Yves-Patrice Le Treut

Model for end-stage liver disease exceptions in the context of the french model for end-stage liver disease score–based liver allocation system†

Model for End‐Stage Liver Disease (MELD) score–based allocation systems have been adopted by most countries in Europe and North America. Indeed, the MELD score is a robust marker of early mortality for patients with cirrhosis. Except for extreme values, high pretransplant MELD scores do not significantly affect posttransplant survival. The MELD score can be used to optimize the allocation of allografts according to a sickest first policy. Most often, patients with small hepatocellular carcinomas (HCCs) and low MELD scores receive extra points, which allow them appropriate access to transplantation comparable to the access of patients with advanced cirrhosis and high MELD scores. In addition to patients with advanced cirrhosis and HCC, patients with a number of relatively uncommon conditions have low MELD scores and a poor prognosis in the short term without transplantation but derive excellent benefits from transplantation. These conditions, which correspond to the so‐called MELD score exceptions, justify the allocation of a specific score for appropriate access to transplantation. Here we report the conclusions of the French consensus meeting. The goals of this meeting were (1) to identify which conditions merit MELD score exceptions, (2) to list the criteria needed for defining each of these conditions, and (3) to define a reasonable time interval for organ allocation for each MELD exception in the general context of organ shortages. MELD exceptions were discussed in an attempt to reconcile the concepts of transparency, equity, justice, and utility. Liver Transpl 17:1137–1151, 2011.

Severe Jaundice Increases Early Severe Morbidity and Decreases Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

BACKGROUND The influence of jaundice on outcomes after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to determine, in a large multicentric series, the influence of severe jaundice (serum bilirubin level ≥250 μmol/L and 300 μmol/L) on early severe morbidity and survival after PD. STUDY DESIGN From 2004 to 2009, twelve hundred patients (median age 66 years, 57% male) with resectable PDAC underwent PD. Patients who received preoperative biliary drainage for neoadjuvant treatment or cholangitis were excluded. Pre- and intraoperative data were collected by a standardized form. Serum bilirubin level and creatinine clearance were analyzed as categorical variables. Predictive factors of severe complications and poor survival (Kaplan-Meier method) were identified by univariate and multivariate analysis. RESULTS Median follow-up was 21 months (95% CI, 19-23). Operative mortality was 3.9% (n = 47), with no predictive factors in multivariate analysis. Severe complications (Dindo-Clavien grade III to IV) occurred in 22% (n = 268), with male sex (p = 0.025), America Society of Anesthesiologists score 3 to 4 (p = 0.022), serum bilirubin level ≥300 μmol/L (p = 0.034), and creatinine clearance <60 mL/min/1.73 m(2) (p = 0.013) identified as predictive factors in multivariate analysis. Overall 3-year survival rate was 41% (95% CI, 37-45%). In multivariate analysis, serum bilirubin level ≥300 μmol/L (p = 0.048), low-volume center (p < 0.001), venous resection (p = 0.014), N1 status (p < 0.01), R1 status (p < 0.001), and absence of adjuvant treatment (p < 0.001) negatively impacted survival. There was a negative relationship between survival at 12 months or later and higher rates of bilirubin. Presence of a biliary stent did not influence early or long-term results. CONCLUSIONS In this multicentric study, serum bilirubin level ≥300 μmol/L increased severe morbidity and decreased long-term survival after PD for PDAC. These findings suggest that biliary stenting is appropriately indicated before PD in patients with PDAC and severe jaundice.

Pancreatic head resectable adenocarcinoma: preoperative chemoradiation improves local control but does not affect survival

BACKGROUND This study assesses the impact of preoperative chemoradiation on recurrence, surgical morbidity, histopathological data and survival in resectable adenocarcinoma of the pancreatic head. METHODS We carried out a retrospective study with an intention-to-treat analysis. From 1997 to 2006, 173 patients with resectable pancreas head carcinoma were treated in two reference centres in France using different treatment strategies. RESULTS Sixty-seven of 85 (79%) patients in the surgery-first (SF) group and 38 of 88 (43%) patients in the chemoradiation (CR) group underwent surgical resection (P < 0.001). Overall morbidity was 40% (15/38) in the CR group and 43% (29/67) in the SF group (P= 0.837). In the CR group, median tumour size was smaller (1.5 cm vs. 3.0 cm; P < 0.001) and fewer patients were node-positive (29% vs. 64%; P= 0.001) than in the SF group. There was less perineural (43% vs. 93%; P < 0.001), lymphatic and vascular (21% vs. 92%; P < 0.001) invasion in the CR group than in the SF group. In both groups, 89% of patients had recurrence (31/35 in the CR group and 57/64 in the SF group; P= 1.000), predominantly involving metastasis and carcinomatosis in the CR group (30/31 vs. 35/57; P < 0.001) and locoregional recurrence in the SF group (24/57 vs. 3/31; P= 0.002). Median survival for all patients and for resected patients in the CR and SF groups was, respectively, 15 months vs. 17 months, and 21 months vs. 18 months (P= non-significant). CONCLUSIONS Preoperative chemoradiation allows for good local control of the disease but does not increase survival, mainly for reasons of metastatic spread. Other options should be developed to improve both local and distant control of the disease.

Assessment of chronic rejection in liver graft recipients receiving immunosuppression with low-dose calcineurin inhibitors

BACKGROUND & AIMS Calcineurin inhibitors represent the cornerstone immunosuppressants after liver transplantation despite their side effects. As liver graft is particularly well tolerated, low doses may be proposed. The aim of this study was to assess the prevalence of chronic rejection in patients with low calcineurin inhibitors regimen and to compare their characteristics with patients under standard doses. METHODS All patients with liver transplantation between 1997 and 2004 were divided into two groups. Low-dose patients (n=57) had tacrolimus baseline levels <5ng/ml or cyclosporine levels <50ng/ml at t0 or <100ng/ml at t+2h and were prospectively proposed a liver biopsy, searching for chronic rejection according to Banff criteria. The remaining patients constituted the standard-doses group (n=40). RESULTS Among the low-dose group, 36 patients in the low-dose group were assessed by biopsy. No chronic rejection was found. Fifty-six percent had only calcineurin inhibitors and 8% received other immunosuppressants only. The median time between liver transplantation and biopsy was 90 months (64-157) and between IS regimen decrease and biopsy was 41 months (11-115). Liver tests were normal in 72% of the patients. Low-dose patients had more often hepatitis B (p=0.045), less past acute rejection episodes (p=0.028), and better renal function (p=0.040). Decrease of calcineurin inhibitors failed in 15% of standard-dose patients without impacting the graft function. In the low-dose group, co-prescription of other immunosuppressants facilitated the decrease (p=0.051). CONCLUSIONS The minimization, or even cessation, of calcineurin inhibitors may be an achievable goal in the long term for most of the liver graft recipients.

Duodenal gastrointestinal stromal tumors (GISTs): arguments for conservative surgery.

IntroductionGastrointestinal stromal tumors (GISTs) of the duodenum are rare. We sought to evaluate the postoperative courses and long-term outcomes of conservative surgery (CS) versus pancreaticoduodenectomy (PD) for patients with non-metastatic duodenal GISTs.MethodsSeventeen patients underwent surgery for duodenal GISTs between January 2000 and January 2012; 11 patients underwent CS (CS group), and six patients underwent a PD (PD group).ResultsMortality was similar between the two groups. Patients in the PD group had longer operative times, more tumors located on the pancreatic side of the duodenum, higher rates of post-operative complications including postoperative pancreatic fistulas, and a longer hospital stay, when compared with patients of CS group. All tumors were resected with clear surgical margins (R0 resection). The median disease-free survival times were not different.ConclusionCS was safe and provided similar oncologic outcomes as PD. CS should be the procedure of choice in patients with GIST that does not involve the pancreatic side of the duodenum.

Impact of transjugular intrahepatic portosystemic shunting on liver transplantation: 12-year single-center experience.

BACKGROUND The purpose of this study was to assess the impact of transjugular intrahepatic portosystemic shunting (TIPS) on liver transplantation (LT). METHODS Seventy-two patients transplanted after TIPS insertion between 1996 and 2008 were compared with 136 matched patients transplanted without prior TIPS. RESULTS At time of LT, 10% of the TIPS were occluded and 32% were misplaced. Shunt removal was difficult in 17% of the TIPS patients and required vena cava clamping in 10%. Collateral venous circulation was less extensive and intra-operative portocaval anastomosis was required more frequently in the TIPS group. No significant difference in transfusion requirements and operative times were observed between the two groups. Postoperatively, liver and renal function tests, in-hospital stay, graft rejection, re-transplantation and 1-year mortality rates were not statistically different. Ascites volume in the first week was greater in the TIPS group (7.6 L vs 6.9 L, P=0.036). In the TIPS group, ascites and collateral circulation were greater if the shunt was occluded at the time of LT. Shunt misplacement or occlusion was not associated with higher intra-operative or postoperative complication rates. CONCLUSION TIPS did not impair LT and can provide a safe bridge for LT in the end-stage cirrhotic patients.

Leucoencéphalopathie multifocale progressive due au virus JC au cours du traitement d’une récidive d’hépatite virale C après transplantation hépatique

Progressive multifocal leucoencephalopathy due to JC virus is a rare complication of liver transplantation. Only four cases have already been described in the literature. This disease is difficult to differentiate from leucoencephalopathy associated with immunosuppressive drugs such as cyclosporin or tacrolimus. Positive diagnosis of progressive multifocal leucoencephalopathy no longer requires cerebral biopsy. It must be confirmed by positive JC virus RNA amplification in the cerebrospinal fluid. We report a case of progressive multifocal leucoencephalopathy occurring 18 months after liver transplantation for hepatitis C-related cirrhosis.

Right hepatolithiasis and abnormal hepatic duct confluence: more than a casual relation?

BACKGROUND Hepatolithiasis (HL) is a rare disease in Western countries. The aim of our study was to investigate a possible relation between the development of right HL and abnormalities of the hepatic duct confluence. MATERIAL AND METHODS Fourteen patients who presented with localized right-sided HL were included in this study. The anatomy of hepatic duct confluence in this group of patients was analyzed and compared with the anatomy of hepatic duct confluence in the general population. RESULTS The Presence of a shift of 1 of the 2 sectorial right ducts was significantly associated with right-sided HL (P = .003). CONCLUSIONS The shift of a sectorial right duct must be considered as one of the anatomic causes of HL. This finding must be considered when surgical treatment of HL is planned.

Le nœud iléosigmoïde : une cause improbable d’occlusion intestinale primitive par strangulation bifocale

Resume Le nœud ileosigmoide est une cause rare et grave d’occlusion intestinale par strangulation bifocale. C’est une urgence chirurgicale dont le retard de prise en charge expose a des lesions de necrose digestive etendue et a une mortalite elevee. A partir d’une observation et d’une revue des cas rapportes dans la litterature, nous precisons les circonstances diagnostiques du nœud ileosigmoide. La presentation clinique initiale est souvent frustre et aspecifique. Le diagnostic de nœud ileosigmoide repose surtout sur l’imagerie. La tomodensitometrie abdominopelvienne avec injection de produit de contraste et balisage digestif transanal semble etre le meilleur examen pour montrer en urgence l’association pathognomonique d’une souffrance de l’intestin grele et d’un volvulus du sigmoide.

Recurrent hepatic hematoma due to familial lysozyme amyloidosis resolves with conservative management.

Aix-Marseille Université, Marseille, France, Service de Médecine Interne, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille (APHM), Marseille, France, Faculté de Médecine, Hôpital Cochin, Laboratoire de Biochimie et Génétique Moléculaire, Assistance Publique des Hôpitaux de Paris (APHP), Université Paris-Descartes, Sorbonne Paris Cité, Paris, France, INSERM, Institut Cochin (U1016), Paris, France, Service de Chirurgie Digestive et Transplantation Hépatique, Hôpital La Conception, Assistance Publique des Hôpitaux de Marseille (APHM), Marseille, France, Service D’Hématologie, Hôpital La Conception, Assistance Publique des Hôpitaux de Marseille (APHM), Marseille, France, and Service de Médecine Interne, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (APHP), Paris, France