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Background: Despite the increasing efficacy of chemotherapy (C), the 5-year survival rate for patients with unresectable colorectal liver metastases (CLM) remains around 10%. Liver transplantation (LT) might offer a curative approach for patients with liver-only disease, yet its superior efficacy compared to C alone remains to be demonstrated. Methods: The TransMet randomised multicentre clinical trial (NCT02597348) compares the curative potential of C followed by LT versus C alone in patients with unresectable CLM despite stable or responding disease on C. Patient eligibility criteria proposed by local tumour boards had to be validated by an independent committee via monthly videoconferences. Outcomes reported here are from a non-specified interim analysis. These include the eligibility of patients to be transplanted for non resectable colorectal liver metastases, as well as the feasibility and the safety of liver transplantation in this indication. Findings: From February 2016 to July 2021, 94 (60%) of 157 patients from 20 centres in 3 countries submitted to the validation committee, were randomised. Reasons for ineligibility were mainly tumour progression in 50 (32%) or potential resectability in 13 (8%). The median delay to LT after randomisation was 51 (IQR 30–65) days. Nine of 47 patients (19%, 95% CI: 9–33) allocated to the LT arm failed to undergo transplantation because of intercurrent disease progression. Three of the 38 transplanted patients (8%) were re-transplanted, one of whom (3%) died post-operatively from multi-organ failure. Interpretation: The selection process of potential candidates for curative intent LT for unresectable CLM in the TransMet trial highlighted the critical role of an independent multidisciplinary validation committee. After stringent selection, the feasibility of LT was 81%, as 19% had disease progression while on the waiting list. These patients should be given high priority for organ allocation to avoid dropout from the transpl, SCOPUS: ar.j, info:eu-repo/semantics/published

Unlike simple obesity, Madelung's disease (MD) is a rare disease characterized by symmetric accumulation of massive adipose tissue on the neck, the superior part of the trunk and limbs, leading to a pathognomonic cosmetic deformity. Here, we report an extremely rare case of MD associated with bilateral gynecomastia in a 61-year-old man, with a history of recent liver transplantation for alcoholic liver disease (ALD).

Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management are unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children. From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22-66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein. Median operative time was 500 min (range 300-730). Median follow-up duration was 22 months (range 2-169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB. Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.

Introduction: Progressive liver graft fibrosis is a cause of graft failure and late death in the follow-up of transplant patients. Early detection of liver graft fibrosis is crucial to improve survival of transplant patients. Liver biopsy is still the gold standard to detect fibrosis of the graft but is an invasive, costly and not complication-free procedure. Transient elastography (TE) might measure graft fibrosis but data are lacking for this population. Regarding the assessment of fibrosis, the Metavir score is still used, but not designed for a transplant cohort. The liver allograft fibrosis semiquantitative scoring system (LAFSc or Venturi Score) was designed and validated to assess the fibrosis in a pediatric transplant population better than with the Metavir score. Aim: Our aims are to determinate if TE could be correlated to histological scores and to validate LAFSc in an adult population. Methods: We included 52 liver transplant recipients followed-up at our institution who underwent per-protocol liver biopsies between 02/2021 and 10/2021. The biopsy was a 6-months, 1-year, 5-, 10-, 15- or 20-years follow-up procedure, depending on the date of the transplantation. A TE (FibroScan®) was performed before each protocol liver biopsy. With TE, we measured liver stiffness and liver steatosis severity assessed by the controlled attenuation parameter (CAP). Each biopsy sample was examined in the department of pathology of our institution, by one experienced pathologist. Graft fibrosis was classified according to Metavir score and LAFSc. The association between Metavir and LAFSc, and between histological scores and TE was tested through the Spearman’s rank correlation coefficient (rho), which was reported alongside the 95% confidence interval (CI). The relationship between the different scores was modelled through linear regressions and r2 were reported. All tests were two-tailed. Significance was retained at p < 0.05. Analyses were run with GraphPad Prism 8.0 (Grap

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The management of portal hypertension complicated by iterative gastro-intestinal bleeding remains challenging, especially in a low-income environment. Interventional radiology and endoscopic treatments are not always accessible, and a definitive surgical option may prove to be lifesaving. We report a new technique of surgical portosystemic shunt that can be performed in all contexts. We describe the surgical technique of a H-shaped splenorenal shunt using autologous rolled up peritoneum as a vascular graft.

Liver transplantation (LT) remains the only curative option for patients suffering from end-stage liver disease, acute liver failure and selected hepatocellular carcinomas and access to the LT-waiting list is limited to certain strict indications. However, LT has shown survival advantages for patients in certain indications such as acute alcoholic hepatitis, hepatocellular carcinoma outside Milan criteria and colorectal cancer metastases. These newer indications increase the pressure in an already difficult context of organ shortage. Strategies to increase the transplantable organ pool are therefore needed. We will discuss here the use of HCV positive grafts as the use of normothermic isolated liver perfusion. Belgian Liver Intestine Advisory Committee (BeLIAC) from the Belgian Transplant Society (BTS) aims to guarantee the balance between the new indications and the available resources.

T. MOREELS (1), L. MONINO (1), G. DAHLQVIST (1), B. DELIRE (1), L. COUBEAU (2), O. CICCARELLI (2), E. BONACCORSI RIANI (2), P. GOFFETTE (3), E. SOKAL (4), H. PIESSEVAUX (1) / [1] Cliniques universitaires Saint-Luc, Brussels, Belgium, Hépato-Gastroentérologie, [2] Cliniques universitaires Saint-Luc, Brussels, Belgium, Transplantation abdominale, [3] Cliniques universitaires Saint-Luc, Brussels, Belgium, Radiologie, [4] Cliniques universitaires Saint-Luc, Brussels, Belgium, Gastroentérologie & Hépatologie Pédiatrique Introduction Biliary complications after liver transplantation are frequently dealt with by means of endoscopic retrograde cholangiopancreatograpy (ERCP) using a duodenoscope. However, when the bile duct is anastomosed on a Roux-en-Y jejunal limb, the biliary system is out of reach for conventional ERCP, and it is accessed usually via percutaneous transhepatic cholangiography (PTC) or surgery. Aim We retrospectively studied the feasibility of single-balloon enteroscopy-assisted ERCP (SBE-ERCP) to evaluate and treat biliary complications in liver transplant patients with Roux-en-Y reconstruction. Methods Between 2016 and 2020 all SBE-ERCP procedures in liver transplant patients were analysed for indications, technical and clinical success and adverse events. Results A total of 40 patients (26 males) with a mean age of 43±3 years (range 13-81) underwent 69 SBE-ERCP procedures. Indications were suspicion of anastomotic stricture (40%), cholangitis (32.5%), bile duct stones (20%), biliary leak (2.5%), haemobilia (2.5%) and sepsis of unknown origin (2.5%). Technical success rate per patient was 85% (34/40). Failure was due to inability to reach the hepaticojejunal anastomosis. SBE-ERCP was normal in 12/34 (35%), confirmed the anastomotic stricture in 12/34 (35%), bile duct stones in 6/34 (18%), indwelling metallic stent in 2/34 (6%) and biliary leak and bile duct torsion both in 1/34 (3%). Biliary endoscopic interventions: balloon dilatation (6-9 mm), plastic

A 36-year-old patient of North African origin (lived in Belgium since childhood) who had been on home haemodialysis (HD) for 24 months for end-stage kidney disease secondary to diabetic nephropathy presented with progressive symptomatic hypercalcaemia. [...]

Liver transplantation (LT) remains the only curative option for patients suffering from end-stage liver disease, acute liver failure and selected hepatocellular carcinomas and access to the LT-waiting list is limited to certain strict indications. However, LT has shown survival advantages for patients in certain indications such as acute alcoholic hepatitis, hepatocellular carcinoma outside Milan criteria and colorectal cancer metastases. These newer indications increase the pressure in an already difficult context of organ shortage. Strategies to increase the transplantable organ pool are therefore needed. We will discuss here the use of HCV positive grafts as the use of normothermic isolated liver perfusion. Belgian Liver Intestine Advisory Committee (BeLIAC) from the Belgian Transplant Society (BTS) aims to guarantee the balance between the new indications and the available resources. (Acta gastroenterol. belg. 2021, 84, 347-359)., SCOPUS: ar.j, info:eu-repo/semantics/published

Biliary tract complications (BTCs) still burden liver transplantation (LT). The wide reporting variability highlights the absence of systematic screening. From 2000 to 2009, simultaneous liver biopsy and direct biliary visualization were prospectively performed in 242 recipients at 3 and 6 months (n = 212, 87.6%) or earlier when indicated (n = 30, 12.4%). Median follow-up was 148 (107–182) months. Seven patients (2.9%) experienced postprocedural morbidity. BTCs were initially diagnosed in 76 (31.4%) patients; 32 (42.1%) had neither clinical nor biological abnormalities. Acute cellular rejection (ACR) was present in 27 (11.2%) patients and in 6 (22.2%) BTC patients. Nine (3.7%) patients with normal initial cholangiography developed BTCs after 60 (30–135) months post-LT. BTCs directly lead to 7 (2.9%) re-transplantations and 14 (5.8%) deaths resulting in 18 (7.4%) allograft losses. Bile duct proliferation at 12-month biopsy proved an independent risk factor for graft loss (P = 0.005). Systematic biliary tract and allograft evaluation allows the incidence and extent of biliary lesions to be documented more precisely and to avoid erroneous treatment of ACR. The combination ‘abnormal biliary tract-canalicular proliferation’ is an indicator of worse graft outcome. BTCs are responsible for important delayed allograft and patient losses. These results underline the importance of life-long follow-up and appropriate timing for re-transplantation., SCOPUS: ar.j, info:eu-repo/semantics/published

The combination of two-stage total hepatectomy and partial liver transplantation (LT) for secondary unresectable liver-only malignancies is producing a great quantity of literature. In the first stage, partial hepatectomy leaves a deportalised right liver while left-graft LT is performed. The second stage is scheduled after enough liver regeneration has occurred and consists of residual liver removal.

Clinical case presentation : We present the case of a 32-year-old Tunisian woman living in Belgium with a 5-year history of liver lesions. Her medical history is marked by two pregnancies, and pleural tuberculosis at the age of 23, treated by antitubercular agents. The lesions were incidentally discovered in 2013 on a CT scan during a workout because of postpartum fever. They measured 8, 28, and 11 mm, respectively, at segments 7, 5, and 6; based on both MRI and ultrasound, they were considered atypical. She was asymptomatic and put under surveillance with no precise diagnosis.

IMPORTANCE: The option of donating organs after euthanasia is not well known. Assessment of the results of organ transplants with grafts donated after euthanasia is essential to justify the use of this type of organ donation. OBJECTIVES: To assess the outcomes of liver transplants (LTs) with grafts donated after euthanasia (donation after circulatory death type V [DCD-V]), and to compare them with the results of the more commonly performed LTs with grafts from donors with a circulatory arrest after the withdrawal of life-supporting treatment (type III [DCD-III]). DESIGN, SETTING, AND PARTICIPANTS: This retrospective multicenter cohort study analyzed medical records and LT data for most transplant centers in the Netherlands and Belgium. All LTs with DCD-V grafts performed from the start of the donation after euthanasia program (September 2012 for the Netherlands, and January 2005 for Belgium) through July 1, 2018, were included in the analysis. A comparative cohort of patients who received DCD-III grafts was also analyzed. All patients in both cohorts were followed up for at least 1 year. Data analysis was performed from September 2019 to December 2019. EXPOSURES: Liver transplant with either a DCD-V graft or DCD-III graft. MAIN OUTCOMES AND MEASURES: Primary outcomes were recipient and graft survival rates at years 1, 3, and 5 after the LT. Secondary outcomes included postoperative complications (early allograft dysfunction, hepatic artery thrombosis, and nonanastomotic biliary strictures) within the first year after the LT. RESULTS: Among the cohort of 47 LTs with DCD-V grafts, 25 organ donors (53%) were women and the median (interquartile range [IQR]) age was 51 (44-59) years. Among the cohort of 542 LTs with DCD-III grafts, 335 organ donors (62%) were men and the median (IQR) age was 49 (37-57) years. Median (IQR) follow-up was 3.8 (2.1-6.3) years. In the DCD-V cohort, 30 recipients (64%) were men, and the median (IQR) age was 56 (48-64) years. Recipient survival

Introduction: Living donor liver transplantation (LDLT) is a well-established alternative to alleviate post-mortem organ shortage in pediatric liver transplantation. Such program, however,should be performed under strict ethical guidelines, and optimal living donor (LD) safety. We hypothesized that serious unexpected perioperative medical and/or surgical events during LD procedure indeed occur in a high volume LDLT center, being a major threat to donor safety. Methods: From July 1993 to October 2018, 433 pediatric LDLT were performed at our institution. All LD medical records were retrospectively reviewed searching for the occurrence of near-miss events (NME). NME was defined as any potentially perioperative harmful event that was identified and controlled before definitive patient harm has happened. Results: LD postoperative morbidity consisted mainly in cut-surface collections, transient pleural effusions, and incisional hernias, in less than 3% each. However, eight (1,8%) serious intraoperative NMEs occurred: accidental vena cava clamp releasing, left hepatic artery (HA)clip sliding both resulting in massive bleeding, donor right HA ligature and section, accidental section of left HA at liver graft hilum, tension pneumothorax following right subclavian vein catheterization, LD intravenous full-heparinization, donor common hepatic duct section, an injury of segment II bile duct. NME management consisted in: vascular control of intraoperative bleeding and microsurgical repair of the arterial lesions, pneumothorax drainage, intravenous protamine administration, Roux-en-Y hepaticojejunostomy reconstruction, repair of segment II bile duct at back-table. None of these NMEs resulted in donor or recipient postoperative morbidity. Conclusions: Despite our minimal morbidity and no mortality rates, 8 serious and potential harmful NMEs were identified in these 433 LDs. All NME were timely recognized and controlled without subsequent donor or recipient harm. NMEs systematic d

Purpose: Adult-to-adult living-donor LT(AALDLT) has been proposed to alleviate allograft shortage. However, it is not commonly considered in Western countries due to easier access to deceased donation, when compared to Eastern countries, and sometimes risky graft-to-recipient body weight ratio (GRBWR). We hypothesized that a priori computation of MELD status and GRBWR might predict LT outcome. Methods: Between 1998 and October 2018 a total of 68 AALDLT were performed at our Centre. Main indications were primary (23/68, 33. 8%) and secondaty (12/68, 17. 6%)liver tumours, cholestatic liver disease (13/68, 19. 1%∗ and alcoholic cirrhosis 10/68(14. 7). The median MELDwas 11 (interquartilerange, IQR7-16). After donor medical and liver volume assessment using MeVis software, 28/68 (41. 2%) liver donors underwent full left and 40/68 cases (58. 8%) right hepatectomy. The median GRBWR was 0. 99% (IQR 0. 78-1. 21%). Results: Overall 3-month patient and graft survivals were 85% and 79%. Retrans-plantationratewas 12% Causes of mortality were: sepsis (4/10, 40%), sudden cardiac arrest (2/10, 20%), multi-organ failure (3/10, 30%), coeliac trunk dissection with sub-sequent bleeding (1/10, 10%). Indications for retransplantation were: hepatic artery thrombosis (2/8, 25%), portal vein thrombosis (2/8, 25%), small-for-size syndrome (2/8, 250/c), graft failure after caval thrombosis (1/8, 12. 5%), massive bleeding from hepatic artery (1/8, 12. 5%). Patients were categorized retrospectively with respect to their MELD status (<15 vs. >15), as well as to their GRBWR (<0. 8% vs. >0. 8%). Four sub-groups of recipients were identified accordingly, with their respective 3-month patient deathrate: group 1 (MELD<15; GRBWRO. 8): 1/13 (7. 7%); group 2 (MELD<15; GRBWR >0. 8): 2/31 (6. 5%); group 3 (MELD>15; GRBWR<0. 8): 1/4 (25. 0%); group 4 (MELD>15; GRBWR >0. 8) 6/20 (30. 0%). The difference in the death rate was statisticalh/significant only for group 2 vs. group 4 (p=0. 045). Conclusions: Reg

Purpose: Living donor liver transplantation (LDLT) is a well-established alterna-tive to alleviate postmortem organ shortage in pediatric liver transplantation. Such program, however, should be performed under strict ethical guidelines, and optimal living donor (LD) safety. In spite of left lobe or left lateral liver resection are very standardizedsurgical procedures in pediatric LDLT Zprograms with minimal morbidity and almost no mortality, we hypothesized that serious unexpected peri-operative medical and/or surgical events during LD procedure indeed occur in a high volume LDLT Zcenter, being a major threat to donor safety. Methods: From July 1993 to October 2018, 433 paediatric LDLT Zwere perfotmed in our institution under a very strict ethical and clinical protocol. LD medical records were retrospectively reviewed searching for preoperatory donor data, surgical and outcome and the occurrence of perioperative near-miss events (NME). NME was defined as any potentially perioperative hamrful event that was identified and con-trolled before definitive patient or recipient harm has happened. Results: There was no mortality in our series. Morbidity consisted mainly in cut-surface collections, transient pleural effusions, in less than 3% each and few incisional hernias. Eight (1, 8%) intraoperative NME occurred in LDs: accidental vena cava clamp releasing, left hepatic artety (HA) clip sliding both resulting in massive intraoperative bleeding, donor right HA ligature and section, accidental section of left HA at liver graft Mum, tension pneumothorax during right sub-clavian vein catheterization, LD intravenous full-heparinization before left portal vein clamping, section of donor common hepatic duct, injury of segment II bile duct at the graft cut surface. NME management consisted in: vascular control of intraoperative bleeding and microsurgical repair of arterial lesions, pneumothorax drainage, intravenous protamine administration, Roux-en-Y hepaticojejunostomy reconst

BACKGROUND: During the last decades, deceased-donor liver transplantation (DDLT) has gained a place in the therapeutic algorithm of well-selected patients harbouring non-resectable secondary liver tumors. Living-donor LT (LDLT) might represent a valuable means to further expand this indication for LT. METHODS: Between 1985 and 2016, twenty-two adults were transplanted because of neuroendocrine (n = 18, 82%) and colorectal metastases (n = 4, 18%); 50% received DDLT and 50% LDLT. In LDLT, 4 (36%) right and 7 (64%) left grafts were used; the median graft-to-recipient-weight ratios (GRWR) were 1.03% (IQR 0.86%-1.30%) and 0.59% (IQR 0.51%-0.91%), respectively. Median post-LT follow-up was 64 months (IQR 17-107) in the DDLT group and 40 months (IQR 35-116) in the LDLT group. DDLT and LDLT recipients were compared in terms of overall survival, graft survival, postoperative complications and recurrence. RESULTS: The 1- and 5-year actuarial patient survivals were 82% and 55% after DDLT, 100% and 100% after LDLT, respectively (P < 0.01). One- and 5-year actuarial graft survivals were 73% and 36% after DDLT, 91% and 91% after LDLT (P < 0.01). The outcomes of right or left LDLT were comparable. Donor hepatectomy proved safe, and one donor experienced a Clavien IIIb complication. Bilirubin peak was significantly lower after left hepatectomy compared with that after right hepatectomy [1.3 (IQR 1.2-2.2) vs. 3.3 (IQR 2.3-5.2) mg/dL; P = 0.02]. CONCLUSIONS: The more recent LDLT series compared favorably to our DDLT series in the treatment of secondary liver malignancies. The absence of portal hypertension and the use of smaller left grafts make recipient and donor surgeries safe. The safety of the procedures and lack of interference with the scarce allograft pool are expected to lead to a more frequent use of LDLT in the field of transplant oncology.

Introduction: Living donor liver transplantation (LDLT) is a wellestablished alternative to alleviate post-mortem organ shortage in pediatric liver transplantation. Such program, however, should be performed under strict ethical guidelines, and optimal living donor (LD) safety. We hypothesized that serious unexpected perioperative medical and/or surgical events during LD procedure indeed occur in a high volume LDLT center, being a major threat to donor safety. Methods: From July 1993 to October 2018, 433 pediatric LDLT were performed at our institution. All LD medical records were retrospectively reviewed searching for the occurrence of near-miss events (NME). NME was defined as any potentially perioperative harmful event that was identified and controlled before definitive patient harm has happened. Results: LD postoperative morbidity consisted mainly in cut-surface collections, transient pleural effusions, and incisional hernias, in less than 3% each. However, eight (1,8%) serious intraoperative NMEs occurred: accidental vena cava clamp releasing, left hepatic artery (HA) clip sliding both resulting in massive bleeding, donor right HA ligature and section, accidental section of left HA at liver graft hilum, tension pneumothorax following right subclavian vein catheterization, LD intravenous full-heparinization, donor common hepatic duct section, an injury of segment II bile duct. NME management consisted in: vascular control of intraoperative bleeding and microsurgical repair of the arterial lesions, pneumothorax drainage, intravenous protamine administration, Roux-en-Y hepaticojejunostomy reconstruction, repair of segment II bile duct at back-table. None of these NMEs resulted in donor or recipient postoperative morbidity. Conclusions: Despite our minimal morbidity and no mortality rates, 8 serious and potential harmful NMEs were identified in these 433 LDs. All NME were timely recognized and controlled without subsequent donor or recipient harm. NMEs systematic

Introduction: Living donor liver transplantation (LDLT) was developed to alleviate post-mortem organ shortage in pediatric liver transplantation. Such program, however, should be performed under strict ethical guidelines, and optimal living donor (LD) safety. We hypothesized that serious unexpected peri-operative medical and/or surgical events during LD procedure indeed occur in a high volume LDLT center, being a major threat to donor safety. Methods: Between July 1993 and October 2018, a total of 433 paediatric LDLT were performed at Cliniques universitaires Saint-Luc, Brussels Belgium. Each LD was carefully selected through medical history, pre-operative work-up, medical advocate and psychologist consultations, and liver US and MRI imaging. Left liver lobectomy was performed through a midline laparotomy as previous detailed (1). All LD medical records were retrospectively reviewed searching for the occurrence of near-miss events (NME). NME was defined as any potentially harmful event during peri-operative period that was identified and controlled before definitive patient harm has happened. No recognition/no control of such events constitute a potential risk for subsequent donor and recipient morbi-mortality. Results: Paediatric recipients results were described elsewhere (1). Neither mortality nor persisting disability was encountered in our series. Morbidity consisted mainly in cut-surface bile collections, transient pleural effusions, and incisional hernias, in less than 3% each. The following 8 (1.85%) intra-operative NME were identified in LD (one case each): 1) tension pneumothorax secondary to right subclavian vein function, 2) accidental ligature-section of donor common hepatic duct, 3) unintended ligature-section of donor right hepatic artery (RHA),4) accidental vena cava clamp release resulting in a massive bleeding, 5) slipping of the left hepatic artery (LHA) Hemolock® clip, 6) full IV LD heparinization, 7) lateral injury of seg. II bile duct evidenced

Liver transplantation is the treatment for end-stage liver diseases and well-selected malignancies. The allograft shortage may be alleviated with living donation. The initial UCLouvain experience of adult living-donor liver transplantation (LDLT) is presented. A retrospective analysis of 64 adult-to-adult LDLTs performed at our institution between 1998 and 2016 was conducted. The median age of 29 (45.3%) females and 35 (54.7%) males was 50.2 years (interquartile range, IQR 32.9-57.5). Twenty-two (34.4%) recipients had no portal hypertension. Three (4.7%) patients had a benign and 33 (51.6%) a malignant tumor [19 (29.7%) hepatocellular cancer, 11 (17.2%) secondary cancer and one (1.6%) each hemangioendothelioma, hepatoblastoma and embryonal liver sarcoma]. Median donor and recipient follow-ups were 93 months (IQR 41-159) and 39 months (22-91), respectively. Right and left hemi-livers were implanted in 39 (60.9%) and 25 (39.1%) cases, respectively. Median weights of right- and left-liver were 810 g (IQR 730-940) and 454 g (IQR 394-534), respectively. Graft-to-recipient weight ratios (GRWRs) were 1.17% (right, IQR 0.98%-1.4%) and 0.77% (left, 0.59%-0.95%). One- and five-year patient survivals were 85% and 71% (right) vs. 84% and 58% (left), respectively. One- and five-year graft survivals were 74% and 61% (right) vs. 76% and 53% (left), respectively. The patient and graft survival of right and left grafts and of very small (<0.6%), small (0.6%-0.79%) and large (≥0.8%) GRWR were similar. Survival of very small grafts was 86% and 86% at 3- and 12-month. No donor died while five (7.8%) developed a Clavien-Dindo complication IIIa, IIIb or IV. Recipient morbidity consisted mainly of biliary and vascular complications; three (4.7%) recipients developed a small-for-size syndrome according to the Kyushu criteria. Adult-to-adult LDLT is a demanding procedure that widens therapeutic possibilities of many hepatobiliary diseases. The donor procedure can be done safely with low mor

Introduction: Biliary atresia (BA) is the main indication for liver transplantation (LT) in the pediatric age. Donor-selection strategy is still matter of debate. Methods: LT performed at our Institution between 1993-beginning of our living donor program-and 2015 were retrospectively analyzed. Patient and graft survivals were studied in BA patients according to age at LT (before and after 2 years-old) and type of donor (living donor vs deceased donor). Among 609 children, recipients of 649 grafts, the indications for LT were as follows: BA (56.1%), cholestatic diseases (19.4%), liver malignancies (7.5%), fulminant hepatitis (4.3%) and others (12.7%). For BA recipients, 150 DD and 216 LD grafts were used: only primary transplantations (342 grafts) were considered for this study. Results: Overall, the median age at LT was significantly lower for BA patients (median: 1.0 year; range: 0.3-15.7) comparing to other indications (3.9 years; 0.1-22.4) (P < 0.0001). Overall 5-year patient and graft survivals were 86.9% and 82.2% respectively for non-BA, vs 95.1%% and 88.8% for BA patients (P = 0.0001 and P = 0.0033). In the BA subgroup (n = 342 pts), the median age was significantly lower when a LD-LT was performed (0.9 years; 0.4-10.8) comparing to DD-LT (1.4 years; 0.3-15.7) (P < 0.0001). 264 patients have been transplanted < 2 years-old (183 LD and 81 DD) and 78 ≥ 2 years-old (31 LD and 47 DD). Overall re-transplantation rate in BA recipients was 9.3%. 5-year PATIENT survival was comparable for patients transplanted ≥ 2 years-old (97.4%) vs those transplanted < 2 years-old (94.1%) (P = 0.9127); conversely, 5-years GRAFT survival was significantly higher when LT was performed < 2 years-old (90.0% vs 84.1%) (P = 0.0316). In the subgroup of children < 2 years-old, 5-year patient and graft survivals were significantly higher after LD-LT (96.6% and 90.6% respectively), than after DD-LT (88.9% and 81.5%) (P = 0.0156 and P < 0.0001). Conclusions: 1) BA constituted the main indica

If endourological approaches are not applicable to treat vesicoureteral anastomotic complications after kidney transplantation, the surgical gold standard in many transplant centers is pyeloureterostomy or ureteroureterostomy using the native ureter. We report an original preperitoneal technique that can be used for vesicoureteral reanastomosis in kidney transplant recipients not eligible for endourological treatment. Between January 2011 and December 2015, 18 kidney transplant recipients underwent this new surgical procedure. Of this number, 15 subjects with at least 1 year of follow-up were included in the analysis. The indications were vesicoureteral reflux, anastomotic stenosis, and leakage in 8, 5, and 2 patients, respectively. Briefly, a double J stent was preoperatively inserted into the grafted ureter. Surgery was performed through a Pfannenstiel incision. The preperitoneal space surrounding the bladder was dissected and the distal part of the grafted ureter was identified and mobilized. The anastomotic area was resected and another vesicoureteral anastomosis was performed (Lich-Gregoir technique), keeping the JJ stent in place for three weeks. This procedure was performed 213 days (range 17-2608) after kidney transplantation. Median surgical duration was 179 minutes (range 112-314) and median hospital stay 8 days (range 4-14). The success rate was 86.7% (13/15), with a median follow-up of 1148 days (range 517-1808). In two patients, symptomatic recurrence of vesicoureteral reflux required a pyeloureterostomy using the native ureter. The authors describe a simple technique that avoids transperitoneal dissection, potentially yielding more esthetic results thanks to easy access, as well as excellent outcomes.

AIMS: To compare the perioperative parameters and excess weight loss between patients operated by laporoscopic Roux-en-Y gastric bypass (LRYGB), as a primary operation or a revisional, for insufficient weight loss after vertical banded gastroplasty (VBG) or adjustable gastric banding (AGB). METHODS: A retrospective analysis of all patients who underwent a LRYGB was performed for the period 2004-2011. Demographics, preoperative body mass index (BMI), co-morbidities, operation time, conversion rate, perioperative complications, hospitalization period, and % of excess BMI loss (%EBMIL) were investigated and compared between groups. RESULTS: Three hundred forty-two laparoscopic gastric bypass operations were performed, 245 were primary, and 97 revisional. Median follow-up was 30 months (range 0-108 months). Mean BMI (kg/m2) before bypass was 45.2 for primary laparoscopic Roux-en-Y gastric bypass (pLRYGB) and 41.1 for revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB). Median operative time and length of stay were longer for rLRYGB 157.5 versus 235 min (p < 0.001) and 6 versus 6.5 days (p = 0.05). Conversion to laparotomy was performed in eight patients, 0.4% of primary and 7.2% of revisional. Morbidity rate was 6.5% in pLRYGB versus 10% in rLRYGB (NS). There was one death in the primary group. Percentage of EBMIL was significantly lower in the revisional group at 12, 18, and 24 months of follow-up. CONCLUSIONS: Revisional and primary gastric bypass have no statistical differences in terms of morbidity. The % of excess BMI loss is lower after revisional gastric bypass during the first 2 years of follow-up. The trend of weight loss or weight regain was similar in both groups.

The aim of the study is to evaluate whether intra-operative induction with anti-lymphocytic serum (ALS) is superior to no induction in adult liver transplantation (LT). The efficacy of ALS induction remains inconclusive in LT, because of poorly designed trials. A randomized controlled trial was conducted, including 206 adults (>15 years) and comparing tacrolimus monotherapy (TAC, n = 109) and tacrolimus plus a single, intraoperative, high-dose (9 mg/kg), rabbit anti-T-lymphocyte globulins (ATLG; n = 97). All patients had similar follow-up, including Banff-scored biopsies. Rejection was considered clinically relevant and treated if pathologic and biochemical changes were concordant. The primary endpoint was immunosuppression minimization to monotherapy; secondary endpoints were biopsy-proven rejection, clinical rejection, patient (PS) and graft (GS) survival. At 1 year, 79/81 (96.3%) ATLG and 101/102 (99.0%) TAC patients were steroid-free (P = 0.585); 28 (34.6%) ATLG, and 31 (30.4%) TAC patients were on double-drug immunosuppression (P = 0.633). One-year PS and GS of ATLG and TAC patients were 84% and 92% (P = 0.260) and 76% and 90% (P = 0.054).Despite significantly a fewer day-7 moderate-to-severe acute cellular rejections (ACR) in ATLG group (10.0% vs 24.0% in TAC group, P = 0.019), cumulative proportion of patients experiencing steroid-sensitive (11.3% ATLG vs 14.7% TAC, P = 0.539), steroid-resistant (2.1% ATLG vs 3.7% TAC, P = 0.686) and chronic rejection (1.0% ATLG vs 0.9% TAC, P = 1.000) were similar. ATLG administration brought about greater hemodynamic instability and blood products use (P = 0.001). At 1 year from LT, ATLG induction did not significantly affect immunosuppressive load, treated rejection, patient, and graft survival. The observed adverse events justify a modification of dosing and timing of ATLG infusion. Long-term results are required to judge the ATLG possible benefits on immunosuppressive load and tolerance induction.

A 26-year-old man was referred to the ophthalmology department with a 1-week history of blurred vision of the left eye; there was no pain or redness. Ophthalmological examination found unilateral choriocapillaropathy with optic nerve oedema. He was in a stable relationship and had not travelled abroad recently, nor had he been in contact with any animals or pets. He had a history of ulcerative colitis diagnosed 2 years earlier for which he was treated for 1 year with azathioprine and oral corticosteroids. Since then he had been totally asymptomatic. [...]

Background: The real incidence of biliary tract complications (BTCs) after liver transplantation (LT) is inaccurate due to the absence of a systematic post-transplant screening protocol. Furthermore, early diagnosis of BTCs can favor endoscopic or radiological treatment, keeping surgical treatment to advanced cases. Here, we review our clinical policy to perform a routine cholangiography within 6mo post- LT on the diagnosis of BTCs. Patients/Methods: Two-hundred fifty-five patients transplanted from January 2000 to April 2009 were included in the present study. Duct-to-duct biliaryanastomosis was performed in 225 patients (66 with T-tube), and 30 underwent a hepatico-jejunostomy. Our policy included a trans T-tube cholangiography (TTC) performed at any time per clinical indication or at 3mo post-LT before T-tube ablation. Percutaneous cholangiography (PTC) was routinely performed at 6mo post-LT or when indicated. Cholangiographic results were reviewed and correlated with patients clinical and biochemistry presentation. Results: From 30 clinically indicated cholangiographies, 22 detected a BTC (73%), when in the 229 routine exams, 59 were positive (25,8%). Positive routine exams correlation with clinical and biochemistry presentation showed that 14 (23,7%) patients had abnormal liver tests, 2 were only symptomatic, 9 had clinical and abnormal liver tests, and 57.6% (34) of all patients were asymptomatic and without biochemistry alteration. Thirty-five patients were treated, mainly by endoscopic procedures or interventional radiology. Twenty-four patients with less than 50% of diameter narrowing were only observed and no later-BTCs were observed. Routine exams complication rate was 3,08% (8/259) with no mortality. Only 9 out 170 patients with normal PTC at 6mo developed late BTCs (120mo follow-up, range 8-204). Conclusion: The incidence of asymptomatic BTCs diagnosed on routine cholangiographies was greater than expected, corresponding for more than half of cases. Fur

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Objective: Assessment of a simple layer peritoneal tube used as an autogenous inferior vena cava replacement. Background: Extensive en-bloc multivisceral resection including major vessels is effective in selected abdominal malignancies, but the need for vascular reconstruction represents a surgical challenge. We describe the use of autologous peritoneum for caval replacement. Methods: Autogenous parietal peritoneum without fascial backing was harvested and tubularized to replace the inferior vena cava (IVC) in four patients with complex abdominal tumors. Surgical morbidity was evaluated using the Clavien–Dindo classification, and graft patency was systematically evaluated with ultrasound. Results: All four patients had multiorgan resections for malignancies involving the retro-hepatic IVC, and they all required the replacement of infrarenal and suprarenal IVC segments. Additionally, all four required a right nephrectomy, two had a combined major hepatectomy, and one patient needed a veno-venous bypass. All had an R0 resection. A clinical follow-up took place between 5 and 11 months after surgery for each patient. Four-month graft patency was confirmed by ultra-sound and TDM with no sign of disease recurrence. Conclusions: Autologous peritoneum without fascial backing is a good and safe option for circumferential replacement of IVC after extensive en-bloc tumor resection with IVC involvement.

BACKGROUND: Chemotherapeutic advances have enabled successful cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) expansion in treating metastatic colorectal cancer. OBJECTIVES: The aims of this study were to evaluate the safety of combining liver surgery (LS) with HIPEC and CRS (which remains controversial) and its impact on overall survival (OS) rates. METHODS: From 2007 to 2015, a total of 77 patients underwent CRS/HIPEC for peritoneal carcinomatosis (PC) of colorectal cancer. Twenty-five of these patients underwent concomitant LS for suspicion of liver metastases (LM; group 2), and were compared with patients who underwent CRS/HIPEC only (group 1). Demographic and clinical data were reviewed retrospectively. RESULTS: Among the group 2 patients, two underwent major hepatectomies, six underwent multiple wedge resections, 16 underwent single wedge resections (one with radiofrequency ablation), and one underwent radiofrequency ablation alone. For groups 1 and 2, median peritoneal cancer index was 6 and 10 (range 0-26; p = 0.08), complication rates were 15.4 and 32.0 % (Dindo-Clavien ≥3; p = 0.15), and median follow-up was 34.2 and 25.5 months (range 0-75 and 3-97), respectively. One group 2 patient died of septic shock after 66 days. Pathology confirmed LM in 21 patients in group 2 (four with benign hepatic lesions were excluded from long-term outcome analysis). Two-year OS rates were 89.5 and 70.2 % (p = 0.04), and 2-year recurrence-free survival rates were 38.3 and 13.4 % (p = 0.01) in groups 1 and 2, respectively. CONCLUSIONS: Simultaneous surgery for colorectal LM and PC is both feasible and safe, with low postoperative morbidity. Further longer-term studies would help determine its impact on patient survival

Calcifying Fibrous Pseudotumors (CFTs) are rare benign tumors of soft tissues. The diagnosis is difficult to establish because of the lack of specific biomarker, clinical features and image findings. The treatment consists of a surgical excision associated with a pathological analysis. We report a case with an unusual presentation. [...]

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An intra-abdominal pseudotumor is a rare complication of hemophilia. Surgical treatment is associated with high morbidity and mortality rates and reported cases are scarce. We present a 66-year-old Caucasian male suffering from severe hemophilia type A treated for 10 years with Factor VIII. Major complications from the disease were chronic hepatitis B and C, cerebral hemorrhage and disabling arthropathy. Twenty-three years ago, retro-peritoneal bleeding led to the development of a large intra-abdominal pseudotumor, which was followed-up clinically due to the high surgical risk and the lack of clinical indication. The patient presented to the emergency department with severe sepsis and umbilical discharge that had appeared over the past two days. Abdominal computed tomography images were highly suggestive of a bowel fistula. The patient was taken to the operating room under continuous infusion of factor VIII. Surgical exploration revealed a large infected pseudotumor with severe intra-abdominal adhesions and a left colonic fistula. The pseudotumor was partially resected en bloc with the left colon leaving the posterior wall intact. The postoperative period was complicated by septic shock and a small bowel fistula that required reoperation. He was discharged on the 73(rd) hospital day and is well 8 mo after surgery. No bleeding complications were encountered and we consider surgery safe under factor VIII replacement therapy.

A 66 years old male developping an acute lower right limb oedema due to an extended venous thrombosis of the common femoral and iliac veins was diagnosed to have a leiomyosarcoma of the inferior vena cava (IVC) involving both renal veins. The characteristics and management of this level II IVC leiomyosarcoma are discussed with particular attention to the renal vein reconstruction and neo-adjuvant therapy.