Evolution of surgical technique in conventional open hepatectomy for living liver donation over a 12-year period in a single center.

We report details of the experience from the largest Italian program with hepatic living donation, focusing particularly on the use of intraoperative ultrasound in liver transplantation and living donation. During a 12-year period we changed our surgical technique in the conventional open procedures thanks to the experience gained into the laparoscopic setting. Intraoperative ultrasound has been implemented during these delicate procedures for ensuring a fast and safer detection of the accessory veins and final severing of the vascular stumps during liver transection.

Laparoscopic approach for an intra-abdominal kidney allograft nephrectomy after pediatric transplantation: a case report.

We report a case of minimally invasive nephrectomy of a kidney transplanted into the abdominal cavity in a child. A 15-year-old girl underwent transplantation with a cadaveric donor kidney due to congenital pyelonephritis, vesicoureteral reflux, and secondary bladder atrophy. The transplant was complicated by hyperacute rejection, cytomegalovirus infection, and anastomotic stenosis of the Bricker neobladder. After recurrent urinary tract infections, the patient was reintroduced to hemodialysis in 2010. After pneumo-peritoneum, we placed 2 10-mm trocars in the hypochondrium and left side and 2 5-mm in the left iliac fossa and right upper quadrant. The transplanted kidney was skeletonized, the artery and vein were cut to the end-to-side anastomoses to the juxta-renal aorta and cava using an automatic 35-mm, stapler, and the ureter was dissected and closed with clips. Via a Pfannestiel minilaparotomy we extracted the allograft. The patient was discharged on the third postoperative day. After 4 months of follow-up, she is alive an on dialysis. Laparoscopic nephrectomy of a kidney transplanted into the abdominal cavity is feasible and safe in centers with skilled minimally invasive techniques.

Unusual presentation of left hepatic vein in deceased donor: case report.

An anomaly of the left hepatic vein was discovered in a deceased donor for whole liver transplantation. This vein was attached by a thin bridge of tissue to the suprahepatic inferior vena cava cuff, which received the right and middle hepatic vein in a common trunk. The left hepatic vein and the common trunk drained together into the right atrium. The thin bridge of tissue connecting the 2 independent vessels was severed, and ex situ reduction of the left lateral segments was using a harmonic scalpel. Although a graft with reduced size is not ideal, ex situ reduction should be considered a valuable option when viability of the left lateral segments is uncertain in the donor or at the back table.

[Hemoperitoneum from rupture of liver subcapsular hematoma after laparoscopic cholecystectomy attributed to ketorolac. Report of a case]. / Emoperitoneo da rottura di ematoma subcapsulare epatico indotto dal ketorolac dopo colecistectomia laparoscopica. Caso clinico.

Ketorolac is one of the most common nonsteroidal anti-inflammatory drugs used to control postoperative pain. However, peri- and postoperative administration of ketorolac is associated with an increased risk of gastrointestinal bleeding as described in the literature. Notwithstanding this event is not frequent, it can expose the patient to serious complications that should be quickly recognised and effectively treated. We present a report about a female patient with cholelithiasis who underwent a laparoscopic cholecystectomy. After the operation, the patient had a haemorrhage that we attributed to surgery in a first time and then to administration of ketorolac.

Postoperative hepatic artery aneurysms development and remodeling in Ehlers-Danlos syndrome type IV. Case report.

Patients affected by Ehlers-Danlos syndrome (EDS) type IV are at risk for aneurysm formation and rupture. This case report shows the extreme vascular fragility of these patients. We studied a 31-year-old man that developed hepatic artery aneurysms 3 weeks after splenectomy. Computed tomography angiography showed the extreme vascular remodeling of the aneurysms. We conclude that remote site complications should be kept in mind by all surgeons in vascular EDS patients even after general surgery operations.

Adult to adult living-related liver transplant: report on an initial experience in Italy.

INTRODUCTION: Living-related liver transplantation has become the treatment of choice for many liver diseases. We present our initial analysis of 53 cases of adult to adult living-related liver transplantation performed in a single institute in Italy. MATERIALS AND METHODS: From January 2002 to September 2006, we performed 53 adult to adult living-related liver transplantations. The donors (age 18-53) all had genetic or emotional relationships; they were all ABO identical or compatible. Recipients (ages 18-68) suffered from cirrhosis secondary to viral etiology (18), hepatocellular carcinoma with viral cirrhosis (24), cystic fibrosis (2), primary biliary cirrhosis (2), hepatocellular carcinoma with non-viral cirrhosis (2), alcoholic cirrhosis (1), ornithine transcarbamylase deficiency (OTC), (1) criptogenic cryptogenic cirrhosis, (1) primary sclerosing cholangitis, (1) biliary atresia and metastatic carcinoid (1). Donor liver resection resulted in 51 right hepatectomies and two left hepatectomies. Graft body weight ratio was always above 0.8%; graft implantation was performed with the piggy back technique and, in 43 cases, with the use of veno-venous bypass. RESULTS: There was neither donor mortality nor need of blood transfusion. Actuarial recipient survival rate at 3 years was 82.66% and graft survival rate was 75.34%. Six patients underwent retransplantation: in four cases due to hepatic artery thrombosis, and in two, due to graft dysfunction. Three patients had one episode each of acute cellular rejection. CONCLUSION: Adult to adult living-related liver transplantation represents a resource to be used in confronting organ shortage, and is a valuable option for decreasing mortality and drop out from the waiting list.

Corticosteroid-free immunosuppression in pediatric liver transplantation: safety and efficacy after a short-term follow-up.

BACKGROUND: We report our results with the use of corticosteroid-free immunosuppression after pediatric liver transplantation, evaluating the efficiency and safety of this protocol in the early posttransplantation period. PATIENTS AND METHODS: From July 2003 to October 2005, 34 liver transplantations were performed in 32 pediatric patients (19 boys, 13 girls) at our institution. Recipient median age was 5 years (range, 0.2-14 years), and median body weight was 10 kg (range, 4-49 kg). Twenty-seven patients received a graft from in situ split liver transplantation, 5 a whole graft. Twenty-nine children (90%) received an immunosuppressive therapy based on methylprednisolone IV bolus at reperfusion (10 mg/kg) plus tacrolimus given at an initial dose of 0.08 mg/kg/d and then adjusted to obtain whole blood trough levels of 10 to 15 ng/mL during the first 3 months and 5 to 10 ng/mL after the 3rd month; basiliximab was given on postoperative days 0 and 4. Biopsy-proven acute rejection episodes were treated by methylprednisone IV boluses. RESULTS: After a median follow-up of 9 months (range, 1-27 months), the overall patient survival rate was 84% and graft survival rate was 79%. Three children (9%) died after their transplantations. Three (9%) experienced episodes of biopsy-proven acute rejection, always treated with IV steroid boluses. Mean RAI score was 4. One patient experienced PTLD that resolved with temporary reduction of immunosuppression. Cytomegalovirus infection rate was 14%. Sepsis occurred in 2 cases (6%). CONCLUSIONS: Initial results with a steroid-free immunosuppressive protocol are encouraging, with low rates of acute rejection and infectious complications as in steroid-based protocols.

A safe immunosuppressive protocol in adult-to-adult living related liver transplantation.

BACKGROUND: In this series of 32 adult-to-adult living related liver transplantations, we assessed the efficacy and safety of basiliximab in combination with a tacrolimus-based regimen. Basiliximab, a chimeric monoclonal antibody directed against the alpha chain of the interleukin-2 (IL-2) receptor (CD25), has been extensively evaluated as induction therapy for cadaveric liver transplant recipients. PATIENTS AND METHODS: Thirty-two adult-to-adult living related liver transplantations were performed in the last 3 years. All patients received two 20 mg doses of basiliximab (days 0 and 4 posttransplantation) followed by tacrolimus (0.15 mg/kg/d; 10-15 ng/mL target trough levels) and steroids (starting with 20 mg IV switched to PO as soon as the patient was able to eat and weaned within 1-2 months). The average follow-up was 395 days after transplantation. RESULTS: Of the patients, 93.75% remained rejection-free during follow-up with an actuarial rejection-free probability of 92.59% within 3 months. Two patients (6%) had one episode of biopsy-proven acute cellular rejection (ACR). Actuarial patient and graft survival rates at 3 years were 86.85% and 81.25%. One patient (3%) experienced one episode of sepsis. There was no evidence of cytomegalovirus infections or side effects related to the basiliximab. We found zero de novo malignancy but we observed two patients with metastatic spread of their primary malignancy during the follow-up. CONCLUSION: Basiliximab in association with tacrolimus and steroids is effective as prophylaxis of ACR among adult living related liver transplant recipients.

Improvements in hepatic parenchymal transection for living related liver donor.

INTRODUCTION: To eliminate mortality and morbidity risk in living related liver donors, we developed a new surgical technique to resect hepatic parenchyma using an ultrasonic surgical aspirator in association with a monopolar floating ball cautery. METHODS: We performed 17 right hepatectomies and 2 left hepatectomies using this technique. We performed a retrospective analysis of perioperative mortality, length of hospitalization (LOS), blood transfused during surgery (IBT), intraoperative blood lost (IBL), biliary complications (BC), and aspartate aminotransferase (AST)/alanine aminotransferase (ALT) peak in the first postoperative week. This group of patients (Group A) was compared, using the analysis of variance (ANOVA) test (P < .05) with 2 different groups of 19 patients: Group B with liver neoplasms that had the same technique as Group A, and Group C wherein a crushing clamp technique was used. RESULTS: All of the analyzed variables showed significative statistical differences, especially between Group A and Group C (IBL, P < .000; IBT, P < .006; LOS, P < .028; BC, P < .000; AST peak, P < .041; and ALT peak, P < .023). DISCUSSION: The association of these 2 techniques seems to reduce the LOS, and the need for intraoperative blood transfusions. Moreover, the surgical complications (biliary leaks) and the postoperative parenchymal cytonecrosis seem to be less using this technique.

Pediatric liver transplantation: preliminary results at Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione.

Between July 2003 and November 2004 14 pediatric liver transplantations (LTx) have been performed in 12 children using cadaveric donors. The primary diseases were as follows biliary atresia in 9 cases, whereas the other 3 children were affected by cystic fibrosis, Langherans cells histiocytosis, and hepatoblastoma, respectively. Median patient waiting time was 103 days (range, 2-158); no patient died while on the waiting list. Patients who underwent transplantation included 7 boys and 5 girls, ranging in age from 6 months to 14 years (median age, 5 years). Recipient median weight was 16 kg (range, 6-38). Donor median age was 19 years (range, 3-47), whereas donor median weight was 74 kg (range, 15-90). All children who underwent primary LTx were United Network for Organ Sharing (UNOS) status 2B. Of the 12 transplanted patients, 9 received a left lateral segment (LLS) from an in situ split liver, whereas 3 received a whole graft. Two children developed an episode of acute cellular rejection on the seventh postoperative day, which was treated successfully with a course of intravenous steroids for 3 days. After a median follow-up of 245 days, 10 children are alive but 2 children died due to primary nonfunction (PNF) on the second postoperative day and septic shock on the fifth postoperative day after retransplantation for acute hepatic artery thrombosis, respectively. One child who underwent retransplantation for hepatic artery thrombosis on the 31st postoperative day after primary LTx is currently alive. Evaluation of our initial data suggests that the split liver technique has the potential to meet the needs of pediatric LTx allowing grafting early in the course of the original disease and reducing waiting time.

Basiliximab in a triple-drug regimen with tacrolimus and steroids in liver transplantation.

BACKGROUND: Basiliximab, a chimeric monoclonal antibody (mAb) directed against the alpha chain of the interleukin-2 (IL-2) receptor (CD25), has been extensively evaluated as induction therapy for kidney transplant recipients, more frequently in combination with a cyclosporine-based regimen. In this study, we assessed the efficacy and safety of basiliximab in combination with tacrolimus and steroids following liver transplantation. METHODS: One hundred fifty-two liver transplant recipients (141 cadaveric donors and 11 living donors [LRLT]) in the last 4 years were treated with 2 20-mg doses of basiliximab (days 0 and 4 posttransplantation) followed by tacrolimus (0.15 mg/kg/d; 10-15 ng/mL target trough levels) and steroids (500 mg intravenous [IV] bolus at the reperfusion followed by 20 mg orally daily and weaning off in 1 or 2 months). Follow-up ranged from 104 to 1630 days after transplantation (mean, 665 days; SD +/- 442.65; median, 509 days). RESULTS: Eighty-five percent of patients remained rejection-free during follow-up with an actuarial rejection-free probability of 78% within 3 months. Nineteen patients had 22 episodes of biopsy-proven acute cellular rejection (ACR). Actuarial patient and graft survival rates at 3 years were 86.7% and 75.8%, respectively. Twenty-seven patients (20.6%) experienced 1 episode of sepsis, requiring temporary reduction of immunosuppressive therapy. There was no evidence of CMV infections or side effects related to basiliximab. We observed 2 de novo malignancies, 1 recurrence from an ileal carcinoid tumor and 1 pulmonary recurrence of hepatocellular carcinoma (HCC) in 1 recipient of LRLT. CONCLUSIONS: Basiliximab in association with tacrolimus and steroids is effective prophylaxis of ACR in liver transplant recipients and does not increase the incidence of infections or adverse effects.

Evolution of a single unit from general to geriatric surgery: a retrospective study comparing surgical management of elderly patients.

The increase in the geriatric population in recent decades was not followed by a corresponding increase in attention on the part of surgeons to elderly patients until, in the '80s, many clinical studies showed that postoperative morbidity and mortality were related to the associated diseases rather than to the patients' age. To evaluate whether greater attention to the elderly is capable of increasing the number of operations that can be performed when necessary, we retrospectively surveyed the activity of a division of general surgery over two different periods of 5 years: the first one from 01/01/1985 to 31/12/1989 and the second from 01/01/1995 to 31/12/1999, when a team was specifically set up to take care of elderly patients. We registered a significant difference in the number of elderly patients operated on for tumours (134 vs. 208), an increase in colorectal neoplasms (24 vs. 70) and significant differences between radical and palliative surgery (P = 0.03). The extension of radical interventions for cancer to the elderly resulted in a moderate increase in postoperative complications. The surgery-related mortality was around 3.5% in both periods. Thus, a team of surgeons specifically dedicated to aged patients can improve the number of surgical operations performed in these subjects when required without any rise in postoperative mortality.