Search

Hepatocellular carcinoma is the most common primary liver tumor, with 905 677 diagnosed cases and 830 180 deaths, in 2020 worldwide. In Argentina, it accounts for the 9th cause of death for cancer in men and the 10th in women. Unlike other highly-prevalent tumors, scientific evidence for most therapeutic options is limited mainly to small cohorts and retrospective studies. The aim of this study is to characterize and describe epidemiologically patients with diagnosis of hepatocellular carcinoma in the Italian Hospital of Buenos Aires during a 12-year period. Overall survival for our cohort was 58%, 46%, and 36% at 1, 3 and 5 years respectively. Average survival for patients receiving palliative treatment was 5 months, while for those who received either non-curative or curative treatment was 23 and 75 months respectively. Recurrence-free survival for those patients who underwent a curative treatment was 89%, 76% y 61% at 1, 3 and 5 years. A thorough analysis of etiology, risk factors, incidence, mortality and treatment was made. The study's importance lies in its large sample size, quantity and quality of data, and will most certainly stimulate the development of local studies in hepatocellular carcinoma.El carcinoma hepatocelular (HCC) es el tumor primario más frecuente del hígado, con 905 677 casos diagnosticados en 2020, en todo el mundo, y 830 180 muertes. Es responsable de la novena causa de muerte por cáncer en los hombres y la décima en mujeres en Argentina. A diferencia de otros tumores de alta prevalencia, la evidencia científica acerca del HCC se limita principalmente a pequeñas cohortes y estudios retrospectivos. El objetivo de este estudio fue describir epidemiológicamente a aquellos pacientes con diagnóstico de HCC en el Hospital Italiano de Buenos Aires en un periodo de 12 años. La supervivencia global para nuestra cohorte fue de 58, 46 y 36% a 1, 3 y 5 años respectivamente. El promedio de supervivencia en pacientes con tratamiento paliativo fue de 5 meses, 23 para aquellos que recibieron tratamientos no curativos y 75 meses para los que recibieron tratamientos curativos. El porcentaje de pacientes libres de enfermedad a 1, 3 y 5 años fue de 89%, 76% y 61% respectivamente. Se realizó un estudio minucioso de la etiología, factores de riesgo, incidencia, mortalidad y tratamientos realizados. Su importancia yace en su tamaño muestral, calidad y cantidad de información disponible.

To explore potential sex differences in outcomes and regenerative parameters post major hepatectomies.Although controversial, sex differences in liver regeneration have been reported for animals. Whether sex disparity exists in human liver regeneration is unknown.Data from consecutive hepatectomy patients (55 females, 67 males) and from the international ALPPS (Associating-Liver-Partition-and-Portal-vein-ligation-for-Staged-hepatectomy, a two stage hepatectomy) registry (449 females, 729 males) were analyzed. Endpoints were severe morbidity (≥3b Clavien-Dindo grades), Model for End-stage Liver Disease (MELD) scores, and ALPPS interstage intervals. For validation and mechanistic insight, female-male ALPSS mouse models were established. t , χ 2 , or Mann-Whitney tests were used for comparisons. Univariate/multivariate analyses were performed with sensitivity inclusion.Following major hepatectomy (Hx), males had more severe complications ( P =0.03) and higher liver dysfunction (MELD) P =0.0001) than females. Multivariate analysis established male sex as a predictor of complications after ALPPS stage 1 (odds ratio=1.78; 95% confidence interval: 1.126-2.89; P =0.01), and of enhanced liver dysfunction after stage 2 (odds ratio=1.93; 95% confidence interval: 1.01-3.69; P =0.045). Female patients displayed shorter interstage intervals (2 weeks, 64% females versus 56% males, P =0.01), however, not in postmenopausal subgroups. In mice, females regenerated faster than males after ALPPS stage 1, an effect that was lost upon estrogen antagonism.Poorer outcomes after major surgery in males and shorter ALPPS interstage intervals in females not necessarily suggest a superior regenerative capacity of female liver. The loss of interstage advantages in postmenopausal women and the mouse experiments point to estrogen as the driver behind these sex disparities. Estrogen's benefits call for an assessment in postmenopausal women, and perhaps men, undergoing major liver surgery.

IMPORTANCE: In patients with resectable colorectal cancer liver metastases (CRLM), the choice of surgical technique and resection margin are the only variables that are under the surgeon’s direct control and may influence oncologic outcomes. There is currently no consensus on the optimal margin width. OBJECTIVE: To determine the optimal margin width in CRLM by using artificial intelligence–based techniques developed by the Massachusetts Institute of Technology and to assess whether optimal margin width should be individualized based on patient characteristics. DESIGN, SETTING, AND PARTICIPANTS: The internal cohort of the study included patients who underwent curative-intent surgery for KRAS-variant CRLM between January 1, 2000, and December 31, 2017, at Johns Hopkins Hospital, Baltimore, Maryland, Memorial Sloan Kettering Cancer Center, New York, New York, and Charité–University of Berlin, Berlin, Germany. Patients from institutions in France, Norway, the US, Austria, Argentina, and Japan were retrospectively identified from institutional databases and formed the external cohort of the study. Data were analyzed from April 15, 2019, to November 11, 2021. EXPOSURES: Hepatectomy. MAIN OUTCOMES AND MEASURES: Patients with KRAS-variant CRLM who underwent surgery between 2000 and 2017 at 3 tertiary centers formed the internal cohort (training and testing). In the training cohort, an artificial intelligence–based technique called optimal policy trees (OPTs) was used by building on random forest (RF) predictive models to infer the margin width associated with the maximal decrease in death probability for a given patient (ie, optimal margin width). The RF component was validated by calculating its area under the curve (AUC) in the testing cohort, whereas the OPT component was validated by a game theory–based approach called Shapley additive explanations (SHAP). Patients from international institutions formed an external validation cohort, and a new RF model was trained to externally validate the OPT-based optimal margin values. RESULTS: This cohort study included a total of 1843 patients (internal cohort, 965; external cohort, 878). The internal cohort included 386 patients (median [IQR] age, 58.3 [49.0-68.7] years; 200 men [51.8%]) with KRAS-variant tumors. The AUC of the RF counterfactual model was 0.76 in both the internal training and testing cohorts, which is the highest ever reported. The recommended optimal margin widths for patient subgroups A, B, C, and D were 6, 7, 12, and 7 mm, respectively. The SHAP analysis largely confirmed this by suggesting 6 to 7 mm for subgroup A, 7 mm for subgroup B, 7 to 8 mm for subgroup C, and 7 mm for subgroup D. The external cohort included 375 patients (median [IQR] age, 61.0 [53.0-70.0] years; 218 men [58.1%]) with KRAS-variant tumors. The new RF model had an AUC of 0.78, which allowed for a reliable external validation of the OPT-based optimal margin. The external validation was successful as it confirmed the association of the optimal margin width of 7 mm with a considerable prolongation of survival in the external cohort. CONCLUSIONS AND RELEVANCE: This cohort study used artificial intelligence–based methodologies to provide a possible resolution to the long-standing debate on optimal margin width in CRLM.

Background: While ALPPS triggers a fast liver hypertrophy, it is still unclear which factors matter most to achieve accelerated hypertrophy within a short period of time. The aim of the study was to identify patient-intrinsic factors related to the growth of the future liver remnant (FLR). Methods: This cohort study is composed of data derived from the International ALPPS Registry from November 2011 and October 2018. We analyse the influence of demographic, tumour type and perioperative data on the growth of the FLR. The volume of the FLR was calculated in millilitre and percentage using computed-tomography (CT) scans before and after stage 1, both according to Vauthey formula. Results: A total of 734 patients were included from 99 centres. The median sFLR at stage 1 and stage 2 was 0.23 (IQR, 0.18–0.28) and 0.39 (IQR: 0.31–0.46), respectively. The variables associated with a lower increase from sFLR1 to sFLR2 were age˃68 years (p =.02), height ˃1.76 m (p ˂.01), weight ˃83 kg (p ˂.01), BMI˃28 (p ˂.01), male gender (p ˂.01), antihypertensive therapy (p ˂.01), operation time ˃370 minutes (p ˂.01) and hospital stay˃14 days (p ˂.01). The time required to reach sufficient volume for stage 2, male gender accounts 40.3% in group ˂7 days, compared with 50% of female, and female present 15.3% in group ˃14 days compared with 20.6% of male. Conclusions: Height, weight, FLR size and gender could be the variables that most constantly influence both daily growths, the interstage increase and the standardized FLR before the second stage.

To evaluate short- and long-term outcomes after live-donor liver transplantation (LT) with hyper-reduced grafts in low-weight pediatric recipients. LT is an established curative therapy for children with end-stage chronic liver disease or acute liver failure. A major problem in pediatric LT has been the lack of size-matched donor organs. The disadvantage of the use of large-for-size grafts is the insufficient tissue oxygenation and graft compression, which result in poor outcomes. The shortage of suitable donors is most notable in children under 10 kg. To overcome such obstacle, in situ hyper-reduced live-donor liver grafts have been introduced. Available articles in the literature are based on small samples and are deficient in long-term follow-up. A single-cohort, retrospective analysis was conducted including 59 pediatric patients under 10 kg who underwent hyper-reduced (in situ “a la carte” left lateral segment reduction) live-donor LT (LDLT) between February 1994 and February 2018. The most frequent cause of liver failure was biliary atresia (70%). Median recipient weight was 8 kg. Vascular complications were confirmed in 15% of the sample, while 45% presented biliary complications. Median follow-up time was 40.3 months. Ten-year overall survival rate was 74%. Pediatric end-stage liver disease score > 23 was associated with a higher risk of post-operative complications. LDLT can be undertaken in children with body weight

Factor XI (FXI) deficiency is a rare congenital hemostatic disorder associated with increased bleeding tendency in trauma, surgery or when other hemostatic defects are present. Perioperative hemostatic management of a patient with a severe FXI deficiency undergoing major oncological liver and colorectal surgery with therapeutic plasma exchange (TPE) with fresh frozen plasma (FFP) is reported.A 54-year-old male with severe FXI deficiency was scheduled for resection of synchronous rectal cancer and multiple liver metastases. Baseline prothrombin time (PT) was 97 %, activated partial thromboplastin time (aPTT) 89 s(s) and FXI levels1 IU/dL. The rotational thromboelastometry (ROTEM™) presented a prolonged INTEM clotting time (CT) = 443 s (RV 100-240 s) and a clot formation time (CFT) = 110 s (RV 30-100 s). TPE with FFP was carried out achieving FXI levels up to 46 IU/dL and an aPTT of 33 s, normalizing thromboelastometry parameters to an INTEM CT = 152 s and a CFT = 86 s before the procedure. After surgery, the patient received daily FFP to maintain FXI levels above 30 IU/dL until discharge on the eighth day. A total of 30 FFP units were transfused during hospital stay. No significant bleeding events neither transfusion related complications were observed during the perioperative period.Given the lack of correlation between FXI levels and bleeding risk, a multidisciplinary approach based on daily FXI levels monitoring, close clinical assessment and factor supplementation is mandatory. In conclusion, TPE with FFP is an efficacious alternative strategy to correct severe FXI deficiency in patients undergoing major surgery.

Objectives: To analyze long-term oncological outcome along with prognostic risk factors in a large cohort of patients with colorectal liver metastases (CRLM) undergoing ALPPS. Background: ALPPS is a two-stage hepatectomy variant that increases resection rates and R0 resection rates in patients with primarily unresectable CRLM as evidenced in a recent randomized controlled trial. Long-term oncologic results, however, are lacking. Methods: Cases in- and outside the International ALPPS Registry were collected and completed by direct contacts to ALPPS centers to secure a comprehensive cohort. Overall, cancer-specific (CSS), and recurrence-free (RFS) survivals were analyzed along with independent risk factors using Cox-regression analysis. Results: The cohort included 510 patients from 22 ALPPS centers over a 10-year period. Ninety-day mortality was 4.9% and median overall survival, CSS, and RFS were 39, 42, and 15 months, respectively. The median follow-up time was 38 months (95% confidence interval 32-43 months). Multivariate analysis identified tumor-characteristics (primary T4, right colon), biological features (K/N-RAS status), and response to chemotherapy (Response Evaluation Criteria in Solid Tumors) as independent predictors of CSS. Traditional factors such as size of metastases, uni versus bilobar involvement, and liver-first approach were not predictive. When hepatic recurrences after ALPPS was amenable to surgical/ablative treatment, median CSS was significantly superior compared to chemotherapy alone (56 vs 30 months, P < 0.001). Conclusions: This large cohort provides the first evidence that patients with primarily unresectable CRLM treated by ALPPS have not only low perioperative mortality, but achieve appealing long-term oncologic outcome especially those with favorable tumor biology and good response to chemotherapy.

Background Surgery is the most effective treatment option for neuroendocrine liver metastases (NELM). This study investigated the role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a novel strategy in treatment of NELM. Methods The International ALPPS Registry was reviewed to study patients who underwent ALPPS for NELM. Results From 2010 to 2017, 954 ALPPS procedures from 135 international centers were recorded in the International ALPPS Registry. Of them, 24 (2.5%) were performed for NELM. Twenty-one patients entered the final analysis. Overall grade ≥3b morbidity was 9% after stage 1 and 27% after stage 2. Ninety-day mortality was 5%. R0 resection was achieved in 19 cases (90%) at stage 2. Median follow-up was 28 (19–48) months. Median disease free survival (DFS) was 17.3 (95% CI: 7.1–27.4) months, 1-year and 2-year DFS was 73.2% and 41.8%, respectively. Median overall survival (OS) was not reached. One-year and 2-year OS was 95.2% and 95.2%, respectively. Conclusions ALPPS appears to be a suitable strategy for inclusion in the multimodal armamentarium of well-selected patients with neuroendocrine liver metastases. In light of the morbidity in this initial series and a high rate of disease-recurrence, the procedure should be taken with caution.

Annals of surgical oncology (2020). doi:10.1245/s10434-019-08192-z, Published by Springer, Berlin [u.a.]

Objective: The aim of this study was to evaluate interstage liver function in associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) using hepatobiliary scintigraphy (HBS) and whether this may help to predict posthepatectomy liver failure (PHLF). Background: ALPPS remains controversial given the high rate of liver-related mortality after stage 2. HBS combined with single photon emission computed tomography (SPECT) accurately estimates future liver remnant function and may be useful to predict PHLF. Methods: Between 2011 and 2016, 20 of 39 patients (51.3%) underwent SPECT-HBS before ALPPS stage 2 for primary (n = 3) or secondary liver tumors (n = 17) at the Hospital Italiano de Buenos Aires (HIBA). PHLF was defined by the International Study Group of Liver Surgery criteria, 50-50 criteria, or peak bilirubin >7mg/dL. Grade A PHLF was excluded, as it requires no change in clinical management. Receiver-operating characteristic curves were used to determine cutoff for HBS parameters. Results: Interstagely, 3 HBS parameters differed significantly between patients with (n = 4) and without PHLF (n = 16) after stage 2. Among these, the HIBA-index best predicted PHLF, with a cutoff value of 15%. The risk of PHLF in patients with cutoff

Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is an innovative, 2-staged hepatectomy which has elicited controversy within the international hepatobiliary community. Uptake of ALPPS has been limited due to concerns related to evidence of high morbidity and mortality, and scant oncologic and outcome data on quality of life (Qol). Demonstrating reasonable long-term benefits with a short-term risk is necessary to support more widespread endorsement of ALPPS. Our aim was to describe the intermediate-term survival and patient-reported quality of life outcomes after an ALPPS. Methods Prospectively collected data from 2 high-volume ALPPS centers, who were pioneers with the technique, were combined and analyzed for disease-free and overall survival from date of the ALLPS. Only patients treated for colorectal liver metastases with >6 month postoperative follow-up were included. All patients had bilateral colorectal liver metastases with an initially unresectable tumor load, and received preoperative chemotherapy. Information concerning the demographics of the patients, characteristics of the tumor, and treatment were analyzed. The well-validated European Organization for Research and Treatment for Cancer Quality of Life Core Questionnaire version 3.0 questionnaire was used to assess patient quality of life. Results A total of 58 patients underwent ALPPS for colorectal liver metastases, and 47 patients met our inclusion criteria. There were no perioperative mortalities, and the rate of severe complications was 21%. At 3 years post-ALPPS, the overall survival was 50%, while the disease-free survival was 13%. The commonest site of first recurrence was the liver alone (38%). Patient-reported quality of life after ALPPS was similar to reference values for general population. Conclusion In select patients operated at experienced centers, ALPPS results in low perioperative risk, satisfactory overall survival, and excellent quality of life. Hepatic recurrence and not systemic recurrence is the most common site of relapse after ALPPS.

Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows the resection of colorectal liver metastases with curative intent which would otherwise be unresectable and only eligible for palliative systemic therapy. This study aimed to compare outcomes of ALPPS in patients with otherwise unresectable colorectal liver metastases with matched historic controls treated with palliative systemic treatment. Methods All patients with colorectal liver metastases from the international ALPPS registry were identified and analyzed. Survival data were compared according to the extent of disease. Otherwise unresectable ALPPS patients were defined by at least 2 of the following criteria: ≥6 metastasis, ≥2 future remnant liver metastasis, ≥6 involved segments excluding segment 1. These patients were matched with patients included in 2, phase 3, metastatic, colorectal cancer trials (CAIRO and CAIRO2) using propensity scoring in order to compare survival. Results Of 295 patients with colorectal liver metastases in the ALPPS registry, 70 patients had otherwise unresectable disease defined by the proposed criteria. Two-year overall survival was 49% and 72% for patients with ≥2 and

The aim of this study was to use the concept of benchmarking to establish robust and standardized outcome references after the procedure ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy).The recently developed ALPPS procedure, aiming at removing primarily unresectable liver tumors, has been criticized for safety issues with high variations in the reported morbidity/mortality rates depending on patient, disease, technical characteristics, and center experience. No reference values for relevant outcome parameters are available.Among 1036 patients registered in the international ALPPS registry, 120 (12%) were benchmark cases fulfilling 4 criteria: patients ≤67 years of age, with colorectal metastases, without simultaneous abdominal procedures, and centers having performed ≥30 cases. Benchmark values, defined as the 75th percentile of the median outcome parameters of the centers, were established for 10 clinically relevant domains.The benchmark values were completion of stage 2: ≥96%, postoperative liver failure (ISGLS-criteria) after stage 2: ≤5%, ICU stay after ALPPS stages 1 and 2: ≤1 and ≤2 days, respectively, interstage interval: ≤16 days, hospital stay after ALPPS stage 2: ≤10 days, rates of overall morbidity in combining both stage 1 and 2: ≤65% and for major complications (grade ≥3a): ≤38%, 90-day comprehensive complication index was ≤22, the 30-, 90-day, and 6-month mortality was ≤4%, ≤5%, and 6%, respectively, the overall 1-year, recurrence-free, liver-tumor-free, and extrahepatic disease-free survival was ≥86%, ≥50%, ≥57%, and ≥65%, respectively.This benchmark analysis sets key reference values for ALPPS, indicating similar outcome as other types of major hepatectomies. Benchmark cutoffs offer valid tools not only for comparisons with other procedures, but also to assess higher risk groups of patients or different indications than colorectal metastases.

Aim: To determine the impact of KRAS mutation status on survival in patients undergoing surgery for colorectal liver metastases (CLM). Patients & methods: Patients with resected CLM and KRAS mutations. Survival was compared between mt-KRAS and wt-KRAS. Results: Of 662 patients, 174 (26.3%) were mt-KRAS and 488 (73.7%) wt-KRAS. mt-KRAS patients had significantly lower recurrence-free survival (HR: 1.42; 95% CI: 1.10–1.84). There were no differences between the groups for sidedness. Poorer survival was associated with mt-KRAS with positive lymph nodes, >1 metastases, tumors >5 cm, synchronous tumors and R1–R2. Conclusion: KRAS mutation status can help predict recurrence-free survival. Primary tumor location was not a prognostic factor after resection. KRAS mutation status can help design a multidisciplinary approach after curative resection of CLM.

Liver resection combined with colorectal surgery (CRS) is the only curative option in many patients presenting with synchronous colorectal cancer and liver metastases (CRLM). Simultaneous resection has been shown to offer benefits in patients with low hepatic tumor load; however, in the setting of in situ colorectal tumor with extensive CRLM and a small predicted future liver remnant (FLR), the use of simultaneous ALPPS and CRS is controversial, lacking outcome data. Thirty-one cases of simultaneous ALPPS and CRS prospectively entered into the International ALPPS Registry were examined. Univariate analysis was used to identify factors associated with 90-day mortality after stage-2. Thirty patients (97%) completed both stages. CRS was performed during stage-1 in 22 patients (73%). Seven patients (23%) had severe complications (Clavien-Dindo ≥ IIIb) following stage-2 ALPPS. The 90-day mortality rate was 15%. Patients who had a severe complication after stage-1 were significantly more likely to have 90-day mortality following stage-2 (p = 0.002). MELD score > 10 on postoperative day-5 after stage-1 was also significantly associated with 90-day mortality (p = 0.011). Disease-free survival and overall survival were 36% and 76% at 1 year, respectively. In light of the high mortality and poor long-term survival identified in this series, the adoption of ALPPS with CRS cannot be recommended without further data. Patients who suffer severe complications or have an elevated MELD score after stage-1 are at higher risk of mortality following stage-2.

The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach. During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified. We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6 % (range 49–79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications. The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and “non-touch” oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.

Objective To evaluate the use of the caudal vena cava collapsibility index (CVCCI) as a predictor of fluid responsiveness in hospitalized, critically ill dogs with hemodynamic or tissue perfusion abnormalities. Design Retrospective observational study. Setting Private referral center. Animals Twenty-seven critically ill, spontaneously breathing dogs with compromised hemodynamics or tissue hypoperfusion. Interventions None. Measurements and main results The electronic medical records were searched for dogs admitted for any cause, from August 2016 to December 2017. We included dogs with ultrasound measurements of: CVCCI, performed at baseline; and velocity time integral (VTI) of the subaortic blood flow, carried out before and after a fluid load. CVCCI was estimated as: (maximum diameter-minimum diameter/maximum diameter) × 100. Dogs in which VTI increased ≥15% were considered fluid responders. The CVCCI accurately predicted fluid responsiveness with an area under the receiver operating characteristic curve of 0.96 (95% CI, 0.88 to 1.00). The optimal cut-off of CVCCI that better discriminated between fluid responders and nonresponders was 27%, with 100.0% sensitivity and 83.3% specificity. At baseline, fluid responders had lower VTI (5.48 [4.26 to 7.40] vs 10.61 [7.38 to 13.23] cm, P = 0.004) than nonresponders. The basal maximum diameter of the caudal vena cava adjusted to body weight was not different between responders and nonresponders (0.050 [0.030 to 0.100] vs 0.079 [0.067 to 0.140] cm/kg, P = 0.339). The increase in VTI was related to basal CVCCI (R = 0.60, P = 0.001). Bland-Altman analysis showed narrow 95% limits of agreement between measurements of CVCCI and VTI performed by different observers or by the same observer. Conclusions The results of this small cohort study suggest that CVCCI can accurately predict fluid responsiveness in critically ill dogs with perfusion abnormalities. Further research is necessary to extrapolate these results to larger populations of hospitalized dogs.

The initial mortality rates of associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) were high. However, recent data from the International Registry show a continuous reduction of early mortality and major morbidity due to risk adjustment in patient selection and less invasive techniques in stage-1 surgery. During the first ALPPS International Consensus in 2015, we introduced a paradigm inversion of ALPPS, the so-called "Mini-ALPPS."We combined a partial liver partition with a novel technique of laparoscopic-assisted percutaneous cannulation of the inferior mesenteric vein for intraoperative transmesenteric portal vein embolization. We report here for the first time, a case of a successful totally laparoscopic Mini-ALPPS, and describe in detail the technical aspects of this new approach.A 61-year-old man with a 6 cm hepatocellular carcinoma compromising the right glissonian pedicle in a fibrotic liver was treated by an extended right hepatectomy using the laparoscopic Mini-ALPPS approach. The patient had an uneventful first stage and was discharged 3 days after. A CT scan performed on postoperative day 8 showed sufficient future liver remnant volume after a 59% hypertrophy. An extended right hepatectomy was uneventfully completed and the patient was discharged 5 days after surgery. The histopathological analysis indicated advanced F4 liver fibrosis and negative tumor margins.This technical innovation allows avoiding a laparotomy to access the mesenteric venous territory and the risks of liver remnant injuries during percutaneous transhepatic approach. This new alternative may result of great utility not only in ALPPS but also for many different circumstances and scenarios.

Background/Aims: Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations influence survival after hepatectomy for colorectal liver metastases (CRLM). However, their prognostic significance has never been evaluated in patients who undergo Associating Liver Partition and Portal vein occlusion for Staged hepatectomy (ALPPS). Methods: Between June 2011 and March 2016, 26 patients underwent ALPPS for CRLM. Complications were classified according to the Clavien-Dindo classification. Bi- and multivariate cox analyses were performed to evaluate variables potentially associated with survival. Results: Overall, morbidity grade ≥3a and 90-day mortality were 38.5 and 0%, respectively. The median follow-up from the time of discharge was 21.5 months (interquartile range 9.6-35.6). One- and 3-year overall survival (OS) was 83.4 and 48.9%, respectively. Patients with mutated (MT) KRAS had a median OS of 15.3 vs. 38.3 months for those with wild-type (WT) KRAS (p < 0.0001). Median disease-free survival was 7.9, 5.6 vs. 12.3 months for MT and WT KRAS, respectively (p = 0.023). KRAS mutation was found to be an independent risk factor for OS (hazard ratio 7.15, 95% CI 1.50-34.11; p = 0.014). Conclusion: KRAS mutation is an independent predictor of poor survival after ALPPS. This finding will help to optimize patient selection, both avoiding futile surgical indication and maximizing the benefit for patients with extensive disease who are otherwise subjected to high-risk aggressive surgery.

OBJECTIVES: The aim of this study was to identify predictors of 90-day mortality after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS), available after stage-1, either to omit or delay stage-2. BACKGROUND DATA: ALPPS is a two-stage hepatectomy for patients with extensive liver tumors with predicted small liver remnants, which has been criticized for its high mortality rate. Risk factors for mortality are unknown. METHODS: Patients in the International Registry undergoing ALPPS from April 2011 to July 2014 were analyzed. Primary outcome was 90-day mortality. Liver function after stage-1 was assessed using the criteria of the International Study Group for Liver Surgery (ISGLS) after stage-1 among others. A multivariable model was used to identify independent predictors of 90-day mortality. RESULTS: Three hundred twenty patients registered by 55 centers worldwide were evaluated. Overall 90-day mortality was 8.8% (28/320). The predominant cause for 90-day mortality was postoperative liver failure in 75% of patients. Fourteen percent of patients developed liver failure according to ISGLS criteria already after stage-1 ALPPS. Those and patients with a model of end-stage liver disease (MELD) score more than 10 before stage-2 were at significantly higher risk for 90-day mortality after stage-2 with an odds ratio (OR) 3.9 [confidence interval (CI) 1.4-10.9, P = 0.01] and OR 4.9 (CI 1.9-12.7, P = 0.006), respectively. Other factors, such as size of future liver remnant (FLR) before stage-2 and time between stages, were not predictive. CONCLUSIONS: This analysis of the largest cohort of ALPPS patients so far identifies those patients in whom stage-2 ALPPS surgery should be delayed or even denied. These findings may help to make ALPPS safer.

The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) strategy induces rapid future liver remnant (FLR) hypertrophy. Hepatocyte cellular and molecular changes associated with liver hypertrophy during ALPPS remain ill-defined in humans.Patients undergoing the ALPPS approach between June 2011 and October 2014 were extracted. Biopsies from the FLR were obtained during the first and second stages. Hematoxylin-eosin staining and immunohistochemical analysis for expression of the proliferating cell nuclear antigen (PCNA) and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) were performed. The proliferative index was defined as: PCNA-TUNEL ratio.Eleven of 34 patients treated were studied during both stages. Median FLR hypertrophy was 104 % in 6 days, with a mean difference between preoperative and postoperative volume of 361 ml (P 0.001). The mean hepatocyte number increased from 52.7 cells/mm(2) in the first stage to 89.6 cells/mm(2) in the second stage (P = 0.001). PCNA expression increased by 190 % between stages with a linear correlation (r = 0.58) with macroscopic hypertrophy. The proliferative index increased from -3.78 cells/mm(2) in first stage to 2.32 cells/mm(2) in the second stage (P = 0.034).The results of the present study indicate that the rapid FLR volumetric increase observed in ALPPS is accompanied by histological and molecular features of hepatocyte cell proliferation.

To determine the safety, feasibility, and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in a single high-volume hepatobiliary center.The ALPPS approach allows achieving resectability of liver malignancies by a rapid and large future liver remnant (FLR) hypertrophy. However, this proposal has been associated with high morbidity and mortality rates.This was a single-cohort, prospective, observational study [NCT02164292]. Between June 2011 and April 2014, patients with liver malignancies considered unresectable due to an insufficient FLR who underwent ALPPS were included.Thirty patients were treated. Median age was 58.6 years (range = 35-81) and 19 patients were males (63%). In a median of 6 days (range = 4-67), the median FLR hypertrophy was 89.7% (range = 21-287). Twenty-nine patients completed the second stage (97% feasibility). Morbidity according to the Dindo-Clavien classification was 53% (grade ≥IIIa 43% and grade ≥IIIb 31%). The mortality rate was 6.6%. Total parenchymal transection was identified as an independent risk factor for complications (P = 0.049). There was not significant difference in terms of FLR hypertrophy between total or partial parenchymal transection (P = 0.45). Median hospital stay was 16 days (range = 11-62). The overall and disease-free survival at 1 year was 78% and 67% and at 2 years was 63% and 40%, respectively.This prospective study on the largest reported single-center experience shows that ALPPS has acceptable morbidity and mortality, together with a high oncological feasibility and hypertrophic efficacy. Partial parenchymal transection seems to reduce morbidity without negatively impacting FLR hypertrophy.

Common bile duct injuries (CBDI) are serious complications of cholecystectomies which are often associated with vascular involvement, meaning that their management represents a major challenge to the physician. We present our experience in major hepatectomy due to CBDI, highlighting indications, postoperative complications, and long-term outcomes. From August 1993 to September 2013, 287 patients with CBDI were treated in our centre. In 15 patients of this group (5 %), a major hepatectomy was performed. Eleven patients presented E4 and four presented E5 injuries of Strasberg classification. Seven patients presented vascular involvement. In 12 patients, prior treatment attempts, either biliodigestive anastomosis, endoscopic or percutaneous drainage, was performed without success. The median time delay between lesional surgery and hepatectomy was 24 months. Right hepatectomy was performed in 10 patients and left hepatectomy in 5. Postoperative morbidity was 60 %. The incidence of serious complications (≥grade IIIa of DC classification) was 40 %. There was no mortality in our study. The mean follow-up was 43.5 months and the overall survival was 100 %. Three patients had a single episode of ascendant cholangitis who were successfully treated with medical treatment. All other patients were asymptomatic during follow-up. No patients required further surgical procedures. In our series, major hepatectomy due to CBDI was a successful treatment with high rates of postoperative morbidity and excellent long-term outcomes which require a multidisciplinary approach in referral centres of HPB surgery.

Background Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new “ALPPS” approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE. Methods A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. Results The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection. Conclusion Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.

Posthepatectomy liver failure is the most severe complication after major hepatectomies and it is associated with an insufficient future liver remnant (FLR). Associating liver partition and portal vein ligation (PVL) has recently been described as a revolutionary strategy to induce a rapid and large FLR volume increase. We aim to describe our surgical technique, patient management, and preliminary results with this new two-stage approach.During the first stage, liver partition and PVL of the diseased hemiliver are performed. The completion surgery is carried out after volumetric studies have demonstrated a sufficient FLR and provided the patient is in good condition. This is usually achieved after 7 days. In the second step, the patient undergoes a completion surgery with right hepatectomy, right trisectionectomy, or left trisectionectomy.Fifteen patients with advanced liver tumors were treated. Nine patients were males and the mean age was 54 years old. The mean difference between the preoperative and postoperative FLR volume was 303 ml (p 0.001), which represented a mean volume increase of 78.4 %. All resections were R0. Morbidity and mortality rates were 53 and 0 %, respectively. The average hospital stay was 19 days.The presented technique was feasible and safe in the hands of experienced hepatobiliary surgeons, with satisfactory short-term results. It induces rapid liver hypertrophy and at the same time it offers the possibility of cure to patients previously declared unresectable.

We had previously described a left lateral segment hyper-reduction technique capable of sizing the graft according to the volume of the abdominal cavity of the recipient.The purpose of our study was to evaluate our 14-year live-donor liver transplantation experience with in situ graft hyper-reduction in children under 10 kg of weight.Between January 1997 and May 2011, we performed 881 liver transplants. Two hundred and seventy-seven (n = 277) involved pediatric recipients, of which 102 (37 %) were from live donors. Thirty-five (n = 35) patients under 10 kg of weight underwent hyper-reduced living donor liver transplants. There were 21 females (60 %) and 14 males (40 %), with a median age of 12 months (range 3-23) and a median weight of 7.7 kg (range 5.6-10).Median operative time was 350 min (range 180-510). Median cold ischemia time was 180 min (range 60-300). Twenty-six (n = 26) patients required intraoperative transfusion of blood products. There were 49 postoperative complications involving 26 patients (74 % morbidity rate). One-, 3-, and 5-year survival rates were 87, 79, and 74 %, respectively. Twenty-eight patients are currently alive.Hyper-reduced grafts provide an alternative approach for low-weight pediatric recipients. The relatively high immediate postoperative morbidity could be related to the complexity of these patients.

Surgical resection is the best option for prolonged survival in patients with primary or secondary liver tumors. A sufficient future liver remnant (FLR) volume is needed to prevent post-hepatectomy liver failure (PHLF). With the aim of increasing FLR, a new two-step technique has been recently developed. Our aim is to report our initial experience with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. Analysis was conducted of ten patients previously considered locally unresectable because of small FLR. During first surgical step liver parenchymal partition and portal vein ligation was performed. Seven days after the first procedure, once volumetric and functional studies have demonstrated an appropriate FLR volume, the resection of the deportalized hemiliver was achieved. This technique was successfully performed in all ten patients (feasibility 100 %). Six were male with mean age of 55.2 years (range 39-77). Mean preoperative FLR volume and FLR/total liver volume were 408.4 ml and 27.8 %. Mean postoperative FLR volume was 733 ml representing a mean volume increase of 325 ml or 82 % (range 31-140) (p < 0.0001). All resections were R0 (4 right hepatectomies, 5 right trisectionectomies and 1 left trisectionectomy). There were two grade A post-hepatectomy liver failures. Morbidity was 40 % and mortality 0 %. With a mean follow-up of 187 days, disease-free survival and overall survival were 80 and 100 %, respectively. ALPPS induces a great and fast FLR hypertrophy allowing R0 resections in patients otherwise considered unresectable because of small FLR volume, without severe PHLF and low mortality in experience centers. Further experience is needed to determine long-term outcomes.

BackgroundEn-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure.MethodsThe authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed.ResultsIn both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months.ConclusionsThis new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.

Caroli's disease (CD) management is still controversial. The purpose of this study is to report the most frequent clinical features, treatment options, and outcome obtained after surgical management of CD. A voluntary survey was conducted. Demographic, clinical, surgical, and pathological variables were analyzed. Six centers included 24 patients having received surgical treatment from 1991 to 2009. Seventeen (70.8%) patients were female, with average age of 48.7 years old (20–71), and 95.5% were symptomatic. There was left hemiliver involvement in 75% of the patients. Surgical procedures included nine left lateral sectionectomies, eight left hepatectomies, and four right hepatectomies for those with hemiliver disease, while for patients with bilateral disease, one right hepatectomy and two Roux-en-Y hepaticojejunostomies were performed. The average length of hospitalization was 7 days. For perioperative complications (25%), three patients presented minor complications (types 1–2), while major complications occurred in three patients (type 3a). No mortality was reported. After a median follow-up of 166 months, all patients are alive and free of symptoms. CD diagnosis was confirmed by histology. Congenital hepatic fibrosis was present in two patients (8.3%) and cholangiocarcinoma in one (4.2%). CD in Argentina is more common in females with left hemiliver involvement. Surgical resection is the best curative option in unilateral disease, providing long-term survival free of symptoms and complications. In selected cases of bilateral disease without parenchymal involvement, hepaticojejunostomy should be proposed. However, a close follow-up is mandatory because patients might progress and a transplant should be indicated.

Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated.All patients registered in the international ALPPS Registry ( www.alpps.org ) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM).The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p 0.004).The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.

The role of liver resection (LR) in patients with non-tumoral hepatic disease (NTHD) remains controversial.To analyze the indications and outcomes of liver resections in patients with NTHD.A retrospective analysis in a multicentric data base was performed. Outcome measures were incidence of postoperative cholangitis, infectious and non-infectious complications, hospital stay and overall mortality.One hundred and fourteen patients underwent LR due to NTHD from January 2001 to November 2011. Fourteen patients presented complex bile duct injuries (CBDI), 18 intra-hepatic lithiasis (IL), 32 liver hydatid cysts (LHC), 10 polycystic liver disease (PLD), 19 Caroli's disease (CD) and 21 other NTHD. Forty seven patients underwent a major hepatectomy and 67 a liver segmentectomy or an atypical liver resection. Thirty four patients (29%) presented surgical related complications. There was not intra or post-operative mortality. In long term outcomes, 98 patients (85%) were asymptomatic, 10 presented episodes of intermittent cholangitis that were treated with antibiotics, and 7 underwent another surgical procedure.LR is a radical and effective procedure to treat benign NTHD instead of other surgical or percutaneous procedures, avoiding multiple sessions of treatment and high post procedure complications rates.

Background Liver remnant function limits major liver resections to generally leave patients with ≥2 Couinaud segments. Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) induces extensive hypertrophy and allows surgeons to perform extreme liver resections. Methods The international ALPPS registry (NCT01924741; 2011–2014) was screened for novel resection type with only 1 segment remnant. The anatomy of lesions and indications for ALPPS, operative technique, complications, survival, and recurrence were evaluated. Results Among 333 patients, 12 underwent monosegment ALPPS hepatectomies in 6 centers, all for extensive bilobar colorectal liver metastases. All patients were considered unresectable by conventional means, and all had a response to or no progression after chemotherapy before surgery. In 2 patients, the liver remnant consisted of segment 2, in 2 of segment 3, in 6 of segment 4, and in 2 of segment 6. Median time to proceed to stage 2 was 13 days and median hypertrophy of the liver remnant was 160%. There was no mortality. Four patients experienced liver failure, but all recovered. Complications higher than Dindo-Clavien IIIa occurred in 4 patients with no long-term sequelae. At a median follow-up of 14 months, 6 patients are tumor free and 6 patients have developed recurrent metastatic disease. Conclusion ALPPS allows systematic liver resections with monosegment remnants, a novelty in liver surgery. Because such resections are difficult to conceive without rapid hypertrophy, we propose to name such resections after the segments constituting the liver remnant rather than the segments removed.

Surgery is the treatment of choice for hilar cholangiocarcinoma (HCC). Obtaining tumor-free margins (RO resection) has been reported as the only prognostic factor associated with increased survival. The aim of this study was to analyze a consecutive series of patients operated with curative intent over a 14-year period.This is a retrospective study of patients operated with curative intent between 1994 and 2008. Hepatic resection was associated with resection of segment 1, extrahepatic bile duct and lymph node dissection in all cases.40 patients, 62% male with a mean age of 58.2 years. Jaundice was the most common presenting symptom (70%). Biliary confluence was compromised in 62% oftumors. Thirty-nine patients underwent major hepatectomy with 95% RO resections and 6 associated vascular resections. Postoperative morbidity was 37.5% and mortality 10%. Overall survival and disease-free survival at 1, 3 and 5 years was 88% and 63%, 55% and 34%, and 43% and 24%, respectively.The association of major hepatectomy with caudate lobe resection and vascular resection when needed, was associated with 95% tumor-free margin and morbidity and mortality rate according to the standards of the international literature. While it is necessary a greater number of cases, associated vascular resection seems to be a feasible and safe option in the treatment of locally advanced HCC.

To describe the role of MDCT-volumetry to monitor and predict liver hypertrophy in a recently introduced surgical technique in patients needing hepatectomy.This prospective study was approved by the local research and ethics committee and patient informed consent was obtained. Twelve consecutive patients were selected for associating liver partition and portal vein ligation for staged-hepatectomy procedure. The mean absolute the future-liver-remnant (FLR) and FLR/total liver volume (TLV) ratio was calculated before and after surgery to determine the degree of hypertrophy. Six days after surgery a new CT-examination was performed to determine the FLR-volume and FLR/TLV. If the enlargement of the FLR was the expected a second-step surgery was performed. Continuous variables are expressed as mean (range). A p0.05 was considered significant.The mean pre-operative FLR-volume was 402 mL and the FLR/TLV was 27%. The mean post-operative FLR-volume 6 days after the first step was 702 mL (range 521-1030 mL) being the mean difference between preoperative and postoperative FLR volume 303 mL (p0.0001). The mean volume increase was 80% ranged from 21-139%. At day six, FLR/TLV was 46.5% (range 33.5-67.7), morbidity was 41% and mortality 0%.MDCT-volumetry has a key role in decision-making, monitoring and predicting liver hypertrophy pre- and postoperatively.

Postoperative liver failure (PLF) is the most feared and severe complication after extensive liver resections.We present an innovative surgical technique that has been employed for the treatment of three patients (two with multiple colorectal liver metastases and one with hilar cholangiocarcinoma) whose livers were previously considered locally unresectable because of an insufficient future liver remnant (FLR). In-situ liver transection with right portal vein ligation was implemented.Six days after surgery a volumetric computed tomography (CT)-scan showed 40-80% hypertrophy of the FLR. The patients then underwent a completion surgery with right hepatectomy or right trisectionectomy. None of the patients developed PLF during a mean hospital stay of 16 days. After a mean follow-up of two months, the three of them are free of disease.This technique induced rapid growth of the FLR, greater than that reported with portal vein occlusion alone. It represents a promising advance in oncological liver surgery that readdresses the current management of patients with primarily unresectable liver disease. Such a revolutionary strategy allows a two-stage surgical approach during a single hospital stay and without PLF. However, further research is needed to determine the long-term outcomes of this technique and to explain the occurrence of such enhanced liver regeneration.

Background Clinical presentation, treatment and prognosis of hepatocellular carcinoma depend on the presence or absence of cirrhosis. In the literature there are few reports of hepatocellular carcinoma in non-cirrhotic patients. Objective To describe a consecutive series of resected patients with hepatocellular carcinoma in non-cirrhotic liver and to identify prognostic factors of recurrence and survival. Material and methods Between 1990 and 2006, 51 patients were operated on. Data were collected retrospectively until 2001 and prospectively from then on. The results of surgery were assessed. Single and multivariate analyses were performed to identify factors associated with survival and disease-free survival. Results Thirty-three patients were male, median age 49.8 years. A major hepatectomy was performed in 72%. Morbidity was 43% and mortality was 0%. One-, two- and three-year survival rates were 90%, 75%, and 67%, respectively. One-, two- and three-year disease-free survival rates were 65%, 41%, and 37%, respectively. Presence of vascular invasion and of positive nodes was statistically significant for survival in univariate analysis but had no statistical significance in multivariate analysis. Conclusions Major hepatic resection is a safe treatment for hepatocellular carcinoma in noncirrhotic patients. Both vascular invasion and presence of positive nodes were associated with poor survival. However, neither of them represented an independent variable.

Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI.Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test.Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively.Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.

Introduction Acute calculous cholecystitis represents one of the most common complications of cholelithiasis. While laparoscopic cholecystectomy is the standard treatment in mild and moderate forms, the need for antibiotic therapy after surgery remains undefined. The aim of the randomised controlled Cholecystectomy Antibiotic Randomised Trial (CHART) is therefore to assess if there are benefits in the use of postoperative antibiotics in patients with mild or moderate acute cholecystitis in whom a laparoscopic cholecystectomy is performed. Methods and analysis A single-centre, double-blind, randomised trial. After screening for eligibility and informed consent, 300 patients admitted for acute calculus cholecystitis will be randomised into two groups of treatment, either receiving amoxicillin/clavulanic acid or placebo for 5 consecutive days. Postoperative evaluation will take place during the first 30 days. Postoperative infectious complications are the primary end point. Secondary end points are length of hospital stay, readmissions, need of reintervention (percutaneous or surgical reinterventions) and overall mortality. The results of this trial will provide strong evidence to either support or abandon the use of antibiotics after surgery, impacting directly in the incidence of adverse events associated with the use of antibiotics, the emergence of bacterial resistance and treatment costs. Ethics and dissemination This study and informed consent sheets have been approved by the Research Projects Evaluating Committee (CEPI) of Hospital Italiano de Buenos Aires (protocol N° 2111). Results The results of the trial will be reported in a peer-reviewed publication. Trial registration number NCT02057679.

Laparoscopic cholecystectomy is the treatment of choice for gallbladder stones. In the current study, this approach was associated with a higher incidence of biliary injuries. The authors evaluate their experience treating complex biliary injuries and analyze the literature.In a 15-year period, 169 patients with bile duct injuries (BDIs) resulting from open and laparoscopic cholecystectomies were treated. The patients were retrospectively evaluated through their records. Biliary injury and associated lesions were evaluated with imaging studies. Surgical management included therapeutic endoscopy, percutaneous interventions, hepaticojejunostomy, liver resection, and liver transplantation. Postoperative outcome was recorded. Survival analysis was performed with G-Stat and NCSS programs using the Kaplan-Meier method.Of the 169 patients treated for BDIs, 148 were referred from other centers. The injuries included 115 lesions resulting from open cholecystectomy and 54 lesions resulting from laparoscopic cholecystectomy. A total of 110 patients (65%) fulfilled the criteria for complex injuries, 11 of whom met more than one criteria. Injuries resulting from laparoscopic and open cholecystectomies were complex in 87.5% and 72% of the patients, respectively. The procedures used were percutaneous transhepatic biliary drainage for 30 patients, hepaticojejunostomy for 96 patients, rehepaticojejunostomy for 16 patients, hepatic resection for 9 patients, and liver transplantation projected for 18 patients. Hepaticojejunostomy was effective for 85% of the patients. The mean follow-up period was 77.8 months (range, 4-168 months). The mortality rate for noncomplex BDI was 0%, as compared with the mortality rate of 7.2% (8/110) for complex BDI. Mortality after hepatic resection was nil, and morbidity was 33.3%. The actuarial survival rate for liver transplantation at 1 year was 91.7%.Complex BDIs after laparoscopic cholecystectomy are potentially life-threatening complications. In this study, late complications of complex BDIs appeared when there was a delay in referral or the patient received multiple procedures. On occasion, hepatic resections and liver transplantation proved to be the only definitive treatments with good long-term outcomes and quality of life.

Hepatic involvement by tuberculosis is a rare type of manifestation of the disease. There are several forms of clinical presentations. One of them is the hepatic tuberculoma in which we base our presentation. Given that hepatic tuberculoma is a rare entity and generally shows inespecific symptoms, it is rarely suspected by the clinical picture. The diagnosis of hepatic tuberculosis is generally done in the intraoperative or postoperative period by analyzing a specimen taken by laparoscopy or laparotomy during the study of a hepatic mass. Laboratory tests or image studies do not give pathognomonic information to conform the diagnosis. The cornerstone in the treatment of this pathology is the antituberculous therapy. Surgical or endoscopic interventions are occasionally required. The role of surgery in the treatment of this pathology is reserved for a few solitary lesions. Once the correct treatment is performed the outcome is favorable. We present 4 cases of hepatic tuberculoma with different imaging and clinical presentations.

BackgroundBile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT).ObjectiveAnalyse the experience using LT as a definitive treatment of BDI in Argentina.Patients and MethodsA national survey regarding the experience of LT for BDI.ResultsSixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990–94 = 3.1%, 1995–99 = 1.6%, 2000–04 = 0.7% and 2005–09 = 0.2% (P < 0.001). The mean age was 45.7 ± 10.3 years (range 26–62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2–157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively.ConclusionsThe use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD.National survey showing a declining use for liver transplantation in the treatment of bile duct injury but highlighting a key role in selected patients with acute liver failure and end stage liver disease