Tullio Piardi

Hepatic abscess: Diagnosis and management

Microbial contamination of the liver parenchyma leading to hepatic abscess (HA) can occur via the bile ducts or vessels (arterial or portal) or directly, by contiguity. Infection is usually bacterial, sometimes parasitic, or very rarely fungal. In the Western world, bacterial (pyogenic) HA is most prevalent; the mortality is high approaching 15%, due mostly to patient debilitation and persistence of the underlying cause. In South-East Asia and Africa, amebic infection is the most frequent cause. The etiologies of HA are multiple including lithiasic biliary disease (cholecystitis, cholangitis), intra-abdominal collections (appendicitis, sigmoid diverticulitis, Crohns disease), and bile duct ischemia secondary to pancreatoduodenectomy, liver transplantation, interventional techniques (radio-frequency ablation, intra-arterial chemo-embolization), and/or liver trauma. More rarely, HA occurs in the wake of septicemia either on healthy or preexisting liver diseases (biliary cysts, hydatid cyst, cystic or necrotic metastases). The incidence of HA secondary to Klebsiella pneumoniae is increasing and can give rise to other distant septic metastases. The diagnosis of HA depends mainly on imaging (sonography and/or CT scan), with confirmation by needle aspiration for bacteriology studies. The therapeutic strategy consists of bactericidal antibiotics, adapted to the germs, sometimes in combination with percutaneous or surgical drainage, and control of the primary source. The presence of bile in the aspirate or drainage fluid attests to communication with the biliary tree and calls for biliary MRI looking for obstruction. When faced with HA, the attending physician should seek advice from a multi-specialty team including an interventional radiologist, a hepatobiliary surgeon and an infectious disease specialist. This should help to determine the origin and mechanisms responsible for the abscess, and to then propose the best appropriate treatment. The presence of chronic enteric biliary contamination (i.e., sphincterotomy, bilio-enterostomy) should be determined before performing radio-frequency ablation and/or chemo-embolization; substantial stenosis of the celiac trunk should be detected before performing pancreatoduodenectomy to help avoid iatrogenic HA.

miR-135a-5p-mediated downregulation of protein tyrosine phosphatase receptor delta is a candidate driver of HCV-associated hepatocarcinogenesis

Background and aims HCV infection is a leading risk factor of hepatocellular carcinoma (HCC). However, even after viral clearance, HCC risk remains elevated. HCV perturbs host cell signalling to maintain infection, and derailed signalling circuitry is a key driver of carcinogenesis. Since protein phosphatases are regulators of signalling events, we aimed to identify phosphatases that respond to HCV infection with relevance for hepatocarcinogenesis. Methods We assessed mRNA and microRNA (miRNA) expression profiles in primary human hepatocytes, liver biopsies and resections of patients with HCC, and analysed microarray and RNA-seq data from paired liver biopsies of patients with HCC. We revealed changes in transcriptional networks through gene set enrichment analysis and correlated phosphatase expression levels to patient survival and tumour recurrence. Results We demonstrate that tumour suppressor protein tyrosine phosphatase receptor delta (PTPRD) is impaired by HCV infection in vivo and in HCC lesions of paired liver biopsies independent from tissue inflammation or fibrosis. In liver tissue adjacent to tumour, high PTPRD levels are associated with a dampened transcriptional activity of STAT3, an increase of patient survival from HCC and reduced tumour recurrence after surgical resection. We identified miR-135a-5p as a mechanistic regulator of hepatic PTPRD expression in patients with HCV. Conclusions We previously demonstrated that STAT3 is required for HCV infection. We conclude that HCV promotes a STAT3 transcriptional programme in the liver of patients by suppressing its regulator PTPRD via upregulation of miR-135a-5p. Our results show the existence of a perturbed PTPRD–STAT3 axis potentially driving malignant progression of HCV-associated liver disease.

A Rare Cause of Chronic Abdominal Pain: Recurrent Sub-torsions of an Accessory Spleen

Accessory spleen is defined as one, two, or three nodules of additional ectopic splenic parenchyma hung by a vascular pedicle generally near the spleen. Despite a relatively high frequency (from 10 to 30 % of the population based on autopsy studies), most accessory spleens are asymptomatic. Although cases of accessory spleen were clearly described in the literature, this perplexing diagnosis is often delayed and rarely made preoperatively. We repot episodic recurrences of abdominal pain in a 66-year-old man attributed to iterative sub-torsions of an accessory spleen, as well as a comprehensive review of the literature.

New Approaches in Locoregional Therapies for Hepatocellular Carcinoma.

PurposeHepatocellular carcinoma (HCC) represent actually the fifth most common cancer worldwide, with liver transplantation and hepatic resection who represent the standard of care of curative treatment. Unfortunately, not all patient could benefit of curative treatment. For such patients, locoregional or systemic therapies represent a valid option in order to achieve the best survival possible.MethodsA review of most interesting paper actually present in literature on locoregional treatment for nonresectable nontransplantable HCC was performed.ResultsA detailed description on each different approach has been detailed in each chapter.ConclusionIn case of nontransplantable and nonresectable HCC, locoregional treatment represent a valid alternative in management of this patients.

Developmental anatomy of the liver from computerized three-dimensional reconstructions of four human embryos (from Carnegie stage 14 to 23).

BACKGROUND & AIM Some aspects of human embryogenesis and organogenesis remain unclear, especially concerning the development of the liver and its vasculature. The purpose of this study was to investigate, from a descriptive standpoint, the evolutionary morphogenesis of the human liver and its vasculature by computerized three-dimensional reconstructions of human embryos. MATERIAL & METHODS Serial histological sections of four human embryos at successive stages of development belonging to three prestigious French historical collections were digitized and reconstructed in 3D using software commonly used in medical radiology. Manual segmentation of the hepatic anatomical regions of interest was performed section by section. RESULTS In this study, human liver organogenesis was examined at Carnegie stages 14, 18, 21 and 23. Using a descriptive and an analytical method, we showed that these stages correspond to the implementation of the large hepatic vascular patterns (the portal system, the hepatic artery and the hepatic venous system) and the biliary system. CONCLUSION To our knowledge, our work is the first descriptive morphological study using 3D computerized reconstructions from serial histological sections of the embryonic development of the human liver between Carnegie stages 14 and 23.

Post-hepatectomy liver failure: Should we consider venous outflow?

Highlights • Post hepatectomy liver failure (PHLF) is similar to the ‘small-for-size’ syndrome (SFSS) in liver transplantation (LT).• We report a case of PHLF involving clinical presentation of posthepatectomy-related SFSS secondary to obstructed venous outflow in the liver remnant, following extended right hepatectomy.• Although inflow hypertension is clearly implicated in the pathogenesis of SFSS some authors have suggested that outflow obstruction is a potential pathogenic factor.• The present case support the hypothesis that outflow obstruction could lead symptoms similar to SFSS.

Laparoscopic Hepatectomy Versus Open Hepatectomy for the Management of Hepatocellular Carcinoma: A Comparative Study Using a Propensity Score Matching

ObjectivesThe aim of this study was to compare the results between laparoscopic hepatectomy and open hepatectomy in two French university hospitals, for the management of hepatocellular carcinoma (HCC) using a propensity score matching.Materials and methodsA patient in the laparoscopic surgery group (LA) was randomly matched with another patient in the open approach group (OA) using a 1:1 allocated ratio with the nearest estimated propensity score. Matching criteria included age, presence of comorbidities, American Society of Anesthesiologists score, and resection type (major or minor). Patients of the LA group without matches were excluded. Intraoperative and postoperative data were compared in both groups. Survival was compared in both groups using the following matching criteria: number and size of lesions, alpha-fetoprotein rate, and cell differentiation.ResultsFrom January 2012 to January 2017, a total of 447 hepatectomies were consecutively performed, 99 hepatectomies of which were performed for the management of hepatocellular carcinomas. Forty-nine resections were performed among the open approach (OA) group (49%), and 50 resections were performed among the laparoscopic surgery (LA) group (51%). Mortality rate was 2% in the LA group and 4.1% in the OA group. After propensity score matching, there was a statistical difference favorable to the LA group regarding medical complications (54.55% versus 27.27%, p = 0.04), and operating times were shorter (p = 0.03). Resection rate R0 was similar between both groups: 90.91% (n = 30) in the LA group and 84.85% (n =) in the OA group. There was no difference regarding overall survival (p = 0.98) and recurrence-free survival (p = 0.42).ConclusionsLaparoscopic liver resection for the management of HCC seems to provide the same short-term and long-term results as compared to the open approach. Laparoscopic liver resections could be considered as an alternative and become the gold standard in well-selected patients.

Comparative Study With Propensity Score Matching Analysis of Two Different Methods of Transection During Hemi-Right Hepatectomy: Ultracision Harmonic Scalpel Versus Cavitron Ultrasonic Surgical Aspirator

Background: Several devices are available for liver parenchyma transection (LPT). The aim of this study was to compare the Ultracision Harmonic scalpel (UHS) with the Cavitron Ultrasonic Surgical Aspirator (CUSA) among patients who underwent hemi-right hepatectomies (RH) to homogenize transection areas. Methods: From September 2012 to June 2015, 24 patients who underwent the UHS surgery approach were matched with 24 patients who underwent the CUSA transection procedure for RH using propensity score matching. Results: Total operative time (TOT) was shorter in the UHS group, 240 minutes (range 172.5-298.8) versus 330 minutes (range 270-400) in the CUSA group (P = .0002). The occurrence of hepatopathy (odds ratio = 17; 95% confidence interval = 1.02-230) and the use of the CUSA device (odds ratio = 8; 95% confidence interval = 0.98-77) were associated with a TOT exceeding 300 minutes in multivariate analysis (P = .05). Conclusions: The UHS is a safe and effective method of LPT as compared to the use of the CUSA system. TOT is statistically decreased.