Mohamed Lakehal

Salvage Esophagectomy after Unsuccessful Curative Chemoradiotherapy for Squamous Cell Cancer of the Esophagus

Surgery was performed on 6 patients after unsuccessful chemoradiotherapy for squamous cell cancer of the esophagus. The operation was very difficult due to post-irradiation sequelae in 5. The postoperative period was uneventful in 4 patients. Median intensive care unit stay and hospitalization were 5 and 47 days, respectively. Survival after surgery reached 44 months in 1 patient (59 months after diagnosis). Outcome was better in patients who had surgery after recurrence rather than after nonresponse to chemoradiotherapy. Salvage esophagectomy can be beneficial, in selected patients, after unsuccessful chemoradiotherapy for cancer of the esophagus by providing longer survival and better quality of life despite operative and postoperative morbidity.

Retrosternal bypass operation for unresectable squamous cell cancer of the esophagus

BACKGROUND A palliative bypass operation may be beneficial when severe dysphagia or tracheoesophageal fistula occurs after radiochemotherapy for unresectable tumor of the esophagus. METHODS Thirty-two patients with an unresectable tumor of the esophagus underwent a palliative retrosternal gastric (29) or colonic (3) bypass operation with ligature of the lower esophagus (3) or drainage (27). Tracheoesophageal fistula was present at operation in 20 (62.5%), including 8 after radiochemotherapy. RESULTS The overall operative mortality rate was 34.4%: 45% with tracheoesophageal fistula and 16.6% without (p < 0.01). Median intensive care and hospitalization times were 5 and 19 days, respectively. Median postoperative survival was 6 months (range, 53 to 492 days). Complications in 21 survivors were lung infections (seven), cervical fistulas (eight), and failure of the esophageal suture (two); 19 patients resumed oral nutrition, and quality of life was excellent in 6. All eight cervical fistulas regressed favorably. Postoperative radiotherapy or chemotherapy did not improve survival. CONCLUSIONS Despite the high operative mortality rate, bypass operation can provide good palliation and allow subsequent radiochemotherapy in selected patients with an unresectable tumor of the esophagus.

Gastric bypass for malignant esophagotracheal fistula A series of 21 cases

OBJECTIVE Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula. METHODS Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n = 19) or ligature (n = 2). RESULTS Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1-30) and 17 days (3-57), respectively. Among the 13 survivors, pulmonary infections (n = 2) and cervical fistulae (n = 5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them. CONCLUSION The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.

Surgical complications and treatment during resection for malignancy of the high bile duct.

Abstract. From January 1968 to January 1997 a series of 50 of 109 patients had undergone resection for high bile duct cancer in our institution in Rennes, France. The overall operative mortality was 12%, but there were no deaths among those who had only tumor resection or those with hepatectomy with vascular reconstruction. The early complications were biliary fistula (four cases) and subphrenic abscess (three cases), of which two of the biliary fistulas resulted in mortality. There were three gastrointestinal hemorrhages; one was due to gastritis related to hepatorenal insufficiency and was fatal. Two other deaths were due to respiratory failure and ascites associated with hepatic insufficiency. In one patient after liver transplantation with cluster resection, a biliary leak and ileocolic fistula were the cause of postoperative mortality. Another patient suffered a ruptured mycotic aneurysm after pretransplant transtumoral intubation, which emphasizes the risk of infection in an immunosuppressed patient. The main late complication was cholangitis (8 cases). This complication is most often a symptom of recurrence (four cases). Some are due to benign causes (intrahepatic lithiasis, intrahepatic foreign body granuloma). Surgical exploration is mandatory to exclude benign complications, which can then be treated palliatively. Four patients presented with recurrence but without cholangitis. In conclusion, the causes of complications after resection of high bile duct cancer should be carefully assessed to choose the correct treatment. Late cholangitis is a symptom of recurrence, but it should be explored and managed precisely.

MELD-based graft allocation system fails to improve liver transplantation efficacy in a single-center intent-to-treat analysis

BACKGROUND Since March 2007, priority access to liver transplantation in France has been given to patients with the highest MELD scores. OBJECTIVE To undertake an intent-to-treat comparison of center-based vs. MELD-based liver graft allocation. METHODS Retrospective cohort analysis (patients listed 6th March 2007 to 5th March 2009; MELD period) with a matched historical cohort (patients listed 6th March 2005 to 5th March 2007; pre-MELD period) in a single high-volume center. Analysis was on an intent-to-treat basis, i.e. starting on the day of wait listing. RESULTS Compared to pre-MELD, fewer patients with a MELD score less or equal to 14 (P=0.002), and more patients with a MELD greater or equal to 24 (P<0.05) were transplanted during the MELD period. For HCC candidates, median waiting time increased (121 vs. 54 days, P=0.01), transplantation rate halved (35% vs. 73.5%, P<0.001) and dropouts due to tumor progression increased (16% vs. 0%, P<0.001). Moreover, postoperative course did not change significantly except for infectious complications (35% vs. 24%, P=0.02); overall patient survival was 69.8 ± 3.1% vs. 76 ± 2.9% (P=0.29) and overall graft survival was 77.6 ± 3.4% vs. 82.8 ± 2.9% (P=0.29). Transplant failures were mainly due to deaths on the waiting list in the previous system, but to dropouts related to disease progression in the new system. Cirrhotic patient survival rate did not change (78.1 ± 4.4% vs. 73.5 ± 4.5%, P=0.42), while that of HCC patients decreased (65.3 ± 5.3% vs. 86.8 ± 4.4%, P=0.01). Post-transplant survival worsened significantly according to pre-transplant MELD score (P=0.009). CONCLUSION The MELD-based graft allocation system introduced discrimination against HCC patients, whose incidence has increased dramatically, and should be reevaluated.

Transplantation foie-rein combinée : indications et résultats

PURPOSE The purpose of this article is to report our experience concerning the indications and results for combined liver-kidney transplantation in our centre. MATERIAL AND METHOD From July 1991 to October 2006, 26 patients underwent combined liver-kidney transplantation in our establishment. This group comprised 16 men and 10 women with a mean age of 50.1 years (range: 19 to 68 years). The main indications were as follows: hepatorenal polycystic disease, type I hyperoxaluria, cirrhosis associated with end-stage renal failure. RESULT The median follow-up was 62.73 (+/-50.9) months. Only two patients of this series died, one at 70 months from gastric cancer, and the other at 89 months from cerebral metastases. Nine patients developed surgical complications (29%). Liver function was normal in the 24 surviving patients. Only one case of loss of renal graft was observed at 12 years and this patient is currently on dialysis. The mean creatinine level in these patients (apart from the dialysed patient) at the last follow-up visit was 120.3 (+/-30.43)micromol/l. CONCLUSION Combined liver-kidney transplantation can be performed with acceptable morbidity and mortality and excellent long-term results.

Use of temporary porto‐caval shunt during liver transplantation with inferior vena cava conservation: An effective method to enhance use of octogenarian graft?

We read with great interest the study of Ghinolfi et al. and wanted to congratulate them for their work. The authors reported their series of 123 liver transplantations (LTs), which were performed with the retrohepatic inferior vena cava (IVC) replacement technique and venovenous bypass, using octogenarian grafts, and they found that donor hemodynamic instability, diabetes mellitus, and donor age–Model for End-Stage Liver Disease (D-MELD) were predictive of higher incidence of ischemic-type biliary lesion incidence in the multivariate analysis. In our center, we routinely perform LTs with retrohepatic IVC preservation and side-to-side cavocaval anastomosis. According to surgeon preference, a temporary portocaval shunt (TPCS) is performed or not. From January 2007 to December 2014, 816 transplantations were performed in our institution, and using the same selection criteria as Ghinolfi et al., we identified 48 LTs performed using octogenarian donors. TPCS was performed in 31 patients and absent in 17 patients. We found that octogenarian graft survival was significantly improved when a TPCS was performed (P 5 0.02; Fig. 1A).We also observed a significant reduction of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) levels in the early postoperative days (PODs), whereas bilirubin levels were similar (Fig. 1B-D). The IVC preservation technique is currently preferred to the IVC replacement technique. In this situation, we found that use of TPCS improves octogenarian graft outcome and biliary biological parameters in the early PODs. Interest of TPCS has been previously shown, and some authors also reported improvement of longterm graft survival. However, these results were not specifically focused on octogenarian grafts. The beneficial effects of TPCS might be explained by the improvement of the recipient’s intraoperative hemodynamic status, a decrease of postreperfusion syndrome incidence, or prevention of splanchnic congestion. In conclusion, we agree with Ghinolfi et al. regarding the safety of octogenarian grafts, and we think that TPCS should be recommended when vena cava preservation is performed, in order to improve outcomes and biliary function in this situation.

Benefits of temporary portocaval shunt during orthotopic liver transplantation with vena cava preservation: A propensity score analysis

During orthotopic liver transplantation (OLT), clamping of the portal vein induces splanchnic venous congestion and accumulation of noxious compounds. These adverse effects could increase ischemia/reperfusion injury and subsequently the risk of graft dysfunction, especially for grafts harvested from extended criteria donors (ECDs). Temporary portocaval shunt (TPCS) could prevent these complications. Between 2002 and 2013, all OLTs performed in our center were retrospectively analyzed and a propensity score matching analysis was used to compare the effect of TPCS in 686 patients (343 in each group). Patients in the TPCS group required fewer intraoperative transfusions (median number of packed red blood cells—5 versus 6; P = 0.02; median number of fresh frozen plasma—5 versus 6; P = 0.02); had improvement of postoperative biological parameters (prothrombin time, Factor V, international normalized ratio, alkaline phosphatase, and gamma‐glutamyltransferase levels); and showed significant reduction of biliary complications (4.7% versus 10.2%; P = 0.006). Survival analysis revealed that TPCS improved 3‐month graft survival (94.2% versus 88.6%; P = 0.01) as well as longterm survival of elderly (ie, age > 70 years) donor grafts (P = 0.02). In conclusion, the use of TPCS should be recommended especially when considering an ECD graft. Liver Transplantation 23 174–183 2017 AASLD

Lateral cavo-caval shunt: an alternative veno-venous bypass in liver surgery

When inferior vena cava (IVC) resection is mandatory during liver surgery, use of a veno-venous bypass (VVB) is usually required despite its specific related adverse events. We describe a safe and alternative technique which allows both derivation of the portal and the caval blood flow by performing a lateral cavo-caval shunt using a prosthetic graft.

A score model for the continuous grading of early allograft dysfunction severity.

We read with great interest the study of Pareja et al. that reported a new score characterizing severity of early allograft dysfunction (EAD), the socalled model of early allograft function (MEAF) score. This interesting score, which is calculated from bilirubin, international normalized ratio, and alanine aminotransferase levels observed within the first 3 postoperative days (PODs), is a continuous score from 0 to 10 that reflects the graft function, whereas most of the previous scores, including the definition of EAD reported by Olthoff et al., are only binary. In order to validate the proposed model, we calculated the MEAF score in our population according to the reported formula. Between 2002 and 2014, 1297 liver transplantations were performed in our center with a median follow-up of 41.4 months. Thirty-two (2.5%) patients were retransplanted or died within the first 2 PODs and were therefore excluded from the analysis. Of the 1265 remaining patients, the MEAF score could be calculated in 785 (62.0%) patients. The median MEAF score value was 4.6, and a significant correlation with graft survival was observed (Fig. 1A). Notwithstanding, the capacity of a MEAF score 8 to predict 3-month graft survival was inferior to the presence of EAD (as reported by Olthoff et al.), as shown by the receiver operating characteristic (ROC) curve (Fig. 1B). Therefore, our data support the effectiveness of the MEAF score as a grading system of the severity of graft dysfunction. However, it is our opinion that this score has some limitations. First, it cannot be calculated in cases of graft or patient death within the first 2 PODs. This major limitation prevents comparison or analysis of liver transplantation efficiency between subgroups or populations because most patients with primary nonfunction who required early retransplantation were excluded. We suggest that patients for whom the MEAF score could not be calculated because of retransplantation or death should be attributed, by default, the maximum score (ie, 10). Moreover, its formula required a calculator and, therefore, limits its utility in clinical practice. A more simple method of calculation, which could be easily used by physicians, may be useful.