Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% ...of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.
Machine perfusion (MP) has revolutionized the field
of kidney transplantation (KT). A large body of
literature has supported its use in different situations,
including graft reconditioning, ...evaluation, and longterm
preservation.1-6 With the increasing number of
kidneys being placed in MP, transplant surgeons
often encounter vascular abnormalities. Multiple
renal arteries have been observed in approximately
30% of kidneys and are always “terminal” (ie,
without overlap in their areas of supply), which
mandates their systematic revascularization in the
recipient.7,8 For this reason, the commercially
available MP devices offer various solutions to
connect more than one artery, such as large clamps
and multiple cannulas. Nevertheless, a bench
reconstruction may be necessary. We do, however,
believe that the decision to use MP should not
condition the technique of vascular reconstruction
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.
Growing experience with the liver splitting technique and favorable results equivalent to those of whole liver transplant have led to wider application of split liver transplantation(SLT) for adult ...and pediatric recipients in the last decade. Conversely, SLT for two adult recipients remains a challenging surgical procedure and outcomes have yet to improve. Differences in organ shortages together with religious and ethical issues related to cadaveric organ donation have had an impact on the worldwide distribution of SLT. Despite technical refinements and a better understanding of the complex liver anatomy, SLT remains a technically and logistically demanding surgical procedure. This article reviews the surgical and clinical advances in this field of liver transplantation focusing on the role of SLT and the issues that may lead a further expansion of this complex surgical procedure.
The shortage of organs has pushed transplant surgeons to accept liver grafts with extended criteria, but severe vascular abnormalities may still discourage the use of otherwise acceptable organs. We ...report herein the case of a liver graft with a 64-mm aneurysm of the proper hepatic artery extended to the origin of the right and left hepatic branches. The graft was deemed unsuitable for transplant by all other centers in the region. However, liver function tests were normal, and there was no evidence of compromised arterial supply. At back table, we resected the aneurysm and anastomosed the right and left hepatic arteries to a vascular graft obtained from the distal tract of the donor's superior mesenteric artery. After portal reperfusion, we anastomosed the mesenteric graft to the recipient's hepatic artery at the origin of the gastroduodenal artery. The postoperative course and the subsequent 6-month follow-up were uneventful. In conclusion, the presence of a hepatic artery aneurysm should not be an absolute contraindication to the use of a liver graft. The present case emphasizes the possibility to utilize an organ that would have been otherwise discarded.
With the increased use of extended-criteria donors, machine perfusion became a beneficial alternative to cold storage in preservation strategy for donor livers with the intent to expand donor pool. ...Both normothermic and hypothermic approach achieved good results in terms of mid- and long-term outcome in liver transplantation. Many markers and molecules have been proposed for the assessment of liver, but no definitive criteria for graft viability have been validated in large clinical trials and key parameters during perfusion still require optimization.In this review, we address the current literature of viability criteria during normothermic and hypothermic machine perfusion and discuss about future steps and evolution of these technologies.
The management of portosystemic shunts in liver transplant recipients relies on appropriate perioperative study. There are several strategies for shunt handling, ranging from preoperative ...interventional procedures to intraoperative surgical interruption or embolization. Appropriate management often results in a successful outcome, although wrong decisions could lead to serious consequences. Here, we report a liver transplant recipient with grade 2 portal vein thrombosis associated with 2 large portosystemic shunts (coronary and mesocaval), which were managed intraoperatively via thrombectomy without shunt ligation. Acute portal vein thrombosis developed early after transplant due to portal steal syndrome. The patient underwent a successful endovascular shunt embolization, with prompt restoration of hepatopetal portal flow and resolution of the portal steal. Use of interventional radiology in perioperative management of transplant patients has recently gained wider importance; our case reported here is particularly suggestive of the good outcomes of a multidisciplinary approach to a threatening complication such as postoperative acute portal vein thrombosis.
: Single hepatocellular carcinoma (HCC) benefits from surgical resection (SR) or US-guided percutaneous ablation (PA), although the best approach is still debated. We evaluated the impact of Li-RADS ...classification on the oncological outcomes of SR vs. PA as single HCC first-line treatment.
: We retrospectively and blindly classified treatment-naïve single HCC that underwent SR or PA between 2010 and 2016 according to Li-RADS protocol. Overall survival (OS), recurrence free survival (RFS) and local recurrence after SR and PA were compared for each Li-RADS subclass before and after propensity-score matching (PS-M).
: Considering the general population, SR showed better 5-year OS (68.3% vs. 52.2%;
= 0.049) and RFS (42.5% vs. 29.8%;
= 0.002), with lower incidence of local recurrence (8.2% vs. 44.4%;
< 0.001), despite a significantly higher frequency of clinically-relevant complications (12.8% vs. 1.9%;
= 0.002) and a higher Comprehensive Complication Index (12.1 vs. 2.2;
< 0.001). Focusing on different Li-RADS subclasses, we highlighted better 5-year OS (67.1% vs. 46.2%;
= 0.035), RFS (45.0% vs. 27.0% RFS;
< 0.001) and lower incidence of local recurrence (9.7% vs. 48.6%;
< 0.001) after SR for Li-RADS-5 HCCs, while these outcomes did not differ for Li-RADS-3/4 subclasses; such results were confirmed after PS-M.
: Our analysis suggests a potential prognostic role of Li-RADS classification, supporting SR over PA especially for Li-RADS-5 single HCC.
Organ shortage is one of the major limitations in the field of liver transplantation, which has led to the consideration of extended criteria donors as a way to expand the donor pool. The use of ...extended criteria donors in cases of high Model for End-Stage Liver Disease scores or urgent recipients could be complicated by increased postoperative mortality. Donors on left ventricular assist devices could be considered extended criteria donors because of the mechanical circulatory support itself and the potential of chronic liver damage due to right ventricular failure, but experiences in the literature are limited. Here, we report the first case of an urgent liver retransplant procured from a left ventricular assist device donor.
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