Actual Risk of Using Very Aged Donors for Unselected Liver Transplant Candidates: A European Single-center Experience in the MELD Era.

OBJECTIVE: To evaluate the whole experience of liver transplantation (LT) with donors ≥70 years in a single center not applying specific donor/recipient matching criteria. BACKGROUND: LT with very old donors has historically been associated with poorer outcomes. With the increasing average donor age and the advent of Model for End-stage Liver Diseases (MELD) score-based allocation criteria, an optimal donor/recipient matching is often unsuitable. METHODS: Outcomes of all types of LTs were compared according to 4 study groups: patients transplanted between 1998 and 2003 with donors <70 (group 1, n = 396) or ≥70 years (group 2, n = 88); patients transplanted between 2004 and 2010 with donors <70 (group 3, n = 409), or ≥70 years (group 4, n = 190). From 2003, graft histology was routinely available before cross-clamping, and MELD-driven allocation was adopted. RESULTS: Groups 1 and 2 were similar for main donor and recipient variables, and surgical details. Group 4 had shorter donor ICU stay, lower rate of moderate-to-severe graft macrosteatosis (2.3% vs 8%), and higher recipient MELD score (22 vs 19) versus group 3. After 2003, median donor age, recipient age, and MELD score significantly increased, whereas moderate-to-severe macrosteatosis and ischemia time decreased. Five-year graft survival was 63.6% in group 1 versus 59.1% in group 2 (P = 0.252) and 70.9% in group 3 versus 67.6% in group 4 (P = 0.129). Transplants performed between 1998 and 2003, recipient HCV infection, balance of risk score >18, and pre-LT renal replacement treatments were independently associated with worse graft survival. CONCLUSIONS: Even without specific donor/recipient matching criteria, the outcomes of LT with donors ≥70 and <70 years are comparable with appropriate donor management.

Combined liver-dual kidney transplant: Role in expanded donors.

Kidney injury is a common clinical feature among liver transplantation (LT) candidates that heavily affects prognosis and complicates the surgical decision-making process. Up to 20% of patients undergoing LT demonstrate some degree of renal impairment, and 2% will benefit from a combined liver-kidney transplantation (LKT). We present a case-control study of all patients who underwent LKT and combined liver-dual kidney transplantation (LDKT) from November 2013 to March 2016. For the selection of LDKT candidates, a histological-based algorithm was applied: when evaluating extended criteria donors (ECDs), with any Remuzzi score between 4 and 7, we would consider performing a LDKT instead of a simple LKT. Study groups were similar for recipient variables. In the LDKT group, donor age, donor risk index, and donor body mass index were found to be significantly higher. Biopsies obtained from all pairs of kidney grafts in the LDKT group demonstrated the following Remuzzi scores: 4+4, 4+4, 7+1, 4+5. Despite longer operative times for the LDKT procedure, no differences were observed regarding the main investigated outcome parameters. Overall survival was 100% (LDKT) and 91% (LKT, P > 0.99). This is a preliminary experience which might indicate that LDKT is a safe, feasible, and resource-effective technique. The evaluation of a larger cohort, as well as the experience from other centers, would be needed to clearly identify its role in the ECD era. Liver Transplantation 23:28-34 2017 AASLD.

Impact of octogenarians on surgical outcome in colorectal cancer.

AIM: Colorectal cancer's (CRC) incidence occupies the second place among malignant tumours in men and the third place in women. The aging of the population raises new questions on the management of CRC in octogenarian patients. The objective of this study was to assess the influence of age (≥80) on treatment and surgical outcome of colorectal cancer. METHOD: In the period between October 1995 and April 2014, a total of 1397 patients underwent emergency and elective surgical interventions for CRC; the first group (Group-Older - GO) was composed of 291 patients 80 years or older (20.9%, of which 46.4% were male). The second group (Group-Younger - GY) included 1106 patients younger than 80 years (79,1%, 57.7% males). RESULTS: Significant differences between the two groups were observed regarding sex (p = 0.001), number of comorbidities (p = 0.001), ASA classification (p < 0.001), emergency presentation (p < 0.001), site of tumor (p = 0.010), need of intraoperative blood transfusions (p < 0.001), 30-days mortality (p < 0.001), 90-days mortality (p < 0.001) and morbidity in accordance with Clavien-Dindo classification (p < 0.001). When combining both elective and emergency procedures, multivariate logistic regression analysis showed that advanced age (≥80 years old) was an independent predictor factor of 30-days mortality (p = 0.023, OR = 2.23) and morbidity (p = 0.088, OR = 1.31), while it was not predictive of 90-days mortality. When considering only elective colorectal surgery, octogenarian age was not found to be a predictive factor of 30-day and 90-day mortality, but predictive of postoperative morbidity. CONCLUSION: Old age (≥80) does not represent a contraindication to CRC elective surgical treatment, in emergency procedures it is associated with an increased risk of postoperative morbidity and mortality.

Salvage liver transplantation after laparoscopic resection for hepatocellular carcinoma: a multicenter experience.

Liver transplantation is the ideal treatment for patients affected by early stage hepatocellular carcinoma and chronic liver disease. Considering organs shortage, alternative treatments have to be adopted to minimize the waitlist drop-out, and in case of recurrence within the accepted criteria, salvage transplantation can be considered. Surgical resection is one of the most effective treatments, with the possibility of oncological radicality and pathological analysis of the specimen. Although these theoretical advantages, surgical strategy cannot be applied to all patients because of the impaired liver function as well as the amount of parenchyma to be resected does not allow a sufficient future liver remnant. Furthermore, resection by laparotomy may lead to strong intra-abdominal adhesions in a contest of portal hypertension and, as potential consequence, increase transplantation difficulty raising morbidity. Laparoscopic liver resection is now performed as a routine procedure in tertiary referral centers, with increasing evidence of long-term results comparable to traditional surgery together with the advantages of a minimally invasive approach. In addition, with a salvage transplantation strategy that has been shown to be comparable to primary transplantation, the patient can live with his native liver avoiding an invasive procedure and long-term immunosuppression, allowing the use of liver grafts for the community. We present the results of an Italian multicenter experience of salvage liver transplantation following the recurrence of HCC initially treated by laparoscopic resection in 31 patients, performed by four referral centers. Mean operative transplantation time was 450 min, morbidity was 41.9%, 90-days mortality was 3.2%, and median post-operative length of stay was 17.9 days. Salvage liver transplantation after laparoscopic liver resection for HCC is comparable to open surgery in terms of operative time, oncologic radicality, morbidity and mortality, with the advantages of laparoscopic surgery.

A case of portal vein arterialization after a liver transplant.

Hepatic artery thrombosis represents a potentially deadly complication after a liver transplant. Portal vein arterialization recently has been proposed as a bridge approach in patients with hepatic artery thrombosis needing a retransplant. We report the case of a 53-year-old man treated with a liver transplant for a cryptogenetic cirrhosis. One month after a liver transplant, a hepatic artery thrombosis was documented, and a portal vein arterialization as bridge therapy for another liver transplant was performed. After surgery, improvement in the patient's liver functioning was seen. No signs of portal hypertension or hepatic abscesses were documented. Unfortunately, 8 months after the liver transplant, the patient experienced a severe urinary infection caused by a multidrug-resistant Klebsiella and died. An increase in the oxygen supply to the liver parenchyma after portal vein arterializations represents rationale use for managing hepatic artery thromboses. Several cases of treating post liver transplant hepatic artery thromboses have been reported in the literature. Portal vein arterializations can be used as bridge therapy in well-selected situations of post-liver transplant hepatic artery thromboses. Strict surveillance should be used to prevent the onset of complications that can exclude a patient from a transplant. The correct timing for retransplant is not fully known, but we think the shorter the time to retransplant, the better is the patient survival.

Laparoscopy in Liver Transplantation: The Future has Arrived.

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic end-stage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.