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Psychosocial disorders ranging from anxiety to severe psychiatric diseases and active alcohol/substance abuse are frequent in liver transplant candidates and potentially associated with worse post- transplant outcomes. Therefore, psychosocial evaluation is mandatory to optimize success after liver transplantation. However, how to carry out this evaluation, the type of intervention needed and its potential impact on patient outcome remain unclear.To investigate whether psychosocial assessment may help in predicting risks of poor outcome; and to investigate whether psychosocial interventions may mitigate these risks and improve posttransplant outcomes, in particular compliance and speed of recovery.Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The protocol was registered on PROSPERO CRD42021238361. Main outcomes assessed were mortality, alcohol relapse, rejection, and medication compliance.Fifteen studies were analyzed including five observational comparative and ten observational noncomparative studies. Preoperative psychosocial evaluation of LT candidates was associated with higher concordance with the treatment plan (i.e., higher adherence to treatment and lower alcohol relapse) and lower rates of rejection. Psychosocial assessment tools were used in some studies to guide the evaluation, but their predictive ability remains debated, and they should not be used in isolation. Most of the interventions were studied in patients with alcohol related issues. In this context, support by specialized teams was associated with better posttransplant outcome, especially through a decrease in post-transplant alcohol relapse.Preoperative psychosocial assessment should be provided in order to detect patients at increased risk of poorer post-transplant outcome, in particular in terms of concordance to the treatment plan (Quality of Evidence; Low | Grade of Recommendation; Strong/For). The experts suggest that, when possible, provision of preoperative psychological assessment and concomitant interventions aimed at improving the concordance to treatment plans will positively impact the success of liver transplantation. (Quality of Evidence; Very Low | Grade of Recommendation; Strong/For].

Resume Introduction La delegation a l’innovation en sante (DIES) a ete creee au sein du ministere des Solidarites et de la Sante pour centraliser et accompagner les projets innovants en sante. A la suite de sa suppression, apres 2 ans et demi d’existence, les membres de cette delegation presentent les projets qui lui ont ete soumis. Methodes Les porteurs de projets etaient recus sans prealable au ministere de la Sante pour exposer l’objectif sanitaire et economique de leur projet. Ces projets etaient classes selon leur objectif, leur typologie, la specialite medicale concernee, la population cible et leur finalite. La DIES graduait leur degre d’innovation, conseillait sur la necessite d’une evaluation scientifique complementaire et orientait eventuellement vers les structures de financement idoines. Resultats D’avril 2016 a decembre 2018, la DIES a recu 269 porteurs quasi exclusivement issus du territoire national de projets centres sur des specialites medicales tres diverses avec une tendance a cibler les maladies chroniques et le handicap. Les porteurs etaient souvent a une etape de developpement economiquement fragile. Moins de 5 % des projets concernaient les medicaments. Plus d’un tiers concernaient des dispositifs medicaux, incluant les projets « chirurgicaux » domines par l’orthopedie, la compensation du handicap, le vasculaire et les pansements. La e-sante, l’organisation des soins et une categorie « non classable », incluant les projets de bien-etre, representaient respectivement 20 % des projets chacune. Pres de 80 % de ces projets pouvaient etre « connectes ». Seuls 15 % de l’ensemble des projets avaient l’ambition de repondre a un besoin non ou mal couvert. Environ un tiers des porteurs de projets presentaient une evaluation clinique ou medicoeconomique avec une methodologie suffisamment rigoureuse pour evaluer l’atteinte de leurs objectifs. Conclusion Les projets de sante, se considerant comme innovants, sont domines par la recherche d’une amelioration de l’organisation du systeme des soins et du parcours des malades avec des applications connectees. La grande majorite de ces projets sera tres difficile a evaluer et cette situation renforce l’interet d’une centralisation des demandes pour ameliorer l’accompagnement des porteurs d’innovation.

Summary Introduction The Delegation for Innovation in Health Care (DIES) was created by the Ministry of Solidarity and Health to centralize and support innovative health care projects. Following its dissolution, only two and a half years after its creation, the members of this delegation aimed to present the projects, which were submitted and treated by the DIES. Methods All potential project leaders were free to explain the objectives of their project to our team. These projects were then classified according to their objective, their type, the medical specialty concerned, the target population and their purpose. The DIES graded the degree of innovation, advised on the need for complementary scientific evaluation and oriented the personnel in charge towards fitting financing structures. Results Between April 2016 and December 2018, the DIES received 269 potential project leaders, almost exclusively from the national territory of France, focused on diversified medical specialties with a slight predilection for chronic diseases and disabilities. The projects were often at an economically tenuous stage of development. Less than 5% of the projects concerned drug therapy. More than a third involved medical devices, including “surgical” projects (predominately orthopedics), disability compensation methodology, vascular problems and bandages. E-health, the organization of care, and a “non-classifiable” category that included wellness projects each represented 20% of the projects. Almost 80% of these projects had some electronically (e-) based mechanism. Only 15% of all projects had the ambition to meet an unmet or poorly covered need. Only about a third of the project leaders presented a clinical or medico-economic evaluation with sufficiently rigorous methodology to assess the achievement of their objectives. Conclusion Innovative health projects are dominated by the search for improvement in the organization of the health care system and the care pathway with e-connected applications. Evaluation of the vast majority of these projects is very difficult and this situation reinforces the idea that these requests should be centralized to improve support for promoters of innovation.

Resume Pour faciliter la prise en charge des reclamations en lien avec la Covid-19, la Direction des Affaires Juridiques et des Droits des Patients de l’AP–HP a constitue une cellule medicale assistee de juristes destinee a revoir l’etat des connaissances et les mesures organisationnelles au cours de la premiere vague de l’epidemie. Cette cellule a regroupe des medecins identifies en raison de leurs competences scientifiques dans les principales specialites impliquees au cours de cette infection et pour certains, par leurs connaissances en matiere de reparation du dommage corporel. A partir des donnees de la litterature scientifique, des tableaux de bord hospitaliers et du recueil des procedures hospitalieres mises en place pour les patients Covid-19 et non Covid-19, l’objectif de cette cellule a ete de recueillir l’etat des connaissances scientifiques et les mesures organisationnelles au debut de l’epidemie, a son pic et au moment du de-confinement. Ce travail montre qu’au cours des trois periodes de cette pandemie des modifications de prise en charge ont ete observees concernant les admissions avec une plus grande selectivite par la prise en compte du terrain et des comorbidites. La prise en charge medicamenteuse a ete en constante evolution et les mesures d’isolement ont ete plus rigoureuses avec interruption des droits de visite. Les mesures hospitalieres de prevention des contaminations avaient pour objectif d’eviter la contamination des sujets non infectes et de proteger les soignants pour maintenir les forces de soins. L’absence de selection des malades admis en reanimation pour assurer une compensation de leur defaillance respiratoire a necessite pour l’AP–HP, un doublement du nombre de lits de reanimation et des transferts inter-regionaux. Dans un contexte de connaissances scientifiques non stabilisees avec des mesures organisationnelles evolutives le recueil de ces donnees devrait faciliter l’analyse des reclamations en lien avec la Covid19 au sein de l’AP–HP et initier une etude prospective face a la seconde vague de cette pandemie.

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

OBJECTIVES The determinants of refractory ascites have not been fully characterized. The aims of this study were to assess liver histopathological alterations associated with refractory ascites and their relationship with comorbidities. METHODS Consecutive patients with cirrhosis who underwent liver transplantation were retrospectively included. Patients' characteristics at the time of listing were analysed. The native livers were reviewed and lesions associated with refractory ascites were examined. RESULTS Out of the 89 patients included, 30 had refractory ascites and 59 did not (including 35 without ascites and 24 with diuretic-sensitive ascites). Patients with and without refractory ascites had a similar amount of fibrous tissue and features of fatty liver disease. By contrast, microvascular changes, namely sinusoidal dilatation (P < 0.001), diffuse perisinusoidal fibrosis (P = 0.001), hepatic venous thromboses (P = 0.004) and vascular proliferation (P = 0.01) were more frequently observed in the livers of patients with refractory ascites. Diabetes (57% vs. 31%, P = 0.02) and alcohol as a causal factor for cirrhosis (80% vs. 42%, P = 0.001) were more frequent in patients with refractory ascites than in those without. By multivariate analysis, refractory ascites was independently associated with diabetes mellitus [odds ratio (OR) (95% confidence interval, CI) 6.15 (1.47-25.71); P = 0.01], alcohol as a causal factor for cirrhosis [OR (95% CI) 4.63 (1.07-20.02); P = 0.04], higher Model For End Stage Liver Diseases [OR (95% CI) 1.21 (1.05-1.38); P = 0.008] and lower serum sodium [OR (95% CI) 0.87 (0.78-0.98); P = 0.03]. CONCLUSION Liver microcirculatory changes are associated with refractory ascites. Diabetes and alcohol may explain refractory ascites by causing microangiopathy.

The liver hanging maneuver (LHM) was described by Belghiti et al. to facilitate liver resection and is done classically by creating a space between the caudate lobe and the inferior vena cava starting on the edge of caudate lobe and extending cranially, in a para-caval fashion, towards the space between the right and middle hepatic veins. LHM facilitates liver transection, guides anatomical resections, decreases blood loss, facilitates harvesting of the liver graft in live donors, and also has oncological advantages. We describe a new approach named “up-to-down” to perform LHM in open and laparoscopic liver resections. This approach was mainly used in obese patients, in laparoscopic liver resections and in cases of failure of the classic approach. The advantages/disadvantages, complications, and different modalities of LHM are also summarized. The peritoneal layer between the liver capsule and the infrahepatic vena cava is opened, and a short blind dissection is initiated on the right anterolateral aspect of the inferior vena cava to the left of the hepatic vein of segment VI. The suprahepatic vena cava is exposed, and the space between the right and middle hepatic veins and the vena cava is created by gentle dissection. A 16-Fr nasogastric tube is positioned in the space between the right and middle hepatic vein, pointing inferiorly, and pushed downwards, in a para-caval manner caudally until it is seen inferiorly. The results of this approach are given. LHM facilitates liver resection, and many variations have been described worldwide in open and laparoscopic liver surgery. The up-to-down approach should be part of the surgical armamentarium in order to offer a safer way to achieve LHM in some patients.

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.

Connected health objects and medical devices.A clear distinction is required between connected devices which change patient's care and those intended to im¬prove his well-being. Connected devices with a medical objective must obtain a CE mark assessing the technical reliability of both the physical piece and the associated software, but also ensuring the control of the hosting of data. Those who demonstrate individual or collective improvement in the diagnosis or treatment of a disease may be financed by the community. This reimbursement is the main tool in France expecting to reduce the digital divide.Objets de santé et dispositifs médicaux connectés.L’expansion des objets connectés impose de distinguer ceux qui modifient la prise en charge d’un malade, à finalité médicale et ceux destinés à améliorer son bien-être. Les dispositifs connectés ayant une finalité médicale doivent obtenir un marquage CE pour évaluer la fiabilité technique de l’objet physique et du logiciel associé mais aussi pour garantir le contrôle de l’hébergement des données. Ceux qui démontrent une amélioration indivi¬duelle ou collective du diagnostic ou du traitement d’une maladie peuvent être pris en charge par la collectivité. Ce soutien financier représente en France le principal outil pour limiter la fracture numérique.

"Robots set up in the operating theater. The patient's benefit after a minimally invasive approach stimulated the robotic approach of abdominal and thoracic surgical procedures. Although much more expensive, the robots improve the vision of the operating field, the precision of the gestures with a faster training course for the surgeon who operates more comfortably. Surgeons eager for technological progress quickly adopted this technique in urology and gynecology and then in thoracic and digestive procedures. In France, the support for this innovation by academic and medical institutions is limited by several factors including the supremacy of Intuitive which imposes its prices, the absence of scientifically proven superiority, the absence of surveys under the responsibility of scientific societies and the lack of criteria concerning the surgeon training.""Les robots s’installent au bloc opératoire. Les bénéfices de l’approche mini-invasive abdominale et thoracique ont stimulé l’approche robotique. Bien que beaucoup plus coûteux, les robots améliorent la vision du champ opératoire, la précision des gestes avec un apprentissage plus rapide pour le chirurgien qui opère plus confortablement. Les chirurgiens avides de progrès technologiques s’emparent rapidement de cette technique en urologie et en gynécologie puis en thoracique et en digestif. Le monopole imposé par la société Intuitive qui impose ses prix, l’absence de supériorité démontrée scientifiquement, de registres sous la responsabilité de sociétés scientifiques et de critères concernant la formation des chirurgiens à cette nouvelle technique ne favorise pas le soutien des institutions françaises pour accompagner cette innovation."

Hemorrhage is the main complication of hepatocellular adenoma (HCA). The aim of this study was to describe a single center's evolving management of patients with hemorrhagic HCA.Between 1990 and 2013, all patients with hemorrhagic HCA were included. During the study period, the management evolved from urgent surgery (period2004) to arterial embolization with (period, 2004-2010) or without (period 2010) delayed resection.A total of 56 patients were identified. The median (range) size of HCA and the hematoma was 80 mm (35-160) and 50 mm (10-160). Patients were treated by urgent resection (group 1, n = 6), delayed resection with or without embolization (group 2, n = 43) and systematic embolization without surgery (group 3, n = 7). Embolization was performed in 0/6, 15/43 and 7/7 in groups 1, 2 and 3. Urgent resection was associated with higher morbidity (p 0.001). Complete necrosis was observed in 0/6, 13/43 and 3/7 patients, and on histology it was associated with embolization (p = 0.001), a hematoma-tumor ratio 60% (p = 0.046) and a cystic non-viable lesion before surgery (p 0.001).Hemodynamic stability can be achieved in patients presenting with hemorrhagic HCA by none surgical means. Subsequent surgery can be completely avoided with such an approach in up to 40% of patients.

Resume La polykystose hepatique (PKH) peut s’integrer dans le cadre de la polykystose hepatorenale autosomique dominante ou de la polykystose hepatique isolee sans atteinte renale. L’histoire naturelle des kystes hepatiques est d’augmenter en taille et en nombre, realisant une maladie evolutive qui peut aboutir a une hepatomegalie tres volumineuse et invalidante. Seules les hepatomegalies symptomatiques (douleur, gene alimentaire, amaigrissement, dyspnee) ou les complications de kystes (infection ou hemorragie intrakystique) doivent etre traitees. Le traitement de la PKH recouvre donc une palette large, allant de l’abstention a la transplantation hepatique en passant par la ponction evacuation avec injection de produit sclerosant, la fenestration coelioscopique et la fenestration par laparotomie associee a une resection hepatique. Le choix entre ces differents traitements depend de la symptomatologie, de l’extension intrahepatique des lesions et du terrain. La resection hepatique est justifiee par le fait que la grande majorite des PKH est constituee de multiples kystes de petite taille, impossibles ou difficiles a fenetrer. Comme les kystes sont repartis de facon inhomogene dans le parenchyme avec le plus souvent un territoire moins atteint, la sauvegarde de ce territoire permet une regeneration hepatique relativement indemne de kystes. Les hepatectomies sur PKH sont techniquement difficiles car les plans ainsi que les structures vasculaires et biliaires sont refoules par les kystes. La transplantation hepatique, isolee ou associee a une transplantation renale, est indiquee en cas de denutrition severe et/ou d’insuffisance renale terminale ou si le volume de parenchyme preserve est insuffisant et laisse prevoir un echec d’une hepatectomie partielle.

Polycystic liver disease (PLD) may consist of autosomal dominant PLD or isolated PLD without renal impairment. The natural history of liver cysts is to increase in size and number, causing progressive disease that can lead to very large and incapacitating hepatomegaly. Only symptomatic hepatomegaly (pain, inability to eat, weight loss, dyspnea) or cystic complications such as infection or intracystic hemorrhage should be treated. The treatment of PLD thus covers a wide range of therapeutic options, ranging from non-intervention to liver transplantation, including needle aspiration evacuation with injection of sclerosant, laparoscopic fenestration and fenestration by laparotomy combined with liver resection. The choice between these different treatments depends on the symptomatology, the intrahepatic extension of the lesions and the patient's general condition. Hepatic resection is commonly chosen since the vast majority of PLD consists of multiple small cysts that are impossible or difficult to fenestrate. Since cysts are inhomogeneously distributed in the hepatic parenchyma with most areas less affected, the preservation of this less-involved territory allows liver regeneration relatively free of cysts. Hepatectomies for PLD are technically difficult because the planes and the vascular and biliary structures are compressed by the cysts. Liver transplantation, whether isolated or associated with renal transplantation, is indicated in cases of severe malnutrition and/or end-stage renal disease or if the volume of remnant parenchyma is insufficient and suggests failure of a partial hepatectomy.

The prolonged life expectancy and increase in aging of the population have led surgeons to propose hepatectomy in the elderly population. In this study, we evaluate the surgical outcome of octogenarians in a single French center. Between 2000 and 2020, 78 patients over 80 years old were retrospectively analyzed. The risk factors of major complications (Clavien-Dindo ≥ grade IIIa) and patient performance after surgery by using textbook outcome (TO) (no surgical complications, no prolonged hospital stay (≤ 15 days), no readmission ≤90 days after discharge, and no mortality ≤90 days after surgery) were studied. The main surgical indication was for malignancy (96%), including mainly colorectal liver metastases (n = 41; 53%) and hepatocellular carcinoma (n = 22; 28%), and major hepatectomy was performed in 28 patients (36%). There were 6 (8%) postoperative mortalities. The most frequent complications were pulmonary (n = 22; 32%), followed by renal insufficiency (n = 22; 28%) and delirium (n = 16; 21%). Major complications occurred in 19 (24%) patients. On multivariate analysis, the main risk factors for major complications were the median vascular clamping time (0 vs 35; P = 0.04) and male sex (P = 0.046). TO was ultimately achieved in 30 patients (38%), and there was no prognostic factor for achievement of TO. Hepatectomy in octogenarians is associated with acceptable morbidity and mortality. Meanwhile, prolonged hepatic pedicle clamping should be avoided especially if hepatectomy is planned in a male patient.

In patients with polycystic liver disease (PLD), development of cysts induces hepatic venous outflow obstruction (HVOO) and parenchymal modifications, challenging the paradigm of a normal noncystic liver parenchyma. The aims were to reappraise the pathology of the noncystic parenchyma, by focusing on HVOO lesions; and to investigate the association with outflow obstruction at imaging and perioperative course after liver resection. This is a retrospective study conducted in one tertiary center between 1993 and 2014. PLD patients (n = 125) who underwent resection (n = 90) or transplantation (n = 35) were included. HVOO parenchymal lesions were assessed for all patients and a liver congestion score was built. Imaging was analysed for 45 patients with computed tomography scan, and perioperative course was assessed in resected patients. At pathology, 92% of patients had HVOO lesions, with sinusoidal dilatation being the most common feature. HVOO was more severe in patients who underwent transplantation compared to liver resection, as assessed by the congestion score. At imaging, all patients had HVOO with at least two hepatic veins involved. Mosaic enhancement pattern of the parenchyma was associated with the severity of hepatic vein obstruction (P = 0.045) and the compression of the inferior vena cava (P = 0.014). In case of liver resection, intraoperative course was characterized by hemorrhage, related to HVOO at imaging. Ascites (44%) and liver failure (9%) in the postoperative period were associated with blood losses and transfusions. Conclusion Hepatic venous outflow obstruction, including development of venous collaterality and parenchymal changes, is frequent in PLD and has major consequences on intraoperative bleeding and postoperative ascites and liver failure. Hepatic venous outflow obstruction should be taken into account to choose the most appropriate surgical treatment. (Hepatology 2017).

Resume Les objets connectes (OC), dispositifs medicaux ou non, sont utilises en recherche clinique pour le recueil de donnees, leur action propre (communication, diagnostic, effecteur…) ou plusieurs fonctions combinees. Leur validation doit porter sur trois axes : la fiabilite technique et clinique, la protection des donnees et la cybersecurite. A ce titre, la table ronde recommande que la typologie des OC, leurs usages et limites soient connus et partages par l’ensemble des acteurs, notamment pour la mise en place de cahier des charges precis. Les OC sont utilises en recherche clinique au cours d’etudes observationnelles (evaluation de l’objet lui-meme ou recueil de donnees), d’etudes randomisees ou un seul groupe dispose de l’OC (evaluation de son impact sur le suivi ou la prise en charge du patient), ou d’etudes randomisees ou les deux groupes disposent de l’OC, celui-ci etant alors utilise comme outil d’aide a l’evaluation. Les avantages de l’usage des OC en recherche clinique comportent l’amelioration de la collecte et de la qualite des donnees, de l’observance des patients et de la pharmacovigilance, une realisation plus aisee des e-cohortes et une meilleure representativite des patients. Les limites et risques societaux identifies sont lies au caractere parfois intrusif de certains parametres recueillis et a la possibilite de detournement de finalite des donnees. La table ronde recommande sur ce dernier point l’anticipation par la securisation des modes de transmission, la qualification des hebergeurs de donnees et l’evaluation de la vulnerabilite de l’objet. Pour cela, une analyse des risques semble necessaire a chaque projet. Il faut egalement documenter precisement le parcours des donnees pour en informer a la fois les patients, mais aussi les professionnels de sante, et garantir une securisation suffisante. L’anticipation reglementaire et l’implication des utilisateurs des la conception de l’etude sont egalement recommandes.

Summary Connected objects (CO), whether medical devices or not, are used in clinical research for data collection, a specific activity (communication, diagnosis, effector, etc.), or several functions combined. Their validation should be based on three approaches: technical and clinical reliability, data protection and cybersecurity. Consequently, the round table recommends that the typology of COs, their uses and limitations, be known and shared by all, particularly for implementing precise specifications. COs are used in clinical research during observational studies (assessment of the device itself or data collection), randomized studies, where only one group has a CO (assessment of its impact on patient follow-up or management), or randomized studies where both groups have a CO, which is then used as a tool to help with assessment. The benefits of using COs in clinical research includes: improved collection and quality of data, compliance of patients and pharmacovigilance, easier implementation of e-cohorts and a better representative balance of patients. The societal limits and risks identified relate to the sometimes intrusive nature of certain collected parameters and the possible misuse of data. The round table recommends the following on this last point: anticipation, by securing transmission methods, the qualification of data hosts, and assessment of the object's vulnerability. For this, a risk analysis appears necessary for each project. It is also necessary to accurately document the data flow, in order to inform both patients and healthcare professionals and to ensure adequate security. Anticipating regulatory changes and involving users starting from the study design stage are also recommended.

RESUME La prostatectomie totale chirurgicale reste le traitement de choix pour un cancer localise. Quel que soit l’approche chirurgicale de la prostatectomie il existe un risque important d’incontinence urinaire et d’impuissance postoperatoire. En depit de son cout tres eleve, l’approche laparoscopique assistee par robotique se developpe massivement sans arguments en faveur d’une reduction des complications et d’une diminution des recidives. A la suite d’une saisine du ministere de la sante, la HAS a evalue en 2016 les dimensions cliniques, organisationnelle ainsi que l’efficience de la prostatectomie robot-assistee afin de statuer sur sa prise en charge par la collectivite. Sur la base des donnees de la litterature, des recommandations des societes savantes et des conclusions d’un groupe de travail, le document elabore par la HAS confirme que: (a) l’approche mini-invasive, incluant la laparoscopie standard et la voie robotique, reduit les pertes sanguines operatoires et diminue la duree d’hospitalisation; (b) toutes les approches chirurgicales ont un taux similaire de dysfonction urinaire et sexuelle en postoperatoire; (c) aucune approche chirurgicale n’apporte un benefice oncologique et (d) il existe une equivalence des resultats cliniques entre la laparoscopie standard et la voie robotique. En depit de ces resultats, la HAS s’est prononcee en faveur d’une prise en charge de la prostatectomie robotique. Les arguments qui ont conduit a cette decision incluent l’adhesion massive des chirurgiens urologues en faveur de cette approche qui ameliore la vision en 3 dimensions du champ operatoire, facilite la gestuelle avec un meilleur confort que la laparoscopie standard. Bien que le nombre d’etudes comparatives a fort niveau de preuves soit limite, il n’existe pas de donnees montrant un sur-risque de complications ou une reduction du benefice carcinologique de l’approche robotique. Enfin le remboursement de cet acte va permettre d’ implementer des procedures de controle de qualite dans les etablissements utilisateurs, de controler l’information partagee avec les malades et surtout obtenir un registre pour evaluer les incidents techniques, les complications et les resultats carcinologiques a long terme d’une pathologie dont l’exerese chirurgicale reste discutee. L’absence de superiorite ne doit pas etre un argument pour se figer sur des procedures classiques et la decision de la HAS vise a controler une veritable innovation.

Background Pre-existing chronic liver diseases and the complexity of the transplant surgery procedures lead to a greater risk of further surgery in transplanted patients compared to the general population. The aim of this monocentric retrospective cohort study was to assess the epidemiology of surgical complications in liver transplanted patients who require further surgical procedures and to characterize their post-operative risk of complications to enhance their medical care. Patients and methods From January 1997 to December 2011, 1211 patients underwent orthotropic liver transplantation in our center. A retrospective analysis of prospectively collected data was performed considering patients who underwent surgical procedures more than three months after transplantation. We recorded liver transplantation technique, type of surgery, post-operative complications, time since the liver transplant and immunosuppressive regimens. Results Among these, 161 patients (15%) underwent a further 183 surgical procedures for conditions both related and unrelated to the transplant. The most common surgical procedure was for an incisional hernia repair (n = 101), followed by bilioenteric anastomosis (n = 44), intestinal surgery (n = 23), liver surgery (n = 8) and other surgical procedures (n = 7). Emergency surgery was required in 19 procedures (10%), while 162 procedures (90%) were performed electively. Post-operative mortality and morbidity were 1% and 30%, respectively. According to the Dindo-Clavien classification, the most common grade of morbidity was grade III (46%), followed by grade II (40%). Conclusion Surgical procedures on liver transplanted patients are associated with a significantly high risk of complications, irrespective of the time elapsed since transplantation.

Except in Budd-Chiari syndrome, alternative drainage pathways have been described rarely. The aim was to describe the alternative collaterals pathways due to tumor hepatic vein (HV) confluence obstruction and its impact in the setting of liver resection.Between 2006 and 2014, preoperative CT scans of 41 patients resected for malignant tumor(s) compressing the HV confluence were assessed for the presence of accessory veins and collateral veins. A 2:1 matched control group was used for comparison of intraoperative outcomes.Intrahepatic collaterals were observed in 28 (68%) patients, mostly between segments 3/4b and 5/4b, and subcapsular collaterals were observed in 12 (29%) patients. Patients with isolated right HV obstruction and with an accessory right HV present had fewer collateral pathways develop than patients without (6 of 10 patients [60%] vs 18 of 19 [95%]; p = 0.036). Segment 1 hypertrophy was present in only 6 (15%) patients. Compared with the control group, there was a significant increase in blood loss (900 mL [range 100 to 3,500 mL] vs 500 mL [range 100 to 2,600 mL]; p0.001), transfusion requirements (71% vs 15%; p 0.001), and vascular clamping (hepatic pedicle: 85% vs 72%; p0.001, inferior vena cava: 41% vs 11%; p0.001) in case of HV obstruction.Development of collateral pathways is not fortuitous and depends on the number of HVs involved and pre-existing accessory veins. The increased blood loss observed in patients with collaterals leads to consider specific vascular clamping.

Summary Background Supra-mesocolic surgery (SMS) is complicated in patients with portal vein cavernoma (PC) and portal decompression is recommended. The aim of this study was to report a large single centre of SMS in patients with PC without portal decompression. Methods Between 2006 and 2013, all patients who met inclusion criteria were analyzed retrospectively. The primary endpoint was the feasibility rate, surgical and postoperative outcome. The secondary endpoints were the long-term outcome of patients who underwent biliary bypass for cholangitis. Risk factors for complications were studied. Results Thirty patients underwent 51 procedures. Pancreatitis was the main etiology of PC (19/30) and biliary obstruction was mainly related to the underlying disease and not to portal cholangiopathy (12/14). All planned procedures were successfully completed. Fourteen patients underwent biliary bypass. Median blood loss (250 ml), transfusion (n = 7), mortality (n = 0), overall morbidity (n = 12) and the median hospital stay (10 days). Good long-term control of cholangitis was achieved in the 9 patients alive with available follow-up. Significant risk factors for complications were a previous abdominal wall scar, previous intra-abdominal surgical field and liver fibrosis. Conclusion SMS can be safely performed in patients with PC. In patients with risk factors for complications, portal decompression should be discussed.

Early biliary complications (EBC) following pancreaticoduodenectomy (PD) are poorly known. This study aimed to assess incidence, predictive factors, and treatment of EBC including bilio-enteric stricture, transient jaundice, biliary leak, and cholangitis.From 2007 to 2011, 352 patients underwent PD. Statistical analysis including logistic regression was performed to determine EBC predictive factors.49 patients (14%) developed 51 EBC, including 7(2%) bilio-enteric strictures, 15(4%) transient jaundices, 9(3%) biliary leaks, and 20(6%) cholangitis with no mortality and a 18% reoperation rate. In multivariate analysis, male gender, benign disease, malignancy with preoperative chemoradiation, and common bile duct (CBD) diameter ≤ 5 mm were predictive of EBC. Of the 7 strictures, all were associated with CBD ≤ 5 mm and 5(71%) required reoperation. Transient jaundice resolved spontaneously in all 15 cases. Among 8 patients with serum bilirubin level50 μmol/L (3 mg/dL) at POD3, 7(88%) developed bilio-enteric stricture. Biliary leak resolved spontaneously in 5(56%); otherwise, it required reoperation. Cholangitis recurred after antibiotics discontinuation in 5(25%).EBC following PD do not increase mortality. EBC are more frequent with male gender, benign disease, malignancy with preoperative chemoradiation, and CBD ≤ 5 mm. Transient jaundice or cholangitis has a favorable outcome, whereas bilio-enteric stricture or biliary leak can require reintervention.

Background Hepatocellular carcinoma (HCC) recurrence remains a key issue after liver transplantation. This study aimed to determine a subgroup of HCC patients within the Milan criteria who could achieve a theoretical goal of zero recurrence rates after liver transplantation. Methods Between 1999 and 2009, 179 patients who received liver transplantation for HCC within the Milan criteria were retrospectively included. Analysis of the factors associated with HCC recurrence was performed to determine the subgroup of patients at the lowest risk of recurrence. Results Seventy-two percent of the patients received a bridging therapy, including 54 liver resections. Eleven (6.1%) patients recurred within a delay of 19±22 months and ultimately died. Factors associated with recurrence were serum alpha-fetoprotein level >400 ng/mL, satellite nodules, poor differentiation, microvascular invasion and cholangiocarcinoma component. Recurrence rates decreased from 6.1% to 3.1% in patients without any of these factors. Conclusions Among HCC patients within the Milan criteria, selecting patients with factors based on histology would allow tending towards zero recurrence, and prior histological assessment by liver biopsy or resection may be essential to rule out poorly differentiated tumors, microvascular invasion, and cholangiocarcinoma component.

Different staging systems have been devised for patients undergoing resection for hepatocellular carcinoma (HCC) with disparate results. The aim of this study was to create a new nomogram to predict individual survival after hepatectomy for HCC. Based on the “Hepatocellular Carcinoma: Eastern & Western Experiences Network,” data from 2046 patients who underwent HCC resections at ten centers were reviewed. Patient survival was analyzed with Cox-regression analysis to construct a unique nomogram and contour plots to predict survival. The nomograms built on the multivariate analyses, which showed that the independent predictors were tumor size, tumor number, vascular invasion, cirrhosis, preoperative bilirubin value, and esophageal varices, showed good calibration and discriminatory abilities with C-index value of 0.62 (95 % CI, 0.59–0.69) and 0.61 (95 % CI, 0.56–0.64) for overall and disease-free survival, respectively. The 5-year survival contour plots showed that the presence of vascular invasion was associated with decreased survival, regardless of the tumor number or size. Cirrhosis and varices were equally associated with decreased survival, according to the tumor number or size. These nomograms accurately predict individual prognosis after HCC resection and support an expansion of the selection criteria for resection. They offer useful guidance to clinicians for individual survival prediction.

A ≥ 1-mm margin is standard for resection of colorectal liver metastases (CLM). However, R1 resection is not rare (10–30%), and chemotherapy could mitigate its impact. The possibility of detaching CLM from vessels (R1 vascular margin) has been described. A reappraisal of R1 resection is needed. A 19-question survey regarding R1 resection for CLM was sent to hepatobiliary surgeons worldwide. Seven clinical cases were included. In total, 276 surgeons from 52 countries completed the survey. Ninety percent reported a negative impact of R1 resection (74% local recurrence, 31% hepatic recurrence, and 36% survival), but 50% considered it sometimes required for resectability. Ninety-one percent of responders suggested that the impact of R1 resection is modulated by the response to chemotherapy and/or CLM characteristics. Half considered the risk of R1 resection to be an indication for preoperative chemotherapy in patients who otherwise underwent upfront resection, and 40% modified the chemotherapy regimen when the tumor response did not guarantee R0 resection. Nevertheless, 80% scheduled R1 resection for multiple bilobar CLM that responded to chemotherapy. Forty-five percent considered the vascular margin equivalent to R0 resection. However, for lesions in contact with the right hepatic vein, right hepatectomy remained the standard. Detachment from the vein was rarely considered (10%), but 27% considered detachment in the presence of multiple bilobar CLM. A negative margin is still standard for CLM, but R1 resection is no longer just a technical error. R1 resection should be part of the modern multidisciplinary, aggressive approach to CLM.

Background & Aims Although hepatocellular adenoma (HCA) is more frequently observed in obese patients, however, the effect of weight loss as a therapeutic option was never studied. Methods In this rapid communication we described our non-surgical management of large HCA (>5 cm) encountered in patients with morbid obesity. Non-surgical management consisted mainly of oral contraception withdrawal and weight loss, which was the only option in two patients. All demographics, radiological and histological data were studied. Patients were followed regularly every 6 months. Results Between 2004 and 2013, 116 patients presented with HCA and 15 with morbid obesity (13%) were studied. Five men underwent surgery and females were either operated (period before 2010; n = 5) or proposed to non-surgical management (period after 2010; n = 5).Weight loss was advocated to all females, including four with residual HCA after resection and to non-operated patients, including two with haemorrhagic HCA. Four (40%) females showed significant weight loss. In resected patients, weight loss allowed stability (n = 1) or slight regression (n = 1) of residual HCA. In the two patients treated only by weight loss, significant decrease was observed in the weight with significant decrease (>50%) in the size and number of HCA to a non-surgical size (

Objective To evaluate the parietal peritoneum (PP) as an autologous substitute for venous reconstruction during hepatopancreatobiliary (HPB) surgery. Background Venous resection during liver or pancreatic resection may require a rapidly available substitute especially when the need for venous resection is unforeseen. Methods The PP was used as an autologous substitute during complex liver and pancreatic resections. Postoperative anticoagulation was standard and venous patency was assessed by routine computed tomographic scans. Results Thirty patients underwent vascular resection during pancreatic (n = 18) or liver (n = 12) resection, mainly for malignant tumors (n = 29). Venous resection was an emergency procedure in 4 patients due to prolonged vascular occlusion. The PP, with a mean length of 22 mm (15-70), was quickly harvested and used as a lateral (n = 28) or a tubular (n = 2) substitute for reconstruction of the mesentericoportal vein (n = 24), vena cava (n = 3), or hepatic vein (n = 3). Severe morbidity included Clavien grade-III complications in 4 (13%) patients but there was no PP-related or hemorrhagic complications. Histological vascular invasion was present in 18 (62%) patients, and all had an R0 resection (100%). After a mean follow-up of 14 (7-33) months, all venous reconstructions were patent except for 1 tubular graft (97%). Conclusions A PP can be safely used as a lateral patch for venous reconstruction during HPB surgery; this could help reduce reluctance to perform vascular resection when oncologically required. Clinical trials identification: NCT02121886.

Objective: The purpose of the study was to analyze clinical presentation, surgical management, and long-term outcome of patients suffering from biliary diverticulum, namely Todani type II congenital bile duct cyst (BDC). Background: The disease incidence ranges between 0.8% and 5% of all reported BDC cases with a lack of information about clinical presentation, management, and outcome. Methods: A multicenter European retrospective study was conducted by the French Surgical Association. The patients' medical records were included in a Web site database. Diagnostic imaging studies, operative and pathology reports underwent central revision. Results: Among 350 patients with congenital BDC, 19 type II were identified (5.4%), 17 in adults (89.5%) and 2 in children. The biliary diverticulum was located at the upper, middle, and lower part of the extrahepatic biliary tree in 11, 4, and 4 patients (58%, 21%, and 21%, respectively). Complicated presentation occurred in 6 patients (31.6%), including one case of synchronous carcinoma. Surgical techniques included diverticulum excision in all patients. Associated resection of the extrahepatic biliary tree was required in 11 cases (58%) and could be predicted by the presence of complicated clinical presentation. There was no mortality. Long-term outcome was excellent in 89.5% of patients (median follow-uptime: 52 months). Conclusions: According to the present largest Western series of Todani type II BDC, the type of clinical presentation rather than BDC location, was able to guide the extent of biliary resection. Excellent long-term outcome can be achieved in expert centers.

Laparoscopic pancreaticoduodenectomy (LPD) is a difficult procedure that has become increasingly popular. Nevertheless, comparative data on outcomes remain limited. Our aim was to compare the outcomes of LPD and open pancreaticoduodenectomy (OPD).Between April 2011 and April 2014, 46 LPD were performed and compared with 46 OPD, which theoretically can be done by the laparoscopic approach. Patients were also matched for demographic data, associated comorbidities, and underlying disease. Patient demographics and perioperative and postoperative outcomes were studied from our single center prospective database.Lower BMI (23 vs 27 kg/m(2), p0.001) and a soft pancreas (57% vs 47%, p = 0.38) were observed in patients with LPD, but there were no differences in associated comorbidities or underlying disease. Surgery lasted longer in the LPD group (342 vs 264 minutes, p0.001). One death occurred in the LPD group (2.1% vs 0%, p = 0.28) and severe morbidity was higher (28% vs 20%, p = 0.32) in LPD due to grade C pancreatic fistula (PF) (24% vs 6%, p = 0.007), bleeding (24% vs 7%, p = 0.02), and revision surgery (24% vs 11%, p = 0.09). Pathologic examination for malignant diseases did not identify any differences between the LPD and OPD as far as size (2.51 vs 2.82 cm, p = 0.27), number of harvested (20 vs 23, p = 0.62) or invaded (2.4 vs 2, p = 0.22) lymph nodes, or R0 resection (80% vs 80%; p = 1). Hospital stays were similar (25 vs 23 days, p = 0.59). There was no difference in outcomes between approaches in patients at a lower risk of PF.This study found that LPD is associated with higher morbidity, mainly due to more severe PF. Laparoscopic pancreaticoduodenectomy should be considered only in the subgroup of patients with a low risk of PF.

Background Liver transplantation (LT) remains the best curative option for early hepatocellular carcinoma (HCC) but is limited by the ongoing graft shortage. The present study aimed at defining the population in which primary liver resection (LR) could represent the best alternative to LT. Methods An exploration set of 357 HCC patients (LR n = 221 and LT n = 136) operated between 2000–2012 was used in order to identify factors associated with survival following LR and define a good prognosis (GP) group for which LR may challenge the results of upfront LT. These factors were validated in an external validation set of 565 HCC patients operated at another center (LR n = 287 LR and LT n = 278). Results In the exploration set, factors associated with survival on multivariate analysis were a solitary lesion, a diameter

Background & aims Prothrombin induced by vitamin K absence-II (PIVKA-II) is a diagnostic and surveillance marker for HCC mainly used in Asia, and has also been shown to be a predictor of microvascular invasion (MVI), a major prognostic factor in HCC. However, experience with PIVKA-II in Europe remains limited. Methods In a French cohort, we conducted a case-control study to compare the performances of α-fetoprotein (AFP) and PIVKA-II serum levels for diagnosis of early stage HCC, and we determined the value of PIVKA-II serum and tissue expression in pre-operative detection of MVI. 43 cirrhotic control patients and 85 HCC cases were included, of which 54 (63.5%) had early stage HCC (n=22 very early, n=32 early). PIVKA-II tissue expression was assessed by immunohistochemistry in HCC surgical samples. Results For the diagnosis of early HCC, PIVKA-II had a sensitivity of 77% and a specificity of 82% at a cut-off of 42 mAU/ml, vs. 61% and 50% for AFP at a cut-off of 5.5 ng/ml (AUC 0.81 vs. 0.58, respectively). A PIVKA-II level >90 mAU/ml was an independent predictor of MVI (HR 3.5; 95% CI 1.08-11.8; p=0.043). High PIVKA-II tissue expression was significantly associated with the presence of MVI (p=0.001). When combining PIVKA-II immunostaining with the PIVKA-II serum level, sensitivity and specificity for the diagnosis of MVI increased from 70% to 87% and 63% to 90%, respectively. Conclusions PIVKA-II was more efficient than AFP for the diagnosis of early HCC, and could be used as a predictive biomarker of MVI.

Although laparoscopic surgery is now extensively used, laparoscopic middle pancreatectomy (LMP) has rarely been described.A 45-year-old woman was diagnosed with branch duct intraductal papillary mucinous neoplasia (IPMN) at the pancreatic neck, which was discovered after numerous attacks of acute pancreatitis. LMP was decided on for treatment.The patient underwent pure LMP with right to left dissection and one-layer pancreatogastric anastomosis. Surgery lasted 160 minutes, with 20 mL of blood loss. A frozen section showed negative margins on both sides. The postoperative course was uneventful with 15 days in the hospital. Histology confirmed the diagnosis of branch duct IPMN with moderate dysplasia and negative margins. The patient is symptom free 6 months after surgery.Our results and the data in the literature suggest that the laparoscopic approach is indicated for middle pancreatectomy because there are no technical or oncological contraindications and the outcome is similar to that with the open approach.

Metabolic syndrome (MS), which is defined as a constellation of clinico-biological features closely related to insulin-resistance has reached epidemic levels in Western Europe and Northern America. Non-alcoholic fatty liver disease (NAFLD) represents the hepatic manifestation of MS. As its incidence parallels that of MS, NAFLD is currently becoming one of the most frequent chronic liver diseases in Western countries. On one hand, MS favors the development of hepatocellular carcinoma (HCC) either through NAFLD liver parenchymal alterations (steatosis; steatohepatitis; fibrosis), or in the absence of significant underlying liver parenchyma changes. In this setting, HCC are often diagnosed incidentally, tend to be larger than in patients developing HCC on cirrhosis and therefore frequently require major liver resections. On the other hand, MS patients are at increased risk of both liver-related postoperative complications and increased cardiorespiratory events leading to non-negligible mortality rates following liver surgery. These deleterious effects seem to be related to the existence of impaired liver function even in the absence of severe fibrosis but also higher cardiorespiratory sensitivity in a setting of MS/NAFLD. Hence, specific medical and surgical improvements in the perioperative management of these patients are required. These include complete preoperative cardiorespiratory work-up and the wide use of preoperative liver volume modulation. Finally, the long-term prognosis after curative surgery for MS-related HCC does not seem to be worse than for other HCC occurring on classical chronic liver diseases. This is probably related to less aggressive tumor behavior with lower micro vascular invasion and decreased rates of poorly differentiated lesions. In this setting, several medical therapies including metformin could be of value in the prevention of both occurrence and recurrence of HCC.

Lateral injury of the bile duct can occur after cholecystectomy, bile duct dissection, or exploration. If direct repair is not possible, conversion to bilioenteric anastomosis can be needed with the risk of long-term bile duct infections and associated complications. We developed a new surgical technique which consist of reconstructing the bile duct with the round ligament. The vascularized round ligament is completely mobilized until its origin and used for lateral reconstruction of the bile duct to cover the defect. T tube was inserted and removed after few months. Patency of the bile duct was assessed by cholangiography, the liver function test and magnetic resonance imaging (MRI). Two patients aged 33 and 59 years old underwent lateral reconstruction of the bile duct for defects secondary to choledocotomy for stone extraction or during dissection for Mirizzi syndrome. The defects measured 2 and 3 cm and occupied half of the bile duct circumference. The postoperative course was marked by low output biliary fistula resolved spontaneously. In one patient, the T tube was removed at 3 months after surgery and MRI at 9 months showed strictly normal aspect of the bile duct with normal liver function test. The second patient is going very well 2 months after surgery and the T tube is closed. Lateral reconstruction of the bile duct can be safely achieved with the vascularized round ligament. We will extend our indications to tubular reconstruction.

Although laparoscopic pancreatic resection (LPR) has become routine, large single-center series are still lacking. Our aim was to analyze the results of a large European single-center series of LPR.Between January 2008 and September 2015, 300 LPRs were performed and studied prospectively, including 165 (55%) distal pancreatectomies, 68 (23%) pancreaticoduodenectomies (PDs), 30 (10%) enucleations, 35 (11%) central pancreatectomies, and 2 (1%) total pancreatectomies.Mean age was 54 ± 15.4 years old (range 17 to 87 years), and most patients were women (58%). Laparoscopic pancreatic resection was performed for malignancy (46%), low potential malignant (44%), or benign (10%) diseases. The mean operative durations were 211 ± 102 minutes (range 30 to 540 minutes) for the entire population and 351 ± 59 minutes (range 240 to 540 minutes) for PD, and decreased with the learning curve. Mean blood loss was 229 ± 269 mL (range 0 to 1,500 mL), and 13 patients (4%) received transfusions. Conversion to an open procedure was required in 12 patients (4%), and only 5 in the last 250 patients (14% vs 2%; p0.001). Mortality occurred in 4 (1.3%) patients and only after PD (5.8%). Common complications were pancreatic fistula (n = 124, 41%), bleeding (n = 35, 12%), and reoperation (n = 28, 9%). The postoperative outcomes were less favorable in procedures with a reconstruction phase (n = 105) than in those without (n = 195), with increased mortality (3.8% vs 0%; p = 0.04), overall morbidity (76% vs % 52%; p 0.001), and mean hospital stay (26 ± 15 days vs 16 ± 10 days; p0.001).Laparoscopic pancreatic resection without a reconstruction phase has excellent outcomes; LPR with a reconstruction phase, especially PD, has less favorable outcomes, and further randomized studies are required to draw conclusions on the safety and benefits of this approach.

Despite widespread advances in laparoscopic surgery, laparoscopic repair of post-cholecystectomy bile duct injury (BDI) has rarely been reported related mainly to technical difficulty. We describe three cases of BDI treated laparoscopically with one illustrated by a video. With our gained experience in hepatic pedicle dissection during laparoscopic pancreaticoduodenectomy, we decided to perform laparoscopic repair of BDI in patients with an intact biliary confluence without vascular injury. Three patients were operated including two women: one was re-operated by subcostal incision for peritonitis and two had undergone cholecystectomy without conversion. Surgical technique is detailed in the manuscript and the video. Laparoscopic repair was performed between 45 and 300 days after cholecystectomy. Surgery lasted between 250 and 270 min with no conversion and no transfusion. The postoperative course was uneventful with a hospital stay ranging from 7 to 9 days. After a mean follow-up of 9–33 months, patients were symptom free with normal liver function tests. The laparoscopic approach can be safely and effectively proposed to a subgroup of patients with BDI. This approach has the advantages of the laparoscopic approach and represents the main new surgical advancement in the management of this complication.