Median arcuate ligament in orthotopic liver transplantation: relevance to arterial reconstruction.

Median arcuate ligament (MAL) syndrome results from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or by fibrous bands of the celiac nervous plexus. In 10% to 50% of cases it is responsible for significant angiographic celiac trunk compression. In orthotopic liver transplantation (OLT), the presence of celiac compression by MAL is considered to be a risk factor for hepatic arterial thrombosis (HAT); it may lead to graft loss. Various surgical procedures have been proposed to overcome the impact of MAL in OLT, but their impact is still ill defined. The aim of our study was to compare standard hepatic artery reconstruction and graft reconstruction (aortohepatic bypass) in terms of HAT among patients with MAL undergoing OLT. We retrospectively reviewed 168 adult recipients of OLT performed from January 1991 to December 1998. Ten cases (5.6%) of celiac compression by MAL were identified after celiomesenteric arteriography. There was no significant difference in terms of HAT incidence when aortohepatic bypass was performed compared to a standard anastomosis; moreover, this was greater in the graft reconstruction group (25% vs 17%; P = .67). In our opinion, the presence of an arcuate ligament should not contraindicate a routine hepatic artery reconstruction.

[Incidence of surgical site infection in ambulatory surgery: results of the INCISCO surveillance network in 1999-2000]. / Incidence des infections du site opératoire en chirurgie ambulatoire: résultats du réseau de surveillance INCISO en 1999-2000.

OBJECTIVES: To estimate the incidence of surgical-site infections (SSI) in ambulatory surgery and to identify risk factors based on the surveillance network INCISO in 1999-2000. PATIENTS AND METHODS: Annually, during a three-month period, each surgical ward had to include 200 consecutive operations. Patients were surveyed over the month following surgery. For each patient, data including peri-operative factors, type of procedure and SSI occurrence were collected on a standardized form by a surgical staff committed for the study. RESULTS: Of the 5,183 patients who underwent an ambulatory surgery, the SSI incidence ratio was 0.4% (95% CI [0.3-0.7]). Orthopedic, gynecologic/obstetrics, head and neck, skin and soft tissues surgery accounted for 83% of all ambulatory procedures. 93% of patients belonged to the 0 risk category of the National Nosocomial Infections Surveillance system (NNIS) index. Emergency, age, american anesthesia risk score (ASA), Altemeier wound class, and procedure duration were not found to be risk factors for SSI in ambulatory surgery. CONCLUSION: Based on these surveillance data, infectious risk was low in ambulatory surgery and was not associated with known SSI risk factors.

[Which adrenal incidentalomas are to be operated?]. / Quels incidentalomes surrénaliens faut-il opérer?

AIM OF THE STUDY: The goal of this retrospective study was to recognize the incidence of adrenal tumors called incidentalomas, that are in fact symptomatic or hormone secreting tumors, to assess if the diagnostic criteria proposed in the literature are reliable for adrenal tumors found incidentally. PATIENTS AND METHOD: The records concerned 147 patients operated between April 1981 and December 2000 for an adrenal mass measuring 3 cm in diameter and larger on CT scan. Clinical and laboratory findings as well as hormone levels and imaging examinations (CT Scan, IRM, scintigraphy) were correlated with operative findings and results of histologic examinations. One hundred and three patients were operated by a traditional approach and forty four by videoendoscopic techniques. RESULTS: In 41 patients (28%), the tumors had to be classified as false incidentalomas (group 1) postoperatively. In 106 patients (72%), the nature of tumor was non definite. In this group 2, there were ten malignant tumors, two pheochromocytomas and 94 benign lesions. Age of patient, size of tumor, increase in size over time and radiological appearance represent criteria that are not reliable to separate malignant from benign tumors. CONCLUSIONS: Tumors of indeterminated and non specific nature only should be classified as incidentalomas. Imaging techniques as well as other criteria of malignancy cannot be relied upon to separate benign from malignant tumors. The risk even small of cancer or pheochromocytoma leads us to recommend excision of tumors > or = 3 cm in radiological diameter. The videoendoscopic approach is a good alternative to open operation in centers with this special expertise.

Reversal of the vasoconstrictor step of hyperacute xenogeneic rejection of the liver by endothelin antagonists.

The role of endothelin in the initial vasoconstrictor step of hyperacute xenogeneic rejection was investigated. Isolated rat livers were perfused in recirculation. Perfusion with human sera provided an ex vivo model of hyperacute rejection in a discordant combination. Perfusion of 10% xenogeneic serum induced a marked (70%) and sustained reduction of the liver flow and induced the release of endothelin into the perfusion medium. In contrast, perfusion of 10% allogeneic serum or of 10% decomplemented human serum induced a weak (25%) and transient reduction of the liver flow and induced the release of minimal amounts of endothelin. The simultaneous administration of BQ 123 and BQ 788, the respective antagonists of ET(A) and ET(B) endothelin receptors, or that of bosentan, a mixed ET(A)/ET(B) antagonist, antagonized the vasoconstrictor effect of 10% xenogeneic human serum, as well as that of 10(-9) M endothelin-1. The vasoconstrictor effects of xenogeneic serum on liver circulation are, at least partly, mediated through the release of endothelin by the graft.

[Videolaparoscopic excision of insulinoma. A study of 5 cases]. / Exérèse vidéolaparoscopique des insulinomes. Etude de cinq observations.

STUDY AIM: Evaluation of the feasibility of the videolaparoscopic resection in pancreatic insulinomas, and reporting of five cases. PATIENTS AND METHOD: From 1996 to 1998, a videolaparoscopic resection was attempted in five patients with sporadic, unique and benign insulinoma. The insulinoma was recognised and localised by preoperative ultrasonography in the pancreatic head (n = 1), body (n = 3) or tail (n = 1). For the videolaparoscopic procedure, three to five trocars were necessary. Cephalic and corporeal insulinomas were approached through an opening of the gastrocolic ligament and caudal insulinoma required mobilisation of the splenic flexure of the colon and dissection of the splenic pedicle. Peroperative ultrasonography was not used. RESULTS: Four resections were exclusively performed with videolaparoscopy: three enucelations and one distal pancreatectomy with splenic preservation. The cephalic insulinoma could not be found by laparoscopic exploration and required a laparotomy to be recognised and enucleated; it was located further down than expected. There were no postoperative complications in four patients. One enucleation was complicated by a pancreatic fistula that required reoperation. All the patients were cured with a 6- to 16-month follow-up. CONCLUSION: Selected insulinomas may be operated on with videolaparoscopy. Preoperative endoscopic ultrasonography is necessary for this selection. Videolaparoscopic approach is contraindicated in multiple insulinomas, in insulinomas located on the posterior wall or deeply located in the head of the pancreas, and in malignant tumors. Videolaparoscopic resection is mainly indicated in unique and benign insulinomas, superficially located on the anterior wall of the pancreas, to be resected by enucleation or distal pancreatectomy. Disadvantage of laparoscopic approach compared to conventional approach is the absence of palpation and difficulty to explore the whole pancreas; advantage is the lack of parietal incision and the good postoperative comfort.

Common bile duct stenosis caused by chronic pancreatitis after liver transplantation for alcoholic cirrhosis.

BACKGROUND: The prevalence of chronic pancreatitis in patients with alcoholic cirrhosis ranges from 7% to 11% and is not considered a contraindication for liver transplantation. METHODS: Among 59 liver transplant recipients grafted for alcoholic cirrhosis, we report two observations of common bile duct stenosis due to chronic pancreatitis. RESULTS: In both cases, pretransplant work-up disclosed no clinical or radiological evidence of chronic pancreatitis. The diagnosis of common bile duct stricture was made 6 and 60 months after liver transplantation. One patient was reoperated upon, and his choledochocholedochostomy was converted into a Rouxen-Y choledochojejunostomy. The second patient experienced metastatic laryngeal carcinoma and died before reoperation. CONCLUSIONS: These observations suggest that common bile duct stricture caused by chronic pancreatitis may occur after liver transplantation for alcoholic cirrhosis, even after a long-standing history of abstinence.

Rationale and technical constraints of a tertiary liver transplantation.

Because of the current shortage of donor organs, the routine performance of tertiary liver transplantation (LT) may be questioned. In this study, the indications of tertiary LT are discussed, paying particular attention to intraoperative technique. Of 501 LTs performed from 1986 to 1995, eight (1.6%) were tertiary LTs. Three patients underwent an emergent third LT because of associated hepatic artery and portal vein thromboses (n = 2) or hyperacute rejection (n = 1). Five patients had an elective third LT for ischemic cholangitis (n = 4) or chronic rejection (n = 1). The 3 patients who underwent retransplantation emergently died early from multiple-organ failure. Because of previous surgery and subsequent technical difficulties, the third LT in the remaining 5 patients required unroutine surgical procedures including the following: intrapericardial control of the suprahepatic vena cava (n = 1), "en bloc" clamping of both the infrahepatic vena cava and the hepatic pedicle (n = 1), arterial reconstruction onto the aorta via an aortoiliac conduit (n = 5), and aortic resection with aortoaortic prosthetic reconstruction (n = 1). Of these 5 patients, 4 required reoperation because of bowel perforation (n = 5) or intraperitoneal bleeding (n = 1). The 5 patients (62%) who were regrafted electively are alive and well after a median follow-up of 45 months. A third LT can be reasonably offered to selected young recipients if performed electively. Tertiary LT may require unroutine surgical procedures and may lead to severe morbidity.

[Single-stage resection of at least 6 liver segments in cases of liver tumors]. / Résection d'au moins six segments anatomiques en un temps pour tumeur du foie.

Seven partial liver resections of at least six hepatic segments (five extended left hepatectomies, also called left trisegmentectomies, and two subtotal hepatectomies) were performed for tumor (of malignant nature in 6 cases). Six of seven patients were admitted for liver transplantation and one for liver resection. These procedures were performed under total vascular exclusion of the liver in six cases (with a veno-venous bypass in two cases) and with the Pringle maneuver in one case. Postoperative liver function was satisfactory in six cases whereas one patient died of hepatic failure on the tenth postoperative day. There was one bile duct stricture at eight months, after extended left hepatectomy. Four patients survived more than one year, three with hepatic tumor recurrence and one with distant metastases. Two patients were still alive, one after fourteen months with tumor recurrence in the liver, the other after seventeen months. In selected cases, partial hepatic resection of more than six segments can be performed for very large tumors. In cases of malignant tumors, a short period of survival with good quality of life can be offered to these patients.