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Background: Split and living donor liver transplantations are both key surgical strategies for development of pediatric liver transplant programs. Often, however, teams tend to prioritize only one preferentially. Methods: In the context of a very active national split liver graft allocation program (Italy), retrospective study of 226 consecutive pediatric first isolated liver transplants performed by a single team using organs from both deceased and living donors. Clinical characterisitics and outcome were compared. Results: In the context of a steadily slowly decreasing split graft offer, living donation activity steadily increased. Deceased and living donation accounted for 52.6% and 47.4% of transplantations, respectively. Both strategies were equally used for transplanting patients up to 30 kg of weight, while deceased donors were predominantly used for older recipients. Technical variants represented 86% of all transplants, with 183 conisting of left lateral segment grafts (76 split liver grafts and 107 left grafts from living donors). Outcome of both surgical strategies was similar, with excellent outcomes at early, mid‐, and long‐term. Conclusions: Splitting livers of deceased donors and using living donation were complementary and non‐competitive strategies for developping pediatric liver transplant activity. Implementing both activities in parallell allowed to maintain stable the number of annual transplant in Italy and allowed to reach superior outcomes. This analysis provides evidence that living donation plays a role in Italy despite an existing very active "mandatory‐split" national policy. [ABSTRACT FROM AUTHOR]

Background: Full‐right/full‐left liver splitting was introduced early in the 90s as part of the great wave of technical innovations that characterized that decade. One approach was to divide the liver on the right of the Cantlie's line and leave the middle hepatic vein with the left graft, with both grafts allocated to adults. Both grafts had some functional disadvantages and exposed the adult recipients to some early hepatic dysfunction, and the results were not great. An alternative approach consisted of an ex situ division of the liver, exactly along Cantlie's line, thus sharing the middle hepatic vein between the two grafts. None of these two techniques were really adopted, and there has been nearly no transplantation of this type in the last decade worldwide. Method and results: The authors propose a variation of the latter technique that was used recently with success: The division of the liver is made simpler; the two grafts are prepared ex situ and need a simple vascular reconstruction (one venous patch on each graft); and the grafts can be implanted using very standard techniques. Conclusion: Because candidates for liver transplantation weighing 25–60 kg (old children, teenagers, and some small adults) are often at some disadvantage in getting size‐matched livers (this range of weight is less represented in the donor population), implementing the latter technique would help provide adequate grafts for them. In Italy, where many livers offered for splitting are not used, there would be ample room for implementing this option within the actual donor pool and allocation system. [ABSTRACT FROM AUTHOR]

Background: Renal transplantation is the most successful therapy for improving survival and quality of life for end-stage renal disease (ESRD). Living donor kidney transplantation (LDKTx) has been used as an alternative to reduce the stay on the waiting list of patients with ESRD. Laparoscopic donor nephrectomy (LDN) has become the standard procedure for LDKTx.Objective: This study aims to describe evolution of surgical technique with LDN at our institute.Materials and Methods: We retrospectively analyzed our experience with LDN performed from January, 2003 to November, 2016, focusing on describing modifications of the surgical technique and devices made during those years. Demographics, operative factors, and postoperative complications of donors were reviewed.Results: From the beginning of our experience with LDKTx we have performed 185 cases. From 2003 to 2016, 144 LDN were performed. Modifying our technique in response to the learning curve, complications encountered, and technological advancements, we experienced low complication rates.Conclusions: Continual refinement with LDN techniques based on intraoperative observations and technological advances is necessary to keep complication rates low and reduce donor morbidity and time for recovery. [ABSTRACT FROM AUTHOR]

Mortality on the paediatric liver transplantation (pLT) waiting list (WL) is still an issue. We analysed the Italian pLT WL to evaluate the intention-to-treat (ITT) success rate and to identify factors influencing success. All children (<18 years) listed for pLT in Italy between 2002-2018 were included (Era 1 [2002–2007]: centre-based allocation; Era 2 [2008–2014]: national allocation; Era 3 [2015–2018]: national allocation+mandatory-split policy). A total of 1,424 patients (median age: 2.0 [IQR 1.0-9.0] years; median weight: 12.0 kg [IQR 7–27]) were listed for pLT. Median WL time was 2 days (IQR 1–5) for Status 1 and 44 days (IQR 15–120) for non-Status 1 patients; 1,302 children (91.4%) were transplanted (67.3% with split grafts), while 50 children (3.5%) dropped off the WL (2.5% death, 1.0% clinical deterioration). Predictive factors for receiving LT included Status 1 (hazard ratio [HR] 1.66, p = 0.001), Status 1B (HR 1.96, p = 0.016), Status 2A (HR 2.15, p = 0.024) and each 1-point increase in PELD/MELD score. Children with recipient's weight >25 kg, blood group O or awaiting pLT combined with other organs had less chance of being transplanted. ITT patient survival rates were 90.5% at 1 year and 87.5% at 5 years, remaining stable across eras. Risk factors for ITT survival were re-transplantation (HR 5.83, p < 0.001), Status 1 (HR 2.28, p = 0.006), Status 1B (HR 2.90, p = 0.014), Status 2A (HR 9.12, p < 0.001), recipient weight <6 kg (HR 4.53, p < 0.001) and low-volume activity (HR 4.38, p = 0.001). In Italy, continuous adaption of paediatric organ allocation policies via the introduction of national allocation, paediatric prioritisation rules and a mandatory-split policy have helped maximise the use of donors for paediatric candidates and to minimise WL mortality without compromising outcomes. Globally, paediatric liver transplant candidates still suffer from high mortality. Over recent decades, the continuous adaption of organ allocation policies in Italy has led to excellent outcomes for children awaiting liver transplantation. The mortality rate of paediatric liver transplant candidates has been minimised to almost zero, mainly using grafts from deceased donors. Paediatric prioritisation rules, national organ exchange organisation and a mandatory-split liver policy have resulted in a unique allocation model for paediatric liver transplant candidates and represent a landmark for the paediatric transplant community. [Display omitted] • In Italy paediatric liver transplant waiting list dropout rate is minimized to 3.5%. • Predictive factors of transplant are urgency, tumours, each added PELD/MELD point. • Survival risk factors are re-transplant, urgency, weight <6 kg, low-volume centre. • National mandatory-split liver policy increases paediatric liver transplant activity. • Paediatric priorisation and national organ allocation are needed to improve outcomes. [ABSTRACT FROM AUTHOR]

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. 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. 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). 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. 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. [Display omitted] • SLT is still considered a challenging procedure and is by no means widely accepted. • Initially poor outcomes for SLT explain the early reluctance to adopt this option. • Improved results with SLT have been reported recently. • Sharing experience has been instrumental in improving outcomes. • SLT is a significant source of paediatric grafts without compromising adults. [ABSTRACT FROM AUTHOR]

Recent series have demonstrated advantages of living donor over deceased donor liver transplantation, with particular benefit for those with low model for end-stage liver disease score. The logic underlying the transplantation of patients before they become too sick is intuitive. It reduces mortality and drop outs from the waiting list and makes transplant surgery less demanding. Those principles have to be balanced with donor safety and transplant benefit for the recipient avoiding early, futile transplantation. The authors report a case of adult to adult right lobe living donor liver transplantation performed for a recipient affected by primary biliary cirrhosis with MELD score of 15, in a transplant center located in an area of Europe characterized by chronic organ shortage.

Background: Liver transplantation (LT) is the only definitive and curative treatment for patients with end-stage liver disease and hepatocellular carcinoma. We aimed to evaluate the impact of the Italian score for organ allocation (ISO) in terms of the waiting-list mortality, probability of LT, and patient survival after LT., Patient and Methods: All of the adult patients on the waiting list for LT at our institute from January 2014 to December 2017 were included in the study. The probabilities of death while on the waiting list, dropout from the list, and LT were compared by means of cumulative incidence functions, in a competing risk time-to-event analysis setting. Uni- and multivariable logistic regression models were used to estimate and compare the probability of death and to find potential risk factors for waiting-list death., Results: There were 286 patients on the waiting list for LT during the study period, 122 of whom entered the waiting list prior to the implementation of ISO (Group A) and 164 afterward (Group B). Group A had 62 transplants, and Group B had 116 transplants. Group B showed a lesser probability of death (P = .005) and a greater probability of transplant (P < .001) compared to Group A. In the 2 groups, post-transplant survival was similar., Conclusion: Based on preliminary clinical experience from a single transplant center, the ISO allocation system demonstrated an overall reduced probability of patient death while on the waiting list without impairing post-LT survival, suggesting that the ISO system might represent an improved method of organ allocation, with a more beneficial distribution of livers., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Postoperative plasma lactate clearance has been established as an important prognostic factor for liver resection morbidity and mortality. The aim of this study was to analyse continuous monitoring of plasma lactate in patients submitted to extended hepatectomy (EH) with special attention to those who received preoperative portal vein branch embolization (PVE) to augment the future remnant liver. In this single center retrospective study, a full revision of 45 medical records was performed from patients who underwent EH at ISMETT from October 1999 to August 2013. Plasma lactates from admission to ICU to day 5 were recorded. Postoperative lactate clearance (ΔLAC) was defined as lactate at postoperative day 5 minus lactate at ICU presentation (hour 0). ΔLAC was analysed in relation to total hospital stay and 90 days' perioperative morbidity and mortality, using Clavien-Dindo classification, and by presence or absence of PVE. Forty-one right and four left EH were performed. 17 patients underwent previous PVE with a mean of 44 ± 28.9 days-to-surgery time and a 24 ± 8.3% degree of hypertrophy. In 39 cases (86.7%), a malignant etiology was the indication for EH, length of surgery was 486 ± 122 min with a median of 300 ml of blood transfusion. In 25 patients, a Clavien grade IIIa or worst complication has been experienced, and in three cases the death occurred during the first 3 months after EH. The median length of hospitalization was 11 days. In patients with preoperative PVE a significative association with an early post-resectional lactate clearance was obtained (p 0.01). Conversely, the univariate analysis measured by t test did not show any significative associations between ΔLAC and a median time of hospital stay longer than 11 days (p 0.08), or the onset of any complications (p 0.67) and of a Clavien's grade of complications ≥IIIa patients (p 0.48). After adjusting for co-variables, results of the multivariate logistic regression analyses confirmed that ΔLAC is not independent or significant predictor for initial poor liver function following EH. In our single center experience, the continuous monitoring of postoperative lactate clearance did not work as an early marker of postoperative liver dysfunction following EH. Although lactate clearance, worked as guide having a clinical utility in the ICU statement for hemodynamic optimization and systemic fluid balance management.

Mini invasive techniques are taking over conventional open liver resections in the setting of left lateral segmentectomy for living liver donation, and hydride procedure are being implemented for the living related right hepatectomy. Our center routinely performs laparoscopic left lateral segmentectomy for pediatric recipient and has been the first in the Europe performing an entirely robotic right hepatectomy. Great emphasis is posed on living donor safety which is the first priority during the entire operation, then the most majority of our procedures are still conventional open right hepatectomy (RHLD), defined as removal of a portion of liver corresponding to Couinaud segments 5-8, in order to obtain a graft for adult to adult living related liver transplant. During this 10 years period some changes, herein highlighted, have occurred to our surgical techniques. This study reports the largest Italian experience with RHLD, focused on surgical technique evolution over a 10 years period. Donor safety must be the first priority in right-lobe living-related donation: the categorization of complications of living donors, specially, after this "highly sensitive" procedure, reflects the need for prompt and detailed reports.

Complex liver trauma often presents major diagnostic and management problems. Current operative management is mainly centered on packing, damage control, and early utilization of interventional radiology for angiography and embolization. In this retrospective observational study of patients admitted to the Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy, from 1999 to 2010, we included patients that underwent hepatic resection for complex liver injuries (grade I to V according to the American Association for the Surgery of Trauma-Organ Injury Scale). Age, gender, mechanism of trauma, type of resection, surgical complications, length of hospital stay, and mortality were the variables analyzed. A total of 53 adult patients were admitted with liver injury and 29 underwent surgical treatment; the median age was 26.7 years. Mechanism was blunt in 52 patients. The overall morbidity was 30 per cent, morbidity related to liver resection was 15.3 per cent. Mortality was 2 per cent in the series of patients undergoing liver resection for complex hepatic injury, whereas in the nonoperative group, morbidity was 17 per cent and mortality 2 per cent. Liver resection should be considered a serious surgical option, as initial or delayed management, in patients with complex liver injury and can be accomplished with low mortality and liver-related morbidity when performed in specialized liver surgery/transplant centers.

Aim: We aimed to determine whether education level and socioeconomic status in a cohort of liver transplant recipients in the south of Italy were potential predictors of graft and patient survival., Methods: This retrospective study included 221 liver transplant recipients at Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione between January 2006 and September 2009. Donor gender and age, cold ischaemic time, extended criteria donors, recipient age, gender, body mass index, primary aetiology, Model for End-Stage Liver Disease score, co-morbidities, patient health score assessed on the basis of clinical follow-up, highest level of education achieved, and socioeconomic status were collected and analysed., Results: Kaplan-Meier analysis of survival measured by education level and socioeconomic status showed a higher survival rate in patients with higher education level (p=0.04) and socioeconomic status (p=0.01). After adjusting for all covariables, results of the multivariate Cox regression analyses showed that only socioeconomic status remained an independent and significant predictor of overall survival (Hazard Ratio=0.16, p=0.03)., Conclusion: Patient survival after liver transplantation was influenced by low income, low educational level, and lack of access to quality health care. Prospective clinical studies are necessary to fully identify the impact of socioeconomic status on long-term health outcomes, and to propose an evidence-based guide to clinical intervention., (Copyright © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)