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Surgical outcomes may be associated with hospital volume and the influence of volume on minimally invasive liver surgery (MILS) is not known.Patients entered into the prospective registry of the Italian Group of MILS from 2014 to 2018 were considered. Only centres with an accrual period of at least 12 months and stable MILS activity during the enrolment period were included. Case volume was defined by the mean number of minimally invasive liver resections performed per month (MILS/month).A total of 2225 MILS operations were undertaken by 46 centres; nine centres performed more than two MILS/month (1376 patients) and 37 centres carried out two or fewer MILS/month (849 patients). The proportion of resections of anterolateral segments decreased with case volume, whereas that of major hepatectomies increased. Left lateral sectionectomies and resections of anterolateral segments had similar outcome in the two groups. Resections of posterosuperior segments and major hepatectomies had higher overall and severe morbidity rates in centres performing two or fewer MILS/month than in those undertaking a larger number (posterosuperior segments resections: overall morbidity 30·4 versus 18·7 per cent respectively, and severe morbidity 9·9 versus 4·0 per cent; left hepatectomy: 46 versus 22 per cent, and 19 versus 5 per cent; right hepatectomy: 42 versus 34 per cent, and 25 versus 15 per cent).A volume-outcome association existed for minimally invasive hepatectomy. Complex and major resections may be best managed in high-volume centres.Los resultados quirúrgicos pueden estar relacionados con el volumen de casos del hospital, pero no se conoce la influencia en la cirugía mínimamente invasiva del hígado (minimally‐invasive liver surgery, MILS). MÉTODOS: Se incluyeron los pacientes registrados en el registro prospectivo del grupo italiano de MILS desde 2014 a 2018. Solo se consideraron centros con extensión de ≥ 12 meses y actividad estable de MILS durante el periodo de reclutamiento. El volumen de casos se definió como el número de MILS efectuado por mes.Se llevaron a cabo un total de 2.225 MILS en 46 centros, 9 de ellos con 2 MILS/mes (n = 1.376 pacientes) y 37 centros con ≤ 2 MILS/mes (n = 849). La proporción de resecciones de segmentos anterolaterales disminuyó con el volumen de casos, mientras que la proporción de hepatectomías mayores aumentó. Los resultados para ambos grupos fueron similares en las seccionectomías lateral izquierda y en las resecciones del segmento anterolateral. Las resecciones del segmento posterosuperior y las hepatectomías mayores presentaron tasas más altas de morbilidad global y morbilidad grave en centros que realizaban ≤ 2 MILS/mes que en los que realizaban 2 MILS/mes (resecciones del segmento posterosuperior, morbilidad global 30,4 versus 18,7%, morbilidad grave 9,9 versus 4,0%; hepatectomía izquierda, 46,2 versus 22,0%, 19,2 versus 5,5%; hepatectomía derecha, 41,7 versus 33,8%, 25,0 versus 14.9%). CONCLUSIÓN: Se observó una asociación volumen‐resultado para la resección hepática mínimamente invasiva. Las resecciones complejas y mayores se pueden manejar mejor en centros de gran volumen.

Background Pancreas transplantation (PT) is the best option of care for patients with type I diabetes mellitus (T1DM). Methods From July 2005 to September 2014, we performed 27 PT from deceased donors (24 simultaneous pancreas-kidney transplantations [SPKT] and 3 pancreas transplantations alone) in a region with a high incidence of T1DM. Results Enteric drainage and systemic venous derivation were accomplished for all PT. Cold and warm ischemia times were 291 ± 70 minutes and 32 ± 9 minutes, respectively. The rate of early re-operations was 33%, mainly because of bleeding occurrence. Mean donor age was 31 ± 11 years; all patients had ABO compatibility and negative cross-match. With a mean follow-up time of 2.3 years, no death was registered. Graft survival of PT was 96.7%, with 1 graft loss in the SPKT group (3.7%) after acute rejection. Nine patients were submitted successfully to re-operation for no life-threatening complications within 30 post-operative days. No early or late episode of vascular thrombosis, pancreatitis, or pancreatic fistula was observed. All patients with a functioning graft had excellent metabolic control, with mean glycosylated hemoglobin level at last follow-up of 5.5% and median fasting glucose level of 95 ± 13 mg/dL, comparable to that in the non-diabetic population. Conclusions In our experience, PT is an excellent therapeutic solution for patients with T1DM. Despite fewer than 5 PT performed per year, graft and patient outcomes were similar to those in high-volume centers.

Background: To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry. Methods: Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis. Results: A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76). Conclusion: Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability. © 2013 Editrice Gastroenterologica Italiana S.r.l.

Background & Aims: The appropriate allocation of grafts from HBcAb positive donors in liver transplantation is crucial, yet a consensus is still lacking. Methods: We evaluated this issue within Liver Match, a prospective observational Italian study. Data from 1437 consecutive, first transplants performed in 2007-2009 using grafts from deceased heart beating donors were analyzed (median follow-up: 1040 days). Of these, 219 (15.2%) were HBcAb positive. Sixty-six HBcAb positive grafts were allocated to HBsAg positive and 153 to HBsAg negative recipients. Results: 329 graft losses occurred (22.9%): 66 (30.1%) among 219 recipients of HBcAb positive grafts, and 263 (21.6%) among 1218 recipients of HBcAb negative grafts. Graft survival was lower in recipients of HBcAb positive compared to HBcAb negative donors, with unadjusted 3-year graft survival of 0.69 (s.e. 0.032) and 0.77 (0.013), respectively (log-rank, p = 0.0047). After stratifying for recipient HBsAg status, this difference was only observed among HBsAg negative recipients (log rank, p = 0.0007), 3-year graft survival being excellent (0.88, s.e. 0.020) among HBsAg positive recipients, regardless of the HBcAb donor status (log rank, p = 0.4478). Graft loss due to de novo HBV hepatitis occurred only in one patient. At Cox regression, hazard ratios for graft loss were: MELD (1.30 per 10 units, p = 0.0002), donor HBcAb positivity (1.56, p = 0.0015), recipient HBsAg positivity (0.43, p

DURING ORTHOTOPIC human liver transplantation (OLT), postreperfusion tissue damage is associated with a significant increase in markers of cytolysis and cholestasis. In the early phases of reperfusion an increase in the steady-state levels of reactive oxygen species (ROS) was observed to correlate with the presence of cytolysis; nevertheless, the role of oxidative stress in causing and/or amplifying postreperfusion damage to human liver grafts has not as yet been conclusively defined. The topology and chronology of the damage in the transplanted liver may be described as an endothelial cell injury that appears in the late stage of cold ischemia, followed immediately after reperfusion by involvement of the whole liver vasculature with concomittant activation of Kupffer cells, which, together with endothelial cells, attract and trigger polymorphonuclear cells (PMNs), the major source of ROS. While oxidative stress occurring in the hepatic vasculature appears to be a primary cause of the reperfusion injury, the role of oxidative reactions in phagocyte recruitment and activation is not yet clear. Hence, patients scheduled for OLT in two different transplantation units were randomly divided into two groups: one group received an intravenous dose of an antioxidant supplement during surgery. During the first 2 hours of reperfusion, we monitored blood indices of oxidative stress and neutrophil activation. RECRUITMENT OF PATIENTS AND METHODS

The influence of steatosis and of other donor and recipient characteristics in affecting liver performance post-orthotopic liver transplantation (OLT) was evaluated in 311 consecutive liver transplantations made in 278 patients. Donor variables considered were age, sex, blood group, cause of death, intensive care unit (ICU) days, need for vasopressors, hepatic enzymes and bilirubin, total and warm ischemia time, and macro- and microvescicular steatosis. Recipient variables considered were age, sex, blood group, biliary output, and post-OLT peak levels of hepatic enzymes. Patient and graft survival were the main outcome indicators. In the multivariate analysis, macrovescicular steatosis involving 25% or more of the hepatocytes was the only variable independently associated with shorter patient survival (p0.05). Five (62.5%) of the eight livers with macrovescicular steatosis involving 25% or more of the hepatocytes incurred in a delayed non-function (DNF) and one (12.5%) in a primary non-function (PRNF). The incidence of DNF and PRNF in the group with macrovescicular steatosis involving less than 25% of the liver cells was 1.6% (p0.001) and 2.3%, respectively. Microvescicular steatosis of any degree was not associated with a worse prognosis. Macrovescicular steatosis involving 25% or more of the hepatocytes identifies marginal livers, the use of which significantly increases the risk of graft non-function post-OLT.

Transplenic decompression of esophageal varices by distal splenorenal shunt according to Warren (DSRS) aims to a selective detention of the esophago-gastric varices, also assuring an adequate portal perfusion and hypertensive state of the porto-mesenteric district. The DSRS though, should and must not be performed in emergency as a high mortality rate is registered in all cases of emergency porto-systemic derivations. A mortality risk is reported even during endoscopic sclerosis if performed in emergency compared to the elective procedure. The scope of our study was to test the validity of a new approach of the hemorrhagic cirrhotic patient: the end point was to stop the bleeding with Glypressin and deferred sclerotherapy, associating a selective shunt at 40-60 days. Out of 32 patients with esophago-gastric variceal bleeding, 8 were selected also for derivative surgery. Results show Glypressin as the first and best therapeutic approach. The drug in many cases stops bleeding or at least reduces the blood loss allowing an easier endoscopic sclerosis. Further sclerosis and/or surgical therapy may assure variceal eradication.