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Background and Aims: Besides the increased risk of perioperative morbidity, graft failure, and mortality, the majority of PVT are diagnosed at liver transplantation (LT). Improving preoperative management and patient selection may lead to better short-term and long-term outcomes and reduce the risk of a futile LT. The authors aimed to identify predictors of adverse outcomes after LT in patients with nonmalignant portal vein thrombosis (PVT) and improve donor to recipient matching by analyzing the results of the Italian cohort of LT recipients., Methods: Adult patients who underwent LT in Italy between January 2000 and February 2020 diagnosed with PVT pre-LT or at time of LT were considered eligible for inclusion. Based on a survey encompassing all 26 surgeons participating in the study, a binary composite outcome was defined. Patients were classified as having the composite event if at least one of these conditions occurred: operative time more than 600 min, estimated blood loss greater than 5000 ml, more than 20 ICU days, 90 days mortality, 90 days retransplant., Results: Seven hundred fourteen patients were screened and 698 met the inclusion criteria. The analysis reports the results of 568 patients that fulfilled the criteria to enter the composite outcome analysis.Overall, 156 patients (27.5%) developed the composite outcome. PVT stage 3/4 at transplant and need for any surgical correction of PVT are independent predictors of the composite outcome occurrence. When stratified by PVT grade, overall survival at 1-year ranges from 89.0% with PVT grade 0/1 to 67.4% in patients with PVT grade 3/4 at LT ( P <0.001). Nevertheless, patients with severe PVT can improve their survival when identified risk factors are not present., Conclusions: Potential LT candidates affected by PVT have a benefit from LT that should be adequately balanced on liver function and type of inflow reconstruction needed to mitigate the incidence of adverse events. Nonetheless, the absence of specific risk factors may improve the outcomes even in patients with PVT grades 3-4., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background & Aims: In Italy, since August 2014, liver transplant (LT) candidates with model for end-stage liver disease (MELD) scores ≥30 receive national allocation priority. This multicenter cohort study aims to evaluate time on the waiting list, dropout rate, and graft survival before and after introducing the macro-area sharing policy., Methods: A total of 4,238 patients registered from 2010 to 2018 were enrolled and categorized into an ERA-1 Group (n = 2,013; before August 2014) and an ERA-2 Group (n = 2,225; during and after August 2014). A Cox proportional hazards model was used to estimate the hazard ratio (HR) of receiving a LT or death between the two eras. The Fine-Gray model was used to estimate the HR for dropout from the waiting list and graft loss, considering death as a competing risk event. A Fine-Gray model was also used to estimate risk factors of graft loss., Results: Patients with MELD ≥30 had a lower median time on the waiting list (4 vs.12 days, p <0.001) and a higher probability of being transplanted (HR 2.27; 95% CI 1.78-2.90; p = 0.001) in ERA-2 compared to ERA-1. The subgroup analysis on 3,515 LTs confirmed ERA-2 (odds ratio 0.56; 95% CI 0.46-0.68; p = 0.001) as a protective factor for better graft survival rate. The protective variables for lower dropouts on the waiting list were: ERA-2, high-volume centers, no competition centers, male recipients, and hepatocellular carcinoma. The protective variables for graft loss were high-volume center and ERA-2, while MELD ≥30 remained related to a higher risk of graft loss., Conclusions: The national MELD ≥30 priority allocation was associated with improved patient outcomes, although MELD ≥30 was associated with a higher risk of graft loss. Transplant center volumes and competition among centers may have a role in recipient prioritization and outcomes., Clinical Trial Number: NCT04530240 LAY SUMMARY: Italy introduced a new policy in 2014 to give national allocation priority to patients with a model for end-stage liver disease (MELD) score ≥30 (i.e. very sick patients). This policy has led to more liver transplants, fewer dropouts, and shorter waiting times for patients with MELD ≥30. However, a higher risk of graft loss still burdens these cases. Transplant center volumes and competition among centers may have a role in recipient prioritization and outcomes., Competing Interests: Conflict of interest The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details., (Copyright © 2021 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: Preoperative biliary drainage may be essential to reduce the risk of postoperative liver failure after hepatectomy for perihilar cholangiocarcinoma. However, infectious complications related to preoperative biliary drainage may increase the risk of postoperative mortality. The strategy and optimal drainage method continues to be controversial., Methods: This is a retrospective multicenter study including patients who underwent hepatectomy for perihilar cholangiocarcinoma between 2000 and 2016 at 14 Italian referral hepatobiliary centers. The primary end point was to evaluate independent predictors for postoperative outcome in patients undergoing liver resection for perihilar cholangiocarcinoma after preoperative biliary drainage., Results: Of the 639 enrolled patients, 441 (69.0%) underwent preoperative biliary drainage. Postoperative mortality was 8.9% (12.5% after right-side hepatectomy versus 5.7% after left-side hepatectomy; P = .003). Of the patients, 40.5% underwent preoperative biliary drainage at the first admitting hospital, before evaluation at referral centers. Use of percutaneous preoperative biliary drainage was significantly more frequent at referral centers than at community hospitals where endoscopic preoperative biliary drainage was the most frequent type. The overall failure rate after preoperative biliary drainage was 43.3%, significantly higher at community hospitals than that at referral centers (52.7% v 36.9%; P = .002). Failure of the first preoperative biliary drainage was one of the strongest predictors for postoperative complications after right-side and left-side hepatectomies and for mortality after right-side hepatectomy. Type of preoperative biliary drainage (percutaneous versus endoscopic) was not associated with significantly different risk of mortality., Conclusion: Failure of preoperative biliary drainage was significantly more frequent at community hospitals and it was an independent predictor for postoperative outcome. Centers' experience in preoperative biliary drainage management is crucial to reduce the risk of failure that is closely associated with postoperative morbidity and mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Despite gaining wide consensus in the management of hepatocellular carcinoma (HCC), minimally invasive liver surgery (MILS) has been poorly investigated for its role in the setting of salvage liver transplantation (SLT). A multicenter retrospective analysis was carried out in 6 Italian centers on 211 patients with HCC who were initially resected with open (n = 167) versus MILS (n = 44) and eventually wait-listed for SLT. The secondary endpoint was identification of risk factors for posttransplant death and tumor recurrence. The enrolled patients included 211 HCC patients resected with open surgery (n = 167) versus MILS (n = 44) and wait-listed for SLT between January 2007 and December 2017. We analyzed the intention-to-treat survival of these patients. MILS was the most important protective factor for the composite risk of delisting, posttransplant patient death, and HCC recurrence (OR, 0.26; 95% confidence interval [CI], 0.11-0.63; P = 0.003). MILS was also the only independent protective factor for the risk of post-SLT patient death (OR, 0.29; 95% CI, 0.09-0.93; P = 0.04). After propensity score matching, MILS was the only independent protective factor against the risk of delisting, posttransplant death, and HCC recurrence (OR, 0.22; 95% CI, 0.07-0.75; P = 0.02). On the basis of the current analysis, MILS seems protective over open surgery for the risk of delisting, posttransplant patient death, and tumor recurrence. Larger prospective studies balancing liver function and tumor stage are strongly favored to better clarify the beneficial effect of MILS for HCC patients eventually referred to SLT., (Copyright © 2020 by the American Association for the Study of Liver Diseases.)

Background: Management of malignancy in elderly patients is challenging. We aimed to assess the impact of age and ageing on overall survival (OS), recurrence-free survival (RFS), tumour-specific survival (TSS) and potential years of life lost (PYLL) after surgery for hepatocarcinoma (HCC)., Methods: Consecutive patients treated for HCC between 2005 and 2015 were evaluated. Patients were divided according to age-decade. Afterwards, elderly patients (≥75 years) were compared with patients < 75 years. A 1:1 propensity matching was used to reduce the risk of bias. Survival was estimated by Kaplan-Meier method and Cox regression analysis., Results: Four hundred and thirty-nine patients were stratified: group 1 (age ≤ 55, n = 72), group 2 (age: 56-65, n = 133), group 3 (age: 66-74, n = 141) and group 4 (age ≥ 75, n = 93). Group 1 had the highest median PYLL (27.6, IQR 24.6-32.5) while group 4 the lowest (2.0, IQR 0-9.6; P < 0.001). Comparing elderly vs younger, there were no significant differences in terms of OS (P = 0.054), TSS (P = 0.321) and RFS (P = 0.240). Ageing was the only variable associated with post-operative complications (OR: 2.51; 95% CI: 1.23-5.13; P = 0.025) and liver-related morbidity was an independent predictor of OS. (HR 2.49, 95% CI: 1.34-4.64, P = 0.004)., Conclusion: Ageing per se is not an absolute contraindication for liver resection, given the acceptable oncologic long-term prognosis, but the worse short-term outcomes in the elderly should induce an accurate patient selection., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: The optimal surgical strategy to lessen the risk of hepatocarcinoma (HCC) recurrence is debated. This study aimed to investigate the role of anatomic resection (AR) and parenchyma-sparing resection (PSR) in HCC recurrence patterns., Methods: The study analyzed 384 cirrhotic patients with a first diagnosis of HCC. Of these patients, 142 underwent AR, and 242 underwent PSR. The two groups were unbalanced at the univariate analysis. To minimize this bias, a 1:1 propensity score-matching analysis (PSA) was used. Disease-free survival (DFS) curves were analyzed by the Kaplan-Maier method., Results: The PSA allowed pairing of 200 patients (100 for AR and 100 for PSR). In this study, 59 patients (62.8%) had recurrence after AR compared with 58 patients (63.7%) after PSR (p = 0.891). The rates of local recurrence were respectively 15.3% and 15.5% (p = 0.968). When microvascular invasion was considered, the median DFS was 10.7 months for AR and 9.4 months for PSR (p = 0.607). In comparisons of AR and PSR, DFS did not differ significantly between subgroups with high histologic grading (p = 0.520), multiple nodules (p = 0.307), and Child-Pugh B (p = 0.679)., Conclusion: Excision of the anatomic segment did not seem to reduce the rate of relapse or recurrence patterns significantly, even in high-risk subgroups.

Liver transplantation is the ideal treatment for patients affected by early stage hepatocellular carcinoma and chronic liver disease. Considering organs shortage, alternative treatments have to be adopted to minimize the waitlist drop-out, and in case of recurrence within the accepted criteria, salvage transplantation can be considered. Surgical resection is one of the most effective treatments, with the possibility of oncological radicality and pathological analysis of the specimen. Although these theoretical advantages, surgical strategy cannot be applied to all patients because of the impaired liver function as well as the amount of parenchyma to be resected does not allow a sufficient future liver remnant. Furthermore, resection by laparotomy may lead to strong intra-abdominal adhesions in a contest of portal hypertension and, as potential consequence, increase transplantation difficulty raising morbidity. Laparoscopic liver resection is now performed as a routine procedure in tertiary referral centers, with increasing evidence of long-term results comparable to traditional surgery together with the advantages of a minimally invasive approach. In addition, with a salvage transplantation strategy that has been shown to be comparable to primary transplantation, the patient can live with his native liver avoiding an invasive procedure and long-term immunosuppression, allowing the use of liver grafts for the community. We present the results of an Italian multicenter experience of salvage liver transplantation following the recurrence of HCC initially treated by laparoscopic resection in 31 patients, performed by four referral centers. Mean operative transplantation time was 450 min, morbidity was 41.9%, 90-days mortality was 3.2%, and median post-operative length of stay was 17.9 days. Salvage liver transplantation after laparoscopic liver resection for HCC is comparable to open surgery in terms of operative time, oncologic radicality, morbidity and mortality, with the advantages of laparoscopic surgery.

Introduction: Worldwide, organ shortage is a major limiting factor to transplantations. One possible way to face graft scarcity is splitting full livers into hemilivers; this procedure would allow transplantation in 2 adult recipients with the use of a single organ from a deceased donor., Objective: The goal of this study was to describe an adult-to-adult split liver operative protocol and share it between centers interested in exploring this procedure., Materials and Methods: A literature review was first conducted to elaborate on the present protocol; second, selection criteria for suitable deceased donors were identified. The technical aspects of performing the procurement were also analyzed; finally, the recipient selection criteria and the transplantation criteria were determined., Results: The donor characteristics should be consistent with the following: age≤55 years; weight≥70 kg; body mass index<28 kg/m2; intensive care unit stay<7 days; sodium level<160 mEq/L if the intensive care unit stay is >2 days; maximum transaminase value 3 times normal; hemodynamic stability; negative for hepatitis B surface antigen, hepatitis C virus, and human immunodeficiency virus; macrosteatosis<20%; macroscopic adequacy; and absence of anatomic anomalies requiring complex reconstruction. The procurement hospital should provide the preoperative computed tomography scan, liver dissector, and the intraoperative ultrasound. Indication for in situ or ex situ splitting depends on the hepatic vein outflow anatomy. Graft-to-recipient weight ratio should be ≥1%, and the graft-to-recipient spleen size ratio should be ≥0.6. United Network for Organ Sharing status 1 and 2A recipients are excluded, as are patients with transjugular intrahepatic portosystemic shunts. Hemiliver transplants are performed as in living-donor liver transplantation, and portal hyperflow is corrected by splenic artery ligation, splenectomy, and portal infusion of vasoactive drugs., Conclusions: The present protocol was proposed to test the validity of the full-left full-right split liver procedure. A retrospective analysis found that 130 transplantations were suitable for this procedure according to the present protocol in the period January 1, 2008, through December 31, 2011 (65 donors). We believe that these numbers could be greatly increased once this procedure is proven feasible and safe within the proposed criteria., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background/aims: The aim of the present study is the analysis of risk factors of postoperative pancreatic fistula (POPF) and of clinical outcome after pancreatoduodenectomy (PD) in a retrospective multicentric review of the patient cohort., Methodology: From January 2003 to July 2013 143 patients underwent PD: 138 cases were included and 3 groups were identified according to the different types of anastomosis: Group 1 invaginating end-to-end pancreatojejunostomy, Group 2 end-to-side pancreatojejunostomy with duct-to-mucosa anastomosis, Group 3 end-to-side pancreatogastrostomy., Results: Twenty-one % of patients developed POPF, 16% in Group 1, 27% in Group 2, 12% in Group 3. Forty % grade A, 13% grade B and 47% grade C total POPF. It results that POPF occurred in 16% of hard and in 40% of soft pancreatic texture; in 11.4% of dilated Wirsung versus 30.8% of non dilated (p = 0.007). Overall actuarial 1 and 3 year survival after PD is 69% and 48% respectively. Perioperative mortality is 5.8% overall, 17.85% for grade C., Conclusions: No differences have been found among surgical anastomosis techniques. Soft tissues seem to increase, while dilated Wirsung seems to decrease POPF rate. The development of POPF increase morbidity but it doesn't affect overall survival, more strictly related to tumour histopathology.

Background: Hepatic pedicle clamping (HPC) during Liver Resection (LR) is a vascular procedure designed to prevent bleeding from the liver during hepatectomy. Outgrowth of pre-existing colorectal micrometastases may occur 5-6 times faster in occluded liver lobes than in non-occluded lobes. We conducted a case-matched analysis at our Institution to assess the effects of HPC on overall and recurrence-free survival in highly selected patients, who underwent LR due to Colorectal liver metastases (CLM)., Materials and Methods: From January 2002 to December 2010, 120 patients operated for CLM were included into this case-matched study. Patients were allocated to two groups: Group-A patients who underwent HPC during LR; Group-B patients who underwent LR without HPC., Results: HPC during liver resection was associated with better overall patient 5-year survival (47.2% in Group-A and 32.1% in Group-B) (P-value = 0.06), and significantly better 5-year recurrence-free survival (49.9% in Group-A vs 18.3% in Group-B) (P-value = 0.010) The Cox regression model identified the following risk factors for worse prognosis in terms of shorter recurrence-free survival and higher incidence of tumor recurrence: no HPC (Group-B) (P-value = 0.032) and positive lymph nodes at the time of LR (P-value = 0.018)., Conclusion: Lack of HPC in selected patients who underwent LR for CLM results to be a strong independent risk factor for higher patient exposure to tumor recurrence. We suggest that hepatic hilum clamping should be seriously taken into consideration in this patient setting., Mini-Abstract: A case-matched study was performed in 120 patients undergoing liver resection due to colorectal liver metastases, comparing patients who received intermittent hepatic pedicle clamping (HPC) with those who did not. The 5-year overall survival rate was similar, but the 5-year recurrence-free rate was significantly higher with no HPC (p = 0.012)., (Copyright © 2013 Elsevier Ltd. All rights reserved.)