ABSTRACT BACKGROUND: Ischemic type biliary lesions (ITBLs), a particular subset of non-anastomotic biliary strictures (NAS), are characterized by intra and extrahepatic strictures that occur in the absence of either hepatic artery thrombosis or stenosis. When they occur within the first year after liver transplantation their development is mostly related to ischemia-reperfusion injury (IRI). The indocyanine green plasma disappearance rate (ICG-PDR) might be able to predict the probability of IRI-induced graft damage after liver transplantation. OBJECTIVE: Our aim was to evaluate the association between ICG-PDR and the occurrence of ITBLs. Secondly, we searched for evidence of IRI in patients presenting ITBLs. METHODS: This retrospective single-centre observational study assessed a cohort of 60 liver transplant patient s . Each patient underwent ICG-PDR on the 1st postoperative day. ITBLs were identified by means of either cholangiography or magnetic resonance imaging evidence of a deformity and narrowing of the biliary tree in the absence of hepatic artery thrombosis/stenosis. RESULTS: ITBLs were discovered in 10 patients out of 60 liver recipients (16.67%) within one year after transplantation. A low ICG-PDR value was found to be a significant predictive factor for ITBL development, with an OR of 0.87 and a 95% CI of 0.77–0.97. Liver biopsies were performed in 56 patients presenting unexplained abnormal liver function test results. A statistically significant association was found between the development of ITBLs and anatomopathological evidence of IRI. LIMITATIONS: Retrospective, single-centre study. CONCLUSIONS: The findings from this study show a relationship between low ICG-PDR values on first post-operative-day and the occurrence of ITBLs within 1 year after transplantation.

We demonstrated that a complete left ureteral substitution with appendix is a feasible and safe technique. To our knowledge, this is the first case of a successful complete substitution of the left ureter with vermicular appendix in an adult patient reported in the literature.

In kidney transplantation (KT), a prolonged cold ischemia time (CIT) in static cold storage as well as a perioperative hemodynamic instability of the recipient have been identified as independent negative prognostic factors for postoperative morbidity and poor graft survival [1]. Even the development of hyperdynamic states and the massive use of inotropic drugs use have been shown to have a detrimental effect on kidney graft [2] .

Background: The most commonly used formula for estimation of the standard liver volume (SLV) in living-donor liver transplantation (LDLT) candidates, are body weight (BW)-based. However end-stage liver disease causes a significant modification of the body mass composition, making BW an unreliable anthropometric parameter. The aim of the study was to investigate whether LT candidates with sarcopenia are at an increased risk of receiving an inappropriate SLV estimation by standard BW-SLV formula. Patients and Methods: Non-BW-SLV estimation formulas were tested in 262 LDLT donors and compared to a standard BW-SLV formula. The anthropometric parameters used were the thoracic width (TW-SLV) and thoracoabdominal circumference (TAC-SLV). Subsequently, sarcopenic and non-sarcopenic LDLT candidates (total, 217 patients) were compared in terms of estimated BW-SLV and non-BW-SLV. The prognosis in patients with sarcopenia, a small for size syndrome (SFSS) was evaluated. Results: In donors, TW-SLV showed comparable concordance with CT scan measured total liver volume as BW-SLV (rho 0.61 and 0.67, respectively). The performance of TAC-SLV was low (rho 0.34). In recipients, the prevalence of pre-LT sarcopenia was 30.4%. Sarcopenic patients were attributed to significantly lower BW-SLV than controls (sarcopenia vs controls, 1063.8ml [1004.1-1118.4] vs 1220.7ml [1115.0-1306.6], p<0.001), despite comparable TW-SLV, age, body high and gender prevalence. As a result, sarcopenic patients received a graft with a statistically lower weight at organ procurement (429g [353-532] vs 472g [400-603], p 0.02), and developed more frequently a SFSS according to the Dahm et al. (27.7% vs 6.8%, p<0.01) and Kyushu (28.7% vs 9.2%, p<0.01) definition. There was significantly worse prognosis wit SFSS than without SFSS besides there were no significant differences of survival between with and without sarcopenia. Conclusion: In sarcopenic patients, BW-SLV formulas are affected by a high risk of SLV underestimation, thus exposing them to an increased risk of postLT SFSS.

When the standard arterial reconstruction is not feasible during liver transplantation (LT), aorto-hepatic arterial reconstruction (AHAR) can be the only solution to save the graft. AHAR can be performed on the infrarenal (IR) or supraceliac (SC) tract of the aorta, but the possible effect on outcome of selecting SC versus IR reconstruction is still unclear. One hundred and twenty consecutive patients who underwent liver transplantation with AHAR in six European centres between January 2003 and December 2018 were retrospectively analysed to ascertain whether the incidence of hepatic artery thrombosis (HAT) was influenced by the type of AHAR (IR-AHAR vs. SC-AHAR). In 56/120 (46.6%) cases, an IR anastomosis was performed, always using an interposition arterial conduit. In the other 64/120 (53.4%) cases, an SC anastomosis was performed; an arterial conduit was used in 45/64 (70.3%) cases. Incidence of early (≤ 30 days) HAT was in 6.2% (4/64) in the SC-AHAR and 10.7% (6/56) IR-AHAR group (p = 0.512) whilst incidence of late HAT was significantly lower in the SC-AHAR group (4.7% (3/64) vs 19.6% (11/56) - p = 0.024). IR-AHAR was the only independent risk factor for HAT (exp[B] = 3.915; 95% CI 1.400–10.951; p = 0.009). When AHAR is necessary at liver transplantation, the use of the supraceliac aorta significantly reduces the incidence of hepatic artery thrombosis and should therefore be recommended whenever possible.

The posology of tacrolimus (TAC) is usually guided by its therapeutic drug monitoring. Some patients reach target concentrations (CTs) quickly, others more slowly. In a retrospective study, 20 kidney transplant recipients were included (mean age, 50.7 ± 14.1 years; weight 64.0 ± 14.2 kg; patients clinically stable for over a year). We studied cytochrome CYP3A5 genotype, in particular CYP3A5 6986A>G, the most important polymorphism related to the metabolism of TAC (wild genotype CYP3A5 *1 genotype, and CYP3A5 *3 variants). One year after transplantation, the CTs were 5.0 to 8.0 ng/mL. The patients were divided into group A (TAC doses < 6.0 mg/d) and group B (TAC doses > 6.0 mg/d). All were tested for the CYP3A5 gene sequence to characterize their polymorphism. Patients with CYP3A5 *1/*1 and *1/*3 were extensive metabolizers, and those with CYP3A5 *3/*3 were poor metabolizers. In group A and group B, the average TAC doses at the time of therapeutic drug monitoring were 3.0 ± 1.4 ng/mL (0.05 ± 0.03 mg/kg) and 12.8 ± 3.7 ng/mL (0.2 ± 0.1 mg/kg), respectively (P < .001). Group A was the poor metabolizers genotype, while in group B, the extensive metabolizers genotype was present. Patients with the CYP3A5 *1/*1 or *1/*3 genotype required 1.5 to 2 times higher doses than patients *3/*3 to reach CT. This genetic test allows clinicians to know, before the kidney transplant, the patient's TAC metabolism pattern and then to optimize the drug exposure.

Short-term patient survival (PS) after liver transplantation (LT) is predicted by MELD score. This SITO-AISF study aimed to identify, besides the MELD score, factors predicting 6- and 12-month PS after LT, in order to develop case-mix models. Primary endpoint was 6-month PS; secondary end-points were 6-month graft survival and 12 month PS. LT was considered futile if associated with 5 years PS < 50% and/or 6 months PS < 60%.

Introduction: Women affected by benign or borderline lesions will undergo a follow-up which includes both regular, usually yearly, clinical examinations and imaging repetition. The present study aims to determine how many women with a previous diagnosis of breast lesion of uncertain significance develop breast cancer during follow-up and to assess their risk factors. Materials and Methods: This retrospective study included women followed up in the present surgical outpatient facility who underwent a diagnosis of breast lesion of uncertain malignant potential (classified equal or greater than B3 or equal or greater than C3) between January 2003 and June 2014. Main outcomes were the occurrence of breast cancer during follow up and the analysis of possible risk factors for breast cancer development. Results: Among 513 included women, 15 developed breast cancer during the follow up for a borderline breast lesion. The cumulative incidence of new breast cancer diagnosis among women with a previous histological or cytological diagnosis of breast lesion of uncertain malignant potential was 4.3% (95% CI, 1.9-6.6%) at seven years of follow up. Furthermore, the presence of atypical ductal hyperplasia (ADH) and lobular intraepithelial neoplasia (LIN) in the surgical excision specimen, as well as the coexistence of hypothyroidism, resulted to be significant risk factors for new breast cancer development among these patients. Conclusions: Due to the great heterogeneity of benign breast disease, further studies are required to better define its risk to evolve into breast cancer, and consequently to optimize their follow up and management in order to reduce over-treatment of low-risk patients, while improving breast cancer diagnosis among high-risk women.

AIM:We aimed to analyze the risk factors for early surgical complications requiring relaparotomy and the related impact on overall survival (OS) in HIV-infected patients submitted to liver transplantation. METHODS:We performed a retrospective study on a nationwide multicenter cohort of 157 HIV-infected patients submitted to liver transplantation in 6 Italian transplant units between 2004 to 2014. RESULTS:The median preoperative model for end-stage liver disease score was 18 (interquartile range 12-26.5). An early relaparotomy was performed in 24.8% of patients, and the underlying clinical causes were biliary leak (8.2%), bleeding (8.2%), intestinal perforation (4.5%), and suspected vascular complications (3.8%). The OS at 1, 3, and 5 years was 74.3%, 68.0%, and 60.0%, respectively, and an early relaparotomy was not a prognostic factor itself, but an increasing number of relaparotomies was associated with decreased survival (hazard ratio = 1.40, 95% confidence interval [CI] 1.07-1.81, P = .01). In the multivariate analysis, preoperative refractory ascites (odds ratio 3.32, 95% CI 1.18-6.47, P = .02) and Roux-en-Y choledochojejunostomy reconstruction (odds ratio 12.712, 95% CI 2.47-65.38, P ≤ .01) were identified as significant risk factors for early relaparotomy. CONCLUSIONS:In HIV-infected liver transplant recipients, an increasing number of early relaparotomies due to surgical complications did negatively affect the OS. Preoperative refractory ascites reflecting a severe portal hypertension and a difficult biliary tract reconstruction requiring a Roux-en-Y choledochojejunostomy were associated with an increased risk of early relaparotomy.

In this retrospective single-center study we evaluated the outcome after kidney transplant in recipients older than 65 years in terms of patient and graft survival and causes of death. Patients and Methods. From 1993 to 2016, 109 consecutive first single kidney transplants in recipients older than 65 years were included. Furthermore, 2 age groups have also been identified (group A, 65-70 years old vs group B, 71-76 years old). Donor and recipient characteristics were analyzed. Other parameters were cold and warm ischemia times, delayed graft function, biopsy-proven acute rejection, and causes of death. Induction immunosuppressive therapy was performed with basiliximab or thymoglobulin. Baseline triple immunosuppression included calcineurin inhibitor, antimetabolite, and steroids. The results of preimplantation biopsies, which were performed in all expanded criteria donors were analyzed and graded according to Karpinski 2009 classification. Results. Overall mortality was 39.4%: 23.2% women and 76.8% men. Causes of death were infections in 42%, tumors in 23%, cardiovascular disease in 14%, cerebrovascular disease in 7%, and unknown in 14%. The most common cause of death in men was infections (52%), and the most common cause in women was tumors (55%). At 1, 3, 5, and 10 years, overall patient survival was 89%, 84%, 72%, and 45%, and overall graft survival was 100%, 97%, 89%, and 84%, respectively. Patient and graft survival were statistically different between group A vs group B (P=.006 and P=.02, respectively). At univariate analysis significant risk factors for increased mortality were age, delayed graft function, and cold ischemia time. At multivariate analysis, delayed graft function maintained statistical significance. Conclusions. Kidney transplantation in patients older than 65 years is safe, feasible, and has good graft survival. Mortality is statistically significant in patients older than 71 years, despite a persistent low graft loss.