Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial.

BACKGROUND: Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula. METHODS: This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed. RESULTS: A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface. CONCLUSION: This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

ANTECEDENTES: La fístula biliar es una de las complicaciones más comunes después de la hepatectomía. Este estudio evalúa el efecto del drenaje biliar transcístico durante la hepatectomía en la aparición de una fístula biliar postoperatoria. MÉTODOS: Este ensayo prospectivo aleatorizado y multicéntrico (Clinical Trial NCT01469442) con dos grupos de estudio (grupo transcístico versus grupo control) se llevó a cabo de 2009 a 2016 en 9 centros. Los pacientes fueron sometidos a una hepatectomía (≥ 2 segmentos) en hígados no cirróticos. El resultado principal fue la aparición de una fístula biliar después de la cirugía. Los resultados secundarios fueron la morbilidad, la mortalidad postoperatoria, la duración de la estancia hospitalaria, la reintervención, la necesidad de reingreso y las complicaciones causadas por los catéteres. Se realizaron análisis por intención de tratamiento y por protocolo. RESULTADOS: Un total de 310 pacientes fueron randomizados. Por intención de tratamiento, 158 pacientes fueron aleatorizados al grupo transcístico y 149 al grupo control. Siete pacientes fueron excluidos del análisis por protocolo por desviaciones del protocolo. La tasa de fístula biliar fue del 5,9% en el análisis por intención de tratamiento y del 6,0% en el análisis por protocolo. Esta tasa fue similar para el grupo transcístico y para el grupo control: 5,7% versus 6,0% (P = 1). No hubo diferencias en términos de morbilidad (49,4% versus 46,9%, P = 0,731), mortalidad (2,5% versus 4,7%, P = 0,367) y reintervenciones (4,4% versus 10,1%, P = 1). La mediana de la duración de la estancia hospitalaria fue mayor para el grupo transcístico (11 versus 10 días, P = 0,042). El riesgo de fístula biliar se correlacionó con el grosor y la longitud de la transección hepática. CONCLUSIÓN: Este ensayo aleatorizado no demuestra la superioridad del drenaje transcístico durante la hepatectomía para prevenir la fístula biliar. No se recomienda el uso de drenaje transcístico durante la hepatectomía para prevenir la fístula biliar postoperatoria.

Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey.

BACKGROUND: The aim was to analyse the impact of cirrhosis on short-term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study. METHODS: 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. RESULTS: 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). CONCLUSION: Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.

ANTECEDENTES: 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. RESULTADOS: 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.

Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients.

PURPOSE: Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery. METHODS: We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics. RESULTS: 164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005]. CONCLUSION: The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

Increased CXCR3+ T Cells Impairs Recruitment of T-Helper Type 17 Cells via Interferon γ and Interleukin 18 in the Small Intestine Mucosa During Treated HIV-1 Infection.

The restoration of CD4+ T cells, especially T-helper type 17 (Th17) cells, remains incomplete in the gut mucosa of most human immunodeficiency virus type 1 (HIV-1)-infected individuals despite sustained antiretroviral therapy (ART). Herein, we report an increase in the absolute number of CXCR3+ T cells in the duodenal mucosa during ART. The frequencies of Th1 and CXCR3+ CD8+ T cells were increased and negatively correlated with CCL20 and CCL25 expression in the mucosa. In ex vivo analyses, we showed that interferon γ, the main cytokine produced by Th1 and effector CD8+ T cells, downregulates the expression of CCL20 and CCL25 by small intestine enterocytes, while it increases the expression of CXCL9/10/11, the ligands of CXCR3. Interleukin 18, a pro-Th1 cytokine produced by enterocytes, also contributes to the downregulation of CCL20 expression and increases interferon γ production by Th1 cells. This could perpetuate an amplification loop for CXCR3-driven Th1 and effector CD8+ T cells recruitment to the gut, while impairing Th17 cells homing through the CCR6-CCL20 axis in treated HIV-1-infected individuals.

Prevalence, incidence and risk factors for donor-specific anti-HLA antibodies in maintenance liver transplant patients.

Although large retrospective studies have identified the presence of donor-specific antibodies (DSAs) to be a risk factor for rejection and impaired survival after liver transplantation, the long-term predicted pathogenic potential of individual DSAs after liver transplantation remains unclear. We investigated the incidence, prevalence and consequences of DSAs in maintenance liver transplant (LT) recipients. Two hundred sixty-seven LT recipients, who had undergone transplantation at least 6 months previously and had been screened for DSAs at least twice using single-antigen bead technology, were included and tested annually for the presence of DSAs. At a median of 51 months (min-max: 6-220) after an LT, 13% of patients had DSAs. At a median of 36.5 months (min-max: 2-45) after the first screening, 9% of patients have developed de novo DSAs. The sole predictive factor for the emergence of de novo DSAs was retransplantation (OR 3.75; 95% CI 1.28-11.05, p = 0.025). Five out of 21 patients with de novo DSAs (23.8%) developed an antibody-mediated rejection. Fibrosis score was higher among patients with DSAs. In conclusion, monitoring for the development of DSAs in maintenance LT patients is useful in case of graft dysfunction and to identify patients with a high risk of developing liver fibrosis.

Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients.

BACKGROUND: Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores. METHODS: From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration. RESULTS: The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively). CONCLUSION: The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

Impact of the strategy for curative treatment of synchronous colorectal cancer liver metastases.

AIM OF THE STUDY: Fourteen to seventeen percent of patients suffering from colorectal cancer have synchronous liver metastases (sCRLM) at the time of diagnosis. There are currently three possible strategies for curative management of sCRLM: "classic", "combined", and "liver-first". The aim of our research was to analyze the effects of the three surgical management strategies for sCRLM on postoperative morbidity and mortality and overall and recurrence-free survival. PATIENTS AND METHODS: Patients treated for sCRLM between October 2000 and May 2015 were included. We defined three groups: (1) "classic": surgery of primary tumor and then surgery of sCRLM; (2) "combined": combined surgery of primary tumor and sCRLM: and (3) "liver-first": surgery of sCRLM and then surgery of primary tumor. RESULTS: During this period, 170 patients who underwent 209 hepatectomies were included ("classic": 149, "combined": 34, "liver-first": 26). The rate of severe complications was higher in the "combined" group compared to the "classic" group (35% vs. 12%, P=0.03), and the "liver-first" group (35% vs. 19%, P=0.25), while there were significantly fewer liver resections. Overall survival at 5 years in our cohort was 46%, without significant differences between the groups, and a median survival of 54 months. Recurrence-free survival of the patients in our cohort was 24% at 5 years, with a median survival time without recurrence of 14 months, without significant differences between the groups. CONCLUSION: All three strategies were feasible and there were no differences regarding overall and recurrence-free survivals between the three approaches. The "combined" strategy group had significantly more severe complications and did not provide better oncological results, despite less aggressive liver disease and more limited liver resections.

Short-term autonomy and survival after hepatectomy in the elderly.

AIM: To study morbi-mortality, survival after hepatectomy in elderly patients, and influence on their short-term autonomy. PATIENTS AND METHODS: This is a retrospective study conducted between 2002 and 2017 comparing patients less than 65 years old (controls) to those more than 65 years old (cases) from a prospective database, with retrospective collection of geriatric data. Cases were divided into three sub-groups (65-70 years, 70-80 years and>80 years). RESULTS: Four hundred and eighty-two patients were included. There was no age difference in number of major hepatectomies (P=0.5506), length of stay (P=0.3215), mortality at 90 days (P=0.3915), and surgical complications (P=0.1467). There were more Grade 1 Clavien medical complications among the patients aged over 65 years (P=0.1737). There was no difference in overall survival (P=0.460) or disease-free survival (P=0.108) according to age after adjustment for type of disease and hepatectomy. One-third of patients had geriatric complications. The "home discharge" rate decreased significantly with age from 92% to 68% (P=0.0001). Early loss of autonomy after hospitalization increased with age, 16% between 65 and 70 years, 23% between 70 and 80 years and 36% after 80 years (P=0.10). We identified four independent predictors of loss of autonomy: age>70 years, cholangiocarcinoma, length of stay>10 days, and metachronous colorectal cancer. CONCLUSIONS: Elderly patients had the same management as young patients, with no difference in surgery or survival, but with an increase in early loss of autonomy.

Nitric oxide production by the alveolar compartment of the lungs in cirrhotic patients.

In cirrhotic patients, alveolar nitric oxide (NO) concentration is increased. This may be secondary to increased output of NO produced by the alveoli (V'(A,NO)) and/or to decreased lung transfer factor of NO. In advanced liver cirrhosis, NO produced by the alveoli may play a role in abnormalities of pulmonary haemodynamics and gas exchanges. In cirrhotic patients, we aimed to measure V'(A,NO) and to compare V'(A,NO) with pulmonary haemodynamics and gas exchange parameters. Measurements were performed in 22 healthy controls and in 29 cirrhotic patients, of whom eight had hepatopulmonary syndrome. Exhaled NO concentrations were measured at multiple expiratory flow rates to derive alveolar NO concentration. V'(A,NO) was the product of alveolar NO concentration by single breath lung transfer factor for NO. V'(A,NO) was increased in patients (median (range) 260 (177-341) nL x min(-1)) compared with controls (79 (60-90), p<0.0001). Alveolar-arterial oxygen tension difference failed to correlate with V'(A,NO). However, cardiac index correlated positively and systemic vascular resistance correlated negatively with V'(A,NO) (r = 0.56, p = 0.001 and r = -0.52, p = 0.004, respectively). In cirrhotic patients, NO was produced in excess by the alveolar compartment of the lungs. Alveolar NO production was associated with hyperdynamic circulatory syndrome but not with arterial oxygenation impairment.

Liberal selection criteria for liver transplantation for hepatocellular carcinoma.

BACKGROUND: To help increase the number of transplants available for hepatocellular carcinoma in cirrhotic livers, this single-centre retrospective study compared the safety and feasibility of new, more liberal, selection criteria--no more than five tumours, with the largest tumour no greater than 5 cm (5/5 criteria)--with classical criteria. METHODS: Data from operations performed in 1990-2005 were extracted from preoperative radiological findings and postoperative specimen analyses, and four groups were constructed: Paul Brousse, Milan, University of California, San Francisco (UCSF) and 5/5 criteria. A fifth group comprised patients whose tumour load exceeded the 5/5 criteria. Survival and recurrence rates were compared. RESULTS: For the 110 patients in the study, survival rates (overall and disease-free) were 72.8 and 66.8 per cent at 5 and 10 years respectively, with a 5.5 per cent recurrence rate. The 5-year survival rate was 65, 77, 68 and 77 per cent for Paul Brousse, Milan, UCSF and 5/5 preoperative radiological criteria, with recurrence rates of 4, 4, 3 and 3 per cent, respectively. On multivariable analysis, the only factor that influenced survival was tumour load in excess of the 5/5 criteria. CONCLUSION: Use of the more liberal 5/5 criteria for selecting patients for liver transplantation results in similar disease-free and overall survival rates to classical criteria.

Drug exposure and perceived adverse drug events reported by liver-transplant patients.

INTRODUCTION: Posttransplant patient outcome and quality of life are affected by different factors, such as post-graft context, psychological state, and polymedication. Many surveys have been carried out to study immunosuppressant ADRs, and have mainly used a questionnaire completed by patients, but few have asked patients about their drug exposure. The aim of this study is to describe drug exposure and adverse drug events (ADEs) reported by liver-transplant patients (LTP). METHODS: This observational, retrospective study assessed questionnaires from LTPs concerning demographic data, drug exposure, and ADEs. RESULTS: 118 LTPs exposed to 5.9 (+/- 2.8) drugs with immunosuppressive regimens, consisting mainly of tacrolimus (79.3%), cyclosporine (18.1%), or sirolimus (2.6%), were also exposed to antihypertensive drugs (43.2%), protonpump inhibitors (30.5%), statins (28.8%), drugs acting on bile composition (26.3%), and diuretics (19.5%). 1,389 ADEs were reported: 30.1% neurological, 13.4% cutaneous, 12.4% hematological, 11.1% digestive, 10.1% osteomuscular, 6.6% cardiovascular, and 16.3% others. Significantly more ADEs were reported by patients exposed to cyclosporine than those receiving tacrolimus (p < 0.05). Patients with a transplant for < 18 months had more tremors and those with a transplant for > 79 months reported more hirsutism, gingival hypertrophia, and arterial hypertension. CONCLUSIONS: This study shows the value of patient-reporting via structured interviews for both drug exposure and ADEs, and the importance of this approach to complement total data collection.

Liver transplantation with reconstruction of the inferior vena cava for hepatocarcinoma on chronic Budd-Chiari: a case report.

Management of Budd-Chiari syndrome, from simple medical treatment to liver transplantation, depends on the acute and chronic evolution of the disease and on the degree of hepatic insufficiency. Herein we have reported the case of a man who underwent transplantation after evolution of a Budd-Chiari syndrome with membranous obstruction of the vena cava and developed 2 lesions of hepatocellular carcinoma. Surgery was difficult due to previous procedures requiring reconstruction of the supra-hepatic vena cava. This case emphasized the timing of liver transplantation versus other treatments to decrease the operative risk.

Biological changes after liver transplantation according to the presence or not of graft steatosis.

AIM: To assess the consequences of graft steatosis on postoperative liver function as compared with normal liver grafts. PATIENTS AND METHODS: From January 2005 to December 2007, liver transplant patients were prospectively included, excluding those who experienced arterial or biliary complications or presented acute rejection. All patients had a surgical biopsy after reperfusion. Patients were compared according to the rate of macrovacuolar steatosis: namely above or below 20%. RESULTS: Fifty-three patients were included: 10 in the steatosis group and 43 in the control group. No significant difference was observed in terms of morbidity, mortality, and primary non- or poor function. Nevertheless, biological changes after the procedure were significantly different during the first postoperative week. Prothrombin time, serum bilirubin, and transaminases were significantly increased among the steatosis group compared with the control group (P < .05). CONCLUSION: This case-controlled study including a small number of patients, described postoperative biological changes among liver transplantations with steatosis in the graft.

[Pancreaticoduodenectomy for cancer of the head of the pancreas]. / Duodénopancréatectomie céphalique pour cancer.

Many modifications of the original technique have been proposed to try to improve the results of the pancreaticoduodenectomy described by Whipple. To evaluate these modifications, we have reviewed randomized controlled trials, meta-analyses, and well-conducted retrospective series. Neither total pancreatectomy nor extended lymph node dissections have shown an improve of survival in retrospective studies. Preoperative evidence of mesenteric or portal vein involvement does not contraindicate pancreatic resection and survival rates are similar to those of patients with no venous involvement. Prospective trials and one meta-analysis have shown neither advantage nor disadvantage of pylorus-preserving pancreaticoduodenectomy or of pancreatico-gastric anastomosis. Three trials and one meta-analysis of pancreatico-gastric anastomosis have failed to demonstrate a decrease in the risk of pancreatic fistula. Two trials suggest that the risk of fistula formation is decreased by implantation of the pancreatic remnant into the jejunum or by trans-jejunal stenting of the pancreatico-jejunal anastomosis with external drainage; but these findings are not supported by a third trial. The results of the antisecretory use of somatostatin are contradictory. Leak and fistula formation were decreased when the criteria for leakage was based on laboratory findings; but in 4 out of 5 trials, somatostatin did not decrease the incidence of clinical fistula. The use of fibrin glue to occlude the pancreatic duct or seal the cut surface of the pancreas did not decrease the rate of intra-abdominal complications. In conclusion, the pancreaticoduodenal resection described by Whipple may still be considered the gold standard for resection of pancreatic cancer. The technical experience of surgeons and their institutional support staff resulted in lower perioperative morbidity and mortality and in higher survival rates.

[Prophylactic antibiotic use in gastro-intestinal surgery: an audit of current practice]. / L'antibioprophylaxie en chirurgie digestive: audit de pratiques.

OBJECTIVE: To evaluate compliance with clinical guidelines on prophylactic antibiotic usage in gastro-intestinal surgery. MATERIAL AND METHODS: The medical charts of one hundred consecutive patients undergoing surgery in the last 6 months of 2006 were analysed as to determine whether the use of prophylactic antibiotics was indicated. Compliance with the prophylactic antibiotic guidelines of the Toulouse teaching hospitals and the Société Française d'Anesthésie et de Réanimation (SFAR) was examined; cases were analyzed by the criteria of the Haute Autorité en Santé for indication, type of antibiotic, time of administration, and duration of treatment. RESULTS: Antibiotic prophylaxis was prescribed in 58% of patients; there was an 85% compliance rate with the indication. Of those receiving antibiotic prophylaxis, the choice of antibiotic was appropriate in 82.8%, but the timing of administration was in compliance in only 39.7%. Duration of antibiotic administration was excessive in 5 cases. The overall rate of compliance with guidelines was 42%. CONCLUSION: Prophylactic antibiotic guidelines were inadequately applied, especially regarding the timing of administration. Further systemic progress is needed to achieve compliance with guidelines and documentation of administration; such evaluations must be repeated on regular basis.

Use of routine CT-SCANS to detect severe postoperative complications after pancreato-duodenectomy.

BACKGROUND: To evaluate the performance of CT-scans performed one week after pancreato-duodenectomy (PD) to detect severe postoperative complications requiring an invasive treatment. PATIENTS AND METHODS: This monocentric retrospective study was conducted on data collected between 2005 and 2013. Patients undergoing PD underwent CT-scan with IV contrast at the end of the first postoperative week. The results of the CT-scans were analyzed to evaluate the usefulness of this procedure. The main assessment criterion was the occurrence of type-III complication (or greater) according to the Dindo-Clavien classification. RESULTS: In total, 138 patients were included. The mortality rate was 2.2%. The postoperative complication rate was 57.2%. The pancreatic fistula rate was 19.6%; 46 patients (33.3%) presented with a severe complication. A total of 138 CT-scans were analyzed: 44 (31.8%) were abnormal, 94 (68.2%) were normal. Among patients with abnormal CT-scans, 17 (39%) presented with a severe complication requiring an invasive treatment. Among the 94 patients with normal CT-scans, 14 patients (15%) presented a severe postoperative complication. Evaluation of the performance of the CT-scans at the end of the first postoperative week found a sensitivity of 55%, a specificity of 75%, a positive predictive value of 39%, and a negative predictive value of 85%. CONCLUSION: Systematic CT-scans performed at the end of the first postoperative week do not effectively detect severe complications after PD and do not help to prevent them.

[Stereotactic hypofractionated radiation therapy as a bridge to transplantation for hepatocellular carcinoma: Case report of a complete pathological response and review of the literature]. / Place de la radiothérapie en conditions stéréotaxiques en traitement d'attente du carcinome hépatocellulaire avant transplantation hépatique : à propos d'un cas de réponse histologique complète sur explant et revue de la littérature.

Patients with hepatocellular carcinoma who are on liver transplant waiting list usually require local treatment to limit any risk of tumour growth. Historically percutaneous radiofrequency ablation or transarterial chemoembolization represented the major therapeutic alternatives. Depending on the size, or the topography of the lesion these two techniques may not be feasible. Radiation therapy under stereotactic conditions has recently emerged in the management of localized hepatocellular carcinoma as an alternative to the focused therapies performed to date. We herein report the case of a 43-year-old patient harbouring a complete histological response on explant after liver stereotactic irradiation and discuss its role in the management of hepatocellular carcinoma before liver transplantation.

[Syphilis hepatitis and liver transplantation]. / Hépatite à syphilis et transplantation hépatique.

We report a case of secondary syphilis hepatitis in a liver-transplant patient. This homosexual male patient presented, 15 years after orthotopic liver transplantation, with non-squamous papulomacular rash, mild cytolysis, and anicteric cholestasis. Laboratory tests showed syphilis seroconversion with a venereal diseases research laboratory (VDRL) titer of 1/256, a Treponema pallidum hemaglutination assay (TPHA) of 1/5120, and a positive IgM fluorescent Treponemal antibody absorbance (FTA-abs). A liver biopsy performed 13 months after the diagnosis showed low-grade hepatitis with a Metavir score of A1F1; it also showed non-specific portal moderate inflammation consisting primarily of neutrophils, with no evidence of cholestasis. He was given benzathine-penicillin at 2,400,000 IU with a transient increase in prednisolone doses. Cytolysis rapidly, and cholestasis progressively disappeared. IgM FTA-abs became negative, whereas VDRL and TPHA titers decreased slightly over time.

Acute renal failure following liver transplantation with induction therapy.

AIMS: To identify the predictive factors for acute renal failure (ARF) in a retrospective study of 100 orthotopic liver transplantations (OLT) performed in 94 patients between 2000 and 2003. METHODS: Acute renal failure (ARF) was defined using the RIFLE criteria, i.e. injury when creatinine doubles or GFR halves, and failure when creatinine trebles or GFR decreases by > 75%. Patients on dialysis pre OLT (n = 3) were excluded from the study. Immunosuppression included steroids, calcineurin inhibitors (CNIs), with (n = 32) or without mycophenolate mofetil. A total of 85% of patients also received induction therapy with antithymocyte globulins (29%) or anti-CD25 monoclonal antibodies (56%). RESULTS: 39 patients (41.5%) and 21 (22.3%) patients developed injury, and failure, respectively. Of these, 10 (10.6%) underwent dialysis. Univariate analysis revealed that acute renal dysfunction with a RIFLE score > or = 3 was significantly associated with a pre-operative serum creatinine level of > 100 micromol/l, pre-operative creatinine clearance of < 75 ml/mn, need for a transfusion (> 10 red packed units), post-operative diuresis of < 100 ml/h, use of vasopressive drugs, times to aspartate (AST) and alanine (ALT) aminotransferase peaks of > 20 and > 24 hours, respectively, relaparotomy, CNIs transient discontinuation, and the use of lower daily dosage of CNIs at post-OLT Days 3, 5, 7 and 15. In multivariate analysis, failure was significantly associated with time to AST peak (> 20 h) (OR 6.35 (1.2 - 33.6), p = 0.029), post-operative diuresis (< 100 ml/h) (OR 9.8 (2.03 47.3), p = 0.004), post-operative use of vasopressive drugs (OR 9.91 (2.02 - 48.7), p = 0.004), and transient CNIs withdrawal (OR 51.08 (7.58-344.1), p < 0.0001). Finally, the occurrence of ARF was significantly associated with an increased number of days on mechanical ventilation, on stay-in intensive care unit (ICU), and on overall hospitalization time. CONCLUSION: ARF is quite common after OLT and significantly increases the post-operative time at the hospital, thereby increasing the OLT cost. Its independent predictive factors are mainly related to perioperative events.

Monitoring HCMV infection with quantitative real-time PCR in HCMV-positive orthotopic liver transplant recipients, and predictive factors for treatment of the first episode of HCMV viremia.

We evaluated the relevance of human cytomegalovirus (HCMV) monitoring with quantitative real-time polymerase chain reaction in 42 consecutive HCMV positive liver transplant patients, and we analyzed the factors that determined the treatment of the first episode of HCMV DNAemia. No patients received anti-HCMV prophylaxis. HCMV infection monitoring was assessed every 2 weeks until day 90 and thereafter at every 3 to 4 weeks until day 180. HCMV infection was detected among 27 patients (64%, ie, 92/380 samples). Of these, 12 had their first HCMV DNAemia treated with IV gancyclovir (group I), whereas the other 15 patients were not treated (group II). Immunosuppressive treatment was not modified in cases of HCMV DNAemia. The median time between transplantation to the first CMV DNAemia was 37 days in group I and 52 days in group II (NS). Median HCMV viral load, whatever the treatment group and whatever the time of DNAemia, was 3 log copies/mL (0.48 to 5.80). Median HCMV viral load of the first positive DNAemia was 3.45 log copies/mL (1.69 to 5.80) in group I and 2.70 log copies/mL (1.15 to 3.94) in group II (P = .01). Even though liver enzymes were increased in almost all patients presenting with HCMV infection, comparison of liver-enzyme levels and hematological parameters between the two groups at first HCMV viremia showed that alkaline phosphatase levels were significantly higher (P = .0011) and hemoglobin levels were significantly lower in group I patients (P = .0443). The only factor that predicted treatment for the first episode of HCMV DNAemia was an alkaline phosphatase level >150 UI/mL at the time of the first HCMV reactivation [odds ratio 20 (1.96 to 203.3); P = .01].