Impact of 2016 Enhanced Recovery After Surgery (ERAS) Recommendations on Outcomes after Hepatectomy in Cirrhotic and Non-Cirrhotic Patients.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) society published new recommendations for hepatectomy in 2016. Few studies have assessed their clinical impact. The aim of this monocentric study was to assess the impact of those guidelines on outcomes after liver surgery with a special focus on cirrhotic patients. METHOD: Postoperative outcomes of patients undergoing hepatectomy 30 months before and after ERAS implementation according to the 2016 ERAS guidelines were compared after inverse probability of treatment weighting (IPTW). Primary endpoint was 90-day morbidity. RESULTS: From 2015 to 2020, 430 patients underwent hepatectomy including 226 procedures performed before and 204 after ERAS implementation. After IPTW, overall morbidity (42.5% vs. 64.7%, p < 0.001), Comprehensive Complication Index (CCI) score (14.3 vs. 20.8, p = 0.004), length of stay (10.4 vs. 13.7 days, p = 0.001) and textbook outcome (50% vs. 40.2%, p = 0.022) were significantly improved in the ERAS group, while mortality and severe complications were similar in both groups. In the non-cirrhosis subgroup (n = 321), these results were confirmed. However, in the cirrhosis subgroup (n = 105), no difference appeared on outcomes after hepatectomy with an overall morbidity (47.5% vs. 65.2%, p = 0.069) and a length of stay (8 vs. 9 days, p = 0.310) which were not significantly different. The compliance rate to ERAS guidelines was 60% in both cirrhotic and non-cirrhotic subgroups. CONCLUSION: Perioperative ERAS program for hepatectomy results in improved outcomes with decreased rate of non-severe morbidity. Although those guidelines are not deleterious for cirrhotic patients, they probably require revisions to be more effective in this patient population.

Revisiting the Surgical Management of Giant Hepatic Hemangiomas: Enucleation Versus Anatomical Resection?

BACKGROUND: Resection is rarely indicated in giant hepatic hemangiomas (HHs) that are symptomatic. Enucleation (EN), compared with anatomical resection (AR), is considered the better technique to resect them as EN has been reported to have lower morbidity while conserving the normal liver tissue. But no study has yet clearly established the superiority of EN over AR. In addition, the independent predictors of postoperative morbidity have not been established. METHODS: All consecutive patients operated for HH at two specialized hepatobiliary centers were reviewed. Patient demographics, operative variables, and postoperative outcomes were analyzed and compared between two techniques. Postoperative complications were graded as per Clavien-Dindo classification of surgical complications. The aims of this study were to compare two techniques of HH resection with respect to postoperative outcomes and to identify the risk factors for 90-day major postoperative morbidity and mortality. RESULTS: A total of 64 patients, including 41 who underwent AR, 22 who underwent EN, and 1 who underwent liver transplantation, were operated for hemangiomas during the study period. Ten patients (9 who were operated for hemangiomas of size ≤4 cm and 1 who underwent transplantation) were excluded. Fifty-four patients, the majority being women (85%), with a median age of 48 years, were operated for giant HH. These patients were classified into two groups based on the technique of resection, namely, EN (22 patients) and AR (32 patients). Both groups were comparable in all aspects except that the number of liver segments resected was significantly more with AR. Postoperative outcomes were similar in both groups. Independent predictors of 90-day major complications including mortality were the use of total vascular exclusion (relative risk [RR]: 2.3, p = 0.028) and duration of surgery >4.5 h (RR: 2.3, p = 0.025). CONCLUSION: Both techniques yield similar results with respect to 90-day postoperative morbidity and mortality. The choice of technique should be based on the location of tumor and simplicity of liver resection.

External validation of the French alpha-fetoprotein model for hepatocellular carcinoma liver transplantation in a recent unicentric cohort - a retrospective study.

Prognostic models of liver transplantation (LT) for hepatocellular carcinoma (HCC) mainly derive from LT cohorts with numerous hepatitis C virus (HCV) patients. The AFP model, which is currently used in France to select LT candidates, was derived from a cohort of LT performed between 1988 and 2001, including a majority of HCV-positive recipients. The emergence of new direct-acting antiviral therapies and subsequent decrease of HCV incidence may change the generalizability of such models. We performed an external validation of the AFP model in a cohort of recipients transplanted between 2005 and 2018. Although multivariable analysis identified all three model's factors (AFP level, largest tumor size, number of nodules) as predictors of tumor recurrence, the AFP model showed poor discrimination and calibration in the present cohort. This poor performance could be related to significant differences between the derivation and the present cohort in terms of etiology, severity of underlying liver disease, tumor burden and differentiation, and use of neoadjuvant treatments. The present findings suggest that the decline of HCV-induced HCC among LT candidates may compromise the generalizability of the AFP model in more recent LT cohorts. Further studies are required for updating or building more robust prognostic models.

Strategies for liver transplantation during the SARS-CoV-2 outbreak: Preliminary experience from a single center in France.

Liver transplantation (LT) during the ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is challenging given the urgent need to reallocate resources to other areas of patient care. Available guidelines recommend reorganizing transplant care, but data on clinical experience in the context of SARS-CoV-2 pandemic are scarce. Thus, we report strategies and preliminary results in LT during the peak of the SARS-CoV-2 pandemic from a single center in France. Our strategy to reorganize the transplant program included 4 main steps: optimization of available resources, especially intensive care unit capacity; multidisciplinary risk stratification of LT candidates on the waiting list; implementation of a systematic SARS-CoV-2 screening strategy prior to transplantation; and definition of optimal recipient-donor matching. After implementation of these 4 steps, we performed 10 successful LTs during the peak of the pandemic with a short median intensive care unit stay (2.5 days), benchmark posttransplant morbidity, and no occurrence of SARS-CoV-2 infection during follow-up. From this preliminary experience we conclude that efforts in resource planning, optimal recipient selection, and organ allocation strategy are key to maintain a safe LT activity. Transplant centers should be ready to readapt their practices as the pandemic evolves.

Cholangitis lenta: An underdiagnosed lesion associated with severe cholestasis following liver transplantation.

BACKGROUND: Cholangitis lenta (CL) represents a specific histological lesion associated with severe cholestasis and related to sepsis. Despite being well known by pathologists, CL has been poorly studied in liver transplantation (LT). METHODS: We performed a retrospective 12-year analysis of the incidence, risk factors, and outcome of CL in LT recipients. Biopsy samples performed within 3 months after LT underwent blinded rereading to identify recipients with CL. RESULTS: Among 587 LT performed, 45 (7.7%) developed CL. Of these, 7 (15.6%) had no signs of clinical sepsis at the time of biopsy, but further investigations revealed positive cultures. Independent factors associated with CL were sepsis at the time of LT (OR = 3.62 [95%CI = 1.63-8.06]), donor age (OR = 1.05 [1.03-1.08]), and operative time (OR = 1.23 [95%CI = 1.02-1.48]). Cholangitis lenta was associated with increased severe morbidity (71.1% vs 33.0%, P < .001), 90-day mortality (24.4% vs 5.9%, P < .001) and decreased one-year graft (62.1% vs 89.4%, P < .001) and patient survival (55.6% vs 87.9%, P < .001). CONCLUSION: Cholangitis lenta represents a possible lesion associated with cholestasis after LT, which strongly affects its outcome. In the event of an unexplained post-transplant cholestasis, the diagnosis of CL must be considered, even in the absence of clinically evident sepsis.

Primary angioplasty or stenting for hepatic artery stenosis treatment after liver transplantation.

BACKGROUND: Endovascular treatment (EVT) by percutaneous transluminal angioplasty (PTA) or stent is the first-line treatment for hepatic artery stenosis (HAS) after liver transplantation, but there are no guidelines to help choose between PTA and stent. METHODS: Retrospective review of HAS EVT after liver transplantation, between 1999 and 2017. HAS was treated by PTA or stent. We report EVT primary effectiveness, arterial patency after 1 year of follow-up, complications, HAS recurrence rate; comparing PTA to stent. RESULTS: Fifty-two HAS were diagnosed in 42 patients. We performed 51 EVT; 34 PTA (66.7%) and 16 stents (31.4%). Global primary EVT effectiveness was 86.3%: 82.3% after PTA and 100% after stent (P = 1.00 after propensity score matching). Recurrent HAS was found in 22.0% of cases: 29.4% after PTA and 6.2% after stenting, (P = .053 after propensity score matching). Patency rate without recurrent HAS or HAT at 12 months was 73.5% with PTA and 93.8% with stent (P = .09), and globally this was 92.8%. There were 7.8% complications: 2.9% after PTA, 12.5% after stenting (P = .23). CONCLUSION: Primary effectiveness was the same for PTA and stenting. There was a strong trend toward more HAS recurrence after PTA than after stenting suggesting that HAS should benefit from primary stenting.

Neoadjuvant conformal radiotherapy before liver transplantation for hepatocellular carcinoma: a propensity score matched analysis of postoperative morbidity and oncological results.

Aim: To assess neoadjuvant conformal radiotherapy (CRT) before orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) not suitable for standard locoregional treatments. Methods: Patients undergoing OLT for HCC with or without prior CRT were compared using 1:3 propensity score matching. Results: After propensity score matching, 23 patients with CRT were compared with 66 control subjects. Severe morbidity rate was 34.8 versus 24.2% in the CRT and non-CRT groups (p = 0.289). Complete pathological response was observed in 47.8% of CRT-targeted nodules. The 1-/3-/5-year disease-free survivals were 77.3, 77.3 and 68.7% in the CRT group versus 85.4, 68.0 and 61.7% in the non-CRT group (p = 0.829). Conclusion: Conformal radiotherapy represents a satisfactory neoadjuvant therapy for OLT candidates not suitable for standard HCC locoregional therapies.

Evaluation of postoperative ascites after somatostatin infusion following hepatectomy for hepatocellular carcinoma by laparotomy: a multicenter randomized double-blind controlled trial (SOMAPROTECT).

BACKGROUND: The majority of patients undergoing hepatectomy for hepatocellular carcinoma (HCC) suffer from underlying liver disease and are exposed to the risk of postoperative ascites, which is favored by an imbalance between portal venous inflow and a diminished hepatic volume. Finding a reversible, non-invasive method for modulating the portal inflow would be of interest as it could be used temporarily during the early postoperative course. Somatostatin, a well-known drug already used in several indications, may limit the risk of postoperative ascites and liver failure by decreasing portal pressure after hepatectomy for HCC in patients with underlying liver disease. We aimed to evaluate the impact of somatostatin postoperative infusion on the incidence of ascites following hepatectomy by laparotomy for HCC in patients with underlying liver disease. METHODS/DESIGN: The SOMAPROTECT study is a multicenter randomized double-blind placebo controlled phase III trial comparing two arms of patients with underlying liver disease undergoing hepatectomy for HCC by open approach. All patients will have primary abdominal drainage before closure. Patients in the experimental arm will receive a postoperative intravenous infusion of somatostatin during 6 days. Patients in the control group will receive a placebo infusion for the same duration. The primary endpoint will be the presence or absence of postoperative ascites occurring during the 90-day postoperative course, defined as ≥500 ml/24 h of fluid in the drains during at least 3 days or any ascites requiring an invasive procedure comprising percutaneous puncture or drainage. Secondary endpoints will be duration and total volume of ascites, postoperative 90-day mortality and morbidity, liver failure, acute renal failure, length of stay in intensive care unit and hospital stay. The total number of patients to be enrolled was calculated to be 152. DISCUSSION: Postoperative ascites remains a major issue after hepatectomy for HCC as it is associated with increased morbidity, liver and renal failure, the need for specific treatments and prolonged hospital stay. This study represents the first randomized controlled trial to assess the benefits of somatostatin on the risk of postoperative ascites after surgery for HCC. TRIAL REGISTRATION: NCT02799212 (ClinicalTrials.gov identifier). Registered prior to conducting the research on 9 June 2016.

Characterization of Pattern Recognition Receptor Expression and Functionality in Liver Primary Cells and Derived Cell Lines.

Different liver cell types are endowed with immunological properties, including cell-intrinsic innate immune functions that are important to initially control pathogen infections. However, a full landscape of expression and functionality of the innate immune signaling pathways in the major human liver cells is still missing. In order to comparatively characterize these pathways, we purified primary human hepatocytes, hepatic stellate cells, liver sinusoidal endothelial cells (LSEC), and Kupffer cells (KC) from human liver resections. We assessed mRNA and protein expression level of the major innate immune sensors, as well as checkpoint-inhibitor ligands in the purified cells, and found Toll-like receptors (TLR), RIG-I-like receptors, as well as several DNA cytosolic sensors to be expressed in the liver microenvironment. Amongst the cells tested, KC were shown to be most broadly active upon stimulation with PRR ligands emphasizing their predominant role in innate immune sensing the liver microenvironment. By KC immortalization, we generated a cell line that retained higher innate immune functionality as compared to THP1 cells, which are routinely used to study monocyte/macrophages functions. Our findings and the establishment of the KC line will help to understand immune mechanisms behind antiviral effects of TLR agonists or checkpoint inhibitors, which are in current preclinical or clinical development.

A systematic review of the anatomical findings of multiple gallbladders.

BACKGROUND: Multiple gallbladders (MG) are a rare malformation, with no clear data on its clinical impact, therapeutic indications or risk for malignancy. METHODS: A systematic review of all published literature between 1990 and 2017 was performed using the PRISMA guidelines. RESULTS: Data of 181 patients extracted from 153 studies were reviewed. MG were diagnosed during the treatment of a gallstone-related disease in 83% of patients, of which 13% had previous cholecystectomy and had a recurrence of biliary stone disease. The sensitivity of ultrasound scan was 66%, and that of magnetic resonance imaging cholangio-pancreatography, 97%. The cystic duct was common to both gallbladders (type1) in 43% and separated (type 2) in 50% of patients. In the latter case, there was no way to differentiate preoperatively an accessory gallbladder from a Todani II bile duct cyst. Cholecystectomy was performed in 129 patients by laparotomy (43%) or laparoscopy (56%). MG was undiagnosed before surgery in 24% of the patients. The postoperative biliary leakage rate was 0.7%. In two patients, gallbladder cancers were detected. CONCLUSION: MG are difficult to diagnose and share a common natural history with single gallbladders, without evidence of increased risk for malignancy. Excision of both gallbladders is indicated in symptomatic stone disease. However, prophylactic cholecystectomy must be considered for type 2 MG, since it cannot be preoperatively differentiated from a Todani II bile duct cyst, which is associated with a risk of malignant transformation.

Hepatic venous pressure gradient after portal vein embolization: An accurate predictor of future liver remnant hypertrophy.

BACKGROUND: The impact of portal hemodynamic variations after portal vein embolization on liver regeneration remains unknown. We studied the correlation between the parameters of hepatic venous pressure measured before and after portal vein embolization and future hypertrophy of the liver remnant after portal vein embolization. METHODS: Between 2014 and 2017, we reviewed patients who were eligible for major hepatectomy and who had portal vein embolization. Patients had undergone simultaneous measurement of portal venous pressure and hepatic venous pressure gradient before and after portal vein embolization by direct puncture of portal vein and inferior vena cava. We assessed these parameters to predict future liver remnant hypertrophy. RESULTS: Twenty-six patients were included. After portal vein embolization, median portal venous pressure (range) increased from 15 (9-24) to 19 (10-27) mm Hg and hepatic venous pressure gradient increased from 5 (0-12) to 8 (0-14) mm Hg. Median future liver remnant volume (range) was 513 (299-933) mL before portal vein embolization versus 724 (499-1279) mL 3 weeks after portal vein embolization, representing a 35% (7.4-83.6) median hypertrophy. Post-portal vein embolization hepatic venous pressure gradient was the most accurate parameter to predict failure of future liver remnant to reach a 30% hypertrophy (c-statistic: 0.882 [95% CI: 0.727-1.000], P < 0.001). A cut-off value of post-portal vein embolization hepatic venous pressure gradient of 8 mm Hg showed a sensitivity of 91% (95% CI: 57%-99%), specificity of 80% (95% CI: 52%-96%), positive predictive value of 77% (95% CI: 46%-95%) and negative predictive value of 92.3% (95% CI: 64.0%-99.8%). On multivariate analysis, post-portal vein embolization hepatic venous pressure gradient and previous chemotherapy were identified as predictors of impaired future liver remnant hypertrophy. CONCLUSION: Post-portal vein embolization hepatic venous pressure gradient is a simple and reproducible tool which accurately predicts future liver remnant hypertrophy after portal vein embolization and allows early detection of patients who may benefit from more aggressive procedures inducing future liver remnant hypertrophy. (Surgery 2018;143:1-2.).

No-touch multibipolar radiofrequency ablation vs. surgical resection for solitary hepatocellular carcinoma ranging from 2 to 5 cm.

BACKGROUND & AIMS: No-touch multibipolar radiofrequency ablation (NTM-RFA) represents a novel therapy that surpasses standard RFA for hepatocellular carcinoma (HCC), but it has not been compared to surgical resection (SR). We aimed to compare the outcomes of NTM-RFA and SR for intermediate-sized HCC. METHODS: Between 2012 and 2016, 141 patients with solitary HCC ranging from 2 to 5 cm were treated by NTM-RFA or SR at a single-center. The outcomes of 128 patients were compared after using inverse probability of treatment weighting (IPTW). RESULTS: Seventy-nine patients had NTM-RFA and 62 had SR. After IPTW, the two groups were well-balanced for most baseline characteristics including tumor size, location, etiology, severity of underlying liver disease and alpha-fetoprotein level. Morbidity was higher (67.9% vs. 50.0%, p = 0.042) and hospital stay was longer (12 [IQR 8-13] vs. 7 [IQR 5-9] days, p <0.001) after SR. Local recurrence rates at one and three years were 5.5% and 10.0% after NTM-RFA and 1.9% and 1.9% after SR, respectively (p = 0.065). The rates of systematized recurrence (within the treated segment or in an adjacent segment within a 2 cm distance from treatment site) were higher after NTM-RFA (7.4% vs. 1.9% at one year, 27.8% vs. 3.3% at three years, p = 0.008). Most patients with recurrence were eligible for rescue treatment, resulting in similar overall survival (86.7% after NTM-RFA, 91.4% after SR at three years, p = 0.954) and disease-free survival (40.8% after NTM-RFA, 56.4% after SR at three years, p = 0.119). CONCLUSION: Compared to SR, NTM-RFA for solitary intermediate-sized HCC was associated with less morbidity and more systematized recurrence, while the rate of local recurrence was not significantly different. Most patients with intrahepatic recurrence remained eligible for rescue therapies, resulting in equivalent long-term oncological results after both treatments. LAY SUMMARY: Outcomes of patients treated for intermediate-sized hepatocellular carcinoma by surgical resection or no-touch multibipolar radiofrequency ablation were compared. No-touch multibipolar radiofrequency ablation was associated with a lower overall morbidity and a higher rate of systematized recurrence within the treated segment or in an adjacent segment within a 2 cm distance from the initial tumor site. Most patients with intrahepatic recurrence remained eligible for rescue curative therapy, enabling them to achieve similar long-term oncological results after both treatments.

Bleeding Recurrence and Mortality Following Interventional Management of Spontaneous HCC Rupture: Results of a Multicenter European Study.

BACKGROUND: The incidence of spontaneous rupture of hepatocellular carcinoma (HCC) is low in Europe, at less than 3%. HCC rupture remains a life-threatening complication, with mortality reported between 16 and 30%. The risk of bleeding recurrence has never been clearly evaluated in such clinical situation. The objectives of this study were to evaluate the current risk of mortality related to HCC rupture and to focus on the risk of bleeding recurrence following interventional management. METHODS: All patients admitted to 14 French-Italian surgical centers for spontaneous rupture of HCC between May 2000 and May 2012 were retrospectively included. Clinical data, imaging features, relevant laboratory data, treatment strategies, and prognoses were analyzed. RESULTS: Overall, 58 of the 138 included patients (42%) had cirrhosis. Thirty-five patients (25%) presented with hemorrhagic shock, and 19% with organ(s) dysfunction. Bleeding control was obtained by interventional hemostasis, emergency liver resection, and conservative medical management in 86 (62%), 24 (18%), and 21 (15%) patients, respectively. Best supportive care was chosen for 7 (5%) patients. The mortality rate following rupture was 24%. The bleeding recurrence rate was 22% with related mortality of 52%. In multivariate analysis, a bilirubin level >17 micromol/L (HR 3.768; p = 0.006), bleeding recurrence (HR 5.400; p < 0.0001), and ICU admission after initial management (HR 8.199; p < 0.0001) were associated with in-hospital mortality. CONCLUSION: This European, multicenter, large-cohort study confirmed that the prognosis of ruptured HCC is poor with an overall mortality rate of 24%, despite important advances in endovascular techniques. Overall, the rate of bleeding recurrence was more than 20%, with a related high risk of mortality.

Liver Transplantation After Neoadjuvant Sorafenib Therapy: Preliminary Experience and Literature Review.

OBJECTIVES: Neoadjuvant therapies before liver transplantation are a common practice in the management of hepatocellular carcinoma, either in the setting of down staging or as a bridge strategy but sorafenib has been little evaluated. MATERIALS AND METHODS: Between 2011 and 2013, 212 LT were performed and we retrospectively reviewed the data on patients who had previously received sorafenib. RESULTS: Five patients were included. The daily sorafenib dose was 400 mg for a mean duration of 17 months before liver transplantation, and was found to be safe (1 severe asthenia). Three patients received sorafenib as bridge therapy after achieving stable tumor disease within the Milan criteria through transarterial chemoembolization or hepatectomy. None patient displayed any living hepatocellular carcinoma tissue after histological examination. The two remaining patients were treated with sorafenib for palliative purposes, and became eligible for transplant after down staging. No tumor recurrence was observed during the 27-month mean follow-up, whereas 2 patients died (multiorgan dysfunction and cerebral hemorrhage). Post-liver transplantation morbidity attributable to sorafenib was mild and secondary to scarring issues: biliary stenosis (n = 2) and evisceration (n = 1). CONCLUSIONS: These few case reports suggest the potential interest and feasibility of controlled studies to assess the efficacy and safety of sorafenib in neoadjuvant setting for hepatocellular carcinoma.

Direct-acting antiviral therapy decreases hepatocellular carcinoma recurrence rate in cirrhotic patients with chronic hepatitis C.

BACKGROUND AND AIMS: Arrival of direct-acting antiviral agents against hepatitis C virus with high-sustained virological response rates and very few side effects has drastically changed the management of hepatitis C virus infection. The impact of direct-acting antiviral exposure on hepatocellular carcinoma recurrence after a first remission in patients with advanced fibrosis remains to be clarified. METHODS: 68 consecutive hepatitis C virus patients with a first hepatocellular carcinoma diagnosis and under remission, subsequently treated or not with a direct-acting antiviral combination, were included. Clinical, biological and virological data were collected at first hepatocellular carcinoma diagnosis, at remission and during the surveillance period. RESULTS: All patients were cirrhotic. Median age was 62 years and 76% of patients were male. Twenty-three patients (34%) were treated with direct-acting antivirals and 96% of them achieved sustained virological response. Median time between hepatocellular carcinoma remission and direct-acting antivirals initiation was 7.2 months (IQR: 3.6-13.5; range: 0.3-71.4) and median time between direct-acting antivirals start and hepatocellular carcinoma recurrence was 13.0 months (IQR: 9.2-19.6; range: 3.0-24.7). Recurrence rate was 1.7/100 person-months among treated patients vs 4.2/100 person-months among untreated patients (P=.008). In multivariate survival analysis, the hazard ratio for hepatocellular carcinoma recurrence after direct-acting antivirals exposure was 0.24 (95% confidence interval: 0.10-0.55; P<.001). CONCLUSIONS: Hepatocellular carcinoma recurrence rate was significantly lower among patients treated with direct-acting antivirals compared with untreated patients. Given the potential impact of our observation, large-scale prospective cohort studies are needed to confirm these results.

Rescue Arterial Revascularization Using Cryopreserved Iliac Artery Allograft in Liver Transplant Patients.

OBJECTIVES: Management of hepatic arterial complications after liver transplant remains challenging. The aim of our study was to assess the efficacy of rescue arterial revascularization using cryopreserved iliac artery allografts in this setting. MATERIALS AND METHODS: Medical records of patients with liver transplants who underwent rescue arterial revascularization using cryopreserved iliac artery allografts at a single institution were reviewed. RESULTS: From 1992 to 2015, 7 patients underwent rescue arterial revascularization using cryopreserved iliac artery allografts for hepatic artery pseudoaneurysm (3 patients), thrombosis (2 patients), aneurysm (1 patient), or stenosis (1 patient). Two patients developed severe complications, comprising one biliary leakage treated percutaneously, and one acute necrotizing pancreatitis causing death on postoperative day 29. After a median follow-up of 75 months (range, 1-269 mo), 2 patients had an uneventful long-term course, whereas 4 patients developed graft thrombosis after a median period of 120 days (range, 2-488 d). Among the 4 patients who developed graft thrombosis, 1 patient developed ischemic cholangitis, 1 developed acute ischemic hepatic necrosis and was retransplanted, and 2 patients did not develop any further complications. CONCLUSIONS: Despite a high rate of allograft thrombosis, rescue arterial revascularization using cryopreserved iliac artery allografts after liver transplant is an effective and readily available approach, with a limited risk of infection and satisfactory long-term graft and patient survival.

Splenectomy during whole liver transplantation: a morbid procedure which does not adversely impact long-term survival.

BACKGROUND: Indications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures. METHODS: Data were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group). RESULTS: Between 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p < 0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP. CONCLUSION: Splenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT.