Publications by authors named "Fabrizio DI Francesco"

73 Publications

The influence of flap design on patients' experiencing pain, swelling, and trismus after mandibular third molar surgery: a scoping systematic review.

J Appl Oral Sci 2021 4;29:e20200932. Epub 2021 Jun 4.

Campania University Luigi Vanvitelli, Multidisciplinary Department of Medical, Surgical and Dental sciences, Naples, Italy.

Third molar removal surgery usually comes accompanied by postoperative discomfort, which could be influenced by the surgical approach chosen. This scoping systematic review aimed at compiling the available evidence focused on the influence of flap design, including envelope flap (EF), triangular flap (TF), and modified triangular flap (MTF), on postoperative pain, swelling, and trismus, as primary outcome measures, and any result mentioning healing promotion or delay, as secondary outcome measure, after mandibular third molar extraction surgery. An electronic search, complemented by a manual search, of articles published from 1999 to 2020 was conducted in the Medline (PubMed), EMBASE and Web of Science databases including human randomized controlled trials, prospective, and retrospective studies with at least 15 patients. The risk of bias of the included studies was assessed either with the Cochrane's Risk of Bias tool or with the Newcastle-Ottawa scale. Every step of the review was performed independently and in duplicate. The initial electronic search recovered 2102 articles. After applying the inclusion criteria, 12 articles were included. For patient's perceived postoperative pain, TF and MTF frequently reported better results than EF. For swelling, the literature is divided, despite a trend favoring EF. For trismus, data showed that its occurrence is mostly associated with the duration of the surgery rather than with the chosen flap. For healing, the limited data is inconclusive. Finally, randomized studies showed a high risk of bias, whereas nonrandomized studies were mostly of good quality and low risk of bias. Although there was no clear consensus regarding the influence of different flap designs for third mandibular molar extraction on postoperative clinical morbidities; the surgeon's experience, estimated surgical difficulty, molar position and orientation, and surg ery duration should be considered when choosing among the different flap designs.
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http://dx.doi.org/10.1590/1678-7757-2020-0932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232931PMC
June 2021

Management of intra-abdominal hypertension during ECMO: Total water-assisted colonoscopy as a step-up minimally invasive treatment, and a literature review.

Endosc Int Open 2021 Jun 27;9(6):E848-E852. Epub 2021 May 27.

Endoscopy Service, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione) Palermo, Italy.

During extracorporeal membrane oxygenation (ECMO), intra-abdominal hypertension (IAH) can impair ECMO venous drainage, reducing its ability to provide an adequate oxygenated blood flow. When medical therapy is ineffective in managing IAH, guidelines recommend a decompressive laparotomy (DL), though the procedure is associated with several complications and poor outcomes. This was a case series of IAH in patients affected with acute respiratory distress syndrome (ARDS) on veno-venous (V-V) ECMO, in whom we performed total water-assisted colonoscopy (t-WAC) to treat IAH. In three patients who underwent t-WAC, we report a real-time intra-procedural reduction of IAH, normalization of ECMO blood flow, and a reduction of vasopressors and lactates. t-WAC was performed in the context of evident abdominal compartment syndrome with multiorgan failure, and in one case was performed because of IAH and ECMO impairment. One patient was discharged alive, while the other two died of multiorgan failure, although the cause of death was apparently not secondary to IAH. During ECMO, in select cases,T-WAC may represent a first-line non-invasive approach.
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http://dx.doi.org/10.1055/a-1399-8209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8159594PMC
June 2021

Bile duct anatomical variations: Relevance for liver division and preparing left split liver grafts for pediatric transplantation: Cohort study.

Int J Surg 2021 Jun 30;90:105979. Epub 2021 May 30.

Department of Pediatrics, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy. Electronic address:

Background: liver lateral section graft is the most common graft type used for transplantation in children worldwide. Compared to whole liver grafts, a higher rate of biliary complications has been described. Historically, 2 techniques have been described for transection of liver - trans-hilar or trans-umbilical parenchymal transection. Though these techniques allow dividing the biliary system at two distinct positions, the usual surgical strategies do not take advantage of this advantage.

Material And Methods: A retrospective study was conducted on 40 candidates who volunteered for donation of their left lateral liver section for transplantation, between October 2017 and April 2019. Preoperative imaging was analyzed to depict the arterial and biliary anatomy of the liver and their variations, with a dedicated attention to the left liver (segments 2, 3 and 4). Anatomy of the biliary system was taken into account for defining the optimal surgical strategy - either through a trans-hilar or a trans-umbilical parenchymal transection.

Results: In 26/40 patients, arterial or biliary variations were much relevant for decision-making on the optimal plane of liver division (trans-umbilical (N = 14) and trans-hilar (N = 26)). This resulted in 23 grafts with a single artery and bile duct, 6 grafts with double arteries and a single bile duct, and 9 grafts with double bile ducts and a single artery; only two grafts had complex anatomy. There was no arterial complication and the overall incidence of biliary problems was 14.7%. All grafts are functioning well at a mean follow-up of 19.6 ± 8.5 months.

Conclusions: Anatomical variations are frequent and their knowledge is relevant for procurement of lateral section liver graft. Knowledge of these variation, or -better- preoperative biliary imaging is helpful in guiding parenchymal transection at procurement and preparing optimal liver grafts.
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http://dx.doi.org/10.1016/j.ijsu.2021.105979DOI Listing
June 2021

Patient satisfaction and survival of maxillary overdentures supported by four or six splinted implants: a systematic review with meta-analysis.

BMC Oral Health 2021 05 8;21(1):247. Epub 2021 May 8.

Periodontal Biology Laboratory, Faculty of Dentistry, Universidad de Chile, Santiago, Chile.

Background: Implant-supported overdentures offer enhanced mechanical properties, which lead to better patient satisfaction and survival rates than conventional dentures. However, it is unclear whether these satisfaction levels and survival rates depend on the number of implants supporting the overdenture. Therefore, this systematic review aimed to compare maxillary overdentures supported by four or six splinted implants in terms of patient satisfaction, implant survival, overdenture survival, and prosthodontic complications.

Methods: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), and EMBASE databases were systematically searched and complemented by hand searching from 2000 to 2019, employing a combination of specific keywords. Studies comparing the use of four versus six implants for supporting overdentures with at least one-year of follow-up after prosthesis installation and including ten fully edentulous patients were included. The risk of bias (RoB) was analyzed with Cochrane's RoB 2 and Newcastle-Ottawa tools. Implants and prosthesis survival rates were analyzed by random-effects meta-analysis and expressed as risk ratios or risk differences, respectively, and by the non-parametric unpaired Fisher's test.

Results: A total of 15 from 1865 articles were included, and reported follow-up times after implant placement ranged from 1 to 10 years. Irrespective of the number of implants used, high scores were reported by all studies investigating patient satisfaction. Meta-analysis and non-parametric Fisher's test showed no statistical differences regarding the survival rate of implants (P = 0.34, P = 0.3) or overdentures (P = 0.74, P = 0.9) when using 4 versus 6 splinted implants to support overdentures, and no significant differences regarding prosthodontic complications were found between groups. Randomized studies presented high RoB and non-randomized studies presented acceptable quality.

Conclusions: Within the limits of this systematic review, we can conclude that the bar-supported overdenture on four implants is not inferior to the overdenture supported by six implants for rehabilitating the edentulous maxilla, in terms of patient satisfaction, survival rates of implants and overdentures, and prosthodontic complications.
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http://dx.doi.org/10.1186/s12903-021-01572-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106178PMC
May 2021

Accuracy, Labor-Time and Patient-Reported Outcomes with Partially versus Fully Digital Workflow for Flapless Guided Dental Implants Insertion-A Randomized Clinical Trial with One-Year Follow-Up.

J Clin Med 2021 Mar 6;10(5). Epub 2021 Mar 6.

Faculty of Dental Medicine, "Titu Maiorescu" University, 67A Gheorghe Petrascu Street, 040051 Bucharest, Romania.

(1) Background: Prosthetically-driven implant positioning is a prerequisite for long-term successful treatment. Transferring the planned implant position information to the clinical setting could be done using either static or dynamic guided techniques. The 3D model of the bone and surrounding structures is obtained via cone beam computed tomography (CBCT) and the patient's oral condition can be acquired conventionally and then digitalized using a desktop scanner, partially digital workflow (PDW) or digitally with the aid of an intraoral scanner (FDW). The aim of the present randomized clinical trial (RCT) was to compare the accuracy of flapless dental implants insertion in partially edentulous patients with a static surgical template obtained through PDW and FDW. Patient outcome and time spent from data collection to template manufacturing were also compared. (2) Methods: 66 partially edentulous sites (at 49 patients) were randomly assigned to a PDW or FDW for guided implant insertion. Planned and placed implants position were compared by assessing four deviation parameters: 3D error at the entry point, 3D error at the apex, angular deviation, and vertical deviation at entry point. (3) Results: A total of 111 implants were inserted. No implant loss during osseointegration or mechanical and technical complications occurred during the first-year post-implants loading. The mean error at the entry point was 0.44 mm (FDW) and 0.85 (PDW), ≤ 0.00; at implant apex, 1.03 (FDW) and 1.48 (PDW), ≤ 0.00; the mean angular deviation, 2.12° (FDW) and 2.48° (PDW), = 0.03 and the mean depth deviation, 0.45 mm (FDW) and 0.68 mm (PDW), ≤ 0.00; (4) Conclusions: Despite the statistically significant differences between the groups, and in the limits of the present study, full digital workflow as well as partially digital workflow are predictable methods for accurate prosthetically driven guided implants insertion.
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http://dx.doi.org/10.3390/jcm10051102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961841PMC
March 2021

An Italian survey on the use of T-tube in liver transplantation: old habits die hard!

Updates Surg 2021 Apr 1. Epub 2021 Apr 1.

Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy.

There is enough clinical evidence that a T-tube use in biliary reconstruction at adult liver transplantation (LT) does not significantly modify the risk of biliary stricture/leak, and it may even sustain infective and metabolic complications. Thus, the policy on T-tube use has been globally changing, with progressive application of more restrictive selection criteria. However, there are no currently standardized indications in such change, and many LT Centers rely only on own experience and routine. A nation-wide survey was conducted among all the 20 Italian adult LT Centers to investigate the current policy on T-tube use. It was found that 20% of Centers completely discontinued the T-tube use, while 25% Centers used it routinely in all LT cases. The remaining 55% of Centers applied a selective policy, based on criteria of technical complexity of biliary reconstruction (72.7%), followed by low-quality graft (63.6%) and high-risk recipient (36.4%). A T-tube use > 50% of annual caseload was not associated with high-volume Center status (> 70 LT per year), an active pediatric or living-donor transplant program, or use of DCD grafts. Only 10/20 (50%) Centers identified T-tube as a potential risk factor for complications other than biliary stricture/leak. In these cases, the suspected pathogenic mechanism comprised bacterial colonization (70%), malabsorption (70%), interruption of the entero-hepatic bile-acid cycle (50%), biliary inflammation due to an indwelling catheter (40%) and gut microbiota changes (40%). In conclusion, the prevalence of T-tube use among the Italian LT Centers is still relatively high, compared to the European trend (33%), and the potential detrimental effect of T-tube, beyond biliary stricture/leak, seems to be somehow underestimated.
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http://dx.doi.org/10.1007/s13304-021-01019-1DOI Listing
April 2021

Clinical and Molecular-Based Approach in the Evaluation of Hepatocellular Carcinoma Recurrence after Radical Liver Resection.

Cancers (Basel) 2021 Jan 29;13(3). Epub 2021 Jan 29.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), University of Pittsburgh Medical Center (UPMC), 90127 Palermo, Italy.

Background: Hepatic resection remains the treatment of choice for patients with early-stage HCC with preserved liver function. Unfortunately, however, the majority of patients develop tumor recurrence. While several clinical factors were found to be associated with tumor recurrence, HCC pathogenesis is a complex process of accumulation of somatic genomic alterations, which leads to a huge molecular heterogeneity that has not been completely understood. The aim of this study is to complement potentially predictive clinical and pathological factors with next-generation sequencing genomic profiling and loss of heterozygosity analysis.

Methods: 124 HCC patients, who underwent a primary hepatic resection from January 2016 to December 2019, were recruited for this study. Next-generation sequencing (NGS) analysis and allelic imbalance assessment in a case-control subgroup analysis were performed. A time-to-recurrence analysis was performed as well by means of Kaplan-Meier estimators.

Results: Cumulative number of HCC recurrences were 26 (21%) and 32 (26%), respectively, one and two years after surgery. Kaplan-Meier estimates for the probability of recurrence amounted to 37% (95% C.I.: 24-47) and to 51% (95% C.I.: 35-62), after one and two years, respectively. Multivariable analysis identified as independent predictors of HCC recurrence: hepatitis C virus (HCV) infection (HR: 1.96, 95%C.I.: 0.91-4.24, = 0.085), serum bilirubin levels (HR: 5.32, 95%C.I.: 2.07-13.69, = 0.001), number of nodules (HR: 1.63, 95%C.I.: 1.12-2.38, = 0.011) and size of the larger nodule (HR: 1.11, 95%C.I.: 1.03-1.18, = 0.004). Time-to-recurrence analysis showed that loss of heterozygosity in the loci (involved in the PI3K/AKT/mTOR signaling pathway) was significantly associated with a lower risk of HCC recurrence (HR: 0.35, 95%C.I.: 0.13-0.93, = 0.036).

Conclusions: multiple alterations of cancer genes are associated with HCC progression. In particular, the evidence of a specific AI mutation presented in 20 patients seemed to have a protective effect on the risk of HCC recurrence.
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http://dx.doi.org/10.3390/cancers13030518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866287PMC
January 2021

Case report: Trans-papillary free stenting of the cystic duct and of the common bile duct in a double biliary ducts anastomoses of a right lobe living donor transplantation.

BMC Surg 2021 Jan 19;21(1):44. Epub 2021 Jan 19.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Di Ricovero E Cura a Carattere Scientifico-Istituto Mediterraneo Per I Trapianti E Terapie ad alta specializzazione) UPMC (University of Pittsburgh Medical Center) Italy, Via E. Tricomi 5, 90127, Palermo, Italy.

Background: One of the major issues related to the living donor liver transplantation recipient outcome is still the high rate of biliary complication, especially when multiple biliary ducts are present and multiple anastomoses have to be performed.

Case Presentation And Conclusion: We report a case of adult-to-adult right lobe living donor liver transplantation performed for a recipient affected by alcohol-related cirrhosis with MELD score of 17. End-stage liver disease was complicated by refractory ascites, portal hypertension, small esophageal varices and portal gastropathy, hypersplenism, and abundant right pleural effusion. Here in the attached video we described the adult-to-adult LDLT procedures, where a right lobe with two biliary ducts draining respectively the right anterior and the right posterior segments has been transplanted. LDLT required a biliary reconstruction using the native cystic and common bile ducts stented trans-papillary with two 5- French 6 cm long soft silastic catheter. None major complications were detected during post-operative clinical courses. Actually, the donor and the recipient are alive and well. The technique we describe in the video, allow to keep the biliary anastomoses protected and patent without having the risk of creating cholestasis and the need of invasive additional procedure. No living donor right lobe transplantation should be refused because of the presence of multiple biliary ducts.
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http://dx.doi.org/10.1186/s12893-020-01045-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816360PMC
January 2021

Inferior vena cava surgical cannulation for infants needing veno-venous extracorporeal membrane oxygenation.

Perfusion 2021 Jan 7:267659120987089. Epub 2021 Jan 7.

Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy.

Introduction: Femoral cannulation for veno-venous extracorporeal membrane oxygenation is challenging in infants because of the diameter of the vein.

Case Report: Prolonged ECMO support (67 days) was necessary for an 8-month-old (8 kg) girl with acute respiratory distress syndrome that was caused by H1N1 influenza. After 30 days on ECMO support and using a single 16 Fr double-lumen cannula (internal jugular vein), a second cannula was necessary to ensure adequate flow. This second 12 Fr single-lumen cannula was surgically placed through the right common iliac vein. An excellent flow profile was then achieved and ECMO continued successfully for 37 more days.

Discussion: As a lifesaving option, this double caval configuration successfully optimized the flow profile and oxygenation, outweighing the related risks.

Conclusion: In small children, a surgical approach to the inferior vena cava can be considered safe, especially in those cases where there is a shortage of adequate cannulas, or when central venous access is difficult.
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http://dx.doi.org/10.1177/0267659120987089DOI Listing
January 2021

Custom abutments on tilted implants in the maxilla: A clinical report.

Dent Res J (Isfahan) 2020 Jul-Aug;17(4):314-318. Epub 2020 Aug 14.

Multidisciplinary Department of Medical, Surgical and Dental Sciences, Campania University Luigi Vanvitelli, Naples, Italy.

The aim of this work is to describe a case of severe disparallelism between two implants supporting a cement-retained bridge, placed in the maxilla, employing two custom-angled abutments. Fractured abutment screw and fractured abutment involved two implant restorations in the maxilla. Once prosthetic components have been removed, a new prosthetic rehabilitation has been planned. The divergence between the implants was measured, obtaining an angle of divergence of 39°. Then, two custom-angled titanium abutments and two metal-ceramic splinted crowns were realized.
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http://dx.doi.org/10.4103/1735-3327.292065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7688041PMC
August 2020

Optimizing Liver Division Technique for Procuring Left Lateral Segment Grafts: New Anatomical Insights.

Liver Transpl 2021 02 29;27(2):281-285. Epub 2021 Jan 29.

Department of Pediatrics, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy.

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http://dx.doi.org/10.1002/lt.25895DOI Listing
February 2021

Adult to Adult Living Donor Liver Transplantation in Recipients with Low MELD: A Strategy Intended to Overcome Donor Shortage.

Dig Dis Sci 2020 12;65(12):3477-3480

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) "ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione)- UPMC (University of Pittsburgh Medical Center) Italy", Via E. Tricomi 5, 90127, Palermo, Italy.

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.
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http://dx.doi.org/10.1007/s10620-020-06522-wDOI Listing
December 2020

Laparoscopic Microwave Thermal Ablation for the Treatment of Hepatocellular Carcinoma in Chronic Hepatic Patients.

J Laparoendosc Adv Surg Tech A 2020 Oct 27;30(10):1072-1075. Epub 2020 Jul 27.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy.

Laparoscopic microwave thermal ablation (LMWTA) is a well-established alternative treatment to liver resection for treatment of liver tumors. The aim of this study was to describe our experience in LMWTA for hepatocellular carcinoma (HCC) in chronic hepatic patients. A study group of 61 consecutive HCC patients treated with LMWTA from January, 2013 to May, 2020 were considered for this study. Patient characteristics, liver function test, operational characteristics, and complications were recorded. Of the 61 patients who underwent LMWTA, median age was 64 (interquartile range [IQR]: 58-71) years, mean body mass index was 26.2 (IQR: 23.2-29.4); 44 patients (72%) presented with an hepatitis C virus etiology, 46 (75%) were Child-Pugh Class A, median model for end-stage liver disease (MELD) score was 8.0 (IQR: 7.0-9.4). Viral infection was confirmed to be the most important risk factor in determining progressive cirrhotic evolution with HCC expression. LMWTA is a safe alternative treatment to traditional surgery, and can be combined with surgery.
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http://dx.doi.org/10.1089/lap.2020.0513DOI Listing
October 2020

ERAS Protocol for Perioperative Care of Patients Treated with Laparoscopic Nonanatomic Liver Resection for Hepatocellular Carcinoma: The ISMETT Experience.

J Laparoendosc Adv Surg Tech A 2020 Oct 22;30(10):1066-1071. Epub 2020 Jul 22.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, and IRCCS ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy.

Liver resection (LR) remains the best therapeutic option for patients with early-stage hepatocellular carcinoma (HCC) with preserved hepatic function and who are not eligible for liver transplantation. After its inception, the enhanced recovery after surgery (ERAS) protocol was widely used for treating patients with liver cancer, although there are still no clear indications for improving upon it in both open and laparoscopic surgery. This study aims to describe our institute's experience in the application of the ERAS protocol in a cohort of HCC patients, and to explore possible factors that could have an impact on postoperative outcomes. We retrospectively analyzed our experience with LR performed from September 2017 to January 2020 in patients treated with ERAS protocol, focusing on describing impact on postoperative nutrition, analgesic requirements, and length of hospitalization. Demographics, operative factors, and postoperative complications of patients were reviewed. During the study period, 89 HCC patients were eligible for LR, and 75% of patients presented with liver cirrhosis. The most prevalent among etiologic factors was hepatitis C virus infection (53 patients out of 89, 60%), followed by nonalcoholic steatohepatitis (18 patients, 20%). The median age was 70 years. Liver cirrhosis did not have an impact on postoperative course of patients. Patients who underwent laparoscopic surgery and nonanatomic LR experienced low complication rates, shorter length of stay, and shorter time of intravenous analgesic requirements. Continual refinement with ERAS protocol for treating HCC patients based on perioperative counseling and surgical decision-making is crucial to guarantee low complication rates, and reduce patient morbidity and time for recovery.
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http://dx.doi.org/10.1089/lap.2020.0445DOI Listing
October 2020

Near Infra-Red Technology to Evaluate Segment IV in Split Liver Transplantation.

J Gastrointest Surg 2020 11 23;24(11):2702. Epub 2020 Jun 23.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione) UPMC (University of Pittsburgh Medical Center) Italy, Via E. Tricomi 5, 90127, Palermo, Italy.

Background: Indocyanine green injected intravenously has been employed in many fields of hepatobiliary surgery such as liver and biliary tree mapping, tumor detection, and graft evaluation in liver transplant. This latter application has, in our opinion, particular potentials when a split liver transplantation is performed 1-3.

Methods: In this study, we used infrared technology to evaluate in real-time the segment 4 region in a recipient of extended right lobe transplantation. Donor data: 50 years old male, brain death, height, 1.70 mt, weight 69 kg; surgical technique employed was in situ standard split liver procurement. Recipient data: 46 years old male, height 1.75 mt; weight 67 k 23 g, affected by cirrhosis secondary HCV infection, with MELD Na 33. Standard orthotopic liver transplantation was performed with indocyanine green intravenous injection at 15 min after arterial reperfusion.

Results: Infrared technology, showed in this video, demonstrates progressive improvement of segment IV viability which was confirmed by the post-operative contrast-enhanced CT scan performed before discharge. The transplant procedure was uneventful and the patient discharged to home 10 days after surgery.

Conclusion: The case reported in this video is, to the best of our knowledge, the first in the English literature showing how near infrared technology has predictive value on the evaluation of a split graft. Fast diffusion of the colorant allows dynamic early evaluation and may confirm the presence of intra-hepatic venous shunt, which will determine a full recovery of the originally ischemic area. On the contrary, a permanent absence of the staining might be predictive of dysfunction.
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http://dx.doi.org/10.1007/s11605-020-04647-xDOI Listing
November 2020

The Role of Salvage Transplantation in Patients Initially Treated With Open Versus Minimally Invasive Liver Surgery: An Intention-to-Treat Analysis.

Liver Transpl 2020 07 25;26(7):878-887. Epub 2020 Jun 25.

Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy.

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.
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http://dx.doi.org/10.1002/lt.25768DOI Listing
July 2020

Impact of Extended-Criteria Donor Liver Grafts on Benchmark Metrics of Clinical Outcome After Liver Transplantation: A Single Center Experience.

Transplant Proc 2020 Jun 26;52(5):1588-1592. Epub 2020 Mar 26.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico - Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy; Department of Surgery and Surgical and Medical Specialties, University of Catania, Catania, Italy. Electronic address:

Background: The adoption of extended criteria for donors remains the best strategy to widen the pool of available liver graft against the chronic shortage of donors. Benchmarking in liver transplantation (LT) offers the unprecedented opportunity to compare clinical outcome measures to a set of validated reference values. We aimed to evaluate the impact of marginal grafts usage in a cohort of low-risk benchmark cases from an area with a very low rate of deceased donation.

Methods: A cohort of low-risk benchmark cases was identified from all adult patients who underwent LT at our center. Among these patients, those transplanted with a graft from an extended-criteria donor (ECD) were identified. Benchmark metrics (length of hospital and intensive care unit stay, incidences of mortality, graft loss, and postoperative complication) were compared with benchmark cutoffs and between the 2 groups.

Results: Two hundred forty-five patients satisfied the inclusion criteria, 146 (60%) of whom received an organ from an ECD. Overall, all benchmark metrics where within the cutoffs limits, except for graft loss (14% vs 11%) and mortality (10% vs 9% 1 year after LT). The ECD group was associated with more grade III complications (60% vs 45%, P = .031), graft loss (18% vs 8%, P = .038), and mortality (14% vs 4%, P = .009). Hepatocellular carcinoma diagnosis was found to be associated with less mortality (odds ratio = 0.42, P = .048).

Conclusion: While ECD graft usage is associated with slightly worse prognosis, our experience suggests that their use can be considered safe, especially when matched on hepatocellular carcinoma recipients.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.050DOI Listing
June 2020

Novel Arterial Reconstruction With Donor Femoral Artery in Split-Liver Transplantation.

Liver Transpl 2020 05 9;26(5):729-730. Epub 2020 Apr 9.

Abdominal Surgery and Organ Transplantation Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, University of Pittsburgh Medical Center Italy, Palermo, Italy.

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http://dx.doi.org/10.1002/lt.25736DOI Listing
May 2020

Impact of Italian Score for Organ Allocation System on Deceased Donor Liver Transplantation: A Monocentric Competing Risk Time-to-Event Analysis.

Transplant Proc 2019 Nov;51(9):2860-2864

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico - Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy; University of Catania, Catania, Italy. Electronic address:

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.
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http://dx.doi.org/10.1016/j.transproceed.2019.02.073DOI Listing
November 2019

Splinting vs Not Splinting Four Implants Supporting a Maxillary Overdenture: A Systematic Review.

Int J Prosthodont 2019 Nov/Dec;32(6):509-518

Purpose: To investigate the influence of splinted vs unsplinted designs for a maxillary overdenture supported by four implants in terms of the outcome measures implant survival, overdenture longevity, and patient satisfaction.

Materials And Methods: A systematic search, complemented by a handsearch, was carried out in the Embase, MEDLINE (PubMed), and Web of Science databases from 2000 to 2018. The PRISMA statement and a PICO approach were adopted. Free-text words were used in the strategy search, including "4-implant-retained overdenture," "4-implant-supported overdenture," "implant-supported overdenture," "implant-retained overdenture," "maxillary overdenture," "splinted design," "un-splinted design," and their combinations. All selected articles provided at least a 1-year follow-up, 10 fully edentulous patients, and at least one of the following clinical outcomes: survival rate of implants, survival rate of overdentures, and/or patient satisfaction scores. Nonparametric Fisher test for unpaired data was adopted in order to analyze data deriving from the survival rates of implants and overdentures.

Results: The initial electronic search produced a total of 2,922 articles. After applying the inclusion criteria, 14 articles were included. The mean follow-up time after implant placement ranged from 1 to 10 years. No statistical difference was detected in the survival rate of implants between the splinted implant group and the unsplinted implant group (P = .1). Only 4 included studies reported an overdenture survival rate of lower than 95%. It is interesting to note that among these 4 studies, 3 employed four splinted implants with a bar anchorage; however, no statistical difference was detected in the survival rate of overdentures between the splinted and unsplinted groups (P = .47). High scores were reported by all studies investigating patient satisfaction.

Conclusion: Within the limits of this systematic review, it can be concluded that the survival rates of implants and overdentures and patient satisfaction with a maxillary overdenture supported by four implants were not influenced by the overdenture design, and no statistical difference was detected between the splinted and unsplinted groups.
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http://dx.doi.org/10.11607/ijp.6333DOI Listing
October 2019

Impact of margin status on long-term results of liver resection for hepatocellular carcinoma: single-center time-to-recurrence analysis.

Updates Surg 2020 Mar 17;72(1):109-117. Epub 2019 Oct 17.

Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Via E. Tricomi 5, 90127, Palermo, Italy.

Occult metastasis from the initial tumor and a de novo second primary hepatocellular carcinoma (HCC) were recognized as the main causes for the onset of early and late HCC recurrence, after liver resection (LR). This study aims to compare the time to recurrence after LR for HCC in which a margin ≤ 1 mm or > 1 mm was achieved. A single-center retrospective study involving 256 patients was conducted from June 2005 to June 2019. HCC patients resected with a radical surgical approach were investigated and stratified into groups A (resection margins ≤ 1 mm) and B (> 1 mm), as measured on final pathologic assessment. Kaplan-Meier estimators were used to estimate the probability of recurrence, and the log-rank test was used to compare groups. Uni- and multivariable (stepwise) Cox regression models were used to assess the effect of several HCC pathological characteristics. Twenty patients were excluded for the presence of microscopic tumor invasion at pathologic analysis (R1); 236 patients underwent radical (R0) LR, and were included in the study and divided into group A (n = 61, 26%), and group B (n = 175, 74%). No differences between the two groups were detected regarding: epidemiology, tumor characteristics, type of LR, and follow-up. The estimated probability of recurrence for group A and group B at 12 and 24 months was 27% and 38%, and, 33% and 46%, respectively. Univariate and multivariable Cox regression model estimates showed that tumor grading (HR 2.1, 95% CI 1.2-3.4, p = 0.006), number of nodules (HR 1.2, 95% CI 1.0-1.4, p = 0.015), and extension of the resection (HR 1.8, 95% CI 1.0-1.1, p = 0.047) were independent risk factors for HCC recurrence, with no significant effect of margin status on time to recurrence. A R0 approach that considers a margin of resection > 1 mm does not improve the likelihood of HCC recurrence. Otherwise, our experience confirms that biologic tumor characteristics are the principal factors predictive of local and systemic recurrence.
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http://dx.doi.org/10.1007/s13304-019-00686-5DOI Listing
March 2020

Crucial Role of Extended Criteria Donors in Deceased Donor Single Kidney Transplantation to Face Chronic Shortage in the Heart of the Mediterranean Basin: A Single-Center Experience.

Transplant Proc 2019 Nov 9;51(9):2868-2872. Epub 2019 Oct 9.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione) UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy. Electronic address:

Background: The gap between organ availability and patients on the waiting list for deceased donor kidney transplants has resulted in the wide use of extended criteria donors (ECDs).We aimed to compare the surgical outcomes of single kidney transplantation (KT) performed at our institute with standard criteria donor (SCD) or ECD grafts, according to the Organ Procurement and Transplantation Network definition.

Patients And Methods: Our retrospective analysis studied 115 adult recipients of KT from January 2016 to July 2018, with kidney grafts procured from adult donors after brain or circulatory death, performed at our institute. Among the 2 recipients' groups, we compared the incidence of early graft loss, delayed graft function, hospitalization, and surgical complications. We compared the evaluation of time to early graft loss with Kaplan-Meier estimators and curves; the hypothesis of no difference in time to graft loss between the 2 groups was tested using the log-rank statistics.

Results: Of the 103 deceased donor kidney transplants during the study period, 129 grafts were used after the regional network sharing allocation. More frequently, ECDs had a greater body mass index than SCDs (25.2 ± 3.9 vs 27.7 ± 5.0, P = .005) and type II diabetes mellitus (0% vs 18%, P = .002). KT recipients who received an ECD graft (73, 63.5%) were older (59.8 ± 9.8 vs 45.2 ± 15.4, P < .001) and presented a higher rate of delayed graft function (56% vs 24%, P = .001). Post-transplant graft loss did not differ among the 2 groups.

Conclusion: Based on clinical experience in a single transplant center, ECD use for KTs is crucial in facing the organ shortage, without impairing post-deceased donor kidney transplant outcomes.
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http://dx.doi.org/10.1016/j.transproceed.2019.02.075DOI Listing
November 2019

Enhanced Recovery after Implementation of Surgery Protocol in Living Kidney Donors: The ISMETT Experience.

Transplant Proc 2019 Nov 9;51(9):2910-2913. Epub 2019 Oct 9.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione) UPMC (University of Pittsburgh Medical Center) Italy, Palermo, Italy; University of Catania, Catania, Italy.

Introduction: Laparoscopic living donor nephrectomy (LLDN) has become the standard procedure for living kidney transplantation. Enhanced recovery after surgery (ERAS) is a multimodal perioperative management aimed at facilitating rapid patient recovery after major surgery by modifying the response to stress induced by exposure to surgery. This association can further reduce hospital stay, surgical stress, and perioperative morbidity of living kidney donors.

Material And Methods: In this retrospective analysis conducted at our institute, we compared the first 21 patients who underwent LLDN enrolled with the ERAS protocol with 55 patients who underwent LLDN with the fast-track protocol in the 5 years prior to ERAS protocol implementation.

Results: We evaluated 76 consecutive patients. After ERAS protocol implementation, elderly living donors had a shorter hospital stay and a faster return to normal life compared with the same age group of patients in the previous period. There were no major differences in median postoperative hospital stay and no meaningful differences in the percentage of complications after surgery and hospital readmissions.

Conclusions: The introduction of the ERAS protocol for patients undergoing LLDN compared with the traditional protocol led to a reduction in postoperative hospitalization in elder donors, without determining a raise in the number of hospital complications and readmissions.
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http://dx.doi.org/10.1016/j.transproceed.2019.04.089DOI Listing
November 2019

Preduodenal Portal Vein Reconstruction at Liver Transplantation: The Challenges and a Solution.

Liver Transpl 2019 12 12;25(12):1841-1844. Epub 2019 Oct 12.

Department of Pediatrics, Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy.

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http://dx.doi.org/10.1002/lt.25636DOI Listing
December 2019

A paradigm shift in the intention-to-transplant children with biliary atresia: Outcomes of 101 cases and a review of the literature.

Pediatr Transplant 2019 11 13;23(7):e13569. Epub 2019 Aug 13.

Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via E. Tricomi, Palermo, 90127, Italy.

For children with BA who do not benefit from Kasai surgery, the only therapeutic option is liver replacement and transplantation. The very decision to proceed for transplantation is a crucial point in time because it is the first step toward the preparation for the transplantation. The former time point is defined in this analysis as "intent-to-transplant" care pathway. In the life of every BA candidate for liver replacement, this point in time varies and mostly depends on the decision of their primary caring teams-about when to switch from supportive care to transplant, and thus to refer to a transplant center. This intent-to-transplant analysis of a series of 101 consecutive infants that were referred to a single transplant team showed that excellent overall outcome (97% survival) has been achieved overall. However, three deaths occurred that were clearly related to a late referral. This analysis and recent observations from other centers strongly support that the timing for referring these children to a transplant center and/or deciding to list them on the waiting list is currently too late and should be anticipated to what it is currently. This paradigm shift in the intention-to-transplant children is likely necessary for giving a better chance to an increased number of children and impacts positively on the general outcome. Networking and defining new tools for a rapid recognition of the infants who need early transplantation are necessary; centralization of these children may be helpful to achieve better outcomes than currently observed.
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http://dx.doi.org/10.1111/petr.13569DOI Listing
November 2019

Unusual venous collateral pathways allow for reperfusion of the intrahepatic portal venous system in children with portal vein thrombosis after split liver transplantation: Clinical relevance and management implications.

Pediatr Transplant 2019 09 22;23(6):e13539. Epub 2019 Jul 22.

Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy.

PVT is the most frequent vascular complication after LT in small children, and a higher incidence has been observed in those transplanted for biliary atresia or with a LLSG. Thrombosis of the PV causes extrahepatic portal hypertension and is associated with splenomegaly and the development of venous neo-collaterals, including gastro-oesophageal varices and splenorenal shunts. It has also been incidentally suggested in the literature that patients who have had a Roux-en-Y loop for a biliary reconstruction may present with a cavernomatous transformation of the distal portion of the loop. In this study, 13 children with CEPH caused by thrombosis of the PV after LT were analysed. The study evidenced the development of two types of hepatopetal venous networks: (a) a large cavernoma along the Roux loop and around the biliary anastomosis, and (b) a network of neo-collaterals in the gastro-duodeno-pancreatic area that connected to the intrahepatic portal branches directly through the liver capsule. These hepatopetal venous networks between the venous system of the surrounding organs or the omentum and the intrahepatic portal branches can be identified by radiologists. The relevance for the transplanting physician and the transplant surgeon is discussed.
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http://dx.doi.org/10.1111/petr.13539DOI Listing
September 2019

Role of Allelic Imbalance in Predicting Hepatocellular Carcinoma (HCC) Recurrence Risk After Liver Transplant.

Ann Transplant 2019 Apr 24;24:223-233. Epub 2019 Apr 24.

Department for Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Mediterranean Institute for Transplantation and High Specialization Therapies (IRCCS-ISMETT), Palermo, Italy.

BACKGROUND One of the most controversial problems for liver transplantation in patients affected by hepatocellular carcinoma (HCC) remains the lack of an oncologic staging system to predict cancer recurrence after liver transplantation (LT). We analyzed allelic imbalance (AI) in 19 microsatellites, and assessed the post-LT HCC recurrence risk. MATERIAL AND METHODS Seventy-one patients were included; 18 had tumor recurrence within 5 years post-transplant. Molecular analysis was done in the primary HCC and peripheral blood samples: a total of 19 microsatellites was used to assess AI. Specific AI was evaluated when outside of range value between 0.66 and 1.5. Based on data in the literature, we grouped the 19 microsatellites into 4 panels. We calculated the fractional allelic imbalance (FAI) to make comparisons between different panels including different subsets of microsatellites. RESULTS We report that AI was associated with HCC recurrence in 3 main loci (D3S2303, D9S251, and D9S254). Tumor recurrence was associated only with 2 specific panels with 9 microsatellites previously reported to be associated with high risk for HCC recurrence. Our data show that fractional allelic imbalance (FAI) index has good negative ability to predict HCC recurrence (Panel 2: negative predictive value of 95%). CONCLUSIONS AI analysis could have prognostic value in risk management of HCC recurrence after LT, especially for early recurrence.
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http://dx.doi.org/10.12659/AOT.913692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500106PMC
April 2019

Normothermic Machine Perfusion in Liver Transplantation: Feasibility and Promise of Avoiding Recooling Before Engrafting.

Liver Transpl 2019 07 6;25(7):1113-1117. Epub 2019 Jun 6.

Abdominal Surgery and Organ Transplantation Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center Italy, Palermo, Italy.

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http://dx.doi.org/10.1002/lt.25473DOI Listing
July 2019

The addition of simvastatin administration to cold storage solution of explanted whole liver grafts for facing ischemia/reperfusion injury in an area with a low rate of deceased donation: a monocentric randomized controlled double-blinded phase 2 study.

BMC Surg 2018 Dec 27;18(1):122. Epub 2018 Dec 27.

Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico - Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center) Italy, Via E. Tricomi 5, 90127, Palermo, Italy.

Background: Liver transplantation is the best treatment for end-stage liver disease. The interruption of the blood supply to the donor liver during cold storage damages the liver, affecting how well the liver will function after transplant. The drug Simvastatin may help to protect donor livers against this damage and improve outcomes for transplant recipients. The aim of this study is to evaluate the benefits of treating the donor liver with Simvastatin compared with the standard transplant procedure.

Patient And Methods: We propose a prospective, double-blinded, randomized phase 2 study of 2 parallel groups of eligible adult patients. We will compare 3-month, 6-month, and 12-month graft survival after LT, in order to identify a significant relation between the two homogenous groups of LT patients. The two groups only differ by the Simvastatin or placebo administration regimen while following the same procedure, with identical surgical instruments, and medical and nursing skilled staff. To reach these goals, we determined that we needed to recruit 106 patients. This sample size achieves 90% power to detect a difference of 14.6% between the two groups survival using a one-sided binomial test.

Discussion: This trial is designed to confirm the effectiveness of Simvastatin to protect healthy and steatotic livers undergoing cold storage and warm reperfusion before transplantation and to evaluate if the addition of Simvastatin translates into improved graft outcomes.

Trial Registration: ISRCTN27083228 .
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http://dx.doi.org/10.1186/s12893-018-0455-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307270PMC
December 2018

Multimodality imaging of the Meso-Rex bypass.

Abdom Radiol (NY) 2019 04;44(4):1379-1394

Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy.

Extrahepatic portal vein obstruction (EHPVO) is the most common cause of upper gastrointestinal bleeding in children. It is defined as thrombosis of the extrahepatic portal vein with or without extension to the intrahepatic portal veins. The Meso-Rex shunt is the gold standard treatment in children with favorable anatomy since it restores physiological portal liver reperfusion. This is achieved by rerouting the splanchnic venous blood through an autologous graft from the superior mesenteric vein (SMV) into the Rex recess of the left portal vein, curing portal hypertension by doing so. General and hepatobiliary radiologists must be familiar with multimodality imaging appearances of EHPVO and with the role of imaging in identifying suitable candidates for Meso-Rex bypass surgery. Imaging might also detect complications of this procedure, some of which might be treated via interventional radiology.
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http://dx.doi.org/10.1007/s00261-018-1836-1DOI Listing
April 2019
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