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International audience; Background: A novel data-driven classification of type 2 diabetes has been proposed to personalise anti-diabetic treatment according to phenotype. One subgroup, severe insulin-resistant diabetes (SIRD), is characterised by mild hyperglycaemia but marked hyperinsulinaemia, and presents an increased risk of diabetic nephropathy. We hypothesised that patients with SIRD could particularly benefit from metabolic surgery.Methods: We retrospectively related the newly defined clusters with the response to metabolic surgery in participants with type 2 diabetes from independent cohorts in France (the Atlas Biologique de l'Obésite Sévère [ABOS] cohort, n=368; participants underwent Roux-en-Y gastric bypass or sleeve gastrectomy between Jan 1, 2006, and Dec 12, 2017) and Brazil (the metabolic surgery cohort of the German Hospital of San Paulo, n=121; participants underwent Roux-en-Y gastric bypass between April 1, 2008, and March 20, 2016). The study outcomes were type 2 diabetes remission and improvement of estimated glomerular filtration rate (eGFR).Findings: At baseline, 34 (9%) of 368 patients, 314 (85%) of 368 patients, and 17 (5%) of 368 patients were classified as having SIRD, mild obesity-related diabetes (MOD), and severe insulin deficient diabetes (SIDD) in the ABOS cohort, respectively, and in the São Paulo cohort, ten (8%) of 121 patients, 83 (69%) of 121 patients, and 25 (21%) of 121 patients were classified as having SIRD, MOD, and SIDD, respectively. At 1 year, type 2 diabetes remission was reported in 26 (81%) of 32 and nine (90%) of ten patients with SIRD, 167 (55%) of 306 and 42 (51%) of 83 patients with MOD, and two (13%) of 16 and nine (36%) of 25 patients with SIDD, in the ABOS and São Paulo cohorts, respectively. The mean eGFR was lower in patients with SIRD at baseline and increased postoperatively in these patients in both cohorts. In multivariable analysis, SIRD was associated with more frequent type 2 diabetes remission (odds ratio 4·3, 95% CI 1·8-11·2; p=0·0015), and an increase in eGFR (mean effect size 13·1 ml/min per 1·73 m2, 95% CI 3·6-22·7; p=0·0070).Interpretation: Patients in the SIRD subgroup had better outcomes after metabolic surgery, both in terms of type 2 diabetes remission and renal function, with no additional surgical risk. Data-driven classification might help to refine the indications for metabolic surgery.Funding: Agence Nationale de la Recherche, Investissement d'Avenir, Innovative Medecines Initiative, Fondation Cœur et Artères, and Fondation Francophone pour la Recherche sur le Diabète.

Context The Igls criteria were developed to provide a consensus definition for outcomes of β-cell replacement therapy in the treatment of diabetes during a January 2017 workshop sponsored by the International Pancreas & Islet Transplant Association (IPITA) and the European Pancreas & Islet Transplant Association. In July 2019, a symposium at the 17th IPITA World Congress was held to examine the Igls criteria after 2 years in clinical practice, including validation against continuous glucose monitoring (CGM)-derived glucose targets, and to propose future refinements that would allow for comparison of outcomes with artificial pancreas system approaches. Evidence acquisition Utilization of the criteria in various clinical and research settings was illustrated by population as well as individual outcome data of 4 islet and/or pancreas transplant centers. Validation against CGM metrics was conducted in 55 islet transplant recipients followed-up to 10 years from a fifth center. Evidence synthesis The Igls criteria provided meaningful clinical assessment on an individual patient and treatment group level, allowing for comparison both within and between different β-cell replacement modalities. Important limitations include the need to account for changes in insulin requirements and C-peptide levels relative to baseline. In islet transplant recipients, CGM glucose time in range improved with each category of increasing β-cell graft function. Conclusions Future Igls 2.0 criteria should consider absolute rather than relative levels of insulin use and C-peptide as qualifiers with treatment success based on glucose assessment using CGM metrics on par with assessment of glycated hemoglobin and severe hypoglycemia events.

One century after the discovery of insulin, the French Health regulations have just authorized the reimbursement for islet transplantation. Intraportal islet allotransplantation from a pancreatic donor is indicated in patients with type 1 diabetes (T1D) complicated with lability or hypoglycemia unawareness, or in case of a functioning kidney graft; islet auto-transplantation may be indicated after pancreatic surgery.Compared with insulin even administered in closed-loop pumps, the specificity of islet allotransplantation is the restoration of C-peptide secretion. Long-term insulin-independence is observed when the engrafted islet mass is sufficient, at the cost of immunosuppression. Fewer low-glucose events and less glucose variability, are observed even with minimal functional islet graft, after islet transplantation as at onset of T1D, when a residual C-peptide secretion is maintained, an objective currently approached with less aggressive immuno-modulating therapies than in the past. Therefore, restoration or preservation of endogen insulin secretion is an important goal, allowing to maintain a long-term glucose balance with more than 70% of time in range 3.9-10mmol/L and less than 3% of time3.9mmol/L, thus reducing the occurrence of diabetic complications. In the clinical setting, - the preservation of C-peptide at early stage of T1D, - the use of technological ressources (multi-injections, sensors, insulin pump, closed-loop systems) at later stages, - and islet transplantation when hypoglycemia awareness becomes impaired are complementary for a personalized care all along the life of T1D patients.

Introduction: In animal research, obtaining efficient and constant pain control is regulatory but challenging. The gold standard pain management consists of opioid analgesic administration, such as buprenorphine or fentanyl extended-release patches. However, as in all drugs with a short half-life time, repeated buprenorphine administrations are needed, leading to multiple injections that affect the research protocol. On the other hand, fentanyl patch efficacy is discussed in some species. These elements highlight the need of an optimal formulation of analgesic drugs for laboratory animals. In this study, we investigated how Recuvyra®, a fentanyl transdermal solution (FTS), validated in dog perioperative pain management, could provide sustained analgesia after a single topical administration in pigs in a surgical context. Methods: A total of 11 minipigs were used in this study. As a preliminary experiment, two different doses were tested as a single application on five pigs: two pigs at full dose (2.6 mg/kg) and three pigs at half dose (1.3 mg/kg). Plasma fentanyl dosages were performed during 4 consecutive days, using liquid chromatography with tandem mass spectrometry detection. The efficacy of FTS was then evaluated in a perioperative period. Six minipigs benefited from a surgical intervention comprising a laparotomy. The FTS was blotted on the skin in a single application 20 min before the surgical incision and plasma fentanyl dosages, clinical examination (body weight, food intake, heart rate, and body temperature) and pain assessment were performed for 7 consecutive days. Results: During the preliminary experiment, all fentanyl concentrations reached the minimum effective concentration (MEC) extrapolated in pigs (fentanylemia ≥0.2 ng/mL) throughout the 4 days. The half dose was chosen for the next step of the study. After the surgical intervention, all plasma fentanyl concentrations remained above the MEC up to 7 days post administration. Pig clinical examinations and pain evaluations showed efficient and constant pain control at the half dose, and few adverse events were observed. Discussion and Conclusion: This study confirms the pharmacological and clinical efficacy of FTS at 1.3 mg/kg in pigs throughout at least 7 postoperative days following laparotomy. The clinical analgesic effect of FTS appears more efficient and well-tolerated than the one observed with repeated injections of buprenorphine. This analgesic drug formulation could be universally used in animal research to provide optimal perioperative pain management and long-term analgesia.

Total pancreatectomy with autologous islet cell transplant (TPAIT) is a treatment option for patients suffering from chronic or recurrent acute pancreatitis, providing benefits of pain relief, enhanced quality of life, and prevention of brittle type 3c diabetes [1]. While surgical procedure requires extensive dissection and elevates risk of bleeding [2, 3], this operation also carries potential risk of portal venous thrombosis(0.9 to 3.4%) when impure or partially purified autologous islet preparations are infused into the portomesenteric circulation[4,5]. To mitigate the risk of thrombosis and to assist with islet engraftment by reducing Instant Blood-Mediated Inflammatory Reaction (IBMIR), anticoagulants are often utilized intra- and post-operatively [6]. Through literature review and personal communications , it is clear that different centers vary in their anticoagulation practices without any consensus guideline on the type, amount, or duration of anticoagulation, nor on the type and targets for postoperative monitoring [7]. The aim of this study is to gather information about the various anticoagulation strategies utilized by programs internationally.

International audience; Objective: Previous studies have unveiled a relationship between the severity of coronavirus disease 2019 (COVID-19) pneumonia and obesity. The aims of this multicenter retrospective cohort study were to disentangle the association of BMI and associated metabolic risk factors (diabetes, hypertension, hyperlipidemia, and current smoking status) in critically ill patients with COVID-19.Methods: Patients admitted to intensive care units for COVID-19 in 21 centers (in Europe, Israel, and the United States) were enrolled in this study between February 19, 2020, and May 19, 2020. Primary and secondary outcomes were the need for invasive mechanical ventilation (IMV) and 28-day mortality, respectively.Results: A total of 1,461 patients were enrolled; the median (interquartile range) age was 64 years (40.9-72.0); 73.2% of patients were male; the median BMI was 28.1 kg/m2 (25.4-32.3); a total of 1,080 patients (73.9%) required IMV; and the 28-day mortality estimate was 36.1% (95% CI: 33.0-39.5). An adjusted mixed logistic regression model showed a significant linear relationship between BMI and IMV: odds ratio = 1.27 (95% CI: 1.12-1.45) per 5 kg/m2 . An adjusted Cox proportional hazards regression model showed a significant association between BMI and mortality, which was increased only in obesity class III (≥40; hazard ratio = 1.68 [95% CI: 1.06-2.64]).Conclusions: In critically ill COVID-19 patients, a linear association between BMI and the need for IMV, independent of other metabolic risk factors, and a nonlinear association between BMI and mortality risk were observed.

Background and Aims In patients with type 1 diabetes and end-stage renal disease, kidney transplantation improves both quality of life and survival. When simultaneous kidney-pancreas transplantation appears too invasive, or after failure of the pancreatic graft, an islet after kidney transplantation (IAK) may be considered to restore a stable endocrine function. The aim of our work was to assess the impact of islet transplantation on kidney transplantation outcomes versus insulin alone. Method In this retrospective parallel-arm cohort study in Lille, we included all type 1 diabetes patients who received a kidney graft from 2000 to 2017, followed by an islet transplantation after kidney (IAK) or not (kidney alone, KA). The primary study endpoint was the change of renal function (estimated glomerular filtration rate, eGFR). Secondary endpoints were glycemic control-related markers, such as HBA1c. Results During the period of study, 14 patients were included in the KA group versus 15 in the IAK group (including 5 after failure of a simultaneous pancreatic graft) were enrolled. At baseline, kidney donor sex, BMI, cause of death, cold ischemia time and recipient sex, waiting time on dialysis, type of dialysis, and number of previous kidney transplantation, were similar between the two groups. Yet, there were significant differences between KA and IAK, considering donor age (resp. 56.0±15.0 vs 35.2±13.7 years, p Conclusion In patients with type 1 diabetes and a functioning kidney graft, IAK was associated with a better glucose control and a slower decrease of eGFR than standard insulin therapy. Our results suggest that IAK should be proposed to type 1 diabetes patients with a functional kidney graft.

Previous studies unveiled a relation between COVID-19 severity and obesity. The aims of this multicenter retrospective cohort study were to disentangle the association of body mass index (BMI) and associated metabolic risk factors, with pneumonia outcomes in critically ill patients with COVID-19, and explore the impact of age and sex on this relationship. Participants were COVID-19 patients admitted in intensive care in 21 centers in Europe, Israel, and USA, between 02/19/2020 and 05/19/2020. The exposure of interest was BMI. The primary and secondary outcomes were the need for invasive mechanical ventilation (IMV), and 28-day mortality. The covariates were age, sex, and diabetes, hypertension, hyperlipidemia, and current smoking. We enrolled 1,461 patients (median age 64 years (Interquartile range (IQR), 40.9-72.0); 73.2% males; median BMI 28.1 kg/m2 (IQR, 25.4-32.3); 1,080 patients (73.9%) required IMV and the 28-day mortality rate was 36.1% (95% confidence intervals (CI), 33.0-39.5). Adjusted mixed logistic regression model showed a significant relation between BMI and IMV: odds ratio 1.27 (95% CI, 1.12-1.45) per 5 kg/m2 in the whole cohort, and 1.65 (95% CI, 0.97-2.79) per 5 kg/m2 in females under 50 years. Adjusted Cox proportional hazards regression model showed a significant association between BMI and mortality, which was only increased in obesity class III (≥40 kg/m2) (Hazard Ratio 1.68 (95% CI 1.06-2.64). In conclusion, we observed in critically ill COVID-19 patients, a linear association between BMI and the need for IMV, independent of other metabolic risk factors, and more pronounced in younger females, and a non-linear association between BMI and mortality risk. Trial Registration: ClinicalTrials.gov Identifier: NCT04391738 Funding Statement: No specific funding. Declaration of Interests:The authors declared no conflict of interest. Ethics Approval Statement: The study complied with standard operating procedures in place, in accordance with the European Data Protection Directive (95/46/EC) and, upon its entry into force, Regulation (EU) 2016/679 (also referred to as the General Data Protection Regulation (GDPR)), and French CNIL frameworks n° MR004 regarding the processing of personal data in clinical studies. The institutional review board from other centers in USA and Israel approved the retrospective case series as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent.

Islet allotransplantation has been shown to be effective in restoring endogenous insulin secretion. Many initial reports showed, however, a sharp decline of islet graft function with time. In the late 1990s we hypothesized that islet transplantation success could be significantly prolonged by increasing islet primary graft function, through the deliberate repetition of islet infusions. We report here the favorable long-term outcome of this strategy in patients with type 1 diabetes and severe hypoglycemia unawareness or after a kidney graft with the Edmonton immunosuppressive regimen. Our results suggest that optimizing initial graft function is essential for the long-term success of beta cell replacement.

Objective. This retrospective study in 87 clinical islet transplants sought to determine if the quantitative in vivo islet potency assay (QIVIPA) based on human c-peptide measurement in normoglycemic immunodeficient mice transplanted with 1% of clinical islet transplant (n = 165) could predict islet function in man after transplantation (tx). Since each recipient receives a mean of 2.7 grafts in our center, the ultimate goal of this work was to prospectively determine the functional islet mass required in 1–3 transplants in the QIVIPA mice to achieve optimal long-term islet function (beta score ≥ 7) in man. Methods. Islet preparations that met in vitro release criteria (200,000 IEQ, viability ≥ 80%, sterility) were transplanted in severe type 1 diabetic patients (n = 87). 2% of the preparation was used for in vitro quality controls, and 2% for in vivo controls: tx under the kidney capsule of two normoglycemic nude or RAG2 mice where fasting c-peptide and glycemia were measured over 30 days. Human islet function was defined by immediate graft function (hCP increase 7 days after tx), primary graft function (PGF = beta score 1 month after the last tx) and beta score at 1 year. Results. The QIVIPA model is robust and reproducible with two mice transplanted per human islet preparation (P Conclusion. Evidence from this retrospective study on 87 clinical islet transplants in 165 mice suggests that in vivo quantitative islet potency assays like QIVIPA in normoglycemic immunodeficient are a key indicator of the quality of manufactured clinical graft preparations as they predict islet function in man, both early function at 7 days post tx, PGF (beta score 1 month after the last tx), and 1-year beta score even when multiple grafts are transplanted per recipient.

The names of the working groups that collaborated in the study reported in this article were inadvertently omitted from the byline. The corrected byline should … 2019;42

Background: Several devices are available for liver parenchyma transection (LPT). The aim of this study was to compare the Ultracision Harmonic scalpel (UHS) with the Cavitron Ultrasonic Surgical Aspirator (CUSA) among patients who underwent hemi-right hepatectomies (RH) to homogenize transection areas. Methods: From September 2012 to June 2015, 24 patients who underwent the UHS surgery approach were matched with 24 patients who underwent the CUSA transection procedure for RH using propensity score matching. Results: Total operative time (TOT) was shorter in the UHS group, 240 minutes (range 172.5-298.8) versus 330 minutes (range 270-400) in the CUSA group ( P = .0002). The occurrence of hepatopathy (odds ratio = 17; 95% confidence interval = 1.02-230) and the use of the CUSA device (odds ratio = 8; 95% confidence interval = 0.98-77) were associated with a TOT exceeding 300 minutes in multivariate analysis ( P = .05). Conclusions: The UHS is a safe and effective method of LPT as compared to the use of the CUSA system. TOT is statistically decreased.

OBJECTIVE The long-term outcome of allogenic islet transplantation is unknown. The aim of this study was to evaluate the 10-year outcome of islet transplantation in patients with type 1 diabetes and hypoglycemia unawareness and/or a functioning kidney graft. RESEARCH DESIGN AND METHODS We enrolled in this prospective parallel-arm cohort study 28 subjects with type 1 diabetes who received islet transplantation either alone (ITA) or after a kidney graft (IAK). Islet transplantation consisted of two or three intraportal infusions of allogenic islets administered within (median [interquartile range]) 68 days (43–92). Immunosuppression was induced with interleukin-2 receptor antibodies and maintained with sirolimus and tacrolimus. The primary outcome was insulin independence with A1C ≤6.5% (48 mmol/mol). Secondary outcomes were patient and graft survival, severe hypoglycemic events (SHEs), metabolic control, and renal function. RESULTS The primary outcome was met by (Kaplan-Meier estimates [95% CI]) 39% (22–57) and 28% (13–45) of patients 5 and 10 years after islet transplantation, respectively. Graft function persisted in 82% (62–92) and 78% (57–89) of case subjects after 5 and 10 years, respectively, and was associated with improved glucose control, reduced need for exogenous insulin, and a marked decrease of SHEs. ITA and IAK had similar outcomes. Primary graft function, evaluated 1 month after the last islet infusion, was significantly associated with the duration of graft function and insulin independence. CONCLUSIONS Islet transplantation with the Edmonton protocol can provide 10-year markedly improved metabolic control without SHEs in three-quarters of patients with type 1 diabetes, kidney transplanted or not.

Total pancreatectomy with intraportal islet autotransplantation (TPIAT) rather than partial pancreatectomy could represent a major shift in the management of patients with resectable pancreatic ductal adenocarcinoma (PDAC) when risks of postoperative pancreatic fistula are well identified. This approach provides a theoretical risk of tumor cell dissemination when islet cells are transplanted into the portal vein. Our objective was to explore the safety of TPIAT in PDAC in a mouse preclinical model of subcutaneous xenotransplantation of human cells isolated from pancreatic specimen during partial pancreatectomy performed for PDAC.Patients requiring pancreatectomy for PDAC were prospectively included. Immunocompromised mice were transplanted with pancreatic cells isolated from the nonmalignant part of the surgical specimen (experimental group). Results were compared with pancreatic tumor implants (control group). Pancreatic grafts were explanted at 6 weeks for histological analyses.Nine patients were included, and 31 mice were transplanted. In the experimental group, explants were microscopically devoid of tumor cell, and no metastasis was observed. In the control group, all explants were composed of tumor.We report in a preclinical model the absence of local and distant spreading of malignant cells after pancreatic islets xenograft isolated from PDAC patients. These data supports the oncological safety of TPIAT as valuable alternative to partial pancreatectomy for PDAC patients with a high risk of postoperative pancreatic fistula.

Epidemiological studies identify tobacco as an independent risk factor for T2D, however, the mechanisms involved remains unclear. Clinical studies incriminate an increase of insulin resistance but a direct effect on pancreatic islet mass is suggested by some animal studies. The aim of this study was to document the association between tobacco smoking and pancreatic islet mass in humans.Total islet mass (TIM) was measured in 484 pancreata from organ donors processed with standardized islet isolation technique for clinical islet transplantation. Number and size of islets were assessed following enzymatic digestion. Functional islet mass was estimated in a cohort of 845 obese subjects, by measuring c-peptide to glucose ratio at 30 min (CP/G-30) following an oral glucose load. Pancreatic islet mass proxies were correlated with donor smoking status and tobacco consumption (generalized linear model).TIM was negatively associated with smoking status in organ donors (estimate:-0.131;P=0.017), independently of other known predictors: BMI (-0.019; P=0.001), age (-0.009; P=0.0001). CP/G-30 was also reduced in vivo in subjects with smoking history. TIM (Figure A-B) and CP/G-30 (Figure C-D) were negatively correlated with the level of tobacco consumption.Pancreatic islet mass was reduced in subjects with smoking history, with a dose-response relationship with tobacco consumption. Our results support the direct implication of smoking in T2D. Disclosure M. Chetboun: None. J.A. Kerr-Conte: None. V. Gmyr: None. D. Thuillier: None. R. Ezzouaoui: None. T. Hubert: None. V. Raverdy: None. A. Bongiovanni: None. M. Daoudi: None. M. Vantyghem: Board Member; Self; Aegerion Pharmaceuticals. Other Relationship; Self; Elsevier. Research Support; Self; Ipsen Biopharmaceuticals, Inc., Novartis Pharmaceuticals Corporation. F. Pattou: None.

Major hepatectomy (MH) can lead to an increasing portal vein pressure (PVP) and to lesions of the hepatic parenchyma. Several reports have assessed the deleterious effect of a high posthepatectomy PVP on the postoperative course of MH. Thus, several surgical modalities of portal inflow modulation (PIM) have been described. As for pharmacological modalities, experimental studies showed a potential efficiency of Somatostatin to reduce PVP and flow. To our knowledge, no previous clinical reports of PIM using somatostatin are available. Herein, we report the results of PIM using somatostatin in 10 patients who underwent MH with post-hepatectomy PVP > 20 mmHg. Our results suggest Somatostatin could be considered as an efficient reversible PIM when PVP decrease is above 2.5 mmHg.

In allogenic islet transplantation (IT), high purity of islet preparations and low contamination by non-islet cells are generally favored. The aim of the present study was to analyze the relation between the purity of transplanted preparations, and graft function during 5 years post-IT. Twenty-four type 1 diabetic patients, followed-up 5 years after IT, were enrolled. Metabolic parameters and daily insulin requirements were compared between patients who received islet preparations with a mean purity < 50% (LOW purity) or ≥50% (HIGH purity). We also analyzed blood levels of carbohydrate 19-9 (CA 19-9) - a biomarker of pancreatic ductal cells - and glucagon, before and after IT. At 5 years, mean HbA1c levels (p=0.01) and daily insulin requirements (p=0.03) were lower in the LOW purity group. Insulin independence was more frequent in the LOW purity group (p

Human islet transplantation is a viable treatment option for type 1 diabetes mellitus (T1DM). However, pancreatic islet inflammation after transplantation induced by innate immune responses is likely to hinder graft function. This is mediated by incompatibility between islets and the blood interface, known as instant blood-mediated inflammatory reaction (IBMIR). Herein we hypothesized that portal venous administration of islet cells with human recombinant antithrombin (ATryn®), a serine protease inhibitor (serpin), which plays a central role in the physiological regulation of coagulation and exerts indirect anti-inflammatory activities, may offset coagulation abnormalities such as disseminated intravascular coagulation (DIC) and IBMIR. The current prospective, randomized experiment was conducted using an established preclinical pig model. Three groups were constituted for digested pancreatic tissue transplantation (0.15 ml/kg): control, NaCl 0.9% ( n = 7); gold standard, heparin (25 UI/kg) ( n = 7); and human recombinant ATryn® (500 UI/kg) ( n = 7). Blood samples were collected over time (T0 to 24 h), and biochemical, coagulation, and inflammatory parameters were evaluated. In both the control and heparin groups, one animal died after a portal thrombosis, while no deaths occurred in the ATryn®-treated group. As expected, islet transplantation was associated with an increase in plasma IL-6 or TNF-α levels in all three groups. However, DIC was only observed in the control group, an effect that was suppressed after ATryn® administration. ATryn® administration increased antithrombin activity by 800%, which remained at 200% for the remaining period of the study, without any hemorrhagic complications. These studies suggest that coadministration of ATryn® and pancreatic islets via intraportal transplantation may be a valuable therapeutic approach for DIC without risk for islets and subjects.

Background: The most feared complication of laparoscopic cholecystectomy (LC) is biliary tract injuries (BTI). We conducted a prospective study to evaluate the role of preoperative magnetic resonance cholangiopancreatography (MRCP) in describing the biliary tract anatomy and to investigate its potential benefit to prevent BTI. Materials and Methods: From January 2012 to December 2016, 402 patients who underwent LC with preoperative MRCP were prospectively included. Routine intraoperative cholangiography was not performed. Patients' characteristics, preoperative diagnosis, biliary anatomy, conversion to laparotomy, and the incidence of BTI were analyzed. Results: Preoperative MRCP was performed prospectively in 402 patients. LC was indicated for cholecystitis and pancreatitis, respectively, in 119 (29.6%) and 53 (13.2%) patients. One hundred and five (26%) patients had anatomical variations of biliary tract. Three BTI (0.75%) occurred with a major BTI (Strasberg E) and two bile leakage from the cystic stump (Strasberg A). For these 3 patients, biliary anatomy was modal on MRCP. No BTI occurred in patients presenting “dangerous” biliary anatomical variations. Conclusion: MRCP could be a valuable tool to study preoperatively the biliary anatomy and to recognize “dangerous” anatomical variations. Subsequent BTI might be avoided. Further randomized trials should be designed to assess its real value as a routine investigation before LC.

Laparoscopic surgery has gained the acceptance of the hepatobiliary surgical community and expert teams are now advocating major laparoscopic liver resections (LLRs). In this setting, the liver hanging maneuver (LHM) has been described in numerous series. We conducted a systematic review to investigate the effectiveness of the LHM in LLR. We performed an electronic literature search using PubMed, EMBASE, and COCHRANE databases. The final search was carried out in December, 2015. We found 11 articles describing a collective total of 104 surgical procedures that were eligible for this study. Laparoscopic LHM was used in LLR for both benign and malignant conditions, and also in living donor liver transplantation (LDLT). The LHM was used mainly in right hepatectomy and only two authors reproduced the original LHM. We investigated the intraoperative parameters, preservation of postoperative liver function, and oncological outcomes. The clear benefit of using the LHM in LLR is for better identification of the parenchymal transection plane with less blood loss. The other benefits of LHM could not be corroborated by solid data on its positive value. In view of the data published in the literature, our findings are not strong enough to support the systematic use of LHM in LLR.

International audience; BACKGROUND:Hepatocellular adenoma (HCA) is a benign hepatic lesion that may be complicated by bleeding and malignant transformation. The aim of the present study is to report on large series of liver resections for HCA and assess the incidence of hemorrhage and malignant transformation.METHODS:A retrospective cross-sectional study, from 27 European high-volume HPB units.RESULTS:573 patients were analyzed. The female: male gender ratio was 8:2, mean age: 37 ± 10 years. Of the 84 (14%) patients whose initial presentation was hemorrhagic shock (Hemorrhagic HCAs), hemostatic intervention was urgently required in 25 (30%) patients. No patients died after intervention. Tumor size was >5 cm in 74% in hemorrhagic HCAs and 64% in non-hemorrhagic HCAs (p < 0.001). In non-hemorrhagic HCAs (n = 489), 5% presented with malignant transformation. Male status and tumor size >10 cm were the two predictive factors. Liver resections included major hepatectomy in 25% and a laparoscopic approach in 37% of the patients. In non-hemorrhagic HCAs, there was no mortality and major complications occurred in 9% of patients.DISCUSSION:Liver resection for HCA is safe. Presentation with hemorrhage was associated with larger tumor size. In males with a HCA >10 cm, a HCC should be suspected. In such situation, a preoperative biopsy is preferable and an oncological liver resection should be considered.