The Rochester Protocol for living donor liver transplantation of unresectable colorectal liver metastasis: A 5-year report on selection, approval, and outcomes

Living donor liver transplantation (LDLT) is a treatment option for select patients with unresectable colorectal liver metastasis. We describe our center's experience of patient selection, insurance approval, and outcomes after LDLT after first referral in March 2019. Of the 206 evaluated patients, 23 underwent LDLT. We found that patients who were referred earlier in their oncologic course were more likely to be eligible for transplantation. After completion of the Rochester Protocol for LDLT eligibility, recipients had a median delay of care of 10 days (IQR, 0-36 days) related to insurance appeal, with 6 patients (30%) having a delay longer than 30 days. LDLT recipients had an overall survival proportion of 100% and 91% at 1 and 3 years and a recurrence-free survival proportion of 100% and 40% at 1 and 3 years, respectively. All donors underwent right hepatectomy, of which only 1 donor had a Clavien-Dindo IIIa complication and readmission. There was no donor mortality. We assert that multidisciplinary care and strict patient selection through the Rochester Protocol were paramount to our center's success. In the appropriately selected patient, LDLT for unresectable colorectal liver metastasis may be justified, and patients should be referred to transplant oncology centers for evaluation.

Prediction model of the T cell-mediated rejection after liver transplantation in children and adults: A case-controlled study

OBJECTIVE

T cell-mediated rejection (TCMR) is a major concern following liver transplantation (LT), and identifying its predictors could help improve post-transplant prognosis. This study aimed to develop a model to predict the risk of TCMR in children and adults after LT.

METHOD

Pre-transplant demographic characteristics, intraoperative parameters, and especially early post-transplant laboratory data for 1221 LT recipients (1096 adults and 125 children) were obtained from the Hospital, University, between 1 January 2015, and 1 January 2022. These data were analyzed to develop the prediction model.

RESULT

The incidence of TCMR was higher in pediatric LT recipients than in adults (17.6% vs. 6.4%, P < 0.001). In adult recipients, seven predictors were identified: donor sex, recipient age, recipient height, and post-transplant levels of serum direct bilirubin, urea, platelets, and neutrophil-to-lymphocyte ratio. In pediatric recipients, four predictors were identified: post-transplant levels of serum monocyte percentage, direct bilirubin, albumin, and gamma-glutamyl transferase. The area under the model's curve incorporating these variables for predicting TCMR after LT was 0.713 (95% confidence interval, CI: 0.655-0.770) in adults and 0.786 (95% CI: 0.675-0.896) in children. Decision curve analyses demonstrated the clinical significance of the model.

CONCLUSION

This study developed a prediction model that may be useful in identifying high-TCMR-risk populations in both adult and pediatric LT recipients.

Explainable and Robust Deep Learning for Liver Segmentation Through U-Net Network

Background/Objectives: Clinical imaging techniques, such as magnetic resonance imaging and computed tomography, play a vital role in supporting clinicians by aiding disease diagnosis and facilitating the planning of appropriate interventions. This is particularly important in malignant conditions like hepatocellular carcinoma, where accurate image segmentation, delineating the liver and tumor, is a critical initial step in optimizing diagnosis, staging, and treatment planning, including interventions like transplantation, surgical resection, radiotherapy, portal vein embolization, and other procedures. Therefore, effective segmentation methods can significantly influence both diagnostic accuracy and treatment outcomes. Method: In this paper, we propose a deep learning-based approach aimed at accurately segmenting the liver in medical images, thus addressing a critical need in hepatic disease diagnosis and treatment planning. We consider a U-Net architecture with residual connections to capture fine-grained anatomical details. We also take into account the prediction explainability, aiming to highlight, in the image under analysis, the areas that are symptomatic for a certain segmentation. In detail, by exploiting the U-Net architecture, two different models are trained with two annotated datasets of computed tomography medical images, resulting in four different experiments. Results: We consider two different datasets to improve robustness and generalization across diverse patient populations and imaging conditions. Experimental results demonstrate that the proposed method obtains interesting performances, with an accuracy ranging from 0.81 to 0.93. Conclusions: We thus show that the proposed method can provide a reliable and efficient solution for automated liver segmentation, promising significant advancements in clinical workflows and precision medicine.

Understanding the Long-Term Relationship in Dyads of Parental Live Liver Donors and Adolescent Young Adults

AIM

This qualitative study aimed to understand how dyads of parental donors and adolescent young adult recipients make sense of living donor liver transplantation from donation to adolescence.

DESIGN

This qualitative study used a focused ethnographic design.

METHODS

Twelve dyads of parental liver donors and their adolescent young adults were interviewed together using a semi-structured interview guide. Data was collected from April 16 to July 30, 2019. All of the interviews were audiotaped and transcribed. The theoretical framework of sensemaking was implemented. Thematic analysis was used, concepts were categorised, connections were made and references to the coding were conducted.

RESULTS

Thematic analysis contributed to the emergence of three categories: connections, reflections and life transitions, and the overarching theme of gratitude for being given or giving the gift of life.

CONCLUSION

The dyads' gratitude increased over time through the social process of sensemaking.

IMPLICATIONS FOR THE PROFESSION AND PATIENTS

As living donor liver transplantation in the paediatric population enters its third decade, understanding how it shapes relationships in dyads of parental donors and adolescent young recipients over time can provide new insights for nurses who work in paediatric transplantation.

IMPACT

This study's findings address the current gap in the literature on the long-term impact of living donor liver transplant dyads and highlight the role of nurses who provide care and guidance at the time of evaluation and surgery to the ongoing support during the years that follow.

REPORTING METHOD

This qualitative study followed EQUATOR guidelines and adhered to the COREQ checklist for qualitative studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Endovascular Treatment for Acute Portal Vein Thrombosis

Acute portal vein thrombosis is characterized by nonspecific abdominal pain, causing severe morbidity and mortality. Prompt diagnosis is crucial to avoid short-term complications such as intestinal infarction, sepsis, and death. The therapeutic goal is to prevent thrombus extension into the mesenteric veins and intestinal ischemia complications. Systemic anticoagulation is the standard treatment. However, endovascular treatments such as thrombolysis, thrombectomy, balloon angioplasty, stent placement, and transjugular intrahepatic portosystemic shunt placement have been performed in patients who are refractory to anticoagulation therapy or at a high risk of intestinal ischemia. This review discusses the clinical and diagnostic considerations in acute portal vein thrombosis, focusing on current endovascular treatments that are effective and safe. However, prospective data are required to compare endovascular treatment techniques and assess their outcomes.

Antibiotic Exposure and Risk of Allograft Rejection and Survival After Liver Transplant: An Observational Cohort Study From a Tertiary Referral Centre

INTRODUCTION

Our goal is to understand whether there is an association between Abx exposure-and the inferred downstream damage to the intestinal microbiome-and the key patient outcomes of overall survival and rejection following liver transplant.

METHODS

We conducted a retrospective cohort study of 462 liver transplant recipients treated at a multistate liver transplant (LTx) service during a 7-year period. The association between antibiotic exposure and outcome was tested across models that addressed antibiotic spectrum, duration, and timing relative to transplant. Cox proportional hazard regression was used to evaluate the relationship between antibiotics with survival and rejection.

RESULTS

The observed 1-year survival in this cohort was 95% (95% CI: 93%, 97%), and 20.8% of patients (96/462) experienced rejection at 1 year. In multivariable analyses, exposure to anaerobe-targeting antibiotics for longer than 14 days pretransplant (p = 0.055) or posttransplant (p = 0.040) was significantly associated with reduced 1-year survival. In multivariable analyses, exposure to any anaerobe-targeting Abx posttransplant was significantly associated with an increased risk of rejection (p = 0.001).

CONCLUSIONS

Exposure to anaerobic spectrum antibiotics either before or after LTx was associated with poor outcomes during the first year posttransplant and provides an impetus to further characterize the relationship between antibiotic use, microbiota disruption, and cellular immunity in liver transplantation.

Gut microbiota differences, metabolite changes, and disease intervention during metabolic - dysfunction - related fatty liver progression

In the current era, metabolic dysfunction-associated steatotic liver disease (MASLD) has gradually developed into a major type of chronic liver disease that is widespread globally. Numerous studies have shown that the gut microbiota plays a crucial and indispensable role in the progression of MASLD. Currently, the gut microbiota has become one of the important entry points for the research of this disease. Therefore, the aim of this review is to elaborate on the further associations between the gut microbiota and MASLD, including the changes and differences in the microbiota between the healthy liver and the diseased liver. Meanwhile, considering that metabolic dysfunction-associated fatty liver and metabolic dysfunction-associated steatohepatitis are abnormal pathological states in the development of the disease and that the liver exhibits different degrees of fibrosis (such as mild fibrosis and severe fibrosis) during the disease progression, we also conduct a comparison of the microbiota in these states and use them as markers of disease progression. It reveals the changes in the production and action mechanisms of short-chain fatty acids and bile acids brought about by changes in the gut microbiota, and the impact of lipopolysaccharide from Gram-negative bacteria on the disease. In addition, the regulation of the gut microbiota in disease and the production and inhibition of related disease factors by the use of probiotics (including new-generation probiotics) will be explored, which will help to monitor the disease progression of patients with different gut microbiota compositions in the future and carry out personalized targeted therapies for the gut microbiota. This will achieve important progress in preventing and combating this disease.

Protocol for an international multicenter, prospective, observational, non-competitive, study to validate and optimise prediction models of 90-day and 1-year allograft failure after liver transplantation: The global IMPROVEMENT Study

More liver transplants (LT) are performed worldwide thanks to extended criteria donors (ECD). This is paralleled by a supposed increased risk of allograft failure (AF) at 90 and 365 days. This study has been designed to portray the LT practice worldwide and investigate models of AF prediction and the impact of risk mitigation strategies for further improving graft and patient outcomes. This is a multicenter, international, non-competitive, observational two segment study on consecutive LTs over two periods (2017-2019 and 2022-2024). A steering committee of LT experts defined the study protocol. The prospective segment will enroll 750 patients from 15 high-volume LT centers (50 per center), and the retrospective segment will enrol 4200 patients from 56 LT centers (75 per center). To provide a snapshot of the LT activity globally and to develop new algorithms for the timely prediction of AF at 90 and 365 days post-LT. The study also aims (1) to validate the existing predictive models and (2) to investigate the best time for re-transplantation, paying attention to the differences in AF and Ischemic cholangiopathy according to the donor types and mitigation strategies implemented in the various settings. Since the adoption of machine perfusion has increased in different proportions worldwide, models will be adjusted according to this parameter. Finally, retrospective and prospective data will be available for further stratifications and modelling according to the degree of decompensation at transplant, gender match, postoperative complications and their management. This protocol was approved by Fondazione Policlinico Universitario Agostino Gemelli IRCCS Ethics Committee (study ID: 4571) and the Institutional Review Board of the University of California, Los Angeles. The provisional study protocol was submitted to the main scientific international societies in the transplant field. Results will be published in international peer-reviewed journals and presented at congresses.

Living Donor Liver Transplant Programs in the United States Need to Be Carefully Nurtured Amidst Expanding Use of Perfusion Technology

Living donor transplantation constitutes a small portion of total transplants in the United States as compared Southeast Asia and Middle East. Recent consensus meeting has identified reluctance on the part of transplant providers and donor financial concerns as the major hindrance in increasing the Living donor liver transplants in US. There is a need to carefully analyze the recent outcome data from across the globe and from large volume North American centers that clearly establishes the benefit of Living donor transplants for both adults and children and reducing wait list mortality. LDLT also provides an opportunity for expanding the indications to offer transplant for indications like colorectal metastasis and intrahepatic cholangiocarcinoma without reducing the number of livers available for traditional indications. Recent expansion of perfusion technology has demonstrated significant increase in utilization of Non heart beating donor livers over the last few years. However, with simultaneous increase in patients being added to the wait list, the wait list mortality and dropouts have been persistently high. In this opinion piece, the authors have looked at the transplant trends in the US in the last few years and advocate for adopting a complementary rather than a singular approach for expansion of LDLT along with new perfusion technologies for increasing the number of liver transplants in the US.

Evolving Transplant Oncology: Evolving Criteria for Better Decision-Making

Transplant oncology integrates a wide variety of fields, such as surgery, oncology, and transplant medicine, intending to increase the range of studies and treatments for hepatobiliary cancers and other liver-related malignant lesions. Liver transplantation (LT) has proven to be an effective treatment for hepatocellular carcinoma. While the Milan criteria are still the gold standard, several new, more inclusive criteria have been proposed, and hepatocellular carcinoma has become a major indication for liver transplantation. The continuous evolution of diagnostic technologies supported this with higher image quality and more accurate staging. This review describes the current applications of transplant oncology in hepatocellular carcinoma, cholangiocarcinoma, neuroendocrine tumors, and liver metastatic disease from colorectal cancer and discusses the path that led to the development of transplant oncology as an organized approach to managing gastrointestinal malignancies through transplantation. More importantly, the significance of a multidisciplinary approach and criteria in the selection of suitable candidates are discussed. In addition, newer aspects of transplant oncology, such as immunotherapy, circulating tumor DNA (ctDNA), novel surgical techniques, and the utilization of artificial intelligence, are presented. Finally, the opportunities and challenges involved in the field's future, as well as the evolution of the criteria used over the years and insightful thoughts for the future of the criteria, are discussed.

The Role of the Gut-Biliary-Liver Axis in Primary Hepatobiliary Liver Cancers: From Molecular Insights to Clinical Applications

Background: Hepatobiliary liver cancers (HBLCs) represent the sixth most common neoplasm in the world. Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) constitute the main HBLC types, with alarming epidemiological projections. Methods: In recent decades, alterations in gut microbiota, with mutual implications on the gut-liver axis and gut-biliary axis permeability status, have been massively investigated and proposed as HBLC pathogenetic deus ex machina. Results: In the HCC setting, elevated intestinal levels of Escherichia coli and other Gram-negative bacteria have been demonstrated, resulting in a close association with increased lipopolysaccharide (LPS) serum levels and, consequently, chronic systemic inflammation. In contrast, the intestinal microbiota of HCC individuals feature reduced levels of Lactobacillus spp., Bifidobacterium spp., and Enterococcus spp. In the CC setting, evidence has revealed an increased expression of Lactobacillus spp., with enhanced levels of Actynomices spp. and Alloscardovia spp. Besides impaired strains/species representation, gut-derived metabolites, including bile acids (BAs), short-chain fatty acids (SCFAs), and oxidative-stress-derived products, configure a network severely impacting the progression of HBLC. Conclusions: In the era of Precision Medicine, the clarification of microbiota composition and functioning in HCC and CC settings can contribute to the identification of individual signatures, potentially providing novel diagnostic markers, therapeutic approaches, and prognostic/predictive tools.

Hyperbilirubinemia does not impair induced liver hypertrophy after portal vein Embolization-a retrospective scandinavian cohort study

BACKGROUND

Portal vein embolization (PVE) may be used to induce hypertrophy of the future liver remnant (FLR) before major hepatectomy. The influence of hyperbilirubinemia on FLR hypertrophy after PVE is controversial. The aim of this study was to compare FLR hypertrophy after PVE between patients with and without elevated P-bilirubin.

MATERIALS/METHODS

This is a Scandinavian retrospective cohort study of patients from five hepatobiliary centres. This study included patients who underwent right-sided PVE from 2013 to 2023. Data were collected from electronic medical records. FLR growth was analysed with respect to normal or elevated P-bilirubin.

RESULTS

In total, 410 patients were included in this study. Among the total cohort, 105 patients had elevated P-bilirubin levels (≥26 μmol/L) at the time of PVE. Elevated P-bilirubin levels were not associated with impaired FLR hypertrophy after PVE, as determined by absolute growth (p < 0.001), relative growth (p = 0.008), degree of hypertrophy (p < 0.001) and kinetic growth rate (p = 0.002). Multivariable analysis revealed that elevated P-bilirubin levels at the time of PVE (p = 0.002) together with the use of N-butyl cyanoacrylate (NBCA) as an embolizing material (p = 0.009) were associated with increased FLR hypertrophy. A larger estimated total liver volume was associated with reduced FLR hypertrophy (p < 0.001).

CONCLUSION

In this multicentre, retrospective cohort study, we were unable to show any negative effect of elevated P-bilirubin on FLR hypertrophy at the time of PVE. There is no need for P-bilirubin levels to normalize before PVE. This study supports the ongoing shift towards NBCA as an embolizing material.

Chronic Hepatitis B in the Transplant Setting: A 30-Year Experience in a Single Tertiary Italian Center

BACKGROUND

Hepatitis B virus (HBV) remains a leading etiology for liver transplantation (LT). In a large cohort of HBsAg-positive patients, this study evaluates long-term patient and graft survival after LT over the past 30 years while analyzing trends and outcomes following waiting list (WL) inclusion over the last 15 years.

METHODS

HBsAg-positive patients who underwent transplantation between 1991 and 2020 and were waitlisted from 2006 to 2020 at Padua Hospital were included in the analysis. Patients were stratified according to hepatitis delta virus (HDV) coinfection, transplant indication (decompensated cirrhosis vs. hepatocellular carcinoma (HCC)), and WL inclusion period.

RESULTS

Among 321 HBsAg-positive LT recipients (31.5% HDV-coinfected, 46.4% HCC), 1-year and 5-year patient/graft survival rates were 87.6%/86.7% and 82.6%/82.2%, respectively. From 2006 to 2020, 284 HBsAg-positive patients were waitlisted (32.6% HDV-coinfected), with a significantly higher prevalence of HCC compared to non-HBV patients (p = 0.008). High-barrier nucleos(t)ide analogues (hbNUCs) significantly reduced mortality (p = 0.041) and improved survival post-WL inclusion (p = 0.007). Survival rates were consistent regardless of LT indication, HDV coinfection, or WL inclusion period. Post-transplant prophylaxis predominantly involved immunoglobulins (HBIG) + NUCs, resulting in only two cases of HBV reactivation, both clinically inconsequential.

CONCLUSIONS

Over the past 30 years, HBV has remained a consistent indication for LT at our center. Thanks to hbNUCs, WL outcomes have improved and HCC has become the main indication for LT.

Latin American expert opinion letter on the feasibility of systemic therapies in combination with locoregional therapies for hepatocellular carcinoma

Recent advances in the systemic treatment of advanced hepatocellular carcinoma (HCC) with immunotherapy have once again reignited discussion over the role of combined therapy in earlier stages. This year, different international meetings have presented recent results from clinical trials on adjuvant therapy alone (IMBrave-050) and combined with transarterial chemoembolization (EMERALD-1 and LEAP-12). Increased enthusiasm for the use of adjuvant and neoadjuvant therapy for liver transplantation, surgery, and local-regional treatment of HCC has been shown. However, the initial results from these trials should be interpreted cautiously as we wait for final analyses and effects on overall survival. In this position paper from the special interest group from the Latin American Association for the Study of Liver Diseases (ALEH), we underline the caveats of the applicability of these potential treatments in our region, explore points of agreement, and highlight areas of uncertainty. Moreover, we underscore the role of hepatologists in the clinical decision-making process and management of these patients.

Sirtuins and Gut Microbiota: Dynamics in Health and a Journey from Metabolic Dysfunction to Hepatocellular Carcinoma

Metabolic dysfunction leading to non-alcoholic fatty liver disease (NAFLD) exhibits distinct molecular and immune signatures that are influenced by factors like gut microbiota. The gut microbiome interacts with the liver via a bidirectional relationship with the gut-liver axis. Microbial metabolites, sirtuins, and immune responses are pivotal in different metabolic diseases. This extensive review explores the complex and multifaceted interrelationship between sirtuins and gut microbiota, highlighting their importance in health and disease, particularly metabolic dysfunction and hepatocellular carcinoma (HCC). Sirtuins (SIRTs), classified as a group of NAD+-dependent deacetylases, serve as crucial modulators of a wide spectrum of cellular functions, including metabolic pathways, the inflammatory response, and the process of senescence. Their subcellular localization and diverse functions link them to various health conditions, including NAFLD and cancer. Concurrently, the gut microbiota, comprising diverse microorganisms, significantly influences host metabolism and immune responses. Recent findings indicate that sirtuins modulate gut microbiota composition and function, while the microbiota can affect sirtuin activity. This bidirectional relationship is particularly relevant in metabolic disorders, where dysbiosis contributes to disease progression. The review highlights recent findings on the roles of specific sirtuins in maintaining gut health and their implications in metabolic dysfunction and HCC development. Understanding these interactions offers potential therapeutic avenues for managing diseases linked to metabolic dysregulation and liver pathology.

Granola consumption with multiple prebiotics in Japanese participants increases Bifidobacterium abundance and improves stress and subjective sleepiness

Background

Sleep is essential for physical and mental health. However, stress-related sleep disorders are common in Japan, and the gut-brain axis may play a role in sleep and stress management. This study investigated whether the consumption of granola containing multiple prebiotic ingredients could alleviate stress and improve insomnia in adults with stress-related sleep problems, regardless of individual differences in the gut microbiota. Additionally, we aimed to investigate the relationship between changes in gut microbiota and the observed improvements.

Method

A single-arm uncontrolled trial was conducted with 27 adults with high stress levels and sleep disturbance. The participants consumed 50 g of prebiotics-containing granola daily for 8 weeks. Subjective sleep quality was assessed using the Athens Insomnia Scale, Epworth Sleep Scale, and Oguri-Shirakawa-Azumi Sleep Inventory-Middle-aged and Aged version (OSA-MA). Stress levels were assessed by administering the Brief Job Stress Questionnaire and Profile of Mood States 2nd edition (POMS2). Gut microbiota composition was analyzed using 16S rDNA sequencing.

Results

After 8 weeks, subjective insomnia scores and sleep onset and maintenance improved significantly, whereas the stress and mood disturbance scores decreased significantly. Gut microbiota analysis showed that the relative abundance of Bifidobacterium increased, whereas that of Bacteroides decreased. Correlation analysis suggested a significant association between increased Bifidobacterium level and reduced stress (r = -0.39, p = 0.0035) and insomnia levels (r = -0.3, p = 0.026).

Conclusion

Prebiotics-containing granola improved subjective sleep quality and reduced stress in adults with stress-related sleep disturbances, which may be attributed to alterations in gut microbiota, particularly the increase in Bifidobacterium abundance.

Amplicon-based analysis reveals link between adolescent acne and altered facial skin microbiome induced by negative emotional states

Introduction

The skin microbiome is integral to maintaining skin homeostasis and is involved in the pathogenesis of acne. Emerging evidence supporting the 'brain-skin axis' suggests that psychological stress may exacerbate acne. Both negative emotional states and acne are highly prevalent among adolescents. Although research has begun to explore this relationship, the role of the skin microbiome in adolescents experiencing emotional disturbances and acne remains poorly understood.

Methods

166 adolescents aged 15-18 were divided into four distinct groups based on their emotional health and acne severity: no acne or negative emotions (NC), acne without negative emotions (NS), negative emotions without acne (YC), and acne with negative emotions (YS). Skin samples were collected from each participant's forehead and analyzed using high-throughput sequencing techniques, followed by comprehensive bioinformatics analyses to evaluate the microbial composition and diversity across the different groups.

Results

Adolescents with both acne and negative emotions exhibited significantly higher acne severity (IGA 2.675 ± 0.090) compared to the group with acne but without negative emotions (IGA 1.952 ± 0.136). Distinct microbial community patterns emerged among the groups, with acne-affected individuals displaying increased α-diversity. Additionally, negative emotions were associated with heightened β-diversity differences between acne-affected individuals. The predominant bacterial phyla identified were Firmicutes, Bacteroidetes, Proteobacteria, and Fusobacteria, with Acinetobacter being more abundant, and Roseomonas and Cutibacterium being less prevalent in adolescents experiencing negative emotions.

Conclusion

This study revealed that the bacterial biomarkers of the disease change when acne is accompanied by negative emotions. Cutibacterium, Acinetobacter, and Roseomonas may be key contributors to acne exacerbation. These findings underscore the importance of considering both emotional and microbiological factors in the management of adolescent acne, particularly within the context of the brain-skin connection.

A qualitative study to understand the challenges of conducting randomised controlled trials of complex interventions in metastatic colorectal cancer

BACKGROUND

The use of interventions such as major liver and lung resection, radiofrequency ablation and transarterial chemoembolization in the management of metastatic colorectal cancer (mCRC) is now relatively commonplace in clinical practice. However, the evidence base regarding these treatments is limited with a lack of high-quality data from randomised controlled trials (RCTs). The aim of this study was to understand the challenges associated with conducting RCTs in advanced mCRC and to identify potential strategies to overcome them, with a view to improving trial design and delivery in this setting.

METHODS

A qualitative study was undertaken with professionals involved in mCRC trials. Participants were identified using trial registries to identify relevant trials. Individual semi-structured, in-depth qualitative interviews were undertaken online using a topic guide. The principles of thematic content analysis were used for data analysis.

RESULTS

Twelve participants were recruited to the study from six trials; three of the trials had completed, two were either terminated or no longer recruiting and one was open to recruitment. Four major themes were identified, and themes were further subdivided to identify specific challenges and solutions to overcome them. The four themes identified were as follows: trial-related processes, organisational/structural challenges, trial design considerations, and stage IV (metastatic) colorectal cancer-specific factors. Significant challenges were described in relation to funding, ethical approval processes, equipoise, patient preferences, logistical issues in trial delivery, and the advanced nature of mCRC including disease progression and palliative care.

CONCLUSIONS

There are a range of strategies which could be implemented to improve the delivery of future trials in this complex setting, from the initial development of a trial through to trial setup, recruitment and follow-up.

Clostridium scindens promotes gallstone formation by inducing intrahepatic neutrophil extracellular traps through CXCL1 produced by colonic epithelial cells

Cholelithiasis is one of the most common diseases of the biliary system. Neutrophil extracellular traps (NETs) in the liver play an important role in accelerating the formation of gallstones. The upstream mechanism of NETs formation remains unclear. In this study, 16S rRNA sequencing was used to screen the differential gut microbiota in mice with gallstones. Transcriptome sequencing was used to screen the differentially expressed core genes and signalling pathways of Clostridium scindens that acted on human colonic epithelial cells. Western blotting was used to verify the protein expression of TLR2 and the NF-κB pathway. RT-PCR was used to verify the mRNA expression of TLR2, CXCL1 and the NF-κB pathway. ELISA was used to verify CXCL1 expression in the supernatant or portal vein blood of mice. Immunofluorescence was used to detect NETs formation in cocultured neutrophils in vitro or in mouse livers. Clostridium scindens was the key differential strain in the formation of gallstones in mice. After treatment with Clostridium scindens, both in vitro and in vivo, the expression of TLR2 was upregulated, the secretion of CXCL1 was increased by regulating the NF-κB pathway. Finally, the formation of NETs and stones was significantly increased. This study reveals a new mechanism of the gut-liver immune axis in the formation of gallstones. Clostridium scindens acts on colonic epithelial cells through TLR2 to regulate the NF-κB pathway and increase the secretion of CXCL1. CXCL1 enters the liver via the portal vein and increases the formation of NETs in the liver, thereby accelerating gallstone formation.

Small intestinal bacterial overgrowth and intestinal methanogen overgrowth in gastrointestinal malignancies

Small intestinal bacterial overgrowth (SIBO) is defined by an abnormal proliferation of colon-specific bacteria in the small intestine, whereas intestinal methanogen overgrowth (IMO) manifests with an increase of methane-producing archaea, specifically Methanobrevibacter smithii. Both conditions can disrupt gastrointestinal motility and manifest with various clinical symptoms. Small intestinal bacterial overgrowth appears to increase the risk of malnutrition and negatively affect malabsorption of essential nutrients such as vitamin B12 and fat-soluble vitamins. This concern is particularly relevant for cancer patients as malnutrition can adversely affect treatment outcomes and mortality rates. Small intestinal bacterial overgrowth prevalence is 2.5-22% in the general population, with significantly higher rates observed in cancer patients, depending on a study, 65% of gastric and colorectal cancer patients, 63.3% of pancreatic cancer patients compared to 13.3% in healthy controls. Gastrointestinal complications, particularly in cases of gastrointestinal cancers, can arise from both the disease itself and its treatment. Managing symptoms becomes more challenging when SIBO occurs as its symptoms are often ambiguous and overlap with those of other conditions. This review summarizes the current state of knowledge on SIBO and IMO in gastrointestinal cancers. Current knowledge on SIBO and IMO, particularly in gastrointestinal cancer, is limited by the lack of validated diagnostic standards, evidence-based nutritional guidelines, and a focus on symptom control rather than underlying mechanisms. There is a need for research on recurrence despite treatment, as well as studies specifically targeting SIBO and IMO in cancer rather than as comorbidities. Future efforts should prioritize developing reliable diagnostics, understanding recurrence mechanisms, and exploring personalized therapies and nutritional interventions.

Combining radiomics and imaging biomarkers with clinical variables for the prediction of HCC recurrence after liver transplantation

To develop and validate an integrated model that combines CT-based radiomics and imaging biomarkers with clinical variables to predict recurrence and recurrence-free survival in patients with HCC following liver transplantation (LT), this 2-center retrospective study includes 123 patients with HCC who underwent LT between 2007 and 2021. Radiomic features (RFs) were extracted from baseline CT liver tumor volume. Feature selection was performed using the Least Absolute Shrinkage and Selection Operator (LASSO) regression method with 10-fold cross-validation in the training cohort (n=48) to build a predictive radiomics signature for HCC recurrence. Combined diagnostic models were built based on the radiomics signature supplemented with imaging features beyond the Milan criteria, the AFP (alpha-fetoprotein) model, and Metroticket 2.0 before LT using multivariate logistic regression. Receiver operating characteristic analyses were performed in both internal (n=22) and external (n=53) validation cohorts, and patients were stratified into either high-risk or low-risk groups for HCC recurrence. Kaplan-Meier analysis was performed to analyze recurrence-free survival. LASSO and multivariate regression analysis revealed 4 independent predictors associated with an increased risk of HCC recurrence: radiomics signature of 5 RF, peritumoral enhancement, satellite nodules, and no bridging therapies. For the prediction of tumor recurrence, the highest AUC of the final integrated models combining clinical variables, non-radiomics imaging features, and radiomics was 0.990 and 0.900 for the internal and external validation sets, respectively, outperforming the Milan and clinical stand-alone models. In all integrated models, the high-risk groups had a shorter recurrence-free survival than the corresponding low-risk group. CT-based radiomics and imaging parameters beyond the Milan criteria representing aggressive behavior, along with the history of bridging therapies, show potential for predicting HCC recurrence after LT.

Large-for-size syndrome prophylaxis in infant liver recipients with low body mass

Transplantation of the left lateral section (LLS) of the liver is now an established practice for treating advanced diffuse and unresectable focal liver diseases in children, with variants of the LLS primarily used in infants. However, the surgical challenge of matching the size of an adult donor's graft to the volume of a child's abdomen remains significant. This review explores historical developments, various approaches to measuring the required functional liver mass, and techniques to prevent complications associated with large-for-size grafts in infants.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2024

The Eastern Canadian Gastrointestinal Cancer Consensus Conference was an annual meeting that was held in St. John's, Newfoundland and Labrador, from 26 to 28 September 2024. This included experts in medical oncology, radiation oncology, surgical oncology, nuclear medicine, and general practitioners in oncology (GPO) from across the eastern Canadian provinces who are involved in the management of patients with gastrointestinal malignancies. This consensus statement generated by the conference addresses multiple topics, including the management of localized rectal cancer, liver-limited colorectal cancer, systemic therapy for advanced biliary tract cancers, radioligand therapy for gastroenteropancreatic neuroendocrine tumors (GEP-NETs), systemic therapy for pancreatic and midgut well-differentiated NETs, and systemic therapy for HER2-positive gastroesophageal cancers.

Lesson learnt from 60 years of liver transplantation: Advancements, challenges, and future directions

Over the past six decades, liver transplantation (LT) has evolved from an experimental procedure into a standardized and life-saving intervention, reshaping the landscape of organ transplantation. Driven by pioneering breakthroughs, technological advancements, and a deepened understanding of immunology, LT has seen remarkable progress. Some of the most notable breakthroughs in the field include advances in immunosuppression, a revised model for end-stage liver disease, and artificial intelligence (AI)-integrated imaging modalities serving diagnostic and therapeutic roles in LT, paired with ever-evolving technological advances. Additionally, the refinement of transplantation procedures, resulting in the introduction of alternative transplantation methods, such as living donor LT, split LT, and the use of marginal grafts, has addressed the challenge of organ shortage. Moreover, precision medicine, guiding personalized immunosuppressive strategies, has significantly improved patient and graft survival rates while addressing emergent issues, such as short-term complications and early allograft dysfunction, leading to a more refined strategy and enhanced post-operative recovery. Looking ahead, ongoing research explores regenerative medicine, diagnostic tools, and AI to optimize organ allocation and post-transplantation car. In summary, the past six decades have marked a transformative journey in LT with a commitment to advancing science, medicine, and patient-centered care, offering hope and extending life to individuals worldwide.

Inflammation and cancer: molecular mechanisms and clinical consequences

Inflammation, a hallmark of cancer, has been associated with tumor progression, transition into malignant phenotype and efficacy of anticancer treatments in cancer. It affects all stages of cancer, from the initiation of carcinogenesis to metastasis. Chronic inflammation induces immunosup-pression, providing an environment conducive to carcinogenesis, whereas acute inflammation induces an antitumor immune response, leading to tumor suppression. Solid tumors have an inflammatory tumor microenvironment (TME) containing cancer cells, immune cells, stromal cells, and soluble molecules, which plays a key role in tumor progression and therapy response. Both cancer cells and stromal cells in the TME are highly plastic and constantly change their phenotypic and functional properties. Cancer-associated inflammation, the majority of which consists of innate immune cells, plays an important role in cancer cell plasticity, cancer progression and the development of anticancer drug resistance. Today, with the combined used of advanced technologies, such as single-cell RNA sequencing and spatial molecular imaging analysis, the pathways linking chronic inflammation to cancer have been largely elucidated. In this review article, we highlighted the molecular and cellular mechanisms involved in cancer-associated inflammation and its effects on cancer progression and treatment response. We also comprehensively review the mechanisms linking chronic inflammation to cancer in the setting of GI cancers.

Strategies for Monitoring and Supporting Living Donors in Korea: An Expert Position Paper

BACKGROUND

The number of organ transplants in South Korea has increased, with a notable rise in living donor transplants. Ensuring their long-term health and well-being is critical to address potential complications and maintain the success of the transplant programs.

METHODS

A diverse advisory panel, including transplant experts and coordinators, was established to evaluate the follow-up care for living donors. The panel reviewed the results of a brief survey of donors regarding their donation experience, follow-up programs, guidelines, and policies from South Korea and other countries, aiming to identify best practices and recommend improvements.

RESULTS

The study found that follow-up care for living donors in South Korea is inconsistent and lacks standardization. Significant variability exists in follow-up practices across different institutions, and comprehensive data on donor health pre- and post-donation are scarce. The need for continuous, systematic follow-up, encompassing both medical and psychological support, is emphasized to ensure donor well-being.

CONCLUSION

Improving follow-up care for living donors is essential. Establishing a national registry and increasing donor advocacy teams are meaningful steps to enhance donor care, ensure long-term health, and maintain ethical standards in organ donation.

LXRα agonists ameliorates acute rejection after liver transplantation via ABCA1/MAPK and PI3K/AKT/mTOR signaling axis in macrophages

INTRODUCTION

Liver X receptor α (LXRα) plays an important role in inflammatory immune response induced by hepatic ischemia-reperfusion injury (IRI) and acute rejection (AR). Macrophage M1-polarization play an important role in the occurrence and development of AR. Although the activation of LXR has anti-inflammatory effects, the role of LXRα in AR after liver transplantation (LT) has not been elucidated.

OBJECTIVE

We aimed to investigate LXRα anti-inflammatory and macrophage polarization regulation effects and mechanisms in acute rejection rat models.

METHODS

LXRα anti-inflammatory and liver function protective effects was initially measured in primary Kupffer cells and LT rat models. Subsequently, a flow cytometry assay was used to detect the regulation effect of LXRα in macrophage polarization. HE staining, TUNEL and ELISA were used to evaluate the co-treatment effects of TO901317 and tacrolimus on hepatic apoptosis and liver acute rejection after LT.

RESULTS

In this study, we found that LPS can inhibit the expression of LXRα and activate MAPK pathway and PI3K/AKT/mTOR. We also found that LXRα agonist (TO901317) could improve liver function and rat survival after LT by activating the level of ABCA1 and inhibiting MAPK. TO901317 could inhibit macrophage M1-polarization by activating PI3K/AKT/mTOR signal pathway to improve the liver lesion of AR rats after liver transplantation. Additionally, co-treatment with TO901317 and tacrolimus more effectively alleviated the damaging effects of AR following LT than either drug alone.

CONCLUSION

Our results suggest that the activation of LXRα can improve liver function and rat survival after LT by regulate ABCA1/MAPK and PI3K/AKT/mTOR signaling axis in macrophages.

A snapshot of challenges and opportunities faced by the scientific workforce in liver transplantation-a survey of the International Liver Transplantation Society (ILTS)

Basic and translational research (B&TR) in liver transplantation (LT) underwent considerable changes and shifts over the past decade. To capture the current landscape and future potential of B&TR in LT, we conducted an online survey within the International Liver Transplantation Society (ILTS) community. The survey aimed to collect comprehensive data on the respondents' characteristics, qualifications, experiences, and research activities, providing the present state and future directions of B&TR in LT. Between October 2023 and January 2024, an online survey consisting of 35 key items was distributed to the ILTS community through newsletters and social media channels. Data were analyzed using a combination of quantitative and qualitative methods. The survey gathered 153 valid responses, with 79% of respondents possessing relevant experience in B&TR and 76% reporting concurrent clinical duties. Some 62% hold faculty positions, with 34% identifying as MDs and 44% holding combined MD/PhD degrees. About 71% of scientists with clinical duties reported challenges in conducting B&TR, with 57% citing a lack of time and 41% pointing to insufficient funding. Nevertheless, 69% of respondents currently receive research funding, with 58% supported by government or public sources. Among early career researchers, 57% reported receiving average or poor mentoring, and 30% indicated insufficient protected time for research. Looking ahead, advancing technologies, machine learning/artificial intelligence, multi-omics, xenotransplantation, and machine perfusion were highlighted as areas with the potential to significantly shift the paradigm in the near future. Our survey captured insights from B&TR scientists within the ILTS, identifying both challenges and opportunities for future developments and aiding in the strategic direction of the society's initiatives.

Machine learning-derived diagnostic model of epithelial ovarian cancer based on gut microbiome signatures

BACKGROUND

Prior studies have elucidated that alterations in gut microbiota are associated with a spectrum of tumors and metabolic disorders. However, the diagnostic value of gut microbiota in epithelial ovarian cancer remains insufficiently investigated.

METHODS

A total of 34 patients with a diagnosis of epithelial ovarian cancer (EOC), 15 patients with benign ovarian tumors (TB), and 30 healthy volunteers (NOR) were enrolled in this study. Fecal samples were collected, followed by sequencing of the V3-V4 region of the 16S rRNA gene. The clinical data and pathological characteristics were comprehensively recorded for further analysis, PICRUSt2 was utilized to conduct an analysis of microbial functional predictions, WGCNA networks were constructed by integrating microbiome and clinical data. LEfSe analysis was employed to identify microbial diagnostic markers, LASSO and SVM analyses were used to screen microbial diagnostic markers in conjunction with the Cally index, to establish a Microbial-Cally diagnostic model. Bootstrap resampling was utilized for the internal validation of the model, whereas the Hosmer-Lemeshow test and decision curve analysis (DCA) were employed to evaluate the diagnostic performance of the model. Plasma samples were subjected to untargeted metabolomics profiling, followed by differential analysis to identify key metabolites that are significantly altered in epithelial ovarian cancer. At the same time, Spearman correlation analysis was used to study the association between key microbiota and differential metabolites. The supernatants from Escherichia coli and Bifidobacterium cultures were co-cultured with SKOV3 cells. Cell proliferation, migration, and invasion were evaluated using Cell Counting Kit-8 (CCK-8) assay, Transwell migration and invasion assays. Apoptosis was assessed by flow cytometry analysis of fluorescence signals from Annexin V and propidium iodide (PI) staining.

RESULTS

Compared to Nor and TB populations, individuals diagnosed with EOC demonstrated a significantly diminished gut microbiota diversity when contrasted with both normal controls and those presenting benign conditions. Specifically, the relative abundance of Bilophila, Bifidobacterium, and other probiotics was significantly reduced in patients diagnosed with epithelial ovarian cancer (EOC), while Escherichia and Shigella demonstrated a marked enrichment within this cohort. Differential microorganisms were identified through the application of machine learning techniques to delineate the characteristic microbial profiles associated with the EOC patients. A significant correlation was identified between the Cally index and microorganisms. In conclusion, we utilized microbial biomarkers alongside the Cally to establish a diagnostic model for epithelial ovarian cancer, receiver operating characteristic (ROC) curve Area Under Curve (AUC) of 0.976 (95%CI 0.943-1.00), The AUC obtained from the Bootstrap internal validation was 0.974. The Hosmer-Lemeshow test revealed a robust concordance between the observed probabilities and the predicted probabilities generated by the model. The decision curve analysis revealed that the model provided a significant net clinical benefit. A total of 233 differential metabolites were identified between the EOC group and the NT (NOR and TB) groups. Among these, eight specific metabolites (HMDB0243492, C09265, HMDB0242046, HMDB0240606, C04171, HMDB0060557, HMDB0252797, and C21412) were exclusively derived from the microbiome. Notably, metabolite HMDB0240606 exhibited a significant positive correlation with Escherichia coli and Shigella, while it showed a significant negative correlation with Ruminococcus. In vitro studies demonstrated that Bifidobacterium possessed anti-tumor activity, whereas Escherichia coli exhibited pro-tumor activity.

CONCLUSION

This study provides the inaugural comprehensive analysis of gut microbiota composition and its differential profiles among patients with epithelial ovarian cancer, those with benign ovarian tumors, and healthy controls in Hunan province, China.

Adjuvant treatment with Capecitabine in patients who received orthotopic liver transplantation with incidental diagnosis of intrahepatic cholangiocarcinoma. Implications on DPYD polymorphisms assessment: report of two cases and review of the literature

In recent years, assessing dihydropyrimidine dehydrogenase (DPD) activity has become crucial for cancer patients undergoing 5-fluorouracil (5FU)-based chemotherapy due to the life-threatening toxicity associated with reduced DPD function. The methods for evaluating DPD activity have evolved, with the analysis of DPYD polymorphisms in blood samples becoming the preferred approach. As the indications for liver transplantation are increasing-particularly due to a rise in cases of cholangiocarcinoma (CCA) and non-resectable colorectal liver metastasis-more cancer patients with a history of liver transplantation may experience disease relapse. Furthermore, 5-fluorouracil chemotherapy is a standard treatment for both cancers. This growing need to evaluate DPD activity in transplanted livers arises because standard tests conducted on blood samples reflect the activity of native liver tissue and may produce misleading results. This paper presents two clinical cases from 2022 to 2023 involving patients who underwent successful liver transplants but were later diagnosed with intrahepatic CCA in the explanted liver. Both patients were subsequently prescribed capecitabine as adjuvant chemotherapy, making it essential to assess DPD activity in donor liver tissue to ensure safe treatment protocols. However, there are currently no established guidelines for this specific patient group. If we follow standard clinical practice, this critical analysis will be insufficient, as it only describes the DPD activity of the native liver. It is imperative to determine the DPD activity of the transplanted liver. In summary, this case report highlights the importance of managing this complex situation effectively.

Proceedings of the 29th Annual Congress of the International Liver Transplantation Society

The 2024 Annual Congress of the International Liver Transplantation Society (ILTS) was from May 1-4 in Houston, Texas, USA, under the theme "Liver Disease and Transplantation: Breaking Barriers and Exploring New Frontiers." In addition to a robust scientific program, the congress also hosted a hands-on cadaveric robotic liver surgery course, a machine perfusion workshop, and a transesophageal echocardiography course. In this report, the ILTS Vanguard and Basic Sciences Committees present a summary of the congress proceedings.

A prospective multicenter validation of RETREAT for posttransplantation HCC recurrence prediction

BACKGROUND AND AIMS

The RETREAT(Risk Estimation of Tumor REcurrence After Transplant) score is a simple risk stratification tool for postliver transplantation (LT) HCC recurrence that has been validated in retrospective cohort studies. A prospective, multicenter study is needed to further demonstrate accuracy especially given the evolving clinical demographics and HCC transplant practice. Our aim is to validate and compare the RETREAT score to other post-LT HCC recurrence risk scores in a contemporary, prospective cohort of patients.

APPROACH AND RESULTS

We prospectively enrolled patients with HCC who underwent LT from 8 centers between 2018 and 2022. The primary outcome was post-LT recurrence-free survival. Secondary outcomes included post-LT and post-recurrence survival. Model performance, determined using the concordance index, Akaike information criterion, integrated Brier score, and calibration, was compared to that of other established risk scores.We included 1166 patients with HCC who underwent LT, of which 78 (6.7%) had post-LT HCC recurrence after a median follow-up time of 2.2 years (IQR 1.2-3.2). The median RETREAT score was 4 (IQR 3-5) in patients with post-LT HCC recurrence and 1 (IQR 1 - 2) in patients without. Those with a RETREAT score of 0, 3, and 5+ had a 99.4%, 84.1%, and 55.6% recurrence-free survival, respectively, at 3 years post-LT. The RETREAT score was also able to stratify post-LT overall and postrecurrence survival. The RETREAT score's concordance index was 0.81 (95% CI: 0.77-0.85) and outperformed the MORAL and RELAPSE scores across multiple metrics.

CONCLUSIONS

The RETREAT score retains high accuracy for predicting post-LT HCC recurrence, further supporting RETREAT-guided post-LT HCC surveillance and care.

Factors predicting lower hospital stay after liver transplantation using a comprehensive enhanced recovery after surgery (ERAS) protocol

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols facilitate patient recovery without increasing complication rates. An ERAS protocol designed for our liver transplant (LT) patients obtained a median hospital length of stay (LOS) of 4 days. However, a proportion of patients do not achieve early discharge. This study aimed to identify factors that predict an LOS≤ 4 days.

METHODS

Identifying factors associated with LOS <4 days in our LT patients.

RESULTS

We performed 293 LTs (2012-2021), LOS≤4 days in 171 (58.4 %). The following factors emerged as statistically predictors of LOS≤4 days in the univariate analysis: male sex, HCC or HCV patients, lower MELD score, lower BAR score, no DCD patients, shorter operative time, no intraoperative transfusion, shorter ICU stay, no Clavien-Dindo complications grade ≥ III, no primary graft dysfunction, no acute rejection, no readmission at 30 days and no retransplantation were associated to LOS≤4 days. However, in the multivariate analysis, the only independent risk factor that predicted LOS≤4 days was the presence of hepatocarcinoma. DCD donors and higher MELD score were negative factors.

CONCLUSIONS

Applying ERAS programs in LT patients is beneficial, safe and extensible to all patients, but those with hepatocarcinoma obtain higher rates of LOS≤4 days.

Split liver transplantation in high MELD score adult recipients: a reappraisal

BACKGROUND

Split liver transplantation (SLT) from deceased donors is a potential solution to the global organ shortage. While effective in patients with mild disease, outcomes in high MELD score recipients remain uncertain and conflicting. This study compares survival in high vs. low MELD score recipients.

METHODS

This retrospective single-centre study included all consecutive patients transplanted with a split liver graft between 2010 and 2022. Two groups of recipients with MELD<25 and ≥ 25 at LT were compared.

RESULTS

The study population included 119 patients (n = 98 with MELD<25, n = 21 with MELD≥25) with an average follow-up of 55 months. Both groups were comparable in terms of indication for transplantation and donor characteristics. The high MELD group required more blood transfusions (7 vs. 3 units; p < 0.001) during LT and had a longer stay in intensive care unit (7 vs. 5 days; p = 0.011). Biliary, arterial, and venous complications were similar between groups, as well as graft survival (5 years: 75 % vs. 61 %, p = 0.35) and long-term overall survival (5 years: 83 % vs. 75 %, p = 0.17).

DISCUSSION

Our results indicate that SLT for patients with MELD≥25 improves access to grafts, is feasible and safe, without significant increased risk of severe complications or decreased long-term overall patient or graft survivals.

Liver transplantation for hepatitis D virus/hepatitis B virus coinfection in Italy: an intention-to-treat analysis of long-term outcomes

Patients with hepatitis D virus (HDV)/hepatitis B virus (HBV)-related end-stage liver disease candidates for liver transplantation (LT) have traditionally been regarded as a special population, although their outcomes are controversial. An intention-to-treat (ITT) analysis of long-term outcomes of HDV/HBV-coinfected patients waitlisted for LT in Italy, between 2011 and 2020, was performed and compared with HBV-monoinfected LT candidates. Of 1731 HBV-infected LT candidates, 1237 (71.5%) had HBV monoinfection and 494 (28.5%) HDV/HBV coinfection. At listing, HDV/HBV-coinfected patients were significantly younger, listed mainly for decompensated cirrhosis, and with fewer hepatocellular carcinoma (HCC) cases; (26% vs 65.8%; P <.0001) compared with HBV-monoinfected patients. HDV/HBV-coinfected patients showed better 5-year ITT survival (83.2%; 95% CI: 79.4%-83.4%, vs 71.6%; 95% CI: 68.8%-74.2%; P < .0001). ITT-multivariable analysis identified the presence of HCC, advanced recipient age, and high model for end-stage liver disease-Na scores as mortality risk factors. Five years after LT, 99.1% of HDV/HBV-coinfected patients received oral nucleos(t)ide analogs, with immunoglobulins against antigen of the hepatitis B virus in 91.8% of cases. HBV and HDV viral recurrences were 1.1% and 0.2%, respectively, whereas recurrent or de novo HCC were 8.9% and 0.3%, respectively. In Italy, HDV/HBV-coinfected patients waitlisted for LT showed more favorable outcomes compared with HBV-monoinfected patients, both before and after LT. These excellent results, from the largest cohort reported so far, suggest that HDV/HBV-coinfected LT recipients do not represent a risky population and may be considered for simpler long-term antiviral prophylactic strategies.

Determining safe washout period for immune checkpoint inhibitors prior to liver transplantation: An international retrospective cohort study

BACKGROUND AND AIMS

Immune checkpoint inhibitors (ICIs) are increasingly used in patients with advanced HCC patients awaiting liver transplantation (LT). However, concerns about the risk of posttransplant rejection persist.

APPROACH AND RESULTS

We conducted an international retrospective cohort study including 119 HCC patients who received ICIs prior to LT. We analyzed the incidence of allograft rejection, graft loss, and posttransplant recurrence with a particular focus on the washout period between the last ICI dose and LT. In this study, 24 of the 119 (20.2%) patients experienced allograft rejection with a median time to rejection of 9 days (IQR 6-10) post-LT. A linear relationship was observed between shorter washout periods and higher rejection risk. Washout periods <30 days (OR: 21.3, 95% CI: 5.93-103, p< 0.001) and between 30 and 50 days (OR: 9.48, 95% CI 2.47-46.8, p =0.002) were significantly associated with higher rejection rates in the univariate analysis compared to the washout period above 50 days. Graft loss as a result of rejection occurred in 6 patients (25%) with rejection. No factors related to grafts were associated with rejection. A longer washout period was not associated with a lower recurrence-free survival posttransplantation at 36 months (71% vs. 67%, p =0.71).

CONCLUSIONS

Our findings suggest that a washout period longer than 50 days for ICIs before LT appears to be safe with respect to rejection risk. While these results may help guide clinical decision-making, future prospective studies are essential to establish definitive guidelines.

Deep learning for hepatocellular carcinoma recurrence before and after liver transplantation: a multicenter cohort study

Hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) is a major contributor to mortality. We developed a recurrence prediction system for HCC patients before and after LT. Data from patients with HCC who underwent LT were retrospectively collected from three specialist centres in China. Pre- and post-operative variables were selected using support vector machine, random forest, and logistic regression (LR). Then, pre- and post-operative models were developed using three machine learning methods: LR, stacking, and two survival-based approaches. Models were evaluated using seven assessment indices, and patients were classified as either high- or low-risk based on recurrence risk. 466 patients were included and followed for a median of 51.0 months (95% CI 47.8-54.2). The pre-DeepSurv model (pre-DSM) had a C-index of 0.790 ± 0.003 during training, 0.775 ± 0.037 during testing, and 0.765 ± 0.001 and 0.819 ± 0.002 during external validation. After incorporating clinicopathologic variables, the post-DeepSurv model (post-DSM) had a 0.835 ± 0.008 C-index during training, 0.812 ± 0.082 during testing, and 0.839 ± 0.001 and 0.831 ± 0.002 during external validation. The post-DSM outperformed the Milan criteria by more accurately identifying patients at high risk of recurrence. Tumour recurrence predictions also improved significantly with DeepSurv. Both pre- and post-DSMs have the potential to guide personalised surveillance strategies for LT patients with HCC.

α-Fetoprotein model versus Milan criteria in predicting outcomes after hepatic resection for hepatocellular carcinoma: multicentre study

BACKGROUND

The Milan criteria and the French α-fetoprotein (AFP) model have both been validated for predicting outcomes after liver transplantation for hepatocellular carcinoma, with the Milan criteria also used for predicting outcomes after hepatic resection. The aim of this study was to evaluate the AFP model's predictive value for recurrence and survival following hepatocellular carcinoma resection and compare its performance with that of the Milan criteria.

METHODS

Data for patients who underwent hepatocellular carcinoma resection between 2002 and 2021 were analysed. For both the AFP model and Milan criteria, patients were divided into two groups: those with hepatocellular carcinoma within and beyond the AFP model (scores ≤ 2 and > 2 points, respectively) and the Milan criteria. Cumulative recurrence and overall survival rates were compared between patients within and beyond the AFP model. Predictions of recurrence and overall survival by the AFP model and Milan criteria were compared using net reclassification improvement and area under the receiver operating characteristic curve analyses.

RESULTS

Among 1968 patients evaluated, 1058 (53.8%) and 940 (47.8%) were classified as beyond on the AFP model and Milan criteria, respectively. After controlling for competing factors on multivariable analyses, being beyond the AFP model was independently associated with recurrence and worse overall survival after resection of hepatocellular carcinoma. Time-dependent net reclassification improvement and area under the receiver operating characteristic curve analyses demonstrated that the AFP model was superior to the Milan criteria in predicting recurrence. Of note, patients who were classified as beyond both the Milan criteria and AFP model had an even higher risk of postoperative recurrence and mortality (hazard ratios 1.51 and 1.47, respectively).

CONCLUSION

The French AFP model demonstrated superior prognostic accuracy to the Milan criteria in predicting recurrence and survival after hepatocellular carcinoma resection. The AFP model not only effectively stratified patient risk but also identified a subgroup of high-risk patients among those beyond the Milan criteria.

Multicenter Belgian prospective registry on minimally invasive and open liver surgery (BReLLS): experience from 1342 consecutive cases

PURPOSE

Minimally invasive liver surgery (MILS) still appears to be adopted with significant variability. We aimed to investigate the diffusion, indications, and short-term outcomes of MILS compared to the open approach.

METHODS

A prospective registry of all liver resections performed for any indication and using any technique between January 1, 2017, and December 31, 2019, was established (BReLLS) and analyzed.

RESULTS

A total of 1342 consecutive liver resections were included, 684 (51%) MILS and 658 (49%) open procedures. MILS was not attempted due to technical complexity in the 46.2% of cases, followed by previous abdominal surgery (22.5%). Patients undergoing MILS had a higher proportion of benign indications and of hepatocellular carcinomas, patients affected by liver cirrhosis with portal hypertension and a lower proportion of major hepatectomies (all p < 0.001). After propensity-score matching, MILS showed better results in terms of surgery duration (p < 0.001), blood loss (p = 0.015), complication rate (p < 0.001), rate of Clavien-Dindo grade ≥ 3 complications (p = 0.012), comprehensive complication index (p < 0.001), length of stay (p < 0.001), readmissions (p = 0.016). Centers performing over 50 liver resections per year had a higher proportion of overall MILS cases (p < 0.001), a similar proportion of major resections (p = 0.362), but a higher prevalence of MILS major resections (p = 0.004), lower 90-day mortality rates (p < 0.001), lower overall complication rates (p < 0.001), and shorter hospital length of stay (p < 0.001).

CONCLUSION

MILS was the preferred technique in half of the cases, particularly in patients with cirrhosis and portal hypertension, and benign lesions. It provided superior short-term outcomes compared to the open approach for both minor and major liver resections in selected patients.

Hidden costs of surgical complications: a retrospective cohort study

Objectives

To quantify how surgical complications impact hospital revenue when their effect on the volume of admissions is considered.

Design

Retrospective analysis of comprehensive administrative data.

Setting

Three university hospitals in France.

Participants

54 637 inpatient stays between 2017 and 2023 in 4 surgical departments (abdominal, orthopedics, thoracic, and urology).

Main outcome measures

Stays were categorized by their diagnosis-related group and occurrence of one or more complications, according to International Classification of Diseases, 10th revision diagnosis codes. First, data were aggregated monthly to determine the impact of variation in the monthly mean length of stay (LOS) on the monthly volume of admissions, using an instrumental variable strategy. Second, LOS and revenue per patient were compared for patients with and without complications. Finally, an estimation of the impact of complications on total revenue was performed.

Results

A total of 54 637 stays were analyzed, with 9735 (17.8%) experiencing at least one complication. The mean LOS was 8.7 days and the mean revenue per patient was €7602. The instrumental variable analysis, designed to account for unobserved confounders, showed that a decrease of 10% in the monthly mean LOS increased the monthly volume of admissions by 9% (95% CI (5.1% to 13.0%), p<0.01). Complications increased the LOS by 10.9 days (95% CI: (8.95 to 13.1), p<0.01) and revenue per patient by €7912 (95% CI: (6420 to 9087), p<0.01), but decreased daily revenue per patient by €211 (95% CI: (-384 to -83.0), p<0.01). Over the study period, the estimated potential loss induced by complications ranged from 6.6% (95% CI (6.3% to 7.0%), p<0.01) to 9.1% (95% CI (8.8% to 9.4%), p<0.01) of actual revenue. Departments with higher complication rates incurred larger potential losses.

Conclusions

Surgical complications reduce total revenue by crowding out short stays that generate more daily revenue. This challenges the consensus that complications are a boon for hospital revenue, instead implying that they shrink hospital net margins (ie, revenue minus costs).

Liver support systems and liver transplantation in acute liver failure

Acute liver failure (ALF) results in a multitude of complications that result in multi-organ failure. This review focuses on the pathophysiological processes and how to manage with these with artificial liver support and liver transplantation (LT). The pathophysiological sequence of events behind clinical deterioration in ALF comes down to two profound consequences of the failing liver. The first is the development of hyperammonemia, as the liver can no longer synthesize urea. The result is that the splanchnic system instead of removing ammonia becomes an ammonia-producing organ system that causes hepatic encephalopathy (HE) and cerebral oedema. The second complication is caused by the necrotic liver cells that release large molecules that originate from degrading proteins, that is damage associated molecular patterns (DAMPs) which causes inflammatory activation of intrahepatic macrophages and an overflow of DAMPs molecules into the systemic circulation resulting in a clinical picture that resembles septic shock. In this context the combined use of continuous renal replacement therapy (CRRT) and plasma exchange are rational and simple ways to remove ammonia and DAMPS molecules. This combination improve survival for ALF patients deemed not appropriate for LT, despite poor prognostic criteria, but also ensure a better stability of vital organs while awaiting LT. The combination of CRRT with albumin dialysis tends to have a similar effect. Currently, the selection criteria for LT for non-paracetamol cases appear robust while the criteria for paracetamol-intoxicated patients have become more unreliable and now consist of more dynamic prognostic systems. For patients that need LT for survival, a tremendous improvement in the post-LT results has been achieved during the last decade with a survival that now reach merely 90% which is mirroring the results seen after LT for chronic liver disease.

Investigation of the Effectiveness of Oleuropein in a Three-Dimensional In Vitro Hepatocellular Tumor Sphere Model

OBJECTIVES

This study was conducted to examine the dose-related effects over time of oleuropein on the proliferation and area of tumor spheroids in hepatocellular carcinoma cells.

MATERIALS AND METHODS

We examined the possible effects of 100 to 500 μM dose concentrations of oleuropein on HepG2 cell proliferation using a real-time cell analyzer. A 3-dimensional hepatocellular carcinoma tumor spheroid model was established by seeding HepG2 cells at a density of 160 cells/well in custom 96-well microplates with low attachment surfaces and culturing for 3 days. Tumor spheres were treated with increasing oleuropein doses for 72 hours, and images were captured every 24 hours. The dose-dependent effects of oleuropein on tumor sphere size were analyzed by measuring the area of tumor spheres with ImageJ software. We conducted oleuropein viability and cytotoxicity analyses using calcein acetoxymethyl ester-based and propidium iodide-based staining in the tumor model.

RESULTS

Oleuropein inhibited cell proliferation; as the dose concentration of oleuropein increased, so did its capacity to inhibit cell proliferation (P < .001). The size of untreated tumor spheres increased at 72 hours (P < .001). However, treatment with 100 to 500 μM oleuropein reduced tumor size by 63.56% to 88.06% compared with untreated cells at the end of 72 hours (P < .001). With increasing concentrations, oleuropein inhibited the viability of tumor spheres, eliminating necrotic death caused by tumor hypoxia.

CONCLUSIONS

Overall, oleuropein reduced the size of tumors by inhibiting tumor proliferation and viability. In this context, oleuropein could be a candidate molecule for further extensive studies to reduce hepatocellular carcinoma tumors to meet Milan criteria for liver transplant.

Reappraisal of tacrolimus levels after liver transplant for HCC: A multicenter study toward personalized immunosuppression regimen

Post-liver transplant (LT) immunosuppression is necessary to prevent rejection; however, a major consequence of this is tumor recurrence. Although recurrence is a concern after LT for patients with HCC, the oncologically optimal tacrolimus (FK) regimen is still unknown. This retrospective study included 1406 patients with HCC who underwent LT (2002-2019) at 4 US institutions using variable post-LT immunosuppression regimens. Receiver operating characteristic analyses were performed to investigate the influences of post-LT time-weighted average FK (TWA-FK) level on HCC recurrence. A competing risk analysis was employed to evaluate the prognostic influence of TWA-FK while adjusting for patient and tumor characteristics. The AUC for TWA-FK was greatest at 2 weeks (0.68), followed by 1 week (0.64) after LT. Importantly, this was consistently observed across the institutions despite immunosuppression regimen variability. In addition, the TWA-FK at 2 weeks was not associated with rejection within 6 months of LT. A competing risk regression analysis showed that TWA-FK at 2 weeks after LT is significantly associated with recurrence (HR: 1.31, 95% CI: 1.21-1.41, p < 0.001). The TWA-FK effect on recurrence varied depending on the exposure level and the individual's risk of recurrence, including vascular invasion and tumor morphology. Although previous studies have explored the influence of FK levels at 1-3 months after LT on HCC recurrence, this current study suggests that earlier time points and exposure levels must be evaluated. Each patient's oncological risk must also be considered in developing an individualized immunosuppression regimen.

Propensity Score-Matched Analysis of Liver Venous Deprivation and Portal Vein Embolization Before Planned Hepatectomy in Patients with Extensive Colorectal Liver Metastases and High-Risk Factors for Inadequate Regeneration

BACKGROUND

Liver venous deprivation (LVD) is known to induce better future liver remnant (FLR) hypertrophy than portal vein embolization (PVE). The role of LVD, compared with PVE, in inducing FLR hypertrophy and allowing safe hepatectomy for patients with extensive colorectal liver metastases (CLM) and high-risk factors for inadequate hypertrophy remains unclear.

METHODS

Patients undergoing LVD (n = 22) were matched to patients undergoing PVE (n = 279) in a 1:3 ratio based on propensity scores, prior to planned hepatectomy for CLM at a single center (1998-2023). The propensity scores accounted for high-risk factors for inadequate hypertrophy, namely pre-procedure standardized FLR (sFLR), body mass index, number of systemic therapy cycles, an extension of PVE to segment IV portal vein branches, prior resection, and chemotherapy-associated liver injury.

RESULTS

The matched cohort included 78 patients (LVD, n = 22; PVE, n = 56). Baseline characteristics were comparable. The number of tumors in the whole liver was similar but more LVD patients had five or more tumors in the left liver (32% vs. 11%; p = 0.024). Post-procedure sFLR was similar but LVD patients had a significantly higher degree of hypertrophy (16% vs. 11%; p = 0.017) and kinetic growth rate (3.9 vs. 2.4% per week; p = 0.006). More LVD patients underwent extended right hepatectomy (93% vs. 55%; p = 0.008). Only one patient had postoperative hepatic insufficiency after PVE, and no patients died within 90 days of hepatectomy.

CONCLUSION

In patients with extensive CLM and high-risk factors, LVD is associated with better FLR hypertrophy compared with PVE and allows for safely performing curative-intent extended major hepatectomy.

Early outcomes of robotic vs open living donor right hepatectomy in a US Center

BACKGROUND

Robotic living donor hepatectomy offers potential advantages but has been limited to high-volume centers, primarily in Asia and the Middle East. We report our experience establishing a robotic living donor right hepatectomy program in a U.S. center with low LDLT volume and no prior laparoscopic donor hepatectomy experience and analyze early outcomes.

METHODS

This retrospective cohort study analyzed 37 living donor right hepatectomies (13 robotic [including one open conversion], 24 open) performed between June 2022 and February 2024.

RESULTS

The robotic group had longer operative times (median [range], 451 [374-568] minutes vs 368 [276-421] minutes; P < 0.001) but less blood loss (median [range], 200 [50-700] mL vs 900 [300-2500] mL; P < 0.001). One case required unplanned open conversion due to gas embolism. Two hematomas/bleeding (Clavien-Dindo grade IIIB) occurred in the robotic group, but no biliary complications. Comprehensive Complication Index, liver function tests, and hospital stays were similar between the two groups, with no 90-day graft failure/mortality.

CONCLUSION

With extensive surgical experience in both open donor hepatectomy and robotic surgery, along with meticulous preparation as a team, U.S. centers with lower LDLT volume and no laparoscopic experience can safely implement robotic living donor right hepatectomy, achieving comparable short-term outcomes to the open approach. Further research on long-term outcomes and donor quality of life is necessary.

Gut microbiome and liver diseases

Symbiotic microbiota plays a crucial role in the education, development, and maintenance of the host immune system, significantly contributing to overall health. Through the gut-liver axis, the gut microbiota and liver have a bidirectional relationship that is becoming increasingly evident as more research highlights the translocation of the gut microbiota and its metabolites. The focus of this narrative review is to examine and discuss the importance of the gut-liver axis and the enterohepatic barrier in maintaining overall health. Additionally, we emphasize the crucial role of the gut microbiome in liver diseases and explore potential therapeutic strategies for liver diseases by manipulating the microbiota.

Liver transplantation for HBV-related liver disease: Impact of prophylaxis for HBV on HCC recurrence

BACKGROUND & AIMS

Conflicting data exist regarding optimal prophylaxis for HBV recurrence (HBV-R) after liver transplantation (LT), particularly in patients with hepatocellular carcinoma (HCC). We assessed current practices for HBV-R prophylaxis in Italy, evaluating rates, risk factors, and the clinical impact of HBV-R and HCC-R.

METHODS

We performed a multicentric, retrospective study involving 20 Italian LT centers. All patients who underwent LT for HBV-related liver diseases between 2010 and 2021 were included. Logistic regression was used to identify predictors of HBV-R and HCC-R. Survival curves were estimated with the Kaplan-Meier method and compared with the log-rank test.

RESULTS

We included 1,205 LT recipients (60.8% with HCC). HBV prophylaxis was prescribed in 99.7% of recipients, mostly with lifelong hepatitis B immunoglobulin+nucleos(t)ide analogues (HBIG+NUCs) (83.9%). Rates of HBV-R were 2.1% and 3.1% in patients transplanted without and with HCC, respectively. Median times from LT were 60 [9.5-77.5] and 5.5 [1-13] months, respectively. Recipients on lifelong HBIG+NUCs experienced lower rates of HBV-R than those in whom HBIG was withdrawn, used only during LT, or in those who received NUCs alone (2.3% vs. 6.2% vs. 1.9% vs. 8%, respectively; p = 0.042). In recipients with HCC, HCC-R rate was 10.8% (median time from LT: 18 months). At multivariate analysis, HBV-R (odds ratio [OR] 10.329; 95% CI 3.665-29.110), Child-Pugh C (OR 3.519; 95% CI 1.305-9.484), and microvascular invasion (OR 3.088; 95% CI 1.692-5.634) were independently associated with HCC-R. Five-year survival was lower in recipients who experienced HCC-R (32.5% vs. 92.4% in those who did not; p <0.001).

CONCLUSION

In Italy, HBV prophylaxis is mostly based on lifelong HBIG+NUCs. HBV-R was rare and not associated with survival in patients transplanted for decompensated cirrhosis. In patients transplanted for HCC, HBV-R was independently associated with HCC-R. The clinical implications of these findings deserve further investigation.

IMPACT AND IMPLICATIONS

In Italy, the combination of high-barrier nucleos(t)ide analogues and hepatitis B immunoglobulins remains the most widely used regimen for antiviral prophylaxis following liver transplantation for HBV-related liver disease. Hepatitis B recurrence after liver transplantation is a rare event and not associated with reduced survival. In transplant recipients with hepatocellular carcinoma, HBV recurrence was independently associated with hepatocellular carcinoma recurrence, though this may simply reflect an epiphenomenon without any causal relationship.

Small for Size Syndrome in Living Donor Liver Transplantation- Prevention and Management

Small-for-size syndrome is a clinical syndrome of early allograft dysfunction usually following living donor liver transplantation due to a mismatch between recipient metabolic and functional requirements and the graft's functional capacity. While graft size relative to the recipient size is the most commonly used parameter to predict risk, small-for-size syndrome is multifactorial and its development depends on a number of inter-dependant factors only some of which are modifiable. Intra-operative monitoring of portal haemodynamics and portal flow modulation is widely recommended though there is wide variation in clinical practice. Management of established small-for-size syndrome centres around meticulous patient care, infection prevention, fluid management and identifying correctable technical complications. However, retransplantation is the only treatment in severe cases. While small-for-size syndrome per se is associated with increased peri-operative mortality, the contribution of non-hepatic organ failure in determining patient outcomes needs further studies.