Small-for-size syndrome and hypoxia : a lesson learned from the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) rapid liver regeneration model in rats

In the setting of major hepatectomy, excessive portal perfusion, “dearterialization” and hypoxia of the liver remnant are considered as the main pathogenic mechanisms for the Small for Size Syndrome (SFSS), a potentially lethal clinical entity. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces rapid and enhanced hypertrophy of an insufficient-for-survival future liver remnant. Based on a rodent model of ALPPS that we developed, we compared the remnant’s inflow in ALPPS and in SFSS-setting hepatectomy. We demonstrated that portal hyperperfusion is essential for rapid liver regeneration, and it is not the sole factor for the development of SFSS. Moreover, ‘dearterialization’ and hypoxia in ALPPS remnants improved survival by activation of an early angiogenic response and preservation of the sinusoidal morphology. When we experimentally induced hypoxia in an upfront SFSS-setting hepatectomy, we rescued survival. Activation of hypoxia sensors had no impact on hepatocyte proliferation but surged an early angiogenic switch and preserved the sinusoidal architecture. Hypoxia protects the liver from SFSS. Our study brings experimental evidence that hypoxia-induced angiogenesis balances sinusoidal remodelling to hepatocyte proliferation, preserves the lobular architecture and allows functional liver regeneration after major hepatectomy.(MED - Sciences médicales) -- UCL, 202

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy.

To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy

Focal Nodular Hyperplasia: A Rare Indication of Resection

Surgical indications of Focal Nodular Hyperplasia (FNH) remain exceptional except in cases of diagnostic uncertainty, symptomatic lesion or increase of tumour volume. We describe the case of FNH compressing the Inferior Vena Cava (IVC)

Pneumopericardium: A Rare Complication of Antireflux Surgery

Pneumopericardium is a rare clinical entity, occurring in the setting of thoracic trauma, malignancies, or mechanical ventilation. Very few cases report pneumopericardium as a complication of gastrointestinal tract surgery. Signs and symptoms may be frustrating, ranging from asymptomatic to chest pain, sepsis, hemodynamic instability, pericarditis, or even cardiac tamponade. Clinical pathognomonic signs of pneumopericardium include pericardial metallic tinkling friction rub and mill wheel murmur. Diagnostic workup includes electrocardiogram, chest radiography, and, computed tomography imaging. A gastro pericardial fi stula should be considered a rare diff erential diagnosis for acute chest pain in patients with a history of gastroesophageal surgery. Rapid recognition and treatment avoid life-threatening complications. The successful outcome of gastro pericardial fi stula treatment depends on both emergency and defi nitive surgical management. The survival rate with conservative management is poor. We present the case of a 78-year-old patient suff ering from pneumopericardium and pericardial infusion, due to a fi brotic fi stula between the Nissen’s valve, occurring 10 years after redo antirefl ux surgery. Treatment included broad-spectrum antibiotics, and emergency surgery for pericardial drainage, biopsy of the valve’s defect, suture, and omentoplasty

Pneumopericardium: A Rare Complication of Antireflux Surgery

Pneumopericardium is a rare clinical entity, occurring in the setting of thoracic trauma, malignancies, or mechanical ventilation. Very few cases report pneumopericardium as a complication of gastrointestinal tract surgery. Signs and symptoms may be frustrating, ranging from asymptomatic to chest pain, sepsis, hemodynamic instability, pericarditis, or even cardiac tamponade. Clinical pathognomonic signs of pneumopericardium include pericardial metallic tinkling friction rub and mill wheel murmur. Diagnostic work-up includes electrocardiogram, chest radiography, and, computed tomography imaging. A gastro pericardial fistula should be considered a rare differential diagnosis for acute chest pain in patients with a history of gastroesophageal surgery. Rapid recognition and treatment avoid life-threatening complications. The successful outcome of gastro pericardial fistula treatment depends on both emergency and definitive surgical management. The survival rate with conservative management is poor.We present the case of a 78-year-old patient suffering from pneumopericardium and pericardial infusion, due to a fibrotic fistula between the Nissen’s valve, occurring 10 years after redo antireflux surgery. Treatment included broad-spectrum antibiotics, and emergency surgery for pericardial drainage, biopsy of the valve’s defect, suture, and omentoplasty

Small for size syndrome (SFSS) and hypoxia: lessons learned from the associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure in rats

Excessive portal hypertension with compensatory arterial constriction of the future liver remnant (FLR) is considered the main cause of SFSS after major hepatectomy. ALPPS combines portal vein ligation and parenchymal transection to obtain rapid hypertrophy of FLR for patients needing marginal hepatectomy, with high risk of postoperative SFSS. This procedure sets the FLR in the same hemodynamic portal conditions as in SFSS, and yet, patients survive, and obtain boosted FLR hypertrophy. [...

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): establishment of an innovating animal model with insufficient liver remnant

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows extended hepatectomy in patientswith an extremely small future liver remnant (FLR). Current rodent models of ALPPS do not include resection resulting ininsufficient-for-survival FLR, or they do incorporate liver mass reduction prior to ALPPS. Differences in FLR volume andsurgical procedures could bias our understanding of physiological and hemodynamic mechanisms. We aimed to establish arat ALPPS model with minimal FLR without prior parenchymal resection. In rodents, the left median lobe (LML) represents10% of total liver. Partial hepatectomy (PHx) sparing LML and pericaval parenchyma represents our reference 87%resection. Thefirst step in the procedure is either portal vein ligation (PVL) corresponding to ligation of all but the LMLportal branches, or PVL with transection between the left and right median lobe segments (PVLT), and is defined as ALPPSstage-1. Second, ligated lobes were removed: PVL-PHx represents a conventional 2-stage hepatectomy, while PVLTfollowed by PHx is a strict reproduction of human ALPPS. In Group A, liver hypertrophy was analyzed after PVL (n=38),PVLT (n=47), T (n=10), and sham (n=10); In group B, mortality and FLR hypertrophy was assessed after PHx (n=42),Sham-PHx (n=6), PVL-PHx (n=37), and PVLT-PHx (n=45). In group A, PVLT induced rapid FLR hypertrophycompared to PVL (p< 0,05). Hepatocyte proliferation was higher in PVLT remnants (p< 0,05). In group B, PHx had a 5-daymortality rate of 84%. Sham operation prior to PHx did not improve survival (p=0.23). In both groups, major fatalitiesoccurred within 48 h after resection. PVL or PVLT prior to PHx reduced mortality to 33.3% (p=0,007) or 25% (p=0.0002) respectively, with no difference between the 2 two-stage procedures (p=0.6). 7-day FLR hypertrophy was higherafter the PVLT-PHx compared to PVL-PHx and PHx (p=0.024). Our model reproduces human ALPPS with FLR that isinsufficient for survival without liver resection prior to the stage-1 procedure. It offers an appropriate model for analyzing themechanisms driving survival rescue and increased hypertroph

Laparoscopic treatment of adult diaphragmatic hernia after minimally invasive hepatectomy: A case report and literature review

Introduction: History of surgery is the second most common cause of acquired diaphragmatic hernia (DH) after trauma. Herein, we present a case of diaphragmatic hernia following minimally invasive laparoscopic liver surgery. We also reviewed the literature on adult DH after hepatectomy, the primary surgical cause. Methods: Clinical case presentation and systematic literature review of adult DH after hepatectomy. Results: A 71-year-old male patient was diagnosed a DH 42 months after a right extended laparoscopic hepatectomy for alveolar echinococcosis. A minimal invasive approach permitted a primary suture with intraperitoneal onlay mesh. There is no sign of recurrence at the 19-months follow-up. The literature review reported only 80 cases. The incidence, type of liver surgery and indications, delay before DH diagnosis, clinical presentation, treatment, and recurrence rate were assessed. Based on this, an algorithm for work-up and treatment is proposed. Conclusion: Although rare, diaphragmatic hernias should be considered in the differential diagnosis of abdominal and/or respiratory symptoms in patients with a history of liver surgery. Computed tomography imaging is the first-choice diagnostic modality, and surgical repair is key. The primary suture should be associated with mesh use. A long-term follow-up of at least two years was proposed to detect DH recurrence