New therapeutic strategy with extracorporeal membrane oxygenation for refractory hepatopulmonary syndrome after liver transplant: A case report.

BACKGROUND: Due to the lack of published literature about treatment of refractory hepatopulmonary syndrome (HPS) after liver transplant (LT), this case adds information and experience on this issue along with a treatment with positive outcomes. HPS is a complication of end-stage liver disease, with a 10%-30% incidence in cirrhotic patients. LT can reverse the physiopathology of this process and restore normal oxygenation. However, in some cases, refractory hypoxemia persists, and extracorporeal membrane oxygenation (ECMO) can be used as a rescue therapy with good results. CASE SUMMARY: A 59-year-old patient with alcohol-related liver cirrhosis and portal hypertension was included in the LT waiting list for HPS. He had good liver function (Model for End-Stage Liver Disease score 12, Child-Pugh class B7). He had pulmonary fibrosis and a mild restrictive respiratory pattern with a basal oxygen saturation of 82%. The macroaggregated albumin test result was > 30. Spirometry demon strated a forced expiratory volume in one second (FEV1) of 78%, forced vital capacity (FVC) of 74%, FEV1/FVC ratio of 81%, diffusion capacity for carbon monoxide of 42%, and carbon monoxide transfer coefficient of 57%. He required domiciliary oxygen at 2 L/min (16 h/d). The patient was admitted to the intensive care unit (ICU) and extubated in the first 24 h, needing high-flow therapy and non-invasive ventilation and inhaled nitric oxide afterwards. Reintubation was needed after 72 h. Due to the non-response to supportive therapies, installation of ECMO was decided with progressive recovery after 9 d. Extubation was possible on the tenth day, maintaining a high-flow nasal cannula and de-escalating to conventional oxygen therapy after 48 h. He was discharged from ICU on postoperative day (POD) 20 with a 90%-92% oxygen saturation. Steroid recycling was needed twice for acute rejection. The patient was discharged from hospital on POD 27 with no symptoms, with an 89%-90% oxygen saturation. CONCLUSION: Due to the favorable results observed, ECMO could become the central axis of treatment of HPS and refractory hypoxemia after LT.

Implementation of an ERAS protocol on cirrhotic patients in liver resection: a cohort study.

The development of laparoscopic liver surgery, the improvement in the perioperative care programs, and the surgical innovation have allowed liver resections on selected cirrhotic patients. However, the great majority of ERAS studies for liver surgery have been conducted on patients with normal liver parenchyma, while its application on cirrhotic patients is limited. The purpose of this study was to evaluate the implementation of an ERAS protocol in cirrhotic patients who underwent liver surgery. We present an analytical observational prospective cohort study, which included all adult patients who underwent a liver resection between December 2017 and December 2019 with an ERAS program. We compare the outcomes in patients cirrhotic (CG)/non-cirrhotic (NCG). A total of 101 patients were included. Thirty of these (29.7%) were patients ≥ 70 cirrhotic. 87% of the both groups had performed > 70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were similar in both groups. The hospital stay was similar in both groups (2.9 days/2.99 days). Morbidity and mortality were similar; Clavien I-II (CG: 44% vs NCG: 30%) and Clavien ≥ III (CG: 3% vs NCG: 8%). Hospital re-entry was higher in the NCG. Overall mortality of the study was 1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%: 80% vs ERAS > 90%: 20%; p: 0.02) and decrease in severity of complications in both study groups. The application of the ERAS program in cirrhotic patients who undergo liver surgery is feasible, safe, and reproducible. It allows postoperative complications, mortality, hospital stay, and readmission rates comparable to those in standard patients.

Liver Transplant With Double Portal Anastomose: A Case Report.

BACKGROUND: Reno-portal reconstruction is a surgical alternative to achieve enough portal flow in liver transplant when there is a complete portal thrombosis, provided there are collaterals or portosystemic shunt, with or without spleno-renal shunt. METHODS: We present the case of a 58-year-old man with enolic cirrhosis and a history of gastrointestinal hemorrhage due to esophageal varices and portal thrombosis. The clinical case was discussed in the Transplant Committee, and the patient was included in the surgical waiting list with a Model for End-Stage Liver Disease score of 17 and Child-Pugh score of A6. The preoperative computer tomography scan showed significant collateral circulation with esophageal varices, varices dependent on the inferior mesenteric vein (IMV) and hypoplasic portal vein. During the operation, a large shunt from the IMV to the iliac territory and type II portal thrombosis were observed, which was managed with eversion thrombectomy. A temporary portocaval shunt was performed, showing minimal flow in the portal vein, which did not improve after ligation of the systemic shunt. It was decided to perform a reno-portal anastomosis, after which the portal flow measurement was 600 cc per minute; because of this, it was decided to supplement portal flow with an end-to-side portoportal anastomosis, obtaining a flow of 1300 cc per minute with low resistance (R0.5). RESULTS: The postoperative period was favorable, with good evolution of liver analytical parameters, with permeability of the porto-portal venous anastomoses, reno-portal, arterial, and suprahepatic anastomoses in the imaging tests. CONCLUSION: If the portal flow is insufficient with a hypoplasic portal vein, a double anastomosis, portoportal, and reno-portal would be a technical resource.

Recipient With Influenza A Infection: Contraindication to Transplant? A Case Report.

Active infections in recipients are considered an absolute contraindication to liver transplantation due to the risk of severe disease caused by the required immunosuppression. Even though viral infections, such as Influenza A, have been treated in liver transplant patients both in the immediate and late postoperative period with favorable outcomes, no cases of prediagnosed Influenza A have been described in which the decision to proceed with the indication had to be made. In certain viral infections, like Influenza A, the paucisymptomatic state and the availability of appropriate treatment could open the door to performing liver transplants with positive results.

Implementación del protocolo ERAS en ancianos sometidos a resección hepática / Implementation of an ERAS protocol on elderly patients in liver resection

Introducción: El aumento en la calidad de vida, la mejora en los cuidados perioperatorios, la aplicación del concepto de fragilidad y un mayor desarrollo de técnicas quirúrgicas permite a pacientes ancianos el acceso a la cirugía hepática. Sin embargo, la edad sigue siendo limitante para la implementación de protocolos ERAS en este grupo. El objetivo del estudio es evaluar la implementación del protocolo ERAS en pacientes ancianos (≥70años) sometidos a resecciones hepáticas. Métodos: Estudio de cohorte prospectivo que incluye pacientes intervenidos de resección hepática durante diciembre de 2017 a diciembre de 2019 sometidos a un programa ERAS, comparando los resultados de pacientes ≥70años (G≥70) frente a <70años (G<70). La fragilidad se midió con el score Physical Frailty Phenotype. Resultados: Se incluyeron 101 pacientes, de los que 32 (31,6%) correspondieron a G≥70. El 90% de ambos grupos verificaron realizar >70% del ERAS. Se encontraron diferencias a favor del G<70 en el inicio de tolerancia y la movilización activa el primer día postoperatorio. La estancia postoperatoria fue superponible (3,07días vs 2,7días). La morbimortalidad fue similar; ClavienI-II (G≥70: 41% vs G<70: 30,5%) y ≥III (G≥70: 6% vs G<70: 8,5%), al igual que los reingresos. La mortalidad global fue <1%. El cumplimiento del ERAS se asoció a un descenso en las complicaciones (ERAS <70%: 80% vs ERAS >90%: 20%; p=0,02) y de la gravedad de las mismas en la serie global y en ambos grupos a estudio. El 6% del G≥70 presentó fragilidad; el único paciente fallecido alcanzó un índice de fragilidad de 4. Conclusión: Los pacientes ancianos son candidatos a entrar en protocolo ERAS obteniendo una rápida recuperación, sin aumentar la morbimortalidad ni los reingresos. (AU)

Background: The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocols. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70years) undergoing liver resection. Methods: A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70years (G≥70) versus <70years (G<70). The frailty was measured with the Physical Frailty Phenotype score. Results: A total of 101 patients were included; 32 of these (31.6%) were patients ≥70years. 90% of the both groups had performed >70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in <70years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; ClavienI-II (G≥70: 41% vs G<70: 30.5%) and Clavien ≥III (G≥70: 6% vs G<70: 8.5%), like hospital readmissions. Mortality was <1%. ERAS protocol compliance was associated with a decrease in complications (ERAS <70%: 80% vs ERAS >90%: 20%; p=0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4. Conclusion: Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions. (AU)

Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis.

BACKGROUND & AIMS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS: Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.

Impact of HCV Treatment on Recurrence of Hepatocarcinoma After Liver Transplantation.

The treatment of hepatitis C virus (HCV) has been a revolution in hepatology. Since the beginning of transplantation, liver cirrhosis and hepatocarcinoma on HCV cirrhosis has been the main etiology of liver transplantation. We set out to analyze the impact that C virus treatment has had on liver transplantation. To do so, we divided our cohort into 2 periods, one before virus treatment (from 2000-2014) and one after the onset of treatment (2014-2020). Taking into account this differentiation, we analyzed the percentage of patients transplanted for hepatocarcinoma over cirrhotic liver by HCV in both groups. Among the patients transplanted for HCV, we analyzed whether there were differences in hepatocarcinoma recurrences according to their serologic status at the time of transplantation.

Implementation of an ERAS protocol on elderly patients in liver resection.

BACKGROUND: The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocolos. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70 years) undergoing liver resection. METHODS: A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70 years (G ≥ 70) versus <70 years (G < 70). The frailty was measured with the Physical Frailty Phenotype score. RESULTS: A total of 101 patients were included. 32 of these (31.6%) were patients ≥70 years. 90% of the both groups had performed >70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in <70 years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; Clavien I-II(G ≥ 70:41% vs G < 70:30,5%) and Clavien ≥ III (G ≥ 70:6% vs G < 70:8.5%), like hospital readmissions. Mortality was <1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%:80% vs ERAS > 90%:20%; p = 0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4. CONCLUSION: Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions.

Prevalence of Anxiety and Depression Symptoms and Their Relationship with Nutritional Status and Mortality in Patients with Colorectal Cancer.

BACKGROUND: Anxiety and depression are common in patients with cancer. The aim of this study is to determine the prevalence of anxiety and depression symptoms in colorectal cancer (CRC) patients awaiting elective surgery and whether there is an association with their preoperative nutritional status and postoperative mortality. METHODS: A prospective study was conducted on 215 patients with CRC proposed for surgery. Data about nutritional status were collected using the Global Leadership Initiative on Malnutrition (GLIM) criteria, while anxiety and depression symptoms data were collected using Hospital Anxiety and Depression Scale (HADS). RESULTS: HADS detected possible anxiety in 41.9% of patients, probable anxiety in 25.6%, possible depression in 21.9%, and probable depression in 7.9%. GLIM criteria found 116 (53.9%) patients with malnutrition. The HADS score for depression subscale was significantly higher in malnourished patients than in well-nourished (5.61 ± 3.65 vs. 3.95 ± 2.68; p = 0.001). After controlling for potential confounders, malnourished patients were 10.19 times more likely to present probable depression (95% CI 1.13-92.24; p = 0.039). Mortality was 1.9%, 4,2%, and 5.6% during admission and after 6 and 12 months, respectively. Compared to patients without depressive symptomatology, in patients with probable depression, mortality risk was 14.67 times greater (95% CI 1.54-140.21; p = 0.02) during admission and 6.62 times greater (95% CI 1.34-32.61; p = 0.02) after 6 months. CONCLUSIONS: The presence of anxiety and depression symptoms in CRC patients awaiting elective surgery is high. There is an association between depression symptoms, preoperative nutritional status, and postoperative mortality.

Primary Graft Dysfunction: Factor V's Value for Its Early Diagnosis.

BACKGROUND: Primary graft dysfunction is a common postoperative complication, lacking consensus regarding diagnostic criteria. Olthoff criteria are the most used, based on blood parameters in the first 7 postoperative days. This lack of consensus and late diagnosis evidence the need of early parameters. This study proposes factor V (FV) as a marker in the first 3 postoperative days for primary graft dysfunction. METHODS: Within a 500-patient database, 27 patients with graft loss in the first 90 days were chosen and compared with a group of 54 patients composed of the immediately preceding and following transplant to each case. Through receiver operating characteristic curves, FV and maximum glutamic pyruvic transaminase (GPT) predictive value on the first 3 postoperative days were assessed. The best threshold value was selected according to the Youden index. RESULTS: FV was significantly higher in the control group, with second postoperative day as the highest discriminative one (area under the curve = 0.893). In addition, a cutoff point of FV 37.50 exhibited a specificity of 92% and sensibility of 69% in predicting allograft failure in the first 3 months. GPT showed a lower validity with area under the curve = 0.77, and a GPT of 1539 presented a specificity of 82% and sensibility of 67%. Combining FV < 37.5 and GPT > 1539, a specificity of 98% and sensibility of 55% was reached. CONCLUSIONS: FV could postulate as an early marker of primary graft dysfunction because of its high specificity despite having a lower sensibility. With de association of FV and GPT the maximum specificity for predicting graft loss in the first 3 months was reached, becoming a promising parameter for further analysis.

Treatment of acute intraoperative Budd-Chiari syndrome by placement of silicone prosthesis.

Complete liver mobilization for major resections sometimes causes liver tilting due to the release of the suspensory elements of the liver. Rarely this may take to a liver abnormal position with acute obstruction to venous flow at the suprahepatic level (Budd-Chiari syndrome). To avoid this complication, techniques such as post-operative stent implantation have been described. The case of a patient who underwent a complete mobilization of the liver for resection of the inferior venous cava and a right renal tumor, was reported. After that, an acute Budd-Chiari Syndrome was observed caused of the liver malposition, which was solved with the placement of two silicone prostheses in the liver cell.

Effects of everolimus plus minimized tacrolimus on kidney function in liver transplantation: REDUCE, a prospective, randomized controlled study.

BACKGROUND AND AIM: reduction in calcineurin inhibitor levels is considered crucial to decrease the incidence of kidney dysfunction in liver transplant (LT) recipients. The aim of this study was to evaluate the safety and impact of everolimus plus reduced tacrolimus (EVR + rTAC) vs. mycophenolate mofetil plus tacrolimus (MMF + TAC) on kidney function in LT recipients from Spain. METHODS: the REDUCE study was a 52-week, multicenter, randomized, controlled, open-label, phase 3b study in de novo LT recipients. Eligible patients were randomized (1:1) 28 days post-transplantation to receive EVR + rTAC (TAC levels ≤ 5 ng/mL) or to continue with MMF + TAC (TAC levels = 6-10 ng/mL). Mean estimated glomerular filtration rate (eGFR), clinical benefit in renal function, and safety were evaluated. RESULTS: in the EVR + rTAC group (n = 105), eGFR increased from randomization to week 52 (82.2 [28.5] mL/min/1.73 m2 to 86.1 [27.9] mL/min/1.73 m2) whereas it decreased in the MMF + TAC (n = 106) group (88.4 [34.3] mL/min/1.73 m2 to 83.2 [25.2] mL/min/1.73 m2), with significant (p < 0.05) differences in eGFR throughout the study. However, both groups had a similar clinical benefit regarding renal function (improvement in 18.6 % vs. 19.1 %, and stabilization in 81.4 % vs. 80.9 % of patients in the EVR + rTAC vs. MMF + TAC groups, respectively). There were no significant differences in the incidence of acute rejection (5.7 % vs. 3.8 %), deaths (5.7 % vs. 2.8 %), and serious adverse events (51.9 % vs. 44.0 %) between the 2 groups. CONCLUSION: EVR + rTAC allows a safe reduction in tacrolimus exposure in de novo liver transplant recipients, with a significant improvement in eGFR but without significant differences in renal clinical benefit 1 year after liver transplantation.

Poor Physical Performance Is Associated with Postoperative Complications and Mortality in Preoperative Patients with Colorectal Cancer.

Introduction: Poor physical performance has been shown to be a good predictor of complications in some pathologies. The objective of our study was to evaluate, in patients with colorectal neoplasia prior to surgery, physical performance and its relationship with postoperative complications and in-hospital mortality, at 1 month and at 6 months. Methods: We conducted a prospective study on patients with preoperative colorectal neoplasia, between October 2018 and July 2021. Physical performance was evaluated using the Short Physical Performance Battery (SPPB) test and hand grip strength (HGS). For a decrease in physical performance, SPPB < 10 points or HGS below the EWGSOP2 cut-off points was considered. Nutritional status was evaluated using subjective global assessment (SGA). The prevalence of postoperative complications and mortality during admission, at 1 month, and at 6 months was evaluated. Results: A total of 296 patients, mean age 60.4 ± 12.8 years, 59.3% male, were evaluated. The mean BMI was 27.6 ± 5.1 kg/m2. The mean total SPPB score was 10.57 ± 2.07 points. A total of 69 patients presented a low SPPB score (23.3%). Hand grip strength showed a mean value of 33.1 ± 8.5 kg/m2 for men and 20.7 ± 4.3 kg/m2 for women. A total of 58 patients presented low HGS (19.6%). SGA found 40.2% (119) of patients with normal nourishment, 32.4% (96) with moderate malnutrition, and 27.4% (81) with severe malnutrition. Postoperative complications were more frequent in patients with a low SPPB score (60.3% vs. 38.6%; p = 0.002) and low HGS (64.9% vs. 39.3%, p = 0.001). A low SPPB test score (OR 2.57, 95% CI 1.37−4.79, p = 0.003) and low HGS (OR 2.69, 95% CI 1.37−5.29, p = 0.004) were associated with a higher risk of postoperative complications after adjusting for tumor stage and age. Patients with a low SPPB score presented an increase in in-hospital mortality (8.7% vs. 0.9%; p = 0.021), at 1 month (8.7% vs. 1.3%; p = 0.002) and at 6 months (13.1% vs. 2.2%, p < 0.001). Patients with low HGS presented an increase in mortality at 6 months (10.5% vs. 3.3%; p = 0.022). Conclusions: The decrease in physical performance, evaluated by the SPPB test or hand grip strength, was elevated in patients with colorectal cancer prior to surgery and was related to an increase in postoperative complications and mortality.

Outcomes of robotic-assisted vs conventional laparoscopic surgery among patients undergoing resection for rectal cancer: an observational single hospital study of 300 cases.

Robotic-assisted laparoscopic surgery attempts to facilitate rectal surgery in the narrow space of the pelvis. The aim of this study is to compare the outcomes of robotic versus laparoscopic surgery for rectal cancer. Monocentric retrospective study including 300 patients who underwent robotic (n = 178) or laparoscopic (n = 122) resection between Jan 2009 and Dec 2017 for high, mid and low rectal cancer. The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, except for sex and ASA status. There were no statistical differences between groups in the conversion rate to open surgery. Surgical morbidity and oncological quality did not differ in either group, except for the anastomosis leakage rate and the affected distal resection margin. There were no differences in overall survival rate between the laparoscopic and robotic group. Robotic surgery could provide some advantages over conventional laparoscopic surgery, such as three-dimensional views, articulated instruments, lower fatigue, lower conversion rate to open surgery, shorter hospital stays and lower urinary and sexual dysfunctions. On the other hand, robotic surgery usually implies longer operation times and higher costs. As shown in the ROLARR trial, no statistical differences in conversion rate were found between the groups in our study. When performed by experienced surgeons, robotic surgery for rectal cancer could be a safe and feasible option with no significant differences in terms of oncological outcomes in comparison to laparoscopic surgery.

Outcome of Liver Transplants Using Donors After Cardiac Death With Normothermic Regional Perfusion.

BACKGROUND AND AIMS: The incorporation of normothermic regional perfusion (NRP) to donors after cardiac death (DCD) allows the recovery of liver grafts without the deleterious effects on graft survival the super-rapid technique may cause. The aim of the present report is to determine if the use of NRP in Maastricht type III DCD donors achieves short- and medium-term results comparable to donors after brain death (DBD). PATIENTS AND METHODS: This is an observational cohort study including 117 liver transplants executed between November 2016 and April 2021, divided into NRP (n = 39) and DBD (n = 78). RESULTS: Donors were younger in the NRP group (NRP 52 vs DBD 59.4 years; P < .005). Liver recipients in each study group were of similar age and severity of liver disease, although the predominant transplant indication in the NRP group was hepatocellular carcinoma. No differences in ischemia times were found. The incidence of early allograft disfunction and primary nonfunction was balanced between NRP and DBD. Eight patients required retransplant, all of them in the DBD group. No differences were found in biliary complications (NRP 12% vs DBD 5%; P = .104). Ischemic cholangiopathy affected a single DBD patient. Graft survival's Kaplan Meier curve shows a better outcome in the NRP group, although the difference did not reach significance (P = .075). CONCLUSIONS: The incorporation of perfusion machines, and specifically the NPR in situ, converts suboptimal liver grafts such as DCD into organs comparable to DBDs.

Abdominal normothermic regional perfusion in controlled donation after circulatory determination of death liver transplantation: Outcomes and risk factors for graft loss.

Postmortem normothermic regional perfusion (NRP) is a rising preservation strategy in controlled donation after circulatory determination of death (cDCD). Herein, we present results for cDCD liver transplants performed in Spain 2012-2019, with outcomes evaluated through December 31, 2020. Results were analyzed retrospectively and according to recovery technique (abdominal NRP [A-NRP] or standard rapid recovery [SRR]). During the study period, 545 cDCD liver transplants were performed with A-NRP and 258 with SRR. Median donor age was 59 years (interquartile range 49-67 years). Adjusted risk estimates were improved with A-NRP for overall biliary complications (OR 0.300, 95% CI 0.197-0.459, p < .001), ischemic type biliary lesions (OR 0.112, 95% CI 0.042-0.299, p < .001), graft loss (HR 0.371, 95% CI 0.267-0.516, p < .001), and patient death (HR 0.540, 95% CI 0.373-0.781, p = .001). Cold ischemia time (HR 1.004, 95% CI 1.001-1.007, p = .021) and re-transplantation indication (HR 9.552, 95% CI 3.519-25.930, p < .001) were significant independent predictors for graft loss among cDCD livers with A-NRP. While use of A-NRP helps overcome traditional limitations in cDCD liver transplantation, opportunity for improvement remains for cases with prolonged cold ischemia and/or technically complex recipients, indicating a potential role for complimentary ex situ perfusion preservation techniques.