Acute diverticulitis with extraluminal air: is conservative treatment sufficient? A single-center retrospective study

BACKGROUND

Acute diverticulitis with extraluminal air constitutes a heterogeneous condition whose management is controversial. The aims of this study are to report the failure rate of conservative treatment for diverticulitis with extraluminal air and to report risk factors of conservative treatment failure.

METHODS

A retrospective study was performed from an institutional review board-approved database of patients admitted with acute diverticulitis with extraluminal air from 2015 to 2021 at a tertiary referral center. All patients managed for acute diverticulitis with covered perforation (without intraabdominal abscess) were included. The primary endpoint was failure of medical treatment, defined as a need for unplanned surgery or percutaneous drainage within 30 days after admission.

RESULTS

Ninety-three patients (61% male, mean age 57 ± 17 years) were retrospectively included. Ten patients had failure of conservative treatment (11%). These patients were significantly older than 50 years (n = 9/10, 90% versus n = 47/83, 57%, p = 0.007), associated with cardiovascular disease (n = 6/10, 60% versus n = 10/83, 12%, p = 0.002), American Society of Anesthesiologists (ASA) score of 3-4 (n = 4/7, 57% versus 6/33, 18%, p = 0.05), under anticoagulant and antiplatelet (n = 6/10, 60% versus n = 11/83, 13%, p = 0.04) and steroid or immunosuppressive therapy (n = 3/10, 30% versus 5/83, 6%, p = 0.04), and with distant pneumoperitoneum location (n = 7/10, 70% versus n = 14/83, 17%, p = 0.001) compared with those with successful conservative treatment. On multivariate analysis, only distant pneumoperitoneum was an independent risk factor of failure (odds ratio (OR) 6.5, 95% confidence interval (CI) [2-21], p = 0.002).

CONCLUSIONS

Conservative treatment with antibiotics for acute diverticulitis with extraluminal air is safe with a success rate of 89%. Patients with distant pneumoperitoneum should be carefully monitored.

Endovascular therapies for hepatic artery stenosis post liver transplantation

PURPOSE

To evaluate primary patency at 12 months after endovascular therapies in hepatic artery stenosis.

METHODS

A retrospective review of all endovascular interventions for hepatic artery stenosis (HAS) after liver transplantation that occurred between June 2013 and November 2020 was performed at a single institution in France. Follow up occurred from 1 month to 4 years (median 15 months). The treatment consisted of dilation with a balloon or stent. We analyzed short-term (technical success and complications) and long-term outcomes (liver function, arterial patency, graft survival at 12 months (GS), and reintervention). We also compared percutaneous balloon angioplasty (PBA) with stent placement. PBA alone was used if < 30% residual stenosis of the hepatic artery was achieved. Stenting was performed if there was greater than 30% residual stenosis and in the case of complications (dissection or rupture).

RESULTS

A total of 18 stenoses were suspected on the basis of routine surveillance duplex ultrasound imaging (peak systolic velocity > 200 cm/s, systolic accelerating time > 10 ms and resistive index < 0.5), all of which were confirmed by angio CT, but only 17 were confirmed by angiography. Seventeen patients were included (14 males, mean age 57 years; and three females, mean age 58 years). Interventions were performed in 17 cases (95%) with PBA only (5/17), stent only (5/17) or both (4/17). Immediate technical success was 100%. Major complications occurred in 1 of 17 cases (5.8%), consisting of target vessel dissection. The analysis of the three (groups PBA only, stent only or both) showed the same procedural success (100%), GS (100%) and normal liver function after the procedures but different rates of complications (20% vs. 0% vs. 0%), arterial patency at 12 months (60% vs. 80% vs. 85%) (p = 0.4), early stenosis (40% vs. 80% vs. 0%) or late stenosis (60% vs. 20% vs. 100%) and requirement for reintervention (40% vs. 20% vs. 14%) (p = 0.56).

CONCLUSION

This study suggests that PBA, stent, or both procedures show the same primary patency at 12 months. It is probably not a definitive answer, but these treatments are safe and effective for extending graft survival in the context of graft shortages.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial

Background

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.

Methods

This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.

Conclusion

This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey

BACKGROUND

The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.

METHODS

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.

RESULTS

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).

CONCLUSION

Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.

Risk score to predict biliary leakage after elective liver resection

Background

Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL.

Methods

In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated.

Results

A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P &lt; 0·001; 15 versus 3·1 per cent in the validation cohort, P &lt; 0·001).

Conclusion

The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.

Efficacy and Safety of Everolimus and Mycophenolic Acid With Early Tacrolimus Withdrawal After Liver Transplantation: A Multicenter Randomized Trial

SIMCER was a 6-mo, multicenter, open-label trial. Selected de novo liver transplant recipients were randomized (week 4) to everolimus with low-exposure tacrolimus discontinued by month 4 (n = 93) or to tacrolimus-based therapy (n = 95), both with basiliximab induction and enteric-coated mycophenolate sodium with or without steroids. The primary end point, change in estimated GFR (eGFR; MDRD formula) from randomization to week 24 after transplant, was superior with everolimus (mean eGFR change +1.1 vs. -13.3 mL/min per 1.73 m² for everolimus vs. tacrolimus, respectively; difference 14.3 [95% confidence interval 7.3-21.3]; p < 0.001). Mean eGFR at week 24 was 95.8 versus 76.0 mL/min per 1.73 m² for everolimus versus tacrolimus (p < 0.001). Treatment failure (treated biopsy-proven acute rejection [BPAR; rejection activity index score >3], graft loss, or death) from randomization to week 24 was similar (everolimus 10.0%, tacrolimus 4.3%; p = 0.134). BPAR was more frequent between randomization and month 6 with everolimus (10.0% vs. 2.2%; p = 0.026); the rate of treated BPAR was 8.9% versus 2.2% (p = 0.055). Sixteen everolimus-treated patients (17.8%) and three tacrolimus-treated patients (3.2%) discontinued the study drug because of adverse events. In conclusion, early introduction of everolimus at an adequate exposure level with gradual calcineurin inhibitor (CNI) withdrawal after liver transplantation, supported by induction therapy and mycophenolic acid, is associated with a significant renal benefit versus CNI-based immunosuppression but more frequent BPAR.

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.

Minimal portal vein stenosis is a promising preconditioning in living donor liver transplantation in porcine model

BACKGROUND & AIMS

The main hindrance in promoting living donor liver transplantation remains the morbi-mortality risk for the donor. Considering the opposed remodeling influence of portal and hepatic artery flows, our working hypothesis was to identify a lobar portal vein stenosis capable of inducing a contralateral liver mass compensatory enlargement, without the downstream ipsilateral atrophic response.

METHODS

Twenty-four pigs entered this study. Six of them were used to establish hemodynamic changes following a progressive left portal vein (LPV) stenosis, in blood flow, pressure and vessel diameter of the LPV, main portal vein and hepatic artery. Sixteen pigs were divided into 4 groups: sham operated animals, 20% LPV stenosis, 50% LPV stenosis, and 100% LPV stenosis. Daily liver biopsies were collected until post-operative day 5 to investigate liver regeneration and atrophy (Ki67, STAT3, LC3, and activated caspase 3) according to the degree of LPV stenosis. Finally, changes in liver volumetry after 20% LPVS were investigated.

RESULTS

A 20% LPV stenosis led to dilatation of the hepatic artery and a subsequent four-fold increase in hepatic arterial flow. Concomitantly, liver regeneration was triggered in the non-ligated lobe and the cell proliferation peak, 5 days after surgery, was comparable to that obtained after total LPV ligation. Moreover, 20% LPV stenosis preconditioning did not induce left liver atrophy contrary to 50 and 100% LPV stenosis.

CONCLUSIONS

A 20% LPV stenosis seems to be the adequate preconditioning to get the remnant liver of living donor ready to take on graft harvesting without atrophy of the future graft.

Noble gas (argon and xenon)-saturated cold storage solutions reduce ischemia-reperfusion injury in a rat model of renal transplantation

BACKGROUND

Following kidney transplantation, ischemia-reperfusion injury contributes to adverse outcomes. The purpose of this study was to determine whether a cold-storage solution saturated with noble gas (xenon or argon) could limit ischemia-reperfusion injury following cold ischemia.

METHODS

Sixty Wistar rats were randomly allocated to 4 experimental groups. Kidneys were harvested and then stored for 6 h before transplantation in cold-storage solution (Celsior®) saturated with either air, nitrogen, xenon or argon. A syngenic orthotopic transplantation was performed. Renal function was determined on days 7 and 14 after transplantation. Transplanted kidneys were removed on day 14 for histological and immunohistochemical analyses.

RESULTS

Creatinine clearance was significantly higher and urinary albumin significantly lower in the argon and xenon groups than in the other groups at days 7 and 14. These effects were considerably more pronounced for argon than for xenon. In addition, kidneys stored with argon, and to a lesser extent those stored with xenon, displayed preserved renal architecture as well as higher CD-10 and little active caspase-3 expression compared to other groups.

CONCLUSION

Argon- or xenon-satured cold-storage solution preserved renal architecture and function following transplantation by reducing ischemia-reperfusion injury.

Regression of new-onset diabetes mellitus after conversion from tacrolimus to cyclosporine in liver transplant patients: results of a pilot study

INTRODUCTION

New-onset diabetes mellitus (NODM) has important implications for long-term outcome following liver transplantation.

AIM

To evaluate the impact of conversion from tacrolimus to cyclosporine in liver transplant patients presenting NODM.

METHOD

In a 12-month pilot study, 39 liver transplant patients with NODM were converted from tacrolimus to cyclosporine. Most patients (59%) were receiving antidiabetic therapy (18% insulin, 41% oral) and all patients had received dietary advice prior to the study.

RESULTS

At month 12, NODM had significantly resolved (FBG<7 mmol/L without treatment) in 36% of patients (95% CI 20.8-51.0%). In the 16 patients not receiving antidiabetic drugs at baseline, mean FBG decreased from 8.1 mmol/L to 6.6 mmol/L (P=0.008) and mean HbA(1c) decreased from 6.4 to 6.0% (P=0.05). Steroids were stopped rapidly in the nine patients receiving steroids at inclusion but NODM resolution was observed in only one of these nine patients. No significant factors were identified that could have affected NODM resolution. There were three episodes of biopsy-proven acute rejection (7.7%), no graft losses and one death. Overall, cyclosporine tolerance was good with no significant change in creatinine clearance at month 12. Total cholesterol increased from 4.6 mmol/L to 5.1 mmol/L (P<0.001).

CONCLUSIONS

These results suggest that liver transplant patients with NODM may benefit from conversion to cyclosporine from tacrolimus through improved glucose metabolism. Confirmation in a prospective, randomized comparative study is required.

Liver transplantation in a patient treated by sorafenib for hepatocellular carcinoma

Sorafenib is a multikinase inhibitor currently used in the palliative treatment of advanced hepatocellular carcinoma. In patients with small hepatocellular carcinoma, sorafenib could be suggested as neoadjuvant therapy to control tumor growth during waiting time for liver transplantation. However, up to now, safety of liver transplantation in patients undergoing sorafenib treatment is not known. Herein, we report a case of successful liver transplantation in a patient treated by sorafenib for hepatocellular carcinoma. In this patient, liver transplantation was performed safely and histological examination of explanted liver evidenced complete necrosis of the largest tumor nodule.

[Mesenteric venous ischemia secondary to portal stenosis following liver transplantation]

We report a case of portal vein stenosis six months after previous orthotopic liver transplantation. The patient presented with mesenteric venous ischemia. He underwent successful percutaneous transhepatic portal vein angioplasty and stent placement.

[Abdominal cystic tumor revealing lymphangioleiomyomatosis]

We report the case of a 39 year-old woman with many years of intermittent abdominal pain who was found to have cystic masses evocative of cystic lymphangioma involving the posterior mediastinal and retroperitoneum. Worsening abdominal pain led to a recommendation for laparoscopic unroofing and decompression of the cysts. During the postoperative period, hemorrhagic shock required reintervention with excision of the tumoral mass. Pathologic examination revealed lymphangioleiomyomatosis (LAM). On the 15th postoperative day, the patient developed a chylopneumothorax which required prolonged chest tube drainage. The presence of multiple polycystic lesions in the pulmonary parenchyma supported the diagnosis of diffuse LAM with primary extrapulmonary presentation. This diagnosis should be considered preoperatively since it modifies the treatment: a complete excision of the cystic lesions seems to be necessary in order to prevent bleeding and lymphatic extravasation.

A national survey of acute hepatitis E in France

BACKGROUND

Few data are available on the incidence, risk factors and contamination pathways involved in acute indigenous hepatitis E in developed countries.

AIMS

To draw up an overall picture of hepatitis E cases, to confirm whether or not the majority of the cases were indigenous and to attempt to identify the risk factors and contamination pathways involved in hepatitis E.

METHODS

This study was performed in the framework of a national network (ANGH) including 96 participating centres. The 19 centres with at least one case of acute HEV reported a total number of 53 cases.

RESULTS

A decreasing South-to-North geographic gradient was observed. A nonspecific clinical profile was observed in many cases. Acute hepatitis E was of indigenous origin in 90% of the patients. The most relevant and/or frequent possible risk factors among the 47 indigenous metropolitan cases were water consumption from a personal water supply, uncooked shellfish consumption and the recent acquisition of a pet pig.

CONCLUSIONS

This national survey confirmed that acute indigenous hepatitis E is an emerging disease in developed countries such as France, and suggests that various risk factors are responsible for acute indigenous hepatitis E contamination in non-endemic countries.

Fortuitous discovery of common bile duct stones: results of a conservative strategy

OBJECTIVE

The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy.

PATIENTS AND METHODS

Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken.

RESULTS

Cholecystectomy was performed in 124 patients with symptomatic gallstones and no signs predictive of stones in the common bile duct. A stone was found fortuitously in the common bile duct in 12 patients. The control cholangiogram was normal in two of these patients on day two (16.7%) and in six others (50%) at the six-week control. All 12 patients remained free of symptoms suggesting the presence of a stone in the common duct. Presence of the drain had no impact on quality-of-life. Endoscopic extraction was finally performed for four patients (33.3%) to remove a stone from the common bile duct.

CONCLUSION

Early surgical or endoscopic extraction of stones in the common bile duct should not be undertaken systematically in asymptomatic patients. Spontaneous asymptomatic clearance of the common bile duct is observed in about half of patients.

[Renal cell carcinoma: management of venous thrombus]

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

Evaluation of glycogen loss in human liver transplants. Histochemical zonation of glycogen loss in cold ischemia and reperfusion

To find a prognosis model of human liver transplant, we evaluate 62 surgical biopsies for the loss of glycogen and its variations in relation to cold ischemia, reperfusion, lobular zonation and donor's ages. We applied univariate, multivariate and discriminant analysis and logistic regression. There was a clear lobular zonation of glycogen during cold ischemia and at reperfusion. During cold ischemia, the mean loss was 48% in periportal zones and 74% in pericentrilobular zones. At reperfusion, it was in the range of 60% in periportal zones and 95% in pericentrilobular zones. It was observed in 64% of the grafts for an ischemia time less than 10 hr and in 82% of the grafts for an ischemia time of 10 hr or more. It was increased by 90% at reperfusion with pericentral predominance. Donors' age was an aggravating factor of glycogen loss beyond 28 years of age. In conclusion, in periportal zones, mean global glycogen depletion was about 54% during cold ischemia and reperfusion. It decreased by 90% at reperfusion with pericentral predominance. Logistic regression has allowed modelization of cold ischemia and reperfusion.

High incidence of colic anastomotic leakage complicating upper abdominal en bloc evisceration for cancer: a 47-patient series

BACKGROUND/AIMS

The purpose of this study was to analyze the early outcome of en bloc extended resection for upper abdominal locally advanced cancer.

METHODOLOGY

A retrospective medical chart review was performed in 47 consecutive patients who underwent an upper abdominal en bloc resection for cancer involving multiple organs or structures at Paoli-Calmettes Institute and Conception Hospital from October 1988 through April 1997. A third of patients underwent a resection of 4 sus mesocolic organs or more.

RESULTS

The postoperative morbidity and mortality rate were respectively, 57% and 19%. Despite a high number of theoretically risky procedures including pancreatic resection and pancreatojejunostomy, total gastrectomy and esophagojejunostomy, total hepatectomy and liver transplantation, the higher percentage of complication was found with colic anastomosis. Five of the 30 patients (17%) who underwent a colic anastomosis developed a colic anastomotic leakage, 4 patients were reoperated and 2 patients died.

CONCLUSIONS

Because of this unacceptably high rate of complications, we propose to systematically perform a protective stoma when an upper abdominal evisceration includes a colic anastomosis.

Effect of ischemia-reperfusion on bile canalicular F-actin microfilaments in hepatocytes of human liver allograft: image analysis by confocal laser scanning microscopy

We studied and quantified the effect of ischemia-reperfusion on hepatic F-actin on bile canalicular and basolateral membranes in human liver allografts by means of confocal laser scanning microscopy imaging. The phalloidin-FITC staining of F-actin was normal in liver hepatocytes before reperfusion but decreased significantly after reperfusion (by 25% of controls). These results indicate that hepatic F-actin alteration is produced during the reperfusion phase. This modification, probably induced by reactive oxygen species, could impair bile canalicular contraction and tight junction permeability and consequently bile secretion in the postoperative period.

Modified AdCTLA-4 vector blocks alloimmune response in vitro

BACKGROUND

Gene transfer of the costimulatory blockade molecule CTLA-4Ig into cold-preserved rat liver allografts results in indefinite allograft survival. Despite local delivery, this mode of immunomodulation is associated with systemic immunosuppression. In an effort to restrict immunosuppression to the graft, we have constructed a novel adenoviral vector, AdCTLA-4ex-TAG, in which the Ig sequence of CTLA-4Ig DNA has been deleted to destabilize the gene product to promote rapid extrahepatic degradation while maintaining its immunosuppressive activity within the graft milieu.

METHODS

(1) Vector construction. CTLA-4 extracellular binding domain (CTLA-4ex) was prepared by PCR-based cloning methods and fused in frame to a genetic element encoding an epitope TAG allowing identification of the transgene product CTLA-4exTAG. CTLA-4exTAG was subcloned into a shuttle vector enabling isolation of AdCTLA-4exTAG. (2) In vitro transfection: AdCTLA-4exTAG was transfected into MH(1)C(1) cells and then supernatant was recovered for Western blot analysis. (3) In vitro alloimmune response was characterized by CFSE proliferation assay. (4) Extrahepatic effect of AdCTLA-4exTAG was characterized by the ability to control tumor growth after implantation of a regressive, immune sensitive cancer cell line (REGb) in the skin of BDIX rats after liver transduction with AdCTLA-4exTAG.

RESULTS

Expression and secretion of the recombinant protein were documented by Western blot after infection of the MH(1)C(1) cell line() with AdCTLA-4exTAG. Addition of infected MH(1)C(1) cell supernatant resulted in abrogation of alloimmune response as shown by markedly diminished division of CD4(+) T cells in a CFSE proliferation assay. Extrahepatic tumor regressed normally after liver transduction with AdCTLA-4exTAG.

CONCLUSIONS

These results show efficient in vitro expression of CTLA-4exTAG after transfection with AdCTLA-4exTAG. The modified protein retains its ability to abrogate in vitro alloimmune response. Efficient control of extrahepatic tumor growth after liver-directed delivery of AdCTLA-4exTAG suggests that the immunosuppressive effect of this vector is restricted to the liver. These results set the ground for the utilization of this novel adenoviral vector in the transplant setting.

Budd-Chiari syndrome secondary to intracardiac extension of hepatocellular carcinoma. Two cases treated by radical resection

Two young women presenting Budd-Chiari syndrome as the primary manifestation of hepatocellular carcinoma with intracardiac extension were treated by debulking of the atrium and inferior vena cava under extracorporeal circulation and major hepatectomy. The first patient who was treated in a single procedure died during the immediate postoperative period. The second patient who was treated in two steps died of meningeal and pulmonary metastases 12 months later. Clinical findings and surgical strategy for this rare condition are discussed in the light of 6 previously reported surgical cases.

Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series

OBJECTIVE

To review the outcome of resection of the suprarenal or infrarenal inferior vena cava (IVC) and possible indications for prosthetic replacement.

SUMMARY BACKGROUND DATA

Involvement of the IVC has long been considered a limiting factor for curative surgery for advanced tumors because the surgical risks are high and the long-term prognosis is poor. Prosthetic replacement of the IVC is controversial.

METHODS

The authors retrospectively reviewed a 7-year series of 14 patients who underwent en bloc resection including a circumferential segment of the IVC. The tumor was malignant in 12 patients and benign in 2. The resected segment of the IVC was located above the kidneys in eight patients and below in six. Resection was performed without extracorporeal circulation in all patients.

RESULTS

In all but one patient, IVC resection was associated with multivisceral resection, including extended nephrectomy (n = 8), major hepatic resection (n = 3), digestive resection (n = 3), and infrarenal aortic replacement (n = 2). Prosthetic replacement of the IVC was performed in eight patients cases and was more common after resection of a suprarenal (6/8) than an infrarenal segment of the IVC (2/6). One patient died of multiorgan failure. Major complications occurred in 29% of patients. Symptomatic complications of prosthetic replacement occurred in one patient (acute postoperative thrombosis, successfully treated by surgical disobstruction). Graft-related infection was not observed. Marked symptoms of venous obstruction developed in three of the six patients who did not undergo venous replacement. In patients undergoing surgery for malignant disease, the estimated median survival was 37 months and the actuarial survival rate was 67% at 1 year.

CONCLUSION

Multivisceral resection including a segment of IVC is justified to achieve complete extirpation in selected patients with extensive abdominal tumors. Prosthetic replacement of the IVC may be required, particularly in cases of suprarenal resection. It is a safe procedure with a low complication rate and good functional results.

Quantitative analysis of glycogen content in hepatocytes of human liver allograft after ischemia and reperfusion

In order to examine glucose metabolism in liver grafts after cold ischemia and reperfusion, the heterogeneous lobular distribution pattern of glycogen content was studied using histochemical quantitative analysis. In most of the cases, this heterogeneous pattern of glycogen was observed after preservation and reperfusion. However, a 42% reduction of glycogen content, expressed as the ratio between stained surface and total surface of liver biopsies, was observed in biopsies after reperfusion. Moreover, both periportal and centrilobular hepatocytes showed a significant decrease in mean optical density after reperfusion (18% and 25%, respectively). The comparison of our results to early postoperative liver function tests and cold ischemia times showed no significant correlation (p<0.05).

Oxidative metabolism of bupivacaine into pipecolylxylidine in humans is mainly catalyzed by CYP3A

Bupivacaine is used to provide prolonged anesthesia and postoperative analgesia. The human cytochrome P450 (CYP) involved in bupivacaine degradation into pipecolylxylidine (PPX), its major metabolite, has, to our knowledge, never been described. Microsome samples were prepared from six human livers and incubated in the presence of bupivacaine. The concentrations of PPX in the microsomal suspensions were assessed, and K(m) and V(max) values were calculated. Bupivacaine incubations were then performed with specific CYP substrates and inhibitors. For each sample of hepatic microsomes, the correlation between the rate of PPX formation and the corresponding erythromycin N-demethylase activity was analyzed. Finally, an immunoinhibition study using an anti-rabbit CYP3A6 antibody and assays with cDNA-expressed human CYP were conducted. The apparent K(m) and V(max) values of bupivacaine were, respectively, 125 microM and 4.78 nmol/min/mg of microsomal protein. The strongest inhibition of bupivacaine metabolism was obtained for troleandomycin (-95% at 50 microM), a specific CYP3A inhibitor. The correlation between PPX formation and erythromycin N-demethylase activity showed an R value of 0.99 whereas anti-rabbit CYP3A6 antibody inhibited the degradation of bupivacaine into PPX by 99%. Finally, CYP1A2 and CYP2E1 cDNA-expressed forms of human CYP did not allow PPX formation, CYP2C19 and CYP2D6 produced only small amounts whereas CYP3A4 most efficiently metabolized bupivacaine into PPX. These results demonstrated that bupivacaine degradation into PPX was mediated in humans by CYP3A.

Effect of ischemia-reperfusion on the heterogeneous lobular distribution pattern of glycogen content and glucose-6-phosphatase activity in human liver allograft

In order to examine glucose metabolism in liver grafts after cold ischemia and reperfusion, the heterogeneous lobular distribution pattern of glycogen content and glucose-6-phosphatase activity was studied using histochemical methods. The characteristic heterogeneous lobular distribution pattern of glycogen and glucose-6-phosphatase was maintained after preservation and reperfusion. However, it appeared that glycogen content decreased in both periportal and centrilobular hepatocytes after reperfusion. The glycogen decrease was higher in periportal hepatocytes. Glucose-6-phosphatase activity was maintained after reperfusion in most of the cases in periportal hepatocytes. In centrilobular hepatocytes, more cases showed a decrease in enzyme activity. It is suggested that ischemia-reperfusion mainly affects the glycogen content in both periportal and centrilobular hepatocytes and that centrilobular glucose-6-phosphatase activity is more sensitive to ischemia-reperfusion injury than periportal hepatocytes.

[Hepatocellular carcinoma in a non-cirrhotic liver. Presentation of series of 77 operated patients]

OBJECTIVE

To present epidemiologic profile of this supposedly rare condition, its diagnostic management and the results of surgical treatment in a population of the mediterranean border.

PATIENTS AND METHODS

Between 1987 and 1999, the records of patients operated on for hepatocellular carcinoma and in whom cirrhosis was not present on pathological examination of liver parenchyma were collected. Data were collected prospectively.

RESULTS

Mean age was 57.6 years. There were 61 men (79%) and 16 women but sex ratio was 1/1 for patients under 50. Hepatitis B and/or C serology was positive in 22 patients (29%). At presentation, 56 patients (73%) suffered of symptoms and there was evidence of tumor at clinical examination in 30 (39%). Sensitivity of alpha-fetoprotein measurement was 55%, and 58% for preoperative percutaneous biopsy. Twelve had exploratory laparotomy only, 61 underwent partial liver resection and 4 were transplanted. Resection was presumed curative in 56 cases (73%). There was one single tumor mass in 41 cases (53%) and its mean size was 10.3 cm. Liver fibrosis was present in 24 cases (29%). After curative resection, 5-year survival rate was 46%, and favorable prognostic factors were: alpha-fetoprotein within normal range, single tumor mass or tumor size less than 10 cm.

CONCLUSION

Hepatocellular carcinoma arising on noncirrhotic liver is not a rare occurrence. It is usually encountered at an advanced stage of the disease. Nonetheless, it remains extirpable in many cases with low postoperative mortality and long term results are better than those of resections for hepatocellular carcinoma on cirrhotic liver.

Morbidity of major hepatic resections: a 100-case prospective study

OBJECTIVE

To assess the morbidity and its main risk factors after major hepatic resection.

DESIGN

Retrospective study of prospectively collected data.

SETTING

University hospital, France.

SUBJECTS

100 consecutive patients who underwent major hepatic resections, 1989-95.

INTERVENTIONS

Major hepatic resection, defined as resection involving 3 or more segments according to Couinaud's classification, in all cases.

MAIN OUTCOME MEASURES

All complications that affected outcome or prolonged hospital stay. Risk factors identified by univariate and multivariate analysis.

RESULTS

45 patients developed at least 1 complication and 7 died. The most common complications were: pleural effusion (n = 21), hepatic failure (n = 12), and ascites (n = 9). Univariate analysis showed that the following variables were significantly related to the morbidity: age >55 years, American Society of Anesthesiologists (ASA) grade II or more, bilirubin >80 micromol/L, alkaline phosphatase activity more than double the reference range, malignant tumours, abnormal liver parenchyma, simultaneous surgical procedures, operative time >4 hours, and perioperative blood transfusion > or =600 ml. The extent of resection did not correlate with postoperative complications. Multivariate analysis showed that volume of blood transfusion > or =600 ml and simultaneous surgical procedures were the most important independent risk factors for complicated outcome.

CONCLUSIONS

The morbidity associated with major hepatic resections remains high, and the main determinants of outcome are intraoperative surgeon-related factors.

[Liver transplantation in the adult: who and when to transplant?]

INTRODUCTION

The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected, or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue.

CURRENT KNOWLEDGE AND KEY POINTS

Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease; and secondly, in an acceptable risk taking manner. Major criteria for indication in the most common liver diseases can be summarized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred, is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 mumol/L is generally required; c) apart from "small" hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications; d) acute liver failure requires early referral to a liver transplant center for potential emergency indication.

FUTURE PROSPECTS AND PROJECTS

In an organ shortage situation which is likely to perdure, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure.

[Retroperitoneal ectopic pregnancy: report of a case]

Retroperitoneal space is an exceptional location of extrauterine pregnancy (four cases have been previously reported). The authors report a case of retroperitoneal ectopic pregnancy. Pathogenesis is discussed.

Inflammatory process complicating giant hemangioma of the liver: report of three cases

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

Intravenous leiomyomatosis with caval involvement: report of a case with radical resection and venous replacement

Intravenous leiomyomatosis is a rare, histologically benign neoplasm that may be malignant in its specific tendency to intravascular extension. A case of intravenous leiomyomatosis with extension into the entire inferior vena cava in a 41-year-old woman is described. The patient was diagnosed with syncope 3 years after hysterectomy and was treated with a 1-stage procedure including venous replacement.

[Prognostic value of E-cadherin expression in hepatocellular carcinoma]

Expression of E-cadherin (E-cad) was investigated immunohistologically in 91 cases of operated hepatocellular carcinomas. An alteration of E-cad immunodetection was found in 56% of tumours. These alterations were correlated with histopathologic features of prognostic value including tumour size (> 3 cm), high nuclear grade and mitotic index. Patients with down-regulated E-cad expression had statistically significant shorter survival than the others. Although E-cad immunodetection was an independent prognostic factor, the Cox multivariate analysis showed that its prognostic value was low when compared to other prognostic factors.

Surgical resection of locally recurrent colorectal adenocarcinoma

BACKGROUND

Recurrence rates after curative resection of colorectal adenocarcinoma remain steady at 50 per cent. Thirty per cent of the deaths are linked to locoregional recurrence. The aim of this study was to evaluate the results of resection for locoregional recurrence.

METHODS

This retrospective review analyzed a series of 120 patients who underwent resection of colonic (56) or rectal (64) locoregional recurrence. Sixty-nine resections were considered as curative. Sixty-one recurrences required extended resection. There were nine synchronous hepatic resections.

RESULTS

The hospital mortality rate was 7 per cent and the morbidity rate was 40 per cent. The overall 5-year survival rate was 27 per cent. Survival was significantly higher: (1) after curative resection (44 versus 0 per cent after palliative resection, P < 0.0001); (2) in women (44 versus 11 per cent for men, P = 0.0036); and (3) after resection for intramural recurrence (45 versus 19 per cent for extramural recurrence, P = 0.0024). Multifactorial analysis showed that curability of the resection was the most important prognostic parameter.

CONCLUSION

The results in this highly selected group seem to justify an attempt at reresection whenever possible. Long-term results may be improved by using adjuvant treatment.

Immunoexpression of E-cadherin and beta-catenin correlates to survival of patients with hepatocellular carcinomas

Expression of E-cadherin (E-cad) and -catenin ( -cat) was investigated immunohistologically in 91 cases of excised hepatocellular carcinomas. Immunodectection was altered in 56% of tumours for E-cad and in 30.8% for -cat. Downregulation of E-cad and -cat correlated with the size of tumours, and high nuclear grade, but only E-cad alteration correlated with the mitotic index. Alterations of E-cad and -cat expression correlated with survival. Although E-cad and -cat immunodetections were independent prognostic factors, their prognostic value was lower than that of current clinicopathological parameters.

[Pelvic recurrence of cancers of the uterine cervix. A study of a series of 49 cases]

BACKGROUND

Pelvic recurrence of cervical cancer is a life-threatening event for patients. The main therapeutic challenge is to locally control such relapses. We present our experience of the surgical treatment of pelvic cervical cancer relapses.

PATIENTS AND METHODS

From July 1980 to January 1994, 49 patients underwent a surgical procedure for pelvic cervical cancer relapse. Forty four tumor relapses were localized in the pelvis and 5 were associated with distant metastases. Surgery was performed alone in 31 cases and in association with radiotherapy in 18 cases. Median follow-up was 34 months.

RESULTS

The treatment was curative in 49% of cases. There was a significant correlation between the initial stage, the site of tumor relapse and surgical curability. Overall actuarial survival was 44% and 24% at 2 and 5 years, respectively. In the curative treatment group, actuarial survival was 71% and 47% at 2 and 5 years, respectively. There was a major surgical complication in 14 cases: 11 reoperations were performed. Thirteen patients are alive of whom 12 with no evidence of disease (median follow-up; 36 months). A local control was achieved in 53% of cases. Age and site of relapse significantly influenced survival.

CONCLUSIONS

The results of this study are comparable with other surgical series despite our less favorable patient selection. For patients experiencing pelvic side-wall infiltration, surgical treatment is a worthwhile palliation in selected cases because it is often the only available therapeutic option.

Mechanically stapled esophagojejunostomy. Results of a prospective series of 176 cases

BACKGROUND/AIMS

To evaluate the reliability of stapled esophagojejunostomy.

MATERIAL AND METHODS

We studied a non-selected prospective series of 176 consecutive total gastrectomies (169 cancers, 7 benign pathologies).

RESULTS

Hand-sewn esophagojejunostomy was performed 5 times after failure of the stapled esophagojejunostomy. There were fourteen hospital deaths (8%), and 63 patients (36%) presented complications. There were 5 anastomotic leaks (2.8%) but non were responsible for deaths. In these 5 cases, there had been an incident during construction of the esophagojejunostomy. Such an incident was the only significant risk factor for an anastomotic leak: 17% after an incident and 0% in the absence of an incident (p < 0.001). We observed no cases of anastomotic stricture.

CONCLUSION

Stapled esophagojejunostomy is a reliable technique when technical precautions are taken. It is easier to reproduce than hand-sewn esophagojejunostomy and has demonstrated low specific morbidity and no direct mortality.

[Recurrence after surgical treatment of epidermoid cancers of the esophagus. Therapeutic approach in 19 patients]

OBJECTIVES

The aim of this study was to report the management of 19 patients with recurrence of esophageal squamous cell carcinoma after surgical treatment.

PATIENTS-METHODS

Nineteen patients with loco-regional recurrent invasion (n = 13) or metastasis (n = 6) of esophageal squamous cell carcinoma were included. Four of the 13 patients with loco-regional recurrent invasion had tracheal involvement. The treatment of the recurrence was a combined radiochemotherapy (n = 12) for loco-regional recurrent invasion in 11 cases and for metastasis in 1 case, associated with a tracheal prosthesis in 1 patient. The other treatments were chemotherapy alone (n = 5), esophageal prosthesis (n = 1) and surgical treatment (n = 1).

RESULTS

There were 7 objective responses among the 12 patients treated with combined radiochemotherapy and none in the group treated with chemotherapy alone. Grade 3-4 toxicity was noticed in 2 cases (severe mucositis). Survival rate of the 19 patients was 52.6% at 1 year and 13.1% at 2 years; it was linked with general health (P = 0.09) and with tracheal involvement (P = 0.04). Survival rate of the 12 patients treated by combined radiochemotherapy was higher: 66% at 1 year and 22.2% at 2 years (median survival time = 16 months).

CONCLUSION

Active medical treatment of recurrence of esophageal squamous cell carcinoma by combined radiochemotherapy can provide a median survival time of 16 months, with a moderate toxicity.

A western surgical experience of peripheral cholangiocarcinoma

The aim of this retrospective study was to analyse outcome in 31 European patients operated on for peripheral cholangiocarcinoma between 1988 and 1995 (hilar cholangiocarcinoma was excluded). Before 1992, in addition to conventional resection, patients with irresectable tumour and with no extrahepatic metastasis underwent total hepatectomy with liver transplantation. Mild abdominal pain was the most frequent presenting clinical sign (11 of 31 patients) and jaundice was present in only four patients. Preoperative histological findings were available for 20 patients but the diagnosis was correct in only eight of these. Nineteen patients had curative surgery: 17 underwent conventional resection and two had total hepatectomy with liver transplantation. Major hepatectomy was performed in 12 of 17 cases, extended to the caudate lobe in five, to the bile duct confluence in four and to the retrohepatic vena cava in one. Postoperative mortality and morbidity rates were three and seven of 19 patients respectively, median survival was 15 months, and actuarial 1-, 2- and 5-year survival rates were 67, 40 and 32 per cent respectively. Twelve patients had only exploratory laparotomy because of the presence of extrahepatic metastasis or irresectable tumour. The invasive nature of peripheral cholangiocarcinoma can explain the limited number of resectable cases and the particularly unfavourable prognosis. Total hepatectomy does not provide survival benefit. Conventional surgery remains the only effective treatment, even for patients with advanced stage tumours.

[Transanal excision of rectal tumors. New applications of the endo-GIA forceps]

Two new applications of the endo-GIA technique are presented for endoluminal intrarectal resection of benign or malignant tumors of the lower or middle part of the rectum. These procedures allow resection of sessile lesions with a large implantation base. Depending on the pathology and the type of implantation, resection can either be total or via the musculosa. Results have been good with this simple procedure which allows total tumor resection and an uneventful post-operative period.