Jean-Yves Mabrut

Erythromycin as a prokinetic agent: risk factors.

Erythromycin (ER) is an antibiotic with prokinetic activity. This property has led to its clinical use to improve gastric emptying in patients with gastroparesis. Several papers have reported the effectiveness of ER in such patients; however few of these studies have been well-conducted methodologically with evaluation of clinical endpoints and their results are often contradictory. A benefit/risk analysis prior to prescription of ER should take into account the numerous medication interactions of this drug as well as the prevention of cardiovascular complications, most notably torsade de pointes and cardiac arrest. The aim of this paper was to provide new insights into these adverse events and allow for better-informed prescription. Risk prevention requires prescription guidelines and effective communication among surgeons, anesthesiologists and pharmacists.

Direct-acting antiviral therapy decreases hepatocellular carcinoma recurrence rate in cirrhotic patients with chronic hepatitis C

Arrival of direct‐acting antiviral agents against hepatitis C virus with high‐sustained virological response rates and very few side effects has drastically changed the management of hepatitis C virus infection. The impact of direct‐acting antiviral exposure on hepatocellular carcinoma recurrence after a first remission in patients with advanced fibrosis remains to be clarified.

Successful modulation of portal inflow by somatostatin in a porcine model of small-for-size syndrome

BACKGROUNDnSomatostatin may prevent the small-for-size syndrome in subjects undergoing extended hepatectomy by decreasing portal pressure.nnnMETHODSnTwenty pigs underwent 70% hepatectomy (H70 group, n = 7), 90% hepatectomy (H90 group, n = 7), or sham laparotomy (control group, n = 6). Splanchnic hemodynamics was measured before and after an intraoperative infusion of somatostatin.nnnRESULTSnThe portal vein flow normalized to liver weight increased in both H70 and H90 groups (from 125 ± 42 to 342 ± 82xa0mL/min/100g, P = .031 and from 140 ± 46 to 530 ± 241, P = .016, respectively). The hepatic venous pressure gradient (HVPG) increased in the H90 group only (from 5.5 ± 5.8 to 13 ± 4.9xa0mm Hg, P = .004). Somatostatin decreased portal vein flow normalized to liver weight in both H70 and H90 groups (from 408 ± 224 to 360 ± 227xa0mL/min/100g, P = .031 and from 560 ± 190 to 466 ± 189xa0mL/min/100g, P = .016), and restored a normal HVPG in the H90 group (from 14.3 ± 4.8 to 7.7 ± 6.1xa0mm Hg, P = .047).nnnCONCLUSIONSnSomatostatin restores a normal HVPG in the setting of small-for-size syndrome and can be considered as an effective pharmaceutical modality of portal inflow modulation after extended hepatectomy.

Management of bleeding liver tumors

Liver tumors bleed rarely; management has changed radically during the last 20years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.

Transthoracic approach for liver tumors

Abdominal approach is commonly used for resection of liver tumors. However, in rare cases, transthoracic approach may be a valuable option for management of lesions located in the hepatic dome or involving the cavo-hepatic junction for very selected patients. This approach can be an open procedure (thoracotomomy), a video-assisted minimally invasive technique (thoracoscopy), or a strictly percutaneously treatment (CT-guided radiofrequency ablation). This approach seems useful for high-risk patients, with previous major abdominal surgery, or awaiting for liver transplantation (bridge concept) with cranially located single lesions. A limited liver resection (tumorectomy or segmentectomy) can be performed, but this approach is also suitable for percutaneous ablation therapy (radiofrequency or cryotherapy), with an acceptable morbidity.

Ligating coronary vein varices: An effective treatment of "coronary vein steal" to increase portal flow in liver transplantation.

We read with great interest the article by Gupta et al., which reported 3 cases of liver transplantation (LT) in recipients with large coronary vein varices (CVVs). On the basis of their findings, the authors recommended routine portal vein flow (PVF) measurement after reperfusion, followed by shunt ligation in case of PVF< 1000 mL/minute or shunt diameter of >1 cm. Since September 2013, we have performed PVF measurements (VeriQ; Medistim ASA, Oslo, Norway) at our institution for every LT recipient with a portosystemic shunt (PSS) identified on preoperative cross-sectional imaging. Among 170 LTs performed until December 2015, we identified 16 recipients with PSS, including 11 splenorenal shunts (SRSs), 4 CVVs, and 1 mixed PSS (Table 1). A renoportal anastomosis was performed in 2 patients with extensive thrombosis. The remaining patients had PVF measurement before and after a PSS clamping test, followed by PSS ligation, except for 2 patients: the first (number 8) had a SRS and a baseline PVF of 2000 mL/minute with only 10% increase after left renal vein (LRV) clamping test; the second (number 11) had received a relatively small graft (graft-to-recipient weight ratio: 1.2%) and his PVF increased by 74%, reaching 345 mL/minute/100 g of liver weight after CVV clamping test; shunt ligation was subsequently abandoned to avoid portal hyperperfusion. During follow-up, 1 patient (number 16) with poor PVF during LT despite SRS ligation developed extensive mesoportal thrombosis 2 weeks after LT and died 5 months afterward. All remaining patients had an uneventful postoperative course with hepatopetal PVF on control Doppler ultrasounds. On the basis of this experience, we would like to emphasize 2 points in addition to the statements made by Gupta et al. First, we believe that in patients with baseline PVF> 1000 mL and CVV> 1 cm, PVF measurement must be performed after a PSS clamping test to verify the absence of portal hyperperfusion (ie, PVF> 250 mL/minute per 100 g of liver weight), especially for smaller grafts. In our series, the patient for whom CVV ligation was abandoned due to portal hyperperfusion had a satisfactory postoperative course, whereas it could be hypothesized that he would have developed small-for-size syndrome in the case of a shunt ligation. Second, we consider that PVF measurement is even more fundamental in cases of SRS because disconnecting SRS implies LRV ligation, a complex maneuver that could cause kidney injury. Hence, for patients with SRS, we recommend shunt ligation only when LRV clamping test results in at least a 15%-20% increase of PVF. Prospective studies are warranted to refine PSS management strategy during LT with the contribution of intraoperative PVF measurement.

Contribution of intraoperative portal flow measurements to the management of porto‐systemic shunts during liver transplantation

We read with great interest the article by Gupta et al., which reported 3 cases of liver transplantation (LT) in recipients with large coronary vein varices (CVVs). On the basis of their findings, the authors recommended routine portal vein flow (PVF) measurement after reperfusion, followed by shunt ligation in case of PVF< 1000 mL/minute or shunt diameter of >1 cm. Since September 2013, we have performed PVF measurements (VeriQ; Medistim ASA, Oslo, Norway) at our institution for every LT recipient with a portosystemic shunt (PSS) identified on preoperative cross-sectional imaging. Among 170 LTs performed until December 2015, we identified 16 recipients with PSS, including 11 splenorenal shunts (SRSs), 4 CVVs, and 1 mixed PSS (Table 1). A renoportal anastomosis was performed in 2 patients with extensive thrombosis. The remaining patients had PVF measurement before and after a PSS clamping test, followed by PSS ligation, except for 2 patients: the first (number 8) had a SRS and a baseline PVF of 2000 mL/minute with only 10% increase after left renal vein (LRV) clamping test; the second (number 11) had received a relatively small graft (graft-to-recipient weight ratio: 1.2%) and his PVF increased by 74%, reaching 345 mL/minute/100 g of liver weight after CVV clamping test; shunt ligation was subsequently abandoned to avoid portal hyperperfusion. During follow-up, 1 patient (number 16) with poor PVF during LT despite SRS ligation developed extensive mesoportal thrombosis 2 weeks after LT and died 5 months afterward. All remaining patients had an uneventful postoperative course with hepatopetal PVF on control Doppler ultrasounds. On the basis of this experience, we would like to emphasize 2 points in addition to the statements made by Gupta et al. First, we believe that in patients with baseline PVF> 1000 mL and CVV> 1 cm, PVF measurement must be performed after a PSS clamping test to verify the absence of portal hyperperfusion (ie, PVF> 250 mL/minute per 100 g of liver weight), especially for smaller grafts. In our series, the patient for whom CVV ligation was abandoned due to portal hyperperfusion had a satisfactory postoperative course, whereas it could be hypothesized that he would have developed small-for-size syndrome in the case of a shunt ligation. Second, we consider that PVF measurement is even more fundamental in cases of SRS because disconnecting SRS implies LRV ligation, a complex maneuver that could cause kidney injury. Hence, for patients with SRS, we recommend shunt ligation only when LRV clamping test results in at least a 15%-20% increase of PVF. Prospective studies are warranted to refine PSS management strategy during LT with the contribution of intraoperative PVF measurement.

Traumatic biliary neuroma after orthotopic liver transplantation: a possible cause of “unexplained” anastomotic biliary stricture

Traumatic biliary neuromas (TBNs) represent a rare cause of biliary stricture (BS) after orthotopic liver transplantation (OLT). Diagnosis is challenging preoperatively and is most often made at pathology after resection. Herein, we report a 20‐year experience of TBN‐related BS.

Gallbladder adenomyomatosis: Diagnosis and management

Gallbladder (GB) adenomyomatosis (ADM) is a benign, acquired anomaly, characterized by hypertrophy of the mucosal epithelium that invaginates into the interstices of a thickened muscularis forming so-called Rokitansky-Aschoff sinuses. There are three forms of ADM: segmental, fundal and more rarely, diffuse. Etiology and pathogenesis are not well understood but chronic inflammation of the GB is a necessary precursor. Prevalence of ADM in cholecystectomy specimens is estimated between 1% and 9% with a balanced sex ratio; the incidence increases after the age of 50. ADM, although usually asymptomatic, can manifest as abdominal pain or hepatic colic, even in the absence of associated gallstones (50% to 90% of cases). ADM can also be revealed by an attack of acalculous cholecystitis. Pre-operative diagnosis is based mainly on ultrasound (US), which identifies intra-parietal pseudo-cystic images and comet tail artifacts. MRI with MRI cholangiography sequences is the reference examination with characteristic pearl necklace images. Symptomatic ADM is an indication for cholecystectomy, which results in complete disappearance of symptoms. Asymptomatic ADM is not an indication for surgery, but the radiological diagnosis must be beyond any doubt. If there is any diagnostic doubt about the possibility of GB cancer, a cholecystectomy is justified. The discovery of ADM in a cholecystectomy specimen does not require special surveillance.

Intraoperative identification of biliocystic communication could be the key to avoiding postoperative complications independent of the adopted surgical technique to treat hydatid cysts: reply.

To the editor, First, we would like to thank Dr. Di Carlo and his colleagues for their interest in our previously published work [1]. In response to their comments, we would like to clarify the following points. Although the World Health Organization (WHO) recommends the use of hypertonic saline solution as a scolicidal agent to treat liver hydatid cysts, there is no ideal agent reported [2]. Our study was a bi-centric study, and the scolicidal agent used was different in the two centers: in the Lyon Center, patients were treated by subadventitial cystectomy (SC) and the agent used was 6 % hydrogen peroxide, while in Brussels, patients were treated by resection of the protruding dome (RPD) and associated to the use of a 20 % hypertonic saline solution. In case of intraoperative evidence of biliocystic communication (BCC), we did not apply any scolicidal agent within the cystic cavity because of the high risk of chemically induced sclerosing cholangitis, as mentioned by Brunetti et al. in the 2010 (WHO) recommendations [2]. In our opinion, whether a BCC is present or not, scolicidal agent should not be injected within the cystic cavity, but only infused without significant pressure, to avoid the risk of biliary injection or gas embolism especially with the use of hydrogen peroxide. However, we also believe that intraoperative identification of BCC is a key factor to decrease postoperative biliary leakage complications. Unfortunately to date, there is no reported flawless method to identify small occult BCC. In our practice, we also first perform an injection of saline into the biliary tree to identify BCCs; methylene blue is used only if no obvious BCC has been previously identified. Despite these precautions, 17.3 and 14.8 % of our patients, respectively, developed postoperative biliary leakage after SC and RPD, with no significant difference between the two groups. However, the rate of long-term cavity-related complications (CRC) was significantly higher after RPD. This could suggest that biliary leakages tend to heal more easily after SC, given it provides an ad integrum restoration of the operated liver. Concerning omentoplasty, a multicenter, prospective, randomized study by Dziri et al. showed that it significantly reduced the rate of deep abdominal collections from 23 to 10 % after radical or conservative surgical management of liver hydatid disease [3]. Therefore, in our study, omentoplasty was performed in most patients in the RPD group. Last, we would like to congratulate Dr. Di Carlo for the management of the gigantic hydatid cyst showed on Figs. 1, 2. They treated a cyst close to the inferior vena cava by RPD, in order to avoid any vascular injury. They obtained a very satisfactory result, with no postoperative cavity as shown on Fig. 2. However, one must take into account that this isolated case concerned a stage CE3 cyst according to the WHO classification [4], with no calcification in cyst wall, which enabled the cavity to collapse K. Mohkam (&) C. Ducerf J.-Y. Mabrut Department of General Surgery and Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, 103, Grande Rue de la Croix-Rousse, Lyon, Cedex 04 69317, France e-mail: kayvan.mohkam@chu-lyon.fr