Fabrizio Di Francesco - Academia.edu (original) (raw)

Papers by Fabrizio Di Francesco

Pediatric Surgery International, 2014

A cavernomatous transformation of the extrahepatic portion of the portal vein is a common cause o... more A cavernomatous transformation of the extrahepatic portion of the portal vein is a common cause of chronic portal hypertension in children. A few attempts at radiological interventions have been reported, but have rarely been successful. In this report, a surgical Meso-Rex bypass was performed to treat complicated prehepatic portal hypertension, after the insertion of an intrahepatic stent for portosystemic shunting had failed. The review of this case nicely illustrates how differently effective are these two shunting procedures-in terms of restoring hepatopetal flow, managing portal hypertension, and establishing-or not-portosystemic connections.

World Journal of Gastroenterology, 2009

Though split-liver and living-related transplantation are routinely performed, they are done almo... more Though split-liver and living-related transplantation are routinely performed, they are done almost exclusively for primary liver transplantation because of potential surgical difficulties. These difficulties are generally related to arterial revascularization, particularly if there is hepatic artery thrombosis. According to UNOS data, of the hepatic retransplantations performed between 1996 and 2007, only 8.7% were done using right or extended right grafts from deceased donors, and 14.3% using right grafts from live donors. Here we report our experience with 5 hepatic retransplantations in which right partial grafts resulting from conventional in situ splits, and one right lobe resulting from an adult-toadult living-related transplant, were successfully used with different modalities of graft arterialization.

World Journal of Gastroenterology, 2010

Liver tumor and other benign liver diseases such as polycystic liver disease can cause massive he... more Liver tumor and other benign liver diseases such as polycystic liver disease can cause massive hepatomegaly and may represent an indication for liver transplantation (LT) in some instances. In this setting, LT can be extremely difficult and challenging due to its decreased mobility and access to vascular supply. Benefit from either a right or a left partial liver resection during the transplant procedure has been advocated to safely accomplish the hepatectomy of the native liver. Although we believe that partial hepatectomy adds some risk to intra-operative bleeding, we alternatively advise a different approach. We have a successful experience with LT in 6 massive hepatomegaly patients due to giant liver lesions. All the transplant procedures were performed without intermediate partial liver resection, showing that selective use of veno-venous bypass can play a significant role in the treatment of massive hepatomegaly. 15 (40): 5112-5113 regarding a case of liver transplantation (LT) for polycystic liver with massive hepatomegaly. After an unsuccessful attempt to defenestrate the cyst, they performed hepatectomy for the native liver during LT accomplishing a left hepatectomy followed by a right hepatectomy because the massive hepatomegaly resulting from the enlarged liver cysts caused a very small surgical space, thus making the classic dissection of the hilar structures extremely difficult.

Transplantation Proceedings, 2009

Living-related donor liver transplantation is the newest and both technically and ethically most ... more Living-related donor liver transplantation is the newest and both technically and ethically most challenging evolution in liver transplantation and has contributed to reduction in donor shortage. We briefly report the technical aspects of surgical procedures performed to achieve a partial graft from a live donor. Eighty-four adult and two pediatric recipients underwent living-related donor liver transplantation at our center. There were no donor deaths, and all patients returned to their normal activities after the perioperative period. This single-center experience may contribute to refinement of the surgical technique required to improve the outcome of these complex operations.

Transplantation, 2008

Pancreas transplantation (PTx) plays a pivotal role in the management of diabetes mellitus. Despi... more Pancreas transplantation (PTx) plays a pivotal role in the management of diabetes mellitus. Despite advances in surgical technique and immunosuppression, the current immunosuppressants account for an increased risk of metabolic complications in the recipients ( 1 ). The greater ...

Pediatric Transplantation, 2009

We report a case of a pediatric patient who received a right-extended liver transplant. The size ... more We report a case of a pediatric patient who received a right-extended liver transplant. The size of the recipient hepatic artery did not match with the donor right hepatic arterial stump. Moreover, recipient arterial anatomy made the direct anastomosis difficult or at increased risk for complications. The recipient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s splenic artery was then mobilized, divided and anastomosed to the donor&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s right hepatic artery. The spleen was preserved and revascularization through collaterals is demonstrated by Angio CT Scan. Doppler US of the transplanted liver demonstrated good flow through the liver and the patient was discharged with perfect liver function. Splenic artery is perfectly suited for hepatic artery anastomosis. The use of splenic artery is favored in particular situations as in the case of a pediatric recipient receiving a right-extended liver graft with small caliber artery.

Liver Transplantation, 2007

Journal of the American College of Surgeons, 2014

Prehepatic portal hypertension (PHPH), related to thrombosis and the cavernomatous transformation... more Prehepatic portal hypertension (PHPH), related to thrombosis and the cavernomatous transformation of the portal vein (PVC), is the single most common cause of portal hypertension in children. Although it can be secondary to the direct damage that relates to neonatal catheterization of the umbilical vein, the latter condition represents <25% of cases, 1-7 and no cause is found in most cases (idiopathic PHPH). Even less commonly, it relates to regional trauma (or surgery, eg, after liver transplantation), tumors, or infection (eg, peritonitis, abscess). Although in the adult age group there is a clear correlation between pre-existing thrombophilia and PVC, coagulation abnormalities are not found to be primarily related to PVC in children, in fact, only minor disorder types have been reported in a small proportion of patients, and most coagulation profile abnormalities observed are acquired and secondary. Anatomically speaking, the initial thrombotic process seems to mainly involve the portal vein trunk, to which it is eventually limited in the typical disease condition; a variable extension, either downstream into the intrahepatic radicals, or upstream into the splanchnic system, or both, can be observed. Remarkably, in children who have had catheterization of the umbilical vein, the processes more than likely start in an inverse manner, with the thrombus initiating within the liver as a consequence of the direct (chemical, physical, or infection) damage of the intrahepatic veins and, more precisely, the left portal system. 2,7,12 A diffuse splanchnic venous thrombosis is exceptional in children (although it is relatively common in adults with thrombophilia). Although part of the portal system is not reachable for decompressive surgery (as the portal trunk and sometimes other veins are thrombosed), various types of portosystemic shunt have been performed with success; the type of shunt depends on the venous anatomy of each patient and the team's preferences (mesocaval and various splenorenal types of shunt). 14-20

Journal of Surgical Research, 2011

In liver transplantation (LT), modern immunosuppressive protocol is focused on early corticostero... more In liver transplantation (LT), modern immunosuppressive protocol is focused on early corticosteroid (CS) weaning. The aim of the study was to investigate all early transplant-related complications using Clavien grading system, in order to identify a significant relation in two homogenous groups of consecutive liver transplanted patients, only different for steroid avoidance in immunosuppressive regimen. One group was treated with a tacrolimus-based CS-free immunosuppressive protocol, the other one underwent tacrolimus plus low dose CS therapy. The preoperative continuous variables analyzed were age, gender, model for end-stage liver disease (MELD) score, and the pre-allocation score for predicting survival following liver transplantation (P-SOFT). There were 39 patients in Group A (CS free) (37.9%), and 64 patients in Group B (CS on board) (62.1%). No statistically significant differences between the two groups were detected regarding the incidence and Clavien grade of complications (P = 0.116). No significant relation was revealed between Clavien rate of complications and tacrolimus-based CS-free immunosuppressive protocol, comparing the two subgroup of patient with P-SOFT score &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 6 and ≥ 6 (P = 0.193). This association was noted comparing the two subgroups on tacrolimus plus low dose CS regimen (P = 0.013). In this series, the use of CS in sick patient is associated with higher morbidity identified by the Clavien classification.

Journal of Pediatric Surgery, 2014

Portal vein aneurysms (PVAs) are usually located at the vein trunk or at its bifurcation, rarely ... more Portal vein aneurysms (PVAs) are usually located at the vein trunk or at its bifurcation, rarely intra-hepatic, or at the umbilical portion. Etiology remains unclear. Three children with PVA were identified over a 5-year period. PVA anatomy was assessed by Doppler Ultrasound, Angio CT/MRI, and trans-jugular retrograde portography. Three children with intrahepatic PVA (including the umbilical portion) were identified during assessment for pre-hepatic portal hypertension: all had splenomegaly and hypersplenism. One presented with massive variceal bleeding. In two cases, a portal vein cavernoma was found, and in the third a severe stricture at the portal bifurcation was observed. Restoration of portal venous flow was achieved by a meso-Rex bypass in two cases and transposing the PV into the Rex in one. High hepatopetal portal flow was restored immediately, with follow-up confirming long-term patency and resolution of signs of portal hypertension with time. These original observations suggest a common initial malformative pattern consisting of a portal venous stricture/web causing a post-stenotic aneurysmal dilatation of the intrahepatic portal branches complicated by thrombosis and cavernomatous transformation of the portal vein trunk. Importantly, the Meso-Rex bypass allows restoring a normal portal flow and cures the portal hypertension.

Digestive and Liver Disease, 2008

Annals of Transplantation, 2012

An ongoing shortage of organs for liver transplantation has led surgeons to continually modify cr... more An ongoing shortage of organs for liver transplantation has led surgeons to continually modify criteria for organ acceptance, which are now defined as extended criteria. The organ shortage becomes more problematic in retransplantation, in which the use of a limited resource such as a liver graft with anatomic variation must be weighed against the risk of a more difficult operation. We report 2 peculiar anatomic variations discovered in deceased donors for whole liver transplantation and confirmed at the back table: 1 with a huge biliary enlargement of the common hepatic duct and 1 with a celiac trunk aneurysm. In the first variation, any potential biliary reconstruction was thought to be at high risk of difficult outflow. The vascular anomaly did not preclude successful performance of a liver retransplantation. We briefly report the use of 2 liver grafts from deceased donors with rare anatomic variations, which is relevant to increasing the liver donor pool. To the best of our knowledge this is the first report of this biliary anomaly. In certain specific settings, strategies based on the appropriate donor-recipient match have allowed the use of grafts that otherwise would have been discarded due to celiac aneurysm.

Abdominal Imaging, 2005

Background: The radiologic evaluation of the transplanted bowel is largely unknown and rather com... more Background: The radiologic evaluation of the transplanted bowel is largely unknown and rather complex because it involves several techniques that depend on indications and times that have not been fully defined. Methods: From December 2000 to November 2002 in the Section of Radiology I of the University of Modena and Reggio Emilia (Modena, Italy), 11 patients with transplanted bowel were studied with different methods: traditional radiologic evaluation with contrast agent (all patients), evaluation of transit time with radiopaque markers (five patients), ultrasonographic (US) evaluation of the intestinal wall and Doppler US of the vascular axes (five patients), computed tomographic (CT) evaluation (all patients), and magnetic resonance (MR) evaluation of the bowel and the vascular axes (five patients). Traditional contrast examination enabled evaluation of the gastroesophageal transit and cardia functionality; anatomy and integrity of the anastomoses (proximal and distal); time of gastric emptying; morphology, tone, and kinesis of the transplanted small bowel loops and time of global transit. The study of transit with radiopaque markers was carried out in five patients to define the time of transit through the entire transplanted bowel, confirm recovery of intestinal motility, and identify possible abnormalities. The US examination was carried out in five patients to evaluate the morphology, thickness, and echo structural features of the intestinal loops. Color Doppler was performed to visualize the superior mesenteric artery and a wall arteriole of the sampled loop. CT examination was performed 2 to 4 weeks after surgery to evaluate the anatomy of the transplanted organs, arterial and venous anastomoses in case of complications identified with other Correspondence to: P. Torricelli;