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Six months of abstinence is typically required before transplantation for alcoholic liver disease. In this study, early liver transplantation improved the 6-month survival rate among selected patients with severe alcoholic hepatitis (77%, vs. 23% without transplantation). Liver transplantation for alcoholic liver disease has a favorable outcome but remains controversial. 1 , 2 Reluctance to perform transplantation in patients with alcoholism is often based on the view that they are responsible for their illness and are likely to resume alcohol use after transplantation. 3 To select the most appropriate patients with severe forms of alcoholic liver disease for transplantation, most programs require a 6-month abstinence period before patients can be considered. Nevertheless, data regarding the 6-month rule as a predictor of long-term sobriety are controversial. 4 Despite the frequent use of the rule, the United Network for Organ Sharing and the . . .

In this study, 34 liver-transplant recipients with recurrent HCV genotype 1 infection were treated with the interferon-free regimen of ombitasvir–ABT-450/r, dasabuvir, and ribavirin. The rate of sustained virologic response was 97% in this difficult-to-treat population. Hepatitis C virus (HCV) presents a global health care challenge, with approximately 170 million people chronically infected. 1 In 2012, approximately 24,000 liver transplantations were performed worldwide, with the largest proportion performed because of HCV-induced liver disease. 2 , 3 In the United States, more than 40% of registrants on the liver-transplant waiting list are infected with HCV. 3 , 4 After liver transplantation, recurrence of HCV infection is universal among recipients with viremia before transplantation. 5 , 6 Fibrosis progression may be accelerated and HCV viral loads may be markedly increased in patients receiving post-transplantation immunosuppressive therapy as compared with patients not undergoing transplantation. 7 – 9 Graft . . .

The ideal closure technique of the pancreas after distal pancreatectomy is unknown. We postulated that standardised closure with a stapler device would prevent pancreatic fistula more effectively than would a hand-sewn closure of the remnant. This multicentre, randomised, controlled, parallel group-sequential superiority trial was done in 21 European hospitals. Patients with diseases of the pancreatic body and tail undergoing distal pancreatectomy were eligible and were randomly assigned by central randomisation before operation to either stapler or hand-sewn closure of the pancreatic remnant. Surgical performance was assessed with intraoperative photo documentation. The primary endpoint was the combination of pancreatic fistula and death until postoperative day 7. Patients and outcome assessors were masked to group assignment. Interim and final analysis were by intention to treat in all patients in whom a left resection was done. This trial is registered, ISRCTN18452029. Between Nov 16, 2006, and July 3, 2009, 450 patients were randomly assigned to treatment groups (221 stapler; 229 hand-sewn closure), of whom 352 patients (177 stapler, 175 hand-sewn closure) were analysed. Pancreatic fistula rate or mortality did not differ between stapler (56 [32%] of 177) and hand-sewn closure (49 [28%] of 175; OR 0·84, 95% CI 0·53–1·33; p=0·56). One patient died within the first 7 days after surgery in the hand-sewn group; no deaths occurred in the stapler group. Serious adverse events did not differ between groups. Stapler closure did not reduce the rate of pancreatic fistula compared with hand-sewn closure for distal pancreatectomy. New strategies, including innovative surgical techniques, need to be identified to reduce this adverse outcome. German Federal Ministry of Education and Research.

The spleen is crucial in regulating immune homoeostasis through its ability to link innate and adaptive immunity and in protecting against infections. The impairment of splenic function is defined as hyposplenism, an acquired disorder caused by several haematological and immunological diseases. The term asplenia refers to the absence of the spleen, a condition that is rarely congenital and mostly post-surgical. Although hyposplenism and asplenia might predispose individuals to thromboembolic events, in this Review we focus on infectious complications, which are the most widely recognised consequences of these states. Because of the high mortality, the fulminant course, and the refractoriness to common treatment of overwhelming infections caused by encapsulated bacteria, prevention through vaccination and antibiotic prophylaxis is the basis of the management of patients who have had splenectomy or have hyposplenism. In this Review, we critically assess clinical and diagnostic aspects of splenic dysfunction and highlight new perspectives in the prevention of overwhelming post-splenectomy infections.

Liver regeneration signals There is growing evidence to suggest that endothelial cells are not simply passive conduits for delivering oxygen and nutrients. During embryogenesis, for instance, they induce organogenesis before the circulation has developed. Experiments in a 70% partial hepatectomy liver regeneration model in mice now reveal a molecular pathway by which endothelial cells can sustain liver regeneration after surgical resection. VEGFR2 activation in a defined subpopulation of liver endothelial cells leads to the upregulation of the endothelial-specific transcription factor Id1, which in turn induces the secretion of Wnt2 and hepatocyte growth factor (HGF), which trigger hepatocyte proliferation. This suggests that vascular niche-derived inductive signals that promote liver regeneration could be utilized to initiate and accelerate liver recovery after these surgical procedures. These authors describe a molecular pathway by which endothelial cells sustain liver regeneration after surgical resection. Activation of vascular endothelial growth factor-A receptor-2 in a defined subpopulation of liver endothelial cells leads to the upregulation of the endothelial-specific transcription factor Id1 , which in turn induces Wnt2 and hepatocyte growth factor, which are secreted from the endothelial cells and trigger hepatocyte proliferation. During embryogenesis, endothelial cells induce organogenesis before the development of circulation 1 , 2 , 3 , 4 . These findings suggest that endothelial cells not only form passive conduits to deliver nutrients and oxygen, but also establish an instructive vascular niche, which through elaboration of paracrine trophogens stimulates organ regeneration, in a manner similar to endothelial-cell-derived angiocrine factors that support haematopoiesis 5 , 6 , 7 . However, the precise mechanism by which tissue-specific subsets of endothelial cells promote organogenesis in adults is unknown. Here we demonstrate that liver sinusoidal endothelial cells (LSECs) constitute a unique population of phenotypically and functionally defined VEGFR3 + CD34 − VEGFR2 + VE-cadherin + FactorVIII + CD45 − endothelial cells, which through the release of angiocrine trophogens initiate and sustain liver regeneration induced by 70% partial hepatectomy. After partial hepatectomy, residual liver vasculature remains intact without experiencing hypoxia or structural damage, which allows study of physiological liver regeneration. Using this model, we show that inducible genetic ablation of vascular endothelial growth factor (VEGF)-A receptor-2 (VEGFR2) in the LSECs impairs the initial burst of hepatocyte proliferation (days 1–3 after partial hepatectomy) and subsequent reconstitution of the hepatovascular mass (days 4–8 after partial hepatectomy) by inhibiting upregulation of the endothelial-cell-specific transcription factor Id1 . Accordingly, Id1 -deficient mice also manifest defects throughout liver regeneration, owing to diminished expression of LSEC-derived angiocrine factors, including hepatocyte growth factor (HGF) and Wnt2. Notably, in in vitro co-cultures, VEGFR2-Id1 activation in LSECs stimulates hepatocyte proliferation. Indeed, intrasplenic transplantation of Id1 +/+ or Id1 −/− LSECs transduced with Wnt2 and HGF ( Id1 −/− Wnt2 + HGF + LSECs) re-establishes an inductive vascular niche in the liver sinusoids of the Id1 −/− mice, initiating and restoring hepatovascular regeneration. Therefore, in the early phases of physiological liver regeneration, VEGFR2-Id1-mediated inductive angiogenesis in LSECs through release of angiocrine factors Wnt2 and HGF provokes hepatic proliferation. Subsequently, VEGFR2-Id1-dependent proliferative angiogenesis reconstitutes liver mass. Therapeutic co-transplantation of inductive VEGFR2 + Id1 + Wnt2 + HGF + LSECs with hepatocytes provides an effective strategy to achieve durable liver regeneration.

Background Percutaneous cholecystostomy is a less invasive method to treat acute cholecystitis in patients who are critically ill or have serious medical comorbidities precluding the use of general anesthesia. It remains controversial whether interval cholecystectomy is warranted. The objectives of the study were to determine the success rate and complications of percutaneous cholecystostomy and the proportion of patients without recurrent attacks in whom interval cholecystectomy was not needed. Methods This was a retrospective review to determine the outcomes after percutaneous cholecystostomy for acute calculous cholecystitis between 1995 and 2007. Administrative data were used to better capture recurrent symptoms requiring treatment. Results Sixty-eight patients with a mean age of 74 years were identified. Sixty-seven (98.5%) underwent successful insertion of the cholecystostomy tubes. Eleven patients suffered tube-related complications, including tube dislodgment (9), tube blockage (1), and bleeding that was controlled with conservative management (1). The initial episode of cholecystitis was treated successfully in 58 patients (85%). The overall in-hospital and 30-day mortality were both 15% (10 patients). A total of 7 patients (10%) underwent cholecystectomy while still in hospital. There were 39 patients at risk for recurrent disease who survived the initial episode and did not receive an interval cholecystectomy. Of these 39 patients, 16 (41%) suffered recurrent gallbladder-related disease. Conclusions Percutaneous cholecystostomy is an alternative to cholecystectomy in patients with acute calculous cholecystitis who are at high risk for surgical mortality and morbidity. It appears to have a low complication rate and good clinical success. Because a significant number of patients suffer recurrent attacks, elective cholecystectomy should be considered routinely. Unfortunately, firm criteria for selecting percutaneous cholecystostomy over cholecystectomy are lacking, and the surgeon’s clinical judgment is critically important.

Background and aims: Splanchnic vein thrombosis is a significant source of complications in candidates for liver transplantation. The aims of this study were: (a) to determine the prevalence of and risk factors for splanchnic vein thrombosis in cirrhotic patients awaiting transplantation and (b) to assess the usefulness of anticoagulation. Methods: A total of 251 cirrhotic patients listed for transplantation were analysed. All underwent systematic screening for thrombosis with Doppler ultrasonography. During the second period of the study, all patients with thrombosis received anticoagulation up to transplantation while during the first period none had received anticoagulation. Results: The incidence of splanchnic vein thrombosis at evaluation was 8.4%. Seventeen additional patients (7.4%) developed de novo thrombosis after evaluation. Independent risk factors for thrombosis were low platelet count (77.4 (36.3) v 111.6 (69.2) 109/l; p = 0.001), a past history of variceal bleeding (47.4% v 29.1%; p = 0.003), and a prolonged interval from listing to transplantation (8.5 (6.8) v 4.8 (4.4) months; p = 0.002). The proportion of partial or complete recanalisation was significantly higher in those who received (8/19) than in those who did not receive (0/10, p = 0.002) anticoagulation. Survival was significantly lower in those who had complete portal vein thrombosis at the time of surgery (p = 0.04). Conclusion: These results support a systematic screening for splanchnic vein thrombosis in patients awaiting transplantation. They suggest that in these patients, anticoagulation is safe and has a significant impact on recanalisation as well as prevention of extension of thrombosis.

Background Function-preserving minimally invasive pancreatectomy is thought to be an ideal approach for pancreatic benign and borderline malignant lesions requiring pancreatectomy. However, it is not that easy to accomplish this goal with the conventional laparoscopic approach. It requires extensive surgeon experience and learned techniques. A robot surgical system was recently introduced to overcome these limitations and it may potentially provide precise and safe laparoscopic surgery. Methods Between March 2006 and July 2010, a total of 45 patients underwent laparoscopic or robot-assisted pancreatectomy performed by a single pancreatic surgeon to preserve the spleen. Twenty-five patients underwent the conventional laparoscopic approach (Lap group) and the other 20 patients underwent robot-assisted surgery (Robot group). The perioperative clinicopathologic variables (age, gender, length of resected pancreas, tumor size, tumor location, amount of bleeding, operation time, length of hospital stay, complications, mortality, and cost) were compared between the two groups, as well as the spleen preservation rate. Results Younger patients preferred robot-assisted surgery to conventional laparoscopic surgery (44.5 ± 15.9 vs. 56.7 ± 13.9 years, p  = 0.010), and the mean operation time was longer in the Robot group (258.2 ± 118.6 vs. 348.7 ± 121.8 min, p  = 0.016). The spleen-preserving rate of the Robot group was considerably superior to that of the Lap group (fail/success, 9/16 vs. 1/19, p  = 0.027). However, robot surgery cost the patients about USD 8,300 (USD 8,304.8 ± 870.0), which was more than twice the amount for the Lap group (USD 3,861.7 ± 1,724.3). There were no significant differences in other clinicopathologic variables. Conclusion Robot-assisted pancreatic surgery could provide an increased chance for spleen preservation in spite of higher cost and longer operation time. More experiences are needed to specifically address the role of robot surgery in the advanced laparoscopic era.

Background and aims: Major liver resection incurs a risk of postoperative liver dysfunction and infection and there is a lack of objective evidence relating residual liver volume to these complications. Patients and methods: Liver volumetry was performed on computer models derived from computed tomography (CT) angioportograms of 104 patients with normal synthetic liver function scheduled for liver resection. Relative residual liver volume (%RLV) was calculated as the relation of residual to total functional liver volume and related to postoperative hepatic dysfunction and infection. Receiver operator characteristic curve analysis was undertaken to determine the critical %RLV predicting severe hepatic dysfunction and infection. Univariate analysis and multivariate logistic regression analysis were performed to delineate perioperative predictors of severe hepatic dysfunction and infection. Results: The incidence of severe hepatic dysfunction and infection following liver resection increased significantly with smaller %RLV. A critical %RLV of 26.6% was identified as associated with severe hepatic dysfunction (p<0.0001). Additionally, body mass index (BMI), operating time, and intraoperative blood loss were significant prognostic indicators for severe hepatic dysfunction. It was not possible to predict the individual risk of postoperative infection precisely by %RLV. However, in patients undergoing major liver resection, infection was significantly more common in those who developed postoperative severe hepatic dysfunction compared with those who did not (p = 0.030). Conclusions: The likelihood of severe hepatic dysfunction following liver resection can be predicted by a small %RLV and a high BMI whereas postoperative infection is more related to liver dysfunction than precise residual liver volume. Understanding the relationship between liver volume and synthetic and immune function is the key to improving the safety of major liver resection.