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Background Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL. Methods In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated. Results A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P < 0·001; 15 versus 3·1 per cent in the validation cohort, P < 0·001). Conclusion The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.

Background The impact of morbidity on long-term outcomes following liver resection for intrahepatic cholangiocarcinoma is currently unclear. Methods This was a retrospective analysis of all consecutive patients who underwent liver resection for intrahepatic cholangiocarcinoma with curative intent in 24 university hospitals between 1989 and 2009. Severe morbidity was defined as any complication of Dindo–Clavien grade III or IV. Patients with severe morbidity were compared with those without in terms of demographics, pathology, management, morbidity, overall survival, disease-free survival and time to recurrence. Independent predictors of severe morbidity were identified by multivariable analysis. Results A total of 522 patients were enrolled. Severe morbidity occurred in 113 patients (21·6 per cent) and was an independent predictor of overall survival (hazard ratio 1·64, 95 per cent c.i. 1·21 to 2·23), as were age at resection, multifocal disease, positive lymph node status and R0 resection margin. Severe morbidity did not emerge as an independent predictor of disease-free survival. Independent predictors of time to recurrence included severe morbidity, tumour size, multifocal disease, vascular invasion and R0 resection margin. Major hepatectomy and intraoperative transfusion were independent predictors of severe morbidity. Conclusion Severe morbidity adversely affects overall survival following liver resection for intrahepatic cholangiocarcinoma.

Background The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease. Methods Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics. Results Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017). Conclusion NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

Background Major oncologic surgery is associated with a high incidence of venous thromboembolic events (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE). However, the incidence and risk factors for symptomatic VTE during curative treatment for patients with esophageal cancer are poorly documented. Methods Data were collected from 30 European centers from 2000 to 2010. The incidence of in-hospital VTE was assessed in 2,944 patients with esophageal cancer having surgery with curative intent, and 50 clinically relevant parameters were assessed as potential risk factors for VTE. Patients received low molecular weight heparin prophylaxis during hospital stay and for 4 weeks after surgery. Results Eighty-four patients (2.9%) developed a symptomatic VTE; all of them had a DVT and 44 were also diagnosed with a PE. In the VTE group there were 19 postoperative deaths recorded, 5 of which (26.3%) were directly caused by PE at postoperative days 7, 10, 21, 45, and 48 despite VTE prophylaxis. In-hospital postoperative mortality was significantly higher in VTE patients (23% versus 7%, p 0.001) and mean hospital stay was also longer in this group (33 ± 24 versus 25 ± 21 days, p 0.001). Multivariable analysis showed that high American Society of Anesthesiologists (ASA) class ( p = 0.008), pneumopathy ( p = 0.002), or an acute respiratory distress syndrome (ARDS) ( p = 0.015) were significantly associated with VTE. Conclusions Patients with ASA class III or IV and those who present a postoperative pneumopathy or ARDS seem to be at higher risk for VTE. Thus, current VTE screening and thromboprophylaxis for these patients might be inadequate and needs further investigation.

Background Clinical pharmacists can help prevent medication errors. However, data are scarce on their role in preventing medication prescription errors in the post-operative period, a high-risk period, as at least two prescribers can intervene, the surgeon and the anesthetist. We aimed to describe and quantify clinical pharmacist' intervention (PIs) during validation of drug prescriptions on a computerized physician order entry system in a post-surgical and post-transplantation ward. We illustrate these interventions, focusing on one clearly identified recurrent problem. Methods In a prospective study lasting 4 years, we recorded drug-related problems (DRPs) detected by pharmacists and whether the physician accepted the PI when prescription modification was suggested. Results Among 7005 orders, 1975 DRPs were detected. The frequency of PIs remained constant throughout the study period, with 921 PIs (47%) accepted, 383 (19%) refused and 671 (34%) not assessable. The most frequent DRP concerned improper administration mode (26%), drug interactions (21%) and overdosage (20%). These resulted in a change in the method of administration (25%), dose adjustment (24%) and drug discontinuation (23%) with 307 drugs being concerned by at least one PI. Paracetamol was involved in 26% of overdosage PIs. Erythromycin as prokinetic agent, presented a recurrent risk of potentially severe drug–drug interactions especially with other QT interval-prolonging drugs. Following an educational seminar targeting this problem, the rate of acceptation of PI concerning this DRP increased. Conclusion Pharmacists detected many prescription errors that may have clinical implications and could be the basis for educational measures.

Radiofrequency ablation, partial or total hepatectomy represent curative treatment options for patients suffering from hepatocellular carcinoma in 2010. In this review article, the role (indication, limits, results) of hepatic resection and liver transplantation are discussed.

We conducted a study to evaluate the efficacy of pegylated interferon/ribavirin in patients who did not respond to previous posttransplant recurrent HCV treatment with IFN/ribavirin combination. Twenty-seven patients were consecutively included in this study and retreated with pegylated interferon alfa-2b (1.5 microg/kg/week) with ribavirin (800-1000 mg daily) for 48 weeks for genotype 1 and 4 and 24 weeks for other genotypes. We compared them with 21 untreated patients enrolled during the same period. Primary endpoint was the SVR and secondary endpoint was histological evaluation 24 weeks after ending therapy. Twenty-seven patients started therapy but 2 (7%) stopped because of side effects. On an intent-to-treat basis, eight patients (30%) had an SVR. Cyclosporine as immunosuppressive therapy during antiviral therapy (p = 0.03) and EVR (p = 0.02) were significantly associated with viral clearance. In 46 patients in whom paired graft biopsies were available, fibrosis score was improved in 76% of treated patients versus 5% in untreated patients. Among treated patients, improvement of fibrosis was not correlated to SVR. Our data show that 30% of patients who have failed prior posttransplantation treatment achieved an SVR when retreated with pegylated interferon alfa-2b/ribavirin. More interesting is that fibrosis score was improved in 65% of treated patients despite failure of HCV eradication.

Gastrojejunocolic fistulae, ultimate complication of anastomotic peptic ulceration, are presently uncommon. We report two recent cases of postoperative gastrojejunocolic fistulas (after duodenal ulcer surgery and total duodenopancreatectomy), which were complicated at time of diagnosis (acute peritonitis and liver cirrhosis) and required a two-stage treatment.

Resume Objectif. – Rapporter une serie de 17 patients operes pour une complication d'œsophagoplastie colique, en evaluant les modalites therapeutiques et les resultats immediats et a distance. Patients et methodes. – De 1985 a 2003, 17 patients d'âge moyen 50 ans (extremes : 23–76) ont ete reoperes pour une complication apres coloplastie pediculise sur les vaisseaux coliques superieurs gauches. La pathologie initiale etait une ingestion de caustique (n = 7), un cancer (n = 6), une perforation de l'œsophage (n = 2), un lymphome gastrique (n = 1) et une fistule œsotracheale (n = 1). La coloplastie avait ete realisee 13 fois de premiere intention et quatre fois de deuxieme intention apres echec d'un premier montage. Neuf patients ont ete operes initialement dans un autre service et nous ont ete adresses secondairement. Les indications de reintervention etaient : une necrose de la coloplastie dans huit cas (47 %) ou une stenose dans neuf cas (53 %). Toutes les necroses ont ete reoperees dans les dix jours postoperatoires. Resultats. – Les necroses ont ete traitees par ablation partielle (n = 5) ou totale (n = 3) de la coloplastie. Les stenoses ont ete traitees par resection–anastomose (n = 3), coloplastie droite (n = 2), plastie colique d'elargissement (n = 2), lambeau libre antebrachial (n = 1) et lambeau tubulise de grand dorsal (n = 1). La mortalite au 30e jour postoperatoire a ete de 12 % (n = 2) et la morbidite de 66 %. Les deces n'ont concerne que des patients reoperes pour necrose. Onze patients (65 %) ont garde ou recupere la continuite digestive (dont les 9 patients operes pour stenose) et huit (73 %) mangent normalement. Quatre patients operes pour necrose sont decedes avant retablissement de la continuite et deux patients sont en attente de retablissement. Conclusion. – Le choix du colon comme substitut œsophagien n'est pas denue de risque. Si les reinterventions pour stenose permettent aux patients de reprendre une alimentation normale, les reinterventions pour necrose sont grevees d'une mortalite elevee et d'un faible taux de retablissement secondaire de la continuite digestive. La restauration de la continuite digestive necessite un eventail d'interventions complexes.

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.

Objectif de l’etude A cote des traitements de reference (chirurgie, radiofrequence), la radiotherapie induit desormais un taux de sterilisation de 90 % des lesions de moins de 5 cm, et d’environ 80 % des lesions de plus 5 cm, justifiant une comparaison therapeutique. Materiel et methode Les dossiers de patients atteints d’un carcinome hepatocellulaire unifocal traite par chemoembolisation (TACE) et irradiation si les patients etaient ineligibles a un traitement de reference, par comparaison a ceux traites par chirurgie, ont ete analyses retrospectivement (analyse statistique : test de Student, analyse uni- et multifactorielle). Resultats Cent-soixante-dix-huit dossiers ont ete analyses, 68 associations de radiotherapie et chemoembolisation et 110 chirurgies, chez 78 % d’hommes, d’âge moyen 66 ans (39–89 ans), atteints d’une cirrhose hepatique sous-jacente pour 52 %, d’une tumeur de taille moyenne de 50 mm (16–220 mm), de moins de 50 mm pour 103, avec une duree moyenne du suivi 33 mois. Le taux de reponse complete apres l’association de radiotherapie et chemoembolisation etait de 92 % si la lesion etait de moins de 5 cm contre 80 % sinon. En cas de lesion de moins de 5 cm, l’âge moyen etait comparable, la cirrhose hepatique plus frequente si le patient recevait une association de radiotherapie et chemoembolisation (p Conclusion L’analyse de cette cohorte de 178 patients atteints d’un carcinome hepatocellulaire unifocal de score Child A a montre que le taux de reponse complete apres l’associations de radiotherapie et chemoembolisation etait eleve. Quelle que soit la taille de la lesion, il n’y avait aucune difference en analyse multifactorielle entre les deux traitements. Ces resultats justifient la mise en place d’un essai randomise comparant l’association de radiotherapie et chemoembolisation et la resection chirurgicale, pour tous les patients, particulierement en cas de tumeur unique de plus de 5 cm.

Summary Background The objective of this study was to gain detailed insight concerning liver transplanted patients’ representations about transplantation, graft rejection and immunosuppressive drugs to adapt the educational follow-up. Patients and methods Semi-structured interviews were conducted with 8 patients. Each interview was recorded and fully transcribed. The verbatim was first coded according to the themes of the Common Sense Model and an inductive approach for the remaining text. Results Transplantation is perceived both as a recovery and a new chronic condition. Participants feel powerless in the face of the risk of graft rejection. This risk is perceived as out of control as it is not associated with specific symptoms and external causes. The individual knowledge gained about transplantation relies on real-life experience shared between patients. Many participants feel anxiety. It responds to stress caused by immunosuppressant medication intake, routine check-ups, potential side effects and chronicity of immunodepression. Messages stressing the importance of the tacrolimus in the medication therapy are strengthened by a pre-discharge pharmaceutical consultation. Discussion and conclusions This study suggests that healthcare providers should systematically seek to determine illness representations to optimize the educational follow-up. The patient education program for liver transplanted patients should include three types of intervention: individualized education, behavioral intervention and psychological support. It should provide a support for stress management and acceptance of the new chronic condition. The involvement of a clinical pharmacist is relevant.

Cryosurgery is a method of in situ destruction of tissue by a freezing process. Results of hepatic cryosurgery are now available for more than 2100 patients and allow to assess its place in the treatment of hepatic malignancies. Mechanisms of tissue destruction and indications of cryosurgery are detailed. With a peri-operative mortality rate of 1.5%, the safety of hepatic cryosurgery is now admitted. Cryosurgery has its own morbidity: increase of transaminases levels, platelets drop, myoglobinuria and rarely renal failure or cryoshock. In selected patients, hepatic cryosurgery is feasible with a laparoscopic or percutaneous approach. Long term results do not support cryosurgery as an alternative to liver resection. This technique enlarges possibilities of surgical treatment for patients with primary and metastatic liver cancers.

Idiopathic portal hypertension is a rare clinical syndrome which may be associated with a spectrum of histological lesions, including nodular regenerative hyperplasia and incomplete septal cirrhosis. Here, we report eight adult patients with idiopathic portal hypertension who experienced an unusually severe clinical evolution characterized by the development of progressive hepatic failure requiring orthotopic liver transplantation. Our aims are: (a) to stress the distinctive clinical presentation of these patients, (b) to describe their biological and histopathological features, and (c) to evaluate the results of orthotopic liver transplantation in this rare indication.Complete clinical charts and histological data were available in all patients. All patients were male. Their age at diagnosis ranged from 17 to 59 years. Complications of portal hypertension revealed the disease in all cases. Medical treatment was performed in all patients and portosystemic shunt in three.The development of progressive hepatic failure led to the indication of liver transplantation after a delay ranging from 3 to 10 years. Explanted livers showed pure nodular regenerative hyperplasia in three patients and incomplete septal cirrhosis in five. Recovery was uneventful. All patients are alive, without recurrence of the disease.This report points to the existence of severe cases of idiopathic portal hypertension occurring without underlying or associated systemic disease and characterized by a poor clinical course and requiring liver transplantation.

Aim of the study The aim of this retrospective study was to report a series of nine aneurysms of the hepatic arteries, including real aneurysms (n = 4), pseudoaneurysms (n = 3) and false aneurysms (n = 2) observed from 1987 to 1999. Patients There were 7 men and 2 women (mean age: 58 years). In 3 cases, the aneurysm was asymptomatic and detected by sonography; in 4 cases it was revealed by rupture with a severe hemorrhage and in 2 cases by cholestasis. The aneurysm was located on right (n = 3), proper and common (n = 3), proper (n = 2), and common (n = 1) hepatic arteries. The aneurysm was associated with hepatocellular carcinoma (n = 1), carcinoma of the head of the pancreas (n = 1) and liver metastases (n = 1). Methods and results Eight patients were operated and one of them was operated three times. Hepatic arterial blood supply was restored in 6 patients with simple suture (n = 1), Goretex graft (n = 2), allograft (n = 2) and autologous vein (n = 1), with one failure which required liver retransplantation. Only one of the three attempts of embolization was successful. One patient with surgical contraindications died from hemobilia after embolization failure. During follow-up, there was one thrombosis of the common hepatic artery which had been excluded and two late deaths: one from rupture of a false aneurysm after bypass with an allograft and one by terminal progression of the cancer. The other 6 patients were alive at the time of this study. Conclusion Clinical characteristics and therapeutic indications of hepatic arterial aneurysm are variable. Management is usually surgical, while embolization is reserved for special circumstances. Restoration of the hepatic arterial blood supply is necessary in aneurysms located on the proper hepatic artery.

Resume But de l’etude : Le but de cette etude retrospective etait de rapporter une serie de12 cancers de la voie biliaire principale proximale traites par resection a visee curative. Patients et methode : Entre 1980 et 1998, 12 patients sur 33 ont eu une resection chirurgicale a visee curative d’un cancer de la voie biliaire principale proximale. Un drainage biliaire preoperatoire a ete realise chez six patients. Parmi ces 12 patients, un seul a eu une resection isolee de la voie biliaire principale. La resection a ete etendue au foie chez 11 patients et a comporte une resection du segment I chez neuf d’entre eux, une hepatectomie gauche chez sept patients, une hepatectomie droite chez trois patients et une segmentectomie IV chez un patient. Un traitement complementaire associant une curietherapie au fil d’Iridium a une radiotherapie externe a ete realise chez trois patients et deux autres patients ont eu une radiotherapie externe seule ou associee a une chimiotherapie. Resultats : Le taux de mortalite a deux mois a ete nul. Cinq patients ont eu des suites simples. Le taux de survie actuarielle a un, deux, trois, et cinq ans a ete respectivement de 81, 57, 28 et 28 %. Une survie prolongee de 88 et 114 mois a pu etre obtenue. Conclusion : Les cholangiocarcinomes du hile sont de mauvais pronostic. Le traitement chirurgical a visee curative necessite le plus souvent de larges resections hepatiques. L’IRM est devenue l’examen le plus efficace pour poser les indications operatoires et choisir la meilleure strategie. Des survies a long terme peuvent etre obtenues grâce a un traitement curatif. L’interet d’un traitement complementaire meriterait d’etre etudie par des etudes controlees.

BACKGROUND Surgery remains the treatment of choice for patients with esophageal squamous cell carcinoma (SCC), but survival rates have not improved over the past decades. The objective of this study was to evaluate the effect of multimodal therapy on resectability, on the overall and on disease free survival (DFS) rates, and on the laryngeal resection rate. METHODS Fifty-five patients (49 men and 6 women) with a mean age of 58 ± 8 years underwent combined modality treatment for esophageal SCC. The tumor location was in the upper one-third of the esophagus in 19 patients, the middle one-third in 22 patients, the lower one-third in 9 patients, and the upper and lower one-thirds in 5 patients. The intent of combined therapy was curative in 87.3% of patients and palliative in 12.7% of patients. Neoadjuvant treatment consisted of two courses of 5-fluorouracil and cisplatin on Days 1–5 and Days 21–25. Radiotherapy was commenced on Day 21 and consisted of 36 grays delivered in 12 fractions over 17 days. Surgery was performed on Day 60. RESULTS Full neoadjuvant treatment was possible in 67.3% of patients and was uneventful in 56.4% of patients. The resection rate was 96.4% (complete macroscopic resection with histologic clear margins [R0], 83.6%; complete macroscopic resection with microscopic disease at the resection margin [R1], 1.8%; and macroscopic residual disease [R2], 10.9%). The operative mortality rate was 0%, whereas the hospital mortality was 7.3%. Twenty-three patients had a complete macroscopic response, 12 of whom (21.8%) had a complete histopathologic response. The tumor stages according to the American Joint Committee on Cancer staging system were pT0N0 in 12 patients, Stage 0 in 8 patients, Stage IIa in 6 patients, Stage IIb in 6 patients, Stage III in 8 patients, and Stage IV in 13 patients. Laryngeal preservation was achieved in 8 of 12 patients in whom total pharyngolaryngoesophagectomy initially was indicated because of tumor response and an R0 resection. The overall survival rates at 1 year, 3 years, and 5 years were 61%, 39%, and 33%, respectively, and the DFS rates were 49%, 32%, and 29%, respectively. The respective survival rates for responders were 82%, 58%, and 53%, and the DFS rates were 68%, 54%, and 48%. CONCLUSIONS Neoadjuvant treatment is tolerated well by most patients. Combination therapy increases the resectability rate and facilitates laryngeal preservation. Significant improvements in the actuarial survival rate and the DFS rate were observed in the group of patients who achieved partial and complete responses. Cancer 2000;89:946–54. © 2000 American Cancer Society.

Resume But de l'etude L'objectif de ce travail etait de rapporter les resultats d'une serie retrospective de 26 patients porteurs de lesions d'endobrachyœsophage, traites par chirurgie antireflux. Materiel et methode De 1979 a 1998, 21 hommes et cinq femmes (âge moyen: 53 ans) ont ete traites pour endobrachyœsophage par une operation antireflux. Dix-neuf (73,1%) avaient des lesions circulaires (etendues sur une hauteur moyenne de 5,9 cm), six (23,1%) des lesions en languettes et un (3,8%) des lesions d'heterotopie gastrique. Aucun ne presentait de lesions en dysplasie severe. Le montage antireflux a ete realise 17 fois par laparotomie et neuf fois par laparoscopie. Un patient a eu une destruction preoperatoire de la muqueuse d'endobrachyœsophage par coagulation argon. Resultats Le suivi clinique moyen a ete de 78 mois. Une surveillance endoscopique de 59,3 mois en moyenne a permis de constater une stabilite des lesions dans 19 cas (73 %) et une regression partielle ou totale dans sept cas (27 %) (dont un patient traite par destruction endoscopique locale et trois patients ayant des lesions en languettes). Aucun cas de dysplasie severe ou d'adenocarcinome n'a ete observe. Conclusion Apres chirurgie antireflux, la regression de la muqueuse d'endobrachyœsophage est possible mais de facon inconstante et imprevisible. Cette intervention antireflux ne met pas a l'abri d'une degenerescence neoplasique, ce qui confirme l'interet d'une surveillance endoscopique et histologique reguliere.

Resume But Le but de cette etude est d'apprecier les resultats oncologiques et fonctionnels apres radiotherapie preoperatoire et anastomose coloanale differee pour cancer du bas rectum. Patients et methode De janvier 1988 a decembre 1997, 35 patients ont ete traites par radiotherapie preoperatoire suivie de resection rectale par une double approche abdominale et transanale permettant la conservation sphincterienne. Trente patients ont eu une echographie endorectale: uT1N0 = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, et uT3N+ = 14. La resection rectale a ete realisee en moyenne 32 jours apres la fin de la radiotherapie et l'extremite distale du colon gauche abaissee en position transanale. Au 5e jour postoperatoire, apres resection du segment colique exteriorise, a ete realisee une anastomose coloanale. Resultats L'examen anatomopathologique a trouve deux tumeurs sterilisees, pT1N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, et pT3N+ = 9. La mortalite hospitaliere a ete nulle. Il n'y a pas eu de fistule anastomotique. Un patient a developpe un abces retrorectal, un autre patient a eu une necrose du colon gauche necessitant une reintervention. Le suivi moyen a ete de 43 mois (6–113). Deux patients ont eu une recidive locale, sept ont eu une metastase et trois ont eu recidive locale et metastase. La survie actuarielle a 1, 3 et 5 ans etait de 97 %, 86 % et 72 %. Le controle local a 5 ans etait de 78 %. Les resultats fonctionnels evalues grâce a un systeme de score, etaient bons dans 59 et 70 % des cas a un et deux ans respectivement. Conclusion Cette technique originale et sure permet la conservation sphincterienne sans colostomie de protection. Elle est parfaitement adaptee a l'utilisation de la radiotherapie avec un taux faible de morbidite locale et de bons resultats fonctionnels.

Resume Objectif de l'etude L'envahissement tumoral des vaisseaux retropancreatiques et en particulier du confluent veineux mesentericoportal (CVMP) est souvent considere comme une contre-indication a la resection des tumeurs malignes du pancreas. L'objectif de cette etude retrospective est de rapporter une serie de 20 patients et de montrer que l'exerese des vaisseaux retropancreatiques supposes envahis est justifiee lorsque c'est le seul obstacle a une resection tumorale complete. Patients et methodes Vingt patients, 11 hommes et neuf femmes (âge moyen: 61,7 ans), ont subi une pancreatectomie droite (n = 14), gauche (n = 2) ou totale (n = 4) pour adenocarcinome (n = 19) ou cystadenocarcinome du pancreas (n = 1), avec resection segmentaire associee du CVPM (n = 17), de la veine cave inferieure (n = 1), d'une artere hepatique droite (n = 1) et d'une artere hepatique commune (n = 1). La continuite veineuse a ete retablie dans tous les cas par anastomose bout a bout et la continuite arterielle une fois par suture bout a bout et deux fois par pontage veineux et arteriel. Resultats II y avait un envahissement histologique de la paroi vasculaire dans neuf cas, un envahissement perivasculaire dans six cas et aucun envahissement tumoral dans cinq cas. La mortalite hospitaliere a ete nulle. Une thrombose veineuse precoce du CVMP repare a ete traitee avec succes par desobstruction et interposition d'un greffon veineux. La survie actuarielle etait de 16 % a 3 ans. Conclusion La resection d'un segment du CVMP peut etre realisee sans augmenter la mortalite et la morbidite de la pancreatectomie. L'envahissement localise de la paroi vasculaire lorsqu'il est le seul obstacle a la realisation d'une exerese tumorale complete ne constitue pas un element de mauvais pronostic. En cas d'adherences serrees entre la tumeur et l'axe veineux, qu'elles soient tumorales ou inflammatoires, la resection veineuse peut faire partie d'une strategie operatoire deliberee. En revanche, l'obstruction complete du CVPM, l'extension extrapancreatique de la tumeur, l'atteinte de l'artere mesenterique superieure ou du tronc cœliaque constituent des contre-indications a l'exerese pancreatique.

Recurrent hepatitis C virus (HCV) in liver transplant patients is a major cause of graft loss, liver failure, and need for retransplantation. The results available to date with the use of interferon alfa (IFN-alpha) in the treatment of recurrent HCV in liver transplant patients have been disappointing. The aim of this study was to evaluate the efficacy and clinical utility of post-transplant combination therapy with IFNalpha2b (3 million units 3 times weekly) and oral ribavirin (1,200 mg/d) for a duration of 6 months, followed by maintenance with ribavirin alone for an additional 6 months. Twenty-one liver transplant recipients with recurrent hepatitis C infection (HCV-RNA-positive; active hepatitis without rejection on biopsy) were enrolled in this study. Pretreatment serum alanine transaminase (ALT) levels were at least two times the upper limit of normal. Before treatment, all patients were HCV-RNA-positive and mean HCV-RNA titers were 125 million genome-equivalents/mL. Mean pretreatment histological score was 6.3 +/- 2. After 6 months of combination therapy, all 21 patients had normal ALTs. Ten patients (48%) cleared HCV-RNA from their serum, as assessed by polymerase chain reaction (PCR), and HCV-RNA levels decreased significantly in the others (P = .0001). Improvement in histological score was seen in all patients after combination therapy (P = .0013). During maintenance ribavirin monotherapy, ALT remained normal in all but 1 of the 18 patients who tolerated therapy. HCV-RNA reappeared in 5 patients, but HCV-RNA levels did not return to pretreatment levels (P = .0004). Comparison of pretreatment and postribavirin monotherapy liver biopsies revealed improvement in all but 1 of the 18 patients who tolerated ribavirin (P = .0002). Side effects were restricted to anemia, which necessitated cessation of ribavirin therapy in 3 patients. No patient experienced graft rejection during the study period. These results are significantly better than those reported with IFN-alpha monotherapy. Most importantly, there was a complete absence of graft rejection. These results suggest that the combination of IFN-alpha and ribavirin is effective in reducing HCV-RNA levels and ameliorating hepatocellular injury in recurrent HCV after liver transplantation, and that maintenance therapy with ribavirin monotherapy can maintain the biochemical and histological response.

Radiofrequency ablation, partial or total hepatectomy represent curative treatment options for patients suffering from hepatocellular carcinoma in 2010. In this review article, the role (indication, limits, results) of hepatic resection and liver transplantation are discussed.

To report a series of 17 patients operated for a complication oesophagocoloplasty, with evaluation of therapeutic modalities, and both early and distant results.From 1985 to 2003, 17 patients with a mean age of 50 years (range: 23-76) were reoperated after coloplasty pediculated on left superior colic vessels. Initial diseases were caustic ingestion (N=7), cancer (N=6), oesophageal perforation (N=2), gastric lymphoma (N=1) and oesotracheal fistula (N=1). Coloplasty has been performed as a first-intent procedure in 13 cases and as a second-intent procedure after failure of a previous operation in 4 cases. Nine patients were initially operated in another center and were subsequently referred in our unit. Complications needing reoperation were graft necrosis in 8 cases (47%) and stricture in 9 cases (53%). All patients with necrosis were reoperated within the 10 first postoperative days.Necroses were treated by complete (N=5) or partial (N=3) resection of the coloplasty. Strictures were treated by resection-reanastomosis (N=3), right ileocoloplasty (N=2), colic stricturoplasty (N=2), a free antebrachial flap (N=1) and a tubulized latissimus dorsi myocutaneous pedicled flap (N=1). The 30-day mortality rate was 12% (N=2) and the overall morbidity rate was 66%. All deaths occurred after reoperation for necrosis. Eleven patients (65%) kept or recovered digestive continuity (including the 9 with stenosis) and 8 (73%) eat normally. Four patients with transplant necrosis died before reestablishment. Four patients operated for necrosis died before restoration of digestive continuity and 2 patients are still awaiting restoration.Use of colon as an oesophageal substitute is risky. Reoperations for stenosis allows satisfactory oral feeding, while reoperation for necrosis is associated with both high early mortality and a low rate of restoration or digestive continuity. This later requires a range of complex surgical procedures.

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.

A patient with congenital factor VII deficiency (baseline activity, 7%) underwent surgery for hepatocellular carcinoma. No literature reference was found concerning the management of this coagulation defect in patients requiring liver surgery. We report one such case, with special reference to the peri-operative management of factor VII replacement therapy and the pharmacokinetic behavior of factor VII. As a result of accidental suprahepatic vein lesion, a bleeding episode occurred. This was associated with an increase in factor VII clearance and volume of distribution values from 1.30 to 3.85 l/h, and from 6.51 to 13.2 l, respectively. After surgery, the patient continued to receive the concentrate every 8 h during the first nine post-operative days. No post-operative bleeding or thrombotic event was observed. The patient was discharged in good condition.

Cryosurgery is a method of in situ destruction of tissue by a freezing process. Results of hepatic cryosurgery are now available for more than 2100 patients and allow to assess its place in the treatment of hepatic malignancies. Mechanisms of tissue destruction and indications of cryosurgery are detailed. With a peri-operative mortality rate of 1.5%, the safety of hepatic cryosurgery is now admitted. Cryosurgery has its own morbidity: increase of transaminases levels, platelets drop, myoglobinuria and rarely renal failure or cryoshock. In selected patients, hepatic cryosurgery is feasible with a laparoscopic or percutaneous approach. Long term results do not support cryosurgery as an alternative to liver resection. This technique enlarges possibilities of surgical treatment for patients with primary and metastatic liver cancers.

The aim of this retrospective study was to report a series of nine aneurysms of the hepatic arteries, including real aneurysms (n = 4), pseudoaneurysms (n = 3) and false aneurysms (n = 2) observed from 1987 to 1999.There were 7 men and 2 women (mean age: 58 years). In 3 cases, the aneurysm was asymptomatic and detected by sonography; in 4 cases it was revealed by rupture with a severe hemorrhage and in 2 cases by cholestasis. The aneurysm was located on right (n = 3), proper and common (n = 3), proper (n = 2), and common (n = 1) hepatic arteries. The aneurysm was associated with hepatocellular carcinoma (n = 1), carcinoma of the head of the pancreas (n = 1) and liver metastases (n = 1).Eight patients were operated and one of them was operated three times. Hepatic arterial blood supply was restored in 6 patients with simple suture (n = 1), Goretex graft (n = 2), allograft (n = 2) and autologous vein (n = 1), with one failure which required liver retransplantation. Only one of the three attempts of embolization was successful. One patient with surgical contraindications died from hemobilia after embolization failure. During follow-up, there was one thrombosis of the common hepatic artery which had been excluded and two late deaths: one from rupture of a false aneurysm after bypass with an allograft and one by terminal progression of the cancer. The other 6 patients were alive at the time of this study.Clinical characteristics and therapeutic indications of hepatic arterial aneurysm are variable. Management is usually surgical, while embolization is reserved for special circumstances. Restoration of the hepatic arterial blood supply is necessary in aneurysms located on the proper hepatic artery.

The prognosis of esophageal carcinoma is closely related to tumor stage and treatment modalities are applied according to the TNM stage of the disease and the performance status of the patient. Selecting the appropriate treatment based on accurate staging is of paramount importance. The subject of this review concerns advances in pretherapeutic assessment of esophageal carcinoma. Advantages and limits of pretherapeutic examinations are exposed with special interest to endoscopic and radiological investigations (sonography, computed tomography, magnetic resonance imaging, PET-scan, endoscopic ultrasonography, bronchoscopy.). Impact on therapeutic management is clarified.

Before highly active antiretroviral therapy were available, disseminated Mycobacterium avium complex infection was common in adults with HIV. Diagnosis was often made by blood culture in these immunocompromised patients. Although Mycobacterium avium complex disease can involve any organ of the body, infection of serosal surfaces is very rare. Mycobacterium avium complex peritonitis is rare and usually occurs in immunocompetent patients with chronic ambulatory peritoneal dialysis. We report a case of Mycobacterium avium complex peritonitis in a patient with alcoholic cirrhosis with no evidence of HIV infection. Diagnosis was made by culture of a lymphocytic ascites which showed Mycobacterium avium complex at 4 weeks. Interestingly, blood and hepatic cultures remained negative. At three months, marked improvement occurred with antimycobacterial treatment, so that orthotopic liver transplantation could be performed.

Surgery remains the treatment of choice for patients with esophageal squamous cell carcinoma (SCC), but survival rates have not improved over the past decades. The objective of this study was to evaluate the effect of multimodal therapy on resectability, on the overall and on disease free survival (DFS) rates, and on the laryngeal resection rate.Fifty-five patients (49 men and 6 women) with a mean age of 58 +/- 8 years underwent combined modality treatment for esophageal SCC. The tumor location was in the upper one-third of the esophagus in 19 patients, the middle one-third in 22 patients, the lower one-third in 9 patients, and the upper and lower one-thirds in 5 patients. The intent of combined therapy was curative in 87.3% of patients and palliative in 12.7% of patients. Neoadjuvant treatment consisted of two courses of 5-fluorouracil and cisplatin on Days 1-5 and Days 21-25. Radiotherapy was commenced on Day 21 and consisted of 36 grays delivered in 12 fractions over 17 days. Surgery was performed on Day 60.Full neoadjuvant treatment was possible in 67.3% of patients and was uneventful in 56. 4% of patients. The resection rate was 96.4% (complete macroscopic resection with histologic clear margins [R0], 83.6%; complete macroscopic resection with microscopic disease at the resection margin [R1], 1.8%; and macroscopic residual disease [R2], 10.9%). The operative mortality rate was 0%, whereas the hospital mortality was 7.3%. Twenty-three patients had a complete macroscopic response, 12 of whom (21.8%) had a complete histopathologic response. The tumor stages according to the American Joint Committee on Cancer staging system were pT0N0 in 12 patients, Stage 0 in 8 patients, Stage IIa in 6 patients, Stage IIb in 6 patients, Stage III in 8 patients, and Stage IV in 13 patients. Laryngeal preservation was achieved in 8 of 12 patients in whom total pharyngolaryngoesophagectomy initially was indicated because of tumor response and an R0 resection. The overall survival rates at 1 year, 3 years, and 5 years were 61%, 39%, and 33%, respectively, and the DFS rates were 49%, 32%, and 29%, respectively. The respective survival rates for responders were 82%, 58%, and 53%, and the DFS rates were 68%, 54%, and 48%.Neoadjuvant treatment is tolerated well by most patients. Combination therapy increases the resectability rate and facilitates laryngeal preservation. Significant improvements in the actuarial survival rate and the DFS rate were observed in the group of patients who achieved partial and complete responses.

The order of revascularization in human liver grafts is still discussed. This study tries to answer this question in terms of hemodynamic data.Fifty-nine patients were randomized in this study to compare hemodynamic data just before and 15 minutes after revascularization of liver grafts in relation to first hepatic artery (n = 29) or first portal vein (n = 30) revascularization procedure.Hemodynamic variations were significantly greater in the portal vein group than in the hepatic artery group in terms of mean arterial pressure, cardiac index, central venous pressure, pulmonary capillary pressure, and systemic vascular resistance. The latter decreased from 741.8 +/- 390.3 to 659.9 +/- 411.1 dynes/ cm5 (NS) in the hepatic artery group versus 807.7 +/-336.7 to 439.7 +/- 215 dynes/cm5 (p0.05) in the portal vein group. Clinical results and postoperative complications, graft characteristics, patient survival, and graft survival were not significantly different between the groups.Initial arterial revascularization of the liver graft leads to a more stable hemodynamic profile during revascularization of the liver graft after vascular unclamping. This technique is always feasible and has become our reference procedure.

The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery.From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient.Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma.Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.

The usual treatment for splenic artery aneurysm is resection under laparotomy. In recent years, the laparoscopic approach has consisted of ligation without resection. More recently,laparoscopic resection was reported by the Cleveland Clinic. In this paper, we describe the technique used in the laparoscopic resection of our first case of laparoscopic resection of splenic artery aneurysm (SAA). The patient was a young woman with a 12-mm SAA discovered on systematic abdominal ultrasound. The laparoscopic procedure was done successfully, and the aneurysm was resected using an ultrasonic dissector. The postoperative course was uneventful, and the patient was discharged on the 3rd postoperative day. Pathological examination revealed the atherosclerotic origin of the aneurysm. The patient is doing well 12 months after surgery, with normal splanchnic Doppler ultrasound. This procedure offers a one-step definitive cure via a minimally invasive surgical procedure.

The aim of this study was to assess the oncology and functional outcome after preoperative radiotherapy and delayed coloanal anastomosis for cancers of the lower third of the rectum.From January 1988 to December 1997, 35 patients received preoperative radiotherapy (45 Gy) followed by rectal resection through a combined abdominal and transanal approach. Thirty patients had preoperative tumor staging with endorectal ultrasonography: uT1N0 = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, and uT3N+ = 14. Colorectal resection was performed on average 32 days after the conclusion of radiotherapy, and the distal colon stump was pulled through the anal canal. On postoperative day 5, the colonic stump was resected and a direct coloanal anastomosis performed.Pathological examination of the specimens revealed complete tumor sterilization in two cases, pT1N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, and pT3N+ = 9. There was no postoperative mortality and there was no leakage. One patient had a pelvic abscess, and another one had left colon necrosis which required re-operation. Median follow-up was 43 months (range 6-113). Two patients had locoregional recurrence, seven had distant metastasis, and 3 had both. Actuarial survival rate at 1, 3 and 5 years was 97%, 86%, and 72% respectively. The rate of local control at 5 years was 78%. Functional results were evaluated by a new scoring system. Function was considered good in 59 and 70% at 1 and 2 years respectively.This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma. It is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results.

Progress in the development of suture materials results in a lower rate of fistulas. Modern techniques for the diagnosis of leakage (contrast study, CT-scan) allow for an early diagnosis and adequate therapy: if possible conservative therapy with drainage of the abscess, adapted antibiotic therapy and parenteral and enteral nutrition are the best methods. In the case of necrosis of the transplant, reoperation permits enables extra time for reconstruction. All the technical possibilities of reconstruction must be known. It is necessary to apply prophylactic precautions to avoid leakage of the anastomosis on the oesophagus.

Massive incisional abdominal wall hernias are frequent and difficult to repair, especially when they are large, multiply recurrent and when associated high with risk factors. We report the long-term results of 192 hernia repairs (in 186 patients) by non-resorbable mesh placed intraperitoneally and fixed by fascia stapler. We describe the details of the technique. There were no deaths. Early and late wound infections occurred in 11.7%, late occlusions in 6.3% and recurrence in 16%. Four percent of patients required removal of the mesh. The main caracteristic of this study was the long follow-up period (mean duration = 77 months). In view of the good results (70%), simplicity and quite execution of this technique, intraperitoneal mesh placement should be considered in the repair of large hernias when a prothesis is required.

Tumoural invasion of the retropancreatic vessels and particularly of the superior mesentericoportal vein confluence (SMPV) is often considered as a contraindication to resection of malignant tumours of the pancreas. The aim of this retrospective study is to report a series of 20 patients and to demonstrate that resection of the vessels supposed to be involved is justified when it is the only barrier to a complete tumoural resection.Twenty patients, 11 men and nine women (mean age: 61.7 years) underwent a right (n = 14), left (n = 2) or total (n = 4) pancreatic resection for pancreatic adenocarcinoma (n = 19) or cystadenocarcinoma (n = 1) associated with partial resection of SMPV (n = 17), inferior vena cava (n = 1), right hepatic artery (n = 1) and common hepatic artery (n = 1). The veins were reconstructed in all cases by end to end anastomosis and the arteries by direct suture in one patient and venous or artery graft in two patients.Tumoural invasion was histologically present in the vascular wall in nine patients, in the perivascular area in six and negative in five. The in-hospital mortality was nil. One patient had an early venous thrombosis of the repaired SMPV which was reoperated and treated with success by desobstruction and venous graft. The 3-year actuarial survival rate was 16%.Segmental venous resection of the SMPV confluence can be performed safely. Localised invasion of the vascular wall, considered as the only obstacle for a complete tumoural resection, is not associated with a poor prognosis. In case of tight adhesions between tumour and SMPV (inflammatory or tumoural) the venous resection may be included in a deliberate surgical strategy. On the other hand, total obstruction of SMPV, extrapancreatic tumoural extension, tumoural invasion of superior mesenteric artery or coeliac trunk are contraindications to pancreatic resection.

Intractable ascites is a rare complication after liver transplantation. In this study, the authors report 2 cases of intractable ascites after liver transplantation. The authors discuss the etiology of ascites and the place of peritoneovenous shunt as a therapeutic option. From 1985 to 1996, 354 liver transplantations were performed. In two cases, liver transplantation was performed for post-VHC liver cirrhosis and giant hemangioma. Both patients developed intractable ascites and were successfully treated by peritoneovenous shunt. The etiologies of ascites after liver transplantations are multiple: mechanical after vascular complication; lymphatic leak after surgical dissection; metabolic disorder; intrahepatic lesion of the graft. In our cases, the etiology of ascites was intrahepatic lesion of the graft due to VHC infection in the first case and acute rejection in the second. Peritoneovenous shunt is a therapeutic option for the treatment of intractable ascites after liver transplantation. Its indication should be considered only for isolated intractable ascites without portal hypertension and without liver cell failure after liver transplantation.

Coeliac stenosis induced by arcuate ligament compression is usually asymptomatic. Current caution is advised during a supramesocolonic surgical procedure in the case of a collateral arterial system due to coeliac stenosis. 11 cases of coeliac stenosis are described. 3 patients underwent duodenopancreatic resection, 8 patients had liver transplantation. 2 patients died after complications due to celiac, stenosis. These cases are described. The authors discuss the diagnostic and therapeutic approach.

Currently, surgical treatment of hepatocellular carcinoma in patients with cirrhosis is not clearly defined. The objective of this study was, in patients with cirrhosis with hepatocellular carcinoma, to compare liver resection to transplantation assessed by patient survival and to determine whether the tumor recurrence might be influenced by prognostic factors.We have gathered all the available data from six French Medical Universities, for 215 patients with cirrhosis with hepatocellular carcinoma surgically treated either by liver resection (102) or by transplantation (113).The overall 5-year survival rate was similar in the transplantation group and in the resection group (32% vs. 31%, p=0.7). However, the 5-year survival rate without recurrence was higher in the transplantation group than in the resection group (60% vs. 14%, p0.001). Three independent prognostic factors influenced significantly the survival without recurrence: the surgical treatment by transplantation (p0.001), the number of tumors (p0.01) and the tumor size (p0.001). With these factors we defined a prognostic index (Ip) which allowed assessment of the probability of survival without recurrence: Ip= (Xie. x 1.41)+(Nbr T. x 0.19)+(Size TV. x 0.16); Xie=surgical treatment (Xie=0 if transplantation, Xie=1 if resection), Nbr.T. and Size TV.=number of tumors and size of the most voluminous tumor, respectively, according to the histologic study.These results and this prognostic index are encouraging for liver transplantation as treatment of hepatocellular carcinoma in selected patients with cirrhosis.

We evaluated a semiquantitative PCR assay prospectively in 40 liver transplant recipients as an aid in making a prompt diagnosis of cytomegalovirus (CMV) infection. For 2 months after transplantation, clinical specimens from patients were tested weekly by PCR, virus isolation from peripheral blood and urine, and CMV serology. The incidence of active CMV infection was 70%. The levels of CMV DNA determined by hybridization of PCR samples and densitometric scanning of blots were assigned a score of 1 to 4 by comparison with four external standards amplified in parallel and corresponding to a range of 80 to 80,000 genomes. The first detection of CMV in blood by PCR occurred at a mean of 15 days, and high-level PCR scores of 3 or 4 were obtained 21 days after transplantation, whereas viremia occurred 33 days after transplantation. Significantly higher levels of CMV DNA were seen in patients with CMV disease (P < 0.05) than in asymptomatic patients. The prevalence of symptomatic CMV infection was 30%. The positive predictive value of PCR was 48%, while the negative predictive value was 100%. After treatment, the clearance of CMV DNA was always observed and the disappearance of symptoms occurred concomitantly with undetectable PCR signals.

Chronic liver failure resulting from hepatitis C virus infection often necessitates orthotopic liver transplantation. Recurrence of hepatitis C virus infection after transplantation is inevitable, and the infection is usually severe. Interferon and ribavirin have both been used to treat hepatitis C virus infection after liver transplantation, but neither interferon nor ribavirin monotherapy has demonstrated sustained biochemical or virologic responses or histologic benefit in transplant recipients with recurrent hepatitis C virus infection. The next logical approach to treatment was combination therapy.Fourteen patients with recurrent hepatitis C virus infection were treated for 6 months with interferon alfa-2b (3 MU thrice weekly) and oral ribavirin (1000 mg/day). After 6 months, patients were maintained on ribavirin monotherapy until the end of the study. Safety and tolerability were satisfactory, and no patients experienced graft rejection during the study.Alanine aminotransferase levels were normalized in all patients after 6 months of therapy. Serum HCV RNA was negative in nine patients; the other five demonstrated a 50% quantitative reduction of HCV RNA. After a mean follow-up of 18 months, all but one patient maintained normal alanine aminotransferase levels. Twelve out of 14 patients achieved a histologic benefit.The biochemical and virologic responses and the histologic benefit seen after combination therapy are significantly better than those reported with either interferon or ribavirin monotherapy. Combination therapy appears to be effective in preventing the progression of HCV-related graft disease after liver transplantation.

A model of heterotopic liver transplantation had been studied. The graft was laid under the recipient liver and the portal blood flow was supplied by anastomosis with the distal part of the splenic vein. Both liver can then receive portal blood through two parallel portal circulation. Liver function of transplant was satisfactory at three months after transplantation. Their had been no alteration of the recipient liver during the same period.