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

Ex situ split liver transplantation from cadaveric donors is an attractive concept allowing transplantation of two recipients with a single liver [1]. However, this technique did not gain wide acceptance because it was associated with increased morbidity and reduced graft survival [2]. The main drawbacks were a risk of bleeding from the cut surface, a high incidence of biliary complications and a prolonged cold ischemia time [2]. To overcome these problems, Rogiers et al. described an in situ splitting procedure which was associated with reduced cold ischemia time, incidence of biliary complications and primary delayed function as well as with improved graft and patient survival rates compared with the ex situ splitting [3]. However, whether performed ex situ or in situ, splitting techniques generate left grafts of limited size as it is usually agreed that the middle hepatic vein belongs to the right liver [4]. Transection is therefore either performed at the level of the falciform ligament [5, 6] or in the middle of segment IV [7] but with the middle hepatic vein being retained with the right graft. With these techniques, it has very seldom been possible to obtain a left graft large enough for an adult recipient.

The majority of patients who underwent surgery for colorectal liver metastases have been previously treated with 5-FU either as adjuvant chemotherapy or as a primary treatment. We have performed a retrospective study to assess whether this chemotherapy increases the risk of liver resection.Mortality, morbidity and histology of the resected liver of two groups of patients having colorectal liver metastases who underwent major resection were studied. The first group included 17 patients who had received at least 2 courses of 5-FU chemotherapy within 3 months prior to liver resection. The second group included 18 patients who had received no chemotherapy and who were used as controls.Perioperative mortality was nil. Intraoperative blood loss during liver resection (1 +/- 2.5 vs. 1.2 +/- 2 units) was similar in the two groups. Changes of liver function tests on days 2 and 5 were similar in the two groups. Morbidity rate was similar in the two groups (29 vs. 22%) with a mean duration of postoperative hospital stay of 19 +/- 9 days in the 5-FU group and 16 +/- 6 days in the control group. Although 7 (41%) patients in the 5-FU group had an abnormal parenchyma consistency as compared to only 3 (17%) in the control group, the pathological findings within the resected specimen were not different.5-FU based systemic chemotherapy does not increase the risk of liver resections.

Recent reports highlighting reduced mortality rates to less than 1% after hepatic resections have evaluated the management of selected patients. The current risk of liver resection in unselected patients needs to be more clearly defined to appreciate the actual risk of new indications.From 1990 to 1997, 747 consecutive patients, including 16 operated in emergency, underwent hepatic resection. Resection was indicated for malignancy in 473 patients (63%). Major resections were performed in 333 patients (45%). An underlying liver disease, including cirrhosis (n = 239) and obstructive jaundice (n = 4), was present in 253 patients (35%). Multivariate analysis of the risk factors for postoperative mortality, morbidity, and transfusion after stratifying patients for the circumstance of the operation and the pathological changes of the remnant liver was performed.There was no intraoperative death and the overall mortality rate was 4.4%. This rate was 25% after emergency liver resection and 3.9% after elective liver resection (p0.001). After elective resection, mortality was significantly higher in patients with cirrhosis (8.7%) or obstructive jaundice (21%) than in patients with a normal liver (1%; p0.001). Analysis of this subgroup of 478 patients with normal liver showed that the mortality rate was 0% in 220 patients operated for a benign disease and in 263 patients who underwent minor resections. All five deaths occurred in patients with a malignancy and resulted from extrahepatic complications. In patients with a malignancy, the only independent predictor of death was an associated extrahepatic procedure. The incidence of postoperative complications was 22% and was influenced by the American Society of Anaesthesiology (ASA) score, extent of resection, presence of a steatosis, and an associated extrahepatic procedure. The incidence of major complications was 8% and of reoperation 3%. Perioperative blood transfusion was required in 112 of 478 (23%) and was not associated with increased mortality.The 1% basic risk of elective liver resection on normal liver suggests that indications of resection for malignancy could be extended, unless an associated extrahepatic procedure is needed. Because of this low basic risk, future studies evaluating resection on normal liver should not consider in-hospital mortality as the only end point.

We investigated intra- and extrahepatic leukocytes during liver regeneration after a 70% partial hepatectomy in the rats using flow cytometry and RT-PCR for cytokine mRNA expression. Our study indicated that LFA-1 CD3+ cell, NK3.2.3++ T cells, and CD5+ B cells, which are activated in autoimmune diseases and malignancy in humans and mice, were activated in the early phase of liver regeneration in the liver and the blood after partial hepatectomy in the rats. On measuring cytokine mRNA expression by RT-PCR, only IFN-gamma mRNA was detected in the normal rat liver. IFN-gamma mRNA expression clearly decreased in the liver on day 1 after partial hepatectomy and increased thereafter. IL-2 and IL-4 mRNA were not detected in the liver regardless of hepatectomy. Every cytokine was detected in normal spleen and increased in the early phase after partial hepatectomy. These were also detected in normal thymus; however, IL-2 and IFN-gamma mRNA expressions decreased and IL-4 mRNA expression increased slightly in the early phase after partial hepatectomy. Thus, the immune system dramatically changed both in the liver and elsewhere in the early phase of liver regeneration after partial hepatectomy.

Background/Aims: After liver transplantionfor autoimmune hepatitis, the long-term results and the incidence of recurrence of primary disease are unknown. Methods: In this retrospective study we reviewed the clinical course of 25 patients transplanted for autoimmune hepatitis and followed for a mean of 5.3 years (2–8.5 years). Results: The actuarial 5-year patient and graft survival rates were 91% (±6%) and 83% (±8%). The actuarial 1-year rate of acute rejection was 50% (±10.2%), which was comparable to that of patients transplanted for primary biliary cirrhosis and primary sclerosing cholangitis. Autoantibodies persisted in 77% of patients, at a lower titer than before liver transplantation. Ten patients were excluded from the study of autoimmune hepatitis recurrence, one because of an early postoperative death and nine because of hepatitis C virus infection acquired before or after liver transplantation. In the remaining 15 patients, who were free of hepatitis C virus infection, 5-year patient and graft survivals were 100% and 87%, respectively. Despite triple immunosuppressive therapy, three patients (20%) developed chronic hepatitis with histological and serological features of autoimmune hepatitis in the absence of any other identifiable cause. The disease was severe in two patients, leading to graft failure and asymptomatic in another, despite marked histological abnormalities. In one of these three patients, autoimmune hepatitis recurred on the second liver graft as well. Conclusions: Patients undergoing liver transplantation for autoimmune hepatitis have an excellent survival rate although severe primary disease may recur, suggesting the need for stronger post-operative immunosuppressive therapy.

Acute rejection is considered as one of the main end-points in the evaluation of immunosuppressive protocols. The aim of this chapter is to assess the accuracy of this marker based on the particularities of liver transplantation.

Despite the recent development of percutaneous ethanol injection and liver transplantation, liver resection remains the reference treatment for hepatocellular carcinoma (HCC). The two drawbacks of this treatment are the risk associated with surgery and the high recurrence rate. Both are related to the almost constant presence of a chronic underlying liver disease. The risk of surgery has decreased significantly over the past 10 years and is currently less than 10%, even after a major hepatectomy, provided that cirrhosis is compensated (Child A) and that there is no superimposed chronic active hepatitis. Recurrence is usually related to de novo carcinogenesis Adjuvant and neoadjuvant therapies have no clearly demonstrated benefit. However, postoperative follow-up is mandatory as some recurrences are arnenable to local treatment, particularly rehepatectomy that has an efficacy comparable to that of first hepatectomy.

Liver resection of hepatocellular carcinoma (HCC) is associated with a high incidence of recurrence, that has a poor prognosis.Assess the rationale for and result of an aggressive treatment of recurrence following resection of HCC.Retrospective analysis of 132 patients with recurrent HCC with special reference to the topography and time of onset of recurrence as well as outcome following treatment of these recurrences. Case-control analysis of the efficacy of repeat hepatectomy and its influence on the long term prognosis of patients with recurrent tumor.Sixty seven percent of the recurrences were exclusively intrahepatic and half of these were limited in size and number. The 5-year survival rate following treatment of limited intrahepatic recurrence by repeat hepatectomy, arterial chemoembolization or percutaneous ethanol injection was 30%. Repeat hepatectomies improved the long term outcome of patients with recurrent HCC.An aggressive approach to tumor recurrence is currently the best way to improve the long term outcome following resection of HCC.

Prevention of intraoperative blood loss during liver resection is of prime concern. Intraoperative blood loss has indeed repeatedly been shown to adversely influence the short-term prognosis of patients undergoing liver resection. There is in addition evidence that it could be associated with an increased risk; of recurrence in patients operated for an hepato-biliary malignancy through impairment of the patient's immune response. The prime concern of the hepato-biliary surgeon is to minimize blood loss through the control of the major vascular structures this may be achieved in several ways that range from segmental portal control to total hepatic vascular occlusion. The type of vascular occlusion should be selected according to the indication and in particular location of the tumour and presence of an associated underlying liver disease, the patient's cardiovascular status and the experience of the operator. Aim of the authors is to describe the various types of vascular control as well as their benefits and drawbacks so as to use the most appropriate technique according, to each patient' requirements.

The prime concert of a hepato-biliary surgeon undertaking liver resection is to minimise blood loss and prevent air embolism through the control of the major vascular structures. Several methods to achieve this are now available and include in particular clamping of the hepatic pedicle and total vascular exclusion. Both techniques are detailed as well as their benefits and drawbacks. For conventional liver resections, total vascular exclusion has no advantage over clamping of the hepatic pedicle in preventing blood loss and is associated with additional morbidity. This technique should be selectively used in patients with tumours involving major hepatic veins or the inferior vena cava.

The precise immunologic mechanisms responsible for chronic rejection of liver allografts are unknown. We have recently shown in a rodent model that recipients of liver allografts developed non-major histocompatibility complex antitissue antibodies. The aim of the present study was to test this hypothesis in the clinical setting.Posttransplant sera of 14 patients undergoing chronic rejection and of 48 control patients (12 liver transplant patients with chronic active hepatitis or liver cirrhosis related to hepatitis C virus [HCV] infection and without chronic rejection, 10 with sclerosing cholangitis, and 26 with normal liver function tests and liver biopsy) were tested for the presence of antitissue antibodies by indirect immunofluorescence. Pretransplant sera of all these patients lacked antitissue antibodies.Antitissue antibodies were detected in 71% of patients who developed chronic rejection (before or at the time of chronic rejection). This incidence was significantly greater than that observed in patients not undergoing rejection (HCV-related chronic active hepatitis, 16%; sclerosing cholangitis, 0%; normal liver biopsy, 7%). All these autoantibodies were directed against the smooth muscle and/or the nucleus. In two patients, anti-smooth muscle antibodies had an antiactin or antivimentin specificity.These results show a strong association between chronic allograft rejection and the development of antitissue antibodies and suggest that these antibodies could be used to identify patients at high risk of developing chronic rejection after liver transplantation.

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The aim of this work was to evaluate outcome in a continuous homogeneous series of more than 1000 liver transplantations in order to determine risk groups.Between November 1984 and February 1995, 1052 isolated orthotopic liver transplantations were performed in 922 patients (530 males, 392 females; mean age 41.7 years; age range 10 months - 78 years) at the Paul-Brousse Hospital liver transplantation unit. Immunosuppression was based on cyclosporin in all patients with FK506 in the most recent cases.Actuarial survival at 1,5 and 8 years for the 922 patients was 80.9, 71.7, and 69.1%. Certain factors affecting the intrinsic risk of transplantation were identified and could be used to calculate supplementary risk due to one or more other risk factors. In adults under 55 years in UNOS stage 1 or 2 (not hospitalized at call in) transplanted after 1990 for non-recurrent (absence of cancer, non-viral disease) chronic liver disease, the risk of death at 1 year was 6.5% and 4.4% between the first and second year. For patients transplanted for acute liver failure and for patients transplanted for chronic liver disease in UNOS stade 3 or 4 (hospitalized or in an intensive care unit at call in), there was a supplementary risk of death at 1 year of 20.3%, 13.3% and 31.6% respectively. There was no supplementary risk of death in these three groups after 1 year. In patients over 55 years, there was a 4.4% supplementary risk during the first year after transplantation and a 2% increase between the first and second year. In patients transplanted for cancer, the supplementary risk was 9.7% during the first year, 11.6% between the first and second year and 2.1% between the third and fifth year.On the basis of these results, it was possible to develop a method for assessing liver transplantation outcome in different units. The proposed criteria is the 1 year survival of patients with the basic risk alone, without any supplementary risk, as well as the retransplantation index (mean number of grafts used per patient). For the Paul-Brousse unit, this criteria is 93.5% (survival at 1 year) for a retransplantation index of 1.1.

Liver allografts are not rejected in the fully incompatible Lewis-RT1(1) (LEW) to blood group D Agouti-RT1a (DA) rat strain combination despite an early infiltration by recipient mononucleated cells that initially display a phenotype, an ability to respond to interleukin-2 (IL-2) and donor-specific cytotoxicity indistinguishable from that observed in the rejected, DA to LEW combination. To further analyze the mechanism of this tolerance, we have compared in these two combinations, as well as in syngeneic grafts and in normal livers, the presence of intrahepatic cytokine transcripts (IL-1 alpha, IL-2, IL-4, IL-6, IL-10, tumor necrosis factor [TNF]-alpha, TNF-beta, and transforming growth factor [TGF]-beta) by a semiquantitative polymerase chain reaction (PCR) or by northern-blotting. In normal livers or syngeneic grafts, IL-1 alpha, TNF-beta, and TGF-beta were the only cytokines detected by these methods. The levels of all cytokine transcripts were increased in allogeneic grafts. Expression of cytokine transcripts was very similar in the two allogeneic strain combinations except IL-4, which was expressed at a much lower level in the nonrejected strain than in the rejected strain from day 2 onward. We conclude that selective downregulation of IL-4 gene expression is associated with, and a potential mediator of, the induction of tolerance in this model.

Little information is available on the indications for, and the efficacy and timing of, liver transplantation in patients with primary sclerosing cholangitis (PSC). This issue is particularly relevant because prolonged survival has been reported in patients who do not undergo transplantation.Long-term results of therapeutic interventions including liver transplantation was assessed in a representative series of 51 patients. Patient survival was compared with that expected from prognostic models.Actuarial symptom-free survival rate in patients treated by nontransplantation biliary surgery (n = 23) was 35% at 10 years. Actuarial survival rate from onset of PSC (56% at 10 years) was identical to that expected from the prognostic model. Actuarial patient (n = 28) survival rate 5 years after transplantation was greater than that expected from prognostic models (89% versus 31%; p0.001). Previous abdominal surgery was associated with an increased in-hospital mortality rate (p0.05). Cumulative actuarial incidence of cancer 5 and 10 years after the onset of PSC was 13% and 31%, respectively.Liver transplantation improves the prognosis of patients with PSC. Failure to identify patients who will benefit from nontransplantation therapeutic interventions or in whom a cancer will develop, and the risk associated with previous abdominal surgery, suggest that liver transplantation should be indicated early after onset of symptoms.

In a model of arterialized rat liver transplantation, the biological indicators of liver dysfunction and the phenotype and in vitro function of graft-infiltrating cells have been compared in rejected (DA-to-Lew) and spontaneously accepted (Lew-to-DA) grafts, 2-8 days after grafting. Recipients of rejected and nonrejected allografts had, during this time, similar loss in body weight and plasma levels of transaminase. The markers of cholestasis, however, increased from days 3 and 4 onward in the recipients of rejected grafts, but remained low and similar in the recipients of nonrejected allografts and those of syngeneic grafts. From days 2 to 6 the phenotype, IL-2 responsiveness, and donor-specific cytotoxic potential of the leukocytes infiltrating rejected and nonrejected allografts were comparable. On days 7 and 8, although the proportion of T cell subpopulations was identical in both combinations, activated CD4+ graft-infiltrating cells were reduced in the nonrejected grafts. Also at this time, donor-specific cytotoxic cells were no longer detected in nonrejected grafts, whereas activity had reached a peak in the rejected grafts. These results suggest that liver grafts in both the LEW--DA (grafts not rejected) and DA--LEW (grafts rejected) strain combinations undergo tissue damage, but that the type of damage differs between the two combinations. Specifically, cholestasis was only observed in grafts that would subsequently be rejected. The difference in graft damage occurred at a very early time point (3 or 4 days after grafting), at which time neither the intensity nor phenotype of the graft infiltrate, its IL-2 responsiveness, or its cytotoxic potential varied between the two combinations. Thus, a lack of immune reactivity, as assessed by these parameters, does appear not to be responsible for spontaneous acceptance of liver transplants in the LEW--DA strain combination.

This retrospective study was done to stress the particular features of perforation of the gastroduodenal ulcer in patients with cirrhosis. From 1979 to 1987, 135 patients were operated upon for perforation of the gastroduodenal ulcer: clinical, biologic and roentgenographic data of 22 patients with cirrhosis were compared with 112 patients without cirrhosis. In the 22 patients with cirrhosis, three gastrectomies and 19 simple closures with omental patch were performed. Clinical ascites was present in 16 of 22 patients with cirrhosis. Acute abdominal pain and leukocytosis were less frequent in patients with cirrhosis (p less than 0.05), whereas associated bleeding in the upper part of the gastrointestinal (GI) tract was more frequent (p less than 0.05). In patients with cirrhosis, abnormal plasma creatinine level and associated upper GI bleeding were more frequent in patients with ascites (p less than 0.05); on the other hand, acute abdominal pain and rebound tenderness were less frequent (p less than 0.05). The incidence of pneumoperitoneum was higher in patients with cirrhosis. Surgical treatment was significantly delayed in patients with cirrhosis and ascites. Ulcers were larger in patients with cirrhosis and ascites than without (p less than 0.001). Over-all morbidity and mortality rates in patients with cirrhosis were 77.3 and 50.0 per cent, respectively. Mortality and morbidity were significantly higher in patients with ascites than without (62.5 versus 16.6 and 100 versus zero per cent, respectively), in patients with prothrombin times of less than 50 per cent and with plasma creatinine levels more than 110 micromolars.

In the last four years, 551 liver transplantations have been performed at the Paul Brousse center, for a total of 840 liver transplantations performed from 1984 to 1992. Several changes have been observed in the field of liver transplantation in the past years. The field of immunosuppression was marked mainly by the advent of FK506 as a preventive treatment of rejection and as a treatment of cortico-resistant rejection. Results are still under analysis. From the surgical viewpoint, the main modification was the advent of UW solution, which extends cold ischemic time. However, our policy was to maintain the cold ischemic time at less than 12 hours. Primary indications for liver transplantations have changed with an increase in the rate of patients transplanted for cirrhosis related to hepatitis virus infection: from 24% in the period 1984-1988 to 42% in the period 1989-1992. The difference was due mainly to HCV-related cirrhosis, which increased from 8% to 20%. Alcoholic cirrhosis was a rare indication in the period 1989-1992 (3.4%); however, it was an increasing indication in the last 2 years. In order to improve the long-term results, major attention was given to the recurrence of initial liver disease. In patients transplanted for HBsAg-positive liver disease, long-term passive anti-HBs immunoprophylaxis was administered, which reduced the rate of HBV recurrence in patients without HBV replication before transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Introduction La resection combinee d’un cancer colorectal (KCR) et de metastases hepatiques (MH) synchrones reste controversee en raison du risque accru de morbidite et du probleme de la voie d’abord. Le but de cette etude a ete d’evaluer l’interet de la laparoscopie colorectale chez les patients operes de KCR avec MH synchrones. Patients et Methodes D’octobre 2005 a juillet 2008, 28 patients (16 femmes, 12 hommes) d’âge moyen 59 ans (extremes : 40 - 77) ont ete operes d’un KCR avec MH synchrones. La resection laparoscopique etait une : colectomie droite (n = 1), transverse (n = 1), gauche (n = 13) ou proctectomie (n = 13). Les MH etaient unilobaires (n = 14) ou bilobaires (n = 14) avec un nombre moyen de MH/patient de 4,6 (extremes : 1 - 17). Le geste hepatique, realise en un temps (n = 21) ou 2 temps (n = 7), par coelioscopie (n = 6), sous-costale droite (n = 17) ou courte mediane sus-ombilicale (n = 5) etait : majeur (> 2 segments, n = 4), mineur (n = 5) ou une resection atypique (n = 19). Pour la chirurgie en 2 temps, une ligature de la branche portale droite etait toujours associee. Resultats La mortalite operatoire etait nulle. Le taux de conversion etait de 3/28 (11 %). La duree operatoire moyenne etait de 370 minutes (170 - 560) La morbidite globale etait de 15/28 (54 %). La morbidite majeure (reintervention, drainage) etait de 8/28 (29 %) dont 3/28 lies a la colectomie (11 %) et 5/28 (18 %) lies a l’hepatectomie. La duree d’hospitalisation moyenne etait de 17 jours (6 - 40). La resection etait R0 dans 28/28 KCR et 24/28 MH (86 %). Conclusion Notre etude suggere que la laparoscopie colorectale regle le probleme de la voie d’abord pour l’hepatectomie. De plus, sa realisation lors du meme temps operatoire fait gagner un temps chirurgical.

The permeability of the biliary epithelium to [14C]ursodeoxycholic acid (UDCA), a hypercholeretic bile acid, was compared to that of the 14C-labeled nonhypercholeretic bile acids cholic acid (CA), taurocholic acid (TCA), and tauroursodeoxycholic acid (TUDCA) by means of anterograde intrabiliary infusions and retrograde intrabiliary injections in the anesthetized rat. Anterograde intrabiliary infusions were performed by perfusing an isolated segment of common bile duct in vivo. After anterograde intrabiliary infusions, the fraction of unrecovered UDCA (that had presumably been absorbed from the biliary lumen) was 11.03 +/- 1.03 (SE)% (n = 6) of the administered dose. It was significantly higher than that of TUDCA (1.25 +/- 0.27%; n = 5; P less than 0.01), CA (2.62 +/- 0.43%; n = 4; P less than 0.01), and TCA (2.57 +/- 0.79%; n = 6; P less than 0.01). In separate experiments, bile was collected from the common bile duct and from the left hepatic duct. UDCA recovered from the left hepatic duct was found in the conjugated form, indicating that, after absorption in the common bile duct, it had been conjugated by the hepatocyte and secreted into bile. After retrograde intrabiliary injections of UDCA and CA, the cumulative percentages of recovered radioactivity were not significantly different (84.50 +/- 2.65 and 87.33 +/- 1.80%, respectively); however, peak recovery of UDCA was significantly delayed compared with that of CA. Moreover, UDCA was recovered mostly in the conjugated form, while CA was recovered mostly in the unconjugated form. These results suggest that, in the rat, UDCA is significantly more absorbed by the biliary tree than CA, TUDCA, and TCA. They support the hypothesis that UDCA undergoes a cholehepatic circulation.

Forty-six patients with pyogenic liver abscess have been treated at Paul Brousse Hospital between 1966 and 1986. The overall mortality was 24 per cent, all 11 deaths occurring in 24 patients seen prior to 1978 when there was often a considerable delay in the diagnosis of liver abscess (mean 90 ± 71 days). In seven patients the diagnosis was not made until post-mortem examination. The mainstay of treatment was surgical drainage. Since 1978 high resolution imaging techniques for the liver, and in particular ultrasound, have been available. The diagnostic delay has been significantly reduced (mean 28±20 days, P < 0·01). Patients are receiving definitive treatment at an earlier stage in the evolution of the disease process, with fewer established complications prior to treatment (P < 0

RésuméLa pancréatectomie gauche (PG) par abord laparoscopique est aujourd’hui une procédure validée : 25 études rétrospectives comparant laparotomie et laparoscopie ont démontré la faisabilité de cette voie d’abord pour les lésions bénignes et malignes localement peu avancées. Cependant, ces études rapportent de nombreuses variantes techniques et le but de cette mise au point est de déterminer si une standardisation peut être proposée pour cette procédure. À partir des données de la littérature et de l’expérience française de l’Association de chirurgie hépato-biliaire et de transplantation hépatique (ACHBT), il paraît licite d’établir certaines recommandations, telles que le contrôle premier de l’artère splénique, l’utilisation d’agrafeuses linéaires pour la section parenchymateuse pancréatique, le contrôle de la veine splénique à sa terminaison et/ou à son origine, la ligature et/ou section systématique de l’artère en cas de ligature de la veine splénique, et en fonction des conditions locales, la conservation des vaisseaux spléniques lorsqu’une conservation splénique est envisagée. Les données actuelles ne permettent en revanche pas d’émettre des recommandations concernant le site idéal de section pancréatique, le type d’installation, et le sens de dissection pancréatique, qui reste affaire d’école. Le contrôle de la veine splénique reste le point critique de cette intervention et va conditionner la stratégie peropératoire.SummaryLaparoscopic distal pancreatectomy is currently a commonly performed procedure. Twenty-five retrospective studies comparing laparotomy and laparoscopy have dealt with the feasibility of this approach for localized benign and malignant tumors. However, these studies report several different techniques. The aim of this review was to determine if a standardized procedure could be proposed. Based on the literature and the experience of surgeons in the French Association of Hepatobiliary Surgery and Liver Transplantation (Association Française de Chirurgie Hépato-biliaire et de Transplantation Hépatique [ACBHT]), we recommend primary control of the splenic artery, use of linear staplers for pancreatic transection, splenic vein control either at its end or its origin, and, depending on local conditions, preservation of the splenic vessels when splenic preservation is envisioned. Current data do not allow establishment of any definitive recommendations as to the ideal site of pancreatic transection, operative patient position, or the direction of dissection, which mainly depends on local practices. Control of the splenic vein remains the critical point of this procedure, and impacts the intra-operative strategy.

Twenty-four patients with liver cell adenomas were referred to Paul Brousse Hospital between 1976 and 1987. This represents the largest reported surgical experience of this pathology from a single centre. Six patients had multiple adenomas, which were associated with glycogen storage disease in four. Two patients had polyadenomatosis, one of whom underwent successful liver transplantation after malignant transformation to hepatocellular carcinoma. Eighteen patients (median age of 33 years, range of 17-45 years) had either a solitary adenoma or two adenomas. Eighty-three per cent were women 87% of whom had received oral contraceptives or other hormone therapy before diagnosis (median duration of 11 years, range of 3-15 years). Fifty per cent of these patients presented with acute hemorrhage into an adenoma. Seventeen patients underwent surgical resection of their adenomas, with the remaining patient currently being treated by arterial embolizations to reduce the tumor size before surgery. There was no operative mortality or serious morbidity, and all patients remain well upon follow-up. Surgical excision of liver adenomas, where this can be done without causing mortality, is recommended. Resection relieves symptoms and removes both the risks of hemorrhaging into the tumour and of malignant transformation to hepatocellular carcinoma.