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Liver transplantation for hepatocellular carcinoma on cirrhosis:Strategies to avoid tumor recurrence

World Journal of Gastroenterology 2011年第43期17卷 4741-4746页

作者： marco vivarelli Andrea Risaliti Department of Surgery and Transplantation University of BolognaS Orsola Hospital Department of Hepatobiliopancreatic and Transplantation Surgery Polytechnic University of MarcheOspedali Riuniti

Hepatocellular carcinoma(HCC) is one of the most frequent neoplasms worldwide and in most cases it is associated with chronic liver *** transplantation(LT) is potentially the optimal treatment for those patients with HCC who have a poor functional hepatic reserve due to their underlying chronic liver ***,due to the limited availability of donors,only those patients whose oncologic profile is favorable can be considered for *** the careful selection of candidates based on strict rules,10 to 20%of liver transplant recipients who have HCC in the native cirrhotic liver develop tumor recurrence after *** selection criteria presently employed to minimize the risk of recurrence are based on gross tumor characteristics defined by imaging techniques;unfortunately,the accuracy of imaging is far from being ***,microscopic tumor features that are strictly linked with prognosis can not be assessed prior to ***-transplantation tumor downstaging may allow transplantation in patients initially outside the selection criteria and seems to improve the prognosis;it also provides information on tumor *** peculiarity of the transplantation setting,when this is compared with other modalities of treatment,is the need for pharmacological immunosuppression:this is based on drugs that have been demonstrated to increase the risk of tumor *** HCC is an aggressive malignancy,immunosuppression has to be handled carefully in patients who have HCC at the time of transplantation and new categories of immunosuppressive agents should be *** chemotherapy following transplantation has failed to show any significant *** aim of the present study is to review the possible strategies to avoid recurrence of HCC after liver transplantation based on the current clinical evidence and the more recent developments and to discuss possible future directions.

关键词： Chemotherapy Hepatocellular carcinoma Immunosuppression Liver transplantation Tumor recurrence

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Multimodal treatment of hepatocellular carcinoma on cirrhosis: An update

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World Journal of Gastroenterology 2013年第42期19卷 7316-7326页

作者： marco vivarelli Roberto Montalti Andrea Risaliti Hepatobiliary and Abdominal Transplantation Surgery Department of Gastroenterology and TransplantationPolytechnic University of Marche60129 AnconaItaly Department of Surgery and Transplantation University of Udine33100 UdineItaly

Hepatocellular carcinoma(HCC)is the most frequent primary liver tumor,and overall,it is one of the most frequent *** association of HCC with chronic liver disease,and cirrhosis in particular,is well known,making treatment complex and *** treatment of HCC must take into account the presence and stage of chronic liver disease,with the aim of preserving hepatic function that is often already impaired,the stage of HCC and the clinical condition of the *** different treatment options include surgical resection,transplantation,local ablation,chemoembolization,radioembolization and molecular targeted therapies;these treatments can be combined in various ways to achieve different ***,liver transplantation is best treatment for early stage HCC on cirrhosis because it removes both the tumor and the chronic disease that produced it;however,the application of this powerful tool is limited by the scarcity of *** and bridging are different strategies for the management of HCC patients who will undergo liver *** professionals,including gastroenterologists,radiologists and surgeons,are involved in the choice of the most appropriate treatment for a single case,and a multidisciplinary approach is necessary to optimize the *** purpose of this review is to provide a comprehensive description of the current treatment options for patients with HCC by analyzing the advantages,disadvantages and rationale for their use.

关键词： Hepatocellular carcinoma Multimodal treatment Locoregional treatments Molecular targeted therapies Liver resection Liver transplantation

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Outcomes of robotic vs laparoscopic hepatectomy:A systematic review and meta-analysis

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World Journal of Gastroenterology 2015年第27期21卷 8441-8451页

作者： Roberto Montalti Giammauro Berardi Alberto Patriti marco vivarelli Roberto Ivan Troisi Department of General and Hepato-Biliary Surgery Liver Transplantation Service Ghent University Hospital and Medical School Department of Gastroenterology and Transplantation Surgery Polytechnic University of Marche-Ospedali Riuniti Division of General Minimally Invasive and Robotic Surgery General Hospital of Spoleto

AIM: To perform a systematic review and metaanalysis on robotic-assisted vs laparoscopic liver ***: A systematic literature search was performed using Pub Med, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria:(1) studies comparing robotic and laparoscopic liver resection;(2) studies reporting at least one perioperative outcome; and(3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy ***: A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time(MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital ***: Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.

关键词： Laparoscopic liver resections Robotic liverresections Outcome Systematic review Meta-analysis

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Predictive factors of short term outcome after liver transplantation: A review

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World Journal of Gastroenterology 2016年第26期22卷 5936-5949页

作者： Giuliano Bolondi Federico Mocchegiani Roberto Montalti Daniele Nicolini marco vivarelli Lesley De Pietri Anaesthesiology Intensive Care and Pain Therapy Medical Residency University of Modena and Reggio Emilia Division of Hepatobiliary and Transplant Surgery Department of Experimental Medicine Polytechnic University of Marche Division of Anaesthesiology and Intensive Care Unit Department of Cardiology Thoracic and Vascular Surgery Critical Care Medicine Arcispedale Santa Maria Nuova-IRCCS

Liver transplantation represents a fundamental therapeutic solution to end-stage liver disease. The need for liver allografts has extended the set of criteria for organ acceptability, increasing the risk of adverse outcomes. Little is known about the early postoperative parameters that can be used as valid predictive indices for early graft function, retransplantation or surgical reintervention, secondary complications, long intensive care unit stay or death. In this review, we present state-of-the-art knowledge regarding the early post-transplantation tests and scores that can be applied during the first postoperative week to predict liver allograft function and patient outcome, thereby guiding the therapeutic and surgical decisions of the medical staff. Post-transplant clinical and biochemical assessment of patients through laboratory tests (platelet count, transaminase and bilirubin levels, INR, factor V, lactates, and Insulin Growth Factor 1) and scores (model for end-stage liver disease, acute physiology and chronic health evaluation, sequential organ failure assessment and model of early allograft function) have been reported to have good performance, but they only allow late evaluation of patient status and graft function, requiring days to be quantified. The indocyanine green plasma disappearance rate has long been used as a liver function assessment technique and has produced interesting, although not univocal, results when performed between the 1th and the 5th day after transplantation. The liver maximal function capacity test is a promising method of metabolic liver activity assessment, but its use is limited by economic cost and extrahepatic factors. To date, a consensual definition of early allograft dysfunction and the integration and validation of the above-mentioned techniques, through the development of numerically consistent multicentric prospective randomised trials, are necessary. The medical and surgical management of trans

关键词： Liver transplant Liver failure Early allograft dysfunction Primary non-function Initial poor function Outcome predictors Post operative Scoring system Indocyanine green Liver maximal functional capacity

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Perioperative thromboprophylaxis in liver transplant patients

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World Journal of Gastroenterology 2018年第27期24卷 2931-2948页

作者： Lesley De Pietri Roberto Montalti Daniele Nicolini Roberto Ivan Troisi Federico Moccheggiani marco vivarelli Division of Anaesthesiology and Intensive Care Unit Department of General SurgeryAUSL Reggio Emilia-IRCCSReggio Emilia 42123Italy Hepatobiliary and Abdominal Transplantation Surgery Department of Experimental and Clinical MedicinePolytechnic University of MarcheAncona 60126Italy Department of General Hepatobiliary and Liver Transplantation SurgeryGhent University Hospital Medical SchoolGhent 185 3K3 9000Belgium

Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation(LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications(intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors(portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis' ' can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors(venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.

关键词： Anticoagulation Liver transplantation Antiplatelets Thrombosis Coagulation Heparin Thromboelastography Thromboprophylaxis Hepatic artery thrombosis Portal vein thrombosis

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Intraductal papillary neoplasm of the bile duct:The new frontier of biliary pathology

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World Journal of Gastroenterology 2023年第38期29卷 5361-5373页

作者： Federico Mocchegiani Paolo Vincenzi Grazia Conte Daniele Nicolini Roberta Rossi Andrea Benedetti Cacciaguerra marco vivarelli Department of Experimental and Clinical Medicine Polytechnic University of MarcheAncona 60126Italy Department of Gastroenterology and Transplant United Hospital of MarcheAncona 60126Italy

Intraductal papillary neoplasms of the bile duct(IPNBs)represent a rare variant of biliary tumors characterized by a papillary growth within the bile duct *** their first description in 2001,several classifications have been proposed,mainly based on histopathological,radiological and clinical features,although no specific guidelines addressing their management have been *** duct neoplasms generally develop through a multistep process,involving different precursor pathways,ranging from the initial lesion,detectable only microscopically,*** intraepithelial neoplasia,to the distinctive grades of IPNB until the final stage represented by invasive *** and advanced investigations,mainly relying on magnetic resonance imaging(MRI)and cholangioscopy,are required to reach a correct diagnosis and to define an adequate bile duct mapping,which supports proper *** recently introduced subclassifications of types 1 and 2 highlight the histopathological and clinical aspects of IPNB,as well as their natural evolution with a particular focus on prognosis and *** surgical resection,including hepatectomy,pancreaticoduodenectomy or both,represents the treatment of choice,yielding optimal results in terms of survival,although several endoscopic approaches have been *** are newly recognized preinvasive neoplasms of the bile duct with high malignant *** novel subclassification of types 1 and 2 defines the histological and clinical aspects,prognosis and *** is mainly based on MRI and *** resection represents the mainstay of treatment,although endoscopic resection is currently applied to nonsurgically fit *** frontiers in genetic research have identified the processes underlying the carcinogenesis of IPNB,to identify targeted therapies.

关键词： Intraductal neoplasm of the bile duct Bile duct neoplasms Cholangiocarcinoma Intraductal papilloma Classification Treatment

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Transoesophageal echocardiography during liver transplantation

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World Journal of Hepatology 2015年第23期7卷 2432-2448页

作者： Lesley De Pietri Federico Mocchegiani Chiara Leuzzi Roberto Montalti marco vivarelli Vanni Agnoletti Division of Anaesthesiology and Intensive Care Unit Azienda Ospedaliero-Universitaria di Modena-Policlinico Transplantation Unit Polytechnic University of Marche Unit of Interventional Cardiology Arcispedale Santa Maria Nuova IRCCS Division of Anaesthesiology and Intensive Care Unit Arcispedale Santa Maria Nuova IRCCS

Liver transplantation(LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver trans-plant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the pro-cedures as a result of both the disease process and the surgery. Transoesophageal echocardiography(TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. More-over, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.

关键词： Liver transplantation Transoesophageal echocardiog

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Neoadjuvant therapy in the treatment of hilar cholangiocarcinoma:Review of the literature

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World Journal of Gastrointestinal Surgery 2019年第6期11卷 279-286页

作者： Fabio Frosio Federico Mocchegiani Grazia Conte Enrico Dalla Bona ANDrea Vecchi Daniele Nicolini marco vivarelli Unit of Hepato-pancreato-biliary and Transplant Surgery Department of Experimental and Clinical Medicine Polytechnic University of Marche

Cholangiocarcinoma(CCA)is a malignant tumor of the biliary system and includes,according to the anatomical classification,intra hepatic CCA(iCCA),hilar CCA(hCCA)and distal CCA(dCCA).Hilar CCA is the most challenging type in terms of diagnosis,treatment and *** is the only treatment possibly providing long-term survival,but only few patients are considered resectable at the time of *** fact,tumor’s extension to segmentary or subsegmentary biliary ducts,along with large lymph node involvement or intrahepatic metastases,precludes the surgical *** achieve R0 margins is mandatory for the disease-free survival and overall *** case of unresectable locally advanced hCCA,radiochemotherapy(RCT)as neoadjuvant treatment demonstrated to be a therapeutic option before either hepatic resection or liver *** liver surgery,RCT is believed to enhance the R0 margins *** patients meeting the Mayo Clinic criteria,RCT prior to orthotopic liver transplant(OLT)has proved to produce acceptable 5-years *** this review,we analyze the current role of neoadjuvant RCT before resection as well as before OLT.

关键词： Hilar cholangiocarcinoma Klatskin tumor Neoadjuvant treatement Radiotherapy Chemotherapy Hepatic resection Liver transplantation

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Radiological response and inflammation scores predict tumour recurrence in patients treated with transarterial chemoembolization before liver transplantation

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World Journal of Gastroenterology 2017年第20期23卷 3690-3701页

作者： Daniele Nicolini Andrea Agostini Roberto Montalti Federico Mocchegiani Cinzia Mincarelli Alessandra Mandolesi Nicola L Robertson Roberto Candelari Andrea Giovagnoni marco vivarelli Division of Hepatobiliary and Transplant Surgery Department of Experimental and Clinical MedicinePolytechnic University of Marche Division of General and Pediatric Radiology Department of Radiological SciencesPolytechnic University of Marche Division of Interventional Radiology Department of Radiological SciencesPolytechnic University of Marche Division of Pathology Department of PathologyPolytechnic University of Marche Division of Radiology Department of RadiologyMemorial Sloan Kettering Cancer Center

To investigate the prognostic value of the radiological response after transarterial chemoembolization (TACE) and inflammatory markers in patients affected by hepatocellular carcinoma (HCC) awaiting liver transplantation (LT).METHODSWe retrospectively evaluated the preoperative predictors of HCC recurrence in 70 patients treated with conventional (n = 16) or doxorubicin-eluting bead TACE (n = 54) before LT. The patient and tumour characteristics, including the static and dynamic alpha-fetoprotein, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio (PLR) measurements, were recorded. Treatment response was classified according to the modified Response Evaluation Criteria in Solid Tumours (mRECIST) and the European Association for the Study of the Liver (EASL) criteria as complete response (CR), partial response (PR), stable disease or progressive disease. After examination of the explanted livers, histological necrosis was classified as complete (100% of the cumulative tumour area), partial (50%-99%) or minimal (< 50%) and was correlated with the preoperative radiological *** to the pre-TACE radiological evaluation, 22/70 (31.4%) and 12/70 (17.1%) patients were beyond Milan and University of San Francisco (UCSF) criteria, respectively. After TACE procedures, the objective response (CR + PR) rates were 71.4% and 70.0% according to mRECIST and EASL criteria, respectively. The agreement between the two guidelines in defining the radiological response was rated as very good both for the overall and target lesion response (weighted k-value: 0.98 and 0.93, respectively). Complete and partial histological necrosis were achieved in 14/70 (20.0%) and 28/70 (40.0%) patients, respectively. Using histopathology as the reference standard, mRECIST criteria correctly classified necrosis in 72.9% (51/70) of patients and EASL criteria in 68.6% (48/70) of cases. The mRECIST non-response to TACE [Exp(b) = 9.2, p = 0.012], exceeding UCSF criteria before

关键词： Liver transplantation Recurrence-free survival Hepatocellular carcinoma Radiological response Locoregional therapies Inflammatory markers Selection criteria

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Are liver nested stromal epithelial tumors always low aggressive?

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World Journal of Gastroenterology 2017年第46期23卷 8248-8255页

作者： Tania Meletani Luca Cantini Andrea Lanese Daniele Nicolini Alessia Cimadamore Andrea Agostini Giulia Ricci Stefania Antognoli Alessandra Mandolesi Maria Guido Rita Alaggio Gian marco Giuseppetti Marina Scarpelli marco vivarelli Rossana Berardi Medical Oncology University Hospital and Polytechnic University Ancona Hepatobiliary and Trans-plantation Surgery Department of Clinical and Experimental MedicineUniversity Hospital and Polytechnic University Ancona Section of Pathological Anatomy Department of Biomedical Sciences and Public HealthUniversity Hospital and Polytechnic University Ancona Department of Radiology University Hospital and Polytechnic University Ancona Pathology Department Padova University

Nested stromal-epithelial tumor(NSET) is a nonhepatocytic and non-biliary tumor of the liver consisting of nests of epithelial and spindled cells with associated myofibroblastic stroma and variable intra-lesional calcification and ossification, which represents a very rare and challenging disease. Most of the reported cases have been treated with surgery, obtaining a long survival outcome. Here, we report the case of a 31-year-old Caucasian man who underwent surgery at our institution for a large, lobulated, multinodular mass of the right hemi-liver. The histological exam confirmed the diagnosis of NSET. After 6 mo from surgery, a liver recurrence was described and a chemoembolization was performed. After a further disease progression, based on the correlation between the histological features of the disease and those of the hepatoblastoma, a similar chemotherapy regimen(with cisplatin and ifosfamide/mesna chemotherapy, omitting doxorubicin due to liver impairment) was administered. However, infection of the biliary catheter required a dose modification of the treatment. No benefit was noted and a progression of disease was radiologically assessed after only four cycles. The worsening of the clinical status prevented further treatments, and the patient died a few months later. This case report documents how the NSET might have an aggressive and non-preventable behavior. No chemotherapy schedules with a proved efficacy are available, and new data are needed to shed light on this rare neoplasm.

关键词： Nested stromal epithelial tumor Liver Rare Chemotherapy Aggressive Metastatic

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