How to face organ shortage in liver transplantation in an area with low rate of deceased donation

Despite advances in patient selection, surgical technique, immunosuppression, and peri-operative management, the need for liver replacement exceeds organ availability. Moreover, in Italy, where the overall rate of cadaver donation is 21 donors per million per year, there are areas of the country, such as Sicily, where the rate of cadaver donation is 9.3 donors per million per year. In fact, this ongoing shortage of organs has led surgeons to develop innovative techniques in an attempt to expand the donor pool, and clinicians are continually modifying criteria to accept organs, particularly the previously defined expanded or marginal donor organs, which are now defined as extended criteria donor. Rarely, in certain specific settings alternative strategies based on the appropriate donor- recipient match allowed the use of grafts that otherwise would have been discarded due to anatomic anomalies. The organ shortage becomes more problematic in the scenario of re-transplantation where the use of a limited resource such as a liver graft must be weighed against the risk of a more difficult surgery.