Davide Cintorino

Efficient human fetal liver cell isolation protocol based on vascular perfusion for liver cell–based therapy and case report on cell transplantation

Although hepatic cell transplantation (CT) holds the promise of bridging patients with end‐stage chronic liver failure to whole liver transplantation, suitable cell populations are under debate. In addition to hepatic cells, mesenchymal stem cells (MSCs) and hematopoietic stem cells (HSCs) are being considered as alternative cell sources for initial clinical cell work. Fetal liver (FL) tissue contains potential progenitors for all these cell lineages. Based on the collagenase incubation of tissue fragments, traditional isolation techniques yield only a fraction of the number of available cells. We report a 5‐step method in which a portal vein in situ perfusion technique is used for tissue from the late second trimester. This method results in the high viabilities known for adult liver vascular perfusion, addresses the low cell yields of conventional digestion methods, and reduces the exposure of the tissue to collagenase 4‐fold. We used donated tissue from gestational weeks 18 to 22, which yielded 1.8 ± 0.7 × 109 cells with an average viability of 78%. Because HSC transplantation and MSC transplantation are of interest for the treatment of hepatic failure, we phenotypically confirmed that in addition to hepatic progenitors, the resulting cell preparation contained cells expressing typical MSC and HSC markers. The percentage of FL cells expressing proliferation markers was 45 times greater than the percentage of adult hepatocytes expressing these markers and was comparable to the percentage of immortalized HepG2 liver hepatocellular carcinoma cells; this indicated the strong proliferative capacity of fetal cells. We report a case of human FL CT with the described liver cell population for clinical end‐stage chronic liver failure. The patients Model for End‐Stage Liver Disease (MELD) score improved from 15 to 10 within the first 18 months of observation. In conclusion, this human FL cell isolation protocol may be of interest for further clinical translation work on the development of liver cell–based therapies. Liver Transpl 18:226–237, 2012.

Efficacy and safety of basiliximab with a tacrolimus-based regimen in liver transplant recipients

Background. Induction with monoclonal antibodies for prevention of acute cellular rejection (ACR) may avoid many of the adverse events associated with polyclonal antibodies. Basiliximab, a chimeric monoclonal antibody directed against the α-chain of the interleukin 2 receptor (CD25), has been extensively evaluated as an induction therapy for kidney transplant recipients, more frequently in combination with a cyclosporine-based regimen. In this study, we assessed the efficacy and safety of basiliximab in combination with a tacrolimus-based regimen after liver transplantation. Methods. Fifty consecutive liver transplants (47 cadaveric donors; 3 living donors) were analyzed. All patients received two 20-mg doses of basiliximab (days 0 and 4 after transplantation) followed by tacrolimus (0.15 mg/kg/day; 10–15 ng/mL target trough levels) and a tapered dose regimen of steroids. Follow-up ranged from 404 to 1,364 days after transplantation (mean 799.89 days, SD±257.37; median 796 days). Results. A total of 88% of patients remained rejection-free during follow-up with an actuarial rejection-free probability of 75% within 3 months. The actuarial patient survival rate at 3 years was 88%, and the graft survival rate was 75%. Twelve (24%) patients experienced one episode of sepsis, requiring temporary reduction of immunosuppressive therapy. There were no immediate side effects associated with basiliximab and no evidence of cytomegalovirus infection or posttransplant lymphoproliferative disorder. Conclusions. Basiliximab in combination with a tacrolimus-based immunosuppressive regimen is effective in reducing episodes of ACR and increasing ACR-free survival after liver transplantation. In addition, basiliximab does not increase the incidence of adverse effects or infections.

Placement of covered self-expandable metal biliary stent for the treatment of severe postsphincterotomy bleeding: outcomes of two cases.

We report two cases of severe postsphincterotomy bleeding in an adult and a pediatric patient treated, as first options, with available techniques to induce hemostasis without success. Because of persisting bleeding, an expandable, partially covered, metallic stent was placed into the choledocho to mechanically compress the bleeding site. The bleeding was stopped. In the following days, both patients remained hemodynamically stable with no further episodes of bleeding. We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

Hepatocarcinoma in a child with cholesterol ester storage disease

1 d Diagnosis of cholesterol ester storage disease (CESD) as suggested in a 5-year-old girl by a liver biopsy perormed because of a large hepatomegaly of fortuitous nding, and confirmed by the measurement of lysosomal cid lipase activity in cultured skin fibroblasts. The patient eveloped portal hypertension and a new liver biopsy, hen 11-year-old, showed micronodular cirrhosis with iffuse microvesicular steatosis. The child was listed for iver transplantation and received an extended right lobe raft (segments I + IV + VIII) obtained by in situ split liver rocurement from a 13-year-old donor. Histological examination of the native liver showed iffuse cirrhotic transformation, mild mixed inflammaory infiltrate, hydropic degeneration and microvesicular teatosis. A 1.4 cm non-encapsulated nodule of trabecuar hepatocellular carcinoma (HCC) (G1/G2) was identified n segment VII (Figs. 1 and 2). Patient underwent postransplant total body CT scan that excluded extra hepatic ocalizations. Post-operative -fetoprotein was normal. The atient did not received adjuvant chemotherapy and 30 onths after transplantation she is in good clinical condition, ithout evidence of HCC recurrence. CESD is a rare autosomal recessive disorder characterzed by accumulation of cholesterol esters and triglycerides n hepatocytes, adrenal cortical spongiocytes, and in histioytes. Patients with CESD may develop a progressive liver ailure necessitating liver transplantation. HCC has been described in a number of genetic and etabolic disorders in children including progressive familal intrahepatic cholestasis, Alagille syndrome, hereditary yrosinemia type I, glycogen storage diseases, alpha-1ntitrypsin deficiency, liver mitochondrial respiratory chain

Comparison of two different techniques of reperfusion in adult orthotopic liver transplantation

Abstract: The aim of this study was to determine the impact of two reperfusion techniques on the peri‐operative hemodynamic changes and early post‐operative graft function of adult patients undergoing orthotopic liver transplantation.

Donor safety in living donor liver donation: An Italian multicenter survey

Major concerns about donor morbidity and mortality still limit the use of living donor liver transplantation (LDLT) to overcome the organ shortage. The present study assessed donor safety in LDLT in Italy reporting donor postoperative outcomes in 246 living donation procedures performed by 7 transplant centers. Outcomes were evaluated over 2 time periods using the validated Clavien 5‐tier grading system, and several clinical variables were analyzed to determine the risk factors for donor morbidity. Different grafts were obtained from the 246 donor procedures (220 right lobe, 10 left lobe, and 16 left lateral segments). The median follow‐up after donation was 112 months. There was no donor mortality. One or more complications occurred in 82 (33.3%) donors, and 3 of them had intraoperative complications (1.2%). Regardless of graft type, the rate of major complications (grade ≥ 3) was 12.6% (31/246). The overall donor morbidity and the rate of major complications did not differ significantly over time: 26 (10.6%) donors required hospital readmission throughout the follow‐up period, whereas 5 (2.0%) donors required reoperation. Prolonged operative time (>400 minutes), intraoperative hypotension (systolic < 100 mm Hg), vascular abnormalities, and intraoperative blood loss (>300 mL) were multivariate risk factors for postoperative donor complications. In conclusion, from the standpoint of living donor surgery, a meticulous and well‐standardized technique that reduces operative time and prevents blood loss and intraoperative hypotension may reduce the incidence of donor complications. Transparency in reporting results after LDLT is mandatory, and we should continue to strive for zero donor mortality. Liver Transplantation 23 184–193 2017 AASLD

Hepatic Hydatid Cyst Causing Thrombosis of the Inferior Vena Cava and Complicated by Hemobilia A Multimodal Sequential Approach in the Treatment

Hydatid cyst is a common health prblem in the Mediterranean basin. As in many countries, human infection with Echinococcus granulosus results in an enlarging parasitic cyst lesion, most frequently observed in the liver. The World Health Organization guidelines recommend chemotherapy with albendazole as the treatment of choice when the disease is not operable or when the puncture– aspiration–instillation–reaspiration (PAIR) procedure is not available or technically feasible. Currently, technical advances accumulated in the field of hepatic surgery allow for a reduced morbidity and mortality with an insignificant disease recurrence rate (1), and surgery remains the mainstay of radical treatment. All operative procedures for hepatic hydatidosis should be considered carefully because any major surgical treatment should be weighed against the fact that echinococcosis is not a malignant disease. With the introduction of therapy with albendazole (2) and newer radiological interventions (3) new therapeutic tools have been provided as consideration in the management of hepatic hydatidosis. The goals of therapy are to treat the associated complications, eliminate local disease, and avoid disese recurrence. However, a large number of different treatments have been introduced through the years due to the fact

Liver regeneration after liver resection: Clinical aspects and correlation with infective complications

AIM To investigate whether early liver regeneration after resection in patients with hepatic tumors might be influenced by post-operative infective complications. METHODS A retrospective analysis of 27 liver resections for tumors performed in a single referral center from November 2004 to January 2010. Regeneration was evaluated by multidetector computed tomography at a mean follow-up of 43.85 d. The Clavien-Dindo classification was used to evaluate postoperative events in the first 6 mo after transplantation, and Centers for Disease Control and Prevention definitions were used for healthcare associated infections data. Generalized linear regression models with Gaussian family distribution and log link function were used to reveal the principal promoters of early liver regeneration. RESULTS Ten of the 27 patients (37%) underwent chemotherapy prior to surgery, with a statistically significant prevalence of patients with metastasis (P = 0.007). Eight patients (30%) underwent embolization, 3 with primary tumors, and 5 with secondary tumors. Twenty patients (74%) experienced complications, with 12 (60%) experiencing Clavien-Dindo Grade 3a to 5 complications. Regeneration ≥ 100% occurred in 10 (37%) patients. The predictors were smaller future remnant liver volume (-0.002; P < 0.001), and a greater spleen volume/future remnant liver volume ratio (0.499; P = 0.01). Patients with a resection of ≥ 5 Couinaud segments experienced greater early regeneration (P = 0.04). Nine patients experienced surgical site infections, and in 7 cases Clavien-Dindo Grade 3a to 4 complications were detected (P = 0.016). There were no significant differences between patients with primary or secondary tumors, and either onset or infections or severity of surgical complications. CONCLUSION Regardless of the onset of infective complications, future remnant liver and spleen volumes may be reliable predictors of early liver regeneration after hepatic resection on an otherwise healthy liver.

Liver resections for liver transplantations.

Split-Liver and living-related donor liver transplantation are the newest and both technically and ethically most challenging developments in liver transplantation and have contributed to a reduction in donor shortage. We report the technical aspects of surgical procedures performed to achieve a partial graft from a cadaveric and a live donor.

Preliminary Report on Introduction of Enhanced Recovery After Surgery Protocol for Laparoscopic Rectal Resection: A Single-Center Experience

INTRODUCTION Laparoscopic rectal surgery seems to improve postoperative recovery of patients who undergo surgery for rectal cancer. The aim of this study was to evaluate preliminary results of implementation of enhanced recovery after surgery (ERAS) protocol for laparoscopic rectal resection (LRR) for cancer at our institute. MATERIALS AND METHODS We conducted a retrospective analysis of prospectively collected data. Patients who underwent LRR for cancer at our institute after introduction of enhanced recovery protocol were compared with a control group of patients who previously underwent surgery with traditional protocol. Primary endpoints evaluated were length of stay (LOS) and rates of complications and readmissions. RESULTS We studied 150 consecutive patients, 56 operated with the traditional approach and 94 according to ERAS protocol. The mean (range) LOS was 10 (4-27) days for patients in control group versus 8.5 (3-32) days for patients in the ERAS group (P = .0823). No evidence of a different rate (P = .227) of complications was registered between the two groups. One patient in each group was readmitted. CONCLUSIONS The introduction of the ERAS protocol in LRR for cancer at our institute led to an initial reduction in hospital LOS, without increase in morbidity or readmission rate compared with our previous experience with traditional protocol.