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

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

Resume Le but de cette etude retrospective etait d’evaluer les resultats du traitement chirurgical du cholangiocarcinome peripherique pris en charge par une meme equipe. Entre 1988 et 2005, 75 patients ont ete operes d’un cholangiocarcinome peripherique. Cinquante-trois resections ont ete pratiquees dont trois iteratives. La decouverte peroperatoire d’une tumeur non resequable a conduit a 27 laparotomies exploratrices dont deux ont ete suivies d’une transplantation hepatique en debut d’experience. Les resections ont ete une hepatectomie majeure dans 85 % des cas et 40 % des resections ont ete etendues a un organe de voisinage. Une lymphadenectomie de necessite a ete realisee 32 fois. La mortalite a ete de 7,8 % (deux embolies pulmonaires massives, une defaillance multiviscerale apres transplantation et une peritonite postoperatoire). La morbidite globale a ete de 47 %. La resecabilite a ete de 66 %. La survie mediane a ete de 19 mois en cas de resection versus quatre mois en cas de non resection ( p p = 0,01). Une marge de resection envahie (R1 ou R2) n’a pas influence significativement la survie (18 mois versus 15 mois). Le cholangiocarcinome peripherique est une tumeur evoluee qui necessite souvent le recours a une hepatectomie majeure, voire etendue. En depit de l’âge et de l’extension tumorale au moment du diagnostic, l’obtention d’une resection complete est un objectif acceptable et raisonnable. Il n’y a pas de place pour les resections palliatives quand le caractere incomplet de l’exerese est previsible.

Resume Nous rapportons l’observation d’une patiente de 39 ans presentant des lesions kystiques anciennes, retroperitoneales et mediastinales evocatrices de lymphangiome kystique, revelees par des douleurs abdominales intermittentes. L’aggravation de la symptomatologie douloureuse a conduit a la realisation d’une fenestration cœlioscopique de decompression. L’evolution a ete marquee par un choc hemorragique necessitant une reprise chirurgicale en urgence avec exerese subtotale des lesions kystiques. Le diagnostic de lymphangioleiomyome a ete porte a l’examen anatomopathologique. Au 15 e jour postoperatoire, la patiente a presente un pneumochylothorax qui a necessite un drainage prolonge. L’association a des lesions kystiques diffuses du parenchyme pulmonaire a permis de porter le diagnostic de lymphangioleimyomatose. Les manifestations abdominales ont ete revelatrices de la lymphangioleimyomatose dans cette observation. Un diagnostic preoperatoire de la maladie aurait indique une exerese d’emblee complete des lesions.

Resume Les hernies de l’aine sont la premiere cause de chirurgie reglee. Pres d’un sujet de sexe masculin sur trois est opere d’une hernie inguinale entre 20 et 60 ans. Le traitement des hernies inguinales pose aujourd’hui la question du choix parmi plusieurs techniques chirurgicales offrant des resultats cliniques comparables mais des resultats fonctionnels et economiques differents. Malgre une litterature plethorique, il n’existe pas de consensus pour la technique de reference. Cette mise au point a pour objectif de preciser les indications des trois techniques les plus utilisees : 1) Herniorraphie par la technique de Shouldice ; 2) Hernioplastie par la technique de Lichtenstein ; 3) Hernioplastie laparoscopique. Dans un premier temps, les principes operatoires de chacune de ces techniques ainsi que les differents criteres d’evaluation de la chirurgie sont presentes. Les resultats de la medecine factuelle sont ensuite exposes. Ce travail montre ainsi que les enjeux du traitement des hernies inguinales de l’adulte sont cliniques, mais aussi fonctionnels et economiques. La question du choix de la technique en pratique quotidienne est ensuite abordee, en essayant d’identifier les determinants de ce choix et les relations qui pourraient exister entre ces determinants, la technique choisie et les resultats fonctionnels et economiques de la chirurgie. Nous proposons finalement des voies de recherche clinique susceptibles d’ameliorer les resultats cliniques mais aussi les resultats fonctionnels et economiques du traitement chirurgicale des hernies inguinales de l’adulte.

Sorafenib is a multikinase inhibitor currently used in the palliative treatment of advanced hepatocellular carcinoma. In patients with small hepatocellular carcinoma, sorafenib could be suggested as neoadjuvant therapy to control tumor growth during waiting time for liver transplantation. However, up to now, safety of liver transplantation in patients undergoing sorafenib treatment is not known. Herein, we report a case of successful liver transplantation in a patient treated by sorafenib for hepatocellular carcinoma. In this patient, liver transplantation was performed safely and histological examination of explanted liver evidenced complete necrosis of the largest tumor nodule.

We report the case of a 63-year-old woman presenting a 26cm right renal angiomyolipoma with intratumoral arteriovenous fistula responsible for a high-output right heart failure. A radical surgical treatment after preoperative embolization allowed rapid improvement of cardiac symptoms with an uneventful postoperative course.

La hernie du triangle de Jean Louis Petit, avec la hernie du quadrilatere de Grynfeltt, constituent le groupe des hernies lombaires, siegeant au niveau de la paroi abdominale posterolaterale. Plus de 300 cas ont ete rapportes, avec une predominance chez l’homme et pour le cote gauche [1-4]. Parmi les differentes etiologies, la hernie de Jean Louis Petit posttraumatique represente 26 % des cas [5, 6]. Elle est souvent consecutive a un traumatisme violent, dans le cadre d’un polytraumatisme. Le diagnostic est alors porte a distance de l’accident, il est souvent meconnu a la phase initiale en raison de la gravite des lesions associees dont le pronostic et le traitement sont prioritaires. Les techniques chirurgicales decrites pour traiter les hernies lombaires sont nombreuses. Alors que les plasties musculaires imposent des dissections etendues, l’approche coelioscopique apparait seduisante en raison de sa simplicite et de son caractere mini-invasif. Elle evite les dissections fastidieuses et offre une bonne exposition du collet de la hernie et de son contenu aisement reductible par cette voie d’abord [7]. Nous rapportons deux observations de patients presentant une hernie post-traumatique du triangle de Jean Louis Petit a revelation tardive, traitees avec succes par mise en place d’une plaque de renfort intra-peritoneale par voie coelioscopique. Le premier patient âge de 45 ans, avait ete victime d’un accident de la voie publique, responsable d’un polytraumatisme avec hemothorax gauche secondaire a une rupture de l’isthme aortique. En urgence un remplacement prothetique vasculaire a ete fait. Les suites operatoires ont ete compliquees par une contusion pulmonaire et un volet thoracique gauche, imposant un sejour en reanimation de 40 jours. Trois mois apres son accident, le patient a decouvert par autopalpation une tumefaction reductible de la region lombaire gauche, situee immediatement au dessus de la crete iliaque. Celle-ci a augmente progressivement de taille, entrainant une gene par son volume et responsable de douleurs aux efforts violents. L’examen clinique et une IRM (figure 1) ont confirme le diagnostic de hernie du triangle de Jean Louis Petit non compliquee. Une reparation par voie coelioscopique a ete proposee. L’exploration per-operatoire a trouve un collet de 5 cm de diametre et un glissement intra herniaire du colon sigmoide facilement reductible. Le sac peritoneal a ete reseque et la reparation parietale a consiste en la mise en place d’une plaque intra-peritoneale de materiel non resorbable en polypropylene, fixee en bas sur la crete iliaque et lateralement sur la partie charnue des muscles de la region au moyen d’agrafes coelioscopiques, sans peritonisation. Les suites operatoires ont ete simples, le patient a quitte le service a J1. Trois mois plus tard, le patient etait asymptomatique, il a pu reprendre une activite physique sans limitation. A la palpation on ne percevait pas de voussure du flanc. La seconde patiente, âgee de 58 ans, avait ete victime d’un polytraumatisme lors d’un accident de la voie publique, avec hemothorax gauche et hematome extra-dural, imposant un sejour de 15 jours en reanimation. Un mois apres la sortie de l’hopital est apparue une masse indolore du flanc gauche, au dessus de la crete iliaque, augmentant progressivement de volume. A l’examen clinique, cette masse etait impulsive a la toux et reductible. Le diagnostic de hernie d u triangle de Jean Louis Petit a ete evoque et confirme par tomodensitometrie. Une reparation sous coelioscopie a ete realisee. Apres resection du sac herniaire, la prothese intraperitoneale non resorbable en Prolene, a ete fixee par des agrafes coelioscopiques en bas sur la crete iliaque et lateralement sur les muscles grand dorsal et grand oblique. A un mois, la patiente a presente une occlusion intestinale du grele d’allure mecanique, secondaire a une bride developpee au depend d’une frange epiploique, imposant une viscerolyse. Les suites ont ete favorables par la suite.

Gallbladder carcinoma is frequently discovered incidentally on pathologic examination of the specimen after laparoscopic cholecystectomy (LC) performed for presumed "benign" disease. The objective of the present study was to assess the role of excision of port-sites from the initial LC for patients with incidental gallbladder carcinoma (IGBC) in a French registry.Data on patients with IGBC identified after LC between 1998 and 2008 were retrospectively collated in a French multicenter database. Among those patients undergoing re-operation with curative intent, patients with port-site excision (PSE) were compared with patients without PSE and analyzed for differences in recurrence patterns and survival.Among 218 patients with IGBC after LC (68 men, 150 women, median age 64 years), 148 underwent re-resection with curative intent; 54 patients had PSE and 94 did not. Both groups were comparable with regard to demographic data (gender, age70, co-morbidities), surgical procedures (major resection, lymphadenectomy, main bile duct resection) and postoperative morbidity. In the PSE group, depth of tumor invasion was T1b in six, T2 in 24, T3 in 22, and T4 in two; this was not significantly different from patients without PSE (P = 0.69). Port-site metastasis was observed in only one (2%) patient with a T3 tumor who died with peritoneal metastases 15 months after resection. PSE did not improve the overall survival (77%, 58%, 21% at 1, 3, 5 years, respectively) compared to patients with no PSE (78%, 55%, 33% at 1, 3, 5 years, respectively, P = 0.37). Eight percent of patients developed incisional hernia at the port-site after excision.In patients with IGBC, PSE was not associated with improved survival and should not be considered mandatory during definitive surgical treatment.

To determine the benefit of surgery for resectable pancreatic adenocarcinomas (PAs) in elderly patients.From 2004 to 2009, 932 patients with resectable PAs underwent pancreatectomies without neoadjuvant treatment in 37 institutions. The patients were divided into three groups according to age:70 years (control group; n = 580); 70-79 years (70s group, n = 288), and ≥ 80 years (80s group; n = 64). Preoperative, intraoperative, postoperative, and histological data were recorded to assess the postoperative course and survival.Preoperative or intraoperative characteristics, and the histological findings were comparable in the three groups. Postoperative mortality and morbidity rates did not differ in the three groups. Adjuvant therapies were more frequently used in younger patients than in elderly patients (p0.01). The overall 1-year, 3-year, and 5-year survival rates of control group/70's group/80's group were 82.2%/75.7%/75.7%, 49.9%/41.8%/31%, and 38.7%/33.2%/0%, respectively (p = 0.16). The median survival of the control, 70s, and 80s groups was 24 months, 35.3 months, and 30 months, respectively. Four independent prognostic indicators were identified by multivariate analysis: venous invasion (hazard ratio (HR) = 2.12), arterial invasion (HR = 2.96), positive lymph nodes (HR = 2.25), and adjuvant treatment (HR = 0.65).Fit elderly patients with resectable PAs should not be excluded from surgical resection of PA solely because of their real age. Moreover, elderly patients seem to obtain similar advantages from pancreatectomies than younger patients.

We report the case of a 39 year-old woman with many years of intermittent abdominal pain who was found to have cystic masses evocative of cystic lymphangioma involving the posterior mediastinal and retroperitoneum. Worsening abdominal pain led to a recommendation for laparoscopic unroofing and decompression of the cysts. During the postoperative period, hemorrhagic shock required reintervention with excision of the tumoral mass. Pathologic examination revealed lymphangioleiomyomatosis (LAM). On the 15th postoperative day, the patient developed a chylopneumothorax which required prolonged chest tube drainage. The presence of multiple polycystic lesions in the pulmonary parenchyma supported the diagnosis of diffuse LAM with primary extrapulmonary presentation. This diagnosis should be considered preoperatively since it modifies the treatment: a complete excision of the cystic lesions seems to be necessary in order to prevent bleeding and lymphatic extravasation.

The aim of this retrospective study was to evaluate the results of surgical treatment of intrahepatic cholangiocarcinoma treated by the same team. Between 1988 and 2005, 75 patients underwent surgery for intrahepatic cholangiocarcinoma. There were 53 resections including three additional interventions for recurrence. Twenty-seven exploratory laparotomies showed non resectable tumors and two were followed by a liver transplantation at the beginning of the study. Major hepatectomy was performed in 85% of resections while hepatectic resection was extended to an adjacent organ in 40%. A lymphadenectomy was performed in 32 cases. Mortality was 7.8% (two massive pulmonary embolisms, one mutiple organ failure after transplantation and one post-operative peritonitis). Global morbidity was 47%. Resectability was 66%. In case of surgical resection, the median survival rate was 18 months versus 4 months without resection (p0.001). Actuarial survival rates at 1 year, 3 years and 5 years were 69, 31 and 27% respectively. Positive nodes decreased the survival rate (13 months versus 20 months, p=0.01). A positive margin (R1 or R2 resection) did not significantly decrease the survival rate (18 months versus 15 months). In conclusion, intrahepatic cholangiocarcinoma is a tumor that often requires a major or an extended hepatectomy. Complete resection is an acceptable and reasonable goal, whatever the patient's age. This radical surgical approach can prolong survival. Palliative surgery is not an option if incomplete resection is predicted.

Inguinal hernia repair is the most commonly performed surgical procedure. Nearly one out of three men between 20 and 60 years of age will undergo hernia repair. Multiple surgical techniques are available which have comparable clinical outcomes but which differ in their functional results and economic impact. Despite an extensive surgical literature, no consensus exists regarding an optimal technique. This review aims to compare the indications for the three most common techniques: 1) the Shouldice repair, 2) the Lichtenstein repair, and 3) the laparoscopic hernia repair. To begin with, we present the operative principals of each repair along with criteria for evaluation of outcomes. Evidence-based outcomes data are then presented. We then address the choice of a surgical technique for everyday practice based on these factors. Finally, we propose avenues for future clinical research which may improve clinical, functional, and economic results in the repair of inguinal hernia of the adult.

To find a prognosis model of human liver transplant, we evaluate 62 surgical biopsies for the loss of glycogen and its variations in relation to cold ischemia, reperfusion, lobular zonation and donor's ages. We applied univariate, multivariate and discriminant analysis and logistic regression. There was a clear lobular zonation of glycogen during cold ischemia and at reperfusion. During cold ischemia, the mean loss was 48% in periportal zones and 74% in pericentrilobular zones. At reperfusion, it was in the range of 60% in periportal zones and 95% in pericentrilobular zones. It was observed in 64% of the grafts for an ischemia time less than 10 hr and in 82% of the grafts for an ischemia time of 10 hr or more. It was increased by 90% at reperfusion with pericentral predominance. Donors' age was an aggravating factor of glycogen loss beyond 28 years of age. In conclusion, in periportal zones, mean global glycogen depletion was about 54% during cold ischemia and reperfusion. It decreased by 90% at reperfusion with pericentral predominance. Logistic regression has allowed modelization of cold ischemia and reperfusion.

We studied and quantified the effect of ischemia-reperfusion on hepatic F-actin on bile canalicular and basolateral membranes in human liver allografts by means of confocal laser scanning microscopy imaging. The phalloidin-FITC staining of F-actin was normal in liver hepatocytes before reperfusion but decreased significantly after reperfusion (by 25% of controls). These results indicate that hepatic F-actin alteration is produced during the reperfusion phase. This modification, probably induced by reactive oxygen species, could impair bile canalicular contraction and tight junction permeability and consequently bile secretion in the postoperative period.

Two young women presenting Budd-Chiari syndrome as the primary manifestation of hepatocellular carcinoma with intracardiac extension were treated by debulking of the atrium and inferior vena cava under extracorporeal circulation and major hepatectomy. The first patient who was treated in a single procedure died during the immediate postoperative period. The second patient who was treated in two steps died of meningeal and pulmonary metastases 12 months later. Clinical findings and surgical strategy for this rare condition are discussed in the light of 6 previously reported surgical cases.

In order to examine glucose metabolism in liver grafts after cold ischemia and reperfusion, the heterogeneous lobular distribution pattern of glycogen content was studied using histochemical quantitative analysis. In most of the cases, this heterogeneous pattern of glycogen was observed after preservation and reperfusion. However, a 42% reduction of glycogen content, expressed as the ratio between stained surface and total surface of liver biopsies, was observed in biopsies after reperfusion. Moreover, both periportal and centrilobular hepatocytes showed a significant decrease in mean optical density after reperfusion (18% and 25%, respectively). The comparison of our results to early postoperative liver function tests and cold ischemia times showed no significant correlation (p0.05).

Bupivacaine is used to provide prolonged anesthesia and postoperative analgesia. The human cytochrome P450 (CYP) involved in bupivacaine degradation into pipecolylxylidine (PPX), its major metabolite, has, to our knowledge, never been described. Microsome samples were prepared from six human livers and incubated in the presence of bupivacaine. The concentrations of PPX in the microsomal suspensions were assessed, and K(m) and V(max) values were calculated. Bupivacaine incubations were then performed with specific CYP substrates and inhibitors. For each sample of hepatic microsomes, the correlation between the rate of PPX formation and the corresponding erythromycin N-demethylase activity was analyzed. Finally, an immunoinhibition study using an anti-rabbit CYP3A6 antibody and assays with cDNA-expressed human CYP were conducted. The apparent K(m) and V(max) values of bupivacaine were, respectively, 125 microM and 4.78 nmol/min/mg of microsomal protein. The strongest inhibition of bupivacaine metabolism was obtained for troleandomycin (-95% at 50 microM), a specific CYP3A inhibitor. The correlation between PPX formation and erythromycin N-demethylase activity showed an R value of 0.99 whereas anti-rabbit CYP3A6 antibody inhibited the degradation of bupivacaine into PPX by 99%. Finally, CYP1A2 and CYP2E1 cDNA-expressed forms of human CYP did not allow PPX formation, CYP2C19 and CYP2D6 produced only small amounts whereas CYP3A4 most efficiently metabolized bupivacaine into PPX. These results demonstrated that bupivacaine degradation into PPX was mediated in humans by CYP3A.

In order to examine glucose metabolism in liver grafts after cold ischemia and reperfusion, the heterogeneous lobular distribution pattern of glycogen content and glucose-6-phosphatase activity was studied using histochemical methods. The characteristic heterogeneous lobular distribution pattern of glycogen and glucose-6-phosphatase was maintained after preservation and reperfusion. However, it appeared that glycogen content decreased in both periportal and centrilobular hepatocytes after reperfusion. The glycogen decrease was higher in periportal hepatocytes. Glucose-6-phosphatase activity was maintained after reperfusion in most of the cases in periportal hepatocytes. In centrilobular hepatocytes, more cases showed a decrease in enzyme activity. It is suggested that ischemia-reperfusion mainly affects the glycogen content in both periportal and centrilobular hepatocytes and that centrilobular glucose-6-phosphatase activity is more sensitive to ischemia-reperfusion injury than periportal hepatocytes.

To present epidemiologic profile of this supposedly rare condition, its diagnostic management and the results of surgical treatment in a population of the mediterranean border.Between 1987 and 1999, the records of patients operated on for hepatocellular carcinoma and in whom cirrhosis was not present on pathological examination of liver parenchyma were collected. Data were collected prospectively.Mean age was 57.6 years. There were 61 men (79%) and 16 women but sex ratio was 1/1 for patients under 50. Hepatitis B and/or C serology was positive in 22 patients (29%). At presentation, 56 patients (73%) suffered of symptoms and there was evidence of tumor at clinical examination in 30 (39%). Sensitivity of alpha-fetoprotein measurement was 55%, and 58% for preoperative percutaneous biopsy. Twelve had exploratory laparotomy only, 61 underwent partial liver resection and 4 were transplanted. Resection was presumed curative in 56 cases (73%). There was one single tumor mass in 41 cases (53%) and its mean size was 10.3 cm. Liver fibrosis was present in 24 cases (29%). After curative resection, 5-year survival rate was 46%, and favorable prognostic factors were: alpha-fetoprotein within normal range, single tumor mass or tumor size less than 10 cm.Hepatocellular carcinoma arising on noncirrhotic liver is not a rare occurrence. It is usually encountered at an advanced stage of the disease. Nonetheless, it remains extirpable in many cases with low postoperative mortality and long term results are better than those of resections for hepatocellular carcinoma on cirrhotic liver.

The ingestion of foreign bodies is the second most frequent cause of aorto-esophageal fistulization after aneurysms of the thoracic aorta.A 28-year-old man died from catastrophic hematemesis 7 days after ingesting a bone splinter. The CT scan performed 3 days before the fatal event had demonstrated a fistulous formation originating in the aorta.Aorto-esophageal fistulae develop progressively from the esophageal perforation caused by the foreign body. Clinically, there is medical chest pain, followed by arterial hematemesis and finally terminal exsanguination. Diagnosis must be achieved during the free intervals in this triad of often rapidly succeeding signs.

Choledochal cysts have an increased risk of biliary tract malignancy, induced by reflux of pancreatic juice and anomalous pancreatobiliary ductal junction. We report one case of congenital choledochal cyst in a 68-year-old female whose malignancy was revealed by history of pain and jaundice. Pancreatico-duodenectomy was performed and the patient was alive 6 months later.

The shortage of cadaveric organ donors imposes a severe limit to the number of liver transplantations. A selection is thus necessary among patients: should the sickest be selected, or those who supposedly have the best chance to survive and recover? Optimizing the timing of transplantation during the course of the disease (not too early, but not too late) is another issue.Suitable candidates for transplantation are patients suffering from an irreversible, symptomatic liver disease. The goals of therapy are: firstly, to favorably modify the natural outcome of the disease; and secondly, in an acceptable risk taking manner. Major criteria for indication in the most common liver diseases can be summarized as follows: a) for chronic parenchymal liver diseases, a Child-Pugh score of 9 or 10, or less if complications have already occurred, is a mandatory and often sufficient criterion; b) for cholestatic liver diseases, a serum bilirubin level higher than 100-150 mumol/L is generally required; c) apart from "small" hepatocellular carcinomas on cirrhotic parenchyma (less than three tumors of less than 5 cm in diameter), most cancers are considered contraindications; d) acute liver failure requires early referral to a liver transplant center for potential emergency indication.In an organ shortage situation which is likely to perdure, early consultative contact between the patient and the liver transplant team will allow improvement in the access to transplantation procedure.

Expression of E-cadherin (E-cad) was investigated immunohistologically in 91 cases of operated hepatocellular carcinomas. An alteration of E-cad immunodetection was found in 56% of tumours. These alterations were correlated with histopathologic features of prognostic value including tumour size (3 cm), high nuclear grade and mitotic index. Patients with down-regulated E-cad expression had statistically significant shorter survival than the others. Although E-cad immunodetection was an independent prognostic factor, the Cox multivariate analysis showed that its prognostic value was low when compared to other prognostic factors.

Expression of E-cadherin (E-cad) and -catenin ( -cat) was investigated immunohistologically in 91 cases of excised hepatocellular carcinomas. Immunodectection was altered in 56% of tumours for E-cad and in 30.8% for -cat. Downregulation of E-cad and -cat correlated with the size of tumours, and high nuclear grade, but only E-cad alteration correlated with the mitotic index. Alterations of E-cad and -cat expression correlated with survival. Although E-cad and -cat immunodetections were independent prognostic factors, their prognostic value was lower than that of current clinicopathological parameters.

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

Giant hepatic hemangiomas are rare entities. They can be symptomatic with pain and increased erythrocyte sedimentation rate. Cholestasis has already been reported. We describe a case of biliary dilatation secondary to a hemorrhagic giant hepatic hemangioma documented on CT and MRI.

Livers of Wistar rats were stored between 0 and 36 hrs. in the University of Wisconsin preservation liquid in order to determine time-related biochemical and morphological hepatic changes. Ursodeoxycholate (100 microM) was also added in the medium to test the hepatoprotective properties of the bile salt. Biochemical assays were performed on hepatic microsomes, plasma and biliary canalicular membranes. Protein and lipid composition of the microsomal and baso-lateral plasma membranes remained stable. Protein and cholesterol content of the biliary canalicular membranes decreased, phospholipid/cholesterol ratio increased between 0 and 36 hrs.; it resulted in a leak of 5'-nucleotidase and leucine amino peptidase activity of these biliary canalicular membranes, especially up to 12 hrs. Between 0 and 36 hrs., the lipid and protein content remained stable in the plasma membranes, as well as both tested enzymatic activities. Observations under electron microscopy showed alterations and underlined fragility of the bile canaliculi, particularly after 24 hrs. preservation. Ultrastructure of sinusoidal membranes showed damaged microvilli. Endoplasmic reticulum remained unchanged, in relation to the stability of the microsomal lipidic, proteic content and hydroxymethylglutaryl-coenzyme A reductase activity, except the decreased protein content after preservation for 36 hrs without ursodeoxycholate. Ursodeoxycholate by itself did not protect against the described disturbances.

Fifty-two consecutive patients undergoing major hepatic resection for liver tumor were divided into two groups according to the operative procedure. Group A consisted of 34 patients in whom vascular inflow occlusion was performed "de principle" during parenchymal division and intrahepatic approach of the portal structures; the mean duration of the portal triad clamping was 43 mn (ranged 17 to 70 mn). Group B patients (18 cases) had hilar division of the structures of that portion of the liver due to be removed, prior to parenchymal division was performed without vascular arrest, except in five "de necessitate" cases during 5 to 22 mn. Groups A and B were comparable in terms of patient age or status, of king of liver tumors and extent of resection. Mean operating duration (215 vs 263 mn), volume of intraoperative blood transfusion (557 vs 1019 ml), intensive care (2.5 vs 4.2 days) and total hospital stays (19.6 vs 30.5 days) were significantly reduced in group A. A higher but transient increase of amino-transferase level was the only biochemical consequence of liver ischemia in group A, whereas postoperative disturbance in serum bilirubin, prothrombin time, fibrinogen, and total protein were significantly greater in group B, probably because of the greater volume of blood transfusion in this group. Thus, routine vascular inflow occlusion with transhepatic approach of the portal structures may be an effective and innocuous procedure for major liver resection.

We report two cases of hepatic angiomyolipoma. The first tumor was disclosed at the time of resection of a cardia carcinoma, and temporarily regarded as a possible metastasis. The second tumor was an enormous necrotic mass of the right liver in a young woman mimicking a sarcoma.

Recurrent angiocholitis attacks occurred in an 80-year-old woman, and repeated investigations could not provide any diagnosis. Subsequently, the patient developed haematemesis. Angiography revealed haemobilia from an intrahepatic cause. Surgical constatations and pathological examination of the resected specimen revealed that haemobilia was due to a non-parasitic cyst of the liver. In this case, haemobilia resulted from two unusual complications of this hepatic lesion: intra-cystic bleeding and communication with an intrahepatic duct. Haemobilia has never been reported as a complication of non-parasitic cyst of the liver.

An unusual form of adenoma of left lobe of liver was detected fortuitously in a young woman with an inflammatory syndrome and an anicteric cholestasis. In this case, a positive correlation existed between the adenoma and the treatment with estrogens, the disappearance of the biologic anomalies after exeresis of the adenoma being suggestive of an increased production of fibrinogen by hepatocytes. The cholestasis was probably the result of pressure exerted by the adenoma. Excision of the adenoma was justified by the risk of hemorrhagic complications and the possibility of malignant changes in the tumor.

Three cases of adrenal cystic lymphangioma are reported. In 1 patient the lesion was complicated by intracystic haemorrhage. The remaining 2 patients had a hepatic lesion which was treated in the same surgical operation as the adrenal cyst. Ultrasonography and computerized tomography play a major role in the exploration of these cysts. Their unexpected discovery has become more frequent since these methods have multiplied, and this raises therapeutic problems. The nature of adrenal cysts is determined at histology. In asymptomatic cysts percutaneous needle aspiration can only have an indicative value.

The case of a 29 year old woman affected by fulminant hepatitis during the third trimester of pregnancy, after a 3 week administration of chlormezanone is reported. Following induced Caesarean delivery, the patient underwent an orthotopic liver transplantation. The mother and her baby were in good condition 26 months after liver transplantation. In this case, chlormezanone was probably responsible for the fulminant hepatitis.

Between 1970 and 1990, 162 patients with carcinoma of the pancreas or the periampullary region were operated upon. A prospective study was conducted in 85 of them who underwent surgery after 1983. The tumour was resected in 63 patients (ductal adenocarcinoma in 43, periampullary carcinoma in 20). Biliary and/or gastrointestinal bypass was performed in 76 patients, and exploratory laparotomy in 23. The operative mortality rate was 3 percent (2/63) among patients with resection and 24 percent (24/99) among those with laparotomy with or without bypass. The longest survival (median: 33 months) was obtained in patients with periampullary tumours; it was 12 months after resection in patients with ductal adenocarcinoma and 4 months in the other cases. The preoperative estimate of unresectability was erroneous in 36.5 percent of the cases. Periampullary tumours were diagnosed only after pathological examination of the lesion removed in 47 percent. These results are in favour of radical surgery, especially since the operative mortality of resection is low and since resection, even palliative, gives a better survival rate than mere bypass.

We report the case of a 45-year-old woman who underwent laparotomy for obstructive jaundice due to an uncommon cystic tumor located in the porta hepatis. Histology of the resected specimen disclosed a cystadenoma of the common hepatic duct. A review of 20 reported cases shows that the preoperative diagnosis is uncommon; wide resection appears to be the treatment of choice since these lesions are susceptible of local recurrence and malignant change.

But Evaluer l’impact sur la survie, le mode de recidive et les donnees anatomopathologiques du traitement du cancer de la tete du pancreas resecable selon deux attitudes : chirurgie d’emblee (CE) versus radiochimiotherapie neoadjuvante (RCT). Patients et Methodes Il s’agit d’une etude retrospective en intention de traiter. De 1997 a 2006, 174 patients ayant un adenocarcinome canalaire resecable de la tete du pancreas ont ete pris en charge dans deux centres referents ayant une strategie differente. 85 patients ont eu une CE et 89 patients une RCT. Les patients ayant une RCT etaient tous reevalues avant chirurgie. Resultats 67 patients (79 %) ont ete reseques dans le groupe CE. Dans le groupe RCT, 33 patients n’ont pas eu de laparotomie apres reevaluation en raison d’une evolution metastatique (42 %) ou locoregionale (36 %) ou en cas de contre-indications operatoires ; 38 patients (43 %) ont ete reseques. Les medianes de survie en intention de traiter dans le groupe CE versus RCT etaient respectivement de 17 mois et 15 mois (ns). Chez les patients reseques, les medianes de survie dans le groupe CE versus RCT etaient respectivement de 17 mois versus 21 mois (p = 0,04) et les survies a 1, 3 et 5 ans etaient respectivement 69 %-79 % (ns), 26 %-18 % (ns) et 9 %-3 % (p = 0,04). 22 % des patients du groupe CE avaient des adenopathies positives contre 7 % pour les patients du groupe RCT (p = 0,02). 31 % des patients du groupe CE avaient des marges de resection positives contre 8 % des patients du groupe RCT (p = 0,03). 89 % des patients ont recidive dans les 2 groupes. Le taux de recidive locoregionale et d’evolution metastatique dans le groupe CE versus RCT etaient respectivement de 52 %-10 % et 76 %-97 %. Conclusion Une majorite de patients evolue pendant la RCT et ne beneficie pas d’une resection curative. Les medianes de survie en intention de traiter sont comparables, mais la survie a long terme des patients reseques apres RCT est inferieure a celle des patients reseques d’emblee. Cependant, l’interet d’une RCT doit etre considere car elle ameliore le controle local.

Out of 150 carcinomas of the pancreas operated from 1970 through 1989, 50 pancreatectomies were performed, including 4 cases of segmental resection of portal vein with total pancreatectomy (2 cases) or duodenopancreatectomy (2 cases). The technical procedure is described and discussed. Segmental resection of portal vein is rare in our experience and has been always performed out of necessity because of the over estimation of the resectability. However, mortality and post-operative stay are not increased.

Hemoptysis is not considered as an hemorrhagic complication of portal hypertension. We report a patient with liver cirrhosis and portal hypertension who developed a hitherto unreported porto-pulmonary transdiaphragmatic collaterality many years after splenectomy. Life threatening hemoptysis complicated this unusual shunt after banal bronchitis. A proximal splenorenal shunt was performed and was completely effective at 26 months.

In cases where double enterostomy is necessary, it is always possible to introduce a balloon catheter into the distal small bowel and to attach it to the deep surface of the abdominal wall, close to the proximal enterostomy. This "indirect" enterostomy facilitates fitting of the productive orifice, as well as resumption of digestion and, ultimately, restoration of the gastro-intestinal tract.

The protein C system is essential in limiting the activation of coagulation in vivo. We report on a 29 year old woman with Budd-Chiari syndrome and occlusion of the inferior vena cava who presented with acute liver failure. She was successfully treated with an emergency mesoatrial shunt. Eight months after surgery, she has no ascites and normal liver function. She had a low concentration of plasma protein C on admission to hospital and during the follow up. Protein C deficiency subsequently was found in her father and two sisters, who were asymptomatic. Hereditary protein C deficiency should be considered in patients with Budd-Chiari syndrome.

The emergency surgical treatment of severe hepatic traumas still carries a high mortality risk. We report a case of severe blunt trauma of the liver managed without surgery under CT guidance. This attitude--which does not exclude surgery as a later resort--requires haemodynamic stability of the patient, close monitoring in a surgical intensive care unit and repeated CT scans.