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Acute pancreatitis can complicate non-selective transcatheter arterial embolization of hepatocellular carcinoma with an incidence ranging from 1,7% (acute clinical pancreatitis) to 40% (biological pancreatitis). This complication is thought to be related to embolization of extrahepatic arterial collaterals. We report herein a case of acute clinical pancreatitis developing within 24 hours after a second course of selective transcatheter arterial chemo-embolization into the proper hepatic artery. Neither anatomical arterial variation nor particular risk factor for acute pancreatitis could be identified. This complication is unusual after selective arterial embolization. Because it may clinically mimick a postembolization syndrome, dosage of serum pancreatic enzymes should be performed systematically in case of abdominal pain following chemoembolization.

Control of symptoms due to hormonal secretion is an integral first-step in the management of patients with functional tumours of the pancreatico-duodenal region. Symptomatic drugs should be employed, as well as systemic chemotherapy for nonresectable tumours on the basis of histological differentiation and tumour evolution. Hepatic chemoembolization yields objective response rate of 50%. Surgery however remains the only curative option. Well-differentiated and resectable tumours should be treated by resection, associated with hepatectomy in cases of resectable metastases. Liver transplantation should be reserved for patients with well-differentiated slowly-progressive tumours demonstrating multiple hepatic metastases with a resectable primary in the absence of other metastatic disease. When medical options are inefficacious in the control of hormonal symptoms, cytoreductive surgery can be an effective option.

Hepatolithiasis is uncommon in Western countries and the relationship with cholangiocarcinoma is unusual. We report the association of hepatolithiasis and a cholangiocarcinoma in a Caucasian patient with a 17-year history of recurrent pancreatitis associated with hepatolithiasis. We discuss work-up and surgical treatment, and stress the need to keep in mind the possible association between hepatolithiasis and cholangiocarcinoma even in Western countries.

Emergency liver transplantation is the treatment of choice for the most severe forms of fulminant hepatitis B. Auxiliary liver transplantation is an attractive alternative, offering the possibility of regeneration and discontinuation of immunosuppression. However, the use of auxiliary transplantation for fulminant hepatitis B is controversial because the remnant part of the native liver could be the source of recurrence of HBV infection. We report the results of auxiliary liver transplantation in six patients with fulminant hepatitis B. Postoperatively, all patients received gancyclovir and anti-hepatitis B surface immune globulins. Graft function has been satisfactory in all cases and all patients had rapid neurologic improvement. One patient died with a functional graft because of disseminated aspergillosis on postoperative day 17. The remaining 5 patients are currently alive. The 4 patients with more than 1-year follow-up had complete regeneration of the native liver and are free of immunosuppression. None of these patients had recurrence of hepatitis B. These results suggest that the use of an auxiliary graft is a safe alternative in selected patients with fulminant hepatitis B. Regeneration of the native liver, even if slow, seems to occur in most cases, allowing discontinuation of immunosuppression, which is a major advantage over conventional transplantation. Finally, the remnant part of the native liver does not compromise immunization against HBV.

Objective: Our aim is to evaluate the feasibility, efficacy, and patency of using coronary stents for the treatment of hepatic artery stenosis after liver transplantation., Conclusion: Hepatic artery stenosis after liver transplantation can be treated using coronary stents. The low rate of complication, high technical success, and 1-year patency rates are encouraging.

The use of small caliber arteries is probably responsible for the higher hepatic artery thrombosis rate initially reported after living related liver transplantation. We described a two-step strategy generating flow-induced enlargement of a small diameter artery in case of left graft dual arterial supply. The smaller arterial branch was ligated during a laparoscopic first-step procedure inducing a 30% enlargement of the remaining branch. The second-step donor hepatectomy was performed 1 week later using a larger artery for successful vascular anastomosis. The flow-induced enlargement of donor hepatic artery may help to reduce hepatic artery thrombosis risk after pediatric living related liver transplantation.

Background: The long-term outcome after resection of hepatocellular carcinoma (HCC) is influenced by parameters related to the tumor and the underlying liver disease. However, the extent of the resection, which can be limited or anatomical (including the tumor and its portal territory), is controversial., Methods: Among 64 Child-Pugh A patients with cirrhosis who underwent curative liver resection for small HCC (< or = 4 cm) between 1990 and 1996, 34 patients underwent limited resection with a margin width of at least 1 cm, and 30 patients underwent anatomic resection of at least 1 liver segment with complete removal of the portal area containing the tumor. The 2 groups were comparable in terms of epidemiologic and pathologic parameters. The major end points were: (1) in-hospital mortality and morbidity; (2) overall and disease-free survival; and (3) rate and topography of recurrence., Results: The 30-day mortality (6% vs 7%) and morbidity (52% vs 47%) rates after limited and anatomic liver resection were not statistically different. The 5- and 8-year overall survival rates after limited versus anatomic resection were, respectively, 35% versus 54% (P <.05) and 6% versus 45% (P <.05). The 5- and 8-year disease-free survival rates were, respectively, 26% versus 45% and 0% versus 21% (P <.05). Local recurrence was more frequently observed after limited resections than after anatomic resections (50% vs 10%, P <.05)., Conclusions: In patients with cirrhosis and a small HCC, anatomic resection achieves better disease-free survival than limited resection without increasing the postoperative risk. Therefore, anatomical resection should be the treatment of choice and considered as the reference surgical treatment compared with other treatments.

Optimal safety for donors is a necessary condition for living related liver transplantation to expand. Although the risks for complications directly related to surgical intervention have been carefully evaluated, the extent and nature of other complications, such as pulmonary embolism, associated with living donation have not been clearly anticipated. We report a case of severe pulmonary embolism followed by ulcer-related upper digestive tract bleeding in an adult donor after right hepatectomy. In this donor, we found an unexpected predisposing coagulation disorder (increased von Willebrand factor activity) postoperatively. This finding led us to include systematic screening for coagulation disorders during evaluation of donors, a policy which led us thereafter to reject definitely or temporarily some candidates for donation. Although the cost-effectiveness of such investigations is not definitely established, we strongly recommend a specific approach to improve donor safety. In addition, we emphasize that the major complications observed in living donors should be systematically reported in an international database.

We report two cases of giant hemangioma of the liver revealed by a clinico-biological syndrome including fever, right upper quadrant pain and a biological inflammatory syndrome, whereas liver function tests and blood cell count were normal. This clinical presentation may help in the diagnosis of giant hemangioma of the liver.

Background/aims: Surgical liver resection has been demonstrated in Asian countries to be the best therapeutic option in patients with hepatocellular carcinoma. Because the value of this treatment is still debated in Western countries, the aim of this paper was to report a European experience of resection for hepatocellular carcinoma., Methodology: From 1990 to 1999, 239 men and 61 women aged from 15 to 77 years old underwent 328 resections including major resection in 138 (42%) cases. Normal liver was present in 53 patients (17%) and chronic liver disease was present in 247 including 152 (50%) with cirrhosis., Results: In-hospital mortality was 6.4% and was significantly influenced by the presence of chronic liver disease (1.7% vs. 7.4%). Mortality after resection in alcoholic patients (14%), in patients with hepatitis C (9%) was significantly higher than in patients chronic hepatitis B (1%) (P < 0.05). The overall survival rates were 81%, 57%, 37%, and 13% at 1, 3, 5 and 10 years. Five-year survival rate was significantly higher (P < 0.05) in patients with normal liver as compared to chronic liver disease (50% vs. 34%). In patients with chronic liver disease parameters, which significantly influenced survival rate, were vascular invasion, tumor differentiation and the extent of resection., Conclusions: In this European study with varied profile of etiologies associated with hepatocellular carcinoma we showed that a five-year survival rate of 40% can be expected after resection and that chronic liver disease is a major factor influencing short and long-term prognosis.

Background/purpose: Laparoscopy represents an alternative to open surgery for virtually all digestive surgery procedures, with the anticipated short-term advantage of reduced esthetic prejudice, postoperative pain, and duration of in-hospital stay. In this study, we investigated the safety and benefits of laparoscopic liver resections in patients with benign solid liver tumors., Methods: Laparoscopic liver resection of up to two segments for benign liver tumor was performed under continuous carbon dioxide (CO(2)) pneumoperitoneum in 21 patients with no underlying chronic liver disease. The risk of gas embolism was assessed by end-tidal CO(2) and O(2) saturation, and the hemodynamic variations were monitored by a Swan-Ganz catheter. The postoperative course was compared with that following open surgery by matched-pair analysis., Results: No patient experienced gas embolism or was converted, and clamping of the hepatic pedicle resulted in hemodynamic variations comparable to those observed during open surgery. Duration of surgery (177 vs 156 min.), intraoperative blood loss (218 vs 285 ml), modifications of postoperative liver function tests, and incidence of postoperative complications (10% vs 10%) were comparable to those after open surgery. Laparoscopic resection was associated with a 50% reduction (15.5 vs 31.6 mg) in morphine consumption during the first postoperative days, a reduction of the delay to oral intake of 0.8 days, and a reduction of in-hospital stay of 1.4 days., Conclusions: Liver resections of up to two segments can be performed by laparoscopy using the same technique as that used during open surgery. However, the benefits observed compared with open surgery appear to be limited.

Background/aims: The purpose of this study was to evaluate the results of liver resection in cirrhotic patients for liver hepatocellular carcinoma located near the diaphragm through an exclusive transthoracic approach., Methodology: Between 1995 and 1999, 19 cirrhotic patients with hepatocellular carcinoma underwent a liver resection through an exclusive transthoracic approach. This approach was indicated in 11 cases for previous upper abdominal surgery, including hepatobiliary surgery in 3 and before liver transplantation in 8. Results of the transthoracic approach were compared to 84 cirrhotic patients who underwent transabdominal limited resection of hepatocellular carcinoma matched for age, sex and localization of the tumor., Results: Resection was feasible by an exclusive transthoracic approach in 18 (95%) cases with a mean operating time of 201 +/- 53 min. In 8 (44%) patients a Pringle maneuver was performed. No postoperative deaths were observed after the transthoracic approach. Pulmonary complications rate was significantly higher (P < 0.001) after transthoracic resection compared to transabdominal resection (67% vs. 25%, P < 0.001). In contrast, ascites were observed in only one (5%) of the transthoracic group compared to 35 (42%) in the transabdominal group (P < 0.01). The resection margin was positive in 3 (17%) after transthoracic approch and in 1 (2%) patient after the transabdominal resection (P < 0.02). In patients who underwent liver transplantation after the transthoracic approach, total hepatectomy was performed without increasing difficulties., Conclusions: The transthoracic approach is a safe procedure for resection of hepatocellular carcinoma located under the right diaphragm in cirrhotic patients. However, this approach allows only limited resection with a high risk of positive margin, resulting in a restriction of indications either for patients with previous major abdominal surgery than before liver transplantation.

As promoters of orthotopic liver transplantation (OLT) with preservation of caval flow, we reviewed our 8-year experience to assess the feasibility and limits of this technique. Preservation of caval flow during OLT, which improves intraoperative hemodynamic stability, was not considered feasible in a significant proportion of transplant recipients. When transient clamping of caval flow is required, causes and consequences of this clamping during all phases of the procedure were not reported. Between 1991 and 1998, a total of 275 OLTs using a whole graft were performed in 259 patients with a policy consisting of a systematic attempt to preserve inferior vena cava (IVC) and caval flow. Preservation of IVC flow was possible in all cases, and no procedure was converted to the conventional technique. Caval flow was maintained throughout the procedure in 246 procedures (90%). Temporary IVC cross-clamping was required in 24 cases during hepatectomy because of difficult dissection and in 5 cases after graft reperfusion because of outflow obstruction; none required the use of a venovenous shunt. IVC cross-clamping during hepatectomy was required more frequently in cases of a large liver, with a mean duration of 11 +/- 4 minutes, but without significant influence on early postoperative risk, including one graft failure (4%) and one postoperative death (4%). Conversely, IVC cross-clamping after reperfusion, with a mean duration of 23 +/- 5 minutes, was associated with four graft failures (80%) and four deaths (80%). We conclude that IVC preservation is feasible in almost all candidates, allowing the use of split livers from cadaveric or living donors independently from their underlying disease. Although preservation of caval flow was possible in the large majority of cases, transient IVC cross-clamping during hepatectomy was well tolerated in contrast to caval clamping after graft reperfusion. Therefore, if necessary, we recommend transient IVC cross-clamping to perform a large cavocaval anastomosis.

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.

Background/aims: Because of a potential risk of needle tract seeding, the use of ultrasound (US)-guided biopsy for the diagnosis of hepatocellular carcinoma (HCC) is controversial. This study was aimed at determining the usefulness, accuracy and safety of this technique as well as the incidence of needle tract seeding., Methods: From 1986 to 1996, 137 patients who underwent resection or transplantation for suspected HCC had US-guided biopsy before surgery. The analysis of the resected liver was compared to the results of biopsy. Patients were assessed with a mean follow up of 38 months., Results: The diagnosis of HCC was established by biopsy in 122 patients (89%). Thirteen of the 15 patients with negative biopsy were shown to have HCC after surgery. The remaining two patients had non-malignant nodules. Sensitivity and accuracy of US-guided biopsy were 90 and 91%, respectively. Accuracy was significantly influenced by the location of the nodule but not by its size. Needle tract seeding occurred in two patients (1.6%)., Conclusions: In this series, the incidence of needle tract seeding was less than 2% and no recurrence was observed after local excision. This risk should be balanced with the risk of deciding an aggressive treatment in a patient without malignancy. Patients with negative biopsy should undergo a second biopsy and/or repeated investigations by imaging techniques.

Background: Because the influence of age on the risk of liver resection is controversial, the outcome of major liver resection in patients older than 65 years was evaluated., Methods: Between 1990 and 1997, 24 patients aged 65 years or more underwent elective right hepatectomy (segments V-VIII) for a malignant liver tumour arising in a normal liver. They were evaluated retrospectively in terms of operative deaths, morbidity and postoperative liver function, and compared with 22 patients aged 40 years or less who had undergone a similar resection during the same interval., Results: Elective right hepatectomy in patients aged 65 years or more resulted in a similar number of deaths (one versus none) and a similar severe complication rate (12 versus 5 per cent) to that observed in patients aged 40 years or less. Evaluation of liver function on days 2, 5 and 8 after operation, in patients aged 65 years or more and 40 years or less, showed that mean prothrombin time was 52 versus 56 per cent, 58 versus 62 per cent and 76 versus 72 per cent respectively (P not significant) and that the mean total serum bilirubin level was 35 versus 38 micromol/l, 32 versus 36 micromol/l and 25 versus 28 micromol/l (P not significant). Postoperative levels of aminotransferases, gamma-glutamyl transpeptidase and alkaline phosphatase were similar in the two groups. Mean(s.d.) duration of hospital stay was 15(7) days in patients aged 65 years or more and 13(4) days in the younger patients., Conclusion: Postoperative liver function after elective right hepatectomy in selected patients older than 65 years was similar to that in younger patients.

Background/aims: 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., Methodology: 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., Results: 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., Conclusions: 5-FU based systemic chemotherapy does not increase the risk of liver resections.

Background: 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., Study Design: 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., Results: 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 (p < 0.001). 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%; p < 0.001). 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., Conclusions: 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.

Background: Modifications of the in situ split liver technique are needed for safe transplantation in two adult recipients with a single donor., Methods: The graft from a brain-dead donor, 187 cm tall and weighing 89 kg, was split in situ with a transection performed along the main portal fissure retaining the middle hepatic vein with the left graft. The right and left grafts, which weighed 985 and 760 g, respectively, were transplanted in two adult recipients weighing 70 and 56 kg, respectively., Results: Both recipients had minor intraoperative blood loss and were discharged from intensive care on day 3. Both grafts were rapidly functional, and the two patients were in excellent condition with normal liver function tests 9 months after surgery., Conclusion: In situ split liver transplantation can be performed with the middle hepatic vein retained in the left graft to obtain a sufficient volume of the two grafts suitable for two adult recipients. This modification of the technique could expand the donor pool for adult recipients.

Background/aims: Most hepatocellular carcinomas are still discovered at an advanced stage and are left untreated as large hepatocellular carcinomas are contraindications to liver transplantation and percutaneous ethanol injection and are usually considered as poor indications for liver resection. The aim of this study was to reassess the results of surgery in these patients., Methods: Between 1984 and 1996, 256 patients underwent resection of biopsy-proven, non-fibrolamellar hepatocellular carcinoma. Of these, 121 had a tumour diameter of less than 5 cm (small hepatocellular carcinomas) and 94 a tumour diameter of more than 8 cm (large hepatocellular carcinomas). The short- and long-term outcome of patients with small and large hepatocellular carcinomas were compared., Results: The in-hospital mortality rate following resection of small and large hepatocellular carcinomas was comparable (11.5 vs. 10.6%), even after stratifying for the presence and severity of an underlying liver disease. In patients with a chronic liver disease, large hepatocellular carcinomas were associated with a greater risk of death and recurrence during the first 2 operative years. In the long term, however (3-5 years), survival and disease-free survival following resection of small and large hepatocellular carcinomas were comparable (34 vs. 31% and 25 vs. 21% at 5 years). Similarly, treatment of and survival after the onset of recurrence were not influenced by the size of the initial tumour., Conclusions: Patients with large hepatocellular carcinomas should not be abandoned and should be considered for liver resection as this treatment may be associated with an in-hospital mortality rate and a long-term survival comparable to that observed after resection of small hepatocellular carcinomas.

Background: Clinical or biological evidence of liver failure is usually considered a contraindication to open liver surgery as it is associated with a prohibitive risk of postoperative death., Methods: This report describes three patients who had resection of a superficial hepatocellular carcinoma suspected either to be ruptured, or at high risk of rupture, using the laparoscopic approach. All three patients had intractable ascites, in two superimposed on active hepatitis. Surgery was per- formed under continuous carbon dioxide pneumoperitoneum with intermittent clamping of the hepatic pedicle., Results: Intraoperative blood loss was between 100 and 400 ml; no blood transfusion was required. The postoperative course was uneventful except for a transient leak of ascites through the trocar wounds. Duration of in-hospital stay was 6-10 days. Liver function tests had returned to preoperative values within 1 month of surgery in all patients., Conclusion: The laparoscopic approach may enable liver resection in patients with cirrhosis and evidence of liver failure that would contraindicate open surgery.

Objectives: Liver transplantation with living related donor has been recently developed to compensate for the insufficient number of liver grafts for children. The major problem is ethical because it implies voluntary mutilation of a healthy person. This paper report results in 37 living related donors., Patients: Recipients were followed in Enfants-Malades Hospital. Investigations and donor surgery were performed at the Digestive Surgery Unit of Beaujon Hospital., Results: One donor was re-operated for bleeding, and another one a biliary fistula treated with percutaneous drainage for one week. The post-operative course was uneventful in the other donors, with a follow-up of between 2 and 50 months. Thirty-three children are alive (90%), one of them underwent a second transplant for arterial thrombosis. Vascular and infectious complications, and the number of rejection episodes were the same as in transplantations with a deceased donor. Biliary complications were frequent (15 patients out of 37) and significantly increased morbidity. A teenage boy who received a small graft (0.9% of his weight) presented initially with hepatic insufficiency without encephalopathy., Conclusion: This technique has been shown to have a good balance between benefits and risks. Our experience confirms this, especially in very young children. Each case should be discussed individually and parental consent should be obtained without external pressure. Experience with this technique should be continued and at the same time the use of cadaveric grafts should be optimized.

Purpose: The aim of the authors was to report their experience with living related liver transplantation (LRLT) in children, particularly focusing on the safety of the two-center "Parisian" strategy., Methods: The records of donors and recipients of 26 pediatric living-related donor liver transplantations performed between November 1994 and March 1998 were reviewed retrospectively. Donors were assessed 1 year after transplantation for medical and overall status., Results: Indications for LRLT included biliary atresia (n = 18), Byler's disease (n = 5), alpha-1-antitrypsin deficiency (n = 1), Alagille syndrome (n = 1), and undefined cirrhosis (n = 1). Liver harvesting consisted of either a complete left hepatectomy (n = 14) or left lateral hepatectomy (n = 12) without vascular clamping. The recipient procedure essentially was the same as in split liver transplantation. Mean overall cold ischemia time averaged 140 minutes (range, 90 to 230 minutes). Twenty-four of 26 patients had end-to-end vascular anastomoses without interposition. Biliary reconstruction consisted of a Roux-en-Y choledochojejunostomy in all patients. All recipients except one received cyclosporine A (CSA). Mean donor hospitalization was 8 days (range, 6 to 13) with normalization of all liver function assays by the time of discharge. There were no donor deaths and two postoperative complications (perihepatic fluid collection and bleeding from the wound). One year after donation, the initial 19 donors had resumed their pretransplant status. Two of the children who underwent transplant died. Thirteen of the recipients required reoperation for hepatic artery thrombosis (n = 2), portal vein thrombosis (n = 2), biliary complications (n = 6), fluid collection (n = 3), small bowel perforation (n = 1), and plication for diaphragmatic eventration (n = 1). With mean follow-up of 2 years, 24 of 26 patients are alive and well (patient and graft survival rate, 92%)., Conclusions: LRLT is still controversial, even with minimal and decreasing donor risk. The "Parisian" strategy consists of harvesting the liver in an adult unit by an adult hepatic surgery team. The transplantation is then performed in a pediatric hospital by the pediatric liver transplantation team. The two steps of the procedure allow units specialized in adult surgery, on one hand, and pediatric liver transplantation, on the other hand, to dedicate themselves completely to their respective procedures, improving the safety of the harvest, and alleviating stress for both the medical staff and the families.

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.

Objective: The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC)., Summary Background Data: Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma., Methods: Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma., Results: The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group., Conclusions: This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.

Background: The spleen may be preserved during distal pancreatectomy (DP) for benign disease. The aim of this retrospective study was to compare the postoperative course of DP with or without splenectomy., Study Design: From June 1992 to June 1997, 40 adult patients without chronic pancreatitis underwent elective DP for benign lesions. Fifteen underwent spleen-preserving DP (Conservative Group) and 25 DP with splenectomy (Splenectomy Group). In spleen-preserving DP, we attempted to preserve the splenic artery and vein., Results: Spleen-preserving DP was successfully performed in all 15 cases. Patient groups were comparable for clinical features, indication for DP, and surgical procedure. There were no postoperative deaths. The overall incidence of pancreatic fistula was 23%, but was significantly higher in the Conservative Group (40%) than in the Splenectomy Group (12%; p < 0.05). Subphrenic abscesses were more frequently observed in the Conservative Group than in the Splenectomy Group (p < 0.05). The mean duration of postoperative hospital stay was 19 days (range 6 to 46 days) in the Conservative Group and 12.5 days (range 7 to 45 days) in the Splenectomy Group (p < 0.05). At the end of mean followup of 30 months (range 8 to 40 months), no severe postsplenectomy sepsis was observed in the Splenectomy Group., Conclusions: In our experience, DP with splenectomy has a lower morbidity rate and we consider it to be the best procedure for benign pancreatic disease.

Background: Lipiodolized chemoembolization of hepatocellular carcinoma (HCC) can induce fever and cytolysis, defined as an increase in serum levels of liver transaminases, which is frequently assumed to result from tumour necrosis. This study aimed to assess the causes of this syndrome, reviewing preoperative data, intraoperative findings, tumour necrosis and the status of non-tumorous liver., Methods: A retrospective study was undertaken of 29 patients treated by neoadjuvant lipiodolized chemoembolization before surgical resection of HCC. Tumour necrosis was assessed in the resected specimen and scored in four stages: absent, 50 per cent or less, more than 50 per cent, and complete. The status of non-tumorous liver parenchyma was classified as either fibrotic or cirrhotic., Results: Cytolysis occurred following chemoembolization in 16 patients and was associated with fever in 11. Postchemoembolization cytolysis with or without fever was more likely to develop in patients with minor fibrotic changes than in those with cirrhosis (14 of 21 with fibrosis versus two of four with cirrhosis, P < 0.05). In contrast, the extent of tumour necrosis did not correlate with the occurrence of symptoms., Conclusion: These results suggest that fever and cytolysis following chemoembolization of HCC are an indication not of tumour necrosis but of injury to the non-tumorous liver.

Objective: To explore the relation of patient age, status of liver parenchyma, presence of markers of active hepatitis, and blood loss to subsequent death and complications in patients undergoing a similar major hepatectomy for the same disease using a standardized technique., Summary Background Data: Major liver resection carries a high risk of postoperative liver failure in patients with chronic liver disease. However, this underlying liver disease may comprise a wide range of pathologic changes that have, in the past, not been well defined., Methods: The nontumorous liver of 55 patients undergoing a right hepatectomy for hepatocellular carcinoma was classified according to a semiquantitative grading of fibrosis. The authors analyzed the influence of this pathologic feature and of other preoperative variables on the risk of postoperative death and complications., Results: Serum bilirubin and prothrombin time increased on postoperative day 1, and their speed of recovery was influenced by the severity of fibrosis. Incidence of death from liver failure was 32% in patients with grade 4 fibrosis (cirrhosis) and 0% in patients with grade 0 to 3 fibrosis. The preoperative serum aspartate transaminase (ASAT) level ranged from 68 to 207 IU/l in patients with cirrhosis who died, compared with 20 to 62 in patients with cirrhosis who survived., Conclusion: A major liver resection such as a right hepatectomy may be safely performed in patients with underlying liver disease, provided no additional risk factors are present. Patients with a preoperative increase in ASAT should undergo a liver biopsy to rule out the presence of grade 4 fibrosis, which should contraindicate this resection.

Background/aims: After liver transplantation for 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.

We analyzed the results of an aggressive surgical approach to intrahepatic cholangiocarcinoma. Between 1990 and 1997, 30 of 42 patients with intrahepatic cholangiocarcinoma underwent resection with curative intent. Mean tumor size was 10 +/- 5 cm, and the tumors were classified as TNM type III, IVa, and IVb in 63%, 34%, and 3% of the patients, respectively. All patients underwent hepaticoduodenal lymphadenectomy. Fifteen patients received adjuvant radio- and chemotherapy. The overall survival rates at 1, 2, and 3 years were 86%, 63%, and 22%, respectively, and the median survival time was 28 months. Tumor recurrence was the main cause of death. Three patients survived for more than 5 years, including 2 patients with no evidence of recurrence. Factors influencing survival were: presence of satellite nodules (P = 0.007) and lymph node invasion (P = 0.05). The width of the resection margin and the use of an adjuvant therapy had no impact on survival. Complete surgical resection may offer a chance for long-term survival in selected patients and may improve the quality of life of patients with more advanced disease.

The technical factors which could influence regeneration of the native liver (NL) in auxiliary liver transplantation (ALT) for fulminant hepatic failure (FHF) are not well known. We studied NL regeneration according to the location of graft anastomosis in the recipient's portal system (superior mesenteric vein versus portal vein), and graft weight (50% reduced-size versus full-size graft) in a rat model of ALT with 80% reduction of the NL, and graft arterialization. NL regeneration was significantly more obvious when the graft was anastomosed on the recipient's superior mesenteric vein, thus establishing venous flow to the NL from the pancreas, the spleen, and the stomach, and when a full-size graft was used. The influence of portal venous flow on NL regeneration, assessed by 3H[-thymidine incorporation, was measurable as early as day 2. Both technical variables in combination resulted in significantly greater regeneration (ratio weight of NL/body weight at day 30: 2.32 +/- 0.68% versus 1.21 +/- 0.63% respectively, P = 0.02). Early preservation of portal flow to the NL is advisable to maximize NL regeneration in ALT. In any case, this regeneration is not impeded by the use of large auxiliary grafts.

Background: The management of chylothorax complicating oesophagectomy remains controversial. Even if medical management alone can be successful, some authors advocate early reoperation. The aim of this retrospective study was to identify the clinical variables associated with a high probability of full recovery with medical treatment., Methods: Among 850 Lewis procedures performed for oesophageal carcinoma, 23 patients (2.7 per cent) developed postoperative chylothorax despite systematic preventive ligation of the main thoracic duct. Patients who responded to conservative management were compared with those requiring reoperation for preoperative radiotherapy, unilateral versus bilateral pleural effusion, delay of occurrence of the chylothorax, and ratio of mean chylous output to body-weight 1 and 5 days after its onset., Results: Conservative management was successful in 14 patients with a mean(s.d.) delay of 12(5) (range 7-21) days and there were no hospital deaths. Reoperation was necessary in nine patients; there were two postoperative deaths and no recurrence of the chylothorax. The only significant difference between reoperated and medically treated patients was the mean(s.d.) chylous output at day 5: 23.5(16.6) versus 6.7(5.5) ml per kg body-weight (P< 0.001). At this time, the output was less than 10 ml/kg in 12 of 14 patients in whom medical treatment was successful (sensitivity 86 per cent), and equal to or greater than this cut-off value in all the patients who underwent reoperation (specificity 100 per cent)., Conclusion: The ratio of chylous output to body-weight on the fifth day after the onset of a chylothorax complicating oesophagectomy seems to reliably predict the success of continuing medical treatment.

Background: Liver resection of hepatocellular carcinoma (HCC) is associated with a high incidence of recurrence, that has a poor prognosis., Aim: Assess the rationale for and result of an aggressive treatment of recurrence following resection of HCC., Methodology: 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., Results: 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., Conclusion: An aggressive approach to tumor recurrence is currently the best way to improve the long term outcome following resection of HCC.

Objective: To assess the efficacy and adverse effects of preoperative transcatheter chemoembolization (CE) on surgical resection, postoperative outcome, and recurrence of hepatocellular carcinoma., Design: A before-after trial comparing a group of patients undergoing liver resection after CE (CE group) with a group of patients undergoing liver resection without prior CE (control group), matched for tumor size and underlying liver disease., Setting: A tertiary care university hospital in a metropolitan area., Patients: Twenty-four patients in each group, treated between 1986 and 1992., Interventions: A mean of 1.6+/-0.2 preoperative CE procedures were performed per patient in the CE group. Tumorectomies, segmentectomies, and major liver resections were performed with a comparable frequency in each group., Results: Overall, CE was not associated with a significant reduction of tumor size (7.8+/-1 cm prior to CE vs 7.1+/-1 cm after CE) or alpha-fetoprotein levels (2560+/-2091 microg/L prior to CE vs 1788+/-1270 microg/L after the last CE). Chemoembolization promoted tumor necrosis but did not influence tumor encapsulation, invasion of the capsule, venous permeation, presence of daughter nodules, or surgical margins. Liver resection was rendered more difficult by preoperative CE as a result of pediculitis and gallbladder lesions in 37% of patients, but the postoperative course was not altered. Disease-free survival (33%+/-12% vs 32%+/-12% at 3 years) and overall survival were comparable., Conclusions: Convincing evidence is lacking to support systematic preoperative CE in patients with initially resectable hepatocellular carcinoma. Further studies should aim to identify the subgroup of patients who may benefit from this neoadjuvant treatment.

Background: Recurrence of primary biliary cirrhosis (PBC) within liver allografts remains a controversial issue. The aims of this study were to evaluate this risk and to determine the presence, if any, of a predictive histological feature., Methods: We reviewed the most recent and the 1-year protocol liver biopsies of 69 patients who received transplants for PBC and of 53 control patients. Histological features consistent with PBC recurrence included nonsuppurative destructive cholangitis, mixed portal infiltrate, fibrosis, and ductopenia. A complete evaluation was undertaken in each patient with these histological features., Results: These histological features were present in six patients who received transplants for PBC (8.7% vs. 0% in the control group) and occurred between 1 and 8 years after transplant. In five of the six patients, anti-mitochondrial antibody-2 (anti-M2) antibodies remained at high titers. Cholestasis was present in four patients, and clinical symptoms in two patients. All six patients were negative for hepatitis C antibodies and hepatitis C RNA in their serum. None had bile duct obstruction. The presence of plasma cells in the portal infiltrate at 1 year after transplant was predictive of this risk of recurrence., Conclusion: The risk of PBC recurrence is real (8.7%). The presence of plasma cells in the portal infiltrate seems to be an early marker of recurrence of PBC in patients transplanted for this indication.

Background: 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., Methods: 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., Results: 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., Conclusions: 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.

Background: The aim of this study was to analyze the humoral immune response associated with orthotopic liver transplantation in the rat liver transplant model, and in particular to test the presence of anti-tissue antibodies., Methods: Rearterialized liver transplantations were performed in the Dark Agouti (DA)-to-Lewis (LEW) and the LEW-to-DA rat strain combinations. Sera of recipients were analyzed by immunofluorescence (on DA and LEW organ sections) and by western blotting (with DA and LEW liver proteins)., Results: We have shown that liver (but not heart or skin) recipients develop a humoral response against non-MHC tissue antigens as evidenced (1) by a pattern of staining comparable to that described in human patients harboring anti-smooth muscle antibodies and (2) by the presence of donor liver peptides recognized in the sera of the recipient by Western blotting., Conclusions: These experiments indicate that orthotopic transplantation of a nonacutely rejected liver allograft is associated with the development of a previously undescribed anti-tissue antibody response that seems to be neither organ nor MHC restricted.

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.

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.

Prevention of intraoperative blood loss during liver resection is an essential prognostic factor for reducing postoperative morbidity and mortality. Several procedures are currently available to ensure vascular occlusion, ranging from selective clamping of a segmental pedicle to total hepatic vascular occlusion. The type of vascular occlusion should be selected according to the indication and, in particular, according to the site of the tumor, presence of associated underlying liver disease, the patient's cardiovascular status, and the experience of the operator. The surgical strategy should be defined with the anesthesiologist and the type of hemodynamic monitoring selected should allow the best choice for management and prevention of complications such as bleeding and air embolism. Transesophageal echocardiography seems to be a new and promising method in this setting.

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.

Despite careful selection of cirrhotic patients with hepatocellular carcinoma (HCC), liver resection remains associated with a greater risk than in patients without underlying liver disease. In this study we assessed by multivariate analysis parameters associated with in-hospital mortality and morbidity in a selected group of 108 Child-Pugh A cirrhotic patients undergoing liver resection of HCC. The overall incidences of in-hospital deaths and postoperative complications were 8.3% and 48.1%, respectively. By univariate analysis, the preoperative serum alanine transferase (ALT) level (p = 0.001) and intraoperative transfusions (p = 0.01) were significantly associated with in-hospital death; however, only the serum ALT concentration was an independent risk factor. In-hospital mortality rates in patients whose serum ALT was below 2N (twofold the upper limit of the normal value), between 2N and 4N, and more than 4N were 3.9%, 13.0%, and 37.5%, respectively. An ALT level greater than 2N was predominantly observed in patients with a hepatitis C virus infection and significantly associated with histologic features of superimposed active hepatitis. Patients with an ALT level greater than 2N experienced an increased incidence of postoperative ascites (58% versus 32%, p = 0.01), kidney failure (16% versus 0%, p = 0.0003), and upper gastrointestinal bleeding (6.4% versus 0%, p = 0.02). These results indicate that the preoperative ALT level is a reliable predictor of in-hospital mortality and morbidity following liver resection in Child-Pugh A cirrhotic patients. Cirrhotic patients with ALT > 2N should undergo only a limited resection; if a larger resection is required, those patients should be considered for nonsurgical therapy or liver transplantation.