Are pyogenic liver abscesses still a surgical concern? A Western experience.

Backgrounds. Pyogenic liver abscess is a rare disease whose management has shifted toward greater use of percutaneous drainage. Surgery still plays a role in treatment, but its indications are not clear. Method. We conducted a retrospective study of pyogenic abscess cases admitted to our university hospital between 1999 and 2010 and assessed the factors potentially associated with surgical treatment versus medical treatment alone. Results. In total, 103 liver abscess patients were treated at our center. The mortality was 9%. The main symptoms were fever and abdominal pain. All of the patients had CRP > 6 g/dL. Sixty-nine patients had a unique abscess. Seventeen patients were treated with antibiotics alone and 57 with percutaneous drainage and antibiotics. Twenty-seven patients who were treated with percutaneous techniques required surgery, and 29 patients initially received it. Eventually, 43 patients underwent abscess surgery. The factors associated with failed medical treatment were gas-forming abscess (P = 0.006) and septic shock at the initial presentation (P = 0.008). Conclusion. Medical and percutaneous treatment constitute the standard management of liver abscess cases. Surgery remains necessary after failure of the initial treatment but should also be considered as an early intervention for cases presenting with gas-forming abscesses and septic shock and when treatment of the underlying cause is immediately required.

Report of the Paris consensus meeting on expanded criteria donors in liver transplantation.

Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. Consensus recommendations are needed. This article reports the conclusions of a consensus meeting held in Paris in March 2007 with the contribution of experts from Europe, the United States, and Asia. Definitions of expanded criteria donors with respect to donor variables (including age, liver function tests, steatosis, infections, malignancies, and heart-beating versus non-heart-beating, among others) are proposed. It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.

Hepatic artery ligation: a simple and safe technique to treat extrahepatic aneurysms of the hepatic artery.

BACKGROUND: Treatment of patients with extrahepatic artery aneurysms (HAAs) is not well defined. The aim of this study was to report 4 patients with HAAs treated by ligation and to underline the rationale of this technique. METHODS: From 2000 to 2006, 4 consecutive patients, including 1 with bile duct compression and 1 with hemobilia, presented with symptomatic HAAs. Preoperative imaging included spiral computed axial tomography with computed axial tomography-assisted arteriography in all patients and diagnostic arteriography in 1 patient. One patient underwent unsuccessful transarterial embolization. All patients were treated surgically by ligation with preservation of the collateral network identified by preoperative imaging. RESULTS: During a 6- to 70-month range of follow-up, there was no postoperative mortality, surgical morbidity, or adverse consequences on liver function tests. CONCLUSIONS: Ligation is a simple and efficient treatment in patients with symptomatic extrahepatic artery aneurysm, even those with bile duct obstruction.

Utility of liver allograft biopsy obtained at procurement.

Extended-donor criteria (EDC) liver allografts potentiate the role of procurement biopsy in organ utilization. To expedite allocation, histologic evaluation is routinely performed upon frozen-section (FS) specimens by local pathologists. This descriptive study compares FS reports by local pathologists with permanent-section (PS) evaluation by dedicated hepatopathologists, identifies histologic characteristics underrepresented by FS evaluation, and evaluates the efficacy of a biopsy decision analysis based on organ visualization. Fifty-two liver transplants using EDC allografts evaluated by FS with PS were studied. Pathologic worksheets created by an organ procurement organization were applied in 34 FS. PS analysis included 7 staining procedures for 8 histologic criteria. PS from 56 additional allografts determined not to require donor biopsy were also analyzed. A high correlation was observed between FS and PS. Underestimation of steatosis by FS was associated with allograft dysfunction. Surgical assessment of cholestasis, congestion, and steatosis was accurate whereas inflammation, necrosis, and fibrosis were underestimated in allografts suffering parenchymal injury. In conclusion, the correlation between FS and PS is high, and significant discrepancies are rare. Biopsy is not a prerequisite for EDC utilization but is suggested in hepatitis C, hypernatremia, donation after cardiac death, or multiple EDC indications. Implementation of a universal FS worksheet could standardize histologic reporting and facilitate data collection, allocation, and research.

Usefulness of follow-up after pancreatoduodenectomy for carcinoma of the ampulla of Vater.

BACKGROUND: The prognosis for carcinoma of the ampulla of Vater (CAV) is better than for pancreatic cancer. The 5-year survival median rate after resection of CAV is 45%, but late recurrences remain possible. Several survival factors have been identified (lymph nodes, perineural invasion), but few data are available on the type of recurrences, their impact and their management. PATIENTS AND METHODS: A total of 41 patients treated by pancreatoduodenectomy (PD) for CAV from 1980 to 2003 were studied retrospectively. Patient selection, long-term survival recurrence rate and recurrence treatment were reviewed. Univariate and multivariate proportional hazards analysis were conducted on this series. RESULTS: The mean follow-up was 48 months. Five-year survival was 62.8%. Eleven patients had recurrences (6-67 months). Recurrence was associated with time to all-causes death (hazard ratio [HR] 4.3, p=0.003). Factors predictive of recurrence were perineural invasion (HR 5.3, p=0.02), lymph node invasion (HR 5.3, p=0.02) and differentiation (HR 0.2, p=0.05). Three patients underwent surgical R0 treatment of their recurrences. Two who presented with solitary liver metastasis are alive and disease-free. CONCLUSIONS: Recurrence represents a serious threat in the prognosis of CAV after surgery. Some of these recurrences, in particular liver metastases, are accessible for a curative treatment. This finding supports the usefulness of a close and long-term follow-up after surgery to improve survival of patients with CAV, especially in the group of patients with a good prognosis.

Leiomyosarcoma of the superior mesenteric vein: a diagnostic and therapeutic challenge.

We report here a case of a very rare entity, a leiomyosarcoma of the mesentericoportal trunk, which was initially misdiagnosed as an unresectable pancreatic cancer invading the mesenteric vein, and which was finally treated by pancreatectomy with mesentericoportal reconstruction. The pitfalls of diagnosis and modalities of resection are discussed.

Extended-donor criteria liver allografts.

Extended-donor criteria liver allografts do not meet traditional criteria for transplantation. Although these organs offer immediate expansion of the donor pool, transplantation of extended-donor criteria liver allografts increases potential short- and long-term risk to the recipient. This risk may manifest as impaired allograft function or donor-transmitted disease. Guidelines defining this category of donor, level of acceptable risk, principles of consent, and post-transplantation surveillance have not been defined. This article reviews the utilization, ethical considerations, and outcomes of extended-donor criteria liver allografts.

Posterior intrathoracic neurinoma cure: a transforaminal resection after a thoracotomy.

Posterior intrathoracic neurogenic tumors often have an intraforaminal extension. Ten percent have an extension intraspinal and are called "dumbbell tumors." The surgically recommended techniques used to treat these conditions may have been applied too systematically, mainly when the diameter of the foramen was obviously enlarged and the possibility of removing the tumor existed. We report two cases to stress the importance of assessing the size of the intervertebral foramina in planning neurinoma cure.

Stent placement in superior vena cava syndrome.

BACKGROUND: Superior vena cava syndrome (SVCS) is often seen in the natural history of malignant thoracic diseases. SVCS is characterized by unpleasant symptoms that usually lead to death. The purpose of our study is to show the efficiency of percutaneous stenting in the superior vena cava for relieving SVCS and the possibility of repeated stenting after recurrence. METHODS: Twenty patients with SVCS caused by malignant diseases who had one or more stents placed in the superior vena cava or its main tributaries were evaluated. RESULTS: Out of 20 patients, 1 died of myocardial infarction 24 hours after the procedure without any signs of pulmonary embolus, hemorrhage, or malposition of the stent. SVCS was successfully controlled in 94% of patients until death or completion of the study. In 3 patients the procedure was repeated (3 to 20 weeks later) because of the recurrence of symptoms. CONCLUSIONS: Percutaneous venous stent placement in the superior vena cava is a simple and effective technique to relieve rapid SVCS caused by malignancies. When recurrence occurs, repeated stenting can be performed successfully.