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Abstract Purpose Tacrolimus (TAC) is the main immunosuppressive drug in liver transplantation. Despite intensive therapeutic drug monitoring (TDM) that relies on whole blood trough concentration (TAC blood), patients still present with acute cellular rejection or TAC-related toxic effects with concentrations within the therapeutic range. TAC concentration in peripheral blood mononuclear cells (TAC PBMC) is considered as an efficient surrogate marker of TAC efficacy. However, it is still not applicable in daily practice. New TDM methods are therefore needed, especially during the early postoperative period. TAC is metabolized in the liver and eliminated through biliary excretion. We therefore hypothesised that TAC concentration measured in excreted bile (TAC bileC) could be a relevant surrogate marker of its efficacy. Methods The Therapeutic Drug Monitoring of Tacrolimus Biliary Concentrations for Liver-Transplanted Patients (STABILE) study is a prospective monocentric trial. During the 7 first days after TAC therapy initiation, TAC bileC was measured. The correlation between TAC bileC and TAC PBMC as well as between TAC blood and TAC PBMC was assessed. The correlations between TAC bileC and liver graft function parameter or with occurrence of neurologic toxic effects were also evaluated. Findings Between May 2016 and April 2017, 41 patients were analyzed. TAC bileC was significantly correlated with TAC PBMC (r = 0.25, P = 0.007). However, a better correlation was found between TAC PBMC and TAC blood (r = 0.53, P < 0.001) and was confirmed in multivariate analysis. However, only TAC bileC was significantly correlated with liver graft function, such as factor V (r = 0.40, P = 0.009) or bilirubin level (r = 0.21, P = 0.01), and significantly lower in patients presenting with neurologic toxic effects (P < 0.001). Receiver operating characteristic curve analysis found that a TAC bileC level lower than 0.20 ng/mL on day 2 after TAC therapy initiation was a good predictive marker of occurrence of neurotoxic effects (AUC = 0.81). Implications TAC bileC is not a better surrogate maker of TAC activity than TAC blood. However, TAC bileC could help predict the occurrence of TAC toxic effects when a T-tube is inserted. ClinicalTrials.gov identifier: NCT02820259. [ABSTRACT FROM AUTHOR]

Background and aims Portopulmonary hypertension (POPH) hampers survival of patients with cirrhosis and portal hypertension and may preclude liver transplantation (LT). Management of such patients with oral pulmonary vasoactive drugs (PVD) has not been standardized. Our aim was to assess the efficacy and safety of oral PVD for management of POPH. Methods All patients treated by oral PVD (bosentan, ambrisentan, sildenafil, tadalafil) for POPH were retrospectively studied. Significant response was defined for the patients who reached the following LT eligibility criteria: mean pulmonary artery pressure (MPAP) <35 mmHg or MPAP between 35 and 50 mmHg with pulmonary vascular resistance (PVR) <250 dyn s cm −5 . Results 20 patients were followed for 38 (19–57) months. Oral PVD improved MPAP (−8 [−19, +2] mmHg), PVR (−201 [–344, –68] dyn s cm −5 ) and 6-min walk distance (+52 [−51, +112] m). Fifty-three percent of evaluable patients reached eligibility to LT criteria, of whom 5 were transplanted. Baseline MPAP > 51 mmHg and/or PVR > 536 dyn s cm −5 predicted non response to treatment. Five-years survival was 53%. No worsening of cirrhosis or serious adverse effect was recorded. Conclusion Oral pulmonary vasoactive drugs are safe in cirrhotic patients with POPH. These treatments improved hemodynamic conditions allowing patients access to liver transplantation eligibility. [ABSTRACT FROM AUTHOR]

Background The Frey procedure has become the standard operative treatment in chronic painful pancreatitis. Biliary diversion could be combined when associated with common bile duct obstruction. The aim of the present study was to evaluate the impact of the type of biliary diversion combined with the Frey procedure on late morbidity. Methods The data from consecutive patients undergoing the Frey procedure and having a minimum follow-up of 2 years were extracted from a maintained prospective database. The mean endpoint was the rate of secondary biliary stricture after the Frey procedure combined with biliary diversion (bilioenteric anastomosis or common bile duct reinsertion in the resection cavity). Results Between 2006 and 2013, 55 consecutive patients underwent the Frey procedure. Twenty-nine patients had common bile duct obstruction (52.7%). The technique of biliary diversion resulted in bilioenteric anastomosis in 19 patients (65.5%) and common bile duct reinsertion in 10 patients (34.5%). Preoperative characteristics and early surgical outcomes were comparable. Pain control was similar. There was significantly more secondary biliary stricture after common bile duct reinsertion than after bilioenteric anastomosis (60% vs 11%, P = .008). Conclusion Combined bilioenteric anastomosis during the Frey procedure is an efficient technique for treating common bile duct obstruction that complicates chronic painful pancreatitis. Bilioenteric anastomosis was associated with less secondary biliary stricture than common bile duct reinsertion in the pancreatic resection cavity. [ABSTRACT FROM AUTHOR]

Background In patients with intrahepatic cholangiocarcinoma (ICC), extended liver resections (ELRs) increase the rate of resectability. The aims of the present study were to evaluate the morbidity and oncologic outcomes of ELR compared with other liver resections (LR) for ICC. Methods All LR for ICC that were performed in our center between January 1997 and September 2013 and conducted with curative intent were included in this retrospective analysis. ELRs were defined by resections of ≥5 liver segments. The factors that influenced the occurrence of major complications (Clavien ≥ 3) and overall survival (OS) were tested with univariate and multivariate analyses. Results One hundred seven patients (82 men and 25 women) were resected, and 27 (25.3%) underwent ELRs. Compared with the LRs, the ELRs were performed in larger tumors ( P = .003) and were significantly associated with more complex surgeries such as vascular ( P < .001) or biliary reconstructions ( P < .001). Multivariate analysis revealed that ELR was an independent risk factor for major complications (odds ratio [OR], 6.2; 95% CI, 2.11–19.62; P < .001). Compared with the other LRs, ELRs had no effects on OS or disease-free survival ( P = .881 and P = .228, respectively). Perioperative blood transfusion (Hazard ratio (HR), 2.51; 95% CI, 1.49–4.23; P < .001), the presence of >1 nodule (HR, 3.17; 95% CI, 1.67–5.97; P < .001), and age ≥65 years (HR, 1.72; 95% CI, 1.03–2.86; P = .036) were independent prognostic factors for OS. Conclusion This study suggests that ELRs performed for large ICCs do not affect negatively oncologic outcomes, despite the increased risk of major complications. [ABSTRACT FROM AUTHOR]

Wandering liver syndrome is an extremely rare congenital disorder. It is mainly diagnosed within the first years of life. Herein we report the case of a 40-year-old woman with hepatoptosis due to the absence of anatomical peritoneal attachments of the liver. Surgical treatment consisted in inserting the floppy right lobe of the liver in a subphrenic retroperitoneal pouch. This original technique provided excellent postoperative result. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) is a common complication following pancreaticoduodenectomy (PD). Our retrospective study aimed to evaluate the influence of enteral nutrition (EN) on DGE incidence after standard PD with antrectomy and Child reconstruction. Methods: We retrospectively analyzed 275 consecutive patients who underwent standard PD between January 2000 and September 2009. Patients operated on after January 2005 received EN (EN group, n = 152) until total oral alimentation. Patients operated on prior to 2005 did not receive EN (control group, n = 123) and were orally fed after removing the nasogastric tube. Primary endpoint was the incidence of DGE according to the International Study Group of Pancreatic Surgery criteria. Secondary endpoints were the incidence of any other complications. Results: The incidence of DGE was 26% vs. 38% ( p = 0.04) in the EN and control groups, respectively, with 17% vs. 19% for grade B DGE (NS) and 9% vs. 19% for grade C DGE ( p = 0.02). The differences in DGE did not significantly decrease the duration of stay (18 ± 11 vs. 19 ± 13 days; NS). Postpancreatectomy hemorrhage was significantly reduced in the EN group (8% vs. 20%, p = 0.008), with the incidence of postoperative pancreatic fistula being similar in both groups (15% vs. 12%; NS). Using multivariate analysis, EN ( p = 0.047, OR = 0.559 [0.315; 0.994]), operative time ( p < 0.001, OR = 1.007 [1.003; 1.010]), and patient age ( p = 0.014, OR = 1.031 [1.006; 1.057]) were independent factors affecting the incidence of DGE. Conclusions: EN reduces DGE and postpancreatectomy hemorrhage after PD. [ABSTRACT FROM AUTHOR]

There are no data to evaluate the difference in populations and impact of centers with liver transplant programs in performing laparoscopic liver resection (LLR). This was a multicenter study including patients undergoing LLR for benign and malignant tumors at 27 French centers from 1996 to 2018. The main outcomes were postoperative severe morbidity and mortality. A total of 3154 patients were included, and 14 centers were classified as transplant centers (N = 2167 patients, 68.7 %). The transplant centers performed more difficult LLRs and more resections for hepatocellular carcinoma (HCC) in patients who more frequently had cirrhosis. A higher rate of performing the Pringle maneuver, a lower rate of blood loss and a higher rate of open conversion (all p < 0.05) were observed in the transplant centers. There was no association between the presence of a liver transplant program and either postoperative severe morbidity (<10 % in each group; p = 0.228) or mortality (1 % in each group; p = 0.915). Most HCCs, difficult LLRs, and cirrhotic patients are treated in transplant centers. We show that all centers can achieve comparable safety and quality of care in LLR independent of the presence of a liver transplant program. [ABSTRACT FROM AUTHOR]