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Introduction: Le processus de rejet de greffe d’îlots de Langerhans ne peut être suivi que par des marqueurs indirects. Parmi les marqueurs potentiels, les microparticules circulantes, marqueurs, in vivo et in vitro, d’un stress cellulaire, semblent un outil intéressant. Patients et méthodes: Nous rapportons une perte de fonction beta cellulaire, par rejet cellulaire supposé, chez une patiente de 43 ans, 1 mois après une première greffe par voie portale. Nous décrivons l’évolution de cette fonction beta cellulaire après traitement d’épreuve par corticothérapie systémique et l’évolution parallèle des microparticules circulantes. Parallèlement, in vitro, les microparticules libérées dans le surnageant de culture de la lignée beta cellulaire RINm5F, traitée par dose croissante de méthylprednisolone, ont été quantifiées. Observations: Cas clinique: Immédiatement après la greffe, le taux de C peptide se positive à 1, 2ng/ml. Un mois après cette greffe, parallèlement à une réapparition d’hyperglycémies post-prandiales, le C peptide s’effondre à 0,3ng/ml. La négativité des anticorps anti-HLA et des anticorps anti GAD et IA2 font retenir par élimination le diagnostic de rejet cellulaire. Parallèlement à l’effondrement du C peptide, le taux de microparticules circulantes est triplé. Au 4e jour d’un traitement par méthylprednisolone, le C peptide réaugmente significativement à 1,3ng/ml alors que le taux de microparticules rediminue significativement. Étude in vitro: contrairement au contrôle positif par H2O2, la méthylprednisolone n’entraîne pas de libération significative de microparticules à partir des cellules RIN. Conclusion: L’efficacité de la corticothérapie systémique sur la fonction beta cellulaire renforce l’hypothèse d’un rejet cellulaire. L’évolution en miroir du C peptide et des taux de microparticules circulantes met en lumière l’intérêt de ce biomarqueur de stress cellulaire dans le monitoring de la greffe d’îlots. L’absence de réponse cellulaire estimée par libération de microparticules, après traitement par corticoïdes, suggère l’absence d’effet délétère de la méthylprednisolone sur la cellule beta. [Copyright &y& Elsevier]

Finding hepatic portal venous gas with pneumatosis intestinalis on computed tomography (CT) represents diagnostic and therapeutic challenge. The intestinal necrosis, particularly associated with acute mesenteric ischemia, is the very first hypothesis to assess, with the underlying question of an urgent surgery. However, knowing the non-surgical causes that have been identified in the last decade seems necessary to better assess the risk-benefit ratio of emergency surgery. Among these causes, we report the case of the acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, whose first line treatment is medical., (Copyright © 2013. Published by Elsevier SAS.)

It is rare for portal vein thrombosis to complicate colorectal liver metastases. However malignant portal vein thrombosis must be anticipated when considering hepatic resection. While this finding may influence long-term survival, it does not absolutely contraindicate hepatic resection. We report here a case of colorectal metastasis to the liver with associated macroscopic malignant portal vein thrombosis treated with hepatic resection; the patient is free from recurrence at 5-year follow-up.

Pancreatic resection is currently the only treatment offering the possibility of long-term survival for patients with pancreatic cancer. Mesentericoportal vein involvement used to be considered a contraindication to pancreatic resection, but recent advances in vascular surgery have gradually extended the indications of curative pancreatic resection to such cases. We report hereby our experience of 100 pancreatic resections combined with mesentericoportal vein resection for pancreatic malignancies, performed between 1989 and 2005. This is one of the largest reported series. The overall mortality rate was 4% and the morbidity rate was 39%. Among the 76 patients who had pancreatic adenocarcinoma, the 5-year survival rate in case of limited mesenterico-portal vein wall involvement (up to the adventitia) was similar to that among patients without histological involvement of the portal vein wall (35.8% and 26.7%, respectively). These results support aggressive management consisting of resection and reconstruction of the mesentericoportal veins in patients with venous involvement, provided curative R0 resection is feasible.

Portal cavernoma is a network of veins whose caliber, initially millimetric or microscopic, is increased and which contain hepatopedal portal blood. It results from occlusion, thrombotic and always chronic, of the extra-hepatic portal system. Diagnosis is mainly done by imaging. Clinical signs of portal cavernoma are usually related to extra-hepatic portal hypertension (hematemesis due to rupture of oeso-gastric varices, splenomegaly, rectal bleeding from ano-rectal varices, growth retardation in children) and sometimes to the cause of portal hypertension (abdominal pain, venous bowel infarction). Occurrence of portal thrombosis is often the conjunction of a local cause and a prothrombotic disorder which must be systematically detected. Biliary consequences of cavernoma are related to compression of common bile duct and are usually asymptomatic. In case of jaundice or cholangitis, portal decompression by portosystemic shunt can be performed to treat both biliary symptoms and portal hypertension.

Despite significant improvement in the results of pancreatoduodenecomy over recent years, the Whipple procedure and its main modifications still has a poor reputation. Based on the principles of evidence-based medicine, we reviewed the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis. Mortality of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and to 3-5% for pancreatic cancer. In contrast, overall morbidity remains high, ranging from 20% to 70%. Delayed gastric emptying accounts for almost 50% of all complications. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. Overall 5-year survival for patients with pancreatic cancer remains poor, ranging from 5% to 15%, with a median survival of 13 to 17 months. Mortality ad morbidity are not related to the type of pancreatoduodenectomy, however patients with pancreatic cancer tend to have a higher risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity compared with standard procedures, however without any survival benefit in the long-term course.

Postoperative liver failure is a severe complication of major hepatectomies, in particular in patients with a chronic underlying liver disease. Preoperative interruption of the portal flow in the liver territories planned to be removed, induces their atrophy and the compensatory hypertrophy of the segments spared by the resection. This interruption can be induced by the surgical ligation of the portal branches or by the percutaneous intraportal injection, under ultrasound guidance, of glues or sclerosing agents. Preoperative portal vein embolisation is usually indicated when the remnant liver accounts for less than 25-40% of the total liver volume. Feasibility is close to 100% and the risk comparable to that of a percutaneous liver biopsy. It is well tolerated and the biological impact is minimal in patients without liver failure. Compensatory hypertrophy of the non-embolised segments is maximal during the first 2 weeks and persists, although to a lesser extent during approximately 6 weeks. The magnitude of hypertrophy is correlated with the volume of parenchyma embolised, and is reduced in diabetic or jaundiced patients or when there is an active chronic liver disease. Liver resection is performed 2 to 6 weeks after embolisation. Retrospective studies and one prospective study suggest that patients so prepared have a reduced perioperative risk and that their long term carcinologic results are not impaired.

Background and Objective: Evaluation of a new pig liver transplantation technique for survival and hypertrophy of a small-sized graft by providing adapted and controlled venous portal flow., Material and Methods: [corrected] Twenty Large-White pigs underwent heterotopic liver transplantation after a mesocaval shunt and ligation of the superior mesenteric vein downstream from the shunt. The donor-to-recipient weight ratio was below 30%. Furthermore, recipient's biliary duct and portal vein into the hilum were tied. In a control group, no mesocaval shunt was performed and the graft received the entire splanchnic venous flow., Results: The mesocaval shunt provided diversion of 60% of the splanchnic blood flow. The median survival of study pigs was 39 days (range: 8-98). Median serum bilirubin levels at 1 week were 12 micromol/L (range: 4-59). At autopsy, graft weight was increased to 2.7 times the initial weight and histological findings were normal. In the control group, all pigs died quickly from acute splanchnic congestion., Conclusion: In a model of heterotopic liver transplantation using small-sized grafts, complete diversion of mesenteric blood flow through a mesocaval shunt resulted in hemodynamic tolerance and hypertrophy of a graft corresponding to less than 30% of the ideal mass.

Study Objective: Hepatic portal venous gas is a radiological symptom associated with a poor prognosis (75% to 90% mortality). The aim of this retrospective study was to report 7 cases observed over a 2-year period., Patients and Method: From June 1997 to November 1999, hepatic portal venous gas was diagnosed in 6 patients by CT scan and in one patient by echosonography. It was not detected in any case by plain abdominal X-rays. Three patients had small bowel obstruction with necrosis, three had extensive superior mesenteric infarction and one had preperforative necrosis of the colon., Results: One patient with extensive intestinal infarction and a metastatic head and neck cancer was not operated. Two patients were operated, but the extensive mesenteric infarction was not amenable to surgical management. Three of the 7 patients died, while the other four patients survived after resection of the necrotic small intestine (n = 3) and left colectomy extended to the transverse colon (n = 1)., Conclusion: Hepatic portal venous gas was associated with intestinal necrosis in the seven cases of this series. The severity of portal venous gas is only correlated with the severity of the disease causing portal venous gas.

Goal: The aim of this study was to assess liver regeneration after partial portal ligation., Methods: 70% partial portal occlusion was obtained by ligation of the left portal vein branch. Total liver weight ratio were measured 96 hours after partial portal occlusion and in sham operated animals. The kinetics of hepatocytes division was evaluated by measuring the incorporation of 5-bromo-21-deoxyuridine into replicating cells at various time points by immunohistochemistry., Results: Partial portal occlusion did not alter the total liver weight 96 hours after surgery. It resulted in atrophy of the ligated lobes and hypertrophy of the lobes with preserved portal flow. Hypertrophy was associated to an increase of the percentage of replicating hepatocytes. The replication rate was maximum at 28 hours with a peak at 12.5% and was prolonged beyond the 48th hour., Conclusions: Partial portal occlusion results in major and prolonged regeneration process in the liver lobes with preserved portal flow.

Study Aim: Klatskin tumors are rare. Prognosis is still poor, and long term survival can be expected only after surgery, which is the treatment of choice. The aim of this study is to report the results of 15 resected cases and, by analysis of the literature, to emphasize the progress of the surgical treatment in hilar cholangiocarcinoma., Patients and Methods: Between 1990 and 1998, 27 patients affected by Klatskin tumor were observed. Eight women and seven men underwent surgical resection. The mean age was 59 years. Thirteen patients (48%) had curative resection (7 hilar resection (HR), 5 HR combined with partial hepatectomy (PH) and 1 HR + PH with portal vein resection). Two patients had palliative resection and surgical drainage., Results: One in-hospital death occurred right after hepatectomy with portal vein resection (6.6%). Postoperative morbidity was 40%. Patients were regularly followed. Ten patients died and 5 were alive at the time of this study. The 1, 2 and 3-year survival after a curative resection was 84%, 54% and 34%. The median survival was 28.5 months. Lymph node involvement did not show a statistically significant difference on median survival between the positive group and the negative group (26.2 vs 29.8 months) because of the small number of patients. Survival after hilar resection at 1, 2, 3, and 5 years was 100%, 57.1%, 28.6% and 0%. Four out of the 6 patients who underwent hilar resection combined with partial hepatectomy were still alive 1, 23, 29, 38 months after resection. Hepatectomy increased mortality (16% vs 0%). Palliative biliary resection and surgical drainage were successfully performed in 2 patients., Conclusion: Aggressive surgical treatment of Klatskin tumor can improve the survival of patients. Careful pre-operative management has to be carried out by a multidisciplinary approach including surgeons, hepatologists, radiologists and pathologists. Hepatic resection including the caudate lobe is often performed in order to obtain microscopic tumor-free margins and curative resection (R0). Biliary drainage and treatment of cholangitis is mandatory before surgery in order to improve the surgical outcome. Surgical treatment is characterized by high technical difficulties, and better results can be achieved by hepatobiliary surgical teams.

Hepatic portal venous gas is a radiological finding due to the presence of gas in the portal vein. It was associated with a mortality rate ranging from 75% to 90% and with an indication for exploratory laparotomy. We report one case following an abdominal trauma. The portal vein gas was detected on CT Scan. The patient who was asymptomatic was not operated on and survived. The severity of this radiological symptom requiring a laparotomy has to be reassessed. CT Scan is the most efficient method to recognize portal vein gas and its larger use has allowed to diagnose more cases not detected by simple abdominal X-rays. In conclusion, surgical exploration should not be done systematically but has to be decided in relation with the clinical status of the patient.

Distal pancreatectomy remains the gold standard for resection of left-sided pancreatic carcinoma. For oncologic and surgical reasons, the control of splenic vessels is an important phase of this operation. Based on anatomical considerations, the two resection techniques are presented in this paper: by first dividing the pancreatic neck or by first removing the spleen.

Aim of the Study: Tumoural invasion of the retropancreatic vessels and particularly of the superior mesentericoportal vein confluence (SMPV) is often considered as a contraindication to resection of malignant tumours of the pancreas. The aim of this retrospective study is to report a series of 20 patients and to demonstrate that resection of the vessels supposed to be involved is justified when it is the only barrier to a complete tumoural resection., Patients and Method: Twenty patients, 11 men and nine women (mean age: 61.7 years) underwent a right (n = 14), left (n = 2) or total (n = 4) pancreatic resection for pancreatic adenocarcinoma (n = 19) or cystadenocarcinoma (n = 1) associated with partial resection of SMPV (n = 17), inferior vena cava (n = 1), right hepatic artery (n = 1) and common hepatic artery (n = 1). The veins were reconstructed in all cases by end to end anastomosis and the arteries by direct suture in one patient and venous or artery graft in two patients., Results: Tumoural invasion was histologically present in the vascular wall in nine patients, in the perivascular area in six and negative in five. The in-hospital mortality was nil. One patient had an early venous thrombosis of the repaired SMPV which was reoperated and treated with success by desobstruction and venous graft. The 3-year actuarial survival rate was 16%., Conclusion: Segmental venous resection of the SMPV confluence can be performed safely. Localised invasion of the vascular wall, considered as the only obstacle for a complete tumoural resection, is not associated with a poor prognosis. In case of tight adhesions between tumour and SMPV (inflammatory or tumoural) the venous resection may be included in a deliberate surgical strategy. On the other hand, total obstruction of SMPV, extrapancreatic tumoural extension, tumoural invasion of superior mesenteric artery or coeliac trunk are contraindications to pancreatic resection.

We report a case of hepatico-portal fistula following liver needle biopsy in a cirrhotic patient with repeated gastrointestinal bleeding related to esophageal varices. Angiographic embolization of the fistula was carried out because of its possible role in portal hypertension, and the potential risks of primary porta-caval shunt. Because of the failure of the embolization, we performed porta-caval shunt with no complications, apart from the hepaticoportal fistula.

A model of heterotopic liver transplantation had been studied. The graft was laid under the recipient liver and the portal blood flow was supplied by anastomosis with the distal part of the splenic vein. Both liver can then receive portal blood through two parallel portal circulation. Liver function of transplant was satisfactory at three months after transplantation. Their had been no alteration of the recipient liver during the same period.

Vascular complications constitute a major cause of morbidity and mortality after liver transplantation. They are dominated by arterial complications, the most frequent being hepatic artery thrombosis. Venous complications essentially consist of portal vein thrombosis. The preventive treatment of vascular complications is based on a better understanding of the risk factors. Close cooperation between surgeon, and radiologist is essential for effective surgical correction, which requires a rapid diagnosis and is designed to save not only the patient's life, but also, whenever possible, the liver transplant.

Although the mandatory mesenterico-portal resection in patients with cancer of the pancreas is thought to have no anticancer effect, this wide exeresis does not increase operative mortality significantly. We performed this operation for a large benign tumour englobing the portal vein. The tumour was completely removed with no major per-operative problem with haemostasis. Venous circulation was reestablished by direct suture without prosthesis. The post-operative period was uneventful and the patient was asymptomatic three years later. We emphasize the technical procedure and draw attention to this operation in non-cancer cases.

Since the first description in 1957, absence of the portal bifurcation has been reported by four different teams, which makes a total of 5 cases and a frequency of 1.90%. Serious complications may occur postoperatively, and this anomaly should be systematically detected. There is a huge portal ring: the main vessel enters the liver, looking like a large right paramedian vein, turns to the right within the parenchyma, reaches the umbilical fissure to send the usual branches of REX' recessus, and ends as a terminal branch for the caudate lobe. The right lateral vein appears as a collateral. Numerous anterior and posterior branches supply segments IV, V and VIII. Two main facts: the portal ring turns around the axis of the middle hepatic vein, which is in the center of the ring. There is a rupture in the portal triad of the left portal pedicle: the vein is intra-hepatic, the artery and biliary duct lie normally in the hilum. The detection of this anomaly should always be done by portography or ultra-sonography. When operating, it is easily detected: there is no portal bifurcation and the left portal vein is missing. The main difficulty is to perform a right hepatectomy. After total vascular by-pass, the portal system is skeletonized and resection achieved. Another solution is to interrupt the portal stem deep in the hilum, divide the main portal fissure along the right margin of the middle hepatic vein and cut the transversal portion of the portal ring.(ABSTRACT TRUNCATED AT 250 WORDS)

Azygo-portal disconnection by the abdominal route consists of devascularization of the lower oesophagus, cardiac orifice and greater gastric tuberosity by ligation of the varices and section of the oesophagus, combined in every case with truncular vagotomy and gastric bypass. In emergencies the abdominal approach enables the bleeding points to be accurately localized. In the treatment of haemorrhages due to portal hypertension, this technique offers an alternative to porto-caval bypasses when these cannot be performed (thrombosis or portal cavernoma) or when the risk of encephalitis is too high. However, contrary to liver transplantation, it is a palliative technique for cirrhotic patients.

A model of heterotopic liver transplantation had been studied. The graft was laid under the recipient liver and the portal blood flow was supplied by anastomosis with the distal part of the splenic vein. Both liver can then receive portal blood through two parallel portal circulation. Liver function of transplant was satisfactory at three months after transplantation. Their had been no alteration of the recipient liver during the same period.

The authors report about the results of 20 azygoportal deconnections for the treatment of hemorrhagic cirrhosis caused by the rupture of esophageal or cardiotuberosal varices. All patients had an ethylic cirrhosis of Child-Pugh classes A (1), B (15) or C (4). All had a contraindication to calibrated laterolateral portocaval shunting. Azygoportal deconnection was performed with a thoracic approach in 7 cases, using a Bérard eso-clip in 6 cases and a Prioton button in 1. In 13 cases the approach was abdominal, using EEA circular mechanical clamps. In this cases, trunk vagotomy was performed in 12 cases, in association with pyloroplasty in 10 cases and gastroenteroanastomosis in 2 cases. Splenectomy was performed in 3 patients and the ligation of the splenic artery in a 4th patient. Mortality at 2 months is of 30%, the 6 deaths being caused by hepatic insufficiency in 3 cases, heart and esophageal fistula after an eso-clip was laid in 1 case. The two patients with chronic ascites died of hepatic insufficiency. Mortality at 2 months is of 23% for patients operated in an elective period, and 43% for semiergent operations. Twenty-six percent of the Child B patients and 50% of the Child C patients died. The percentage of residual varices is 57% in the surviving patients. Every second patient had complementary sclerosis. All had had azygoportal deconnection with mechanical clamps. Bleeding recurred in 2 patients (16.6%). Survival is 50% at 1 year and 39% at 3 years.

Out of 150 carcinomas of the pancreas operated from 1970 through 1989, 50 pancreatectomies were performed, including 4 cases of segmental resection of portal vein with total pancreatectomy (2 cases) or duodenopancreatectomy (2 cases). The technical procedure is described and discussed. Segmental resection of portal vein is rare in our experience and has been always performed out of necessity because of the over estimation of the resectability. However, mortality and post-operative stay are not increased.

Percutaneous transluminal angioplasty was performed in 3 patients with stenotic portosystemic shunt (one splenorenal, one mesocaval, and one arterialized splenoportal shunt). In the first two cases, the procedure was successful, followed immediately by widening of the shunt and a decrease of the splenorenal and mesocaval pressure gradient. Shunt patency was confirmed at long term as the patients showed no evidence of esophageal varices or recurrent variceal bleeding. In the third case, results were disappointing as thrombosis of the shunt occurred at the end of the procedure. Nevertheless, we conclude that percutaneous transluminal angioplasty should be the first intention procedure for treating stenosis of portosystemic shunts.

It is possible to obtain two hepatic transplants from a single cadaveric liver by separation or right and left livers or by separation of the right lobe from the left lobe medial to the umbilical cleft. We attempt to define the ideal basis of separation of the structures of the portal pedicle, based on anatomical study of 25 livers. One should ideally section the left portal vein, the right branch of the hepatic artery, the left hepatic duct. The segment I must be systematically resected, the segment IV must be resected after a separation of the right lobe from the left lobe. A cholangiogram and an arteriogram are indispensable prior to hepatic division.

In order to evaluate the benefit of arterialization of the portal vein in conjunction with a therapeutic end-to-side porto-caval shunt, we started in December 1979 a prospective randomized study, comparing these two techniques in Child class A and B cirrhotic patients with a hepatopetal portal flow of at least 100 ml per min. Sixty-four patients have been included in the study: 33 underwent a porto-caval shunt (NART) and 31 were arterialized (ART). The two groups of patients were similar as regards clinical and hemodynamic parameters. The operative mortality was lower after arterialization, considering the whole group (ART: 6.5%, NART: 12%) and high risk patients (Child class B: ART: 0%, NART: 22%--emergency operation: ART: 0%, NART: 17%) but the differences were not statistically significant. Postoperative ascites was more frequent in arterialized patients (ART: 45%, NART: 18%; p = 0.02), with an increased need for reoperation (ART: 26%, NART: 6%; p less than 0.05). The mean follow-up period is 56.9 +/- 28.1 months (SD) for the 58 surviving patients. The five-year actuarial survival rate is 68% for ART patients and 60.6% for NART patients (NS). In child B patients the five-year actuarial survival rate is 75% in ART patients and 22% in NART patients (p less than 0.05). Actuarial estimation of arterialization patency--proved by angioscan--is 38% at five years. There were no significant differences in the incidences of postoperative and long-term encephalopathy and liver function between the two groups. In conclusion, arterialization of the portal vein in conjunction with a therapeutic end-to-side porto-caval shunt improved survival in high risk patients (Child class B), did not increase operative mortality in Child A and B patients, was followed by a higher incidence of postoperative ascites and did not decrease the incidence of long-term encephalopathy.

The authors report a stab wound of the right branch of the portal vein observed at the Lariboisière hospital, and discuss 27 published cases of traumatic lesions of the portal vein or its branches. The treatment of choice of these lesions is mainly suture, which is the best procedure when there is a frank lesion without loss of tissue. Furthermore, we have found that ligature of one branch of the portal vein is possible, even if one does not carry out removal of the liver in the corresponding area. On the other hand, in no case, in a patient without liver disease or portal hypertension, should one carry out sudden total interruption of the portal blood flow.

An 8-year old girl with chronic renal failure underwent allogeneic renal transplantation with implantation of the renal vein of the graft on the portal vein, as the inferior vena cava was obstructed by thrombosis. The possible technical obstacles to renal transplantation are reviewed on that occasion, and solutions are suggested. In the presence of thrombosis of the inferior vena cava it seems necessary to determine its level and to look for a patent venous segment all the way up to the diaphragm. If no such segment is found, then the renal vein can be implanted on the portal vein.