Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation(LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient's tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient's safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begunwith left lateral sectionectomy,which is performed for adult to child living donation.In this setting,the laparoscopic technique is now well standardized,is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach.On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach,the hand assisted approach and the hybrid approach have been reported.Hence,even-though several reports highlight the feasibility of these procedures,the true benefits of laparoscopy over laparotomy remain to be fully assessed.This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.

Complete hepatocellular carcinoma necrosis following sequential porto-arterial embolization

Most patients with hepatocellular carcinoma (HCC) are not eligible for curative treatment,which is resection or transplantation. Two recent series have emphasized the potential benefits of preoperative arterio-portal embolization prior to surgical resection of such tumours. This preoperative strategy offers a better disease free survival rate and a higher rate of total tumor necrosis. In case of non resectable HCC it is now widely accepted that transarterial chemoembolization (TACE) leads to a better survival when compared to conservative treatment. Thus,the question remains whether combined portal vein embolization (PVE) may enhance the proven efficiency of TACE in patients with unresectable HCC. We herein report the case of a 56-year-old cirrhotic woman with a voluminous HCC unsuitable for surgical resection. Yet,complete tumour necrosis and prolonged survival could be achieved after a combined porto-arterial embolization. This case emphasizes the potential synergistic effect of a combined arterio-portal embolization and the hypothetical survival benefit of such a procedure,in selected patients,with HCC not suitable for surgery or local ablative therapy.

COVID-19 in a liver transplant recipient:Could iatrogenic immunosuppression have prevented severe pneumonia?A case report

BACKGROUND Coronavirus disease(COVID)is a new and highly contagious infectious disease caused by the coronavirus(COVID-19 or severe acute respiratory syndrome coronavirus 2).There is limited data regarding the incidence and management of COVID-19 in immunocompromised patients’post-transplantation.In the pre-COVID-19 era,these patients were already at an increased risk of developing opportunistic infections.These often manifested with atypical symptoms.CASE SUMMARY We report another case of uneventful COVID-19 pneumonia in a 58-year old male who was 18 mo’post liver transplantation.He received tacrolimus monotherapy since July 2019.The clinical manifestations included only epigastric pain radiating to the right hypochondrium,nausea and vomiting.He had no fevers,cough,shortness of breath,anosmia or dysgeusia even if the chest computed tomography scan revealed an extension of the multiple patchy ground-glass density shadows to the upper lobe of the left lung too.He was hospitalised and received a course of oral chloroquine(200 mg×3 per day)for a period of 10 d.Interestingly,the COVID 19 infection was uneventful though there were no modifications to his tacrolimus dosing.He was successfully discharged.We performed subsequent follow-up via telemedicine.CONCLUSION In light of the current pandemic,it is even more important to identify how the liver recipient’s patients present and are managed,especially for immunosuppression treatment.

Adult human liver slice cultures:Modelling of liver fibrosis and evaluation of new anti-fibrotic drugs

BACKGROUND Liver fibrosis can result in end-stage liver failure and death.AIM To examine human liver fibrogenesis and anti-fibrotic therapies,we evaluated the three dimensional ex vivo liver slice(LS)model.METHODS Fibrotic liver samples(F0 to F4 fibrosis stage according to the METAVIR score)were collected from patients after liver resection.Human liver slices(HLS)were cultivated for up to 21 days.Hepatitis C virus(HCV)infection,alcohol(ethanol stimulation)and steatosis(palmitate stimulation)were examined in fibrotic(F2 to F4)liver slices infected(or not)with HCV.F0-F1 HLS were used as controls.At day 0,either ursodeoxycholic acid(choleretic and hepatoprotective properties)and/or α-tocopherol(antioxidant properties)were added to standard of care on HLS and fibrotic liver slices,infected(or not)with HCV.Expression of the biomarkers of fibrosis and the triglyceride production were checked by quantitative reverse transcription polymerase chain reaction and/or enzymelinked immunosorbent assay.RESULTS The cultures were viable in vitro for 21 days allowing to study fibrosis inducers and to estimate the effect of anti-fibrotic drugs.Expression of the biomarkers of fibrosis and the progression to steatosis(estimated by triglycerides production)was increased with the addition of HCV and/or ethanol or palmitate.From day 15 of the follow-up studies,a significant decrease of both transforming growth factorβ-1 and Procol1A1 expression and triglycerides production was observed when a combined anti-fibrotic treatment was applied on HCV infected F2-F4 LS cultures.CONCLUSION These results show that the human three dimensional ex vivo model effectively reflects the in vivo processes in damaged human liver(viral,alcoholic,nonalcoholic steatohepatitis liver diseases)and provides the proof of concept that the LS examined model permits a rapid evaluation of new anti-fibrotic therapies when used alone or in combination.

Robotic versus laparoscopic liver resection for huge (≥10 cm) liver tumors: an international multicenter propensity-score matched cohort study of 799 cases

Background:The use of laparoscopic(LLR)and robotic liver resections(RLR)has been safely performed in many institutions for liver tumours.A large scale international multicenter study would provide stronger evidence and insight into application of these techniques for huge liver tumours≥10 cm.Methods:This was a retrospective review of 971 patients who underwent LLR and RLR for huge(≥10 cm)tumors at 42 international centers between 2002-2020.Results:One hundred RLR and 699 LLR which met study criteria were included.The comparison between the 2 approaches for patients with huge tumors were performed using 1:3 propensity-score matching(PSM)(73 vs.219).Before PSM,LLR was associated with significantly increased frequency of previous abdominal surgery,malignant pathology,liver cirrhosis and increased median blood.After PSM,RLR and LLR was associated with no significant difference in key perioperative outcomes including media operation time(242 vs.290 min,P=0.286),transfusion rate rate(19.2%vs.16.9%,P=0.652),median blood loss(200 vs.300 mL,P=0.694),open conversion rate(8.2%vs.11.0%,P=0.519),morbidity(28.8%vs.21.9%,P=0.221),major morbidity(4.1%vs.9.6%,P=0.152),mortality and postoperative length of stay(6 vs.6 days,P=0.435).Conclusions:RLR and LLR can be performed safely for selected patients with huge liver tumours with excellent outcomes.There was no significant difference in perioperative outcomes after RLR or LLR.

Comment on: survival outcomes after portal vein embolization and liver resection compared with liver transplant for patients with extensive colorectal cancer liver metastases

We read with great interest the work of Dueland et al.recently issued in JAMA Surgery(1).In this retrospective study gathering data from several prospective cohorts from Norway,the authors compare oncological outcome of patients who underwent liver transplantation(LT)vs.portal venous embolization(PVE)followed by liver resection(LR)for colorectal liver metastasis(CRLM).