D. Pinelli

Extended right split liver graft for primary transplantation in children and adults

Skepticism remains about the use of the extended right (ER) split graft (segments I, IV–VIII) for adult liver transplantation. We analyzed the results of primary liver transplantation performed with an ER graft in adult and in pediatric recipients. At our Institution, between October 1997 and June 2005, 32 primary liver transplantations with an ER graft were performed in 22 adult and 10 pediatric recipients. All the splitting procedures were performed in situ. Actuarial patient and graft survival among the adult recipients of the ER graft were 100% and 100% at 1 year, and 94% and 94% at 5 years. In the pediatric recipients, patient and graft survival were 90% and 79% both at 1 and 5 years. No hepatic artery thrombosis (HAT) occurred in the adult group, while in the pediatric recipients HAT occurred in two cases. A higher biliary morbidity occurred in the ER graft group when compared with the whole size graft 34% versus 13% (P = 0.03). However, this did not affect patient and graft survival. The results of this study may represent a further argument in favor of extensive splitting of all suitable grafts.

A prospective policy development to increase split-liver transplantation for 2 adult recipients: Results of a 12-year multicenter collaborative study

Objective:To analyze in a multicenter study the potential benefit of a new prospective policy development to increase split-liver procedures for 2 adult recipients. Background:Split-liver transplantation is an important means of overcoming organ shortages. Division of the donor liver for 1 adult and 1 pediatric recipient has reduced the mortality of children waiting for liver transplantation but the benefits or disadvantages to survival when the liver is divided for 2 adults (adult-to-adult split-liver transplant, AASLT) compared with recipients of a whole graft have not been fully investigated. Methods:We developed a computerized algorithm in selected donors for 2 adult recipients and applied it prospectively over a 12-year period among 7 collaborative centers. Patient and graft outcomes of this cohort receiving AASLT either as full right grafts or full left grafts were analyzed and retrospectively compared with a matched cohort of adults who received a conventional whole-liver transplant (WLT). Univariate and multivariate analysis was done for selected clinical variables in the AASLT group to assess the impact on the patient outcome. Results:Sixty-four patients who received the AASLT had a high postoperative complication rate (64.1% grade III and IV) and a lower 5-year survival rate than recipients of a WLT (63.3% and 83.1%) Conclusions:AASLT should be considered a surgical option for selected smaller-sized adults only in experimental clinical studies in experienced centers.

Lung transplantation with grafts from elderly donors: a single-center experience.

INTRODUCTION Use of extended criteria donors is one of the strategies to face the scarcity of donors for lung transplantation. METHODS Between November 2002 and May 2009, we performed 52 LTs in 50 recipients, 10 of whom (group A) received lungs from donors aged 55 years or older (median, 58.5; range, 56-66 years) for comparison with 28 patients (group B) transplanted with lungs from donors younger than 55 years (median, 25.5; range, 15-54 years). We excluded 9 children and 3 recipients of combined liver plus lung transplantations from the study. RESULTS Recipient age, gender, and indications for transplantation did not differ significantly between the 2 groups. Neither were there significant differences in PaO2/FiO2 ratios before lung retrieval, or length of the ischemic time The first PaO2/FiO2 on arrival to the intensive care unit (ICU) and the median length of ICU stay were similar. All patients, except 2 who died in the operating theatre, were extubated between 3 and 216 hours after the transplantation. Hospital mortality was similar in both groups: 3 patients in group A and 2 in group B (P = .1). The median portions of the predicted 1-second forced expiratory volume (FEV1) at 6 months after transplantation did not differ in the 2 groups: 62.4% in group A versus 70% in group B (P = .85). CONCLUSION Lung grafts from donors older than 55 years can be effectively used for transplantation, thus increasing the total organ pool.

Combined double lung-liver transplantation for cystic fibrosis without cardio-pulmonary by-pass.

Sequential bilateral single lung‐liver transplantation (SBSL‐LTx) is a therapeutic option for patients with end stage lung and liver disease (ESLLD) due to cystic fibrosis (CF). A few cases have been reported, all of them were performed with the use of cardio‐pulmonary by‐pass (CPB). We performed SBSL‐LTx in three young men affected by CF. All the recipients had respiratory failure and portal hypertension with hypersplenism. Along with lung transplants, two patients received a whole liver graft and one an extended right graft from an in situ split liver. During transplantation neither CPB nor veno‐venous by‐pass (VVB) were employed. Immunosuppression was based on basiliximab, tacrolimus, steroids and azathioprine. The three recipients are alive with a median follow‐up of 670 days (range 244–1533). Combined SBSL‐LTx is a complex but effective procedure for the treatment of ESLLD due to CF, not necessarily requiring the use of CPB or VVB.

The successful management of a Bronchoesophageal fistula after lung transplantation: a case report

We describe an unprecedented, disastrous complication after bilateral lung transplantation (BLT), a bilateral bronchial dehiscence with a right bronchoesophageal fistula leading to life‐threatening septic shock. We also report the successful endoscopic management of this complication by double stenting and stress the efficacy of the multidisciplinary approach to this critical case.

Intestinal Transplantation in Children: The First Successful Italian Series

The preliminary experience of the first Italian program of pediatric intestinal transplantation is presented herein. A multidisciplinary group with broad experience in pediatric solid organ transplantation started the program. Nine children with complications of chronic intestinal failure were listed for transplantation. One child died on the waiting list; one received an isolated liver transplantation; three isolated intestinal; three multivisceral; and one, a combined liver/intestine transplantation. There was no in-hospital mortality, and all children were weaned from parenteral nutrition. The recipient of the multivisceral graft died after 14 months for unknown causes. All other recipients are alive after a median follow-up of 13 months. Patient and graft actuarial survivals for recipients of intestinal grafts were 100% at 1 year and 75% at 2 years.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in ovarian and gastrointestinal peritoneal carcinomatosis: results from a 7-year experience

Background An increasing promising evidence and increasing long-term oncologic outcomes support the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as locoregional treatment for peritoneal carcinosis (PC) especially from ovarian and gastrointestinal tumors, but also for others cancers. Methods A prospective monocentric study was performed in Papa Giovanni XXIII Hospital, Bergamo (Italy). Patients and tumor characteristics were analyzed. Overall survival (OS), disease free survival (DFS) and morbidity were analyzed with Kaplan-Meier curves and log-rank testing. Results A total of 150 patients undergone CRS + HIPEC were analyzed from January 2011 to June 2017. The principal origins of PC were: gastric cancer (GC) (n=40), colon cancer (n=31), appendiceal cancer (AC) (n=18), ovarian cancer (OC) (n=49), others (n=12). Major morbidity [≥3 Common Terminology Criteria for Adverse Events (CTCAE)] and perioperative mortality rates were 38% and 2.7% respectively. Re-operation rate was 15.3%. Median OS is 9, 35, 47, 51, 82 months (29% 3-year OS; 27% 5-year OS; 48% 5-year OS; 40% 5-year OS; 67% 5-year OS respectively) in GC, colorectal cancer (CRC), OC, others tumors and AC respectively. Median DFS is 4, 14, 17, 19, 82 months (32% 3-year DFS; 22% 5-year DFS; 29% 5-year DFS; 11% 5-year DFS; 67% 5-year DFS respectively) in GC, CRC, others tumors, OC and AC respectively. Conclusions A therapeutic approach that combined CRS + HIPEC could achieve long-term survival in selected groups of patients with PC from gastrointestinal, gynecological and others tumors with acceptable morbidity and mortality. A good expertise and a high volume of patients are necessary to manage PC and to further improve results.

Value of HCC-MELD Score in Patients With Hepatocellular Carcinoma Undergoing Liver Transplantation:

Context: Liver transplantation (LT) is considered the ideal therapy for patients with hepatocellular carcinoma (HCC) having cirrhosis but the shortage of liver donors and the risk of dropout from the wait list due to tumor progression severely limit transplantation. A new prognostic score, the HCC-model for end-stage liver disease (HCC-MELD), was developed by combining α-fetoprotein (AFP), MELD, and tumor size, to improve risk stratification of dropout in patients with HCC. Objectives: In this study, we investigated the ability of the HCC-MELD score in predicting the posttransplant for patients fulfilling Milan criteria (MC). Design: Two hundred patients with stage II tumor were retrospectively reviewed from a total of 1290 transplants performed at our institution from October 1997 through April 2015. Cox regression analysis was performed to identify the prognostic factors impacting the posttransplant survival. Results: Overall survival at 1, 5, and 10 years was 89.3%, 71.1%, and 67.2%, whereas disease-free survival was 86.4%, 66.5%, and 52.4%, respectively. Multivariate analysis showed HCC-MELD score (hazard ratio [HR] 39.6, P < .001) and microvascular invasion (HR 2.41, P = .002) to be independent risk factors for recurrence, whereas HCC diameter (HR 1.15, P = .041), HCC-MELD (HR 15.611, P = .006), and grading (HR 2.17, P = .03) proved to be predictive factors of poor overall survival. Conclusion: Our study showed the validity of the HCC-MELD equation in the evaluation of patients undergoing LT for HCC. This score offers a reliable method to assess the risk of waiting list dropout and predict posttransplantation outcomes.

206 THE UN-SUSTAINABLE MATCH IN HCV LIVER TRANSPLANT PATIENTS

206 THE UN-SUSTAINABLE MATCH IN HCV LIVER TRANSPLANT PATIENTS A.W. Avolio, S. Agnes, M.C. Lirosi, M. Salizzoni, A. Pinna, B. Gridelli, L. De Carlis, M. Colledan, G. Gerunda, U. Valente, G. Rossi, G. Ettorre, A. Risaliti, V. Mazzaferro, F. Bresadola, M. Rossi, G. Tisone, F. Zamboni, L. Lupo, O. Cuomo, F. Calise, A. Vitale, N. Nicolotti, R. Romagnoli, A. Cucchetti, S. Gruttadauria, I. Mangoni, D. Pinelli, R. Montalti, M. Gelli, L. Caccamo, G. Vennarecci, D. Nicolini, E. Regalia, U. Baccarani, Q. Lai, T. Manzia, E. Tondolo, M. Rendina, A. Perrella, E. Scuderi, B. Antonelli, C. de Waure, M. Angelico, P. Burra, A. Gasbarrini, U. Cillo, Donor-to-Recipient Italian Liver Transplant (DR2-ILTx) Study Group. Liver Transplant Center, “A.Gemelli”Hospital, Catholic University, Rome, Liver Transplant Center, “S. Giovanni Battista” Hospital, University of Turin, Turin, Liver Transplant Center, “S. Orsola” Hospital, University of Bologna, Bologna, Liver Transplant Center, IsMeTT-UPMC, Palermo, Liver TransplantCenter, “Niguarda” Hospital, Milan, Liver Transplant Center, “Ospedali Riuniti”, Bergamo, Liver Transplant Center, University of Modena and Reggio Emilia, Modena, Liver Transplant Center, “S. Martino” Hospital, University of Genoa, Genoa, Liver Transpantation Center, IRCCS Foundation, “Maggiore” Hospital, Milan, Liver Transplant Center, “San Camillo-Forlanini” Hospital, Rome, Liver Transplant Center, “Umberto I” Hospital, Polytechnic University of Marche, Ancona, Liver Transplant Center, National Cancer Institute, IRCCS Foundation, Milan, Liver Transplant Center, University of Udine, Udine, Liver Transplant Center, “Umberto I” Hospital, “La Sapienza” University, Liver Transplant Center, “Tor Vergata” University Hospital, Rome, Liver Transplant Center, “G. Brotzu” University Hospital, Cagliari, Liver Transplant Center, Department of Emergency and Organ Transplant, University of Bari, Bari, Liver Transplant Center, Laparoscopic Hepatobiliary Surgical Unit, “A. Cardarelli” University Hospital, Liver Transplant Center, Hepatobiliary Surgical Unit, “A. Cardarelli” University Hospital, Naples, Liver Transplant Center, Department of Surgical and Gastroenterological Sciences, University of Padua, Padova, Epidemiology and Biostatistics Unit, Institute of Hygiene, Catholic University, Rome, Italy E-mail: alfonso.avolio@tin.it

187 PRE-EMPTIVE DIAGNOSTIC AND THERAPEUTIC APPROACH OF ANASTOMOTIC BILIARY STRICTURES AFTER PEDIATRIC LIVER TRANSPLANTATION

infection who undergo immuno-suppressive therapies. It is still believed to be rare in HIV infection. However, it is potentially life-threatening. We aimed to analyze the clinico-virological factors associated with HBV-SRR in 5 HIV-1-seropositive patients and the HBV serological background for such event in the Marseilles public hospitals HIV cohort. Methods: HBVDNA was quantified using Roche Cobas Ampliprep/TaqMan assay. Direct HBVDNA amplification/sequencing was performed from serum using in-house protocols. HBV serologies were performed using Axsym Abbott assays. HBV-SRR was defined as evolution from re-appearence of HBsAg and serum HBVDNA in anti-HBc antibodies (Ab)+ patients, concomitantly with a dramatic ALT rise. Results: 1,076 HIV+ patients had HBV serology during the 2 past years. 67 (6.2%) were HBsAg+, 473 (44%) had serology indicating past-HBV infection, among whom 248 had an anti-HBs antibodies (Ab) titer 100 IU/L in 55% and 60% of patients with a serology indicating past infection or VI, respectively. HBsAg-/anti-HBcAb+ and HBsAg/anti-HBcAb+/anti-HBsAb patterns were significantly more frequent in male (P< 10−5 and 0.018, respectively). 4/5 patients presenting HBVSRR were male, mean age = 49 y, mean ALT = 1704 IU/L (1477–1931), mean prothrombin index = 68% (45−93), mean serum HBVDNA = 9 log10 copies/mL (6.9−9.5), mean HIV load = 4.5 log (<1.6−4.9), mean CD4 = 220/mm3 (154–308). Acute hepatitis E or transient spontaneous HCV clearance were observed in 2 patients. All patients interrupted anti-HIV/HBV drugs (TDF, 3TC, and/or FTC) prior to HBV-SRR. HBV genotype was A in 3 patients, and D in 2. Amino acid substitutions within HBsAg “a” determinant were found at positions 133 and/or 144 from 2/5 patients. Neither HBV drug-resistance mutations nor pre-core/core promoter mutations were observed. Conclusions: Our data highlight that a substantial proportion of HIV infected patients are at risk of HBV-SRR. This latter diagnosis should be considered in HIV-infected patients with unexplained severe ALT rise. Our results suggest that male might be at higher risk of HBV-SRR. HBV VI should be proposed to HBV-seronegative HIV-infected patients.