Quantitative T2 Mapping of Acute Pancreatitis.

BACKGROUND: Quantification of the T2 signal by means of T2 mapping in acute pancreatitis (AP) has the potential to quantify the parenchymal edema. Quantitative T2 mapping may overcome the limitations of previously reported scoring systems for reliable assessment of AP. PURPOSE: To evaluate MR-derived pancreatic T2 mapping values in AP and correlate them with markers of disease severity. STUDY TYPE: Prospective single-center study. POPULATION: 76 adults with AP (20-91 years, females/males: 39/37). FIELD STRENGTH/SEQUENCE: Fat suppressed multiecho spin-echo prototype sequence to quantify T2 signal at 3T MRI. ASSESSMENT: The severity of AP was assessed clinically, biologically, and by contrast-enhanced CT (CECT) performed 48-72 hours after symptom onset. MRI was then performed ≤24 hours after CT. Two readers blinded to any clinical information independently evaluated the T2 values by placing three regions of interest inside the pancreatic head, body, and tail on the T2 mapping MR sequence. Results were compared with corresponding CECT images as the standard and clinical severity parameters, using the length of hospital stay as our primary endpoint. STATISTICAL TESTS: Continuous variables were compared using the Spearman's rank correlation coefficient, analysis of variance (ANOVA) or Student's t-test. RESULTS: T2 values significantly correlated with the length of hospital stay (rs (74) = 0.29), CT severity index (CTSI) (rs (73) = 0.61; CTSI 0-3: 72 ± 14 msec, CTSI 4-10: 88 ± 15), intensive care unit (ICU) admission (t(2.77) = -3.41) and presence of organ failure (t(6.72) = -3.42), whereas the CTSI and Ranson score were not significantly related with ICU admission (CTSI: P = 0.24; Ranson score: P = 0.24) and organ failure (CTSI: P = 0.11; Ranson score P = 0.11). CONCLUSION: T2 mapping correlates with AP severity parameters and is useful for assessing the severity of AP with higher sensitivity than the usual clinical and radiological scoring systems. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 2.

Tc-99m mebrofenin hepatobiliary scintigraphy to assess future liver remnant function before major liver surgery.

BACKGROUND AND OBJECTIVES: Assessment of liver function is paramount before hepatectomy. This study aimed to assess future liver remnant function (FLR-F) using hepatobiliary scintigraphy (HBS) and to compare it to FLR volume (FLR-V) in the prediction of posthepatectomy liver failure (PHLF). The impact of volume and function gains were also assessed in patients undergoing portal vein embolization (PVE) or liver venous deprivation (LVD). METHODS: All consecutive patients undergoing major hepatectomy between 02/2018 and 09/2021 with preoperative HBS were included. FLR-V was expressed as percentage of total liver volume and analyzed using preoperative computed tomography. FLR-V and FLR-F gains after embolization were expressed in percentage. Receiver operating characteristic analysis was performed to compare both methods in predicting PHLF. RESULTS: Thirty-six patients were included. PVE and LVD were performed in 4 (11%) and 28 patients (78%), respectively. Overall, PHLF occurred in eight patients (22%). FLR-F gain after embolization showed significant ability to predict PHLF (area under the curve [AUC] = 0.789), with cut-off value of 150% showing a sensitivity of 1.00, a specificity of 0.42, and a negative predictive value of 1.00. CONCLUSION: Preoperative HBS shows a high sensitivity to predict PHLF when HBS is performed twice to measure the function gain after venous embolization.

Tumor burden in patients with early and intermediate-stage hepatocellular carcinoma undergoing liver resection: a retrospective multicenter study on clinical and oncological outcomes.

BACKGROUND: According to the Barcelona Clinic Liver Cancer (BCLC) staging system, liver resection (LR) is recommended for early-stage (BCLC-A) hepatocellular carcinoma (HCC) but not for intermediate-stage (BCLC-B). This study aimed to assess the outcomes of LR in these patients using a subclassification tumour burden score (TBS). METHODS: All consecutive patients that underwent LR for BCLC-A and BCLC-B HCC between 01/2010 and 12/2020 in 4 tertiary referral centers were included. Clinical outcomes and overall survival (OS) were assessed in relation to TBS and BCLC stages. RESULTS: Among 612 patients included, 562 were classified as BCLC-A and 50 as BCLC-B. The incidence of overall postoperative complications (56.0 vs 41.5%, p = 0.053) and mortality (0 vs 1.6%, p = 1.000) were similar between BCLC-A and BCLC-B patients. OS was significantly higher for BCLC A/low TBS than BCLC B/low TBS (p = 0.009), while patients with medium and high TBS had similar OS, irrespective of BCLC stage (respectively p = 0.103 and p = 0.343). CONCLUSIONS: Patients with medium and high TBS had comparable OS and DFS, irrespective of BCLC A or B stage, and postoperative morbidity was comparable. These results highlight the need for refinement of the BCLC staging system, and LR could be considered for selected intermediate stage (BCLC-B) according to the tumour burden.

[2023 update on alveolar echinococcosis]. / Échinococcose alvéolaire : prise en charge en 2023.

Alveolar echinococcosis is a rare but severe parasitic disease and is now in Europe the parasitic infection associated with the most morbidity and mortality. Its prevalence is increasing in Switzerland in both urban and rural areas. Echinococcosis is a differential diagnosis that should be considered when facing a cystic hepatic lesion. Moreover, this parasitic infection is increasing amongst immunocompromised patients, making the diagnosis more complex, because of atypic lesions and a more rapid evolution. At the current time, several treatment options, both surgical and medical, can offer patients a good prognosis and maintain a good quality of life.

L'échinococcose alvéolaire est une parasitose rare mais sévère. En Europe, il s'agit de l'infection parasitaire causant le plus de morbimortalité. Son incidence est en augmentation en Suisse dans les zones urbaines et rurales. L'échinococcose est donc un diagnostic différentiel à évoquer face à une lésion kystique hépatique. En outre, cette infection parasitaire est en augmentation chez les patients immunosupprimés, chez qui le diagnostic est plus complexe en raison de lésions atypiques et d'une évolution plus rapide. À l'heure actuelle, plusieurs modalités de traitements chirurgicaux et médicamenteux permettent d'offrir un bon pronostic aux patients tout en maintenant une bonne qualité de vie.

[Management of acute cholecystitis]. / Prise en charge de la cholécystite aiguë.

Acute cholecystitis is an inflammation of the gallbladder most often related to gallstones. The diagnostic and severity criteria are well described by the Tokyo criteria. Early laparoscopic cholecystectomy remains the treatment of choice. It can also be performed in elderly patients and in pregnant women during any trimester. For patients not eligible for surgery, percutaneous or echo-endoscopic gallbladder drainage (EUS-GBD) are effective treatment alternatives. The management of acute cholecystitis must therefore be adapted to each patient by carefully evaluating the risks and benefits associated with surgery.

La cholécystite aiguë est une inflammation de la vésicule biliaire le plus souvent liée à des calculs biliaires. Les critères diagnostiques et de sévérité sont bien décrits par les critères de Tokyo. La cholécystectomie laparoscopique précoce reste le traitement de choix. Elle peut être également réalisée chez les patients âgés et chez les femmes enceintes pendant n'importe quel trimestre. Pour les patients non éligibles à la chirurgie, les drainages de la vésicule biliaire par voie percutanée ou échoendoscopique (EUS-GBD) sont des alternatives thérapeutiques efficaces. La prise en charge de la cholécystite aiguë doit donc être adaptée à chaque patient en évaluant de façon attentive les risques et bénéfices associés à la chirurgie.

[Novelties on the management of alveolar echinococcosis]. / Nouveautés dans la prise en charge de l'échinococcose alvéolaire.

Alveolar echinococcosis is an endemic parasitosis in Switzerland. This pathology mainly infects the liver and develops similarly as a malignant tumor with its ability to spread into the hepatic parenchyma and its capacity of developing distant lesions via hematogenous dissemination. Treatment is based on complete surgical resection coupled with albendazole treatment. Recently, ex vivo liver resections with auto-transplantation have been shown to be feasible in case of end-stage alveolar echinococcosis. Moreover, new biomarkers such as programmed death-ligand 1 (PD-L1), a protein with immunomodulation property, have shown their potential impact on the treatment and follow-up of patients with alveolar echinococcosis.

L'échinococcose alvéolaire est une parasitose endémique en Suisse. Cette pathologie touche principalement le foie et se développe telle une tumeur maligne, par sa propension à envahir le parenchyme hépatique et par sa capacité à développer des lésions à distance par voie hématogène. Le traitement repose sur une exérèse chirurgicale complète couplée à un traitement d'albendazole. Récemment, des techniques de résection hépatique ex vivo avec auto-transplantation ont montré leur faisabilité en cas d'échinococcose alvéolaire avancée. De plus, de nouveaux marqueurs, comme le programmed death-ligand 1 (PD-L1), protéine jouant un rôle dans l'immunomodulation, ont montré leur potentiel impact pour le traitement et le suivi des patients atteints d'échinococcose alvéolaire.

[Surgery Sustainability in surgical practice : the "green surgery" concept and its innovations]. / Chirurgie - Pratique chirurgicale et durabilité : le concept de chirurgie verte et ses innovations.

Awareness of climate change grows in the population and people develop eco-responsible habits in their daily and professional life. The health care system is nowadays responsible for 4.6% of global greenhouse gases emissions, and most of them comes from hospital activity. The operating room is one of the greatest contributors of the overall energetic cost and generates a large amount of hospital waste. As an example, all laparoscopic procedures in the US has an energy cost similar to an 80'000 inhabitants city during one year. A better understanding of the environmental impact of surgery is necessary to identify what can be done to limit the ecological impact of surgery without compromising standards of care.

La population est de plus en plus sensibilisée au changement climatique et développe des habitudes écoresponsables dans la vie quotidienne et professionnelle. Le système de santé est aujourd'hui responsable de 4,6 % des émissions de gaz à effet de serre dans les pays développés, dont la plupart proviennent de l'activité hospitalière. Le bloc opératoire est l'un des plus grands contributeurs au coût énergétique global et génère une grande quantité de déchets hospitaliers. À titre d'exemple, aux États-Unis, l'ensemble des laparoscopies a un coût énergétique annuel similaire à celui d'une ville de 80 000 habitants. Une meilleure compréhension de l'impact écologique de la chirurgie est nécessaire pour identifier ce qui peut être fait pour limiter l'impact écologique de la chirurgie sans compromettre les normes de soins.

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons.

OBJECTIVES: To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons. METHODS: Retrospective data (1/2008-12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories. RESULTS: The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56-0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings. CONCLUSIONS: The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously. KEY POINTS: • The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.

Correlation Between Portal Pressure and Indocyanine Green Retention Rate is Unaffected by the Cause of Cirrhosis: A Prospective Study.

BACKGROUND: Accurate estimation of the hepatic functional reserve before liver resection is important to avoid post-hepatectomy liver failure (PHLF). The aim of the present study was to evaluate the association of indocyanine green retention test with portal pressure by the cause of cirrhosis (non-viral vs. viral) and assessed postoperative outcomes including incidence of PHLF in patients with viral and non-viral cirrhosis. METHODS: The cohort includes 50 consecutive patients with liver cirrhosis scheduled for liver resection for primary liver tumors at the Lausanne University Hospital between 2009 and 2018. RESULTS: There were 31 patients with non-viral liver cirrhosis (Non-virus group) and 19 with viral liver cirrhosis (virus group). The indocyanine green retention rate at 15 min (ICG-R15) (p = 0.276), Hepatic Venous Portal Gradient (HVPG; p = 0.301), and postoperative outcomes did not differ between the non-virus group and viral group. ICG-R15 and HVPG showed a significant linear correlation in all patients (Spearman's rank correlation coefficient, ρ = 0.599, p < 0.001), the non-virus group (ρ = 0.555, p = 0.026), and the virus group (ρ = 0.534, p = 0.007). A receiver operating characteristic curve analysis showed that ICG-R15 was a predictor for presence of portal hypertension (PH; HVPG ≥ 12 mmHg) (area under the curve [AUC] = 0.780). The cut-off value of ICG-R15 for predicting the presence of PH was 16.0% with 72.3% of sensitivity and 79.0% of specificity. CONCLUSIONS: The ICG-R15 level was associated with portal pressure in both patients with non-virus cirrhosis and patients with virus cirrhosis and predicts the incidence of PH with relatively good discriminatory ability. CLINICAL TRIAL NUMBER: https://clinicalTrials.gov(ID:NCT00827723) LOCAL ETHICS COMMITTEE NUMBER: CER-VD 251.08.

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy.

PURPOSE: Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. METHODS: A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. RESULTS: Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. CONCLUSIONS: We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

[Preoperative liver venous deprivation]. / Embolisation portale et sus-hépatique combinée avant hépatectomie ma.

Some hepato-biliary cancers require major liver resections. Post hepatectomy liver failure is a complication that occurs when the remnant liver cannot maintain its synthetic and excretory functions. To overcome this issue, portal vein embolization has been developed to induce future remnant liver hypertrophy preoperatively. However, up to 20% of patients cannot proceed to the hepatectomy due to insufficient hypertrophy or tumor progression in the interval between the embolization and the planned surgery. Liver venous deprivation (LVD) is a technique that combine ipsilateral portal and hepatic vein embolization. With this technique, the hypertrophy seems to be faster and more important, with low complications rate and no mortality associated with the procedure.

Certains cancers hépatobiliaires nécessitent des résections hépatiques majeures. L'insuffisance hépatocellulaire est une complication postopératoire avec un risque de mortalité qui survient lorsque le foie restant ne peut maintenir ses fonctions de synthèse et d'excrétion. L'embolisation de la veine porte a été développée pour induire une hypertrophie du futur foie restant en préopératoire afin d'éviter cette complication. Cependant, 20 % des patients ne peuvent pas bénéficier de l'hépatectomie en raison d'une hypertrophie insuffisante ou d'une progression de la maladie oncologique dans l'intervalle entre l'embolisation et la chirurgie. L'embolisation portale et sus-hépatique combinée est une technique qui consiste à combiner durant le même geste l'embolisation de la veine porte et de la veine sus-hépatique ipsilatérale. Par cette technique, l'hypertrophie semble alors plus rapide et importante, avec peu de complications et aucune mortalité en lien avec la procédure.

Pancreaticogastrostomy after pancreaticoduodenectomy without suturing the pancreas.

The aim of the present paper was to describe a new and easy technique for performing pancreaticogastrostomy (PG) through simple pancreatic invagination by a single binding suture without suturing the pancreatic parenchyma. The present study included all consecutive patients who underwent elective pancreaticoduodenectomy from 2007 to 2015. The intraoperative and postoperative outcomes after PG (PG group) were compared with those of patients who underwent pancreaticojejunostomy (PJ) (PJ group). Out of 270 patients, 88 PG and 182 PJ patients were assessed. The rate of clinically significant PF was similar between the PG and PJ groups (10.2% vs. 13.2%, respectively; p = 0.487), despite the risk of pancreatic fistula being higher in the PG group. There were no significant differences in the intraoperative and postoperative outcomes or mortality between the groups. This easy invagination technique for PG is simple, safe and reproducible with a low risk of postoperative pancreatic fistula.

Hepatectomy in patients with inherited blood coagulation disorders can be safely performed with adequate coagulation factor replacement.

BACKGROUND: Haemophilia and von Willebrand disease (VWD) are common inherited bleeding disorders. Although patients with haemophilia or VWD have a high risk of hepatitis virus infection and hepatocellular carcinoma (HCC), little is known about the safety of liver resection in these patients. METHODS: From 2006 to 2016, there were seven hepatectomies with haemophilia A and three hepatectomies with VWD for malignant liver tumours at tertiary care hospitals in Japan and Switzerland. To evaluate the safety of hepatectomy in the blood coagulation disorder group (BD group), short-term outcomes in these patients were compared with 20 hepatectomies (non-BD group) for HCC, matched to a 2:1, operative procedure, period and background liver. RESULTS: Ten liver resections were performed in patients with haemophilia or VWD with administration of recombinant FVIII or VWF concentrate. Comparison of the BD vs non-BD group revealed no significant differences in the operative time (327 vs 407 minutes, P = 0.359), estimated blood loss (730 vs 820 mL, P = 0.748), red blood cell transfusion rate (10.0% vs 5.0%, P = 0.605), major complication rate (Clavien-Dindo grade III or IV) (10.0% vs 5.0%, P = 0.605) or mortality rate (0% vs 0%, P > 0.999). Additionally, the length of the postoperative hospital stay was similar between the two groups (13 vs 14 days, P = 0.296). CONCLUSION: Liver resection for treatment of HCC in patients with haemophilia or VWD can be safely performed through an appropriate perioperative administration protocol of coagulation factors.

Fine-Tuning Tumor Endothelial Cells to Selectively Kill Cancer.

Tumor endothelial cells regulate several aspects of tumor biology, from delivering oxygen and nutrients to shaping the immune response against a tumor and providing a barrier against tumor cell dissemination. Accordingly, targeting tumor endothelial cells represents an important modality in cancer therapy. Whereas initial anti-angiogenic treatments focused mainly on blocking the formation of new blood vessels in cancer, emerging strategies are specifically influencing certain aspects of tumor endothelial cells. For instance, efforts are generated to normalize tumor blood vessels in order to improve tumor perfusion and ameliorate the outcome of chemo-, radio-, and immunotherapy. In addition, treatment options that enhance the properties of tumor blood vessels that support a host's anti-tumor immune response are being explored. Hence, upcoming anti-angiogenic strategies will shape some specific aspects of the tumor blood vessels that are no longer limited to abrogating angiogenesis. In this review, we enumerate approaches that target tumor endothelial cells to provide anti-cancer benefits and discuss their therapeutic potential.

Acidic tumor microenvironment abrogates the efficacy of mTORC1 inhibitors.

BACKGROUND: Blocking the mechanistic target of rapamycin complex-1 (mTORC1) with chemical inhibitors such as rapamycin has shown limited clinical efficacy in cancer. The tumor microenvironment is characterized by an acidic pH which interferes with cancer therapies. The consequences of acidity on the anti-cancer efficacy of mTORC1 inhibitors have not been characterized and are thus the focus of our study. METHODS: Cancer cell lines were treated with rapamycin in acidic or physiological conditions and cell proliferation was investigated. The effect of acidity on mTORC1 activity was determined by Western blot. The anticancer efficacy of rapamycin in combination with sodium bicarbonate to increase the intratumoral pH was tested in two different mouse models and compared to rapamycin treatment alone. Histological analysis was performed on tumor samples to evaluate proliferation, apoptosis and necrosis. RESULTS: Exposing cancer cells to acidic pH in vitro significantly reduced the anti-proliferative effect of rapamycin. At the molecular level, acidity significantly decreased mTORC1 activity, suggesting that cancer cell proliferation is independent of mTORC1 in acidic conditions. In contrast, the activation of mitogen-activated protein kinase (MAPK) or AKT were not affected by acidity, and blocking MAPK or AKT with a chemical inhibitor maintained an anti-proliferative effect at low pH. In tumor mouse models, the use of sodium bicarbonate increased mTORC1 activity in cancer cells and potentiated the anti-cancer efficacy of rapamycin. Combining sodium bicarbonate with rapamycin resulted in increased tumor necrosis, increased cancer cell apoptosis and decreased cancer cell proliferation as compared to single treatment. CONCLUSIONS: Taken together, these results emphasize the inefficacy of mTORC1 inhibitors in acidic conditions. They further highlight the potential of combining sodium bicarbonate with mTORC1 inhibitors to improve their anti-tumoral efficacy.

A new formula for calculating standard liver volume for living donor liver transplantation without using body weight.

BACKGROUND & AIMS: The standard liver volume (SLV) is widely used in liver surgery, especially for living donor liver transplantation (LDLT). All the reported formulas for SLV use body surface area or body weight, which can be influenced strongly by the general condition of the patient. METHODS: We analyzed the liver volumes of 180 Japanese donor candidates and 160 Swiss patients with normal livers to develop a new formula. The dataset was randomly divided into two subsets, the test and validation sample, stratified by race. The new formula was validated using 50 LDLT recipients. RESULTS: Without using body weight-related variables, age, thoracic width measured using computed tomography, and race independently predicted the total liver volume (TLV). A new formula: 203.3-(3.61×age)+(58.7×thoracic width)-(463.7×race [1=Asian, 0=Caucasian]), most accurately predicted the TLV in the validation dataset as compared with any other formulas. The graft volume for LDLT was correlated with the postoperative prothrombin time, and the graft volume/SLV ratio calculated using the new formula was significantly better correlated with the postoperative prothrombin time than the graft volume/SLV ratio calculated using the other formulas or the graft volume/body weight ratio. CONCLUSIONS: The new formula derived using the age, thoracic width and race predicted both the TLV in the healthy patient group and the SLV in LDLT recipients more accurately than any other previously reported formulas.