ABSTRACT. OBJECTIVE

Preservation of hepatic parenchyma is important in liver surgery to prevent postoperative liver failure. Furthermore, reports have shown a prolonged survival and a lower recurrence rate after minor resections compared to major hepatectomies in patients with colorectal liver metastases (CRLM’s). However, laparoscopic parenchymal-preserving liver resections (LPPLR) can be technically challenging. A shift toward parenchyma-sparing liver surgery can be observed in the reports of most hepatobiliary centers.

METHODS

Technical aspects of LPPLR are demonstrated using 3 videos in High Definition.

RESULTS

The first patient had a solitary giant CRLM in segment V and VIII. Neoadjuvant chemotherapy was given resulting in a 25% volume reduction of the lesion. A laparoscopic anterior sectionectomy was performed preventing a right hemihepatectomy. The second patient had 5 CRLM’s. After conversion chemotherapy a LPPLR was performed. One CRLM was resected in the left hemi liver and 3 resections were performed in the right hemi liver (posterior sectionectomy, metastasectomy segment V and VIII). The third patient had 7 CRLM’s. He received 18 cycles of oxaliplatin-based chemotherapy with cetuximab. Since persistent progression was noted and CRLM’s remained unresectable, bilobar selective internal radiation therapy (SIRT) was performed. A major response was observed and 7 months after SIRT the patient underwent a LPPLR of 6 CRLM’s. A laparoscopic left lateral sectionectomy and 3 non-anatomical resections were performed with a radiofrequency ablation of a central lesion in the right hemi liver. Pathology showed no residual tumor (TRG 1).

CONCLUSION

The emergence of more effective systemic chemotherapies with biologicals and SIRT for the treatment of CRLM’s often creates a possibility for parenchymal-preserving liver resections. Since prolonged survival is observed in patients who underwent parenchymal preserving liver resections, LPPLR should be performed more frequently although it’s technically more challenging.

ABSTRACT. Introduction :

Tricuspid valve endocarditis accounts for 3% of all cases of endocarditis. The most common microbial agent is Methicillin sensitive Staphylococcus aureus (MSSA). Its clinical presentations differs from septicemia to right heart failure and pulmonary embolism. Intra-venous drug users and patients with pacemakers are the most susceptible to present this kind of infections.

Method :

We present the case of a 18 years old male patient with right arm cellulitis, spondylodiscite, septic embolisms in the two lungs and right pyelonephritis. The identified microbial agent in this no-drug user patient with tricuspid valve endocarditis was MSSA. After 3 weeks antibitherapy, We performed a tricuspid valve repair under cardiopulmonary bypass by sternotomy. Two large septic vegetations, positionned on the cordae of the septal leaflet, were resected, with superficial resection of the muscular septum at the level of the cordae insertion. We put in place 2 gortex neo-cordae and a 30 mm 3D medtronic annulus.

Result :

The patient continued to have many pics of temperature in the few days after the operation. No more MSSA was identified in blood culture but on the bacterial analysis of the vegetations. No atrioventricular block. Trans Thoracic Echocardiography showed a normal tricuspid valve with no vegetations nor regurgitation. One month later, the patient had an embolisation of a mycotic aneurysm of a pulmonary arterial branch of the posterior segment of the right lower lobe. AT 3 months follow-up, the patient is alive and returned home.

Conclusion :

Tricuspid valve repair for endocarditis is safe and feasible. It demands association between antibiotherapy, extensive resection and good expertise in reconstructive valve surgery in order to allow less morbidity.

ABSTRACT. The classic procedure for aortobifemoral bypass is open surgery. Since the first totally laparoscopic aortobifemoral bypass reported in 1997 by Yves–Marie Dion, laparoscopy has been accepted by several authors as a possible minimal invasive alternative for aortoiliac occlusive disease. The transperitoneal left retrocolic and retrorenal approaches are generally used. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. Whatever the approach, the aortoprosthetic anastomosis is a major difficulty making those techniques unpopular despite obvious advantages for the patients. We report a clampless and sutureless approach for the proximal anastomosis of a totally retroperitoneoscopic aortobifemoral bypass using the EndoVascular REtroperitoneoScopic Technique (EVREST).

ABSTRACT. We would like to present the case of of 71-year old female who recently had a laparoscopic right hemicolectomy with lymphadenectomy for a pT3N1b adenocarcinoma of the ascending colon. One month after surgery, a new CAT-scan showed a new enlarged lymph node of about 2cm on the left side, near the IMA and IMV. She was then treated with adjuvant Folfox and after completion of chemotherapy, a new CAT-scan showed that the lymph node was more necrotic but of same size as before chemotherapy. Since this was the only lesion found, we performed a laparoscopic resection of this lymph node. After close-nodal dissection we saw a transient ischemia of the descending colon, which was conservatively treated.

ABSTRACT. VIDEO CASE - A 17-year-old female patient presented to our emergency room with acute right lower quadrant pain. The pain started the day before and had grown in intensity. Physical examination, with tenderness over McBurney’s point and inflammatory laboratory values, indicated a possible acute appendicitis. The ultrasound study was inconclusive. We decided to do an explorative laparoscopy. During the filmed procedure, we discovered an intraabdominal free foreign body (a marker) which was responsible for the complaints. No stomach, rectal or vaginal perforation was found. Note: Winner of the 2015 BGES-BAST video session.

ABSTRACT. Median arcuate ligament syndrome is a rare cause of chronic abdominal pain characterized by impingement of the celiac axis by the arcuate ligament. Although there are only small series in the literature laparoscopic release of the ligament has proved feasible and is now the treatment of choice.

A 50 year-old patient with a 3 year history of postprandial epigastric pain and bloating accompanied by severe weight loss underwent extensive investigations revealing no anomaly other than an 80-85% stenosis of the celiac axis by an arcuate ligament. Other causes of pain having been excluded the patient underwent laparoscopic release of the arcuate ligament. Trocar placement was identical to a fundoplication. Main steps of this 80-minute procedure included : 1) Incision of the gastrohepatic ligament 2) Incision of the peritoneum overlying the caudal portion of the right crux 3) Lateral retraction of the lesser curvature of the stomach 4) Separation of the diaphragmatic cruces to expose the abdominal aorta cranial to the celiac axis 5) A tape is placed around the left gastric vessels that are retracted ventrally and to the right. The neck of the pancreas is retracted caudally. 6) Dissection using a cautery hook and ultrasonic device follows the left gastric artery and celiac axis to its origin on the aorta, carefully transecting all muscular, fibrous and nervous tissues overlying the artery. The initial field of dissection is rejoined and the abdominal aorta is further denuded to reveal the entire length of the celiac axis. The patient experienced immediate relief of postprandial pain and was discharged the following day.

Median arcuate ligament syndrome is a rare condition whose existence continues to be questioned. Pain may be due to postprandial splanchnic ischemia or compression of nervous plexuses by the ligament. In well selected patients laparoscopic release brings immediate and dramatic relief of this debilitating condition.

ABSTRACT. Objective:

To present a case of a symptomatic Morgagni hernia in a patient with concomitant gastro-gastric fistula after GBRY and our laparoscopic technique to repair them.

Methods:

Video presentation of our laparoscopic technique to repair a Morgagni hernia with an IPOM placed mesh and safe fixation to the diaphragm using glue. During the same procedure the gastro-gastric fistula was transected.

Results:

We present a case of a 28-year old female with a history of GBRY and simultaneous primary repair of a Morgagni hernia. She presented at our A&E with a symptomatic hernia recurrence. Imaging revealed, in addition to the hernia, a gastro-gastric fistula. A laparoscopic transection of the gastro-gastric fistula and gastric remnant resection was performed. The hernia was repaired by an augmented Dynamesh® IPOM mesh. Liquiband® Fix8™ was used to secure the mesh to the diaphragm, solving the otherwise difficult and possible dangerous diaphragmatic fixation. Due to a symptomatic trocar hernia on POD 2 a revision was performed giving us a unique view on the mesh after 2 days.

Conclusion:

We support the use of intra-abdominal glue fixated IPOM mesh to the diaphragm to repair a hernia of Morgagni. Concomitant transection of a gastro-gastric fistula seems to be safe.

ABSTRACT. * PM and EvV contributed equally to this work. BACKGROUND Pancreatic neuroendocrine tumors (pNET) are rare tumors and account for 1-2% of pancreatic neoplasms. Most of them are non-functionnal tumors and surgical treatment is the cornestone in localized disease. CASE REPORT We report the case of a 23-year-old obese (BMI 38 kg/m2) woman who presented herself at the emergency service for evaluation of an severe epigastric pain with posterior irradiation and nausea. At clinical examination, there was no tenderness, no abdominal mass at palpation and no jaundice. Biologically, glucagon, insulin, VIP, pancreatic polypeptide and gastrin were within normal range. At abdominal US and CT-scan, a mass of 7,7 cm of the distal pancreas was described. An US endoscopy and FNA were perfomed and confirmed the neuroendocrine nature of the tumor. Furthermore, there was no radiologic suspicion for loco-regional or distant metastasis. No abnormal fixation was found at octreoscan and FDG-PETscan showed a fixation of the distal pancreas, compatible with a low differentiated neuroendocrine tumor. A laparoscopic distal pancreatectomy with splenectomy and lymphadenectomy was then performed (video). Definitive pathological examination revealed a pT3 N0 (0/26 lymph nodes) well differenciated pNET grade G2 with intermediate mitotic count (3/10 HPF) and Ki67 10.6 %. Postoperative course was marked by a left basal pneumonia. One year after surgery, patient is well with no sign of local or distant recurrence. DISCUSSION We will focused on review of pNET management and comparison of open and laparoscopic approach for distal pancreatectomy.

ABSTRACT. OBJECTIVE

Laparoscopic distal pancreatectomy(LDP) is commonly performed for lesions of the pancreatic body and tail. Recent literature suggests an increase in the re-admission rate after LDP, therefore negating any gained length of hospital stay(LHS) benefit compared with open distal pancreatectomy(ODP). The intention of the study was to examine differences in hospital stay, operative time, readmission rate, early and late morbidity and mortality.

METHODS

A matched case control study was set up to analyse the difference between open and laparoscopic distal pancreatectomies in a tertiary hospital setting regarding hospital stay, operative time, readmission rate, early and late morbidity as well as 1 year-mortality rate.

RESULTS

13 LDP’s were matched and compared with 13 ODP’s interventions from a retrospectively recorded database at our department. Median age was 58 years. Sex, ASA scores, indication for resection and preoperative comorbidities were equally distributed among both groups. The LDP had significantly shorter mean operative time (226 vs.299 minutes; p=0.048) and a decreased hospital stay compared with ODP (p=0.019). Pancreatic fistula rates were comparable, with one grade C fistula in the LDP group. No significant difference was seen in the 30-day morbidity. There was a higher re-admission rate (90 days) in LDP, but the results were not significant. Patients who underwent a LDP had a significant lower late morbidity rate (after 30 days) and a higher 1-year survival rate (p=0.039 and p=0.043 respectively).

CONCLUSION

LDP has a significantly lower LHS and therefore a lower total clinical cost compared with ODP. More extended studies are necessary to investigate if the benefit of lower LHS is offset with a higher readmission rate. No significant difference could be observed in early morbidity in contrast with a higher late morbidity and a lower 1-year survival rate in patients who underwent an ODP.

ABSTRACT. Aim: Acute pancreatitis may lead to activation of the systemic inflammatory response syndrome (SIRS), causing pyrexia and tachycardia. To prevent adverse effects like antibiotic resistance or colitis, the British Society of Gastroenterology (BSG) guidelines advise against use of antibiotics unless there is an identifiable source of sepsis or more than 30% necrosis on the CT scan.

Methods: Retrospective analysis identified 110 patients diagnosed with acute pancreatitis between September 2014 to September 2015. This included patients with mild to severe pancreatitis managed on the wards and in the intensive care unit (ICU). 55 were excluded due to incorrect diagnosis or unavailable notes. Drug charts were reviewed to identify presence of and indication for antibiotic. Pathology and radiology systems were used to identify presence of positive blood cultures and necrosis on CT scans respectively.

Results: The median age of patients was 55.5 years. Of 55 patients with acute pancreatitis, 10/55(18%) had evidence of necrosis on CT. The extent of necrosis was not reported in any of these patients. 23/55(42%) were prescribed antibiotics during their inpatient stay, with pancreatitis documented as the indication in 14/55(25%). Only 6/23(46%) of patients had cultures taken, of which 2/23(33%) were positive.

Conclusion: Much improvement is needed to prevent inappropriate antibiotic prescription. Findings will be presented locally to the surgical, microbiology and radiology department. A pancreatitis proforma is being designed and will be implemented to increase awareness and ensure patients are managed more appropriately in line with the BSG guidelines.

ABSTRACT. Objective Pancreaticoduodenectomy is still associated with significant morbidity. Preoperative risk assessment and patient selection remains challenging. Frailty, a standardized measure of physiological reserve, has emerged as an important predictor of operative risk among surgical patients. This frailty index could be useful to select patients for surgical intervention. Methods All patients (n=193) who underwent a pyloric-preserving (81%) or classic pancreaticoduodenectomy (19%) for malignant lesions between 2009 and 2015 were included. Frailty was assessed by a validated modified frailty index (mFI). Primary outcome of overall morbidity, Clavien IV complications, postoperative exocrine insufficiency,displayed by the need for enzyme supplements, days of hospital stay as well as the 2-year survival were evaluated. Results The median age and BMI were 66 years and 24 kg/m² respectively. The mean American Society of Anaesthesiologists score was 2.5. The median mFI was 0.09 (range 0-0.45). As the mFI increased, the rate of overall morbidity increased. Patients with a mFI of 0, 0.09 and 0.18 or more had respectively 32.5%, 51.8% and 65.5% of overall morbidity in the first 30 days (p=0.024). Even the late overall cumulative morbidity after 30 days increased in patients with a higher mFI (33.3%, 51.9%,57.7%) (p=0.035). The proportion of Clavien Dindo IV from a mFI of 0 to 0.18 increased from 2.6% to 16.4% (p=0.005). Also the 2-year survival was inversely proportional with the mFI (mFI 0: 72.4% vs. mFI 0.18: 44.2% (p=0.004)). No significant difference was observed for both exocrine insuffiency and total hospital stay. Conclusion The frailty index is significantly associated with increased morbidity and mortality after pancreaticoduodenectomy for malignant lesions. As the population becomes older, preoperative selection to minimize morbidity and mortality is important. The frailty could be a useful tool to improve risk stratification.

ABSTRACT. OBJECTIVE Dumping is currently seen as a negative side effect of roux-en-y gastric bypass (RYGB), although it probably helps patients to stick to their prescribed diet, avoiding sweets and sugars. In this study we assess the role of dumping on weight loss in patients with conversion of failed restrictive surgery into RYGB.

METHODS Hundred consecutive patients, who had redo RYGB between 2006 and 2011 because of inadequate weight loss or band intolerance after laparoscopic adjustable gastric banding (LAGB), were analysed. Seven patients were lost to follow-up, therefore a total of ninety three patients were included. Percentage excess weight loss (% EWL) was used to objectify weight loss. The Sigstad clinical diagnostic index was used to assess dumping syndrome.

RESULTS Fifty-five patients (59.1%, mean age 43.0±10.8) were found to suffer from dumping. Overall, dumpers showed a greater %EWL than non-dumpers (83,8±48.0% vs 66.9±44.1% respectively, p=0.0725). When RYGB was performed because of inadequate weight loss following LAGB (%EWL <50% after 12 months), dumping played a key role in weight loss (88.0±21.2% vs 68.9±34.5%, p=0.0137). This effect positively correlates to post-LAGB body mass index (BMI) with a statistically significant result at BMI > 35kg/m² (82.4±15.7% vs 58.4±32.4%, p=0.00341). A regression analysis of Sigstad dumpingscore and %EWL shows that dumping tends to higher %EWL. No difference between dumpers and non-dumpers was observed when RYGB was performed only because of complications or band intolerance.

CONCLUSIONS This study provides new insights in the effect of dumping on weight loss in patients with conversion of failed restrictive surgery into RYGB. We believe early dumping in this patient group helps them to achieve a desired diet behavior modification and is as such a positive side-effect rather than a complication.

ABSTRACT. Background and aims The Roux-en-Y gastric bypass is considered as the golden standard bariatric surgical procedure. Our standardized technique of the fully stapled laparoscopic RNY gastric bypass (FS-LRYGB) was previously described and has shown a low mortality and morbidity. Small surgical and anesthesiological improvements have been implemented over the years and some complications might be further reduced. Objectives The primary objective is to analyze the short term major surgical complications. Secondly, the reduction in total complications, in leaks and in bleeding over time were analyzed. Thirdly, possible risk factors for bleeding complication were analyzed. Material and methods We counted all complications of a prospectively kept database on 10 000 laparoscopic RNY gastric bypasses performed between April 2004 and May 2015. Patients were split in 5 cohorts and total number and type of complications were analyzed. A multivariate logistic regression was used to identify the risk factors for bleeding. Results There was a successful 30 day follow-up in 98.6% (n=9855). Two patients died within 30 days after surgery (0,02%). In 195 patients there was a severe surgical related complication (1,98%), which needed a surgical revision in 80 patients (0,81%). Anastomotic leakage occurred in 7 patients (0,07%); iatrogenic bowel perforation with need for reoperation occurred in 2 (0,02%). In 156 patients there was postoperative bleeding (1,58%), which needed surgical re-intervention in 43 patients (0,44%). Lateral entrapment of the small bowel occurred in 12 patients (0,12%). In 13 patients a re-intervention was performed for other reasons (0,13%). There is a significant decrease in complications, bleedings and in surgical re-interventions for bleeding. Male gender, older age and earlier year of operation was a significant risk factor for bleeding. Conclusion This study on 10000 FS-LRYGB confirms that complete standardization and gradual implementation of surgical and anesthesiological improvements can further diminish the complication rate, particularly the risk of bleeding.

ABSTRACT. Objective Most Belgian general surgical centres lack the benchmarking tools for performance measurements. In the context of an accreditation pathway, we introduced a prospective short-term outcome registration module embedded in our electronic health records. We aimed to evaluate a means for non-academic care centres, to target opportunities for improvement by performing simple database management and analysis.

Methods Over a 14-month period (May 2014 to July 2015), 72 consecutive patients (M/F: 36/36, mean (range) age: 69 (21 - 92) years) undergoing a right hemicolectomy, were included in a prospective database. All postoperative complications were graded by the Clavien-Dindo scale. The comprehensive complication index (CCI) was calculated for all procedures following the intention-to-treat (ITT) principle.

Results Thirty-eight of 72 (53%) patients developed a complication. The overall complication rate (ITT) was 48 % vs. 75 % for a laparoscopic vs. open approach respectively (p=0.12). Two (2/12) patients died in the open approach group. Of all 60 patients undergoing a laparoscopic approach, eight (13%) were converted to an open approach. Overall complication rate for converted patients was 88%. The mean/median (range) CCI was 11.6/0 (0 – 94.8), 33.3/34.6 (0 – 72.5) vs. 37.7/28.2 (0 – 100) for laparoscopic, laparoscopic converted vs. open right hemicolectomies respectively (p=0.0012). No statistical difference in CCI was found between converted and open right hemicolectomies.

Conclusion Intraoperative conversions from laparoscopic to open right hemicolectomy are associated with worse postoperative outcomes, however not when compared to a primary open approach. Even with a high index of suspicion for conversion to an open approach, starting the procedure laparoscopically does not impair outcome.

ABSTRACT. Objectives: Advances in chemotherapy have allowed the expansion of surgical indications to treat metastatic colorectal cancers. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been used successfully in metastatic colorectal cancers. However the value and the safety of this procedure with simultaneous liver metastases (LM) resection remain controversial. The purpose of the study was to evaluate the impact of concomitant liver surgery, HIPEC and CRS on the overall complication and survival rates. Methods: From 2007 to 2015, 77 patients underwent CRS and HIPEC for peritoneal carcinomatosis (PC) of colorectal cancer. Twenty-five of them had concomitant surgery for suspicion of LM. Demographic and clinical data were retrospectively reviewed. Results: Among the 25 patients who underwent liver surgery associated with CRS and HIPEC, 2 had major hepatectomies, 6 multiple wedge resections, 16 single wedge resections (one with radiofrequency ablation), and one radiofrequency ablation. Median number of LM was 1 (range 1-3). Median Peritoneal Carinomatosis Index was 10 and 6 in the LM+PC group and the PC group respectively (range 0-26, p=NS]. Pathology confirmed LM in 21 patients; all the resections were complete. Complication rates (Dindo-Clavien ≥3) were 32.0% and 21.4% in the LM+PC group and the PC group respectively (p=NS). One patient from the LM+PC group died of septic shock after 66 days. Median follow-up was 19 months (range 3-97) and 29 months (range 0-75) in the LM+PC group and the PC group respectively. The 2-year overall survival was 59.8% in the LM+PC group and 83.5% the PC group (p=0.04) whereas the 2-year disease-free survival was 13.1% in the LM+PC group and 37.4% in the PC group (p=0.01). Conclusions: Simultaneous surgical treatment of colorectal LM and PC is safe, feasible and does not increase postoperative morbidity. Further and larger studies with a longer follow-up are needed to determine the impact on survival and patient selection.

ABSTRACT. Objective: Fistula-tract Laser Closure (FiLaC) is a novel and promising technique for the treatment of anal fistulas. It is a sphincter-saving technique where the fistula tract is closed with a radial laser diode. Our aim is to test this new technique and report our short-term results. Methods: In this retrospective study, twelve patients underwent anal fistula treatment in two stages. During a first surgery, a loose seton is inserted in the fistula tract to homogenize and reduce the diameter. If there is an underlying abscess, it is incised and drained. In a second stage, usually 4-6 weeks after the first surgery, a radial laser diode is inserted through the external orifice in the fistula tract which is then closed by applying a constant energy whilst withdrawing the fibre. The tissue shrinks due to the heat delivery and afterwards the fibrosis seals the tract. Results: After a median follow-up of 8,5 (4-12) months, we had a healing rate of 58%. Failure was observed in 5 out of 12 patients, 4 of which had a previous surgery for anal fistula or Crohn’s disease. No postoperative incontinence or complication was noted. Conclusions: Even though we didn’t reach the results of other studies, we think that this method is still a viable option as a sphincter sparing method since it is an easy method and seemingly without risk of incontinence or major complications. It is especially useful in long fistulas which involve a lot of sphincter. In case of a failure, the procedure can simply be repeated. More studies are needed to better define the indications and the methodology.

ABSTRACT. OBJECTIVE Pressurized intraperitoneal aerosol chemotherapy is a new minimally invasive technique to deliver chemotherapeutic drugs into the peritoneal cavity of patients with unresectable peritoneal carcinomatosis. We report about the practical organization and implementation of this technique and its impact on patients’ early postoperative recovery. METHODS Every practical step until the first procedure was retrospectively reviewed together with the indications to perform this technique, the number of procedures in each patient and the postoperative recovery. RESULTS To perform this kind of surgery, a specific certificate is necessary. Working with vaporized chemotherapeutics in the operation room is potentially dangerous. Therefore, an extensive checklist was made; two simulation procedures were performed; and several meetings with nurses, the department of security (for preventive actions and preparation in case of aerosol leakage in the operation room), pharmacists (for suited preparation and administration of chemotherapeutics); anesthesiologists (for patient monitoring outside the operation room and early postoperative follow-up) and a specialist of pressure injectors were necessary. No increased platinum concentrations were detected in the air during the first two procedures. Every surgery occurred uneventful. Seventeen surgeries have been performed in 11 patients, of whom 4 underwent 2 procedures and 1 underwent 3 procedures. The primary disease was cancer of colorectal (3), gastric (3), cholangio (1), esophageal (1), mesothelial (1), breast (1) and ovarian (1) origin. Postoperative recovery was uneventful except for one patient, who developed a toxic inflammation of the abdominal wall, which was successfully treated with antibiotics. CONCLUSIONS This is a new surgical procedure for the treatment of unresectable peritoneal carcinomatosis. This technique is safe for the surgical team under controlled circumstances. Its practical implementation requires extensive teamwork. The impact of this chemotherapeutic procedure on patients’ postoperative recovery is limited.

ABSTRACT. Objective: To evaluate the efficacy of sacral neurostimulation (SNS) on all symptoms of low anterior resection syndrome (LARS).

Methods: All patients who underwent sacral neurostimulation for LARS at our institution were prospectively enrolled in the study. Recruitment phase was 12 months. Patients included had been diagnosed with major LARS (30 to 42 on the LARS score) after low anterior resection (LAR) and were unresponsive to conservative therapy. Diagnostic work-up included manometry and colpo-cysto-defaecography, LARS and Wexner scores.

Results: Eight patients underwent implantation of the SNS device. With neurostimulation, patients showed a substantial decrease in their Wexner scores: the median score was reduced from 19.0 to 3.0 (p=0.012). Median LARS score dropped from 40.0 to 9.5 (p=0.012). Incontinence significantly declined from 7.0 to 4.0 (p=0.028) and incontinence for liquid stool dropped from 3.0 to 0.0 (p=0.018). Frequency of bowel movements significantly decreased from 3.0 out of 5, to 0.0. (p=0.017), clustering of stools significantly decreased (p=0.012) and decreased (p=0.012).

Conclusion: Our study shows that SNS is effective for all symptoms of LARS: both fecal incontinence and the outcome for fragmentation and urgency showed a significant improvement.

ABSTRACT. Objective The efficacy of radiotherapy (RT) depends on the presence of molecular oxygen. Several lines of evidence suggest that anti-angiogenic therapy ‘normalizes’ tumor microvascular structure and function, leading to improved blood supply, oxygenation, and RT efficacy. Here, we examined whether Cediranib, a pan–VEGF receptor tyrosine kinase inhibitor, improves microvascular function and tumor control in a mouse colorectal cancer model. Methods CRC xenografts (HT29 cells) were induced in dorsal skinfold window and. Mice were treated for 5 days with vehicle, RT (1.8Gy daily), Cediranib (6mg/kg PO), or combined therapy. Functional and structural vascular changes, as well as tumor growth, were analyzed using intravital microscopy (IVM), DCE-MRI, probe measurements (interstitial fluid pressure (IFP) and oxygenation (O2)) and immunohistochemistry. Results Tumor growth in the combination group was significantly delayed (P < 0.0001) compared to controls or monotherapy (Fig1), with a tumor doubling time of 13.16 days with RT versus 27.13 days with combination treatment. Addition of cediranib to RT led to an increase in apoptotic rate (IHC) and decrease in proliferation rate (IHC) in comparison to RT alone. Furthermore, IVM analyzes showed that VEGFR-inhibition with cediranib led to a microvessel normalization with decreased microvessel permeability (p<0.0001), tortuosity (p=0.0066) and a trend to decreased vessel diameters. Conclusions The combination of external RT with the VEGFR-inhibitor Cediranib enhances tumor control in a colorectal xenograft mouse model. The imaged structural and functional vascular changes elucidate the concept of vascular normalization and its potential therapeutic window.

ABSTRACT. Objective: To assess the impact of the addition of monoclonal antibodies to the cytotoxic chemotherapy regiment in colorectal liver metastases (CLM) on the pathological changes related to chemotherapy.

Background: Standard chemotherapy used in the treatment of CLM is known to induce significant pathological injury in non-tumoral liver parenchyma. The addition of Bevacizumab, a monoclonal antibody, has been reported to have a protective effect on sinusoïdal lesions related to Oxaliplatin administration.

Methods: One hundred patients who underwent liver resection for at least one segment for CLM were prospectively enrolled in a multicentric study between 2012 and 2015. Patient’s clinical data including administered chemotherapy, tumor stage and post-operative morbidity were collected. A centralized analysis of the non-tumoral liver parenchyma was performed by a single specialized liver pathologist. Steatosis, Steatohepatitis, Sinusoidal Obstruction Syndrome (SOS) and Nodular Regenerative Hyperplasia (NRH) were graded.

Results: SOS and NRH are found to be strongly correlated with the administration of chemotherapy especially Oxaliplatin. Bevacizumab was confirmed to have protective effect on the liver with lower incidence of SOS related to Oxaliplatin. The overall incidence of SOS has decreased overtime (13% in the 2012-2015 period vs 44% in the 2000-2010 period; p< 0.001). This finding correlates with the more frequent use of Bevacizumab in addition to Oxaliplatin (27% in the 2012-2015 period vs 7% in the 2000-2010 period; p<0.001). There were strong correlations between grade 2 and 3 NRH and post-operative complications, especially those related to liver dysfunction following even minor liver resections.

Conclusions: Bevacizumab was found to decrease the incidence of SOS secondary to Oxaliplatin in patients with CLM. Incidentally we found that the rate of NRH was underestimated and had strong correlation with severe complication after liver resection.

ABSTRACT. Background :

Abdominal vacuum-assisted closure is nowadays a useful option for non-closable abdomen following sever septic condition. A skin graft is afterwards needed to cover the bowels but this creates a large abdominal wall defect.

Methods :

We describe a new modified parietal reconstruction with intra-peritoneal polypropylene mesh. We use the hydrosurgery technology to preserve the full-thickness skin graft previously used to cover the defect. This graft preservation grants a protection for the underlying mesh in order to reduce the infectious risk and get a better abdominal wall reconstruction. We applied hydrosurgery to desepithelialise the internal graft in order to enhance a better adhesion of overlying subcutaneous tissue and thereby avoid the development of seroma.

Results : Good fonctionnal outcomes were obtained with this wall reconstruction with a good healing and no recurrence or seroma.

Conclusion : The use of hydrosurgery after a partial skin graft internalization in the management of important abdominal wall defect covered with a mesh seems promising. However, further investigations need to be led to corroborate this observation.

ABSTRACT. INTRODUCTION: Neuroendocrine tumors (NETs) are defined as epithelial neoplasms with predominant neuroendocrine differentiation. They can arise in most organs of the body. It is well known that the liver is a common site for metastasis. However, primary hepatic NETs are extremely rare, with only 150 cases reported in the literature. The diagnosis is based upon both the histopathological confirmation and the exclusion of extrahepatic disease.

CASE PRESENTATION: A 22-year-old woman presented with acute epigastric pain. A gastroscopy was performed and demonstrated gastro-oesophageal reflux disease. However, non-invasive imaging with ultrasound and MRI showed a hypervascular lesion with focal hemorrhage located at the right hepatic lobe, suggesting a hepatocellular adenoma. The maximum diameter of the mass was 4,8 cm and in close relationship with the anterior and posterior branches of the right portal vein. Due to the symptomatic presentation and the manifestation of focal hemorrhage, the indication for resection was made. Preoperative assessment of liver function showed a reduced mebrofenin uptake rate at the left hepatic lobe, therefore surgery was preceded by a portal vein embolization of the right liver. A right hepatectomy was performed. Surprisingly, histopathological examination revealed a neuroendocrine tumor, grade 2 with immunohistochemically positive staining for chromogranin-A and synaptophysin. Surgical margins were free. Postoperatively, a whole-body PET with Ga-DOTA-D-Phe-Tyr-octreotide did not show an occult primary tumor, so the final diagnosis of a primary hepatic NET was made. Follow-up with MRI, chromogranin A serum levels and Ga-DOTA-TOC scan showed no recurrence at 1-year follow-up.

CONCLUSION: Because of their low incidence and their nonspecific clinical presentation, primary hepatic NETs are often diagnosed at an advanced clinical stage. Pathological examination, often after resection, remains the golden standard for diagnosis. Surgical resection remains the mainstay of therapy.

ABSTRACT. Objective To analyze early postoperative outcomes after laparoscopic common bile duct exploration (LCBDE) for common bile duct stones.

Methods All 69 consecutive patients (M/F: 29/40, median age (range): 65 (15 – 92) years) undergoing LCBDE from September 1st 2013 to 11th of March 2016 were analyzed. Two patients were excluded because of other indications for LCBDE: common bile duct injury (n=1), dysplastic choledochal polyp (n=1). Complications were registered in a prospective fashion and graded using the Clavien-Dindo classification and Comprehensive Complication Index.

Results Sixty-seven (97%) of 69 patients underwent LCBDE for the managment of common bile duct stones. Patients were admitted with cholecystitis, cholangitis or pancreatitis in 40%, 6% and 11% of cases respectively. A transcystic approach and choledochotomy was used in 35 (52%) and 32 (48%) patients respectively. Patients had a previous laparotomy in 15/67 (22%). In ten (15%) patients a history of previous Roux-en-Y was present. Two patients were converted to laparotomy. Stone clearance was succesful in all but one patient (99%). Median (range) operating time was 105 (45 – 240) min. Major complications (Clavien-Dindo grade >or= 3b) occured within 90 days postoperatively in 5 (7%) patients: bile leak (n=3), cholangitis (n=1), pancreatitis (n=1). Median (range) comprehensive complication index (CCI) was 0 (0 – 42.4). Median (range) postoperative length of hospital stay was 2 (1 – 13) days. Two (3%) patients were readmitted within 30 days of surgery.

Conclusions LCBDE for common bile duct stones is a highly effective procedure with a low postoperative risk of complications.

ABSTRACT. Abdominal aortic aneurysms are a quite common and potentially life-threathening finding. Treatment of AAAs consists of surgical repair. After decades of open surgery being the gold standard, endovascular aneurysm repair (EVAR) now has become the most common procedure in elective AAA repair. Despite its minimally invasive nature, EVAR, like open surgery, is not free of rare, though serious complications. We report a case of spinal infarction with atypical presentation following EVAR-procedure (i.e. paraparesis with completely intact sensibility). With a short steroid cycle and sustained hypertension, a moderate improvement in neurologic outcome was achieved.

ABSTRACT. Abstract Purpose Early type I endoleak is the most common complication after endovascular repair with chimney (Ch-EVAR). Although managed conservatively in 70% of the cases, treatment imposes when the diameter of the aneurysm increases. Several treatment options have been reported, ranging from open repair to endovascular repair such as endoanchors of embolisation by coils, glue or Onyx. We report a case of successful repair of a type Ia endoleak after Ch-EVAR by b-EVAR (branched endovascular repair). Case report A 79-year old gentleman underwent in 2011 an elective repair of a juxtarenal aneurysm by an endovascular prosthesis with chimney (Gore Viabahn Endoprosthesis) in the left renal artery (LRA). Postoperative imaging showed a type I endoleak, which remained stable for 4 years. After 4 years, diameter of the aneurysm increased, due to proximal extension of disease, and treatment imposed. Since none of the forementionned repairs were suitable, a custom-made multibranched aortic endograft (X – tra design, Jotec) with four branches (the celiac trunk (CT), the superior mesenteric artery (SMA), the right renal artery (RRA) and the chimney graft (CG)) was designed. Postoperative imaging after BEVAR showed a type II endoleak originating from a lumbar artery and resolution of type Ia endoleak, with four patent branches. Conclusion Type 1a endoleaks after Ch-EVAR can be treated effectively with a branched aortic endograft (b-EVAR) in selected cases.

ABSTRACT. Objective: To present an endovascular approach for the treatment of a bilateral deep femoral artery aneurysm.

Methods: A 74-year-old male patient was referred to our department due to an asymptomatic pulsatile mass in both groins. This was an incidental finding in the preoperative assessment before cardiac surgery (coronary artery bypass graft (CABG) and ascend-ing aortic aneurysm replacement). The patients history revealed a transient ischemic attack (TIA), resection of a cholangiocarcinoma and arteritis temporalis. Duplex ultrasound demonstrated a bilateral deep femoral artery aneurysm; Computed tomography (CT) angiography confirmed these findings. The maximal diameters of the left- and the right-sided aneurysm were measured to be 50 mm and 30 mm respectively. A staged endovascular approach was preferred. First, the left-sided aneurysm was treated. Surprisingly, the distal outflow of the aneurysm had thrombosed. The deep femoral artery aneurysm was coiled, and the origin of the vessel was sealed with an Amplatzer vascular plug. The right-sided aneurysm was treated using a covered stent.

Results: Endovascular treatment of both deep femoral artery aneurysms was successful. The postoperative course was uneventful and a control CT angiography showed exclusion of both aneurysms.

Conclusions: A true deep femoral artery aneurysm is a rare clinical entity. A bilateral deep femoral artery aneurysm is even more exceptional. Most patients are asymptomatic, although pain, rupture and acute limb ischemia have been documented as presenting symptoms. Several open surgical (ligation, replacement with interposition graft) and endovascular (coil embolisation, covered stent) therapeutical strategies have been proposed. Treatment seems to be indicated regardless of the diameter of the aneurysm, due to the the risk of rupture or limb ischemia. Endovascular treatment appears to be an appropriate and less invasive treatment for deep femoral artery aneurysms.

ABSTRACT. Objectives: Evaluate the advantages of a hybrid operating room against a mobile fluoroscopic C-arm during fenestrated graft Endovascular Aortic Aneurysm Repair (f-EVAR).

Design: A retrospective analysis of prospectively collected data.

Material and methods: A single-center study where patients treated with f-EVAR for infra-, juxta-, suprarenal aneurysm or type IV thoracoabdominal aneurysms were identified between January 2006 and November 2014. Primary endpoints were 30-day mortality, deterioration of renal function, radiation exposure, peri-operative complications and target vessel patency. Secondary endpoints were endoleak rate and re-interventions. Most analyses were performed using Statistical Package for the Social Sciences (SPSS V 20.0). Survival analysis has been using the Kaplan and Meier method.

Results: 74 Patients were treated (75,5 ± 6,1 age, 89,2% male), 50 (68%) by a mobile C-arm and 24 (32%) in a hybrid operating room. The 30-day mortality in the C-arm group was 6% and 0% in the hybrid room. Kaplan-Meier curves revealed no significant difference between the 2 groups (p=0.32). There was no significant discrepancy observed for radiation exposure (p=0.43), peri-operative complications (p=0.19), target vessel patency (p=0.30) and re-interventions. Technical success rate was not significantly higher (p=1.00) for the hybrid room. Median operation time and fluoroscopy time was 180, 48.5 minutes in the C-arm group and 165.5, 40 minutes in the hybrid group (p=087; p=0.56), respectively. Statistically significant difference among these groups was only found in the median contrast dose (p=0.01), without affecting post-procedural renal insufficiency (p=0.07).

Conclusions: Contrast dose in f-EVAR is significant lower with a fixed angiographic system than with a portable C-arm. There is a trend of lower operating and fluoroscopy time, better technical rate and lower mortality rate in the hybrid group, without statistical significance. Further studies are mandatory to recommend complex endovascular procedures performing only in hybrid operating rooms.

ABSTRACT. OBJECTIVE

We describe a case of a 48 year old patient presenting an asymptomatic inferior pancreaticoduodenal artery aneurysm associated with a celiac axis stenosis and treated by endovascular approach (coils and stent).

METHODS

Percutaneous right femoral artery access (Seldinger) was employed. We performed an aorto-celio-mesenteric angiography and a selective catheterization of the superior mesenteric artery for angiography. The aneurysm was identified with its afferent neck arising directly from the proximal segment of the superior mesenteric artery. The efferent neck is in communication with an hypertrophic inferior pancreaticoduodenal arcade that is visible by retrograde blood flow confirming the existence of a celiac axis stenosis. We then catheterized the aneurysm with a 5 Fr. Terumo and deployed a 8mm diameter coil to close the afferent neck. Thereafter 3 coils of 8 mm and 8 coils of 5 mm diameter were placed into the aneurysm to ensure its embolization. Finally, a self expandable stent was deployed into the proximal superior mesenteric artery covering the afferent neck. The post-procedure angiography shows an occlusion of the aneurysm sac and patency of the superior mesenteric artery and inferior pancreaticoduodenal arcade.

RESULTS

The post-operative course was excellent and the patient left hospital at day one post-procedure with an anti-platelet treatment.

After six-months follow up, the patient remains asymptomatic and an injected CT-Scan confirms thrombosis of the aneurysm whereas the superior mesenteric artery and inferior pancreaticoduodenal arcade remain patent.

CONCLUSIONS

Inferior pancreaticoduodenal artery aneurysm is uncommon with an incidence of almost 2 % of all visceral arterial aneurysms. It is usually incidentally detected but the mortality rate after rupture remains high (40 to 60%). A selective angiography or an injected multislice CT-scan is necessary for the diagnosis. Given that surgery should be difficult due to the hazardous anatomy, endovascular approach seems to be the best choice when feasible.

ABSTRACT. Objective With a frequency ranging between 2 and 41%, superficial and deep surgical site infections (SSI) are the most common complication after ileostomy closure. No consensus exists on the optimal type of fascial, subcutaneous fat and skin closure. Our aim was to analyse complications after ileostomy closure at our institution.

Methods A retrospective analysis was performed of 41 consecutive patients (M/F: 27/14, mean age (range): 64 (30–89) years, mean BMI (range): 25 kg/m2 (21-34) undergoing ileostomy closure at a non-academic teaching hospital during a nine-month time period. Data were collected through a specially designed drop-down-menu software application receiving input immediately post-surgery, on discharge, on day 21 revision and on day 90 after discharge. All postoperative complications within 90 days postoperatively were graded by the Clavien-Dindo scale. The comprehensive complication index (CCI) was calculated for all procedures. Type of anastomosis, fascial closure, subcutaneous drains and skin closure technique were left to the discretion of the surgeon. The primary endpoint was SSI. Secondary endpoints were fascial dehiscence and total length of hospital stay.

Results SSI were found in 7 of 41 (17%) patients undergoing ileostomy closure: superficial incisional SSI (n=2), deep incisional SSI (n=3) and organ/space SSI (n=2). Fascial dehiscence was observed in 2 patients. Other complications were prolonged ileus (n=2), urinary retention (n=1) and leakage of the blind loop of a colonic pouch (n=1). There was no anastomotic leakage in this series. Grading of complications identified 8 minor (TOSGS grade I - IIIa) and 4 major (TOSGS grade IIIb - IV) complications. Median (range) CCI was 0,0 (0,0 – 42,4). Median (range) length of hospital stay was 4 days (3 – 30).

Conclusion The high rate of SSI after ileostomy closure was in line with the surgical literature and leaves room for preventive therapeutic measures.

ABSTRACT. AIM : To evaluate the effect of an aggressive approach for the treatment of locally advanced gastric adenocarcinomas, using HIPeC after radical extended resection .

METHODS : Between April 2008 and September 2015, 16 patients with locally advanced gastric carcinoma was selected for extensive total gastrectomy and HIPeC. 2 patient's were rejected because of an extensive peritoneal carcinomatosis. Seven women and seven men were then concerned. Average age of 53years old. All patients presented at least an usT3N1Mx cancer. Twelve patients received neo-adjuvant chemotherapy. All the patients were treated with a D2-total gastrectomy and for 5 of them, a duodenopancreatectomy had to be added for the removal of positive lymph nodes. An adjuvant chemotherapy was also performed after surgery in 6 patients (42,85%). One patient underwent a second HIPeC for recurrence, 16 months after the first one.

RESULTS : The mean interval between diagnosis and surgery was 5,86 months (0-16).At the time of operation, PCI was low (1 ranging from 0 to 10) since severe peritoneal carcinomatosis was excluded. There were two in-hospital deaths (14,2%) due to liver acute failure for one and severe pancreatitis followed by multiple organ failure for the second one. On histology, five adenocarcoinomas were of the diffuse type, eight of the intestinal type according to Lauren classification. One patient presented a full response to prior chemotherapy, as no tumor was found on specimen. On average, 22 lymph nodes were harvested per procedure. Mean hospital stay was 23,31 days (5-60). Morbidity was encountered in 43% of the patients. The mean survival after procedure was 33,4 months (ranging 0-75 months). Five patients are alive without disease (9 – 121 months) while two are on palliative chemotherapy.

CONCLUSION : Despite a high morbidity, such approach can procure a significant survival for T3N1 – T4 gastric cancer.

ABSTRACT. AUTHORS : J. DELSA, J.M. WEERTS,FRCS Eng , G. SCORCE, D. FRANCART, C. JEHAES, B. MONAMI, Ch. WAHLEN, S. MARKIEWICZ

AIM : To evaluate the results and the quality of life of patients presenting an advanced colorectal carcinoma (CRC) treated by debulking surgery and HIPeC .

METHODS : Twenty-three out of twenty-nine consecutive patients' records were fully analysed in terms of surgery performed, morbidity-mortality rate, follow-up in terms of survival and quality of life (QOL). The patient presented with an advanced CRC.

RESULTS : 23 patients (F : 14, M : 9) with a mean age of 59 (ranging 40-74) were treated for an advanced colorectal cancer : 65,2% of Stage IV, 17,4% of Stage III, 17,4% of Stage II. The majority were moderately differentiated adenocarcinomas (78,2%). Almost all of the patients encountered a neo adjuvant chemotherapy prior to their debulking surgery. The mean PCI was evaluated at the time of surgery at 4.3 (0-12) ; all the procedures were performed with the intention to treat and a R0 resection was always completed. The mean duration of surgery was 6 h30. Oxaliplatin was the main intraperitoneal antimitotique agent used for a duration of 30 minutes. The post operative period was uneventful for 74% of the patients with a mean hospital stay of 13 days. Global morbidity was up to 30.4%, increasing the hospital stay for these patients to 20, 4 days. One month post-operative mortality was 4.3% (pulmonary embolism). The rate of recurrence at 6 months was 43, 7% , the one at 1 year, 52, 1%. Four patients are free of disease at 2 years. The global survival rate at 3 years is 70% and 42,8% at 5 years. The QOL of the surviving patients is under evaluation at present.

CONCLUSION : The first results of this aggressive approach is in concordance with the literature and will be evaluated in a larger series.

ABSTRACT. Objective Hiatal hernia is a rare but morbid complication after esophagectomy. Since the increased survival of esophageal cancer, the incidence of hiatal hernias after esophagectomy (HHAE) rises. Mounting evidence also suggest that hiatal hernias are more common following minimally invasive esophagectomy. The aims of this study were to define the incidence and presentation of HHAE in our population and its correlation with type of esophagectomy, tumour status at diagnosis and pre-operative chemo- and/or radiotherapy. Methods A retrospective monocentric cohort study was performed (11/2000 - 04/2015). In order to determine whether HHAE occurred, all pre- and post-operative computed tomography images and radiology reports were reviewed. Additionally the type of surgery, tumour status and oncological treatment were reviewed. Results Of all 73 patients reviewed 6 (8.2%) developed HHAE after initial surgery. The mean time between esophagectomy and diagnosis was 9,2 months. All hernias occurred into the left chest. They contained mostly colon and small intestine. Five patient had pre-operative chemoradiotherapy, one only had chemotherapy. These 6 patients all underwent a partial esophagectomy by laparoscopy and right thoracotomy. Tumour stage at moment of diagnosis was stage II B or higher. pTNM varied from pTisN0 to pT3N1. Three patients were symptomatic (obstruction) and needed surgery for hernia repair (2 urgent and 1 elective). Conclusion Hiatal hernias after esophagectomy are more common than assumed. The incidence rises as more minimally invasive surgery is performed. HHAE are mostly present at the left side. Considering they can be associated with high morbidity (incarceration and strangulation), early recognition is important and immediate repair is recommended.

ABSTRACT. Objective Functional problems following sphincter-preserving resection including bowel (low anterior resection syndrome; “LARS”), sexual and urinary dysfunction are underestimated. Symptoms are accepted and patients are lost to follow-up without treatment. We aim to review the literature for predisposing factors of functional outcome after LAR so patients can be informed about this late complication and its treatment.

Methods Review of the literature using EBM-practicenet, NICE, NHG, HAS, SIGN, NCCN and Cochrane library was performed with emphasis on incidence, risk factors and treatment methods.

Results Bowel dysfunction (LARS) is encountered in 40-46% of all patients following low anterior resection (LAR). Mentioned risk factors are radiation therapy, female sex, TME compared to PME, younger age at surgery and postoperative complications (especially anastomotic leakage). Possible treatments vary from medication (loperamide), pelvic floor rehabilitation and feedback training with trans-anal irrigation to interventional methods (incl. surgery and neurostimulation). Female sex is a clear risk factor for voiding dysfunction in general. Approximately 33-51% of all patients develop (stress-) incontinence, depending on the criteria used. In a study of 785 patients, 26% had difficulty with bladder emptying. Symptomatic treatment is advised. Sexual dysfunction after LAR is seen in 39-76% of all patients. Poor physical condition at the moment of surgery (ASA status ≥ III) is the main risk factor. Older age and history of neo-adjuvant therapy are also clinically relevant. In general, symptomatic treatment is advised.

Conclusion Bowel (LARS), voiding and sexual dysfunction are frequently seen after LAR. Pro-active assessment of risk factors should be performed preoperatively in order to inform patients about the occurrence of this late complication and the treatment modalities.

ABSTRACT. Introduction: A revisional procedure by biliopancreatic limb lengthening can be considered for well-selected patients with insufficient weight loss after gastric bypass.

Methods: The prospective data of a single center experience are reported. Surgical technical details consists of measuring both alimentary and biliopancreatic limb, transecting the alimentary limb just proximal to the enteroenterostomy and making a new side to side anastomosis much more distal at the biliopancreatic limb. Depending on the existing length of the alimentary limb, the new common limb is counted until a total limb length of 300cm is reached. In no circumstances a common limb length of less than 100cm is accepted.

Results: From January 2014 until now, 30 patients were operated. Mean age was 46.5 years with a M/F ratio of 1/5. Mean BMI preoperatively was 41 kg/m². Mean BMI before initial RNY bypass was 50.6 kg/m² with 16/30 (53%) of the patients in the superobese group (BMI > 50kg/m²). Mean time between RNY and distalisation procedure was 79 (37-183) months. There was one conversion to open surgery because of extensive adhesions and one relaparoscopy for an iatrogenic perforation of the small bowel. Mean length of stay in the hospital was 2.19 nights (1-6). After a mean follow-up of 10.5 (3-20) months a mean BMI of 34.17 kg/m² is noted with a mean %EWL of 55.33%. 13/30 patients suffered from diarrhea, generally controllable with loperamide. One patient needed a conversion because of severe malnutrition and hypoalbuminemia. Two patients with heavy diarrhea and consequently social isolation, are considering a conversion.

Conclusion: For patients with weight regain after a RNY, a conversion to a distal RNY bypass can be considered. In our group of 30 patients substantial additional weight loss was achieved with a short follow-up. However, long-term results should be awaited including the evolution of important side effect as diarrhea and hypoproteinemia.

ABSTRACT. Objective The aim of this study is to evaluate the presently available fixation devices used for laparoscopic ventral hernia repair (LVHR). Evidence on both permanent and resorbable fixation is reviewed as well as atraumatic fixation options such as cyanoacrylate glues. Methods An extensive literature search was performed in the PubMed database from its onset until Februari 2016. The primary focus is to give an update regarding the use of new fixation devices in laparoscopic ventral hernia repair. We evaluate the use of resorbable tacks as well as cyanoacrylate glue as single mesh fixation device. Fixation strength is described as are possible side effects and the impact on postoperative pain and recovery. Results

Permanent fixation devices such as titanium tacks provide greater fixation strength (31.98 N/cm2) than absorbable devices on short-term evaluation, while at long-term equal fixation strength was observed for Sorbafix® (29.56 N/cm2) and Protack® (27.77 N/cm2). Absorbatack® is the only tack that had resorbed after six months. Recent data suggest that absorbable tack fixation is associated with higher risk of hernia recurrence than non-absorbable tacks. However, possible morbidity has been reported for permanent tack fixation such as tack migration and erosion. So far, no clinical study could prove an improvement regarding postoperative pain when using absorbable devices. The use of cyanoacrylate glue can guarantee a solid mesh fixation in small fascial defects. Application of the glue might be challenging but if well positioned, burst strength testing exceeds 100N in all our samples. Its use is safe, with little side effects, and preliminary data suggest reduced postoperative pain compared to the conventional fixation devices.

Conclusions In an experimental set-up both resorbable tacks and cyanoacrylate glue succeeded in their goal to keep the mesh well-positioned to the abdominal wall. Larger clinical studies are needed to investigate their impact on postoperative pain and patient welfare.

ABSTRACT. Objective: Aortic valve Cusp restoration frequently requires tissue substitute to the cusp tissues for anatomic and physiologic restoration. Principally any biocompatible material is a suitable substitute, however the main concern is durability and growth potentials. Porcine small intestinal submucosal extracellular matrix (SIS-ECM: CorMatrix®, CorMatrix Cardiovascular, Roswell, Ga) is newly available biomaterial for cardiac repair. It promotes regeneration, growth, and resistance to failure mechanisms. We report bicuspidization of severely stenotic unicuspid aortic valve, in a 12 years old boy, using CorMatrix® patch.

Mathods: Our patient presented with congenital aortic valve stenosis, treated with balloon valvoluplasty during infancy, which progressed into sever asymptomatic aortic valve stenosis. Echocardiography showed dysplastic severely stenotic aortic valve with complete fusion of the commissure between the right and the non coronary cusps. Peak and mean gradient were 86/61 mmHg, with good biventricular function. Surgically, we opened the raphe between the right and left commissure, shaved the cusps and resected the commissure between the left and the non-coronary one. We used a triangular patch of hydrated 4-ply CorMatrix sheet, to create a 180°/180° bicsupid aortic valve. Results: Surgery was uneventful and immediate surgical and echocardiographic results were satisfactory. Discharge Echo revealed mild residual aortic regurgitation with peak gradient being 17mmHG. Follow up is over three years, and serial clinical and echocardiogic studies showed asymptomatic, and normally growing boy, with stable well-functioning repaired aortic valve, without any change in leaflet size, integrity , function, or progression of post-operative mild insufficiency.

Conclusions: Bicuspidization and reconstruction of stenotic unicuspid aortic valve, using CorMatrix patch is feasible. The material is thin and pliable, and aids the complexity of the procedure. It support satisfactory immediate surgical and echocardiographic results and stable growing functional dynamics. It could potentially possess new characteristics that would make it a reasonable alternative to currently used pericardial patches for pediatric patients.

ABSTRACT. Objective: Nodal staging, a major prognostic factor in colorectal cancer (CRC), is used to determine which patients should receive adjuvant chemotherapy. Indocyanine green fluorescence imaging (ICG-FI) represents a promising technique for improving nodal detection through identification of sentinel lymph nodes (SLNs). The aim of this study was to evaluate the role of ICG-FI in SLN detection compared to the standard ‘blue dye’ technique. Methods: Twenty patients with CRC admitted for elective colectomy were included (NCT01995591). Ex vivo SLN detection was performed successively using patent blue (PB) (2 ml) and free ICG (0.5 mg/ml-2 ml) injected around the tumor, intraserosally. Results: Both techniques resulted in identification rates of 95% (19/20). Sensitivity was 43% for the PB technique and 57% for ICG. Correlation between the techniques was 83%. FI was more sensitive in patients with BMI >25. Serial sectioning with hematoxylin/eosin analyses of blue and/or fluorescent LN(s) did not allow upstaging of patients. Three patients had occult micrometastases detected by immunohistochemistry in fluorescent SLNs. Conclusions: The use of ICG-FI is superior to the blue dye technique in patients with BMI >25. However, the sensitivity of ICG-FI in SLN detection remains low with a high rate of false negative results.

ABSTRACT. Objective: Therapeutic decision-making concerning the use of neoadjuvant and adjuvant chemotherapy in peritoneal carcinomatosis (PC) of colorectal cancer (CRC) origin is often difficult. The objective of this study was to evaluate the attitudes of Belgian oncologists with regard to the role of chemotherapy in this setting. Methods: An anonymous survey including 5 questions about the use of neoadjuvant and/or adjuvant chemotherapy was sent by mail to 65 Belgian oncologists. Results: Actually, 22 oncologists responded to the survey. A total of 56.5% reported being involved occasionally (1-15 patients/year) and 43.5% frequently (>15patients/year) in making therapeutic decisions regarding PC of CRC origin. Systemic neoadjuvant chemotherapy would be recommended by 39% and not recommended by 61%. Interestingly, 39% would propose systemic adjuvant chemotherapy, 30.4% would propose chemotherapy in cases of response to neoadjuvant chemotherapy, and 30.4% would never propose adjuvant chemotherapy. Fifty-two percent of oncologists reported that their decisions were based on specific evidence in the literature, while 52.2% based decisions on similar clinical situations, and 4% did not have a basis for their decisions. A majority of oncologists, 91%, agreed that decision-making in this setting is never easy and that more clear recommendations are needed. Conclusions: Preliminary results of this survey show that the use of neoadjuvant and adjuvant chemotherapy in resectable patients with PC of CRC origin varies and that the majority of oncologists need more clear recommendations.

ABSTRACT. Objective: Cytoreductive surgery (CRS) of locally advanced ovarian cancer has evolved in the last few years from surgery to remove macroscopic residual disease (<1cm; R2b) to complete macroscopic surgery with no gross residual disease (R1). Several studies have demonstrated the prognostic role of maximalist surgical treatment. Nevertheless, several authors have expressed doubts about the benefit of such an aggressive surgical attitude. The aim of this study was to evaluate the impact of the adoption of a maximalist surgical approach on patient prognoses.

Methods: This was a retrospective study using prospectively collected data on patients who received either conservative or aggressive surgical treatment for primary ovarian cancer stage IIIc/IVa between January 2006 and June 2013.

Results: Data for 101 patients were evaluated. Median age was 59.5 years (range 31-89 years). Average disease free survival (DFS) for the patients who underwent R1, R2a (<2.5mm), and R2b (>2.5mm) surgery was 22 months, 9.7 months, and 6.8 months, respectively (p=0.002), and overall survival was 86 months, 43 months, and 27.5 months, respectively (p=0.002). Surgical perioperative Clavien grade 3/4 morbidity and mortality were the same in both groups (aggressive vs conservative) at 13.2% vs 15.2% and 0.99% vs 1.98%, respectively.

Conclusion: The adoption of an aggressive surgical attitude using complete cytoreductive surgery has a direct impact on ovarian cancer patient prognoses improving both DFS and OS without increasing morbidity and mortality.

ABSTRACT. OBJECTIVE: Malignant bowel obstruction (MBO) represents the second most frequent cause of intestinal obstruction. MBO may be due to the primary tumor and/or secondary to peritoneal carcinomatosis (PC). Few publications have focused on therapeutic management of PC-related MBO. The aim of this study was to evaluate the actual therapeutic care of PC-MBO.

METHODS: This was an observational prospective study including patients admitted for PC-MBO between August 2014 and March 2015. A dedicated person examined the patient at admission and evaluated symptom evolution during hospitalization at different time points with the Symptom Assessment System Questionnaire (ESAS-R) for each consenting patient as a function of the adopted therapeutic treatment (conservative vs interventional).

RESULTS: Nineteen patients (2 men, 17 women) with a median age of 61 years were enrolled, representing a total of 40 hospitalizations for PC-MBO episodes. PCs were from colorectal and gynecological origin in 42.1% and 57.9%, respectively. Eighteen patients were treated with palliative intent and 1 with potentially curative intent. Seventeen patients received conservative treatment including corticotherapy for 13 patients (77%). Conservative treatment was effective in 7 patients (54%) but 6 patients needed further interventional treatment. Two patients were treated with immediate surgery. Patients treated successfully with initial conservative treatment (including corticotherapy) tended to require additional medical therapy after the third MBO episode. Nasogastric tube and parenteral nutrition did not improve the symptomatology of patients treated conservatively.

CONCLUSIONS: PC-MBO appears mostly in patients with digestive and/or gynecological PC who were treated with palliative chemotherapy and had not received previous curative surgical treatment. Conservative treatment, including corticotherapy, is effective in the first 3 episodes but becomes ineffective thereafter, necessitating further interventional treatment.

ABSTRACT. OBJECTIVE A case report of a symptomatic unruptured aneurysm of the infrarenal aorta after endovascular aneurysm repair (EVAR) due to a late type Ia endoleak, treated by a endovascular ‘chimney’ procedure, is presented in relation to the current literature.

METHODS We report a case of a 67 year old men, three years after EVAR for an infra-renal aneurysm, who presented on the emergency departement with acute abdominal pain, irradiating to the back and groin bilaterally. A graft related complication was not suspected until additional executed abdominal ultrasound revealed an increase in diameter of the aneurysm sac. Subsequent Computed Tomography Angiography showed a new derived type Ia endoleak with enlargement of the aneurysm sac, without extravasation. An endovascular ‘chimney’ procedure was performed with placement of a covered stent in a low tributary right renal artery in addition to a proximal graft extension.  To review the literature we performed a pubmed search concerning the incidence, causes and treatment options of symptomatic aneurysm and late aneurysm rupture after EVAR.

RESULTS Symptomatic aneurysm or late aneurysm rupture is a rare (< 1%) complication after EVAR. The predominant causes are endoleaks, in particular type I en III endoleaks. A large proportion of these cases can be treated by endovascular methods, which are associated with lower mortality compared with open surgical repair (21% vs. 37%). A chimney procedure is a viable emergent available treatment option for type Ia endoleak, as an alternative to the custom made fenestrated and branched endografts. 

CONCLUSION Consistent lifelong surveillance after EVAR is essential for early detection of stent graft failure and prevention of late complications such as aneurysm rupture.

ABSTRACT. Objectives: We hypothesize that porcine small intestinal submucosal extracellular matrix (SIS-ECM; CorMatrix®, CorMatrix Cardiovascular, Roswell, Ga) may have advantages over other pericardial patches used for aortic valve repair, by remodelling to resemble the native aortic cusp, complete biodegradation with replacement by host normal cells and tissues, in addition to having a durable and strong architecture. This study aimed to test the surgical feasibility, physiological function, remodelling behaviour, and outcomes of CorMatrix as a suitable biological patch for aortic valve repair.

Methods: The non-coronary cusp was replaced with one of three commercially available materials for cardiac repair (CorMatrix, Gore-Tex, or porcine pericardium) in four animals. Follow-up was 120 days. We performed echocardiographic studies to evaluate valve position, geometry, and function pre and post implantation. Explants were examined by semi-quantitative histopathological analysis with immunohistochemistry and collagen assessment.

Results: Three pigs survived the demanding operation, of which two concluded the planned study period: one harbouring a CorMatrix graft and the other a Gore-Tex graft. Immediate surgical and echocardiographic outcomes were satisfactory. At four months CorMatrix patch was almost totally replaced by tissue resembling the native aortic valve cusp, suggesting biodegradability and partial structural remodelling. Gore-Tex patch resisted structural changes. However, a loss of function and cusp mobility was noted due to thickened both biomaterials.

Conclusions: CorMatrix is potentially suitable biodegradable tissue engineered material for cardiovascular application. In growing pig model and in high pressure aortic valve cusp position, it shows signs of degradation and remodelling to resemble the native cusp. Further preclinical studies are required to verify its safety and benefits at critical cardiovascular anatomical locations.

ABSTRACT. Introduction Passenger lymphocyte syndrome (PLS) is an immune-mediated hemolysis after minor ABO incompatible solid organ donation. Minor ABO incompatibility (eg, from a type-O donor to a type-A, -B, or -AB recipient) is characterized by the ability of donor B lymphocytes to produce antirecipient isoagglutinins.

Case We describe two cases of patients who underwent orthotopic liver transplantation with minor ABO incompatibility. A 64 year old female patient with primary biliary cirrhosis and bloodtype B+ and a 53 year old male patient with ethylic liver cirrhosis and bloodtype A+ both received an O+ liver. Postoperatively, tacrolimus and low dosis corticosteroid based immunosuppression was given according to the standard protocol. Recovery was uneventfull in both cases. The two patients developed a progressive anemia with a drop to 6.2 g/dl on the fourteenth postoperative day for the first case and a drop to 5.9 g/dl on the fifteenth postoperative day for the second. A gastroscopy and CT angiogram were performed and these investigations showed no signs of active bleeding. Extra blood tests were performed and hemolysis was suspected. The direct antiglobulin test was positive for IgG, anti-B-antibodies were found in the first case and anti-A-antibodies in the latter and the diagnosis of PLS was made in both cases. Treatment consisted of plasmapheresis and immunoglobulins in the first case and high dose steroids in the second case. Both treatments were effective and the anemia resolved.

Discussion In PLS, donor lymphocytes produce antibodies to the recipient, this causes immune-mediated hemolysis. Presentation of PLS is typically 1-3 weeks after transplantation. Treatment consists of RBC transfusions and steroids, and only in resistant cases plamapheresis and IVIG. Since minor ABO incompatible solid organ donation is accepted and regularly performed, we should think about PLS when anemia without signs of active bleeding occurs in the postoperative period after liver transplantation.

ABSTRACT. OBJECTIVE Non insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a recently described complication of Roux-en-Y gastric bypass (RYGB) characterised by pathologic features of nesidioblastosis and hyperinsulinemic hypoglycemias that can occur months to years after surgery. Increased incretin production appears to be one of the involved mechanisms. Treatment includes appropriate diet, pharmacotherapy and surgical procedures; partial or total pancreatectomy, laparoscopic reversal of RYGB (with or without sleeve gastrectomy) and gastric banding have been proposed. Currently, there is no Gold Standard to NIHPS management. We present the case of a 57-year-old woman with a history of silastic ring vertical gastroplasty (SRVG) converted into RYGB who suffered from severe daily episodes of neuroglycopenia due to NIPHS, with poor response to conservative and medical treatments.

METHODS At first, as it is suggested in recent literature, we decided to perform a gastrostomy using the excluded stomach to assess if a conversion to original anatomy would be efficient to reduce episodes of hypoglycemia. As the result was conclusive, we reversed laparoscopically the RYGB and added a gastric banding to keep control on the patient’s weight.

RESULTS After a short asymptomatic course of two months, mild hypoglycemias recurred, on average once every three weeks, easily managed by sugar intakes. A Preeexisting gastroparesis was worsened after the intervention, possibly caused by vagus nerve injury secondary to the multiple gastric procedures. After a year, the patient resumed a regular lifestyle. Her weight gain was limited to 8 kilograms thanks to appropriate adjustments of the gastric band.

CONCLUSIONS This is the first case of NIPHS after RYGB treated with combined laparoscopic reversal of gastric bypass and gastric banding. In case of NIPHS, we expect this approach will allow to overcome hypoglycemic episodes while keeping weight control. Further studies with long term follow-up are necessary.

ABSTRACT. OBJECTIVE Three-dimensional (3D) visualization have been designed to overcome the lack of depth perception and reduced spatial orientation inherent to two-dimensional (2D) laparoscopy. We carried out a prospective comparative study of 3D vs. high definition 2D imaging systems in bariatric surgery. METHODS All consecutive patients who underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (GBP) between November 2015 and February 2016 were included in the study. Procedures were performed by two experienced surgeons using the same techniques. The major outcomes consisted of procedure difficulty assessment using a 5-grade Likert scale and operative time. For time comparison, surgical procedures were divided in several key steps. RESULTS There were 13 males and 21 females with a mean age of 40 years and a mean BMI of 44. 3D was used in 16 patients (12 SG / 4 GBP) and 2D in 18 (12 SG / 6 GBP). Patients’ characteristics were similar in both groups. Mean difficulty scores showed no significant difference comparing 3D and 2D groups: 1,41,1 (NS). In SG, the specific time for gastric tubulization and the total operative time were significantly shorter in 3D group: 17 vs. 25 min. (p<0.01) and 50 vs. 60 minutes (p<0.05) respectively. In GBP, the specific time for creation of the two anastomoses and the total operative time were also significantly shorter in the 3D group: 43 vs. 56 min (p<0.01) and 81 vs. 100 min. (p<0.02) respectively.

CONCLUSIONS Despite that procedure difficulty was not rated easier, we observed a significantly shorter operative time in both SG and GBP when using 3D system.

ABSTRACT. Background & aims: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered as the gold standard for the treatment of obesity. However, a significant number of patients will present either weight regain or insufficient weight-loss after LRYGB, with reoperation rates of 2.1-20 %. On the other hand, revisional LRYGB after failed restrictive procedures provides poorer results than primary LRYGB in terms of weight loss . Moreover, primary LRYGB doesn’t have good results in super-obese patients (BMI>50). Our aim was to evaluate the results of a new malabsorptive distal LRYGB (DLRYGB) in those three categories of patients. Objectives: We describe the mid-term results of a modified technique of DLRYGB either as a primary or a revisional procedure. Material & Methods: From 2013 to 2015, we performed a DLRYGB in 30 patients. We created three subgroups: one group of super-obese patients without previous bariatric surgery (‘primary’ group), one group of patients after previous restrictive procedure (‘revisional’ group) and one group of patients after previous LRYGB (‘distalisation’ group). Results: In the ‘primary’ group (10 patients)the mean excess weight loss (EWL %) at 12 months was 75% and 83.6% after more than one year. In the ‘revisional’ group (9 patients)the mean EWL% at 12 months was 73.6% and 84.7% after more than one year. In the ‘distalisation’ group (11 patients) the mean EWL% at 12 months was 50.16%.Two patients have had significant but transient protein deficiencies and two other patients had significant diarrheas controlled by medication. Moreover, one patient had a postoperative bleeding from the jejuno-jejunal anastomosis which stopped spontaneously after discontinuation of heparin. Conclusion: DLRYGB, as a primary or a revisional procedure, seems to be efficient and safe with an excellent EWL at 12 months. However larger series and longer follow-up are necessary to confirm these results and the indications.

ABSTRACT. Objectives: Despite laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered as the gold standard for the treatment of obesity and related co-morbidities, a significant number of patients suffer from either weight regain or weight-loss failure, with reoperation rates of 2.1-20 % .Conversion from a standard LRYGB to a malabsorptive distal LRYGB is one option among several revisional procedures. There is no general consensus about the optimal limb lengths in the distal LRYGB and it is usually a matter of individual practice. In the present study, we describe our personal technique and our first results. Material & Methods: From 2013 to 2015, 11 patients (5M/6F) with mean BMI 40.6 (37-46) required conversion from primary standard LRYGB to distal LRYGB, either for failure of weight loss (n=8) or for weight regain (n=3). After measuring the total small bowel length, we adopted the following configuration: common limb length of 100 cm, Roux limb of 2/3 and bilio-pancreatic limb of 1/3 of the rest of the bowel. Roux limb length was minimum 300 cm. The aim was to increase malabsorption while avoiding malnutrition. Results: Operating time ranged from approximately 150 to 180 min and the mean hospital stay was 3.9 days (3-5). We had one postoperative complication which occurred 5 days after the operation and stopped spontaneously after stopping the low molecular weight heparin prophylaxis. The mean excess BMI loss in patients with follow-up >12 months (5 patients) was 54.68 % if we consider the BMI before distalization and 63.86 % if we consider the BMI before primary bypass. One patient had significant protein and vitamin deficiencies and one patient had significant diarrheas. Conclusion: Laparoscopic conversion of failed LRYGB to a distal one, using a modified technique, seems to be feasible, safe and effective. Nevertheless, this technique requires greater surgical skills and experience.

ABSTRACT. Jacques A. Gruwez and Henri Bismuth

ABSTRACT. Aim of the study: To analyze feasibility and safety of preoperative transarterial radioembolization(TARE) for treatment of hepatocellular carcinoma (HCC) in cirrhotic patients.

Patients and methods: We retrospectively analyzed patients in whom TARE was planned as preoperative treatment, focusing on TARE feasibility and safety, drop-out rate (patients refuted for surgery due to TARE side-effects), operative morbidity and mortality.

Results: In 32 patients, refuted for liver transplantation but candidate for surgery, TARE was proposed as preoperative treatment. All patients were Child A (mean MELD: 8.2, range: 6-14). Mean number of HCC was 1 (range: 1-4), mean size 35 mm (range: 10-160). After simulation, TARE was refuted in 10 patients, due to poor targeting (4), pulmonary shunts (3), extrahepatic accumulation (2), technical failure (1). In the 22 treated patients, TARE-morbidity was 11/22, including minor complications (6), gastroduodenal ulcers (2), worsening of liver function (3). Post-TARE, surgery was refuted in 7 patients, due to tumor progression (3), liver failure after additional portal vein embolization (1), comorbidities (2), loss of follow-up (1). In the 15 operated patients with preoperative TARE, resection was performed in 8 cases (minor/major: 3/5), RF in 5 and combined resection and RF in 2. Minor complications (Clavien

Conclusion: These preliminary results suggest that TARE is safe in preparation to surgery for HCC in cirrhotic patients. TARE-related morbidity was limited and did not contraindicate subsequent surgery in most of the cases. Furthermore, no additional operative morbidity was observed in patients receiving preoperative TARE as compared with surgery only. The oncological benefit of this strategy remains to be determined with longer follow-up.

ABSTRACT. OBJECTIVE. Laparoscopic liver resection (LLR) is a worldwide increasing procedure. Anatomical resections including major hepatectomies have been described and increasingly performed, especially for primary and metastatic liver tumors. We provide a comprehensive analysis on a large multicentric patient population coming from 4 specialized European Institutions.

METHODS. Demographics, pathologic characteristics, surgical treatments and outcomes of 2247 patients receiving a LLR between January 2000 and September 2015 were reviewed. Primary endpoints were: analysis of overall indications, morbidity and mortality of LLR. Secondary endpoints included type of hepatectomy, blood loss, conversion rate, operative time and length of hospital stay (LOS). In addition oncological outcomes like margin width, R-status, recurrence-free survival in case of CRLM and HCC were analyzed.

RESULTS. A total number of 2247 patients with a mean age of 61 years were analyzed. Cirrhosis was presented in 154 patients (7%). Indications for LLR were malignancy in 1672 patients (75.5%) and benign lesions in 544 patients (24.5%). CRLM was the most frequent indication in the malignancy group (62.7%), followed by HCC (15.7%). There were 155 (6.8%) conversions to open procedures. Hand assistance was seldom used (n=17, 0.7%) patients. Major hepatectomies were performed in 313 patients (14%). Mean estimated blood loss was 470 mL, with a mean operation time of 3.3 hours. Mean LOS was 5.7 days. Major complications (≥ grade 3 Clavien-Dindo) occurred in 6.2%. Ninety-day mortality was 1.3%. R0 resection was achieved in 1605 patients (96%). RFS for HCC at 5-y was 69.5% and 31% for CRLM.

CONCLUSIONS. This is the largest series of laparoscopic liver surgery ever analyzed. Upon this multi-center experience, LLR is a safe and effective approach to the management of surgical liver diseases yielding morbidity, mortality and oncological outcomes comparable to that of conventional surgery.

ABSTRACT. Background: The laparoscopic approach of postero-superior (PS) segments is hindered by the limited visualization and curvilinear resection plans. However, with the increased experience, many centres are increasingly approaching these segments laparoscopically. The aim of this study was to compare perioperative and oncologic results of open and laparoscopic liver resections for lesions located in PS segments. Methods: Data from 179 open and 148 laparoscopic resections in PS segments performed between 2006 and 2014 in 7 specialized European hepatobiliary units with experience in both techniques were retrospectively assessed using the propensity score analysis. Finally, 86 conventional open (OLR) and 86 laparoscopic liver resections (LLR) for maximum of two lesions with the largest not exceeding 5 cm in size were compared. Results: Overall postoperative complication rates were significantly higher in the OLR vs. LLR (27.9 vs. 14%, respectively; p=0.038). The comprehensive complication index was higher in OLR vs. LLR although this difference did not reach statistical significance (26.7±16.6 vs. 18.3±8; p=0.108, respectively). Days of analgesia therapy and postoperative hospital stay were significantly shorter in the LLR group: 3.4±4.3 vs. 1.6±0.8 and 7.3±4.8 vs. 3.9±2 days, respectively for LLR and OLR. Five-years recurrence-free survival rates for hepatocellular carcinoma and for colorectal liver metastasis (OLR vs. LLR) were similar: 73.2% vs. 72.5%; p= 0.75; and 29.7% and 27.6%; p= 0.44, respectively. Conclusions: Laparoscopic resections of tumours in PS segments in selected patients, is feasible and lead to significant fewer complications and identical oncological outcomes compared to that of conventional open surgery.

ABSTRACT. Background: Traumatic biliary neuromas (TBNs) represent a rare cause of biliary stricture (BS) after orthotopic liver transplantation (OLT). Diagnosis is challenging preoperatively and is most often made at final pathology after resection. Herein we report a 20-year experience of TBN-related BS. Methods: Medical records of 1030 adult patients undergoing OLT from 1991 to 2014 were reviewed. Patients with histologically proven TBN were identified among those presenting a BS. Results: Over the study period, 52 patients developed an anastomotic BS. Of these, 17 had repeat surgery and specimen examination which identified TBN in 5 instances. All 5 patients with TBN had a duct-to-duct biliary reconstruction during OLT. Median delay from OLT to onset of symptoms was 69 months (range 4–239). Clinical manifestation was jaundice (n=3) or liver function tests alteration (n=1), and 1 patient had a retro-obstructive choleperitoneum due to downstream BS. Preoperative imaging showed a specific feature consisting of a compressive mass in only one patient. Four patients underwent TBN resection combined with hepaticojejunostomy, and had an uneventful postoperative course. One patient was treated by TBN resection and duct-to-duct reconstruction; he died from acute pancreatitis on postoperative day 21. After a median follow-up of 40.5 months (range 10–54), no recurrent BS occurred. Conclusion: Traumatic biliary neuromas represent a possible diagnosis for unexplained anastomotic BS after OLT. Surgical excision combined with hepaticojejunostomy is effective, allows histological diagnosis and prevents from recurrence.

ABSTRACT. Objective: Cirrhosis in children is often associated to a portal vein (PV) hypoplasia (PV caliber ≤ 4mm), and to severe alterations of liver hemodynamics, particularly in case of biliary atresia (BA). We hypothesized that these pathologic parameters are correlated to a more severe degree of clinical cirrhosis.

Methods: External PV caliber, and intraoperative flowmetry of native liver hemodynamics were studied prospectively at liver transplantation (LT) in 52 children (median age: 1 year), including 23 BA. The gradient between PV pressure and central venous pressure (PVP-CVP) was invasively measured to estimate the severity of portal hypertension in the native liver. These parameters were correlated to the clinical severity of cirrhosis (Pediatric end-stage liver disease score (PELD), using the patient's values for serum bilirubin, serum albumin, the international normalized ratio for prothrombin time, whether the patient is less than 1 year old, and whether the patient has growth failure (< -2 standard deviation) to predict survival).

Results: The prospective hemodynamic studies showed that: (1)pediatric cirrhosis was associated with a reduction of pre-LT total liver flow of more than 60% (median: 36 ml/min/100gr of liver),compared to values in non cirrhotic children (median: 86 ml/min/100gr) (p=0.0022);(2)total flow of native liver was correlated with PELD(tau=-0.33; p=0.00068);(3)PVP-CVP gradient was high (median: 14.5 mmHg), and was also correlated with PELD (tau=0.391; p=0.000072);(4)PV hypoplasia was only observed in children with BA (p=0.01);(5)BA was also characterized by a more severe reduction of pre-transplant total liver flow/100gr of liver (median: 25 ml/min/100gr of liver; p=0.0000054).

Conclusions: Pediatric cirrhosis is associated to severe native liver hemodynamic disturbances, which are correlated with PELD. Children affected by BA have more severe alterations of pre-transplant liver hemodynamic parameters. These hemodynamic factors, which are correlated with the clinical severity of cirrhosis, could be considered as additional elements to evaluate the degree of emergency for a LT.

ABSTRACT. Objective: Orthotopic liver transplantation is a standard treatment of end-stage liver diseases. Few informations are available about long-term results after adult liver transplantation. This study analyses medical complications, health status, changes of immunosuppression, recurrence of primary disease and quality of life of adult recipients 20 years after liver transplantation. Materiel and method Between February 1984 and December 1994, 348 transplantations were performed in 301 adults (> 15 years).Seventy-six (36.3%) patients survived more than twenty years. Complete information about the status of life of 41 other patients was unavailable. Data about health status of 53 patients, followed up exclusively in our institution were analyzed. Results Actual 1, 5, 10, 15 and 20 years survival rates of the 301 patients were 76.7; 64.1; 55.5; 45.4 and 36.3% respectively. Twenty years after transplantation: 14 patients (30.4%) had normal liver tests, 31 (58.5%) were on monotherapy Cyclosporine, Tacrolimus, Mycophenolate Mofetyl or Azathioprine and 9 (17%) had no immunosuppression at all. Twenty-two (41.5%) patients developed recurrent primary disease, 30 (56.6%)renal failure, 14 (26.4%) de novo diabetes, 32 (60.4%) arterial hypertension, 19 (35.8%) had cardiovascular complications, 35 (66%) presented hypercholesterolemia, 21 (39.6%) osteoporosis, ten (18.9%) cataract and 20 (37.7%) developed de novo tumor. Quality of live at 20 years of this cohort defined by Karnofsky score was excellent (>80%) in 78,6% of patients. Conclusion Results 20 years after liver transplantation show the need to provide a regular follow-up in order to detect and/or to treat complications of transplantation timely. One should opt for a minimization immunosuppression strategy in order to reduce its' harmful , sometimes lethal, side effects treatment.

ABSTRACT. Objective: The role of radiological response to loco-regional therapies, alpha-fetoprotein modification, inflammatory markers and length of waiting time have been recently shown to be important selection criteria for the risk of intention-to-treat -death and recurrence in patients with hepatocellular cancer waiting for liver transplantation . A novel and easy prognostic score based on the combination of these, pre-operatively available, variables has been developed from a long-waiting time training set and then validated in a short-waiting time set. Methods: the training set consisted of 179 patients listed for LT during the period Jan2000-Dec2012 from the UCL Brussels Transplant Centre; the validation set of 110 patients listed during the period Jan 2005-Dec2014 from the Ancona Liver Centre. Results: The proposed Time–Radiological-response–Alpha-fetoprotein–INflammation (TRAIN) score was the best predictor of microvascular invasion, a well-known risk factor for recurrence. A TRAIN score ≥1.0 excellently stratified both the investigated populations in terms of intention-to-treat survival and recurrence. When compared with Milan Criteria, the proposed score allowed to obtain an increase of potentially transplantable patients (+8.9% in training set and 24.6% in validation set) without an additive risk of recurrence. Conclusions: The proposed TRAIN score is an easy selection tool based on variables available before liver transplantation. This score enables the selection process to be refined in the two different scenarios of long and short waiting times. If longer, the score is better at predicting risk of death during the waiting time; in case of shorter waiting time, the score is better at identifying risk of post-transplant recurrence.

ABSTRACT. Introduction: Due to the shortage of and/or lack of access to deceased donors, living donor liver transplantation (LDLT) has contributed to allow the transplantation of children in a timely fashion regarding the evolution of their diseases. We reviewed our 23 year experience. Patients and Methods: The data of 350 living donors and transplant recipients (median age: 1.25y; range: 0.3-16.5y) were retrospectively collected. The indications for LT were: biliary atresia (62%), hepatic malignancies (12%), familial cholestases (11%), metabolic diseases (7%), and others (8%). From 2001 onwards, steroid-free immunoprophylaxis was implemented in all children. Moreover, ABO-incompatible LT was performed in 21 children (6%) since 2001. Results: No mortality or persisting disability was encountered in the 350 living donors of this series. Overall patient and graft survivals in the recipients were 96% and 95% at one year, and 94% and 92% at five years, respectively. The retransplantation rate was 8/350 (2.3%), including two children who finally died. The results were analyzed considering five eras. A striking feature was the progressive increase of the proportion of LDLT/total pediatric LT along the eras as follows: 1993-7: 57/152 (38%); 1998-2001: 38/100 (38%); 2002-7: 66/161 (41%); 2008-11: 80/101 (79%); 2012-15: 108/122 (88%). When comparing 1993-7 and 2007-11 eras, 5 year patient and graft survival rates increased from 89% to 98%, and 86% to 96%, respectively. Conclusions: Our results indicate: (1) the increasing recourse to LDLT at our pediatric LT program; (2) the safety of living donor surgery and management; (3) the improvement of overall results of LDLT along the eras. A detailed assessment of the risks/benefits balance of steroid-free immunosuppression in pediatric LT is ongoing.

ABSTRACT. Objective: Liver hemodynamic disturbances and portal vein (PV) complications are frequently observed in pediatric liver transplantation (LT). A previous retrospective study demonstrated that, in case of PV hypoplasia (PV caliber ≤ 4mm), PV reconstruction using latero-lateral portoplasty seemed to provide the best technical results. We hypothesized that some pre-transplant liver hemodynamic parameters could predict the need to do a portoplasty for PV reconstruction during the LT procedure.

Methods: A prospective study of pre-transplant liver hemodynamics was done in 52 children (median age 1 year; range: 0.5-14), 33 being affected by biliary atresia (BA). The hepatic hemodynamic parameters were studied preoperatively by Doppler-ultrasound, and intraoperatively by invasive flowmetry. The technique used for PV reconstruction during the LT procedure was also recorded.

Results: Latero-lateral portoplasty was used for PV reconstruction in 21 of the 52 patients included, 19 of these 21 children being affected by BA. Several pre-LT Doppler ultrasound findings were found as good predictors of the need to do a portoplasty for PV reconstruction: a median internal PV caliber of 3.4 mm (range: 3-4; p=0.00044), a median PV velocity of 7 cm/sec (range: -6-16; p=0.0005), and a median pre-transplant arterial resistive index (ARI) of 0.93 (range: 0.9-1; p=0.0016) (table). In the intraoperative period, several findings were also found as good predictors of the need to do a portoplasty for PV reconstruction: a median external PV caliber of 4.7 mm (range: 4.2-5.5; p= 0.000037), a median pre-transplant total liver flow/100gr of liver of 23 ml/min (range: 15-32; p=0.0016) (table).

Conclusions: In pediatric LT, latero-lateral portoplasty for PV reconstruction can be used in case of PV hypoplasia, particularly in children with BA. Several non-invasive and invasive native liver hemodynamic parameters seem to constitute potential predictors of the need to do a portoplasty for PV reconstruction during the LT procedure.