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Preoperative inflammatory biomarkers such as the Platelet-to-Lymphocyte Ratio (PLR) and the Neutrophil-to-Lymphocyte Ratio (NLR) strongly predict the outcome in surgically treated patients with hepatocellular carcinoma (HCC), while nutritional biomarkers such as the Controlling Nutritional Status (CONUT) and the Prognostic Nutritional Index (PNI) show an analogue prognostic value in hepatic resection (HR) but not in liver transplant (LT) cases. Data on the impact of LT on the inflammatory and nutritional/metabolic function are heterogeneous. Therefore, we investigated the post-LT trend of these biomarkers up to postoperative month (POM) 12 in 324 HCC patients treated with LT. Inflammatory biomarkers peaked in the early post-LT period but at POM 3 leveled off at values similar (NLR) or higher (PLR) than pre-LT ones. CONUT and PNI worsened in the early post-LT period, but at POM 3 they stabilized at significantly better values than pre-LT. In LT recipients with an overall survival >1 year and no evidence of early HCC recurrence, 1 year post-LT NLR and PNI independently predicted patient overall survival, while 1 year post-LT PLR independently predicted late tumor recurrence. In conclusion, at 1 year post-LT, the nutritional status of liver-transplanted HCC patients significantly improved while their inflammatory state tended to persist. Consequently, post-LT PLR and NLR maintained a prognostic value for LT outcome while post-LT CONUT and PNI acquired it.

Background: Hepatocellular carcinoma (HCC) is the leading cause of primary liver cancers. Surveillance of individuals at specific risk of developing HCC, early diagnostic markers, and new therapeutic approaches are essential to obtain a reduction in disease-related mortality. Apurinic/apyrimidinic endonuclease 1 (APE1) expression levels and its cytoplasmic localization have been reported to correlate with a lower degree of differentiation and shorter survival rate. The aim of this study is to fully investigate, for the first time, the role of the mitochondrial form of APE1 in HCC., Methods: As a study model, we analyzed samples from a cohort of patients diagnosed with HCC who underwent surgical resection. Mitochondrial APE1 content, expression levels of the mitochondrial import protein Mia40, and mtDNA damage of tumor tissue and distal non-tumor liver of each patient were analyzed. In parallel, we generated a stable HeLa clone for inducible silencing of endogenous APE1 and re-expression of the recombinant shRNA resistant mitochondrially targeted APE1 form (MTS-APE1). We evaluated mtDNA damage, cell growth, and mitochondrial respiration., Results: APE1's cytoplasmic positivity in Grades 1 and 2 HCC patients showed a significantly higher expression of mitochondrial APE1, which accounted for lower levels of mtDNA damage observed in the tumor tissue with respect to the distal area. In the contrast, the cytoplasmic positivity in Grade 3 was not associated with APE1's mitochondrial accumulation even when accounting for the higher number of mtDNA lesions measured. Loss of APE1 expression negatively affected mitochondrial respiration, cell viability, and proliferation as well as levels of mtDNA damage. Remarkably, the phenotype was efficiently rescued in MTS-APE1 clone, where APE1 is present only within the mitochondrial matrix., Conclusions: Our study confirms the prominent role of the mitochondrial form of APE1 in the early stages of HCC development and the relevance of the non-nuclear fraction of APE1 in the disease progression. We have also confirmed overexpression of Mia40 and the role of the MIA pathway in the APE1 import process. Based on our data, inhibition of the APE1 transport by blocking the MIA pathway could represent a new therapeutic approach for reducing mitochondrial metabolism by preventing the efficient repair of mtDNA.

The aim of the present study was to investigate whether LT candidates with sarcopenia are at an increased risk of receiving an inappropriate standard liver volume (SLV) estimation by standard body weight (BW)-derived SLV formula. Non-BW-SLV estimation formulas were tested in 262 LDLT donors and compared to a standard BW-SLV formula. The anthropometric parameters used were the thoracic width (TW-SLV) and thoracoabdominal circumference (TAC-SLV). Subsequently, sarcopenic and non-sarcopenic LDLT candidates (total, 217 patients) were compared in terms of estimated BW-SLV (routine method) and non-BW-SLV. In donors, TW-SLV showed comparable concordance with CT scan measured total liver volume as BW-SLV. The performance of TAC-SLV was low. In recipients, the prevalence of pre-LT sarcopenia was 30.4%. Sarcopenic patients were attributed a significantly lower BW-SLV than non-sarcopenic (sarcopenia vs no-sarcopenia, 1063.8 ml [1004.1-1118.4] vs. 1220.7 ml [1115.0-1306.6], P < 0.001), despite comparable TW-SLV, age, body height, and gender prevalence. As a result, sarcopenic patients received a graft with a statistically lower weight at organ procurement and developed more frequently a small-for-size syndrome (SFSS) according to the Dahm et al. (27.7% vs. 6.8%, P < 0.01) and Kyushu (28.7% vs. 9.2%, P < 0.01) definition. Therefore, In sarcopenic patients, BW-SLV formulas are affected by an high risk of SLV underestimation, thus exposing them to an increased risk of post-LT SFSS., (© 2020 Steunstichting ESOT. Published by John Wiley & Sons Ltd.)

Background: Native hepatectomy represents the most demanding surgical step during orthotopic whole liver transplantation (LT). The surgical risk assessment of LT candidates is currently mainly based on clinical and laboratory data, but even preoperative imaging data may be predictive of a complex native hepatectomy., Methods: A retrospective study on a cohort of 110 LT recipients was conducted. The radiologic variables investigated on pre-LT multidetector computed tomography scan were the length of the retrohepatic inferior vena cava (IVC-L), volume of the dorsal liver sector (DLS-V), complete encirclement of the IVC by the DLS (IVC-CE), max diameter of the native liver (L-D), max diameter of the spleen (S-D), and presence of large spontaneous portosystemic shunts (SPSS). The parameters defining complex native hepatectomy were the operative time, number of red blood cell (RBC) units transfused, IVC replacement technique switch, and post-LT relaparotomy for major bleeding., Results: In a multivariate analysis, the operative time was predicted by hepatocellular carcinoma (HCC) diagnosis (regression coefficient [RC]: 18.237, P = .009), S-D (RC: 3.733, P = .007), and IVC-CE (RC: 20.174, P = .01); the RBC units transfused by an history of gastroesophageal variceal bleeding (RC: 2.503, P = .039), Model for End-Stage Liver Disease (MELD) score (RC: .259, P = .039), and L-D (RC: -0.519, P = .027); the switch to a IVC replacement technique by L-D (odds ratio [OR]: 0.641, P = .028) and IVC-L (OR: 1.065, P = .023); and the relaparotomy for bleeding by L-D (OR: 0.632, confidence interval [CI]: 0.437 to 0.916, P = .015)., Conclusions: Pre-LT multidetector computed tomography (MDCT) seems to be a very useful tool in the surgical risk assessment of LT candidates., (Copyright © 2020. Published by Elsevier Inc.)

Background: The delayed graft function (DGF) in kidney transplantation (KT) is a risk factor for long-term poor graft survival. The pathogenesis is multifactorial but mainly related to an ischemia-reperfusion injury. However, the graft hemodynamics have been recently identified as a key aspect for early DGF risk assessment and potential therapeutic intervention., Methods: A pilot study on 20 single kidney grafts from donor after brain death with intraoperative measurement of graft arterial flowmetry, 30 minutes after reperfusion. Exclusion criteria were grafts with multiple arteries or severe atherosclerosis of the recipient's external iliac artery., Results: KT recipients with DGF (n = 4, 20%) were homogenous with controls (n = 16) in terms of cold ischemia time, donor age, recipients' hemodynamic parameters, renal artery, and recipients' external iliac artery diameters. Nonetheless, at transplant, the kidney grafts that developed DGF were characterized by a significantly higher renal artery resistive index (DGF vs no-DGF 0.96 ± 0.04 vs 0.77 ± 0.13, P = .02), as well as lower flow extraction rate (24.8% ± 11.8 vs 59.2% ± 21.1, P < .01)., Conclusions: Intraoperative arterial graft flowmetry seems to be an effective tool to identify grafts at high risk of DGF., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The end-stage liver disease causes a metabolic dysfunction whose most prominent clinical feature is the loss of skeletal muscle mass (SMM). In living-donor liver transplantation (LDLT), liver graft regeneration (GR) represents a crucial process to normalize the portal hypertension and to meet the metabolic demand of the recipient. Limited data are available on the correlation between pre-LDLT low SMM and GR., Methods: Retrospective study on a cohort of 106 LDLT patients receiving an extended left liver lobe graft. The skeletal muscle index (SMI) at L3 level was used for muscle mass measurement, and the recommended cut-off values of the Japanese Society of Hepatology guidelines were used as criteria for defining low muscularity. GR was evaluated as rate of volume increase at 1 month post-LT [graft regeneration rate (GRR)]., Results: The median GRR at 1 month post-LT was 91% (IQR, 65-128%) and a significant correlation with graft volume-to-recipient standard liver volume ratio (GV/SLV) (rho -0.467, P<0.001), graft-to-recipient weight ratio (GRWR) (rho -0.414, P<0.001), donor age (rho -0.306, P=0.001), 1 month post-LT cholinesterase serum levels (rho 0.397, P=0.002) and pre-LT low muscularity [absent vs. present GRR 97.5% (73.1-130%) vs. 83.5% (45.2-110.9%), P=0.041] was noted. Moreover in male recipients, but not in women, it was shown a direct correlation with pre-LT SMI (rho 0.352, P=0.020) and inverse correlation with 1 month post-LT SMI variation (rho -0.301, P=0.049). A low GRR was identified as an independent prognostic factor for recipient overall survival (HR 6.045, P<0.001)., Conclusions: Additionally to the hemodynamic factors of portal circulation and the quality of the graft, the metabolic status of the recipients has a significant role in the GR process. A pre-LT low SMM is associated with impaired GRR and this negative impact is more evident in male recipients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/hbsn.2019.11.08). The authors have no conflicts of interest to declare., (2020 Hepatobiliary Surgery and Nutrition. All rights reserved.)

Background: The Controlling Nutritional Status (CONUT) score is a newly developed laboratory-derived immunonutritional score which has been validated as prognostic marker for survival and tumor recurrence in surgically treated patients with various tumor types, including hepatocellular carcinoma (HCC). The aim of the present study was to test the CONUT score performance in HCC patients treated with liver transplantation (LT)., Methods: A retrospective study on a bi-centers cohort of 280 HCC patients submitted to LT between 2006 and 2017 was performed. Indication to LT was limited to Milan criteria or UCSF criteria, defined by preoperative imaging., Results: Median pre-LT CONUT score was 5 (interquartile range 3-7). Overall patients' survival at 1, 3, and 5 years was 84%, 76.6%, and 68.3%, respectively. Multivariate analysis showed that HCC recurrence (hazard ratio [HR] = 1.987, P = .012] and pre-LT neutrophil to lymphocyte ratio (NLR) (HR = 1.064, P = .003) were independent risk factors for reduced survival. Cumulative incidence of HCC recurrence at 1, 3, and 5 years was 5.1%, 11.5%, and 15.5%, respectively. Pre-LT platelet-to-lymphocyte ratio (PLR) (subdistribution hazard ratio [SHR] = 1.086, P = .044], tumor max diameter (SHR = 1.695, P < .001), and bilobar tumor distribution (SHR = 6.892, P = .006) were independent risk factors for tumor recurrence. The CONUT score did not show any prognostic value., Conclusions: The CONUT score did not predict poor survival or tumor recurrence in LT recipients., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

BACKGROUND Hypothermic machine perfusion (HMP) appears to exert a reconditioning effect on the ischemic damage of kidney grafts. However, some concerns still remain about its real effectiveness when it is delayed after a preliminary period of static cold storage (SCS) or with prolonged overall cold ischemia time (CIT). MATERIAL AND METHODS The effect of HMP on hemodynamic, metabolic, histological and ultrastructural features of grafts was investigated in 21 single-kidney grafts treated with a delayed HMP after SCS and with a total CIT of over 24 h. RESULTS The mean CIT, SCS, and HMP times were 29 h, 12 h, and 18 h, respectively. Longer SCS was associated with higher vascular resistance and lower arterial flow. In the pre- vs. post-HMP comparison, a significant decrease in arterial resistances and increase of flow were recorded. The hemodynamic improvement was independent of HMP duration. The perfused grafts retained some metabolic activity, with a statistically significant decrease of pH, pO2, and glucose levels, and increase of lactates in the perfusion liquid, by the end of HMP. Longer SCS was associated with higher pH and greater pO2 decrease during HMP. Light microscopy and transmission electronic microscopy revealed no significant variations in nuclear, cytoplasmic, or ultrastructural damage. SCS, HMP, and CIT were not identified as risk factor for delayed graft function or rejection. CONCLUSIONS A delayed and extended HMP can recover the graft hemodynamic function, maintain some metabolic activity, and stabilize the accumulated ischemic damage due to a preliminary SCS.

Objectives: The presence of an inferior right hepatic vein significantly modifies the outflow pattern of the right liver and may have an impact on graft regeneration., Materials and Methods: Study patients were donors and recipients with 3-dimensional computed tomography scan simulation. We studied the physiologic impact of the inferior right hepatic veins on right liver regeneration in donors of left lobe grafts (step1; n = 60 patients) and the efficacy of a inferior right hepatic vein reconstruction policy based on a vessel caliber > 5 mm criteria in recipients of right liver grafts (step 2; n = 38 patients)., Results: In step 1, the regeneration rate at 1 month was comparable between future liver remnants with inferior right hepatic vein (regeneration rate of 28.3%) and without inferior right hepatic vein (regeneration rate of 30.2%). In step 2, at 3 months after living-donor liver transplant, we observed no significant differences in regeneration rates among grafts anatomically without an inferior right hepatic vein (regeneration rate of 60.7%), grafts with an inferior right hepatic vein but no reconstruction (regeneration rate of 64.9%), and grafts with an inferior right hepatic vein and its reconstruction (regeneration rate of 68.1%). Within the latter subgroup, grafts with a dominant inferior right hepatic vein showed a greater regeneration of the anterior sector with inversion of the anterior-to-posterior sector regeneration ratio compared with right hepatic vein-dominant grafts (inferior right hepatic vein-dominant vs right hepatic vein-dominant showed anterior sector regeneration rates of 85.7% vs 52.1%; P = .02; anterior/posterior sector regeneration ratio was 2.3 vs 0.6, respectively; P = .04)., Conclusions: The reconstruction policy for inferior right hepatic vein with caliber > 5 mm is effective but should be implemented with computed tomography scan simulation. Right lobe grafts with a dominant inferior right hepatic vein are at higher risk of impaired regeneration due to expected large volumes of hepatic venous congestion if the middle hepatic veins tributaries or the inferior right hepatic veins are not reconstructed and an increased rate of right hepatic vein complications.

Background: Gastrointestinal perforation (GIP) is a rare complication after adult liver transplant (LT) associated with high morbidity and mortality. Limited data are available about clinical risk factors and underlying pathogenic mechanisms., Methods: The retrospective study included all GIP cases from a consecutive cohort of 361 LT recipients during the period 2005-2017. Clinical variables were investigated as potential risk factors for GIP, and radiologic and histopathologic evaluations were undertaken to identify any causative mechanism., Results: A total of 22 patients developed at least 1 episode of GIP (prevalence 6.1%) at a median time of 18.5 [interquartile range, 12.5-28.5] days after LT. The perforations occurred in the small bowel (63.6%), transverse colon (27.3%), right colon (22.7%), left colon (9.1%), and stomach (9.1%). A total of 27.3% of patients developed multiple sites of GIP, and in 31% GIP recurred after curative surgery. The 30-day mortality rate after relaparotomy was 40%. A history of previous abdominal surgery (odds ratio, 2.5) and early post-LT relaparotomy due to other complications (odds ratio, 2.6) were significant risk factors for GIP. No thromboembolic or steno-occlusive complications of any splanchnic vessel were detected at computed tomography scan, while histopathology examination on perforated gastrointestinal segments excluded cytomegalovirus infection, graft-vs-host disease, and inflammatory bowel disease. In all the cases, ischemic necrosis with aspecific microangiopathy and microembolization were the pathologic features detected., Conclusions: GIP is a severe complication after LT with frequent multiple gastrointestinal involvement and recurrence after curative surgery. The pathologic underlying mechanism is usually microvascular ischemia. Clinical risk factors are history of previous abdominal surgery and early post-LT relaparotomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: We aimed to analyze the risk factors for early surgical complications requiring relaparotomy and the related impact on overall survival (OS) in HIV-infected patients submitted to liver transplantation., Methods: We performed a retrospective study on a nationwide multicenter cohort of 157 HIV-infected patients submitted to liver transplantation in 6 Italian transplant units between 2004 to 2014., Results: The median preoperative model for end-stage liver disease score was 18 (interquartile range 12-26.5). An early relaparotomy was performed in 24.8% of patients, and the underlying clinical causes were biliary leak (8.2%), bleeding (8.2%), intestinal perforation (4.5%), and suspected vascular complications (3.8%). The OS at 1, 3, and 5 years was 74.3%, 68.0%, and 60.0%, respectively, and an early relaparotomy was not a prognostic factor itself, but an increasing number of relaparotomies was associated with decreased survival (hazard ratio = 1.40, 95% confidence interval [CI] 1.07-1.81, P = .01). In the multivariate analysis, preoperative refractory ascites (odds ratio 3.32, 95% CI 1.18-6.47, P = .02) and Roux-en-Y choledochojejunostomy reconstruction (odds ratio 12.712, 95% CI 2.47-65.38, P ≤ .01) were identified as significant risk factors for early relaparotomy., Conclusions: In HIV-infected liver transplant recipients, an increasing number of early relaparotomies due to surgical complications did negatively affect the OS. Preoperative refractory ascites reflecting a severe portal hypertension and a difficult biliary tract reconstruction requiring a Roux-en-Y choledochojejunostomy were associated with an increased risk of early relaparotomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: An extended-release formulation of tacrolimus designed for once-daily administration (LCP-TAC) is a new prolonged-release tacrolimus (TAC-PR) formulation using a drug delivery technology designed to enhance the bioavailability of drugs compared with TAC-PR. The aim of this study was to retrospectively compare de novo administration of LCP-TAC and TAC-PR for therapeutic trough levels and daily dosage during the first 30 days after first liver transplant (LT)., Methods: A total of 35 patients submitted to first LT between 2016 and 2018 were retrospectively enrolled: 16 received LCP-TAC, while 19 received TAC-PR as de novo immunosuppression. Patients were analyzed for daily dosage and trough levels at postoperative days (PODs) 3, 7, 15, and 30., Results: The initial dose of tacrolimus did not differ between LCP-TAC and TAC-PR (mean, 5.19 [SD, 1.72] mg/d vs mean, 5.26 [SD, 1.91] mg/d, P = .90). On PODs 7, 15, and 30 the daily dosage was statistically lower for LCP-TAC compared with TAC-PR (mean, 5.44 [SD, 2.06] mg/d vs mean, 7.68 [SD, 2.91] mg/d, P = .01; mean, 5.33 [SD, 2.23] mg/d vs mean, 8.82 [SD, 2.35] mg/d, P < .001; and mean, 5.38 [SD, 2.50] mg/d vs mean, 9.81 [SD, 3.78] mg/d, P < .001, respectively). The therapeutic trough levels were significantly higher for LCP-TAC on POD 3 (mean, 5.05 [SD, 3.58] ng/mL vs mean, 2.42 [SD, 2.75] ng/mL, P = .03) and POD 5 (mean, 7.35 [SD, 5.12] ng/mL vs mean, 4.17 [SD, 2.05] ng/mL, P = .04), while no differences were found on PODs 7, 15, and 30.The percentage of patients on POD 3 achieving a trough level higher than 6 ng/mL was higher for LCP-TAC than TAC-PR (40% vs 13%, P = .05)., Conclusions: LCP-TAC after LT is safe and might enhance bioavailability, reducing the amount of drug necessary to achieve therapeutic trough levels compared with TAC-PR., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Vascular complications are the main cause of early graft loss in renal transplant (RT). A graft with multiple vessels represents the most validated risk factor. The aim of the present study was to identify potential predictive factors for acute vascular complications causing graft loss when graft vascular anomalies are excluded., Methods: This is a retrospective case-control (1:3 ratio) study extrapolated from the RT series of the Renal Transplant Unit - Udine University Hospital, during the period 1993-2017. Grafts with multiple vessels and retransplant cases were excluded., Results: The overall prevalence of graft loss due to acute vascular complications was 2.6% (25/961). Seventeen complicated recipients had grafts without vascular anomalies (case group). The median time between RT and complication was 6 days (interquartile range, 4-23 days). The following types of vascular complications were recorded: 5 isolated renal artery thromboses (0.5%), 4 isolated renal vein thromboses (0.4%), 4 combined renal artery and vein thromboses (0.3%), 3 renal artery ruptures due to mycotic arteritis (0.3%), and 1 renal artery nonmycotic pseudoaneurysm (0.1%). No differences were recorded between the groups in terms of donors and grafts characteristics. Complicated recipients showed a statistically higher prevalence of thromboembolism history (P = .046) and vascular atherosclerosis (P = .048). During the postoperative course, blood stream infections (P = .02), acute rejection (P = .03), bleeding from a nonmacrovascular source (P = .04), and multiple reintervention because of nonvascular complications (P = .03) were identified as significant risk factors., Conclusions: Recipient characteristics and post-RT complications rather than donor and graft characteristics are relevant risk factors for graft loss due to acute vascular complications when graft vascular anomalies are excluded., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The aim of the study was to analyse the risk factors for early surgical complications requiring relaparotomy and the related impact on overall survival (OS) in HIV-infected patients submitted to liver transplantation. Thus a retrospective investigation was conducted on a nationwide multicentre cohort of 157 HIV patients submitted to liver transplantation in six Italian Transplant Units between 2004 and 2014. An early relaparotomy was performed in 24.8% of cases and the underlying clinical causes were biliary leak (8.2%), bleeding (8.2%), intestinal perforation (4.5%) and suspect of vascular complications(3.8%). No differences in terms of prevalence for either overall or cause-specific early relaparotomies were noted when compared with a non-HIV control group, matched for MELD, recipient age, HCV-RNA positivity and HBV prevalence. While in the control group an early relaparotomy appeared a negative prognostic factor, such impact on OS was not noted in HIV recipients. Nonetheless increasing number of relaparotomies were associated with decreased survival. In multivariate analysis, preoperative refractory ascites and Roux-en-Y choledochojejunostomy reconstruction were significant risk factors for early relaparotomy. To conclude, in HIV liver transplanted patients, an increasing number of early relaparotomies because of surgical complications does negatively affect the OS. Preoperative refractory ascites reflecting a severe portal hypertension and a difficult biliary tract reconstruction requiring a Roux-en-Y choledochojejunostomy are associated with increased risk of early relaparotomy., (© 2019 Steunstichting ESOT.)

Objectives: Hepatic venous congestion is associated with impaired graft regeneration in living-donor liver transplant, and the management of middle hepatic vein tributaries in the right lobe graft represents an unresolved issue. In this study, we aimed to investigate the precise outflow pattern of segments 5 and 8 between the right hepatic vein and middle hepatic vein and the respective regeneration rates after living-donor liver transplant with right lobe graft, as available data on these relevant topics are scarce., Materials and Methods: We conducted a retrospective analysis of computed tomography scans with 3-dimensional simulation, vessel reconstruction, and volume measurement of 38 right lobe grafts without middle hepatic vein. Follow-up time was 3 months after living-donor liver transplant., Results: In donors, segments 5 and 8 measured 141.9 ± 48.8 mL (21.0% of graft volume) and 230.4 ± 52.5 mL (34.3% of graft volume), respectively, with significant difference between volumes (P < .01). Percentage of segmental venous drainage in segment 5 was 55.5 ± 17.2% for the middle hepatic vein and 41.0 ± 20.9% for the right hepatic vein; drainage in segment 8 was 46.4 ± 13.2% for the middle hepatic vein and 52.9 ± 13.2% for the right hepatic vein. The outflow pattern was significantly different between segments for both veins (P = .01 for middle hepatic vein and P < .01 for right hepatic vein), showing that segment 5 was statistically more dependent on the middle hepatic vein and segment 8 was more dependent on the right hepatic vein. For living-donor liver transplant recipients, the prevalence of middle hepatic vein tributary reconstruction was 39.5%. At 3-month follow-up, the regeneration rate for the posterior sector was 85.8 ± 39.9%, whereas rates for segments 5 and 8 were 33.4 ± 39.7% and 68.4 ± 41.0%, respectively (P < .01)., Conclusions: In living-donor liver transplant with right lobe graft and without middle hepatic vein, segment 5 is the most vulnerable graft area for impaired regeneration. Segments 5 and 8 should be evaluated independently on the basis of their respective outflow patterns to more precisely plan the outflow management and patient outcomes.

Aim: Sarcopenia is associated with high morbidity and mortality before and after liver transplantation (LT). The aim of the study was to evaluate the chronological changes in skeletal muscle mass (SMM) at different time points post-LT and to identify the risk factors for long-term low SMM., Methods: The skeletal muscle index at L3 level (L3-SMI) was used for muscle mass measurement, and the recommended cutoff values of the Japanese Society of Hepatology guidelines were used as criteria for defining low muscularity., Results: Preoperative low SMM was recognized in 35.1% of cases. At 1 year after LDLT, 28.9% of patients showed low SMM, without any significant prevalence change in comparison with the preoperative phase (35.1%) or 1 month post-LT (30.7%). Post-LT intensive care unit (ICU) length of stay (OR 1.14, P = 0.03), biliary complications (OR 5.88, P = 0.02), pre-LT low SMM (OR 3.36, P = 0.05), and 1 month post-LT low SMM (OR 10.16, P < 0.01) were found to be independent risk factors for low SMM at 1 year post-LT in multivariate analysis. The development of de novo low SMM at 1 year post-LT was a negative prognostic factor for OS (HR 9.08, P = 0.001)., Conclusions: Intensive care unit length of stay, biliary complications and preoperative and 1 month post-LT low SMM were predictive factors for long-term low SMM. Newly developed low SMM at 1 year post-LT was a prognostic factor for a poor patient survival., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

In this case report, we share our experience with an emerging complication in laparoscopic surgery caused by the use of barbed sutures for an off-label indication. We describe a postoperative volvulus caused by the adhesion of the small bowel and V-Loc suture after a ventral laparoscopic rectopexy in a 48-year-old female patient. We also suggest cutting flush the end of the V-Loc and extending the follow-up of these patients.

Surgery-related morbidity has been identified as prognostic risk factor for tumor recurrence for several tumor types, but data regarding hepatocellular carcinoma (HCC) are limited and controversial. The aim of this study was to analyze the impact of surgical complications on the risk of HCC recurrence after hepatic resection (HR). A Retrospective study was conducted on a cohort of patients submitted to HR in a tertiary teaching hospital, between January 2006 and December 2015. 112 patients were submitted to HR during the study period. Cirrhosis was present in 84% of cases, with portal hypertension in 19.6%. The median MELD score was 8 (range 6-15). The median number of lesions per patient was 1 (range 1-5) with a mean diameter of 5.4 ± 3.8 cm. Major HR were performed in 18.2% of cases. Overall post-op morbidity was 48.2% with Clavien-Dindo (CD) severity score ≥3 in 15.2% of cases. The most frequent complications were infected biloma (19.6%) and liver failure (14%). HCC recurred in 48% of patients. At univariate analysis overall post-op complications (HR 2.313, p = 0.003), CD score >2 (HR 2.075, p = 0.047), post-op liver failure (HR 2.990, p = 0.007), post-op iperbilirubinemia (HR 1.151, p = 0.049), post-op bleeding (HR 2.633, p < 0.001) and infected biloma (HR 2.696, p = 0.001) were risk factors for HCC recurrence. At multivariate analysis post-op liver failure (HR 4.081, p < 0.0001) and infected biloma (HR 2.971, p < 0.0001) maintained statistical significance for HCC recurrence. Thus Major surgical complications after HR, especially post-op liver failure and infected biloma are risk factors for HCC recurrence.

Objective: The informed consent process is a fundamental element of best practice in the surgical patient's care. The aim of the present study is to investigate the value of informed consent from the patient's perspective in a Teaching Hospital. In particular, the role of the Residents within this process is analyzed to compare their performance with that of Consultants., Design: This is a prospective observational study based on a consecutive cohort of patients who were offered an elective surgical procedure during the period April 2015 - September 2015., Setting: The study was conducted in the Surgical and Transplantation Unit of the University Hospital of Udine, Italy, accredited by the Joint Commission International., Participants: The study population consisted of 236 patients. The participants were asked on a voluntary basis to fill in a self-evaluating questionnaire after being requested to complete a written informed consent before the operation., Results: In the present study we didn't register any significant difference of patient's satisfaction over informed consent when we evaluated the performance of Residents in comparison to Consultants., Conclusions: We believe that our positive results may be related to our educational training approach. However, adequate education of Residents about seeking informed consent is not sufficient to guarantee an effective informed consent process if it is not supported as a counterpart by the promotion of correct and positive patient knowledge and perception of the Residents' skills, clinical role and responsibilities., Key Words: Educational program, Informed consent, Informed consent process, Patient's satisfaction, Resident.

Aim: To investigate the type and timing of evolution of incidentally found branch-duct intraductal papillary mucinous neoplasms (bd-IPMN) of the pancreas addressed to magnetic resonance imaging cholangiopancreatography (MRCP) follow-up., Methods: We retrospectively evaluated 72 patients who underwent, over the period 2006-2016, a total of 318 MRCPs (mean 4.4) to follow-up incidental, presumed bd-IPMN without signs of malignancy, found or confirmed at a baseline MRCP examination. Median follow-up time was 48.5 mo (range 13-95 mo). MRCPs were acquired on 1.5T and/or 3.0T systems using 2D and/or 3D technique. Image analysis assessed the rates of occurrence over the follow-up of the following outcomes: (1) imaging evolution, defined as any change in cysts number and/or size and/or appearance; and (2) alert findings, defined as worrisome features and/or high risk stigmata ( e.g ., thick septa, parietal thickening, mural nodules and involvement of the main pancreatic duct). Time to outcomes was described with the Kaplan-Meir approach. Cox regression model was used to investigate clinical or initial MRCP findings predicting cysts changes., Results: We found a total of 343 cysts (per-patient mean 5.1) with average size of 8.5 mm (range 5-25 mm). Imaging evolution was observed in 32/72 patients (44.4%; 95%CI: 32-9-56.6), involving 47/343 cysts (13.7%). There was a main trend towards small (< 10 mm) increase and/or decrease of cysts size at a median time of 22.5 mo. Alert findings developed in 6/72 patients (8.3%; 95%CI: 3.4-17.9) over a wide interval of time (13-63 mo). No malignancy was found on endoscopic ultrasound with fine-needle aspiration (5/6 cases) or surgery (1/6 cases). No clinical or initial MRCP features were significantly associated with changes in bd-IPMN appearance ( P > 0.01)., Conclusion: Changes in MRCP appearance of incidental bd-IPNM were frequent over the follow-up (44.4%), with relatively rare (8.3%) occurrence of non-malignant alert findings that prompted further diagnostic steps. Changes occurred at a wide interval of time and were unpredictable, suggesting that imaging follow-up should be not discontinued, though MRCPs might be considerably delayed without a significant risk of missing malignancy., Competing Interests: Conflict-of-interest statement: Nothing to disclose.

Background: Training programs for resident surgeons represent a challenge for the mentoring activity. The aim of the present study is to investigate the impact of our training program for laparoscopic cholecystectomy on patient's safety and on the modulation of the residents' exposure to clinical scenario with different grades of complexity., Material and Methods: This is a retrospective study based on a clinical series of laparoscopic cholecystectomy performed in a teaching hospital. Study population was grouped according to the expertise of the attending primary operator among resident surgeons. Four groups were identified: consultant (C), senior resident (SR); intermediate level resident (IR); junior resident (JR). The intraoperative and postoperative outcomes were confronted to evaluate the patient's safety profile., Results: 447 patients were submitted to LC: 96 cases were operated by a C, 200 by SR, 112 by IR and 39 by JR. The mean operative time was the longest for the JR group. A statistically higher rate of conversion to open approach was registered in C and IR groups in comparison to JR and SR groups. However, in C and IR groups, patients had worse ASA score, higher BMI and more frequent past history of previous abdominal surgery, cholecystitis or pancreatitis. Overall, it was not registered any statistically significant difference among the groups in terms of length of hospital stay and prevalence of major postoperative complications., Conclusion: Applying an educational model based on both graduated levels of responsibility and modulated grade of clinical complexity can guarantee an high safety profile.

Background: Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy., The Aims of Our Study Were: (1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy., Methods: This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed., Results: The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94)., Conclusions: Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Unlabelled: Gallbladder perforation with hemorrhage may be the source of massive hemoperitoneum under rare and extreme circumstances. In cirrhotic patients the bleeding may be associated with the tearing of gallbladder varices and represents a fatal complication, as reported in all the cases available in literature. The incidence of gallbladder varices in the setting of portal hypertension ranges 12-30%, although literature data are limited. We describe the case of an end-stage cirrhotic patient without portal thrombosis awaiting for orthotopic liver transplantation, who developed a fatal hemoperitoneum caused by massive bleeding from ruptured varices of both gallbladder wall and cholecystic fossa. The review of the literature was also performed., Key Words: Cirrhosis, Gallbladder, Hemoperitoneum, Perforation, Portal hypertension, Varices.

Sorafenib has improved the median overall survival of unresectable or otherwise untreatable hepatocellular carcinoma (HCC) of ∼3 months, compared to supportive cares. Complete response, although rare, has been reported. The authors reported herein a case of complete biochemical and radiological remission of advanced unresectable HCC with lymph node metastasis and tumoral portal vein thrombosis treated by 5 months therapy with sorafenib followed by adjuvant Yttrium-90 radioembolization. At 12 months follow-up, there is no evidence of HCC recurrence.

Objective: To present our technique of ureteral replacement with an appendicovesicostomy for the treatment of extended ureteral stricture after kidney transplantation. Ureteral stricture represents a urologic complication that may cause progressive function impairment and graft loss. Symptomatic ureteral stenosis is generally treated with a percutaneous nephrostomy and ureteral stenting. This approach may be initially effective, but often does not offer a long-term solution., Methods: A 48-year-old Caucasian man underwent kidney transplantation from a heart-beating deceased donor. The graft was transplanted to the right iliac fossa. Ureterovesical anastomosis was performed following the Lich-Gregoir technique. The postoperative period and follow-up were uneventful. Six months later the patient experienced an episode of acute pyelonephritis with hydronephrosis. A percutaneous nephrostomy was inserted, and an anterograde pyelography confirmed proximal dilatation with severe distal stenosis involving the entire ureter including the ureterovesical anastomosis. A 9 French Double-J stent was inserted antegradely and the patient was prepared for surgery., Results: We decided therefore to use the appendix as a conduit between the proximal transplant ureter and the bladder It was interposed with an isoperistaltic orientation and anastomosed to the ureter proximally and to the bladder distally (Lich-Gregoir reimplantation) using interrupted absorbable 5/0 sutures over a 10-Fr Double-J stent. The urethral catheter was removed on day 9 postoperatively and the patient was discharged with normal parameters. At 1 year follow-up the patient remains well., Conclusion: The positive outcome confirms how the use of appendix as ureteral replacement is feasible and effective, allowing the salvage of the renal allograft., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Macrocystic serous cystadenomas (MaSCA) are rare benign tumor of the pancreas which represent an atypical macroscopic morphologic variant of serous cystadenomas (SCA). They are characterized by a limited number of cysts with a diameter of >2 cm and share imaging features overlapping those of mucinous cystic neoplasm (MCN) and branch-duct intraductal papillary mucinous neoplasm (BD-IPMN), thus frequently making the pre-operative radiologic diagnosis difficult., Materials and Methods: Four cases of MaSCA, which were surgically treated in our structure, are reported., Results: Two women (62 and 39 year-old) presented with upper abdominal pain and palpable mass underwent CT with evidence of a lobulated cystic neoformation (98 × 70 and 94 × 75 mm respectively) originating from the body and the tail of the pancreas respectively. They underwent distal pancreatectomy for suspected MCN. A 38 year-old woman underwent laparoscopic distal pancreatectomy because of the incidental finding of an unilocular cystic lesion in the pancreatic tail (23 mm) of indeterminate origin (MCN, SCA or metastasis). In a 40 year-old woman, admitted for acalculous acute pancreatitis, an unilocular cystic lesion in the body of the pancreas (62 mm) was detected and confirmed after 2 months at CT, therefore she underwent distal pancreatectomy for suspected pseudocyst or SCA. In all of the 4 patients the histological examination of the specimens revealed a MaSCA., Conclusion: Imaging techniques have a low diagnostic power in terms of differentiation of MaSCA from malignant lesions (as MCNs and BD-IPMN). In the clinical practise of MaSCA, surgery appears to gain indications that are wider than those correlated to the pathologic outcome, because of the necessity of a correct differential diagnosis from potentially malignant cystic tumors and the frequent symptoms requiring treatment., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Aim: Idiopatic thrombocytopenic purpura (ITP) is the most common indication for splenectomy. The failure rate of surgery is about 8% and the failure rate after splenectomy is approximately 28% for all patients. When the presence of an accessory spleen is diagnosed, splenectomy is recommended. Laparoscopic approach is considered the first choice., Patients and Methods: At our Department, between July and November 2011 two patients underwent laparoscopic accessory splenectomy for recurrence of ITP. Both patients had a previously laparoscopic splenectomy. Preoperative Magnetic Resonance (MR) was performed in both the cases revealing the presence of an accessory spleen., Results: The operative time was 105 and 100 minutes respectively. No perioperative complications occured. Hospital stay was four days in both cases. The first patient had a disease free period of two months; the second one of one month. Both patients restarted immunosuppressive therapy., Conclusions: The relapse of thrombocytopenia post-splenectomy can be associated with the presence of an accessory spleen. The laparoscopic accessory splenectomy should be considered the first choice approach. Surgical accessory splenectomy allows a transitory remission of the disease.

Splenic cysts are relatively rare entities. The differential diagnosis for these lesions includes parasite infections, results of previous trauma or infarction, congenital forms, primitive splenic neoplasm or cystic metastasis. They can be either symptomatic, causing mainly abdominal pain, or asymptomatic, thus being diagnosed as in incidental finding during radiological examination for other clinical reasons: among these a raised serum level of CA 19-9 can be a case. It has been demonstrated that epidermoid and mesothelial congenital cyst can be associated with a pathological level of this tumor marker which is usually correlated to biliopancreatic and colonic carcinomas. The aim of the present study is to present the case of an asymptomatic epidermoid splenic cyst associated with a continuous increase of CA 19-9 and to describe the applied clinical workup and surgical management by laparoscopic total splenectomy. Moreover, to analyze the demographics, clinical and pathological features of these infrequent lesions and to confront our therapeutic management with that of the other reported cases, we conducted a systematic review of the literature.