Image in transplantation surgery: median arcuate ligament in liver transplantation.

Low inserted median arcuate ligament (MAL) may cause extrinsic coeliac trunk compression and MAL syndrome (association of post-prandial epigastric pain, weight loss and nausea or vomiting). In liver transplantation (LT), liver graft arterial supply depends on the recipient's hepatic artery, as the gastro-duodenal artery has generally been ligated. A decreased graft arterial flow caused by coeliac trunk stenosis might induce hepatic artery thrombosis leading to graft loss. In this short report, the authors describe LT procedure during which recipient's hepatic artery pressure was dramatically decreased after ligature of the gastro-duodenal artery. Dissection and division of the MAL allowed to restore an excellent blood flow through the hepatic artery. This report reminds how important it is to be able to recognize and how to manage a stenosing MAL in LT.

Acute pelvic inflammatory disease as a rare cause of acute small bowel obstruction.

Introduction: Small bowel obstruction (SBO) is a common presentation to emergency abdominal surgery. The most frequent causes of SBO are congenital, postoperative adhesions, abdominal wall hernia, internal hernia and malignancy. Patients: A 27-year-old woman was hospitalized because of acute abdominal pain, blockage of gases and stools associated with vomiting. Abdominal computed tomography showed an acute small bowel obstruction without any obvious etiology. In view of important abdominal pain and the lack of clear diagnosis, an explorative laparoscopy was performed. Diagnostic of pelvic inflammatory disease was established and was comforted by positive PCR for Chlamydia Trachomatis. Results: Acute small bowel obstruction resulting from acute pelvic inflammatory disease, emerging early after infection, without any clinical or X-ray obvious signs was not described in the literature yet. This infrequent acute SBO etiology but must be searched especially when there is no other evident cause of obstruction in female patients. Early laparoscopy is mostly advised when there are some worrying clinical or CT scan signs.

Does comfort therapy during controlled donation after circulatory death shorten the life of potential donors?

INTRODUCTION: Controlled donation after circulatory death (DCD) remains ethically controversial. The authors developed a controlled DCD protocol in which comfort therapy is regularly used. The aim of this study was to determine whether this policy shortens the DCD donors' life. METHODS: The authors retrospectively analyzed prospectively collected data on patients proposed for DCD at the University Hospital of Liege, Belgium, over a 56-month period. The survival duration of these patients, defined as duration between the time of proposal for DCD and the time of circulatory arrest, was compared between patients who actually donated organs and those who did not. RESULTS: About 128 patients were considered for controlled DCD and 54 (43%) became donors. Among the 74 non-donor patients, 34 (46%) objected to organ donation, 38 patients (51%) were denied by the transplant team for various medical reasons, and two potential DCD donors did not undergo procurement due to logistical and organizational reasons. The survival durations were similar in the DCD donor and non-donor groups. No non-donor patient survived. CONCLUSIONS: Survival of DCD donors is not shortened when compared with non-donor patients. These data support the ethical and respectful approach to potential DCD donors in the authors' center, including regular comfort therapy.

A modified surgical model of fulminant hepatic failure in the rat.

BACKGROUND: There is a need for better animal models of fulminant liver failure (FHF). Eguchi et al described an interesting surgical model of FHF in the rat. This model includes 68% partial hepatectomy, ischemia of 24% of the liver mass, and 8% of remnant liver left intact. In the original description by Eguchi et al, rats were administered subcutaneous glucose. However, the authors found that normothermic FHF rats with subcutaneous glucose died from deep hypoglycemia. In this report, we describe a modification of that model, and show that administration of intravenous glucose allows better survival and development of intracranial hypertension. METHODS: We operated on FHF rats using the procedure described by Eguchi et al, kept them normothermic, and maintained normoglycemia by continuous intravenous glucose injection (glucose 10%, 1 mL/h). At 24 h, we monitored liver blood tests (n = 5), intracranial pressure (n = 5), clinical encephalopathy, and survival (n = 10), and compared them with sham and 68% hepatectomy rats. RESULTS: The FHF rats developed acute cytolysis, cholestasis, and liver failure, as demonstrated by the liver blood tests. They experienced progressive encephalopathy and intracranial hypertension leading to death. Mean survival was 45.9 h. Of 10 FHF rats from the survival evaluation cohort, one survived 7 d. Laparotomy showed necrosis of lateral liver lobes and enlargement of omental lobes with a normal hepatic aspect, suggesting liver recovery. CONCLUSIONS: This surgical rat model mimics the features of human FHF and seems interesting for further research into the pathophysiology and therapeutic management of the disease.

What is the potential increase in the heart graft pool by cardiac donation after circulatory death?

Heart transplantation remains the only definite treatment option for end-stage heart diseases. The use of hearts procured after donation after circulatory death (DCD) could help decrease the heart graft shortage. The aim of this study was to evaluate the potential increase in heart graft pool by developing DCD heart transplantation. We retrospectively reviewed our local donor database from 2006 to 2011, and screened the complete controlled DCD donor population for potential heart donors, using the same criteria as for donation after brain death (DBD) heart transplantation. Acceptable donation warm ischemic time (DWIT) was limited to 30 min. During this period 177 DBD and 70 DCD were performed. From the 177 DBD, a total of 70 (39.5%) hearts were procured and transplanted. Of the 70 DCD, eight (11%) donors fulfilled the criteria for heart procurement with a DWIT of under 30 min. Within the same period, 82 patients were newly listed for heart transplantation, of which 53 were transplanted, 20 died or were unlisted, and 9 were waiting. It could be estimated that 11% of the DCD might be heart donors, representing a 15% increase in heart transplant activity, as well as potential reduction in the deaths on the waiting list by 40%.

Results of kidney transplantation from controlled donors after cardio-circulatory death: a single center experience.

The aim of this study was to determine results of kidney transplantation (KT) from controlled donation after cardio-circulatory death (DCD). Primary end-points were graft and patient survival, and post-transplant complications. The influence of delayed graft function (DGF) on graft survival and DGF risk factors were analyzed as secondary end-points. This is a retrospective mono-center review of a consecutive series of 59 DCD-KT performed between 2005 and 2010. Overall graft survival was 96.6%, 94.6%, and 90.7% at 3 months, 1 and 3 years, respectively. Main cause of graft loss was patient's death with a functioning graft. No primary nonfunction grafts. Renal graft function was suboptimal at hospital discharge, but nearly normalized at 3 months. DGF was observed in 45.6% of all DCD-KT. DGF significantly increased postoperative length of hospitalization, but had no deleterious impact on graft function or survival. Donor body mass index ≥30 was the only donor factor that was found to significantly increase the risk of DGF (P < 0.05). Despite a higher rate of DGF, controlled DCD-KT offers a valuable contribution to the pool of deceased donor kidney grafts, with comparable mid-term results to those procured after brain death.

Consequences of pneumoperitoneum on liver ischemia during laparoscopic portal triad clamping in a swine model.

BACKGROUND: Portal triad clamping (PTC) may be required during laparoscopic liver resection to limit blood loss. The aim of this study was to test in a swine model the hypothesis that during laparoscopic PTC, increased intraperitoneal pressure may alter hepatic vein reverse circulation, inducing a more severe hepatic ischemia compared with PTC performed in laparotomy. METHODS: Fifteen pigs were randomized into three groups: laparoscopy (1 h of pneumoperitoneum at 15 mmHg and 3 h of surveillance), open PTC (1 h PTC through laparotomy and 3 h of reperfusion), and laparoscopic PTC (1 h PTC with 15 mmHg pneumoperitoneum and 3 h of reperfusion). PTC was performed under mesenteric decompression using a veno-venous splenofemoral bypass. Hepatic partial oxygen tension and microcirculatory flow were continuously measured using a Clarke-type electrode and a laser Doppler flow probe, respectively. Liver consequences of PTC was assessed by right atrium serum determination of transaminases, creatinine, bilirubin, INR, and several ischemia/reperfusion parameters, drawn before PTC (T0), before unclamping (T60), and 1 (T120) and 3 h after reperfusion (T240). Histology was performed on T240 liver biopsies. RESULTS: Compared with open PTC, laparoscopic PTC produced a more rapid and more severe decrease in hepatic oxygen tension, indicating a more severe tissular hypoxia, and a more severe decrease in hepatic microcirculatory flow, indicating a decrease in hepatic backflow. At T240, the laparoscopic PTC livers suffered from a higher degree of hepatocellular damage, shown by higher transaminases and increased necrotic index at pathology. CONCLUSIONS: These results indicate that in this pig model, laparoscopic PTC induces a more severe liver ischemia, related to decreased hepatic oxygen content and decreased hepatic backflow. If confirmed by clinical studies, these results may indicate that caution is necessary when performing prolonged PTC during laparoscopic hepatic resection, particularly in cirrhotic or steatotic livers.

Multicenter study of 19 aortopulmonary window parathyroid tumors: the challenge of embryologic origin.

BACKGROUND: Ectopic abnormal parathyroid glands are relatively common in the superior mediastinum but are rarely situated in the aortopulmonary window (APW). The embryological origin of these abnormal parathyroid glands is controversial. The purpose of this investigation was to investigate the embryological origin and the surgical management of abnormal parathyroid glands situated in the APW. METHODS: The databases of patients operated on for primary, secondary, and tertiary hyperparathyroidism at eight European medical centers with a special interest in endocrine surgery were reviewed to identify those with APW adenomas. Demographic features, localization procedures, and perioperative and pathology findings were documented. The embryological origin was determined based on the number and position of identified parathyroid glands. RESULTS: Nineteen (0.24%) APW parathyroid tumors were identified in 7,869 patients who underwent an operation for hyperparathyroidism (HPT) and 181 patients (2.3%) with mediastinal abnormal parathyroid glands. Ten patients had primary, eight had secondary, and one had tertiary HPT. Sixteen patients had undergone previous unsuccessful cervical exploration. In three patients, an APW adenoma was suspected by preoperative localization studies and was cured at the initial operation. Sixteen patients had persistent HPT of whom 15 were reoperated, resulting in 6 failures. Evaluation of 17 patients who had bilateral neck exploration allowed us to determine the most probable origin of the APW parathyroid tumors: 12 were supernumerary, 4 appeared to originate from a superior, and 1 from an inferior gland. CONCLUSIONS: Abnormal parathyroid glands situated in the APW are rare and usually identified after an unsuccessful cervical exploration. Preoperative imaging of the mediastinum and neck are essential. The origin of these ectopically situated tumors is probably, as suggested by our data, from a supernumerary fifth parathyroid gland or from abnormal migration of a superior parathyroid gland during the embryologic development.

Pancreas graft drainage in recipient duodenum: preliminary experience.

Pancreas graft survival has continuously improved over the years to become a main treatment option of uncontrolled complicated diabetes. Rejection remains the major challenge as it often goes unnoticed until severe damage of the graft manifests itself by elevated blood sugar. Pancreas enzymes monitoring in the blood and in the urine is a sensitive marker of rejection but lack of specificity. Biopsy remains the gold standard. Cystoscopy-guided biopsy of bladder-drained pancreas has a good success rate for obtaining tissue but the vesical drainage exposes to metabolic and urologic morbidity. Percutaneous pancreas biopsy can be performed with a low morbidity rate but severe complications can occur. We discuss a technique of pancreas transplantation with the drainage of exocrine secretions of the pancreatic graft in the recipient duodenum, which permits easy monitoring of the graft by upper endoscopy of the duodenum.

Cadaveric liver transplantation for non-acetaminophen fulminant hepatic failure: a 20-year experience.

AIM: To investigate the long-term results of liver transplantation (LT) for non-acetaminophen fulminant hepatic failure (FHF). METHODS: Over a 20-year period, 29 FHF patients underwent cadaveric whole LT. Most frequent causes of FHF were hepatitis B virus and drug-related (not acetaminophen) liver failure. All surviving patients were regularly controlled at the out-patient clinic and none was lost to follow-up. Mean follow-up was 101 mo. RESULTS: One month, one-, five- and ten-year patient survival was 79%, 72%, 68% and 68%, respectively. One month, one-, five- and ten-year graft survival was 69%, 65%, 51% and 38%, respectively. Six patients needed early (< 2 mo) retransplantation, four for primary non-function, one for early acute refractory rejection because of ABO blood group incompatibility, and one for a malignant tumor found in the donor. Two patients with hepatitis B FHF developed cerebral lesions peri-transplantion: One developed irreversible and extensive brain damage leading to death, and one suffered from deep deficits leading to continuous medical care in a specialized institution. CONCLUSION: Long-term outcome of patients transplanted for non-acetaminophen FHF may be excellent. As the quality of life of these patients is also particularly good, LT for FHF is clearly justified, despite lower graft survival compared with LT for other liver diseases.

Prolonged anhepatic state after early liver graft removal.

Two-stage liver transplantation, i.e. salvage emergent total hepatectomy with prolonged anhepatic state, and subsequent liver transplantation, has been described as a life-saving procedure in selected cases. The principal drawback of two-stage liver transplantation is the fact that anhepatic patient survival only depends on the future availability of a liver graft. The pathophysiologic alterations induced by total hepatectomy are not fully known, as it is not known how long a patient may be anhepatic before it is too late for hope of survival. In this report the authors describe the cases of three liver recipients who had to undergo salvage liver graft removal early during or after liver transplantation as a life-saving maneuver. All were afterwards registered for emergent liver retransplantation. Mean anhepatic period was 20 hours (Range: 17-24 hours). Two patients survived and fully recovered. From this experience and from other cases reported in the literature, the authors concluded that total hepatectomy may be life-saving in some cases if a liver graft is available in a timely manner.

Laparoscopic spleen-preserving distal pancreatectomy: description of an original posterior approach.

We are describing in this paper the original and innovative technique we used to perform a spleen-preserving distal pancreatectomy. With the patient positioned on her right lateral side, we inserted four laparoscopic ports in the left subcostal region to enable an upper view on the spleen and its rear attachments. With this approach, we opened and dissected this plan located between the left kidney and the rear aspect of the spleen and of the pancreas. These structures, once liberated naturally, felt "en-bloc" out of the way because of the patient's lateral positioning and the gravity, exposing the operative field without any artificial retraction. Beyond this greater exposure, this new approach offers many other advantages, such as the easiness to be performed by only two operators and the preservation of the anterior abdominal cavity, the great omentum, the splenic vessels, and the short gastric vessels left untouched.

Report of two cases of gastric cancer after bariatric surgery: lymphoma of the bypassed stomach after Roux-en-Y gastric bypass and gastrointestinal stromal tumor (GIST) after vertical banded gastroplasty.

We report two new cases of gastric cancer diagnosed after a bariatric operation. The first case is a 66-year-old male who 3 years after gastric bypass suffered from a perforation of the fundus that was found to be secondary to a diffuse large B-cell lymphoma of the distal stomach. The second case is a 47-year-old woman who presented 12 years after a vertical banded gastroplasty with a gastric pouch outlet obstruction caused by a gastrointestinal stromal tumor (GIST). Based on the few reports of cancer in the literature, analysis of these cases suggests that the main risk of gastric cancer after bariatric surgery comes from the delayed diagnosis of malignancy.

Pylephlebitis of the portal vein complicating intragastric migration of an adjustable gastric band.

Pylephlebitis, or septic thrombophlebitis of the portal vein, is an infrequent but life-threatening complication of abdominal septic events. The authors report the occurrence of pylephlebitis and multiple liver abscesses induced by a neglected intra-gastric migration of an adjustable silicone gastric band. The patient was successfully treated by broad-spectrum antibiotics and total gastrectomy with Roux-en-Y esophago-jejunostomy. Postoperative recovery was marked by acute liver failure that was managed conservatively. The patient is alive and well at 1-year follow-up. This case emphasizes the interest in early removal of the band when intra-gastric migration is diagnosed.

Risk of upper gastrointestinal cancer after bariatric operations.

The authors discuss the potential influence of obesity surgery on the risk of cancer, focusing on the upper GI tract directly affected by operations. There is currently no substantiation for an increased risk of cancer after bariatric surgery, because there are only about 25 reports of subsequent cancer of the esophagus and the stomach. However, this review emphasizes the need to detect potential precancerous conditions before surgery. Candidates for postoperative endoscopic surveillance may include patients >15 years after gastric surgery, but also patients symptomatic for gastroesophageal reflux disease in whom a high incidence of Barrett's metaplasia has been reported. The greatest concern is a delay in diagnosis from inadequate investigation due to mistaking serious upper GI symptoms as a consequence of the past operation.

Brain edema and intracranial hypertension in fulminant hepatic failure: pathophysiology and management.

Intracranial hypertension is a major cause of morbidity and mortality of patients suffering from fulminant hepatic failure. The etiology of this intracranial hypertension is not fully determined, and is probably multifactorial, combining a cytotoxic brain edema due to the astrocytic accumulation of glutamine, and an increase in cerebral blood volume and cerebral blood flow, in part due to inflammation, to glutamine and to toxic products of the diseased liver. Validated methods to control intracranial hypertension in fulminant hepatic failure patients mainly include mannitol, hypertonic saline, indomethacin, thiopental, and hyperventilation. However all these measures are often not sufficient in absence of liver transplantation, the only curative treatment of intracranial hypertension in fulminant hepatic failure to date. Induced moderate hypothermia seems very promising in this setting, but has to be validated by a controlled, randomized study. Artificial liver support systems have been under investigation for many decades. The bioartificial liver, based on both detoxification and swine liver cells, has shown some efficacy on reduction of intracranial pressure but did not show survival benefit in a controlled, randomized study. The Molecular Adsorbents Recirculating System has shown some efficacy in decreasing intracranial pressure in an animal model of liver failure, but has still to be evaluated in a phase III trial.

Carcinoid tumor of the appendix: a consecutive series from 1237 appendectomies.

AIM: To report the experience of the CHU Sart Tilman, University of Liege, Belgium, in the management of appendiceal carinoid tumor. METHODS: A retrospective review of 1237 appendectomies performed in one single centre from January 2000 to May 2004, was undertaken. Analysis of demographic data, clinical presentation, histopathology, operative reports and outcome was presented. RESULTS: Among the 1237 appendectomies, 5 appendiceal carcinoid tumors were identified (0.4%) in 4 male and 1 female patients, with a mean age of 29.2 years (range: 6-82 years). Acute appendicitis was the clinical presentation for all patients. Four patients underwent open appendectomy and one a laparoscopic procedure. One patient was reoperated to complete the excision of mesoappendix. All tumors were located at the tip of the appendix with a mean diameter of 0.6 cm (range: 0.3-1.0 cm). No adjuvant therapy was performed. All patients were alive and disease-free during a mean follow-up of 33 mo. CONCLUSION: Appendiceal carcinoid tumor most often presents as appendicitis. In most cases, it is found incidentally during appendectomies and its diagnosis is rarely suspected before histological examination. Appendiceal carcinoid tumor can be managed by simple appendectomy and resection of the mesoappendix, if its size is

Laparoscopic Magenstrasse and Mill gastroplasty. First results of a prospective study.

BACKGROUND: The Magenstrasse and Mill (M&M) procedure is a vertical gastroplasty creating a tubular pouch extending from the cardia to the antrum. This "incomplete sleeve" avoids gastric resection or band placement. In this paper, we report our experience of the laparoscopic approach of the technique in a selected obese population excluding prominent grazer and/or sweet eaters. MATERIAL AND METHODS: One hundred patients (39 males, 61 females) underwent the procedure in a prospective trial. Mean age was 40 years (range 18-68). Mean preoperative BMI was 43.2 kg/m(2) (range 35-62). RESULTS: The procedure was performed by laparoscopy starting with the creation of a circular opening at the junction of antrum and corpus followed by a vertical stapling to the angle of Hiss. Mean duration of the procedure was 67 (range 40-122) min. No intraoperative complication occurred. Mean hospital stay (SD) was 2.5 (0.9) days. The single postoperative complication consisted in a mild stenosis that responded to endoscopic dilatation. After a mean follow-up of 15 months (range 9-24), mean percentage of excess body weight loss (SD) was 48(14), 59(18) and 68(24)%, respectively at 3, 6, and 12 months. Quality of life appeared satisfactory with a low incidence of gastroesophageal reflux. The procedure was associated with improvement or resolution of diabetes, arterial hypertension, and dyslipemia at 1 year. CONCLUSIONS: Our experience demonstrated that the M&M procedure could be performed safely laparoscopically. The satisfactory results on weight loss, obesity-associated mordities, and quality of life will need to be confirmed on longer follow-up.

The use of mycophenolate mofetil in liver transplant recipients.

Mycophenolate mofetil is an important drug in the modern immunosuppressive arsenal. Mycophenolate mofetil is the semisynthetic morpholinoethyl ester of mycophenolate acid. Mycophenolate acid prevents T and B cell proliferation by specifically inhibiting a purine pathway required for lymphocyte division. This paper extensively reviews the experience of mycophenolate mofetil use in liver transplant recipients. In randomised trials, mycophenolate mofetil decreased the rate of acute rejection after liver transplantation, without a significant increase of septic complications. However, so far, there are no data indicating that mycophenolate mofetil increases liver transplant patient or graft survivals. Mycophenolate mofetil is interesting because of its particular side effects profile, which is very different from the other immunosuppressants. The absence of mycophenolate mofetil nephrotoxicity is of specific interest in liver recipients with impairment of renal function. The monitoring of mycophenolate acid area under the concentration time curve might be interesting to limit side effects and provide better clinical efficacy but the exact role of mycophenolate acid monitoring in liver recipients has yet to be further evaluated in large series.

Effects of parecoxib on the prevention of postoperative peritoneal adhesions in rats.

BACKGROUND: No systemic preventive therapy has been successful in inhibiting the development of postoperative peritoneal adhesions (PPAs). OBJECTIVE: The aim of this study was to evaluate the potential effects of 5 day administration of parecoxib, on PPA prevention and on suture or wound healing in rats. METHODS: In a model of PPAs induced by peritoneal electrical burn, 30 rats were randomized into 3 groups according to parecoxib administration route (control; intraperitoneal (IP); intramuscular (IM)). Plasma and peritoneal levels of PAI-1 and tPA were measured at T0, after 90 min of surgery (T90), and on postoperative day 10 (D10). In a cecum resection model, 20 rats were randomized into two groups (control and IP parecoxib), and abdominal wound healing and suture leakage were assessed at D10. In both models, PPAs were evaluated quantitatively and qualitatively on D10. RESULTS: Administration of parecoxib significantly decreased the quantity (p < .05) and the severity (p < .01) of PPAs in both models. In addition, parecoxib administration did not cause healing defects or infectious complications in the two models. In the peritoneal burn model, IP or IM parecoxib administration inhibited the increase of postoperative plasma and peritoneum PAI-1 levels, an increase that was observed in the control group (p < .01). No anastomosis leakage could be demonstrated in both groups in the cecum resection model. CONCLUSION: This study showed that, in these rat models, parecoxib might reduce PPA formation. Confirmation of the safety of parecoxib on intestinal anastomoses is required and should be investigated in further animal models.