Eric Savier

Split-liver Transplantation for Two Adult Recipients: Feasibility and Long-term Outcomes

ObjectiveTo identify the outcomes and risks of split-liver transplantation (SLT) for two adult recipients to determine the feasibility of more widespread use of this procedure to increase the graft pool for adults. Summary Background DataThe shortage of cadaver liver grafts for adults is increasing. Using livers from donors defined as optimal, the authors have been developing techniques for SLT for two adult recipients at their center. MethodsFrom July 1993 to December 1999, 34 adults have undergone SLT with grafts from optimal donors prepared by ex situ split (n = 30) or in situ split (n = 4), and 88 adults received optimal whole-liver grafts that were not split. Four split-grafts were transplanted at other centers. The outcomes of transplantation with right and left split-liver grafts were compared with those of whole-liver transplants. The main end points were patient and graft survival at 1 and 2 years and the incidence and types of complications. ResultsFor whole-liver, right and left split-liver grafts, respectively, patient survival rates were 88%, 74%, and 88% at 1 year and 85%, 74%, and 64% at 2 years. Graft survival rates were 88%, 74%, and 75% at 1 year and 85%, 74%, and 43% at 2 years. Patient survival was adversely affected by graft steatosis and recipients inpatient status before transplantation. Graft survival was adversely affected by steatosis and a graft-to-recipient body weight ratio of less than 1%. Primary nonfunction occurred in three left split-liver grafts. The rates of arterial (6%) and biliary (22%) complications were similar to published data from conventional transplantation for an adult and a child. SLT for two adults increased the number of recipients by 62% compared with whole-liver transplantation and was logistically possible in 16 of the 104 (15%) optimal cadaver donors. ConclusionsSplit-liver transplantation for two adults is technically feasible. Outcomes and complication rates can be improved by rigid selection criteria for donors and recipients, particularly for the smaller left graft, and possibly also by in situ splitting in cadaver donors. Wider use will require changes in the procedures for graft allocation and coordination between centers experienced in the techniques.

Auxiliary Partial Orthotopic Versus Standard Orthotopic Whole Liver Transplantation for Acute Liver Failure: A Reappraisal From a Single Center by a Case-Control Study

ObjectiveTo reappraise the results of auxiliary partial orthotopic liver transplantation (APOLT) compared with those of standard whole-liver transplantation (OLT) in terms of postoperative death and complications, including neurologic sequelae. Summary Background DataCompared with OLT, APOLT preserves the possibility for the native liver to recover, and to stop immunosuppression. MethodsIn a consecutive series of 49 patients transplanted for fulminant or subfulminant hepatitis, 37 received OLT and 12 received APOLT. APOLT was done when logistics allowed simultaneous performance of graft preparation and the native liver partial hepatectomy to revascularize the graft as soon as possible. Each patient undergoing APOLT (12 patients) was matched to two patients undergoing OLT (24 patients) according to age, grade of coma, etiology, and fulminant or subfulminant type of hepatitis. All grafts in the study population were retrieved from optimal donors. ResultsBefore surgery, both groups were comparable in all aspects. In-hospital death occurred in 4 of 12 patients undergoing APOLT compared with 6 of 24 patients undergoing OLT. Patients receiving APOLT had 1 ± 1.3 technical complications compared with 0.3 ± 0.5 for OLT patients. Bacteriemia was significantly more frequent after APOLT than after OLT. The need for retransplantation was significantly higher in the APOLT patients (3/12 vs. 0/24). Brain death from brain edema or neurologic sequelae was significantly more frequent after APOLT (4/12 vs. 2/24). One-year patient survival was comparable in both groups (66% vs. 66%), and there was a trend toward lower 1-year retransplantation-free survival rates in the APOLT group (39% vs. 66%). Only 2 of 12 (17%) patients had full success with APOLT (i.e., patient survival, liver regeneration, withdrawal of immunosuppression, and graft removal). One of these two patients had neurologic sequelae. ConclusionsUsing optimal grafts, APOLT and OLT have similar patient survival rates. However, the complication rate is higher with APOLT. On an intent-to-treat basis, the efficacy of the APOLT procedure is low. This analysis suggests that the indications for an APOLT procedure should be reconsidered in the light of the risks of technical complications and neurologic sequelae.

Right colon to rectal anastomosis (Deloyers procedure) as a salvage technique for low colorectal or coloanal anastomosis: postoperative and long-term outcomes.

BACKGROUND: After extended left colectomy, it may be difficult to take down a well-vascularized colon into the pelvis and perform a tension-free colorectal or coloanal anastomosis. The Deloyers procedure comprising complete mobilization and rotation of the right colon while maintaining the ileocolic artery may be used in this circumstance. OBJECTIVE: The aim of this study is to report postoperative and long-term outcomes after the Deloyers procedure as a salvage technique for colorectal anastomosis or coloanal anastomosis. DESIGN: From a prospective database, we retrospectively reviewed all patients who underwent a Deloyers procedure. SETTING: This study was conducted at the Colorectal Unit in a tertiary referral teaching hospital. PATIENTS: Between 1998 and 2011, 48 consecutive patients underwent a Deloyers procedure. Indications were as following: Hartmann reversal (n = 17), previous colorectal anastomosis-related complications (n = 11), diverticular disease (n = 6), left colon cancer (n = 6), ischemic colitis (n = 3), iterative colectomy for cancer (n = 3), rectal cancer local recurrence (n = 1), and synchronous colon cancer (n = 1). RESULTS: There were 38 men and 10 women (median age at surgery, 67 years). Colorectal anastomosis and coloanal anastomosis were performed in 38 and 10 patients. Thirty-one patients had defunctioning stoma. Mortality and early morbidity rate was 2% and 23%. Three patients (6%) had severe complications (Dindo ≥3). There was no anastomotic leakage. Reoperation was required in 2 patients for intra-abdominal hemorrhage. The median hospital stay was 12 days. The median follow-up was 26 months. All patients had their ileostomy closed. Twenty-three percent of patients developed late complications. The median number of bowel movements per day was 3 (range, 1–7), but 67% of patients had fewer than 3. One patient required an ileostomy refashioning because of poor functional results, and 23% of patients routinely take loperamide-based medication. LIMITATION: The retrospective nature of the study was a limitation. CONCLUSIONS: The Deloyers procedure is safe, associated with low morbidity and good long-term functional results. It represents a safe alternative to total colectomy and ileorectal anastomosis.

The anterior approach : the right way for right massive hepatectomy

Although the use of an anterior approach for right hepatectomies for massive tumors has been reported, the technique of anterograde hepatectomy has not yet been described in full. The aim of this paper is to give a detailed, illustrated report of our anterograde technique. Alternative techniques are also discussed so as to provide the surgeon with other tested options. The technique described here is the right hepatectomy extended to segments 4 and 1, but it may be slightly modified for other large hepatectomies, including left-sided hepatectomies.

Nonalcoholic Fatty Liver Disease Increases the Risk of Hepatocellular Carcinoma in Patients With Alcohol-Associated Cirrhosis Awaiting Liver Transplants

BACKGROUND & AIMS Many patients with alcohol-associated cirrhosis also have diabetes, obesity, or insulin resistance-mediated steatosis, but little is known about how these disorders affect the severity of liver disease. We analyzed the prevalence and prognostic implications of metabolic risk factors (MRFs) such as overweight, diabetes, dyslipidemia, and hypertension in patients with alcohol-associated cirrhosis awaiting liver transplants. METHODS We performed a retrospective study of 110 patients with alcohol-associated cirrhosis (77% male; mean age, 55 y; 71% with >6 mo of abstinence) who received liver transplants at a single center in Paris, France, from 2000 through 2013. We collected data on previous exposure to MRFs, steatosis (>10% in the explant), and histologically confirmed hepatocellular carcinoma (HCC). RESULTS HCC was detected in explants from 29 patients (26%). Steatosis was detected in explants from 47 patients (70% were abstinent for ≥6 mo); 50% had a history of overweight or type 2 diabetes. Fifty-two patients (47%) had a history of MRFs and therefore were at risk for nonalcoholic fatty liver disease. A higher proportion of patients with MRF had HCC than those without MRF (46% vs 9%; P < .001). A previous history of overweight or type 2 diabetes significantly increased the risk for HCC (odds ratio, 6.23; 95% confidence interval [CI], 2.47-15.76, and odds ratio, 4.63; 95% CI, 1.87-11.47, respectively; P < .001). MRF, but not steatosis, was associated with the development of HCC (odds ratio, 11.76; 95% CI, 2.60-53; P = .001) independent of age, sex, amount of alcohol intake, or severity of liver disease. CONCLUSIONS Patients with alcohol-associated cirrhosis who received transplants frequently also had nonalcoholic fatty liver disease. MRFs, particularly overweight, obesity, and type 2 diabetes, significantly increase the risk of HCC.

Mehrzeitige Leberresektionen bei colorectalen Lebermetastasen Das Paul Brousse-Konzept

Abstract. Hepatic resection is currently the only form of treatment that offers a chance of long-term survival, with rates ranging from 25 % to 39 %. However, a curative operation can be performed in only 10 % of patients with colorectal metastases to the liver. Our policy is to increase the number of patients that can benefit from liver resection. Liver metastases can be considered as irresectable mainly in three different situations (sometimes associated): (I) large and/or poorly located tumors; (II) bilateral tumors in both liver lobes; (III) tumors technically resectable, but not operable because the liver remnant is too small, which is associated with a prohibitive risk of postoperative severe liver failure. The aim of this paper is to report the strategies we use in our center to achieve curative resection in these three schematic situations despite initial contraindications.Zusammenfassung. Die Leberresektion ist häufig die einzige Behandlungsform, die eine Chance zu langfristigem Überleben bietet, mit Raten von 25–39 %. Aber nur bei 10 % der Patienten mit colorectalen Metastasen in der Leber kann eine kurative Operation durchgeführt werden. Wir sind grundsätzlich darum bemüht, die Zahl der Patienten, die von einer Leberresektion profitieren können, zu erhöhen. Lebermetastasen sind hauptsächlich in drei Erkrankungssituationen (die manchmal in Kombination auftreten) als irresektabel anzusehen: 1) große und/oder schlecht lokalisierte Tumoren, 2) bilaterale Tumoren in beiden Leberlappen, 3) technisch resektable, aber wegen zu kleiner verbleibender Leber mit dem (zu großen) Risiko eines schweren postoperativen Leberversagens inoperable Tumoren. Der folgende Beitrag soll die Strategie unseres Zentrums erläutern, mit der angestrebt wird, in den genannten Situationen trotz initialer Kontraindikation kurative Resektionen durchzuführen.

Rate of employment after liver transplantation in France: a single-centre study.

Background A return to gainful employment is an important outcome parameter after liver transplantation (LT). A recent study in the USA has shown a very high rate of unemployment after LT (75%). To date, there are no available data in France, where the public health insurance programme guarantees financial protection for everyone. Aims The aim of this study was to assess the employment rate after LT in a French LT centre and to determine factors associated with employment after LT. Methods All patients who had undergone liver transplantation at our centre between January 2000 and April 2011 and who met the following criteria responded to a questionnaire: (i) between 18 and 65 years old at the time of LT, (ii) alive 1 year after LT, (iii) alive, not retired and released from the hospital at the time of survey, (iv) French residents who were affiliated with French national health insurance. Results A total of 345 LTs were performed in 314 patients during the study period. Of the patients, 109 were excluded from the study: 23 had died within the first year after LT, 28 had died at the time of the survey, three were still in the hospital, seven were living in a foreign country, 11 had retired and 37 were older than 65 years after LT. Two hundred five patients were included in the study. The response rate was 76.6% (157/205). Patients responded a mean 6.1±0.9 years after LT, 77.7% were French nationals, 73.2% were men, and the mean age at LT was 48.8±9.9 years. The aetiologies of liver disease were as follows: alcohol 32.5%, hepatitis C 26.1%, alcohol and hepatitis C 3.8%, hepatitis B 15.3%, biliary cirrhosis 5.1%, autoimmune 2.5% and other causes 14.7%. Two years after LT, 43.3% of patients were employed. The demographic variables associated with post-LT employment were male sex (P<0.001), age under 40 years at LT (P=0.02), a sedentary job (P=0.007), raising children under the age of 18 years at the time of LT (P=0.01), a high level of education (P=0.001), not being affiliated with the French universal health coverage or ‘CMU’ (P=0.001). Only 53.3% of the patients who did not return to work after LT stated that they felt like they had a physical disability. Conclusion The rate of return to work after LT in France was 43.1%, which was higher than that reported in the US study. However, this rate remains low and policies supporting return to work are needed to help liver recipients who wish to work after LT.

Long-Term Results of Transplantation for Hepatocellular Carcinoma With or Without Cirrhosis: 15 Years’-Experience at Paul Brousse Hospital

Hepatocellular carcinoma (HCC) still remains a controversial indication for liver transplantation (LT). An evaluation of long-term results is mandatory to define the patients who are likely to benefit from cadaveric or living-related LT. During 15 years’ experience, 220 LTs were performed consecutively at a single institution for HCC in patients with or without underlying cirrhosis (195 and 25 cases, respectively). The patients were younger and the proportion of females was higher in the noncirrhotic group (P < 0.001). Perioperative mortality (≤2 months) was 4% in cirrhotic and 0% in non cirrhotic patients. In spite of a higher incidence of recurrence related to more extensive tumors in HCC without cirrhosis (54% vs. 20%, P < 0.001), survival after transplantation was similar: 60% and 48% at 5 and 10 years, respectively, for patients without cirrhosis, and 73% and 39%, respectively, for patients with underlying cirrhosis (P not significant). While the combination of size and number of tumors was highly predictive of recurrence and survival in the cirrhotic group, this was not the case for non-cirrhotic patients. However, portal invasion was poorly associated with survival in both groups. HCC with and without underlying cirrhosis represents two separate entities with different patterns of evolution. The criteria of selection for transplantation should follow different policies in these two groups of patients.

Enhanced Recovery in Liver Transplantation: A Feasibility Study

BackgroundEnhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT.MethodsWe designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery.ResultsTen patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0–10.5) days versus 18.0 (14.3–24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm.ConclusionConsidered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.