Liver transplantation for non-resectable colorectal liver metastases: the International Hepato-Pancreato-Biliary Association consensus guidelines

Colorectal cancer is a prevalent disease worldwide, with more than 50% of patients developing metastases to the liver. Despite advances in improving resectability, most patients present with non-resectable colorectal liver metastases requiring palliative systemic therapy and locoregional disease control strategies. There is a growing interest in the use of liver transplantation to treat non-resectable colorectal liver metastases in well selected patients, leading to a surge in the number of studies and prospective trials worldwide, thereby fuelling the emerging field of transplant oncology. The interdisciplinary nature of this field requires domain-specific evidence and expertise to be drawn from multiple clinical specialities and the basic sciences. Importantly, the wider societal implication of liver transplantation for non-resectable colorectal liver metastases, such as the effect on the allocation of resources and national transplant waitlists, should be considered. To address the urgent need for a consensus approach, the International Hepato-Pancreato-Biliary Association commissioned the Liver Transplantation for Colorectal liver Metastases 2021 working group, consisting of international leaders in the areas of hepatobiliary surgery, colorectal oncology, liver transplantation, hepatology, and bioethics. The aim of this study was to standardise nomenclature and define management principles in five key domains: patient selection, evaluation of biological behaviour, graft selection, recipient considerations, and outcomes. An extensive literature review was done within the five domains identified. Between November, 2020, and January, 2021, a three-step modified Delphi consensus process was undertaken by the workgroup, who were further subgrouped into the Scientific Committee, Expert Panel, and Transplant Centre Representatives. A final consensus of 44 statements, standardised nomenclature, and a practical management algorithm is presented. Specific criteria for clinico-patho-radiological assessments with molecular profiling is crucial in this setting. After this, the careful evaluation of biological behaviour with bridging therapy to transplantation with an appropriate assessment of the response is required. The sequencing of treatment in synchronous metastatic disease requires special consideration and is highlighted here. Some ethical dilemmas within organ allocation for malignant indications are discussed and the role for extended criteria grafts, living donor transplantation, and machine perfusion technologies for non-resectable colorectal liver metastases are reviewed. Appropriate immunosuppressive regimens and strategies for the follow-up and treatment of recurrent disease are proposed. This consensus guideline provides a framework by which liver transplantation for non-resectable colorectal liver metastases might be safely instituted and is a meaningful step towards future evidenced-based practice for better patient selection and organ allocation to improve the survival for patients with this disease.

Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants

BACKGROUND

Metabolic-bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy-especially stratified by pre-existing diabetes status-are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic-bariatric surgery versus usual care.

METHODS

We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic-bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic-bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472.

FINDINGS

Among 1470 articles identified, 16 matched cohort studies and one prospective controlled trial were included in the analysis. 7712 deaths occurred during 1·2 million patient-years. In the overall population consisting 174 772 participants, metabolic-bariatric surgery was associated with a reduction in hazard rate of death of 49·2% (95% CI 46·3-51·9, p<0·0001) and median life expectancy was 6·1 years (95% CI 5·2-6·9) longer than usual care. In subgroup analyses, both individuals with (hazard ratio 0·409, 95% CI 0·370-0·453, p<0·0001) or without (0·704, 0·588-0·843, p<0·0001) baseline diabetes who underwent metabolic-bariatric surgery had lower rates of all-cause mortality, but the treatment effect was considerably greater for those with diabetes (between-subgroup I² 95·7%, p<0·0001). Median life expectancy was 9·3 years (95% CI 7·1-11·8) longer for patients with diabetes in the surgery group than the non-surgical group, whereas the life expectancy gain was 5·1 years (2·0-9·3) for patients without diabetes. The numbers needed to treat to prevent one additional death over a 10-year time frame were 8·4 (95% CI 7·8-9·1) for adults with diabetes and 29·8 (21·2-56·8) for those without diabetes. Treatment effects did not appear to differ between gastric bypass, banding, and sleeve gastrectomy (I² 3·4%, p=0·36). By leveraging the results of this meta-analysis and other published data, we estimated that every 1·0% increase in metabolic-bariatric surgery utilisation rates among the global pool of metabolic-bariatric candidates with and without diabetes could yield 5·1 million and 6·6 million potential life-years, respectively.

INTERPRETATION

Among adults with obesity, metabolic-bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without.

FUNDING

None.

An international multicenter study of protocols for liver transplantation during a pandemic: A case for quadripartite equipoise

BACKGROUND & AIMS

The outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources.

METHODS

We performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources.

RESULTS

Seventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic.

CONCLUSIONS

This four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems.

LAY SUMMARY

There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.

The benefits of back pain

BACKGROUND

Chronic lower back pain (CLBP), without definable cause, is a symptom commonly presented to GPs, accounting for a significant proportion of their workload; it is also a common reason for sickness absence, and thus of national economic importance.

OBJECTIVES

This qualitative study aims to explore how sufferers of CLBP describe their pain and its impact on their lives, and how their problem is dealt with in the consultation with their family doctor.

METHOD

Semi-structured interviews were carried out with a sample of attenders at a back pain clinic set up in general practice. Transcription and analysis was carried out using a grounded-theory approach.

RESULTS

Sufferers of CLBP describe withdrawal from normal social obligations, including work. They view their GP as being unable to help and, because of this, the doctor becomes a resource through which their social and economic inactivity can be legitimated.

CONCLUSIONS

Presenting with CLBP permits the patient a good deal of power over the GP: it is difficult for the GP to challenge the patient's ideas without damaging the relationship. GPs are forced to collude with the patient's definition of ill-health, which may not be in the best interests of the patient or society.

Annual assessments of patients aged 75 years and over: views and experiences of elderly people

BACKGROUND

The 1990 contract requires general practitioners to offer all their patients aged 75 years and over an annual health check. Increasing importance is being placed on consumers' views of service provision.

AIM

A study was undertaken in June 1992 to investigate elderly patients' views and experiences of the annual health check, and to compare these with the previously reported views of general practitioners and practice nurses who had also been surveyed as part of the study.

METHOD

Twenty family health services authorities wrote to a sample of 1500 elderly patients asking if the patient's name could be passed to researchers. Patients who agreed were then interviewed.

RESULTS

A total of 664 elderly patients (44%) were interviewed. Only 64% of respondents were aware of their entitlement to a health check. Vulnerable patients, such as those in poor health or who lived alone, were less likely to know about the health checks than other patients. Only 31% of respondents thought they had had a health check. Of these, fewer than half recalled the doctor or nurse discussing the findings with them, although 80% of doctors reported that they always or mostly discussed results with patients. Elderly patients were more likely to recall the physical aspects of the health check rather than discussion about particular health aspects. However, doctors and nurses felt that routine checks were useful for giving advice rather than detecting medical problems. Of those who had had a health check, 82% reported no improvement in their health as a result, but 93% thought that they were a good idea. Only 7% of doctors thought they were of value, compared with the majority of nurses.

CONCLUSION

It appeared that the inverse care law was operating, with those more in need of the service being less likely to have known about it. Discrepancies were found between general practitioners' and practice nurses' reports of service provision and those of elderly patients. Evidence about the cost-effectiveness of regular health checks may help the conflict between professional scepticism and consumer enthusiasm for these assessments.

Annual assessment of patients aged 75 years and over: general practitioners' and practice nurses' views and experiences

BACKGROUND

The new contract for general practitioners, introduced in 1990, required them to offer an annual assessment, or 'health check', to patients aged 75 years or more.

AIM

A study was undertaken to collect details of practice organization of these assessments, general practitioners' and practice nurses' experience of assessments, and their views of the value of such assessments.

METHOD

A nationwide postal survey of 1000 general practitioners and interview surveys with general practitioners and practices nurses from 150 practices were carried out in 1992.

RESULTS

The postal survey yielded a response rate of 69% and the interview survey a practice response rate of 76%. Organization of assessments varied enormously between, and often within, practices with a variety of methods of invitation and assessment instruments being used. Of general practitioners 13% did not use a letter of any sort to invite patients to attend, and many doctors excluded certain patients from assessment, particularly those who were seen regularly or had been seen recently. However, 70% of general practitioners estimated that they had assessed over 60% of their elderly patients in the first year (1990-91). A substantial proportion of assessments were estimated to have been conducted on an opportunistic basis and few practices were doing all the assessments of those aged 75 years and over in the patients' homes. In the majority of practices, the general practitioners and practice nurses were the only personnel carrying out assessments. Only 9% of the doctors and 34% of the nurses interviewed had been specially trained to carry out the assessment; 54% of nurses said they would like more training in this area. Both doctors and nurses reported that the assessments did detect previously unknown problems, although over half of doctors reported that they rarely picked up new mental health problems. Increased referrals to social services as a direct result of the assessments were reported by 63% of doctors. The majority of doctors and nurses reported that routine assessments were useful in providing advice and reassurance to elderly people. Two thirds of doctors said they would continue to offer at least selected groups of their elderly patients routine assessments, even if not contractually obliged to do so.

CONCLUSION

The findings suggest that the experiences of the first two years of this activity had convinced some general practitioners that routine assessment of elderly patients is worthwhile. However the increased demand for other services must obviously be met by an increase in resources if the effectiveness of these assessments is not to be undermined.