Experience of post-traumatic growth among parents of children with biliary atresia undergoing living-related liver transplantation: a descriptive phenomenological study

Objectives: To explore the experience of post-traumatic growth among parents of children with biliary atresia undergoing living-related liver transplantation.Methods: Participants were recruited within 2 weeks of their child's transplant surgery using purposive sampling. Transcripts were analyzed using Colaizzi's descriptive analysis framework, with collaborative analysis conducted using NVivo 12 software and a post-traumatic growth model.Results: Five themes were identified: (a) experiencing a devastating blow, (b) cognitive reconstruction under overwhelming pain, (c) an arduous journey of decision-making, (d) rebirth in adversity and (e) post-traumatic growth. Parents undergo significant post-traumatic responses to their child's diagnosis of biliary atresia and liver transplantation, marking two major traumatic events. During the diagnostic stage, parents experience intense post-traumatic reactions characterized by emotional fluctuations and intrusive thoughts. The early treatment phase represents a crucial time for parents to transition from `denial of reality' to `accepting diseases'. The process of liver transplantation is also a significant traumatic event, accompanied by a final hope. Parents in the stable period after liver transplantation feel fortunate, hopeful and grateful, and their post-traumatic growth manifests gradually.Conclusions: Parents' experience of post-traumatic growth involves dynamic changes. Tailored intervention strategies should be developed for different stages to enhance their post-traumatic growth and psychological well-being. During the early treatment stage, mental health professionals could provide cognitive interventions to encourage parents to express their negative emotions and guide them to develop positive cognition toward traumatic events. The coping strategies and increasing personal growth are also important. In the postoperative stage, mental health professionals need to fully evaluate the coping styles of parents, and encourage them to establish effective internal coping strategies, while classic gratitude interventions could be given during the post-traumatic growth stage. Future research could involve a longitudinal qualitative study to explore parents' post-traumatic growth experiences at different stages of their children's transplantation process.

The gut microbiota: an emerging modulator of drug resistance in hepatocellular carcinoma

Liver cancer is usually diagnosed at an advanced stage and is the third most common cause of cancer-related death worldwide. In addition to the lack of effective treatment options, resistance to therapeutic drugs is a major clinical challenge. The gut microbiota has recently been recognized as one of the key factors regulating host health. The microbiota and its metabolites can directly or indirectly regulate gene expression in the liver, leading to gut-liver axis dysregulation, which is closely related to liver cancer occurrence and the treatment response. Gut microbiota disturbance may participate in tumor progression and drug resistance through metabolite production, gene transfer, immune regulation, and other mechanisms. However, systematic reviews on the role of the gut microbiota in drug resistance in liver cancer are lacking. Herein, we review the relationships between the gut microbiota and the occurrence and drug resistance of hepatocellular carcinoma, summarize the emerging mechanisms underlying gut microbiota-mediated drug resistance, and propose new personalized treatment options to overcome this resistance.

Peculiarities of implantation of the right graft veins into the inferior vena cava during living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) is a crucial alternative to deceased donor transplantation, especially in regions with limited access to cadaveric organs. Right lobe graft implantation into the inferior vena cava (IVC) requires advanced surgical techniques to optimize outcomes and reduce complications.

AIM

To compare two venous anastomosis techniques—direct polytetrafluoroethylene (PTFE) grafting of V5-V8 veins to the IVC vs triangulation to the right hepatic vein (RHV)—in terms of graft viability and postoperative outcomes.

METHODS

A retrospective analysis was conducted on 96 patients who underwent LDLT with right lobe grafts between 2014 and 2023. Patients were divided into three groups: (1) No venous outflow reconstruction; (2) PTFE graft direct anastomosis to the IVC; and (3) PTFE graft anastomosis using triangulation to the RHV. Perioperative and postoperative outcomes, including bile duct complications, alanine aminotransferase/aspartate aminotransferase levels, and graft perfusion, were compared across groups.

RESULTS

Group 3 (triangulation to RHV) showed significantly improved venous outflow, fewer complications, and faster normalization of liver function tests. Bile duct complications were highest in group 1 (12.8%) and lowest in group 3 (7%). Doppler ultrasonography revealed better graft perfusion in group 3 compared to groups 1 and 2.

CONCLUSION

Triangulation to the RHV improves graft viability, reduces biliary complications, and enhances early postoperative outcomes compared to direct PTFE grafting to the IVC.

Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.

Discovery of tetracyclic 1,2,4-triazoline-fused dibenzo[b,f][1,4]oxazepine as a potent anti-colorectal cancer agent with good efficacy and low toxicity

A series of tetracyclic 1,2,4-triazoline-fused dibenzo[b,f][1,4]oxazepines were evaluated as novel anti-tumor agents. MTT assay conducted in four human cancer cell lines (SW620, A549, MCF-7, HepG2) showed that 1,2,4-triazoline-fused dibenzo[b,f][1,4]oxazepine decorated by a methyl group on the benzene ring of 1,2,4-triazoline moiety exhibited a superior antiproliferative activity against SW620 cells with a IC50 value of 0.86 μM. The above compound was thus chosen for further investigation on its anti-colorectal cancer (CRC) effect, and displayed inhibitory effects on the proliferation of HCT116 and CT26 cells with IC50 values of 0.96 μM and 1.71 μM, respectively. Furthermore, this compound could effectively suppress colony formation and induce cell cycle arrest and apoptosis in SW620 cells. Western blot analysis demonstrated that it exerted the anti-tumor activity through blocking the PI3K-AKT signaling pathway. Next, we examined its in vivo anti-tumor activity by establishing a subcutaneous CT26 xenograft model, and found that it significantly reduced the tumor sizes with limited toxicity. Collectively, these findings suggest that this compound could be utilized as a promising candidate against CRC.

Revolutionizing hepatobiliary surgery: Impact of three-dimensional imaging and virtual surgical planning on precision, complications, and patient outcomes

BACKGROUND

Hepatobiliary surgery is complex and requires a thorough understanding of the liver’s anatomy, biliary system, and vasculature. Traditional imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI), although helpful, fail to provide three-dimensional (3D) relationships of these structures, which are critical for planning and executing complicated surgeries.

AIM

To explore the use of 3D imaging and virtual surgical planning (VSP) technologies to improve surgical accuracy, reduce complications, and enhance patient recovery in hepatobiliary surgeries.

METHODS

A comprehensive review of studies published between 2017 and 2024 was conducted through PubMed, Scopus, Google Scholar, and Web of Science. Studies selected focused on 3D imaging and VSP applications in hepatobiliary surgery, assessing surgical precision, complications, and patient outcomes. Thirty studies, including randomized controlled trials, cohort studies, and case reports, were included in the final analysis.

RESULTS

Various 3D imaging modalities, including multidetector CT, MRI, and 3D rotational angiography, provide high-resolution views of the liver’s vascular and biliary anatomy. VSP allows surgeons to simulate complex surgeries, improving preoperative planning and reducing complications like bleeding and bile leaks. Several studies have demonstrated improved surgical precision, reduced complications, and faster recovery times when 3D imaging and VSP were used in complex surgeries.

CONCLUSION

3D imaging and VSP technologies significantly enhance the accuracy and outcomes of hepatobiliary surgeries by providing individualized preoperative planning. While promising, further research, particularly randomized controlled trials, is needed to standardize protocols and evaluate long-term efficacy.

The impact of high intrapatient variability of tacrolimus in peripheral blood mononuclear cells on the outcomes of kidney transplantation

BACKGROUND

Tacrolimus (TAC) is a key immunosuppressive agent for kidney transplantation, but its narrow therapeutic window and high intra-patient variability (IPV) complicate therapeutic drug monitoring. The clinical significance of PBMC-based IPV in predicting graft rejection and infection remains unclear.

METHODS

A total of 47 renal transplant recipients were enrolled. Intracellular TAC concentrations were analyzed and quantified using liquid chromatography-tandem mass spectrometry. The primary endpoint was the occurrence of the first adverse event, including acute rejection or infection of any etiology. The IPV of peripheral blood mononuclear cells (IPVPBMC) and whole blood (IPVWB) was calculated as the coefficient of variation of dose-corrected concentrations from day 14 to month 12 post-transplantation. A Cox proportional hazards model was employed to identify risk factors associated with kidney transplant outcomes.

RESULTS

Within the first year post-transplantation, the incidence of acute rejection was significantly higher in the High-IPVWB group compared to the Low-IPVWB group (P = 0.024). Moreover, the IPVWB in the rejection group was significantly higher than in the stable group (P = 0.034), and High-IPVWB and extended post-operative hospital stay served as independent predictors of rejection within the first year. Additionally, High-IPVPBMC, deceased donors, and longer hospital stay were the main risk factors for early infection following transplantation.

CONCLUSIONS

Both IPVPBMC and IPVWB are significantly associated with graft rejection and infection. Monitoring IPVPBMC and IPVWB within the first six months post-transplantation could help identify high-risk patients and improve clinical management strategies.

Association between everolimus combination therapy and cancer risk after liver transplantation: A nationwide population-based quasi-cohort study

The potential of everolimus (EVR) in reducing hepatocellular carcinoma (HCC) among recipients following liver transplantation has been reported. This nationwide population-based quasi-cohort study investigated whether combining EVR with calcineurin inhibitor therapy affects the risk of HCC and extrahepatic cancers compared to a time duration-matched cohort of recipients not receiving EVR. Using data covering the entire population from Korea, liver transplant recipients who had initiated immunosuppressants between June 2015 and February 2020 were included, and divided into 2 groups: the EVR combination and noncombination groups. We calculated adjusted hazard ratios (aHRs) and absolute risk reduction for the risk of HCC and extrahepatic cancer with EVR combination therapy using a Cox regression model. A time duration-matched retrospective cohort of 932 recipients in both of the groups was identified. The EVR combination group showed a lower risk of HCC (aHR, 0.53; 95% confidence interval, 0.30-0.94) and extrahepatic cancers (aHR, 0.30; 95% confidence interval, 0.14-0.63) compared to the noncombination group. The absolute risk reduction was 0.004 for HCC and 0.012 for extrahepatic cancer. The findings suggest that adding EVR to calcineurin inhibitor therapy reduces cancer risk in liver transplant recipients, highlighting the importance of considering cancer risk when choosing immunosuppressive therapies.

Safety and efficacy of simultaneous liver transplantation and sleeve gastrectomy in morbid obese patients with end-stage liver disease: The LT-SG study

In obese patients, metabolic dysfunction-associated steatotic liver disease is becoming a leading etiology of end-stage liver disease and HCC. Simultaneous liver transplantation and sleeve gastrectomy (LT-SG) have been proposed in the United States, but the safety and efficacy of the procedure have not been widely explored in Europe. Between January 2016 and December 2022, morbidly obese patients listed for liver transplantation at Tor Vergata University were enrolled in the LT-SG study. Primary outcomes were (1) safety expressed as 30- and 90-day overall survival and (2) major postoperative complications (Clavien-Dindo >IIIa). The secondary outcome was efficacy expressed as a 3-year %excess body mass index (BMI) loss. Eleven patients were enrolled in the study. The median BMI at transplantation was 42 (IQR 38-48). Indications of LT-SG were HCC (63.6%) and cirrhosis (36.4%). In 54% of cases, donors had high-risk characteristics (eurotransplant donor risk index >1.6). The 30- and 90-day overall survival were 63.6% and 54.5%, respectively. All deaths occurred in patients with P-SOFT >15 or in patients who had at least 3 of the following characteristics: >60 years, BMI >45, metabolic syndrome, MELD >25 or eurotransplant donor risk index >1.6. The 6 months, 1, 2, and 3 years %excess BMI loss was 73%, 60%, 50%, and 43%, respectively. LT-SG is a complex procedure that may carry excess risk in an unselected population. It should be considered only in highly selected patients. Standard donors are recommended, and prioritization of severely obese patients on the waiting list should be considered.

Comparing the performance of 3 sarcopenia definitions for predicting adverse events prior to liver transplant

BACKGROUND

Sarcopenia is a syndrome of severe muscle wasting, associated with adverse outcomes related to liver transplantation (LT). There are several approaches used to identify sarcopenia. We aimed to investigate the prevalence of sarcopenia using 3 different criteria and determine how these performed in relation to clinical outcomes.

METHODS

The cohort study included 237 adults with cirrhosis referred for LT. Sarcopenia was identified using (1) CT-defined; and the (2) original and (3) updated European Working Group on Sarcopenia in Older People criteria (EWGSOP1 and 2). Logistic regression was used to estimate OR and 95% CI for the relationships between sarcopenia and receiving an LT, unplanned admissions pre-LT, surgical complications, and length of stay for the LT admission. Fine-Gray competing risk analysis explored the impact of sarcopenia on receiving an LT and unplanned admissions. The AUC determined the predictive utility of the criteria.

RESULTS

The prevalence of CT-defined sarcopenia (52%) was more than twice and 4-fold that of EWGSOP1-defined (22%) and EWGSOP2-defined (11%) sarcopenia, respectively. No criteria demonstrated a significant association with time to LT nor the time to unplanned admissions pre-LT. Similarly, none of the 3 criteria had superior predictive utility for the clinical outcomes for unplanned hospital admissions pre-LT of receiving an LT, with all 3 criteria having identical moderate AUCs for unplanned admissions (0.70) and similar weak AUCs (≤0.55) for the likelihood of receiving an LT.

CONCLUSIONS

Sarcopenia in patients undergoing LT evaluation is prevalent. EWGSOP criteria appear to offer no advantage over CT-only criteria in identifying patients at increased risk of adverse LT outcomes. Bedside measures of muscle function may be of benefit in tracking the effectiveness of interventions targeting sarcopenia.

Recipient prioritization and graft choice in liver transplantation for colorectal liver metastasis

PURPOSE OF REVIEW

Liver transplantation for metastatic colorectal cancer has been shown to be efficacious in the well selected patient. In the United States, there remains controversy on the appropriate selection criteria and optimal graft type to be utilized in these patients. Our group advocates for strict recipient selection and early access to quality grafts for these recipients.

RECENT FINDINGS

In the past two years, there has been an explosion of centers reporting outcomes after liver transplantation for colorectal liver metastases. In North America, the publications have focused on single center experiences. The group in Oslo has reported their long-term outcomes of all transplanted patients. The TransMet randomized controlled trial has demonstrated efficacy of liver transplantation with chemotherapy over chemotherapy alone.

SUMMARY

Liver transplantation for metastatic colorectal cancer is an efficacious procedure for the well selected patient. Regardless of graft type, potential liver transplant recipients with liver limited unresectable colorectal liver metastases should be evaluated with a strict criterion to determine eligibility. Once eligible, patients should receive early access to high quality grafts.

Precision Monitoring of Immunosuppressive Agent Concentrations in Cardiac Tissue of Pediatric Heart Transplant Recipients

BACKGROUND

Management of immunosuppressive therapy after heart transplantation is typically guided by blood trough levels. Although tissue concentrations of immunosuppressive agents reportedly correlate with acute rejection in liver and kidney allografts, data in pediatric heart transplant recipients remain limited.

METHODS

We enrolled 41 pediatric heart transplant recipients who underwent follow-up endomyocardial biopsy (EMB) between July 2021 and December 2023. For nine of those patients, serial data were collected up to 24 weeks post-transplantation. Myocardial tissue concentrations of tacrolimus (TAC), everolimus (EVR), mycophenolic acid (MPA), and mycophenolic acid glucuronide (MPAG) were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), while blood concentrations were quantified by LC-MS/MS or immunoassays.

RESULTS

Significant correlations were observed between myocardial and blood concentrations at EMB for TAC (r = 0.73, p < 0.0001), MPA (r = 0.79, p < 0.0001), and MPAG (r = 0.50, p < 0.0001). However, for EVR there was no significant correlation. Longitudinal analysis demonstrated that the tissue-to-blood TAC and EVR ratios decreased with age. No significant rejection events were observed during the study period, precluding the analysis of rejection risk.

CONCLUSION

Myocardial TAC, MPA, and MPAG concentrations are associated with blood levels, whereas those of EVR showed no significant correlation. Further, the tissue perfusion efficiencies of TAC and EVR decreased with age. This study highlights the value of LC-MS/MS for immunosuppressant monitoring after pediatric heart transplantation.

Development and validation of a new prognostic tool for hepatocellular carcinoma undergoing resection: The Weighted Alpha-Fetoprotein Tumor Burden Score (WATS)

PURPOSE

This study aimed to develop and validate a novel prognostic index, the Weighted Alpha-Fetoprotein Tumor Burden Score (WATS), for predicting outcomes in hepatocellular carcinoma (HCC) patients undergoing resection.

MATERIALS AND METHODS

A total of 772 resected HCC patients were included. WATS was developed and validated using an 8:2 cohort split. The score was derived from multivariate Cox regression, resulting in the formula: WATS = 0.73 × tumor number +0.17 × tumor size +0.1 × ln AFP. The time-dependent ROC curve assessed the score's predictive ability, while restricted cubic splines evaluated the dose-response relationship between WATS and prognostic outcomes. Kaplan-Meier curves and multivariate Cox regression further validated the prognostic accuracy.

RESULTS

In the training cohort, AUCs for progression-free survival (PFS) at 1, 2, 3, 4, and 5 years were 0.683, 0.664, 0.661, 0.633, and 0.620, respectively; for overall survival (OS), they were 0.757, 0.732, 0.703, 0.672, and 0.670, respectively. In the validation cohort, AUCs for PFS were 0.711, 0.654, 0.671, 0.662, and 0.684, respectively; for OS, they were 0.724, 0.688, 0.642, 0.698, and 0.721, respectively. WATS outperformed other complex indicators and staging systems. RCS analysis showed a linear relationship between WATS and outcomes. The nomogram based on WATS demonstrated excellent discrimination, calibration, and clinical benefit.

CONCLUSION

WATS is a novel, reliable prognostic tool for HCC post-resection, offering enhanced patient stratification and risk assessment, thereby improving clinical management.

Effects of Probiotics on Liver Diseases: Current In Vitro and In Vivo Studies

Various types of liver or hepatic diseases cause the death of about 2 million people worldwide every year, of which 1 million die from the complications of cirrhosis and another million from hepatocellular carcinoma and viral hepatitis. Currently, the second most common solid organ transplant is the liver, and the current rate represents less than 10% of global transplant requests. Hence, finding new approaches to treat and prevent liver diseases is essential. In liver diseases, the interaction between the liver, gut, and immune system is crucial, and probiotics positively affect the human microbiota. Probiotics are a non-toxic and biosafe alternative to synthetic chemical compounds. Health promotion by lowering cholesterol levels, stimulating host immunity, the natural gut microbiota, and other functions are some of the activities of probiotics, and their metabolites, including bacteriocins, can exert antimicrobial effects against a broad range of pathogenic bacteria. The present review discusses the available data on the results of preclinical and clinical studies on the effects of probiotic administration on different types of liver diseases.

Liver metastases from colorectal cancer: A joint ESSO-EAHPBA-UEMS core curriculum collaboration

Colorectal liver metastases (CRLM) are a major indication for liver surgery in Europe, highlighting the need for standardized knowledge and training in surgical oncology. The European Society of Surgical Oncology (ESSO) has updated its core curriculum to provide a structured framework for education. Previous publications have addressed pancreatic, hepatocellular, and biliary tract cancers to support candidates preparing for the European Board of Surgery Qualification (EBSQ) exams in Surgical Oncology and Hepato-Pancreato-Biliary Surgery. However, a dedicated guide for CRLM remains absent. This article aims to fill that gap by offering a structured reference on CRLM, covering epidemiology, staging, genetics, and diagnosis of metastatic colorectal cancer. It also outlines multidisciplinary treatment strategies, including systemic, surgical, interventional, and palliative approaches. A structured literature review was conducted using PubMed to identify the most updated (inter)national management guidelines, prioritizing recent multicentre studies, systematic reviews, and meta-analyses published from January 2020 to January 2025. By bridging the gap between the ESSO core curriculum and detailed subspecialty training, this guide provides an essential resource for hepatobiliary surgeons and surgical oncologists. It serves as a valuable tool for those preparing for board examinations while promoting a standardized approach to CRLM education and management across Europe.

Evolving surgical techniques for hepatolithiasis: A retrospective analysis of 164 liver resections at a Western center

OBJECTIVE

To assess the outcomes of liver resection for primary intrahepatic lithiasis in a Western population, emphasizing the evolution of surgical techniques, including minimally invasive surgery, and their impact on patient outcomes.

METHODS

We performed a retrospective analysis of 164 patients who underwent liver resection for primary intrahepatic lithiasis at the Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy. Data included demographics, surgical techniques, complications, and long-term outcomes. Minimally invasive surgery was introduced and progressively adopted, and its outcomes were compared with open surgery using propensity score matching. This represents the largest Western dataset on liver resection for primary intrahepatic lithiasis published to date.

RESULTS

Liver resections were predominantly unilateral (96%) and commonly targeted the left liver (65%). Minimally invasive surgery use increased to 60% in the most recent period, showing reduced morbidity and shorter hospital stays compared with open surgery. Postoperative complications included bile fistula (16%) and septic events (30%). Independent risk factors for bile fistula were previous cholangitis (odds ratio, 4.7; P = .006) and major hepatectomy (odds ratio, 7.8; P = .002). Septic complications were associated with previous cholangitis (odds ratio, 2.3; P = .026), bilateral lithiasis (odds ratio, 4.0; P = .010), and major hepatectomy (odds ratio, 3.5; P = .003), with minimally invasive surgery providing a protective effect (odds ratio, 0.34; P = .028). Long-term follow-up revealed a 20% recurrence rate, linked to incomplete intraoperative stone clearance (hazard ratio, 2.645; P = .019) and biliary fistula (hazard ratio, 2.799; P = .016). Cholangiocarcinoma occurred in 6.6%, underscoring the need for surveillance.

CONCLUSION

Liver resection is an effective, curative treatment for primary intrahepatic lithiasis in Western populations. Minimally invasive surgery advancements significantly improve short-term outcomes, bridging the East-West gap in primary intrahepatic lithiasis management and highlighting the importance of individualized surgical approaches.

Liver transplantation for primary and secondary liver tumors: Patient-level meta-analyses compared to UNOS conventional indications

BACKGROUND AND AIMS

Liver transplant (LT) for transplant oncology (TO) indications is being slowly adopted worldwide and has been recommended to be incorporated cautiously due to concerns about mid-long-term survival and its impact on the waiting list.

APPROACH AND RESULTS

We conducted 4 systematic reviews of all series on TO indications (intrahepatic cholangiocarcinoma and perihilar cholangiocarcinoma [phCC]) and liver metastases from neuroendocrine tumors (NETs) and colorectal cancer (CRLM) and compared them using patient-level meta-analyses to data obtained from the United Network for Organ Sharing (UNOS) database considering conventional daily-practice indications. Secondary analyses were done for specific selection criteria (Mayo-like protocols for phCC, SECA-2 for CRLM, and Milan criteria for NET). A total of 112,014 LT were analyzed from 2005 to 2020 from the UNOS databases and compared with 345, 721, 494, and 103 patients obtained from meta-analyses on intrahepatic cholangiocarcinoma and phCC, and liver metastases from NET and CRLM, respectively. Five-year overall survival was 53.3%, 56.4%, 68.6%, and 53.8%, respectively. In Mantel-Cox one-to-one comparisons, survival of TO indications was superior to combined LT, second, and third LT and not statistically significantly different from LT in recipients >70 years and high BMI.

CONCLUSIONS

Liver transplantation for TO indications has adequate 5-year survival rates, mostly when performed under the selection criteria available in the literature (Mayo-like protocols for phCC, SECA-2 for CRLM, and Milan for NET). Despite concerns about its impact on the waiting list, some other LT indications are being performed with lower survival rates. These oncological patients should be given the opportunity to have a definitive curative therapy within validated criteria.

Postoperative hepatic insufficiency despite preoperative portal vein embolization: Not just about the volumetrics

BACKGROUND

Future liver remnant hypertrophy is the primary endpoint of portal vein embolization before major hepatectomy. However, even when adequate future liver remnant is achieved, postoperative hepatic insufficiency is not universally averted. We aimed to identify preoperative risk factors of postoperative hepatic insufficiency despite the use of portal vein embolization.

METHODS

Patients who underwent portal vein embolization followed by major hepatectomy at 6 academic medical centers were retrospectively reviewed. Postoperative hepatic insufficiency was defined as postoperative peak bilirubin >7 mg/dL. Preoperative variables associated with postoperative hepatic insufficiency were analyzed.

RESULTS

From 2008 to 2019, 164 patients underwent portal vein embolization followed by major hepatectomy. Twenty (12%) patients developed postoperative hepatic insufficiency. On univariate analysis, postoperative hepatic insufficiency was associated with older age, performance status, preoperative biliary drainage, smaller pre- and post-portal vein embolization future liver remnant volumes, diagnosis of cholangiocarcinoma/gallbladder cancer, and preoperative cholangitis. There was significant future liver remnant hypertrophy noted even in the setting of postoperative hepatic insufficiency (from 27% to 39%); however, degree of hypertrophy >5% (100% vs 93%, P = .6) and kinetic growth rate >2%/week (95% vs 82%, P = .3) did not differ between the postoperative hepatic insufficiency and non-postoperative hepatic insufficiency groups. On multivariate analysis, the diagnosis of cholangiocarcinoma/gallbladder cancer and preoperative cholangitis (postoperative hepatic insufficiency incidence 34% and 62%, respectively), but not future liver remnant volumetrics, were independently associated with postoperative hepatic insufficiency. Postoperative hepatic insufficiency raised post-hepatectomy 90-day mortality from 3.5% to 45% and hospitalization from 7 days to 16 days (both P < .001).

CONCLUSION

Postoperative hepatic insufficiency still occurs in 12% of patients after major hepatectomy despite preoperative portal vein embolization. In addition to traditional volumetric information, surgeons should be aware of preoperative cholangitis and cholangiocarcinoma/gallbladder cancer as powerful predictors of this fatal complication.

Deceased donor liver utilisation and assessment: Consensus guidelines from the European Liver and Intestine Transplant Association

Over the past two decades, the application of machine perfusion (MP) in human liver transplantation has moved from the realm of clinical exploration to routine clinical practice. Both in situ and ex situ perfusion strategies are feasible, safe, and may offer improvements in relevant post-transplant outcomes. An important utility of these strategies is the ability to transplant grafts traditionally considered too risky to transplant using conventional cold storage alone. While dynamic assessment and ultimately transplantation of such livers is an important goal for the international liver transplant community, its clinical application is inconsistent. To this end, ELITA (the European Liver and Intestine Transplant Association) gathered a panel of experts to create consensus guidelines regarding selection, approach, and criteria for deceased donor liver assessment in the MP era. An eight-member steering committee (SC) convened a panel of 44 professionals working in 14 countries in Europe and North America. The SC identified topics related to liver utilisation and assessment for transplantation. For each topic, subtopics were created to answer specific clinical questions. A systematic literature review was performed, and the panel graded relevant evidence. The SC drafted initial statements addressing each clinical question. Statements were presented at the in-person Consensus Meeting on Liver Discard and Viability Assessment during the ELITA Summit held from April 19-20, 2024, in Madrid, Spain. Online voting was held to approve statements according to a modified Delphi method; statements reaching ≥85% agreement were approved. Statements addressing liver utilisation, the definition of high-risk livers, and strategies and criteria for dynamic liver assessment are presented.

Enhancing the prognostic accuracy of the RETREAT score with AFP-L3 and DCP tumor markers

The RETREAT (Risk Estimation of Tumor Recurrence After Transplant) Score is a validated tool to predict post-transplant HCC recurrence risk. Alpha-fetoprotein (AFP) bound to Lens culinaris agglutinin (AFP-L3) and des-gamma-carboxyprothrombin (DCP) measured at transplant predict worse post-LT survival and may improve the RETREAT score. Our cohort comprised 284 patients transplanted for HCC who were within or downstaged to Milan, with 23 (8.1%) experiencing HCC recurrence. The modified RETREAT (mRETREAT) score assigns AFP-L3 ≥15% 2 points and DCP ≥7.5 ng/mL 3 points. Patients with a modified RETREAT score ≥4 showed a 3-year recurrence-free survival of 73.2% versus 97.8% recurrence-free survival if <4. In comparison, the original RETREAT score had a 3-year recurrence-free survival of 80.0% if ≥2 versus 98.0% if <2. mRETREAT demonstrated a superior AUC of 0.86, compared to the original RETREAT's 0.82, and enhanced calibration and accuracy with a lower Brier score (0.04). The integration of AFP-L3 and DCP into the RETREAT score appears to enhance the prediction of post-LT HCC recurrence. Given these promising results, further study in a larger multicenter cohort is warranted for empiric derivation and validation of a modified RETREAT score, including AFP-L3 and DCP.

Donor-Related Risk Factors for Normothermic Machine Perfusion in Liver Transplantation: A Meta-Analysis

BACKGROUND AND AIMS

During normothermic machine perfusion (NMP), a variety of criteria are used to gauge the suitability of an organ for transplantation. However, the relations between donor factors and these criteria are poorly understood. The aim of this meta-analysis was to investigate the association between donor-related risk factors and the decision to transplant a liver subjected to NMP.

METHODS

A comprehensive literature search was performed for articles published up to March 2025 in four databases, reporting livers subjected to NMP for viability assessment prior to transplantation. Effect size (ES) was calculated using Cohen's D and log odds ratio.

RESULTS

Out of 806 unique articles, 18 were included in this meta-analysis, encompassing 690 liver grafts that underwent NMP. Following viability assessment during NMP, utilisation rate was 82% from donors after brain death and 68% from donors after circulatory death (ES: 0.08, p = 0.88). Transplanted livers had shorter cold ischemia time (ES: -0.34, p = 0.003) and lower liver weight (ES: -0.53, p < 0.001). Donor age, BMI and donor warm ischemia time did not differentiate between transplanted and unused groups. Differences were observed in viability assessment for lactate clearance (ES: 2.0, p = 0.005), glucose metabolism (ES: 2.2, p < 0.001), bile production (ES: 1.0, p = 0.003) and pH (ES: 1.9, p < 0.001). Excellent outcomes, including 10% non-anastomotic strictures, 89% graft survival and 93% patient survival, were achieved in a large cohort of high-risk livers.

CONCLUSION

Cold ischemia time and liver weight were identified as donor-related risk factors, whereas donor type, age and donor warm ischemia time appear not to impact the decision to transplant during NMP.

The 2024 ILTS-ILCA consensus recommendations for liver transplantation for HCC and intrahepatic cholangiocarcinoma

Liver transplantation (LT) provides the best long-term survival outcomes for patients with liver cancer. As a result, the field of transplant oncology has grown greatly over the past few decades, and many centers have expanded their criteria to allow increased access to LT for liver malignancies. Center-level guidelines and practices in transplant oncology significantly vary across the world, leading to debate regarding the best course of treatment for this patient population. An international consensus conference was convened by the International Liver Transplantation Society and the International Liver Cancer Association on February 1-2, 2024, in Valencia, Spain to establish a more universal consensus regarding LT for oncologic indications. The conference followed the Delphi process, followed by an external expert review. Consensus statements were accepted regarding patient assessment and waitlisting criteria, pretransplant treatment (including immunotherapy) and downstaging, living donor LT, post-LT patient management, and patient- and caregiver-related outcomes. The multidisciplinary participants in the consensus conference provided up-to-date recommendations regarding the selection and management of patients with liver cancer being considered for LT. Although participants deferred to center protocols in many cases, there was great interest in safely expanding access to LT for patients with larger tumor burden and biologically amenable lesions.

Children Are Not Small Adults: Addressing Limited Generalizability of an Adult Deep Learning CT Organ Segmentation Model to the Pediatric Population

Deep learning (DL) tools developed on adult data sets may not generalize well to pediatric patients, posing potential safety risks. We evaluated the performance of TotalSegmentator, a state-of-the-art adult-trained CT organ segmentation model, on a subset of organs in a pediatric CT dataset and explored optimization strategies to improve pediatric segmentation performance. TotalSegmentator was retrospectively evaluated on abdominal CT scans from an external adult dataset (n = 300) and an external pediatric data set (n = 359). Generalizability was quantified by comparing Dice scores between adult and pediatric external data sets using Mann-Whitney U tests. Two DL optimization approaches were then evaluated: (1) 3D nnU-Net model trained on only pediatric data, and (2) an adult nnU-Net model fine-tuned on the pediatric cases. Our results show TotalSegmentator had significantly lower overall mean Dice scores on pediatric vs. adult CT scans (0.73 vs. 0.81, P < .001) demonstrating limited generalizability to pediatric CT scans. Stratified by organ, there was lower mean pediatric Dice score for four organs (P < .001, all): right and left adrenal glands (right adrenal, 0.41 [0.39-0.43] vs. 0.69 [0.66-0.71]; left adrenal, 0.35 [0.32-0.37] vs. 0.68 [0.65-0.71]); duodenum (0.47 [0.45-0.49] vs. 0.67 [0.64-0.69]); and pancreas (0.73 [0.72-0.74] vs. 0.79 [0.77-0.81]). Performance on pediatric CT scans improved by developing pediatric-specific models and fine-tuning an adult-trained model on pediatric images where both methods significantly improved segmentation accuracy over TotalSegmentator for all organs, especially for smaller anatomical structures (e.g., > 0.2 higher mean Dice for adrenal glands; P < .001).

Comparative Efficacy of Non-Pharmacological Interventions on Anxiety, Depression, Sleep Disorder, and Quality of Life in Patients With Liver Transplantation: A Systematic Review and Network Meta-Analysis

AIMS

To compare and rank the efficacy of different non-pharmacological interventions on anxiety, depression, sleep disorders, and the quality of life in liver transplantation patients.

BACKGROUND

In recent years, numerous non-pharmacological interventions have been developed to address anxiety, depression, sleep disorders, and the quality of life in liver transplantation patients. However, it remains unclear which non-pharmacological intervention serves as the most effective and preferred approach.

DESIGN

A systematic review and network meta-analysis in accordance with the PRISMA guidelines.

METHODS

Relevant randomised controlled trials were extracted from eight electronic databases. A network meta-analysis was then performed to evaluate the relative efficacy of the non-pharmacological interventions for liver transplantation patients. The quality of the data was assessed using the Cochrane Risk of Bias tool. We registered this study in PROSPERO, number CRD42023450346.

RESULTS

A total of 25 randomised controlled trials were included. Spouse support education combined with mindfulness training, individualised psychological intervention, and cognitive behavioural therapy were found to be significantly effective for both anxiety and depression. The top three interventions against anxiety were spouse support education combined with mindfulness training, individualised psychological intervention, and exercise rehabilitation training. Meanwhile, individualised psychological intervention, spouse support education combined with mindfulness training, and cognitive behavioural therapy were the top-ranked three interventions for reducing depression. Sleep hygiene education was the most effective to improve sleep disorders. Continuous care based on a mobile medical platform emerged as the most effective intervention in improving the quality of life.

CONCLUSION

Several non-pharmacological interventions appeared to be effective in treating anxiety, depression, sleep disorders, and improving the quality of life among liver transplantation patients. More high-quality clinical trials should be incorporated in the future to investigate the reliability of existing findings.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals should be encouraged to apply these promising non-pharmacological interventions during clinical care.

NO PATIENT OR PUBLIC CONTRIBUTION

This study did not directly involve patients or public contributions to the manuscript.

Deciphering the Relative Contribution of CYP3A4 Versus P-Glycoprotein for the Shared Substrate Cyclosporine-Commentary on Lown et al

The oral bioavailability of cyclosporine, a substrate of both CYP3A4 and P-glycoprotein, is subject to large inter-individual variability, which requires frequent monitoring of plasma concentrations. In 1997, the study by Lown et al. showed that-in addition to hepatic CYP3A4-the expression of P-gp in the intestine significantly influences the pharmacokinetics of cyclosporine in kidney transplant patients. The results contributed considerably to a better understanding of the function of the intestinal P-glycoprotein for drug clearance.

Pediatric Liver Transplant Pathology: An Update and Practical Consideration

This review provides a summary of the diagnostic approach to pediatric liver transplantation (LT) pathology. It emphasizes the pathologic features of T-cell-mediated rejection, the most common finding on liver allograft biopsies, and discusses other forms of rejection, including the less frequent antibody-mediated rejection. The article incorporates insights from the recently published Banff 2022 Liver Group Meeting Report. Additionally, it covers other complications such as biliary and vascular issues, infections, and disease recurrence. Finally, the review summarizes the potential applications of novel technologies, including next-generation pathology and artificial intelligence, in the context of pediatric LT pathology.

Tumor biology characteristics score based on alpha-fetoprotein and protein induced by vitamin K absence or antagonist II as a predictor for recurrence and survival after curative resection for hepatocellular carcinoma: a multicenter cohort study

BACKGROUND

Current hepatocellular carcinoma (HCC) staging systems lack comprehensive assessment of tumor biologic characteristics. This study aimed to develop and validate a tumor biology characteristics score (TBCS) based on alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist II (PIVKA-II) to predict long-term oncologic outcomes after HCC resection.

METHODS

In this multicenter retrospective cohort study, patients who underwent curative resection for HCC between June 2018 and December 2022 were included. TBCS (range, 2-6 points) was calculated by combining preoperative AFP (<20, 20-199, and ≥200 ng/mL) and PIVKA-II levels (<40, 40-399, and ≥400 mAU/mL). Patients were stratified into low (2 points), medium (3-4 points), and high TBCS groups (5-6 points). The primary outcomes were recurrence-free survival (RFS) and overall survival (OS).

RESULTS

A total of 695 patients were analyzed; the low, medium, and high TBCS groups comprised 132 (19.0%), 233 (33.5%), and 330 patients (47.5%), respectively. Notably, 5-year RFS was 30.4%, 14.7%, and 9.7%, whereas 5-year OS was 42.1%, 35.5%, and 23.5% for low, medium, and high TBCS groups, respectively (both P <.001). Multivariate analysis identified TBCS as an independent predictor of both RFS (medium TBCS: hazard ratio [HR], 1.583; 95% CI, 1.219-2.057; P =.001; high TBCS: HR, 1.895; 95% CI, 1.473-2.438; P <.001) and OS (high TBCS: HR, 1.781; 95% CI, 1.353-2.343; P <.001).

CONCLUSION

The novel TBCS combining AFP and PIVKA-II effectively stratified patients with HCC into distinct prognostic groups after curative-intent resection, independently predicting both RFS and OS. This score may help identify high-risk patients for more intense postoperative recurrence surveillance and receipt of adjuvant therapies.

A novel nomogram to predict the recurrence of hepatocellular carcinoma after liver transplantation using extended selection criteria

BACKGROUND

Liver transplantations (LTs) with extended criteria have produced surgical results comparable to those obtained with traditional standards. However, it is not sufficient to predict hepatocellular carcinoma (HCC) recurrence after LT according to morphological criteria alone. The present study aimed to construct a nomogram for predicting HCC recurrence after LT using extended selection criteria.

METHODS

Retrospective data on patients with HCC, including pathology, serological markers and follow-up data, were collected from January 2015 to April 2020 at Huashan Hospital, Fudan University, Shanghai, China. Logistic least absolute shrinkage and selection operator (LASSO) regression and multivariate Cox regression analyses were performed to identify and construct the prognostic nomogram. Receiver operating characteristic (ROC) curves, Kaplan-Meier curves, decision curve analyses (DCAs), calibration diagrams, net reclassification indices (NRIs) and integrated discrimination improvement (IDI) values were used to assess the prognostic capacity of the nomogram.

RESULTS

A total of 301 patients with HCC who underwent LT were enrolled in the study. The nomogram was constructed, and the ROC curve showed good performance in predicting survival in both the development set (2/3) and the validation set (1/3) (the area under the curve reached 0.748 and 0.716, respectively). According to the median value of the risk score, the patients were categorized into the high- and low-risk groups, which had significantly different recurrence-free survival (RFS) rates (P < 0.01). Compared with the Milan criteria and University of California San Francisco (UCSF) criteria, DCA revealed that the new nomogram model had the best net benefit in predicting 1-, 3- and 5-year RFS. The nomogram performed well for calibration, NRI and IDI improvement.

CONCLUSIONS

The nomogram, based on the Milan criteria and serological markers, showed good accuracy in predicting the recurrence of HCC after LT using extended selection criteria.

Safety and efficacy of combined portal and hepatic vein embolisation in patients with colorectal liver metastases (DRAGON1): a multicentre, single-arm clinical trial

Background

Major liver resection is often required for complete clearance of colorectal liver metastases (CRLM). Patients with insufficient future liver remnant (FLR) volume/function are at high risk of post-hepatectomy liver failure (PHLF) and require FLR hypertrophy-inducing procedures to enable safe resection. The most recent variant of these procedures is combined portal and hepatic vein embolization (PVE/HVE). The DRAGON 1 trial evaluates the safety and efficacy of PVE/HVE, while assessing recruitment potential for the DRAGON 2 randomized trial.

Methods

DRAGON 1 is a prospective, single-arm, international, multicenter trial. Patients with upfront unresectable CRLM due to a small FLR were included. The primary outcome was the ability of centers to recruit three patients and perform PVE/HVE and liver resection without 90-day mortality. Secondary outcomes included recruitment capacity, PVE/HVE technical details, FLR volume changes, complications, and resection rates. The study is registered at ClinicalTrials.gov, identifier: NCT04272931.

Findings

In total, 102 patients were included from 43 centers. Twenty-four centers (24/43 = 56%) recruited three or more patients, and 20 centers (20/43 = 47%) achieved this without 90-day mortality. Of 96 patients undergoing PVE/HVE, no post-embolization mortality occurred, though major complications were reported in two patients. Resection was completed in 86 patients (86/96 = 90%), with seven patients (7/86 = 8%) dying within 90 days. PHLF grade B/C (International Study Group of Liver Surgery criteria) occurred in 19 patients (19/86 = 22%).

Interpretation

DRAGON 1 demonstrates that PVE/HVE is safe, with no embolization-related mortality, low morbidity, and high resection rates in upfront unresectable CRLM.

Funding

The Dutch Cancer Society, National Institute for Health and Care Research UK, Maastricht UMC+, Abbott Laboratories and Guerbet.

Stratifying risk in ACLF-3 patients: The impact of circulatory and respiratory failure on one-year post-transplant outcomes

BACKGROUND

In patients with Acute-on-Chronic Liver Failure grade 3 (ACLF-3), the number of organ failures (OF) before liver transplant (LT) is associated with poorer outcomes following LT. We hypothesized that ACLF-3 patients with circulatory and/or respiratory failure before LT would experience worse prognosis after LT.

METHODS

We analyzed ACLF-3 patients from the U.S. Scientific Registry of Transplant Recipients, categorized by OF combinations at the time of LT: 1) circulatory failure with other non-respiratory OF, 2) both circulatory and respiratory failures with other OF, 3) all other OF combinations excluding (1) and (2). Cox regression models assessed one-year mortality, and logistic regression examined one-year functional status.

RESULTS

Of 5054 ACLF-3 patients, 14 %(728/5054) died within one-year post-LT. The distribution was: 427 patients had circulatory failure with other OF, 1042 had circulatory and respiratory failure with other OF, and 3357 had all other possible combinations of OFs. Patients with both circulatory and respiratory failures experienced higher post-LT mortality than those with circulatory failure plus other OF (one-year Hazard Ratio (HR) for death: 1.32, 95 %CI: 1.08-1.62, p < 0.01). No differences were found between those with circulatory failure plus other OF and those with OF other than circulatory or respiratory. Patients with OF other than circulatory and respiratory failures had better one-year functional status compared to those with circulatory OF (OR for poor functional status: 0.73, 95 %CI: 0.54-0.98, p < 0.01).

CONCLUSION

Specific OF combinations affect post-LT outcomes in ACLF-3 patients. Combined respiratory and circulatory failure at LT time was associated with poorer outcomes, regardless of the number of OF.

Cross-organ hierarchy of HLA molecular mismatches in donor-specific antibody development in solid organ transplantations

Donor-specific antibodies (DSAs) against human leukocyte antigen (HLA) play a crucial role in antibody-mediated rejection, a major barrier to successful organ transplantation. Donor-recipient HLA molecular incompatibility critically influences DSA susceptibility, commonly assessed by analyzing mismatches in the HLA eplet repertoire. This study, including six distinct liver, lung, and kidney transplant cohorts from two centers (978 donor-recipient pairs), explores associations between individual eplet mismatches and DSA development. Certain mismatched eplets are strongly linked to DSA development, while others show weaker associations, a trend consistent across different organ types. Machine learning leverages these hierarchical associations to develop an eplet risk score (ERS), outperforming traditional eplet mismatch assessments. Furthermore, T cell proliferation in mixed lymphocyte reaction in vitro correlates with the ERS, attenuated by antibody-mediated inhibition of a mismatched DSA-associated eplet. These results establish the differential immunological impacts of mismatched HLA eplets as integral in clinical practice and therapeutic innovation.

Precision in Liver Surgery: A Comparative Analysis of Volumetry Techniques

BACKGROUND

Future liver remnant volume (FLRV) is a critical determinant of safety for hepatectomy. This study assesses concordance between imaging-based measured FLRV (mFLRV), and body surface area (BSA)-based standardized FLRV (sFLRV), and their association with post-hepatectomy complications.

MATERIALS AND METHODS

All major hepatectomy between 1999 and 2021 were assessed for agreement between mFLRV and sFLRV using concordance correlation coefficient (CCC). Association between each method and major postoperative complications, post-hepatectomy liver failure (PHLF), or grade 4/5 morbidity was compared using logistic regression model and area under the receiver-operating characteristic (AUC) curve to evaluate the discriminatory power of each volumetry method separately.

RESULTS

A total of 1749 patients were included, 49% were female, median age was 60 years, 70.2% had metastatic disease, and 49.7% received preoperative chemotherapy. Median sFLRV (41.3%) was higher than mFLRV (39.4%). Major complications were observed in 5.1% (n = 90). Concordance between mFLRV and sFLRV was moderate, CCC = 0.78 (95% CI 0.75-0.79) but was poor (CCC = 0.39; 95% CI 0.32-0.43) among patients with mFLRV ≤ 35% (n = 528). In this subset, sFLRV overestimated remnant volume in 63% (n = 333) with ≥ 5% overprediction in 145 patients (27.5%). Factors associated with ≥ 5% variation were lower weight (p = 0.003), lower BMI (p = 0.003), and lower BSA (p = 0.004). Both methods performed similarly in predicting major complications with AUC of 0.64 and 0.63 for sFLRV and mFLRV, respectively.

CONCLUSIONS

Imaging- and BSA-based volumetry are moderately correlated, with poor concordance among patients with smaller FLRV where sFLRV overestimated remnant volume. Both techniques can be safely used for volumetric assessment before major hepatectomy.

The Italian Score for Organ Allocation: A Ten-Year Monocentric Retrospective Analysis in Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND

The Italian Score for Organ Allocation (ISO), a transplant benefit oriented allocation system, was introduced in Italy in 2016. The main objective of this study is to identify risk factors for Drop-Out in hepatocellular (HCC) patients enlisted for LT before (Pre-ISO Era) and after ISO (ISO Era) introduction, while the secondary objective is to evaluate the survival results.

METHODS

CIFs for liver transplantation and Drop-Out were estimated and compared between eras. Factors associated with Drop-Out were identified through multivariable competing risks regression. Survival results were compared using the log-rank test.

RESULTS

Between 2011 and 2020, 410 patients with HCC were listed for LT. We observed 103 vs. 217 LT and 49 vs. 41 Drop-Outs (p < 0.001) during the Pre-ISO and ISO Era, respectively. In the multivariable analysis, ISO ([sHR] 0.43; 95%CI 0.28-0.66, p < 0.001) and Alcoholic Cirrhosis ([sHR] 0.27, 95%CI 0.11-0.70; p = 0.007) were revealed to be protective factors for Drop-Out. One year after listing, the CI for Drop-Out decreased from 13.2% to 6.2% (p = 0.02). Despite no differences observed in post-LT survival, a significant difference in the intention-to-treat survival from enlisting was found (p = 0.0019).

CONCLUSIONS

Among other factors, ISO results were protective for the Drop-Out risk in HCC patients awaiting LT, with a benefit in ITT-OS survival.

Etiology and Risk Factors for Splanchnic Vein Thrombosis in Non-Cirrhotic, Non-Neoplastic Patients: A Narrative Review

Splanchnic vein thrombosis (SVT) is a heterogeneous group of disorders affecting the portal, mesenteric, splenic, and hepatic veins. While frequently associated with liver cirrhosis and malignancy, SVT also occurs in non-cirrhotic, non-neoplastic patients. This narrative review evaluates the epidemiology and risk factors for SVT in this population. The prevalence and incidence of SVT in non-cirrhotic, non-neoplastic patients remain incompletely characterized, with estimates varying widely across studies. The clinical significance of SVT relates to potential complications, including intestinal ischemia, portal hypertension, and a possible underlying systemic disorder. Risk factors for SVT can be categorized into local abdominal conditions, thrombophilias, and systemic disorders. Local factors include inflammatory bowel disease, pancreatitis, abdominal surgery, and trauma. Thrombophilias, both inherited and acquired, are significant contributors to SVT risk. Systemic conditions associated with SVT include autoimmune disorders, pregnancy, hematological diseases, and infections. The complex interplay of these risk factors highlights the need for a comprehensive evaluation of SVT patients. Early recognition and management of these conditions can prevent potentially life-threatening complications and guide decisions regarding anticoagulation and long-term follow-up.

Enhancing Organ Availability: Increased DCD Liver Utilization Following Implementation of a Normothermic Machine Perfusion Program

In Australia, donation after circulatory death (DCD) liver utilization remains below that of comparable healthcare systems in the Northern Hemisphere, due to concerns over higher rates of early hepatocellular dysfunction/nonfunction and ischemic cholangiopathy, coupled with limited organ availability and challenging organ transport logistics. To address this, the Queensland Liver Transplant Service introduced the OrganOx Metra normothermic machine perfusion (NMP) device in 2018. Positive outcomes were initially reported for 10 livers, including five DCD livers deemed unsuitable for static cold storage (SCS). This retrospective, historical-control study evaluated whether NMP availability improved DCD liver utilization. The NMP era (June 2018 to June 2021) was compared to the SCS era (June 2015 to June 2018), with all DCD activity included, regardless of the preservation technique. Donor data were sourced from the DonateLife Queensland database, and patient outcome data were gathered from the electronic medical records of Princess Alexandra Hospital, Queensland. The NMP era showed significantly higher rates for medically suitable DCD offers(90.5% vs. 66.1%, p < 0.01), higher rates of formal DCD offers (88.1% vs. 61.0%, p < 0.01), greater DCD planned retrieval rate (56.6% vs. 23.7%, p < 0.01), and higher implantation rate as a proportion of all DCD offers (18.8% vs. 5.9%, p < 0.01). More potentially viable DCD grafts were declined because of the lack of suitable recipients, suggesting an abundance of available livers and reduced waitlist. Despite increased DCD utilization and a higher mean modified UK DCD risk score in the NMP era (1.5 vs. 0, p = 0.05), there was no increase in early allograft dysfunction, primary nonfunction, ischemic cholangiopathy, or re-transplantation.

Chimerism and immunological tolerance in solid organ transplantation

In solid organ transplantation, chimerism inevitably occurs via the coexistence of donor-derived cells from the graft and host cells throughout the recipient. However, long-term immunosuppressive treatment is needed to suppress host immune responses to the foreign organ graft. The deliberate induction of stable mixed bone marrow chimerism to achieve donor-specific immunological tolerance in solid organ graft recipients is an ambitious goal that may significantly contribute to the long-term survival of solid organ grafts and their recipients. While this strategy has been effectively established in laboratory animals and some promising clinical case series have been reported, widespread clinical application is still limited by the toxicity of the necessary conditioning regimens. On the other hand, the naturally occurring chimeric state resulting from the bidirectional transplacental cell trafficking during pregnancy, the so-called feto-maternal microchimerism, can also induce immune tolerance and thus influence the outcome of mother-to-child or child-to-mother organ transplantation. This review provides an overview of the field's historical development, clinical results, and underlying principles of (micro) chimerism-based tolerance.

Investigating the Causality and Pathogenesis of Primary Sclerosing Cholangitis in Colorectal Cancer Through Mendelian Randomization and Bioinformatics

Introduction: The relationship between autoimmune diseases and cancer risk has been increasingly studied. Colorectal cancer, a common malignancy with high morbidity and mortality, has been closely linked to inflammatory bowel disease (IBD) in previous research. However, the association and pathogenesis between primary sclerosing cholangitis (PSC) in autoimmune diseases and colorectal cancer remain incompletely understood. Our study directly investigated the relationship between PSC and colorectal cancer, excluding the influence of IBD, and provided new insights into this association. Methods: Mendelian randomization (MR) analysis was first used to investigate the potential causal relationship between PSC and colorectal cancer. Sensitivity analyses were performed to verify the reliability of the MR results. Transcriptomic data were then analyzed based on the Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO) database, combined with clinical prognostic data for the final identification of core differential genes. Results: MR analysis demonstrated that genetic susceptibility to PSC was associated with an increased risk of colorectal cancer in a European population cohort (ratio: 1.038, 95% confidence interval: 1.016-1.060, and p < 0.001). Furthermore, sensitivity analyses confirmed the robustness of the MR results. Univariate and multivariate Cox analyses identified five core genes: NEDD4L, PPP1R1A, NRG1, KCNJ16, and NECAB2. Patients grouped according to high or low expression of NRG1 showed significant differences in their prognosis (p < 0.001). Conclusion: Our MR study provides evidence that genetic susceptibility to PSC is significantly associated with an increased risk of colorectal cancer in European populations. Analysis of transcriptomic data suggests that NRG1 can be used as a novel biomarker to predict patient prognosis when colorectal cancer and PSC coexist.

TRIM29 promotes liver metastasis via enhancing hepatic colonization by stabilizing FAM83H to regulate keratin network in colorectal cancer

Liver metastasis is a frequent and severe event of colorectal cancer (CRC), and patients with liver metastases typically exhibit poor prognosis, high recurrence rates and low responsiveness to treatment. However, the precise molecular mechanisms underlying the liver metastasis in CRC remain poorly understood. In this study, through a comprehensive multi-omics approach, we here identify CRC cells with high tripartite motif-containing protein 29 (TRIM29) expression as the critical subset responsible for liver metastasis. Omics-sequencing pathway analyses combined with in vitro functional assays revealed that CRC cells expressing high TRIM29 expression displayed enhanced cell adhesion, proliferation and liver metastasis capabilities. Mechanistically, TRIM29 interacts with FAM83H and stabilizes it by reducing its ubiquitination and degradation, thereby redistributing cellular keratins, which activates the NF-κB pathway and upregulates PLXNB2 expression to enhance cell adhesion and proliferation to promote hepatic colonization and drive CRC liver metastasis. Interestingly, TRIM29 upregulates the expression of PLXNB2 that can bind to the hepatocyte-specific ligand SEMA4G. Importantly, targeting TRIM29-FAM83H-elicited keratin redistribution and PLXNB2 elevation effectively abrogated CRC liver metastasis. Our findings position TRIM29 as a central driver of liver metastasis in CRC and highlight its potential as a therapeutic target for reducing the risk of liver metastasis in patients.

Laparoscopic resection of a cecal carcinoma with a Retzius vein shunt: A case report

RATIONALE

A Retzius shunt between the ileocecal vein and inferior vena cava is rare. To avoid major hemorrhage due to shunt injury, it is essential to evaluate vascular abnormalities on preoperative imaging and to confirm anatomic structures in detail during the operation.

PATIENT CONCERNS

A 71-year-old woman with diabetes and asthma developed anaemia.

DIAGNOSES

She was diagnosed with cecal cancer by endoscopy and found to have a venous malformation forming a Retzius shunt from the ileocecal vein to the inferior vena cava on computed tomography.

INTERVENTION

Laparoscopic ileocecal resection was performed. Colonic mobilization and resection of the ileocecal vessels were performed while minimizing traction on the shunt. After confirming the anatomy, the Retzius shunt was resected without complications.

OUTCOMES

The patient experienced an unremarkable postoperative clinical course without complications.

LESSONS

This case involved a rare vascular anomaly associated with colorectal cancer, characterized by an abnormal blood vessel connecting the inferior vena cava and mesenteric veins. When abnormal vessels are detected on preoperative abdominal computed tomography, a Retzius shunt should be considered. Detailed review of the imaging, careful surgical manipulation to avoid shunt damage, and thorough anatomical verification, are important to perform a safe operation.

Surgical management of Caroli disease in a low-mid income country: a single-center study and review of literature

INTRODUCTION

Caroli disease is an uncommon congenital condition characterized by non-obstructive intrahepatic bile duct dilation. When coupled with liver fibrosis or cirrhosis, it is termed Caroli syndrome. This disorder can lead to the development of gallstones, inflammation of the bile ducts, and an elevated susceptibility to cholangiocarcinoma. Typically, Caroli disease presents with involvement in less than 20% of the liver, predominantly affecting a single lobe (either left or right). Monolobar disease can often be effectively addressed through liver resection, while bilobar disease may necessitate the consideration of liver transplantation.

METHODS

A retrospective study was undertaken involving patients diagnosed with Caroli disease who underwent liver resection. The research included cases from Surgery B Department at Ibn Sina University Hospital in Rabat, covering the period from January 2010 to January 2023.

RESULTS

Nine patients who underwent liver resection for Caroli disease were identified, with an average age of 54 years (range: 17-76), and 44.4% (n = 4) being females. The study comprised 6 cases with disease limited to the left lobe and 3 to the right. The average time interval between initial symptoms and the definitive diagnosis was 4 years (range: 0-24 years). Surgical procedures included left lobectomy in 4 cases, left hepatectomy in 3 cases, right hepatectomy in 1 case, and sub-segmentectomy in 2 cases. Biliodigestive anastomosis was performed in 4 cases. Complications occurred in 2 patients (22.2%), and synchronous cholangiocarcinoma was observed in a single case (11.1%).

CONCLUSION

Consideration of Caroli disease as part of the differential diagnosis is crucial in cases of recurrent cholangitis. Liver resection stands out as the treatment of choice for patients with localized Caroli disease. The critical importance of early intervention is highlighted by the potentially fatal consequences of delayed diagnosis or treatment.

Laparoscopic associating liver partition and portal vein ligation for staged hepatectomy for colorectal liver metastases: A single-center experience

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a procedure used for patients with initially unresectable colorectal liver metastases (CRLM). However, the procedure has been reported to be associated with high morbidity and mortality. Laparoscopic ALPPS has recently been reported as a minimally invasive technique that reduces perioperative risks.

AIM

To assess the safety and feasibility of full laparoscopic ALPPS in patients with CRLM.

METHODS

A retrospective analysis was conducted on all consecutive patients with CRLM who underwent full laparoscopic ALPPS at the Sixth Affiliated Hospital of Sun Yat-sen University between March 2021 and July 2024.

RESULTS

Fifteen patients were included, 13 with synchronous liver metastases. Nine patients had more than five liver tumors, with the highest count being 22. The median diameter of the largest lesion was 2.8 cm on preoperative imaging. No extrahepatic metastases were observed. RAS mutations were detected in nine patients, and 14 underwent preoperative chemotherapy. The median increase in future liver remnant volume during the interstage interval was 47.0%. All patients underwent R0 resection. Overall complication rates were 13.3% (stage 1) and 53.3% (stage 2), while major complication rates (Clavien-Dindo ≥ IIIa) were 13.3% (stage 1) and 33.3% (stage 2). No mortality occurred in either stage. The median hospital stay after stage 2 was 10 days.

CONCLUSION

Full laparoscopic ALPPS for CRLM is safe and feasible, with the potential for reduced morbidity and mortality, offering radical resection opportunities for patients with initially unresectable CRLM.

Comparison of outcomes between surgery and non-surgery after conversion therapy for advanced gastric cancer with unresectable factors: a systematic review and meta-analysis

BACKGROUND

Advanced gastric cancer (AGC) with unresectable factors presents a significant treatment challenge. Conventional treatments such as systemic chemotherapy, radiotherapy, and immunotherapy can delay disease progression but often yield limited outcomes. For stage III-IV gastric cancer with unresectable factors, conversion therapy based on chemotherapy can achieve tumor downstaging, providing a subset of patients with the opportunity for curative surgery. However, the efficacy of multimodal approaches combining chemotherapy, with or without immunotherapy, and conversion surgery compared to chemotherapy alone remains controversial.

METHODS

We conducted a systematic review and meta-analysis of high-quality studies published between January 2014 and November 2024, assessing the role of surgery following conversion therapy in advanced gastric cancer. Relevant studies were retrieved from PubMed, Embase, and Web of Science databases. All included studies were observational; no randomized trials were available. Clinical data, including overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and adverse event (AE) rates, were analyzed using RevMan 5.4.

RESULTS

Twelve observational cohort studies were included. Conversion surgery(CS) was associated with improved 1-year, 3-year, and 5-year OS rates (RR 0.38, 95% CI: 0.31-0.47; RR 0.64, 95% CI: 0.54-0.76; RR 0.77, 95% CI: 0.65-0.91, respectively) and increased 1-year and 3-year PFS rates (RR 0.57, 95% CI: 0.49-0.99; RR 0.67, 95% CI: 0.57-0.78, respectively). No significant difference in AE rates was observed between groups.

CONCLUSIONS

Conversion surgery following chemotherapy in stage III-IV gastric cancer is associated with improved OS and PFS in observational studies. However, these findings may reflect inherent prognostic differences between groups, as surgery was only feasible for chemotherapy responders. Prospective trials are needed to validate causality.

Recent Strategies to Attenuate Hepatocellular Carcinoma Recurrence After Liver Transplantation: A Narrative Review

Hepatocellular carcinoma (HCC) is one of the leading causes of liver transplant worldwide. While liver transplantation offers a survival advantage for early-stage HCC patients, post-transplant recurrence remains a significant concern, affecting up to 15% of recipients. We sought to conduct a comprehensive review related to HCC recurrence after liver transplant. Tumor-related factors such as poor differentiation, vascular invasion, and elevated tumor biomarkers like alpha-fetoprotein are key predictors of recurrence. Donor-related factors, including graft type and surgical procedures, can also influence outcomes, though their effects are less conclusive. Advancements in patient selection criteria and scoring systems, such as the Milan Criteria and RETREAT score, have improved risk stratification by incorporating tumor size, biomarkers, and response to pre-transplant treatment. Despite these measures, recurrent HCC after transplantation poses treatment challenges. Curative approaches such as resection are feasible for localized or oligometastatic recurrence and offer the best outcomes when applicable. Locoregional treatments, including ablation and transarterial chemoembolization, provide options for unresectable cases but have limited long-term efficacy. Systemic therapies, including targeted agents like sorafenib, regorafenib, and lenvatinib, have shown modest benefits in managing advanced recurrent HCC. Emerging immunotherapy approaches hold promise but face unique challenges due to the required immunosuppression in transplant recipients. Multidisciplinary evaluation remains essential for tailoring treatment plans. Future efforts should focus on refining predictive tools and exploring novel therapies to improve survival outcomes for patients with recurrent HCC after liver transplantation.

Can Intra-Operative Ablation-Specific Features Based on Ultrasound Fusion Imaging be Used to Predict Early Recurrence of Hepatocellular Carcinoma After Microwave Ablation: A Proof-of-Concept Study

Purpose

Intra-operative factors are crucial to early recurrence of hepatocellular carcinoma (HCC) after microwave ablation (MWA), but few models have been developed based on intra-operative data to predict HCC recurrence after MWA. To quantify the intra-operative factors associated with MWA and establish an artificial intelligence (AI) model for predicting early recurrence of HCC after ablation based on contrast-enhanced ultrasound (CEUS) fusion imaging.

Patients and Methods

79 hCC patients, who underwent MWA with one-year follow-up and intraoperative CEUS fusion imaging assessment were retrospectively included. Three classifiers (support vector machine (SVM), random forest (RF), and multilayer perceptron (MLP)) were developed to predict early HCC recurrence from CEUS fusion images. Thirteen ablation-specific features were defined and screened using minimum redundancy maximum relevance (mRMR), and leave-one-out cross-validation (LOOCV) was adopted for performance evaluation. Comparative analyses were conducted among classifiers and between a senior interventional doctor and the best classifier in terms of the area under the receiver operating characteristic curve (AUC).

Results

Of 79 eligible patients who were included, 22 were in the early-recurrence (age 60.18 ± 10.97; 20 males) and 57 were in the non-early recurrence (age 58.81 ± 10.89; 50 males). Six features were selected out by mRMR for early recurrence prediction and AUCs of three models were 0.84 (95% CI: 0.74, 0.94) 0.79 (95% CI: 0.69, 0.89) and 0.77 (95% CI: 0.67, 0.88) (p = 0.20 and 0.23 for SVM and RF, respectively), which was significantly better than that achieved by senior doctor's assessment (AUC, 0.56; 95% CI: 0.44, 0.68; p = 0.002 for MLP).

Conclusion

The prediction model based on ablation-specific features using intra-operative ultrasound fusion imaging data was feasible to predict early recurrence of HCC after MWA and showed great potential in guiding the real-time adjustment of the intra-operative ablation strategy so as to achieve precise ablation.

Role of Lymphopenia in Early prediction of Infection Following Orthotopic Liver Transplantation in Cirrhotic Patients

Infections remain a main cause of morbidity and mortality following orthotopic liver transplantation (OLT). Patients with end-stage liver cirrhosis exhibit a deregulation of their immune response, making them more susceptible to infections. From a prospective database, we retrospectively assessed the ability of preoperative lymphopenia, as a marker of this immune dysregulation, to predict the occurrence of early postoperative bacterial infections during post-OLT ICU hospitalization in patients with cirrhosis. Between January 2011 and December 2021, we included 445 patients. Post-OLT infections occurred in 92 patients (21%) and were mainly represented by bacteriemia (39%), pneumonia (37%) and surgical site infection (30%). Preoperative lymphocyte count ≤1.150 × 109/L was identified as an independent risk factor, as well as preoperative encephalopathy, intraoperative RBC transfusion >2 and intraoperative maximum norepinephrine dose >0.5  μg.kg-1.min-1 (all p < 0.05). Bootstrap analysis validated these results (p < 0.05). The risk factors were integrated into the PRELINFO score which was associated with the risk of infection (p < 0.05). The depth of preoperative lymphopenia was also associated with the risk of infection and postoperative correction of lymphopenia was slower in patients who developed an infection than in those who did not. Preoperative blood lymphocyte count should be incorporated into the assessment of the risk of early post-OLT bacterial infections.