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Introduction We sought to evaluate the effect of age on postoperative outcomes among patients undergoing major liver surgery for perihilar cholangiocarcinoma (PHCC). Methods 77 patients were included. Patients were categorized into two groups: the “n = 54) and the “≥ 70-year-olds” group (n = 23). Results Median LOS was 19 both for P = 0.72). No differences in terms of severe complication were detected (44.4% Clavien–Dindo 3–4–5 in P = 0.60). Within 90 postoperative days, 11 patients died, 6 in P = 0.29. The median follow‐up was 20 months. The death rate was 72.2% and 78.3% among patients P = 0.043. Adjusting for hypertension and Charlson comorbidity index in a multivariate analysis, the HR for age was 1.93 (95% CI 0.84–4.44), P = 0.12. Relapse occurred in 43 (81.1%) patients in the P = 0.26). Adjusting for hypertension and Charlson comorbidity index in a Cox model, the HR for age was 1.52 (95% CI 0.67–3.46), with P = 0.32. Conclusions ≥ 70-year-old patients with PHCC can still be eligible for major liver resection with acceptable complication rates and should not be precluded a priori from a radical treatment.

The performance of biliary reconstruction for restoring bilioenteric continuity after bile duct resection for hepatopancreatobiliary (HPB) tumors or during liver transplantation represents a basic skill for HPB and transplant surgeons. Such reconstruction may involve duct-to-duct anastomosis (or choledochocholedochostomy) or bilioenteric anastomosis, depending on the underlying disease, anatomy and indications. This chapter will describe the techniques of duct-to-duct and bilioenteric anastomoses focusing on their basic principles, techniques and application in oncological HPB surgery and liver transplantation.

Background Dual kidney transplantation (DKT) is a largely accepted strategy to enlarge the donor pool. Niguarda Hospital started this program in December 2010, and 38 DKT have been performed. In our series, we included recipients older than those in the other series published in literature. The aim of this study was to know if our recipient selection criteria for DKT are safe. Methods We reviewed our data base of DKT and analyzed recipients' medical history, surgical technique, post-operative complications, graft survival, morbidity, and mortality. We then compared our results with the literature. Results From December 2010 to April 2015, 38 DKT were performed in Niguarda Hospital. Delayed graft function was present in 21 recipients. Explantation of both kidneys was performed in 1 patient and explantation of 1 kidney in 6 patients. Post-operative complications were present in 8 patients. Five patients returned to hemodialysis after DKT. One recipient died of medical post-operative sepsis. The mean follow-up was 24 months. Graft survival and patient survival were 86.84% and 97.93%, respectively. Compared with the literature, our series had similar mortality and morbidity rates, even if recipients' age was higher than in other series. Conclusions The strategy of DKT allocation in elderly recipients is safe. Further studies have to be performed to optimized selection of the recipients for DKT not to disadvantage younger patients in the transplant waiting list and to improve the technique of organ evaluation and preservation to refine graft allocation.

Early everolimus (EVR) introduction and tacrolimus (TAC) minimization after liver transplantation may represent a novel immunosuppressant approach. This phase 2, multicenter, randomized, open-label trial evaluated the safety and efficacy of early EVR initiation. Patients treated with corticosteroids, TAC, and basiliximab were randomized (2:1) to receive EVR (1.5 mg twice daily) on day 8 and to gradually minimize or withdraw TAC when EVR was stable at >5 ng/mL or to continue TAC at 6-12 ng/mL. The primary endpoint was the proportion of treated biopsy-proven acute rejection (tBPAR)–free patients at 3 months after transplant. As secondary endpoints, composite tBPAR plus graft/patient loss rate, renal function, TAC discontinuation rate, and adverse events were assessed. A total of 93 patients were treated with EVR, and 47 were controls. After 3 months from transplantation, 87.1% of patients with EVR and 95.7% of controls were tBPAR-free (P = 0.09); composite endpoint-free patients with EVR were 85% (versus 94%; P = 0.15). Also at 3 months, 37.6% patients were in monotherapy with EVR, and the tBPAR rate was 11.4%. Estimated glomerular filtration rate was significantly higher with EVR, as early as 2 weeks after randomization. In the study group, higher rates of dyslipidemia (15% versus 6.4%), wound complication (18.32% versus 0%), and incisional hernia (25.8% versus 6.4%) were observed, whereas neurological disorders were more frequent in the control group (13.9% versus 31.9%; P < 0.05). In conclusion, an early EVR introduction and TAC minimization may represent a suitable approach when immediate preservation of renal function is crucial.

Three different standard types of liver bipartition producing six different types of grafts can be created by following a plane directed on the right or the left line of the middle hepatic vein (MHV): a) splitting for adult and pediatric recipients with left lateral graft (LLG) and right extended graft (REG), b) splitting for two adults or for adult and pediatric recipients of large size with creation of left graft (LG) and right graft (RG), c) splitting for two adult recipients with creation of full left graft (FLG) and full right graft (FRG). The absence of an extrahepatic portal vein bifurcation is an absolute contraindication to liver splitting. Division of the portal branches to Segment I optimizes the freeing/lengthening of the left portal vein for the implantation. Identifying the portal tract entering the caudate process at its lower aspect is helpful in preparing for the division of the hilar plate. Early division of the Arantius remnant allows a safe encircling and control of the left hepatic vein. During in situ splitting technique for adult and pediatric recipients, a 1–2-min. selective clamping of the left hepatic vein (LHV) may provide assurance that the hepatic venous drainage of Segment IV is not jeopardized. Recognition of independent segment II and III suprahepatic venous outflow (

In this Chapter we discuss the technical details of the right hemihepatectomy for living donor liver transplantation in adults by open technique. Successful donor outcome and the recipient’s hope for the highest probability of a successful transplant are relevant factors that ethically support the choice for living donor liver tranplantation.

The main goal of allocation system is to guarantee an equal access to the limited resource of liver grafts for every class of patients on the waiting list, balancing between the ethical principles of equity, utility, benefit, need, and fairness. The aim of this review was to analyze liver allocation policies among these organizations, focusing on HCC. The European area considered for this analysis included 6 macro-areas or countries, which are congregated from the same policy of liver sharing and allocation. By this definition, the 6 areas identified are: Centro Nazionale Trapianti (CNT) in Italy; Eurotransplant (Germany, the Netherlands, Belgium, Luxembourg, Austria, Hungary, Slovenia, and Croatia); Organizacion Nacional de Transplantes (ONT) in Spain; Etablissement francais des Greffes (EfG) in France; NHS Blood Transplant (NHSBT) in the United Kingdom and Ireland; Scandiatransplant (Sweden, Norway, Finland, Denmark, and Iceland); Romanian National Policy. Each identified area, as network for organ sharing in Europe, adopts a basic allocation system that consider a policy center oriented or patient oriented. Priorization of patients affected by HCC in the waiting list for deceased donors liver transplant worldwide is dominated by 2 main principles: urgency and utility. The main message of this review is the absence of a common organs allocation policy over the Eurpean countries. Despite that, long-term survival of the community of patients listed for transplant due to HCC results, however, highly acceptable in Europe and comparable to the long-term survial reported in the UNOS register.