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Liver transplantation has considerably evolved over the last two decades. With improvements in surgery and patient care, the one-year patient survival rate is now about 84% in Europe. This improvement has occurred in all indications, including hepatocellular carcinoma. The advent of new surgical techniques designed to palliate the graft shortage, such as the use of split liver and living donors, has not negatively affected the survival curve.

Radical hepatectomy-- the only curative treatment for colorectal liver metastasis--is feasible in 75 to 85% of cases. In 1990 we showed that chemotherapy rendered some otherwise unresectable colorectal liver metastases resectable. We have now treated more than 200 such patients, with respective 5-year and 10-year overall survival rates of 30% and 18%. This difficult surgery involves major hepatectomy in 55% of patients, repeat hepatectomy (up to four procedures) in 36% of patients, and associated pulmonary resection in 20% of patients. We have also pioneered the use of presurgical liver parenchyma augmentation, in order to permit major hepatectomy without risking post-operative liver failure due to inadequate parenchymal tissue. New medical treatments, including monoclonal antibodies against tumoral growth factors (cetuximab) and vascular growth factors (bevacizumab), are also proving useful for tumor shrinkage prior to surgical resection.

Surgery is the only curative treatment for patients with colorectal liver metastases with recent reports documenting 5-year survival results of 40-50%. In unresectable patients, the use of more effective regimens of chemotherapy has contributed to improve the results of survival at short term and new onco-surgical strategies have emerged. By allowing resection of previously unresectable liver metastases, these onco-surgical strategies now offer 15-20% of patients a real potential of long-term remission (5-year survival 30-40%). Chemotherapy is also used in the adjuvant setting, to prevent post-operative recurrence. In resectable metastases, it may also be used as neo-adjuvant treatment to control tumor progression before surgery and to select the patients likely to really benefit from liver resection. The objective of this article is to describe this multidisciplinary approach of liver metastases and to report the results of these new strategies.

If the ratio liver graft weight/recipient body weight ratio is below 0.8%, there is a high risk of primary non function of the graft in almost 50% of cases. We report the first elective Auxiliary Partial Orthotopic Liver Transplantation using a small cadaveric left graft for cirrhosis. The graft weight/recipient body weight rate was 0.6%. This technique avoided the small-for-size syndrome in the early postoperative period. The native right liver was resected two months later. With a follow-up of 5 years, the patient is in good condition. This original technique could be a solution to increase the number of transplantations using small grafts, especially left grafts, provided by splits or living donors.

To measure the impact of strict monitoring on long term permeability of TIPS.From November 1991 to December 2002, 208 patients (152 men and 66 women managed for the placing of a TIPS following failure with sclerotherapy or refractory ascites were included. The permeability of the prosthesis was controlled on the surgical piece. Revision of the TIPS was performed at the same time as the diagnosis of obstruction using trans-jugular angiography. The TIPS permeability was classified into 3 categories: primary permeability (duration of permeability recorded up until any intervention); assisted primary permeability (duration of continuous permeability with or without percutaneous intervention); secondary permeability (total duration of permeability with or without treated occlusion).Among the 218 patients in the study, 108 had been monitored for less than one year (49.5%), 29 for between 1 and 2 years (13.5%), 27 between 2 and 3 years (12.5%), 16 between 3 and 4 years (7.5%), 15 between 4 and 5 years (7%) and 23 for more than 5 years (10%). The mean follow-up period was of 24.1 +/- 27.2 months (median: 13.7). Current survival of these patients was of 81.2 +/- 2.9% at 1 year, 62.9 +/- 4.2% at 3 years and 52 +/- 4.9% at 5 years. Thirty-four patients were lost to follow-up (16%), after a mean follow-up of 22.9 +/- 26.7 months (median: 9.7). All these patients exhibited a permeable TIPS during their last control. One hundred and thirty-five patients (62%) had never presented obstruction of the TIPS, with a mean follow-up of 19.5 +/- 26.2 months (median: 7.4); 83 patients (38%) exhibited 117 episodes of obstruction; 24 two episodes, 7 three and 3 more than three; 4 exhibited thrombosis provoked by an invalidating encephalopathy and contraindicating transplantation, 2 of them following a first episode of thrombosis. The current primary, primary assisted and secondary permeability rates were respectively: 67.7 +/- 3 and 514 +/- 3.7%, 79.9 +/- 2.3% and 69.3 +/- 3.4%, 94.4 +/- 1.8% and 91 +/- 2.6% at 1 and 3 years (p = 0.0001, Log Rank = 65.3). Univariate analysis revealed a relationship between the onset of an episode of early or late obstruction and the patients' age at the time the TIPS was inserted, Child's score before, and the pre- and post-surgical gradient. In multivariate analysis, none of these elements reached significance.Although the use of TIPS in the treatment of portal hypertension follows the course of development of all surgery towards minimally invasive methods, it should not be considered as a surgical portal shunt or as a permanent treatment: long-term permeability is only obtained with strict and regular monitoring and the possibility of rapid intervention in the case of obstruction.

Nine centers have reported 15 cases of liver transplantation for Rendu-Osler-Weber's disease with liver involvement. Six cases are reported to analyse the specific technical and hemodynamical aspects.Five women and 1 man were transplanted for Rendu-Osler-Weber's disease. The clinical presentation was biliary disease in 3 cases, portal hypertension in 2 cases, cardiac failure in 1 case. Systemic hemodynamics were assessed at the beginning and at the end of the transplantation procedure.The procedure lasted from 11 to 15 hours (median=13 hours and 15 minutes). Blood transfusion during the procedure varied from 16 to 88 blood units (median=59 blood units). Six patients had hyperkinetic syndrome at the beginning of the procedure. At the end of transplantation, mean arterial pressure significantly increased (from 66 +/- 2 to 72 +/- 6 mmHg, p0.05), whereas cardiac output (from 9.2 +/- 3.0 à 5.7 +/- 0.5 L/mn, p0.05) significantly decreased. Two patients died at D2 and D11 and 4 are alive 3 to 7.5 years (median=4 years 9 months) after transplantation with a normal liver function and without any cardiac symptoms.Liver transplantation for Rendu-Osler-Weber's disease is a difficult procedure. When successful, liver transplantation is curative of both the liver disease and the hyperkinetic state.

Liver transplantation was contraindicated in patients with diffuse thrombosis of the portal vein until the recent use of graft portal vein reperfusion with the caval flow or one of its tributaries. Long term results of these procedures are reported here.Eight patients with diffuse portal vein thrombosis were transplanted by portal reperfusion via latero-terminal anastomosis between the native caval vein and the graft portal vein (2 patients) or termino-terminal between the native left renal vein and the graft portal vein (6 patients).Three patients died 3, 3 and 6 months following transplantation from intracerebral hemorrhage, cardiac arrest, and chronic rejection respectively. Three patients had complicated portal hypertension. Five patients were alive at home with a median follow-up of 9 months (2 to 37 months) with normal liver and kinase functions.Portal reperfusion with the caval vein flow allows transplantation of patients with diffuse poral vein thrombosis. According to our experience and to the analysis of the literature, reno-portal anastomosis is preferable to cavo-portal reconstruction.