Aims Liver resection is considered the standard treatment of colorectal metastases (CRLM). However, to date, no long term oncological results and data regarding repeat hepatectomy after laparoscopic approach are known. The aim of this study is to analyze single center long-term surgical and oncological outcomes after liver resection for CRLM. Methods A total of 57 open resections (OR) were matched with 57 laparoscopic resections (LR) for CRLM. Matching was based mainly on number of metastases, tumor size, segmental position of lesions, type of hepatectomy and type of resection. Results Morbidity rate was significantly less in the LR group (p = 0.002); the length of hospital stay was 6.5 ± 5 days for the LR group and 9.2 ± 4 days for the OR group (p = 0.005). After a median follow up of 53.7 months for the OR group and 40.9 months for the LR group, the 5-y overall survival rate was 65% and 60% respectively (p = 0.36) and the 5-y disease free survival rate was 38% and 29% respectively (p = 0.24). More patients in the LR group received a third hepatectomy for CRLM relapse than in the OR group (80% vs. 14.3% respectively; p = 0.015). Conclusions Laparoscopic resection for CRLM offers advantages in terms of reduced blood loss, morbidity rate and hospital stay. It provides comparable long-term oncological outcomes but can improve further resectability in patients with recurrent disease.

Introduction and Aims:We employ a hydrogel scaffold to improve the overall hepatocyte engraftment after transplantation, and to improve efficacy.The scaffold is comprised of a fibrinogen backbone cross-linked with polyethylene glycol diacrylate (PEG-DA) side chains that form a hydrogel when mixed with cells and photo-polymerized.This biocompatible and biodegradable hydrogel provides a mechanical support as well as immunological protection, while maintaining cell function for the critical period early after cell transplantation.To assess and optimize the short-term (3 day) viability and function of a hepatocyte cell line after cell encapsulation within the hydrogel construct.Methods: Cell viability (Huh7) was estimated by propidium iodide (PI) labeling and fluorescein diacetate (FDA) staining.Viability was quantified using an MTT assay.Albumin and the urea production (in the medium) was used to assess hepatocyte function.Results were compared with normal cell cultures without a scaffold. Results:The number of polymer encapsulated cells without additional PEG-DA as measured by the MTT assay increased by three-fold within three days, (P < 0.05).The cell number increased by two-fold when adding 2% additional PEG-DA.The viability of the encapsulated cells with 0% PEG-DA as measured by PI/FDA staining was comparable to cell cultures without the polymer (95%±1.1% after 3 days) but lower when adding 2% additional PEG-DA (85%±1% after 3 days).Albumin concentration was higher at day 3 in encapsulated cells: 12.8 mg/l (P < 0.05) with 0% PEG-DA, and 15.4 mg/l (P < 0.05) with 2% PEG-DA, compared to 9.5 mg/l in cell cultures without the polymer.The urea concentration also increased to 3.0 mg/dl and 2.7 mg/dl, with and without additional 2% PEG-DA, respectively (P < 0.05), compared to 3.3 mg/dl in cell cultures without the polymer.The cell/polymer constructs were injected to rat liver, spleen and subcutis; the constructs were stable for 3 days post transplantation, allowing for new vessels to develop.Conclusions: The in-vitro Huh7 viability and function after polymerization in PEGylated protein hydrogel constructs was comparable to cells without the polymer.This is an important step for the development of injectable tissue engineered liver analogs for transplantation.

In the management of giant incisional hernias with loss of domain several surgical obstacles have to be addressed. Adequate coverage of the defect using mesh, sufficient local tissue advancement and prevention of wound and mesh infections are prerequisites for success. We present a case of a complicated giant incisional hernia repair after oncologic surgery, in which we chose for an intraabdominal mesh repair using a composite mesh. The patient developed a wound dehiscence and mesh infection, successfully treated with negative pressure therapy followed by a free ALT perforator flap. Several surgical techniques are discussed to manage these complicated hernias, such as progressive pneumoperitoneum, the component separation technique and the importance of soft tissue coverage (e.g. anterolateral thigh flap). In cases of wound complications, negative pressure therapy and new soft tissue coverage are discussed.

The interaction of systemic hemodynamics with hepatic flows at the time of liver transplantation (LT) has not been studied in a prospective uniform way for different types of grafts. We prospectively evaluated intraoperative hemodynamics of 103 whole and partial LT. Liver graft hemodynamics were measured using the ultrasound transit time method to obtain portal (PVF) and arterial (HAF) hepatic flow. Measurements were recorded on the native liver, the portocaval shunt, following reperfusion and after biliary anastomosis. After LT HAF and PVF do not immediately return to normal values. Increased PVF was observed after graft implantation. Living donor LT showed the highest compliance to portal hyperperfusion. The amount of liver perfusion seemed to be related to the quality of the graft. A positive correlation for HAF, PVF and total hepatic blood flow with cardiac output was found (p = 0.001). Portal hypertension, macrosteatosis >30%, warm ischemia time and cardiac output, independently influence the hepatic flows. These results highlight the role of systemic hemodynamic management in LT to optimize hepatic perfusion, particularly in LDLT and split LT, where the highest flows were registered.

Background. Hepatic artery thrombosis (HAT) represents a devastating complication after liver transplantation (LT), occurring in 1.6%-9.2% of adult recipients. Treatments of HAT include thrombectomy and thrombolysis (with or without redo of the arterial anastomosis), percutaneous thrombolysis through an angiogram, liver retransplantation, and clinical observation.Methods. We retrospectively analyzed data from 739 adult LTs between January 1992 and September 2009. HAT was classified as early (E-HAT), when occurring within the first 30 days after LT, or late HAT (L-HAT), when diagnosed from the 2nd month onward. HAT suspected clinically was confirmed by Doppler ultrasound and angiography in all cases. Attempted revascularization was defined as early (ER) if performed within the first 2 weeks after LT and late (LR) if performed between 15 and 30 days.Results. After a median follow-up (FU) of 62 months (range, 1-227 months), HAT occurred in 31/739 grafts (4.3%). E-HAT was recorded in 25/31 cases (3.4%) and L-HAT in 11/31 eases (0.8%). ER was performed in 20/31 patients (65%) leading to 62% graft salvage; it was 81% when the revascularization was performed within the first week after LT (P = ns). LR was unsuccessful in all cases (P = .08). The overall incidence of BC among rescued grafts was 54% without graft loss during FU. Graft survival was 79% versus 71%; and 50% versus 50% at 1 and 3 years for E-HAT and L-HAT, respectively (P = ns).Conclusions. Urgent revascularization in cases of early HAT may decrease graft loss, especially when performed within the first week after LT, with improved overall outcomes.

To evaluate the feasibility, the reproducibility, the safety and the efficacy of a recently introduced preperitoneal memory-ring patch (Polysoft®, Davol Inc., C.R. Bard Inc., Crawley, UK) by a prospective multicentric observational study.

OBJECTIVE:Split liver transplantation (SLT) allows grafting of 2 recipients with 1 allograft. Results of adult SLT have improved since its first introduction. Children benefit most from SLT, while among some adult liver transplanters there are concerns about splitting a liver, turning a good quality graft into a marginal one. We performed a single center retrospective review to address this issue.PATIENTS AND METHODS:Between June 2001 and August 2008, we performed 22 extended right liver graft (eRLG) transplantations in 21 adult patients.RESULTS:Eleven donors (50%) did not meet the Eurotransplant criteria for optimal donors. Forty-one percent of eRLG donors showed hemodynamic instability at the time of harvest. Eighteen (82%) splitting procedures were performed ex situ. The main indications for transplantation were alcoholic liver cirrhosis (32%), hepatitis C-related cirrhosis (18%), and acute liver failure (18%). Mean recipient age was 54 years (range, 17-69 years); median Model for End-Stage Liver Disease (MELD) score was 15 (range, 7-40). Patients were followed for a median of 16 months (range, 4-92 months) following transplantation. We observed 5 (23%) vascular and 3 (14%) biliary complications. Overall patient survival was 84% at 3 years; overall graft survival was 79%. For the 11 patients who had undergone transplantation after 2007, we observed a 100% patient and graft survival.CONCLUSION:After an initial learning curve and provided careful selection, exceptions to classical donor criteria for splitting can be accepted with successful outcomes comparable to those after whole liver transplantation.

BACKGROUND:The prognosis of pancreaticobiliary tumors is poor. The aim was to assess the feasibility of radiotherapy (RT) and concomitant gemcitabine and oxaliplatin in locally advanced pancreatic cancer and distal cholangiocarcinoma.PATIENTS AND METHODS:Twenty-two patients with locally advanced pancreatic (n = 17) or biliary tract cancer (n = 5) were included. They received two cycles of gemcitabine/oxaliplatin followed by 5 weeks of RT in combination with a weekly fixed dose gemcitabine and an escalating dose of oxaliplatin from 40 up to 70 mg/m(2). National Cancer Institute-Common Toxicity Criteria 3.0 was used to score weekly the treatment-related toxicity.RESULTS:The patients treated at a dose of 40 mg/m(2) of oxaliplatin had no dose-limiting toxicity. At 50 mg/m(2), two patients developed grade 4 thrombocytopenia. Nine patients received 60 mg/m(2), one developed grade 4 thrombocytopenia. Grade 4 thrombocytopenia in two patients and grade 3 diarrhea in one patient were observed with 70 mg/m(2). Median time to progression was 8 months and median overall survival was 17 months.CONCLUSIONS:RT in combination with gemcitabine and oxaliplatin is feasible in patients with locally advanced pancreaticobiliary cancer. The reported time to progression underlines the potential activity of this regimen. The dose of 60 mg/m(2) of oxaliplatin can be considered as the recommended dose.

La transplantation hépatique donneur vivant (THDV) est devenue une alternative reconnue à la transplantation hépatique conventionnelle. Le but de cette étude a été d’évaluer en l’absence de tout effet-centre, les résultats chez le receveur et les risques chez le donneur, à partir des données prospectives du Registre Européen de Transplantation Hépatique (ELTR). D’octobre 1991 à juin 2007, 2 409 THDV (4 %) ont été réalisées parmi les 66 377 transplantations faites dans le même temps dans 71 centres en Europe. Les données des THDV ont été comparées à ceux de la transplantation conventionnelle/foie entier. Le nombre de THDV a augmenté régulièrement pendant 10 ans (de 17 en 1992 à 309 en 2002) pour atteindre un plateau, voire une discrète diminution plus récemment (279 en 2006). Initialement réservée aux enfants, la THDV est maintenant utilisée principalement chez l’adulte (2/3 des cas en 2006). Le foie droit a été utilisé dans 92 % des cas chez l’adulte et le lobe gauche dans 85 % des cas chez l’enfant. Chez le donneur, la mortalité post-opératoire a été de 0,2 %, impliquant 5 des 2 409 donneurs, en rapport avec une embolie pulmonaire (1 cas), un sepsis (2 cas), une insuffisance cardiaque (1) ou une défaillance multi-organes associée à un myélome (1). Le taux de complications précoces (≤ 3 mois) a été de 20 %, corrélé à l’importance de l’hépatectomie (27 % foie droit vs 11 % lobe gauche, p < 0,01). Chez le receveur les indications de transplantation étaient comparables pour les cirrhoses (65 vs 58 %). En revanche la THDV était moins utilisée en cas d’hépatite fulminante (3 vs 7 %, p < 0,01) ou en cas de retransplantation (2 vs 10 %, p < 0,01), mais elle était utilisée plus fréquemment pour cancer (21 % versus 13 %, p < 0,01). Les survies à 5 ans du greffon et du patient ont été de 70 et 76 % respectivement. Ces survies étaient meilleures chez l’enfant (77 et 84 %) que chez l’adulte (64 et 70 %, p < 0,001). Comparativement aux TH foie entier réalisées dans la même période, la survie du patient et du greffon après THDV était meilleure chez l’enfant (77 et 84 % vs 70 et 81 % respectivement, p < 0,01) mais similaires chez l’adulte (64 et 71 % vs 63 et 71 %). La THDV représente 4 % des transplantations réalisées en Europe. Elle est maintenant principalement utilisée chez l’adulte pour des indications qui ne sont pas tout à fait superposables à celles de la TH classique. Le risque de mortalité chez le donneur est de 0,2 % avec un taux de complications précoces de l’ordre de 20 %. Comparativement aux transplantations hépatiques conventionnelles, elle donne globalement de meilleurs résultats chez l’enfant et des resultants similaires chez l’adulte.

BACKGROUND:Mesh techniques are the preferable methods for repair of small ventral hernias, including umbilical and epigastric hernias, as primary suture repair shows high recurrence rates. Recently, the Ventralex (Davol Inc., C.R.Bard, Inc., RI, USA) hernia patch was introduced with promising preliminary short-term results. METHODS:In this short technical note we describe both the surgical technique for adequate patch placement and the material characteristics of this device with associated pro's and con's. CONCLUSION:For small ventral hernia repair the Ventralex patch is a very elegant and quick to use mesh device. Although it is meant to be used intraperitoneally, it is also possible to place the patch in the preperitoneal space. However, probably due to the less controllable mesh deployment, and the interaction between the different materials, especially in the preperitoneal space, extra attention and some caution during placement is warranted using this device.

Introduction : Most patients with gastro-enteropancreatic neuro-endocrine tumours present with liver metastases at the time of diagnosis. As metastases are usually widespread in the liver, though remain confined to this organ for long periods of time, liver transplantation could be in some cases a possible treatment option.Material and methods: We herein report the case of a 24-year-old male with Zollinger-Ellison syndrome, who was referred to our department after having had a right hepatectomy for metastatic lesions, followed by chemotherapy. At that time, the site of the primary tumour was undefined. Following the diagnosis of a primary gastrinoma in the pancreatic head after selective angiography of the pancreatic vessels with hormonal sampling tests in our institution, the decision was made to offer a living donor liver transplantation (LDLT).Results : A right lobe LDLT was carried out together with a Whipple's procedure. The operation was uneventful and five years later the patient remains in an excellent clinical condition, although with a suspicion of relapsed gastrinoma.Discussion : according to the literature, some conditions, such as the 1-step combined surgery, gastrinoma primary tumour and duodeno-pancreatical localisation are considered as poor prognostic factors, whereas young age and turnout expression of Ki-67 < 5% are linked to a more favourable outcome. We think that in cases of long-lasting stability of the disease under chemotherapy, together with the presence of a low Ki-67 expression index, such a treatment could be proposed to young and symptomatic patients, provided the resection of the primary tumour is feasible. Long-term survival may be achieved in metastatic gastro-enteropancreatic neuro-endocrine tumours after LDLT combined with Whipple's procedure, despite tumour relapse.

Minimization or withdrawal of immunosuppressive treatments after organ transplantation represents a major objective for improving quality of life and long-term survival of grafted patients. Such a goal may be reached under some clinical conditions, particularly in liver transplantation, making these patients good candidates for tolerance trials. In this context in liver transplantation, the central questions are (1) how to promote the natural propensity of the liver graft to be accepted, (2) which type of immunosuppressive drug should be used for induction and maintenance, and (3) which biomarkers could be used to discriminate tolerant patients from those requiring long-term immunosuppression. Induction therapies using aggressive T-cell-depleting agents may favor graft acceptance. However, persistent and/or rapidly reemerging cell lines, such as memory-type cells or CD8(+) T cells, could represent a significant barrier for induction of tolerance. The type of maintenance drugs also remains questionable. Calcineurin inhibitors may be eventually deleterious in the context of tolerance protocols, through inhibitory effects on regulatory T cells, that are not observed with rapamycin. In conclusion, significant efforts must be made to achieve reliable strategies for immunosuppression minimization or withdrawal after organ transplantation into the clinics.

15022 Background: Metastatic spread is the leading cause of colorectal cancer deaths. In a minority of patients, peritoneal carcinomatosis (PC) develops in the absence of distant metastasis. It is ...

Mortality on liver transplantation (OLT) waiting lists has increased dramatically. Until recently, non-heart-beating donors (NHBD) were not considered suitable for OLT, because of a higher risk of primary graft nonfunction (PNF) and biliary strictures. However, recent experimental/clinical evidence has indicated that NHBD-OLT is feasible when the period of warm ischemia is short.Purpose. To characterize the results of NHBD-OLT in Belgium, a survey was sent to all Belgian OLT centers.Results. Between January 2003 and November 2005, 16 livers originating from NHBD were procured and transplanted. The mean donor age was 48.8 years, including 9 males and 7 females with mean time of stop-therapy to cardiac arrest being 18 minutes and from cardiac arrest to liver cold perfusion, 10.5 minutes. Mean recipient age was 52.2 years including 12 males and 4 females. Mean cold ischemia time was 7 hours 15 minutes. No PNF requiring re-OLT was observed. Mean post-OLT peak transaminase was 2209 IU/L, which was higher among imported versus locally procured grafts. Biliary complications occurred in 6 patients requiring re-OLT (n = 2), endoscopic treatment (n = 2), surgical treatment (n = 1), or left untreated (n = 1). These tended to be more frequent after prolonged warm ischemia. Graft and patient survivals were 62.5% and 81.3%, respectively, with a follow-up of 3 to 36 months.Conclusion. This survey showed acceptable graft/patient survivals after NHBD-LT. The NHBD-liver grafts suffered a high rate of ischemic injury and biliary complications and therefore should be used carefully, namely with no additional donor risk factors, lower risk recipients, and short cold/warm ischemia.

Sirolimus (SRL) is associated with many side effects including hypercholesterolemia, anaemia, impaired wound healing and abnormal liver function tests. Limb lymphedema has only been reported several times in renal transplant recipients. We present a case of lower limb lymphedema that occurred in a 59-year-old liver transplant recipient after being on a SRL regimen for seven months. Extensive diagnostic investigations could not reveal signs of infection, venous obstruction or malignancy. After discontinuation of SRL, the lymphedema gradually resolved during the next three months. The pathologic mechanism behind this phenomenon is unknown, but antiangiogenetic and antiproliferative properties of SRL have been hold responsible. Further studies are necessary to explain this rare side effect.