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Background The relevance of laparoscopic resection of intrahepatic cholangiocarcinoma (ICC) remains debated. The aim of this study was to compare laparoscopic (LLR) and open (OLR) liver resection for ICC, with specific focus on textbook outcome and lymph node dissection (LND). Methods Patients undergoing LLR or OLR for ICC were included from two French, nationwide hepatopancreatobiliary surveys undertaken between 2000 and 2017. Patients with negative margins, and without transfusion, severe complications, prolonged hospital stay, readmission or death were considered to have a textbook outcome. Patients who achieved both a textbook outcome and LND were deemed to have an adjusted textbook outcome. OLR and LLR were compared after propensity score matching. Results In total, 548 patients with ICC (127 LLR, 421 OLR) were included. Textbook-outcome and LND completion rates were 22.1 and 48.2 per cent respectively. LLR was independently associated with a decreased rate of LND (odds ratio 0.37, 95 per cent c.i. 0.20 to 0.69). After matching, 109 patients remained in each group. LLR was associated with a decreased rate of transfusion (7.3 versus 21.1 per cent; P = 0.001) and shorter hospital stay (median 7 versus 14 days; P = 0.001), but lower rate of LND (33.9 versus 73.4 per cent; P = 0.001). Patients who underwent LLR had lower rate of adjusted TO completion than patients who had OLR (6.5 versus 17.4 per cent; P = 0.012). Conclusion The laparoscopic approach did not substantially improve quality of care of patients with resectable ICC.

Background & Aims Herein, we aimed to establish benchmark values – based on a composite indicator of healthcare quality – for the performance of laparoscopic left lateral sectionectomy (LLLS) and laparoscopic right hepatectomy (LRH) using data from expert centers. Methods Data from a nationwide multicenter survey including all patients undergoing LLLS and LRH between 2000 and 2017 were analyzed. Textbook outcome (TO) completion was considered in patients fulfilling all 6 of the following characteristics: negative margins, no transfusion, no complication, no prolonged hospital stay, no readmission and no mortality. For each procedure, a cut-off laparoscopic liver resection (LLR) volume by center was associated with TO on multivariable analysis. These cut-offs defined the expert centers. The benchmark values were set at the 75th percentile of median outcomes among these expert centers. Results Among 4,400 LLRs performed in 29 centers, 855 patients who underwent LLLS and 488 who underwent LRH were identified. The overall incidences of TO after LLLS and LRH were 43.7% and 23.8%, respectively. LLR volume cut-offs of 25 LLR/year (odds ratio [OR] 2.45; bootstrap 95% CI 1.65–3.69; p = 0.001) and 35 LLR/year (OR 2.55; bootstrap 95% CI 1.34–5.63; p = 0.003) were independently associated with completion of TO after LLLS and LRH, respectively. Eight centers for LLLS and 6 centers for LRH, including 516 and 346 patients undergoing LLLS/LRH respectively, reached these cut-offs and were identified as expert centers. After LLLS, benchmark values of severe complication, mortality and TO completion were defined as ≤5.3%, ≤1.2% and ≥46.6%, respectively. After LRH, benchmark values of severe complication, mortality and TO completion were ≤20.4%, ≤2.8% and ≥24.2%, respectively. Conclusions This study provides an up-to-date reference on the benchmark performance of LLLS and LRH in expert centers. Lay summary In a nationwide French survey of laparoscopic liver resection, expert centers were defined according to the completion of a textbook outcome, which is a composite indicator of healthcare quality. Benchmark values regarding intra-operative details and outcomes were established using data from 516 patients with laparoscopic left lateral sectionectiomy and 346 patients with laparoscopic right hepatectomy from expert centers. These values should be used as a reference point to improve the quality of laparoscopic resections.

The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.This retrospective study included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short-term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection.Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010).Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.El objetivo de este estudio fue analizar el impacto de la cirrosis en los resultados a corto plazo después de la resección hepática laparoscópica (laparoscopic liver resection, LLR) en un estudio de cohortes multicéntrico nacional. MÉTODOS: Este estudio retrospectivo incluyó todos los pacientes sometidos a LLR en 27 centros entre 2000 y 2017. La cirrosis se definió como fibrosis F4 en el examen histopatológico. Los resultados a corto plazo de los pacientes con hígado cirrótico (cirrhotic liver CL) (pacientes CL) y los pacientes con hígado no cirrótico (non-cirrhotic liver, NCL) (pacientes NCL) se compararon después de realizar un emparejamiento por puntaje de propension del volumen del centro, las características demográficas y del tumor, y la extensión de la resección.Del total de 3.150 pacientes incluidos, se realizó LLR en 774 (24,6%) pacientes CL y en 2.376 (75,4%) pacientes NCL. Las tasas de complicaciones graves y mortalidad en el grupo de pacientes CL fueron del 10,6% y 2,6%, respectivamente. La insuficiencia hepática posterior a la hepatectomía (post-hepatectomy liver failure, PHLF) fue la principal causa de mortalidad (55% de los casos) y se produjo en el 3,6% de los casos en pacientes CL. Después del emparejamiento, los pacientes CL tendieron a tener tasas más altas de complicaciones graves (razón de oportunidades, odds ratio, OR 1,74; i.c. del 95% 0,92-0,41; P = 0,096) y de PHLF (OR 7,13; i.c. del 95% 0,91-323,10; P = 0,068) en comparación con los pacientes NCL. Los pacientes CL estuvieron expuestos a un mayor riesgo de mortalidad (OR 5,13; i.c. del 95% 1,08-48,6; P = 0,039) en comparación con los pacientes NCL. Los pacientes CL presentaron tasas similares de complicaciones cardiorrespiratorias graves (P = 0,338), de fuga biliar (P = 0,286) y de reintervenciones (P = 0,352) que los pacientes NCL. Los pacientes CL tuvieron una estancia hospitalaria más larga (11 versus 8 días; P = 0,018) que los pacientes NCL. La experiencia del centro fue un factor protector independiente de PHLF (OR 0,33; i.c. del 95% 0,14-0,76; P = 0,010) pacientes CL. CONCLUSIÓN: La presencia de cirrosis subyacente sigue siendo un factor de riesgo independiente de peores resultados en pacientes sometidos a resección hepática laparoscópica, incluso en centros con experiencia.

Background The accuracy of the assessment of the nodal status in resected cephalic pancreatic adenocarcinoma (PA) depends on the number of examined lymph nodes (NELN). This study assesses the impact of the NELN on N staging and survival and propose a minimal number of examined lymph nodes (MNELN) ensuring reliability of the pN status determination. Methods 188 consecutive patients treated by pancreaticoduodenectomy (PD) for PA. Correlations between NELN and survivals of pN0 and pN1 groups and with the rate of pN1 patients were studied. A probability model based on the binomial law was built to estimate the MNELN able to detect pN1 patients with a sensitivity ≥95%. Results Overall and disease free 5-year survivals were 27.2% and 24.6% respectively. 135 patients (71.8%) were staged pN1. The median NELN was 17 (range 0–68). Overall and disease free survivals of pN1 patients were not related to NELN. The influence of NELN on survival in pN0 patients due to stage migration did not reach significance. The probability model showed that a MNELN of 16 nodes was required to detect pN1 patients with a sensitivity of 95%. Conclusion A MNELN of 16 is required to assess pN status and should be considered as a quality criterion in future studies and trials on PD for PA.

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

Endothelial damage within the sinusoids of the liver probably plays a key role in primary liver dysfunction following transplantation. The aim of this work was to study the serum levels of two potential markers of endothelial damage, creatine kinase-BB and soluble thrombomodulin, during human graft revascularization. Thirteen human liver grafts were preserved in UW solution (mean time: 13.8 h). Creatine kinase-BB and transaminase activities and soluble thrombomodulin levels were measured: 1) in effluent and 2) in serum samples sequentially collected before revascularization, then during the first 120 min of revascularization and first post-operative week. No correlation was observed between serum values (peak) and effluent values. In serum, pre-operative creatine kinase-BB activities were correlated with soluble thrombomodulin levels (p = 0.01). Both increased significantly during the first minutes of the revascularization, then decreased markedly. In contrast, AST activity was maximal at day 1. This detectable and early release of creatine kinase-BB and soluble thrombomodulin in blood is in keeping with the early occurence of endothelial damage. Together with previous data, these findings suggest that serum determination of these two markers may be a useful tool in the assessment of endothelial injury in liver transplantation.

Resume La pancreatite auto-immune (PAI), aujourd’hui mieux definie, est une affection dont le nombre de cas rapportes augmente. Elle peut etre associee a un diabete ou a d’autres maladies auto-immunes, a des lesions biliaires repondant comme les lesions pancreatiques a la corticotherapie. Nous rapportons le cas d’un homme de 34 ans, opere d’une rectocolite hemorragique, chez qui une premiere poussee de pancreatite aigue etait attribuee a une probable tumeur intracanalaire papillaire et mucineuse du pancreas (TIPMP) segmentaire du canal principal. Aucune lesion biliaire n’etait detectee par l’imagerie. L’examen anatomopathologique de la splenopancreatectomie gauche infirmait ce diagnostic et revelait une PAI. Une corticotherapie etait instituee. Il s’agit, a notre connaissance, du premier cas rapporte de PAI mimant une TIPMP du canal principal.

Background The significance of positive para-aortic nodes in patients with resectable pancreatic carcinoma is unclear. This study sought to evaluate the accuracy of intraoperative detection and prognostic significance of these lymph nodes in patients with resected adenocarcinoma of the pancreatic head. Methods From 2000 to 2010, para-aortic node sampling was performed prospectively in all patients before pancreatoduodenectomy. Frozen sections were created and nodes categorized as positive or negative for metastases. Surgeons were blinded to the frozen-section results. This was followed by standard histopathological assessment of corresponding paraffin-embedded, haematoxylin and eosin-stained material. Nodes considered uninvolved by this analysis were examined immunohistochemically for micrometastases. Results A total of 111 consecutive patients were included, with a median follow-up of 20·8 (range 1·5–126) months. The 1-, 2- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 73·6, 54·0 and 24·7 per cent, and 51·8, 28·1 and 18·8 per cent respectively. Para-aortic node involvement was always associated with peripancreatic lymph node metastasis, and was detected by frozen-section analysis in 12 patients and by haematoxylin and eosin staining in 17. Sensitivity and specificity of frozen-section examination for detecting para-aortic lymph node metastases were 71 and 100 per cent respectively. Median OS for patients with and without para-aortic node involvement on frozen-section analysis was 9·7 versus 28·5 months respectively (P = 0·012), and 15·7 versus 27·2 months (P = 0·050) when assessed by haematoxylin and eosin staining. Median DFS for patients with and without para-aortic node involvement on frozen-section examination was 5·6 versus 12·9 months respectively (P = 0·041), and 8·4 versus 12·9 months (P = 0·038) for haematoxylin and eosin analysis. The presence of micrometastases in para-aortic nodes was not significantly associated with altered OS or DFS. Conclusion Para-aortic node sampling with frozen-section examination detects distant lymphatic involvement reliably. It should be performed systematically. When metastases are found, they should be considered a contraindication to pancreatic resection.

Background After pancreaticoduodenectomy, severe pancreatic fistula may require salvage relaparotomy in patients with largely disrupted pancreaticojejunal anastomosis. Completion pancreatectomy remains the gold standard but yields high mortality and severe long-term repercussions. The authors report the results of a pancreas-preserving strategy used in this life-threatening condition. Methods Two hundred fifty-four pancreaticoduodenectomies with pancreaticojejunal anastomosis were performed between 2005 and 2011; 21 patients underwent salvage relaparotomy for grade C pancreatic fistula. Largely dehiscent pancreaticojejunal anastomoses were dismantled in 16 patients. Four patients underwent completion pancreatectomy, whereas in 12 patients detailed here, the remaining pancreas was preserved and drained by wirsungostomy with exteriorization or closure of the jejunal stump. Repeat pancreaticojejunal anastomosis was later planned to preserve pancreatic function. Results One patient died of recurrent hemorrhage on day 1 after wirsungostomy (8.3%). All but 1 survivor developed postoperative complications, and 3 needed reoperation before hospital discharge. The median hospital stay was 62 days (range, 29 to 156 days). After a median delay of 130 days (range, 91 to 240 days) from salvage relaparotomy, repeat pancreaticojejunostomy was attempted in 10 patients and was successful in 9 (1 completion pancreatectomy was performed). One patient died postoperatively (10%). Long-term endocrine function was unaltered in 66% of patients who benefited from this conservative strategy. Conclusions This pancreas-preserving strategy yielded a whole mortality rate of 17% for largely disrupted pancreaticojejunal anastomosis requiring salvage relaparotomy. It compares favorably with systematic completion pancreatectomy and achieved preservation of remnant pancreatic function in 75% of patients.

A 73-year-old man, who previously underwent laparotomy for pancreatic adenocarcinoma, was admitted in the emergency room for acute small bowel obstruction related to a strangulated Spieghelian hernia. On CT-scan, the hernia was located at the lateral border of the right rectus abdominis muscle below the external oblique muscle, among the transverse abdominis and internal oblique muscles layers. Spieghelian hernias (or hernia of the linea semilunaris) often occur at the level of a weak spot where the linea accurata crosses the linea semilunaris, when the posterior layer of the rectus gain changes its conformation. This weak spot is limited underneath by the inferior epigastric artery. When examining a patient with a previous history of laparotomy presenting with acute small bowel obstruction, it is mandatory to exclude a possible strangulated Spieghelian hernia before concluding to postoperative intra-abdominal adhesions. Spieghelian hernias are asymptomatic in approximately 90% of cases but entail a high risk of strangulation. Consequently, herniorrhaphy through a local approach route or open/laparoscopic mesh repair is always required.

Summary Purpose Mucinous cystadenomas are tumors arising mostly from the ovaries and pancreas. They can also arise from the kidneys, lungs, liver and appendix, but are rarely seen in the mesocolon. Recently, they have been included in an updated classification of mesenteric cysts and cystic tumors. The WHO classification (ICD 10) divides them into three subcategories according to their malignant behavior. Methods This report of two cases of mucinous cystadenoma of the mesocolon discusses the diagnostic and therapeutic modalities as well as the pathophysiological pathway(s) of development of these neoplasms. Results and conclusion The diagnosis of mucinous cystadenomas of the mesocolon is challenging due to the absence of specific clinical, biological and radiological features, and is often made during or after laparotomy. Preoperative biopsy is not useful and may even lead to misdiagnosis or peritoneal spillage. Surgery is the only curative treatment, but the modalities of resection are still a subject of debate.

Pancreaticoduodenectomy is an alternative to pancreas-sparing duodenectomy for radical treatment of duodenal lesions. The aims of this study were to assess the results of pylorus-preserving pancreaticoduodenectomy (PPPD) for severe duodenal polyposis in familial adenomatous polyposis in terms of morbidity, long-term influence on functional results, the recurrence rate of cancer or jejunal polyps, and survival.All patients operated on for a PPPD between 1992 and 2009 were included. Clinical data, endoscopic findings, and pathologic examinations were evaluated.A total of 19 patients underwent PPPD for severe duodenal polyposis (17 Spigelman IV, 1 Spigelman III, and 1 invasive carcinoma). Postoperative mortality was nil. The postoperative morbidity rate was 42%, including 4 pancreatic fistulae (21%) and 2 delayed gastric emptying (11%). Pathologic examination found 7 invasive carcinomas, of which only 1 was known before resection. One third of patients operated on without a preoperative diagnosis of malignancy already had an invasive duodenal carcinoma. After a mean follow-up of 58 months, 16 patients were alive. Thirteen patients underwent endoscopic follow-up, and new adenomas were found in 4 (31%). All were treated successfully during the same endoscopic procedure. PPPD did not modify the functional result after coloproctectomy.PPPD remains a safe and efficient therapeutic option for severe duodenal polyposis in familial adenomatous polyposis patients.

In recent years, autoimmune pancreatitis (AIP) has been increasingly recognized. It can be associated with diabetes mellitus and other systemic autoimmune diseases, or with bile ducts lesions, which are also responsive to steroid therapy as pancreatic lesions. We report the case of a 34-year-old man with a history of a first acute pancreatitis, attributed to an intraductal papillary-mucinous neoplasm of the pancreas (IPMN) with segmental involvement of the main pancreatic duct. A spleno-pancreatectomy was performed, and pathological examination of the specimen diagnosed autoimmune pancreatitis. A treatment with corticosteroids was carried out. To our knowledge, this is the first reported case of AIP mimicking IPMN of the main pancreatic duct.

We tested the effects of low (20% O2) and high (70% O2) oxygen tension on the morphological and biochemical integrity of human liver slices incubated for up to 72 h in supplemented Williams' E medium in a dynamic rotating culture system. High oxygen tension was more effective than low oxygen tension for preserving morphological integrity in long-term culture (48-72 h). After 72 h of culture with 70% O2, the lobular pattern was well preserved, and the survival of hepatocytes (approximately 80%) and other cell types was good. Immunohistochemical studies showed good preservation of the region-specific expression of CYP2EI and CYP3A4 isoenzymes for up to 72 h of incubation in 70% O2. As compared to 20% O2, the oxidized glutathione content and reactive oxygen species production were slightly increased in 70% O2, suggesting that minimal oxidative stress occurred with the high oxygen tension. In conclusion, despite slight oxidative stress associated with high oxygen tension, 70% O2 appeared more appropriate than 20% O2 for preserving the morphological and biochemical integrity of human liver slices cultured in a dynamic organ culture system for up to 72 h.

To report the results of a pancreaticojejunostomy in the treatment of chronic pancreatitis, and to assess the role of residual cephalic ductal obstruction in pain recurrence.Thirty seven patients with painful chronic pancreatitis whose pancreatic duct diameter exceeded 6 mm were treated by lateral pancreaticojejunostomy and were retrospectively studied. Deobstruction of the cephalad portion of the main pancreatic duct was complete in 21 patients (group A), while residual obstruction was noted in 16 patients (group B).One patient died post-operatively (2.7%) and 6 patients underwent complications (16%) that were treated without reoperation. With a median follow-up of 52 months, 26 patients were pain free (70%). Pain recurrence occurred in 3 patients in group A (14%) who were treated medically, versus in 8 patients in group B (50%) of whom 4 needed iterative surgery. Ongoing alcoholic addiction did not influence pain recurrence, which onset significantly altered the weight increase observed after pancreaticojejunostomy.Lateral pancreaticojejunostomy has a low morbidity rate and offers long lasting pain relief in 86% of patients whose cephalad main pancreatic duct is completely deobstructed.

To determine the viability and differentiation of human hepatocytes immunoprotected by encapsulation and transplanted in rats without immunosuppression.Freshly isolated human hepatocytes were encapsulated in hollow fibers and transplanted in the peritoneal cavity of immunocompetent rats. The fibers were explanted for analysis at D3, D7 and D14 following transplantation. Morphological features under light and electron microscopy and gene expression were compared to those of non-transplanted encapsulated hepatocytes (D0). Human cytochrome P450 3A and albumin mRNAs were quantified by Northern blot. Cytochrome P450 3A proteins were detected by Western blot and cytochrome P450 3A enzyme activity was assessed by measuring the formation of 6beta-hydroxytestosterone by high performance liquid chromatography.Transplanted hepatocytes were more than 60 % viable and exhibited morphological criteria of hepatocytic differentiation up to D7. Albumin and cytochrome P450 3A transcripts were also detected up to D14. At D3 and D7, albumin mRNA levels were of 30 %, compared to control D0 hepatocytes, while cytochrome P450 3A5 and cytochrome P450 3A4 mRNA levels were 65 % and 0 %, respectively. Cytochrome P450 3A immunoreactivity was detected by Western blot up to D14 and 6beta-hydroxylase activity was 17 % at D3 compared to D0, supporting with disappearance of cytochrome P450 3A4 mRNA.Human hepatocytes remain viable for a short period, following encapsulation and intraperitoneal transplantation in rat. Other experimental conditions need to be tested to prevent or delay a decrease in hepatocyte specific gene expression.

BACKGROUND—Chronic distal colitis may cause troublesome symptoms and alter quality of life. When medical treatment fails to control symptoms, patients and doctors are often reluctant to consider surgical resection because of the relatively small portion of the large bowel affected by the disease. AIM—To assess the outcome of restorative proctocolectomy (RP) in patients with distal colitis who required surgery for chronic debilitating symptoms and failed medical management. PATIENTS/METHODS—From 1986 to 1996, of 263 patients receiving RP for ulcerative colitis, 27 (16 men) were operated on for distal ulcerative colitis limited to the rectum and sigmoid colon. Bowel function and quality of life were compared before and one year after RP. RESULTS—The mean (SD) duration of ulcerative colitis was 11 (6) years. RP was performed at a mean age of 46 (10) years. All the pouches were J-shaped, and a diverting loop ileostomy was always performed. Mean (SD) hospital stay was 25 (10) days. Seven complications occurred in six patients. Previously unknown severe dysplasia was discovered on the colectomy specimen in two patients. After RP there was a significant decrease in mean (SD) daytime stool frequency (8.2 (4) v 4.7 (2), p

Background Patients with familial adenomatous polyposis (FAP) are at risk for adenomas and cancers in the duodenum but the ideal management of duodenal polyposis remains uncertain. Methods The outcome of surgical resection was analysed in 18 patients with FAP who had severe duodenal polyposis. Results Duodenotomy and clearance of duodenal adenomas was performed seven times in six patients. There were two duodenal leaks and, after a mean follow-up of 53 (range 36–72) months, duodenal adenomas recurred in all patients and five had severe polyposis. Pancreatoduodenectomy was performed in seven patients with severe duodenal polyposis. Histology of the specimens revealed two unsuspected duodenal carcinomas at an early stage. After a mean follow-up of 42 months all patients were alive and well, and there was no case of jejunal polyposis. Pancreatoduodenectomy was attempted in five patients with duodenal cancer and only one survived more than 4 years. Conclusion Surgical excision of duodenal adenomas should be discussed before carcinoma occurs. Surgical polypectomy fails to guarantee a polyp-free duodenum and carries a risk of postoperative complications whereas pancreatoduodenectomy eliminates the risk of duodenal cancer with an acceptable morbidity rate. Pancreatoduodenectomy could be offered to some patients with large or multiple villous duodenal adenomas repeatedly showing severe dysplasia.

Ion and fluid transport across the biliary epithelium contributes to bile secretion. Since endothelin (ET)-1 affects ion transport activities and is released by human gallbladder- derived biliary epithelial cells in primary culture, we examined the expression of ET peptides and ET receptors and the influence of ET-1 on ion transport in this epithelium ex vivo. In freshly isolated gallbladder epithelial cells, preproET-1, -2, and -3 mRNAs were detected by reverse transcription PCR and ET-1 isopeptide was identified by chromatography. The cells also displayed ET receptor mRNAs and high-affinity binding sites for ET-1, mostly of the ETB type. Electrogenic anion secretion across intact gallbladder mucosa was stimulated by forskolin, secretin, and exogenous ATP, as assessed by short-circuit current (Isc) increases in Ussing-type chambers. ET-1 inhibited forskolin- and secretin-induced changes in Isc, without affecting baseline Isc or ATP-induced changes. Accordingly, ET-1 significantly reduced the accumulation of intracellular cAMP elicited by forskolin and secretin in the epithelial cells, and this effect was abolished by pertussis toxin. This is the first evidence that ET-1 is synthesized and inhibits, via a Gi protein-coupled receptor, cAMP-dependent anion secretion in human gallbladder epithelium, indicating a role in the control of bile secretion by an autocrine/paracrine mechanism.

Since the first attempts at resection of Klatskin tumours, an increasingly aggressive surgical treatment has been proposed. Results obtained after examination of the specimen have shown that a significant proportion of resections were palliative. Curative resection appears to be difficult to perform selectively.This retrospective study evaluates the results of a surgically-oriented management of hilar bile duct cancers. Thirty-nine patients were operated on in the period 1982-1994. Eighteen resections were carried out, requiring liver resection in 13 cases. Pathology of the specimen showed that the resection had been curative in 14 cases. The remaining 21 patients had surgical palliation, i.e. bypass and/or stenting.In the resection group, there was no death but four patients suffered severe complications. The 1- and 5-year survival rates were 67 and 47 per cent respectively, with a median survival of 26 months. In the palliation group, the mortality rate was 14 per cent and median survival was 7 months.In the absence of evident contraindications, surgical exploration is worthwhile as it allows detection of the cases where curative resection is possible. Curative resection often requires a major hepatectomy, but mortality and morbidity may be kept low, and it offers a real hope of cure.

We report the initial and long-term results of non surgical procedures performed for the treatment of biliary strictures in liver transplant patients. Twelve liver transplant patients with biliary strictures underwent 16 interventional radiological procedures. Initial technical success was achieved in 11 of 12 patients (91%). Within long-term, with a follow-up of 27 months, primary success rate (only one procedure) was 58% (7 of 12 patients). Three restenoses occurred. They were all treated by interventional radiological procedures. The secondary success rate (one or more procedures) was 83% (10 of 12 patients). Two complications occurred including one pancreatitis and one cholangitis. Non surgical management may be performed for patients with biliary strictures after liver transplantation.

The aim of this study was to analyse characteristics of patients who survived more than 5 years after liver resection of colorectal metastases.A multicentre retrospective study collected 1818 patients who underwent curative resection of hepatic metastases between 1959 and 1991. Among the 747 patients operated on before 1987, 102 survived longer than 5 years, and were compared with patients who survived less than 5 years.Three risk factors proved independently significant in multivariate analysis between the two groups: serosa infiltration (P = 0.003), involvement of peritumoral lymph nodes around the primary colorectal tumour (P = 0.04), and a liver resection margin of less than 1 cm (P = 0.02). There was no significant difference for other parameters studied (location of primary tumour, location, number and size of metastases, type of resection). A trend towards a shorter survival of patients with increased carcinoembryonic antigen serum level was observed.Resection of colorectal hepatic metastases can provide long-term survival even in patients with poor prognostic factors. It seems justified to undertake resection of colorectal liver metastases whenever it may be performed safely as a curative treatment.

Hepatocyte transplantation could be an alternative to whole organ transplantation to correct enzymatic disorders. To this end, it would be of major importance to use xenogeneic cells without immunosuppression. The aim of this study was to investigate the survival and metabolic activity of encapsulated xenogeneic hepatocytes in the absence of immunosuppression. For this purpose, we used Gunn rats genetically incapable of bilirubin conjugation.Xenogeneic (from guinea pigs) and allogeneic (from Lewis rats) hepatocytes (2x10(7)) were isolated, macroencapsulated in hydrogel hollow fibers made with an acrylonitrile-sodium methallyl-sulfonate copolymer, and transplanted into the peritoneum of Gunn rats without any immunosuppression. Plasma bilirubin levels were evaluated weekly. Bilirubin conjugates in bile and cell morphology were studied after 5 and 12 weeks, respectively.In Gunn rats transplanted with xenogeneic hepatocytes, a significant decrease in the serum bilirubin level was observed between 3 and 9 weeks after transplantation when compared with controls transplanted with empty hollow fibers: it fell to 62% of the initial level at weeks 5-7 (P0.01). A comparable result was observed in Gunn rats transplanted with encapsulated allogeneic cells. Bilirubin conjugates were observed in bile samples of rats transplanted with encapsulated hepatocytes. After explantation, hollow fibers appeared intact with minimal fibrosis. Cell viability and hepatocyte morphology were preserved.These results indicate that macroencapsulated xenogeneic hepatocytes can survive and remain functional for more than 2 months when transplanted in vivo in the absence of any immunosuppression.