Impact of a Multidisciplinary Team on Alcohol Recidivism and Survival After Liver Transplant for Alcoholic Disease.

BACKGROUND: Alcohol use disorders have a prevalence of 10% among the population of the United States and Europe and are one of the most frequent causes of liver cirrhosis in the Western world. Currently, alcohol-related liver cirrhosis represents one of the most frequent indications to liver transplant (LT), both as independent cause or associated with hepatitis C virus or hepatitis B virus infections. Starting from 2014, a multidisciplinary team involving surgeons, gastroenterologists, clinical toxicologists, psychiatrists, and psychologists was developed within the Modena Liver Transplant Center. METHODS: We retrospectively reviewed our prospectively maintained institutional database of liver transplants in order to identify cirrhotic patients eligible for LT with a diagnosis of alcohol use disorder. RESULTS: A total of 756 liver transplants were performed at Policlinico University Hospital, University of Modena, and Reggio Emilia, MO, Italy, between November 2000 and November 2017; 102 patients who underwent LT were considered eligible for inclusion in the study. CONCLUSIONS: The multidisciplinary approach, together with blood, urinary, and hair tests, allows identification of early recurrences and improves survival. Further studies are necessary to understand how multidisciplinary teams can change the 6-month rule in patient selection.

Gastric Mucormycosis in a Liver and Kidney Transplant Recipient: Case Report and Concise Review of Literature.

Mucormycosis is an uncommonly encountered fungal infection in solid organ transplantation. The infection is severe and often results in a fatal outcome. The most common presentations are rhino-sino-orbital and pulmonary disease. We describe a rare case of gastric mucormycosis in a patient with a combined liver-kidney transplant affected by glycogen storage disease type Ia. A 42-year-old female patient presented with gastric pain and melena 26 days after transplantation. Evaluation with upper endoscopy showed two bleeding gastric ulcers. Histological examination of gastric specimens revealed fungal hyphae with evidence of Mucormycetes at subsequent molecular analysis. Immunosuppressive therapy was reduced and antifungal therapy consisting of liposomal amphotericin B and posaconazole was promptly introduced. Gastrointestinal side effects of posaconazole and acute T-cell rejection of renal graft complicated management of the case. A prolonged course of daily injections of amphotericin B together with a slight increase of immunosuppression favored successful treatment of mucormycosis as well as of graft rejection. At 2-year follow-up, the woman was found to have maintained normal renal and liver function. We conclude that judicious personalization of antimicrobial and antirejection therapy should be considered to resolve every life-threatening case of mucormycosis in solid organ transplantation.

Multimodal oncological approach in patients affected by recurrent hepatocellular carcinoma after liver transplantation.

OBJECTIVE: Hepatocellular Carcinoma (HCC) represents the fifth most common malignancy and the third cancer-related cause of death worldwide. Liver transplantation (LT) is an excellent treatment for patients with small HCC associated with cirrhosis. The purpose of this review is to investigate the possible strategies for the treatment of HCC recurrence after LT based on current clinical evidence. MATERIALS AND METHODS: A systematic literature search was performed independently by two of the authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. The search was limited to studies in humans and to those reported in the English language. RESULTS: Thanks to the introduction of strict selection criteria, LT for HCC has achieved a survival rate of 85% at five years. However, the recurrence of HCC after transplantation remains a serious problem that affects about 20% of post-transplant cases. While most recurrences occur within the first 2 years, late recurrences have been described. The prognosis of recurrence is poor despite numerous proposals of the therapeutic option. Lower levels of immunosuppressive therapy and use of mammalian targets of rapamycin (mTORs) is a potential preventive strategy to reduce HCC recurrence post-Lt. Surgical resection and locoregional therapies (mainly TACE and RFA) play a very important role and are associated with improved survival. Conversely, multikinase inhibitors such as Sorafenib and their association with mTOR inhibitors play a role in cases of advanced HCC recurrence not suitable for the surgical or ablative approach. CONCLUSIONS: Treating HCC recurrence is a multidisciplinary workup involving hepatologists, surgeons, oncologists and radiologists in order to offer a patient-tailored therapy.

Multimodal approach of advanced gastric cancer: based therapeutic algorithm.

Gastric cancer (GC) is the third leading cause of cancer death in both sexes worldwide, with the highest estimated mortality rates in Eastern Asia and the lowest in Northern America. However, the availability of modern treatment has improved the survival and the prognosis is often poor due to biological characteristics of the disease. In oncology, we are living in the "Era" of target treatment and, to know biological aspects, prognostic factors and predictive response informations to therapy in GC is mandatory to apply the best strategy of treatment.The purpose of this review, according to the recently published English literature, is to summarize existing data on prognostic aspects and predictive factors to response to therapy in GC and to analyze also others therapeutic approaches (surgery and radiotherapy) in locally, locally advanced and advanced GC. Moreover, the multidisciplinary approach (chemotherapy, surgery and radiotherapy) can improve the prognosis of GC. The purpose of this review, according to the recently published English literature, is to summarize existing data on prognostic aspects and predictive factors to response to therapy in GC and to analyze also others therapeutic approaches (surgery and radiotherapy) in locally, locally advanced and advanced GC. Moreover, the multidisciplinary approach (chemotherapy, surgery and radiotherapy) can improve the prognosis of GC.

Vacuum-Assisted Closure Therapy in Patients Undergoing Liver Transplantation With Necessity to Maintain Open Abdomen.

BACKGROUND: Negative-pressure wound therapy (NPWT) has been recognized as a valid method of temporary abdominal closure. The role of open abdomen (OA) in the management of abdominal sepsis has been a controversial issue. Recent experimental and clinical studies have indicated that vacuum-assisted closure (VAC) is associated with superior outcomes in the treatment of OA conditions, but sufficient proof of efficacy and effectiveness is lacking. METHODS: We enrolled in this observational study all patients who had undergone liver transplantation (LT) for all causes between 2007 and 2014 in whom we needed to use VAC therapy, describing the pathology that led to the complication, length of hospitalization, graft survival, microbial identifications, and causes of death. RESULTS: We enrolled 11 patients-6 men (55%) and 5 women (45%), from 41.92 to 64.96 years old (mean, 57.62 ± 6.56 years) -who went to LT for different pathologies. The mean hospital stay was 56.72 ± 36.40 days (range, 8-133 days). Graft survival was 35.65 ± 31.61 months (range, 1.51-89.19 months). Six of 11 patients died (55%) of different causes; in particular, 4 patients died 1 to 3 months after the procedures that led to the condition of OA for septic shock and subsequent multi-organ failure. CONCLUSIONS: Complications related to the use of NPWT, such as painful management and bleeding, are rare and mild when the device is used properly. Although studies are needed to verify the real cost/benefit ratio in this application of VAC therapy, we consider it a useful means to treat the OA condition.

Incidental Intra-Hepatic Cholangiocarcinoma and Hepatocholangiocarcinoma in Liver Transplantation: A Single-Center Experience.

BACKGROUND: Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract that is a challenging issue for the medical community, with increasing incidence. Risk factors for CCA are similar to those known for hepatocellular carcinoma (HCC), such as cirrhosis, chronic hepatitis B and C, obesity, diabetes, and alcohol. We describe the outcome and the management of patients who underwent liver transplantation (LT) with an incidental diagnosis of intrahepatic (iCCA) or hepatocholangiocarcinoma (CHC). METHODS: From 2000 to May 2015, 655 LT were performed LT at the Liver Transplant Center in Modena, Italy. We retrospectively reviewed the pathological data of the explanted livers, finding 5 cases of iCCA or CHC. The pathological examination of the explanted livers showed 1 case of iCCA; 1 case of multifocal HCC associated with a nodule of iCCA; 2 cases of CHC associated with nodules of HCC; and 1 case of CHC associated with iCCA. Mean disease-free survival (DFS) was 15.49 months (1.55-42.04) and mean overall survival (OS) was 24.76 months (3.91-75.49). All patients died of recurrent tumor progression. RESULTS: iCCA incidental finding after LT affects patient outcomes, massively causing OS and DFS reduction. We stress the necessity of a more accurate selection of the candidates whenever an augmented risk of iCCA or CHC is present. CONCLUSIONS: Further investigations are required to better understand the role of LT in these patients and to define the best management for them once they have been transplanted and the histological examination reveals the presence of iCCA or CHC.

Energy sources in alpine skiing (giant slalom).

The energy cost of a giant slalom event was measured in eight skiers of national level. The lap lasted on average 82 s. VO2 was measured during the first, the second and the last third of the lap in different trials and also during recovery from a complete lap. Blood lactate was measured at the end of a lap. From the data obtained it was possible to calculate that: a) VO2, as measured during the lap, would correspond at steady state to 80% of the VO2max of the subjects; b) the total metabolic power delivered during the lap should be equal to about 72 ml O2 X kg-1 X min-1, corresponding to 120% of VO2max of the subjects. Considering the short duration of the trial and the power output delivered during maximal efforts on a bicycle ergometer, it appears that the giant slalom is not a very high energy demanding event.