferior vena cava and to their therapeutic management. This preservation technique has considerably influenced the surgical phases of liver transplantation, increasing hepatectomy time and modifying the number of vascular anastomoses.

METHODS

Our retrospective multicentric study, based on data from 1361 adult patients that had undergone orthotopic liver transplantation with preservation of the inferior vena cava in France between 1991 and 1997, analyzed the concomitant surgical complications. Type of cavo-caval anastomosis performed (piggyback, end-to-side, or side-to-side), use of a temporary portacaval anastomosis, technique-related complications, and mortality, were investigated.

RESULTS

Cavo-caval anastomosis was side-to-side in 50.6% of cases (n=689), piggyback in 42.7% (n=582), and end-to-side in 6.6% (n=90). In total, 882 temporary portacaval anastomosis were carried out. Fifty-five patients presented with one or more complications related to the preservation of the inferior vena cava technique; i.e., overall morbidity was 4.1% (55/1361). Overall mortality was 0.7% (10/1361). Mortality rate for patients who presented with surgical complication was 18%. A total of 64 complications were recorded: 57 (89%) were in the perioperative or immediate postoperative period and 7 (11%) were postoperative.

CONCLUSIONS

These retrospective, descriptive results show significant advantages in favor of side-to-side anastomosis in terms of vascular complications. Certain factors should be evaluated specifically at pretransplant assessment to prevent certain serious complications; principally, these are anatomic factors of the recipient (inferior vena cava included in segment I, anatomic abnormalities of the inferior vena cava) and graft size. Depending on these factors, surgeons must be able to adapt the orthotopic liver transplantation, either before or during orthotopic liver transplantation, preferring the standard technique.

Favorable nutritional outcome after isolated liver transplantation for liver failure in a child with short bowel syndrome

A patient with short gut syndrome presented with end-stage liver disease. She underwent an isolated liver transplantation at the age of 3.5 years. Parenteral nutrition was discontinued 1.5 years after surgery. At 7 years of age, the patient has maintained normal nutritional indices and growth while on a normal oral diet. This observation suggests that liver transplantation alone can be a valuable alternative to the combined small bowel/liver transplantation in short bowel syndrome when intestinal adaptation is expected and if the ileocecal valve is present and that improvement of gut function can occur after successful liver transplantation.