Viability assessment of livers donated after circulatory determination of death during normothermic regional perfusion

BACKGROUND

Abdominal normothermic regional perfusion (A-NRP) allows in-situ reperfusion and recovery of abdominal organs metabolism in donors after circulatory death (DCD). Besides improving liver transplantation outcomes, liver injury and function can be assessed during A-NRP.

METHODS

To refine liver viability assessment during A-NRP, prospectively collected data of controlled DCD donors managed at our Institution between October 2019 and May 2022 were retrospectively analyzed. Baseline characteristics, procedural variables and A-NRP parameters of donors whose liver was successfully transplanted were compared to those of donors whose liver was discarded.

RESULTS

Twenty-seven donors were included and in 20 (74%) the liver was accepted (positive outcome). No differences between study groups were observed concerning baseline characteristics and warm ischemia times (WIT). Initial lactate levels were positively correlated with functional WIT (r2  = 0.4, p = 0.04), whereas transaminase levels were not. Blood flow during A-NRP was comparable, whereas oxygen consumption (VO2 ) was significantly higher in the positive outcome group after 1 h. Time courses of lactate, AST and ALT were significantly different between study groups (p < 0.001). Donors whose liver was accepted showed faster lactate clearance, a difference which was amplified by normalizing lactate clearance to oxygen delivery (DO2 ) and VO2 . Lactate clearance was correlated to transaminase levels and DO2 -normalized lactate clearance was the parameter best discriminating between study groups.

CONCLUSIONS

DO2 -normalized lactate clearance may represent an element of liver viability assessment during A-NRP.

How to Preserve Steatotic Liver Grafts for Transplantation

Liver allograft steatosis is a significant risk factor for postoperative graft dysfunction and has been associated with inferior patient and graft survival, particularly in the case of moderate or severe macrovesicular steatosis. In recent years, the increasing incidence of obesity and fatty liver disease in the population has led to a higher proportion of steatotic liver grafts being used for transplantation, making the optimization of their preservation an urgent necessity. This review discusses the mechanisms behind the increased susceptibility of fatty livers to ischemia-reperfusion injury and provides an overview of the available strategies to improve their utilization for transplantation, with a focus on preclinical and clinical evidence supporting donor interventions, novel preservation solutions, and machine perfusion techniques.

How Can Machine Perfusion Change the Paradigm of Liver Transplantation for Patients with Perihilar Cholangiocarcinoma?

Perihilar cholangiocarcinomas (pCCA) are rare yet aggressive tumors originating from the bile ducts. While surgery remains the mainstay of treatment, only a minority of patients are amenable to curative resection, and the prognosis of unresectable patients is dismal. The introduction of liver transplantation (LT) after neoadjuvant chemoradiation for unresectable pCCA in 1993 represented a major breakthrough, and it has been associated with 5-year survival rates consistently >50%. Despite these encouraging results, pCCA has remained a niche indication for LT, which is most likely due to the need for stringent candidate selection and the challenges in preoperative and surgical management. Machine perfusion (MP) has recently been reintroduced as an alternative to static cold storage to improve liver preservation from extended criteria donors. Aside from being associated with superior graft preservation, MP technology allows for the safe extension of preservation time and the testing of liver viability prior to implantation, which are characteristics that may be especially useful in the setting of LT for pCCA. This review summarizes current surgical strategies for pCCA treatment, with a focus on unmet needs that have contributed to the limited spread of LT for pCCA and how MP could be used in this setting, with a particular emphasis on the possibility of expanding the donor pool and improving transplant logistics.

Normothermic Regional Perfusion and Hypothermic Oxygenated Machine Perfusion for Livers Donated After Controlled Circulatory Death With Prolonged Warm Ischemia Time: A Matched Comparison With Livers From Brain-Dead Donors

Prolonged warm ischemia time (WIT) has a negative prognostic value in liver transplantation (LT) using grafts procured after circulatory death (DCD). To assess the value of abdominal normothermic regional perfusion (A-NRP) associated with dual hypothermic oxygenated machine perfusion (D-HOPE) in controlled DCD LT, prospectively collected data on LTs performed between January 2016 and July 2021 were analyzed. Outcome of controlled DCD LTs performed using A-NRP + D-HOPE (n = 20) were compared to those performed with grafts procured after brain death (DBD) (n = 40), selected using propensity-score matching. DCD utilization rate was 59.5%. In the DCD group, median functional WIT, A-NRP and D-HOPE time was 43, 246, and 205 min, respectively. Early outcomes of DCD grafts recipients were comparable to those of matched DBD LTs. In DCD and DBD group, incidence of anastomotic biliary complications and ischemic cholangiopathy was 15% versus 22% (p = 0.73) and 5% versus 2% (p = 1), respectively. One-year patient and graft survival was 100% versus 95% (p = 0.18) and 90% versus 95% (p = 0.82). In conclusion, the association of A-NRP + D-HOPE in DCD LT with prolonged WIT allows achieving comparable outcomes to DBD LT.

Outcome of liver transplantation with grafts from brain-dead donors treated with dual hypothermic oxygenated machine perfusion, with particular reference to elderly donors

Prompted by the utilization of extended criteria donors, dual hypothermic oxygenated machine perfusion (D-HOPE) was introduced in liver transplantation to improve preservation. When donors after neurological determination of death (DBD) are used, D-HOPE effect on graft outcomes is unclear. To assess D-HOPE value in this setting and to identify ideal scenarios for its use, data on primary adult liver transplant recipients from January 2014 to April 2021 were analyzed using inverse probability of treatment weighting, comparing outcomes of D-HOPE-treated grafts (n = 121) with those preserved by static cold storage (n = 723). End-ischemic D-HOPE was systematically applied since November 2017 based on donor and recipient characteristics and transplant logistics. D-HOPE use was associated with a significant reduction of early allograft failure (OR: 0.24; 0.83; p = .024), grade ≥3 complications (OR: 0.57; p = .046), comprehensive complication index (-7.20 points; p = .003), and improved patient and graft survival. These results were confirmed in the subset of elderly donors (>75-year-old). Although D-HOPE did not reduce the incidence of biliary complications, its use was associated with a reduced severity of ischemic cholangiopathy. In conclusion, D-HOPE improves postoperative outcomes and reduces early allograft loss in extended criteria DBD grafts.

Time-resolved structural dynamics of the out-of-equilibrium charge density wave phase transition in GdTe3

We use ultrafast electron diffraction to study the out-of-equilibrium dynamics of the charge density wave (CDW) phase transition in GdTe3, a quasi-two-dimensional compound displaying a unidirectional CDW state. Experiments were conducted at different incident fluences and different initial sample temperatures below Tc. We find that following photo-excitation, the system undergoes a non-thermal ultrafast phase transition that occurs in out-of-equilibrium conditions. The intrinsic crystal temperature was estimated at each time delay from the atomic thermal motion, which affects each Bragg peak intensity via the Debye Waller factor. We find that the crystal temperature stabilizes with a 6 ps timescale in a quasi-equilibrium state at temperature T q . e . . We then relate the recovery time of the CDW and its correlation lengths as a function of T q . e . . The charge density wave is suppressed in less than a picosecond while its recovery time increases linearly with incident fluence and initial temperature. Our results highlight that the dynamics is strongly determined by the initial sample temperature. In addition, the transient CDW phase recently observed along the transverse direction in LaTe3 and CeTe3 is not observed in GdTe3.

Clinical assessment of liver metabolism during hypothermic oxygenated machine perfusion using microdialysis

Background

While growing evidence supports the use of hypothermic oxygenated machine perfusion (HOPE) in liver transplantation, its effects on liver metabolism are still incompletely understood.

Methods

To assess liver metabolism during HOPE using microdialysis (MD), we conducted an open‐label, observational pilot study on 10 consecutive grafts treated with dual‐HOPE (D‐HOPE). Microdialysate and perfusate levels of glucose, lactate, pyruvate, glutamate, and flavin mononucleotide (FMN) were measured during back table preparation and D‐HOPE and correlated to graft function and patient outcome.

Results

Median (IQR) MD and D‐HOPE time was 228 (210, 245) and 116 (103, 143) min. Three grafts developed early allograft dysfunction (EAD), with one requiring retransplantation. During D‐HOPE, MD glucose and lactate levels increased (ANOVA = 9.88 [p = 0.01] and 3.71 [p = 0.08]). Their 2nd‐hour levels were higher in EAD group and positively correlated with L‐GrAFT score. 2nd‐hour MD glucose and lactate were also positively correlated with cold ischemia time, macrovesicular steatosis, weight gain during D‐HOPE, and perfusate FMN. These correlations were not apparent when perfusate levels were considered. In contrast, MD FMN levels invariably dropped steeply after D‐HOPE start, whereas perfusate FMN was higher in dysfunctioning grafts.

Conclusion

MD glucose and lactate during D‐HOPE are markers of hepatocellular injury and could represent additional elements of the viability assessment.

Switch from intravenous or intramuscular to subcutaneous hepatitis B immunoglobulin: effect on quality of life after liver transplantation

BACKGROUND

Hepatitis B immunoglobulin (HBIG) therapy is available in intravenous (IV) or intra-muscular (IM) formulations. Recently, a subcutaneous (SC) formulation was introduced. This study evaluated changes in quality of life when liver transplant (LT) recipients were switched from IV or IM HBIG to the SC formulation.

METHODS

This multicentre, observational study involved adults who had undergone LT at least 1 year prior to study entry. Quality of life was evaluated using the ITaLi-Q questionnaire, assessing the impact of HBIG therapy on daily activities and patient satisfaction, and the SF-36 Health Survey. Patients completed the questionnaires prior to switching from IV or IM HBIG to SC HBIG and 6 months later.

RESULTS

Eighty-six patients were enrolled; before the switch, 68.6% were receiving IM HBIG and 31.4% IV HBIG. After 6 months, significant improvements in 7 of the 8 ITaLi-Q domains were found, particularly side effects, need for support to adhere to the therapy and satisfaction with the HBIG therapy. Significant improvements in several SF-36 domains were documented, including physical functioning, physical and emotional role limitations, pain, social functioning, physical and mental summary scores.

CONCLUSIONS

The SC route of administration reduces side effects and their interference with daily life, ameliorates negative feelings, and increases patient autonomy.

Hypothermic Oxygenated Machine Perfusion of Liver Grafts from Brain-Dead Donors

Hypothermic oxygenated machine perfusion (HOPE) was introduced in liver transplantation (LT) to mitigate ischemia-reperfusion injury. Available clinical data mainly concern LT with donors after circulatory-determined death, whereas data on brain-dead donors (DBD) are scarce. To assess the impact of end-ischemic HOPE in DBD LT, data on primary adult LTs performed between March 2016 and June 2018 were analyzed. HOPE was used in selected cases of donor age >80 years, apparent severe graft steatosis, or ischemia time ≥10 hours. Outcomes of HOPE-treated cases were compared with those after static cold storage. Propensity score matching (1:2) and Bayesian model averaging were used to overcome selection bias. During the study period, 25 (8.5%) out of 294 grafts were treated with HOPE. After matching, HOPE was associated with a lower severe post-reperfusion syndrome (PRS) rate (4% versus 20%, p = 0.13) and stage 2–3 acute kidney injury (AKI) (16% versus 42%, p = 0.046). Furthermore, Bayesian model averaging showed lower transaminases peak and a lower early allograft dysfunction (EAD) rate after HOPE. A steeper decline in arterial graft resistance throughout perfusion was associated with lower EAD rate. HOPE determines a significant reduction of ischemia reperfusion injury in DBD LT.

Hypothermic Oxygenated Machine Perfusion for Liver Transplantation: An Initial Experience

OBJECTIVES

Due to widespread exploitation of extended criteria donors, machine perfusion is emerging as an alternative to static cold storage for organ preservation. Hypothermic oxygenated machine perfusion has been associated with improved outcomes after liver transplant, both in laboratory and clinical settings. Here, we present our initial experience with hypothermic oxygenated machine perfusion, evaluating incidence of postreperfusion syndrome, early allograft dysfunction, and long-term biliary complications.

MATERIALS AND METHODS

End-ischemic dual (hepatic artery and portal vein) hypothermic oxygenated machine perfusion was carried out for 150 to 200 minutes before organ implantation in 4 liver transplants considered at increased risk due to donor, recipient, or matching issues.

RESULTS

No device malfunction occurred. Theatre logistics were minimally affected. Incidences of post-reperfusion syndrome and early allograft dysfunction were 25% and 50%. At 6-month follow-up, all patients were alive with normal hepatic function and no evidence of ischemic cholangiopathy.

CONCLUSIONS

In our experience, hypothermic oxygenated machine perfusion appeared safe and logistically simple. Further studies are needed to assess the real value of this technique and to identify which subset of patients would benefit from its implementation.

Liver transplantation with an uncommon full right hemiliver graft after hydatid cysts resection: Case report and review of the literature

Because of widespread organ shortage, the transplant community has been exploiting more and more so-called "extended criteria" donors. In this scenario, liver grafts harboring benign tumors or large cysts represent an infrequent but potentially valuable source of viable grafts. We depict a challenging case of liver transplantation performed using a graft harboring two large Echinococcus granulosus hydatid cysts in close proximity with the hilar plate and complicated by cystobiliary communication. Although liver transplantation using grafts with hydatid cyst has been rarely reported (three published cases), our case was peculiar as one of the cysts was located close to the hilum and was ruptured into the left hepatic duct. The graft was finally accepted taking into account the low risk profile of the recipient, the good quality and size of the remnant liver parenchyma, and only after complete resection of the cysts was achieved. Although the recipient had a complication due to biliary confluence necrosis, at 10-months follow-up he is in good health with normal hepatic function, and a graft that could have been otherwise discarded was successfully used. The decision process along with technical and management issues are discussed.

Impact of viral eradication with sofosbuvir-based therapy on the outcome of post-transplant hepatitis C with severe fibrosis

BACKGROUND & AIMS

Several studies have shown that new direct-acting antivirals maintain their efficacy in liver transplant (LT) recipients with severe hepatitis C virus (HCV) recurrence. We determined the clinical impact of sofosbuvir/ribavirin in LT through the changes in liver function and fibrosis state at 24 and 48 weeks after treatment.

METHODS

Between June 2014 and July 2015, 126 patients (30 F3, 96 F4 Metavir stage) were enrolled to receive sofosbuvir + ribavirin (24 weeks, 118 patients) or sofosbuvir + simeprevir + ribavirin (12 weeks, 8 patients); treatment was initiated at a median time of 4.3 years from LT. Median follow-up after therapy completion was 461 days.

RESULTS

All 30 F3 patients achieved a sustained virological response at week 24 after treatment (SVR24) and showed a distinct amelioration of the AST-to-platelet ratio index (APRI), FIB-4 and liver stiffness at elastography by week 24 post-therapy, which were maintained at week 48. Of the 96 F4 cirrhotic patients, 72 (75%) achieved SVR24 accompanied by significant improvement of liver function, which was maintained at week 48 (Child B-C 22% baseline, 11% week 24, 7% week 48); APRI, FIB-4 and liver stiffness further improved significantly between weeks 24 and 48 of follow-up. Among the 77 responders (27 F3, 50 F4) who underwent elastography at baseline and at the end of follow-up, 39 (50.6%; 18 F3, 21 F4) exhibited a regression in fibrosis stage.

CONCLUSION

At about 1 year from the completion of successful sofosbuvir-based therapy, patients with post-LT HCV and severe fibrosis experienced a long-term liver function improvement accompanied by a regression of fibrosis stage in half of them.

SAXS investigations of the morphology of swift heavy ion tracks in α-quartz

The morphology of swift heavy ion tracks in crystalline α-quartz was investigated using small angle x-ray scattering (SAXS), molecular dynamics (MD) simulations and transmission electron microscopy. Tracks were generated by irradiation with heavy ions with energies between 27 MeV and 2.2 GeV. The analysis of the SAXS data indicates a density change of the tracks of ~2 ± 1% compared to the surrounding quartz matrix for all irradiation conditions. The track radii only show a weak dependence on the electronic energy loss at values above 17 keV nm(-1), in contrast to values previously reported from Rutherford backscattering spectrometry measurements and expectations from the inelastic thermal spike model. The MD simulations are in good agreement at low energy losses, yet predict larger radii than SAXS at high ion energies. The observed discrepancies are discussed with respect to the formation of a defective halo around an amorphous track core, the existence of high stresses and/or the possible presence of a boiling phase in quartz predicted by the inelastic thermal spike model.

Ion-induced elongation of gold nanoparticles in silica by irradiation with Ag and Cu swift heavy ions: track radius and energy loss threshold

Systematic investigations of the energy loss threshold above which the irradiation-induced elongation of spherical Au nanoparticles occurs are reported. Silica films containing Au nanoparticles with average diameters of 15-80 nm embedded within a single plane were irradiated with 12-54 MeV Ag and 10-45 MeV Cu ions at 300 K and at normal incidence. We demonstrate that the efficiency of the ion-induced nanoparticle elongation increases linearly with the electronic energy transferred per ion track length unit from the energetic ions to the silica film. Ion beam shaping occurs above a threshold value of the specific electronic energy transfer. Three relevant regions are identified with respect to the original size of the Au nanoparticles. For 15 and 30 nm diameter particles, elongation occurs for electronic stopping power larger than 3.5 keV nm(-1). For Au nanoparticles with 40-50 nm diameter an electronic stopping power above 5.5 keV nm(-1) is required for elongation to be observed. Elongation of Au nanoparticles with 80 nm diameter is observed for electronic stopping between ∼ 7-8 keV nm(-1). For all combinations of ions and energies, the ion track temperature profiles are calculated within the framework of the thermal spike model. The correlation between experimental results and simulated data indicates a thermal origin of the increase in the elongation rate with increasing the track diameter.

Role of thermodynamics in the shape transformation of embedded metal nanoparticles induced by swift heavy-ion irradiation

Swift heavy-ion irradiation of elemental metal nanoparticles (NPs) embedded in amorphous SiO(2) induces a spherical to rodlike shape transformation with the direction of NP elongation aligned to that of the incident ion. Large, once-spherical NPs become progressively more rodlike while small NPs below a critical diameter do not elongate but dissolve in the matrix. We examine this shape transformation for ten metals under a common irradiation condition to achieve mechanistic insight into the transformation process. Subtle differences are apparent including the saturation of the elongated NP width at a minimum sustainable, metal-specific value. Elongated NPs of lesser width are unstable and subject to vaporization. Furthermore, we demonstrate the elongation process is governed by the formation of a molten ion-track in amorphous SiO(2) such that upon saturation the elongated NP width never exceeds the molten ion-track diameter.

GnRH antagonist-induced inhibition of the premature LH surge increases pregnancy rates in IUI-stimulated cycles. A prospective randomized trial

BACKGROUND

Our prospective randomized controlled trial was designed to assess whether the use of GnRH antagonists can improve the success rate of controlled ovarian stimulation (COS)/intrauterine insemination (IUI) treatments, via inhibition of the premature LH rise.

METHODS

A total of 104 patients were randomly divided, using a randomization list, into two groups: in group A (n = 52), recombinant FSH (rFSH) was given with GnRH antagonist Cetrorelix, and in group B (n = 52), the patients received rFSH alone in a manner similar to that of group A. The primary outcome measure was clinical pregnancy rate per couple.

RESULTS

The pregnancy rate per patient was 53.8% in group A and 30.8% in group B (P = 0.017). The rate of premature LH surge was 7% in group A and 35% in group B (P < 0.0001). A premature luteinization was observed in two cycles of 144 in group A (1.4%) and in 16 cycles of 154 in group B (10.4%) (P = 0.001). The mean values of LH and progesterone were significantly lower in patients receiving GnRH antagonist than in those who did not (3.3 +/- 3.3 mIU/ml in group A versus 9.9 +/- 7.9 mIU/ml in group B, P < 0.0001, for LH; 1.3 +/- 1.1 ng/ml versus 2.1 +/- 1.9 ng/ml for group A and B, respectively, P < 0.0001, for progesterone).

CONCLUSION

The use of GnRH antagonist in COS/IUI cycles improves pregnancy rate, preventing the premature LH rise and luteinization.

Incidence of Prostate Cancer in Sicily: Results of a Multicenter Case-Findings Protocol

OBJECTIVE

To establish the incidence of prostate cancer (PCa) in Sicily in patients who entered an early detection protocol.

METHODS

From February 2002 to February 2004, 16,298 subjects aged 40-75 entered the protocol. Patients with suspicious DRE, PSA>10 ng/ml, PSA<or=2.5 ng/ml, from 2.6 to 4 ng/ml or from 4.1 to 10 ng/ml with F/T PSA of <or=15%, <or=20% and <or=25% respectively underwent needle biopsy according to an extensive protocol.

RESULTS

3266 patients were eligible for biopsy; PSA was <or=4 in 12.7% and <or=10 ng/ml in 63.9% of patients. A PCa was found in 1171 cases (36.9%) with a relationship between PCa incidence and PSA and age respectively (chi2-test, p<0.0001); 51.8% of patients with PCa had a PSA<10 and 8.8% a PSA<4 ng/ml; 49% were clinically staged as T1c. The estimated odds ratios for each age group showed increased risk for PCa in the fourth decade with PSA between 2.6 and 4 ng/ml (12.5 times higher) and in the fifth decade with PSA between 4.1 and 10 ng/ml (6.2 times higher).

CONCLUSIONS

Age and serum PSA levels are the major risk factors for PCa. On their basis it is possible to modulate the most suitable timing for early diagnosis in individual patients.

Partial crystallization of an amorphous alloy by electronic energy deposition

The first experimental evidence is reported of crystallization induced in an amorphous alloy by a high density of electronic excitation deposited along the path of swift heavy ions. The formation of nanocrystalline iron boride phases was observed in an amorphous Fe73.5Cu1Nb3Si13.5B9 alloy irradiated at low temperature with 5 GeV Pb ions up to fluences of 1 x 10(11) ions cm-2. No evidence for the formation of the Fe(Si) phase was found. This phenomenon was interpreted in terms of the relaxation of the high level of energy deposited in electronic excitations along the path of Pb ions in the target, which induces extensive stress and strain that could destabilize the amorphous structure.

An uncommon case of cutaneous facial metastasis as the first manifestation of renal carcinoma

The authors report an unusual case of a 67-year-old man without urinary symptoms, with facial neoplasm. After biopsy, histological findings revealed a clear cell metastasis from renal carcinoma. Intravenous pyelography plus abdominal and brain CT scan were therefore performed, revealing renal cancer with widespread metastasis, making surgery impossible. Given the peculiarity of this case, the authors also give data from international literature which show that this type of first manifestation of renal carcinoma is very uncommon.

[Bladder hernia]

A case of bladder hernia in a 61 years old patient affected by benign prostatic hypertrophy is presented. Pre-operative diagnosis was made by cystography. After an adenomiomectomy of the prostate, the patient underwent the resection of the herniated bladder which gave the bladder its normal shape with only a slight reduction of its capacity. Inguino-scrotal bladder hernias are very rare; recognized predisponing factors are weakening of muscular and connective structures of the inguinal canal, and bladder hypotonia secondary to urethro-prostatic obstruction. These hernias, according to the anatomical position of the hernial sac, bladder and peritoneum, are classified in paraperitoneal (most frequent), intraperitoneal and extraperitoneal. The typical symptom of this disease is the two-stage micturition: the patient after a first spontaneous voiding, presses the mass and voids again. Other than cystography, useful diagnostic means are urography and cystoscopy which may confirm the diagnosis and rule out associated urinary disease. The treatment consists of either simple reduction of the bladder hernia, if the hernia is small, or resection of the herniated portion of the bladder, if the hernia is large or is associated with other diseases (e.g. tumors). Bladder resection is then followed by closure of the bladder wall in two layers and by inguinal hernia repair.

[Papilloma of the gallbladder]

Gall-bladder papilloma, although rare to be found, should be considered as a precancerous lesion, the sole treatment of which is the surgical one. The authors, starting from three cases of such pathology, they had the opportunity to observe, deal with histogenesis, symptomatology and treatment of such disease, and indicate the possibility for a careful diagnosis through the modern diagnostical means.

[Our experience with closed injuries of the pancreas]

The authors illustrate the types of anatomo-pathologic lesions, symptomatology, diagnostical means and treatment of pancreatic blunt trauma. They describe their experience about 4 cases (1,94%) of pancreatic trauma out of 210 abdominal blunt trauma. They, moreover, emphasize the usefulness of laparoscopy as an investigating mean offering a sure diagnostical reliability.

[Spontaneous hemoperitoneum]

The authors report their experience of 11 cases of hemoperitoneum due to hemorrhagic endoabdominal neoformation, diagnosed through laparoscopy, and the diagnosis of which was confirmed by the biopsy under the sight. They describe the casuistry observed: 4 hepatic neoplasms (11,9%); 4 ovary neoplasmus (12,1%); 1 neuroblastoma (10%); 2 ovary endometriosic cysts (16,6%). They, at last, emphasize the usefulness of laparoscopy as an investigating mean offering a sure diagnostical reliability.

[Closed injuries of the liver]

The authors shortly illustrate the etiopathogenesis, symptomatology, diagnosis, complications and treatment of liver blunt trauma. They describe their experience of 33 hepatic lesions out of 210 abdominal blunt trauma with a 12,1% mortality, and emphasize the usefulness of the laparoscopic investigation in the precocious diagnosis of such disease.