251
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Aurello P, Dente M, D'Angelo F, Nigri G, Cescon M, Ramacciato G. Intestinal occlusion resulting from a small bowel adenocarcinoma as first onset of Crohn's disease in a healthy patient. Am Surg 2009; 75:189-190. [PMID: 19280822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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252
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Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M. Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? Ann Surg Oncol 2009; 16:817-25. [PMID: 19156463 DOI: 10.1245/s10434-008-0281-8] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 11/18/2008] [Accepted: 11/18/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic carcinoma frequently infiltrates the portal vein or the superior mesenteric vein; pancreatectomy combined with portal vein/superior mesenteric vein resection represents a potentially curative treatment in these cases but is still a controversial procedure. METHODS After performing a computerized Medline search, 12 series published during the last 8 years were selected, enrolling 399 patients who underwent pancreatectomy combined with portal vein/superior mesenteric vein resection for pancreatic carcinoma. Data were examined for information about indications, operation, adjuvant therapies, histopathology of resected specimens, perioperative results, and survival. Also, previous literature regarding the issue was extensively reviewed. RESULTS Operative mortality and postoperative complication rates ranged from 0 to 7.7% and 16.7% to 54%, respectively. Median survival varied from 13 to 22 months; 5-year survival rate ranged from 9% to 18%. CONCLUSIONS The current literature suggests that portal vein/superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that increases the number of patients who undergo curative resection and, therefore, provides important survival benefits to selected groups of patients. This procedure should always be considered in case of suspected tumor infiltration of portal/superior mesenteric vein to achieve clear resection margins, in the absence of other contraindications for resection.
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Affiliation(s)
- Giovanni Ramacciato
- Azienda Ospedaliera Sant'Andrea, UOC Hepatobiliary and Pancreatic Surgery, II Faculty of Medicine, University of Rome La Sapienza, Via di Grottarossa 1035-1039, Rome, Italy.
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253
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Ravaioli M, Grazi GL, Piscaglia F, Trevisani F, Cescon M, Ercolani G, Vivarelli M, Golfieri R, D'Errico Grigioni A, Panzini I, Morelli C, Bernardi M, Bolondi L, Pinna AD. Liver transplantation for hepatocellular carcinoma: results of down-staging in patients initially outside the Milan selection criteria. Am J Transplant 2008; 8:2547-57. [PMID: 19032223 DOI: 10.1111/j.1600-6143.2008.02409.x] [Citation(s) in RCA: 283] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Conventional criteria for liver transplantation for patients with hepatocellular carcinoma are single HCC <or= 5 cm or less than or equal to three HCCs <or= 3 cm. We prospectively evaluated the possibility of slightly extending these criteria in a down-staging protocol, which included patients initially outside conventional criteria: single HCC 5-6 cm or two HCCs <or= 5 cm or less than six HCCs <or= 4 cm and sum diameter <or= 12 cm, but within Milan criteria in the active tumors after the down-staging procedures. The outcome of patients down-staged was compared to that of Milan criteria after liver transplantation and since the first evaluation according to an intention-to-treat principle. From 2003 to 2006, 177 patients with HCC were considered for transplantation: the transplantation rate was comparable between the Milan and down-staging groups: 88/129 cases (68%) versus 32/48 cases (67%), respectively. At a median follow-up of 2.5 years after transplantation, the 1 and 3 years' disease-free survival rates were comparable: 80% and 71% in the Milan group versus 78% and 71% in the down-staging. The actuarial intention-to-treat survival was 27/48 patients (56.3%) in the down-staging and 81/129 cases (62.8%) in the Milan group, p = n.s. The proposed down-staging criteria provide a comparable outcome to the conventional criteria.
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Affiliation(s)
- M Ravaioli
- Department of Liver and Multi-organ Transplantation, Pathology Division of the F. Addarii Institute, Sant' Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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254
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Cucchetti A, Piscaglia F, Caturelli E, Benvegnù L, Vivarelli M, Ercolani G, Cescon M, Ravaioli M, Grazi GL, Bolondi L, Pinna AD. Comparison of recurrence of hepatocellular carcinoma after resection in patients with cirrhosis to its occurrence in a surveilled cirrhotic population. Ann Surg Oncol 2008; 16:413-22. [PMID: 19034578 DOI: 10.1245/s10434-008-0232-4] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Revised: 10/13/2008] [Accepted: 10/14/2008] [Indexed: 12/17/2022]
Abstract
The presence of cirrhosis is the only risk factor that is advocated for recurrence of hepatocellular carcinoma (HCC) 2 years after hepatic resection compared with noncirrhotic control subjects; however, data for cohorts of exclusively patients with cirrhosis are lacking. This study was designed to assess risk factors and annual incidence of early (<2 years) and late (>2 years) recurrence after resection of cirrhosis and to compare these findings with those of patients with cirrhosis enrolled in HCC surveillance programs (HCC occurrence). Data from 204 patients with cirrhosis resected for HCC and 150 surveilled for cirrhosis were retrospectively collected and compared using propensity score matching to overcome biases of nonrandomized study. Risk factors for early recurrence (incidence = 21.8%/year) were higher serum alpha-fetoprotein (AFP) levels, poorly differentiated tumor, and presence of microvascular invasion (P < 0.05). Risk factors for both late recurrence (18.4%/year) and HCC occurrence (3.3%/year) were male gender, older age, and higher serum transaminase levels; multiple primary tumors and higher AFP were additional risk factors for late recurrence and HCC occurrence respectively (P < 0.05). After propensity adjustment, resected patients with less than two risk factors for late recurrence showed an annual incidence of HCC (6.2%/year) similar to that of surveilled patients with > or =2 risk factors (5.8%/year; P = 0.898). Early and late recurrence of HCC for patients with cirrhosis after resection have distinct risk factors. Annual incidence of HCC 2 years or more after resection may be similar to that of general patients because the same risk factors are involved; assessment of these characteristics could be useful in tailoring clinical management.
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255
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Ravaioli M, Grazi GL, Cescon M, Cucchetti A, Ercolani G, Fiorentino M, Panzini I, Vivarelli M, Ramacciato G, Del Gaudio M, Vetrone G, Zanello M, Dazzi A, Zanfi C, Di Gioia P, Bertuzzo V, Lauro A, Morelli C, Pinna AD. Liver transplantations with donors aged 60 years and above: the low liver damage strategy. Transpl Int 2008; 22:423-33. [PMID: 19040483 DOI: 10.1111/j.1432-2277.2008.00812.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
According to transplant registries, grafts from elderly donors have lower survival rates. During 1999-2005, we evaluated the outcomes of 89 patients who received a liver from a donor aged > or = 60 years and managed with the low liver-damage strategy (LLDS), based on the preoperative donor liver biopsy and the shortest possible ischemia time (group D > or = 60-LLDS). Group D > or = 60-LLDS was compared with 198 matched recipients, whose grafts were not managed with this strategy (89 donors < 60 years, group D < 60-no-LLDS and 89 donors aged > or =60 years, group D > or = 60-no-LLDS). In the donors proposed from the age group of > or =60 years, the number of donors rejected decreased during the study period and the LLDS was found to be responsible for this in a significant manner (47% vs. 60%, respectively P < 0.01). Among the recipients transplanted, the clinical features (age, gender, viral infection, child and model for end-stage liver disease score) were comparable among groups, but group D > or = 60-LLDS had a lower mean ischemia time: 415 +/- 106 min vs. 465 +/- 111 (D < 60-no-LLDS), P < 0.05 and vs. 476 +/- 94 (D > or = 60-no-LLDS), P < 0.05. After a median follow-up of 3 years, the 1- and 3-year graft survival rates of group D > or = 60-LLDS (84% and 76%) were comparable with group D < 60-no-LLDS (89% and 76%) and were significantly higher than group D > or = 60-no-LLDS (71% and 54%), P < 0.005. In conclusion, the LLDS optimized the use of livers from elderly donors.
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Affiliation(s)
- Matteo Ravaioli
- Liver and Multi-organ Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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256
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Ravaioli M, Grazi GL, Vetrone G, Kimura T, Zanello M, Ercolani G, Cescon M, Varotti G, Del Gaudio M, Tuci F, Cucchetti A, La Barba G, Vivarelli M, Lauro A, Ramacciato G, Pinna AD. A new liver transplant priority for patients with hepatocellular carcinoma. Hepatogastroenterology 2008; 55:1742-1745. [PMID: 19102382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND/AIMS Patients with hepatocellular carcinoma on the waiting list for liver transplantation are excluded due to causes related to liver failure and tumor progression. We analyze the various factors to suggest a new liver transplant priority. METHODOLOGY We evaluated the outcome on the list of 309 patients with hepatocellular carcinoma and causes of drop-out from the list were divided as death, "too sick" and tumor progression. The impact of model for end stage liver disease score, tumor stage and waiting time on the causes of drop-outs was evaluated. RESULTS During the study period, 197 patients had a liver transplantation, 50 were still on the list and the remaining 62 were removed from the list (28 deaths, 30 tumor progressions, and 4 "too sick"). The receiver operating characteristic curves analysis showed that the model for end stage liver disease score predicted the rate of deaths on the list at 1-year (p<0.001). The waiting time and the tumor stage predicted the rate of drop-outs for tumor progression at 1-year on the list (p<0.05). CONCLUSIONS Patients with hepatocellular carcinoma on the waiting list should have priority based on their model for end stage liver disease score, waiting time with tumor and tumor stage.
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Affiliation(s)
- Matteo Ravaioli
- Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
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257
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Lodato F, Berardi S, Gramenzi A, Mazzella G, Lenzi M, Morelli MC, Tame MR, Piscaglia F, Andreone P, Ballardini G, Bernardi M, Bianchi FB, Biselli M, Bolondi L, Cescon M, Colecchia A, D'Errico A, Del Gaudio M, Ercolani G, Grazi GL, Grigioni W, Lorenzini S, Pinna AD, Ravaioli M, Roda E, Sama C, Vivarelli M. Clinical trial: peg-interferon alfa-2b and ribavirin for the treatment of genotype-1 hepatitis C recurrence after liver transplantation. Aliment Pharmacol Ther 2008; 28:450-7. [PMID: 18549463 DOI: 10.1111/j.1365-2036.2008.03761.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment of hepatitis C virus (HCV) recurrence after liver transplantation (LT) is difficult with low response rates. AIM To assess the safety and efficacy of pegylated-interferon (PEG-IFN) alfa-2b + ribavirin (RBV) in patients with post-LT recurrent genotype-1 HCV and to establish stopping rules according to response. METHODS Fifty-three patients with post-LT HCV recurrence were enrolled. Patients received PEG-IFN alfa-2b 1.0 micro/kg/week plus RBV 8-10 mg/kg/day for 24 weeks. Those with 'early virological response at week 24' (EVR24) continued treatment for 24 weeks (group A). Patients without EVR24 were randomized to continue (group B) or to discontinue (group C). RESULTS Overall sustained virological response (SVR) was 26% (14/53). Alanine aminotransferase, rapid virological response, EVR12, EVR24, undetectable serum HCV-RNA at weeks 12 (cEVR12) and 24 (cEVR24) were related to SVR. cEVR12 and cEVR24 (OR: 14.7; 95% CI: 2.02-106.4) were independent predictors of SVR. All patients with SVR, had cEVR12. No patient in groups B and C achieved end-of-treatment response. One patient in group B had SVR. CONCLUSIONS Pegylated-interferon alfa-2b was effective in one of four of patients with HCV genotype 1 after LT. Treatment should be discontinued in patients with no virological response at week 12. Further studies are needed to evaluate whether a longer treatment period may be beneficial in patients with > or =2 log10 drop in HCV-RNA at week 24.
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Affiliation(s)
- F Lodato
- Department of Digestive Diseases and Internal Medicine, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola-Malpighi, Bologna, Italy
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258
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Zanfi C, Lauro A, Cescon M, Ansaloni L, Grazi GL, Cucchetti A, Ravaioli M, Zanello M, Pironi L, Pinna AD. RECOVERY FROM LIVER DYSFUNCTION AFTER ADULT ISOLATED INTESTINAL TRANSPLANTATION WITHOUT LIVER GRAFTING. Transplantation 2008. [DOI: 10.1097/01.tp.0000332119.05227.d7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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259
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Ravaioli M, Masetti M, Dazzi A, Romano A, Spaggiari M, Grazi GL, Ercolani G, Cescon M, Di Gioia P, De Ruvo N, Montalti R, Ballarin R, Di Benedetto F, Ridolfi L, Alvaro N, Ramacciato G, Morelli C, Gerunda E, Pinna AD. Model for End-Stage Liver Disease (MELD) system to allocate and to share livers: experience of two Italian centers. Transplant Proc 2008; 40:1814-5. [PMID: 18675057 DOI: 10.1016/j.transproceed.2008.05.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The use of the Model for End-stage Liver Disease (MELD) score to prioritize patients on liver waiting lists and to share organs among centers was effective according to US data, but few reports are available in Europe. MATERIALS AND METHODS We evaluated the outcome of 887 patients listed between April 2004 and July 2006 in a common list by two transplant centers (University of Bologna [BO] and University of Modena [MO] ordered according to the MELD system. Patients with hepatocellular carcinoma had a score calculated according to their real MELD, tumor stage, and waiting time. RESULTS Five hundred eighty-six (67%) patients were listed from BO and 291 (33%) from MO. The clinical features of recipients (sex, age, blood group, and real MELD) were comparable between centers. The number of liver transplantations performed was 307, and 273 (89%) recipients had a calculated MELD >or=20. Liver transplantations were equally distributed according to the number of patients listed: 215 out of 586 (36.7%) for BO and 92 out of 291 (31.6%) for MO. The median real MELD of patients transplanted was 20, and 246 out of 307 (80.1%) grafts transplanted were functioning. The dropouts from the list were 124 (14%), and 87 (70%) of these patients had a calculated MELD >or=20. CONCLUSION The MELD system was effective to share livers among the two Italian centers. According to this policy, livers were allocated to the recipients with the highest probability of dropout and who had a satisfactory survival after liver transplantation.
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Affiliation(s)
- M Ravaioli
- Department of Liver and Multi-organ Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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260
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Ercolani G, Ravaioli M, Grazi GL, Cescon M, Del Gaudio M, Vetrone G, Zanello M, Pinna AD. Use of vascular clamping in hepatic surgery: lessons learned from 1260 liver resections. ACTA ACUST UNITED AC 2008; 143:380-7; discussion 388. [PMID: 18427026 DOI: 10.1001/archsurg.143.4.380] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS Several techniques have been introduced to minimize intraoperative bleeding in hepatic surgery. Ischemia-reperfusion injuries and intestinal congestion are the main drawbacks of vascular clamping. We hypothesized possible negative effects on early postoperative outcomes associated with different types of vascular clamping during liver resections and evaluated how attitudes have changed in the past 20 years. DESIGN Retrospective review. SETTING Academic research institute. PATIENTS Patients who underwent 1260 consecutive liver resections, 338 of them (26.8%) in patients with cirrhosis. MAIN OUTCOME MEASURES Postoperative complications and mortality were analyzed relative to liver disease, blood transfusion, vascular clamping, and type of liver resection. RESULTS Vascular clamping was applied in 594 patients (47.1%). Operative mortality was 4.4% in the vascular clamping group and 2.9% in the nonclamped group, a statistically nonsignificant difference. On multivariate analysis, blood transfusion, major hepatectomies, and the presence of cirrhosis were statistically significantly associated with postoperative complications. Among the overall cohort and among patients with cirrhosis, there was statistically significantly reduced use of vascular clamping and of blood transfusion during the past 20 years. The lowest incidences of severe complications occurred among cases of continuous or hemihepatic clamping. Among 338 patients with cirrhosis, 155 (45.9%) received some type of vascular control; morbidity and mortality rates were similar in the groups with vs those without vascular control. On multivariate analysis, only blood transfusion was statistically significantly associated with postoperative morbidity. Postoperative complications were statistically significantly reduced among patients receiving intermittent compared with continuous clamping. CONCLUSIONS Vascular clamping can be applied without additional risk during partial hepatectomy. Intermittent or hemihepatic clamping is preferable in patients with cirrhosis.
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Affiliation(s)
- Giorgio Ercolani
- Department of Surgery and Transplantation, S Orsola Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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261
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Del Gaudio M, Ercolani G, Ravaioli M, Cescon M, Lauro A, Vivarelli M, Zanello M, Cucchetti A, Vetrone G, Tuci F, Ramacciato G, Grazi GL, Pinna AD. Liver transplantation for recurrent hepatocellular carcinoma on cirrhosis after liver resection: University of Bologna experience. Am J Transplant 2008; 8:1177-85. [PMID: 18444925 DOI: 10.1111/j.1600-6143.2008.02229.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Liver resection (LR) for patients with small hepatocellular carcinoma (HCC) with preserved liver function, employing liver transplantation (LT) as a salvage procedure (SLT) in the event of HCC recurrence, is a debated strategy. From 1996 to 2005, we treated 227 cirrhotic patients with HCC transplantable: 80 LRs and 147 LTs of 293 listed for transplantation. Among 80 patients eligible for transplantation who underwent LR, 39 (49%) developed HCC recurrence and 12/39 (31%) of these patients presented HCC recurrence outside Milan criteria. Only 10 of the 39 patients underwent LT, a transplantation rate of 26% of patients with HCC recurrence. According to intention-to-treat analysis of transplantable HCC patients who underwent LR (n = 80), compared to all those listed for transplantation (n = 293), 5-year overall survival was 66% in the LR group versus 58% in patients listed for LT, respectively (p = NS); 5-year disease-free survival was 41% in the LR group versus 54% in patients listed for LT (p = NS). Comparable 5-year overall (62% vs. 73%, p = NS) and disease-free (48% vs. 71%, p = NS) survival rates were obtained for SLT and primary LT for HCC, respectively. LR is a valid treatment for small HCC and in the event of recurrence, SLT is a safe and effective procedure.
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Affiliation(s)
- M Del Gaudio
- Liver and Multiorgan Transplantation unit, S. Orsola-Malpighi Hospital, University of Bologna Italy, Bologna, Italy.
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262
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Lauro A, Altimari A, Di Simone M, Dazzi A, Cescon M, Zanfi C, Miklosova Z, Corti B, Gruppioni E, D'Errico A, Cautero N, Giustozzi G, Ansaloni L, Ramacciato G, Gruttadauria S, Gruttadauria G, Pinna A. Acute Cellular Rejection Monitoring After Intestinal Transplant: Utility of Serologic Markers and Zoom Videoendoscopy as Support of Conventional Biopsy and Clinical Findings. Transplant Proc 2008; 40:1575-6. [DOI: 10.1016/j.transproceed.2008.03.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Revised: 02/14/2008] [Accepted: 03/11/2008] [Indexed: 10/21/2022]
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263
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Cescon M, Grazi GL, Cucchetti A, Ravaioli M, Ercolani G, Vivarelli M, D'Errico A, Del Gaudio M, Pinna AD. Improving the outcome of liver transplantation with very old donors with updated selection and management criteria. Liver Transpl 2008; 14:672-9. [PMID: 18433035 DOI: 10.1002/lt.21433] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Advanced donor age is a risk factor for poor outcome in liver transplantation (LT). We reviewed 553 consecutive transplants according to donor age categories [group 1 (n = 173): <50 years; group 2 (n = 96): 50-59 years; group 3 (n = 132): 60-69 years; group 4 (n = 111): 70-79 years; group 5 (n = 41): > or =80 years]. Clinical parameters were comparable between groups. Group 5 had the highest proportion of pretransplant liver biopsy (85%), with only 1 graft showing macrovesicular steatosis > 30%, and the lowest ischemia time. Five-year graft survival was significantly higher in group 1 (75%) versus groups 3 (60%) and 4 (62%; P = 0.01 and P = 0.001, respectively) and in group 5 (81%) versus groups 3 and 4 (P = 0.04 and P = 0.01, respectively). Donor age of 60-79 years, recipient hepatitis C virus-positive status, Model for End-Stage Liver Disease score > or = 25, and emergency LT were predictors of poor survival. In hepatitis C virus-positive patients, 5-year graft survival was 72% in group 1, 85% in group 2, 52% in group 3, 65% in group 4, and 71% in group 5 (group 1 versus group 3, P = 0.04; group 2 versus group 3, P = 0.03). In conclusion, older donor grafts managed with routine graft biopsy and short ischemia time may work effectively, regardless of the severity of the recipient's liver disease.
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Affiliation(s)
- Matteo Cescon
- Liver and Multiorgan Transplant Unit, Department of Surgery and Transplantation, University of Bologna, Bologna, Italy.
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264
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Grazi GL, Cescon M, Ravaioli M, Corti B, Pinna AD. Successful liver transplantation from a 95-year-old donor to a patient with MELD score 36 and delayed graft arterialization. Am J Transplant 2008; 8:725-6. [PMID: 18294175 DOI: 10.1111/j.1600-6143.2007.02114.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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265
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Ramacciato G, Nigri G, Di Santo V, Piccoli M, Pansadoro V, Buniva P, Bellagamba R, Cescon M, Ercolani G, Cucchetti A, Lauro A, Del Gaudio M, Ravaioli M, Valabrega S, D'Angelo F, Aurello P, Stigliano A, Toscano V, Melotti G. [Minimally invasive adrenalectomy: transperitoneal vs. retroperitoneal approach]. Chir Ital 2008; 60:15-22. [PMID: 18389743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Laparoscopic adrenalectomy is now regarded as the procedure of choice for most adrenal glands presenting surgical pathology. The primary adrenal-specific contraindication to laparoscopic adrenalectomy today is the presence of a large adrenal mass with evidence of local infiltration or venous invasion. We used our multicentre experience to compare the transperitoneal (TLA) and retroperitoneal (RLA) minimally invasive approaches. In our study we found statistically significant differences between RLA and TLA in terms of duration of surgery (148 minuti vs. 112; p < 0.005), intra-operative blood loss (439 cc vs 333 p < 0.005; p < 0.005) and time of first oral intake (1.2 +/- 0.5 days vs 1.8 +/- 1.08 days; p < 0.005). The RLA approach is preferable in cases of previous abdominal surgery, but its learning curve is extremely steep. TLA access needs a less demanding learning curve and tends to be faster than RLA, where the working area is penalised by limited manoeuvring space. There is no clear preference between TLA and RLA in the literature. However, the experience of the surgeon still remains the most important variable when choosing between the two approaches.
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Affiliation(s)
- Giovanni Ramacciato
- Chirurgia Generale D, Azienda Ospedaliera Sant'Andrea, II Facoltà di Medicina e Chirurgia, Università degli Studi La Sapienza, Roma
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266
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Ramacciato G, D'Angelo F, Aurello P, Nigri G, Valabrega S, Pezzoli F, Ravaioli M, Cescon M, Cucchetti A, Lauro A, Del Gaudio M, Ercolani G. [Right hemicolectomy for colon cancer: a prospective randomised study comparing laparoscopic vs. open technique]. Chir Ital 2008; 60:1-7. [PMID: 18389741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Since 2001 we have conducted a prospective randomised study of right laparoscopic-assisted hemicolectomy vs open right hemicolectomy for right colon cancer in order to assess the differences in intraoperative and postoperative results as well as oncological clearance. Thirty-three patients with right colon cancer received laparoscopic-assisted right hemicolectomy (LRH) and were compared with 33 patients who underwent open right hemicolectomy (ORH). We analysed morbidity and mortality, number of postoperative days of starving, postoperative days tolerating a liquid diet and a soft diet, duration of postoperative ileus, as well as the distance of the resection margin from the tumour (< 5 cm or >5 cm), and the number of lymph nodes found in the resected specimen. We also compared the length of operative time, blood loss, and any associated surgery. Morbidity occurred in 1 patient undergoing LRH (3.0%) as against 4 patients (12.1%) in the ORH group (p < 0.05). Postoperative ileus lasted 3.15 days (range: 3-5 days) in the LRH group vs 3.0 days (range: 1-4 days) in the ORH group. Median operative time was 251 min (range: 130-360 min) in the LRH group vs 222.9 min (range: 135-360 min) in the ORH group, while blood loss amounted to a median of 135 mi (range: 100-300 ml; SD +/- 42.9 mi) in the LRH group vs. 404.1 ml (range: 250-1000 ml; SD +/- 159.3 ml) in the ORH group (p <0.05). The distance of the resection margin from the tumour was more than 5 cm in both groups. In the LRH group a median of 12.7 lymph nodes were removed (range: 9-31; SD +/- 4.5) vs. 18 lymph nodes in the ORH group (range: 8-29; SD +/- 3.9) (p < 0.05). Associated surgery was performed in 15.1% of cases in both groups. In our experience LRH presents a statistically significant advantage in terms of morbidity and blood loss compared to ORH. Equivalent oncological clearance was obtained, fulfilling the stated criteria of 5 cm free resection margins and number of lymph nodes resected, though we removed fewer lymph nodes in LRH compared to ORH (p < 0.05).
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Affiliation(s)
- Giovanni Ramacciato
- UOC Chirurgia Generale D, Azienda Ospedaliera Sant'Andrea, Roma II Facoltà di Medicina e Chirurgia, Università La Sapienza, Roma
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267
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Cescon M, Grazi GL, Ravaioli M, Cucchetti A, Ercolani G, Pinna AD. Modified outflow reconstruction with a venous patch in domino liver transplantation. Liver Transpl 2007; 13:1756-7. [PMID: 18044779 DOI: 10.1002/lt.21180] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Matteo Cescon
- Liver and Multiorgan Transplant Unit, Department of Surgery and Transplantation, University of Bologna, Bologna, Italy.
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268
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Ravaioli M, Cescon M, Mikus E, Grazi GL, Ercolani G, Kimura T, Tuci F, Mikus PM, Bernardi M, Pinna AD. Liver and partial atrium transplantation for chronic Budd-Chiari syndrome. Liver Transpl 2007; 13:1758-9. [PMID: 18044780 DOI: 10.1002/lt.21256] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Matteo Ravaioli
- Department of Liver and Multi-Organ Transplantation, University of Bologna, and Sant'Orsola-Malpighi Hospital, Bologna, Italy.
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269
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Aurello P, Rossi S, D'Angelo F, Nigri G, Cicchini C, Ciardi A, Coluccia P, Ercolani G, Cescon M, Cucchetti A, Ravaioli M, Del Gaudio M, Ramacciato G. [Angiogenic factors and their relation to stage, lymph-node micrometastases and prognosis in patients operated on for gastric cancer]. Chir Ital 2007; 59:435-444. [PMID: 17966762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The aim of the present study was to investigate the expression of a number of angiogenic factors such as VEGF, VEGF-C, TGF-alpha and apoptosis in an attempt to relate these biological markers to TNM staging, lymph-node status and prognosis. Angiogenic factors and apoptosis were studied immunohistochemically in 72 gastric cancer cases. The search for micrometastases was performed with an immunohistochemical technique in 20 NO cases. Apoptosis determination was assessed with the TUNEL assay. The chi2 test according to Pearson was used for statistical analysis. The apoptotic index was related to both stage and prognosis: high expression cases showed an earlier stage (p < 0.02) and a better prognosis (p < 0.05). The determination of high neovessel density was related to poorer 5-year survival (p < 0.05). Only the expression of VEGF-C correlated inversely with prognosis (p < 0.05). The presence of micrometastases was unrelated to any of the biological markers studied. Our results partly confirm those reported in the literature. The present study revealed a number of biological markers that may be helpful for identifying particular subgroups of patients. More investigation with similar techniques in large prospective series is needed as a support to clinical practice.
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Affiliation(s)
- Paolo Aurello
- Dipartimento di Chirurgia P Valdoni, Seconda Facoltà di Medicina e Chirurgia, Università degli Studi di Roma La Sapienza, Azienda Ospedaliera Sant' Andrea, Roma
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270
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Lauro A, Zanfi C, Ercolani G, Dazzi A, Golfieri L, Amaduzzi A, Pezzoli F, Grazi GL, Vivarelli M, Cescon M, Varotti G, Del Gaudio M, Ravaioli M, Cucchetti A, La Barba G, Zanello M, Vetrone G, Tuci F, Catena F, Ramacciato G, Pironi L, Pinna AD. Italian Experience in Adult Clinical Intestinal and Multivisceral Transplantation: 6 Years Later. Transplant Proc 2007; 39:1987-91. [PMID: 17692673 DOI: 10.1016/j.transproceed.2007.05.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PATIENTS AND METHODS Between December 2000 and November 2006, 28 isolated intestinal transplants and nine multivisceral transplants (five with liver) from cadaveric donors have been performed for short gut syndrome (n = 15), chronic intestinal pseudo-obstruction (n = 10), Gardner's syndrome (n = 9), radiation enteritis (n = 1), intestinal atresia (n = 1), and massive intestinal angiomatosis (n = 1). Indications for transplantations were: loss of venous access, recurrent sepsis due to central line infection, and/or major electrolyte and fluid imbalance. Liver dysfunction was present in 19 cases. All patients were adults of median age at transplant of 34.7 years and mean weight 59.6 kg. All recipients were on total parenteral nutrition for a mean time of 38.8 months. Mean donor/recipient body weight ratio was 1.1. RESULTS The mean follow-up was 892 +/- 699 days. Twenty-five patients were alive (67.5%) with 3-year patient survivals of 70% for isolated intestinal transplantations and 41% for the multivisceral transplantations (P = .01). The mortality rate was 32.5% with losses due to sepsis (63%) or rejection. Our 3-year graft survival rates were 70% for isolated intestinal transplantations and 41% for multivisceral transplantations (P = .02); graftectomy rate was 16%. These were 88% of grafts working properly with patients on regular diet with no need for parenteral nutrition. DISCUSSION AND CONCLUSIONS Induction therapy has reduced the doses of postoperative immunosuppressive agents, especially in the first period, lowering the risk of renal failure and sepsis, mucosal surveillance protocol for early detection of rejection dramatically reduced the number of severe acute chronic rejections.
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Affiliation(s)
- A Lauro
- Liver and Multiorgan Transplant Unit, University of Bologna, Policlinico S Orsola-Malpighi, Bologna, Italy
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271
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Grazi GL, Vetrone G, Ercolani G, Cescon M, Ravaioli M, Zanello M, Corti B, Pinna AD. Associated benign liver tumors in idiopathic granulomatous hepatitis: A case report. Hepatol Res 2007; 37:568-71. [PMID: 17540000 DOI: 10.1111/j.1872-034x.2007.00082.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We report a unique association of ruptured hepatocellular adenoma, focal nodular hyperplasia and granulomatous hepatitis in a young woman taking oral contraceptives. Diffuse granulomatous hepatitis was found in the liver parenchyma, which was associated with a large granulomatous mass of the left lobe and loco-regional granulomatous lymphadenitis. We cannot give a full explanation of the situation, which represented a challenge in the diagnosis and in the treatment of this patient.
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Affiliation(s)
- Gian Luca Grazi
- Liver and Multi-organ Transplantation, F. Addarii Institute of Oncology, Department of Oncology and Haematology, Sant'Orsola-Malpighi Hopsital, University of Bologna, Bologna, Italy
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272
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Golfieri L, Lauro A, Tossani E, Sirri L, Dazzi A, Zanfi C, Vignudelli A, Amaduzzi A, Cucchetti A, La Barba G, Pezzoli F, Ercolani G, Vivarelli M, Del Gaudio M, Ravaioli M, Cescon M, Grazi GL, Grandi S, Pinna AD. Coping Strategies in Intestinal Transplantation. Transplant Proc 2007; 39:1992-4. [PMID: 17692674 DOI: 10.1016/j.transproceed.2007.05.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The psychological construct of coping has been studied extensively in other medical populations and has more recently been applied in the field of transplant psychology. Coping can be defined as all abilities used by people to face problematical and stressful situations, as the data in literature describe the experience of transplantation. The purpose of this study was to describe the coping styles used by 25 intestinal transplant recipients. To assess the coping strategies, we used the Italian version of Coping Orientation to Problems Experienced (COPE) by Sica, Novara, Dorz, and Sanavio (1997). The authors divided these strategies into three classes: problem-focused, emotion-focused, and potentially disadaptive strategies. This questionnaire is usually used in a medical setting. Even if the long process of psychological-clinical adaptation required by intestinal transplantation put patients in a passive acceptance of their situation and their incapacity to face it, our patients showed high levels of problem-focused strategies, indicators of positive outcomes for this intervention. Anyway, this is a slow and gradual path that goes with the psychological distress and the need for a peculiar psychological support of problem-focused strategies. The result suggested that assessment of coping strategies should be explored in intestinal transplant to encourage the use of action-oriented methods and discourage those with possible negative effects.
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Affiliation(s)
- L Golfieri
- Liver and Multiorgan Transplant Unit, Policlinico S Orsola-Malpighi, University of Bologna, Bologna, Italy.
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273
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Cucchetti A, Siniscalchi A, Ercolani G, Vivarelli M, Cescon M, Grazi GL, Faenza S, Pinna AD. Modification of acid-base balance in cirrhotic patients undergoing liver resection for hepatocellular carcinoma. Ann Surg 2007; 245:902-8. [PMID: 17522516 PMCID: PMC1876948 DOI: 10.1097/01.sla.0000256356.23026.9f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine modifications of acid-base balance of cirrhotic patients undergoing hepatectomy for hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA Acid-base disorders are frequently observed in cirrhotics; however, modifications during hepatectomy and their impact on prognosis have never been investigated. METHODS Two hundred and two hepatectomies for HCC on cirrhosis were reviewed. Arterial blood samples were collected immediately before and at the end of resection. Preresection and postresection acid-base parameters were compared and related to patient characteristics and postoperative course. The accuracy of acid-base parameters in predicting postoperative liver failure, defined as an impairment of liver function after surgery that led to patient death or required transplantation, was assessed using receiver operating characteristic analysis (ROC). RESULTS All patients showed a significant reduction in pH, bicarbonate, and base excess at the end of hepatectomy (P < 0.001 in all cases), worsened by intraoperative blood loss (P < 0.010) and preoperative Model for end-stage liver disease score > or =11 (P < 0.010). ROC curve analysis identifies patients with postresection bicarbonate <19.4 mmol/L at high risk for liver failure (50.0%) whereas levels >22.1 mmol/L did not lead to the event (0%; P < 0.001). Postoperative prolongation of prothrombin time and increases in bilirubin, creatinine, and morbidity were also more frequent in patients with lower postresection bicarbonate, resulting in a longer in-hospital stay. CONCLUSION In cirrhotic patients, a trend toward a relative acidosis can be expected during surgery and is worsened by the severity of the underlying liver disease and intraoperative blood loss. Postresection bicarbonate level lower than 19.4 mmol/L is an adverse prognostic factor.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Surgery and Transplantation, Policlinico Sant'Orsola-Malpighi, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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274
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Lauro A, Dazzi A, Ercolani G, Zanfi C, Golfieri L, Amaduzzi A, Cucchetti A, La Barba G, Grazi GL, D'Errico A, Vivarelli M, Cescon M, Varotti G, Del Gaudio M, Ravaioli M, Di Simone M, Faenza S, Pironi L, Pinna AD. Rejection Episodes and 3-Year Graft Survival Under Sirolimus and Tacrolimus Treatment After Adult Intestinal Transplantation. Transplant Proc 2007; 39:1629-31. [PMID: 17580204 DOI: 10.1016/j.transproceed.2007.02.067] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Revised: 11/25/2006] [Accepted: 02/05/2007] [Indexed: 11/19/2022]
Abstract
PURPOSE Mammalian target of rapamycin (mTOR) inhibitors have been recently introduced in clinical practice after intestinal transplantation. We focused on Sirolimus (Rapamycin) to examine effects on rejection and graft survival following intestinal transplantation. PATIENTS AND METHODS Twenty isolated intestinal recipients and 5 multivisceral patients (2 with liver) in our series were divided into 3 groups: patients started on Sirolimus (because of nephrotoxicity or biopsy-proven rejection), who continued therapy longer than 3 months (n = 11); patients started on Sirolimus (because of nephrotoxicity or biopsy-proven rejection), who received therapy less than 3 months because of side effects (n = 4); and a control group, who never received rapamycin (n = 10). RESULTS During prolonged treatment combined with Tacrolimus (Prograf), both Sirolimus groups showed a decreased number of acute cellular rejections (P < .01). Cumulative 3-year graft and patient survival rates were 81% in the Sirolimus greater than 3 months group, 100% in the Sirolimus less than 3 months group, and 80% and 90% in the control group, respectively (P = .63 and P = .62). CONCLUSION In our experience, the use of mTOR-inhibitors in combination with calcineurin-inhibitors seemed to be more effective than monotherapy to reduce the number of rejections. Side effects can limit its use as maintenance therapy.
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Affiliation(s)
- A Lauro
- U.O. Chirurgia dei Trapianti di Fegato e Multiorgano, University of Bologna, Policlinico S. Orsola-Malpighi, Massarenti no. 9, Bologna 40138, Italy.
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275
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Lauro A, Zanfi C, Ercolani G, Dazzi A, Golfieri L, Amaduzzi A, Grazi GL, Vivarelli M, Cescon M, Varotti G, Del Gaudio M, Ravaioli M, Pironi L, Pinna AD. Twenty-five consecutive isolated intestinal transplants in adult patients: a five-yr clinical experience. Clin Transplant 2007; 21:177-85. [PMID: 17425742 DOI: 10.1111/j.1399-0012.2007.00620.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PATIENTS AND METHODS Between December 2000 and December 2005, 25 isolated intestinal transplants from cadaveric donors have been performed for short gut syndrome (short bowel syndrome, 52%), chronic intestinal pseudo-obstruction (24%), Gardner syndrome (16%), radiation enteritis (4%) and massive intestinal angiomatosis (4%). Indications for transplantation were: loss of venous access, recurrent sepsis due to central line infection, major electrolyte and fluid imbalance. Liver dysfunction was present in 13 cases. All patients were adult; median age was 36.3 yr and mean weight at transplantation 61.6 kg. All recipients were on life-threatening parenteral nutrition for a mean time of 23.7 months. Mean donor/recipient body weight ratio was 1.08. Rejection monitoring was accomplished by graft ileoendoscopies and intestinal biopsies through the temporary ileostomy. Our immunosuppressive regimen was based on induction therapy with three different protocols: daclizumab for induction, tacrolimus and steroids as maintenance therapy; alemtuzumab for induction and low-dose tacrolimus as maintenance; thymoglobulin for induction and maintenance based on low-dose tacrolimus. Closure of the abdomen at the end of transplantation represented a technical problem with several options performed: graft reduction, only skin closure, prothesic meshes, abdominal closure in two steps, cutaneous flaps and abdominal wall transplant in one case. RESULTS The mean hospital stay was 37 days. The mean follow-up 27 months. Twenty patients are alive (80%) with two- and five-yr patient survival rate of 80% and 66%; mortality rate was 20% due to sepsis in all cases. Our two- and five-yr graft survival rate is 76% and 64%, graftectomy rate was 16%. Sixteen grafts are working properly, with no need of parenteral nutrition. We diagnosed 35 mild acute cellular rejection (ACRs), seven moderate ACRs and three severe ACRs (two needed graftectomy). We experienced two episodes of chronic rejection biopsy-proven. Rapamicine was added in case of renal failure or biopsy-proven intestinal rejection. Graft-vs.-host disease was not seen in our series while post-transplant lymphoproliferative disease in two cases. After discharge, the most common indication for medical support was dehydration. The abdominal wall transplant did not experience any rejection. DISCUSSION AND CONCLUSIONS Induction therapy has reduced the amount of postoperative immunosuppressive agents, especially in the first period, lowering the risk of renal failure and sepsis and the mucosal surveillance protocol for early detection of rejection dramatically reduced the number of severe ACR.
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Affiliation(s)
- A Lauro
- Liver and Multiorgan Transplant Unit, University of Bologna - Policlinico S. Orsola-Malpighi, Bologna, Italy.
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276
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Lauro A, Amaduzzi A, Dazzi A, Ercolani G, Zanfi C, Golfieri L, Grazi GL, Vivarelli M, Cescon M, Varotti G, Del Gaudio M, Ravaioli M, Siniscalchi A, Faenza S, D'Errico A, Di Simone M, Pironi L, Pinna AD. Daclizumab and alemtuzumab as induction agents in adult intestinal and multivisceral transplantation: A comparison of two different regimens on 29 recipients during the early post-operative period. Dig Liver Dis 2007; 39:253-6. [PMID: 17275428 DOI: 10.1016/j.dld.2006.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Revised: 10/20/2006] [Accepted: 11/21/2006] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Induction therapy has been recently adopted for intestinal transplant. PATIENTS AND METHODS We compared during first 30 days post-transplantation 29 recipients, allocated in two groups, treated with Daclizumab (Zenapax) or Alemtuzumab (Campath-1H). RESULTS During first month, 45% of Daclizumab recipients experienced six acute cellular rejections (ACRs) of mild degree, while 63% of them developed an infection requiring treatment. We found three acute cellular rejections in 17.6% of Alemtuzumab recipients, two with moderate degree; 64.7% of them required treatment for infection. DISCUSSION AND CONCLUSIONS Graft and patient 3-years cumulative survival rate were not significantly different between groups. Alemtuzumab seems to offer a better immunosuppression during first month.
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Affiliation(s)
- A Lauro
- Liver and Multiorgan Transplant Unit, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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277
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Dazzi A, Lauro A, Zanfi C, Ercolani G, Vivarelli M, Grazi GL, Cescon M, Di Simone M, D'Errico A, Lazzarotto T, Faenza S, Pironi L, Pinna AD. Steroids in intestinal transplantation. Clin Transplant 2007; 21:265-8. [PMID: 17425756 DOI: 10.1111/j.1399-0012.2006.00637.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recently, new immunosuppressive protocols after intestinal transplantation have been proposed to avoid steroids use and their adverse effects. We evaluated the impact of steroids on survival and post-transplant complications in our experience. PATIENT AND METHODS In our retrospective study we considered the mean daily dosage of steroids received by 25 patients after intestinal/multivisceral transplantation (minimal follow-up was six months). We analyzed graft and patient survival rates, correlation with rejection and infectious episodes and steroids side effects. RESULTS After a mean follow-up of three yr, we did not find any significant difference in steroid doses between our immunosuppressive protocols. Patients with a mean dosage of prednisone higher than 20 mg/d experienced a lower graft (p = 0.009) and patient (p = 0.02) survival rate. The side effects of steroids after transplant were similar. Infections were more frequent during steroids administration (p = 0.04). DISCUSSION AND CONCLUSION Steroids therapy may be useful to treat acute rejection, but in our experience high steroids regimen did not improve graft and patient survival, increasing infectious rate. We assumed that high dose of steroids can be avoided as maintenance therapy, except in selected cases.
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Affiliation(s)
- A Dazzi
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, University of Bologna, Bologna, Italy
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278
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Venturi A, Piscaglia F, Silvagni E, Righini R, Fabbrizio B, Cescon M, Bolondi L. Role of real-time contrast-enhanced ultrasound in the assessment of metastatic portal vein thrombosis. Ultraschall Med 2007; 28:75-8. [PMID: 17304414 DOI: 10.1055/s-2007-962847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Patients with liver disease or systemic pathology are more prone to develop portal vein thrombosis. Non-neoplastic thrombosis is characterised by absence of intrathrombotic perfusion, corresponding to marked hypoechogenicity at contrast-enhanced ultrasound. We report two cases of portal vein thrombosis in which contrast-enhanced ultrasound showed marked hypoechogenicity in the late phase. This late phase perfusional contrast pattern is consistent with non-neoplastic thrombosis, but is actually similar to that of metastatic liver lesions. Echo-guided needle biopsy indeed yielded histological results consistent with carcinoma. Repeated contrast-enhanced ultrasound showed presence of intratumoural perfusion in the arterial phase, suggestive of the neoplastic nature of the thrombus. Our cases suggest that CEUS with second generation contrast agents in patients with portal thrombosis should include the evaluation of both arterial and portal phases in order to provide accurate non-invasive diagnosis of metastatic portal vein thrombosis.
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Affiliation(s)
- A Venturi
- Department of Internal Medicine and Gastroenterology, St. Orsola-Malpighi University Hospital, Bologna, Italy
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279
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Cescon M, Spada M, Colledan M, Torre G, Andorno E, Valente U, Rossi G, Reggiani P, Cillo U, Baccarani U, Grazi GL, Tisone G, Filipponi F, Rossi M, Ettorre GM, Salizzoni M, Cuomo O, De Feo T, Gridelli B. Feasibility and limits of split liver transplantation from pediatric donors: an italian multicenter experience. Ann Surg 2006; 244:805-14. [PMID: 17060775 PMCID: PMC1856607 DOI: 10.1097/01.sla.0000218076.85213.60] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To report the results of a multicenter experience of split liver transplantation (SLT) with pediatric donors. SUMMARY BACKGROUND DATA There are no reports in the literature regarding pediatric liver splitting; further; the use of donors weighing <40 kg for SLT is currently not recommended. METHODS From 1997 to 2004, 43 conventional split liver procedures from donors aged <15 years were performed. Nineteen donors weighing < or =40 kg and 24 weighing >40 kg were used. Dimensional matching was based on donor-to-recipient weight ratio (DRWR) for left lateral segment (LLS) and on estimated graft-to-recipient weight ratio (eGRWR) for extended right grafts (ERG). In 3 cases, no recipient was found for an ERG. The celiac trunk was retained with the LLS in all but 1 case. Forty LLSs were transplanted into 39 children, while 39 ERGs were transplanted into 11 children and 28 adults. RESULTS Two-year patient and graft survival rates were not significantly different between recipients of donors < or =40 kg and >40 kg, between pediatric and adult recipients, and between recipients of LLSs and ERGs. Vascular complication rates were 12% in the < or =40 kg donor group and 6% in the >40 kg donor group (P = not significant). There were no differences in the incidence of other complications. Donor ICU stay >3 days and the use of an interposition arterial graft were associated with an increased risk of graft loss and arterial complications, respectively. CONCLUSIONS Splitting of pediatric liver grafts is an effective strategy to increase organ availability, but a cautious evaluation of the use of donors < or =40 kg is necessary. Prolonged donor ICU stay is associated with poorer outcomes. The maintenance of the celiac trunk with LLS does not seem detrimental for right-sided grafts, whereas the use of interposition grafts for arterial reconstruction should be avoided.
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Affiliation(s)
- Matteo Cescon
- Liver and Lung Transplantation Unit, Azienda Ospedaliera "Ospedali Riuniti", Bergamo, Italy
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Lauro A, Zanfi C, Ercolani G, Dazzi A, Golfieri L, Amaduzzi A, Grazi GL, Vivarelli M, Cescon M, Varotti G, Del Gaudio M, Ravaioli M, Pironi L, Pinna AD. Recovery From Liver Dysfunction After Adult Isolated Intestinal Transplantation Without Liver Grafting. Transplant Proc 2006; 38:3620-4. [PMID: 17175349 DOI: 10.1016/j.transproceed.2006.10.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Indexed: 12/20/2022]
Abstract
PURPOSE We sought to evaluate liver function recovery after isolated intestinal transplantation in adults with irreversible intestinal failure. PATIENTS AND METHODS Over a 5-year period, we transplanted 34 adult patients, 25 of whom received an isolated intestinal graft, 4 a multivisceral graft without a liver, and 5, a multivisceral graft with a liver. Among the group of patients transplanted with the isolated graft we selected 14 recipients with pretransplant liver dysfunction, namely, a serum bilirubin >2 mg/dL (normal value: 1.2) and/or transaminases >100 IU/mL (NV, 37/40). Other inclusion criteria were total parenteral nutrition, period > 3 months, no diagnosis of portal hypertension or cirrhosis. Two patients had biopsy-proven liver fibrosis. RESULTS At discharge, all patients recovered liver function to normal values: mean bilirubin blood level was 0.9 +/- 0.96 mg/dL (range: 0.3-1.6) and mean transaminases were 26 +/- 9 and 31 +/- 18 IU/mL (range: 10-44/27-65). After a mean follow-up of 2 years, only one patient has an elevated alanine aminotransferase level without clinical signs of liver disease. Type of pretransplant liver disease did not impact on survival rates. CONCLUSION In selected cases, an isolated intestinal or a multivisceral graft without a liver can represent a "liver salvage therapy" for an early failing liver in patients with irreversible intestinal failure. Pretransplant liver disease is not a negative prognostic factor.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, Bologna, Italy.
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281
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Ercolani G, Cucchetti A, Cescon M, Ravaioli M, Grazi GL, Pinna AD. Predictive indices of morbidity and mortality after liver resection. Ann Surg 2006; 244:635-7; author reply 637. [PMID: 16998379 PMCID: PMC1856548 DOI: 10.1097/01.sla.0000239644.28302.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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282
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Ravaioli M, Grazi GL, Ercolani G, Cescon M, Pinna AD, Ballardini G. The Future Challenge in the MELD Era: How to Match Extended-Use Donors and Sick Recipients. Transplantation 2006; 82:987-8. [PMID: 17038919 DOI: 10.1097/01.tp.0000238705.29588.fc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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283
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Lauro A, Dazzi A, Ercolani G, Cescon M, D'Errico A, Di Simone M, Grazi GL, Vivarelli M, Varotti G, De Ruvo N, Masetti M, Cautero N, Di Benedetto F, Siniscalchi A, Begliomini B, Lazzarotto T, Faenza S, Pironi L, Pinna AD. Results of intestinal and multivisceral transplantation in adult patients: Italian experience. Transplant Proc 2006; 38:1696-8. [PMID: 16908252 DOI: 10.1016/j.transproceed.2006.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE We report our experience with intestinal and multivisceral transplantation in Italy. METHODS We performed 23 adult isolated intestinal transplants and seven multivisceral ones, three with liver, between December 2000 and June 2005. Indications for transplantation were loss of venous access (n = 14), recurrent sepsis (n = 10), and electrolyte-fluid imbalance (n = 6), 14 of whom also presented with total parenteral nutrition (TPN)-related liver dysfunction. Immunosuppression was based on induction agents like daclizumab (followed by tacrolimus and steroids) in the first period; alemtuzumab or thymoglobulin (with tacrolimus) in a second period after 2002. RESULTS The mean follow-up was 742 +/- 550 days. Three-year patient actuarial survival rate was 88% for intestinal transplants and 42% for multivisceral (P = .015). Three-year graft actuarial survival rate was 73% for intestinal patients and 42.8% for multivisceral (P = .1). Graft loss was mainly due to rejection (57%). Complications were mainly represented by bacterial infections (92% of patients), relaparotomies (82%), and rejections (72%). Full bowel function without any parenteral nutrition or intravenous fluid support was achieved in 60% of recipients with functioning bowel including 95% on a regular diet. One patient underwent abdominal wall transplantation as well. DISCUSSION AND CONCLUSION Intestinal transplantation has achieved high rates of patient and graft survival with even longer follow-up. Early referral of patients, especially in cases of TPN-liver disease, is mandatory to obtain good outcomes and avoid high mortality rates on the transplant waiting list. Immunosuppressive management remains the key factor to increase the success rate.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, University of Bologna, Policlinico S. Orsola-Malpighi, PAD 25, Via Massarenti 9, 40138 Bologna, Italy.
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284
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Cucchetti A, Ercolani G, Cescon M, Ravaioli M, Zanello M, Del Gaudio M, Lauro A, Vivarelli M, Grazi GL, Pinna AD. Recovery from liver failure after hepatectomy for hepatocellular carcinoma in cirrhosis: meaning of the model for end-stage liver disease. J Am Coll Surg 2006; 203:670-6. [PMID: 17084328 DOI: 10.1016/j.jamcollsurg.2006.06.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Revised: 06/06/2006] [Accepted: 06/20/2006] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatectomy for hepatocellular carcinoma in cirrhosis is followed by an impairment of liver function that can lead to patient death. The model for end-stage liver disease (MELD) is considered an index of hepatic functional reserve, and its assessment on postoperative course may properly identify individuals at risk of liver failure. STUDY DESIGN Two hundred hepatectomies for hepatocellular carcinoma in cirrhosis were reviewed. Irreversible postoperative liver failure was defined as an impairment of liver function after hepatectomy that led to patient death or required transplantation. The MELD scores at postoperative days (POD) 1, 3, 5, and 7 were calculated and kinetics of changes investigated with t-test; logistic regression was applied to identify predictive variables of postoperative liver failure. RESULTS Kinetics of postoperative MELD score showed an impairment of liver function between PODs 1 and 3; 185 patients in whom postoperative liver failure did not develop showed a considerable decrease in MELD score between PODs 3 and 5 (11.9+/-2.8 and 10.6+/-2.4, respectively, p<0.001). On the contrary, 15 patients, who experienced the event, showed an increase in MELD score between PODs 3 and 5 (18.2+/-3.9 and 18.3+/-3.6, respectively; p=0.845). Multivariate analysis showed preoperative MELD score (p<0.001), major hepatectomy (p=0.028), and MELD score increase between PODs 3 and 5 (p=0.011) as independent predictors of irreversible postoperative liver failure. Scores are reported as mean+/-SD. CONCLUSIONS Recovery from liver impairment after hepatectomy for hepatocellular carcinoma in cirrhosis starts from POD 3; MELD scores increasing between PODs 3 and 5 may identify patients at risk of liver failure and represents the trigger for beginning intensive treatment or evaluating salvage transplantation.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Surgery and Transplantation, University of Bologna, Policlinico S Orsola-Malpighi, Bologna, Italy
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285
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Cescon M, Grazi GL, Lauro A, Varotti G, Dazzi A, Ercolani G, Ravaioli M, Del Gaudio M, Cucchetti A, Ramacciato G, Pinna AD. Incidence, clinical significance, and outcome of vascular alterations in intestinal biopsies after isolated small bowel transplantation: a single-center experience. Transplant Proc 2006; 38:1728-30. [PMID: 16908263 DOI: 10.1016/j.transproceed.2006.05.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mild and moderate vascular alterations in intestinal biopsies after isolated small bowel transplantation (SBT) have uncertain clinical significance. METHODS We retrospectively investigated the incidence, association with acute cellular rejection (ACR), treatment, and outcome of mild and moderate vascular changes in 15 adult SBTs performed between December 2000 and October 2003. The semiquantitative Ruiz score for vascular changes in intestinal mucosa was used. RESULTS A total of 332 biopsies were analyzed. All patients had at least one sample showing mild or moderate vascular injury, which was globally found in 117 biopsies (35% of the total; 29% mild and 6% moderate). No cases of severe vascular injury were observed. First appearance of vascular alterations occurred 2 to 36 days after SBT (median: 6). Patients with vascular injury had a higher incidence of associated ACR than patients without this feature (16% vs 5%, P = .001). Patients with moderate vascular injury were also more likely to have moderate-to-severe ACR than patients showing no or mild vascular changes (14% vs 2%; P = .015). Treatment of rejection was more frequently administered with simultaneous diagnosis of ACR than in cases of isolated vascular alterations (84% vs 26%; P < .0001). Only one graft (7%) was lost due to severe ACR. DISCUSSION Mild and moderate vascular changes are common findings in early post-SBT biopsies. They are frequently associated with ACR and parallel its severity. The clinical impact of mild or moderate vascular injury appears to be of little relevance.
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Affiliation(s)
- M Cescon
- Liver and Multiorgan Transplant Unit, Department of Surgery and Transplantation, Padiglione 25, Policlinico Sant'Orsola-Malpighi, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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286
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Ravaioli M, Grazi GL, Ballardini G, Cavrini G, Ercolani G, Cescon M, Zanello M, Cucchetti A, Tuci F, Del Gaudio M, Varotti G, Vetrone G, Trevisani F, Bolondi L, Pinna AD. Liver transplantation with the Meld system: a prospective study from a single European center. Am J Transplant 2006; 6:1572-7. [PMID: 16827857 DOI: 10.1111/j.1600-6143.2006.01354.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The efficacy of the Meld system to allocate livers has never been investigated in European centers. The outcome of 339 patients with chronic liver disease listed according to their Meld score between 2003 and 2005 (Meld era) was compared to 224 patients listed during the previous 2 years according to their Child score (Child era). During the Meld era, hepatocellular carcinomas (HCCs) had a 'modified' Meld based on their real Meld, waiting time and tumor stage. The dropouts were deaths, tumor progressions and too sick patients. The rate of removals from the list due to deaths and tumor progressions was significantly lower in the Meld than in the Child era: 10% and 1.2% versus 16.1% and 4.9%, p < 0.05. The 1-year patient survival on the list was significantly higher in the Meld era (84% vs. 72%, p < 0.05). The prevalence of transplantation for HCC increased from 20.5% in the Child to 48.9% in the Meld era (p < 0.001), but between HCCs and non-HCCs of this latter era the dropouts were comparable (9.4% vs. 14.9%, p = n.s.) as was the 1-year patient survival on the list (83% vs. 84%, p = n.s.). The Meld allocation system improved the outcome of patients with or without HCC on the list.
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Affiliation(s)
- M Ravaioli
- Liver and Multi-organ Transplantation, Sant 'Orsola-Malpighi Hospital, University of Bologna, Italy
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287
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Ercolani G, Grazi GL, Ravaioli M, Del Gaudio M, Cescon M, Varotti G, Ramacciato G, Vetrone G, Zanello M, Pinna AD. Histological recurrent hepatitis C after liver transplantation: Outcome and role of retransplantation. Liver Transpl 2006; 12:1104-11. [PMID: 16710855 DOI: 10.1002/lt.20725] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Impact of hepatitis C virus (HCV) recurrence on long-term outcome after orthotopic liver transplantation (OLT) is highly variable, and the role of retransplantation is still debated. From 1996 to 2003, 131 OLT with histologically proven HCV recurrence and 6 months of follow-up were retrospectively reviewed. One and 5-yr overall survivals were 90.7 and 81.3%, respectively. The mean time of HCV recurrence was 10.1 +/- 6.2 months in patients whose donor's age was less than 70 yr old, and 6.6 +/- 4.7 in patients whose donor's age was more than 70 (P < 0.01). The mean time between OLT and HCV recurrence was 10.7 +/- 8.2 months among patients still alive, and 5 +/- 4.2 among the 20 who died (P = 0.02). In 16 (12.2%) patients, retransplantation was required for severe HCV recurrence; 5 are still alive and 11 (68.7%) died. The mean survival time was 16.2 +/- 6 months if re-OLT was performed within 12 months from first OLT, and it was 45.9 +/- 10 months if re-OLT was performed later (P < 0.01). In conclusion, donors older than 70 yr are at high risk of early HCV recurrence; expectancy of life is significantly reduced in case of histologically proven recurrence within 6 months. Outcome is quite dismal in patients with early HCV recurrence requiring retransplantation within 1 yr of first OLT.
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Affiliation(s)
- Giorgio Ercolani
- Department of Surgery and Transplantation, Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy.
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288
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Ravaioli M, Ercolani G, Grazi G, Cescon M, Varotti G, Del Gaudio M, Vetrone G, Zanello M, Tuci F, Pinna A. lymphadenectomy for liver tumors: A safe procedure in a tertiary center which improves the staging of the disease. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.3622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3622 Background: the role of regional lymphadenectomy for liver metastases and primary liver tumors, but not extra-hepatic bile duct cancer, is debated. Methods: from April ’99 to December ’04, we prospectively evaluated 142 patients treated with liver resections and with the following pre-operative diagnosis: 63 (44.4%) colorectal metastases (M-CR), 48 (33.8%) hepatocellular carcinoma (HCC), 16 (11.3%) non-colorectal metastases (M-NCR) and 15 (10.6%) intra-hepatic cholangiocellular carcinoma (CCC). The regional lymphadenectomy of the hepato-duodenal ligament and of the common hepatic artery was performed in all cases. The incidence and the influence on survival of lymph node metastases were analyzed. Results: 42 “wedge” resection (29.6%), 55 segmentectomies (38.7%) and 45 major hepatectomies (31.7%) were performed. The mean operative time was 292±131 minutes and 96 cases (67.6%) had no blood transfusions during the procedures. Operative mortality (within 30 days) was 3.5%, 48 cases (33.8%) developed post-operative complications and the most common was ascites. The mean hospital stay was 9±5 days. The mean number of nodes (LN) removed were 6.5±5 (range 6–30) and 63 LN (6.5%) had micro-metastases. The incidence of lymph node metastases (LN+) according to the pre-operative diagnosis was: 15.9% M-CR, 4.2% HCC, 37.5% M-NCR and 40% CCC. The mean follow-up was 37.4±22.6 months, 107 patients (75.4%) are alive and 44 (31.7%) developed tumor recurrence, which was more frequent in LN+ (54.2% vs. 27%, p<0.05). The 1-and 3-years patient survival was significantly affected by lymph node metastases: 92% and 85% LN- vs. 79% and 64% LN+, p<0.05. Conclusions: the regional lymphadenectomy for liver tumors is a safe procedure in tertiary referred centers. The presence of lymph node metastases was an important prognostic factor, which should be evaluated to improve the treatment strategies. No significant financial relationships to disclose.
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Affiliation(s)
- M. Ravaioli
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - G. Ercolani
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - G. Grazi
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - M. Cescon
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - G. Varotti
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - M. Del Gaudio
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - G. Vetrone
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - M. Zanello
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - F. Tuci
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
| | - A. Pinna
- S.Orsola-Malpighi Hospital; University of Bologna, Bologna, Italy
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289
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Lauro A, Zanfi C, Dazzi A, Golfieri L, Amaduzzi A, Ercolani G, Cescon M, Siniscalchi A, Grazi GL, Vivarelli M, Varotti G, Ravaioli M, Del Gaudio M, Di Benedetto F, Cucchetti A, La Barba G, Vetrone G, Zanello M, Pironi L, Faenza S, Pinna AD. Surgical approach to complicated intestinal failure for benign disease in adult patients: transplantation or surgical rehabilitation? Transplant Proc 2006; 38:1145-7. [PMID: 16757290 DOI: 10.1016/j.transproceed.2006.02.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Surgical approaches to complicated benign intestinal failure are gaining acceptance, especially in the pediatric population. Less international experience has been obtained in adult patients, who are usually treated with total parenteral nutrition (TPN). An intestinal rehabilitation program was started in our institution with comprehensive medical rehabilitation, surgical bowel rescue, and transplantation. Among 38 adult patients referred by our gastroenterologists for bowel rehabilitation and surgically treated in our institution, 92.2% received TPN on admission. After careful evaluation, 71% underwent transplantation. Five patients died, but 18 recipients were completely weaned off TPN at follow-up. Eleven patients underwent surgical resection of the affected bowel and a subsequent program of intestinal rehabilitation: they were all alive and weaned off TPN at discharge. At a 2-year mean follow-up, deaths occurred only in the transplant population. Therefore, intestinal surgical rescue, if successful, is optimal in adult patients.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, University of Bologna, Italy
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290
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Cucchetti A, Ercolani G, Vivarelli M, Cescon M, Ravaioli M, La Barba G, Zanello M, Grazi GL, Pinna AD. Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis. Liver Transpl 2006; 12:966-71. [PMID: 16598792 DOI: 10.1002/lt.20761] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The objective of this study was to predict postoperative liver failure and morbidity after hepatectomy for hepatocellular carcinoma (HCC) with cirrhosis. The model for end-stage liver disease (MELD) score is currently accepted as a disease severity index of cirrhotic patients awaiting liver transplantation; however, its impact on prognosis after resection of HCC on cirrhosis has never been investigated. One hundred fifty-four cirrhotic patients resected in a tertiary care setting for HCC were retrospectively analyzed. For each patient, the MELD score was calculated and related to postoperative liver failure and complications (morbidity). Hospital stay and 1-year survival was also investigated. MELD accuracy in predicting postoperative liver failure and morbidity of cirrhotic patients was assessed using receiver operating characteristic (ROC) analysis. Eleven patients (7.1%) experienced postoperative liver failure leading to death or transplantation. ROC analysis identified cirrhotic patients with a MELD score equal to or above 11 at high risk for postoperative liver failure (area under the curve [AUC] = 0.92, 95% confidence interval [CI] = 0.87-0.96; sensitivity = 82%; specificity = 89%). Forty-six patients (29.9%) developed at least 1 postoperative complication: ROC analysis identified patients with a MELD score equal to or above 9 at major risk for postoperative complications (AUC = 0.85, 95% CI = 0.78-0.89; sensitivity = 87%; specificity = 63%). Cirrhotic patients with MELD score below 9 had no postoperative liver failure and low morbidity (8.1%). In conclusion, the MELD score can accurately predict postoperative liver failure and morbidity of cirrhotic patients referred for resection of HCC and should be used to select the best candidates for hepatectomy.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Surgery and Transplantation, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
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291
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Ramacciato G, Varotti G, Quintini C, Masetti M, Di Benedetto F, Grazi GL, Ercolani G, Cescon M, Ravaioli M, Lauro A, Pinna A. Impact of biliary complications in right lobe living donor liver transplantation. Transpl Int 2006; 19:122-7. [PMID: 16441361 DOI: 10.1111/j.1432-2277.2005.00248.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Biliary reconstruction is one of the most challenging parts of right lobe living donor liver transplantation (RL LDLT), and biliary complications have been reported as the first source of surgical complications of this procedure. We reviewed biliary reconstruction and complications in 27 consecutive RL LDLTs. We compared the first 14 procedures (group 1) to the last 13 (group 2). Seven patients (25.9%) experienced a biliary complication (five leaks and two strictures). The incidence of biliary complications was 11.1% in RL grafts with a single duct and 55.5% in graft presenting multiple bile ducts (P = 0.03). Four of the 18 patients with a duct-to-duct reconstruction (22.2%) and three of the 11 patients with a Roux-en-Y reconstruction (27.3%) developed a biliary complication (P = ns). The incidence of biliary complications significantly decreased from 42.9% (n = 6) in the first group to 7.6% (n = 1) in the second group (P = 0.05). The overall 1-year graft and patient survival were 57.1% and 64.3% in group 1 versus 100.0% and 100% in group 2 (P = 0.01; P = 0.006). Biliary complications remain one of the most important technical complications affecting RL LDLT. Nevertheless, attention and surgical refinement can lead to a significant reduction of the biliary complication rate, improving graft and patient survival.
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Affiliation(s)
- Giovanni Ramacciato
- Department of Surgery and Transplantations, Liver and Multiorgan Transplantation Unit, S.Orsola Hospital, University of Bologna, Italy
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292
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Ravaioli M, Grazi GL, Ercolani G, Cescon M, Del Gaudio M, Zanello M, Ballardini G, Varotti G, Vetrone G, Tuci F, Lauro A, Ramacciato G, Pinna AD. Liver allocation for hepatocellular carcinoma: a European Center policy in the pre-MELD era. Transplantation 2006; 81:525-30. [PMID: 16495798 DOI: 10.1097/01.tp.0000198741.39637.44] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Policies to decrease dropout during waiting time for liver transplantation (LT) are under debate. METHODS We evaluated the allocation system from 1996 to 2003, when recipients had priority related to Child-Pugh score and donors >60 years were mainly offered to recipients with hepatocellular carcinoma (HCC). The outcomes of 656 patients with chronic liver disease (142 HCC and 514 non-HCC) listed for LT were prospectively evaluated, considering recipient and donor features. RESULTS Transplantation and dropout rates were similar between HCC and non-HCC patients: 64.1% vs. 70.6% and 26% vs. 22.6%. Multivariate analysis showed the probability of being transplanted within 3 months was related to Child-Pugh score >10 and to HCC, whereas the probability of being removed from the list within 3 months was only related to Child-Pugh score >10. HCC patients had a lower median waiting time (97 vs. 197 days, P<0.001), a higher rate of donors > 60 years (50.5% vs. 33.5%, P<0.005) and with steatosis (31.6% vs. 14.3%, P<0.01), but a lower Child-Pugh score (9.1+/-2.1 vs. 9.6+/-1.7, P<0.05) than non-HCC patients. The 5-year patient survival was comparable since registration on the list and since LT: 56.9% and 77% in the HCC group vs. 61.4% and 79% in the non-HCC patients. Donors > 60 years affected outcome after LT in the non-HCC group, but not in the HCC patients. CONCLUSION By allocating donors >60 years mainly to HCC patients, we controlled dropout without affecting their survival and the outcome of non-HCC patients.
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Affiliation(s)
- Matteo Ravaioli
- Department of Liver and Multiorgan Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
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293
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Ercolani G, Ravaioli M, Grazi GL, Cescon M, Varotti G, Gaudio MD, Vetrone G, Zanello M, Principe A, Pinna AD. The role of liver resections for metastases from lung carcinoma. HPB (Oxford) 2006; 8:114-5. [PMID: 18333258 PMCID: PMC2131419 DOI: 10.1080/13651820500471970] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Liver resections are usually considered the treatment of choice for colorectal and neuroendocrine metastases. Recently, the morbidity and mortality rates for liver surgery have dramatically decreased. Therefore, hepatic resection has been applied in selected cases of non-colorectal, non-neuroendocrine hepatic metastases. We report our experience with three cases of liver metastases from lung carcinoma and review the literature, to evaluate the role of liver surgery for this indication.
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Affiliation(s)
- Giorgio Ercolani
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Matteo Ravaioli
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Gian Luca Grazi
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Matteo Cescon
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Giovanni Varotti
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Massimo Del Gaudio
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Gaetano Vetrone
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Matteo Zanello
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Alfonso Principe
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
| | - Antonio Daniele Pinna
- Department of Surgery and Transplantation, University of Bologna, S. Orsola HospitalBolognaItaly
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294
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Cescon M, Grazi GL, Grassi A, Ravaioli M, Vetrone G, Ercolani G, Varotti G, D'Errico A, Ballardini G, Pinna AD. Effect of ischemic preconditioning in whole liver transplantation from deceased donors. A pilot study. Liver Transpl 2006; 12:628-35. [PMID: 16555338 DOI: 10.1002/lt.20640] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The effect of ischemic preconditioning (IPC) in orthotopic liver transplantation (OLT) has not yet been clarified. We performed a pilot study to evaluate the effects of IPC in OLT by comparing the outcomes of recipients of grafts from deceased donors randomly assigned to receive (IPC+ group, n = 23) or not (IPC- group, n = 24) IPC (10-min ischemia + 15-min reperfusion). In 10 cases in the IPC+ group and in 12 in the IPC- group, the expression of inducible nitric oxide synthase (iNOS), neutrophil infiltration, and hepatocellular apoptosis were tested by immunohistochemistry in prereperfusion and postreperfusion biopsies. Median aspartate aminotransferase (AST) levels were lower in the IPC+ group vs. the IPC- group on postoperative days 1 and 2 (398 vs. 1,234 U/L, P = 0.002; and 283 vs. 685 U/L, P = 0.009). Alanine aminotransferases were lower in the IPC+ vs. the IPC- group on postoperative days 1, 2, and 3 (333 vs. 934 U/L, P = 0.016; 492 vs. 1,040 U/L, P = 0.008; and 386 vs. 735 U/L, P = 0.022). Bilirubin levels and prothrombin activity throughout the first 3 postoperative weeks, incidence of graft nonfunction and graft and patient survival rates were similar between groups. Prereperfusion and postreperfusion immunohistochemical parameters did not differ between groups. iNOS was higher postreperfusion vs. prereperfusion in the IPC- group (P = 0.008). Neutrophil infiltration was higher postreperfusion vs. prereperfusion in both groups (IPC+, P = 0.007; IPC-, P = 0.003). Prereperfusion and postreperfusion apoptosis was minimal in both groups. In conclusion, IPC reduced ischemia/reperfusion injury through a decrease of hepatocellular necrosis, but it showed no clinical benefits.
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Affiliation(s)
- Matteo Cescon
- Liver and Multiorgan Transplant Unit, Department of Surgery and Transplantation, University of Bologna, Bologna, Italy
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295
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Vetrone G, Ercolani G, Grazi GL, Ramacciato G, Ravaioli M, Cescon M, Varotti G, Del Gaudio M, Quintini C, Pinna AD. Surgical therapy for hepatolithiasis: a Western experience. J Am Coll Surg 2005; 202:306-12. [PMID: 16427557 DOI: 10.1016/j.jamcollsurg.2005.09.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 09/10/2005] [Accepted: 09/16/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatolithiasis is very common in East Asia but infrequent in Western countries, and few reports have been published in European series. In East Asia, the association between cholangiocarcinoma and hepatolithiasis is well recognized, but, on the contrary, hepatolithiasis is uncommon in Europe and the United States, and the relationship with cholangiocarcinoma is not well established. The goal of this study was to analyze the perioperative and longterm results of surgical therapy for hepatolithiasis. STUDY DESIGN Record review of 22 patients was done to locate immediate (operative morbidity and mortality) and longterm (stone recurrence and survival) results of patients with hepatolithiasis who underwent surgical treatment. RESULTS There were 19 (86.4%) hepatic resections and 10 (45.5%) hepatico-jejuno-anastomoses. Operative mortality was absent and morbidity rate was 27.3%. Right hepatectomy was predictive of postoperative complications at multivariate analysis (p = 0.04). One (4.5%) patient had an unknown associated cholangiocarcinoma at time of surgical intervention. Mean followup was 67.59 +/- 65.67 (range 12 to 215) months. None presented recurrent cholangitis during the followup period. CONCLUSIONS Surgical therapy is a safe and effective management for hepatolithiasis. The possibility of developing cholangiocarcinoma in inveterate hepatolithiasis is real, and hepatic resection removes this risk.
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Affiliation(s)
- Gaetano Vetrone
- Department of Liver and Multiorgan Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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296
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Varotti G, Grazi GL, Vetrone G, Ercolani G, Cescon M, Del Gaudio M, Ravaioli M, Cavallari A, Pinna A. Causes of early acute graft failure after liver transplantation: analysis of a 17-year single-centre experience. Clin Transplant 2005; 19:492-500. [PMID: 16008594 DOI: 10.1111/j.1399-0012.2005.00373.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite satisfactory overall results reported, early post-operative period after liver transplantation (LT) still represents a critical time with persistently high rate of graft loss. We retrospectively reviewed our experience of 17 yr in LT, analysing the impact on grafts and patient survivals of the acute complications affecting the graft in the early period following LT. To evaluate the changes that occurred over the years in case of early acute graft failure (EAGF), the study population was divided into three equal groups of 223 patients corresponding to three different periods. Ninety (13.5%) experienced an EAGF. Causes of EAGF were hepatic artery thrombosis (HAT) in 32 cases (4.8%), primary graft non-function in 29 cases (4.3%), caval stenosis in 19 (2.8%), early irreversible acute rejection in 6 (0.9%) and portal vein thrombosis in 4 (0.6%). The use of elderly donors and the introduction of the piggyback technique proved to be associated with a higher incidence of HAT and caval stenosis, respectively. Female recipients of male donors were independently associated with Primary graft non-function. Of 90 patients with EAGF, 20 (22.2%) died within the first month after LT, 34 (37.8%) underwent retransplantation (ReLT) and 36 (40%) received conservative treatment. Conservative treatments increased from 3.6% in the first group to 47.0 and 66.8% in the second and third one (p = 0.000). One-year graft and patient survival of patients with EAGF significantly improved over the three eras analysed. The incidence of EAGF remains consistent. Nevertheless, a better understanding of the clinical situations and changes in treatment strategies have led to significant improvements in terms of graft and patient survival rates, now close to the survival rate of EAGF-free patients.
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Affiliation(s)
- Giovanni Varotti
- Department of Surgery and Transplantation, Liver and Multiorgan Transplantation Unit, S. Orsola Hospital, University of Bologna, Italy
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297
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Seyama Y, Makuuchi M, Takayama T, Cescon M, Kokudo N. Can a small ultrasonic dissector equipped for electrocautery improve the results of hepatic resection? Hepatogastroenterology 2005; 52:1845-8. [PMID: 16334790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND/AIMS In liver surgery, blood loss during hepatic transection is important. The use of an ultrasonic dissector was not always superior to conventional clamp crushing for performing hepatic parenchymal transections. The purpose of this study is to evaluate the effect of an ultrasonic dissector equipped with electrocautery in hepatic surgery. METHODOLOGY A prospective study was conducted in 66 consecutive patients who underwent a partial hepatectomy using a new small ultrasonic dissector equipped for electrocautery. To evaluate the effectiveness of using the new instrument, the surgical outcomes were compared with those of historical control. RESULTS The surgical outcomes of procedures using the new ultrasonic dissector were comparable to those of patients in the conventional ultrasonic dissector group; median blood loss, transection time, transection speed, percentage of tumor exposure at surgical margin, morbidity rate. The number of technical errors and the percentage of patients with an incomplete landmark appearance were lower in the new dissector group, but the differences were not significant. The distribution of hepatectomy grades also did not differ significantly. CONCLUSIONS The surgical outcome of hepatectomies performed using an ultrasonic dissector cannot be significantly improved by the addition of an eletrocautery function to the dissector.
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Affiliation(s)
- Yasuji Seyama
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Japan.
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298
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Varotti G, Ramacciato G, Ercolani G, Grazi GL, Vetrone G, Cescon M, Del Gaudio M, Ravaioli M, Ziparo V, Lauro A, Pinna A. Comparison between the fifth and sixth editions of the AJCC/UICC TNM staging systems for hepatocellular carcinoma: multicentric study on 393 cirrhotic resected patients. Eur J Surg Oncol 2005; 31:760-7. [PMID: 15975760 DOI: 10.1016/j.ejso.2005.04.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2004] [Revised: 04/01/2005] [Accepted: 04/22/2005] [Indexed: 01/22/2023] Open
Abstract
AIMS To compare the prognostic efficacy of the 5th and 6th edition of the TNM staging system for HCC. METHODS We retrospectively applied the old and the new systems to 393 resected patients, comparing the efficacy of both in prognostic evaluation. RESULTS The 1-, 3- and 5-year overall survival rates were 89.7, 71.1 and 56.3%, respectively. The 1-, 3- and 5-year disease-free survival rates were 79.4, 54.6 and 39.4%, respectively. Among the factors evaluated, Child's grade B and C (p=0.001) and presence of multiple nodules (p=0.01) were found to be related either to a worse long-term survival or to a worse disease-free survival. Stratifying patient survivals according to the old TNM system, we found significant differences only between stages II and IIIA (p=0.001); otherwise stages I and II (p=0.9) as well as stages IIIA and IVA (p=0.9) showed similar survival rates. Analysing the new TNM system, we found a more homogeneous staging stratification, with significant differences both between stage I and II (p=0.02) and between stage II and IIIA (p=0.05). CONCLUSIONS In the present multicentric study, long term overall and disease-free survival after liver resection for HCC was strongly affected by the number of tumours and the underlying liver disease. Our results suggest that the new classification appears to achieve an accurate stratification of patients, simpler than the previous edition, as well as a more reliable comparative analysis of outcome after hepatic resection for HCC.
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Affiliation(s)
- G Varotti
- Liver and Multiorgan Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy.
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299
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Del Gaudio M, Grazi GL, Ercolani G, Ravaioli M, Varotti G, Cescon M, Vetrone G, Ramacciato G, Pinna AD. Outcome of hepatic artery reconstruction in liver transplantation with an iliac arterial interposition graft. Clin Transplant 2005; 19:399-405. [PMID: 15877805 DOI: 10.1111/j.1399-0012.2005.00363.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In case of anomal hepatic arterial inflow, it can be necessary to perform revascularization of the liver allograft by iliac arterial interposition graft. METHODS We analyzed retrospectively 613 liver transplants in a 16-yr period. The hepatic artery (HA) graft group (n = 101) consisted of patients with arterial inflow based on recipient infrarenal aorta using donor iliac artery graft tunneled through the transverse mesocolon. The control group (n = 512) consisted of patients who underwent liver transplantation with routine HA reconstruction. RESULTS Both groups are homogeneous and comparable. In case of retransplantation, arterial conduit with iliac graft was adopted more frequently instead of conventional arterial anastomosis (24.8% vs. 9%, p < 0.0001). The 1-, 3- and 5-yr overall survival was 85.41, 79.42, 76.57% in the control group and 76.21, 73.43, 73.43% in the HA graft group, respectively (p = ns). The 1-, 3- and 5-yr graft survival was better in the control group (81.51, 73.66, 69.22% vs. 71.17, 62.50, 53.42%) (p = 0.01). In case of retransplantation, the 1-, 3- and 5-yr overall (57.81, 53.95, 41.96% vs. 60, 51.95, 49.85%) and graft survival (57.52, 53.68, 41.75% vs. 56, 50.4, 40.3%) was similar in control and HA graft group, respectively (p = ns). Hepatic artery thrombosis (HAT) rate is 21.8% vs. 8.6% (p < 0.0001) in HA graft group and control group, respectively. The only factor independently predictive of early HAT resulted arterial conduit (p = 0.001, OR = 3.13, 95% CI: 1.57-6.21). Retransplant procedure, donor age and arterial iliac conduit were found to be a significant risk factors for late HAT, at univariate analysis. At multivariate analysis, donor age >50 yr old resulted the only factor independently associated with late HAT (p < 0.0001, OR = 1.05, 95% CI: 1.02-1.07). CONCLUSION Iliac arterial interpositional graft is an alternative solution for arterial revascularization of liver allograft in case of retransplantation when the use of HA is not possible. In case of primary transplantation, is better not to perform arterial conduit if it is possible, for poor graft survival and high incidence of early HAT, especially in case of liver donor aged over 50 yr.
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Affiliation(s)
- Massimo Del Gaudio
- Liver and Multiorgan Transplantation Unit, University of Bologna, S.Orsola-Malpighi Hospital, Italy.
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300
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Cescon M, Spada M, Colledan M, Andorno E, Valente U, Rossi G, Reggiani P, Grazi GL, Tisone G, Majno P, Rogiers X, Santamaria ML, Baccarani U, Ettorre GM, Cillo U, Rossi M, Scalamogna M, Gridelli B. Split-liver transplantation with pediatric donors: a multicenter experience. Transplantation 2005; 79:1148-53. [PMID: 15880059 DOI: 10.1097/01.tp.0000161719.44492.8b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Outcomes of split-liver transplantation (SLT) with pediatric donors have never been specifically reported. METHODS A prospective multicenter study on SLT using donors younger than 15 years was conducted. Thirty-nine split-liver procedures generating a left lateral segment (LLS) and an extended right graft (ERG) were performed. In three cases, no recipient was found for ERG. In all but one case, the celiac trunk was maintained with LLS. Data were available for 67 grafts (90% of the total): 38 LLSs and 9 ERGs transplanted into 46 children and 20 ERGs transplanted into 20 adults. Sixty-two (93%) grafts were used for primary transplants and five (7%) for retransplantation. SLT were performed with 15 donors 10 years of age and less and with 24 between 11 and 15 years. RESULTS Median follow-up was 24 months. Two-year patient and graft survival were 87% and 82%. Patient and graft survivals were not significantly different between pediatric and adult recipients, between recipients from donors 10 years of age and less and those between 11 and 15 years, and between recipients of LLS and ERG. Arterial complications occurred in 6% of cases (8% in the < or = 10 year donors group, 5% in the 11-15 year donors group). The incidence of other complications was similar between groups. CONCLUSIONS SLT with pediatric donors, even younger than 10 years, provided results comparable with those achievable using adult donors. The similar incidence of arterial complications among patients receiving LLS or ERG suggests that maintenance of the celiac trunk with LLS is not detrimental for right-sided grafts.
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Affiliation(s)
- Matteo Cescon
- Centro Trapianti di Fegato, Chirurgia III, Ospedali Riuniti, Bergamo, Italy
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