Emergency Liver Retransplantation With Marginal Donors.

BACKGROUND: The goal of the present study is to determine if using marginal donors negatively impacts the outcomes of emergency liver retransplantation. METHODS: A retrospective case-control study was performed, including all emergency liver retransplantations done in our center between 1990 and 2021. Recipients from the control group received the second grafts from "ideal donors", and patients from the case group received them from marginal donors. Analyzed variables included demographics of recipients and donors, complications, and survival rates. RESULTS: 38 emergency retransplantations were performed. 23 recipients were included in the control group, and the remaining 15 were in the case group. The second donors from the case group were significantly older (mean age 58 vs 71 years old, P < 0.0001). On the contrary, there were no differences between groups regarding the mean age of recipients, comorbidities, Model for End-Stage Liver Disease scores, or causes of retransplantation (the most common was hepatic artery thrombosis). No differences were found in early perioperative death rates (control group 26.1% vs case group 20%, P =1) and, although the case group seemed to have slightly poorer outcomes in long-term survival (control group 70%, 61%, and 55% vs case group 73%, 59%, and 39%, respectively, at 1, 5, and 10 years), the differences were not statistically significant (log-rank = 0.808). CONCLUSIONS: The use of marginal donors for emergency liver retransplantation was proved safe in our study, as there were no differences in complications or in short- or mid-term survival rates.

Importance of Preventing Inadvertent Perioperative Hypothermia During Liver Transplant.

BACKGROUND: Inadvertent perioperative hypothermia (IPH) leads to a series of deleterious effects that can be especially in complex procedures such as liver transplant. The implementation of a protocol is key to ensure the patient's normothermia. METHODS: A cohort of 209 patients who underwent liver transplant in a tertiary hospital in a period between January 2016 and December 2018 was retrospectively analyzed. The patients were divided into 2 groups: group 1, patients with normothermia (core body temperature ≥ 36°C) and group 2, patients with hypothermia (core body temperature < 36°C). Mortality between both groups at 1 month, 1 year, and 3 years is compared. Postoperative morbidity is also compared. RESULTS: The incidence of IPH is 21.5%. Patients with normothermia present with statistical significance: a lower mortality at 1 year; a lower need for transfusion of platelets, plasma, fibrinogen consumption, or massive polytransfusion; and lower primary graft dysfunction, graft and surgical complications, rejection, hemodynamic complications, and metabolic and surgical reintervention. No significant differences were found in mortality at 1 month or 3 years in the need for prolonged mechanical ventilation; hospital readmission; length of stay in the intensive care unit or in hospital stay; rate of red blood cell transfusion; vascular, biliary, respiratory, or digestive complications; refractory ascites; or neurologic, kidney, hematological, endocrine, thrombotic, nutritional, or infectious issues. CONCLUSIONS: The incidence of IPH is relatively low in our patients, based on what is described in the literature, and in most cases it is mild. There is a reduction in complications fundamentally related to the consumption of blood products and the graft.

Impact of the Acute and Chronic Liver Failure-Sequential Evaluation of Organ Failure Scoring System on the Prognosis of Liver Transplant.

BACKGROUND: The use of the Model of End-Stage Liver Disease (MELD) to predict morbidity and mortality after orthotopic liver transplant (OLT) is controversial. Acute and chronic liver failure-sequential evaluation of organ failure (CLIF-SOFA) is a new score that assess the patient's global status and that have been developed exclusively for patients with end-stage liver disease. The objective is to evaluate whether the CLIF-SOFA system predicts postoperative morbidity and mortality in the short and medium term. METHODS: A cohort of 123 patients who underwent OLT in a tertiary care hospital between January 2016 and December 2017 was retrospectively analyzed. The patients were divided into 2 groups: group 1 with a CLIF-SOFA score <7 and group 2 with a score CLIF-SOFA ≥7. RESULTS: Patients with a CLIF-SOFA ≥7 present, with statistical significance, had higher mortality at 1 and 3 years; longer duration of admission to the critical care unit; longer hospital stay; need for prolonged mechanical ventilation; surgical reintervention; higher rate of transfusion of blood products; pulmonary, neurologic, hemodynamic, surgical, infectious, kidney, metabolic, thrombotic, vascular, and graft complications; and need for kidney replacement therapy. However, no statistically significant differences were found in mortality in the first month, the need for hospital readmission, retransplant, digestive, endocrine, nutritional, hematologic, or biliary complications, and the presence of ascites. CONCLUSIONS: The role of CLIF-SOFA as a prognostic factor for mortality after OLT must be taken into account. Our results should be taken with caution, and more studies are necessary.

A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation.

PURPOSE: A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort. METHODS: An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included. RESULTS: A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%. CONCLUSION: Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.

Liver Transplantation: Analysis of Preservation Solutions in the Andalusian Registry.

BACKGROUND: The initial objective of this study is to analyze the impact on survival of the preservation solution used. Secondarily, the influence of donor age, underlying pathology, and graft ischemia time is investigated. METHODS: A multicenter retrospective analytical observational study has been carried out. A population of 1822 liver transplant recipients is studied in 4 Andalusian hospitals between 1995 and 2014. Survival of the patient and graft is analyzed by groups based on the conservation solution used, the age of the donor, the pathology indicated for transplant and the ischemia time, and the relationship between the variables through a bivariate study. A descriptive and predictive multivariate analysis of the variables was performed. RESULTS: Comparison of the graft and patient survival functions for each preservation solution did not differ significantly. The bivariate analysis shows a significantly higher utilization of Celsior and histidine-tryptophan-ketoglutarate solution in graft loss. The comparison between donor age groups showed significant differences in favor of donor grafts younger than 50 years. In the multivariate analysis of patient and graft survival, the donor age obtained a hazard ratio of 1.008 (P < .005) with donors older than 47.6 and 47.5 years, respectively. CONCLUSIONS: Survival analysis between pathology groups found significant differences, not obtaining predictive power for patient or graft survival in the multivariate study. No significant differences were found in survival according to ischemia time, but there was a relationship between early graft loss and longer mean cold ischemia times up to 18 hours.

Mortality after Transplantation for Hepatocellular Carcinoma: A Study from the European Liver Transplant Registry.

Background and Aims: Prognosis after liver transplantation differs between hepatocellular carcinoma (HCC) arising in cirrhotic and non-cirrhotic livers and aetiology is poorly understood. The aim was to investigate differences in mortality after liver transplantation between these patients. Methods: We included patients from the European Liver Transplant Registry transplanted due to HCC from 1990 to November 2016 and compared cirrhotic and non-cirrhotic patients using propensity score (PS) calibration of Cox regression estimates to adjust for unmeasured confounding. Results: We included 22,787 patients, of whom 96.5% had cirrhosis. In the unadjusted analysis, non-cirrhotic patients had an increased risk of overall mortality with a hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.23-1.52). However, the HR approached unity with increasing adjustment and was 1.11 (95% CI 0.99-1.25) when adjusted for unmeasured confounding. Unadjusted, non-cirrhotic patients had an increased risk of HCC-specific mortality (HR 2.62, 95% CI 2.21-3.12). After adjustment for unmeasured confounding, the risk remained significantly increased (HR 1.62, 95% CI 1.31-2.00). Conclusions: Using PS calibration, we showed that HCC in non-cirrhotic liver has similar overall mortality, but higher HCC-specific mortality. This may be a result of a more aggressive cancer form in the non-cirrhotic liver as higher mortality could not be explained by tumour characteristics or other prognostic variables.

Results of Early Liver Retransplantation.

BACKGROUND: Liver retransplantation can be classified as urgent (when performed in the first week after the transplantation) or elective, which may be considered as early (first month post-transplantation) or late (after the first month). The time in which retransplantation takes place is determined by the cause that makes it necessary. The goal of this study is to analyze the causes and results of early retransplantation in our center. METHODS: A retrospective analysis of liver retransplantations performed within the first month after the original transplantation in our center between 2007 and 2017 was carried out. The variables analyzed were demographic, causes of the first transplant and retransplantation, and the complications and mortality resulting from the latter. RESULTS: A total of 698 liver transplants were performed, including 67 patients who required retransplantation (8.9%). Among these, 37 were late elective retransplantations and 30 were early retransplantations. Regarding the latter, the causes that led to the first transplant were hepatocellular carcinoma (46.7%) and noncholestatic cirrhosis (30%). On the other hand, the main precipitants of the retransplantation were hepatic artery thrombosis (60%) and primary graft failure (13.3%). The reoperation rate was 16.7%, and the perioperative mortality rate was 16.7%. The 1-, 2-, and 5-year survival rates were 83.3%, 76.7% and 59.9%, respectively. CONCLUSION: Despite the high perioperative morbidity of liver retransplantation, its results in terms of survival are similar to those of the global series of liver transplantation.