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Immunohistochemistry (IHC) and/or MSI-PCR (microsatellite instability-polymerase chain reaction) tests are performed routinely to detect mismatch repair deficiency (MMR-D). Classical MMR-D tumors present a loss of MLH1/PMS2 or MSH2/MSH6 with MSI-High. Other profiles of MMR-D tumors have been described but have been rarely studied. In this study, we established a classification of unusual MMR-D tumors and determined their frequency and clinical impact. All MMR-D tumors identified between 2007 and 2017 were selected. Any profile besides the classical MMR-D phenotype was defined as unusual. For patients with unusual MMR-D tumors, IHC, and PCR data were reviewed, the tumor mutation burden (TMB) was evaluated and clinical and genetic features were collected. Of the 4948 cases of MMR testing, 3800 had both the available IHC and MSI-PCR results and 585 of these had MMR-D. After reviewing the IHC and PCR, 21% of the cases initially identified as unusual MMR-D were reclassified, which resulted in a final identification of 89 unusual MMR-D tumors (15%). Unusual MMR-D tumors were more often associated with non-CRC than classical MMR-D tumors. Unusual MMR-D tumors were classified into four sub-groups: i) isolated loss of PMS2 or MSH6, ii) classical loss of MLH1/PMS2 or MSH2/MSH6 without MSI, iii) four MMR proteins retained with MSI and, iv) complex loss of MMR proteins, with clinical characteristics for each sub-group. TMB-high or -intermediate was shown in 96% of the cancers studied (24/25), which confirmed MMR deficiency. Genetic syndromes were identified in 44.9% (40/89) and 21.4% (106/496) of patients with unusual and classical MMR-D tumors, respectively (P

Background Portal vein thrombosis (PVT) is a common complication following splenectomy. It affects between 5 and 55% of patients undergoing surgery with no clearly defined pre-operative risk factors. The aim of this study was to determine the pre-operative risk factors of PVT. Patients and method Single centre, retrospective study of data compiled for every consecutive patient who underwent splenectomy at Toulouse University Hospital between January 2009 and January 2019. Patients with pre- and post-surgical CT scans have been included. Results 149 out of 261 patients were enrolled in the study (59% were males, mean age 52 years). The indications for splenectomy were splenic trauma (30.9%), malignant haemopathy (26.8%) and immune thrombocytopenia (8.0%). Twenty-nine cases of PVT (19.5%) were diagnosed based on a post-operative CT scan performed on post-operative day (POD) 5. Univariate analysis identifies three main risk factors associated with post-operative PVT: estimated splenic weight exceeding 500 g with an OR of 8.72 95% CI (3.3–22.9), splenic vein diameter over 10 mm with an OR of 4.92 95% CI (2.1–11.8) and lymphoma with an OR of 7.39 (2.7–20.1). The role of splenic vein diameter with an OR of 3.03 95% CI (1.1–8.6), and splenic weight with an OR of 5.22 (1.8–15.2), as independent risk factors is confirmed by multivariate analysis. A screening test based on a POD 5 CT scan with one or two of these items present could indicate sensitivity of 86.2% and specificity of 86.7%. Conclusion This study suggests that pre-operative CT scan findings could predict post-operative PVT. A CT scan should be performed on POD 5 if a risk factor has been identified prior to surgery.

Summary Aim To study morbi-mortality, survival after hepatectomy in elderly patients, and influence on their short-term autonomy. Patients and methods This is a retrospective study conducted between 2002 and 2017 comparing patients less than 65 years old (controls) to those more than 65 years old (cases) from a prospective database, with retrospective collection of geriatric data. Cases were divided into three sub-groups (65–70 years, 70–80 years and > 80 years). Results Four hundred and eighty-two patients were included. There was no age difference in number of major hepatectomies (P = 0.5506), length of stay (P = 0.3215), mortality at 90 days (P = 0.3915), and surgical complications (P = 0.1467). There were more Grade 1 Clavien medical complications among the patients aged over 65 years (P = 0.1737). There was no difference in overall survival (P = 0.460) or disease-free survival (P = 0.108) according to age after adjustment for type of disease and hepatectomy. One-third of patients had geriatric complications. The “home discharge” rate decreased significantly with age from 92% to 68% (P = 0.0001). Early loss of autonomy after hospitalization increased with age, 16% between 65 and 70 years, 23% between 70 and 80 years and 36% after 80 years (P = 0.10). We identified four independent predictors of loss of autonomy: age > 70 years, cholangiocarcinoma, length of stay > 10 days, and metachronous colorectal cancer. Conclusions Elderly patients had the same management as young patients, with no difference in surgery or survival, but with an increase in early loss of autonomy.

Resume Objectif Etudier la morbi-mortalite, la survie des hepatectomies chez le sujet âge, ainsi que l’influence sur l’autonomie a court terme. Patient et methode Il s’agit d’une etude retrospective realisee de 2002 a 2017 comparant les patients de moins de 65 ans (temoins) aux plus de 65 ans (cas) a partir d’une base de donnees prospective avec recueil retrospectif des donnees geriatriques. Les cas etaient repartis en trois sous-groupes (65–70 ans, 70–80 ans et > 80 ans). Resultats Au total, 482 patients ont ete inclus. Il n’y avait pas de difference en fonction de l’âge sur le nombre d’hepatectomies majeures (p = 0,5506), la duree de sejour (p = 0,3215), la mortalite a 90 j (p = 0,3915) et les complications chirurgicales (p = 0,1467). Il y avait plus de complications medicales Clavien 1 parmi les patients de plus de 65 ans (p = 0,1737). Il n’y avait pas de difference de survie globale (p = 0,460) et sans recidive (p = 0,108) en fonction de l’âge apres ajustement sur le type de maladie et d’hepatectomie. Un tiers des malades avaient des complications geriatriques. Le taux de « sortie a domicile » diminuait significativement avec l’âge de 92 a 68 % (p = 0,0001). La perte d’autonomie precoce a la sortie augmentait avec l’âge, elle etait de 16 % entre 65 et 70 ans, de 23 % entre 70 et 80 et de 36 % apres 80 ans (p = 0,10). Nous avons identifie quatre facteurs predictifs independants de perte d’autonomie : un âge > 70 ans, le cholangiocarcinome, une duree de sejour > 10 jours, et le caractere metastatique metachrone de cancer colorectal. Conclusions Les patients âges avaient la meme prise en charge que les patients jeunes, sans difference sur les suites operatoires ou la survie, mais avec une augmentation de la perte d’autonomie precoce.

Resume But de l’etude Quatorze a 17 % des patients sont porteurs de metastases hepatiques synchrones (MHsCCR) au moment du diagnostic. Trois strategies de prise en charge curative des MHsCCR sont possibles : « classique », « combinee » et « foie premier ». Le but de cette etude est d’analyser les resultats des 3 strategies sur la morbi-mortalite postoperatoire et la survie globale et sans recidive. Patients et methodes Tous les patients pris en charge pour MHsCCR entre 2000 et 2015 au CHU de Toulouse Rangueil ont ete inclus. Trois groupes ont ete definis : (1) « classique » : chirurgie du primitif, puis chirurgie des MHsCCR ; (2) « combine » : chirurgie du primitif et chirurgie des MHsCCR en meme temps ; (3) « foie premier » : chirurgie des MHsCCR puis chirurgie du primitif. Resultats Cent soixante-dix patients qui ont eu 209 hepatectomies ont ete inclus (149 « classiques», 34 « combines » et 26 « foie premier »). Le taux de complications severes etait plus eleve dans le groupe « combine » que dans le groupe « classique » (35 % vs 12 %, p = 0,03), et que dans le groupe « foie premier » (35 % vs 19 %, p = 0,25), alors que les gestes de resections hepatiques etaient plus simples. La survie globale a 5 ans etait de 46 % sans difference significative entre les 3 groupes, avec une mediane de survie de 54 mois. La survie sans recidive etait de 24 % a 5 ans, avec une mediane de survie sans recidive de 14 mois, sans difference significative. Conclusion Les trois strategies etaient realisables et il n’existait pas de differences en termes de survies globales et sans recidive entre les trois approches. Il existait plus de complications severes dans le groupe « combine », sans meilleurs resultats oncologiques malgre une maladie hepatique moins importante et des gestes de resection hepatique plus limites.

Summary Aim of the study Fourteen to seventeen percent of patients suffering from colorectal cancer have synchronous liver metastases (sCRLM) at the time of diagnosis. There are currently three possible strategies for curative management of sCRLM: “classic”, “combined”, and “liver-first”. The aim of our research was to analyze the effects of the three surgical management strategies for sCRLM on postoperative morbidity and mortality and overall and recurrence-free survival. Patients and Methods Patients treated for sCRLM between October 2000 and May 2015 were included. We defined three groups: (1) “classic”: surgery of primary tumor and then surgery of sCRLM; (2) “combined”: combined surgery of primary tumor and sCRLM: and (3) “liver-first”: surgery of sCRLM and then surgery of primary tumor. Results During this period, 170 patients who underwent 209 hepatectomies were included (“classic”: 149, “combined”: 34, “liver-first”: 26). The rate of severe complications was higher in the “combined” group compared to the “classic” group (35% vs. 12%, P = 0.03), and the “liver-first” group (35% vs. 19%, P = 0.25), while there were significantly fewer liver resections. Overall survival at 5 years in our cohort was 46%, without significant differences between the groups, and a median survival of 54 months. Recurrence-free survival of the patients in our cohort was 24% at 5 years, with a median survival time without recurrence of 14 months, without significant differences between the groups. Conclusion All three strategies were feasible and there were no differences regarding overall and recurrence-free survivals between the three approaches. The “combined” strategy group had significantly more severe complications and did not provide better oncological results, despite less aggressive liver disease and more limited liver resections.

Purpose To evaluate the impact of blended learning using a combination of educational resources (flipped classroom and short videos) on medical students’ (MSs) for radiology learning. Material and methods A cohort of 353 MSs from 2015 to 2018 was prospectively evaluated. MSs were assigned to four groups (high, high-intermediate, low-intermediate, and low achievers) based on their results to a 20-MCQs performance evaluation referred to as the pretest. MSs had then free access to a self-paced course totalizing 61 videos based on abdominal imaging over a period of 3 months. Performance was evaluated using the change between posttest (the same 20 MCQs as pretest) and pretest results. Satisfaction was measured using a satisfaction survey with directed and spontaneous feedbacks. Engagement was graded according to audience retention and attendance on a web content management system. Results Performance change between pre and posttest was significantly different between the four categories (ANOVA, P = 10−9): low pretest achievers demonstrated the highest improvement (mean ± SD, + 11.3 ± 22.8 points) while high pretest achievers showed a decrease in their posttest score (mean ± SD, − 3.6 ± 19 points). Directed feedback collected from 73.3% of participants showed a 99% of overall satisfaction. Spontaneous feedback showed that the concept of “pleasure in learning” was the most cited advantage, followed by “flexibility.” Engagement increased over years and the number of views increased of 2.47-fold in 2 years. Conclusion Learning formats including new pedagogical concepts as blended learning, and current technologies allow improvement in medical student’s performance, satisfaction, and engagement.

Resume But de l’etude Le but de l’etude etait d’evaluer le role pronostique de 4 solutions de conservation en transplantation hepatique (TH). Patients et methodes Il s’agit d’une etude retrospective a partir de toutes les TH de tous les centres francais (n = 22) enregistrees dans la base de donnees prospective de l’Agence de la Biomedecine (Cristal) entre 2008 et 2013. Les solutions de preservation utilisees etaient : Celsior, IGL-1, SCOT 15 ou UW. Les criteres d’exclusion etaient : solution inconnue ou inhomogene ou solution HTK (3 % seulement des TH). Le critere principal de jugement etait la survie des patients. Les criteres secondaires etaient la survie des greffons et la duree de reanimation. Resultats Parmi 6347 TH realisees, 4928 ont ete incluses pour lesquelles la solution de preservation utilisee etaient Celsior (30 %), IGL-1 (44 %), SCOT 15 (10 %) et UW (16 %). La survie des patients etait de 86 %, 80 % et 74 % a 1, 3 et 5 ans, respectivement, sans difference entre les 4 solutions (p = 0,78). La survie des greffons etait respectivement de 82 %, 75 % et 69 % a 1, 3 et 5 ans, sans difference entre les 4 solutions (p = 0,80). Le sejour en reanimation etait different selon la solution utilisee en analyse univariee (p Conclusion Le type de solution de conservation utilisee (Celsior, IGL-1, SCOT 15 ou UW) n’a pas d’influence sur la survie des patients ou des greffons apres TH.

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).La fístula biliar es una de las complicaciones más comunes después de la hepatectomía. Este estudio evalúa el efecto del drenaje biliar transcístico durante la hepatectomía en la aparición de una fístula biliar postoperatoria. MÉTODOS: Este ensayo prospectivo aleatorizado y multicéntrico (Clinical Trial NCT01469442) con dos grupos de estudio (grupo transcístico versus grupo control) se llevó a cabo de 2009 a 2016 en 9 centros. Los pacientes fueron sometidos a una hepatectomía (≥ 2 segmentos) en hígados no cirróticos. El resultado principal fue la aparición de una fístula biliar después de la cirugía. Los resultados secundarios fueron la morbilidad, la mortalidad postoperatoria, la duración de la estancia hospitalaria, la reintervención, la necesidad de reingreso y las complicaciones causadas por los catéteres. Se realizaron análisis por intención de tratamiento y por protocolo.Un total de 310 pacientes fueron randomizados. Por intención de tratamiento, 158 pacientes fueron aleatorizados al grupo transcístico y 149 al grupo control. Siete pacientes fueron excluidos del análisis por protocolo por desviaciones del protocolo. La tasa de fístula biliar fue del 5,9% en el análisis por intención de tratamiento y del 6,0% en el análisis por protocolo. Esta tasa fue similar para el grupo transcístico y para el grupo control: 5,7% versus 6,0% (P = 1). No hubo diferencias en términos de morbilidad (49,4% versus 46,9%, P = 0,731), mortalidad (2,5% versus 4,7%, P = 0,367) y reintervenciones (4,4% versus 10,1%, P = 1). La mediana de la duración de la estancia hospitalaria fue mayor para el grupo transcístico (11 versus 10 días, P = 0,042). El riesgo de fístula biliar se correlacionó con el grosor y la longitud de la transección hepática. CONCLUSIÓN: Este ensayo aleatorizado no demuestra la superioridad del drenaje transcístico durante la hepatectomía para prevenir la fístula biliar. No se recomienda el uso de drenaje transcístico durante la hepatectomía para prevenir la fístula biliar postoperatoria.

BACKGROUND Colorectal cancer is the third most common cancer in men and the second most common in women worldwide. Almost a third of the patients has or will develop liver metastases. Neoadjuvant chemotherapy (NAC) has recently become nearly systematic prior to surgery of colorectal livers metastases (CRLMs). The response to NAC is evaluated by radiological imaging according to morphological criteria. More recently, the response to NAC has been evaluated based on histological criteria of the resected specimen. The most often used score is the tumor regression grade (TRG), which considers the necrosis, fibrosis, and number of viable tumor cells. AIM To analyze the predictive factors of the histological response, according to the TRG, on CRLM surgery performed after NAC. METHODS From January 2006 to December 2013, 150 patients who had underwent surgery for CRLMs after NAC were included. The patients were separated into two groups based on their histological response, according to Rubbia-Brandt TRG. Based on their TRG, each patient was either assigned to the responder (R) group (TRG 1, 2, and 3) or to the non-responder (NR) group (TRG 4 and 5). All of the histology slides were re-evaluated in a blind manner by the same specialized pathologist. Univariate and multivariate analyses were performed. RESULTS Seventy-four patients were classified as responders and 76 as non-responders. The postoperative mortality rate was 0.7%, with a complication rate of 38%. Multivariate analysis identified five predictive factors of histological response. Three were predictive of non-response: More than seven NAC sessions, the absence of a radiological response after NAC, and a repeat hepatectomy (P < 0.005). Two were predictive of a good response: A rectal origin of the primary tumor and a liver-first strategy (P < 0.005). The overall survival was 57% at 3 yr and 36% at 5 yr. The disease-free survival rates were 14% at 3 yr and 11% at 5 yr. The factors contributing to a poor prognosis for disease-free survival were: No histological response after NAC, largest metastasis > 3 cm, more than three preoperative metastases, R1 resection, and the use of a targeted therapy with NAC (P < 0.005). CONCLUSION A non-radiological response and a number of NAC sessions > 7 are the two most pertinent predictive factors of non-histological response (TRG 4 or 5).

International audience; OBJECTIVE: To compare two techniques of remnant liver hypertrophy in candidates for extended hepatectomy: radiological simultaneous portal vein (PVE) and hepatic vein embolization (HVE); namely liver venous deprivation (LVD), and ALPPS. SUMMARY BACKGROUND DATA: Recent advances in chemotherapy and surgical techniques have widened indications for extended hepatectomy, before which remnant liver augmentation is mandatory. ALPPS and LVD typically show higher hypertrophy rates than PVE, but their respective places in patient management remain unclear. METHODS: All consecutive ALPPS and LVD procedures performed in eight French centers between 2011 and 2020 were included. The main endpoint was the successful resection rate (resection rate without 90-day mortality) analyzed according to an intention-to-treat principle. Secondary endpoints were hypertrophy rates, intra- and post-operative outcomes. RESULTS: Among 209 patients, 124 had LVD 37 [13,1015] days before surgery, while 85 underwent ALPPS with an inter-stages period of 10 [6, 69] days. ALPPS was mostly-performed for colorectal liver metastases (CRLM), LVD for CRLM and perihilar cholangiocarcinoma. Hypertrophy was faster for ALPPS. Successful resection rates were 72.6% for LVD ± rescue ALPPS (n=6) versus 90.6% for ALPPS (p

Highlights • Solitary gastric metastasis of RCC are scarce. • When feasible, surgical or endoscopic treatment of gastric metastasis should be performed. • Risk of metastatic recurrence is significant and must be taken into consideration in the therapeutic strategy., Introduction Renal cell carcinoma (RCC) represents above 3 % of all cancers. At diagnosis, above 25 % of patients with RCC present an advanced disease. Gastric metastasis of RCC is associated with poor outcome. We report the case of a patient treated for a gastric metastasis of RCC and we conducted a systematic review of the literature to report all published cases of RCC patients with gastric metastasis. Case presentation In December 2010, a 61-year-old man was treated by open partial nephrectomy for a localized right clear cell RCC. In September 2018, a metachronous gastric metastasis was found on CT scan. The lesion was located on the lesser curvature of the stomach, measuring 4.5 cm long axis. No other secondary lesions were identified. A laparoscopic wedge resection, converted to laparotomy was performed. Two years later, in September 2020, a CT scan was performed, revealing a 17 mm adenopathy behind the hepatic hilum and a surgical management was performed, including a lymph node dissection of the hepatic hilum and the hepatic artery. Actually, he remains healthy. Clinical discussion and conclusion Our systematic review suggests that solitary gastric metastasis of RCC are scarce. In comparison of patients with multiple metastatic sites, the median survival of patients with solitary gastric metastasis is longer.

Background Anastomotic biliary strictures (AS) is the main surgical complication after liver transplantation. The aims of this study are to investigate the risk factors of AS, its management and its impact on overall survival and survival of the graft. Methods All patients who had received a liver transplantation with duct-to-duct anastomosis at Toulouse University Hospital between 2010 and 2016 were included. Results Of 225 included patients, 56 (24.9%) presented with AS. The median time to discovery of AS was 83 days and 69.6% of the AS appeared within 6 months. Transplantation in critically ill patients, with a liver score >800 points, was an independent predictive factor of survival (P = 0.003). The first-line treatment was endoscopic (87.5%), with a success rate of 79.6% and a median of 4 procedures per patient in 12 months. In cases of failure of endoscopic therapy, percutaneous treatment had a high failure rate (50%). AS had no impact in terms of overall survival or in terms of graft survival. Conclusion AS do not have any repercussions on patient or graft survival, requiring long endoscopic treatment with multiple procedures. In the event of failure of this first-line endoscopic treatment, it seems preferable to turn directly towards surgical repair.

The sulcus of the caudate process is a horizontal groove on the inferior face of the liver. Its prevalence has not previously been determined. Because of its location, it represents a helpful extra-biliary landmark that could be used in biliary surgery to decrease bile duct injury. The goal of this study is to determine the prevalence of Rouviere’s sulcus and describe its anatomy and relevant surgical applications. We conducted a literature review on the various characteristics of the sulcus, selecting anatomical clinical studies and dissections. We performed 10 cadaveric dissections in the Laboratory of Anatomy at Purpan University to determine the contents. We selected 12 anatomical studies, conducted between 1924 and January 1st, 2020, which included 2394 patients. The prevalence of the sulcus is 78.24% ± 9.1. Classification of Singh was used to describe anatomical characteristics. Type I (“deep sulcus”) was identified in 50.4% ± 9.8 of cases, mostly consisting of Type Ia (open). Type II (“slit-like”) was estimated to account for 13.3% ± 13.2, whereas Type III (“scar”) described 12.3% ± 8.0. Average dimensions were estimated for length (26 mm ± 5.7), width (6.5 mm ± 1.5), and depth (7.9 mm ± 1.75). The content of the sulcus consists of the right portal vein and its division, the right hepatic artery, along with the right hepatic bile duct. The sulcus determines the orientation of the common bile duct. The sulcus of the caudate process is a reliable extra-biliary landmark, which presents a useful tool for reducing bile duct injuries during hepatobiliary surgery.

Resume Objectif de l’etude Evaluer la performance diagnostique de l’examen tomodensitometrique (TDM) systematique une semaine apres duodenopancreatectomie cephalique (DPC) dans la detection des complications severes necessitant un traitement invasif. Patients et methodes Cette etude monocentrique retrospective a ete realisee a partir de donnees collectees entre 2005 et 2013. Tous les patients operes d’une DPC avaient un TDM systematique a la fin de la premiere semaine postoperatoire. Les resultats de ce TDM etaient analyses afin d’evaluer l’interet de cette pratique. Le critere de jugement principal etait l’apparition de complications de grade III ou plus dans la classification de Dindo-Clavien. Resultats Cent cinquante-trois patients ont ete inclus. Les taux de mortalite et de morbidite etaient respectivement de 2,2 % et de 57,2 % ; 19,6 % des patients ont presente une fistule pancreatique et 46 patients (33,3 %) ont eu une complication severe. Quinze patients ont ete reoperes avant le TDM systematique. Cent trente-huit TDM ont ete analyses : 44 (31,8 %) etaient consideres comme anormaux, 94 (68,2 %) comme normaux. Chez les patients ayant un TDM anormal, 17 (39 %) ont eu une complication severe necessitant un traitement invasif. Pour les 94 patients avec un TDM normal, 14 patients (15 %) ont developpe une complication severe apres la realisation du TDM. L’evaluation de la performance du TDM a la fin de la premiere semaine postoperatoire retrouvait une sensibilite de 55 %, une specificite de 75 %, une valeur predictive positive de 39 %, et une valeur predictive negative de 85 %. Conclusion Le TDM systematique realise a la fin de la premiere semaine postoperatoire ne permet pas de detecter les complications severes apres DPC et de les traiter precocement.

International audience; Objective - The goal of this study was to evaluate the prognostic role of four preservation solutions in liver transplantation (LT). Patients and methods - This is a retrospective study originating from 22 French centers performing LT, registered in the prospective databank of the Cristal Biomedicine Agency between 2008 and 2013. The preservation solutions used were Celsior (CS), Institut Georges Lopez (IGL)-1, Solution de Conservation des Organes et des Tissus (SCOT) 15 and University of Wisconsin (UW) solutions. Exclusion criteria were preservation with unknown or inhomogeneous solutions, or Histidine-tryptophan-ketoglutarate (HTK) solution (representing only 3% of LT). Patient survival was the main endpoint. Secondary endpoints were graft survival and duration of stay in intensive care. Results - Of 6347 LT performed, 4928 were included in this study, for which the distribution of preservation solution was CS (30%), IGL-1 (44%), SCOT 15 (10%) and UW (16%). Patient survival was 86%, 80% and 74% at 1, 3 and 5 years after LT, respectively, without any statistically significant difference between the four solutions (P=0.78). Graft survival was 82%, 75% and 69% at 1, 3 and 5 years after LT, respectively, without any statistically significant difference between the four solutions (P=0.80). Duration of intensive care was different according to the solution used in univariate analysis (P

Hartmann’s reversal procedures are often fraught with complications or failure to recover. This being a fact, it is often difficult to select patients with the optimal indications for a reversal. The post-recovery morbidity and mortality rates in the literature are heterogeneous between 0.8 and 44%. The identification of predictive risk factors of failure of such interventions would therefore be very useful to help the practitioner in his approach. Given these elements, it was important to us to analyze the practice of two French university hospitals in order to highlight such risk factors and to allow surgeons to select the best therapeutic strategy. We performed a bicentric observational retrospective study between 2010 and 2015 that studied the characteristics of patients who had undergone Hartmann surgery and were subsequently reestablished. The aim of the study was to identify factors influencing morbidity and postoperative mortality of Hartmann’s reversal. Primary outcome was complications within the first 90 postoperative days. 240 patients were studied of which 60.4% were men. The mean age was 69.48 years. The median time to reversal was 8 months. 79.17% of patients were operated as emergency cases where the indication was a diverticular complication (39.17%). Seventy patients (29.2%) underwent a reversal and approximately 43% of these had complications within the first 90 postoperative days. The mean age of these seventy patients was 61.3 years old and 65.7% were males. None of them benefited from a reversal in the first three months. We identified some risk factors for morbidity such as pre-operative low albuminemia (p = 0.005) and moderate renal impairment (p = 0.019). However, chronic corticosteroid use (p = 0.004), moderate renal insufficiency (p = 0.014) and coronary artery disease (p = 0.014) seem to favour the development of anastomotic fistula, which is itself, a risk factor for mortality (p = 0.007). Our study highlights an important rate of complications including significant anastomotic fistula after Hartmann’s reversal. Precarious nutritional status and cardiovascular comorbidities should clearly lead us to reconsider the surgical indication for continuity restoration.

Objectifs : evaluer la correlation radio-histologique de la reponse des CHC postchimioembolisation selon les scores RECIST 1.1, mRECIST, EASL et la captation lipiodolee, les facteurs predictifs de reponse radiologique et de necrose tumorale post-CEL et leur influence sur la survie globale et sans recidive des patients transplantes hepatiques. Patients et methodes : tous les patients transplantes hepatiques avec CHC ayant recu une chimioembolisation entre 01/05/2007 au 31/12/2018 ont ete inclus. La reponse des nodules hypervasculaires a ete evaluee sur les scores mRECIST, EASL et la captation lipidolee et celle des nodules hypovasculaires selon les scores RECIST 1.1 et la captation lipiodolee. Resultats : 70 patients avec 122 CHC hypervasculaires et 28 hypovasculaires ont ete inclus. 34,3% patients ont eu une reponse radiologique complete (RC). Les taux de concordance de mRECIST et EASL avec la necrose tumorale etaient respectivement de 56% et 57% ; celle de la captation lipiodolee etait de 49% pour les nodules hypervasculaires. Les concordances pour les scores RECIST 1.1 et la captation lipiodolee etaient respectivement de 53% et de 50% pour les nodules hypovasculaires. Une atteinte bilobaire hepatique etait predictive de reponse radiologique incomplete. La necrose tumorale majeure etait significativement correlee a la variation du taux d'aFP entre la premiere CEL et la transplantation hepatique. La survie globale a 5 ans etait de 64% et la survie sans recidive de 60% a 5 ans. Une reponse radiologique complete ameliorait de facon statistiquement non significative les survies globale et sans recidive. Conclusion : la reponse radiologique est significativement liee a la necrose tumorale histologique, mais avec une correlation faible : specificite=35%, VPP=54%. En cas de reponse radiologique complete, la survie globale et sans recidive semblent ameliorees.

But Identifier les criteres clinicoradiologiques de resecabilite de l’adenocarcinome pancreatique et developper un score predictif de resecabilite au diagnostic. Methodes Entre 2014 et 2017, 814 patients ont ete inclus par 15 centres de la cohorte prospective BACAP (Base clinicobiologique sur l’adenocarcinome du pancreas : NCT02818829 ). Trois groupes ont ete definis : resecable (Res), localement avance (LA) et metastatique (Met). Des analyses uni et multivariees et un score predictif ont ete realises. Resultats Parmi les 814 patients inclus, 703 ont ete analyses : 164 Res, 266 LA et 273 Met. La mediane de survie etait de 21, 15 et 9 mois, respectivement. En multivarie, 6 criteres etaient associes a une faible probabilite de resecabilite : thrombose cruorique (p = 0,017), score OMS 1 (p = 0,032) > 2 (p = 0,010), douleur abdominale (p = 0,003), perte de poids > 8 % (p = 0,019), localisation tumorale (tete/queue) (p = 0,005) et taille tumorale 20–33 mm (p 33 mm (p http ://jdlp.fr/resectability/ ) avait une precision de 81,17 % et une aire sous la courbe ROC de 0,82 (IC95 % [0,78 ; 0,86]). Conclusions Cette etude permet de definir un profil predictif de resecabilite. La presence de criteres pejoratifs ou un score BACAP

Summary Background To evaluate the performance of CT-scans performed one week after pancreato-duodenectomy (PD) to detect severe postoperative complications requiring an invasive treatment. Patients and methods This monocentric retrospective study was conducted on data collected between 2005 and 2013. Patients undergoing PD underwent CT-scan with IV contrast at the end of the first postoperative week. The results of the CT-scans were analyzed to evaluate the usefulness of this procedure. The main assessment criterion was the occurrence of type-III complication (or greater) according to the Dindo-Clavien classification. Results In total, 138 patients were included. The mortality rate was 2.2%. The postoperative complication rate was 57.2%. The pancreatic fistula rate was 19.6%; 46 patients (33.3%) presented with a severe complication. A total of 138 CT-scans were analyzed: 44 (31.8%) were abnormal, 94 (68.2%) were normal. Among patients with abnormal CT-scans, 17 (39%) presented with a severe complication requiring an invasive treatment. Among the 94 patients with normal CT-scans, 14 patients (15%) presented a severe postoperative complication. Evaluation of the performance of the CT-scans at the end of the first postoperative week found a sensitivity of 55%, a specificity of 75%, a positive predictive value of 39%, and a negative predictive value of 85%. Conclusion Systematic CT-scans performed at the end of the first postoperative week do not effectively detect severe complications after PD and do not help to prevent them.

International audience; Pancreatic cancer is a public health problem because of its increasing incidence, the absence of early diagnostic tools, and its aggressiveness. Despite recent progress in chemotherapy, the 5-year survival rate remains below 5%. Liquid biopsies are of particular interest from a clinical point of view because they are non-invasive biomarkers released by primary tumours and metastases, remotely reflecting disease burden. Pilot studies have been conducted in pancreatic cancer patients evaluating the detection of circulating tumour cells, cell-free circulating tumour DNA, exosomes, and tumour-educated platelets. There is heterogeneity between the methods used to isolate circulating tumour elements as well as the targets used for their identification. Performances for the diagnosis of pancreatic cancer vary depending of the technique but also the stage of the disease: 30-50% of resectable tumours are positive and 50-100% are positive in locally advanced and/or metastatic cases. A significant prognostic value is demonstrated in 50-70% of clinical studies, irrespective of the type of liquid biopsy. Large prospective studies of homogeneous cohorts of patients are lacking. One way to improve diagnostic and prognostic performances would be to use a combined technological approach for the detection of circulating tumour cells, exosomes, and DNA.

Alpha-fetoprotein (AFP) is the main tumor biomarker available for the management of hepatocellular carcinoma (HCC). Although it is neither a good screening test nor an accurate diagnostic tool for HCC, it seems to be a possible prognostic marker. However, its contribution in liver transplantation for HCC has not been fully determined, although its use to predict recurrence after liver transplantation has been underlined by international societies. In an era of organ shortages, it could also have a key role in the selection of patients eligible for liver transplantation. Yet unanswered questions remain. First, the cut-off value of serum AFP above which liver transplantation should not be performed is still a subject of debate. We show that a concentration of 1000 ng/mL could be an exclusion criterion, whereas values of < 15 ng/mL indicate patients with an excellent prognosis whatever the size and number of tumors. Monitoring the dynamics of AFP could also prove useful. However, evidence is lacking regarding the values that should be used. Today, the real input of AFP seems to be its integration into new criteria to select patients eligible for a liver transplantation. These recent tools have associated AFP values with morphological criteria, thus refining pre-existing criteria, such as Milan, University of California, San Francisco, or "up-to-seven". We provide a review of the different criteria submitted within the past years. Finally, AFP can be used to monitor recurrence after transplantation, although there is little evidence to support this claim. Future challenges will be to draft new international guidelines to implement the use of AFP as a selection tool, and to determine a clear cut-off value above which liver transplantation should not be performed.

AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), after failure of previous portal embolization. We also performed a literature review. METHODS Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization (PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps (ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened during the interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification. RESULTS From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc (221-380), 450 cc (372-506), and 660 cc (575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4% (0.3-0.5), 0.6% (0.5-0.8), and 1% (0.8-1.2). Median volume growth of FLR was 69% (18-92) after PVE, and 45% (36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc (254-513), leading to an increase of +149% (68-199). After ALPPS-2, 4 patients had stage I-II complications. Three patients had more severe complications (one stage III, one stage IV and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure. CONCLUSION Rescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.