Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients

PURPOSE

Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery.

METHODS

We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics.

RESULTS

164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005].

CONCLUSION

The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

Impact of the strategy for curative treatment of synchronous colorectal cancer liver metastases

AIM OF THE STUDY

Fourteen to seventeen percent of patients suffering from colorectal cancer have synchronous liver metastases (sCRLM) at the time of diagnosis. There are currently three possible strategies for curative management of sCRLM: "classic", "combined", and "liver-first". The aim of our research was to analyze the effects of the three surgical management strategies for sCRLM on postoperative morbidity and mortality and overall and recurrence-free survival.

PATIENTS AND METHODS

Patients treated for sCRLM between October 2000 and May 2015 were included. We defined three groups: (1) "classic": surgery of primary tumor and then surgery of sCRLM; (2) "combined": combined surgery of primary tumor and sCRLM: and (3) "liver-first": surgery of sCRLM and then surgery of primary tumor.

RESULTS

During this period, 170 patients who underwent 209 hepatectomies were included ("classic": 149, "combined": 34, "liver-first": 26). The rate of severe complications was higher in the "combined" group compared to the "classic" group (35% vs. 12%, P=0.03), and the "liver-first" group (35% vs. 19%, P=0.25), while there were significantly fewer liver resections. Overall survival at 5 years in our cohort was 46%, without significant differences between the groups, and a median survival of 54 months. Recurrence-free survival of the patients in our cohort was 24% at 5 years, with a median survival time without recurrence of 14 months, without significant differences between the groups.

CONCLUSION

All three strategies were feasible and there were no differences regarding overall and recurrence-free survivals between the three approaches. The "combined" strategy group had significantly more severe complications and did not provide better oncological results, despite less aggressive liver disease and more limited liver resections.

Short-term autonomy and survival after hepatectomy in the elderly

AIM

To study morbi-mortality, survival after hepatectomy in elderly patients, and influence on their short-term autonomy.

PATIENTS AND METHODS

This is a retrospective study conducted between 2002 and 2017 comparing patients less than 65 years old (controls) to those more than 65 years old (cases) from a prospective database, with retrospective collection of geriatric data. Cases were divided into three sub-groups (65-70 years, 70-80 years and>80 years).

RESULTS

Four hundred and eighty-two patients were included. There was no age difference in number of major hepatectomies (P=0.5506), length of stay (P=0.3215), mortality at 90 days (P=0.3915), and surgical complications (P=0.1467). There were more Grade 1 Clavien medical complications among the patients aged over 65 years (P=0.1737). There was no difference in overall survival (P=0.460) or disease-free survival (P=0.108) according to age after adjustment for type of disease and hepatectomy. One-third of patients had geriatric complications. The "home discharge" rate decreased significantly with age from 92% to 68% (P=0.0001). Early loss of autonomy after hospitalization increased with age, 16% between 65 and 70 years, 23% between 70 and 80 years and 36% after 80 years (P=0.10). We identified four independent predictors of loss of autonomy: age>70 years, cholangiocarcinoma, length of stay>10 days, and metachronous colorectal cancer.

CONCLUSIONS

Elderly patients had the same management as young patients, with no difference in surgery or survival, but with an increase in early loss of autonomy.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial

Background

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.

Methods

This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.

Conclusion

This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey

BACKGROUND

The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.

METHODS

This retrospective study included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short-term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection.

RESULTS

Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010).

CONCLUSION

Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.

Increased CXCR3+ T Cells Impairs Recruitment of T-Helper Type 17 Cells via Interferon γ and Interleukin 18 in the Small Intestine Mucosa During Treated HIV-1 Infection

The restoration of CD4+ T cells, especially T-helper type 17 (Th17) cells, remains incomplete in the gut mucosa of most human immunodeficiency virus type 1 (HIV-1)–infected individuals despite sustained antiretroviral therapy (ART). Herein, we report an increase in the absolute number of CXCR3+ T cells in the duodenal mucosa during ART. The frequencies of Th1 and CXCR3+ CD8+ T cells were increased and negatively correlated with CCL20 and CCL25 expression in the mucosa. In ex vivo analyses, we showed that interferon γ, the main cytokine produced by Th1 and effector CD8+ T cells, downregulates the expression of CCL20 and CCL25 by small intestine enterocytes, while it increases the expression of CXCL9/10/11, the ligands of CXCR3. Interleukin 18, a pro-Th1 cytokine produced by enterocytes, also contributes to the downregulation of CCL20 expression and increases interferon γ production by Th1 cells. This could perpetuate an amplification loop for CXCR3-driven Th1 and effector CD8+ T cells recruitment to the gut, while impairing Th17 cells homing through the CCR6-CCL20 axis in treated HIV-1–infected individuals.

[Stereotactic hypofractionated radiation therapy as a bridge to transplantation for hepatocellular carcinoma: Case report of a complete pathological response and review of the literature]

Patients with hepatocellular carcinoma who are on liver transplant waiting list usually require local treatment to limit any risk of tumour growth. Historically percutaneous radiofrequency ablation or transarterial chemoembolization represented the major therapeutic alternatives. Depending on the size, or the topography of the lesion these two techniques may not be feasible. Radiation therapy under stereotactic conditions has recently emerged in the management of localized hepatocellular carcinoma as an alternative to the focused therapies performed to date. We herein report the case of a 43-year-old patient harbouring a complete histological response on explant after liver stereotactic irradiation and discuss its role in the management of hepatocellular carcinoma before liver transplantation.

Prevalence, incidence and risk factors for donor-specific anti-HLA antibodies in maintenance liver transplant patients

Although large retrospective studies have identified the presence of donor-specific antibodies (DSAs) to be a risk factor for rejection and impaired survival after liver transplantation, the long-term predicted pathogenic potential of individual DSAs after liver transplantation remains unclear. We investigated the incidence, prevalence and consequences of DSAs in maintenance liver transplant (LT) recipients. Two hundred sixty-seven LT recipients, who had undergone transplantation at least 6 months previously and had been screened for DSAs at least twice using single-antigen bead technology, were included and tested annually for the presence of DSAs. At a median of 51 months (min-max: 6-220) after an LT, 13% of patients had DSAs. At a median of 36.5 months (min-max: 2-45) after the first screening, 9% of patients have developed de novo DSAs. The sole predictive factor for the emergence of de novo DSAs was retransplantation (OR 3.75; 95% CI 1.28-11.05, p = 0.025). Five out of 21 patients with de novo DSAs (23.8%) developed an antibody-mediated rejection. Fibrosis score was higher among patients with DSAs. In conclusion, monitoring for the development of DSAs in maintenance LT patients is useful in case of graft dysfunction and to identify patients with a high risk of developing liver fibrosis.

Liver resection after downstaging hepatocellular carcinoma with sorafenib

Background. Sorafenib is a molecular-targeted therapy used in palliative treatment of advanced hepatocellular carcinoma in Child A patients. Aims. To address the question of sorafenib as neoadjuvant treatment. Methods. We describe the cases of 2 patients who had surgery after sorafenib. Results. The patients had a large hepatocellular carcinoma in the right liver with venous neoplastic thrombi (1 in the right portal branch, 1 in the right hepatic vein). After 9 months of sorafenib, reassessment showed that tumours had decreased in size with a necrotic component. A right hepatectomy with thrombectomy was performed, and histopathology showed 35% to 60% necrosis. One patient had a recurrence after 6 months and had another liver resection; they are both recurrence-free since then. Conclusion. Sorafenib can downstage hepatocellular carcinoma and thus could represent a bridge to surgery. It may be possible to select patients in good general condition with partial regression of the tumour with sorafenib for a treatment in a curative intent.

Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients

BACKGROUND

Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores.

METHODS

From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration.

RESULTS

The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively).

CONCLUSION

The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

Liberal selection criteria for liver transplantation for hepatocellular carcinoma

Background

To help increase the number of transplants available for hepatocellular carcinoma in cirrhotic livers, this single-centre retrospective study compared the safety and feasibility of new, more liberal, selection criteria—no more than five tumours, with the largest tumour no greater than 5 cm (5/5 criteria)—with classical criteria.

Methods

Data from operations performed in 1990–2005 were extracted from preoperative radiological findings and postoperative specimen analyses, and four groups were constructed: Paul Brousse, Milan, University of California, San Francisco (UCSF) and 5/5 criteria. A fifth group comprised patients whose tumour load exceeded the 5/5 criteria. Survival and recurrence rates were compared.

Results

For the 110 patients in the study, survival rates (overall and disease-free) were 72·8 and 66·8 per cent at 5 and 10 years respectively, with a 5·5 per cent recurrence rate. The 5-year survival rate was 65, 77, 68 and 77 per cent for Paul Brousse, Milan, UCSF and 5/5 preoperative radiological criteria, with recurrence rates of 4, 4, 3 and 3 per cent, respectively. On multivariable analysis, the only factor that influenced survival was tumour load in excess of the 5/5 criteria.

Conclusion

Use of the more liberal 5/5 criteria for selecting patients for liver transplantation results in similar disease-free and overall survival rates to classical criteria.

Biological changes after liver transplantation according to the presence or not of graft steatosis

AIM

To assess the consequences of graft steatosis on postoperative liver function as compared with normal liver grafts.

PATIENTS AND METHODS

From January 2005 to December 2007, liver transplant patients were prospectively included, excluding those who experienced arterial or biliary complications or presented acute rejection. All patients had a surgical biopsy after reperfusion. Patients were compared according to the rate of macrovacuolar steatosis: namely above or below 20%.

RESULTS

Fifty-three patients were included: 10 in the steatosis group and 43 in the control group. No significant difference was observed in terms of morbidity, mortality, and primary non- or poor function. Nevertheless, biological changes after the procedure were significantly different during the first postoperative week. Prothrombin time, serum bilirubin, and transaminases were significantly increased among the steatosis group compared with the control group (P < .05).

CONCLUSION

This case-controlled study including a small number of patients, described postoperative biological changes among liver transplantations with steatosis in the graft.

Nitric oxide production by the alveolar compartment of the lungs in cirrhotic patients

In cirrhotic patients, alveolar nitric oxide (NO) concentration is increased. This may be secondary to increased output of NO produced by the alveoli (V'(A,NO)) and/or to decreased lung transfer factor of NO. In advanced liver cirrhosis, NO produced by the alveoli may play a role in abnormalities of pulmonary haemodynamics and gas exchanges. In cirrhotic patients, we aimed to measure V'(A,NO) and to compare V'(A,NO) with pulmonary haemodynamics and gas exchange parameters. Measurements were performed in 22 healthy controls and in 29 cirrhotic patients, of whom eight had hepatopulmonary syndrome. Exhaled NO concentrations were measured at multiple expiratory flow rates to derive alveolar NO concentration. V'(A,NO) was the product of alveolar NO concentration by single breath lung transfer factor for NO. V'(A,NO) was increased in patients (median (range) 260 (177-341) nL x min(-1)) compared with controls (79 (60-90), p<0.0001). Alveolar-arterial oxygen tension difference failed to correlate with V'(A,NO). However, cardiac index correlated positively and systemic vascular resistance correlated negatively with V'(A,NO) (r = 0.56, p = 0.001 and r = -0.52, p = 0.004, respectively). In cirrhotic patients, NO was produced in excess by the alveolar compartment of the lungs. Alveolar NO production was associated with hyperdynamic circulatory syndrome but not with arterial oxygenation impairment.

Hépatite à syphilis et transplantation hépatique

We report a case of secondary syphilis hepatitis in a liver-transplant patient. This homosexual male patient presented, 15 years after orthotopic liver transplantation, with non-squamous papulomacular rash, mild cytolysis, and anicteric cholestasis. Laboratory tests showed syphilis seroconversion with a venereal diseases research laboratory (VDRL) titer of 1/256, a Treponema pallidum hemaglutination assay (TPHA) of 1/5120, and a positive IgM fluorescent Treponemal antibody absorbance (FTA-abs). A liver biopsy performed 13 months after the diagnosis showed low-grade hepatitis with a Metavir score of A1F1; it also showed non-specific portal moderate inflammation consisting primarily of neutrophils, with no evidence of cholestasis. He was given benzathine-penicillin at 2,400,000 IU with a transient increase in prednisolone doses. Cytolysis rapidly, and cholestasis progressively disappeared. IgM FTA-abs became negative, whereas VDRL and TPHA titers decreased slightly over time.

Predictive factors for cytomegalovirus infection after orthotopic liver transplantation using an ultrasensitive polymerase chain reaction assay

The predictive factors for cytomegalovirus (CMV) infection in de novo liver transplant patients were determined at 3 months posttransplantation. We included all consecutive patients except those who died or who had lost their graft within 1 month posttransplant. We recorded both donor (D) and recipient (R) data. Immunosuppression utilized tacrolimus, steroids, with or without mycophenolate mofetil, and/or induction therapy with anti-CD25 monoclonal antibodies. CMV prophylaxis was administered only to those at high risk of CMV infection, namely, D+/R- patients. These cases received intravenous ganciclovir at 500 mg/d for the first 2 weeks followed by oral ganciclovir at 500 mg for the following 3 months. The median time to CMV infection was 1 month. The significant predictive factors for CMV infection were D/R CMV status, (P = .002): D+/R+ versus other patients (P = .01), D-/R- versus other patients (P = .002), D+ versus D- (P = .009). In addition infection was associated with the original liver disease (hepatitis C virus infection or alcohol-related cirrhosis; P = .03), R+ vs. R- (P = .03), donor age (<45 or >45 years; P = .01), lymphocyte count at M2 (< or >1300/mm(3); P = .02), hemoglobin levels at 1 and 3 months, and platelet and white blood cell counts at day 7. The independent predictive factors were recipient CMV sero-status (R+ vs R-; odds ratio = 10.2), donor age >45 years (odds ratio = 11.4) and lymphocyte count at M2 <1300/mm(3) (odds ratio = 7.33). This study showed that the major factors associated with CMV infection were recipient CMV status, donor age, and lymphocyte count.

Predictive factors for anemia within the first year after orthotopic liver transplantation

We sought to determine the prevalence and predictive factors for posttransplant anemia within the first year after orthotopic liver transplant (OLT) among 97 consecutive patients. Anemia was defined at months 6 and 12 according to the WHO criteria, that is, a hemoglobin (Hb) level of <12 g/dL for women and <13 g/dL for men. Immunosuppression relied on tacrolimus and steroids, with or without mycophenolate mofetil. Anemia was present in 64.5%, 50%, and 52.8% of patients pre-OLT versus 6 and 12. Thirty-three percent (month 6) and 30.3% (month 12) of anemic patients received recombinant erythropoietin therapy. A multivariate analysis revealed that the independent predictive factors for anemia at month 6 were mean corpuscular volume (<85 fL) at day 7, daily steroid dosage (<0.3 mg/kg), serum creatinine (>130 mumol/L), and Hb level (<11 g/dL) at month 1. Independent predictive factors for anemia at month 12 were daily steroid dosage at month 1 (<0.3 mg/kg), hematocrit at month 1 (<33%), red blood cell count at month 6 (<3.75 T/L), daily dosage at month 1 of cyclosporine or tacrolimus, and etiology of end-stage liver disease other than alcohol abuse. We concluded that anemia was highly prevalent within the first year of post-OLT. This observation deserves further investigation and appropriate treatment.

Monitoring HCMV Infection With Quantitative Real-Time PCR in HCMV-Positive Orthotopic Liver Transplant Recipients, and Predictive Factors for Treatment of the First Episode of HCMV Viremia

We evaluated the relevance of human cytomegalovirus (HCMV) monitoring with quantitative real-time polymerase chain reaction in 42 consecutive HCMV positive liver transplant patients, and we analyzed the factors that determined the treatment of the first episode of HCMV DNAemia. No patients received anti-HCMV prophylaxis. HCMV infection monitoring was assessed every 2 weeks until day 90 and thereafter at every 3 to 4 weeks until day 180. HCMV infection was detected among 27 patients (64%, ie, 92/380 samples). Of these, 12 had their first HCMV DNAemia treated with IV gancyclovir (group I), whereas the other 15 patients were not treated (group II). Immunosuppressive treatment was not modified in cases of HCMV DNAemia. The median time between transplantation to the first CMV DNAemia was 37 days in group I and 52 days in group II (NS). Median HCMV viral load, whatever the treatment group and whatever the time of DNAemia, was 3 log copies/mL (0.48 to 5.80). Median HCMV viral load of the first positive DNAemia was 3.45 log copies/mL (1.69 to 5.80) in group I and 2.70 log copies/mL (1.15 to 3.94) in group II (P = .01). Even though liver enzymes were increased in almost all patients presenting with HCMV infection, comparison of liver-enzyme levels and hematological parameters between the two groups at first HCMV viremia showed that alkaline phosphatase levels were significantly higher (P = .0011) and hemoglobin levels were significantly lower in group I patients (P = .0443). The only factor that predicted treatment for the first episode of HCMV DNAemia was an alkaline phosphatase level >150 UI/mL at the time of the first HCMV reactivation [odds ratio 20 (1.96 to 203.3); P = .01].

Prise en charge de la lithiase de la voie biliaire principale

Choledocholithiasis is a not uncommon and potentially grave condition which requires a well-adapted approach. Echo endoscopy and biliary MRI have improved the ability to make the diagnosis non-invasively, but intraoperative cholangiography remains the most accurate study. A surgical approach permits simultaneous treatment of both choledocholithiasis and the associated cholecystolithiasis; laparoscopic common duct exploration has been more frequently performed through a laparoscopic approach in recent years, but this procedure requires specific equipment and surgical experience. In most circumstances, surgery should be preferred to endoscopic clearance of the common duct, but endoscopy may be preferred in the setting of severe cholangitis or pancreatitis. The importance of a systematic search for asymptomatic choledocholithiasis is once again emphasized.

Acute renal failure following liver transplantation with induction therapy

AIMS

To identify the predictive factors for acute renal failure (ARF) in a retrospective study of 100 orthotopic liver transplantations (OLT) performed in 94 patients between 2000 and 2003.

METHODS

Acute renal failure (ARF) was defined using the RIFLE criteria, i.e. injury when creatinine doubles or GFR halves, and failure when creatinine trebles or GFR decreases by > 75%. Patients on dialysis pre OLT (n = 3) were excluded from the study. Immunosuppression included steroids, calcineurin inhibitors (CNIs), with (n = 32) or without mycophenolate mofetil. A total of 85% of patients also received induction therapy with antithymocyte globulins (29%) or anti-CD25 monoclonal antibodies (56%).

RESULTS

39 patients (41.5%) and 21 (22.3%) patients developed injury, and failure, respectively. Of these, 10 (10.6%) underwent dialysis. Univariate analysis revealed that acute renal dysfunction with a RIFLE score > or = 3 was significantly associated with a pre-operative serum creatinine level of > 100 micromol/l, pre-operative creatinine clearance of < 75 ml/mn, need for a transfusion (> 10 red packed units), post-operative diuresis of < 100 ml/h, use of vasopressive drugs, times to aspartate (AST) and alanine (ALT) aminotransferase peaks of > 20 and > 24 hours, respectively, relaparotomy, CNIs transient discontinuation, and the use of lower daily dosage of CNIs at post-OLT Days 3, 5, 7 and 15. In multivariate analysis, failure was significantly associated with time to AST peak (> 20 h) (OR 6.35 (1.2 - 33.6), p = 0.029), post-operative diuresis (< 100 ml/h) (OR 9.8 (2.03 47.3), p = 0.004), post-operative use of vasopressive drugs (OR 9.91 (2.02 - 48.7), p = 0.004), and transient CNIs withdrawal (OR 51.08 (7.58-344.1), p < 0.0001). Finally, the occurrence of ARF was significantly associated with an increased number of days on mechanical ventilation, on stay-in intensive care unit (ICU), and on overall hospitalization time.

CONCLUSION

ARF is quite common after OLT and significantly increases the post-operative time at the hospital, thereby increasing the OLT cost. Its independent predictive factors are mainly related to perioperative events.

Efficacy and safety of induction therapy with rabbit antithymocyte globulins in liver transplantation for hepatitis C

BACKGROUND

Hepatitis C virus (HCV)-related end-stage liver disease (ESLD) is the leading cause for orthotopic liver transplantation (OLT). However, in recent years, the long-term results of OLT in this setting are worsening, possibly due to the powerful immunosuppressants in use. The aim of our study was to assess the safety and efficacy of induction therapy using rabbit antithymocyte globulin antibodies (RATG).

METHODS

Over an 18-month period from January 2000 to June 2001, 16 patients underwent OLT for HCV-related ESLD and survived more than 1 month posttransplantation. They received induction therapy based on RATG (Thymoglobulins, Sangstat, France) at 1 mg/kg per day for 3 consecutive days, and it was then adjusted to maintain a CD2 count below 50/mm(3). Overall, RATG was given for a median of 5 days for a total dose of 406 +/- 45 mg. Steroids were started pretransplant and tacrolimus on day 1. The primary end-points were patient and graft survivals at 6 months posttransplantation, incidence of rejection, infectious complications (bacterial, viral, and fungal) and recurrence of HCV infection based on biochemical, virological, and histologic criteria.

RESULTS

The survival rates were 100% for patients and 93.7% for grafts. The acute rejection rate was 37.5%. The median time to acute rejection was 15.5 days. There was only one serum sickness case. Cytomegalovirus infections occurred in 25% of patients. The rate of de novo diabetes that required insulin therapy was at 50%. The rate of HCV recurrence was 56.25%. In addition, HCV RNA serum concentrations increased significantly posttransplantation (>1 log). In conclusion, RATG induction therapy is safe and efficient in HCV-positive liver recipients.

Orthotopic Liver Transplantation With Vena Cava Preservation in Cirrhotic Patients: Is Systematic Temporary Portacaval Anastomosis a Justified Procedure?

INTRODUCTION

We evaluated the peri- and postoperative effects of the lack of a temporary portocaval anastomosis (TPCA) during orthotopic liver transplantation (OLT) in 84 patients with cirrhosis.

PATIENTS AND METHODS

From December 1996 to December 2002, 156 liver transplant recipients included (54%; 60 men and 24 women) of mean age 52 +/- 9 years with portal hypertension. In whom peri- and postoperative data were analyzed.

RESULTS

The median fall in mean arterial pressure upon vascular clamping and unclampings was 20 mm Hg (range 15 to 75), while the median duration of portal vein clamping was 77 minutes. The median amount of blood autotransfusion was 1100 mL (range 0 to 5400). The median number of red blood cell and fresh-frozen plasma units transfused were 5 and 6.5, respectively. The median intraoperative urinary output was 72 mL/h (range 11 to 221). Three patients (3.5%) presented a perioperative complication, but no perioperative death was observed. Six patients experienced an early postoperative complication (<10 days): five hemodynamic complications and one transient renal failure, which did not require hemodialysis. One patient (1%) died at 12 hours after OLT from acute pulmonary edema.

CONCLUSION

This study shows that systematic TPCA during OLT with preservation of the native retrohepatic vena cava in cirrhotic patients does not appear to be justified. In contrast, peri- and postoperative hemodynamic parameters as well as blood component requirements were comparable to those of the literature reporting OLT with straightforward TPCA.

Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy

BACKGROUND

The purpose of this study was to analyze the short-term outcome and to determine risk factors after distal pancreatectomy (DP).

METHODS

This prospective single-center study included 61 patients undergoing DP with splenic preservation in 6 (10%). The diagnoses included pancreatic adenocarcinoma (n = 9), neuroendocrine neoplasms (n = 17), benign neoplasm (n = 26), pseudocyst (n = 4), chronic pancreatitis (n = 2), and other diagnoses (n = 3). Twelve clinical factors were studied. The chi-square test was used for univariate analysis.

RESULTS

The median duration of the postoperative hospital stay was 10 days (range, 5-155 days). Two patients (3%) died postoperatively; 12 patients (20%) had one or more intra-abdominal complications with reoperation necessary in 3 patients (5%): 6 pancreatic fistula (10%), 11 intra-abdominal collections (18%), 1 postoperative hemorrhage (2%). Univariate analysis showed that a body mass index >25 kg/m 2 was the only risk factor for intra-abdominal complication ( P = .003).

CONCLUSIONS

DP is associated with an intra-abdominal morbidity rate of 20%, which is increased for patients with a body mass index >25 kg/m 2 .

Embolisation transhépatique percutanée d’un pseudoanévrisme post-traumatique de l’artère hépatique

Pseudoaneurysm of the hepatic artery is a rare complication of blunt abdominal trauma. We report a case of post-traumatic pseudoaneurysm diagnosed several months after the initial traumatism in a 18-year-old man who presented recurrent abdominal pain. This pseudoaneurysm was successfully treated by association of both classical endovascular treatment and transhepatic percutaneous embolization.

Pancréatites récidivantes après duodénopancréatectomie céphalique : réintervention pour sténose de l'anastomose pancréatico-jéjunale

Stenosis of the pancreaticojejunostomy is a late and rarely symptomatic complication of pancreaticoduodenectomy, observed in approximately 30% of cases. Treatment of symptomatic strictures is difficult. We report a case of reoperation for stenosis of the pancreaticojejunostomy responsible for recurrent pancreatitis. The treatment strategy is discussed.

[Cystic pancreatic tumors]

Cystic tumors of the Pancreas (CTP) are rare (less than 5% of all pancreatic tumors). We have limited our study to CTP of epithelial origin which represent 90% of all CTP. These can be divided into three subgroups: (1) Benign tumors with no risk of malignant progression (serous cystadenoma). (2) Tumors with risk of malignant degeneration (mucinous cystadenoma, intraductal papillary mucinous tumors (IPMT), and pancreatic solid-cystic papillary tumor. (3) Malignant tumors (cystadenocarcinoma, IPMT with malignant degeneration). The latter two groups of CTP require radical resection while serous cystadenoma does not require surgical intervention unless symptomatic. The ability to determine preoperatively the exact nature of a CTP is of tremendous importance; cytologic examination and biochemical assays of cyst fluid aid greatly in this determination. Better understanding of the biologic evolution of CTP has increased the indications for surgical resection but the risks of postoperative morbidity and mortality in these patients must not be underestimated.

[Reoperation for refractory postoperative chylous ascites: value of peritoneovenous shunt combined with closure of lympho-peritoneal fistula]

Postoperative chylous ascites is a rare but serious complication resulting in denutrition, lymphopenia and infection. The first-intent treatment is usually conservative. We report a case of chylous ascites after retroperitoneal lymphadenectomy for testicular cancer, persisting despite conservative treatment then successfully treated by lymphostasis combined with peritoneovenous shunt. In case of high-output postoperative chylous ascites in low-risk patients with presumed localization of fistula, reoperation is indicated for lymphostasis. We advise to associate a peritoneovenous shunt in case of incomplete closure of the lymphoperitoneal fistula to avoid the morbidity of prolonged ascites.

[Hiatus calibration decreases postoperative dysphagia after laparoscopic fundoplication: case-report study]

STUDY AIM

The risk of dysphagia after antireflux surgery seems to be increased with laparoscopy compared with open surgery. Calibration of the hiatus is usually done by the surgeon's finger during open surgery. The aim of this study was to assess the results of laparoscopic calibration with a Fogarty balloon catheter.

PATIENTS AND METHODS

Between 1999 and 2001, 21 patients had a laparoscopic Toupet 240 degrees fundoplication with hiatus calibration using a 4 ml-inflated 8G Fogarty balloon catheter. These patients were compared with a group of 21 patients without hiatus calibration, matched for age, sex, preoperative dysphagia and esophageal dysmotility. Judgment criteria was early and/or late postoperative dysphagia (> 3 months).

RESULTS

Median follow-up was 13 months. The rate of early dysphagia with and without calibration were 66% and 48% respectively (NS). Median duration of early dysphagia with and without calibration were 25 and 43 days respectively (p = 0.05). No patient with calibration had late dysphagia. One patient (5%) without calibration had unexplained late dysphagia for 2 years. He had preoperative esophageal dysmotility without oesophagitis.

CONCLUSION

Hiatus calibration with a Fogarty balloon catheter decreased early postoperative dysphagia duration after Toupet laparoscopic fundoplication. This easily reproducible technical point standardizes the hiatus closure and should be recommended.

[Large abdominal parietectomy for late abdominal wall recurrence of colonic cancer: reconstruction with latissimus dorsi free flap with delayed insertion]

Parietal recurrence following conventional treatment of colorectal cancer is an infrequent event and is usually associated with an intra-abdominal recurrence. The study aim was to report a large solitary abdominal wall recurrence observed 80 months after the resection of a sigmoid adenocarcinoma and treated by a left hemiparietectomy associated with a segmental colectomy. The abdominal wall reconstruction combined a prosthesis and a latissimus dorsi myocutaneous free flap with delayed insertion after initial transfer.

[Radio-guided resection of residual metastatic lymph node from a previously resected neuroendocrine tumor]

Neuroendocrine tumors are slowly growing and carry a high risk of recurrence. Somatostatin receptor scintigraphy is considered as the gold standard for preoperative evaluation and postoperative follow-up. The use of an intraoperative detection probe makes easier a complete resection of abdominal residual or recurrent tumor. These resections may be incomplete because of the small size of the tumor and the postoperative adhesions. Radio-guided surgery is recommended in order to reduce the need for reoperation.

[Primary carcinoid tumor and horseshoe kidney: potential association]

The authors present the ninth case of primary carcinoid tumour arising in a horseshoe kidney. The diagnosis and treatment were delayed due to the benign cystic appearance of the initial lesion. This exceptional association must be kept in mind, as horseshoe kidney is associated with an increased risk of malignant tumours, especially for carcinoid tumours. The minimally aggressive nature of these tumours generally allows limited surgical resection.

[Liver transplantation in the presence of a non-functional portal vein: an original technique]

STUDY AIM

The aim of this retrospective study was to report an original technique for heterotopic liver transplantation with the graft in the left hypochondrium, and to discuss the indications and limitations of this technique.

PATIENTS AND METHOD

Over the past ten years, four patients were treated by this technique; this constitutes 2% of all liver transplantations carried out during this period.

RESULTS

No immediate per- or postoperative mortality related to the surgical procedure was noted. Moreover, no severe hemodynamic complications occurred during the per- or postoperative period. In three out of four cases, hepatic function was fully restored within 48 hours. Long-term survival (50 and 97 months) was observed in two patients.

CONCLUSION

Heterotopic liver transplantation in the left hypochondrium is an alternative to orthotopic liver transplantation; it is a technique that is easy, non-aggressive, and with good long-term results. It is indicated in cases where the main portal vein is non-functional (following total thrombosis or porto-caval shunt), and orthotopic liver transplantation is therefore not possible.

Otoacoustic emissions and medial olivocochlear suppression during auditory recovery from acoustic trauma in humans

It is well known that the large inter-individual susceptibility to noise exposure makes it impossible to predict the degree of hearing loss which will develop after any given intense noise exposure. The acoustic trauma which sometimes occurs affects cochlear mechanisms, the damage being most probably due to deactivation of the active processes of the outer hair cells (OHCs), which receive direct efferent innervation. The present report is of a follow-up study involving young military personnel recovering auditively from impulse noise exposure, and seeks to assess changes in cochlear status by means of otoacoustic emissions (OAEs) and their modulation by the medial olivocochlear (MOC) system. The study investigated the relationship between recovery of cochlear function and variables that could serve as predictors of vulnerability to noise-induced hearing loss (NIHL). Thirty-six subjects with unilateral NHIL above 4 kHz were included. Normal and affected ears were compared with respect to click-evoked and spontaneous OAEs (CEOAEs and SOAEs, respectively) and for contralateral CEOAE suppression. Measurements were obtained: (i) just after the traumatic exposure (D0); (ii) 3 days after this first measurement (D3); and (iii) 30 days after (D30). Significant improvement in the 4, 6 and 8 kHz thresholds was observed for the affected ear, with large inter-subject variability. No significant change was observed in CEOAE amplitude or MOC suppression, whereas incidence of SOAE was found to increase in the affected ear, leading to higher SOAE prevalence on this side I month after the intense noise exposure. There was no significant correlation between NIHL at 4, 6 and 8 kHz and MOC functioning on D0, but significant correlations were obtained between audiometric threshold improvement by D3 and contralateral CEOAE suppression, with better recovery in subjects with greater MOC suppressive action. The MOC system could be an underlying mechanism in post-traumatic auditory threshold recovery.

Analysis of the French liver transplant waiting list, 1992-1996

BACKGROUND

In organ transplantation, each country has specific rules of allocation. We have retrospectively evaluated the French liver transplant waiting list for the period 1992-1996, during which time the rules for allocation remained stable. Mortality while on the waiting list and waiting times were the two principal endpoints.

METHODS

Using the Etablissement Français des Greffes (EFG) registry, the study was conducted in three steps: (1) description of the waiting list population; (2) analysis of the outcome of patients, with the use of a logistic model to explain death while on the waiting list; (3) estimation of waiting times and use of a Cox model to explain waiting times.

RESULTS

The distribution of patients with regard to degree of urgency, age, blood type, and liver disease was variable according to the the EFG region. The outcome of patients was variable according to blood type and to EFG region. Patients classed as "extremely urgent" did not have a different outcome compared to elective patients. The logistic model indicated that two factors influenced the death: blood group and EFG region. Waiting times were variable according to EFG region; age and blood group had an influence on waiting times for a graft. The Cox model indicated the independent influence of EFG region on waiting times.

CONCLUSION

We found geographical disparities between patients with respect to time on the waiting list. However, the database must be improved by including the risk profile of each patient, leading to changes in rules for a better allocation of transplants.

Prevention of deep abdominal complications with omentoplasty on the raw surface after hepatic resection. The French Associations for Surgical Research

BACKGROUND

Several methods have been suggested to treat the hepatic raw surface after resection. Among these, omentoplasty (OP) has been employed occasionally but there are no clinical studies that clearly demonstrate its usefulness.

METHODS

Of 172 randomized patients undergoing hepatic resection between January 1991 and December 1994, 5 were withdrawn for protocol violation, leaving 167 who were randomly allotted to undergo OP (n = 87) on the hepatic raw surface or not (NO; n = 80). This procedure was performed for malignant tumor in 125 cases, benign tumor in 33, and for other causes in 15. Six patients had more than two types of lesions, and 32 patients had associated cirrhosis. Sixty-five major and 102 minor hepatic resections were performed. The main outcome measures studied were the number of patients with deep abdominal complications (DAC; deep bleeding or hematoma, deep infection, with or without pus discharge through drains, bile leakage), as well as repeat operations and postoperative death. Patients were divided into two strata according to the site of the lesion with respect to the diaphragm: (1) in contact (posterosuperior segments II, VII and VIII) or (2) not in contact (anterior segments III, IV, V, and VI).

RESULTS

Both groups were comparable as regards patient demographics, intraoperative procedures, intraoperative search for bile leaks and intraoperative transfusion requirements. Fewer patients had DAC in OP (n = 11) than in NO (n = 15) (difference not significant). Ten patients (6%) required repeat operations: 4 in OP without immediate mortality and 6 in NO, 3 followed by death. One further patient in OP required repeat operation after discharge and died. Four patients died in OP and 7 in NO, 1 and 4 of DAC, respectively (not significant). Deep abdominal complications were significantly associated with major hepatic resection (P <0.05) whereas postoperative death was significantly correlated with cirrhosis (P <0.05).

CONCLUSIONS

OP on the raw surface after hepatic resection lowers the rate of all complications related to DAC (except biliary leaks) and their severity (repeat operations and death) but not significantly so. OP is not recommended as a routine measure to complete elective hepatic resections.

[Laparoscopic treatment of perforated peptic ulcer]

STUDY OBJECTIVE

Contribution to evaluation of the place of laparoscopic surgery in the treatment of perforated peptic ulcer.

PATIENTS AND METHODS

Between January 1992 and November 1997. 17 consecutive patients underwent laparoscopic suture of a perforated peptic ulcer, with or without omentoplasty.

RESULTS

Treatment was performed entirely by laparoscopy in 13 cases (76%). The median operating time was 105 min (50-220 min). The median number of doses of analgesia administered to each patient was 8 (3-20 doses). The medium hospital stay was 6 days (2-23 days). Two patients (12%) died. In 11 cases, gastroscopy was performed between 1 and 4 months after the operation, revealing healing of the ulcer in 10 cases and persistence of the ulcer in one case. None of the patients were readmitted to hospital for ulcer complications, with a median follow-up of 35 months (1-63 months).

CONCLUSION

The laparoscopic treatment of perforated duodenal is a technically simple and effective procedure, intermediate between conventional surgical treatment and Taylor's method. Laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer.