Introduction: Malnutrition increases postoperative morbidity and mortality. The objective of this study was to evaluate preoperative refeeding in malnourished patients at risk of refeeding syndrome (RS). Methodology: A retrospective study, conducted between June 2016 and January 2017, reported to the CNIL, compared two groups of malnourished patients: a group of refeeding patients (RP) and a group of non-refeeding patients (NRP). The inclusion criteria were weight loss of more than 10% or albuminemia less than 35 g/L and RS risk factor. The primary endpoint was postoperative morbidity. The secondary endpoints were weight change and serum albumin over 6 months. Results: Seventy-three patients (30 RP and 43 NRP) were included. At the time of initial management, median weight loss was 18% [1-71], while albuminemia was 26 g/L [13-40] in the RP group and 32.5 g/L [32-48] in the NRP group (P= 0.01). The overall postoperative morbidity rate was 88% (83% RP versus 90% NRP, P= 0.47), and there was no significant difference between the 2 groups. The rate of anastomotic complications was 4% for RP versus 26% for NRP (P= 0.03) after exclusion of liver surgery. Medium-term weight loss tended to be greater in RP (P=0.7). Nutritional support was continued until the third postoperative month in 13% of RPs vs. no NRPs (P=0.0002). Conclusion: After preoperative renutrition, we did not observe a decrease in morbidity but rather a decrease in the rate of anastomotic complications in favor of the RP group. This study underscores the middle-term importance of nutritional management in view of preserving the benefits of preoperative renutrition. (C) 2019 Elsevier Masson SAS. All rights reserved.

La dénutrition augmente la morbi-mortalité postopératoire. L’objectif était d’évaluer la renutrition préopératoire chez les patients dénutris à risque de syndrome de renutrition inappropriée (SRI). Étude rétrospective, entre juin 2016 et janvier 2017, comparant 2 groupes de patients dénutris : un groupe patients renutris (PR) et un groupe non renutris (PNR). Les critères d’inclusion étaient la perte pondérale de plus de 10 % ou une albuminémie inférieure à 35 g/L et un facteur de risque SRI. Le critère de jugement principal était la morbidité postopératoire. Les critères de jugements secondaires étaient l’évolution pondérale et l’albuminémie sur 6 mois. Soixante-treize patients (30 PR et 43 PNR) ont été inclus. Au moment de la prise en charge, la médiane de perte de poids était de 18 % [1–71], l’albuminémie à 26 g/L [13–40] dans le groupe PR et 32,5 g/L [32–48] dans le groupe PNR (p = 0,01). Le taux global de morbidité postopératoire étaient de 88 % avec 83 % dans le groupe PR versus 90 % dans le groupe PNR (p = 0,47). Le taux de complications anastomotiques était de 4 % pour les PR contre 26 % pour les PNR (p = 0,03) après exclusion des chirurgies hépatiques. La perte de poids à moyen terme avait tendance à être supérieure chez les PR (p = 0,7). Un soutien nutritionnel était poursuivi jusqu’au troisième mois postopératoire chez 13 % des PR contre aucun des PNR (p = 0,0002). Après renutrition préopératoire, nous n’avons pas observé une diminution de la morbidité, mais une diminution du taux de complications anastomotiques en faveur du groupe PR. L’étude souligne l’importance sur le moyen terme d’une prise en charge nutritionnelle afin de préserver les bénéfices d’une renutrition préopératoire. Undernutrition increases postoperative morbidity and mortality. The objective was to evaluate preoperative refeeding in malnourished patients at risk of refeeding syndrome (RS). Retrospective study, between June 2016 and January 2017, reported to the CNIL, comparing two groups of malnourished patients: a group of refeeding patients (RP) and a group non refeeding patients (NRP). The inclusion criteria were weight loss of more than 10% or albuminemia less than 35 g/L and risk factor RS. The main judgment criteria was postoperative morbidity. The criteria for secondary judgments were weight change and serum albumin over 6 months. Seventy-three patients (30 RP and 43 NRP) were included. At the time of initial management, the median weight loss was 18% [1–71], albuminemia 26 g/L [13–40] in the RP group and 32.5 g/L [32–48] in the NRP group (P = 0.01). The overall postoperative morbidity rate was 88% (83% RP versus 90% RNP P = 0.47), there was no difference between the 2 groups. The rate of anastomotic complications was 4% for RP versus 26% for PNR (P = 0.03) after exclusion liver surgery. Medium-term weight loss tends to be greater in RA (P = 0.7). Nutritional support was continued until the third postoperative month in 13% of PRs against none of the PNRs (P = 0.0002). After preoperative renutrition, we did not observe a decrease in morbidity but a decrease in the rate of anastomotic complications in favor of the PR group. The study emphasizes the middle-term importance of nutritional management in order to preserve the benefits of preoperative renutrition.

SIMCER was a 6-mo, multicenter, open-label trial. Selected de novo liver transplant recipients were randomized (week 4) to everolimus with low-exposure tacrolimus discontinued by month 4 (n = 93) or to tacrolimus-based therapy (n = 95), both with basiliximab induction and enteric-coated mycophenolate sodium with or without steroids. The primary end point, change in estimated GFR (eGFR; MDRD formula) from randomization to week 24 after transplant, was superior with everolimus (mean eGFR change +1.1 vs. -13.3 mL/min per 1.73 m2 for everolimus vs. tacrolimus, respectively; difference 14.3 [95% confidence interval 7.3-21.3]; p < 0.001). Mean eGFR at week 24 was 95.8 versus 76.0 mL/min per 1.73 m2 for everolimus versus tacrolimus (p < 0.001). Treatment failure (treated biopsy-proven acute rejection [BPAR; rejection activity index score >3], graft loss, or death) from randomization to week 24 was similar (everolimus 10.0%, tacrolimus 4.3%; p = 0.134). BPAR was more frequent between randomization and month 6 with everolimus (10.0% vs. 2.2%; p = 0.026); the rate of treated BPAR was 8.9% versus 2.2% (p = 0.055). Sixteen everolimus-treated patients (17.8%) and three tacrolimus-treated patients (3.2%) discontinued the study drug because of adverse events. In conclusion, early introduction of everolimus at an adequate exposure level with gradual calcineurin inhibitor (CNI) withdrawal after liver transplantation, supported by induction therapy and mycophenolic acid, is associated with a significant renal benefit versus CNI-based immunosuppression but more frequent BPAR.

Introduction Les complications pulmonaires representent une des principales complications postoperatoires apres hepatectomie [1] . Le clampage hepatique ameliore les conditions operatoires, notamment le saignement. Cependant, pour certains auteurs, il augmenterait le risque de sepsis post hepatectomie [2] . L’objectif de cette etude est d’identifier les facteurs de risque de complication pulmonaire apres hepatectomie. Patients et methodes Etude observationelle, retrospective, monocentrique, incluant les patients operes d’une hepatectomie entre janvier et decembre 2013. La complication pulmonaire etait definie par un syndrome de detresse respiratoire aigue (SDRA), un œdeme aigu du poumon (OAP), une pneumopathie, une embolie pulmonaire et/ou un epanchement pleural draine survenant dans les 7 premiers jours postoperatoires. Une hepatectomie majeure etait definie par une resection d’au moins 3 segments hepatiques. Le clampage hepatique pouvant etre intermittent ou continu. Les donnees demographiques, comorbidites et caracteristiques peroperatoires ont ete analysees en univariee et multivariee. Resultats Durant la periode d’inclusion, 94 hepatectomies ont ete realisees. Soixante-treize pour cent des hepatectomies ont ete realisees avec clampage vasculaire, 36 % intermittent et 64 % continu (dont 38 % une exclusion vasculaire du foie et 62 % un clampage du pedicule hepatique). Une hepatectomie majeure a ete realisee chez 45 patients (48 %). Une complication pulmonaire a ete observee chez 33 patients (35 %). La duree de sejour en soins intensifs et reanimation etait de 8 (± 5) jours dans le groupe complications pulmonaires versus 3 (± 7) jours dans le groupe absence de complications pulmonaires (p 70 ans (p = 0,95), le BMI > 30 kg/m2 (p = 0,07), le clampage hepatique (p = 0,06), la presence d’une BPCO (p = 0,06) et un score ASA > 2 (p = 0,054) n’etaient pas significativement associes a une complication pulmonaire. La presence d’une hepatopathie (p = 0,02), d’une hepatectomie majeure (p = 0,002) et d’un saignement peroperatoire > 500 mL (p = 0,03) etaient significativement associes a la survenue d’une complication pulmonaire. En analyse multivariee, deux facteurs etaient predictifs d’une complication pulmonaire: la realisation d’une hepatectomie majeure (OR = 3,94 IC 95 % [1,50–10,58] p = 0,005), et la presence d’une BPCO (OR = 3,33 IC 95 % [1,19–9,28] p = 0,021). Le clampage hepatique, intermittent ou continu, n’etait pas significativement associe a la survenue de complication pulmonaire ( Tableau 1 ). Discussion Plus d’un tiers des malades operes d’hepatectomie ont presente une complication pulmonaire postoperatoire. Nous avons identifie 2 facteurs de risque : la realisation d’une hepatectomie majeure et la presence d’une BPCO. L’ischemie hepatique ne semble pas favoriser les complications pulmonaires. Une explication pourrait etre que la qualite de l’acte chirurgical permis par le clampage compenserait l’effet deletere pulmonaire de l’ischemie reperfusion hepatique.

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Transfusion and Haemostasis

Eyraud D, Ben Menna M, Vaillant JC, Kitajima K, Lebray P, Pavie A, Poynard T, Coriat P, Hannoun L. Perioperative management of combined heart–liver transplantation in patients with cirrhosis, renal insufficiency, or pulmonary hypertension. Clin Transplant 2011: 25: 228–234. © 2010 John Wiley & Sons A/S. Abstract: Stating the main problem: Only few reports have detailed perioperative management and outcome of combined heart and liver transplantation (CHLT), and none describe the long‐term renal function. Methods: Three patients presented clinical signs of cardiomyopathy with reduced ejection fraction and proven cirrhosis with evidence of portal hypertension. Two of them presented renal failure, and the other pulmonary hypertension. After cardiac transplantation and closure of the sternum, liver transplantation was performed using systematically venovenous double‐limb (portal and caval) bypass. Results: Mean cold ischemic time for heart and liver was 2 h 46 min and 12 h 47 min, respectively. Intraoperative hemodynamics remained grossly stable during surgery. Mean transfusions were 12 red blood cell packs. All three patients received anti‐R‐Il2 antibodies at post‐operative day 1 and 4. Mean plasma creatinine concentration was 90 ± 8 μmol/L one yr post‐CHLT, vs 160 ± 62 μmol/L pre‐CHLT. All three patients are alive with functional grafts after a mean follow‐up of 26 months (12–38). Conclusion: CHLT could be performed safely through two consecutive and independent usual procedures. Perioperative hemodynamic stability, minimal blood loss, and routine splanchnic decompression are probably major determinants of a favorable outcome and good long‐term renal function.

We report a case of transient symptomatic transferred IgE-mediated peanut allergy after elective blood-group compatible liver transplantation. We show that the allergy was transient and therefore passive, authorizing further uneventful peanut consumption. Skin tests with commercial peanut extract and native peanut were performed in the recipient. Circulating specific IgE against peanut and recombinant peanut allergens (rArah1, rArah2, rArah3) was measured in stored serum samples collected from the recipient between 6 months before and 8 months after liver transplantation. Specific IgE levels in the donor were measured at the time of multiorgan donation. In the recipient, diagnosis of IgE-mediated peanut anaphylaxis was based on the clinical history and detection of specific IgE against peanut and recombinant major peanut allergens (rArah1, rArah2 and rArah3). Skin tests were negative and specific IgE undetectable 6 months after the clinical reaction. Oral peanut challenge was negative excluding persistent peanut allergy. This case confirms that IgE-mediated peanut allergy can be transferred by liver transplantation and shows that it may be transient and therefore passively acquired.

Entre los pinzamientos hepáticos, la exclusión vascular del hígado (EVH) es una técnica que es indispensable dominar para realizar hepatectomías. Permite controlar la vena cava o las venas infrahepáticas, que son fuente de hemorragias importantes o de embolias gaseosas, potencialmente mortales. Tras recordar la anatomía de la vena cava inferior infrarrenal y de la confluencia subhepática de la cava, se describen los diferentes tipos de EVH: EVH total, simplificada, sin pinzar la cava, con enfriamiento del hígado in situ o ex situ, con derivación venovenosa. La EVH induce lesiones por isquemia-reperfusión que hay que tener en cuenta antes de la exéresis, como la cantidad y calidad de parénquima hepático funcional restante. Estas lesiones por isquemia-reperfusión pueden atenuarse mediante prácticas que limiten la duración del pinzamiento del pedículo, ya sea continua o intermitente, o poder realizar la EVH sin pinzar la cava. El enfriamiento del hígado permite prolongar la isquemia durante varias horas. Se consiguen realizar técnicas complejas, con reconstrucción vascular, que pueden realizarse in situ o ex situ. En este último caso, la hepatectomía se realiza fuera de la cavidad abdominal, con o sin sección del pedículo hepático. Las importantes modificaciones hemodinámicas inducidas por la EVH se acompañan de una adaptación neurohormonal que se recordará. La «prueba de EVH», realizada antes de comenzar la hepatectomía, permite predecir la tolerancia a este tipo de pinzamiento y adaptar la volemia y la anestesia. En caso de intolerancia, es necesario disponer de una alternativa técnica como la derivación venosa extracorpórea. El despinzamiento y los cuidados de la zona de sección obedecen a reglas anestésicas y quirúrgicas simples pero rigurosas.