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Background: Packing is a life-saving procedure in patients undergoing emergency surgery for blunt hepatic trauma, especially when massive blood transfusions, acidosis, or hypothermia have resulted in coagulation disorders. The purpose of this study was to apply this concept to the setting of elective liver surgery., Methods: Elective packing was performed in 7 patients who had sustained prolonged bleeding mainly related to partial outflow obstruction during the course of liver resection (n = 3) or transplantation (n = 4). At the time of packing, conventional methods of hemostasis had failed and surgery had lasted for 490 (range, 380-695) minutes, blood loss was 5,700 (range, 2,100-13,700) ml, and all patients had coagulation disorders (prothrombin time PT <30%, platelets <45 g/l), hypothermia (body temperature 35.4 °C), acidosis (median blood pH 7.24; serum lactate 6.5 mmol/l) and required catecholamine support., Results: Unpacking was performed after a median of 37 (range, 26-60) hours. At that time, all patients were normothermic, with platelet counts >45 g/l, PT >30%, and restored acid-base balance. Active bleeding had stopped, and secondary fascia closure was feasible. With a minimum follow-up of 6 months, all patients are alive without sequel., Conclusions: Packing is a safe and efficient means to control venous bleeding when conventional methods of hemostasis have failed, knowing that commonly the reason for failure of conventional method of hemostasis is partial outflow obstruction.

Serum alpha-fetoprotein (AFP), the main serum marker of hepatocellular carcinoma, may increase in some benign conditions involving the liver but is usually within normal values in focal nodular hyperplasia (FNH) in adults. We present a case of a FNH associated with serum AFP increase, and in which both the lesion and the non-lesional adjacent liver showed AFP-positive immunostained areas. Moreover, only one case of FNH with AFP-positive immunostaining has been previously reported. In addition, our case of FNH is remarkable as it displayed some morphological and immunophenotypical features of progenitor cells. The serum AFP levels rose after liver resection and progressively returned to the preoperative high values. These findings are concordant with the hypothesis that FNH is a regenerative process, and suggest that regenerative areas in the liver might be the source of AFP production., (© 2011 The Authors. Pathology International © 2011 Japanese Society of Pathology and Blackwell Publishing Asia Pty Ltd.)

Background: Incidental gallbladder cancer (GBC) is frequently discovered on the specimen when cholecystectomy for a benign disease is performed. The objective of the present study was to assess the management of incidental GBC patients in a French registry., Methods: Data on patients with GBC treated between 1998 and 2008 were retrospectively collated in a French, multicenter database., Results: The registry contained 218 patients with incidental GBC (67 men and 151 women; median age = 64 years; age range = 31-88). One hundred forty-eight (68%) patients underwent re-resection after a median time interval of 48 days (range = 2-245). The most common complete procedure (66% of cases) was 4b + 5 segmentectomy with lymphadenectomy but not bile duct resection. Port-site excision was performed in 54 patients. The mortality and morbidity rates were 3 and 37%, respectively. Resection of the common bile duct (43%) increased postoperative complications (60 vs. 23%, p = 0.0001). Local residual tumor was found in 83 (56%) patients; it was significantly correlated with the T stage and influenced long-term survival. R0 was obtained in 143 (97%) patients and port-site invasion was histologically confirmed in one patient (1.8%). After a median follow-up period of 34 months, the 1-, 3-, and 5-year survival rates for the 148 patients with re-resection were 76, 54, and 41%, respectively. Re-resection significantly increased survival in patients with T2 (p = 0.0001) and T3 (p = 0.04) disease. Resection of the common bile duct increased neither R0 resection nor overall survival (p = 0.06)., Conclusion: This study validates the concept of re-resection in T2 and T3 GBC. Bile duct resection increases postoperative morbidity but does not improve survival. There is currently a modification in the surgical management of incidental GBC, with minor liver resection and no common bile duct resection.

Aims: To compare selective and non-selective TACE techniques in the treatment of HCC with a special emphasis on clinical and liver tolerance, tumour response and survival., Methods: 184 patients with advanced HCC were retrospectively included. Three different TACE techniques were compared: non selective lipiodol-chemotherapy + non selective embolisation (TACE-technique group 1), non selective lipiodol-chemotherapy + selective embolisation (group 2), and selective lipiodol-chemotherapy + selective embolisation (group 3)., Results: In multivariate analysis TACE-technique group is an independently significant prognostic factor for poor clinical tolerance, poor liver tolerance and tumour response. The rate of patients with poor clinical tolerance was lower in group 3 (27.0%) than in groups 1 (64.1%, p < 10(-3)) or 2 (66.7%, p < 10(-3)). The rate of patients with poor liver tolerance was higher in group 2 (34.0%) than in groups 1 (17.6%, p = 0.050) or 3 (6.9%, p = 0.011). The rate of patients with tumour response was higher when embolisation was selective versus non-selective, i.e., group 2 + 3 (78.7%) versus group 1 (62.5%, p = 0.054). Overall survival was not significantly different between the three groups (p = 0.383)., Conclusion: Both selective techniques resulted in better tumour response. As for improving tolerance, our study suggests that the main technical factor is the use of selective lipiodol-chemotherapy injection.

Introduction: Jaundice is frequent in patients with gallbladder cancer (GBC) and indicates advanced disease and, according to some teams, precludes routine operative exploration. The present study was designed to re-assess the prognostic value of jaundice in patients with GBC., Methods: Patients with GBC operated from 1998 to 2008 were included in a retrospective multicenter study (AFC). The main outcome measured was the prognostic value of jaundice in patients with GBC focusing on morbidity, mortality and survival., Results: A total of 110 of 429 patients with GBC presented with jaundice, with a median age of 66 years (range: 31-88). The resectability rate was 45% (n=50) and the postoperative mortality and morbidity rates were 16% and 62%, respectively; 71% had R0 resection and 46% had lymph node involvement. Overall 1- and 3-year survivals of the 110 jaundiced patients were 41% and 15%, respectively. For the 50 resected patients, 1- and 3-year survivals were 48% and 19%, respectively (real 5-year survivors n=4) which were significantly higher than that of the 60 non-resected patients (31%, 0%, p=0.001). Among the resected jaundiced patients, T-stage, N and M status were found to have a significant impact on survival. R0 resection did not increase the overall survival in all resected patients, but R0 increased median survival in the subgroup of N0 patients (20 months versus 6 months, p=0.01)., Conclusion: This series confirms that jaundice is a poor prognostic factor. However, the presence of jaundice does not preclude resection, especially in highly selected patients (N0)., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: This year, the 7th edition of the AJCC staging manual has for the first time attributed a unique pTNM staging to intrahepatic cholangiocarcinoma (IHCC) that is intended to replace the 2 Western and ideally also the 2 Eastern systems currently in use. This proposal, which has not yet been validated, was tested in the current study., Methods: Among 522 patients operated on with curative intent for an IHCC between 1994 and 2008 in tertiary hepatobiliary centers, those with mass-forming-type IHCCs, an R0 resection, and accurate pathological node staging were retained for evaluation. The distribution of these patients and their actuarial survival in the new TNM stages (as well as in the 4 previous ones) were compared., Results: Only 163 patients fulfilled the inclusion criteria, mainly because of the lack of routine lymphadenectomy, but patients and tumors characteristics of this population were representative. These patients were evenly distributed between AJCC 7th edition stages (stage I, 28%; stage II, 32%; stage III, 35%), which was not the case for the other systems. With an average follow-up of 34 months in survivors, the AJCC 7th edition was more discriminating than the others in predicting survival (median for stage I not reached; for stage II, 53 months, P = .01; for stage III, 16 months, P < .0001). Survival of these patients according to the 2 Japanese classifications was identical to that anticipated., Conclusions: The 7th edition is clinically relevant and may be applicable worldwide, provided routine lymphadenectomy at the time of surgery for IHCC becomes the standard of care., (2010 American Cancer Society.)

Introduction: Surgical resection is the only option for long-term survival in patients with hilar cholangiocarcinoma (HC), but it is associated with high morbidity and mortality. The aim of the present study was to prospectively assess the perioperative management and short-term outcomes of surgical treatment of HC in a recent, multi-institutional study with a short inclusion period., Methods: Between January and December 2008, a register prospectively collected data on patients operated on for HC (exploratory or curative surgery) in eight tertiary centers. The register focused on perioperative management, resectability, surgical procedures employed, morbidity, and mortality. The study cohort consisted of 56 patients (40 men and 16 women) with a median age of 63 years (range, 33-83 years)., Results: Among the 56 patients, 47 (84%) were jaundiced and 42 (75%) tumors were classified as Bismuth-Corlette type III-IV. Nine patients (16%) underwent staging laparoscopy and four (7%) received neoadjuvant chemotherapy. Preoperative biliary drainage (endoscopy, 42%) was performed in 38 (81%) jaundiced patients and portal vein embolization (right side, 83%) was performed prior to surgery in 18 patients (32%). Among these 56 patients, curative resection was achieved in 39 (70%). All underwent major liver resection (>3 segments), bile duct resection, and lymphadenectomy. Thirteen patients (36%) underwent portal vein resection, one of whom also required pancreaticoduodenectomy. Eighty-two percent of resected patients (n = 32) had no proof of malignancy prior to hepatectomy. Clear surgical margins were obtained in 77% (n = 30). The postoperative mortality was 8% and complications occurred in 72% of the resected patients. Seven (25%) patients required reoperation, and 15 (54%) patients required percutaneous drainage. In a univariate analysis, the risk factors for morbidity were intraoperative blood transfusion (p = 0.009) and vascular clamping (p = 0.006). The median length of hospitalization was 20 ± 13 days., Conclusion: Curative resection for HC is associated with a high rate of R0 resection. However, surgery is associated with high levels of morbidity and mortality, despite intensive perioperative management.

Pulmonary embolism occurs more frequently after hepatectomy than previously thought but is infrequently associated with peripheral deep vein thrombosis. In this paper, we report 2 cases of postoperative hepatic vein thrombosis after liver resection. Both patients had undergone major hepatectomy of a non-cirrhotic liver largely exposing the middle hepatic vein. Clots were incidentally found in the middle hepatic vein 4 and 17 d after surgery despite routine systemic thrombo-prophylaxis with low molecular weight heparin. Coagulation of the transition plan in a context of mutation of the prothrombin gene and inflammation induced biloma were the likely predisposing conditions. Clots disappeared following curative anticoagulation. We conclude that thrombosis of hepatic veins may occur after liver resection and is a potential source of pulmonary embolism.

Objective: Hepatocellular adenomas (HCAs) classically develop in women who are taking oral contraceptives and have a risk of malignant transformation into hepatocellular carcinoma (HCC). HCA with malignant transformation is, however, an ill-defined entity thought to be an anecdotic pathway to HCC. The objective of this study was to characterise malignancy occurring within HCA., Design, Setting and Patients: A series of histology proven HCAs managed between 1993 and 2008 in a tertiary hepato-biliary centre (218 patients, 184 women and 34 men) were screened to identify HCA with malignant transformation., Main Outcome Measures: The incidence of HCA with malignant transformation was analysed through the study period and associated conditions were retrieved. They were sub-typed according to their molecular features and the malignant compartment was mapped., Results: Areas of HCC within HCA were observed in 23 patients and the risk of malignant transformation was 4% in women and 47% in men. The number of women whose HCA had malignant changes has remained stable during the study period and oral contraception was the only associated condition. The number of men with such transformation has markedly increased since 2000 and the metabolic syndrome has become the most frequent associated condition. Two-thirds of HCAs with malignant transformation were β-catenin activated and one-third displayed cell atypias. Both features were more prevalent in men. The median diameter of HCA with malignancy was 10 cm and only three were 5 cm or less., Conclusion: Prevalence of malignancy within HCA is 10 times more frequent in men than in women and management of HCA should primarily be based on gender. Whereas oral contraception is a classical cause of HCA in women but a marginal cause of HCC, the metabolic syndrome appears as an emerging condition associated with malignant transformation of HCA in men, and is the likely predisposing condition for HCC in this setting.

Background: The new global epidemic, overweight and obesity, has a significant role in the etiology of liver tumors. However, the impact of body weight on the outcome after liver resection is unknown., Methods: We carried out a prospective study of 684 patients who underwent liver resections. Patients were stratified according their body mass index (BMI) as follows: normal (<25 kg/m(2)) (52%), overweight (25-29 kg/m(2)) (34%), and obese (≥30 kg/m(2)) (14%), and according to the extent of resection, as either minor or major hepatectomy. Preoperative and intraoperative characteristics and outcomes were prospectively studied. The Dindo-Clavien classification of morbidity was used., Results: Overall postoperative morbidity and morbidity rates were not influenced by BMI. Pulmonary complications were significantly more frequent in obese patients irrespective of the extent of resection. During major resection obese had longer pedicular clamping and more frequently required blood transfusion. After major resection, major morbidity (Dindo-Clavien grade III or more) was more frequent in obese (57%) and overweight (54%) patients than in patients of normal body weight (35%; P < 0.05), including a higher rate of respiratory complications and ascites and longer intensive care unit (ICU) and hospital stays. Obesity and overweight were independent predictors of major morbidity (OR 2.6, 95% CI 1.2-5.8 and OR 1.9, 95% CI 1.2-3.2, respectively), and obesity was a predictor of the need for blood transfusion (OR 3.3, 95% CI 1.4-7.9) after major resections., Conclusions: Obese and overweight patients are at increased risk of potentially life-threatening morbidity after major hepatic resections. Because the risk of mortality is not increased significantly, there is no justification for a compromise in the indication or extent of surgery.

Objective: In an attempt to refine the indications for liver resection (LR) for highly symptomatic polycystic liver disease (PLD), we focused on the characteristics, technical difficulties, postoperative outcome, and long-term follow-up of PLD patients who underwent either LR or liver transplantation (LT)., Methods: Since 1995, among 72 patients with massive hepatomegaly, 45 patients underwent LR associated with contralateral cyst fenestration whereas 27 underwent LT associated with simultaneous kidney transplantations in 23. The LR group was characterized by absence of end-stage renal insufficiency, absence of ascites, and better nutrition status. In the LR group, the volumetry of the spared noncystic parenchyma was preoperatively assessed whereas pathological analysis focused on fibrosis and vascular congestion., Results: After LR, the mortality was nil and overall morbidity was 71%, including biliary leak in 20% and ascites in 42%. Persistent and massive ascites was observed in 8 patients who have undergone extensive resection and had significantly more frequently fibrosis on the analysis of their resected surgical specimens (P = 0.002). A volume of the remnant noncystic parenchyma less than 30% and the presence of vascular changes on the specimen were associated with higher risk of complications. The 5-year survival was 95% and among the 43 survivors, after a mean follow-up of 41 months, 36 (83%) patients stated that they were satisfied, with complete relief of symptoms in 30 (70%). After LT, the postoperative mortality was 15% and the overall morbidity was 85%, including 12 patients who required reoperation. Severe complications were more frequent in the presence of denutrition and preoperative ascites. The 5-year survival was 85% and after a mean follow-up of 36 months all survivors had complete relief of symptoms due to hepatomegaly., Conclusions: In case of massive hepatomegaly from PLD without end-stage renal failure, LR should be considered first when preserved remnant liver volume represents at least 30% of the total volume liver in the absence of vascular changes or fibrosis.

Background: Sorafenib is the standard treatment for patients with an advanced stage of hepatocellular carcinoma (HCC). The aims of this study were (i) to evaluate the tolerance and survival of sorafenib-treated patients, in a nonselected population, especially in Child-Pugh B patients; and (ii) to identify potential prognostic factors of survival., Patients and Methods: From April 2007 to December 2008, 50 patients received sorafenib for advanced HCC. Seventeen (34%) were Child-Pugh B patients. We recorded adverse events and the duration of treatment and survival. For 34 patients with histopathologically proven HCC, immunophenotypical analysis was carried out using antibodies against cluster differentiation 34, vascular endothelial growth factor, phosphorylated ERK, cytokeratin 19, and phosphorylated stat3., Results: Patients with Child-Pugh B cirrhosis had a more advanced stage of the disease compared with Child-Pugh A patients. The occurrence of adverse events was similar in Child-Pugh A and Child-Pugh B patients. Duration of treatment until discontinuation for bad tolerance was lower in Child-Pugh B patients (1.8 vs. 5 months, P=0.02). Survival of Child-Pugh A patients was higher compared with Child-Pugh B patients (8.9 vs. 2 months, P=0.004). Barcelona Clinic Liver Cancer stage, Eastern Cooperative Oncology Group Performance Status, portal vein impairment, extra-hepatic spread, and alpha-foetoprotein were also prognostic factors. In multivariate analysis, the sole factor associated with survival was the Barcelona Clinic Liver Cancer stage. None of the immunohistological markers used was associated with tolerance and survival., Conclusion: Occurrence of adverse events is similar in Child-Pugh A and Child-Pugh B patients. Nevertheless, the survival of Child-Pugh B patients is very low. Whether liver function or tumor spread is responsible for mortality is unclear. Opportunity of treatment for Child-Pugh B patients is questionable. The immunophenotype of tumoral tissue was not predictive of survival.

The increasing incidence of hepatocellular carcinoma (HCC) has led several countries to standardize and update its management. This review aims at summarizing these evolutions through six questions focusing on diagnosis and treatment. The radiological diagnosis of this tumor has been refined. Besides being hypervascular at the arterial phase, the "washout" in particular at the late phase of injection has become a prominent feature. Although routine ultrasound remains the corner stone of screening, contrast ultrasound has become a very reliable characterization tool as it allows continuous monitoring of the vascular kinetics. Biopsy of the tumor allows identification of conventional or molecular prognosis features, some of which could be used in current practice. The metabolic syndrome is an increasing etiology of HCC and carcinogenesis in this context may not always require the development of formal underlying cirrhosis. Associated (in particular cardiovascular) conditions account for an increased morbidity-mortality following surgery. Liver transplantation is the most effective treatment of early-stage tumors. The limited availability of grafts has led some countries including France to implement new allocation rules that are still evaluated and might need to be refined. Sorafenib is the first medical treatment shown to be effective in the treatment of HCC. This efficacy is however still limited and its indication is therefore restricted to Child-Pugh A, OMS 0-2 patients in whom a potentially curative treatment is contraindicated., ((c) 2010. Published by Elsevier Masson SAS.)

As adenoma in other locations, hepatic adenoma (HA) may transform into hepatocellular carcinoma (HCC) and hepatocyte dysplasia is most probably the intermediate step between both conditions. Malignant HA may appear as microscopic or macroscopic areas of HCC within the HA. These areas are typically well differentiated and without vascular extension or satellite nodules. AFP measurements are not reliable as they are usually normal. The risk of malignant transformation of HA cannot be reliably quantified yet. Several series are concordant to show that approximately 5% of patients whose HA have been resected had pathological evidence of HCC within their HA. This figure however does not take into account fully transformed HA where evidence of the preexisting benign lesion might have disappeared. The risk of malignant transformation is correlated with the diameter of the HA and it is very unusual when it is <5 cm and the same holds true for patients with multiple HA. These results suggest that small HA could be safely observed as they are also at low risk of bleeding. These conclusions might not apply to male patients who are at lower risk of HA, except in specific conditions, but appear to be at a much higher risk of malignant changes., (Copyright 2010 S. Karger AG, Basel.)

Background & Aims: Hepatocellular adenoma (HA) is associated with risk of bleeding and malignancy, justifying resection. Patients with multiple forms of HA are difficult to manage. We evaluated the characteristics and outcome of 122 patients with single and multiple HAs after surgery., Methods: From 1990 to 2004, 122 patients (14 male) underwent surgical resection. Complications (hemorrhage and malignancy) were assessed according to size, number, and histologic subtype (steatotic, telangiectatic, and unclassified), with a mean follow-up period of 70 months., Results: Hemorrhagic HA occurred in 21% of cases and malignant HA occurred in 8%. Risk of complications was not related to the number of HAs but was associated with size (>5 cm), especially of telangiectatic and unclassified subtypes. Patients with steatotic HA had a low risk of complications. Malignant HA was more frequent in men (43%); all patients treated by partial resection survived, without recurrent malignancy, after a mean follow-up period of 78 months. After 109 patients with benign HA revealed recurrence or progression of HA in 8% and regression in 9% of cases. No complications were observed in 11 women who became pregnant during the follow-up period., Conclusions: Patients with HAs greater than 5 cm, telangiectatic or unclassified subtypes, and men have an increased risk of complicated disease; resection should be restricted to these patients. The risk of complications was not related to the number of HAs, so patients with multiple HAs do not need liver transplantation.

Background/aims: Hepatic cholangiocarcinomas are tumors with poor prognosis and with increasing incidence worldwide. The aim of the study was to compare morphological features and protein profiles of hilar and peripheral cholangiocarcinomas., Methods: Clinicopathological data were collected from 111 cholangiocarcinomas (59 peripheral and 52 hilar). Protein expression, assessed on tissue samples using tissue microarray and protein array technologies, was compared between both types of tumors and with extrahepatic cholangiocarcinoma and hepatocholangiocarcinoma., Results: Hilar cholangiocarcinomas were smaller in size (mean: 2.7 vs. 8 cm, p<0.001), were more often well differentiated adenocarcinomas (65% vs. 36% well differentiated, p<0.01) and carried out stronger perineural invasion (83% vs. 42%, p<0.001) than peripheral cholangiocarcinomas. Regarding protein expression, hilar cholangiocarcinomas more often expressed MUC5AC (62% vs. 22%, p<0.0001), Akt2 (54% vs. 27%, p<0.001), CK8 (98% vs. 81%, p<0.005) and annexin II (92% vs. 66%, p<0.001). Interestingly, VEGF A expression was more frequently encountered in peripheral cholangiocarcinoma (69% vs. 25%, p<0.0001) and correlated with increased vascular density. Using protein array antibody, we identified filamin A as significantly overexpressed (>2-fold) in peripheral cholangiocarcinomas., Conclusions: Our results show that hilar and peripheral cholangiocarcinomas display specific protein profiles, especially regarding VEGF expression. This suggests a potential benefit for anti-angiogenic therapies in peripheral hepatic CCs.

Background: Resection of the rectal primary neoplasm with synchronous liver metastases (LM) is warranted, because this is the only strategy with curative potential. Combined resection remains controversial because of the risk of morbidity and necessity of a curative abdominal approach to warrant liver resection. Laparoscopic colorectal resection may be beneficial and could facilitate this procedure., Methods: Between February 2006 and June 2007, 10 patients underwent 1-step laparoscopic resection for primary rectal cancer combined with open resection of synchronous LM., Results: All patients underwent a laparoscopic mesorectal excision (n = 10). Liver resections included right hepatectomy (n = 1), bi- or trisegmentectomy (n = 3), and metastasectomy (n = 6). The rectosigmoid specimen was extracted through the right subcostal or a short midline incision used for open liver resection, except in 3 patients who underwent a 1-step totally laparoscopic resection of both the colorectal and hepatic neoplasms. The overall morbidity was 40%. The median hospital stay was 12 days (range, 5-40). Overall morbidity (29% vs 40%) and hospital stay (12 vs 12 days) were similar to those observed in a previous cohort of 27 patients undergoing laparoscopic mesorectal excision only., Conclusion: This pilot study suggests that laparoscopic rectal resection with synchronous resection of LM is feasible with low morbidity and short hospital stay. Moreover, laparoscopy facilitates the operation approach for synchronous major hepatectomy.

Scope: Cholangiocarcinoma, or biliary tract tumors, are rare tumors for which survival is short, as diagnosis is often made at an advanced stage. Indeed, diagnosis remains difficult, since symptoms are often unspecific and appear at latest stages. This article presents an update of recent data and therapeutic options., Current Situation and Salient Points: Several etiologic factors have been identified, but for most patients, none of these factors can be found. Prognosis is often poor, and remains difficult to establish because of the lack of sufficient large-scale studies looking at the impact on preexisting tumor characteristics on overall survival. Surgery remains when possible the gold standard. When tumor removal is impossible, due to a local extension, the appropriate care of patients remains to be defined. Chemotherapy has been proposed with evidence of objective response but limited data on its ability to prolong overall survival and to enhance quality of life. Active chemotherapies appear to be made from combination of an antimetabolite, such as 5-fluorouracile or gemcitabine, and a platinum drug., Perspectives: In the near future, indications of chemotherapy could be enlarged and targeted therapy might also be used, since several molecules have been tested in preclinical studies, and be offered to patients in clinical trials.

Background: Postcholecystectomy complex bile duct injuries involving the hilar confluence, which are often associated with vascular injuries and liver atrophy, remain a considerable surgical challenge. The aim of this study is to report our experience of major hepatectomy with long-term outcome in these patients., Methods: From January 1987 to January 2002, 18 patients underwent a major hepatectomy for complex bile duct injuries. The hilar confluence was involved in all cases and was associated with vascular injuries in 13 (72%), including arterial injuries in 11, and partial liver atrophy in 15 (83%). The average time interval between the initial cholecystectomy and hepatectomy was 43 +/- 63 months and 16 (88%) patients had previously undergone an average of 2 (range 1-3) surgical repairs., Results: Major liver resection included a right hepatectomy in 14 (78%) patients, a left hepatectomy in 3, and a left trisectionectomy in one. There was no postoperative mortality, but severe postoperative morbidity was experienced in 11 (61%) patients, including biliary fistula in 7 (39%), prolonged ascites in 8 (44%) and hemorrhage requiring reoperation in one. With a median follow-up time of 8 years (range 3 to 12), 17 (94%) patients have excellent or good results, including 13 patients without symptoms., Conclusion: This study shows that salvage major hepatectomy is an efficient treatment for patients with complex hilar bile duct injuries and should be considered before liver transplantation or recourse to metallic stents.

Background: Aim of this retrospective study was to compare induction of left liver hypertrophy after right portal vein ligation (PVL) and right portal vein embolization (PVE) before right hepatectomy for liver metastases., Materials and Methods: Between 1998 and 2005, 18 patients underwent a PVE, whereas 17 patients underwent a PVL during a first stage laparotomy., Results: There was no complication related to PVE or PVL. After a similar interval time (7 +/- 3 vs 8 +/- 3 weeks), the increase of the left liver volume was similar between the two groups (35 +/- 38 vs 38 +/- 26%). After PVE and PVL, right hepatectomy was performed in 12 and 14 patients, respectively. Technical difficulties during the right hepatectomy were similar according to duration of procedure (6.4 +/- 1 vs 6.7 +/- 1 h, p = 0.7) and transfusion rates (33 vs 28%, p = 0.7). Mortality was nil in both groups, and morbidity rates were respectively 58% for the PVE group and 36% for the PVL group (p = 0.6)., Conclusion: Right PVL and PVE result in a comparable hypertrophy of the left liver. During the first laparotomy of a two-step liver resection, PVL can be efficiently and safely performed.

Unlabelled: In patients with cirrhosis, endotoxic shock is a major complication of portal hypertension, which is related partly to intrahepatic endothelial nitric oxide synthase (eNOS) down-regulation. High-density lipoproteins (HDLs), whose plasma levels are reduced in cirrhosis, have an anti-inflammatory effect by neutralizing circulating lipopolysaccharide (LPS), and they increase eNOS activity in endothelial cells. Therefore, the aim of this study was to assess the effects of reconstituted high-density lipoprotein (rHDL) administration on the LPS-induced proinflammatory response, intrahepatic eNOS regulation, and portal hypertension in cirrhotic rats. Cirrhotic and control rats were pretreated with rHDL or saline and challenged with LPS or saline. The neutralization of LPS in HDL was assessed by the measurement of HDL-bound fluorescent LPS levels. Plasma tumor necrosis factor alpha (TNFalpha) and lipopolysaccharide binding protein (LBP) levels were measured. The expression of hepatic TNFalpha, LBP, inducible nitric oxide synthase (iNOS), and caveolin-1 (a major eNOS inhibitor) and the activity of protein kinase B (Akt; a major eNOS activator) and eNOS were determined. The portal pressure was measured. The plasma HDL levels were significantly lower in cirrhotic rats than in control rats. In cirrhotic rats, the plasma levels of HDL-bound fluorescent LPS were 50% lower than those in controls, and they were restored after rHDL administration. The plasma TNFalpha levels were significantly higher in LPS-challenged cirrhotic rats than in controls and significantly decreased after rHDL administration. rHDL administration decreased hepatic TNFalpha, LBP, iNOS, and caveolin-1 expression, restored hepatic eNOS and Akt activity, and significantly lowered the portal pressure and intrahepatic vascular resistance., Conclusion: In cirrhotic rats, rHDL administration decreases the hepatic proinflammatory signals induced by LPS, restores the hepatic eNOS activity, and lowers the portal pressure. This suggests that the decrease in circulating HDL in cirrhosis plays a role in the excessive proinflammatory response and intrahepatic eNOS down-regulation.

The 1-year spontaneous mortality rate in patients with Budd-Chiari syndrome (BCS) approaches 70%. No prospective assessment of indications and impact on survival of current therapeutic procedures has been performed. We evaluated a therapeutic strategy uniformly applied during the last 8 years in a single referral center. Fifty-one consecutive patients first received anticoagulation and were treated for associated diseases. Symptomatic patients were considered for hepatic vein recanalization; then for transjugular intrahepatic portosystemic shunt (TIPS), and finally for liver transplantation. The absence of a complete response led to the next procedure. Assessment was according to the strategy, whether procedures were technically applicable and successful. At entry, median (range) Child-Pugh score and Clichy prognostic index were 8 (5-12), and 5.4 (3.1-7.7), respectively. A complete response was achieved on medical therapy alone in 9 patients; after recanalization in 6, TIPS in 20, liver transplantation in 9, and retransplantation in 1. Of the 41 patients considered for recanalization, the procedure was not feasible in 27 and technically unsuccessful in 3. Of the 34 patients considered for TIPS, the procedure was considered not feasible in 9 and technically unsuccessful in 4. At 1 year of follow-up, a complete response to TIPS was achieved in 84%. One- and 5-year survival from starting anticoagulation were 96% (95% CI, 90-100) and 89% (95% CI, 79-100), respectively. In conclusion, excellent survival can be achieved in BCS patients when therapeutic procedures are introduced by order of increasing invasiveness, based on the response to previous therapy rather than on the severity of the patient's condition.

Background: Selective transarterial chemoembolization (TACE) and portal vein embolization (PVE) could improve the rate of hypertrophy of the future liver remnant (FLR) in patients with chronic liver disease. This study evaluated the feasibility and efficacy of this combined procedure., Methods: Between November 1998 and October 2004, 36 patients with cirrhosis and hepatocellular carcinoma underwent right hepatectomy after PVE. Additional TACE preceded PVE by 3-4 weeks in 18 patients (TACE+PVE group) and the remaining 18 patients had PVE alone (PVE group)., Results: PVE was well tolerated in all patients. The mean increase in percentage FLR volume was significantly higher in the TACE+PVE group than in the PVE group (mean(s.d.) 12(5) versus 8(4) percent; P=0.022). The rate of hypertrophy was more than 10 percent in 12 patients in the TACE+PVE group and in five who had PVE alone (P=0.044). Duration of surgery, blood loss, incidence of liver failure and mortality (two patients in each group) were similar in the two groups. None of the 17 patients with an increase in FLR volume of more than 10 percent died, whereas there were four deaths among 19 patients with a smaller increase. The incidence of complete tumour necrosis was significantly higher in the TACE+PVE group (15 of 18 versus one of 18; P<0.001), with a higher 5-year disease-free survival rate (37 versus 19 percent; P=0.041)., Conclusion: Sequential TACE and PVE before operation increases the rate of hypertrophy of the FLR and leads to a high rate of complete tumour necrosis associated with longer recurrence-free survival., (Copyright (c) 2006 British Journal of Surgery Society Ltd.)

The spleen plays a central role in the pathophysiology of several potentially severe diseases such as inherited red cell membrane disorders, hemolytic anemias, and malaria. Research on these diseases is hampered by ethical constraints that limit human spleen tissue explorations. We identified a surgical situation--left splenopancreatectomy for benign pancreas tumors--allowing spleen retrieval at no risk for patients. Ex vivo perfusion of retrieved intact spleens for 4 to 6 hours maintained a preserved parenchymal structure, vascular flow, and metabolic activity. Function preservation was assessed by testing the ability of isolated-perfused spleens to retain Plasmodium falciparum-infected erythrocytes preexposed to the antimalarial drug artesunate (Art-iRBCs). More than 95% of Art-iRBCs were cleared from the perfusate in 2 hours. At each transit through isolated-perfused spleens, parasite remnants were removed from 0.2% to 0.23% of Art-iRBCs, a proportion consistent with the 0.02% to 1% pitting rate previously established in artesunate-treated patients. Histologic analysis showed that more than 90% of Art-iRBCs were retained and processed in the red pulp, providing the first direct evidence of a zone-dependent parasite clearance by the human spleen. Human-specific physiologic or pathophysiologic mechanisms involving clearing or processing functions of the spleen can now be experimentally explored in a human tissue context.

In patients with multiple colorectal liver metastases, the technical limits of curative surgery can be overcome by both reducing tumor volume with preoperative chemotherapy and by increasing the future remnant liver with portal vein embolization. Chemotherapy is generally discontinued before the embolization because it is alleged to impair hypertrophy of the future remnant liver. We have tested this assumption by comparing two groups of patients who had undergone right portal vein obstruction: 10 patients in whom chemotherapy was maintained until surgery and 10 patients in whom it was interrupted at least 1 month prior to portal obstruction. The two groups, with and without chemotherapy, were comparable for patient's age (60 +/- 9 versus 61 +/- 9 years), number of metastases (7.7 +/- 3 versus 6.2 +/- 3), and future remnant liver volume (25 +/- 9% versus 23 +/- 5% of the total liver). After right portal vein obstruction, the increase of the future remnant liver was comparable in the two groups (33 +/- 26% versus 25 +/- 7%). Liver resection was performed in 14 patients (7 in each group) with a similar morbidity rate (57% in each group). In conclusion, continuing chemotherapy while portal vein obstruction is performed did not impair the hypertrophy of the future remnant volume nor the postoperative course after liver resection. Therefore, chemotherapy can be safely continued until liver surgery, when portal vein obstruction is indicated.

Background: One of the main concerns after living donor liver transplantation is the risk of morbidity and/or mortality that it imposes on the donors. Respiratory postoperative complications in living liver donors have already been reported but their frequency seems to be underestimated. We designed a prospective study to evaluate the rate and the nature of postoperative pulmonary complications in 112 consecutive donors., Methods: The medical records of the 112 living liver donors operated on at our center from 1998 to 2003 were reviewed and all the cases of respiratory complications were retrieved. Moreover, since 2000, all patients had a computed tomography angiography of the thorax at day 7 on a prospective basis., Results: In all, 112 hepatectomies (44 right and 68 left) for adult-to-adult or adult-to-child liver donation were performed in our center. No postoperative mortality was recorded. Fourteen major respiratory complications developed in of 11 of 112 donors (9.8%), in all cases after right hepatectomy, and included nonsevere pulmonary embolism (n=7), right pleural empyema (n=3), and bacterial pneumonia (n=3). Minor respiratory complications (7.1% of the donors) included iatrogenic pneumothorax (n=3) and pleural effusion requiring thoracocentesis (n=5). Abdominal complications (mainly biliary leak) developed in 10 donors (8.9%), who in the vast majority remained free of pulmonary complications., Conclusions: In our series, pulmonary complications are frequent in living liver donors. These complications are mainly observed after right hepatectomy. The particular prevalence of pulmonary embolism should lead to focus on its early diagnosis and prevention.

Donor risk is the main obstacle in the development of living-donor liver transplantation in Western countries. The knowledge of a wide and uneven range of donor morbidity has come mainly from various retrospective analyses of complications in the literature. Donor outcomes have not been prospectively analyzed. From 1995, the intra- and postoperative courses of 127 living-donor hepatectomies were prospectively analyzed and recorded. All adverse events were classified and stratified according to the extent of surgery, including 45 left-lateral sectionectomies (LLS); 25 left hepatectomies (LH), and 57 right hepatectomies (RH). There was no donor death. The overall rate of significant complications was 20%, ranging from 8% after LH to 32% after RH. The overall incidences of surgical complications, reoperations, and hospital readmissions were 8%, 3%, and 5%, respectively. However, the prospective accumulation of all adverse events revealed an overall postoperative morbidity of 51%, ranging from 32% after LH to 66% after RH. In conclusion the incidence of postoperative adverse events after living donation is nearly 50% as revealed by prospective screening. These results allow more accurate information for potential donors. This study confirms that right hepatectomy carries three times higher risk of morbidity as compared to left-sided resections, leading to reappraisal of the use of left grafts in adults.

Objective: To standardize the definition of postoperative liver failure (PLF) for prediction of early mortality after hepatectomy., Summary Background Data: The definition of PLF is not standardized, making the comparison of innovations in surgical techniques and the timely use of specific therapeutic interventions complex., Methods: Between 1998 and 2002, 775 elective liver resections, including 69% for malignancies and 60% major resections, were included in a prospective database. The nontumorous liver was abnormal in 43% with steatosis >30% in 14%, noncirrhotic fibrosis in 43%, and cirrhosis in 12%. The impact of prothrombin time (PT) <50% and serum bilirubin (SB) >50 micromol/L on postoperative days (POD) 1, 3, 5, and 7 was analyzed., Results: The lowest PT level was observed on postoperative day (POD) 1, while the peak of SB was observed on POD 3. These 2 variables tended to return to preoperative values by POD 5. The median interval between hepatectomy and postoperative death was 15 days (range, 5-39 days). Postoperative mortality significantly increased in patients with PT <50% and SB >50 microml/L. The conjunction of PT <50% and SB >50 micromol/L on POD 5 was a strong predictive factor of mortality. In patients with significant morbidity, this "50-50 criteria" was met 3 to 8 days before clinical evidence of complications., Conclusions: The association of PT <50% and SB >50 microml/L on POD 5 (the 50-50 criteria) was a simple, early, and accurate predictor of more than 50% mortality rate after hepatectomy. This criteria could be identified early enough, before clinical evidence of complications, for specific interventions to be applied in due time.

There are no reports of cholangiocarcinoma complicating post radiotherapy cholangitis. We report the case of a 40 year old patient who had undergone thoracoabdominal radiotherapy for Hodgkin's disease, 22 years ago. This radiotherapy was complicated, many years later, by chronic pancreatitis and cholangitis. Recurrent angiocholangitis led us to schedule a biliodigestive anastomosis. During surgery, cholangiocarcinoma was discovered. The patient died from his carcinoma some months later.

Background: Biliary metallic stents (MS) are being used increasingly to treat patients with malignant bile duct strictures. In patients with benign strictures, MS are contraindicated because these stents are considered unremovable. The aim of this study was to report the operative treatment of patients with benign biliary strictures at the hepatic confluence stented with MS., Methods: Five patients with a benign hilar stenosis stented with MS underwent liver resection with biliodigestive anastomoses. The operations were designed to remove all MS by a combined biliary and hepatic resection., Results: After preoperative portal vein embolization in 2 patients and percutaneous biliary drainage in 2 others, all underwent a major hepatectomy with resection of the biliary confluence and a biliodigestive anastomosis. One patient also underwent resection of the portal vein bifurcation that could not be freed from the bile duct wall. Four patients experienced postoperative complications. With a mean follow-up of 37 months (range, 31-47 months), all patients have remained symptom-free., Conclusions: Operative treatment of benign hilar strictures in patients with MS is possible if they are managed similarly as patients with hilar malignancies. This demanding procedure should be considered an alternative to liver transplantation for benign strictures treated with MS, but the procedure requires expertise in advanced hepatic resections.

Background: During pancreaticoduodenectomy, early neck division may be inadequate, particularly in cases of replaced or accessory right hepatic artery (RHA) or diffuse intraductal papillary and mucinous neoplasm (IPMN) or when invasion of superior mesenteric artery is suspected., Methods: Modification of the technique of pancreaticoduodenectomy with dissection of the superior mesenteric vessels performed from behind the head of the pancreas before any pancreatic or digestive transection. The pancreas is divided later, after adequate mobilization of the specimen from the vessels, on either the neck or the body, according to underlying disease., Results: We used this technique successfully in 20 patients with a replaced or accessory RHA, which was successfully preserved in 19; one patient had inadvertent division of a 2-mm diameter accessory RHA that was ligated with no postoperative complications. Additionally, we used this technique in 18 patients with IPMN-14 pancreaticoduodenectomies extended to the body and 4 total pancreatectomies-and in 3 patients with adenocarcinoma involving the porto-mesenteric confluence and needing en-bloc vascular resection., Conclusions: Early division of retroperitoneal margin is a useful technical variant of pancreaticoduodenectomy, which can be recommended in selective indications to improve safety and radicality of the procedure.

The location of a pseudocyst (PC) in the liver is an exceptional event, and intrahepatic PCs are mainly located in the left lobe. We report here a case of right intrahepatic PC following acute pancreatitis associated with cystic (aberrant pancreatic) dystrophy of the duodenal wall (CDDW) and chronic pancreatitis. Morphological assessment (ultrasound, computed tomography [CT] scan, and cholangio-magnetic resonance imaging [MRI]) revealed a 10-cm right intrahepatic collection and rupture of the main pancreatic duct. Percutaneous puncture permitted us to detect a high level of amylase in the collection, confirming the diagnosis of intrahepatic PC. Surgical drainage concomitant with pancreatico-duodenectomy for the treatment of CDDW resulted in disappearance of the collection. The mechanism involved in this patient was rupture of the pancreatic duct in the retroperitoneal cavity and erosion reaching the right hepatic parenchyma. Although intrahepatic PCs are rare, the diagnosis of intrahepatic PC complicating acute pancreatitis can be confirmed by a high level of amylase in the collection. Asymptomatic intrahepatic PCs can be treated conservatively, and symptomatic intrahepatic PCs can be managed either transcutaneously or surgically.

The split-liver technique is an important means to alleviating donor shortage. Its development is, at least in part, hindered by the risk of biliary complications, particularly when splitting is performed ex situ. We present a simple technique aimed at improving the identification of the biliary anatomy at the hilar level and the safety of the procedure.

Ten percent of patients who undergo resection for hepatocellular carcinoma (HCC) associated with chronic liver disease have no detectable cause for this underlying liver disease. Recent studies have shown that patients with cryptogenic chronic liver disease frequently have risk factors for nonalcoholic fatty liver disease (NAFLD). This study examines the incidence of risk factors for NAFLD in patients with chronic liver disease who underwent resection for HCC. Among 210 patients with chronic liver disease who underwent resection for HCC, 18 (8.6%) had no identifiable cause for the underlying liver disease. These patients were assessed for obesity, diabetes mellitus, and histological features of the tumor and the adjacent liver parenchyma. Comparisons were made with matched patients with alcohol- and chronic-viral-hepatitis-related HCC. The prevalence of obesity (50% vs. 17% vs. 14%), diabetes (56% vs. 17% vs. 11%), aspartate aminotransferase/alanine aminotransferase ratio<1 (50% vs. 19% vs. 17%), and steatosis>20% (61% vs. 17% vs. 19%) was significantly higher in patients with cryptogenic liver disease than in patients with alcohol abuse and chronic viral hepatitis (P<0.0001 for each). Well-differentiated tumors were significantly more common in patients with cryptogenic liver disease (89% vs. 64% in patients with alcohol-related HCC vs. 55% in patients with chronic viral hepatitis-related HCC, P<0.0001). In conclusion, the hypothesis that obesity and diabetes mellitus may be important risk factors for cryptogenic chronic liver disease in patients with HCC is supported by the analysis of surgically treated patients. Whether HCC is primarily related to obesity and diabetes mellitus or secondarily to a NAFLD-like parenchymal lesions remains to be clarified.

The harvesting of the middle hepatic vein (MHV) with a right hepatectomy for living-donor liver transplantation allows an optimal venous drainage for the recipient but can also have adverse effects for the donor. This study compares morbidity, early liver function, and volume regeneration in 2 groups of donors who underwent right hepatectomy with (MHV+, n = 21) or without (MHV-, n = 20) MHV harvesting during 2 successive periods. The operative time was 401 +/- 60 minutes in the MHV+ group compared with 392 +/- 63 minutes in the MHV- group, and the transection time was 152 +/- 53 minutes in the MHV+ group compared with 131 +/- 30 minutes in the MHV- group (not significant). Blood loss in the MHV+ group was 773 +/- 343 mL compared with 613 +/- 361 mL in the MHV- group (not significant). The graft weight and remnant liver volume ratio were similar in the MHV+ and MHV- groups (763 +/- 200 gm vs. 832 +/- 156 gm and 42% +/- 9.5% vs. 43% +/- 8.3%, respectively). Postoperative biologic liver function tests showed that prothrombin time (PT) ratio on postoperative days 1 and 3 were significantly lower in the MHV+ group compared with the MHV- group (53% vs. 65% and 63% vs. 72%, respectively, P <.05). There were no differences in postoperative alanine aminotransferase and aspartate aminotransferase peak levels between the MHV+ and MHV- groups (319 +/- 198 IU /L vs. 310 +/- 110 IU /L and 317 +/- 226 IU /L vs. 296 +/- 125 IU /L, respectively). Bilirubin maximal blood level was similar in the 2 groups (32 +/- 17 micromol/L in the MHV+ group vs. 43 +/- 16 micromol/L in the MHV- group, P <.05). No donor died. The overall morbidity was lower in the MHV+ group compared with the MHV- group (36% vs. 55%; P >.05, not significant). The donor's remnant liver volume regeneration, evaluated by computed tomography (CT) volumetric study on day 7, was similar in the 2 groups (97% +/- 29% in the MHV+ group and 103% +/- 39% in the MHV- group, P >.05). The results of this comparative study show that right hepatectomy with the MHV neither affects morbidity nor impairs early liver function and regeneration in donors.

Objective: To evaluate the feasibility and postoperative course of liver transplantation (LT) in cirrhotic patients who underwent liver resection prior to LT for HCC., Summary Background Data: Although LT provides longer survival than liver resection for treatment of small HCCs, donor shortage and long LT wait time may argue against LT. The feasibility and survival following LT after hepatic resection have not been previously examined., Methods: Between 1991 and 2001, among 107 patients who underwent LT for HCC, 88 met Mazzafero's criteria upon pathologic analysis of the explant. Of these, 70 underwent primary liver transplantation (PLT) and 18 liver resection prior to secondary liver transplantation (SLT) for recurrence (n = 11), deterioration of liver function (n = 4), or high risk for recurrence (n = 3). Perioperative and postoperative factors and long-term survival were compared., Results: Comparison of PLT and SLT groups at the time of LT revealed similar median age (53 vs. 55 years), sex, and etiology of liver disease (alcohol/viral B/C/other). In the SLT group, the mean time between liver resection and listing for LT was 20 months (range 1-84 months). Overall time on LT waiting list of the two groups was similar (3 vs. 5 months). Pathologic analysis after LT revealed similar tumor size (2.2 vs. 2.3 cm) and number (1.6 vs. 1.7). Perioperative and postoperative courses were not different in terms of operative time (551 vs. 530 minutes), blood loss (1191 vs. 1282 mL), transfusion (3 vs. 2 units), ICU (9 vs. 10 days) or hospital stay (32 vs. 31 days), morbidity (51% vs. 56%) or 30-day mortality (5.7% vs. 5.6%). During a median follow-up of 32 months (3 to 158 months), 3 patients recurred after PLT and one after SLT. After transplantation, 3- and 5-year overall survivals were not different between groups (82 vs. 82% and 59 vs. 61%)., Conclusions: In selected patients, liver resection prior to transplantation does not increase the morbidity or impair long-term survival following LT. Therefore, liver resection prior to transplantation can be integrated in the treatment strategy for HCC.

The maximum extent of hepatic resection compatible with a safe postoperative outcome is unknown. The study goal was to determine the incidence and impact of a small remnant liver volume after major liver resection in patients with normal liver parenchyma. Among 265 major hepatectomies performed at our institution (1998 to 2000), 138 patients with normal liver and a remnant liver volume (RLV) systematically calculated from the ratio of RLV to functional liver volume (FLV) were studied. Patients were divided into five groups based on RLV-FLV ratio from /=60%. Kinetics of postoperative liver function tests were correlated with RLV. Postoperative complications were stratified by RLV-FLV ratios. Ninety patients (65%) underwent resection of up to four Couinaud segments. The RLV-FLV ratio was

Objective: To compare the clinical presentation and results of treatment of postcholecystectomy bile duct injuries in patients with and without arterial injuries., Summary Background Data: Incidence and impact of arterial injuries in patients with a postcholecystectomy biliary injury are unknown, although they are claimed to increase the risk of septic complications, difficulty of biliary repair and risk of recurrent stricture., Methods: Fifty-five patients referred for postcholecystectomy biliary strictures and who underwent surgical repair were prospectively evaluated by celiac and superior mesenteric angiography. Circumstance and presenting symptoms of the biliary injury in patients with and without vascular injury as well as intra- and postoperative outcome in the 43 patients who underwent a Hepp-Couinaud biliary repair were compared., Results: Incidence of vascular injury was 47%, the most frequent of which was right-sided hepatic artery disruptions (36%). Indication of cholecystectomy (cholecystitis, 42 vs. 45%), technique of resection (laparoscopy, 80 vs. 79%) as well as delay of recognition and presenting symptom of the biliary injury were comparable in patients with and without vascular injury. Among patients undergoing a biliary repair, the level of the biliary injury (Bismuth's type III or IV 63% vs. 54%), duration of surgery, and incidence of postoperative complications (21 vs. 21%) were also comparable in patients with and without arterial injury. One patient in each group experienced recurrent biliary stricture., Conclusions: The discovery of a disruption of the right branch of the hepatic artery should not affect management of the biliary stricture when if a Hepp-Couinaud repair is performed.

Objective: To assess the impact of liver hypertrophy of the future liver remnant volume (FLR) induced by preoperative portal vein embolization (PVE) on the immediate postoperative complications after a standardized major liver resection., Summary Background Data: PVE is usually indicated when FLR is estimated to be too small for major liver resection. However, few data exist regarding the exact quantification of sufficient minimal functional hepatic volume required to avoid postoperative complications in both patients with or without chronic liver disease., Methods: All consecutive patients in whom an elective right hepatectomy was feasible and who fulfilled the inclusion and exclusion criteria between 1998 and 2000 were assigned to have alternatively either immediate surgery or surgery after PVE. Among 55 patients (25 liver metastases, 2 cholangiocarcinoma, and 28 hepatocellular carcinoma), 28 underwent right hepatectomy after PVE and 27 underwent immediate surgery. Twenty-eight patients had chronic liver disease. FLR and estimated rate of functional future liver remnant (%FFLR) volumes were assessed by computed tomography., Results: The mean increase of FLR and %FFLR 4 to 8 weeks after PVE were respectively 44 +/- 19% and 16 +/- 7% for patients with normal liver and 35 +/- 28% and 9 +/- 3% for those with chronic liver disease. All patients with normal liver and 86% with chronic liver disease experienced hypertrophy after PVE. The postoperative course of patients with normal liver who underwent PVE before right hepatectomy was similar to those with immediate surgery. In contrast, PVE in patients with chronic liver disease significantly decreased the incidence of postoperative complications as well as the intensive care unit stay and total hospital stay after right hepatectomy., Conclusions: Before elective right hepatectomy, the hypertrophy of FLR induced by PVE had no beneficial effect on the postoperative course in patients with normal liver. In contrast, in patients with chronic liver disease, the hypertrophy of the FLR induced by PVE decreased significantly the rate of postoperative complications.