Les premières évaluations cliniques de la myotomie per-orale endoscopique (POEM) pour achalasie sont favorables, aussi bien en ce qui concerne les résultats cliniques et manomètriques, qu'en ce qui concerne les effets secondaires. Nous présentons les résultats d'une série prospective de POEM réalisée chez 39 patients. Les premiers patients étaient naïfs de tout traitement instrumental alors qu'après les 20 premier cas, l'indication de POEM a pu également être portée chez des patients ayant déjà été traités par myotomie chirurgicale ou dilatation endoscopique.

La transplantation hépatique adulte à partir de donneur vivant (THDVA) est une alternative pour augmenter l'accès à la transplantation (et réduire la mortalité sur liste d'attente) ; elle est la seule modalité de transplantation dans certains pays, en particulier en Asie, Afrique ou au Moyen-Orient, où le prélèvement sur donneur cadavérique est impossible. Le but de cette étude était de rapporter l'expérience d'une procédure de transfert de compétence depuis un centre français vers un centre égyptien, en particulier l'importance de l'effet de courbe d'apprentissage. Entre décembre 1998 et décembre 2006, 128 THDVA ont été réalisées à Lyon (hôpital Édouard Herriot) ou au Caire (Wady El-Neel Hospital). Les patients ont été séparés en 3 groupes : 1 (malades greffés à Lyon (formation initiale de l'équipe égyptienne), 2 (malades greffés au Caire par l'équipe française et transfert progressif à l'équipe égyptienne) et 3 (malades greffés au Caire par l'équipe égyptienne). Les patients de chaque groupe ont été séparés en 2 phases successives : A (phase initiale) et B (seconde phase). Ont été comparés les résultats des groupes 1A et 3A pour évaluer la faisabilité du transfert de compétence, et les phases A aux phases B pour étudier l'effet de courbe d'apprentissage. La comparaison des groupes 1A et 1B mettait en évidence une réduction significative de la durée opératoire du donneur, du temps d'ischémie froide, des besoins transfusionnels du donneur et du receveur. De même, le taux de complications post-opératoires chez le donneur était significativement inférieur dans le groupe B : complications majeures (16 % vs 12,5 %), et complications mineures (36 % vs 25 %), ainsi que les complications post-opératoires chez le receveur : complications biliaires (28 % vs 8,3 %) et toutes complications (60 % vs 33 %) et la mortalité à 1 an (12 % vs 0 %). Les mêmes résultats étaient retrouvés en comparant les groupes 3A et 3B. La comparaison des groupes 1A et 3A ne mettait pas en évidence de différence significative concernant les données peri-opératoires (durée opératoire du donneur, temps d'ischémie froide, besoins transfusionnels du donneur et du receveur), ni les complications post-opératoires du donneur et du receveur. Nos résultats montrent que le transfert de compétence en THDVA est faisable relativement rapidement, même vers un centre n'ayant pas d'expérience en transplantation à partir de donneur cadavérique, après une phase d'apprentissage qui est la même que dans un contexte de développement de la THDVA dans un centre expérimenté en transplantation hépatique.

Background and objective: Continuous monitoring of cardiac output during liver transplantation is essential to evaluate the patient's haemodynamic tolerance to acute volume variations. The aim of this study was to compare the cardiac output values obtained with a transoesophageal echo-Doppler and those obtained with a continuous thermodilution cardiac output pulmonary artery catheter. Methods: Twenty adult patients were prospectively studied during a 5 min hepatic vascular exclusion test performed at the end of the dissection phase. Echo-Doppler and continuous thermodilution cardiac output, mean arterial pressure and end-tidal CO2 were measured before and at the end of the test. Results: Before the test, echo-Doppler cardiac output was 7.0 +/- 2.7 L min(-1) and thermodilution was 9.4 +/- 3.1 L min(-1), (R = 0.85, P < 0.001). The end test values were, respectively, 3.5 +/- 2.7 and 7.8 +/- 3.5 L min(-1) (R = 0.23, P = 0.34). Bland and Altman analysis showed a bias of -2.2 before the test, which increased to -4.4 at the end of the test. Mean arterial pressure decreased from 85.5 +/- 15 to 66.8 +/- 16 mmHg, end-tidal CO2 from 31.4 +/- 2.3 to 23.8 +/- 2.7 mmHg. Conclusion: Echo-Doppler cardiac output values are different from those measured by thermodilution cardiac output in these patients. Echo-Doppler cardiac output monitoring seems to detect the output changes, which can occur during acute haemodynamic changes more rapidly than thermodilution cardiac output in the course of liver transplantation.

A juxtaposition of long and short RR intervals was observed in 2 hypertensive patients recovering from major surgery under spontaneous ventilation. Sinus rhythm was ascertained throughout the recording. These oscillations could not be linked one-to-one to ventilatory cycles.

Adverse effects associated with calcineurin inhibitors may impact their clinical utility in some patients. This study characterizes the clinical outcomes of liver transplanted (LT) patients who experienced diabetes mellitus (DM) on tacrolimus-based regimen and were converted to cyclosporine-based therapy. Since January 2002, all patients with DM on a tacrolimus-based regimen were recruited and converted to cyclosporine-based therapy, after a 6-month minimal follow-up after LT. Clinical and laboratory data related to the clinical course of the patients were recorded. Twenty-five patients were included after a median delay of 54 months after LT [seven women and 18 men, 51 years (range 30-69)]. There were 11 patients with insulin-treated DM (ITDM), 14 patients with noninsulin-treated DM (NITDM), and the glycemic control was poor (HbA1c > 6.5%) in 13/25 patients (52%). After a median follow-up of 20 months after conversion, there were four patients with ITDM, 17 patients with NITDM, and four patients without DM, and the glycemic control was poor in 3/25 patients (12%). Four patients returned to tacrolimus because of arterial hypertension or digestive side-effects. In conclusion, our results suggest that conversion from tacrolimus to cyclosporine in stable LT patients with DM is well tolerated and beneficial on glycemic control.

O27 Aims: To evaluate results of split liver transplantation in two adults. Patients and methods: From february 2000 to january 2004, 26 adult patients received 13 full-left lobes grafts and 13 right liver grafts. All livers were split ex-situ. Donors were 11 males and 2 females with a mean age of 25 years (range : 19 – 38); of those, 7 (54%) had one episode of hemodynamic instability. Exact knowledge of vascular and biliary distribution was assessed by careful pedicle dissection and back table arteriography and cholangiography. Section of the liver was performed with harmonic scalpel along the main portal scissure, hemostasis and biliostasis was completed with running sutures along both cut surfaces. The left lobe comprised segments 1 to 4 according to the Couinaud classification, the middle hepatic vein and the inferior vena cava. For each graft, arterial and portal supply was preserved according to vascular anatomy, in most cases separation was achieved at the origin of the left and right branches. The common bile duct was retained with the right liver graft in all cases. All grafts were transplanted orthotopically with preservation of the inferior vena cava for the right liver grafts and after removal of it for the left liver grafts. All grafts were weighted and when the graft-to-recipient weight ratio (GRWR) was less than 0.9%, a porto-mesenterical disconnexion was done by performing a H-graft meso-caval shunt and ligation of the superior mesenteric vein downstream the shunt. Results: Mean GRWR was 1.12% (range : 0.9 – 1.6) in patients who received the right liver and 0.81% (range : 0.57 – 1.36) in patients with left liver. For those who had porto-mesenterical disconnexion, the mean GRWR was 0.7% (range : 0.57 – 0.89). mean cold ischemia time was 695 min (range : 420 – 940) and 743 min (range : 490 – 980) for the right and left liver grafts respectively (NS). After LT, none of the patients had initial primary graft non-function, hepatic artery or portal vein thrombosis. In patients with left livers main complications comprised bacterial hepatitis (n=3), sepsis (n=4), progressive hepatic ischemia due to spontaneous porto-systemic shunts (n=2), biliary stenosis (n=1) and cardiac failure (n=1). Two of these patients had early retransplantation. In patients with right liver grafts, 2 patients experienced hepatic vein stenosis which resolved after radiologic balloon dilatation, 2 sepsis and 1 biliary stenosis. Both biliary stenosis were successfully treated with endoscopic manœuvrers. After a mean follow-up of 20 months (range : 3 – 48), patient and graft survivals are 92% and 92% and 69% and 60% for right and left grafts respectively. Causes of patient death were sepsis in 3 patients and cardiac failure in 2. Conclusions: While transplanted right liver cadaveric grafts give good results in adult recipients, outcome is less satisfactory with full-left split liver grafts. Improvement of results with left grafts will necessitate better selection of donors and recipients as well as more technical refinements.

P560 Aims: The efficacy of duct-to-duct biliary reconstruction in transplantation of partial liver grafts obtained from living donors (LD) and split livers from cadaveric donors (SLCD) was evaluated. Patients and methods: From july 2000 to December 2003, 71 liver transplantations (LT) with partial grafts from living donors (n=59) and cadaveric left split livers (n=12) were performed in 61 adult and 10 pediatric recipients by using 49 right lobes (all from LD), 18 left lobes (from 11 SLCD and 7 LD), and 4 left lateral segments (from 3 LD and 1 SLCD). In all cases, duct-to-duct biliary reconstruction was done. Six patients (8.4%) died during the first 3 months after LT and were excluded from the study. In the remaining 65 patients, biliary reconstruction was achieved by interrupted 6/0 resorbable sutures between the donor right bile duct and the recipient common bile duct (n=31), the two joined posterior and anterior sectorial right donor bile ducts and the recipient common bile duct (n=9) and the donor left bile duct and the recipient common bile duct (n=22). In 9 cases, a double duct-to-duct right separated biliary (from posterior and anterior sectors) anastomosis was done. In all biliary anastomosis but one, an external biliary stent was pushed upward into the anastomosis through the wall of of the recipient common bile duct. Results: Fourteen biliary complications occured in 13 patients (20%), including 6 bile leaks (9.2%) from the anastomotic site (4 cases) and the cut surface (2 cases) and 8 anastomotic stenosis (12.3%). Although the difference was not statistically significant, biliary complicatons were more common in right than in left liver graft transplantations (23.9% versus 10.5%) and in living donor grafts than in split grafts (23.2% versus 0). The number of biliary anastomoses (one or two) performed per graft did not influenced the incidence of biliary complications (21.8% versus 22.2%). The incidence of hepatic artery thrombosis was nil. Anastomotic bile leakages resolved after surgical revision in 2 cases, with endoscopic stenting in 1 case and external drainage in the last case. The 2 bile leaks from the cut surface spontaneously resolved after external drainage. Successful outcome of anastomotic biliary stenosis occured following endoscopic manœuvrers in 7 cases and surgical treatment in 1 case. After a mean follow-up of 18.3 months (range : 3 – 45), patient and graft survivals were 87.3% and 85.3% respectively. Conclusion: Whatever the type of partial liver grafts, duct-to-duct biliary reconstruction with an external stent is feasible in almost all cases and represents a safe and efficient option especially in left grafts from split livers.

A152 Aims: In France, the number of liver transplant patients directly depends on cadaveric graft procurement. Waiting time before liver transplantation (LT) dramatically increased during the past recent years, because of graft scarcity and of an increasing number of candidates. This situation led us to start an adult-to-adult living donor liver transplantation (AALDLT) program in 1998 in our center. The aim of this retrospective study was to compare the outcome of all adult patients put on the waiting list between 1998 and 2003 with respect of the graft used: cadaveric vs living donor. Patients and Methods: Between January 1998 and September 2003, 430 patients were put on waiting list in our center. AALDLT was performed in 32 cases (7.4%). This population was compared to the group of 266 adults who had had cadaveric LT (CLT) according to clinical and biological parameters at the time of listing, on the waiting list. One year survival from the time being on the waiting list and after LT was assessed for each group. Results: Comparison of patients with AALDLT and CLT is summarized in the Table.Figure* Significant difference Conclusion: Our results strongly suggest that an adult-to-adult living donor LT is efficient and, is able to improve the access to LT by reducing the waiting time and pre-transplant mortality. Moreover, patient survival was excellent in spite of their worse condition compared with that of patients having CLT.

P568 Aims: Hepatic involvement in hereditary haemorrhagic telangiectasia is common but often asymptomatic. However, in some cases, the vascular lesions that involve the liver may lead to high- output cardiac failure and pulmonary hypertension and hepatobiliary manifestations requiring liver transplantation (LT). We report the long term results of LT in this indication. Patients & Methods: Between 1993 and 2003, ten patients with hereditary haemorrhagic telangiectasia and hepatic involvement received transplants. Indication for LT was right-sided heart failure (n=10) with pulmonary hypertension (n=8), biliary abcesses (n=1), and/or hemobilia (n=1). Left-to-right intrahepatic shunt output was estimated to range between 34% and 57.5% of cardiac output. Results: The patients were 9 women et 1 men, with a median age of 53 years (range 36-64). Operating time was 225 to 510 minutes (median : 260 minutes). Transfusion requirement was 0 to 16 blood units (median : 4 blood units). Hyperdynamic circulation disappeared after liver transplantation in all patients. Results of computed tomography and right-sided heart catheterization performed 6 months post-LT were normal and each patient continues to be asymptomatic. Median follow-up period currently is 48 months (range 12-122). Several complications occured during follow-up : digestive bleeding requiring transfusion and endoscopic treatment (n=2), epistaxis requiring transfusion (n=2), hepatic artery aneurysm from the native common hepatic artery requiring surgical treatment (n=1) and cerebral hemorrhage from aneurysm rupture (n=1). Overall survival was 90% (one patient died at one month post-LT from cardiac failure). Conclusions: Our report strongly suggests that LT can be considered as the best curative treatment that may prevent the irreversible evolution of cardiopulmonary disease in patients with hereditary haemorrhagic telangiectasia, but long term prognosis is related to other organ involvement of the disease.

O167 The aim of this retrospective study was to analyse and compare patient and graft survival, early graft function and post-operative surgical complications in recipients according to the type of graft they received. Patients and methods: Since october 1990 to march 2003, 661 LT were performed in 640 patients (565 adults and 96 children) by using 493 whole livers (WL) and 168 (25.4%) partial liver grafts (PL). In adults, 462 had had a WL and 103 (18%) a PL. PL were obtained from split cadaveric grafts in 52 cases (44 right lobes and 8 left lobes) and living donors in 51 cases (47 right lobes and 4 left lobes). Statistical analysis : survivals were compared by using the Kaplan-Meier survival curves and the follow-up with Log-Rank tests. Results: The study period was divided in two parts according to the initiation of adult LT program with right liver lobe from living donor in december 1998. Between october 1990 and november 1998, among 313 LT performed in adult patients 293 were done by using a whole liver graft and 20 (6.4%) with a partial graft (16 right split grafts and 4 left liver grafts from living donor). One year survivals were 87.5%, 87.5% and 25% in patients with whole, right split and live donor left liver grafts respecctively. During the second period from december 1998 to march 2003, 251 adult patients had LT and among them, 83 (33%) received a partial liver graft (28 right and 8 left grafts from split livers and 47 right livers from living donors). Six out the 8 patients who received a left liver, had a meso-caval disconnection in the aim to decrease the portal inflow. In patients who received a PL, the cirrhosis was more advanced at the time of LT than in those who had a WL (patient Child C status : 54% vs 33.5%, p>0.05), moreover the rate of hepatocarcinoma was much higher (p>0.05) (figures 2 & 3). The rates of hepatic artery thrombosis and early retransplantation (within the first year) was similar in both groups (1.3% vs 1.6% and 2.9% vs 2.6% respectively). One year patient survival was 87% in patients with WL and 83.8% in those with PL (p=NS). According to the type of PL, patient survival was 88.5% in those who had a right liver lobe (n=91), 70% with a left lobe (n=12). Moreover, patients who received a right lobe from a living donor (n=47) and a left lobe from a split cadaveric graft (n=8) had a 1-year survival of 91.3% and 87% respectively. In 6 patients who had had a small-for-size left split liver lobe, a porto-mesenterical disconnection was performed through a mesocaval shunt to avoid an overperfusion syndrome. Conclusions: The early survival of adult patients receiving a partial liver graft was not affected in spite of their worse conditions and the more demanding techniques compared with those having a whole liver graft.

P567 Aims: Intractable ascites carries great morbidity by affecting appetite, renal function, and quality of life. Peritoneovenous shunts (PVS) have been largely used to treat intractable ascites, and the aim of this pilot study was to determine the efficacy of this method in patients listed for liver transplantation (LT), during the waiting period. Patients and Methods: Between January 1999 and December 2003, PVS was electively inserted in 30 (25 males and 5 females) cirrhotic patients, 50.3 years of median age (range 30-66), who failed multiple large-volume paracenteses and diuretic therapy, when listed for LT. In all patients the Child-Pugh’s score was 9 or above. Three patients had previous variceal bleeding, and four patients had previous spontaneous bacterial peritonitis. Prophylactic antibiotic therapy was administered to all patients before and after undergoing PVS. Data were collected until LT or the present time, and were compared to historical cohort (1996-1998) as control. Results: No operative death or severe postshunt coagulopathy occurred. Diuretics were administred after PVS insertion in 20 patients (75%). Four patients died before LT (multiorgan failure (n=2), oropharyngeal carcinoma (n=2)) in a median delay of 9 months after PVS insertion. Complications included : bacterial peritonitis (n=2), shunt intraperitoneal migration (n=2) leading to removal or change of PVS. PVS provided palliation for intractable ascites in 25 patients (83%). Renal function improved in 15 (50%) patients. Serum albumin level increased in 20 (66%) patients. Eighteen patients were transplanted in a median delay of 6 months (range 3-12) after PVS insertion. During LT, there was no intra-operative complications related to PVS. When compared to an historical cohort of 18 patients transplanted before 1999 in our institution, the occurrence of post-LT acute renal failure was significantly lower in the PVS group (3 /18 vs 13/18, p<0.05). Conclusions: Our results suggest that PVS might be beneficial in patients with refractory ascitis waiting for liver grafts and could prevent post-operative acute renal failure.

In children, living donor liver transplantation has been shown to be efficient in treating end-stage liver diseases when the left lateral segment is harvested. In adults, more liver mass is needed to provide adequate hepatic function. The aim of this study is to report 2 successful cases of living donor liver transplantation using a right hepatic lobe from adult.In 2 sons, the right hepatic lobe was harvested without the middle hepatic vein for transplantation in their fathers who were suffering from end-stage liver cirrhosis. Hepatectomy was done without vascular inflow occlusion after dissection of vascular and biliary structures, itself strictly restricted to the right side. In recipients, the graft was implanted orthotopically with preservation of the native inferior vena cava and after temporary porto-caval shunt.The duration of donors procedures was 7 h and 11 h 45 min; intra-operative transfusions comprised of 700 mL from cell-saver in the first case, and 1300 mL plus 1 autologous red blood cell unit in the second case. Graft weights were 770 g and 1100 g. None of the donors experienced liver failure and both were able to leave the hospital 9 days after the operation. In recipients, initial graft function was excellent in the first case and correct in the second case, despite the necessity to redo intra-operatively the hepatic vein anastomosis secondary to a twisting. Patients were discharged 20 and 40 days respectively following transplantation.Adult living donor liver transplantation using a right hepatic lobe is efficient and safe. This option could contribute to reducing the mortality of patients on the waiting list.

STUDY AIM:In children, living donor liver transplantation has been shown to be efficient in treating end-stage liver diseases when the left lateral segment is harvested. In adults, more liver mass is needed to provide adequate hepatic function. The aim of this study is to report 2 successful cases of living donor liver transplantation using a right hepatic lobe from adult.PATIENTS AND METHODS:In 2 sons, the right hepatic lobe was harvested without the middle hepatic vein for transplantation in their fathers who were suffering from end-stage liver cirrhosis. Hepatectomy was done without vascular inflow occlusion after dissection of vascular and biliary structures, itself strictly restricted to the right side. In recipients, the graft was implanted orthotopically with preservation of the native inferior vena cava and after temporary porto-caval shunt.RESULTS:The duration of donors procedures was 7 h and 11 h 45 min; intra-operative transfusions comprised of 700 mL from cell-saver in the first case, and 1300 mL plus 1 autologous red blood cell unit in the second case. Graft weights were 770 g and 1100 g. None of the donors experienced liver failure and both were able to leave the hospital 9 days after the operation. In recipients, initial graft function was excellent in the first case and correct in the second case, despite the necessity to redo intra-operatively the hepatic vein anastomosis secondary to a twisting. Patients were discharged 20 and 40 days respectively following transplantation.CONCLUSION:Adult living donor liver transplantation using a right hepatic lobe is efficient and safe. This option could contribute to reducing the mortality of patients on the waiting list.