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Lauterio A, Cillo U, Spada M, Trapani S, De Carlis R, Bottino G, Bernasconi D, Scalamogna C, Pinelli D, Cintorino D, D'Amico FE, Spagnoletti G, Miggino M, Romagnoli R, Centonze L, Caccamo L, Baccarani U, Carraro A, Cescon M, Vivarelli M, Mazaferro V, Ettorre GM, Rossi M, Vennarecci G, De Simone P, Angelico R, Agnes S, Di Benedetto F, Lupo LG, Zamboni F, Zefelippo A, Patrono D, Diviacco P, Laureiro ZL, Gringeri E, Di Francesco F, Lucianetti A, Valsecchi MG, Gruttadauria S, De Feo T, Cardillo M, De Carlis L, Colledan M, Andorno E. Improving outcomes of in situ split liver transplantation in Italy over the last 25 years. J Hepatol 2023; 79:1459-1468. [PMID: 37516203 DOI: 10.1016/j.jhep.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND & AIMS Split liver transplant(ation) (SLT) is still considered a challenging procedure that is by no means widely accepted. We aimed to present data on 25-year trends in SLT in Italy, and to investigate if, and to what extent, outcomes have improved nationwide during this time. METHODS The study included all consecutive SLTs performed from May 1993 to December 2019, divided into three consecutive periods: 1993-2005, 2006-2014, and 2015-2019, which match changes in national allocation policies. Primary outcomes were patient and graft survival, and the relative impact of each study period. RESULTS SLT accounted for 8.9% of all liver transplants performed in Italy. A total of 1,715 in situ split liver grafts were included in the analysis: 868 left lateral segments (LLSs) and 847 extended right grafts (ERGs). A significant improvement in patient and graft survival (p <0.001) was observed with ERGs over the three periods. Predictors of graft survival were cold ischaemia time (CIT) <6 h (p = 0.009), UNOS status 2b (p <0.001), UNOS status 3 (p = 0.009), and transplant centre volumes: 25-50 cases vs. <25 cases (p = 0.003). Patient survival was significantly higher with LLS grafts in period 2 vs. period 1 (p = 0.008). No significant improvement in graft survival was seen over the three periods, where predictors of graft survival were CIT <6 h (p = 0.007), CIT <6 h vs. ≥10 h (p = 0.019), UNOS status 2b (p = 0.038), and UNOS status 3 (p = 0.009). Retransplantation was a risk factor in split liver graft recipients, with significantly worse graft and patient survival for both types of graft (p <0.001). CONCLUSIONS Our analysis showed Italian SLT outcomes to have improved over the last 25 years. These results could help to dispel reservations regarding the use of this procedure. IMPACT AND IMPLICATIONS Split liver transplant(ation) (SLT) is still considered a challenging procedure and is by no means widely accepted. This study included all consecutive in situ SLTs performed in Italy from May 1993 to December 2019. With more than 1,700 cases, it is one of the largest series, examining long-term national trends in in situ SLT since its introduction. The data presented indicate that the outcomes of SLT improved during this 25-year period. Improvements are probably due to better recipient selection, refinements in surgical technique, conservative graft-to-recipient matching, and the continuous, yet carefully managed, expansion of donor selection criteria under a strict mandatory split liver allocation policy. These results could help to dispel reservations regarding the use of this procedure.
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Affiliation(s)
- Andrea Lauterio
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Silvia Trapani
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Riccardo De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Giuliano Bottino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Davide Bernasconi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Chiara Scalamogna
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenico Pinelli
- Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Davide Cintorino
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | | | - Gionata Spagnoletti
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Marco Miggino
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Renato Romagnoli
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Leonardo Centonze
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Caccamo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Umberto Baccarani
- Department of Medicine, Liver Transplant Center, University of Udine, Italy
| | - Amedeo Carraro
- Liver Transplant Unit, University and Hospital Trust of Verona, Italy
| | - Matteo Cescon
- Hepatobiliary Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic University of Marche, Ancona, Italy
| | - Vincenzo Mazaferro
- Department of Oncology and Onco-Hematology, University of Milan, Italy; Department of Surgery, Istituto Nazionale Tumori Fondazione IRCCS Milan, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Giovanni Vennarecci
- Division of Hepatobiliary Surgery and Liver Transplant Center, AORN Cardarelli, Naples, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation AOU Pisana, Pisa, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
| | - Salvatore Agnes
- Department of Surgery, Transplantation Service, Catholic University of the Sacred Heart, Foundation A. Gemelli Hospital, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit Azienda Ospedaliera Policlinico, University of Modena and Reggio Emilia Modena, Italy
| | - Luigi Giovanni Lupo
- General Surgery and Liver Transplantation Unit, University of Bari, Bari, Italy
| | - Fausto Zamboni
- Department of Surgery, General and Hepatic Transplantation Surgery Unit, A.O.B. Brotzu, Cagliari, Italy
| | - Arianna Zefelippo
- Division of General Surgery and Liver Transplantation, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico di Milano, Milano, Italy
| | - Damiano Patrono
- Liver Transplant Center, General Surgery 2U, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pietro Diviacco
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
| | - Zoe Larghi Laureiro
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, European Reference Network "TransplantChild", Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Padua University Hospital, Padova, Italy
| | - Fabrizio Di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
| | - Alessandro Lucianetti
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Maria Grazia Valsecchi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre-B4, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy; Department of Surgery and Medical and Surgical Specialties, University of Catania, 95124, Catania, Italy
| | - Tullia De Feo
- North Italy Transplant Program (NITp), UOC Coordinamento Trapianti, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cardillo
- Italian National Transplant Center-Istituto Superiore Di Sanità, Rome, Italy
| | - Luciano De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Colledan
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Organ Failure and Transplantation, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Enzo Andorno
- Department of Hepatobiliarypancreatic Surgery and Liver Transplantation Unit, A.O.U. S. Martino, Genova, Italy
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