E. Vibert

Therapeutic strategies in symptomatic portal biliopathy.

Summary Background Data:Chronic portal obstruction can lead to formation of portal cavernoma (PC). Half of all patients with PC will develop cholestasis, termed portal biliopathy, and some will progress to symptomatic biliary obstruction. Because of the high hemorrhage risk associated with biliary surgery in patients with PC, the optimal therapeutic strategy is controversial. Methods:Retrospective review of a single hepatobiliary center experience, including 64 patients with PC identified 19 patients with concurrent symptomatic biliary obstruction. Ten patients underwent initial treatment with a retroperitoneal splenorenal anastomosis. For the remaining 9 patients, portal biliopathy was managed without portosystemic shunting (PSS). Outcomes, including symptom relief, the number of biliary interventions, and survivals, were studied in these 2 groups. Results:Within 3 months of PSS, 7 of 10 patients (70%) experienced a reduction in biliary obstructive symptoms. Five of these 10 patients subsequently underwent uncomplicated biliary bypass, and none has recurred with biliary symptoms or required biliary intervention with a mean follow-up of 8.2 years. For patients without PSS, repeated percutaneous and endobiliary procedures were required to relieve biliary symptoms. Four of the 9 patients with persistent PC required surgical intrahepatic biliary bypass, which was technically more challenging. With a mean follow-up of 8 years, 1 of these 9 patients died of severe cholangitis, 1 remained jaundiced, and 7 were asymptomatic. Conclusions:This study, which represents the largest published experience with the surgical treatment of patients with symptomatic portal biliopathy, indicates that retroperitoneal splenorenal anastomosis improves outcomes and should be the initial treatment of choice.

Two-stage hepatectomy versus 1-stage resection combined with radiofrequency for bilobar colorectal metastases: a case-matched analysis of surgical and oncological outcomes.

Objectives:The aim of this study was to compare the long-term results of 2 surgical strategies for patients with bilobar colorectal liver metastases (bCRLM). Background:Two-stage hepatectomy is the surgical strategy mostly chosen for treating extensive BCLM with the pitfall of dropout after the first stage. One-stage strategy combining limited resections and radiofrequency ablation could be proposed as an option in this population. Patients and Methods:Between 2000 and 2010, 272 patients were consecutively operated in 2 expert centers practicing 1- or 2-stage hepatectomy for bCRLM. A case-match study (1:1) was conducted using number and size of nodules, synchronous presentation, primary node status, and extrahepatic disease as matching variables to compare overall survival (OS) and disease-free survival (DFS). The analysis was performed in intention to treat, including patients who did not undergo the second stage. Results:In the case-match analysis (156 matched patients), median OS and DFS did not differ significantly between patients in 1- and 2-stage hepatectomy, respectively: 37.2 and 34.5 months (P = 0.6), 9.4 and 7.5 months (P = 0.25). Multivariate analysis confirmed the absence of impact of strategy on OS and DFS. Primary advanced T stage and synchronous presentation were predictors of poor OS (HR = 3.67 and 1.92); CEA more than 200 ng/mL, absence of postoperative chemotherapy, and extrahepatic disease were predictive of recurrence (HR = 2.77, 1.85 and 1.69, respectively). Conclusions:This first case-match study demonstrates that on an intention-to-treat analysis 1- and 2-stage hepatectomy in patients with bCRLM achieve comparable OS and DFS, despite the high dropout of the 2-stage strategy.

A new definition of sarcopenia in patients with cirrhosis undergoing liver transplantation.

Although sarcopenia is a common complication of cirrhosis, its diagnosis remains nonconsensual: computed tomography (CT) scan determinations vary and no cutoff values have been established in cirrhotic populations undergoing liver transplantation (LT). Our aim was to compare the accuracy of the most widely used measurement techniques and to establish useful cutoffs in the setting of LT. From the 440 patients transplanted between January 2008 and May 2011 in our tertiary center, we selected 256 patients with cirrhosis for whom a recent CT scan was available during the 4 months prior to LT. We measured different muscle indexes: psoas muscle area (PMA), PMA normalized by height or body surface area (BSA), and the third lumbar vertebra skeletal muscle index (L3SMI). Receiver operating characteristic curves were evaluated and prognostic factors for post‐LT 1‐year survival were then analyzed. PMA offered better accuracy (area under the curve [AUC]u2009=u20090.753) than L3SMI (AUCu2009=u20090.707) and PMA/BSA (AUCu2009=u20090.732), and the same accuracy as PMA/squared height. So, for its accuracy and simplicity of use, the PMA index was used for the remainder of the analysis and to define sarcopenia. In men, the better cutoff value for PMA was 1561 mm2 (Seu2009=u200994%, Spu2009=u200957%), whereas in women, it was 1464 mm2 (Seu2009=u200952%, Spu2009=u200991%). A PMA lower than these values defined sarcopenia in patients with cirrhosis awaiting LT. One‐ and 5‐year overall survival rates were significantly poorer in the sarcopenic group (nu2009=u200957) than in the nonsarcopenic group (nu2009=u2009199), at 59% versus 94% and 54% versus 80%, respectively (Pu2009<u20090.001). In conclusion, pre‐LT PMA is a simple tool to assess sarcopenia. We established sex‐specific cutoff values (1561 mm2 in men, 1464 mm2 in women) in a cirrhotic population and showed that 1‐year survival was significantly poorer in sarcopenic patients. Liver Transplantation 23 143–154 2017 AASLD

Le cavernome portal : diagnostic, étiologies et conséquences

Portal cavernoma is a network of veins whose caliber, initially millimetric or microscopic, is increased and which contain hepatopedal portal blood. It results from occlusion, thrombotic and always chronic, of the extra-hepatic portal system. Diagnosis is mainly done by imaging. Clinical signs of portal cavernoma are usually related to extra-hepatic portal hypertension (hematemesis due to rupture of oeso-gastric varices, splenomegaly, rectal bleeding from ano-rectal varices, growth retardation in children) and sometimes to the cause of portal hypertension (abdominal pain, venous bowel infarction). Occurrence of portal thrombosis is often the conjunction of a local cause and a prothrombotic disorder which must be systematically detected. Biliary consequences of cavernoma are related to compression of common bile duct and are usually asymptomatic. In case of jaundice or cholangitis, portal decompression by portosystemic shunt can be performed to treat both biliary symptoms and portal hypertension.

Intention‐to‐treat analysis of percutaneous endovascular treatment of hepatic artery stenosis after orthotopic liver transplantation

Hepatic artery stenosis (HAS) is a rare complication of orthotopic liver transplantation (LT). HAS could evolve into complete thrombosis and lead to graft loss, incurring significant morbidity and mortality. Even though endovascular management by percutaneous transluminal angioplasty ± stenting (PTA) is the primary treatment of HAS, its longterm impact on hepatic artery (HA) patency and graft survival remains unclear. This study aimed to evaluate longterm outcomes of PTA and to define the risk factors of treatment failure. From 2006 to 2012, 30 patients with critical HAS (>50% stenosis of HA) and treated by PTA were identified from 870 adult patients undergoing LT. Seventeen patients were diagnosed by post‐LT screening, and 13 patients were symptomatic due to HAS. PTA was completed successfully in 27 (90%) patients with angioplasty plus stenting in 23 and angioplasty alone in 4. The immediate technical success rate was 90%. A major complication that was observed was arterial dissection (1 patient) which eventually necessitated retransplantation. Restenosis was observed in 10 (33%) patients. One‐year, 3‐year, and 5‐year HA patency rates were 68%, 62.8%, and 62.8%, respectively. Overall patient survival was 93.3% at 3 years and 85.3% at 5 years. The 3‐year and 5‐year liver graft survival rates were 84.7% and 64.5%, respectively. No significant difference was observed in patient and graft survivals between asymptomatic and symptomatic patients after PTA. Similarly, no difference was observed between angioplasty alone and angioplasty plus stenting. In conclusion, endovascular therapy ensures a good 5‐year graft survival (64.5%) and patient survival (85.3%) in patients with critical HAS by maintaining HA patency with a low risk of serious morbidity (3.3%). Liver Transplantation 22 923–933 2016 AASLD

Systematic computer tomographic scans 7 days after liver transplantation surgery can lower rates of repeat-transplantation due to arterial complications.

Arterial complications are a major cause of graft lost after liver transplantation (LT). The aim of our study was to assess the clinical impact of systematic early postoperative injected computed tomographic (CT) scans after LT rather than its performance on demand in the event of abnormalities. Two series of consecutive transplantation patients in different periods (1997-1999, 231 patients versus 2008-2010, 250 patients) were analyzed. During the first period, an injected CT scan was only performed in the event of clinical, biological, or ultrasound abnormalities revealed by tests performed daily during the first week after surgery. During the second period, in addition to standard follow-up examination, an injected CT scan was performed systematically at approximately postoperative day 7. During the first (versus the more recent) period, both recipients (whose ages were 46 ± 13 years versus 50 ± 12 years; Pxa0= .004) and donors (whose ages were 42 ± 17 versus 52 ± 17 years; Pxa0= .0001) were younger and end-stage liver disease was more common (34% versus 12%; Pxa0= .0001), but hepatocellular carcinoma (7% vs 26%; P = .0001) and retransplantation (2% versus 7%; Pxa0= .01) were less frequent. Postoperative mortality was higher during the first period (14% versus 4%; Pxa0= .0003). The incidence of early arterial thrombosis (<1 month) was similar (1.3% versus 1.6%; Pxa0= .78), but that of arterial stenosis was higher with a systematic CT scan (1.7 versus 4.4; Pxa0= .07). As a consequence of the early detection and treatment of arterial abnormalities, the repeat LT rate due to late arterial thrombosis was nil in the second period and 2.1% (5/231) in the first period. In conclusion, a systematic CT angiogram at the end of the first postoperative week reduced retransplantation rates due to late hepatic artery thrombosis by detecting patients at risk who required specific treatment.

First experience of liver transplantation with type 2 donation after cardiac death in France

Organ donation after unexpected cardiac death [type 2 donation after cardiac death (DCD)] is currently authorized in France and has been since 2006. Following the Spanish experience, a national protocol was established to perform liver transplantation (LT) with type 2 DCD donors. After the declaration of death, abdominal normothermic oxygenated recirculation was used to perfuse and oxygenate the abdominal organs until harvesting and cold storage. Such grafts were proposed to consenting patientsu2009<u200965 years old with liver cancer and without any hepatic insufficiency. Between 2010 and 2013, 13 LTs were performed in 3 French centers. Six patients had a rapid and uneventful postoperative recovery. However, primary nonfunction occurred in 3 patients, with each requiring urgent retransplantation, and 4 early allograft dysfunctions were observed. One patient developed a nonanastomotic biliary stricture after 3 months, whereas 8 patients showed no sign of ischemic cholangiopathy at their 1‐year follow‐up. In comparison with a control group of patients receiving grafts from brain‐dead donors (nu2009=u200941), donor age and cold ischemia time were significantly lower in the type 2 DCD group. Time spent on the national organ wait list tended to be shorter in the type 2 DCD group: 7.5 months [interquartile range (IQR), 4.0‐11.0 months] versus 12.0 months (IQR, 6.8‐16.7 months; Pu2009=u20090.08. The 1‐year patient survival rates were similar (85% in the type 2 DCD group versus 93% in the control group), but the 1‐year graft survival rate was significantly lower in the type 2 DCD group (69% versus 93%; Pu2009=u20090.03). In conclusion, to treat borderline hepatocellular carcinoma, LT with type 2 DCD donors is possible as long as strict donor selection is observed. Liver Transpl 21:631‐643, 2015.

Cholécystite alithiasique de l’adulte : étiologies, diagnostic et traitement

Resume La cholecystite alithiasique represente 2 a 14xa0% des cholecystectomies pour cholecystite aigue. Sa principale etiologie est l’ischemie de la paroi vesiculaire, qui survient le plus souvent chez des malades hospitalises en reanimation, surtout en cas d’antecedent cardiovasculaire ou de diabete. Les cholecystites alithiasiques associees au HIV sont plus rares et de meilleur pronostic. Les autres etiologies sont exceptionnelles. Le diagnostic de cholecystite alithiasique est difficile, l’echographie est l’examen le plus employe mais manque de specificite dans les cholecystites ischemiques. Dans tous les cas, la cholecystectomie constitue un traitement definitif qui permet d’affirmer avec certitude le diagnostic. Le drainage percutane doit etre reserve aux malades ne pouvant supporter une anesthesie generale. Le traitement medical seul n’a pas de place dans la prise en charge des cholecystites alithiasiques.

Outcomes of surgical shunts and transjugular intrahepatic portasystemic stent shunts for complicated portal hypertension

Transjugular intrahepatic portasystemic stent shunt (TIPSS), instead of surgical shunt, has become the standard treatment for patients with complicated portal hypertension. This study compared outcomes in patients who underwent TIPSS or surgical shunting for complicated portal hypertension.

Repeat liver retransplantation: rationale and outcomes.

Liver retransplantation remains the only option for recurrent graft failure. The aim of our study is to identify predictive factors involved in patients and graft survival for patients undergoing repeat retransplantation (RRT).