Characteristics, Trends, and Outcomes of Liver Transplantation for Primary Sclerosing Cholangitis in Female Versus Male Patients: An Analysis From the European Liver Transplant Registry.

BACKGROUND: The influence of sex on primary sclerosing cholangitis (PSC), pre- and postliver transplantation (LT) is unclear. Aims are to assess whether there have been changes in incidence, profile, and outcome in LT-PSC patients in Europe with specific emphasis on sex. METHODS: Analysis of the European Liver Transplant Registry database (PSC patients registered before 2018), including baseline demographics, donor, biochemical, and clinical data at LT, immunosuppression, and outcome. RESULTS: European Liver Transplant Registry analysis (n = 6463, 32% female individuals) demonstrated an increasing number by cohort (1980-1989, n = 159; 1990-1999, n = 1282; 2000-2009, n = 2316; 2010-2017, n = 2549) representing on average 4% of all transplant indications. This increase was more pronounced in women (from 1.8% in the first cohort to 4.3% in the last cohort). Graft survival rate at 1, 5, 10, 15, 20, and 30 y was 83.6%, 70.8%, 57.7%, 44.9%, 30.8%, and 11.6%, respectively. Variables independently associated with worse survival were male sex, donor and recipient age, cholangiocarcinoma at LT, nondonation after brain death donor, and reduced size of the graft. These findings were confirmed using a more recent LT population closer to the current standard of care (LT after the y 2000). CONCLUSIONS: An increasing number of PSC patients, particularly women, are being transplanted in European countries with better graft outcomes in female recipients. Other variables impacting outcome include donor and recipient age, cholangiocarcinoma, nondonation after brain death donor, and reduced graft size.

The impact of age on post-operative liver function following right hepatectomy: a retrospective, single centre experience.

BACKGROUND: An increasing number of patients undergoing liver resection are of advancing age. The impact of ageing on liver regeneration and post-operative outcomes following a major resection are uncertain. We aimed to investigate risk factors for patients who developed Post Hepatectomy Liver Failure (PHLF) following right hepatectomy with age as the primary risk-factor. METHOD: Patients undergoing right hepatectomy between July 2004-July 2018 were included. ROC analysis was performed to identify at which age PHLF development-risk increased. Secondary endpoints were length of stay (LOS), complications, and cost. RESULTS: 332-patients were included. ROC demonstrated a cut-off age of 75-years in which PHLF risk increased. >75 there was an increased risk of PHLF (35% >75yrs vs. 7% <75yrs (p = <0.001), OR = 8.8 (95% CI = 3.6-21)) There was no difference between the age groups for any other PHLF risk factor. Patients >75yrs had longer LOS (11-days vs. 7-days (p = 0.04). Patients who developed PHLF had increased hospital costs: £10,987.50 (£6175-£46,050) vs. £2575 (£900-£46,050 p = 0.01). CONCLUSIONS: Patients >75yrs have increased risk of developing PHLF after right hepatectomy, contributing to increased mortality and economic burden. Pre-operatively identifying patients at-risk of PHLF is important to consider liver volume optimization strategies and improve outcomes.

Does the extent of lymphadenectomy, number of lymph nodes, positive lymph node ratio and neutrophil-lymphocyte ratio impact surgical outcome of perihilar cholangiocarcinoma?

BACKGROUND: Lymph node (LN) status is an important predictor of survival following resection of perihilar cholangiocarcinoma (PHCCA). Controversies still exist with regard to the prognostic value of optimum extent of lymphadenectomy, total number of nodes removed, LN ratio (LNR) and neutrophil-lymphocyte ratio (NLR) on overall survival (OS) and disease-free survival (DFS) following PHCCA resection. METHODS: From 1994 to 2010, 84 PHCCAs were resected; 78 are included in this analysis. Kaplan-Meier survival curves were studied using log-rank statistics to assess which variables affected OS and DFS. The variables that showed statistical significance (P<0.05) on Kaplan-Meier univariate analysis were subjected to multivariate analysis using Cox proportional hazards model. RESULTS: Five-year OS for node-positive status (n=45) was 10%, whereas node-negative (n=33) OS was 41% (P<0.001). Similarly, 5-year DFS was worse in the node-positive group (8%) than in the node-negative group (36%, P=0.001). There was no difference in 5-year OS (31 vs. 12%, P=0.135) and DFS (22 vs. 16%, P=0.518) between those with regional lymphadenectomy and those who underwent regional plus para-aortic lymphadenectomy, respectively. On univariate analysis, patients with 20 or more LNs removed had worse 5-year OS (0%) when compared with those with less than 20 LNs removed (29%, P=0.047). Moderate/poor tumour differentiation, distant metastasis and LN involvement were independent predictors of OS. Positive LNR had no effect on OS. Vascular invasion and an LNR of at least 0.37 were independent predictors of DFS. NLR had no effect on OS and DFS. CONCLUSION: Extended lymphadenectomy patients (≥20 LNs) had worse OS when compared with those with more limited (<20 LNs) resection. An LNR of at least 0.37 is an independent predictor of DFS.

En bloc kidney transplant from young pediatric donors: a scope to increase the donor pool.

We report 2 cases of en bloc kidney transplants from young pediatric donors with successful outcomes. We underscore the underuse of this significant donor source, and discuss the factors that may be related to the reasons for reluctance in accepting these kidneys for transplant.

Papillary adenoma arising in the left hepatic duct: an unusual tumour in an uncommon location.

Bile duct adenomas are rare tumours that arise more frequently in the distal extrahepatic biliary tree. We report the case of a papillary adenoma arising at the junction of the common and left hepatic ducts and review the available literature on this rare entity. A 73-year-old lady presented with a history of mild weight loss and vague upper abdominal pain. Routine blood tests revealed an elevated c-glutaryl transferase, and an ultrasound scan showed gross dilatation of the intrahepatic and extrahepatic biliary tree. Subsequent radiological imaging confirmed biliary dilatation and identified tumour within the left and common hepatic ducts with the provisional diagnosis of cholangiocarcinoma. At laparotomy, there was no evidence of extraductal tumour, and choledochoscopy showed a papillary lesion within the common hepatic and proximal left hepatic ducts. The tumour was excised and the biliary tree was reconstructed. Histological evaluation of the resected specimen confirmed a papillary adenoma with mild dysplasia. This case illustrates that not all biliary tumours are cholangiocarcinomas and referral to a hepatopancreaticobiliary unit for investigation and treatment is mandatory for all cases of obstructive jaundice.

Outcomes in right liver lobe transplantation: a matched pair analysis.

Split liver transplantation (SLT) has proven to be an effective technique of increasing the donor pool and thereby reducing adult and paediatric waiting list mortality. There remains concern regarding complications in adult recipients. Here, we compare SLT with matched whole liver grafts. Adult recipients of primary extended right lobe grafts (ERL) were matched to recipients of whole liver transplantations (WLTs) according to the following criteria: model of end-stage liver disease (MELD) score, recipient age, indication for liver transplantation and year of transplantation. Twenty-seven pairs of recipients were transplanted for chronic liver disease. The overall 30-day patient survival rates after ERL and WLT were 88.9% and 92.5% and 3-year survival rates after SLT and WLT were 77.8% and 85.2% respectively (log-rank = 0.38). Two patients with SLTs had hepatic artery thromboses and were retransplanted with none from the WLT group. The prevalence of a biliary leak was higher among the SLT group (n = 4) compared with none in the WLT group (P = 0.05). Patients with preoperative hyponatraemia showed a trend towards poorer survival after SLT compared with WLT. Our data suggest that SLT with extended right liver lobes, although not significantly different, shows a trend towards a poorer outcome.

Prognostic utility of postoperative C-reactive protein for posthepatectomy liver failure.

HYPOTHESIS: C-reactive protein (CRP) is an acute-phase protein produced by the liver. We hypothesize that an early dampened CRP response after major liver resection is of prognostic importance in predicting posthepatectomy liver failure (PHLF). DESIGN: Serum CRP levels were determined on postoperative days 1, 3, and 7 in patients undergoing liver resection (stratified into minor [/=5 segments]). Correlations were made with indices of PHLF (hyperbilirubinemia, coagulopathy, ascites, and encephalopathy), multi-organ dysfunction syndrome, sepsis, and death. SETTING: Division of Hepatobiliary and Transplant Surgery, Leeds Teaching Hospitals National Health Service Trust, England. PATIENTS: One hundred thirty-eight individuals who underwent liver resection. MAIN OUTCOME MEASURES: Sepsis, PHLF, and mortality. RESULTS: A total of 138 liver resections (39 minor, 51 standard, and 48 extended) were included. Median serum CRP levels on day 1 were significantly lower after extended liver resection (28 mg/L; range, 5-119 mg/L [to convert to nanomoles per liter, multiply by 9.524]) compared with standard resection (41 mg/L; range, 5-85 mg/L) and minor resection (51 mg/L; range, 8-203 mg/L; chi(2) = 19; P < .001). Similar differences were observed on day 3 (chi(2) = 27; P < .001). Postoperative day 1 CRP levels were significantly lower in patients developing PHLF (hyperbilirubinemia, P = .001; ascites, P < .001; coagulopathy, P = .002; and encephalopathy, P < .001) or multiorgan dysfunction syndrome (P = .009) or who died (P = .01). Day 1 serum CRP levels and extent of resection were independent predictors of PHLF in multivariate analysis. CONCLUSION: The early dampened CRP response after major liver resection may reflect poor hepatic reserve that could have prognostic utility.

Outcomes after major hepatectomy in elderly patients.

BACKGROUND: We aimed to study the early and longterm outcomes of patients 70 years and older undergoing major liver resections, and compare the results with patients below the age of 70 years. STUDY DESIGN: All patients undergoing major liver resection (defined as three segments or more) from January 1993 to June 2004 were included. Patients were studied in two groups: 70 years of age and older (group E, elderly) and less than 70 years old (group Y, young). Early outcomes and longterm survival were analyzed. RESULTS: A total of 517 patients underwent major liver resection: group E, n=127; group Y, n=390 patients. There was no difference in operative mortality (group E, 7.9%; group Y, 5.4%; p=0.32) or postoperative morbidity (p=0.22) between the groups. Overall and disease-free survivals were not notably different for all patients (59% versus 57%, p=0.89; 60% versus 55%, p=0.28, respectively) or for a subgroup of patients with colorectal liver metastases (61% versus 55%, p=0.76; 60% versus 47%, p=0.07) in groups E versus Y, respectively. In multivariable analysis, American Society of Anesthesiologists grade 3 (p=0.024, hazard ratio [HR]=1.59, versus grade 1, 95% CI=1.06 to 2.39) and intraoperative transfusion>3 U (p<0.0005, HR=2.56, 95% CI=1.84 to 3.56) were predictors for overall survival. More than three tumors (p=0.025, HR=1.41, 95% CI=1.04 to 1.90) and redo resection (p=0.001, HR=2.80, 95% CI=1.51 to 5.19) were predictors of disease-free survival. CONCLUSIONS: Major liver resections can be safely performed in patients 70 years of age or older, with early results and survival similar to those in the younger than 70 age group. American Society of Anesthesiologists grade 3 and intraoperative transfusions>3 U were predictors for overall survival, and more than three tumors and redo resection were predictors for disease-free survival.