MPox virus: an unusual aetiology of peritonitis.

We describe a rare case of severe disseminated monkeypox (MPox) virus infection complicated by peritonitis in a 44-year-old man living with well-controlled HIV. The patient was successfully treated with tecovirimat without requiring surgery. MPox should be considered in the differential diagnosis of non-bacterial peritonitis in patients at risk of infection.

Metabolomic profiling highlights the metabolic bases of acute-on-chronic and post-hepatectomy liver failure.

BACKGROUND: Posthepatectomy liver failure (PHLF) is the main limitation to extending liver resection but its pathophysiology is not yet fully understood. The aim of the study was to describe the metabolic adaptations that occur with PHLF. METHODS: A retrospective study of 82 patients using nuclear magnetic resonance metabolomics to identify and quantify intra-hepatic metabolites was performed. The metabolite levels were compared using metabolic network analysis ADEMA between fatal PHLF (FLF) and non fatal PHLF and according to PHLF/ACLF grading. RESULTS: Metabolomic profiles were significantly different between patients presenting FLF and non FLF or grade 3 ACLF versus < grade 3 ACLF. In the patients undergoing hepatectomy, valine, alanine and glycerophosphocholine were identified as powerful biomarkers to predict FLF (AUROC 0.806, 0.802 and 0.856 respectively). Network analysis showed an activation of aerobic glycolysis with glutaminolysis as observed in highly proliferating systems. Inversely, ACLF3 showed deprivation of glucose and lactate compared to lower ACLF grade. CONCLUSION: Clinical andbiological severity of ACLF and PHLF correlate with specific metabolic adaptations. Metabolomics can predict fatal liver failure after hepatectomy and underline significant differences in the metabolic patterns of ACLF and PHLF.

Liver transplantation for hereditary hemorrhagic telangiectasia: a systematic review.

AIM: To evaluate the indications, timing and results of liver transplantation in patients affected by hereditary hemorrhagic telangiectasia (HHT), by undertaking a systematic review of the current literature. METHODS: Electronic bibliographical databases were searched on MEDLINE and Pubmed according to the PRISMA criteria. A total of 58 articles were initially found, 11 have been excluded because of single center series later included in the European Liver transplant Registry (ELTR), already reported in this study. Thirty-eight articles have been excluded because they did not report specifically new cases of liver transplantation for hereditary hemorrhagic telangiectasia. Finally 9 articles were included in the analysis. RESULTS: A total of 56 patients who underwent liver transplantation for HHT are present in the English literature. One additional patient is presented in this article, for a total of 57 patients worldwide. To date, the most consistent published series is the one of the ELTR, including patients from 15 liver transplantation centers in the period 1985-2003 with a mean follow-up of 69 months. Ten-year patient and graft survival is 82.5% CONCLUSION: Liver transplantation should be considered as a radical but definitive treatment option in patients affected by HHT with liver or cardiac involvement not responsive to medical treatment.

Prognostic Impact of Tumor Multinodularity in Intrahepatic Cholangiocarcinoma.

BACKGROUND: The prognostic value of tumor multinodularity in intrahepatic cholangiocarcinoma (ICC) remains debated. We aimed to evaluate the impact of tumor multinodularity according to the presence and distribution of multiples ICC's nodules. METHODS: A retrospective review of a prospectively maintained database of patients undergoing resection for ICC from January 1995 to September 2017 was performed. Prognostic factors for survival were assessed by multivariate Cox analysis. Tumoral nodules were defined according to their number (single and multiple) and localization (satellites and contralateral). RESULTS: Out of 120 selected patients, 64 (53%) had single and 56 (47%) had multiple lesions. Multiple lesions included tumors with satellites (n = 40; 71.5%) and tumors with contralateral lesions (n = 16; 28.5%). Patients with multiple tumors had significantly larger mean main lesion size (p = 0.02), required a higher rate of perioperative transfusion (p = 0.04), had a greater rate of lymph node involvement (p < 0.0001), vascular invasion (p = 0.04), and poor differentiation (p = 0.04) than single tumors. Patients with single tumors experienced a 5-year survival significantly longer (40%) than patients with multiple tumors (14%; p = 0.004). Patients having tumors with satellites had inferior median overall survival and 5-year survival rates (20 months, 7%) compared with patients with contralateral tumors (33.6 months, 29%) (p = 0.09). Multivariable analysis identified tumor multinodularity, morbidity, tumor size < 5 cm, poor differentiation, and lymph node involvement as independent prognostic factors for overall survival. CONCLUSIONS: Tumor multinodularity represents an independent risk factor for survival in ICCs and identifies a category of patients in need of more effective perioperative treatment.

Impact of early remote organ dysfunction on long-term survival after liver transplantation.

BACKGROUND: Attention is focused on graft function although extrahepatic organ dysfunction often occurs. Renal failure, cardiovascular events and sepsis have individually shown a significant impact on short- and long-term outcomes. The aim of the study was to identify how extrahepatic organ dysfunction (EROD) and allograft dysfunction (EAD) may be associated and their relative impact on long-term survival. METHODS: A retrospective study was conducted in a unicentric cohort of 294 patients transplanted between 2009 and 2014. The composite endpoint EROD was defined as requirement during the hospitalization of de novo renal replacement therapy, reintubation/ventilation > 7 days or cardiovascular event. Donor and recipient characteristics were evaluated as predictive of EROD in uni- and multivariate analysis. Main endpoint was overall survival evaluated by Kaplan-Meier method. RESULTS: EROD occurred in 91 patients (31%) among whom 42 also experienced EAD (46%). Predicting factors associated with EROD were IL6 level (P = 0.002) and lab-MELD (P < 0.001). Only patients experiencing both EAD and EROD had a worse survival (P = 0.001). In patients without EAD, time to normalization of bilirubin and INR were longer in patients with EROD compared to those without EROD (P = 0.002 and P = 0.008 respectively). CONCLUSIONS: The composite endpoint described as early remote organ dysfunction could be used as a predictive factor after transplantation and should be included in future studies together with early allograft dysfunction. Identifying patients in whom EROD and EAD occur together or one after the other could help to better predict long-term outcomes.

Passive mesenterico-saphenous shunt: An alternative to portocaval anastomosis for tailored portal decompression during liver transplantation.

BACKGROUND: Temporary portocaval shunt has a positive impact on short-term outcomes after liver transplantation. An alternative to temporary portocaval shunt is a distal passive decompression through mesenterico-saphenous shunt. The purpose of this study was to compare outcomes of these two types of surgical portosystemic shunt and discuss their respective place during the anhepatic phase. METHODS: Patients transplanted with portal decompression during a 4-year period were included. Patients were compared according to two types of surgical decompression techniques: temporary portocaval shunt (n = 44) and mesenterico-saphenous shunt (n = 77). Spontaneous >5-mm portosystemic shunts were described as absent, nonpersistent, distal, or proximal. Intraoperative portal pressure variations and inhospital course were compared between the two groups, with special attention on the impact of competing spontaneous and surgical shunts. RESULTS: Mesenterico-saphenous shunt and temporary portocaval shunt showed a comparable hemodynamic efficiency, with no significant difference in terms of portal pressure variations. We found no significant difference in terms of reperfusion syndrome (P = .956), transfusion rate (P = .575), renal failure (P = .239) nor early allograft dysfunction (P = .976). There was a significantly higher risk of early allograft dysfunction when competing surgical and spontaneous shunts were used (P = .002) with a lesser hemodynamic efficiency (analysis of variance test; P = .04). CONCLUSION: Portacaval or mesenterico-saphenous shunts offer similar hemodynamic efficiency without impacting the outcomes after liver transplantation. Their respective place and the place of portal decompression should be discussed regarding the presence of portal thrombosis and pre-existing portosystemic shunts. Evaluation of the anatomy and the efficiency of these shunts may guide tailored portal decompression.

Management of the splenic vein during a pancreaticoduodenectomy with venous resection for malignancy.

Nowadays, pancreaticoduodenectomies (PD) with an "en-bloc" resection of the spleno-mesenterico-portal (SMP) venous axis are safely performed at tertiary centers for patients presenting venous invasion. However, for tumors infiltrating the SMP confluence optimal management of the splenic vein (SV) remains a matter of debate. Simple SV ligation has been associated with the development of sinistral portal hypertension, gastrointestinal bleeding and hypersplenism over the long term. To avoid these complications, reconstructive methods such as the direct implantation of the SV into a SMP "neoconfluence", the inferior mesenteric vein-SV anastomosis and the distal spleno-renal shunt have been reported. This article summarizes the different technical solutions available and the current evidence supporting the optimal management of the SV stump during a "safe" radical PD for pancreatic cancer. Technical issues, advantages as well as drawbacks of the different techniques, are discussed.