Novel Benchmark for Adult-to-Adult Living-donor Liver Transplantation: Integrating Eastern and Western Experiences

Temporal evolution of living donor liver transplantation survival-A United Network for Organ Sharing registry study

Living donor liver transplantation (LDLT) is a curative treatment for various liver diseases, reducing waitlist times and associated mortality. We aimed to assess the overall survival (OS), identify predictors for mortality, and analyze differences in risk factors over time. Adult patients undergoing LDLT were selected from the United Network for Organ Sharing database from inception (1987) to 2023. The Kaplan-Meier method was used for analysis, and multivariable Cox proportional hazard models were conducted. In total, 7257 LDLT recipients with a median age of 54 years (interquartile range [IQR]: 45-61 years), 54% male, 80% non-Hispanic White, body mass index of 26.3 kg/m2 (IQR: 23.2-30.0 kg/m2), and model for end-stage liver disease score of 15 (IQR: 11-19) were included. The median cold ischemic time was 1.6 hours (IQR: 1.0-2.3 hours) with 88% right lobe grafts. The follow-up was 4.0 years (IQR: 1.0-9.2 years). The contemporary reached median OS was 17.0 years (95% CI: 16.1, 18.1 years), with the following OS estimates: 1 year 95%; 3 years 89%; 5 years 84%; 10 years 72%; 15 years 56%; and 20 years 43%. Nine independent factors associated with mortality were identified, with an independent improved OS in the recent time era (adjusted hazards ratio: 0.53; 95% CI: 0.39, 0.71). The median center-caseload per year was 5 (IQR: 2-10), with observed center-specific improvement of OS. LDLT is a safe procedure with excellent OS. Its efficacy has improved despite an increase of risk parameters, suggesting its limits are yet to be met.

A critical analysis of surgical outcomes indicators in hepato-pancreato-biliary surgery: From crude mortality to composite outcomes

BACKGROUND

Indicators of surgical outcomes are designed to objectively evaluate surgical performance, enabling comparisons among surgeons and institutions. In recent years, there has been a surge in complex indicators of perioperative short-term and long-term outcomes. The aim of this narrative review is to provide an overview and a critical analysis of surgical outcomes indicators, with a special emphasis on hepato-pancreato-biliary (HPB) surgery.

METHODS

A narrative review of outcome measures was conducted using a combined text and MeSH search strategy to identify relevant articles focused on perioperative outcomes, specifically within HPB surgery.

RESULTS

The literature search yielded 624 records, and 94 studies were included in the analysis. Included papers were classified depending on whether they assessed intraoperative or postoperative specific or composite outcomes, and whether they assessed purely clinical or combined clinical and socio-economic indicators. Specific indicators included in composite outcomes were categorized into three main domains: intraoperative metrics, postoperative outcomes, and oncological outcomes. While postoperative mortality, complications, hospital stay and readmission were the indicators most frequently included in composite outcomes, oncological outcomes were rarely considered.

CONCLUSIONS

The evolution of surgical outcomes has shifted from the simplistic assessment of crude mortality rates to complex composite outcomes. Whether the recent explosion of publications on these topics has a clinical impact in real life is questionable. Outcomes from the patient perspective, integrating social and financial indicators, are not yet integrated into most of these composite analytical tools but should not be underestimated.

Advocating for a "shift-to-left" in transplant oncology: left grafts, RAPID and dual graft

The extension of liver transplantation to new oncologic indications might exacerbate the shortage of grafts. Living donor liver transplantation (LDLT) may emerge as a viable resource, although its diffusion in the Western world is still very limited. Several groups have advocated for minimizing the impact on donors by reducing the extent of donor hepatectomy, i.e., shifting from right-lobe to left-lobe or left-lateral segment donation ("shift-to-left"). This is particularly relevant when dealing with non-established indications and could make it more acceptable both for potential donors and for the recipients. Left grafts can be transplanted straightforward, despite a higher risk of small-for-size syndrome, or they can be used in the setting of dual-graft LDLT or RAPID procedures, despite technical complexity. This review will expose the most relevant features of each technique, highlighting their strengths and pitfalls and focusing on outcomes. This wide set of tools should be available at high-volume transplant centers, to propose the best technique to adapt to donor-recipient matching.

6,126 hepatectomies in 2022: current trend of outcome in Italy

PURPOSE

Whether hospital volume affects outcome of patients undergoing hepatobiliary surgery, and whether the centralization of such procedures is justified remains to be investigated. The aim of this study was to analyze the outcome of liver surgery in Italy in relationship of hospital volume.

METHODS

This is a nationwide retrospective observational study conducted on data collected by the National Italian Registry "Piano Nazionale Esiti" (PNE) 2023 that included all liver procedures performed in 2022. Outcome measure were case volume and 30-day mortality. Hospitals were classified as very high-volume (H-Vol), intermediate-volume (I-Vol), low-volume (L-Vol) and very low-volume (VL-VoL). A review on centralization process and outcome measures was added.

RESULTS

6,126 liver resections for liver tumors were performed in 327 hospitals in 2022. The 30-day mortality was 2.2%. There were 14 H-Vol, 19 I-Vol, 31 L-Vol and 263 VL-Vol hospitals with 30-day mortality of 1.7%, 2.2%, 2.6% and 3.6% respectively (P < 0.001); 220 centers (83%) performed less than 10 resections, and 78 (29%) centers only 1 resection in 2022. By considering the geographical macro-areas, the median count of liver resection performed in northern Italy exceeded those in central and southern Italy (57% vs. 23% vs. 20%, respectively).

CONCLUSIONS

High-volume has been confirmed to be associated to better outcome after hepatobiliary surgical procedures. Further studies are required to detail the factors associated with mortality. The centralization process should be redesigned and oversight.

Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Outcomes of Fully Robotic Recipient Living Donor Liver Transplant in Relation to the Open Approach

BACKGROUND

Over the past 20 y, robotic surgery has entered nearly all surgical disciplines, aiming to improve patient outcomes. Liver transplantation has evolved with these advancements, and fully robotic liver transplants represent the latest innovation in this field. This study reports on the world's first series of fully robotic recipient liver transplants from robotic living donors, comparing them with matched cases from the standard open transplant approach.

METHODS

A case-control study was conducted at our center from August to December 2023. Patient selection criteria for robotic recipient liver transplantation included a Model for End-stage Liver Disease score of ≤25, specific anatomical characteristics, and logistics. A propensity score analysis with a 1:4 matching ratio was used.

RESULTS

The study analyzed 10 fully robotic living donor and robotic recipient liver transplant pairs with a median donor age of 29 y and a recipient age of 61 y. The main indication for transplantation was nonalcoholic steatohepatitis (6/10). There was 1 robotic to open conversion, and the median operation time was 10 h, with a median hospital stay of 13 d, shorter than the 18 d in the open group. Three recipients experienced a complication, and there was no mortality.

CONCLUSIONS

The first-ever series of fully robotic living donor recipient liver transplants showed encouraging initial results with a markedly reduced hospital stay. The ultimate goal is to refine the technique to offer robotic liver transplants to the majority of recipients, overcoming the current selection criteria. Further research and a planned randomized controlled trial will aim to confirm these results.

Outcomes of 6000 living donor liver transplantation procedures: a pioneering experience at ASAN Medical Center

Living donor liver transplantation (LDLT) has emerged as a favorable alternative to deceased donor liver transplantation, significantly reducing waitlist mortality, particularly in Asian countries with very low deceased organ donation rates. Asan Medical Center (AMC) in South Korea has pioneered innovative LDLT surgical techniques and become established as an extremely high-volume center for LDLT. This retrospective study analyzed 6000 consecutive LDLT procedures, including 510 dual-graft procedures, performed at AMC between December 1994 and January 2021. Of these, 312 LDLT procedures were performed in children aged < 18 years. In adult recipients, liver cirrhosis (LC) related to viral hepatitis was the most common indication, occurring in 69.8% of cases. Biliary atresia (46.8%) was the most common indication for pediatric LDLT. This study demonstrated outstanding long-term outcomes, with patient survival rates at 1, 5, 10, and 20 years of 92.7%, 85.9%, 82.1%, and 70.9%, respectively, in LDLT group for adults aged 50 and under at the time of LDLT, and 92.9%, 89.0%, 88.1%, and 81.9%, respectively, in the pediatric group. The in-hospital mortality rate of adult recipients was 3.8% (n = 214/5688). This study demonstrates the importance of refined surgical techniques, selection of grafts tailored to the recipient, and comprehensive multidisciplinary perioperative patient care in expanding the scope of LDLT and improving recipient outcomes.

The psychology, legality, ethics and medical aspects of organ donation by minors

Any individual who has not attained the chronological age of legal majority as per national law is termed a minor. The concept of living donation (LD) has always been a subject of ethical debate and further compounding the controversy is the question of LD by minors. The decision for a minor to donate poses a special challenge as it involves a close family unit of parent-child relationship. Such an emotionally loaded situation wherein questions of attachment, perceived duties, moral obligation are likely to cloud a truly informed consent on the part of the minor to donation, who may find themselves in a vulnerable position. Furthermore, a minor's cognitive ability to comprehend the gravity of LD and when required defy parental coercion need to be elucidates before a minor is accepted for LD. Experts have set out stringent conditions which need to be met prior to the exceptional circumstance that a minor is considered for organ donation. Such donations should require parental permission, child's assent and the involvement of a paediatric-trained donor advocacy team. This article debates the question of minors acting as live donors from ethical, medical, psychosocial and legal viewpoints with an aim to present internationally defined circumstances when a minor may morally participate as a LD, thereby laying the foundation for future deliberations in this regard using traditional metrics to juxtapose divergent courses of action.

Liver transplantation for intrahepatic cholangiocarcinoma: who, when and how

PURPOSE OF REVIEW

Using transplant oncology principles, selected patients with intrahepatic cholangiocarcinoma (iCCA) may achieve long-term survival after liver transplantation. Strategies for identifying and managing these patients are discussed in this review.

RECENT FINDINGS

Unlike initial reports, several modern series have reported positive outcomes after liver transplantation for iCCA. The main challenges are in identifying the appropriate candidates and graft scarcity. Tumor burden and response to neoadjuvant therapies have been successfully used to identify favorable biology in unresectable cases. New molecular biomarkers will probably predict this response in the future. Also, new technologies and better strategies have been used to increase graft availability for these patients without affecting the liver waitlist.

SUMMARY

Liver transplantation for the management of patients with unresectable iCCA is currently a reality under strict research protocols. Who is a candidate for transplantation, when to use neoadjuvant and locoregional therapies, and how to increase graft availability are the main topics of this review.

Propensity score matched analysis and risk stratification of donors with G6PD deficiency in living donor liver transplantation

INTRODUCTION

Glucose 6 phosphate dehydrogenase (G6PD) deficiency (G6PDd) can trigger hemolysis following surgical stress. Differentiating G6PDd-related post-operative hemolytic episodes (PHE) and post-hepatectomy liver failure may be challenging especially in living donors where donor safety is paramount. We analysed outcomes of our cohort of G6PDd liver donors.

METHODS

G6PDd individuals with no evidence of hemolysis were considered as living donors if there was no alternative family donor. Outcomes of G6PDd donors undergoing left lateral/left lobe donation (Group LL) and right lobe donation (Group RL) were compared with non-G6PDd donors matched in a 1:3 ratio using propensity score matching.

RESULTS

59 G6PDd donors (5.8% of 1011) underwent living donor hepatectomy (LiDH) during the study period. LL-G6PDd donors (22.37%) had higher post-operative peak bilirubin level compared to matched controls, but no difference in morbidity or need for post-operative blood transfusion.RL-G6PDd donors (37.63%) had higher peak bilirubin level, morbidity (16.2% vs. 3.6%, p = 0.017) and more post-operative blood transfusion (21.6% vs. 6.4%, p = 0.023) as compared to matched non-G6PDd cohort. Four RL-G6PDd donors (10.8%) developed PHE. Low G6PD activity (15% vs. 40%, p = 0.034) and lower future liver remnant (FLR) (34.3% vs. 37.8%, p = 0.05) were identified as risk factors for PHE.

CONCLUSION

We report the largest to-date series of G6PDd individuals undergoing LiDH and confirm the safety of LL donation in G6PDd. Our analysis identifies specific risk factors for PHE and suggests that right lobe LiDH be avoided in individuals with less than 25% G6PD activity when the FLR is less than 36%.